Comparison of colonoscopy and the contrast enema in five hundred patients with colorectal disease. Endoscopic examination of the entire colon (colonoscopy) is an important new method of diagnosis and treatment of diseases of the colon and rectum, particularly cancer. The records of 500 patients who had one or more contrast enemas and subsequent colonoscopy were analyzed in an attempt to evaluate the competitive and complementary features of the two methods. The endoscopists had the advantage of having a radiologic report or radiographs available to them. In general, when the level of abnormality could be reached, colonoscopy had a higher degree of accuracy, particularly since observation could be combined with biopsy. This was particularly true in the case of polyps in which colonoscopy confirmed 166 radiologically described growths plus an additional 118 lesion, twenty-one of which were over 1 cm in diameter. By endoscopic excision of these polyps via the colonoscope, malignant changes can be identified, a conclusion rarely reached by radiographic means alone. With respect to cancer, exclusive of polyps, only twenty-four of thirty-two cases were diagnosed by x-ray study alone. Another nine, interpreted aa demonstrating malignancy from the radiographs, had cancer excluded when subjected to endoscopic confirmation. Colonoscopy has also proved valuable in identifying lesions of the cecum, notoriously a problem for the radiologist, and in identifying milder degrees of inflammatory change which are undetectable by radiographic means. Colonoscopy and the contrast enema are best reported as completmentary rather than competitive approaches, and by their combined use, diagnostic accuracy is greatly enhanced.


The injured colon: therapeutic considerations. A prospective randomized study was carried out at the Detroit General Hospital over a two year period to evaluate methods of management in 165 patients with colonic injuries. Results of the study show that primary closure is a safe and reiable method of management when rigid criteria are incorporated in an ongoing protocol. Moreover, the technic of exteriorization is a safe adjunct to management and is recommended in any patient with a colonic injury above 18 cm in which one suture line is required and in which the additional operating time of twenty minutes will not compromise the management of secondary injuries. Patients not fulfilling these criteria should have primary colostomy. These principles make it possible to reduce the need for primary colostomy to approximately 50 per cent in a large ongoing group of patients with colonic injury.


Absorption of carbohydrates and vitamins in the preserved and transplanted small intestine. A significant impairment in the intestinal absorption of D-xylose and vitamin A was observed in the first weeks after preservation and transplantation of the whole small bowel. Functional recovery was only observed in long-term survivors, usually transplanted dogs that lived more than five weeks. There was no impairment in the absorption of vitamin B12. Only prolonged survivors showed low normal limits of vitamin B12.


Jejunal mucosal graft: a sutureless technic for repair of high bile duct strictures. A simplified sutureless technic for the repair of high bile duct strictures is described. The technic combines the principle of a transhepatic tube together with a mucosal graft formed by removing a seromuscular patch near the end of a Roux-en-Y loop of jejunum creating a mucosal outpouching. The biliary tree is entered at the hilum of the liver and a latex rubber tube is drawn through the liver and anchored to the Roux-en-Y loop through the previously created mucosal diverticulum. The tube is pulled back into the liver carrying with it the sleeve of jejunal mucosa into the duct system in contact with the epithelium of the intrahepatic ducts. The technic is simple, easy, and quick. There is no difficult and tedious duct dissection of hepaticodochojejunal anastomosis to perform. It provides mucosa to mucosa approximation and eliminates the need for sutures through or near the mucosa to compromise the blood supply and prevent  primary healing. The stent tube is easily removed without reoperation when desired. Finally, there is access to the biliary tree for daily irrigation, radiography, and cultures. From 1969 to 1972, sixty-one repairs were performed in fifty seriously ill patients utilizing the principles of this sutureless technic. All had had failure of previous attempts at repair with an average of 2.86 previous biliary tract operations per patient. Eight-five per cent of the patients have had an ultimately successful result. The mean postoperative hospital stay was only 19.6 days. Although the follow-up period is still short, these preliminary results are most encouraging.


Pathophysiology of stress ulcer and its prevention. II. Prostaglandin E1 and microcirculatory responses in stress ulcer. PGE1 completely prevented the formation of stress ulcers when administered in doses of 4 to 5 mg/kg or more. However, at this dose, complications and mortality were significant.


Mechanical cleansing of contaminated wounds with a surfactant. Mechanical cleansing of a wound with a sponge soaked in a surfactant has prevented the development of experimental wound infection. The surfactant utilized for wound cleansing is Pluronic F-68, a member of a family of block copolymers called Pluronic polyols. Long-term toxicity studies and clinical trials suggest that this surfactant is safe for human use. Pluronic F-68 is a nonionic detergent that does not have any intrinsic antibacterial activity. Although mechanical cleansing with saline-soaked sponges effectively removes bacteria, it damages the wound and impairs its resistance to infection. The severity of the damage to the skin exerted by the sponge can be correlated with its porosity. Sponges with a low porosity are abrasive and exert more damage to skin than do sponges with a higher porosity. The addition of Pluronic F-68 to even the most abrasive sponges ensures that the bacterial removal efficiency of the sponge scrub is maintained, while tissue trauma is minimized. This dual effect of the surfactant results in a dramatic reduction in the infection rate of contaminated wounds. On the basis of these results, a clinical trial with surfactant-soaked sponges would appear to be indicated.


Pathophysiology of stress ulcer and its prevention. I. Pharmacologic doses of steroid. The efficacy of a large dose of Decadron on stress ulcer formation in restrained rats has been studied using microangiohistologic technics. When a pharmacologic dose of Decadron was administered twenty-four hours prior to the procedure, Dacadron prevented ulcer formation.


Tracking respiratory therapy in the trauma patient. The respiratory index (RI), P(AaDO2)/PaO2, was investigated in a retrospective study of 177 intubated patients treated at the Maryland Institute for Emergency Medicine. An RI of 0.1 to 0.37 is normal. Patients with an RI of 2 or greater were intubated. Those patients who reached an RI of 6 or more had an associated 12 per cent probability of survival. The RI reflects the presence of pulmonary shunting in a variety of circumstances including atelectasis, pulmonary contusion, and pulmonary emboli. A nomogram that allows the course of the patient with respiratory problems to be followed is described. Movement along the same isobars or between isobars can be followed by plotting the PaO2 against the FI0-2. Thus, the rationale and effect of respiratory therapeutic manipulations may be recorded graphically.


Development of a plastic surgical teaching service in a women's correctional institution. A plastic surgical teaching service has been organized at a women's correctional institution to provide a previously unrecognized medical need and to serve a valuable educational function for our residents in training. A total of 177 surgical candidates demonstrating a wide range of reconstructive problems including tattoos, scars, keloids, neoplasms of the skin and hands, deformities of the face and breasts, and numerous disabilities of the hands were identified among 241 inmates requesting examination. Thus far, 116 operative procedures have been performed on 101 patients. Patient acceptance has been high, and the support of prison authorities has been enthusiastic. Persistent efforts to convince legislators of the wisdom of supporting this program financially have only been partially successful and will require further accumulation of sociologic data bearing on the rehabilitative potential of the detained patient with a correctable deformity. Meanwhile, residents in training gain maturity as they provide a very "private" type of service for what has traditionally been considered a very "public" population of patients.


Head and neck cancer manpower study.

Head and neck cancer manpower study. 1. Approximately 40,000 cases of cancer of the head and neck (excluding skin) are diagnosed each year. 2. Approximately 20,000 of these cases and 30,000 cases of skin cancer are treated by 366 head and neck cancer surgeons. 3. Ninety per cent of the cases are treated by 63 per cent of the surgeons. 4. Fifty-eight per cent of the surgeons care for between 50 and 300 cases per year. 5. While 2,759 new board-certified surgeons of all specialties are recruited annually to maintain a work force of 46,000 board-certified surgeons (3), apparently 730 potential head and neck cancer surgeons are being prepared to maintain a work force of approximately 450 head and neck cancer surgeons. 6. These findings indicate the need for in-depth study of the manpower needs in head and neck cancer surgery by all who are responsible for the training of surgeons in this field.


Immediate oophorectomy and adrenalectomy in the treatment of stage III breast carcinoma. A ten year follow-up study. One hundred twenty-two patients with state III breast carcinoma had radical mastectomy with or without adjunctive radiation therapy, chemotherapy, or steroids. Thirteen randomly selected persons in the group had immediate bilateral oophoroadrenalectomy. Survival ranged from 10 to 147 months (median, 68.0) with seven of thirteen patients (53.8 per cent) alive five years and three of thirteen (23.0 per cent) alive ten year or longer. No statistical difference in survival or disease-free intervals with respect to menopausal status was observed in the nine patients of this group who died. One hundred and nine patients treated by conventional therapy without endocrine ablation had shorter five year (37.6 per cent) and ten year (15.6 per cent) survival intervals. The difference in survival intervals was statistically significant at p smaller than 0.01. This study suggests that immediate endocrine ablation may prolong survival in patients with stage III breast carcinoma.


Lymphedema of the upper limb after surgery for breast cancer. Radical mastectomy is followed by swelling of the arm, and although the number of surgeons employing the operation is decreasing, postmastectomy lymphedema continues to be a serious complication. In the present report based on 158 women who underwent modified radical (126) or simple (32) mastectomy and occasionally radiation for histologically proved adenocarcinoma of the breast, the pathogenesis and treatment of postmastectomy lymphedema are discussed. The following conclusions can be drawn: (1) The occurrence of postmastectomy lymphedema diminishes the less extensive the operation. (2) Mild lymphedema that develops early postoperatively tends to subside. (3) Conservative treatment in the majority of cases is effective in controlling postmastectomy lymphedema of a mild to moderate degree. (4) Modified radical mastectomy, which is as radical as Halsted's operation, is rarely followed by lymphedema.


Experience with pancreatoduodenectomy in a cancer hospital. Records of twenty-nine patients with adenocarcinoma of the pancreas, ampulla of Vater, common bile duct, and colon who were treated with pancreatoduodenectomy were reviewed. Operative mortality was 24 per cent. Survival was adversely affected by incomplete excision of the primary lesion, the presence of metastases in lymph nodes, and severe biliary obstruction. Twenty-two patients (76 per cent) died from the operation or were not cured. Pancreatoduodenectomy was of dubious value in the treatment of carcinoma of the head of the pancreas.


