A Tribute to Richard commendably, and with good Vineyard of Surgery.

to labour

in the ...

conscience to work

WILLIAM CLOWES (1544-1604) Maister in Chirurgerie and Chirurgeon to the Queen

Editorial Board and the many contributors and readers of the Archives of Surgery express warm and deepest gratitude to Richard Warren, MD, for his labors and leadership as Chief Editor for the past seven years. In his early years in this post, he bolstered and solidified the status of the journal. Readability, good papers, and a wide base of content were stressed by him. His disarming integrity and wonderful Yankee individualism provided for the Archives a uniqueness that we hope can be continued. He expressed himself on the editorial pages with clear, firm opinions and recommendations on a number of issues in surgery and introduced the departments of brief clinical notes and panels by correspondence, and the sections of editorial comments and abstracts. During his tenure, the Archives has prospered and enjoys an excellent reputation in the world of surgery. In the last several years, he has skillfully and courageously guided the journal through these difficult times for medical publications. When inflation sent publication costs soaring, when the tax-exempt status of scientific journals was questioned, when the financial stability of the Amer¬ ican Medical Association was threatened and the future of the Archives was in doubt, Dr Warren held fast. In characteristic fashion, he described this difficult period in an editorial in June 1975, stating, "At this moment in its history, the Archives is enjoying strong metabolic fluxes." He carried out his intent to retire only after restoring stability and assuring the publication's future. During these years, the Archives of Surgery has been privileged to be led by such a wonderful representative of one of the outstanding first families of American surgery. During our American Bicentennial period, it is particularly appropriate to recognize the contributions of the Warrens of Boston. In 1659 Peter Warren, a mariner, settled in the Roxbury section of Boston. He was the great grandfather of Joseph Warren (1741-1775), a physician and leader for

The appreciation

...

Warren, MD independence who gave his life in 1775 at the Battle of Bunker Hill as a general officer of the Revolutionary Army at the head of his troops. Joseph's brother, John Warren

a leader in the establishment of the medical institution of Harvard College, served as the first professor of anatomy and surgery of the school, and was a founder of the Massachusetts Medical Society. In the next generation, John Collins Warren (1778-1856) was also a professor of anatomy and surgery at the Harvard Medical School and cofounder and first surgeon of the Massachu¬ setts General Hospital. On Oct 16, 1846, he performed the historic and first public operation using ether anesthesia, in the Bullfinch Building of the Massachusetts General Hospital. For eight years he served as editor of the Boston Medical and Surgical Journal. He was followed by his son, Jonathan Mason Warren (1811-1867), who was a visiting surgeon at the Massachusetts General Hospital and intro¬ duced the art of plastic surgery in the United States. It was he who first performed a free transplant of human skin. In turn, his son, John Collins Warren (1842-1927), became a professor of surgery at Harvard Medical School and visi¬ ting surgeon at the Massachusetts General Hospital. John Collins Warren pioneered in bringing to the United States Lister's technique of healing without infection, and with Henry Bowditch brought the new Harvard Medical School into completion in 1906. His son, John Warren, born in 1874, was associate professor of anatomy at Harvard and contributed to the fundation on which all modern medicine and surgery is based. Richard Warren, born in 1907, is a grandson of John Collins Warren and the son of Joseph Warren, a distin¬ guished professor of law at Harvard. He attended Harvard College and received his MD degree from the Harvard Medical School in 1934. He served an internship at the Massachusetts General Hospital, followed by residency training at the Peter Bent Brigham Hospital. He has carried on and added luster to the tradition of his family not only by his many contributions to Harvard, to Boston, and to American surgery but also for the person that he is. During World War II, Dr Warren served with the 5th and 105th General Hospitals, being mustered out as a lieu¬ tenant colonel. His devotion to teaching and community service was recognized in his appointment as chief of the

