- Email: [email protected]
TREATMENT OF ACUTE CHOLECYSTITIS
210
exceedingly difficult to exterminate. The new agree(July 1) between shippers and seamen to cooperate in ensuring the cleanliness of crews’ quarters should go a long way towards ridding the merchant service of a preventable evil.
Severe acute cholecystitis Ehnmark regards as a disease with a high mortality. In the worst cases, although the risk is great, he thinks immediate operation is right, unless the condition is quite hopeless. Cholecystostomy is then his choice. In other cases it is reasonable to expect spontaneous improvement, and cholecystectomy undertaken during the " clinical interval " bears, in his opinion, a comparatively small risk. It is not the practice in Uppsala to operate for the first attack, unless life is in danger.
ment
TREATMENT OF ACUTE CHOLECYSTITIS
,
THE best time for operation in acute cholecystitis is debated by Ehnmark in a monograph entitled the gall-stone disease.1 Surveying the fluctuation of surgical opinion, he shows how at one time acute cholecystitis has been treated as an urgent surgical emergency, while at others operation has been postponed until the acute symptoms have subsided. As early as 1903 Riedel advised operation within twentyfour hours of the onset of the attack; by 1920 operation during the interval was widely supported, both in this country and in Germany ; while from that date onwards an increasing number of surgeons in German and in Scandinavian countries, Ehnmark finds, insisted on surgical treatment in the acute stage. Still later more support has been shown for operation after subsidence of the attack, but in Scandinavia opinion seems to have remained very much divided. The one item on which Ehnmark finds general agreement is that grave cases, with pronounced peritoneal irritation or with perforation, ought to have immediate operation unless the patient’s condition is hopeless. For cases of less severity there are at present three opinions : operate at once, as for appendicitis ; wait a few days, till the most acute symptoms have subsided; operate only after the attack has passed, when the temperature and pulse are normal, the abdominal tenderness has gone, and the patient is eating and is feeling pretty well. Ehnmark thinks that surgeons who advocate postponement till the morbid process is at an end are offering a theoretical opinion on which they could not act in practice. To obtain complete healing takes so long-several weeks or months-that the patients would be discharged from hospital, and would be unlikely to consent to readmission at the desired time. He himself proposes the term " clinical interval" to designate the stage of the disease in which temperature has become normal, abdominal symptoms and possible jaundice have disappeared, and the patient may be allowed out of bed. From his own careful analysis of 257 operations for acute cholecystitis performed in the surgical clinic of the University of Uppsala, he is convinced that operation is best performed in this clinical interval. The most significant feature of the Uppsala figures is the drop in operative mortality in the cases treated during the last period under survey-namely, 1932-35. In the first two periods (1922-27 and 1928-31) it is about equally high (14.8 and 13-3 per cent. respectively), but in the third it has dropped to 3-5 per cent. Having tried to examine all the factors that could have contributed to this result Ehnmark is persuaded that the sole significant change was that during the years 1932-35 the patients were operated on in a later stage of the disease, or after a longer time in hospital. Since 1932 almost all the moderately severe cases have been operated on in the clinical interval, whereas before that date most of them were operated on while the attack was in progress. Even of the severe cases, less than half have, since 1932, had the operation in the acute stage, whereas in 1922-31 it was the exception to wait. 1. The Gall Stone
Disease, by Ernst Ehnmark, Acta chir. scand.
1939, 82, suppl. 57.
