Hopeless Cases Research Articles

Bronchiectatic Sequelae of Pulmonary Tuberculosis and Its Subsequent Complications

The following case is presented for the interesting sequelae of far advanced, bilateral pulmonary tuberculosis. In the pre-chemotherapy era, the patient to be discussed would probably have died rather promptly. At the present time, many of these formerly hopeless cases survive, but with extensive residual pulmonary destruction. Bronchiectasis is one form this destruction may assume. The following case report represents the sequelae of bronchiectasis and subsequent complications.

An experimental evaluation of scleral shortening operations.

The penetrating scleral resection operation, as advocated by Lindner 1 in 1933, salvaged many previously hopeless cases of retinal detachment. Following this advance in detachment therapy, the full-thickness scleral resection became accepted by most opthalmic surgeons. However, the frequent operatiye complications of hemorrhage and vitreous loss during full-thickness sclerectomies prompted the development of safer scleral shortening operations. The lamellar-scleral resection, as advocated by Dellaporta, 2 Paufique, 3 and Shapland, 4 has gained increasing usage in recent years. Schepens * further modified the lamellar-scleral resection by infolding polyethylene tubing in the base of a lamellar-scleral preparation. Recently, I reported a new type of scleral shortening operation, 5 the scleral fold, which seems to offer certain advantages. These modified scleral shortening procedures represent the basic improvements in operative technique since Muller first devised the scleral resection, 53 years ago, for use in myopia. In all these years there has been little experimental consideration

ACUTE TRAUMATIC POSTERIOR DISLOCATION OF AN INTERVERTEBRAL DISC WITH PARALYSIS

Unfortunately there is still a marked tendency on the part of many surgeons to overlook completely, or ignore until too late, those signs and symptoms which are indications for surgery in injuries of the spine and spinal cord. All too frequently the general attitude is that a cord injury is an utterly problem, and it is useless to do anything about it. As a result, those individuals who might have had a chance of recovery actually do become hopeless cases. The early indications for surgery in spinal-cord injuries are usually given as: 1. A history of progression of neurological signs. 2. Compound fractures of the spine, particularly in those cases with spinal-fluid leaks. 3. Marked encroachment of bony fragments upon the spinal canal, as exhibited in the roentgenograms. 4. With a lumbar-puncture needle in place, evidence of complete blockage of the spinal fluid on jugular compression. To these it is believed a fifth should be added: 5. Evidence of blockage of a column of pantopaque upon myelographic examination in those cases which, in spite of a negative Queckenstedt test, have a definite sensory level. The first two indications listed require no discussion, but the last three should be commented upon. It should be emphasized that, at operation, 30 or 40 per cent. more damage to the vertebrae may be noted than can be visualized in the roentgenogram. As shown in Case 2, if one relies merely upon a positive jugular-compression test as an indication that operation should be performed, extruded discs may be missed. It is obvious that this test will be negative as long as a subarachnoid space of the diameter of a No. 20 needle is still present. The validity of the test is good for that moment during which the procedure is being performed. It is known that oedema may gradually develop in the injured cord or cauda equina hours or even a few days after this initial test has been performed; and, unless the procedure is repeated several times, a true surgical lesion may be overlooked. For this reason it is advocated that early pantopaque myelography be performed in these lesions where there is no block to jugular compression, and yet a good sensory level is present. A word of caution is offered to those doing myelography on these individuals. In order to prevent further damage to the injured cord, the patient should be anchored securely to a board on the x-ray tilt table, with a firm supporting yolk at the shoulders and adjustable ankle supports. This enables tilting of the patient into an almost vertical head-down position, without compression of the vertebral column or the spinal cord. It would seem unnecessary to emphasize these criteria, but only too rarely are they followed. In all of the cases reported here, operation was performed much later than it should have been, and the degree of disability has, at least theoretically, been increased proportionately. These cases should be regarded as surgical emergencies. After early accurate diagnosis, operation should be performed immediately by a competent surgeon, for the elements of the central nervous system do not, in general, withstand prolonged compression without the occurrence of irreversible anatomical changes.

