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Blood glucose, plasma free fatty acids (FFA), cholesterol, phospholipids, and triglycerides were measured in blood obtained by heel prick from 32 neonatal surgical patients suffering from various cogenital malformations which prevented and adequate intake of milk. The result of almost complete starvation for up to 7 days was investigated and the effects of a surgical operation were studied in 12 of the babies. All the babies weighed more than 2 kg at birth. A surgical operation caused a rise in blood glucose concentration but a variable change in plasma concentration of FFA. Blood glucose returned to normal within 8 to 12 hr. The plasma concentrations of cholesterol and phospholipids did not change except in two babies in whom the concentration of both fell. Four to 24 hr after operation the plasma triglyceride level fell by an average of 25% but later rose. During starvation for 7 days the blood glucose concentration was maintained within normal limits. Plasma FFA concentration normally rose during the first 2 days of life and was very high between days 3 and 5. Plasma triglyceride, cholesterol, phospholipids, and total esterified fatty acids also increased after birth. The results suggest that during starvation in the neonate there is rapid mobilisation of fat from adipose tissue stores and a reduction in the peripheral utilisation of glucose. There was no evidence to suggest any impairment of fat mobilisation or metabolism even after starvation for 7 days. After surgical injury, these changes were accentuated because the rate of utilisation of fat was greater than that of mobilisation.

A variety of chemical agents and surgical procedures have dramatic influences on the ontogenetic development of noradrenergic neurons. Because of space limitations, in-depth descriptions of each of the neurotoxins could not be given, and the reader is referred to review articles which present a different perspective on uses of the agents (Breese, 1975; Jonsson, 1980; Kostrzewa, 1988; Kostrzewa and Jacobowitz, 1974; Thoenen and Tranzer, 1973).

Tracheo-graft fistulae developed in two patients who required intermittent positive pressure ventilation and intubation with conventional cuffed tracheostomy tubes following resection of post-cricoid carcinomata by pharyngolaryngo-oesophagectomy. Pressure necrosis of the posterior tracheal muscle and the anterior wall of the graft occurred as a direct result of compression of these structures between the tracheostomy cannula and air cuff, and the vertebral bodies at the thoracic inlet. This post-operative complication has not been encountered in subsequent resections since the introduction and routine use of a modified cuffed tracheostomy tube. The adjustable neck plate guards against trauma to the tracheostome, inadvertent intubation of one of the major bronchi in each individual patient and the siting of the cuff beyond the thoracic inlet. Unintentional over-inflation of air cuffs remains a hazard whereas only ambient air re-expands the foam cuff. This property of the cuff also ensures against surgical injury to the posterior tracheal wall during the operation. Pressure necrosis of the posterior tracheal wall by the main tracheostomy cannula is minimised by suitably modifying the curvature and length of the cannula for use in patients with end-tracheostomies.

After injury, the body concerns itself with regaining and preserving its integrity. There is an immediate immunologic response to meet entering pathogens; hemostasis is achieved and the healing process begins. Fundamental to the fight for integrity is the conservation of all of those tissues that contribute to this effort. The preservation of the body cell mass depends upon an adequate source of nutrition, primarily a source of amino acids and energy.

Triceps skinfold (TS), arm muscle circumference (AMC) and body weight (BW) were studied prospectively in 20 adults, admitted to elective operations on the digestive tract, in order to evaluate these anthropometric parameters in planned surgical procedures performed in non-critically ill, non-stressed patients. Mean duration of the preoperative period was 19.2 days (range 1--38), and of the postoperative period, 14.1 days (range 6--31). Mean changes for BW were, respectively, -0.2% and -2.5%, AMC decreased -0.5% before operation and -3.4% afterwards, and TS was reduced to -1.9% in the preoperative phase, and to -8.4% postoperatively. These results are consistent with minimal anthropometric changes during the presurgical stay, with more striking decreases after operative injury. Postoperative findings were further examined in relationship to degree of surgical trauma and length of postoperative hospitalization. After the arbitrary selection of a 10% reduction as the limit for significant decrease in any of the analysed parameters, the percentage of impaired measurements was determined in the sub-groups of medium and large operations, two consecutive procedures, as well as postoperative stay of 6 to 14 days, 15 to 21 days, and over 3 wks. Decreased parameters comprised 6.0% (2/33) of the observations after moderate surgical manipulation, 27.7% (5/18) after serious trauma, and 66.6% (6/9) after two operations. Simarilarly they represented 2.7% (1/36) of the findings in patients discharged within 2 weeks, 33.3% (4/12) in those staying between 2--3 weeks, and 66.6% (8/12) in the cases remaining for longer periods. Despite the limited sensitivity of anthropometric parameters in the detection of acute moderate changes in body constitution, they were useful in separating the patients undergoing medium surgical injury from those subjected to more severe metabolic stress, when only changes greater than 10% of initial value were considered.

From 1965 through 1976, 35 patients with surgical injury of the ureter were treated by operations requiring ureteral anastomoses. Stenting devices were used in 31 patients with only 2 failures. Stents were omitted in 4 patients with 2 failures. We have been satisfied with and prefer stenting ureteral anastomoses in the management of surgical ureteral injury, particularly when there is delayed recognition of the injury or previous irradiation. Previous objections to stenting are unjustified.

