Cardiac screening procedures

Seven per cent of a sample group of civil service employees were found to have diagnosable heart disease. The diagnosis was made on the basis of a complete physical examination and history taken by a specialist in internal medicine and/or heart disease. In addition a questionnaire form related to symptoms of heart disease was filled out by the patient, and various laboratory tests were made. As a technique in cardiac case-finding, the electrocardiogram was the best single device. Of all the cases of heart disease in this survey 65 per cent were detected from tracings obtained by using all 12 leads, and 57 per cent if only the three standard limb leads were taken; but of the presumably normal persons, 13 per cent would be erroneously suspected of possible heart disease by this technique. Heart disease was detected in 50 per cent of the diagnosed cases on the basis of answers to three of the questions in the questionnaire. Eighteen per cent of normal persons would also have been suspected of having heart disease by this case-finding device. Although the survey reported did not develop a simple cardiac case-finding technique, the data presented indicated that a questionnaire history-form, if judiciously used and evaluated, may be of value to physicians who examine large numbers of patients who are unwilling to submit to a complete cardiac evaluation.     

TRANSURETHRAL PROSTATECTOMIES—A Review of 560 Cases

Of 560 prostatectomies in an 11-year period on patients with benign or malignant disease of the prostate gland, almost 98 per cent were done transurethrally.Although many of the patients were considered to be in poor condition preoperatively, results achieved by the transurethral operation were excellent or good in 91 per cent of those who had benign disease of the prostate and in 84 per cent of those with malignant invasion. The rate of deaths attributable to the operation was 3.1 per cent in the group of patients with benign disease, 5.3 per cent in patients who had cancer.Complications, such as urinary incontinence, persistent pyuria, epididymitis, strictures of the urethra and of the meatus, and contracture of the neck of the bladder, arose in a surprising number of cases.     

TUBERCULOSIS CONTROL IN CALIFORNIA MENTAL HOSPITALS

Diagnosis, the first step in tuberculosis control, is accomplished in the mental hospitals of California by x-ray examination of all patients annually and of new or returning patients on admission. This routine has been carried on since 1937.Tuberculous patients with active disease are segregated in one of three specially staffed and equipped units at the Patton, Sonoma and Napa hospitals. Those in whom disease is likely to recur are likewise segregated for special care and observation. Those in whom disease is inactive or not definitely diagnosed are not segregated but are observed by physicians of the Bureau of Tuberculosis Control of the California Department of Public Health in collaboration with the staffs of the institutions.Since the establishment of this program the proportion of new or previously unrecognized cases of tuberculosis has been reduced from 0.83 per cent, a year after the program was begun, to 0.37 per cent, while recurrence or progression of previously recognized disease has been reduced from 12.3 per cent at the first survey to 5 per cent at the most recent.Overcrowding in all hospitals has been the chief obstacle to the success of the program.     

NEEDLE BIOPSY OF THE LIVER—General Considerations

Needle biopsy of the liver provides concrete diagnostic information that cannot be as readily obtained in any other way. This report reviews 401 liver biopsies in 312 patients.The major indications for use of this procedure are: To determine the cause of an obscure liver enlargement; to establish the cause of jaundice; to distinguish between malignant disease and cirrhosis of the liver; to determine when hepatitis has subsided; and to evaluate the results of treatment. At times, systemic disease that has not been recognized by other means may be diagnosed by this technique. There is risk in performing this test, and the 0.25 per cent mortality in this series compares favorably with that reported from other clinics. Where the diagnosis by biopsy could be compared with observations at operation or autopsy, the correct diagnosis was made by biopsy in 85 per cent of cases. Greater accuracy was obtained by two or more biopsic examinations in one case then by single biopsy.In several cases in which surgical operation was considered, biopsic information made it unnecessary, and vice versa.     

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.     

