Blood volume is a complex problem not fully understood. The volume of blood in circulation is not a static quantity, rather, it is the net effect of counteracting forces in dynamic equilibrium. There are constant additions to the circulation and losses from the circulation, which in healthy persons tend to balance each other. Water, salts and nonprotein nitrogenous products pass back and forth through the capillary endothelium, into and out of the blood stream, with considerable freedom. Plasma proteins, which escape slowly, are matched by fresh accretions from lymph and from protein stores. Blood cell losses are replaced by newly formed cells. The result of this ceaseless activity is, within limits of physiological variation, a fairly constant blood volume. But, under abnormal conditions of hemorrhage, trauma and many diseases, that balance is upset and the volume of blood is altered. If the imbalance is severe, the efficiency of the entire
The many new drugs introduced in recent years to relieve the tremor, rigidity, and poverty of movement of paralysis agitans (Parkinson's disease) give testimony to the fact that no universally effective treatment for this disorder has been discovered. The introduction of trihexyphenidyl (Artane)1 was an important advance in therapy, but its effectiveness is limited, and it has not entirely replaced the older solanaceous alkaloids, namely, atropine, scopolamine (Hyoscine), stramonium, and hyoscyamus. Initial successes with synthetic compounds, such as Rabellon,2 which contains belladonna alkaloids, caramiphen hydrochloride (Panparnit),3 diethazine (Diparcol),4 and the antihistaminics, principally diphenhydramine (Benadryl) hydrochloride,5 were encouraging, but these agents now seem to be inadequate for the majority of patients with paralysis agitans and have, for the most part, been reduced to the status of adjunct drugs. Similarly, agents tending to reduce spasticity, the curare derivatives and mephenesin (Tolserol),6 seem to have very limited
Although employed in cesarean section throughout the country since 1941, spinal anesthesia was not given extensively for this procedure at Children's Hospital in San Francisco until 1947. Since then, however, it has practically replaced all other forms of anesthesia for cesarean section at this institution. As shown in table 1, there were 13,508 deliveries at Children's Hospital during the six year period from 1947 through 1952. These included 1,427 cesarean sections, of which 1,236 were performed under spinal anesthesia, for an incidence of 86.61%. The shift to spinal anesthesia can be attributed only to some very definite advantages, which the majority of the obstetric surgeons of this staff recognized. The more important of these are, first, the complete absence of all irritating drugs and the untoward complications associated with inhalation anesthesia.1 In the 18 months prior to January, 1947, one patient died from inhalation of vomitus, following inhalation anesthesia,
• True cryptorchism must be distinguished from high retracted testis, which is normal in some boys up to the age of puberty. In true cryptorchism the testis cannot be palpated or, if palpable, cannot be displaced into the scrotum.
An undescended testis can produce enough androgenic hormone to fulfill its endocrine function, but it is liable to mechanical injury and is unable to produce spermatozoa. The psychological need for correction is an important consideration. The evidence that such correction reduces the danger of subsequent malignancy is unconvincing.
Orchiopexy generally involves both the treatment of an indirect inquinal hernia and the repositioning of the testis. In this series of operations there has never been recurrence of the hernia. Operations of the Torek type for repositioning, whereby the testis is temporarily bound to the thigh, are likely to damage the blood supply and give very poor results. The operation here described involves freeing the ductus deferens down to the base of the bladder and the spermatic vessels well up to the inferior pole of the kidney so as to minimize all tension. It is done on one side at a time. The operation is best done between the ages of 9 and 11. In a group of patients studied 10 years or more after bilateral orchiopexy, 79% have been shown to be fertile.
The search for a medicament with sedative and relaxant properties has been a never-ending one in the progress of medicine. The earlier agents used included paraldehyde, chloral hydrate, and bromides. In 1903,1 the use of barbituric acid and its derivatives was a significant advance in this field, until the accompanying hazards of addiction, overdosage, and toxicity became apparent. While barbiturates are still the most widely used medicaments, the search progressed with the use of anticonvulsants (especially hydantoin derivatives). Even antihistaminic agents play a lesser role as sedatives. Meparfynol has also been introduced as a sedative-hypnotic, but here one must be alert to the possibility of liver damage.
