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During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare. We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patient's own living tissue, retaining its blood supply and using it as an internal support. Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum. We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.

78 women whose diastolic blood pressure exceeded 90 mmHg were selected for the study. 19 of the group chose the IUD as a contraceptive measure (the control group) 33 chose the combination oral contraceptive Ovulen (1 mg ethynodiol diacetate/.1 mg mestranol 12 chose the progestogen minipill norgestrel .75 mg and 14 chose the progestogen minipill ethynodiol diacetate .25 mg. The IUD group consistently gained weight during the year of monitoring though the other groups showed varied increases. Increased blood pressure is often recognized in association with oral contraceptive use and estrogen is often regarded as a cause of hypertension. In this study women using the combination oral contraceptive and progestogen minipills evidenced a decrease in blood pressure. This difference was significant at p

There is a marked increase in the incidence of urinary tract stones in patients who have undergone intestinal bypass for obesity. Increased urinary excretion of oxalate is a regular finding in such patients. Taurine and cholestyramine did not influence hyperoxaluria in the two patients tested with each drug. In patients with small bowel bypass, caloric intake is an important factor in determining the magnitude of hyperoxaluria. We do not believe that the resultant susceptibility of these patients to renal calculi is a contraindication to intestinal bypass; however, it is a potential complication that should be considered preoperatively and brought to the attention of the patient.

Approximately 1,000 coronary bypass procedures were performed at New York University between February 1968 and December 1973. This report reviews all elective operations performed for angina between 1968 and 1972, a total of 448 patients. In this five-year period the percentage of diseased arteries bypassed rose from 40% to 84%, and operative mortality decreased from 28% to less than 3%. There were a total of 28 operative deaths, mostly from myocardial infarction and low cardiac output. Operability was nearly 95%. The only fixed contraindication was chronic congestive failure. Over one-half of the patients had an abnormal ventriculogram, and there was some history of mild congestive failure in nearly 20%. Elevation of left ventricular end-diastolic pressure above 20 mm before operation was associated with a higher operative mortality, but the late mortality was similar to those with a normal preoperative end-diastolic pressure. In 383 surviving patients, angina was eliminated or greatly improved in 86%, unimproved in 12% and worse in 2%. Late angiograms were performed on 201 patients, studying a total of 445 venous grafts with an overall patency rate of 71%. Graft occlusion was sporadic and unpredictable, but over 90% of patients with multiple grafts remained with at least one patent graft. A late myocardial infarction occurred in 32 out of 420 patients surviving operation, and was fatal in eight. The cumulative incidence over a period of five years was 17%. Twenty-three deaths occurred following discharge from the hospital. Life-table analyses showed a five-year survival of 77% when all deaths were included, and a five-year cardiac survival of 81% when non-cardiac deaths were withdrawn alive at the time of death. The expected survival in a comparable population group without coronary disease was 92%, while data published by Sones of patients treated without operation showed a five-year cardiac survival of 66%. Current operative techniques have an operative mortality of 2-3% and a subclinical infarction rate of 5-10%. The ideal graft is yet evolving, but data with internal mammary artery grafts are most encouraging. A future goal should be a five-year graft patency of at least 80%. Because many infarcts probably develop from a relatively small decrease in coronary blood flow, either during rest or mild activity, the likelihood that future data will demonstrate a marked increase in longevity with bypass grafting is great.

From 1948 through June 1971, 173 patients with squamous-cell carcinoma of the supraglottic larynx were treated by primary irradiation. The results were analyzed by staging of the primary lesions and specific extensions of disease. Primary irradiation of exophytic lesions of the supraglottic larynx offers a high control rate and preservation of the voice. Laryngectomy salvages a high percentage of the failures. In lesions of the suprahyoid epiglottis, moderate infiltration of the valleculae, although a cause of failure, is not a contraindication for primary irradiation as infiltration of the pre-epiglottic space is in lesions of the infrahyoid epiglottis.

Both medical and surgical therapy are available for the treatment of aortic dissection. To help determine which form of treatment is indicated for which patients, all cases of aortic dissection at the Peter Bent Brigham Hospital from 1963 to 1973 were reviewed. The most important feature in determining the patient's clinical status and response to therapy was the site of dissection, that is, the ascending or descending aorta. Of 31 patients with dissection of the ascending aorta, 26 had one or more of the following contraindications to medical therapy: congestive heart failure (8 patients), hemopericardium (8 patients), new aortic insufficiency (13 patients) or jeopardized carotid or coronary arteries (4 patients). Medical therapy was successful in only 1 of 9 patients with dissection of the ascending aorta; 17 of 22 patients having surgical correction of this lesion did well and were discharged. The clinical status of the 14 patients with dissection limited to the descending aorta was quite different. None had a contraindication to medical therapy. Medical therapy was instituted in all 14, and was successful in 6; dissection progressed in 8 patients despite medical therapy, and subsequent surgery was successful in only 2. We conclude that the treatment of choice for dissection of the ascending aorta is prompt surgical therapy. In patients with dissection limited to the descending aorta, medical therapy is usually feasible and often successful.

Children with severe rheumatic valvular insufficiency have a grave prognosis. Valve replacement in these patients is often delayed because of the fear of operating during the active phase of the disease. Four cases of successful valve replacement during active rheumatic fever (RF) are presented. Review of the literature revealed 5 additional cases. The relative risks of medical therapy and valve replacement are assessed in both active and inactive childhood rheumatic disease. Guidelines for selection of surgical candidates are discussed. We believe that active RF is not a contraindication to valve replacement; rather, in certain cases long-term survival following valve replacement during active RF is far better than long-term survival with medical management.

