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The Post-ureteroscopic Lesion Scale (PULS) was designed as a standardized classification system for ureteral lesions after uretero(reno)scopy (URS). This study evaluates its routine use and a possible clinical impact based on a representative patient cohort.Data of 307 patients in 14 German centers within the BUSTER project were used to test 3 hypotheses (H): PULS score shows a high interrater reliability (IRR) after independent assessment by urologic surgeon and assistance personnel (H1); PULS score is correlated with the frequency of postoperative complications during hospital stay (H2); post-URS stenting of the ureter is associated with higher PULS scores (H3).Median age of patients was 54.4 years (interquartile range [IQR] 44.4-65.8; 65.5% male). Median diameter of index stones was 6 mm (IQR 4-8) with 117 (38.4%) pyelo-caliceal and 188 (61.6%) ureteral stones. Overall, 70 and 82.4% of patients had pre-stenting and post-URS stenting, respectively. Stone-free status was achieved in 68.7% after one URS procedure with a complication rate of 10.8% (mostly grade 1-2 according to Clavien-Dindo). PULS scores 0, 1, 2 and 3 were assessed in 40%, 52.1%, 6.9% and 1% of patients, respectively, when estimated by urologic surgeons. PULS score showed a high IRR between the urologic surgeon and assistance personnel (κ = 0.883, p 0.001), but was not significantly correlated with complications (ρ = 0.09, p = 0.881). In contrast, a significant positive correlation was found between PULS score and post-URS stenting (ρ = 0.287, p 0.001). A PULS score of 1 multiplied the likelihood of post-URS stenting by 3.24 (95% confidence interval 1.43-7.34; p = 0.005) as opposed to PULS score 0.Removal of upper urinary tract stones using URS is safe and efficacious. Real-world data provided by this study confirm a high IRR of the PULS score and its clinical impact on the indication for post-URS stenting. A future prospective randomized trial should evaluate a possible standardization of post-URS stenting based on PULS score assessment.

This catalogue presents 70 species distributed in two genera for Colombia: Gigantodax with 5 groups, and Simulium with 6 subgenera and 17 groups. Three species are recorded for the first time: Gigantodax vulcanius, G. gracilis, and Simulium pautense, and the distributional range is expanded to S.ochraceum, S. paynei, S. metallicum, and S. callidum.

Here we revise Eoneria Aczdl, 1951, a small genus of flies in the Neriidae, previously known from two species from Argentina. We describe a new species, E. aczeli SepúlvedaCarvalho from Colombia, provide new records from Brazil, a distribution extension from Argentina and a new genus diagnosis, as well as an identification key based on adult morphology.

The Membracidae are a relatively diverse group with nearly 400 genera and 3200 species. For Colombia 93 genera and 394 species were previously known. Study of the literature and 3744 specimens deposited in ten colections in Colombia, as well as non-systematic collections and field observations done in Colombia between 2011 and 2014, led us to record 116 genera and 474 species grouped in 9 subfamilies and 23 tribes, distributed in 24 departments. Thirteen genera were new country records. In addition, 1449 records of host plants and 262 records of associated Hymenoptera were obtained from literature, the examined collections and new, non-systematic field trips. For each genus a differential diagnosis is presented, as well as notes on biology, distribution and some taxonomic comments. Illustrated keys for the genera of Colombian Membracidae and known distributional maps are given. After examination of several Anobilia species, we propose the new combinations Stilbophora flava (Tode, 1966) n. comb., Stilbophora luteimaculata (Funkhouser, 1914) n. comb., Stilbophora sagitatta (Tode, 1966) n. comb., Stilbophora silvana (Tode, 1966) n. comb., Stilbophora tripartita (Fairmaire, 1846) n. comb., and Stilbophora variabilis (Tode, 1966) n. comb. The male of Sakakibarella sinuosa Creão-Duarte is described.

