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Sepsis is a leading cause of death following major trauma and complicated abdominal surgery. Tumor necrosis factor-alpha (TNF) is believed to be a central mediator in the inflammatory response syndrome. Numerous methods of blunting the TNF response in sepsis have been attempted with suggestion of increased survival and decreased organ injury. Thalidomide, shown in vitro to selectively inhibit TNF production, has been used clinically in states of chronic TNF elevation with encouraging results. In this study, we examined the effect of thalidomide administration in a rat model of acute septic shock. Femoral artery cannulation was performed and baseline TNF measured. Dose response was determined by giving varying doses of thalidomide by gavage. Rats were injected intraarterially with endotoxin and serial samples drawn. TNF was measured by ELISA. For survival, thalidomide was given by gavage and endotoxin injected intraperitoneally. Serum TNF elevation occurred after endotoxin injection with peak levels at 90 min. Thalidomide treated rats had lower TNF levels at all time points (P =0.01 at 90 and 120 min), with the inhibition being dose dependent. Survival in treated rats exceeded that of untreated rats (53% vs 19%, P =0.05) at 48 and 72 hr. In conclusion, we found that thalidomide administration leads to increased survival following acute endotoxemia, which may be due to the observed TNF inhibition.

Objective To examine the effect of alpha-tocopherol, a free radical scavenger, on RBC deformability, mixed venous hemoglobin saturation (SvO2), arterial-venous oxygen content difference (C[a-v]O2), pHv, and survival during sepsis. Design Randomized controlled study. Interventions Sprague-Dawley rats were randomized to three groups: sham, cecal ligation and puncture, or alpha-tocopherol/cecal ligation and puncture (pretreatment with alpha-tocopherol before cecal ligation and puncture). Measurements and main results The cecal ligation and puncture group had a significantly (p less than .05) higher SvO2 and lower C (a-v)O2, pHv, and survival rate when compared with alpha-tocopherol/cecal ligation and puncture and sham groups. No difference in pHa existed between groups. Conclusions The alpha-tocopherol treatment improves survival in sepsis. RBC deformability during sepsis is prevented by alpha-tocopherol, suggesting that free radicals may cause the decrease in RBC deformability. This study provides indirect evidence that decreased RBC deformability may play a role in the physiologic peripheral shunting and decreased microcirculatory flow that occurs during sepsis.

One hundred consecutive trauma patients who underwent planned emergency intubation with muscle paralysis in the ED were studied to investigate the safety of these procedures and to determine their impact on the evaluation of patients with suspected head injury. Patients were intubated by either a surgeon (n = 47) or anesthesiologist (n = 53), and paralyzed with either vecuronium (n = 59) or succinylcholine (n = 41). Nasal intubation was used in 40 patients, oral in 57, and cricothyroidotomy in three. Ninety-four patients with suspected head injuries had a CT scan performed. Fifty-five (59%) had a positive scan and 15 required emergent neurosurgical intervention. Only two patients had lateral cervical spine roentgenograms before intubation; seven patients were eventually found to have cervical fractures. No patient suffered a neurologic deficit. One patient developed aspiration pneumonia following intubation. The three failed intubations occurred in patients with multiple facial fractures. We conclude that induced paralysis and intubation in the ED is safe, can facilitate the diagnostic workup, and may be a potentially life-saving maneuver in combative trauma patients.

Translocation of carbon-14-labeled Escherichia coli from the gut was studied at the specified times in the following groups of rats: Group 1, 5 hours after ligation of the superior mesenteric artery; Group 2, 5 hours after laparotomy and exposure of the superior mesenteric artery with gentle removal and replacement of the intestines; and Group 3, 5 hours after handling but no surgical manipulation. Both living and dead bacteria were administered by means of gavage, and the effect of viability, intestinal ischemia without reperfusion, and bowel manipulation on the translocation of enteric bacteria was assessed. We demonstrated that (1) even gentle bowel manipulation causes bacteremia as great as that associated with ligation of the superior mesenteric artery; (2) dead E. coli are absorbed into the blood in the presence of bowel manipulation or ischemia but less effectively than are live E. coli; (3) live bacteria are found in highest concentration in the lung and in descending order in the liver, kidney, heart, and spleen; (4) dead bacteria absorbed from the gut are found in highest concentration in the kidney and the liver. Lesser amounts are found in the lung, spleen, and heart.

