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The patient was an 88-year-old woman with a 10-year history of hypertension. She was suspected to have been hit by a car. At the time of the event, she was conscious and able to stand on her own and had no obvious injuries. She was sent home, but she lapsed into unconsciousness and was nonresponsive after 2 hours. She was sent to the hospital, and her heartbeat and breathing stopped. After half an hour of rescue attempts, her heartbeat did not recover, and she was declared dead. During the autopsy, a small subcutaneous hemorrhage was observed below the right knee joint. No obvious internal organ injuries or bone fractures were observed. The deceased also had mild atherosclerosis in the coronary arteries and an old cerebral infarction in the right cerebellum. The tissue histopathological tests showed distinct fat embolism in multiple organs, including the brain, lungs, kidneys, liver, and pancreas. A postmortem blood biochemistry test of the heart blood showed that the levels of low-density lipoprotein, cholesterol, triglycerides, and free fatty acids in the blood were increased, and the level of C-reactive protein was elevated. According to the autopsy results, the direct cause of death was multiorgan fat embolism. This case suggests that aging, hypertension, and hyperlipidemia may be risk factors for nontraumatic fat embolism under stressful conditions.

Context: Deep vein thrombosis (DVT) is a well-known complication of spinal cord injury (SCI). Low-molecular-weight heparin (LMWH) may be used in SCI patients who develop DVT, but can lead to subcutaneous bleeding. If subcutaneous bleeding occurs, then lymphedema, cellulitis, muscle or tendon tearing, or baker’s cyst rupture should be considered in the differential diagnosis. Findings: Herein, we present a 61-year-old female patient who was hospitalized for rehabilitation due to paraplegia, and used LMWH due to DVT development. The patient suddenly developed pain, swelling, and discoloration of the left lower extremity. Although subcutaneous hemorrhage was considered initially, ultrasound and MRI revealed a ruptured Baker’s cyst. In addition to supportive therapy, ultrasound-guided aspiration was performed. Conclusion/Clinical Relevance: In this report, we present a case of clinically severe Baker’s cyst rupture, which occurred in the lower extremity of a SCI patient using LMWH due to DVT in the same extremity. To our knowledge, no similar cases have been reported.

Objective: Patients with severe motor and intellectual disabilities (SMID) often develop complications, including paralysis of the extremities due to abnormal muscular tonicity. Furthermore, the incidence of sudden death, which may be caused by pulmonary thromboembolism (PTE), is approximately 4.2%. Deep vein thrombosis (DVT) is attracting attention as an embolic source. In this study, DVT was confirmed in SMID patients by lower extremity venous ultrasound. The oral anticoagulant, warfarin, and novel oral anticoagulant, edoxaban tosilate hydrate, were administered, and their efficacies and safeties were evaluated. Materials and Methods: DVT patients were randomly allocated to warfarin and edoxaban groups. The frequency of hemorrhagic events and incidence of adverse events were investigated to evaluate efficacy and safety. Results: DVT was detected in 14 (8.4%) out of 167 patients. Four (0.067/person-month) hemorrhagic events occurred in the warfarin group from subcutaneous hemorrhage due to bruises caused by postural changes. Three (0.042/person-month) events occurred in the edoxaban group due to nasal hemorrhage caused by tracheal aspiration. There was no significant difference (p=0.5383) between groups. Conclusion: No significant differences were observed in hemorrhagic events between SMID patients with DVT treated with warfarin and edoxaban.

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Veterinary forensic pathology plays a crucial role in animal death investigations. Recent years have seen increased attention given to this field in Taiwan. Here we report a grave crime that aroused public indignation in Taiwan, when in December 2015, a missing free-roaming cat was allegedly strangled by a suspect, according to witnesses. Surveillance video footage of the cruel incident surfaced that showed the cat, without visible signs of struggle, strangled by both hands of the suspect and kicked in the abdomen’s left side. The body was stored in a travel bag when found in the suspect’s motorcycle trunk three days after the cat had been missing. The radiographs revealed a suspected luxation of cervical vertebrae 6 and 7 (C6–C7). At forensic necropsy and histopathology, neck compression with subcutaneous hemorrhage at the left submandibular area, bruising of the neck, tears in the wall of the left external jugular vein, and pulmonary lesions were identified, all consistent with asphyxiation. Hemorrhages of the epidural space of the C7 vertebra, the spinal nerve at the level of C7, and surrounding soft tissues were noted. The pathological findings were in line with the suspect’s confession, the witnesses’ statements, and the video footage. The process and outcome of this case reflected society’s growing awareness of animal welfare and the increased attention that the authorities are giving crimes against animals in Taiwan, and the link between pathologic findings and the crime.

