Autopsy in California

From information complied from death certificates registered in 1952 and 1962 an examination was made of California''s autopsy performance and the characteristics of deaths in which autopsy was done. The data indicated that California had an overall autopsy rate of 37 per cent of total deaths in 1962, probably higher than any other state. In the decade reviewed, there was a 62 per cent absolute increase in autopsies and a 7 per cent increase relative to total deaths.Substantial increases in the proportion of deaths in which autopsy was done were found for physician-certified deaths in both metropolitan and nonmetropolitan counties and for coroner-certified deaths in nonmetropolitan counties. For all but two of forty-five selected natural causes of death there were increases in the proportion of deaths in which autopsy was done.Seventy per cent of deaths occurred in some type of facility. About one-half of all deaths occurred in general hospitals, and autopsy was done in 42 per cent of such cases.The dual factors of a high autopsy rate and overrepresentation of deaths brought to autopsy in white males, ages 35-64, support the validity of a reported decline in California''s death rate for arteriosclerotic heart disease.     

COMPLICATIONS FOLLOWING SUBTOTAL GASTRECTOMY

Four hundred consecutive cases in which subtotal gastrectomy was done for duodenal and gastric ulcer were reviewed. The mortality rate was 3.5 per cent. There were 57 complications, an incidence of 14 per cent. Of the fatal complications, duodenal stump disruption was the most common and serious—11 cases and 7 deaths. The other fatal complications included various types of obstruction, pulmonary embolus, hemorrhagic pancreatitis and separation of the abdominal incision. Of the nonfatal complications, obstruction of the stoma, anastomotic bleeding, pneumonia, venous thrombosis and wound infection were the most common.Catheter duodenostomy is helpful in the closure of a difficult duodenal stump. Where this was done in the present series there were no fatalities.Electrolyte balance, correction of protein deficiencies, blood replacement and the judicious use of antibiotics are important prophylactic factors against postoperative complications.     

Severe euthyroid cardiac disease; technique for treatment with radioiodine

It is possible to safely lower the basal metabolism of patients suffering from severe cardiac disease by administering multiple small doses of radioiodine in order to achieve symptomatic relief. From the present study, multiple small doses of I(131) appeared to be as effective as single or multiple large doses of this material and complications such as thyroiditis, temporary thyrotoxicosis and bone marrow depression were almost always avoided. No damage to the parathyroid glands or the recurrent laryngeal nerve was observed. No radiation sickness developed after therapy.A scintigram of the thyroid gland was useful in determining the size, shape and function of the thyroid gland before and during radioiodine treatment and helped to determine the need for additional treatment. In order to prevent the distressing symptoms of the myxedema state, desiccated thyroid was administered when necessary. In the series of 278 euthyroid patients with severe cardiac disease who were treated with radioactive iodine, results were excellent in 35 per cent of cases and good in 44 per cent. In 21 per cent there was no improvement.     

Ciprofloxacin in the treatment of infections in oncology patients

Treatment of infectious complications with ciprofloxacin in 65 patients provided good and satisfactory results in 67.7 and 20.0 per cent of the cases, respectively. The drug was efficient in sepsis, urogenital infections, respiratory infections and postoperative purulent complications. Ciprofloxacin showed a broad antibacterial spectrum. 96.3 per cent of the isolates belonging to aerobic organisms causing purulent inflammatory processes, including those with high antibiotic resistance levels, such as Pseudomonas spp., Proteus spp., Klebsiella tribe and Staphylococcus aureus were sensitive to the drug. In its antibacterial spectrum ciprofloxacin was similar to ofloxacin. The advantage of ciprofloxacin is its possible use not only orally but also intravenously. Adverse reactions to ciprofloxacin were observed in 5 (7.7 per cent) out of the 65 patients. In two cases discontinuation of the drug use was required. The use of ciprofloxacin in treatment of infectious complications in oncological patients is promising.     

Mortality rates in patients with burns; a report of experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956. The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection. No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived. No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection. The lowest mortality rate was in the age group of 15 through 35 years.     

MORTALITY RATES IN PATIENTS WITH BURNS—A Report of Experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956.The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection.No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived.No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection.The lowest mortality rate was in the age group of 15 through 35 years.     

