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Non-invasive diagnostic tools in the field of head and neck oncology : A liquid biopsy for head and neck cancers

The development of a liquid biopsy for head and neck cancers via  ScienceDirect Publication: Oral Oncology Publication ...

Τρίτη, 1 Νοεμβρίου 2016

Pyogenic granuloma (PG) of the oral cavity and nasal cavity

Unusual site of pyogenic granuloma: Case report
Publication date: Available online 31 October 2016
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Shankar Ramasundram, Irfan Mohamad, Sivakumar Kumarasamy, Valuyeetham Kamara Ambu
Pyogenic granuloma (PG) is a relatively common benign vascular lesion of the skin and mucosa. While PG of the oral cavity and nasal cavity is a well-known entity, oropharyngeal localization has never been reported. We present a 56-year-old woman with sore throat, hemoptysis and dysphagia due to a tumor at oropharynx. Initial suspicion of malignancy was ruled out by excision biopsy of the lesion. Histologically it was reported as pyogenic granuloma of the oropharynx.

1. Introduction

The first case of pyogenic granuloma (PG) occurring in human was described and called as “Botryomycosis hominis”.1 PG was since then called in a number of names such as granuloma pediculatum benignum, benign vascular tumor, pregnancy tumor, vascular epulis and Crocker and Hartzell’s disease.1 In 1904, Hartzell coined the term “pyogenic granuloma” or “granuloma pyogenicum”.1 and 2 The facts that PG does not produce pus and does not represent a true granuloma, made this term a misnomer.2 It varies in size from several millimeters to a few centimeters and usually presents as a polypoidal red mass. In the early stages, it resembles granulation tissue and bleeds easily and also friable. PG can occur on skin and mucosal surface of the proximal aero-digestive tracts.2 and 3 Common site of occurrence at aero-digestive tract is in the oral cavity.4 Though its most common occurrence in oral cavity, there are reported cases of it in the face, nose, lips, small bowel, colon, rectum, genitals and on burn scars.2356 and 7 There are also reported cases of PG occurring on epiglottis, post cricoid and trachea.789 and 10 However, to our knowledge there is no report of a PG arising from oropharynx to date.

2. Case report

A 56-year-old Indian lady presented with of sore throat for one-month duration. She also complained of dysphagia and odynophagia with occasional sensation of food being stuck in the throat. She experienced 2 episodes of blood stained sputum while coughing in the last one month. Her oral intake was reduced since the onset of the sore throat. She also complained also of occasional shortness of breath and voice change. Otherwise, she denied any history of fever, lost of weight, history of foreign body ingestion or chemical burn and inhalation injury. She denied of having any allergies and also had no family history of malignancy. She also had no history of alcohol consumption, smoking or betel nut chewing. Examination of head and neck, along with ear and nose were unremarkable. Oral examination revealed no abnormality and hygiene was fair. Flexible nasopharygolaryngoscopy (FNPLS) revealed an exophytic mass arising from left side of posterior pharyngeal. It was pedunculated and measured around 1.0 cm in diameter with white in color (Fig. 1). It was not obscuring the airway. The rest of the pharyngeal structures appeared normal. Laryngeal structures along with bilateral vocal cords appeared healthy and mobile. Other head and neck and systemic examination were unremarkable.
FNPLS revealing an exophytic mass arising from left side of posterior pharyngeal ...
Figure 1. 
FNPLS revealing an exophytic mass arising from left side of posterior pharyngeal wall.
We proceeded with a computerized tomography for her and it revealed an enhancing pedunculated mass arising from left posterior pharyngeal wall, just above the level of epiglottis. It measured 0.9 × 1.3 × 1.7 cm (APxWxCC). The anterior portion of the mass was abutting the epiglottis. Inferiorly it extended into the hypopharynx (Fig. 2). There was no local extension of the mass seen. Rest of the pharyngeal and laryngeal structures were normal. No neck nodes were seen and the great vessels of the neck were all normal. Based on the clinical presentation and findings, we were highly suspicious of an oropharyngeal malignancy.
An enhancing pedunculated mass abutting the epiglottis.
Figure 2. 
An enhancing pedunculated mass abutting the epiglottis.
Direct laryngoscopy and esophagoscopy with biopsy was performed under general anesthesia. Intra-operatively, a friable mass arising from left side of posterior pharyngeal wall was visualized. The mass was not infiltrating into adjacent structures. Larynx and its inlet were unremarkable. Esophagus was also healthy looking up to 25 cm from upper incisor. A wide excision biopsy of oropharyngeal mass was done with minimal blood loss. Post-operatively, patient was nursed in general ward. She progressed well and was discharged home on the 2nd day after surgery.
She was seen 2 weeks later with no active complaints. FNPLS revealed minimal slough over left side of posterior pharyngeal wall. Rest of the pharyngeal and laryngeal structures were unremarkable. Histopathological examination of the biopsy was consistent with pyogenic granuloma. Fragments of markedly inflamed tissue with extensive acute ulceration with only focal area of mature squamous epithelium were seen (Fig. 3). The stroma of sample showed lobules of capillary proliferations and neutrophils infiltration with area of necrosis. No obvious atypical cells or malignancy seen. Bacterial colonies were seen but stains for fungus were negative.
HPE revealing fragments of inflamed tissue with acute ulceration. Also seen ...
Figure 3. 
HPE revealing fragments of inflamed tissue with acute ulceration. Also seen lobules of capillary proliferations and neutrophil infiltration with area of necrosis.
She was again seen 6 weeks after surgery, in which the endoscopic findings revealed full recovery with no abnormality on the pharyngeal wall.

