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When I look back on the processes of history, when I survey the genesis of America, I see this written over every page: that the nations are renewed from the bottom, not from the top; that the genius which springs up from the ranks of unknown men is the genius which renews the youth and energy of the people.
— Woodrow Wilson
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TENDON AND NERVE INJURIES OF THE HAND H. Minor Nichols, M.D.
UROLOGIC COMPLICATIONS IN ABDOMINAL SURGERY James W. Headstream, M.D.
ADDRESS AND REPORT OF THE PRESIDENT Howard A. Nelson, M.D.
EMERGENCY MEDICAL CARE OF THE INJURED Douglas Lindsey, M.D.
FRACTURE PROBLEMS Leslie V. Rush, M.D.
NEW
Dramamine-D
brand of dimenhydrinate with dextro-amphefamine sulfate
EFFECTIVELY TREATS THE NAUSEA AND KEEPS THE PATIENT ALERT
When prescribing an antinauseant and drowsiness is undesirable, Dramamine-D alleviates1'6 the nausea yet keeps the patient alert.
Dramamine-D is available on prescription only.
Each scored, orange tablet of Dramamine-D contains 50 mg. of Dramamine and 5 mg. of dextro-amphetamine sulfate.
References:
1. Arner, O., and Others: Nord. med. 58:1346 (Sept. 12) 1957.
2. Wilner, S.: Canad. M. A. J. 77:199 (Aug. 1) 1957.
3. Bruner, J. M. R. : U. S. Armed Forces M. J. 6:489 (April) 1955.
4. Diamant, A. H.: Nord. med. 48:1324 (Sept. 26) 1952.
5. Wendt, G. R., and Cameron, J. S.: Personal communication, Jan. 4, 1955.
6. Stough, A. R.: Personal communication, Aug. 10, 1957.
Tendon and Nerve Injuries of the Hand'
H. MINOR NICHOLS, M I).
Portland, Oregon
ANATOMY, PATHOLOGY AND PHYSIOLOGY- TENDON INJURIES
Flexor Tendons: The tendons which flex the fingers and thumb originate as pinnate or bi- pinnate musculo-tendinous structures in the fore- arm. To move the fingers from full extension to full flexion requires a tendon excursion amounting to about 1/2 inches in the hand, and with wrist motion 2'A inches in the forearm. This motion takes place without friction, the tendons being surrounded by loose areolar tissue in the forearm or palm, or are carried in tendon sheaths lined with mesothelium cells in the digits. The sheaths are strong enough to prevent bowing and fit the tendons perfectly. Swelling of the tendons from injury, either traumatic or surgical, will prevent sliding here. There are two tendons in the sheath of each finger — the sublimis and profundus, and one tendon — the long flexor — in the thumb. The sheaths extend from the metacarpophalangeal joint to the distal joint. Another sheath lies in the car- pus beneath the transverse carpal ligament. Here, nine tendons and the median nerve are all con- tained in a common tunnel, separated by a few thin membranous bursae and some blood vessels, and areolar tissue.
The palm or the forearm are complicated ana- tomically as there are not only nine to eleven tendons but also nerves, blood vessels, lumbrical muscles, etc. In the forearm and palm the mo- bility of the tissues enables the tendons to slide better after repair than within the sheaths.
Extensor Tendons: The dorsum of the hand has only one short sheath about 1 inch long be- neath the dorsal carpal ligament. The extensor tendons move in loose areolar tissue. Extensor tendons are flattened to ovoid in shape from the muscles to the metacarpophalangeal joints. From this area outward they change to complicated triangular membranous structure whose central portion receives the extensor tendons and whose lateral portion receives the tendons of the interos- seus and lumbrical muscles. Each tendon receives its blood supply from mesentery-like structures in the forearm and hand, and in the sheaths them- selves by two or three long spring-like vessels.
’"Presented before sixty-ninth annual session of the Mid-South Postgraduate Medical Assembly, Feb- ruary 11-14, 1958, Memphis, Tennessee.
PATHOLOGY
When a tendon is cut the ends retract, bleeding occurs and, depending on whether blood supply is interfered with or not, a portion of tendon may actually undergo degeneration showing later al- teration of its normal pattern and increased vas- cularity. After division, during healing, a pseudo- pod of soft gelatinous fibrous material grows out from the end of the tendon and attaches itself to whatever happens to be near. If the tendon ends are held together this structure initiates healing. When tendons heal they heal by callus which, after three weeks, gradually resolves. If this callus has become adherent to fixed structures such as bare bone oi injured tendon sheath, this fixation is usually permanent. Surgical manipulation or motion before healing is complete increase adhe- sions.
PHYSIOLOGY
Movement of the fingers is accomplished by the synchronous action of the flexor tendons, ex- tensor tendons and intrinsic muscles of the hand. While each of these functions can be tested sep- arately, they overlap clinically and a separate mo- tion must be performed against resistance for each test. The profundus tendons flex the distal joints of the fingers and the sublimis tendons the middle joints, and the long flexor of the thumb the distal joint of the thumb. Flexion at the metacarpo- phalangeal joints can be carried out actively by the long flexors or by the intrinsic muscles. These small muscles can also extend the interphalangeal joints but not the metacarpophalangeal joints.
DIAGNOSIS
Whenever a hand has been lacerated, tests should be carried out to ascertain the function of tendons and nerves. One should never fail to do this. In a baby the tests are often difficult to carry out. Here, the hand should be observed while the baby moves it and the effect on the digits of flexing or extending the wrist can be noted.
ANATOMY, PATHOLOGY AND DIAGNOSIS- NERVE INJURIES
The two important nerves of the hand are the median and ulnar which are found in the palm and volar surface of the forearm. The median nerve runs approximately down the middle of the forearm, under cover of the flexor sublimis muscles,
1
2
Injuries of the Hand — Nichols
June, 1958
to just above the wrist. Here, it is in a rather superficial position for a short distance before passing under the transverse carpal ligament with the flexor tendons. From here its motor branch goes to the thumb muscles and the sensory branch- es pass out to the sides of the thumb, index, long, and one-half the ring fingers. The ulnar nerve runs down the forearm under cover of the flexor carpi ulnaris along with the ulnar artery, then passes between the layers of the carpal ligament into the palm, thence its sensory branch goes to the little and one-half the ring fingers while the muscular branch passes deeply into the palm where it accompanies the deep palmar arch. The ulnar nerve, through its muscular branches, supplies all the small muscles of the hand excepting those pro- ducing opposition of the thumb. Loss of this nerve function makes the hand quite awkward for fine motions and picking up small objects as well as- resulting in anesthesia of the little finger, half the ring finger, and a strip of the ulnar side of the palm about 1 inch wide. The median nerve sup- plies sensation to the rest of the front of the hand so when it is cut most of the hand is quite numb, and the thumb cannot be brought around to the opposed position because of paralysis of the small thenar muscles.
Whenever either of these nerves is cut, the pa- tient is usually aware of it immediately, although at times the doctor may miss it in his examination.
DIAGNOSIS
A simple test for intact small muscle enerva- tion in the hand is to have the patient spread the fingers and bring them together again and abduct the thumb away from the plane of the palm. To test sensation one need only to prick the digits on each side with a pin. Some confusion may exist where one or several branches are cut or where the nerve is simply bruised. If the nerve is simply bruised it will ordinarily start to recover in a mat- ter of a few days or weeks. By paying careful attention to the anatomy one should be able to diagnose the exact location of a lesion in any part of a nerve by a few simple tests.
PATHOLOGY
Nerve injury wrecks the hand, not only by loss of sensation and mobility, but by trophic changes as well. Paralyzed muscles atrophy and eventually undergo fibrous degeneration. The skin becomes dry and smooth, the joints stiffen and the bones lose calcium. Because of muscle im- balance the hand is thrown into odd positions such as the claw-hand of combined median and ulnar nerve palsy, the flat hand of median nerve palsy
or the little finger contracture of the ulnar nerve palsy.
When a nerve is severed the peripheral part of the nerve swells as the axones degenerate. The proximal end forms a small tumor composed of scar tissue and neurones called a neuroma. When a nerve is repaired the fibers grow out at the rate of about I inch a month, the degree of regenera- tion being directly proportional to the suitability of the case and the skill of the operator.
TREATMENT
Nerve and tendon injuries commonly occur to- gether in lacerations of the hand such as those caused by knife wounds, glass cuts, etc. These so- called “tidy” wounds are suitable cases for pri- mary repair, and highly skilled repair of these injuries immediately after they occur will produce the best results. If circumstances are not favor- able for a primary tendon or nerve suture, even if indicated, a careful skin closure will permit a secondary repair under ideal conditions without jeopardizing the end result. The secondary repair can be carried out either a few days or a few weeks later. I usually prefer to wait about thirty days, and observe the wound progress carefully as kindly healing is essential.
In the selection of cases for primary repair one should avoid crushing injuries, saw cuts, open frac- tures or wounds with ground-in dirt. A time limit of eight hours should not be exceeded. Favorable surroundings with good anesthesia and trained hospital personnel are essential.
The skin of the hand may be prepared as for any other operation but the wound itself should be protected from the action of strong antiseptics and preferably should only be flushed out with saline. Suitable drapes isolate the extremity and all operative room personnel should be masked. A previously applied blood pressure cuff on the upper arm is used routinely. Blood is expressed from the arm with an esmarch bandage and the cuff then inflated to 300 mm. of mercury. Small instruments of the type used by the plastic sur- geon add greatly to the operator’s finesse. Rough handling of tissues should be avoided and drying out prevented by saline applications. Proper ex- posure of the wound (usually necessary) involves an incision which is midlateral in the finger, paralleling the creases in the palm, or across the wrist and then up or down the border of the forearm. The original laceration should rarely be incised transversely. A routine exploration should follow to disclose what has been damaged. If the case is suitable, all tendons and nerves should be repaired at the same time as prolonged splinting
June, 1958
President’s Address — Nelson
3
incident to repeated surgery is not good for the hand. Tendons which are cleanly cut heal well with primary suture to give good results with proper selection of cases.
Tendons should be joined end to end using the least amount of non-irritating suture material which will satisfactorily maintain apposition. The tendon repair will only work if it lies in loose tissue, not against bare bone, damaged tendon sheath or questionable skin wounds. Tendons are usually more awkward to handle than nerves and, there- fore, should be sutured first. Nerve rotation may produce malalignment of fibers and should be avoided The nerve ends are approximated using 6-0 silk, placing interrupted sutures in the peri- neurium; following this the nerve is injected with novaeain or saline to align the fibrils. Before wound closure, one should attempt to cover the nerve or tendon repair by swinging a flap of areo-
lar tissue over it. The tourniquet is then released and the bleeding points are tied. Wound closure is usually by single layer of interrupted non-ab- sorbable sutures in the skin only. Drainage is rarely necessary. The wound is dressed with a single layer of grease gauze and mild compression applied with kerlex and sheet-wadding. A plaster splint is applied to keep the repaired tendons and nerves relaxed. This means flexion of the wrist for structures on the volar surface, and extension of the wrist and metacarpophalangeal joints for struc- tures on the dorsum. Post-operatively, the hand should be kept elevated and the patient should be kept in the hospital for at least a day or so. ft kindly healing occurs the wound need not be in- spected for a week. All tendon repairs (and most nerves) need to be splinted for three weeks to a month.
232 Medical Arts Bldg.
Address and Report of the President
NINETIETH ANNUAL SESSION, MISSISSIPPI STATE MEDICAL ASSOCIATION
HOWARD A. NELSON, M. D.
Greenwood, Miss.
Exactly thre hundred sixty-two days ago at Biloxi, Mississippi, the trust and respon- sibility of guiding the affairs and fortunes of your Mississippi State Medical Association were re- posed in me. Today, 1, as most all others in whom you have vested trust and authority, stand before you to be judged upon my stewardship. The talents I return are not necessarily those of my own earning because our association is a smoothly- functioning team effort.
Mississippi medicine is meeting the challenge in this day of space and the atom. Just as trans- portation, communication, and the weapons of war have erased time and distance in a turbulent world, so it is with medicine that there is not and can never be again professional isolation or the doubtful convenience of time and dis- tance between the physician and the social, eco- nomic complexities which have become a part of his practice. Like Caesar’s Gaul, the art and science of healing is divided in parts and provinces with which an enlightened, able profession recognizes it must deal. While the science of medicine achieves victory upon victory in the conquest over disease, the art has assumed new shapes and meanings. Because personal health is the com- mon denominator of all modern endeavor, there
is something of us in the circumstances under which care is provided and the social, economic, educational, and industrial aspects of our way of life.
These realizations come into sharp focus for that one of, your number whom you select to serve as your President. During the past year, the ful- fillment of our collective responsibilities has brought me before many local, state, and national groups in behalf of your service aims. The satis- faction of achievement, the habit of success, the drive and determination to do the job, and the challenges of getting on with it made the exces- sive demands of my office a series of stimulating opportunities and pleasant endeavors. Your warm and cordial support, the wholesome climate in which you pursue this most noble of professional endeavors, and your willing, able assistance has given me new and rich experiences along with satisfaction.
It has been my privilege to visit each of the component societies conducting regular meetings where I was asked to appear. I sat with your committees, the Council, and worked at regional and national levels including the American Medical Association and Southern Medical Association. It was gratifying to continue my service of some* four
4
President’s Address — Nelson
June, 1958
years as a member of the Committee on Maternal and Child Care of the American Medical Associa- tion and to accompany our officers and delegates in representing your wishes before medicine’s parent body.
As 1 visited you individually and appeared before your component societies, I tried to make the point of our responsibilities and the extensive- ness of our activity. Few if any organizational en- deavors parallel ours because MSMA regularly conducts activities which inevitably characterize it as a substantial business endeavor. On many occasions I have stated that our association has grown from a small group concerned chiefly with didactic academics to the present institution of scientific and socioeconomic prominence.
The 1957-58 association year was one of grati- fying achievement through the efforts of many. Our local societies continue to extend their sev- eral and ever-growing capabilities in constructive programs of community service. Professional edu- cation has a new and vital meaning and the general character of the local medical community has been strengthened. Our state association com- mittees have found new dimensions of depth and productivity. The Council, our able, energetic governing body, has given generously of time and effort in guiding the affairs of the association. Few state medical associations could boast of a better officer corps than you selected to assist your President.
It is apparent that we are reaping additional profits of success and achievement through wise investments of resource and effort in our busy headquarters, the Central Office. While we are presently well equipped and staffed, our ad- ministrative capibilities are operating at maximum capacity in carrying out our annual million dollar- plus program. I join wholeheartedly with other officers, committee chairmen, and your Executive Secretary in commending the splendid young women in supervisory and specialized endeavors in our office for their competence, enthusiasm, ability, and achievement. Our Central Office Head- quarters Building is, indeed, as much a credit to your foresight and planning as it is a valuable property investment and symbol of the service we are endeavoring to render. We must continue to provide realistically and wisely for the conduct of our affairs through the Central Office and view with objectivity the necessity for maintaining a dynamic, pragmatic folio of administrative policies.
Utter necessity and compelling challenges from which no default is possible require that we recog- nize our medical association administration as big business. If these urgent needs are to be met
effectively, then we must continue to provide generously the modern tools of a complex business world, adequate operational facilities, necessary staff training, and realistic compensation for those people who devote their lives and careers to our organizational and professional purposes.
Philosophically, Mississippi medicine is reach- ing a new and advanced level in professional ma- turity. We have learned how to engage in ad- vanced socioeconomic research and, for the first time this year, we have extended the scope of such studies to national level with our own com- mittee and staff resources. We have found that there is no such thing as the easy or casually derived answer. The single line or sentence of useful fact and ultimate truth is laboriously writ- ten.
We are discovering that failure to achieve in- tellectualism, social and economic vigilance, and the development of exhaustive research and study data is nothing more — nothing less — than a de- fault of professional and organizational responsi- bility. The costly luxury of complacent inactivity is grease on the skids toward professional doom.
American medicine no longer fights a global war for professional freedom. The bold frontal assault of Wagner-Murray-Dingell was almost easy compared to the recent series of peripheral, cold medical wars and the political brush-fire skirmishes which harass and threaten the American system of medical care.
This is the age of the paradox where science reigns supreme and the promise of a fuller, health- ier life for all Americans is being better under- written by dedicated disciples of healing each day. Yet, in this progress man may have sown the political seeds of his own social and economic destruction when he permits the political gnaw- ing away of hard-won freedom.
Too often medical leaders talk of freedom in broad and non-specific terms. Perhaps ultimately the doctor can be a better freedom fighter if he views the issue from the listening end of the stethoscope, the big end of the otoscope, and from the flat end of the hypodermic syringe.
It’s neither sinful nor immoral to pursue an honest course of enlightened self interest where the ultimate objective is one of service in a climate of free choice, personal freedom, and the dignity and wellbeing of our fellow man.
There is, in our professional armamentarium, effective medication against political, social, and economic “little strokes” to which American medi- cal freedom seems so susceptible. Let’s not stand in dumbfounded amazement at our medical Cape Canaveral while other camps of thought and
June, 1958
Nelson
President’s Address-
philosophy fill the American orbit with socialistic sputniks.
Doctors must make a living reality of having descended from the cloistered ivory tower of the past. Most of us may have come down the steps but all of us are not yet out of the ground level entrance.
Too many physicians seem to accept the hue and cry of medicine’s enemies: “We are against everything and in most cases we are not positive by being for something” At most gatherings of physicians we find someone saying “ . . . we ought to offer an alternate if we plan to oppose this issue.” Is this a spurious, rugged individual- ism; a coverup for failure to understand the issue; or worst of all, an indifference toward pro- fessional responsibility?
If American medicine is to discharge its .self- assumed, ethically-demanded responsibility, it must neither fear nor fail to stand up and be counted. There is neither dishonor nor vulner- ability of purpose and objective in honest negation. All but two of the Ten Commandments begin with “Thou shalt not . . .” Yet, a few of us would brand these divine injunctions as negative posi- tions.
There is solid affirmation in what otherwise might appear as an act much against the British as he was for freedom. In our fertile Mississippi Delta, we spray the cotton bolls not to the end of being exclusively against the boll weevil but rather because we are for cotton.
Need we then fear in facing up to unsound, harmful social and economic issues with a firm, well-founded position of opposition?
Just as there can be no compromise of quality in our professional endeavor, neither can there be compromise of integrity in our philosophical positions. The affirmative is solidly grounded in medicine’s dedication, its service endeavor, and the positive results.
We have far greater reason to fear more the weakest in our midst than the strongest in our opposition. Mississippians particularly and Ameri- cans generally are ready to cast their lots with integrity and there is neither reason nor necessity for medicine to retreat into the obscurity of in- decision and fear. Mississippi medicine is a posi- tive, constructive, and uplifting force for good with increasing capability, unlimited potentiality, and uncompromised dedication.
With a heart full of gratitude, I return your charge and relinquish the commission you gave me, taking as a priceless personal possession the certain knowledge that truth is your quest; dili- gence, your staff; and service, your purpose.
“This institution .... is one of a very few insti- tutions which typify the best in Christian higher education.’’
For catalogue and urther information write:
Lawrence T. Lowrey President,
Blue Mountain Mississippi
' u / rouwec pi* 1673
Urologic Complications in Abdominal Surgery"
JAMES W. HEADSTREAM, M.D.
Little Rock, Arkansas
fnr1 he true incidence of accidental trauma to -L the ureter in the course of abdominal and pelvic surgery is extremely difficult to determine. For example, complete unilateral ligation of the ureter may cause no symptoms and result in silent atrophy of the kidney. Estimates of the incidence of ureteral injury range from 0.5 to 3 per cent for ordinary major abdominal and gynecologic procedures to 10 per cent or higher for the more radical operations for malignant disease. The rela- tive ratio of unilateral to bilateral injury is said to be 6 to l1.
Accidental injury to one or both ureters has probably occurred from the onset of surgical ef- forts to eradicate disease of the female reproduc- tive organs and of the colon and rectum. The first nephrectomy by Simon in 1869 was for an uretero- abdominal fistula.
Most ureteral injuries occur during gynecological operations and in the performance of abdomino- perineal resection for carcinoma of the rectum.
The three most common types of injury to the ureters are ligation, crushing with a hemostat, and incision or section during sharp dissection. Exten- sive stripping of the ureter with subsequent slough has been a less common injury. This is more prone to occur in a post irradiated case of carcinoma of the cervix which is subjected to radical surgery. The ureter will seldom tolerate both radiation and radical surgery.
The most common sites of injury are in the ovarian fossae, to the portion of the ureter near the uterine arteries, and to the segment close to the uterine cervix.
Injury to the ureter generally falls into two classifications, those recognized immediately and those discovered during the postoperative period. Either one or both ureters may be involved and each classification poses its own particular prob- lems.
The most common sequelae of ureteral injury are ureterovaginal and ureteroabdominal urinary fistula.
MANAGEMENT OF URETERAL INJURIES RECOGNIZED AT TIME OF OPERATION
Ligation or acute angulation of the ureter rec- ognized during the surgical procedure is treated
’’Presented before the Mississippi Chapter of the American College of Surgeons, January, 1958, Jack- son. Miss.
by removal of the offending ligature, followed by inserting an ureteral catheter for seven to ten days.
Incomplete section of the ureter may be treated by simple closure of the incised area with fine cat- gut sutures, leaving an indwelling, splinting cath- eter for seven days. Extraperitoneal drainage is, of course, used in all cases in which the urinary tract has been opened.
A completely divided ureter requires end-to-end anastomosis if it is at an accessible level. The anastomosis is made with four sutures of 0000 chromic catgut placed in the muscularis only. The area may be splinted with a T tube introduced through an incision proximal to the anastomosis or more preferably by the use of two separate catheters. One of these is passed downward through the anastomosis and another upward to the renal pelvis for drainage. (Fig. 1)
ff the severed meter is low, ureteronecystostomy is the procedure of choice. It seems that most any technique of re-implantation into the bladder as long as it is low in the bladder is acceptable. There will be later vesico-ureteral reflux in some cases
6
June, 1958
Urologic Complications in Abdominal Surgery — Headstream
no matter what technique is used. A splinting catheter is not necessary if a linear incision through the ureter is made above the anastomotic site to provide good drainage while healing occurs. Of course, supra-pubic bladder drainage and extra- vesical drains are used. (Fig. 2)
If a large segment of ureter has been excised, end to-end anastomosis or re-implantation into the bladder is not possible. A decision must be made whether to ligate permanently the ureter or to use some temporary diversion method until
Fig. 3 a. Destruction ot large segment of ureter from solitary kidney during colon resection. Tempo- rary nephrostomy. Six weeks later the upper third of the left ureter anastomosed across midline to lower two-thirds of remaining right ureter, re-estab- lishing urinary drainage.