Methylmethacrylate was used adjunctively in the internal fixation of thirty-five pathological fractures and in sixteen patients in whom fractures were imminent. Effective fixation and stability were achieved after all procedures. Without the use of methylmethacrylate, twenty procedures associated with extensive destruction would not have achieved satisfactory fixation. Because stability of the osseous structure can be restored by the methylmethacrylate, extensive bone destruction is not a contraindication in the selection of patients. Relief of pain and functional improvement were rated as follows: good in thirty-eight cases, fair in six, and poor in seven. There were no failures of the fixation and no significant complications from the methylmethacrylate.

Eight cases of amebiasis complicated by an acute surgical abdomen and treated surgically are presented. An uncomplicated postoperative course followed early diagnosis and treatment whereas delayed diagnosis resulted in marked morbidity but no fatalities. Amebiasis, therefore, is not a contraindication to early surgery, but, if unrecognized, will result in marked morbidity and mortality.

A histological diagnosis was made in 166 (73%) of 227 aspiration needle biopsy procedures. In 45 (20%) no diagnosis was made on the aspiration specimen but was achieved at a later date by other means. In the remaining 15 (7%) no diagnosis was made by any means. Proven complications occurred in 51 biopsies (23%); none was serious. The risk of needle track implantation does not appear to be a contraindication to aspiration biopsy. Comparative results from aspiration biopsy and sputum examination are presented. The indications for aspiration biopsy are discussed. It appears to be a reasonably safe technique which yields valuable results in the investigation of thoracic lesions.

The presence of significant left main arterial stenosis has been considered a relative contraindication to OPCAB surgery. The development of newer techniques and an increasing understanding of the hemodynamic changes make the surgeons confident to perform OPCAB in patients with significant left main artery stenosis. Between January 2004 to March 2008, 145 patients with left main artery stenosis underwent OPCAB surgery at NICVD. Gradual adoption and integration of maturing heart surgery in fast years led to a trend towards overall improvement in CABG outcomes. Off-pump coronary artery surgery appears to be a safe and effective technique in patients with significant Left Main coronary artery disease. The postoperative morbidity and length of ICU and hospital stay are shorter. OPCAB could be an effective alternative to the conventional method CABG with same or better early results and is cheap and cost effective. The long-term results are to be evaluated DOI: 10.3329/bmj.v37i2.3592 Bangladesh Medical Journal 37(2) 2008 46-49

1. 1. The wide diversity of opinion on previous pelvic surgery as a contraindication to vaginal hysterectomy is summarized from the literature. 2. 2. Seventy-one additional cases are reported in which vaginal hysterectomy was undertaken following previous pelvic surgery. Failure to accomplish vaginal hysterectomy occurred in 2 of these patients. 3. 3. This series of cases confirms the existing evidence that vaginal hysterectomy after almost any type or extent of previous pelvic surgery is a practical and safe procedure. 4. 4. The concept is presented that previous pelvic surgery itself frequently provides an indication for rather than a contraindication to vaginal hysterectomy.

Since 1955 a number of conflicting reports have appeared concerning the efficacy of anticoagulant agents against cerebrovascular disease. Some of the variation of opinion has been caused by different concepts of what may be accomplished by the treatment and by the fact that clinical categories of strokes may respond differently to therapy. The evidence accumulated to date suggests that anticoagulant therapy may favorably influence the natural history of (1) impending stroke (intermittent focal cerebrovascular insufficiency, transient ischemic attacks), (2) advancing stroke, particularly in the vertebrobasilar system, and (3) recurrent cerebral embolization from a cardiac source. In most reports it is said that anticoagulant therapy is of no benefit when completed stroke is present and under such a circumstance may be unduly dangerous. Hemorrhagic complications continue to be a problem. Careful control of the degree of anticoagulation must be maintained; it may reduce the incidence of complications. Severe systemic hypertension, which cannot be medically controlled, appears to be a contraindication to longterm therapy.

1. 1. We do not feel that our conclusions can be final at the present time, but the results have been satisfactory enough to warrant the continued use of these drugs for a further time. 2. 2. This method of sedation can be given earlier in the course of labor than most methods in vogue up to the present time. 3. 3. Primiparous patients seem to respond more definitely than do multiparous. 4. 4. If one uses this procedure, he should be prepared to deliver the patient with outlet forceps at the termination of the second stage of labor. 5. 5. There is no contraindication to giving inhalation anesthesia to complete the delivery. 6. 6. There has been no harmful effect upon the mother or the child. 7. 7. These patients should be watched carefully at all times following the injection. 8. 8. The injection should be given by a person who is particularly trained in the administration of rectal medication. 9. 9. There was no evidence of the child suffering from either the injection of the drugs or the small amount of inhalation anesthesia given to the mother at the end of the second stage. 10. 10. Relaxation of the pelvic muscles seem to be better than under ordinary circumstances. 11. 11. There is a tendency, we believe, for slightly more bleeding than normal, but this has not been definitely proved. 12. 12. Protection of the buttocks and the perineum, particularly as small amounts of material is expelled, should be carefully done. 13. 13. Patients given this instillation can not be depended upon to cooperate during the second stage of labor because if not entirely unconscious, are mentally confused to the point of being irrational. 14. 14. The contraindications as listed above should be particularly stressed, and especially toxemia where the amount of liver damage is not definitely known, as the therapeutists tell us that the barbituric acid preparations are eliminated principally through this organ. 15. 15. In our limited experience this method of analgesia has proved satisfactory enough and not fraught with any danger, so that we will continue its use until a larger series has been collected.