Needle biopsy of the liver; general considerations

Needle biopsy of the liver provides concrete diagnostic information that cannot be as readily obtained in any other way. This report reviews 401 liver biopsies in 312 patients. THE MAJOR INDICATIONS FOR USE OF THIS PROCEDURE ARE: To determine the cause of an obscure liver enlargement; to establish the cause of jaundice; to distinguish between malignant disease and cirrhosis of the liver; to determine when hepatitis has subsided; and to evaluate the results of treatment. At times, systemic disease that has not been recognized by other means may be diagnosed by this technique. There is risk in performing this test, and the 0.25 per cent mortality in this series compares favorably with that reported from other clinics. Where the diagnosis by biopsy could be compared with observations at operation or autopsy, the correct diagnosis was made by biopsy in 85 per cent of cases. Greater accuracy was obtained by two or more biopsic examinations in one case then by single biopsy. In several cases in which surgical operation was considered, biopsic information made it unnecessary, and vice versa.     

Operations on the adrenal glands

Various conditions of the adrenal gland are amenable to surgical treatment. Removal of a pheochromocytoma is almost always indicated when the tumor is diagnosed. The results of extirpation have been excellent in cases in which patients were operated upon before the onset of chronic hypertension. Removal of the "nerve cell" tumors of the adrenal is indicated if metastasis cannot be demonstrated. Hypofunction of the adrenal cortex may be partially alleviated by the repeated implantation of pellets of desoxycorticosterone acetate. Hyperfunction of the adrenal cortex causes a variety of clinical manifestations depending upon which of the numerous hormones are affected. Removal of a cortical tumor alleviates these symptoms. These tumors are malignant in more than 50 per cent of cases, and recurrence is frequent. Bilateral hyperplasia of the glands rather than a tumor may be present. In such circumstances, resection of 95 per cent of the adrenal tissue is effective in controlling the symptoms of the disease. Total bilateral excision of the adrenals is, at present, under investigation as a means of treatment for a variety of conditions.     

Cytologic Diagnosis of Gastric Cancer

Follow-up of cytologic examinations of specimens obtained from 187 patients by gastric lavage with saline solution, without the use of enzymes or abrasive devices, showed a false positive rate of 0.6 per cent and a false negative rate of 17 per cent.To achieve satisfactory results with such examinations, great attention to detail in obtaining, preparing and examining the specimens is essential. Cytologic examination should be done in any case in which gastric cancer is suspected clinically or roentgenographic or gastroscopic findings arouse suspicion.     

Microflora of gastric juice and its sensitivity to antibiotics in post-gastrectomy gastritis

Fifty four patients with postresection gastritis and 13 healthy adults were examined. 141 microbial cultures belonging to 33 species were isolated from the gastric juice of the patients. In the healthy persons 27 cultures belonging to 7 species were isolated from the gastric juice. In the gastric juice of the patients there predominated enteric bacteria and enterococci (64.8 +/- 6.5 and 57.4 +/- 6.7 per cent respectively). Among the enteric bacteria Escherichia coli and Proteus spp. were the most frequent. Contamination of the gastric juice by such microbes amounted to 10(5)-10(9) microbial bodies per 1 ml. The isolates were mainly sensitive to gentamicin (84.8 +/- 2.9 per cent).     

TREATMENT OF ASTHMA: Somatic and Psychiatric

Various conditions of the adrenal gland are amenable to surgical treatment. Removal of a pheochromocytoma is almost always indicated when the tumor is diagnosed. The results of extirpation have been excellent in cases in which patients were operated upon before the onset of chronic hypertension. Removal of the “nerve cell” tumors of the adrenal is indicated if metastasis cannot be demonstrated.Hypofunction of the adrenal cortex may be partially alleviated by the repeated implantation of pellets of desoxycorticosterone acetate. Hyperfunction of the adrenal cortex causes a variety of clinical manifestations depending upon which of the numerous hormones are affected. Removal of a cortical tumor alleviates these symptoms. These tumors are malignant in more than 50 per cent of cases, and recurrence is frequent. Bilateral hyperplasia of the glands rather than a tumor may be present. In such circumstances, resection of 95 per cent of the adrenal tissue is effective in controlling the symptoms of the disease.Total bilateral excision of the adrenals is, at present, under investigation as a means of treatment for a variety of conditions.     

