influence of DIC is acute hepatic failAs supporting evidence, he refers to the article previously published in The Journal (216:1195,1971) in which endotoxins were identified in a pa¬ tient with fatal heat stroke who dem¬ onstrated modest evidence of DIC but frank hemorrhage necrosis of the liver at autopsy. This would seem to be rather speculative evidence at best, because in most patients with heat stroke, DIC is evident long be¬ fore there is evidence of liver injury. Indeed, it often appears in the ab¬ sence of evident liver injury. Jaundice occurs in 5% or less of patients with severe heat stroke, and severe hepatic necrosis in even fewer instances. In experimental studies conducted on human subjects, it has been shown that either artificially induced fever or exercise can activate mild DIC. This would appear to be physiological. On the other hand, in those pa¬ tients with extremely severe heat stroke with evident extensive tissue destruction, perhaps such heroic mea¬ sures would be warranted in an at¬ tempt to salvage life. Such evidence would include persistent anuria, muscle necrosis, electrocardiographic ure.
abnormalities, jaundice, persistent
cerebral dysfunction, and gross evi¬ dence of DIC. It should be emphasized that the use of intra-aortic steroids, bowel sterilization, and peritoneal dialysis would hardly be necessary in the ma¬ jority of patients with heat stroke who respond promptly to cooling. James P. Knochel, MD Dallas
Operability
in
Bronchogenic Carcinoma To the Editor.\p=m-\Numerousprognostic
factors have been evaluated in bronchogenic carcinoma, and Dr Stoloff has now considered identification of tumor in a stem bronchus as a contraindication for surgical intervention (227:299, 1974). Thus far, tumor size, cell type, lymphovascular invasion, and node involvement have been shown to be important prognostic factors.1-6 Indeed, node involvement is the basis of our present staging system.7 We are not aware of other studies correlating precise anatomic endobronchial location with nodal involvement and survival. Exact differentiation between main stem and peripheral bronchial tumor involvement is often difficult bronchoscopically, especially when dealing with lesions at
the upper lobe orifice and from information available in a retrospective series, such as Dr Stoloff's. Furthermore, if endobronchial location or distance from the carina proves to be
prognostically important,
one
must
remember the anatomic difference in length between the right (1 to 1.5 cm) and left (4 to 6 cm) main stem bronchi. For these reasons, we did not at¬ tempt to separate main stem from peripheral bronchial location in 104 recently seen patients, but simply confirmed that these tumors were vi¬ sualized and biopsy-proved through the rigid bronchoscope.8 Of these cases, 38% were clinically operable, and 26%, resectable. There were seven long-term, clinically cancer-free pa¬ tients; five were still alive at an aver¬ age of 48 months, and two were dead of other causes at 15 months and ten years after resection. In all seven cases of long-term survival, squamous cell lesions were present, while none of the 11 cases involving adenocarcinoma were resectable. The 30-day op¬ erative mortality was low at 2.5%, compared with 9.6% in Dr Stoloff's series. Our results would indicate that a positive endoscopie biopsy finding for bronchogenic carcinoma should not be used as an absolute criterion of nonresectability. With the very elderly patient, particularly one with adenocarcinoma, we might not be as enthu¬ siastic to explore following biopsy. One must remember that Dr Gra¬ ham's first pneumonectomy on Dr Gilmore had previously positive biopsy results for bronchogenic epidermoid carcinoma. Dr Gilmore lived more than 30 years following the pro¬ cedure and had positive nodes. Terry L. Gueldner, MD Medical Center Seattle G. Hugh Lawrence, MD Good Samaritan Hospital Portland, Ore
Virginia Mason
1. Feinstein AR, Gelfman NA, Yesner R: The diverse effects of histopathology on manifestations and outcome of lung cancer. Chest 66:225, 1974. 2. Higgins GA, Lawton R, Heilbrunn A, et al: Prognostic factors in lung cancer. Ann Thorac Surg 7:472,1969. 3. Kirsh MM, Prior M, Gago O, et al: The effect of histological cell type on the prognosis of patients with bronchogenic carcinoma. Ann Thorac Surg 13:303, 1972. 4. Slack NH, Chamberlain A, Bross IDJ: Predicting survival following surgery for bronchogenic carcinoma. Chest 62:433, 1972. 5. Shields TW: General Thoracic Surgery. Philadelphia, Lea & Febiger Publishers, 1972. 6. Wellons HA, Johnson G, Benson WR, et al: Prognostic factors in malignant tumors of the lung. Ann Thorac
Surg 5:228,
1968.
