Pictures of Episcopal hospital, Philadelphia, PA: part I (1851-1926).

The merit of images, often posed, often retouched, as historical documents has been debated by numerous scholars. Nonetheless, portraits, illustrations, and photographs form one of the more delightful avenues for recapturing elements of medical care as it was practiced in the past. Part one of this two-part photo-essay records the first cycles of growth and contraction that characterized the history of one of Philadelphia's foremost medical institutions: The Hospital of the Protestant Episcopal Church of Philadelphia.

Mechanical reliability, surgical complications, and patient and partner satisfaction of the modern three-piece inflatable penile prosthesis.

OBJECTIVES: The modern three-piece inflatable penile prosthesis (IPP) has undergone multiple revisions since its introduction in 1973. We reviewed devices placed since the last major revision by American Medical Systems (AMS) in 1987. METHODS: A retrospective chart review was refined with data from an independent patient and partner survey. RESULTS: Two hundred twelve consecutive penile prosthetic devices placed by a single surgeon over an 8-year period are reviewed. One hundred sixty-nine of the devices were three-piece inflatables with 146 being primary implants. The average device has been in place 36.5 months (range 9 to 102). The infection rate in 146 primary three-piece devices was 2.1%. The infection rate in 46 secondary implants or revisions was 6.5%, excluding seven salvage attempts. Mechanical failure in 122 primary AMS devices placed was 4.1%. Mechanical failure in 24 Mentor devices was 4.2% if one discounts connector failures that were revised in 1990. A surgical complication and revision rate of 1.4% was noted in the 146 primary implants. An independent telephone survey achieved a 57% and 24% response rate in patients and partners with three-piece devices placed. In the group of 86 patients with a primary three-piece device placed and complete follow-up, the probability of having a normally functioning device placed in a single operative procedure was 90.6% at 3 years. On a 1 to 10 scale looking at all primary devices, secondary devices, revisions, and infections, the average and median satisfaction rate was as follows: 8.2, 8.5; 8.4, 9.0; 7.7, 7.75 for the Ultrex patients, CX 700 and Mentor patients, and all partners, respectively. CONCLUSIONS: The modern three-piece IPP is an excellent surgical option offering a very safe, reliable return to sexual activity for our patients.

Back-pressure testing to prevent autoinflation of penile prosthetic devices.

Autoinflation of a penile prosthetic device can be a frustrating experience for the patient and surgeon alike. Although there are many causes of autoinflation, elevated reservoir pressure at the time of surgical placement is one of the more common etiologies. We describe a simple, quick technique to quantitate reservoir pressures and volume, preventing pressures that could lead to autoinflation.

Endocrine screening for sexual dysfunction using free testosterone determinations.

PURPOSE: Controversy exists concerning the need for routine endocrine screening in impotent men. Debate also continues as to what hormonal studies are necessary, the role of the free fraction of testosterone and whether a history of decreased libido or testicular atrophy can predict these endocrinopathies. MATERIALS AND METHODS: We reviewed 508 consecutive men who presented with sexual dysfunction within a 22-month period. Testosterone data were available for 268 patients (53%) and prolactin data were available for 170 (33%). RESULTS: Hypogonadism, defined as 2 abnormal total testosterone levels, was found in 42 of our 268 patients (15.6%). A history of decreased libido by patient questionnaire and/or testicular atrophy on physical examination could not predict these cases. A normal free fraction of testosterone saved further unnecessary endocrine evaluation in 50% of patients with hypogonadism. Hypoprolactinemia was noted in 3 of 170 patients (1.8%). CONCLUSIONS: Routine endocrine screening remains a necessary part of the evaluation for sexual dysfunction. A history of decreased libido and/or testicular atrophy on physical examination cannot predict hypogonadism. Measurement of free fraction of testosterone will further lessen unnecessary endocrine evaluations by 50% and should become standard practice in screening for hypogonadism. Prolactin levels are necessary only in patients with hypogonadism and/or a history of decreased libido.

Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Manometric study of the voluntary inhibition action in normal volunteers.

PURPOSE: A voluntary inhibition action whereby a voluntary squeeze of the external sphincter causes reflex relaxation of the rectum has been previously proposed but not proven. Such a reflex would enable the subject to defer defecation to a socially acceptable time. The purpose of this study was to determine whether or not such a reflex exists. METHODS: We measured rectal compliance with and without a voluntary squeeze using a specially designed balloon catheter in nine subjects. RESULTS: When corrected for increased intra-abdominal pressure caused by inadvertent Valsalva's maneuver during voluntary squeezing, there was a significant increase in rectal compliance during voluntary contraction of the external sphincter (P < 0.01). CONCLUSION: This lends support to the proposed existence of the voluntary inhibition action.

Oral terbutaline for the treatment of priapism.

The widespread use of penile injections in the management of erectile dysfunction has led to an increased incidence of priapism. It has been suggested that terbutaline, a beta-agonist, might be beneficial in treating priapism in this setting. We randomized 24 patients with prolonged erections to a prospective, double-blind, placebo-controlled trial. We did not find any benefit of oral terbutaline over placebo in these patients.

Experience with triple-drug therapy in a pharmacological erection program.

