Intrathoracic rupture of the spleen.

The case is reported of a 15-year-old girl who presented following trauma and was found to have a massive congenital diaphragmatic hernia through the foramen of Bochdalek. The spleen, which was intrathoracic, had ruptured. No other similar cases have been reported in the literature hitherto.

Congenital duodenal diaphragm in an adult: an unusual case associated with coeliac disease and recurrent peptic ulceration.

A case of congenital duodenal diaphragm in an adult is reported. A correct preoperative diagnosis of this rare condition was made. The duodenal diaphragm was associated with both coeliac disease and recurrent peptic ulceration, resulting in a complicated clinical course.

Ureteric obstruction due to sigmoid diverticulitis.

Two cases in which the ureter was obstructed by an inflammatory diverticular mass are presented. The difficulties of distinguishing such a mass from a carcinoma both clinically and at operation are emphasized. In order to minimize the risk of ureteric injury and to facilitate planning of the operative procedure, it is recommended that intravenous pyelography should be performed before resection of a suspected diverticular mass.

The effects of major and minor trauma on lymphocyte kinetics in mice.

The effects of major and minor trauma on the circulating white blood cell populations of C57BL mice were followed. The results showed that not only major trauma (nephrectomy) but minor injury and stress (e.g. injection, bleeding) triggered a highly significant fall (50-70%) in the number of lymphocytes circulating in the blood. The fall was a gradual one, with the maximal drop 2 h after the operation or handling procedure. Major trauma resulted in a fall in both B and T lymphocytes. Minor trauma produced a fall in B lymphocytes only. A 3-4 fold increase in circulating polymorph numbers also accompanied major trauma, but no increase was observed after minor trauma. The blood picture returned to normal generally within 24 h of both minor and major trauma. Repetition of the trauma stimulus after recovery led to a renewed trauma response. Bilateral adrenalectomy abolished the lymphocyte response to major and minor trauma and decreased the polymorph response to major trauma by more than 50%, indicating that stress hormones played a role in these changes. Studies with 51chromium-labelled lymphocytes, transferred into traumatized and adrenalectomized animals, suggested that decreased entry of lymphocytes into the blood (rather than increased exit from the blood into the tissues, or cell death) was the most likely mechanism of the lymphopenia following trauma.

Changing trends in breast carcinoma.

In view of the more open medical and public discussion of breast cancer, and considering the general dissatisfaction with radical forms of surgery and radiotherapy, we examined computer records of 1,014 patients with carcinoma documented by the Tasmanian Breast Survey between 1956 and 1976. In the two epochs, 1956 to 1966 and 1967 to 1976, there was a 14% increase in the proportion of patients presenting with Stage I carcinoma, and a 9% decrease in the proportion of patients with Stage II (P = 0.0075) but there was no change in the proportion of patients with Stages III and IV. The utilization of radical mastectomy decreased markedly, irrespective of stage (P = 0.0000), as did the utilization of radiotherapy (P = 0.0000). The mean age at presentation did not change significantly.

Primary sarcoma of the liver. Report of a case with excellent response to hepatic artery ligation and infusion chemotherapy.

A case of primary undifferentiated sarcoma of the liver in a 66-year-old woman is reported. The similarity of the presenting symptoms to those of a hepatic abscess is emphasized. The patient's response to palliative treatment by means of hepatic artery ligation and chemotherapy was excellent. We believe that this is the first report of such a response in a sarcoma localized to the liver. This therapy may well be useful in symptomatic patients in whom partial hepatectomy is not feasible.

A trial of 5-fluorouracil and Corynebacterium parvum in advanced colorectal carcinoma.

This study has confirmed that patients who have advanced colorectal carcinoma have impaired responsiveness to delayed-hypersensitivity skin testing, and also have elevated levels of serum IgM. Serial observations of delayed-hypersensitivity skin tests, total lymphocyte counts, T-lymphocyte counts, B-lymphocyte counts, and serum immunoglobulin levels failed to reveal any consistent pattern of responses in patients treated with either chemotherapy alone or chemoimmunotherapy. In 33 patients chosen at random to receive either 5-FU alone or 5-FU in combination with intramuscularly administered C. parvum, there was no evidence of objective response or influence on survival. Intramuscularly administered C. parvum, in the dose and schedule used, produced no evident immunologic or therapeutic effect.

Mesenteric lymphatic obstruction in Crohn's disease.

The lymphatic drainage of diseased and normal bowel was studied in 21 patients undergoing surgery for Crohn's disease. Mesenteric lymphatic obstruction was a consistent feature, identified in areas of small bowel macroscopically affected by Crohn's disease. This finding was also observed in some areas of apparently unaffected small bowel. Subsequent examination of these areas confirmed the presence of early Crohn's disease. This method of study may prove to be of value for determining the extent of operative resection in patients with Crohn's disease. Experimental lymphatic obstruction in animals failed to produce pathological changes of Crohn's disease, suggesting that this feature is an epiphenomenon and is not of primary importance in the pathogenesis of regional enteritis.

Chemoimmunotherapy in disseminated melanoma and colorectal carcinoma.

Non-specific immunotherapy with monthly intramuscular injection of Corynebacterium parvum has been investigated by randomized clinical trials in patients with advanced cancer. Thirty-six patients with disseminated melanoma were treated with either imidazole carboxamide (DTIC) alone or DTIC plus C.parvum. A 19% objective response rate was observed. The mean survival time was similar for both groups. Thirty-three patients with disseminated colorectal cancer were treated with either 5-fluorouracil (5FU) alone or 5FU plus C.parvum. No objective responses were observed. The mean survival time was similar for both groups. No advantage has been demonstrated in either tumour group by adding C.parvum to standard chemotherapy.

