RUPTURE OF DISSECTING ANEURYSM OF THE AORTA—The Relationship of Effort to Onset

Physicians are constantly being asked to testify in cases in which a complication of a degenerative disease occurred during the course of employment. In one of two such cases reported herein, compensation was granted, in the other, not.A physician can say for certain that the effort did not cause the disease, but he cannot say for certain that it had nothing to do with the rupture.     

SURGICAL MANAGEMENT OF DISSECTING ANEURYSM—The Use of a Simplified Bypass

The alarming mortality in cases of dissecting aneurysm of the aorta has stimulated the development of a surgical technique which results in re-entry of the dissecting channel. During the operative procedure prolonged cross-clamping of the aorta is necessary. While hypothermia will provide protection to the spinal cord and kidneys during reasonable periods of aortic occlusion it will not relieve back pressure on the left ventricle.By the use of a simple bypass blood is drained from the left atrium into a reservoir and then pumped into the lower aorta via the femoral artery. Thus an adequate supply of oxygenated blood is delivered to the spinal cord and kidneys distal to the occlusion while the left ventricular pressure is decompressed to normal levels. The volume of the shunted blood is simply controlled by monitoring the brachial artery pressure with a cuff sphygmomanometer. This simplified bypass has permitted successful repair of a dissecting aneurysm with complete occlusion of the thoracic aorta for a period of two hours.     

STRAWBERRY HEMANGIOMAS—The Natural History of the Untreated Lesion

A review of the literature on the natural history of strawberry hemangiomas revealed over-whelming evidence of the satisfactory spontaneous involution of over 95 per cent of these lesions without the scarring and danger of other sequelae inherent in the various forms of treatment.In a study of 105 strawberry nevi observed for more than one year, 97 per cent of the lesions had either completely disappeared or were regressing satisfactorily.A cross-section study of 1,735 consecutively examined children in routine pediatric practice showed hemangiomas to be present in 10.1 per cent of all infants from birth to one year of age but that this incidence drops to 1.5 per cent in children over five years of age, confirming the fact of spontaneous involution.     

THE MANAGEMENT OF ALLERGIC PATIENTS—The Role of the Internist

There has been an increasing trend in the United States toward intensive specialization in allergic diseases. Whereas the tendency toward specialization has led to greater knowledge of the scientific aspects of allergic phenomena, it has somewhat diverted the specialists'' attention from the many clinical problems that await solution.Effective treatment of the allergic patient depends in no small measure on the broad viewpoint and clinical experience of the internist. This fact has been reemphasized by the growing awareness of the significance of the secondary or precipitating causes, such as climatic, nutritional, hormonal and psychogenic factors which influence allergic manifestations. Overemphasis on specialization in allergic diseases with their wide ramifications may defeat the main objective—a successful therapeutic result.To meet this challenge, the internist should be trained in allergy and yet retain a broad approach to the more basic problems of internal medicine. This objective may be attained by certain modifications in undergraduate medical instruction in allergy. Postgraduate training sponsored by our national allergy societies affords internists an excellent opportunity to advance their knowledge of clinical allergy.     

DIAGNOSIS OF ABDOMINAL LESIONS—The Use of Intravenous Aortography,Nephrotomography and Retrograde Aortography

New and safe methods of investigating the kidney by x-ray visualization of its circulation are now available. This can be done either by injecting large amounts of contrast material through a vein and then taking multiple x-ray exposures of the kidneys, or by injecting the contrast material backward into the aorta to the level of the renal arteries.Another method of x-ray examination now available is taking body section films of the kidneys when the contrast medium is in the kidney substance. This makes the kidney outline extremely sharp and allows more precise diagnosis.     

CANCER OF THE LARYNX—The Advantages of More Conservative Treatment

Properly administered irradiation therapy for cancer of the larynx in properly selected cases can be successful. Reported herein is the case of a woman 49 years of age with a Grade 3 squamous cell carcinoma of the larynx, who at first was scheduled for radical operation but was treated by irradiation therapy with an estimated total dose of 5292 r given in 29 treatments. The tumor and all subjective and objective symptoms disappeared. The patient was still well when last observed a year later.     

