George P. Rosemond

Stresses affecting surgical performance and learning: I. Correlation of heart rate, electrocardiogram, and operation simultaneously recorded on videotapes

Abstract Operative performance and cardiac response (heart rate and electrocardiograms) were evaluated in surgical personnel during 33 operations. These were recorded on videotapes for subsequent analysis. Fatigue and operative difficulty were associated with tachycardia in susceptible personnel. Operative performance was impaired during the former with probable impaired learning. Likewise when performance difficulties arose during surgery, the instructor joining the “scrubbed team” provided a more meaningful learning environment than did his sideline advice. This approach appears to offer a method for studying the relationship between stress, surgical performance and the learning of surgical skills.

MANAGEMENT OF PATIENTS WITH CARCINOMA OF THE BREAST IN PREGNANCY

There has been an “old wives’ tale” going the rounds that breast carcinoma in pregnancy is a relatively common, but hopeless condition. It has been compared with inflammatory carcinoma. The gamut of therapy has been run from no treatment at all to a conglomeration of all treatment methods employed at once. For example, there are many who believe that the prognosis of breast cancer occurring during pregnancy is uniformly so poor that pregnancy should be immediately terminated and that radiation therapy, locally, should be employed along with radical mastectomy. Following termination of pregnancy, it has been advised by some to routinely remove both ovaries and by the most pessimistic, to immediately begin hormonal therapy of one sort or the other even in the absence of metastatic disease. For obvious reasons, I am sure no one would care to use chemotherapy unless the fetus has been completely evacuated. It is true that the occurrence of breast cancer in a woman of any age is a catastrophe. It is especially true that such an occurrence in a young female, particularly a young mother or a young prospective mother, is a most regretable situation. But it does not necessarily mean that the end of the world has arrived especially if the diagnosis is made early while the disease is limited to a small breast portion and shows no evidence of spread to the axilla. There are a number of considerations generally accepted which seem worthy of further evaluation. In such whole population studies as were conducted in Connecticut’ and are now being conducted in Philadelphia County, there is nothing to indicate that the prognosis in young women is appreciably different from women in other age groups. It is generally accepted that marriage and childbearing tends to decrease the incidence of breast cancer at least to a slight degree. It is probably true that the palliative effect obtained in inoperable breast cancer using hormone therapy can be obtained about as well with the use of estrogens as with the use of testosterone and certain people have advised using both simultaneously in the postmenopausal female. Are there estrogen-dependent tumors or is the palliative effect merely an indication of a change in hormonal balance in the individual? In TABLE 1, borrowed from Westberg’s study? it appears that Stage I carcinomas treated during pregnancy have a better prognosis than one would expect. Although the total number of cases is small, Westburg showed that as applied to this study, Stage I cases occurring during pregnancy compare with similar cases in the nonpregnant female. An analysis of individual cases from the Philadelphia study3 would tend to indicate certain tumors occurring in pregnant women remain localized for reasonably long periods of time and do not necessarily display the accelerated rate of growth so often associated with breast carcinoma occurring during pregnancy. From such studies as the Philadelphia Study and Westburg’s study, it appears likely that delay in diagnosis is a more important factor than the relationship to pregnancy. Although the Philadelphia Study has not been completed and comments concerning it must be considered preliminary, the overall five-year

Portal vein blood flow determination in the unanesthetized human by umbilicoportal cannulation

Abstract A direct method for quantitation of portal vein flow in the unanesthetized, unsedated human being is described. In patients with normal livers, portal flow decreases following exercise and increases in the postprandial period. In patients with alcoholic cirrhosis there is a trend toward a decreased response of the portal flow to exercise and to oral stimulus of hypertonic glucose. This method is proposed to provide improved preoperative characterization of portal hemodynamics and allow better selection of patients and procedures for decompression of portal venous hypertension in the patient with esophageal variceal hemorrhage.