Leopold Freund, who first used x-rays for therapeutic purposes (1897), was also the first to report the disappearance of inflammatory symptoms after x-ray treatment (1904). Thus, following irradiation for diseases of the hair, such as sycosis, the furuncles so often accompanying that condition cleared up without further treatment. As a rule, however, an exacerbation of the inflammatory symptoms, such as edema and suppuration, was observed before the hair fell out. This gave rise to the assumption that irradiation invariably leads to a greater or less increase of an inflammatory process, and the conclusion was drawn that the presence of inflammation is a contraindication to radiotherapy. Although observations to the contrary were repeatedly published, this attitude generally prevailed up to 1924, when Heidenhain and Fried, and also Pordes, reported their results, about which Holzknecht informed American radiologists in 1926. Since that time it has been known that x-rays are able to exert a favorable influe...

The results of chlorpropamide treatment of 100 diabetic patients observed for up to one year are recorded. The average initial dosage was 500 mg. and maintenance dosage 250 mg. The following conclusions are drawn: 1. Chlorpropamide is a potent antidiabetic compound capable of producing hypoglycaemic symptoms. In the present series it gave a good or excellent response in 71 per cent, of diabetic patients. With better co-operation a further 10 per cent, would have had similar control. 2. The main contraindication to this form of treatment irrespective of the patient’s age is the presence of ketonuria without infection. Disordered fat and glucose metabolism in “ juvenile type ” diabetes requires insulin treatment. 3. Severe obesity tends to produce refractoriness to chlorpropamide. 4. Weight gain in responsive patients is common and does not depend only on the diet. 5. No significant difference of response in the sexes was observed. 6. Toxic reactions sufficient to stop treatment occurred in two patients, one suffering allergic erythema and the other leucopenia. One patient had minor digestive upset. Reference is made to the literature regarding the results obtained by other workers and the incidence of toxic effects. Evidence from the literature relating to an anti-ketotic effect from chlorpropamide is presented.

ACTIVE bleeding, the threat of bleeding or bleeding in the immediate past remains the only definite contraindication to the use of artificial-kidney hemodialysis.1 2 3 Predialysis heparinization of the patient to prevent blood coagulation in the extracorporeal circuit is considered to be largely responsible for exacerbations of such bleeding. Therefore, a technic of "regional heparinization" of the dialyzer circuit was devised by Gordon et al.4 to reduce the threat of hemorrhage. This procedure consisted of the infusion of heparin into the blood leaving the patient and of protamine into the blood re-entering the patient. This permitted adequate anticoagulation of the blood in . . .

1.l. Data obtained in six patients with pulmonary stenosis and left to right intracardiac shunts of blood are presented. In four patients there were coexisting ventricular septal defects, and in two patients atrial septal defects were demonstrated. 2.2. The factors governing the direction of the intracardiac shunts in such patients include the degree of pulmonary stenosis, the degree of compensation of the right ventricle and, in those with associated ventricular septal defects, the degree of dextroposition of the aorta. 3.3. In the four patients with pulmonary stenosis and left-to-right intraventricular shunts, a possible relationship to the tetralogy of Fallot has been considered. 4.4. A predominant left-to-right intracardiac shunt in the presence of pulmonary stenosis should be evaluated as a possible contraindication to valvulotomy.

1. 1. Auricular flutter is a common result of quinidine therapy given for conversion of auricular fibrillation to normal sinus rhythm. 2. 2. The appearance of auricular flutter is in itself not a contraindication to continue quinidine therapy. In most instances if the dosage of quinidine is maintained or increased, conversion to a regular sinus rhythm will result. 3. 3. Cardiac enlargement and congestive heart failure in themselves are not contraindications to quinidine therapy. The danger of embolic phenomena remains a possibility, but since this occurs even more commonly if the auricular fibrillation persists, it cannot be considered a definite contraindication.

Local therapy with the sulfonamide compounds is of value in the prevention and treatment of certain infections which are of a more or less superficial nature. The sulfonamide compounds when used locally rarely cause toxic reactions. Their use apparently does not interfere with the healing of wounds. Sulfanilamide and sulfathiazole are the drugs of choice, and they need not be sterilized before use. Systemic use is indicated in the treatment of the more severe infections and as a prophylactic measure before the extraction of infected teeth in patients suffering from rheumatic heart disease (to reduce the possibility of the development of subacute bacterial endocarditis). The occurrence of a previous toxic reaction is the principal contraindication to the use of these drugs. Treatment is begun early and orally, if possible. A large initial dose and a smaller maintenance dose are given. Soda bicarbonate is administered simultaneously, fluid output must be above 1200 c.c. per day, and special diet is unnecessary. In severe infections the level of the drug in the blood is determined. Use of the drug is stopped when convalescence is well established. Toxic reactions of importance include nausea and vomiting, cyanosis, acidosis, drug fever, skin eruptions, anemia, leucopenia, jaundice, cerebral complications, and urinary tract complications.

