Long-term prognosis in children with recurrent abdominal pain. The present study is a follow-up of 34 cases admitted to a paediatric department with recurrent abdominal pain (RAP) in 1942 and 1943. 45 persons without a history of RAP were selected at random and included as controls. Using a questionnaire, there was a higher incidence of gastrointestinal symptoms among persons with a history of RAP during childhood than among controls (P less than 0.05). 18 of the original 34 cases who still had symptoms were re-examined; 11 had a clinical picture consistent with a diagnosis of irritable colon, 5 had a picture compatible with both irritable colon and peptic ulcer/gastritis, and 2 had duodenal ulcer. Abdominal pains occurred no more frequently among children of parents who had had RAP during childhood than among children of parents without such a history. However, there was a higher incidence of abdominal pain among children of parents who were complaining of abdominal discomfort at the time of the investigation than among children whose parents were without such symptoms (P less than 0.005).


Childhood organic neurological disease presenting as psychiatric disorder. Over a period of one year 12 children with complaints which had been diagnosed as due to a psychiatric disorder presented to a paediatric neurological unit where neurological disease was diagnosed. The group was characterized by behavioural symptoms such as deteriorating school performance, visual loss, and postural disturbance, which are unusual in children attending child psychiatric departments. It is suggested that where there is diagnostic uncertainty the presence of these physical symptoms calls for periodic neurological reassessment, and attention is drawn to the rare but serious disorders which may thus be diagnosed. Making an organic diagnosis, however, should not preclude psychosocial management of emotional reactions in these families.


Neonatal secretion of secretin.

Neonatal secretion of secretin. The plasma levels of secretin have been measured in mothers after labour, and in their babies at birth and on day 4 of life. The mean cord venous level was higher than the maternal level, and there was a significant correlation between the individual maternal and cord values. The level had again increased by day 4, and at this time the secretin level was inversely proportional to the blood glucose level.


Revised standards for triceps and subscapular skinfolds in British children. Revised centile standards are given for triceps and subscapular skinfold measurements in boys and girls aged from one month to 19 years. The school age data are based on London measurements made in 1966, and the infant data on Midland Infant Welfare Clinic figures in 1966-67. All centiles are above those given in the earlier standards published in 1962, and particularly so in infancy. It is emphasized that the standards represent what is, not what ought to be.


Venous thromboembolism in infancy and childhood. A retrospective study of Scottish hospital inpatients aged 15 years or less has revealed, over a 4-year period, 36 cases of venous thrombosis or phlebitis. Of these 10 were considered to have deep venous thrombosis; 2 cases were associated with obvious pulmonary embolism and 2 cases developed chronic venous insufficiency. change in the coding allocations are proposed. There are "high risk" situations in childhood disease in which a diagnosis of venous thromboembolic disease should be considered and investigated.


Effect of seasonal variation in daylight on bilirubin level in premature infants. The effect of daylight on the serum bilirubin level of preterm infants (birthweight less than 2500 g) during the first 10 days of life was studied in a district of Finland (Oulu, latitude 65 degrees ĺ) with large seasonal variations in the length of daylight (range 3 to 22 h). 86 preterm infants born consecutively during one calendar year were studied in incubators where they were completely exposed except for nappies. A significantly lower bilirubin value from the fifth day of life onwards was recorded ih the group of infants born during the light half of the year, compared with the infants born during the dark half of the year. Only 4 infants developed total bilirubin levels higher than 255 mumol/l in the "light group", as compared with 10 in the "dark group". 2 infants in the light group required exchange transfusion, while 4 in the dark group did. It is concluded than natural light conditions are of importance in the design of wards for newborn infants.


The histoid variety of lepromatous leprosy. Three cases of the so-called "histoid variety" of lepromatous leprosy are reported. This variety has definite clinical features, associated with characteristic histological and bacteriological findings. Some of the features presented by our patients are similar to those described originally by Wade, especially the resistance to treatment. Considering the discrepancies existing among the authors which studied the subject, our opinion is that further studies should be done in order to elucidate the controversial points,


Nerves and nerve endings in pigmented nevi. Part I. Electron microscopic investigations revealed numerous unmyelinated nerve fibres in different types of pigmented nevi. The structure of these fibres was similar to the cutaneous unmyelinated fibres. Axon terminals were observed between nevus cells and smooth muscle cells, the former proved to be efferent-type free endings. Pure receptor-type endings were rarely seen. The contradiction between the receptor-like construction ov nevic corpuscles and the abundance of the effector-type endings is discussed.


[Effect of ultraviolet light on human chromosomes (author's transl)]. Lymphocytes were cultured in quartz flasks and irradiated by UV light. Time of exposure and moment of application varied. After UV treatment, pulverization of the chromosomes occurred and larger nuclear fragments which might be products of an abnormally proceeding mitosis with chromatin confluence were observed. The usual chromosome aberrations such as breaks, special segments, abnormal chromosomes and polyploidy have been rarely observed, but are found more often in those cultures where pulverization and nuclear fragments are less abundant. A number of mitoses in the irradiated cultures, however, shows no chromosomal aberrations. The ratio of unaffected to unaffected mitoses is dose-dependent. Chromosome fragmentation can result from UV irradiation occurring at any instance during the time of culture. One finds maximum and minimum amounts of damage when a constant dose is applied at various times.


[The chemotactic effect of blister roof, blister fluid and blister floor on polymorphonuclear leucocytes in dermatitis herpetiformis Duhring (author's transl)]. The chemotactic response of polymorphonuclear leucocytes to the blister roof, the blister fluid and the floor of the bulla, the underlying papillary dermis with the basement membrnae, were studied by a modified Boyden-assay in four patients with dermatitis herpetiformis. In the same way experimental suction blisters of the peri-lesional skin were investigated. The blister roofs showed no chemotactic activity contrary to the blister fluid and especially the underlying papillary dermis which attracted polymorphonuclear leucocytes in a high degree.


[The effect of some solvents on the epidermis (author's transl)]. The ultrastructure of epidermis pretreated with 0,1 N sofium hydroxide, ether-ethanol mixture and 0,5 M sodium thioglycolate was studied. Sodium hydroxide dissolves the keratohyalin granules and the inter fibrillar material in the keratin. It has no effect on the epidermal and keratin fibers and on the marginal dense band of the horny cells. It "produces" a keratin pattern in the psoriatic horny layer. After sodium thioglycolate treatment the keratohyalin disappears, the epidermal and keratin fibers show a periodicity and the cementing material in the horny cells is more opaque. After lipid extraction the structure of keratohyalin becomes inhomogenous. The effect is somewhat similar to that of sodium thioglycolate but there is no periodicity in the horny layer. The intercellular contact layers of desmosomes as well as the Selby-Odland bodies disappear after each kind of treatment, The different effect of sodium thioglycolate on the horny layer and on the keratohyalin implies that the material of the keratohyalin and of the cementing substance are not identical.


Cholinesterase (ChE) response and related mortality among birds fed ChE inhibitors. Patterns of mortality and inhibition of brain and plasma ChE in birds treated with ChE inhibitors were studied in an attempt to determine the validity of using ChE activity as a monitoring and diagnostic technique. Analysis of brain ChE activity proved to be reliable for diagnosing and monitoring effects of selected ChE inhibitors in birds. Brain ChE inhibition exceeding 20 percent indicated exposure, and inhibition greater than 50 percent was sufficient for diagnosing cause of death. Individuals that died from dietary exposure to parathion-1 or carbofuran had brain ChE activities below 55 percent of normal; although individuals could survive with brain ChE activity lower than 50 percent. Problems associated with collection, storage, and analysis of tissues for ChE activity are discussed.


The persistence of ethion and zolone residues on grape folliage in the central valley of California. The hazard of serious intoxication of agricultural field workers by organophosphate insecticide residues has led to the establishment of reentry intervals in California. In the attempt to extend this concept nationally, it has been found that there is a lack of relevant field data for setting of such standards. In an effort to expand knowledge of the relationship between foliar residue levels and occupational hazard, an examination of the persistence and transport of ethion, Zolone, and their oxygen analogs on grape foliage was conducted. Both dislodgeable and penetrated residues were followed for 28 days post-application for both insecticides while soil surface residues were followed for ethion only. A marked difference is seen in the decay rates of the dislodgeable vs. the penetrated residues of ethion, the dislodgeable residues decaying more quickly. This difference is not apparent for Zolone. Of particular significance to worker hazard is the finding that the oxones of both ethion and Zolone in the dislodgeable residues reach a plateau after approximately seven days and do not degrade further by day 28.


A multiclass, multiresidue analytical method for determining pesticide residues in air. A multiresidue method for chlorinated, organophosphate and N-methyl carbamate insecticides has been developed for use in the National Air Monitoring Program. The method involves partitioning and extracting the pesticides from the ethylene glycol trapping solvent with methylene chloride followed by fractionation and cleanup by elution through a silica gel column. The chlorinated compounds are determined by electron capture GC, phosphate compounds by flame photometric GC, and carbamates by electron capture GC after derivatization with pentafluoropropionic anhydride. Recovery data and limits of detectability are presented for 11 chlorinated, 7 phosphate, and 7 carbamate pesticides at high and low levels. It is expected that the method will be applicable to many other compounds not successfully determined by the present analytical procedure, and that it may be adaptable for the analysis of pesticide residues in foods and other environmental samples.


The effect of mirex on reproduction of Japanesequail and on characteristics of eggs from Japanese quail and chickens. Laying White Leghorn chickens were fed mirex at 0, 5, 10, 20, 40, 80, and 160 ppm for 12 weeks, and laying Japanese quail were fed mirex at 0, 5, 40, and 80 ppm for 12weeks. The data suggest that dietary mirex at these levels did not affect egg production, egg weight, shell thickness, shell calcium, the proportion of broken eggs, or the proportion of soft-shelled eggs of either chickens or quail. Statistical significance (P greater than 0.05) associated with dietary mirex was detected in the analysis of eggshell weight for chickens; however, because a dose-response relationship of shell weight vs. level of mirex fed was not evident, this observation was attributed to chance. The data suggest that dietary mirex did not affect eggshell weight, fertility, or hatchability of quail. Mirex accumulation in eggs and carcasses of both species was proportional to dose and was slightly higher in quail than in chickens.


