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A definitive preoperative diagnosis is not readily available for the majority of patients with an enlarging thyroid gland or nodule, but thyroid needle biopsy yields an immediate, safe, and accurate histopathologic diagnosis. In a review of 460 patients having thyroid needle biopsy at the Cleveland Clinic from 1967 to 1976, sufficient biopsy material was available for diagnosis in 410 patients. In 44 patients operations were performed for benign disease for a variety of reasons. In 23 patients operations were performed for thyroid malignancy; in 14 of the latter group the diagnosis was made by needle biopsy and confirmed surgically. Of 9 other patients operated on for thyroid malignancy, 6 had thyroid surgery because needle biopsy showed a follicular neoplasm in which malignancy could not be ruled out, and in the remaining 3, clinical findings and the hypercellular nature of the biopsy prompted operation. In an additional 9 patients thyroid malignancy was diagnosed by needle biopsy, but no operation was performed (1 because of age and prohibitive cardiac risk, 2 because the cancer was metastatic to the thyroid from a separate primary, and 6 because the neoplasms were lymphoma or small cell undifferentiated carcinomas that were treated by radiotherapy). There were 3 complications in 460 biopsies (transient recurrent nerve palsy, hematoma, and local discomfort), all of which were short-lived and minimal. The true value of needle biopsy was that 393 patients with benign disease were spared unnecessary surgery. After a quarter century of experience with this technique, the authors propose that needle biopsy be used more often to eliminate the mortality, morbidity, and significant cost of unnecessary thyroid surgery, and the uncertainty and expense of less accurate diagnostic methods.

Ileostomy is the main cause of complications in the surgical treatment of chronic, nonspecific ulcerative colitis. The principal complication is ileostomy dysfunction (obstruction) in the immediate postoperative period. The importance of this complication cannot be overemphasized. In a review of 210 patients undergoing ileostomy, Warren and McKittrick1 reported that 62% of their patients had dysfunction. Of 37 deaths in that series, were attributed to dysfunction of the ileostomy and its sequelae and 3 others were thought to have been possibly related to ileostomy dysfunction. The number of deaths from ileostomy dysfunction was second only to the number of deaths from peritonitis. Today, with the decreasing incidence of fatal postoperative peritonitis, it would appear that the ileostomy itself constitutes the primary postoperative hazard.Our experiences with the ileac stoma have led us to believe that the construction of the conventional ileostomy violates a fundamental surgical principle, i. e., the vulnerable serosa of the ileostomy is left exposed. Inflammatory changes in the projecting ileostomy are

In Swiss mice, previously immunised with sarcoma 180, a second implant of the same tumour failed to establish itself. Treatment of such animals, during the period of immunisation, with rabbit antisera to mouse thymus, spleen (A.L.S.), and brain suppressed the development of immunity and permitted growth of the second tumour implant. The growth of the tumour, expressed as a tumour index (the average tumour weight multiplied by the proportion of mice with tumour take) was related to the immunosuppresive activity of a specific preparation of A.L.S. This experi- mental model offers many advantages in a study of the properties, purification, and mode of action of A.L.S.

It is the purpose of this paper to restate the principle of anoci-association as applied to surgical operations, to describe its application, and to present the results of operations by this method as compared with an equal number of operations performed by other methods.My argument assumes that physical action and emotional activity are only expressions of motor stimulation; it assumes that there are in every active animal and in man stores of energy which when released are expressed in motion or emotion; that when these stores of energy are consumed fatigue or exhaustion is produced. The stored energy of the body may be discharged by physical injury of sensitive parts of the body, by emotional excitation or by physical exertion.It is of highest importance to know that inhalation anesthesia does not prevent injury impulses from reaching the brain-cells and making them discharge their nervous energy, thus causing exhaustion

The experience in abdominal surgery in the great war may be discussed under the following headings: (a) comparison between the intestine of the average soldier and of the average civilian; (b) the factor of exhaustion—the effect of cold and wet; (c) the time factor; (d) the comparative effects of lesions of the solid and of the hollow viscera; (e) combined thoracic and abdominal wounds; (f) the phenomena and treatment of internal hemorrhage; (g) the prevention and treatment of shock, before, during and after operation; (h) the anesthetic factor; (i) the incidence of bronchopneumonia after abdominal operations; (j) retroperitoneal infections; (k) the treatment of peritonitis; (l) operative technic, and (m) comparison with civilian abdominal surgery. COMPARISON BETWEEN THE INTESTINE OF THE AVERAGE SOLDIER AND OF THE AVERAGE CIVILIAN Soldiers whose general condition had not been too greatly impaired by exhaustion from fighting, by wet and cold, or by shock or hemorrhage

