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Surgical treatment of congenital umbilical hernia
SEW
Sm~cs
VOL.
III, No. I
Progress
ROCH, M., and FROMMEL, E., Geneva. LocaI anesthesia in the treatment of viscera1 and serous pains. (Anesthksie IocaIe sous-cutanee dans Ie traitement de douIeurs d’origines vis&raIes et &reuses.) Presse mkd. Par., March 26, 1927, No. 25, p. 385. The authors report on eighteen cases of angina pectoris, acute pericarditis, puImonary gangrene, pIeurisy, choIecystitis, etc., treated by the method suggested by Lemaire severa years ago. This consists in subcutaneous IocaI infihration of ro C.C. of a 0.5 per cent soIution of novocaine over the area of referred viscera1 pain. The authors inchne to the opinion expressed by Mackenzie that by this procedure they are able to interrupt the efferent pathway of a viscerosensory reffex and thus afford relief to the patient. The onIy inconvenience in the method is that if appIied to conditions that may be surgica1 in character, there is danger of masking symptoms.-HENRY MILCH. KOENNECKE, W., OIdenburg. Adhesive pericarditis and its surgical treatment (SchweiIige Pericarditis und ihre chirurgische Behandlung). iviinchen med. W’chnschr., ApriI 22, 1927, Ixxiv, 675. Adhesive pericarditis is characterized by no definite cIinica1 picture. The history of a previous acute pericarditis, the presence of an enIargement of the Iiver and a marked ascites and the fluoroscopic appearances of an abnormaIIy quiet cardiac puIs.ation make the diagnosis. SurgicaIIy, two types may be differentiated: that in which the pericardium is adherent to the anterior chest waI1; and that in which the pericardium is concentricaIIy thickened and impairs heart action. In the former instance simpIe remova of the third to sixth ribs anteriorIy to aIIow expansion of the heart is sufficient to insure amelioration of symptoms. In the second type, simpIe remova of the ribs is insufficient and the heart must, in addition, be freed of its impeding fibrous enveIope. To faciIitate removal, a portion of the Ieft sterna1 margin must be removed and the fibrous enveIope incised over the Ieft ventricIe. Thereupon the rest of the membrane is removed by the use of the finger, care being taken not to puncture the heart waI1. It is apparentIy unnecessary to carry dissection beyond the ventricIes. The wound is compIeteIy cIosed Ieaving onIy a few strands of catgut to act as a drain. UnIess the Iiver has been irreparabIy damaged, reIief shouId be prompt.
in Surgery
American
Journal
of Surgery
93
LOEVENHARDT, A. S., and CRANDALL, L. A., Madison, Wis. CaIcium carbonate in the treatment of gastric hyperacidity syndrome and in gastric and duodena1 ulcer. J. Am. M. Ass., May 14, 1927, Ixxxviii, 1557. CaIcium carbonate used without any other inorganic salt is the best antacid for use in the gastric hyperacidity syndrome, and in gastric duodena1 uIcer, for the foIIowing reasons: I. It is exceedingIy bIand. 2. It is insoIubIe, being onIy a potentia1 aIkaIi: i.e., an aIkaIi in the presence of acids stronger than carbon dioxide. 3. It is without effect on the bowel. 4. It causes the minimum disturbance of the acid-base equiIibrium of the body and of the minera metaboIism. It is practicaIIy fooIproof in the hands of the patient. It is best used in the form of compressed tabIets which disintegrate readiIy and which contain a very smaI1 amount of a carminative, such as oi1 of cinnamon. SEBI?NING, W., Frankfurt. Late results after acute necrosis of the pancreas. (FoIgezust;inde nach akuter Pankreasnekrose). ;Lled. Klinik, ApriI 15, 1927, xxiii, 551. The author has been abIe to foIIow over a period varying from one-half to seventeen years, twenty-one patients who survived after operation for acute necrosis of the pancreas. He comes to the concIusion that: I. Transitory disturbances of carbohydrate metaboIism are frequent within the first onehaIf year and even after the Iapse of many years diabetes and even death from diabetic coma may supervene; 2. Disturbances arising from the Iack of the externa1 secretions of the pancreas are rare and can be easiIy controIIed by the administration of pancreatic extracts; 3. Recurrences are extremeIv rare; 4. The formation of pancreatic cysts is but very 0ccasionaIIy seen; 5. FistuIas usuaIIy hea spontaneousIy; 6. Adhesions seIdom cause any trouble; 7. Incisiona hernias are reIativeIy frequent. SAUNDERS, H. P., Chicago. SurgicaI treatment of congenita1 umbiIica1 hernia. Ill. iVIed. J., March, 1927, li, 204. The cord of every baby shouId be carefuIIy examined for hernia immediateIy after delivery. The prognosis of Iarge congenita1 umbiIica1
