Gerald T. Golden

Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room

: In the majority of patients in this series of 1,000, acute abdominal pain was due to conditions that required neither surgical intervention nor hospitalization. Eleven of the 1,000 patients had an early missed diagnosis in the emergency clinic for which a subsequent operation was needed, and twenty underwent an operation which subsequent diagnosis showed was not required. All false-negative evaluations occurred in patients with early appendicitis or small bowel obstruction. Most false-positive results were due to acute infections of the female genitourinary tract in patients operated on to exclude appendicitis or a tubo-ovarian abscess. The following factors help identify the high risk patient with an acute surgical abdomen: (1) pain for less than 48 hours; (2) pain followed by vomiting; (3) guarding and rebound tenderness on physical examination; (4) advanced age; (5) a prior surgical procedure. The presence of these features demands careful evaluation and a liberal policy of admission and observation. White blood cell counts, body temperature, and abnormal abdominal roentgenograms may add confirmatory evidence but are not particularly helpful as screening devices.

A comparative appraisal of emphysematous cholecystitis.

There is ample evidence from this retrospective comparison to indicate that emphysematous cholecystitis does merit clinical distinction apart from acute cholecystitis. It is an acute infection of the gallbladder caused by a specific group of bacteria that may be aided by some aspect of local ischemia. Cholelithiasis does not seem to be a major factor in the pathogenesis of emphysematous cholecystitis, and this, in association with some dependence upon ischemia, may account for the predominance of this disease in males rather than females. Gangrene is a common feature of the pathologic process, and thus it is not surprising that the diagnosis of emphysematous cholecystitis implies a risk of gallbladder perforation that is five times that expected from ordinary acute cholecystitis. The key to identifying this disease is the plain abdominal roentgenogram which in most instances will make the diagnosis and provide an impetus for early operative intervention.

Surgical management of epidermoid carcinoma of the anus

An analysis of twenty-six cases of epidermoid carcinoma of the anus from the University of Virginia Medical Center and 1,060 cases from the surgical literature has been presented. We believe this review justifies the following conclusions. (1) Considerable delay in diagnosis frequently occurs, adversely affecting the prognosis of patients with this disease. (2) Abdominoperineal resection remains the treatment of choice. Wide local excision is inadequate for most lesions, and should be reserved for lesions of the anal verge less than 2 cm in diameter with favorable histology, that is, low grade of malignancy. (3) Large lesions and those with a high grade of malignancy are associated with a poor prognosis, but even these patients may sometimes be cured with aggressive surgical excision. (4) Synchronous inguinal node metastases are associated with a poor prognosis, but an occasional patient may be cured by iliofemoral node dissection. (5) Iliofemoral node dissection is indicated for metachronous inguinal node metastases in the absence of distant spread. (6) Iliofemoral node dissection should not be performed if these nodes are not clinically involved with metastases. Approximately 70 per cent of these patients will not need this procedure and would therefore have this resection and its attendant morbidity unnecessarily.

Nonoperative management of fingertip pulp amputation by occlusive dressings.

Nonoperative management of fingertip pulp amputations has been employed in eighteen adults. After wound cleansing and debridement, the wound was covered by an occlusive dressing. Healing of the amputated fingertip occurred within four weeks. The healed fingertip had an excellent sensory perception, normal range of motion and an acceptable cosmetic appearance. This satisfactory outcome was realized with less than ten days lost from work.

Galactocele of the breast

Abstract Galactocele is an uncommon lesion occurring in the breast, and five cases are presented in this report. Our experience supports the belief that galactocele occurs most frequently in lactating females in the postpartum period. However, two unusual cases are presented. Meticulous surgical technic is required in resection of these lesions to prevent postoperative milk fistula formation. If signs of acute inflammation of the cyst are present, surgical intervention should be delayed, if possible, until evidence of inflammation has subsided.

Intractable ascites: a complication of ventriculoperitoneal shunting with a Silastic catheter.

Abstract The fifth reported case of ascites secondary to a Silastic ventriculoperitoneal catheter occurred in a three year old girl in whom the device was placed for hydrocephalus secondary to tumor. Abdominal exploration revealed serosal irritation with adhesions in the midjejunum. Malabsorption caused by chronic inflammation or subclinical peritonitis provides the best explanation for this rare complication.

Perforated duodenal ulcer

Abstract The records of 131 patients with perforated duodenal ulcer have been reviewed. Sixty-seven per cent of these patients were treated by simple closure of the ulcer or nonoperatively. Of this subgroup, 80 per cent had significant symptoms of peptic ulcer disease requiring medical or surgical treatment and 69 per cent required a second surgical procedure. Thirtyseven patients were treated by a definitive surgical procedure for duodenal ulcer at the time of perforation and all survived. In this group of patients, only one required further surgery for complications of peptic ulcer. We believe that antrectomy and vagotomy or pyloroplasty and vagotomy should be utilized in the treatment of perforated duodenal ulcer unless specific contraindications are present.

Damage to tissue defenses by vasoconstrictors

The paper investigates the effect of solutions of local anesthetic agents on the ability of wounds to resist infection as well as the influence of the injection techniques on the dissemination of bacteria through the wound. On the basis of these studies, the following recommendations are made: (1) a regional nerve block with 1% lidocaine administered through a 27 gauge needle is indicated before wound cleansing; (2) if the wound is not susceptible to a regional nerve block, anesthetize the wound by injecting the agent through the skin around the periphery of the wound; (3) avoid the use of epinephrine with the anesthetic agent.

A technic of lower extremity mesh grafting with early ambulation

Abstract The use of mesh grafts and a gelatin boot permits early ambulation in selected patients.

A new filtered sump tube for wound drainage.

A new filtered sump tube has been designed for drainage of collections of fluids from wounds without the danger of infection by airborne contaminants. A two-staged filter has been attached to the vent lumen that removes particulate matter and bacteria from the air that passes through the filter. A clinical evaluation of this tube confirms the superiority of sump drainage as compared with closed suction drainage in the removal of fluids from wounds or cavities.