Direct evaluation of mitral valve function during surgery following conservative procedures. A method is described whereby mitral valve function can be tested during cardiopulmonary bypass under physiological conditions. This method avoids the risk of systemic air embolism during testing and can be used even in the presence of aortic regurgitation. Monitoring left ventricular pressure simultaneously with aortic root pressure prevents any overdistention of the left ventricle. This method has been in use at Guy's Hospital since 1970 and has been satisfactory and safe.


Coronary steal by internal mammary graft with subclavian stenosis. The internal mammary artery was used for 66 of 312 grafts in 100 patients. One vessel was not used because of damage, but in no other case was any reason found for witholding the internal mammary graft. Brachial pulsation and blood pressure were normal and the sectioned mammary artery bled more than 50 ml. per minute, but subclavian bruits were not routinely sought. In other series there has been a 0.5 to 2 per cent incidence of subclavian stenosis in subjects requiring coronary grafts. A case is presented in which subclavian stenosis was mild and undetected. The lesion caused a reversal of flow in the mammary shunt when the purse-string suture around cannula was tied and protamine and vasodilators were given. The patient died--the only death in the series. Had coronary artery steal been suspected, it could easily have been recognized and corrected, and the patient's survival assured. Awareness of its possibility and careful clinical screening of patients, with subclavian arteriograms whenever doubt exists, should reduce the risk. Distally based mammary grafts may invite this complication, and nondirectional flowmeters make its recognition less easy.


Simple d-transposition of the great arteries. Results of early balloon septotomy followed by two-stage surgical correction. The follow-up of 44 patients with simple d-transposition of the great arteries is presented. All had balloon atrial septotomy shortly after birth. If an operation was needed at or before one year of age, atrial septectomy was carried out. Correction was done between the ages of 19 and 64 months. Of the 44 patients, 34 (77 per cent) are living and doing well (27 after the Mustard procedure), 3 (7 per cent) are lost to follow-up, and 7 (16 per cent) are dead. Death was due to technical problems during initial catheterization and balloon septotomy in 2 patients, occurred after septectomy in one (3 per cent), and after the Mustard procedure in one (4 per cent). There was one sudden inexplicable death in a 1 1/2-month-old patient, and 2 patients died with pulmonary vascular obstructive disease. Because of the relatively low over-all mortality and morbidity and the low surgical mortality rate for both palliation and correction, we believe that two-stage surgical correction of transposition of the great arteries is preferable to early one-stage correction in the infant.


Intraoperative hemodynamic evaluation of the Björk-Shiley tilting disc aortic valve. Intraoperative cardiac output and aortic and left ventricular pressures were measured simultaneously in 15 consecutive patients before and after aortic valve replacement (AVR) with the Björk-Shiley tilting disc valve. The predominant lesion in these patients was aortic stenosis. The following hemodynamic indices were calculated: aortic valve area (AVA), determined by Gorlin's formula, effective orifice area, and effective area index. Their applicability as hemodynamic criteria of the immediate hemodynamic performance of the replaced valve is discussed. By every criterion, AVR greatly improved the hemodynamic performance. The effective area index seemed more suitable than the other indices for the intraoperative hemodynamic evaluation of the replaced aortic valve.


Isolated idiopathic chylopericardium.

Isolated idiopathic chylopericardium. The case history of a young asymptomatic patient with primary chylous pericardium is reported. On the basis of this case and those reported in the literature, we suggest that diagnosis should be established by echocardiograms, cardiac angiograms, and pericardiocentesis. Lymphangiograms are useful for the detection of the underlying abnormality of the lymph vessels. Pericardiectomy together with thoracic duct ligation are suggested as the preferred treatment. We propose that generalized lymphatic abnormality is the underlying mechanism of this entity. This lymphatic abnormality could be associated with impaired cellular immunity, although no such impairment was found in our patient.