3. Discussion

PG is a common disease resulted from a reactive inflammatory response to various causes including local irritants or hormonal changes. The size of the lesion varies from few millimeters to several centimeters and rarely does a PG is greater than 2 cm in size.2 and 3PG is unlikely to have infiltrative or malignant potential but recurrence is common after simple excision and also in pregnancy.1
PG is a non-neoplastic inflammatory hyperplasia that responds to various stimuli such as chronic local irritation, trauma, hormonal changes, bone marrow transplant, and reactions to grafts.5 However, it can recur after surgical excision.3 There are two different histological types of PG namely lobular capillary hemangioma (LCH) type and non-LCH type, which represent histological features of the lesion and are currently preferred terms.2
PG occurs over a wide range of age 4.5–93 years.1 However there are also reported cases of PG occurring in neonates.10 The highest incidence of age is in the second and fifth decades of life.1 PG has a predilection towards females than males.1 Saravana, reported a 77% of female predominance which may be because of vascular effects of female hormones.5 There cases of PG reported in immunocompromised patients.7 Our patient though elderly did not show any signs of immunosuppression.
Both the reported cases of PG occurring in epiglottis and trachea, presented with hemoptysis as in our case.8 and 9 Additionally, our patient also had dysphagia, odynophagia, voice change and shortness of breath. Such symptomatic patients require further investigation regardless of their age. FNPLS or direct laryngoscopy with or without bronchoscopy should be considered.789 and 10
PG in our patient was found to be an exophytic mass, which is pedunculated, friable and whitish in color arising from left side of posterior pharyngeal wall in the oropharynx. Normal characteristic of PG are soft, painless, vascular and friable with deep red to reddish-purple in color.1 and 2 In concordance with the clinical findings, histologically the lesion showed an inflamed tissue and extensive acute ulceration with focal area of matured squamous epithelium. The stroma of PG in our patient showed lobules of capillary proliferations and neutrophils infiltration with area of necrosis. PG has a lobular growth pattern and rich in vascular proliferation.10 Ulceration of squamous epithelium overlying the PG can be focal to complete with varying degree of neutrophil infiltration involving the mucosa.10
Differential diagnosis of PG includes peripheral giant cell granuloma, peripheral odontogenic fibroma, peripheral ossifying fibroma, hemangioma, conventional granulation tissue, hyperplastic gingival inflammation, Kaposi’s sarcoma, bacillary angiomatosis, angiosarcoma and nonHodgkin’s lymphoma.1 Due to the rare sub site of the lesion in the oropharynx, oropharyngeal squamous cell carcinoma (OP-SCC) was also considered. Patients with Human Papilloma Virus-negative OP-SCC usually presents with sore throat, dysphagia and neck masses.11 However the incidence rate of OP-SCC (excluding base of tongue and tonsil) is much lower compared to base of tongue and tonsil.12
Surgical excision is the treatment of choice for PG.15 and 6 Excision, curettage, electrodessication, chemical cauterization and laser surgery are the among the options available for the treatment of cutaneous PG.9 Whereas, mucosal PG can be treated with snare cautery, excision biopsy or plaque radiation.9 In our case we performed a wide excision biopsy for her and followed her up with scopes to monitor recurrence.

