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Complete severance of the pancreas and its treatment with repair of the main pancreatic duct of Wirsung
Complete Severance of the Pancreas and Its Treatment with Repair of the Main Pancreatic Duct of Wirsung REPORT JOHN N. PELLECRINI,
From
tbe
Surgical
Service
M.D.
2792d
Tinker Air Fo%e Base, Oklahoma.
OF A CASE
AND IGNATIUS J. STEIN, M.D., Tinker
USAF
type. White bIood ceI1 count was not performed; however, the hemogIobin was I 2.2 gm. per cent and the hematocrit 37 voIumes per cent. UrinaIysis was within normal limits. The serum amyIase was 300 units. Fiat plate of the abdomen which was taken on admission showed no free air under the diaphragm; however, there were biIatera1 increased markings aIong the IateraI borders of the psoas muscIes. The patient was taken immediately to the operating room for expIoratory Iaparotomy. Procedure. Under genera1 anesthesia a left rectus muscIe retracting incision was made between the costal border and the umbiIicus. ApproximateIy 500 cc. of free blood was found within the peritonea1 cavity, welling upward into the wound from an area above the stomach to the right of the gaIIbIadder and below the liver. Examination of the peritoneal contents revealed that the spIeen and stomach were intact. There was no opening in the large or small intestines and the kidneys and peIvic organs were normaI. The lesser omentum was compIeteIy Iacerated and the stomach was dispIaced distally. The liver surface was Iacerated approximateIy four inches media1 to the gaIIbIadder but was not actively bleeding. The pancreas was lacerated compIeteIy through at the junction of the head and the body and active bIeeding was taking pIace from the superior and inferior pancreatic arteries. The porta vein was exposed in the depths of the rent in the Iesser omental sac, and the posterior peritoneum was torn up to the foramen of WinsIow in such a way that the finger couId be passed from the left to the right through the foramen of Winslow as we11 as from the right to the left and carried above the porta vein, hepatic artery and common duct. Active bleeding from the cephalad portion of the pancreas was controIIed by grasping with fine hemostats and ligatures of No. 4-o silk, and the necrotic portions of the pancreas at the Iacerated site were excised. ExpIoration of the pancreatic sub-
Hospital,
INCE the first case of compIete severance of pancreas was reported by Travers in I 827 [5], reported experiences in managing this probIem have been generally unsatisfactory. In October 1959 Letton and WiIson [3] reported two cases of severance of the pancreas treated by Roux-Y anastomosis (pancreaticojejunostomy) which avoided the comphcations of IistuIas and pseudocyst formation, previousIy encountered by surgeons who empIoyed other operative technics. None of the technics described the repair of the main pancreatic duct of Wirsung. This articIe is concerned with a traumatic, nonpenetrating, severance of the pancreas and the method used for repair with re-establishment of the continuity of the main pancreatic duct of Wirsung.
S the
CASE
Air Force Base, Oklahoma
REPORT
On October 19, I 959, a thirty-seven year old white woman (E. J. R.) was admitted to our hospita1 following an auto accident. The steering whee1 of her car struck her in the abdomen. The patient had had no previous accident or operation. PhysicaI examination on admission reveaIed the patient to be sIightIy stuporous, cold and clammy. AbdominaI examination showed the epigastrium to be sIightIy tender and the remainder of the examination with the exception of a lacerated Iip and hand, was noncontributory. Rigidity of the abdomen progressed rapidly in the emergency room. Blood pressure decreased to 60/40 mm. Hg and the puIse became rapid (I 20) and thready. Laboratory Data. On admission the Iaboratory data reveaIed the patient to be a B-positive blood 707
American
Journal of Surgery, Volume IOI, June 1961
PeIIegrini
and Stein
FIG. I. Shown above are the serum amyIase Ievels of E. J. R. on admission (A) and during the postoperative days u&I discharge (D), on second admission and the subsequent days in the hospita1 before being discharged, and at biweekly checkups during the six week foIIow-up period.
