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SHORTLY after the introduction of the sulfonamide drugs as antibiotics, they were used intraperitoneally as a prophylaxis against peritonitis. Innumerable reports indicated that they were effective, but most surgeons abandoned their intraperitoneal use when penicillin was made available, because it appeared to be more effective than the sulfonamide compounds. Of these two drugs penicillin appears definitely to be more helpful against colon bacilli, but neither can be classified as being extremely effective against these organisms. Although streptococci and other pyogenic bacteria are occasionally isolated as causative organisms in peritonitis Escherichia coli is much commoner and even when a mixed infection occurs it is usually the predominant organism. Therefore, in the treatment or prophylaxis of peritonitis there would appear to be a need for an antibiotic agent which would be more effective against Esch. coli. The introduction of the oral use of succinylsulfathiazole in 1941 by Poth and Knotts1and

Carcinoma of the colon is a very insidious lesion presenting very few early manifestations. Change in bowel habits, hemorrhage from the rectum and abdominal pain are the three most common symptoms. The lesion is less invasive than many tumors, as indicated by the fact that the five-year survival rate following resection is between 50 and 55 per cent. The postoperative mortality rate at the present time is in the neighborhood of 3 or 4 per cent.

Since the incidence of cancer in nontoxic nodular goiter as reported by us in 1944 appeared high (17.1%), we made another study during the next four years and discovered an incidence almost identical (17.2%). Our figures on incidence of cancer in nontoxic nodular goiter appeared so high because we were the first authors to break down the goiters into the three different types and to discover that the incidence was high in only one type of goiter and not in the others. The incidence of cancer was only 4.6% in toxic nodular and toxic diffuse goiter added together For decades, we have known that goiter is a geographic disease. It is possible that carcinoma of the thyroid is slightly geographical. At least it appears that there is a slightly geographical relationship in regard to the 16 patients we have observed in our clinic with cancer during 1944–1949; of these 16 patients, 11 had advanced malignant disease. We cannot have accurate figures on results regarding treatment of our cases until long-term follow-up is concluded.

Visualization of the gallbladder by x-ray was first achieved in 1923 by the intravenous introduction into the body of a halogenated compound which was excreted by the liver into the bile ducts and gallbladder [1--4]. This was the first time that visualization of an organ had been accomplished by introducing a substance into the body and obtaining a roentgenogram after the substance had been metabolized and localized primarily in one organ. Previously, visualization of an organ had been achieved only by introducing a substance opaque to the x-ray directly into the lumen and obtaining a roentgenogram to outline its inner wall. By 1925 visualization of the gallbladder had also been accomplished by the oral administration of halogenated compounds [5,6]. The drugs employed for intravenous and oral cholecystography had been synthesized specifically for that purpose based on earlier experimental work of other investigators. The following account describes in detail the experimental background of cholecystography, its origin, and its development and use during the ensuing fifty years.

The increased use of steroids in the treatment of general medical problems has been paralleled to a moderate extent by the increased use of these drugs for surgical patients in the preoperative and postoperative periods, as well as during operative procedures. In our experience, there are three situations in which steroid therapy is indicated. The first is in acute severe injury or illness in which acute adrenal insufficiency is suspected because of a significant fall in blood pressure not explained by blood loss or coronary disease. In many instances it is difficult to be sure that these patients have a true adrenal insufficiency, and, if they recover, it is not always clear whether steroid therapy was responsible. Admittedly, this is not a very common situation. The second category of patients in whom steroid therapy is indicated are those who have been receiving steroid medication for arthritis or colitis for weeks

Although much confusion still exists as to the classification of acute pancreatitis, an attempt should be made to identify the type of disease, particularly since the treatment and prognosis are apt to be different in the various types. All cases of acute pancreatitis may be divided roughly into an acute edematous (interstitial) type, and an acute hemorrhagic or necrotic type. It is possible that the acute edematous type is caused primarily by obstruction, whereas the main factor in the production of the hemorrhagic or necrotic type is the development of tryptic digestion within the gland. The clinical manifestations of the two groups may be very similar indeed, except that the acute edematous type is invariably the milder and is never associated with shock. It should be remembered that an acute pancreatitis, particularly of the edematous type, may readily be overlooked unless the pancreas is palpated. Areas of fat necrosis may likewise be overlooked unless special care is taken to search for them, particularly since they are occasionally located only along the surface of the pancreas. The value of the blood amylase test as a diagnostic aid has been discussed. From the experiences of the author and others who are using this test, it appears that a rise in the blood amylase level is rather consistently encountered, particularly in the acute edematous type early in the disease. It is significantly true that the rise in the blood amylase may persist no longer than two or three days. The level may then fall to normal, or more commonly in the author's experience, below normal. Obviously, if the patient is not seen during the first two or three days of the attack, the blood amylase test may be of no diagnostic value. This fact must be remembered lest the test receive undue condemnation. However, the author has noted the persistence of a high blood amylase in several cases for many days after the onset of the attack. The treatment of the acute edematous type appears definitely to be conservative. After the acute phase of the disease has receded, attention should then be directed toward operative correction of the cholecystic disease which is so frequently present in acute pancreatitis. There is difference of opinion as to the treatment of acute hemorrhagic or acute necrotic pancreatitis. Many surgeons advise immediate operation. Others advise conservative treatment and operation on the biliary tract later, as indicated. The author is inclined to favor strongly the latter method of treatment.

