CHOLEDOCHOLITHIASIS—Correlation of Preoperative with Operative and Postoperative Data to Enhance Diagnostic Insight

One hundred cases of common bile duct explorations were reviewed in an attempt to obtain information that might give insight into the diagnosis and definitive treatment of choledocholithiasis. Fifty of the hundred patients had common duct stones. Correlations were made between the incidence of choledocholithiasis as proved at operation, and the following factors: Kind and number of choledochal exploratory criteria used, the clinical diagnosis of common duct stones, and the pathologic features of gallbladders removed.The incidence of stones was statistically related to aging.The most frequent choledochal exploratory criteria were common duct dilatation or thickening (63 cases) and history of jaundice (50 cases).The most reliable single criterion in “diagnosing” common duct stones was palpable common or hepatic duct stones, the diagnosis having been correct in 15 of 17 such cases.The most reliable combination of criteria was a history of jaundice, plus palpable stones, with correct diagnosis in all such cases.The clinical diagnosis of choledocholithiasis was correct in only 17 per cent of cases.The correlation of the incidence of common duct stones with the degree of gallbladder disease—that is, acute or chronic—did not provide information that might be helpful in diagnosing choledocholithiasis.The incidence of proven retained common duct stones was 3 per cent, the non-fatal postoperative complication rate was 21 per cent and operative mortality was 1 per cent.     

GASTRIC RESECTION—Preoperative and Postoperative Care

Perhaps in no other field of surgery does attention to minute detail play so important a role in determining success as it does in gastric operations.As surgery of the stomach develops toward even greater security and favorable results can be expected with greater confidence, the several aspects of preoperative and postoperative care hitherto regarded as secondary demand closer consideration.     

RUPTURE OF THE GASTROINTESTINAL TRACT—Dealing with Lesions Caused by Non-Penetrating Trauma

The possibility of rupture of the gastrointestinal tract should be considered in every case of abdominal trauma, and the patient should be carefully observed for a period of 12 to 48 hours. There are many factors that may confuse diagnosis, but in the presence of persistent pain and tenderness, persistent or recurring shock, fever, leukocytosis, roentgen demonstration of free intra-abdominal air, or of other signs of peritonitis, operation should be carried out. The mortality rate is much higher when definitive treatment is delayed more than 12 hours.     

BILIARY TRACT ANOMALIES—The Utilization of Modern Techniques in Differential Diagnosis

The diagnostic aids used in dealing with biliary disease in adults were applied to the study in infants of the principal congenital anomalies of the biliary tract such as choledochal cyst, biliary atresia and biliary stenosis.Choledochal cysts were distinguished from other upper abdominal masses occurring in childhood by the use of intravenous cholecystography.Since the clinical manifestations in infants with biliary atresia or stenosis are almost identical to those associated with the obstructive phase of neonatal hepatitis, the problem of differentiation is difficult. The serial total serum bilirubin curve, a careful analysis of the pigment content of feces and urine and duodenal intubation for bilirubin determinations were found to be useful in making the distinction. Operative cholangiograms were helpful in some cases. Frozen section examinations of liver tissue during operation were of little value except to demonstrate certain unusual cases of intrahepatic biliary atresia. Routine liver function studies, including serum transaminase determination in a limited number of cases, did not help in differentiation.     

RECURRENT PILONIDAL CYST AND SINUS—A Plan of Preoperative Preparation,Operation and Postoperative Care

Evaluation ten years following radical excision and primary closure of recurrent pilonidal cysts led to the conclusion that the method of preoperative and postoperative care and the surgical technique employed gave satisfactory results. In 50 patients operated upon, the duration of symptoms varied from ten days to six years. Primary healing was achieved in all but one case in which there was slight skin overlapping. Thirty-three of the 50 patients were located for appraisal at the end of ten years. Three had had recurrences.The procedure involved eradication of acute infection preoperatively, wide, en bloc radical excision, with primary closure reattaching flaps centrally to the presacral fascia, and drainage of the depths of the wound.     

CARCINOMA OF THE PROSTATE—Diagnosis and Treatment

About 28 per cent of men between the ages of 71 and 75 have cancer of the prostate. Many of them do not die of the disease, but with the life span ever increasing, this problem is becoming more important.In the early stages the condition is asymptomatic; when the symptoms of urinary obstruction arise, the cancer is usually too advanced for cure. Cure depends on early diagnosis and, therefore, on routine rectal examination. The solitary hard nodule of early prostatic cancer becomes a stony hard fixed prostate as the condition progresses. X-ray and acid phosphatase studies are of help only after the cancer has metastasized. As many as 50 per cent of patients with rectally palpable early carcinoma of the prostate can be cured by radical perineal prostatectomy. Often, simple enucleation or transurethral resection is sufficient to effect cure in the case of occult carcinoma. However, some observers believe that when cancer is detected by microscopic examination of a prostate that has been removed, a radical operation should be done as soon after the initial operation as feasible. Early orchidectomy and estrogen therapy are of considerable help in slowing the process of advanced prostatic cancer and may postpone the need of transurethral resection to relieve obstruction. When these measures fail, bilateral adrenalectomy, cortisone therapy, pituitary irradiation, and pituitary extirpation have been employed, with moderate success, in an effort to diminish the androgen level.     

