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The usefulness of serum amylase determinations in evaluating and quantitating experimental canine pancreatitis is controversial. Serum amylase in the dog is normally 20 to 30 times higher than in man. On the other hand, some authors have stated that amylase is not normally excreted in dog urine. To evaluate the use of amylase determinations in experimentally produced canine pancreatitis, the pancreatic duct was ligated in five dogs, and serum and urine amylase measured daily for 9 days. The amylase methods used in this study had bypassed maltase activity, the cause of canine hyperamylasemia, but elevated serum levels were still found preoperatively. The techniques compared consisted of an automated Somogyi saccharogenic process expressed in maltose units percent, and an amyloclastic (Amylochrome) method; neither measured maltase. These methods correlated well; both serum and urine values had a P value at the 0.001 level. Postoperatively, serum amylase rose 30 to 40 times preoperative levels, and amylase appeared within 3 days after serum elevations in these animals. Possibilities for canine hyperamylasemia include a multienzyme complex producing erroneously high amylase values, increased amylase production, and lack of excretion or degradation of amylase. A fourth possibility, that of a macroamylase molecule in dog serum, was disproved by a rapid detection column method which revealed no abnormal amylase. The measurement of amylase clearance corrected by creatinine clearance was valueless because of decreased urine excretion. Whereas CAm/CCr percent in man is normally from 1 to 4%, it was found in this study that the canine preoperative average was 0.066%. These results emphasize again the marked differences in the behavior of the canine and human amylase systems, and for this reason, experimental studies of pancreatitis in the dog should be interpreted with caution.

The clinical, radiologic and pathologic features of 37 patients diagnosed as having primary sclerosing cholangitis (PSC) were reviewed. Sixty-two per cent were men, and 35% had ulcerative colitis. The patients demonstrated considerable variability in their natural history and pathology. It appeared that they could be divided into four fairly distant groups (1) sclerosing cholangitis affecting primarily the distal common bile duct; (2) sclerosing cholangitis occurring soon after an attack of acute necrotizing cholangitis; (3) chronic diffuse sclerosing cholangitis; and (4) chronic diffuse sclerosing cholangitis associated with inflammatory bowel disease. It is suggested that the patients in these groups may have different etiologies, may respond to different treatment regimes, and may have different prognoses.

Operative endoscopy of the biliary system has been employed with ever increasing frequency at the UCLA Hospital during the last three years. In addition to its established value with respect to disclosing unsuspected stones in the bile ducts, choledochoscopy has been of great value in terms of more accurate diagnosis and staging of periampullary and bile duct neoplasms. It has been observed that many biliary tract carcinomas are multicentric in origin and that cholangiography is not adequate to identify small intrahepatic ductal lesions. More than one cell type of bile duct carcinoma may be present in the same patient. Choledochoscopy should be used in addition to the conventional criteria for resectability in all patients with ductal or periampullary carcinoma. Use of this technic will spare some patients needless radical procedures and should improve long-term cure rates by identifying those patients with truly localized disease for curative resections.

Sclerosing diseases of the biliary system encompass a spectrum ranging from primary sclerosing cholangitis (usually of the extrahepatic biliary tree) to primary biliary cirrhosis of the intrahepatic bile canaliculi. In a study of 35 patients with primary intra- and extrahepatic biliary sclerosis, age of onset, sex distribution, symptomatology, associated diseases, radiographic abnormalities and chemical profile were considered. The difficulty of differentiating sclerosing cholangitis and biliary cirrhosis from other causes of obstructive jaundice preoperatively was stressed, in addition to points of differential clinical and laboratory findings. The etiology of these entities as well as the possibility that they represent variant clinical manifestations of the same disease process were also considered. Mechanical and pharmacological treatment alternatives that were attempted included drainage procedures, the easiest and most widely used of which was the T-tube. However, this could prove to be a source of infection and should therefore be removed early, inasmuch as cholangitis represents a major cause of morbidity. Steroids have been used with varying effectiveness; subjective improvement was generally attained, although objective improvement has been difficult to document. When choleuretics and cholestyramine were administered, we noted significant palliation. Antibiotics were reserved for treatment of cholangitis. Until the underlying etiology of this rare malignant sclerosing process is found, only symptomatic treatment can be offered.

