Portal de Periódicos da CAPES

Notable presentations in the history of the South Atlantic Association of Obstetricians and Gynecologists

2005; Elsevier BV; Volume: 193; Issue: 2 Linguagem: Inglês

10.1016/j.ajog.2005.03.047

1097-6868

Robert G. Brame,

Medical Research and Practices

It is my pleasure and great honor to be permitted to make this address to you for I have long been enamored of the history of this organization and with the story of medicine throughout the 20th century. This Association is certainly a major player in that history, and while today is not the past, we, too, are part of that evolution and we will soon, ourselves, be a part of that history. Through us, the past endures but each new step in our science accumulates a future hopefully brighter than what we have known before. Like the frames of a motion picture film, the static scenes of our accomplishments, then and now, when run in sequence, make a continuum and provide an ongoing vitality that ties us to the past, and establishes the fertile soil out of which new thoughts emerge. We would have no foundation on which to build the future were it not for the efforts of those who preceded us. We are no more than the next frames in that motion picture, and we shall be, in the same way, prologue to those who succeed us. I must begin my presentation by paying homage to members whose works have made mine a great deal easier. First, Dr William Kirkley1Kirkley WH. The first 50 years of the SAAOG. Unpublished. Written permission of author obtained.Google Scholar compiled a very detailed history of the organization under the title of “The first fifty years of the SAAOG.” It has been an excellent resource. Other historic accounts have been presented, Dr Hudnall Ware in 1954,2Ware H. The first 15 years.Am J Obstet Gynecol. 1954; 68: 505-509PubMed Scopus (2) Google Scholar and in 1958, Dr Manley Hutchinson.3Hutchinson M.E. The South Atlantic Association of Obstetricians–Gynecologists, a twenty-year old obstetrical and gynecological society.Am J Obstet Gynecol. 1958; 76: 699-705PubMed Scopus (2) Google Scholar I find no further attempt to bring the history up to date. Most of my own information comes from my review of all the published articles from meetings which took place between 1938 and 2003 in the American Journal of Obstetrics and Gynecology. I also reviewed all the programs and Bylaws since 1941. My presentation, therefore, covers primarily those talks that were published. The seminal act which initiated the Association was apparently a letter addressed to prospective members, and written by Dr Robert A. Ross, mailed on October 23, 1937. The first actual meeting took place at the Charlotte Hotel in 1938, and lasted 2 days. Dr Oren Moore presided over that gathering and introduced a set of bylaws that was adopted. Dr Moore may be remembered by some as the author of the comment about a speaker at the podium, like me, describing him as fully dilated with nothing presenting. Seventy members were present and elected to membership. I must quote to you now a description of the origination of this organization that appears in Dr Kirkley's report, and I quote “…the SAAOG has been referred to as a specialists organization conceived in a North Carolina bar, with a gestation period of two years, laboring through five Southern states, with parturition occurring February 4, 1938 at the Hotel Charlotte …”1Kirkley WH. The first 50 years of the SAAOG. Unpublished. Written permission of author obtained.Google Scholar The meetings have been held, with 4 exceptions, within the area of the South Atlantic. Meetings outside have been held in Havana, Bermuda, Acapulco, where it was reported that over half the membership suffered severe cases of Montezuma's revenge, and in New Orleans. Since the 1980s, all meetings have been within the region. I wish now to turn your attention to what I feel is the most important part of the organization and the raison d'tre for its existence, the scientific program. I hope that you will understand that my attempt to report, as the title suggests, the ‘notable presentations' is filled with a huge amount of personal bias. I am sure that if any one of you were to cover, as I have, all of the presentations that have been published, and all the programs, you would probably make different selections. If I include something you think unfit, or if I omit something you think especially worthy, it was not willful, nor was it meant to suggest that I know better than you what is meant by “notable,” only that I was the one making the choices. And now, if you will, look with me at the programs. An important part of the program has been Case Presentations before a learned panel that has been utilized in 33 of the 64 previous meetings. This has usually consisted of 3 to 5 cases, most of them of an unusual nature, followed by erudite examination by members who are usually distinguished for their intellectual contribution to our specialty. Some of the more interesting topics include, in 1956, “Twin pregnancy with one twin blighted” by R. C. Forman,4Forman R.C. Twin pregnancy with one twin blighted.Am J Obstet Gynecol. 