Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Hospitals and Physicians

Hospital-Phyiscians Relationships: Case Student and Commentaries on Medical Staff Problems, edited by Nathan Hersey, 239pp, 823.50, Rockville, Md, Aspen systems Corp, 1982

Relations between the medical and legal professions are so strained by malpractice litigation that it often goes unnoticed that most mainstream lawyers do not belong to, indeed may even harbor reservations about the trial bar. Consequently, we may inadequately acknowledge the legal professions as a useful and honorable one, with much to teach us about handling our affairs. The goal of his book although Nathan Hershey states it somewhat differently is to dramatize the range of awkward situations that plausibly could arise in any hospital and that should, therefore, be anticipated in the drafting of any hospital's medical staff bylaws. The medical staff, writing its bylaws, resembles the man writing his will, who must be diplomatically persuaded to include "boilerplate" provision against eventualities he refuses to take seriously but that does, nevertheless, litter the landscape of human affairs

In this book, a series of fictionalized episodes parade before us the respected staff physician in whom a drug or alcohol problem develops, the emotionally overwrought house officers who gets carried away by misguided sympathy, the fully qualified applicant for staff privileges who is, nevertheless, unwanted, the surgical super salesman or other "big admitter" whose business is more welcome than his behavior, the feuds that can spill over into hospital affairs when medical partnerships disrupt, and other marionettes.

Following each vignette is a brief commentary, but the real message lies in the depiction of messes that result from (characteristic?) failure to follow"due process." Like any advocate, Nathan Hershey attempts to show that following a well-defined, fair procedure saves the client money and trouble in the long run. But one gains the distinct impression that, to his great credit, Mr. Hershey is genuinely dismayed at some disorderly processes he has observed, occasionally seeming to have given rise to unjust and unwise behavior by hospital trustees who seemed to think almost any behavior was tolerable as long as it provoked no bad publicity, physicians who seemed to think any methods of approach was justified by a well-motivated goal, and hospital administrators who seemed to think anything was acceptable as long as they didn't get caught. Presumably, the caricatures in the book are unusual instances of poor behavior, offered to suggest what must be avoided rather than to imply what is typical. However, one gets a distinct impression that these examples are disguised but not fanciful. The message comes through that how the Establishment behaves under provocation does matter, that behaving well need not be inconsistent with righteous motives, desirable outcomes, or respectable public image. Indeed, whenever society perceives that its arrangement is leading to the emergence of inappropriate elites, society promptly contemplates new arrangements. The subliminal message in this book is a very creditable one.

This reviewer recommends the book for wide circulation but does reserve a right to criticize a bit. To continue the analogy with writing a will, most of us see that our 40-page wills were largely produced by an automatic typewriter producing standard paragraphs; hospital staff bylaws will mostly be the same. This book would be a more important statement if it risked a set of proposed model bylaws that could be measured against those of the Joint Commission on the Accreditation of Hospitals, which are sneered at on page 89. Since there will be comparatively few decision branches that tailor standard boilerplate to the individual situation, it would have been helpful to have these points identified and discussed in detail.

Possibly Mr. Hershey regrets as much as this reviewer does that the hospital lawyer is not fully in a position to appreciate the major scientific and sociological forces that are causing novel dissension to arise. For example, the spreading migration of specialists to the suburbs and rural areas was bound to cause commotion in organizations that were stabilized by different anticipations. The malpractice liability muddle has undermined confidence in the judicial system at the same time that it has coerced more involvement with it. The 1965 Social Security Administration Amendments have created an unwelcome allegiance of hospital trustees to the regulations of the Department of Health and Human Services, thereby creating the true legal basis for what now masquerades as antitrust theory, consumer protection, and fair trade. If the courts carry this public utility idea much further, there will be no need for medical staff bylaws at all because we shall have open staffing. At least, the logic would be that if you can't exclude non-physicians from a hospital medical staff, it is hard to see how you could justify excluding any physician.

George RossFisher,MD


Cardiothoracic Surgery

A Practice of Cardiothoracic Surgery, by M.P. Holden, 432 pp, with illus,$49.50, Littleton, Mass, John Wright-PSG, 1962.

Any writing about this evolving field rapidly becomes a compromise with impossibilities. No one agrees, for example, on when to operate for aortic regurgitation. The author quotes Lord Brock, saying that most of our answers about when to operate are still too empiric. Nevertheless, in giving some provisional replies, this book represents one surgeon's assimilation of disparate opinion, how he thinks, and how he acts in detail.

Senior readers may disagree about initial conservative treatment of postinfarction ventricular septal defects or grafting only the anterior descending branch for left main coronary disease. (MOst US surgeons graft the circumflex also.) . The author underestimates some mortality, eg. 2% for mitral valve replacement. Similarly, few believe that 95% of patients who have undergone coronary bypass will stay symptom-free.

