Torsion of the normal uterine adnexa in premenarchal girls

Two cases are reported of torsion of the normal uterine adnexa in premenarchal girls. In one patient, aged 3 yr, both the ovary and fallopian tube had undergone torsion. The second patient, aged 11 yr, had sustained torsion of the fallopian tube alone. This is the first reported case of torsion of the fallopian tube occurring without torsion of the ovary in a patient in this age group. The mechanisms of torsion of normal uterine adnexa are described and the operative management is discussed.

Wilder Penfield: his legacy to neurology. Exciting beginnings

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Idiopathic scrotal edema

An eight-year experience consisting of 30 cases of idiopathic scrotal edema has been analyzed. The condition is characterized by a minimally painful scrotal swelling produced by subcutaneous edema. A normal testis and cord enable one to differentiate it from some other causes of scrotal swelling such as torsion of the testis and epididymo-orchitis. A connection with trauma, periurethral disease, or streptococcal disease appears unlikely. A localized allergic phenomenon, perhaps a local form of angioneurotic edema appears to be the most likely etiologic factor.

Pelvic hydronephrosis in children: a review of 219 personal cases

A series of 238 hydronephrotic kidneys in 219 children is reported. The condition was more common in the male than in the female subject and occurred more frequently on the left side. It was often bilateral, especially in infants, with an abdominal mass as the common presenting feature. Loin or abdominal pain was the most frequent complaint in older children. In some cases hydronephrosis presented as a ruptured kidney following trauma. Only 1 patient was hypertensive. The lesion was asymptomatic in 18 cases and the incidence of urinary infection was low. Dismembered pyeloureteroplasty was the procedure of choice for reconstruction. Preliminary nephrostomy was used rarely and nephrectomy was done in 10 per cent of the kidneys. Of the 7 reoperations 4 were for persistent obstruction and 3 were because stones had formed after the pyeloplasty. The late results, assessed clinically and radiologically, have been entirely satisfactory. Many kidneys of initially doubtful value showed useful improvement after reconstructive operation and no secondary nephrectomies were performed. The only death in the series occurred 2 1/2 years postoperatively and was unrelated to the urinary tract.

Plantar neuroma: analysis of results following surgical excision in 145 patients

Few series deal with the long-term results of surgical exision of plantar neuromas. The results of a study with a 21.5 month average follow-up are presented. Of 145 patients undergoing surgery from 1970 to 1973, 85 returned for examination and roentgenograms. There were 13% with unsatisfactory results and 21.3% with some pain remaining. Caution should therefore be used in assuring patients of complete relief.

Electroconvulsive shock increases the behavioural responses of rats to brain 5-hydroxytryptamine accumulation and central nervous system stimulant drugs

1 A single electroconvulsive shock (ECS) of 150 V for 1 s increased the concentration of rat brain 5-hydroxyindoleacetic acid (5-HIAA) but did not alter brain 5-hydroxytryptamine (5-HT) or tryptophan concentrations 3 h later. 2 A single ECS decreased 5-HT synthesis 3 h and 6 h later. Synthesis was back to normal after 24 hours. The ECS-treated rats did not show greater hyperactivity produced by the increased brain 5-HT accumulation following administration of L-tryptophan and tranylcypromine at any time up to 24 h later. This suggests that a single electroshock does not alter 5-HT functional activity. 3 Twenty-four hours after the final ECS of a series of 10 shocks given once daily, the rats were given tranylcypromine and L-tryptophan. They displayed greater hyperactivity than control rats not treated with ECS, suggesting that ECS increases 5-HT functional activity. Brain concentrations of 5-HT, 5-HIAA and tryptophan were then unchanged by ECS. 5-HT synthesis and accumulation of 5-HT following tranylcypromine and L-tryptophan were not altered by ECS. 4 The hyperactivity following administration of the 5-HT agonist 5-methoxy N,N-dimethyltryptamine was enhanced by repeated (10 day) ECS, suggesting altered post-synaptic responses to 5-HT receptor stimulation. 5 Repeated ECS enhanced locomotor activity following tranylcypromine and L-DOPA. It did not alter brain noradrenaline or dopamine concentrations. 6 The latent period before a pentylenetetrazol-induced convulsion was shortened by repeated ECS. 7 Following repeated ECS there appears to be increased neuronal sensitivity to certain stimuli producing centrally mediated behavioural stimulation. This is discussed in relation to the mechanism by which electroconvulsive therapy (ECT) produces its therapeutic effect.