Sclerosing cholangitis is a nonspecific condition characterized by gross and microscopic pathologic changes of a chronic inflammatory nature involving the wall of the biliary ductal system and occasionally surrounding tissue. Primary sclerosing cholangitis (PSC) is one form of this process. Of unknown etiology, PSC generally has an unfavorable prognosis, and therefore it is important to differentiate this condition from other causes of bile duct sclerosis. Each of the various conditions producing clinical and pathologic evidence of sclerosing cholangitis demonstrates certain specific characteristics that usually enable its identification. (Table I.) In its differing forms, PSC may mimic the findings of any of the other four causes of sclerosis. We believe, however, that it would be a mistake to attempt identification of cases of PSC by a set of rigid criteria that may or may not be valid. Positive identification of this disease process must await more precise diagnostic procedures—perhaps a specific immunologic test similar to the serum antimitochondrial antibody test that Sherlock [11] has reported to be positive in 88 per cent of cases of primary biliary cirrhosis and consistently negative in surgically obstructive jaundice and cholestasis associated with the sclerosing cholangitis of ulcerative colitis. Notwithstanding our discussion of certain important specific diagnostic criteria that help to identify the various causes of sclerosing cholangitis (Table II, see pages 318–319), we must still admit that in certain patients the true cause of the biliary pathology will be established only with the passage of time. This is particularly true when PSC is suspected, and at times it is also true in cases of suspected bile duct carcinoma when positive histologic confirmation cannot be obtained. The ultimate unfavorable outcome prevalent in both of these diseases makes such an uncertain diagnosis a particularly trying position for the patient as well as his surgeon.

In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.

We have previously reported our efforts to minimize postgastrectomy symptoms in two patients with benign disease who underwent resection of the head of the pancreas and the duodenum. In these cases the pylorus and first portion of the duodenum were preserved during pancreaticoduodenectomy. Our experience has now been extended to encompass 18 patients, eight of whom were available for comprehensive evaluation an average of six months postoperation. These studies have attempted to differentiate malabsorption of pancreatic insufficiency from possible gastrointestinal dysfunction of the new alimentary connection. Pancreatic insufficiency was evaluated by a 72-hour stool collection and radioactive trioctanoate (RATO) test. Gastrointestinal absorption was evaluated by D-xylose excretion and the Schilling test, as well as serum vitamin. A, vitamin B-12, carotene, folate, iron, and total iron binding capacity. Gastrointestinal secretion and motility were assessed by using pyloric fluoroscopy, gastric barium emptying, the Hunt test, and gastric acid analysis. Finally, a questionnaire regarding clinical symptoms of postgastrectomy syndromes and malabsorption was answered. Although every patient exhibited marked pancreatic insufficiency by laboratory tests, 88% described normal formed bowel movements, and weight loss was claimed by only 25%. Other test findings were generally normal. While the follow-up period has been limited to three years, the current data demonstrate that gastrointestinal function subsequent to preservation of the pylorus has not thus far predisposed to postgastrectomy syndromes or marginal ulcers. All of the patients required intensive pancreatic enzyme replacement.

In the seventy-two years since its founding, the American College of Surgeons has changed from an organization directed toward improving the skills of a large number of poorly educated and essentially untrained physicians who were already doing surgery, to an international organization of approximately 50,000 surgeons over 95 per cent of whom have already been certified by a surgical specialty board. The College today, in addition to its numerous scientific meetings and ongoing educational programs, participates, with other organizations, in the accreditation of properly functioning hospitals, in maintaining standards of surgical training programs and in the examination and certification of candidates after the completion of the required training in approved programs. Today the College engages in a far wider range of activities than could have been envisioned by its founders and indeed, it has become an influential voice for surgery throughout the world. But its primary purpose has remained unchanged. Simply stated, it is to improve the care of the surgical patient.