The genus Glyphidops Enderlein, 1922, the most widespread and speciose of the New World genera of Neriidae (Diptera), is revised herein. Glyphidops (Glyphidops) ruselatus, new species, G. (G.) steyskali, new species and G. (G.) coracinus, new species are described. Of the 16 previously described species, which were last treated by Aczél (1961), the following synonyms are proposed: Chaetomeristes peruanus Enderlein is treated as a junior synonym of G. (G.) bullatus (Enderlein); Nerius dispar Cresson, Oncopsia neutra Hennig and Oncopsia dubia Hennig are treated as junior synonyms of G.(O.) durus (Cresson) and Oncopsia seductrix Hennig, is treated as a junior synonym of G. (O.) flavifrons (Bigot). The species Telostylus vittatus Cresson, is removed from synonymy with G. (G.) filosus (Fabricius) and revalidated as senior synonym of G. ochreus Hennig. A new diagnosis for the genus and all species are provided, as is an identification key to species. New locality records are provided for Costa Rica, Colombia, Venezuela, Guyana, Ecuador and Brazil.

With the aging of the population, the medical and social costs of skeletal fragility leading to fractures will cause an immense burden on society unless effective prophylactic and therapeutic regimens can be developed. Exercise is suggested as a possible regimen against involutional bone loss. The purpose of the present meta-analysis is to address a quantitative review of the randomized controlled trials (RCTs) and nonrandomized controlled trials (CTs) on the effects of exercise training programs on bone mass, measured as bone mineral density (BMD) or bone mineral content (BMC), of the lumbar spine (LS) and the femoral neck (FN) in pre- and postmenopausal women. The literature from 1966 through December 1996 was searched for published RCTs and CTs. Study treatment effect is defined as the difference between percentage change in bone mass per year in the training group and the control group. Overall treatment effects (OTs) with the 95% confidence intervals of these study treatment effects were calculated using inverse-variance weighting. Of the 62 articles identified, 25 met the inclusion criteria and were maintained for further analyses. The weighted OTs for the RCTs showed very consistently that the exercise training programs prevented or reversed almost 1% of bone loss per year in both LS and FN for both pre- and postmenopausal women. The two OTs that could be calculated for strength training programs did not reach significance. The OTs for the CTs were almost twice as high as those for the RCTs, which gives an indication of the confounding introduced by the nonrandom allocation of the subjects to groups.

The antitumour activity of docetaxel was investigated in patients with advanced malignant melanoma. Docetaxel, 100 mg/m 2 , intravenous, over 60 min, was administered every 3 weeks. Response evaluation was performed after two cycles. No prophylactic treatment with steroids or antihistamines was given. 38 patients were included, 36 were eligible and evaluable for toxicity and 30 patients were evaluable for response. The main haematological toxicity was neutropenia [17 patients with common toxicity criteria (CTC) grade 4 and 11 CTC grade 3] with nadir after 5–8 days and rapid recovery. The most frequent non-haematological toxicity was generalised alopecia (83% of the patients). Asthenia, malaise and fatigue were also seen in 58%. Skin toxicity was also frequent. Hypersensitivity reactions (erythematous rash, urticaria, blood pressure changes and tachycardia), seen in 42% of the patients, were mild to moderate. Oedema was registered in one fifth of the patients and developed after four or more treatment cycles. The overall response rate in the evaluable patients was 17% (five partial responders). We conclude that docetaxel has activity in advanced malignant melanoma.