Laboratory rats in profound hemorrhagic shock, but minimally restrained and unanesthetized, were exposed to 915 MHz microwave energy to rewarm the core tissues, which were cooled by approximately 4OC to 6OC during shock The survival rate of the animals that were rewarmed during the postshock period, after resuscitation was affected, was significantly higher than the survival rate of the animals that were rewarmed during shock, prior to resuscitation, and higher as well than the control group of shocked animals in whom no thermal intervention was attempted.

Background: Percutaneous endoscopic gastrostomy (PEG) tubes have replaced nasogastric tubes and Stamm gastrostomy tubes as a preferred means of feeding for patients with head and neck cancers, as recommended by the results of large series. A patient with stomal seeding of squamous cell carcinoma of the upper aerodigestive tract by PEG placement was reported. A review of literature was performed. Methods: A Medline search of implantation of squamous cell carcinoma from the upper aerodigestive tract to PEG exit site since the introduction of PEG was performed. Results: Two reports of implantation of squamous cell carcinoma of the upper aerodigestive tract to PEG exit site were found. Both patients and our patient were staged T4. Conclusions: Implantation of squamous cell carcinoma from the upper aerodigestive tract to the PEG exit site is a rare and late complication. Its prevalence is not known. For patients with a significant amount of squamous cell carcinoma in the upper aerodigestive tract, we recommend Stamm gastrostomy over PEG insertion by the pull technique. There is no report of such late complication by the push technique.

Hemorrhagic shock has been demonstrated to increase the susceptibility to bacterial infection [1–5]. Infection rates in patients who had sustained hemorrhagic shock complicating penetrating abdominal injury have been shown to be two to three times that for normotensive patients [4, 5]. Esrig demonstrated that a sublethal injection of endotoxin (lipopolysaccharide, LPS) resulted in significant mortality in rats following hemorrhagic shock [1]. This increased susceptibility to infection has been documented to persist for several days following shock in both rodent and murine models [2, 3]. Shock has also been demonstrated to result in numerous alterations in both cell-mediated and humoral immunity [3, 6, 7]. Among these is the failure of the bone marrow to mount a normal myelopoietic response to a challenge of intraperitoneal LPS following shock [8]. We have demonstrated that rats challenged with LPS after hemorrhagic shock resulted in a decline in the number of bone marrow granulocyte-macrophage colony-forming units (CFU-GM) compared with un-shocked rats [8]. Simultaneous with the loss of normal myelopoiesis is the appearance of serum factors inhibitory to CFU-GM growth.

Thirty-nine hemodynamically stable trauma patients were evaluated prospectively by laparoscopy before planned celiotomy. Laparoscopy was performed using a forward-viewing laparoscope connected to two high-resolution video monitors. The mechanism of injury was blunt trauma in eight, stab wounds (SWs) in 16, and gunshot wounds (GSWs) in 15. Laparoscopy correctly identified the presence of an intraperitoneal injury in 26 patients. Six other patients had retroperitoneal injuries, five of which were seen on laparoscopy. The remaining seven patients had no demonstrable intraperitoneal or retroperitoneal injuries, did not undergo celiotomy, and were observed without morbidity. In comparison with findings at surgery, laparoscopy identified injuries to the liver in eight of ten, to the diaphragm in three of three, to the colon in two of three, to the stomach in three of three, to the kidney in one of one, to the spleen in none of three, and to the small bowel in none of four patients. Visualization of the spleen was achieved in only one patient. The extent of the hemoperitoneum was underestimated from the laparoscopic examination in all nine patients with greater than 750 mL of peritoneal blood, four of whom had undetected active bleeding. Laparoscopy was performed easily in all patients and there were no complications associated with its use. In conclusion, the absence of an intra-abdominal injury was correctly identified with laparoscopy in 11 patients and laparoscopy may decrease the need for celiotomy in selected patients. However, the inability to "run the small bowel," visualize the spleen, and evaluate hemorrhage limits the utility of laparoscopy in determining which patients with laparoscopically visualized injuries will require celiotomy.