A study of experimental colovesical fistula. An experimental study of colovesical fistulas in dogs was undertaken to gain insight into the clinical implications of such a fistula. The fistula itself was well tolerated by the animals. However, distal urinary tract or gastrointestinal obstruction led to sepsis and death.


Thyroid hemangioma.

Thyroid hemangioma. A case is presented of a fifty-six year old man with a thyroid hemangioma presenting as a neck mass with tracheal deviation and unilateral vocal cord paralysis. A standard thyroid scan yielded equivocal findings. The diagnosis was determined preoperatively by the use of a 99m-technetium angiogram that disclosed the vascular nature of the lesion. Subsequent arteriography demonstrated the main arterial supply of the mass to be from both inferior thyroid arteries. Operative removal of the mass was accomplished through a standard transverse cervical incision. Pathologic study revealed that the vascular tumor involved both the surrounding normal thyroid parenchyma and also a microfollicular adenoma. This case points out the value of utilizing all available diagnostic means in atypical cases of thyroid disease.


Hyperoxaluria and urinary tract calculi after jejunoileal bypass. Five patients with jejunoileal shunt for morbid obesity in whom postshunt hyperoxaluria and recurrent urinary tract calculi developed are presented. All the stones were composed of calcium oxalate. The twenty-four hour urinary oxalic acid levels were also elevated in twenty of twenty-six patients who had had jejunoileal shunt for six months or longer. No correlation was present between urolithiasis and the degree of hyperoxaluria.


Acute ischemia of the limb in a newborn treated successfully by thrombectomy. A seven day old dehydrated male infant was found to have acute ischemia of the leg due to acute thrombotic occlusion of an external iliac, common and superficial femoral, and popliteal arteries. Early thrombectomy and arterioplasty resulted in complete remission of ischemia. Our success with direct vascular surgery prompts us to recommend this form of treatment in preventing neonatal gangrene. To our knowledge, this is the first report of successful thrombectomy in a newborn infant.


Saphenous vein-popliteal artery fistula for chornic hemodialysis. A saphenous vein arteriovenous fistula for chronic hemodialysis can be formed in the thigh by tunneling the vein subcutaneously, anastomosing the distal end to the popliteal artery, and leaving the proximal end attached to the femoral vein. Of seven fistulas, only one has thrombosed spontaneously. There were no instances of infection, vascular insufficiency, or high output cardiac failure. A saphenous vein-popliteal artery fistula can be a satisfactory method of maintaining vascular access in those patients who require chronic hemodialysis but who have no available sites in the upper extremities for construction of a fistula.


Spatial distribution of mitosis in mouse epidermis. The cells of the upper strata of mammalian epidermis are flattened and aligned to form regular columnar units. It has been suggested that the position of the smaller underlying basal cells is related to the overlying cell columns. Examination of the position of metaphase figures in sheets of mouse epidermis indicated that mitosis occurs principally in cells lying just within the periphery of the cell columns but that there is no alignment of interphase basal cells within the columnar peripheries which could account for this position of mitosis.


A comparison of secondary palate development with different in vitro techniques. Palatal processes from 14-day fetal C57BL mice were cultured under varying conditions for 48 hours and prepared for light and electron microscopy. Disruption of the epithelium along the medial border occurred when single palatal processes were explanted onto Millipore filters, plasma clots, or lens paper in subjacent contact with nutrient medium. Paired processes under the same culture conditions demonstrated typical midline epithelial disruption and mesenchymal fusion. Regions of mesenchymal necrosis occurred in processes grown on nutrient agar in a dish or submerged in nutrient medium. In similar cultures medial epithelial disruption did not occur in single processes and mesenchymal fusion of paired processes was either delayed or did not occur. Disruption of the epithelium along the medial border in single palatal processes, and mesenchymal fusion in paired palatal processes, occurred when palates were grown on nutrient agar supported above but in contact with nutrient medium. The results indicated that responses of palatal epithelium and mesenchyme may be altered by different in vitro procedures. These observations emphasize that many factors must be considered in interpreting developmental changes in palatal processes grown in vitro.


On the development of the lymphoid follicles of the bursa of Fabricius. The structural features of the development of the bursa of Fabricius in white Leghorn chick embryos are depicted at carefully timed intervals during embryogenesis, with emphasis on the sequence of events between the ninth and twelfth days of incubation. The direction and character of the migration of lymphoid cell precursors and granulocytes from the intravascular space to intraepithelial sites, where the formation of the primitive lymphoepithelial nodule takes place, is demonstrated. The mechanism of the mode of migration of these cells through the stromal epithelial interface is described and illustrated with electron micrographs and their role in the development of the primitive lymphoid follicles is described and discussed.


A simple, single-injection method for inducing long-term paralysis in embryonic chicks, and preliminary observations on growth of the tibia. A method for inducing paralysis in embryonic chicks is described. This involves single injections of the neuromuscular blocking agents, D-tubocurrarine Chloride or decamethonium iodide, into 10-day embryos. The dose which optimises survival and paralysis is determined along with the effect of the drugs on embryonic growth. Decamethonium iodide at a dose of 1 mg per embryo gave maximum survival and paralysis to 18 days of incubation. Paralysis was assessed by observation of treated embryos in ovo and by examination of embryos removed from their shells between 11 and 18 days of incubation. Embryos were completely paralysed 24 hours post-injection and remained paralysed until 18 days of incubation. Paralysed embryos failed to hatch. Development of the leg musculature was severely retarded in paralysed embryos. This method of inducing paralysis has considerable advantages over previous continuous infusion methods. The growth and collagen content of the tibia in the paralysed embryos was reduced and these results, and other applications of the method, are discussed.


Cyclicity in tumescence of the perineal labia of female lowland gorillas. The first group norms on the periodic occurrence of tumescence in the perineal labia of female lowland gorillas were obtained in 9 captive subjects. Individual mean cycle lengths for 8 adult females in 2 experiments ranged from 25.9-36.3 days with overall means of 31.1 and 32.5 days. The one subadult female had a mean cycle length of 40.7 days. The median and modal duration of maximal labial tumescence were 1.8 and 1 day, respectively. Data from 3 animals on which menses were recorded during 6 cycles yielded relatively consistent postswelling phase durations of 8-11 days and durations of menstruation of 1-2 days. The data from 2 conceptions of 1 female suggested that time of ovulation was closely associated with the day of detumescence. These data are discussed in terms of certain differences as well as similarities which exist between the gorilla and its closest relative, the chimpanzee. The contribution of these data to the area of comparative reproduction is enhanced because of the significant taxonomic affiliations of the gorilla species.


Cardiovascular responses to calcium administered intravenously to man during halothane anesthesia. Calcium chloride (7 mg/kg) was administered intravenously to six healthy volunteers anesthetized with halothane. Cardiovascular changes were measured during constant ventilation and anesthetic depth under three conditions: 1) respiratory alkalosis, 2) normocarbia, and 3) respiratory acidosis. At each Paco2, calcium infusion significantly increased cardiac index, left ventricular minute work index, and stroke index. Heart rate, total peripheral resistance, and cardiac pre-ejection period decreased. No significant change in mean arterial blood pressure or central venous pressure followed calcium administration, and no arrhythmias occurred. It is concluded that calcium administration increases myocardial performance, presumably by increasing the availability of intracellular calcium ion for actomyosin interaction.


Comparative toxicities of halothane, isoflurane, and diethyl ether at subanesthetic concentrations in laboratory animals. Effects of 35-day exposures to subanesthetic concentrations of halothane, isoflurane, and diethyl ether were measured in mice, rats, and guinea pigs which were in a phase of rapid body growth. Halothane produced a greater decrement in weight gain and a greater incidence of hepatic degenerative changes than isoflurane or diethyl ether despite its administration at lower anesthetic concentrations. Isoflurane results were intermediate between those of halothane and diethyl ether. No consistent injury to any organ other than the liver was found.


Metabolism in vitro of enflurane, isoflurane, and methoxyflurane. Specific activities of enflurane, isoflurane, and methoxyflurane defluorinases were measured in microsomes prepared from the livers of Fischer 344 rats; the ratio of these activities was 23:3:1. Pretreatment with phenobarbital significantly increased the defluorinase activities of all three agents. Factors that influence anesthetic drug metabolism are discussed; tissue solubility is considered to be the most important.


Intracranial pressure during hypotension and subsequent vasopressor therapy in anesthetized cats. The effects of vasopressor therapy on intracranial pressure (ICP) during hypotension were evaluated in 45 adult cats anesthetized with pentobarbital and hyperventilated via an endotracheal tube with nitrous oxide, 70 per cent, and oxygen, 30 per cent, to maintain Paco2 25 plus or minus 5 torr. Hypotension was induced by intravenous administration of trimethaphan camsylate or sodium nitroferricyanide and by hemorrhage. Vasopressor (norepinephrine, ephedrine, or isoproterenol) administration in the absence of hypotension caused slight transient increases in ICP. Trimethaphan produced increases in ICP averaging 4.3 mm Hg, while sodium nitroferricyanide caused no change and hemorrhage decreased ICP by 3.9 mm Hg. After hypotension was established, vasopressors caused increases in ICP of 1-21 mm Hg. The greatest increase was seen with norepinephrine administration during sodium nitroferricyanide-induced hypotension. Increases in ICP were pronounced in absolute magnitude and rapidity of rise but were of short duration (2 to 5 minutes). The elevation of pressure might be of clinical significance in patients who have pre-existing intracranial hypertension or space-occupying lesions.


