Martin L. Dalton

Major vascular injury from high-pressure water jet

High-pressure water jets are used in industry as a cleaning and cutting tool. Penetrating injuries by these devices can produce minimal external evidence of extensive internal damage. We report a literature review and the case of a limb-threatening injury to the lower extremity caused by such a device.

Multifocal mesenchymal hamartoma of the chest wall in infancy

The authors report on an infant who had multifocal mesenchymal hamartoma of the right posterior chest wall. The tumors were found incidentally, on a chest radiograph, during routine evaluation for upper respiratory tract infection. Resection of both lesions with chest wall reconstruction was performed, with a good result. Only 46 cases of this unusual tumor have been reported previously, and only two of them were multifocal.

The first lung transplantation

The first lung transplantation in a human occurred at the University of Mississippi Medical Center on June 11, 1963. I was privileged to participate in this historic event, and I am pleased to share my thoughts with the readership of The Annals of Thoracic Surgery.

Naming the bronchopulmonary segments and the development of pulmonary surgery

An international agreement on bronchial nomenclature and anatomy was not reached until well after operations for bronchopulmonary segmental disease were well developed. R. C. Brock, in 1950, was the reporter of the efforts of The Thoracic Society of Great Britain to bring some order to this confused state. This Society delayed its action until an ad hoc committee made up of members from other countries and specialties met at the International Congress of Otorhinolaryngology in 1949. The anatomy and nomenclature of the bronchopulmonary segments was agreed upon. The Thoracic Society then accepted the report of the ad hoc committee. The system was followed closely by the first Nomina Anatomica in 1955. This report did not open new surgical vistas but was the marker indicating that pulmonary surgery was now mature.

H. Milton: Visionary surgeon

Current wisdom holds that median sternotomy is the creation of cardiac surgeons as the premier approach to the heart. In fact, this innovative and resourceful procedure was perfected by an obscure English surgeon in Cairo, Egypt (U.A.R.), in 1897. H. Milton designed a vertical sternal-splitting approach for the excision of tuberculous mediastinal nodes and employed it successfully in a patient. Modern medicine owes a great debt to H. Milton for this significant, albeit unrecognized, contribution. The details of the life of this unsung surgeon, such as are known, are presented.

Champ Lyons: An Incomplete Life

The life of Champ Lyons, MD, is presented, with emphasis on his tenure as Chairman of the Department of Surgery of the Medical College of Alabama (University of Alabama in Birmingham School of Medicine) from 1950 until 1965. Before becoming chairman Dr. Lyons, as an esteemed microbiologist, participated in the early use of penicillin in wounded servicemen during World War II. Later in his career, he made many contributions to the emerging disciplines of vascular and cardiac surgery. After a brief illness in 1965, Dr. Lyons expired due to a brain tumor. His relatively brief career and his unanticipated sudden demise have lessened the fame of Dr. Lyons to which he is justly entitled. It is the purpose of this presentation to reawaken the surgical community to the importance of this giant of American surgery.

Cardiopulmonary assessment: is improvement needed?

Clinical parameters alone have repeatedly been proven unreliable in assessing cardiopulmonary status, especially in hemodynamically unstable patients. To learn if we had a diagnostic problem in our hospital, we compared physician assessment of cardiac index (CI) and thoracic fluid content (TFC) to values obtained using impedance cardiography (ICG). We selected the newest available ICG monitor, the BioZ, which employs this noninvasive technology. For CI measurements we have shown it to be equivalent to thermodilution and to be more reproducible (variability: 6.3% vs. 24.7%). Physician assessment of CI and TFC (high, normal, or low) was compared to the BioZ monitor’s results in 186 patients, considered to be hemodynamically unstable, from the emergency room, the intensive care units, and the floors. Normal values were defined for CI (2.5–4.2 L/min m2) and for TFC (males: 30–50 kohm−1 and females: 21–37 kohm−1). The concordance between physician assessment and the BioZ was 51% for CI with Kappa of 0.14 and 58% for TFC with Kappa of 0.19. Attendings did slightly better than the surgical residents with CI (52% vs. 48%) but slightly worse with TFC (57% vs. 61%). The potentially serious conditions of low CI and high TFC were misdiagnosed 42% and 46% of the time, respectively, by all physicians. Analysis of the data revealed that physician use of clinically available objective hemodynamic data, such as heart rate, blood pressure, and pulse pressure index, would not have been helpful. Furthermore, assistance from the pulmonary artery catheter (PAC) is often not available in our hospital, which has experienced a 90% decrease in its utilization over the past six years. Considering the increasing acuity of our aging patient population, accurate assessment of cardiopulmonary status is needed. The use of ICG could be a valuable addition to the physician’s armamentarium.

The importance of teaching surgical history in a general surgery residency program

Abstract Because we recently realized our department had a shortcoming in teaching surgical history to our residents, which resulted in near total ignorance of the history of their chosen specialty, we decided to poll all the general surgery residency program directors in the United States regarding the teaching of surgical history. Questionnaires were mailed to 265 programs and 159 (60%) responded. Of this group, 149 (94%) reported that they were convinced that the study of surgical history had an important place in surgical education. However, only 19 of the reporting programs (12%) indicated that they had a formal program for teaching surgical history. With our departmental failing with regard to teaching surgical history, reinforced by the results of our poll, we opted to improve the teaching of history to surgical residents. We began a bimonthly, relatively informal surgical history session with presentations by residents and faculty. This has renewed interest in the history of our specialty of residents and faculty alike. We urge all programs to incorporate a similar surgical history format to benefit the program, but especially to benefit the residents.