Late relapse of pulmonary blastomycosis after adequate treatment with amphotericin B. Case report. A 53-year-old man experienced relapse of pulmonary blastomycosis 9 years after having been treated successfully with amphotericin B and responded satisfactorily to retreatment. Relapse of blastomycosis after adequate treatment with amphotericin B is apparently uncommon. However, published reports include relatively few patients who have had long-term follow-up.


Cigar inhaling.

Cigar inhaling. Carboxyhemoglobin concentrations were compared in 3 groups of outpatients who had inhaled cigarettes in the past. Group 1 consisted of 16 current nonsmokers; group 2, 24 inhaling cigarette smokers; group 3, 10 inhaling cigar smokers. An arterial blood sample was analyzed for carboxyhemoglobin and hemoglobin, and oxygen saturation was calculated and measured. Mean +/- SE carboxyhemoglobin concentrations were 1.0 +/- 0.1, 4.6 +/- 0.5, and 8.4 +/- 1.4 per cent, respectively, for the 3 groups (P less than 0.005). Although calculated oxygen saturation values were not significantly different, measured oxygen saturation values were 96.7 +/- 0.7, 93.0 +/- 1.0, and 88.4 +/- 1.8 per cent, respectively (P less than 0.025). Hemoglobin concentrations in smokers were higher than in nonsmokers (P less than 0.001). This study indicated that cigar smokers who intentionally inhale have higher carboxyhemoglobin concentrations and lower measured oxygen saturation values than cigarette inhalers. This may be even more detrimental to their health than cigarette smoking.


A preliminary study of the effect of a vibrating pad on bronchial clearance. The effect of vibration (41.0 +/- 5.4 Hz; 2 mm amplitude) on the clearance of lung secretions was ascertained in 10 patients with chronic bronchitis who complained of difficulty in raising sputum. Vibration was applied to the back for one hour by an electrically driven pad while the patients reclined on a couch with the trunk at 45 degrees to the vertical. Each patient had randomized control and experimental runs of 5 hours' duration that were identical in all respects except for vibration. The rate of clearance of secretions from the lung was assessed by serial whole lung counts after inhaling monodispersed tracer particles tagged with a gamma-emitting radioisotope (technetium-99m) and by sputum production. The mean rates of clearance and of sputum production were slightly higher during the vibration runs than the control runs but the differences were not significant.


The evolution of biochemical damage in the rat lung after acute cadmium exposure. Rats were exposed once to a polydisperse aerosol of 0.005 M cadmium chloride for 2 hours. Controls were saline-exposed rats and unexposed rats. Total extractable lipid, malate, lactate, isocitrate, and glucose-6-phosphate dehydrogenases were measured on the organelle-free cytosol from homogenized lungs at periods up to 10 days after exposure. The wet weight, dry weight, ribonucleic acid, and deoxyribonucleic acid content of the lungs were also determined. Ultrastructural appearances were studied at the same time intervals in a separate experiment. Total lipid content, lactate dehydrogenase, and glucose-6-phosphate dehydrogenase activities showed approximate doubling by the fourth day after exposure, this change coinciding with doubling of wet lung weight and total lung deoxyribonucleic acid content. Malate dehydrogenase activity showed a high peak 1 hour after exposure before decreasing to follow the pattern of lactate and glucose-6-phosphate dehydrogenase. The changes found may be a nonspecific reaction to lung injury, comparable with oxygen, ozone, and nitrogen dioxide. These results in Type II cell proliferation, which would enhance glucose-6-phosphate dehydrogenase content and resistance to peroxidation. Lipid accumulation could be a similar response. However, the initial elevation in malate dehydrogenase activity is more in keeping with a specific mitochondrial injury (with some ultrastructural support), perhaps with leakage of mitochondrial enzymes. This suggests that there may be more than one mechanism at work in the injury. It is significant that despite the marked structural and functional changes, none of the rats died after the exposure, which makes the injury a model worthy of further investigation.


Mechanisms of bronchial hyperreactivity in normal subjects after upper respiratory tract infection. Inhalation of histamine diphosphate aerosol (1.6 per cent, 10 breaths) produced a 218 +/- 54.6 per cent (mean +/- SE) increase in airway resistance in 16 normal subjects with colds compared with a 30.5 +/- 5.5 per cent increase in 11 healthy control subjects (P less than 0.01). There was no significant difference in mean baseline airway resistance between the two groups. Inhalation of saline produced no significant change in airway resistance in either group. Isoproterenol hydrochloride (0.5 per cent, 1 breath) or atropine sulfate aerosol (0.2 per cent, 20 breaths) each reversed and prevented the increase in airway resistance by histamine, indicating that the bronchoconstriction was caused by smooth muscle contraction and that post-ganglionic, cholinergic pathways were involved in the mechanism. In 6 subjects with colds, citric acid aerosol (10 per cent, 5 breaths) caused bronchoconstriction that lasted up to 30 sec after inhalation, a significantly greater effect than that observed in control subjects or in the same subjects after recovery (P less than 0.05). Prior inhalation of atropine aerosol (0.2 per cent, 20 breaths) prevented the bronchoconstriction after citric acid aerosol in all 6 subjects. The threshold concentration of citric acid that produced cough in 7 subjects with colds was significantly lower than that in control subjects or in the 7 subjects after recovery (P less than 0.05), suggesting that the exaggerated cholinergic response was due to a decreased threshold for stimulation of the rapidly adapting sensory receptors in the airways. We have provided evidence that respiratory viral infections that produce airway epithelial damage temporarily cause these subjects to develop more bronchoconstriction after inhaling smaller doses of histamine than do healthy subjects. The fact that atropine prevents this response and that the threshold to cough is temporarily decreased is compatible with our hypothesis that airway epithelial damage by infection exposes and, thus, "sensitizes" the rapidly adapting airway receptors to inhaled irritants, causing increased bronchoconstriction via a vagal reflex. Damage to the airway epithelium may occur as a result of mechanical factors, inhaled chemicals, and pollutants, such as ozone, infections, or perhaps as a result of the action of materials released endogenously (e.g., from mast cells, white blood cells, or platelets). "Sensitization" of rapidly adapting sensory receptors in the airways may be an important factor in asthma and in other diseases of airways.


Pulmonary mechanics after uncomplicated influenza A infection. Pulmonary mechanics were evaluated in 13 nonsmoking adults with acute, uncomplicated influenza A/Port Chalmers/73(H3N2) virus infection. Subjects had no evidence of lower respiratory tract involvement on physical examination. Viral and/or scrologic evidence of influenza infection was established for all subjects. Physiologic measurements included forced expiratory rates by spirometry and total pulmonary resistance (RT) measured at 3, 5, 7, and 9 cycles per sec by the oscillometric technique. Subjects were studied at time of acute illness and at 1, 3, and 5 weeks thereafter. Spirometric measurements were initially normal in all subjects and did not change significantly throughout the study. Elevated RT measured at 3 cycles per sec and an abnormal degree of frequency dependence of RT, determined by comparing RT at 3 cycles per sec to RT at 9 cycles per sec, were initially present in 10 of 13 subjects. All 7 of these subjects initially abnormal who were tested 7 days after the onset of illness had abnormal frequency dependence. At 3 weeks, 7 of the 10 subjects initially abnormal continued to have frequency dependence of RT. All but 2 subjects reverted to normal levels by 5 weeks. Frequency dependence of RT indicates that acute influenza infection produces uneven time constants in the airways. A generalized increase in peripheral airway resistance or localized compliance changes could account for these abnormalities. Because these abnormalities persisted well beyond the period of clinical illness, these data imply that asymptomatic mechanical dysfunction of the lungs is a frequent sequela to acute influenza A virus infection. RT measured by the oscillometric method was a suitable noninvasive method for detecting abnormal airway time constants in these subjects with acute upper respiratory diseases.


Closing volume in coal miners.

Closing volume in coal miners. Closing volume and closing capacity were determined in 82 working Appalachian coal miners and in a comparable group of control subjects. Abnormalities of closing volume and closing capacity were related to other measurements of pulmonary function. The relationship of smoking history, dust exposure, and presence of pneumoconiosis and bronchitis to elevations of closing volume and closing capacity was determined. It was shown that nonsmoking miners had elevated closing volume and closing capacity when compared to control subjects. Miners who were smokers or ex-smokers also had elevated closing capacity when compared to control subjects. Neither bronchitic symptoms nor the radiographic presence of pneumoconiosis were associated with an elevation of closing volume or closing capacity.


Influence of relative humidity on functional effects of an inhaled SO2-aerosol mixture. Lightly anesthetized guinea pigs were exposed to 1 ppm of sulfur dioxide (SO2) and 1 mg per m3 of sodium chloride aerosol, individually and in combination, at low and high relative humidities. At low relative humidity (less than 40 per cent) the aerosol was a crystal, at high relative humidity (greater than 80 per cent) a droplet. Exposures lasted one hour. Changes in pulmonary mechanical function characterized by an increase in flow resistance and decrease in compliance were seen only when the mixture was administered at high relative humidity. The effect is ascribed to absorption of the highly soluble SO2 into the droplet before inhalation.


The prevalence of farmer's lung in an agricultural population. Four hundred seventy-one persons associated with farming or dairy production were surveyed by means of a questionnaire for evidence of hypersensitivity lung disease due to inhalation of moldy hay or grain (farmer's lung). Of these, 172 were evaluated with spirometry, serologic studies, and chest roentgenographs. A history typical of the farmer's lung syndrome was given by 14 of the 471 subjects (3.9 per cent). Precipitating antibodies to Micropolyspora faeni were identified in sera from 2 of these 14 subjects (14 per cent), and spirograms were abnormal in 4 (28 per cent). The prevalence of farmer's lung in this community (i.e., 3 per cent) is comparable to that found in epidemiologic studies in Britain and Scotland. Farmer's lung disease may be an important occupational illness of dairy and cattlemen in this country, but the diagnosis may be overlooked frequently because of the lack of patient and/or physician awareness.