Anesthetic biotransformation and renal function in obese patients during and after methoxyflurane or halothane anesthesia. Anesthetic biotransformation and renal function were studied in obese adult patients (148 plus or minus 8 kg; mean plus or minus SE) anesthetized for three hours with 60 per cent nitrous oxide plus either methoxyflurane or halothane for elective jejunoileal small-bowel-bypass operations. There was no evidence of persistent renal dysfunction in any patient postoperatively, but serum osmolality was elevated 72 hours after methoxyflurane anesthesia. Urine concentrating ability was not determined. Peak serum ionic fluoride concentration was 55.8 plus or minus 5.8 muM/1 two hours after discontinuation of methoxyflurane. Urinary ionic fluoride and oxalate excretions increased postoperatively. Compared with previously reported data from nonobese patients, serum ionic fluoride concentrations in obese patients increased more rapidly during methoxyflurane anesthesia and peaked higher and sooner after discontinuation of methoxyflurane. The peak serum ionic fluoride concentration was 10.4 plus or minus 1.5 muM/1 at the conclusion of halothane anesthesia, significantly more than the corresponding value in nonobese patients. Intraoperative liver biopsies from 23 of 27 patients showed moderate to severe fatty metamorphosis. Fatty liver infiltration may have increased hepatic anesthetic uptake and exposed more methoxyflurane or halothane to hepatic microsomal enzymes. The more rapid elevation and higher peak levels of serum ionic fluoride following methoxyflurane, and to a lesser extent following halothane, may reflect increased anesthetic biotransformation in obese compared with nonobese patients. To avoid excessive serum ionic fluoride elevations the authors recommended limiting low-dose methoxyflurane anesthesia delivered to obese patients with potential fatty liver infiltration to no more than three hours.


Halothane and isometric contractions of isolated pregnant rat myometrium. The effects of halothane on isometirc contractions of isolated pregnant uterine muscle strips were evaluated in tissue obtained from 13 midpregnant rats. Peak developed tension was depressed in a dose-related manner at halothane concentrations above 0.8 vol per cent, but was not affected at lower halothane concentrations. Time to peak tension was reduced 10-20 per cent, and relaxation time, 10 per cent, by halothane concentrations ranging up to 2.2 per cent. Total resting tension consisted of a passive component and a calcium-dependent component. In concentrations above 0.8 per cent, halothane rapidly removed 100 per cent of the calcium-dependent resting tension. At lower concentrations, halothane reduced it 50 per cent. The passive component of resting tension was unaffected by halothane. These actions of halothane can prevent postpartum hemostasis. They occur even with very low anesthetic concentrations and  can be detected soon after introduction of anesthetic into the muscle bath. This indicates that the hemostatic hazards associated with the use of halothane for delivery may not be prevented by limiting the concentration of halothane or the duration of anesthetic exposure.


Myocardial metabolism during pentobarbital anesthesia in dogs. Myocardial substrate utilization and hemodynamics were determined in dogs before and one hour and two hours after intravenous administration of sodium pentobarbital. Although total body O2 consumption decreased, along with arterial O2 concentration, there was no significant change in mean arterial pressure or cardiac output. Arterial free fatty acid (FFA) concentration and myocardial FFA remained the major energy source for the heart. Arterial glucose concentrations decreased significantly after pentobarbital, but myocardial uptake of glucose remained unchanged. Neither arterial lactic acid concentration nor myocardial lactate uptake was affected. Mocardial pyruvate uptake, by contrast, while remaining quantitatively the least of the contributors of energy measured, was more than double one hour after pentobarbital injection despite the fact that arterial pyruvate concentration did not increase. It is concluded that pentobarbital reduces the FFA utilization of both the whole animal and of its myocardium. The energy consumption of the whole animal is similarly diminished, whereas the energy used by myocardium is unchanged, other substrates evidently being substituted for FFA as energy sources.


Etidocaine, bupivacaine, and lidocaine seizure thresholds in monkeys. The central nervous system toxicities of etidocaine, bupivacaine, and lidocaine were studied during constant-rate intravenous infusions in rhesus monkeys. Comparison of drug effects was achieved by determining the drug dosages and arterial plasma concentrations that induced electrical seizure activity. The central nervous system toxicity of etidocaine was similar to that of bupivacaine. The toxicity of each was four times greater than that of lidocaine. Since the drug infusion rates were proportional to anesthetic potencies in clinical usage, the therapeutic-toxic ratios of these three drugs are similar.


Study of daily caloric intake of patients in the coronary intensive care unit. A retrospective analysis of the caloric intake of patients in the coronary intensive care unit was undertaken after discovery of two cases of severe hypoglycemia. An unsuspected number of extremely low daily caloric intakes were found after careful analyses. The surviving group (50 patients) had less than 600 calories on 19.5% of the patient days and under 800 calories on 28.8% of patient days. In the nonsurviving group (29 patients) caloric intake was under 600 calories on 48.8% of patient days and under 200 calories on 22.7% of patient days. This study indicates the importance of monitoring actual caloric intake to avoid unrecognized extreme caloric deprivation and its possible complications.


Effect of beta adrenergic blocking agents (alprenolol and propranolol) in essential hypertension. The antihypertensive effect of two adrenergic blocking agents (Alprenolol and Propranolol) have been studied in a group of 107 patients with essential hypertension. A significant reduction of 20 mmHg in the systolic blood pressure was recorded for the group using Alprenolol and 25 mmHg in the group using Propranolol. The corresponding decrease of 7-10 mmHg in the diastolic blood pressure for the entire group was also significant. These two drugs may be of therapeutic value in essential hypertension, independently or in combination with other antihypertensive drugs.


An enormous intrahepatic shunt between portal vein and hepatic one. An autopsy case of an enormous shunt between intrahepatic portal vein and hepatic vein in a 57-year-old man who showed an Inose's type of hepatocerebral disorder for 6 years is described. The shunt measuring up to more than 1 cm in diameter was located in the right-upper angle of the right liver lobe. The wall of the shunt lacked both the muscular layer and the elastic lamellae. Based upon the histopathology and the clinical history, this shunt was considered not to be a congenital malformation but a vascular disorder resulted from the parenchymal collapse of the liver.


A canine model for comparative study of respiratory and systemic immunologic reactions. A canine model for the comparative study of lower respiratory and systemic immunologic reactions is described. The techniques of bronchopulmonary lavage and percutaneous splenic aspiration were employed to obtain serial samples of pulmonary and systemic lymphocytes. The morphologic features and the yield of cells obtained by these procedures were characterized. The presence of lymphocytes and plasma cells among the cell populations obtained by pulmonary lavage was confirmed by electron microscopy. The effect of serial bronchopulmonary lavage per se on the yield, composition, and functional properties of bronchoalveolar lymphocytes and macrophages was found to be minor. By contrast, the effect of immununization on these parameters was marked and easily detected. Evidence is presented that at least 2 anatomically and functionally different populatons of immunocytes subserve the lower respiratory tract, namely, the hilar lymph node cells and the bronchoalveolar lymphocytes. It is concluded that the canine model is well suited for the investigation of respiratory and systemic immunity and is useful for the study of bronchoalveolar lymphocyte and alveolar macrophage function, either independently or in concert with the study of pulmonary host defense and the pathogenesis of lung disease.


Lung growth after unilateral pneumonectomy: quantitation of collagen synthesis and content. Unilateral pneumonectomy in the adult rabbit causes the mass of the remaining lung to double within one month. The content and synthesis of lung collagen were compared in 113 rabbits with pneumonectomy, thoracotomy without pneumonectomy, or pneumonectomy with subsequent wax plombage. By the twenty eighth day after left pneumonectomy, total lung collagen and cell number were nearly 100 per cent greater than matched control values, but the density of both collagen and cell number remained constant and unchanged from control. This collagen accumlation was preceded by an increase in the rate of collagen synthesis per cell and in the per cent of lung total protein synthesis represented by collagen synthesis. In normal neonatal lung growth, total lung mass, collagen, and cell number increase. During this same period there is also an increase in the per cent of collagen synthesis represented by lung total protein synthesis; however, in contrast to postpneumonectomy adult lung growth, the density of collagen increases. Obliteration of the empty hemithorax with wax after pneumonectomy resulted in suppression of the increases in right lung cell number, collagen synthesis, and collagen accumlation seen with pneumonectomy alone. This could have generalized implications relating to the control of lung gene expression in that lung cell replication and/or lung cell differentiation may, in part, be controlled by the available space into which the lung may grow.


The philadelphia pulmonary neoplasm research project. Thwarting factors in periodic screening for lung cancer. This report describes the problems of the Philadelphia Pulmonary Neoplasms Research Project, begun in 1951, when 6,027 male volunteers 45 years of age and older were enrolled in a study designed to screen them every 6 months for 10 years with questionnaires and chest photofluorograms. These volunteers tended to be slightly younger and to include fewer nonwhites that the corresponding Philadelphia population. The volunteers included more smokers than older American urban men in general, but among smokers the distribution by smoking habits was similar. The average probability of having 2 consecutive semiannual screening examinations was 57 per cent. The risk of lung cancer was higher among noncompliant men than among compliant ones. During the 10-year period of observation, 121 men developed lung cancer; only 8 per cent survived 5 years. Aside from the screening method, the factors that thwarted early detection and surgery among the men with lung cancer were (1) the interval between a negative roentgenogram and detection of cancer, which exceeded 6 months in 45 per cent; (2) an interval of 6 months or less between a negative roentgenogram and detection of cancer in 20 per cent, with a delay of 3 months or more before appropriate action was taken; (3) advanced age (70+ years) in 25 per cent at the time of detection of cancer; (4) nonmalignant disease contraindicating surgery in 31 per cent. One or more of these factors was present in 84 per cent of the men with lung cancer, leaving only a small segment for whom improvements in the screening method would be expected to be of value.


Dose response of patients with asthma to inhaled isoproterenol. In 12 patients with asthma, inhalation of approximately 0.02 mg of isoproternol produced as much increase in peak expiratory flow rate (PEFR) as had a previous inhalation of approximately 0.16 mg of isoproternol at a time when the pre-treatment PEFRwas similar. A group or patients recorded measurements of their PEFR before and after inhalation of varying doses of isoproterenol, ranging from 0 to 0.08 mg. In each patient, only data obtained when control PEFRs were similar were utilized. A maximal effect was noted after inhalation of 0.02 mg of isoproterenol, and no further increase of PEFR was noted after inhalation of larger doses. Inhalation of 0.02 mg or less of isoproterenol produces a maximal effect on PEFR of patients with asthma.


Mycobacterium simiae infection in the United States. A case report and discussion of the organism. The clinical and bacteriologic features of a case of mycobacteriosis in which Mycobacterium simiae was thought to be the causative agent are presented. The unique features of this organism, includeing its positive niacin reaction and photochromogenicity, which may lead to confusion  with other mycobacterial species, are duscussed.


