Pride and
To the Editor.\p=m-\Ienjoyed reading Dr Richard Warren's editorial, entitled "Power and Prejudice," in the January 1978 issue of the Archives (113:13\x=req-\ 14, 1978). Having benefited from his attitude, I am deeply appreciative of his insight and sympathy. Unfortunately, these qualities have not been shared by many other editors and reviewers, especially during the recent
past.
Objective criticism and helpful suggestions should be welcomed by all
writers. However, too many reviewers submit criticisms that betray a lack of familiarity with the subject matter. Too frequently they indulge in misinterpretations indicative of prejudice or inability or disinclination to properly interpret the written word. Indeed, one often receives the impression that criticisms are inappropriately harsh and designed to assure rejection rather than to salvage what is meritorious. Obviously, everything that is submitted for publication is not worth publishing. However, capacity for publication is much more limited than required to fulfill our needs, even after eliminating inferior manuscripts. Furthermore, editorial policy is influenced by reader acceptance, which may preclude publication of unpopular but important articles. As a result, vehicles for communicating scientific and basic medical observa¬ tions may not be available to many
investigators.
There appears to be a solution. Elec¬ tronic memory banks offer an almost unlimited capacity for storage of data. With proper organization of such facilities, investigators could record their observations in plain AngloSaxon devoid of redundant historical or philosophical notations. When cross-indexed, this information could be retrieved as needed. Publication time would be reduced. Moreover, under these circumstances editors would be under little pressure to reject articles because of lack of space,
personal prejudice, literary stvle.
Appendectomy Does Not Predispose to Right-Sided Ectopic Pregnancies A 20-year review of ectopic pregPrevious
Prejudice
or
questionable
DAVID V. PECORA, MD Wilmington, Del
nancies at the Naval Regional Medical Center at Portsmouth, Va, yielded 556 cases between 1956 and 1976. One hundred nine patients (19.6%) had
previous appendectomy. were 48 (44%) right-sided ectopic pregnancies and 61 (56%) left-sided ectopic pregnancies. Partial tubal occlusion retarding the undergone
a
In this group, there
passage of the fertilized ovum is one mechanism postulated for tubal pregnancies.1,2 It seems reasonable, there-
fore, that women with prior appendectomies might be at increased risk for
right-sided tubal pregnancies secondary to penitubular adhesions. Almost 20% of the patients in this series had a previous appendectomy. These 109 patients demonstrated no predilection for right-sided ectopic gestations. In fact, 56% of these patients had left\x=req-\ sided ectopic pregnancies. We therefore conclude that a previous appendectomy does not predispose to right\x=req-\ sided ectopic pregnancies. LT COMDR A. D. CROMARTIE,
MC,
tions that did not delay discharge. Like Chang and Farha, my colleagues and I have had no pulmonary or urinary tract complications and have had 100% patient acceptance. Even the two of our own recurrences of which we are aware were repaired under local anesthesia at the patient's request. Ten repairs have been done on physicians, four of whom were surgeons. Although this series extends over 14 years, the cost analysis, to be of current worth, must be restricted to today's prices. During 1976 and the first quarter of 1977, the average hospital stay for inguinal hernia repair done under general anesthesia in the main hospital operating suite was 4.5 days, and the average total cost to the patient (excluding surgeon and assistant fees) was $1,144.08. For comparable surgery done in our outpa¬ tient surgical facility, the average postoperative stay was 2.2 hours, and the average total stay from admission through surgery and postoperative observation was 3.9 hours. The cost to the patient averaged $228.20, the lowest charge being $174 and the
USNR COMDR P. J. KOVALCIK, MC, USNR Portsmouth, Va
1. Novak ER, Woodruff JD (eds): Novak's Gynecologic and Obstetric Pathology. Philadelphia, WB Saunders Co, 1967, p 435. 2. Woodruff JD, Pauerstein CJ: The Fallopian Tube, Baltimore, Williams & Wilkins Co, 1969, p 183.
Inguinal Herniorrhaphy
highest $330.