Despite his enthusiasm, Holden's invigorating style and English perspective offer a worthwhile reading experience. After learning that transthoracic reoperations are now being performed to cure myasthenia that was unsuccessfully first treated by cervical thymectomy or that the author's waiting list for coronary bypass surgery is now 18 months long, the reader emerges wiser and more thankful to be part of the American healthcare system. The chapters on the esophageal disease will also sharpen our perceptions.

By writing a condensed book rather than a vast, encyclopedic tome, the author has wisely chosen between "the alternatives of Plinius: either of writing what deserves to be written or of writing what deserves to be read".

Alan T. Marty, MD

Evansville, Ind

Neurology, Psychiatry

Psychiatric Aspects of Neurologic Disease, vol.2, edited by D. Frank Benson and Dietrich Blumer (Seminars in Psychiatry, Milton Greenblatt, ed), 325 pp. with ilus, $24.50. New York, Grune & Stratton Inc., 1982

Volume 1 of this series appeared in 1975; volume 2 has been written by 13 authors, all of whom are different from those who wrote for volume 1, with the exception of the editors. The epilepsies, the dementias, and certain movement disorders are topics discussed in both volumes.

A survey of the contents will indicate the range of coverage of the borderland between neurology and psychiatry, for which the term neurobehavioral is suggested. Richard L. Strub opens with a review of the acute confusional state, a behavioral response to widespread disruption of cerebral metabolism to literally thousands of agents or metabolic imbalances.

In a chapter by the editors on the psychiatric manifestations of epilepsy, the behavioral change during the prodromal state, during the fetus, postictally and intellectually (epileptic psychoses), is described, as well as the psychological response to the seizure disorder itself. Michael R. Trimble, writing on the interictal psychosis of epilepsy, considers among other things the relationship between psychosis, epilepsy, and dopamine, which may increase the seizure threshold but provoke or exacerbate psychosis.

A chapter by Kenneth C. Rickler is concerned with episodic dyscontrol, states of explosive behavior of wide-ranging etiology. The nature of this complex condition invokes the ancient controversy as to whether innate or acquired factors are responsible. Psychotherapy plus medical therapy has been more helpful than either alone.

The midsection of the volume (four chapters, one each by Cummings, Benson, Cutting, and Wells) addressed the diagnosis and treatment of a variety of dementias. A chapter by Blumer considers the problem of chronic pain based on the analysis by George Engel of more than two decades ago. Blumer describes the variant of the depressive disease that is represented by the pain-prone disorder and notes the high incidence of shortened rapid eye movement latency in sleep and of nonsuppression in the dexamethasone suppression test. At the time of writing, these were considered to be biologic markers of depressive disease.

The topic of tardive dyskinesia is authoritatively reviewed by Christopher G. Goetz and Harold L. Klawans. Michael P. Alexander reviews thoroughly the common problem of traumatic brain injury. A study of amnesia as a clinical approach to understanding memory is the work of the editors, Benson and Blumer.

Michael R. Trimble and Igor Grant discuss the psychiatric aspects of multiple sclerosis and conclude that there is no evidence of a predisposing personality.

The volume closes with David B. Rosenfield's consideration of stuttering, which like all the other chapters, is interesting and informative.

This excellent volume makes for fascinating reading about a burgeoning field, transcending the classical discipline of neurology and psychiatry. There is no limit to need for scientific material oriented toward understanding these and other borderland problems. One can think of additional topics for succeeding volumes, for example, the sleep disorders, including narcolepsy, cataplexy and sleep paralysis, and those depressive disorders that are tending toward the neurological side, if indeed sides are to be drawn.

What of causal implications, which, if approached in this volume, are done so diffidently? Do or do not the emotions have access generally to neural structures, and may they be acting over time, encouraging a spectrum of neurobehavior from tranquility to abject disequilibrium, depending on their nature, in a process perhaps skin to kindling? Parenthetically, kindling as currently understood is discussed in this volume by Trimble (pp 85 and 86) under the heading of the interictal psychoses of epilepsy.

It has been argued by Ashley Montagu that experience organizes neural systems in a fashion that permits expression of aggressive behavior. If this is so, may "evasive action" taken in formative years become an aspect of prevention?

The chapters are pleasingly coordinated from one to the next by concise and graceful interspersed commentary. An index of 11 pages appears adequate. Checking in our medical library reveals that volume 1 has been under consistent demand since 1975; I would expect volume 2 to fare likewise. It is a well-planned and thoughtful clinical treatise, which those concerned with neurobehavior would do well to have accessible.

Charles D. Aring, MD

University of Cincinnati

College of Medicine


Parenterals an Enteral Nutrition for the Hospitalized Patient, by Howard Silberman and Daniel Eisenberg, 306 pp, with illus, @27.50, Norwalk, Conn, Appleton-Century Crofts, 1982.