Hemodynamic effects of controlled degrees of coronary artery stenosis in short-term and long-term studies in dogs. Coronary and aortic blood flow, aortic and distal coronary blood pressure were measured with electromagnetic flowmeters and pressure gauges in 15 anesthetized dogs with the chest left open. Increasing degrees of known, fixed, partial coronary artery obstruction were applied with concentric plastic cylinders 3 mm. in length and with varying internal diameters. Because these plastic cylinders are radiolucent and can also be permanently implanted, postoperative arteriograms were taken to evaluate the degree of stenosis produced. At necropsy the degree of obstruction was checked by ligating and removing the narrowed vessel and examining a histologic section of a stenosed portion. The reactive hyperemic response to a 20 second complete occlusion was recorded with amounts of obstruction varying from 10 to 90 per cent. The reactive hyperemia began to decrease with an average of 36 +/- 10 per cent stenosis. A pressure gradient of 10 mm. Hg across the obstruction occurred with an average of 57 +/- 8 per cent stenosis. The reactive hyperemic response was abolished with an average of 75 +/- 6 per cent stenosis, and with greater degrees of stenosis the total flow began to decrease below control levels. The phasic coronary flow pattern was also altered with increasing amounts of fixed partial obstruction. As the per cent of stenosis was increased, the ratio of diastolic to systolic coronary flow decreased. When reactive hyperemia was abolished, very little diastolic-to-systolic variation remained.


Post-traumatic intracardiac shunts. Report of two cases and review of the literature. Intracardiac shunts consequent to penetrating thoracic injury have been reported in 94 patients. Two additional cases are reported emphasizing the frequently complex anatomic abnormalities, the variability in clinical course, and the favorable outcome of repair. From a review of the literature, it is apparent that most such lesions should be corrected, since patients are at a continual risk of symptomatic cardiac dysfunction and repair offers an excellent prognosis with minimal morbidity.


Single coronary artery with a fistula to the main pulmonary artery in a patient with tetralogy of Fallot. The presence of a single coronary artery arising in the anterior cusp and terminating in a large fistula to the main pulmonary artery was noted during the preoperative evaluation of a patient with tetralogy of Fallot. Recognition of this rare association dictated the use of a valved conduit to avoid injury to the left anterior descending coronary as it crossed the right ventricular outflow tract and permitted abolition of intracardiac shunting by ligation of the fistula. It is postulated that the increasing arterial saturation noted in this patient prior to intracardiac repair may have been related in part to progressive augmentation in flow through the coronary fistula to the main pulmonary artery.


Prognosis of patients after open mitral commissurotomy. Actuarial analysis of late results in 100 patients. The continuing controversy between proponents of open and closed commissurotomy might be clarified by analysis of late follow-up with modern actuarial techniques that provide a true perspective of patient risk. We have used open mitral commissurotomy exclusively for 15 years in 100 patients. There was one operative death from pancreatitis and one late death from cancer; the actuarially projected survival rate (+/- the standard error) at 10 years is 97 per cent (+/- 2). Thirteen patients had preoperative emboli, 6 of whom were in sinus rhythm and 7 in atrial fibrillation. Two patients had postoperative emboli, both in sinus rhythm. The actuarial chance of remaining free of embolism at 10 years is 97 per cent (+/- 2). Sixteen patients required reoperation on the mitral valve for functional deterioration. The remaining survivors were in Class I or II when last seen. The actuarial chance of not requiring a reoperation after 5 years is 91 per cent (+/- 4) and at 10 years, 38 per cent(+/- 16). Results in different centers are difficult to compare for many reasons, but imprecise statistical methods further obscure such comparisons. The use of actuarial techniques may help to define the role of open mitral commissurotomy.


