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Summary Attention has been directed to the need for constant vigilance in safeguarding young infants from accidentally ingesting small foreign objects that may become lodged in the esophagus. Prompt dislodgment and removal of these objects may avoid dire complications. If undiagnosed, their lodgment in the esophagus may give rise to respiratory symptoms and findings of a bronchitis unresponsive to any medication. This pulmonary involvement is dissipated after removal of the foreign body. The essentiality of roentgen-ray examination of the chest even in young infants with unexplained respiratory symptoms cannot be under estimated in the early detection of a foreign body arrested in the esophagus. In our case it was conjectured that the accidental ingestion of the foreign body (paper clip) that became lodged in the esophagus might have occurred during the neonatal period, whence the respiratory symptoms had their onset.

1. The three leading surgical approaches to the revascularization of an ischemic myocardium are those of: a.) Beck: heart surface abrasion; insertion of coarsely ground asbestos; occlusion of the coronary sinus to 3 mm.; and application of the pericardium and mediastinal fat pad to the surface of the heart; b.) Thompson: insertion of magnesium silicate, a non-absorbable and irritating substance into the pericardial sac. c.) Vineberg: implantation of the left internal mammary artery into the left ventricle via a myocardial tunnel. 2. Noteworthy and provocative animal experiments to show the validity of revascularization procedures have been carried out by: a.) Beck, who has shown that his technique adds a flow of 4.7 c.c. of blood per minute to an ischemic area of myocardium, and that the quantity of backflow decreases the mortality in dogs whose coronaries were subsequently ligated; b.) Vineberg, who has demonstrated anatomically functioning vessels of arteriolar size between the coronary circulation and the extracardiac source, these anastomoses protecting the animal from a myocardial infarction post ligation of one of the major coronaries. He has also artificially recreated the gradual occlusive process of atherosclerosis, and by exercise tolerance tests has shown that animals receiving his procedure midway in their ischemic decline from normal tolerance regain most of their exercise potential, whereas the controls continue to lose their original exercise tolerance. 3. The human results of coronary heart disease surgery are promising: there has been a substantial decrease in the pain of angina pectoris, and an increase in the work capacity of the coronary heart disease patient; and there is some evidence that the eventual life expectancy of patients undergoing surgery has been increased. 4. It is evident that the greatest difficulty in justly appraising the benefits of surgery to the coronary heart disease patient is the lack of proper control series anywhere in the literature.

The methods of therapy of skin cancer depend to a great extent upon two main factors: the skill of the operator and the type of lesion. One may choose whatever method one has in full command. The best may sometimes be a combination of methods. Both dermatologic and surgical judgment should be used. The points concerning the second factor, namely the lesion, are its characteristics such as: size, location, type, previous therapy, age, sex, physical condition and life expectancy of the patient. Another point to consider is whether the method of choice will be applied in the office or in the hospital.

A test strip has been developed for the detection of increased amounts of VMA and metanephrine in the urine. The strip is both inexpensive (less than 15 cents per strip) and simple to use, and is based on the color change of the LaBrosse spot test. It has an acceptable false positive incidence (1:400). It is suggested that such an approach would be useful in decreasing the mortality and morbidity associated with neuroblastoma in childhood, if such a strip were to be employed on a mass screening basis until the child is 7 yr of age. The test strip can also be currently used on a routine basis for follow-up examination in children with previously diagnosed neuroblastoma, and as a screening test for hypertensive patients with a potential for pheochromocytoma, regardless of age.

1. A new type of air cleaner, based on the electrostatic principle, is described. 2. This air cleaner is 100 per cent efficient in removing pollen from the air. 3. It is practically 100 per cent efficient in removing not only coarser but also fine dust particles from the air, including all chemicals, in liquid or solid form, except vapors and gases. 4. Its efficiency is much greater than that of the mechanical filter. It is easily washed and need not be replaced. 5. The electrostatic cleaner offers no problem in ventilation, for it does not influence the temperature or the humidity of the room in which it operates. It is not noisy. 6. A study of 61 patients seems to indicate that the electrostatic cleaner has a place in the treatment of certain refractory cases of Hay fever, pollen asthma, and bronchial asthma. Hay fever and pollen asthma patients, for the most part, experience symptomatic relief for the period during which they are confined to an air cleaned room.

Summary 250 urine specimens were classified into 7 categories on the basis of viable counts and the bacteria found. The results of 7 bacteriuria screening tests performed on the same specimens are presented in relation to this classification. Four rapid culture tests and a triphenyltetrazolium chloride reduction test proved capable of detecting specimens classed as ‘significant’ or ‘not significant’ bacteriuria with accuracies between 95 and 85%. For more accurate and subtle categorization of specimens, a calibrated drop viable count procedure is recommended.

SUMMARY A 15-year-old girl developed rhabdomyolysis with myoglobinuria after anaesthesia during which suxamethonium 250 mg was injected in divided doses. The laboratory methods used for demonstration of myoglobinuria are described. The study was extended to 63 patients submitted to minor surgery. Myoglobinuria could not be demonstrated in any of these cases whether or not anaesthesia included suxamethonium as a single dose of 1 mg/kg. Creatine kinase activity measurement in 25 of these patients disclosed no significant difference between pre- and postoperative values. It is concluded that myoglobinuria in the patient presented was due to an excessive dose of suxamethonium.

In this short paper an attempt is made to impress upon the medical profession the value of plaster-of-Paris as a form of immobilization. The article also stresses the fact that good plaster-of-Paris bandages are a definite requisite for satisfactory plaster work. It also stresses the fact that careful, thoughtful application of plaster is necessary in order to avoid complications. Some of the dangers are mentioned and instructions given to avoid these complications. The value of plaster as an adjunct in the office in the care of fractures or other joint conditions is also mentioned. The care and the making of the bandage are carefully described.

Forty-seven closed condylotomies were performed on osteoarthritic cases, the first 22 of which are reviewed in this paper. Attention is drawn to the different investigations in the literature on osteoarthritis of the temporomandibular joint. The patients requiring treatment suffered from different types of pain and clicking in the joint or from headache and various temporomandibular joint dysfunction symptoms. Every patient in this series had radiographic degenerative changes in the temporomandibular joint. After the operation the symptoms either totally disappeared or diminished considerably. The subjective satisfaction rate after the operation was high. Osteoarthritis is considered in this paper to be a primary degenerative, progressive affection of the joint which results in various joint derangements and reflectory muscle symptoms.

Middle ear neoplasm with imperforate drum is seldom seen due to the difficulty of the early detection. Two operated cases of such condition are dealt with in this paper. The first case is the adenoid cystic carcinoma of 17 years old male and the second is the glomus jugulare tumor of 59 years old male. The symptoms of these two cases are full feeling, tinnitus and hearing loss of the conductive type in the affected ear, which are not particular only to this condition. Each case showed 3 years' and 2 years' survival without recurrence after the operation respectively. The early detection of the middle ear neoplasm leads to the good result. So as to confirm this condition at an early stage of clinical course it seems very important for the otologist to keep in mind the presence of mass lesion of the middle ear and its clinical features. It is authors' opinion that the drum is natural anatomical barrier in this neoplastic condition of the middle ear. From this view point the clinical stage of the middle ear neoplasm is classified into three stages, which is described in this paper.

0 PERATIVE measures for the relief of leucorrhea aim to remove the infected endocervical mucosa, from which the discharge originates. This paper tabulates the results obtained by conical excision of the cervix in 130 patients operated upon at the Long Island College Hospital, between February, 1927, and May, 1930. Only proved cases of inflammatory cervicitis, and those followed for at least one year are included in this study. Trichomoniasis was excluded in cases of vaginal discharge recurring after operation. Viewed in the light of end-results, removal of the endocervix either by amputation, or the more conservative excision, has not proved entirely satisfactory. R. M. Rawls, in a series frpm the Woman’s Hospital, in which the technic of Emmett was employed, reported 60.7 per cent cured, 31.1 per cent improved, 7.1 per cent unimproved and 1.1 per cent as aggravated following operation. H. B. Matthews, employing the Sturmdorf technic in a series of 70 cases, recorded 70 per cent cured, 22.8 per cent improved, and 7.2 per cent unimproved. In a follow-up group of 75 patients from the Bellevue Clinic, operated upon by the Sturmdorf technic, F. W. Sovak tabulates 88 per cent cured, 4.7 per cent improved, and 5.3 per cent as unimproved. In this series of 130 cases, the Sturmdorf technic was used, although in the older patients and in those requiring extensive plastic operation, removal of the cervix was more radical. Catgut replaced silkworm for the inversion suture in restoration of the portio. Preoperative preparation consisted of thorough application of one-half strength tincture of iodine to the vulva, vagina, and cervix. Where curettage was performed, a quarter-inch iodine pack was placed in the cervical canal and retained during extirpation. In cases of prolapse, douches of bicarbonate of soda and boro-glyceride tamponade were employed for several days prior to operation. In this series of 130 cases, 103 or 79.2 per cent were cured, 23 or 17.7 per cent were improved, and 4 or 3.1 per cent received no benefit (Table I). In one of every five cases therefore the ultimate operative result was unsatisfactory. It is the purpose of this paper to analyze the causes of failure. Broadly speaking, leucorrhea, recurring after cervical operation may be immediate or late. In the latter instance, a symptom-free interval of several months is present and vaginal discharge results from reinfection

