Perspectives of rural surgical practice in Georgia.

The decline of rural surgery is a cause of great concern. In an attempt to identify the decisive factors involved in entering and maintaining a rural practice of general surgery, information was solicited by questionnaire from Georgia surgeons practicing in communities with a population less than 25,000. Some of the issues were availability of ancillary services, number of procedures performed, perceived problems affecting practice, relationship with their principal hospital, and satisfaction with practice and lifestyle. Only responses from residency-trained surgeons or Fellows of the American College of Surgeons were used for analysis. This study identified both the assets and the liabilities of rural surgical practice. If the rural surgeon is to be preserved in the USA, all surgeons must be made aware of the problems encountered in a rural surgical practice and aid in the search for solutions.

Median sternotomy.

Although median sternotomy was succinctly described in 1897, "Milton's procedure" was essentially unused until it was recommended in 1957. With the advent of coronary bypass operation in 1968, median sternotomy became one of the most commonly performed surgical procedures. Even with the increasing use of median sternotomy for cardiac operations, thoracic surgeons have been reluctant to apply this operative modality in their practice. This is understandable because most pulmonary problems present in a distinctly unilateral manner and the tendency of most thoracic surgeons is to avoid median sternotomy in favor of the more familiar lateral thoracotomy. However, with the increasing use of CT scans of the chest, more patients with bilateral pulmonary pathologic factors are being identified. Median sternotomy is ideally applicable to this patient group for preservation of pulmonary function and for diminishing patient discomfort. Certainly, median sternotomy is infinitely preferable to staged bilateral thoracotomy if the same therapeutic goals can be accomplished. Younger thoracic surgeons who are trained in cardiac operation are less reluctant to use median sternotomy in the treatment of noncardiac disorders. This factor may account for the recent reports of increased usage of median sternotomy. It is a very natural tendency to use that with which one is familiar. Nonetheless, median sternotomy, other than for cardiac operation, is currently underused. The situation may ultimately be corrected as the use of median sternotomy is more fully appreciated. This relatively atraumatic, nonmuscle dividing approach to the anterior mediastinum, heart, lungs, diaphragm, pleural cavities, aortic arch and great vessels and liver deserves to be seriously considered as an appropriate alternative to more familiar, but more traumatic, approaches.

H. Milton: visionary surgeon.

Current wisdom holds that median sternotomy is the creation of cardiac surgeons as the premier approach to the heart. In fact, this innovative and resourceful procedure was perfected by an obscure English surgeon in Cairo, Egypt (U.A.R.), in 1897. H. Milton designed a vertical sternal-splitting approach for the excision of tuberculous mediastinal nodes and employed it successfully in a patient. Modern medicine owes a great debt to H. Milton for this significant, albeit unrecognized, contribution. The details of the life of this unsung surgeon, such as are known, are presented.

Naming the bronchopulmonary segments and the development of pulmonary surgery.

An international agreement on bronchial nomenclature and anatomy was not reached until well after operations for bronchopulmonary segmental disease were well developed. R. C. Brock, in 1950, was the reporter of the efforts of The Thoracic Society of Great Britain to bring some order to this confused state. This Society delayed its action until an ad hoc committee made up of members from other countries and specialties met at the International Congress of Otorhinolaryngology in 1949. The anatomy and nomenclature of the bronchopulmonary segments was agreed upon. The Thoracic Society then accepted the report of the ad hoc committee. The system was followed closely by the first Nomina Anatomica in 1955. This report did not open new surgical vistas but was the marker indicating that pulmonary surgery was now mature.

Julian's reintroduction of Milton's operation.

Four years after the first successful open heart operation in 1953, most cardiac surgeons were using bilateral anterior thoracotomy. This tedious, time-consuming, complication-prone, painful procedure was abandoned only after Julian and associates demonstrated the marked superiority of median sternotomy. Although median sternotomy was described by Milton in 1897, it was a seldom-used procedure at the time of Julian and associates' publication in 1957. The present-day routine use of median sternotomy for virtually all cardiac operations is a testimonial to the foresight and practicality of Julian's experience.