A group of 170 impotent men achieved usable erections during a 26-month period with a combination of papaverine, phentolamine and prostaglandin E1 (triple-drug therapy) injected intracorporeally. Of the patients 146 elected to enter a pharmacological erection program using this combination. Patient age ranged from 24 to 85 years and the average duration on the program was 11.2 months. Average injection volume was 0.36 cc per injection (range 0.1 to 1). Among those patients managed by our nurse clinician, only 3 episodes of priapism were encountered (1.7%). Scarring was documented in 7 of 170 patients (4.2%) 1 week to 21 months after starting the injections. Pain was encountered in 6 of 170 patients (3.5%). A superior dose response coupled with a low incidence of priapism, pain and scarring have led us to use triple-drug therapy as our agent of choice in the pharmacological management of erectile dysfunction.

Pressure sores. How to prevent and treat them.

The consequences of immobility among hospitalized and bedridden patients, especially the elderly, can be devastating if pressure sores develop. Such sores are not only painful for the patient and expensive to manage, but they are potentially life-threatening. What can be done to prevent them? Which patients are most vulnerable? The authors address these questions and discuss treatment options.

Survival after resection of carcinoma of the splenic flexure.

Nine hundred ten patients undergoing colectomy for colon cancer were studied retrospectively. Seventy-four cancers (8 percent) were located at the splenic flexure. The stage at presentation was no different between splenic flexure cancers and colon carcinomas at other sites. Although splenic flexure cancers had twice the incidence of obstruction as did other colon cancers and obstruction in the overall series adversely affected survival, there was no difference in survival between splenic flexure cancer patients and patients with other colon cancers.

Colonoscopy in critically ill patients. What conditions call for it?

Indications for colonoscopy in the intensive care unit include acute lower intestinal bleeding, sigmoid volvulus, pseudo-obstruction of the colon, and suspicion of pseudomembranous colitis. Although the incidence of cardiorespiratory complications may be higher in these critically ill patients, the procedure can be done safely with proper attention to detail. Because of colonic dilatation, endoscopy can often be done without bowel preparation.

Surgical treatment of anorectal fistula in patients with Crohn's disease.

Forty-seven patients with Crohn's disease were operated upon for fistula in ano during a 22 year period with an average follow-up time of 82 months. In 29 of the patients, the fistulotomy or fistulectomy wound healed primarily; in 37, a state of complete healing or minimal disability, sometimes after multiple fistulotomies, was achieved. Five patients required proctectomy, but the need for removal of the anorectum was not caused by surgical treatment of the fistula in any instance. Of the 31 patients who had a classical internal opening at the dentate line, 23 healed primarily after surgical treatment of the fistula, compared with only seven of 16 patients without such an internal opening. The 21 patients in whom the rectum was not involved and in whom there was a classical internal opening at the dentate line were an especially favorable group: 18 of these healed primarily after surgical treatment of the fistula, and although ten of them had one or more recurrences of the fistulas, 18 ultimately achieved a state of complete healing or minimal disability. We conclude that operative treatment of fistula in ano is a safe and effective modality in a carefully selected group of patients with Crohn's disease.

Safe resection for diverticular disease of the colon.

A retrospective study of 83 patients undergoing surgery for diverticular disease over two years at a colorectal specialty hospital was undertaken to assess the safety of resection. No patient had free perforation. Eighty-nine percent of 46 patients with neither abscess nor fistula underwent resection and primary anastomosis, the remainder undergoing other resectional therapy; there was no mortality in this group. Of the 37 patients with abscesses, fistulas, or both, all had resections with or without primary anastomoses and one of these 37 patients died (2.7 percent mortality). In the entire series of 83 patients, the operative mortality was 1.2 percent, although 69 percent had morbidity. Resection can be performed safely for diverticulitis, and primary anastomosis can be safely added in uncomplicated and selected complicated cases.

Evaluation of the first 300 patients treated at an outpatient center for male sexual dysfunction.

A comprehensive multidisciplinary evaluation was carried out on 300 outpatients seen consecutively at a specialized impotence center. Psychologic evaluation was coupled with the use of contemporary diagnostic modalities. Nocturnal penile tumescence testing, penile vascular studies, pharmacologic diagnostic testing and dynamic infusion cavernosography have been used advantageously. In addition to psychologic counseling for all treatment categories, treatment alternatives have included hormonal and pharmacologic agents and penile prosthetic implantations.

Pharmacological erection: diagnosis and treatment applications in 69 patients.

Pharmacological erection is becoming an accepted form of treatment in the impotent patient. We report on our experience in 69 men with organic and psychogenic etiologies using intracorporeal injection with a mixture of papaverine hydrochloride and phentolamine mesylate. A good response was achieved in all patients except those with severe arterial or venous insufficiency. Although it was used primarily in cases of organic impotence, we found intracorporeal injection to be valuable in the patient with psychogenic impotence as an adjunct to sex therapy. Auto-injection was practiced by 74 per cent of our patients with a good response and 50 per cent noticed subjective improvement in the ability to obtain natural erections. Priapism was the most significant complication and occurred in 8.7 per cent of the patients. However, most patients have expressed satisfaction with this alternative to penile implantation.

Computers in surgical education.

Medical records and billing are not the only hospital settings that can benefit from the use of microcomputers. The authors describe how a microcomputer in their department of surgery preserved valuable time for teaching and patient care.

The use of cyclic home hyperalimentation for malabsorption in patients with scleroderma involving the small intestines.

When scleroderma involves the small intestines, malnutrition with resulting immune incompetence and sepsis can occur. Two cases are presented in which patients with scleroderma involving the gastrointestinal tract were treated with cyclic home hyperalimentation, restoring their nutritional status and improving their quality of life.