Fig.’ 3b. Postoperative IVP
more definitive surgery can be accomplished at a later date. If the kidney is a solitary one, or the status of the opposite one is not positively known, renal function must be preserved. (Fig. 3 a, b)
Temporary diversion methods such as nephros- tomy, or securing a ureteral catheter through the proximal segment with nonabsorbable suture ma- terial and bringing the catheter out extraperi- toneally are applicable.
If adequate information such as a preoperative excretory urogram is available, and the opposite kidney known to be normal, and if there is no infection in the injured side, and the risk of pro- longed surgery is significant, probably the best procedure is ligation of the ureter. Of course, the possibility of later nephrectomy exists.
8
Urologic Complications in Abdominal Surgery — Headstream
June, 1958
It the loss of ureter is low, a tube from the bladder wall can be constructed to bridge the gap, if the patient’s condition will permit the ad- ditional operative period. (Fig. 4)
MANAGEMENT OF INJURY WHEN RECOGNIZED LATE
Bilateral ureteral ligation or angulation should be suspected in any pelvic case in which there is a cessation of urinary output in the absence of shock. Mechanical obstruction must be ruled out. and this can be simply accomplished by sys- toscopy and retrograde catheterization. In case of such findings there is considerable divergence of opinion as to whether deligation or temporary nephrostomy is indicated. If the patient’s condi- tion permits, it is my opinion that deligation is the procedure of choice. A search for the offending ligature in the re-opened abdomen is extremely difficult and hazardous without the help of a cystoscopist, passing large catheters from below to the point of obstruction. In so doing, the surgeon can readily identify the ligated area and the su- tures can be removed. Then the catheters are passed to the renal pelves and left indwelling for two weeks. (Fig. 5 a, b)
There may be no sign or symptom of unilateral ligation, but in some cases, mild renal pain or tenderness may be a clue to this complication.
Fig. 5a. Case of bilaterally ligated ureters during hysterectomy. Cystoscopy revealed obstruction. De- ligation was performed.
Excretory urography is very helpful, or retrograde pyelography, if indicated, is helpful.
Fig. 6a. Ureterovaginal fistula following hysterec- tomy. Ureteroneocystostomy 6 weeks later.
June, 1958
Urologic Complications in Abdominal Surgery — Headstream
9
Oftentimes the first sign of unilateral ureteral injury is the occurrence of an ureterovaginal fistula which is the result of necrosis approximately one week postoperative. There is usually satisfactory drainage which prevents hydronephrosis. The pre-
Fig. 6b. Postoperative IVP.
Fig. 7a Ureterovaginal fistula following hysterec- tomy. IV.P (note absence of function requiring sur- gery 10 days later). Bladder flap technique.
ferred time for repair is about six weeks after the original injury. (Fig. 6 a, b)
F'ig. /b. Postoperative IVP.
Fig. 8 Uretero-abdominal fistula following hys- terectomy. Temporary nephrostomy. Four weeks la- ter, ureter catheterized and nephrostomy tube re- moved. Ureteral repair not necessary. (One advan- tage of catgut sutures in pelvic surgery.)
10
Urologic Complications in Abdominal Surgery — Headstream
June, 1958
Re-implantation of the ureter into the bladder or the bladder flap method in those too high for re-implantation will correct the majority. (Rig. 7
a, b)
Of lesser incidence is uretero-abdominal fistula, presenting ascites, ileus and sepsis. Temporary nephrostomy with retroperitoneal drainage a n d later ureteral repair is the usual management. (Fig. 8)
Another type of ureteral obstruction producing hydronephrosis is the occasional case of medial deviation of the ureters complicating proctosig- moidectomy. In this a patient following abdomino- perineal resection may develop bilateral hydro- ureteronephrosis with serious upper urinary tract complications. The ureter shows medial deviation and dilatation from the mid sacral region upward. This condition may be obviated if care is taken to develop adequate peritoneal flaps and the pel- vic floor is reconstructed without tension upon the ureter.
The bladder may be injured occasionally in pro- cedures within the pelvis. An incision into the bladder recognized at the time of surgery is treat- ed by a single layer closure with chromic catgut followed by insertion of an indwelling urethral catheter for a few days.
Vesicovaginal fistula is more likely to occur in total hysterectomy. This particular type of fis- tula is usually difficult to approach vaginallv, due to its high location, and is better repaired by an
Fig. 9. Transvesical approach for repair of vesico- vaginal fistula. Traction on string and ball affords good exposure of fistula.
Fig. 10a. Postoperative IVP in case of vesico- ureterovaginal fistula incurred during hysterectomy. Neoureterocystostomy and transvesical repair of vesicovaginal fistula.
Fig. 10b. Cystogram (absence of vesicoureteral reflux ) .
abdominal approach with separation of bladder from vagina and transvesical repair. (Fig. 9) Occasionally a vesicoureterovaginal fistula may be encountered. In these the ureter is re-implanted into the bladder and transvesical closure of the
June, 1958
Urologic Compin' ilions in Abdominal Surgery — Headstkeam
vesicovaginal fistula is accomplished. (Fig. 10 a, b) Optimal time for repair is three months after in- jury.
PREVENTION OF URETERAL INJURIES
A more complete urologic study prior to sur- gery when a difficult pelvic procedure is con- templated will be helpful in several respects. In- travenous urography would disclose the presence of ureteral anomalies, the possibility of solitary or ectopic kidney, as well as any disease process, such as pyelonephritis, calculi, etc. This knowledge would be helpful in avoiding injury to these struc- tures and, in event of injury, would make the decision of management much easier.
There are divergent opinions about preoperative placing of ureteral catheters to assist the surgeon in locating the ureters readily.
11
Most of the avoidable injuries to the ureter re- sult from lack of vigilance in the placing of clamps and ligatures.
M ore bladder and ureteral injuries follow pro- cedures where the surgeon reports that the dis- section was easy and satisfactory, than when it is reported as difficult. In the large uterine or ovarian tumors and infiltrating colon neoplasms the sur- geon usually identifies the ureter early in the operation and thereby avoids injury.
The meticulous surgeon has little need for identifying catheters, and the other type very likely would obtain a false sense of security, injuring both ureter and splinting catheter.
REFERENCES
1. Dick. Norman S.: Surgical Injuries to the Ureter, Surg. Clin. N. A., June 1957.
Today, as never before, prayer is a binding necessity in the lives of men and nations. The lack of emphasis on the religious sense has brought the world to the edge of destruction. Our deepest source of power and perfection has been left miserably undeveloped. Prayer, the basic exercise of the spirit, must be actively practiced in our private lives. The neglected soul of man must be made strong enough to assert itself once more. For if the power of prayer is again released and used in the lives of common men and women; if the spirit declares its aims clearly and boldly, there is yet hope that our prayers for a better world will be answered. — Alexis Carrel
Emergency Medical Care of the Injured*
DOUGLAS LINDSEY, M.D., Dr. P.H., F.A.C.S.f Lacassine, Louisiana
Ms intehest in emergency medical care of the injured covers parts of four decades. I have not been a doctor of medicine quite that long, but before I was of Boy Scout age I experienced my first tornado. I was drafted to go around town, to knock on such doors as were still standing, and to collect chamber pots and wash basins for use in the local National Guard Armory which was filled with wounded lying on the other doors of the town, now off their hinges and placed across saw horses from the adjacent lumber yard.
Since that time I have had a peculiar predilec- tion for disaster. When they lit the fuse under Texas City I was close enough at hand to be summoned to the scene by the echo of the blast itself. I was once spared an undesired duty of escorting a visiting dignitary when the ammuni- tion dump next to the airfield blew up with a roar that demanded attention. More recently, Hur- ricane Audrey severely damaged my homestead and I had to walk and wade the last five miles of the journey to rejoin my family there. And from time to time there have been lesser incidents of train wrecks, fires, and military actions.
I mention these things for two reasons. First, in the hope that I might benefit from the con- fused distinction between an- expert and a special- ist— I have certainly specialized in acute epidemic trauma. And second, to point out that you, too, may have luck like this. Not so much of it, I hope. But even if you consider my misfortunes extreme, and draw a statistical frequency distri- bution ranging on the abscissa entirely to the left of my own experience, it is evident that an awful lot of you are going to see a great deal of trauma in future years, and very few of you will see a really negligible amount. I can say with assur- ance that simple chance and complicated circum- stances will bring a considerable amount of trauma to your attention, regardless of the fact that the sign on your door may read “Practice Limited to Cardiology.” You may immediately transfer these patients to the care of someone else, but you can hardly do so without being obligated to render some sort of emergency treatment in the mean- time.
"Address delivered at the University of Mississippi Medical Center. Jackson, on January 10, 1958, under the auspices of the Medical Education for National Defense Program.
(Presently at Walter Reed Army Medical Center, Washington, D. C.
Even if you know that you are going to work in orthopedics or general surgery, in which trauma will be a large element in the practice of a pro- fession which requires long training and a high degree of complex skill, the really simple funda- mentals of the earliest care of the injured are quite worthy of your attention. The practice of surgery is not made up entirely of the
careful and intricate rites in the hushed
temple of the operating room, or the learned deliberations over data on charts. There are many times when it takes on all the appearance of a rat race; when decisions are made on the run, and while running in circles; and when decisions must be translated into actions of a rather simple mechanical order.
One does not have to postulate a nuclear war, or even a major natural disaster in order to see good reasons for learning the supposedly routine techniques of first aid, or for developing a .per- sonal philosophy and pattern of action for one’s own part in the earliest care of the severely in- jured under very trying circumstances. Let me give two examples.
Cumulative mortality following severe injury shows a curve of rapid rise, with later levelling- off. (,Fig. 1) It is one of the brightest facets of modern surgery that hospital treatment has been able to force such a levelling-off that only two or three per cent of battlefield wounded die after admission to a hospital (experience of the United
EFFECT OF EARLIER INITIAL TREATMENT
Fig. 1. More lives can be saved by earlier initial treatment than by perfection of hospital care. (Not previously reproduced.)
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States Army in Korea, 1950-1953). Our knowledge of what happens in the first minutes and hours after injury is somewhat hazy, but it appears to me that we can save a great many more lives by earlier treatment than we can by attaining abso- lute perfection in hospital care.
Another example of the need for advance plan- ning; some time in April the high school next door to your hospital will hold its spring prom. If, on that night, one teen-ager idly remarks to another: “My Dad’s ’54 station wagon will outrun your Dad’s 58 convertible,” the result is likely to be one convertible load of bodies in the morgue, and one station wagon load of injured in the emergency room of the University Hospital. These five or six seriously injured patients would certainly incite an intense buzz of activity. And this activity would probably give a strong appearance of confusion and stress — except that your professional superiors have long been giving detailed attention to plans for emergency care of the injured. Without such forethought, I believe you would have to set the pressure sensitivity of your panic buttons at five patients instead of fifty. And I am quite certain that, if you were the senior surgical specialist in one of the smaller towns of the state, the simul- taneous admission of these five or six patients to your fifty-bed hospital would confront you with something more than just the appearance of stress. You would be in for many hours of grueling work, and work which carries little immediate and in- herent satisfaction — it contains too many inter- ruptions and apparent digressions. Your surgery would be liberally salted with obstinate delay and clamorous emergency, conflict of supply and de- mand, expediency and adaptation, forced delega- tion of work, and running consultation.
The skills and judgments demanded in such situations are exactly those demanded of the staff of a military hospital which is attempting to care for a great mass of wounded after a swift, accurate, and vicious blow by the enemy. I do not feel that I am mouthing platitudes to say that the technical skills demanded in these situations are precisely those encompassed in the professional practice of medicine; and that the character of the judgment which is necessary to put these skills to good use is that contemplated by the ill-defined term “triage.”
I am most willing to admit that triage is not self-explanatory, whereas the term “sorting," to which triage has been freely translated, does have an immediate meaning. I have used the term sort- ing in medical context, and I am in good com- pany with other authors who do. But now I am beginning to deplore the passing of the older term. Triage is not entirely encompassed by sorting. True, triage comes from the French, trier, mean-
ing to cull, or sort and dispose of. As such, it has a slight surgical-lexicographical connection — the great American surgeon Halsted must have been a great man at triage, since, I am told, he in- sisted on picking out one by one the beans which were to be ground for his coffee. Triage may well mean to cull and to sort if it is applied to coffee beans, but to me it does not mean just to “cull” or “sort" if it is applied to living human beings. To translate the French noun triage into an Eng- lish gerund .sorting is an even poorer rendition of meaning than to translate the delicate noun liaison into the blunt intransitive verb, to fornicate.
Triage means roughly the process of deciding what is to be done first, and what is to be done next after that. It is a series of decisions made over a period of time structure, and made on the basis of individual wounds and individual reactions in the dynamics wound physiology. It is a bitter travesty to pass off as the entire process of triage some fancy system of hanging vari-colored tickets on patients as they enter the door; even worse is the business of stamping patients with indelible ink on the forehead or the dorsum of the hand. I simply do not believe that human patients can be definitively classified by department store meth- ods, as stock for the specialty shop on the sixth floor, or stock for the salvage table in the base- ment.
Triage is a continuous process. And triage is concurrent with treatment. Triage involves the decision that treatment is needed at once, or that treatment can be deferred. If treatment is given, then the current category of the patient is thereby changed; if treatment is not given, then the clinical status of the patient changes, and his category changes with it. It is for this reason that any list of sorting classifications will fail, no mat- ter in how much detail it is written.
If you accept that triage is continuous, and is concurrent with treatment, there are then only two principles of triage to learn, and you will know triage — if you know medicine.
LIFE takes precedence over LIMB or FUNC- TION.
The IMMEDIATE takes precedence over the ULTIMATE.
It is possible to describe the process of triage using only one patient with several wounds and complications, but the illustration is perhaps more clear if at least two patients are used.
Let us suppose that Mr. A and Mr. B have been involved in the same explosion, and you are called to see them both at the same time. Mr. A has a compound fracture of the thigh, with lacera- tion of the femoral artery; he also has a penetrat-
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ing wound of the abdomen. Mr. B lias an open wound of the chest, and a penetrating wound of the eyeball with intraocular foreign body. Both are severely burned.
The first priority is a tourniquet on Mr. As thigh, to stop the spurting of blood from the femora. Next priority goes to temporary occlu- sion of Mr. B’s sucking chest wound. Both of
these are wounds which are immediate threats to life. It is foolish to argue over whether “hemor- rhage," genericallv described deserves precedence over or subordination to “asphyxia,” genericallv
described. Both are measured in degree, and it is relative danger which will count.
With third priority we move from Mr. B back to Mr. A’s belb wound; it is a threat to life, but not so urgent, usually, as is gross hemorrhage or impending asphyxia. If you are treating these pa- tients at the scene of the accident, or in a tempo- rary aid station, the action demanded by this
third priority is simply to see that Mr. A gets out on the first ambulance, not the second one. If you are treating these patients in the hospital
PATIENT ALPHA PATIENT BRAVO
All woundi dirty, both politnfa burned
Concurrently, or os convenient, tetonus Immunizotion , ontlblotics, fluids, catheterization
Fig. 2. Triage is concurrent with treatment, and priorities change between patients as treatment is carried out. (Not previously reproduced.)
Fig. 3. Centripetal pressure from a tourniquet will occlude vessels even in interosseous areas. (From Am. J. Nurs., 57: 444-445, 1957.)
emergency room, the action is to schedule A for operation as soon as possible, and to start pre- paring him for the surgery. Once this start is made, you can turn to the fourth priority — still Mr. A, but this time for his injured lower ex- tremity. Even without the abdominal wound he would still deserve a high priority for definitive surgery. The tourniquet is a hazard to the limb, and something better must be arranged for, and without delay.
For fifth priority we turn back to Mr. B. The eye wound is a serious threat to a most important function, but it is probable that the ophthalmic surgery can be put off for a little while — at least a few hours — without the delay critically affecting the end result.
Sixth priority is back again to Mr. A for the fractured femur. Bui if by now he has not already been put up in a fairly decent splint — good enough to permit him to be moved to the operating room for his abdominal and vascular surgery — this is a sure sign that you are working alone. Either you have no assistants, or they are useless for the time being. If you are working in any reasonably staffed emergency room, a great deal will have been going on for some time: someone will have been making out records, starting fluids, passing tubes, scheduling surgery, collecting specimens for the laboratory, and making the rounds with anti- biotics and tetanus toxoid. But even if you are working alone, the continuous and concurrent na- ture of triage is evident. You bounce from one patient to the other as priorities change, but the priorities change principally by virtue of what you have done to change them. Please note that first precedence for the ambulance and the op- erating room went to a third priority wound.
It takes several years to teach you the thera- peutic techniques of your profession, and it is out of place for me to make a pass at reviewing it now. But it is not amiss to review with you some of the simple procedures of that which is loosely called “first aid." Since laymen are admitted to the practice of first aid, there is a tendency for professional people to bow out of it; they assume that it is “off limits" to them; that it is beneath their dignity; or that they are certified experts in it by virtue of their holding a professional de- gree. None of these assumptions are true. There will always be times and places when even the physician is limited to the materiel and techniques of the first aider. When these occasions occur, the public expects a masterful performance from him who holdeth the M.D. degree. But he often lacks the practical ability to deliver a performance of good caliber. The unfamiliarity of the circumstan-
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ces and the raw material seems to induce a sort of block in the process of transforming professional knowledge into simple and effective action.
For hemorrhage, the simplest and most effec- tive means of control is direct pressure over the wound. With rare exceptions, direct pressure con- trol of major arterial bleeding means direct manual pressure — and this ties down one assistant per wound. The so-called “pressure dressing” will con- trol capillary and venous bleeding. However, it will not control major arterial bleeding unless the dressing is wrapped on so tightly that it is in effect a tourniquet itself, though seldom a really good one. Dependable and lasting control of bleed- ing from a major artery is effected only by clamp, ligature, or a good tourniquet.
It may be indulgence in semantic quibbling, but 1 have never believed in the dictum that the tourniquet is a method of last resort, if by that you mean it is to be used after all lesser methods have been tried and found wanting. Such a trial and error process is expensive in blood, and you may come to the last resort when it is too late. If you are faced with major arterial bleeding from an extremity, and if you cannot see fit to clamp and tie at once, then use a tourniquet at once. I say this with an emphasis which implies convic- tion, but I must admit that the supporting data are not unequivocal. Like the old lady who sent a neighbor to get some good bluing (“You break off a piece, and put it in water, and if it’s good bluing, it either sinks, or it floats, but I can’t re- member which”), I recognize that the tourniquet is either a life-saver or a really dangerous instru- ment. Maybe both.
A tourniquet is not to be loosened periodically. But it should be removed as soon as it is possible to make some better arrangement. I have implied freely that a tourniquet is a hazard to limb; it can be a hazard to life, too, through tourniquet shock. It is difficult to formulate a rule of thumb as to when to remove a tourniquet; the best you can do is to tell them to put it on and leave it on. But you are not laymen; you are the ones who can decide that the tourniquet can and should come off.
If a tourniquet is used, it goes as low on the limb as possible; it is neither necessary nor de- sirable to arbitrarily place it above the elbow or knee. A tourniquet for the control of major arterial bleeding must be quite tight. The only way to learn how tight is quite tight is to put one on your own thigh, twist it up until it hurts, and then palpate for your dorsalis pedis. Chances are that it will still be pulsating. Uncomfortably tight may not be tight enough.
Acute obstruction of the airway is an emergency ranking with or above severe hemorrhage. For- tunately, a complete obstruction of the upper air- way is often due to a foreign body, or to dis- organization and collapse of the musculature from massive wounds of the jaw and neck. These can often be remedied by simple extraction of the for- eign body; placing traction on the tongue after transfixing it with a safety pin; manually reposi- tioning the damaged parts into something ap- proaching anatomical alignment; or placing the patient in the “coma” position. Certainly these measures may give a few moments of respite in which to prepare for tracheostomy.
Tracheostomy may, of course, be indicated for lower airway obstruction as well, or for central de- pression of respiration in head wounds, either to cut down on upper airway dead space, to diminish resistance to air flow, or to facilitate aspiration of the bronchial tree.
In general, in the earliest care of the severely injured, tracheostomies are too few and too late, but the procedure must not be taken lightly. The operation creates a significant postoperative nurs- ing problem. The patient cannot cough, and he cannot cry out for help. I have seen one patient drown in his own blood, coming from an unno- ticed skin bleeder in the tracheotomy incision. And in the laboratory in which I work, we have no- ticed in shocked animals that a tracheostomy, done for the purpose of making accurate ventilatory studies, cuts down the survival time of the animal by something like 20 per cent.
In spite of these sobering considerations, if you have any doubt about whether or not your patient needs a tracheostomy, he probably does.
An open wound of the chest is usually far easier to deal with than is respiratory obstruction. All it takes in the initial stages is a good gauze dressing — say an abdominal pad — large enough to cover the hole with a good margin. Vaseline gauze is useful but not essential. The dressing can be reinforced with adhesive tape as time permits.
So much for wounds which are immediate threats to life. The ultimate threats to life include;
Shock — from any cause.
Infection — principally in the body cavities.
Continued bleeding, not accessible except by major surgery.
Wounds of the abdomen fall into all three of these categories. The surgical literature of trauma does document the role of intraperitoneal bleeding as a cause of death, but too often infection gets the most emphasis. A patient with a belly wound deserves top priority for surgery. Contrary to the official position of the armed forces, I believe he
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always will hold a top priority, atomic war or no.
If the volume of patients, or the time distance from the hospital, indicates a significant delay before abdominal surgery can be performed, there is still a great deal which can be done. Antibiotics, fluids, and a Levine tube cannot be passed off as either idle temporizing or as “routine” preopera- tive preparation. They may provide enough active support to tide the patient over a major delay before his time comes at the operating table.