Advances in the treatment of pulmonary alveolar proteinosis. Our currecnt technique for lung lavage is described. This technique can be safely and effectively applied to patients with pulmonary alvelar proteinosis who require therapy. Normal saline alone is as effective a solution as one containing heparin and acetylcysteine. Chest percussion during lung lavage considerably enhances the yeild of each lavage and thus shortens the time required for the procedure. Lung lavage results in remarkable clearing of the chest roentgenogram and reversal of the physiologic defects and symptoms of the patient by the following day. In our experience this improvement lasts for at least one year.


The prevalence of mycoplasmal complement-fixing antibodies in sarcoidosis. Complement-fixing antibody titers to Mycoplasama pnuemoniae were measured in the sera of 31 patients with sarcoidosis and 31 control subjects matched by age, sex, and race. Data indicated a binomial distribution and a geometric mean titer of 1:32 in patients with sarcoidosis. In contrast, the control data were skewed,with a geometric mean titer of less than 1:8. Possible explanations include generalized increase in antibody formation, unusual susceptibility to infection with M.pneumoniae, and sarcoidosis as one consquence of infection with M.pneumoniae.


Importance of histologic classification of carcinoma of the gallbladder. In summary, we have reviewed 914 patients who underwent primary biliary procedures at the University of Kentucky between 1962-1970. Twenty-one (2.5%) of these patients were found to have carcinoma of the gallbladder. There were differences in histological evidence of invasion and in survival between invasive, microinvasive and in situ carcinomas. The changing age of the population and the increasing incidence of cholelithiasis make it likely that the incidence of carcinoma of the gallbladder will also increase. Today, aggressive surgical therapy will probably not change the prognosis for invasive carcinoma.


Transduodenal sphincteroplasty for biliary tract disease. Transduodenal sphincteroplasty is an efficient and easy method for dealing with benign biliary tract disease. With it a permanent wide-open stoma is created between the common bile duct and the duodenum, which is established only by complete division of the muscular sphinteric mechanism. Specific indications for sphincteroplasty include multiple common duct stones or "sludge", primary biliary calculi, unremovable intrahepatic stones, impacted ampullary stones, or stenosis of the sphincter of Oddi. Conditions unrelieved by sphincteroplasty include biliary dyskinesia "post-cholecystectomy syndrome", and relapsing pancreatitis with biliary disease. Sixty-five patients are presented who underwent transduodenal sphincteroplasty for benign biliary tract disease in various categories. Satisfactory results were obtained in 53 patients. Coincident pancreatic disease was associated with the least satisfactory results.


Surgical treatment of esophageal stricture in patients with scleroderma. Two patients with dense distal esophageal strictures associated with progressive systemic sclerosis (scleroderma) are discussed. Both were treated with a Thal-Nissen procedure. Both patients now can eat without difficulty and have experienced no dysphagia. Although the peristalsis in the esophagus is markedly depressed or absent, food still can pass through the Nissen wrap into the stomach. The Thal-Nissen patch and fundoplication is an effective and well-tolerated operative procedure for the unusual patient with distal esophageal stricture and scleroderma.


Primary hyperparathyroidism in a referral hospital. A series of 46 patients had a tissue diagnosis of primary hyperparthyrodism. Forty (88%) had a single adenoma, one had multiple adenomas; four exhibited parathyroid hyperplasia and one had carcinoma of the parathyroid. The incidence establishing the diagnosis has increased in recent years because of routine multichemistry screening for calcium. The most reliable "diagnostic" laboratory finding was an elevated serum calcium: 96 per cent of our patients had serum calcium above the upper limit of normal. Forty-one patients had lesions removed; parathyroid carcinoma (1), hyperplasia (3), and adenomas (37). Only two patients have presistent disease postoperatively: one with hyperplasia who apparently had an inadequate resection of her involved glands and one who had biopsy of an adenoma without further surgical management.


Endometriosis causing acute small bowel obstruction: report of a case and review of the literature. Endometriosis causing acute small bowel obstruction is a clinical complex which should be considered in the differential diagnosis of intestinal obstruction. Theories as to etiology and pathogenesis are discussed. The best clue to preoperative diagnosis of the lesion is a careful history with regard to previous episodes of ileus having menstrual periodicity. The lesion itself usually causes obstruction by kinking or volvulus secondary to serosal adhesion formation, and more rarely by stenosis or intussusception. The treatment of total small bowel obstruction secondary to endometriosis is surgical, with resection of the involved bowel and end-to-end anastomosis.


Isolated tuberculosis of appendix.

Isolated tuberculosis of appendix. Two patients with acute appendicitis are discussed. On histologic examination both were found to have tuberculosis associated with pyogenic infection. Subsequent investigations failed to reveal tuberculous lesions elsewhere in the body. Both patients have responded well to appendectomy and antituberculous drug therapy.


Gardner's syndrome and villous adenoma of jejunum. A case of Gardner's syndrome in association with villous adenoma of the jejunum is presented. The discussion stresses that the presence of small intestinal neoplasia in Gardner's syndrome, especially of duodenal sweep and pancreas, is not an infrequent occurrence. Life-long follow-up after total colectomy is indicated for these patients.


Lymphoid polyposis of the terminal ileum and colon: a source of clinical error. A case of lymphoid polyposis of the terminal ileum is presented. The clinical errors arising from confusion of this disorder with adenomatous polyposis are discussed.


Chronic interstitial nephritis: etiologic factors. Whether chronic interstitial nephritis (pyelonephritis) mainly results from kidney infection is widely debated. We studies 101 patients with interstitial nephritis, selected from 320 patients with newly diagnosed chronic renal disease, for frequency of etiological factors. Eleven had no etiologic factor(s) identified; 89 had clearcut factor(s): anatomic abnormalities 31, analgesic abuse 20, hyperuricemia 11, nephrosclerosis 10, stones 9, sickle cell disease1, tuberculosis 1, multiple causes7. Bacterial infection (present in 27%) was found only with another preceding primary cause of renal damage. Analgesic abusers frequently denied drug ingestion; 15% had urinary tract infection and 20% classical papillary necrosis. Two had family histories of analgesic abuse with nephropathy. We conclude that interstitial nephritis is a common form of chronic renal disease, is seldom idiopathic, rarely results from bacterial infection alone in adults, and frequently results from analgesic abuse in the United States.


Oxidative injury to erythrocytes, cell rigidity, and splenic hemolysis in hemodialyzed uremic patients. In 23 hemodialyzed patients the metabolic defect of erythrocytes related to uremia and potentiated by dialysis was studied to establish a possible link with the shortened erythrocyte survival. A highly significant correlation was found between sulfhemoglobin provoked by oxidative stress and erythrocyte rigidity measured by filterability. Impaired filterability also correlated with the degree of splenic sequestration. Both sulfhemoglobin and impaired filterability correlated with the degree of hemolysis. Finally, erythrocyte survival showed a highly significant correlation with the degree of anemia. From osmotic fragility, plasma trapping, erythrocyte ATP and 2,3-diphosphoglycerate (DPG), and serum phosphorus, calcium, and magnesium measurements it seems unlikely that either spheric transformation or sol-gel transformation of the membrane is causing the increased erythrocyte rigidity. In view of the impaired erythrocyte defense capacity against oxidative injury, cell content rigidity as mediated by reduced hemoglobin solubility is a more likely explanation. Our results give a rational basis for a trial of splenectomy in severely anemia hemodialyzed patients.


Resolution of primary amyloidosis during chemotherapy. Studies in a patient with nephrotic syndrome. A patient with primary amyloidosis with evidence for a plasma cell dyscrasia but no abnormal immunoglobulin components had nephrotic syndrome with severe renal impairment. Kidney and bone marrow had extensive amyloid infiltration. She was treated with penicillamine, malphalan, prednisone, and fluoxymesterone; through 6 months renal function gradually improved; urine protein excretion dropped dramatically, serum albumin rose; liver size decreased; the bone marrow returned towards normal. During the next 4 1/2 years melphalan, prednisone, and fluoxymesterone treatment was continued with further improvement in renal function to normal levels. The morphologic characteristics and cellular relations of amyloid fibrils in the bone marrow were studied before, during, and after successful chemotherapy; the findings are evidence for a dual role for the reticuloendothelial cell in the formation and destruction of primary amyloidosis. This patient's response suggests that a multi-agent chemotherapy approach should be further studied.


Effects of hyaluronidase administration on myocardial ischemic injury in acute infarction. A preliminary study in 24 patients. The effect of hyaluronidase on myocardial ischemic injury was examined in 13 patients with acute myocardial infarction, and the results were compared with 11 patients who did not receive hyaluronidase. A 35-electrode precordial mapping method was used to assess the rate of resolution of ST segment elevations. In the 11 control patients, the sum of ST segment elevations (sigmaST) fell after 2 hours to an average of 93.5% plus or minus 17.3% (SEM) and after 24 hours to 89.6% plus or minus 7.6% of the initial values, while the number of electrodes exhibiting ST segment elevations exceeding 0.1 mV (NST) fell to 98.0% plus or minus 12.3% and 94.3% plus or minus 10.4% of the initial values respectively. In the hyaluronidase-treated group, at the same time sigmaST fell significantly more (P less than 0.05), to 54.1% plus or minus 5.0% and 51.3% plus or minus 11.8% and NST was also more markedly reduced (P less than 0.05) to 50.7% plus or minus 7.8% and 50.1% plus or minus 12.4%, thus indicating that hyaluronidase can accelerate the reduction of myocardial ischemic injury in patients with acute myocardial infarction.


Comparative left ventricular dimensions in trained athletes. Little is known about the structure of athletes' hearts of anatomic variations associated with training. Echocardiograms of 56 active athletes were obtained. Mean left ventricular end-diastolic volume and mass were increased in athletes involved in isotonic exercise, such as swimming (181 ml, 308 g) and running (160 ml, 302 g), compared with controls (101 ml, 211 g); wall thickness was normal (less than or equal to 12 mm). Athletes involved in isometric exercise, such as werstling and shot putting, had normal mean left ventricular end-diastolic volumes (110 ml, 122 ml), but increased wall thickness (13 to 14 mm) and mass (330 g, 348 g). Thus, athletes participating in isotonic exercise had increased left ventricular mass with cardiac changes similar to those in chronic volume overloads. Athletes participating in isometric exercise had increased left ventricular mass with cardiac changes similar to those in chronic pressure loads, recognizing greater left ventricular mass and volume in well-trained athletes aids in interpreting values deviating from "normal" limits.