stance revealed, with diffIcuIty, the proxima1 and
adjacent to the poIyethyIene infant feeding tube and the choIedochostomy was cIosed using interrupted No. 4-o silk sutures. The duodenostomy was then closed transverseIy and the Iaceration of the liver was repaired. Drains were placed into the lesser peritonea1 sac to the right of the foramen of WinsIow and brought out through a stab wound in the right flank. Two drains were pIaced in the Iesser sac through the rent in the gastrohepatic omentum and brought out through a stab wound in the Ieft flank. No attempt was made to suture the gastrohepatic omentum. The T tube from the common bile duct and the poIyethyIene pancreatic tube in association with it were Iet out through a stab wound in the right flank. The incision was then cIosed. A pressure dressing was appIied and the patient, beginning to react, was returned to the ward in fair condition. During the operative procedure she received z units of bIood as we11 as 2,000 cc. of 5 per cent dextrose in distiIIed water and withstood the procedure very we11showing very few variations in blood pressure and puIse rate. Course in Hospital. The patient enjoyed a rather benign postoperative course, considering the nature of her lesions, and reacted we11 from the anesthesia. The biIe drainage from the T tube was adequate throughout. The pancreatic tube did not function for two days but on the third postoperative day pure, cIear pancreatic secretion was drained through the poIyethyIene tube. From this point on, pancreatic juice and biIe drained freeIy through their respective tubes. On the third postoperative day bowe1 sounds returned and the patient was given a fat free-diet. Serum amyIase during patient’s hospita1 stay is shown in Figure I. It remained at the level of 150 units even after the patient was discharged from the hospita1. The gIucose IeveI was no higher
dista1 end of the main pancreatic duct of Wirsung. To expose the common biIe duct adequateIy in this case, the cystic duct was mobiIized, ligated near the galIbIadder and cut and a choIecystectomy was performed. A poIyethyIene tube was inserted into the remainder of the cystic duct and passed down the common duct. A choIedochostomy was then performed and a poIyethyIene infant feeding tube was passed down the common duct into the duodenum and the first poIyethyIene tube was extracted. The cystic duct stump was then cIamped and doubIy ligated. The duodenum was mobilized by using the method of Kocher and roIIed to the Ieft exposing its posterior surface. The duodena1 wail was intact. The duodenum was opened IongitudinaIIy a distance of 3 cm. and the poIyethyIene infant feeding tube, which had come through the opening of the common biIe duct into the ampulla of Vater, was grasped with a cIamp and the papiIIa and sphincter were cIearIy demonstrated. A mosquito clamp was placed into the papiIIa of Vater and a sphincterotomy of the sphincter of Oddi was performed. Exposure of the cephaIad portion of the main pancreatic duct was achieved with diffIcuIty and the poIyethyIene infant feeding tube was passed into it from the ampuIIa and through the cephalad portion of the pancreas into the area of the pancreatic Iaceration. When the main pancreatic duct was identified in the caudad portion of the Iaceration, the tube was fed to the Ieft into the duct and into the tai1 portion of the pancreas and sutured in pIace with a No. 4-o siIk ligature. The posterior, inferior and anterior surfaces of the pancreas were then approximated and sutured with interrupted No. 4-o silk sutures pIaced through the capsuIe. A T tube was inserted into the common biIe duct
708
Severance
of Pancreas
and
than 114 mg. per cent throughout the course of her hospita1 stay. On the fifteenth postoperative day a11 medications were discontinued and the T tube and poIyethyIene tube were removed. The pathologic report read as folIows: (I) fat necrosis; (2) hemorrhagic necrosis of the pancreas; (3) hemorrhagic necrosis of the soft tissue adjacent to the gaIlbIadder. The patient was discharged from the hospital on the twenty-second hospital day and was placed on a regular diet. Six weeks after operation she was readmitted to the hospital compIaining of chills, weakness and slight temperature eIevation. The patient referred to no abdomina1 complaints. Her appetite was satisfactory atid she was abIe to eat a11 foods without causing discomfort. The serum amylase at the time of this admission was 428.5 units; on the next hospita1 day the value was 576 units. The patient was pIaced on a regimen of fat free diet and administered atropine, gr. 1/150, every six hours intramuscuIarIy. With two days of this treatment the serum amyIase IeveIs returned to normal, the temperature and weakness subsided and the patient was discharged from the hospita1 asymptomatic and in satisfactory condition.
