New York Medical College - Fleuroscope Yearbook (Valhalla, NY)

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BY WILLIAM RUBIN to emerge from their experimental stage into one of general, unanimous approval. The major development in surgery during 1933 had been in the field of the endocrine system. Hollman and Railsback added to the number of cases of hyperinsulinism already treated successfully by surgery, their own case of partial resection of the pancreas. Adenomata of the islands of Langerhans has been found not to be a rare condition. The change in secondary sexual characteristics with virilism, hirsutism, amenorrhea and abnormal deposits of fat in adrenal cortical tumors, basophilic adenomata of the pituitary tCushing's Syndromel, and, that peculiar ovarian tumor, arrhenoblastoma, no longer presents the hopeless prognosis of former years. The large group of disturbances due to endocrine deficiencies such as myxedema, diabetes mellitus, parathyroid tetany and Addison's disease may all become amenable to surgical treatment. Already much work has been done along these lines of hetero-glandular and homoglandular transplantation. Difficulties which are gradually being overcome are: ill surrounding the transplant With a suitable nutrient medium: C23 providing adequate circulation for each cell: C39 preventing pressure necrosis of the tender grafts by surround- ing tissue. To prevent the last, the loose areolar tissue of the axilla or groin is selected as a bed for the transplant. ln order to help the gland to adapt itself to its new environment, it is first grown in a culture medium of beef embryo juice and serum saline, next in the serum from the donor finally in the serum from the recipient and then heparinized plasma for one month before trans- planting. We may very Well ask, Are We on the threshold of the door to the fountain of youth? Much interest has been aroused in the field of thoracic surgery, especially by the increasingly frequent and successful removal of a lobe or even of an entire lung. Advances in technic have been rapid so that the mortality in several clinics has been reduced to less than fifteen per cent. Carr has con- tributed an important improvement to the operative procedure. He has devised a small automatic hilum clamp by which strong ligation tension may be applied. This appears to have marked advantage in safety over the previous methods of ligature or suture of the contents of the hilar stump. The clamp is left on for fifteen days and is then removed through a small intercostal incision. I-lilum occlusion is complete, so that resection of the diseased lobe may be carried out immediately after application of the clamp. Excision of an entire lung is now practiced in selected cases of bronchioqenic carcinoma. Lobec- tomy is gradually winning the approval of Graham, Lillienthal, Coryllos, and others, in selected cases of bronchiectasis and lung abscess. An extremely interesting approach to coronary disease of the heart has been undertaken by C. S. Beck. By means of a pedicle graft to the heart from the pectoralis major he was able experimentally, and then in one patient, to develop a collateral circulation to this vital organ. Further reports on other patients subjected to this operation are yet to be published. One hundred seventy three

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RECENT ADVANCES IN MCDERN SURGERY 1935 - 1936 IF we were to compare surgery at the beginning of the twentieth century with that of our present decade, we should find amazing progress in operative technic, in the methods for the early recognition of surgical conditions, and in the rapidly expanding number of human disorders amenable to surgical treatment. It is very difficult for surgeons of any age to appraise the value of existing methods as to their permanence and lasting merit. They are apt to consider their procedures as having reached the acme of perfection and the finality of law. Improvements, if possible, surgeons have often agreed, would be slight and inconsequential. Many surgeons of the last century would have considered as heresy the frequent sympathectomies and thoracoplasties of today. However, we must not be too severe in our criticism of their self-com- placency and peremptoriness. In general, good surgeons have acquired their knowledge of operative procedures, their skill, and their diagnostic judgment through years of patient study and diligent application in the development of their own methods as well as those of their contemporaries. Surgery has been concerned for many years with the correction of mechanical defects of the body. The surgeon of today is no longer content with the removal of diseased organs. His desire is to restore the whole organ- ism to its physiological harmony-reconstructive surgery. Many of the ductless glands are now being treated with brilliant success. Surgical treat- ment of dysfunctions of the adrenals, parathyroids, even the pancreas is being practiced rather widely and many ,spectacular results are reported in the literature. So, too, a better knowledge of the anatomy, physiology, and pathology of different parts of the nervous system has in recent years aided much in the diagnosis of abnormal conditions of that system, and has permitted great advances in their surgical treatment. Now there is no ganglion or strand of the sympathetic nervous system which is not exposed or removed for various conditions of pain, paralysis, or dysfunction. When one reads of all the bene- fits which accrue from ablations of parts of the sympathetic nervous system one cannot help wondering why it was censured at its inception, for every one seems better in every way when he gets rid of it. This question might be asked of the appendix vermiformis which may be only a useless vestigial structure but what a boon to the young rising surgeon. With the trend of medicine, generally, toward prevention, surgery will and must contribute its share. 'New instruments, we are almost convinced, will not only improve technical skill, but as diagnostic aids will enable the surgeon to determine and correct disorders of function possibly even before morbid pro- cesses develop. It will be necessary to include only the most important contributions to surgery of recent years in this report, although the usefulness and significance of many others remains unquestioned. Most of the procedures mentioned have been tried with repeated success, some very recent ones however, are waiting One hundred seventy-two

