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For the past 20 years, internal anal sphincterotomy has generally been considered to be the standard operation for an anal fissure. We sought an alternative form of treatment because of the wound complications inherent in this operation. Anal dilatation, precisely performed with a Parks' retractor opened to 4.8 cm or with a 40-mm rectosigmoid balloon, has been found to cure successfully the fissure in 93 percent and 94 percent, respectively, of each group and to be associated with fewer complications.

The effects of intravenous ethanol and ethanol plus furosemide on pancreatic capillary blood flow (PCBF) were investigated using a laser-Doppler flowmeter. Forty Sprague-Dawley male rats were divided into 4 groups: (1) control, (2) 80% ethanol, (3) 80% ethanol plus furosemide, and (4) furosemide. Mean arterial blood pressure and heart rate were monitored. Levels of serum amylase, calcium, electrolytes, ethanol, and furosemide (groups 3 and 4) were measured, and samples of pancreatic tissue were obtained. The ethanol and furosemide levels were statistically different (p0.05). PCBF significantly decreased (p0.05) in group 2, increased (p0.05) in group 3, and did not differ (p0.05) between groups 1 and 4. Histopathologic analysis revealed swollen acini in group 2 and sparse focal necrosis without acinar swelling in group 3. The depressant effect of ethanol on PCBF may be the result of its direct action on pancreatic cells causing edema and capillary compression rather than on primary vascular control mechanisms that adjust blood flow. Furosemide counters this effect.

This study was designed to study the importance of lumenal pH and antral distention on G-cell numbers. Antrocolic transpositions (ACT) were performed in female Sprague-Dawley rats, orienting the peristalsis of the transposed antra to result in either filling or emptying. In some animals a segment of parietal cell bearing corpus mucosa was left with the antrum to provide a relatively acid lumen. Sham operations were performed in controls. The rats were sacrificed after 15 days. The self-filling antra were grossly distended compared with the self emptying antra. G cells were quantitated by means of a double-antibody immunofluorescence technique. All ACT rats had significantly increased G-cell numbers and serum gastrin levels compared with controls. The magnitude of the increase depended on the presence or absence of distention and an acid environment. The most marked hyperplasia occurred in the group with distended antra and no acid. The group with self-filling antra but an acid lumen showed a significant but lesser increase. The least degree of hyperplasia was observed in the group with self-emptying antra and an acid lumen. These data indicate that both distention and a nonacid lumenal pH encourage G-cell hyperplasia. The nonacid lumen is a more potent stimulus than distention but the two are synergistic.

Pylorus-preserving gastrectomy has been advocated in the management of gastric ulcer with a view to reducing gastric acidity while preserving motor and emptying function in the gastric remnant. In the animal studies reported herein, performed on parasympathetically denervated (Heidenhain) fundic gastric pouches, significant decrease in volume and free acid output occurred after pyloric-preserving gastrectomy when compared with control values. These data confirm that the goals of the operation, in terms of diminution of acid secretory rate without sacrifice of the pyloric sphincteric mechanism, are achievable.

Chronic exogenous high dose adrenal cortical steroid administration to dogs resulted in a 137% increase in G-cell mass with an associated enhancement of peak serum gastrin levels. Adrenalectomy caused a halving of G-cell numbers without significant changes in serum gastrin levels. Adrenal cortical steroids appear to have an important trophic role for the G-cell.

New experience in management of infection associated with PTFE graft ex posure in angioaccess is presented. Primary closure or rotating skin flap of these open wounds usually fail. Simple local wound care and systemic antibiotic administration are the first step to control and localize the infection. A mature PTFE graft can tolerate exposure for an indeterminate period of time. Once the infection is clinically controlled, salvage of the infected graft can be achieved by revision and removal of the infected portion of graft.