Repair
of Main
Duct
amyIase or an amyIase which remains constantIy high in spite of any conservative treatment is indicative of the deveIopment of a pseudocyst. Some authors describe a chronic cholecystitis deveIoping after transduodena1 sphincterotomy due to the refIux of duodena1 contents into the DoubiIet states that biIiary tract. However, an intact duodena1 waI1 wiI1 prevent the reffux of the duodena1 contents into the biIiary tract after sphincterotomy. The same authors who described the chronic choIecystitis after sphincterotomy, also stated, that this inflammation of the gaIIbIadder wouId be aIIeviated by cholecystectomy. It is to be mentioned here that a choIecystectomy was performed on our patient and the possibiIity of a chronic choIecystitis was eIiminated. The cIosure of the duodenostomy was done transverseIy in our case. However, in a recent pubIication by Madden [4], DoubiIet describes a IongitudinaI cIosure as his preference, since this interferes Iess with the peristaItic activity of the duodenum. Our patient has been folIowed four months since operation. Since her second discharge the patient’s genera1 condition has been satisfactory. She has gained approximateIy five pounds and has offered no compIaints. She has returned to her norma work, is eating a11 foods and is feeling weI1.
COMMENTS
The usefuIness of sphincterotomy in chronic reIapsing pancreatitis has been described by DoubiIet and Mulholland [I], and others [2,6]. Their series has been extensive and their resuIts have been satisfactory. According to the same authors pseudocysts of the pancreas are thought to be prevented by sphincterotomy since drainage from the pancreas is facilitated by such a procedure. A causative mechanism in pancreatitis has been described as a spasm of the sphincter of Oddi. This spasm wouId produce a sufficient obstruction to aIIow a reflux of biIe saIts into the pancreatic duct. The biIe saIts wouId in turn cause an inflammation of the pancreas after their aIkaIinization by the pancreatic secretion. The inflammation wouId, in turn, aggravate the spasm of the sphincter of Oddi and a vicious cycle wouId then begin. EtioIogic factors of pseudocysts are beIieved to be pancreatitis, biliary tract disease and trauma. The sphincterotomy performed on E. J. R was done to precIude this. It is a practice at this hospita1 to obtain serum amyIase vaIues on a11 patients who are admitted with abdominal trauma. If abnorma1, the amyIase IeveI is foIIowed even after discharge from the hospita1. Our experience Ieads us to beIieve that a progressiveIy rising serum
SUMMARY I. A case of severance of the pancreas and its successfu1 treatment by repair of the main pancreatic duct of Wirsung, as weI1 as suture of the Iaceration of the pancreatic capsuIe have been described. We know of no other case in the literature in which this method has been used. 2. A commentary on the operation and serum amyIase levels has been given. 3. FoIIow-up studies on this patient to date have been satisfactory. ADDENDUM
The patient presented herseIf to the Prenatal CIinic of this hospita1 on June 29, 1960 and was found to be pregnant approximately three months, with estimated date of deIivery being December 27, 1960. The patient’s prenata course was foIIowed in conjunction with the Surgical Service of this hospital and the course was entireIy uncomplicated. At no time 709
PeIIegrini
and Stein
during her pregnancy did she show any signs or symptoms of pancreatitis or any other abnormahty. On November zg, 1960 at I I ~30 P.M. she was admitted to the Obstetrica Ward of this hospita1 with premature spontaneous rupture of the membranes occurring at approximateIy IO:OO P.M. Her Iabor progressed rapidIy and without complications and at 2~00 A.M., on November 30, 1960 she was deIivered by low forceps over a median episiotomy of a normal six pound, eight ounce maIe infant. Her postpartum course was uncompIicated and both mother and baby were discharged from the hospital on the fourth postpartum day, December 4, 1960, in good condition.
REFERENCES I. DOUBILET, H. and Mu LHOLLAND,J. H. The surgiczd treatment of pancreatitis. S. Clin. Nortb America, 29: 339, 1954. 2. GRAY, S. H., PROBSTEIN, J. G. and SACHAR, L. A. Chronic cholecystitis produced by division of the sphincter of Oddi. Arch. Surg., 59: 1007, 1949. 3. LETTOX, A. H. and WILSON, J. P. Traumatic severance of the pancreas treated by Roux-Y anastomosis. Surg. Cynec. @ Obst., log: 473, Igfg. A. MADDEN. J. L. AtIas of Technics in Suwerv, P. 466. New York, 1958. AppIeton-Century-Crofts; Inc. 5. TRAVERS, B. HospitaI reports: St. Thomas HospitaI. Lancet, 12: 384, 1827. 6. WELLS, B. B. CIinicaI Pathology Application and Interpretation, 2nd ed. PhiIadeIphia, 1956. W. B. Saunders Co. 7. UnpubIished data.