Similarly, a urethral catheter should be passed and left in place if there is likely to be any con- siderable time lag in a patient with presumptive penetration of the bladder. True, your urologist colleague prefers to receive his patients without prior instrumentation, but it is reasonable to ex- pect that he would also prefer to receive them without a well established extravasation.
1 may well be wrong in not placing some res- ervations on the classification of infection as an ultimate rather than an immediate threat. An en- teric bacterial factor in the rapid promotion of irreversible shock is getting more and more at- tention, so much so that the bacterial factor in the wound now stands in relative neglect. In our lab- oratory we are obtaining some most interesting data from the study of a “naturally occurring” infection in an experimental wound. We delib- erately inflict the wound, but we do not inject bacteria or grind in street dirt. A wound infection occurs without any further effort on our part, and it often is of such virulence as to kill the animal in 8-12 hours. This is certainly a rapid course, in comparison to traditional teachings on the time relationships of wound infections.
Perhaps the most important ultimate threat to life is that conglomeration known as “shock.” The fact that I place shock as an ultimate threat indi- cates that I distinguish it from simple exsanguina- tion. I mention shock from “any cause,” simply because I do not know what the causes are.
I believe it safe to speak about the treatment of shock to a professional audience. But if you are teaching emergency medical treatment to lay- men you have to discuss diagnosis before treat- ment, and I question the practical utility of de- tailed clinical descriptions of the various shock states. For example, there is one syndrome which includes: an anxious facies, a sweaty brow, pale skin, a drawn and haggard look, dulling of visual and auditory perception, a detached attitude to- ward the realities of environment, hypotension, and bradycardia. Now my own normal pulse rate is 58, my normal blood pressure is 90/60, and in other respects I present a walking picture of this type of shock. However, I doubt if I would be of much
use as a training aid in teaching laymen how to discriminate between who will benefit from in- tensive shock treatment and who will not.
Several years ago I became sufficiently im- pressed with the futility of teaching laymen the fine points of shock, and I came to the point of deleting all references to shock per se from an in- tensive 8-week course of instruction for lay medi- cal assistants. They were still taught gentle handling, judicious relief of pain, protection from the elements, allaying of fear, and positioning of the patient. But they were taught that all patients deserve these things, and no attempt was made to pass off on them the myth that these things constitute a regimen of “treatment” for shock. For treatment they were given a tangible and simple rule of thumb as to amount of presumptive blood volume loss, and presumptive need for blood re- placement:
Amputation. Major Wound, or fracture Forearm, foot Arm, calf
Thigh, buttock, shoulder
Burn Blood Volume Or Loss
10-20% 500 ml
20-30% 1000 ml
30% plus 1500 ml
If whole blood, plasma, or plasma expanders are available to you in the emergency situation, then use them according to what you have other- wise been taught. If they are not, then use saline solutions in quantities two or three times as great.
When threats to life, immediate and ultimate, have been countered as best you can, then you turn to threats to limb, organ, and function. For early emergency work this essentially means threats to limh; repair of vital organs is the subject of complex surgery. If you do not already have your own standard pattern for emergency splinting. I offer the following:
For the upper extremity, the chest is a useful and readily available splint. A good illustration of this principle is Figure 20 in Hampton’s textbook on Wound of the Extremities in Military Surgery. Taking the cue from Hampton, the Medical Train- ing Center of the United States Army went one step further in developing a multi-purpose upper extremity splint for use by aidmen in the field. It is made of three triangular bandages, and has come to be called the “Aidman’s velpeau.”
The sling supports the forearm and elbow. The hand can be bandaged in position of function against the knot on the upper chest. The humerus is splinted neatly against the chest wall if a little padding is placed under the elbow. If the tails of the sling are reversed, with the external or super- ficial tail going over the uninjured shoulder, the tendency is to force the shoulder up and back, giving good support to a fractured clavicle. If the
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forearm is fractured, the rig is improved by the addition of a single volar splint — basswood, wire ladder, cardboard, or folded magazine. With such modifications as these this splint can be used for anything between the sternoclavicular joint and the middle phalanx.
For the foot, ankle, and lower leg, one of the best splints is a wire ladder arrangement. If stand- ard materials are not available, improvised splints of pillows or newspapers will do well enough for a while.
For fractures of the thigh, some sort of traction splinting is desirable, but I belong to the minority who feel that this is not a matter of prime im- portance.
If you are willing to take the time to actually study and practice its use, the Army Leg Splint is an excellent choice for splinting the thigh. How- ever, it is far too complex to be figured out on the spot for the first trial.
For general emergency use the best lower-ex- tremity splint I know of is the Stryker splint, a padded aluminum shell, with provisions for simple traction.
We have now covered the distance from chin to heel with outlines of treatment procedures, hut it is not the picture of these techniques that I
Fig. 5. A wire ladder arrangement gives smooth and even support to a fractured lower leg'. (From Surg. Clin. N. Am.. 36: 1191-1208, 1956.)
wish to leave with you. I would like to use this brief presentation as a base to show to you how even the earliest emergency care of the injured — the so-called first aid — is a matter of the logical application of the basic medical knowledge which is already in your possession. Let us take some of the points in which my recommendations differ from those you may read in first aid manuals, and
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Fig. 7. The Army leg splint is quite effective, but its use should be practiced in advance of the emer- gency. (From Am. J. Nurs., 56: 1120-1124, 1956.)
let us apply the basic medical sciences to an ex- amination of “Why?”.
For example, on splinting the upper extremity I mentioned padding under the elbow. This is not because the elbow is a bony prominence, which is often the first rationalization offered. The pad- ding is needed there to help splint the humerus, because there is a void space behind an elbow which is supported in a sling. If you give three triangular bandages and an abdominal pad to a supposedly well-trained lay first aider, most of the time the ABD pad will wind up in the axilla. I am sure that you studied the anatomy of the axilla as a four-sided pyramidal space, but when the arm is apposed to the chest the space is simply not there any more. Any padding placed in the axilla becomes a very effective fulcrum for wedg- ing out the upper fragment of a fractured humerus, and for compressing the brachial vessels and the brachial plexus against it. (Fig. 8)
I mentioned the need for a single volar splint in fractures of the forearm. The tradition is for two, one dorsal and one volar. If you inquire into another of the medical basic sciences — medi- cal history — I believe you will find that this dates from the pre-plaster-of-Paris days of fracture treat- ment. In definitive treatment of a forearm fracture by board splints, two are required — to orce the forearm muscles down between the radius and
ulna and prevent a disabling synostosis. One splint is quite enough for emergency work.
Perhaps you noticed that I did not mention elevation in the control of hemorrhage. True, elevation will help control venous and capillary bleeding, but this is not the real problem. How much help is elevation in arterial hemorrhage? Very little. In the first place, it is hard to make any arrangement to elevate the most difficult bleeders. Suppose you can elevate the wound — for example, the radial artery is severed at the wrist. If you lay the patient down, and raise his arm as high as it will go, elevation alone will not con- trol the bleeding until the patient has bled down to below 50 mm. of mercury blood pressure. This is a simple matter of the mathematics of the spe- cific gravity of mercury and blood, the conver- sion factor between millimeters and inches, and the length of the human arm and forearm.
Look again at sucking wounds of the chest. Am I either naive or careless in stating that a gauze dressing is an effective dressing? I think not. On what does the danger of a sucking chest wound depend? It is the relative ease with which air goes in and out the chest hole as compared to its transit through the normal airway. Have you ever thought of trying to breathe with a wet (bloody, that is) dressing tied firmly over your nose and mouth?
In connection with hemorrhage and shock I mentioned saline solutions, without hesitation or apology, and in the same paragraph with human blood, human plasma, and colloid plasma ex- panders. What kind of presumptuousness and overboard-expediency is this? During the study of surgery you have undoubtedly taken sober note of references to the effect that saline is of dubious and transitory value, “since it does not stay very long in the circulation.” What is the circulation? Is it limited to the contents of the arteries, veins, and capillaries? Or is the circulation, on which the life of cells and organs depends, inclusive of all the body’s fluid content? When you looked at the statement that saline is of transitory value did you forget your study of the physiology of hemor- rhage? If you bleed an animal over a period of time the hematocrit of the latter part of the blood removed is much lower than that of the first. The animal compensates for blood volume loss by call- ing fluid into the blood stream. Where did this fluid come from, and was it serving any useful purpose there? Might it not be that the animal would benefit greatly if we could give back to him some fluid that he could leak back the other way? Further, in any type of shock there is usually continuing fluid and blood volume loss — either
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through the wound, or into damaged tissue. Extra saline will help the animal compensate for this loss. Yes, saline solutions do “leak” from the vessels, but this leakage is no bad thing. And the effect of saline is by no means transitory. If you give enough saline solution to a severely bled-out animal you can change the altered values of circulatory dy- namics (such as blood pressure, A-V oxygen dif- ference, and cardiac output, but not hematocrit or hemoglobin) back to nearly normal, and they will stay at the improved values for 16-18 hours. But it takes really large doses before saline begins to take peerage with plasma. Every experimenter is hesitant to go on record with definite figures when he is extrapolating to humans from labora- tory data, but I am forced to give some definite figure as to what is “really large.” The situation is somewhat comparable to the marketing of olives, which come in six sizes larger than large: extra large, mammoth, giant, jumbo, collossal, and super- colossal! If you are going to use saline solutions alone in the treatment of severe shock, the quan- tities must be supercollossal. Five or six liters is not enough; it takes about 150 ml per kilogram; 15 per cent of body weight; 10 or 11 liters for an average adult!
If you should become convinced of the value of saline solutions, or if you are forced by default to use them in spite of skepticism, do not forget the value of the oral route. Unless the patient is in fairly profound shock, he can take and retain oral fluids. The standard solutions in current use are lactated Ringer’s solution; and a mixture of sodium chloride and sodium bicarbonate, which apparently goes back to Haldane. In my private opinion, both of these solutions taste outright awful, and I cannot swallow and keep down even one liter, much less ten. But we have just com- pleted some work which indicates that more palat- able solutions are quite feasible. We now have one which fizzes like champagne, has a tang like ginger ale, and a flavor so good that my children will drink it for an afternoon snack. I personally am able to take and retain several liters at a time. And when I give it to fatally burned mice, it sal- vages as many or more of them than does Haldane’s solution and lactated Ringer’s.
The science and art of medicine is the guide to emergency treatment, whether that treatment is given from a tin cup, or a sterile intravenous set, or whether the treatment is given in a well- equipped hospital, or in the crudest of roadside circumstances. Suppose you are invited next Christmas to go duck-hunting with one of your undergraduate classmates from Baton Rouge. He has prospered in the insurance business while
you are starving your way through medical school. He has an airplane, and he uses it to commute to his well-equipped hunting and fishing house- boat camp on Lost Lake in the Louisiana marshes. The two of you tell your wives: “Don’t look for us back soon; if the ducks are flying we will stay gone a couple of days.”
On landing, your friend flats out too high; the plane crashes, burns, and sinks in the lake. You have time to get him out, but he is badly burned over the lower body; his right arm is a mess, and the ulnar artery is severed just below the bifurca- tion of the brachial; his left chest is stove in, with an open pneumothorax; he has a penetrating wound over the pubis, that probably goes into the blad- der; he is comatose and cyanotic, but still has a pretty good blood pressure.
You have been to the camp before, and you know that the cabinets in the kitchen are likely to contain some ulcer medicine, adhesive tape, and some shotgun Asian Flu remedies, but no blood, plasma, oxygen, or syringes. Nevertheless, if you cannot preserve this man’s life over the next 48-72 hours before the sheriff comes flying down to look for you, you have missed out on a lot they were trying to teach you during your first two years in medical school.
You clamp one hand on the right arm, with the thumb compressing the brachial artery against the humerus. With your other hand you stuff a handkerchief into the hole in the chest, and roll the patient over with the left side down. Then you put a tourniquet on the right arm, roll him back over, and bind up the chest tightly. Then you do a tracheotomy with your penknife, insert- ing as a tube something trivial like the outer sleeve of your new plastic duck call. Then you put him left side down again, and tie off the ulnar artery with a piece of eight-pound braided silk fishing line. You splint the upper extremity. You take the polyethylene tube which your friend used for siphoning gas, and cut off a four-foot and a two-foot length. After flaming to round the ends, you put one in as a urethral catheter, and the other as a nasogastric tube.
You go to the kitchen cabinet, put nine table- spoons o salt and nine tablespoons of soda and all the penicillin and tetracycline tablets and troches you can find into a three-gallon bucket and you fill it up with water. Then you start putting the solution down the stomach tube — about six quarts in three to six hours, the rest in 12-18 hours. Then you sit back, watch the urine drip from the catheter, and pray.
When the sheriff comes, your patient will be alive. This, to my mind, is the practice of medi- cine, not first aid.
t_yUec(ica£ Cente/i (jUisce^any
Bringing the psychiatry department faculty up to six members, Dr. L. C. Hanes, Jr., joined the University Medical Center staff May 1 as an as- sistant professor.
He came to the University from Browne-Mc- Hardy Clinic in New Orleans, where he had been a staff psychiatrist for the last year after having been on the Veterans Administration hospital staff in New Orleans.
Dr. Hanes graduated from Texas Tech and got his M.D. degree from the University of Texas Medical Branch in 1944. He interned at the U. S. Naval Hospitals in Shoemaker, Calif., and Aiea Heights, Hawaii, returning to the University of Texas in Galveston for his residency training.
He is a member of the American Medical As- sociation and of the American Psychiatric Asso- ciation.
Other psychiatry department faculty members are Dr. F. J. Moore, professor and chairman; Dr. Oscar Hnbbard, professor, Dr. William Gillen, as- sistant professor who is also acting chief of the division of neurology. Dr. Niles Newton, assistant professor, part-time, and Dr. Boland Toms, as- sociate.
Alpha Omega Alpha
As the school year draws to a close, academic achievement takes the spotlight with special hon- ors and awards being announced.
On May 16, Mississippi Alpha chapter of Al- pha Omega Alpha honor medical society, installed at the University Medical Center last year, initiat- ed eight members.
Dr. Curtis P. Artz, associate professor of sur- gery, was tapped as an honorary member. Stu- dent initiates were: Russell E. Morris of Jackson, Arthur Lindsey of Cleveland, Bobby Jennings of Lambert, Dennis Magee of Tylertown, all seniors; William F. Lynch of Jackson, Norris Knight of Jackson and Charles Sledge of Sunflower.
Morris also received the first $100 Student Scien- tific Award given by the local AOA chapter. His winning paper was entitled “Cellular Events in Acute Obstructive Pancreatitis as Observed in the Living Mouse Pancreas.”
Dr. David M. Hume, professor of surgery and chairman of the department at the Medical Col- lege of Virginia, delivered the initiation address at a dinner in the King Edward Hotel.
A junior AOA initiate, Charles Sledge, was pre- sented the Roche award, a watch and scroll, which goes to the student with the highest scholastic- average covering his first two years in medical school. Sledge also got a Mosby award for scholas- tic achievement.
Other Mosby winners are Morris Jennings, Rob- ert L. Nix of Winona and Kelly S. Segars of Belmont.
The Sandoz prize, their “Atlas of Hematology,” went to the 12 top-ranking seniors. They are: Miss Walterine Herrington of Union, James Graham of Richton, Magee, Jennings, Nix, Bill Eure of Hat- tiesburg, Robert McKinley of Jackson, Russell Can- non of Bruce, Jeff Hodges of Lucedale, Haynes Heslep of Indianola, Morris and Lindsey. An- nouncement of the Leathers Medal award is made during the commencement exercises.
Fifty-Year Club
Members of the Mississippi State Medical .As- sociation Fifty-Year Club met for lunch with Dr. D. S. Pankratz, dean of the medical school, at the University Medical Center during the May state association meeting. Thirty members were present.
Medical Alumni Officers
Dr. James Grant Thompson of Jackson was elected president of the Ole Miss Medical Alumni at a dinner meeting in Jackson on May 14. He succeeds Dr. Ashford Little of Oxford. Dr. Robert Massengill of Brookhaven was named vice-presi- dent. Rapidly developing into an effective organiza- tion, the Medical Alumni association draws most of its members from medical certificate alumni for whom class agents have been appointed.
Get Fellowships
Two of the school of medicine’s first graduates, Dr. Talbot McCormick and Dr. Campbell Gilli- land, have received residency training fellowships.
Dr. McCormick, who was awarded the first Leathers Medal, has received a $1,000 Meade Johnson award for graduate training in general practice. He’ll take his G. P. residency at Huey P. Long Charity hospital in Pineville, La.
Dr. Gilliland will complete his internship at the University Hospital July 1 and will remain there as a pediatric resident on a $4800 Wyeth Fellow- ship covering two years.
INTERPRETING MEDICAL LITERATURE
STAFF OF REVIEW
JOSEPH P. MELVIN, Jr., M.D. Cordiology
HARVEY F. GARRISON, Sr., M.D. Pediatric*
JAMES D. HARDY, M.D., and STAFF, Department of Surgery, Unrvertity Medical Center Surgery
CARDIOLOGY
An Evaluation of the Serum Glutamic Oxalacetic
Transaminase Activity in Pericarditis
By: Robert B. Kalmansohn and Richard W. Kal- mansohn, Department of Medicine, University of California Medical Center, Los Angeles, Calif.
The serum transaminase has been studied ex- tensively since 1939, and after a simple photo- metric method for its determination was de- scribed in 1955, it assumed considerable clinical importance. Nearly all the investigators have agreed as to the value of the serum transaminase levels in myocardial infarction, and most of the literature suggests that a difference of diagnosis can be made between myocardial infarction and pericarditis on the basis of serum transaminase levels. However, an occasional case of pericar- ditis is reported in which the serum transaminase level is high, and these authors report seven consecutive cases of pericarditis, five of which were cases of nonspecific pericarditis and two of which were cases of myocardial infarction com- plicated by pericarditis. Six of the seven patients had elevated serum transaminase level and in four of these patients the maximum level was below 75 units but in two the levels exceeded 100 units and were well within range of levels seen in patients with transmural myocardial in- farction. This clinical impression is reinforced by adequate experimental bases, as pericarditis pro- duced in dogs by talc and cultures of alpha Streptococcus produced rise in SCO titles to a significant degree. Experimental data suggested that the SGO titre was only of value in differenti- ating acute myocardial infarction from pericarditis if the levels were within the normal range.
Undoubtedly the subepicardio-myocarditis oc- curring in pericarditis produces the changes in electrocardiogram and, without doubt, produces the elevation in serum transaminase. When more cases of pericarditis are followed closely, we will probably see more cases with elevated serum transaminase levels.
Comment: It has been my impression that not only the level of serum transaminase might dis- tinguish two conditions, pericarditis and myo- cardial infarction, but that the speed of the rise is of some help in differentiation. Serum transa- minase levels in definite myocardial infarction be- gin to rise as early as the fourth or even sixth hour, and in most cases by the end of twelve hours definite elevations have occurred. In none of the cases of pericarditis that I have seen, even with extensive involvement, have serum tran- saminase levels been secured early enough. The history of pericarditis is that of an upper respira- tory infection progressing into a picture of so- called pneumonia or bronchitis or pleurisy, and by the time the physician sees the patient the most acute stage of subepicardio-myocarditis has already passed. Possibly, if pericarditis were an acute, dramatic event, such as myocardial in- farction, earlier levels would be secured and un- doubtedly more pericarditis would be seen with in'crease in SGO titres.
PEDIATRICS
The Management oe Hemangiomata: A Plea foh Conservation in Infancy. H. M. Blackfield, F. A. Torrey, W. J. Morris and V. B. A. Low Beer. Plast. and Reconstruct. Surg. 20:38-44 (July) 1957 ( Baltimore ) .
This study adds to the previously reported evi- dence that hemangiomas and nevi presenting at or soon after birth frequently undergo complete or nearly complete spontaneous involution over a pe- riod of a few years, the great majority disappear- ing by five years of age. The authors examined 685 patients with various types of hemangioma, many of whom had multiple lesions. Two hundred twenty-five of these patients received no treatment, and most of the lesions spontaneously involuted or are going through the various stages of involution. Patients treated earlier by other methods showed the same type of involution as did those receiving no treatment, casting doubt on the effectiveness of some forms of treatment. The authors concluded that spontaneous regression of the most common hemangiomas of infancy and childhood must be accepted as a fact. In some cases involution may progress slowly, while in a small percentage re-
21
Interpreting Medical Literature
June, 1958
99
gression does not occur. It surgery is to be carried out early, due to family pressure, one should wait until involution has started so that a more con- servative excision can be carried out. If surgery can be delayed until the preschool age, most lesions will have disappeared. The large lesions which have undergone a few years of involution present a much more simple surgical problem. Any radical
method of treatment which may damage normal tissue or prevent its growth should be rejected.
Comment: Our experience has been similar to the authors. We would urge that their suggestions relative to the treatment of these cases be carried out. Certainly many cases have been treated that would have completely subsided in time.
MISSISSIPPI ACADEMY
OF GENERAL PRACTICE
INFORMATION HANDBOOK READY
The Handbook is being distributed free to all members of the Mississippi State Medical Asso- ciation. Printing of this volume culminates three years of work by the committee composed of Wm. E. Lotterhos, chairman, and S. K. Johnson and S. S. Kety.
It contains information about Mississippi laws pertaining to medical practice, adoption, hospitals, and welfare agencies. Also included are facts about the AAGP and AMA and their constituent chapters in Mississippi.
Our thanks go to the committee for preparing this gold-mine of information for our use. Thanks also to Wyeth Laboratories, Inc., for their generous support of the project. Extra copies of the Hand- book are available for $1.50 per copy.
LUNCHEON SUCCESSFUL
The Academy luncheon held during the recent MSMA session was a big success, with 64 mem- bers and guests in attendance. The new AAGP movie depicting highlights of 10 years of Acad- emy growth was shown.
M. S. M. A. OFFICERS
Mississippi Academy members, as usual, were elected to several important positions in MSMA. Guy T. Vise, MAGP director from Meridian, as- sumed the presidency. Congratulations and good luck! Wm. E. Lotterhos, Jackson, was chosen to serve a three-year term as secretary-treasurer un- der the newly adopted Constitution and By-Laws.
