VOL. LIX • NO. 11/12 • 2018

VOLUME LIX • NO. 11/12 • 2018

MISSISSIPPI’S FIRST BOARD OF HEALTH 1877

DR. WIRT JOHNSTON

DR. J. M.TAYLOR

DR. F. W. DANCY

PRESIDENT

SECRETARY

CORINTH

HOLLY SPRINGS

JACKSON

JACKSON

DR. A. H. CAGE

DR.T D. ISOM

DR. W. M. COMPTON

DR. P. F. WHITEHEAD

CANTON

OXFORD

JACKSON

VICKSBURG

DR. C. A. RICE

DR. P. J. McCORMICK

DR. JOHN WRIGHT

DR. R. G. WHARTON

BRANDON

YAZOO CITY

SARDIS

PORT GIBSON

DR. D. L. PHARES

DR. E. W. HUGHES

DR. S.V. D. HILL

DR. A. G. SMYTHE

WOODVILLE

GRENADA

MACON

BALDWYN

DR. ROBERT KELLS

C O M M E M O R A T I V E

E D I T I O N

Regularly priced at $80, the book is on sale now!

Pickup in Ridgeland for $49.95 or $57.95 includes shipping.

Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs.

The volume is a piece of our history that every Mississippian can appreciate.”

– Curtis Wilkie, journalist, author, and professor at Ole Miss

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018. $80.00

VOL. LIX • NO. 11/12 • NOVEMBER/DECEMBER 2018

SPECIAL ARTICLES

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President Michael Mansour, MD

ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

President-Elect J. Clay Hays, Jr., MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Richard D. deShazo, MD Sheila Bouldin, MD Wesley Youngblood, M3 and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Acting Executive Director Scott Hambleton, MD

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Jill Gordon, MSMA Director of Marketing. Ph. 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

Copyright © 2018 Mississippi State Medical Association.

The Healers – A History of Medicine in Mississippi Lucius “Luke” Lampton, MD

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Civil War Medicine in Mississippi – An Overview: Some Myths, Some Realities Sidney W. Bondurant, MD

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Mississippi, MASH, and Arterial Repair – The Intersection of Surgical History and Pop Culture Michael C. Trotter, MD

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Remembering Arthur C. Guyton, MD John E. Hall, PhD

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First Heart and Lung Transplants – James D. Hardy, MD Marc Mitchell, MD

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1878 Epidemic – Yellow Fever in Mississippi Deanne L. Stephens, PhD

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Mississippi Medicine and the Civil Rights Struggle – Reflections from a Black Mississippian, Physician, and Educator Loretta Jackson-Williams, MD, PhD

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DEPARTMENTS From the Editor – Celebrating Medical Heroes and History Lucius M. Lampton, MD

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Commentary – Medical Student of the Day Complements the MSMA Doctor of the Day Program Joseph Maxwell, M4

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Commentary – The American College of Emergency Physicians, San Diego, October 2018 Philip Levin, MD

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President’s Page – Professionalism and Population Health Management Michael Mansour, MD

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Editorial – Benefits vs Risks D. Stanley Hartness, MD

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Images in Medicine: Leonard Wright Sanatorium Lucius M. Lampton, MD

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Poetry and Medicine: To a Young Physician John Greenleaf Whittier (1807-1892)

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Una Voce – Why I Still Believe in Christmas Cards Dwalia S. South, MD

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RELATED ORGANIZATIONS MDAH – Guyton, Hardy Portraits Unveiled at Hall of Fame Dedication

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MSDH – Mississippi Provisional Reportable Disease Statistics

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INDEX

Official Publication

MSMA • Since 1959

Subject

571

Author

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INFORMATION FOR AUTHORS

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ABOUT THE COVER

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F R O M

T H E

E D I T O R

Celebrating Medical Heroes and History T

his special double issue of your Journal celebrates the 150th meeting of the Mississippi State Medical Association’s House of Delegates.

This year’s annual session, held August 16-18, 2018 at the Westin Hotel in Jackson, featured an impressive historical program as part of the 150th Commemorative Celebration.

The speakers and their presentations were selected by MSMA’s 150th Lucius M. Lampton, MD Commemorative Committee, which Editor met for more than two years preparing for the event. Chaired by the brilliant medical historian Dr. Michael C. Trotter, the committee included the following members: Drs. Ralph Didlake, Randy Easterling, Hugh Gamble, Dwalia South, Marty Tucker, Helen Turner, and me.

The special CME program that Saturday was emceed by Dr. J. Edward Hill and focused on defining events and individuals in the history of Mississippi medicine: yellow fever, Civil War medicine, medicine and the civil rights struggle, Mississippi and M.A.S.H., William Faulkner’s battle with alcohol addiction, Arthur Guyton, James D. Hardy, and a survey of the state’s medical history via photographic images.

The much-anticipated keynote address was given by two-term Governor Haley Barbour who reflected on the role that the medical community played in accomplishing comprehensive tort reform during his administration as well as the state’s response to Hurricane Katrina in 2005. Many in attendance reflected in glowing terms about that extraordinary day!

The state’s medical history is largely a forgotten drama peppered with forgotten heroes. Despite its “forgotten” status, the state’s medical history shaped the larger history of Mississippi in both social and political terms. The Commemorative Committee asked the Journal to publish this special issue containing many of that day’s significant presentations to preserve them for posterity. Your JMSMA thanks the gracious contributors for preparing their talks for publication: Sidney Bondurant, MD; Michael Trotter, MD; Marc Mitchell, MD; John Hall, PhD; and Deanne Stephens, PhD. So, enjoy this wonderful issue.

In addition to our usual departments and columns, these history articles will give you the robust flavor of our 150th Commemorative Celebration. The work of the Committee was dedicated in honor and memory of all Mississippi physicians, without whom this Journal and the articles in it would not have been possible. Q Contact me at LukeLampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo, M3

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

EPIDEMIOLOGY/PUBLIC HEALTH Mary Margaret Currier, MD, MPH Thomas E. Dobbs, MD, MPH

NEPHROLOGY H. Allen Gersh, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD James J. Withers, MD

CARDIOVASCULAR DISEASE Cameron Guild, MD Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Vincent E Herrin, MD INTERNAL MEDICINE Daniel P. Edney, MD W. Mark Horne, MD Daniel W. Jones, MD Brett C. Lampton, MD Jimmy Lee Stewart, Jr., MD

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OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Darden H. North, MD ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RHEUMATOLOGY C. Ann Myers, MD UROLOGY W. Lamar Weems, MD

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The Healers

A History of Medicine in Mississippi LUCIUS "LUKE" LAMPTON, MD, JMSMA EDITOR

T

he great Greek physician Hippocrates in ancient times described the importance of place (climate, water supply, and environment) in medicine. The earliest records of the area known as Mississippi indicate that the region possessed a distinctive medical sense of place, with the state’s own sultry “clime” and native diseases long influencing this area’s history. Before the arrival of European explorers and settlers, Mississippi’s Native Americans confronted disease and illness through healers, conjurers, or shamans.

These medical men or jugglers held prominent positions in early Native American culture, often in the priestly class, and utilized medicine made from native herbs and roots, as well as religious ceremony and ritual, to treat sickness. Their skill as herbalists and the success of their treatments, such as scarification and sucking, impressed some of the early Europeans in the eighteenth century. Le Page Du Pratz praised the cures of the Natchez “surgeons” as superior to those of the French physicians. Although they called the Choctaw and Yazoo medicine men “charlatans,” both Jean-Bernard Bossu and Dumont de Montigny acknowledged their talents for cures using botanical and nonbotanical medicines in the treatment of wounds, snakebites, and other ailments.

There is archeological evidence of an extraordinary decline in Indian populations after the earliest arrival of European immigrants.

Many historians speculate that pandemic diseases erupted in the sixteenth century, with European diseases such as measles, smallpox, typhoid, scarlet fever, mumps, rubella, malaria, pertussis, and influenza ravaging the native populations, which had little immunity to them.

These epidemics decimated entire nations and cultures, reshaping which Indian groups dominated the Mississippi landscape. These massive changes in population size and distribution in the Southeast emerge in the aftermath of Hernando de Soto’s expedition. However, that expedition was not the only or even primary source of disease spread.

Later interaction with Europeans via trade and even the movements of the Native American slave trade proffer more likely mechanisms for the extension of these new infectious diseases. Clearly, the arrival of Europeans introduced novel diseases which precipitated over an extended period significant illnesses, mass mortality, and fundamental population change. There are Choctaw migration stories that suggest their migration to central Mississippi was made to find a land free of disease during a period of widespread death and sickness.

The European arrival not only brought viral and bacterial diseases but also parasitic diseases, bestowing what would become many of the endemic diseases of the area which did not exist in the area before their arrival.

The Europeans, too, were ravaged by illnesses and died with great frequency from the time of their first arrival in Mississippi. In June

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1542, the once-vigorous warrior Soto, then 42 years of age, died of a slow, wasting fever. The French would suffer similar afflictions in subsequent years. Writing in 1701 from Fort Maurepas, near Biloxi, Colonial French Governor Sauvolle commented to the Count de Pontchartrain (minister of the French colonies) that he had thirty sick men who could not “recover from a tertian fever that saps their strength.” Sauvolle would himself die at the Mississippi fort that same month, said to be the state’s first recorded death of yellow fever, a new viral disease introduced to the New World by Aedes aegypti-infested slave ships voyaging from West Africa.

The area’s first physicians and surgeons were French, trained in Europe, and they arrived with the earliest European settlements.

Biloxi and Natchez had numerous physicians and even hospitals in the French colonial period, largely due to the French military presence, which usually provided a surgeon with medical supplies. Spanish and English physicians were also present in the colonial period, during different times of dominion. The American period, which began in 1798, brought with it the dominance of English and American medical traditions, with Americans in the isolated Natchez District early realizing the dangers of disease and the importance of public health.

The first law focused on disease prevention was passed by the Legislative Assembly of the Mississippi Territory on March 18, 1799.

Entitled “A Law Concerning Aliens and Contagious Diseases,” the act was crafted to prevent the spread of epidemic disease, specifically the plague, yellow fever, and smallpox, and authorized the governor, with the advice of a physician, to take measures to prevent the spread of disease and to aid the sick. The first public health emergency of the American period was a smallpox epidemic which erupted in New Orleans in the spring of 1802. Territorial Governor William C. C. Claiborne utilized the earlier law and attempted to enforce both quarantine and vaccination to save the territory from a medical disaster.

He established a smallpox “hospital camp” in the spring of 1802 to separate those with the illness from the rest of the population. He also placed the respected Virginia-born physician brothers, William and David Lattimore, in charge of the camp, empowering them to lead a mass vaccination of more than two-thirds of the population of the Natchez District. Claiborne further persuaded the Territorial Legislature on May 13, 1802, to pass an act to prevent specifically the “importation and spread” of smallpox, with fines and imprisonment as punishment. His efforts proved successful in preventing a serious outbreak of the disease and were the most significant early uses of public health measures in Mississippi.

Natchez possessed a number of brilliant and energized physicianleaders who fostered impressive medical accomplishments for the territory and state, from the earliest public hospital to the first board of

THE OATH OF HIPPOCRATES – “I swear by Apollo the physician…” begins one of the most important professional statements in world history and one of the most universally known Greek medical texts: The Hippocratic Oath. In it, a new physician swears upon a number of healing Greek gods that he, as an artist, will uphold numerous standards of professional conduct. The oath also clearly designates the obligation of the student of medicine to his teacher and to other physicians, and those obligations resemble that of a family. One historian even noted that the Oath’s creation “may have marked the early stages of medical training to those outside the first families of Hippocratic medicine, the Asclepiads of Kos, by requiring strict loyalty.” Note that the Oath does not contain the phrase, “First, do no harm,” which is often attributed to it.

(There is Hippocratic writing similar to the phrase here and elsewhere!) This ancient broadside is taken from a copy of the 1964 “Clinic” annual of Jefferson Medical College of Philadelphia, Pennsylvania, one of the antebellum schools of choice for Mississippians.

health. Natchez Hospital, the state’s first charity hospital and one of the first in the United States, was incorporated in January 1805, dedicated to caring for the poor of the city as well as the indigent boatmen who became sick while in the city. Soon after statehood, in February 1818, an extensive public health act was enacted by the Legislature which created a board of health for Natchez. This was the first board of health established in the state, with five appointed commissioners, and the act also provided for a physician to serve as health officer. These commissioners of health and police managed the cleanliness and hygiene of the city, from its sewers to its burial ground, and also oversaw the protection of the city from communicable diseases.

The Lattimore brothers, who had arrived in Natchez in 1801 and advised Claiborne during the smallpox epidemic, became prominent medical and political leaders in Mississippi’s territorial and early statehood era. While both were major figures, it was William Lattimore (1774-1843) who contributed most significantly. William, who moved to Amite County, served as Mississippi’s first Territorial Congressman from 1803-1817. In that capacity, he selected the line of division of

the Mississippi Territory and led the admission of the territory into the Union as a state. He also was one of the three men who in 1822 selected the site for the state capital, which became Jackson. Lattimore also was one of the leading members of the state’s first constitutional convention. In 1823, he unsuccessfully ran for the governorship of the state, losing to Walter Leake.

While Lattimore’s political accomplishments are significant, his medical accomplishments, especially in advancing the state on the path of medical licensure, are also critical. He helped create and was appointed with his brother to serve on the state’s first board of medical licensure, the Board of Medical Censors. The General Assembly of the state of Mississippi passed on February 12, 1819, the state’s first law to regulate the admission of physicians and surgeons to practice in Mississippi. Governor David Holmes made the first appointments to the seven-member Board of Censors, who were “to license those who practice Physic and Surgery.” A second board of medical censors, the “Eastern Board of Medical Censors,” was created by the Legislature on February 10, 1821, to lessen the inconvenience of candidates in the

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eastern parts of the state in traveling to reach the place of examination (Natchez). A third board of censors was created 1827, and the license laws were further strengthened until 1836, when the state Supreme Court outlawed the boards due to the statute’s “tenure of office,” and demanded that the boards have limitations on tenure to be in compliance with the Mississippi Constitution of 1832. This decision was in the middle of the Jacksonian Era and resulted from the suit of a Wilkinson County man named Bryant who appealed his conviction of practicing medicine without a license to the Supreme Court. He not only won his case but invalidated on a technicality the entire physician licensure process in the state. The ruling effectively removed any state control over the practice of medicine for the next 46 years, although the well-organized physicians of Natchez did succeed in 1844 in reestablishing by state law a board of medical censors for Adams County.

There were many efforts to create a statewide organization of physicians. In January 1829, the legislature incorporated the “Medical Society of the State of Mississippi.” Little is known of this first society or how long it survived. A decade later, Jackson physicians led an effort to organize the “Grand K.A. Society of Hippocrates of the State of Mississippi.” That organization was created on March 15, 1839, in Jackson. An attempt to organize the various local medical societies into a state-wide organization resulted in the creation of the “Mississippi State Medical Society,” in Jackson on January 14, 1846, with the famous antebellum physician, Dr. Samuel A. Cartwright of Natchez, elected as its first president. This group was officially recognized by the American Medical Association and sent delegates to the 1846 formation meeting, but it too stumbled into dissolution several years later, after its godfather Cartwright removed to New Orleans. In December 1856, the Mississippi State Medical Association was established in Jackson, after a convention of the state’s physicians met in Jackson. William Young Gadberry of Benton was the leader of the effort and was named the association’s first president, with M.S. Craft as Secretary. The association adjourned to meet in November 1857, but no other meeting was held until April 20th 1869, when many of these same physicians gathered in Vicksburg to reestablish this state association, which became a potent force in medicine and politics in the state. Other health professionals established state associations. State pharmacists, led by Matthew F. Ash, John F. Buck, and William P. Creecy, established the Mississippi State Pharmaceutical Association in 1871. In April 1875 at Vicksburg, state dentists established the Mississippi Dental Association, with Dr. J. D. Miles serving as first president. The Mississippi Nurses Association was founded in 1911 by a small group of nurses at the Natchez Hospital in Natchez, with Ms. Jennie Quinn serving as its first president.

Medical professionals in the nineteenth century were among Mississippi’s most literate and educated. Many of the state’s earliest and most talented writers and scholars were physicians, including George Elliott Pendergrast, George Pfeiffer, Henry Tooley, C. H. Stone, John Wesley Monette, Samuel A. Cartwright, William H. Holcombe, and Henry Clay Lewis of Yazoo County. Holcombe was a national leader in the homeopathic medical movement and wrote prolifically in areas of medicine and poetry. Lewis wrote frontier humor under the pseudonym of the Louisiana “Swamp Doctor” Madison Tensas,

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EARLY STATE LAW – Among the first laws in the state regarding physicians was this 1824 act.

MD, achieving national fame and influencing American literature.

Many other Mississippi physicians published extensively in the nation’s antebellum medical journals, and after the Civil War, the reestablished state medical association began publishing annual “Transactions of the Mississippi State Medical Association,” which continued into the 1920s. The brilliant John Monette published an extensive treatise on yellow fever in the Washington Lyceum’s South-Western Journal in 1837/8, but no medical journal would be published in the state until September 1891 when The Mississippi Medical Monthly, edited by Drs. N. L. Clarke and Hugh H. Haralson of Meridian, appeared. After a spirited few years, this pioneer publication ceased printing, later to emerge in 1897 as the Medical Record of Mississippi, printed in Biloxi by Haralson alone. It would soon be renamed the Journal of the Mississippi State Medical Association after the Mississippi State Medical Association assumed its management and moved it to Vicksburg. In 1906, its name was changed back to the Mississippi Medical Monthly. This monthly journal would cease publication, and by 1929, The Mississippi Doctor, published by W. H. Anderson, MD, in Booneville, became the official organ of the MSMA. In January 1960, the first issue of the Journal of the

MISSISSIPPI’S FIRST MEDICAL JOURNAL – The Mississippi Medical Monthly, edited by Drs. N. L. Clarke and Hugh H. Haralson of Meridian, first printed in September 1891. This cover is from 1893.

Mississippi State Medical Association was published by the MSMA, and this journal remains an influential scientific publication and one of the last remaining monthly medical journals in the South.

The first physicians in Mississippi often did not attend medical school but rather apprenticed under physicians who trained them. By the early 1800s, most Mississippi physicians received their training from medical schools in such cities as New York, Philadelphia, New Orleans, Augusta (Georgia), Louisville (Kentucky), and Lexington (Kentucky). The first formal medical training in the state was created at Centenary College in Brandon Springs, Mississippi, in 1843.

Centenary, an ambitious Methodist school, existed only four years at its Mississippi location before moving its campus to Jackson, Louisiana, and later Shreveport. During its four-year existence in Mississippi, the institution offered a bachelor of medicine degree (BS in Medicine) which was the state’s first formal medical curriculum. Several of the graduates practiced medicine, and this appears to be the first formal physician education program in the state, which was consistent with mid-nineteenth century standards. The second medical school established in the state was the short-lived Kirk’s Clinical Institute

of Medicine and Surgery, chartered in 1882 in Meridian. A medical school had been formulated for the University of Mississippi as early as 1870, but due to poor resources, that two-year medical school, absent clinical training, did not open at Oxford until June 1903. An attempt to extend Oxford’s medical course occurred in 1908-10 at Vicksburg.

This four-year course lasted but a year, as the University board chose to discontinue it and return to the two-year curriculum. Mississippi’s first offering of the MD degree occurred at Mississippi Medical College, which was chartered in 1906 at Meridian. This ambitious four-year institution, which admitted two women in its first class, graduated hundreds of physicians, with its clinical training performed at the Matty Hersee Hospital. Sadly, it fell victim to severe criticism in the 1910 Flexner report, which resulted in its closure by 1913. This left Mississippi with no four-year school of medicine for almost a half century.

The diseases in the state in the nineteenth century were plentiful and malignant. Wrote one Mississippi physician of the native diseases: “The ailments that afflict us to a greater or less extent embrace very nearly the entire nomenclature of disease. I have seen almost every form of sickness in the state…Malarial fever is the permanent and universally diffused endemic of the state; we have it in its mildest and most malignant form; every shade and grade, simple and complicated.”

Dr. J. P. Moore of Yazoo City reviewed the native health of the state in 1871, making a list of the diseases which embraced the “great aggregate of the death-rate of the state, the most fatal in the order as mentioned.”

These included pneumonia, malarial fever, inflammation of the brain and membranes, mostly affecting children, typhoid fever, dysentery, diarrhea, consumption, cholera infantum, influenza, scarlet fever, diphtheria, and irritative fever. Mortality schedules recorded for the state from 1850-1880 substantiate Moore’s assertions, with a wide range of diseases noted as causes of death, including childbirth, hives, suicide, and teething. Great strides would soon progress medical practitioners beyond the long-established therapeutics of blood-letting, purgatives, mercury, digitalis, opiates, and “counter-irritation.” The most dreaded of all diseases in the state in the nineteenth century was yellow fever. Epidemics occurred almost annually from the 1820s to 1905.

The Union blockade of Southern ports during the American Civil War significantly restricted the Caribbean shipping trade, instituting an unintentional yellow fever quarantine which freed Mississippi of yellow fever for the war’s duration. After trade was reestablished, yellow fever returned to the state in its malignant form in 1867 and became the primary public health threat for Mississippians until eradication measures were discovered for its vector (A. aegypti mosquito), thus eliminating state epidemics by 1905.

Race and poverty have played roles in both the complexity of illness and the delivery of health care in the state. In the antebellum period, Mississippi physicians early recognized the distinctiveness of genetics in illness, such as improved yellow fever and hookworm

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resistance in those of West African descent. Drs. Luke Pryor Blackburn and A.H. Brenham opened in Natchez in 1854 an “Infirmary for the Cure of All Diseases of Colored Persons,” a for-profit hospital to care for slaves and Natchez’s large population of free persons of color. Dr. Samuel Cartwright of Natchez became the state’s most prominent antebellum specialist on slave physiology and health, although his research and writings were poisoned by his political and racial views.

The first black physician appeared in Vicksburg in 1865, although entry into the profession was slow for blacks, and by 1890, only 34 black physicians and surgeons practiced in the state. However, by 1901, fifteen of the state’s black physicians, who were not allowed in the then-segregated MSMA, formed the Medico-Chirurgical Association of Mississippi (now the Mississippi Medical and Surgical Association), which remains a vital professional association focused on the needs of the black physician. By 1955, black physicians did achieve a “scientific designation” which allowed their participation at MSMA scientific and society meetings, and by 1966, the first black was granted full member status. Early hospitals operated by black physicians included: Alcorn A and M College Hospital (Lorman), Afro-Americans Sons and Daughters Hospital (Yazoo City), and the Taborian Hospital (Mound Bayou). Prior to the ending of racial segregation at the University of Mississippi School of Medicine in 1964, most black physicians were trained outside of Mississippi, usually at Meharry Medical College or Howard University Medical School, often assisted by the Mississippi Medical Education Program, which was created 1946 and provided scholarships to any out-of-state accredited medical school in the United States. From 1947 to 1974, Meharry Medical College established one of the earliest rural training programs in the United States, sending residents and interns to the Taborian Hospital in Mound Bayou.

The Tufts-Delta Health Center, located in Mound Bayou, opened its doors in November 1967 as one of the nation’s first comprehensive community health centers.

Although the American Civil War advanced the surgical skills of the average Mississippi physician, the conflict retarded most public health and organized medicine initiatives in the state. The return of yellow fever in the post war period resulted in the creation of county boards of health in coastal counties by 1876 to quarantine ports to prevent the spread of disease. By 1877, a multi-year effort of the revived Mississippi State Medical Association produced legislation to create the Mississippi State Board of Health. Originally unfunded and granted few powers, the Board’s creation was the most important medical event in Mississippi’s history. Over the next decade, physicians further refined its purpose and activities, including the registration of vital statistics, such as marriages, births, and deaths; sanitary regulations; quarantine powers; county health officer nominations; physician licensure; and legislative funding. The board played a major role in Mississippi’s three epidemic outbreaks: Yellow Fever in 1878, smallpox in 1900-1, and influenza in 1918-19. Smaller epidemics included smallpox in 1878 and yellow fever in 1897, 1898, and 1905. Board of examiners were also legislated for dentists (1892), pharmacists (1906), and nurses (1914).

The major physicians of the latter nineteenth century were: Robert Kells of Jackson, Thomas J. Mitchell of Jackson, William Compton of Holly Springs, J. M. Taylor of Corinth, P .F. Whitehead

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of Vicksburg, T. D. Isom of Oxford, Wirt Johnston of Jackson, D. L. Phares of Starkville, and John Y. Murry of Ripley. The major physicians of the early twentieth century were Waller Smith Leathers of Oxford, Peter Rowland of Oxford, Walter W. Crawford of Hattiesburg, T. M. Dye of Clarksdale, Sidney D. Redmond of Jackson, Augustus Street of Vicksburg, B. S. Guyton of Oxford, E. F. Howard of Vicksburg, J. C. Culley of Oxford, Hugh A. and Paul G. Gamble of Greenville, Henry Boswell of Magee, Lloyd T. Miller of Yazoo City, and Felix J. Underwood of Nettleton.

Waller Leathers, a Virgina-born Johns Hopkins and Harvard educated academic physician, organized the Ole Miss medical school in 1903 and served as its Dean until 1924. In addition, Leathers served as the executive director of the State Board of Health from 1910 to 1924. His leadership created a “full-time” Department of Health, and he was a nationally recognized authority on public health and medical education. Leathers embraced research and encouraged aggressive attacks on hookworm infestation, influenza, pellagra, and malaria, working closely with Dr. Joseph Goldberger and the Rockefeller Foundation. His successor as State Health Officer, Felix Underwood, served until 1958 and created a nationally respected health agency which improved the health of Mississippians. Assisting Underwood was Mary D. Osborne, RN, who served as the Department’s Supervisor of Public Health Nursing from 1922-1946. Also prominent during this period was Dr. Henry Boswell, called Mississippi’s “Conqueror of the White Death,” who served for decades as superintendent of the Mississippi State Tuberculosis Sanatorium at Magee. Along with Underwood and Dr. D. V. Galloway, Boswell played a vital role on the Commission on Hospital Care which was set up in 1946 to administer the Hill-Burton program in fostering hospital development.

In the early 1940s, State Health Officer Underwood with other physician-leaders began the drive for a four-year school of medicine in the state, promoting it to address state physician shortages. The legislative champion was Hinds County Senator Hayden Campbell, who authored the legislation passed in 1950 to establish and construct a four-year school and teaching hospital in Jackson on the site of Mississippi’s first insane asylum on North State Street. The institution was dedicated on October 24, 1955, and awarded its first MD degrees in 1957. Among its most prominent physician-professors were David Pankratz; Robert Q. Marston; J. Robert Snavely; James D. Hardy; Herbert Langford; Thomas Brooks; Blair Batson; and Arthur C. Guyton. By the mid-1970s, a School of Dentistry, a School of Nursing, and a School of Health-Related Professions joined the School of Medicine and University Hospital to create an extraordinary health center, known as the University of Mississippi Medical Center.

The Mississippi Regional Medical Program, created in 1965 and led by Drs. Guy Campbell and Theodore D. “Bob” Lampton, made a monumental impact on the health delivery system of Mississippi.

Some of the program’s major accomplishments included the first stroke intensive care unit, the state’s blood bank system, a state-wide cardiopulmonary resuscitation program, the first renal transplant program, the first regional newborn care system, the first regional renal program, the first radiation therapy program, the first coronary care units, and the first ongoing effort to provide continuing health

education for all types of health care providers. The visionary program phased out in 1977, and due to the political ineptitude of the Cliff Finch administration, the state bungled transitioning MRMP into a functional health planning agency, leaving a legacy of poor health planning in Mississippi for decades.