Therapeutic nutrition is barely in its second decade as an established medical discipline. Its intricate methodology, based on complex biochemical and physiological phenomena, makes it abstruse and somewhat unappreciated by the practitioner at large. Books on the subject are either encyclopedic in scope, aimed at the specialist or too superficial to be of any value as a reference for the clinician. The authors of this work have succeeded where many others have failed. They have written a concise yet comprehensive text on the definitive current information on therapeutic nutrition, backed by extensive and recent references.

The text is divided into ten chapters. Each is organized into subsections and has a summary and bibliography at its end. The first chapter details the consequences of malnutrition on the body as a whole and on the different organ systems. The next chapter deals with the evaluation of nutritional status, with emphasis on the practical, clinical, and laboratory methods. The following chapter describes the nutritional requirements of the patient and the different routes of nutrients administration. The fourth chapter details enteral nutrition, including indications, nutrient formulation, techniques of feeding, patient monitoring, and complications. The fifth through the eighth chapters cover the general principles of parenteral nutrition as well as historical background , formulation, composition and preparation of nutrient as well as historical background, formulation, composition and preparation of nutrient solutions, vascular access, administration monitoring, dosage, metabolic effects, adverse reactions, and complications both in general and on individual systems and body organs. The ninth chapter compares the efficacy and effectiveness of the different methods of nutritional support. The last chapter is dedicated to the clinical application of therapeutic nutrition for the condition such as gastrointestinal fistulas, burns, and liver disease.

The book has accomplished its goal of being concise and practical. Controversial opinions are objectively presented without bias. The precise, crisp text, supplemented by comprehensive tables and good, realistic photographs, makes it a reference as well as a handy how-to book. This is enhanced by its manageable size and attractive format.

The book should be a welcome addition to the library of medical students, residents, and practitioners and will surely become a classic.

Alexander E. Medme, MD

Hurley Medical Center

Michigan State University


The Human Body

The Human Body, by the editors of US News Books, Blood: The River of Life, by Jake Page: The Eye Window to the World , by Last Wertenbaker; The Heart: The Living Pump, by Goods P. Davis, Jr. and Edwards Park; Reproduction: The Cycle of Life, by Karen Jensen; The Skeleton: Fantastic Framework, by Kathy E. Goldberg, 163, 159,165,and 165,pp, with illus, $15.95 each, Washington, DC. US News Books, 1961 and 1962.

US News Books is providing an excellent science resource library for the general reading public (including persons trained in the medical arts and teachers and students of the psychological and biological sciences) through the publication of its series The Human Body. This service has already been acknowledging by the American Heart Association, which only recently awarded its Blakeslee Prize for "outstanding achievement in the area of educating the public on the heart, its functions and dysfunctions," to the publisher for its book The Heart.

Other volumes currently available are The Skeleton, Blood, Reproduction, The Eye, The Brain, Muscles, and Skin,. The books are published approximately every three to four months. Some 20 are anticipated in the complete set, and future titles will include The Cell, Digestive System, Genetic and Heredity, and Wonders of the Ear.

A historical survey, coverage the particular subject at hand, begins each approximately 165-page text. This is followed by a cultural resume as background for current medical knowledge and practice. Ensuing chapters provide a physiological and electrochemical tour of the organ system and how it functions. Studies unique to the particular topic are reviewed (eg, creativity and sleep in The Brain, color in The Eye, and paleontology in The Skeleton). Finally, each book closes with a chapter on current research and investigations of future interest. All this, however, is a basic format. The uniqueness of the books lies in their extensive use of colorful photo essays and other visuals, which complement an easy-to-read text, as well as the employment of an impressive cadre of experts, including such notables as Lewis Thomas from Sloan-Kettering Institute, Rye, NY, Eugene Braunwald from Harvard, Cambridge, Mass, and Solomon Snyder from Johns Hopkins, Baltimore, in addition to specialist consultants for individual subjects, to assure authoritative current material.

The Human Body will, no doubt, be compared with the well-known Library of Health,published by Time life. It needn't be. The Time Life books are "designed to familiarize readers with the latest advances in medical science as a guide in maintaining their own health and fitness" .and are concerned with the discussion of specific health problems, such as Coping with the Common Cold, Dealing With Headaches, Exercising for Fitness, and The Prudent Use of Medicines.

Anatole France once said that "the whole art of teaching is only the art of awakening the natural curiosity of the mind for the purpose of satisfying it afterward." I can recommend US News Books series The Human Body as an aid such discovery in presenting a multi-level learning experience that is both inviting and effective.

Irwin M. Segel, MD

Plush-Prebytarin- St. Luke's

Medical Center


Stoke Rehabilitation

Mossman's Problem-Oriented Approach to Stroke Rehabilitation, by John W. Sharpless, ed 2; 491 pp, with illus, $39.75 paper $32.50, Springfield III, Charles C. Thomas Publisher,1982.