Repair under local anesthesia in our experience results in an 80% reduction in cost to the patient, carries no significant morbidity and no mortali¬ ty, permits intraoperative testing of the repair, and has had 100% patient acceptance—a hard combination
to
beat!
ROBERT C. Seattle
COE, MD
Under Local Anesthesia To the Editor.\p=m-\Thearticle by Chang and Farha on inguinal herniorrhaphy under local anesthesia (Arch Surg 112:1069-1071, 1977) presents needed and convincing evidence in favor of this approach, but neglects what in my experience has proved to be its most impressive by-product\p=m-\the financial savings realized. A recent analysis of a personal series of 140 groin hernia repairs done under local anesthesia in a manner comparable to Chang and Farha's shows age ranges from 14 to 94 years, maximum postoperative stay of six days and minimum stay of 30 minutes, and three minor complica-
Downloaded From: http://archsurg.jamanetwork.com/ by a Michigan State University User on 06/10/2015
A New Method of Gastric Drainage Following Truncal Vagotomy
It is generally believed that some of the unpleasant sequelae of truncal vagotomy (TV) and pyloroplasty are caused not by nerve section but instead are related in some way to irreparable destruction of the bidirec-
tionally competent pyloric ring. Experience of the earlier vagotomists was that an accompanying drainage operation was necessary to avoid gastric stasis. Further scrutiny of these earlier publications, however, shows that although symptoms of stasis occur, they are by no means
universal, and according
to Glenn1 "diminish within a period of 6-10 weeks." Slaney et al2 went as far as claiming that in their series of 74 TVs without a drainage operation "in no case did serious gastric stasis arise." It therefore appears that after TV alone, gastric retention never develops in many patients, and in the majority in whom it does, such stasis improves with time and does not constitute a long-term problem. It seemed to us that if patients could be tided over the early period, return of gastric muscle activity could be expected to cope with the normal gas¬ tric outlet resistance. A method of accomplishing this is to forcibly dilate the pylorus (using Hegar dilators passed through a small antral gastrotomy incision) thus pro¬ ducing reduced outflow resistance through which the vagotomized stom¬ ach can empty in the early postopera¬ tive period. With the passage of time, recovery of pyloric muscle activity should accompany the return of gas¬ tric motility, thus leading to a more normal pattern of gastric emptying. Such an operation (TV + stretch) is at
present being compared prospectively with TV + pyloroplasty. A sympto¬ matic evaluation of each
operation is being accompanied by objective as¬ sessment of the gastric emptying of radioactively labeled solid and liquid meals both preoperatively and postoperatively.
Results in the 20 cases so far studied show that a TV + stretch operation does not result in either early or late (up to 18 months) gastric stasis, and
furthermore, "precipitate emptying"
noted only in cases of TV + pylor¬ oplasty. This latter phenomenon re¬ quires further examination, but at was
it would appear that TV + stretch may well be a far more rational and complication-free proce¬
present
dure than those currently used. NEIL LONGRIGG, MB, CHB,
MD, FRCS
ROBERT PRINGLE,
Dundee, Scotland
CHM, FRCS
1. Glenn F: Present status of surgical treatpeptic ulcer. JAMA 145:790-794, 1951. 2. Slaney G, Beran PG, Brook BN: Vagotomy for chronic peptic ulcer. Lancet 2:221-224, 1956. ment of
Perforation of the Colon Due to Clay Ball
To the Editor.\p=m-\A40-year-old woman had acute onset of abdominal pain. The physical examination was consis-
