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In the course of exploring the possibility of employing crystallized bovine albumin (Cohn) as a blood substitute, instances of delayed serum sickness characterized by myalgia, arthralgia, urticaria, petechial rash and fever occurring ten to twenty-one days after injection was noted in approximately 8 per cent of the patients injected. The usual therapeutic agents such as epinephrine, ephedrine, codeine and calcium gluconate, although helpful in the mild cases, afforded no relief in the more severe reactions. The generalized myalgia and arthralgia in some cases were especially severe, and it was primarily to relieve distressing pain that intravenous procaine was given. However, the subsidence of all the manifestations of serum sickness was a pleasant surprise and occurred with such frequency as to encourage its employment in all subsequent instances of serum sickness. Furthermore, we have attempted to explore its utility in the management of other states of hypersensitivity. A series of preliminary

Conclusions1. Bilateral vagotomy (infra- and supradiaphragmatic) failed to protect against ulcer or erosion (gastric and/or duodenal) produced by chronic histamine action in the dog, cat and rabbit.

ConclusionsEvidence is presented to show that increased concentration of the blood following burns is an important factor in the occurrence of gastro-duodenal ulcer after experimental burns. (The occurrence of gastro-intestinal congestion, erosion and/or ulcer in burns is directly related to the occurrence of hemoconcentration).Moreover, gastro-intestinal abnormality following burns, even when accompanied by histamine administration, may be prevented by avoidance of the hemoconcentration of burns by proper therapy.The incidence of gastric and/or duodenal ulceration provoked by hemoconcentration in burns is markedly increased when histamine-in-beeswax administration accompanies the burn.

Cancer ranks second only to cardiovascular disease as the commonest cause of death in this country. Of all deaths due to carcinoma, one fourth to one third are due to gastric cancer. As the age of the population increases, the number of persons who die from gastric carcinoma will also grow larger, so that by 1960 it has been estimated that 40,000 patients will succumb to gastric carcinoma annually. 1 The very frequency of gastric cancer suggests that any approach to the problem of reducing the death rate from malignant growths must include a serious consideration of how the number of persons who die from gastric cancer may be diminished. In the course of outlining a study to determine likely precursor groups of gastric carcinoma, 2 it was considered that the results of therapy of this disease at this institution during the preceding ten years should be determined so as

Conclusions1. Benadryl fails to alter the gastric secretory response to histamine stimulation in pouch dogs. 2. Benadryl (given in 100 mg doses in beeswax mixture intramuscularly) fails to protect against the histamine-provoked ulcer in dogs.

Conclusions1. Experimental burns, when accompanied by administration of histamine-in-beeswax mixture, produce gastric and/or duodenal ulceration in which the incidence of hemorrhage is high. 2. Experimental burns abet the ulcer diathesis.