THE PROBLEM OF PROGNOSIS IN PANCREATITIS

Prognosis in pancreatitis is at best difficult and uncertain. Certain complicating factors, however, occur in statistically established percentages of chronic cases: Calcification in 35 to 50 per cent, diabetes (usually mild) in 15 to 25 per cent, and cysts, pseudo-cysts or abscesses in 10 to 15 per cent. Steatorrhea (which may cause severe malnutrition) and diabetes are more common in cases in which calcification develops.     

SEVERE EUTHYROID CARDIAC DISEASE—Technique for Treatment with Radioiodine

It is possible to safely lower the basal metabolism of patients suffering from severe cardiac disease by administering multiple small doses of radioiodine in order to achieve symptomatic relief.From the present study, multiple small doses of I¹³¹ appeared to be as effective as single or multiple large doses of this material and complications such as thyroiditis, temporary thyrotoxicosis and bone marrow depression were almost always avoided. No damage to the parathyroid glands or the recurrent laryngeal nerve was observed. No radiation sickness developed after therapy.A scintigram of the thyroid gland was useful in determining the size, shape and function of the thyroid gland before and during radioiodine treatment and helped to determine the need for additional treatment. In order to prevent the distressing symptoms of the myxedema state, desiccated thyroid was administered when necessary.In the series of 278 euthyroid patients with severe cardiac disease who were treated with radioactive iodine, results were excellent in 35 per cent of cases and good in 44 per cent. In 21 per cent there was no improvement.     

INTRACELLULAR SYNTHESIS OF CHONDROITIN SULFATE

In autoradiograms of slices of costal cartilage, incubated for 4 hours in a salt solution containing S³⁵-sulfate and then washed extensively and dehydrated, about 85 per cent of the radioactivity was assignable to the chondrocytes. From alkaline extracts of similarly prepared slices of cartilage, 64 to 83 per cent of the total sulfur-35 in the slices was isolated as chondroitin sulfate by chromatography on an anion-exchange resin. In view of the estimate that only about 15 per cent of the radioactivity was in the matrix, the isolation of 64 to 83 per cent of the total sulfur-35 as chondroitin sulfate is a strong argument that the chondrocytes are the loci in which chondroitin sulfate(s) is synthesized.     

SALIVARY GLAND TUMORS

In a review of a series of 248 salivary gland tumors, seen over a 28-year period, all pathologic material was brought up to date by reclassification according to more recent criteria and nomenclature. In parotid tumors, a probable lowered recurrence rate and a definite decrease in incidence of permanent facial nerve paralysis was found in the more recent cases in which the "Y" incision was used, with identification of the seventh nerve as it leaves the stylomastoid foramen. The five-year recurrence rate for primary mixed tumor was 8.3 per cent, and in recurrent cases it was found to be 18.1 per cent. Of 44 patients with malignant salivary gland tumors in all sites who were observed for five years or more, 32 or 72.7 per cent survived five years.     

Survival in acute myocardial infarction; factors observed in 318 patients

Factors influencing survival in a group of 318 cases of acute myocardial infarction were analyzed. The mortality rate for the entire series was 41 per cent. Among the men it was 39.5 per cent; among women, 44.4 per cent. The mortality rate increased with the age of the patient. Twenty-six per cent of all deaths occurred within the first 24 hours, 44 per cent within 72 hours, and 71 per cent within the first week following hospital admission. Increased mortality rate was associated with previous history of congestive failure, myocardial infarction, hypertension or cardiomegaly. As to circumstances immediately preceding an infarction, the only ones that seemed to be related to a high mortality rate were hemorrhage and the postoperative state. Not only the presence but the degree of shock, congestive failure, cyanosis and dyspnea adversely influenced chances for survival. Duration, location, radiation and number of attacks of pain did not appear to be associated with extraordinary mortality rates. Anterior was slightly more common than posterior infarctions, and the mortality rate was much higher. Thromboembolic complications and certain disorders of rhythm and of conduction definitely worsen prognosis. Comparison of average mortality data as reported in different studies on acute myocardial infarction is improper and misleading because of the great differences between the kinds of patients included in various series reported upon. A standard method of grading the severity of acute myocardial infarction would help toward sounder comparisons.     

