THE PROBLEM OF DIVERTICULITIS—Surgical Management

The disease of diverticulitis now is encountered with increasing frequency due to the increasing average age of our population. Low mortality following resection and anastomosis and the excellent results after this procedure have broadened the indications for operation in this disease. From 1942 to 1955, 160 such operations for diverticulitis of the sigmoid colon were carried out at the Massachusetts General Hospital with a mortality of 3 per cent. The results, except in the few cases where too conservative a resection was carried out and a secondary operation was necessary to produce a cure, have been excellent.     

TUMORS OF THE URACHUS—Report of Five Cases

Reports of three patients with malignant and one with benign urachal tumor are presented.Survival of one patient in good health 11 years after removal of adenocarcinoma of a urachal cyst with vesical invasion is reported.Methods of diagnosis and treatment are discussed.     

CARCINOMA OF THE THORACIC ESOPHAGUS—A Discussion of Early Diagnosis and Surgical Treatment

Dysphagia, substernal or epigastric distress, and regurgitation of food are important early symptoms in the diagnosis of carcinoma of the esophagus. Temporary remission in symptoms does not rule out esophageal cancer. The use of thick barium meal and routine thorough examination of the esophagus in upright and supine positions in all upper gastrointestinal roentgen studies, even though the clinical symptoms point to the upper abdomen, are of great importance.The spread of the cancer to both mediastinal and subdiaphragmatic lymph nodes makes transthoracic thoracolaparotomy the one approach which will permit the surgeon to perform a one-stage esophagogastrostomy, and to adequately evaluate and deal with cancerous tissue on both sides of the diaphragm. This one-stage procedure permits the patient to swallow normally after operation, and the costly and time-consuming uncertainties of the many-staged operations are avoided. The comfort which the operation gives to otherwise doomed patients, along with the improving postoperative mortality rate, offers new hope to those who have cancer of the esophagus.     

A STUDY OF INFLATION OF THE LUNGS OF THE NEWBORN—A Preliminary Report

There seems to be no reasonable doubt that the lungs in a newborn expand progressively during the first few days of life. Some degree of atelectasis seems to be perfectly normal. This is indicated by a number of roentgenographic studies (including those here reported); by the reported findings of pathologists; by the fact that in experimental animals the lungs inflated very unevenly; and by the fact that aeration of only a portion of the lung is needed for complete oxygenation of the blood. The relation of atelectasis to neonatal death is not entirely clear and is probably not always the same. The infant may die from other causes before the lungs are fully expanded. Atelectasis may develop secondarily to other debilitating conditions. The frequent coincidence of prematurity and extensive atelectasis is impressive. It may be that the lungs are so incompletely formed that they cannot expand. On the other hand, atelectasis and massive collapse in the adult is a serious condition and there seems to be no good reason to suppose that this cannot also occur in infants and be serious per se.The air pressures found necessary to expand the lungs in rabbit fetuses were found to be about ten times what adult humans use in quiet respiration and were of about the same magnitude as the pressures found necessary to expand the lungs of stillborn humans. An attempt to produce atelectasis in newborn rabbits by chilling was most inconclusive. Atelectasis did develop in three of 15 animals used in the experiment, but the relation to chilling was not at all clear.     

THE CARCINOLYTIC EFFECT OF ACTINOMYCIN C—A Report of Clinical Studies

Actinomycin C was administered to 35 patients with a variety of malignant states. There was no evidence of any toxic reaction.Of 11 patients with Hodgkins disease, four had brief objective remission ranging from two to four months. Individual patients with chronic myelogenous leukemia, multiple myeloma and neuroblastoma had short periods of clinical improvement.The usefulness of actinomycin C appears to be limited. It may best be used in instances of Hodgkin''s disease where pancytopenia prevents the use of other agents.     

CARCINOMA OF THE ESOPHAGUS AND GASTRIC CARDIA—With Special Reference to Treatment

During the last five years the thoracic and abdominothoracic approaches in esophageal and gastric surgery have become established. With improvements in surgical and anesthetic technique mortality rates have declined. Preoperative and postoperative care are of great importance.     

USE OF TRANQUILIZERS IN DISEASES OF THE SKIN—A Preliminary Report

Tranquilizing agents such as chlorpromazine and reserpine were used in various diseases of the skin in which the psychogenic factors were considered important etiologic agents. While a tranquilizing effect was obtained in the majority of instances, the side reactions and variation in response were so great as to render these agents unsatisfactory for routine use as tranquilizers. Meprobamate (marketed under the trade names Miltown and Equanil) was then used on a group of dermatologic patients with more consistent tranquilizing effect and comparatively little unpleasant side reactions. It is felt that further study of the use of meprobamate as a tranquilizing agent in dermatology is worth while.     

PREVENTION OF THE FLUID-ELECTROLYTE “PROBLEM” BY SIMPLE MEANS

Proper fluid balance may be maintained in patients after operation by the employment of simple, inexpensive procedures which may be carried out even in the smallest hospitals.Daily weighing of patients, measurement of fluid intake and output, and knowledge of the probable electrolyte content of fluid losses are adequate guides for replacement of fluids and electrolytes. An increase in body weight is a warning of overhydration.The content of the solution used for replacement is dictated by the route of fluid output—whether from the gastrointestinal tract, the skin, or the kidneys. Insensible losses (by perspiration and respiration) are fairly static.Except to replace extrarenal losses, parenteral administration of normal saline solution in the immediate postoperative period is contraindicated.Mistakes in replacement methods, especially those causing overhydration, are particularly hazardous for elderly patients.     

THE REMOVAL OF STONES FROM LOW IN THE URETER—A Report on an Improved Method

Extraction of stones from the lower part of the ureter can be facilitated by use of a long filiform which permits the attachment and introduction of dilating Phillips catheters of increasing caliber and of various stone extractors. The filiform must be left in place, with the tip superior to the stone, until the ureter has been successfully dilated, the stone extracted and a drainage catheter inserted. The filiform serves to guide the instruments up the ureter.Smooth muscle relaxation, or “tone paralysis,” is achieved by leaving each dilating catheter in the ureter for at least ten minutes.A combination of spinal and local anesthesia is used, and this contributes further to the desired ureteral relaxation. This simple method was used successfully in 34 of 35 consecutive cases to remove a stone in the lower part of the ureter.