Tools to cope more effectively with the bowel obstruction problem have been gradually evolving over the past four decades. It is possible to recognize most varieties of acute intestinal obstruction early enough to salvage the patient from the threat of a disorder that a few decades ago commanded a forbidding mortality. Great intestinal distention does not loom as difficult a problem today as it did four decades ago. The large residual mortality of intestinal obstruction today concerns primarily strangulating varieties. In fact, more than half the deaths from intestinal obstruction derive from the profession's failure to deal promptly with strangulated hernias and with internal strangulations before the bowel becomes nonviable. The current achievement with intussusception contrasts strikingly with our failure to deal competently with other strangulating varieties of intestinal obstruction. So similarly, the accomplishment with congenital intestinal atresia bespeaks the finesse of modern-day surgeons in coping with anastomoses of small tubular structures. The profession needs to take a more serious interest in intubation technics in dealing with intestinal distention, to which developments my colleagues, Doctors Arnold Leonard and Richard Edlich, have made significant contributions. The team approach to the problem of intestinal obstruction is essential. Every hospital with an interest in intestinal obstruction should have on its Bowel Obstruction Team an intestinal intubator with both interest and expertise. Leonard and Edlich and others who have achieved striking success with intestinal decompression by per oral intubation have a responsibility to train intubators and to transmit their expertise to others who can carry on. The problem in many respects is not unlike the history of utilization of gastroscopy for diagnosis. Only within the past decade have most American hospitals enjoyed ready access to competent gastroscopists, despite the fact that Mikulicz's first effort with gastroscopy traces back more than a century. It is important to preserve the skill and expertise that experienced intubators have acquired. Their lessons and experience will be lost unless transmitted to younger professional associates. Early diagnosis, prompt surgical management of all strangulated hernias, and per oral decompression of the distended small bowel prior to and/or at operation in all simple obstructions are fundamental criteria for success in any plan of treatment. When the obstruction is complete, after operative decompression, the obstructing mechanism must be removed surgically. For incomplete simple obstructions of the small intestine following adequate decompression, operation may not be necessary. Most instances of paralytic ileus, not septic in nature, respond favorably to conservative management. In colic obstructions, early decompression proximal to the obstruction is indicated. Effective intestinal decompression, preserving the sterility of the peritoneal cavity lies at the root of the matter. This recounting of a long experience in attempting to understand the bowel obstruction problem suggests that clinical observation, reinforced by experimental studies, is a useful tool in lending a forward thrust to improved accomplishment.

A variety of talents characterize the leaders of various eminent schools of surgery over the past two centuries that eludes precise delineation. There appears to be no standard pattern or model of performance. This brief narrative depicts some of the striking and primary qualities that have distinguished the leaders of a few notable schools of surgery during this period.

Glasgow's medical faculty traces back to the illustrious 16th century surgeon Peter Lowe. Its regius professorship, which dates from 1815, has been occupied by many luminaries including Joseph Lister, William Macewen, Charles Illingworth and Andrew W. Kay. William Macewen was Johns Hopkins's first choice for professor, but the opportunity was then awarded to William Halsted (1889–1922), who developed America's first great school of surgeons, a tradition restored by Blalock from 1941 to 1964.

A readily reproducible experimental wound infection model has been developed to assess the determinants of infection in primarily closed contaminated wounds. The needle puncture tract, the suture material, the diameter and quantity of suture remaining within the wound, and the tightness with which each suture is tied have been identified as factors which enhance the inflammatory response of the contaminated wound to infection. The increased likelihood of infection attending primary closure of contaminated wounds with percutaneous sutures gives strong support to the thesis that percutaneous sutures should be avoided in the closure of contaminated wounds.

Conclusions1. Human plasma administered intravenously is retained and utilized. A patient to whom a daily average of 450 cc of plasma was given over a 5-day period was maintained in positive nitrogen balance. 2. Human plasma appears to be a better agent than blood to employ to maintain nitrogen equilibrium in starvation states. 3. Bovine plasma can be given intravenously to man in fairly large quantities; it is retained and apparently utilized.

A Modern Delilah: When your President, Dr. Leo G. Rigler, our erstwhile Professor of Roentgenology at the University of Minnesota, asked me to give the 1958 Carman Lecture of the American Radiological Society on gastric cancer, I experienced mixed emotions in arriving at a decision. In the first instance, I could not have refused any reasonable request from Leo Rigler, a colleague whom every member of the faculty of the Medical School during his tenure had come to admire, love, and respect. Those of you privileged to know him well know whereof I speak. Radiologist, teacher and friend, of whom one is tempted to speak only in superlatives, he possesses still another unique attribute—that of being able to change the quality of the day for the better for those with whom he associates. Blessed and lucky beyond description is that man who has such a wife or friend. As a surgeon, coming to you with the results of surgical therapy of a dreadful scourge, I knew it would be exceedingly difficult to bring any new or...

