Chronic hypokalemic nephropathy: a clinical study. Description of 23 patients (21 women, 2 men) with an average age of 36.6 (19--68) years, who were hypokalemic during 6.5 years on the average (range 1/2--16 years). The cause of the potassium depletion was malnutrition (anorexia nervosa, vomiting) and/or abuse of laxatives and/or diuretics. With increasing duration of potassium depletion renal function deteriorated; in two cases terminal renal failure developed. Histology of the kidneys (9 cases) showed the picture of chronic abacterial interstitial nephritis. Urinalysis was negative or non-specific. The blood pressure levels were normal or low, hypertensive values being exceptional. Aside of hypokalemia a tendency to hyponatriemia, hypochloremia and metabolic alcalosis was observed, the latter turning into hypokalemic normochloremic acidosis with advancing renal insufficiency. Plasma renin activity and aldosterone concentration or excretion frequently were elevated, but no close correlation was found between these parameters or with the blood pressure. Bacterial infection of the urinary tract occured, if at all, in the late phase and seems to be complication rather than the cause of the kidney disease. The discussion of other possible pathogenetic factors leads to the conclusion that the term "chronic kaliopenic nephropathy" is justified. Some diagnostic and therapeutic consequences are mentioned.


Pharmacokinetic and pharmacodynamic studies of infusions with [Sar 1, Val5, Ala8] angiotensin II (saralasin). A modification of the infusion test with saralasin, an angiotensin II antagonist for the detection of renin-dependent high blood pressure was studied in renal hypertensive rats and in normotensive and hypertensive subjects. Infusion was started at a rate of 0.01 microgram/kg x min saralasin and the dose was increased ten-fold at 15 min intervals. A significant fall of diastolic blood pressure was observed at the dose of 0.1 microgram/kg x min in renal hypertensive rats, in healthy subjects treated with diuretics, and in patients with renovascular hypertension (saralasin responders). Plasma concentrations of angiotensin I, angiotensin II and of saralasin as well as plasma renin activity were measured. At the lowest infusion rate of 0.01 microgram/kg x min, saralasin plasma levels were 40-fold higher than plasma angiotensin II levels. The decrease in arterial blood pressure occurred at lower doses of saralasin than the increase of plasma renin due to inhibition of feedback on the renin secreting cells. It is concluded that if the saralasin test is performed by a stepwise increase of the infusion rate, potentially dangerous complications such as hypo- or hypertensive reactions can be avoided. The diagnostic reliability is improved by such a procedure since false positive and false negative responses may be prevented. The pressor effect of saralasin in non-renin dependent patients is an advantage since it causes a more marked difference of blood pressure change between saralasin responders and non-responders.


Depilatory effects of certain chemicals during the first hair growth cycle in sucking mice. The chemicals were administered, subcutaneously, orally or topically. Generally, the depilation produced in the mice by mimosine or cyclophosphamide differed from that produced by the steroid analogues tested. In the first 2 cases almost completely naked mice were commonly seen, while in the steroid-treated groups the complete inhibition of all hair fibres was rare. This is discussed in relation to the effects of the same compounds on wool growth in sheep. When related to bodyweight, the doses of cyclophosphamide (62 mg/kg0.75) and dexamethasone (5--10 mg/kg0.75), that depilated mice in our experiments were in good agreement with those reported to inhibit the growth of wool fibres in some sheep. An example of synergism in depilatory effect between dexamethasone and cyclophosphamide is also presented. The time of onset and the initial spread over the body of the 2nd hair cycle in depilated mice was observed.


Cytology of the bone marrow in the Mongolian gerbil. Heterophils were the most numerous cells (39%), followed by the normoblasts (27%) and lymphocytes (8%). Significant differences between males and females were observed in the total number of heterophils (42 and 35% respectively, P less than 0.002), heterophil myelocytes (12 and 10%, P less than 0.01) and the myeloid:erythroid ratio (1.9:1 and 1.4:1, P less than 0.03). Heterophils presented both annular and polymorphous nuclei, which appeared to develop along separate lines. The ring series began with a small nuclear 'vacuole' which increased in size with maturation of the cell. Ring-forms comprised 1/3 of the total heterophil population in the marrow. Eosinophils and basophils also demonstrated annular nucleated forms. Mature heterophils tended to have a scarcity of stainable specific granulation. Eosinophil granules were larger than those of the heterophil, slightly refractile and did not react avidly with eosin. Basophil granules, conversely, reacted strongly with the methylene-blue component of Wright-Giemsa stain and were metachromatic. Normoblasts retained their cytoplasmic basophilia to a greater degree than comparable cells in man.


Cuffed tube tracheostomy in the dog.

Cuffed tube tracheostomy in the dog. A surgical technique of performing tracheostomy in dogs requiring prolonged intubation with either cuffed or uncuffed tubes is described. Cannulae used in humans are anatomically unsuitable for the dog. The cannula and cuff described in this paper did not predispose to severe mechanical trauma to the trachea and we attempted to minimize factors that may predispose to tracheal damage during the period of intubation and the subsequent development of late tracheal injuring after extubation. A simple method of humidification in these healthy dogs proved adequate; neither tenacious tracheobronchial secretion nor the retention of secretions were seen.


Spontaneous glomerular basement membrane changes in the golden Syrian hamster (Mesocricetus auratus): a light and electron microscope study. Changes in apparently healthy hamsters, consistent with proteinuria, are reported, but no IgG deposits or amyloid in the glomeruli were detected. Further investigation is required into the significance and the aetiology of these, as yet, obscure alterations.


Volvulus at the ileocaecal junction in germfree mice. 16 cases of intestinal volvulus were observed in a total of 200 inbred C57BL/6N, GR/N, and DBA/2N germfree mice during the course of 2 years. The volvulus was a twisting of the caecum at the junction of the ileum, caecum and colon, resulting in occlusion and death. In each case the caecum was greatly enlarged. During the same period no intestinal volvulus was seen in 5 other germfree strains or in F1 to F4 generations of identical strains of microflora-associated and conventionalized mice.


Modification of a guinea-pig hopper to reduce food wastage. Food utilization in relation to gain in bodyweight was reduced by 18% without significantly affecting the growth of male guinea-pigs.


Balantidiosis in a chimpanzee (Pan troglodytes). A young adult chimpanzee died after a brief gastrointestinal illness characterized by profuse soft stool, vomiting and dyspnoea. Necropsy examination revealed a severe typhlitis and colitis with pseudomembrane formation, and acute aspiration pneumonia. Balantidium coli, a common intestinal parasite, was found in large numbers in the mucosal and submucosal layers of the colon and caecum. The inflammation and degree of invasion associated with Balantidium coli indicates that it was a primary pathogen.


Ectopic pregnancy in 2 guinea-pigs.

Ectopic pregnancy in 2 guinea-pigs. The foetuses were completely developed and were found in the peritoneal cavities of strain 13/N guinea-pigs in their 3rd pregnancies. One foetal placenta was attached to the left side of the peritoneal wall, the other adhered to the pyloric region of the stomach.


Incidence of natural virus infections of laboratory animals 1976--1977. The incidence of clinical viral disease in mice, hamsters, rats, guinea-pigs and rabbits in the United Kingdom in 1976--1977 is recorded. The significance of these diseases is discussed and recommendations for their control are made.


Intraocular melanoma in the rat.

Intraocular melanoma in the rat. 8 cases are reported of intraocular melanoma encountered in treated and untreated rats from 6 chronic toxicity studies.


Antiserum-mediated demyelination in vivo: a sequential study using intraneural injection of experimental allergic neuritis serum. Primary segmental demyelination accompanied by mononuclear phagocytes was induced by injection of antiserum into rat peripheral nerve, and the morphologic sequence of events was studied. Antisera were obtained from rabbits with experimental allergic neuritis (EAN) produced by the inoculation of emulsified bovine peripheral nerves in complete Freund's adjuvant. Sera were injected directly into rat sciatic nerve to circumvent the blood-nerve barrier. Recipient rats developed sensorimotor paralysis on the side injected with experimental allergic neuritis sera. Intense focal demyelinative lesions resulted from injection of experimental allergic neuritis sera. Control sera obtained from rabbits inoculated with bovine serum albumin in complete Freund's adjuvant did not produce paralysis or demyelination. The earliest change was damage to Schwann cells, seen 20 minutes after antiserum injection. Within a few hours lamellar splitting and vacuolation of myelin began to paranodal regions and Schmidt-Lanterman clefts and there were infiltrating polymorphonuclear cells. By 8 hours without the detectable presence of monocytes or macrophages, myelin vesiculation became advanced and widespread. By 15 hours, endoneurial edema had reached its maximum. Macrophages were found in association with myelinated nerve fibers. From that time through the next 5 days, demyelination progressed to complete denudation of axons by macrophage phagocytosis of myelin. Activated cytoplasm of Schwann cells reinvested demyelinated axons, often in concert with persisting phagocytic macrophages. Peripheral nerve demyelination thus transferred evolved rapidly, and myelin destruction occurred prior to the appearance of monocytes or macrophages. Demyelinating activity was lost after absorption by purified peripheral nerve myelin but not by liver or kidney and was heat-labile and complement dependent (T. Saida, K. Saida, D. H. Silberberg, and M. J. Brown: Nature 272: 639, 1978).


Pragmatics and early childhood language disorders: communicative interactions in a half-hour sample. An early childhood language analysis and intervention program, based on two models of pragmatics, is described. The theoretical constructs of each pragmatics model are described first, followed by a discussion of how the clinicians in the program translate these constructs into procedures for the analysis of and intervention with language disorders in preschool-aged children. Mention is made in conclusion of the limitations within which the program operates.


The clinical interaction analysis system: a system for observational recording of aphasia treatment. This paper describes the Clinical Interaction Analysis System (CIAS), a system for recording events that occur in treatment sessions for aphasic individuals. The development of the CIAS is summarized, the event categories contained in the CIAS are described, and the uses of the CIAS are discussed. Information about the reliability of the CIAS is also presented.