7. Carr
DT, Mountain CF: The staging of lung cancer. Semin Oncol 3:229, 1974. 8. Gueldner TL, Lawrence GH: Bronchoscopically biopsy-proven bronchogenic carcinoma: Prognostic implications. Am Surg, to be published.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/10/2015
Reply.\p=m-\DrsGueldner and Lawraise the question of operability on patients with an endoscopic biopsy-demonstrated cancer and state that they have observed seven long\x=req-\ term, clinically cancer-free patients among that group. My observations suggest that, in terms of long-term survival, a better discriminant could be obtained in their series were they In
rence
to isolate all cancers located within the main stem bronchi (227:299, 1974).
Using the date of roentgenographic detection as the date of entry into the study, the five-year survival for such persons was 2%. This meant one long\x=req-\ term survivor of 132 persons with main stem lesions, and this patient lived five years from the date of x-ray diagnosis, without a surgical resection. When one looks at persons with tumors distal to the main stem bronchus, such as those in peripheral bronchi, with bronchoscopic abnormalities other than the detection of a tumor, or persons with normal bronchoscopic findings, the cumulative five-year survival improves progressively.
I am hopeful that Drs Gueldner and Lawrence can further define their series of cases with respect to the lo¬ cation of bronchial tumors. If they were to separate those with main stem bronchial cancers from the re¬ mainder of the group, I believe they would find too poor a five-year sur¬ vival to justify attempts at curative surgery. On the basis of data avail¬ able, I must conclude that patients with main stem endobronchial carci¬ nomas have almost no chance of a five-year survival with current meth¬ ods of treatment and probably should not be subjected to attempts at cura¬ tive surgical procedures. I appreciate the opportunity of re¬ plying to this interesting letter. Irwin L. Stoloff, MD Jefferson Medical College
Philadelphia
Physostigmine and Anticholinergic Poisoning To the Editor.\p=m-\Iread with interest the article by Newton on the use of physostigmine salicylate in the treatment of tricyclic antidepressant poisoning (231:941, 1975). Newton concludes that in his series at a regional
poisoning treatment center, over\x=req-\ dosage with these drugs is a benign event and that the use of a specific antidote
was
treatment.
not indicated in its
His report, nevertheless, documents the rapid reversal of coma by physostigmine, confirming our results (230: 1433, 1974) and the results of others. We would object to Newton's conclusions for the following reasons: (1) Although there is a low incidence of fatality in this overdose situation, fatalities do occur and cannot be ignored. These fatalities are frequently in children or young adults and are due to cardiac arrhythmias or complications of coma, such as pneumonia. (2) The population reported in Newon's series includes no serious arrhythmias and no children, and no comment is made on the duration or expense of hospitalization or on the occurrence of complications such as pulmonary infections due to intuba¬ tion. (3) The complications reported as due to physostigmine, namely, in¬ creased salivation, bradycardia, and possibly a grand mal seizure, are not serious and can easily be controlled. It certainly is not clear that the grand mal seizure in the case reported was due to the physostigmine rather than the original intoxicant. Rumack (personal communication) has a series of more than 700 patients treated with physostigmine for anti-
cholinergic poisonings. Perhaps most impressive about his series is the
documented reversal of severe ven¬ tricular arrhythmias by physostig¬ mine. Finally, it should be noted that physostigmine is useful not only for the treatment of tricyclic antidepressant poisoning but for the re¬ versal of severe intoxication by a va¬ riety of drugs with anticholinergic
properties (Pediatrics 52:449, 1973). Furthermore, as in Newton's case 9,
failure of physostigmine to arousal in a presumably in¬ toxicated patient can serve as a diagnostic test, indicating another underlying neurologic or metabolic condition. Any annoying side effects from physostigmine (such as diar¬ rhea, increased secretions, or brady¬ cardia) can be quickly reversed with the
produce
peripherally acting anticholinergic agent such as propantheline bromide (Pro-Banthine) (not atropine, as Newton suggests; centrally acting at¬ ropine would potentiate the central nervous system effect of the original a
intoxicant).
