Management of primary hyperparathyroidism in the elderly. M. A. Block, A. Xavier, B. E. Brush. / Amer Geriat Soc 23:385-389, 1975. Of 166 surgical patients for whom the diagnosis of primary hyperparathyroidism was established over a 20-year period, about one-third were over 60 years of age. For an additional 9 patients, no operation was advised, usually because of other life-endangering disease and the presence of only a mild degree of hypercalcemia without complications. In recent years, nearly 50% of the patients did not have renal calculi or osteitis fibrosa cystica; this was unrelated to age. Most of the patients with management problems were seen since 1965. Age alone was not a dominant factor in relation to serious complications from hypercalcemia, the presence of other critical disease increasing the risk of operation, or the development of major postoperative complications. The only death from primary hyperparathyroidism occurred in a 74-year-old patient who refused reoperation and died from an acute hypercalcemic crisis. A liberal, but selective, policy of surgical t r e a t m e n t is j u s t i f i e d for p r i m a r y h y p e r parathyroidism in the elderly. Patients for whom the diagnosis of primary hyperparathyroidism is established may be separated into three groups: those for whom early operation is indicated, those for whom operation should be delayed to permit recovery from other life-endangering acute disease, and those for whom operation is unjustified because of m in ima l uncompl i ca ted hypercalcemia and other serious disease greatly limiting life expectancy. These categories encompass all age groups and are not restricted to the elderly. All patients require periodic re-evaluation. Treatment of rheumatoid arthritis with gold. G. B. Bluhm. Semin Arth Rheum 5:147-166, 1975. The clinical benefit from gold therapy in rheumato id arthr i t is (RA) was first suggested by Forestier. Only recently have controlled evaluations of gold therapy, by objective and subjective clinical measurements, confirmed significant relief from joint swelling and pain, as well as improved function, in patients who received gold. Because gold salts can also reduce or arrest progression of rheumatoid joint disease as evaluated by x-ray, its continued use is appropriate for treatment until such time as prevention and cure of RA is discovered. From 1927 to 1975 a wealth of published reports about gold preparations, tissue distribution, mode of action, selection of patients, regimens for administration, clinical results, and drug toxicity has accumulated. Representative articles are cited for these points and used to outline a practical regimen of gold therapy for the patient with active rheumatoid disease. Guidelines for treatment are detailed in the article and wi l l hopefully permit the patient to reap the maximum benefit of gold therapy. Spontaneous closure of paravalvular leak after mitral valve replacement. W. Duvernoy, L. Gonzalez-Lavin, and D. T. Anbe. Chest 68:102-104, 1975. F. C. Complications after prosthetic valve replacement may be multiple. In biologic valves, valve detachment and cusp perforation may occur. If this is of significant magnitude, reoperation may be required. This report describes recurrent mital regurgitation after mitral valve replacement with a Hancock porcine xenograft. The regurgitation subsided spontaneously three months later. We felt that a paravalvular leak closed, with progressive fibrosis and tightening of the annulus. Functional results in this patient were excellent. Diagnosis and management of the common congenital cardiac defects. G. M. Folger. Mich Med 74:623-633, 1975. The neonate with symptomatic heart disease presents a challenge to the pediatrician, neonatologist, and pediatric cardiologist. Proper care, including prompt diagnosis and surgical management where indicated gives this infant, although desperately il l, significant chance to survive. Often there are no sequelae associated with the condition or its treatment. This communication out l ines the maneuvers in recogni t ion of the stressed newborn and the differentiation of pul-

In a 1973 study of 200 aged patients with groin hernias, a comparatively high incidence of the type known as sliding hernia was noted. The present study of 60 patients over age 70 seen at the Henry Ford Hospital between the years 1940 and 1972 was devoted specifically to the problem of sliding hernias. The threat of bowel strangulation is often advanced as a reason for the operative repair of such hernias, but this complication is rare. Bowel dysfunction, constipation and local discomfort are far more common, and gave rise to annoying symptoms in 75 percent of the patient studied. Barium enema x-ray examinations often revealed some degree of bowel obstruction. Most often the sigmoid colon the left side and the ileocecal segment on the right side constituted the sliding components of the hernia; the bladder was involved less often. Repair of 62 sliding hernias in 60 patients was performed successfully. There were no deaths, and only one recurrence of the hernia.