According to Webster, the verb wither indicates that something has become dry and sapless or has lost vitality, force, or freshness. Is surgical oncology withering? One can find evidence that this might be so. The American Board of Surgery has recently denied a Certificate of Additional Competency in Surgical Oncology. After a period of growth, the membership of our society has plateaued in the last 2 to 3 years, with the number of members entering barely balancing the number superannuated because of age. The care of the cancer patient seems in many instances to have become more and more fragmented. I encountered a patient the other day at my own hospital who was under chemotherapeutic care by our Section of Medical Oncology for a lesion of the head and neck. The patient had a recurrent carcinoma that was obstructing his hypopharynx, and the Ear, Nose, and Throat Service was asked

Sixty-three patients with advanced unresectable squamous cell carcinoma of the head and neck were treated with a combination of chemotherapy, radiation, and surgery. We observed a 75% response to neoadjuvant chemotherapy. The 5-year survival rate for all 63 patients was 20%, and only 3 patients were alive at 8 years. The 5-year survival rate for patients who completed the treatment plan and received chemotherapy, radiation, and surgery was 43% compared with 20% for those who had chemotherapy and radiation but refused surgery. Development of a second primary cancer was the cause of death in 62% of the patients who survived more than 24 months.

Translocation of intestinal bacteria to the blood during hemorrhagic shock (HS) has been confirmed in rats and humans. The current study was designed to trace the path of translocated intestinal bacteria in a murine HS model. Thirty-one rats were gavaged with 1,000,000 counts of viable 14C oleic acid-labeled Escherichia coli. Forty-eight hours later the animals were bled to 30 mmHg until either 80% of their maximal shed blood was returned or 5 hours of shock had elapsed and they were resuscitated with Ringer's lactate as previously described. Control animals were cannulated but not shocked. Eight rats immediately after shock and resuscitation, 6 rats 24 hours after shock, 3 rats 48 hours after shock, and 4 animals that died in shock had their heart, lung, liver, spleen, kidney, and serum harvested, cultured, and radioactive content measured. Translocated enteric bacteria are found primarily in the lung immediately after shock with redistribution to the liver and kidney 24 hours later. Animals surviving to 48 hours were capable of eliminating the majority of the bacteria from their major organ systems. Positive cultures for E. coli were also found in the blood, lung, liver, and kidney. We speculate that the inflammatory response stimulated by the bacteria in these organs may contribute to the multiple-organ failure syndrome seen after HS.

Betadine (polyvinylpyrrolidone-iodine) antiseptic solution was evaluated as to safety and efficacy on intraperitoneal application in 220 rat experiments, and compared with cephalothin and kanamycin solutions as intraperitoneal antimicrobial agents. We found that intraperitoneal Betadine solution is apparently safe to rats at doses of 2.5 ml/kg or less as regards acute and chronic toxicity. In experimental peritonitis, intraperitoneal Betadine solution produced significantly increased survival (P < 0.0001) over untreated controls, and was as effective as intraperitoneal cephalothin or kanamycin in a monomicrobial peritonitis. Intraperitoneal Betadine solution is well absorbed. Our results suggest that further studies of this application of Betadine solution are indicated.

We have developed a technique for forming a new larynx from a cervical "bucket handle" flap to replace the larynx after laryngectomy in patients who have had radiation of the neck. Experience with the technique in six patients suggests that it is more successful than previous procedures used in such patients and may offer some advantages as a general technique of laryngeal construction. The procedure is designed to preserve speech and swallowing without aspiration, but translaryngeal breathing is sacrificed and respiration requires a permanent tracheostomy tube.

In recent research, hemorrhagic shock and septic shock have been studied as two separate entities. We have developed a treated model of hemorrhagic shock in which unrestrained and unanesthetized rats are bled to a mean arterial pressure of 30 torr until 80% of the maximum shed volume must be returned. Rats are maintained preshock and treated post shock with a 20% glucose-electrolyte solution. Survival of these animals is 62% at 24 hours post shock and all animals are dead at 72 hours post shock. Blood cultures obtained during shock become positive at 2 hours into the shock period and are significant compared to controls at 3 to 5 hours of shock (p less than 0.0001). Blood cultures obtained after the period of shock are significantly positive at 24 and 48 hours post shock (p less than 0.05) compared to controls. Intrashock cultures are monomicrobial; the majority of post-shock cultures are polymicrobial. All cultured organisms are normal rat enteric flora. Histologic changes of renal failure are also demonstrated post shock. We suggest that bacterial invasion, possibly from the gut, plays a role in the sepsis seen in patients following severe hemorrhagic shock. Sepsis may precede rather than follow the immune incompetence which accompanies shock.