Dogs prepared with gastric fistulas and Heidenhain pouches had vagal stimulation in a continuous fashion by 2-DG (25 mg/kg/hr) before and after antrectomy. An 86 per cent fall in gastric fistula acid output was seen after antrum removal. Heidenhain pouch acid output fell by 36 per cent after antrectomy and the mean acid output was not significantly greater than basal levels. Increased doses of 2-DG (50 mg/kg/hr and 100 mg/kg/hr) post antrectomy failed to restore gastric fistula output to preantrectomy levels. Small doses of pentagastrin coupled with 2-DG (25 mg/kg/hr) did significantly increase acid secretion more than did the individual effects of pentagastrin and 2-DG combined, demonstrating true synergism. 2-DG and barely suprathreshold pentagastrin were as effective as quadrupling the 2-DG dose alone. The loss of antral gastrin, however, after antrectomy was not compensated for by the supplementary pentagastrin. Vagal-antral gastrin, although small in magnitude, is believed to be an important contributor to the vagal mechanism of acid secretion by virtue of its potentiating synergism with parasympathetic innervation of the oxyntic glands.

The effect of sustained vagal nerve stimulation by continuous intravenous infusion of 12.5 mg per kg-hr of 2-deoxy- d -glucose was studied in dogs with simple gastric fistulas. Gastric juice volume, hydrogen ion content, and electrolyte and pepsin concentration and output were measured as were serum electrolytes and sugar. Levels of acid and pepsin secretion formed a plateau after 2 to 3 hr which was maintained without evidence of fatigue for 24 hr. Hourly acid output approximated two-thirds or four-fifths of the response to 0.05 mg per kg of histamine base given subcutaneously or 150 mg per kg of 2-deoxy- d -glucose given intravenously, respectively. An essential component of the thesis which claims vagally driven gastric acid hypersecretion as a critical feature of duodenal ulcer diathesis is a physiological possibility.

Summary Two groups of dogs were prepared, one group with gastric fistulas, the other with isolated innervated antrums. The gastric fistula dogs were maximally stimulated with a histamine infusion; the effects of insulin and potassium on gastric acid secretion were studied before and after vagotomy. In the second group of dogs, Antral motility was studied under the influence of insulin and potassium. In addition, tests were performed on atropinized gastric fistula dogs and on both groups while receiving a dextrose infusion. The following results were obtained. 1.Insulin caused an inhibition of histamine-stimulated gastric acid secretion. Inhibition commenced during the third 15-min period and reached a nadir 90 min after insulin injection. The inhibitory phenomenon was completely prevented or reversed by a continuous potassium infusion or an acute potassium load, respectively. 2.The protective role of potassium was not dependent upon an intact parasympathetic mucosal innervation. 3.Antral motility was acutely inhibited and then stimulated by insulin. Neither inhibition nor stimulation was influenced by a continuous potassium infusion. 4.Insulin inhibition of acid secretion persisted in the absence of hypoglycemia; inhibition of motility was apparently prolonged as a result of the absence of ensuing stimulation. 5.Because of their different inhibitory patterns and their differences in response to a potassium infusion, it is suggested that acid secretory and antral motility inhibition may have separate mechanisms. In an attempt to explain these findings, a working hypothesis is outlined.

Highly selective vagotomy was performed on five dogs. Postoperatively, gastrin cell (G cell) hyperplasia occurred in all dogs. Mean preoperative G cell numbers increased from 350 to 530/cm mucosal length (p less than 0.02). Antral tissue gastrin also increased by 100 per cent (6.7 x 10(6) to 13.7 x 10(6) pg/gm tissue, p less than 0.05). Basal and stimulated serum gastrin were unchanged following highly selective vagotomy. The cause for G cell hyperplasia is not clear, but is probably multifactorial.

Evaluation of gastric acid secretion and serum gastrin response to proximal or distal intestinal bypass and subsequent resection was undertaken. Ten dogs with gastric fistulas underwent control secretory studies consisting of basal acid output (BAO), maximal vagal stimulation (2 deoxy-d-glucose (2DG) 150 mg/kg iv), maximal histamine stimulation (160 μg/kg/hr iv), and test meal stimuli. Serum gastrin was measured basally and following gastric stimulation. Dogs were then divided into two bypass groups: Group I, distal bypass, leaving 40 cm jejunum and 4 cm ileum; and Group II, proximal bypass, leaving 4 cm jejunum and 40 cm ileum. Postoperatively, repeat studies were performed. Both groups then underwent resection of the bypassed segments followed by repeat secretory and gastrin tests. BAO was significantly increased in Group I dogs. BAO increased from a control of 0.04 ± 0.02 to 0.51 ± 0.19 meq H+/60 min (±SEM). No significant changes in BAO were observed in Group II following bypass. Acid secretion to maximal vagal or maximal histamine stimulation was not significantly different in either group. Serum gastrin response was unchanged in either group following a test meal. In Group I dogs, resection of the previously bypassed bowel produced a further significant increase in BAO (1.44 ± 0.4 meq H+/60 min). After resection of the bypassed bowel, there was no significant change in basal or stimulated gastrin. Gastric fistula BAO increased following 90% distal but not proximal bypass; subsequent resection of the bypassed segment produced a further increase in BAO. Acid secretory responses to both histamine and 2DG were not influenced by either bypass or resection. An increase in BAO without a change in the background of serum gastrin may suggest the presence of a gastric secretory inhibitor in the distal small bowel.

