A series of 104 consecutive patients treated at the Massachusetts General Hospital between 1933 and 1978 for primary hyperplasia was reviewed. Early in this period (1933-1958) nine patients were treated by what was the considered subtotal resection (five with clear cell and four with chief cell hyperplasia). Hypercalcemia persisted in four cases; three from inadequate resection and one (case 170) associated with a fifth gland in the mediastinum that was removed at a second stage operation. Later (1959-1978), adequate subtotal resection, leaving 30 to 50 mg of viable hyperplastic tissue, was performed in 28 patients (7 with clear cell and 21 with chief cell hyperplasia). The operation was successful in 27 patients (96%). In one patient (case 442) subtotal resection failed, and hypercalcemia recurred, requiring a second operation. Sixty-seven patients in this series had excision of one, two, or three (but not more than three) glands. Of these 21 (31%) had persistent hypercalcemia after operation and required further surgery. Transient hypocalcemia occurred in 40 patients, permanent hypocalcemia in two. This study shows that subtotal resection, leaving 30 to 50 mg of viable tissue, is the surgical treatment of choice for primary parathyroid hyperplasia. It is effective in the great majority of patients. We have not found total parathyroidectomy with autotransplantation necessary and believe that it should be reserved only for selected cases.

Presentation of CaseA 44-year-old woman was admitted to the hospital because of a thoracic mass.She was well until five weeks earlier, when symptoms of a respiratory-tract infection developed. Fatigue and a nonproductive cough persisted. Ten days before entry she noticed an intermittent "weighty" sensation in the anterior portion of the chest that occasionally radiated to the back. An x-ray film of the chest, obtained elsewhere, was reported to show a large hilar mass. She was referred to this hospital.She had smoked 1 1/2 00BDackages of cigarettes daily for 30 years. During the year before admission she had . . .

Parathyroid hyperplasia of all four glands was found to be the cause of primary hyperparathyroidism in 85 of 557 cases seen at the Massachusetts General Hospital between 1930 and 1973. There were 66 cases of chief cell hyperplasia and 19 cases of clear cell hyperplasia that were grossly, microscopically, and ultrastructurally distinct. Although the clinical findings overlap, there are several differences in the signs and symptoms between these two forms of hyperplasia. Both types are treated by subtotal removal of all the parathyroid tissue. Removal of insufficient tissue has left residual hyperparathyroidism in 45% of those with chief cell hyperplasia and 11% of those with clear cell hyperplasia after what was thought to be definitive surgery. Postoperative hypoparathyroidism was found in 15% of the patients with chief cell hyperplasia and in none with clear cell hyperplasia. These findings further suggest that removal of three and one-half glands in the more than 86% of patients with one gland involvement (adenoma or carcinoma) as the cause of primary hyperparathyroidism is unwarranted.

An unusual case of primary hyperparathyroidism involving six parathyroid glands is reported. Despite markedly elevated parathormone levels, neoplastic features were not found. This patient also had ovarian dysgenesis and hypertrophy and clear cell appearance of the salivary glands.

A comprehensive program of therapy has evolved with collaborating roles for surgery, pathology, radiotherapy, and chemotherapy. Our experience includes 131 patients with breast cancer treated at the Massachusetts General Hospital since 1956 by limited excision of the cancer. The tumors of 10 patients were noninvasive or sluggishly so; the patients received no further therapy. Because of the invasive character of their tumor, 121 patients received heavy postoperative irradiation. In 12 of these 121, the irradiation has been followed by immediate and prolonged chemotherapy. It is too soon to judge the effect of the chemotherapy, but survival rates of those treated by limited excision and primary irradiation compare favorably with those of patients treated by radical mastectomy.

Presentation of Case First admission. A 38-year-old woman was admitted to the hospital because of recurrent renal colic and diarrhea.She was well until eight years previously, when renal colic developed, and bilateral nephrocalcinosis was found. Five years before entry a diagnosis of hyperparathyroidism was made at another hospital; two parathyroid glands were removed, and one contained an adenoma. Hypercalcemia persisted postoperatively. One year before entry she began to pass several watery stools daily. The renal colic and diarrhea persisted, and she was admitted to this hospital for evaluation.A dizygotic twin sister had recurrent nephrolithiasis and had undergone . . .