High altitude stress and retinal hemorrhage: relation to vascular headache mechanisms. Retinal hemorrhage occurred in 36% of 39 subjects exposed to altitudes at or above 14,200 feet. In subjects with a history of vascular headaches at sea level, there was a higher incidence of and more severe altitude headache, as well as a higher incidence of retinal hemorrhage than among those previously headache-free. In subjects without altitude headache, none had retinal hemorrhage. In subjects with altitude headache, 42% had retinal hemorrhage. A progressive rise in the incidence of retinal hemorrhage was correlated with progressively greater intensity of altitude headache. Factors that intensified the rate or degree of exposure, including rapid ascent and strenuous exertion, appeared to increase the likelihood of hemorrhage. An optimal balance between acclimatization and subsequent altitude stress appeared to prevent retinal hemorrhage. Increased retinal blood flow, retinal vessel engorgement, increased retinal vein and prevenous capillary pressure, and possibly decreased intraocular pressure may contribute to the pathogenesis of retinal hemorrhage.


Responses to cotton dust.

Responses to cotton dust. Twelve cotton textile workers were studied: (1) to compare standard measures of volume and expiratory flow, maximal expiratory flow volume (MEFV) curves, closing volume (CV), and closing capacity (CC) in detection of airway narrowing with cotton dust exposure; (2) to evaluate the response of arterial blood gases to exposure; (3) to measure changes in leukocytes in peripheral blood and airway secretions; and (4) to assess the temporal relationships and correlations between measures. Change in expiratory flow (FEV) most consistently and significantly discriminated between the control and cotton dust exposures. Vmax50%FVC was a more sensitive indicator, but variance was increased proportionately. CV and CC changed inconsistently with relatively large variances. The PaO-2 decreased overall and two subjects had large decrements. Peripheral blood and polymorphonuclear cell counts increased with exposure to cotton dust and polymorphonuclear leukocytes were recruited to the nasal mucosa. Chest tightness and decreased flow were temporally correlated with leukocyte recruitment that may be important in respiratory disease among cotton textile workers and therefore deserves further investigation.


Geographic distribution of selenium in human milk. Data were collected on the selenium concentration in human mature milk from a total of 241 subjects who resided in or near cities located in 17 states across the United State. The overall mean value for the selenium content of mature human milk was 0.018 ppm Se. Most of the individual values for selenium in human milk fell within the narrow range of 0.007 to 0.033 ppm Se, yet there was evidence for geographic variations in the selenium content of milk collected from the various cities.


Prevention of Ozonide-Induced Heinz Bodies in human Erythrocytes by Vitamin E. Methyl oleate ozonide, a proposed intermediary in ozone intoxication, produced Heinz  body inclusions in human erythrocytes at concentrations of from 10-4 to 2 x 10-3 M. Daily oral supplementation with either 100 mg or 200 mg of D-alpha-tocopheryl acetate prevented Heinz body formation by methyl oleate ozonide. These observations suggest that the protective effects of vitamin E against ozone-produced toxicants occurs in man as well as in animals.


Effects of formaldehyde and ozone on the trigeminal nasal sensory system. The effects of formaldehyde and ozone on the electrical activity of the nasopalatine nerve were studied in anesthetized rats. The response (increase in action potential frequency) of nasopalatine and ethmoidal nerves to brief presentations of formaldehyde, ozone, or amyl alcohol was a power function of stimulus concentration. When formaldehyde was presented continuously for one hour, it produced a decrease in nasopalatine nerve response to amyl alcohol that varied directly with the formaldehyde concentrations employed. Perfusion of the nasal cavities with air for one hour following the formaldehyde exposure resulted in a partial recovery of the neural response to amyl alcohol. Ozone exposures of 5 ppm lasting one hour produced an increase in nasopalatine nerve response to amyl alcohol. Air perfusion following the ozone exposure reduced the neural response to amyl alcohol, but not to preexposure levels.


Multielement residues in tissues of guinea pigs fed sweet clover grown on fly ash. Yellow sweet clover (Melilotus officinalis) was harvested from fly ash dumped in a landfill site at Lansing, NY. This clover was chopped, dried, and formulated at 45% into an otherwise purified diet and fed to six guinea pigs for 90 days. Control sweet clover was harvested from gravelly subsoil and processed and fed to another group of guinea pigs for the same period. Samples of fly ash, gravelly subsoil, sweet clover, liver, kidneys, and left-rear gastrocnemius muscle of all guinea pigs were freeze-dried and analyzed for 35 elements by neutron activation analysis. The fly ash contained 28 elements at higher levels than the gravelly subsoil, while the clover harvested from fly ash contained 19 elements in increased amounts over those in the clover harvested from the gravel soil. Growth rate of both groups of guinea pigs was similar. Rubidium and selenium were present at higher levels in the tissues of guinea pigs fed the fly ash clover.


Tracheal mucous transport in Beagles after long-term exposure to 1 ppm sulfur dioxide. Tracheal mucous velocity was determined in eight purebred beagle dogs exposed intermittently to 1 ppm sulfur dioxide for 12 months. Three control dogs were also studied. Teflon disks filmed at constant speed through a bronchofiberscope served as indicators of mucous motion. An average of 16 disks were analyzed in each dog. Although there was no significant difference in average velocity for controls and the SO-2-exposed animals, the frequency distribution curve of individual disk velocities in SO-2-exposed dogs revealed significant slowing. No significant differences in mechanics of breathing and gas exchange were found between the two groups. It appears that long-term exposure to low levels of SO-2 produces an impairment of mucociliary activity as one of the first signs of pulmonary dysfunction.


Long-term exposure to sulfur dioxide, sulfuric acid mist, fly ash, and their mixtures. Results of Studies in Monkeys and guinea pigs. Groups of cynomolgus monkeys and guinea pigs were exposed to mixtures of sulfur dioxide, fly ash, and sulfuric acid mist. The exposure concentrations varied between 0.1 and 5.0 ppm for sulfur dioxide, 0.1 and 1 mg/cu m for sulfuric acid mist, while a concentration of approximately 0.5 mg/cu m was used for fly ash. The duration of exposure was 52 weeks for guinea-pigs and 78 weeks for monkeys. Pulmonary function tests and serum biochemical and hematological analyses were conducted prior to and periodically during the exposure period. At the termination of exposure, the lungs were examined microscopically. Analysis of the data revealed that in groups exposed to the mixtures of pollutants, sulfuric acid mist was responsible for the effects observed. No synergistic action between the pollutants was detected.


First rib fracture: a hallmark of severe trauma. First rib fractures occurred in 55 patients. This injury is a harbinger of major trauma with 35 patients suffering a major chest injury, and abdominal and cardiac injuries occurring in 18 and eight patients respectively. The mortality associated with this injury was high (36.3%). Neurologic lesions accounted for the majority of deaths, however, unrecognized abdominal injuries and pulmonary complications were significant causes of mortality. Brachial plexus injury (5) and Horner's syndrome (3) occurred in survivors. Three patients had an associated injury of the subclavian artery, and the importance of this association is stressed. One late-developing post-traumatic thoracic outlet syndrome occurred. A fracture of the first rib is a hallmark of severe trauma; its presence should alert the clinician to: 1) generalized massive trauma with abdominal, chest, and cardiac injuries; 2) local injury to the subclavian artery and brachial plexus and; 3) necessity of long-term followup for late-developing sequelae.


Effectiveness of peritoneal lavage in blunt abdominal trauma. To analyze the effectiveness of peritoneal lavage and to define its limitations in the evaluation of patients who have sustained blunt abdominal trauma, a prospective study of 500 such patients was undertaken by the Trauma Service at the Naval Hospital, San Diego. Utilizing a qualitative colorometric method to evaluate the degree of hemoperitoneum, patients could rapidly be divided into three clinical groups: strongly positive, weakly positive, and negative. Using this method, patients with a strongly positive peritoneal lavage had a 94% incidence of significant intra-abdominal injuries. In 333 patients with a negative lavage, there was no documented incidence of significant intra-abdominal injuries. Visceral angiography and abdominal echography were utilized in this group of patients to identify those with significant intra-abdominal injuries. By utilizing this approach, there were only eight unnecessary celiotomies in the total group of 500 patients. It is concluded, therefore, that peritoneal lavage is a safe, rapid, and effective means of evaluating patients who have sustained blunt abdominal trauma.


Cricopharyngeal myotomy: treatment of dysphagia. Six patients are presented who underwent cricopharyngeus myotomy for dysphagia. The clinical history and cine studies appear to be the most useful assessments in defining patients with dysphagia who may improve after a myotomy. Etiological factors which may precipitate poor coordination of the swallowing mechanism and a relative cricopharyngeus muscle obstruction include neuromuscular disorders, radical oral surgery, central nervous disease, and idiopathic disorders, although the exact physiology of the cricopharyngeus muscle in health and disease is not as yet delineated, the muscle is being implicated in many problems as the inciting factor of upper esophageal dysphagia. The operation of cricopharyngeus myotomy is a relatively simple procedure and should be done with little morbidity and mortality in properly selected cases.


Spinal ischemia following abdominal aortic surgery. Serious spinal cord ischemia may follow infrarenal abdominal aortic surgery. Five cases are summarized and added to the 23 previously published cases in order to identify this syndrome, emphasize its importance, and draw attention to the possibility of spontaneous recovery which may occur. The multifactorial complex which comprises each patient's clinical picture clouds a precise and specific cause for paraplegia in these cases. However, neither hypotension, steal phenomena nor emboli are necessary for completion of the syndrome. The relevant spinal cord arterial anatomy indicates that the common anomalies which occur favor development of spinal cord ischemia in the arteriosclerotic population which requires aortic surgery. No means of prevention is possible at this time.