94
American Journal of Surgery
Progress
hernia is grave, but better in cases treated surgicaIIy than in those treated conservativeIy. The quickest and Ieast traumatic procedure consists of ligating the umbiIica1 vesseIs securely as cIose to the abdomina1 waIIs as possibIe. The sac is then opened proIonging the incision up and down the abdomen above and beIow the umbiIicus just as far as is necessary in order to repIace the contents without having to squeeze and handIe them too much. As soon as they are a11repIaced, the sac is removed, transfixed and Iigated, thus cIosing the peritoneum. The other Iayers are then cIosed by through and through mattress sutures of siIkworm gut incIuding a11 the Iayers and cIosing the entire incision in this manner. MAYO, CHARLES H., and DIXON, CLAUDE F., Rochester, Minn. RetroperitoneaI Iipoma: A report of three cases. Minn. Med., May, 1927, x, 272. The symptoms of retroperitonea1 Iipoma are variabIe. Of tweIve cases reported by Masson and Horgan six patients first noticed a sensation of increased pressure in the abdomen, six compIained of sIight abdomina1 pain and two of pain in the back. In onIy one case was the pain severe. Six compIained of food distress and occasionaIIy vomited. Five had quite obstinate constipation and six had Iost weight. In cases in which the Iipoma was degenerating the symptoms were acute, with fever, IocaIized tenderness and an increase in Ieucocytes. About 7g per cent of the tumors were in the abdominal cavity and 21 per cent in the peIvis. They usuahy arise from the pararena fat, but may arise from the renaI capsuIe, the mesentery, the pararecta1 or retrorecta1 fat. They occur quite equahy on both sides of the abdomen, possibIy more often on the Ieft than right. The uItimate prognosis is usuaIIy grave. In von Wahlendorf’s series the operative mortaIity was 25 per cent; in Masson and Horgan’s series, 16 per cent. Recurrence is not uncommon and often with recurrence there is sarcomatous change. RetroperitoneaI Iipomas are more common than has been supposed, and expIoration should be carried out in a11 cases of abdomina1 tumor, particuIarly if the enIargement has been sIow and no organic disturbance can be elicited. RetroperitoneaI lipoma before remova often resembIes sarcoma, grossIy. A specimen shouId aIways be examined microscopicaIIy
in Surgery
JULY, rgz,
and if no malignant change is found the tumor is usuaIIy removed. Mayo removed the tumors through a right rectus incision 2.5 cm. from the umbiIicus. This affords good exposure for exploration and can be extended as desired. It is apparentIy much better than the posterior incision advised by Krogius, which would be feasibIe for expIoration of smaI1 tumors Iying near the kidney. In these three cases the tumor spread within the mesentery of the transverse colon. Their origin was therefore on the Ieft side of the spine. In two of the cases the omenturn was taken up in the great spread of the tumor. FAURE, J. L., Paris. The MikuIicz tampon in intestina1 surgery. (Le Mikulicz en chirurgie intestinaIe.) Presse m&d., March 30, 1927, No. 26, p. 401. Faure makes a pIea for the empIoyment of the MikuIicz tampon which has practicaIIy faIIen into disuse. He shows that unti1 some vaccine is discovered which wiI1 prevent the deveIopment of postoperative infections of the peritonea1 cavity, the MikuIicz tampon is practicaIIy the onIy certain means of preventing death in a number of the serious intra-abdomina1 operations. Its use is especiaIIy desirabIe in cases of carcinoma of the uterus, in resections of the colon, and in puruIent appendicitis. He points out that in a series of 36 cases of operations on the coIon, the MikuIicz tampon was not used in 20 cases with an operative mortaIity of 40 per cent. In 16 cases in which the Mikuhcz tampon was used, the operative mortaIity was onIy 13.3 per cent ahhough these cases were more serious than those in the other series. Of 9 cases of abdominoperinea1 resection of the rectum for cancer, onIy one died. Of 15 cases of puruIent appendicitis, g with generaIized peritonitis, operated upon by Roux-Berger using the MikuIicz tampon, there were no deaths and onIy one with weakness of the abdomina1 waI1. In 13 simiIar cases with 5 generaIized peritonitides in which the tampon was not used, 4 died, 3 had stercora1 fistuIas, 2 had puruIent pIeurisies, 2 eventrations and onIy 2 heaIed without any untoward incident.-HENRY MILCH. ROBERT A., AtIantic City. Concerning the Sgambati urine test in peritonitis. J. Med. Sot. N. J., ApriI, 1927, xxiv, 22 I.