We would agree with Newton that there is no need to use physostigmine routinely in the treatment of tricyclic antidepressant or other anticholiner¬ gic poisonings. The vast majority of
these patients are mildly intoxicated and will recover spontaneously. How¬ ever, we believe that physicians should be aware of the usefulness of this drug for diagnostic purposes and for the quick and effective reversal of coma in the patient with life-threat¬
ening arrhythmias nary complications.
or severe
pulmo¬
Bruce D. Snyder, MD University of Minnesota St Paul
Thank You, United States of America To the Editor.\p=m-\Permitme to thank the United States of America for what she has done for me. On Jan 7, 1967\x=req-\themiddle of winter in the United States\p=m-\alonely figure in summer jacket arrived at O'Hare Airport, Chicago, after about a 16-hour flight from hot and humid
The lonely figure was in the United States for a rotating internship, to be followed by a residency program in surgery. That lonely figure was I. After about eight years in the United States and passing through about three hospitals, I finally completed my surgical residency at St Mary's Hospital, Rochester, NY. After this, I had a 1 1/2-year fellowship for renal transplantation and hemodialysis at Bellevue and New York University Hospitals. During the course of my residency program, I obtained my Canadian Board certification (FRCS). I have just recently passed part 1 of the American Board examination. My wife, who also joined me while I was in the United States, obtained her master's degree in geography at Syracuse University and is now work¬ ing toward her PhD at Pittsburgh
Nigeria.
University. Even though
my life in the United completely smoothsailing, the fact is that anyone who is ready to work hard and persevere will always succeed in the United States of America; this is the mark of a great country. I am not saying that every¬ thing is perfect in the United States,
States
was
only
course,
in Heaven. that some
The United States of America—in
terms of education and other thingshas given my wife and me as much as, if not more than, my own country
could give
pensate for what that great country
did for me, but, even though I am not there now, I will always con¬ sider that country my second home. I intend to be a good United States' ambassador in my own little way, and for all I gained, I want to say, "Thank you very much, United States of
living
America."
Oluwole G. Ajao, MD,
Ibadan, Nigeria
FRCS(C)
Abbreviations To the Editor.\p=m-\Itseems to me that at the time that there are articles being considered (ABC), dutifully edited (DE), and found good (FG) for publication, an editor may show hesitation to interfere judiciously (HIJ), perhaps because he thinks his knowledge lacking (KL) compared with that of eminent members of national
organizations (MNO), and, therefore, for the sake of peace, quiet, and restraint (PQR), he sets the text in unaltered version (STUV), thus failing to act the wise xenogogue (WX) and meekly accepting the yoke of zeitgeist (YZ). ABC+DE+FG summary: cf MNO) \m=therefore\PQR \ar=r\STUV\m=ne\WX\m=therefore\YZ In
(HIJ \m=therefore\KL
.
Luke Harris, MD Summit, NJ
My initial instinct was to deny that alle¬ gation (DTA). But when I left "xenogogue" (XaG) alone editorially, forcing the reader to trace the word etymologically, I realized that I must plead guilty (G). The letter is not merely delightful but instructive: Dr. Harris has the courtesy to spell out each abbreviation the first time used. Other thors: please take note!—Ed.
au¬
not
perfection is expected Nevertheless, I am sure people would have something to complain about even if they resided in paradise! but, of
my country will benefit from my sur¬ so they also owe a lot to the United States. There is nothing I can do to com¬
gical training,
me.