Myocardial ischemia during cardiopulmonary bypass. The hazards of ventricular fibrillation in the presence of a critical coronary stenosis. The effect of a critical coronary artery stenosis on myocardial blood flow and metabolism in the fibrillating heart was assessed by placing 10 dogs on cardiopulmonary bypass, venting the ventricle, inducing ventricular fibrillation, and applying critical stenosis to the left anterior descending coronary artery (LAD). Endocardial and epicardial blood flows were measured by the radioactive microsphere technique prior to the application of the stenosis and after one hour and 2 hours of fibrillation. Intramyocardial oxygen tension (PO2) and carbon dioxide tension (PCO2) were continuously monitored in the LAD-supplied myocardium by a mass spectrometer probe inserted at midmyocardial depth. Selective arterial-coronary venous lactate differences were determined at control, one hour, and 2 hours. At the end of the 2 hour period, vital dye injection defined the distribution of the LAD. Endocardial flow to the myocardium of the stenosed LAD was reduced by 50 per cent after one hour and by 70 per cent after 2 hours (p less than 0.05). Epicardial flow fell 40 per cent after one hour and 50 per cent after 2 hours (p less than 0.05). Endocardial and epicardial flow in the distribution of the unstenosed circumflex coronary artery remained unchanged. Changes in myocardial PO2 and PCO2 in the LAD-supplied myocardium indicated the development of severe ischemia in all 10 dogs and suggested myocardial infarction in 5. There was a conversion from lactate extraction to lactate production during the 2 hour period of ventricular fibrillation. From this study, it is concluded that the myocardium distal to a critical stenosis suffers a progressive reduction in flow during ventricular fibrillation which does not occur in regions supplied by unstenosed coronary arteries. Thus prolonged fibrillation in the presence of a flow-limiting coronary stenosis may play a role in the pathogenesis of myocardial infarction during coronary bypass surgery.


Hemodynamic responses to dopamine infusion at controlled normal and low cardiac output states in the anesthetized dog. In order to isolate the renal and pulmonary vascular effects of dopamine, we employed a dog preparation utilizing fixed venous return in order to control cardiac output at either a normal or low flow state. Dopamine infusion was carried out at doses of 8 and 16 microng/Kg./min. Heart rate, mean systemic arterial pressure, mean pulmonary artery pressure, and renal blood flow were measured. Changes in mean systemic arterial pressure, mean pulmonary artery pressure, and renal blood flow were not significant at either doses of dopamine. There was a dose-related increase in heart rate, most significant with a dose of 16 microng/Kg./min. and low cardiac output. No evidence was found to substantiate the existence of a specific dopaminergic receptor in the renal vasculature when cardiac output was controlled.


Early operative intervention for complications of acute myocardial infarction. Cardiac operations were performed on 21 patients for treatment of complications of acute myocardial infarction unresponsive to vigorous drug therapy. There were six hospital deaths (28.5 per cent) and 15 survivors 3 to 50 months postoperatively. Fourteen of the 15 survivors are asymptomatic (Class I N.Y.H.A.); one patient remains in Class III. The average time from infarction to operation was 7 days;  operative mortality rate was unrelated to the time from infarction to operation. Five of six deaths were in patients with preoperative cardiogenic shock who were not supported by an external cardiac assistance device. The two survivors of cardiogenic shock, treated preoperatively with the intraaortic balloon pump (IABP), are now asymptomatic. Early operative intervention is recommended to decrease the mortality rate in patients with complications of acute myocardial infarction unresponsive to conventional medical therapy. Preoperative treatment with the IABP is advised for the patient in cardiogenic shock.


Effect of perfusate temperature on myocardial protection from ischemia. During reperfusion, functional and metabolic recovery of the isolated working rat heart from one hour of ischemia was best in hearts selectively cooled at the onset of the ischemic interval by perfusion with 5 to 10 ml. of 10 degrees C. or 15 degrees C. Krebs-Henseleit buffer. Hearts similarly perfused at 4 degrees C., 20 degrees C. recovered significantly less well or not at all. Immediately after the hour of ischemia and prior to reperfusion, the absolute levels of glycogen and high-energy phosphates were best in the hearts perfused at 4 degrees C. However, metabolic function was best preserved in those perfused at 10 degrees C. and 15 degrees C., as evidenced by rapid recovery of high-energy phosphates and glycogen to control levels compared to metabolic deterioration in the 4 degrees C. group.