Some observations in a case of acoustic neuroma. The subject was a 47-year-old male with a moderate asymmetrical sensorineural hearing loss that initially presented cochlear signs except for positive stapedius reflex results. Over the course of only five weeks, he developed the audiological constellation of retrocochlear involvement. The retrocochlear results were confirmed by the removal of an acoustic tumour. The results highlight the importance of audiological monitoring and reflex measures in the identification of acoustic neuromas. Several observations provide insight into the apparent relationship between loudness and the stapedius reflex. The findings are discussed with reference to a proposed extension of Borg's recent theory that elevated reflex thresholds and reflex decay reflect differing degrees of the eighth nerve destruction.


Reading skills, auditory comprehension of language, and academic achievement. The purpose of this study was to investigate the relationship between scores made by kindergarten children on a test of reading readiness skills and tests of auditory reception of language, and between their scores on a test of academic achievement and tests of auditory reception of language. There was a significant positive correlation between all tests compared.


Response bias in children's phonological systems. The purpose of this study was to determine the extent to which auditory and visual stimuli influence certain sound productions of children. Grade level and position of the target sound were the two variables studied. Children were shown a meaningful picture and were asked to repeat the name of the picture as spoken by the experimenter who misarticulated one phoneme in the word. It was found that children in the lower grades tend to repeat the word as it should be articulated, whereas children in higher grade levels tend to repeat the word as it was spoken. Position of the phoneme in the word was not found to be a relevant variable. Support is given to the use of nonmeaningful instruction material as stimuli when teaching new sounds to young children.


A comparison of home and clinic gathered language samples. Language samples were gathered for 12 normal children representing a range of linguistic levels in a clinic setting with unstructured clinician-child interaction, and the home setting with unstructured mother-child interaction. Comparison of the samples revealed that children with an average utterance length four to five morphemes produced significantly longer utterances in the home setting. A comparison of frequency counts for various forms and construction types indicated the presence of syntactic preferences in each setting that could be traced to the nature of the underlying interaction. Clinic sampling was conducive to the description of ongoing or imminent activity, while home sampling stimulated substantially higher frequencies of past tense and modal verb forms, complex utterances, and questions. While there were frequency of occurrence differences between settings, the variety of forms and construction types was found to be similar. The results should be useful to clinicians as they interpret the significance of the presence, absence, or frequency of various syntactic structures in clinic language samples.


Teflon laryngoplasty: an acoustical and perceptual study. A 61-year-old male with a 24-year history of unilateral vocal fold paralysis was evaluated by a speech-language pathologist and an otolaryngologist for 52 weeks following Teflon injection. Tape recordings of the patient's voice were obtained one week prior to and one, eight, 20, and 52 weeks subsequent to Teflon injection. The recorded samples were presented in the backward-play mode to a panel of speech-language pathology graduate students to obtain ratings of the degree of hoarseness, roughness, and pleasantness. Results of the perceptual aspect of this study revealed a general reduction in perceived hoarseness and an enhancement of perceived pleasantness following Teflon injection. Measurement of selected acoustic properties revealed a lowering of median fundamental frequency, a reduction of fundamental aperiodicity for isolated but not excerpted vowels, an elimination of certain frictional noise components, and an increase of certain harmonic components following Teflon injection.


Acoustic neurinoma in a child: a case study. This case study reports the audiological and surgical findings for a nine-year-old boy with an acoustic neurinoma. He was suspected of having a right ear retrocochlear lesion following three audiological evaluations in four years. The initial evaluation indicated normal hearing ability. The second and third evaluations indicated a progressive right ear hearing loss, characterized by reduced word discrimination ability and absent acoustic reflexes. The patient had a 5 cm acoustic neurinoma compressing and adherent to the brain stem. The tumor was successfully removed following three operations employing an otoneurological and neurosurgical team approach through a retromastoid exposure. Postoperative recovery was uneventful. Facial nerve function was not disturbed, however attempts to preserve hearing on the involved side were not successful.


The effect of the gestural prompt on syntax training. The purpose of this study was to investigate the facilitative effects of prompts in syntax training as compared to the same procedure without the gestural prompt. Ten normal children, ranging in age from four years to five years, five months were trained to produce the double object syntactic structure. In training the double object, the experimental group was presented a picture and asked by the examiner "What is the (person) doing? The (person) is (verbing) the --." The subject was to complete the intraverbal lead with the appropriate indirect-direct object combination. A gestural prompt was given at this point to aid the child in producing the correct response. The prompt was also presented in the subsequent event as corrective feedback or verbal reinforcement. The control group was presented the same picture stimuli and verbal stimuli, but without the gestural prompt accompanying the antecedent event or the subsequent events. The results obtained from this study indicated that there was no significant difference between the two groups regarding the number of sessions required to reach criterion. The data did show, however, that the experimental group made fewer errors within any one session than did the control group up to the sessions in which criterion was reached.


Interpersonal communication skills of speech-language pathology undergraduates: the effects of training. Interpersonal communication skills of 55 speech-language pathology students, who had participated in one of three 16-hour training programs, were assessed during a coached-client interview in which the students served as clinicians. No meaningful differences in verbal responses were found among groups. Less than 20% of all the students' responses were considered facilitative. A follow-up investigation of students' responses therapy sessions at the end of their first clinical practicum yielded no significant differences among groups. The nonverbal behaviors of all three groups were generally adequate and essentially similar. Findings indicating that students in other human services curricula demonstrated a greater frequency of facilitative responses following skill training, led to a study of the comparative pretraining skill levels of the two populations. The few significant differences found did not account for the wide differences in posttraining skill levels.


Enzymatic conversion of proteins to glycoproteins by lipid-linked saccharides: a study of potential exogenous acceptor proteins. Previous studies have shown that a membrane preparation from hen oviduct catalyzes transfer of oligosaccharide from oligosaccharide-P-P-dolichol to denatured RNase and alpha-lactalbumin. To gain further insight into the structural requirements of a protein that allow it to serve as a substrate for glycosylation, the acceptor ability of a variety of other modified proteins containing the tripeptide sequence-ASN-X-(SER/THR)-has been investigated. Of 7 proteins tested, 2 (ovine prolactin and rabbit muscle triosephosphate isomerase) could be enzymatically glycosylated by a particulate preparation from hen oviduct. The remaining 5 proteins, assayed as either S-carboxymethylated or S-aminoethylated derivatives, were inactive as carbohydrate acceptors. However, cyanogen bromide treatment of 2 of the inactive proteins, bovine catalase and concanavalin A from jack bean, yielded peptide fragments which served as substrates for glycosylation. These results suggests that for some proteins, disruption of the tertiary structure is sufficient to allow attachment of carbohydrate. Other denatured proteins may possess additional restrictions imposed by their secondary structure. In certain cases, these restrictions are removed when the polypeptide chain is fragmented.


Sialic acid: a specific role in hematopoietic spleen colony formation. Vibrio cholerae neuraminidase (VCN) treatment of donor bone marrow cells results in a reduction in the number of hematopoietic colonies (CFUs) formed in the spleens of lethally irradiated mice. Treatment of marrow cells with sodium periodate under mild conditions, known to preferentially oxidize sialic acid, also reduced CFUs while subsequent potassium borohydride reduction restored CFUs to 80% of control levels. Innoculum viability as measured by in vitro incorporation of tritiated precursors into proteins, nucleic acids, and oligosaccharides was unaffected by VCN treatment. The ability of bone marrow cells in culture to respond to the hormone erythropoietin, as measured by the incorporation of 59Fe into cyclohexanone-extractable heme, was also not affected by neuraminidase, making a cytotoxic effect of the VCN preparation unlikely. Incubation of VCN-treated marrow with either beta-galactosidase or trypsin had no effect on the VCN-induced reduction in CFUs. These results are consistent with the idea that membrane sialic acid plays a direct and specific role in the implantation and development of CFUs.


Actin--membrane interactions: association of G-actin with the red cell membrane. Chemically tritiated actin from rabbit skeletal muscle was used to investigate the association of G-actin with the red cell membrane. The tritiated actin was shown to be identical to unmodified actin in its ability to polymerize and to activate heavy meromyosin ATPase. Using sealed and unsealed red cell ghosts we have shown that G-actin binds to the cytoplasmic but not the extracellular membrane surface of ghosts. Inside-out vesicles which have been stripped of endogenous actin and spectrin by low-ionic-strength incubation bind little G-actin. However, when a crude spectrin extract containing primarily spectrin, actin, and band 4.1 is added back to stripped vesicles, subsequent binding of G-actin can be increased up to 40-fold. Further, this crude spectrin extract can compete for and abolish G-actin binding to unsealed ghosts. Actin binding to ghosts increases linearly with added G-actin and requires the presence of magnesium. In addition, actin binding is inhibited by cytochalasin B and DNAase I. Negative staining reveals an abundance of actin filaments formed when G-actin is added to reconstituted inside-out vesicles but none when it is added to unreconstituted vesicles. These observations indicate that added G-actin binds to the red cell membrane via filament formation nucleated by some membrane component at the cytoplasmic surface.


Properties and action mechanism of the toxic lectin modeccin: interaction with cell lines resistant to modeccin, abrin, and ricin. The toxic lectin modeccin, which inhibits protein synthesis in eukaryotic cells, is cleaved upon treatment with 2-mercaptoethanol into two peptide chains which move in polyacrylamide gels at rates corresponding to molecular weights 28,000 and 38,000. After reduction, the toxin loses its effect on cells, while its ability to inhibit cell-free protein synthesis increases. Like abrin and ricin it inhibits protein synthesis by inactivating the 60S ribosomal subunits. Modeccin binds to surface receptors containing terminal galactose residues. Competition experiments with various glycoproteins indicate that the modeccin receptors are different from the abrin receptors. In addition, they were present on HeLa cells in much smaller numbers. Moreover, mutant lines resistant to abrin and ricin were not resistant to modeccin and vice-versa. The toxin resistance of various mutant cell lines could not be accounted for by a reduced number of binding sites on cells. The data are consistent with the view that the cells possess different populations of binding sites with differences in ability to facilitate the uptake of the toxins and that in the resistant lines the most active receptors have been reduced or eliminated.


