Showing papers in "American Journal of Surgery in 1935"

Scalenus anticus (naffziger) syndrome

Abstract: T HE presence of supernumerary ribs in the cervica1 region has been known since the origina observations of WiIIshirel to cause symptoms in some cases because of the pressure exerted by the rib on the brachia1 pIexus and subcIavian artery. CIinicians have, however, repeatedIy observed that cervica1 ribs may occur without producing symptoms and that in many cases with a uniIatera1 cervica1 rib symptoms may occur on the contraIatera1 side in which no rib is demonstrabIe. ToreIIi2 reported IOO cases of cervica1 rib, onIy 9 of which produced symptoms. Adson and Coffey3 found that cervica1 rib occurs more often on the Ieft side, but symptoms are present more commonIy on the right side. The fact that pressure symptoms identica1 with those produced by cervica1 ribs can occur in the absence of supernumerary ribs in the cervica1 region had Ied many4+14 to concIude that the subcIavian structures are compressed by the first rib. The position of the first thoracic rib is only reIative and even though it may be eIevated with respect to the vertebra1 coIumn, few, if any, symptoms wiI1 resuIt unIess it is raised with respect to the subcIavian structures as symptoms occur onIy when the brachia1 pIexus and subcIavian artery are compressed. ConverseIy, in the absence of eJevation of the first rib with respect to the vertebra1 coIumn, symptoms occur if there is depression of the shouIder with a resuIting puI1 on the subcIavian structures or a reIativeI;v Iow origin of the brachia1 pIexus, causing anguIation over the first rib. Thus it may be concluded that symptoms occur onIy when there is aIteration * From the Departments of Surgery, Tulane University School of Medicine, Charity Hospital, and Touro Infirmary, New Orleans, 12a.

Treatment of hemangiomas

Abstract: The methods used in the treatment of hemangiomas, and the results obtained at The Children's Hospital over a period of four and one-half years have been reviewed. Broadly, these consisted in: 1. 1. Use of the Kromeyer lamp in the treatment of port wine nevi. 2. 2. Excision of the tumor whenever it would not result in deformity or be injurious to adjacent parts. 3. 3. Use of carbon dioxide snow to fade the capillary tumors, and that portion of the mixed tumors that is near enough the surface to be reached by the CO2 penetration. 4. 4. Use of endothermy coagulation to sclerose the deeper portion of the mixed and cavernous tumors. Other methods of sclerosing mentioned earlier, namely, radium, x-ray, platinum needle fulguration, etc., have not been used in this clinic during the past four and one-half years, so that conclusions on a comparative basis are not possible. However, the use of these other methods on a smaller series before the period covered in this review, and those seen in our clinic that were treated elsewhere by these methods, were all, in our opinion, far less satisfactory than the present outline of treatment. The endothermy coagulation has proved to be of decided value in reduction of the size of the tumor in every case in which it was used. The treatment is not difficult, and although it does require a general anesthetic, the time it consumes is short. As it produces no systemic reaction, it may be carried out for the most part in the Out-Patient Department. It has now been used in enough individual instances to convince us that it is an extremely effective method of treating those tumors in which snow or excision has not been advisable. However, it must be strongly emphasized that in many instances, no one method in itself has been self-sufficient, but the judicious combination of them all has proved the most satisfactory in this clinic.

Diverticula of the female urethra

Abstract: U RETHRAL pouches or diverticuIa have been described since 1814. The earIiest reference is found in Sir Charles Mansfield Clarke’s “Disease of FemaIes.” He states: “Sometimes a pouch forms in the posterior part of the urethra in which a few drops of urine Iodge and from which situation it may be pressed out by the finger appIied to the part.” The majorrty of case reports are confined to urethra1 diverticuIa found in the maIe. This series of 6 cases of diverticuIa in the femaIe were seen on the GynecoIogicaI and UroIogical services of St. Luke’s HospitaI since 1929. I am indebted to the members of these departments for the priviIege of presenting these cases.

Full term intra-abdominal pregnancy

Abstract: The important points in the management of extra-uterine pregnancy with a viable fetus have been discussed. Three hundred eleven cases have been collected from the literature and 5 new cases added, the senior author's case being the only one fully described. The additional 4 cases not described in detail have never before appeared in the literature. The information regarding them has been given to us by the doctors who had them in their charge. Permission to cite them has been given by: Drs. A. C. Posner and Carl Eggers, New York; and Drs. George Nordlinger and Raymond T. Holden, Jr., Washington, D. C. A complete table including in all 316 cases is appended.