This textbook has a unique quality in that it is suitable for all the allied health professionals as well as the physicians who make up a rehabilitation team. In other words, this is a good basic text for any stroke rehabilitation program, describing the various problems stroke patients have, by what means these problems are solved, and which allied health professional provides the solutions. Each one of the 25 chapters deals with a particular problem in detail, giving the methodology to relieve the problem not only with a concise and accurate text but also with man excellent illustrations.

There is nothing controversial in the book. It should be acceptable to any program that is interested in the rehabilitation of stroke. The book, therefore, is eminently suitable for physicians and residents who are interested in improving their expertise in stroke rehabilitation generally and knowing what can be done by the various allied health professionals.

However, there is only one major criticism I have with the book in this regard. It lacks a chapter on team management. Although it deals with the problems by describing the use of a team of allied health professionals, there is never a mention of how these professionals coordinate their services, how they interact, and how the term problems themselves are treated. Perhaps this could be added in a third edition. This does not detract from the value of the book, and I recommend it wholeheartedly as the main reference for any stroke program.

Henry H. Stomming,MD

Department of Physical Medicine and Rehabilitation

Mayo Clinic

Rochester, MInn


Medical Complications During Pregnancy by Gerard N. Burrow and Thomas F. Ferris, ed 2: 583 pp, with illus, $49, Philadelphia, WB Saunders Co, 1982.

It is well known that every system in the body is affected by pregnancy to a greater or lesser extent. What is less well known is the manner in which the normal changes of pregnancy modify the course of almost every disease. Also, the drugs commonly used to treat such disease may or may or may not be suitable for use in pregnancy. Unfortunately, most textbooks of medicine give little or no consideration to pregnancy, contenting themselves with the observation that the effects of this or this or that drug in pregnancy are either harmful or unknown or that the risks must be weighed against the benefits.

This book is not designed as a complete text of general medicine, but it is an admirable and comprehensive survey of the manifestations of medical illnesses in pregnancy and the manner in which they should be dealt with. Virtually all system are considered. Each section is opened by a review of normal physiological changes of pregnancy and, for the specific disease itself and discussion of the manner in which the disease is modified by pregnancy. In each case, the diagnostic and therapeutic measures that are appropriate in pregnancy are discussed, and pointed reference is made to the measures ordinarily used that are to be avoided in pregnancy. Due attention is given to the effects of the disease on the fetus, the possible teratogenic effects of the drugs used to treat it, and in many cases, the preventive measures that may be taken to avoid the disease in the first place.

The text is written in uniformly crisp, strong prose by a group of authors who are actively engaged in teaching and are well known in the fields about which they write. The tabular and graphic materials are well selected and informative, as are the illustrations. The reference lists are appropriately categorized and extensive. Like virtually all books, the references lag behind by a year or two, but this does not detract from their value to the student who wishes to pursue a subject in greater depth.

This book makes for pleasant and highly instructive casual reading or study, but it should also be immediately available for reference by residents in training obstetricians, and medical specialists who have occasion to treat pregnant patients.

David M. Danforth, PhD, MD

Northwestern University Medical School



The American Blood Supply, by Alvin W. Drake, Stann. Finklestein, and Harvey M. Sapolsky(MIT Press Series in Health and Public Policy, vol. 5, Jefferey E. Harris, ed). 161 pp. $20, Cambridge Mass, MIT Press 1982.

This small volume, part of a series being produced by the MIT Press, is an original and scholarly monograph authored by a group of individuals with diverse backgrounds. The text, directed toward those who have technical and administrative involvement with blood procurement and utilization in this country cover geostrophic that extend from the origination of the blood supply and blood procurement from the donor to a discussion o the organizations involved in that procurement.

It is apparent from the frank and factual discussion of the logistics and politics of blood providers that the authors are well acquainted with the diverse philosophies in practice in the United States. Supportive statements are made in regard to the American blood system hat it is envisioned to be better than it is occasionally described and that the quality of blood supply is high and carefully monitored. The nonprofit organization involved in blood collection are described as performing their duties of a collection with a great deal of efficacy and dedication. The authors point out with some concerns that the public is misinformed about the blood system and is likewise misinformed about blood policies. As blood banking in the United States becomes "cartelized," the authors encourage the public to create oversight mechanisms that are similar to those used in every other private monopoly presently serving the public

The text is adequately supported b\y clearly readable tables and is carefully divided by small headings in each chapter that guide the reader carefully through the authors' blunt but realistic group of topics, which bring clarity to the forefront some of the political problems that have inhibited redevelopment . of a national blood policy. In short, although not material of interest to a wide audience, this monograph deliberately and honestly discusses the problems of "The American Blood Supply."

Edgar H. Pierce Jr. MD

Nashville, Tenn


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