1956; 72: 1180-1181PubMed Scopus (3) Google Scholar notable to me because he didn't have ultrasound and the diagnosis was made post delivery. Another was “Pyometra exceeding one gallon” by Jim Ingram,5Ingram J.M. Pyometra exceeding one gallon.Am J Obstet Gynecol. 1962; 84: 852-853PubMed Scopus (1) Google Scholar another “Vivax malaria in the first trimester” by Zack Newton,6Newton ZB. Vivax malaria in the first trimester. Paper presented at: Fortieth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists; January 29, 1979.Google Scholar and last, but not least, “Scuba diving in pregnancy” by J. F. Newhall.7Newhall J.F. Scuba diving in pregnancy.Am J Obstet Gynecol. 1981; 140: 893PubMed Scopus (11) Google Scholar Guest speakers have been a constant part of the program, and some of those guests have made up the audience that discussed those presentations. Is it any surprise that there were some very nervous presenters when the guest lists were composed of such people as Dr Nick Eastman, for many years author/editor of Williams Obstetrics, Dr Richard Telinde, the father of our most popular surgical text, Milton McCall, master of radical surgery and developer of the McCall culdoplasty, and Roy Pitkin, for years senior editor of the Green Journal. Mini-presentations, likewise, have been a part of the program, beginning in 1974 and in most of the programs in the 1970s and 80s. These usually consisted of a report on a medical situation, sometimes a new procedure or instrument, and occasionally a patient report, similar to Case Presentations we've just discussed. The Foundation Prize Thesis was established in 1948 with a prize of $100. The first thesis was given by Dr Willis Brown of Arkansas,8Brown W.E. Jennings P.F. Bradbury J.T. The absorption of radioopaque substances used in hysterosalpingography.Am J Obstet Gynecol. 1949; 58: 1041-1053Abstract Full Text PDF PubMed Scopus (13) Google Scholar the second in 1949 by Dr Kermit Krantz of Kansas.9Krantz KE. The presence of smooth muscle in the human placenta and its apparent role in the circulation of the intervillous space. Paper presented at: Twelfth annual meeting of the South Atlantic Association of Obstetricians and Gynecologists; February 8, 1950.Google Scholar It has been awarded a total of 12 times since its inception, and has included a host of highly specialized topics. In 1969, it was awarded to Dr Frank Locke for his presidential address,10Locke F. Is the South Atlantic Association of Obstetricians and Gynecologists fulfilling its responsibility?.Am J Obstet Gynecol. 1969; 105: 1-8PubMed Google Scholar the only time that a member has been accorded such an honor for a presidential address. The John McCain student fellowship was started in 1982 and, while there is some overlap, it seems almost to have replaced the Foundation prize. The McCain lectures were given early on by non-MDs through the 12th presentation in 1993, but in 1995, it was called, in the program, the McCain Lecture, and was given by a resident physician about cold knife conization.11Moore B.C. Higgins R.V. Marroum M. Predictive factors from cold knife conization for residual cervical intraepithelial neoplasms in subsequent hysterectomy.Am J Obstet Gynecol. 1995; 173: 361-368Abstract Full Text PDF PubMed Scopus (74) Google Scholar It has for the most part since then been presented by physicians. The Cullen Richardson lecture was given in 2003, and was presented by Dr Bobby Shull of Texas, who addressed the many fine qualities of the physician for whom the lectureship was named.12Shull B. A Cullen Richardson: noticer, pioneer, mentor and friend.Am J Obstet Gynecol. 2003; 189: 403-407Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Scientific papers reflecting someone's research effort have been the backbone of the programs since inception, almost universally analyzed by a prepared discussant, which was then followed by a general discussion by the audience. Many outstanding research projects have been reported here that have influenced our practice, as well as they have reflected the times. I wish, therefore, at this point to use cesarean section as reflective of the influence of the then-current thinking on the programs of the South Atlantic, as well as possibly showing the impact of the science reiterated at this meeting on the practice of medicine. Interestingly, one of the earliest presentations about cesarean section was made in 1947 by Settle and Wilson from Charlottesville about using local sulfathiazine in the peritoneal cavity to reduce febrile morbidity, a concept that was not renewed until the 70s.13Settle J.M. Wilson L.A. Cesarean section in potentially infected patients using sulfathiazole in the uterus and peritoneal cavity.Am J Obstet Gynecol. 