Riedel's struma

Abstract: 1. 1. The diagnostic features are the stony hard tumor, the immobility, the dyspnea from tracheal compression as shown by x -ray in the advanced cases out of proportion to the size of the tumor, the lack of toxic symptoms and of cervical node involvement. 2. 2. The treatment of choice is surgical, complete thyroidectomy, especially when both lobes are involved, and the case is operable. If not, at least a wedge-shaped piece should be removed from the isthmus to relieve the pressure over the trachea. The results of x -ray treatment have not been noteworthy and the data relative to such treatment are meager. 3. 3. Rectal anesthesia is preferable in these cases, avertin is the choice when fibrous extension has not passed the capsule and the prethyroid muscles and adjacent tissues are not involved, and the trachea not constricted. In the advanced cases with marked constriction of the trachea and involvement of adjacent tissues, oil-ether colonic anesthesia as developed by Gwathmey in the Stuyvesant Square Hospital, gives a prolonged anesthesia with a minimum of danger, and the surgeon can do a careful operation without worrying about the length of time he is taking. No doubt the mortality from operations on the earlier cases reported would have been lessened with this type of anesthesia. 4. 4. The pathology is that of a replacement fibrosis, of an earlier lymphoid cell invasion. 5. 5. While the mortality was rather high in the first cases reported and many cases were abandoned as inoperable, or a tracheotomy only was performed, it is noticeable in the later cases that the mortality has diminished to a practically negligible figure. 6. 6. Most of the writers who have either written articles or reported cases, with the exception of Hashimoto in 1912 and Graham and McCullough in 1931, have not chosen to separate the two types of strumas, Riedel's and Hashimoto's, but have considered them to be different stages of development of the same disease.

Catgut allergy: With a note on the use of alloy steel wire for sutures and ligatures

Abstract: Catgut brings a mixed blessing to the surgeon For the very desirable asset of absorbability it carries a number of liabilities By producing allergic reactions in the tissues it retards healing Its persistence cannot be foretold A wound closed by chromic catgut may open four or five days later with most of the catgut absorbed Again, bits of intracuticular suture, labelled oo plain, may extrude from the skin weeks after its insertion It cannot be sterilized by any known chemical method Silk is especially to be preferred in operations upon the thyroid From its lack of capillarity, and toleration by the tissues, annealed rustless steel wire is deserving of wider trial as a suture, and occasionally, in septic wounds, as a ligature

Progress of maggot therapy

Abstract: A survey has been made of the use of sterile blowfly maggots in surgery in the treatment of suppurative infections. The treatment has been given in every State in the United States and in Canada, and 605 surgeons have used the method upon 5750 cases. It has also spread to many other countries. A list is given of the various infections which have been treated with maggots. The opinion of the surgeons using this method was obtained and is shown in tabular form: 8.8 per cent of the opinion was unfavorable or neutral and 91.2 per cent favorable to the maggot treatment. The objections to the method which were made are shown and discussed. A representative bibliography is given.

Davidson tannic acid treatment of burns

Abstract: The original paper of Davidson recommending tannic acid for burns outlined a treatment that has been changed but little in ten years' time. We believe that the spray method of 5 per cent tannic acid is the most convenient way of application. Any discussion that might arise as to the correctness of his statement of the theory of toxemia of burns should not be allowed to confuse the issue, as such tremendous improvement in the results has been reported. We should like to emphasize again as Davidson did the great importance of instituting immediately the best known and accepted means for the prevention of shock or the treatment of it, if present, when the patient is admitted. The ideal treatment must exclude all confusion and excitement in the room. Every effort to obtain the patient's confidence should be made, at the same time allaying apprehension. Sedatives, preferably morphine or codein, should be given at once as this is so effective in quieting fear. We believe that the room should be kept very warm, 90 ° or over. The foot of the bed should be elevated. First intravenous salt solution should be given and then transfusions of blood, after grouping has been determined. The technique of the preparation for and the application of tannic acid is here given as we practice it. Our method of procedure in the treatment of a burn case is as follows: 1. 1. Morphine or codein should be given at once. 2. 2. The grime of work is removed without undue scrubbing, using ether or benzine. 3. 3. The surrounding unburned skin area is thoroughly cleaned with soap and water. 4. 4. The blisters are widely opened under careful aseptic technique, using sterile instruments and sterile gloves, and the loose areas of skin are removed. The extent of the debridement and scrubbing must depend on the patient's condition. Too much manipulation may aggravate or produce shock. 5. 5. The patient is placed in bed on sterile sheets. 6. 6. The burned area is sprayed with a 5 per cent aqueous solution of tannic acid every fifteen minutes until a dark mahogany colored coagulum is obtained. This usually requires from ten to eighteen hours. 7. 7. A cradle to support the bed covers is placed over the patient. 8. 8. Sufficient electric lights are introduced between the covers to provide a temperature of 90 °. In addition to providing heat, the lights also aid in the drying process and therefore hasten the tanning. 9. 9. The greatest care is taken in the handling of these patients in their rooms and so far as technique is concerned one must treat them exactly as one would treat a surgical incision. 10. 10. The coagulum is allowed to remain in place until it frees itself and curls up at the edges as healing takes place, at which point it is cut away. 11. 11. Should serum collect underneath, as may occur when there has been complete destruction, or should infected fluid cause its loosening, the coagulum should be removed sufficiently to allow drainage and treatment. 12. 12. The denuded areas which are left after loosening and removal of the coagulum has taken place, should be immediately prepared and early skin grafting carried out. 13. 13. As soon as possible, after healing has taken place, physiotherapy should be instituted to increase function, if indicated. 14. 14. Should contractures occur in spite of all efforts to prevent them, plastic operations must be carried out to restore function.

