Showing papers in "A.M.A. Archives of Surgery in 1955"

Relation of thyroid neoplasms to hashimoto disease of the thyroid gland

Abstract: THE SIMULTANEOUS occurrence of a neoplasm and Hashimoto disease (Hashimoto "thyroiditis," lymphadenoid goiter, struma lymphomatosa) in a thyroid gland has been noted infrequently. In a study concerned primarily with the clinical aspects and pathogenesis of various types of thyroiditis, a significant statistical relation was found between malignant thyroid neoplasms and Hashimoto disease of the thyroid gland. Thirty-seven malignant neoplasms were observed in 302 glands which also displayed the characteristic lesions of Hashimoto disease, a frequency which would occur by chance less than 1 time in 1,000. 1 The present study was concerned with 73 patients who had benign or malignant thyroid epithelial neoplasms associated with Hashimoto disease of the thyroid gland. Included in the study for comparative purposes were 207 patients who had only benign or malignant thyroid epithelial neoplasms and 205 patients who had Hashimoto disease without thyroid neoplasms (Table 1). All patients were observed during the last 10

Submucosal saline wheal as safety factor in fulguration of rectal and sigmoidal polypi

Abstract: SURGICAL textbooks emphasize the need for care in the electrosurgical treatment of adenomatous polypi of the upper rectum and sigmoid colon, particularly when the lesion is on the anterior rectal wall or above the peritoneal reflection. In these areas, through-and-through coagulation of the colonic wall may lead to (1) injury to the vagina, in the female, or to the seminal vesicles or bladder, in the male; (2) delayed hemorrhage, when separation of too deep a slough uncovers a blood vessel of large size; (3) intestinal obstruction due to adhesion of a loop of small bowel to serosal exudate over a coagulated area, 1 or (4) peritonitis, when the necrotic area borders on peritoneum. The true incidence of such complications is not known, and it is reasonable to assume that the occasional fatality, with the unfavorable stigma it attaches to the operating surgeon, is not always reported in the literature. In

A New Type of Portal-to-Systemic Venous Shunt for Portal Hypertension

Abstract: Surgeons today are being called upon to treat patients of all ages for portal hypertension because of its associated symptoms of gastrointestinal hemorrhage, ascites, and congestive hypersplenism. The efficacy of decompressive shunting procedures has been demonstrated repeatedly in persons with extrahepatic or intrahepatic types of portal venous obstruction.* The majority of symptomatic patients are amenable to the conventional splenorenal or portacaval shunt. However, there remain four sizable groups of patients for whom such established procedures are impossible: (1) the "postsplenectomy bleeder" with cavernomatous changes in the portal vein itself, (2) the patient with preexistent thrombosis and recanalization of the portal vein and its major tributaries, (3) the person with excessive bleeding at surgery from periportal or perisplenic collateral vessels, and (4) the small child in whom the difficulties of obtaining an adequate-sized, patent portal-to-systemic venous shunt may be almost insurmountable. In each such case, the primary problem is that of

A bacteriologic study of portal-vein blood in man.

Abstract: Previous studies have been done in this laboratory to ascertain the role of intestinal bacteria in hepatic necrosis following excision of the hepatic arterial vasculature in dogs. 1 It was demonstrated by culturing portal-vein blood from apparently normal healthy dogs that there was continual seeding of the liver by bacteria that passed from the gastrointestinal tract to the liver by way of the portal vein. It has not been shown in man that bacteria migrate from the gastrointestinal tract into the portal circulation, except in the presence of serious intraperitoneal infections or inflammatory lesions of the gastrointestinal tract. This investigation was undertaken in order to determine whether bacteria enter the portal circulation in the absence of infectious processes. MATERIALS AND METHODS Portal-vein blood obtained from 25 patients at the time of laparotomy was cultured. There was no selection of patients with regard to intraabdominal pathology or type of operation, except

Carcinoma of the thyroid and other diseases of the thyroid in identical twins.