MENTAL DISORDERS OF THE AGED—The Role of the State Hospital in the Treatment; Report of a Pilot Study

The number of patients age 65 and over at the Agnews State Hospital now constitutes over one-third of the resident population. The geriatric population is increasing in all California state hospitals.Because this is a relatively new area of concern for the psychiatric institution, the role of the state hospital in the care of the aged is not yet clearly defined.A pilot study of admissions in this age group committed from one county during a 12-month period was undertaken, with an attempt made to evaluate the suitability of the patient for commitment, as well as special problems in admission, treatment during hospitalization, and release from the hospital. The study indicated 42 per cent of persons admitted were considered unsuitable for commitment. Physical illness was found to be a major factor in precipitating admission and a predominating factor in the treatment program after admission. Almost 40 per cent of the patients died within a year after admission.     

PREVENTION OF CARDIAC ARREST—The Role of the Anesthesiologist

Many operating room deaths from “cardiac arrests” are potentially avoidable as well as potentially reversible. The incidence of these catastrophes may be substantially reduced by careful and adequate preoperative evaluation and preparation of the patient, by constant care and vigilance in the administration of anesthetic agents and adjuvants, and by close cooperation between members of the surgical team, with the safety of the patient being the first consideration at all times.     

THE REPAIR OF DIFFICULT INGUINAL HERNIAS—Resection of the Spermatic Cord

A method of removing the cord structures from the inguinal canal and preserving the testis and the portion of the spermatic cord distal to the external ring was used in repair of large or recurrent hernias in 14 patients. Only one patient had pronounced testicular atrophy. In one case there was recurrence through the femoral canal. The procedure is simpler and shorter than removal of the testicle as well as the cord.     

COMPRESSION NEUROPATHY OF THE ULNAR NERVE—A Common Condition Occurring at Bed Rest

Compression neuropathy of the ulnar nerve at bed rest appears to be quite common. The symptoms are dysesthesia, weakness and later atrophy in the area of distribution of the nerve. Special attention is required for prevention or for early discovery of the condition in time for treatment to bring about prompt recovery. Physical therapy with electrical stimulation may be useful in the more severe cases. When the condition is progressive or recalcitrant, anterior transplantation of the nerve may be necessary.     

PANCREATITIS AND CARCINOMA OF THE PANCREAS—Some Aspects of the Pathologic Physiology

The physiological phenomena accompanying pancreatic disease in adults are related to the local and generalized reaction of the body to the blockage and/or leakage of the three enzymes—amylase, lipase and trypsin. The measurements of amylase and lipase in the serum are the most reliable criteria in the diagnosis of acute disease. Related changes may include hypocalcemia, hypopotassemia, hyperlipemia, hyperglycemia and decreased renal function.In chronic pancreatitis, there is less fluctuation in the amounts of the enzymes in the blood. The presence of diabetes mellitus, demonstration of calculi by x-ray, and examination of the stools for excess fat and meat fibers are more important diagnostic guides.In cancer of the pancreas, function tests using secretin stimulation of the gland followed by an examination of the external secretion or determination of the serum amylase have been used with some success.     

DETERMINING THE SITE OF BRAIN TUMORS—The Use of Radioactive Iodine and Phosphorus

By tests using radioactive iodine combined with diiodofluorescein, the site of tumors was correctly determined in 61 per cent of 39 cases of tumors of the cerebral hemispheres. In 19 cases where the focal radioactivity was increased 24 per cent or more over that of the surrounding area, there were no errors in localization. Fifteen patients with expanding intracranial lesions were tested at operation with radioactive phosphorus and 14 lesions were correctly localized. This procedure in which the needle probe was used was found of great value in rapidly locating and outlining the area of involvement.     

SCINTIGRAMS OF THE THYROID GLAND—The Diagnosis of Morphologic Abnormalities with I131

Functioning thyroid tissue containing sufficient radioiodine can be visualized by scanning the gland with a directional scintillation counter.⁴ This visual representation of the gland is called a “scintigram.” Scintigrams have been invaluable in the detection and study of both “toxic” and non-functioning nodules, diffuse enlargement in hyperthyroidism and the subsequent reduction in gland size after treatment, carcinoma, and aberrant thyroid tissue.