Other MAGP members elected were: George
Townsend, Forest, and Frank Massengill of Brook- haven, vice-president; associate editor. Moncure Dabney, Crystal Springs; trustee, N. C. House, Batesville; Council on Medical Service, George
Hicks of Pascagoula; Judicial Council, Lamar Bail- ey, Kosciusko, and A. T. Tatum, Petal. Council on Socio-Economic Affairs, Mai Biddell of Winona; Council on Constitution and By-Laws, John B. Howell of Canton.
SEPTEMBER ASSEMBLY
It isn’t too early to start making plans to at- tend the Mississippi Academy’s annual session in Jackson. The dates — September 17 and 18.
MISSISSIPPI HEART ASSOCIATION
An “emergency” identification card for the pro- tection of patients on long-term anticoagulant therapy is now available to physicians from the Mississippi Heart Association, says Dr. Wesley Lake of Gulfport, president.
Designed as a wallet insert, the card points out that the bearer is being treated with anticoagulants which slow down clotting of the blood. The card advises that a doctor be called in case of emer- gency, bleeding, injury or illness, since the patient may require an antidote.
Space is provided for the name of the indi- vidual’s physician, his address and phone number and for the kind of anticoagulant prescribed and the patient’s blood type. The card was designed with the approval of the Committee on Prothrom- bin Determinations of the American Heart Asso- ciation.
Dr. Lake, installed as MHA president in April, points out that this card is but one of the many services the Mississippi Heart Association offers to assist the physician with the management of his patients.
A complete list of available pamphlets for pa- tients and professional literature and films may be requested from the Mississippi Heart Association in Jackson *,
Fracture Problems
Leslie V. Rush, M.D. Meridian, Miss.
Problem No. 22 of a Series
THE HUM E R U S
SHAFT
Slightly curved pin gives best fixation. Diameter: one-fourth inch or three-six- teenths inch dependent upon size of mar- row cavity. Small antero-lateral incision to admit one finger for manipulation. Care- fully avoid distraction. Cast rarely neces- sary.
BELOW DELTOID INSERTION
Oblique fracture this direction tends to- ward distraction and shear. Obliquity in opposite direction gives compression and stable fixation. Pin must be curved.
TRANSVERSE NECK FRACTURE
Pectoralis major pulls shaft medially. Pin (one-eighth or three-sixteenths inch diameter) resists this pull by exerting three-point pressure.
The pin is introduced through the supero-lateral surface of greater tuberosity. Operation often done as a closed pro- cedure.
Problem No. 22
Problem No. 22
SHORT UPPER FRAGMENT
Pin introduced obliquely in short upper fragment produces angulation as it con- forms to axis of marrow cavity. Longer fragment does not angulate because three- point pressure forces pin into curve deflecting point at proper angle into medullary canal.
SHORT DISTAL FRAGMENT (Angle of Insertion) (Direction of Obliquity)
OTHER FACTORS
(A) Correct angle of insertion.
(B) Bad: Wrong angle of insertion in short fragment.
(C) Good: Curved pin, good angle of insertion, long upper fragment, irregular fracture line — excellent fixation.
(D) Bad: Oblique fracture below deltoid insertion. Straight pin introduced at im- proper angle gives distraction and angulation.
(E) Good: Note direction of obliquity. Fixation stable with firm bone compres- sion .
Fracture Problems
Problem No. 22
CHECK LOCK
The Problem: Unstable short oblique fracture, large medullary canal. Tends to non-union because of shear, distraction and rotary stress. This simple leverage trick can stabilize the fracture and produce contact compression of the bone ends.
ABDUCTED HEAD
Method of manipulating the head into position through a small incision using two small awl-reamers.
Problem No. 22
Fracture Problems
COMMINUTED HEAD AND NECK
(A) Bag of bones may require excision of fragments.
(B) Oblique fractures with angulation usually best treated with hanging cast. If pin is used it must be passed through the head.
(C) In children leave the head of pin high to simplify removal.
(D) In the elderly, if the pin is not to be removed, countersink head of pin so that it will not interfere with early shoulder motion.
SHORT DISTAL FRAGMENT
Fixation is usually satisfactory if medullary cavity is one inch long. Ream canal in distal fragment if necessary. Double pins might be driven upwards from condyles, instead. Hanging cast might be necessary.
HANGING CAST
Casts are seldom necessary in the pinned humerus.
Neck Region: Healing is usually rapid and fixation is stable so far as active motion is concerned. Passive rotary motion can disturb fixation. Lateral x-rays should be made through the chest and not by forcing the humerus into external rotation. Early circumduction exercises are helpful.
Shaft: Fractures of the shaft can usually be securely locked by the pin so that external sprinting is not neces- sary.
June, 1958
Editorials
23
THE MISSISSIPPI DOCTOR
The journal with a vision which encourages a plan of de- livering modern medicine to the masses at less cost to the individual and more profit to the practitioner. It chompions the community hospital, the hub around which this service must be built.
Entered as second-class matter, January 19, 1926, at the post office at Booneville, Miss., under the Act of March 3, 1870. Annual subscription, $3.00.
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W. H. ANDERSON, M.D. |
Editor-in-Chief |
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MILDRED P. ANDERSON |
Assistant Editor |
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MID-SOUTH POSTGRADUATE MEDICAL ASSEMBLY |
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J. Max Roy, M.D |
President |
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Forrest City, Ark. |
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W. G. Stephenson, M.D |
President-elect |
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Chattanooga, Tenn. |
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Julian K. Welch, Jr., M.D |
Vice-President |
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Brownsville, Tenn. |
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Robert Peeples, M.D |
Vice-President |
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Greenwood, Miss. |
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Ernest J. Stroud, M.D. |
Vice-President |
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Jinesboro, Ark. |
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Thurman Crawford, M.D |
Secretary-T reasurer |
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Memphis, Tenn. |
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Mid-South Associate Editors |
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H. King Wade, M.D |
Hot Springs, Ark. |
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Frank M. Acree, M.D |
Greenville, Miss. |
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R. L. Sanders, M.D |
Memphis, Tenn. |
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MISSISSIPPI STATE MEDICAL ASSOCIATION |
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Guy T. Vise, M.D. |
Meridian |
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President |
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Stanley A Hll, M.D. |
Corinth |
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President-elect |
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Wm. E. Lotterhos, M.D. |
Jackson |
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Secretary |
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Rowland B. Kennedy |
Jackson |
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Executive Secretary |
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State Assocate Editors |
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Wm. M. Dabney, M.D. |
Crystal Springs |
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Louis F. Rittelmeyer, M.D. |
Jackson |
The Publication Committee is not responsible for the au- thenticity of opinion or statements made by authors or in communications submitted to this Journal for publication. The author or communicant shall be held entirely responsible.
Address all material for publication to W. H. Anderson, M.D., 104 Hospitality Street, Booneville, Mississippi.
LEADERSHIP
Someone has said that a leader is a man who has something, has started somewhere with it, and is able to carry some others along with him.
DR. VISE HEADS MSMA
Dr. Guy Vise of Meridian is the new pres- ident of the Mississippi State Medical Association. He is a general practitioner in medicine and sur-
gery, qualifies well for the Academy of General Practice. He has been very active in organized medicine, enjoys a large practice, and is keenly interested in all human affairs that make for a better community and state. The state association should go forward in safety under his leadership.
DR. HILL ELECTED PRESIDENT-ELECT
Dr. Stanley Hill is now president-elect of the Mississippi State Medical Association. He lives at Corinth, the gateway to the great state of Mis- sissippi on the northeast. Dr. Jim Hill, his father, the beloved, served as president several years ago. Dr. Stanley has been very active in organized medicine across the years. He has been outstand- ing as speaker of the house of delegates. He is worthy and well trained for the presidency of the association.
The new secretary of the Mississippi State Med- ical Association is Dr. William E. Lotterhos. He has a keen appetite for work, is able and accurate. He is outstanding in organized medicine in Mis- sissippi.
GOOD STATE MEETING
The state meeting was unusually good in many respects The Section on Surgery was one of the best we have attended anywhere at any time. Dr. James Hardy, Professor of Surgery at our Medical School, was chairman of the section, and it was well planned and expertly executed. The Section on Obstetrics and Gynecology had also a most informative and interesting innova- tion, Dr. Walter H. Simmons, chairman.
Medicine in Mississippi is progressing signifi- cantly and it is easy to see that our four-year school is contributing in no small degree to this growth. Loyalty and pride are our just debt of gratitude.
HONOR TO DR. UNDERWOOD
On June 23 in the Victory Room of the Heidel- berg Hotel, Jackson, Mississippi, there will be a celebration of historic importance. Dr. .Felix J. Underwood will be honored with a recognition dinner. Mr. Clayton Rand will be the speaker, and friends are expected to gather from all parts of the state. Dr. Underwood has witnessed one- half of the march of medicine since its beginning with now more than fifty years service. He did general practice for awhile and then was chosen executive secretary of the State Board of Health. His name is known around the world.
The service he has rendered will be a monu-
24
Editorials
June, 1958
ment to him down the ages. The people of this state attest to a health program second to none. Theirs has been life and life more abundant.
When we honor Dr. Felix Underwood we honor ourselves. Few men have shown greater devotion to a noble cause. His devotion has been aug- mented by outstanding native organizing ability and by constant and sustained study in the field of public health. He has been a great friend to the medical profession. Few men in medicine have seen the interdependence of public health and medical practice as clearly as he. He has not shirked his duty as a citizen, nor failed to build friendships in and out of medicine which have reflected great favor upon his state.
It will be a privilege to join in the Underwood celebration.
... THE WORLD OVER
In response to our plea for a September, 1949, journal for our depleted files, a good doctor friend responded, as did Miss Louise Williams, Missis- sippi State Board of Health librarian. In her nice letter which accompanied the gift, she told us of a practice which libraries engage in to help one another keep up their files. She wrote:
“We, of course, feel a little responsibility in seeing to it that good journals are placed where they can continue to serve and that is why we find it so helpful to participate in the Medical Library Association Exchange. We receive so much from this source which we request each month with no obligation other than reimbursement of postage to the donor. In return we reciprocate about once every year or so by offering our duplicates. On our last offering we sent a total of 2500 items to 160 libraries in this country and abroad. This altruistic activity has a wonderful effect on strengthening medical libraries the world over.”
We commend Miss Williams and her staff for the excellent work that has been done through her library through the years. The above ex- presses somewhat the fine dedication that has characterized the work of this librarian in all her services to physicians in her own state and else- where.
FIFTY YEARS OF SERVICE
You will note in this issue the announcement of the celebration of the 50th anniversary of the Wallace Hospital in Memphis on June 14. To them we wish to offer our most cordial con- gratulations. This institution has served well and is just now in the beginning of a bigger and better day. The mentally sick are occupying over half
of our hospital beds now. The importance of pre- vention and treatment in this field can not be over- estimated. The stigma of mental illness is disap- pearing but the challenge of its cure is multiplied.
News and Comment
MISSISSIPPI STALE MEDICAL ASSOCIATION OFFICERS FOR 1958-59
President — Guy T. Vise, M.D., Meridian; presi- dent-elect— Stanley A. Hill, M.D., Corinth; Secre- tary-Treasurer— William E. Lotterhos, M.D., Jack- son; Executive Secretary — Rowland B. Kennedy, Jackson; Vice-Presidents— A. H. Little, M.D., Ox- ford, Frank Massengill, M.D., Brookhaven, George
G. Townsend, M.D., Forest; Historian — D. S. Pankratz, M.D.. Tackson; Editor — W. H. Anderson, M.D., Booneville; Associate Editors — William M. Dabney, M.D., Crystal Springs, Louis F. Rittel- meyer, M.D., Jackson; Speaker of the House of Delegates — Lawrence W. Long, M.D., Jackson; Vice-Speaker of the House of Delegates — B. B. O Mara M.D., Biloxi; Delegates to the AM A — J. P. Culpepper, Jr., M.D, Hattiesburg, John F. Lucas, M.D., Greenwood; Alternate Delegates- to the AMA— B. B. O’Mara, M.D., Biloxi, George E. Twente. M.D., Jackson; Board of Trustees — PI. H. McClanahan, Jr., M.D., Columbus, chairman (Dis- trict 3), John G. Archer, M.D., Greenville, vice- chairman (District 1 ), C. D. Taylor, Jr., M.D., Pass Christian, secretary (District 9), N. C. House, M.D., Batesville (District 2), Mai S. Riddell, Jr., M.D., Winona (District 4), John B. Howell, Jr., M.D., Canton (District 5), Lamar Arrington, M.D., 1115 - 22nd Avenue, Meridian (District 6), C. P. Crenshaw, Jr., M.D., Collins (District 7), Everett
H. Crawford, M.D., Tylertown (District 8).
DISTRICT VII AMERICAN COLLEGE OB-GYN TO MEET IN SEPTEMBER
District VII of the American College of Obstet- ricians and Gynecologists will be held in Jackson, Mississippi, September 12 and 13, 1958.
The program will begin with a fellowship hour on Thursday evening, September 11. The follow- ing day will be given to a scientific program of papers, round tables, and movies. Plans are also being made for the ladies’ entertainment.
The place of meeting will be the King Edward Hotel.
MEDICAL PROGRESS ASSEMBLY
The first annual meeting of the Medical Prog- ress Assembly will be held at the Tutwiler Hotel, Birmingham, Alabama, September 7, 8, and 9,
June, 1958
News and Comment
25
1958. Sixteen of the country’s outstanding medi- cal authorities will appear on the scientific pro- gram.
The Assembly is sponsored by the Birmingham Academy of Medicine.
NURSING SCHOOL AT BOONEVILLE WELL UNDER WAY
The nursing students of the Northeast Missis- sippi Junior College, Booneville, Mississippi, have completed their first year of work which was primarily academic and have now entered into the clinical phase of their training at the Northeast Mississippi Hospital. At a reception given at the Hospital May 26, 1958, the officials of the college and the hospital indicated their satisfaction in the operation of the nursing school.
This is the first effort in Mississippi of a junior college operating a nursing school. It has many advantages over the hospital school in that edu- cation of nurses now takes its rightful place in our educational system. This is a three-year course and when students have satisfactorily completed their work they will receive an Associate of Arts degree from the junior college and will be eligible to take the state board examination to become a registered nurse. The course seems to have more appeal to the students than the hospital school because it is a part of the college system.
Recruitment is thus far easy; the next session class is already filled. The recruiting forces of the college play a big part in the popularity of the course. It is expected that eventually about twenty students will be enrolled at the beginning of each college year.
WALLACE HOSPITAL CELEBRATES HALF CENTURY
On June 14, the Wallace Hospital, Memphis, Tennessee, will celebrate its 50th anniversary.
The Wallace Hospital has a half-century of serv- ice. It was established by the late Dr. W. R. Wal- lace, who was a pioneer in the field of psychiatric treatment.
The Wallace Hospital is located on a 12-acre tract, 10 miles from downtown Memphis, with a 50-bed capacity. Today, the two sons of Dr. Wal- lace carry on this work, adhering to the theory originally designed and carried out by their father, to keep the hospital small enough that individual care could be stressed and a close relationship be established with both patients and their families.
The guest speaker will be Rabbi James A. Wax, who has long been interested and actively engaged in the state’s mental health program.
A buffet supper will be served on the lawn out- side the hospital.
FIFTY-YEAR CLUB
The Fifty-Year Club had a nice meeting at the state meeting at the Medical Center with Dean Pankratz as host. The club has a fine host just waiting for next year at Biloxi.
Dr. W R. Hand of Philadelphia was the last to receive a fifty-year pin. A fine ceremony was held at his home and his own son. Dr. C. R. Hand, presented it. We are sure it was a lovely and impressive occasion with close friends, rela- tives, doctors and ministers present.
ANNOUNCEMENTS
Dr. L. C. Hanes, Jr., formerly a psychiatrist with the Browne McHardy Clinic, New Orleans, La., has been named an assistant professor of psychiatry at The University of Mississippi School of Medicine, effective May 1- Dr. Hanes received his M.D. degree from Texas Technologic College, Lubbock, in 1944 and interned at U. S. Naval Hospitals in Shoemaker, Calif., and Aiea Heights, Hawaii. His psychiatric residency training was re- ceived at the University of Texas Medical Branch, Galveston, Texas.
The University of Mississippi School of Medi- cine, Jackson, has scheduled three postgraduate courses for physicians in June. They are Abdom- inal Surgery, June 11 and 12; Obstetrics-Gyne- cology, June 18 and 19, and Internal Medicine, June 25-26.
Major General William E. Shambora, com- manding general of Brooke Army Medical Center, Fort Sam Houston, Texas, will deliver the grad- uation address at The University of Mississippi’s second Commencement June 8 in Jackson. Can- didates for doctor of medicine degrees number 44 as against 24 in the school’s first graduating class last year.
26
Woman’s Auxiliary
June, 1958
Mrs. Mayo Flynt
MERIDIAN DOCTOR'S WIFE HEADS AUXILIARY Mrs. James Thompson President-elect
Poised, attractive Mrs. Mayo Flynt of Meridian accepted the gavel from the outgoing president, Mrs. A. E. Brown of Columbus, at the May meet- ing of the Auxiliary to the Mississippi State Medi- cal Association in Jackson, to serve the stale or- ganization in the year ahead.
The new president comes to office well pre- pared in experience and ability for enthusiastic leadership. She lives a busy life, not only as a doctor’s wife but also as a mother, civic leader, and club woman. A graduate of Delta State Col- lege, Mrs. Flynt plunged whole-heartedly into social, church and community life upon becoming the wife of Dr. Flynt. Golfing, garden and literary clubs claimed her talents until growing children drew her into Scouting and the Parent-Teachers Association, which she served as president. She served as sponsor of Beta Sigma Phi sorority in 1956, was a DeMolay mother in 1957, is a mem- ber of Junior Auxiliary and Family Service. She is also a past-president of East Mississippi Medi- cal Auxiliary.
The Auxiliary looks forward to a year of happy
sailing with Mrs. Flynt at the helm. She is already making up her schedule for visiting the various auxiliary groups over the state.
Lovely Mrs. James Thompson of Pascagoula is the president-elect of the organization.
DOCTORS' WIVES ENTERTAINED WITH PARTY IN WALDRON HOME
Members of the Woman’s Auxiliary to the Mis- sissippi Medical Association and visitors were beau- tifully entertained Wednesday morning, May 14, at a coffee party in the home of Dr. and Mrs. Willard L. Waldron at 4217 Crane Boulevard.
The hostesses, charming in pastel summer frocks, were Mrs. Waldron, president of the local Central Medical Auxiliary; Mrs. Lee Reid of Jackson and Mrs. Arthur E. Brown of Columbus, president of the state auxiliary.
Mrs. Waldron’s home was decorated throughout with pink flowers accenting the dominant color note of its decor. Especially lovely was the coffee table, placed against the wide windows of the dining room, and graced by clear glass apothe- cary jars holding arrangements of pink peonies, carnations and stock. Bird-of-paradise was used in the family room, while the pink theme was con- tinued again on the terrace where blooming pink caladiums grew in natural surroundings.
Receiving the large number of callers at the door were Mrs. George Owen and Mrs. H. C. Ricks, both of Jackson. Mrs. John M. Chenault of Decatur, Ga., national “Today’s Health” chairman; and Mrs. Walker L. Curtis of College Park, Ga., Southern Medical Auxiliary, received with the three hostesses.
Mrs. R. C. O’Ferrall of Jackson presided at the guest register. Coffee was poured by Mrs. Mayo Flynt of Meridian, state president-elect of the auxiliary; Mrs. Guy Vise of Meridian, Mrs. Howard Nelson of Greenwood and Mrs. James Thompson of Moss Point, new president-elect.
Others assisting were Mrs. George E. Twente, Mrs. N. L. Gill Jr., Mrs. Thomas G. Ross, Mrs. Frank Donaldson, Mrs. W. F. Hand, Mrs. Law- rence Long, Mrs. F. E. McCullough, Mrs. Jack King, all of Jackson; Mrs. S. B. Platt, Mrs. W. L. Stallworth, both of Columbus; Mrs. S. Lamar Bailey of Kosciusko, and Mrs. Joseph B. Rogers of Oxford.
Mental health should have the interest and the help of every physician in the state as well as every other citizen. An illness that occupies half of our hospital beds certainly deserves our most active efforts.
The Relationships of Tobacco Use to Diseases of the Ear, Nose and Throat*
FLETCHER D. WOODWARD, M.D.f Charlottesville, Va.
Smoking has been both man’s solace and his sorrow since the American Indian first gave him tobacco, no doubt in retaliation for his many acts of thievary, treachery, humiliating treatment and atrocities. If true, vengeance has been wreaked, not only on the third and fourth generations, but on all succeeding generations.
“Why does man smoke?" has been a question asked thousands of times but, as yet, no satis- factory answer has been given. However, among the reasons are: To relieve nervous tension,
probably because the act of smoking diverts us by occupying the senses of smell, taste, sight and touch. To get a lift, probably because of the sympathomimetic action of nicotine. To prevent overeating, probably since smoking suppresses gas- trie motility, for it does not affect the blood sugar level. To appear grown up or sophisticated.
To satisfy the atavistic oral craving to place things in the mouth. To occupy the hands in a social ritual. Or, perhaps the same reasons apply to smoking as my former professor of medicine gave for man’s reason for drinking: to decrease the sor- rows of this life, which are far too many; or to increase the pleasures, which are far too few.
Whatever the reasons for smoking might be, it is a habit that, once acquired, is seldom given up, indicating that tobacco contains a habit-forming drug, regardless of the contrary opinions now held. The alkaloid nicotine seems to be the most likely suspect, because small subcutaneous doses will alleviate the desire to smoke, and regular smokers can tolerate larger doses than non-smokers. Also, all smokers are willing to tolerate the unpleasant tars in tobacco in order to get the nicotine effect. Statistics have shown a marked increase in the consumption of tobacco in recent years, largely because of the increase in cigarette consumption.
In fact, cigar consumption decreased and snuff, chewing tobacco, and pipe tobacco also dimin- ished during the same period. Last year 441 bil- lion cigarettes were consumed, an increase of 4 per cent, nearly a pack per person per day. Along with this increase there has also been a correspond- ing increase in many of man’s woes, such as cancer of the lung, cardiovascular disease and many other less serious ailments.
tFrom the Department of Otolaryngology, Univer- sity of Virginia Hospital, Charlottesville, Virginia.
