Brock E. Brush

Megacolon in teen-aged and adult patients

SummaryMegacolon may be classified as primary or aganglionic, secondary or acquired, and functional or psychogenic. In addition, there are other mechanisms, currently poorly understood, that cause megacolon.Diagnostic studies of the patient with megacolon should include a detailed history, physical examination, rectal and sigmoidoscopic examinations, a rectal biopsy, and (for functional megacolon) psychiatric evaluation. Age of onset, encopresis, and dilatation and elongation of the colon with a narrow rectal or rectosigmoid segment are import details to consider in the differential diagnosis. Biopsy of the rectum will prove the presence or absence of ganglion cells. Careful attention should be given to patients with constipation, lest some of them be unnecessarily relegated to lifetimes of avoidable embarrassment and suffering.We have described the cases of four patients with megacolon who had reached their teens or even young adulthood before being treated. The Swenson pull-through procedure produced excellent results in each case.

Experiences with the repair of groin hernia in 200 patients aged 70 or older.

ABSTRACT: A survey was made of the records of 200 patients (158 men and 42 women) aged 70 or older who had undergone repair of groin hernias. In the aged women, femoral hernias were the most common; indirect hernias were seen much less frequently, and there were no direct hernias. In the aged men, large indirect sliding inguinal hernias and simple indirect inguinal hernias were the most common; direct inguinal hernias were seen less frequently than expected. The most serious and easily overlooked complication of hernia, particularly in old women, is bowel strangulation in association with femoral hernia. The operative procedures were individualized and varied. Local anesthesia was used for all poor‐risk patients and was the method of choice in 185 of the 200 patients. A 1% solution of chlorprocaine was the preferred anesthetic agent.

Management of Primary Hyperparathyroidism in the Elderly

Of 166 surgical patients for whom the diagnosis of primary hyperparathyroidism was established over a 20‐year period, about one‐third were over 60 years of age. For an additional 9 patients, no operation was advised, usually because of other life‐endangering disease and the presence of only a mild degree of hypercalcemia without complications. In recent years, nearly 50 per cent of the patients did not have renal calculi or osteitis fibrosa cystica; this was unrelated to age. Most of the patients with management problems were seen since 1965. Age alone was not a dominant factor in relation to serious complications from hypercalcemia, the presence of other critical disease increasing the risk of operation, or the development of major postoperative complications. The only death from primary hyperparathyroidism occurred in a 74‐year‐old patient who refused re‐operation and died from an acute hypercalcemic crisis. A liberal, but selective, policy of surgical treatment is justified for primary hyperparathyroidism in the elderly. Patients for whom the diagnosis of primary hyperparathyroidism is established may be separated into three groups: those for whom early operation is indicated, those for whom operation should be delayed to permit recovery from other life‐endangering acute disease, and those for whom operation is unjustified because of minimal uncomplicated hypercalcemia and other serious disease greatly limiting life expectancy. These categories encompass all age groups and are not restricted to the elderly. All patients require periodic re‐evaluation.

Postoperative Pulmonary Complications in the Geriatric Age Group

ABSTRACT: Postoperative pulmonary complications are a serious danger to any patient who undergoes surgery. The increase in geriatric surgery has brought into focus certain marginal factors that can spell the difference between success and failure. In a series of 300 elderly patients who underwent major surgery at the Henry Ford Hospital, there were 34 in whom clinical and radiologic evidence of atelectasis developed. In 19 others, x‐ray examination of the chest showed various infiltrates suggesting pneumonitis, and sputum cultures grew coliform bacteria. Despite appropriate treatment, 5 patients died from postoperative pulmonary complications. Illustrative cases of hypoventilation, atelectasis, pneumonia and pneumothorax are presented. Recommendations are made for the care of the elderly undergoing major surgery, including the preoperative identification of chronic lung disease, determination of the respiratory reserve, preoperative exercises in deep breathing and coughing for use after operation, adequate oxygenation during the surgical procedure, close supervision of postoperative respiratory ventilation for the first seventy‐two hours, selective use of mechanical respiratory assistance, and emphasis on early ambulation.