Thousands of
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/10/2015
people in
Inappropriate Coining of Word. In the
ORIGINAL
CONTRIBUTION, "Pro-
grammed "Trendscription': A New Approach to Electrocardiographic Monitoring," published in the April 7
issue (232:39-43,1975), the neologism "trendscription" should not have been coined or used in the title and text. "Trendscriber" is a trademark of American Optical Corporation, and it has filed an application for registration of the trademark.
abnormalities, jaundice, persistent
cerebral dysfunction, and gross evi¬ dence of DIC. It should be emphasized that the use of intra-aortic steroids, bowel sterilization, and peritoneal dialysis would hardly be necessary in the ma¬ jority of patients with heat stroke who respond promptly to cooling. James P. Knochel, MD Dallas
Operability
in
Bronchogenic Carcinoma To the Editor.\p=m-\Numerousprognostic
factors have been evaluated in bronchogenic carcinoma, and Dr Stoloff has now considered identification of tumor in a stem bronchus as a contraindication for surgical intervention (227:299, 1974). Thus far, tumor size, cell type, lymphovascular invasion, and node involvement have been shown to be important prognostic factors.1-6 Indeed, node involvement is the basis of our present staging system.7 We are not aware of other studies correlating precise anatomic endobronchial location with nodal involvement and survival. Exact differentiation between main stem and peripheral bronchial tumor involvement is often difficult bronchoscopically, especially when dealing with lesions at
the upper lobe orifice and from information available in a retrospective series, such as Dr Stoloff's. Furthermore, if endobronchial location or distance from the carina proves to be
prognostically important,
one
must
remember the anatomic difference in length between the right (1 to 1.5 cm) and left (4 to 6 cm) main stem bronchi. For these reasons, we did not at¬ tempt to separate main stem from peripheral bronchial location in 104 recently seen patients, but simply confirmed that these tumors were vi¬ sualized and biopsy-proved through the rigid bronchoscope.8 Of these cases, 38% were clinically operable, and 26%, resectable. There were seven long-term, clinically cancer-free pa¬ tients; five were still alive at an aver¬ age of 48 months, and two were dead of other causes at 15 months and ten years after resection. In all seven cases of long-term survival, squamous cell lesions were present, while none of the 11 cases involving adenocarcinoma were resectable. The 30-day op¬ erative mortality was low at 2.5%, compared with 9.6% in Dr Stoloff's series. Our results would indicate that a positive endoscopie biopsy finding for bronchogenic carcinoma should not be used as an absolute criterion of nonresectability. With the very elderly patient, particularly one with adenocarcinoma, we might not be as enthu¬ siastic to explore following biopsy. One must remember that Dr Gra¬ ham's first pneumonectomy on Dr Gilmore had previously positive biopsy results for bronchogenic epidermoid carcinoma. Dr Gilmore lived more than 30 years following the pro¬ cedure and had positive nodes. Terry L. Gueldner, MD Medical Center Seattle G. Hugh Lawrence, MD Good Samaritan Hospital Portland, Ore
Virginia Mason
1. Feinstein AR, Gelfman NA, Yesner R: The diverse effects of histopathology on manifestations and outcome of lung cancer. Chest 66:225, 1974. 2. Higgins GA, Lawton R, Heilbrunn A, et al: Prognostic factors in lung cancer. Ann Thorac Surg 7:472,1969. 3. Kirsh MM, Prior M, Gago O, et al: The effect of histological cell type on the prognosis of patients with bronchogenic carcinoma. Ann Thorac Surg 13:303, 1972. 4. Slack NH, Chamberlain A, Bross IDJ: Predicting survival following surgery for bronchogenic carcinoma. Chest 62:433, 1972. 5. Shields TW: General Thoracic Surgery. Philadelphia, Lea & Febiger Publishers, 1972. 6. Wellons HA, Johnson G, Benson WR, et al: Prognostic factors in malignant tumors of the lung. Ann Thorac
Surg 5:228,
1968.