In recent years, mephenesin2 has entered the field. Partial success has been obtained with its use in certain anxiety states,3 in certain neurological and muscular disorders,4 and as an adjunct in alcoholism. The relative success of this preparation suggested
Bacillary dysentery historically is a disease of major importance to confined population groups. Epidemics occur repeatedly aboard ship, in institutions for the mentally defective and mentally ill, and in orphanages, jails, and prison camps. Experience with dysentery in the United Nations prisoner-of-war camp in Korea followed this historical pattern, despite the preventive measures instituted by the authorities. An important contributing factor to this lack of effectiveness was the high endemic level of infection at the time of capture. Bacteriological examination of 1,000 prisoners at the time they were brought to the camp showed 8% to be infected with pathogenic Shigella. During the past decade sulfonamide therapy has been established as highly effective in shigellosis.¹ The treatment of the sick persons in Korea was complicated by the fact that almost all the cases of bacillary dysentery were due to sulfonamide-resistant shigellae. This finding, based first on clinical observations, was supported later
There are comparatively few reports in the literature of large series of cases bearing on the prognosis of angina pectoris and coronary occlusion, and the available reports show considerable differences in their findings. Some of the reports refer only to cases that were followed till death and do not include those of patients still living, thus conveying a wrong impression of the actual prognosis.
As examples of the differences in the longevity figures of angina pectoris as reported in the literature are the following: Herrick and Nuzum1 in a study of 200 patients, 50 of whom died, found the average longevity for the dead group to be three years. Mackenzie2 reported on 380 patients, 214 of whom died, with an average longevity for the dead group of 5.4 years. White3 reported on 200 patients, 66 of whom died with an average longevity of 3.4 years for the
The headache that frequently follows spinal anesthesia is sometimes associated with visual and auditory difficulties and dizziness. This syndrome was studied in connection with 9,277 anesthetizations by the spinal technique, and the data were compared with those from 1,000 other patients who were given general anesthesia over the same period of time. The over-all incidence of the headache, which occurred in 9,277 anesthetizations, was 1,011, or 11%. The oldest patients were least susceptible to it, and men were less susceptible than women. Its incidence when needles of small diameter were used was much less than that with needles of large diameter; the 22-gauge needle was found best for routine use. Headache could be virtually eliminated by the employment of a 24-gauge needle. The data on duration and time of onset of the headache, on the effects of postural changes, and on the visual and auditory phenomena indicate that this syndrome results from a decrease in cerebrospinal fluid pressure and that the decrease is caused by leakage of the fluid.
A critical evaluation of spinal anesthesia was made by studying the records of 8,460 patients who received 10,098 injections of spinal anesthetics; this group was compared with a group of 1,000 persons who received general anesthetics for the same types of operations and with 100 persons who received spinal anesthetics after induction with general anesthetics. No instance of adhesive arachnitis, transverse myelitis, or cauda equina syndrome was found, but neurological complications occasionally resulted from lumbar puncture per se. Two cases are described in which various persistent symptoms and disabilities followed unsuccessful attempts at administration of spinal anesthetics; in 17 other cases of difficult lumbar puncture paresthesias and other complaints occurred after the successful injection of the anesthetic. In spinal anesthesia proper selection of patients is essential, and lumbar puncture, whether for purposes of diagnosis or anesthesia, must be performed with meticulous attention to certain well-known details of technique.
In anesthesiology there is a continuing healthy criticism of the agents and techniques used to achieve practical and safe conditions for surgical operations. This criticism arises both from within the ranks of the specialty and from outside. Hardly a drug or method is free of major disadvantages. Recent reports have described what seems to be an increasing incidence of cardiac arrest under anesthesia.¹ General anesthesia and particularly the employment of multiple agents have been blamed in part for this increased mortality. We hear that ether is not the safe agent it once was thought to be² and that curare may possess an inherent toxicity.³ Spinal anesthesia, an anesthetic technique with great advantages for the patient, surgeon, and anesthetist, is relatively free from the criticism of toxicity and the mortality associated with general anesthesia; on the other hand, the great hazard of spinal anesthesia in the minds of
The maximal temperature rise in man from which there can be complete recovery is a question of both practical and theoretical interest, which perhaps, in the future, can be definitely answered on the basis of numerous well-documented reports. At present, a categorical statement concerning this is not possible. Undoubtedly, the duration of the hyperthermia is of great importance in survival. In the older literature, there are a number of fantastic reports of extreme hyperthermia, ranging from 120 to 170 F; it is obvious these are fradulent.
