Carbolic Acid before Joseph Lister: Rail Ties, Sewage, Manure, and the Great Stink.

Before Joseph Lister's landmark Lancet publications on the use of carbolic acid wound dressings in 1867, surgeons Jules Lemaire in France and Enrico Bottini in Italy had already used carbolic acid on hundreds of patients to control suppurative wounds. After Friedlieb Runge isolated it from coal tar in 1834, a number of scientists recognized the efficacy of carbolic acid in preventing decay and neutralizing the stench of dead animals and human cadavers. Frederick Calvert, Alexander McDougall, and Angus Smith in Manchester promoted a powdered form of carbolic acid as a deodorizing agent to treat municipal sewage across the United Kingdom, most notably during London's famous "Great Stink" of 1858. Edmond Corne in France introduced his formulation, which Alfred-Armand-Louis-Marie Velpeau, Ferdinand LeBeuf, and Lemaire adapted for clinical use in 1859. Lemaire wrote extensively on carbolic acid and its surgical application in three publications from 1860 to 1862. In 1866, Bottini published his experience of 600 cases where it was used. In 1865, Lister began to use carbolic acid in open fractures after Thomas Anderson, his colleague in agricultural chemistry at the University of Glasgow, told him about its use in Carlisle sewage works. This article traces the rich history of carbolic acid from an unknown compound in coal to the cornerstone of Listerism in late-19th-century operating rooms.

The Clandestine Operations Performed on President Grover Cleveland and the Rationale for Surgical Secrecy.

The 1893 operations to remove a maxillofacial tumor from President Grover Cleveland aboard a private yacht remained a secret until long after his unrelated death from heart disease. Many historical studies have suggested that Cleveland kept his health and surgical care confidential because of the fragility of the economy during the Panic of 1893. Although that observation is true, it does not fully address the underlying reason for why the public would react poorly to news about an operation on the president. The death of Ulysses S. Grant eight years prior unearthed the denial, stigma, and fear of cancer felt by many Americans. Despite revolutionary 19th century advances in anesthesia, pathology, and surgery, the social history of "cancerphobia" ran deep.

The Rise of the Surgeon in the Seventeenth Century Virginia Colony.

Life in the early American colonies presented unique challenges to the British colonists. There was an acute need for health-care providers in the early Virginia colony at Jamestown. Many of the medical men who first arrived at Jamestown were surgeons who adapted themselves to fit the medical needs of the community. These men trained in the British system where they sat beneath physicians in a hierarchy that did not consider surgeons to be doctors. Through their service to the colonists, early surgeons earned the reputation traditionally given to physicians in Great Britain. The colonists in Virginia respected the surgeons and viewed them as doctors, which allowed surgeons to stand on equal ground with physicians as the colonies grew to eventually become the United States of America.

"Yes, I Shot the President, but His Physicians Killed Him." The Assassination of President James A. Garfield.

President James A. Garfield suffered two gunshots on July 2, 1881, but did not die until 80 days later of complications from sepsis. He might have survived had his injuries not been contaminated, either by the gunshots themselves or the interventions that followed. "Yes, I shot the president," said Charles Guiteau, Garfield's assassin, "but his physicians killed him." The drama of Garfield's struggle to survive his injuries evoked enormous national interest, a harbinger of the medical dramas and documentaries of today. D. Willard Bliss, a former Civil War surgeon, and his handpicked consultants underwent daily scrutiny by the professional community and lay press. As the President died because of his injuries, the surgeons' reputations suffered. A primary criticism was the supposed lack of antiseptic interventions in Garfield's care, especially when probing the wound with unwashed hands. Inserting a finger into the wound, however, was a basic part of examination of a gunshot wound at the time. Many American surgeons had not accepted Listerian antisepsis at the time of the event, and aseptic techniques, such as scrupulous handwashing and surgical gloves, had not yet been developed. In the context of surgical practice of the era, his surgeons followed the standards of care of the time.

Gamma-guided diagnostic peritoneal lavage for detection of bowel perforation.

HYPOTHESIS: Bowel perforation can be diagnosed by detection of orally administered technetium Tc 99m sulfur colloid ((99m)Tc SC) in diagnostic peritoneal lavage (DPL) fluid using a handheld gamma-detection probe. DESIGN: A canine intestinal-injury model was used to test the hypothesis. The (99m)Tc SC (55.5 MBq) was administered in 500 mL of saline via a nasogastric tube. A DPL with 500 mL of saline was performed at 60, 90, and 120 minutes after administration of (99m)Tc SC. The radioactivity in the DPL effluent was measured using a handheld gamma probe. A DPL effluent count that was 3 SDs above the background count was considered a positive test result. Twenty animals with perforation and 5 without perforation (negative control) were studied. RESULTS: There were no false-positive gamma-DPL test results. Sensitivity improved by time up to 90 minutes. The lowest positive count in the DPL effluent measured by the gamma probe corresponded to 0.2% of the administered activity. No radioactivity was detected in blood and urine samples or liver and spleen specimens. The sensitivity, specificity, accuracy, positive predictive values, and negative predictive values at 90 minutes were 95%, 100%, 96%, 100%, and 83%, respectively. CONCLUSIONS: gamma-Guided DPL is a highly sensitive and 100% specific test in the detection of small-bowel perforation. Clinical studies are warranted to determine the patient-specific factors affecting diagnostic accuracy.

Cytoreductive surgery in patients with advanced-stage carcinoid tumors.