Systemic mastocytosis, characterized by infiltration of multiple organs by neoplastic mast cells, is a well-described entity in human medicine with specific criteria for diagnosis, but is ill defined in veterinary literature. Hemostatic disorders are reported in humans affected by systemic mastocytosis but have not been well described in veterinary literature. A 5-y-old, spayed female Greyhound dog had a 1-mo history of progressive ventral cutaneous edema, hemorrhage, and pain. Cytology of an antemortem aspirate from the subcutis of the ventral abdomen was suggestive of mast cell neoplasia, but no discrete mass was present. The dog was euthanized and submitted for autopsy; marked subcutaneous edema and hemorrhage were confirmed. The ventral abdominal panniculus and dermis superficial to the panniculus carnosus were infiltrated by a dense sheet of neoplastic mast cells. The neoplastic cells contained toluidine blue–positive granules and formed aggregates within the bone marrow and several visceral organs, including the liver, spleen, heart, and kidney. Diffuse edema and hemorrhage is an unusual presentation of mast cell tumors in dogs. Antemortem tests, including complete blood count, coagulation profile, and viscoelastic coagulation testing, were suggestive of a primary hemostatic defect. We discuss here the diagnostic criteria used in humans, how these can be applied to veterinary patients, and the limitations of the current diagnostic framework.

A case involving an adult dismembered body with myositis ossificans (MO) is described. A woman in her 20s was found dead in her cohabitants' room. The body had dismembered into 15 pieces. Computed tomography showed ectopic mineralization in the bilateral upper arms and thighs. On autopsy, the skin and soft tissue were in the process of adipocere formation. Darkened areas that appeared to be subcutaneous hemorrhage were distributed on the face, left chest, and back. Bilateral upper arms and thighs showed organized granulations adherent to underlying bone. Microscopically, these organized lesions represented mature bone tissue in the periphery, cartilage tissue in the middle layer, and fibrotic tissue in the central part. These were typical findings of MO. Myositis ossificans and subcutaneous hemorrhage seemed to be evidence of antemortem repetitive physical abuse. In cases of dismemberment, the absence of organs and parts of the body provide limitations to determining cause of death. In forensic fields, adult autopsy cases involving MO are rare. This is an unusual case in which MO revealed antemortem physical abuse despite dismemberment of the body.

Acquired hemophilia A (AHA) is an extremely rare and serious bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Approximately, 10% of patients with AHA have an underlying malignancy. We report on a 46-year-old man with AHA and advanced oral cancer who presented with massive bleeding after surgery. Preoperative blood coagulation tests showed no abnormalities. He underwent radical tumor resection followed by reconstruction using a free rectus abdominal musculocutaneous flap. Massive subcutaneous hemorrhage developed in his neck and abdomen on the first postoperative day. The hemorrhage remained uncontrolled, despite embolization of the responsible vessels. Subsequent laboratory data showed prolonged activated partial thromboplastin time and decreased FVIII levels. On the basis of his clinical course and the presence of the FVIII inhibitor, we speculated that the patient suffered from AHA. We administered recombinant activated factor VII and prednisolone, after which the spontaneous bleeding stopped and the subcutaneous hemorrhage resolved. A review of the literature identified only three previous documented cases of AHA associated with head and neck cancer. This case indicates that AHA should not be ruled out in patients with uncontrolled postoperative bleeding, while attempting to ensure bleeding control and preventing potentially catastrophic fatal consequences.

The clothing of a forty-five-year-old man became entrapped by the mixing rotator while he was operating a soybean milling machine. His clothing was wound around the rotator, and tightened around his neck and chest, causing strangulation and a loss of consciousness. He was rescued by his coworkers and transported to our hospital by helicopter. Upon arrival, he regained consciousness. A physiological examination revealed multiple petechiae on his face and strangulation marks with subcutaneous hemorrhage on his neck and upper trunk. In addition, he had motor weakness of the right upper extremity and bilateral paresthesia from C5 to Th1. All radiological studies were negative. He was admitted for observation. After the patient’s creatine phosphokinase level peaked and his focal neurological signs improved, he was discharged on foot on the 6th hospital day. Accidental ligature strangulation with cervical nerve root injury, in which an article of clothing is caught in an electrical machine and strangles the wearer, is very rare. This case is presented for its rarity and the unique pattern of injury.