710
From
tbe
Surgical
Service
M.D.
2792d
Tinker Air Fo%e Base, Oklahoma.
OF A CASE
AND IGNATIUS J. STEIN, M.D., Tinker
USAF
type. White bIood ceI1 count was not performed; however, the hemogIobin was I 2.2 gm. per cent and the hematocrit 37 voIumes per cent. UrinaIysis was within normal limits. The serum amyIase was 300 units. Fiat plate of the abdomen which was taken on admission showed no free air under the diaphragm; however, there were biIatera1 increased markings aIong the IateraI borders of the psoas muscIes. The patient was taken immediately to the operating room for expIoratory Iaparotomy. Procedure. Under genera1 anesthesia a left rectus muscIe retracting incision was made between the costal border and the umbiIicus. ApproximateIy 500 cc. of free blood was found within the peritonea1 cavity, welling upward into the wound from an area above the stomach to the right of the gaIIbIadder and below the liver. Examination of the peritoneal contents revealed that the spIeen and stomach were intact. There was no opening in the large or small intestines and the kidneys and peIvic organs were normaI. The lesser omentum was compIeteIy Iacerated and the stomach was dispIaced distally. The liver surface was Iacerated approximateIy four inches media1 to the gaIIbIadder but was not actively bleeding. The pancreas was lacerated compIeteIy through at the junction of the head and the body and active bIeeding was taking pIace from the superior and inferior pancreatic arteries. The porta vein was exposed in the depths of the rent in the Iesser omental sac, and the posterior peritoneum was torn up to the foramen of WinsIow in such a way that the finger couId be passed from the left to the right through the foramen of Winslow as we11 as from the right to the left and carried above the porta vein, hepatic artery and common duct. Active bleeding from the cephalad portion of the pancreas was controIIed by grasping with fine hemostats and ligatures of No. 4-o silk, and the necrotic portions of the pancreas at the Iacerated site were excised. ExpIoration of the pancreatic sub-
Hospital,
INCE the first case of compIete severance of pancreas was reported by Travers in I 827 [5], reported experiences in managing this probIem have been generally unsatisfactory. In October 1959 Letton and WiIson [3] reported two cases of severance of the pancreas treated by Roux-Y anastomosis (pancreaticojejunostomy) which avoided the comphcations of IistuIas and pseudocyst formation, previousIy encountered by surgeons who empIoyed other operative technics. None of the technics described the repair of the main pancreatic duct of Wirsung. This articIe is concerned with a traumatic, nonpenetrating, severance of the pancreas and the method used for repair with re-establishment of the continuity of the main pancreatic duct of Wirsung.
S the
CASE
Air Force Base, Oklahoma
REPORT
On October 19, I 959, a thirty-seven year old white woman (E. J. R.) was admitted to our hospita1 following an auto accident. The steering whee1 of her car struck her in the abdomen. The patient had had no previous accident or operation. PhysicaI examination on admission reveaIed the patient to be sIightIy stuporous, cold and clammy. AbdominaI examination showed the epigastrium to be sIightIy tender and the remainder of the examination with the exception of a lacerated Iip and hand, was noncontributory. Rigidity of the abdomen progressed rapidly in the emergency room. Blood pressure decreased to 60/40 mm. Hg and the puIse became rapid (I 20) and thready. Laboratory Data. On admission the Iaboratory data reveaIed the patient to be a B-positive blood 707
American
Journal of Surgery, Volume IOI, June 1961
PeIIegrini
and Stein
FIG. I. Shown above are the serum amyIase Ievels of E. J. R. on admission (A) and during the postoperative days u&I discharge (D), on second admission and the subsequent days in the hospita1 before being discharged, and at biweekly checkups during the six week foIIow-up period.