The panelists discuss general principles of medical management of duodenal ulcer, criteria of intractability, the role of stress, the status of gastric analysis, the chances of successful medical management, and the relative merits of various surgical technics.

During the past four or five decades cancer has received more public attention than any other disease. There has been a 15% increase in deaths from cancer in males and a 9% decrease in the female population per 100,000 during the past 15–20 years. It appears more and more likely that viruses play a vital role in the development of human cancer, thus raising the possibility of development of an anti-cancer vaccine, although many questions remain unanswered. A great deal of research has been done on tumor antigenicity and the use of anti-tumor vaccines in animals since 1943 when Gross first reported regression of intradermal sarcoma following injection of autoantibodies. Since that time cancer antibodies have been found to be produced by the human being, and it has been shown conclusively that some people have a resistance to cancer whereas others may have little or none. Surgery, irradiation, and chemotherapy remain the only three effective methods of treatment, although the latter cannot as yet be considered curative. Until a marked improvement is attained in anticancer drugs it is the author's opinion that the greatest possiblity of significant improvement in results of treatment for cancer lies in the development of effective combinations of methods.

Attention is called to the important differences between malignant gastric ulcer and the proliferative tumor. Likewise the great difficulty in differentiation between malignant and benign ulcer is emphasized. The operability rate in carcinoma of the stomach still remains only 50 per cent or less. The five year survival in patients having resection of the stomach for malignant ulcer is 45 to 50 per cent, whereas it is only 25 per cent in patients having “curative” operation for the proliferative tumor.

Seven per cent of 767 patients with cancer studied more than five and as many as ten years ago in our laboratory had positive blood samples. A similar frequency of positive blood samples was obtained when only those patients considered “curable” were tabulated, or those patients studied before, during, and after operation. The survival rate in the entire group of 767 patients was not different with regard to positive or negative blood samples, being 13 and 12 per cent, respectively. The survival rate for “curable” patients with positive blood samples was no different from the survival rate for those with negative blood samples; it was 32 per cent for each category. Although there is no apparent difference in the five to ten year survival rates of all 767 cancer patients, regardless of whether the blood samples are positive or negative, a definite trend is apparent in the decreased survival of patients with a shower of circulating cancer cells during or after operation. Only two of twenty-three patients (8 per cent) with showers of cancer cells demonstrated during operation were alive and well five to ten years postoperatively as compared with a 16 per cent survival (26 of 182) of patients with negative blood samples at all times before, during, and after operation. Also, vascular metastases developed in 39 per cent of those patients with showers of circulating cancer cells during operation as compared with only 18 per cent of those patients with all negative blood samples.

ConclusionsThere is an immediate dilution of capillary and venous blood in the dog after a single large hemorrhage performed under local anesthesia. This dilution is absent when a similar hemorrhage is performed after the induction of intravenous sodium amytal anesthesia. There may even be a concentration of the blood under this circumstance. As soon as the effects of the anesthesia wear off dilution promptly appears.

We have observed that following infections and toxemias of a severe nature, the same changes take place in the human thyroid as occur in the thyroid gland of animals, but to a lesser extent. These changes are loss in colloid, hyperplasia, desquamation of acinous cells and decrease in iodine content. Administration of iodine by mouth is followed by an absorption of iodine by the thyroid glands of patients with exophthalmic goiter, adenomatous goiter (toxic or non-toxic) and normal glands. Injection of lipiodol into the lungs of 2 patients with lung abscesses and bronchiectasis produced a rise in the iodine content of the thyroid gland, to the extent of four or five times normal. This suggests that iodine can be absorbed from lipiodol, since the amount that escaped into the alimentary tract hardly seems sufficient to produce such a pronounced change in the iodine content of the thyroid. It seems probable that the tendency toward recurrence of exophthalmic goiter after operation can be predicted by the iodine content of the gland and its histological response to iodine. Hyperplasia of the type which can scarcely be differentiated from that seen in exophthalmic goiter is not uncommonly found in the thyroid glands of patients dying from acute infections.

IT HAS, of course, long been desired to get some material which, after entering the gall bladder, would make it visible to the X-ray—to enable more accurate diagnoses of lesions involving the gall bladder to be made. In looking around for a suitable substance, it was felt that certain requirements would have to be met. In the first place, it must be a substance which could be introduced by injection subcutaneously or intravenously, or could be given by mouth. This substance must be something which would be excreted almost entirely by the bile, and, further, enter the gall bladder, and, finally, it must be a substance which would not be toxic in the proportion necessary to produce a shadow. Therefore, before starting in, it follows that any substance which we may obtain to visualize the gall bladder must be a substance which will be excreted by the liver into the gall bladder through the bile. It, therefore, follows that if the function of the liver is disturbed so that any theoretical substance may not be...

