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Several modifications and details of techniques that were found useful in venous valve reconstruction are described. Related technical outcome data are also presented.Five hundred eighty-two valve segments were reconstructed in 347 limbs using a variety of different techniques.Intraoperative valve competence was achieved in 86% of 347 limbs. The incidence of technical stenosis was 4%, thrombosis of repair1%, loss due to hematoma/infection1%, and operative mortality 0%. Postoperative duplex competence was achieved fully in 78% and partially in 16%; 6% remained refluxive. Rapid postoperative healing of stasis ulcer occurred in 93%.The expanded variety of technical options in valve reconstruction allows optimization for the individual patient. Regardless of pathology, a functional venous valve can be reconstructed in most patients utilizing one of the described techniques.

The purpose of our study of hemorrhagic shock in dogs was to examine the efficacy of adding Ringer's lactate to shed blood replacement in increasing animal survival rates. The standard Wiggers' hemorrhagic shock technic was used in two groups of ten animals each. Intravascular pressures, cardiac output, oxygen consumption, arteriovenous oxygen differences, extracellular fluid PO 2 and pH, electrolyte changes, and survival rates were determined. There was a positive correlation between changes in cardiac output, central venous oxygen content, and PO 2 and extracellular fluid PO 2 as measured using subcutaneously implanted Silastic tubing and perforated plastic balls. Four of the dogs that received shed blood alone survived, whereas five of the dogs that received shed blood plus Ringer's lactate survived. This difference was not statistically significant.

Three groups of a total of 26 puppies were subjected to surface-induced hypothermia with or without limited left-heart bypass to seek recovery after 2.5-hr total circulatory arrest. In spite of various protective measures, surface-induced hypothermia which was carried out until the effective circulation ceased, failed to protect the animal from 2.5-hr circulatory arrest. With a combination of limited leftheart bypass, the central nervous tissue tolerated the procedure better than expected. Metabolic derangements, although severe immediately after the procedure, were reversible. Respiratory distress was a serious problem, which was considerably alleviated in the 3rd group of 10 puppies by perfusion of the lung with a solution approximating the intracellular electrolyte composition. Six puppies of this group survived the procedure, 5 without any persistent disorders. These results indicate the possibility of 2.5-hr hypothermie circulatory arrest.

1. 1. The daily twenty-four hour secretion of nondialyzable mucosubstances and acid has been measured in seven dogs with both antral and fundic pouches for three week control and three week test periods during which 150 mg. of cortisone was administered daily by intramuscular injection. 2. 2. Cortisone significantly decreased the antral secretion of mucosubstances and the secretory volume but did not appreciably alter the acidity. 3. 3. The amount of free acid secreted in the fundic pouches almost doubled during cortisone treatment, and the amount of mucosubstances was reduced an average of 31 per cent. This reduction in mucus was statistically significant in only two of the seven dogs, possibly because hyperacidity serves as a mucin secretagogue. 4. 4. In three of the dogs, bleeding ulcers developed around the body pouch cannulas but no ulceration occurred in the main part of the stomach or the gastroduodenal anastomosis. 5. 5. Preliminary analyses of two hour fasting gastric secretion samples in sixteen control and fourteen prednisone-treated patients showed the average secretion of mucosubstances to be 39 per cent lower in the steroid-treated patients. However, the wide range of values obtained in the controls precludes statistical validation of this difference. 6. 6. The reduction in mucus secretion during steroid administration may contribute to ulcerogenesis, but the increase in free acid secretion could represent an important additional factor.