stance revealed, with diffIcuIty, the proxima1 and
adjacent to the poIyethyIene infant feeding tube and the choIedochostomy was cIosed using interrupted No. 4-o silk sutures. The duodenostomy was then closed transverseIy and the Iaceration of the liver was repaired. Drains were placed into the lesser peritonea1 sac to the right of the foramen of WinsIow and brought out through a stab wound in the right flank. Two drains were pIaced in the Iesser sac through the rent in the gastrohepatic omentum and brought out through a stab wound in the Ieft flank. No attempt was made to suture the gastrohepatic omentum. The T tube from the common bile duct and the poIyethyIene pancreatic tube in association with it were Iet out through a stab wound in the right flank. The incision was then cIosed. A pressure dressing was appIied and the patient, beginning to react, was returned to the ward in fair condition. During the operative procedure she received z units of bIood as we11 as 2,000 cc. of 5 per cent dextrose in distiIIed water and withstood the procedure very we11showing very few variations in blood pressure and puIse rate. Course in Hospital. The patient enjoyed a rather benign postoperative course, considering the nature of her lesions, and reacted we11 from the anesthesia. The biIe drainage from the T tube was adequate throughout. The pancreatic tube did not function for two days but on the third postoperative day pure, cIear pancreatic secretion was drained through the poIyethyIene tube. From this point on, pancreatic juice and biIe drained freeIy through their respective tubes. On the third postoperative day bowe1 sounds returned and the patient was given a fat free-diet. Serum amyIase during patient’s hospita1 stay is shown in Figure I. It remained at the level of 150 units even after the patient was discharged from the hospita1. The gIucose IeveI was no higher
dista1 end of the main pancreatic duct of Wirsung. To expose the common biIe duct adequateIy in this case, the cystic duct was mobiIized, ligated near the galIbIadder and cut and a choIecystectomy was performed. A poIyethyIene tube was inserted into the remainder of the cystic duct and passed down the common duct. A choIedochostomy was then performed and a poIyethyIene infant feeding tube was passed down the common duct into the duodenum and the first poIyethyIene tube was extracted. The cystic duct stump was then cIamped and doubIy ligated. The duodenum was mobilized by using the method of Kocher and roIIed to the Ieft exposing its posterior surface. The duodena1 wail was intact. The duodenum was opened IongitudinaIIy a distance of 3 cm. and the poIyethyIene infant feeding tube, which had come through the opening of the common biIe duct into the ampulla of Vater, was grasped with a cIamp and the papiIIa and sphincter were cIearIy demonstrated. A mosquito clamp was placed into the papiIIa of Vater and a sphincterotomy of the sphincter of Oddi was performed. Exposure of the cephaIad portion of the main pancreatic duct was achieved with diffIcuIty and the poIyethyIene infant feeding tube was passed into it from the ampuIIa and through the cephalad portion of the pancreas into the area of the pancreatic Iaceration. When the main pancreatic duct was identified in the caudad portion of the Iaceration, the tube was fed to the Ieft into the duct and into the tai1 portion of the pancreas and sutured in pIace with a No. 4-o siIk ligature. The posterior, inferior and anterior surfaces of the pancreas were then approximated and sutured with interrupted No. 4-o silk sutures pIaced through the capsuIe. A T tube was inserted into the common biIe duct
708
Severance
of Pancreas
and
than 114 mg. per cent throughout the course of her hospita1 stay. On the fifteenth postoperative day a11 medications were discontinued and the T tube and poIyethyIene tube were removed. The pathologic report read as folIows: (I) fat necrosis; (2) hemorrhagic necrosis of the pancreas; (3) hemorrhagic necrosis of the soft tissue adjacent to the gaIlbIadder. The patient was discharged from the hospital on the twenty-second hospital day and was placed on a regular diet. Six weeks after operation she was readmitted to the hospital compIaining of chills, weakness and slight temperature eIevation. The patient referred to no abdomina1 complaints. Her appetite was satisfactory atid she was abIe to eat a11 foods without causing discomfort. The serum amylase at the time of this admission was 428.5 units; on the next hospita1 day the value was 576 units. The patient was pIaced on a regimen of fat free diet and administered atropine, gr. 1/150, every six hours intramuscuIarIy. With two days of this treatment the serum amyIase IeveIs returned to normal, the temperature and weakness subsided and the patient was discharged from the hospita1 asymptomatic and in satisfactory condition.