SALIVARY GLAND TUMORS

In a review of a series of 248 salivary gland tumors, seen over a 28-year period, all pathologic material was brought up to date by reclassification according to more recent criteria and nomenclature. In parotid tumors, a probable lowered recurrence rate and a definite decrease in incidence of permanent facial nerve paralysis was found in the more recent cases in which the “Y” incision was used, with identification of the seventh nerve as it leaves the stylomastoid foramen. The five-year recurrence rate for primary mixed tumor was 8.3 per cent, and in recurrent cases it was found to be 18.1 per cent.Of 44 patients with malignant salivary gland tumors in all sites who were observed for five years or more, 32 or 72.7 per cent survived five years.     

PERFORATED PEPTIC ULCER—Selective Gastric Resection in Emergency Treatment

In a series of 240 cases of perforated peptic ulcer prior to 1952 there was a total mortality of 17 per cent. This included cases treated conservatively as a planned procedure or because of other morbid conditions and undiagnosed cases, all ending in death.In cases treated by simple suture, mortality was 2.6 per cent for patients under 50 years of age and 17 per cent for those over 50, the rate rising very steeply with each decade over 50.From 1953 through 1959 selective gastric resection was carried out, the operation being done in all cases of perforated gastric ulcers, of chronic duodenal ulcers and of perforations associated with hemorrhage.During this period 303 perforated ulcers were treated, with a mortality of 15.5 per cent. Patients with associated morbid conditions and those admitted moribund and died, or died undiagnosed were again included.In this series also the mortality increased steeply from age 50 onward.Gastric resection was carried out in 148 cases of perforated peptic ulcer with a mortality of 6 per cent. In 105 cases under 60 years of age there were no deaths but in those over 60 the mortality rate was 21.8 per cent. Results in the patients who had resection, as determined after three years of observation, compared favorably with the results in patients who were treated by suture.The mortality of perforated ulcers in females was higher than in males.Emergency gastric resection has a definite place in the treatment of perforated peptic ulcer.     

BACTERIAL MENINGITIS AND OTHER DISEASES AFFECTING THE MENINGES—A Review of 349 Cases

Three hundred and forty-nine cases of disease affecting the meninges were observed at the San Bernardino County Charity Hospital in an eight year period.A total of 29 patients with meningococcal, H. influenzae and pneumococcal meningitis were treated. There were four deaths, of which three occurred during the first 24 hours in the hospital.Of 22 cases of unclassified meningitis, four probably were tuberculous, four probably were meningococcal and two probably were of virus origin.Under present treatment programs the differentiation between viral and bacterial meningitides is difficult and it is possible, therefore, that the reported incidence of the two groups may not represent the facts.Of 22 cases of unclassified meningitis, 12 had no specific characteristics which would permit a clinical diagnosis. One of the patients died.Of 70 cases of clinical meningitis, the infecting organism was identified in 69 per cent.Meningococcal meningitis made up only 17 per cent of 70 cases of purulent meningitis observed between July 1, 1945, and July 1, 1948.     

Bacterial meningitis and other diseases affecting the meninges; a review of 349 cases

Three hundred and forty-nine cases of disease affecting the meninges were observed at the San Bernardino County Charity Hospital in an eight year period.A total of 29 patients with meningococcal, H. influenzae and pneumococcal meningitis were treated. There were four deaths, of which three occurred during the first 24 hours in the hospital. Of 22 cases of unclassified meningitis, four probably were tuberculous, four probably were meningococcal and two probably were of virus origin. Under present treatment programs the differentiation between viral and bacterial meningitides is difficult and it is possible, therefore, that the reported incidence of the two groups may not represent the facts. Of 22 cases of unclassified meningitis, 12 had no specific characteristics which would permit a clinical diagnosis. One of the patients died. Of 70 cases of clinical meningitis, the infecting organism was identified in 69 per cent. Meningococcal meningitis made up only 17 per cent of 70 cases of purulent meningitis observed between July 1, 1945, and July 1, 1948.     