KILDUFFE,
In 1920, Sgambati described a urine reaction
Sm~cs
VOL.
III, No. I
Progress
ROCH, M., and FROMMEL, E., Geneva. LocaI anesthesia in the treatment of viscera1 and serous pains. (Anesthksie IocaIe sous-cutanee dans Ie traitement de douIeurs d’origines vis&raIes et &reuses.) Presse mkd. Par., March 26, 1927, No. 25, p. 385. The authors report on eighteen cases of angina pectoris, acute pericarditis, puImonary gangrene, pIeurisy, choIecystitis, etc., treated by the method suggested by Lemaire severa years ago. This consists in subcutaneous IocaI infihration of ro C.C. of a 0.5 per cent soIution of novocaine over the area of referred viscera1 pain. The authors inchne to the opinion expressed by Mackenzie that by this procedure they are able to interrupt the efferent pathway of a viscerosensory reffex and thus afford relief to the patient. The onIy inconvenience in the method is that if appIied to conditions that may be surgica1 in character, there is danger of masking symptoms.-HENRY MILCH. KOENNECKE, W., OIdenburg. Adhesive pericarditis and its surgical treatment (SchweiIige Pericarditis und ihre chirurgische Behandlung). iviinchen med. W’chnschr., ApriI 22, 1927, Ixxiv, 675. Adhesive pericarditis is characterized by no definite cIinica1 picture. The history of a previous acute pericarditis, the presence of an enIargement of the Iiver and a marked ascites and the fluoroscopic appearances of an abnormaIIy quiet cardiac puIs.ation make the diagnosis. SurgicaIIy, two types may be differentiated: that in which the pericardium is adherent to the anterior chest waI1; and that in which the pericardium is concentricaIIy thickened and impairs heart action. In the former instance simpIe remova of the third to sixth ribs anteriorIy to aIIow expansion of the heart is sufficient to insure amelioration of symptoms. In the second type, simpIe remova of the ribs is insufficient and the heart must, in addition, be freed of its impeding fibrous enveIope. To faciIitate removal, a portion of the Ieft sterna1 margin must be removed and the fibrous enveIope incised over the Ieft ventricIe. Thereupon the rest of the membrane is removed by the use of the finger, care being taken not to puncture the heart waI1. It is apparentIy unnecessary to carry dissection beyond the ventricIes. The wound is compIeteIy cIosed Ieaving onIy a few strands of catgut to act as a drain. UnIess the Iiver has been irreparabIy damaged, reIief shouId be prompt.
in Surgery
American
Journal
of Surgery
93
LOEVENHARDT, A. S., and CRANDALL, L. A., Madison, Wis. CaIcium carbonate in the treatment of gastric hyperacidity syndrome and in gastric and duodena1 ulcer. J. Am. M. Ass., May 14, 1927, Ixxxviii, 1557. CaIcium carbonate used without any other inorganic salt is the best antacid for use in the gastric hyperacidity syndrome, and in gastric duodena1 uIcer, for the foIIowing reasons: I. It is exceedingIy bIand. 2. It is insoIubIe, being onIy a potentia1 aIkaIi: i.e., an aIkaIi in the presence of acids stronger than carbon dioxide. 3. It is without effect on the bowel. 4. It causes the minimum disturbance of the acid-base equiIibrium of the body and of the minera metaboIism. It is practicaIIy fooIproof in the hands of the patient. It is best used in the form of compressed tabIets which disintegrate readiIy and which contain a very smaI1 amount of a carminative, such as oi1 of cinnamon. SEBI?NING, W., Frankfurt. Late results after acute necrosis of the pancreas. (FoIgezust;inde nach akuter Pankreasnekrose). ;Lled. Klinik, ApriI 15, 1927, xxiii, 551. The author has been abIe to foIIow over a period varying from one-half to seventeen years, twenty-one patients who survived after operation for acute necrosis of the pancreas. He comes to the concIusion that: I. Transitory disturbances of carbohydrate metaboIism are frequent within the first onehaIf year and even after the Iapse of many years diabetes and even death from diabetic coma may supervene; 2. Disturbances arising from the Iack of the externa1 secretions of the pancreas are rare and can be easiIy controIIed by the administration of pancreatic extracts; 3. Recurrences are extremeIv rare; 4. The formation of pancreatic cysts is but very 0ccasionaIIy seen; 5. FistuIas usuaIIy hea spontaneousIy; 6. Adhesions seIdom cause any trouble; 7. Incisiona hernias are reIativeIy frequent. SAUNDERS, H. P., Chicago. SurgicaI treatment of congenita1 umbiIica1 hernia. Ill. iVIed. J., March, 1927, li, 204. The cord of every baby shouId be carefuIIy examined for hernia immediateIy after delivery. The prognosis of Iarge congenita1 umbiIica1
94