with generalized peritonitis. Chest roentgenogram showed sub\x=req-\ diaphragmatic air; abdominal x-ray films showed radiopaque material in the bowel and two radiopaque masses in the pelvis. Findings on exploratory laparotomy included free feces, gravel and grass blades in the peritoneal and pelvic cavity, plus two rounded masses of clay containing grass blades and gravel. The largest mass measured 6 cm in diameter. There was a 5-cm perforation of the left colon that was exteriorized as loop colostomy. The abdomen was closed with one layer of monofilament wire after irrigation and drainage were completed. After a tormentous postoperative course, complicated with sepsis and wound abscesses requiring two weeks of intensive supportive treatment, the patient's condition started to improve. Her abdominal wound healed subsequently. Eight weeks after the initial procedure, the colostomy was closed, and patient was discharged with satistent
factory recovery. Comment.\p=m-\Althoughinitially described by Berry1 in 1894, stercoraceous perforation2 of the colon contin¬ ues to be a rare entity that carries high mortality. Death is usually due to sepsis, peripheral vascular collapse, and metabolic acidosis, secondary to generalized peritonitis. This common¬ ly occurs in elderly, invalided, or mentally unbalanced patients; our patient was younger and mentally sound. The habit of eating clay was an old family custom; they collected clay that contained gravel and grass from
the hills and baked it, then ate it as snack with soft drinks. She was doing this since she was 5 years old. The treatment of this often lethal condi¬ tion is prompt exploratory laparotomy with exteriorization of the perforated segment when feasible and proper drainage. Intensive supportive therapv is essential. JOSE E. SANCHEZ -A., MD
Wise, Va
1. Berry J: Dilatation and rupture of the sigmoid flexure. Br Med J 1:301, 1894. 2. Bauer JJ, Weiss M, Dreiling DA: Stercoraceous perforation of the colon. Surg Clin North Am 52:1047-1053. 1972.
In Vitro Activity of Sulfadiazine Compounds of Zinc and Silver
To the Editor.\p=m-\Thevalidity of in vitro evaluation of the sensitivity of microorganisms to sulfonamide compounds has long been questioned because of the minimal inoculum and minimal
Downloaded From: http://archsurg.jamanetwork.com/ by a Michigan State University User on 06/10/2015
media that must be used and because of bacteriostatic nature of the drug. Recently, sulfadiazine compounds of zinc and silver have been reported to be effective topical therapeutic agents for Pseudomonas infection of burns.1.2 Further, it has been indicated2 that the growth of P aeruginosa was inhibited by as low a concentration as 0.05 \g=m\M of sulfadiazine silver and 0.025 \g=m\M of sulfadiazine zinc per millimeter of nutrient broth. On the other hand, the concentration of the drug inhibitory for Klebsiella, Escherichia coli, and Staphylococcus were 0.025, 0.25 and 0.05 \g=m\M/ml of nutrient broth, respec-
tively.
The marked activity reported of these compounds prompted us to study the in vitro sensitivity of a variety of organisms to sulfadiazine silver and sulfadiazine zinc in standard nutrient broth according to the technique of Fox et al.2 Fifty strains of P aeruginosa, and 15 strains each of Klebsiella, E coli, and S aureus isolated from burns and wound infec¬ tions were investigated. Sulfadiazine zinc did not inhibit the growth of any of these organisms even at 500 /ig/ml. Sulfadiazine silver, on the other hand, was active in the 20 to 40-"g/ml range for different organisms. Two strains of P aeruginosa were remarkably sensitive to this drug, with no visible
growth
even at 5 u,g/ml. The in vivo efficacy of sulfadiazine zinc noted in animal experiments might perhaps be attributable to zinc ions, which are required for wound healing and are toxic to microorga¬ nisms. In fact, when zinc was added to the in vitro test system in the form of ZnS04, 400 fig/ml of this metal brought about a total inhibition of most of the strains of P aeruginosa. In view of the role played by zinc in wound healing and its toxicity to microorganisms, sulfadiazine zinc is perhaps more suitable for topical application in burns as compared with sulfadiazine silver, since the silver ions not only do not participate in wound healing but may even be toxic to the host tissue. C. N. NAGESHA I. KARUNA SAGAR Mangalore, India 1. Fox CL: Silver sulfadiazine: A
therapy
new
topical
for Pseudomonas in burns. Arch Surg 96:184-188, 1968. 2. Fox CL Jr, Modak SM, Stanford JW: Zinc sulfadiazine for topical therapy of Pseudomonas infection in burns. Surg Gynecol Obstet 142:553\x=req-\ 559, 1976.