According to McNeal,¹ 114.8 F is the upper limit of hyperthermia that may be accepted as authentic without strong substantiating evidence. In his monograph on animal heat, Richet² listed 109 instances of hyperthermia, ranging from 107.6 to 112.2 F, with only 13 instances of survival, a survival incidence of about 11% for the group. Castellani and Chalmers,³ under the classification "hyperpyrexial
The treatment of chronic myelogenous leukemia with roentgen rays is a generally accepted procedure. For many years the local irradiation of the spleen, long bones and other areas of infiltration was the most widely used technic. During the past two decades the method of total body irradiation has gained favor, and many investigators now feel that better control of the disease can be achieved by this procedure. Although cure has not been possible with radiation therapy, studies such as those of Minot and co-workers1 have shown that comfortable or useful life may be prolonged.In 1936 it was shown experimentally that when radioactive phosphorus (P32) in the form of sodium mono-hydrogen phosphate was injected into leukemic mice the sites of greatest concentration of the phosphorus atoms were the infiltrated bone marrow and infiltrated soft tissues such as lymph nodes, liver and spleen. Since P32 emits beta rays
The effect of dextran infusions upon the bleeding time was studied in 22 women and 235 men. In 42 % of the subjects the infusion of one liter of 6 % solution of dextran measurably prolonged the bleeding time; in 8% of the subjects the bleeding time after infusion exceeded 30 minutes. The effect was maximal from three to nine hours after the infusion and was not accounted for by any demonstrable dilution or reduction of fibrinogen or thrombocytes. Comparison of dextran preparations showed that those of highest molecular weight had the most marked effect in prolonging the bleeding time. The use of dextrans as plasma expanders carries a risk of serious failure of the hemostatic mechanism and is contraindicated in patients who are known to have a tendency to bleed or who have received large transfusions of whole blood.
In the United States variations from state to state in death rates from cardiovascular diseases have been unexplained on dietary, racial, or social bases. One variable environmental influence to which all persons are exposed is potable water. Statistical analyses of water hardness and death rates from all causes, cardiovascular diseases, coronary heart disease, and noncardiovascular diseases, showed highly significant correlations for all but noncardiovascular causes. Similar relationships were demonstrated for caucasoid men, aged 45 to 64 years, by state and, in the case of coronary disease, in the 163 largest cities. Of 21 constituents of finished municipal water in each city, highly significant correlations were found for magnesium, calcium, bicarbonate, sulfate, fluoride, dissolved solids, specific conductance, and pH. In all cases correlations were negative, i. e., softer water was associated with higher death rates. Some factor either present in hard water or missing or entering in soft water appears to affect death rates from degenerative cardiovascular disease.
A HISTORICAL REVIEW OF MYASTHENIA GRAVIS FROM 1672 TO 1900
Henry R. Viets, M.D., BostonAlthough myasthenia gravis was not described with any pretense of completeness as a clinical entity until the last quarter of the 19th century, a reference by Thomas Willis, an astute 17th century English clinician, indicates that Willis knew of the disease and recognized the chief symptom of asthenia of the voluntary muscles, with recovery after rest. The description of the weakness in his patient (1672),1 first noticed by Guthrie (1903),2 occurs in his book on the physiology and pathology of disease, with illustrative cases, "De anima brutorum," published in two separate editions the same year in Oxford and in London.An English translation of "De anima brutorum" was made by S. Pordage in 1683 and published as "Two Discourses Concerning the Soul of Brutes" in "Dr. Willis's Practice of Physick" (London, 1684).3
One hundred years ago the word anemia was in use, although few measurements of blood had been performed. Purpura and plethora were classified, but there were few, if any, supporting laboratory studies. Blood cells were examined in the fresh state without staining, and blood cell counting was just beginning. Fifty years ago, reduced platelets were described in connection with purpura hemorrhagica, and the blood groups were discovered. A little over a quarter of a century ago, the effects of liver in pernicious anemia opened wide the newer hematology, in which pathophysiology was emphasized. At present we are at the beginning of the era of hematological chemistry. This will undoubtedly lead to expansion in the fields of coagulation disorders, immunohematology, and the hemoglobin abnormalities. The prevention of useless blood loss and the conservation of this most precious fluid for an increasingly healthy society must be the constant aim of the worldwide fraternity of hematologists.