Abstract: Any disease occurring in one identical twin may be expected to occur in the other at the same time or at some future time. In a recent report (1953) of sympathicoblastomas occurring in 3-month-old identical twins Lee 1 stated that "when a tumor, especially a malignant tumor, is recognized in one of identical twins, there is a considerable possibility that a malignant lesion, usually, but not always, of a similar type will appear in the other twin." In the study of disease in twins one of the difficult problems is the identification of identical (monozygotic) twins. Unidentical (dizygotic) twins of the same sex may so closely resemble each other that they may not be distinguished from identical twins unless one placenta for both is recorded at birth. Rosanoff and associates 2 emphasize this problem, as shown in Table 1, taken from their report of a study of schizophrenia in 142

Anatomy of the pancreas; a study with special reference to the duct system.

Abstract: The anatomy of the pancreatic duct system has been the subject of numerous studies since the first published account by Wirsung (Fig. 1). This original and inaccurate report was later modified by Santorini to approximate more closely the arrangement found in human beings. Although studies of the pancreatic ducts continued, descriptions varied, largely because of the difficulty of demonstrating the exact relations of the ducts. When Opie popularized the common channel theory of pancreatitis, he lent an impetus to the efforts of anatomists and surgeons to demonstrate more clearly the finer anatomy of the duct arrangement at the ampulla of Vater and in the pancreatic head. It was not the object of this study to repeat the excellent observations made by Opie and his successors concerning the detailed anatomy of the ampulla of Vater; it was rather our effort to demonstrate the exact course of the pancreatic ducts through the

Injuries of the Liver

Abstract: Injuries of the liver whether blunt or penetrating in nature are occurring with increasing frequency and severity. In spite of this, the average surgeon will not be called upon to care for more than an occasional patient with such an injury. Estes 1 pointed out in 1953, when making the annual oration on trauma before the American College of Surgeons, that unless the individual surgeon has had war experience in the therapy of abdominal trauma he is not likely to avoid the pitfalls that beset attempts at successful treatment of these lesions. The present study consists of, first, an analysis of my personal experience with wounds of the liver seen in civilian practice; second, a review of the liver-injury cases admitted to a city-county general hospital during the last 10 years (1944 to 1954, 81 cases), and, third, a report prepared at the close of the last war for the

SUBMUCOUS LIPOMA OF STOMACH: Case Report and Review of the Literature

Abstract: MASSIVE hemorrhage from an unknown source in the gastrointestinal tract remains one of the most perplexing problems in surgery. Lacking a history of preexisting ulcer or gastritis, negative physical findings, a questionable roentgenogram, the following case report illustrates such a problem with a most unusual lesion as the bleeding source. J. P., a 49-year-old white man, was admitted to Faith Hospital on April 25, 1953, with a complaint of tarry stools of five days' duration. The black stools had increased in frequency and volume in the 48 hours prior to admission. Except for the gradual progressive weakness, there were no associated symptoms. There was nothing in the past history suggestive of gastrointestinal disease. However, for the past two years this patient had been under medical care for hypertension and episodes of auricular fibrillation. During this time he had received various drugs including phenobarbital, veratrum viride (Vertavis), mannitol hexanitrate (Nitranitol), alkavervir

Bilateral Adrenalectomy in the Treatment of Cancer of the Breast

Abstract: The treatment of mammary cancer by endocrine methods rests on the concept of hormonal dependence, which characterizes many of these neoplasms. It has been shown that some methods of alterations in endocrine balance can constitute effective palliation in many cases. Surgical castration and administration of sex steroids have been used as the chief therapeutic armamentarium for metastatic cancer of the breast in the past decade and a half. In 1951 an important method of treatment of the disease was introduced by the finding that in certain types of mammary cancer there is an adrenal component which sustains and propagates the disease.1Surgical excision of the adrenal glands in patients maintained on cortisone has proved to be effective in producing regression of mammary cancer in certain cases.* In his Hunterian lecture Cade11commented, "Bilateral adrenalectomy is an encouragement in the pursuit of an ideal which is to control cancer

Prolonged experimental occlusion of thoracic aorta during hypothermia.

Abstract: ELECTIVE occlusion of major vessels proximal to vital structures in normothermic animals and humans has been limited in time because of tissue necrosis following prolonged ischemia. The known effect of general hypothermia in reducing tissue metabolism suggested the possibility of utilizing this technique as a means for prolonging regional ischemia without tissue or organ damage. The desirability of an essentially bloodless field for certain surgical procedures is obvious and has interested many clinical investigators in the past. Raffuci and Wangensteen, 12 in 1950, found that the maximal safe period of occlusion of the hepatic artery and portal vein in normal dogs was 20 minutes. Lengthening the occlusion time produced hepatic necrosis. Burch and his colleagues, 5 in 1953, successfully resected a temporarily bloodless left lobe of the liver in two patients while occluding the aorta above the celiac axis for 10-minute intervals. Both of these reports were during normothermia. Increasing

Carcinoma of male breast.