Beta Irradiation of the Eye

Recent reports and discussion of the value and dangers of irradiation of the eye with the beta rays of radon have been both enthusiastic and pessimistic. The present uncertainty can be attributed to many factors, among which may be mentioned : ( 1 ) Variability in dosage and technique of application, with too little attention being paid to the characteristics of the irradiation used, the distance of the applicator from the eye, localization of the area to be treated, and possible cumulative effects; (2) ignorance of the differential sensitivity of the normal tissues of the eye and those tissues which are to be destroyed by irradiation; and (3) difficulty in comparing the results of beta treatment with untreated controls. Often the beta irradiation clinic becomes a convenient spot to which hopeless cases can be referred regardless of theoretical or practical justification. In this paper, the various techniques and effects of beta irradiation will be discussed in an effort to arrive at a selection of suitable cases for treatment, and to utilize a dose sufficiently large to destroy undesirable tissue without undue damage to the normal structures of the eye. In addition, we will report some preliminary experiments on the use of beta irradiation following chemical burns of the eye, especially in regard to vascularization of the cornea.

Indications for Pulmonary Resection for Tuberculosis Both by Lobectomy and Pneumonectomy

1) Pulmonary resection has a definite place in the surgical therapy of pulmonary tuberculosis in salvaging otherwise hopeless cases. 2) With the exceptions cited, we prefer thoracoplasty to lobectomy and pneumonectomy in the treatment of pulmonary tuberculosis. This point of view is based on the fact that the mortality from thoracoplasty is considerably lower than pulmonary resection and to date, the late results of resection seem to offer no better chance of permanent cure. 3) When thoracoplasty fails, the following measures are considered before performing pulmonary resection: (1) Revision thoracoplasty. (2) Creation of extrapleural space and packing. (3) Cavity drainage. (4) In some cases, no further surgery. 4) Primary pulmonary resection is preferred to thoracoplasty for: (1) Lower and middle lobe cavities. (2) Tuberculomata and blocked cavities. (3) Persistent bronchostenosis. (4) Symptomatic bronchiectasis. 5) From the point of view of the pathological pulmonary changes, the type of disease most amenable to lobectomy and pneumonectomy is that characterized by fibroid and caesating lesions of the lung in which the mode of spread is principally by way of the bronchus. Since the prognosis following thoracoplasty in this type of lesion is also good, it is unusual that the surgeon is confronted with the problem of primary pulmonary resection. 6) Primarily, hematogenous or lymphogenous disseminated pulmonary tuberculosis is a contra-indication to resection, as these types of disease are progressive and removal of one part of the lung does not alter the course of the lesions in the remaining part of the lung. 7) If thoracoplasty is unsuccessful, then revision thoracoplasty, plombage, and cavity drainage should be considered before lobectomy or pneumonectomy is performed. Pulmonary resection is to be preferred to cavity drainage, if the pulmonary capacity of the patient permits. 8) In selecting any case for lobectomy or pneumonectomy, the surgeon must be certain that the patient has sufficient pulmonary reserve. Contralateral pleural thickening and diaphragmatic paralysis, along with fibrosis, calcification, and emphysema of the lung are the most important conditions in lowering the patient's breathing capacity. 9) In the surgical management of over 1,000 cases of pulmonary tuberculosis, we have performed lobectomy and pneumonectomy in 40 cases with early and late mortality of 27.5 per cent. In approximately an equal number of cases, resection was indicated but not performed for various reasons. This represents a very hopeless group of cases where for the most part, thoracoplasty had failed, and no other treatment would cure. 10) Lobectomy and pneumonectomy are indicated in many patients where thoracoplasty has failed or obviously will not succeed. The actual number of patients upon whom it is possible to perform pulmonary resection is greatly reduced because of these factors: (1) contralateral tuberculosis; (2) instability of the contralateral lesion, and (3) low pulmonary reserve. 11) We are by no means satisfied that the indications we have presented will stand the test of time. Our point of view lies somewhere between the eager advocates for pulmonary resection, whose enthusiasm has not yet been supported by satisfactory long-time results, and those who roundly condemn lobectomy and pneumonectomy for pulmonary tuberculosis. 12) It is becoming steadily more evident that it is not technical skill alone that will lead to a higher percentage of permanent arrests in pulmonary tuberculosis. The basic tendency of the disease in each particular case is variable. Thus, the more able we become in recognizing the type of pulmonary involvement, the more accurately we will place lobectomy and pneumonectomy in their proper relationship with other therapeutic procedures.