4. Conclusion

PG is a non-malignant, tumor-like lesion that can occur anywhere in the body. The diagnosis of vascular lesion such as PG is consistent with the patient’s initial presentation of hemoptysis. In our case there was a possibility of OP-SCC as there was symptoms and scope findings that was suggestive of it but histopathology cleared the doubt. We also demonstrate the capacity for development and safe excision of the lesion in an uncommon pharyngeal sub site.


    • 2
    • S. Limmonthol, C. Sayungkul, P. Klanrit
    • Oral pyogenic granuloma presenting as an atypically large soft tissue mass: a case report
    • J Oral Maxillofac Surg Med Pathol, 26 (2) (2014), pp. 258–261
    •  |   | 
    • 4
    • E.C.M. Luna, E. De Freitas, M.R. Silva, F.N. Chaves, F.W.G. Costa, A.P.N.N. Alves, F.B. Sousa, et al.
    • Exuberant pyogenic granuloma in an unusual site
    • Oral Surg Oral Med Oral Pathol Oral Radiol, 120 (2) (2015), p. e43
    •  | 
    • 7
    • G. Kuruvilla, G. Ra, A. Lacson, H. El-Hakim
    • Pyogenic granuloma as a complication of prolonged nasogastric tube insertion in an immuno-compromised host
    • Int J Pediatr Otorhinolaryngol Extra, 4 (1) (2009), pp. 14–16
    •  |   | 
    • 10
    • Q. Xu, X. Yin, J. Sutedjo, J. Sun, L. Jiang, L. Lu
    • Lobular capillary hemangioma of the trachea
    • Arch Iran Med, 18 (2) (2015), pp. 127–129
    • 12
    • D.J. Weatherspoon, A. Chattopadhyay, S. Boroumand, I. Garcia
    • Oral cavity and oropharyngeal cancer incidence trends and disparities in the United States: 2000–2010
    • Cancer Epidemiol, 39 (4) (2015), pp. 1–8

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2. Akdogan O, Ozcan I, Ozbek C, Dere H. Tinnitus after cochlear implantation. Auris Nasus Larynx. 2009;36:210-212. [abstract]

3. Pan T, Tyler RS, Ji H, Coelho C, Gehringer AK, Gogel SA. Changes in the tinnitus handicap questionnaire after cochlear implantation. American Journal of Audiology. 2009;18:144-151. [abstract]

4. Andersson G, Freijd A, Baguley DM, Idrizbegovic E. Tinnitus distress, anxiety, depression, and hearing problems among cochlear implant patients with tinnitus. Journal of the American Academy of Audiology. 2009;20:315-319. [abstract]

5. Rothholtz VS, Tang Q, Wu EC, Fine EL, Djalilian H, Zeng F-G. Exploring the parametric space of tinnitus suppression in a patient with a cochlear implant. Laryngoscope. 2009;119.

6. Di NW, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Transtympanic electrical stimulation for immediate and long-term tinnitus suppression. International Tinnitus Journal. 2009;15:100-106.[abstract]

7. Litre CF, Theret E, Tran H et al. Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus. Brain Stimulation. 2009;2:132-137. [abstract]

8. Evans RW, Ishiyama G. Migraine with transient unilateral hearing loss and tinnitus. Headache: The Journal of Head & Face Pain. 2009;49:756-759. [abstract]

9. Pirodda A, Brandolini C, Raimondi MC, Ferri GG, Borghi C. Tinnitus as a warning for preventing vasovagal syncope. Medical Hypotheses. 2009;73:370-371. [abstract]

10. Anderson JE, Teitel D, Wu YW. Venous hum causing tinnitus: case report and review of the literature. Clinical Pediatrics. 2009;48:87-89. [abstract]

11. Liess BD, Lollar KW, Christiansen SG, Vaslow D. Pulsatile tinnitus: a harbinger of a greater ill? Head & Neck. 2009;31:269-273. [abstract]

12. Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus. Journal of Vascular Surgery. 2009;50:183-185. [abstract]