Metastatic medullary thyroid carcinoma in sputum. A light and electron microscopic study

Medullary thyroid carcinoma (MTC) was diagnosed in a 43-year-old male by light microscopy, electron microscopy and immunohistochemistry. Five years after thyroidectomy, malignant cells with the typical cytologic and electron microscopic features of MTC were seen in his sputum, and extensive pulmonary metastases from MTC were subsequently documented at autopsy. Sputum examination is a useful diagnostic technique in patients with MTC in whom pulmonary metastases are suspected.     

Needle biopsy in diagnosis of prostatic cancer

Four methods available for the diagnosis of carcinoma of the prostate-digital rectal evaluation, prostatic smear, needle biopsy and open perineal or transurethral biopsy-were studied and correlated.One hundred ten patients with clinical indications of cancer of the prostate were subjected to needle biopsy and open perineal or transurethral biopsy. Seventy of the same patients had prostatic smear examination. Using the open perineal biopsy or the positive transurethral biopsy as the standard, the accuracy of prostatic palpation, prostatic smear and needle biopsy were obtained.A high degree of correlation (74 per cent) was demonstrated between digital rectal evaluation and positive surgical biopsies in both early and late cases. There were 17 false positive clinical diagnoses. The prostatic smear showed an overall correlation of 45 per cent when compared with the results of positive surgical biopsy. The overall accuracy of needle biopsy was 73 per cent. However, in the last 39 cases, including eight in which the carcinomas were of groups A and B (curable), the needle accuracy was 100 per cent. When there is clinical indication of malignant disease of the prostate, needle biopsy of the lesion is warranted and should be done before definitive or palliative treatment is undertaken.     

Application of the Macrophage Migration Inhibition Test to Screen Patients with Early Cancer and Obtain Prognostic Determinations of Cancer Treatment

A modified direct method of the macrophage migration inhibition test (MMIT) was attempted on a large number of patients with malignant or benign tumors. Results of the MMIT in almost all patients with benign tumors were negative except for those with hydatidiform moles, dermoid cysts and viral benign tumors such as verruca plana which were positive. The number of cases determined as false positives were exceptionally few. Conversely, about the half of the patients with malignant tumors were positive. The majority of negative cancer patients were confirmed pathologically to be advanced cases and, therefore, were postulated to have been immunologically unresponsive. The remaining false negative patients were diagnosed to be very early cases with their malignant foci too small to be effective antigenic stimuli. The MMIT was also performed postoperatively on some of the patients using autologous antigens, which had been preserved by freezing, for examination of changes in the per cent migration index. The results led the authors to conclude that postoperative repetitions of the test permitted them to tell that cancer cells had been completely eradicated or that a relapse might occur in the near future. Examinations of cross reactivity between tumor antigens revealed that such reactivity exists between cancer antigens and antigens originating in hydatidiform moles and that there is also a very strong cross reactivity between allogeneic cancer antigens regardless of differences in the organs of origin. This fact suggests that the present test is effective for the screening of preoperative patients with early cancer.     

SUBTOTAL GASTRIC RESECTION—An Appraisal of a Means of Treatment of Benign Peptic Ulceration of the Stomach and Duodenum

In a series of 400 cases of subtotal gastric resection for the treatment of benign ulceration of the stomach and duodenum, the mortality, morbidity and recurrence rate was acceptably low. Fifty-six per cent of the patients had a perfect result, 38 per cent satisfactory, and 6 per cent unsatisfactory. However, the postoperative nutritional status was sufficiently interfered with in a number of patients whose preoperative weight was subnormal that the routine adoption of 75 per cent gastric resection must be questioned. Vagotomy with either pyloroplasty or partial resection may prove to be the most valuable procedure for patients of this type. In properly selected patients, however, gastric resection is a rewarding procedure for both patient and surgeon.     