(1753-1815), became

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surgical service of the Veterans Administration Hospital in West Roxbury in 1949, serving until 1962, following which he was put in charge of the cardiovascular surgical

division. He was named a member of the Board of Consul¬ tation of the Massachusetts General Hospital, surgeon at the Peter Bent Brigham Hospital, clinical professor of surgery at the Harvard Medical School, and, for a period, director of the Department of Surgery of the Cambridge Hospital. He played a major role in the development of the Veterans Administration programs and hospitals nation¬ ally and fostered the strong academic ties that have provided excellent care for veterans. He developed and edited the major textbook, Surgery, published in 1963, which was authored by him and his colleagues on the Harvard faculty. He also wrote a monograph, Procedures in Vascular Surgery, and made many valuable contribu¬ tions to the work on problems of amputation, rehabilitation and vascular disease. We salute Rich Warren: friend, colleague, statesman, an

American surgery.

patriot,

and

a

worker in the

vineyard of

In Appreciation to Robert Goldwyn, MD

In these endeavors with the Archives, Dr Warren has been assisted most ably by Robert M. Goldwyn, MD, also of Boston. As Assistant Chief Editor, Dr Goldwyn has provided valuable help in setting and maintaining editorial policy and thrust of the journal. He has also been Book Review Editor. We are grateful to Dr Goldwyn for his excellent contributions. ARTHUR E. BAUE, MD New Haven, Conn Reference 1. Churchill ED (ed): To Work in the of Collins Warren (1842-1927). sity Press, 1958.

cences

J.

Vineyard of Surgery: The ReminisCambridge, Mass, Harvard Univer-

If You Don't Know will

deny that the logical aphorism, "If you don't know," is true. Yet, in medicine we make assumptions and act accordingly when we do not know the underlying problem with certainty. If the patient's condition improves, our "clinical judgment" was correct; if not, we alter the therapy. In many clinical situations this type of deductive therapy is effective, since

know, No traditionally one

you don't

time exists to allow for trial and error. In these cases, studies involving invasive methods are not necessary. However, in critically ill patients, reliance on symptoms and signs to identify abnormal cardiorespiratory patterns may lead to wrong conclusions and do the patient a real disservice. In them, time is not available to alter therapy after failure becomes fully apparent. Critically ill patients with incipient or actual multiple organ-systems failure have little tolerance to anything but prompt, proper therapy. Wrong assumptions that can lead to incorrect therapy are not rare. For example, patients with multiple serious injuries or those with an acute or chronic illness who undergo major surgical procedures associated with a large blood loss, multiple transfusions, and prolonged anesthesia frequently become oliguric in the postoperative period. The most common cause of this is hypovolemia. The next is occult left ventricular failure, which I have found increas¬ ingly frequently, even in younger patients, particularly if there is unsuspected heart disease, sepsis, or if hypotension

has occurred. Acute renal failure is the third most common cause. It is far less frequent than prerenal failure, and may occur in the absence of known hypotension, transfusion reaction, or nephrotoxic drugs. Postrenal failure should always be considered, but rarely presents a diagnostic problem. Because measurements of blood loss may not be accurate and third space collections are not detectable, water balance and body weight measurements may not be helpful. Frequently a loop diuretic, eg, furosemide, is given to differentiate prerenal from renal failure, even though it is well known that for an inadequate urine response to indicate renal failure the circulating blood volume must be normal-one of the conditions that is to be determined. More importantly, if the patient was hypovolemic the diuresis will decrease the blood volume and the cardiac output further and contribute to organ-systems failure. The urine specific gravity may be helpful but is not always reliable. The osmolality or urea nitrogen urine/plasma ratio, or the creatinine clearance, are more definitive, but these take time and do not differentiate between the most common causes of oliguria: hypovolemia and occult cardiac failure. To illustrate, let me sketch a familiar sequence. The procedure of choice is an accurate central venous pressure (CVP) measurement.1 If it is not elevated, an intravenous infusion, appropriate for that clinical condition, is begun. If the CVP remains low and the urine output does not

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A tribute to Richard Warren, MD.

A Tribute to Richard commendably, and with good Vineyard of Surgery. to labour in the ... conscience to work WILLIAM CLOWES (1544-1604) Maister in...
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