DEATH OF A GORILLA "
Moina " only survived the death of her spouse Mok" for about seventeen months. She refused food, lost interest in life, and became savage with her keepers when roused. In May she developed cracks and abrasions on her hands and feet which she picked and gnawed until they became large septic sores; these it was impossible to dress or treat otherwise than by squirting antiseptics on them through the bars of her den. Finally gangrene of the right foot and leg developed and she died of sepsis and toxaemia from the gangrenous leg. At the post-mortem examination Colonel A. E. Hamerton, pathologist to the Zoological Society, could find no pathological lesions others than those associated with septicaemia. Histological examination of the peripheral arteries and nerves has noL so far revealed anything to account for the primary lesions on hands and feet. These, he thinks, were probably traumatic in origin. CLINICAL APPLICATIONS OF TESTOSTERONE
THE last few months have seen several attempts, especially in the United States, to multiply the uses of testosterone. In view of the resemblance between many androgens and progesterone, Rubinstein and Abarbanellhave tried testosterone propionate for dysmenorrhoea, and report complete relief in 16 out of 26 cases, and partial relief in 4. The patients that benefited were those with " essential" dysmenorrhcea, attributed largely to hormonal imbalance, and in those with structural abnormalities of uterus or tubes the symptoms were sometimes made worse. The remedy works, it is supposed, by depressing pituitary gonadotrophic secretion, reducing the formation of oestrogen, and favouring luteinisation and the progestational response of the myometrium. In a different field Edwards, Hamilton and Duntley2 claim to have used testosterone propionate with success in the treatment of organic disease of the peripheral vessels. This use of the hormone was first suggested by its general vascular effect on the skin-arterialisation in such regions as the head, palms and soles, as revealed by a recording spectrophotometer-and benefit is reported in three men with thrombo-angiitis obliterans and in four cases of arteriosclerosis. In reviewing the undisputed clinical uses of testosterone, Kearns 3 concludes, first, that it is an effective means of substitution therapy in castrated or cryptorchid patients, and secondly, that inunction of free testosterone in a greaseless base is as effective as intramuscular injection of the propionate. The inunction of male hormone which has been studied in this country by Foss4 is deemed Rubinstein, H. S., and Abarbanel, A. R., Amer. J. Obstet. Gynec April, 1939, p. 709. 2. Edwards, E. A., Hamilton, J. B., and Duntley, S. Q., New Engl. J. Med. May 25, 1939, p. 865. 3. Kearns, W. M., J. Amer. med. Ass. June 3, 1939, p. 2255. 4. Foss, G. L., Lancet, 1938, 2, 1284, 1308; 1939, 1, 502. 1.
exceedingly difficult to exterminate. The new agree(July 1) between shippers and seamen to cooperate in ensuring the cleanliness of crews’ quarters should go a long way towards ridding the merchant service of a preventable evil.
Severe acute cholecystitis Ehnmark regards as a disease with a high mortality. In the worst cases, although the risk is great, he thinks immediate operation is right, unless the condition is quite hopeless. Cholecystostomy is then his choice. In other cases it is reasonable to expect spontaneous improvement, and cholecystectomy undertaken during the " clinical interval " bears, in his opinion, a comparatively small risk. It is not the practice in Uppsala to operate for the first attack, unless life is in danger.
ment
TREATMENT OF ACUTE CHOLECYSTITIS
,
THE best time for operation in acute cholecystitis is debated by Ehnmark in a monograph entitled the gall-stone disease.1 Surveying the fluctuation of surgical opinion, he shows how at one time acute cholecystitis has been treated as an urgent surgical emergency, while at others operation has been postponed until the acute symptoms have subsided. As early as 1903 Riedel advised operation within twentyfour hours of the onset of the attack; by 1920 operation during the interval was widely supported, both in this country and in Germany ; while from that date onwards an increasing number of surgeons in German and in Scandinavian countries, Ehnmark finds, insisted on surgical treatment in the acute stage. Still later more support has been shown for operation after subsidence of the attack, but in Scandinavia opinion seems to have remained very much divided. The one item on which Ehnmark finds general agreement is that grave cases, with pronounced peritoneal irritation or with perforation, ought to have immediate operation unless the patient’s condition is hopeless. For cases of less severity there are at present three opinions : operate at once, as for appendicitis ; wait a few days, till the most acute