SummaryThe aural microphonic of guinea pigs was recorded from the round window and from copper wires applied to or passing through tiny holes drilled through the bony shell of the cochlea. When the guinea pig's respiration fails gradually, the microphonic falls to a few percent of its original strength before the heart stops. The failure is partly reversible if respiration improves.Frequently near the postmortem level the microphonic undergoes partial or complete half-wave rectification. The phase corresponding to condensation in the external canal is more depressed than the phase corresponding to rarefaction. This effect also is temporarily reversible.Extensive surgical injury including amputation of the two apical turns may cause little or no change in the microphonic (1000 cycles per second) at the round window over several hours.

Facial trauma, malignant tumors, and surgical injury were major causes of extratemporal facial nerve paralysis in our series of 32 patients on whom nerve repair was performed. Imperfect but excellent functional restoration was brought about by nerve suture in five patients, by nerve grafting in 18, and by nerve decompression in two. The results of nerve anastomosis in seven patients were disappointing. Success in the facial nerve repair required accurate preoperative diagnosis of the site and severity of the nerve injury and of malignant lesions by sialography and electrophysiological examinations. Process of functional recovery after the repair observed clinically and by electromyography was corroborated by the histological findings in experimental animals.

Pre- and postoperative angiograms and myocardial images obtained using the capillary blockade principle were compared in 10 dogs in which a left ventricular mural injury had been produced surgically by means of a crush clamp. Care was taken to avoid damage to the major coronary arterial branches during surgical injury. Postoperative myocardial images demonstrated a left ventricular perfusion defect in 8 of the 10 dogs. The authors stress (a) the importance of imaging the injured area of the myocardium in tangent and (b) the supplementary nature of the information gained from myocardial imaging and coronary angiography.

• Proximity of the cerebral cortical veins to the overlying dura predisposes them to surgical injury. Labbe's vein, draining a major portion of the posterior temporal and inferior parietal lobes, occurs on the left in 77% and on the right in 66% of patients. Interruption of this vein during otologic surgery may produce devastating neurologic consequences. In this regard, the roentgenographic anatomy of cerebral cortical venous drainage is reviewed. Technical treatment of the temporal dura should include those techniques familiar to the neurosurgeon that ensure the protection of the temporal lobe and its superficial venous drainage.

The commonly referenced mortality of cardiac valve replacement surgery is 2 to 5%. Some of this mortality is due to therapeutic misadventure during the procedure. Therapeutic misadventure during cardiac valve replacement may result in patterned injury of the heart, so that postmortem examination can establish the nature of the surgical injury. A case of patterned myocardial injury during valve replacement surgery is presented, with a review of literature and associated cases.

The purpose of this study was to investigate whether regression of sensory analgesia during constant epidural bupivacaine infusion was different in postoperative patients with acute pain than in patients with chronic nonsurgical pain. Sensory levels of analgesia (to pinprick) and pain (on a five-point scale) were assessed hourly for 16 hours during continuous epidural infusion of 0.5% plain bupivacaine (8 ml/hr) in 12 patients with chronic nonsurgical pain and in 30 patients after major abdominal surgery performed under combined bupivacaine and halothane--N2O general anesthesia. No opiates were given. If sensory analgesia decreased more than five segments from the initial level or if the pain score reached 2 (moderate pain), the patient was removed from the study. Initial levels of sensory analgesia after loading doses of 21.8 +/- 0.5 and 19.3 +/- 0.8 ml bupivacaine 0.5% were similar (T3.8 +/- 0.3 and T3.8 +/- 0.5) in the surgical and chronic pain patients, respectively (mean +/- SEM). Of the surgical patients, only 4 of the 30 (13%) maintained the initial level of sensory analgesia, and a pain score below 2 throughout the study compared with 7 of the 12 patients with chronic pain (58%) (P less than 0.01). Mean duration of sensory blockade was significantly longer (P less than 0.005) in the patients with chronic pain than in surgical patients (13.1 +/- 1.2 and 8.5 +/- 0.7 hours, respectively). Thus, surgical injury hastens regression of sensory analgesia during continuous epidural bupivacaine infusion. The underlying mechanism remains to be determined.

The late results of operations to correct stricture of the bile ducts were investigated in 265 patients who responded to requests for follow-up study. They had undergone altogether 308 operations from 1 to 25 years before the time of the study. In every case but one the stricture followed surgical injury. The operations done to correct the stricture were usually either choledochocholedochostomy or choledochoduodenostomy, and the results of these two were about the same, with 68 and 69% of good or excellent results in the patients reporting. Even when strictures were so located that no patent extrahepatic duct was visible, it was often possible to relieve the biliary obstruction by special procedures. Two patients were pregnant at the time of operation, and there were 19 subsequent deliveries in 14 patients, all but one delivery being normal, full-term, and spontaneous. Among the 191 patients followed up for more than five years, there were 28 deaths and 16 of these were ascribed to cirrhosis or liver failure.

The word "extracapsular" is used in the title of this paper to imply fixation of the kidney by a method entirely external to the tunica fibrosa as distinguished from any method that implies either invasion of that tunic or surgical injury to the kidney itself. The further significance of the term as it is here used may be made clear by a brief description of the essential features of the operative procedure that I have employed for the last several years—indeed, since 1904— for the anchorage of the pathologically movable kidney,1as follows: TECHNIC OF EXTRACAPSULAR NEPHROPEXY 1. The patient is placed in the classical position on the well side with a firm pad, preferably pneumatic, under the same side. The equally classic incision about 1 cm. below the costal margin and about 10 cm. in extent is made obliquely downward and forward. This dissection is carried through the