Subtotal gastric resection; an appraisal of a means of treatment of benign peptic ulceration of the stomach and duodenum

In a series of 400 cases of subtotal gastric resection for the treatment of benign ulceration of the stomach and duodenum, the mortality, morbidity and recurrence rate was acceptably low. Fifty-six per cent of the patients had a perfect result, 38 per cent satisfactory, and 6 per cent unsatisfactory. However, the postoperative nutritional status was sufficiently interfered with in a number of patients whose preoperative weight was subnormal that the routine adoption of 75 per cent gastric resection must be questioned. Vagotomy with either pyloroplasty or partial resection may prove to be the most valuable procedure for patients of this type. In properly selected patients, however, gastric resection is a rewarding procedure for both patient and surgeon.     

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.     

A SURVEY OF THE RESULTS OF TREATMENT OF GASTRIC CANCER IN SAN FRANCISCO

A survey was made of all patients treated for gastric cancer on the clinic services of the Stanford University Hospital during the 30-year period 1919 to 1948. During the last decade of the survey there were impressive gains in the surgical treatment of this disease. It was possible from 1944 to 1948 to do a gastric resection on half the patients seen with cancer of the stomach. Also, there was a pronounced decrease in resection mortality so that from 1939 to 1948 the mortality rate for subtotal gastrectomy for cancer was 3 per cent.The over-all five-year survival rate was discouragingly low—4.6 per cent. On the other hand, 23 per cent of those surviving gastric resection lived for five years.A survey of the management of carcinoma of the stomach from 1939 to 1948 was made in 11 general hospitals in San Francisco. A wide range of resectability and resection mortality rates was observed. The cases from these hospitals were combined with those from Stanford for the same period to form a composite group of 1,128 patients. Analysis of this group of cases from 12 representative hospitals in San Francisco showed encouraging trends toward higher resectability rates with a lower resection mortality.     

Use of bleomycetin in malignant testicular tumors and the problem of studying bleomycin analogs

The efficacy of the chemotherapy of 16 patients with metastases of malignant tumors of the testicle was studied. The chemotherapy included vinblastine, platidiam and bleomycetin. The latter was used in a dose of 10 mg daily intramuscularly or as long-term intravenous infusions. As a result of the treatment complete and partial regression of the tumors was observed in 5 (31 per cent) and 4 (25 per cent) patients, respectively. Leukopenia was the main side effect. By present the total doses of bleomycetin had amounted to 250 mg for 4 patients and to 300-350 mg for 7 patients. No signs of pulmonary toxicity were observed with the use of these doses. The problem of clinical studies of bleomycin analogs is discussed.     

Results of the clinical study of the antineoplastic antibiotic bleomycetin

Bleomycetin was applied to the treatment of 68 patients with common forms of malignant tumors. The objective therapeutic effect was observed in 21 patients (31 per cent). The frequency of the favourable therapeutic effects was the most significant in the group of patients with generalized forms of lymphogranulomatosis: objective remissions for 1 to 4 months and stabilization of the tumor process were attained in 12 (41 per cent) and 8 out of 29 patients, respectively, in 9 patients (31 per cent) treated with bleomycetin progression of the underlying disease was recorded. A less pronounced therapeutic effect (33 per cent of the remissions) was recorded in the patients with nonlymphogranulomatous lymphomas. The use of bleomycetin in 48 out of 68 patients was complicated by certain adverse reactions. Intravenous infusions of bleomycetin in a dose of 10-15 mg twice a week (the total dose up to 125 mg) may be recommended as the initial therapeutic regimen in the oncological practice. The trials have showed that bleomycetin made in the USSR has a sufficiently pronounced activity against lymphogranulomatosis and nonlymphogranulomatous lymphomas. In this respect it is not inferior to the bleomycin analog made in Japan.     

DICUMAROL AND QUINIDINE IN THE AMBULATORY TREATMENT OF CHRONIC AURICULAR FIBRILLATION

Thirty-three patients with chronic auricular fibrillation were treated with digitalis and quinidine and in addition were given Dicumarol® to reduce the risk of embolism. In 21 of the patients the fibrillation was caused by rheumatic heart disease, and in 12 by arteriosclerosis or hypertension. Normal sinus rhythm was restored in 55 per cent of the 33 patients, in 67 per cent of those with arteriosclerosis or hypertension, and in 45 per cent of those with rheumatic heart disease. Embolism did not occur.