Of 166 surgical patients for whom the diagnosis of primary hyperparathyroidism was established over a 20-year period, about one-third were over 60 years of age. For an additional 9 patients, or operation was advised, usually because of other life-endangering disease and the presence of only a mild degree of hypercalcemia without complications. In recent years, nearly 50 per cent of the patients did not have renal calculi or osteitis fibrosa cystica; this was unrelated to age. Most of the patients with management problems were seen since 1965. Age alone was not a dominant factor in relation to serious complications from hypercalcemia, the presence of other critical disease increasing the risk of operation, or the development of major postoperative complications. The only death from primary hyperparathyroidism occurred in a 74-year old patient who refused re-operation and died from an acute hypercalcemic crisis. A liberal, but selective, policy of surgical treatment is justified for primary hyperparathyroidism in the elderly. Patients for whom the diagnosis of primary hyperparathyroidism is established may be separated into three groups: those for whom early operation is indicated, those for whom operation should be delayed to permit recovery from other life-endangering acute disease, and those for whom operation is unjustified because of minimal uncomplicated hypercalcemia and other serious disease greatly limiting life expectancy. These categories encompass all age groups and are not restricted to the elderly. All patients require periodic re-evaluation.

ABSTRACT: A survey was made of the records of 200 patients (158 men and 42 women) aged 70 or older who had undergone repair of groin hernias. In the aged women, femoral hernias were the most common; indirect hernias were seen much less frequently, and there were no direct hernias. In the aged men, large indirect sliding inguinal hernias and simple indirect inguinal hernias were the most common; direct inguinal hernias were seen less frequently than expected. The most serious and easily overlooked complication of hernia, particularly in old women, is bowel strangulation in association with femoral hernia. The operative procedures were individualized and varied. Local anesthesia was used for all poor‐risk patients and was the method of choice in 185 of the 200 patients. A 1% solution of chlorprocaine was the preferred anesthetic agent.The important complications included wound infection in 7 cases and seroma in 7 cases; infection occurred most frequently in association with gangrenous bowel in the hernial sac. As would be expected, urinary‐tract complications were common since nearly half of the men had benign prostatic hypertrophy. One death occurred in the immediate operative period (third postoperative day) from a cerebrovascular accident. Other deaths after postoperative intervals ranging up to fifteen years were caused by concurrent diseases and seemed unrelated to the hernial operation. The postoperative recurrence rate for hernia was 2 per cent. Surgical repair of groin hernia in aged patients can improve the quality of their lives, and in certain cases (e.g., bowel strangulation) can be a life‐saving measure.

ABSTRACT: Postoperative pulmonary complications are a serious danger to any patient who undergoes surgery. The increase in geriatric surgery has brought into focus certain marginal factors that can spell the difference between success and failure. In a series of 300 elderly patients who underwent major surgery at the Henry Ford Hospital, there were 34 in whom clinical and radiologic evidence of atelectasis developed. In 19 others, x‐ray examination of the chest showed various infiltrates suggesting pneumonitis, and sputum cultures grew coliform bacteria. Despite appropriate treatment, 5 patients died from postoperative pulmonary complications. Illustrative cases of hypoventilation, atelectasis, pneumonia and pneumothorax are presented. Recommendations are made for the care of the elderly undergoing major surgery, including the preoperative identification of chronic lung disease, determination of the respiratory reserve, preoperative exercises in deep breathing and coughing for use after operation, adequate oxygenation during the surgical procedure, close supervision of postoperative respiratory ventilation for the first seventy‐two hours, selective use of mechanical respiratory assistance, and emphasis on early ambulation.

ABSTRACT: Many patients with the complications of peptic ulcer disease are in the geriatric age group. This is partly the result of the overall increase in this segment of the population in recent years, and partly the result of delay in the referral of younger patients with intractable forms of the disease. Hemorrhage is the most common life‐threatening manifestation of peptic ulcer in the geriatric patient. Prompt evaluation by esophagogastroscopy and barium x‐ray examination is of paramount importance in proper management. Perforation of peptic ulcer is less common in the elderly. When diagnosed, it requires immediate surgical treatment. Pyloric obstruction should be suspected in a patient with chronic nutritional depletion, superimposed acute dehydration, electrolyte imbalance and even shock. Nasogastric decompression of the dilated stomach and re‐establishment of fluid and electrolyte balances should be attended to before carrying out definitive surgical treatment.Geriatric patients tolerate major surgery relatively well, but only if special attention is given to associated medical and metabolic abnormalities. Chronic obstructive lung disease with diminished pulmonary reserve is among the most common of these associated disorders. The prevention of serious pulmonary complications demands aggressive management both before and after operation for peptic ulcer. Diminished cardiovascular reserve must be taken into account if postoperative congestive heart failure or pulmonary edema is to be prevented. The presence of renal disease also should be evaluated as a factor in postoperative complications.

