Archive for the ‘medical history’ Category

Why healthcare is in trouble.

Friday, November 8th, 2013

Our health care system has been built up over the years in a jury-rigged, ramshackle fashion. Before World War II, there was very little health insurance and what there was often was the product of labor union contracts. The early years were concerned with accident insurance and workers compensation laws.

The American life insurance system was established in the mid-1700s. The earliest forms of health insurance, how­ever, did not emerge until 1850, when the Franklin Health Assurance Com­pany of Massachusetts began providing accident insurance, to cover injuries re­lated to railroad and steamboat travel. From this, sickness insurance covering all kinds of illnesses and injuries soon evolved, but the first modern health insurance plans were not formed until 1930.

The Baylor program for school teachers was the first in 1929.

Medical insurance took stride in 1929 when Dr. Justin Ford Kimball, an administrator at Baylor University Hospital in Dallas, Texas, realized that many schoolteachers were not paying their medical bills. In response to this problem, he developed the Baylor Plan – teachers were to pay 50 cents per month in exchange for the guarantee that they could receive medical services for up to 21 days of any one year.

In those days, the concern was lost wages more than hospital care.

In 1939, the American Hospital Association (AHA) first used the name Blue Cross to des­ignate health care plans that met their standards. These plans merged to form Blue Cross under the AHA in 1960. Considered nonprofit organizations, the Blue Cross plans were exempted from paying taxes, enabling them to maintain low premiums. Pre-paid plans covering physician and surgeon services, includ­ing the California Physicians’ Service in 1939, also emerged around this time. These physician-sponsored plans com­bined into Blue Shield in 1946 and Blue Cross and Blue Shield merged into one company in 1971.

The modern insurance plans were very recent in origin. I was there for much of it. The commercial insurers fought the status of Blue Cross, which was not required to have reserves. Blue Cross asserted that it promised hospital care, not payment, so reserves were not necessary.

The 1940s and 1950s also saw the proliferation of employee benefit plans, and the included health insurance pack­ages became more and more compre­hensive as strong unions negotiated for additional benefits. During the Second World War, companies competing for labor had limited ability to use wages to attract employees due to wartime wage controls, so they began to compete through health insurance packages. The companies’ healthcare expenses were exempted from income tax, and the resulting trend is largely responsible for the workplace’s present role as the main supplier of health insurance.

The war produced much of this as wage limitations were in force but fringe benefits, like health insurance, were permitted. A lot of this history is contained in Paul Starr’s book The Social Transformation of American Medicine.

From the first, commercial insurers focused on employer plans while Blue Cross and Blue Shield (which was founded by the California Medical Association to pay doctor bills) were individual plans.

In 1954, Social Security coverage included disability benefits for the first time, and in 1965, Medicare and Medicaid pro­grams were introduced, in part because of the Democratic majority in Congress. In the 1970s and 1980s, more expen­sive medical technology and flaws in the health care system led to higher costs for health insurance companies. Responding to higher costs, employee benefit plans changed into managed care plans, and Health Maintenance Organizations (HMOs) emerged. Man­aged care plans are unique in that they involve a particular network of health­care providers that have been verified for healthcare quality and that have agreements with the insurer about price and related issues. HMOs were originally primarily nonprofit, but they were quickly replaced by commercial interests, and managed care only suc­ceeded in temporarily slowing the growth of healthcare costs.

Two major changes came in the 1970s. In 1978, the federal government established what were called Professional Standards Review Organizations or PSRO. All doctors had to receive training in how to do these reviews and it was immediately apparent that cost was the only consideration, not quality of care.

I decided to educate myself and took a course from an organization called “The American Board of Quality Assurance and Utilization Review Physicians. I took the exam and passed, then attended the annual meeting. This was about 1986. People I met at that meeting informed me that the exams were graded by throwing them up in the air. Any that landed balancing on one edge were flunked. Nonetheless, the experience was valuable because I could see what was coming.