Combined therapeutic regimens integrating chemotherapy, radiation therapy, and surgery are reported to be effective in treating advanced squamous cell carcinomas of the head and neck. The current study evaluates 58 consecutive patients with advanced (T4, N3) head and neck cancers. Forty patients (multimodal group) were treated with 2 courses of chemotherapy (cisplatin 2 mg/kg; methotrexate 280-560 mg/m2 with leucovorin rescue; bleomycin 30 mu X 3) followed by radiation therapy and surgery. Eighteen patients (combined group) were treated with preoperative radiation therapy followed by surgery. In the multimodal group there were 27 (67.5%) partial responses and nine (22.5%) complete responses, for an overall response rate of 90%. Response rates by site of primary lesion were: oral cavity, 11 of 11; oropharynx, 13 of 17; hypopharynx, 5 of 5; and larynx 7 of 7. Distant metastases (skin, lung, bone, central nervous system [CNS]) appeared in 16 patients (40%) (P less than 0.05 versus combined) at a median time of 8.5 months after diagnosis, 15 in patients having a partial (11) or complete (4) response. Thirteen patients (33%) developed distant metastases within 1 year of diagnosis (P less than 0.05 versus combined). In 11 of these patients, the primary lesion and neck disease were resectable. Two thoracotomies were performed for solitary pulmonary metastases; one was resected for cure. Fifteen patients (38%) underwent curative resection; 11 (73%) were alive at 1 year, and ten (67%) were free of disease. Overall survival was 20 of 40 (50%) at 1 year. In the combined group, there were 14 partial responses (78%) and no complete responses. Early distant metastases appeared in two patients (12.5%), at 2 and 6 months after diagnosis. Seven patients (38%) underwent curative resection; six of seven (86%) were alive at 1 year, four of seven (57%) were disease-free. Six of 16 patients at risk (37.5%) survived 1 year. After combined therapy, six of ten patients (60%) with responses to therapy survived 1 year versus 12 of 20 responders (57%) without distant metastases in the multimodal group. It is concluded that multimodal therapy for advanced head and neck cancer results in a higher response rate than with conventional combined therapy. The incidence of early and postoperative distant metastases was increased after the multimodal regimen. At 1 year there were no differences in survival between the combined and multimodal groups for responders without early metastases. Further observation is needed to determine the net long-term effects of this regimen. A prospective randomized comparison of combined and multimodal therapy for advanced lesions is indicated.

Voice rehabilitation is a major problem after laryngectomy. A new method to construct a pseudolarynx after total laryngectomy by suturing the trachea to the hyoid bone is described. The surgical technic is relatively simple. Patients are able to speak in the immediate postoperative period without intensive therapy. The quality of speech is good. Aspiration of liquids is a common problem, but in time patients learn to swallow with minimal or no aspiration. This procedure could be utilized in selected cases for good voice rehabilitation after total laryngectomy.

Various types of drains were inserted into the peritoneal cavity of twenty-eight dogs. After one to seven days, all drains failed to show the presence of 200 cc of colored fluid injected intraperitoneally. On autopsy, all tubes were surrounded and occluded by omentum.

Responses of general surgeons to a questionnaire on breast cancer were analyzed to determine the current trends in the management of this disease. A 21-item questionnaire was mailed to members of the New Jersey Chapter of the American College of Surgeons in 1982 and the responses, received on noncoded, anonymous answer sheets, were analyzed for frequency distribution. These responses were compared to previously recorded responses to the same questions for 1971 and 1977. Seventy-six percent of the respondents in 1982 performed needle aspirations often or always, compared to 36% in 1971 and 80% in 1977. The use of routine mammography has increased from 16% in 1971 and 20% in 1977 to 38% in 1982. Modified radical mastectomy is now the most common type of procedure employed in the management of stage I breast cancer, with 89% of respondents in favor of this approach compared to 15% in 1971 and 60% in 1977. Fifty-nine percent of the respondents are not opposed to breast reconstruction following mastectomy versus 14% in 1971 and 49% in 1977. For patients with axillary nodes, chemotherapy with multiple agents was recommended by 76% of general surgeons in 1982, compared to 58% in 1977. These results indicate a continuing trend towards increasing use of needle aspiration and routine mammography for diagnosis and for employment of chemotherapy with multiple agents in the adjuvant treatment of patients with positive axillary nodes. Furthermore, modified radical mastectomy is the operation of choice for stage I cancer of the breast for increasing numbers of surgeons.