The role of aggressive surgical resections as well as criteria for resectability in patients with advanced carcinoid tumors is not clearly defined. Thirty patients (17 male and 13 female) who were previously diagnosed to have "unresectable carcinoid disease" were treated using a multimodality approach over a period of 2 years. Extensive liver involvement was present in 28 of 30 (93%) of the cases. Small bowel involvement was noted in 22 of 30 (73%), and peritoneal/retroperitoneal/mesenteric invasion was observed in 15 of 30 (50%) of the cases. Three patients had remote metastases (brain, bone, and eye). Twenty of 30 (66%) patients had carcinoid syndrome with severely disabling symptoms. Eight patients (26%) had small bowel obstruction. All patients underwent at least one surgical exploration/intervention. Radiofrequency ablation (RFA) of one or more liver lesions was performed as an adjunct in 22 of 30 (73%) patients. Six patients (20%) had a second surgical procedure. There were 11 complications in eight patients (27%) after the initial operation. Median hospital stay for patients who underwent RFA only, RFA/liver resection, and liver resection with abdominal tumor debulking were 2, 4, 8, and 16 days respectively. Twenty-five of 30 patients (83%) showed symptomatic improvement. Mean pre- and postoperative Karnofsky physical performance scores were 55 and 85 respectively (P < 0.02). Small bowel obstruction was due to adhesions in five patients. All patients with intestinal obstruction had complete relief of their symptoms postoperatively. 5-Hydroxyindolacetic acid levels decreased by 50 per cent in all patients with follow-up determinations available. Aggressive surgical exploration and tumor debulking could be performed with significantly improved symptomatic outcome and relatively minor complications. Longer follow-up is needed for assessment of effect on survival.

Colorectal cancer in patients younger than 40 years of age.

Previous studies have suggested a poor outcome for patients presenting with colorectal cancer under the age of 40 years. This study was conducted to evaluate the outcomes of these patients during a 10-year period at the Medical Center of Louisiana in New Orleans. A retrospective study was designed to review all patients under the age of 40 with a diagnosis of colorectal cancer from January 1990 to December 2000. There were 664 patients presenting with colorectal cancer during the 10-year period; of these 24 presented for surgery under the age of 40. There were 17 male and seven female patients. The median age was 35 years (range 22-39). Eleven (44%) patients had a positive family history of colorectal cancer. Seven lesions were right sided, one transverse, eight left sided, and eight rectal. Histologically 20 lesions were typical adenocarcinomas and four were mucinous. Twelve were stage IV, six stage III, five stage II, and one stage I. Twenty-one patients underwent resection, six with stoma formation; three patients had stoma formation only for a total of nine stomas (38%). The mean operative duration was 3.3 +/- 1.9 hours. The operative mortality was 4 per cent with a complication rate of 17 per cent. The eight rectal cancer patients received preoperative chemoradiation therapy (33%). Twelve (50%) patients with colon cancer received postoperative 5-fluorouracil-based chemotherapy. The mean survival for all patients was 24.7 +/- 23.2 months. Estimated 5-year survival using Kaplan-Meier analysis was 30 per cent. We conclude that colorectal cancer patients less than 40 years of age present at an advanced stage and tend to have a positive family history. In general patients tolerate surgery well, with stoma formation in more than one-third. Long-term survival is as predicted for their advanced stage of presentation. The study highlights the need for early diagnosis in this patient group.

Medical malpractice matters: medical record M & Ms.

Accurate and thorough chart documentation is extremely important not only for patient continuity of care but also for medical legal risk reduction. It is common knowledge that a large percentage of court cases involving health care practitioners rely substantially on the chart documentation to determine outcomes. In this article, the authors have outlined particular court cases that illustrate the dramatic influence medical documentation has had in case law.

Florida International University: development and accreditation of Miami's Public College of Medicine.

Anticipating pressing health care needs in the region, Florida International University (FIU) proposed the FIU College of Medicine (COM), which was approved by the Florida Board of Governors in March 2006. The FIU COM provides a program of study enabling graduates to pursue a wide spectrum of professional careers. This includes careers in general and subspecialty private practice, academic medicine, public service, health care, and public policy leadership. Irrespective of career choice, the special emphasis of the FIU COM mission is its focus on community health in a diverse metropolitan region. Clinical facilities are met through a public partner and multiple private hospital affiliations. Educational objectives are organized into five strands reflecting the breadth of medical education and running concurrently through the four-year curriculum: (1) human biology, (2) disease, illness, and injury, (3) clinical medicine, (4) professional development, and (5) medicine and society. Founding teaching faculty with expertise in the core basic sciences will not only introduce core scientific concepts during the initial seven months but reinforce these same concepts during organ system integrated courses and clerkships. The Neighborhood Health Education Learning Program is an FIU COM innovation in which each medical student is a member of a team that throughout the four-year curriculum identifies and addresses health care needs and factors affecting health outcomes. Preliminary approval of FIU COM was conferred in February 2008, with the first cohort of 40 students matriculating in August 2009.

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

BACKGROUND: The operating room is a dynamic environment in which proper teamwork is essential. After piloting a simulation-based interdisciplinary operative team training program, we examined the impact of these sessions on the participants. METHODS: Three interdisciplinary operating room teams participated in the training model. Each team of 3 or 4 members completed the training in a virtual minimally invasive operating room using a standardized operative scenario. Upon completion of the training, participants completed a voluntary and anonymous training effectiveness questionnaire. RESULTS: All 10 participants completed the training evaluation questionnaires. Across the 3 teams, all participants felt that the training was worthwhile and would participate again. Eight participants said that the session would change their practices in the operating room. All participants felt that the session was effective in promoting team communication skills and crisis-related teamwork. Nine of the 10 felt that the training model was effective in recognizing operating room errors. CONCLUSIONS: Implementing true interdisciplinary team training with a high-fidelity simulation can be accomplished effectively. Team training has the potential for facilitating positive behavioral changes in operating room personnel that are important for adaptive team function in a crisis situation.