Summary1. Experimental intestinal distention of anesthetized dogs produces an elevation of intraperitoneal pressure which, however, does not increase at the same rate as the intraluminal pressure. 2. Venous pressure in the lower extremities of experimentally distended, anesthetized dogs increases with increasing intraperitoneal pressure. At the same time, the rate of blood flow from the lower extremities to the carotid is slower. 3. Shock, eventually produced by prolonged intestinal distention, is relieved by deflation, blood transfusion and the steep Trendelenburg position. 4. Intestinal distention is attended by diminished respiratory movements, stasis of abdominal and peripheral venous blood, and extravascular loss of whole blood and plasma. 5. Pressure in the inferior vena cava is not observed to be altered in experimental intestinal distentions in which the intraintestinal pressures reached 50 cm of water—a pressure in excess of the upper limit of sustained intraluminal pressure observed clinically. ...

Summary Blood flow has been measured in the gastric, hepatic and mesenteric arteries as well as the portal vein of dogs during gastric hypothermia. A reduction in gastric flow of 58%, a reduction in hepatic flow of 51.6%, a reduction in portal flow of 36% and a reduction in mesenteric artery flow of 23% were observed. Resistance was greatly increased across both gastric and intestinal beds. Hepatic temperature was observed to decrease during gastric hypothermia.

Conclusions1. Exclusion of the antrum from continuity with the residual gastric pouch is the chief ulcerogenic factor in the Sauvage operation in which the antrum is anastomosed to the esophagus (Group II dogs). 2. Stomal peptic ulcer was not observed in vagally innervated total gastric pouches when the antrum remained in contact with the residual gastric pouch (Group I dogs). 3. Augmentation of the secretion of acid from an isolated Heidenhain pouch attends antral migration or exclusion (Group II dogs). Diminution of secretion from such a pouch was observed when the vagally innervated entire stomach, with the antrum in its normal position, was attached to the side of the duodenum as a blind pouch (Group I dogs).

The bowel distal to the point of obstruction is normal anatomically, whereas the proximal bowel exhibits anatomical changes. Alvarez1 states that most of the motor activities of the stomach and bowel are brought about and regulated largely by the internal pressure due to the presence of food or gas, on which basis an eventual condition of inactivity in the bowel distal to a complete obstruction would appear to be understandable. But the distal bowel has been found to evacuate enemas and transport barium in approximately normal time. In this study an attempt has been made to study the motor activity of the distal segment of the bowel in the presence of simple obstruction. There were 22 dogs obstructed, the point of severance being usually 3 to 5 feet above the ileo-caecal valve. The proximal end was turned in and the distal end anchored to the skin in 8 dogs. In 14 others both ends were inverted.Small rubber balloons were inserted into the bowel and the contractions of the bowel recorded upon a smoked drum...

Summary and ConclusionsThere is a marked shortening of the bowel in simple ileal obstruction (30 to 50%). The bowel wall above the site of simple ileal obstruction increases over 100% in weight. When the factor of shortening of the bowel is eliminated, the increase of weight is 34%. Edema of the bowel wall accounts for only 7% increase in weight. Next to shortening of the bowel the increase of blood in the bowel wall is most responsible for its great increase in weight.

ConclusionsThe factors of post-hemorrhagic anemia and shock are evaluated in relation to their effect on the histamine-provoked ulcer in dogs. Our evidence indicates that anemia and hemodilution occurring without shock is a mild ulcer abetting factor. However, post-hemoTrhagic shock, even of relatively brief duration aids and abets the ulcer susceptibility most likely through its vasoconstrictor effect on the small blood vessels with resultant localized anemic areas in the mucosa.The combined effects of post-hemorrhagic anemia and shock on the ulcer diathesis are synergistic in that together they give a higher incidence of histamine-provoked ulcer than does either alone.

Summary Resection of either the jejunum or ileum does not alter gastric hypersecretion following portacaval shunt. Ileectomy increases the susceptibility of a dog with portacaval shunt to meat intoxication.

Conclusions1. Changes in the gastric mucosa produced by continuous irritation are described.2. The sequence of events following irritation is compared in colon, small bowel, and stomach.3. The process of regeneration after superficial destruction of the mucosa is described and is offered as a possible simple explanation for the resistance of the stomach to auto-digestion.4. The possible implication of this mechanism in the pathogenesis of gastric ulceration is suggested.