Infusion of prostaglandin E1 is known to exert a beneficial effect in hemorrhagic shock. It is also known that hemorrhagic shock lowers hepatic stores of high-energy phosphates and that restoration of hepatic ATP is associated with improved organ function and survival. The present study was undertaken to evaluate the effect of infusion of exogenous prostaglandin E1 on (1) hepatic ATP levels and (2) restoration of hepatic ATP-dependent intracellular function. Rats were subjected to hemorrhagic shock, resuscitated, and then treated with either prostaglandin E1 or a saline placebo. Ten minutes after the completion of treatment, hepatic ATP levels were significantly higher in prostaglandin-treated animals (1.37 ± 0.43 μmol/g) than in animals receiving the placebo (0.70 ± 0.11 μmol/g). Creatine phosphate levels were also higher in the prostaglandin-treated group (1.59 ± 0.16 μmol/g) than in the placebo-treated group (0.89 ± 0.14 μmol/g). Lactate production ratios, an index of ATP-dependent membrane function, were near the theoretical normal of 100% in unshocked, untreated animals (95 ± 10%). They were significantly reduced (57 ± 10%) in animals receiving only placebo, but were not significantly different from unshocked animals in those receiving prostaglandin E1 following shock (91 ± 10%). It is concluded that prostaglandin infusion improves both hepatic high-energy phosphate levels and ATP-dependent intracellular function following hemorrhagic shock. This might be due to replenishing the purine base, selectively increasing hepatic blood flow, or both.

Skin grafts are an important component in immediate reconstruction after extensive resection in the head and neck region. Edgerton [I] has written extensively on their use in the area of the laryngopharynx, and others [2,3] have remarked on their effectiveness in lining the tonsillar area, palate, and tongue. Most of the patients we treat with Tesions in the higher clinical stages have received 6,000 r of cobalt radiation prior to operation. Originally, we were reluctant to use skin grafts in the radiated areas and attempted to draw the structures together for primary closure wherever possible. Patients with carcinoma of the maxilla were an exception to this rule. Part of the repair in these patients for years has been the immediate lining of the defect with a split thickness graft [4]. These grafts usually take well despite high doses of preoperative radiation. Encouraged by this, we began to use skin grafts to cover extensive areas of postradiation resection in the laryngopharynx and oropharynx.

In a model of severe hemorrhagic shock in rats, blood culture findings became positive within 2 to 4 hours of shock. The organisms cultured were primarily gram-negative. To test the hypothesis that the gut was the source of the bacteria, E. coli labeled with carbon-14 oleic acid were fed to rats undergoing hemorrhagic shock. Their plasma was then assayed for carbon-14 activity. Seven of the 14 shocked animals demonstrated increased plasma carbon-14 activity during or after shock. The mortality rate was 100 percent 80 hours postshock, and all animals had E. coli on subsequent blood culture. The seven rats without increased plasma carbon-14 activity had a survival rate of 83 percent postshock. Sham-shocked animals did not exhibit plasma carbon-14 levels greater than the background levels. These data suggest that bacterial translocation occurs during hemorrhagic shock and that the gut is the source of the bacteremia seen during hemorrhagic shock.

A survey of patients with surgical problems was conducted in an inner city hospital emergency department during eight equally spaced weeks in 1969 and again in 1972. Among 8,776 patients there was little change in the incidence of the commonest types of injury, lacerations and fractures. Infections and dental problems showed a modest decline. Over this same period the number of patients annually dead on admission from violence and drug abuse rose from 259 to 321. Patients admitted with injuries inflicted by others also rose, from 718 to 884. The pattern of surgical problems and injury reflects the socio-economic problems of the city. Some progress has occurred in those areas amenable to preventive medicine but problems requiring social as well as medical intervention are still on the increase.