A single-agent dose-escalating Phase I and pharmacological study of the polyamine synthesis inhibitor SAM 486A was performed. A dosing regimen of four weekly infusions followed by 2 weeks off therapy was studied. Fifty patients were entered into the study. Dose levels studied were 1.25, 2.5, 5, 8, 16, 32, 48, 70, 110, 170, 270, and 325 mg/m2/week. Pharmacokinetic sampling was done on day 1, and trough samples were taken weekly during the first treatment cycle. Pharmacodynamic sampling was done on days 1 and 22. At 325 mg/m2/week, dose-limiting toxicity was seen (one patient each with grade 4 febrile neutropenia, grade 3 neurotoxicity, and grade 3 hypotension with syncope and T-wave inversions on electrocardiogram). The recommended dose for further testing was set at 270 mg/m2/week. Infusion time was increased from 10 to 180 min due to facial paresthesias and flushing and somnolence. Drug exposure increased linearly with dose. Mean +/- SD t1,2 at 70-325 mg/m2 doses was 61.4+/-26.2 h, with a large volume of distribution at steady state. In peripheral blood leukocytes, a clear relationship between dose and inhibitory effect on S-adenosylmethionine decarboxylase or changes in intracellular polyamine pools was not recorded. SAM 486A can be administered safely using a dosing regimen of four weekly infusions followed by 2 weeks off therapy. The recommended dose for Phase II studies using this regimen is 270 mg/m2/week.

Carzelesin (U-80244), one of the synthetic DNA minor groove binding cyclopropylpyrroloindole analogues, was selected for clinical development because of its high potency, promising antitumor activity in murine solid tumors and leukemia, and significant therapeutic efficacy against colon and rhabdomyosarcoma xenografts. In this Phase I study, carzelesin was given daily for 5 consecutive days to (a) determine the maximum tolerable dose (MTD) and the pattern of toxicity of this schedule; (b) define the pharmacokinetic profile of the parent, as was done for the intermediate compound U-76073 and the DNA-reactive agent U-76074; and (c) document any antitumor activity observed. Carzelesin was given as a 10-min infusion with a constant-rate infusion pump. Treatment was repeated every 4 weeks or when blood counts had recovered to normal values. The starting dose of 12 microgram/m2/day was escalated by 20-30% increments until the MTD (defined as the dose leading to grade 4 hematological or grade 3 nonhematological toxicity in at least two of six patients) was reached. Pharmacokinetic studies were planned on days 1 and 5 of the first cycle in at least two patients per dose level. Plasma levels of carzelesin, U-76073, and U-76074 were determined by high-performance liquid chromatography with UV detection and a detection limit of 0.5 ng/ml. Twenty-five patients were entered in the study, and 56 cycles were evaluable for hematological toxicity. Subsequent dose levels evaluated were 24, 30, 35, and 40 microgram/m2. Both neutropenia and thrombocytopenia were dose limiting and cumulative, with a high interpatient variability. Neutropenia occurred earlier (median time to neutrophil nadir and recovery, 15 and 29 days, respectively) than thrombocytopenia (median time to platelet nadir and recovery, 25 and/=26 days, respectively); there were delays of treatment because of persisting thrombocytopenia in all patients treated at the MTD. At the MTD, the peak plasma concentrations of carzelesin were achieved at the end of the infusion and were higher than those found cytotoxic in vitro against tumor cell lines. Carzelesin was detectable up to a maximum of 1 h after the infusion. Smaller amounts of U-76073 were detectable for a maximum of 30 min only at the MTD, whereas U-76074 was never found. An 8-month partial remission was reported in one previously untreated patient with hepatocellular carcinoma at 40 microgram/m2. The MTD was fixed at 40 microgram/m2 daily; 35 and 30 microgram/m2 are the daily doses recommended for Phase II studies in good- and poor-risk patients. The daily regimen for 5 days seems to offer no advantage over the single intermittent schedule that has been selected for the Phase II program in Europe.

Summary Background Gemcitabine is a water-soluble analogue of deoxycytidine which has shown significant antitumour activity in a broal panel of slow-growing murine and human carcinomas. Objective responses have been reported in early clinical studies in breast, head and neck, non-small cell lung cancer patients. The weekly schedule was selected for disease-oriented phase II studies because of its better tolerabil-ity as compared to daily or twice-weekly schemes. Patients and methods Gemcitabine (1000 mg/m2) was given as a 30. min. infusion, weekly for three consecutive weeks, followed by one-week rest, every 4 weeks. Twenty-nine patients with locally advanced/metastatic gastric cancer and 39 patients with metastatic malignant melanoma entered the study. No prior chemotherapy for advanced disease had been given in all cases. Results Among 26 evaluable patients with gastric cancer, 1 partial response (PR) of 9 months (4%), 11 no change (NC) and 14 tumour progression (PD) were observed. Of 33 evaluable patients with malignant melanoma, 1 patient achieved a PR for 10 months (3%), 2 had NC and 30 PD. Toxicity was similar in the two groups with moderate myelosuppression, mainly neutropenia, mild to moderate nausea and vomiting in 70% of patients and fatigue grade 1–2 in 50%. Conclusions At the tested schedule gemcitabine has no relevant antitumour activity in previously untreated patients with advanced malignant melanoma or gastric cancer.