Estimating health risks in studies of the health effects of asbestos. Epidemiologic studies of respiratory cancer hazards associated with asbestos exposure in working populations should provide some estimate not only of whether an excess in cancer exists but of the magnitude of this excess. While most studies seem to be in agreement as to the existence of an excess, there is considerable disagreement as to its magnitude. For 11 studies, estimates of relative risk for respiratory cancer range from about 1.2 to 9.2. Four features of these 11 studies can be identified that account for some of the variation in results: some studies include workers whose exposure to asbestos was too recent to be likely to produce cancer by the end of the follow-up period, and results are diluted by the presence of these workers; in most studies, the wrong population was used for estimating expected numbers of deaths; in some studies, death certificates for the study population were corrected based on a review of other medical records, but then comparisons were made with expected deaths derived from uncorrected death certificates; finally, in most studies, level and duration of exposure is unknown, and this is clearly a factor that determines the magnitude of the respiratory cancer risk. For 6 of the 11 studies it was possible from published material to correct results roughly for the first 3 of these factors and much of the variation disappeared. Problems in the 11 studies reviewed here should be considered in planning and reporting on epidemiologic investigations in the future.


Presence of a bradykinin-like substance in pulmonary washings. Pulmonary washings were studied for the presence of bradykinin-like substances and the capacity for their formation and degradation. Bronchopulmonary lavage with saline was performed in anesthetized, exsanguinated Syrian golden hamsters with a cell yield of 99 per cent alveolar macrophages. In the presence of inhibitors of both kinin formation (hexadimethrine) and destruction (1,10-phenanthroline), immunoreactive kinin was found in bronchopulmonary lavage fluid (12.5 ng per 5 x 10(6) cells lavaged), washings of pooled macrophages (5.62 ng per 5 x 10(6) cells washed), and lysates of alveolar macrophages (3.97 ng per 5 x 10(6) cells lysed). Higher kinin concentrations were obtained by selective inhibition of kinin-destroying enzymes with phenanthroline. Inhibition of kinin formation with hexadimethrine alone rendered nearly all concentrations below the limit of detectability. These findings demonstrated that the capacity for kinin formation and degradation exists in pulmonary washings. The precise origin of this kinin and its forming and destroying enzymes (whether from the pulmonary alveolar macrophage, other sites in the bronchopulmonary tree, or plasma) is not yet known.


Indications for mediastinoscopy in bronchogenic carcinoma. In an attempt to formulate indications for mediastinoscopy, the histologic tumor type and the radiographic manifestations of the tumor were correlated with the occurrence of mediastinal node metastases in 121 patients who had potentially resectable bronchogenic carcinoma. Our results demonstrated that mediastinal metastases occur commonly in patients with central lesions irrespective of cell type, but that the histologic tumor type has a definite influence on the frequency of mediastinal involvement in patients with parenchymal masses or peripheral lesions. Our results also demonstrated that the absence of radiographic evidence of mediastinal involvement cannot be given strong consideration when selecting patients for mediastinoscopy, because almost 50 per cent of patients with mediastinal involvement did not have mediastinal widening on the chest roentgenogram. Our results, in conjunction with currently accepted principles governing the management of patients with bronchogenic carcinoma, have allowed us to propose a logical approach for the use of mediastinoscopy in the prethoracotomy evaluation of patients with potentially resectable lung cancer.


Rifampin and cell-mediated immune responses in tuberculosis. To estimate the potential adverse consequences of rifampin therapy on cell-mediated immunity in tuberculosis, we measured in vitro lymphocyte responses to phytohemagglutinin, concanavalin A, pokeweed mitogen, and in vitro and in vivo responses to purified protein derivative tuberculin. Thirty-seven patients treated with therapeutic combinations containing rifampin were compared with 13 persons who had never received the drug. After initial improvement, responses to phytohemagglutinin became depressed in patients receiving rifampin for periods of 4 to 24 months. No significant changes were noted in lymphocyte responses to concanavalin A or pokeweed mitogen. In vitro and in vivo responses to purified protein derivative tuberculin were not altered. Because a favorable therapeutic outcome was achieved in all subjects, we concluded that rifampin does not have clinically significant immunosuppressive activity.


The use of radioisotope techniques for the evaluation of patients with pulmonary disease. Although it is true that pulmonary perfusion scanning is generally accepted primarily in the differential diagnosis of pulmonary embolism, the introduction of regional ventilation studies with radioactive 133Xe, the use of the computer to provide quantitative data, and the advances being made in cardiovascular nuclear medicine indicate that nuclear medicine procedures will be used more and more in the evaluation of patients with a variety of lung and heart diseases. They have already proved of value in the following circumstances: (1) differential diagnosis of pulmonary embolism; (2) assessment of regional involvement in pulmonary parenchymal disease, including degenerative, neoplastic, and infectious diseases; (3) detection of bullous disease and the determination of the possible effectiveness of surgery; (4) assessment of the response to radiation therapy in patients with carcinoma of the lung; (5) detection of pulmonary venous hypertension in patients with mitral valve or left ventricular disease; (6) detection of cor pulmonale; (7) differential diagnosis of cyanosis in newborn infants.


Goodpasture's syndrome: two cases with contrasting early course and management. In 2 patients with hemoptysis and hematuria, Goodpasture's syndrome was documented by clinical presentation, demonstration of circulating anti-glomerular basement membrane antibodies, and demonstration of linear immunofluorescence along glomerular and alveolar basement membranes. One patient was considered to have progressive disease and was treated with prednisone and cyclophosphamide. During the subsequent 18-month follow-up period, clinical remission occurred with eventual disappearance of hematuria and detectable circulating anti-glomerular basement membrane antibodies. The other patient did not have active hemoptysis at the time of referral and no therapy was instituted. After 12 months of follow-up, hemoptysis remains quiescent but hematuria and positive circulating anti-glomerular basement membrane antibodies persist. Although therapy appears to have been particularly effective in one patient, the benign course of the other patient precludes premature enthusiasm for early intervention.


Exacerbation of porphyria during treatment of pulmonary tuberculosis. Several attacks of acute intermittent porphyria complicated the treatment of a patient with pulmonary tuberculosis. To determine whether the attacks were drug-induced, the ability of a variety of antituberculous drugs to induce (delta)-amino-levulinic acid synthetase activity in a rat liver model was assessed. Pyrazinamide was found to be capable of significantly inducing amino-levulinic acid synthetase activity; the other antituberculous drugs caused either slight or no induction of amino-levulinic acid synthetase. The data suggest that pyrazinamide was capable of causing an exacerbation of the patient's porphyria. Tuberculosis, by causing debility, may also have aggravated this patient's previously latent porphyria.


Computerized roentgenographic determination of total lung capacity. A computerized technique for measuring total lung capacity from radiographic chest films based on methods originally suggested by Barnhard and associates has been developed. Total lung capacity is automatically determined by tracing the margins of the lungs in both posteroanterior and lateral radiographs with a commercially available hypersonic coordinate digitizer. The results compare favorably with those obtained using a body plethysmograph. This simple, automatic procedure requires minimal training, is rapid, and can be easily implemented.


Gunshot wounds of the suprarenal abdominal aorta. A review of recent series of penetrating aortic injuries is presented. The highest mortality rates were found with injuries of the suprarenal abdominal aorta. Five patients with this injury, four of whom survived, are presented. Factors preventing rapid exsanguination in some patients are explained. Surgical management, including the controversy of arterial debridement, is discussed. The possibility of missing an aortic perforation at operation with five examples from the literature is pointed out.


Sciatic artery aneurysm: a case report including operative approach and review of the literature. A case of aneurysmal dilatation of a persistent sciatic artery is presented along with an operative approach allowing both adequate exposure of the aneurysm and the potential for proximal control of the feeding vessel in the pelvis. The embryologic origin of this residual vessel is discussed as well as the previous case reports of similar lesions.


Care of patients with hypocalcemia after parathyroidectomy. In this series of 56 patients diagnosed as having hyperparathyroidism, 37 per cent were found to have multiple gland involvement. The data seem to indicate that routine screening has increased the number of patients operated upon each year. Hypocalcemia in the postoperative period may be manifest by a variety of symptoms, but in general does not seem to affect the postoperative course. The postoperative low point of serum calcium seems directly temporally related to the highest preoperative levels-the higher preoperative levels take longer to reach lowest postoperative levels. Several techniques of management are described.


Colonoscopy and polypectomy.

Colonoscopy and polypectomy. Experience with 100 colonoscopies in 88 patients in a community hospital is presented. The instrument used was the F09000PL 165 cm ACMI colonoscope for the first 88 cases, and the F9A 160 cm ACMI colonoscope for the last 12. There were no complications. The preparation of the patient and the technique of colonoscopy and polypectomy are detailed. Indications and contraindications are outlined and discussed. Colonoscopy in this series has definitely saved 16 patients and possibly another 20 patients from laparotomy.


Near total pancreatectomy in the treatment of acute hemorrhagic pancreatitis. A case of near total pancreatectomy for acute hemorrhagic pancreatitis is presented. The procedure is highly recommended for severely ill patients, when biliary and gastric diversion have failed to arrest the inflammatory process, and retroperitoneal drainage has proved inadequate in removing the vasoactive polypeptides. These play a decisive role in the overall picture of shock.


Venturi insufflation oxygenation during nonintubated endolaryngeal microsurgery. Two hundred patients are reviewed in whom endolaryngeal suspension microsurgical procedures were performed under intravenous anesthesia and Venturie insufflation oxygenation without significant complication. The technique allowed the glottic space to remain free of cumbersome intraluminal apparatus. Arterial blood studies revealed that adequate oxygenation was achieved while normal pH and PCO2 was maintained. It is a technique which should be considered in microsurgical laryngeal procedures.


Pulmonary barriers to oxygen transport in chest trauma. The pathodynamics of respiratory insufficiency are based upon the impairment of movement of O2 from the atmosphere to the pulmonary capillary blood. In blunt chest trauma the mechanisms can be clarified in terms of mechanical barrier phenomena. Two barriers are identified. The first is the mass or gross lung-thorax complex and is determined by integrity of the chest wall and ventilation of the lungs. Impairments are manifested by reduced PaO2. The second is the micro complex of the alveolocapillary membrane. The disturbance is a combination of VA/Q alterations and increased diffusion barrier block and is manifested by reduced PaO2 and increased A-aDO2. These are summarized in Table 5. The degree of alteration in PaO2, and especially in A-aDO2, can distinguish between flail (loss of chest wall integrity) and flail plus contusion (VA/Q and a-c block). Management of chest wall-lung gross problems is well established and relatively successful. The micro barrier disturbance is more complex and difficult.


