Origins of modern premedical education.

The author reviews the contributions of those individuals and major academic and professional organizations responsible for the development of the modern concepts of the premedical education of a physician. The late 19th century gave rise to scientifically-based medical education in U.S. medical education. It followed that this new emphasis, in medical schools, on laboratory investigation of disease processes demanded a sound introduction to the natural sciences by those who would be candidates for this type of challenging education. Starting with a vocal few, the message gradually was received throughout the country that a properly schooled physician must have the equivalent of a broad baccalaureate education in the natural sciences as well as in the traditional humanities. This essential was recognized by a small nucleus of individuals responsible for the creation of The Johns Hopkins University in 1876 and its school of medicine in 1893; the group was led by the university's first president, Daniel Coit GILMAN: Almost simultaneously other established academic institutions incorporated similar changes and a new era began.

Linking substance abuse and serious mental illness service delivery systems: initiating a statewide collaborative.

In the past, persons with serious mental illness and substance abuse often found themselves in parallel systems of care that inadequately addressed their needs. Recent advances have seen the development of an integrated approach to care for these disorders in both the public and private sectors. While some state departments of mental health have developed integrated systems of care for public sector patients, no department appears to have developed such a system for both public and private clients, and there appears to be no published journal report of a model to induce cooperation by all stakeholders. This article outlines a two-step approach by the Massachusetts Department of Mental Health to foster stakeholder cooperation in designing an integrated system of care for both public and private clients with co-occurring disorders.

Scholarship, humanism, and the young physician.

It is time to understand the value of a broad liberal education for those college students who aim to be physicians, both because the medical curriculum is becoming more humanistic (which a liberal education would support) and because three enormous challenges confront physicians and educators alike: the relentless tide of biomedical discoveries, the great financial burden that medical care imposes, and the public's desperate plea for physicians who are more caring and communicative. A liberal education--meaning a course of study that is largely unrestricted and that attempts to sample the entire breadth of human knowledge--can help the premedical student cultivate, ripen, and enrich fundamental proficiencies such as accurate recording of observations, communicating ideas well, dealing with human emotions and becoming sensitive to human frailties, learning to listen and respond appropriately, learning to make sound judgments, and cultivating empathy and compassion. These are all skills that a liberal education can help the young student learn early rather than late, skills that prepare the student for dealing later with complex social, ethical, and clinical issues as a physician. A liberal education also can help prepare the student to take advantage of other general educational opportunities that are available in the small, closed community of a residency, such as learning to both assume and delegate responsibility, to participate in rational debate while respecting the opinions of others, and to exercise mature judgment, civility, empathy, and compassion. While a liberal education will not necessarily make the student a more technically proficient doctor, for some it will be essential to awaken and sharpen those essential skills that a physician needs to rise to the top of a profession that never fails to recognize excellence and humanity.

Nathan Smith and the Johns Hopkins connection.

The lives of Nathan Smith and his descendants touched eight American medical schools: Dartmouth, Yale, Bowdoin, Vermont, Jefferson, Maryland, Transylvania, and Johns Hopkins.

Surgical treatment of Hirschsprung's disease in adults.

A series of eight adult patients with lifelong refractory constipation are presented. All were proved to have Hirschsprung's disease. In some of the patients, the diagnosis was initially determined in childhood. However, the other patients were not found to have this hereditary disorder of the motor function of the colon and rectum until adulthood. The lengths of the terminal aganglionic segments were quite variable, ranging from 2 to more than 25 centimeters. Rectal myectomy alone or in combination with anterior resection proved to be curative and obviated the need for extensive pelvic dissection which otherwise would be hazardous in male patients.

Endorectal pull-through operation in adults after colectomy and excision of rectal mucosa.

Ileal endorectal pull-through can be performed in adults after abdominal colectomy and excision of rectal mucosa. The procedure requires a painstaking dissection of the mucous membrane of the rectum to ensure cure of the polyposis or ulcerative colitis for which it is carried out. Some cases of ulcerative colitis are inappropriate for this dissection, and Crohn's disease prohibits the use of this operation. Fifteen operations in adults are described herein. Certain technical maneuvers have been of help to us and these are described. We have favored a diverting ileostomy maintained for 3 months. A pouch, positioned in the rectum, has hastened the return toward normal control. Sphincter control and responses have been uniformly good. Dilatations and sphincter exercises are routinely employed. Strictures are not rare but are amenable to correction by digital stretching.

Stabilization of ileostomy position with fascia.