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Denk and De Takats have obtained satisfactory results from the use of intravenous doses of papaverine in acute embolic occlusion. By relieving vessel spasm they claim to receive as good results with this harmless pro- cedure as may be expected from performing an embolectomy. However, it is advised that the injections should be made immediately upon the diagnosis of pulmonary or peripheral embolism. In advanced cases where the injections of the papaverine have not improved the circulation, embolectomy, of course, becomes imperative. Disorders of the gastro-intestinal tract continue to present difficulties. Of the four drugs commonly used for intestinal distention, pituitrin, physostigmin, peristaltin CCibal, and acetylcholine, Gerthin and Bargen, from a series of observations, found that pituitrin alone was a marked stimulant. They con- sidered it the only drug of this group likely to prove effective regularly in augmenting the peristalsis of the atonic or paralyzed bowel. Pituitrin acted in three to five minutes and had gradually diminishing effects for three quarters to one and one half hours. Experiments performed by Blalock in an effort to find the factors respon- sible for the rapidly developing signs and symptoms of ruptured peptic ulcer indicate that the various gastro-intestinal juices, especially bile, when free in the abdominal cavity, produced a marked drop in blood pressure. He believes that cc dilatation of the many intra-abdominal blood vessels causes the primary fall in blood pressure which is followed by the secondary decrease in cardiac output. Priestly and McCormack, advised serum therapy in addition to ordinary treatment for generalized peritonitis secondary to ruptured appendix: a dis- tinctly lower mortality rate was found in those cases where it was used as compared to a control series in which serum was not given. Weinberg has prepared three sera, one a polyvalent antiserum for the anaerobes most com- monly found in these cases, another a colon bacillus anti-serum, and finally a so-called complimentary serum to combat other invaders, i. e. streptococcus, staphylococcus and related organisms. Best and Hicken have rendered an interesting account on visualization of the biliary tract by injections of radio-opaque fluids into the common duct during operations ..... a method they called immediate cholangiographyn. They injected a contrast medium, usually about an ounce, into the gall-bladder, cystic duct, or common bile duct and immediately took X-rays. They felt these studies were important in visualizing the duct system and in demonstrating over-looked stones. When the duct system was injected post-operatively thru catheters or fistulas they found a surprising number of cases of spasm of the ducts. They also found that glyceryl trinitrate, magnesium sulphate, atropine, cream, and olive oil had very evident therapeutic value in these cases of spastic dysynergia. Rothman, Meranza and Meranza, during the past year have been studying blood phosphatase and its relationship to jaundice. After observing a large number of cases of obstructive and non-obstructive jaundice they have con- cluded that a value greater than 10 units suggests obstruction. They found this test to be of greater value than any other in the differentiation of these two types of jaundice. Without doubt the most fascinating of the recent developments in neuro- surgery is that of the surgical approach to the treatment of intractable pain and essential hypertension. Adson, in l934, relieved an otherwise incurable fronto- One hundred seventy-four