Long-term survival of patients with carcinoma of the esophagus in Puerto Rico. From 1950 to 1971 a total of 4,342 cases of carcinoma of the esophagus were reported to the Central Cancer Registry of the Puerto Rico Health Department. Fifty-eight patients with histologic proof of their diagnosis survived five or more years, for an absolute survival of 1.3 per cent. Neither location of the tumor or type of treatment made much difference in average survival. In fact, 20 of the 58 patients had metastasis or extension of the tumor to adjacent tissues at sometime in their clinical course.


The value of thoracoplasty before extensive unilateral resection for pulmonary tuberculosis. Among 24 patients who required extensive unilateral resection for tuberculosis, 17 underwent adequate thoracoplasty before resection and seven others received either no thoracoplasty before resection or an inadequate one. These two groups were comparable as to severity of disease and operative risk. The incidence of serious complications was 83 per cent in the latter group compared to 12 per cent in the former. While the number of patients in each group is too small for a statistically valid comparison, the results suggest that an adequate thoracoplasty before resection is of definite value in preventing pleural complications after extensive unilateral resection for tuberculosis.


Role of gastrin determinations in clinical surgery. Patients with recurrent ulcer without retained antrum and with a complete vagotomy will have a low gastric acid output. Those with incomplete vagotomy and gastric resection will have a fasting and histamine-stimulated gastric acid output which are normal' this is as though they had no previous gastric operation. Both groups of patients will have a normal fasting and postprandial serum gastrin. Patients with recurrent ulcer associated with retained antrum will have a fasting and histamine-stimulated acid output above normal. In the latter, fasting serum gastrin will be increased twice normal but not as markedly increased as found in Zollinger-Ellison syndrome. Patients with retained antrum will have a marked postprandial increase in serum gastrin about two times the fasting level. Those patients with this syndrome will have markedly elevated fasting and histamine-stimulated gastric acid as well as marked hypergastrinemia.


Current opinion on iliofemoral venous thrombectomy. Iliofemoral venous thrombosis is discussed and a technique of iliofemoral venous thrombectomy is presented. Operative phlebography is recommended. The personal recommendations of leading American vascular surgeons in treating the patient with acute iliofemoral venous thrombosis are presented. I recommend thrombectomy for phlegmasia cerulea dolens, and in previously healthy, young ambulatory patients with phlegmasia alba dolens who are seen within 48 hours following thrombosis and have failed to show clinical improvement after a trial of bed rest, elevation of the lower extremities, and intravenous heparin. The majority of patients seen with phlegmasia alba dolens will best be served with nonoperative treatment.


Effects of antibiotics on prevention of infection in contaminated abdominal operations. A prospective study was undertaken on 102 patients with massice intraperitoneal contamination from traumatic or spontaneous perforation of intestinal or pancreaticobiliary tract to determine the effects of combined systemic and intraperitoneal antibiotic administration on the prevention of the postoperative sepsis, intra-abdominal abscess formation and wound infection. Large doses of gentamicin and clindamycin were given parenterally before, during, and after the operation for five days. In addition, the peritoneal cavity and the abdominal incision were irrigated intraoperatively with antibiotic solution containing the same antibiotics. The drugs were given so as to provide a potent level of antibiotics during the operation and in the immediate postoperative period. The postoperative wound infection rate was 4 per cent, intra-abdominal abscess 2.9 per cent, sepsis 1 per cent, resulting in a total infectious complication rate of 7.9 per cent. This is a marked reduction in the incidence of infectious complications and compares favorably with the results from either parenteral or intraperitoneal therapy alone. Furthermore, no complications were encountered due to this method of therapy. These results do not indicate that antimicrobial drugs be given prophylactically to all surgical patients, but they strongly suggest the advantages of combined systemic and intraperitoneal antibiotics in the management of patients with massive intraperitoneal contamination.


Role of emergency laparotomy in acute pancreatitis. Two hundred and thirty-seven cases of acute pancreatitis were reviewed and the etiology and prognostic features were analyzed. The following were found to adversely affect prognosis: female sex, old age and low blood pressure, jaundice or disorientation on admission. The results also indicate that if a patient survives the first attack of acute pancreatitis, he is unlikely to have an overwhelming fatal attack later on. One hundred and ninety-four patients were treated conservatively, with a mortality rate of 8.8 per cent and morbidity rate of 20 per cent. Thirteen patients were semi-electively operated on for biliary tract disease with no mortality. The remaining 30 patients underwent emergency laparotomy. The mortality in this latter group was 23 per cent and the morbidity rate was 77 per cent. These results suggest that emergency laparotomy should only be advised for specific indications. In addition, our data suggest that if laparotomy is performed for acute pancreatitis, the peripancreatic area should not be drained unless an abscess or pancreatic necrosis is present.


Anomalous location of the papilla of Vater. The location of the papilla of Vater in the third (horizontal portion) of the duodenum is a rare finding. In this report the thirty-eighth case is described and the available world literature is reviewed.


Internal and external supravesical hernia. Two cases of supravesical hernia are described. One was a rare posterior internal supravesical hernia discovered only at exploratory laparotomy after exhaustive but fruitless diagnostic procedures. The surgical  anatomy of anterior and posterior internal supravesical hernia is discussed and a simplified terminology is proposed.


Acute appendicitis in the geriatric patient. Fifty patients over 60 with proven acute appendictis are analyzed with regards to the preoperative clinical picture, diagnosis, operative findings and management, and the role of associated medical diseases.


Management of asymptomatic carotid bruits. Asymptomatic carotid bruits may originate in the internal carotid artery from atherosclerotic plaques which predispose to strokes in certain individuals over the age of 40. Certain recently developed noninvasive screening tests are helpful in determining the hemodynamic significance of these bruits, which ultimately require arteriography to determine precise diagnosis and significance. If hazardous lesions are demonstrated, carotid endarterectomy may be recommended for selected patients without multiple risk factors to prevent the occurrence of ischemic cerebral episodes.


Management of foot conditions of the diabetic patient. Twenty-five years' experience in the management of the diabetic foot is reviewed. Diagnostic aids and surgical principles which proved worthwhile in preventing major amputations are stressed.


Increased risk for spondylitis stigmata in apparently healthy HL-AW27 men. Evidence for ankylosing spondylitis was sought by clinical, radiologic, and ophthalmologic examination in HL-A W27-positive men, aged 18 or older, selected from a tissue-donor population. Back pain of 3 months' duration or longer (P less than 0.05), back stiffness, restricted lumbar flexion and chest expansion, sacroiliac erosions (P less than 0.05) and sclerosis, and ophthalmologic sequels of anterior uveitis were found more often in the 24 men of the W27 group than in a control group of 31 men lacking this antigen. Based upon accepted criteria, 3 W27 persons had definite spondylitis and an additional 3 W27 persons and one control subject had findings strongly suggestive of spondylitis (P less than 0.05). This striking frequency, if extrapolated to the general population, would place approximately 1 of 4 W27-positive men at risk for this disease.


Unilateral proptosis due to monostotic fibrous dysplasia. An unusual case of monostotic fibrous dysplasia causing proptosis in a 30-year-old man is reported with an apparently sudden onset and progression over a 1 month period. Methods of investigation and the establishment of a diagnosis are detailed.


Retinal hemorrhages in the newborn.

Retinal hemorrhages in the newborn. There were 100 babies examined within 24 hours of birth. Retinal hemorrhages were found in 35% of newborns. Birth trauma from forceps delivery and prolonged labor were thought to be significant. Babies born by cesarean section were less likely to have retinal hemorrhages. Asphyxia was also found to be significant. The role of low plasma prothrombin levels, the vacuum extractor and increased intracranial pressure were discussed as etiologic agents. According to Von Noorden in 1973 there appears to be no positive correlation between hemorrhage of the macula and the occurrence of strabismus.


Intermittent exophthalmos due to orbital varicose vein accompanied by varicose veins of the legs. A case of intermittent exophthalmos due to orbital venous veins in which there were associated varicose veins of the legs is described. Of note was the preservation of vision despite the long history (28 years) of the disturbance.


Adrenochrome staining of soft contact lenses. A clinical case of adrenochrome staining of a soft contact lens is described. A laboratory model for such staining is then described in which a soft lens is boiled in a basic, saturated solution of L-DOPA. Repetition of this process in fresh solutions of L-DOPA can achieve any level of black staining desired. The lens can then be made transparent by immersing it in a 3% solution of hydrogen.


Unusual ocular presentation of sarcoidosis. A patient is presented with a probable sarcoid granuloma involving the surface of the optic disc. Systemic steroid administration resulted in a resolution of the fundus changes and return of normal vision. Although ocular sarcoidosis is usually manifested by anterior segment inflammation, it is apparent that it may also produce proliferative lesions of the optic nerve.


Variations of primary angle closure glaucoma: precise diagnosis and treatment. Differential diagnosis of the three presently recognizable variations of primary angle closure glaucoma is briefly reviewed. Precise diagnosis is important, since medical and surgical treatment varies according to type.


Transorbital removal of intracranial foreign body in middle fossa. A limited access to the middle cranial fossa can be achieved by an opening created in the posterior portion of the lateral orbital wall. An intracranial foreign body was removed by this method.


Modified trabeculectomy incision for c ataract extraction. Preservation of the fistula site from previous filtering surgery for glaucoma at the time of cataract surgery is difficult. A modified trabeculectomy incision for cataract extraction following successful filtering surgery for glaucoma is described.


Crosslinkage theory of senile cataracts. The theory of crosslinkage as a cause of aging of all living organic tissues has withstood the test of time. Nearly all the past theories of senile cataract formation contain elements involving a potent crosslinking agent. Therefore crosslinkage may now be recognized as the common denominator in past theories of senile cataracts. This paper proposes that crosslinkage is the mechanism for senile cataract formation.


Alpha-chymotrypsin glaucoma.