I was president of the Orange County Medical Association that year and had served for eight years on the Commission on Legislation of the CMA, now called The Council on Legislation. This gave me an opportunity to meet many legislators, many state level and some federal. The impression they made on me was that few knew anything about medicine and most were not very intelligent.

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Obamacare is coming next month

Tuesday, September 24th, 2013

UPDATE: So far, as October 4, there is no evidence that anyone has enrolled in Obamacare. The one person alleged to have done so has now been shown to have been lying and the details he offered to the eager press, were phony. It appears the IT collapse is continuing.

UPDATE #2 There appears to have been 1% or less of applicants who negotiated the maze actually signed up. The web site is closed for the weekend to fix “glitches.” I still suspect it would have been better strategy to allow the October 1 rollout of this mess and focus on the debt ceiling for a potential shutdown.

UPDATE #3: Here is an informed discussion of Obamacare and the IT mess that created it.

To add insult to injury, the administration outsourced the building of this costly contraption to CGI Group, a Canadian firm. CGI, whose U.S. operations are based in Northern Virginia, “just so happened” to increase the number of H-1B visas it requested from 172 in 2011 to 299 in 2012. It seems more than a little likely that the Obamacare project gave jobs to foreigners while needlessly leaving fully dozens or perhaps even hundreds of qualified citizen IT professionals on the unemployment line.

It gets even worse. CGI was “officially terminated in September 2012 by an Ontario government health agency after the firm missed three years of deadlines and failed to deliver the province’s flagship online medical registry.”

Oh well.

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The War on Drugs

Thursday, August 15th, 2013

My sentiments on the whole drug question have been influenced by some experience with the medical aspect of the problem. Drugs are slipping out of any control due to developments in synthetic variations of older substances that stimulate brain chemistry, sometimes in unknown ways. The traditional drugs, if we can use that term, are also slipping out of control with Mexican drug wars replacing the Columbian cartels even more violent than their predecessors.

What about marijuana ? It is widely used by the younger generation and, while I do think there are some harmful consequences, especially in potential schizophrenics, the fact is that the laws are widely ignored and do little good and much harm. First, what about the link to psychosis ?

Epidemiological studies suggest that Cannabis use during adolescence confers an increased risk for developing psychotic symptoms later in life. However, despite their interest, the epidemiological data are not conclusive, due to their heterogeneity; thus modeling the adolescent phase in animals is useful for investigating the impact of Cannabis use on deviations of adolescent brain development that might confer a vulnerability to later psychotic disorders. Although scant, preclinical data seem to support the presence of impaired social behaviors, cognitive and sensorimotor gating deficits as well as psychotic-like signs in adult rodents after adolescent cannabinoid exposure, clearly suggesting that this exposure may trigger a complex behavioral phenotype closely resembling a schizophrenia-like disorder. Similar treatments performed at adulthood were not able to produce such phenotype, thus pointing to a vulnerability of the adolescent brain towards cannabinoid exposure.

This suggests that adult use may be less harmful.

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Australian health care

Saturday, November 12th, 2011

I posted a comment in response to a question on the blog but WordPress ate it so I will try to Post some thoughts about the Australian system. In the 1970s, Australia may have had the best system in the world but politics, as usual, screwed it up. When I was first starting out in the 1970s, we were out for dinner with a couple of Australian surgeons. They explained the system as it existed at the time. The hospitals were almost all owned by the states which funded them. There was a private health care system, called “Medicare” in which individuals who wanted private care paid a monthly premium though the Post Office. All hospital care was in the state owned public hospitals. The hospital based specialists cared for everyone regardless of insurance status in the same setting.

In the early days of the National Health Service in England, a similar situation existed with private patients in NHS hospitals. Then, in the early 1970s, under the Labour government, the unions of NHS employees refused to care for private patients. The result was that Harley Street specialists and their patients left for Belgium. A few years later, there was a small scandal in which the Labour Health Minister had her hysterectomy performed in Belgium by a private specialist. Such hypocrisy is an old story.