A trial of imidazole carboxamide and corynebacterium parvum in disseminated melanoma: clinical and immunologic results.

Nonspecific immunotherapy with monthly intramuscular (IM) injections of Corynebacterium parvum has been investigated in patients with disseminated melanoma. Forty-nine patients were randomized to receive either imidazole carboxamide (DTIC) alone or DTIC plus C parvum. A 24% overall objective response rate was observed, with no significant difference between the response rate or survival of the two treatment groups. Immunologic studies revealed no significant difference between the two groups. One patient undergoing chemoimmunotherapy demonstrated profound pancytopenia which responded to cessation of therapy, but toxic reactions were otherwise minimal. No advantage was obtained by adding IM injected C parvum to standard chemotherapy in the treatment of disseminated melanoma.

A search for a transmissible agent in Crohn's disease.

Controversy exists as to whether a transmissible agent is responsible for Crohn's disease. Previous reports have suggested that sarcoid-like granulomas can develop in animals following inoculation of homogenates derived from bowel affected by Crohn's disease. This study involved the injection of Crohn's tissue homogenates into experimental animals under a variety of conditions which might be expected to favour the demonstration of such an agent. Homogenates have been inoculated into the ileum of rats, mice, and rabbits and also given inoculated into ileum and footpads of rats which have previously been rendered lymphoedematous by surgical interruption of the draining lymphatics. Bowel homogenates from a total of 17 patients with Crohn's disease have been injected into 91 experimental animals. No macroscopic or microscopic changes indicative of Crohn's disease were detected. Thus study does not support the suggestion that a transmissible agent is present in Crohn's disease.

The immune competence of patients with inflammatory bowel disease.

Previous investigations of immune function in patients with Crohn's disease have yielded conflicting results. A comprehensive study of immune competence-peripheral lymphocyte count, serum immunoglobulin levels (IgG, IgA and IgM), lymphocyte response to PHA, Mantoux test, and DNCB response-has been performed in a large number of patients with inflammatory bowel disease. A total of 52 patients with Crohn's disease, 20 patients with ulcerative colitis, and 46 control patients with benign gastrointestinal disease were investigated. The patient groups were subdivided into ;well' and ;ill' in view of the differing clinical states of patients with inflammatory bowel disease. Some of the Crohn's and colitis patients were receiving steroid therapy. The peripheral blood lymphocyte count and lymphocyte response to PHA were similar in all patient groups. Serum IgA levels were elevated in Crohn's disease but fell significantly in ;ill' Crohn's patients following excisional surgery. Serum IgM levels rose significantly in ;ill' Crohn's patients after surgery. Steroid therapy was associated with diminution of both Mantoux and DNCB responses in the ;ill' Crohn's patients. There was no evidence of impairment of immune competence in either Crohn's disease or ulcerative colitis.

Clinical syndromes of mastalgia.

232 patients attending a breast clinic with breast pain as the primary presenting symptom were studied prospectively to define clinical syndromes and to attempt to elucidate aetiological factors. Those women in whom mastalgia was a minor aspect of their complaint, or who were primarily seeking reassurance that they did not have cancer, were excluded. Most mastalgia patients could be placed into well-defined subgroups on the basis of clinical, radiological, and pathological features. After excluding causes of pain arising outside the breast, six specific groups with widely differing aetiological bases were defined, leaving only 7% unclassified lithout known aetiology. The six defined groups were cyclical pronounced mastalgia, (believed to be hormonally based), duct ectasia. Tietze syndrome, trauma, sclerosing adenosis, and cancer. Psychological factors were found to be less important than has been previously suggested. Classification of patients with mastalgia into homogeneous subgroups is a prerequisite of any therapeutic study.

Cellular immunity in cancer: comparison of delayed hypersensitivity skin tests in three common cancers.

Cellular immunity was studied in three homogenous groups of patients with cancer to determine whether the pattern of depression of immune competence varied between solid tumours with different patterns of clinical behaviour. Delayed hypersensitivity skin responses were measured in patients with carcinoma of the breast, stomach, and colon and matched controls. Response to 2,4-dinitrochlorobenzene (DNCB) was used as an indication of primary responses and the Mantoux reaction as an index of recall responses. Responses were diminished in all three cancer groups, but there were significant differences between each type of cancer and even between different control groups. Cellular immunity was lost earliest and to the greatest extent in patients with colonic cancers and tended to be retained until a late stage in breast cancer, with gastric cancer occupying an intermediate position. Thus, while there was some degree of correlation between depressed immunity and prognosis our results gave no evidence that general host immune competence could explain the worse prognosis of gastric than colonic cancer. Paradoxical findings in patients with breast cancer suggested a great complexity in the host tumour interaction. Assessments of immune competence in cancer patients must be related to specific types of neoplasms with appropriate control groups if the results are to be meaningful.

Role of intragastric pressure, pH, and pepsin in gastric ulceration in the rat.

A method of continuous gastric perfusion with "artificial gastric juice" was used in a study of individual factors (intragastric pressure, pH, and pepsin) known to participate in the pathogenesis of peptic ulcers. This method allowed change of only one factor at a time, while the other two remained constant. The gastric mucosa of normal rats, fasted for 48 hr, was found to be resistant to the ulcerogenic effects of artificial gastric juice perfused through the stomach for 6 hr without increasing the intragastric pressure. Perfusion of hydrochloric acid (pH 1.3) under increasing pressure produced ulceration of the corpus as well as forestomach portion of the stomach. The degree of gastric ulceration paralleled increases in intragastric pressure, acidity, and pepsin proteolytic activity. Inhibition of pepsin activity by a pepsin inhibitor protected the gastric mucosa even at the very low pH of 1.3. These results demonstrate that under the experimental conditions used, hydrochloric acid alone in the absence of pepsin does not produce ulceration of the rat stomach.