symptoms have subsided; operate only after the attack has passed, when the temperature and pulse are normal, the abdominal tenderness has gone, and the patient is eating and is feeling pretty well. Ehnmark thinks that surgeons who advocate postponement till the morbid process is at an end are offering a theoretical opinion on which they could not act in practice. To obtain complete healing takes so long-several weeks or months-that the patients would be discharged from hospital, and would be unlikely to consent to readmission at the desired time. He himself proposes the term " clinical interval" to designate the stage of the disease in which temperature has become normal, abdominal symptoms and possible jaundice have disappeared, and the patient may be allowed out of bed. From his own careful analysis of 257 operations for acute cholecystitis performed in the surgical clinic of the University of Uppsala, he is convinced that operation is best performed in this clinical interval. The most significant feature of the Uppsala figures is the drop in operative mortality in the cases treated during the last period under survey-namely, 1932-35. In the first two periods (1922-27 and 1928-31) it is about equally high (14.8 and 13-3 per cent. respectively), but in the third it has dropped to 3-5 per cent. Having tried to examine all the factors that could have contributed to this result Ehnmark is persuaded that the sole significant change was that during the years 1932-35 the patients were operated on in a later stage of the disease, or after a longer time in hospital. Since 1932 almost all the moderately severe cases have been operated on in the clinical interval, whereas before that date most of them were operated on while the attack was in progress. Even of the severe cases, less than half have, since 1932, had the operation in the acute stage, whereas in 1922-31 it was the exception to wait. 1. The Gall Stone
Disease, by Ernst Ehnmark, Acta chir. scand.
1939, 82, suppl. 57.
DEATH OF A GORILLA "
Moina " only survived the death of her spouse Mok" for about seventeen months. She refused food, lost interest in life, and became savage with her keepers when roused. In May she developed cracks and abrasions on her hands and feet which she picked and gnawed until they became large septic sores; these it was impossible to dress or treat otherwise than by squirting antiseptics on them through the bars of her den. Finally gangrene of the right foot and leg developed and she died of sepsis and toxaemia from the gangrenous leg. At the post-mortem examination Colonel A. E. Hamerton, pathologist to the Zoological Society, could find no pathological lesions others than those associated with septicaemia. Histological examination of the peripheral arteries and nerves has noL so far revealed anything to account for the primary lesions on hands and feet. These, he thinks, were probably traumatic in origin. CLINICAL APPLICATIONS OF TESTOSTERONE
THE last few months have seen several attempts, especially in the United States, to multiply the uses of testosterone. In view of the resemblance between many androgens and progesterone, Rubinstein and Abarbanellhave tried testosterone propionate for dysmenorrhoea, and report complete relief in 16 out of 26 cases, and partial relief in 4. The patients that benefited were those with " essential" dysmenorrhcea, attributed largely to hormonal imbalance, and in those with structural abnormalities of uterus or tubes the symptoms were sometimes made worse. The remedy works, it is supposed, by depressing pituitary gonadotrophic secretion, reducing the formation of oestrogen, and favouring luteinisation and the progestational response of the myometrium. In a different field Edwards, Hamilton and Duntley2 claim to have used testosterone propionate with success in the treatment of organic disease of the peripheral vessels. This use of the hormone was first suggested by its general vascular effect on the skin-arterialisation in such regions as the head, palms and soles, as revealed by a recording spectrophotometer-and benefit is reported in three men with thrombo-angiitis obliterans and in four cases of arteriosclerosis. In reviewing the undisputed clinical uses of testosterone, Kearns 3 concludes, first, that it is an effective means of substitution therapy in castrated or cryptorchid patients, and secondly, that inunction of free testosterone in a greaseless base is as effective as intramuscular injection of the propionate. The inunction of male hormone which has been studied in this country by Foss4 is deemed Rubinstein, H. S., and Abarbanel, A. R., Amer. J. Obstet. Gynec April, 1939, p. 709. 2. Edwards, E. A., Hamilton, J. B., and Duntley, S. Q., New Engl. J. Med. May 25, 1939, p. 865. 3. Kearns, W. M., J. Amer. med. Ass. June 3, 1939, p. 2255. 4. Foss, G. L., Lancet, 1938, 2, 1284, 1308; 1939, 1, 502. 1.