Gastric and Duodenal Ulcer—A Surgeon's Approach

A surgeon must have a clear conception of the indications for operation for either gastric or duodenal ulcer. He must realize that his indications must be modified by his operative mortality. The operation he carries out must be determined by several factors. It is the author''s opinion that the various types of distal partial gastrectomy are those most likely to succeed and to produce the fewest undesirable postoperative sequelae.     

OPERATIONS IN UPPER EXTREMITY AMPUTEES

The surgeon is obligated to prepare the patient mentally as well as physically for amputation. Acceptance of his loss by the patient, his family and contemporaries is important in his adjustment to his environment. He must provide the best stump possible, direct the postoperative shrinking and conditioning of the stump, prescribe the prosthetic device best suited to the needs of the individual, make sure it fits and functions, and that the patient is instructed in its maximum use.There are definite indications for ablation of a part. All possible length in the upper extremity should be preserved.Amputation in children with congenital deformities should usually be postponed until demanded by the family. The growth centers should be preserved if feasible. Congenital upper extremity amputees should ordinarily be fitted within the first two years.Neuromata, spurs, redundant tissue, scars, and phantom pain should generally be treated by other than surgical methods. Revisions, including cineplasty, should be undertaken only after careful study and when there are clear indications that benefit to patient will ensue.     

CONTROVERSIAL PROBLEMS IN ADENOTONSILLECTOMY

It is doubtful that the tonsils or adenoids contribute sufficiently to immunity or to hematopoiesis to warrant withholding adenotonsillectomy when there is need for the operation. Focal infection, rheumatic fever and allergic disease must be evaluated in the individual case. A seldom discussed reason for operation is the prophylaxis or treatment of malformation of the nose, sinuses, mouth and jaw. Well defined indications for adenotonsillectomy include frequent occurrence of infection, peritonsillar abscess, cervical lymph node disease believed caused by tonsillar infection, otitis media, and hypertrophy sufficient to embarrass swallowing or breathing. The operation may also be indicated in certain cases of impaired hearing, halitosis, or anorexia, and sometimes for carriers of diphtheria.Psychic trauma can be obviated by proper preparation of a child for the operation he is to undergo.There is a good evidence of evidence of relationship between recent adenotonsillectomy and infection with poliomyelitis—and a good deal of evidence to the contrary. Nationwide rules cannot be established on the basis of the evidence presented thus far. Since in many cases it is unwise to put off adenotonsillectomy, each case in each community in each season must be evaluated separately.     

Severe Colonic Bleeding

Patients requiring emergency operation for severe acute colonic hemorrhage usually arrive in the operating room inadequately studied and the point of bleeding not known. A well planned procedure for making an operative diagnosis is lacking.The fact that diverticular disease is the most common cause of massive colonic bleeding, dominates the surgical management of this problem. A critical interpretation of the color and the consistency of the stools must be made by the surgeon. Since the bleeding lesion is usually otherwise clinically silent, the character of the stools may be the only indication of the level of bleeding and the rate and the amount of the blood loss. A proctoscopic examination, followed by an emergency barium enema study if possible, is always done before subjecting a patient to laparotomy.The indications for emergency operation include acute exsanguinating hemorrhage, less severe but persistent colonic bleeding and recurrent colonic bleeding. The steps for the operative diagnosis and the surgical procedure utilized for a specific situation are discussed.     

Closure to efficient causation, computability and artificial life

The major insight in Robert Rosen's view of a living organism as an (M,R)-system was the realization that an organism must be “closed to efficient causation”, which means that the catalysts needed for its operation must be generated internally. This aspect is not controversial, but there has been confusion and misunderstanding about the logic Rosen used to achieve this closure. In addition, his corollary that an organism is not a mechanism and cannot have simulable models has led to much argument, most of it mathematical in nature and difficult to appreciate. Here we examine some of the mathematical arguments and clarify the conditions for closure.     