Culdoscopy and peritoneoscopy are compared and the authors experience with 102 peritoneoscopies is presented. In culdoscopy the patient position is knee-chest the usual anesthesia used is a local one and a pneumoperitoneum is created spontaneously by air. In peritoneoscopy the patient position is lithotomy usually a general anethesia is used and the pneumoperitoneum is induced through carbon dioxide nitrous oxide or oxygen introduction. Indications for the procedures include infertility pelvic pain suspect tubal pregnancy and other obscure pelvic pathology. Contraindications for culdoscopy include fixed retroversion cul-de-sac mass prior culpotomy with extensive scar formation absent or rudimentary vagina vaginitis children and contraindication to the knee-chest position. Peritoneoscopy is contraindicated when there is technical difficulty in the introduction of either the pneumoperitoneum or the trochar and sleeve such as is found with extensive abdominal wall adhesions in the case of acute surgical abdomen with peritonitis ileus or intestinal obstruction and in patients with a medical contraindication to general anesthesia pneumoperitoneum or Trendelburg position. Peritoneoscopy is especially useful when culdoscopy is contraindicated as in 23 of the 102 patients in the authors series. In this series of peritoneoscopies complications occurred in 3 patients. Most complications reported in the literature have occurred while creating the pneumoperitoneum. Lysis of ovarian and tubal adhesions is performed easily by means of manipulating probe with cautery tip. Photography in color can be readily performed for proper documentation of findings at peritoneoscopy.

1. 1. The clinical data of sixty-four deaths from rupture of the uterus are presented; twenty-seven were spontaneous and thirty-seven were the result of trauma. 2. 2. In all but three cases, rupture took place in the lower segment of the uterus. The role of cervical scarring in the etiology of rupture is emphasized. 3. 3. Internal version is the most frequent cause and should be recognized as an extremely hazardous procedure under certain unfavorable conditions. 4. 4. That strong fundal pressure can rupture a uterus is shown by three cases in this series. 5. 5. Four deaths occurred from the use of pituitary extract during the first stage of labor. Despite this, the judicious use of minute doses in carefully selected cases of uterine inertia is advised. 6. 6. The diagnosis of rupture of the uterus is often not made sufficiently early for survival of the patient. Routine exploration of the uterus after traumatic vaginal procedures is indicated, especially if shock is present. 7. 7. The essence of adequate treatment for complete rupture of the uterus is prompt massive blood transfusion and hysterectomy. Shock is no contraindication to operation.

T HIS paper was stimulated in part by the interest displayed in the panel discussion of complications of anorectal surgery presented at the 1954 meeting of the American ProctoIogic Society. During that discussion there was reference to the inclusion of raw surfaces in hemorrhoidal surgery for the purpose of drainage, and the role played by raw surfaces in relation to postoperative pain. This report is flased on a five-year series of about 700 cases. The procedure empIoyed in these cases is best described as “anorectopIasty,” one purpose of \vhich is to eliminate raw surfaces. It has been stated that no one surgical technic so far devised assures a uniformIy satisfactory operative cure in all cases of complicated hemorrhoids. InnumerabIe technics have been proposed for the removal and cure of internal hemorrhoids; they probably far outnumber those described for any other invoIved field or organ. I wish to describe a technic for radica1 cure of hemorrhoids, and comment on its advantages and disadvantages. Also, the anorectal status of IOO cases subjected to the procedure wiII be reviewed, \vith reports of the condition from two months to one year after operation. This procedure is indicated for the removal of all types of internal hemorrhoids whether or not associated with rectal prolapse, anal ulcer or chronic anorectal infection. Uncomplicated anorectal hstufa in the presence of surgical hemorrhoids is not a contraindication. It is an elective procedure; however, it is contraindicated in acute prolapse with diffuse thrombosis. Preparation qf Patient. The operative site should be as free from inflammatory reaction as possible. The freedom from untoward reaction postoperatively is influenced in anorectal surgery, as in tonsil or gallbladder surgery, by the absence of infection at the time of operation. The patient is prepared for surgery by the use of a high protein and low carbohydrate diet, elimination of chemica1 irritants from the proxima1 gastrointestina1 cana and by Iocal appIication of bacteriostatic agents calculated to control any infection present. The period of preparation wiI1 depend upon the amount of apparent IocaI infection present and may rc

Alprenolol, a new beta adrenergic receptor blocking agent, was evaluated as an antiarrhythmic drug in 49 patients with 78 episodes of premature contractions or tachyarrhythmias of supraventricular or ventricular origin. A clinically and statistically significant reduction in frequency of premature contractions was obtained. In addition, a clinically and statistically significant reduction in ventricular rate occurred in those patients with tachyarrhythmias. No severe adverse effects were noted during the study. The results indicate that alprenolol can be used safely and effectively in the treatment of cardiac arrhythmias occurring during acute myocardial infarction. Congestive heart failure was not considered a contraindication when it was judged clinically that the arrhythmia aggravated the heart failure.

1. 1. Mesenteric adenitis is, in most cases, a non-specific inflammatory infection of the mesenteric nodes from a nearby or distant focus of infection, occurring most commonly in children during seasonal epidemics of upper respiratory infections, and strongly suggests appendicitis. 2. 2. The symptom complex of mesenteric adenitis is not pathognomonic, yet can be suspected by a thorough analysis and a finer interpretation of the order and quality of symptoms which differ from appendicitis. 3. 3. Exploration is both excusable and indicated when the abdominal pain is associated with mild or no constitutional reaction. Operation is contraindicated when the patient is acutely ill and the nasopharyngeal mucosa and the ear drums are deeply injected. Appendectomy either cures or helps in the retrogression of pathologic nodes. In most cases, the hyperemia induced by exploration exerts a beneficial effect upon the enlarged nodes. 4. 4. Biopsy is always a scientific asset, and there is no contraindication to its performance, except in suppurating nodes.