Background The distal transradial approach (dTRA) for coronary catheterisation is a newly introduced alternative to the conventional transradial approach. This technique is expected to decrease the incidence of haemorrhagic complications and improve patient comfort. However, limited data are available regarding the application of this technique in patients with acute myocardial infarction (AMI). This study investigated the feasibility and safety of the dTRA for primary percutaneous coronary intervention (PCI) in patients with AMI. Methods This study included patients with AMI who underwent primary PCI via the distal radial artery across 3 Japanese hospitals between January 2018 and January 2019. Patients' background, procedural characteristics, and clinical outcomes including the incidence of haemorrhagic complications were analysed. Results This study enrolled 95 consecutive patients with AMI, including 68 patients (71.6%) with ST-segment elevation myocardial infarction (STEMI), in whom distal radial artery puncture was attempted for primary PCI. The patients included 70 men (73.7%), and the mean age was 72.2±12.4 years. Among these patients, cannulation was successfully performed in 89 patients (93.7%). A 5-, 6-, or 7-French sheath (conventional or slender) was used in this study. Cannulation was performed using a forearm radial artery approach in patients in whom dTRA failed. PCI was successfully performed in all patients. The meantime to achieve haemostasis was 6.3±5.3 hours, and no major bleeding complications occurred. Based on The Early Discharge After Transradial Stenting of Coronary Arteries trial haematoma scale, grade I, II, and III subcutaneous haemorrhages were observed in 16 (16.8%), 4 (4.2%), and 1 patient (1.1%), respectively. No patient developed a haematoma > grade IV. In patients with STEMI, the mean door-to-balloon time was 39.4±31.9 min, and the mean puncture-to-balloon time was 19.7±14.2 min. Conclusions The distal radial approach is feasible and safefor primary PCI in selected patients with AMI.The application of the dTRA may serve as a less invasive strategy for the treatment of patients with AMI.

Rationale: Felty syndrome is a rare and life-threatening type of rheumatoid arthritis (RA). Patient concerns: A patient with RA had skin rash and subcutaneous hemorrhage, with a significant decrease in blood hemoglobin (Hb), white blood cell count (WBC), and blood platelet count (BPC). Diagnoses: The patient had a history of RA, splenomegaly, decreased Hb, WBC, BPC, and normal immunological indexes, combined with a series of bone marrow related tests and genetic tests. Interventions: She was given high-doses of glucocorticoids intravenously, followed by oral prednisone and cyclosporine maintenance therapy. Outcomes: Her symptoms were resolved within 2 weeks after the start of immunosuppression. After 2 weeks of discharge, the Hb, WBC, BPC basically returned to normal, and prednisone gradually decreased. Lessons: Felty syndrome is a rare complication of RA. Reductions in Hb, WBC, BPC, and subcutaneous hemorrhage should be considered strongly as the possibility of Felty syndrome. Multi-disciplinary diagnosis and related tests of bone marrow and genes are helpful for diagnosis and correct treatment.

Aim: Hemorrhage is an important complication of heparin-thromboprophylaxis after surgery. We attempted to clarify the incidence rate of prolonged activated partial thromboplastin time (APTT), representative of hemorrhagic tendency, in Japanese women who received thromboprophylaxis with unfractionated subcutaneous heparin administration after cesarean section (CS). We also determined factors which affected postoperative APTT. Methods: We studied 280 women who were administered thromboprophylaxis with unfractionated subcutaneous heparin 5000 IU two times per day after CS. Postoperative APTT under heparin was measured and the incidence of its prolongation was determined. Preoperative APTT, blood loss during surgery, postoperative hematocrit, postoperative serum total protein level, and postpartum body weight were measured, and their correlation with postoperative APTT was determined. Results: Preoperative and postoperative APTT values were 28.3 (26.7–30.3) and 33.8 (31.0–37.5) seconds for median (interquartile range), respectively. Overall, 7.1% of patients showed ≥45 s postoperative APTT. Two patients (0.7%) showed ≥60 s APTT, one of whom suffered subcutaneous hemorrhage around the abdominal incision with complete healing. There were no other hemorrhagic complications. Preoperative APTT positively, and postpartum body weight inversely, correlated with postoperative APTT. The amount of blood loss, postoperative hematocrit, and postoperative serum total protein level did not correlate with postoperative APTT. No discernible deep vein thrombosis or pulmonary embolism occurred. Conclusion: Although 7.1% of women under heparin-thromboprophylaxis showed a prolonged APTT that was 150% of the preoperative APTT, serious side effects were not observed. Subcutaneous administration of unfractionated heparin, if checking APTT prolongation 1 day after surgery, may be safe method of thromboprophylaxis after CS.