To the Editor.\p=m-\Ienjoyed reading Dr Richard Warren's editorial, entitled "Power and Prejudice," in the January 1978 issue of the Archives (113:13\x=req-\ 14, 1978). Having benefited from his attitude, I am deeply appreciative of his insight and sympathy. Unfortunately, these qualities have not been shared by many other editors and reviewers, especially during the recent
past.
Objective criticism and helpful suggestions should be welcomed by all
writers. However, too many reviewers submit criticisms that betray a lack of familiarity with the subject matter. Too frequently they indulge in misinterpretations indicative of prejudice or inability or disinclination to properly interpret the written word. Indeed, one often receives the impression that criticisms are inappropriately harsh and designed to assure rejection rather than to salvage what is meritorious. Obviously, everything that is submitted for publication is not worth publishing. However, capacity for publication is much more limited than required to fulfill our needs, even after eliminating inferior manuscripts. Furthermore, editorial policy is influenced by reader acceptance, which may preclude publication of unpopular but important articles. As a result, vehicles for communicating scientific and basic medical observa¬ tions may not be available to many
investigators.
There appears to be a solution. Elec¬ tronic memory banks offer an almost unlimited capacity for storage of data. With proper organization of such facilities, investigators could record their observations in plain AngloSaxon devoid of redundant historical or philosophical notations. When cross-indexed, this information could be retrieved as needed. Publication time would be reduced. Moreover, under these circumstances editors would be under little pressure to reject articles because of lack of space,
personal prejudice, literary stvle.
Appendectomy Does Not Predispose to Right-Sided Ectopic Pregnancies A 20-year review of ectopic pregPrevious
Prejudice
or
questionable
DAVID V. PECORA, MD Wilmington, Del
nancies at the Naval Regional Medical Center at Portsmouth, Va, yielded 556 cases between 1956 and 1976. One hundred nine patients (19.6%) had
previous appendectomy. were 48 (44%) right-sided ectopic pregnancies and 61 (56%) left-sided ectopic pregnancies. Partial tubal occlusion retarding the undergone
a
In this group, there
passage of the fertilized ovum is one mechanism postulated for tubal pregnancies.1,2 It seems reasonable, there-
fore, that women with prior appendectomies might be at increased risk for
right-sided tubal pregnancies secondary to penitubular adhesions. Almost 20% of the patients in this series had a previous appendectomy. These 109 patients demonstrated no predilection for right-sided ectopic gestations. In fact, 56% of these patients had left\x=req-\ sided ectopic pregnancies. We therefore conclude that a previous appendectomy does not predispose to right\x=req-\ sided ectopic pregnancies. LT COMDR A. D. CROMARTIE,
MC,
tions that did not delay discharge. Like Chang and Farha, my colleagues and I have had no pulmonary or urinary tract complications and have had 100% patient acceptance. Even the two of our own recurrences of which we are aware were repaired under local anesthesia at the patient's request. Ten repairs have been done on physicians, four of whom were surgeons. Although this series extends over 14 years, the cost analysis, to be of current worth, must be restricted to today's prices. During 1976 and the first quarter of 1977, the average hospital stay for inguinal hernia repair done under general anesthesia in the main hospital operating suite was 4.5 days, and the average total cost to the patient (excluding surgeon and assistant fees) was $1,144.08. For comparable surgery done in our outpa¬ tient surgical facility, the average postoperative stay was 2.2 hours, and the average total stay from admission through surgery and postoperative observation was 3.9 hours. The cost to the patient averaged $228.20, the lowest charge being $174 and the
USNR COMDR P. J. KOVALCIK, MC, USNR Portsmouth, Va
1. Novak ER, Woodruff JD (eds): Novak's Gynecologic and Obstetric Pathology. Philadelphia, WB Saunders Co, 1967, p 435. 2. Woodruff JD, Pauerstein CJ: The Fallopian Tube, Baltimore, Williams & Wilkins Co, 1969, p 183.
Inguinal Herniorrhaphy
highest $330.