Alpha-chymotrypsin glaucoma. The postoperative course of 141 eyes in 115 patients undergoing uncomplicated intracapsular cataract extraction was reviewed. Alpha-chymotrypsin as used in our institution did not increase the percentage of eyes developing significant postoperative ocular hypertension. Smaller amounts of enzyme and a shorter waiting period than have heretofore been advocated are adequate for clinically effective zonulysis and appear to be protective against "enzyme glaucoma." Indeed, we found that among non-diabetics, those receiving enzyme experienced a lower incidence of postoperative ocular hypertension than did those not receiving enzyme. The one factor in our series related to an increased percentage of postoperative hypertensive responses was diabetes mellitus.


Clinical experience with hydrophilic lenses in monocular aphakia. Fifty monocular aphakes were fitted with hydrophilic aphakic contact lenses. Twenty-seven (54%) could wear the lenses for one week or more without removal. Eighteen (35%) could wear the lenses from 1 to 7 days. Five (10%) could not be fitted. No serious complications were noted although corneal epithelial problems and neovascularization needed careful observation. No case of clinical infection, conjunctival or corneal was noted.


Senile (atonic) entropion.

Senile (atonic) entropion. The etiology and surgery of senile entropion are reviewed. Many of the presumptive causes of this clinical entity including the vague neurological etiology which caused it to be labeled "spastic" have been found baseless, and the explanation of the elder Fuchs, later confirmed by Duke-Elder, that the cause of senile entropion is due to degenerative tissue changes has been found to be more logical and more compatible with the anatomic findings. There have always been two methods of surgical repair of senile entropion: (1) unwinding the lid by resection of horizontal strips of skin or skin and muscle, and (2) by resection of vertical spindles and triangles of tissue to tauten the lids horizontally. I prefer the latter technique.


Corneal thickness in glaucoma.

Corneal thickness in glaucoma. The central corneal stromal thickness of patients with open angle glaucoma, secondary glaucoma (the majority aphakic), or a history of unilateral acute angle closure glaucoma were measured and compared with the stromal thickness of a group of normal patients. In open angle glaucoma, there was a small but significant increase in the average stromal thickness. This thickness increase was, in all likelihood, due to an abnormal function of the endothelium in this disease since the level of the intraocular pressure did not seem to be a factor. There was no correlation between stromal thickness and duration of the glaucoma or type of anti-glaucomatous medication. Most cases of secondary glaucome, controlled medically or not, had markedly increased corneal thickness, again, most likely, due to endothelial damage rather than to level of intraocular pressure. After an angle closure attack, permanent damage to the cornea was found to be rare.


Mooren's ulcer: two cases occurring after cataract extraction and treated with hydrophilic lens. Two patients developed Mooren's ulcer following cataract extraction. The first case was complicated by ocular trauma 8 years prior to surgery and by vitreous loss at the time of surgery. The second patient underwent cataract extraction without complication. Surgical trauma may have been the inciting factor in the development of these ulcers. Both patients experienced dramatic relief of ocular pain following the application of hydrophilic lenses. There was no apparent alteration in the course of the disease in either case. The use of hydrophilic soft lenses is suggested for symptomatic relief of the severe ocular pain experienced by patients with Mooren's ulcer.


Further experience with trabeculectomy.

Further experience with trabeculectomy. Trabeculectomies performed on 33 eyes were compared to 28 standard filtering procedures done at the same institution during a 4 year period. The success rates in the two groups of patients whether white or black were statistically comparable, 92% in the trabeculectomy group and 77% in the standard filtering surgical group. Only cases of phakic open angle glaucoma, chronic angle closure and combined mechanism glaucoma were considered. Cases of secondary glaucoma, previous surgical failure and aphakic nonpupillary block glaucoma did uniformly poorly. When trabeculectomy was performed with "enhanced cyclodialysis" early results in a few cases were successful. The incidence of flat anterior chamber and cataracts with permanent reduction in visual acuity was significantly less in the trabeculectomy group than in the standard filtering procedure group. These results support previous studies which support trabeculectomy as successful as standard filtering procedures with the advantage of having fewer permanent serious complications.


Surgical treatment of congenital nystagmus in patients with singular binocular vision. Operative treatment of congenital jerk-type nystagmus with ocular torticollis in patients with single binocular vision is discussed. The mechanism causing the head turn as well as the methods used in measuring the head turn and the selection of surgical procedures to correct it are analyzed. The results of 7 cases operated upon for this condition are presented.


Analysis of the total bile acid distribution in human intestinal aspirates by gas liquid chromatography. A method for the quantitative determination of the total bile acid content of human intestinal aspirates is presented. This method was applied to duodenal samples from ten normal subjects and distal jejunal samples from seven of these subjects. Enzymatic and radioactive monitoring of the procedures utilized yielded recoveries of 89 to 100 percent of bile acids.


Interpretation of cerebrospinal fluid proteins by gel electrophoresis. The use of polyacrylamide gel electrophoresis (PAGE) for the separation of proteins in cerebrospinal fluid (CSF) results in greater definition than does a "routine" method such as cellulose acetate electrophoresis. Unconcentrated CSF is easily separated into as many as 18 bands by the use of PAGE. By means of a modified PAGE method described in this paper, unconcentrated and untreated CSF is quickly and conveniently analyzed for protein constituents. This modification involves a continuous buffer environment, a pore-size concentration gradient and CSF in amounts of 0.1 to 0.4 ml. Sucrose addition is not necessary in this procedure. Whereas most central nervous system (CNS) disease states do not yield consistently distinctive protein patterns, some diseases, such as vascular disease, infectious meningitis and some metastatic tumors, yield significantly altered patterns. It is suggested that the chief value of CSF protein electrophoresis at the present time is to follow the course of a CNS disease.


Analysis of the conjugated bile acid distribution in human intestinal aspirates using gas liquid chromatography. The conjugated bile acid pattern was evaluated in intestinal aspirates of five normal subjects and five patients known to have an abnormal bile acid distribution. The glycine/taurine (G/T) ratios for total bile acids were determined by gas liquid chromatography (GLC) and by enzymatic assay using 3-hydroxysteroid dehydrogenase (STDH). By both methods G/T ratios in normal samples approximated 3.0 as previously reported. A discrepancy between ratio values obtained by the two methods was found in patient samples. It is suggested that the presence of keto bile acids in patient aspirates correlates with this discrepancy. The G/T ratios for individual bile acids were obtained by GLC. The G/T ratio for cholic acid was higher than previously reported. Recovery studies showed that a loss of taurocholic acid in the extraction procedure employed did not account for the high G/T-cholic acid.


Bence jones proteins: nature, metabolism, detection and significance. The nature of Bence Jones proteins is developed by a review of the pertinent literature. This is followed by a discussion of their metabolism and catabolism under normal and abnormal clinical conditions. Various methods for the detection of Bence Jones proteins are critically reviewed and the significance of these proteins in various disorders is assessed.


Biochemical aids in the diagnosis of Parkinson's disease. Degeneration of dopamine (DA) containing neurons in the basal ganglia of Parkinsonian patients causes a reduction in cerebrospinal fluid (CSF) concentrations of the principal metabolite of dopamine, homovanillic acid (HVA). Not only are steady state HVA levels depressed, but there is substantial diminution in the rate of HVA accumulation in CSF during the oral administration of probenecid, a drug which inhibits HVA transport from the spinal fluid compartment. Two methods for the measurement of HVA in human CSF, employing fluorometry or gas liquid chromatography-mass spectroscopy, are described and the results compared in patients with Parkinsonism as well as other central nervous system disorders.


Xanthogranuloma in adults.

Xanthogranuloma in adults. Nine cases of cutaneous xanthogranuloma in adults are reported. These lesions were histologically indistinguishable from the xanthogranulomas in infants and children (juvenile xanthogranuloma), and, like those in the young, they were not associated with abnormalities of serum lipids. Unlike juvenile xanthogranuloma, however, in our small sample there was no concomitant involvement of the eye in adult xanthogranuloma.


Laboratory diagnosis of parasitic and fungal diseases of the central nervous system. This review is presented to bring attention to those fungal and parasitic organisms that have been associated with central nervous system (CNS) infection and to offer an approach for handling their laboratory diagnosis. Treatment of the cerebrospinal fluid (CSF) to yeild best results on direct smear examination and culture are discussed. Culture procedures and staining methods to be done are given in chart form. Those immunologic tests useful in supporting the diagnosis of fungal or parasitic CNS infections are also included.


Comparison of three methods for plasma fibrinogen. Three plasma fibrinogen methods are presented based on (1) clottable protein assay by Biuret reagent, (2) measurement of clot absorbance and (3) thrombin time. These methods show good correlation and adequate precision on normal subjects as well as heparinized plasmas. The effects of interference owing to hemolysis, lipemia, bilirubin, heparin and fibrinogen degradation products are discussed briefly.


Hereditary hemorrhagic telangiectasia with cerebrovascular malformations. Three cases of hereditary hemorrhagic telanglectasia (HHT) with cerebrovascular malformation are presented. Previous reports of HHT have given little attention to its association with cerebrovascular malformation, despite frequent neurological symptoms in patients with HHT. Eleven other cases of HHT with neuropathologic or radiographic evidence of cerebrovascular malformation have been reported in the literature. We think that this association may be more frequent than previously suspected. The subtlety of the symptoms in HHT is stressed, and it is suggested that patients with cerebrovascular malformation be examined carefully for HHT, and vice versa.


Diabetic neuropathy, A review of clinical manifestations. Diabetic neuropathy in some form or other afflicts a majority of patients with diabetes mellitus. Neuropathic disturbance of sensory, motor or autonomic nerves may occur singly or in combination. Cranial nerve and other mononeuropathies generally resolve spontaneously. Autonomic neuropathy which can result in orthostatic hypotension, gastroparesis diabeticorum, nocturnal diarrhea, atonic bladder and impotence, although chronic, may wax and wane in clinical severity. Neuritis, disesthesias and painful sensory neuritis may resolve with good diabetic control; on occasion, diphenylhydantoin has been of therapeutic benefit.


Successful management of lichen myxedematosus. Report of a case. Radiation therapy led to local resolution of a case of lichen myxedematosus, which, to our knowledge, is the first reported successful treatment of the disease by radiation therapy. Radiation therapy is only the second therapeutic modality that is effective in the treatment of lichen myxedematosus. We propose specific criteria for the diagnosis of lichen myxedematosus to facilitate future studies into the nature of this disease.