Sclerosing cholangitis is a nonspecific pathological condition characterized by gross and microscopic changes of a chronic inflammatory nature; these involve the wall of the biliary ductal system and, occasionally, the surrounding tissue. Primary sclerosing cholangitis is one form of this disease (Fig. 10.1), but the lack of characteristic pathological changes and of distinguishing clinical features has made it difficult to identify primary sclerosing cholangitis as a clinical entity, to evaluate various forms of treatment, and to establish a definite prognosis of the disease.

Current reviews of the treatment of cancer of the pancreas, most of which evaluate cases treated in the past one or two decades, continue to present discouraging results. The advantages and disadvantages of performing a resection must be carefully evaluated for each patient. The dilemma of resection should be discussed with the patient before operation and when capable he or she should influence the decisions the surgeon anticipates facing during the operation. Pancreatoduodenectomy is the treatment of choice for carefully selected cases of carcinoma of the head of the pancreas and other periampullary carcinomas. Total pancreatectomy has not, at this point, been shown to provide sufficient advantages to warrant routine adoption as the treatment of choice when resection is to be performed.

Review of a 26-year experience with transduodenal sphincteroplasty and sphincterotomy was undertaken (1) to analyze critically the indications for and results of these procedures and (2) to determine which preoperative factors correlate with a good or poor outcome. Of 109 patients, 78 underwent sphincteroplasty, whereas 31 had a transduodenal sphincterotomy. Surgical indications included: group 1, 53 patients with common duct stones; group 2, 28 patients with dyskinesia or stenosis of the sphincter of Oddi (without choledocholithiasis or recurrent pancreatitis); and group 3, 28 patients with recurrent pancreatitis. Three elderly group 1 patients who presented with cholangitis died after surgery (a hospital mortality of 2.7%). Seventy-nine of the 103 patients (77%) in whom follow-up was obtained achieved an excellent or good result. Results were almost identical with sphincteroplasty and sphincterotomy. Abnormal preoperative liver function tests were the only predictors of a good postoperative outcome (p less than 0.05). Group 3 patients (good results in 63%) had significantly poorer (p less than 0.05) outcome than group 1 and 2 patients. Results were worst in group 3 patients who had undergone previous abdominal or pelvic surgery (p less than 0.025) and in group 2 patients who were narcotic users (p less than 0.025). The authors conclude that transduodenal sphincteroplasty or sphincterotomy can be performed relatively safely, but caution that careful selection of patients is important when the indication for surgery is either ampullary stenosis or recurrent pancreatitis.

As a preliminary step in studying the effect on gastric acid secretion in dogs following biliary diversion through isolated intestinal conduits, blind-ended intestinal conduits were constructed and the biliary channel was left undisturbed at this time. The results were surprising in that a significant absolute increase in gastric acid secretion occurred in all dogs, within the range of 65-286%, by merely disconnecting a segment of small bowel from the mainstream of flow of intestinal contents. This effect may be due to the "intestinal phase of gastric secretion hormone" and may in itself provide a partial explanation for the well-documented increase in gastric acid production caused by the Exalto-Mann-Williamson procedure and by choledochoenterostomy utilizing a Roux loop.