Repair under local anesthesia in our experience results in an 80% reduction in cost to the patient, carries no significant morbidity and no mortali¬ ty, permits intraoperative testing of the repair, and has had 100% patient acceptance—a hard combination
to
beat!
ROBERT C. Seattle
COE, MD
Under Local Anesthesia To the Editor.\p=m-\Thearticle by Chang and Farha on inguinal herniorrhaphy under local anesthesia (Arch Surg 112:1069-1071, 1977) presents needed and convincing evidence in favor of this approach, but neglects what in my experience has proved to be its most impressive by-product\p=m-\the financial savings realized. A recent analysis of a personal series of 140 groin hernia repairs done under local anesthesia in a manner comparable to Chang and Farha's shows age ranges from 14 to 94 years, maximum postoperative stay of six days and minimum stay of 30 minutes, and three minor complica-
Downloaded From: http://archsurg.jamanetwork.com/ by a Michigan State University User on 06/10/2015
A New Method of Gastric Drainage Following Truncal Vagotomy
It is generally believed that some of the unpleasant sequelae of truncal vagotomy (TV) and pyloroplasty are caused not by nerve section but instead are related in some way to irreparable destruction of the bidirec-
tionally competent pyloric ring. Experience of the earlier vagotomists was that an accompanying drainage operation was necessary to avoid gastric stasis. Further scrutiny of these earlier publications, however, shows that although symptoms of stasis occur, they are by no means
universal, and according
to Glenn1 "diminish within a period of 6-10 weeks." Slaney et al2 went as far as claiming that in their series of 74 TVs without a drainage operation "in no case did serious gastric stasis arise." It therefore appears that after TV alone, gastric retention never develops in many patients, and in the majority in whom it does, such stasis improves with time and does not constitute a long-term problem. It seemed to us that if patients could be tided over the early period, return of gastric muscle activity could be expected to cope with the normal gas¬ tric outlet resistance. A method of accomplishing this is to forcibly dilate the pylorus (using Hegar dilators passed through a small antral gastrotomy incision) thus pro¬ ducing reduced outflow resistance through which the vagotomized stom¬ ach can empty in the early postopera¬ tive period. With the passage of time, recovery of pyloric muscle activity should accompany the return of gas¬ tric motility, thus leading to a more normal pattern of gastric emptying. Such an operation (TV + stretch) is at
present being compared prospectively with TV + pyloroplasty. A sympto¬ matic evaluation of each
operation is being accompanied by objective as¬ sessment of the gastric emptying of radioactively labeled solid and liquid meals both preoperatively and postoperatively.
Results in the 20 cases so far studied show that a TV + stretch operation does not result in either early or late (up to 18 months) gastric stasis, and
furthermore, "precipitate emptying"
noted only in cases of TV + pylor¬ oplasty. This latter phenomenon re¬ quires further examination, but at was
it would appear that TV + stretch may well be a far more rational and complication-free proce¬
present
dure than those currently used. NEIL LONGRIGG, MB, CHB,
MD, FRCS
ROBERT PRINGLE,
Dundee, Scotland
CHM, FRCS
1. Glenn F: Present status of surgical treatpeptic ulcer. JAMA 145:790-794, 1951. 2. Slaney G, Beran PG, Brook BN: Vagotomy for chronic peptic ulcer. Lancet 2:221-224, 1956. ment of
Perforation of the Colon Due to Clay Ball
To the Editor.\p=m-\A40-year-old woman had acute onset of abdominal pain. The physical examination was consis-