We report a case of infective endocarditis of the mitral valve, which was accompanied by pulmonary emboli traveling through an atrial septal defect. An 18-year-old male was admitted to our hospital due to a fever, polyarthritis and subcutaneous hemorrhage. Transthoracic echocardiography revealed a mobile mass and possible vegetation lodged in the mitral valve and a secundum-type atrial septal defect. Computed tomography revealed a hepatic, splenic and renal embolic infarction. During antibiotic therapy, he felt a sudden right flank pain. Follow-up computed tomography revealed a pulmonary embolic infarction that drifted through an atrial septal defect. This association is the first report, of pulmonary emboli which migrated through an atrial septal defect from the mitral valve.

Necrotizing fasciitis is relatively rare. We report a case of necrotizing fasciitis secondary to anorectal abscess. A 32-year-old man was admitted to the hospital because of perianal pain. The patinet had had incision and drainage for anorectal abscess on outpatient base at a clinic, but the condition was aggravated. The patient was admitted to the hospital when the seemed very sick and showed oliguria and shock. At the right side of his anus there was seriously gangrenous skin with erosion and subcutaneous hemorrhage. We performed additional incision, drainage and resection of necrotic tissue 11×6cm in size under spinal anesthesia. There was neither purulent discharge nor muscular involvement. After the surgery the patient was transferred to the intensive care unit, because shock and acute renal failure persisted since before surgery and respiratory failure subsequently occurred. Despite our treatment, he died of DIC and MOF three days after admission. Culture yielded Escherichia coli and Bacteroides. We consider that our case was compatible of necrotizing fasciitis. Necrotizing fasciitis is surgical emergency with high mortality rate. Early diagnosis and wide resection of necrotic tissue are very important.

Objectives Intracavernous needle injection is an effective delivery method for pharmacotherapy of erectile dysfunction. Needle phobia, pain, and concern about local tissue injury have stimulated the search for new, less invasive means of inducing penile erection. In this preliminary communication, we evaluate a jet injector as an alternative to needle injection for intracavernous delivery of vasoactive drugs. Methods Jet injection was evaluated in three groups of rats receiving either India ink, saline, or papaverine into the penis. The ability of the jet injection to penetrate through the tunica albuginea and deliver liquid to the corpora cavernosa smooth muscle was assessed by the degree of staining within the corpus cavernosum (ink group), histologic change (saline group), and rise in intracavernous pressure (papaverine group). Erectile capacity following cavernous nerve electric stimulation was compared before and 1 hour after injection of saline or papaverine. Results Ink traversed the skin and tunica albuginea with extensive deposition noted within the cavernous spaces. Varying degrees of subcutaneous hemorrhage were seen with saline jet injection; however, the corpus cavernous smooth muscles showed no evidence of injury. Jet injection of papaverine 3250 gmg significantly increased cavernous pressure (39.4 ± 4.6 cm H2O) compared with saline injection (2.8 ± 1.3 cm H2O). Conclusions We conclude that acute jet injection is an effective method for intracavernous delivery of drugs. Long-term effects should be evaluated prior to clinical use.

Abnormal development in Bh quail embryos was histologically examined. In addition to the abnormal plumage pigmentation in Bh-heterozygotes and homozygotes, and subcutaneous hemorrhage and liver degeneration in homozygotes as previously reported, the lungs in all 10-day homozygotes examined showed hemorrhage, suggesting that the Bh gene may also be expressed in this organ. Other organs, including the esophagus, the gizzard, the small intestine, the large intestine, the pancreas, the metanephros, the heart, the gonads and the hemopoietic organs in heterozygotes and homozygotes were histologically normal on days 7 and 10, though the development of homozygotes was slightly delayed. Primordial germ cells and hemopoietic cells were normally developed in gonads and hemopoietic organs such as the bursa of Fabricius and the spleen of the homozygote, respectively. These results suggest that Bh is a mutation inducing pleiotropic effects such as plumage pigmentation changes in both heterozygotes and homozygo...

We report a rare case in which life-threatening subcutaneous hemorrhage following minor blunt trauma developed in an elderly patient taking ticlopidine and aspirin. An 82-year-old woman taking ticlopidine and aspirin tripped on a road. She noted only mild pain at the left lower abdomen. However, the hematoma gradually enlarged, and she developed hemorrhagic shock. Emergently performed contrast-enhanced abdominal computed tomography showed a large hematoma (20 x 10 x 7 cm), including contrast extravasation, which was located beneath the skin of the left lower abdominal quadrant and within the external and internal oblique muscles. Emergency pelvic arteriography showed massive contrast extravasation from the left superficial iliac circumflex artery. Transcatheter arterial embolization (TAE) was successfully performed, using gelatin sponge pledgets and micro-size stainless steel coils. After TAE, hemodynamics stabilized. The patient was discharged uneventfully on day 12.