Chronic subdural hematoma: Diagnosis and treatment

Abstract: 1. 1. The paper is based on a series of 24 cases of intracranial encapsulated subdural hematoma. 2. 2. The lesion is of traumatic origin with rare exceptions. If is difficult to exclude slight trauma as the causative agency even in those cases thought to be spontaneous. 3. 3. In many cases the injury producing the bleeding was considered slight or even trivial and caused no concern at the time. Fracture of the skull was found in only 2 of the 24 cases of the series. 4. 4. The patient may be free from complaint for weeks or months after the injury causing the clot, but this so-called “free interval” has been over-emphasized. In probably more than 50 per cent of the cases there are symptoms of cerebral disturbance, chiefly headache, from the time of the injury until the clot is removed. 5. 5. The diagnosis may be strongly suspected or made if injury is recalled by the patient and he complains of headache, accompanied by stupor, mental changes and signs of compression. Signs of compression may vary from day to day. 6. 6. When subdural hematoma is suspected a bilateral trephine exploration should be made in the upper temporal region. One opening on each side is sufficient for diagnosis and evacuation of a clot. Regardless of symptoms, signs or operative findings, both sides should be explored during one operation, unless a preliminary ventriculogram has shown a unilateral lesion. If a clot is found on neither side a ventriculogram may be necessary to make the diagnosis. 7. 7. An osteoplastic flap is never required as a primary procedure unless the burr-opening shows solid clot and this is unusual. As a secondary procedure it may be needed to remove solid portions of clot not evacuated through the small bone opening. There is no reason to believe that the retained sac is harmful. At any rate the sac is probably never removed completely with any type of operation. 8. 8. Delayed convalescence of the patient is often associated with non-expansion of the brain on the side of the clot and a postoperative subdural hydroma. Drainage should be used when a cavity is left in the subdural space, by removal of the clot. 9. 9. The clot was removed in every patient of the series. There were 4 deaths.

Anterior extraperitoneal approach to the lumbar sympathetic nerves

Abstract: A new technique for the extraperitoneal removal of the lumbar sympathetic nerves is described. The entire operation is performed through a muscle-splitting incision which makes it possible to get the patients out of bed in from three to five days. The exposure is adequate for the removal of the entire lumbar chain and the entire operation can be performed very rapidly. We feel that the operation is far superior to any heretofore described because it offers better exposure, a rapid removal of the sympathetic nerves, no danger of hernia formation and is apparently without any except incidental mortality.

Adrenal cortical hyperfunction

Abstract: 1. 1. Five cases of adrenal cortical hyperfunction treated surgically by unilateral adrenalectomy are described. Four of the patients were benefited and one died. 2. 2. Histologic examination revealed a pathognomonic alteration of the reticular zone. 3. 3. The symptomatology is reviewed, and the pathogenic relationship of the pituitary, ovary and adrenal to the disorder is discussed. 4. 4. A differential diagnosis between this cortical hyperfunction, basophilic adenoma, arrhenoblastoma and related endocrinopathies is presented. 5. 5. The operative procedure is described.

Benign fibrous stenosis of the common duct

Abstract: 1. 1. A case of benign fibrous stenosis of the pancreatic portion of the common duct in an adult that resembles the pathology found in the congenital type of benign fibrous stenosis is reported. 2. 2. The literature of fibrous stenosis of the common duct and its causes is reviewed. 3. 3. The causes suggested in the previously reported cases and the findings in the present report do not explain the lesions found, so far.

Carcinoma of the thyroid gland

Abstract: 1. 1. Five cases of carcinoma of the thyroid are reported in individuals under twenty years of age. 2. 2. The lesion was suspected before operation in only 1 case; in 4 the diagnosis was made by microscopic study. 3. 3. A nodular adenomatous goiter, first observed during puberty, had been present in all cases for an average of 4.5 years. 4. 4. Follow-up studies of 4 patients showed them all to be alive with no recurrence or metastasis for periods of two and one-half to three years after operation. No follow-up data are available in one case. 5. 5. The removal of rapidly enlarging thyroid nodules or predominantly adenomatous goiters in children and young adults is advocated in selected cases.