Pain is greatly relieved in 85 per cent of cases. In 5,800 analgesized labors we have observed no increase in asphyxia at birth or in the still-birth rate. There is no prolongation of the perineal stage or increase in forceps delivery. The only contraindication to the procedure is uterine inertia and the only restriction is not to start too soon. The woman should be in active labor; that is, pains every four to five minutes, lasting forty seconds by the watch, and in a primipara, preferably the cervix should have attained a dilatation of two or more finger tips. The mechanism of labor must be as closely followed by the obstetrician as if no analgesia were being employed. The drugs required—morphine, magnesium sulphate, ether, and quinine—are easily obtained and well known in their action. The quinine is found to be an essential ingredient in the rectal instillation formula. The applicability of the method is much greater than that of scopolamine amnesia. It can be used safely and effectively by the physician in home confinements and does not require the services of a trained anesthetist. We are assured that this is the safest and most effective manner of relief of the pain of childbirth over a period of hours that has yet been devised, and are convinced that it will abolish the most dreadful part of the ordeal of labor without danger to either the mother or her baby.

A preoperative study of symptoms and the operative results judged by the vision, fields, and tension on 143 eyes are presented. Ninety-five eyes had vision of 0.1 or more before operation and 48 had less than that amount of vision. An analysis of those cases in which the fields were constricted to within a few degrees of the fixation point is made, and the results show that such a constriction should be no contraindication to surgical intervention. The findings corroborate the results of Eerola, whose survey of the literature showed that late infections from all sources were only 1.8 percent and that the fear of this condition is exaggerated. From the Division of Ophthalmology, University of Chicago, Dr. E. V. L. Brown, Director. Read before the Chicago Ophthalmological Society, March 16, 1936.

Congestive failure has been considered a relative contraindication to antisyphilitic therapy in cardiovascular syphilis since the arsphenamine era, when severe reactions were reported following administration of this vasculotoxic drug. After having observed no severe reactions to penicillin in a series of patients with cardiovascular syphilis, it was decided to administer the antibiotic as initial therapy for individuals in congestive failure. This report summarizes observations on twelve such patients. There were no severe reactions during the course of treatment in the entire group. Digitalis and other measures to restore compensation were used concomitantly with penicillin. All the patients were improved upon completion of therapy. Case histories of 2 patients who died two months after treatment, are given. The significance of observations on the entire group is discussed.

An analysis of 400 patients surgically treated for acute perforation of gastroduodenal ulceration has been presented. Two hundred seventyseven patients were treated by immediate subtotal gastrectomy, with a mortality rate of only 2.2 per cent, while the mortality in 110 patients treated by simple closure was 10.9 per cent. During a period when immediate subtotal gastrectomy was used with increased frequency, the total operative mortality rate decreased. This led us to the conclusion that immediate subtotal gastrectomy is the treatment of choice for patients with acute perforated gastroduodenal ulceration, unless some specific contraindication exists, such as associated severe disease, presence of shock or purulent peritonitis. The follow-up results indicate that immediate gastrectomy has given good or excellent results in 87.3 per cent of seventy-three followed patients with benign disease.

BNORMAL uterine bleeding is a A problem frequently confronting the physician. Since accurate diagnosis is complicated and often burdensome for both the patient and the physician, there is a tendency to rely upon hormone therapy which often yieIds gratifying results. However, the indiscriminate use of injection therapy with a multiplicity of hormones is not without danger. 1 In spite of this injection therapy for uterine bleeding is becoming increasmglg popular with the physician. It is obvious that proper treatment can follow only when an accurate diagnosis is first estabhshed. To establish an etioIogic diagnosis in a case of uterine bleeding, a certain minimum of oflice procedure is required. A complete physical examination is the first essential Careful visual and manual examination of the peIvic organs is extremeIy important. Simple blood studies and a basal metabolic rate and other oflice laboratory procedures may be indicated. After the routine physical and gynecologic examination a number of patients wiI1 fail to show any adequate cause for the bleeding. Pelvic examination may be norma or unsatisfactory because of obesity, tenderness or v-oluntary or invoIuntary spasm. Some of these patients are investigated further with a diagnostic curettage. This procedure requires hospitaIization and anesthesia, is disturbing emotionalIy and may. be burdensome linanciaIly. It is possrbIe that a curettage, even when properly done, may not reveal the cause of the bleeding. (Fig. I .) It is not justifiabIe then, without further investigation, to attribute uterine bleeding to endocrine disturbance even when a pelvic examination fails to reveal any pathologic disorder. Because of these difliculties it was decided to investigate the possible advantages and feasibility of routine hysterography in patients with uterine bleeding. Contraindications. Hysterography is considered by many”” to be contraindicated in bIeeding because oil may be introduced through open sinuses or malignant cells may be diffused through the tubes into the peritoneal cavity. There have been reports ‘.‘) of oil emboli in the vessels of the broad ligaments and death from generalized embolization. These comprications occurred as a result of using an oily radiopaque medium in the procedure. In this study a non-oily radiopaque material is used calIed Rayopake. It is the diethanolamine saIt of 2,+dioxo-3-iodo6-methy tetrahydropyridine acetic acid, with 354 per cent concentration of polyvinyl alcohol. No iI effects were observed in our series and none have been reported. As wiI1 be noted below, smaller amounts of radiopaque material (I .5 to 3.0 cc.) are used. This diminishes the likelihood of dissemination of emboli.’ The objection may be raised that profuse uterine bleeding wouId make the intrauterine injection of radiopaque material impossible or untrustworthy. Experience in reading hysterograms wiI1 eIiminate this error. One of our most concIusive diagnoses (Case III) was made under just such circumstances. Contraindications to hysterography do exist. Most important of these is the presence of acute inflammation. Chronic inflammation is no deterrant since the amount of radiopaque material injected is sufficient only to outline the uterine cavity and there is IittIe opportunity for the spread of disease through the fimbriated ends of the tubes. Bleeding in possible early pregnancy is another contraindication but there have been reports of pregnancies going to term in spite of