PEUTZ,1in 1921, reported the association of skin pigmentation and small bowel polyps in several members of a family. Jeghers2added two such patients to the literature in 1944 and, in 1949 along with McKusick and Katz,3he established the syndrome as an entity which appears to be inherited as a mendelian dominant. Since that time additional cases have brought the reported number to somewhat over 100.4 An additional patient, a 41/2-year-old girl with the rare syndrome of mucocutaneous pigmentation and gastrointestinal polyposis, is presented below because of the associated presence of a granulosatheca cell tumor of the ovary with resultant precocious puberty. The interest aroused by the coincidence of these two rare disorders has been further stimulated by the isolated reports5,6of two other cases of Peutz-Jeghers syndrome associated granulosa cell tumors. Report of a Case A 41/2-year-old girl was admitted for

Motility patterns in innervated canine antral pouches closely resemble those found in the main stomach. Denervated fundic (Heidenhain) and denervated antral pouches, however, have distinct and characteristic motility patterns which differ from those found in the main stomach or innervated antral pouches, a phenomenon well-documented by Robins and Boyd, 1 Bercovitz 2 and Quigley and Templeton. 3 Sugawara, 4 using a complete transection and reanastomosis technique at the junction of the antrum and body of the stomach to divide the intrinsic and extrinsic nerve plexuses, concluded that the postanastomotic (distal, denervated) segment manifested antiperistaltic activity, prolongation of spike discharge interval, and increased force of contraction. Motility remained unchanged in the preanastomotic segment. All of the above observations suggest that the vagally denervated antral pouch has characteristic motility and may, in the absence of extrinsic parasympathetic innervation, respond independently of the remaining stomach to various stimuli. The following study was undertaken

Abdominal hernia as a concomitant of cirrhosis of the liver has been variously reported as having an incidence of between 16% 1 and 42%, 2 depending upon the presence of associated ascites. A reasonable hypothesis for the relationship has been offered by Altschule who has suggested that hernias form as a result of a long-standing increase in intra-abdominal pressure. In view of the observation that less than half of patients with large amounts of abdominal fluid form them, a latent congenital defect is a probable precursor. 3 Although the commonly encountered hernias are either umbilical or inguinal, both may be found in the same patient. The complications of untreated hernias of this nature are well known and include incarceration of the bowel, with or without strangulation. While spontaneous perforation of an umbilical hernia in infants (omphalocele) has from time to time been recorded in the English literature, 4 the condition

Cirrhosis of the liver has become an increasingly important disease in recent years and in 1958 was eighth among the leading causes of death in the United States. 1 It has been estimated that one-third to one-half of the 350,000 cirrhotic patients currently alive will ultimately die of some complication of their disease. 2 Despite their frequently advanced age, poor general condition, and because of concurrent though unrelated disease, the constituents of this large group are commonly candidates for elective as well as emergency surgery. The surgeon faced with the responsibility and problem of operating upon a patient with known or suspected cirrhosis has been handicapped by the relative paucity of available information on the general response of the cirrhotic to procedures not directly related to his hepatic condition. The purpose of this study has been to reexamine some of the currently accepted concepts of the response to surgery in

THE superiority of plastic catheters and cannulas over steel needles and trochars for intravenous use and for diagnostic and therapeutic body-cavity drainage appears well established. Although many have been demonstrated as adequate for the various procedures for which they are intended certain shortcomings have limited their usefulness and efficiency.1 2 3 4 5 In some cases the cannulas are introduced into the body cavity through steel trochars, thereby limiting the maximal diameter of the catheter to the internal diameter of the trochar. In others the cannulas are adapted to a steel hub requiring disassembly and reassembly for reuse. This has further disadvantages in the . . .