An ileostomy that maintains its protrusion in a stable manner can be fashioned by the technique of Brooke. However, in a significant number of patients, recession or prolapse of the ileostomy occurs, tending to displace an appliance. A safe and effective technique is described whereby the ileostomy is stabilized without danger. A ribbon of fascia, obtained from the abdominal wall, is passed through the mesentery adjacent to the bowel between vessels, at its point of exit from the peritoneum. It is neither wrapped around the bowel nor sutured to it. The ends of the fascia are securely sutured to the peritoneum and transversalis fascia. This secures the position of the ileostomy without the danger of fistula from suturing the bowel wall. It may be used for recession or prolapse. It may be supplemented by passing additional fascia or suture elsewhere in the mesentery or into other available tissue.

Ileostomy options. Asking the right questions.

The patient requiring ileostomy may have the opportunity to choose from four options. The Brooke ileostomy has afforded thousands of patients a secure, comfortable life. Appliances adhere well, and complications are few. The continent ileostomy or Kock pouch permits a patient to forego the wearing of an appliance. It is about 90 per cent successful but has a significant complication rate. Crohn's disease and physical frailties preclude its use. In "endorectal pull-through," the colon and rectal mucous membrane are removed to cure polyposis or ulcerative colitis. The ileum is led through the rectal muscular cylinder and anastomosed to the anus. The operation is tedious and not uniformly successful. A period of training must follow. It is unfit for people with Crohn's disease. Ileal anastomosis to a rectal segment is simpler but leaves disease behind. It may be used in Crohn's disease but may expose the patient to the hazard of recurrent disease or cancer. We must understand and ask the right questions if we are to give our patients the right answers.

A method for primary reconstruction following radical excision of sacrococcygeal pilonidal disease.

A great variety of procedures have been proposed for the cure of Sacrococcygeal pilonidal disease. Initial enthusiasm has usually given way to disappointment when it is realized that the treatment is painful, the hospitalization is prolonged, the aftercare is tedious or the original condition appears to have recurred. A technique is described which permits the total extirpation of cyst and sinus tracts while allowing for a tensionless wound closure by advancement of a buttock flap. Hospitalization is brief and the postoperative course is comfortable. Fifty such operations have been performed since November 1968. In the first group of thirty patients operated upon between three and ten years ago, a single bonafide failure occurred. An additional twenty patients have been successfully treated for an overall failure rate of 2%.

Substrate form of D-frutose 1,6-bisphosphate utilized by fructose 1,6-bisphosphatase.

Rapid quench kinetic experiments on fructose 1,6-bisphosphatase demonstrate a stereospecificity for the alpha anomer of fructose 1,6-bisphosphate relative to the beta configuration. The beta anomer is only utilized after mutarotation to the alpha form in a process that is not enzyme catalyzed. Studies employing analogues of the acyclic keto configuration indicate that the keto form is utilized at a rate less than 5% that of the alpha anomer, a finding also confirmed by computer simulation of the rapid quench data. Chemical trapping experiments of the keto analogue, xylulose 1,5-bisphosphate, and the normal substrate suggest that interconversion of the acyclic and anomeric configurations is retarded by their binding to the enzyme. A hypothesis is advanced attributing substrate inhibition of fructose 1,6-bisphosphatase to possible binding of the keto species.

Salvage after anastomotic leak in Crohn disease. Utilization of a new, simple diverting ileostomy.

It may be possible to manage an anastomotic leak following resection for Crohn disease by drainage, suture, and proximal loop ileostomy. This report describes success with a simple diverting ileostomy.

Permanent ileostomy without external appliance: Kock internal reservoir (pouch) operation.

Employing a surgical technique described by Dr. Nils Kock of Göteborg, Sweden one can create a continent ileostomy beyond an internal reservoir of ileum for patients who have had total proctocolectomy. This operation is designed to obviate the necessity for wearing an external appliance. Instead, the patient introduces a catheter through the ileostomy into the reservoir of ileum three or four times daily and evacuates it in a convenient manner. Our experience with seven patients, as well as a useful opertive variation of our own, is described. In six patients the procedure was carried out at the time of proctocolectomy. Currently six of the seven patients function without an appliance. Two of the seven had serious postoperative complications which were associated with the pouch. While a number of physical and emotional advantages are ascribed to the procedure, the specific hazards of the complex surgery, the extra time consumed daily in emptying the reservoir, and the necessity for further surgery if the pouch fails to function in a satisfactory manner must be balanced against them. Over the short term, the experience of our patients with this operation has been favorable. Larger series have been reported by Dr. Kock and by Dr. Beahrs at the Mayo Clinic. While 80% of their patients have had satisfactory eventual outcomes, a larger number of secondary operations and an ultimate 20% incidence of unsatisfactory results dictate the necessity for a guarded approach to this procedure.