Civilized man has many diseases and infirmities in common with primitive man and the lower animals— accidents of birth, irregularities of adolescence and nutrition, cancer, infections and infectious diseases. On the other hand, there are certain diseases such as hyperthyroidism, neurocirculatory asthenia, peptic ulcer, diabetes and other less clearly defined diseases that are peculiarly the lot of civilized man. One should expect to find, then, that the mechanism the disturbance of which produces these diseases would be the mechanism on which civilized man's characteristics depend. The one characteristically human organ is the brain; the rise of the brain and its dominance has won for man his place in nature. It is characteristic of civilized man that his life is projected on rational lines, that it is full of work and worry as compared with that of the lower races of man and the lower animals.One would expect, therefore, that

The literature of the work hitherto done to discover some blood test for cancer is presented by Richard Weil.1 The technic followed in our work at Lakeside Hospital is based on that in current use, modified to meet clinical requirements.I have heretofore reported for the American Society of Cancer Research our observations on hemolysis in malignant tumors. This is in the nature of a report of progress in our investigation. The technic has been greatly improved and now seems to be quite accurate. It is exacting, must be precisely done, and every step amply surrounded by checks and controls.Dr. D. A. Prendergast made the first series of observations, after which Miss Ora Lewis took all the responsibility of the technic for seven months and made many improvements during the period of her painstaking work. Dr. A. M. Tweedie has been carrying on the work since Miss Lewis'

Among the total of 2,169 operations for goiter which have been performed by my associates and myself, 1,020 have been for exophthalmic goiter.This statement at once suggests the query, On what basis were the cases of exophthalmic goiter differentiated from the other forms of goiter? Our rule has been to class as exophthalmic goiter every case in which, at the time of operation, there are symptoms of increased basic metabolism not due to any current exciting cause, and in which these symptoms are relieved or cured by diminishing thyroid activity. THE RÔLE OF THE THYROID IN EXOPHTHALMIC GOITER Among our cases we have seen no normal thyroids, hyperplasia being present in about 70 per cent.; most of the remaining 30 per cent. being adenomas, with a few colloid goiters (Marine, Graham).That hyperplasia is not a cause but a concomitant effect of exophthalmic goiter is shown by the following

The principal resources at present for the treatment of hemorrhage may be included in the following:(a) The administration of various fluids, such as normal saline, Ringer's or Locke's solution; (b) posture; (c) bandaging or other means of compressing the extremities and the abdomen; (d) stimulants.The effect of stimulants diminishes with the increasing gravity of the hemorrhage, and in every progressive case a stage is finally reached in which the anemic centers no longer respond. The heart muscle, however, retains much of its susceptibility to such drugs as digitalis, and may be functionally seriously damaged by the injudicious administration of this drug. Posture and bandaging may be considered together, as their aim is that of throwing as much of the diminished quantity of blood to the heart and the brain as is possible to help tide over the crisis. It is at once obvious that such measures are strictly

Technique.— The dog was given subcutaneouslythe dose noted. After waiting a certain time an anastomosis was made between one of his vessels (usually, for convenience, the external jugular) and an artery (carotid) of a donor, of equal or usually larger size. When this was perfect, the toxic dog was bled, usually from a femoral artery, as rapidly as possible, to complete exsanguination, and the transfusion was in no case started till cessation of respiration gave warning of the limit's being reached. When this occurred the blood was allowed to flow, under control, until the pulse returned in every case to a better quantity than before. The time taken in transfusing was usually about 15 minutes. (The venous anastomosis was made because more blood went into the donee by it.)The experiments were next varied in this way; instead of treating a toxic dog with normal blood, an exsanguinated normal dog was transfused from one which had been given the toxin subcutaneously some time previous, as noted below. To be sure of an excess of toxin the dose was doubled. The technique was the same, under ether with careful asepsis. The vascular anastomosis was made before the normal dog was bled. The time is calculated from when the dose was given till the transfusion was started. In the fourth experiment one donor (St. Bernard dog weighing 40 k.) supplied three small dogs one after another with sufficient blood.No further observations of these dogs were made. The paralyzed dog is certainly suggestive of diphtheritic paralysis. The dog lived for over a month in this paralyzed state, but when he died I was not informed and the body was buried.