Abstract: APPROXIMATELY 1% of all carcinomas of the breast occur in males.1Although the disease is uncommon, the addition in recent years of various types of hormonal therapy makes it advisable to review our cases and attempt to compare the results of these newer methods of therapy with the more standard methods. For this purpose the cases at the Massachusetts General Hospital from 1914, the Collis P. Huntington Memorial Hospital from 1919, and the Pondville State Cancer Hospital have been examined. The staffs of these three hospitals overlap, and so there has been a general uniformity in the management of the cases. MATERIAL STUDIED Seventy-five patients were available for clinical examination. Twenty-five of these had previously received some form of definitive therapy, whereas 50 had received no treatment other than biopsy. The patients were in all stages of the disease. Sixty of the 75 patients were actually treated in our

Retromandibular parotid tumors; their surgical treatment and mode of origin.

Abstract: One thinks of the parotid gland as lying external or superficial to the ascending ramus of the mandible. About 80% to 85% of the parotid does in fact lie in such a position. There is a small portion, however, which hooks around the posterior margin of the mandible and extends for variable distances medial to this structure. Tumors arising from this retromandibular portion present an entirely different problem, from the point of view of both symptoms and management, from that which is encountered in the classic and better-known tumor arising from the superficial portion of the gland. Judged from the clinical histories of patients with this tumor, their therapy has been the source of considerable perplexity on the part of the physicians to whom they have applied for help. Their occurence in such an anatomically inaccessible area has led some to declare such growths as "inoperable" or to recommend x-ray

An anatomical approach to the problem of massive gastrointestinal hemorrhage.

Abstract: Gastrointestinal bleeding is a frequent problem and the localization of the site of hemorrhage may be a challenge Many lines of approach have contributed information expressing the differentiation of the causes for bleeding It was felt that the reported anatomical investigations of the problem were not extensive enough and that an additional study of an autopsy series would be enlightening Therefore, this work was undertaken The importance of the gastrointestinal bleeding problem is illuminated by the observation that hemorrhage as a cause of death at autopsy at the Cook County Hospital has more than doubled since a previous review of 1938 62 LITERATURE Chalmers and co-workers, 11 reporting from a similar type of charity institution, stated that in 24 of 101 necropsies, fatal gastrointestinal hemorrhage was not suspected clinically The clinical accuracy for the diagnosis of the source of bleeding was 53% This difficulty in ascertaining site of bleeding has

Prophylactic antibiotic therapy

Abstract: SOME OF THE current practices of antibiotic prophylaxis are becoming matters of considerable concern. Antibiotic therapy has unquestionably had a profound effect on the practice of surgery, but the persistent trend toward extending antibiotic prophylaxis indiscriminately to every patient undergoing an operative procedure is creating a number of serious problems. In the first place, it has produced in many surgeons a false sense of security which is not based upon fact. The use of antibiotics may give an erroneous impression that everything possible has been done for the prevention of an infection and that any infection developing in the wound does so because of the failure of the antibacterial action of the agent used rather than the neglect of established surgical principles or important technical details. The occurrence of the infection is usually the result of inadequate removal of devitalized tissue and foreign bodies or the development of devitalized tissue postoperatively as the result of

Facial Nerve Grafting in Treatment of Parotid Gland Tumors: New Technique

Abstract: Tumors of the parotid gland have been of particular interest to the clinician and the pathologist for the past 100 years. Their varied cellular arrangements have made their complete pathological classification a perplexing one. In the past, this situation was exaggerated by lack of an adequate correlation between the pathological classification and the appropriate therapy, thus causing the end-result analysis of the curative efforts directed against these tumors to be, in many instances, confusing. Recent efforts to clarify the microscopic classification of these tumors have been noteworthy. These classifications serve to emphasize the importance of the segregation of the various tumors of the parotid gland into their specific, microscopic categories, thus permitting the clinician to establish not only a more thorough and effective method of treatment, but a more accurate prognosis. Tumors of the parotid gland are divided into benign and malignant groups. Benign tumors of the parotid gland consist

