Jacques Lisfranc 1790–1847

Jacques Lisfranc was born in Saint-Paul-Jarrest (Loire), France, April 2nd, 1790, the son of a physician. Early in his youth he demonstrated a particular interest and aptitude for the field of medicine as he observed and commented upon his father's ministrations to his patients. He accomplished his preliminary studies at the Lyceum in Lyons and then went to Paris to continue his medical training at the Hôtel-Dieu. It was there that he came under the tutelage of Dupuytren. It was soon said that Lisfranc was at least as worthy as his superior. Later the two men developed a certain animosity toward each other which became manifest rather severely in the medical political arenas of the time. Lisfranc received his doctorate of medicine in 1812 at a time that France was involved in the Napoleonic wars. He was commissioned as a surgeon and distinguished himself in campaigns in Saxony and in France. Following the war he established his practice in Paris. Fortuitously, one day Lisfranc rescued a magistrate who fell from his horse. By this serendipitous meeting Lisfranc was invited to join the faculty of medicine at the Hospital of Pity. He rose rapidly to chief of surgery and developed the reputation of being extremely competent, truly a master surgeon. For over 20 years he was affiliated with that institution and wrote numerous articles on such diverse subjects as shoulder disarticulation, the application of the stethoscope in the diagnosis of fractures, and on diseases of the uterus. In addition, he wrote two books which were well received—one onSurgery at the Hospital of Pity and the other onOperative Medicine. ThisClassics presentation has been selected because it has been generally attributed that Lisfranc was the first person to remove a cancerous tumor from the rectum. The technique involves essentially a transanal approach. As was the custom of the day, the report appears as narrated presumably by one of his assistants. Among the many distinctions Lisfranc achieved, he was founding member and ultimately President of the French Academy of Medicine and Chevalier of the Legion of Honor. Lisfranc developed an enormous clinical practice, and in spite of many physical infirmities he persisted in his surgery until the day of his death, May 12, 1847, at the age of 57.     

Anatomic Location of the Tongue Base Neurovascular Bundle

Knowledge of the location of the hypoglossal/lingual artery neurovascular bundle (HLNVB) is essential in performing tongue base resections for neoplasm and for obstructive sleep apnea. Transoral and transcervical resections of the tongue base may be performed with greater exposure and certainty when the relationship of the HLNVB to local landmarks is understood; knowledge of the HLNVB allows resection of a larger amount of contralateral tongue base during partial glossectomy without violating the contralateral remnant tongue's blood supply. Ten cadaver heads were dissected to determine the position of the HLNVB with respect to soft tissue and bony landmarks at the tongue base. Our results indicate the position of the tongue base HLNVB is significantly inferior and lateral, that is, 2.7 cm inferior and 1.6 cm lateral to the foramen cecum, 0.9 cm superior to the hyoid bone, and 2.2 cm medial to the mandible. This inferolateral location allows the potential for aggressive tongue base resection without neurovascular compromise.     

Complications of combined radical hysterectomy and pelvic radiation

Long-term gastrointestinal (GI) and urinary tract (UT) complications were evaluated in 48 women treated by radical hysterectomy (RH) and pelvic node dissection (PND) and in 25 women who received 5000–5400 rad of external pelvic radiation (RT) after RH-PND. No major complications developed in the surgery-only group, but the 5-year minor GI complication rate was 4% and the 5-year minor UT complication rate was 10%. In 9 patients receiving RT at 200 rad/day, one major GI complication (13%) and one major UT complication (14%) developed. In 16 patients receiving RT at 180 rad/day only minor GI complications (7%) and minor UT complications (13%) developed. The conclusion is that after RH-PND, adjunctive RT delivered at 180 rad/day through four ports results in acceptable, minimal complications.     

Percutaneous Absorption of Nicardipine and Ketorolac in Rhesus Monkeys

Vehicle effects on the percutaneous absorption of nicardipine base, nicardipine hydrochloride, ketorolac acid, and ketorolac tromethamine were determined using the rhesus monkey as an in vivo model for human skin penetration. Vehicles investigated included blends of propylene glycol, trimethylene glycol, ethanol, Azone, Tween 20, water, and long-chain fatty acids. Formulations were prepared such that the compound dose, application area, and percentage saturation of the compound in the vehicle were held constant. Variations in absorption of the compounds were therefore attributable to vehicle effects. Each formulation was applied to three monkeys for a period of 24 hr using 10 Hill Top Chambers. Plasma samples were taken at appropriate intervals for 36 to 48 hr. The results indicated that trimethylene glycol and Tween 20 did not enhance absorption of the test compounds despite claims by other investigators. Azone and ethanol provided moderate enhancement of both the rate and the extent of absorption, while long-chain fatty acids in combination with propylene glycol significantly enhanced penetration. In general, higher fluxes were observed with the more lipophilic compounds nicardipine base and ketorolac acid as compared to the hydrochloride and tromethamine salts.     

Cerebrospinal fluid lactate and pyruvate concentrations and their ratio

ObjectivesDeterminations of cerebrospinal fluid (CSF) lactate and pyruvate concentrations and CSF lactate:pyruvate (L/P) ratios are important in several clinical settings, yet published normative data have significant limitations. We sought to determine a large dataset of stringently-defined normative data for CSF lactate and pyruvate concentrations and CSF L/P ratios.Design and methodsWe evaluated data from 627 patients who had determinations of CSF lactate and/or CSF pyruvate from 2001 to 2011 at the Cleveland Clinic. Inclusion in the normal reference population required normal CSF cell counts, glucose and protein and routine serum chemistries and absence of progressive brain disorder, epilepsy, or seizure within 24 h. Brain MRI, if done, showed no evidence of tumor, acute changes or basal ganglia abnormality. CSF cytology, CSF alanine and immunoglobulin levels, and oligoclonal band analysis were required to be normal, if done. Various inclusion/exclusion criteria were compared.Results92 patients fulfilled inclusion/exclusion criteria for a reference population. The 95% central intervals (2.5%–97.5%) for CSF lactate and pyruvate levels were 1.01–2.09 mM and 0.03–0.15 mM, respectively, and 9.05–26.37 for CSF L/P. There were no significant gender-related differences of CSF lactate or pyruvate concentrations or of CSF L/P. Weak positive correlations between the concentration of CSF lactate or pyruvate and age were noted.ConclusionsUsing stringent inclusion/exclusion criteria, we determined normative data for CSF lactate and pyruvate concentrations and CSF L/P ratios in a large, well-characterized reference population. Normalcy of routine CSF and blood analytes are the most important parameters in determining reference intervals for CSF lactate and pyruvate.     

Hypnotically induced amnesia versus ablation of memory

33 hypnotizable Ss, all capable of achieving the criterion of amnesia for a 7-digit number, were divided into 3 groups: 2 hypnotized and 1 pretend. The distributions of errors for an amnesic performance of these groups were compared with the theoretical chance distribution of errors expected in an amnesic performance. Both hypnotized groups differed signiticantly from the pretend group and from the theoretical distribution, while the performance of the pretend group did not differ significantly from the chance distribution. The performance of the pretend group conformed to the expectancy for amnesia significantly better than did the performance of either of the hypnosis groups.