George M. Curtis

Traumatic rupture of the spleen

T RAUMATIC rupture of the normaI spIeen is not the clinica rarity it was formerIy thought to be. Its increased incidence is both real and apparent. On the one hand, this is due to better diagnosis; on the other it is accounted for by the year-to-year increase in automobiIe and industria1 accidents. It is aIso important to note that in reports thus far avaiIabIe from EngIand ruptured spIeen is high on the list of abdomina1 injuries incident to bIast. The exact incidence of traumatic rupture of the spIeen is diffIcuIt to determine. That it is higher than is commonIy recognized is one of our fundamenta1 concIusions. That the diagnosis is too frequentIy missed we know from experience at our own institution. This is one of the prime reasons for again caIIing the attention of the profession to this resuIt of trauma. Working as we do in a genera1 hospita1 which serves private patients as we11 as a teaching institution for the medica1 schoo1, we have the opportunity to observe the methods of a considerable group of surgeons in the management of accident cases. During the present year, two cases (Nos. 19 and 20) of traumatic rupture of the spIeen remained undiagnosed unti1 necropsy. In reviewing the pertinent Iiterature one is impressed by the Iarge number of papers reporting one or two cases of spIenic rupture, indicating that many surgeons stiI1 consider it rare enough to warrant a paper composed of a singIe case report. That the true incidence is far greater is indicated by the report of Wright and Prigot.48 They found traumatic rupture of the spIeen in one out of every 666 accident cases of a11 kinds admitted to the HarIem HospitaI in New York City. At the University HospitaI our incidence has been computed to be one out of every 920 accident admissions of a11 types. * From the Department of Research Surgery, The Ohio State University. This investigation was aided by a grant from the Comly Fund of The Ohio State University.

Delayed suture in the management of wounds

Abstract In a series of traumatic wounds in which delayed suture was utilized time interval has been shown to exert a vital influence on wound repair as well as hospital stay and “return to duty” status. This investigation has revealed that the optimum time interval for delayed suture is four to five days following the initial wound surgery. Seventy-two per cent of those patients with wounds closed in six days or less were returned to duty in an average of twenty-seven days whereas in those with a time interval of seven days or more only 49 per cent were returned to duty in an average of thirty-two days. Since healing approaching 100 per cent may be obtained in wounds closed during the optimum time interval, it would appear that the scope of delayed suture might with advantage be extended beyond the realm of traumatic surgery.

Selective physiologic débridement with topical tryptic enzymes

Abstract 1. 1. The authors experiences with crystallinetrypsin tryptar) has been briefly reviewed. 2. 2. Chymotrypsin and trypsin together in equal enzyme strength exhibit potentiated proteolysis-more than 200 per cent more rapid than an equal concentration of trypsin alone. 3. 3. Chymotrypsin is relatively non-toxic, does not delay healing or alter the microscopically visible course of events when applied to open wounds. 4. 4. A number of illustrative cases show the adequacy of the new enzyme system of trypsin and chymotrypsin in handling fibrinopurulent necrotic lesions which have failed to respond to the usual surgical measures. 5. 5. The combination of trypsin and chymotrypsin in equal enzyme strength when properly applied to the fibrinopurulent necrotic lesion which has failed to respond adequately to the usual surgical measures, rapidly eliminates noxious elements which prevent healing. In the presurgical preparation of the lesion in which tissue salvage is imperative this new enzyme system offers a safe, effective means of eliminating all necrotic detritus, leaving the healthy viable tissue intact and unaltered. Herein lies the uniqueness of this physiologic enzymatic cleansing process: it automatically halts its dkbridement at the fine line between life and death.

Pertinent factors influencing repair in traumatic wounds.