This paper deals with the matter of pathologic differentiation in lesions of the uterine cervix or body, which clinically are suspicious of cancer, i.e., those cases in which biopsy or diagnostic curettage is usually called for. While cancer will rarely be found where there is no clinical suspicion whatever of its presence, it is revealed in a not inconsiderable proportion of cases which clinically are only suspicious. In an even larger proportion such lesions will be found to be benign, so that a patient will be spared the misfortune of the unnecessarily radical treatment which would be entailed by a policy of operating “on suspicion,” or because of a belief that the suspicious lesion is precancerous. Most lesions which are precancerous, in the sense of predisposing to cancer, in themselves are easily curable by simple conservative measures. In the cervix, especially, pseudomalignant pictures are extremely common, especially with chronic inflammations and polypi, but, with few exceptions, the microscope will clear up the diagnosis and point the way to the proper treatment. These pseudomalignant lesions are discussed in the paper, more especially as they bear upon the diagnosis of cancer. As cases come to the gynecologist earlier, there will be an increasing proportion in which the microscope will be essential for making rather than merely confirming the diagnosis of cancer. In doubtful cases involving the endometrium, representing chiefly cases of uterine bleeding in women beyond thirty-five where an obvious cause is not present, the microscope is essential in a much larger proportion of instances. Follow-up studies have shown the general trust-worthiness of microscopic examinations after biopsy and diagnostic curettage, for the microscopic diagnosis, when made by a competent pathologist, is rarely belied by the operative findings or the subsequent course of the patient.

The practice of medicine is an art rather than a science because of its lack of constants. While many pathological processes present a high percentage of variables, only a few have a greater disparity of symptoms, signs, opinions and reports than ectopic pregnancy. It is this inconsistency that makes ectopic pregnancy so fascinating to study and, at times, so difficult to diagnose. We found in our series that only 7 per cent of the cases of tubal pregnancy followed a textbook pattern. Certainly most diseases present a more routinely typical picture than that. In the various reports on ectopic pregnancy that have been published in the past ten years many discrepancies have been noted. One wonders just how great these differences actually are. With this query in mind we have condensed most of the literature of the past decade. Naturally enough, we have been curious to find how our own statistics compare. For this reason we have inserted throughout this paper our results in three hundred consecutive surgical cases of tubal pregnancy occurring between Jan. 1, 1943, through Dec. 31, 1952. It was discovered during this study that no deaths occurred in the series during the decade under discussion. The majority of cases were treated at the Shreveport Charity Hospital while the remainder were treated in a private institution. Abdominal pregnancies have been excluded since they are of sufficient interest to warrant a separate examination later. We wish to emphasize that while this paper will list differences in the reports studied, we have no intention of theorizing as to their cause. To be sure, some of these differences will be unimportant, some are only apparent rather than actual, and an unfortunate few will be due to our inability to interpret correctly some authors' facts. Any discrepancy due to this human factor is obviously unintentional and represents one of the risks inherent in condensing material of this type.

The purpose of this report is twofold-first, to present a probable case of adiposity of the heart diagnosed clinically ; and secondly, to again direct attention in the differential diagnosis of unexplained cardiomegaly to this entity which, to the author’s knowledge, has heretofore been only a postmortem diagnosis. Such a presentation appears to be timely in view of the practically complete absence of a discussion on this subject in the literature and standard cardiology texts of the past one to two decades. This is all the more impressive at a time when the problem of obesity and its complications is of such vital concern to all practicing physicians. Almost every paper written by those internists and cardiologists who have recently reviewed the effects of obesity on the cardiovascular system makes no mention of this condition. In fact, in a comprehensive article entitled, “Unusual Forms of Heart Disease,” which appeared in a cardiology journal as late as October, 1954, the only reference to this entity was in the form of two words, “possibly obesity,” under the classification of “conditions precipitating or accelerating the development of the more usual forms of acquired heart disease.” As another manifestation of the obscurity of this condition nowadays, Dr. Paul White recently stated that although he had made mention of it in his textbook, he had never personally recognized such a case.2 One cannot help but agree with Burchell that many of those rarer cardiac conditions, which do indeed lend spice to the diagnostics of cardiology, could be all but forgotten, and possibly without loss, in the daily practice of medicine. His statement that unusual manifestations of common diseases probably mislead the physician more often than do unusual diseases, however, also holds much truth and import, particularly if a specific treatment is available as in the case of obesity.1 Like so many other unusual diagnoses, this condition, variously labeled as adiposity of the heart, cor adiposum, the fatty heart, lipomatosis of the heart, lipomatosis cordis and fatty infiltration of the myocardium, has had its cyclic periods of interest and popularity, but primarily as reports dealing with post-mortem findings. Among the last significant papers written on the subject, two appeared in the same volume of the Archives of Internal Medicine published in 1933.�’ ‘ The pathological findings in the fatty heart have been classically set forth by Corrigan and Saphir. In an analysis of the 58 necropsied cases reviewed with evidence of fatty infiltration of the myocardium, the usual site of the predominant infiltration was in the right ventricle.3 Others have confirmed this observation. The interventricular septum may be involved to the degree of producing an actual complete heart block.5 Frequently

I T is the purpose of this paper to emphasize again that the “fetal” adenoma or mixed tumor of the thyroid’ is a true neopIasm and that from it arise the Iarge majority of malignancies occurring in the thyroid. If a definite rehrtionship can be estabIished between feta1 adenoma and thyroid malignancy then the surgica1 remova of this common tumor of the thyroid whiIe it is yet benign becomes the obvious procedure for cancer prophylaxis with regard to this organ. The confusion surrounding the term “ adenoma” in thyroid Iiterature makes its definition imperative. The term “adenoma” means “benign epitheIia1 new growth” and its use in referring to the bosseIations or noduIes of oId coIIoid goiters is not correct or permissibIe. The adjective “feta1” is pureIy descriptive and is used to emphasize the simiIarity of the histoIogic picture of an adenoma and embryonic thyroid tissue. In this paper the term “adenoma” refers to those weII-encapsuIated ovoid or spheroida growths which arise in otherwise norma or in goitrous thyroid gIands (Fig. I). They most often are singIe but may be muItipIe, and vary in size from 2 mm. to IO cm. or more in diameter. They are freeIy movabIe, may displace the trachea or esophagus and frequentIy cause only mechanica symptoms. On cut section they show a thick fibrous tissue capsuIe which is often partIy hyaIinized or shows caIcification. The adjacent thyroid tissue is compressed, atrophic and forms a portion of the tumor’s capsule. Within the adenoma there often, if not always, is a fibrous tissue core, steIIate in appearance, surrounded by pyramidshaped Iobes of ceIIuIar tissue. Depending upon the tumor’s age, size and extent of

Summary 1. The first claim of the paper is a definite program of growth of the face expedited, retarded, warped or inhibited in consequence of constitutional ill health or disturbances in the endocrine pattern. 2. The second section of the paper ends with the claim that simple fleshy adenoid masses may interfere with the freedom of respiratory passage but do not necessarily have any association with physical debility or with the permanence of mouth habits. These conditions tend to cure themselves through the growth of the nasopharynx after the period when the pharyngeal tonsil becomes stationary, but a marked example at the age of forty-seven years is exhibited in photograph and contrasted with the normal condition of the throat. 3. The claim of the third section is the significance of allergy in its effect on the respiratory passages either in temporarily increasing the size of the adenoid mass or in producing a congestion of the nasal turbinates equally effective in causing obstruction of respiratory passages and thus producing mouth habits which in turn call for and impede the corrective attention of the orthodontist. 4. The general conclusions of the whole presentation are that the orthodontist has really a great and constructive interest in the anatomical form, in the growth pattern, and in the physiological state of the nasal passages, and it is impossible for him to attain the good results which he seeks so long as there is a center of disturbance in the neighboring area of the face reducing the efficacy of his procedures.