1947; 54: 801-803PubMed Scopus (1) Google Scholar In 1949, W. Z. Bradford presented a review of 2600 deliveries in which 85 patients had labors more than 30 hours and a few greater than 50 hours.14Bradford W.Z. Woltz J.H.E. Bradford Jr., W.Z. Prolonged labor.Am J Obstet Gynecol. 1949; 58: 1092-1098Google Scholar He concluded that after 50 hours, no further efforts should be made to avoid either forceps or section. Little could he know or anticipate the behavior of obstetricians in the latter part of the 20th century. In 1952, President Ed Colvin presented a conclusion that the-then current section rate, varying between 2% and 6% was adequate15Colvin E.D. Expansion vs restriction of cesarean section.Am J Obstet Gynecol. 1952; 64: 483-487Google Scholar In 1953, when the organization was visiting Cuba, Dr Ortiz-Perez, the host, informed the society how to avoid cesarean section by the use of symphysiotomy, a procedure which fortunately never gained wide acceptance in this country.16Ortiz-Perez J. Symphysiotomy versus difficult forceps.Am J Obstet Gynecol. 1953; 66: 781-783PubMed Scopus (4) Google Scholar In 1976, Hunter Jones collated his experience with 2500 sections with no maternal deaths. His rate of section of 6% he thought was adequate, but his survey of other hospitals suggested to him that rates could rise as high as 25%, an achievement that obviously would not have pleased him, but was oh, so prophetic.17Jones O.H. Cesarean Section in present day obstetrics.Am J Obstet Gynecol. 1976; 126: 921-930Google Scholar In 1990, Ramon-Sanchez presented his reduction of section rates from 28% to 11% through a very dedicated effort to stop an excessive repeat section rate, then prevalent.18Ramon-Sanchez L. Kaunitz A.M. Peterson H.B. Martinez-Schnell B. Thompson R.J. Reducing cesarean section at a teaching hospital.Am J Obstet Gynecol. 1990; 163: 1081-1088Abstract Full Text PDF PubMed Scopus (68) Google Scholar In 2003, you will recall, there was a formal discussion by University of Virginia faculty about the pros and cons of “patient choice section.”19Williams C.D. Finnerty J.J. Newberry Y.G. West R.W. Thomas T.S. Pinkerton J.V. HIV infected patients who seek assisted reproductive technology for infertility.Am J Obstet Gynecol. 2003; 189: 333-341Abstract Full Text Full Text PDF PubMed Google Scholar I believe that these documents clearly reflect the tenor of the times, and how the South Atlantic has been in the forefront of contemporary practice. The single most talked about subject, probably of all time in this organization, has been the uterine cervix. There have been no fewer than 23 presentations about either Pap smears, intraepithelial lesions, or how to diagnose cancer when it was not readily visible. Among the first, and of great importance, was the unpublished lecture by Dr George Papanicolaou to the meeting in 1946 about cytology, which was in the early stage of its development.20Papinicolaou G. Demonstration of the diagnosis of uterine cancer by vaginal smears. Paper presented at: the South Atlantic Association of Obstetricians and Gynecologists Association; February 14, 1946.Google Scholar In 1958, Henry Heins of Charleston addressed the role of smegma in causation of carcinoma of the cervix.21Heins H.C. Dennis E.J. Prat-Thomas H.R. Possible role of smegma in carcinoma of the cervix.Am J Obstet Gynecol. 1958; 76: 726-735PubMed Scopus (22) Google Scholar Other pertinent topics that help reveal the evolution of the management of intraepithelial neoplasia include the first presentation before the South Atlantic about colposcopy in 1968 by Scott and others from Miami,22Scott J.W. Brass P. Sackinger D. Colposcopy and cytology-results in 1100 patients.Am J Obstet Gynecol. 1969; 103: 925-929PubMed Scopus (11) Google Scholar the first discussion of loop electrosurgical excision in 1992 by Hans Krebs et al,23Krebs J.B. Pastor L. Helmkamp B.F. Loop electrosurgical excising procedures for cervical dysplasia: experience in a community hospital.Am J Obstet Gynecol. 1993; 169: 289-295Abstract Full Text PDF PubMed Scopus (44) Google Scholar the first discussion of cytologic screening following hysterectomy for benign disease by Joanne Piscatelli from Duke in1995,24Piscatelli J.T. O'Shea T.M. Anderson R.L. Cytological screening after hysterectomy for benign disease.Am J Obstet Gynecol. 1995; 173: 424-432Abstract Full Text PDF PubMed Scopus (38) Google Scholar to be followed by a presentation on the spontaneous resolution of grade 1 CIN in a private population by R. K. Falls in 1999.25Falls R.K. Spontaneous resolution rate of grade 1 cervical intraepithelial neoplasia in a private practice population.Am J Obstet Gynecol. 