Acute slipped capital femoral epiphysis

Of 12 cases of acute slipping of the capital femoral epiphysis (representing 11 patients), results were satisfactory in nine cases and poor in three cases at follow-up (in two of the three cases with poor results, reduction was lost postoperatively). Five of nine patients with prodromal symptoms were seen by a physician but were undiagnosed or untreated before the acute slipping. An additional patient had roentgenographic evidence of an early (asymptomatic) slipping capital femoral epiphysis one year before the acute slipping. Preferred treatment is gentle manipulation and fixation with multiple threaded pins, followed by crutch walking for three to four months. Spica casting is not recommended because of an increased incidence of acute articular cartilage necrosis and the possibility of late recurrence of slipping.

Traumatic rupture of the ileum

Three cases of patients who sustained rupture of the ileum following blunt trauma to the abdomen are reported. The onset of symptoms was delayed for a period which varied between 5 and 12 hours after the injury.

As so many of these patients are either asymptomatic or have minimal symptoms for the first 6 hours after the injury it might be advisable to admit all cases of abdominal injury to hospital for observation.

Laboratory investigations of the haemoglobin, white-blood count, and serum amylase contributed nothing to the early diagnosis of the condition. Plain radiographs of the abdomen show gas under the diaphragm in only 34 per cent of cases of traumatic rupture of the ileum.

Needle aspiration of the abdomen for liberated intestinal contents was not carried out in this series. In other series this procedure was found to be accurate in 90 per cent of cases of traumatic rupture of the small bowel. This is the only investigation which can be regarded as making a useful contribution to the early diagnosis of the condition.

Laparotomy was carried out between 5 and 15 hours after the injury. There was gross contamination of the peritoneal cavity by intestinal contents. This was due in all 3 cases to a single laceration on the antimesenteric border of the bowel. The lacerations were situated at distances varying between 15 and 22.5 cm. from the ileocaecal valve and were between 1.3 and 2.5 cm. in diameter. These were closed using two layers of chromic catgut. The peritoneal cavity was washed out with saline and Noxyflex.

The death of 1 patient in the series occurred 13 hours after the injury and was due to a myocardial infarct. The mortality-rate of 33 per cent for the series is similar to that described in other reports.

Post-pneumonectomy oesophageal fistula

The complication of oesophagopleural fistula is described in eight of 1,389 patients (0·5%) who underwent pneumonectomy for carcinoma of the bronchus. All the patients had a right pneumonectomy performed and seven of the eight patients developed a bronchopleural fistula before developing an oesophageal fistula. The complication appeared between two weeks and 22 months after pneumonectomy. All the fistulae occurred on the right side; three were at the level of the bronchial stump and five were within 5 cm below the stump. The cause of the fistula was thought to be the development of a peribronchial abscess which ruptured into the oesophagus. The complication was diagnosed by the presence of food particles on the dressings in those patients with chest drains in situ. It was confirmed by Gastrografin swallow. The size of the fistulae varied between 3 and 8 mm.

Successful immediate surgical closure of the fistula was accomplished in three patients. Feeding was continued using a gastrostomy.

Five patients unfit for surgery and treated by palliative measures died.

Advances in the understanding and treatment of head injury

The author describes his personal involvement in head injury prevention and management over the past 40 years. He reviews the evolution of knowledge concerning the role of increased intracranial pressure, and considers the importance of cerebral vasoparalysis in the production of signs and symptoms following head injury, and the development of methods of recording intracranial pressure continuously, over hours and days.The development of an experimental compression model has led to a fuller understanding of edema of the brain and has provided a means of studying, by light and electron microscopy, the histological changes that result from edema. More recently, analyses of biochemical changes and disturbed membrane function have opened up a new avenue of potential treatment. Moreover, it is now clear that cerebral vascular dilatation and abrupt pressure increase can be produced in the monkey, in over 50% of cases, by lesions in the dorsomedial nucleus of the hypothalamus. Similar lesions may occur in the human and this suggests other therapeutic approaches. There is, then, a genuine hope of a breakthrough in the management of head injuries.