During total pancreaticoduodenectomy for chronic pancreatitis, four patients received an intraportal pancreatic mixed-cell autograft prepared by collagenase digestion. The technique of this autotransplantation procedure was successfully developed using a normal canine pancreas, but has proved difficult to apply in the human chronic pancreatitis model. Our four patients became insulin-dependent, with proof of intrahepatic insulin production in only one patient. Three factors have contributed to the lack of graft success: 1) the preoperative endocrine status, 2) systemic hypotension and portal hypertension secondary to graft infusion, and 3) difficulty applying the successful technique in a normal dog pancreas to an extensively scarred human pancreas. The preoperative insulin response during a glucose tolerance test was blunted or delayed in the three patients tested. An immediate decrease in blood pressure and rise in portal pressure occurred in every patient and prevented infusion of the entire graft (30-50%) in three patients. Unfortunately, the patient with the most compromised insulin status was the only patient able to receive the entire graft. Our experience would indicate that further refinements in technique are necessary to prevent the vascular reaction and allow infusion of the entire graft. Furthermore, normal islet cell function is necessary before a successful graft can be expected.

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to l-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primary carcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

THE FIRST successful arterial repair for renovascular hypertension in man was reported inThe Journalby Freeman and associates in 1954. 1 Subsequently, arterial repair (or replacement) has become a widely accepted therapy for this condition. Since many candidates for such an operation are young, it is desirable to know how long the repaired or reconstructed renal artery can provide for adequate blood flow to the kidney. Unfortunately, this kind of information is scarce. The following report demonstrates that a repaired artery can provide adequate flow of blood to the kidney for as long as 20 years. Report of a Case A 23-year-old woman came to the emergency room of UCLA Hospital on Oct 4, 1955, for treatment of a bee sting. Her blood pressure was 200/130 mm Hg. A subsequent examination showed stenosis of the right renal artery. Ureteric catheterization studies showed diminished urine flow and decreased phenolsulfonphthalein (PSP)

• We report a retrospective study of 107 cases of carcinoma of the sigmoid colon and upper rectum treated for primary cure at the University of California at Los Angeles Hospital between 1955 and 1970. Excluded from this analysis were patients treated by abdominoperineal resection, local excision, fulguration, or abdominoperineal pull-through procedures. Ninety-one patients were treated by local segmental resection and 16 by left hemicolectomy. Both groups were similar in regard to patient age and general health, lesion size, location, and pathological Dukes' classification. Five-year survival was 70.3% after local segmental resection and 56.3% after left hemicolectomy. Hospital mortality was 1% after the former and 6.2% after the latter. Rate of recurrence after local segmental resection was 41% of that seen after left hemicolectomy, while complications were one-third as great. The present results after local segmental resection are comparable to the results reported in the literature when hemicolectomy was the procedure used. The data presented suggest that local segmental resection is an effective cancer operation for carcinoma of the sigmoid and upper rectum, and is fraught with a lesser morbidity and mortality than a radical left hemicolectomy. ( Arch Surg 112:920-923, 1977)

Reports from different centers comparing the incidence of intrahepatic and extrahepatic portal hypertension have varied widely. In several recent accounts (7, 9, 10, 18) the conditions have been reported to occur with about equal frequency, as has been the case in our center. In other reports, however, extrahepatic obstruction has been much more common (5, 15, 16).

Seventy-four patients underwent operation for chronic pancreatitis during a 22 year period at UCLA Hospital. Follow-up data obtained for 60% of these patients an average of 3.2 years postoperation were analyzed by computer for statistically significant benefit between paired operation combinations and the variables of pain relief, stool habits, alcohol use, readmission for pancreatitis, and narcotic use. The combined group of total and cephalic pancreaticoduodenectomy proved more effective with respect to pain relief and readmission (p less than 0.05) than the group that had pseudocyst drainage. The comparison of groups that underwent resection or ductal drainage showed no statistical differences for the above variables. Regardless of type of operation, if the patient had evidence of pancreatic calcifications and had abstained from alcohol postoperatively, the likelihood of a return to normal activity was more favorable (p less than 0.05).

