Stephen L. Wangensteen

Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room

: In the majority of patients in this series of 1,000, acute abdominal pain was due to conditions that required neither surgical intervention nor hospitalization. Eleven of the 1,000 patients had an early missed diagnosis in the emergency clinic for which a subsequent operation was needed, and twenty underwent an operation which subsequent diagnosis showed was not required. All false-negative evaluations occurred in patients with early appendicitis or small bowel obstruction. Most false-positive results were due to acute infections of the female genitourinary tract in patients operated on to exclude appendicitis or a tubo-ovarian abscess. The following factors help identify the high risk patient with an acute surgical abdomen: (1) pain for less than 48 hours; (2) pain followed by vomiting; (3) guarding and rebound tenderness on physical examination; (4) advanced age; (5) a prior surgical procedure. The presence of these features demands careful evaluation and a liberal policy of admission and observation. White blood cell counts, body temperature, and abnormal abdominal roentgenograms may add confirmatory evidence but are not particularly helpful as screening devices.

Mechanism of the protective effects of prostaglandins E1 and F2α in canine endotoxin shock

Abstract Prostaglandins E 1 (PGE 1 ) and F 2α (PGF 2α ) were studied for their ability to alter the course of a standardized endotoxin shock procedure in dogs. 3 hr after the administration of E. coli endotoxin, mean arterial blood pressure (MABP) was reduced 44% and cardiac output (CO) 60%. At this time plasma activities of the lysosomal protease, cathepsin D, increased 670%, and of a myocardial depressant factor (MDF), 310%. Dogs treated with PGF 2α had consistently higher MABP and CO, while plasma cathepsin D and MDF activities were moderately elevated. In addition, post-endotoxin survival was significantly improved. PGE 1 -treated dogs exhibited a higher MABP and CO, while plasma cathepsin D and MDF activities were only slighly elevated, and survival time increased ( p 1 , but not PGF 2α markedly reduced the rate of release of proteases from isolated hepatic and pancreatic lysosomes subjected to thermal activation. An enhanced release of splanchnic proteases appears to lead to the formation of MDF, a peptide involved in the pathophysiology of endotoxin shock. Prostaglandin E 1 may protect in endotoxin shock by suppressing the release of lysosomal proteases and the subsequent formation of MDF, whereas PGF 2α may protect either by circulatory support or by some secondary mechanism for preventing the release of lysosomal enzymes.

Mechanism of the lack of a beneficial response to inotropic drugs in hemorrhagic shock.

Lanatoside C, glucagon, and isoproterenol, three inotropic agents were found to be ineffective in prolonging survival or in improving the over‐all circulatory status of dogs in hemorrhagic shock, despite their temporary effectiveness as inotropic agents. Lanatoside C constricted the splanchnic circulation leading to lysosomal disruption, release of cathepsin D, and production of a myocardial depressant factor (MDF). Glucagon dilated the splanchnic circulation only transiently but directly disrupted splanchnic lysosomes and thus MDF was produced. Isoproterenol dilated the peripheral vasculature to such an extent that circulatory collapse ensued. Other inotropic agents may be of value in the treatment of postoligemic shock, but potentially deleterious side effects must be considered when they are administered in circulatory shock.

Changing prospects for the new surgical resident

Drastic changes have occurred in medicine in the last few years. Overproduction of medical students has led to increased competition for surgical residency positions, with consequent changing prospects for the surgical resident. Despite the perceived overproduction of trained surgeons, little has been done to curtail the output of surgeons from training programs.

The effects of purified cathepsin D infusions in intact animals

Cathepsin D, a potent acid proteinase, has been implicated in the pathogenesis of circulatory shock. The infusion of purified preparations of cathepsin D into intact animals resulted in significant depressions in core body temperature but failed to reproduce the cardiovascular disturbances seen in shock states.