The incidence of acute massive hemorrhage in hemodialysis (HD) patients is thought to be higher than in healthy individuals, and a large, expanding subcutaneous hematoma can result in necrosis of the overlying skin. We evaluated the efficacy of intra-arterial treatment for acute massive subcutaneous hemorrhage in HD patients. Seven HD patients with subcutaneous hemorrhage following minor blunt trauma were treated using superselective transarterial embolization, between July 2005 and October 2012. After examining the site of the hemorrhage using contrast-enhanced computed tomography (CT), embolizations were performed using microcoils, gelatin sponges, or N-butyl cyanoacrylate. Hematoma evacuation or skin grafting was performed as needed. Four men and three women with a mean age of 70 years (range, 63-82 years) comprised the study population. Sites of bleeding were as follows: lower leg (N = 3), upper leg (N = 1), buttock (N = 1), precordia (N = 1), and forearm (N = 1). Blood transfusions were administered to five cases. All patients were successfully salvaged using transarterial embolization. Six patients underwent hematoma evacuation after transarterial embolization, and two patients underwent split-thickness skin grafting for skin necrosis. We established a treatment strategy for HD patients with acute subcutaneous hemorrhage. Immediate confirmation of the site and the degree of bleeding with contrast-enhanced CT and early treatment using the transarterial embolization and as needed, hematoma evacuation are effective for preventing skin necrosis in HD patients with acute subcutaneous hemorrhage.

Head injuries can be broadly divided into blunt force and penetrating, or closed and open injuries, simple in concept, but infinitely variable in individual cases. The types of injuries are limited in number, but extremely complex in each case. In this chapter, types of head injuries are listed and reviewed in turn with illustrated case examples. The scalp provides an ideal anatomic arrangement for development of abrasions, contusions, and lacerations because of scalp soft tissue overlying the hard, rounded bony prominences of the cranium. Traumatic subcutaneous hemorrhage of the scalp may be broadly localizing, but when it underlies an abrasion, contusion, or laceration, it would be an indicator of the impact point. The biomechanics of the mechanisms at play in skull fractures are relevant in assessing types and directions of forces occurring in any injury. Head injury potentially results in a wide variety of consequences that interact in complex ways. A common method of categorizing these consequences is to divide them into primary and secondary effects. Primary effects result from direct injury to central nervous system (CNS) parenchymal and supporting structures. Secondary vascular effects may include events, such as external compression due to brain parenchymal swelling or hematoma, hydrocephalus, an increase in intracranial pressure, impaired reactivity to physiologic stimuli, vascular dilatation; vascular spasm, thrombosis or embolism, infarction, abnormal vascular permeability with tendency for edema and/or hemorrhage, and traumatic aneurysms or arteriovenous fistulae. The role of immediate post-head injury apnea as a contributory factor in subsequent events, leading to hypoxic-ischemic CNS injury, has been increasingly appreciated.

Endoscopic Sinus Surgery (ESS) is generally accepted as a safe surgery, however, surgeons who have poor understanding of surgical anatomy and variation of paranasal sinus cause troubles such as injury lamina papyracea, blood vessel and ethmoid roof (CSF leak) during surgery. Orbital tissue injury is the most frequent among the problems of sinus surgery. When only orbital fat tissue is pulled out, the patient will have just edema and subcutaneous hemorrhage around the eye. However, if the orbital muscle, especially medial rectal muscle, is injured, disturbance of eye movement occurs. Severe bleeding during surgery generally causes these problems, because surgical field is not identified under endoscope. Therefore, the important things which prevent injury and perform safe surgery are as f of lows : 1. Full knowledge of surgical anatomy 2. Manipulation of forceps under clear observation 3. Control bleeding, pain and blood pressure by sufficient anesthesia 4. Selection of appropriate forceps and correct manipulation of forceps 5. Adequate and quick treatment for injuries.

An unusual case of traumatic basal subarachnoid hemorrhage (SAH) due to a mechanical tear of the basilar artery is reported. A 70-year-old man who had been suffering from cerebrovascular dementia was found dead in a ditch. Externally, subcutaneous hemorrhage with abrasions was observed on the left side of the forehead, face, and lower jaw, together with small contusions in the left superciliary arch. Internally, a 3-mm-long transversal tear of the basilar artery was observed, and dislocations of both C6-C7 and T1-T2 as well as a small fracture of the processus spinosus of C5 were found. No pathological vascular lesions such as aneurysms and vasculitis, other than arteriosclerosis, were observed in the vertebral-basilar system. Ethanol was not detected in the intracardiac blood or in the urine. These findings indicate that when the man fell into the ditch, severe hyperextension occurred as a result of minor blunt forces to the face, and that the traumatic tear of the basilar artery was mechanically caused by overstretching due to hyperextension of the head. It is also suggested that due to his advanced age the muscle tone of the neck might have declined, impairing its defense action, and that head hyperextension might, therefore, occur rather more readily under such conditions.