Intrauterine life, sustained only by two small arteries and a tortuous vein coursing through a long flexible cord, hangs by a very delicate thread. That fetal fatalities occur so seldom from cord complications seems incredible. Gradually, however, it has become more apparent that cord abnormalities are frequently involved in Nature's plan for "survival of the fittest," especially in view of Javert and Barton's 12 findings in early and late abortions. They found 35 per cent of the available cords for study to be abnormal and inconsistent with life, with torsion occurring in 15.3 per cent, looping in 5.7 per cent, and knotting in 0.9 per cent. As pregnancy progresses the incidence of knotting apparently decreases, while the incidence of looping (and probably torsion) increases, if we are to refer to Lundgren and Boice's 13 figure of 0.3 per cent for knotting and Atwood's 1 figure of approximately 25 per cent for looping in the viable stages of pregnancy. These percentages probably reflect the fact that the more serious cord disorders kill the fetus in the early stages of pregnancy, leaving the lesser, though no less potentially dangerous, disorders until later gestation. It is these abnormalities which occur after viability has been reached with which we are concerned in this paper. Intrauterine death from cord abnormalities most frequently involves anoxia of the fetus. Clementson 6 lists the general types of anoxia as anoxemic, histotoxic, cord obstruction, and anemic, the latter two being those in which cord complications may be directly involved. He further divides cord obstruction anoxia into the following causes: loops of cord about the fetus, prolapse of the cord, true knots, breech delivery with cord compression, and short cord. To this we might add torsion, new growths, and partial rupture of the cord with hematoma formation causing vascular obstruction. Anemic anoxia may be caused by complete laceration of the cord or its vessels with bleeding external to the cord's amniotic covering. Other sources of obstructive or anemic anoxia are so rare that their consideration is not warranted. It is the purpose of this paper to summarize briefly, in so far as is possible, the incidence, associated fetal mortality, influencing factors, and general considerations of cord anoxia; to present two additional cases; and to discuss methods by which our fetal salvage rate may be increased.

This paper presents the results of a random clinical trial designed to contrast megavoltage (4 MV linear accelerator) with conventional therapy (300–500 KV) in the radical treatment of bladder cancer. Two hundred and thirty-four patients were included in the trial and allocation to treatment was on a true random selection basis in accordance with the principles set out in Part 1 of this series of papers (Paterson 1958). It is concluded that subject to qualitative differences there is no strong evidence to suggest that the MV treatment is superior to the KV treatment.

1. 1. For the prevention of pregnancy I use a variant of the Graefenberg ring, viz., a silkworm gut ring consisting of 3 or 4 threads to which a short piece of silver thread is fastened in order to ascertain at any time by x-ray whether or not the ring is still in place. 2. 2. I have inserted a total of 866 rings in 329 patients, and a further 150 since the beginning of the writing of this paper. Some women have worn rings for more than 20 years—one patient for more than 27 years—the rings being changed every 9 to 12 months. 3. 3. The method is absolutely harmless. In the course of 28 years of experience I have not observed a single inflammation of any kind whatever, even in the presulfa and prepenicillin era. Histological examinations of the uterine mucosa immediately upon removal of the ring have never shown any inflammatory or other pathological changes; the examination of the tissue formed on the ring merely showed signs of foreign body reaction such as are formed after operation and which result from silk threads which have been sewn in. 4. 4. I have in no case used sulfa preparations or antibiotics. 5. 5. The ring method proved to be 25 times as safe as the diaphragm method. 6. 6. The inscrtion of the ring is practically painless and requires no anesthesia. After insertion the patient can immediately resume her usual occupation. 7. 7. The silver ring with its 1.3 per cent failures proved safer than the silkworm gut ring in its original form (2.4 per cent failures). In spite of that I have given up the silver ring for reasons mentioned in this paper. In recent years since I have formed the ring of 4 instead of 3 silkworm gut threads, and intertwined them thrice instead of twice, there have been no failures at all. In view of the fact that before that change, in about 5 per cent of the cases, the ring slipped out of place, I would recommend regular examinations in order to discover this in time for the ring to be removed and a new one inserted before conception occurs. 8. 8. No miscarriage occurred in those cases where pregnancy took place while the ring was in situ. No malformation of the fetus or placenta was seen in these cases. No cases of sterility have occurred after removal of the ring. All women who wished to become pregnant became so spontaneously without any treatment, generally within one to 4 months and in 2 cases within 6 months. 9. 9. In 28 years of experience I have not seen a single case of carcinoma of the cervix or the corpus in ring-wearers. 10. 10. Ovarian tumors and fibroids among ring-wearers were not more frequent than in other healthy women; I observed, among 329 women, 2 benign ovarian tumors and 6 fibroids, some of which appeared only several years after removal of the ring. 11. 11. No endometriosis occurred. 12. 12. No extrauterine gravidity occurred as a consequence of the ring. 13. 13. Increased and prolonged bleedings occur sometimes in the early stages of wearing the ring, but usually disappear within 2 to 3 months. There is usually a slight brownish secretion one or 2 days before and after menstruation. In some cases, on the other hand, I have observed a shortening of prolonged menstrual bleedings, probably for psychological reasons. 14. 14. In some women menstruation which previously had occurred only every 2½ to 3 months became perfectly normal while they wore the ring. 15. 15. In hypoplasia of the uterus the ring may stimulate growth. In one severe case I have seen gravidity after years of sterility. Further experience in this field is necessary. 16. 16. I had to remove the ring in only 2 of my cases; in one of them because of heavy menstrual bleeding and in the other because of recurrent slight intermenstrual bleedings. In both cases, the ring had been introduced about 8 weeks post partum. Although cases of this kind account for less than 0.25 per cent of the total, I recommend that the ring should not be inserted until 3 months post partum. For the majority of cases 2 months post partum is sufficient. 17. 17. The cause of the effectiveness is not known. Different possibilities are discussed in this paper; investigations are still being pursued in various directions.

Since the paper of Weiss and associates 1 reporting 9 cases of scleroderma heart disease, other authors have described new cases, making mention of the electrocardiographic changes found in such patients. However, most of these reports concern a small number of cases, and the electrocardiograms are not discussed in detail. † †After this paper was prepared, a new report by Windesheim and Parkin appeared. 23 Several electrocardiographic alterations have been described, all of them nonspecific. The purpose of this article is to report our experience with a larger series of patients, correlating the electrocardiograms with the clinical, physiopathologic, and morphologic findings.

In recent years a number of papers have been published indicating the advantages of the immunologic pregnancy test as a rapid and reliable method. This paper evaluates a new 3 minute pregnancy slide test based on the inhibition of agglutination of HCG-coated latex particles. Its accuracy and sensitivity were evaluated on random urine specimens from patients with normal pregnancies, abnormal pregnancies, and a group of nonpregnant women. The time post partum when the test became negative was determined. Several clinical cases demonstrate the importance of the test in diagnosis. The sensitivity lies in the range of 3 I.U. per milliliter. The test had an over-all accuracy of 95 per cent in the pregnant women studied, with a 98 per cent figure in pregnancy under 18 weeks.

tion of the aorta are to be found in the literature.3 � This paper describes such anomalies as they were found in two of our surgical cases, which showed unusual features not hitherto described in the literature available to us. These anomalies, although rare, are of practical importance with a view to differential diagnosis. The etiology of coarctation is still obscure. The two cases presented in this paper should be taken into account in any attempt to explain the condition on the basis of embryological considerations. The descriptions so far given in the literature stated that the right subclavian artery or the right aortic arch occurred distal to the coarctation.1’ 2� 8 We were unable to find a single report on a right subclavian artery or a double arch proximal to the coarctation. And it was precisely this condition which we found in the two patients to be described. Edwards4 recently described a case of Taussig-Bing complex with coarctation, in which the right subclavian artery arose proximal to the coarctation. In the first of our two cases the right subclavian artery arose from the aorta above the coarctation; in the second case the double aortic arch was localized above the coarctation. In both cases the coarctation was found opposite the insertion of the ligamentum arteriosum. Ca8e 1 :* ** M. V., female, aged 19. The onset of symptoms, in 1946, was characterized by pain in the chest, loss of weight and fatigability, which continued until a severe hemoptysis occurred in 1948. Investigation at the time failed to reveal any tuberculous process but a mediastinal tumor was demonstrable by X-rays. The patient was referred to us at the St. Antonius Ziekenhuis, Utrecht. The patient gave no impression of being very ill. The blood pressure determined in the arms was 150/90. Heart: slight systolic murmur. Pirquet tuberculin test: negative. Hematology normal. Fluoroscopy showed a tumor dorsal to the left main bronchus, The esophagus was displaced to the right. Tomography of the hilar region showed marked stenosis of the left main bronchus caused by the tumor. The presence of severe stenosis was confirmed by bronchography. Bronchoscopic examination showed that the bronchial wall was normal and that the stenotic part was still patent, Angiocardiography: apparently satisfactory filling of the tumor with contrast medium suggested a probable aneurysm or a highly vascular neoplasm. Another severe hemoptysis occurred during the patient’s stay in the hospital, this time causing what was considered vital danger. The blood pressure of 150/90 did not strike us as hypertension, and the possibility of coarctation was consequently not considered. An operation was performed in spite of an uncertain diagnosis. The thorax was opened (March 3, 1949; surgeon: A. G. B.), and numerous adhesions were separated without difficulty. The first striking feature was found in the fact that a right subclavian artery arose distal to the left subelavian artery. The right radial pulse was suppressed when this vessel was clamped. The artery extended

