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We studied the incidence of decreased red blood cell deformability (RBCD) in sepsis and the association between decreased RBCD and oxygen free radical generation (as measured by malonyldialdehyde) and the occurrence of multiple-system organ failure (MSOF). Patients were divided into three groups: septic (n = 28), nonseptic (n = 15), and control (n = 5). Serial measurements of deformability index, malonyldialdehyde, and MSOF were made. The deformability index for the septic group (0.23 +/- 0.17) was significantly less than that for the nonseptic (1.12 +/- 0.48) and control (1.11 +/- 0.25) groups. The malonyldialdehyde levels for the septic group (4.5 +/- 1.0 nmol/mL) were significantly greater than those for the nonseptic (2.7 +/- 0.9 nmol/mL) and control (2.6 +/- 0.8 nmol/mL) groups. The MSOF index for the septic group (10.1 +/- 2.5) was significantly greater than that for the nonseptic (7.6 +/- 1.7) and control (6.0 +/- 0.0) groups. An inverse correlation existed between malonyldialdehyde and deformability index ( = .501, less than .001, n = 40) and between deformability index and MSOF index (= .350, less than .05, n = 61). We conclude that RBCD is decreased during human sepsis; free radicals generated during sepsis may play a role in the decrease in RBCD. Decreased RBCD may contribute to the MSOF that occurs during sepsis.

• Red blood cell (RBC) "deformability" is necessary for maintenance of normal microcirculation. To determine whether RBC deformability was affected in human or murine sepsis, a deformability index was determined in a human study and a murine model. Deformability was decreased postoperatively in patients with sepsis (0.49 ±0.12) compared with patients without sepsis (1.62±0.13) and normal control volunteers (1.51 ±0.17). Deformability was decreased in rats that had undergone cecal ligation and puncture (0.37±0.06) compared with that of sham-operated rats (0.76 ±0.12), as well as in endotoxemic rats (0.38 ±0.4) compared with control rats (0.82 ±0.11). These data suggest that RBC deformability decreases in both human and murine sepsis. This effect could be an important factor in the disordered oxygen utilization noted in human sepsis, and its correction could lead to better tissue oxygenation and preserved organ function. ( Arch Surg 1988;123:217-220)

The early diagnosis of retroperitoneal abscess may offer considerable difficulty. The initial course of infection in the retroperitoneal space is surprisingly latent and symptoms are often minimal or absent. Frequently the patient comes to the doctor late in the course of the disease and, even then, the correct diagnosis may be long delayed. This condition has been little studied in the laboratory. The only experimental work published in the American literature is that of Meyer, 7 who observed that when known amounts of bacteria were injected into the retroperitoneal space of the dog, the spread of infection was associated with fewer constitutional symptoms, and with a lower mortality, compared with the result of an equal amount of bacteria injected into the peritoneal cavity. He concluded that the retroperitoneal space was better able to control and contain infection than the peritoneal sac. These experiments are not strictly comparable with the usual

Fifteen years have elapsed since first publication of this volume. The first edition, rich in detail and scholarship, was judged the classic in its field; this work has maintained the same standard. Extensively rewritten, expanded, and updated, the new edition has a larger page size and 78 pages have been added. Organization of the subject includes an initial 3 chapters on normal and abnormal anatomy and physiology, followed by 3 chapters on diagnosis, 14 on various aspects of benign and malignant lesions other than adenocarcinoma, 14 on the various lesions of adenocarcinoma, and 5 on treatment. Everything one could possibly wish to know concerning the breast seems to be covered. Much of the work bears the authority of Haagensen's 40 years of experience at Columbia-Presbyterian Medical Center where he specialized in disease of the breast. The chapter on selection of patients for operation describes many criteria which he introduced and