1. 1. Always be seated to correct cleft lips and palates. 2. 2. Seasons of the year have no influence on the optimum time for operation. 3. 3. The future happiness of the child and the parents is made or broken by surgery. 4. 4. The baby is not to be operated upon before one or two weeks of age; it is not an emergency. 5. 5. The lip is to be closed first at about two weeks of age and the palate is to be closed in three to six months. 6. 6. The baby is placed in Trendelenburg position for operation. 7. 7. There may be lack of development of upper jaw in some cases. A denture or orthodontia ill compensate for this. 8. 8. Many serious conditions develop if the palate is closed at two years of age or older. 9. 9. Early closure of the palate (at three to six months of age) will prevent abnormalities of development. 10. 10. Early closure of palate is a “must” when a child has an associated otitis media or a micrognathia. 11. 11. Indications and contraindication for the wearing of a prosthetic appliance are as follows: The use of a denture is indicated (a) when a cleft cannot be closed surgically, (b) to close the nasopharyngeal space, (c) to restore vertical dimension, (d) to restore anteroposterior dimension, (e) to restore lateral dimension, and (f) to restore the occlusal plane. A denture is contraindicated in patients whose defect (a) can be corrected by orthodontia; (b) can be corrected by bridgework; (c) can be corrected by exercise; (d) has a possible chance of developing normally. 12. 12. Failure of palatal healing is not due to infection but to tension and destruction of blood supply. 13. 13. Suggestions for facilitating the technic of early closure are as follows: (a) use a suture in the tongue; (b) use a tongue depressor and elevator (“tongue controller”); (c) use a catheter and wire for administering anesthesia for repairing bilateral cleft lips; (d) use an aspirator instead of a sponge; (e) use the smallest atraumatic needle and suture; (f) cut sutures short on the knot or 1 mm. long; (g) leave the tongue suture in until the baby is fully conscious; (h) administer fluids and food as soon as tolerated; (i) administer penicillin for the first week; (j) administer sedation as required; (k) use an indwelling catheter for one or two weeks for feeding; (l) do not restrain the baby for inspection of the palate postoperatively; (m) have an aspirator in the room at all times; (n) use straight arm restraints during the healing period to prevent fingers from getting into the mouth; and (o) feed the baby with an ear syringe, medicine glass, teaspoon or plastic cup with a cover and spout.

Can the aging process be altered to prevent the pathologic changes that impair function? The matter should be put in proper perspective. This involves biologic and other forms of research as well as the therapeutic application of current knowledge. About 40 per cent of elderly patients under general hospital care are admitted for surgical treatment. In 1973, the total is expected to reach 2.5 million. Morbidity and mortality associated with surgery are highest among the elderly. However, with the use of new procedures and stress on the factors involved in proper pre- and postoperative care, the risk has been greatly reduced. Age-over-65 is no longer a contraindication to surgery. The matter of careful evaluation and treatment is discussed under the following categories: status of the patient, status of the various organs and systems (including the effect of trauma), elective versus emergency operations, and the prognosis, especially in relation to such disorders as biliary-tract disease, cardiovascular disease, cancer, and degenerative hip disease. Preoperative assessment must be thorough and complete. If the situation is not an emergency, there should be a period of corrective nutrition, activity, supportive medication, and instruction of the patient regarding what he may expect. For selective surgical procedures, the response to those measures determines the type of anesthetic and the extent and nature of the operation. The stress of the surgical procedure should never exceed the patient's tolerance. The immediate postoperative care (recovery room) is extremely important. The objective is to prevent complications. The experience of the surgeon, the cooperation of all involved, and meticulous attention to detail are required in the surgical care of the elderly.

Summary A series of ninety-four male patients over seventy years of age who underwent 106 inguinal hernia repairs is analyzed. Factors influencing transoperative and postoperative morbidity and mortality are evaluated. The results showed a 20 per cent incidence of postoperative complications with only 0.9 per cent mortality. A review of the literature dealing with morbidity and mortality of inguinal herniorrhaphy in geriatric patients is presented, supporting the proposed concept that elective repair of inguinal hernia in elderly patients has no absolute or relative contraindication. However, the morbidity and mortality increase greatly when surgery is performed under emergency conditions.

A review of 90 patients with carcinoma of the esophagus, treated at the Medical College of Virginia from January, 1961 through December, 1966, is presented.Factors affecting survival and symptomatic relief are discussed. The following points are stressed: (1) obstruction requiring gastrostomy before or during radiation therapy is a contraindication to starting or continuing radiation therapy due to the poor survival and lack of symptomatic relief; (2) the development of a tracheoesophageal fistula before or during the course of radiation therapy is a contraindication to further irradiation; (3) a tumor dose of at least 5,000 to 6,000 rads or above should be our goal whenever there are no contraindications; (4) palliative radiation therapy should be attempted to prevent esophageal obstruction when more radical therapy is not indicated; (5) in this series the addition of radiation therapy to surgery whether pre- or postoperatively did not significantly alter the cure or survival statistics.