Intestinal obstruction

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus. Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation. Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

INTESTINAL OBSTRUCTION

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus.Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation.Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

PROBLEMS IN VENTILATION IN THE IMMEDIATE POSTOPERATIVE PERIOD

In the present day practice of surgical anesthesia, drugs and techniques are used which require or lead to cessation of voluntary respiration by the patient. Respiration is then controlled by the anesthesiologist. At the termination of operation many patients do not breathe adequately for variable periods of time. The causes include obstruction, excessive sedation, muscle relaxants, the effect of controlled respiration itself and various miscellaneous factors. A diagnosis is made by taking into consideration the drugs and techniques which have been used and the character of the patient''s respiratory efforts, if any. The cause may then be treated. In some cases antidotes are available. However, until truly adequate spontaneous respiration is observed for some time the patient must have his efforts assisted. High oxygen concentrations must not be substituted for adequate ventilation.     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient''s acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

Advances in the Theory and Practice of Exchange Transfusions

In the management and prevention of hemolytic disease of the newborn, exchange transfusions seem destined to remain the mainstay of therapy for some time to come.Our current knowledge of bilirubin metabolism has altered the indications for the procedure and introduced such useful new adjuncts to therapy as albumin infusions. The decision to do an exchange transfusion cannot be made by any one rule, but must be individualized for each patient and take into account all the factors known to influence the risks of bilirubin toxicity and the exchange procedure. A thorough evaluation of the infant''s condition, particularly his cardiorespiratory and metabolic status (including blood pH, gas and albumin determinations), will provide valuable information as a guide to therapy. The limited capacity of some newborn infants to make adequate physiological adaptations to a variety of stresses imposed by the procedure influences the preparation of donor blood, the rate and volume of exchange and the time at which it should be done.A clear understanding of the mechanics of the exchange and the distribution of indirect bilirubin within the body will permit more accurate prediction of what can be accomplished in bilirubin removal and correction of hematocrit with exchanges of different volumes. When weighing the risk of kernicterus against that of exchange transfusion, the experience of the operator and the availability of suitable facilities cannot be ignored.     

Take Russia to 'task' on bioweapons transparency

In the run-up to his reelection, Russian president Vladimir Putin outlined 28 tasks to be undertaken by his administration, including one that commanded the development of weapons based on “genetic principles.” Political pressure must be applied by governments and professional societies to ensure that there is not a modern reincarnation of the Soviet biological warfare program.     

Carotid endarterectomy for prevention of stroke.

Carotid endarterectomy, a frequently performed operation, has been used as a strategy for preventing stroke in patients with carotid bifurcation disease. The safety and efficacy of the operation were recently challenged by a number of sources. Three major responses to this challenge were to retrospectively review the natural history of carotid bifurcation disease compared with the immediate and long-term results of carotid endarterectomy, to initiate 6 prospective randomized trials to determine the efficacy of carotid endarterectomy for a variety of indications, and to develop appropriateness initiatives and guidelines for using this surgical procedure by organizations concerned with health care policy. I review the current status of these 3 areas of endeavor. In those areas where studies are complete, carotid endarterectomy has been shown to be highly effective in reducing stroke risk. Risk reduction has ranged from 66% to 80% compared with medical management. Based on these sources and findings, I present a list of indications for the operation for surgeons who are able to do the operation safely and within the guidelines established by the Stroke Council of the American Heart Association.     

Transpalpebral browpexy

Transpalpebral browpexy could be performed as an adjuvant procedure to the upper blepharoplasty or as a separate procedure. It is done by separating interdigitalizing connections between the orbicularis and frontalis muscles, moving the orbicular part of the orbicularis muscle with overlying brow to the more cephalad position and again uniting both of these muscles with nonresorbable sutures in a new higher position. During the years 1990 to 1999, 55 patients (47 women and eight men) were operated on with this technique, which was partially developed by the author. Additional time required to achieve transpalpebral brow stabilization during standard blepharoplasty was approximately 30 minutes. Forty-three patients were followed, 38 of them for longer than 4 years. The elevation effect gradually decreased but persisted, with wide variations, between 1.5 and 7 more years. At the last follow-up examination, 36 of 43 patients had maintained lateral brows in the same position as before operation and sometimes even higher, which was appreciated by the patients. Complications were very few and they were correctable. Transpalpebral browpexy proved to be a useful addition to blepharoplasty and can be used for the minor adjustments after an open coronal or endoscopic brow lift. Particular indications included patients with lateral brow ptosis and discrete forehead wrinkles and balding men.     

