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

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temporal migriane by a combination of surgical procedures designed to diminish the angiospasm and desensitize the meningeal vessels. Instant and complete relief followed periarterial sympathectomy of the common carotid artery and removal of the superior cervical sympathetic ganglion along with six centimeters of the cervical sympathetic trunk. In 1935 Adson used a technic whereby the splanchnic nerves are sectioned and the first and second lumbar ganglia, together with a portion of the suprarenal gland, are excised. He claims that a modified high kidney incision gives excellent exposure. He believes this operation is superior to, and less formidable than a bilateral and ventral rhizotomy of the thoracic and lumbar roots from the sixth thoracic to the second lumbar segment, inclusive. Promptly following operation the systolic blood pressure is capable of dropping from 270mm. of mercury or more, to lOOmm. Improvement in clinical symptoms is more manifest than the actual drop in blood pressure. Retinal hemorrhage, spasm, and papilledema will often disappear following sympathectomy. Cardiac and renal functions also improve. Flothow and Swift reported a review of 100 cases in which sympathetic ganglionectomy was performed for various purposes. In scleroderma only some of the symptoms were ameliorated. In Raynaud's disease better results were obtained when only the lower extremities were involved. The question of operability or degree of vasospasm in thrombo-angitis obliterans was simpli- fied by the diagnostic injection of sympathetic nerves or by spinal anesthesia. Crile performed denervation of the suprarenals in over three hundred cases of various sympathetic disorders. Over 9O'k of those having neuro- cir- culatory asthenia, hyperthyroidism or peptic ulcer were cured or greatly im- proved. Selected cases of diabetes, epilepsy, and early hypertension also showing promising results, Crile's latest exploits have been localized about the celiac ganglion and aortic plexus. Whether young or old patients are concerned, Crile's treatment of essential and malignant hypertension by means of a bilateral excision of the celiac ganglion and denervation of the aortic plexus affords promise of permanent relief. Craig suggests section of the presacral nerves in cases of uncontrollable bladder pain or dysfunction, severe dysmenorrhea, or I-Iirschsprung's disease. Leriche and Fontaine advocate novocain infiltration of the lumbar sympa- thetic nerves for the treatment of post-operative femoral phlebitis. Pearl and Shapiro found that instances of abnormal sweating as to color, odor or chemi- cal composition calls for surgical intervention. Sympathetic ganglionectomy at the proper level will produce a total inhibition of sweating in the desired regions. They claim that the accompanying rise in peripheral vasoconstriction gives no uncomfortable symptoms. Levine has furnished us with evidence to show that the vagus in man is not the constrictor nerve of the bronchial mus- culature, and that impulses for bronchial constriction must therefore be con- tained in the sympathetic fibres. With this in mind he attempted to interrupt this sympathetic reflex mechanism in bronchial asthma. In 23 cases of intract- able bronchial asthma treated by injection of the communicating rami complete relief was obtained in 75W, with varying degrees of improvement in the re- mainder. The management of brain abscess is still in a state of confusion. Many surgeons are in doubt when to drain an abscess, and are uncertain as to the procedures to use. A similar disagreement exists in the treatment of head injuries. Temple Fay regularly presents data, to support the treatment of One hundred seventy five

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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

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cerebral trauma by dehydration and fluid limitation. He claims a mortality of only 13.8921 after the third hour of admission. Zierold on the other hand wishes to destroy the common belief that increased intra-cranial pressure is a com- mon, if not constant, accompaniment to severe head injury. Zierold questions the possibility of treatment by spinal drainage or by the use of hypertonic solutions in any case of increased intracranial pressure of a degree sufficient to endanger life. Significant advances have been made in the exposure of the cranial nerves. Peet presented fourteen cases of complete cure of glossopharyngeal neuralgia by intra-cranial section of the glossopharyngeal nerve. The symp- toms are those of sudden sharp excruciating pains which shoot down from the ear, base of tongue or posterior pharynx. Dandy finds the cause of Menieres disease to lie in the sensory root of the auditory nerve. Patients were cured by intracranial section of the nerve. A successful exposure of the facial canal was obtained by Tremble and Penfield in 1936. With the advent of ventriculography and encephalography a new and valuable aid in the diagnosis of intra-cranial lesions has been acquired. les- sen, Schoenfeld and Freeman made use of thorium dioxide as a contrast medium for ventriculograms in 1933. A recent innovation in cerebral arterio- graphy is the use of colloidal thorium for injections into the internal carotid artery to be followed soon after by a rapid series of skull films. That this method is not without danger was shown by Shih and lung who experimentally produced thrombocytopenic purpura by the intravenous injection of thorium dioxide in rabbits. Alexander, lung and Lyman again, found ependymal inflammation in certain cases, after the introduction of thorium into the ven- tricles. The miscellaneous contributions and noteworthy achievements which have been described are readily seen to have permeated all branches of surgery. That many of the stumbling blocks to health have been mowed down by the surgeon's knife must be granted but that numerous perplexing problems have been created, the solutions of which have merely been begun, cannot be denied. Although I am sadly unqualified to comment upon the training of a sur- geon, a few thoughts and observations are inescapable. Bedside instructions and the acquisition of diagnostic ability are to be highly recommended. How- ever, with the current practice of deep-seated and intricate explorations of organs and tissues a very thorough knowledge of surgical anatomy becomes indispensable. How can this be better acquired than by actual dissection upon the cadaver? It is perhaps only as a senior that the medical student realized the value of the many hours spent in the dissection room during his first year. Why should not the medical student as well as the interne have the opportunity of returning to the cadaver with the new interest and under- standing of one who is really prepared to intercept his findings? Surgical pro- cedures may be practiced upon the cadaver to very good advantage in prepar- ation for the surgery of the operating room, which to my mind, is delayed far too long. If we consider operative technic a mechanical skill to be developed just as any other act of skill it should be apparent that only thru early and persistent practice will it be acquired. Surgeons who have combined an irre- proachable surgical technic along with their diagnostic acumen and insight into pre and post operative care will always win our respect and admiration. -ill One hundred seventy-six