The literature on the efficacy and dangers of steroids in herpes simplex infection is beset with inconsistencies. Corticosteroids constitute an absolute contraindication in herpes simplex keratitis as their exacerbating effects in this disease have been convincingly demonstrated (1-4). On the other hand, topical steroids for skin and mucous membrane herpetic lesions have not been established as either beneficial, inconsequential, or harmful (5). Nor have the local or systemic uses of steroids been conclusively incriminated as either potentiating herpes simplex infection or stimulating activity of the latent virus, despite expressed fears to the contrary. Stroud (6) showed exacerbation of herpetic lesions with increasing doses of steroids used systemically, but these were given to patients with an already defective immunologic system and degenerating condition, the ideal stage for any infectious process. In the herpes simplex infection following intracranial operations for trigeminal neuralgia, Burdick et al. (7) failed to demonstrate an effect on the incidence of this complication by topical application of corticosteroids preoperatively. Focal adrenocortical necrosis, often with adrenal insufficiency due to disseminated herpes simplex infection in infancy occurs (8-11), but with the reported irregularities of steroid effects in herpes simplex infections the clinician is in a dilemma as to the risks of corticosteroid therapy.

1. 1. No single anesthetic agent which is available at the present time is ideal for all operations upon the thyroid gland. 2. 2. In some instances, it is essential to avoid the psychic shock of operation under local anesthesia and in these cases, particularly in younger patients, a basal anesthesia is of definite advantage. 3. 3. It is inadvisable to subject elderly or debilitated patients to the depressant effects of either general or basal anesthetics. In these cases the postoperative course is smoother if the operation can be performed under local anesthesia with a minimum of gas oxygen analgesia. 4. 4. It should be remembered that the drug sensitivity of patients with hyperthyroidism varies with the basal metabolic rate and that patients with high rates tolerate larger doses of morphine and larger doses of the basal anesthetics than do those with normal or low metabolic rates. 5. 5. In patients who are poor operative risks and to whom it is not desirable to administer a basal anesthetic, yet whose temperament is such that psychic trauma should be avoided, it is important to have the patient become accustomed to the presence of the anesthetist and the gas machine before the operation. If this plan is followed, if the operation is performed in the patient's room, and if an adequate dose of morphine is given before the operation, the great majority of patients can be carried through the operation under local anesthesia without experiencing undue apprehension or discomfort. 6. 6. In young patients who are good risks, there is no contraindication to the administration of an adequate basal anesthesia, so that amnesia can make the operation an experience which can be looked back upon without unpleasant recollections. 7. 7. Avertin in doses of 60 or 70 mg. per kilogram of body weight or paraldehyde in doses of 1.4 c.c. per 10 pounds body weight is a satisfactory basal anesthetic for young patients who are good operative risks. Our preference is for avertin.

1. 1. Wound healing is impaired in the presence of a marked amount of sugar. 2. 2. I prefer a small amount of sugar in the urine in what we might call the “chronic” diabetic who has been operated upon. 3. 3. Preoperative care and preparation increases the recovery percentage. 4. 4. Careful selection of the anesthetic is essential. 5. 5. The preoperative and postoperative cooperation of the medical attendant reduces the surgical risk in the diabetic. 6. 6. The proper use of insulin, with glucose is responsible for a marked decrease in the mortality. 7. 7. Finally, diabetes is no contraindication to surgery.

Some recent findings, in respect of tuberculosis in Edinburgh, are presented and particular attention is given to the younger members of the population. It is recognised that Heaf grade I tuberculin reactors at school may not all have been infected by tubercle bacilli, and it has been thought that some might benefit from B.C.G. vaccination. The evidence given confirms the value of B.C.G. vaccination in the prevention of tuberculous disease in the community. Some Heaf grade I reactors have tuberculous disease, however, which is a contraindication to routine vaccination of this group. Another contraindication is that Heaf grade I reactors, as a whole, have acquired a degree of immunity to subsequent tuberculous disease, approximating that conferred on tuberculin negative children by B.C.G. vaccination, and possibly less likely to diminish as the years progress. Widening the scope of B.C.G. vaccination and employment of anti-tuberculosis drugs, might be advantageous and merits consideration.

Dermatologic side effects of Eugynon and Anconcen were studied in 50 volunteers for 7 months. Erythema and pigmentation sensitivity and sebum secretion increased during the 1st month of treatment and fell sharply thereafter. Sweat production was similarly influenced but did not decrease so sharply. About 1/3 of the subjects presented a slight loss of anagen hair at the beginning of the study but this was made up for later. Although vascular changes were noted they were very slight but consonant with the reported thromboembolic side effects; fluid retention on the other hand was on the order of 10%. Medical or family history of thrombosis or varicosis should therefore be considered a contraindication to the use of ovulation inhibitors.