1999; 181: 278-282Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Even toxemia of pregnancy and induction of labor, both old Southern favorites, have enjoyed each only about half the attention of the cervix. Dr Robert Bartholomew of Atlanta made a presentation describing some of the changes in the placenta occurring in the patient with toxemia in 1941.26 Dr Robert A. Ross made his Presidential address in 1947, in which he asserted that late toxemia of pregnancy remained the number one problem in obstetrics in the South.27 For many years thereafter, the treatment of toxemia, in Dr Ross's words, was to “let the sun shine on the placenta.” That dogma persisted, unchallenged, until the paper of Guy Harbert and Willie Anderson in 1977, which reported on the conservative management of toxemia and changed some of the thinking of the previous 30 years.28 The first presentation about oxytocin induction of labor was given in 1950 by Dr R. Gordon Douglas of New York, and many presentations on that issue were made subsequently.29 Prostaglandins were introduced first by Bill Brenner of Chapel Hill in a discussion of his use in producing abortion.30 The first demonstration of the utility of misoprostol in inducing labor was made in 1996, and several publications regarding cervical ripening with that compound have been given since. There have been a number of serious medical issues that have been marked either by only a single presentation, or by only a few that stand out because many of them deal with very important issues. For example, the only talk I could find about syphilis, the 2-millennia scourge of mankind, occurred in 1948.31 That single talk probably represented the fact that thereafter, syphilis was no longer a major problem. In 1951, Robert Bartholomew presented his concept of a marginal sinus in the placenta, an idea not refuted until years later, and one which was accepted for many years as fact.32 In 1965, P. E. Thornhill presented his experience with external version of breeches, anticipating by many years the widespread use of this procedure.33 The topic was not repeated until the work of Newman in 1993 from MUSC, almost 30 years later.34 In 1957, Rufus Ellet made the first talk about Stein-Leventhal syndrome, and in 1959,35 Bill and Mason Andrews gave the first report on the effect of estrogen/progesterone on both ectopic and normally implanted endometrium.36 Jim Ingram discussed for the only time, the then-current abortion laws in 1969 in a review that retains much of its pertinence even for today.37 Dick Mattingly, a guest in 1976, presented the first discussion of diethylstilbestrol exposure in utero.38 The first discussion of male transsexualism-male genital reconstruction was presented by U. G. Turner of Virginia.39 In 1980, the Jones' presented extracorporeal fertilization, opening a new era of human reproduction, and foretelling the great interest of the lay and professional press following their success in this area.40 This followed a presentation that was given in 1980 but was not published. Intrauterine contraceptive devices have, by my own view, been infrequent topics, with only 4 formal presentations, although the only presentation about severe infection accompanying its use was made in a brief patient presentation by Tom Rowland in 1971.41 Age at the time of pregnancy has been examined on several occasions, in primigravid women over age 30 by Frank Locke,42 in women under age 20 by Joe Donnelly,43 and in mothers over age 40 by Ed Horger in 1976.44 The first, and for many years the only, discussion of HIV infection was given by J. Gloeb in 1988.45 It was only after the year 2000 that any further presentations about this issue were made, a dearth of attention I find astonishing. The issue of domestic violence was first discussed by Linn Parsons in 1996.46 In both 1956 and in 1971, the elegant Eleanor Easley spoke candidly about the problems of women in the male-dominated culture of the time, in which she contended that “For women…industry, ingenuity and efficiency do not bring about direct reward…since success for a woman means to get and keep a husband.” I doubt that I need to comment about the changes in that view that have taken place.47,48 There have been a number of papers dealing with issues medical, but not directed toward a scientific topic. Among the earliest of these was the Presidential address of R. A. Bartholomew in 1942 entitled “Utopian obstetrics,” in which he encouraged group practice with, incidentally, division of income. I doubt that he realized how farsighted he was.49 The public school teaching of human reproduction was addressed by Jack Monroe in 1965, in which he exhorted his colleagues to support this activity.50 To the best of my knowledge, this topic has never been repeated, even though it is an important issue never