27
The otolaryngologist is the first to see many of these cases because of the high incidence of symptoms referable to the air and food passages and, because of his special interest in the res- piratory tract, the ears and eyes, and his general interest in medicine, it is most important that he familiarize himself with the problem as a whole and the early symptoms and signs of tobacco poisoning so that he can recognize, as well as treat and frequently prevent, serious diseases which may be impending.
For many years he has noted the fact that smoking was a factor in cough, hoarseness, sore throat, stuffy noses, nasal discharge, dizziness, deafness, visual disturbances and a host of other complaints. Rut, due to the fact that he smoked himself, that his leading medical journals accepted the blatant ads of the tobacco hucksters, (in which they claimed that their particular product soothed the throat and never produced a cough, how much less harmful one product was because of an in- finitesimally smaller amount of nicotine, how bene- ficial the various lengths and filters were), and since these statements were attributed to various medical experts, who always remained unknown, and since the officers and members of our national medical associations allowed themselves to be lav- ishly entertained by tobacco companies, is it any wonder that the otolaryngologist was slow to raise his voice in protest and to realize he had been prostituted?
Reports of Ochsner', Graham and Wydner, Hammond and Horn", Doll and Hill1, and many others presented such a serious indictment of smoking that we can no longer let our personal habits or beliefs influence us but must make an attempt to evaluate the whole problem so that facts can be ascertained for use in future advice to our patients. Such authorities as these stated that: Cancer of the lung now causes four times as many deaths in men and two times as many in women as it did twenty years ago; that last year it caused 25,000 deaths in this country; that any man past fifty years of age who smokes a pack a day has fifty times as much chance of lung cancer as a non-smoker; that of 700 cases of lung cancer only nine were non-smokers; that of 1357 men with cancer of the lung in England only one- half of one per cent were non-smokers; that for
28
Tobacco Use — Woodward
July, 1958
men who smoked a pack of cigarettes per day the death rate for heart disease and cancer as a whole was double that of non-smokers for certain ages; that, according to Bryant and Wood', smok- ing yields coronary spasm and anginal pain at times, and coronary disease develops before the seventh decade significantly more often in smokers than non-smokers. Statements like these mean it is high time that we change our casual attitude toward tobacco use and re-evaluate the whole problem for, if it was a factor in the 25.000 deaths from cancer of the lung and the 500,000 deaths from coronary thrombosis last year, it is certainly time for the medical profession to recognize and utilize the fact.
What is tobacco? Avoiding any botanical dis- cussion. I can say that there are some 2,500 grades recognized at this time; that of the four types used in cigarette manufacture, i.e., Burley, Maryland, flue-cured and Levantine, there are sixty-six grades of Burley alone; and that the leaf content of acids, carbohydrates, waxes and other components varies according to the position of the leaf on the plant stem, weather conditions, region of growth and cultural practices. The amounts of nicotine and tar containing portions of carbon monoxide, carbon dioxide, ammonia, aldehydes, arsenic, acrolein, for- mic acid, sulfural, glycerine, diethylene glycol, benzopyrine and the hydrocarbon combustion prod- ucts found in smoke vary according to the type ol tobacco, the rapidity and frequency of smoking and the plex chemical problem and, regardless of the amount of money and the number of re- search laboratories available, the substances harm- ful to man will not be quickly ascertained.
However, as far as its effects on the human body are concerned, they can be simply divided into those caused by nicotine, those caused by the tar portions — either irritative or carcinogenic — and those resulting from the allergenic properties of tobacco itself or smoke.
Nicotine is an alkaloid and one of the most toxic known, the intravenous lethal dose being from 60 to 120 mgm. Since the average cigarette con- tains about 22 mgm. the contents of approximate- ly three cigarettes would cause death if injected intravenously.
Nicotine stimulates, then depresses the central and sympathetic nervous systems and the adrenal medulla. Its effects are similar to those of curare and muscarine.
The physiological effects of sweating, faintness, tachycardia, nausea and vomiting appear in non- smokers after one to six mg. of nicotine is in- jected subcutaneously. Larger doses are tolerated by regular smokers. However, in smoking a regular
cigarette only about 21 per cent, or 4.5 mg., of the nicotine content enters the mouth and of this perhaps, 0.5 mg. is absorbed.
The physiological effects of nicotine from smok- ing one cigarette are: to increase the blood pres- sure an average of 15 mm. systolic and 10 mm. diastolic and the pulse from five to twenty beats per minute. It contracts the peripheral blood ves- sels for from a few minutes to one-half hour. Nico- tine also causes anginal pain and an altered elec- tro- and ballisto-cardiogram at times. It reduces vital capacity and chest expansion; reduces gastric motility and secretions; causes the posterior pitui- tary lobe to release an antidiuretic hormone sim- ilar to vasopressin, which constricts blood vessels such as the coronary. It aggravates cardiovascular disease. Thrombo-angiitis obliterans occurs more frequently and is more severe in smokers. The same holds for other types of peripheral vascular disease.
The only facts I have been able to find in favor of nicotine are that: Fortunately, there is consid- erable human variation in its effects. It does not retard growth and does not interfere with preg- nancy. The milk content in nursing mothers does not harm the infant. It does not alter blood sugar levels and, finally, it does not act as a carcino- genic agent.
The effects of tar portions are much more ob- scure than those of nicotine. However, if they are divided into irritative and carcinogenic effects it helps somewhat to understand the problem al- though, of course, one merges into the other.
First, the mechanical effects of holding a pipe stem or cigar in one position in the mouth or a chew of tobacco or snuff in the same area causes a constant, low-grade, local irritation. This effect, in addition to that of tobacco itself, predisposes to epithelial changes characterized as leukoplakia or low grade epidermoid carcinoma.
Second are the more widely disseminated irri- tative effects on the mucous membranes of the nose, pharynx, tongue, larynx and lungs, charac- terized by nasal stuffiness and discharge; sore- ness of the mouth, tongue and throat; hoarseness from inflammation, edema or epithelial changes in the vocal cords",7; and cough. These effects are aggravated if other diseases exist, such as allergic rhinitis, asthma, sinusitis or pharyngeal, laryngeal or pulmonary disease. This is particularly true in chronic infections and ulcerative processes. Of all the irritative effects caused by smoking cough is the most frequent.
These results are due to the various substances in tobacco itself, as well as to other substances created by combustion. The number of cigarettes
29
Tobacco Use — Woodward
July, 1958
smoked, rapidity of smoking, length of butt and type of tobacco must also be considered.
Does tobacco or tobacco smoke contain a car- cinogenic agent? This is the question that has precipitated such a widespread furor recently among doctors, the public and the cigarette manu- facturers for the rising trend of cigarette con- sumption and cancer of the lung has caused great concern. Dr. Alton Ochsner has estimated that one male smoker in ten or twelve will die of cancer of the lung by 1970 if the present trend is continued.
Dr. Raymond Pearl of Johns Hopkins University first drew attention to this trend in 1938 in his study of nearly 7,000 white men, divided almost equally between non-smokers, moderate and heavy smokers between the ages of thirty and fifty. He found that almost twice as many smokers died as did non-smokers by age seventy. Dr. Sidney Cut- ler, in a recent study, estimates that the risk of cancer of the lung alone is from five to fifteen times greater in the smoker than in the non- smoker. These two conclusions are in close accord with those of Hammond and Horn and Ochsner which have been previously quoted.
Enough evidence has already been accumulated to prove pretty well that the increase in cancer of the lung is not due to carbon monoxide nor to the various noxious fumes and dusts. The accusa- tion of these factors by smoking medical men is probably another example of wishful thinking. Since painting the shaved backs of mice with to- bacco tar produced epidermoid cancer in 44 per cent of the mice, as reported by Graham and Wydner, one must conclude that there is a car- cinogenic agent in tobacco or its smoke. Further evidence to support this conclusion is: that the type of cancer found is predominantly epidermoid; that cigarette smoke is deeply inhaled; that if one smokes a pack a day for one year, a fifth of a gallon of tar is deposited on the mucous mem- branes of the mouth, throat and lungs; that pipe and cigar smokers do not inhale deeply so the incidence of cancer of the lung is less. The inci- dence is still less in those who chew tobacco or snuff. It seems that the carcinogenic agent is pro- duced by combustion and must be inhaled over a long period of time in order to produce malig- nant changes.
In a study of 100 consecutive cases of carcinoma of the larynx at the University of Virginia Hos- pital it was found that it occurred three and one- half times more often in those who smoked a pack or more a day than in non-smokers and, since the smoke bypasses the larynx and is retained in the lung, the incidence of fifteen to one in the
lung is further evidence that tobacco smoke con- tains a carcinogenic agent. Admitting that many smokers die of other causes, that some people are not susceptible to cancer and that they also vary in their tolerance and susceptibility to tobacco the evidence has accumulated to such an extent that it can now be said that it is up to the tobacco companies either to prove it is not true or to find and eliminate the harmful substances from tobacco. This would still leave the nicotine content and its harmful effects as the second horn to this dilemma.
Evidence so far presented does seem to indi- cate that there is a carcinogenic agent in tobacco smoke and that, when inhaled over a long period of time, it will produce cancer in a large percent- age of smokers.
The nature of this agent is, of course, unknown but coal tar research has proved that some of the hydrocarbons resulting from combustion can cause cancer.
Druckerv, of Germany, showed that hydrocar- bons fluoresce when exposed to ultra violet light and, when captured by blowing smoke in a flask, he found that approximately fifty per cent of the fluorescent materials were higher aromatic hydro- carbons. However, if the smoke was first inhaled ninety per cent of the hydrocarbons were retained in the lungs. So, it is possible that they could be a factor in the production of cancer of the lung.
Studies by the Chemical Laboratory of the American Medical Association revealed that pres- ent-day filters remove only a portion of the nico- tine and from ten per cent up to fifty per cent of the tars, at best, and offer no protection against the higher aromatic hydrocarbons. The best of the present-day filters is another cigarette. However, further investigation of silica gel — benzonite, dia- tomaceous earths and many other substances — may produce a more efficient filter but, first, the carcinogenic agent must be identified and re- moved by the filter before filters can be of any value in the prevention of cancer.
Other findings of the A. M. A. Laboratory were that denieotinized cigarettes contained one-half of the amount of nicotine of a regular cigarette but the same amount of tars. Low nicotine content Kentucky, type 31V, tobacco was found to be lower in nicotine content but higher in tars. So, as far as the physiologic effect of tobacco smoke is concerned it seems to make very little difference whether one smokes this brand or that, king-sized or regular, this filter tip or that filter tip, denico- tinized or type 31V Kentucky. If only the tobacco companies would now omit reference to filters, medical tests and slogans and the doubtful testi-
30
Tobacco Use — Woodward
July, 1958
monials of actors and singers as to the condition of their larynges after smoking, then, the doctor’s efforts to induce his patients who present evidence of tobacco poisoning to quit smoking would be greatly simplified.
The amount of nicotine which enters the mouth from the different methods of tobacco use varies approximately from low to high in chewing to- bacco, pipe, cigar and cigarette whereas the amount of tars which enter varies approximately from low to high in cigarette, cigar, pipe and chewing tobacco. Since one is the reverse of the other, perhaps, it would be best to revert to the snuffing habit which was so fashionable in the eighteenth century before the cigarette supplanted it in the early Victorian era.
In addition to the effects of nicotine and tars, tobacco or tobacco smoke itself may exhibit al- lergenic properties and cause a reaction in the peripheral vascular bed of a shock organ, such as the nose, bronchi, vascular system, eyes and ears. Such a reaction in the eye may cause amblyopia; in the ear, vertigo, tinnitus and deaf- ness and in the brain, a vascular headache. No doubt, there is a histamine release in all these phenomena.
Tobacco, now, stands indicted but, not yet, condemned on all counts and the outcome is, no doubt, being carefully watched by the insurance companies for the rates may soon be higher for the man who smokes a pack or more of cigarettes a day.
“How can I stop smoking?” is the first anxious question asked by one who either wishes to stop because of a guilt complex or fear or by one who has been told to stop for health reasons, either apparent or impending. Unfortunately, there is no easy way. The personal decision must be reached calmly and coolly but, when once made, the sooner it is executed the better. The first three days seem to be the hardest but no compromise can be made. There is no such thing as tapering off. A benzedrine tablet in the morning and a sedative at inght may be helpful. One should not change his way of life or try to change those of his family or friends. He may carry and hold a match but under no circumstances light a cig- arette for his companion. Recovery from smoking symptoms is usually prompt and pleasing. Your mouth feels better, your nose and head feel bet- ter, your cough disappears and your appetite is improved. These good effects at the time of blackest despair help to tide one over the period of severe tobacco craving and, as the weeks and months go by, desire finally leaves and you are free again.
Many suggestions have been offered to help: post-hypnotic suggestion, deep breathing when the desire to smoke asserts itself, the use of candy or chewing gum, the use of various tablets contain- ing alpha lobeline sulphate, the use of mock cig- arettes or cigars and, the most helpful in my experience, a nicotine-free tobacco extract in the form of a compressed tablet. This tablet gives the tobacco taste but is free of nicotine and, of course, carcinogenic smoke.
In conclusion, I can only say that one should not use tobacco; that if one is unable or unwilling to quit, then, he should use either snuff or a moderate number of cigars a day, without in- haling.
We doctors should be willing to set the ex- ample and to bolster our determination in this revolution let us consider the following facts in addition to those previously listed.
According to Dr. John R. Heller, of the National Cancer Institute, a non-smoker’s chance of getting cancer of the lung is one in two hundred and seventy-five, a heavy smoker’s chance is one in ten in this country and one in eight in England.
There were 25,000 deaths in this country last year from cancer of the lung, one per cent of the total. Eighty per cent of these deaths could have been prevented by not smoking cigarettes. Forty- two per cent of the adults now smoke cigarettes and consume nearly a pack a day per smoker.
The Rritish are being warned by the following posters put out by the British Government, act- ing on the findings made by the Medical Research Council.
Smoking and Health
It is my duty to warn all cigarette smokers that there is now conclusive evidence that they are running a greater risk of contracting lung cancer than non-smokers. The risk mounts with the number of cigarettes smoked. Giving up smok- ing reduces the risk.
To All Smokers
There are now the strongest reasons to believe that smokers — particularly of cigarettes — run a greater risk of lung cancer than non-smokers. The more cigarettes smoked, the greater the risk.
An American study group composed of repre- sentatives from the National Cancer Institute, Na- tional Heart Association, American Cancer Society and American Heart Association concluded: “The sum total of scientific evidence established beyond reasonable doubt that cigarette smoking is a causa- tive factor in the rapidly increasing incidence of human epidermoid cancer of the lung.”
Youth should be warned of the dangers of ac- quiring the habit. Perhaps, the economic aspects
July, 1958
Effect of Hysterectomy on Young Women — Field
31
of spending some fifteen to twenty dollars a month on cigarettes instead of gasoline will be a strong deterrent. Finally, if they succumb to the alluring appeals of the tobacco companies they will become enslaved too and in later life, no doubt, will feel as one of my colleagues feels who consistently says that he will not give up smoking because it is the one thing left to him that he can still do as well as he did many years ago.
BIBLIOGRAPHY
1. Ochs'ner, Alton, et al: Bronchogenic Carcinoma.
J.A.M.A., Vol. 148, No. 9, March 1, 1952.
2. Wydner and Graham: Tobacco Smoking as a
Possible Etiologic Factor in Bronchogenic Car- cinoma: Study of 684 Proved Cases. J.A.M.A.. 143:329, May 27, 1950.
3. Hammond and Horn: The Relationship Between Human Smoking Habits and Death Rates. J.A. M.A.. Vol. 155, No. 15, August 7, 1954.
4. Doll and Hill: A Study of the Etiology of Car- cinoma of the Lung. British Med. Jour.. Vol. 2. No. 4797.
5. Bryant and Wood: Tobacco Angina. Amer. Heart Jour., Vol. 34, No. 1, July 1947.
6. Myerson, M. C.: Smokers Larynx. Ann. O.R.L., June 1950.
7. Wallner, L. Smokers Larynx. Laryngoscope, April 1954.
Effect of Hysterectomy on Young Women ::
RICHARD T. FIELD, SR., M.D.
RICHARD J. FIELD, JR., M.D.
The Field Clinic, Centreville, Miss.
Following the work done by Jacobs, Daily, and Wills of Baylor University College of Medicine on this problem, we were prompted to review our cases in a similar manner. It is our opinion that the uterus is present for reproductive purposes, which if lost due to disease, should be removed if symptomatic regardless of patient’s age. We have not believed hysterectomy in this group would produce any serious consequences and this study was undertaken to evaluate our opinion. METHOD OF STUDY
Since 1946, 332 hysterectomies have been per- formed in this clinic. Of this group 44 were under thirty years of age and this report is a complete follow-up of 27 of these young women. This group represents 13.2 per cent of our total number of hysterectomies, which in comparison with some clinics appears quite high. However, this reflects our opinion as to the management of these cases as expressed in the introduction. The questions asked were as follows: 1) Do you feel that your operation was worth while and are your symptoms relieved? 2) Has the operation affected your sexual life? 3) Are you concerned about having no future menstrual periods? 4) Are you concerned that you will not be able to become pregnant? 5) Do you have any hot flushes or extreme nervousness, and if so, do you take any treatment for these symp- toms? These questions were asked of the patients just as stated and all interviews were conducted by one individual (RJF,Jr.).
RELIEF OF SYMPTOMS
Twenty-three patients were completely relieved of their symptoms, four were classified as poor re- sults and are as follows: 1. A 30-year-okl multi-
para for chronic pelvic inflammatory disease. Both ovaries were left in place. She complained of re- current right lower quadrant pain and dyspareunia following surgery. Examination nine years follow- ing surgery revealed enlarged right cystic ovary. This was removed and patient now well and asymptomatic. We believe this cystic degenera- tion to have been caused by inadequate blood sup- ply to the ovary. 2. A 30-year-old multipara op- erated for chronic pelvic inflammatory disease. Her right ovary was left in place. She was much improved since surgery but still has some pelvic pain. We believe this due to chronic oophoritis as the remaining ovary is tender, but not enlarged on recent pelvic examination. 3. A 28-year-old multipara who complained of persistent left lower quadrant pain. She was operated with a diagnosis of pelvic inflammatory disease with bilateral cys- tic ovaries. Both ovaries were removed. Examina- tion revealed a normal postoperative pelvis. This patient has a very difficult domestic problem and is very unstable mentally. We do not believe all her symptoms referrable to her pelvis. 4. A 30- year-old multipara who was operated for chronic endometritis and salpingitis. Both ovaries were left in place. She now complains of pain in the lower abdominal quadrants. She lives in another part of the country, and we have not had the opportunity to re-examine her. Again as in 2) re- ported above, we believe pain due to either oophoritis or degenerative cystic ovaries.
EFFECT ON SEXUAL LIFE There was decided improvement in nine of these cases. No change in sixteen and increased diffi- culty with intercourse in one. The latter is the same case discussed previously, 4) under symptom
32
Effect of Hysterectomy on Young Women — Field
July, 1958
relief. There was no loss of libido in any of these cases and one reported definite improvement in libido. Of the nine cases with decided improve- ment, all had inflammatory disease and severe dyspareunia prior to surgery and it is our feeling that the surgery definitely produced the relief. There was no significant change in the amount of vaginal lubrication in any case and it is our feeling that the case with continuing dyspareunia will need bilateral oophorectomy in the future, if she will accept it, for chronic oophoritis.
AS REGARDS FUTURE PREGNANCY
Six patients out of our 27 expressed desire for more children. Only one in the entire group was a nullipara. At the time of interview it was not be- lieved to cause any serious problem with any of these six patients.
VASOMOTOR DISTURBANCES
Eight patients reported no vasomotor symptoms whatever Six patients reported mild, but transient symptoms. Six patients reported transient, but se- vere symptoms and seven reported persistent ner- vousness and flushes which have required en- docrine substitutional therapy for relief. The fol- lowing table shows the type of surgery performed upon each group:
1. No symptoms — 8 patients
Ovary Status
2 bilateral oophorectomy
3 unilateral oophorectomy
3 ovaries not disturbed
2. Mild transient symptoms — 6 patients
3 bilateral oophorectomy
1 unilateral oophorectomy
2 ovaries not disturbed
3. Severe transient symptoms — 6 patients
3 bilateral oophorectomy
2 unilateral oophorectomy
1 ovaries not disturbed
4. Persistent severe symptoms — 7 patients
2 bilateral oophorectomy
4 unilateral oophorectomy
1 ovaries not disturbed.
The above information leaves us perplexed as to the value of leaving or removing the ovaries during this type of surgery. As one can readily understand there is no definite correlation what- soever between these groups as regards whether or not the ovaries were disturbed. This leads us to three conclusions, 1 ) undoubtedly in these women there is some psychogenic overlay which cannot be accurately determined but definitely effects their postoperative symptomatology, 2) the age- old question arises as to whether or not the uterus has some definite endocrine function and 3) is the varying response of the adrenals to ovarian dis- turbance responsible. The answer to the above group of patients and the type of surgery done upon them seems to lie somewhere between these
three possibilities. Even in the persistent severe group of patients, they all have been adequately relieved by substitutional therapy and we do not find this a contra-indication to the surgery. In com- parison with the findings of the Baylor group, however, we find that our vasomotor symptoms were much more evident than were theirs which we cannot explain. This may be due to the in- evitable variance in interviewing these patients, but we find a definite group of vasomotor symp- toms in a very significant number of our patients.
DISCUSSION
From our study we tend to agree with the Bay- lor group that the more complete type of surgery is indicated in spite of the individual’s age if the reproductive organs cannot perform this function. However, we did encounter more vasomotor dif- ficulties in our study than they and we cannot correlate these disturbances entirely to the removal or not of the ovaries. It makes one wonder once again if the uterus may have some endocrine func- tion and to desire a thorough study of the adrenal mechanisms in these with persistent symptoms.
Two of our failures are believed due to leaving in ovaries which are the source of chronic infec- tion in an effort to prevent these vasomotor dis- turbances. From this study we are convinced that not only should the uterus be removed if diseased, but no efforts should be made to leave in place a diseased ovary as it will more than likely neces- sitate further surgery, and the removal of both ovaries does not by any means produce a severe problem.