• The records of 1,079 patients with gastric carcinoma were reviewed. Of these, only 21 (about 2%) had had previous gastric surgery for benign disease, usually peptic ulcer. The average interval between the original gastric surgery and the discovery of stomach cancer was 26.9 years. The symptoms of cancer presentation were not distinguishable from other forms of the postgastrectomy syndrome. Gastric cancer tended to develop in these patients during the sixth decade of life, irrespective of when they had had their original gastric surgery, strongly suggesting an age-related factor. Although it would appear that previous gastric surgery for benign disease is not a major risk factor for the subsequent development of gastric cancer, such a relationship may exist. Patients who have undergone gastrectomy should be followed up carefully for the recurrence of symptoms. ( Arch Surg 1982;117:294-297)

To the Editor:— Dr. Eisenstadt is correct in pointing out that bishydroxycoumarin is not generally given in divided dosages and that 200 mg. per day is an uncommonly large amount. My original protocol read "50 mg. q. d."; it was misinterpreted by the editors as "50 mg. q. i. d.," or four times the intended amount, and the error was overlooked in proofreading. Dr. Eisenstadt is misinformed in believing that a prothrombin time of 21% "would hardly be low enough to cause the nose bleeding." A number of authors have pointed out that no reliable relation can be discerned between the onset of hemorrhage and the prothrombin, bleeding, or coagulation times. While it appears desirable to maintain a prothrombin time of 15 to 25% of normal in a patient taking bishydroxycoumarin, intravascular clotting has occurred at lower and hemorrhagic diathesis at higher levels. As pointed out in the protocol, "blood

This "little" textbook of surgery has enjoyed exceptional popularity among medical students for more than a decade, and if there has ever been justification for a concise guide to clinical practice, then this third edition nicely fills that slot. The complexities of surgical practice and the increased obligations of the practitioner to incorporate surgical judgment in the fund of knowledge upon which he draws for the proper management of patients has clearly become overwhelming to the neophyte student. There is a natural tendency among members of this group to emphasize in their undergraduate medical training those areas which they think will be most helpful to them in future practice. It must be kept in mind that most medical students do not choose surgery as a lifetime career. It is my view, then, as a teacher of surgery, that the surgical education presented to medical students—andespeciallythose who are

Gastric motility in the conscious state in dogs has been studied traditionally by intraluminal balloon techniques; extraluminal strain gauge transducers 1-5 and implanted electrodes 6-10 have been used more recently. The latter methods more closely approximate normal physiologic conditions as they involve no intragastric contact or distention, factors which may have a direct or indirect stimulatory effect on motor activity. The balloon techniques, however, have the virtue of simplicity and convenience and require for their execution comparatively inexpensive and easily managed equipment. The gastric preparation ideally suited to simultaneous secretory and motility studies (utilizing a balloon technique) should have two "pouches" which have both morphologic and physiologic identity with the stomach. Construction of the usual innervated antral pouch, 11-13 however, completely separates the antrum from the proximal portion of the stomach, thus creating an unphysiologic or artificial state. Moreover, reestablishment of gastrointestinal continuity by gastroenterostomy in effect precludes accurate and

There has been recent editorial emphasis on the long-standing observation that gastric malignancy in the United States has been on the steady decrease for the past 2½ decades and very probably longer (Fig 1).64During the years 1930 to 1955 the age-adjusted mortality rates have fallen approximately 23%.45,64From a clinical aspect the decline has become so striking, in fact, that a number of medical centers have recorded a drop in admissions for this disease in excess of 50% since 1952.64By way of contrast, death from carcinoma of all types has increased during the same interval, and, while the mortality rate from carcinoma of the stomach has fallen from 19.8 to 11.2 per 100,000 population, that from carcinoma of the colon and rectum has remained stable (Fig 2).45The trend has not been confined to the United States alone; comparably reduced death rates have been