A 49-year-old man collided against an infielder when he slid into second base during a recreational baseball game. He was unable to continue in the game due to diffuse pain and swelling of his hindfoot. A rupture of the Achilles tendon was diagnosed incidentally on palpation and observation of a positive Thompson's squeeze test. Subcutaneous hemorrhage at the lateral aspect of the heel and a small bone fragment under the lateral malleolus on an anteroposterior plain radiograph indicated a fracture of the calcaneal wall. At surgery, a complete rupture of the Achilles tendon and an avulsion of the calcaneofibular ligament from the calcaneal wall were seen. Both injuries were surgically repaired, and the patient subsequently did well. The mechanism of injury was thought to be impact hyperdorsiflexion of the ankle with rupture of the Achilles tendon accompanied by an inversion injury. Using a literature search, it was found that this combination of injuries has not been previously reported.

Hirschsprung's disease has been considered to cause intestinal perforation in rare cases. Even if a perforation occurs, the majority of cases are associated with the long-segment or total colonic type. Our case developed the perforation in the neonatal period in spite of being of the recto-sigmoidal type, and it affected the cecum. We do not have a good explanation for this condition. However, the pathological examination of the specimens of the perforated cecum revealed some necrosis (ulceration, subcutaneous hemorrhage, congestion and severe edema) which was considered to be caused by ischemia, secondary to a localized vascular accident in the wall of the distended intestine.

Adult bullfrogs, Rana catesbeiana, were exposed to water supersaturated with atmospheric air. Exposure to a differential pressure (δP) of 250 mm Hg [total gas pressure (TGP) = 132.9% of atmospheric pressure] resulted in a 40% mortality within one day owing to the accumulation of gas in the vascular system. Exposure to a AP of 128 mm Hg (TGP = 116.8%) for four days had no effect on bullfrog mortality, but produced subcutaneous gas bubbles in the webbing and on body surfaces, followed by hyperemia (tissue engorged with blood through blood vessel dilation), and petechial (small subcutaneous hemorrhage spot) and ecchymotic (large subcutaneous hemorrhage spot) hemorrhaging. Owing to accumulation of gas under the skin, these frogs typically floated and were unable to remain submerged. These clinical signs are similar to those commonly reported for “redleg” disease syndrome in bullfrogs. When held at a δP of 67 mm Hg (TGP = 108.8%) for 27 days, no clinical signs of gas bubble trauma were observed.

It has been found that the intradermal inoculation into rabbits of influenza virus (PR 8) suspensions caused edema, erythema and sometimes slight subcutaneous hemorrhage. Microscopically, infiltration of leucocytes, dilatation of blood capillaries, hemorrhage and edema in corium and degeneration of the epithelial cells were observed.Hemagglutination titer in the site of the inoculation was decrease rapidly within 24 hours after inoculation, and multiplication of the virus could not be detected at the site.Active immunization could not inhibit completely the production of skin lesion, but skin lesion-producing effect of the virus was neutralized by antiviral serum.Skin lesion-producing effect of the virus was destroyed markedly by inactivation of the virus with merzonin, heat or ultraviolet irradiation, and it was strengthened by sonic vibration and by repeated freezing and thowing. These features were similar to the results obtained in lung consolidation-producing effect and lethal effect of the virus in mice.Some autonomic blocking agents and corticosteroid hormone had almost no effect on the production of skin lesion by the virus except tetraethylammonium bromide had slightly inhibitory effect.