In Australia, the Labor Party campaigned in the 1984 election telling voters that, if they were elected, health care would be free. They would abolish the Medicare premium. As it happened, they had made no provision to pay doctors. It’s not clear if this was the result of ignorance on their part or if it was a calculated risk in an election they did not expect to win.

I visited Australia a few years later and saw the remains of the mess. Big states, like New South Wales, had no private hospitals and hospital based specialists, like surgeons, had no source of income. Patients dropped their Medicare premium and the doctors were screwed. With time, there has been a reorganization and official descriptions gloss over the story. If you read this description, for example, there is no description of the chaos that I found in 1988. There were daily newspaper stories, at the time, of patients going without treatment.

I was visiting friends, two GPs in Toowoomba, in Queensland. From them, I learned considerable background. Queensland, the most conservative Australian state, had both private and public hospitals. The public hospitals were not on the same level of sophistication and equipment as the private ones. The doctors in Queensland told their patients that, if they wanted private care, they had better pay their Medicare premiums. My friends owned their own office building and surgery center (called day-surgery). The public hospital also had a day surgery across the street from the private one. A year after my visit, the public hospital approached the two GPs and asked them if they would take over management of the publicly own day surgery as well as their own.

I think most of the major mistakes of the Labor government have been corrected with time. I don’t think the system is as good as it was 30 years ago.

The pleasures of medicine; or not.

Sunday, March 7th, 2010

UPDATE: Nearly half of all physicians plan to quit if Obamacare passes. Many will phase out but it will be a disaster. I’m sure Obama has plans to fix it.

I have been a physician for almost 44 years. I graduated from medical school in 1966 and finished my residency training as a surgeon in 1972. Since I began medical school in 1962 (For the second time but that’s another story), I spent ten years learning to do what I did until I retired from surgery in 1994 after back surgery. I have gone on doing medical things since then but I had to give up surgery. The 27 years I spent as a surgeon (including my training) were the best years of my life. Had I not injured my back in college, I would still be practicing, even at 72. The early years of my career as a surgeon were the golden age of medicine in this country. We still could not cure some diseases and we especially were limited in our ability to deal with infection in some cases but the life of a physician or a surgeon was the best it would ever be.

About 1987, things really began to change for the worse. Some of it was the fault of the profession, some the fault of politics and some the fault of human nature. In 1978, the first political reaction to the rapid growth in the cost of medicine appeared. It was called PSRO, or Professional Standards Review Organization. Of course, it had little relationship to professional standards and everything to do with cost. We all had to participate like some Red Guards self examination in Mao’s China. We learned how to analyze care for what were purportedly quality issues but we all immediately recognized as cost. All the doctors of the hospital staff had to attend these classes and learn how to do this. Then we had to “volunteer” for committees to review cases to see if they met the standards. The standards always seemed to focus on cost issues, such as length of stay. Length of stay is an American obsession. A few years after this first experience with self examination, we began to have demands from Medicare and insurance companies for AM admissions before surgery.

AM admission is one of the examples of the lunatic aspect of government intervention in medicine. People who were to have major operations were expected to get up at 4 AM the day of surgery and come to the hospital at 5:00 for a 7:30 surgery. They were given instructions about not eating or drinking after midnight or whatever. Why not just have them come in at 6 PM the night before and be prepared then. ? They would sleep better with a sleeping pill, we would know for sure that they hadn’t had a late snack in spite of instructions and the hospital staff would know they were there, ready for surgery.

When this began, I asked what I thought was a logical question. Why are we doing this ? Cost, I was told. Why charge for the admission day before surgery? We could just make that a free day since the patients came in after 3 PM anyway. Nobody ever answered. The hospital had to add staff for the early morning shift. Sometimes a patient would not show up or arrive too late for their 7:30 case. Then we would scramble around to see if the next patient could come in early instead of the 10 o’clock they had been told. The schedule would be shifted around and the charge nurse would call the next surgeon to see if he could come in early, only to find he was doing surgery in another hospital at that time. I was sure, and still am, that the costs were no different and the aggravation and even the danger was increased for no good reason. It’s a bit like the Army. “Why are we doing this sir?” “Because I said so !” “Thank you sir.” A stint in the Army is helpful in understanding how government works.