Solitary nonparasitic Cyst of the Liver: Review of the Literature and Report of Two Patients

Abstract: Sir Benjamin C. Brodie, 20 in 1846, described seeing a young lady with a cystic tumor of the upper right abdomen which disappeared after aspiration of 2 pt. of clear, watery fluid. This case has often been referred to in the literature as that of one of the earliest solitary cysts of the liver reported. Present-day diagnostic requirements would make it at least open to suspicion as a proved instance of solitary nonparasitic cyst of the liver. As time has passed, numerous reports of this entity have appeared, and it has become of greater interest. Recent technical advances in surgery of the liver should make such cysts easier to extirpate. Wikle and Charache 135 state that the earliest reported case was that of Brisbane, on April 1, 1856, from postmortem findings. Review of this case leads me to believe that it was one of polycystic disease rather than a solitary

Pressures in the Pancreatic and Common Ducts: Values During Fasting, After Various Meals, and After Sphincterotomy; An Experimental Study

Abstract: Normal physiologic pressures in the pancreatic and common bile ducts have proved difficult to measure. Various methods of recording pressures have been described,* but all the methods have involved either producing a fistula or occlusion of the major duct by the recording cannula. The preliminary objective of the present investigation was to develop a method whereby the pressures could be recorded without producing a fistula or occluding the ducts and without interfering with any sphincteral mechanism which might control the flow of bile or pancreatic juice from the ducts into the duodenum. A method was developed which satisfactorily met these criteria, a method by which simultaneous recordings of pressures in the pancreatic duct, in the common bile duct, and in the duodenal lumen could be made from cannulae placed in these organs. The experiments were carried out on trained dogs which had fully recovered from the operative procedures of placing

Cancer of the esophagus.

Abstract: During the past 23 years, 603 patients with carcinoma of the esophagus have been admitted to the Veterans Administration Hospital, Hines, Ill. An analysis of these patients has been undertaken to determine the incidence of this disease in relationship to total admissions and to malignancies of other organs and to note any change in its frequency. As this time interval covers periods of various forms of therapy, a comparison of results has been computed. Prior to 1946, "Hines" was a tumor center for veteran patients from the entire country. This explains the higher percentage of admissions of patients with malignant diseases before this date. In 1946, Deans Committees were established to help supplement professional staffs of Veterans Hospitals. Tumor services were developed throughout the country to handle malignant disease locally. As a result, statistics at "Hines" depict the incidence of malignant disease in the veteran population of the local community

Unusual Manifestations of Parathyroid Adenoma

Abstract: Although the clinical manifestations and pathological physiology of hyperparathyroidism are now quite well recognized and understood, the diagnosis is still frequently overlooked until the opportunity for cure has been lost. This impression is borne out by the fact that when we recently surveyed the diagnostic files of seven general hospitals in a service area embracing about 1,500,000 persons over a 15-year period, only 11 proved cases of parathyroid adenoma were found. Nine of these cases are from hospitals with which we are directly connected, and only two were collected from other sources. Among the 11 cases 4 were discovered at autopsy and in 7 the clinical diagnosis was made during life and confirmed at operation. Only 1 of the 11 cases was recognized in connection with urinary calculus as the presenting symptom. In another case a nephrectomy had been done for a large ureteral stone with septic destruction of the

Study of basic physiologic changes associated with hypothermia.

Abstract: THE SEARCH for a method which would permit intracardiac surgery under direct vision has focused attention on induced hypothermia by surface cooling as a means to this end. Bigelow first demonstrated that significant reduction of oxygen consumption of the tissues occurred as a result of lowering body temperature and that during profound hypothermia the circulation could be interrupted for as long as 15 minutes.* Confirmation of these observations has come from additional experiments on animals and from clinical experience with hypothermia during surgery of the heart and great vessels.† However, the relatively high incidence of ventricular fibrillation and death in dogs at body temperatures below 28 C. poses a real hazard for practical application to clinical surgery. Furthermore, little is known of acid-base balance and metabolic behavior in mammals in the hypothermic state, and the few studies which have been made are in disagreement.‡ The studies presented in this paper

Experimental evaluation of prolonged hypothermia.