Drug resistance of the causative agent of Grigo'rev-Shiga dysentery (Shigella dysenteriae 1)isolated in the USSR

Forty strains of S. dysenteriae 1 isolated in the USSR within 1986-1988 were tested for their resistance to 11 antibacterial drugs. It was shown that 92.5-97.5 per cent of the isolates were resistant to chloramphenicol (Cm) and tetracycline (Tc), 22.5 per cent to streptomycin (Sm), 17.5 per cent to nalidixic acid (Nal) and 10 per cent to ampicillin (Ap) and polymyxin (Pm). Resistance to Cm Tc (51.4 per cent) and Cm Tc Nal (13.5 per cent) represented the predominating phenotype. 35 per cent of the strains carried conjugative R plasmids. In the majority of the cases, the determinants of resistance to Cm and Tc were transferred, which must define the high frequency of the strains resistant to Cm and Tc. All the tested strains were sensitive to gentamicin, neomycin, rifampicin, cefamezin and ciprofloxacin. Since the strains of S. dysenteriae 1 proved to be highly sensitive to the tested drugs it appeared possible to consider them as the drugs of choice in etiotropic therapy of patients with dysentery caused by the pathogens of the Grigoryev-Shiga group.     

Effects of Airspeed and Humidity Changes on Spore Discharge in Sordaria fimicola

An improved experimental system is described for studying therate of spore discharge in Sordaria fimicola subjected to anair-stream of controlled rate and relative humidity. Under nearlysaturated conditions the rate of air-flow does not seem to affectthe rate of discharge. Reduction of the R.H. from 95 per centto 70 per cent or 35 per cent leads to an immediate but temporaryincrease in discharge rate. 70 per cent R.H. seems only to affectactual discharge, but prolonged exposure to 35 per cent R.H.interferes as well with earlier stages in spore development.It is suggested that the immediate effect on discharge is physicalrather than biochemical. There is evidence that the perithecialwall plays some part in the control of spore discharge.     

Prolonged antibacterial action of polymer coated suture materials]

The antimicrobial activity of capromed, a surgical polymer-coated sutural material containing dioxidine, quinoxidine or gentamicin was studied in vitro and in vivo. Capromed was shown to be active against the hospital strains of S. aureus, E. coli, Proteus spp., Klebsiella spp. and P. aeruginosa. The antimicrobial activity of ADH and AG threads was preserved for 3 to 4 days after implantation. The DH-2 and G-2 threads preserved their activity for 6 to 7 days. It was concluded that the duration of thread antimicrobial activity depended on the properties of the polymer coating the thread. Capromed was applied to 280 operation wounds in 275 patients. There was no wound suppuration in the group of patients after pure operations (n = 62). In the group of patients after conditionally pure operations (n = 130) suppuration was observed in 2 patients (1.3 per cent). In patients with contaminated wounds (n = 88) suppuration in 5 of them (5.7 per cent) was recorded. The total number of the purulent complications after using capromed in surgical operations amounted to 2.5 per cent. In the control group purulent complications were stated in 8.2 per cent of the cases.     

A THERAPEUTIC REGIMEN FOR TUBERCULOUS MENINGITIS

The results of treatment of tuberculous meningitis in Highland Alameda County Hospital, since the advent of streptomycin, in 34 cases were: dead, 21 patients, or 61 per cent; alive, 10 patients, or 29 per cent. Three cases were excluded from the ultimate report due to inadequate follow-up. The mean survival time of the ten survivors at the time of report was 35 months, the longest being 74 months.The composite results of treatment elsewhere, as reported in the literature, have been: dead, 892, or 59 per cent; alive, 629, or 41 per cent.The pathogenesis of the disease and the effects of chemotherapy are discussed.A therapeutic regimen for tuberculous meningitis is presented, which has been used at Highland Hospital since INH became established as the most effective component in the combined chemotherapeutic attack on the disease.     

Dermatopathic Lymphadenopathy—A Clinicopathologic Analysis of Lymph Node Biopsy Over a 15-Year Period

Forty cases of dermatopathic lymphadenopathy were found in a series of 906 consecutive lymph node biopsies (4.8 per cent).The histologic development and progression of the disease was correlated with the clinical state of the patient.In 35 of 40 cases the patients had active skin disease at the time of the biopsy; one of the remaining five patients had Hodgkin''s disease, one had multiple myeloma and one had secondary syphilis. In the other two, no organic cause was found.In nine cases (22.5 per cent), the histological pattern typical of dermatopathic lymphadenopathy was associated with malignant lymphoma. Except for two biopsies, which showed coexisting malignant lymphoma and dermatopathic lymphadenopathy, no histologic features were found which distinguished patients with malignant lymphoma from the remainder.While the pathogenesis of the lymph node changes remains obscure, the histologic features suggest that it is at least in part an immune response, although the nature of the responsible antigen is unknown.