Irreversibles an enigma in experimental animals and in man. Much work has been done in an effort to elucidate the pathophysiological changes which characterize the state of "irreversibility" so that specific therapy may be directed at these disturbances. Even though irreversible shock cannot be defined as precisely in man as in the dog, it seems likely that the basic metabolic consequences of prolonged shock are similar in both species. The differences in the pathological manifestations of shock between man and experimental animals seem related to differences in susceptibility of various organs to the hemodynamic changes of shock. Lillehei 1 has proposed a unified concept in which the stage of irreversibility, whether induced by hemorrhage, bacterial endotoxins, or myocardial failure, is characterized by loss of tone in precapillary arterial sphincters while postcapillary sphincters remain constricted. The result is a progressive loss of plasma from the vascular system, stagnant anoxia and congestion

To the Editor:— We note with mild amusement that Dr. Hanson would have us substitute one eponym for another. Hartmann did indeed add lactate to Ringer's solution, giving us a better balanced solution with a closer resemblance to the electrolyte content of extracellular fluid and some buffering capacity. Since Dr. Hanson does not wish to invoke the eternal debate concerning the use of eponyms in scientific writing, we feel that Hartmann's solution is the better eponym for the solution we use. Perhaps we are all victims of the language differences that tend to grow up between specialties. Among surgeons, internists, anesthesiologists, and pediatricians the term "Hartmann's" is a familiar one made comfortable to us by long usage. The commercial solution is labeled "Hartmann's Solution" in large letters. Pathologists and those of other specialties who have less reason to use this material may find this terminology strange. If so, any questions

A hundred patients each lost over 1,000 ml of blood while undergoing surgery and received two to three times that volume of Hartmann's solution. Postoperative mortality and morbidity were not affected by the lack of blood in the replacement regimen. Age group and physical condition of these patients were representative of the hospital population, and patients over 60 years old in American Society of Anesthesiologists (ASA) risk classifications 3 and 4 were included. Eighty-six percent of the group lost from 1 to 1.5 liters of blood; only 14% lost a larger amount. Serum electrolyte levels were unaffected. Hematocrit readings and total protein concentrations decreased but remained within physiologic limits. No unexpected complications were encountered in the postoperative period, and hospitalization was not prolonged. Only four patients required subsequent transfusions postoperatively.

The occurrence of high fever in an otherwise well child, a day or two after operation, leads the experienced surgeon to throw back the sheets and look for a saphenous phlebitis at the site of a cut-down. The child is usually not particularly ill, although there is generally a visible erythema, tenderness, induration along the course of the vein, and frequently edema of the leg. Blood cultures made by ordinary methods are generally sterile. The condition responds at once to withdrawal of the intravenous cannula, polyethylene catheter, or indwelling needle and local application of hot compresses. The plastic indwelling catheters have become particularly popular and have led to the more frequent use of continuous intravenous drips. A number of reports have appeared listing the hazards and complications which result from use of this technique.1Septic thrombophlebitis is probably the most serious complication and has led to bacteremia and septicemia

Advanced cancers of the hypopharynx and larynx respond poorly to treatment by either irradiation or operation, especially when they are associated with metastases to the cervical nodes. Survival figures at five years for lesions of the larynx with spread to cervical nodes range from 4% to 26%.11,12Whether they were treated by operation or irradiation, survival rate for similar lesions of the hypopharynx is reported as 10% to 20%.13 Challenged by a group of patients with a high incidence of advanced lesions, in 1962 we embarked on a technique of integrating "curative" levels of radiation therapy followed by en bloc resection of the larynx or hypopharynx and adjacent lymph nodes in four to six weeks. The rationale for this approach follows: (1) It was hoped that the application of a high level of radiation therapy in the so-called curative range would afford maximum tumor regression, and allow either

In the course of metabolic studies in dogs following nephrectomy and ureteral ligation, it was noted that the chloride content of the excreta was often quite high. Since the excreta in this situation is almost entirely vomitus, we were attracted to a consideration of the components of gastric juice in uremia. The available data is sketchy in this regard. Peters 1 noted that the gastric aspirate in patients with chronic uremia was low in both chloride and titratable acidity. Schreiner and Maher 3 in an extensive review of the subject of the gastrointestinal symptoms of uremia do not refer to any studies of the acidity or electrolyte content of gastric juice under these circumstances. They take note of the high incidence of uremic gastritis, heart burn, vomiting, and gastric bleeding in uremia, and are inclined to favor the high concentration of ammonia which develops in the intestinal tract as the