That was the beginning. Next came calling the insurance company for permission to do surgery. In 1987 came the new way of being paid for care. It was called Resource Based Relative Value Scale, or RBRVS. A Harvard professor came up with a new way to pay for care. The methodology was supposed to account for the value of inputs in determining what Medicare (and quickly all insurance companies followed suit) would pay. It is related to the “Labor Theory of Value.” If you follow the link, you will see who thought this up. The original Relative Value System was developed by the California Medical Association in the 1930s. It was constructed by doctors to rate services, relative to each other, on what the price should be. I have previously covered some of this in a post on “How we got here.” Now, we have arrived at a system that is so onerous and counterintuitive that doctors have lost a lot of the pleasure of private practice. As usual, Thomas Sowell has something to say about it that concisely summarizes the foolishness of the present situation. If that is not enough, there are numerous examples of what government medicine eventually looks like. If you remove the pleasure, pretty soon everyone turns into the DMV or the Post Office employee. I mean no insult to those people but psychology has rules about behavior. Read the Thomas Sowell article. He always has something worth while to say. This is even better than most.

How we got here in health care.

Thursday, June 11th, 2009

For those who have not read Paul Starr’s book , The Social Transformation of American Medicine, or my own chapter on medical economics, here is a brief introduction to American medical economic history. Along the way, I will mention some European history.

The first government health plan was in Germany, established by Bismark, who introduced a disability and old age insurance program in 1883. Initially, retirement age was set at 70 and later lowered to 65. His reason was to preempt the Socialists in the German political world. The German health care system evolved over the next 100 years but it is not a government single payer system.

In Germany, statutory health insurance, which covers 90 percent of the population, is financed by a payroll tax. The individual’s premium is not a per-capita levy, as it is in the United States. It is purely income-based. Ostensibly, about 45 percent of the premium is contributed by employers, although economists are persuaded that ultimately all of it comes out of the employee’s take-home pay (See this and this).

An employee’s non-working spouse is automatically covered by the employee’s premium.

The Clinton Plan was allegedly based on the German model.

The health insurance premiums paid by Germans are collected in a national, government-run central fund that effectively performs the risk-pooling function for the entire system. This fund redistributes the collected premiums to some 200 independent, nongovernmental, competing, nonprofit “sickness funds” among which Germans can choose.

The sickness funds are based on employment or the town in which the subscriber lives. The Germans have different priorities than we do. For example, our fixation on hospital length of stay (LOS) is absent. I presented a paper on hemorrhoid surgery to the European laser medicine society in 1988. Most of the questions after my presentation concerned my policy of doing hemorrhoid surgery as an outpatient procedure. The Germans think that is cruel and recommend hospital stays of several days. They also have (most Germans have, anyway) a benefit for two weeks of spa treatment per year. I once had a patient in Orange County who was eligible for German health care, as well. He had his surgery here but he returned to Germany each year for his two weeks of government paid spa care.

I have already done a lengthy analysis of the French system which I think the best model for US reform.

Now, some US history. American medicine was purely private and fee-for-service until the Depression. There were public hospitals, like Charity Hospital in New Orleans, or Bellevue Hospital in New York, or Cook County Hospital in Chicago, or the Massachusetts General Hospital in Boston, or the Los Angeles County General Hospital in Los Angeles. In 1928, the new LA “Big County” hospital opened and during the Depression it offered the finest care in California. I have been told by older physicians that doctors denigrated “the County” to patients, not out of concern for their welfare but because of concern that private patients would choose to go there leaving private doctors in dire straits. Those great public hospitals could have formed a nucleus for care of the poor even today but they were destroyed or badly damaged by Medicaid after 1965 which refused to pay the county hospitals as it emphasized (often inferior) private care over the public hospitals. The budget shortfalls occurred just before the illegal aliens began to flood the public hospitals. The result has been a distinct decline in quality of care.

