TRANSURETHRAL PROSTATECTOMIES—A Review of 560 Cases

Of 560 prostatectomies in an 11-year period on patients with benign or malignant disease of the prostate gland, almost 98 per cent were done transurethrally.Although many of the patients were considered to be in poor condition preoperatively, results achieved by the transurethral operation were excellent or good in 91 per cent of those who had benign disease of the prostate and in 84 per cent of those with malignant invasion. The rate of deaths attributable to the operation was 3.1 per cent in the group of patients with benign disease, 5.3 per cent in patients who had cancer.Complications, such as urinary incontinence, persistent pyuria, epididymitis, strictures of the urethra and of the meatus, and contracture of the neck of the bladder, arose in a surprising number of cases.     

ITCHING IN THE EAR CANAL DUE TO HYPOCERUMENOSIS—An Effective Method of Treatment

Itching of the ear canal, with oozing, edema and cracking of the skin due to absence or insufficiency of wax was treated in more than 200 cases by instructing the patient to massage the ear canal with a cotton tip applicator soaked with a hydrocortisone preparation and inserted a half to three-quarters of an inch beyond the meatus.Some 95 per cent of patients reported good to excellent results in three to four days after the beginning of treatment. In the remainder results were fair.     

Surgical Treatment of Mitral Insufficiency

Sixty-four patients with pure mitral insufficiency were operated upon. Thirty of them had torn chordae tendineae. It was possible to repair the mitral valve in 57 patients and there were five operative deaths. One patient had a femoral artery embolus and another had a cerebral embolus. The incidence of peripheral embolization was 4 per cent compared with 40 per cent reported for ball valve replacement.Forty-eight of the 57 patients with repair (84 per cent) were living and well with at most a grade II/VI apical systolic murmur up to seven and a half years after operation. There has been no evidence of recurrence in these patients.In approximately 90 per cent of patients with pure mitral insufficiency, repair should be performed. When feasible, repair is more satisfactory than valvular replacement, with not only excellent long-term results, but far less morbidity than is reported with ball valve replacement.     

CIRRHOSIS OF THE LIVER—Clinical Course in 2,377 Patients at San Francisco General Hospital

The records of 2,377 patients with Laennec''s cirrhosis were reviewed for the period 1947-1957. The chief presenting symptom was ascites in 46 per cent, bleeding in 23 per cent, coma in 18 per cent, jaundice in 9 per cent, and both jaundice and ascites in 4 per cent. Nearly half of the patients died during the period under study—one-third from hepatic failure, one-third from gastrointestinal bleeding, and one-third from other causes, most of which were related to alcoholism.Massive gastrointestinal bleeding occurred in 21 per cent of the patients at some time in their clinical course, and in the 10 per cent of these in whom ulcer was demonstrated, one-fifth died as a result of the hemorrhage. Of those presumed to be bleeding from esophageal varices, 64 per cent died at the first hemorrhage and 10 per cent at subsequent hemorrhages; 85 per cent of all those who bled from varices were dead at the end of one year, and 91 per cent were dead at the end of three years.The survival curve of a group of patients who bled once and were good operative risks but had received no operative treatment was compared to the survival curve for entire group who survived the first hemorrhage. The three-year survival in the good risk group was 47 per cent; for the group as a whole it was 30 per cent. The difference in mortality rate was primarily due to an increased number of deaths from hepatic failure in the combined group, whereas 60 per cent of the good risk group died of recurrent gastrointestinal hemorrhage.As 86 per cent of those who were to die of gastrointestinal bleeding did so at the first hemorrhage, it was concluded that any decided improvement in the salvage rate achievable by operation must come from some means of diagnostic forecast of the likelihood of bleeding, with resort to prophylactic operation in such cases.     

Hypersensitivity to house dust; a preliminary report on treatment of children with antigens at two different dosage levels

Two comparable groups of children with allergic sensitivity primarily to house dust were treated respectively with low (1:1,000,000) and high (1:100) dilutions of Endo house-dust extract. In the two groups there were 47 patients with asthma, 5 with chronic allergic rhinitis, and 10 with both. After an average of 16 to 18 months of injection treatment, good to excellent results were obtained by 75 per cent of the patients on low dosage and 80 per cent on high dosage. Change of dosage from low to high in five cases, and from high to low in five others, made no perceptible difference in results. Continuous and regular treatment seemed to be more important than the size of dose. The apparent effectiveness of small doses of dust extract may be due to the polysaccharide nature of the material which persists as an active antigen in the tissues.     