n the late 1950’s a tremendous increase in the incidence of staphylococcal pneumonia and empyema occurred throughout many of the I pediatric centers in the country. This increase was thought to have been caused by the emergence of antibiotic-resistant strains of bacteria [3]. Several papers appeared in the literature reflecting this changing pattern [4, 6, 71, and some strict rules for surgical management were advised in order to decrease mortality in this disease [6]. Formerly, this mortality ranged from a high of 100% in some series [l] to about 25% in other centers [5, 61. The generally accepted surgical routine was to insert a chest tube in all children who exhibited pleural fluid containing gram-positive cocci. This was followed frequently by conversion to open drainage with or without rib resection, and finally decortication if there was no definite improvement in two or three weeks and a captive lung was assumed to be present. Strict adherence to these principles brought the mortality down to around 10 or 12% [6]. Since about 1962, pleural empyema in children, particularly that due to staphylococci, has become less virulent, probably entirely as the result of newer antibiotic agents. Now certain transgressions can be taken from the older rules of management in order to shorten the hospital stay and decrease the discomfort of these children. It is the purpose of this paper to review the experience with all children diagnosed as having primary pneumonia and secondary empyema over the past 20 years at the Children’s Hospital of Los Angeles, in order to compare present-day management with that practiced 10 years ago.

Relapse following, artificial pneumothorax \ therapy is constantly associated in the literature with contra-selective or imperfect collapse of the lung. Little has bccn written to suggest that relapse may occur when the lung is entirely free, after unimpeded nlcchanical collapse has bccn achieved. On the contrary such reports as arc available suggest that after perfect collapse of the hmg has bccn obtained, that is, when the pneumothorax is completely free from adhesions, relapse does not occur. .Evidence is produced in this paper to show that relapse may occur evcn when a completely-fi 'ee pneumothorax llas been obtained in unilateral disease, and, moreover, ttmt the factors underlying relapse are not necessarily related to the presence of adhesions or to contra-sclcctive collapse. Fifty-eight cases with unimpeded relaxation of the lung which subsequently relapsed have bccn analysed, and from the data presented a definite factor emergeci which is constantly associated with relapse, namely, atclectasis, or absorption collapse of a significant volume of lung. The group comprises patients who, given the best mechanical opportunity of controlling disease, should have improved as judged by all the accepted standards; nevertheless the), suffered relapse. Atelectasis is the sole feature common to all but three patients in the entire series; it is suggested here, and will be proved in subsequent analyses, that absorption-atelectasis was the chief causative feature leading to relapse. It was by no means the only cause; it served, however, as a precipitating factor, when it occurred at a critical time in the treatment. Turner and Collins [30] found that among 4 ~ cases of lncchanically perfect pneumothoraces, only o relapsed; both developed plcural effusions. No patient suffered from progression of disease in the treated lung, or spread of disease to thc opposite hmg. Hurst and Schwartz [17] induced pneumothoraces in z,ooo cases, in only 27 was pneumothorax pcrfccL with the lungs free from adhesions. No relapses occurred amongst these. These two papers illustr.ate why relapse amongst good pncumothorax cases has not been investigated. A perfect pneumothorax is uncommon, and r e l apse developing afterwards is a rarity. The need for the investigation is evidcnt: by studying a group of unimpeded pneumothorax relapses, conclusions may bc reached w h i c h are applicable to all pnetimothoraccs, the bulk of effective though mechanically imperfect ones included. This investigation is clarified by the absence of significant pleural adhesions, which themselves might lead to relapse.

There is no intent in this paper to review the entire subject of dissecting aneurysm, which has been fairly well covered in numerous articles. Most cases are treated by the internist. However, there is a surgical problem. It is in those patients with abdominal symptoms that the surgeon is confronted with a diagnostic dilemma. Presumably, one of four patients with dissecting aneurysm of the aorta may present signs and symptoms indicating an abdominal surgical emergency. All patients with hypertension who present evidence of an acute surgical condition of the abdomen of doubtful etiology should be suspected of having a dissecting aneurysm or aortic rupture. Two recent case reports have been added for illustration. Both patients entered the hospital within a few weeks of each other and their hospital course stimulated this paper.

An experience with this operation including thirty eyes forms the basis of this paper. The technic is described with modifications based on such experience. The theoretic basis for such an operation is discussed, with objections that may be urged to the theory. The paper was read at the Colorado Congress July 29, 1921, but a note embodying subsequent observations is added.

A series of nineteen cases of severe and often fulminating infection, six terminating fatally, in children following splenectomy is presented. Except for two cases of traumatic rupture of the spleen, the major indication for splenectomy was based on the needs arising from an established blood disorder. The infections fell into several well defined categories: meningitis, acute benign pericarditis (in patients with Cooley's anemia), acute endocarditis and sepsis. In the cases in which bacterial diagnosis was possible pneumococcus was the most frequent offender and of the clinical types, meningitis was most common. Pneumococcic meningitis predominated in this and other reports. In the majority of cases the interval between splenectomy and infection was two years or less, with a range from one day to sixteen years. The age at splenectomy extended from thirteen months to seventeen years. There was no diminution in the concentration of gamma globulin in these patients. The cases described in this paper, together with current reports of a similar nature, suggest more than a random association between splenectomy and susceptibility to infection. An extensive experimental background implicates the spleen in fundamental processes relating to resistance to infection. The sample reported in this paper is avowedly small in comparison with the ever increasing number of splenectomies. Nevertheless, while the benefits accruing from splenectomy are substantial and well documented, the potential hazards demand that exact criteria be established in selecting patients for the operation. In the light of the experience cited in this paper, the young splenectomized patient requires close supervision for several years postoperatively so that immediate and energetic treatment may be instituted in the event of sudden and severe illness. Specific prophylaxis presents manifold problems which await further study