Disappearance of vascular calcifications during treatment of renal osteodystrophy. Two patients treated with high doses of vitamin D and aluminum hydroxide. In two patients with chronic renal failure, extensive renal osteodystrophy, and vascular calcifications, treatment with high doses of vitamin D3 and aluminum hydroxide was followed by healing of the osteodystrophy and marked resolution of the vascular calcifications. The importance of adequate serum phosphate control during this treatment is stressed. It is postulated that the presence of pathologic bone that was rendered more avid for mineral by the action of vitamin D contributed to the disposal of calcium and phosphorus derived from the calcified vessels and from a positive external balance.


Methyl iodide intoxication. A case report. A 41-year-old chemist developed methyl iodide intoxication. His case is presented with a review of pertinent literature. Characteristics of the poisoning include a delay between exposure and onset of symptoms; early systemic toxicity with congestive changes in the lungs and oliguric renal failure; prominent cerebellar and Parkinsonian neurologic symptoms as well as seizures and coma in severe cases; and psychiatric disturbances that can last from months to years. Although methyl iodide is a rare form of intoxicant, its manifestations are similar to that of poisoning with the other monohalomethanes that are not uncommon.


Unconjugated hyperbilirubinemia. Physiologic evaluation and experimental approaches to therapy. The plasma concentration of unconjugated bilirubin is determined by the rate at which newly synthesized bilirubin enters the plasma (bilirubin turnover) and the rate of irreversible bilirubin removal by the liver (hepatic bilirubin clearance). Measurement of each of these variables by kinetic studies with radiolabeled bilirubin permits a precise classification of cases of unconjugated hyperbilirubinemia into those due to increased bilirubin turnover (for example, hemolysis), those due to decreased bilirubin clearance (for example, Gilbert's syndrome), and those in which both mechanisms operate. The ability to quantitate hepatic bilirubin clearance makes it possible to detect gilbert's syndrome even in the presence of concomitant hemolysis. Of the hereditary disorders of bilirubin metabolism, Gilbert's syndrome is common but innocuous, whereas Crigler-Najjar syndrome is rare but devastating. An unusual case of Crigler-Najjar syndrome is described in which bilirubin encephalopathy developed at age 10. Various modalities used in an attempt to reduce her plasma bilirubin concentration by either increasing bilirubin clearance or reducing bilirubin turnover are described.


The American Board of Internal Medicine recertification examination: process and results. On 26 October 1974, 3356 diplomates of the American Board of Internal Medicine (ABIM) took a 1-day written examination for recertification consisting of multiple-choice, matching, and true-false questions derived from the American College of Physicians' Medical Knowledge Self-Assessment Program III and the ABIM Certifying Examination pool. The passing score was set by using a normative standard applied to a reference group of internists practicing general internal medicine who had had 2 or more years of residency training completed between the years 1949 and 1958. The passing score represented approximately 63% correct answers. The failure rate for the total number of examinees was 4.3%. Mean score of examinees showed an inverse relation with age but relatively slight differences when analyzed according to the degree of subspecialization, practice setting, hospital affiliation, or size of patient community.


Porphyria in relation to surgery and anaesthesia. A review is presented of the more recent biochemical findings in the hepatic porphyrias. The clinical aspects of acute porphyria are re-emphasized and illustrated with a case history. In particular the differentiation between porphyria and surgical causes of abdominal pain is stressed. The anaesthetic management is discussed and details of diagnostic and screening tests are given.


Liver biopsy.

Liver biopsy. An account is given of the findings obtained with open liver biopsy in 111 patients with various diseases, including 78 with cholecystitis and colelithiasis where unsuspected liver pathology, including biliary cirrhosis, was found in 37 patients. An exact diagnosis of hepatic metastasis by biopsy has therapeutic importance in malignant diseases, and in some patients, particularly those with argent-affinoma, liver involvement is compatible with normal life for many years.


Split ileostomy in the treatment of Crohn's disease of the colon. Because of the problems associated with surgical resection of Crohn's disease of the colon a more conservative approach has been used in Oxford since 1960. The inflamed large bowel has been defunctioned by an external diversionary ileostomy and subsequently the disease has been treated with topical and oral corticosteroids. The technique of the split ileostomy used for this purpose is described and the indications for the operation and early results of its use in 69 patients are recorded. In carefully chosen cases the method has two advantages over primary resection. In some patients the inflammation improved sufficiently for continuity of the bowel to be restored without resection being necessary and without medical treatment being required. In others the ileostomy resulted in a marked improvement in general health which has made the subsequent major resection a safer procedure. As an extension of the technique the use of an external faecal diversion by ileostomy is recorded in a further 11 patients who had a synchronous resection of a segment of bowel affected by Crohn's disease.


Gynaecology and general surgery.

Gynaecology and general surgery. The gynaecological disorders most likely to be met by the general surgeon are those that present with acute abdominal symptoms and those unexpectedly encountered at laparotomy. The former group includes ectopic pregnancy, acute salpingitis, and complications of ovarian cysts and abortion and the latter endometriosis, ovarian tumours, and myomatosis. The characteristics and treatment of these various conditions are described and principles outlined for the guidance of the general surgeon in dealing with gynaecological problem.


How should the common bile duct be explored? An attempt has been made to find which of 3 operations currently in use for exploring the bile ducts gave the best clinical results. For this purpose 3 series of consecutive patients treated at The London Hospital over a 12-year period have been studied retrospectively. The operations used were as follows: (1) conventional supraduodenal choledochotomy; (2) transduodenal biliary sphincterotomy; and (3) a combined approach. The mortality in the supraduodenal series was 4 (4%) of 101 patients and in the transduodenal series 2 (2.4%) of 82 patients. Both routes were used in 26 patients, of whom 2 (7.7%) died. Early complications were commoner after choledochotomy than after biliary sphincterotomy, but when both procedures were combined the incidence was higher still. Late complications were also more frequent after both the supraduodenal and the combined approach, residual or recurrent stones and cholangitis being 6 times more common than after sphincterotomy alone. Postexploratory cholangiography, however, was not used routinly in the supraduodenal series and might conceivably have reduced this factor further, but not below 3. Stenosis occurred in one patient after choledochotomy and in one patient after the combined operation but not after sphincterotomy alone. In this study, therefore, transduodenal biliary sphincterotomy gave the lowest mortality and morbidity. With the combined procedure, however, the mortality and morbidity were much higher than after either method alone.


Assessment and treatment of recurrent peptic ulceration. From the experience of treating 91 patients with a proven recurrent ulcer we consider that if a proven ulcer is shown to be present and a gastrin-secreting tumour is excluded an appropriate reoperation will almost always produce a successful result (94 per cent). Before subjecting patients to reoperation all attempts must be made to secure a precise diagnosis. The following investigations should be performed: barium meal, panendoscopy of the upper gastrointestinal tract, determination of maximum acid output (with insulin test and gastrin analysis if appropriate), and cholecystography. Before accepting a diagnosis of recurrent ulcer at least 2 of the first 3 tests should be postive. If the primary operation was a resection we advocate vagotomy alone as the second operation, provided there are no local complications such as stenosis, bleeding, or fistula. If the primary operation was a vagotomy and the recurrence is associated with a positive response to the insulin test we advocate revagotomy and antrectomy. If the insulin test is negative we normally repeat the test; if it is still negative then we use antrectomy alone.


[Determination of neomycin in the film-forming aerosol preparation "Neotizol'"]. A colorimetric method for guantitative determination of neomycin in the aerozol preparation "Neotizol" was developed. The determination was performed after neomycin isolation from the film-forming composition with the carboxylic ion exchange resins IRC-50 and KB-2 containing 2.5-3 per cent of divinylbenzol. The results of the colorimetric determination were compared with the data of the microbiological assay. The results of neomycin determination in the aerozol preparation "Neotizol" were treated statistically.


[Effect of carbenicillin and its combination with prodigiozan and lysozyme on the course of an experimental inflammatory process of Proteus etiology]. Biological properties of 142 Proteus strains isolated from patients were studied. Sensitivity of Proteus to II antibiotics was tested. The isolates were resistant to most of the antibiotics. The highest number of the isolates was sensitive to ampicillin (77.1 minus or plus 7.16) and especially to carbenicillin (82.6 plus or minus 6.16). This provided the use of carbenicillin for the treatment of experimental septicemia in albino mice and wound processes in rabbits with Proteus complications. The high therapeutic effect of the antibiotic was shown in experiments with 210 albino mice and 44 rabbits. The therapeutic effect of carbenicillin increased when it was used in combination with prodigiozan and especially in combination with prodigiozan and lysozyme.


[Effect of repeated cycles of tetraolean and oleandomycin administration on the indices of nonspecific resistence of the body in experimental staphylococcal sepsis]. The effect of repeated cycles of tetracycline and oleandomycin administration on the complement titer, content of lysozyme and bactericidal properties of the serum in rabbits with experimental staphylococcal sepsis was studied. It was shown that the septic process induced by intravenous inoculation of staphylococci was accompanied by stimulation of the host nonspecific resistance. However, repeated inoculations of the animals resulted in exhaustion of the host protective forces and decreased non-specific resistance. The use of tetracycline in experimental staphylococcal sepsis was accompanied by an increase in the complement titer, lysozyme content and bactericidal properties of the serum after both the 1st and 2nd cycles of the drug administration. The use of oleaudomycin induced an increase in the contents of the complement, lysozyme and bactericidal properties of the serum at the background of staphylococcal sepsis only after the 1st cycle. The repeated cycle of oleandomycin administration was accompanied by a decrease in the above indices. Such conditions should be taken into account in choosing the antibiotic for treatment of septic cases especially when repeated cycles of the drug administration are used.


[Antibiotic sensitivity of the causative agent of glanders]. Sensitivity of the glanders causative agent to 20 antibiotics representing different groups is described. The results of the in vitro studies showed that most of the antibiotics were not active against the glanders causative agent, except for polymyxin M, levomycetin and their combination. Some relative activity was observed with neomycin. The "indicators" method used by the authors for determination of the M. mallei sensitivity to the antibiotics allowed the shortening of the time of the test by 8 to 10 hours.