Repair
of Main
Duct
amyIase or an amyIase which remains constantIy high in spite of any conservative treatment is indicative of the deveIopment of a pseudocyst. Some authors describe a chronic cholecystitis deveIoping after transduodena1 sphincterotomy due to the refIux of duodena1 contents into the DoubiIet states that biIiary tract. However, an intact duodena1 waI1 wiI1 prevent the reffux of the duodena1 contents into the biIiary tract after sphincterotomy. The same authors who described the chronic choIecystitis after sphincterotomy, also stated, that this inflammation of the gaIIbIadder wouId be aIIeviated by cholecystectomy. It is to be mentioned here that a choIecystectomy was performed on our patient and the possibiIity of a chronic choIecystitis was eIiminated. The cIosure of the duodenostomy was done transverseIy in our case. However, in a recent pubIication by Madden [4], DoubiIet describes a IongitudinaI cIosure as his preference, since this interferes Iess with the peristaItic activity of the duodenum. Our patient has been folIowed four months since operation. Since her second discharge the patient’s genera1 condition has been satisfactory. She has gained approximateIy five pounds and has offered no compIaints. She has returned to her norma work, is eating a11 foods and is feeling weI1.
COMMENTS
The usefuIness of sphincterotomy in chronic reIapsing pancreatitis has been described by DoubiIet and Mulholland [I], and others [2,6]. Their series has been extensive and their resuIts have been satisfactory. According to the same authors pseudocysts of the pancreas are thought to be prevented by sphincterotomy since drainage from the pancreas is facilitated by such a procedure. A causative mechanism in pancreatitis has been described as a spasm of the sphincter of Oddi. This spasm wouId produce a sufficient obstruction to aIIow a reflux of biIe saIts into the pancreatic duct. The biIe saIts wouId in turn cause an inflammation of the pancreas after their aIkaIinization by the pancreatic secretion. The inflammation wouId, in turn, aggravate the spasm of the sphincter of Oddi and a vicious cycle wouId then begin. EtioIogic factors of pseudocysts are beIieved to be pancreatitis, biliary tract disease and trauma. The sphincterotomy performed on E. J. R was done to precIude this. It is a practice at this hospita1 to obtain serum amyIase vaIues on a11 patients who are admitted with abdominal trauma. If abnorma1, the amyIase IeveI is foIIowed even after discharge from the hospita1. Our experience Ieads us to beIieve that a progressiveIy rising serum
SUMMARY I. A case of severance of the pancreas and its successfu1 treatment by repair of the main pancreatic duct of Wirsung, as weI1 as suture of the Iaceration of the pancreatic capsuIe have been described. We know of no other case in the literature in which this method has been used. 2. A commentary on the operation and serum amyIase levels has been given. 3. FoIIow-up studies on this patient to date have been satisfactory. ADDENDUM
The patient presented herseIf to the Prenatal CIinic of this hospita1 on June 29, 1960 and was found to be pregnant approximately three months, with estimated date of deIivery being December 27, 1960. The patient’s prenata course was foIIowed in conjunction with the Surgical Service of this hospital and the course was entireIy uncomplicated. At no time 709
PeIIegrini
and Stein
during her pregnancy did she show any signs or symptoms of pancreatitis or any other abnormahty. On November zg, 1960 at I I ~30 P.M. she was admitted to the Obstetrica Ward of this hospita1 with premature spontaneous rupture of the membranes occurring at approximateIy IO:OO P.M. Her Iabor progressed rapidIy and without complications and at 2~00 A.M., on November 30, 1960 she was deIivered by low forceps over a median episiotomy of a normal six pound, eight ounce maIe infant. Her postpartum course was uncompIicated and both mother and baby were discharged from the hospital on the fourth postpartum day, December 4, 1960, in good condition.
REFERENCES I. DOUBILET, H. and Mu LHOLLAND,J. H. The surgiczd treatment of pancreatitis. S. Clin. Nortb America, 29: 339, 1954. 2. GRAY, S. H., PROBSTEIN, J. G. and SACHAR, L. A. Chronic cholecystitis produced by division of the sphincter of Oddi. Arch. Surg., 59: 1007, 1949. 3. LETTOX, A. H. and WILSON, J. P. Traumatic severance of the pancreas treated by Roux-Y anastomosis. Surg. Cynec. @ Obst., log: 473, Igfg. A. MADDEN. J. L. AtIas of Technics in Suwerv, P. 466. New York, 1958. AppIeton-Century-Crofts; Inc. 5. TRAVERS, B. HospitaI reports: St. Thomas HospitaI. Lancet, 12: 384, 1827. 6. WELLS, B. B. CIinicaI Pathology Application and Interpretation, 2nd ed. PhiIadeIphia, 1956. W. B. Saunders Co. 7. UnpubIished data.
710