O. Theron Clagett

The clinical syndrome associated with pulmonary arteriovenous fistulas, including a case report of a surgical cure

Abstract The clinical syndrome, consisting of cyanosis, clubbing of fingers, and polycythemia related to pulmonary arteriovenous fistula, is discussed and the importance of the diagnosis in view of the availability of surgical cure is emphasized. The first case with the unusual complication of collateral circulation to the thoracic wall and with surgical cure by lobectomy is presented. It is believed that this is the ninth case of pulmonary arteriovenous fistula to be recognized clinically and reported and the fifth patient to be cured by surgical treatment.

Present status of thymectomy in treatment of myasthenia gravis

F EW medical papers have had the catalytic effect of that published in 1939 by Blalock and associates 1 describing apparent success in the treatment of myasthenia gravis by removal of a tumor from the region of the thymus gland. The paper was most timely and is generally credited with introducing the era of frequent thymectomy which, after a feeble beginning in 1941, became fully established in 1942. The paper was timely because by 1939 neostigmine and sulfonamide therapy had been available for only a short time; furthermore, thoracic surgery only recently had attained relative maturity. As a consequence of these developments a number of well trained and experienced thoracic surgeons were available and anxious to perform thymectomy on patients who had myasthenia gravis, and physicians, particularly those who were serious students of myasthenia gravis, had been sufficiently impressed by the gradual accumulation of evidence since 1901 of a relationship between myasthenia gravis and the thymus gland that they were willing to make available to the thoracic surgeons certain of their patients who had this disease. Now, more than thirteen years after the era of frequent thymectomy began, the investigators who have attempted to determine the value of thymectomy do not present a united front with regard to its advisability in the treatment of myasthenia gravis. Naturally this failure to agree creates confusion among those who look to these investigators for guidance. The consensus of those students of myasthenia gravis in the United States who have not participated directly in the study of large series of patients undergoing thymectomy apparently was reflected by Westerberg, 2 who stated in effect that thymectomy evidently is not of great value or it would not be so difficult to determine whether or not it is helpful. We believe that recently available data allow * From The Mayo Foundation, Rochester, Minnesota,

Diffuse infiltrating scirrhous carcinoma of the breast. Special consideration of the single‐filing phenomenon

The phenomenon of single filing in carcinoma of the breast was demonstrated in 140 (3.2%) of 4320 patients seen at the Mayo Clinic between 1943 and 1957. The age distribution, symptoms and signs, gross pathologic findings and size of the tumors did not show different features from mammary carcinoma in general. Bilaterality was present in 15 patients (11%), which is a higher rate than in mammary carcinoma in general. Regional lymph nodes were metastatically involved in 51% of the group. Single filing is formed by desmoplastic strands of mostly medium‐sized cells followed in frequency by small and large cells. Mitotic figures are rare. Single filing was found in connection with infiltrating or noninfiltrating lobular carcinomas in 21.2% and with areas of intraductal carcinomas in 36%. The prognostic outlook for patients without lymph node involvement is somewhat similar to that of patients having carcinoma of the breast in general; that for patients with positive lymph nodes is poor, with a 9% chance of 10‐year survival.

PHARYNGEAL AND ESOPHAGEAL DIVERTICULA.

Summary Traction diverticula of the esophagus are not uncommon, but they certainly are an infrequent cause of esophageal dysfunction. When symptoms occur, one should suspect unrelated associated disease of the esophagus, and appropriate studies should be carried out to exclude the possibility of more serious processes. Rarely, a traction diverticulum of the esophagus will become complicated. Spontaneous esophagotracheal or bronchial fistula is the most serious and frequent complication. This requires prompt recognition and early surgical management to prevent fatal suppurative pulmonary complication.

CVII Resection and Anastomosis of the Trachea: An Experimental Study

The purpose of this report is to describe the results one and one-half to two and one-third years after resection of a portion of the trachea in a series of 7 dogs. In a previous report we related our early studies on resection of the trachea. In that report! early data on the present series of dogs were included. At the time of the first report this series of dogs had been observed for two and one-half to thirteen months.