SUMMARY
1. This is a follow-up study of hysterectomies performed upon women of 30 years of age and under.
2. The study involved interviews with these women regarding the operation and the changes it has produced.
3. It is our conclusion that pelvic surgery with the removal of both diseased ovaries should not be deterred because of age if reproductive func- tions have been lost.
4. The question as to possible endocrine function of the uterus is brought up again in view of the vasomotor changes occurring in spite of leaving in both ovaries.
5. The role of the adrenal glands in these cases is considered.
6. It is possible that psychogenic overlay may confuse the picture in evaluating these symptoms.
References
Jacobs, Warren M., Daily, Harold I., and Wills. Seward H.: The Effect of Hysterectomy on Young Women. Surg. Gyn. Obst.. 1957, Vol. 104: 307-309.
What Should Our Present Attitude Be Regarding Carcinoma of the Lung*
JULIAN JOHNSON, M.D.t Philadelphia, Pa.
Inasmuch as the surgical treatment of cancer of the lung has been carried out successfully for about twenty-five years, it would seem to be an appropriate time to take stock as to what may be accomplished by our present approach.
In reviewing our cases at the hospital of the University of Pennsylvania from f939 to 1956, we found that approximately 600 patients with cancer of the lung entered our institution. Forty- three per cent of this group showed evidence of inoperability without the necessity of exploratory thoracotomy and only 38 per cent of the group underwent pulmonary resection after having been explored. The operative mortality for all patients resected was 7 per cent and the five-year survival rate for all patients resected was 25 per cent. When one considers, however, that only 38 per cent of the entire group were submitted to resection, the five-year survival rate for the entire group was only 9 per cent. Only one patient survived five years following exploratory thoracotomy without resection. He survived five years without the benefit of any specific form of therapy.
While a 9 per cent five-year survival rate for the entire group is certainly not as high as we would like it to be, nevertheless a 25 per cent five-year survival rate for those patients resected is certainly worth working for and, in fact, these figures are quite similar to those for carcinoma of the stomach, for example.
It would seem obvious from these statistical data that if the diagnosis of carcinoma of the lung could be made earlier so that all patients could be submitted to resection, our five-year survival rate for the entire group could be tripled to a figure of 25 to 30 per cent. Perhaps the best sur- vival data following pulmonary resection have been those collected by Dr. Edgar Davis in which it was found that the patient with asymptomatic car- cinoma of the coin type undergoing resection had an 80 per cent chance of five-year survival. If it were possible to pick up all carcinomas of the lung in this stage, it would obviously be possible to increase tremendously our five-year salvage.
As a result of this type of thinking, there has been a tremendous effort on the part of the medi-
■Professor of Surgery, Schools of Medicine, Uni- versity of Pennsylvania, Philadelphia, Pennsylvania.
'Presented before the sixty-ninth annual session of the Mid-South Postgraduate Medical Assembly, February 11-14, 1958, Memphis, Tennessee.
cal profession to increase the chances of cure for patients with carcinoma of the lung by an earlier diagnosis of the disease. One of the forms of bringing this about has been routine chest x-rays on all men, particularly over forty, perhaps on a six months basis, in order to pick up the lesion at an early date. Great efforts have been made by the Cancer Society to encourage patients with symptoms of the disease to report to the medical profession as early as possible and also great ef- forts have been made in an educational program to get the medical profession to pursue the diag- nosis as quickly as possible on the patients who submit themselves with symptoms. In addition to this effort to increase the five-year survival rate, the surgeon has made greater efforts in trying to accomplish the same thing by increasing the scope of his resection so that at times portions of the chest wall, diaphragm, pericardium or other struc- tures in the mediastinum have been resected in an effort to get around the tumor. So far, it probably has not been demonstrated that exten- sion of the surgical procedure is going to make any great difference in the over-all salvage of pa- tients with carcinoma of the lung, but it is cer- tainly hoped that the increased efforts on the part of the medical profession at large will in- crease the number of patients who come to early operation and thereby add some to the salvage.
I would' be the first to admit that if every pa- tient went to his doctor at the very first symptoms and if every doctor made the diagnosis upon the first visit and the patient was immediately sub- mitted to operation that we could not hope to get anywhere close to 100 per cent cure with cancer of the lung. I have had the unhappy experience of operating upon a patient before he had a symp- tom of any sort of cancer of the lung, only to have him die of metastasis within a matter of a few months. I have had the experience of operating upon a number of patients within a matter of two or three weeks of the very first symptoms, only to find the lesion entirely unresectable and, as a matter of fact, it is not at all uncommon to find the very first symptom of cancer of the lung to be produced by the metastatic lesion rather than by the primary lesion itself. Indeed, 7 per cent of the series of patients who entered the hospital of the University of Pennsylvania did so because of a neurologic complaint due to metastasis to either the brain or a major nerve.
33
34
Carcinoma of the Lung — Johnson
July, 1958
Fortunately, all of these lesions do not act alike and we have seen some where the cancer ob- viously moved slowly and considerable time was allowed for the clinician to make the diagnosis. 1 have one patient, for example, who had hemoptysis for a three-year period while in the Army and was studied very carefully without a diagnosis being made. One year after discharge from the Army or four years following his first hemoptysis, a small coin lesion was found in his right lower lung field. He was treated as a patient with tuberculosis for an additional year, so that I operated upon him five years after his first symptom. At that time the lesion still seemed to be early and he has now gone for almost ten years following his resection. An- other patient came to our hospital with hemoptysis, was carefully studied and no lesion found, although the hemoptysis obviously came from the right up- per lobe. He was followed by serial films and re- peated bronchoscopies for two years before the lesion finally appeared in the right upper lobe at which time it was resected and still appeared to be an early lesion. He also has gone on for a five- year cure. This simply demonstrates that some cancers of the lung move rapidly, metastasize rap- idly and kill the patient relatively rapidly, whereas other cancers of the lung move slowly and are not nearly so likely to metastasize.
In an effort to review this obvious difference in types of tumors, many pathologists have gone over them from the standpoint of cell type. There can be no question that there is considerable differ- ence in cell types and that the prognosis of the patient with an epidermoid carcinoma of the lung is much better than one with an undifferentiated carcinoma of the lung. Nevertheless, there still seem to be tremendous variations among the pa- tients with the same cell type. Several years ago. Dr. Fred Collier, who was at that time one of our surgical pathologists, reviewed our series of pa- tients from the standpoint of the phenomena of blood vessel invasion by the tumor cells. It was his thought that the demonstration of blood vessel in- vasion in the surgical specimen might correspond with the presence or absence of metastasis outside of the lung and might offer a much better prog- nosis from the standpoint of what would happen to the patient, as well as give us an explanation of the great variability of the course of patients with carcinoma of the lung. In our series of patients, he found that 75 per cent of the resected specimens showed blood vessel invasion by the tumor cells, whereas 25 per cent did not. Blood vessel invasion is much more common in certain cell types than others. For example, 100 per cent of the patients with undifferentiated carcinoma showed blood ves-
sel invasion, whereas only 63 per cent of epider- moid carcinomas had blood vessel invasion and 45 per cent of bronchiolar carcinomas had blood ves- sel invasion. The question naturally arose as to whether the presence or absence of blood vessel in- vasion was of great importance in the prognosis. Fortunately, it was possible to obtain a 100 per cent follow-up on the group of patients who had been operated upon more than five years ago and it was found that 75 per cent of the patients with- out blood vessel invasion in the tumor survived five years, whereas only 6 per cent of those with blood vessel invasion lived five years. Indeed, in that group of patients without blood vessel inva- sion without lymph node spread and without ob- vious spread to the surrounding structures, 90 per cent of the patients survived five years. It would seem then that this finding was of tremendous prognostic significance and, indeed, it fits in very well with the data which has been reported from Rochester in which series it has been possible to isolate tumor cells from the blood stream in about 75 per cent of cases.
If one takes these factors into consideration, it would seem quite obvious that blood vessel in- vasion or the spread of the tumor cells through the blood stream is a most important factor in the prognosis as to five-year cure. Unfortunately, we do not know when the tumor turns from a non- invasive one to an invasive one. We, for example, have seen small tumors with blood vessel invasion and the patient died early, whereas we have seen at least one huge tumor in which there was not blood vessel invasion and the patient got a five- year survival. If it were possible to determine before operation whether the patient has blood vessel in- vasion in his tumor, I think there would be a real question as to whether the patient with invasion should be submitted to pulmonary resection. Un- fortunately, we are not able to do this at the pres- ent time. The recovery of carcinoma cells from the blood stream might well be a more direct ap- proach to this than efforts at obtaining the infor- mation by bronchoscopic biopsy or aspiration bi- opsy.
It would seem evident that if a patient can be brought to pulmonary resection before his car- cinoma has invaded the blood stream, he has a very excellent chance of five-year survival, namely in the neighborhood of 75 per cent or above. The fact that in the past we have been able to pick up only 25 per cent of the patients while they are still in this happy state of affairs should not alter our enthusiasm for making efforts at early diag- nosis. On the other hand, once having made the diagnosis of carcinoma of the lung, it would seem
July, 1958
Parenteral Iodine Treatment — Wieters
35
likely that an operation which gets around the tumor grossly is fairly satisfactory for the patient whose tumor has not already invaded the blood stream, and that a more radical approach will be of no great value in the patient whose tumor has already invaded the blood stream. It might be in- ferred, therefore, that we should continue to make every effort to bring about an early diagnosis of cancer of the lung but that the value of super- radical surgery in the extirpation of extensive tu- mors may be open to some question.
SUMMARY
1. At the Hospital of the University of Pennsyl- vania in the last fifteen years a 25 per cent five- year survival rate has been obtained for all pa- tients undergoing resection for carcinoma of the lung. This is a 9 per cent 5-year survival rate for all patients who enter the hospital with this dis-
ease. The mortality for pulmonary resection has been 7 per cent.
2. The medical profession should continue its efforts toward the early diagnosis of carcinoma of the lung for at the present time it appears to be the best means of increasing our salvage rate in this disease.
3. There would seem to be little doubt that the presence or absence of blood vessel invasion in the surgical specimen is of great prognostic value in the outcome for the patient, since we obtained a 75 per cent five-year survival rate when blood vessel invasion was not present as opposed to a 6 per cent five-year survival rate when blood ves- sel invasion was observed. It would seem obvious, therefore, that our efforts should be directed to- ward an early diagnosis before blood vessel invasion has occurred.
Parenteral Iodine Treatment in Acute Infections and Arteriosclerosis
REPORT BASED ON 1,250 CASES AND A SURVEY OF MEDICAL LITERATURE
JOHN C. WIETERS, M.D. Bryson City, N. C.
In a period of five years, parenteral iodine medication was used successfully in a series of 1,250 cases of acute infections of diverse etiolo- gy and of arteriosclerosis. Altogether more than 9,000 intramuscular or intravenous injections were given.
The medication used for the intramuscular in- jections was a colloidal iodine preparation* con- taining elemental iodine 2 mg., potassium iodide 4 mg., starch 30 mg., and distilled water q.s. in each 2 cc. ampul.
The average dose for adults is 2 cc. by intra- muscular injection twice a week. In emergencies, where faster action and daily treatments are in- dicated, slow intravenous injections of cerium iodide are preferred.
This colloidal iodine preparation has three out- standing advantages in the broad field of iodide therapy.
1 ) The iodine reaches the therapeutic target immediately, without the delay and uncertainty of oral administration.
2) The iodine is provided in colloidal form, in combination with starch, from which it is released
* Available to physicians as Kamide ampuls, sup- plied by Swan’s Laboratories of Andrews, N. C.
gradually to the tissues which are the seat of local pathology.
3) The patient’s full cooperation is assured at all times and he necessarily remains under the direct supervision of his physician.
Parenteral cerium iodide was used for the intra- venous injections. This preparation** contains cerium iodide 9 mg-, elemental iodine 3 mg., dex- trose 15 mg., and distilled water q.s. in each 2 cc. ampul.
The average dose for adults is 2 cc. by slow intravenous injection, which may be repeated daily as needed.
Intravenous cerium iodide has three definite advantages in the broad field of emergency iodide medication :
1 ) The intravenous route reaches the thera- peutic target in seconds.
2) Cerium iodide reaches the lesions through the bloodstream virtually unchanged.
3) A form of effective medication is provided in acute infections, where daily visits and treat- ments are often needed.
** Available to physicians as Ceride ampuls, sup- plied by Swan's Laboratories of Andrews, N. C.
36
Parenteral Iodine Treatment — Wieteks
July, 1958
ACUTE INFECTIONS
It is the concensus of medical opinion that the thyroid gland needs an adequate supply of iodine in order to perform its functions properly. Thus Goodman and Gilman1 say that the iodides are effective therapeutic agents and are of particular value in the treatment of hyperthyroidism and the prophylaxis of goiter.
The minimum daily requirement of iodine is 0.1 mg. Near the seacoast iodine is abundant in the drinking water and vegetables and the oc- currence of deficiency is uncommon. However, in certain inland areas of high altitude neither the water nor the local vegetables contain sufficient iodine and simple goiter is prevalent (Barr).
Cretinism is endemic in the village of Cogne, Aosta, in the Dolomite Italian Alps. Almost the en- tire population consists of tiny cretins. This is be- cause the natives drink melted snow lacking in iodine content. Simple goiter is likewise prevalent in the Swiss Alps, Himalayas, Pyrenees, Andes and mountainous areas of the United States, Canada, and Mexico.
In animal experiments and pathological studies, Cole and Womack" established the fact that the thyroid gland takes an active part in the mech- anisms combating acute infections and fevers. They observed that lesions of the thyroid gland produced by infections and toxemias closely re- sembled the microscopical picture seen in exoph- thalmic goiter and toxic adenoma. In both con- ditions the iodine content of the thyroid gland was markedly reduced. From their studies they concluded that “it seems logical to assume that administration of iodine to patients with infectious processes, especially of the acute type, might be beneficial.”
A survey of medical literature shows that par- enteral injections of iodides have been reported to be beneficial in numerous acute infections of diverse etiology. This wide list of diseases includes herpes zoster (Ruggles4, Beers5), poliomyelitis (Horder", Miranda Ortiz and Gonzalez Calzada7, Edward8,”), epidemic encephalitis (Economs10), erysipelas (Kewalram11), pneumonia (MeSwee- ney12), septicemia (Chopra13), septic abortion (Bouche14), parotitis ( Altemeier15) , bubonic plague ( Bharadwaj18, Vassalo17), puerperal fever with pel- vic peritonitis (Erfurth18, Bobrik19), and acute in- fections generally (Cooke and Womack3, Wadhj- wani20, Shelmire21).
With respect to poliomyelitis, herpes zoster and epidemic encephalitis, it is to be noted that iodine is an effective viricide (Gershenfeld22) .
In our own experience covering a total of 1,250
cases with 9,000 treatments', intramuscular or in- travenous iodine proved valuable in a wide variety of acute infections of diverse etiology. The con- ditions treated successfully included herpes zoster, acute phlebitis, acute cystitis, acute mastitis, acute otitis media, acute follicular tonsillitis, acute sinusi- tis, influenza, undulant fever, furunculosis, pyo- dermatitis, acute iritis, and other acute infections.
In view of the diverse origin of the above dis- eases, it is obvious that the effect of the iodine therapy is nonspecific. We believe that the ex- planation is to be found in rapid replenishment of the iodine content of the depleted thyroid gland, a very important factor in the mechanism of combating all acute infections.
The patients covered by this report came from the neighborhood of the Great Smoky Mountains of North Carolina and Tennessee. This is a region in which the iodine content of the drinking water and local vegetables is low and in which many residents would be likely to suffer from a latent iodine depletion.
It is to be noted also that the favorable re- sults of Miranda Ortiz and Gonzalez Calzada in poliomyelitis came from Mexico City, which city is inland and has an elevation of over 7,000 feet; while Edwards' successful results in the same disease were reported from Winnipeg, which is located in the goiter belt of western Canada.
In cases where iodine depletion reduces re- sistance to acute infections, it is to be expected that intramuscular or intravenous injections o f iodine in a utilizable form that reaches the de- pleted tissues immediately and unchanged would produce prompt and favorable results.
ARTERIOSCLEROSIS
The value of iodides in the treatment of arterio- sclerosis is widely accepted by medical authorities.
Sollmann23 states that the iodides are employed in arteriosclerosis, coronary sclerosis, angina pec- toris and aortic aneurysm. He adds that, in the lighter grades of these conditions, their continued administration seems to give gradual relief to the functional phenomena, especially the pain.
Bastedo24 recommends the iodides in arterio- sclerosis, atherosclerosis and arterial hypertension. McGuigan25 says that they are beneficial in pre- mature arteriosclerosis, essential arterial hyper- tension, aneurysm of the aorta and angina pectoris.
There are numerous other medical textbooks in which favorable reference is made to the use of the iodides in arteriosclerosis: Cushny20, Osier27, Solis-Cohen and Githens28, Hare29, Wilcox30, Wyck- off1, Piersol32, Boas and Boas33, and Hiller34.
Experimentally, numerous investigators have re-
July, 1958
Effect of Hysterectomy on Young Women — Field
37
ported favorable results with iodine in the treat- ment of atherosclerosis in rabbits produced high cholesterol feeding (Liebig35, Seel and Creuzberg3", Turner37, Ungar38, Rosenthal30, Page and Bernhard"’, Damrau11, Masson42, Mardones and Jiminez43).
Clinically, numerous original reports on the suc- cessful treatment of arteriosclerosis with iodides have been published: Wyckoff3', Bix'4, Guggen- heimer and Fisher43, Stevens4'1, Damrau41, Seel'7, and Feinblatt, Feinblatt and Ferguson48,40.
In this connection the reports of Feinblatt, Fein- blatt and Ferguson48,40 are of special interest, be- cause they are as recent as 1955-56 and these investigators administered the iodides intramus- cularly and intravenously in a large group of pa- tients with arteriosclerosis. They observed pro- found relief of the symptoms of arteriosclerosis.
In more than 90 per cent of our cases of arterio- sclerosis treated with intramuscular injections of colloidal iodine or slow intravenous injections of cerium iodide, our results were very satisfactory and in many cases they were really outstanding. The symptoms relieved included headaches, diz- ziness, leg cramps, asthenia, amnesia and disorien- tation. In many cases of hypertension due to ar- teriosclerosis, we were able to reduce the blood- pressure decidedly in three days.
We have observed no adverse reactions to either the intramuscular or intravenous injections.
CONCLUSIONS
1. Study of 1,250 cases comprising more than 9,000 treatments demonstrates that intramuscular colloidal iodine and intravenous cerium iodide in- jections are safe and effective in the treatment of acute infections of diverse etiology and of arteriosclerosis.
2. Parenteral iodine medication quickly replen- ishes the iodine content of the thyroid gland, which is depleted in acute infections. It has been established that the thyroid gland takes an active part in combating acute infections and fevers.
3. Iodine administered intramuscularly or in- travenously rapidly reduces hypercholesteremia and thereby aids in the treatment of reversible arteriosclerosis.
4. When administered by the intramuscular or intravenous route, the iodine quickly reaches the therapeutic target unchanged and unaffected by the digestive juices.
5. Better therapeutic results are obtained in inland and mountainous areas where the natural
supply of iodine in drinking water and local veg- etables may be deficient.
6. A comprehensive survey of medical litera- ture confirms the value of parenterally adminis- tered iodine in the treatment of acute infections of diverse etiology and of arteriosclerosis.
7. No ill effects were observed from the intra- muscular or intravenous injections.
REFERENCES
1. Pharmacological Basis of Therapeutics, 2nd ed., 1955, p. 827.
2. Cecil’s Textbook of Medicine, 7th ed., 1947, p. 1325.
3. J.A.M.A. 90:1274, 1928.
4. Arch. Dermat. and Syph. 23:472, 1931.
5. J.A.M.A. 112:2552, 1939.
6. Lancet 1:340, 1927.
7. M. Times 83: 107, 1955.
8. Manitoba Med. Rev. 34:337, 1954.
9. M. Times 84:704, 1956.
10. Cited by Solis-Cohen and Gaithens, Pharma- cotherapeutics, Materia Medica and Drug Action, 1928, p. 1429.
11. Indian M. Rec. 50:141, 1930.
12. Lancet 2:3, 1940.
13. Handbook of Tropical Therapeutics.
14. J.A.M.A. 87:362, 1926.
15. Surgery 20: 191, 1946.
16. J.A.M.A. 86:1585, 1926.
17. Ibid. ref. No. 10.
18. Therap. d. Gegenw. 65:539, 1924.
19. Med. Klin. 22:892, 1926.
20. Indian M. Gaz. 59:413, 1924.
21. Texas J. Med. 22:644. 1926-27.
22. Reddish’s Antiseptics, Disinfectants, Fungicides, etc., 1954, p. 182.
23. Manual of Pharmacology, 7th ed., 1948, p. 818.
24. Pharmacology, Therapeutics and Prescription Writing, 5th ed., 1947, p. 729.
25. Applied Pharmacology, 1940, p. 187.
26. Pharmacology and Therapeutics, 1940, 12th ed., p. 78.
27. Principles and Practice of Medicine, 14th ed., 1942, 'p. 1107.
28. Ibid. ref. No. 10, p. 1425.
29. Practical Therapeutics, 21st ed., 1930, p. 338.
30. Materia Medica and Therapeutics, 12th ed., p. 650.
31. Cowdry’s Arteriosclerosis, 1933, p. 572.
32. Cyclopedia of Medicine 7:350, 1933.
33. Coronary Artery Disease, 1949, p. 313.
34. Kyser’s Therapeutics in Internal Medicine, 2nd ed., 1953, p. 696.
35. Med. Klin. 25:1100, 1929.
36. Arch. f. exper. Path. u. Pharmakol. 161:674,1931.
37. J. Exper. Med. 58:115, 1933.
38. Arch f. exper. Path. u. Pharmakol. 175:536, 1934.
39. Arch. Path. 18:827, 1934.
40. Arch. Path. 19:530, 1935.
41. M. Rec. 144:373, 1936.
42. Bern Thesis, 1940.
43. Rev. de med. y ' aliment. 6:63, 1943-44.
44. Wien. klin. Wchnschr. 38:1256, 1925.
45. J.A.M.A. 92:353, 1929.
46. Clin. J. 59:529, 1930.
47. Fortschr. d. Therap. 14:297, 1938.
48. Am. J. Digest. Dis. 22:5, 1955.
49. M. Times 84:741, 1956.
INTERPRETING ME
STAFF OF REVIEW
JOSEPH P. MELVIN, Jr., M.D. Cardiology
HARVEY F. GARRISON, Sr., M.D. Pediatrics
JAMES D. HARDY, M.D., and STAFF, Department of Surgery, University Medical Center Surgery
CARDIOLOGY
PITFALLS IN THE DIAGNOSIS OF PULMONARY HYPERTENSION
By JONAS BRACHFELD, et al Department of Medicine, Hahnemann Medical College and Hospital
(In American Heart Journal. Vol. 55, No. 6, Page 905)
The diagnosis of primary pulmonary hyperten- sion is creating increasing interest in the litera- ture, although the nature of this condition remains obscure. The clinical picture is entirely nonspecific and essentially consists of a syndrome in young adults characterized by weakness, malaise, dyspnea on effort, not associated with orthopnea until late, hoarseness due to pulmonary artery enlargement and chest pain simulating angina. Syncope on ef- fort and sudden death after trivial surgical pro- cedures may be the only manifestations, hemoptysis is rare and right heart failure and cyanosis are frequently seen in the end stages.