Gamma globulin inhibition of fibrin clot formation. Myeloma gamma globulins have been reported to interfere with fibrinogen-fibrin conversion. A patient with multiple myeloma is described with a gamma globulin IgG1lambda concentration of 11 g per dl, prolonged thrombin time and poor clot retraction. Purified gamma globulin from the patient's serum and from normal serum caused prolongation of the thrombin time and reptilase clotting time assays in both normal plasma and in solutions of bovine fibrinogen. In addition, fibrin clots formed during the thrombin time assays were found to be ultrastructurally abnormal. This data suggests that the interaction of gamma globulin in the polymerization of fibrin may, in at least some cases, be due to nonspecific protein interaction.


Delayed purpuric reaction following superficial dermabrasion. A hemorrhagic reaction of unknown cause can occur approximately five weeks after superficial dermabrasion of tattoos. This reaction may lead to alarm in the patient and possibly to increased scarring the area treated. Intralesional corticosteroid injections have sped resolution. It is wise to forewarn patients of this potential complication of tattoo dermabrasion.


Parotid space tumors of non-salivary origin. A review of 700 parotidectomies showed that 98 procedures were performed for parotid space tumors of non-salivary origin. The clinical presentation in this group of patients did not differ significantly from the larger group of salivary tumors except for a higher incidence (12%) of the former in the younger age group. Of the 98 cases, 54 proved to be lymph node tumors, both neoplastic and inflammatory and 44 were tumors of various somatic origins. Among the latter group, bone and joint tumors, vascular lesions and some connective tissue tumors may be recognized preoperatively. Generally, however, the entire group of non-salivary tumors can be distinguished only intra-operatively, if at all. Correct recognition may lead to variations in operative techniques and extent of resection.


Civilian arterial injuries.

Civilian arterial injuries. During 1968-1973, 122 patients with 126 arterial injuries were treated. In 94 instances (90 patients), these injuries involved extremities. Systolic blood pressure was below 90 mm Hg upon admission in 55.6% of all patients and 37.7% of those with injuries to arteries of the extremities. The decision for operative exploration and repair of arteries of extremities was based largely on clinical grounds (shock, loss of pulse). Preoperative arteriography was needed infrequently, while operative angiography was nearly routine. Although several cases of late revascularization or traumatic thrombosis of renal artery have been reported, hypertension complicates the postoperative period, and early, aggressive approach is essential. Mortality was 10.6%, from aortic injuries. There were no deaths among patients with arterial injuries distal to inguinal ligament or thoracic outlet. The amputation rate from reconstruction failure was 1.1%, none occurring in the last 3 years of the series. The high patency rate and lack of evidence of pulmonary embolization suggest that associated venous injuries be repaired routinely. Arterial injuries represent ideal lesions (normal arterial wall with excellent run-in and run-off). Prompt treatment of shock and early, proper management of patients' mechanical disruptions will salvage many lives and most limbs.


Meckel's diverticulum.

Meckel's diverticulum. One hundred and ninety surgically documented cases of Meckel's diverticulum encountered at the Mayo Clinic during a 51-year period, 1920 through 1971, are reviewed. In 39 patients, the diverticulum was left undisturbed. In 51 patients, the diverticulum was the primary surgical disease, and, in 100 patients, the diverticulum was removed incidentally. The clinical features are presented as well as the surgical considerations. Meckel's diverticulum is a relatively frequent development anomaly with eccentric manifestations, and its surgical management has intrigued physicians for over 350 years. Dr. Charles W. Mayo stated, "Meckel's diverticulum is frequently suspected, often looked for, and seldom found."


Burn morbidity: a followup study of physical and psychological disability. Fifty-one burn patients were studied in a retrospective manner to determine the effects of the burn injury on their ability to return to their pre-burn physical and social status. The results of this study indicate that: 1) 79% of the patients were able to return to work or school, though 45% required a change in work and 25% were not able to continue with their peer groups in school; 2) the average time of disability was 6 months; 3) there was a significant psychological morbidity as demonstrated by self-confessed depression, juvenile delinquency and divorce. There is a need for awareness of these problems so that proper counseling can be offered to the burn patient and his family both during his hospitalization and after discharge.


The effects of femoropopliteal vein graft failure on limb function. Twenty-one patients were followed for an average of 40 months following occlusion of femoropopliteal vein grafts. Serial recordings of the resting ankle pressure index and treadmill walking time were correlated with the patient's clinical status, and compared to the preoperative values. Graft failure resulted in a return to preoperative status in ten of 11 limb salvage patients. There were 5 amputations, 3 died of unrelated causes, and 2 were subsequently improved by further reconstructions. At last followup, 3 of 10 patients who were operated on for claudication were unchanged, 6 were improved, and one became worse. In no case did graft failure result in the development of advanced ischemia. Femoropopliteal graft failure did not have a significantly adverse effect on limb function or survival in patients presenting with claudication, nor did it complicate the subsequent course of patients in whom the initial aim was limb salvage.


Carcinoembryonic antigen (CEA) as a prognostic and monitoring test in clinically complete resection of colorectal carcinoma. The prognostic and postoperative monitoring capabilities of the CEA assay were compared to pathological staging of the operative specimens, clinical followup including endoscopy, radiology and scanning techniques, as well as DNCB skin testing and laboratory enzyme determinations (alkaline phosphatase and transaminase). A total of 46 patients with curative resection for colorectal carcinoma were studied. This included 23 patients with recurrent tumors compared to 23 long-term survivors without signs of recurrence at the time of the study. Preoperative CEA determinations were a good prognostic tool comparable to pathological staging of the specimen. Post operative CEA monitoring was the earliest sign of recurrence in 14 of 23 patients and was positive at the time of recurrence determined by other methods in 20; it was negative in only three cases. The incidence of false positive results among the non recurrent group became a lesser problem when repeated elevated values were required before considering the patient as having a recurrence. From these data, it seems reasonable to propose the use of a second-look operation in patients with maintained elevation of circulating CEA and no clinical signs of tumor presence, if we are to treat recurrence at an early stage. Chemotherapy would be an alternative way to deal with this problem, since the absence of clinical signs in general correlate with small bulk of tumor which at this time may be more susceptible to chemotherapeutic agents.


Primary carcinoma of the appendix.

Primary carcinoma of the appendix. Primary adenocarcinoma of the appendix is rare and less than 200 cases are on record. The present material consisted of 20 cases collected from different hospitals. The cases are described in respect of sex and age-distribution, symptoms, treatment and prognosis. Of 7 patients with malignant mucocele, 6 subjected to appendectomy only, were still alive 5 years after the operation. Of 12 patients with colonic type of adenocarcinoma, 3 had been treated with appendectomy only. Of these, 2 were still alive 5 years after the operation. The remaining 9 patients had undergone right hemicolectomy. Only one of them was alive 5 years after the operation. A compilation of a further 39 cases garnered from the literature, however, showed that 60% had survived at least 5 years after right hemicolectomy, compared with 46% after appendectomy alone. Appendectomy alone is probably a sufficiently radical operation for malignant mucocele provided the tumor has not grown through the submucosa and that it is confined to the tip of the appendix. Right hemicolectomy is indicated for the colonic type of adenocarcinoma.


Evaluation of catheter placement in the treatment of venous air embolism. Venous air embolism is a potential complication of many surgical, therapeutic, and diagnostic procedures. Aspiration of air via a catheter placed in the superior vena cava or right atrium or placed in the pulmonary outflow tract and pulled through the right heart chambers had been advocated for the treatment of venous air embolism. In this study, three catheter positions were analyzed to determine which was best for removal of gas after induction of massive venous air embolism in dogs. In 18 dogs, 9 of which were suspended by their forelegs to simulate the sitting position used in posterior fossa exploration and 9 of which were supine, a Swan-Ganz catheter was placed in the right atrium, right ventricle, or pulmonary artery. A measured amount of air was injected into the left jugular vein and syringe aspiration of the air was attempted through the catheter. In the group with the catheter in the pulmonary artery, aspiration was continuous while the catheter was withdrawn through the right heart chambers. The amount of air aspirated varied widely among the three catheter positions, and no one catheter position proved superior to the other two.


Mechanical circulatory assistance with intra-aortic balloon counterpulsation for major abdominal surgery. Intra-aortic balloon counterpulsation (IABC) provides effective mechanical circulatory assistance (MCA) in many patients with cardiac disease characterized by low cardiac output and/or myocardial ischemia. The intra-aortic balloon pump (IABP) has been used almost exclusively in the care of patients with cardiac disease as their primary medical disorder. This report presents use of the IABP in three cases where cardiac disease was present, but abdominal pathology necessitating urgent surgical intervention was the primary medical concern. Experience with these three cases suggest that operative and early postoperative use of IABC in patients with documented heart disease undergoing major non-cardiac surgical procedures may reduce the high incidence of cardiac complications.


Attempted retrograde cannulation of the ampulla: a probable cause of mass in the pancreas. Two patients developed a focal mass in the head of the pancreas presumably following attempted endoscopic retrograde cholangiopancreatography (ERCP). These lesions grossly mimicked carcinomas of the pancreas. In one case a radical pancreatoduodenectomy was performed because of the misleading gross findings. A focal mass in the pancreas following ERCP may develop due to asymptomatic pancreatitis caused by the procedure.


Microaggregate formation in stored human packed cells: comparison with formation in stored whole blood and a method for their removal. Experiments were performed to compare the formation of microaggregates in stored human whole blood (WB) with that in stored packed cells (PC) and also to compare the effectiveness of standard blood transfusion filters with dacron wool (Swank) micropore transfusion filters in removing such microaggregates. After 5, 10, 15 and 20 days of storage SFP and debris weights of PC's were considerably greater than those of matched WB samples. Passage of either WB or PC's through standard blood transfusion filters resulted in small decreases in SFP and debris weights. Passage of either WB or PC's through dacron wool (Swank) transfusion filters led to striking and highly significant decreases in both SFP and debris weights. When stored PC's were diluted to the same hematocrits as their corresponding WB samples, SFP remained considerably elevated above those of the WB samples. On the basis of this research, it is concluded that centrifugation of blood during component separation leads to a significant increase in microaggregate formation over and above that which progressively occurs during storage and that the risk of pulmonary microembolization during transfusion with stored PC's is greater than that during WB transfusion. For this reason, dacron wool (Swank) filters should always be used when PC's are being transfused.