The State Department of Health, under the leadership of Alton Cobb, MD, MPH, reasserted itself as a national leader in public health from 1973 to 1993. Cobb had earlier distinguished himself as the first director of the Medicaid program in Mississippi. As Mississippi’s State Health Officer, Cobb introduced the district system at the department as opposed to the county system. He also introduced and led the state’s Certificate of Need program. Infant mortality went progressively down during his two decades of service. He created or developed programs in the state like home health and WIC. He led the separation of the Board of Medical Licensure from the Board of Health in 1982 and initiated lay membership on the Board of Health.

Following Cobb was longtime state epidemiologist Ed Thompson, MD, MPH, who served as State Health Officer from 1993-2002.

During this period, the department achieved the highest immunization rates in the country, lowered TB case rates below the national average for the first time in 30 years, and pushed the state’s syphilis rate below the national average for the first time since the CDC began keeping records. Thompson returned as State Health Officer in 2007 after a crisis in leadership at the State Department of Health, which also resulted in the reconstitution of the Board of Health with a higher percentage of physician members and the requirement that the board chair be a physician. Thompson and the new Board restored order at the department and led its return as a respected state agency. In December 2009, Thompson died, and Mary Currier, MD, MPH, who had long served as state epidemiologist, was appointed his successor as State Health Officer. Under her leadership, Mississippi’s Department of Health garnered national praise in an era of anemic funding for its public health work, achieved national accreditation status, and opened a new state of the art public health laboratory, named after Thompson.

Currier retired at the end of October 2018, and the Board appointed Deputy State Health Officer and past state epidemiologist, Thomas E. Dobbs, MD, MPH, to replace her.

At the beginning of the twenty-first century, the medical community faced a tort liability crisis, physician shortages, and a poorly coordinated trauma system. After “white coat” rallies by physicians at the state Capitol and significant public pressure at the grassroots level, comprehensive tort reform legislation was passed in specials sessions in 2002 and 2004, which relieved the malpractice crisis in the state.

Along with tort reform, the creation of the Mississippi Rural Physician Scholarship Program by the Legislature in 2007 was a major step to improve declining physician numbers in rural and underserved areas in Mississippi. Also, to improve the state’s physician shortage, the William

Carey University College of Osteopathic Medicine was established in 2008 in Hattiesburg, becoming the state’s second medical school and the first in the region to focus on osteopathic medicine. In 2012, the Office of Mississippi Physician Workforce (OMPW) was established by the Legislature. Located within the University of Mississippi Medical Center, this important office oversees the state’s physician workforce development needs by evaluating existing physician numbers and geographic distribution and by nurturing the creation of residency programs in specialties where they are needed. Although the state began the development of a statewide trauma system decades earlier, the system was fragmented and unfunded. Legislation in 2008 created a funded mandatory “pay or play” trauma system network which became a model for rural states across the country. In 2011, the STEMI Network was created with the leadership of the Mississippi

PEN AND INK SKETCH – Dr. Felix J. Underwood in 1929. The artist was Harry Palmer, and Underwood’s signature is below the print.

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MEDICAL LICENSE 1903 – This is a typical early medical license from Mississippi. It belonged to Dr. B.L. Crawford, a MSMA president. Note that two character witnesses were required (which were Dr. Crawford’s brother and brother-inlaw, both physicians) and that an extensive listing of professional schooling and training was included. Also, it was signed by the entire Board of Health of that period, which included many of the most prominent medical leaders of the state.

Health Care Alliance to improve cardiovascular mortality and morbidity, followed by the Stroke Network in 2013 to better stroke outcome. Overseen and coordinated by the Department of Health, Mississippi became the first state in the country to develop three systems of care with data already revealing remarkable improvements in outcome and mortality rates.

The August 2017 dedication of the University of Mississippi’s new $76 million School of Medicine building, named in honor of Governor Phil Bryant, marked a new chapter in both medical education and health care for Mississippi. The 151,000-square-foot facility at the Jackson campus allows the medical school to expand its class size to 165 students, the largest in its history, with hopes of addressing the state’s physician needs in the coming years of the twenty-first century. Q Selected Bibliography Bridgforth, Lucie Robertson. Medical Education in Mississippi. Jackson: University of MS Alumni Association, 1984; Duffy, John. The Rudolph Matas History of Medicine in Louisiana. Vol. I and II, Baton Rouge: LSU Press, 1958; Harrell, Laura D. S. “Medical Services in Mississippi, 1890-1970,” in McLemore, Richard A. (Ed.) A History of Mississippi, Vol. II. Hattiesburg: University Press of Mississippi,1973; Lampton, Lucius. “Yellow Fever,”

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in Kellerman and Bope’s Conn’s Current Therapy 2018, Philadelphia: Elsevier, 2018; Lampton, T. D. Twelve Years of Challenge and Change... 1965-1977, Mississippi Regional Medical Program, 1977; Underwood, Felix and R. N. Whitfield. Public Health and Medical Licensure in the State of Mississippi, Vol. 1, 1798-1937; Vol. 2, 1938-1947.

Jackson: Tucker, 1938; 1950.

Author Information Practicing in Magnolia, Dr. Lampton has served as Editor and Associate Editor of the Journal of the Mississippi State Medical Association for more than two decades writing thousands of articles on medicine and health care and receiving national awards for excellence in writing and journalism. He also served as Medical Editor of the Mississippi Encyclopedia writing multiple entries on the history of medicine in Mississippi. He recently contributed Dr. Lampton a chapter to America’s leading primary care text Conn’s Current Therapy. Dr. Lampton has also served as a member of the Mississippi State Board of Health since 2006 and served as chair of that Board from 2007-2017. Dr. Lampton specializes in Family Medicine in multiple settings. He has been recognized as Mississippi’s Family Physician of the Year by the Mississippi Academy of Family Practice and has received national citation for his hospice work. He co-authored Images in Mississippi Medicine, a Photographic History of Medicine in Mississippi that was published by the MSMA to commemorate the 150th meeting of the House of Delegates.

Civil War Medicine in Mississippi

An Overview: Some Myths, Some Realities SIDNEY W. BONDURANT, MD Abstract: During the American Civil War, battles were fought in all areas of the state. This article gives a brief overview of what was current practice of medicine and surgery in the 1861-1865 time frame of the Civil War and discusses a few myths and realities about medical care of that time with an emphasis on the Vicksburg Campaign of 1863.

Key Words: Civil War, medicine, surgery The American Civil War lasted from the winter/spring of 1861 to the spring/summer of 1865. The total number of killed and wounded will never be accurately tallied but recent publications by historians estimate the deaths to be up to 750,000.1 The number of wounded would have been higher than that number by many thousands.

Myths and Realities Myth: Medical care of Civil War soldiers was not state of the art. It was Middle Ages in both concept and delivery.

Reality: “State of the Art” care is based on what is thought to be most effective by the established authorities of the time. Civil War medicine reflected the treatment received by most civilian Americans of the time. Civil War doctors made many changes in medical care during the war that were based on their own experiences that were notable improvements in healthcare.

Medical And Surgical Advances During The War 1. Use of quinine for the prevention and treatment of malaria 2. Use of quarantine which virtually eliminated yellow fever 3. Successful treatment of hospital gangrene with bromine and isolation 4. Development of ambulance system for battlefield evacuation of wounded 5. Use of trains and ships to transport patients 6. Safe use of anesthetics 7. Establishment of large general hospitals and establishment of specialty hospitals 2 There were not many hospitals in existence before the Civil War. The ones that did exist were mostly for use by the poor or for specialized populations. The wealthy were cared for in their homes by servants

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and a doctor who made house calls. The middle class were cared for in their homes by family members.

There was a hospital in Vicksburg called the Marine Hospital. It was built to care for the “specialized population” of river boatmen. These men would be far from their homes because of their work so they had no family to care for them. During the Siege of Vicksburg the Confederates established a gun battery near the hospital and called it the Marine Hospital Battery. This made the area a military target so the building was not favored as a hospital site by either physicians or patients. It was common during the Civil War to use any structure that had rooms with beds, or space for beds, as a hospital.

The Washington Hotel in Vicksburg was appropriated by the Confederate authorities and turned into a large hospital. Field hospitals were established by both sides near battlefields using tents or whatever buildings were available. Farm houses, barns, schools and churches were frequently appropriated for use as hospitals by the armies who were in the area. After care in the field the wounded soldiers were transferred to the established general hospitals that had been set up by the government. One of the largest in the South was the Chimborazo Hospital in Richmond, Virginia. It could care for four thousand patients, had its own ice making machinery, bakery, and its own vegetable and dairy farms.3 The Civil War brought about the development of “Specialty Hospitals," a totally new concept. Confederate Army of Tennessee Surgeon Samuel Stout established hospitals that specialized in the care of ophthalmology cases, venereal disease, hernia, gangrene, and another for orthopedic cases all in Georgia.4 A Union Army contract physician, Dr. Silas Weir Mitchell, commanded the Turner's Lane Hospital in Philadelphia, Pennsylvania, that cared for neurological cases only. He became known as “The Father of American Neurology.”5 Myth: The only treatment a Civil War doctor would do for an injured soldier was amputation.

Reality: “Almost true” but not quite.

About 75% of surgical procedures were amputations.6 To understand why we need to look at what was causing the injuries and the effects of those implements of war.

The rifled long arm firing a Minie’ ball was accurate out to about five hundred yards.8

Figure. Battlefield Ammunition

When the older smooth bore musket firing a round ball was in use, the attacking infantry could advance close to the defenders before being at high risk of getting hit by a bullet. That changed dramatically with the advent of Captain Minie’s bullet coming down a rifled gun barrel.

Top: Artillery Shell Fragment; Middle row left to right: 1.) Unfired .58 caliber Minie Ball. 2.) Fired (impacted) Minie Ball. 3.) .69 caliber Round Musket Ball. 4.) Pistol bullet with tooth marks. 5.) Round Ball with multiple teeth marks; Bottom Front: Fired (impacted) pistol bullet.

Personal Collection of the Author.

What Caused Battlefield Injuries? 7 Minie’ Ball

76%

Musket Ball

12%

Shell Fragment

9%

Pistol Shot

3%

“Grape & Canister”

1%

Solid Shot

0.3%

Sword & Bayonet

less than 1%

What Was Flying Around on the Battlefield There was nothing “small” about the Minie’ ball. This bullet was a conical-shaped solid lead .58 caliber projectile that was used in a rifled barrel long arm weapon. It was named for its inventor, French Army Captain Claude Etienne Minie.’ The rifled barrel long arm quickly replaced the older smooth bore musket that fired a .69 caliber round lead ball in the Union Army but it took a longer time for the Confederates to replace their old weapons. Technology quickly advanced and soon many Union soldiers were carrying repeating rifles. The problem for the average soldier was that his officers (at least the ones who had benefited from a West Point education) were trained in Napoleonic infantry tactics that relied on the known fact of the smooth bore musket being accurate only to about fifty to eighty yards.

The data on the site of injury for battlefield deaths show why most operations performed were amputations. Injuries to the trunk, head, and neck were found in 92% of the dead. Injuries to the extremities comprised 8% of the dead. The only soldiers hit who survived long enough to get to a hospital were those with extremity wounds.9 Once the soldier made it to a hospital the surgeon had to decide about treatment. There were generally two options. One was to dress the wound and control bleeding with pressure and the other was to amputate. The wounded soldier was rarely asked to participate in the decision. He was just told what the doctors were going to do, and he followed orders. Occasionally a soldier would object to amputation, and the surgeon would just shrug his shoulders and move on to the next patient. The surgeons were so overwhelmed with patients they did not have the time or inclination to discuss it with the soldier patient. Those with chest and abdominal wounds did not receive an option of surgery since few survived after operations for wounds in those areas. Most soldiers with abdominal wounds died either quickly from blood loss or slowly, like Confederate General J. E. B. Stuart, from peritonitis. There were rare exceptions like Union General Joshua L. Chamberlain who had a Minie’ ball traverse his pelvis from one acetabulum to the other. The bullet passed through his bladder and urethra and left him with a urethrocutaneous fistula. Chamberlain had the pleasure of reading his own obituary while recovering in a hospital.

The Army had released his obituary to the newspapers assuming he would die like almost all abdominal wound cases did. Five months later, he was back in combat.

Most deaths from amputation were from infection. Civil War doctors did not understand infection. The “State of the Art” pathophysiology understood by doctors of that era was that too much blood flow to the injured area caused “inflammation” and they needed to control fluid flow in order to prevent tissue loss and prevent death. Had Dr. Joseph Lister been ten years sooner to present his paper10 in 1857 rather than 1867 then many deaths would have been prevented in the Civil War. Civil War surgeons had no knowledge of antiseptic surgical techniques and operated on one patient after the other with no cleaning of their hands, clothing, or instruments in between patients. The appearance of pus after an amputation was an expected event. “Laudable pus” was yellow-green, viscous, and creamy. Frequently the patient would survive this infection, which was most likely from Staphylococcus aureus.

“Thin pus” was serosanguinous and frequently led to death. This infection was most likely from Streptococcus pyogenes. One surgeon noted that sometimes nurses caring for patients who had thin pus would later develop erysipelas.2,11

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Union Zouave regiment ambulance drill near Brandy Station, Virginia.

Myth: Civil War operations were done without anesthesia. They would just “give 'em a bullet to bite on.”

Reality: Anesthesia was introduced in the USA in the 1840's. Both ether and chloroform were available to Civil War surgeons although chloroform was preferred because of the inflammability and instability of ether.

Chloroform supplies in the South were either made in Southern laboratories or brought from England by blockade runners. Open mask was the main method used although one Confederate surgeon, Dr. J. J.Chisolm, invented a nasal device with two prongs that reduced the amount of chloroform used per operation by about 90%. This inhaler device was used in the Confederate hospitals in the latter half of the war. Since the Union blockade considered chloroform contraband, it was a difficult commodity to obtain in the South and a 90% saving per case was significant.12 The extensive manufacturing capability of the Northern states allowed them to make adequate amounts of chloroform to supply the Union Army.

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Biting on a bullet during an operation may have happened in a few cases but there is little written to document that. I have found bullets with teeth marks on them when doing archaeology in Civil War camps but most appear to be animal teeth marks. One did appear to be human teeth marks and both a dentist and dental lab technician agreed that the marks were likely human.

The final stage of the Vicksburg Campaign began when Union General U. S. Grant landed south of Port Gibson at Bruinsburg on May 1, 1863.

There was no major opposition to the landing, but the next day saw the Battle of Port Gibson followed by major battles at Raymond, Jackson, Champion Hill, Big Black River Bridge, First Assault at Vicksburg, Second Assault at Vicksburg and then the Siege of Vicksburg lasting to the Surrender of Vicksburg on July 4, 1863. Grant managed to keep the Rebel commanders confused as to his intentions during all the fighting and maneuvering about. When Grant and his 77,000 men settled in for the Siege of Vicksburg there were 33,000 Confederates in Vicksburg and 30,000 in the area between Jackson and the Big Black River. As he had fought the battles from Port Gibson to Big

Below: Union Army Dr. Anson Hurd, 14th Indiana Infantry Regiment, caring for wounded Confederates in a tent field hospital after the Battle of Sharpsburg in Maryland. Left: Union Army camp of Logan's Division at the Shirley House in Vicksburg. Bottom left: Confederate camp and trenches in Vicksburg. From the collection of The Library of Congress, Washington, D.C.

Black River Bridge he had left his 2000 wounded behind to be cared for in “enemy territory”by the nineteen Union surgeons he left with them. The Confederates did the same thing but they were leaving their wounded in “friendly territory.” So you had Union surgeons caring for Union patients and Confederate surgeons caring for Confederate patients often in the same town. Grant's Medical Director, Regular Army Surgeon Madison Mills, even dispatched four Union surgeons along with wagons of medical supplies to “enemy territory” to supply those wounded and he ordered them to also assist and share the supplies with the Confederate surgeons who were overwhelmed with work.13

During the entire Vicksburg Campaign the risk of loss of a soldier from his unit was always greater due to disease than to combat.

Between 40% and 50% of Confederate soldiers were either in hospitals or on the camp sick list during the Campaign. It was about 30% for the Union Army.16

The Civil War was the first to see the concept of treating medical officers as non-combatants. Dr. Hunter McGuire, Medical Director for Confederate General “Stonewall” Jackson, conceived the idea and put it into practice at the Battle of Winchester, Virginia. Medical officers acting as doctors only during a battle would not be made prisoners of war but would be allowed to continue caring for the sick and wounded. A medical officer could be made a prisoner if he were engaged in other military duties such as acting as a messenger or if a capturing commander felt there was a good reason to detain him, such as saying “he had seen too much.”14, 15

Medical therapy was a sort of hit-or-miss type of treatment and scientific pharmacology was still in its infancy. There were still many doctors practicing who were of the Benjamin Rush school of “Bleed and Purge” theory of medicine. The theory was that too much blood and body fluids caused “inflammation” and thus disease. Bleeding, emetics, and laxatives were thought to relieve the excess and thus heal all sorts of illness.

Diarrhea and malaria combined to account for about half the sick list numbers. Catarrh (probably upper respiratory infections), pneumonia, measles, typhoid, and smallpox accounted for the other half. Interestingly, “epilepsy” also was a diagnosis for a small number of sick list cases. This may have actually been meningitis.

Two common medications were “blue mass” pills which were 33% mercury chloride and calomel which was also a mercury compound.

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Since the standard dose for blue mass pills contained about 200 times the upper limit of what is now the maximum amount of “safe” exposure to mercury today, it is no wonder that symptoms of mercury poisoning were common in the Civil War. When Union Surgeon William Hammond took calomel and tartar emetic off the Army formulary he caused a revolt in the Army Medical Corps and public criticism by many civilian doctors as well. He was dismissed from his position as Surgeon General and eventually sent to a court-martial on some spurious charges.17 The use of those mercury-containing compounds was so fixed in the practice of medicine at that time for the treatment of all manner of illnesses that the established physicians felt that Hammond was accusing all of them of incompetence.

Although the use of blue mass and calomel was a big “miss,” there were some “hits.” Civil War doctors mostly got the use of quinine right.

They were reasonably successful in diagnosing malaria and knew that quinine worked. They also knew that it could prevent malaria as well as treat it although limited supplies kept its use as a prevention measure to a minimum on the Confederate side. What they did not know was the association between malaria and mosquitoes. Stagnant water was not seen as a military priority. This allowed lots of breeding areas for mosquitoes in and around army camps. Since the “sickly season” lasts longer in the South where most of the war was fought, malaria was a problem for both sides throughout the war.18 After the surrender of Vicksburg, Union General William T. Sherman was so comfortable and secure in his camp near the plantation of Parson Fox between the Big Black River and Vicksburg that he sent for his wife and some of his children to join him there. The family had a wonderful time there and young Willie Sherman became a favorite of the soldiers. He was already the favorite son of his famous father.

When Sherman was ordered to move to Chattanooga, he put the family on a riverboat for the return trip home to Ohio. On the day of their departure young Willie fell ill with diarrhea that was eventually diagnosed as typhoid. By the time the boat reached Memphis he was near death. General Sherman got the best medical care the Union Army and the civilian doctors of Memphis could provide but they had no treatment for typhoid. To the end of his life Sherman never got past his grief over the death of Willie. He frequently expressed recrimination over bringing his family to the “sickly” area of Vicksburg in the late summertime.19 The famous American jurist, author, and philosopher Oliver Wendell Holmes, Jr. was also a Civil War veteran of the 20th Massachusetts Infantry. He saw a lot of combat and had been wounded several times.

In a speech in 1884 he stated, “Through our great good fortune, in our youth our hearts were touched with fire. It was given to us to learn at the outset that life is a profound and passionate thing.”20 I suspect that most veterans today who have served in combat zones agree with Holmes that “life is a profound and passionate thing” and that “in our youths our hearts were touched with fire.” I am not so sure that most would agree that it was “through our great good fortune.” But the American Civil War was another era, another experience and we have to look at it through the eyes that actually saw it and not our eyes of today to understand Holmes' quote. In my reading what those 512 VOL. 59 • NO. 11/12 • 2018

soldiers on both sides wrote of their experiences I am always amazed at their ability to face privation, maiming, and death with such little complaining. It was truly another era. Q References 1. Gugliotta G. “New Estimate Raises Civil War Death Toll” The New York Times.

April 3, 2012. www.nytimes.com/2012/04/03/science/civil-war-toll-up-by20-percent-in-new-estimate.html Accessed September 28, 2018.

2. Reilly RF, Medical and surgical care during the American Civil War 1861-1865, Baylor University Medical Center Proceedings Dallas, TX. 2016 April:29(2):138-142.

3. “Chimborazo Hospital.” National Park Service. February 26, 2015. www.nps. gov/rich/learn/historyculture/chimborazo.htm. Accessed September 28, 2018.

4. Cunningham HH. Doctors in Gray, ed.2, Baton Rouge, LA: Louisiana State University Press;1960:267.

5. Carroll D. “Silas Weir Mitchell;” National Museum of Civil War Medicine; January 29, 2017. www.civilwarmed.org/mitchell. Accessed September 28, 2018.

6. Beller SP. Medical Practices in the Civil War, Charlotte, VT: Beller Publishing; 1992:67.

7. Bollet AJ. Civil War Medicine: Challenges and Triumphs, Tucson, AZ: Galen Press; 2002:84.

8. Davis WC. First Blood: Fort Sumpter to Bull Run, Alexandria, VA: Time-Life Books; 1983:50-51.

9. Bollet. op. cit. 84.

10. Lister J. On the antiseptic principle in the practice of surgery. Brit Med J. 1867; ii:246.

11. Dammann G, Bollet AJ., Images of Civil War Medicine, New York, NY: Demos Medical Publishing; 2007:166.

12. Hambrecht FT, Rhode M, Hawk A., Dr. Chisolm's inhaler: A rare Confederate medical invention. J South Carolina Med Assoc. May 1991;277-280.

13. Gabel CR. Staff Ride Handbook for the Vicksburg Campaign December 1862 – July 1863, Fort Leavenworth, KS: Combat Studies Institute; 2001:63-67.

14. Bierle SK. “Unconditional Release: Dr. Hunter McGuire's Precedent in American Military Medicine”; May 24, 2018. www.civilwarmed.org/ winchester-accord/. Accessed September 28, 2018.

15. Freemon FR, Gangrene and Glory: Medical Care During the American Civil War, Urbana, IL: University of Illinois Press; 2001:82.

16. ibid., 118-119.

17. ibid., 142.

18. ibid., 206-209.

19. Bassett T. “The Death of Willie Sherman”, The New York Times; October 12, 2013. https://opinionator.blogs.nytimes.com/2013/10/12/the-death-ofwillie-sherman/. Accessed September 28, 2018.

20. Holmes Jr. OW. Speeches of Oliver Wendell Holmes. Boston, MA; Little, Brown and Co.; 1934:3.

Author Information Dr. Bondurant practiced obstetrics and gynecology in Grenada, Mississippi, from 1985 to 2011. He retired from clinical practice and is now Chief Medical Officer at Medical Spark Biologics, LLC in Jackson, Mississippi. He is a Vietnam veteran, and he resides in Madison. Reprints will not be available.

Dr. Bondurant

Presented at the Commemorative Program for the 150th Anniversary of the Annual Session of the House of Delegates of the Mississippi State Medical Association.

August 18, 2018 “Ideal vascular surgery is difficult surgery. It requires special equipment, a great deal of time, and, on the part of the surgeon, highly specialized experience and dexterity.”

– DeBakey and Simeone, 1946

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Mississippi, MASH, and Arterial Repair

The Intersection of Surgical History and Pop Culture MICHAEL C. TROTTER, MD Introduction In December 1971, two high school senior boys took their dates to see the movie M*A*S*H. As they were leaving the theater afterwards, one of the boys remarked, “That was the coolest thing I have ever seen.” The boys remained friends over the years, and one became a surgeon while the other became a family physician. Years later the two were recalling high school memories. The surgeon asked the family practitioner if he recalled the double-date and if that movie and its sequelae influenced his attraction to medicine. “None whatsoever,” replied the FP. “I was too worried what my (recent) ex-girlfriend would think when she found out I went out with someone else.” The surgeon said, “I don’t understand why I thought that movie was so great.” The FP replied, “Me neither…… but surgeons will.”

The surgeon smiled and said, “Yep. Probably right.”

The surgical historical milestone of successful arterial repair for acute arterial injury was one of several medical innovations that occurred during the Korean War that forever changed practice and benefitted patients. This milestone occurred at the time and place of the popular 1968 novel MASH: a novel about three army doctors and the 1970 movie M*A*S*H. Notably, arterial repair is mentioned with more than passing interest four times in the novel and twice in the movie. This article examines the details of that milestone and connects individuals involved in its development who later served as models for medical historical fiction.

Arterial Repair Comes of Age In World War II (1941-1945), amputation rates were 48.9% following arterial ligation and 44.4% following arterial repair.1 Thus, according to vascular surgical historian Steven G. Friedman, MD, “The prospects for the repair of battlefield vascular injuries appeared grim” following WW II.2 Conceptually this led to a policy of ligation for all vascular injuries as the United States entered the Korean War (1950-1953). Exceptions were those amenable to simple transverse suture repair or simple end-to-end anastomosis.3 The clinical advances made during the Korean War included the use of the mobile army surgical hospital, helicopter aeromedical evacuation, field testing of body armor, the use of plastic containers for blood collection and distribution, arterial repair for arterial injury, and dialysis for acute kidney injury.4,5,6 (Figure 1) The Mobile Army Surgical Hospital (MASH) ultimately evolved from the portable surgical hospitals (PSH’s) of the Pacific Theater and the Auxiliary Surgical Groups (ASG’s) of the European Theater during WW II. They were developed upon the recommendation of the Army Ground Forces despite the opposition of the Army Medical Department and its Chief of General Surgery, Lt. Col. Michael E. DeBakey, MD. The MASH was approved on August 23, 1945, and

became a hallmark of medical care during the Korean conflict.7,8 The establishment of arterial repair was a milestone in the evolution of vascular surgery and was pioneered by essentially unheralded individuals at the intersection of a specific time and place – Korea in 1952.

In 1949 a program was begun at Walter Reed Army Hospital (later Medical Center – WRAMC) to study vascular repair in wartime. This small group consisted of one surgeon, Lt. Col. Carl W. Hughes, MD and one vascular resident, Maj. Edward J. Jahnke, MD.9,10,11 By the latter part of 1950 and early 1951 they were having good results repairing the chronic sequelae of arterial injury: pseudoaneurysms and arteriovenous fistulas that resulted from combat injuries. They gained experience with vascular surgical techniques, demonstrated the importance of restoration of arterial continuity utilizing arterial repair, and showed the preference of autogenous vein grafts over homologous arterial grafts for interposition grafting.12,13,14 In December 1951, a U. S. Army Surgical Research Team of the Army Medical Service Graduate School had been deployed from Walter Reed (WR) to Korea with a mission to improve combat medical and surgical care.9,10,11 Capt. John M. Howard, MD, headed the team and served at the 11th Evacuation Hospital and the 8209th MASH. One area of focus was vascular injury, and the initial attempts at repair were futile with inadequate instruments.9 Resident Jahnke was deployed to Korea as a member of the Surgical Research Team in April 1952. He was 28 years old and sent for temporary duty to the 8055th MASH with appropriate vascular instruments. (Figure 2) The goal was to improve the treatment of arterial injuries with arterial repair and thereby avoid amputation. This was accomplished, and outcomes and results improved significantly.9,10 After Jahnke returned to WR, surgeon Hughes went to Korea assigned to the Surgical Research Team to continue the mission. MASH 8055th surgeons as well as surgeons from other MASH units were taught arterial repair by both Jahnke and Hughes on anesthetized dogs using Potts ductus clamps brought from the U.S.9,15 Amputation rates dropped significantly.9 (Figure 3) The results of this new-found success were quickly reported, and the dissemination of information began. Jahnke returned from his deployment with the 8055th MASH after September 1952.