A retrospective review of all colonoscopic polypectomies performed in a busy surgical endoscopy unit over a 6-month period was undertaken. All patients were included who presented with colonic polyps measuring less than 1 cm in diameter for which sufficient specimens were available for histopathologic examination. In all, 262 were polyps removed from 206 patients; of these, 158 (60%) were neoplastic. There was a statistically significant predilection for polyps in the right colon to be neoplastic. Worrisome histologie patterns (severe dysplasia, carcinoma in situ, or invasive carcinoma) were seen in 18 specimens (6.5%). In two patients, polypoid carcinoma could be identified; in one case it involved a lesion measuring 0.2 cm in diameter. Since these lesions exhibit no distinctive gross features, only their endoscopie removal and histologie study can ensure proper diagnosis and treatment.

Preoperative plasma CEA levels were measured in 93 selected patients with histologically defined colorectal adenomata removed at fibroptic colonoscopy in order to determine whether CEA levels are elevated in patients with colonic polyps, or vary with different histologic patterns. None of the patients had inflammatory bowel disease, previous history of carcinoma, or evidence of liver disease. Fifteen percent of the patients had elevated CEA levels (greater than or equal to 2.5 ng/ml; Hansen method), and two-thirds of these were between 2.5 and 4.0 ng/ml. Increased association of elevated CEA levels was noted with old age, villous adenomas (2- to 4-fold), and increased tumor size (greater than 2.3-cm diameter; 2-fold), but not with foci of dysplasia or carcinoma in situ as such. One-half (7/14) of the patients with elevated CEA levels showed the following: two patients had villous tumors with carcinoma in situ, one had a villous adenoma, two had mixed villous and tubular adenomas (with a high proportion of villous pattern), and two were subsequently shown to have carcinoma elsewhere in the colon. It is uncertain that the polyps were the source of the elevated circulating CEA levels; other factors including smoking and patient selection need to be considered. This preliminary study suggests that patients with colorectal adenomata and elevated circulating CEA may be at higher risk for the development of carcinoma. Further follow-up studies of the malignant potential of the polyp-bearing colon are essential.

Colonic pseudo-obstruction refers to a condition in which physical and radiologic findings identical to those associated with mechanical obstruction of the large bowel are found but in which no organic cause of the colonic distention is present. Cases of this condition have been reported in the world literature, of which 40 per cent have followed the termination of pregnancy or uterine operation. Three cases of this syndrome are presented. One followed normal vaginal delivery; one followed cesarean section, and the third followed elective abdominal hysterectomy. The literature on the subject is reviewed, and a possible anatomicophysiologic explanation, based upon a sympathetic-parasympathetic neurostimulatory imbalance, is put forward.

Opportunistic systemic fungal infections are more frequent than generally realized. Increased awareness and a high index of suspicion of fungal super-infection in the presence of sepsis is required to bring about recognition and therapy. The intravenous catheter is an important portal of entry or may act as a foreign body favoring localization of a septic process. In its presence, fungemia must be guarded against. Whenever an intravenous catheter is removed, its tip should be cultured. Removal alone may be a critical item in therapy. In febrile patients, in whom the course of fever is not established, frequent blood cultures with attention directed specifically at fungi should be obtained. Fungi are not easily isolated and identified and only by requesting special attention from the microbiologist can the diagnosis be established in the average institutional laboratory in time to permit appropriate therapy. Since available therapeutic measures are strikingly effective when instituted early, awareness and alertness on the part of the clinician constitute the key to cure.