This study was undertaken to determine the amount and histologic appearance of the persistent thymic tissue removed post mortem from 20 patients over 60 years of age with myasthenia gravis. One patient died several days after thymectomy. No recognizable thymic tissue on gross examination was seen in any patient. On microscopic examination, 11 patients had no thymic tissue. The other nine patients, including the one with thymectomy, all showed marked involution of the thymus. No germinal centers were seen. The thymus glands of two additional patients, still alive after thymectomy at ages 62 and 70, showed similar findings. Marked involution of the thymus also was found in each of six elderly controls. Thymectomy is not likely to be effective treatment of the elderly myasthenic patient.

Presentation of Case*A 53-year-old man was admitted to the hospital† because of dyspnea.He was well until one year previously, when his exercise tolerance began to decrease, and he became progressively tired at his custodial job. Five months before admission he experienced the first of numerous episodes of hemoptysis; a dry cough developed and was occasionally productive of sputum that was streaked with bright-red blood. One month before entry an episode of hemoptysis was accompanied by sharp pain in the right side of the chest. The neck became stiff, and the temperature rose to 38.3° C. An x-ray film . . .

Most pathologists have been trained for years to immerse surgical specimens and viscera removed at autopsy in formalin, sometimes even before they are examined and dissected, to preserve their cell detail and configuration. The result is a colorless, hard, rigid, often unrecognizable specimen that bears no resemblance to the colorful, soft, pliable original tissue observed by the surgeon or the autopsy prosector. For teaching purposes, especially to undergraduate medical students, it is almost mandatory for the specimens to be fresh, as observed in the patient, and not in the preserved state. Unfortunately, only a few pathologists abide by this principle. . . .

Presentation of CaseA 73-year-old man was admitted to the hospital because of dyspnea.He was well until six years before admission, when he entered the hospital for a prostatectomy. Examination disclosed splenomegaly in addition to prostatic enlargement; no other abnormality was found. Routine laboratory studies were negative except that the differential count revealed 20 per cent atypical lymphocytes. After discharge the patient was seen periodically in the clinic. Three years before entry cervical lymphadenopathy was observed; splenomegaly persisted. A biopsy of an enlarged lymph node disclosed lymphadenitis.Five months before admission he came to the clinic because of fever . . .

Presentation of CaseAn 86-year-old woman was admitted to the hospital because of dyspnea.Twenty-seven years previously a basal blowing systolic murmur was heard. Eleven years before admission a calcified coin lesion in the upper lobe of the right lung was demonstrated on an x-ray film of the chest. Isoniazid was taken sporadically; no change in the lesion was seen. Six years before entry the patient came to the hospital because of weight loss. A Grade 2 systolic murmur was heard and was maximal at the lower left sternal border. An x-ray film of the chest (Fig. 1) showed cardiac . . .

Presentation of Case* First admission. A 42-year-old man was admitted to the hospital because of a heart murmur.Scarlet fever had occurred at the age of six years, and at 11 years a murmur was first heard. He had been well and vigorous until 10 years before admission, when he experienced fatigue and dyspnea while skiing at an elevation of 2000 meters. On return to an accustomed altitude he was free of symptoms and able to backpack with his family without difficulty. There was no history of rheumatic fever.The temperature, pulse and respirations were normal. The blood pressure . . .

Presentation of Case*A 50-year-old man was admitted to the hospital because of gastrointestinal bleeding.For more than 20 years he had experienced epigastric burning that was relieved by antacids. Fourteen years before admission he had an acute anteroseptal myocardial infarct, from which he recovered without incident. Hypertension was found and was treated with an unknown medication. Three years before entry pain developed in the back and in the left leg, and examination disclosed a pulsatile epigastric mass. An abdominal aortic aneurysm was resected, and the symptoms disappeared.Nine months before admission he began to pass maroon stools. He entered . . .

Presentation of CaseA 26-year-old married woman, gravida 1, para 0, was admitted to the hospital because of persistent flank pain.Eighteen months before admission she entered another hospital because of pain in the right lower quadrant of the abdomen. Three months previously a pregnancy test had been positive. Physical examination revealed an abdominal mass that arose 26 cm above the symphysis pubis. Marked tenderness and slight rebound tenderness were elicited over the abdomen, particularly in the right lower quadrant. No fetal heart sounds were audible. An abdominal exploration disclosed a right ovarian tumor, 21 by 15 by 7 cm, . . .