SURGICAL
Indications for Operation in Exophthalmic Goiter.
Prof. H. Starck states that among 450 cases of Basedow’s disease observed in the last few years sixty-nine were operated on by prominent surgeons, nearly all of which had been seen by him before the operation. From his observations he concludes: 1. Operation effected a cure (i. e., complete physical and mental restoration) in approximately 30 per cent, improvement in 35 to 40 per cent, while in the other cases it proved ineffective or was followed by a change for the worse. 2. The operative mortality was 9 per cent (6 deaths in sixty-nine cases). Kocher had a mortality of only 3.1 per cent; according to others, however, it is 12 per cent. 3. If the surgeon accepts the view that a persistent thymus is responsible for a fatal outcome, although no positive evidence is at hand, he must determine whether this gland be present before resorting to resection of the struma; if it is, ligation of the vessels or resection of the thymus is to be considered. 4. The choice of the anesthetic is of great importance as to the outcome of the operation. The Basedow’s type with predominating nervous, myasthenic and psychic symptoms is best operated on under general anesthesia, the other cases under local anesthesia. 5. Operation is contraindicated in status lymphaticus; if it can not be avoided, a local anesthetic should be employed. 6. In many cases the operation only lays the foundation for successful internal treatment. 7. The most unfavorable time for operation is that of increasing intensity of the disease; the most favorable, the stage of latency, or arrest. 8. The most suitable cases for operation are those in which there is a “goiter heart;” also some cases with classical Basedow’s symptoms. Only slight success is to be expected in the presence of a nervous-myasthenic-psychic symptom complex with but moderate cardiovascular symptoms. 9. The size of the goiter as determined by palpation is no criterion as regards the question of operation. Small, soft goiters are often of greater significance than large, firm ones. 10. The blood picture also is of no importance in considering the operative treatment, since it is not materially influenced by operation.—The International Journal of Surgery.
Acute Appendicitis.
John B. Deaver says the important points that have to be learned about this disease are that it is the most common intra-abdominal inflammation; that indigestion is often a forerunner, preparing the soil for the infection; that being an infectious disease and the most common infectious disease of the abdominal cavity, the appendix constitutes the avenue by way of which infection most commonly invades the upper abdomen. He considers acute appendicitis from the anatomical, etiological, bacteriological, and pathological standpoints: the points of the latter touched upon chiefly are in connection with peritonitis and abscess. The portions of the peritoneum most susceptible to infection are the diaphragmatic and enteronic. The differential points between a diffuse and a localized peritonitis are that in the former the pain is greater, the abdominal breathing more restricted and the rigidity and tenderness embrace a greater area of the overlying abdominal wall; upon auscultation the peristaltic waves are heard over a greater area and the abdominal breathing is less marked in the diffuse than in the localizing variety. In the early stages the tenderness and rigidity are best elicited by slight pressure. If the symptoms and signs, namely, pain, vomiting, fever, tenderness, and rigidity are interrupted, the diagnosis of acute appendicitis may be considered doubtful. Leucocytosis is of value as a confirmatory symptom when the patient reacts well to the infection. The most important point in the differential diagnosis is the distinction between acute cholecystitis and acute appendicitis. Acute pancreatitis, perforated ulcer, or perforated gall bladder, present symptoms so much more intense than those of acute appendicitis that they should not give rise to confusion. As to the treatment, the writer states most emphatically that in all cases of acute abdominal pain nothing in the shape of a purgative or aperient medicine should be given until the cause of the pain is understood. In his experience purgatives play the greatest amount of havoc in acute abdominal conditions; 90 per cent of cases of perforating peritonitis have been purged. In the presence of peritonitis and in the absence of operation the patient should be set up in bed, given nothing by mouth, not even cracked ice; he should be given enteroclysis by the Murphy method and have an icebag over the site of rigidity and tenderness; the icebag is useful to prevent the doctor from making too many examinations and for its local anesthetic affect. The idea that it has any effect in controlling inflammation is fallacious. In diffuse peritonitis, in the absence of peristalsis and of a definite point of localization, it is the writer’s practice to defer operation until the peritonitis becomes a localized or localizing one. The principles of anatomical and physiological rest, assisting the functions of the peritoneum, absorption and exudation, are defeated by any treatment other than the foregoing.—Medical Record.
Effect of Phloridzin on Tumors.
In the experiments cited by Wood and McLean the animals were injected with phloridzin in suspension in olive oil. Treatment was begun, as a rule, seventeen days after inoculation. All treated animals were kept rigidly on a diet of meat and lard, while the control animals were given the regular laboratory diet of dry bread and vegetable. From time to time, at the end of the second or third day period following injections of the phloridzin, the collected urines were examined for sugar with Fehling’s solution and were found to give a positive reaction in the case of the treated animals on the carbohydrate-free diet, while the urine of the untreated animals as well as a phloridzin solution gave a negative reaction. The animals under treatment rapidly became emaciated, the fur roughened, and they appeared to be very ill; a great many died soon after beginning of the treatment. For the experiments with the Buffalo rat sarcoma, 324 animals were inoculated, with 90.4 per cent of “takes.” For the experiments with mouse sarcoma No. 396 mice were inoculated, with 97.7 per cent positive. Among the mice bearing spontaneous tumors and Crocker Fund mouse sarcoma No. 180, there were no cases of absorption of the tumor under treatment. The Buffalo rat sarcoma showed a much smaller percentage of absorption among the treated animals than among the controls, 37 per cent as compared with 58.4 per cent. In the majority of the experiments the growth among the treated animals was much more vigorous than that among the controls. Considering the very great variability of growth of the Buffalo rat sarcoma, as well as the high percentage of cases of spontaneous absorption occurring constantly, but with a great irregularity in different series of animals, the futility of using this tumor for therapeutic experiments or of basing conclusions on such investigations, is at once evident. Any “cures” obtained in work with the Buffalo rat sarcoma must be ascribed to spontaneous absorption rather than to the effect of the therapeutic agent.—The Journal of the Amer. Med. Asso.
Diagnosis of Extent of Injury in Cases of Abdominal Wounds.
Kausch has found that it is impossible to determine whether or not the intestines or other viscera have been injured, by the discovery of free air in the abdominal cavity. This is an almost certain sign of perforation, according to his experience, which has been wide and varied. The army corps to which he is consulting surgeon has served in turn in Belgium and France, Alsac, Galicia, Russian Poland and Serbia. A very small incision will reveal whether there is free air in the abdominal cavity. He makes the exploratory buttonhole for the purpose in the epigastrium under local or general anesthesia. The thicker the abdominal wall, the longer the incision, from 1 to 3 cm. The peritoneum need be only punctured; a pinhead hole is enough. If air streams out, he proceeds at once to a regular laparotomy. If not, the patient is spared a major operation for the time being at least. He has had cases in which a bullet passed through the abdomen, front and rear, without perforating the gastro-intestinal tract. When there was perforation, death was inevitable without operative relief, and he is convinced that his prompt operating saved a certain proportion of such cases. No one was ever harmed by the operation after an abdominal wound. Kausch was kept informed by telephone where fighting was under way, so that he was on the spot, ready to operate, before the wounded began to come in.—The Journal of the Amer. Med. Asso.