One hundred patients on methadone maintenance admitted to our surgical service were analyzed. The average duration of prior narcotics abuse was ten years and was followed by an average of 2.2 years of methadone maintenance treatment. Sixty-three patients were admitted on an emergency basis, half of these for trauma. Sixty-two patients underwent operative procedures. There were four deaths, none directly related to methadone use. Five patients were admitted for intestinal obstruction secondary to methadone ingestion. This disease entity results from fecal impaction which is induced by methadone's spastic effect on the gastrointestinal tract. Evidence of chronic liver disease was present in half the patients. The associated medical illnesses presented no problems with anesthesia. WHILE METHADONE MAINTENANCE WAS CONTINUED IN THE ACCUSTOMED DOSAGE, POSTOPERATIVE ANALGESIA WAS ACCOMPLISHED SATISFACTORILY WITH 5O TO 100 MG DOSES OF MEPERIDINE AT 3 HOUR INTERVALS, AS REQUIRED.

Two cases of severe bronchial spasm in patients under general anaesthesia are presented. In the first case the bronchial spasm, according to our clinical impression, was due to histamine release following a rapid intravenous injection of 15 mg of d-tubocurarine; 100 mg of lignocaine, administered intravenously, abolished the spasm. In the second case the spasm was induced reflexly by the intubation of the trachea in a patient under thiopentone anaesthesia; 40 mg of procaine, intravenously, ended the attack. The possible mechanisms by which local anaesthetic drugs may induce relaxation of the bronchial muscle are discussed.

1. 1. A new class of proteins which was intimately associated with the insoluble matrix was demonstrated in the skin, joint capsula and placenta of rat, rabbit, calf and human. These proteins correspond to 20–40% of the noncollageneous proteins in the whole tissue and were designated acidic structural proteins because of their property to undergo a reversible isoelectric precipitation between pH 3.7 and 5.7. 2. 2. The acidic structural proteins occur in the tissue in two different states of aggregation. The one part could be solubilized by either 8 M urea, 6 M guanidine, 2% sodium dodecyl sulfate or 0.1 M Na2CO3; the other, and in most cases, predominating part could be solubilized only by dilute NaOH or NaBH4. It seems possible that the latter part is covalently cross-linked. After the solubilization the acidic structural proteins are probably denatured and now highly soluble in water. 3. 3. The acidic structural proteins have a carbohydrate content mostly not exceeding 1%. Acidic mucopolysaccharides are virtually absent. The amino acid composition is quite different from those of collagen and elastin and is characterized by about 25 mole% acidic and 35–40 mole% hydrophobic amino acid residues. Significant amounts of tryptophane, but practically no hydroxyproline, were present.

Primary adenocarcinoma of the duodenum is rare. An extensive experience with fiberoptic esophagogastro-duodenoscopy in our institution has indicated that duodenal neoplasms may be more frequent than suspected and are readily diagnosed by this modality. With this mind, clinical, pathological, diagnostic and therapeutic aspects of the 71 patients with primary carcinoma of the duodenum reported in the literature in the last 10-year period, 1965-1974, were reviewed. It would appear that fiberoptic endoscopy of the upper gastro-intestinal tract should become the major diagnostic tool for this disease. It enables biopsies, brushings and washings to be taken. A preoperative histological diagnosis ensures that both patient and surgeon can be prepared for major abdominal surgery. It is imperatire that during the endoscopic examination, the entire duodenum be examined. Pancreatico-duodenectomy appears to offer the best chance of long term survival in patients whose lesion is resectable. The role and value of adjuvant chemo- and radiotherapy is still to be determined.