Chairmen of academic surgical departments in the United States and Canada were questioned as to the administration, practice, and education of critical care medicine in their university hospitals. Sixty-one percent of departments had surgeons as surgical intensive care unit (SICU) directors, 67% preferred to have a surgeon as director, and 93% of those who had a surgeon as director were in favor of that arrangement. Eighty-four percent felt that involvement in the ICU did not detract from an individual's operating ability. Despite this perceived manpower demand, only 9.4% of all surgical ICUs and 3.4% of those ICUs with a surgeon as director had fellowships in critical care medicine. Rotations through the SICU were available in only 55% of programs and these tended to be only 1 or 2 months as a junior resident. These data indicate a need to increase the amount of training available to surgical residents if the desire to have surgeons direct our surgical intensive care units is to be fulfilled.

The classic symptoms of hypovolemic shock have probably been recognized since prehistoric times. Clear, written descriptions did not emerge until the 19th century, and the syndrome implied impending, unpreventable death until the 20th century. We now have the tools for resuscitation of the large majority of patients in shock. When the shock syndrome is encountered in the field, away from the hospital and the emergency room, rapid transportation to these areas of more sophisticated diagnosis and treatment is indicated.

A case of primary non-Hodgkin's lymphoma of the duodenum is presented. A review of the English literature documented 95 cases, and the presenting signs, symptoms, and radiographic findings have been abstracted. Attention is also drawn to the treatment of 27 cases, 11 of which (41%) survived for 2 or more years. Ten of the 11 long-term survivors were treated with radiotherapy with or without resection, whereas only one long-term survivor was treated by surgery alone.

From the Tumor Registries of the East Orange, New Jersey, Veterans Administration Medical Center, and the College of Medicine and Dentistry of New Jersey/New Jersey Medical School, 1,066 cases of head and neck cancer were reviewed. Blacks comprised 32% of the population reviewed. Charts of 70 patients, 45 years old or younger, were examined. Seventy percent of this group was black. At diagnosis, the proportion of patients 45 years old or younger was 14% for blacks and 2.9% for whites, a significant difference (P less than 0.001). Seventy-six percent of lesions in black patients and 86% in white patients were situated above the hypopharynx. Sixty-one percent of all patients 45 years old or younger had Stage III or IV lesions when first diagnosed, regardless of race. Black-to-white survival rates were 23 to 40% after 2 years, and 5 to 13% for those at risk after 5 years. Prognosis is poor for younger patients, in general, and worse for young black patients than for whites.

Twelve patients with advanced locoregional (Stage III and IV) squamous cell carcinoma of the oral cavity and oropharynx underwent treatment with cisplatin, vinblastine, bleomycin, and 5-fluorouracil, given by intra-arterial infusion, as primary adjuvant therapy, in preparation for radiation therapy and surgery. Responses were observed during or immediately after infusion therapy in 8 of 12 (67%) of patients (1 complete response, 7 partial responses). Infusion chemotherapy was followed by radiation therapy alone in five patients and by radiation and surgery in six patients. The protocol was initiated in August 1981, and six patients are now free of their primary cancer, at 21 to 36 months, whereas six have died with disease. Arterial infusion of a combination of effective antineoplastic agents is a promising method for the preparation of selected patients for radiation therapy and surgery, as it is less likely to produce serious systemic toxicity and it requires a shorter period than systemic neoadjuvant chemotherapy.

Previous investigations of a treated model of hemorrhagic shock in the rat indicated the frequent occurrence of bacteremia that appeared to derive from the gut. This paper determines the incidence of bacteremia and endotoxemia during the acute shock period and compares this with similar observations in humans in varying degrees of shock. Studies in 26 rats indicated that bacteremia and endotoxemia was present in 50% and 87%, respectively, by the end of 2 hours at a mean arterial pressure of 30 mmHg. Observations in 50 patients admitted to the trauma unit showed that positive bacterial blood cultures were present in 56% when the admission systolic blood pressure was 80 mmHg or less (p less than 0.01 compared with either of the other groups). Endotoxemia was noticed in two such patients. Direct access of bacteria and endotoxin to the blood stream may occur during hemorrhagic or traumatic shock and is the probable cause of subsequent sepsis in traumatized patients when no other source is apparent.

