MULTIPLE MYELOMA—A Review of 26 Cases

Multiple myeloma is a rare, malignant disease of bone marrow which affects principally the vertebrae, ribs, pelvis and skull but may involve any part of the skeleton. Severe demineralization and destructive lesions of bones, producing severe pain and debility, are distinctive features. The disease is further distinguished by abnormalities of blood proteins and in some cases by the excretion in the urine of Bence-Jones protein, which seldom, if ever, is found in association with any other disease.X-ray examination is frequently helpful. In 22 of 24 cases (of a series of 26 cases) in which films were available, definite abnormalities were noted. Spontaneous fractures, particularly of vertebrae, are common.The diagnosis of the disease rests on the identification of the myeloma cell. This is best accomplished by aspiration of bone marrow. In several of the 26 cases in the series diagnosis was made by a neurosurgeon at the time of operation to relieve pressure on the spinal cord. The myeloma cell has a very characteristic appearance.In the present series the average duration of life after the onset of symptoms was only nine months. One patient, however, survived for at least ten years.     

THERAPEUTIC DONOR INSEMINATION—A Review of 440 Cases

Of 399 patients inseminated therapeutically with the semen of a donor, 303 became pregnant, the great majority of them within six months of the time inseminations were begun. The average number of inseminations was 6.2 and the average number of menstrual cycles over which they were carried out was 3.55. The greatest number of pregnancies occurred between the twelfth and the fifteenth day of the menstrual cycle.Seven patients had four pregnancies by this method, 17 had three and 59 had two.Emotional problems related to children of artificial insemination were far fewer than those associated with adoption.     

CARCINOMA OF THE THYROID GLAND—A Review of 106 Cases

In a review of 106 cases of carcinoma of the thyroid gland, it was noted that a solitary thyroid nodule is the most outstanding single physical sign in this disease. It should be investigated by biopsy of a specimen removed at operation. Patients and physicians were sometimes guilty of delay in this regard.Papillary carcinoma involved multiple foci within the gland in at least half of the cases and there was a high incidence of regional lymph node metastasis associated with this type.Doubt was cast on conclusions by other investigators that carcinoma of the thyroid rarely is lethal in patients less than 40 years of age.     

Diabetic Ketoacidosis—A Review of Cases at a University Medical Center

Twenty-five cases of diabetic ketoacidosis were studied retrospectively with respect to clinical characteristics and results of therapy. In this series (as with all 88 patients admitted in the last five years with a diagnosis of diabetic ketoacidosis) there were no deaths. Infection was found to be the most common precipitating event, documented by physical findings and cultures in one-third of these cases.In about two-thirds of the cases, electrocardiograms which were read as abnormal on admission reverted to normal after therapy.In all patients serum potassium levels decreased from admission values; one patient became symptomatically hypokalemic.Low serum potassium levels on admission and early vigorous bicarbonate therapy are emphasized as major predisposing factors of symptomatic hypokalemia. None of the patients had overt hyperosmolar coma, lactic acidosis or cerebral edema during therapy.     

Histoplasmosis—A Review of Three Cases Studied in San Diego County

Three cases of histoplasmosis, a disease seldom reported in California, were diagnosed clinically by the authors in San Diego County. It is probable that there is a higher incidence of this disease in California than is at present recognized.Travel history, histoplasmin skin testing and serologic studies for mycotic infection are important in the diagnosis. Cultures of secretions and biopsy material are of great value if positive; but negative cultures (at least in non-endemic areas) do not rule out the disease. Travel and migration to and from endemic areas present opportunities for this disease to constitute a diagnostic problem far from the geographic area in which the disease was acquired.Although usually benign, histoplasmosis may be severe in the acute state, may disseminate or may be chronically active and progressive. Amphotericin B is the only effective chemotherapeutic agent and it is usually reserved for these forms of the disease.     

Thyroid Storm—A Review of Cases at University of California,San Francisco

Retrospective study of the diagnosis and management of the 8 cases of thyroid storm in a series of 400 hyperthyroid patients led to conclusion that thyroid storm is a clinical diagnosis based on a life-endangering illness in a hyperthyroid patient whose hyperthyroidism has been severely exacerbated by a serious precipitating illness, and that storm is manifest by the symptoms of hyperpyrexia, tachycardia and striking alterations in consciousness. No laboratory tests were diagnostic of storm, and the underlying precipitating cause of thyroid storm was the major determinant of survival. Vigorous therapy must include blocking synthesis of thyroid hormones with antithyroid drugs, blocking release of preformed hormone with iodine, meticulous attention to hydration and supportive therapy, as well as correction of precipitating cause of storm. The blocking of the sympathetic nervous system with reserpine or guanethidine or with alpha and beta blocking drugs may be exceedingly hazardous and requires skillful management and constant monitoring in a critically ill patient.     

Atrial Septal Defect,Ostium Secundum Variety—A Review of 117 Cases

Atrial septal defect is one of the most common congenital cardiac lesions seen at most centers. Typically one notes on physical examination a pulmonic lift with associated right ventricular lift. Wide splitting of the second sound is assocated with a Grade II to III systolic pulmonary ejection murmur. Characteristically, the electrocardiograph discloses an incomplete or complete right bundle branch block.This lesion is often well tolerated into the third and fourth decades of life. Subsequently one notes progressive cardiac symptomatology and eventual inoperability due to fixed pulmonary vascular changes.Our experience would indicate this entity to be readily correctable with an extremely low morbidity and mortality. Good result can be anticipated in all age groups.     

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.     