PRIMARY CARCINOMA OF THE LUNG

Primary carcinoma of the lung is a common disease that is usually not difficult to detect even in its early stages. The constructive results of surgical extirpation are favorable when compared with other visceral malignant tumors, and, more important, steady improvement is being recorded. In the past decade the medical profession has made real progress toward earlier diagnosis of this disease, and there are many reasons to believe that the time lag between onset and recognition will be still further reduced. During the same period many of the technical obstacles to the successful surgical management of pulmonary cancer have been surmounted. The operative mortality rate at first appeared formidable because advanced and oftentimes hopeless cases were being approached with technics that were inadequate at the best. As technical problems were solved and more favorable stages of the disease recognized, the operative hazards have been reduced correspondingly. The problem of primary

The Management of Advanced Cancer of the Breast

Radiologists see more cancer than anyone else and therefore are believed by the public and by some of their colleagues to be experts. Although they are not ordinarily required to undertake the general care of cancer patients, their opinion is often sought on the advisability of various surgical and radiological procedures, as well as the problems that arise in the management of the disease. For the purpose of this discussion, advanced cancer of the breast can be divided into two groups. In the first group the disease is local and advanced to the stage of ulceration and fixation to the walls of the chest. Most of these patients are old and metastasis, therefore, is not widespread although some—but not all—have carcinomatous involvement of the axillary lymph nodes. The principal manifestations of the second group are widely disseminated metastases, which may occur with or without such local signs as ulceration. Obviously the two groups present widely different problems and must be considered separately. In the first group, with pronounced local symptoms, modern surgery has much to offer. The principal object of surgery is to remove the primary ulcerating tumor. The size and extent of lesions that can be removed by skillful surgeons are surprising. I have seen enormous areas denuded and successfully covered with skin from the unaffected breast. There is, of course, no objection to the removal of the breast tissue from the opposite side and the utilization of its skin to cover the area. Since the diagnosis is obvious in advanced, ulcerating cancer of the breast, the usual objections to preoperative irradiation do not apply. In fact, the most spectacular results of x-ray treatment are seen in advanced lesions. Long after hope of cure by the most extensive operation has had to be abandoned, much can be accomplished by skillful and judicious x-ray treatment. Ulcers often heal, the tumor in the breast shrinks, and the enlarged axillary nodes disappear. It is not at all uncommon for x-ray treatment to produce so much improvement in advanced and seemingly hopeless cases that it is possible to perform an operation with some hope of a permanent cure. X-ray treatment is not a substitute for operation, and whenever the chances for complete cure seem reasonably good, irradiation should be used only to supplement the work of the surgeon. There is but one exception to this rule, and that is the older patient. After the age of seventy or perhaps sixty years, cancers grow slowly. By careful x-ray treatment, repeated whenever necessary, it is often possible to shrink the tumor and retard its growth enough to enable the patient to live out her normal life without ever having any of the unpleasant symptoms of advanced cancer. The foul odor of ulcerating cancer of the breast is extremely distressing to the patient. When the ulcer is recurrent and cannot be excised or healed by x-ray treatment, some means must be found of diminishing this unpleasant symptom.

MANAGEMENT OF RESPIRATORY COMPLICATIONS OF POLIOMYELITIS

THE PROBLEM of severe bulbar poliomyelitis is largely one of secretional obstruction of the respiratory tract, with secondary anoxia. The satisfactory result of management based on that idea and the rapid change in the aspect of apparently hopeless cases on clearing the airway suggest that anoxia is more important than the virus infection itself. Poliomyelitis occurs chiefly in sporadic epidemics, and the physician who meets it for the first time is likely to find the respiratory complications bewildering. In this discussion, based on four years' experience of poliomyelitis and previous experience of respiratory obstruction, an attempt will be made to visualize the mechanisms involved and to present in some detail the measures that will give relief. The prevention and the relief of anoxia are the urgent indications. The statistics accumulated by Priest, Boies and Goltz¹in the course of their fine management of a large series of cases indicate that