A computerized analysis of prognostic variables was performed in 96 proven cases of extrahepatic bile duct carcinoma treated over a 24-year period at UCLA. Forty-nine percent of the lesions were in the upper third of the bile ducts and 47% of these were resected, for an operative mortality rate of 23% and a maximum survival rate of 4.5 years. Palliative procedures in this region were associated with a 16% mortality rate and maximum survival rate of three years. The patients whose lesions were in the middle third suffered no operative mortality rate for resection or palliation and had a 12% five-year survival rate, with the longest survivor lasting 11 years. In the lower third lesions, 67% were resected by Whipple's procedures, for an 8% mortality rate and a five-year survival rate of 28% extending to nine years. Resection of these difficult carcinomas offers the best hope of survival but must be weighed against the high operative mortality risk in those lesions located in the hilar region.

Traditional management of patients with primary sclerosing cholangitis (PSC) has included steroids and/or choledochotomy plus prolonged T-tube drainage. The authors have not been convinced, however, that either of these therapies significantly influence the course of the disease. Therefore, a more aggressive surgical approach was adopted that included performance of a choledochoenteric anastomosis in all patients with PSC who had either (1) a major area of extrahepatic blockage, or (2) primary involvement of the extrahepatic bile ducts. Using this approach, 17 of 22 patients (77%) managed surgically at the UCLA Medical Center from 1974 through 1980 have undergone a choledochoenteric anastomosis. Of these 17 patients, 13 (77%) have had an excellent or good result following surgery. Four patients whose disease was confined to the common bile duct have all had excellent results (mean follow-up 49.3 months since surgery). In addition, 18 of the entire group of 22 patients (82%) are still alive, a mean of 52.2 months after operation and 64.7 months following establishment of the diagnosis. These results in 22 patients encourage the authors to continue to pursue an aggressive surgical approach for patients with primary sclerosing cholangitis.

Despite reports to the contrary, unobstructed drainage of 50% of an otherwise normal liver through either the right or left uninfected hepatic duct is adequate to restore normal liver function, even if the obstructed lobe remains in place. An undrained liver lobe, if present, may require no further treatment. As long as it is completely obstructed and uninfected, it will undergo a progressive asymptomatic atrophy. Cholangitis invariably develops behind a partial lobar ductal obstruction, producing jaundice, pruritus, and fever. Unless unobstructed, uninfected biliary flow can be achieved through a segmental or lobar duct, it is better that the duct be completely obstructed and the affected liver parenchyma allowed to atrophy, provided there is normal biliary flow from the residual 50% of liver. This concept is important in the management of injured anomalous segmental or lobar hepatic duct and in the palliative treatment of bile duct carcinoma. Localized intrahepatic infections communicating with abnormal biliary ducts will require hepatic resection of the infected parenchyma and ducts for cure. The abnormality may be saccular dilatation of the intrahepatic ductal system with abscess formation or intrahepatic abscess associated with stenosis of the ductal system from trauma to the duct, to the duct and liver, or to retained intrahepatic stones. Diffusely situated intrahepatic abscesses secondary to ductal abnormalities can be treated with systemic antibiotics, local drainage of a dmoninant abscess, and efforts to improve biliary drainage.

PRIMARY intraluminal tumors of the aorta must be exceedingly rare. There is, to our knowledge, only 1 other case in the literature that resembles to any degree the case reported below.1 Our patient is a young woman in whom a tumor of mesenchymal origin occluded the aorta just beyond the arch, producing the physical signs of coarctation of the aorta. Furthermore, extension of the tumor into the renal arteries resulted in the clinical features of malignant hypertension of the Goldblatt-kidney type. Successful surgical removal of the tumor and its extensions has resulted in complete resolution of the hypertensive disease. Case . . .

Several factors determine the mortality and morbidity resulting from blunt trauma to the liver. While the presence of multiple injuries is of undoubted importance, adequate drainage of the perihepatic area, decompression of the biliary tree when indicated, and hepatic lobectomy when required form the basis of surgical management, and decrease the morbidity and mortality associated with this serious injury.