HYPERSENSITIVITY TO HOUSE DUST—A Preliminary Report on Treatment of Children with Antigens at Two Different Dosage Levels

Two comparable groups of children with allergic sensitivity primarily to house dust were treated respectively with low (1:1,000,000) and high (1:100) dilutions of Endo house-dust extract. In the two groups there were 47 patients with asthma, 5 with chronic allergic rhinitis, and 10 with both.After an average of 16 to 18 months of injection treatment, good to excellent results were obtained by 75 per cent of the patients on low dosage and 80 per cent on high dosage. Change of dosage from low to high in five cases, and from high to low in five others, made no perceptible difference in results. Continuous and regular treatment seemed to be more important than the size of dose.The apparent effectiveness of small doses of dust extract may be due to the polysaccharide nature of the material which persists as an active antigen in the tissues.     

MENINGITIS—A Review of One Year's Cases from an Active Children's Hospital Service

Fifty-six cases of bacterial meningitides, other than tuberculous, observed in a period of one year on an active children''s hospital medical service were reviewed. All age groups were involved but most commonly infected were patients in the first year of life. There was no inordinate incidence of infection with any one kind of organism in any specific age bracket, except possibly for infection with enteric organisms which in the present series occurred preponderantly in infants less than six months old. Meningococcus and H. influenza type B were the most common organisms; they were the infecting agents in 71 per cent of cases. Of the immediate complications noted, subdural effusions were the most common (23 per cent of this series). In all except two cases, effusion was resolved by multiple aspirations. In two cases craniotomy was done with good results. Ten electroencephalograms were made and all were abnormal. In most of the patients, multiple antibiotic and chemotherapeutic drugs were used, parenterally during the first few days of hospitalization and then orally as tolerated. Intraspinal therapy was not given. Four of the 56 patients died.     

PRESENT STATUS OF DERMABRASION

The use of dermabrasion for cosmetic purposes is becoming less popular due to limitations inherent in the method despite the fact that it is still the best method available for the minimizing of acne scarring. Planing for precancerous skin is increasing in demand because of definite benefits to be gained from its use. While the method has not attained universal acceptance for the latter purpose, 80 per cent of dermatologists who have tried this approach, and who answered a questionnaire, rate the benefits obtained as excellent or good. Only 3.5 per cent considered the results as poor. In a five-year period between two questionnaires, there was in general a trend away from enthusiasm for this modality, but esteem for it as a way of dealing with precancerous skin held up better than opinion of its use for cosmetic purposes.     

Palliative care: views of patients and their families.

OBJECTIVE--To investigate the current problems and needs of terminally ill cancer patients and their family members, and to discover their views of hospital, community, and support team services. DESIGN--Prospective study of patients and families by questionnaire interviews in the patients'' homes. SETTING--Inner London and north Kent (London suburbs). SUBJECTS--65 Patients, each with a member of their family or a career. MAIN OUTCOME MEASURES--Ratings of eight current problems and ratings and comments on three services-hospital doctors and nurses, general practitioners and district nurses, and the support team staff-obtained after a minimum of two weeks'' care from palliative care support teams. RESULTS--Effect of anxiety on the patient''s nearest career. and symptom control were rated as the most severe current problems by both patients and families; a few patients and families identified other severe problems. Families'' ratings of pain control, symptom control, and effect of anxiety on the patient were significantly worse than the patients'' ratings (p less than 0.05). Support teams received the most praise, being rated by 58 (89%) patients and 59 (91%) of family members as good as excellent. General practitioners and district nurses were rated good or excellent by 46 (71%) patients and 46 (71%) family members, but six (9%) in each group rated the service as poor or very bad, and ratings in the inner London district were significantly worse than those in the outer London district. Hospital doctors and nurses were rated good or excellent by 22 (34%) patients and 35 (54%) of family members, and 14 (22%) patients and 15 (23%) family members rated this service as poor or very bad. Negative comments referred to communication (especially at diagnosis), coordination of services, the attitude of the doctor, delays in diagnosis, and difficulties in getting doctors to visit at home. Family members were more satisfied with the services than were patients. CONCLUSIONS--Palliative care needs to include both the patient and family because the needs of the family may exceed those of the patient. Support teams and some hospital and community doctors and nurses met the perceived needs of dying patients and families, but better education and organisation of services are needed.     

