The Southern surgeon最新文献

An attempt has been made to discuss, briefly, some of the pathologic pictures and processes peculiar to anesthetic agents and technics. As surgical procedures increase in length and complexity, and as the poorer risk patients are now considered suitable for many major surgical procedures, anesthesia has of necessity become more of a problem, and anesthetic complications should be borne in mind during the preoperative study of these patients, and should be watched for during the operative postoperative course.

A technic of abdominal aortography has been presented. The procedure is simple, and very little special equipment is necessary. It is relatively harmless, and in our series we have had no fatalities or untoward reactions. Five cases have been presented. In the case of acute aortic occlusion due to a saddle thrombus, we feel that little additional information was obtained by aortography. The procedure in an already desperately ill patient was harmful. In fact, the mere administration of an anesthetic was dangerous. Such cases in nearly all instances are easily recognized, and if seen early enough, aortic embolectomy should be done without loss time. Two cases of aneurysm of the abdominal aorta were presented. One of these was explored and treated, while in the other case, the aortogram revealed that both renal vessels took their origin from the portion of the aorta involved, and the patient was not subjected to surgery which was contraindicated. Aortograms in suspected abdominal aortic aneurysms are of distinct value. Not only do they corroborate the clinical impression, but they also reveal the exact level of the lesion and in most cases its extent as well. Useless exploration is avoided when major branches, such as the renal arteries, are involved. In Figure 4 the aneurysm failed to fill. We do not know whether this was a technical error, but are inclined to believe it was due to abnormal currents in the aneurysm. We hope to gain further knowledge of this type of filling defect as more aneurysms are studied with serial x-rays. In the last two cases presented, we feel that aortography was of decided value. Chronic occlusion of the aortic bifurcation is rare, and although it may be suspected clinically, the exact diagnosis can only be made by aortogram or exploration. Further, the cephalad extension of the thrombosis can be accurately seen. In a case such as the last presented, a partial occlusion can be visualized, and repeated aortography will be of value in studying the progress of the disease. I feel it is worthwhile to mention in closing that in the two cases of chronic aortic occlusion, no large, collaterals to the affected extremities were visualized. However, both of the patients improved following resection of the occluded segments and lumbar sympathectomy. We do not feel that the failure to visualize collateral arterial channels should be a contraindication to the surgical therapy of this disease.

1. Frontal lobotomy is an effective procedure for the relief of intractable pain. 2. Unilateral frontal lobotomy for the relief of pain is less successful than the bilateral (standard) operation. 3. Unwanted changes in personality and intellect are apt to be severe after the bilateral procedure. These changes, though of less degree, also occur with the unilateral operation performed by standard technic. 4. To broaden the use of this type of operation for intractable pain of noncancerous origin a less disabling procedure is necessary. This may possibly be accomplished by limiting the size of the bilateral operation or by selective bilateral destruction of certain areas of the frontal lobes. 5. A new procedure in which a small symmetrical destructive lesion is produced in the lower medial quadrant each hemisphere has been successful in relieving pain.

1. Forty-nine patients who had vagotomy and 33 who had gastric resection, which constitute all of the cases since the opening of this hospital, have been reviewed and compared. 2. There have been no hospital deaths in either series with the exception of one case moribund from acute hemorrhage, who was explored only as a last resort. 3. Surprisingly enough, the number and severity of complications have been higher following vagotomy than following gastrectomy. 4. Results thus far are somewhat in favor of vagotomy with drainage over subtotal gastrectomy. The apparent advantage of vagotomy over gastrectomy will be further enhanced when we consider the following three factors: a. Although in our small series there has been no mortality following either procedure in elective cases, the literature shows a definitely greater number of fatalities following gastrectomy than following vagotomy. b. The great majority of patients who have undergone gastrectomy remain gastric cripples, whereas the only limitation in diet, tobacco and alcohol imposed upon our postvagotomy patient has been "everything in moderation." c. In this particular comparative study, 50 per cent of the gastrectomy series were for gastric ulcer which are notorious for their favorable response to any type of surgery.

This report deals with 17 cases of carcinoma of the esophagus, the total number that have been treated at the Veterans Hospital, Louisville, Kentucky, since its opening in April, 1946. It is much too early to judge end results on the living cases; however, the series is representative and, we think, should be added to the growing literature. Several authors have already very well summarized the evolution of surgical management of this disease since Adams and Phemister in the 1938 reported the first successful transthoracic resection and esophagogastrostomy for carcinoma to be performed in this country. The pertinent data in these cases are set forth in Tables I and II.

An attempt has been made in the foregoing to mention some of the gastrointestinal anomalies that are occasionally met, even thought many of the congenital defects are relatively uncommon in their occurrence. Any or all of them should be kept in mind in the newborn when it does not follow the usual course of events in regard to intake of formula, or other unusual developments within the first few days of life. There has been no effort made to set out the actual surgical management of the situation that presents itself. Rather an effort has been made to stress prodromal symptoms, physical and roentgenologic findings. Careful preoperative preparation of these infants must be stressed time and again. Actually, the preoperative preparation is of much greater importance than the mechanical management of the defect present from a surgical standpoint. A newborn with an obstructive lesion and in whom the blood chemistry and protein values are unbalanced is a poor surgical risk. After careful restoration of these values, the infants tolerate major surgery remarkably well.