Studies of the diphtheria toxin receptor on Chinese hamster cells. Concanavalin A, wheat germ agglutinin and the ovalbumin glycopeptide are all inhibitors of the cytotoxic effect of diphtheria toxin on Chinese hamster cells. Ovalbumin glycopeptide loses its inhibitory property after treatment with beta-N-acetylglucosaminidase. This demonstrates the importance of the glycopeptide structure for the mechanism of inhibition. The glycopeptide may be a toxin cell-surface receptor analogue. Diphtheria toxin-resistant mutants were isolated in order to search for cells that might have an altered toxin receptor. One mutant was 10- to 15-fold more resistant to diphtheria toxin than wild-type cells when protein synthesis was measured as a function of toxin concentration. However, when protein synthesis was measured as a function of time at a high toxin concentration, the time before onset of inhibition was identical in the mutant and wild-type cells. We present evidence indicating that the resistance of this mutant can be accounted for by a decreased affinity of toxin for a cell-surface receptor.


Glycophorins A, B, and C: a family of sialoglycoproteins. Isolation and preliminary characterization of trypsin derived peptides. Two new sialoglycoproteins, glycophorin B and glycophorin C, were isolated from erythrocyte membranes by extraction with lithium diiodosalicylate, partition in aqueous phenol, gel filtration in detergent, and preparative polyacrylamide gel electrophoresis in sodium dodecyl sulfate. The two proteins were characterized by amino acid and carbohydrate analysis, separation of tryptic peptides, and isolation and purification of the amino terminal glycopeptide from each polypeptide chain. Glycophorin B is found in two forms in electrophoretograms of normal erythrocyte membranes, corresponding to monomer and dimer, as has been similarly described for glycophorin A. By using antibodies to a carboxy terminal determinant of glycophorin A, and direct staining of gels with antibodies and 125I-protein A from Staph. aureus, as well as by two-dimensional immunoelectrophoreis, only the two known forms of glycophorin A are detectable. The data confirm and extend the notion that the sialoglycoproteins in human red cells are dimeric molecules which are either preformed in the membrane or which can readily  be generated in vitro. Only glycophorin A and glycophorin C are sensitive to trypsin while in situ in the intact red blood cells.


Plasma alpha amino-n-butyric acid: leucine ratio. Normal values in alcoholics. A gas--liquid chromatographic method was developed and employed to determine the plasma ratio of alpha-amino-n-butyric acid to leucine in 40 alcoholic patients and 9 healthy controls. The findings did not support the hypothesis that the ratio may be an empirical marker for alcoholism.


Drinking patterns of alcoholics differing in levels of perceived and experienced control. In men alcoholics, control orientation appears to be related to perceived benefits of drinking, while the level of control experienced in social situations appears to be related to the consequences of drinking.


Adolescent problem drinking. Psychosocial correlates in a national sample study. A profile, developed using multivariate analysis of psychosocial data from a national survey of adolescent drinking, indicated that problem drinking was part of a general adaptation to self, others and circumstances rather than an isolated activity.


A profile instrument for the quantification and assessment of alcohol consumption. The Khavari Alcohol Test. The construction of a profile instrument for the quantification of beer, wine and distilled spirits consumption, based on the reported use of 2303 men and women, is presented.


Stressful life events and alcohol problems among women seen at a detoxication center. No strong temporal associations were found between the occurrence of stressful life events and the onset of alcohol problems.


Use of the life table method in determining attrition from treatment. Life table analysis of attendance at an outpatient clinic indicates levels of attrition similar to those reported by follow-up and other studies of treatment for drug dependence. With appropriate qualifications, rates of attrition may be viewed as measures of treatment outcome.


Alcoholism and correlates of mortality. Implications for epidemiology. In 935 alcoholics, alcoholism increased the risk of death more in upper-class than in lower-class alcoholics, the middle-class alcoholics holding an intermediate position closer to that of the upper-class alcoholics.


Swimming as a measure of motor impairment after ethanol and pentobarbital in rats. Ethanol and pentobarbital produced dose-dependent increases in time required by rats to swim a straight alley to an escape ladder.


Comparative effectiveness of self and family forms of the Michigan Alcoholism Screening Test. Scores on the Michigan Alcoholism Screening Test completed by both patients and members of their families did not differ significantly; the scores indicated agreement with a psychiatric diagnosis of alcoholism in 70% of the cases.


Trail Making Test improvement in abstinent alcoholics. The improvement in Trail Making Test performance of men alcoholics over a period of 3 weeks suggests that long-term recovery from brain dysfunctioning is a common occurrence in alcoholics.


Public attitudes toward increasing the price of alcoholic beverages. Approximately half of all respondents surveyed in Ontario are satisfied with current pricing of alcoholic beverages, and approximately two-thirds of all drinkers surveyed would pay more if higher prices would help reduce the prevalence of alcoholism.


Some considerations in using cirrhosis mortality rates as indicators of the prevalence of alcoholism. Analysis of data on death certificates indicates that the value of P (the percentage of all deaths due to cirrhosis of the liver that can be attributed to alcoholism) in the Jellinek estimation formula is a function of sex, race and whether or not an autopsy was performed.


Splenic cysts.

Splenic cysts. Benign non-parasitic cysts of the spleen are very uncommon, with a total of 651 cases having been described in the literature to date. Because of their uncommon nature, and the fact that their symtoms may be vague, a high index of suspicion is necessary if they are to be diagnosed. The therapy of choice is surgical excision by splenectomy and the accompanying cystectomy. The prognosis following such therapy is excellent.


Surgical adjuvant immunotherapy for colorectal cancer. One hundred forty-four Wistar-Furth rats in 12 therapeutic groups have been studied in a long-term comparison of the effectiveness of nonspecific immunotherapy with MER (methanol extraction residue) vs active-specific immunotherapy with neuraminidase-modified tumor cells. Six months after surgical adjuvant immunotherapy a 100% improvement in survival was achieved with MER immunotherapy compared to untreated control animals. In addition, the use of MER enhanced the value of active-specific immunotherapy where both modalities were combined in sequence. The predicted value of MER-BCG (Bacillus Calmette-Guerin) for the immunotherapy of solid tumors was borne out by these results suggesting that present ongoing clinical trials of MER as adjuvant therapy for large bowel cancer should prove to be successful if properly controlled. The pattern of survival in these experiments suggests that surgical adjuvant immunotherapy is cytostatic rather than cytocidal, and implies the need for long-term, repeated immunizations.


Hemangiopericytoma of the uterus: report of a case with a comprehensive review of the literature. A case of locally recurrent and metastatic uterine hemangiopericytoma successfully treated with surgery, radiotherapy and chemotherapy is presented. The patient is alive without evidence of detectable tumor, 13 years after the initial diagnosis. Review of the literature revealed 64 reported cases of uterine hemangiopericytoma. The clinical features are not sufficiently characteristic to enable the diagnosis to be made preoperatively. However, with the help of histological and ultrastructural studies a definite diagnosis of hemangiopericytoma can be made. The primary treatment is radical surgery which usually involved total hysterectomy and bilateral salpingo-oophorectomy. The prognosis of uterine hemangiopericytoma is better than that of other sites. However, long follow-up of these patients is necessary because of the tendency to local and distant recurrence many years after the initial treatment. The recurrent tumor should be treated aggressively with surgery, radiotherapy, and chemotherapy as long-term survival is not unusual.


Leiomyosarcomas of the extremities: angiography as a diagnostic aid. Thirteen cases of leiomyosarcomas of the extremities are reported. Most of the cases were operated on without information concerning benignancy or malignancy. Plain radiographs showed amorphous calcification in two cases. Three cases had angiographic study and all revealed malignant neovascularity. In no literature that we reviewed was angiography mentioned in the cases of leiomyosarcomas of the extremities. Venography alone has been done in many reported cases. The leiomyosarcoma of the extremities looks often benign but is notorious for local recurrences and distant metastases.


Combination therapy with mitomycin C, 5-fluorouracil, and cytosine arabinoside for nonresectable malignant tumor in man. The effectiveness of MFC (mitomycin C, 5-fluorouracil and cytosine arabinoside) therapy for nonresectable cancers and cancers recurring after surgery was investigated in 60 patients with solid cancers aged 26 to 69 years. Treatment was effective in 28 patients (47%) including seven (12%) who showed a very good response. Side effects included anorexia, vomiting, melena, anemia, decreased leukocyte and platelet counts, and impaired renal function. In particular, hemorrhage of the digestive tract should be watched carefully during MFC therapy. MFC therapy is suitable for solid tumors of the breast and digestive organs, especially with metastases to the lymph nodes. Response to treatment is generally seen after 6--10 doses. If there is no response at this time, treatment should be changed. In cases where induction of remission is successful, maintenance therapy should be continued keeping the frequency of administration to a minimum. Remission is readily induced with MFC therapy, but because of the problems of hemorrhage of the digestive tract, and bone marrow suppression, its use for outpatient treatment is not considered safe. Therefore, alternative treatment should be given for long term maintenance of remission. FAMT (5-fluorouracil, cyclophosphamide-endoxan, mitomycin C, chromomycin A3 -toyomycin) therapy is considered safe and suitable for maintenance therapy in outpatients. Three cases in which MFC therapy was very effective are described to illustrate the treatment program.


BCG immunotherapy: effects of dose and route of administration on survival of mice bearing established tumors. Bacillus Calmette-Guérin (BCG) was administered in various doses by four different routes to C3H/HeJ mice bearing well-established syngeneic MC-42 fibrosarcomas. Injections of BCG into established primary tumors decreased survival of tumor-bearing mice as compared to saline-injected controls. Of the three dosage groups, high-dose (10(8) viable organisms) intralesional BCG was most detrimental. The injection of low-dose BCG (10(4) organisms) into established tumors or subcutaneously at a distant site also shortened host survival times. Other subcutaneous injections and injections of BCG into the peritoneal or pleural cavities had no significant effect on survival, regardless of dosage. The dose-dependent effects of BCG immunotherapy which may prolong or shorten survival are discussed.


Myxedema coma and inappropriate antidiuretic hormone secretion after deep neck irradiation: clinical implications and report of a case. A case report is presented in which myxedema coma and inappropriate antidiuretic hormone secretion developed as a result of radiation therapy and surgery to the neck area in a patient with recurrent metastatic squamous cell carcinoma of the floor of the mouth. Laboratory findings of low thyroxine level and the findings of persistent hyponatremia and hypoosmolality of serum in spite of persistent sodium loss in the urine were helpful in diagnosing the problem. Treatment included thyroid hormone replacement and fluid restriction resulting in complete reversal of her condition. We believe that patients with head and neck cancer who have undergone a course of radiation to the neck, and particularly when thyroid function might have been altered by previous subtotal thyroidectomy as part of a curative resection, should be carefully followed with periodic thyroid function assays and serum electrolytes with particular attention to serum sodium values.