HDR-plesiotherapy for the treatment of anogenital extramammary Paget's disease

BackgroundExtramammary Paget disease (EMPD) is a rare condition that most commonly affects the anogenital region in the elderly. It may be associated with an underlying invasive carcinoma. Surgical excision is nowadays considered a standard treatment for extramammary Paget's disease, although this approach might not be suitable for all patients. Good rates of local control and cosmetic outcome have been achieved by using high-dose-rate (HDR) plesiotherapy in the treatment of skin tumors arising in different locations.Material and methodsWe present the results observed in a patient with EMPD treated by HDR plesiotherapy with a custom-made mold up to a final dose of 54 Gy in 12 fractions of 450 cGy over 4 weeks.ResultsAfter a follow-up of 18 months, the patient is alive and without evidence of local or distant relapse. Acute toxicity was acceptable and cosmetic result was considered as excellent.ConclusionThis technique represents an attractive alternative for those patients who are not candidates for surgical procedures because of unacceptable risk of disfigurements or functional impairment, medical contraindications or patient preference.     

SEVERE EUTHYROID CARDIAC DISEASE—Technique for Treatment with Radioiodine

It is possible to safely lower the basal metabolism of patients suffering from severe cardiac disease by administering multiple small doses of radioiodine in order to achieve symptomatic relief.From the present study, multiple small doses of I¹³¹ appeared to be as effective as single or multiple large doses of this material and complications such as thyroiditis, temporary thyrotoxicosis and bone marrow depression were almost always avoided. No damage to the parathyroid glands or the recurrent laryngeal nerve was observed. No radiation sickness developed after therapy.A scintigram of the thyroid gland was useful in determining the size, shape and function of the thyroid gland before and during radioiodine treatment and helped to determine the need for additional treatment. In order to prevent the distressing symptoms of the myxedema state, desiccated thyroid was administered when necessary.In the series of 278 euthyroid patients with severe cardiac disease who were treated with radioactive iodine, results were excellent in 35 per cent of cases and good in 44 per cent. In 21 per cent there was no improvement.     

MORTALITY RATES IN PATIENTS WITH BURNS—A Report of Experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956.The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection.No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived.No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection.The lowest mortality rate was in the age group of 15 through 35 years.     

Mortality rates in patients with burns; a report of experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956. The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection. No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived. No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection. The lowest mortality rate was in the age group of 15 through 35 years.     

Myasthenia Gravis: Comparative Evaluation of Medical and Surgical Treatment

Sixty-eight patients with myasthenia gravis were evaluated and compared to determine the results of medical and surgical treatment; eight patients with thymoma were evaluated separately. In the group of 30 non-thymoma patients treated medically 50% of patients derived moderate to good improvement over a mean follow-up period of 11 years. Ten per cent of patients in this group died from myasthenia.In the group of 30 non-thymoma patients treated by thymectomy, 83% achieved good to excellent improvement. There was no surgical or myasthenic mortality over a mean follow-up period of nine years.The results of treatment in the eight thymoma patients were decidedly inferior and there was no significant difference between the medically and surgically treated patients. Fifty per cent showed only moderate improvement during a mean follow-up of five years and 50%, after initial improvement, deteriorated later and died from myasthenia between three and four years after thymectomy.Two additional patients had thymoma without myasthenia. Neither of them had developed myasthenia, two years following thymectomy in one case and after 25 years in the other, despite recurrence of the tumour with extensive invasiveness in the very long-standing case.     