Intubation of the entire obstructed small bowel at surgery has been accomplished in forty-four of forty-seven patients with the use of a coiled spring tube as an oral enterostomy. Refinements in this apparatus have contributed to the ease of passage and safe use of this device. We believe this tube may come to serve a useful purpose in the operative management of intestinal obstruction.

THE mortality in acute intestinal obstruction continues to be prohibitively high. Recent reports from large municipal hospitals where cases of bowel obstruction are frequently seen indicate that from 35 to 60 per cent of patients operated upon for acute bowel obstruction die (Miller). Despite the fact that marked improvement is manifest in the results of practically all other acute abdominal catastrophes, the mortality of obstruction to-day is almost that of forty years ago. This is due in large measure to late diagnosis, for any number of statistical studies indicate that when cases come to operation early the results compare fairly satisfactorily with the issue attending the surgery of other acute abdominal disorders. Finney reports a mortality of 36 per cent in 217 cases, but within the first 12 hours the mortality was 5 per cent and for the 12-to-24-hour period, 11 per cent. Whereas the mortality in the entire group of 128 cases of acute intestinal obstruction reported by Tuttle was 41.3 per cent, in ...

ConclusionsAlthough the length of bowel involved is of importance in shortening the survival period following strangulation cbstructions, the type of obstruction is of greater significance.

Roentgenology has played a most significant role in the accomplishments of surgery. In visceral surgery, of the abdomen and thorax, the surgeon has become especially dependent upon information revealed by roentgenograms. The plate-reading room of the roentgenologist has become the informal consulting center for the surgeon, where both negative and positive roentgen findings are sought eagerly, and efforts are made at fusion and synthesis of factual data relating to obscure cases. In the proper interpretation of the significance of intestinal distention, the roentgen findings afford most helpful assistance, so useful, in fact, that this source of factual information must never be neglected by the clinician. I make no apologies in presuming to discuss before a body who considers its chief function the recognition of clinical disorders, the role of diagnostic criteria in the choice of therapeutic procedure in the management of a disorder. Preoccupied as you may be with the detection of the presence of bowel ...

Summary 1.Pancreatic secretion in the dog following pilocarpine stimulation was markedly reduced by pancreatic hypothermia (15° to 23° C.) 2.The mortality rate for pancreatic necrosis evoked by injection of bile salts or duodenal juice into the pancreatic duct, or by the Shwartzman reaction, was enhanced slightly by use of systemic (25° to 30° C.) or local (15° to 23° C.) hypothermia. 3.Permeability of the cat esophagus to perfused human bile enriched with ox bile salts was not significantly altered by hypothermia (18° to 20° C).

Conclusions1. The incidence of gastrojejunal ulcer in dogs attending complete intragastric regurgitation of the duodenal loop contents is dependent upon the length of the afferent duodenojejunal loop. 2. In 11 dogs in which complete duodenal drainage by means of a short afferent loop (8 to 15 cm) was established, only one dog developed a gastrojejunal ulcer, an incidence of 9.1%. 3. Five out of 6 dogs undergoing the same operation in which the proximal jejunal loop was long (75 to 90 cm) developed stomal ulcer, an incidence of 83.3%. Four of these died of generalized peritonitis secondary to perforated ulcers.

SummarySodium ricinoleate, 1%, papain 1-50,000, and amfetin and defibrinated rabbit's blood were found most efficacious in obviating adhesion formation after painting the traumatized peritoneal surface with iodine. Sodium ricinoleate would appear to be particularly valuable in that it is not rendered inactive in the presence of infection.In this study, the following substances were compared with regard to their relative effectiveness in preventing peritoneal adhesions in rabbits: defibrinated ox blood, defibrinated rabbit blood, amniotic fluid, amfetin,∗ sodium ricinoleate (1%), blood serum of dog, ether, hypertonic glucose (10%), normal saline, papain 1–50,000, air, air and sodium ricinoleate (1%), air and amfetin.The method was as follows: under ether anesthesia, the abdomen of the rabbit was opened and a culture taken with sterile precautions. Intraperitoneal adhesions were produced by roughening the peritoneum and intestines with a knife or rubbing with gauze, and painting the raw surfaces with tinctu...