The Depression brought the first health plans for the middle class. In Dallas, in 1929, the Baylor University hospitals established a plan for school teachers. For six dollars per year in dues, the subscriber was entitled to 21 days of hospitalization. Similar plans began in California and New Jersey and finally, a plan called “Blue Cross” won a suit in New York that exempted it from insurance company reserve requirements. The hospitals were not selling insurance but promising services, hospital care, and did not need to maintain cash reserves.

Blue Shield plans began in California where the California Medical Association devised a plan in which low income subscribers would be guaranteed physicians services. The AMA, in those days still very powerful, opposed the plan but it persisted and a fee schedule was established in spite of Federal Trade Commission opposition. At one point, when I was first in practice, the FTC required the CMA to surrender all copies of the fee schedule, called Relative Value Schedule (RVS) but Medicare required that doctors use the RVS for billing ! We all had xerox copies of the RVS for a while. Such was the stupidity we encountered.

Until the Second World War, medicine was relatively inexpensive and of limited effectiveness. Surgery was effective in curing most surgical conditions after 1900. Critical care came as a result of the war and antibiotics arrived just in time for the war casualties. Blood banks began about 1937 at Cook County Hospital. Few medical conditions other than infection were treatable until the 1950s. Hypertension was the cause of death for President Roosevelt but there were no effective drugs until the 1950s. Winston Churchill’s life was saved in 1943 by sulfa drugs in an episode little known to historians. The “golden age” of medicine began about 1950.

Health insurance in America began with unions and the Stone Cutters Union had the first health plan that would pay for delivering a baby in 1887. In 1945, the United Rubber Workers Union established a health plan that paid $50 for delivery of a normal pregnancy. For years, the doctors in Butler, PA had collected a fee of $50 for this service. That was the established fee. When the insurance began to pay this $50 fee, the doctors increased their fees to $75. Here was the beginning of the destruction of the profession although it seemed to be progress at the time. The union health plan increased its payment to $75 and the doctors then raised their fees to $125. They were now back to the original arrangement with patients. The patient paid $50 cash and the insurance paid the rest. Here was the fatal bargain. A third party was paying the bill and both the doctor and the patient had little responsibility. The cost issue began here. In 1969, my second son was born in Pasadena at a cost (hospital bill) of about $260. It was not covered by insurance. A few years later, with insurance paying the bill, the price was more than ten times that amount.

The French had similar cost issues in the 1950s after the French system was established in the aftermath of the war. Our own system was also a consequence of the war as wage and price controls allowed a loophole for “benefits.” The employer offered health benefits as an inducement for scarce labor when 12 million men were in uniform. In France, President De Gaulle settled the issue by scolding the medical associations and asserting “I saved France on a colonel’s salary !” A national fee schedule was established but it is not mandatory. It does, however, provide the fee schedule that is paid by the health plans. Doctors and hospitals may charge more but the balance is up to the patient to pay. Canada made a terrible mistake by banning private practice. The result has been emigration plus a disincentive for young physicians to train in long programs since they will not be rewarded financially for the specialty and the hours and years invested. We are already seeing a similar effect in this country as medical students choose “lifestyle” specialties, which allow shift work, like Emergency Medicine, and which avoid long hours and weekend call.

The factors that have brought the crisis include technology, the incentive for both patient and doctor to overuse benefits, plus the aging population. The Obama program, if passed, does not seem to bar private practice. I am seeing doctors dropping out of Medicare and practicing on a cash basis. Whether that will become an issue if there is a large exodus from the government option is a question.

One major issue is the fact that medical bills do not reflect real costs. A hospital bill for $100,000 may in fact represent only $25,000 in insurance payments. The cash patient is at a huge disadvantage. This becomes a factor if you have a 20% co-pay, as many high deductible policies do. The “20%” you pay may be more than the amount paid by the insurance company for the “80%” share they have. The 20% co-pay is based on the inflated retail price of the care. It also makes medical IRAs far less useful since the cash market is using inflated retail prices that may by four times the negotiated price the insurance plan, or Medicare, may pay.