In a typical case there are the physical signs of pure right ventricular hypertrophy with ac- centuated second sound and palpable heave over the precordium. X-rays show a prominent right ventricular and pulmonary artery salient, and the pulmonary hilar vessels are increased in size while the peripheral lung fields show decreased vas- cularity. The left atrium and pulmonary paren- chyma are normal. Electrocardiogram shows right ventricular hypertrophy and frequently suggests right atrial hypertrophy. However, none of these signs are reliable and the entire picture can be imitated by: (1) Diseases of the pulmonary paren- chyma (this is excluded chiefly by the finding of normal lung fields and primary pulmonary hyper- tension). (2) Intracardiac or intervascular shunts (extremely difficult to exclude some of these even after doing cardiac catheterization). (3) Lesions of the pulmonary arterial vasculature other than those due to shunts, such as embolic occlusion of the pulmonary artery due to multiple pulmonary infarcts, schistosomiasis, amniotic fluid emboli and
DICAL LITERATURE
microscopic thromboses due to cryoglobulinemia or sicklemia. (4) Obstruction of the pulmonary veins or of the mitral valve (the latter being the most commonly misdiagnosed entity simulating primary pulmonary hypertension.
Cases are presented showing the ease of mis- diagnosis even with sophisticated work-ups, and the authors summarized the article by stating that the above other four causes of right ventricular hypertrophy and pulmonary artery and right ven- tricular hypertension should be excluded before the diagnosis of primary pulmonary hypertension is made. The importance of left heart catheteriza- tion in excluding cases of occult mitral stenosis is stressed and a case is described in which such dis- ease was present with the unusual etiology of endocardial fibroelastosis involving the mitral valve
Comment: This is a diagnosis that in my lim- ited experience is extremely difficult to make with any degree of assurance. The most frequent imita- tors of primary pulmonary hypertension are: high pressure left-to-right shunts, such as ventricular septal defect, an aortic septal defect or a patent ductus arteriosus with atypical murmurs, and also, of course, the case of atypical mitral stenosis. Diagnosis can be suspected, however, if the other causes of pulmonary artery hypertension are kept in mind and systematically and thoroughly ex- cluded.
PEDIATRICS
Staphylococcus Pneumonia in Childhood. J. Kringelbach and J. Winge. Ugesk. Iaeger 120:143- 150 (Jan. 30) 1958 (In Danish) (Copenhagen).
Staphylococcus pneumonia occurs most frequent- ly during the first three months of life. The mor- tality is considerable. Two main types are de- scribed: (1) an acute fulminating type, often
fatal after a few days, and (2) a more prolonged and less malignant form which does not react to sulfonamide preparations or penicillin. During the course of the latter type empyema or pneumo- thorax develops, possibly with tension or pyopneu- mothorax. Roentgenologic examinations show in- filtrations, frequent atelectases and pneumatocele formation. The diagnosis is suggested by the clin- ical course and may be verified by culture from the lungs or pleurae. Plasma-cell pneumonia is es-
July, 1958
News and Comment
39
peciallv to be considered in differential diagnosis. Treatment consists in administration of tetracycline preparations, use of oxygen, and gastric aspirations; pleural complications are treated surgically. Among the 228 patients with pneumonia treated in the pediatric department of the Copenhagen County Hospital in Gentofte from 1955 to March, 1957, there were 13 cases of staphylococcus pneumonia or empyema, 1 1 of them in infants less than one year old. Of the six deaths in the entire series, three occurred in infants less than four months of age.
COMMENT
Staphylococcus infection is one among the most serious types of infection with which we have to deal. No one drug or antibiotic alone is sufficient to cure these infections, and it is a very serious condition under any circumstance. A child so in- fected should be in a hospital where it may be treated and receive diagnostic and progress ex- aminations, which are very essential in this con- dition.
(jUedica^ Ce^e/t (jUtseefcy
A 25-year-old woman graduate swept the board of senior honors in the second University of Mis- sissippi School of Medicine Commencement, June 8.
Dr. Walterine Herrington of Union received the medical school Leathers Medal which goes to the graduating student selected as outstanding by the faculty and Dr. D. S. Pankratz, dean.
Leadership abilities and motivation are con- sidered along with scholarship in making the se- lection, Dr. Pankratz explains.
Although scholastic achievement was not the only consideration in Dr. Herrington's recogni- tion, the dark-eyed State Medical Education schol- arship student rated top spot in her class in grades for the four years.
This accomplishment brought her a $100 cash award offered all medical schools by the Ameri- can Medical Women’s Association. The winner must be a woman who leads her class scholas- tically.
Dr. Herrington expects to practice in one of Mississippi’s rural communities as required by her scholarship agreement. Partner in practice, as in internship at Memphis City Hospitals will be her husband. Dr. Charles Bell of Pope, to whom she was married June 15. Dr. Bell is also a 1958 graduate of the University of Mississippi School of Medicine.
Dr. Herrington is a charter member of Missis- sippi Alpha chapter, Alpha Omega Alpha, serving as secretary during her junior and senior years. Her record of scholastic excellence reaches back through pre-med work at Mississippi College and East Central Junior College.
Dr. Herrington’s awards were presented during
commencement exercises in the First Baptist Church. Forty-four doctor of medicine degrees and 14 bachelor of science in nursing degrees were conferred by Chancellor J. D. Williams.
Nurse Award
The first Faculty Award for a graduating nurs- ing student was presented during the commence- ment with Miss Jeanette Waits of Leland selected for the honor. Chosen by the department of nurs- ing faculty and its chairman, Miss Christine Ogle- vee, the Faculty Award winner is judged on grades, personality and nursing art.
GP Fellowship
Dr. Benjamin F. Banahan of Jackson who com- pleted his internship at the University Hospital June 30, has received a $1,000 Meade Johnson fellowship for general practice training. Dr. Ban- tihan will remain at the University Hospital for his GP residency.
New Interns
Eleven of the 24 new interns set to start work in University Hospital July 1 are 1958 graduates of the University of Mississippi Medical School.
They are Henry W. DeWitt of Hattiesburg, Wil- liam R. Eure of Hattiesburg, Milton Fant of Jack- son, Patrick G. McLain of Brandon, John A. Mc- Leod, HI, of Hattiesburg, Robert L. Nix of Wi- nona, James C. Waites of Waynesboro, Milton R. York of Jackson, and J. P. Tones of Jackson.
Other new interns, their homes and schools are: William F. Childres of Houston, Texas, Baylor; William C. Garre of Amarillo, Texas, University of Texas Southwestern; Richard T. Green of Lake Charles, Louisiana, Tulane; Walter P. Griffey, Jr.,
40
News and Comment
July, 1958
of Baltimore, Maryland, Vanderbilt; Joe S. Hester of Starkville, University of Tennessee; David L. McNeil of Houston, Texas, Baylor; John R. Mont- gomery of Town Creek, Alabama, University of Alabama.
Louis S. Riley, Jr., of Hattiesburg, Baylor; Carl Edward S. Sills of Jackson, Tulane; Thomas S. Stolee of Minneapolis, Minn., University of Minne- sota; George R. Walker, Jr., of Birmingham, Uni- versity of Alabama; Lloyd C. Warr of Clanton, Alabama, University of Alabama, and Hardy B. Woodbridge, Jr., of Ridgeland, Tulane.
The Department of Anesthesiology at the Uni- versity of Mississippi School of Medicine in Jackson has been designated a separate department and Dr. Leonard W. Fabian named as professor and chairman.
FIFTY-YEAR CLUB
A luncheon meeting of the Fifty-Year Club was held at 12:30 p.m. on Tuesday, May 13, 1958, at the University Medical Center, Jackson, Mis- sissippi. Dr. D. S. Pankratz, director of the Uni- versity Medical Center, was host.
The followinrg members of the club were present: Dr. Isaac Edwards, Canton; Dr. Lancelot L. M inor, Memphis, Tennessee, R.F.D.; Dr. Har- vey F. Garrison, Sr., Jackson; Dr. William W. Mc- Bryde, Ethel; Dr. G. W. F. Rembert, Jackson; Dr. B. L. Crawford, Tylertown; Dr. James R. Hill, Corinth; Dr. James H. Fox, Jackson; Dr. Hal M. Terry, Goodman; Dr. Richard N. Whitfield, Jack- son; Dr. B. Z. Welch, Biloxi; Dr. George W. Bounds, Meridian; Dr. Hunter L. Scales, Starkville; Dr. David A. Ratliff, Columbia; Dr. E. C. Parker, Gulfport; Dr. J. S. McIntosh, Jackson; Dr. Felix J. Underwood, Jackson; Dr. W. H. Frizell, Presi- dent, Brookhaven.
Others in attendance included: Dr. Howard A. Nelson, president, State Medical Association, Greenwood; Dr. C. A. Pender, Kosciusko; Dr. W. FI. Anderson, sponsor, Booneville; Mrs. D. A. Ratliff, Columbia; Dr. D. S. Pankratz, Jackson; Miss Cleta Brinson, secretary to Dr. Underwood, Jackson.
Dr. W. H. Frizell presided and called upon Dr. James R. Hill to give the invocation.
In presenting his report as secretary of the club, Dr. Felix J. Underwood stated that since the club was organized in 1948, 143 physicians had been presented fifty-year certificates and pins and that
Dr. Fabian comes to Mississippi from Duke University School of Medicine where he has been an assistant professor since 1955.
He is a diplomate of the American Board of Anesthesiology, member of the American Society of Anesthesiologists, the International Anesthesia Research Society and the American Medical As- sociation. He took his residency training at the University of Arkansas Medical Center where he also interned after having received both his M.D. and B.S. degrees from the University of Arkansas.
Dr. Fabian has been active in anesthesia re- search at Duke and is co-inventor of a precision vaporizer recently evaluated there. He is partic- ularly interested in pediatric thoracic anesthesia.
He replaces the late Dr. G. Bittenbender, first professor of anesthesiology at the University of Mississippi Medical Center.
60 members were living at the present time. He read the names of the following members who had passed away since the last meeting: Dr. Henry L. Lewis, Liberty; Dr. James H. Stennis, Mathis- ton; Dr. William D. McCalip, Yazoo City; Dr. He rvey L. Shannon, Flora; Dr. Newnan C. Wald- rep, Tishomingo; Dr. Hugh L. McKinnon, Hatties- burg; Dr. Walter Eugene Clark, Philadelphia; Dr. Charles II. Holman, Carrollton; Dr. Benjamin J. Marshall, Whitfield; Dr. D. O. Pierce, Jonestown; Dr. Seale Harris, Birmingham, Alabama (honorary member); Dr. Rudolph Matas, New Orleans, La. (honorary member).
The following officers of the club were unani- mously re-elected for the coming year:
Dr. W. H. Frizell, president, Brookhaven.
Dr. 13. L. Crawford, vice-president, Tylertown.
Dr. Fel ix J. Underwood, secretary, Jackson.
Dr. W. II. Anderson, sponsor, Booneville.
It was a pleasure to deliver a fifty-year pin to Dr. Thomas Clay at Tutwiler at the six o’clock fish fry a few days ago. He was the first white male child born in Tutwiler and his wife the first white female child. Dr. Clay’s practice has repeat- and stood the test for fifty years and his folks dearly love him. Respect, admiration and appre- ciation were all in evidence, for him, the lovely wife and family. Three pins and certificates have been presented in Tutwiler — Drs. Baxtrom, Den- son, and Clay.
It was good to have Dr. LeRoy Wilkins present. He is a beloved citizen of the Delta.
July, 1958
Editorials
41
THE MISSISSIPPI DOCTOR
The journal with a vision which encourages a plan of de- livering modern medicine to the masses at less cost to the individual and more profit to the practitioner. It champions the community hospital, the hub around which this service must be built.
Entered as second-class matter, January 19, 1926, at the post office at Booneville, Miss., under the Act of March 3, 1870. Annual subscription, $3.00.
W. H. ANDERSON, M.D. Editor-in-Chief
MILDRED P. ANDERSON Assistant Editor
MID-SOUTH POSTGRADUATE MEDICAL ASSEMBLY J. Max Roy, M.D. President
Forrest City, Ark.
W. G. Stephenson, M.D President-elect
Chattanooga, Tenn.
Julian K. Welch, Jr., M.D Vice-President
Brownsville, Tenn
Robert Peeples, M.D.
Ernest J. Stroud, M.D.
Jinesboro, Ark.
Thurman Crawford, M.D
Memphis, Tenn.
Vice-President
Vice-President
Secretary-Treasurer
Mid-South Associate Editors
H. King Wade, M.D. Hot Springs, Ark.
Frank M. Acree, M.D Greenville, Miss.
R. L. Sanders, M.D. Memphis, Tenn.
Greenwood, Miss.
MISSISSIPPI STATE MEDICAL ASSOCIATION
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Guy T. Vise, M.D. |
Meridian |
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President |
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Stanley A. Hll, M.D. |
Corinth |
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President-elect |
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Wm. E. Lotterhos, M.D. |
Jackson |
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Secretary |
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Rowland B. Kennedy |
Jackson |
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Executive Secretary |
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State Associate Editors |
Wm. M. Dabney, M.D. Crystal Springs
Louis F. Rittelmeyer, M.D. Jackson
The Publication Committee is not responsible for the au- thenticity of opinion or statements made by authors or in communications submitted to this Journal for publication. The author or communicant shall be held entirely responsible.
Address all material for publication to W. H. Anderson, M.D., 104 Hospitality Street, Booneville, Mississippi.
'YOU OWE IT TO YOURSELF"
June is over, and July is half gone. In a few weeks the children will be starting to school again, which should make this a good time to stop and think — have you set aside any time to “take off” and relax and be with your family?
It might be a good time to take stock of some things, too; for instance, whether you are putting first things first, or just putting them off. Every
day it seems we are reminded of one or more of our obligations — to our patients, our community, our church, our alma mater , and to “humanity. But there is seldom anyone around who cares to remind you of your most basic and most important obligation — the dual responsibility you bear for yourself and your family.
First, your obligation is to take care of your- self, because a dead physician is not worth much to anybody except perhaps the undertaker. An occasional week or two of vacation is not time stolen from those who might get sick while you are away; but it is a means of insuring your health, so that you will be around to take care of them next year.
And your family — your obligation to them must be considered. Can you afford to be away from work for a few weeks, or does your wife need a new freezer or a new fur? Chances are what she really wants and needs most is a little time with her husband. And the children? You already know the answer to that.
It really boils down to this: what is MOST im- portant to you? Admittedly, your many obliga- tions are serious ones. But you can’t do justice to your patients while completely neglecting your- self. And a doctor’s duty to his community and to “humanity” cannot be fulfilled unless he starts with his family.
Summer is half over. What are you doing about it? Believe 1 11 get the kids and go fishin’.
(L. F. R.)
TRUTH - DILIGENCE - SERVICE
(Guest editorial contributed by Dr. John M. Alford, Greenwood, Mississippi)
As one reflects on recent happenings at the state medical meeting, a mixed feeling of approval and disapproval is experienced: approval for the excellent production of the convention and the brisk interest in our field of medical practice; disapproval for expressions and exhibitions of our persistent entrenched position. This position is characterized by expressions that use the terms “rugged individualist”, “doctors are individual- ists , “enlightened self-interest ”, “honest negation" and preserving our system of freedom as a bul- wark against socialism. The overtone of these expressions points toward men more interested in self-seeking than actual dedication to self- forget- ting in the greater interest of the health and welfare.
Can an institution such as our medical asso- ciation shift its outlook enough to shake off some
42
Editorials
July, 1958
of the shackles of traditions that prevent re- creating a vision of truth, diligence and service? To do that our common conscience is going to have to be penetrated enough to realize our mistakes. An individual and associational self- analysis to the extent of pain and rededication is needed. Are we “one of the last bulwark of free- dom” in our American society or are we in a Pharisaical rut? Are we “rugged individuals” or are we individuals ruggedly irresponsible? Is self- interest ever enlightened? Self interest directs ener- gy and purpose inward and with connotations of “getting-yours” in this race for survival. Is that illuminating our society? If one reflects a little it is undeniable tlrnjt self-forgetting is the only enlightened way. It is the only way that creates anything of great worth. Of course this has always been on an individual level in the lives of great men and women of history. Can an institution, can a medical association rise to such a level of enlightened self-forgetfulness? If it does, it will need to re-direct its energy away from service to members in the form of negotiating contracts and fee schedules, obtaining insurance contracts at reduced rates, lobbying for, or against, this or that legislation not in the self-interest of our as- sociation. Its financial statement will have to look less like something acceptable to corporation stock- holders, who are confronted with the probability that a larger plant will be needed soon to house the enlarging production line; (cynically, one could add in the pursuit of truth, diligence and service). Service to whom, diligence for whom and truth towards what ultimate goal is the ques- tion self-reflection asks of our association with its A. D. 1958 financial statement. If our medical association rises to the real challenge of our time it will think in terms of becoming totally, publicly related and less in terms of the technique of pub- lic relations, a technique which probably has developed as a result of individuals orienting them- selves along the lines of the modern selling “pitch”, an orientation that Fromm regards as “non-productive” for the greater good.
Criticism is running high towards the medical association and some of it we privately admit is justified. To diagnose the thing that is incipient, hidden but actually responsible for an illness re- quires very careful and sometimes painful analysis. It requires knowledge from many specialties sometimes. It also requires the acknowledgment that something may be wrong. Our association needs this type of scrutiny. It needs to enlist other fields of knowledge where men are genuinely studying man from other specialized standpoints.
Sociology will tell us something of the organic nature of society, anthropology will enlighten us. more as to whence came we, a help to deciding where we might be going. Psychology is seeking to plumb the depths of man’s being and acquiring knowledge not found in formal medical studies. Creators of art and literature express truth for our time often with a clearness unexcelled. Where is there an organization in our society today that penetrates and permeates all the areas of the lives of people to the extent that the medical profession does? Where is there another organiza- tion with this intimate relationship to people that also has the academic background the medical profession has had and does maintain to some extent? What other organization except our medi- cal profession is logically suited to take the lead in instituting means to integrate formally and make functional this knowledge and truth gained from the humanities, especially the academic humanities? It is a challenge and it is a chance to break from some of our fixed habits and shackling traditions. Our medical association should begin to use its time and energy in this more creative pursuit in the interest of mankind, rather than directing so much effort towards service to members. Our organization is not a union, it should not be a pressure group, its executive functions should not be heavy with service to members. We are constituted with a more noble purpose than that. Let us be diligent.
J.M.A.
DR. UNDERWOOD HONORED
On June 23 at the Heidelberg Hotel in Jackson, a great tribute was paid to a great man at a six o’clock dinner. Dr. Felix [. Underwood was duly praised for his 45 years of outstanding service in public health. This great occasion was sponsored by the official public health workers of Missis- sippi. Dr. A. L. Gray, assistant executive officer, was master of ceremonies and did the job ex- ceedingly well.
Gov. J. P. Coleman spoke briefly and to the point in giving due credit to Dr. Underwood as a health officer and a citizen and at the same time reviewed medical progress and pointed out the value medicine has been to our people. Governor Coleman has shown his friendship toward the medical profession and his interest in our four- year medical school and our hospital system.
Mr. Clayton Rand, well-known Mississippi edi- tor and platform speaker, traced the progress of medicine and public health in our state and na- tion in an entertaining manner while paying a fine
July, 1958
News and Comment
43
tribute to Dr. Underwood. His grasp of medical progress, his wit and humor, proved him equal to a big assignment, which he filled exceedingly well.
Dr. Underwood responded to the glowing tri- butes in an sincere and appropriate manner, giving due credit to his co-workers. A great executive, a man of health vision, and a man of practical application sufficient to make our dreams come true, he merited the ovation extended him for the service he has rendered. This evidence was not expressed by public health workers alone, nor from members of the medical profession, but it came from a cross section of the people of Mississippi and it came from other states and other nations. The life and the work of Dr. Un- derwood has added mightily to the length and volume of human life in Mississippi and across the nation.
Dr. A. L. Gray takes over as Dr. Underwood’s successor. He is able and safe in his own right. In public health as in the field of medicine great challenges are ahead. We shall continue to go forward with Dr. Gray.
DR. WALDROP RETIRES
Dr. H. G. Waldrop is retiring as health officer for Prentiss, Tippah, Alcorn and Tishomingo coun- ties after fifteen years of faithful service. On June 16 in Booneville a fitting tribute was paid to him as a practitioner, a health officer and a citizen. The four counties were represented. Dr. Waldrop is a native of Alabama, served in World War I, then served as a general practitioner for many years mostly in Union, Prentiss and Tippah counties. His fine wife and two daughters have been splendid helpers across the years. He lost his only son in World War II. Those who paid tribute on the occasion were Drs. R. B. Caldwell, president State Board of Health, A. L. Gray and J. A. Milne of the State Board of Health, Jackson, and W. H. Anderson, Booneville. Dr. Waldrop has been a builder of health assets and a fine Christian citizen.