Homotransplantation of the liver necessarily entails variable periods of hepatic anoxia. Hypoxia or direct hepatic trauma at the time of transplantation results in accumulation of toxic metabolites and the release of a vasoactive substance which is capable of producing profound and sustained hypotension. Only minor alterations in serum electrolytes, bilirubin, and alkaline phosphatase are present in the venous effluent gathered from the revascularized liver graft. Serum transaminase levels were in general less elevated when the donor liver was perfused hypothermically and the duration of hepatic ischemia was short. Injection of the plasma fraction from the venous effluent of the revascularized liver graft, with exclusion of the dog's liver vasculature, resulted in sustained hypotension. Acidotic effluent and bacteria in the effluent were not universally productive of hypotension. The formation of a vasoactive substance from disintegration of liver cells, either due to trauma, anoxia or acidosis, may be responsible for this hypotension. This problem may be partially obviated by diversion of the accumulated blood in the newly vascularized transplanted liver for a protracted period of time before recirculation in the recipient is permitted.

An analysis was made of thirty-six patients with pancreaticoduodenal tumors treated by pancreaticoduodenal resection. The operative mortality has been lowered in the last four years to 5.9 per cent. Nearly 17 per cent of the patients have been long-term survivors, that is, for more than four years and in one instance for more than twelve years. The continued use of pancreaticoduodenal resection in the treatment of such tumors is justified. A rare case of carcinoma of the head of the pancreas was encountered in a three year old child who is still living four years after pancreaticoduodenal resection. Concurrent mixed parotid tumors have been found in two patients with carcinoma of the pancreas. The long-term survival in this series is believed to have been affected by: Early tumor detection and radical resection . Recognition of the importance of vague abdominal symptoms and of diabetes as early indications of pancreaticoduodenal tumor is helpful in tumor detection. The site of origin of the tumor . The greatest relative number of long-term survivors have had tumors of the bile duct. Patients with lesions of the ampulla of Vater have been second. Those with primary carcinoma of the head of the pancreas have rarely become long-term survivors. Resection of the portal vein when it was involved with a tumor was performed in three patients with repair of the vein by end to end anastomosis in one by Teflon patch grafts in two others. Although this maneuver permits resection of an otherwise inoperable tumor, it has not been seen to increase survival time. The location of the tumor in the pancreas . Tumors in the uncinate process of the gland have posed difficult problems in resection and the survival rate has been poor. Inanition . Severe persistent nutritional disturbances generally indicate recurrence of the tumor. However, in rare cases of patients who adjust poorly to the altered physiology after pancreaticoduodenal resection, death may occur from inanition without evidence of tumor recurrence.

Blunt trauma to the abdomen may produce a wide range of intra-abdominal injuries. Subcapsular hematoma of the liver, disruption of the common bile duct, and subcapsular disruption of the pancreatic duct are three injuries discussed; all are rare, isolated injuries frequently accompanied by minimal initial abdominal signs and symptoms. Each injury, however, has serious potential late complications. The diagnosis and treatment of these conditions are discussed with a view toward preventing or minimizing the late complications.

Experience with the surgical management of portal hypertension in nineteen children treated at the UCLA Hospital has been analyzed. On the basis of this clinical experience certain observations have been made. 1. 1. Patients with portal vein thrombosis (PVT) who survive through childhood may live until late adulthood with decreasing frequency and severity of variceal bleeding. None of the eight patients with PVT in the present series has died. 2. 2. Splenectomy alone does not prevent variceal hemorrhage and may make it difficult to visualize or shunt the portal venous system later. 3. 3. Gastrectomy may delay but not prevent bleeding and may be a cause of morbidity in itself. 4. 4. Medical therapy will control hemorrhage in most small children with PVT until they are of sufficient size to undergo a shunt operation. 5. 5. Variceal bleeding is not without risk in children with PVT and emergency variceal ligation may be necessary. 6. 6. End to side mesocaval, splenorenal, or portacaval shunts are preferred when feasible in children with PVT. Makeshift shunts are unsatisfactory. Distal splenorenal anastomosis is recommended when the splenic vein is thrombosed. 7. 7. Many children with intrahepatic portal venous obstruction have mild hepatocellular disease and may experience a good prognosis if variceal hemorrhage is controlled by a shunt. An aggressive approach is recommended in these children who frequently do not tolerate variceal hemorrhage well. 8. 8. Long-term chemotherapy with hepatotoxic drugs may produce hepatic scarring and portal hypertension which is amenable to shunt procedures. 9. 9. Side to side or end to side portacaval anastomoses are preferred in children with intrahepatic portal obstruction and may be performed successfully even in young children.