Operative Surgery: Thorax edited by W. P. Cleland, ed 2; 426 pp, with illus, $31, Philadelphia: J. B. Lippincott Co., 1968. There is no longer a dearth of atlases available for surgical education. The vacuum, once only partially filled by one or two satisfactory texts, now no longer exists. There are excellent presentations of standard operative techniques in general abdominal and thoracic and cardiovascular procedures. Any emerging text at this time must, therefore, compete in fairly sophisticated company. These two volumes from part of a large series of books on operative surgery, are designed to describe techniques in surgery of the eyes, ears, nose, and throat, general abdominal surgery, the hand, head and neck, neurosurgery, obstetrics and gynecology, orthopedics, and, finally, vascular surgery. The volumes are obtainable as a set or individually and must be judged on their individual merits. The first volume devotes itself to general considerations in surgery

Textbook of Operative Surgery, by Eric L. Farquharson, ed 3; 951 pp, 1,000 illus, $23.50, Edinburgh and London: E. & S. Livingstone Ltd. (Baltimore: Williams & Wilkins Co.), 1966. The spate of surgical books appearing in recent years has literally deluged the professional public with a variety of "standard texts" upon which to draw. The two veterans discussed here have survived the rigors of a first and second edition and are currently being presented anew to the surgical reader. The first, by Gius, although an example of a work predominantly written by one man, was accomplished with assists from coauthors on sections of highly specialized interest. Moreover, editorial criticism of the text in numerous additional areas was provided by colleagues, the final outcome demonstrating a well-balanced and polished digest. The book is extremely readable and concise and can be successfully completed by the medical student on a six- or eight-week

Surgery of the extrahepatic biliary tree constitutes a significant proportion of the work of the general surgeon. In addition, many practitioners who would ordinarily not attempt "major" operative surgery, consider cholecystectomy fair game. As the editors of this text point out, there are three ways in which poor results from biliary tract operations may be incurred: (1) The operation should not have been performed in the first place, eg, when it is done for symptoms actually arising from another cause. (2) The operation may be inadequately performed, eg, when calculus material is left residual in the common duct. (3) The operation is improperly performed, eg, when damage to the right hepatic artery or the common duct is sustained. Because of the apparent simplicity but actual complexity of the extrahepatic biliary tree, there are few areas of the abdomen in which the challenge to the surgeon's imagination and technical skill is

The Craft of Surgery . 2 vol. Edited by Philip Cooper. 1,510 pp, 1,040 illus. $42.50. Little, Brown & Co.. 34 Beacon St, Boston 6, 1964 It is highly improbable that a truly definitive atlas of surgical technique will ever be available to the practicing surgeon; nor is this a particularly lamentable deficit. It is to be expected that while a basic and unified approach to many surgical problems has evolved, the details and niceties of most general operative procedures have an infinite variety of refinements, far too numerous to be encompassed by a single text. Consequently, books on the art and craft of surgery are rarely competitive but rather are complementary. And so it is with two recently published texts, one written by Madden and the other edited by Cooper. Madden's Atlas of Technics in Surgery is an expanded two-volume second edition of a highly successful text which first appeared in 1958 as a single tome. Each procedure illustrated is depicted by the artist as the author performs it. One virtue of this type of

An increasing number of deaths have been attributed to hemorrhagic diathesis complicating bishydroxycoumarin (Dicumarol) therapy. Since its introduction to clinical use in 1941, a variety of indications have been described for the use of orally given anticoagulants.1These include nonfatal pulmonary embolism, primary and postoperative phlebothrombosis and thrombophlebitis, sudden embolic or thrombic arterial occlusion, postoperative venous thrombosis or embolism, and myocardial infarction. The hazards of anticoagulation have also been emphasized. Duff and Shull,2in their review of the first 23 fatalities due to bishydroxycoumarin therapy, summarized the most commonly encountered contraindications. Significant hepatic or renal insufficiency leads their list. Included, too, are ulcerative lesions of the gastrointestinal tract, blood dyscrasias with associated bleeding tendencies, subacute bacterial endocarditis, threatened and incomplete abortions, and obstetric cases near term. Historical Background The basic investigations of Solandt and others3paved the way for the current widespread use of anticoagulants in the