Extrahepatic biliary ductal injury in closed trauma

Abstract The fourth case of hepatic duct injury due to closed abdominal trauma is reported. Diagnostic features concerning biliary ductal injury as well as pathophysiology of these injuries are discussed. The important clinical difference between the effects of infected and sterile bile in the peritoneal cavity are emphasized. Treatment is briefly mentioned. A tabulation of the recorded cases of biliary ductal injury since Lee and Wherrys review is included.

Value and limitations of aspiration biopsy for lung lesions.

We have been convinced of the value of needle biopsy in diagnosing malignant lesions of the lung since shortly after we first started using it in 1936. From 1936 to 1947 inclusive, we performed biopsies by this method in approximately 272 lesions of the lung, in 231 patients. It was necessary to repeat the procedure in a number of patients, and on numerous occasions we were unable to made a diagnosis. We were greatly encouraged by the excellent reports of Craver (1, 2) from Memorial Hospital, which appeared in 1939 and 1940. Memorial Hospital diagnosticians are still enthusiastic about this procedure. Others, however, including Ochsner (3) and Holman (4), who are experienced in diagnosing and operating on patients with carcinoma of the lung, have been strongly opposed to what we have come to consider a very useful method of diagnosis. We do not contend that all patients who are suspected of having pulmonary carcinoma should have needle biopsy. We much prefer, in fact we insist, that needle biopsy be prece...

Colonic diverticula and hemorrhage

SummaryApproximately 17 per cent of 500 patients with diverticular disease had colonic hemorrhage. In most cases the bleeding was mild, but it is potentially a lethal complication. In this series the associated mortality was 3.6 per cent. If the bleeding site is readily identifiable it is reasonable to resect the involved area; if not, total abdominal colectomy with ileorectal anastomosis is the preferred procedure. Selective arteriography is now performed more often, and has been helpful in localizing the site of hemorrhage in several patients.

Hematoma of the rectus abdominis muscle complicated by anticoagulation therapy

Abstract Anticoagulants can enhance the pathophysiology of hematoma of the rectus abdominis muscle and can lead to hypovolemic shock. Surgical decompression of this lesion is often necessary for diagnostic and therapeutic purposes. In two of the three cases presented definitive surgery was achieved with the patients having local anesthesia. This technical aspect is important because it decreases the risk in a patient who is typically old, obese, and with underlying cardiovascular and pulmonary disease. Acute oliguria, present in two patients with large low lying hematomas of the rectus sheath, is probably due to extrinsic compression of the urinary bladder.

Leiomyosarcoma of the colon—A revised prognosis

SummaryExtrarectal leiomyosarcoma of the colon is a pathologic rarity. An unduly optimistic prognosis has been reported. Our experience with a rapidly lethal case prompted this review. Follow-up information was requested from previous reviewers. Only two cases of five-year survival without disease have been documented. Because of these statistics and the early deaths of ten patients, we believe that the optimism previously mentioned is unwarranted.

Penetrating Abdominal Wounds in a Civilian Population

Abstract Our experience with penetrating abdominal wounds have been reviewed. The major cause of death is massive hemorrhage and its sequelae. The management of various organ injuries has been reviewed. Peritoneal sepsis proved to be a rather minor complication in this civilian group. The purpose of this report is to analyze our experience, during a ten year period, with 196 penetrating abdominal wounds. Since 94 per cent of these patients were managed by the house staff, principles concerning this type of trauma are reviewed. We strongly urge that all penetrating abdominal wounds be examined to rule out intraperitoneal injury. The over-all mortality rate was 3.6 per cent with no deaths occurring in forty-one patients in whom exploratory examination revealed no intraperitoneal penetration or injury.

Histidine metabolism after portacaval shunt in the rat

Abstract Following end-to-side portacaval shunt in the rat with a normal liver, there is a significant increase in enzymatic activity of histidase and histidine-pyruvate transaminase, but no significant change in urocanase activity is noted. Significantly increased excretion of histidine and histamine is observed after end-to-side portacaval shunt, but no significant difference is noted in the excretion of imidazolepyruvic acid. The mechanism of induction of these enzymes is unknown. Administration of substrate does not induce the aforementioned enzymes.