In November 1952, he presented the initial experience with the treatment of vascular trauma at the 8055th MASH in 77 consecutive unselected patients at the 59th Annual Meeting of the Association of Military Surgeons of the United States. Repair was undertaken in major arterial injuries with transverse suture, end-to-end anastomosis, or vein graft interposition. Anticoagulation was not used in these typically multi-injured patients. Use of Potts coarctation clamps, vessel debridement, fine suture, and times from wounding to NOVEMBER/DECEMBER • JOURNAL MSMA

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Figure 1. Aeromedical evacuation at the 8055th MASH

Figure 3. Receiving ward 8055th MASH

Kellum recalled these Sikorsky H-5 helicopters were used at the 8055th MASH and not the Bell-47 associated with the movie and television series. Note the patient pods. (Courtesy of the Kellum family. Reproduced with permission.)

Kellum’s notation is on the back of the photograph. (Courtesy of the Kellum family. Reproduced with permission.)

Figure 2. 8055th MASH and aerial view

Figure 4. 8055th MASH OR before (inset) and after a battle

(Courtesy of Jeremiah Henry Holleman, Jr., MD. Reproduced with permission.)

(Courtesy of Jeremiah Henry Holleman, Jr., MD. Reproduced with permission.)

repair were found to be important and were discussed.16 The initial publication by Jahnke appeared in March 1953 and was followed by publications with Jahnke as the lead author in April, May, and August of 1953. Emphasizing the factors and techniques above as well as proximal control, vessel mobilization, flushing the repair, use of antibiotics, and tissue coverage of the repair, amputation rates ranged from 8.8 to 11.7 % in these first four reports.3,16,17,18 Importantly, 14 patients were able to be followed up with arteriography at WRAMC within four to seven months post repair, and all 14 repairs were patent.3 Jahnke acknowledged “the Commanding Officer and the

Staff of the Mobile Army Surgical Hospital, 8055 Army Unit in Korea, who assisted in all of the vascular repairs.”3,16,18 (Figure 4) The Korean Armistice Agreement ending hostilities was signed in June 1953. The new knowledge and information about arterial repair generated during the conflict continued to be spread. In 1954 a statistical survey of 218 extremity Korean War arterial injuries from January – September 1952 was reported.19 Additionally, an updated analysis of cases was reported by Hughes followed by a detailed overview of the subject by Jahnke and Hughes.20,21 All the data and information reinforced the conclusion that “primary arterial suture

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Figure 5. Major Jeremiah Henry Holleman, MD

Figure 6. Agrippa Spence “Grip” Kellum, MD

Commanding Officer 8055th MASH. (Courtesy of Lucius “Luke” M. Lampton, MD. Reproduced with permission.)

(Courtesy of the Kellum family. Reproduced with permission.)

is the procedure of choice in vascular wounds if the greatest number of functional as well as viable limbs are to be saved.”21 In April 1954, the U. S. Army Medical Service Graduate School held a course at WRAMC titled “Recent Advances in Medicine and Surgery based on Professional Medical Experiences in Japan and Korea 1950 – 1953.” Hughes and Jahnke spoke on arterial repair based on their experiences.22,23 Interestingly, a parallel effort had been undertaken in the U. S. Navy and Marine Corps. It was led by Lt. (jg) Frank C. Spencer, MD, of Easy Medical Company of the 1st Marine Division. Spencer had spent two years of residency training at Johns Hopkins under Alfred Blalock, MD, followed by two years at UCLA under William Longmire, MD. When he was activated for duty at the outbreak of the Korean War, he spent the first year at the U. S. Naval Hospital in Oakland, CA, caring for combat vascular injuries from Korea. He was then assigned for overseas duty and arrived in Korea in the summer of 1952 as Chief of Surgery of the forward Marine medical unit and organized an “experimental vascular repair program” as military regulations mandated ligation for arterial injury. Over the ensuing year Spencer, like his Army colleagues, had a favorable experience with arterial repair for arterial injuries. However, he used primarily arterial homografts rather than autogenous vein grafts. Spencer was visited by Hughes a few months after his program began, and Hughes provided him with a pair of Potts clamps to use instead of the rubbershod bulldog clamps he had assembled. Hughes noted this encounter in his 1954 report. Spencer reported his experience and results in 1955 in which he referenced the earlier work of Jahnke and that of Hughes. His amputation rate was 22%.20,24,25,26 Eventually the Korean War experience establishing arterial repair for arterial injuries rather than ligation began to be summarized. In 1955 Capt. Frank K. Inui, MD, published the experience from the

46th Surgical Hospital in Korea that spanned the last 18 months of the war. He compared and contrasted the amputation rates during the period of arterial ligation (62%, January – April 1952) and the amputation rates during the period of arterial repair (7%, April 1952 – June 1953). Importantly, he noted the advent of arterial repair as April 1952 which coincides with Jahnke’s arrival at the 8055th MASH.27 In 1957 at the Annual Meeting of the Society for Vascular Surgery in New York Jahnke presented the follow-up of 115 patients at WRAMC who had undergone arterial repair in Korea between August 1952 and December 1953 and who subsequently underwent arteriography at WRAMC. Late thrombosis occurred in 33 (28.7%).

None required amputation. Eight (72.7%) symptomatic patients were successfully revised, thereby identifying the concepts of revision vascular surgery and secondary patency. This report was published in February 1958.28 In April 1958, Hughes published a report that pulled all the information together in a clear, concise, and definitive fashion. He also noted that there had been “duplication of reporting” on arterial repair during the Korean War. Of the five reports he cited as duplications, four had Jahnke as the lead author,29 yet Jahnke’s publications and presentations after his experience at the 8055th MASH appear to be the earliest and may be more correctly termed ‘preliminary’ as opposed to ‘duplicate.’ Certainly, the magnitude of this vascular surgery milestone deserved reporting early and often.

In the words of John Howard, MD, “And soldiers walked ... who might have not.”9 In November 1958, Hughes and Jahnke came full circle when they published five-year follow-up on 202 patients with 215 traumatic arteriovenous fistulas and aneurysms, most sustained during the first two years of the Korean War. They noted that the late results with reconstructive vascular surgery were as gratifying as the early results had been, thereby ‘closing the loop’ on what they had started in 1950 – 1951.30 NOVEMBER/DECEMBER • JOURNAL MSMA

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Who Else was There?

The experiences of a military surgeon during the Korean War led to a successful fiction novel in 1968. This gave rise to a popular movie in 1970 and subsequently a long-running and award-winning television series (1972-1983). Concerning general popularity and awareness today, it would appear the chronology is reversed with the television series being most popular followed by the movie and then the novel. Embedded in this trio of entertainment vehicles were milestones of surgical history not generally known to the widely entertained audience of the novel, movie, and television series. Importantly, fictional characters and actors did not reveal the pioneering individuals who believed in a concept, proved its credibility, published results, and established a new standard of care.

Jeremiah Henry Holleman (1915-2011) was a native Mississippian who was born in Hattiesburg in 1916, graduated from Millsaps College in 1939, attended the two-year University of Mississippi Medical School in Oxford, and received his MD degree from the University of Tennessee in Memphis in 1943.15,31,32 He then completed a nine-month rotating internship at Norwood Hospital in Birmingham, AL, and entered the U. S. Army as a General Medical Officer in 1944. He served in the European Theater until the end of the World War II.15,32 Following discharge, he returned to Norwood Hospital (later Carraway Methodist Hospital) and completed a general surgery residency under Dr. Ben Carraway.15 He then settled in Columbus, MS, in the practice of general surgery and joined the Rotary Club and the Army National Guard 31st Infantry Division (“Dixie Division”). Holleman became Commander and Artillery Brigade Surgeon of the 31st Division Artillery Medical Detachment.15 He was activated in January 1951 and deployed to Korea in September 1951 where he became Commanding Officer (CO) of the 8055th MASH at age 35.15,32 (Figure 5) Hiester Richard Hornberger (1924-1997) served as a surgeon at the 8055th MASH during the Korean War. He was born in New Jersey and grew up in New Jersey and Maine, where the family later moved.

He graduated from Bowdoin College and Cornell University Medical College, the latter in 1947.31,33,34 Following that, he entered a surgical residency which was interrupted before completion. This appears to have been due to activation from Army reserve status as opposed to the “Doctors Draft Act” enacted September 9, 1950, and Hornberger entered the Army.33,35,36 His initial military experience was not a good one, and he arrived at the 8055th MASH in the fall of 1951 as a replacement surgeon at age 27.15 About the same time or shortly after that Hornberger arrived at the 8055th MASH, another replacement surgeon, Agrippa Spence ‘Grip’ Kellum (1923-2001), arrived. (Figure 6) Kellum was a native Mississippian who was born in Guntown in 1923, graduated from the University of Mississippi, and attended the two-year University of Mississippi Medical School in Oxford. He then completed his medical education at Harvard Medical School, graduating in 1948. Following this, he entered a general surgery residency at Grady Hospital and Emory University in Atlanta. As a participant in ROTC in college, he was activated for military service after his third year of training and assigned to an evacuation hospital in Korea. He was initially part of a neurosurgery team which was sent to the 8209th MASH where the neurosurgery team subsequently

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dissolved. Kellum, age 28, was then sent to the 8055th MASH where he and Hornberger were tent-mates.15,31,32 (Figure 7) Following Hornberger’s and Kellum’s arrival at the 8055th MASH, James Francis Dickson, III arrived towards the end of 1951. Dickson was a Boston native born in 1924. He graduated from Dartmouth College in 1944 and received his MD degree from Harvard Medical School in 1947. He then entered general and thoracic surgery training on the Harvard Surgical Service at Boston City Hospital (BCH) Figure 7. Dick Hornberger and Grip Kellum outside The Swamp

(Courtesy of Jeremiah Henry Holleman, Jr., MD. Reproduced with permission.)

Figure 8. Dick Hornberger and Jim Dickson outside The Swamp

(Courtesy of Jeremiah Henry Holleman, Jr., MD. Reproduced with permission.)

where he was mentored by Dwight E. Harken, MD.15,31,32,37,38 He may have spent time as a Fellow in the Thorndike Memorial Laboratory at BCH. During this period he contributed to the surgical literature.39,40 It is unclear how Dickson entered military service – volunteered, activated, or drafted – but the “Doctors Draft Act” seems the most likely cause. He arrived at the 8055th MASH in late fall 1951 at age 27 and became the third person in the tent with Hornberger and Kellum.

(Figure 8)

Figure 9. Inside The Swamp

Dickson named their tent “The Swamp” after his room in college and placed an African symbol (later adopted by Somerset Maugham as his literary symbol) on the door as a good luck charm.32 (Figure 9) Holleman had been the CO at the 8055th MASH for about two months when Hornberger and Kellum arrived in the fall of 1951 followed by Dickson before the end of the year. Hornberger’s nickname was “Horny” as a contraction for Hornberger, and Kellum’s nickname was “Gipper” as a contraction for Agrippa.32 Holleman recalled Jahnke serving at the 8055th MASH and teaching arterial repair on anesthetized dogs.15,32 Additionally, Holleman photographed what may well be the first successful arterial repair (or one of the earliest) at the 8055th MASH.41 (Figure 10) Kellum vividly recalled the advent of arterial repair during his time at the 8055th MASH. In fact, Kellum received a letter from a grateful New Zealand soldier on whom he had performed arterial repair and saved his leg.32 (Figure 11) In Dale Sherman’s MASH encyclopedia is the photograph in Figure 7 with an inscription by Kellum to Hornberger:33 Horny: Memories of 1952 Your friend, “Gippah”

Interestingly, Dickson graduated from Harvard Medical School one year ahead of Kellum, and one wonders if they were aware of each other before their 8055th MASH experience.31 Kellum also recalled Dickson removing an intracardiac foreign body. This is consistent with Dickson’s training under Boston mentor Harken who had accomplished it 13 times without a death during WW II and reported it in 1945.32,42 Holleman and many of the MASH medical Kellum is inside a sleeping bag. (Courtesy of the Kellum family. Reproduced with personnel participated in the regular meetings of the Thirty-Eighth permission.)

Figure 10. Arterial repair 8055th MASH

Figure 11. Arterial repair 8055th MASH 1952

Original Kodachrome taken by Holleman and labeled by him at the time. Holleman’s notation on the back of the slide: “Artery injury During Korean war. A First in Military Surgery." This may be the first successful arterial repair at the 8055th MASH in 1952 or one of the earliest. (Courtesy of Jeremiah Henry Holleman, Jr., MD. Reproduced with permission.)

Original Kodachrome by Holleman. (Courtesy of Jeremiah Henry Holleman, Jr., MD. Reproduced with permission.)

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Parallel Medical Society.15,32 Dickson was the featured speaker at the group’s first-anniversary meeting in 1952, and his topic, “Surgery of the Rheumatic Heart,” included a clinical film reflecting his academic interests in Boston.43 Holleman left Korea after his 12-month tour of duty. After discharge, he returned to Columbus and resumed his surgical practice. He continued his friendship with Hornberger. He would visit Hornberger in Maine and host Hornberger in Mississippi, both on multiple occasions. He developed a long-standing friendship with Kellum. Holleman was certified by the American Board of Surgery (ABS) in 1955 and also became a Fellow of the American College of Surgeons (ACS) the same year. He remained in Columbus the remainder of his professional life and was a prominent leading citizen involved in many civic, philanthropic, and church activities such as President of the Rotary Club and recipient of its Paul Harris Fellow Award. Additionally, he pursued his passion for fishing and lure collecting. He retired in 1992 and died in 2011 at age 94.15,31,32,44 (Figure 12) Hornberger left Korea following his tour of duty and traveled home with Kellum as described in the novel. He worked within the Veterans Administration hospital system immediately after the war. This enabled him to meet the requirements of the ABS for certification. Following this, he completed a thoracic surgery fellowship in New York where a mentor was prominent New York thoracic surgeon J. Maxwell Chamberlain. Hornberger decided not to embark into the new field of cardiovascular surgery and returned to Maine where he would incorporate general thoracic surgery into his practice and remain for the remainder of his professional life. He received certification from the ABS in 1955, the American Board of Thoracic Surgery (ABTS) in 1957, and became a Fellow in the ACS in 1958. He retired in 1988 and died in 1997 at age 73.15,31,33,44,45 After returning stateside with Hornberger, Kellum returned to Atlanta and finished his general surgery training at Grady Hospital

and Emory University. He then spent a short time in private practice in Dothan, AL, before returning to Tupelo, MS, where he practiced with his father and brothers in the multi-specialty Kellum Clinic. He was certified by the ABS in 1957 and became a Fellow in the ACS in 1960. He lived in Tupelo the rest of his life, was active in his church, and pursued his passions for gardening and fishing. He remained close friends with both Holleman and Hornberger in the years after the war

Figure 13. Henry Holleman, MD

Figure 14. Grip Kellum, MD

1995. (Courtesy of Jeremiah Henry Holleman, Jr., MD. Reproduced with permission.)

Early 1990s. (Courtesy of Lucius “Luke” M. Lampton, MD. Reproduced with permission.)

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Figure 12. September 21, 1952

Kellum performed successful arterial repair on Lt. Douglas A. Oliver, RNZA. He received a letter of thanks from Oliver for saving his leg. (Courtesy of the Kellum family. Reproduced with permission.)

and hosted his friend Hornberger on his visits to Mississippi. He died in 2001 at age 78.15,31,32,44,46 (Figure 13) Dickson was the last of the “Swampmen” to leave Korea. He returned to Boston where he completed his training under Harken.47 He became certified by the ABS in 1957 and eventually a Fellow in the ACS in 1980. He did not obtain certification by the ABTS. He practiced thoracic and cardiovascular surgery in Boston and New York City from 1954 – 1960 when he left clinical medicine. From 1961 – 1965 he was a Special Fellow at the Electronics Systems Laboratory at Massachusetts Institute of Technology (MIT). He was appointed

by President Lyndon Johnson as Senior Consultant for Health with the Commission on Technology, Automation and Economic Progress. In 1965 Dickson became Director for Engineering and Biology at the National Institutes of Health (NIH). President Richard Nixon appointed him Director of Health for the Advisory Council on Health in 1970. In 1976 Dickson served as Deputy Assistant Secretary for Health, Department of Health, Education and Welfare.

He then became Assistant Surgeon General under Surgeon General C. Everett Koop and President Ronald Reagan.31,32,37,38,44,48,49 In the 1980’s Dickson was involved in the bold initiatives of the federal government’s anti-smoking campaign and the AIDs report under Koop’s tenure. When President George H.W. Bush was elected in 1988 there was the possibility that Koop could be appointed Secretary of Health and Human Services. Dickson was prepared to delay his retirement to continue working with his friend Koop. The Koop appointment did not materialize, and Dickson appears to have retired between 1989 -1992. He is listed as retired status by the American College of Surgeons at age 94.49,50 When Jahnke returned to WRAMC after September 1952, he worked to get the results of arterial repair at the 8055th MASH and other units presented and published as noted previously. He became certified by the ABS in 1954, by the ABTS in 1955, and became a Fellow in the ACS in 1956. He moved into the rapidly developing field of cardiovascular surgery, remained on the staff at WRAMC, and published prolifically. He eventually ascended to the rank of colonel and became Chief of the Thoracic Surgical Service at WRAMC. Jahnke ended his military career in 1970 and relocated to Santa Barbara, CA, where he joined the Santa Barbara Clinic. He was instrumental in initiating cardiac surgery in Santa Barbara and remained there the remainder of his professional career. Jahnke died in 2012 at age 88.31,44,48,51,52 These individuals – Jahnke, Holleman, Hornberger, Kellum, and Dickson – were present at the time and place of the advent of arterial repair and witnessed and participated in this milestone of surgical history.

Books and Movies: Hollywood Takes an Interest Hornberger authored his first book, MASH: a novel about three army doctors, based on his collective memories of real people, places, and events under the pseudonym Richard Hooker.53 According to Hornberger, the pseudonym referenced his golf game.32, 33 In the Foreword of the book, Hornberger gives a disclaimer: “The characters in this book are composites of people I knew, met casually, worked with, or heard about. No one in the book bears more than a coincidental resemblance to an actual person.” 53 Hornberger’s

humorous writing style based on real people and events is evident in letters he wrote home to his parents while in Korea.54 Despite the disclaimer, the characters and events in the novel are mostly based in varying degrees of reality as Hornberger experienced it at the 8055th MASH, which became the 4077th MASH of the book.32 One of the strongest aspects of that reality is the realistic and accurate way the medicine is portrayed. That likely came about as a result of the collaboration between Hornberger and W. C. Heinz.

W. C. Heinz (1915-2008) had a well-regarded career in journalism. He was a WW II correspondent, sportswriter, and fiction/ non-fiction writer. Heinz used his reporter’s skill set to write a 1961 Life magazine cover story about ‘a day in the life’ of a thoracic surgeon.

The thoracic surgeon in the story was modeled after J. Maxwell Chamberlain who gave Heinz the necessary access to research the story. The successful magazine article became Heinz’s second novel, The Surgeon, in 1963.33,55,56,57,58 The original manuscript was not an easy sell. After 17 rejections from publishers, Hornberger asked mentor and friend Chamberlain to connect him with Heinz to see if he would review the manuscript.

Heinz agreed, and the result was the successful and popular novel published by William Morrow and Company in 1968.33,53,55 It appeared that Heinz’s talent for accuracy and clarity in medical reporting again proved successful. The book became 20th Century Fox’s 1970 award-winning movie M*A*S*H with Robert Altman as director and Ring Lardner, Jr., writing the screenplay. The film won an Academy Award for Best Adapted Screenplay.33,55 The second inspiration from Hornberger’s novel was the long-running (1972 – 1983) and award-winning television series. It was evident the movie was related to the book and not so evident, over time, that the book and movie were related to the television series. Author Hornberger and tent-mate Kellum enjoyed the movie but did not care for the television show.32,33,46 The television series drifted away from the book and movie in terms of characters that were developed for their entertainment value to situation-comedy audiences.33 The accuracy and authenticity of surgical history such as a milestone of vascular surgery did not appear to be a priority for the television series. On occasion when surgical history was incorporated into plot lines of the television show, the facts were modified or distorted for the entertainment agenda. One of the more notable examples concerned the story of the death of Charles R. Drew, MD, which was represented inaccurately.59,60,61 The 1970 movie was not Hollywood’s first experience with this subject. In 1953 MGM released Battle Circus directed by Richard Brooks who also wrote the screenplay. It starred Humphrey Bogart as chief surgeon Maj. Jed Webbe (a ‘Hawkeye Pierce‘– type character) and June Allyson as nurse Ruth McCara who is also Bogart’s love interest. Although arterial repair is not referred to in the movie, the film does highlight two medical advances of the Korean conflict – the use of helicopter transport and the mobility of the forward surgical hospital. Interestingly the original title of MASH 66 was changed to Battle Circus to reflect the similarity to the mobility of a circus. It was filmed in 1952, and technical advisor for the movie was Lt. Col. Kryder E. Van Buskirk, the first CO of the 8076th MASH in Korea during 1950-51. The 8076th was the pattern for the fictional 8066th of Battle Circus.33,62,63 Also in 1953 the non-fiction book Back Down the Ridge by W.

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L. White was published by Harcourt, Brace and Company. William Lindsay White (1900-1973) was the son of Pulitzer Prize – winning newspaper editor William Allen White of the Emporia Gazette. He graduated from Harvard and served as a war correspondent during WWII. He continued his journalism career with the Washington Post and Fortune magazine before returning home to Emporia, Kansas, after his father’s death in 1946 to lead the Emporia Gazette until his death in 1973. He wrote 14 books, including They Were Expendable, which became a successful motion picture. Written in the style of a war correspondent, Back Down the Ridge tells the story of medical care during the Korean War. It follows the journey from wounding to battalion aid station to MASH to Japan and finally home with personal stories of the wounded soldiers and remarkably accurate details of their medical care while highlighting the newest medical innovations.

Specifically, White tells the story of Jahnke and successful arterial repair at the 8055th MASH in great detail.64,65 Hornberger would write two more books under his pseudonym of Richard Hooker with no assistance. The first, Mash Goes to Maine (1972), was a true sequel but not as successful as his original novel. It was dedicated to Heinz. Hornberger continued the writing formula of including fictionalized accounts of events in his own life. Interestingly, this novel details Hawkeye Pierce completing his tenure at a VA Hospital, meeting the requirements for ABS certification, and then proceeding with a thoracic surgery fellowship in New York under renowned thoracic surgeon “Maxie Neville.”66 This second book was heralded for capturing “the essence and character of true Mainers.”

In the same article, Hornberger and his fictional Hawkeye Pierce were among five surgeons cited as having “major pivotal roles in the development and progress of surgery in the state of Maine.”67 Pocket Books approached Hornberger and felt strongly that a series of short novels tied to the movie, and now television, characters would be very profitable. Hornberger was reluctant as he was focusing on his surgical career, but he did agree to have them ‘ghost-written’ if he could select the writer and approve the material. He finally agreed on William E. Butterworth, a Korean War veteran and talented writer, who would produce a series of 12 light-hearted books for the Pocket Books series between 1975 and 1977. Although the pseudonym Richard Hooker appeared on the series’ covers along with Butterworth’s name, the books were written solely by Butterworth.33,68 Hornberger’s third novel, MASH Mania (1977) was written as Hornberger’s interests were focused on clinical surgery and his practice, including the emerging field of bariatric surgery. This novel details the adventures of the “Swampmen” now ensconced in their own group private practice in Hornberger’s Maine.33,69,70 It was his last book, and MASH writing was finished for Hornberger.

Sorting Through Fact and Fiction Given Hornberger’s disclaimer at the outset of the original novel, various individuals have been identified over the years as the models for the main fictional characters, primarily Hawkeye Pierce and Trapper John McIntyre. This appears to be related to the popularity of the television series and journalistic searches in the lay press for ‘real-life’ Korean War MASH personnel. Additionally, the medical literature has also identified individuals felt to be the models for these characters based on their military service records, the timing of medical innovations during the Korean War, and again, the popularity

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of the television series. However, do these individual experiences claim ownership of iconic pop cultural figures and surgical milestones based on time and place? The question arises as to how much does image and reality merge as noted by Cowdry in his article MASH vs. M*A*S*H.71 The answer would seem to be ‘perhaps,’ ‘maybe,’ and ‘possibly partially.’ Above all else, however, is the fact that all of those who served in MASH units during the Korean War rendered valuable, noble, critically important, and commendable service to the war effort, saving lives and relieving tremendous suffering. Considering age and memory and within the context of this article, it is worthwhile to examine these issues somewhat closer.

Perhaps the best known of these ‘other’ versions is that of Otto F. Apel, Jr., MD.2 He wrote his memoir MASH: An Army Surgeon in Korea in 1998. Apel served at the 8076th MASH for twelve months starting in the summer of 1951 after being affected by the “Doctors Draft Act” while in a surgical residency at St. Luke’s Hospital in Cleveland, OH. Apel’s memoir notes the advent of successful arterial repair in Korea as late summer of 1951 – before Jahnke – when he and a colleague discussed vein grafting at the 8076th MASH. Both had read about it, neither had seen it, neither had performed it, and neither was aware of any other attempts at arterial repair in Korea. They decided to proceed, and Apel devoted a chapter to his arterial repair experience in his book. He describes initially using 2-0 suture, abdominal surgery instruments, improvised arterial occluders, regional intraoperative heparin, and he states they were “very successful.” He notes they did over 100 arterial repairs in 1951 and “well over 200” through August 1952. Records and follow-up were not kept because the initial repairs were done on North Korean and Chinese prisoners before extending the treatment to injured American soldiers, the procedure was against military policy, and the different medical evacuation chains for the international military forces. In his book, Apel reproduces a paper he wrote on vascular repair in the fall of 1952 shortly after his return from Korea. It describes their experience from August 1951 to August 1952 and includes surgical indications, time interval, techniques noted above, postoperative management, associated vein injuries, and then gives short case vignettes for 10 patients. Of these 10 patients, seven involved the upper extremity and three involved the lower extremity, one of which was vein ligation. Arterial repair consisted of simple suture in four, end-to-end anastomosis in three, vein grafting in two, and vein ligation in one. The paper was never published or submitted for publication. Apel believed that the pioneering work at WRAMC was based on “arterial repair done in the MASH units” which had been introduced in Korea by non-military career MASH surgeons from civilian institutions and not vice-versa. Apel was a consultant for the television series and believed that several of the TV episodes were factual as they were based on his experiences.72 Arterial repair at the 8076th MASH and Apel and colleagues are not mentioned in the publications of Jahnke, Howard, Hughes, or Spencer. Arterial repair is not mentioned in a detailed article on the 8076th MASH by its initial CO Van Buskirk and published in 1953 nor in a review of the operation of the 8076th MASH published in 1987.73,74 Additionally, the Society for Vascular Surgery History Project Work Group interviewed Milton Weinberg, MD, in 2016. Weinberg served at the 8055th MASH from June 1951– January 1952. When asked about arterial repair he stated that he never saw a vessel that he thought could be repaired, implying that arterial repair was not being done during his tenure.75 Finally, Hughes cites two groups of

cases before April 1952 that underwent attempted arterial repair. The earliest group had a success rate of 22.2% (4/18), and the second group had a success rate of 27.5% (11/40). He did not identify the hospital(s) or MASH units involved and noted that there were other instances of attempted arterial repair, none of which were reported.29 It would seem intuitive that if the surgical milestone of successful arterial repair had occurred at the 8076th MASH before Jahnke as Apel describes, its importance and the compassion of the profession would have superseded any regulations that may have hindered its application.