Sobre a leucotomia pré-frontal de Egas Moniz

Sobre a leucotomia pré-frontal de Egas Moniz

Refrigeration anesthesia

<h2>Abstract</h2> The use of refrigeration anesthesia for major amputations of the limbs is a sound surgical procedure. It is applicable in particular to the poor risk patient since there is scarcely any shock accompanying the procedure. It is possible to perform major amputations safely with this form of anesthesia in what formerly were hopeless cases because of debility or septicemia. It lowers the incidence of stump infections in those patients requiring amputation because of infection. Pain is relieved in most instances after the application of cold, thus adding to the ease and comfort of the patient as well as facilitating preoperative preparation. The postoperative period is likewise free from pain, and the patient may carry on without missing a meal. This is especially important in diabetics as the diet and insulin do not have to be changed. There is ease and quickness of operation in these cases. Poorly nourished tissues may be saved although refrigeration will not restore devitalized tissue. Edema and drainage may be controlled postoperatively when necessary. There is also a reduction in the incidence of thrombosis and embolism. This method of anesthesia is also valuable in severe crushing wounds of the extremities or other injuries that require amputation. This form of refrigeration is not intended to supersede other forms of anesthesia when the general condition of the patient is good, but is a valuable adjunct in the treatment of the poor risk patient.

The Endocrine Glands and Cancer

Patients with advanced malignant growths should be, and in most cases are, treated palliatively with roentgen rays or radium. The alleviation of symptoms when these agents are properly employed, in appropriate dosage, is too well known to require comment, yet it is striking how often we see what is considered a cancerocidal dose administered to a hopelessly incurable patient. We must, unfortunately, consider three out of every four cases referred to us as incurable. In most instances it is obvious which patients have early and sufficiently localized lesions to receive cancerocidal quantities of radiation. In such cases even a severe reaction is a small price to pay for eradication of the neoplasm. In the hopeless cases, however, the radiation reactions are without such compensation and are frequently so severe that the patient suffers more from the treatment than from the disease. This is well exemplified in the treatment of prostatic cancer, either with platinum radium needles or radon seeds, when the im...

Acceptance of defeat in Germany.

The Nazis and generals are hopeless cases and will not be influenced by the nature of the peace. Many workers who gained rewards under Nazism may also identify their welfare with that of the Nazis, but a labor-socialist government could win the support of a majority and minimize post-war resentment of defeat. National pride is more important to the middle classes. They should not be offered aid with dishonor. Punishment and sacrifices should be immediate but not long-drawn-out. If decent Germans understand the moral debt contracted by the Nazis they will strive to atone, but the suggestion must come from neutral agencies (the churches) rather than from the victors. Through suffering, Germany may gravitate toward democracy. (PsycINFO Database Record (c) 2006 APA, all rights reserved)

The changing conception of cancer of the prostate

The changing conception of cancer of the prostate

AMPUTATION FOR PERIPHERAL VASCULAR DISEASE

In spite of significant additions to the conservative therapy of peripheral vascular disease, such as suction and pressure therapy, intermittent venous hyperemia, iontophoresis with acetylbetamethylcholine hydrochloride (mecholyl) and other measures (the value and limitations of which have been recently analyzed from this clinic1), there still remains a group of cases in which amputation must be performed either as a life-saving measure or to rid the patient of a painful and functionless limb which undermines his morale and lowers his earning capacity. It has seemed to us that since the advent of the newer conservative measures, which are urged and demanded by patients even in obviously hopeless cases, patients come later than ever for amputation, thereby increasing the mortality and discrediting the procedure. In this brief study we wish to present our experience with major and minor amputations done for peripheral vascular disease by ourselves or under our supervision in the

Observations on Human Beings with Cancer, Maintained at Reduced Temperatures of 75°–90° Fahrenheit