Serial CEA levels in colorectal carcinoma on adjuvant immuno (chemo) therapy. Serial CEA levels have been studied preoperatively, and one day, 10--15 days, four months, and eight months after surgery in a group of colon cancer patients who started soon after surgery a protocol of adjuvant immuno(chemo)therapy with Levamisole R and BCG R. Results showed a decrease of mean values of plasma CEA levels from preoperatively to four months after surgery, while eight months after surgery a slight increase was noted. Some of the patients in whom disease recurred showed persistent high levels of CEA, while one patient was consistently a false-negative notwithstanding a bone recurrence. While the prognostic value of serial CEA determinations is confirmed, the possibility of restarting (or intensifying) a protocol of adjuvant immunochemotherapy given high CEA levels and a negative clinical picture is discussed.


Gastric carcinoma survival at the Pennsylvania Hospital -- 1964 to 1974. Despite major improvements in diagnosis, anesthesia, surgical techniques, and postoperative care, the survival rate for adenocarcinoma of the stomach remains a dismal one. In our series of 109 patients, almost all patients seen were diagnosed too late to effect any kind of surgical care. In the period from January 1964, to December 1974, 122 patients were admitted to Pennsylvania Hospital with a diagnosis of gastric adenocarcinoma. Of the 109 patients followed to their death, only seven survived 5 years; the longest survival was 80 months. Among the 33 patients not resected, median survival was only one month. Of the 74 patients who had surgical resections survival ranged from a median of 5.5 months for those who had total gastrectomy to a median  of 8 months for those receiving subtotal gastrectomy.


Mediastinal lymphangioma.

Mediastinal lymphangioma. Mediastinal lymphangioma is an uncommon benign tumor accounting for 0.7 to 4.5% of all mediastinal masses. Lymphangiomas consist of dilated cystic lymph spaces lined by single layers of endothelium and do not undergo malignant change. Most mediastinal lymphangiomas are asymptomatic. There are no specific radiological findings. Surgical excision is the treatment of choice and the prognosis is excellent.


Primary malignant hemangioendothelioma of the liver: survival following nonoperative treatment. A case of primary hemangioendothelioma is presented. Following autodearterialization, the patient received 5-fluorouracil orally and total hepatic radiation. To date, 30 months later, he remains alive and active with residual hepatic defect on liver scan, but no indication of progression of disease. Primary malignant hemangioendothelioma is discussed briefly in terms of etiology, pathology, diagnosis, and treatment, and a treatment plan is presented. This case also presented an unusual side effect of 5-fluorouracil therapy -- mononeuritis multiplex -- and is presented out of interest.


An evaluation of intraabdominal involvement in Hodgkin disease. An analysis of the staging procedure in 80 patients with histologically confirmed Hodgkin disease was performed at Tata Memorial Hospital, Bombay. There was a marked male preponderance. The mixed cellularity type of Hodgkin disease is the commonest histological variety (47.5%) and has the highest incidence of subsequently proven generalized disease (76%). The lymphocytic predominant variety was the next most common (27.5%) and was present as unsuspected disease in 45% of cases. Systemic symptoms were associated with advanced disease in 57% of clinical IB and 73% of clinical IIB cases. Splenic involvement was histologically confirmed in 41% of cases with stage I disease and 52% of cases with stage II disease and was associated with liver involvement in two cases. A lymphogram was performed, in addition, prior to the laparotomy in 40 cases and the lymphogram-laparotomy concordance was approximately 72% in our series. This stresses the importance of a staging laparotomy.


HLA antigens in patients with juvenile diabetes and their first-degree relatives. The relationship between HLA antigens and juvenile-onset diabetes mellitus was examined. Tissue typing for HLA antigens was carried out in 77 control subjects and in 133 individuals from 29 families, each of which contained one or more patients with juvenile-onset diabetes. A significant increase in the frequency of B18 antigen was found in the juvenile-onset index cases. In these index cases, the frequency of HLA antigens B8 and B15 was increased and the frequency of B7 and B12 was decreased, but these findings were not significantly different from those in the control subjects. Two examples of recombinations were noted among the 29 families, and in both instances the recombinations were present in the index case. In this selected population of diabetic patients and their first-degree relatives, there were three siblings (6%) who had juvenile-onset diabetes mellitus. This frequency of diabetes in siblings is much more than would be expected in individuals of the same age group. Two nondiabetic siblings had haplotypes identical to those of a diabetic sibling. These nondiabetic siblings may represent prediabetic individuals. The most frequent haplotype noted in diabetic patients and their first-degree relatives was A1, B8, which was present in approximately 25% of the index cases and first-degree relatives.


Obstructive disease of the airways associated with stage I sarcoidosis. Stage I sarcoidosis usually presents with roentgenographic evidence of hilar adenopathy and the patients are totally asymptomatic. However, five patients were studied at the Mayo Clinic who had stage I sarcoidosis associated with obstructive disease of the airways. Four of the five presented with dyspnea, wheezing, and cough, and they were found to have expiratory slowing on physical examination. One patient was asymptomatic and her physical examination was normal. On pulmonary function testing, she had a decrease in maximal midexpiratory flow, and at fiberoptic bronchoscopy, mucosal changes consistent with noncaseating granuloma of sarcoidosis were seen. All five patients had the classic roentgenographic appearance of sarcoidosis, with hilar and right paratracheal adenopathy. Endobronchial involvement is well known in sarcoidosis, but its significance in stage I disease has not been emphasized in the literature. An awareness of this possibility is important because it may be an indication for bronchoscopy and mucosal biopsy in the patient with stage I sarcoidosis, particularly when the patient presents with dyspnea, wheezing, and cough. Also, corticosteroid, therapy may be indicated in selected patients with stage I sarcoidosis.


Brachial plexus injuries.

Brachial plexus injuries. Brachial plexus injuries are uncommon. They are, however, complicated lesions because of the concomitant injury to adjacent structures and the imposing anatomy of the brachial plexus. Physicians who will be consulted in the management of such injuries should periodically consider the principles of management. Diagnosis of these injuries is based on clinical examination, myelography, axon reflex testing, and electrophysiologic studies. The lesion may be open or closed and supraclavicular or infraclavicular. It may be in continuity or there may be nerve disruption or root avulsion from the spinal cord. The anatomic relationships of the brachial plexus are reviewed, the pathophysiology of direct trauma, secondary trauma, and iatrogenic trauma is discussed, and the treatment of the various types of traumatic brachial palsy is surveyed.


On the localization of lactate dehydrogenase in the ovaries and reproductive tracts of rats and mice. The localization of lactate dehydrogenase in the ovaries and reproductive tracts of rats and mice has been studied by a methodology which minimizes loss of this soluble enzyme by diffusion, and allows comment on the subunit composition of the cellular enzyme. The results differ significantly from previous data with conventional methodologies. In particular, the major localization of activity in the present study was identified in interstitial cells, and not the corpora lutea or granulosa cells; and it was noticeable that neither species exhibited massively greater expression of lactate dehydrogenase activity in the oocytes than in adjacent cell types of the reproductive tract. The goblet cells of the Fallopian tube stained intensively for activity of this enzyme. These results have been discussed in relation to the discordant data in the literature, the important role of lactate dehydrogenase in mammalian development, and the evidence for a masking of the activity of this enzyme in oocytes and pre-implantation ova.


The age dependence of intracellular proteolysis: changes of the substrate proteins. Liver cytosol proteins of young (4--6 months) and old (18--27 months) rats were degraded in vitro by papain, pronase, trypsin, pepsin, cathepsin D from rat liver and a soluble lysosomal enzyme mixture from rat liver. We could demonstrate the capability of the latter enzyme mixture to degrade proteolytically the cytosol proteins of young animals about 20% faster than those of the older animal group. Digesting radioactive labelled "young" cytosol in the presence of unlabelled "old" cytosol the possibility could be excluded, that this effect was due to an inhibitor of macromolecular size present in the "old" cytosol.


Increase in volume of the chick wing bud at the beginning of its development. Serial sections in the transverse body plane were used to determine the volume of the limb bud and of its parts--namely, the apical ectodermal ridge, the ectodermal epithelium, the coat zone, the vascular zone, and the plug during the period between the onset of its formation (Hamburger and Hamilton's stage 17) and the stage of nerve fibre ingrowth (HH 22 +). During that period the anlage of the wing was shown to increase in volume, mainly by increasing in length, with the increase being more than 8 times during a 28 hr incubation. Various components differed in their growth rate. The apical ectodermal ridge did not increase at all. The part that increased most--48 times--was the plug which gives rise to the cartilaginous primordium of the skeleton of the wing. The proportions of the various zones changed markedly during growth.


The differentiation-pattern in dependence of the proportion between inducing and induced cells studied on gastrula-ectoderm of Ambystoma mexicanum. The dependence of the differentiation-pattern of competent amphibian ectoderm on the proportion of inducing and induced material was studied. To do so different masses of LiCl-treated tissue were combined with a constant mass of untreated material. LiCl-treated isolates corresponding in size with the treated portions in the combinations served as controls. The experiments seem to show at least three factors responsible for the differentiation-pattern of the combinations: the number of inducing cells, the number of cells to be induced, and the competence of the ectoderm, which depends on the stage of development.


Surface topography of isolated gastrula ectoderm of Triturus vulgaris. The surface topography of the outer cell layer of the two-layered gastrula ectoderm of Triturus vulgaris resembles that of the other amphibians: the cells are tightly packed and devoid of pseudopodia. The cells of the inner layer are spherical and interconnected with pseudopodia of various lengths. After excision of the ectoderm the peripheral cells of the outer layer elongate perpendicularly to the edge of the explant, while the number of pseudopodia on the inner layer greatly increases. The results show that the curling-up of the explant and formation of a sphere results from locomotor activity of the cells in both layers.