7. Carr
DT, Mountain CF: The staging of lung cancer. Semin Oncol 3:229, 1974. 8. Gueldner TL, Lawrence GH: Bronchoscopically biopsy-proven bronchogenic carcinoma: Prognostic implications. Am Surg, to be published.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/10/2015
Reply.\p=m-\DrsGueldner and Lawraise the question of operability on patients with an endoscopic biopsy-demonstrated cancer and state that they have observed seven long\x=req-\ term, clinically cancer-free patients among that group. My observations suggest that, in terms of long-term survival, a better discriminant could be obtained in their series were they In
rence
to isolate all cancers located within the main stem bronchi (227:299, 1974).
Using the date of roentgenographic detection as the date of entry into the study, the five-year survival for such persons was 2%. This meant one long\x=req-\ term survivor of 132 persons with main stem lesions, and this patient lived five years from the date of x-ray diagnosis, without a surgical resection. When one looks at persons with tumors distal to the main stem bronchus, such as those in peripheral bronchi, with bronchoscopic abnormalities other than the detection of a tumor, or persons with normal bronchoscopic findings, the cumulative five-year survival improves progressively.
I am hopeful that Drs Gueldner and Lawrence can further define their series of cases with respect to the lo¬ cation of bronchial tumors. If they were to separate those with main stem bronchial cancers from the re¬ mainder of the group, I believe they would find too poor a five-year sur¬ vival to justify attempts at curative surgery. On the basis of data avail¬ able, I must conclude that patients with main stem endobronchial carci¬ nomas have almost no chance of a five-year survival with current meth¬ ods of treatment and probably should not be subjected to attempts at cura¬ tive surgical procedures. I appreciate the opportunity of re¬ plying to this interesting letter. Irwin L. Stoloff, MD Jefferson Medical College
Philadelphia
Physostigmine and Anticholinergic Poisoning To the Editor.\p=m-\Iread with interest the article by Newton on the use of physostigmine salicylate in the treatment of tricyclic antidepressant poisoning (231:941, 1975). Newton concludes that in his series at a regional
poisoning treatment center, over\x=req-\ dosage with these drugs is a benign event and that the use of a specific antidote
was
treatment.
not indicated in its
His report, nevertheless, documents the rapid reversal of coma by physostigmine, confirming our results (230: 1433, 1974) and the results of others. We would object to Newton's conclusions for the following reasons: (1) Although there is a low incidence of fatality in this overdose situation, fatalities do occur and cannot be ignored. These fatalities are frequently in children or young adults and are due to cardiac arrhythmias or complications of coma, such as pneumonia. (2) The population reported in Newon's series includes no serious arrhythmias and no children, and no comment is made on the duration or expense of hospitalization or on the occurrence of complications such as pulmonary infections due to intuba¬ tion. (3) The complications reported as due to physostigmine, namely, in¬ creased salivation, bradycardia, and possibly a grand mal seizure, are not serious and can easily be controlled. It certainly is not clear that the grand mal seizure in the case reported was due to the physostigmine rather than the original intoxicant. Rumack (personal communication) has a series of more than 700 patients treated with physostigmine for anti-
cholinergic poisonings. Perhaps most impressive about his series is the
documented reversal of severe ven¬ tricular arrhythmias by physostig¬ mine. Finally, it should be noted that physostigmine is useful not only for the treatment of tricyclic antidepressant poisoning but for the re¬ versal of severe intoxication by a va¬ riety of drugs with anticholinergic
properties (Pediatrics 52:449, 1973). Furthermore, as in Newton's case 9,
failure of physostigmine to arousal in a presumably in¬ toxicated patient can serve as a diagnostic test, indicating another underlying neurologic or metabolic condition. Any annoying side effects from physostigmine (such as diar¬ rhea, increased secretions, or brady¬ cardia) can be quickly reversed with the
produce
peripherally acting anticholinergic agent such as propantheline bromide (Pro-Banthine) (not atropine, as Newton suggests; centrally acting at¬ ropine would potentiate the central nervous system effect of the original a
intoxicant).