Since 1859 there has been a section of the American Medical Association, with various names and with varying emphases, devoted to meteorology, medical topography, epidemic diseases, hygiene, sanitary science, industrial medicine, public health, and preventive medicine. The history of the section reflects the changes resulting from the solution of old problems and the emergence of new ones. Important advances resulted from the indentification of parasites and vectors concerned in transmissible diseases, the discovery of methods of immunization, the recognition of deficiency diseases, and the development of chemotherapy. New problems arise from the pollution of air and water by an increasingly dense population, the increase in the average age of the population, the constant introduction of new chemicals and processes into industry, and the accumulating exposure to ionizing radiations. In view of the accomplishments of the past, it is stimulating to consider the problems that lie ahead.
It is a great honor to stand in the place which has been occupied by so many illustrious men over the 100 years that the Section on Surgery has existed. The names of those who contributed to the deliberations of the Section conjure up a history of surgical progress in America. It would be difficult for me to review the musings that a survey of the transactions of the Section bring to mind. To chronicle names, dates, and subjects would be simple but dry. As the Chairman's address should be related to theme of the occasion, I have taken this opportunity to track down from records the answer to a question which has long been on my mind: How did the Section get its curious designation, "The Section on Surgery, General and Abdominal"? Why the adjectives "General" and "Abdominal"? Why the conjunction "and"? Why are the adjectives used as supplements?
Information was gathered on the smoking habits of 187,783 white men between the ages of 50 and 69 between January 1 and May 31, 1952. The men were subsequently traced through October 31, 1955. 11,870 men died during this period. The total experience covered 667,753 man years. For microscopically proved cases of cancer and for the total cases reported as cancer it was found that the death rates were higher among regular cigarette smokers than among men who never smoked, that the mortality ratio increased with the number of cigarettes smoked each day, and that the death rates were higher among pipe and cigar smokers than among men who never smoked. 7316 deaths occurred among regular cigarette smokers; this was an excess of 2665 over the 4651 deaths that would have occurred had the age-specific death rates for smokers been equal to that for nonsmokers. Coronary disease accounted for 52.1% of the excess; lung cancer accounted for 13.5% of the excess; and cancer of other sites accounted for 13.5% of the excess. An extremely high association between cigarette smoking and death rates for men with lung cancer was found in both rural areas and large cities. Only 338 deaths were ascribed to pulmonary diseases other than lung cancer. Only 1120 (9.4%) of the 11,870 deaths were attributed to diseases other than cancer, cardiac, circulatory, and pulmonary diseases and accidents, violence, and suicide. Only 3 of the specific disease entities - gastric and duodenal ulcers and cirrhosis of the liver - showed a statistically significant degree of association with smoking habits. The most important finding of this study was the high degree of association between cigarette smoking and the total death rate.
Brucella abortus, strain 19, is widely used for the inoculation of cattle against brucellosis. Without losing its antigenicity, the virulence of this strain of the organism has been greatly attenuated by extensive subculture and animal passage. The strain has, until recently, been considered relatively innocuous to humans. Recently Spink and Thompson1 noted the paucity of reports of human brucellosis caused by Br. abortus, strain 19, and, therefore, they reported two such cases resulting from acccidental inoculation with this organism. Both cases involved veterinarians. One case was the first in which the organism was isolated from the blood stream and its presence well documented bacteriologically. These authors warned that the antigen should be handled cautiously and only by qualified personnel.
This report is of a similar experience, also involving a veterinarian who was accidentally inoculated with Br. abortus, strain 19. While bacteriological proof of brucellosis is lacking, this case serves