American Journal of Surgery
Progress
hernia is grave, but better in cases treated surgicaIIy than in those treated conservativeIy. The quickest and Ieast traumatic procedure consists of ligating the umbiIica1 vesseIs securely as cIose to the abdomina1 waIIs as possibIe. The sac is then opened proIonging the incision up and down the abdomen above and beIow the umbiIicus just as far as is necessary in order to repIace the contents without having to squeeze and handIe them too much. As soon as they are a11repIaced, the sac is removed, transfixed and Iigated, thus cIosing the peritoneum. The other Iayers are then cIosed by through and through mattress sutures of siIkworm gut incIuding a11 the Iayers and cIosing the entire incision in this manner. MAYO, CHARLES H., and DIXON, CLAUDE F., Rochester, Minn. RetroperitoneaI Iipoma: A report of three cases. Minn. Med., May, 1927, x, 272. The symptoms of retroperitonea1 Iipoma are variabIe. Of tweIve cases reported by Masson and Horgan six patients first noticed a sensation of increased pressure in the abdomen, six compIained of sIight abdomina1 pain and two of pain in the back. In onIy one case was the pain severe. Six compIained of food distress and occasionaIIy vomited. Five had quite obstinate constipation and six had Iost weight. In cases in which the Iipoma was degenerating the symptoms were acute, with fever, IocaIized tenderness and an increase in Ieucocytes. About 7g per cent of the tumors were in the abdominal cavity and 21 per cent in the peIvis. They usuahy arise from the pararena fat, but may arise from the renaI capsuIe, the mesentery, the pararecta1 or retrorecta1 fat. They occur quite equahy on both sides of the abdomen, possibIy more often on the Ieft than right. The uItimate prognosis is usuaIIy grave. In von Wahlendorf’s series the operative mortaIity was 25 per cent; in Masson and Horgan’s series, 16 per cent. Recurrence is not uncommon and often with recurrence there is sarcomatous change. RetroperitoneaI Iipomas are more common than has been supposed, and expIoration should be carried out in a11 cases of abdomina1 tumor, particuIarly if the enIargement has been sIow and no organic disturbance can be elicited. RetroperitoneaI lipoma before remova often resembIes sarcoma, grossIy. A specimen shouId aIways be examined microscopicaIIy
in Surgery
JULY, rgz,
and if no malignant change is found the tumor is usuaIIy removed. Mayo removed the tumors through a right rectus incision 2.5 cm. from the umbiIicus. This affords good exposure for exploration and can be extended as desired. It is apparentIy much better than the posterior incision advised by Krogius, which would be feasibIe for expIoration of smaI1 tumors Iying near the kidney. In these three cases the tumor spread within the mesentery of the transverse colon. Their origin was therefore on the Ieft side of the spine. In two of the cases the omenturn was taken up in the great spread of the tumor. FAURE, J. L., Paris. The MikuIicz tampon in intestina1 surgery. (Le Mikulicz en chirurgie intestinaIe.) Presse m&d., March 30, 1927, No. 26, p. 401. Faure makes a pIea for the empIoyment of the MikuIicz tampon which has practicaIIy faIIen into disuse. He shows that unti1 some vaccine is discovered which wiI1 prevent the deveIopment of postoperative infections of the peritonea1 cavity, the MikuIicz tampon is practicaIIy the onIy certain means of preventing death in a number of the serious intra-abdomina1 operations. Its use is especiaIIy desirabIe in cases of carcinoma of the uterus, in resections of the colon, and in puruIent appendicitis. He points out that in a series of 36 cases of operations on the coIon, the MikuIicz tampon was not used in 20 cases with an operative mortaIity of 40 per cent. In 16 cases in which the Mikuhcz tampon was used, the operative mortaIity was onIy 13.3 per cent ahhough these cases were more serious than those in the other series. Of 9 cases of abdominoperinea1 resection of the rectum for cancer, onIy one died. Of 15 cases of puruIent appendicitis, g with generaIized peritonitis, operated upon by Roux-Berger using the MikuIicz tampon, there were no deaths and onIy one with weakness of the abdomina1 waI1. In 13 simiIar cases with 5 generaIized peritonitides in which the tampon was not used, 4 died, 3 had stercora1 fistuIas, 2 had puruIent pIeurisies, 2 eventrations and onIy 2 heaIed without any untoward incident.-HENRY MILCH. ROBERT A., AtIantic City. Concerning the Sgambati urine test in peritonitis. J. Med. Sot. N. J., ApriI, 1927, xxiv, 22 I.
KILDUFFE,
In 1920, Sgambati described a urine reaction