In this paper information is given concerning 1059 cesarean sections of all types which were performed at the Chicago Lying-In Hospital from July 1, 1915, to July 1, 1929. Since there were 51,323 deliveries at this hospital and its dispensary services, the incidence of abdominal delivery for the last fourteen years was 2.06 per cent, or one cesarean section for every 48.5 cases. The maternal mortality for the 874 cervical operations was 1.26 per cent. If the 21 Porro operations which were performed after a laparotrachelotomy are added, the death rate is 1.23 per cent. For the 147 classic cesarean sections, the mortality was 4.76 per cent and this is reduced to 4.27 per cent if the 17 Porro operations, which were done after a classic cesarean section, are added. All of the figures quoted in this paper are gross figures. None of the statistics was “corrected.” The following information is based only upon the 874 cervical operations. The chief indications for the laparotrachelotomies were cephalopelvic disproportion 42.1 per cent, previous cesarean section with test of labor 11.3 per cent, previous cesarean section without test of labor 6.5 per cent, toxemia without convulsions 9.7 per cent, eclampsia 1.8 per cent, placenta previa 4.8 per cent, abruptio placentae 3.2 per cent, dystocia dystrophia syndrome 4.9 per cent, a number of previous still-births 4.2 per cent, and cardiac disease 3.3 per cent. Only 50 per cent of the patients were in labor at the time of operation, and of these 38.1 per cent had labor pains between 1 and 25 hours, 9.3 per cent had pains between 25 and 50 hours, and 2.6 per cent had been in labor from two to four days. In 21.4 per cent of the cases, the membranes were ruptured when the cesarean section was performed, and the interval between the rupture of the membranes and the time of operation varied from one hour to eight days. Ether was the anesthetic employed in 35.8 per cent of the cases, novocaine alone in 55.1 per cent, novocaine with ether or gas in 6.1 per cent, ethylene in 2.6 per cent and nitrous oxide in 0.4 per cent. During the past year 92 per cent of all the cesarean sections were performed under local anesthesia. Sterilization by means of operations on the fallopian tubes was performed in 9.6 per cent of all the cases. If the Porro operations are included, the incidence of sterilization was 11.7 per cent. The cause of death in the 11 fatal cases was as follows: peritonitis 3, pneumonia (after ether) 2, sepsis 1, gangrenous appendicitis 1, pulmonary embolism 1, antepartum eclampsia 1, postpartum eclampsia 1, and tuberculous meningitis 1. The maternal mortality according to the indications was as follows: cephalopelvic disproportion 0.8 per cent, repeated laparotrachelotomy 1.6 per cent, toxemia without convulsions 1.2 per cent, eclampsia 6.3 per cent, placenta previa no deaths, abruptio placentae 7.1 per cent, cardiac disease 3.4 per cent, and tuberculous meningitis 100 per cent. Fever after operation was present in 43.4 per cent of the cases. The main causes of pyrexia in the 196 cases where the etiology was known, were infected wounds 6.1 per cent, pyelitis and cystitis 4.8 per cent, bronchitis 2.1 per cent, pneumonia 1.3 per cent, grip 1.0 per cent, endometritis 0.9 per cent and lochiometra 0.9 per cent. In 46.7 per cent of the cases the patients left the hospital within fourteen days after operation and in 84.6 per cent they went home within eighteen days. The fetal mortality according to the indications for the operation was as follows: cephalopelvic disproportion 3.3 per cent, repeated laparotrachelotomy no deaths, toxemia without convulsions 7.5 per cent, eclampsia no deaths, placenta previa 23.8 per cent, abruptio placentae 35.7 per cent, and psychosis 100 per cent. The chief causes of death among the 40 infants were as follows: dead before operation 22.5 per cent, prematurity 25 per cent, atelectasis 20 per cent, monsters 10 per cent, and congenital heart disease 5 per cent. Among the 21 patients who had Porro operations there were no maternal deaths and two fetal deaths (9.5 per cent).

p” LLIATIVE operations are freThe patients were, in generaI, in very quentIy performed on patients with poor physica condition by the time they far advanced cancer, in order to arrived for treatment, and in spite of a reIieve them of painfu1 manifestations carefu1 preoperative regime of high ffuid of the disease and to proIong their Iives. and high carbohydrate intake and transThe vaIue of some of these operations is fusions, they often remained desperate we11 estabIished, of others it is stiI1 under surgica1 risks, to be operated upon onIy question. To be worth whiIe, a paIIiative after the most serious consideration. operation done for an eventuaIIy fatal The Iiterature on carcinoma of the head Iesion must, in fact, either free the patient of the pancreas dates back to the first from an intoIerabIe symptom or proIong description of the condition by Mondiere’ Iife that at the same time is made comfortin 1836. Certain cIassica1 papers have been abIe enough to be worth the Iiving. written since then, notabIy the papers by If one advises such a paIIiative operaDaCosta2 in 1858, AnceIet3 in 1864, Bard tion, the risks and benefits shouId be and Pic4 in 1888, MiraIIie5 in 1893, understood so that they may be cIearIy Herringham in 1894, Oser’ in 1898, and presented to the patient or his famiIy. HuIst* in 1905. Since I g Ig severa imporFor this purpose, therefore, many studies tant papers have been added, among these of the end-resuIts of such operative probeing those of Futcherg in IgIg, SpeedlO cedures must be made, which are as yet in 1920, Eustermanll in 1922, Parmentier far from being compIete. and ChabeI12 in 1923, Kiefer13 in 1927, BiIiary intestina1 anastomosis for obi and FriedenwaId and CuIIen14 in 1929. structive jaundice due to carcinoma of the There has been a comparativeIy smaI1 head of the pancreas or of the biIe ducts number of articIes in recent years and this is a paIIiative operation, the resuIts of is particuIarIy true of those deaIing with which are not yet cIarified by a Iarge the postoperative resuIts folIowing paIIianumber of studies of end-resuIts. In an tive operations. In 1928 Judd and Parker15 endeavor to find whether this procedure discussed carcinoma of the pancreas from was worth whiIe in our hands, we have this point of view in a paper on “AnastofoIIowed the course of 30 patients with mosis for Obstructive Jaundice.” cancer of the head of the pancreas on The maIady is most often seen in the whom some form of biIiary intestina1 Iarge genera1 hospitaIs and statistics show anastomosis was performed. that I to 2 per cent of the tota number of The diagnosis of carcinoma of the head cancers are found in the pancreas. Twentyof the pancreas was not confirmed by nine cases of cancer of the pancreas, positive microscopic evidence except in either primary or secondary, were found those cases that came to autopsy; in the in 23,61 I coIIected autopsies in Vienna by others it was made on the gross examinaBiach.16 Of 41,949 patients admitted to tion carried out during the examination, a the medica wards of Johns Hopkins method obviousIy not entireIy reIiabIe. HospitaI, a cIinica1 diagnosis of cancer * From the Department of Surgery, University of Michigan.

Cyanosis has been described in schistosomal chronic "cor pulmonale." However, even in this condition it is not a common manifestation. 1,2,8,9,11,12 Its presence has been attributed to right heart failure, 1,9,11,12 and its relative infrequency may be due to the absence of diffuse and severe sclerosis of the pulmonary capillaries. 6 In a previous paper, one of us 5 described the formation of pulmonary arteriovenous fistulas through the necrotizing action of embolic schistosome ova on the small pulmonary arteries and adjacent pulmonary veins. The role of these A-V fistulas in the arterial distribution of schistosome ova was the object of a paper in one of the cases to be reported. 7 In our experience there is an increasing number of schistosomiasis patients in whom the finding of marked cyanosis cannot be explained by an existing schistosomatic "cor pulmonale." The purpose of this paper, which is based on two cases with necropsy, is to emphasize the importance of these fistulas as a major factor in the pathogenesis of cyanosis in certain patients with Manson's schistosomiasis.

Pulmonary displacement associated with an anomalous artery has been frequently described since the advent of much chest surgery. The earliest adequate report of such a case is generally attributed to Tissler in his D#{252}sseldorf thesis, unpublished but quoted by Muller.’ Earlier classical descriptions by Rektorzek2 (1861), and Humphrey3 (1884) and later Simpson4 (1908) are quoted by McCotter.5 These cases reviewed by McCotter were all autopsy cases in children under two years of age. In over 6,000 post-mortems at the Hospital for Sick Children in the past 25 years, there was no case. It would therefore appear a rare pathological finding after death and not a killing disease of the young, albeit it may be a severely crippling one. Extralobar sequestration on the other hand is usually an autopsy diagnosis, and rather likely to remain one. Forty-two cases of intralobar sequestration have been reported in recent years, up to November 1951 (Cole6). Since then Kergin7 has published the record of five cases and Bruzzoni8 of one. In this paper six further cases are described. They were all seen at the Sick Children’s Hospital, and were diagnosed in part clinically preoperatively and the others by examination of the specimen after excision and by the finding of an aberrant artery when the portion of lung was removed. The first of these cases diagnosed at the time of operation was in 1948. The resected lung was being discussed at a pathological conference as something of a problem. The surgeon, Dr. F. R. Wilkinson, arrived late, but having read Pryce’s9 paper the night before, was able to distinguish himself as a diagnostician. Some of the cases reported in this paper were seen prior to this time, but diagnosed in retrospect. The surgeon had however, noted the systemic artery when he removed the mass. Pryce’#{176} had reported the condition earlier but little attention appeared paid to the first paper until the second one was published. Brief mention of two cases was made by Haight1’ in 1941. The term intralobar sequestration has been applied to these cases since Pryce’s paper in 1948. The purpose in reporting the following cases is to add to the list of published cases, and perhaps make some suggestions whereby clinical diagnoses can be made. Awareness of the anomaly and its clinical course make preoperative diagnosis easy. It has been made in all those seen since 1948. Cases with pulmonary agenesis seen at the hospital have not been Included in this paper despite the fact that most observers now consider them to be due to the same embryonic accident produced earlier. Brief mention should be made of three cases in which pneumonectomies were done. We would not subscribe to a theory attributing all kinds and degrees