Microheterogeneities, non-equivalance, and embryonic induction. The thrust of this report is to stress the importance of microheterogeneities in the microenvironment of differentiating tissues as a possible inducer or regulator of differentiation. During chondrogenesis both qualitative and quantitative changes occur in the proteoglycan population. Using molecular sieve chromatography, these changes can be characterized and used as indices of differentiation. Microheterogeneities of the extracellular matrix may be an example of "non-equivalence" as a regulatory device for differentiation.


Differentiation of the epiblastic part of chick Hensen's node in coelomic cavity. When implanted into the coelomic cavity the epiblastic, non-invaginated part of Hensen's node of chick blastoderm at Hamburger--Hamilton stage 3 to 3+ can differentiate into various tissues. These include neural, mesodermal, and endodermal ones, which are not essentially different from those derived from a complete node in similar conditions.


Developmental approaches to organ restoration. This paper discusses the problem of applying the achievements of developmental biology to organ restoration. Experiments on artificially induced transdifferentiation as a prerequisite for organ restoration are reviewed. The advantage of using cells that start differentiation from the dedifferentated state is that they can participate in the construction of new organs. However, cell transdifferentiation is not sufficient for biomedical purposes, since the problem of construction of typically formed organs--namely, the morphogenesis of groups of differentiating cells--remains to be solved. Data, where a partial approach to typical organ restoration has been achieved are analysed. This serves as a tentative step in the application of developmental-biological approaches to the problem of organ restoration.


Mesodermalization of amphibian gastrula ectoderm in transfilter experiments. Transfilter experiments were carried out with competent gastrula ectoderm of Triturus vulgaris and Ambystoma mexicanum as the reacting materials and blastoporal lip, alcohol-treated bone marrow and archenteron roof as the inducing materials, It was shown that a mesodermal inducing substance is able to penetrate Nuclepore filters of different pore sizes (3.0, 1.0, 0.4, 0.2 micrometer). The degree of mesodermal differentiations depends on the reacting materials, the inductors and the filters which were used in the transfilter experiments.


A proteoglycan with affinity for the vegetalizing factor: characterization by density gradient centrifugation. A crude proteoglycan fraction isolated from chicken embryos has an affinity for the vegetalizing factor, which induces mesodermal and endodermal tissues in gastrula ectoderm of Triturus alpestris. Binding of the factor to the crude proteoglycan results in inactivation of the vegetalizing factor. The crude proteoglycan was centrifuged in CsCl and CsCl-urea density gradients. Most of the inactivating material was recovered from the gradients in the high density proteoglycan fraction. Part of the inactivating material was found in glycoproteins of lower density. It is concluded that not all of the polysaccharide moiety of the proteoglycan is involved in binding of the vegetalizing factor. The proteoglycan is inactivated by incubation with hyaluronidase.


Neural induction, a two-way process.

Neural induction, a two-way process. A quantitative analysis of Triturus alpestris recombinates of newly invaginated "caudal" archenteron roof with either competent gastrula ectoderm or non-competent neurula ectoderm has demonstrated that neuralisation evoked by the underlying archenteron roof affects, in its turn, the regional differentiation of the latter. It does so by enhancing its notochordal differentiation; so, neural induction is clearly a two-way process. Somite differentiation is not significantly different in the two series. This is especially remarkable since both series show positive correlations between the amounts of notochordal and somite structures. The explantation is that the correlation coefficients differ considerably in the two series. The possible reason for this is discussed. Moreover the recombinates with competent gastrula ectoderm demonstrate that the size of the neural structures is determined by the total mass of the axial mesoderm and not by that of the notochord or that of the somites separately.


Metabolic inhibitors and kidney tubule induction. The induction of kidney tubules in metanephric mesenchyme has previously been shown to require close contact between the interacting tissues. In our study we show that low concentrations of inhibitors of RNA, DNA and protein synthesis inhibit tubule induction, although they do not seem to prevent the formation of contacts between the interacting tissues. The effective concentrations were about the same as those which inhibited the synthesis of macromolecules. Cycloheximide caused an increased synthesis of RNA. Low concentrations of Mitomycin C inhibited DNA synthesis but not tubule formation. A concentration of the inhibitors which caused weakened induction also caused a marked decrease in leucine incorporation. We concluded therefore, that a decrease in protein synthesis in the inducing tissue is responsible for the inhibition of induction.


The retention of circulating Walker-256 cells by Walker-256 tumours. When Walker-256 cancer cells are injected into the portal veins of rats bearing Walker-256 tumours in their livers, the retention of the injected cancer cells by the tumours is considerably less than in the surrounding liver. After applying defined general criteria for "homing" phenomena to the data, it is concluded that compared with the liver, they demonstrate "antihoming". The observations are explained in terms of a deficient arrest process within the tumours.


[Occlusion of pancreatic duct system by injection of a fast-solidifying amino acid solution (author's transl)]. The effect of the occlusion of the pancreatic duct system with a new alcoholic solution of amino acids has been studied in animal experiments. The solution becomes solid in the duct system, is microbiologically indifferent and becomes disintegrated within 11 days. This time, however, is sufficient to keep a high-grade atrophy of the exocrine parenchyma. With this method one doesn't risk the provocation of an acute pancreatitis. The development of fistulas following exploratory excision is prevented by the filling of the duct system. The solution could be qualified for a therapeutical acceleration of the "burning-out" of the chronic pancreatitis.


[Bile duct reconstruction with pendunculate jejunal grafts (author's transl)]. A pedunculate patch, obtained from a disconnected segment of jejunum, was implanted into the longitudinal incision of the ductus choledochus. Intra-operatively, the findings were based upon direct cholecystocholangiography; postoperatively, upon laboratory tests. After an observation period of 12 months a new cholangiography of the transplant was made along with a selective picture of the mesenteric arteries. The choledochus duct with the transplant was examined histologically. Three dogs died immediately postoperatively of peritonitis due to suture insufficiency. Five dogs died of invaginate ileus. These animals, as well as the remaining 8 dogs showed macroscopically and microscopically a smooth and uneventful healing of the transplant at the end of the observation period. Radiographies showed free flow of the biliary duct system. The selective mesenteric arteriographies evidenced beginning anastomosis between the transplant and the capillaries of the bile duct. Based on the results presented, the pedunculate jejunal graft can be considered well suited as an expansion graft for the bile duct.


[Further investigations of insufficient stretching-closing mechanism of the terminal esophagus (author's transl)]. The anatomy of the closing mechanism of the terminal esophagus was studied in the dogs since this animal is frequently utilized for investigations of esophageal function. With the aid of a special method we have demonstrated a stretching-closing mechanism similar to that of the human subject. An operatively placed hiatus hernia with a tendency to reflux shows the expected reaction of the muscular screw mechanism. This insufficient stretching-closing mechanism is similar to an insufficient "ring sphincter". The reconstruction of the closing mechanism by means of "stretching and gastropexie" which has proven successful in practice is discussed.


[Transperitoneal resorption in acute and chronic peritonitis (author's transl)]. Two forms of peritonitis have been examined on 60 rats (Wistar) in three groups. Group 1 = acute peritonitis, group 2 = chronic peritonitis and group 3 = control. All animals have had an injection of an aminoglycosid antibiotic and a proteinase inhibitor into the peritoneal cavity. One intended to measure the influence of the proteinase inhibitor for different kinds of inflammation of the function of resorption of the peritoneum. Serum concentration of the antibiotic after 30, 60, and 90 min was measured. In clinical dosage the resorption of protein-bonded aminoglycosid antibiotics was decreased. The healthy control animals didn't show any effects. Connections concerning molecule size of protein-bonded substances and proteolytic ferments are in discussion. The practical relevance of these results could be found in an retarding effect of the resorption of protein-bonded toxines.


[Concentration of lysozyme during mineralization in callous tissue of healing fractures (author's transl)]. Investigations have suggested that lysozyme (E.C. 3.2.1.17) is involved in bone mineralization. High concentrations of lysozyme is found in the growth plate near cartilage bone junction, where it is located at the collagen fibrils and in the ground substance. Quantitative studies of lysozyme levels were made in ossifying tissue of healing fractures, to confirm the existence of this relationship on bone repair. Callous tissue, serum samples and normal bone was collected from 42 rats at 15 intervalls during a 50 day healing period. Agar gel diffusion test was used for quantitation of lysozyme. Electrophoresis of tissue extract and standard henn egg white lysozyme served as control. Lysozyme levels in callous tissue increased significantly (4--5-fold) from 4.--21. day p. trauma and subsequently decreased. The concentration in serum samples did not change significantly. Changes in Ca concentration and histological studies during tests confirm a direct relationship between bone mineralization and lysozyme level changes.


[Surgical problems of iatrogenic esophagus perforations (author's transl)]. With increase of invasive investigations of the upper digestive tract an increase of complications is also expected. From 1968--1977 eleven patients with iatrogenic esophagus perforation were referred to the department of general surgery, University of Kiel. Symptoms, diagnosis and different treatment, depending on localization and time of perforation and underlying disease are described.


[Stable postoperative phase after total artificial heart-replacement in animal-experiments (author's transl)]. Presented are results of an analysis of more than 30000 data which were sampled in seven long-surviving calves after total artificial heart-replacement (more than 35 days survival). The continuity of 24 types of data (hemodynamic, labor- and physical data) are transformed for every animal in time-equidistant datafields and after this an average continuity for all seven animals is calculated and plotted. Twenty days after the operation the data have reached the preoperative values in nearly all cases, indicating a stable phase starting, according to the clinical condition of the animals.


[Conservative treatment of other forms of hyperthyroidism (author's transl)]. Patients with toxic nodular goiter have only a slight chance for spontaneous remission. The same is true for hyperthyroid decompensated autonomous adenomas and iodine-induced thyrotoxicosis (jodbasedow). We therefore recommend antithyroid drugs only for preoperative preparation or for the therapy administered between fractionated 131I doses. The latter is indicated in patients over 40 years of age with a small goiter. The risk of hypothyroidism is less than 1% according to the experiences of eight thyroid centers. Experiences with euthyroid autonomous adenomas suggest no specific therapy. These patients may be managed under most circumstances by periodic follow-up evaluations.