Primary peritonitis in infancy and childhood. Primary peritonitis, rarely diagnosed preoperatively, is an uncommon disease accounting for 2.1% of all pediatric abdominal emergencies. It is often associated with urinary or hepatic pathology, the former the source of the infecting organism in the majority of cases, and presents with characteristic symptoms depending upon whether it occurs in infancy or childhood. The symptoms and signs which allow for a positive prospective diagnosis are illustrated by comparing this disease to those entities with which it is most often confused, e.g. diffuse peritonitis of other etiologies, and include a short duration of symptoms, associated urinary tract infection and an absence of free air on abdominal roentgenograms. In the past, gram positive organisms were the most common infecting agent; however, in this series gram negative bacteria accounted for 69% or the organisms. Antibiotics with a gram negative spectrum and exploratory laparotomy with appendectomy are the hallmarks of therapy, the latter replaced by abdominal tap only in the patient who satisfies the criteria for primary peritonitis and in whom an associated disease makes the risk of surgery prohibitive.


Amylase clearance in differentiating acute pancreatitis from peptic ulcer with hyperamylasemia. Thirty-four patients with abdominal pain, tenderness, and hyperamylasemia suggesting acute pancreatitis were studied prospectively to elucidate the relationship between peptic ulcer disease and pancreatitis. Confirming evidence of pancreatitis and/or ulcer was obtained either at laparotomy of by upper gastrointestinal roentgenograms. The presence or absence of pancreatitis was substantiated by measurement of the amylase/creatinine clearance ratio, which is significantly higher (p less than 0.001) in patients with acute pancreatitis (9.3 plus or minus 0.9), than in patients without pancreatitis (3.1 plus or minus 0.2). Nine of the 34 patients were found to have gastric or duodenal ulcers. However, seven of the nine, despite an elevated serum amylase, had no sign of pancreatitis at surgery, on radiological examination, or by elevation of the amylase/creatinine clearance ratio (3.1 plus or minus 0.4). It is suggested that hyperamylasemia associated with peptic ulcer disease is most often not indicative of acute pancreatitis and that treatment is most appropriately directed at the ulcer.


Cardiopulmonary adjustments following single high dosage administration of methylprednisolone in traumatized man. Pharmacologic doses of methylprednisolone sodium succinate were administered to 10 critically ill patients when the steroid was the only variable. Measurements of respiratory and circulatory physiologic parameters were obtained in all patients prior to injection and at 30 and 90 minutes following injection of methylprednisolone sodium succinate. A significant increase in Cardiac Index was seen (P less than .01) which appeared to be in association with a decrease in pulmonary vascular resistance (P less than .01) at a time when physiologic shunting of blood through the lungs increased (P less than .01). These changes imply improved perfusion of non- or poorly ventilated portions of the lungs. Four of ten patients demonstrated removal of lactate by the lung during the control period. Following methylprednisolone sodium succinate injection, 9 of 10 patients demonstrated production or a washout of lactate from the lungs.


Abdominal aneurysm and horseshoe kidney: a review. Two patients with aortic abdominal aneurysms in association with horseshoe kidney are presented, making a total of 34 cases recorded in the literature. In 29 patients, the aneurysm was resected and five patients were non-resectable. Because of the abnormalities in vascular supply to the abnormal kidney, it is important to diagnose the combination of aneurysm and horseshoe kidney preoperatively. An error in diagnosis should be unusual if an intravenous pyelogram is routinely obtained on all patients. This study may reveal abnormalities which will allow the diagnosis of horseshoe kidney to be made or suspected. If the intravenous pyelogram is abnormal, it should be followed by an aortogram. This may substantiate the diagnosis of aneurysm and horseshoe kidney and provide the necessary detailed information regarding the pattern of blood supply and its relationship to functioning tissue. The amount and disposition of functioning renal parenchyma may be further amplified by renal scan. If this sequence is followed, the unanticipated combination of abdominal aneurysm and horseshoe kidney should be rare.


The effect of dextran on the lysability of ex vivo thrombi. The lysability was determined of thrombi formed in Chandler tubes before and after infusion of 500 ml dextran 70 to patients undergoing cholecystectomy. 125I-labelled fibrinogen was given the day before operation. Following incubation of the thrombi formed in plasmin, radioactivity remaining in the thrombi and released to the supernatant was determined, as well as fibrinolytic degradation products in the supernatant, using an immunoelectrophoretic method. The dextran infusion was found to increase the radioactivity released from the thrombi to the supernatant from 15.5 plus or minus 7.6% to a maximum of 27.3 plus or minus 8.2% four hours after the infusion (P less than 0.001). A corresponding significant rise of the FDP concentration in the supernatant from 16.8 mug/ml to 44.1 mug/ml was found at the same time. After 24 hours the radioactivity had returned to initial values. The results indicate that dextran infused into patients during surgery increases the lysability of thrombi. It is suggested that this finding at least partly explains the antithrombotic effect of dextran.


Antitumor immune response following injection of neuraminidase-treated sarcoma cells. Mice inoculated with MCA-10 sarcoma cells which had previously been incubated with Vibrio cholerae neuraminidase (VCN) demonstrated a significantly lower tumor incidence (9/26) than mice injected with untreated sarcoma cells (10/10) or sarcoma cells incubated with heat-inactivated neuraminidase (28/29) p less than .05. Rechallenge of nontumor-bearing mice from the VCN group with untreated sarcoma cells resulted in a low tumor incidence (4/11), indicating that these mice had developed systemic immunity following the initial injection of VCN-treated tumor cells. These mice also demonstrated significant lymphocytotoxicity against MCA-10 target cells compared with normal control mice (p less than .05). Subsequent cytotoxicity experiments, utilizing groin lymph node and splenic lymphocytes from mice five days following leg injection of VCN-treated, heat-inactivated VCN-treated or untreated MCA-10 cells, demonstrated that the mice injected with VCN-treated tumor cells demonstrated greater antitumor immunity both locally and systemically. This magnification of tumor immunity is postulated as the mechanism by which neuraminidase treated MCA-10 sarcoma cells grew less well in C57 mice than cells incubated with heat-inactivated VCN or cells left untreated.


Acute renal insufficiency complicating major cardiovascular surgery. Thirty-one patients underwent hemodialysis for renal failure as a complication of major cardiovascular surgery at the University of Minnesota (1968-1973). Only eight patients (26%) survived. A review of the literature shows that since the beginning of hemodialysis the mortality of those patients has not improved. Infection was the overwhelming cause of death. The infections were difficult to diagnosis because they were frequently associated with abdominal abscesses that were almost uniformly overlooked. Several possible ways of improving these patients survival are: 1) the use of early operative interventions of second look type; 2) improved hygenic measures in the care of these patients; 3) more selective antibiotic treatment based on frequent reculturing; and 4) daily short dialysis in association with hyperalimentation.


Gastrocolic and gastrojejunocolic fistulae: report of twelve cases and review of the literature. Seven gastrocolic and five gastrojejunocolic fistulae were recorded at Charity Hospital between 1940 and 1970. Such fistulae occurred in males more often than females. In this series, as in others, the most common cause was gastric surgery for peptic ulcer disease. Pain, diarrhea, and weight loss were clinical findings in half the patients; anemia, leukocytosis, electrolyte disturbances and hypoalbuminemia were common laboratory findings. A fistula was demonstrated radiologically in nine of the twelve patients, management of these patients included no operation (3); two-stage procedure (2); and one-stage procedure (7); with a recent trend toward the one-stage procedure. A case report of a fistula resulting from postoperative complications of perforative appendicitis in which a successful combination of hyperalimentation and diverting colostomy was used is presented.


The role of inflammation in bronchial stump healing. The roles of inflammatory response and closure technique in the development of bronchopleural fistula were evaluated. Canine bronchial stumps closed with 3-0 silk and studied 14 days later were characterized by a dense inflammatory infiltrate. Stumps closed with 3-0 chromic catgut suture showed a moderate inflammatory response with disintegration of suture material. However, stumps closed with the automatic stapling device (TA-30) showed the best healing and a minimal degree of inflammation. These findings correlated well with leakage pressures. The average leakage pressure for the silk closed stumps was 139.44 mm Hg plus or minus 78.9 SD. This was significantly lower (P less than 0.02) than the average leakage pressure for staple closed stumps (251.25 mm Hg plus or minus 82.9 SD). It is concluded that the minimal amount of inflammation following staple closure will be associated with improved bronchial stump healing and a lower incidence of bronchopleural fistula.


The diagnosis of jaundice by the minilaparotomy open transhepatic cholangiogram. The precise diagnosis of the etiology of jaundice is of considerable value to the clinician in caring for the icteric patient. A series of twenty-three patients who underwent minilaparotomy (open transhepatic cholangiogram) is presented. This procedure allows for inspection, biopsy, cholangiography and omental venography under direct visualization and at minimal risk to the patient. In this series the cause of jaundice was successfully determined in 96% of the cases. Cholangiography was used to visualize the ducts in 20 patients and in 2 others, the diagnosis was made by inspection and liver biopsy. The literature on alternative diagnostic methods is reviewed and compared to other procedures the minilaparotomy has relatively few contraindications and many advantages. It is a useful and safe technique in the face of abnormal clotting factors, obstructive jaundice, ascites or hepatitis. By using the multiple diagnostic modalities available in a minilaparotomy, the rate of successful diagnosis equals or exceeds that of the other procedures. It is therefore recommended that this approach be considered as a diagnostic tool in the evaluation of jaundice.


Studies on bile salt deconjugation following small bowel bypass procedures. Using the glycine-l-14C-cholic acid (14C-GCA) test, bile salt deconjugation and excretion were studied in 26 subjects with morbid exogenous obesity before and at selected intervals after jejuno-ileal bypass. In the preoperative group there was no malabsorption or intestinal bacterial deconjugation of the bile salts. In the immediate postoperative period (with relative sterilization of the bowel) there was only a trace of 14C in the breath, but the fecal 14C was highly elevated, indicating severe malabsorption without bacterial activity. In the 8 to 10 day postoperative period both the breath and fecal 14C content were highly elevated, indicating malabsorption and normal bacterial activity. Five to 8 months postoperatively both the breath and fecal 14C content showed only moderate elevation, indicating adaptation. It is suggested that the 14C-GCA test is useful in evaluating the adequacy of small bowel bypass procedures and also in following the adaptive response after the bypass. A significant increase in the breath and fecal 14C soon after surgery followed by rapid decrease suggests an adequate bypass and unusually fast adaptation. If the increase in the breath and fecal 14C soon after the bypass is only moderate, then that suggests an inadequate bypass.