Debate has continued over the identities of the iconic pop cultural characters of MASH. Suggestions for the Hawkeye Pierce character have included Keith Reemstma, John Davis, John Howard, Frank Spencer, Alvin Bronwell, John Vester, Curtis Artz, and Sam Gilfand.6,76,77,78,79,80 Suggestions for the Trapper John McIntyre character have included John Howard and John Lyday.80,81,82 Lucius “Luke” M. Lampton, MD, appears to be the only individual to have conducted interviews with Hornberger and his Mississippi friends, tent-mate Kellum and CO Holleman, on the subject. He documented this in a 1994 article, and the evidence supports the contention that Hornberger based his characters Pierce and McIntyre on himself and Dickson and character Duke Forrest on Kellum.32 Hornberger may well have added attributes of the various individuals listed above to the basic template.

Summary and Conclusions Arterial repair for acute arterial injuries was established during the Korean War. The documented evidence supports the connection that Ed Jahnke appears to have led the initial successful efforts in 1952 at the 8055th MASH. Richard Hornberger, Henry Holleman, Grip Kellum, and Jim Dickson served together at the 8055th MASH in 1952 when Ed Jahnke was there and were involved in the advent of arterial repair. Hornberger wrote the novel MASH: a novel about three army doctors based on his experiences and his colleagues while there. The book can be considered medical historical fiction.

Hornberger remained in surgical practice but continued to write, producing two sequels to his original novel. Each appears to be fictionalized accounts of his life and surgical career. Four of the main characters were largely based on himself (‘Hawkeye’), Holleman (‘Col. Blake’), Kellum (‘Duke’), and Dickson (‘Trapper John’). Hornberger was talented, intelligent, driven, and an independent thinker. His classic novel will forever be linked to Mississippi and a milestone of surgical history. Q References

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4. Baker MS. Military medical advances resulting from the conflict in Korea, part I: Systems advances that enhanced patient survival. Mil Med. 2012; 177(4):423-429.

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32. Lampton L. Mississippi and the real MASH. J Miss State Med Assn. 1994; 35(3):67-77.

6. Flint L. The surgical legacies of Hawkeye Pierce. J Am Coll Surg. 2013; 216(4):515-524.

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34. H. Richard Hornberger, 73, Surgeon Behind ‘M*A*S*H’. Available at: www. nytimes.com/1997/11/07/arts/h-richard-hornberger-73-surgeon-behind-m-as-h.html. Accessed August 13, 2018.

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Surg. 2006; 243(5):612-618.

62. Miller F. Battle Circus (1953). Available at: www.tcm.com/tcmdb/title/2091/ Battle-Circus/articles.html. Accessed August 23, 2018.

63. Woodard SC. The Story of the Mobile Army Surgical Hospital. Mil Med. 2003; 168(7):503-513.

64. White WL. Back Down the Ridge. New York: Harcourt, Brace and Company, 1953.

36. “Original Hawkeye Sees No M*A*S*H Humor.” Newspaper clipping. Personal collection. Kellum Family.

65. Kansas Historical Society. William Lindsay White. Available at: www.kshs.org/ kansapedia/william-lindsay-white/16683. Accessed August 27, 2018.

37. Recent News. drkoop.com: About Us: Corporate Info: Medical Advisory Board.

Available at: http://www.zoominfo.com/p/James-Dickson/18776810. Accessed August 15, 2018.

66. Hooker R. M*A*S*H Goes to Maine. New York: William Morrow and Company, Inc., 1972.

38. Dickson JF. The 1976 Herbert M. Platter Luncheon Address. Federation Bulletin.

1976; 63(7):195-203.

39. Harken DE, Dexter L, Ellis LB, Farrand RE, Dickson JF. The surgery of mitral stenosis: III. finger fracture valvuloplasty. Ann Surg. 1951; 134(4):722-742.

40. Harken DE, Ellis LB, Dexter L, Farrand R, Dickson JF. The responsibility of the physician in the selection of patients with mitral stenosis for surgical treatment.

Circulation. 1952; 5:349-362.

41. Jeremiah H. Holleman, Jr., M.D. Email to the author. 07/14/18.

42. Shumaker H. The evolution of cardiac surgery. Indianapolis: Indiana University Press, 1992. 174.

67. Goldfarb WB. History of surgery in Maine. Arch Surg. 2001; 136:448-452.

68. Kazek K. Alabama has an interesting M*A*S*H connection, in addition to Wayne Rogers. Available at: www.al.com/entertainment/index.ssf/2018/03/alabama_ has_an_interesting_mas.html. Accessed March 12, 2018.

69. Hooker R. M*A*S*H Mania. New York: Dodd, Mead, & Company, 1977.

70. Hornberger HR. Gastric bypass. Am J Surg. 1976; 131(4):415-418.

71. Cowdrey AE. MASH vs M*A*S*H. Medical Heritage. 1985; 1(1):4-11.

72. Apel OF, Apel P. MASH: An Army Surgeon in Korea. Lexington, KY: University Press of Kentucky, 1998.

73. Van Buskirk KE. The mobile army surgical hospital. Mil Surg. 1953; 113(1):27-31.

43. Government Services. Army. Thirty-Eighth Parallel Medical Society. JAMA. 1952; 150(4):1418.

74. Mothershead JL, Crook SL. Operation of the 8076th MASH. Combat support in Korea. Center of Military History. 1987; 116-119.

44. American Board of Surgery. Email to the author. 01/22/18.

75. Milton Weinberg, M.D. “An Interview with Milton Weinberg, MD: Korean Wartime Surgeon.” Interview by Walter J McCarthy, MD, John White, MD, & James S. T. Yao, MD. Society for Vascular Surgery History Project Work Group.

February 12, 2016. Lake Forest, IL. Available at: vsweb.org/Weinberg. Accessed October 14, 2018.

45. American Board of Thoracic Surgery. Personal communication to the author.

10/05/18.

46. Susan Kellum Robin. Personal communication to the author. 08/09/18.

47. Harken DE, Black H, Dickson JF, Wilson HE. De-epicardialization: a simple, effective surgical treatment for angina pectoris. Circulation. 1955; 12(6):955-962.

48. American Board of Thoracic Surgery. Email to the author. 02/09/18.

49. Archives and History. American College of Surgeons. Email to the author.

08/16/18.

76. Flint L. Who is Hawkeye? Surgery. 2002; 131:357-358.

77. Ferraro T. M-A-S-H Models will miss show. Available at: https://www.upi.com/ Archives/1983/02/28/M-A-S-H-Models-will-miss-show/3297415256400/ Accessed January 28, 2018.

78. Adams DB. The life and death of Curtis Artz. Am Surg. 2018; 84(7):1123-1128.

50. Koop CE. KOOP: The Memoirs of America’s Family Doctor. New York: Random House, 1991. 309-311.

79. Kirkland RC. MASH Angels: Tales of an Air-Evac Helicopter Pilot in the Korean War. Short Hills, NJ: Burford Books, Inc., 2009.

51. Graffy ET, Daniel ES. Sansum Clinic: a legacy of medical innovation. NOTICIAS. Journal of the Santa Barbara Historical Museum. 2015; 54(2):103.

80. Zyromski NJ. “Perseverance is my forte”: John M. Howard, MD. Surgery. 2009; 146: 519-520.

52. Edward J. Jahnke, III, M.D. Personal communication to the author. 08/10/18.

81. Reber HA. Memorial Tribute to John M. Howard, MD. Pancreas. 2011; 40(6): 807-808.

53. Hooker R. MASH: a novel about three army doctors. New York: William Morrow and Company, 1968.

54. Hornberger R. “Cpt. H. Richard Hornberger, MD, Shares with His Parents the Antics of His Fellow MASH (Mobile Army Surgical Hospital) Antics.” War Letters.

Ed. Andrew Carroll. New York: Scribner. 2001. 353-356.

55. Congdon L. Legendary sports writers of the golden age: Grantland Rice, Red Smith, Shirley Povich, and W. C. Heinz. Lanham, MD: Rowman & Littlefield, 2017. 135138.

56. Heinz WC. “The Man with a Life in his Hands.” Life. January 20, 1961. 70-78.

57. Schudel M. Obituaries. W. C. Heinz, 93; He Broke New Ground in Journalism.

Available at: www.washingtonpost.com/wp-dyn/content/article/2008/03/04/ AR2008030402835.html. Accessed August 21, 2018.

58. Heinz WC. The Surgeon. Garden City, New York: Doubleday & Company, Inc., 1963.

59. Nakayama D. Charles Drew and his surgeon, Charles Kernodle. History of Surgery. 11/23/17. acscommunities.facs.org. https://acscommunities.facs.org/ viewdocument/re-charles-drew-and-his-surgeon-c?CommunityKey=5b6ae51123ab-4ace-9153-7d4449d7fe1f&tab=librarydocuments.

60. Craft PP. Charles Drew: dispelling the myth. South Med J. 1992; 85(12):12361240, 1246.

61. Cornwell EE, Chang DC, Leffall LD. Dr. Charles Drew, a surgical pioneer. Ann

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82. Martin D. John Lyday, 78, Real-Life Trapper John, Dies. Available at: https://www. nytimes.com/1999/12/24/arts/john-lyday-78-real-life-trapper-john-dies.html.

Accessed October 13, 2018.

Author Information Dr. Trotter earned his undergraduate degree from the University of Tennessee at Knoxville and his medical degree from the Wake Forest University School of Medicine. He completed his general surgical training at the University of Alabama at Birmingham and followed this with fellowships in vascular surgery at Baptist Hospital in Memphis and cardiothoracic surgery at the Ochsner Clinic in New Orleans. He practiced cardiothoracic and vascular surgery at Delta Regional Medical Center in Greenville, Mississippi, until his retirement from surgical practice in 2014. He maintains a strong interest in medical Dr. Trotter history, particularly surgical history of the South and Civil War medicine and has authored multiple articles on these subjects. He has been a guest lecturer and invited speaker at numerous regional and national venues. He served as chair of the MSMA Commemorative Committee organizing the 150th Anniversary Commemorative Program.

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ANGELA SHANNON, MD ɷ PEDIATRIC GASTROENTEROLOGY G.I. ASSOCIATES ɷ FLOWOOD ɷ MADISON ɷ TUPELO

Remembering Arthur C. Guyton, MD JOHN E. HALL, PhD

T

he sudden loss of Dr. Arthur C. Guyton in an automobile accident on April 3, 2003, and the loss of his devoted and remarkable wife, Ruth Weigle Guyton, one week later as a result of injuries from the accident stunned and saddened all who were privileged to know them. Arthur Guyton was a giant in the fields of physiology and medicine, a leader among leaders, a master teacher, and an inspiring role model for people throughout the world.

Arthur Clifton Guyton was born in Oxford, Mississippi, to Dr. Billy S. Guyton, an eye, ear, nose, and throat specialist and dean of the University of Mississippi Medical School, and Kate Smallwood Guyton, a math and physics teacher who had been a missionary in China before their marriage. During his formative years, he enjoyed watching his father work at the Guyton Clinic, playing chess and swapping stories with William Faulkner, and building sailboats (one of which he later sold to Faulkner) and countless mechanical and electrical devices, which he continued to do throughout his life.

Arthur Guyton’s brilliance shone early. He graduated top in his class at the University of Mississippi, distinguished himself at Harvard Medical School, and began his postgraduate surgical training at

Massachusetts General Hospital.

His medical training was interrupted twice – once to serve in the Navy during World War II and again in 1946 when he was stricken with poliomyelitis during his final year of residency training. Suffering paralysis in his right leg, left arm, and both shoulders, he spent nine months in Warm Springs, Georgia, recuperating and applying his inventive mind to building the first motorized wheelchair controlled by a “joy stick,” motorized hoists for lifting patients, special leg braces, and other devices to aid the handicapped. For those inventions he received a Presidential Citation. He returned to Oxford where he devoted himself to teaching and research at the University of Mississippi School of Medicine and was named chair of the Department of Physiology in 1948. In 1951 he was named one of the 10 outstanding men in the nation. When the University of Mississippi moved its medical school to Jackson in 1955, he rapidly developed one of the world’s premier cardiovascular research programs.

His remarkable life as a scientist, author, and devoted father is detailed in a biography published on the occasion of his “retirement” in 1989.1

Dr. Guyton demonstrating the first motorized wheelchair to panel of physicians at Warm Springs, Georgia – 1947.

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part of the everyday vocabulary of hypertension researchers. Dr. Guyton’s far-reaching concepts have been, and will continue to be, the foundation for generations of cardiovascular and hypertension researchers.

Dr. Guyton received more than 80 major honors from diverse scientific and civic organizations and universities throughout the world. A few of these that are especially relevant to cardiovascular and hypertension research include the Ciba Award from the Council for High Blood Pressure Research, the William Harvey Award from the American Society of Hypertension, the Research Achievement Award of the American Heart Association, the Merck, Sharp, and Dohme Award of the International Society of Hypertension, and the Wiggers Award of the American Physiological Society. It was appropriate that in 1978 he was invited by the Royal College of Physicians in London to deliver a special lecture honoring the 400th anniversary of the birth of William Harvey who discovered the circulation of the blood.

Arthur C. Guyton, MD (1919 –2003)

A Great Scientist Arthur Guyton’s research contributions, which include more than 600 papers and 40 books, are legendary and place him among the greatest figures in the history of cardiovascular research. His research covered virtually all areas of cardiovascular regulation and led to many seminal concepts that are now an integral part of our understanding cardiovascular physiology and disorders such as hypertension, heart failure, and edema. It is difficult to discuss cardiovascular regulation without including his concepts of cardiac output and venous return, negative interstitial fluid pressure and regulation of tissue fluid volume and edema, regulation of tissue blood flow and whole body blood flow autoregulation, renalpressure natriuresis, and long-term blood pressure regulation.

Perhaps his most important scientific contribution, however, was his unique quantitative approach to cardiovascular regulation through the application of principles of engineering and systems analysis. He had an extremely analytical mind and an uncanny ability to integrate bits and pieces of information, not only from his own research but also from that of others, into a quantitative conceptual framework.

He built analog computers and pioneered the application of large-scale systems analyses to modeling the cardiovascular system before digital computers were available. With the advent of digital computers, his cardiovascular models expanded dramatically in the 1960s and 1970s to include the kidneys and body fluids, hormones, and autonomic nervous system, as well as cardiac and circulatory functions.2,3 He provided the first comprehensive systems analysis of blood pressure regulation and used this same quantitative approach in all areas of his research, leading to new insights that are now

A Master Teacher Although Dr. Guyton’s research accomplishments are legendary, I believe his contributions as an educator have had an even greater impact on the world. The fact that he and Ruth raised 10 remarkable children, all of whom became outstanding physicians, is a great educational achievement in itself.

Eight of the Guyton children graduated from Harvard Medical School, one from Duke Medical School, and one from the University of Miami Medical School after receiving a PhD from Harvard.

An article published in Reader’s Digest in 1982 highlighted their extraordinary family life.4 The success of the Guyton children did not occur by chance. Dr. Guyton’s philosophy of education was to “learn by doing.” The children, therefore, participated in countless family projects that included the design and construction of their home and heating system, swimming pool, tennis court, sailboats, homemade gocarts and electrical cars, gadgets for their home, and electronic instruments for their Oxford Instruments Company. Television programs such as Good Morning America and 20/20 described the remarkable home environment that Arthur and Ruth Guyton created to raise their family. They are a wonderful family, sharing the values of hard work and dedication, teamwork, the excitement of learning and discovery, and a deep love for each other. His devotion to family is beautifully expressed in his Textbook of Medical Physiology5 that bears this dedication: “To My Father for his uncompromising principles that guided my life; My Mother for leading her children into intellectual pursuits; My Wife for her magnificent devotion to her family; My Children for making everything worthwhile.”

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William Faulkner, sailing on Sardis Lake, Mississippi, on a sailboat built by Arthur Guyton. Guyton and his family enjoyed the boat; however, he later sold it to his neighbor, William Faulkner, the 1949 Nobel prize winning author.

of graduate students and postdoctoral fellows. He trained over 150 scientists, of whom at least 29 became chairs of their own departments and six became presidents of the American Physiological Society.

He gave students confidence in their own abilities and emphasized his belief that “people who are really successful in the research world are self-taught because they are teaching themselves beyond where other people are.” No one has been more prolific in training leaders of physiology than Arthur Guyton. In 2001, he received the Eugene Braunwald Academic Mentorship Award from the American Heart Association.

Like many of his trainees, my first association with Dr. Guyton occurred through his famous Textbook of Medical Physiology long before I came to Mississippi. His book is a masterpiece, presenting the key concepts in a clear and interesting manner that makes studying physiology fun. He wrote this book to teach his students, not to impress his professional colleagues, and its popularity with students has made it the most widely used physiology textbook in history. This accomplishment alone was enough to ensure his legacy.

Through his Textbook of Medical Physiology, which has been translated into at least 22 languages, he has probably done more to teach physiology to the world than any other individual in history. Unlike most major textbooks, which often have as many as 10 to 20 authors, the first eight editions of the Textbook of Medical Physiology were written entirely by Dr. Guyton, over a period of nearly 40 years. This feat is unprecedented for any physiology or medical text. When he invited me to help with the 9th and 10th editions, I was absolutely elated and honored. His textbook is unique in the history of medical publishing.

For his many contributions to medical education, Dr. Guyton received the 1996 Abraham Flexner Award from the Association of American Medical Colleges. He is also honored each year by the American Physiological Society through the Arthur C. Guyton Teaching Award.

An Inspiring Role Model

Dr. John Hall, Arthur C. Guyton Professor and Chair of Physiology and Director, Mississippi Center for Obesity Research at UMMC, said, “This is one of my favorite pictures because it shows why he was such an outstanding mentor and educator – he is smiling and welcoming any student or faculty member who came to talk with him. One of his greatest contributions to medical education was his Textbook of Medical Physiology that was first published in 1956.”

Dr. Guyton was a master teacher and personally taught every medical student at the University of Mississippi for over 50 years. Even though he was always busy with service responsibilities, research, writing, and teaching, Dr. Guyton was never too busy to talk about a new research idea or a new experiment or to talk with a student who was having difficulty. He would never accept an invitation to give a prestigious lecture if it conflicted with his teaching schedule. His contributions to education are also far reaching through generations

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Dr. Guyton’s accomplishments extended far beyond science, medicine, and education. He was an inspiring role model for life as well as for science. No one was more inspirational or influential on my own life and scientific career than Dr. Guyton, and I suspect most of his trainees feel the same way. Dr. Guyton taught us much more than physiology – he taught us life, not so much by what he said, but by his unspoken courage and dedication to the highest standards.

He had a special ability to inspire people through his indomitable spirit.

Although he was severely crippled with polio, no one who ever worked with Arthur Guyton thought of him as being handicapped. His brilliant mind, his indefatigable devotion to science, education, and family, and his spirit and courage captivated students and trainees, professional colleagues, politicians, business leaders, and virtually everyone who knew him.

Those who did not know him well were often curious about how he accomplished so much despite his “handicaps.” Elvin Smith, one of

Guyton Family - This picture was taken in 1989, but his family continues to expand, and the number of doctors coming from this family continues to grow.

Dr. Guyton’s students, who later became chair of physiology and executive vice president of the medical school at Texas A&M, tells a story about the time Dr. Guyton took him and other members of the department to attend a banquet at which Dr. Guyton and Eudora Welty (who won a Pulitzer Prize for fiction among many other honors) received the first Outstanding Mississippian Award. After the ceremony, the students were standing next to Dr. Guyton as he was being congratulated. One of the ladies in the line stopped to talk to Elvin and to Jack Crowell, a faculty member and former student, and asked, “Isn’t it amazing what Dr. Guyton has accomplished with his handicaps?” With little hesitation, Jack looked up and said, “Yes ma’am, it sure is amazing, and Elvin and I are two of his biggest handicaps.” Those of us who worked with Dr. Guyton never thought of him as handicapped. We were too busy trying to keep up with him.

Dr. Guyton’s courage in the face of adversity humbled us. He would not succumb to the crippling effects of polio. I am fairly confident that no repairman ever crossed his doorstep, except perhaps for a social visit. He and his children not only built their home but also repaired each and every malfunctioning appliance and home device no matter the difficulty or the physical challenge. He built a hoist to lower himself into the “hole” beneath their house to repair the furnace and septic lines when calling a repairman seemed to be the only option to those who did not know him well. On trips to meetings, he walked long distances across airport terminals when using a wheelchair would have been much easier. His struggle to rise from his chair and walk to the podium for a lecture was moving, but the audience was always more impressed when he forcefully articulated his brilliant

In addition to raising ten doctors, he taught every medical student at the University of Mississippi for 55 years. In fact, he continued to give lectures to the medical students about the importance of physiology to clinical medicine until his death in 2003. As you can see, he did not use PowerPoint. He favored simple, clear explanations that he illustrated on the overhead projector.

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Arthur Guyton’s interesting life and contributions to the world of science, medicine and education are recounted in this biography, published in 1989 soon after his retirement as chair of Physiology at UMMC.

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concepts. His courage challenged and inspired us. He expected the best and somehow brought out the very best in people. Seeing his indomitable spirit and the challenges that he overcame, how could his trainees not do their best?

ike many of his trainees, my first association with Dr. Guyton occurred through his famous

Textbook of Medical Physiology, long before I came to

Mississippi. His book was a masterpiece, presenting

As a symbol of their deep respect and affection for him, Arthur Guyton’s students and trainees always referred to him as “The Chief ” or “Dr. Guyton” no matter how long they had known him.

He told me many times that I should call him “Arthur” instead of “Dr. Guyton.” This is one of the few instances where I did not follow his advice. It just didn’t feel right. Dr. Guyton was like a father to me and, I suspect, to most of his trainees. He not only taught us physiology but also important lessons of life.

key concepts in a clear and interesting manner that made studying physiology fun. He wrote this book to teach his students, not to impress his professional colleagues, and its popularity with students has made it the most widely used physiology textbook in history. Equally impressive is the fact that he wrote

We celebrate the magnificent life of Arthur Guyton, recognizing that we owe him an enormous debt. He gave us an imaginative and innovative approach to research and many new scientific concepts of cardiovascular regulation, he gave countless students throughout the world a means of understanding physiology, he gave many of us exciting research careers, and most of all, he inspired us—with his devotion to education, his unique ability to bring out the best in those around him, his warm and generous spirit, and his courage.

We will miss him tremendously, but he will remain in our memories as a shining example of the very best in humankind. Dr. Arthur Guyton was a real hero to the world, and his legacy is everlasting. Q

the first eight editions entirely by himself. I was privileged to work with Dr. Guyton on the textbook starting over 25 years ago with the 9th and 10th editions, and his passing in 2003 have continued writing the 11th, 12th, and 13th editions of the book. Through his Textbook of Medical Physiology, which has been translated in at least 22 languages and is the most widely read physiology textbook of all time, he has probably done more to teach

Author Information Dr. Hall, Arthur C. Guyton Professor and Chair of Physiology and Director, Mississippi Center for Obesity Research at UMMC, received his doctorate in Physiology at Michigan State University and postdoctoral training at UMMC before joining the faculty in 1976. Hall’s major research interests include cardiovascular and renal physiology, mechanisms of hypertension, obesity and metabolic disorders. Since 1975 his research has been funded by NIH. He has Dr. Hall penned over 600 publications, including 21 books and the Textbook of Medical Physiology that has been published in 22 languages. He is former Editor-in-Chief of Hypertension and The American Journal of Physiology and served as President of the American Physiological Society and the Inter-American Society of Hypertension, Chair of the Scientific Councils American Heart Association, Chair of the Hypertension Council and on the Executive Committees of several international societies. Hall has received numerous awards for his research and teaching and has mentored over 145 fellows and trainees.

References 1. Brinson C, Quinn J. Arthur C. Guyton: His Life, His Family, His Achievements.

Jackson, Miss: Hederman Bothers Press; 1989.

“

physiology to the world than any other individual

2. Guyton AC, Coleman TG. Quantitative analysis of the pathophysiology of hypertension. Circ Res. 1969;24(suppl I):I1–I19.

in history.”

3. Guyton AC, Coleman TG, Granger HJ. Circulation: overall regulation. Annu Rev Physiol. 1972;34:13–46.

—John E. Hall, PhD

4. Bode R. A doctor who’s dad to seven doctors—so far! Reader’s Digest.December 1982:141–145.

5. Guyton AC. Textbook of Medical Physiology. Philadelphia, Penn: W.B. Saunders Co; 1956. * Parts of this article were reprinted with permission from the following paper: Hall JE. In Memoriam: Arthur C. Guyton, MD (1919-2003). Hypertension 2003; 41: 1175-1177.

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Distinguished Mississippians

Guyton, Hardy Portraits Unveiled at Hall of Fame Dedication

O

n December 11, 2018, the portraits of two giants of Mississippi medicine were dedicated into the Hall of Fame of the State of Mississippi. In the historic House of Representatives Chamber of the Old Capitol Museum, paintings of Dr. Arthur C. Guyton and Dr. James D. Hardy were unveiled in a public ceremony followed by a reception.

Offering remarks were Dr. LouAnn Woodward, vice chancellor and dean of the University of Mississippi Medical Center School of Medicine; Dr. John E. Hall, the Arthur C. Guyton Professor and chair of the UMMC Department of Physiology; and Dr. Christopher D. Anderson, chair of the UMMC Department of Surgery.

Arthur Clifton Guyton was born September 8, 1919, in Oxford, Mississippi. He attended medical school at Harvard University to pursue a surgical career. During his residency, Guyton was diagnosed with polio, and the residual paralysis forced him to turn from surgery to medical research. His rehabilitation inspired him to design special crutches and braces, hoists for lifting patients, and the motorized wheelchair with joystick; a presidential citation followed in 1956 for these inventions.

That same year Guyton published the first edition of Textbook of Medical Physiology. The book, now in its thirteenth edition, is still the best-selling physiology textbook in the world. Guyton's groundbreaking work on cardiovascular physiology influenced the way physicians treat hypertension, congestive heart failure, and edema today. The National Institutes of Health grant that he was awarded in 1968 is still ongoing and is among the longest-running grants in NIH history. Dr. Arthur C. Guyton died in 2003. (See related article, “Remembering Arthur C. Guyton, MD”) James Daniel Hardy was born May 14, 1918, in Newala, Alabama. He graduated in 1942 from the University of

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Pennsylvania School of Medicine, then served in the U.S. Army Medical Corps during World War II. In 1955, Hardy became the founding chairman of surgery at the University of Mississippi Medical Center in Jackson. In 1963, he led the team that performed the world’s first lung transplant. The following year Hardy and his team transplanted the heart of a chimpanzee into a dying man, predating the first human-to-human heart transplant by three years.

Hardy served as president of the Society of University Surgeons, the Society of Surgical Chairmen, the Southern Surgical Association, the American College of Surgeons, the American Surgical Association, and the International Society of Surgery. Throughout his career, he authored 24 books and 466 papers, while also producing more than 200 medical films. Dr. James D. Hardy retired in 1987 from UMMC and died in 2003.

(See related article, “First Heart and Lung Transplants – James D. Hardy, MD”) Steve Moppert, a past “best in show” winner of the National Portrait Competition, painted both portraits. His paintings are included in the permanent collections of the Louisiana State University Medical Center Mississippi Governor’s Mansion, Mississippi College, and the University of Mississippi Medical Center.