In reviewing the records of 893 operations on the biliary tract and 331 operations on the stomach performed by my associates, Dr. Bunts and Dr. Lower, and myself, together with those performed by other surgeons at the Lakeside Hospital, we find that the clinical course of certain patients after gastric resections and after common-duct operations is similar in many respects. At the time of operation pulse and temperature are normal, but the patient is emaciated and sallow in appearance; his vitality is much reduced; his demeanor is melancholic and he is alternately possessed by hope and despair. After the operation his downward course and exit strikingly resemble the sinking and disappearance of the unwary traveler who has been trapped by quicksand.Statistics show that no clinic has ever reduced the mortality rate of any considerable series of resections of the stomach below 10 per cent., and the mortality rate of

IN THE field of cancer we have seen the emergence of many radical ideas about treatment. Most of them, like Lysenko's concepts of evolution, were soon forgotten. I refer to the routine use of radical total pneumonectomy for cancer of the lung, radical prostatectomy for stage I and II prostatic cancer, total gastrectomy for cancers of the distal part of the stomach, total thyroidectomy and classical radical neck dissection for all papillary carcinomas of the thyroid, and the extended radical mastectomy for medial quadrant cancers of the breast. I believe that the conventional radical mastectomy also will follow Lysenko's theory—on the path to oblivion.To me, the most disturbing part of Anglem's paper is his almost paranoid criticism of all who do not agree with him, especially his personal and bitter attack on Dr. Vera Peters. Fortunately, Peters' reputation can stand by itself, for it was she who first conceived

It is sometimes desirable to treat open wounds by application of penicillin solution. In cases when a penicillin saturated pack cannot be applied in such a way as to reach all the recesses or when the contour of the wound is such that it will not hold the solution, a device for sealing the entrance of the wound to retain the solution is of value.In patients with external biliary fistulas the constant saturation of the dressings with bile makes the patient wet and uncomfortable. The same is true in the case of fistulas of the small intestine, and in addition secretions digest the skin if it is not protected. There is often a need for a device which will collect the secretions and at the same time protect the skin.The need for some way to collect the fluid and protect the skin was quite urgent in the case of a

I have observed in cases having growing cancers that isodermic grafts of skin from husband and from son caused a marked local reaction, characterized by excessive exudation, edema, redness and finally by the complete break-down of the grafts, while autodermic grafting later was entirely successful.Tests in other cases were made by applying a single isograft alongside of autografts. In the cases thus far known to have at the time growing cancer, the isografts did not live. In other cases, we have not yet the final data. Histologic studies showed degeneration of the deeper cellular elements of the isografts. Nine cases were thus observed.

In a series of observations on the neurocytes of the cortex, the cerebellum and the medulla in shock, infection, Graves'disease, iodoform, strychnia and alcohol poisoning, these cells, principally in the fatal cases, showed a marked alteration in the nucleusplasma relation and in the size of the cell.In the infections, in Graves'disease, in iodoform poisoning and in shock, these changes while varying greatly were in some degree seen in most of the cells. In alcohol and strychnia poisoning some cells were extremely altered while others were but slightly or not at all changed. The changes were studied by counting and measurement and compared with the normal. Due allowance was made for the great variation in the normal. A study of a large series of normal animals served as a basis for comparison. For example, in the normal no cell showing destruction of the nucleus and nucleolus with rupture of the cell membrane was observed, while in the fatal cases from the various diseases studied, there were many such cells. The tissue was all taken fresh, much of it was taken during life and dropped immediately in the fixative solution.

ELSEWHERE in this issue of Elsewhere Journal, page 405, is presented a reasonable plan of treatment for asymptomatic thyroid nodules. The line of thought therein contrasts sharply with the opinions of some who believe (and can prove by statistics) that nodules in the thyroid are of no consequence. It contrasts also with the opinions of others who believe (and can prove by statistics) that all thyroid nodules should be removed. The author of the plan believes (and can prove by statistics) that some thyroid nodules should be removed and that others should not.The confusion of opinions and statistics in medical teaching is not limited to nodules of the thyroid. The treatments for gallstones, gastric ulcers, and polyps of the colon also have been subjected to the "all-or-none" principle. Yet to these and to many other problems there may be reasonable clinical and statistical approaches.Although it is not known