Doctors may be willing to practice on a cash basis with realistic bills approximating the actual Medicare payment. I have heard of orthopedic surgeons doing total hips for $1200.00, far less than the usual billed fee but approximately what Medicare actually pays. If such a surgeon bills that fee, Medicare (if he is still a member) will reset his fee “profile” at that rate, then pay him 25% of that lower fee. Thus, the surgeon must drop out of Medicare completely to switch to a market price practice. Will hospitals be willing to do this ? I doubt it. Will Obama’s new plan reset the prices so they represent actual costs ? I doubt it.

The 1918 flu pandemic

Wednesday, December 31st, 2008

Genetic engineering may have explained the mortality of the 1918 flu. Apparently, three genes are responsible for the viruses ability to infection lung and not just bronchus.

“We wanted to know why the 1918 flu caused severe pneumonia,” Kawaoka said in a statement.
They painstakingly substituted single genes from the 1918 virus into modern flu viruses and, one after another, they acted like garden-variety flu, infecting only the upper respiratory tract.
But a complex of three genes helped to make the virus live and reproduce deep in the lungs.
The three genes — called PA, PB1, and PB2 — along with a 1918 version of the nucleoprotein or NP gene, made modern seasonal flu kill ferrets in much the same way as the original 1918 flu, Kawaoka’s team found.

There was a second reason for the high mortality in 1918-1920. The principles of thoracic surgery, including the physiology of respiration were not understood at the time. Thousands of flu cases, those with pneumonia, developed a secondary bacterial pneumonia and then developed empyema. Empyema is a collection of infected fluid in the space between the lung and the chest wall. We now know how to treat this condition. The principles of treatment are here. Note the observation that Hippocrates understood the principle of empyema; namely that thin fluid in the collection could be drained by an opening in the chest wall but the patient would die. Hippocrates didn’t understand why. The knowledge of lung physiology would not come until the 19th century. However, Hippocrates did observe that draining thick pus through an opening in the chest did not result in the death of the patient in all cases, as it did in those where the fluid was thin and watery. What was the reason ?

We now know that a relative vacuum exists between chest wall and lung. The chest wall is rigid and, during respiration, it changes its volume by using the “bucket handle effect” of the ribs.

The space between lungs and chest wall is shown along with the general anatomy. That space is what fills with fluid in cases of pneumonia that develop empyema.

The ribs are curved and, when the muscles of the chest wall pull up on them, as shown by the arrows, the cross section of the chest cavity increases because of the “bucket handle” effect. With expiration, the ribs move back down and the volume of the chest cavity decreases. This volume shift, aided by the piston effect of the diaphragm, moves air in and out of the chest. The lungs are not attached to the chest wall, allowing them to slide up and down and accommodate their shape to the shape of the chest wall. If there is a hole in the chest wall, the air can move into the space between the lung and chest wall, collapsing the lung. This is called a “sucking chest wound” in trauma care. If the hole in the chest wall is larger than the trachea, air will move more easily in and out of the chest and respiration through the trachea will stop. This was the great barrier to chest surgery that was not overcome until the 1920s. The flu epidemic, and the research into the cause of death in so many cases, led to the understanding of how the chest works.

I recently reviewed a book about the history of the 1918 flu epidemic and, because it ignored the issue of empyema, I could not finish it. They had only half the story. The story of empyema, and the cause and cure, resulted from work of the Empyema Commission, chaired by Evarts Graham, professor of surgery at Washington University of St Louis medical school. Here is one of many scholarly works describing his great accomplishment. Unfortunately, little of this has penetrated the general history of the epidemic in spite of 90 years. In a recent article about the military cases during the First World War, it states: During World War I, the overall empyema mortality rate among US military forces was 61%. The same, or greater, mortality was seen in the flu cases that occurred in the same period. Untreated empyema was virtually 100% fatal.