[Effect of the antibiotic sibiromycin on the bioelectrical activity of the heart and the serum transaminase activity in dogs]. Experiments with dogs showed that daily intravenous administrations of sibiromycin in doses of 1.5 or 1 gamma/kg resulted in significant changes in the ECG: delayed heart rythm, narrowed R peak amplitude, lower P peak or its absence, presence of coronary T peak and location of S-T segment above the isoline, which corresponded to the increase in the transminase activity of the blood serum. When sibiromycin was used in a dose of 0.75 gamma/kg 30 times a day and in a dose of 1.5 gamma/kg 2 times a weak for 13 times T, P R peaks on the ECG changed. The cardiotoxic effect of sibiromycin depended on the dose. When used in a single dose of 5 gamma/kg, in a dose of 0.37 gamma/kg 30 times a day or in a dose of 2 or 1.5 gamma/kg once a weak for 7 times, sibiromycin had no toxic effect on the heart.


[Effect of antibiotic therapy on the experimental production of antiviral antibodies]. Because of the practical value of the study of peculiar properties of antinfluenza immunity under conditions of the use of tetracycline, streptomycin and penicillin, the experiments were performed on albino mice and rats. The studies showed that the antibiotics inhibited the intensity of production of specific antibodies, i.e. antihemagglutinines and virus neutralizing antibodies in the process of antiinfluenza immunization of the animals which must be connected with changes in the cells of the immunoreactive system, suppression of the activity of the metabolic processes.


[Toxic action of morphocycline on pregnant rats]. Morphocycline was administered intravenously to rats of Wistar line in doses of 100, 50 and 20 mg/kg at various periods of pregnancy. It was found that a single administration of morphocycline in the above doses to the rats on the 9th day of their pregnancy resulted in abortus in some female rats. Death and resorption of the fetus were more frequent after the antibiotic use in doses of 20 and 50 mg/kg. Repeated administrations of morphocycline in doses of 20 mg/kg resulted in abortus and postimplantation death of the fetus most pronounced in the animal groups treated with the antibiotic during the periods of the 7th to the 10th and from the 11th to the 14th days of pregnancy. The teratogenic activity of morphocycline was slightly pronounced. It was observed in some fetus after both single and repeated administrations of the antibiotic.


Topical colchicine therapy for recalcitrant psoriasis. Once daily applications of 1.0% colchicine in hydrophilic ointment for 6 to 12 weeks produced substantial resolution of recalcitrant psoriatic plaques, especially those on the trunk. With occlusion, lower concentrations of the drug (0.25% and 0.50%) were usually effective. A thick viscous base (hydrophilic petrolatum) was more effective than a hydrophilic cream base (hydrophilic ointment), presumably because of greater occlusivity. Treatment with topically applied colchicine may be valuable when other measures fail to control localized thick plaques of psoriasis. Its use is still experimental and should be restricted to small areas until more is known about its percutaneous absorption.


Scabies: histological study of inflammatory lesions. Histological findings of the inflammatory lesions of scabies are distinctive enough to guide the pathologist in the direction of this diagnosis. It is characterized by a combination of an acute, vesicular, eczematous type of epidermal change and an erythema multiforme type of dermal reaction. When this combination is present, a search should be made to expose the organism in tissue sections or in scrapings of the cutaneous lesions.


A new formula for depigmenting human skin. Complete depigmentation of the noraml skin of adult male blacks was procured by the daily application for five to seven weeks of a formula consisting of 0.1% tretinoin, 5.0% hydroquinone, 0.1% dexamethasone, and hydrophilic ointment. Depigmentation was not attainable when any one of the components was omitted. The formula was therapeutically effective in treatment of melasma, ephelides, and postinflammatory hyperpigmentation. Senile lentigines were resistant to this therapy.


Electron microscopical and biochemical analysis of colloid milium. Two new cases of colloid millium were studied by several methods to examine if collagen is the source of colloid. Wound-healing experiments in the lesion revealed that colloid is reproduced de novo with possible interaction with epidermal cells. Unfixed, native colloid did not contain collagen and salt extraction did not alter the ultrastructure of colloid. Tissue culture of colloid fibroblasts produced colloid-like substance. These results suggest that colloid is not a degeneration product of collagen. Disc electrophoresis of extracted colloid produced a distinct band, which is absent in the normal skin control. Amino acid analysis of colloid suggests that colloid may contain the recently described class of glycoprotein, called "structural glycoprotein" that is not related to collagen because it does not contain hydroxyproline and hydroxylysine and contains only a small amount of glucose. These biochemical data support the conclusion reached in electron microscopical studies.


Alteration of hypertrophic scars induced by mechanical pressure. Hypertrophic scars and contractures may be rapidly resolved through application of pressure and forced extension. Examination of pressure-treated scars by scanning and transmission electron microscopy demonstrates a reduction in intercollagen cohesiveness and increasing numbers of vesicular fibroblasts. Assays of chrondroitin sulfate A show a decrease from the excessive levels found in untreated hypertrophic scars. It is suggested that the application of pressure increases an already present condition of hypoxia, which results in degeneration of many fibroblasts. The ratio of collagen synthesis to degradation would, then, be altered in favor of the latter, resulting in resolution of the scar.


Precocious noduloulcerative cutaneous syphilis. A man had widespread, noduloulcerative syphilitic lesions that appeared, chronologically, during the "secondary" stage of syphilis. There were no systemic manifestations of the disease, except for possible periostitis. The darkfield examination and spinal fluid examinations were negative for syphilis. It is suggested that the term "malignant" syphilis should be discarded in favor of nonduloulcerative cutaneous syphilis.


Raynaud disease with oral manifestations. A young women with a history of Raynaud phenomenon, without underlying disease, manifested spasms of the tongue at times when the episodes of the hands were most severe. Striking changes in the appearance of the tongue occurred.


Familial progressive systemic scleroderma. Three patients seen with similar findings of progressive systemic scleroderma. Two of the patients, a father and son, had very similar skin changes, sclerodactyly, Raynaud phenomenon, gastrointestinal involvement, and pulmonary symptoms. The three patients were from the highly inbred Brandywine triracial isolate. This isolate is a group of families who have been inbreeding since 1660 and now have the highest gene frequencies for sickle cell anemia and oculocutaneous albinism in the United States. There have been only a few reported cases of familial scleroderma and the hereditary aspect of the disease has not been well established. This report shows that the mortality for scleroderma in this isolate is at least 250 times the mortality of the general population, thus suggesting a probable genetic predisposition for the disease.


Lymphangiosarcoma arising in congenital lymphedema. An 85-year-old woman with congenital lymphedema of the right upper extremity developed a small purplish papule on the forearm, which was the first clinical evidence of lymphangiosarcoma. The lesion grew rapidly and became necrotic and ulcerated. The patient experienced severe pain. A mid-arm amputation was performed. Microscopical examination of the amputated limb showed widespread histological involvement of skin, muscle, and subcutaneous tissue by lymphangiosarcoma. The need for continuous monitoring of patients with both primary and secondary lymphedema is emphasized, since early diagnosis of the developing lymphangiosarcoma and rapid surgical intervention provide the best prognosis for survival.


Pseudopseudohypoparathyroidism with fibrous dysplasia. Pseudopseudohypoparathyroidism and pseudohypoparathyroidism have been thought to represent variants of the same disease process, Albright hereditary osteodystrophy. A 31-year-old woman with the characteristic features of pseudopseudohypoparathyroidism, such as shortened metacarpals and metatarsals, round facies, and normal serum calcium values, was studied. Underdeveloped metacarpal and metatarsal heads produced an important diagnostic sign, Albright dimpling sign, which dermatologists can use to make the correct diagnosis. The presence of this sign, together with roentgenographic evidence, will usually exclude other diagnostic possibilities. Our patient had a normal response to parathyroid hormone infusion, including increased urinary adenosine 3',5' cyclic monophosphate excretion. Radiological, light microscopic, and electron microscopic studies of the mandible showed fibrous dysplasia, a disease commonly reported to be present with hyperparathyroidism, but, to our knowledge, never before reported in association with any variant of hypoparathyroidism.


Chronic urticaria from isophane insulin therapy; sensitivity associated with noninsulin components in commercial preparations. A young woman with diabetes mellitus developed chronic urticaria after changing from isophane been insulin suspension to isophane beef-pork insulin suspension. She reverted to treatment with her original insulin preparation, but urticaria failed to terminate. While in the hospital, her eruption began each afternoon at the site of insulin injection. Zinc single-peak beef insulin suspension, a purer preparation with different additives than isophane beef insulin, was substituted, and urticaria terminated rapidly. Intradermal skin testing using single-peak (purified) preparations indicated that the patient was sensitive to beef and pork forms of isophane insulin but not to beef and pork forms of zinc insulin. The patient later had a brief recurrence of urticaria following oral erythromycin and tetracycline therapy but did not develop lesions at sites of insulin injection.


Localized scleroderma.

Localized scleroderma. Familial scleroderma is rare; only seven documented instances of the disease have been reported, to our knowledge. This report adds two more families to the literature. Three children in one family and two in the other had clinically and histiologically established localized scleroderma.


Orally given indomethacin and blood flow response to UVL. Blood flow in normal skin and skin treated with ultraviolet light (UVL) has been determined by measuring the clearance of epicutaneously applied xenon 133 gas. Mean blood flow in UVL-irradiated skin was 25.7 ml/100 gm/min, which is about twice that found in normal skin (12.2 ml/100 gm/min). Orally administered indomethacin reduced by one third the increase in blood flow produced by UVL irradiation.


Granulomatous panniculitis in erythema nodosum. A group of ten patients with granulomatous panniculitis was studied; five had erythema induratum of the tuberculous or the nontuberculous type and five had erythema nodosum. In both groups, histiocytic giant cells and lymphocytic inflammation of the fat were seen microscopically. Massive caseation was seen in the patients who had erythema induratum, but this was not a distinguishing feature between the tuberculous and the nontuberculous type. The clinical history in all instances was a reliable guide to diagnosis. No specific cause was found, and treatment was not specific. tin granulomatous panniculitis, the clinical pattern of disease is confusing in view of the histologic findings, and the diagnosis can be made with confidence only if the clinical findings are carefully correlated to the course of the disease.