Fourteen patients in whom the diagnosis of coronary insufficiency had been confirmed by electrocardiograms obtained with the patients at rest or with exercise have been studied by coronary angiography. Eight of these who had the classic "effort angina" with depression of the S-T segment induced by two-step exercise or treadmill exercise were found to have single or multiple coronary occlusions conforming to the description of Blumgart, Schlesinger and Davis. One patient showed elongated narrow segments without occlusions. Another showed multiple local narrowed segments in the same vessel without occlusions. Three patients showed localized narrow segments strategically located so as to compromise the circulation to a large area of myocardium. These patients had predominantly nocturnal angina. Two had electrocardiographic changes during periods of pain, but not with standard exercise. These cases are believed to correspond to Prinzmetal's variant form of angina. In one case of adult coarctation, angina on effort was associated with depression in the S-T segment. The presence of adequate coronary arteries seen angiographically suggested that this form of coronary insufficiency is due to a discrepancy between the available myocardial blood supply and the greatly increased work of the heart during exercise. The findings indicate that myocardial ischemia may be brought about as a consequence of several different distributions of coronary atheroma. A rational surgical approach to the problem of coronary heart disease will depend on the recognition of these several types.

Coronary artery injections of radio-opaque material into the vessels of autopsy hearts first disclosed that angina pectoris in most cases is due to extensive narrowing and occlusion of the...

THE MISCIBLE substance on the interface of basic science and clinical medicine formed by previous generations of scientists and clinicians is what we call today "modern scientific medicine." Certain segments of knowledge that have been added to the fields of mathematics, physics, and chemistry and almost the total body of knowledge from the more closely related broad fields of anatomy, histology, physiology, bacteriology, and pathology provide most of the factual information from which we diagnose, treat, and prevent disease today. The clinician of today knows from the works of a previous era that the serum of blood normally contains a total of approximately 5 mEq of calcium and 2 mEq of inorganic phosphate per liter. He also knows that there are usually two pairs of parathyroid glands located close to the upper and lower poles on the posterior surface of the thyroid gland, and that they are about 5×5×3 mm

The present status of the homograft problem from a practical aspect is briefly reviewed. The initial work in the tissue transplant laboratory at the University of California Medical Center is summarized. Previous work on the phenomenon of acquired tolerance is briefly reviewed. Three types of experiments in acquired tolerance in the chick embryo are presented, using a technic for embryonic cross transfusion developed in our laboratory: (1) Tolerance to homografts induced by this method is variable in degree and permanence. The method is most effective when applied to chick embryos of twelve to eighteen days' incubation. (2) After embryonic cross transfusion a significantly greater incidence of permanent homograft take is obtained when the test graft is performed between the chicks when they are one day of age rather than when they are two weeks old. (3) When repeat homografts are performed between the same individuals, first at two weeks of age and then at fifteen days of age, the two-week graft invariably sloughs first and there is a significant incidence of primary graft survival in the face of secondary graft slough. This situation holds true in chicks subjected to embryonic cross transfusion as well as in untreated chicks. The possibility that under certain conditions graft adaptation as well as host tolerance may be responsible for homograft survival is suggested. The tentative concept of one of us (J. A. C.) with regard to the total mechanism is presented. The use of homografts in adults from a palliative aspect is discussed.