It has been previously reported that a filterable microorganism belonging to the genus Leptospira has been recovered from the blood or organs of human beings suffering from the disease known as yellow fever in Guayaquil, and that the organism, which has been termed Leptospira icteroides, induces in certain experimental animals the characteristic symptoms and lesions observed in the patients from whom it was isolated. It has also been previously shown that the serum from patients recovering from an attack of yellow fever in Guayaquil had the power to agglutinate and dissolve the organism when introduced into the peritoneal cavity of a normal guinea pig (Pfeiffer phenomenon). Moreover, the guinea pigs which had once been inoculated with the blood of yellow fever patients without succumbing to the infection, notwithstanding the fact that they had shown a definite febrile reaction after 4 to 5 days, were found to be refractory to a subsequent inoculation of a culture of Leptospira icteroides All these observations pointed to the possible relation of this organism to the disease known as yellow fever in Guayaquil. The demonstration of the filterability of the organism and the transmission of the infection with the same organism by Stegomyia calopus have further strengthened the probable etiological significance of the organism in yellow fever. It was by no means a simple problem to determine the relation existing between Leptospira icteroides and Leptospira icterohæmorrhagiæ. An experiment reported in a previous paper seemed to justify the view that the two leptospiras are closely related but not identical, yet it was necessary to exhaust various other modes of differentiation before the distinction between them was firmly established. The present paper continues this phase of the inquiry in further detail. There have been taken up here the phenomena of agglutination, the reaction of Pfeiffer, complement fixation, the protective properties of various monovalent and polyvalent immune sera, and active immunity. As the result of experiments in connection with these immunity phenomena the following data are presented. Monovalent immune sera prepared by several successive injections in an animal naturally refractory to Leptospira icteroides possess the power to agglutinate in vitro not only the homologous strains, but also all other strains of icteroides tested. On the other hand, a slight effect, or none at all, has been observed when these immune sera have been mixed in vitro with various strains of Leptospira icterohæmorrhagiæ. A similar relation exists between the monovalent anti-icterohæmorrhagiæ sera and the various strains of Leptospira icteroides; that is, there is a slight agglutinating effect in some instances upon the icteroides strains, but it is never so strong as that occurring in tests against the icterohæhagiæ strains. The Pfeiffer reaction gave a sharper differentiation between the two groups, for in most instances the phenomenon was specific for the group. There were occasional doubtful reactions, but not enough to warrant a confusion of the two groups. Polyvalent immune sera, one specific for icteroides, and the other for icterohæmorrhagiæ, showed a high titer of neutralizing power for the cultures of the homologous groups. It was found, however, that the action of the sera is by no means absolutely specific, because the injection of a sufficient amount of the anti-icteroides serum apparently prevented a fatal outcome in a guinea pig inoculated with multiple minimum lethal doses of a culture of Leptospira icterohæmorrhagiæ, and vice versa. The specificity of the serum was demonstrated only when it was used in smaller quantities. More or less specificity was shown by the complement fixation reaction, but it was not absolute. Weak fixation occurred when the anti-icteroides serum was mixed with one or the other of the icterohæmorrhagiæ strains and vice versa, and strong fixation occurred only when the antiserum was mixed with one of the icteroides strains. The question naturally arises whether or not this apparent specificity is due to the homology of the serum and not altogether to a difference in genus of the strains. In other words, it is justifiable to question whether all these variations in the degree of intensity of the reaction are not due to strain variations of the same genus. This question is not finally settled by the present investigation, in which only four icteroides and nine icterohæmorrhagiæ strains have been carefully studied. Nevertheless, on the basis of the findings with these thirteen strains, it seems probable that Leptospira icteroides and Leptospira icterohæmorrhagiæ are closely allied but are nevertheless distinct in their immunological reactions. Perhaps the difference between the two may amount to that between subspecies or races. It has been pointed out earlier that the pathogenicity of the two is also distinct, inasmuch as icteroides produces chiefly icterus and nephritis and icterohæmorrhagiæ hemorrhage and nephritis, the icterus being less and the hemorrhage more prominent in the evolution of the latter infection. In the study of active immunity—exclusive of vaccination—difficulty has been experienced in the evaluation of the results, owing to the existence of natural resistance to infection among guinea pigs. A guinea pig may recover from the inoculation of Leptospira icteroides and then resist a subsequent inoculation with a virulent strain of Leptospira icterohæmorrhagiæ, a condition simulating that brought about by the identity of the two organisms. However, the refractoriness of such an animal to icterohæmorrhagiæ may be due to its natural immunity to it. In the present study, therefore, only those guinea pigs were selected which had reacted typically—though in mild degree —to the icteroides infection, in order to determine whether they were subsequently immune to the inoculation of icterohæmorrhagiæ. Indeed, by this mode of experimentation it was found that the guinea pigs which had once passed through an attack of the icteroides infection were absolutely immune to a second infection with the same organism but reacted severely and sometimes fatally to a later inoculation of icterohæmorrhagiæ. Although there were a number of instances in which a previous infection with icteroides did not confer any perceptible immunity upon the guinea pigs against icterohæmorrhagiæ, another group of guinea pigs showed a considerable resistance to the icterohæmorrhagiæ infection as compared with those which had never been inoculated with icteroides. There is not much doubt, therefore, that an icteroides attack brings about, in some instances at least, a certain degree of resistance to the icterohæmorrhagiæ infection. Hence the study of the phenomena of active immunity strongly indicates that icteroides is closely related immunologically to icterohæmorrhagiæ.

SummaryChicks reared for 4 weeks on a modified non-fat milk diet deficient in copper developed mild anemia, leg weakness, bone deformities and a high incidence of subcutaneous hemorrhage. Mortality amounted to 23% and most deaths resulted from internal hemorrhage associated with rupture of major vessels. Histologic studies suggest a derangement of connective tissue metabolism with the major defect in elastic tissue.

