ment that such programs would offer

Postgraduate Training in the United Foreign Medical Graduates

States for

To the Editor.\p=m-\Havingbeen responsible for the teaching of medical

students and residents in the field of surgery for some 20 years, I have studied in detail the article entitled

"Surgical Manpower" (Arch Surg 108:637, 1974). There is no question that the problem of the foreign medical graduate is a very major one as it concerns the United States. However, as it concerns

the countries from which these

foreign medical graduates come, and I am thinking primarily of the so\x=req-\ called developing countries, it is a sheer disaster. It has been estimated

by some that up to 40% of recent graduates from a single medical college here in India have gone abroad. There is no question that these physicians are needed in their home coun-

try. Furthermore, frequently the

training they receive abroad is not pertinent to the conditions they will be facing when and if they return to

their home country. I believe that there are many ways in which the "developed" countries can better contribute to the develop¬ ment of medicine in the so-called de¬ veloping nations. Basically what is needed is an exchange type of pro¬ gram or an affiliation that will allow physicians who are already estab¬ lished and on the permanent staff of institutions in the developing nations to obtain short periods of suitable training abroad. However, it is in¬ creasingly difficult to find institutions in America that will recognize the need for this and will take established physicians and surgeons for short pe¬ riods of training with the under¬ standing that they will return to their country of origin. I believe that such physicians should be permitted to go abroad for no more than a year and should probably go as exchange visitors. I personally believe that or¬ ganizations such as the American College of Surgeons could perform an excellent service to both the United States and the developing nations if

the best form of continuing education for physicians from developing na¬ tions. In a very real sense, this would be a true partnership of srreat value. F.C. EGGLESTON, MD

Ludhiana, Punjab India

Defunctionalizing

a

Colostomy

To the Editor.\p=m-\Increasing use of stapling devices has prompted us to devise a simplified method for performing a defunctionalizing colos-

tomy.

Often the loop colostomy is employed by the surgeon as a compromise for complete fecal diversion in sick patients because of its simplicity, efficiency, and lack of complications. The technique we use converts this to

completely diverting colostomy by bringing out a loop of bowel through the abdominal wall; placement of a glass rod below the loop of bowel through an avascular segment of mesentery and onto the abdominal wall; ligation of the distal part of the bowel a

with the 30-

or

55-mm automatic sta-

pler (Figure, A); and formation of the A, Ligation of distal part of bowel with 30- or 55-mm automatic stapler. B, Formation of proximal limb stoma by opening bowel wall with cautery 24 to 48 hours postoperatively.

they were to serve as a clearinghouse

for such programs. I have discussed this type of pro¬ gram with many physicians and sur¬ geons here in India, both expatriates and nationals. They are all in agree-

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limb stoma by opening the bowel wall with a cautery 24 to 48 hours postoperatively (Figure, B). A distal stoma may be created if distal decompression becomes necessary. We have used this technique in pa¬ tients with the surgical complications of sigmoid diverticulitis. RICHARD F. BRODMAN, MD HAROLD R. BRODMAN, MD Bronx, NY

proximal

Hemoptysis: Iatrogenic Aortobronchial Fistula

Occult

Editor.\p=m-\Hemoptysisis quite in primary pulmonary disorders, including carcinoma and tuberculosis, as well as in mitral stenosis. Recently, we had the opportunity to evaluate and repair a unique To the

common

additional cause that shows the need for exhaustive evaluation when the hemoptysis is occult in nature. A 56-year-old farmer had a two\x=req-\ month history of intermittent, bright hemoptysis, initiated by exercise. He was otherwise asymptomatic and had a 40-pack year history of smoking. Aside from a hemoglobin value of 9.2 gm/100 ml, results of an extensive battery of laboratory tests, including sputum cytology and cultures, were normal. The chest roentgenogram showed mild cardiomegaly and clear lung fields, consistent with prior catheterization-documented mild aortic insufficiency. He had undergone an uneventful repair of a coarctation of the aorta seven years earlier. Results of bronchography were normal, but fiberoptic bronchoscopy showed blood in the apical-posterior segment of the left upper lobe. An aortobronchial fistula from the coarctation repair was postulated and shown by aortography. This was successfully repaired by di¬ rect closure of the involved aorta and left upper lobectomy. No mycotic an¬ eurysm was found, and the patient remains asymptomatic over a 12month follow-up. The importance of an exhaustive evaluation for occult hemoptysis is emphasized by this case. Entrapment of the peripheral lung with a subse¬ quent chronic erosion following co¬ arctation repair, not the initially

suspected carcinoma, represented a unique, but repairable cause in this

oatient.

GERARD S. KAKOS, MD YASH P. KATARIA, MD JOHN S. VASKO, MD Columbus, Ohio