We would agree with Newton that there is no need to use physostigmine routinely in the treatment of tricyclic antidepressant or other anticholiner¬ gic poisonings. The vast majority of
these patients are mildly intoxicated and will recover spontaneously. How¬ ever, we believe that physicians should be aware of the usefulness of this drug for diagnostic purposes and for the quick and effective reversal of coma in the patient with life-threat¬
ening arrhythmias nary complications.
or severe
pulmo¬
Bruce D. Snyder, MD University of Minnesota St Paul
Thank You, United States of America To the Editor.\p=m-\Permitme to thank the United States of America for what she has done for me. On Jan 7, 1967\x=req-\themiddle of winter in the United States\p=m-\alonely figure in summer jacket arrived at O'Hare Airport, Chicago, after about a 16-hour flight from hot and humid
The lonely figure was in the United States for a rotating internship, to be followed by a residency program in surgery. That lonely figure was I. After about eight years in the United States and passing through about three hospitals, I finally completed my surgical residency at St Mary's Hospital, Rochester, NY. After this, I had a 1 1/2-year fellowship for renal transplantation and hemodialysis at Bellevue and New York University Hospitals. During the course of my residency program, I obtained my Canadian Board certification (FRCS). I have just recently passed part 1 of the American Board examination. My wife, who also joined me while I was in the United States, obtained her master's degree in geography at Syracuse University and is now work¬ ing toward her PhD at Pittsburgh
Nigeria.
University. Even though
my life in the United completely smoothsailing, the fact is that anyone who is ready to work hard and persevere will always succeed in the United States of America; this is the mark of a great country. I am not saying that every¬ thing is perfect in the United States,
States
was
only
course,
in Heaven. that some
The United States of America—in
terms of education and other thingshas given my wife and me as much as, if not more than, my own country
could give
pensate for what that great country
did for me, but, even though I am not there now, I will always con¬ sider that country my second home. I intend to be a good United States' ambassador in my own little way, and for all I gained, I want to say, "Thank you very much, United States of
living
America."
Oluwole G. Ajao, MD,
Ibadan, Nigeria
FRCS(C)
Abbreviations To the Editor.\p=m-\Itseems to me that at the time that there are articles being considered (ABC), dutifully edited (DE), and found good (FG) for publication, an editor may show hesitation to interfere judiciously (HIJ), perhaps because he thinks his knowledge lacking (KL) compared with that of eminent members of national
organizations (MNO), and, therefore, for the sake of peace, quiet, and restraint (PQR), he sets the text in unaltered version (STUV), thus failing to act the wise xenogogue (WX) and meekly accepting the yoke of zeitgeist (YZ). ABC+DE+FG summary: cf MNO) \m=therefore\PQR \ar=r\STUV\m=ne\WX\m=therefore\YZ In
(HIJ \m=therefore\KL
.
Luke Harris, MD Summit, NJ
My initial instinct was to deny that alle¬ gation (DTA). But when I left "xenogogue" (XaG) alone editorially, forcing the reader to trace the word etymologically, I realized that I must plead guilty (G). The letter is not merely delightful but instructive: Dr. Harris has the courtesy to spell out each abbreviation the first time used. Other thors: please take note!—Ed.
au¬
not
perfection is expected Nevertheless, I am sure people would have something to complain about even if they resided in paradise! but, of
my country will benefit from my sur¬ so they also owe a lot to the United States. There is nothing I can do to com¬
gical training,
me.
Thousands of
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/10/2015
people in
Inappropriate Coining of Word. In the
ORIGINAL
CONTRIBUTION, "Pro-
grammed "Trendscription': A New Approach to Electrocardiographic Monitoring," published in the April 7
issue (232:39-43,1975), the neologism "trendscription" should not have been coined or used in the title and text. "Trendscriber" is a trademark of American Optical Corporation, and it has filed an application for registration of the trademark.