Summary and ConclusionsMeasurements of acid and pepsin values and determination of degree of digestion attending perfusions of the cat esophagus with gastric juice, obtained from patients after gastric resection for duodenal ulcer, have been made. These results indicate that esophageal perfusion employing the gastric juice of patients previously operated upon is a sensitive method for evaluating the likely protective effect of such operations against recurrent ulcer. Following procedures known to be associated with recurrent ulcers, gastric juice from some patients can be shown to have proteolytic digestive power not unlike that seen with untreated duodenal ulcer. After operations known from clinical experience to protect fully against recurrent ulceration, the gastric juice of patients uniformly shows acid peptic digestion in the range of normals. This technic of assessment indicates that the protection afforded by some gastric resections is inadequate and that recurrence is likely to follow. The operati...

ConclusiosFat emboli may cause gastric and/or duodenal erosions or ulcers. The presence of fat emboli after intravenous injection of fat may be demonstrated in the lung, brain, kidney and stomach. Its rate of disappearance in experimental animals is such that after 4 days it is found in sections of lung tissue in 41%, brain 11.1%, kidney 34.4% and the stomach of 3.7% of the sections examined. On the contrary, in sections of those animals sacrificed within one to four days after the intravenous injection of fat, the incidence of demonstrable fat emboli in the same tissues was: lung 91%, brain 61%, kidney 73.9% and stomach 47.8%.

ConclusionsThe material presented here leads to the conclusion that in simple obstruction only slight changes (congestion, edema) can be demonstrated and frequently no alteration of microscopic structure is to be observed. Grossly the bowel regularly appears hyperemic but no inflammatory or degenerative changes are observed on histologic study.

AN ADDITION to a voluntary hospital in which a university has an important stake is an event that merits the commendation of all who have a serious interest in medical education. This is an occasion that definitely suggests a reciprocal interest of the community in the university and of the university in the community. There is adequate precedent in this country for this type of relation between institutions of learning and hospitals. Moreover, the more completely the two groups can fuse their responsibilities into a common effort, the better. It is significant that Harvard University, one of the great universities . . .

ConclusionsThere appears to be a direct correlation between the iall in blood pressure and the time, length, and type of vascullar occlusions. In general, the longer the time and the longer the loop, the greater the fall in blood pressure. The type of obstruction, however, is of even greater importance than the time and length of the occlusion. In those instances in which the veins were ligated and in the encirclement strangulations (Group I), in which the arteries were not entirely occluded, the fall1 in pressure was much more rapid than in those instances (Group III), in which the arteries were absolutely occluded regardless of the condition of the veins.

The purpose of this study is to assess the effectiveness of antiseptic agents in the treatment of a reproducible experimental wound infection. 1. 1. Irrigation of contaminated wounds with either 70 per cent ethyl alcohol, benzalkonium chloride, 0.25 per cent chloramine, aqueous iodine, tincture of iodine, povidone-iodine, or crystal violet provided significant protection against the development of frank infection in contaminated wounds. The effectiveness of irrigation with these various antiseptic agents in the treatment of contaminated wounds did not differ significantly. 2. 2. Irrigation of wounds with dilute solutions of either ethyl alcohol (10 and 56 per cent) or chloramine (0.1 per cent) was ineffective in the treatment of the contaminated wound. 3. 3. Treatment of contaminated wounds by irrigation with 0.5 per cent silver nitrate solution enhanced the incidence of wound infection. 4. 4. Irrigation of contaminated wounds with solutions of carbolic acid (1 to 5 per cent) was regularly associated with early mortality from phenol poisoning. Treatment of contaminated wounds with a more dilute solution of carbolic acid (0.5 per cent), which did not kill the animals, was ineffective in providing protection against the development of subsequent infection.