Abstract: At present, hypothermia is used in cardiac surgery and other situations where there is deliberate temporary interruption of major blood supply for short periods of time.* Its value in conditions where reduction in metabolism and "physiologic" hypotension would be desirable has been suggested.† Acute pulmonary disease, emboli, anemic crises, lower nephron oliguria, shock, myocardial infarction, and thyrotoxicosis are but a portion of the list presented by Swan7in a notable critique of the present status of hypothermia where the value of this procedure might be speculated upon. For use in such situations, it is conceivable that prolonged hypothermia might be resorted to. Further, the occasion may well arise where hypothermia for surgery may by necessity be extended beyond the relatively short periods of time now in use. Although in recent years there has been much fundamental investigation upon hypothermia, most of the experiments have been concerned with methods of

Pyloric Stenosis and Gastric Ulcer

Abstract: In 1953, L. R. Dragstedt1developed the concept that gastric ulcers are usually due to a hypersecretion of gastric juice of humoral or hormonal origin dependent upon hyperfunction or dysfunction of the gastric antrum, whereas duodenal ulcers are usually due to a hypersecretion of gastric juice of nervous origin. In previous experiments, Dragstedt, Oberhelman, and Smith2found that transplantation of the antrum of the stomach into the colon as a diverticulum caused a long-continued hypersecretion of gastric juice with the formation of chronic progressive ulcers in dogs. This hyperfunction of the gastric antrum when transplanted into the colon was abolished when the portion of colon containing the antrum transplant was excluded from intestinal continuity by means of a Thiry-Vella fistula and the isolated colon was washed clean of all traces of fecal material and food.3Obstruction to the isolated colon containing the antrum transplant produced a hypersecretion

PRIMARY TUMORS OF THE SOFT TISSUES OF THE EXTREMITIES EXCLUSIVE OF EPITHELIAL TUMORS: An Analysis of Five Hundred Consecutive Cases

Abstract: This exhibit presents some of the benign and malignant soft-tissue tumors of the extremities, exclusive of epithelial structures and lymph nodes. The tumors are grouped into six categories, one cabinet being devoted to each category. Each cabinet contains six of the more unusual and more important tumors which are considered to be derived from a single basic cell type. The incidence of the six categories, and of the individual tumors within each category, was derived from analyzing 500 consecutive cases of primary soft-tissue tumors of the extremities seen in the surgical pathology laboratory in the interim of approximately 2I/2 years. In this series, 14.6% of all the tumors, including the nonneo-plastic masses, were malignant. I. FIBROMATOUS TUMORS (See Pages 463-464) In our series 12% of the primary soft-tissue tumors were in this group. Sixty-seven per cent of the fibromatous tumors were malignant. The fibroblast is the mesenchymal element from which

Method of blood vessel anastomosis by means of metal clips; an experimental study.

Abstract: IN JOINING together the tubular structures of the body, surgical craftsmanship approaches art. Successful anastomosis is based upon knowledge of the tube's structure, blood supply, mode of healing, and, above all, the properties of its contents. The means at hand are the smallest consideration. The ideal vascular anastomosis represents a watertight junction sufficiently strong to resist lateral and longitudinal tension, whose inner surface offers neither mechanical nor biochemical inducement for thrombosis. The ultimate repair must not deform the lumen or hinder the growth of the vessel. In addition, the operation must be accomplished well within the safe time limit of occlusion for the area supplied by the vessel. By the turn of the century, techniques necessary to the attainment of this aim, such as triangulation of the vessel and intima-to-intima approximation by means of everting sutures, had been devised.* However, the exacting and sometimes exasperating nature of blood vessel suture

Extent of mandibular Resection Reguired for Treatment of Oral Cancer

Abstract: A properly planned operation for cancer of the mouth often includes the removal of a segment of the mandible or maxilla because oral cancer arises upon these structures or eventually may extend to them. Malignant growths are commoner in the lower than in the upper oral cavity, and the mandible is attacked several times as frequently as the maxilla. The lower jaw is functionally the more important of the two, and resection of it creates a serious defect. A logical plan based upon anatomical and surgical principles and a knowledge of the growth habits of cancer should be used for determining the proper extent of resection without creating needless deformity. This rule should be applied to the individual case rather than treatment being based on routine. The mandible becomes the host of malignant tumor by one of five methods. It is rarely the site of metastasis. Two instances of metastases

Primary tumors in inguinal hernial sacs.