The Hall of Fame contains 136 distinguished Mississippians, including Gulf Coast artist Walter Anderson, author Eudora Welty, civil rights hero Medgar Evers, Choctaw chief Pushmataha, and federal judge Burnita Shelton Matthews. Any Mississippian – native or adopted – deceased at least five years may be nominated for the Hall of Fame. Elections are held once every five years, and only five people may be inducted into the Hall each cycle. Portraits of members of the Hall of Fame hang in the historic Senate Chamber and throughout the Old Capitol Building.

From left to right: Dr. Jean Guyton Gispen (daughter of Arthur Guyton, MD), Dr. John E. Hall, chair of the Department of Physiology at the University of Mississippi Medical Center; Mississippi Department of Archives and History Board of Trustees President Kane Ditto; Dr. Christopher D. Anderson, chair of the Department of Surgery at UMMC, and Dr. Bettie Hardy Story (daughter of James Hardy, MD). Q

About the Cover ...

Images in Mississippi Medicine – The cover images are taken from the book by the same name. Written by longtime editors of the Journal MSMA, Lucius “Luke” Lampton, MD and Karen A. Evers, Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi provides an extraordinary and unrivaled account of the evolution of medicine in Mississippi from territorial times to today’s latest technology. This magnificently illustrated book offers a unique array of rare photographs and historical images as well as compelling essays

by Dr. Lampton which reveal the untold story of Mississippi’s medical history, a largely forgotten drama peppered with forgotten but brilliant medical heroes who helped shape the larger history of the state in both political and social terms.

Published to recognize and commemorate the 150th Anniversary of the Mississippi State Medical Association House of Delegates, the 266-page hardback book provides a comprehensive narrative history of medicine in the state with accompanying images spanning the decades.

Included among the 300-plus images are those on the cover. Clockwise: Mississippi’s First Board of Health, 1877; Surgical Amphitheatre at Mississippi State Charity Hospital, Vicksburg, 1908; Hardy’s Invalid Carriage, Jackson, 1907.

The story of medicine is the story of men and women and their endeavors to care for their patients and advance their profession. The book’s chapters explore with fascinating narrative and vivid imagery the

rise of hospitals and medical institutions, physician pioneers, the history of the treatment of mental illness, the emergence of public health, the crusade for medical education, and the accomplishments of organized medicine.

An old idiom asserts that a picture speaks a thousand words, and the hundreds of images in the book tell the story of medicine with texture, color, and depth words often can’t convey. Mississippi has always possessed a distinctive medical sense of place, with its history strongly influenced by its sultry climate as well as native and imported diseases.

The long struggle of physicians was arduous in their efforts to battle the state’s significant health challenges, which included poverty, race, and an often-malignant climate. This unique collection of rarely seen historic medical images dates from the antebellum period to modern medicine and tells in vivid imagery Mississippi’s important story.

Attendees of the 150th Commemorative Gala received the coffeetable style book complimentary as a keepsake. Over two decades in the making, this book will prove essential to anyone interested in medicine in the state. The book makes an excellent, original gift for doctors, medical students, and history buffs. If you missed out, order your copy today at MSMAonline.com or call Dominica Thames at 601-853-6733, ext 312. Receive a volume discount when you order three or more. Save on shipping and by picking up at MSMA headquarters. Questions, call Karen Evers, ext. 323.

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First Heart and Lung Transplants

James D. Hardy, MD, at UM School of Medicine MARC MITCHELL, MD

n March 23, 1953, Dean David Pankratz selected 34-year-old James D. Hardy, MD (Figure 1) to be the first Chairman of the Department of Surgery at the University of Mississippi School of Medicine.1,2 The first clinical chair appointed at the new four-year medical school in Jackson, Hardy would hold the position for 32 years. He would eventually become a world renowned surgeon, but the first ten years of his tenure as department chair are by far the most remarkable of his career and brought considerable notoriety to the new medical school.

O

performed the first open heart operation at the University Hospital.

The Department of Surgery in 1955 consisted of seven full time faculty members, including Hardy. Four of the seven were general and cardiothoracic surgeons. The other three represented anesthesia, neurosurgery, and orthopedic surgery. Three of the original four original General Surgery faculty members, including Hardy, eventually served as department chairs: Curtis P. Artz, MD became chair at the Medical University of South Carolina, and Watts R. Webb, MD became chair at Tulane University.

A native of Alabama, Hardy attended medical school and trained in surgery under Isidor S. Ravdin, MD at the University of Pennsylvania.

Hardy was profoundly influenced by his experiences at Penn and modeled his surgery training program after the Penn program.3 The General Surgery and Thoracic Surgery residency programs were certified by the Conference Committee for Graduate Training in Surgery in 1956.

Hardy was a dedicated researcher who considered research to be an integral part of an academic department of surgery, once again modeling his department after the one at Penn. In 1955, he secured a five-year $250,000 National Institutes of Health grant and immediately initiated programs of basic science and clinical research with an emphasis on cardiovascular physiology and transplantation.

Hardy focused on lung transplantation, while Webb worked on heart transplantation. Their efforts would eventually result in the world’s first heart and lung transplants performed at the University Hospital.

During his first five years as department chair, Hardy had 25 abstracts on the program of the Surgical Forum of the American College of Surgeons, including seven in both 1958 and 1959. The Surgical Forum was one of the most prestigious arenas for researchers to present their work, and the University of Mississippi and Hardy dominated the

In 1955 Hardy left his position as director of surgical research at the Medical College of the University of Tennessee in Memphis and moved to Jackson to begin building his department. The University of Mississippi Hospital admitted its first patient on July 1, 1955, and the first surgical patient underwent repair of an incarcerated inguinal hernia

by Hardy that same day. Less than 4 years later, on January 27, 1959, he Figure 1. James D. Hardy, MD in the late 1950s

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Figure 2. The first lung transplant patient

Figure 3. Intra-operative photo of the first heart transplant

program. By 1963 Hardy was ready to move forward with heart and lung transplants. He developed four criteria for the first lung transplant: 1 – the patient must have a fatal condition, 2 – there must be a high probability that the patient would benefit from the procedure, 3 – removal of the recipient lung must not further impair lung function, 4 – the left lung would be transplanted.

The recipient was a prisoner with an untreatable cancer involving the entire left lung. On June 11, 1963, a donor became available. Martin L. Dalton, Jr., MD who was the senior thoracic surgery resident and who did much of the work in the lung transplant research lab procured the donor lung. Hardy and Webb performed the transplant. Dalton would go on to have a very productive academic career, becoming Chairman of the Department of Surgery and then Dean at Mercer University School of Medicine. While Hardy was performing the transplant, Dalton was called to the emergency department to care for a man who was shot in the chest. That man was Medgar Evers, the civil rights activist who was brutally murdered. The murder received national attention and greatly overshadowed the lung transplant. Bob Dylan wrote the song “Only a Pawn in Their Game” about the murder.

The film “Ghosts of Mississippi” chronicled the trial and eventual conviction in 1994 of the murder, Byron De La Beckwith. There were rumors that Evers was the donor for the transplant, but they were untrue. Hardy learned about the murder after he completed the transplant.

The lung transplant was a success. The patient survived for 18 days (Figure 2), eventually dying of renal failure. Hardy summed the experience this way, “First, clinical homotransplantation of a lung is readily accomplished technically. Second, a homotransplanted lung can participate in respiratory support of the recipient. Third, immunologic response in our patient was suppressed with available drugs the eighteen days that the patient survived. Fourth, experience with this case opens the way to further careful exploration of lung homotransplantations in man.”4 In January 1964, a 68-year-old man was dying of hypertensive cardiomyopathy and experiencing emboli from his heart to his legs.

His cardiologist described the situation as unequivocally critical with life expectancy measured in hours only. Dalton and Webb had left the NOVEMBER/DECEMBER • JOURNAL MSMA

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University of Mississippi by this time. On January 23, 1964, Hardy performed the world’s first human heart transplant (Figure 3) using a donor heart from a chimpanzee. The heart functioned for 90 minutes demonstrating that a human heart transplant was technically feasible, before failing from rejection and being undersized.

Figure 4. Dr. Hardy as President of the American College of Surgeons

This event brought considerable notoriety to Hardy and the University of Mississippi. The heart transplant was praised in Europe but widely criticized in the United States. Hardy said that he became a “pariah in American surgery” and never performed another heart transplant.

It would be over three years before the first successful human heart homotransplant was performed by Dr. Christian Bernard in South Africa. That patient survived for 18 days. In 1984 Leonard L. Bailey, MD, transplanted a baboon heart into an infant receiving widespread praise.

Lung transplantation did not progress as rapidly as heart transplantation. Joel D. Cooper, MD, is widely acknowledged as performing the first successful lung transplant in 1983. Ironically Hardy’s patient was not considered a success because he survived only 18 days, the same as the first successful heart transplant by Bernard.

Hardy went on to become one of the most accomplished academic surgeons in the world. Some of his achievements include serving as president (Figure 4) of the American Surgical Association (1975) and the American College of Surgeons (1980). The American Surgical Association is the world’s most prestigious surgical organization and the American College of Surgeons the world’s largest. He was a prolific writer who published 24 books, authored 466 peer reviewed manuscripts, 139 book chapters, made over 200 films and was editor of the World Journal of Surgery.

Surgical education was an important aspect of Hardy’s career and perhaps the part he was most proud of. During his career, Hardy trained 178 residents. His residents were exceptionally loyal to him.

He was an outstanding mentor to his residents and junior faculty, producing eight chairs of surgical departments, a medical school dean and university president.

Hardy had a long and impressive academic career of over 40 years, but the first decade he spent at the University of Mississippi was by far the most important. During that time, he built an academic surgery department at a brand-new medical school, started residency programs and conducted basic science research which ultimately lead to the first heart and lung transplants.

Hardy’s legacy is secured at the University of Mississippi by the clinical sciences building which bears his name and an endowed chair and lectureship. In addition, he trained hundreds of surgeons, many of whom settled in Mississippi and the surrounding states. His broader legacy is the thousands of heart and lung transplants performed worldwide every year. James D. Hardy truly was one of the most influential surgeons of the 20th century. Q

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References 1. Quinn J. Promises Kept: The University of Mississippi Medical Center. Jackson, MS: University of Mississippi Medical Center and University Press of Mississippi, 2005.

2. Sansing D. The University of Mississippi: A Sesquicentennial History. Jackson, MS: University Press of Mississippi, 1999.

3. Hardy JD. The Academic Surgeon: An Autobiography. Mobile, AL: Magnolia Mansions Press, 2002.

4. Hardy JD. The World of Surgery 1945–1985: Memoirs of One Participant.

Philadelphia: University of Pennsylvania Press, 1986.

Author Information

Dr. Mitchell

Dr. Marc Mitchell is Chair of the Department of Surgery at the University of Mississippi Medical Center. With areas of practice in Vascular and Endovascular Surgery, Dr. Mitchell also works at the G.V. “Sonny” Montgomery VA Medical Center. He graduated from the University of Georgia and earned his medical degree from Georgetown University. He completed further surgical studies at the National Institutes of Health, the University of Mississippi and the University of Pennsylvania. Dr. Mitchell has received numerous awards and honors and has been published multiple times.

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1878 Epidemic

Yellow Fever in Mississippi DEANNE L. STEPHENS, PHD

W

hen yellow fever struck Mississippi in the summer of 1878, citizens hoped that the disease would not reach epidemic proportions that year. Mississippians were used to the annual visitations of yellow fever. A long history with the disease dated back and through colonial conquests, territorial status, and 1817 statehood. During the nineteenth century, Mississippians and Louisianans experienced an especially harsh epidemic in 1853 and thereafter nervously anticipated the severity of each season, hoping annually for a mild outbreak. In 1878, however, yellow fever swept the state with unprecedented consequences. This epidemic counted 16,461 cases that resulted in 4,118 deaths.1 Mississippi officials had created a State Board of Health in 1877, but it was powerless to meet the medical and provisional needs of those who suffered under the strains of the 1878 epidemic. Paltry financial appropriations had accompanied the newly created health board, and with no understanding of the etiology of the disease, the 1878 yellow fever epidemic eclipsed all other outbreaks in Mississippi.

The exact origin of yellow fever is unknown, but it probably first appeared in East or Central Africa with transmission between primates and humans. Europeans introduced it from Africa into the New World after 1492 via commercial shipping along the African transatlantic trade routes. More than likely, the holds of slave-trading ships transported the disease to commercial markets in Mexico, the Caribbean, and then North America.2 Once established in the New World, yellow fever spread along maritime and overland trade routes. The virus spread easily, carried by the ever-present Aedes aegypti mosquito and by viremic individuals. This species of mosquito readily acclimates to environments created by humans since it breeds well in stagnant or slow-moving water such as that found in water casks, holds of ships, and cisterns.3 The mosquito vector is well adapted to an urban, human environment. Therefore, since the yellow fever virus cannot exist independently of a host, it must multiply both in vertebrates, such as monkeys and humans, and in arthropods, such as mosquitoes. In a classic urban epidemic, humans and A. aegypti are interdependent organisms.

The course of yellow fever can be horrific, as described by many.

The first symptoms to appear are a high fever, flushed face, bloodshot eyes, and chills. Temperatures often soar to between 102 and 104 degrees. The victim’s fever then drops, and a look of general health and improvement ensues. Despite that appearance, the disease continues to make its way through the victim’s body. Shortly after

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the lull of symptoms, the skin begins to turn yellow because of dramatic jaundice, and other symptoms such as nausea, constipation, headache, and often-severe muscular pains in the legs and back develop. At this stage, bleeding begins in the mucous membranes, gums, and stomach in the more acute cases. A common term for yellow fever, “black vomit,” derives from the regurgitation of partially digested blood. Black vomit is usually the harbinger of death in yellow fever patients, often occurring within the last two days of the victim’s life. Today, medical science knows that damage to the liver, kidneys and heart occurs as the yellow fever virus travels throughout the victim. Modern physicians know that in the most severe yellow fever cases, death generally results from renal or heart failure, toxemia, and internal infections. Nineteenth-century physicians did not understand the disease nor did they know how to treat it even though several medical schools of thought addressed it and other maladies.

Allopaths, or traditional physicians, often tried “heroic” methods of treatment to produce effects different from the symptoms of the disease they were treating, and the prescriptions were usually in massive doses. Allopathy was more popular in the 1853 epidemic, but it still had its adherents in the 1878 visitation. One such physician was a Dr. Gibson of the Yazoo City region. Gibson kept a detailed prescription book that he used in treating patients. In it, he listed eighteen prescriptions for yellow fever. One of these medications mixed a solution of arsenic, quinine sulphate, and cherry laurel water with a few drops of sulphuric acid to dissolve the quinine. The yellow fever patient took a teaspoonful of this mixture after meals. The arsenic, of course, affected the patient severely and created even more health issues. Gibson’s remedy exemplifies the medical ignorance concerning yellow fever and its etiology, a characteristic common to both physicians and the public in 1878.4 Homeopaths advocated a different medical approach to treat yellow fever. This medical school, originating in Germany in the early nineteenth century, stressed the use of the smallest amount of pharmaceuticals to treat a disease. The doctrine of infinitesimal dosages was its prevailing principle of treatment. Two homeopathic physicians practiced in Vicksburg during the 1878 yellow fever epidemic, Dr. A. O. H. Hardenstein and his son, Dr. Earnest Hardenstein. The Hardensteins adamantly believed that homeopaths should “not use leeches, practice bloodletting, blistering or put the patient in an icebox.” They referred to these treatments as “needless cruelty.” 5 The physio-medical adherents had their roots in an earlier group,

Mississippi in 1878, including towns and cities most affected by the yellow fever epidemic.

This poster was printed by the Lampton Mercantile Company of Magnolia in the late nineteenth century during a Mississippi yellow fever epidemic. It suggests the great public fear the words "yellow fever" would induce in the general population in that era before 1905.

the botanico-medical movement, founded by Samuel Thomson in the late 1700s. Based on Thomson’s theory that vegetable materia medica was more effective than the prescriptions of the medical establishment, these physicians used a wide variety of herbs and other plants in their treatments. By 1878, the original movement has evolved into the botanics. They were especially popular in the South during the nineteenth century. For example, one 1873 list of physicians in Mississippi included 646 regular physicians (allopaths), 13 homeopaths, and 49 mostly botanics. John S. Haller, Jr., wrote, “In most instances, their [the allopaths] chief sectarian rivals were the homeopaths, except in the South, where the numbers of miscellaneous practitioners (many of the holdovers from Thomsonianism) continued to vie even with the regulars.” 6 Allopaths, homeopaths, and botanics used pharmaceuticals of all types to produce far different results in their yellow fever patients.

Even though all physicians encountered great trouble in treating yellow fever victims, they recognized that nursing care was critical to their patients’ recuperation if the person lived past the initial stages.

The Howard Association was one philanthropic organization that provided nurses and physicians to help alleviate the suffering in the 1878 yellow fever epidemic.

Organized in 1837 in New Orleans, Louisiana, the Howard Association was a group of thirty civic-minded volunteers who chartered this charitable society to treat particularly the indigent, regardless of race, color, or sex. The Howards provided the necessary medical personnel and provisions to all, however. They incorporated in 1842, and obtained a state charter from Louisiana, becoming associated primarily with yellow fever care. From its founding in 1837 and in the epidemic of 1878, it generously provided medical assistance in every annual outbreak both within and outside of Louisiana. Local groups of volunteers in other states also organized across the epidemic-stricken South and based their outreach on the original tenets of the Howards. They even called themselves Howards. For example, in Canton, Mississippi, in 1878 a group referring to themselves as Howards created a separate hospital for African American yellow fever victims. The organization hired

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nursing personnel from beyond the epidemic’s swath and paid their salaries, transportation costs and room and board. The Howards, regardless of their location, relied mostly upon donations to accomplish their work.7 The treatment yellow fever victims received in the 1878 epidemic depended upon geographical accident, word of mouth, a physician’s school of thought, and adequate provisional care as well as nursing.

Private and parochial charities operated throughout the epidemic to relieve the suffering of Mississippians during the epidemic. Private individuals donated monies and goods to victims. Although the citizens of Mississippi benefited from the aid of sundry organizations and charities as well as additional medical personnel during the 1878 epidemic, many Mississippians suffered and died.

In July 1878 when yellow fever broke out in Mississippi, its march across the state followed the major transportation routes at that time, railroads and waterways. Railroads had begun to play a dominant role in Mississippi’s expanding economy in the 1870s, and by 1880 approximately 1,127 railroad miles crisscrossed the state. Two key railroad cities, Vicksburg and Meridian, experienced significant population growth as a result.8 When yellow fever appeared in those two municipalities and other areas that year, Mississippians took advantage of the improved railroad network to flee from the contagion, thus inadvertently spreading the disease. Viremic individuals and virus-carrying mosquitoes traveled the rails to other locales.

In addition, watercraft steaming on the myriad waterways of Mississippi also became vessels of disease transmission. The exact cause of yellow fever’s introduction into Mississippi in 1878 is unknown, but most contemporary officials agreed that the towboat John Porter was the source of contagion. Chugging upriver from already-infected New Orleans, the John Porter was a “floating charnel house carrying death and destruction to nearly all who had anything to do with her.” The boat reached its terminus at Pittsburgh, Pennsylvania, after landing at towns along the Mississippi and Ohio Rivers. From the time the boat left New Orleans until it reached Pittsburgh, twenty-three people on board died of yellow fever.9 As some Mississippians and others carried the disease across the state via railroads and watercourses, others spread yellow fever as they fled on foot while seeking refuge in fever-free areas. To counter pedestrian and carrier movement, certain locales enacted quarantine lines to thwart people from entering their region. Armed shotgunwielding citizens often guarded these quarantine lines. In protecting their town, however, the appointed militia also created barriers to all travel and trade. Many officials believed that if they isolated their cities, then the contagion could not reach them. This method of disease control in Mississippi dates back to 1799 when territorial

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lawmakers prohibited any vessel or immigrant with a contagious disease such as yellow fever or smallpox from entering the region. In 1803 and 1807, the Mississippi territorial government strengthened its original law to include a fine of two thousand dollars or twelve months in prison for anyone who willfully brought a contagious disease into its boundaries.

In 1817 when Mississippi became a state, Natchez organized the first city board of health and established a quarantine station at Bacon’s Landing, two miles below the city to protect it from contagious diseases. The Mississippi law code empowered all other towns in 1858 to pass regulations adopting measures to prevent the introduction of yellow fever and other diseases. From 1857 to 1876, legislators passed no new health laws, even though officials organized the Mississippi State Medical Association in 1869. One year prior to the creation of the state Board of Health in February 1877, Jackson, Harrison, and Hancock Counties had created a coastal board of health to guard against yellow fever and to organize quarantine stations in each of those counties.10 Health officials who attempted to maintain quarantine lines in 1878 often found themselves at odds, however, with local business interests, particularly along the Mississippi Gulf Coast where tourist trade especially from New Orleans was vital to the economy.

Quarantine regulations and enforcement consequently had no uniformity as some locales chose to enforce the lines strictly and others chose to ignore them. The Pascagoula Democrat-Star reported on July 26, 1878, that Pascagoula and Mississippi City “do not believe there is any probability of fever getting into our ports this summer, as a strict quarantine is kept up at all the towns.”11 Biloxi, however, had a less stringent quarantine, since its health officials did not want to fight local business interests and possibly stymie its economy. Throughout the epidemic months, situations such as this existed across the state with erratic quarantine. The State Board of Health did not establish statewide regulations so quarantines control fell on the shoulders of individual localities.

The town of Holly Springs provides an excellent case study both of what worked and of what did not work in a crisis managed by a patchwork of local officials. Since the Mississippi State Board of Health was unable to enforce quarantine regulations or provide provisions and consistent action points, citizens across the state took it upon themselves to address the impact of the epidemic.

In early September 1878, as news spread of yellow fever across Mississippi, the majority of the citizens of Holly Springs fled ahead of the contagion. According to Helen Craft Anderson, “Men, women, and children struggled in one mighty effort as the first flight from the presence of an unseen foe. Trunks were packed hastily with such articles as came nearest to hand.” As the alarm continued

(Taken from Frank Leslie's Illustrated Newspaper, September 21, 1878, courtesy Dr. Lucius Lampton Collection.)

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Forward and extract from The Epidemic of 1878 In Mississippi / Report of the Yellow Fever Relief Work Through J. L. Power, Grand Secretary of Masons and Grand Treasurer of Odd Fellows. A Practical Demonstration of the Generosity and Gratitude of the American People. Jackson, Miss. Clarion Steam Publishing House. 1879. A copy of this report was sent free to every person through whom relief funds were received. To others, the cost was fifty cents per copy—with profits, if any, over the cost of publication, to go to the Relief Fund.

throughout the first week of September, “the streets leading to the depot were crowded, while every available vehicle was filled with baggage and human beings in one confused rush of frantic fear lest the outgoing train should leave them, and every moment of detention had in it the tick of death.” This scene of mass confusion occurred throughout Mississippi as citizens boarded trains to any destination outside of yellow fever’s perimeters. In Holly Springs and elsewhere, the refugees included most “leading citizens” and “pillars of the community”—the only insiders able to mobilize effective relief.

Those who stayed were the “sick, the dying, the poor who could not leave and the few who would not.” 12 Those who stayed in Holly Springs after the mass exodus found comfort in charity, not in city or state government measures. Some had remained out of a sense of duty. These local health officials and volunteers remaining to care for yellow fever victims quickly requisitioned the Marshall County courthouse and turned it into a hospital. The beds for yellow fever patients consisted of simple straw

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piles that attendants could easily remove when they became soiled.

Community help was not sufficient, however, so outside charity came to the aid of the city. From Nazareth, Kentucky, twelve Sisters of Charity quickly established a nursing station at the makeshift hospital. The local priest, Father Anacletus Oberti, from St. Joseph’s Catholic Church, directed them after their arrival.13 While some patients were fortunate to have family members to nurse them at home, others had to rely upon the kindness of strangers. These volunteers exhibited remarkable devotion toward their patients. At the Marshall County courthouse hospital the Sisters of Charity labored long hours under the guidance of Howard Association doctors, many from outside of Mississippi. One author described the sisters’ work in the following manner: “Like angels of mercy, they hovered over the loathsome spot day and night, caring not who the patient might be if only his life could be spared. One by one these sisters fell until six of them, with the faithful priest, Father Oberti, lay dead.” 14 A single monument marks their collective

grave in Holly Springs. The remaining residents of Holly Springs were extremely grateful to the Howard Association for sending and sponsoring medical personnel. Additionally, monetary relief began pouring into the city. The Mississippi Masons often collected the donations and then distributed the monies through the local Howard Association or Masonic representative in each locale. By September 20, Holly Springs’ remaining citizens had received approximately four thousand dollars through these relief disbursements to purchase medicine and food, pay doctor bills and funeral expenses, and care for children orphaned by the epidemic.

Holly Springs reported 1,239 cases of yellow fever with 309 deaths in the 1878 epidemic.15 Cities across Mississippi suffered through the epidemic, as mortality rates climbed through the fall of 1878. Vicksburg, for example, recorded 5,000 cases of fever and 1,140 deaths. It had the highest case and death numbers of any city, but other locales experienced extraordinary rates also during the epidemic. Grenada listed 1,040 cases and recorded 326 deaths. By the end of November, locales from the Mississippi Coast to northern reaches of the state, listed 16,461 total cases with 4,118 deaths.16 Officials reported these numbers to a United States Congressional investigation in 1879, but the actual case and mortality figures will probably remain unknown.

Some family members secretly buried their loved ones, and victims with no family to care for them died anonymously. Moreover, record keeping in the African American communities was sketchy at best, so accurate numbers are impossible to ascertain. Regardless, of discrepancies in tallies, the 1878 epidemic reaped its horrific harvest.

By December 1878, the yellow fever epidemic in Mississippi waned as cold weather and mosquito-killing frosts occurred. Citizens began to recover from the devastating loss of life and economic hardship created by the quarantine efforts and chaos of panic.

The total amount of monetary donations given to Mississippi was $22,632.42 to help relieve its stricken citizens and towns. The United States government also contributed $150,000 of supplies, medicines, and other provisions such as caskets to the state.17 No yellow fever epidemic before or after the 1878 scourge has rivaled its widespread death and destruction. Q References 1.

Conclusions of the Board of Experts Authorized by Congress to Investigate the Yellow Fever Epidemic of 1878, Being in Reply to Questions of the Committees of the Senate and House of Representatives of the Congress of the United States, upon the Subject of Epidemic Disease. (Washington, D.C.: Government Printing Office, 1879).

2.

Henry Rose Carter, Yellow Fever: An Epidemiological and Historical Study of Its Place or Origin (Baltimore: Williams and Wilkins, 1931), 81-197.

3.

C. H. Stone, History of the Mild Yellow Fever: Natchez, 1848, (Vidalia, LA: Concordia Intelligencer Office, 1849), 553.

4.

Notebook of Dr. Gibson, n.d., 98-99. In possession of the Burkhalter Family of Glen Allen, MS.

5.

Earnest Hardenstein, The Yellow Fever Epidemic of 1878 and Its Homeopathic Treatment (New Orleans: J. S. Rivers, 1879), 37.

6.

John S. Haller, Jr. Medical Protestants: The Eclectics in American Medicine, 1825-1939 (Carbondale: Southern Illinois University Press, 1994), 162-163.

7.

Jo Ann Carrigan, The Saffron Scourge: A History of Yellow Fever in Louisiana, 1796-1905 (Lafayette, LA: University of Southwestern Louisiana Press, 1994), 346-350; Peggy Bassett Hildreth, “Early Red Cross: The Howard Association of New Orleans, 1837-1878.” Louisiana History 20 (Winter 1979), 49-75. The Howards became obsolete after the 1878 epidemic as state boards of health and national agencies expanded their roles in public health. The Howards continued to list themselves as a charitable organization in New Orleans’s directories, however, as late as World War I.