The prevention and treatment of hypoxia embraces a considerable segment of surgical practice. The hypoxia may be acute or chronic and may be produced through a variety of mechanisms. These involve abnormalities of respiration, heart action, blood volume and blood composition. There may exist occlusive disease of larger arteries, or excessive or inadequate constriction of the arterioles, leading to hypoxia either from spasm or from lack of peripheral resistance to maintain an adequate systemic arterial blood pressure. There may develop defective flow through elements of the microcirculation, as well as defective oxygen utilization by the cell and the subcellular fractions. Increased interstitial fluid, the result of lymphatic or venous stasis, may also result in hypoxia and abnormal metabolism at the cellular level. Hypoxia ultimately results in disintegration of the cellular processes, due in part to the resulting metabolic acidosis, with eventual death of the tissue. The consistently effective prevention and management of hypoxia requires a comprehensive awareness of the many different pathologic conditions which may result in hypoxia at the tissue level. While admittedly the factors which influence the efficiency with which the component parts of the cell utilize oxygen to perform their respective biochemical processes must await further study, there is much that can be done to combat hypoxia of the cells of various organs. This is accomplished through improvement of the various components of respiration, by correcting lesions of the heart and of the aorta and its branches, by preventing hypotension through maintaining a quantitatively and qualitatively adequate circulating blood volume and peripheral resistance, and by being aware of specific problems of thrombosis in the smaller arteries and the microcirculation, where increasingly appreciated rheologic factors are of much importance.

T HE bihary tract confronts the surgeon with a wide range of chaIIenging problems. The purpose of this communication is to present a series of patients whose biIiary lesions were of special interest. These cases incIuded the following: (I) Stones of the common duct (retained and recurrent stones above a stenotic sphincter of Odd i, spontaneous passage of a retained stone, “stone” simulated on cholangiogram by the lobe of the Iiver) ; (2) strictures of the common duct (operative injury stricture with stone formation proximaIIy, congenital stricture bypassed with intrahepatic cholangiocholecystoenterostomy en Roux Y, false stricture on choIangiogram; (3) idiopathic retroperitonea1 fibrosis; (4) biliary fistula as common cause of Iow sodium syndrome.

1. 1. The technical and physiologic management of functioning adrenocortical tumors is reviewed. The clinical pictures produced by various types of hyperadrenocorticism are Cushing's syndrome, hyperaldosteronism, the adrenogenital syndrome, feminization and mixed syndromes. 2. 2. The findings in the history and physical examination which suggest endocrine dysfunction should lead to specific plasma and steroid analyses that are essential to establish the diagnosis on the firmest possible basis. 3. 3. The clinical picture produced is determined by the specific chemical formula of the overproduced steroid, in addition to the age and sex of the patient. 4. 4. Functioning adrenocortical tumors are frequently malignant and the prognosis is thus often poor. 5. 5. The patient with Cushing's syndrome may complain only of weakness and weight gain for many months prior to the development of other more striking physical features of the condition. The diagnosis is established by the demonstration of an increased rate of production of gluco-corticoids. This may be done with control plasma levels, response to the intravenous infusion of ACTH and measurement of corticoid excretion in the urine. The urinary excretion of 17-ketosteroids is also elevated in many cases. Collateral laboratory data of value are derived from the blood count, plasma electrolyte values and urinalysis. The functioning adrenocortical tumor is excised, and during and after operation hydrocortisone is infused in substantial doses to prevent acute adrenocortical failure. An analysis of a far advanced case is presented. Long term follow-up examinations are important aspects of management. 6. 6. Hyperaldosteronism due to functioning tumors of the adrenal cortex is now a well established entity. The condition should be at least considered in any patient who has hypertension, unexplained episodes of muscular weakness, hypokalemia with hypochloremia or alkalosis, and episodes of polyuria and polydipsia. There is a tendency toward hypernatremia. The diagnosis is confirmed by the demonstration of an increased level of aldosterone excretion in the urine. 7. 7. The adrenogenital syndrome is due to an excessive production of androgens by adrenal hyperplasia or neoplasia. Such patients exhibit an increased level of 17-ketosteroid excretion in the urine at operation. The level of corticoid excretion may also be elevated. The tumor frequently appears to be encapsulated but is often malignant with blood vessel invasion, and recurrences are common. A case analysis is presented. 8. 8. The qualitative and quantitative diagnosis of hyperadrenocorticism has now become far more precise than it was a decade ago. Furthermore, the hazard of acute postoperative adrenocortical insufficiency has been almost abolished by the availability and liberal use of effective replacement therapy.