3 min after simultaneous i.v. administration of phenazone (200 mg/kg) and of pentetrazole (50 mg/kg) or of phenazone and of the convulsively active S-(+)-1-methyl-5-phenyl-5-propyl barbituric acid = (+)-MPPB (75 mg/kg), respectively, phenazone concentrations in liver, spleen and fat tissue of rats are lower, in brain tissue, however, it is higher than those of the control (rats receiving phenazone only); the distribution pattern of (+)-MPPB between the tissues corresponds to that of phenazone after simultaneous administration of pentetrazole. In rats anaesthetized by hexobarbital (35 mg/kg) or by the anaesthetically active R-(-)- 1-methyl-5-phenyl-5-propyl barbituric acid = (-)-MPPB (75 mg/kg), respectively, phenazone tissue distribution is at the same time (3 min) not different from that of the control; the tissue distribution pattern of (-)-MPPB corresponds to that of phenazone after simultaneous administration of hexobarbital. Following pretreatment with diazepam, reserpine and phenoxybenzamine, respectively, the tissue distribution pattern of (+)-MPPB, in the rats approaches that of (-)-MPPB. The distribution of (-)-MPPB in the tissues corresponds to that of (+)-MPPB, if the animals receive simultaneously pentetrazole or are electrically stimulated, respectively, to cause a convulsive seizure.

A 32-year old Dominican woman with signs and symptoms of an acute abdomen, was found to have tuberculous peritonitis. Our experience with this patient is presented along with a review of the literature. Population shifts may bring about an increased number of cases in this country. Awareness of this entity will avoid unnecessary diagnostic errors and laparotomy. The surgeon should also be versed in the total management and be prepared to handle the surgical complications of the disease.

The records of 50 patients with 67 major civilian type vascular injuries treated in a large urban center from 1967 to 1975 were reviewed in terms of nature of the injury, form of surgical management and early and late results. Civilian injuries differ in many aspects from those of their military counterparts and often require different treatment. In both, however, treatment protocols should be periodically re-evaluated for a number of reasons, chiefly among which are changing patterns of delivery of the injured patient to the medical center and advances in technical skills. Notable in the presently reported series were the low mortality and the absence of a need for amputation, with a limb salvage rate of 100 per cent. Despite modern advances in technical proficiency in vascular reconstruction, there is still a place for careful vascular ligation in the definitive surgical management of major vascular trauma.

"Pseudo-obstruction of the colon" refers to a condition in which physical and radiological findings identical to those associated with mechanical obstruction of the large bowel are found but in which no organic cause for the colonic distention is present. These cases may involve progressive proximal large bowel dilatation to the point of cecal perforation or necrosis. We have collected eight cases of our own which will be presented. The various etiologic factors reported in the literature will be discussed and analyzed and we will offer an anatomicophysiologic explanation of a possible mechanism, based on sympathetic-parasympathetic neurostimulatory imbalance.

When bilirubin levels are elevated, visualization of the biliary ducts is only possible by endoscopic transampullary cholangiography or by P.T.C. Cannulation of the biliary tree is difficult under the best of circumstances and when obstruction exists at the caudal end of the ducts, success is frequently precluded. P.T.C. then becomes the modality of choice, since visualization can be achieved in 98% of cases when obstruction exists. These methods are complementary. Each should be used when the other fails. Their dual application and complementary role in "difficult" jaundice cases is elaborated upon in the 16 cases reported in this current series. Their combined use should help elicit the diagnosis in almost all cases of jaundice.

"Pseudo-obstruction of the colon" refers to a condition in which physical and radiologic findings identical to those associated with mechanical obstruction of the large bowel are found, but in which no organic cause of colonic distention can be identified. These cases may involve progressive proximal large-intestinal dilation to the point of cecal perforation or necrosis. Two cases of spontaneous perforation of the cecum and one case of gangrene of the cecum secondary to proximal distention of the right colon that followed pseudo-obstruction of the colon are presented. Various etiologic factors reported in the medical literature are discussed and analyzed, and an anatomicophysiologic explanation of a possible mechanism, based on sympathetic-parasympathetic neurostimulatory imbalance, is offered.