Soft-tissue calcification in systemic lupus erythematosus. Calcification of soft tissues is known to occur frequently in progressive systemic sclerosis (PSS) and dermatomyositis. To our knowledge, only seven case reports have appeared concerning this abnormality in systemic lupus erythematosus (SLE). We describe four patients with well-documented SLE who developed calcification in subcutaneous tissue, muscle, or periarticular structures. The pattern and localization of the calcification can mimic those seen in other disorders.


Pruritic maculopapular skin lesions in sarcoidosis. An unusual clinical presentation. Pruritic maculopapular rash occurred in a 23-year-old black man. The lesion remained undiagnosed and required frequent hospital admissions. Twenty years after the onset of symptoms, the skin and lymph node biopsy specimens showed noncaseating granulomas. Sarcoidosis should always be included in the differential diagnosis of pruritic skin lesion.


Lymphocyte transformation in mycosis fungoides. Lymphocyte transformation tests with PHA were carried out in 26 patients with mycosis fungoides (MF) in different stages of the disease. In premycotic and infiltrative stages of MF there were no significant disturbances in the lymphocyte response to PHA. Inhibition of DNA synthesis and blastic transformation was observed only in the tumorous stage. The results are in favour of the nosological distinctiveness of mycosis fungoides within the lymphoma group.


[The effect of salicylic acid on epidermal cell proliferation kinetics in psoriasis. Autoradiographic in vitro-investigations(author's transl)]. Salicylic acid in the therapeutic concentrations from 0.5 to 10% does not affect the rate of proliferation of psoriatic epidermal cells. In 18 patients suffering from psoriasis the H3-I (H3-thymidine labelling index) was determined using autoradiographic in vitro labelling techniques. In 12 of these patients double-labelling with C14-and H3-thymidine was used to determine the H3-I, the DNA-synthesis time (ts) and the duration of the cell-cycle (tc). No significant changes were observed following external application of salicyclic acid in white Vaseline in concentrations of 0.5, 2 and 10% for one week.


[Hydrotherapy in cauterization wounds. A histologic study (author's transl)]. Investigations have have been carried out in guinea pigs to test the usefullness of hydrotherapy. Concentrated sulfuric acid was applied to the skin for a period of 30 sec and 5 min. After this the skin was washed with tap water for 1 hr. The treated area was then subjected to macroscopic and microscopic examination. When the acid was applied for 30 sec, followed by rinsing, an almost complete restitution of the skin was found on the test area macroscopically and microscopically. Significant differences were also observed after an exposition of 5 min in comparison with untreated control animals.


[The effect of fumaric acid monoethylester on the synthesis of nucleic acids and proteins of PHA-stimulated human lymphocytes (author's transl)]. Fumaric acid monoethylester (FAME) inhibits the incorporation of 14C-Thymidin, 14C-Uridin, 14C-Alanin and 14C-Leucin into acid-insoluble biopolymers of cultivated PHA-stimulated human lymphocytes. At high concentrations of FAME (500 mug/ml culture medium) the inhibition of nucleic acid synthesis is 6 times higher on the average than the inhibition of protein synthesis. However, the application of the cis-isomer, maleic acid monoethylester (MAME), results in an increase of the incorporation rate of the labelled precursors into the RNA and DNA. This is 3.5--9.3 times higher than after application of FAME. The results demonstrate the specific inhibition by FAME. The rate of labelling of nucleic acids is decreased above 10 mug FAME/ml culture medium and in the case of MAME above 50 mug/ml medium. As an explanation of the specific action of FAME its influence on the enzymes of the nucleic acid synthesis, the citric acid cycle or a faulty synthesis of enzymes are discussed.


[Effect of arsenic on the incorporation of 14C-thymidine into DNAP of phytohaemagglutinin-treated lymphocytes (author's transl)]. In lymphocyte cultures stimulated with PHA Na2HAsO4 is able, independent of the arsenic doses used (10 mug, 30 mug, 50 mug/ml culture medium), to increase the 14C-thymidine incorporation in acid precipitable biopolymers. The increase was 17 plus or minus 4% at 1 hr exposure to arsenic, compared with control cultures which were not exposed to arsenic. The administration of 30 mug and 50 mug Na2HAsO4/ml medium at incubation periods between 2 and 18 hrs resulted in a decrease in the radioactive incorporation rate into the DNA which was dependent on dose and time. Using 10 mug Na2HAsO4 per ml medium, the 1 hr stimulation is followed by an inhibition (up to approximately 35%, control equals 100%), which lasts for approximately 3 hrs. This is followed by an increase in the 14C-thymidine incorporation into the DNA for a further 2 hrs. The course of the inhibition curve with 10 mug Na2HAsO4 and with exposure times between 6 and 18 hrs the decreases again dependent on dose and time. As an explanation of the stimulation of the 14C-thymidine utilisation by arsenic, we suppose an increased repair activity. This may lead to a situation where (labelled) bases which are added outside the synthesis phase are incorporated into the DNA. The inhibition of 14C-thymidine incorporation which is dependent on dosage and time, with larger doses of arsenic can be explained by a prevailing influence of enzymes of the synthesis system (e.g. polymer arsenic), while the unusual course of the inhibition curve under the influence of 10 mug Na2HAsO4 shows that an activation and inhibition of enzyme systems (synthesis and repair) which is displaced in time is taking place. Apart from this, disturbances of regulation processes of the DNA replication and the initiation overlap can also be suspected as a cause of the phenomena observed.


Immune response to primary immunization with brucella antigen in mycosis fungoides. The immune response to primary immunization with brucella antigen was studied in 8 patients with mycosis fungoides and 11 controls. The development of as well cellular as humoral hypersensitivity to brucella antigen was followed by in vitro techniques. Both, patients with mycosis fungoides and controls were studied for previously acquired delayed hypersensitivity to tuberculin by skin test. The distribution of B and T cells was encountered among the patients. Previously acquired cellular immunity was found equal in the two groups, however, induction of cellular hypersensitivity to brucella antigen was found depressed in mycosis fungoides patients compared with the controls. Also the humoral response to brucella antigen could seem depressed, only one of seven patients with mycosis fungoides had a positive titer, while seven of eleven controls had positive titres following vaccination; but the difference between the two groups was not significant.


[Excision repair in lymphocytes of psoriasis (author's transl)]. Psoriasis is a autosomal hereditary disease of the skin, which has been treated with a great number of possibly carcinogenic substances. No increase of maligonomies has been observed except for the tumors induced by arsenic. The question may be asked whether the psoriatic cell has additional or more effective mechanisms to eliminate onocogenic somatic mutations. In this study the capacity of the excision repair of circulating blood lymphocytes from 12 psoriatic patients has been investigated and compared to a control group of equal size. After irradiation with ultraviolet light, the lymphocytes are incubated with 3 H-thymidine and at various intervals the radioactivity in the cell material precipitated with perchloric acid is measured. It appears, that the excision reapir in lymphocytes from patients with psoriasis and normal persons is equal. In addition, the influence of hydroxyurea on the thymidine incorporation in lymphocytes has been studied.


Development of occupational standards.

Development of occupational standards. Criteria and recommended occupational safety and health standards have been developed by the National Institute for Occupational Safety and Health as a basic adversary review and comment process. Several changes in the process designed to alleviate problem areas include the preparation of work practice standards and the addition of supplementary requirements to the existing promulgated standards.


Dermal irritancy of metal compounds. Studies with palladium, platinum, lead, and manganese compounds. Dermal irritancy of 14 materials, including several compounds of palladium, platinum and lead, and methylcyclopentadienyl manganese tricarbonyl, plus deionized water (negative control) and glacial acetic acid (positive control), was tested on male albino rabbits weighing 2 to 3 kg. Procedures and evaluation criteria were adopted from those in use by the National Institute for Occupational Safety and Health. Five materials were evaluated as unsafe for intact or abraded skin contact as judged by severity of responses: glacial acetic acid (C3H5PDCl)2, (NH4)2PdCl4, (NH4)2PdCl6, and PtCl4; one as safe for intact, but not for abraded, skin: K2PdCl6; and two as safe for intact skin but not for abraded skin unless protected: K2PdCl4 and PdCl2. The remainder were evaluated as safe for intact or abraded skin contact (irritancy grade less than 1 on a scale of 4): H2O, Pd(NH3)2Cl2, PdO, PtO2, PtCl2, PbCl2, PbO, MMT.


Carboxyhemoglobin in nonsmokers: a mathematical model. A study was made of existing mathematical models for both carbon monoxide (CO) and carboxyhemoglobin (COHb) buildup. From these models a combined model was derived for calculating delta%COHb in nonsmokers in an enclosed space in which excess concentrations of CO may occur. For simplicity the model was restricted to those occasions where CO concentration was at equillibrium or came to equillibrium in a time-short compared with exposure time. The equation derived was for delta%COHb calculated from CO, ventilation, respiration, persons, smokers, height, weight, cigarettes, and exposure time. Comparisons with published data show excellent agreement of calculated and observed values.


Utensil swab test: its effectiveness in food service sanitation programs. The effectiveness of the utensil swab test as part of the periodic inspection of food establishments was studied both as an indicator of cleanliness during the period between inspections and as an educational tool. Two to seven samplings were taken at intervals of two to three months at 95 food establishments in rural areas in the northern part of Israel. A statistical analysis showed a high variation and almost no correlation between repeated samplings of the same establishment. Also, no trend to suggest an educational effect was found. We concluded that, though the swab test had proved to be useful in special projects, it had no value as part of the periodic sanitary inspections.


Sequential changes in cerebral blood flow and distribution of flow within the brain during hemorrhagic shock. Sequential changes in cerebral blood flow as well as in regional blood flow to the brain (brain stem, cerebellum, hypothalamus, white matter and grey matter) were measured in unanesthetized dogs subjected to gradual prolonged hemorrhage according to a protocol which stimulates the most commonly encountered type of clinical hemorrhagic shock. Microspheres labeled with five different radioactive isotopes were injected into a left atrial catheter at five different times: control, early hypotension (immediately after hemorrhage), late hypotension (just before reinfusion of the shed blood), as well as one and eight hours after reinfusion of the shed blood. Immediately after hemorrhage, the total cerebral blood flow decreased slightly, but increased when calculated as a percent of the cardiac output. In the late hypotensive, hypovolemic stage, there was decreased flow calculated both as percentages of cardiac output and absolute flow as compared with the initial response to hemorrhage. Immediately after reinfusion of the shed blood, there were further reductions of flow. Eight hours subsequently, flow rose to values slightly above control. The patterns of each region was almost identical to that of the total cerebral flow. Since each of the major regions of the brain are approximately equally affected, changes in the level of consciousness and other cerebral functions occurring with hypovolemic shock may reflect circulation of the white matter as well as that of the whole brain.