8.

Ralph D. Cross and Robert W. Wales, eds. Atlas of Mississippi (Jackson, MS: University Press of Mississippi, 1974), 44-45. Vicksburg’s population increased from 3,158 in 1860 to 12,443 in 1870. Meridian saw an increase from 2,709 in 1870 to 4,008 by 1880

9.

J. M. Keating, A History of the Yellow Fever: The Yellow Fever Epidemic of 1878 in Memphis, Tenn. (Memphis: Howard Association, 1879), 95.

10. Felix J. Underwood and R. N. Whitfield, Brief History of Public Health and Medical Licensure: State of Mississippi, 1799-1930. Jackson, MS: Mississippi State Board of Health, n.d., 1-8.

11. Pascagoula Democrat-Star (Pascagoula, MS), July 26, 1878.

12. Helen Craft Anderson, “Chapter in the Yellow Fever Epidemic of 1878.”

Publications of the Mississippi Historical Society 10 (1909): 223-229; Sherwood Bonner, “The Yellow Plague of ’78: A Record of Horror and Heroism.” Youth’s Companion, April 3, 1879, 117-119.

13. Hamilton, Holly Springs, Mississippi, 83.

14. R. M. Swearingen, “Tribute to Sister Corinthia,” 1878, Marshall County Museum, Holly Springs, Mississippi; Cleta Ellington, Christ: The Living Water: The Catholic Church in Mississippi (Jackson, MS: Mississippi Today, 1989), 172-173.

15. Conclusions of the Board of Experts Authorized by Congress to Investigate the Yellow Fever Epidemic of 1878.

16. Conclusions of the Board of Experts Authorized by Congress to Investigate the Yellow Fever Epidemic of 1878.

17. J. L. Power, The Epidemic of 1878 in Mississippi: Report of the Yellow Fever Relief Work through L. L. Power, Grand Secretary of Masons and Grand Treasurer of Odd Fellows (Jackson, MS: Clarion-Steam, 1879).

Author Information Deanne L. Stephens, Associate Dean of the College of Arts and Sciences at the University of Southern Mississippi Gulf Coast campus, has lived on the Mississippi Gulf Coast since 1972, attending Biloxi High School, Mississippi Gulf Coast Community College, Mississippi State University and the University of Southern Mississippi. She earned her PhD in American history from the University of Southern Mississippi with an emphasis in medical history and Southern studies. She has taught at Tulane Dr. Stephens University, Mississippi Gulf Coast Community College and the University of Southern Mississippi. Her publications include Plague among the Magnolias: The 1878 Yellow Fever Epidemic in Mississippi and numerous articles about hookworm disease, geophagy, and other cultural and medical themes of the South.

She is active with the Mississippi Historical Society and the Gulf South Historical Association. Currently, she is the Associate Dean of the College of Arts and Sciences at the University of Southern Mississippi Gulf Coast campus.

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Mississippi Medicine and the Civil Rights Struggle

Reflections from a Black Mississippian, Physician, Educator LORETTA JACKSON-WILLIAMS, MD, PhD

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his past August, I had the honor to participate in the Commemorative Celebration of the 150th meeting of the Mississippi State Medical Association. It is important for our state and its citizens that the organization has had the opportunity to grow, thrive and evolve. During the celebration, I delivered the Dr. Robert Smith Lecture and took that occasion to publicly thank Dr. Smith, who attended, for paving the way for me to be here in the state and working at the University of Mississippi School of Medicine. He and others like him provided healthcare for the community, fought to improve the lives of those in the community, and provided a road map of sacrifice to follow in the medical profession. These reflections are deeply personal for me and are organized around my perceptions of the impact of the Civil Rights Struggle on healthcare in Mississippi, the role that organized medicine in Mississippi has contributed to healthcare and the legacy effect of the struggle. To have an appreciation for my perspective, it is important to provide more information about my background.

I was born as a package deal in 1965 in Indianola, Mississippi.

Dr. Hurt delivered my twin sister Claretta Carla Sullivan and me.

At that time, ultrasound was not routinely used, and no one knew until our arrival that twins were imminent. We have two older siblings who were born in the 1950s in Laurel, Mississippi. Our parents were born in the 1920s in Mississippi in Claiborne and Hinds counties. Our household represented multiple generations and several areas of the state. Both of my parents lost their parents while they were young; were raised by other members of their families since they were among the younger children in the family; attended Southern Christian Institute (SCI), a boarding school that provided early education for blacks in Edwards, Mississippi; attended Jarvis Christian College in Texas with further studies by my father at Alcorn State University and Jackson State University; and were educators in the Sunflower County School system with my father leading the development of a Head Start program.

We were born and raised in Indianola, Mississippi, which was a small Delta town at the time that was racially segregated by the railroad track with whites on the north side and blacks on the south side.

Our house on Roosevelt Street was not far from the railroad tracks as it went past Club Ebony on Hannah Avenue.

A lot of the other Southern black families that I knew looked a lot like my family – hardworking parents who pushed their children to succeed and protected us from society and its definition of us as much as they could. I was an early adolescent before I understood

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that one of my uncle’s sons was killed by a white mob in Hinds County and that my mother’s older sister in Vicksburg worked as a maid.

Because of our parents, we all attended small, Christian colleges for undergraduate degrees – for my brother it was Chapman University in Orange, California, and then Butler University in Indianapolis, Indiana; for my older sister it was Jarvis Christian College in Texas; for us, it was Tougaloo College. All of us have advanced degrees with three of us with doctorates. For our family, there was an understanding that education is the cornerstone for progress and we all had to move forward – not for ourselves, but for our families, our community, and our people.

From Tougaloo College, I was afforded many opportunities and exposed to some thought-provoking people. They included Dr. Robert Smith; Dr. Theodore Jones, a local orthodontist and graduate of Tougaloo College; Dr. Richard McGinnis, a professor of chemistry; and Rev. Ed King, a civil rights icon. I participated in the Minority Access to Research Careers Program, spent a summer at the University of Vermont in Burlington and joined the Early Selection Program at Boston University Medical Center as a candidate in the dual MD/PhD program.

In Boston, I learned I was a minority not only because I was a black female but also because I was a southerner and economically disadvantaged. It was eye-opening. I also learned that shopkeepers in Boston, Massachusets, had the same routine of following me as the shopkeepers on Front Avenue in Indianola. There was much racial tension in Boston during my 8 years with the ongoing work towards desegregation of the Boston school system.

While in Boston, I got involved with the National Medical Association through the Student National Medical Association. I served as a local, regional and national officer, eventually serving as national president. I had great African-American mentors while there including the following: Dr. Deborah Prothrow-Stith who was faculty at that time but now serves as the Dean at Charles R. Drew University College of Medicine in Los Angeles, California; Dr. Kenneth Edelin, who was faculty during my time but had served as chair of Ob/Gyn and had been a central figure to the issues related to abortion in the 1970s; Dr. Bruce Jackson, who was a researcher in the Department of Biochemistry; and Dr. Louis Sullivan who was an alumnus of Boston University School of Medicine. They and many others were great role models for me.

Loretta Jackson and her twin sister Claretta Carla were born and raised in segregated Indianola, Mississippi, giving Dr. Jackson-Williams a unique perspective on being a southerner and economically disadvantaged. Today she says, “I go to work every day not focused on our troubled past or trying present, but on our tremendous future.”

After all of this time in Boston, I looked for new opportunities and better weather out west. After an externship in Denver, Colorado, one of the faculty suggested a program in Oakland, California. Since one of my mother’s younger sisters participated in the migration from Mississippi in the 1940s and landed in Oakland, California, I figured this was a great place to visit. I fell in love with the program at Highland Hospital, completed residency training there and stayed for a year as faculty.

The Bay Area of California was not exempt from racial tensions. This tension was heightened after the ban on affirmative action policies for college admissions in the 1990s. This was a vastly different view than expected by me for the “liberal golden state.”

While in California I married a Mississippi guy, James Williams, who is also from the Delta (Tallahatchie County), and we decided to return to Mississippi with our young family. We were a part of the group of Mississippians who returned to the state because of deep family ties. We returned with skills that allowed us to pursue careers within the state. For us, our abilities were education and medicine.

After traveling around the country, I realized that our racial challenges in Mississippi and the way it made me feel were not so different than the challenges in other parts of the country. Mississippi has a more visible history to the nation and is working through that history in a

very public manner. This allows people around the nation to believe that our Mississippi racial “sin” is greater. However, the consequences of racism, especially for the opposed, are major no matter the depth, and the entire nation has to grapple with the issues of racism.

During the very active Civil Rights Struggle in the Mississippi there were some major changes in healthcare. A number of the hospitals were integrated to maintain federal funding. Dr. Aaron Shirley, who founded the Jackson Medical Mall, became the first AfricanAmerican resident, and Dr. Helen Barnes became the first black faculty at the University of Mississippi School of Medicine. Some federally qualified health centers were established. Some educational opportunities in higher education were broadened such that black students began to have access to majority white schools within the state.

At the same time, some black people left the state just like my aunt had in the 1940s. This included black physicians who could not gain medical staff membership, admitting privileges to hospital or income for their work. This included Dr. Clinton Battle who was in Indianola. He helped gather evidence for the Till lynching trial and was economically driven out of the state.

Everyone who remained had less community structural support.

The economic opportunities shifted particularly for the rural parts of

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the state. After the height of the Civil Rights period, federal support dwindled. Thriving communities such as Mound Bayou, Mississippi, which was founded by former slaves and had the first federally qualified health care center in the United States, shriveled. This was noted all across the Delta. There is a stunning correlation between these areas of the state with poor health outcomes and the 1860 census areas where a large percentage of the population was enslaved at the time. Those areas were also once thriving local agricultural areas, but now, healthy food is difficult to find, specifically, in a number of the mostly poor, rural areas.

Another significant development that affected healthcare in the state was organized medicine. Organized medicine provided a collective voice and access by physicians to medical staff membership. Also, it served as an advocate for its constituent group.

The National Medical Association was founded in 1895 as the equivalent organization to the AMA but for black physicians who were not allowed to join the AMA. The organizational structure and purpose for the NMA mirrored the AMA organizational structure and purpose for a different group of people. This dual development of a white and black organization also occurred in Mississippi.

Eventually, the Mississippi Medical and Surgical Association was formed, and it still exists and is active today. This organization did not have the support and resources to grow, thrive and evolve. Its continued existence could be considered separate and distinct from MSMA. The reality, however, is that there is shared membership for both, shared goals for better healthcare and outcomes in the state, and shared policy development needs.

This is the same struggle of the doctors who fought for justice during the Civil Rights Movement. There are a number of organizations which developed to organize to support the civil rights activists.

The story of the Medical Committee for Human Rights or the MCHR is powerfully presented in The Good Doctors by John Dittmer who also taught for a period of time at Tougaloo College. The MCHR helped desegregate hospitals, set up free health clinics to care for the civil rights activists and established the model for the comprehensive federally qualified health centers.

As I reflect on the legacy of the civil rights struggle and its aftermath, I believe that we have all as physicians now inherited a state that has health outcomes in the wrong direction for some health indices such as infant mortality rate and chronic disease burden. Also, we have very limited resources to reverse the trends. These issues are continuing to shift from a primary racial divide to a socioeconomic divide.

As leaders in the delivery and advocacy for healthcare in the state, irrespective of where we practice – rural or suburban, underserved or adequately resourced – it seems that this is our clarion call for action. We will not be economic drivers of communities as espoused during the recent Health Summit if we do not have in place effective preventive medicine measures to prevent chronic disease development, creatively manage our population with chronic disease and have in place a robust educational system to allow improvement in our health literacy and the development of future generations of physicians for all of our communities. It seems to me that we are really in this together as our profession accepts responsibility for tackling these issues.

I was truly inspired by the resolutions of the 150th House of Delegates meeting because it appears that we are answering the call.

I, therefore, go to work every day not focused on our troubled past or trying present but on our tremendous future. Q Author Information Loretta Jackson-Williams, MD, PhD, FACEP, is Vice Dean for Medical Education and Professor of Emergency Medicine at UMMC School of Medicine Dr. JacksonWilliams grew up in Indianola. She graduated from Tougaloo College with a degree in chemistry. While in college, she intermittently worked as a substitute teacher in her local public school system. In 1994 she completed her studies at Boston University School of Medicine Dr. Jackson-Williams with a doctorate in biochemistry and a medical degree.

She completed her residency in emergency medicine at Highland Hospital in the Alameda County Medical Center of Oakland. As a resident, she served as the research chief. Dr. Jackson-Williams joined the faculty of the Department of Emergency Medicine at the University of Mississippi Medical Center in 1999 with a focus on student education in the department. She is committed to delivering an exceptional educational program to produce competent, capable and compassionate physicians.

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C O M M E N T A R Y

Show Lawmakers the Face of Organized Medicine During Legislative Session- Medical Student of the Day Complements the MSMA Doctor of the Day Program

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wo years ago, the Mississippi State Medical Association (MSMA) created the Medical Student of the Day program, designed to complement the Doctor of the Day program where MSMA member physicians take turns staffing a walk-in clinic for legislators at the Mississippi State Capitol during legislative sessions. Medical Student of the Day was introduced to encourage and create opportunities for student participation; MSMA member students can register to join a physician mentor for their day at the Capitol.

On March 12, 2018, I had the privilege of joining Dr. Philip Merideth of the University of Mississippi Medical Center as Medical Student of the day. We arrived at the Capitol at 2:00 pm and made our way to the clinic office where Capitol Nurse Apphia McCollough greeted us. After briefing us on the ins and outs of the clinic, she guided us over to the Senate chamber. On the way there, we bumped into the Senator from our home district, J. Walter Michel, who welcomed us to the Capitol and caught us up on the current legislative business.

After arriving in the Senate chamber, we watched as Lt. Governor Tate Reeves opened the session and then stood as Senator Michel introduced us to his colleagues on the Senate floor. Afterward, we met the Lt. Governor for a picture. We then headed over to the House of Representatives, where we met our home district representative, Mr. Bill Denny.

After many warm greetings, we returned to the Capitol Clinic where our work began. We joined the Capitol nurse to see patients and provide basic medical care, seeing a variety of complaints from joint pain to conjunctivitis. It was a truly unique opportunity because it provided a chance not only to meet state legislators but also to interact with them as a medical provider, assessing their problems and answering their questions under the guidance of Dr. Merideth.

During my time in medical school, I have seen more and more how healthcare policy affects all aspects of medical practice. I believe that policy advocacy is a critical role for physicians, and to fulfill this role we must reach out and engage with our representatives to share our concerns and advise them as they shape the policies that determine how to deliver health care in our state. The Medical Student of the Day program is an excellent opportunity to see up close how the legislature functions and to rub elbows with our elected leaders in a professional

550 VOL. 59 • NO. 11/12 • 2018

Philip Merideth, MD, and Joseph Maxwell, IV- M4, UMMC, teamed as Doctor and Medical Student of the Day respectively.

setting, an invaluable experience for anyone interested in building the relationships necessary for advocating effective policy. I encourage all of my fellow medical students to take advantage of this singular opportunity.

– Joseph L. Maxwell, IV, M4 University of Mississippi Medical Center, Class of 2019 Sign up to be Student or Doctor of the Day at the Capitol for the 2019 Legislative Session at MSMAonline.com under the ADVOCACY header.

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Protected scope of practice at State Capitol Pushed through a new stronger seatbelt law Saved vital funding for Health Department Successfully defended strong vaccination laws Added 2 new member benefit partners Promoted the economic impact of physicians Championed new Heroin & Opioid Summit Made available 277 hours of CME Spoke out against unwarranted prescribing rules Brought the AMA Pre-diabetes program to Mississippi

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C O M M E N T A R Y

An Incredible Experience: The American College of Emergency Physicians, San Diego, October 2018

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round me, the young people swirl. Confident, determined, their smiles grace most every face. I talk with a tall, dark man in a Muslim cap; he’s a first-year resident from New York City, excited about the lectures. A gangly twenty-six-year-old from Boise tells me he’s met some of his medical school buddies. An eighteen-year-old Asian Indian with accented English babbles with the excitement of his first time in America… spent at the ACEP national conference in San Diego.

Emergency Room physicians and students have come from across the globe to gather at this sensational event.

From eight-in-the-morning until six-in-the-evening, except for a short lunch break, a smorgasbord of seven to ten lectures proceed simultaneously, changing every half or full hour, with a side option of training labs to refresh or learn new skills. The vendor floor must hold a thousand booths, with giveaways, demonstrations, and educational entertainment. Free food and drink flow for the taking, or walk across the street to Old Town San Diego, a haven of restaurants, art galleries, and boutiques.

The parties deserve a paragraph of their own, though I’ll describe only one. The Shumaker Group, the BIG name in physician group staffing, hosted the opening ceremony this year. For 2018, this, the College’s 50th anniversary, the Shumaker Group rented the whole heart of Old Town. Yep, they fenced off three blocks of prime restaurant and shopping, each restaurant offering free specialty foods inside and on the street. Live bands. Entertainers. Eight-person foosball tables (I played the middle). This was the biggest best party I’ve ever been to!

The lectures always fascinate me, like the cardiologist who kept showing potentially fatal EKGs, making everyone in the audience cringe, thinking of patients we’d sent home. One of the best cancer lectures I’ve heard in my life took only twenty-minutes. The oncologist covered five points, good examples, good summary, good mnemonics.

And then there are the lectures I don’t get, full of abbreviations, movies of ultra-sounds I can’t read, and generic drug names that I’ve never seen.

Everyone around me is hanging on every word, and I try to also, though, well, “What did she say?” Is it the acoustics or is it my fading hearing? The conference is set up in this huge convention center, with seeming miles between the classrooms, certainly not designed for older folks with bad knees. And with all this food … who can keep on a diet?

Ah … the tribulations of getting older.

I started off talking about the young people, because, in fact, everyone is so young. There are still ER doctors my age, don’t get me wrong. At the Mississippi State Alumni party, there were three of us gray hairs … and over a dozen thirty-year-olds. I meet other oldsters waiting for lectures, in the halls, and at the parties, these over sixtyyear-olds who still work. Yes, they still work, but rarely as ER doctors.

Clinics. Fast tracks. Occupational therapy. What’s happened to us?

We founded this organization. Now … it belongs to the young ones.

This year I’m in my fortieth-year practicing emergency medicine. When I started, we scribbled our chart-notes on carboned paper. The technicians developed X-rays by dipping them into vats of silver. Benadryl was prescription, Tagamet didn’t exist, and drug representatives handed out Ritalin and Valium as samples. Things have changed. My how they’ve changed.

Dr. Philip Levin The year before I graduated from medical school, 1977, my teaching hospital bought one of the first CAT scans in the country. Before CAT scans reached the ERs where I worked, if we suspected bleeding inside the head, we were supposed to drill holes in the skull to find out. When CAT scans finally reached the smaller ERs, it required a neurologist’s okay to order the head scans. Now, well, if a patient has so much as a headache, she’ll end up with a CAT … or maybe two. I’m not saying this is right or wrong, just different.

I’ve tried to keep up. Every year I’ve studied for, taken, and passed my board tests in both family medicine and emergency medicine. Yet I’ve lost skills. I quit putting in central lines several years ago. To me, the bedside ultrasound machine’s screen only shows a bunch of wavy lines.

So many drugs have come out it seems like I’m finding a patient on a new one every shift.

I have valuable abilities, of course. Years of experience have provided me with awareness and judgment. I can feel a special sense when something’s not right and order appropriate tests. I have tricks, such as the other day when none of the nurses could find a vein, and I slipped one right into the patient’s neck. I can come up with great treatments and recognize rashes. And, boy, can I take a history.

Last month I received my Medicare card. I have enough money in the bank. I could move to the clinic, or even stop working. I could … but I love being an emergency physician. The joy of making a lifealtering diagnosis, the heart-warmth of redirecting a life, the calming of being able to understand and address someone’s suffering, these happen to me every day I work. I can’t imagine any other job this fulfilling.

I’m an oldster now. Yet I’m not ready to quit. No, as long as they feel I am still doing a good job, and, well, as long as I feel that way, too, I’ll still be in the ER. I’ll be back to ACEP’s national conference next year in Denver.

It’s an incredible experience immersing in the world of emergency medicine’s progress. The excitement and education and comradery may be reasons enough. But there’s something more fundamental. This is what I do. This is who I am. I’m an ER doctor, like all these young guys and gals around me. And I’m proud.

– Philip L. Levin, MD Emergency Medicine, Gulfport, JMSMA Editorial Advisory Board member

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Every day during the legislative session, the Capitol Medical Unit is staffed by a full time nurse and an MSMA volunteer physician who provides basic health care services to legislators and capitol staff. As a Doctor of the Day, you’ll see firsthand the everyday operations of the Mississippi Legislature and be recognized on both the Senate and House floors at the opening of each day’s session. Volunteers can choose from a half day on Monday or Friday or a full day on Tuesday, Wednesday or Thursday. Session begins in January.

up at today at www.MSMAonline.com.

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Central Medical Society was proud to celebrate the 150th anniversary of the Mississippi State Medical Association with you!

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P R E S I D E N T ’ S

P A G E

Professionalism and Population Health Management

T

he Mississippi State Medical Association (MSMA) has always promoted the well-being of patients above all else. This is a guiding principle of the medical profession subscribed to by all medical societies. This remains the hallmark of professionalism in a changing healthcare environment. Professionalism has been extensively defined and lends the added benefit of promoting wellness and population health in a way that promotes the best interest of patients individually and the best interest of communities as a whole.

The Physicians Charter on Medical Professionalism was published in 2002 as a combined effort of US and European medical societies to guide physicians in the presence of a changing health care environment where for-profit entities such as healthcare systems sought to have an influence on directing health care.

The Charter supports physicians’ efforts to ensure that healthcare systems and physicians remain committed both to the patient welfare and to the basic tenets of social justice.

The fundamental principles guiding the Charter on Medical Professionalism included the primacy of patient welfare, patient autonomy, and social justice. 1 Based on these principles, a set of professional responsibilities was developed. These professional responsibilities included commitments to professional competence, honesty with patients, patient confidentiality, maintaining appropriate relations with patients, improving quality, improving access to care, commitment to a just distribution of finite resources, improving scientific knowledge, maintaining trust by managing conflicts of interest and commitment to professional responsibilities.

Challenges to the practice of medicine center on decreasing disparities among the needs of patients, the available resources to meet those needs and the increasing influence of market forces to transform healthcare systems.

Physicians must reaffirm their active dedication to the principles of professionalism, as well as their commitment to the welfare of their patients and to the collective efforts to improve the health care system for the welfare of society. 1 Because of physicians' close relationships to healthcare organizations, the Charter on Professionalism for Healthcare Organizations was

558 VOL. 59 • NO. 11/12 • 2018

developed for hospitals and hospital systems. In order to effectively care for patients, maintain a healthy workforce, and improve the health of populations, these organizations must attend to the four domains addressed by the charter: patient partnerships, organizational culture, community partnerships, and operations and business practices. Impacting Michael Mansour, MD the social determinants of health will require collaboration among healthcare organizations, government, and communities.

As a commitment to community partnerships, model organizations collaborate with other healthcare organizations in the community and serve to reduce health disparities related to factors such as education, income, and environment. They focus particularly on preventable root causes of illness and access to appropriate, effective, culturally sensitive healthcare. 2 The MSMA is leading discussions on how medical professionals can partner with hospitals, private, and government entities to address population health and prevention in workplaces, schools, and in everyday life. The Mississippi State Medical Association is meeting with the Mississippi Hospital Association, Governor Phil Bryant’s office, the Mississippi Economic Council, the YMCA, and the Mississippi Department of Health to look for ways in which we can work together to achieve these goals of improving health and decreasing disparities in care for the promotion of healthier lifestyles and better outcomes.

The economic incentives to employers are apparent with a healthier workforce and lower cost of health insurance. The same economic incentive is apparent to government entities that must bear the financial burden of caring for chronically ill and disabled patients.

The idea of creating a culture of health has been promoted by the Mississippi State Health Improvement Plan called UpRoot. UpRoot looks for deep-rooted issues obstructing our efforts to be healthier.

This program seeks to promote a culture of health beginning in our schools, workplaces, and neighborhoods. The UpRoot program encourages Mississippi employers to promote employee wellness programs and seeks to increase the percent of school health councils in full compliance with the Mississippi Healthy Students Act of 2007.

Many employers and insurance companies now promote wellness.

Businesses that are self-insured find it particularly beneficial to actively promote prevention and wellness.

Organizations also have an ethical obligation to help identify and address social and environmental factors that adversely affect health.2 The determinants of health and well-being include health care which contributes 10% to overall health, genetics which contributes 30% to overall health, social and environmental factors contribute 20%, and individual behavior contributes 40%.

Because social and environmental factors and individual behavior contribute 60% to the health and well-being of individuals, we must broaden our focus and effort to ensure that these determinants of health are properly addressed and do not contribute to chronic illness, disability, and the rising cost of healthcare.

The commitment to partner with community organizations, civic leaders, and government entities to make innovative strategic investments in health prevention and wellbeing will leverage improved community health in a way that should enhance the general quality of life for Mississippians and decrease the cost of healthcare.2

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Partnering with community organizations and institutions such as schools to address disparities in health may produce lasting results that can change the culture that has contributed to poor health outcomes.

Team-based care is particularly effective in carrying out protocolbased preventive health and wellness programs. Physicians must exhibit both professionalism and leadership skills to function effectively in environments that are team-based.

Professionalism is an indispensable element in the compact between the medical profession and society that is based on trust and putting the needs of patients above all other concerns.3 The MSMA will continue to develop relationships and work with groups that understand the importance of wellness and prevention in promoting the wellbeing and prosperity of all people. Q

Michael Mansour, MD President, Mississippi State Medical Association References 1. Project of the ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002;136:243-246.

2. Egener BE, Mason DJ, McDonald WJ et al. The charter on professionalism for health care organizations. Acad Med. 2017 Aug;92(8):1091-1099.

3. Professionalism: Good for Patients and Health Care Organizations. Breenan MD, Monson V. Mayo Clinic Proceedings. 2014; 89(5):644-652.

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E D I T O R I A L

Benefits vs. Risks

T

he exasperation in the letter was palpable. An MSMA member recently wrote to question the value of board certification for his specialty, considering what he deemed the meager benefits realized versus the burdensome time, requirements, and costs involved. He was particularly troubled by scope of practice encroachment and asked, “Where has the Board been in this regard except in my wallet?

Why should I continue being board certified when I can still continue what I do without that glorified piece of paper?”

Providentially, Stakeholder Beliefs About the Future of Continuing Certification survey findings crossed by desk soon after, making his letter even more plaintive.

To aid the American Board of Medical Specialties (ABMS) in decisions about the future of its Maintenance of Certification (MOC) programs, the online survey elicited input from three key stockholders, one of which was physicians. In all, the survey involved 34,616 physicians with responses from all 24 ABMS Member Boards and all 50 states. Interestingly, it was noted in what appeared sort of like a “black box warning” that the survey used a “convenience sample” likely to reflect selection bias.

Survey findings noted that one in 10 physicians valued MOC, 46% had mixed feelings, and 41% did not place any value on the program. When asked about their concerns, physicians cited “costs”(58%), “burdensome”(52%), and “does not accurately measure my ability as a clinician”(48%). “Doesn’t help me improve my practice meaningfully” (43%) was the fourth most popular response. Some physicians expressed an interest in having continuing education focus on practice-relevant continuing medical education (CME) opportunities, selfassessment, open book exams, and quality of care assessments.