Incidental splenectomy: a review of the literature and the New York Hospital experience. 981 consecutive splenectomies at The New York Hospital were reviewed. 18.9% were removed incidental to some other procedure, either to facilitate exposure or because of uncontrolled bleeding from capsular tears. The primary operation with which this was most frequently associated was gastric resection for peptic ulcer disease, accounting for 20.5% of the spleens so removed. Conversely, the incidental splenectomy was noted in only 0.91% of all gastrectomies and 1.4% of all left colectomies designated as nonradical procedures. It is therefore seldom a necessary procedure. Incidental splenectomy is more frequent when midline abdoiminal incisions are employed, less frequent with paramedian or left rectus splitting incisions. 85% of the spleens removed incidentally were grossly and microscopically unremarkable; lacerations most probably result from excessive manipulation rather than pathological changes predisposing to rupture. The postoperative morbidity and mortality is discussed and is felt to be increased significantly by the incidental splenectomy.


Pedal vasomotor tone following aortofemoral reconstructions: a randomized study of concomitant lumbar sympathectomy. A prospective randomized trial was undertaken to evaluate effects of lumbar sympathectomy as an adjunct to reconstructive surgery of the lower limb. The objective of this study was to assess the early postoperative effect of these procedures on pedal vasomotor tone. A pedal arterial resistance index (PARI) at rest was derived from the ratio of the ankle-digit systolic pressure gradient and pedal blood flow measured plethysmographically. Studies were performed on 32 normal individuals and pre- and postoperatively in 29 patients undergoing aortic reconstruction, 12 of whom were randomly chosen to have lumbar sympathectomy. The mean postoperative PARI in 17 patients who had reconstructions alone was 42+/-7 (S.E.M.) units which approximated the preoperative PARI (43+/-9 units) and normal control values (45+/-6 units). In contrast, 12 patients who had a concomitant lumbar sympathectomy had a significant reduction in the postoperative PARI (8+/-1 units, Pless than 0.005). These initial results indicate that the addition of lumbar sympathectomy to an aortic reconstruction may enhance blood flow to the foot by significantly reducing outflow resistance.


Diagnosis and surgical treatment of mediastinal parathyroid tumors. Experience and problems in the localization, diagnosis and surgical treatment of mediastinal parathyroid tumors are reported. Arteriography, pneumomediastinum and, especially, selective blood withdrawal with assay of parathyroid hormone, have proven valuable to the authors. Scintigram, intravital staining methods and venography are less productive. Retrosternal parathyroid tumors that can be removed from a Kocher incision should not, for practical reasons, be classified with the mediastinal tumors. The authors recommend the one-phase operation. If, after an intensive search of the neck and behind the sternum, no tumor has been found, it is advisable to incise the sternum step by step and revise the anterior mediastinum in the same session.


Fresh and cultured thyroid gland: survival and function after implantation. Isogeneic or allogeneic thyroid glands were implanted into thyroidectomized recipeint rats. These grafts, either fresh or cultured, were placed in hamstring muscle pocket or under the renal capsule. Survival and function of the grafts were evaluated by: restoration of normal levels of serum thyroxine, weight gain, kidney transamidinase (a thyroxine-induced enzyme), and histological appearance of re-excised implants. A isografts, fresh and cultured, functioned well as ectopic thyroid glands, though restoration of normal serum thyroxine levels was more rapid for the fresh implants. Fresh allografts functioned transiently but then failed due to rejection. No function was detected for cultured allografts, and rejection was seen histologically. The rat thyroid allograft therefore differs from the rat parathyroid allograft, which often can function for several months despite histological evidence of rejection. Maintenance in tissue culture prior to implantation does not appear to alter the longterm immunogenicity of either organ.


Lumbar sympathectomy in end stage arterial occlusive disease. Sixty-one patients had lumbar sympathectomies performed for end stage occlusive vascular disease manifested by gangrene of less than one-half of the foot, ulcerating ischemic lesions, rest pain or rapidly progressive markedly limiting intermittent claudication. The operative procedure was standardized to permit removal of the lowermost preganglionic fiber at the level of the crus of the diaphragm and the ganglionated chain to the crossing of the iliac vessels. The immediate postoperative mortality was 6.5% from cardiac causes. Over all improvement rate was 60% while early amputation rate was 40% for the entire group. Those patients with rest pain had the poorest prognosis with an amputation rate of 53%. The results are compared to other groups and factors of patient selection, anatomy of the sympathetic chain in relation to operative technique, physiology of decentralization versus devervation are discussed. The procedure is worthwhile in patients who are not candidates for arterial reconstruction who are faced with the prospect of early amputation.


Renovascular hypertension from renal artery compression by congenital bands. Renal artery compression by fibromuscular bands containing sympathetic nerves and ganglia was encountered in 3 of 75 patients with renovascular hypertension. The hypertension was successfully managed by resection of the bands. The absence of mortality and morbidity dictates that the "stenotic" area of the renal artery be explored, especially in children and adults with minimal angiographic evidence of visceral atherosclerosis, before proceeding with a bypass graft to the renal artery.


Basal and meat extract plasma gastrin before and after parietal cell vagotomy and selective gastric vagotomy with drainage in patients with duodenal ulcer. Basal and meat extract stimulated plasma gastrin (PG) levels and basal and stimulated gastric acid secretion were evaluated pre and postoperatively in duodenal ulcer patients who underwent parietal cell vagotomy without antral drainage (normal duodena) (PC, n=32) or selective vagotomy with drainage (pyloric stenosis) (SV +P, n=11). Before operation, both groups had comparable basal PG values of 52+/-13 pg/ml (PCVP) AND 51+/-18 PG/ML (SV+P), while the peak gastrin level to meat extract stimulation was 173+/-40 pg/ml for the total group of patients. After both operations basal PG levels increased (107+/-18 pg/ml (PCV) and 152+/-45 pg/ml (SV+P) and the gastrin response to meat extract stimulation was augmented after PCV, while the response after SV+P was the same as before operation. Patients with PCV often demonstrated an acid response following meat extract stimulation (3.6+/-0.9 mEq HC1/hr), and pentapeptide stimulation (18.8+/-2.0 mEq/hr) while patients with SV/P showed a minimal response (1.3+/-1.2 mEq HC1/hr meat extract), and 10.7+/-1.8 mEq/hr pentapeptide stimulation. The comparatively intact acid response in the PCV patients may augur a high ultimate recurrence rate.


Aspiration pneumonia: experimental evaluation of albumin and steroid therapy. An experimental model using an ex vivo perfused ventilated canine pulmonary lobe was used to study aspiration pneumonia. After intrabronchial acid instillation, the lobe weight tripled, air way pressure and pulmonary artery pressure doubled, and intrapulmonary shunting increased from 5.5% to 53.4%. If large quantities of albumin were added to the lobe perfusate 5 minutes after intrabronchial acid instillation, weight gain, air way and pulmonary artery pressure, and intrapulmonary shunting were unchanged from control levels. If large quantities of steroid were added to the lobe perfusate 5 minutes after intrabronchial acid instillation, the lobe weight doubled but air way pressure and pulmonary artery pressure, and intrapulmonary shunting were not significantly different from control values. It is surmised that intrapulmonary acid aspiration causes an immediate and marked changed in pulmonary capillary permeability. Albumin administration by counteracting this permeability change, and steroid administration by modifying the permeability change, are both beneficial following acid aspiration.


Influence of hemorrhage on adrenal secretion, blood glucose and serum insulin in the awake pig. A study was performed to quantitate the adrenal medullary and cortical response to hemorrhage in awake animals bled at different rates and to relate these responses to simultaneous changes in blood glucose and serum insulin. A series of awake  pigs were bled either slowly or rapidly of 30% of their calculated blood volume. Infusions of exogenous epinephrine were performed in an additional series of unbled animals and infusions of epinephrine plus hydrocortisone were similarly performed in an additonal series. Increase in blood glucose and epinephrine secretion rate following hemorrhage were found to be significantly dependent upon the rate of initial hemorrhage. Cortisol secretion was found to rise significantly during and following hemorrhage in both rapidly and slowly bled animals. Serum insulin levels remained at baseline levels during shock, despite the presence of significant hyperglycemia. In unbled animals infused with epinephrine at rates comparable to those measured in shock, elevations in blood glucose were markedly lower, shifting to the right of the dose-response curve during hemorrhage. Simultaneous infusions of cortisol and epinephrine resulted in a dose-response curve which did not differ significantly from that following infusion of epinephrine alone.


Reoperation for recurrent thoracic outlet syndrome. Recurrent thoracic outlet syndrome that requires reoperation accounts for 1% of first rib resections. Symptoms in a series of 30 patients were mainly neurological and consisted of pain and paresthesia involving the neck, shoulder, arm, and hand and were severe and unrelenting. Recurrence of symptoms ensued from one month to seven years following initial rib resection, with the majority appearing within the first three months. Nerve conduction velocities were diminished to an average of 51 m per second, well below the normal of 72 m per second. Reoperation was required after a period of extensive physiotherapy and muscle relaxants. The high posterior thoracoplasty approach is recommended for all reoperations, as it gives better exposure to achieve safe neurolysis of the plexus and complete excision of the regenerated periosteum and posterior rib remnant, which were present in almost all patients. Results of reoperation were gratifying, and postoperative nerve conduction velocities were improved to an everage of 66 m per second.


Revascularization of the septal artery.

Revascularization of the septal artery. The septal artery has been infrequently considered for bypass grafting due to its apparent inaccessibility. Twelve patients have recently been found to have a large single obstructed septal artery that supplied an area of left ventricle great enough to justify revascularization. A review of 100 normal arteriograms showed that 30% (30/100) of the patients had a septal artery of sufficient size to sustain a graft. Early restudy of 8 of the 12 patients who received septal bypasses showed all grafts to be patent and functioning well.


Thoracic aneurysmectomy utilizing direct left ventriculofemoral shunt (TDMAC-heparin) bypass. Use of a temporary heparin-coated ventriculofemoral shunt in 2 patients in the successful management of traumatic aneurysms of the descending thoracic aorta is described. Safe and effective bypass protection can be achieved by direct ventriculofemoral diversion when cannulation of the left subclavian artery or ascending aorta is hazardous. The use of a heparinized shunt bypass without systemic anticoagulation considerably simplifies the operation.