[Other forms of hyperthyroidism: indications and operative procedures (author's transl)]. Hyperthyroid hot nodules, toxic nodular goiter, and rarely thyroid cancer with thyrotoxicosis represent the majority of hyperthyroid cases in goiter areas. Even though these patients usually fall into higher age groups, surgery after thyrostatic premedication is usually the optimal form of therapy if there are no serious medical risks. While toxic adenomas possibly require only unilateral procedures, toxic nodular goiters should be bilaterally resected; thyroid cancer with thyrotoxicosis is treated as other forms of thyroid cancer.


[Retroperitoneal vascular injuries (author's transl)]. From 1973-1977, 21 retroperitoneal vascular injuries were seen at the Medical School of Hannover. Vascular lesions of polytraumatized patients were treated 12 times. The rest were iatrogenic traumas after laminectomy, herniotomy, and hip replacement as well as after urologic and gynecologic operations. The overall mortality was 43%. Surgical treatment of the different vascular regions is discussed.


[Retroperitoneal injuries: fractures of the spine and pelvis (author's transl)]. Within the area of retroperitoneal injuries, bone injuries of the spine and pelvis are discussed in terms of immediate diagnosis and early treatment. Particular attention should be given to the required operative position and to the intensive postoperative care in terms of the stability or instability of spinal injuries. In view of the total injury, pelvic fractures are often underrated. Extreme blood loss is to be expected in dorsal and ventral vertical fractures and luxations. Irreductible dorsal luxations should be surgically set and stabilized.


[Retroperitoneal lesions of the duodenum and pancreas (author's transl)]. The prognosis depends upon timely surgical intervention. Contusions and hematomas of the pancreas are treated through abdominal drainage. Pancreatic duct lesions require resection or pancreaticojejunostomy. Fresh duodenal perforations may be treated by primary suture. In cases of extensive tears, partial gastrectomy combined with selective vagotomy may be the surgical treatment of choice, in rare cases, duodenopancreatectomy. Conservative or surgical treatment of the duodenal hematoma will depend entirely upon the clinical picture.


[Special aspects of retroperitoneal trauma in children (author's transl)]. During childhood, the retroperitoneal trauma resulting from birth has some specific aspects. Besides the rupture of the parenchymatous organs, in particular bleeding of the suprarenal glands occurs. The indication for surgical intervention must be based on the general condition of the child. Substitution of hypoprothrombinemia will be necesary in most cases. Intramural duodenal hematoma and rupture of the ureter in the immediate vicinity of the pelvoureteral connection, are observed especially in childhood. Retropneumooperitoneum following the increasingly popular method of intermittent respiration by above atmospheric pressure respiration of the newborn is now more frequently observed, as is necrosis of the wall of the bladder by instillation of medication and catheters in the arteries of the navel.


[Overview: varicosis (author's transl)]. The prevalence and sociomedical importance of peripheral venous diseases and peripheral venous disorders are discussed on the basis of a prospective epidemiologic field study (Basle Study) among 4529 apparently healthy workers and clerks of the Basle pharmaceutical industry. Prevalence: Pulmonary embolism was reported in 2% phlebitis in 10%. Varicose veins were present in 56% and signs of chronic venous insufficiency in 16%, respectively. Reticular and hyphen web varices predominated. Stem varicose veins were found in 15%. The sociomedical importance of varicose veins is evaluated according to the rates of complication and treatment. A medically significant varicosity was present in 12% of this working population. Three percent presented severe alterations that already had caused complications and 9% presented changes indicating.


[Technical aspects of phlebography in varicosis of the lower limbs (author's transl)]. Ascending phlebography is a safe and reliable method for preinterventional differential diagnosis of primary and secondary venous insufficiency. With the combined use of fluoroscopy and spot filming, the technique yields functional information on the venous valves and communicating veins. It also permits exact localization of peripheral and proximal varicosis and venous aneurysms. In addition, the plevic and inferior vena cava inflow can be evaluated.


[Vein surgery, functional investigation, surveying equipment (author's transl)]. The different physical screening tests (ultrasound-Doppler technique, plethysmography, phlebodynamometry) are easily documented and provide a less dangerous, less expensive, and more comprehensive statement about the venous hemodynamics of the lower extremity. The number of diagnostic errors can be minimized, and the indication for operation is reliable.


[Venous surgery: varicose veins (author's transl)]. varicose veins of the long saphenous vein and short saphenous vein. locally developed varicose veins and all forms of edema. When there is doubt, venography and tracing of the lymphatic vessels should be performed. Preservation of the lymphatic channels: incision in the groin higher than usual. Note the seven variations of the junction of the short saphenous vein. In case of damaged deep veins, operative treatment only if venous pressure curve shows improvement after compression of the superficial varicose veins.


[Varicose veins: sclerosing therapy (author's transl)]. Every varicosis can be treated without operation if injection therapy is correctly carried out. The patient stands upright, a thick needle (1.2 mm) is inserted into the varix. The venous blood flows out, the patient lies down. Injection is made with the leg in a high position (30 degrees), compression follows each sclerosing injection. Intraarterial injections can be avoided by using a thick needle. Retained intravaricose blood should be incised to avoid pigmentation. Rapid treatment is possible with 3-5 days. As with our ordinary treatment, we give 5-10 injections daily with Varigloban 2-8%.


[Obstruction of the venae cavae: surgical considerations (author's transl)]. In cases of obstruction of the superior or inferior vena cava--or of both the caval veins--it is always necessary to find out whether surgical therapy is indicated. In relatively rare cases it is possible to achieve better results by means of operative treatment than with conservative therapy only.


[Vein reconstruction in lower limb injuries (author's transl)]. Reconstructive venous surgery is essential in lower limb injuries to avoid circulatory insufficiency when the main vein is severed. The repair requires a vein graft with adequate lumen--two segments of the saphenous vein are slit open and sutured together. A technique for atraumatic preparation of this composite graft is described. A peripheral temporary A-V fistula is advocated to prevent thrombosis of the graft.


[Reflux esophagitis--morphology (author's transl)]. Comparative evaluation of the clinical and morphologic-histologic findings in reflux esophagitis led to the following staging; Stage I: Discrete leukocyte infiltrations of the tunica propria, and epithelial changes primarily of a hyperregenerative nature (noticeable only by histology). Stage II: macroscopic changes with erythematous stripes in the mucosa, which are shown histologically to be erosions or fibrinous necrosis; endoscopic feature: "white stripes." Stage III: deep, confluent necrosis with stenosis. This clinical-morphologic staging is a basis for therapy.


[Functional morphology of the lower esophagus in reflux disease (author's transl)]. The function of the lower esophagus is discussed from a biomechanical point of view. The functional elements consist of the typical structure of the muscle fibers and of the construction of the opening to the stomach. In the active phase, the esophageal muscle fibers open the cardiac orifice, and during the resting stage, the normal longitudinal tension of the esophagus is responsible for closure. Biomechanical studies reveal the sliding hiatal hernia and reflux as momentary states in the pathomechanics of the lower esophagus. Hormonal regulation is unimportant. Based on biomechanical studies, a reasonable therapeutic approach is gastropexy.


[Significance of diagnostic procedures in reflux esophagitis (author's transl)]. The diagnosis of reflux esophagitis can be confirmed by a variety of diagnostic procedures. Beside the morphologic findings of the reflux demonstrated by X-ray, endoscopy, and histology, the degree of disturbed cardial function can be determined by manometry, pH determination, and scintiscan. Each method entails a number of errors. Therefore a distinction must be made between absolutely necessary and valuable methods for clarifying the degree of the symptoms of esophageal reflux.


[Indication for conservative therapy of reflux esophagitis (author's transl)]. Conservative treatment is sufficient for the majority of patients with pathologic gastroesophageal reflux and reflux esophagitis proved by endoscopic and histologic examination. The indications for operation are failure of conservative therapy with progressive reflux esophagitis, or the occurrence of rare complications such as stenosis or massive hemorrhage. Even in these complicated cases the decision to operate will depend on the clinical status and risk factors for individual patients.


[Reflux esophagitis: surgical indications (author's transl)]. Reflux esophagitis is a benign disease. Therefore, therapeutic indications are of special significance. Surgery is undisputed in cases of failure of conservative therapy. For the first time reliable data are available on the effectiveness and on the barriers of conservative therapy, because of initial results from double blind studies. According to these results, healing of reflux esophagitis of grades I and II can be expected under conservative therapy. However, most of the patients in grades III to IV, resisted conservative therapy, so an operation is indicated.


[Reflux esophagitis: operative method in adults: fundoplication (author's transl)]. When the indications for fundoplication are correctly applied and followed, the standard anterior wall method has been proved both clinically and experimentally to be the best antireflux operation; it offers excellent immediate and long-term results. It is debatable whether it should be combined with a vagotomy when the peptic element is excessive, for while this approach is undisputed in the presence of an ulcerated draining path, it calls for important considerations in its manner of execution. Gastropexy alone is an inadequate solution in all its technical modifications: We reserve it as the operation of choice for cases of paraesophageal volvulus of the stomach.


[Reflux esophagitis: operative procedures in the adult: gastropexy (author's transl)]. Fundophrenicopexy is an effective procedure for repairing important mechanical parts of the LES. Pre- and postoperative measurement of pressure in 52 patients demonstrated an increase from x = 20.1 mm Hg to x = 39.25 mm Hg. Fundophrenicopexy is the more simple surgical management compared with fundoplication and is followed less frequently by complications. If anatomical conditions allow, fundophrenicopexy is preferred in surgical treatment of reflux esophagitis.


[Reflux esophagitis: operative procedures in children: fundoplication (author's transl)]. Hiatus hernia and peptic esophagitis in children lead in 20% of the cases to peptic stenosis, thus rendering a reflux-preventing operation mandatory in many patients. We consider fundoplication as the operation of choice and have used it for 17 years. The early and late mortality varies between 1.2% and 1.4% and can be lowered even further through improvement of treatment. Functional complications such as "gas bloat syndrome," dysphagia, diarrhea, disappear spontaneously in the first 2-3 months after surgery. The only severe late complication is the development of a paraesophageal hernia months after surgery: This complication can be avoided through better technique. Out of 61 patients who were examined 10 or more years after operation, 58 are totally free of symptoms.