MATERNAL AND PERINATAL DEATHS IN CALIFORNIA

In a 29-month period, 151 of 373 deaths of California women occurring during or within 90 days of termination of pregnancy were studied jointly by the California Medical Association and the California State Department of Public Health. Twenty-two per cent of the deaths reviewed were considered unavoidable. In 74 per cent, one or more avoidable factors were identified. Avoidable factors could not be identified in 4 per cent of the cases.Thirty-three per cent of the cases considered to have avoidable factors were attributed to be solely the responsibility of the attending physician. Inadequate hospital facilities were held responsible in less than 1 per cent of deaths, while responsibility in 26 per cent of the deaths was laid directly to patient error or refusal. In 40 per cent of the avoidable deaths, more than one avoidable factor was identified.Nonobstetric conditions accounted for the greatest proportion of the deaths, followed by hemorrhage, toxemia of pregnancy, sepsis, abortion and ectopic pregnancy.The findings of this study compare closely with those of similar studies in other states, including Minnesota and Massachusetts.     

Prepartum nausea and vomiting; a new approach to treatment

A controlled study of 101 patients indicated that a combination of amphetamine and Rauwolfia was effective in the treatment of prepartum nausea and vomiting. Good to excellent results were obtained in 53 (83 per cent) of 64 patients who received the combination. Five patients reported fair results; six were not benefited by the treatment. Only five of a control group of 37 patients who received placebos reported good results. In addition to relief of the symptoms of nausea and vomiting, concomitant emotional disturbances, notably anxiety and depression, were alleviated by the drug combination.     

Severe euthyroid cardiac disease; technique for treatment with radioiodine

It is possible to safely lower the basal metabolism of patients suffering from severe cardiac disease by administering multiple small doses of radioiodine in order to achieve symptomatic relief. From the present study, multiple small doses of I(131) appeared to be as effective as single or multiple large doses of this material and complications such as thyroiditis, temporary thyrotoxicosis and bone marrow depression were almost always avoided. No damage to the parathyroid glands or the recurrent laryngeal nerve was observed. No radiation sickness developed after therapy.A scintigram of the thyroid gland was useful in determining the size, shape and function of the thyroid gland before and during radioiodine treatment and helped to determine the need for additional treatment. In order to prevent the distressing symptoms of the myxedema state, desiccated thyroid was administered when necessary. In the series of 278 euthyroid patients with severe cardiac disease who were treated with radioactive iodine, results were excellent in 35 per cent of cases and good in 44 per cent. In 21 per cent there was no improvement.     

ECTOPIC PREGNANCY—Early Diagnosis,Clinical Errors and Conservative Operation

This report of eight years'' experience with extrauterine pregnancy by a single gynecologist is an exposition of how the diagnosis was made or why it was missed.Of 26 diagnoses of ectopic pregnancy, five were false (20 per cent); and in three cases (10 per cent) the diagnosis was not made promptly—a total error of 30 per cent.Ectopic pregnancy will be discovered earlier if obstetric patients are always examined shortly after missing the first menstrual period.A palpable adnexal mass was present in 19 of 21 ectopic pregnancies (90 per cent). A mass was palpable in only one of five cases erroneously diagnosed as ectopic pregnancy (20 per cent).Decidual casts were passed by four patients, two of whom did not have ectopic pregnancy.If two gynecologists do not agree on the question of extrauterine pregnancy, a third opinion should be sought or culdoscopy employed.Enucleation of the conceptus and salvage of the oviduct is advocated.     

Treatment of deep vein thrombosis with streptokinase.

From September 1962 to May 1972 145 patients with acute or subacute deep vein thrombosis confirmed by phlebography were treated with streptokinase. During the same period 42 patients considered unfit for thrombolytic therapy were treated with herapin and oral anticoagulants. The results, assessed by repeat phlebography, in 93 of the patients treated with streptokinase were compared with those in 42 patients treated with heparin. The age, sex, and severity of occlusion were roughly similar in both groups. Streptokinase treatment was successful in 42 per cent, partially successful in 25 per cent, and unsuccessful in 32 per cent of the 93 patients compared with none, 10 per cent, and 88 percent respectively in the 42 patients treated with heparin. Streptokinase was more effective when the thrombus was in proximal rather than calf veins. Thrombi of more than six days old were readily lysed. Plasma fibrinogen levels were below 0-8 g/1 (80 mg/100 ml) in nearly all patients successfully treated. The incidence of pulmonary embolism was no greater with streptokinase than with heparin treatment. Only prolonged follow-up would show whether thrombolytic treatment would be effective in preventing late complications of deep vein thrombosis such as chronic venous insufficiency.