Pulmonary valvulotomy under inflow stasis for isolated pulmonary stenosis. One hundred ten patients were operated upon between 1961 and 1972 for isolated pulmonary stenosis by the inflow stasis technique. Analysis of the preoperative and postoperative clinical and catheterization data define the role of inflow stasis as an acceptable method of pulmonary valvulotomy except in relieving stenosis due to a dysplastic pulmonary valve. Patient ages ranged from 2 days to 36 years. All underwent preoperative catheterization and 69 (63%) were restudied postoperatively. Mean preoperative and postoperative peak systolic gradients were 93 and 23 mm Hg, respectively. Mean valve areas before and after operation were 0.38 and 1.10 cm2/m2. Operative mortality was 3.6% (4 patients), and there was 1 late death. Two of the dead were children 2 and 9 days old, respectively. Four patients required reoperation for residual gradients; 2 had dysplastic pulmonary valves. The overall results were excellent or good in 78%, fair in 15%, and poor in 7%. Patients with dysplatic pulmonary valves were in the poor or fair group, and it is recommended that the inflow stasis technique not be used for this type of pulmonary stenosis. The excellent surgical exposure, adequate time for valvulotomy, low morbidity, and freedom from problems of cardiopulmonary bypass are reasons for continued use of this technique for treatment of selected patients with pulmonary valve stenosis.


Cerebrovascular blockade associated with thoracotomy and its prevention with a platelet inhibitor. Dogs subjected to a thoracotomy in which a rib-spreading retractor was employed developed filling defects in the cerebral microcirculation attributable to obstruction by microemboli. These changes were not observed in control groups and could be prevented in the experimental group by pretreatment with RA233, a platelet inhibitor. It is possible that microembolic-related complications of operations and trauma, such as pulmonary insufficiency, might be ameliorated by the use of platelet inhibitors.


The extracorporeal pump filter--saint or sinner? An arterial line filter can become a grave source of platelet and fibrin destruction, with widespread deposition on the filter to form a membrane across the mesh, as proved by careful scanning electron microscopy. The same filter, when subjected to the low flows of the cardiotomy line, was well tolerated and served a very useful function. There was a 260% improvement in platelet counts and a 170% reduction in chest drainage when the arterial line filter was not used, perhaps through elimination of a degree of consumptive coagulopathy. Neurological changes did not occur in the absence of the arterial line filter, and operative mortality was 4.8% (5 of 103 patients).


Contralateral recurrent myxoma of the heart. Nineteen recurrences of a left atrial myxoma have been reported in 16 patients. This paper deals with the removal of a right ventricular myxoma three and one-half years following excision of a left atrial tumor. Because of the possibility of recurrence, postoperative follow-up of all patients with intracardiac myxomas is mandatory.


Vertebral osteomyelitis. Still a diagnostic pitfall. Vertebral osteomyelitis is still a diagnostic problem. Nonspecific symptoms (low-grade fever, malaise, and weight loss) may dominate. Specific infections may be suggested by the history, and the diagnosis may be reinforced by a transient response to antibiotics. The patient may have symptoms resulting from a secondary paravertebral abscess. Even with fever, back pain, and point tenderness over the vertebral column, the correct diagnosis may not be considered. Predisposing conditions include drug addiction, instrumentation of the infected urinary tract, bacteremia from other causes, or previous back surgery. Diagnosis is made by roentgenographic studies and isolation of the causative organism from blood cultures or from the infected area. Staphylococcus aureus is the most common pathogen, although other microorganisms may be responsible. Intensive intravenous antibiotic treatment appears to be curative, without surgical debridement, external stabilization, or porlonged oral administration of antibiotics.


The Jewish Hospital of St. Louis therapeutic grand rounds no. 13. Cushing disease. Although several effective therapies for Cushing disease have been demonstrated, associated complications, side-effects, and production of adrenal insufficiency indicate the continuing need for a completely satisfactory treatment. Of the surgical approaches to the adrenal gland, total adrenalectomy offers the most predictable amelioration, but is necessitates lifelong replacement and augmentation therapy and can be followed by progressive sella enlargement and hyperpigmentation. Drugs can inhibit adrenal steroid biosynthesis or selectively destroy the zona fasciculata. Inhibitors can be overwhelmed by endogenous ACTH increases, and cause variable electrolyte changes and side-effects. The adrenocorticolytic drug (o,pDDD) is slow in onset, irreversibly destroys adrenocortical reserve, and is poorly tolerated in the gastrointestinal tract. Conventional pituitary irradiation is unpredictably effective in only half of the cases, but is not often followed by the serious neurologic sequelae and hypopitiutarism observed after implantation and heavy particle therapy. Selective hypophysectomy via modern techniques is relatively new, but apparently offers a direct, and possibly, definitive therapeutic option in this disorder.


Normal renin uremic hypertension. Study of cardiac hemodynamics, plasma volume, extracellular fluid volume, and the renin angiotensin system. Studies were undertaken in 33 uremic patients with or without hypertension, 11 normal subjects, and 15 essential hypertensive patients to assess cardiac hemodynamics, plasma volume, extracellular fluid volume, and peripheral renin levels. Cardiac output and intraarterial blood pressure were measured and peripheral vascular resistance index calculated. These studies suggest that uremic hypertension with normal renin values and hypervolemia is hemodynamically sustained by an increase in peripheral resistance rather than by an increased cardiac output. The renin angiotensin system plays a secondary role as compared to overexpansion in the genesis of hypertension in normoreninemic uremic hypertension.


Pituitary tumors and hyperprolactinemia. Hyperprolactinemia was demonstrated in eight of nine patients with clinical evidence of pituitary tumors without acromegaly or Cushing syndrome. Hourly sampling for 24 hours disclosed elevation of serum prolactin concentrations, whereas, measurable serum growth hormone levels were found rarely. Although eight of these patients were hypersecreting prolactin, only four of them were lactating. Prolactin secretion was characterized by moderate hourly fluctuations of serum levels and absence or blunting of the normal sleep-related augmentation of secretion. Patients with the highest serum prolactin concentrations tended to have the largest pituitary tumors, as indicated by pneumoencephalography. In two patients followed-up with serum prolactin determinations after treatment, a fall in serum prolactin concentrations correlated with clinical improvement. Future study will hopefully establish the value of serum prolactin determinations in following tumor growth before and after pituitary ablative therapy.


Serum bile acids in primary biliary cirrhosis. Fasting serum bile acid levels were measured by gas-liquid chromatography in 56 patients with primary biliary cirrhosis. Of these, 52 (93%) had increased levels (greater than 2mug/ml), including 14 of the 18 with normal serum bilirubin concentrations. The four patients with normal bile acid levels had early lesions as judged by histological and clinical criteria. With progression of the disease, as indicated by the histological features of the lesions, total bile acid levels increased, and the ratio of serum cholic-to-chenodeoxycholic acid decreased. Ratios of serum cholic-to-chenodeoxycholic acid below 1 occurred predominantly in patients with advanced or terminal disease. These studies suggest that serial measurement of serum bile acids may aid in the evaluation of primary biliary cirrhosis.


Mycobacteriosis in patients with malignant disease. Mycobacteriosis was found in 59 patients with malignant disease in a five-year period from 1968 to 1973. Thirty patients (51%) had mycobacteriosis that was caused by atypical mycobacteria. The most frequent organisms were Mycobacterium kansasii and M fortuitum. The most frequent tumors associated with mycobacteriosis were squamous cell carcinoma of the head and neck, testicular carcinoma, and lung carcinoma. The only predisposing factor was treatment with cancer chemotherapy. Mortality due to mycobacterial infections was most frequently associated with those infections caused by M tuberculosis. Although mycobacteriosis is relatively uncommon in cancer patients, if it is present, atypical mycobacteria should be looked for because, in these patients, these organisms cause more than 50% of mycobacteriosis.


Echinocytes and acquired deficiency of plasma lipoproteins in burned patients. Spiculated red blood cells (RBCs) (echinocytes) and decreased levels of plasma lipoproteins developed concomitantly in severely burned (more than 35% body surface burned) patients. The RBCs were characterized as flat cells with spicules evenly distributed over the surface, and the erythrocyte lipid content was slightly increased. No evidence of excessive hemolysis was found, although modest shortening of RBC life-span could not be excluded. Development of echinocytes presaged a poor prognosis similar to that observed with acanthocytosis in cirrhosis. Striking decreases in plasma alpha-lipoprotein, cholesterol, and phospholipid values were observed and could be explained in part by loss of alpha- and pre-beta-lipoproteins through damaged microvasculature as these were recovered from blister fluid. Decreased plasma lipoproteins and echinocyte development appeared to be temporally related; the degree of echinocytosis correlated with decreases in plasma lipid values and plasma protein values, but no causal relationship can be inferred because of the multiplicity of changes in severely burned patients.


Is audit relevant to the medical wards of a teaching hospital. The initial purpose of an experimental program of close personalized supervision of ward patients by attending physicians in addition to house staff in a teaching hospital was to determine whether such personalized care would raise the quality of care and lower the cost and length of stay. By subjective measurements, an improvement in the quality of care was perceived. However, neither length of stay nor hospital charges were reduced when compared to a control population. Moreover, the data suggest that auditing the length of stay and hospital charges does not necessarily measure the quality of medical care.


Myokymia and facial contraction in multiple sclerosis. Continuous unilateral facial myokymia and facial contraction occurred in a patient with multiple sclerosis and there was subsequent resolution of these abnormalities. I compare abnormal facial movements of this type with those caused by other neurological diseases and discuss the possible mechanism of myokymia in diseases of the central and peripheral nervous systems.


Wegener granulomatosis with aphasia.

Wegener granulomatosis with aphasia. Wegener granulomatosis, a necrotizing granulomatous vasculitis that characteristically involves the respiratory tract and the kidneys, may affect the nervous system. Despite the relative frequency of neurologic manifestations, there has not been a single report of Wegener granulomatosis manifesting as a cerebral vascular accident. Our patient had limited Wegener granulomatosis with aphasia as the symptom that was observed first. A dramatic recovery occurred after corticosteriod and cytotoxic therapy.