F. J. D., Denver ChiIdren’s HospitaI No. ~-8703, a girl aged sixteen years, was admitted March 7, 1942, because of a marked anemia. The provisiona diagnosis was anemia, etioIogy unknown. Her family history was negative with no known bIeeding tendency. In her past history, chiIdren’s diseases were noted, she was subject to winter coIds, the tonsiIs and adenoids had been removed at seven years without incident and she had had bronchopneumonia two years before. She had aIways been pale as Iong as she can remember. More severe paIIor came in attacks usuaIIy foIlowing some infection or gastrointestina1 upset. These attacks were associated with nausea and vomiting, cramps, pain in the back and marked weakness. They occurred severa times yearIy. She was toId that after these attacks her hemogIobin became as low as 40 per cent. After each attack she took liver and iron medicine and graduaIIy improved. There was never noted any blood by bowel but at times the stools were quite black which appearance was ascribed to the iron. She has had a food craving, often eating paper, usually the unprinted part of magazines. Menstruation started a year before entrance and had been reguIar and scant. PhysicaI examination was essentiaIIy negative except for her skin which was paIe and wax-like. The mucous membranes were aIso quite paIe. Over the heart was heard a systolic murmur most pronounced at the base. The abdomen was negative except that the spIeen couId be feIt on deep inspiration. On admission the hemogIobin was 22 per cent, red bIood count I, 120,000, white bIood count 6,400 with 79 per cent poIymorphonucIears and 18 per cent Iymphocytes; there were no abnorma1 ceIIs. ReticuIocytes made up I .6 per cent of the reds. The stooIs were strongIy positive for bIood by the guaiac and benzidene test on a meat-free diet. The tota protein was sIightIy Iow, 4.8. AI1 other Iaboratory tests incIuding an icteric index, red ceil fragiIity, sterna1 puncture, gastric anaIysis and bIood Wassermann were negative. A gastrointestina1 x-ray series was normal, the jejunum and iIeum being checked three times. Sigmoidoscopic examination was negative. The chiId received frequent transfusions, a tota of six preoperativeIy but the highest bIood IeveI was onIy 44 per cent with 2,880,ooo red bIood corpuscles. This was on March 31, 1942. However, on ApriI 8, 1942, the chiId had rather severe abdomina1 pain, food craving appeared-she desired oIives and paper-and the stooIs appeared quite dark but not tarry. FolIowing transfusion a Iaparotomy was done on ApriI II, 1942. A right rectus retracting incision reveaIed immediateIy a purpIish tumor covering roughIy 4 inches of the iIeum over its whoIe circumference about 14 inches above the cecum. There were no adhesions. The bIood suppIy did not seem to be excessive. The appearance was that of a mass of deep purpIe varicose veins. No other abnormaIity in the intestine was noted. There was a Iong norma appearing appendix and no MeckeI’s diverticulum. Six inches of the smaI1 intestine were resected, the ends cIosed and a IateraI anastomosis performed with an inner Iayer of continuous fine catgut and an outer of interrupted silk. (Figs. I and 2.) The postoperative course was entireIy uneventful. The bIood remained up without transfusion, the stooIs were negative for blood and the bIood count at the time of discharge on

Individuals participating in the Tecumseh Community Health Study, in 1959–1960 (TCHS I) and 1962–1965 (TCHS II), had serum uric acid determinations by an enzymatic spectrophotometric method, SUA(ES), as part of a comprehensive health examination. Among the 1633 male and 1725 female subjects, the mean serum uric acid concentration had increased by 0.32 mg per 100 ml for males, and by 0.18 for females, over the the average of 4.1 yr between determinations. It was found that, approximately, 40 per cent of subjects had a decrease, and 56 per cent, an increase, in serum uric acid concentration. The change was greater than plus or minus 2.0 mg per 100 ml for 28.7 per cent of males and 19.4 per cent of females. Decreases of as much as 8.2, and increases of as much as 9.9 mg per 100 ml were observed. How much of the average increase, in an average 4.1 yr interval between tests, is due to ageing, except for males in the age range of 10–19 yr, is problematical. It seems probably that most of the average increase was due to technical factors in performance of the test. In the study of 1962–1965, serum uric acid determinations were done by two methods. An automated colorimetric method was compared with an enzymatic spectrophotometric method. Both methods showed the same types of distribution curves of serum uric acid concentrations and curves of age-sex specific mean serum uric acid. The values obtained by the automated colorimetric method were slightly, but, consistently, higher to a statistically significant degree than those of the enzymatic spectro-photometric method. For 2092 male subjects, the mean SUA(AC) was 0.21 mg per 100 ml greater than the mean SUA(ES), while for 2104 females subjects, this difference was 0.14. Of 4196 study subjects, whose sera were tested by both methods, about 90.0 per cent showed an agreement of the two values within ± 0.9 mg per 100 ml. However, 1.9 per cent of males and 1.6 per cent of females, had ES values which exceeded AC values by 2.0 mg per 100 ml, while 2.8 per cent of male and 2.3 per cent of female subjects had AC values greater than ES values by 2.0 mg per 100 ml. The extremes of differences range from 4.4 to 7.3 mg per 100 ml. The data in this paper gives us increased confidence in the essential validity of the mean age and sex distributions of serum uric acid values, from the Tecumseh Community Health Studies, published in an earlier paper [2]. It is concluded that, for the purposes of population studies, the automated colorimetric method is more advantageous than the enzymatic spectrophotometric method, because of its lesser cost. Comparison of the results of the two studies emphasizes the problems of definition of hyperuricemia. Further mathematical analysis of the distribution curves obtained in such studies may lead to definitions of normo- and hyperuricemia of greater precision for clinical purposes.

Summary The thoracic surgeon attached to a large sanatorium where active treatment is carried out must be prepared to perform a large number of thoracoscopies, especially where a policy of' examining all pleural spaces by thoracoscopy is adopted. This policy is in my opinion of value and the selection of cases for operation should not rest on x-ray alone. The adhesion section results for one year are reported along with certain aspects of interest in the technique and findings at thoracoscopy. I would like to acknowledge my gratitude to Mr F. A. H. Simmonds, Medical Director, Clare Hall Hospital, for his helpful advice in the preparation of this paper. This paper was read before the Middlesex Tuberculosis Association on January 17, I945.

A. Summing up this entire paper we may say that the methods of diagnosing tuberculosis at the present time are: 1) The patient-physician relationship in which, because an individual suffers with symptoms, he consults a physician and is examined by him. Provided that suspicion is sufficiently aroused, an x-ray is taken. 2) The work of sanatoria and Public Health officials, Tuberculosis Associations, private physicians and local groups, among contacts. These workers realize that from 15 to 30 times as much tuberculosis is found among individuals who are in direct contact with a tuberculous person as in the general population. Examination of contacts is usually done by means of the x-ray. Some few still cling to the idea that tuberculin tests should be made first and those that are positive be x-rayed. Many authorities now agree that the x-ray is the only safe method to depend on, regardless of the tuberculin reaction, particularly in adults. 3) X-ray studies of the chests of normal individuals at various times during life, such as, before obtaining employment, at the time of marriage, before undergoing long educational careers, during the high school years and on entering and leaving college. 4) Tuberculin testing, which is responsible for approximately 5 to 10 per cent of the cases in sanatoria being brought to light. B. We have shown the relative inefficiency of the physical examination and of symptoms in either leading us to the diagnosis or in clinching the diagnosis. Where the findings are negative, little or no reliance can be placed upon either of these factors. C. The expensive and questionable wholesale tuberculin-testing of school children, with subsequent x-raying, without adequate investigation of the contacts which these children make, is to be looked upon as digging for lead when gold lies on top of the ground. D. The 99 per cent efficiency in minimal cases and the almost 100 per cent efficiency in moderately and far-advanced cases, make the x-ray the chief instrument of diagnosis. We realize that the practical disadvantage of high cost prohibits large scale, application to the point where it is an efficient weapon in locating the disease. From the public health standpoint, consideration should be given to the combination of tuberculin testing the children and their contacts, together with the x-raying of those whose chests appear suspicious of active infection by fluoroscope. Lastly, the more widespread the use of the x-ray is made economically possible by means of the paper film and miniature celluloid film. In conclusion, as Dr. J. Arthur Myers has stated so ably, “Therefore, in arriving at final diagnoses of diseases of the chest, we must constantly keep in mind that no single phase of the examination is adequate. While the x-ray is of great value in locating lesions, it remains just one part of an examination of which there are many important parts. The final diagnosis in many cases is reached only when one has brought together all available evidence so that the clinical picture of the disease is complete.” It is obvious that no one test or group of tests now available can make the diagnosis 100 per cent certain. Until such a time arrives that a test is devised which is 100 per cent infallible, every factor must be considered as a facet in the jewel which makes the diagnosis. Until more skepticism is evinced toward negative findings of the physical examination and the tuberculin test, and greater reliance is placed upon the fluoroscope, the miniature x-ray films and the standard x-ray, there will be little change in the dark picture of late cases entering the sanatorium.