Abstract: Contents of inguinal hernial sacs may be protean. They can include almost any structure in the abdomen as well as benign and malignant lesions which afflict these structures. Also, metastatic foci to the peritoneal lining of the sac can result from remote and adjacent malignant processes. This paper is concerned only with neoplastic processes found primarily within a hernial sac. In 1899 Lejars 4 presented a classification of tumors of hernial sacs: intrasaccular, saccular, and extrasaccular. The microscopic pathological descriptions of representative cases were, for the most part, not complete. Nevertheless, adhering to this classification, Pagliani, 6 in 1937, collected from the foreign literature four documented intrasaccular tumors: Nove and Josserand *—lipoma of appendix; Patel †—carcinoma of appendix; Gros and Denard ‡—fibrosarcoma of mesentery; Richard 7 —fibroma of mesentery. He also found a single case of saccular tumor (Rossi §—mesothelioma of sac) but no extrasaccular tumors. In addition, he presented

Postmortem Skin Homografts in the Treatment of Extensive Burns

Abstract: The successful management of fluid-balance problems associated with the early phase in the clinical course of patients having extensive burns has prevented death from this complication in many of these patients. After survival through the early phase of the postburn period, these patients may develop further complications caused by the presence of a burn wound covering an extensive area. Such items as continued fluid loss, protein loss, and infection exact a great toll in the survival rate of these patients. Liedberg, Reiss, and Artz1have recently shown that septicemia is a common cause of death in the severely burned patient. This may result from a large open wound, colonized by many species of bacteria. These observations emphasize the need for early coverage of all burned areas. In an ideal situation, burned areas should be grafted with sheets of autogenous skin, but in the extensively burned patient there may be

Diabetic neuropathic arthropathy of feet; summary report of seventeen cases.

Abstract: In neuropathic arthropathies of the feet there is a history of one or more of the following conditions: diabetes, syphilis, nerve and spinal defects, birth defects (idiopathic myelodysplasia), trauma, alcoholism, syringomyelia, leprosy, poliomyelitis, and peripheral nerve disorders. The diabetic form of neuropathic arthropathies of the feet has been brought to the attention of the general practitioner, the internist, and the orthopedic surgeon with increasing frequency. Whereas tabes of syphilitic origin was formerly the usual cause of these painless deformities of the feet, with complicating soft tissue infections, ulcers, and osteomyelitis, the diabetic neuropathic foot is now showing the higher incidence. Perhaps there is greater alertness in recognition. Certainly there must be a correlation with the higher incidence of diabetes generally, coupled with poor public awareness of the possible consequences of neglect. At the same time that reports on this diabetic foot disability are appearing more frequently, there have been noticeably

Replacement of arterial segments, utilizing flexible orlon prostheses

Abstract: BEGINNING in 1944 and in the ensuing years we have been active in the investigation of the problems of arterial homografts. Early in this work we felt the need for some method for preserving such grafts for use at a time considerably after their removal. Initially, we advocated the use of rapidly frozen grafts and showed that such grafts could be kept for prolonged periods of time at temperatures of -70 C.* Later the rapid freezing process was supplemented by drying in the frozen state, 3 and after this we devised the method for the sterilization of such grafts with the use of ethylene oxide, both as a liquid and as a gas. 4 The culmination of this process has therefore been the use of freeze-dried grafts which can be kept indefinitely in sealed vacuum tubes after being taken without aseptic precautions. For the past two years all the homografts

Management of adrenocortical insufficiency during surgery.

Abstract: Adrenocortical insufficiency, known to be present in patients with Addison's disease and in patients who have had bilateral adrenalectomy, may also be induced in patients who have been receiving therapy with cortisone or other corticosteroids. The possibility of death following surgical intervention in such persons has been pointed out.* This is particularly apt to occur in cases where emergencies require surgery to be performed without benefit of prior work-up and preparation. We wish to describe our experiences in the management of three patients with adrenocortical insufficiency, each with a different problem, who required surgical intervention. We have had six patients with hypoadrenalism at the Hospital for Special Surgery in the past two years who required surgery; hence, it is by no means a rare problem. Five of the six patients had cortisone-induced cases of hypoadrenalism. All were prepared for surgery but one, and in only one who required emergency surgery