It is not an infrequent experience to see a subcutaneous hemorrhage in the eye-lid or conjunctiva localized not always ipsilaterally but sometimes contralaterally after an Oto-Rhino-Laryngological operation, especially after a sinus operation.In order to eludidate the cause of the hemorrhage, the author performed the following experimental study on the rat: croton oil was injected into the tissue of the wall of the paranasal sinus or into the buccal mucosa through the lip. Ipsi- or contralateraly located palpebral hemorrhage was obeerved to occur following the injection.Histological study of the palpebral tissue revealed that the lesion was mainly due to the vascular disturbance with edema, vaso-dilatation, stagnation of blood cells and hemorrhage, as well as localized necrosis in severly damaged areas.Lesions were also found in the lungs, liver, kidneys and other organs. Suzuki. Iida and Fukazawa described similar lesions due to vascular disturbance in those organs of the pig produced as a manifestation of the Reilly's phenomenon.In the author's experiment, intensity of the palpebral hemorrhage and of the lesions in those organs pararelled with each other.These facts has induced the author to interprete the hemorrgagic lesion in the eye-lid as a manifestation of the Reilly's phenomenon.

The treatment of pregnant rats with Phenobarbital, 50 mg. per kilogram of body weight, throughout gestation results in a significant increase in embryonic death and a 28 per cent incidence of fetal subcutaneous hemorrhage. Placentas of treated animals weighed less than controls and exhibited a significant increase in demethylation activity. The results of this investigation indicate that Phenobarbital stimulates hepatic demethylation of aromatic amines in the maternal but not the fetal liver. No changes in milk production and mammary gland deoxyribonucleic acid (DNA) content occurred as a result of drug administration.

A 72-year-old man underwent aortic valve replacement and coronary artery bypass graft using cardiopulmonary bypass with right axillary artery cannulation. After undraping, petechial and subcutaneous hemorrhage with blister formations were found in right upper extremity. Axillary artery cannula was considered to compress right subclavian and disturb venous return in the right subclavian vein, which caused an acute compartment syndrome during cardiopulmary bypass. This case was a rare,but severe complication of cardiopulmonary bypass with right axillary artery cannulation.

H. McC., aged 2, was brought to Children's Hospital at Denver from Lead, S. D., with a history of having swallowed a jackstone one week previously. Two unsuccessful attempts to remove the foreign body had been made, and as a result the boy was in a serious condition, with high fever and rapid pulse. Physicial examination showed interstitial emphysema of the neck and of the supraclavicular fossae, with some mottling of the skin in the latter regions due to subcutaneous hemorrhage, presumably from a laceration in the esophagus. Roentgenograms showed the presence of a jackstone in the esophagus at the level of the manubrium. Mediastinal emphysema was seen to be present, extending downward around and below the heart and upward into the neck. Roentgenograms taken subsequently, after the patient had ingested a small amount of barium sulfate, showed evidence of an opening in the esophagus, with some of the swallowed

To the Editor.— Although this is an important finding, most pigmented nail bands seen in clinical practice are due to less esoteric causes. A host of factors can be related to local or diffuse discoloration of the nail bed or nail plate, and many of these have characteristic physical findings. Subcutaneous hemorrhage, the most common cause of darkening of part of a nail, is usually accompanied by a history of pain or trauma. Pigmentation of the nail caused by chromogenic fungae is accompanied by onycholysis. Multiple bands can be seen in patients with Peutz-Jeghers syndrome1,2and some drugs, such as antimalarials, can produce longitudinal pigmentation in the nail bed. Increase in melanin in the nail bed is also seen with vitamin B12deficiency3and pinta.4 Narrow pigmented bands which extend from the proximal nail fold to the distal free edge in an otherwise normal nail suggest

To the Editor.— Hemophilia is an inherited defect in coagulation characterized by persistent bleeding following trauma. Hemarthrosis represents the most characteristic type of hemorrhage but bleeding also frequently occurs from the mouth, gums, lips, tongue, gastrointestinal tract, lungs, and even intracranially. 1,2 The skin may be involved with subcutaneous hemorrhage which spreads rapidly over the body. We are unaware of any report regarding acne as a potential source of bleeding in this disease. Recently, we have done follow-up studies on two brothers with classical hemophilia, one of whom experienced prolonged bleeding into nodular cystic lesions of acne. Report of a Case A 17-year-old white boy with a one year history of progressively severe acne involving his face, shoulders, and back was referred to the Acne Clinic of the Hospital of the University of Pennsylvania. The patient also suffered from hemophilia A with a factor VIII level of less than