resolved. Roy Parker, in his 1981 Presidential address, reviewed the GMENAC report, which predicted a large surplus of Ob/Gyn physicians in the year 1990,51 only to have, 2 years later, Warren Pearse argue that GMENAC was wrong, and he predicted that supply and demand would balance, a position certainly supported by subsequent events.52 An analysis of 500 obstetric and gynecologic malpractice claims was presented by C. J. Ward in 1991. It is an excellent review and remains as pertinent today as it was 13 years ago.53 I would be remiss if I did not remind you of the significant work of Jim Finnerty and his group at the University of Virginia. Philosophy may have become, among modernists, the stepchild of science, but he has denied that subjugation with a cornucopia of sober and sometimes disturbing debates. His has been a risky undertaking because the ethical issues that he has addressed encompass areas in which everyone is an expert but no one accepts the views of another. He has reminded us that even the most scientific among us can find no inalterable truth in these turbulent waters. Since 1996, and almost yearly thereafter, they have addressed such issues as fetal-maternal conflicts, parental rights, ethical issues in managed care, and in everyday practice, end-of-life decisions, HIV, and assisted reproduction, and last year, the issue of elective cesarean section. They are the only ones among us who have attempted to breach the formidable barriers defending these perilous seas of angst and uncertainty. And we applaud them for that.54-59 Presidential addresses have covered a wide array of topics, but preponderantly they have been calls to the members to seek altruistic goals, and to better serve both our patients and the public. Some others of them have addressed specific scientific topics or specific other issues confronting our specialty. Time will permit me to cover only a few of these in both categories, but it is obvious to me that all the Presidential addresses were formed out of both serious contemplation of the issues and diligent work in producing very masterful documents. I have enjoyed reading all of them, and believe all of them to be cogent and useful contributions to our literature and to our minds. Waverly Payne entitled his talk “Hysterectomy—a problem in public relations,” and it would be as timely now as it was in 1956.60 W. Z. Bradford, in 1964, addressed the need for an expanded role for the gynecologist in the field of geriatrics,61 and only in 1996 did Glen Hurt add his voice to Bradford's, pleading for increased attention to the postmenopausal age group, and for a rededicated effort in both practice and research to properly serve these patients.62 Bradford's prescience provided early direction for a role we all now accept, as Hurt reaffirmed, as part of our duty. Mason Andrews, whose father had given the Presidential address 23 years earlier, spoke in 1973 of the marriage between medical educators and practitioners presaging the development of area health education centers, soon thereafter to become a fact of life in most of the Southeast.63 Bill Kirkley, in 1980, raised an issue that I believe remains as unsettled and still as controversial now as then in his address entitled “Fetal survival—what price.” It is a critique worth rereading now.64 Bill Mixon, in 1985, cited the problem of few women physicians in Ob/Gyn, the interference of hi-tech medicine on the humanistic aspects of medicine, the looming liability crisis, the potential alteration in incomes of physicians, and what he suspected to be the increasingly materialistic motivation of students entering medical school. I don't know if he had a crystal ball, but he certainly seemed to have a clear view of the future.65 Bill Lehew in 1992 reviewed the problem of teenage pregnancy,66 while Sam Goodrich in 1995 lamented the increase in single parent families, as well as general family fragmentation.67 Tommy Rowland, in 1998, discussed the role of Ob/Gyns as gatekeepers, and warned of the possible intrusion of other areas of medicine into our specialty.68 Several presentations have been directed at physician happiness: Ed Horger's survey in 1993 of physician satisfaction, followed by Murray Freedman's “Physician, heal thyself” in which he talked of happiness in one's profession.69,70 The presentation in 1971 by Cullen Richardson, I think, warrants special mention. While it was not a Presidential address, I include it with the more altruistic speeches because of its somber and uplifting theme. That presentation was a rather profound discussion of the ontologic basis of humanity that distinguishes us from the rest of the animal kingdom, and was put together by him along with other physicians, scholars in the humanities, and theologians of his acquaintance. He focused on human birth and its meaning as representative