After exhaustion or shock due to the condition for which operation is performed; after starvation from cancer or obstruction; after hemorrhage from perforating ulcers, etc., or following the physiologic disturbance produced by an operation itself—for instance, resection of the stomach, of the gallbladder, of the intestine, etc.—the most common danger incident to abdominal operations is infection. In civilian surgery, the principal sources of abdominal infection are the appendix, the gallbladder, the tubes, ulcers, or the operation itself; while in military surgery, infection may be due to missiles, clothing, or the contents of the hollow viscera—especially the last.It follows that a consideration of methods of prevention and treatment of abdominal infection has a direct bearing on every type of abdominal operation. The scheme of treatment to be presented is based on a total experience in all types of operations of my colleagues Dr. F. E. Bunts, Dr. W. E. Lower

If we view man and the lower animals as adaptive mechanisms, governed by the universal laws of physics and chemistry, then we must believe that every phase of human or animal behavior is occasioned by and in turn occasions physical and chemical changes in the body. Therefore an understanding of the vast alterations in the behavior of the anesthetized organism— changes which may range from the slightest depression of mental power through progressively deeper stages of unconsciousness to death, necessitates a search for the physical and chemical changes caused by the anesthetic. Accordingly, in this study we shall consider (a) the gross behavior of the anesthetized individual in a consideration of the relation of anesthesia to normal sleep; (b) the influence of ether and of nitrous oxid on the histologic structure of certain organs; (c) the relation of ether and of nitrous oxid to the hydrogen-ion concentration of the blood

Drainage of the common duct presents three dangers: much bile is lost, cicatricial contraction occasionally occurs, and should the drain-tube be occluded, or even if it be not occluded, bile may escape into and infect the peritoneal cavity beyond the field of operation.Owing to an interesting physiologic fact, the loss of bile may become a serious danger—a danger which is usually overlooked—as normally the bile passes through the intestinal tract, and the bile-salts are reabsorbed, return to the liver, again become a constituent of fluid bile, and thus continue their circuit. The continuous loss of bile by drainage in a good-risk patient may cause no apparent damage, but in elderly subjects and in poor risks from any cause, the steady loss of bile-salts and of fluid may prove fatal. In gallbladder drainage the bile can be collected and, as Yates has suggested, may be returned to the bowel; but

In a recent survey1 made by a committee of the Ohio Chapter of the American College of Surgeons, with Dr. S. O. Hoerr as chairman, it was found that for the group of 29 hospitals regarded as being among the best in the State of Ohio the mortality for a total of 2562 elective operations for duodenal ulcer was 4.3%. Eighty-nine per cent of the operations were performed by Board-Certified surgeons or Fellows of the American College of Surgeons. This mortality occurred in the past five years and did not include deaths following emergency operations for bleeding or perforation. The highest reported mortality was 7.8% and the lowest 0%.Differences in mortality appeared to be mainly the result of differences in the types of operation employed. The state-wide mortality for elective gastric resection was 4.9%, whereas the mortality for operations exclusive of resection (mostly vagotomy with a drainage procedure)

Direct transfusion of the whole blood from immune dogs to dogs with actively growing, artificially implanted tumors has been carried out upon a series of six animals. The operative method of this transfusion is the same as has been used by one of us in a large series of experiments previously reported in the proceedings of this society.1In the first set of three, sufficient time has elapsed to determine the outcome, and we give below brief data of each experiment in this series.I. Dog 116. Planted Jan. 7, 1907. Tumors were first seen on Feb. 20; continued to grow slowly. March 20, transfusion experiment — dog was bled 400 c.c. and immediately transfused with 550 c.c. of blood from dog 244, in which implantation had occurred on Jan. 18th; tumors were first noticed on Feb. 6th, and had continued to grow until Feb. 20th, when they began to regress. Regression complete March 7th. Three days after transfusion, dog 244 was again planted with tumor. Four plants were made with positive results in three and tumors are growing at the present time. The immunity which dog 244 possessed as a result of the previous growth and regression of the tumors could not have been very marked. The effect of this transfusion upon tumors of dog 116 was negative, since they continued to grow until the death of the animal in a cachetic condition four weeks later.11. Dog I 25. Weight I 3 kilos. Tumors were planted Dec. 6th. All plants grew and continued to increase in size until the day of transfusion, March 20. On this day the dog was bled 500 C.C. and immediately transfused with the same quantity of blood from Dog 163. The latter animal had previously grown these tumors, but they had completely regressed. Repeated implantations failed to give tumor growth, and although the animal had the mange and was in poor physical condition, he was used for the donor in the transfusion.