SUMMARY 1.The effect of selected drugs and various inorganic ions on ventricular fibrillation and mortality following experimental coronary artery occlusion has been investigated. 2.Control mortality of 80 per cent and early fibrillation of 30 per cent was obtained following ligation of the left anterior descending coronary artery immediately at its origin. 3.When coronary occlusion was delayed for 20 days post-pericardotomy in three animals there was no mortality and two of the three animals failed to demonstrate any change in the pre and postocclusion electrocardiogram. 4.Mortality of 80 per cent and fibrillation of 40 per cent resulted when acidosis was produced by hydrochloric acid. 5.Mortality of 80 per cent and fibrillation of 60 per cent resulted when alkalosis was produced by the infusion of sodium bicarbonate. 6.A mortality rate of 60 per cent and a fibrillation rate of 60 per cent resulted when hyperkaliemia was produced. 7.Hypercalcemia produced a mortality of 80 per cent and fibrillation of 60 per cent. 8.Following the infusion of a relatively small amount of sodium chloride an unexpected 100 per cent mortality and 80 per cent fibrillation rate resulted. 9.A mortality rate of 100 per cent and a fibrillation rate of 100 per cent followed the infusion of procaine. 10.The intravenous administration of papaverine produced mortality and fibrillation rates of 60 per cent. 11.Quinidine administered intravenously yielded a mortality rate of 60 per cent and fibrillation rate of 60 per cent. 12.The influence of infusion of certain ions and drugs upon the concentration of other ions was determined. 13.It would appear from this study that if potassium is the excitatory agent for ventricular fibrillation that myocardial potassium in ischemia is unaffected by the plasma concentration of potassium and is on a metabolic basis. 14.If potassium is the agent inciting ventricular fibrillation it would appear from this study that myocardial metabolism of potassium in myocardial ischemia is unaffected by blood pH insofar as decreasing early fibrillation is concerned. 15.None of the drugs or ions employed in this study showed any beneficial effect on reducing mortality or ventricular fibrillation following coronary artery occlusion. We gratefully acknowledge the electrocardiographic interpretation of Dr. Thomas M. Blake.

This is the eleventh meeting of the Society for During recent years, however, much information Surgery of the Alimentary Tract. Although the has come to light [I$]. Of course, in few diseases Society is now securely established, we are still in has the ultimate cause of death, the ultimate lethe process of developing our ultimate position in sion in terms of biochemistry and biophysics, been the mainstream of American surgery. Further- defined. Yet an increasingly large catalogue of more, our maturation is being achieved in a time distant or systemic effects of localized malignant of vigorous scientific and social development which tumors has been documented (Figure l), and it is will alter the basic structure of surgical practice to this body of information that I wish to direct in this country. attention. Only a few years ago it was commonly stated that our field held few challenges. Voices were raised that something must be done to arouse interest in alimentary tract problems. Such statements would scarcely be justified today. It will be my purpose to emphasize that rarely before have alimentary tract challenges and prospects been more exciting or approachable. Furthermore, certain possible philosophical objectives of our Society will be ex

assignment. The endocrine response to surgery has been included. The review is confined to publications in English. Rather than merely to acknowledge briefly the contents of a series of disconnected articles, we have charted a rather deliberate course through the field of "surgical endocrinology," taking due note of the publi­ cat ions encountered along the way. The objective has been to provide both a balanced discussion and an effective survey of the pertinent recent litera­ ture. In view of both space and subject limitations, some rather arbitrary re­ strictions have had to be imposed. The following topics will be considered: (a) the endocrine response to major surgery; (b) hypophysectomy for ad­ vanced cancer; (c) the thyroid; (d) the parathyroids; (e ) the thymus; (f) the pancreas (limited to diseases of the islets of Langerhans) ; (g) the adrenal cortex; (h) the adrenal medulla; and (z) the" ovary and testis.