Of the physician respondents, 96% were Board Certified.

Additionally, 64% were currently enrolled in a primary specialty

562 VOL. 59 • NO. 11/12 • 2018

MOC program with 33% currently enrolled in a subspecialty MOC program.

The survey ultimately concluded that while a small percentage of physicians value MOC, most had either mixed views or did not value MOC. MOCs were thought to be Dr. Hartness too costly and burdensome, not an accurate depiction of their abilities or relevant to their practice, and duplicative.

As an aside, a study published in JAMA in August 2017 found that the nonprofit organizations administering the certification process are collecting a lot more money than they are spending.

Study authors investigated fees charged to physicians for certification examination and finances of the 24 ABMS member boards.

In fiscal year 2013, member boards reported $263 million in revenue and $234 million in expenses—a difference of $24 million in surplus. Exam fees accounted for 88% of revenue and 21% of expenditures whereas office and employee compensation and benefits accounted for 42% of expenses.

Although limited because of reliance on data from IRS Form 990, the authors said that Board certification should have value as a meaningful educational and quality improvement process.

They continued, “Although some evidence suggests board certification may improve performance and outcomes, the costs to physicians are substantial.”

It’s obvious that the jury is still out on this issue, but it’s also obvious that our letter writer is not a voice of one calling out in the desert, “Beware ye the way of the Board!”

– Stanley Hartness, MD JMSMA Associate Editor

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Mississippi WƌŽǀŝƐŝŽŶĂů ZĞƉŽƌƚĂďůĞ ŝƐĞĂƐĞ ^ƚĂƟƐƟĐƐ November 2018

ΎDŽŶƚŚůLJ ƐƚĂƚŝƐƚŝĐƐ ĂƌĞ ƉƌŽǀŝƐŝŽŶĂů͘ ŝƐĞĂƐĞ ƚŽƚĂůƐ ŵĂLJ ĐŚĂŶŐĞ ĚĞƉĞŶĚŝŶŐ ŽŶ ĂĚĚŝƚŝŽŶĂů ƌĞƉŽƌƚŝŶŐ ĨƌŽŵ ŚĞĂůƚŚĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ŝŶǀĞƐƚŝŐĂƚŝŽŶ͘ dŚĞƐĞ ŶƵŵďĞƌƐ ĚŽ ŶŽƚ ƌĞĨůĞĐƚ ƚŚĞ ĨŝŶĂů ĐĂƐĞ ĐŽƵŶƚƐ͘

counts.

Zoonotic Diseases

Enteric Diseases

Vaccine Preventable Diseases

Mycobacterial Diseases

Sexually Transmitted Diseases

Public Health District

**

State Totals**

I

II

III

IV

V

VI

VII

VIII

IX

Nov 2018

Nov 2017

YTD 2018

YTD 2017

Primary & Secondary Syphilis

6

5

2

0

1

0

1

6

1

22

26

371

291

Early Latent Syphilis

3

8

1

1

1

1

0

1

1

17

61

705

504

Gonorrhea

103

79

78

68

201

89

42

112

88

860

929

Chlamydia

217 146

164

183

422

147 113

182

220

8,952 8,323

1,794 2,220 20,346 19,144

HIV Disease

4

1

2

2

5

1

0

4

0

19

44

460

431

Pulmonary Tuberculosis (TB)

0

0

0

0

0

0

1

0

0

1

4

59

35

Extrapulmonary TB

0

0

0

0

0

0

0

0

0

0

0

8

7

Mycobacteria Other Than TB

2

7

0

2

3

1

2

4

4

25

39

290

409

Diphtheria

0

0

0

0

0

0

0

0

0

0

0

0

0

Pertussis

1

0

0

0

0

1

0

0

1

3

2

43

34

Tetanus

0

0

0

0

0

0

0

0

0

0

0

0

0

Poliomyelitis

0

0

0

0

0

0

0

0

0

0

0

0

0

Measles

0

0

0

0

0

0

0

0

0

0

0

0

0

Mumps

1

0

0

0

0

0

0

0

0

1

2

9

26

Hepatitis B (acute)

0

0

0

0

0

0

0

0

0

0

9

38

41

Invasive H. influenzae disease

1

1

0

1

0

0

0

0

0

3

11

68

60

Invasive Meningococcal disease

0

0

0

0

0

0

0

0

0

0

0

1

2

Hepatitis A (acute)

0

0

0

0

0

0

0

0

0

0

0

11

2

10

8

2

2

10

5

1

0

4

42

71

Shigellosis

0

0

1

1

9

3

0

5

4

23

31

253

166

Campylobacteriosis

3

11

5

4

6

3

0

3

4

39

42

558

449

E. coli O157:H7/STEC/HUS

0

0

0

0

0

1

0

0

0

1

3

67

24

Animal Rabies (bats)

0

0

0

0

0

0

0

0

0

0

0

0

1

Lyme disease

0

0

0

0

0

0

0

0

0

0

0

4

1

Rocky Mountain spotted fever

0

0

0

0

1

0

1

0

1

3

4

136

169

West Nile virus

0

0

0

0

0

0

0

0

0

0

1

49

63

Salmonellosis

Totals include reports from Department of Corrections and those not reported from a specific District.

564 VOL. 59 • NO. 11/12 • 2018

1,072 1,045

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Presented and sponsored by Mississippi Business Journal

I M A G E S

I N

M I S S I S S I P P I

M E D I C I N E

Where William Faulkner Died:

THE LEONARD WRIGHT SANATORIUM, BYHALIA

T

his is an aerial view of the legendary alcohol and drug treatment facility which achieved international fame as the site of Nobel Laureate William Faulkner’s death on July 6, 1962.

Leonard Davidson Wright, Sr., MD (1909-2003) opened the 22-bed private hospital in 1949. This image is taken from an ad in a 1958 copy of the Mississippi Doctor, the journal predecessor of JMSMA. The ad routinely appeared not only in that publication but in other medical journals across the South. The ad notes that the sanatorium was located “24 miles” southeast of Memphis on Highway 78 on “20 acres of beautifully landscaped grounds” to provide “restful surroundings,” as well as emphasizing that it was air-conditioned.

An August 1956 ad from the Texas State Journal of Medicine noted that the institution specialized in the treatment of “alcoholic and drug addiction and mild nervous disorders,” offering “ACE and ACTH therapy if indicated” and “Antabuse is given if requested.”

Wright’s approach to treat acute alcoholism was to utilize alcohol in diminished doses to prevent DTs and to supplement nutrition

566 VOL. 59 • NO. 11/12 • 2018

with vitamins. ACE (Adrenocortical extract) and ACTH (Adrenocorticotropic Hormone) were state-of-the-art “hormone treatment” for DTs and psychosis associated with alcohol withdrawal and even for a period were considered a possible “cure” for alcoholism which was then perceived by many as a chronic metabolic or endocrine disease. Antabuse (disulfiram) is an oral medication which was the first medicine approved by the FDA for the treatment of alcohol abuse and dependence. The respected and successful Wright Sanatorium, which was frequented by wealthy Southerners from across the mid-South for more than two decades, would close in January 1972.

The Faulkner family’s association with the sanatorium began in 1952 with his wife Estelle’s admission for alcohol treatment. Faulkner himself would be admitted several times to the facility in the 1950s, for both chronic alcoholism and gastric hemorrhage. His admission to room 8D on the first floor on the night of July 5, 1962, was no different than his usual admissions, except that he was complaining

of chest and back pain in addition to his alcoholism. Several hours after his admission, near 1:30 am on July 6, Faulkner was sitting on his bed, complaining of an upset stomach, then groaned and fell over, apparently the victim of an acute cardiac arrest from an MI or fatal arrhythmia or perhaps a pulmonary embolus. Dr. Wright, who lived on the hospital grounds, arrived within 5 minutes, found Faulkner without vitals, and began CPR, but he soon called the code and pronounced him dead. Wright’s discharge diagnosis for Faulkner was “Acute pulmonary edema probable cardiac origin,” although Wright later told historian Joseph Blotner that he died of an acute MI. Historians Jack D. Elliott, Jr., and Sidney W. Bondurant, MD, have written the definitive account of Faulkner’s death at the Sanatorium entitled “Death on a Summer Night: Faulkner at Byhalia,” which utilizes original medical records recovered from the institution.

The article has been accepted and will soon be published by The

Journal of Mississippi History. Above are images of Faulkner writing, both in longhand and by typewriter. See also the image of Faulkner’s grave in Oxford, revealing the bottles of alcohol which frequently litter the plot. The gravesite is a popular destination for students and admirers who toast the writer with a drink and often leave a bottle of liquor, usually his preferred bourbon, in tribute. Byhalia, located in west Marshall County not far from its border with DeSoto County, derives its name from a nearby creek which in Chickasaw means “white oaks standing.” My thanks to Dr. Bondurant and Mr. Elliott for an advance copy of their article which was the primary resource in the writing of this essay. If you have an old or even somewhat recent photograph or image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. Q — Lucius M. “Luke” Lampton, MD, JMSMA Editor

NOVEMBER/DECEMBER • JOURNAL MSMA

567

P O E T R Y

A N D

M E D I C I N E

Edited by Lucius Lampton, JMSMA Editor

To a Young Physician [For this special historical issue, we print an old poem from the nineteenth century that your editor discovered in a rare 1872 medical journal: â&#x20AC;&#x153;The Physicianâ&#x20AC;&#x2122;s Monitor for 1872â&#x20AC;? vol. 1, no. 2, page 26. Its author is the well-known Quaker poet John Greenleaf Whittier (1807-1892).

This Massachusetts poet was a contemporary of Longfellow and in his day a household name in the United States. He was also recognized as a leading anti-slavery voice in the country, and his poems frequently centered on his abolitionist sentiments. Although not a physician, he was very FORVH WR DQG PXFK LQĂ&#x20AC;XHQFHG E\ KLV IDPLO\ SK\VLFLDQ (OLDV :HOG 7KLV SRHP DSSHDUV WR EH XQLTXH as a variant of his later poem, â&#x20AC;&#x153;To a Young Physician, With Doreâ&#x20AC;&#x2122;s Picture of Christ Healing the Sick,â&#x20AC;? also called â&#x20AC;&#x153;Christ the Healer.â&#x20AC;? This early version contains a few different stanzas and multiple alternate words and phrases. It appears to be an early evolution of a poem which would EH ÂżQDOL]HG LQ D GLIIHUHQW IRUPDW E\ :KLWWLHUÂśV 4XDNHU URRWV ÂżQG UHDG\ H[SUHVVLRQ LQ WKLV inspirational poem. â&#x20AC;&#x153;The paths of pain are thine,â&#x20AC;? he tells young physicians. He continues:â&#x20AC;&#x153;Smite down the dragons, fell and strong.â&#x20AC;? Young and old Mississippi physicians still are smiting down such dragons along those paths of pain! Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] â&#x20AC;&#x201D; ED.

The paths of pain are thine. Go forth With healing and with hope; The suffering of sin-sick earth Shall give thee ample scope.

Before the unveiled mysteries Of life and death, go stand With guarded lips and reverent eyes, And pure of heart and hand.

Smite down the dragons, fell and strong, Whose breath is fever fire; No knight of fable or of song Encountered foes more dire.

So shalt thou be with power endued From Him who went about The Syrian hill-paths, doing good, And casting devils out.

The holiest task by Heaven decreed, An errand all divine, The burden of our mortal need To render less, is thine.

That holy Helper liveth yet, Thy friend and guide to be; The Healer by Genesaret Shall walk the rounds with thee.

No crusade thine for cross or grave, But for the living man.

Go forth to succor and to save All that thy skilled hands can.

â&#x20AC;&#x201D; John Greenleaf Whittier (1807-1892) â&#x20AC;&#x153;The Physicianâ&#x20AC;&#x2122;s Monitor of 1872â&#x20AC;?

568 VOL. 59 â&#x20AC;˘ NO. 11/12 â&#x20AC;˘ 2018

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U N A

V O C E

Why I Still Believe in Christmas Cards

M

y Bigmama, Dora Lee Whitten McCown, bequeathed me the legacy of a deep appreciation for life’s simplest joys-long, cooling drinks of water from the gourd dipper by the side of her well-house, little afternoon siestas on sweltering August days next to that softly droning ‘Sears and Roebuck’ floor fan of hers, chocolate stacked teacakes, mud ‘frog houses’ we made at the end of the long cotton rows, and her timeworn shoebox from Braddock’s Dry Goods store packed full of wonderful old Christmas cards tied with string. While all the others of the family had to drag cotton sacks through Papaw’s fields, Bigmama and I were excused. I was too little to be of much use, and Bigmama had suffered what Dr. Mauney called “a light stroke” back in the early 50’s. She and I were spared the ardors of field work in those stifling and back-breaking days over in the big cotton patch we called the “Old Flat.”

Instead, life for us was grand. I was around 5, and in some ways so was she. Papaw had to put the ‘side-planks’ on his pickup to hold the day’s cotton harvest. My duty was to tromp around in the cotton to pack it down so that an even bigger load could be hauled to the gin. When the truck bed would get almost full, Bigmama would pull out her box of Christmas greetings from years’ past to begin our afternoon entertainment. In the mountain of soft whiteness, it was easy to pretend we were sitting in a snow bank. We would daydream about how it would not be long before old St. Nick would be coming to see us. Over shared King Leo peppermint sticks carefully wrapped in wax paper, she would tell me about the excitement of her childhood Christmases of long ago. We would examine those lovely yellowing old Christmas cards of hers over and over again until we literally almost wore them out and were both covered in that silvery glitter that never failed to fly. She would go over the front of the card for me, and then read the sweet rhyming greeting inside, then finally the hand-scrawled message at the bottom and the “With Love From” part. At that point, I was to shout the name of the friend or relative who had sent her the card. It was a marvelous game that neither of us ever tired of playing.

In the back of my Papaw Willie’s truck, under a sweet gum shade at the end of a 30-acre cotton field, both of us could taste, see and feel the thrilling promise of Christmas just around the corner.

Well over fifty years later comes the advent of yet another Christmas. For the past few years, it has seemed more like a dreadful chore than the magical time it once was. All I can think about when dragging those huge boxes of seemingly endless collections of glass balls, beads and bangles down from the attic is how soon I will endure the time-consuming pain of wagging them back upstairs. What a dreadfully overblown pile of artificial cheer I have accumulated over the decades. It looks as if Santa Claus has barfed all over my living room floor yet again. The more stuff I drag and wag the darker my mood seems to become. But, in the most remote corner of the attic storage room dedicated to the housing of our accumulated Christmas paraphernalia I find THEM once again….under the growing pile of defunct Christmas lights (that I might someday find time to rescue) I once again found the remaining fragments of my Christmas spirit. In a green tangle of wire that should have met its demise in a dumpster long 570 VOL. 59 • NO. 11/12 • 2018

ago lay my motley collection of Christmas cards. A 55-gallon drum would likely not hold them all.

It is heart-yanking feeling to discover something once again unconsciously hidden away from yourself for years. There were numerous pasteboard shoe boxes full of bound Christmas cards and letters dating back through the 40 years since I left home for medical school. They have all been there every year when I do the Dwalia S. South, MD ritual wagging and dragging thing with the wreaths, garlands and plastic poinsettias, but somehow I have not always appreciated their presence.

A closer examination of some of the boxes brought a flood of emotions at the familiar sweet handwriting of my Mother on envelopes sent from Rural Route One, Ripley, to a homesick girl in a dormitory room at 2500 North State Street in Jackson, Mississippi… big pretty cards with Memphis, Tennessee postmarks from my older sister Shirley and family at 806 North Mendenhall… and in later stacks, “Happy Holidays” greetings sent to a young pregnant intern’s apartment off Old Hickory Boulevard in Jackson, Tennessee, these from literally everyone my husband Chard and I knew. All of them were deemed necessary to keep in the Bigmama tradition I had been taught. They all found their way back home with me somehow.

In many of the years, the cards contained congratulatory messages…for graduations, new jobs, marriages, or babies. Some cards brought words of consolation for the losses that particular year had bestowed. Without fail they contained newsy messages and updates framed by closing phrases such as “come see us sometime,” or “please write soon,” and then, most importantly, the “with love from” part.

A deep and abiding appreciation for the meaning and importance of heartfelt and handwritten Christmas cards was bestowed upon me over a half century ago by my Bigmama through the childish games we played in my Papaw’s cotton field. Now I AM the Bigmama of the family, and with the passing of every immediate family member older than me, it has become a bit of a scary feeling. After my Mother died in 2014, I discovered in one of her linen drawers some of Bigmama’s treasure trove of Christmas cards and family photos. These are as valuable as pieces of silver and gold to me now.

An old familiar Christmas carol tells us about ‘tidings of comfort and joy.” I didn’t know it then, but I do now, that Christmas cards are precisely that…heartfelt prayers and hopes lovingly sent to our friends and family asking God to grace us with health, happiness, and a better year ahead. Oh, Lord, do we ever need exactly that!

Because of my simple Bigmama’s loving example to me, I vow to never cut corners by not making that once a year effort to send out some Christmas cards… and to not ever begrudge the time spent addressing envelopes or the laborious writing for the one-hundredth time… “With Love From.”

â&#x20AC;˘ Index â&#x20AC;˘ VOLUME LIX January - December 2018

SUBJECT INDEX The letters used to explain in which department the matter indexed appears are as follows: â&#x20AC;&#x153;CPSâ&#x20AC;? for Clinical Problem Solvingâ&#x20AC;?; â&#x20AC;&#x153;E,â&#x20AC;? Editorial; â&#x20AC;&#x153;L,â&#x20AC;? Letters to the Editor; â&#x20AC;&#x153;PB,â&#x20AC;? Physicianâ&#x20AC;&#x2122;s Bookshelf; â&#x20AC;&#x153;PM,â&#x20AC;?

Poetry and Medicine; â&#x20AC;&#x153;PP,â&#x20AC;? Presidentâ&#x20AC;&#x2122;s Page; â&#x20AC;&#x153;S,â&#x20AC;? Special Article; â&#x20AC;&#x153;UVâ&#x20AC;? Una Voce; the authorâ&#x20AC;&#x2122;s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization.

(SLGHPLF Yellow Fever in Mississippi [D Stephens], 540 -AA Case of Metastatic Melanoma of the Heart Diagnosed Antemortem [M Williams, D Hansen, N Sheehan], 396 A Patient-Centered Approach to the Opioid Overdose Crisis [J Schneider], 232 A Survey of Environmental and Behavioral Aspects of Human West Nile Cases in Mississippi [W Varnado, J Goddard], 134 An Unexpected Souvenir: Lyme Disease Presenting as Temporomandibular Joint Arthritis [J Xie, R Chandran, N Washington], 410 AMA AMA Launches â&#x20AC;&#x153;Share Your Storyâ&#x20AC;?

Campaign to Document Opioid Use Disorder Barriers to Care, 151 AMA Presents Medal of Valor to Civil Rights Physician Activist Dr. Robert Smith, 121 Big Picture: Solely Focusing on Either Gestational Diabetes or Hypertension Loses Site of Future Health Implications, 150 Asclepiad

-B-CCivil War Medicine in Mississippi: An Overview: Some Myths, Some Realities [S Bondurant], 508 Comprehensive School Health Education and the Future of Health in America [J Hill], 370 Cost-Effectiveness Analysis of Procedure Equipment in a Pain Clinic: The Physicianâ&#x20AC;&#x2122;s Role in Managing Healthcare Cost [L Kurnutala, K Dang, R Nguyen, N Sibai], 392 Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A New Treatment Modality for Primary or Secondary Peritoneal Cancer in Mississippi [W Christopher, A Seawright, J Wynn, T Earl, C Anderson, S Orr], 145 Clinical Problem-Solving [presented and edited by the Dept. of Family Medicine, UMMC] Commentary An Incredible Experience: The American College of Emergency Physicians, San Diego, October 2018 [P Levin], 553 Avoid the Social Networks: A Mobile Communication

Platform Should Provide a 6HFXUH (IÂżFLHQW :RUNĂ&#x20AC;RZ >7 Haas], 218 Five Inadvertent HIPAA Violations

by Physicians [T Haas], 259 Healthcare is a Catch-22 for the Uninsured [A Cloy], 217 Mississippi, We All Need to CHIP in on this One [L Friedrich], 161 NPs and Elderly Care: We Can Do Better [K Pannel], 312 Role of Vitamin D and NEC - An Emerging Risk Factor [P Garg], 220 Show Lawmakers the Face of Organized Medicine During Legislative Session Medical Student of the Day Complements the MSMA Doctor of the Day Program [J Maxwell, IV], 550 Tax Cuts & Jobs Act of 2017: A Brief Overview [M Carraway, Jr.], 160 Why Marijuana Will Not Fix the Opioid Epidemic [K Finn], 488 Cover â&#x20AC;&#x153;Dr. Michael Mansourâ&#x20AC;?, October â&#x20AC;&#x153;Fireworks at Old Waverlyâ&#x20AC;? [M Pomphrey], June/July â&#x20AC;&#x153;Images in Mississippi Medicineâ&#x20AC;?, November/December â&#x20AC;&#x153;Mississippi Civil Rights Leaders Emphasize Social Determinants of Healthâ&#x20AC;? [J Johnson], August

NOVEMBER/DECEMBER â&#x20AC;˘ JOURNAL MSMA

571

â&#x20AC;&#x153;Opioid Special Editionâ&#x20AC;?, January â&#x20AC;&#x153;Pointing the Wayâ&#x20AC;? [S Hartness], February â&#x20AC;&#x153;Rainbow Fallsâ&#x20AC;? [M Pomphrey], April â&#x20AC;&#x153;Sunset over Moon Lakeâ&#x20AC;? [R Brahan], May â&#x20AC;&#x153;This Little Light of Mine light sculptureâ&#x20AC;? [S Hartness], March â&#x20AC;&#x153;Turkey Tail Mushroom (Trametes versicolor)â&#x20AC;? [J Bumgardner], September

-DDisposable Versus Conventional Bronchoscope Cost for Percutaneous Dilatational Tracheostomy [A Robichaux, A Wilhelm, C Moore, L Jackson], 242 Distinguished Mississippians: Guyton, Hardy Portraits Unveiled at Hall of Fame Dedication, 532

-EEarly Stage Prostate Cancer: An Analysis of Treatment Modality by Race in Mississippi [K McKay, J Bailey, L Zhang, E Jones], 190 Economics of Population Health and Prevention: Is an Ounce Worth a Pound of Cure? [T Hanna], 380 Editorials A Plan to Reduce Narcotics in Mississippi by Twenty Percent [B Kitchens], 28-E A Safer Approach to Pain Exists [S McAllister], 52-E A View from Behind the Counter [H Rifkin], 18-E %HQHÂżWV YV 5LVNV >6 +DUWQHVV@ 562-E 'RFWRUVÂś 'D\ $ 7LPH WR 5HĂ&#x20AC;HFW Look Ahead, 168-E Electronic Medical Records: It Takes a Forest! [S Hartness], 304-E

572 VOL. 59 â&#x20AC;˘ NO. 11/12 â&#x20AC;˘ 2018

Gun Violence, Opioid Addiction, and the Role of Physicians [L Ramsey], 22-E How Primary-Care Physicians Can Integrate Addiction Screening, Referrals into their Practices [S Pannel], 24-E Opioid Addiction from an Emergency Room Physicianâ&#x20AC;&#x2122;s Perspective [P Levin], 58-E Opioid Summit: A Slippery Slope?

[S Hartness], 56-E Population Health and Prevention: Evolving Science and Potential Salvation [M Mansour], 332-E To Cut or Not To Cut: Is Waiting the Best Solution to Many of Medicineâ&#x20AC;&#x2122;s Problems? [B Cross], 305-E The Other Side of the Opiate Crisis: Why Increasing Opiate Hurdles May Negatively Impact End of Life Patient Care [K Merkelz], 32-E The Rural Difference [T Arnold], 57-E

-FFamilial Gigantiform Cementoma in Twins: A Case Report [A Hartzog, D Kowalczyk, J Carron], 246 Fatal Acute Sickle Cell Intrahepatic Cholestasis Despite Exchange Transfusion: A Case Report and Literature Review [C Capra, W Aldred, S Patnana, B Borg, V Herrin], 204 First Heart and Lung Transplants: James D. Hardy, MD, at UM School of Medicine [M Mitchell], 536 From the Editor [L Lampton] As We Lay Dying, 330 Celebrating Medical Heroes and History, 498 Creating a Culture of Health, 430 Is Universal Primary Care the Answer?, 182 Magnolia Three Times, 126 Medicineâ&#x20AC;&#x2122;s â&#x20AC;&#x153;Secret Sauceâ&#x20AC;?, 390

Stand There, Donâ&#x20AC;&#x2122;t Just Do Something, 74 The Physicianâ&#x20AC;&#x2122;s Role in the Opioid Epidemic, 2 Thereâ&#x20AC;&#x2122;s Always Next Month..., 274 Wisdom in Tillersonâ&#x20AC;&#x2122;s Farewell, 230

-GGeneral Anesthesia without the Use of Muscle Relaxant for a Patient with Myasthenia Gravis and Multiple Comorbidities: A Case Report and Literature Review [R Roberts, N Manimekalai], 250 Genome-Wide Association Studies (GWAS) Improve Understanding of Autism Spectrum Disorders in Mississippi and Beyond [S White, K Callahan, S Ramachandran, D Sarver, R Annett], 140 -HHow Clinicians Can Better Interface with Surgical Pathologists for Better Patient Care [V Manucha, V Shenoy, M Vargas, I Akhtar, D Shenoy, J Lewin], 82 Hyperbaric Oxygen in vitro against MRSA 301 and P. aeruginosa 19660 [C Jordan, A Sullivan, M Marquart, E Hamadain, R Williamson, L Haynie, J Bain, A Benton], 442

-IImages in Mississippi Medicine Foster General Hospital, Jackson, 1943 [L Lampton], 123 Greenville Colored Kingâ&#x20AC;&#x2122;s Daughters Hospital, 19051953 [L Lampton], 177 Kingâ&#x20AC;&#x2122;s Daughterâ&#x20AC;&#x2122;s Home, Greenville, 1905 [L Lampton], 224

Kingâ&#x20AC;&#x2122;s Daughterâ&#x20AC;&#x2122;s Hospital, Greenville, 1927 [L Lampton], 270 Klan Poster Against UMMC, 1950 [L Lampton], 426 May Farinholt-Jones, MD, First Female member of MSMA [Lampton], 386 Washington County General Hospital, 1958 [L Lampton], 321 Where William Faulkner Died: The Leonard Wright Sanatorium, Byhalia [L Lampton], 566 In Memoriam, 384

-LLeaves of Three, How Bad Can It Be? [C Cochran, D Keyes, C Doo, T Huynh, J Wyatt], 400 Leadership Are You a Physician Leader?, 92 Are You an Introvert? It Might Mean Youâ&#x20AC;&#x2122;re a Good Leader [H Brown], 88 Drug Drop Boxes Underused Tool in Opioid Fight [T Beacham], 119 Growing Leaders in Medicine, 93 Leading Amidst Generation Change [D Ritchey], 110 Outreach Program Gets Mental Health Help to Underserved [C Torrence], 118 The Higher You Go: A Physician Leader Shares Lessons Learned [D Norris], 107 The Leader in my Mirror [C Sampson], 108 The Value of Leadership Training: Leadership Academy Student Perspectives, 114 Why Doctors Make Poor Leaders and What You Can Do About It [D Drummond], 90 Legalese Decipher the Code: Keep Your Patients Safe [J Jackson, C Torrence], 268

