Burke Syphax

Clinical aids in strangulation intestinal obstruction

Summary The following findings and their frequency were noted in seventy-four patients with strangulation intestinal obstruction: (1) abdominal tenderness, 82 per cent; (2) tachycardia, 70 per cent; (3) leukocytosis, 64 per cent; (4) severe, constant, and frequent back pain, 58 per cent; (5) fever, 52 per cent; (6) shock guarding, 31 per cent; (7) palpable abdominal mass or irreducible hernia, 29 per cent; (8) shock (hypotension), 28 per cent; (9) subnormal temperature, 19 per cent; and (10) bloody diarrhea, 5 per cent. Peritoneal tap aided in some doubtful cases but x-ray findings were not consistently helpful. Fourteen patients were admitted with other primary diagnoses—pancreatitis, appendicitis, salpingitis, and twisted ovarian cyst—who later proved to have strangulation intestinal obstruction. Apparently, the single most important factor delaying correct diagnosis in these cases was the failure to recognize the common occurrence of signs of peritonitis in patients with strangulation intestinal obstruction. Careful search for signs and symptoms of strangulation intestinal obstruction should lead to earlier diagnosis and treatment with subsequently lower mortality.

Evaluation of nipple discharge in benign and malignant diseases

The evaluation of nipple discharges unrelated to gestation should proceed in an orderly fashion. Our experience, based on evaluation of 257 ducts from 182 patients, suggest that location of the lesion can be assured with or without a palpable mass by using contrast mammography. Serous and bloody discharges are the most important types of secretions. Eleven of the papillary lesions and cancers presented this fluid, except 4 papillomas which had clear secretions. Nonspontaneous discharges of all types arc followed and exploration delayed until either a mass, positive Pap smear, or contrast mammogram is evident. Even though cancer is suspect in patients after the age of 40, our series shows that papillomas are the most frequent lesion encountered in the fourth and fifth decades. However, in the sixth decade, cancer comprised 50 percent of all lesions causing nipple discharge. Needless mastectomy can be avoided in patients without a palpable mass by locating and removing the duct of discharge and basing surgical treatment on die microscopic report.

Appendicitis: A continuing surgical challenge

Abstract Appendicitis remains a common surgical entity. The diagnosis is often unclear because of an atypical history and obscure physical findings. Four illustrative cases are presented. Awareness of atypical presentations of this disease, through both history and physical examination, will enhance diagnostic acumen. In doubtful cases a period of careful observation with serial evaluations of the patient will be necessary to arrive at a correct diagnosis. A high index of suspicion in cases of peritonitis and/or paralytic ileus of undetermined etiology should allow earlier diagnosis of this common and sometimes fatal illness. The difficulties posed in differentiating salpingitis and appendicitis are emphasized.

SUPRA-AMPULLARY CARCINOMA OF THE DUODENUM.

Abstract A case of supra-ampullary adenocarcinoma of the duodenum is presented which was treated by modified Whipple pancreatoduodenectomy. Technical considerations in the reconstruction of gastrointestinal continuity and some postoperative problems (pancreatic insufficiency and gastrojejunal ulceration) are discussed.