During World War I, empyema treated by thoracotomy was associated with a mortality of > 30%. This prompted the establishment of the Empyema Commission, which recommended chest tube drainage for treatment.

The surgeons who were treating the flu cases, just as those treating empyema due to war wounds, used the old Hippocratic treatment of draining the pus from the empyema. Note that in the war wound cases, 70% of these patients survived. The flu cases were different and almost all died in a few hours after the fluid was drained. The difference was that the empyema in flu cases was due to streptococcus infection, which produces a thin fluid and does not cause the lung to stick to the chest wall. When the chest was opened, the lung collapsed and these already sick patients succumbed. Hippocrates had predicted this. The war wound cases did better because the staph infections of the pre-antibiotic days (“Laudable pus”) caused the lung to stick to the chest wall and it would not collapse.

Eventually, Graham learned that using a tube instead of an open hole to drain the pus, and placing the chest tube under water at its lower end, would seal the air leak but allow drainage of the pus. His work opened the door to thoracic surgery and, today, would save most of the cases in a new flu epidemic. Graham was also the first to warn of the association between smoking and lung cancer, a disease he was to die of 1957. He performed the first successful removal of a lung for cancer and his patient attended his funeral 24 years later.

Genetics is a powerful tool in the treatment of disease but physiology is still as important. Scientists understand the first but may not be aware of the other factors. There is no substitute for the experience of treating patients.

Neuroscience, the next medical frontier

Monday, December 15th, 2008

When I was a freshman medical student, I spent a summer working in the VA psychiatric hospital in west Los Angeles. While there, I spent many hours talking to chronic schizophrenic patients, some from World War II and one even from World War I. I watched electro-shock therapy for psychosis and spent hours listening to the professor there, George Harrington. He was one of the two or three most impressive men I met in medicine. He was convinced that psychosis was an organic disease and had no confidence in psychoanalysis to explain anything to do with psychosis. I was very interested in psychiatry for a while but my exposure to other psychiatrists in medical school soon ended my enthusiasm.

Now, neuroscience is one of the most promising areas in medicine. We have increasing evidence of the anatomy of mental illness. Obsessive-compulsive disorder can now be cured with a surgical interruption of a feedback loop in the brain. Functional MRI can show differences in the response to stimuli between schizophrenic and non-schizophrenic twins.

Now, we are getting to the analysis of normal function. The visual cortex seems to have a map of the retina contained in it. By analyzing the fMRI of the visual cortex in a subject looking at a picture, it has now been possible to reconstruct the image from the fMRI. We can look at the brain in a functional way and read what it is seeing.

The next step, and it is coming fast. is to create a biological-electronic interface. We already have one called the cochlear implant. It is able to restore hearing by stimulating hair cells in the ear. A visual implant would stimulate the optic nerve when the rods and cone cells are lost.

If I were a medical student today, I would be looking very hard at this field. When I was a medical student 46 years ago, I decided that the science of the brain and the immune system were too primitive at the time to have any implication for clinical work. I decided that, if I wanted to go into research, I would be better off as a physical chemist. That was true then but is no longer true.

Michael DeBakey dies at 99

Saturday, July 12th, 2008

–Houston Chronicle, ‘Dr. Michael DeBakey: 1908-2008 — ‘Greatest surgeon of the 20th century’ dies’: ‘Dr. Michael Ellis DeBakey, internationally acclaimed as the father of modern cardiovascular surgery – and considered by many to be the greatest surgeon ever – died Friday night at The Methodist Hospital in Houston. He was 99. Methodist officials said DeBakey died of natural causes. They gave no additional details.

‘Medical statesman, chancellor emeritus of Baylor College of Medicine, and a surgeon at The Methodist Hospital since 1949, DeBakey trained thousands of surgeons over several generations, achieving legendary status decades before his death. During his career, he estimated he had performed more than 60,000 operations. His patients included the famous – Russian President Boris Yeltsin and movie actress Marlene Dietrich among them – and the uncelebrated.’