PRIMARY POSTPARTUM HEMORRHAGE

Postpartum hemorrhage is the outstanding cause of maternal mortality, and a redoubtable contributor to puerperal death from other causes, notably infection and renal failure. The clinical situations in which hemorrhage is liable to occur must be better known, so that anticipatory and preventive measures can be taken. Recent knowledge about defibrinated blood in women with degenerative changes at the placental site must be incorporated in the thinking and practice of physicians dealing with obstetrical cases. The indications, limitations, and hazards of the various anesthetic methods available for parturient women should be carefully considered in the circumstances of each case.     

Primary postpartum hemorrhage

Postpartum hemorrhage is the outstanding cause of maternal mortality, and a redoubtable contributor to puerperal death from other causes, notably infection and renal failure. The clinical situations in which hemorrhage is liable to occur must be better known, so that anticipatory and preventive measures can be taken. Recent knowledge about defibrinated blood in women with degenerative changes at the placental site must be incorporated in the thinking and practice of physicians dealing with obstetrical cases. The indications, limitations, and hazards of the various anesthetic methods available for parturient women should be carefully considered in the circumstances of each case.     

ON THE INDEPENDENCE OF SYSTEMATICS

Abstract— Before the publication of On the Origin of Species the standing patterns of natural history—common plan, homology, ontogenetic parallelism, and the hierarchy of groups — were taken as indications of a biological order that had not yet been understood. Darwin covered all of these in chapter 13 of the Origin , arguing that his theory was the first to provide a reasonable explanation for the existence of such patterns. Since Darwin took these relations to be established by previous biology, and used them as evidence for the explanatory power of his theory, he was clearly of the opinion that they were independent of that theory. Although several modern figures have argued to the contrary, it seems that Darwin was right. The patterns listed above are recoverable from observation without reference to evolutionary theory, which theory may then be applied to provide an account of the processes by which they may have come about. That aspect of systematics concerned with the identification of the empirical patterns evidently constitutes a study prior to and independent of theories of process.     

Two puzzles for Marquis's conservative view on abortion

Don Marquis argues that abortion is morally wrong in most cases since it deprives the fetus of the value of its future. I criticize Marquis’s argument for the modified conservative view by adopting an argumentative strategy in which I work within his basic account: if it is granted that his fundamental idea is sound, what follows about the morality of abortion? I conclude that Marquis is faced with a dilemma: either his position must shift towards the extreme conservative view on which abortion is never morally permissible, or he must abandon any recognizably conservative view. This dilemma suggests that Marquis’s view is either deeply implausible or that he cannot use this argument to successfully support his preferred position.     

Design Guidelines for Deadlock-Handling Strategies in Flexible Manufacturing Systems

Deadlock-free operation of flexible manufacturing systems (FMSs) is an important goal of manufacturing systems control research. In this work, we develop the criteria that real-time FMS deadlock-handling strategies must satisfy. These criteria are based on a digraph representation of the FMS state space. Control policies for deadlock-free operation are characterized as partitioning cuts on this digraph. We call these structural control policies (SCPs) because, to avoid deadlock, they must guarantee certain structural properties of the subdigraph containing the empty state; namely, that it is strongly connected. A policy providing this guarantee is referred to as correct. Furthermore, an SCP must be configurable and scalable; that is, its correctness must not depend on configuration-specific system characteristics and it must remain computationally tractable as the FMS grows in size. Finally, an SCP must be efficient; that is, it must not overly constrain FMS operation. We formally develop and define these criteria, formulate guidelines for developing policies satisfying these criteria, and then provide an example SCP development using these guidelines. Finally, we present an SCP that guarantees deadlock-free buffer space allocation for FMSs with no route restrictions.     

Apples, oranges and unknown fruit

For many microbiologists their ultimate goal is to understand microbial life at the whole-cell level. Here, Fred Neidhardt gives his view that attention must be paid to the growth conditions for this goal to be realized.     

Sex Education in the Schools— The Doctor's Role

Physicians may be asked to act as consultants in the development of sex education programs in the schools or to contribute as professional experts. As most medical libraries contain very little material on this subject, the doctor must turn to public libraries, which have books ranging from useless to excellent. These must be examined critically. In his role of healer, the doctor may minimize his roles of teacher and community model, and thereby lose many opportunities to communicate with members of other professions and thus extend health education beyond the limits of his practice.