This paper represents an extensive review, spanning 30 years of experience with 404 patients with gastrointestinal fistulas. It includes the first period (1945-1960) during the introduction of antibiotics, the second period (1960-1970) which saw rapid improvements in parasurgical care including, respiratory support, perfection of antibiotics, some introduction of nutritional support and improved monitoring, and the third period which saw the introduction of parenteral nutrition specifically central venous hyperalimentation using hypertonic glucose and amino acids (1970-1975) in the treatment of patients with fistulas. The principal causes for mortality in the historical sense were malnutrition, sepsis and electrolyte imbalance. Mortality among patients with gastrointestinal cutaneous fistulas decreased between the first and second periods from approximately 48 to 15%. Surprisingly, mortality did not decrease further in the "hyperalimentation period" although spontaneous closure of gastrointestinal fistulase increased. The results suggest that the improvement in mortality in patients with gastrointestinal cutaneous fistulas is mostly due to the introduction of improved parasurgical care. It is acknowledged that nutritional support was practiced in the 1960's although this was generally not in the form of hyperalimentation. The addition of hyperalimentation in large scale to the treatment of gastrointestinal cutaneous fistulas has improved spontaneous closure and is a valuable part of the armamentarium. The decrease in mortality however, cannot be attributed to parenteral nutrition.

We studied the pancreatic and enteric hormone profile of a 46-year-old woman who had hyperglycemia and a pancreatic tumor. Before operation, there was no evidence of overproduction of glucagon or insulin. The tumor's ultrastructure had a distinctive endocrine morphology, resembling D cells. Prompted by the recent demonstration of somatostatin in D cells of pancreatic islets, we analyzed the tumor and found a large quantity of immunoreactive somatostatin (301 ng per milligram of tissue). Insulin, glucagon, gastrin, vasoactive intestinal polypeptide and human pancreatic polypeptide were present in only trace quantities. The tumor cells were cultured in monolayers, which remained viable up to 51 days and released somatostatin into the culture medium. In seven insulinomas and two glucagonomas, we found the somatostatin content either much lower (less than 0.6 ng per milligram of tissue) or undetectable. After complete resection of the tumor, our patient became euglycemic and has remained so for the past 20 months.

Abdulmajid, 0. A., Ebeid, A. M., Motaweh, M. M., and Kleibo, I. S. (1976). Thorax, 31,[635][636][637][638][639][640]. Aspirated foreign bodies in the tracheobronchial tree: report of 250 cases. During the last 14 years 250 patients with aspirated foreign bodies in the tracheobronchial tree were admitted to Kuwait Chest Diseases Hospital. Ninety-six per cent of the cases were under 10 years of age and 38% gave a clear history of foreign body inhalation. The rest were diagnosed either clinically, from the chest radiograph findings or because of unexplained pulmonary symptoms. In 247 cases, bronchoscopy under general anaesthesia was successful in removing the foreign bodies. In only three cases was bronchotomy needed. Seventy per cent of the foreign bodies were melon seeds. Asphyxia and cardiac arrest occurred in four cases during bronchoscopy but the patients were successfully resuscitated. In 10 cases a tracheostomy was done before bronchoscopy and the removal of the foreign body, while in five it was needed after the bronchoscopy. Fifteen patients developed late complications such as recurrent pneumonia or atelectasis of the lung. Early diagnosis and adequate treatment are essential to prevent pulmonary and cardiac complications and to avoid radical lung surgery. PATIENTSOf our 250 patients, 105 were under 2 years of age (42%), 105 were aged 2-6 years (42%), and 30 were 6-10 years old (12%). Only 4% of cases were above 10 years of age. One hundred and forty patients were female (46%) and 110 were male (44%). Of the foreign bodies, 70% were located in the right bronchial tree, 17% in the trachea, and only 13% in the left bronchial tree. wheezing, cough, and dyspnoea which gave rise to a suspicion of foreign body inhalation. 3. Radiographic findings: 80% of patients showed normal radiographic findings and only 8% showed a definite foreign body shadow (Fig. 1). In eight cases the radiograph showed bilateral obstructive emphysema due to partial obstruction of the trachea, and in 12 cases it showed right or left lung emphysema due to partial obstruction of the bronchi (Fig. 2). Ten patients showed atelectasis of a lobe, of which seven were right lower lobes (Fig. 3) and three left lower lobes (Fig. 4). NATURE OF FOREIGN BODIESSeventy per cent of the foreign bodies were melon seeds and 15%1 were peanuts, shells of various nuts, and almond kernels. The rest (15%) were screws (9 cases), metal pins (6 cases), fish bones (4 cases), a rosary bead, metal clips (2 cases), an ear-ring, a pebble, a nail cutter, and a metal toy (Fig. 5).