13. Delgado F, Munoz F, Bravo-Rodriguez F, Jurado-Ramos A, Oteros R. Treatment of dural arteriovenous fistulas presenting as pulsatile tinnitus. Otology and Neurotology. 2009;30:897-902. [abstract]

14. Cowley PO, Jones R, Tuch P, McAuliffe W. Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: Resolved after carotid artery stenting. American Journal of Neuroradiology. 2009;30:995-997. [abstract]

15. Stimmer H, Borrmann A, Loer C, Arnold W, Rummeny EJ. Monaural tinnitus from a contralateral inferior colliculus hemorrhage. Audiology & Neurotology. 2009;14:35-38. [abstract]

16. Latifpour DH, Grenner J, Sjodahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. International Tinnitus Journal. 2009;15:94-99. [abstract]

17. Department of Health. Provision of services for adults with tinnitus: a good practice guide. 2009. [full text]

18. DH. Tinnitus Map of Medicine care pathway. 2010. [Full text]

19. BTA. Tinnitus: guidelines for primary care. 2010. [Full text]

20. Schneider P, Andermann M, Wengenroth M et al. Reduced volume of Heschl's gyrus in tinnitus. NeuroImage. 2009;45:927-939. [abstract]

21. Landgrebe M, Langguth B, Rosengarth K et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. NeuroImage. 2009;46:213-218. [abstract]

22. Melcher JR, Levine RA, Bergevin C, Norris B. The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research. 2009;257:63-74. [abstract]

23. Lanting CP, de KE, van DP. Neural activity underlying tinnitus generation: Results from PET and fMRI. Hearing Research. 2009;255:1-13. [abstract]

24. Kaltenbach JA. Insights on the origins of tinnitus: an overview of recent research. Hearing Journal. 2009;62:26-31. [Full text]

25. Shulman A, Goldstein B, Strashun AM. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. International Tinnitus Journal. 2009;15:5-50. [abstract]

26. Schutte NS, Noble W, Malouff JM, Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology. 2009;48:428-432. [abstract]

27. Hesser H, Pereswetoff-Morath CE, Andersson G. Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology. 2009;54:381-390.[abstract]

28. Argstatter H, Krick C, Bolay HV. Music therapy for chronic tinnitus. Heidelberg treatment model. Psychotherapeut. 2009;54:17-26. [abstract]

29. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal. 2009;15:51-61.[abstract]

30. Langguth B, Salvi R, Elgoyhen AB. Emerging pharmacotherapy of tinnitus. Expert Opinion on Emerging Drugs. 2009;14:687-702. [abstract]

31. Campbell KCM. Emerging pharmacologic treatments for hearing loss and tinnitus. ASHA Leader. 2009;14:14-18. [Full text]

32. Hesser H, Westin V, Hayes SC, Andersson G. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research & Therapy. 2009;47:523-528. [abstract]

33. Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology. 2009;48:295-299. [abstract]

34. Shulman A, Goldstein B. Subjective idiopathic tinnitus and palliative care: a plan for diagnosis and treatment. Otolaryngologic Clinics of North America. 2009;42:15-38. [abstract]

35. Forti S, Costanzo S, Crocetti A, Pignataro L, Del BL, Ambrosetti U. Are results of tinnitus retraining therapy maintained over time? 18-month follow-up after completion of therapy. Audiology & Neuro-Otology. 2009;14:286-289. [abstract]

36. Bessman P, Heider T, Watten VP, Watten RG. The tinnitus intensive therapy habituation program: a 2-year follow-up pilot study on subjective tinnitus. Rehabilitation Psychology. 2009;54:133-138. [abstract]

37. Gudex C, Skellgaard PH, West T, Sorensen J. Effectiveness of a tinnitus management programme: A 2-year follow-up study. BMC Ear, Nose and Throat Disorders. 2009;9. [Full text]

38. Henry J, Zaugg T, Myers P, Kendall C, Turbin M. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health. 2009;11:33-48. [abstract]

1. Hazell JW, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol. 1990;19:1-5. [Abstract]

2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

Norena AJ, Eggermont JJ. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. Neuroreport. 2006;17:559-563. [Abstract]

Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

Schlee W, Mueller N, Hartmann T, Keil J, Lorenz I, Weisz N. Mapping cortical hubs in tinnitus. BMC Biol. 2009;7:80. [Full text]

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"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."


"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

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Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians


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