In clinical lung allotransplantation, the recipient's remaining diseased lung has caused severe ventilation perfusion imbalance in the graft. We have performed one-stage bilateral lung replantation on 26 dogs as a prototype for possible future solution of this physiologic problem. Pulmonary edema was the main cause of death. Ten dogs lived more than 1 month after operation; seven are still alive and vigorous up to 6 1/2 months. X-ray films of the chest, pulmonary arterial pressures, angiograms, and blood gas levels are normal. Conclusions are that (1) pulmonary edema is proportional in severity to the degree of anoxic damage to the graft, and is potentially reversible; (2) one-stage total pulmonary denervation is readily tolerated by the dog; and (3) simultaneous bilateral lung replantation with long-term survival and nearly normal dynamics of ventilation and pulmonary circulation is feasible.

T HE PROBLEMS which may arise before, during and following gastric surgery are of intense interest to a wide spectrum of physicians. Perhaps no other truly major operation is performed more often by the general surgeon than is subtotal gastrectomy. It is the purpose to review 604 consecutive cases of gastric surgery performed largely for peptic ulceration and neoplasia. In the course of this survey the pathophysiologic mechanisms involved in certain common and less common complications will be examined. The emphasis will be placed on relatively early complications, since in some circumstances too little time had elapsed since operation to permit valid analyses regarding the incidence of late complications such as marginal ulceration. More than one-half our patients had a follow-up period of less than five years.

The early history of the Society for Surgery of the Alimentary Tract has been reviewed, and the remarkable progress in gastrointestinal surgery over the first 25 years of its existence has been acknowledged. The challenging dimensions of the problems that remain unsolved have been emphasized, and the directions that fruitful research may take in the next quarter century have been suggested. The alimentary tract surgeon will be called upon to adapt to change, and to move into new fields of clinical physiology and surgery. The discoveries and progress to be anticipated in the years to come are vast.

New Zealand White rabbits were exposed to cold (8°C) and their ears heated selectively by thermal radiation for short periods. Although other skin temperatures remained unchanged, the mild heating of the ears to 30°C inhibited shivering and resulted in a substantial decrease in oxygen consumption and internal body temperature. These observations indicate the presence of thermal receptors in rabbits' ears and their importance in thermoregulation.

Autotransplantation of the kidney provides a means of preserving renal function without nephrostomy when high ureteral injury cannot otherwise be corrected. A case is reported in which the right ureter, placed behind an aortic prothesis 6 yr earlier, was unwittingly severed during resection of a large aneurysmal homograft with insertion of a Teflon bifurcation replacement. The ureteroureteral anastomosis became strictured. The left kidney was hydronephrotic and right nephrostomy was associated with repeated infection. The right kidney was successfully transplanted to the right iliac fossa, the renal artery being anastomosed to the external iliac artery and the renal vein to the external iliac vein. The ureteral segment was readily implanted into the bladder. Postoperative studies revealed increasingly efficient function of the autotransplanted kidney as reflected by indigo carmine excretion, renal scanograms, and excretory urogram.

HEART TRANSPLANTATION has interested many investigators. 1-5 Studies of related problems were begun in our laboratory in 1956. Webb and his associates studied such factors as practical methods for homologous cardiac transplantation, 6 cardiopulmonary transplantation, 7-8 restoration of function of the refrigerated heart, 9 and cardiac metabolism as influenced by ischemia and refrigeration. 10 The operative mortality was high, but extended survival of some dogs with orthotopic homotransplants was achieved. Collateral studies were conducted by other members of the department. 11-14 Thus, in the spring of 1963, Webb and the senior author (J.D.H. ) considered that the laboratory and clinical heart work justified a planned approach directed toward eventual heart transplantation in man. This objective, a natural outgrowth of transplantation research, was cleared with the administrative officials of the University Medical Center. It remained for us to evaluate further the methods available for preservation of the heart during its transplantation. While