H. Brodie Stephens

RETROGRADE ARTERIOGRAPHY IN THE DIAGNOSIS OF CARDIOVASCULAR LESIONS. II. COARCTATION OF THE AORTA

Excerpt In a previous communication1the usefulness of retrograde arteriography in the diagnosis of aneurysms and peripheral vascular lesions was discussed. The present paper is concerned with the v...

Achalasia of the esophagus

Summary Achalasia is a neuromuscular disorder of the esophagus associated with the degeneration or absence of the myenteric nerve plexuses. Peristalsis is uncoordinated or absent in the body of the esophagus; this, coupled with failure of the gastroesophageal sphincter to relax, results in dysphagia. The hypersensitive muscular response to methacholine occurs classically in achalasia and allows an early diagnosis to be made, which is when treatment is more effective. The two most commonly used methods of management are forceful bougienage and extramucous esophagocardiomyotomy. Both procedures are most effective in early stages of achalasia. Each procedure has its advocates and each has its rightful role. The patient with a redundant sigmoid-shaped esophagus is best considered for myotomy; dilatation in these circumstances may be hazardous. Patients with associated conditions such as hiatal hernia, epiphrenic diverticula, suspected gastroesophageal malignancy, peptic ulcer disease, and recurrent achalasia after myotomy are best treated surgically. The direct surgical approach has merit not only in treatment of the patients with achalasia intractable to conservative measures but also as an alternative to repeated bougienage. Good to excellent results were obtained in 78 per cent of the patients who underwent cardiomyotomy; various types of bougienage yielded good to excellent results in 45 per cent. When extensive dilatation, redundancy, and kinking of the esophagus have developed, careful, unhurried, and deliberate cardiomyotomy accomplished under direct vision and with absolute control of the length, breadth, and extent of the myotomy is less hazardous. In this series, there was no mortality and the incidence of postoperative esophagitis was low. The number of esophageal perforations (three patients; 5.5 per cent) from forceful bougienage, the total lack of mortality, and the gratifying results have led us in recent years to use cardiomyotomy frequently as the primary treatment for achalasia.

Coarctation of the aorta in children

Summary Our experience in fourteen cases of coarctation of the aorta has been presented. Twelve of these cases have had some type of surgical correction. An analysis of our material places our patients into two clinical groups. The importance of coarctation of the aorta as a cause of cardiac decompensation in children under 5 years of age is demonstrated in our Group I. Group II demonstrates the early appearance of the degenerative effects of continued hypertension. The values of retrograde arteriography have been outlined, the methods of surgical repair reviewed, and the results detailed. Our concepts of the indications for surgical treatment of coarctation of the aorta in children are presented.

Empyema in children

Summary Empyema in children is discussed, with special emphasis on the diagnosis and treatment of this condition. Sixty cases in children less than 12 years of age are reviewed.

The surgical treatment of esophageal hiatus hernia

Abstract The surgical treatment of esophageal hiatus hernias is closely related to an understanding of the disturbed anatomy and physiology of the cardioesophageal sphincter mechanism, the diaphragmatic crural opening and the inferior esophageal constrictor. Emphasis is placed upon the importance of the three-in-line sphincter mechanisms. Their normal function prevents regurgitation and maintains the normal motor function of the lower esophagus. The interplay of these systems, some of which may act normally and others abnormally, may explain many of the heretofore confusing symptoms produced by an esophageal hiatus hernia. In the absence of disabling disease of the major body systems, operative repair of an esophageal hiatus hernia is justified, for not only are the symptoms produced by either type of hernia distressing, but also the persistent or recurrent inflammation (initially confined to the esophageal mucosa) may eventually lead to submucous fibrosis, ulceration, stricture formation or perhaps even carcinoma. When stricture formation occurs, surgery becomes a necessity and is not only more formidable than the primary repair but also is frequently far less successful.

Primary carcinoma of the lung

Abstract 1. 1. Primary cancer of the lung is a frequently occurring tumor and is particularly common in the male. 2. 2. Bronchoscopy will be negative in approximately 40 per cent of the cases of early carcinoma of the lung. 3. 3. Mass examination of our male population over the age of forty, using the miniature roentgen film technic, is suggested as a means to diagnose early cancer of the lung. 4. 4. Pulmonary symptoms appearing in a male forty years of age or older should be considered due to carcinoma of the lung until proved otherwise. 5. 5. Exploratory thoracotomy is a safe surgical procedure and should be the method of choice to establish the diagnosis when the other diagnostic procedures are equivocal. 6. 6. Pneumonectomy, with removal of the mediastinal lymph-nodes, is the only treatment for early carcinoma of the lung. 7. 7. The present results in the treatment of cancer of the lung can be greatly improved by earlier diagnosis of the disease.

Lesions Incompatible With Life but Surgically Correctable in Infancy and Early Childhood

This presentation deals primarily with the diagnosis and surgical treatment of congenital anomalies that usually require correction in the immediate postnatal period. Abnormalities which are not surgical emergencies in the first few days of life but may be surgically correctable in early childhood, such as anomalies of the aortic arch and congenital heart disease, are discussed briefly.