[Reflux esophagitis: operative procedures in children: gastropexy (author's transl)]. During the past 15 years, 165 children with reflux disease, following mobilization of the esophagocardiasphere, were treated with a hiatal plastic operation, a semicircular esophagofundofixatio, and gastropexy. Among 140 children who were reexamined one or more times, 131 exhibited normal clinical, radiologic, and, in part, endoscopic findings up to 15 years after the operation. Fifteen percent of the children had peptic esophagostenosis, which was healed through extramucous longitudinal esophagotomy, antireflux plastic surgery, and six additional bougienage treatments.


[Patterns of injuries of restrained car passengers (author's transl)]. A detailed analysis of actual traffic accidents involving car passengers wearing seat belts was carried out by an interdisciplinary team. The passengers were examined for the severity of their injuries, the combination of their injuries, and the practicality of their seat belt system. The type of injury to the car, the speed, and the line of impact were related to the injuries. Incorrect use of the belt system, malfunction due to external causes, and construction defects in the seat belt system were described and evaluated according to their specific importance.


[Head injuries (author's transl)].

[Head injuries (author's transl)]. The majority of mortalities after car accidents are due to head injuries. These are followed by injuries to the thorax, abdomen, and extremities. Correctly used seat belts may prevent up to 70% of the head injuries and decrease the effects of other injuries as well. At least half of those who are killed in car accidents would be alive today if they had worn a seat belt.


[Trauma to the cervical spine (author's transl)]. Thirty-five occupants fatally injured (despite the use of seat belts) in head-on collisions suffered severe injuries to the craniocervical junction (ring fractures of the base of the skull, fractures of the upper cervical vertebrae, or disruptions between the cervical vertebrae) if there was extensive trauma against the head or if submarining under shoulder belts took place. If three-point belts were used, few or no neck injuries were observed if there was only a slight impact between the head and some part of the car, and there was no instability of the cervical spine due to pathologic changes.


[Traffic accidents and seat belts: thorax injuries (author's transl)]. The types of injuries to 313 automobile accident victims, especially thorax injuries, are compared. Independent of seat belt use (42%), there was in general a higher degree of injury. Those wearing seat belts had a markedly less severe AISm (median degree of injury of body region) and less severe thorax injury. Severe thorax injury was first found at speeds greater than 24 km/h above average. Severer thorax injury is to be expected with defective seat belts (AISm = 1.25) than with properly functioning belts (AISm = 0.32).


[Pacemaker and seat belt (author's transl)]. Although seat-belt-induced traffic accident injuries to wearers of pacemakers are rare, about 50,000 pacemaker patients have to "buckle up." A study of 450 pacemaker patients indicated that, as in the general population about 50% use their seat belts. Fifty percent of the patients felt uncomfortable or showed local damage of the area overlying the pacemaker. Studies with dummies revealed a 7-cm upward dislocation of the pacemaker caused by the negative acceleration and by the seat belt itself during the crash. This could be prevented by an external cap protecting the pacemaker.


[Seat belt related abdominal injuries (author's transl)]. Seat belts reduce the severity of trauma in car accidents. There is a definite decrease in the percentage of head injuries, while abdominal lesions seem to increase. Experimental and clinical investigations show a predominance of abdominal wall injuries and liver ruptures. The seat belt syndrome requires close observation of the patient in the intensive care unit. An increasing number of late intestinal obstructions after a seat belt injury due to lesions of the intestinal wall are reported.


[Decompression technique for ileus: emptying of the intestine with the fingers (author's transl)]. Intestinal obstruction and distension with stasis of the intestinal contents have to be dealt with simultaneously. Opening of the small intestine for aspiration may cause infection and is not necessary. Aspiration via a Miller-Abbot tube is complicated and time consuming. Beginning at the proximal end of the jejunum the contents of the small intestine can be emptied without risk into the stomach by digital pressure. The contaminated intestinal contents can be aspirated via a gastric tube, relieving distension and restoring intestinal circulation and motility. The simplicity of this method, its immediate effect, and its lack of complications are evident.


[Decompression technique: intestinal emptying with a tube (author's transl)]. The goal of treating postoperative ileus must be decompression of the intestine in order to prevent further development of the disease. Two different methods are available: (1) closed decompression (a) by stripping the intestine orally or aborally, or (b) through an intraluminal intestinal tube, and (2) open decompression through enterotomy. Because stripping of the intestine leads to traumatization of the intestinal wall, suction through an intraluminal intestinal tube can be considered preservative. Preoperatively, the tube is inserted through the nose into the stomach and from there is directed through the pylorus and the duodenum into the upper jejunum. Decompression of the intestine with a long intestinal tube also permits prophylactic intestinal splinting and prevents additional adhesions, kinking, and resulting new ileus conditions.


[Small bowel obstruction: decompression by suction through an enterotomy (author's transl)]. Decompression using a sucking apparatus with many large openings, inserted through an enterotomy, is a fast and suitable method. The danger of wound infection can be considerably reduced by careful technique and by antibiotics. Nevertheless, open suction should be used only when the peritoneal cavity is already infected, or when closed decompression by retrograde stripping into the stomach is not possible.


[Adhesion prophylaxis: treatment with tube splints (author's transl)]. One of the stated goals of the abdominal surgeon is to find a sure prophylaxis for the threat of ileus due to adhesions. The numerous conservative methods, such as intra-abdominal dispensing of campher oil, olive oil, etc., are viewed in relation to the operative procedures of small intestine plication according to Nobel and mesenteric plication according to Child. Both operations, however, are accompanied by numerous complications. Inner intestinal splints with long tubes have proved efficacious in the prophylaxis of adhesions in early postoperative ileus. The tube is doubly effective: It relieves the intestine and thereby aids in better microcirculation of the intestinal wall and simultaneously guarantees a splinting of the intestine in the physiologically correct position. On the average, the tube is removed after 12-14 days.


[Adhesive prophylaxis: Noble's intestine plication (author's transl)]. By chronic recidivating ileus with massive extensive adhesions, small intestine plications according to Noble or Childs and Philipps, respectively, have stood the test of time. In view of the total lethality rate of 5%, no plication should be attempted for acute ileus syndrome or for local or diffuse peritonitis. Serious complications include fistulization, intestinal perforation, recurring ileus, and peritonitis. Prophylactic plication is not recommended. The cases treated by the surgical department of the university clinic in Mainz, which include a total of 233 laparotomies for chronic adhesions of the ileus, reflect strict adherence to indications for small intestine plication. Among our own cases, we had no postoperative lethality.


[Postoperative peritonitis (author's transl)]. Postoperative peritonitis is still one of the most common complications following abdominal surgery. The main reason is leakage of an anastomotic suture line. The diagnosis can be masked by a delayed appearance, by veiling of otherwise typical symptoms, or by misjudging minor symptoms. Therefore, the critical evaluation of sometimes minimal intestinal disorders or small changes in heart and respiratory rate seem to be very important. Only early relaparotomy yields satisfactory results. The aims of an operation for peritonitis should be definitive rather than palliative. The cause of peritonitis has to be corrected surgically to manage this severe clinical picture successfully.


[Peritoneal drainage without antibiotics (author's transl)]. The mortality of generalized peritonitis in serious. The drainage of the peritoneal cavity for diffuse peritonitis is essential but difficult, and it should be combined with peritoneal lavage. The drainage system must be properly adapted to the intraperitoneal liquid circulation. The local use of antibiotics is not indicated. Systemic administration is obvious, because in about 80% of cases, it is an anaerobic infection with Bacteroides fragilis, a dreadfully tough organism, which impairs the function of organs such as lung, heart, kidney, brain, and liver.


[Postoperative peritonitis: intraperitoneal lavage with antibiotics (author's transl)]. Despite antibiotics, mortality in postoperative peritonitis has increased in the last 50 years. The main reasons are: modern medical technology and different types of patients. Operations are an unphysiologic intervention into the peritoneal cavity. The peritoneum is part of an immunologic defense system against bacterial growth and penetration into the peritoneal cavity. Circulatory and lymphatic vessels are in close contact. RES of the liver and spleen is stopped directly and indirectly by antibiotic drugs, and there is no pharmacodynamic direction after intraperitoneal injection. There is clinical improvement in mortality following lavage with antibiotics.


[Management of a systematic follow-up clinic (author's transl)]. The essential differences between the common, irregular medical check-up, as practiced in the follow-up clinics in England and Scandinavia, and the type practiced in the systematic follow-up clinic in the "Marburg experiment" are presented with examples. The necessity of the latter for clinical knowledge, for the attending surgeon, for special patients, and last but not least, for clinical research, is stressed. Based on examples from the Marburg systematic follow-up clinic for duodenal ulcer studies, its practicability is discussed.


[Problems and pitfalls in controlled clinical studies (author's transl)]. The problems encountered in prospective clinical trials are discussed: knowledge of the literature, precise formulation of the question answering the problem, number and qualifications of patients, duration of the trial, parameters to be measured. A surgical trial can hamper the education of the residents, or it can be devaluated by incompetent surgeons. Patients do not come for follow-up for several reasons (change of domicile, absence of disturbances, disagreeable tests).


[B. Parenteral feeding. Metabolic dysfunction in the postoperative and post-traumatic phase]. A fundamental knowledge of postaggression metabolism, i.e., postoperative and posttraumatic metabolism, is necessary for prophylaxis and treatment of its deleterious dysfunctions. These may be due to disturbed regulation of the water, electrolyte, and acid-base balance, the oxygen supply to cells, energy metabolism as well as structural and functional metabolism (with special emphasis on protein metabolism), and vitamin and trace-element metabolism. This schematic synopsis is a preliminary introduction to this topic.


[Metabolic deficiencies in gastroenterology (author's transl)]. Metabolic disturbances are one of the main reasons for complications in gastroenterologic surgery. There is a large number of inflammatory, neoplastic, and iatrogenic illnesses that cause considerable deficiencies. The intensity of disturbances depends on localization, duration, and extension of the pathologic alterations. Important for the postoperative outcome is the preoperative compensation of caloric and protein deficiencies: 1.5 g of amino acids per kg body weight/24 h and energy 160-200 joule per kg body weight/24 h.


[Mammary carcinoma (author's transl)].