Sliding Inguinal Hernia in Patients Over 70 Years of Age

In a 1973 study of 200 aged patients with groin hernias, a comparatively high incidence of the type known as sliding hernia was noted. The present study of 60 patients over age 70 seen at the Henry Ford Hospital between the years 1940 and 1972 was devoted specifically to the problem of sliding hernias. The threat of bowel strangulation is often advanced as a reason for the operative repair of such hernias, but this complication is rare. Bowel dysfunction, constipation and local discomfort are far more common, and gave rise to annoying symptoms in 75 percent of the patients studied. Barium enema x‐ray examinations often revealed some degree of bowel obstruction. Most often the sigmoid colon on the left side and the ileocecal segment on the right side constituted the sliding components of the hernia; the bladder was involved less often. Repair of 62 sliding hernias in 60 patients was performed successfully. There were no deaths, and only one recurrence of the hernia.

Complications of Peptic Ulcer Disease in Geriatric Patients

ABSTRACT: Many patients with the complications of peptic ulcer disease are in the geriatric age group. This is partly the result of the overall increase in this segment of the population in recent years, and partly the result of delay in the referral of younger patients with intractable forms of the disease. Hemorrhage is the most common life‐threatening manifestation of peptic ulcer in the geriatric patient. Prompt evaluation by esophagogastroscopy and barium x‐ray examination is of paramount importance in proper management. Perforation of peptic ulcer is less common in the elderly. When diagnosed, it requires immediate surgical treatment. Pyloric obstruction should be suspected in a patient with chronic nutritional depletion, superimposed acute dehydration, electrolyte imbalance and even shock. Nasogastric decompression of the dilated stomach and re‐establishment of fluid and electrolyte balances should be attended to before carrying out definitive surgical treatment.

Gastrointestinal Hemorrhage in Geriatric Patients

ABSTRACT: Gastrointestinal hemorrhage in the elderly is described under the headings: 1) a single episode of hematemesis, melena or rectal bleeding, 2) active persistent bleeding, 3) slow persistent bleeding, and 4) periodic bleeding. Illustrative cases are presented. Although the signs and symptoms are sometimes misleading, a careful history and examination will suggest the diagnosis in 70 per cent of cases. However, sometimes it is very difficult to locate the bleeding point preoperatively. Endoscopy, radiography and angiography are valuable aids. Initially, it is important to learn whether the hemorrhage comes from the upper or the lower gastrointestinal tract, as the selective diagnostic and surgical procedures differ. In all cases the effective management of major gastrointestinal hemorrhage requires rapid identification of the source of bleeding.

Management of complicated biliary-tract disease in geriatric patients.

The surgical complications of biliary‐tract disease are discussed in relation to a study comprising 18 cases of cholecystoduodenal fistula, 6 cases of gallstone ileus, and representative cases of gallstones, pancreatitis and suppurative cholangitis. The average age of the patients was 67 years. The findings led to the following conclusions: 1) age is an important factor in the increased risk in these complicated cases, but with careful management, surgery can be successful; 2) acute cholecystitis usually can be treated conservatively in aged patients, but all too often the patients ignore the recommendation for an elective operation and are later admitted to the hospital with complications that demand emergency surgery; 3) this sequence of events applies particularly to patients with biliary calculi, who should undergo an elective operation before more serious complications develop. Had our patients been operated on earlier, the surgical risk would have been minimal and the complications would have been prevented.

Tantalum Oxide and Wound Healing Experimental Study

Summary Small cutaneous defects on the abdomen of guinea pigs were treated with sterile tantalum oxide powder. The healing time of these wounds was compared with that of control wounds dressed with sterile gauze or sterile talc. No consistent acceleration of healing of the tantalum oxide-treated wounds could be demonstrated under the conditions of the experiment.

Paradoxical Blood Concentrating Effect of Intravenous Four Normal Plasma Injections

Conclusions (1) The intravenous injection of concentrated glucose solution causes an immediate blood dilution. This dilution is greater than would be expected if the vascular tree were a closed system. (2) The intravenous injection of concentrated dog and human plasma under similar conditions not only causes no dilution, but a paradoxical blood concentration.