Abstract Clinical observations on two series of patients with a total of over 1,700 traumatic wounds have been presented in an effort to emphasize some of the pertinent factors influencing wound repair. These factors have included (1) a correct concept of debridement; (2) the hazard of secondary wound infections; (3) the indications and advantages of delayed suture; (4) the use and abuse of wet dressings; (5) the importance of pressure dressings; (6) the desirability of immobilization; (7) the value of blood replacement and (8) a re-emphasis of the role of adequate protein levels in wound repair. Most of these observations are based upon military surgical experience. On the other hand, it appears to us that the same fundamental principles of management apply to any traumatic wound regardless of whether it is military or civilian in origin. It is admitted, however, that the extent of the application of those principles may differ in the two types of wounds. The time lag, extent, magnitude and location of the wound, as well as the environment of the patient and the type of clothing worn at the time of wounding are all pertinent factors which will influence the extent of the debridement. Furthermore, these same factors will decide whether the wound may be closed by primary suture or left open until a localized immunity has developed and then closed by delayed suture. If these fundamental principles and pertinent factors are constantly borne in mind, it is the opinion of the authors that the surgeon or physician responsible for the care of traumatic wounds will be rewarded by less infections, less disability and a much earlier return of the patient to his usual employment.

Diagnosis of clostridial myositis

Abstract 1. 1. Certain etiologic factors have been established, which if constantly borne in mind, will make the surgeon so alert to an impending clostridial infection, that early diagnosis and prompt energetic treatment will be accomplished before the infection has had an opportunity to become firmly established. 2. 2. These etiological factors, which favor clostridial infection are: (1) major vascular injury; (2) compound fractures; (3) prolonged time lag; (4) wounds contaminated with manured soil; (5) thigh and buttock wounds; (6) wounds with marked tissue destruction and (7) wounds contaminated with woolen clothing. 3. 3. Certain diagnostic criteria have been established which will not only aid in establishing a diagnosis of clostridial myositis, but will also aid in differentiating it from the relatively benign clostridial infection anaerobic cellulitis. 4. 4. These criteria are: (1) toxemia or shock or both; (2) pain at the site of injury; (3) high pulse rate, out of proportion to the temperature; (4) anemia (1.5 to 2 million); (5) hypotension; (6) moderate temperature, 100 ° to 102 °F. and (7) muscle involvement, which does not bleed or contract when cut. The discharge, odor and crepitation are inconstant and unreliable signs in clostridial myositis. Although the recent war has provided an opportunity for an improved knowledge of these infections, the problem has not as yet been satisfactorily solved. It is our earnest hope that laboratory and clinical investigation will be relentlessly continued, so that in the event of another war, we may better cope with this deadly complication of traumatic wounds.

Cyclic Variations in Urinary Excretion of Iodine in Women.

While investigating the daily urinary excretion of iodine in patients with goiter, we observed a rise in the urinary output of iodine during the first 2 days of menstruation in one (Fig. 1, B), with non-toxic nodular goiter, and a premenstrual rise in the other (Fig. 1, A), with exophthalmic goiter. Several investigators have reported an increase in the blood iodine during menstruation. 1 , 2 , 3 , 4 It has also been reported that menstrual blood is considerably higher in iodine content than venous blood. 3 , 5 Since the urine was not obtained by catheterization some unavoidable contamination occurred. However, 50 to 100 cc. of menstrual blood would be required to give the increase found during the menstrual period in the patient (B), and blood was not grossly evident in the specimens. To further investigate this cyclic variation, 2 women without evidence of thyroid disease (C and D) were studied throughout the entire menstrual cycle. During these studies the subjects were allowed a general diet. Care was taken to exclude foods known to be high in iodine content, and particularly sea foods. The ages are as follows: A-18, B-39, C-27, and D-32. All 4 showed either a premenstrual or menstrual rise in urinary iodine excretion (Fig. 1). Subject C showed the premenstrual rise during 2 consecutive periods. B, C, and D showed a rise 6 to 8 days after the onset of menstruation. A, C, and D presented a rise 14 to 18 days after the onset of menstruation. It will be noted that the variation in the urinary iodine excretion does not parallel that found in the blood iodine by previous workers. At present we are not prepared to discuss the mechanism of this cyclic variation in the urinary excretion of iodine. Further investigation is in progress.

Acetone fractionation of blood and urinary iodine.

Summary 1. All of the urinary iodine appears to be acetone-soluble. 2. There is an acetone-soluble; and acetone-insoluble but water-soluble; and an acetone and water-insoluble form or forms of iodine in the blood. 3. The quantitative relationship between the iodine fractions of the blood varies with the form of iodine ingested. 4. The acetone-soluble fraction of the blood iodine may possibly contain the iodine compounds which will later be excreted in the urine. 5. The true significance of these fractions is as yet unknown.