During a little more than three years the authors have been interested in observing the effects of reduced temperatures upon embryonal cell growth and activity, especially in its possible application clinically to the cancer field. These observations have included studies upon chick embryos, various forms of plant life and tissue cultures, as well as upon hopeless cases of human cancer. It has been shown by Fay and Henny that the prolonged local application of temperatures of 40°-50° Fahrenheit to human neoplastic lesions resulted regularly in the relief of pain and in reduction of the size of the tumor. In these initial studies, carefully controlled temperature readings by means of an extremely accurate and rapidly recording thermocouple (Henny) were obtained. Subsequently, similar skin temperature readings were made in cases where the entire body temperature was reduced, in an effort to maintain levels at least comparable to those found normally existing in the extremities; i.e., 86°-88° Fahrenheit. The rationale for this procedure is explained on the basis of the comparative infrequency of either primary or secondary neoplastic lesions below the elbows or knees, where the only apparent difference from other portions of the body lies in the lower temperature existant. It was felt that this level of approximately 90° Fahrenheit must represent a subcritical level in respect to embryonal cell

Artificial Fever as a Therapeutic Agent

Throughout the course of medical history heat has always been a prominent therapeutic agent for the prevention or cure of various diseases. In most instances it was used in an empirical manner without any thought of producing fever in the patient. Paradoxically fever has, from the earliest days, been looked upon with suspicion and alarm and antipyretics have been freely used to combat its supposedly harmful effects. Only occasionally did some observer record cases in which he believed fever had been beneficial. Forty-seven years ago Welch stated that it would be very unusual if Nature had developed and retained fever to such an extent if it did not serve some useful purpose. Statements such as this created little discussion until Wagner-Jauregg, in 1918, conclusively demonstrated that malarial fever could be successfully employed in the treatment of the hitherto hopeless cases of dementia paralytica. His favorable results were soon confirmed by other investigators throughout the world. The mortality assoc...

The Evaluation of the Roentgen Treatment of Laryngeal Carcinoma

Introduction THE evaluation of the therapeutic methods utilized for this disease is not an easy task. There are several reasons for this. Firstly, even to-day, the technic of radiation therapy has not yet been standardized. The results which any therapist is able to show at present are, therefore, in a sense experimental. Secondly, usually none but the most advanced and hopeless cases have been submitted for radiation treatment. The early intrinsic cases of carcinoma, cases which surgeons consider suitable for operation, are seldom subjected to radiation. Thirdly, there is much to be desired in the manner in which the results are summarized statistically. Despite all this, such an analysis of the literature as is now possible would indicate that results obtained by radiation treatment in the advanced and hopeless cases are encouraging. Many sufferers have been rendered clinically free of the disease, or have had their lives prolonged in relative comfort. It is on the basis of experience, mainly, with this...

The present status of radiation therapy in cancer of the ovaries

The method of treatment for carcinoma of the ovary at the New York City Cancer Institute is described and commented upon. A discussion of the methods used and the statistics of cases treated is given, emphasizing the following points: 1. (1) All cases of ovarian carcinoma should be treated by surgery and irradiation. 2. (2) Many types of carcinoma of the ovary are radiosensitive. 3. (3) Life is definitely prolonged in many cases where surgical treatment has been combined with irradition, as against those patients who had surgical treatment alone. 4. (4) Even in hopeless cases the patient may benefit a great deal by palliative x-ray therapy.

Irradiation of Radiosensitive Tumors

IN a study of radiosensitive tumors it may be of interest to review one or two cases living for a number of years that had malignant tumors and that were treated with the roentgen ray. Patients are from time to time referred for roentgen therapy who either have an inoperable tumor, or a large tumor which is inaccessible to operation, or for palliative treatment. It is gratifying to find that the results in some of these hopeless cases are excellent, the patient remaining clinically well for years. Therapeutic roentgen rays have been used for some years as a diagnostic agent in identifying the pathology of certain varieties of tumors. Desjardins (1), who has rather thoroughly reviewed this method of studying tumors, states that the specific sensitiveness of each kind of cell is the dominant single fact of radiology and should be recognized as a law. This sensitiveness appears to be related to the natural life cycle. Thus the lymphocytes, the metabolic cycle of which among human cells is the shortest, are a...

Surgery of the sympathetic nervous system

A brief review of the recent advances in the surgery of the sympathetic nervous system is presented in the hope that further interest will be aroused that will tend to a more complete knowledge of this mechanism, which undoubtedly holds the key to many unsolved problems. In such a limited survey of this field many valuable references have been omitted and it is with regret that all worthwhile contributions cannot be listed. However it is obvious that careful and deliberate selection of patient and operation will be of distinct advantage in many apparently hopeless cases, with a minimal mortality in skilled hands.