ABSTRACT: Gastrointestinal hemorrhage in the elderly is described under the headings: 1) a single episode of hematemesis, melena or rectal bleeding, 2) active persistent bleeding, 3) slow persistent bleeding, and 4) periodic bleeding. Illustrative cases are presented. Although the signs and symptoms are sometimes misleading, a careful history and examination will suggest the diagnosis in 70 per cent of cases. However, sometimes it is very difficult to locate the bleeding point preoperatively. Endoscopy, radiography and angiography are valuable aids. Initially, it is important to learn whether the hemorrhage comes from the upper or the lower gastrointestinal tract, as the selective diagnostic and surgical procedures differ. In all cases the effective management of major gastrointestinal hemorrhage requires rapid identification of the source of bleeding.

1Henry Ford Hospital, Detroit, Michigan Read at the meeting of the American Proctologic Society, New York, New York, June 11 to 14, 1972 Department of General Surgery Department of Gynecology and Obstetrics

ABSTRACT:The surgical complications of biliary‐tract disease are discussed in relation to a study comprising 18 cases of cholecystoduodenal fistula, 6 cases of gallstone ileus, and representative cases of gallstones, pancreatitis and suppurative cholangitis. The average age of the patients was 67 years. The findings led to the following conclusions: 1) age is an important factor in the increased risk in these complicated cases, but with careful management, surgery can be successful; 2) acute cholecystitis usually can be treated conservatively in aged patients, but all too often the patients ignore the recommendation for an elective operation and are later admitted to the hospital with complications that demand emergency surgery; 3) this sequence of events applies particularly to patients with biliary calculi, who should undergo an elective operation before more serious complications develop. Had our patients been operated on earlier, the surgical risk would have been minimal and the complications would have been prevented.

Femoral hernias occurred in 216 patients in a period of six years, with an overall recurrence rate of 6.5%. The McVay repair, used in cases of strangulation, incarceration, and recurrence, as well many routine cases, was performed upon 101 patients; the McVay Moschcowitz repair was performed upon 23 patients. There were nine recurrences (7.3%) after these two operations. The Moschcowitz repair was performed 46 times with four recurrences (9%). The Bassini operation or lower approach was utilized 44 times in uncomplicated cases, with a recurrence in only one patient (2.3%). We feel that the McVay repair has given the best overall results. The Bassini repair is recommended in selected cases.

Swelling of the arm following radical mastectomy may become severe, painful, and quite disabling. The problem has been with us since the beginining of radical breast surgery. It was thoroughly studied by Halsted,1and his observations and opinions on the subject remain a classic to this day. He observed that in many instances, a year or more following the operation and without return of the disease, there would occur sudden or gradual swelling of the upper extremity. Halsted also studied patients with swelling of the arm in whom no surgery had been done, as well as those in whom late postoperative swelling accompanied a recurrence of the disease. In many instances when Halsted removed the axillary and supraclavicular nodes and resected a portion of the subclavian and axillary veins, no edema of the arm developed. He further observed that less difficulty occurred after skin grafting than after some plastic closures.

Since 1950, our laboratory has conducted a continuous program, directed toward the sterilization of blood and its components, against the hepatitis virus.1Out of 700 chemical, physical, and physicochemical agents evaluated with virus seeded blood and plasma, propiolactone (β-propiolactone; Betaprone) has consistently proved to be the most effective drug and ultraviolet the most suitable physical agent. The essential properties for this conclusion are: 1. Virucidal potency 2. Lack of toxicity of the final product 3. Best preservation of the physiological properties of the blood components 4. Lack of allergic reactions 5. The wide margin of safety between virucidal concentration and toxicity levels Various methods have been recommended for the sterilization of human plasma against the hepatitis agent. Since the hepatitis virus is not available for laboratory studies, data can only be obtained from those laboratory viruses which are more resistant to physical and chemical inactivation and from human volunteer