1) Data has been presented on 30 cases with endobronchial tuberculosis in which pulmonary resection has been used as a form of treatment. Of these 30 cases, 12 were desperate risks and 18 were reasonable risks. Patients facing an early fatal course were considered as desperate risks. Any salvage in this group was considered as pure gain. /[See figure in the PDF file/] 2) The operative mortality in reasonable risks was 5.5 per cent and in desperate risks 58.3 per cent. 3) Tuberculous empyema and permanent fistula were eliminated as complications of pulmonary resection in all except one of the 19 patients treated after January, 1942, when individual ligation technique was employed and the bronchial stump was routinely reinforced with pleura. 4) Ulceration in the bronchial stump and contralateral spread were the most common complications and continue to challenge the thoracic surgeon. 5) Tuberculous bronchitis, either active or inactive, which must be traversed in doing a resection, is not within itself a contraindication. /[See figure in the PDF file/] On the contrary this complication often is an indication for resection. 6) Active tuberculosis in the lung to be resected, even if it is rapidly spreading, is not a contraindication to resection. In fact, delay may rob these patients of their only chance to get well. 7) A contralateral lesion in itself is not a contraindication to resection, unless this lesion is uncontrolled or uncontrollable.

Summary.— Data for 9 selected patients were used to show that rosacea-like dermatitis (RLD) is to be regarded as an intolerance reaction of seborrhoeic skin to topically-applied strong corticosteroids, such as betamethasone valerate and fluocinolone acetonide. A comparison of the geographical ranges of RLD and the use of strong corticosteroids shows that, in all countries considered, strong corticosteroids had been introduced long before RLD was observed. RLD can be cured by use of a powder suspension that is free from corticosteroids or fatty substances.

Necrotizing enterocolitis of infancy is a fulminating disease, not entirely restricted to the neonatal period, but with a predilection for the premature infant.Our review of the world literature and our own experience with 20 proven cases indicate that the roentgenographic findings have generally permitted accurate diagnosis. One or more of the following major roentgenographic findings were present in virtually all of the reported cases: pneumoperitoneum; pneumatosis intestinalis; portal venous gas; and small bowel distention. The colon was not usually distended unless it was extensively involved with roentgenographically apparent pneumatosis.The presence of pneumatosis on preliminary plain roentgenograms is an absolute contraindication to contrast enema examinations which are generally not needed to establish the diagnosis.The differential diagnosis from other pathologic processes is discussed.

Summary: 1 A series of 22 foetal transfusions performed in 16 patients over a period of 12 months is presented. 2 In infants hydropic at the first transfusion the procedure was of no benefit, all such infants dying in utero. Demonstrable hydrops is at present a contraindication to foetal transfusion. 3 Of 8 infants not hydropic at the first transfusion, 6 survived and were well at periods of 2 months of age and more. One developed hydrops prior to a second transfusion and one died in the neonatal period at 32 weeks after 3 foetal transfusions. 4 Amniotic fluid analysis is considered to be of the utmost importance in the selection of cases. 5 Some points in the technique are briefly discussed. No notable risks to foetuses so treated have yet been demonstrated. 6 The place of foetal transfusion in the management of pregnancy complicated by rhesus sensitization is discussed. Theoretically it should not be necessary in more than 1 in 2,000 pregnancies. Benefits accruing from the procedure are the saving of some babies poised between the risks of intrauterine death and neonatal death from prematurity, the drawing of attention to the prognostic value of amniotic fluid analysis by spectrophotometry, and an indication of the principle that it is possible to treat an infant in utero. 7 Any patient with rhesus sensitization whose amniotic fluid shows an optical density for the 450 mμ peak of above 0.20 between 28 and 32 weeks of pregnancy should be considered for foetal transfusion.

WHEN artificial-kidney hemodialysis is performed, the patient is ordinarily heparinized to prevent activation of the coagulation mechanism as the blood passes through the extracorporeal circuit. The use of this anticoagulant is largely responsible for the fact that active uncontrollable bleeding, particularly from the gastrointestinal tract, remains the only absolute contraindication to the use of the artificial kidney.1 2 3 4 In the first part of this report5 it was demonstrated that a very prolonged clotting time could be achieved in a part of the circulation without appreciably affecting the clotting time in the remainder of the circulation. One of us (E.R.S.) suggested that . . .

The management is described of a severe diabetic subjected to open heart surgery, with particular emphasis on the methods used to avoid metabolic acidosis. Diabetes is not a contraindication to open heart surgery using a high output pump; hypothermia with a low output pump is likely to cause a severe metabolic disorder due to the inability to utilize glucose. In cardiac patients who need 50 per cent dextrose intravenously it should be given slowly to avoid overloading the circulation due to its osmotic pressure.

A procedure of percutaneous renal biopsy in the prone position has been performed mainly following the Kark and Muehrcke's procedure with minimal modifications. This report was based on a study of first 133 instances of attempted percutaneous needle biopsy of kidney in 88 patients with various renal diseases. Fundamental problems on the clinical application of renal biopsy ; technique, diagnostic evaluations, influence on renal function, side effects and complications, indication or contraindication for this procedure, were investigated and methodology was discussed.

Age, exercise tolerance, preoperative pulmonary function and associated diseases were correlated with postoperative mortality and morbidity in a group of 75 patients undergoing pneumonectomy over a ten-year period. No patient who completed the standard exercise tolerance test experienced cardiorespiratory mortality or morbidity subsequent to pneumonectomy, Eight of 14 patients who failed to complete the exercise tolerance test experienced serious cardiorespiratory complications. There were no significant differences between patients who had uncomplicated pneumonectomies and patients who had complications as regards other measurements of pulmonary function. Ability to complete the exercise tolerance test is associated with a low cardiorespiratory morbidity and mortality after pneumonectomy. Failure to complete the exercise tolerance test is a relative contraindication to pneumonectomy. The exercise tolerance test should be used whenever feasible in routine evaluation of the patient preparatory to pneumonectomy.