DeBakey was an amazing pioneer in surgery. In 1938, he and his mentor, Alton Ochsner, published an article on the drainage of subphrenic abscess, a surgical plague in the days before antibiotics. Patients with perforated appendicitis were kept in the hospital for weeks in “Fowler’s position,” to avoid the dreaded complication of subphrenic abscess. Fowler’s position, inadequately explained in that Wikipedia article, was a seated position in bed to allow pus to drain into the pelvis where it could be drained through the rectum or, in females, through the vagina. Before DeBakey’s and Ochner’s article, the approach to a subphrenic abscess, above the liver and below the diaphragm, was extremely dangerous. It was also common because lying flat in bed tended to allow pus to flow up to the space above the liver. They found that the space could be drained through an approach through the 11th rib. It was easy and effective in the days before antibiotics made subphrenic abscess rare. He should be famous for that alone. The rest of his career will be covered extensively by others but I fear his first great contribution may be ignored. He was a great man.

Tuskeegee

Sunday, May 4th, 2008

There is so much horse shit being put out about the Tuskeegee Study,  most recently this weekend, that it is time to add a few facts. Syphilis was a great scourge brought to Europe from the Americas by Columbus’ crew when they returned. It was ferocious when the epidemic was still new. With time, the manifestations of the disease were less horrible but it was very common. By 1600, one third of Paris was infected. With time, as in all infectious diseases, the virulence declined but it was still a serious disease.

The first successful treatment was with the use of Mercury, first described by Paracelsus who cured nine syphlitics with mercury in 1530. He also provided the first accurate description of the disease and described its manifestations. For centuries after, it was said “One night with Venus may lead to a life with Mercury.” The treatment was onerous and needed to be repeated periodically for life. The discovery of mercurial diuretics in the 1920s came about accidentally through the treatment of syphlis cases with heart failure from syphlitic heart lesions. When I was a medical student, the only powerful diuretics we had were still mercurials.

In 1905, Paul Ehrlich was searching for an antibiotic for syphilis when he stumbled upon the use of organic arsenic. Eventually, by 1910, he announced the new drug called compound 606, or Salvarsan. This was more effective than Mercury and moderately less toxic but it was not the “silver bullet” that he had been searching for. Of course, we currently have hysteria over tiny doses of Mercury in vaccines to prevent contamination.

In 1932, the Public Health Service began a study of negro males who were infected with syphilis. No one was “given” syphilis. This Wikipedia entry, while somewhat biased in tone, gets the facts right in the beginning. The group of subjects was divided into those with early signs, such as genital lesions, and those who were in what is called the “latent phase.” Those with early signs were treated with arsenicals. There was no evidence that latent phase syphilis was treatable.

Instead, we get this sort of thing;
And, you know, you can explain them, as he explained, for instance, the idea that the government in fact would infect blacks with AIDS, by saying, well, remember Tuskegee, when the government actually did infect blacks with syphilis. He does come from a different era, a different age. And so the way he presents himself is very different.

from Sally Quinn of the Washington Post who should know better but probably doesn’t do science.

The discovery and manufacture of penicillin came about in the 1940s and by 1950 there are serious questions about whether treatment should have been offered to those men. The  treatment of tertiary syphilis, especially neurosyphilis, requires very high doses of penicillin, doses that were not available until after 1950.
Penicillin remains the treatment of choice for all stages of syphilis, although it penetrates the blood brain barrier poorly. Treatment with intramuscular benzathine penicillin 2.4 million units stat, or 600,000 units procaine penicillin daily does not produce treponemicidal levels within the CSF. However, the incidence of neurosyphilis is low in immunocompetent patients treated with such regimens during early syphilis.

In late syphilis, it is the policy to treat everyone.

Does penicillin cure tertiary syphilis ? Sometimes.

Should the “Tuskegee Boys” have been offered penicillin in 1950 and after ? Yes.

Would it have made a difference ? I don’t know.

I do know that Reverend Wright and Sally Quinn are ignoramuses although he may actually know better.