MENINGITIS—A Review of One Year's Cases from an Active Children's Hospital Service

Fifty-six cases of bacterial meningitides, other than tuberculous, observed in a period of one year on an active children''s hospital medical service were reviewed. All age groups were involved but most commonly infected were patients in the first year of life. There was no inordinate incidence of infection with any one kind of organism in any specific age bracket, except possibly for infection with enteric organisms which in the present series occurred preponderantly in infants less than six months old. Meningococcus and H. influenza type B were the most common organisms; they were the infecting agents in 71 per cent of cases. Of the immediate complications noted, subdural effusions were the most common (23 per cent of this series). In all except two cases, effusion was resolved by multiple aspirations. In two cases craniotomy was done with good results. Ten electroencephalograms were made and all were abnormal. In most of the patients, multiple antibiotic and chemotherapeutic drugs were used, parenterally during the first few days of hospitalization and then orally as tolerated. Intraspinal therapy was not given. Four of the 56 patients died.     

PHEOCHROMOCYTOMA—A Report of 12 Cases

In a series of 12 cases of pheochromocytoma, 11 patients were clinically cured by operation and one died of malignant tumor.It has been reported that of patients presenting with hypertension, 0.5 to possibly 2 per cent will be found to have pheochromocytoma. This small group of patients will have a good chance of cure of hypertension by surgical removal of the tumor.Hypertension and manifestations of hypermetabolism are classically seen in pheochromocytoma, but these symptoms vary, and hypertension may be entirely absent.Hypertension which is no longer dependent on pressor amines may result after prolonged circulation of pressor substances in the bloodstream. The quantity and proportion of the pressor amines in the circulation are largely responsible for the variable clinical picture.The Regitine® test is an excellent screening test but is not absolutely specific for pheochromocytoma.The histamine test should not be employed in patients whose blood pressure exceeds 160/110 mm. of mercury, lest it set off cerebrovascular accident.A modification of the Garlock transdiaphragmatic incision that was used in the present series of cases affords unparalleled exposure and facility in the removal of pheochromocytoma.     

PROSTATECTOMY—A Survey of 2,000 Cases

A statistical analysis was made of 2,000 consecutive cases in which prostatic operations were done in the period 1947-1957 at the Southern Pacific General Hospital. The operations included transurethral resections as well as perineal, retropubic and suprapubic prostatectomy.The mortality rates were lowest for transurethral resection and highest for retropubic prostatectomy. Coronary artery disease and pulmonary embolism were the chief causes of death. It was generally felt that preliminary partial vasectomy previous to transurethral resection added very little to successful convalescence. Although distilled water was used routinely for irrigation during transurethral resection, there was no incidence of lower nephron nephrosis.The incidence of recurrence of prostatic obstruction was highest by far after transurethral resection.     

PRIMARY CARCINOMA OF THE GALLBLADDER—Review of 173 Cases

One hundred seventy-three cases of primary carcinoma of the gallbladder were analyzed. In the group studied they made 2.11 per cent of all malignant tumors found at autopsy and were found in 1.89 per cent of all cases in which operation was done on the biliary tract. There was no appreciable change in the incidence of this tumor at autopsy during the period studied (1918-1948) at the Los Angeles County Hospital. Sixty-eight per cent of the cases were in females. A particularly high incidence was noted in Mexican females.Upper abdominal pain, loss of weight, nausea and vomiting, jaundice, and palpable mass or enlarged liver were the most common clinical features. Approximately one-third of the patients in whom the lesion was found at operation and one-fifth of all the patients whose records were studied had a history of chronic gallbladder disease.All but two of the 38 patients operated on were dead or had clinical recurrence within two years. One was alive and well 12 years after cholecystectomy.The most common gross appearance, particularly at autopsy, was a large tumor mass replacing the gallbladder and radiating to nearby organs, particularly the liver. In about one-third of the cases the tumor was grossly limited to the gallbladder. Polypoid tumors occurred in only about 10 per cent of the cases and most of the tumors were diffusely growing adenocarcinoma. Perforation appeared in nine cases, usually with fistula to the gastrointestinal tract. All of the tumors were histologically adenocarcinoma, usually of simple glandular structure. No purely squamous cell growth occurred.Gallstones were found in 79.8 per cent of the cases.     

RUBELLA ARTHRITIS—A Study of Twenty Cases

Twenty patients, five males and fifteen females, who had rubella arthritis were observed for periods ranging from one to ten years after recovery.Rubella arthritis in these patients was characterized by polyarthritis associated with fibrositis, myalgia, paresthesias and muscular weakness. All of the male patients but only one-third of the females had involvement of the knee joints. The small joints of the hands were the joints most commonly affected in women. Post-rubella arthritis rheumatic symptoms, especially fibrositis, persisted for many months in almost half of the females, not at all in the males.The leukocyte content of the blood tended to be low and the erythrocyte sedimentation rate accelerated in the few patients in which determinations were done.Latex tests were performed in 17 patients. Ten of the 17 were studied with the three-stage technique of Hall. Results of inhibition tests were positive in 80 per cent of the patients with rubella arthritis studied who were tested within 18 months after the onset of illness. None of the patients tested 18 months or more after rubella arthritis had positive reaction.     

TETANUS IN CALIFORNIA—Epidemiology and a Review of 232 Cases

A study was made of records of the 232 reported cases of tetanus in California, from 1953 through 1958. Cases occurred in 30 of California''s 58 counties. Two-thirds of the patients lived in suburban and urban areas. Two-thirds of the cases occurred in persons over the age of 20 years. The incidence was twice as high in males as in females. Forty-seven per cent of the patients died, with the highest death rates being in persons over the age of 40 years.Sixty-three per cent of the injuries associated with these 232 cases occurred in the home environment and 17 per cent at the place of employment.Ninety-one per cent of the patients had never been immunized with tetanus toxoid, or if they had been immunized, had not received the booster injections necessary to maintain effective immunity. Nine per cent gave a history of having had one or more injections of tetanus toxoid within five years.