The vaginal smear method appears to have established itself as a valuable screening test, but it is not comparable to biopsy as a decisive diagnostic procedure, nor can it distinguish between intraepithelial and invasive cervical cancer. The possibilities of vaginal and cervical cytology should be fully explored by those fully qualified to do so, and the chief workshop for this purpose should for the present be well-organized and well-equipped clinics. There are still too many pitfalls and limitations to recommend its general adoption among practicing gynecologists. There must still be uncertainty as to the future role to be played by cytological studies, and some justification for the feeling that their importance has been overaccentuated and overpublicized, for reasons elaborated in this paper. There is no need for vaginal smear studies in the vast majority of cases of clinical cancer, with existing lesions, either obvious or suspicious, though there can certainly be no criticism of their supplementary employment. The omission of biopsy in such cases is far more culpable than the omission of vaginal smears. While intraepithelial carcinoma is now commonly accepted as a precursor of invasive cancer of the traditional clinical type, there is still much uncertainty as to the chronological and histological relations between the two. The lack of crystallization of opinions as to the therapy of intraepithelial carcinoma is understandable in view of our still meager knowledge on these points. Only about 10 per cent of clinical cancers are in the favorable Stage I, so that there is still a tremendous need for the education necessary to enlarge this group. The precursory lesions thus far revealed constitute a numerically tiny group, and they appear to be receiving a disproportionate amount of the educational effort. Is our cancer campaign getting a bit out of balance? The study of lesions believed to be precursory to clinical cancer, especially intraepithelial cancer, is of intense interest, and has great scientific potentiality. On the other hand, it is my opinion that at the present time the lives of many more women will be saved by an intensification of our efforts to increase the proportion of Stage I cases than can be saved by the search for cancer in this preinvasive form. It is difficult at this time to predict whether or when vaginal cytology will ever become a generally available diagnostic aid. Until such time, which does not appear to be in the very near future, the practicing gynecologist who makes full and conscientious use of universally available methods, including biopsy in the presence of even very small suspicious lesions, will not miss many cancers in a still highly favorable therapeutic stage. In the screening field, vaginal cytological methods offer definite advantages over biopsy, even of the multiple type, but smears in themselves should not be made the basis for treatment. The limitations of biopsy in women with ostensibly normal cervices can be largely overcome by some such method of surface biopsy as that described in this paper. It is recommended as a valuable procedure, especially in cases where the cytological smears have been positive.

The pilosebaceous apparatus is a target organ under androgen influence. Acne and hirsutism are found to occur in clinical situations associated with excessive androgen secretion. In several instances, however, no androgen excess can be demonstrated in patients with acne and hirsutism within the limitations of our present knowledge and techniques. It has been suggested that in these situations the possibility of increased end organ sensitivity to androgens be given serious consideration (1). The long search for an agent that could neutralize this effect culminated in a detailed study of 17a-methyl-B-nortestosterone (Fig. 1). This synthetic compound was reported to have anti-androgenic properties in rats and mice by Saunders et al (2). Studies done in our laboratory on experimental animals confirmed this antiandrogenic activity and indicated that it also possessed weak antigonadotropic and possibly weak androgenic properties (3). Competition for receptor sites at the target organ level is thought to be its mechanism of action as an antiandrogen. In the human, 17-methyl-B-nortestosterone was found effective in the management of acne and hirsutism and the results were reported in earlier papers (4, 5). Quantitative data were obtained using facial hair collection or sebum analysis in a limited number of patients. In the majority of cases the main criterion used for improvement in acne was the disappearance of existing lesions and marked lessening of new eruptions. Improvement in hirsutism was judged in general by decrease in hair growth and the frequency of shaving. The purpose of this paper is to present the results obtained in 55 patients after the withdrawal of the drug. The study is largely confined to young women and only two males. The use of 17a-methyl-B-nortestosterone in the male may be limited by the finding by Caplan (6) of gynecomastia in 12 of 13 cases, although this complication was not observed in our 2 cases. While Caplan did not observe any real improvement of acne, an excellent response was obtained in our 2 male patients. The improved condition during therapy as compared to the return of the pretreatment status some weeks or months after discontinuation of the drug, seemed to lend weight to the efficacy of the antiandrogenic agent. MATERIAL AND METHODS 17a-methyl-B-nortestosterone1 was administered orally to 55 patients (53 females and 2 males) in daily doses ranging from 50 to 600 mg for periods of 1 to 22 months, beginning with a 50 mg dose and increasing by increments of 50-100 mg. While on this regimen, no other forms of medication were administered. Complete blood counts, urinalysis, coagulation time, SGOT, SGPT, BUN, alkaline phosphatase and serum creatinine were performed in all the patients at various intervals of time in order to study hepatic, renal and hemopoietic function during treatment. In several patients the estimation of 17 ketosteroids, 17 ketogenic steroids and steroid fractionations were carried out. The results were reported earlier (5). RESULTS The effect of the administration of this compound on acne and hirsutism is shown in Table I. Although the total number of patients was 55, most of the patients had a combination of acne and hirsutism, thus giving a total of 75 points of study. Although the criterion of improvement was based on subjective judgement, nonetheless the results were quite obvious. Beneficial results were observed in 26 of 35 patients with acne (74.3%). Lessening of hirsutism was noted in 21 of the 40 patients studied (52.5%). The best effects were achieved with dosages ranging from 200 to 400 mg/day. Improvement in acne frequently was noted within a short time of one or more weeks. The more severe cases of acne showed the greatest improvement, while the diminution of hirsutism was more gradual and not related to the degree of hypertrichosis. 117a-methyl-B-nortestosterone used in this study was supplied by the Smith Kline&French Laboratories, Philadelphia, Pa. 348 ANTIANDROGEN IN ACNE 349 The interpretation of the results shown in Table I could be subject to two major criticisms. Firstly, the observations in Table I were subjective in many instances for want of distinct criteria for the quantitative evaluation of acne and hirsutism. Secondly, a double blind study for the efficacy of the drug would have been of great value. We had hoped to carry out i a double blind study with 17-methyl-B-nortestosterone during the second phase of our clinical trials but the drug was withdrawn from clinical trials pending further animal experimentation. In the absence of a double blind study to evaluate the efficacy of 17a-methyl-B-nortestosterone, it may be helpful to mention A that the use of oral contraceptives has been tried extensively by many investigators for the management of acne (7-10). In a study with i the classical contraceptive pill and the sequential form of the pill in our clinic, done r under the same conditions as with 17a-methyl- jr B-nortestosterone, the improvement in acne o was noted to be 50% in cases with the classical e and 46.8% with the sequential form (11). The \,beneficial outcome with 17-methyl-B-nortes- f, tosterone was found to be 74.3%. The compari- n son of the effect of this agent with those of oral contraceptive pills, offers in a measure additional confirmation to its efficacy. Further confirmation of its efficacy was ob- ,, tained by follow up studies after termination of therapy at varying intervals ranging from a few months to two years. The regressive changes noted on therapy were in almost every instance confined to the period of therapy and a short interval thereafter. Recurrence , took place in all the patients with acne and in most of those with hirsutism (Table II). The clinical laboratory tests were within Fig. 1. Formula of 17a-methyl-B-nortestosterone TABLE I Results under treatment with 17a-methyl-~B-nortestosterone Ko.of cases Doubtful beneficial Improvement effects ox no change ACHE 35 9 26 HIRSUTISM 40 19 21 I0TAL 75 28 47 TABLE II Results after discontinuation of the treatment with 17a-methyl-B-nortestosterone No.of cases No change Reappearance of symptoms ACNE 26 - 26 HIRSUTISM 21 8 13 TOTAL A 7 8 3 9 range of normal. Of interest was the uniform increase in urinary 17 ketosteroids. Interference of the drug in the routine method of Drekter et ai.(12) for total ketosteroids was shown to be responsible for this effect (5). Tolerance for the age and absence of evident toxicity permitted its use for prolonged periods of time. CONCLUSIONS The introduction of an antiandrogen into our therapeutic armamentarium is a goal long sought. This agent, 17a-methyl-B-nortestoster-one was the first such preparation assayed clinically. The relative absence of untoward reactions and the lack of derangement in the other endocrine systems were features of this drug. We can conclude that the rational management of the manifestations of increased sensitivity to endogenous androgens is through the administration of an antiandrogen. The excellent results obtained, though temporary, offer promise to the long time approach of the treatment of acne and idiopathic hirsutism. It is hoped that continued search for the ideal antiandrogen will continue.