RIPLEY DEDICATES NEW HOSPITAL WING
On Sunday, June 29, the Ripley citizenry dedi- cated a new wing to their fine hospital now mak- ing 52 beds. Mr. Erst Long of Ripley was master of ceremonies and Hon. Fred B. Smith was the chief speaker. Mr. B. G. Horton is the able ad- ministrator.
This hospital has made a fine record in service to the people and in handling its finances as well. As we recall it was the second Hill-Burton Hos- pital to be built in Mississippi. Dr. John Tate is
president of the board of trustees. Ripley and Tip- pah County are on the up and up in medical service.
News and Comment
NEW PRESIDENT OF MSMA
Dn. Vise
Tennessee born and educated, the new presiden, of the Mississippi State Medical Association, Dr. Guy T. Vise, received his B.S. and M.D. degrees from the University of Tennessee in 1930 and 1932, respectively. Following an internship at the Southern Baptist Hospital in New Orleans, a resi- dency from 1934 to 1938 at Matty Hersee Hospi- tal in Meridian, he was also resident surgeon at the Matty Hersee Hospital two years before en- tering active practice in Meridian.
From the beginning of his practice Dr. Vise has identified himself with organized medical groups, holding memberships in his local and state societies, the Southern Medical Association, South- eastern Surgical Congress, International College of Surgeons, and Academy of General Practice. He served on the MSMA Council from 1952 to 1956, and has been clinical instructor in the De- partment of Preventive Medicine at the Univer- sity Medical Center.
Mississippi doctors have found Dr. Vise genu-
44
ine, a personable, hard-working physician with vision and leadership ability. That his helpmate is the beautiful Mailande Martin Vise is no sec- ondary asset. They are the parents of five children, a daughter, and four sons, the eldest of whom is a student at Harvard.
Dr. Vise is head of the Vise Clinic in Meridian, and is actively engaged in community and church affairs, practicing good public relations along with medicine as a good doctor-citizen.
DR. GUNDERSEN PRESIDENT; DR. ORR PRESIDENT- ELECT OF AMA
Dr. Louis M. Orr, urologist of Orlando, Fla., was chosen unanimously as president-elect of the American Medical Association at the San Fran- cisco meeting. Dr. Orr, who in recent years has been vice speaker of the House of Delegates and chairman of the A.M.A. Committee on Federal Medical Services, will become president at the June, 1959, meeting in Atlantic City, succeeding Dr. Gunnar Gundersen of La Crosse, Wisconsin, who became the 112th president.
The 1958 Distinguished Service Award of the American Medical Association was voted to Dr. Frank Hammond Krusen, professor of physical medicine and rehabilitation, Mayo Foundation, Rochester, Minn.
M iami Beach will be the place of the 1960 meeting, and New York the 1961 meeting.
Other officers are; Dr. W. Linwood Ball of Richmond, Va., vice-president; Dr. E. Vincent Askey of Los Angeles, re-elected speaker, and Dr. Norman A. Welch of Boston, vice-speaker.
Dr. Warren W. Furey of Chicago was elected for a five-year term on the Board of Trustees, succeeding Dr. E. S. Hamilton of Kankakee, 111. Dr. Raymond M. McKeown of Coos Bay, Ore., was re-elected for a five-year term, and Dr. R. B. Robbins of Camden, Ark., was named to fill the unexpired term of Dr. F. J. L. Blasingame.
DEATHS
DR. HUGH C. McLEOD
Dr. Hugh C. McLeod, 63-year-old Hattiesburg physician, died May 15 at University Hospital after becoming ill at Heidelberg Hotel.
The prominent surgeon was attending the annual session of the Mississippi State Medical Association at the hotel.
A native of Purvis, Dr. McLeod had lived in Hat- tiesburg since 1921. He was a graduate of the Uni- versity of Mississippi and Tulane University Medical School. He had been practicing 38 years and was a fellow in the American College of Surgeons and National College of Surgeons.
A member of the board of stewards of Main Street Methodist Church, Hattiesburg, he was past presi- dent of the Kiwanis Club, a member of the Elks
July, 1958
Club and a colonel on the staff of Gov. Paul B. Johnson.
He was a former president of the South Mississippi Medical Association and a member of the Board of Trustees of Institutions of Higher Learning.
Survivors include his wife, Mrs. Bessie Golden McLeod; two sons, Dr. H. C. McLeod, Jr., resident in surgery of Oschner's Clinic in New Orleans and John A. McLeod III, senior medical student at University Medical Center; two daughters, Mrs. C. C. Sullivan of Hattiesburg and Mrs. O. J. Miller of Monroe, La.; a sister Mrs. H. A. Gilliam of Hattiesburg; a brother, Dan McLeod of Hattiesburg.
DR. CAMERON MONTGOMERY Dr. D. Cameron Montgomery, 73, nationally known eye, ear, nose and throat specialist, died at his home May 29. He had been ill for a year.
Dr. Montgomery, born in Greenville, received part of his education at Vanderbilt University in Nashville, Tenn. He received an AB degree in 1906 and was awarded his M.D. degree at Jefferson Medical College in Philadelphia in 1910.
For 44 years Dr. Montgomery engaged in the practice of medicine. He was a member of the American College of Surgeons and the American Medical Association.
A veteran of World War I, he served as a lieuten- ant in the medical corps. He was for a time presi- dent of the First National Bank of Greenville and was chairman of the board of that bank at the time of his death.
Survivors include his widow; three sons, Dr. G. C. Montgomery, Jr., of Greenville; Dr. John A. Mont- gomery of Birmingham, Ala., and William D. Mont- gomery of Greenville; and a half brother.
DR. DEWITT T. BROCK
Services were held for Dr. Dewitt T. Brock, 68, Jackson physician and surgeon who died May 20.
He was a native of Franklinton, La., and a for- mer resident of McComb but had been in Jackson since 1932.
He was superintendent of Charity Hospital for two years and later was associated with the Shands, O'Ferrall Clinic. He was a member of the Central Medical, Mississippi, and the American Medical Association, was a Mason, a Shriner, a former president of the Jackson Exchange Club and a member of the First Baptist Church of McComb.
Dr. Brock was a veteran of World War I, a past commander of the American Legion post at McComb and served on the staff of the late Governor Mike Conner.
Survivors include his wife, the former Lucille Brumfield of Liberty; a son, Dr. D. T. Brock, Jr., of Jackson; three daughters, Mrs. C. C. Ferguson, Mrs. Dora B. Mooney, both of Jackson, and Mrs. Paul Bre- land of Memphis; three sisters, Miss Lena Brock of Jackson, Mrs. Dora Knight of Goodman, and Mrs. Bessie Thornhill of McComb; a brother, Dr. H. D. Brock of McComb; seven grandchildren and two great-grandchildren.
DR. WILLIAM ROBERT HAND
Dr. William Robert Hand, 78, prominent Philadel- phia physician, for more than half a century who last month was nominated for membership in the Mis- sissippi Medical Association’s honorary Fifty-Year Club, died at his home in Philadelphia June 5.
Dr. Hand received his medical education at Mem- phis Hospital Medical College, graduating in 1908.
Dr. Hand, a past president of the East Mississippi Medical Society, is survived by his wife, Mrs. Ester Hand, two sons, two daughters, two brothers, a sister and seven grandchildren.
Deaths
Indications for Operative Treatment in Gynecology5"
FRANK R. LOCKE, M. D.f Winston-Salem, N. C.
Within hecent years tlie definitive nature of diseases of the female reproductive sys- tem has been increasingly recognized, and the pathologic significance and natural history of the common pelvic lesions have been well estab- lished. Agreement has now been reached in re- gard to the significance of lesions which were once controversial, such as intra-epithelial squam- ous cell carcinoma of the cervix. The field of gynecology, in contrast to the field of medicine, is relatively free of controversy resulting from inadequacies of knowledge, and gynecologic and obstetric concepts and philosophies have become increasingly uniform in recent years.
In spite of this extensive knowledge and general agreement regarding the fundamental significance of pelvic lesions, the operative management of pelvic disease is almost as variable as the geo- graphic location of the patients concerned. It is incredible that the interpretation of pelvic disease is as varied as the therapy suggests; instead, dif- ferent concepts regarding the application of sur- gical treatment must be responsible.
The purpose of a surgical procedure is to re- move a pathologic lesion or correct an anatomic deformity. In the field of general surgery, certain specific and non-specific lesions are recognized as indications for surgical intervention. The mod- ern trend in gynecology, however, does not permit the arbitrary application of these principles, but favors a rational scientific approach to each in- dividual problem.
In the past there existed distinct schools of thought relative to special problems in obstetrics and gynecology; these divergences resulted pri- marily from didactic or empiric attitudes. Empiric- ism has practically disappeared from the field of obstetrics and gynecology, and has been replaced by individualization of the patient, exact diagnosis whenever possible, and appraisal of the signifi- cance of the pathologic lesion in relation to the general welfare of the patient. A few decades ago
‘'Presented (by invitation) at the 90th Annual Ses- sion of the Mississippi State Medical Association, Jackson. Mississippi, May 13-15, 1958.
(Department of Obstetrics and Gynecology, Bowman Gray School of Medicine of Wake Forest College, and the North Carolina Baptist Hospital, Winston- Salem. North Carolina.
an automaton might have carried on an acceptable gynecologic practice by the appropriate applica- tion of empiric rules. The modern obstetrician and gynecologist, to practice in a creditable fashion, must have a reasonable knowledge of the entire field of medicine and its interrelations with pelvic disease.
The intelligent application of surgical therapy requires a broad understanding of the pathologic, physiologic and psychologic processes of women. In the majority of cases operation is an elective procedure, and almost unlimited time is allowed for evaluation of the cause-effect relationship be- tween the symptom complex and existing path- ology. Hysterectomy is performed as an emergency operation only in cases where obstetric trauma causes rupture of the uterus and, on rare oc- casions, in cases of obstetric hemorrhage.
In the vast majority of gynecologic patients it is possible to make a definite diagnosis of the specific condition present, but fine judgment is often re- quired because of the vague (non-specific) char- acter of many gynecologic complaints and the similarity between symptoms of functional and organic disease. General study of the patient is usually necessary to establish beyond a reasonable doubt that satisfactory relief of symptoms will result from a hysterectomy.
In order to obtain excellent results in the prac- tice of pelvic surgery, the physician must develop a superior understanding of feminine attitudes and emotional reactions. He must reach a re- lationship with the patient which will permit him :o differentiate the functional and organic com- ponents of gynecologic complaints, and to arrive at a decision of management which is most likely to succeed. The effects of a given operative pro- cedure must always be weighed against the con- sequences of other treatment for the existing pelvic disease.
The removal of normal structures in pelvic op- erations has been a target for unjust criticism, with the implication that the presence of limited benign pathologic changes in an organ justifies its surgical excision. It must be remembered that the removal of a normal uterus is required for the adequate treatment of most patients with pro- cidentia. On the other hand, the performance of
46
Operative Treatment in Gynecology — Lock
August, 1958
a hysterectomy for fibroids or endometriosis may be Completely unjustified, and may destroy the patient’s happiness and security.
Patients with pelvic complaints are easily divided into three distinct groups:
GROUP A: Patients who present definite path- ologic findings to account for all of their symptoms, or lesions which endanger their lives.
GROUP B: Those patients who have symptoms in excess of the physical findings.
GROUP C: Patients complaining of numerous symptoms which cannot be ex- plained by any physical findings.
GROUP A —PATIENTS WITH DEFINITE PELVIC DISEASE Benign Lesions
In a variety of benign gynecologic conditions there is no controversy concerning the indications for hysterectomy by either the abdominal or the vaginal route. This group of patients present ex- tensive and clear-cut pathology, and symptoms ob- viously attributable directly to the lesions which are present. Uterine fibromyomas, uterine ade- nomyosis and complete procidentia are the com- mon lesions encountered. Even in these cases, however, the decision to perform a hysterectomy for benign disease must take into account the patient’s age, marital status, and desire for further pregnancies. Although conservative procedures may afford little hope of permanent cure, there is a small group of patients for whom the risk of a second operative procedure at a later date may be fully justified. A superficial review of the literature will confirm that myomectomy, resection of adenomyosis, or correction of genital prolapse may often be successfully carried out, regardless of the extent of the disease process, if there is sufficient indication for preserving the uterus in the patient concerned. In my personal experience more than 40 uterine fibroids, the largest 17 cm. in diameter, were successfully removed from a pa- tient who subsequently became pregnant and was delivered of a full term, healthy child.
Gynecologists are in complete agreement con- cerning the wisdom of removing the uterus when bilateral oophorectomy is performed. This organ has no purpose in the absence of the ovaries, and its presence makes carcinoma of the cervix or endometrium a potential hazard. The operative risk is seldom increased significantly by the addi- tion of hysterectomy to procedures which require castration.
Malignant Lesions
Various factors influencing the public and the medical profession have favored an increasing trend toward the early diagnosis of uterine cancer. In the North Carolina Baptist Hospital the vast majority of patients now presenting themselves for treatment of uterine cancer are in the early stages of the disease, when successful treatment is the rule rather than the exception.
Carcinoma of the Cervix
The investigations of the past decade have led to agreement about the significance of intra- epithelial squamous cell carcinoma of the cervix. It is generally recognized that Papanicolaou smears, punch biopsies, and quadrant biopsies are totally inadequate for the specific diagnosis of intra-epithelial carcinoma of the cervix. It is a well known fact that areas of intra-epithelial car- cinoma are usually associated with invasive squam- ous cell carcinoma of the cervix, particularly at the margin of the lesion. To provide adequate tissue tor pathologic study in cases of suspected intra- epithelial squamous cell carcinoma, conization of the cervix must be done with a knife, in a manner to remove all of the diseased tissue on the portio of the cervix and to include the endocervical canal for a depth of at least 2 cm. The pathologist has a heavy responsibility in cases of this type, and must perform serial block studies of the cones of tissue in order to obtain comprehensive and ac- curate appraisal of the extent of the disease.
Once a diagnosis of intra-epithelial carcinoma of the cervix has been made and the absence of invasive carcinoma definitely established, treat- ment by hysterectomy is indicated. Although there are minor differences of opinion concerning the technique which should be used, all authorities agree that the ovaries should - be conserved in younger women, and that a significant portion of the adjacent vaginal cuff should always be re- moved in conjunction with the total hysterectomy. The use of intensive irradiation therapy compar- able to that used in treatment of invasive car- cinoma is unnecessary in cases of clearly estab- lished intra-epithelial carcinoma, and there is no justification for submitting a young woman to the extensive morbidity which is associated with this plan of treatment.
It is regrettable that the excellent investigative work demonstrating effectiveness of radical opera- tive treatment in early invasive squamous cell carcinoma of the cervix has led to the widespread use of inadequate surgical procedures for this disease. There is no place for limited surgical pro- cedures in the treatment of squamous cell car-
August, 1958
Operative Treatment in Gynecology — Lock
47
cinoma of the cervix. In at least 15 per cent of the patients with lesions so small that they can be diagnosed only on microscopic examination, re- gional lymph gland metastasis has already oc- curred. Barely a week passes in which I do not see a patient who has had recurrence within a few weeks following total hysterectomy and bi- lateral salpingo-oophoreetomy performed with the idea that it is a radical procedure. Once the uterus has been removed, we are severely handicapped in our attempts to give adequate irradiation ther- apy without great danger of injury to secondary structures. The results with irradiation therapy for invasive carcinoma of the cervix are not ideal; however, when standardized plans of treatment art administered by competent therapists, the re- sults invariably equal or exceed those accomplished by primary operative treatment. The morbidity is not excessive, and the mortality is negligible. Rich- ard W. TeLinde recently made the following state- ment relative to this disease; “Before a man undertakes the Wertheim operation for Stage I carcinoma of the cervix, he should look himself in the eye and ask himself, “Have I any right to operate on this woman with my operative ex- perience when f can get just as good results by irradiation’?"
In the treatment of invasive carcinoma of the cervix, no operation should be considered which does not remove the upper one-half to one-third of the vagina, the entire uterus, the tubes and ovaries, all of the parametrial tissues, and every fragment of expendable tissue from the bifurca- tion of the aorta to the superior surface of the levator muscles. This is an extremely radical and hazardous procedure.
Malignant Lesions of the Endometrium
Total hysterectomy and bilateral salpingo- oophorectomv are clearly indicated in the treat- ment of carcinoma of the endometrium. The results recorded by various authors in the treatment of this condition are extremely variable, and range from an over-all salvage of approximately 40 per- cent to salvage rates of 90 per cent or more in series of considerable size. Such favorable results probably reflect alertness on the part of the pro- fessional referring group, and a high level of in- telligence among the patients which has led them to seek medical attention early in the course of the disease. Special techniques in the operative procedures are probably another significant factor- in the results obtained, since they might serve to protect the patient from traumatic spread of the neoplasm during the course of the operation.
There is some difference of opinion regarding
the value of pre-operative irradiation for carcinoma of the endometrium. We do well to recall that pre-operative irradiation for treatment of endo- metrial carcinoma was initiated because of the poor results observed when primary operation alone was the standard procedure in this disease. Recent publications which criticize pre-operative irradiation in the treatment of carcinoma of the endometrium point out that such therapy occasions some delay in elimination of the tumor. On the other hand, it is well known that pre-operative irradiation will destroy the tumor in a large per- centage of cases, and excellent results can be ex- pected in those patients who show no residual tumor at the time of operation. Each author is con- vinced that his method is best. The series reported are generally small, however, and it is impossible to obtain an accurate comparison based on the stages of the disease and its duration prior to treatment. I am convinced that pre-operative ir- radiation is of major importance in the treatment of endometrial carcinoma, appreciably reducing the frequency of recurrence in the vaginal cuff, and manipulative spread of the tumor at operation.
Uterine sarcoma occurs infrequently. There is considerable doubt concerning the value of irra- diation in the treatment of this lesion. Since metastasis is primarily hematogenous, it is unlikely that radical procedures which include lymphad- enectomy have any particular advantage in the treatment of this condition.
Ovarian Carcinoma
Total hysterectomy with bilateral salpingo- oophoreetomy is the treatment of choice for ovar- ian carcinoma. At one time some authorities ad- vocated leaving the uterus, so that intracavitary irradiation of the pelvis might be carried out post- operatively. Most gynecologists have discontinued the practice, however, since the results were not improved by irradiation therapy. Involvement of the uterus and tubes is common in carcinoma of the ovary, and free carcinoma cells have recently been demonstrated in Papanicolaou smears and in the uterus and tubes of patients with ovarian carcinoma.
GROUP B— PATIENTS WITH SYMPTOMS IN EXCESS OF THE PHYSICAL FINDINGS
It is well recognized that two patients with identical pathologic findings may present histories which are totally different. Patients who have moderate degrees of pelvic relaxation with asso- ciated cystocele and rectocele, mild grades of uterine prolapse, small uterine fibromvomas, lim- ited involvement with adenomvosis or endo-
48
Operative Treatment in Gynecology — Locke
August, 1958
metriosis, and residual adnexal disease from pelvic infections often complain of symptoms which seem excessive in relation to the objective pathologic findings present. In these cases, the decision to perform an operation requires excellent judgment.
The history provided by the patient is usually the only source for obtaining information con- cerning subjective complaints. The severity of the symptoms is apt to be colored by emotional factors, particularly cancerphobia. The widespread pub- licity emphasizing the early signs and symptoms of cancer has increased the incidence of early diagnosis remarkably, but has also made cancer- phobia a universal problem. The stability of the patient and her sensitivity to pain may be ex- pected to influence the symptomatology. Patients in this group are often found to have trying prob- lems in their personal lives. They are frequently victims of stress phenomena which produce symp- toms related to many various organs.
Complaints related to organic pelvic disease can often he recognized by their specific and consis- tent character. Such symptoms are usually in- creased during menstruation. They may also bear a consistent relationship to physical activity, stand- ing for long periods, and other specific factors. Vague complaints which vary in character and in time relationships are much more often the result of functional disease.
The complaint of excessive uterine bleeding may be very difficult to evaluate. In the absence of anemia no operative procedure should be advised until a general study of the patient has been made.
It has been our experience that specific and accurate diagnosis can be made in more than 90 per cent of the patients with gynecologic com- plaints if the history and physical findings are carefully correlated. The patient’s attitude and the symptoms produced by mild to moderate grades of benign pelvic disease usually reflect the attitude of the physician who makes the diag- nosis, and his presentation of the situation to the patient, it is obvious that the physician must have confidence in the accuracy of his diagnosis when he reassures a patient and recommends conserva- tive management of uterine fibroids of moderate size, endometriosis producing tolerable symptoms, or an adnexal mass resulting from hydrosalpinx or a post inflammatory cyst of the ovary. Patients with lesions of this type who can be observed periodically often lead successful, comfortable and productive lives with the use of an occasional aspirin or codeine tablet when symptoms occur.
A program of corrective exercises for the man- agement of moderate grades of pelvic relaxation,
cystocele and rectocele with associated urinary stress incontinence was thoroughly understood and extensively used in the latter part of the nineteenth century. In recent years the principal proponent of this plan of treatment has been Kegel of Los Angeles. Those of us who have adopted his exer- cises have been impressed by the remarkable im- provement of many patients who might otherwise have required operative treatment. The modern woman leads a sedentary life, and does little work which employs the levator muscle group. Stress incontinence may be consistently improved by exercise programs, and completely relieved in the majority of patients who do not have extensive injury of the bladder musculature and pelvic sup- portive tissues.
Patients in group B are candidates for operation when their symptoms are clearly and specifically the result of pelvic pathology which can be con- clusively demonstrated on examination. The symp- toms which result from the patient’s functional reaction to the presence of pelvic disease should be eliminated before a decision to operate is made.
GROUP C— PATIENTS WHO HAVE SYMPTOMS IN THE ABSENCE OF DEMONSTRABLE PELVIC DISEASE
Exploratory laparotomy is rarely performed on the gynecologic service of the North Carolina Bap- tist Hospital. I have been unable to find a single instance during the seventeen years that this service has been conducted in which some obscure pelvic pathologic entity was found by an ex- ploratory operation. In rare cases we