Urea production related to intraperitoneal inflammation. To eluicdate a possible connection between the amount of urea production and degree of intraperitoneal complication 24 hour urea production was studied in patients having undergone appendectomy. The base material consisting of 60 patients with an uncomplicated postoperative course was divided into three groups: 1) 20 patients with a normal appendix without any infection, 2) 20 patients with acute appendicitis without perforation, and 3) 20 patients with acute appendicitis with perforation and varying degrees of peritonitis. Twenty-four hour urea production was determined from the second to seventh postoperative day. A significant difference in postoperative urea production was found between the three groups mentioned, the patients in group 3 had the highest and the patients in group 1 the lowest urea production. Further, all three groups showed a gradual, significant decrease in urea production from second to seventh postoperative day. Two patients with intraperitoneal complications after appendectomy had a significantly increased urea production.


Twenty-four hour left ventricular bypass with a centrifugal blood pump. A new centrifugal blood pump system has been developed for left ventricular bypass by the addition of non-thrombogenic blood surface materials and an ultrathin-walled cannula for the retrograde cannulation of the left ventricle. Partial LV bypass at 3 to 6 L/min was undertaken in 55 calves without thoracotomy. In 20 it was continued for 24 hours, with 13 survivors who were eventually sacrificed. Eleven of the last 14 experiments were completed without mishap. Heparin was employed only during pump insertion. Hematologic changes were limited to moderate platelet depression, and tolerable hemolysis (average serum level 21 mg% in the last 13 experiments). Normal clotting parameters and the absence of significant fibrin split product formation correlated with the absence of gross thrombosis and few minor renal emboli observed at autopsy. This pump system appears to have several advantages over previously described equipment for LV bypass.


Barium granuloma of the rectum: an uncommon complication of barium enema. Barium sulfate granuloma of the rectum may develop when this contrast material is forced through a discontinuity in the rectal mucosa. The ensuing mass may be confused with carcinoma. Preoperative biopsy and attention to plain films will prevent unnecessary inappropriate surgery.


Axillary-femoral bypass graft patency without aorto-femoral pressure differential: disuse atrophy of ipsilateral ileo-femoral segment. Differential aorto-femoral pressure gradient is not required to assure axillary-femoral bypass graft patency for a brief period of time. One-hundred twenty-three days elapsed from axillary-femoral graft construction to elective removal of the functioning conduit in an individual without aorto-femoral pressure differential. During this time, reversible "disuse atrophy" of the ipsilateral ileo-femoral arterial system occurred. It is suggested that phasic differences in pulse wave propagation between the aorto-iliac-femoral and axillary-femoral circuits maintained graft patency and accompanying decreased flow volume in the ileo-femoral arterial circuit resulted in "disuse atrophy."


A new variant of intra-abdominal hernia. A new variant of intra-abdominal hernia is presented. Available evidence suggests that this type of intra-abdominal hernia may be more prevalent than previously reported. Patients suffering from crampy, intermittent abdominal pain whose routine radiographic gastrointestinal studies are unrevealing often are labeled as having psychogenic disorders. Three cases are present giving similar histories and routine findings in which mesenteric arteriography coupled with careful small bowel series has revealed a surgically curable lesion. Such patients should have judicious mesenteric angiography coupled with routine radiographic gastrointestinal studies in search of small intramesenteric herniae which are readily correctible.


Boerhaave syndrome: report of a case treated non-operatively. An unique case of Boerhaave's Syndrome is presented in which the patient survived without any surgical treatment. We believe that this was due to non-contamination of the mediastinal and pleural cavities as shown by serial contrast roentgenograms of the esophagus.


Marginal ulcer in achlorhydric patients. Recurrent gastrojejunal ulceration is reported in three patients with histamine-fast achlorhydria. In none of these patients was extruding suture material responsible for the ulceration. However, all three patients had a history of alcohol abuse, and one abused aspirin as well. These cases demonstrate that achlorhydria does not protect against anastomotic ulceration. It is suggested that surgical manipulation produces an increased susceptibility to mucosal damage, and that it is erroneous to consider all anastomotic ulceration as a continuation or recurrence of acid peptic disease.


The effect of bile acid synthesis on cholesterol secretion into the bile. Cholesterol secretion into the bile has been shown to be related to the bile acid secretion rate. It has been suggested that the availability of bile acid micelles controls the entry of cholesterol into the bile. However, previous data could have been interpreted to indicate that  bile acid synthesis controls cholesterol secretion into the bile. To discover whether bile acid synthesis has a significant influence on cholesterol secretion, Rhesus monkeys were studied during the period of increasing bile acid secretion and bile acid synthesis, which begins 6-10 hours following interruption of the enterohepatic circulation of bile acids. This is the only condition in which bile acid synthesis and bile acid secretion increase simultaneously. The cholesterol secretion rate fell signficantly during this period, and this effect was enhanced by phenobarbital administration. An increasing cholesterol secretion rate would have been expected if micellar attraction controlled cholesterol secretion under these conditions. Bile acid synthesis appears to have an important influence upon cholesterol secretion into the bile.


Microcirculation of the normal and inflamed canine pancreas. Pancreas of normal dogs and the inflamed gland of experimental pancreatitis were studied by intra-arterial injection of Microfil, a silicone-rubber compound especially suited for study of the microcirculation. Duodenal vasculature and lobular vessels of the pancreas were studied as were those supplying the duct. Inter-lobular vessels were well visualized in the normal pancreas and intralobular vessels formed a fine reticular pattern throughout the cleared lobules. A complex network of vessels in the pancreatic duct was observed using this technique, apparently derived from the interlobular vessels. The blood supply of each layer of the duodenum was evaluated. Intraductal trypsin injection produced focal areas of pancreatitis associated with edema, poor vascular filling and spastic changes of the lobular vessels. Extravasation of Microfil, although not apparent on normal specimens, was prominent in inflamed specimens and suggested vascular weakness and disruption. Pancreatic lobules adjacent to inflammatory areas showed definite evidence of dilatation. The inflamed pancreatic ducts were markedly edematous, thickned, and showed incomplete vascular filling. When the duodenum adjacent to pancreatitis was injected with Microfil, edema and vasoconstriction were especially prominent in the duodenal muscular layer.


Renal cell carcinoma presenting as right atrial tumor with successful removal using cardiopulmonary bypass. A 58-year-old male presented with signs and symptoms of right sided heart failure. Diagnostic evaluation revealed a right renal cell carcinoma with extension into the vena cava and right atrium. Surgical management included radical right nephrectomy with retroperitoneal lymph node dissection, inferior vena caval resection, and removal of the intra-atrial tumor thrombus using a cardiopulmonary bypass. Two years after surgery the patient is alive and well with no evidence of recurrent disease.


Occult inguinal hernia in the female.

Occult inguinal hernia in the female. Inguinal hernioplasty was performed in a series of 14 female patients with occult inguinal hernias over a period of five years. During this time 194 herniorrhaphies were performed and thus the incidence of repair for occult hernia was 8%. These patients represent a definite syndrome which has not been sufficiently documented in the surgical literature. The condition is defined and the anatomic pathology documented photographically. The mean age in this series was 20 years with a range of 15-45 years. Thirteen of the 14 cases were followed a mean of 10 months postoperatively. Ten of these were considered excellent results and were symptom-free. The remaining three cases were judged as good results but objective evaluation was less conclusive. There have been no recurrences. The anatomic basis for this syndrome has been documented by others. The absence of an impulse on clinical examination is explained on the basis of size of the hernias and the difference in the anatomy between males and females. Occult inguinal hernia in the female is clinically recognizable on the basis of intermittency, character, and localization of pain and after the exclusion of other pathologic conditions. This syndrome should be entertained in the differential diagnosis of lower abdominal pain in the female. Hernioplasty is safe and effective therapy and returns the patient to normal activity.


Traumatic injury to the portal vein.

Traumatic injury to the portal vein. Traumatic injuries to the upper abdominal vasculature pose difficult management problems related to both exposure and associated injuries. Among those injuries that are more difficult to manage are those involving the portal vein. While occurring rarely, portal vein injuries require specific therapeutic considerations. Between January, 1968, and July, 1974, over 2000 patients were treated operatively for abdominal trauma at the Ben Taub General Hospital. Among these patients, 22 had injury to the portal vein. Seventeen portal vein injuries were secondary to gunshot wounds, 3 to stab wounds, and 2 to blunt trauma. Associated injuries to the inferior vena cava, pancreas, liver and bile ducts were common. Three patients had associated abdominal aortic injuries, two with acute aorto-caval fistulae. Nine patients died from from failure to control hemorrhage. Eleven were long-term survivors, including two who required pancreataico-duodenectomy as well as portal venorrhaphy. Late complications were rare. The operative approach to patients with traumatic injuries to multiple organs in the upper abdomen, including the portal vein, requires aggressive management and predetermined sequential methods of repair. In spite of innumerable associated injuries, portal vein injuries can be successfully managed in a significant number of patients using generally available surgical techniques and several adjunctive maneuvers.


New diagnostic and therapeutic techniques in the management of pyogenic liver abscesses. An unexplained increase in the frequency of pyogenic liver abscesses of unknown etiology has, fourtunately, been paralleled by significant advances in diagnostic and therapeutic methods. This report reviews experience with 14 patients operated upon at NYU Medical Center since 1971. Eight cases (57%) were cryptogenic. Other abscesses were associated with biliary disease (3); abdominal sepsis (2); and trauma (1). Abscesses were present on hospitalization in 12 patients. Clinical findings included fever (101-108 F); 100%; leucocytosis, 71%; anorexia and vomiting, 50%; localized tenderness and hepatomegaly, 50%; hypoalbuminemia, 86%; hypocholesterolemia, 78%; elevated SGOT, 71%; and elevated aikaline phosphatase, 43%. Technetium hepatic scintiscans showed focal defects in 10 of 12 patients (83%), but did not detect multiple abscesses in 2 of these. Hepatic arteriography performed in 10 patients was highly accurate, outlining single abscesses in 6 and multiple abscesses in 4. Furthermore, in one patient a false positive scintiscan was demonstrated by negative arteriography, confirmed by autopsy. In 4 patients, arteriography indicated an abscess in the posterior-superior area of the right hepatic lobe. With precise anatomical localization, a trans-thoracic approach permitted uncomplicated drainage in each case. This approach provides excellent exposure and direct drainage for abscesses in this area. An additional therapeutic adjunct in two patients, with 4 and 11 abscesses each, was postoperative intraportal infusion of antibiotics through the umbilical vein. Thirteen patients (83%) recovered, one dying from pulmonary embolism. Primary hepatic abscesses occur with increasing frequency. Primary hepatic abscesses occur with increasing frequency. Primary hepatic abscesses occur with increasing frequency. The methods described allow more precise preoperative diagnosis and direct surgical drainage.