There are still many practitioners who have only a vague idea of the nature and significance of endometriosis, which is fairly common, especially in the form of pelvic endometriosis. In this condition aberrant endometrium is found in various locations within the pelvic cavity and especially in the ovaries. The theories concerning the origin of this ectopic uterine mucosa are discussed in the paper. The symptomatology and the findings on pelvic examination are often quite like those of chronic pelvic inflammatory disease and in the majority of cases the diagnosis is not made until the time of operation. In some, however, a strongly presumptive diagnosis can be made, as where the patient suffers with menstrual pain referred to the rectum, lower sacral or coccygeal region, or where one or more small nodules are palpable in the region of the uterosacral ligaments. All grades of the lesion are encountered, varying from very mild cases in which the endometriosis appears to be only of scientific interest rather than clinical importance, to those in which the aberrant endometrial growth is widespread and extensive, with perhaps bilateral endometrial cysts, numerous “implants” throughout the pelvis and perhaps extensive rectal infiltration, with even obstruction of the bowel as a possibility. The management of pelvic endometriosis must take cognizance of these variations and must be individualized on the basis not only of the extent of the lesion but also of such factors as the age of the patient and the importance of conserving the possibility of reproductiveness. In the majority of cases conservative operations are indicated, even though one can not be sure that further extension of the condition will not occur, with perhaps the necessity of secondary operation. Where the disease is very widespread and the patient approaching middle life, it is advisable that the operation include complete removal of ovarian tissue, as abolition of ovarian function is the only effective means of inhibiting further growth of the aberrant endometrium. As discussed in the paper, radiotherapy is only occasionally indicated in the treatment of pelvic endometriosis.

The profunda femoris artery is the primary source of blood flow to the thigh and is the major collateral route for supply to the knee and lower part of the leg when the superficial femoral and popliteal arteries are obstructed. (Figure 1.) Fortunately, the profunda femoris artery is less frequently involved in the atherosclerotic process than is the common or superficial femoral artery [1,2]. However, Martin and co-workers [3] have shown that when arteriosclerosis obliterans involves the profunda femoris artery, the disease is located at the orifice or in the proximal portion in 74 per cent of the cases. This is best appreciated by a lateral angiogram. Bypass procedures from the aorta to the femoral artery and from the femoral to the popliteal and calf vessels have been the primary technics employed for revascularization of the lower limb. Procedures to restore flow to the lower extremity, utilizing the profunda femoris artery in the presence of obstruction of the superficial femoral artery, have been neglected. Recently, the value of this approach in revascularization of the limb when the appropriate anatomic circumstances are present has been emphasized [3,4]. This paper reviews our experience with various technics for repair of the profunda femoris artery and points out the place of profunda femoris artery repair in revascularization of the lower extremity.

The recognized late complications of necrotizing enterocolitis are intestinal stenosis and internal fistulae. Malabsorption is a possible complication but has not yet been reported. The case of necrotizing enterocolitis reported in this paper survived severe septicemia and later developed extensive proximal and distal colonic strictures and an intervening enterocyst. Intestinal stenosis in the newborn or the infant may follow such causes as necrotizing enterocolitis or exchange transfusion, but it is suggested that, whatever the immediate precipitating factor, a common pathogenesis exists, namely, intestinal ischemia resulting in necrosis of the bowel wall, followed by healing with fibrosis and consequent stenosis.

In this paper, we shall review 131 cases of carcinoma of the esophagus and cardia from three institutions covering a 10 year period from 1962 to 1972. Wide variations and approaches to the problems proved an opportunity to evaluate the role of various approaches to the quality of survival. We found that such procedures as feeding gastrostomy and cancer dilatation have little if any place for effective management. Direct, effective preparation, resection, and replacement provided the best quality of survival when appropriate. Procedures that did not relieve esophageal obstruction and prevent tracheoesophageal fistula were undesirable on the bases of both quality and longevity of survival. Management which delayed the removal of the obstruction allowed further deterioration of the patient's condition, in many instances placing the patient in the category of being preterminal.

A ventilatory system consisting of spontaneous breathing with continuous positive airway pressure has dramatically decreased mortality in newborn infants with hyaline membrane disease. 1 In the past 2 yr, we have applied this new technique in the management of noncardiac thoracic and abdominal emergencies in more than 25 small infants, most of whom were newborn. The purpose of this paper is to describe the use of continuous positive airway pressure breathing (CPAPB) in this group of babies with life-threatening conditions, which included intestinal atresia, meconium peritonitis, fecal peritonitis, gastroschisis, omphalocele, tracheoesophageal fistula, and diaphragmatic hernia (Table 1). As an adjunctive measure in the management of respiratory insufficiency associated with these conditions, we believe this new system has contributed importantly to the survival of these infants. A common denominator in this group of varied newborn emergencies was pulmonary dysfunction which was usually manifested by peripheral arterial unsaturation associated with right to left pulmonary shunting. The pulmonary abnormality was often a concomitant complication of severe metabolic acidosis, sometimes in the presence of gram-negative septicemia. Since these congenital anomalies all required urgent operative procedures, the above physiologic derangements were further distorted by anesthesia and the surgical trauma. In the past, pulmonary insufficiency, combined with severe sepsis and metabolic acidosis, was frequently lethal; but the postoperative courses in this group of infants have demonstrated improved respiratory function with the use of CPAPB. Selected cases have been chosen from this series to illistrate this experience.

This report is based on 502 culdotomies performed by the author and his associates. The method is commonly but erroneously called colpotomy . Of the 502 culdotomies, 293 were performed for tubal interruption, 209 were done for diagnosis and other surgical procedures. There were 9 complications, 3 requiring abdominal intervention. The operation is an incision into the cul-de-sac and is a practical means of investigating the pelvis to determine the status of the uterus, tubes, and ovaries. It has been the first step in vaginal hysterectomy technique. In the uncomplicated cases patients for tubal interruption were discharged from the hospital 42 hours after admission. No pregnancies have followed. W hen the operations were done for other purposes the hospital stay averag ed 72-96 hours. Preliminary evaluation includes a Papanicolaou smear. Chronic or recent pelvic inflammatory disease must be eliminated. Preoperative vaginal preparation with Gantrisin cream has been used. The operation may be done with a general or local anesthetic, preferably with an analgesic such as Demerol or morphine. Iv lactated Ringer's solution is also given and Valium at intervals. A transverse incision is made through the cul-de-sac. Unclotted blood encountered may indicate the existence of an ectopic pregnancy. Details of the technique are described. Approximately 30 minutes are required for the operation. Postoperatively the patient uses the Gantrisin cream 3 times weekly. Culdotomy is considered an efficent and practical approach to the pelvis for diagnosis and therapy. Discussion of the paper by others follows.

Real time, two-dimensional, images of the heart can now be obtained with the multiscan ultrasound system recently introduced. To assess the clinical usefulness of this technique a cooperative study was carried out in four cardiac centers. This paper describes the experience with and the results in 580 patients with different ages and disorders. Since a unique feature of multiscan is the instantaneous display of cardiac geometry and anatomy, structure recognition was chosen as the most important parameter to analyze. Image quality or recognition levels for eight specific cardiac structures were documented. Results also include recognition levels for different age and disease groups and a comparison between the four centers. In addition, information was gathered on the general diagnostic capability of the multi-element system and the possibility of quantitation of dimensions. Aortic root, anterior mitral valve leaflet and left ventricular posterior wall were the structures most readily recognized. Excellent or good images were seen in two-thirds of all patients. Best visualization was obtained in young patients. A positive diagnosis could be made or confirmed in about one half of the patients with valvular, congenital or myocardial disease and in nearly all patients with pericardial effusion. As experience was gained, the diagnostic importance of the technique shifted from structure recognition towards analysis of left ventricular function. It is clear that the multiscan system does allow excellent orientation and yields quick, non-invasive information of pertinent clinical value. The method provides an immediate overall impression of the heart. It is foreseen that this technique in combination with existing time-motion recording methods will expand the use of echocardiography drastically.

In the last 50 years, 15 malignant ovarian tumors have been encountered at the Hospital for Sick Children, Toronto. This paper will analyze and report this series.