with generalized peritonitis. Chest roentgenogram showed sub\x=req-\ diaphragmatic air; abdominal x-ray films showed radiopaque material in the bowel and two radiopaque masses in the pelvis. Findings on exploratory laparotomy included free feces, gravel and grass blades in the peritoneal and pelvic cavity, plus two rounded masses of clay containing grass blades and gravel. The largest mass measured 6 cm in diameter. There was a 5-cm perforation of the left colon that was exteriorized as loop colostomy. The abdomen was closed with one layer of monofilament wire after irrigation and drainage were completed. After a tormentous postoperative course, complicated with sepsis and wound abscesses requiring two weeks of intensive supportive treatment, the patient's condition started to improve. Her abdominal wound healed subsequently. Eight weeks after the initial procedure, the colostomy was closed, and patient was discharged with satistent
factory recovery. Comment.\p=m-\Althoughinitially described by Berry1 in 1894, stercoraceous perforation2 of the colon contin¬ ues to be a rare entity that carries high mortality. Death is usually due to sepsis, peripheral vascular collapse, and metabolic acidosis, secondary to generalized peritonitis. This common¬ ly occurs in elderly, invalided, or mentally unbalanced patients; our patient was younger and mentally sound. The habit of eating clay was an old family custom; they collected clay that contained gravel and grass from
the hills and baked it, then ate it as snack with soft drinks. She was doing this since she was 5 years old. The treatment of this often lethal condi¬ tion is prompt exploratory laparotomy with exteriorization of the perforated segment when feasible and proper drainage. Intensive supportive therapv is essential. JOSE E. SANCHEZ -A., MD
Wise, Va
1. Berry J: Dilatation and rupture of the sigmoid flexure. Br Med J 1:301, 1894. 2. Bauer JJ, Weiss M, Dreiling DA: Stercoraceous perforation of the colon. Surg Clin North Am 52:1047-1053. 1972.
In Vitro Activity of Sulfadiazine Compounds of Zinc and Silver
To the Editor.\p=m-\Thevalidity of in vitro evaluation of the sensitivity of microorganisms to sulfonamide compounds has long been questioned because of the minimal inoculum and minimal
Downloaded From: http://archsurg.jamanetwork.com/ by a Michigan State University User on 06/10/2015
media that must be used and because of bacteriostatic nature of the drug. Recently, sulfadiazine compounds of zinc and silver have been reported to be effective topical therapeutic agents for Pseudomonas infection of burns.1.2 Further, it has been indicated2 that the growth of P aeruginosa was inhibited by as low a concentration as 0.05 \g=m\M of sulfadiazine silver and 0.025 \g=m\M of sulfadiazine zinc per millimeter of nutrient broth. On the other hand, the concentration of the drug inhibitory for Klebsiella, Escherichia coli, and Staphylococcus were 0.025, 0.25 and 0.05 \g=m\M/ml of nutrient broth, respec-
tively.
The marked activity reported of these compounds prompted us to study the in vitro sensitivity of a variety of organisms to sulfadiazine silver and sulfadiazine zinc in standard nutrient broth according to the technique of Fox et al.2 Fifty strains of P aeruginosa, and 15 strains each of Klebsiella, E coli, and S aureus isolated from burns and wound infec¬ tions were investigated. Sulfadiazine zinc did not inhibit the growth of any of these organisms even at 500 /ig/ml. Sulfadiazine silver, on the other hand, was active in the 20 to 40-"g/ml range for different organisms. Two strains of P aeruginosa were remarkably sensitive to this drug, with no visible
growth
even at 5 u,g/ml. The in vivo efficacy of sulfadiazine zinc noted in animal experiments might perhaps be attributable to zinc ions, which are required for wound healing and are toxic to microorga¬ nisms. In fact, when zinc was added to the in vitro test system in the form of ZnS04, 400 fig/ml of this metal brought about a total inhibition of most of the strains of P aeruginosa. In view of the role played by zinc in wound healing and its toxicity to microorganisms, sulfadiazine zinc is perhaps more suitable for topical application in burns as compared with sulfadiazine silver, since the silver ions not only do not participate in wound healing but may even be toxic to the host tissue. C. N. NAGESHA I. KARUNA SAGAR Mangalore, India 1. Fox CL: Silver sulfadiazine: A
therapy
new
topical
for Pseudomonas in burns. Arch Surg 96:184-188, 1968. 2. Fox CL Jr, Modak SM, Stanford JW: Zinc sulfadiazine for topical therapy of Pseudomonas infection in burns. Surg Gynecol Obstet 142:553\x=req-\ 559, 1976.