Results of radical resection for periampullary cancer. This report concerns 348 pancreatoduodenectomies, including 13 total pancreatectomies. Operative mortality over 30 years was 15%, operative mortality since 1962, 10%. Precise factors influencing operability, mortality, morbidity, and long-term palliation or cure are emphasized. The necessity for making a distinction among tumors arising in the ampulla of Vater, the intrapancreatic portion of the common bile duct, and the duodenum surrounding the papilla of Vater and carcinomas arising in the head of the pancreas is the most important factor in the approach to periampullary malignant tumors. Even with this large experience, the impression of the operating surgeon at the time of resection was incorrect in 10% of the patients in whom a reons who do not resect carcinomas arising in the head of the pancreas and who may have had less experience in this specialized field may be rejecting an even larger per cent of patients with more favorable periampullary malignant tumors. The influence of previous exploration, manipulation, and biopsy on morbidity, mortality, and survival is discussed. The significance of nodal involvement and residual tumor at the neck of the pancreas and the point of division of the common bile duct and the uncinate process is discussed. These data justify continued selective application of pancreatoduodenectomy for periampullary cancer and identify areas where further improvement can be made.


Pancreaticogastrostomy: a further evaluation. The anastomosis between the remaining pancreas and the intestinal tract after various types of pancreatic resection has been the site of complications responsible for considerable morbidity and mortality. After Whipple resections reestablishment of pancreatic-intestinal continuity has generally been accomplished in some manner between the pancreas and upper jejunum. This suture line has at times failed, often as the result of postoperative pancreatitis, giving rise to hemorrhage, abscess, and fistula formation. Since 1963, 25 patients undergoing pancreaticoduodenal resection have had some portion of their pancreas implanted into the back wall of the stomach. The operations have been done by the resident and senior staff of the Department of Surgery at the University of Pennsylvania. Morbidity has decreased and operative mortality has fallen from 20-30% to 8%. The technique is not difficult and there seems to be less tendency for the anastomosis to leak. Pancreatic function is usually adequate. The procedure is useful after radical resection of the pancreaticoduodenal region or at times after pancreatic trauma.


Changing patterns in the management of pancreatic pseudocysts. The records of patients treated from 1938 through June, 1974, for pancreatic cysts have been reviewed. There was 205 cysts including 168 pseudocysts, 21 neoplastic, 13 retention, and 3 congenital pseudocysts. An analysis of two eras has been made: cysts treated prior to 1962 (56 patients) and cysts treated after 1962 (98 patients). In the earlier era 66.4% of patients were treated by external drainage and 34% by excision or internal drainage. By marked contrast in the more recent era only 27% were treated by external drainage and 73% by excision or internal drainage. The recurrence rate fell from 27% in the earlier era to 6% in the modern era. Improved morbidity was evidenced by a reduction from 32.2% to 15.3% in additional procedures required. Individualization in the treatment of pseudocyts with adherence to establish criteria for procedure selection with increased reliance on excision or internal drainage, as well as early diagnosis and timely intervention have improved the results of surgical therapy in this disease.


Conservative surgical treatment of reflux esophagitis and esophageal stricture. During a recent 3-year period, 17 consecutive patients were seen with advanced fibrotic esophageal strictures secondary to alkaline-acid-pepsin reflux. From detailed preoperative evaluations alone it was impossible to determine whether therapy should consist of excisional surgery, esophagogastroplasty or intra-operative dilatation with correction of reflux. Only at operation could the length, extent, degree and severity of the stricture be fully determined. Each of the 17 patients was treated by controlled dilatation, coupled with an antireflux procedure. This simplified approach proved successful on strictures thought preoperatively to be undilatable. It appears that this conservative approach is applicable to many advanced strictures and excisional and plastic procedures should be reserved for those cases that prove unyielding to intraoperative dilatation. The true appraisal of a reflux stricture and the choice of surgical procedure is best determined at the operating table.


Cardiac contusion: a capricious syndrome. Cardiac contusions are being recognized with frequency. Among 507 patients with non-penetrating chest injuries, 210 had serial electrocardiograms sufficient to evaluate the heart. Forty-five of these 210 patients (21%) had cardiac contusions. These 45 patients and 3 others who were confirmed to have cardiac contusions at necropsy, comprise the 48 patients in this series. Life-indangering cardiac complications occurred in 14 (29%) of the 48 patients, and 4 patients died. The development of cardiac complications following cardiac contusions appears to have a significant relationship to the presence of shock, hypoxia and to factors related to the severity of multiple injuries. These observations have therapeutic implications in management of patients with cardiac contusions through prevention of hypovolemia and hypoxia and avoidance of fluid overload as well as treatment of specific cardiac complications.


Management of thoracic outlet syndrome.

Management of thoracic outlet syndrome. This overall management program for thoracic outlet compression syndrome is based upon experience with 153 extremities in 149 patients and the results of others. The following conclusions are documented and discussed. 1) Diagnosis is based chiefly upon history; physical signs are inconstant and often absent. 2) Major vascular problems are unusual; angiography is not always necessary. 3) Electromyography is not always critical but does aid in diagnosis of carpal tunnel syndrome. 4) Non-operative treatment relieves most patients; operative decompression is indicated for a minority. 5) Transxillary first rib resection, with removal of cervical rib is the best operation. 6) Carpal tunnel decompression should be done concomitantly when needed. 7) Operation is relatively safe.


Hepatic portoenterostomy: an assessment of its value in the treatment of biliary atresia. A series of 12 infants undergoing hepatic portoenterostomy for incorrectable-type biliary atresia is reviewed. There has been no evidence of a sustained postoperative increase in bile excretion or improvement in biliary cirrhosis in any patient. Survival statistics for the group as a whole are poor with a mean postop survival time of 11 months and a mean total survival time of 15.3 months. These survival times are worse than that previously reported for infants with untreated biliary atresia. Our disappointing results with hepatic portoenterostomy raise doubts concerning its value in the treatment of biliary atresia.


An analysis of twenty years' experience with operations for carcinoma of the stomach. We analyzed the records of 242 consecutive patients with adenocarcinoma of the stomach operated on for cure. We correlated survival with several factors, including the type of primary lesion, the operation performed, operative mortality, state of regional lymph nodes, margins of the resected specimens, and duration of preoperative symptoms. Overall survival at 5 years was only 18.6% and at 10 years was 7.1%. Patients with small malignant gastric ulcers, however, enjoyed increased survival at 5 years (53.8%) and at 10 years (15.0%). Overall operative mortality was 7.1%, but was 0% for patients with small malignant gastric ulcers. Even with large or high-lying lesions, radical operation can be accomplished with acceptable mortality and definite chance for cure. Thirteen of 45 five-year survivors had positive lymph nodes, and 7 of the 45 had positive margins of resection. Longer symptomatic preoperative periods, correlated positively with increased survival. Thirty patients with preoperative symptomatic periods exceeding 24 months had a 30.0% 5-year survival. Perhaps some of these lesions underwent malignant change in areas of symptomatic benign disease. We advocate early operation for gastric ulcers which do not heal promptly and stay healed.


Chemotherapy as an adjuvant to surgery for colorectal cancer. A combined intraoperative and postoperative adjuvant program of 5 minus Fluorouracil (5 FU) for patients undergoing "curative" resection for adenocarcinoma of the colon and rectum was initiated as a randomized clinical trial in January 1968. Patients at the Medical College of Virginia and the University of Virginia were randomly assigned to an intraluminal 5 FU or intraluminal control (Saline) group and were so treated at the time of surgical resection if findings at operation indicated that all gross neoplastic disease could be resected. Patients with operative findings denoting incurability were eliminated from the study after surgical exploration. Those patients receiving intraluminal 5 FU (30mg/kg) received intravenous 5 FU (10mg/kg) on each of the two first postoperative days and 5 subsequent postoperative courses of oral 5FU (90 mg/kg in each 18 day course) over a one year period. By December 31, 1973 (6 years) 156 patients undergoing "curative" resection were entered into the study. SU therapy with the control or "No Treat" group reveal no significant benefit from this intensive adjuvant course of 5 FU thus far. Continued assessment of these patient groups and their subgroups will be required to develop confidence in these findings but the data thus far suggest no potential benefit from this particular adjuvant program.


Is childhood thyroid cancer a lethal disease? The clinical, pathological, surgical, postoperative findings and survivorship of 58 patients younger and 513 patients older than 21 years at the time of diagnosis with thyroid neoplasms are reported. The younger patients have a predominance of well differentiated carcinomas which are more likely to be follicular. The lesions tend to be more advanced at the time of diagnosis, are treated by more aggressive surgery in the younger patients and are associated with a much better prognosis. Lack of progression of well to poorly differentiated neoplasms and a greater sensitivity to and dependence upon TSH in young patients, are two factors which may contribute to the striking difference in the prognosis of well differentiated thyroid carcinoma related to age.


Aortic and other arterial injuries.

Aortic and other arterial injuries. Three hundred sixty arterial injuries in 353 patients are reviewed. They covered a wide spectrum of injuries and included 36 aortic injuries and 19 cases of carotid truama. The mortality rate of 12% was in large part due to aortic injuries. Shock was the predominant cause of death. Infection was the most frequent non-fatal complication. Pulmonary complications were surprisingly uncommon. With methods and techniques discussed in the paper, 90% satisfactory end results were achieved. The amputation rate was 6% where extremity injuries were involved.


