Donald D. Kozoll

Correlation of liver function and liver structure: Clinical applications

Abstract 1.1. An attempt has been made to illustrate the aid in diagnosis and management of liver diseases derived from the use of liver function tests and liver biopsy findings, and correlations between them. 2.2. The significance of a series of liver function tests and the indications and contraindications of liver biopsy in liver disease and other hepatomegalies are briefly diseussed. 3.3. Correlation between morphologic and functional findings helps in evaluation of liver function tests and reveals that most liver function tests give abnormal results in diffuse parenchymal diseases whereas in focal alterations, regardless of severity, none or only a few tests may be pathologic. 4.4. Based on morphologic and functional criteria, acute hepatic damage was subdivided into viral, toxic, biliary and purulent types; different forms in each group were illustrated by clinical, laboratory and morphologic criteria. The various forms of cirrhosis were similarly discussed. 5.5. The improvement in diagnosis of liver diseases derived from use of liver function tests and the additional help of liver biopsies is demonstrated. Liver biopsy also can be applied to the critical evaluation of therapeutic procedures in hepatic disease.

Progress in the treatment of acute appendicitis

Abstract 1. 1. The mortality rate for the removal of acute non-perforated appendices was well under 1 per cent, without significant improvement in recent years. 2. 2. A lowering of the mortality rate from 26.4 per cent to 13.9 per cent has occurred in the treatment of acute perforated appendices with appendiceal peritonitis; this is attributed chiefly to chemotherapy. 3. 3. The greatest improvement in the treatment of acute appendiceal abscesses occurred from non-operative intervention. 4. 4. The McBurney-McArthur muscle-splitting incision is associated with the lowest mortality rate; the closer the incision is made to the mid-line, the higher the mortality rate. 5. 5. Appendectomy with drainage of the peritoneal cavity was associated with the highest mortality rate. 6. 6. Appendectomy without drainage of the peritoneal cavity showed a much lower mortality rate than similar cases which were drained. 7. 7. Appendectomy with drainage of the wound (usually for a perforated appendix) showed a mortality rate slightly lower than appendectomy without drainage but a much lower incidence of wound infections. 8. 8. The surgical principles thought to be of value in the treatment of acute appendicitis are discussed in full detail.

Blood Chemical Changes Following Intravenous Administration of a Casein Hydrolysate to Human Subjects.

Summary Injection of 45 g of Parenamine intravenously at slow speeds produced an average plasma amino acid N rise of +4.9 mg per 100 cc during the injection with a return to normal in 2 hours. Rises to levels above 10 mg per 100 cc produced by rapid injection may be associated with nausea and vomiting. A progressive though slight rise in blood urea takes place during and after the injection, accompanied by increased urea excretion. Serum inorganic phosphate is lowered during the injection and returns to normal by the end of the injection. Only a negligible drop in CO2 combining power occurred during the injection. Intravenously injected glucose did not alter the curves produced by the amino acid injection.

SYMPTOMS AND SIGNS IN THE PROGNOSIS OF MASSIVELY BLEEDING GASTRODUODENAL ULCER.