Physiologic effects of transfusing red blood cells with high or low affinity for oxygen to passively hyperventilated, anemic baboons: systemic and cerebral oxygen extraction. Anemic, passively hyperventilated baboons were given preserved red blood cells either with increased or with slightly reduced affinity for oxygen to restore the red cell volume. In the high affinity group there was a 50% increase in cerebral blood flow immediately after the transfusion, but there was no significant change in the low affinity group. The cardiac output decreased slightly in the low affinity group, and increased slightly but insignificantly in the high affinity group. Two hours after transfusion the cerebral blood flow had returned to normal in the high affinity group. In both groups there was a decrease in arterial blood pH and an increase in Po2 in blood from the pulmonary artery and the jugular vein after transfusion. A 40% restoration of the 2,3 DPG level occurred within 4 hours of the transfusion of red cells with high affinity for oxygen, and this rapid increase was associated with increases in blood pH and inorganic phosphorus levels. Preserved red cells with high affinity for oxygen and low 2, 3 DPG levels significantly increased the cerebral circulation during the 2-hour posttransfusion period. These findings lend support to the recommendation that preserved red cells with normal or elevated 2,3 DPG levels be administered to patients in hemorrhagic or septic shock, and to patients subjected to extracorporeal circulation during cardiac surgery in order to lessen the demand for increased blood flow and to ensure adequate tissue oxygenation during the postoperative period.


Comparison of filtering efficiency of four new in-line blood transfusion filters. Efficient removal of debris from stored human blood prior to transfusion has become increasingly important. The debris, consisting largely of microaggregates of platelets and fibrin, is not effectively removed by passage through a standard transfusion filter. This study evaluated the performance of four of the currently available small pore in-line blood transfusion filters. Filters tested included the Bentley PF-127, the Pall Ultipor SQ-40, the Swank In-Line IL-200 and the Fenwal Microaggregate Blood Filter. A standard blood administration filter was also tested, the McGraw V-2950. The rate of blood flow through the filters was recorded using single and multiple units of blood. The screen filtration pressure and debris weight of the filtered blood were studied to compare effectiveness of filtration. The Swank filter was effective in debris removal and maintained good flow rates. The Bentley and Fenwall filters removed debris nearly as well, but had reduction of flow rates after smaller infusions. The Pall filter maintained high flow rates but did not remove debris as effectively, particularly with pressure infusion. The standard 170 mu pore blood transfusion filter does not remove microaggregates.


The association of parathyroid adenoma and non-medullary carcinoma of the thyroid. Thyroid carcinoma was discovered in five of 56 (8.9%) patients operated upon for hyperparathyroidism. In only one instance was a mass palpated preoperatively. An additional 26% of the 56 patients had either multinodular goiter or follicular adenomas. It is thus important to biopsy the thyroid nodules which may represent malignancy.


Intra-aortic balloon counterpulsation: potential for therapy in hemorrhagic shock with associated myocardial failure. After attaching appropriate monitoring devices enabling the measurement of the slope of the left ventricular function curve, left atrial pressure, mean aortic pressure, peak left ventricular pressure, and tension time index, three groups of ten dogs were subjected to varying periods of hemorrhagic shock until a slope of their ventricular function curve was reduced to either 75% (Group I), 50% (Group II), or 25% (Group III) of their baseline value. Resuscitation was attempted in all dogs by the intravenous infusion of shed blood plus additional balanced salt solution. This infusate was administered to maintain either the mean aortic pressure within 15 mm Hg of the baseline value or a left atrial pressure of 15 mm Hg, whichever occurred forst. One half of the dogs received, in addition, intra-aortic balloon counterpulsation. All dogs not receiving counterpulsation expired within two hours. There was no apparent effect of counterpulsation on Group I animals. Three of five animals (Group II) and four of five animals (Group III) receiving counterpulsation survived to the end of the experiment with significant (p smaller than .01) improvement in the parameters monitored. The utilization of counterpulsation as an adjunct to treatment in hemorrhagic shock is suggested.


Mesenteric thrombosis following splenectomy. Three cases of postsplenectomy mesenteric thrombosis, two associated with thrombocytosis, are presented. Experience has shown that persistent thrombocytosis, accompanied by abnormal platelet function, is not a benign condition and may be associated with thrombosis. When encountered, postsplenectomy thrombocytosis of greater than 800,000 per mm-3 must be evaluated by platelet function studies and anticoagulation begun. Post-prandial cramping abdominal pain may be an early symptom of thrombosis, demanding immediate anticoagulation. Low-dose heparin, ASA, and dipyridamole are three of the more commonly used treatment modalities. Small bowel resection is indicated if thrombosis occurs.


Fecal impaction following methadone ingestion simulating acute intestinal obstruction,. A hitherto unreported clinical entity, namely fecal impaction following methadone ingestion simulating acute intestinal obstruction, is described. Five cases admitted to the Surgical Service of the Beth Israel Medical Center in New York City are discussed. The nature and pathogenesis of the obstruction are analyzed and a suggested method of managing these cases is presented. It is emphasized that with expansion and increasing acceptance of Methadone Maintenance Treatment Programs, the number of such cases will increase. It is thus important that physicians become aware of the existence of this syndrome since involvement in methadone maintenance may be a life-long commitment for persons involved, thus increasing the incidence of the complication. It is also imperative to avoid unnecessary, and possibly harmful surgical intervention in such cases.


Primary pulmonary leiomyosarcoma: case report and review of literature. A case of primary leiomyosarcoma of the lung is added to the literature. Previously, 66 cases were documented. This is a case of a 55-year-old male, a pulmonary cripple for many years, with a collapsed left lower lobe found by roentgenogram, verified by bronchoscopy and bronchograms. Biopsy of lesion was reported as low grade leiomyosarcoma. Despite pulmonary function studies showing a vital capacity of 37% of predicted normal, a left pneumonectomy was preformed. Postoperatively, the patient had a tachycardia which gradually decreased in the next several months. Two months following operation pulmonary function studies were essentially unchanged from those made preoperatively. Arterial gas studies are presented pre and postoperatively.


Results of conservative treatment of breast cancer at ten and 15 years. The ten-year survival of patients at the Cleveland Clinic treated by operations less than radical mastectomy was 45% compared with 43% in identically staged patients of the "National Cancer Registry" treated predominantly by radical mastectomy. The five and ten-year survival rates of patients treated by simple operations was higher than that of a similar group of patients treated by radical operations, but at 15 years there was no difference. The late deaths from cancer in the patients treated conservatively occurred in patients with favorably staged cancers who never had local recurrences and most of whom had no involvement of nodes. The incidence of local recurrence was no higher after simple operations than after the radical procedure. The ten-year incidences of local recurrence and of death from cancer were the same after partial mastectomy as after total mastectomy. It is pointed out that differences in staging the cancers and in reporting the survival rates invalidate comparisons of results from different institutions. The figures presented suggest that conservative operations and radical operations give the same survival rates at ten and at 15 years.


Diabetes insipidus secondary to penetrating thoracic trauma. Three cases of diabetes insipidus following non-cranial trauma are presented. They are believed to be the first of their kind reported. The etiology, pathogenesis and differential diagnosis of diabetes insipidus are discussed. The literature if briefly reviewed and similarities between patients with DI due to long bone trauma with fat embolism, post open heart surgery hypotension, Sheehan's syndrome following postpartum hemorrhage, DI and our own patients are discussed. It is concluded that the diabetes insipidus is caused by selective disruption of posterior pituitary circulation due to fat globules, thrombi and hypovolemia resulting in hypoxia and tissue necrosis.


Vagotomy and double pyloroplasty for peptic ulcer. Seventy patients with peptic ulcers (55 duodenal and 15 gastric) were treated by truncal vagotomy and doulbe pyloroplasty during the past four years. Clinical and experimental data as presented lead us to believe that transecting the pylorus twice produces an incontinent pyloric sphincter and a larger gastric outlet than is found in other methods of pyloroplasty. This decreases gastric stasis and has led to a lower ulcer recurrence rate (1.5%). In addition the untoward postoperative sequelae are minimal. The 70 patients treated (for the most pare consecutive cases) exhibited the usual complications of peptic ulcer disease. Thirty-three had intractable pain, 23 bleeding (15 massive), 13 obstruction, and one acute perforation. There were no operative or postoperative deaths and the only serious postoperative complication was unrelated to the double pyloroplasty. During the followup period four patients have died of unrelated diseases. Of the remaining 66 patients one developed a probable recurrent peptic ulcer which has responded to medical management. Four patients have intermittent dumping, three have mild diarrhea and one has failed to gain weight, Constipation and weight gain are more common complaints. It would appear that vagotomy with double pyloroplasty is a safe and effective operation for peptic ulcers and that further clinical trials are warranted.


Pancreatic exocrine secretion during and after pregnancy. Pancreatitis occurring in late pregnancy and in the puerperium has been documented as an entity unrelated to cholelithiasis or hyperlipidemia. Canine pancreatic exocrine function has been studied during pregnancy and the puerperium. Pancreatic secretion was evaluated in eight pregnant female mongrel dogs prepared with Thomas duodenal and gastric fistulae, during pregnancy (corresponding to the third trimester in humans), during the puerperium, and several months after whelping. Basal secretion (volume and HCO3) was increased during pregnancy and the puerperium. The response to exogenous secretin  (submaximal and maximal) was unchanged during pregnancy but decreased in the puerperium. Resting enzyme output was increased during pregnancy and the puerperium; the responses to cholecystokinin-pancreozymin during pregnancy were even more profoundly increased. Although the mechanism is speculative, these alterations in pancreatic function might contribute to the development of pancreatitis in pregnancy and the puerperium.