Stenotic and obstructive lesions in acute dissecting thoracic aortic aneurysms. The present study of 33 operatively treated patients, 88 per cent of whom survived the procedure, is concerned with an important problem associated with acute thoracic aortic dissection, the stenotic and obstructive lesions of the aorta and its branches. Their variety and nature are described, as are the additional operative procedures deemed necessary at the time of the operation, immediately thereafter, or later on. Much has been learned about these difficulties from clinical and autopsy observations and especially from careful arteriographic surveys. They seem to be generally well withstood following resectional and grafting procedures upon the affected segment of the thoracic aorta. Occasionally, additional operative manipulations may be necessary at the same time, for example, interpolation of grafts between the ascending aortic graft and a coronary when the origin of the latter is sheared off by the dissection, and distal arterial manipulations when the patient still has ischemic lower extremities immediately after the primary procedure. Later operations must sometimes be performed because of persistence of complaints such as intermittent claudication. It is extremely rare that immediate reoperation is advisable because of indications of intra-abdominal ischemia. Much more can be learned from careful pre- and postoperative arteriographic study.


The changing pattern of post-traumatic respiratory distress syndrome. During a one year period, 78 patients at the Denver General Hospital required mechanical ventilation following injury. Thirteen patients were judged to have Respiratory Distress Syndrome. Of these, 9 had classic early onset RDS but, with intravenous fluid restriction following resuscitation, diuretics and careful mechanical ventilation, all recovered. Six patients, all of whom were septic, developed late onset RDS 5 or more days after injury; 5 died. Disparity between early and late onset of RDS is emphasized; the one with good, the other with dismal prognosis. The current need is to improve treatment of late onset RDS, which frequently is associated with bacterial infection.


The influence of diet on response to hemorrhagic shock. Prior nutrition is known to influence tolerance to hypovolemic shock. This study was undertaken to determine the influence of dietary composition on the response of animals subjected to hypovolemic shock. Particular attention was directed to the role of high and low protein diet content with a proportionate change in carbohydrate content to yield isocaloric diets. Rats were placed on one of three diets and were subsequently subjected to shock either by 1) hemorrhage to a pre-determined mean arterial blood pressure, or by 2) hemorrhage of a pre-determined volume of blood based on per cent of body weight. Serial measurements were made of blood pressure, blood volume removed, survival time,hematocrit, blood glucose, pH and blood gases. The results indicate that a high protein diet does not prolong tolerance to recurrent blood loss but there is a greatly reduced tolerance to hemorrhage shock in rats whose body weight was maintained on a low protein/high carbohydrate diet. The latter animals also exhibited impaired refill of plasma volume and a paradoxical, continuing hyperglycemic response during hypovolemia. This study suggests that although an abundant supply of blood glucose is available as an energy source, glucose uptake in the peripheral tissues is inhibited during hypovolemia by unknown mechanisms and thus homeostasis is curtailed. The protein content of the diet may be a critical factor in carbohydrate use during shock.


Incidence and significance of intraperitoneal anaerobic bacteria. To amplify recent interest in anaerobic infections following abdominal disease, trauma, or surgery, 512 consecutive patients subjected to emergency celiotomy had both aerobic and anaerobic cultures taken of peritoneal fluid as well as all complicating wound and intra-abdominal infections. Average time between peritoneal entry of abscess drainage and specimen incubating under anaerobic conditions was less than two minutes. During 4 of the seven study months, patients had antibiotic therapy randomized, with clindaymcin or cephalothin being sole parenteral agents and given intravenously prior to operation and for 5 days thereafter. Results demonstrated that anaerobes uniformly contaminate the peritoneal cavity whenever distal or obstructed intestine has been perforated, irrespective of the cause. Although all but one of the 123 complicating wound and intra-abdominal infections were due solely or at least in part to aerobic pathogens, 2/3 of such infections also contained one or more different anaerobic species acting in synergism with the aerobes. No significant difference in incidence of postoperative infection or in infecting bacteria could be found with respect to antibiotic administered or etiology of perforation. Indeed, duration of bacterial exposure to atmospheric oxygen was the most critical factor influencing culture recoverability of anaerobic organisms, likelihood of ensuing wound or peritoneal sepsis participated in by an anaerobe, and success in control of established infections harboring anaerobes.


Subcutaneous extraperitoneal repair of ventral hernias: a biological basis for fascial transplantation. Two fundamental biological differences between normal fascia and scar tissue are rate of collagen turnover and physical weave of collagen subunits. Both factors account for unsatisfactory results following ventral hernia repair unless scar tissue is excised and normal fiscia used. Removal of scar and identification of normal fascia often require extensive dissection, entrance into the peritoneal cavity, and sometimes requires lysis of intestinal adhesions with occasional injury to bowel. Simple imbrication of the hernia sac, as in treatment of a direct inguinal hernia, without excision usually results in recurrence of the hernia because of remodeling and attenuation of scar tissue. A new procedure, based upon the technique of direct inguinal hernia repair without opening peritoneum, has been performed on 12 patients with large ventral hernias. The procedures, performed entirely in a subcutaneous plane, involves imbrication of scar, transfer of a massive fascial onlay graft, and use of an internal stent. Patients have been followed for one to 5 years; there have been no recurrences. Inductive influence of the fascial transplant has been measured in two patients; a tenfold increase in net collagen synthesis and deposition occurs for at least one year following transplantation of fascia to an imbricated scar recipient area.


The use of the TDMAC-heparin shunt in replacement of the descending thoracic aorta. The use of a flexible polyvinyl tube bonded with tridodecylmethylammonium-heparin (Gott) as a temporary shunt during the resection of lesions of the descending thoracic aorta has proven a safe and simple means of providing adequate circulation to the abdominal viscera and spinal cord. This technique avoids the metabolic consequences of ischemia to the lower body, diminishes left ventricular afterload during aortic clamping, and obviates the requirement for systemic anticoagulation associated with pump bypass. Between September 1970 and October 1974, 24 patients have been operated using the TDMAC shunt. There were two deaths (9%) among the 22 patients undergoing elective resections. Two patients with acutely dissecting and ruptured aneurysms expired. Followup data has been obtained on all patients from one to 46 months postoperative. The ease with which the shunt is inserted and its adaptability to varied clinical and anatomic situations is stressed. We feel that TDMAC-Heparin shunt provides the best method of circulatory support for elective operative procedures on the descending thoracic aorta.


Resection of the ascending aorta using profound local hypothermia for myocardial protection. Resection of the ascending aorta with or without aortic valve replacement requires prolonged interruption of myocardial blood flow. Profound local cardiac hypothermia was used in 8 patients, 5 of whom had simultaneous aortic valve replacement. Three patients with acute dissections were encountered, one with cardiac tamponade secondary to intrapericardial rupture. The duration of aortic cross-clamp time varied from 43 to 122 minutes. There were no complications related to the cooling technique. There were no operative or hospital deaths. One patient died of myocardial infarction at 6 weeks. These results coupled with the experience of others suggest that coronary perfusion during periods of obligatory anoxia in unnecessary. Local cardiac hypothermia offers a satisfactory alternative for myocardial protection during prolonged aortic crossclamping.


Quality, quantity and distribution of medical education and care: regulation by the private sector or mandate by government? The public, the federal government and most state governments have become increasingly concerned with the lack of access to primary care as well as the specialty and geographic maldistribution problems. Currently, there is a race in progress between the private sector and the federal government to devise solutions to these problems. In the federal sector, varying pieces of legislation are under active consideration to mandate the correction of specialty and geographic maldistribution; proposals include: 1) setting up federal machinery to regulate the numbers and types of residencies; 2) make obligatory the creation of Departments of Family Practice in each medical school; 3) withdraw current education support from medical schools causing tuition levels to increase substantially--federal student loans would then provide the necessary leverage to obligate the borrower to two years of service in an under-served area in exchange for loan forgiveness. In the private sector, for the first time in the history of the United States, the five major organizations involved in medical care have organized to form the Coordinating Council on Medical Education (CCME) and the Liaison Committee on Graduate Medical Education (LCGME). One of the initial major endeavors of the CCME has been to address itself to the problem of specialty maldistribution. The LCGME has been tooling up to become the accrediting group for residency training thus providing an overview of the quality and quantity of specialty training. It will be the intent of this presentation to bring the membership of the Southern Surgical Association an up-to-date report on these parallel efforts. The author's personal hope is that the private sector can move sufficiently rapidly to set up its own regulatory mechanisms and avert another federally controlled bureaucracy that will forever change the character of the medical profession in the United States.


Surgical management of Menetrier's disease with protein-losing gastropathy. Three patients with Menetrier's disease and protein-losing gastropathy who were studied during a 12 year period have been presented. The characteristic findings which differentiate them from patients with hypertrophic hypersecretory gastropathy, including the Zollinger-Ellison syndrome, are: 1) hypertrophy of gastric mucosa with giant rugal folds involving the fundus, cardia and body of the stomach but sparing the antrum; 2) muscosal hypertrophy consisting of gastric mjcus-secreting cells while parietal cells and chief cells are diminished in number and may be absent from many microscopic sections; 3) gastric secretion of large volume containing excess mucus, low to absent hydrochloric acid and protein concentration 5 or 6 times normal (1.7 mg/ml); 4) hypoalbuminemia and hypoglobulinemia due to loss of serum proteins fron gastric mucosa into the gastric lumen; 5) rare association with gastric ulcer. Unlike the Zollinger-Ellison syndrome none of our patients had duodenal ucler or multiple endocrine adenomatosis or a family history of these conditions. We have found no authenticated reports in the literature which document a relationship of Menetrier's disease ( as defined above) with multiple endocrine adenomatosis. Menetrier's disease with protein-losing gastropathy is a potentially lethal disorder of unknown cause with no specific treatment. Resection of the site of gastric protein losses as first done by Waugh is logical and effective. One of our three patients died in hospital before gastrectomy was done. Two others have done well for 11 months and 12 years, respectively, after total gastrectomy with Roux-en-Y esophagojejunostomy and Hunt-Lawrence jejunal pouch.


Blood transfusions in elective operations: comparison of whole blood versus packed red cells. For some years the use of packed red cells in elective operations has been encouraged on an empirical basis. From the clinical and laboratory information gathered in this prospective, randomized, but unblined study of 294 patients subjected to elective general, thoracic, or gynecologic operations, the use of packed cells in such situations appears rational. Such practices minimize demand upon a unique human resource, may give patients fewer undersirable elements in blood transfusions, and do not increase the morbidity or mortality of patients receiving transfusion.