In previous studies we have noted an incidence of suture line recurrence following resection for cancer of the colon in approximately 10 per cent of patients. Prophylactic measures consisting of preliminary ligation of the lumen of the bowel several centimeters proximal and distal to the tumor, excision of the tissue crushed by the clamps, and irrigation of the bowel before performance of the anastomosis, have been employed in 101 patients over a five year period. In this group of patients, all of whom have been followed up for at least one year, we have been unable to find a single incidence of recurrence of disease at the suture line.

Cancer cells can be recovered from veins draining tumors of the colon and rectum. It would appear that the presence of such venous emboli would affect adversely the surgical cure rate in colon and rectal cancer.

Fifteen cases of carcinoma of the thyroid gland in children and adolescents between 5 and 20 years of age were treated at the University of Illinois Research and Educational Hospitals from 1936 to 1956. Twenty years of age was chosen as the maximum in this study, since this is the time when the child has reached maturity and growth has ceased. Winship and Chase (1) compiled 285 cases from the literature up to 1955, but no definite maximum age was stated. Our Pathology Department, in accordance with the classification of Warren et al. (2), reported our series of 15 cases, of which 7 or 46.6 per cent were papillary adenocarcinoma, 5 or 33.3 per cent were adenocarcinoma, and 3 or 20.0 per cent were adenocarcinoma in adenoma (adenoma malignum).

In an effort to determine the efficacy of cortical extract in the prophylaxis and the treatment of shock, the extract was given to animals subjected to shocking procedures and to human beings having major operations of a magnitude apt to produce shock. In animals, shock was produced by hemorrhage and by massage of the intestine with the animal under ether anesthesia. In experimental shock produced by hemorrhage cortical extract exerted a definite but slight tendency to decrease the severity of shock, particularly when the extract was given with fluids (glucose and electrolytes). Fluids alone, i.e., without cortical extract, did not significantly prevent the fall in blood pressure although the actual survival time following hemorrhage was increased. When cortical extract was given an hour or two before institution of intestinal massage (to produce shock), the average drop in systolic blood pressure after forty minutes of massage was only 19.5 mm., contrasted with 35.3 mm. in animals not receiving extract prophylactically. Moreover, when hemorrhage of a constant rate was instituted ninety minutes after intestinal massage was begun, there was a survival time of thirty-six and five-tenths minutes in animals receiving cortical extract, contrasted with a survival time of only twenty-one minutes in animals not receiving cortical extract. When glucose and electrolytes were given in addition to extract, the effect was still more prominent, there being no drop in blood pressure after forty minutes of massage and an average of only 7.5 mm. after fifty-five minutes of massage. In other words, the beneficial effect of cortical extract and fluids (glucose and electrolytes) in prevention of shock was comparable to that which might be expected from plasma. When extract was given after shock had already been produced in animals very little beneficial effect could be demonstrated; there was little or no rise in blood pressure although further drop was slightly delayed. Falling drop determinations showed an increase in specific gravity of blood in shock, and a decrease after hemorrhage as reported by others. Cortical extract showed a definite but slight tendency to counteract the increase in specific gravity produced by shock. In human beings the use of cortical extract in the presence of shock was limited to a few cases due to the relative infrequency of shock, but in every instance the effect appeared to be beneficial. In order to determine whether or not cortical extract would exert a favorable influence in prevention of shock, the average pulse rate and blood pressure was computed in a series of fifteen patients receiving cortical extract prophylactically, and upon whom major operations of unusual duration and severity were performed. From the hospital records an equal number of operations (in which no cortical extract was given), with equal number of types and duration, were obtained and the average pulse rate and blood pressure likewise determined. In the patients receiving cortical extract prophylactically, the pulse rate averaged eight beats per minute slower, and the systolic blood pressure 12 mm. higher than in the patients not receiving extract. This suggests that the cortical extract tends to minimize the changes which might be interpreted as being changes preliminary to the development of shock. Observations on animals as well as patients showed that the extract was much more effective when given prophylactically, than when given after shock was already produced.

Although we may not be fully aware that each discovery in science is dependent upon another of equal importance, we realize this fact when we undertake a study of the development of any significant idea. Since this is true, we often wonder why the author of one discovery does not capitalize on it and proceed with the development of the other which appears to follow so obviously. It is amazing how seldom this progression is made by one man or group of men. The concept of cholecystography was developed by Evarts Graham and was based upon two previous discoveries. One of these was the demonstration by Abel and Rowntree (1), in 1910 that phenoltetrachlorphthalein was excreted almost entirely in the bile. The other was the demonstration by Rous and McMaster (2), in 1921, that the normal gallbladder was able to concentrate bile eight to ten times by absorbing water (Fig. 1). Abel and Rowntree were searching for a cathartic which could be given by hypodermic injection, hoping also for one which had a prolonged a...