[Mammary carcinoma (author's transl)]. The new discoveries concerning mammary carcinoma promise hope and offer surgeons a demanding challenge. Many more opportunities can now be offered to patients suffering from this dreaded disease, including new diagnostic methods, a wide range of operations, various adjuvant applications of radiotherapy and chemotherapy, a wholly new armamentarium of hormonal and chemical approaches to advanced disease, cosmetic reconstruction, and gentle terminal care. Some of the new findings are true breakthroughs, others remain mirages. Especially in the choice of the type of mastectomy, surgeons must be cautious: The new is not necessarily the best.


[C. Controversial technical and methodological problems in abdominal surgery. 1. Bile: a) Procedures in intraoperative actualization of papillary stenosis. Papillotomy in principle]. A critical comment on the question of papillotomy en principe is made, based on results from more than 7000 gallbladder operations and over 500 papillotomies, performed at the surgical departments of the municipal hospitals in Braunschweig and Lüneburg. In principle, too few papillotomies are carried out in many hospitals. The duration and seriousness of the cholecystitis is to a large degree responsible for the frequency of the formation of a papilla stenosis. Out of 232 multiple gallbladder operations performed at the Braunschweiger Hospital, 130 were necessary because of an incorrect opinion about the indication at the time of the first operation, in most cases due to an overlooked stenosis of the papilla.


[Other methods: dilatation, T-tube (author's transl)]. In the Department of Surgery of the University of Mainz we prefer dilatation for treatment of stenosis of the papilla. In 1063 cases out of 4058 operations for cholelithiasis, we opened the choledochus. In 944 patients, a dilatation was performed; 40 were treated by papillotomy; in 79 cases, primarily in the past, we performed a biliodigestive anastomosis. In 106 patients we finished the procedure by inserting a T-tube; in 838 cases primary closure of the choledochus was performed. In 12 complications of the dilatation (perforation, pancreatitis, restenosis), there was no mortality; therefore we conclude that dilatation of the papilla is a safe, simple, and effective procedure.


[Endoscopic papillotomy (author's transl)]. Endoscopic sphincterotomy (EST) is a useful alternative to re-intervention of the bile ducts in cases of choledocholithiasis in the aged patient. The rate of success of EST is 87.7%, the rate of complications 8.4%, and the rate of mortality 1.1%. Mortality from EST is lower than that from transduodenal papillotomy or reoperation of the bile ducts. Late complications after EST are unknown and not to be expected.


[Conservative treatment of acute pancreatitis (author's transl)]. Since 1962, the conservative treatment of acute pancreatitis has been supported by delayed operation whenever necessary, based on clinical criteria. Of 65 patients operated upon, 22 died (33%). The overall mortality rate of 129 treated patients is 30%.


[Early operation in acute pancreatitis: operative procedures (author's transl)]. The failure of conservative treatment in severe acute hemorrhagic-necrotizing pancreatitis is one main reason for operative treatment of the diseases by removal of the necrotic masses. In cases of partial necrosis of the pancreas, mortality was significantly reduced by operative treatment; in subtotal and total necrosis only a few patients survived. Early diagnosis and early operation should be done before life-threatening complications occur.


[Preoperative preparation in colorectal surgery: antibiotics (author's transl)]. Out of a total of 2727 operations of the large bowel because of tumors and inflammatory disease, performed over a 14-year period, 897 were one-stage resections of the colon and rectum without relaxing colostomy. Standard preoperative preparation of the bowel consists of a balanced diet, laxatives, and enema supplemented by 9 g Neomycin and 1.8 g Achromycin, within a 2-day period. Disturbances in wound healing occurred in 12.5%, seroma included. Anastomotic insufficiency occurred in 4%, and fatal fecal peritonitis due to tumors in 1.3% and due to diverticulitis in 1.2%. Total mortality was about 5.7%. Postoperative hospitalization after resections because of tumors was 15 days and because of diverticulitis, 19 days.


[Whole-gut irrigation for large bowel preparation in colorectal surgery (author's transl)]. In a controlled trial with 32 patients, whole-gut irrigation (wgi) was compared with elemental diet as a method of large-bowel preparation. Cleansing effect, caloric intake (bad taste of diet), and preparation time were significantly better in the first group (wgi). Since 1976, 203 patients have undergone wgi. Investigations concerning the effect of addition of antibiotics to the irrigant revealed optimum reduction of fecal flora with neomycin--bacitracin--clindamycin.


[Large bowel preparation in colon surgery: elemental diet (author's transl)]. None of the usual methods of bowel preparation guarantee an aseptic large bowel. The intention is to reduce intestinal flora quantitatively, which can be achieved by mechanical cleansing alone. During the preparation period caloric and amino acid intake is insufficient. Therefore alimentation with elemental diet is necessary. The patient gets an adequate caloric and protein supply. The diet is totally absorbed in the small intestine, the large bowel remains clean, and the bacterial flora is reduced.


[Colonic stenosis with primary resection (author's transl)]. A primary resection and reanastomosis of the colon is often the procedure of choice, even in the presence of a significant stenotic element, provided there are no mayor disturbances of water-electrolyte homeostasis. In a series of 100 consecutive colonic resections (23 complicated by perforation, 9 by ileus, and 2 by bleeding), 97 patients were treated by primary resection (92 without a protective colostomy). No untoward effects were noted specifically due to this technique. The overall mortality rate was 4%, a favorable result when compared with the cumulative risk of a multiple stage procedure.


[Principles in stenosing surgical disease: multiple-staged surgery (author's transl)]. Colonic surgery today is usually performed in a one-stage procedure. Multiple resection is indicated only for bowel obstruction or severe inflammation. There is some discussion about the necessity of colostomy in left colon resection, mainly in cases of anterior resection. We strongly suggest a double loop transverse colostomy, since anastomotic leaks are frequent even with subtile techniques, and increasingly old high-risk patients have to be operated upon. Also, the fact that younger residents operate is no justification for forsaking this safety measure. According to the literature, most surgeons feel this way.


[Transsphincteric approach to the rectum in cases of low early cancer (author's transl)]. Based on 4 years of experience with the transsphincteric approach to the anorectum in 24 cases of low-situated cancers of the rectum, an attempt is made to demonstrate which tumors are treatable by this method and which are not. Exophytic or polyploid tumors with a diameter of not more than 3-4 cm, that are easily palpated and appear freely mobile, and have histologically a differentiated pattern may be approached by transsphincteric resection, under the condition that the tumor has not spread across the wall of the rectum or into adjacent lymph nodes. The method is not recommended in any other instances becauses of the high risk of recurrencies.


[Principles of radical surgery of gastric carcinoma (author's transl)]. For over a decade, therapeutic results in cases of macrocarcinoma have remained almost constant. The absolute 5-year survival rate is 10-15%. However, in cases of early detection, the 5-year survival rate is over 90%. Systematic screening to detect the cancers early has resulted. The practical results is the systematic observation of high-risk groups. The therapy of choice for macrocarcinoma and cancer that is detected early is subtotal resection. Resection of the cardia should be replaced by gastrectomy, which should also be performed only when defined diagnostic criteria are met.


[Early cancer of the lower rectum: indication for excision (author's transl)]. Early cancer of the rectum, limited to mucosa and submucosa, can be expected in 11% of all malignant lesions of the rectum. Metastatic spread is found in a high percentage of cases (up to 50%), especially in exulcerated or sessile tumors. Local excision of this lesion is therefore restricted to very few, favorable cases, because the rate of recurrence is high. Low anastomosis after resection shows not only a high rate of recurrence, but also many cases with incomplete or complete anal incontinence. Therefore, radical excision of the rectum with colostomy remains the therapy of choice.


[D. Documentation and statistics. Therapy code for all surgically active disciplines]. The study group of the German Society for Medical Documentation. Information and Statistics presents a suggested code that is an extension of VESKA. Since it only extends from Head to Gynecology, the Eltze-Eichler code is recommended for Orthopedics and Extremities. A general 6-digit code classified under different facets is being developed.


[Tumor surgery: principles of radical treatment (author's transl)]. The 5-year survival rate for curative radical resections of colorectal cancer including Dukes' stages A-C has not improved during the last 20 years. The main principles of surgical treatment have now been realized: en-bloc resection of the tumor together with its lymph drainage system, primary high ligature of the supplying blood vessels, prophylaxis of peroperative metastases and a high total resection rate with low operative mortality. In the future, an improved prognosis must come from prophylaxis, early diagnosis, and improved methods of irradiation and chemotherapy, because the limits of surgical treatment have been reached.


[Faults and dangers in treating hand injuries (including tendons and bones) (author's transl)]. Diagnostic procedures include: critical examination of the wound of sensibility, of vascularization, of tendon function, of stability of bones and joints, and examination by roentgen diagnosis. Therapeutic procedures include: the operation, immobilization, active training of noninjured joints, and rehabilitation. Injuries of flexor tendons are treated by the specialist following the method of Kleinert; those of bones and joints can be easily stabilized by Kirschner pins.


[Microvascular and microneural repair: technique and results (author's transl)]. Microsurgical technique permits repair of arteries and veins of a diameter of 0.5-2 mm. The success rate rose to 80-90% because of the frequent use of vascular grafts. This led to a high success rate in replantation of amputated parts. But repair of digital vessels is indicated even if the basal circulation is present to improve healing of other structures (tendons, nerves) and so to avoid late ischemic complaints. Free transfer of toes to replace digits in cases of multiple digital loss has its place in reconstructive hand surgery. It became possible because of the satisfactory return of sensibility after nerve repair. Microsurgery of peripheral nerves makes it possible to adapt the surgical technique to intraneural structures (mono-, oligo- or polyfascicular pattern with and without grouping). The results of nerve repair have been improved by the widespread use of nerve grafting. This is also true for cases that, in the past, were regarded as prejudicial to a useful recovery.


[Amputation involving the hand: indication and technique (author's transl)]. More than 3% of all work-related hand injuries result in partial or total amputation of fingers or hands (of 14621 patients with hand injuries, 479 patients had 878 amputations). When there is no possibility or indication for microsurgical replantation, the aim of the surgical effort is to rebuild a sensitive, vigorous grasp. The different procedures for plastic surgery of the hand are discussed.