One hundred seventy-four cases of squamous cell cancer of the tonsil (SCCT) were reviewed. Radiation therapy (RT) alone was used in 81 patients, surgery alone (S) in 19 patients, preoperative RT + S in 49 patients, and chemotherapy [( C] methotrexate plus bleomycin plus cisplatin) in 25 patients. The 5-year survival was 83% in Stage I (n = 21), 72% in Stage II (n = 19), 23% in Stage III (n = 34), and 15% in Stage IV (n = 100). RT and S were equally effective in Stages I and II. In Stage III, the 5-year survival for RT + S was 31% versus 11% for RT alone; and in Stage IV, the respective 3- and 5-year survivals for RT + S were 24% and 15% versus 6% and 0%, respectively, for RT alone. There was an 84% response rate to C, and the patients who completed C + RT + S had 3- and 5-year survival rates of 41.7% and 32%, respectively. Our results indicate that RT + S appears to offer better survival in Stage III and IV SCCT. The high response rate in early survival data seen with C + RT + S suggests a promising role for this approach.

Of the 3,907 cases of primary head and neck or lung cancer diagnosed between 1961 and 1984, 94 patients were identified with a history of cancer at both sites. The total incidence of lung cancer in our head and neck cancer patients was 5.4 percent. Of the 94 patients, 73 had both cancers diagnosed at our institution. These 73 patients were further analyzed. Squamous cell carcinoma accounted for 63 percent of the lung cancers. Twenty of the lung cancers were synchronous and 47 were metachronous after head and neck cancer. Of the synchronous lung cancers, 50 percent were postoperative stage I, whereas only 11 percent of the metachronous cancers were postoperative stage I. The lung cancer survival rate was significantly better for the synchronous cancer group at 5 years (34 percent) than for the metachronous cancer group (5 percent). The better survival rate was evidently due to the greater proportion of early-stage lung lesions. The relatively large number of advanced-stage lung lesions in the metachronous cancer group suggests that aggressive screening of head and neck cancer patients for lung cancer may detect more metachronous lung cancers at an earlier stage and thus improve the survival rate of these patients.

This paper reviews eighty patients dying of acute pancreatitis, fifty in a hospital population and thirty who died in the community without ever receiving medical care. Our findings suggest the following conclusions: Death in the hospital from acute pancreatitis is often associated with misdiagnosis. Such patients frequently have associated disease which obscures the primary diagnosis and enzyme levels which are either not elevated or elevated only moderately. When no medical therapy is received by patients, death occurs earlier in the course of the disease, often associated with edematous pancreatitis, and often in younger patients. Acute lesions of the liver are found in half of these patients and we have speculated as to whether this is a cause or a result of the acute pancreatitis. Finally, the different incidence of edematous, hemorrhagic, and suppurative pancreatitis in the two groups indicated that edematous pancreatitis is the earlier lesion and leads subsequently to hemorrhagic and suppurative pancreatitis.

The case histories of six women with simultaneous primary squamous cell carcinomas of the uterine cervix and the ororespiratory tract are reported. They represent 1.6% of the cervical carcinomas seen in a 4-year period and 22.2% of the total ororespiratory carcinomas in women in a similar period. A review of the literature reveals only infrequent reports of this combination of neoplasms. Etiologic factors appear to be related to environment, being associated with low socioeconomic status, poor hygiene, multiparity and prolonged tobacco usage. The authors suggest that similar combinations of these easily accessible cancers may be detected in populations of comparable economic status.

For many years, the Weber-Fergusson incision has been the standard approach for removing part or all of the maxillary sinus. Exposure is excellent and cosmetic results are generally gratifying. As our experience with these procedures has increased, we have found that the lower half or two thirds of the maxilla can be just as easily resected transorally, avoiding any facial incision. The initial incision is made in the gingivo-buccal sulcus and is extended beyond the midline to include some of the sulcus on the contralateral side. The nasal cartilages are cut and the soft tissues of the middle one third of the face can be lifted up like a curtain to expose the maxilla. For lesions of the entire maxilla involving the orbital plate and requiring orbital exenteration, the only facial incision required is a 6–8 cm transverse extension from the lateral angle of the palpebral fissure. The bridge of soft tissue bounded by the mouth below and the palpebral fissure plus the lateral extension above can be retracted up and down to expose the underlying maxilla during its excision. Any risk of poor reapproximation of the lip with notching is avoided. These approaches are especially valuable if heavy radiation predisposing to incisional breakdown has preceded operation.

Twenty-two patients with advanced cancer in the area of the head and neck were treated by combining major curative radiation (5000-8000 rads) and a composite operation including excision of the primary lesion and bilateral radical neck dissection. The mortality and morbidity of combining these two treatment methods was quite acceptable and did not exceed mortality and complication rates for this type of operation done without prior radiation.