NEWER CONCEPTS OF ANATOMY OF THE LUNGS—Advantages to Surgeons,Internists, Bronchoscopists and Radiologists

In the newer concept of the anatomical divisions of the lungs, the bronchopulmonary segment is the primary unit. Specific lung areas are identified by their relationship to the branch of the bronchus that serves them. The left upper lobe apical segment, for example, is that which is supplied by the left upper lobe apical bronchus. The boundaries of the segments are definitive; thin tissue surrounds each segment.Some diseases of the lungs tend to progress only “through channels”—reaching a segment via the specific airway serving it, and then frequently remaining within the segmental boundaries.The concept is of particular importance to surgeons because of the trend toward segmental resection and salvage of vital lung tissue. In addition, a more definitive nomenclature, useful to surgeons, internists, radiologists and bronchoscopists in designating the location of a lesion or a foreign body, is possible.     

DETECTION OF PULMONARY TUBERCULOSIS—Comparative Value of Routine Radiologic Examinations and Routine Laboratory Procedures

The abnormalities disclosed by the usual laboratory diagnostic procedures (blood cell count and hemoglobin determination, sedimentation rate determination, urinalysis, and serologic test for syphilis) are compared with the number revealed by stereophotoroentgen chest examination in a series of 951 patients.The number of significant abnormalities uncovered by the routine stereophotoroentgen examination of the chest was comparable to the number disclosed by the usual laboratory procedures used in patient evaluation.Some form of radiologic examination of the chest should be included in the routine laboratory procedures required for patient evaluation.     

THE PLIOCENE MICROMAMMALIAN FAUNA FROM JINGLE, SHANXI——A DISCUSSION OF THE AGE OF JINGLE RED CLAY

<正> The Cenozoic deposits of Jingle area was first explored by Teilhard de Chardin & Young in 1929, and six species of mammals: Hipparion houfenense, Gazella blacki Antilospira licenti, Elephas sp., Cervus sp., and Rhinocerotidae gen. indet, were found from the Red Clay in Loc. 1 (Hefeng). Based on the Jingle Fauna, Teilhard de Chardin & Young concluded that the fossil-bearing layer was situated between the typical Hipparion richthofeni Red Clay (Pontian) and the Sanmenian deposits (Polycene) (Teilhard de Chardin & Young, 1930, 1931) and called it "Upper Pontian". Since then, Jingle Formation (or Jingle Red Clay) has been widely used in the stratigraphic generalization of North China (Pei et al., 1963) although its definition and age assignment have never been cleared up. "Jinglean" was put into use for the first time as a stage name by Li et al. (1984, in Chinese) to represent Early Pliocene tentatively: "It may be equivalent to Early Pliocene, more plausibly, it is later ...... Jinglean was temporarily used here to represent Early Pliocene by tradition." In order to make clear the age of Jingle Red Clay and enrich the Hefeng Fauna, a field survey was made in the Summer of 1986 by Chen Xiaofeng and the author. An assemblage of fossil micromammals was unearthed by means of wet-sieving techniques. About 1 ton of sediments from Hefeng (Loc. 86007, or Loc. 1) and Xiagaoai (Loc. 86008, or Loc. 2) in Jingle county (see fig. 1), yielded over 1000 specimens of small mammals. The specimens are from four layers (see table 1), and the present paper only deals with the micromammals from the sand layer and the Red Clay at Hefeng (fig. 2).     

THE ROLE OF PSYCHOTHERAPY IN ALLERGY—Credits and Debits

Psychological problems play an important role in the production and exacerbation of allergic disease, just as they do in other illnesses, especially those of a chronic nature entailing economic and social problems. Some psychotherapy is implicit in the practice of all physicians. While most patients make satisfactory progress with whatever treatment is outlined, a few do not, and they may be helped if a little extra time is taken to investigate and rebalance their mental environment. In the treatment of patients with allergic disease, dealing with emotional problems is considered as adjunctive to specific desensitization.     

A STUDY OF INFLATION OF THE LUNGS OF THE NEWBORN—A Preliminary Report

There seems to be no reasonable doubt that the lungs in a newborn expand progressively during the first few days of life. Some degree of atelectasis seems to be perfectly normal. This is indicated by a number of roentgenographic studies (including those here reported); by the reported findings of pathologists; by the fact that in experimental animals the lungs inflated very unevenly; and by the fact that aeration of only a portion of the lung is needed for complete oxygenation of the blood. The relation of atelectasis to neonatal death is not entirely clear and is probably not always the same. The infant may die from other causes before the lungs are fully expanded. Atelectasis may develop secondarily to other debilitating conditions. The frequent coincidence of prematurity and extensive atelectasis is impressive. It may be that the lungs are so incompletely formed that they cannot expand. On the other hand, atelectasis and massive collapse in the adult is a serious condition and there seems to be no good reason to suppose that this cannot also occur in infants and be serious per se.The air pressures found necessary to expand the lungs in rabbit fetuses were found to be about ten times what adult humans use in quiet respiration and were of about the same magnitude as the pressures found necessary to expand the lungs of stillborn humans. An attempt to produce atelectasis in newborn rabbits by chilling was most inconclusive. Atelectasis did develop in three of 15 animals used in the experiment, but the relation to chilling was not at all clear.