Viability properties in autologous fascia lata heart valve grafts: a transmission electron microscopical study. Four frame-mounted autologous fascia lata heart valve grafts in situ for 18 to 41 months as well as one free-mounted fascia cusp in situ for 10 years were examined by transmission electron microscopy (TEM). In all cusps, areas of well-preserved subcellular structures were found as well as areas with degeneration and fragmentation of both nuclear and collagen fibers. Fibrocytes, fibroblasts, and a special cell form, the myofibroblast, were encountered. The appearance of this last cell form may explain the shrinkage phenomenon encountered in these valves, all retrieved at reoperation because of valve dysfunction. Some of the fascial cells thus stayed alive within the bloodstream for up to 10 years.


Complications associated with membrane lung support by venoarterial perfusion. A series of patients supported with long-term venoarterial perfusion is presented. Gas exchange was achieved with a membrane oxygenator at flows usually in excess of 50% of the patient's baseline cardiac output. Perfusions were maintained for 7 to 12 days. Two major complications were encountered: thromboembolic myocardial infarction and liquefaction necrosis of the lung. Possible etiologies and suggestions for prevention are discussed.


An abdominal left ventricular assist device: preclinical studies. An abdominally positioned left ventricular assist device (ALVAD) has been evaluated in our most recent series of 25 calves weighing 99 plus or minus 12 kg. The ALVAD is a pneumatically actuated bladder pump, positioned subdiaphragmatically and connected between the left ventricular apex and the infrarenal abdominal aorta. The mean survival time in the calves was 41 days and the longest 65 days. The major effects of the pump are reduction of all indices of left ventricular work and increases in systemic perfusion. In the awake, unanesthetized calf, left ventricular pressure, dP/dt, and stroke work were decreased while peak aortic pressure, stroke volume, and cardiac output increased. These effects were corroborated at cardiac catheterization two to four weeks postoperatively; left ventriculograms also showed increases in ejection fraction. These data demonstrate the ALVAD's effectiveness in assuming left ventricular function and support over extended periods. The device has been developed for short-term postoperative clinical use in patients with reversible left ventricular failure.


Management of spontaneous pneumothorax.

Management of spontaneous pneumothorax. Recurrence is the most common complication of spontaneous pneumothorax. Open thoracotomy with resection of obliteration of blebs and parietal pleurectomy provides the best protection against recurrence. Twenty-seven consecutive patients underwent open thoracotomy for recurrent pneumothorax with no mortality and minimum morbidity and have remained free from recurrence. We believe that thoracotomy should be more widely used in the treatment of what is called spontaneous pneumothorax, since this treatment may remove the real cause of the disease.


A new operation for d-loop transposition of the great vessels. Transposition of the great vessels remains a major problem for the cardiac surgeons. Although the Mustard (intraatrial baffle) procedure has provided the means for physiological correction of this anomaly, there are many complications that plague the lives of the survivors. This report describes an operation that is essentially extracardiac and achieves the desired goal of simple switching of the great vessels. Future revisions of the outflow tract prosthesis may become a major problem, but probably less of one than the complications that have been and will be associated with the intraatrial baffle procedure.


Muscular ventricular septal defect repair made easy. Correction of the unique problem of congenital muscular ventricular septal defects is facilitated by approaching through an incision in the apex of the left ventricle parallel to the septum. This incision seems to be well tolerated by the heart, as borne out by our experience and that of others.


The use of vein allografts as sidearms for intraaortic balloon insertion. Femoral artery cannulation for intraaortic balloon counterpulsation may be attended by difficulties due to changes in the vessel wall and the inherent stiffness of Dacron grafts. A substitute technique utilizing venous allografts is described. The advantages are enumerated and are related to allograft pliability. Fifty-nine such procedures have been done without related complications.


Chondroma of the trachea: report of a case and review of the literature. Chondroma of the trachea is an extremely rare neoplasm. A patient is described who required surgical treatment for this abnormality on three separate occasions over a nineteen-year period. The last two instances represent either local recurrence or new primary growths. The most recent presentation was that of a very large mediastinal mass causing tracheal compression, dysphagia, and superior vena caval obstruction. The clinical and pathological features of chondromas of the tracheobronchial tree are discussed. Because of its recognized potential for local recurrence, a localized chondroma of the trachea is best managed by tracheal resection.


Balanced drainage of the contaminated pneumonectomy space. The patient who needs a pneumonectomy but has an infected pleural cavity faces the probability of an empyema of the pneumonectomy space. Balanced drainage of a contaminated space may avoid this very serious complication. A patient with obstructing bronchogenic carcinoma associated with distal parenchymal suppuration and empyema is discussed. A pneumonectomy with balanced drainage of the pleural space was performed. After three weeks the mediastinum was stable, and daily irrigation of the space with antibiotic solution was begun. Following foourteen days of irrigation, the cavity was filled with antibiotic solution and closed. Follow-up has shown no subsequent space problems or infection. Balanced drainage is a useful method of dealing with a contaminated pneumonectomy space.


Cardiac and pulmonary diseases. A pathophysiologic interelationship. Left heart diseases, in particular mitral stenosis, are often associated with anatomic and functional alterations of the lung. According to the pulmonary structures involved they could be named chronic secondary intersticial and vascular lung diseases. Congenital heart diseases with pre- or post-tricuspid shunts are also often associated with anatomic and functional alterations of the lung. This condition also constitutes a chronic secondary vascular lung disease (atrial septal defect) or a chronic primary vascular lung disease ( ventricular septal defect, patent ductus arteriosus). Primary lung diseases (interstitial pulmonary fibrosis, pulmonary emphysema, recurrent pulmonary embolism) are often associated with right ventricular hypertrophy with or without dilation, a condition commonly named chronic cor pulmonale. On the whole the interrelationships between heart and lung diseases are as follows: a) anatomic and functional alterations of the lung due to left heart diseases are mediated through pulmonary venous hypertension; b) anatomic and functional alterations of the lung due to congenital heart diseases are mediated through the increased pulmonary blood flow with or without transmission of the systemic blood pressure to the pulmonary vasculature, and c) anatomic and functional alterations of the right ventricle due to primary or secondary lung diseases are mediated through arterial pulmonary hypertension. In summary, the interrelationships between heart and lung diseases are mainly mediated through the pulmonary venous or pulmonary arterial hypertension.


[Respiratory changes in obesity. Functional and clinical aspects. Study of 26 cases]. A study was made, at the altitude of Mexico City, of the clinic aspects and of the pulmonary function of 26 obese subjects more than 45% overweight. This excess weight habitually produces severe disturbances in pulmonary and/or heart function. In 50% of the patients, clinic, radiologic and electrocardiographic manifestations were found which suggested the existence of pulmonary arterial hypertension. This provoked right heart failure in 19% of the cases. The most constant alterations in the pulmonary volumes was the decrease in the VER, which occurred in 96% of the cases. Most of the patients had hypoxemia (92.5), which was produced mainly by the increase in venoarterial shunts. Although the clinic manifestations were similar to those described in Pickwick's syndrome, alveolar hypoventilation was presented in only a minority of the cases. No relationship was found between the degree of obesity and alveolar hypoventilation. Altitudes of 2,200 meters or more apparently favor hypoxemia in obese patients, and "protects" them from the hypercapnea. The altitude of Mexico City may be one of the reasons why alveolar hypoventilation is observed in only 15% of the cases.


[Comparison of 2 angiographic methods to determine the expulsion fraction of the left ventricle]. Left ventricular volume and ejection fraction were determined by two methods of one plane angiography in 50 cases of ischemic heart disease. Statistical analysis of the results obtained by both methods showed no significant differences.


[Bradyarrhythmias in the acute phase of myocardial infarct]. The functioning of the Intensive Care Units has permitted a better study and treatment of the arrhythmias which complicate the acute phase of myocardial infarction. 1,100 charts of patients admitted to the Coronary Unit of the National Institute of Cardiology of Mexico were reviewed. Acute myocardial infarction was demonstrated in 819 of them by the usual methods. The frequency and characteristics of the following bradiarrhythmias were studied: sinus bradicardia, sinus stoppage, seno-atrial block, migration of the atrial pacing, union rhythm and slow ventricular tachycardia. Sinus bradicardia was presented in 23.7% of the infarctions, sinus stoppage in 2.4%, migration of the atrial pacing in 9.4%, nodal rhythm in 7.2% and slow ventricular tachycardia in 7.8%. Bradiarrhythmias, generally considered as "lesser" arrhythmias, favor the appearance of lethal arrhythmias, regardless of the degree of mechanical failure, and thus should be treated actively.


[Familial congenital cardiopathy].

[Familial congenital cardiopathy]. 1. The authors report on the frequency of family congenital heart disease in a consecutive series of 380 congenital patients, studied in the lapse of one year in the Pediatric Cardiology Service of the National Institute of Cardiology of Mexico. 2. They report that of 380 families with one member with congenital heart disease, 13 had two or more members with heart malformations. 3. They point out that the index of frequency of family congenital heart disease was 34 per 1,000, a figure higher than that of other authors 6,40 (18 and 20 per 1,000). 4. They demonstrated that in families with an affected member, the possibility that there is another member with heart disease rises 5 to 7 times above the figure of prevalence expected for the general population. 5. They comment that the greater the numbers of patients with congenital heart disease in a family, the greater the probability is that there will be a descendent with cardiovascular malformation. 6. They make note that the normality of the chromosomatic studies of this and other investigations should not be an obstacle for postulating the genetic component in the multifactorial ethiology of congenital heart diseases. 7. Finally, they emphasize the importance of performing a complete cardiologic study of the family having a member with congenital heart disease.