Letters Dr. Southâ&#x20AC;&#x2122;s truth-telling essay is applauded [B McGee], 216-L Editorial regarding politics of opioid crisis â&#x20AC;&#x153;right on pointâ&#x20AC;? [P Davis], 172-L Hand referral system averts risk [W Lineaweaver], 484-L Has Mississippiâ&#x20AC;&#x2122;s refusal to expand Medicaid doomed the stateâ&#x20AC;&#x2122;s rural hospitals? [W Lineaweaver], 172-L Lyme disease agent not detected in deer ticks from Mississippi [J Goddard, A Varela-Stokes, T Nations, S Portugal, A Walker, W Varnado], 375-L Mississippi Dental Board reviews ÂłUHJV´ IRU RIÂżFH EDVHG JHQHUDO DQHVWKHVLD SXWV TXDOLÂżFDWLRQV and best practices under scope [H Matthias], 306-L Moth in a human ear: A special report of non-bacterial, ÂżVKLQJ DVVRFLDWHG H[WHUQDO otitis [J Goddard, J North], 216-L Opioid issue praised for quality content [J Schneider], 216-L Retiring UMMC cardiothoracic surgeon Dr. Giorgio Aru UHĂ&#x20AC;HFWV RQ KLV \HDUV RI medical practice [G Aru], 374-L Schneiderâ&#x20AC;&#x2122;s approach makes medical sense, MBML restrictive regulations not patientcentered [J Morrison], 306-L -MMalignant Solitary Fibrous Tumors of the Nasal Cavity [E Tillotson, M Gonzalez], 297 Mississippiâ&#x20AC;&#x2122;s Battle with the Social Determinants of Health: A Review and Commentary [R DeShazo, K McCullouch], 334 Mississippi Medicine and the Civil Rights Struggle: 5HĂ&#x20AC;HFWLRQV from a Black Mississippian, Physician, Educator [L Jackson-Williams], 546 Mississippi, MASH and Arterial

Repair: The Intersection of Surgical History and Pop Culture [M Trotter], 515 MACM MAFP MMCAC Physician-led Medicaid Group Endorses Unlimited Doctor Visits [S Demetropoulos], 173 MSBML An Interview with new MSBML Executive Director: Dr. Kenneth Cleveland [S Scott], 208 MSDH Mississippi Provisional Reportable Disease Statistics, December 2017, 122 Mississippi Provisional Reportable Disease Statistics, January 2018, 159 Mississippi Provisional Reportable Disease Statistics, February 2018, 263 Mississippi Provisional Reportable Disease Statistics, August, 2018, 493 Mississippi Provisional Reportable Disease Statistics, November, 2018, 564 0LVVLVVLSSL 6WDWH +HDOWK 2IÂżFHU Retires [M Currier], 492 MSMA 2018 Annual Session Recap, 476 2018 Annual Session Resolutions, 482 Committee Seeks Candidates for 9DFDQFLHV LQ 060$ 2IÂżFHV 23 'HÂżQLQJ (YHQWV LQ WKH (YROXWLRQ of Medicine in Mississippi - Celebrating the 150th Anniversary of the MSMA House of Delegates [K Evers], 164 Jill Gordon Joins Staff as Marketing

NOVEMBER/DECEMBER â&#x20AC;˘ JOURNAL MSMA

573

Director, 95 Meet the MSMA Staff, 210 Physician Leadership Academy Christy Vowell, DO, 106 Physician Leadership Academy Corey Jackson, MD, 100 Physician Leadership Academy Dedri Ivory, MD, 99 Physician Leadership Academy John Vanderloo, MD, 105 Physician Leadership Academy LaToya Mason, MD, 102 Physician Leadership Academy - Lori Marshall, MD, 101 Physician Leadership Academy Michelle Owens, MD, 104 Physician Leadership Academy Renia Dotson, MD, 96 Physician Leadership Academy Roderick Givens, MD, 97 Physician Leadership Academy Shawn McKinney, MD, 103 Physician Leadership Academy Tamara Glenn, MD, 98 Recap of the 2018 Legilaslative Session, 264 -NNon-syndromic Mitochondrial Hearing Loss Successfully Treated with Bilateral Cochlear Implantation: A Case Report [K Bounds, L House, J Carron], 289 NIH NHLBI Renews Landmark Jackson Heart Study for Six More Years, 486 New Members, 167, 272, 311, 388 -OOrigins of Opioid-Related Deaths: What is the Evidence? [M Johnson, R DeShazo], 4

-PPercutaneous Mitral Valve Repair in Mississippi [J Fisher, B Heindl, C Douglas, T Waites], 234 Population Health Management: The Scope, Training, and

574 VOL. 59 • NO. 11/12 • 2018

Practice :KDW DUH WKH %HQH¿WV for Mississippi? [B Beech, N Gaughf, S Murphy], 344 Preparing Medical Students to Practice 21st Century Medicine: The Prevention and Population Health Curriculum at the University of Mississippi School of Medicine [J Mann, L Mena, A Penman], 354 Prevalence Estimate and Cost of Hemoglobin Disorders among African Americans in Mississippi [L Cooper, T Walker, B Polk, L Smith, C Karlson, M McNaull, S Majumdar], 236 Prevention and Wellness: A MultiSpecialty Clinic Approach [B Batson, J Fitzpatrick], 376 Primary Hepatic Leiomyosarcoma [M Sessums, D Ray, T Earl, C Subramony, M Gonzalez], 194 Personals, 260, 261 Physician’s Bookshelf Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018. $80.00 [P Levin], 490-PB Physician’s Health Corner Poetry and Medicine A Deadly Bug... [R Cannon], 124-PM Am I Going to Get a Shot? [J McEachin], 387-PM Backing into the Future [J McEachin], 322-PM Five words from four letters (A poem for 6th graders) [J McEachin], 494-PM Greenwood - 1942... [J McEachin], 225-PM Just Call It Something, Doc!! [J McEachin], 271-PM Paean to My Poets [J McEachin], 68-PM Ten-Year-Old’s Injection Ruse [J McEachin], 427-PM To a Young Physician [J Whittier],

568-PM Turks #1 [S Anderson], 176-PM President’s Page Address of the 150th President, William M. Grantham, MD [W Grantham], 412-PP Everyone is Talking about It...[W Grantham], 17-PP If We Are Not Part of the Solution, We Will Be Part of the Problem [W Grantham], 262-PP Inaugural Address of the 151st President of MSMA Michael Mansour, MD, FACP, FACC [M Mansour], 471-PP 0DLQWHQDQFH RI &HUWL¿FDWLRQ Playbook Puts Power in Your Hands [W Grantham], 214-PP Professionalism and Population Health Management [M Mansour], 558-PP Things a President Learns [W Grantham], 372-PP Thoughts on Leadership [W Grantham], 116-PP We Are Back on Track [W Grantham], 303-PP We Got “Street Cred” [W Grantham], 157-PP

-QQuality of Life in Patients with Bladder Cancer after Bladder Preservation Therapy using Chemoradiation [A Albert, S Vijayakumar], 200 -RRacial Differences for Accelerated Partial Breast Irradiation (APBI) for the Treatment of Early Stage Breast Cancer [V Michael, J Bailey, L Zhang, E Jones], 84 Remembering Arthur C. Guyton, MD [J Hall], 526

-SSmoke-Free Ordinances in Mississippi Predict Lower Hospital Admission Rates

for Acute Cardiovascular, Stroke, and Pulmonary Events [R McMillen, E McClelland, A Winter], 285 Special Article Governor’s Opioid and Heroin Study Task Force [R Easterling], 41-S New Study Shows “Physicians Mean Business”: Mississippi Doctors Boost the State Economy, 154S

-TThe Challenges in Anesthetic Management of Patients with Trisomy 18 [S Fishkin, M Sathyamoorthy, R Wardlaw, J Reed], 466 The Global and National Perspective of the Noncommunicable Disease Epidemic [J Harold], 360 The Healers: A History of Medicine in Mississippi [L Lampton], 500 The Hidden Repercussions of the Opioid Crisis in Mississippi’s Children: Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome [L Tucker, T Nation, R Savich, D Tucker, S Ramachandran, D Lindsay, C Blackshear, R Annett], 293 Tick-borne Diseases in Mississippi [J Goddard, L Lampton], 432 Top 10 Facts You Should Know About Arthritis of the Thumb [C Cushing], 462 About Bullous Skin Disorders: Dermatopathologic Approach [B Hodge, R Brodell], 254 About Diabetic Eye Disease [C Parish, K Crowder], 78 About Endometriosis [L Ramsey, L Fleming], 406 About Human PapillomavirusAssociated Oropharyngeal Squamous Cell Cancer [W Replogle, R Cannon], 458 About Inpatient Acute Kidney Injury

[S Salim, J Medaura, V Garla, N Lawson, V Palabindala], 132 About Naloxone [M Taylor, J Fisher, B Rifkin, H Rifkin], 12 About Non-Alchoholic Fatty Liver Disease: A Review for the Primary Care Provider [J Beck, K Gilkison, J McKee, E Plott], 280 About Pediatric Fever [P Redmond, N Watkins, B Dillard, M Frascogna], 128 About Sleep Terrors in Children [L Hernandez, O Rodriguez], 76 About Stinging Insect Allergy [J Perkins], 188 About The Reemergence of Syphilis [L Lampton, D Pendergrass, P Pendergrass, P Byers, K Johnson, J Stewart, M Marturano, Z Schwartz], 184 About Women in Medicine [A Patel, M Sheth], 408 Sport-Related Concussion [B Tollefson, R Grantier, P O’Brien], 276

'U 1LFN DQG (OYLV $ )RUW\ Year Retrospective, 226-UV The Painkiller Panic: From Pandemic to Pandemonium, 70-UV Walking With the Black Dog, 323UV Washed in the Blood, 178-UV Why I Still Believe in Christmas Cards, 570-UV

-V-W-

-UUpdate on the US Drug Overdose Epidemic [S Hambleton], 14 UProot: Building a Healthier Mississippi from the Ground UP, A New Approach to an Old Problem [M Currier, P Byers, T Waites], 348 Utilizing Technology and TeamBased Care to Improve Cardiovascular Health in Mississippi [D Clark, D Jones], 366 UMMC A Typical Day at JFC..., 420 Brunson Named MSBML President, 417 UMMC Student Experiences at the Jackson Free Clinic [C Mullins], 418 UMC SOM Una Voce [Dwalia S. South] The Doctor Who “Cared Too Much”

NOVEMBER/DECEMBER • JOURNAL MSMA

575

Volume LIX January - December 2018

AUTHOR INDEX The letters used to explain in which department the author’s matter indexed appears are as follows:“CPS” Clinical Problem Solving”; “E,” Editorial; “H” Hardy Abstract; “I,” Images in Mississippi Medicine; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce.

A Akhtar, Israh, 82 Albert, Ashley, 200 Aldred, L. Wesley, 204 Anderson, Christopher D., 145 Anderson, R. Scott, 176-PM Annett, Robert D., 140, 293 Arnold, Timothy, 57-E Aru, Giorgio, 374-L B Bailey, Jessica H., 84, 190 Bain, Jennifer L., 442 Batson, Bryan N., 376 Beacham, Timothy, 119 Beck, Jared R., 280 Beech, Bettina M., 344 Benton, Angela H., 442 Blackshear, Chad, 293 Bondurant, Sidney W., 508 Borg, Brian, 204 Bounds, Kelsey L., 289 Brahan, Robert, May cover Brodell, Robert T., 254 Brown, Hannah O., 88 Bumgardner, Joe R., September cover Byers, Paul, 184, 348 C Callahan, Kristen B., 140 Cannon, C. Ron, 124-PM, 458 Capra, Carter, 204 Carraway, Michael A., Jr., 160 Carron, Jeffrey D., 246, 289 Chandran, Ravi, 410 Christopher, Wade O., 145 Clark, Donald, III, 366 Cloy, J. Anthony, 217 Cochran, Caitlin A., 400 Cooper, LaQuita, 236 Cross, Britt, 305-E Crowder, Kimberly W., 78 Currier, Mary, 348, 492 Cushing, Carolyn A., 462 576 VOL. 59 • NO. 11/12 • 2018

D Dang, Kevin, 392 Davis, Margaret “Peggy”, 172-L Demetropoulos, Steven, 173 DeShazo, Richard D., 4, 334 Dillard, Benjamin, 128 Doo, Caroline, 400 Douglas, Christopher, 234 Drummond, Dike, 90 E Earl, Truman Mark, 145, 194 Easterling, Randy, 41-S Evers, Karen A., 164 F Finn, Kenneth, 488 Fisher, Jason, 12, 234 Fishkin, Semyon, 466 Fitzpatrick, John M., 376 Fleming, Laurie W., 406 Frascogna, Melissa N., 128 Friedrich, Lauren, 161 G Garg, Parvesh Mohan, 220 Garla, Vishnu, 132 Gaughf, Natalie, 344 Gilkison, Karin S., 280 Goddard, Jerome, 134, 216-L, 375-L, 432 Gonzalez, Maria F., 194, 297 Grantham, William M., 17-PP, 116-PP, 157-PP, 214-PP, 262-PP, 303-PP, 372-PP, 412-PP Grantier, Richard L., 276 H Haas, Tracey, 218, 259 Hall, John E., 526 Hamadain, Elgenaid, 442 Hambleton, Scott, 14 Hanna, Therese L., 380 Hansen, Doris, 396

Harold, John Gordon, 360 Hartness, D. Stanley, 56-E, February cover, March cover, 304-E, 562-E Hartzog, Anna Jade, 246 Haynie, Lisa A., 442 Heindl, Brittain, 234 Hernandez, Luis A., 76 Herrin, Vincent, 204 Hill, J. Edward, 370 Hodge, Bonnie D., 254 House, Laura K., 289 Huynh, Thy, 400 I J Jackson, Jon Corey, 268 Jackson, Lana, 242 Jackson-Williams, Loretta, 546 Johnson, Jay D., August cover Johnson, Kendra L., 184 Johnson, McKenzie, 4 Jones, Daniel W., 366 Jones, Ellen, 84, 190 Jordan, Christina D., 442 K Karlson, Cynthia, 236 Keyes, Danielle, 400 Kitchens, Ben E., 28-E Kowalczyk, David, 246 Kurnutala, Lakshmi N., 392 L Lampton, Lucius M. “Luke”, 2, 74, 123, 126, 177, 182

184, 224, 230, 270, 274, 321, 330, 386, 390, 426, 430, 432, 498, 500, 566 Lawson, Nicki, 132 Levin, Philip L., 58-E, 490-PB, 553 Lewin, Jack, 82 Lindsay, Dana, 293 Lineaweaver, William C., 172-L, 484-L M Majumdar, Suvankar, 236 Manimekalai, Natesan, 250 Mann, Joshua R., 354 Mansour, Michael, 332-E, 471-PP, 558-PP Manucha, Varsha, 82 Marquart, Mary E., 442 Marturano, Matthew N., 184 Matthias, Heddy-Dale, 306-L Maxwell, IV, Joseph L., 550 McAllister, Sherry, 52-E McClelland, Emily, 285 McCullouch, Kyle, 334 McEachin, John D., 68-PM, 225PM, 271-PM, 322-PM, 387PM, 427-PM, 494-PM McGee, Robert Ray “Bob”, 216-L McKay, Kevin, 190 McKee, John D., 280 McMillen, Robert, 285 McNaull, Melissa, 236 Medaura, Juan A., 132 Mena, Leandro, 354 Merkelz, Kurt, 32-E Michael, Veeresh, 84 Mitchell, Marc, 536 Moore, Cindy, 242 Morrison, John C., 306-L Mullins, Courtney, 418 Murphy, Sydney, 344 N Nation, Tara, 293 Nations, Tina M., 375-L Nguyen, Raisa, 392 Norris, David J., 107 North, John H., 216-L O O’Brien, Patrick, 276 Orr, W. Shannon, 145

P Palabindala, Venkataraman, 132 Pannel, Katherine, 312 Pannell, R. Stephen, 24-E Parish, Corey Breland, 78 Patel, Avani, 408 Patnana, Srikrishna, 204 Pendergrass, Desiree, 184 Pendergrass, Peter, 184 Penman, Alan D., 354 Perkins, Jessica B., 188 Plott, Eric V., 280 Polk, Beryl, 236 Pomphrey, Martin, April cover, June/July cover Portugal, Santos, 375-L R Ramachandran, Sujith, 140, 293 Ramsey, Lauren H., 406 Ramsey, Logan H., 22-E Ray, David, 194 Redmond, Paul, 128 Reed, John M., 466 Replogle, William H., 458 Rifkin, Brian, 12 Rifkin, Heather, 12, 18-E Ritchey, Donna, 110 Roberts, Rachel, 250 Robichaux, Andrew, 242 Rodriguez, Oscar M., 76 S Salim, Sohail Abdul, 132 Sampson, Charles “Chuck”, 108 Sarver, Dustin E., 140 Sathyamoorthy, Madhankumar, 466 Savich, Renate, 293 Schneider, Jennifer, 216-L, 232 Schwartz, 2LT Zachary E., 184 Scott, Sid, 208 Seawright, Ashley H., 145 Sessums, Mary Tucker, 194 Sheehan, Natale, 396 Shenoy, Divya, 82 Shenoy, Veena, 82 Sheth, Michelle, 408 Sibai, Nabil, 392 Smith, Larry, 236 South, Dwalia S., 70-UV, 178-UV, 226-UV, 323-UV, 570-UV Stephens, Deanne L., 540 Stewart, James D., 184

Subramony, Charulochana, 194 Sullivan, Amy L., 442 T Taylor, Meagan, 12 Tillotson, Eric, 297 Tollefson, Brian J., 276 Torrence, Chassity, 118, 268 Trotter, Michael C., 515 Tucker, Douglas, 293 Tucker, Lauren, 293 U V Varela-Stokes, Andrea, 375-L Vargas, Mirna, 82 Varnado, Wendy C., 134, 375-L Vijayakumar, Srinivasan, 200 W Waites, Thad, 234, 348 Walker, Aaron, 375-L Walker, Thia, 236 Wardlaw, Russel G., 466 Washington, Nina, 410 Watkins, Nicholas, 128 White, Sabrina V., 140 Whittier, John Greenleaf, 568-PM Wilhelm, Andrew, 242 Williams, Madison H., 396 Williamson, Randall S., 442 Winter, Amy, 285 Wyatt, Julie, 400 Wynn, James J., 145 X Xie, Jesse Juncong, 410 Y Z Zhang, Lei, 84, 190

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578 VOL. 59 • NO. 11/12 • 2018

• INSTRUCTIONS FOR AUTHORS • The Journal of the Mississippi State Medical Association (JMSMA) welcomes material for publication submitted in accordance with the following guidelines. Address all correspondence to the Editor, Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS, 391582548. Contact Karen Evers, managing editor, with any questions concerning these guidelines: (601)853-6733, ext. 323.

STYLE: Articles should be consistent with JAMA/ JMSMA style. Please refer to explanations in the AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007. JAMA and JMSMA style differs from APA style. JAMA: http://jama.ama-assn.org/misc/ifora.dtl Quick reference quide:http://www.docstyles.com/amastat.htm.

Any manuscript that does not conform to the AMA Manual of Style, 10th edition will be returned for revision.

MANUSCRIPTS should be of an appropriate length due to the policy of the Journal to feature concise but complete articles.

(Some subjects may necessitate exception to this policy and will be reviewed and published at the Editor’s discretion.) The language and vocabulary of the manuscript should be understandable and not beyond the comprehension of the general readership of the Journal. The Journal attempts to avoid the use of medical jargon and abbreviations. All abbreviations, especially of laboratory and diagnostic procedures, must be identified in the text. Manuscripts must be typed, double-spaced with adequate margins. (This applies to all manuscript elements including text, references, legends, footnotes, etc.) The original and one duplicate hard copy should be submitted. In addition, the Journal also requires manuscripts in the form stated above be supplied in Windows OS-compatible digital format. You may email digital files as attachments to KEvers@MSMAonline.com or supply them on a portable memory storage medium. All graphic images should be included as individual separate files in TIFF, PDF, or EPS format. Please identify the word processing program used and the file name. Pages should be numbered. An accompanying cover letter should designate one author as correspondent and include his/her address and telephone number. Manuscripts are received with the explicit understanding that they have not been previously published and are not under consideration by any other publication. Manuscripts are subject to editorial revisions as deemed necessary by the editors and to such modifications as to bring them into conformity with Journal style. The authors clearly bear the full responsibility for all statements made and the veracity of the work reported therein.

REVIEWING PROCESS: Each manuscript is received by the managing editor, and reviewed by the Editor and/or Associate Editor and/or other members of the MSMA Committee on Publications and its review board. The acceptability of a manuscript is determined by such factors as the quality of the manuscript, perceived interest to Journal readers, and usefulness or importance to physicians. Authors are notified upon the acceptance or rejection of their manuscript. Accepted

manuscripts become the property of the Journal and may not be published elsewhere, in part or in whole, without permission from the Journal MSMA. TITLE PAGE should carry [1] the title of the manuscript, which should be concise but informative; [2] full name of each author, with highest academic degree(s), listed in descending order of magnitude of contribution (only the names of those who have contributed materially to the preparation of the manuscript should be included); [3] a one- to two-sentence biographical description for each author which should include specialty, practice location, academic appointments, primary hospital affiliation, or other credits; [4] name and address of author to whom requests for reprints should be addressed, or a statement that reprints will not be available.

ABSTRACT, if included, should be on the second page and consist of no more than 150 words. It is designed to acquaint the potential reader with the essence of the text and should be factual and informative rather than descriptive. The abstract should be intelligible when divorced from the article, devoid of undefined abbreviations. The abstract should contain: [1] a brief statement of the manuscript’s purpose; [2] the approach used; [3] the material studied; [4] the results obtained. Emphasize new and important aspects of the study or observations. The abstract may be graphically boxed and printed as part of the published manuscript.

KEY WORDS should follow the abstract and be identified as such. Provide three to five key words or short phrases that will assist indexers in cross indexing your article. Use terms from the Medical Subject Heading list from Index Medicus when possible.

Available at: http://www.nlm.nih.gov/mesh/authors. html.

SUBHEADS are strongly encouraged. They should provide guidance for the reader and serve to break the typographic monotony of the text. The format is flexible but subheads ordinarily include: Methods and Materials, Case Reports, Symptoms, Examination, Treatment and Technique, Results, Discussion, and Summary.

REFERENCES must be double spaced on a separate sheet of paper and limited to a reasonable number. They will be critically examined at the time of review and must be kept to a minimum.

You may find it helpful to use the PubMed Single Citation Matcher available online at: http://www.ncbi.nlm.nih. gov/ entrez/query/static/citmatch.html to find PubMed citations. All references must be cited in the text and the list should be arranged in order of citation, not alphabetically. Reference numbers should appear in superscript at the end of a sentence outside the period unless the text cited is in the middle of the sentence in which case the numeral should appear in superscript at the right end of the word or the phrase being cited. No parenthesis or brackets should surround the reference numbers.

Personal communications and unpublished data should not be included in references, but should be incorporated in the text.

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References must conform to proper style to be eligible for review.

Contact managing editor Karen Evers for an easy-to-follow guide with examples of how to use JMSMA/ JAMA reference citation format. The following form should be followed: Journals: [1] Author(s). Use the surname followed by initial without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used, followed by “et al.” [2] Title of article. Capitalize only the first letter of the first word. [3] Name of Journal. Abbreviate and italicize, according to the listing in the current Index Medicus available online at http://www.nlm.nih.gov/bsd/aim.html.

[4] Year of publication; [5] Volume number: Do not include issue number or month except in the case of a supplement or when pagination is not consecutive throughout the volume. [6] Inclusive page numbers. Do not omit digits. Do not include spaces between digits of the year, volume and page numbers.

Example: Bora LI, Dannem FJ, Stanford W, et al. A guideline for blood use during surgery. Am J Clin Pathol. 1979;71:680-692.

Books: [1] Author(s). Use the surname followed by initials without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used followed by “et al.”

[2] Title. Italicize title and capitalize the first and last word and each word that is not an article, preposition, or conjunction, of less than four letters. [3] Edition number, [4] Editor’s name. [5] Place of publication, [6] Publisher, [7] Year, [8] Inclusive page numbers. Do not omit digits.

Example: DeGole EL, Spann E, Hurst RA Jr, et al. Bedside Examination, in Cardiovascular Medicine, ed 2, Smith JT (ed).

New York, NY: McGraw Hill Co; 1986:23-27.

FIGURES require high resolution digital individual scans to be provided. Printed copies should also be submitted in duplicate in an envelope (paper clips should not be used on illustrations since the indentation they make may show on reproduction).

Legends should be typed, double-spaced on a separate sheet of paper. Photographic material should be high-contrast glossy prints. Patients must be unrecognizable in photographs unless specific written consent has been obtained, in which case a copy of the authorization should accompany the manuscript. All illustrations should be referred to in the body of the text. Omit illustrations which do not increase understanding of text.

Illustrations must be limited to a reasonable number. (Four illustrations should be adequate for a manuscript of 4 to 5 typed pages). The following information should be typed on a label and affixed to the back of each illustration: figure number, title of manuscript, name of senior author, and arrow indicating top.

TABLES should be self-explanatory and should supplement, not duplicate, the text. The brief descriptive title, usually written as a phrase rather than a sentence, appears above to distinguish the table from other data displays in the article. Data should be aligned horizontally not to exceed 6.5". Tables should be numbered and supplied on individual pages separate from manuscript body text 580 VOL. 59 • NO. 11/12 • 2018

with placement indicated within. See Section 4 of the "AMA Manual of Style" for specific Figure and Table components and proper presentation of data.

ACKNOWLEDGMENTS are the author’s prerogative; however, acknowledgment of technicians and other remunerated personnel for carrying out routine operations or of resident physicians who merely care for patients as part of their hospital duties is discouraged. More acceptable acknowledgements include those of intellectual or professional participation. The recognition of assistance should be stated as simply as possible, without effusiveness or superlatives.

SUBMISSIONS TO JMSMA SCIENTIFIC SERIES Top 10 Facts You Need to Know Series The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information.

Guidelines: 1) Articles should consist of 10 numbered paragraphs. Each of the paragraphs will begin with a fact that physicians need to know and a brief explanation of why. Facts will be referenced for each of the 10 points. 2) Suggested organization of manuscript is Introduction, Point 1, Point 2, etc., Conclusion, and References. 3) Articles will be about 3 pages (about 700 words) in length written at a level that can be easily understood by a practicing physician of any specialty. 4) A reference supporting the fact offered should be provided for each of the 10 points. Citations should not be review articles.

5) If there are specialty society guidelines in the area being discussed, the essential features of the recommendations should be included in the official guidelines cited in the references.

UpToDate Series The purpose of this series of articles is to provide brief reviews on topics of general interest to the practicing physicians of Mississippi in areas where recent developments in diagnosis or treatment have occurred. Guidelines: 1) Articles should be practical and useful to physicians in office or hospital practice. 2) Suggested organization of manuscripts is Introduction, Diagnosis, Recent developments, Conclusion, and References. 3) Articles will be about 6 pages (1500 words) or so in length written at a level that can be easily understood by a practicing physician of any specialty. 4) Only include those references useful to physicians who desire further information in the area. Five to eight references that will be useful to those who desire further information should be included. 5) Figures are great as are “callouts,” i.e., boxes with key points to remember emphasizing the “take home” messages. 6) If there are specialty society guidelines on the topic, the essential features of the recommendations should be summarized in the text and the official guidelines should be cited in the references.

GALLEY PROOF - The principal author will receive a PDF via email to review. It is the author's responsibility to proof and approve it. Corrections should be clearly marked and returned promptly. If you desire reprints, inquire about prices to order. ❒

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