IgA deficiency and autoimmune hemolytic disease. A case of familial selective IgA deficiency associated with autoimmune hemolytic disease is reported that illustrates the therapeutic implications when these two entities coexist. Immunoglobulin screening is recommended for patients with AHD who require blood transfusions, in order to identify IgA-deficient patients who may have anti-IgA anaphylactic reactions.


Tricuspid regurgitation following inferior myocardial infarction. Tricuspid regurgitation developed in two patients after inferior wall myocardial infarction. Neither patient had preexisting valvular heart disease or evidence of endocarditis, and neither had suffered chest trauma. Because abnormalities in right ventricular function may occur after inferior infarction, and because other known causes of tricuspid incompetence were not present, we postulate that these patients developed valvular regurgitation from dysfunction of the papillary muscle complex controlling tricuspid valve function, a mechanism similar to that proposed to explain mitral regurgitation seen with inferior wall ischemia.


Malignant myelosclerosis.

Malignant myelosclerosis. Malignant myelosclerosis, as described by Lewis and Szur, is characterized by an acute, rapidly fatal illness, with anemia, leukopenia, thrombocytopenia, myeloblasts in the blood, and a "dry tap" on bone marrow aspiration. This entity has been only rarely reported in the American literature. We report three additional cases of myelosclerosis. The patients were 70, 37, and 46 years old with a survival of eight weeks, six weeks, and 11 months, respectively. Bone marrow biopsy specimen showed fibrosis in tow with increased reticulum fibers and blast cells in all. At autopsy, the spleen and liver wereinfiltrated with leukemic cells. In two cases, the lymph nodes were involved. Extramedullary erythropoiesis was also seen. We believe that malignant myelosclerosis is best interpreted as an acute myeloproliferative disorder sharing features with acute leukemia and agnogenic myeloid metaplasia.


Platelet function and coagulation in patients with Wilson disease. Sixteen patients with Wilson disease (hepatolenticular degeneration) were studied from the hemostatic point of view, particularly with regard to platelet function. Five of the patients had a mild bleeding tendency that was characterized by easy bruising. Moderate thrombocytopenia was observed in three of the five bleeders and in two of the others. One bleeder was thrombocytotic and hyperfibrinogenemic. Bleeding times, platelet retention and prothrombin consumption were abnormal rarely. However, 15 of the 16 patients had some abnormality of platelet aggregation: one when adenosine diphosphate was added to platelet rich plasma, three when epinephrine was added, and the remainder when collagen was added. The collagen abnormalities were delayed or absent aggregation (five patients, four of whom were bleeders) and absence of a change of shape (12 of the 16 patients). Platelet aggregation was completely normal in only one patient.


Heinz body hemolytic animea. "Bite cells" -a clue to diagnosis. Morphologically abnormal red blood cells were noted on routine Wright-stained peripheral blood smears of two patients with Heinz body hemolytic anemia. The abnormal cells had the appearance of having had a piece bitten and are, therefore, termed "bite cells". In the two cases presented, these bite cells led to the suspicion of oxidative hemolysis, which was demonstrated in each case. Both patients were being treated with phenazopyridine hydrochloride when anemia developed. In each case, withdrawal of this drug led to correction of the anemia and the disappearance of bite cells from the blood.


Characteristics of pleural effusions associated with pulmonary embolism. Pleural fluid characteristics were analyzed in 26 patients with pulmonary embolism. All determinations were highly variable. A bloody effusion occurred in 65%, while clear fluid was found in 35%. White blood cell counts had a wide distribution of values; polymorphonuclear leukocytes predominated in 61% and lymphocytes in 39%. Less than two thirds of tested specimens were exudates by standard criteria. Only 27% of effusions had the "typical" pattern of bloody appearance, polymorphonuclear predominance, and characteristics of an exudate. Roentgenographically evident infiltrates occurred in 62% and were correlated with bloody pleural fluid (P less than .01), which suggests that infarction is not necessary for effusion to occur, but may account for a bloody appearance. The variability of these results indicates that there are no typical or diagnostic pleural fluid findings in pulmonary embolism.


Diagnostic problems in suppurative lung disease. Eleven of 48 (23%) patients diagnosed as having lung abscess or empyema presented diagnostic problems in the localization of infected material. All 11 patients were found eventually to have empyemas, all but one of which was complicated by bronchopleural fistulas. Difficulty in distinguishing abscess from empyema on a chest roentgenogram delayed diagnostic and therapeutic thoracentesis from 1 to 12 days. Pleural effusions were noted in all but one of the patients who did not initially have a bronchopleural fistula. In addition, once the bronchopleural fistula became established, the extension of the air-fluid level to the chest wall, the tapered borders of the air-fluid pocket, and the extension of the lesion across fissure lines were noted, in retrospect, to be suggestive of pleural localization. Delay in the evacuation of empyema fluid can lead to chronic complications and increased morbidity. Early identification and treatment of pleural effusions may avoid these diagnostic and therapeutic problems.


Nephrosclerosis postpartum and in women taking oral contraceptives. The condition of a patient with postpartum nephrosclerosis improved during heparin therapy. Review of the literature disclosed 29 other patients with the same histopathologic characteristics, eight of whom also recovered substantial renal function after anticoagulation therapy. Also reported is a patient in whom  renal failure occurred while she was taking oral anovulatory agents. Renal biopsy specimen showed the same histopathologic features, which raises the question of similar factors mediating the expression of this disease. We suggest a uniform terminology for this syndrome, either postpartum nephrosclerosis or nephrosclerosis in women taking oral contraceptives.


Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease. In a series of 320 consecutive patients referred because of precordial pain, the costosternal syndrome was found to be the underlying cause in 21, while in nine others, this syndrome was found to be coexisting with coronary heart disease. In our opinion, because of the current readiness to diagnose coronary artery disease, local causes for chest pain often are overlooked. The frequency of this syndrome is relatively high, both as a sole cause of chest pain and combined with coronary artery disease. Local injection of steroids was followed by improvement in the majority of our patients.


The various faces of diabetes in the young: changing concepts. Diabetes included several disorders associated with hyperglycemia. A difference in inheritance between the families of juvenile-onset- and maturity-onset-type diabetics, provides evidence for genetic heterogeneity. Heterogeneity of insulin responses to glucose was foung among nonobese patients with maturity-onset-type diabetes. Prospective studies in young patients have shown that glucose intolerance may not progress for as long as 22 years and that subnormal insulin responses to glucose have not decreased further, up to 12 years. However, patients who progressed to diabetes requiring insulin had insulin responses that were subnormal or below the control mean. None whose insulin responses exceeded this mean have decompensated. Thus, insulin response to glucose has prognostic implications. A tentative classification of diabetes in the young is proposed. There was a significant correlation between muscle capillary basement membrane width and known duration of carbohydrate intolerance.


Cardiac arrhythmias in acute central nervous system disease. Successful management with stellate ganglion block. Cardiac rhythm disturbances and ECG wave-form abnormalities have been described with CNS disease or injury in experimental animals and in man. Unilateral sympathetic stimulation has been shown to produce similar changes in ventricular repolarization and reduce the fibrillation threshold. A patient with a ruptured congenital aneurysm of the basilar artery developed an accelerating ventricular tachycardia associated with an episode of active intracranial bleeding. The rhythm disturbance proved refractory to all modalities of chemotherapy, including lidocaine, phenytoin, atropine, procainamide, digoxin, and propranolol. The ECG showed a repolarization abnormality similar to that described with left stellate ganglion stimulation. Left stellate ganglion block was carried out with 15 ml of 1% lidocaine. An effect on the tachyarrhythmia was noted in five minutes. By 15 minutes, the rhythm disturbance was abolished. The repolarization abnormalities improved over a period of hours. Successful management with left stellate ganglion block suggests that this form of therapy may have clinical application in arrhythmias associated with CNS disease.


Multifocal fibrosis involving the thyroid, face, and orbits. Our patient had fibrous thyroiditis with unusual facial and retroorbital fibrosis. Systemic fibrosis, which is more typical of the multifocal fibrosclerosing syndromes, was not evident. Treatment with steroid alone, surgery, and radiotherapy failed to maintain a remission. The combination of steroid and cyclophosphamide therapy appears to have been successful.


Sudden death caused by benign tumor of the atrioventricular node. Histologic study of the conduction system of the heart of a 16-year-old girl who died suddenly demonstrated a benign mesothelioma of the AV node, with almost complete replacement of the structure by the tumor. Teh past history was unremarkable, except for few syncopal episodes at 9 and 11 years of age and during pregnancy. Immediately postpartum, she developed a 2:1 AV block and intermittent complete AV block. Six weeks later, during diagnostic work-up in the cardiac catheterization laboratory, she died suddenly. Electrophysiological studies during this work-up disclosed complete AV dissociation, with normal QRS complexes. The block was proximal to the His-bundle recording site, with a normal H-V interval. Occasional syncopal attacks in young adults should alert the physician to the possibility of this diagnosis and lead to pacemaker insertion.


Evaluation of sclerosing cholangitis by endoscopic retrograde cholangiopancreatography. Endoscopic retrograde cholangiopancreatography contributed considerably to diagnosis or subsequent management of two cases of sclerosing cholangitis, In the first patient, sequential studies helped to determine the timing and nature of the surgical intervention that was used. In the second patient, the diagnosis was suggested by ERCP, which led to surgical exploration and biopsy of the common bile duct to confirm the diagnosis. The quality of the films obtained in both patients was excellent. We suggest that ERCP is a relatively noninvasive and accurate means of follow-up in cases of sclerosing cholangitis.


Sarcoid granulomatous nephritis occurring as isolated renal failure. A woman had clinically isolated renal failure caused by granulomatous sarcoid nephritis. At the onset of her illness, there were no historical, physical, or clinical features to suggest a definite causative diagnosis. After a renal biopsy specimen disclosed noncaseating epithelioid granulomas, a course of steroid therapy resulted in prompt disappearance of uremic symptoms and amelioration of her renal failure. Although leukopenia, delayed cellular immunity, and the response to steroids increased the suspicion that the patient had sarcoidosis, it was not until identical granulomas were obtained via mediastinal node biopsy that the diagnosis was confirmed. Sarcoidosis may occur as isolated renal failure. Renal biopsy is indicated to ensure early diagnosis and prompt treatment of this steroid-responsive lesions.