Data have been presented showing the applicability of indicator-dilution technique to the entire human peripheral circulation during open-heart surgery. Initial results from simultaneous tagged red cell and plasma protein indicator-dilution curves demonstrate a consistently greater volume of distribution for plasma proteins than for red cells.

Endoscopic removal of 343 colonic polyps more than 0.5 cm in size, located from the cecum to the sigmoid colon and beyond the reach of rigid sigmoidoscopes, is reported. Diagnostic colonofiberscopy is a valuable procedure permitting direct visual examination of the entire colon with a high degree of safety. More than 1,800diagnostic colonofiberscopies have been performed in our unit without a single complication. The polypectomy procedures via the colonofiberscope were done without mortality and with only a single immediate complication, which responded to conservative measures. Endoscopic removal of colonic polyps is proposed as a safe, practical alternative to either laparotomy and colotomy or repeated barium-enema studies in the management of the patient with a colonic polyp. The endoscopic approach allows differentiation of malignant from nonmalignant polyps by complete excision, thus permitting definitive cancer therapy measures to be undertaken promptly and with assurance. Endoscopic removal of colonic polyps is not advised for endoscopists who have not first achieved considerable experience and dexterity in diagnostic colonoscopy. Endoscopic removal of colonic polyps is best accomplished by an experienced endoscopist supported by the full spectrum of general hospital resources, after the patient has been thoroughly evaluated medically. It should be carried out on an inpatient basis. When a patient has a colonic polyp, an alert should be maintained for unsuspected colonic cancer unrelated to the polyp, lest the less serious lesion monopolize the clinical situation.

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

The exact location of a mass palpable in the ventral abdomen is sometimes difficult to define. Uncertainty may exist whether it lies in the peritoneal cavity or is situated within the abdominal wall. Laparoscopy is a safe and readily available method to clarify such a diagnostic dilemma,' thus avoiding an exploratory laparotomy. CASE REPORT A 42-year-old white woman was admitted to Beth Israel Medical Center for elective excision of a Morton's neuroma. On the fourth postoperative day she manifested clinical signs suggestive of a pulmonary embolus, and physical examination disclosed left calf tenderness with a Homan's sign. The patient was put at bed rest, and heparin was given in doses sufficient to maintain the partial thromboplastin time at twice normal levels. Six days after commencement of anticoagulant therapy, she complained of right lower quadrant pain and nausea. Examination revealed a temperature of 1OO.4°F and a tender, non-fluctuant mass measuring 6 cm x 8 cm in the right lower quadrant of the abdomen close to an appendectomy scar. Abdominal scout films showed a normal gas pattern. A presumptive diagnosis of an intramural or pericecal hematoma was suggested by a surgical consultant. Heparin therapy was immediately discontinued. The mass remained tender and did not change in size or consistency over the next 5 days. At laparoscopy, requested to clarify the nature of the mass, no intra-abdominal abnormality was found. It was quite apparent that the large mass in the right lower quadrant lay within the abdominal wall itself, producing marked bulging into the peritoneal cavity on its inner aspect. Manual pressure on the anterior abdominal wall moved the mass toward the telescope. The diagnosis of a hematoma within the anterior abdominal wall was made. The patient's further course was uneventful, and the hematoma eventually resolved spontaneously. DISCUSSION Hematoma formation within the rectus sheath is not uncommon, with many cases on record. Interest stems chiefly from its mimicking of intra-abdominal disease. Sometimes the diagnosis is correctly made only by laparotomy.2 In the great majority of instances, abdominal wall hematomas are situated below the level of the umbilicus and are on the right side twice as often as the left.3The commonest source of the bleeding is a ruptured inferior epigastric vein.The mechanism of this condition is quite variable with direct trauma being most frequent. Spastic muscular contractions such as may occur during seizures, severe coughing, and sexual intercourse have been described.sCollagen disorders, degenerative vascular diseases, and blood dyscrasias may also be predisposing factors,3 and the entity has been associated with pregnancy.In the postoperative patient an improperly placed suture injuring the inferior epigastric vessels shou Id be considered.