[Indications and radiological measurements in the evaluation of pulmonary artery hypertension]. Different radiologic indexes and measurements proposed in the evaluation of pulmonary artery hypertensión (PAH) were reviewed. The postero-anterior chest roentgenograms of 250 subjects were studied. In all cases the pulmonary artery pressure was known from cardiac catheterization. The diameter of the right pulmonary artery was larger than 1.7 mm. in 45% of cases with PAH. The pulmonary-lobar-transverse-thoracic index (PL/T) was abnormal (+38%) in 74% of cases with PAH, and normal in cases with increased pulmonary flow. The index of Ozawa, distance between the midline and the more prominent portion of the pulmonary arch, related to the transverse diameter of the left hemithorax overestimated the mean pulmonary pressure when normal and underestimated the same with PAH. A new index is described. The relation of the right pulmonary artery with the transverse diameter of the hemithorax on the same side (r/h index). It was abnormal in 24% of the cases with PAH and it was always normal in cases with increased pulmonary flow. The more sensitive and specific measurement seems to be the PL/T index.


[Radiography of the left cavities of the heart using the levophase of pulmonary angiography. Preliminary study]. The method for visualizing the left cavities of the heart by means of levophase of pulmonary angiography is described. Its indications and advantages, and the simplicity of the technique are described, and the low risk this procedure places on the patient are emphasized.


[Dopamine in essential arterial hypertension: excretion of its metabolite homovanillic acid]. The results obtained in a group of 66 hypertensive patients in which the AHV values were 5.7 plus and minus 0.4 mM/24 hrs., were reported. These values were compared to those obtained in 42 healthy subjects: 7.0 plus and minus 0.5 mM/24 hrs. The difference was statistically significant P less than 0.05. The values of excretion of urinary dopamine in both groups were also presented. A value of 225.7 plus and minus 13.0 mug/24 hrs. was obtained for the hypertensives, while the value for the healthy groups was 361.2 plus and minus 16.5. The statistical study in this case showed a high significance p smaller or less than 0.001. There were no changes in the levels of adrenaline and noradrenaline nor in the metabolite of these two amines, that is, AVM.


[Anatomo-vectorcardiographic correlation in ventricular growth in congenital heart diseases]. Anatomo-vectorcardiographic correlations were studied in 59 cases of congenital heart disease. In the group with interventricular septal defect and pulmonary hypertensión, a statistically significant correlation between the thickness of the free right ventricular wall, at its outflow tract, and the inscription time of the vertex of the S loop, was found. In the group of Fallot's tetralogy, the segmentary hypertrophy of the right ventricle, which is the most frequent, explains very well the terminal portion of frontal and sagittal vectorcardiograms located below the 0 point. In the group with interatrial septal defect and pulmonary hypertension, a statistically significant correlation between the thickness of the antero-lateral superior third of the free right ventricular wall and the inscription time of the vertex of the S loop, was shown. In the group of congenital malformations with repercussion on the left ventricle (interventricular septal defect, patent ductus arteriosus and coarctation of aorta), a statistically significant correlation between the anatomical findings of a hypertrophied superior third of this ventricle and the inscription time of the vertex of the R loop, was observed.


[Acute coronary oclussion and cardiogenic shock. Experimental study with closed thorax]. Nineteen dogs in whom an intent to produce cardiogenic shock due to acute myocardial infarction are studied. The dogs are maintained with closed chest and acute myocardial infarction is produced by injecting a bolus of metalic mercury in the left circumflex coronary artery using two different methods. Comparatively, the results show that a more selective embolism is obtained with the double catheter technique than by the introduction of a single coronary arteriograph catheter. Eight of the 19 dogs died. Six due to accidental introduction of mercury in the anterior interventricular artery together with the left circumflex artery, and 2 due to rupture of the ascending aorta during the maneuvre of placing the coronary arteriograph catheter. In the eleven dogs that survived the following parameters were taken every hour during a period of four to six hours. a) Hemodynamic: Left ventricle pressure, cardiac output by thermodilution, maximum dp/dt and Vmax, central venous pressure, cardiac rate and diuresis; b) Metabolic: Gases and lactate in arterial, venous and coronary sinus blood. Cortisol blood levels. All dogs were anaesthetized with thiobarbital during the venous cutdown and later sedated with morfine. They were maintained breathing atmospheric air. Cardiogenic shock was established when the diuresis fell from 170 cc/hour to an average of 43 cc/hour, the mean arterial pressure fell by 20%, the cardiac output by 58%, Vmax descending 20%, the telediastolic pressure of the left ventricle rose from 2.8 mm. Hg to 19.6 mm. Hg and the presence of acidoses was demonstrated by metabolic studies. Since the dog is maintained with a closed chest and breathing atmospheric air, this is an excellent method for the production of cardiogenic shock in conditions similar to the humain without the influence of other variables. In this way a better knowledge of shock is obtained and different terapeutic measures can be studied.


Pathophysiology of ventricular tachycardia in man. Programmed electrical stimulation of the heart as a method to study mechanisms of arrthythmias is discussed in patients with ventricular tachycardia. Chronic recurrent ventricular tachycardia seems to be based on a reentry mechanism. Observations in patients with ventricular tachycardia during the first 24 hours after myocardial infarction suggest a focal origin of the arrhythmia.


Provoking factors in bronchial asthma.

Provoking factors in bronchial asthma. Asthmatic patients were identified as having asthma on the basis of lung function studies (76%), objective physical findings of asthma (11%), or a strong history of asthma (13%). Each of the 234 patients so identified was assigned to an asthma subgroup determined by careful clinical assessment of the major provoking factor or factors for his asthmatic episodes; minor provoking factors were also identified. Only 20% of the patients had asthmatic episodes provoked by a single factor. Most asthmatics had at least one major and one or more minor provoking factor(s). Reagin-mediated mechanisms constituted the major provoking factor in 25% of patients and were a minor provoking factor in an additional 20% of the patients. Thus, in only 45% of the patients, were reaginic mechanisms responsible for some part of their asthmatic episodes.


Nephrotoxicity associated with cephalothin administration. Variable degrees of acute renal failure developed in three patients receiving therapy with cephalothin sodium. The course and findings were consistent with acute tubular necrosis of the oliguric and nonoliguric types. One patient had protracted oliguria, a second experienced transient oliguria, and one had normal urine output. All had urinary sediment changes consistent with tubular necrosis, and the two oliguric patients had elevated urine sodium concentrations. No other causes for renal failure could be detected, and all recovered after discontinuation of cephalothin therapy, although peritoneal dialysis was required in one patient. These observations indicate that cephalothin is capable of inducing renal damage in man.


Indomethacin treatment of pericarditis in chronic hemodialysis patients. Symptomatic pericarditis occurs in the course of maintenance hemodialysis and often requires pericardiectomy in addition to other conventional measures. Three of 11 such patients were treated with frequent dialysis and general supportive treatment. Two of these required pericardiocentesis. The other eight received indomethacin; this was followed by prompt defervescence and abatement of pain within 6 to 24 hours. Only one patient required pericardiocentesis. On every occasion when treatment was discontinued during the first week, symptoms recurred. After three weeks to four months, the drug dosage could be tapered and discontinued. The pericardial aspirate was hemorrhagic in all three patients who required pericardiocentesis. Indomethacin appears to be effective in the treatment of the pericarditis associated with dialysis and precludes the need for invasive procedures.


Major factors in the development of diabetes mellitus in 10,000 men. The average annual incidence of diabetes among 8,688 adult men followed up for five years was 8.0/1,000 with Asian, African and Israeli-born having higher rates than European-born. Multivariate analysis of the findings suggested the following: the most significant variables associated with the development of diabetes are overweight and peripheral vascular disease; the high incidence of diabetes in immigrants from Asia and Africa might be an example of Neel's "thrifty genotype" or failure of adaptation to relatively rapid environmental changes; serum cholesterol level, blood pressure, uric acid level, and education were important also; and the probability of developing diabetes within five years rises from 17/1,000 (when the major variables are low or absent) to 450/1,000 (when they are high and present). This has important clinical implications.


Insulin therapy in patients with systemic insulin allergy. Insulin was administered to 12 of 15 patients with systemic insulin hypersensitivity. Eight patients with a history of a systemic reaction to insulin but not receiving current therapy were skin-tested and desensitized. Four receiving insulin had temporary dose reduction followed by slow increase to therapeutic levels. No noticeable reactions recurred in any of them. Levels of IgE antibodies against insulin were determined in 12. Substantial elevations were found in eight. These levels declined rapidly in three desensitized patients who were studied in contrast to the slower decline in three patients who were not desensitized. Insulin can be cautiously administered if necessary to patients with prior systemic insulin hypersensitivity. Evidence that IgE antibodies are against the insulin molecule in at least some patients indicates the need for a desensitization regimen.


Hereditary pancreatitis. Nonspecificity of aminoaciduria and diagnosis of occult disease. Hereditary pancreatitis appears in many different ways and in a variety of age groups, spanning both pediatric and adult medicine. The variable expression of hereditary pancreatitis is emphasized by the difficulty in diagnosing it in a patient obviously at risk because of a severely affected father and son. The morphine prostigmine test and hypotonic duodenogram were most helpful. Aminoaciduria previously associated with this disorder is coincidental or nonspecifically related to acute pancreatic inflammation. The increased risk for pancreatic carcinoma (about 20%) is emphasized by the concern for that complication in the proband's grandfather.


Thyroid function after radiation and surgery for head and neck cancer. Preoperative radiation followed by surgical excision is accepted therapy for head and neck cancer. The effects of these modalities on thyroid function were evaluated in a prospective study. Sixty-one patients were given cobalt 60 radiation. Results showed that 41 patients (67%) were euthyroid, 12 patients (20%) were clinically and chemically hypothyroid, and 8 patients (13%) had transient loss of thyroid reserve. Permanent hypothyroidism occurred frequently in patients with hemithyroidectomy, but rarely in those treated with radiation alone. Onset of hypothyroidism was zero to six months, with transient loss of thyroid reserve occurring up to 18 months. This constitutes the initial report of an ongoing systematic study of thyroid function in such patients. The high incidence of hypothyroidism indicates a need for careful periodic evaluation.


Nephrotoxicity of combined cephalothin-gentamicin regimen. Two patients developed acute tubular necrosis, characterized clinically by acute oliguric renal failure, while they were receiving a combination of cephalothin sodium and gentamicin sulfate therapy. Patients who are given this drug regimen should be observed very carefully for early signs of nephrotoxicity. High doses of this antibiotic combination should be avoided especially in elderly patients. Patients with renal insufficiency should not be given this regimen.