Abstract Approximately 50 per cent of all patients with massive gastroduodenal ulcer hemorrhage bled from one to seven days before admission to the hospital. The others had bled repeatedly for periods of weeks or years. Those with a duodenal ulcer sought admission sooner than those with a gastric ulcer. There seemed to be no critical period in the duration of hemorrhage in our patients affecting mortality rates. Pain occurred at some period in the history of over 80 per cent of the patients bleeding massively, slightly more often in patients with gastric ulcers than in those with duodenal ulcers. The pain localized most often in the epigastrium. Radiation to the back was more frequent with gastric ulcers. Over one-third of the patients described a time sequence to the pain, and had a lower mortality rate than those who did not. The pain was improved in over 45 per cent of the patients; most effectively by alkalies, then by food in general, and then by milk. Relief of pain was experienced more often in patients with gastric bleeding; the mortality rates were significantly lower than in those with bleeding whose pain was unrelieved by such measures. Hematemesis occurred in over two-thirds of the patients. Repeated emesis was seen in three-fourths of those patients and was associated with increased mortality rate as compared to a single emesis. The vomitus most often was described as “coffee grounds,” then as “red blood,” then as “tarry blood,” and least often as “blood clots.” There was no substantial difference as to the color or character of the blood from a gastric or duodenal ulcer. Melena occurred in approximately 83 per cent ot the patients, just as frequently with gastric as with duodenal ulcer. The prognosis was the same with melena as with hematemesis. An antecedent ulcer history or complication was established in 58.0 per cent of patients with gastric ulcers, and 70.7 per cent ot those with bleeding duodenal ulcers; more than 50 per cent of these patients had these complaints over a period of one or more years, the actual length of time ran longer in patients with duodenal ulcer, but had little effect upon the mortality rate of either group. The mortality rate for patients with a positive ulcer history was significantly less than the 42.0 per cent of gastric and 29.3 per cent of those with bleeding duodenal ulcers who did not have a past history of ulcer. Intractable pain was the most frequent specific ulcer complication, followed by previous hemorrhage, previous ulcer operation, previous perforation, and previous obstruction; all of these complications occurred more frequently in patients with duodenal ulcers. Clinical symptoms of shock were noted in two-thirds of patients with bleeding gastric ulcers and in three-fourths of those with bleeding duodenal ulcers. Weakness was the most frequently noted of these symptoms, followed by fainting, collapse, sweating, chills and pallor. Shock alone did not adversely affect the mortality rate. Approximately one-third of the patients with hemorrhage from gastric ulcer had systolic blood pressures below 80 mm. Hg, as did approximately one-fourth of patients with hemorrhage from duodenal ulcer. Patients with gastric ulcers with systolic shock levels always had higher mortality rates than patients with duodenal ulcers at the same systolic pressures. The incidence of hypertensive systolic pressures was the same in those with gastric and duodenal ulcers, 6.9 per cent. This is considerably below the hospital incidence of hypertension and the anatomic evidence of cardiac hypertrophy in necropsies of patients with peptic ulcer hemorrhage. In this series, the mortality rate of patients with bleeding gastric ulcers with hypertension was 45.3 per cent and in those with bleeding duodenal ulcers with hypertension it was 22.3 per cent. The admitting temperature was a sensitive index of prognosis. Patients with subnormal temperatures and those with a fever in excess of 100 °F. had significantly higher mortality rates. A pulse rate in excess of 100 beats per minute was often noted and the effect upon the mortality rate varied directly as the degree of rise in pulse. Tachypnea indicated a grave prognosis in patients with gastroduodenal hemorrhage. The nutritional status of the patient was also a reliable prognostic sign. Patients who were well nourished, but not obese, had a better than average prognosis; this was seen more often in patients with duodenal ulcers than in those with gastric ulcers. Thinness, emaciation, and dehydration was seen more often in patients with gastric ulcers; in this group, the mortality rate was higher. Physical signs portending a grave prognosis were: distended abdomen, poor oral hygiene, rales, emphysema, cardiac enlargement and hepatomegaly. Abdominal tenderness, most often epigastric, was present in approximately 50 per cent of the series of patients and was without discernible influence upon the mortality rate.

Effects of surgery on morbidity and mortality in acute gastroduodenal perforations

Abstract 1. 1. Patients benefiting from ulcer management at some time prior to perforation experienced a significantly lower mortality rate. 2. 2. Intensive conservative therapy prior to delayed operation for perforation, or instead of it, was associated with mortality rates above 50 per cent. 3. 3. Delay in surgical consultation for perforation beyond three hours was identified with a progressively rising mortality rate. 4. 4. The promptness of performing the operation was more important than the experience of the surgeon. 5. 5. Spinal anesthesia was associated with the lowest mortality, general anesthesia was intermediate and local anesthesia was the highest. 6. 6. The duration of operation, except for the poor risk patients, had no effect upon the mortality rate. 7. 7. The need for blood transfusions, prolonged intragastric siphonage and oxygen after operation for perforation was associated with increased mortality rates. 8. 8. The most frequent postoperative complications were fever, wound infection and pneumonia. The most lethal complications were peritonitis, shock and hemorrhage. 9. 9. Although the incidence of postoperative fever, pneumonia, peritonitis, abscess and wound infection decreased in 1946 to 1955 to a fourth its incidence in 1936 to 1945, the mortality rate of those patients in whom complications were still developing, actually rose from 25.3 per cent to 39.4 per cent. 10. 10. Approximately 26.7 per cent of the survivors of perforation of a peptic ulcer in this series of patients, further ulcer complications developed requiring readmission. 11. 11. Subsequent operation was required in 25 per cent of the survivors of peptic perforation. 12. 12. Generalized peritonitis was the cause of death in 75 per cent of patients; the three next most frequent causes were pneumonia, intra-abdominal abscess and hemorrhage. 13. 13. The introduction of sulfonamides resulted in a decrease of infectious complications, particularly in patients with duodenal perforations. Penicillin and streptomycin brought further improvement. A small but significant increase in the incidence of these infections was seen in the last three years of this study.

Studies of Pectin Administration to Patients Not in Shock.

Conclusions Pectin solution is a effective hemodiluting agent in patients not in shock. It lowers total plasma protein, hematocrit, hemoglobin, and plasma non-protein-nitrogen. It raises the venous and arterial pressure slightly and the sedimentation rate of the erythrocytes markedly.

Factors in the etiology and management of postoperative ventral hernias.

Abstract From a survey of the records of 213 patients with postoperative ventral hernia we have been able to correlate the following etiologic factors. These hernias occur more often in the female than the male and more often in the white than the Negro race. Of this series of patients 95 per cent were overweight. The initial surgical procedure leading to the hernia was in the following order of frequency, namely, abdominal hysterectomy, appendectomy, recurrent incisional hernias, cholecystectomy, cesarean section, perforated peptic ulcer, umbilical hermorrhaphy and stab wounds. Vertical appendectomy incisions were followed by a relatively higher incidence of herniation. A detailed program of management of the patient with a postoperative hernia is given in the effort to lower an unduly high mortality rate and morbidity as seen in a charity hospital.