of a higher purpose in life. He states, and I quote, but I have rearranged the order, “There is in the innocence of the newborn baby the symbol of man's original purity and perfection…human reproduction involves the noetic, the psychic and somatic dimensions…It is in the noetic dimension that man searches for meaning and answers to the ultimate questions…when we speak of the noetic dimension of human reproduction, we are referring to the extent to which reproduction becomes for man sacred and in what measure it provides existential meaning.”71 Now, let me return to Presidential matters. Bayard Carter in 1953 warned that we must embrace the past but make it prologue to the future, that we must widen our scientific base if we are to progress, and he cautioned that “A condition of perpetual apology for ignorance is difficult to sustain,” which sounds so much like Dr Carter that I had to include it.72 John McCain, in 1971, called upon the Association to exert its leadership in providing one standard of care, and to expanding the number of minorities in medicine.73 Frank Greiss, likewise, in 1989 challenged us to work toward both affordable accessability and the provision of high-quality medical care. “Our professionalism and especially our altruism must remain pervasive for if we surrender our obligation to legislative and commercial forces, who will remain the public's unbiased medical advocate.”74 Hank Jennings addressed it in his talk in 1997, in which he urged that we fight for quality medical care for everyone in spite of third party intrusions.75 Interestingly, the Presidential address in 1975 by Dr Jim Ingram praised the Presidential address as a valuable asset to the organization, but pleaded that it not be made mandatory because it might deter some good candidates from accepting the Presidency.76 I believe that it is obvious to everyone that I have been profoundly impressed by the quality of material which I have reviewed for this presentation, and I am sorry that I cannot give you greater detail and wider coverage, but the minutae in this kind of talk has the potential of being boring enough without treading further on the mind's ability to maintain its attention span. Finally, of all the documents I reviewed, one has left on me the most indelible impression, and I wish to share with you a part of it. Dr Lawrence Hester gave his Presidential address in 1965, widely quoted subsequently by Dick Sosnowski and by Tucker Lafitte in their Presidential addresses.77 Dr Hester reviewed the beneficial impact of various external forces that influence medical care, but his major contribution was his assertion that we need both competence and compassion. I paraphrase. Compassion alone is not sufficient, but the consistent application of competence is compassion, and we should be ever mindful of the fact that compassion without competence is fraud. I believe that there is great beauty and wisdom in Dr Hester's words that compel us to maintain both our respect for our patients and our commitment to professionalism. Continued membership in this organization bestows the honor of the recognition of our dedication to these goals, but also compels us to meet the high standards that I believe this society has upheld in the past, and hopefully will uphold in the future. I believe it has done more than this, but if the light that shines from these proceedings has passed through no more than a pinhole into our intellects, we are better for it and our world is better. We are what we know, and we are made larger by the science and scholarship that has radiated from here into a far larger domain than just these walls. This podium has vibrated with the knowledge emanating from many learned pens where dogma has been confronted and made to reaffirm itself. The provocative dialectic born here has brought new vigor to some old thoughts, retiring some others as no longer tenable, and putting forth a synthesis of new ideas to carry forward our mission to advance and renew. Here, we have re-embraced our fundamental commitment to serve our fellow man and our endeavors, therefore, have helped to build health care into a much more benevolent and humane milieu, and into a profoundly more accurate technology. Let this look backwards reflect the nostalgia that we feel, but let it also show, with great reverence, what this noble organization has meant not only to its members, but to the greater community of mankind. The precedent of excellence set by these dissertations has certified the importance of this kind of organization to obstetrics and gynecology. The past cannot guarantee the future, but the fertile soil provided here offers great hope that the South Atlantic will maintain its preeminent position in medical education and in the advancement of health care. Thank you for permitting me to make this presentation.