Percutaneous aspiration biopsy of nodular lung lesions. Over a 24 month period, 39 patients with nodular lung leasions suspected of being malignant on chest x-ray study underwent transthoracic needle aspiration biopsy. An accuracy rate of nearly 100 per cent was obtained in 34 of the lesions subsequently proved to be malignant. Achieving these results requires very close cooperation between the departments of radiology, cardiology, and cytopathology.


Monitoring of intraoperative heparinization and blood loss following cardiopulmonary bypass surgery. Two protocols of heparin management during cardiopulmonary bypass were compared to assess the role of the activated clotting time (ACT) in relation to postoperative blood loss. The study was divided into two groups: Group I, the control group, in which 3 mg. of heparin per kilogram was given as the initial dose and maintained at a dose of 1.5 mg. per kilogram every 45 minutes during cardiopulmonary bypass, and Group II, in which the initail dose of heparin was 2 mg. per kilogram and additional dosage were based upon the ACT. We found a striking decrease in postoperative blood loss as well as a decrease in the amount of heparin administered during cardiopulmonary during cardiopulmonary bypass in Group II patients. In addition, less protamine was required to neutralize the heparin in the second group after bypass. Thus, when patients are given too much heparin, as in our control group, the effectiveness of protamine is decreased. We would like to stress the value of the ACT in controlling heparin administration as well as postoperative blood loss in cardiopulmonary bypass surgery.


Melanoma of the head and neck.

Melanoma of the head and neck. A retrospective review from 1935 to 1962 of 772 melanomas involving the head and neck seen at the Pack Medical Foundation (PMF) is presented with the main emphasis of 660 cutaneous and mucosal melanomas. Clark's levels for pathologic invasion are presented and correlated to 289 cases with 19 percent in Level II and 81 percent deeply invasive at Level III, IV, and V. The face was the most commom location with the cheek alone accounting for 22.3 percent of all the cases. The male to female ratio was 1.5 to 1 with 76 percent of the cases being equally distributed among the fourth through the seventh decades. 55.9 percent were local disease, Stage I, with 33.5 percent, Stage II, and 10.6 percent, Stage III or distal disease. The five-year or greater absolute cure rate in positive nodal disease was 12.6 percent. Elective versus no elective neck dissection in Stage IA disease demonstrated a five-year or greater absolute cure rate of 55 percent as compared to 38.5 percent. Distal metastases occurred in 30 percent of cases with elective neck dissection but in 70 percent of those cases with therapeutic neck dissection. The absolute five-year or greater cure rate was able to be analyzed in 556 cases. The rate was 25.6 percent for the mucosal and cutaneous lesions combined; an 8 percent rate for mucosal alone and 27.8 percent for cutaneous melanoma. The five-year or greater absolute cure rate for those cases treated totally at PMF was 35.4 percent.


Malignant neoplasms of the nasal cavities and paranasal sinuses: (a retrospective study). This study presents a retrospective look at 115 patients evaluated here from 1957 to 1974. In this series, 57 percent were males and 43 percent females, 84 percent were Caucasian and 16 percent Negro. Lesions confined to or originating in the antrum made up 67 percent while nonantral lesions were 33 percent. Mean age at diagnosis was 59.1 years. Smoking and drinking history did not appear to be contributory. Antral lesions were retrospectively staged according to Sisson's TNM classification. Sixteen tumor types were involved, with the most common being epidermoid. Diagnosis was most often made by intranasal or Caldwell-Luc biopsy. Most frequent symptoms, as well as earliest symptoms, were nasal obstruction, localized pain, and epistaxis. Average duration of symptoms was 6.4 months. Therapy was generally in the form of radiotherapy alone, preoperative radiotherapy and surgery, surgery and postoperative radiotherapy, or surgery alone. Local recurrences occurred in 44 percent of antral lesions and 50 percent of non-antral lesions. Regional (cervical) nodal metastases developed in 25 percent of antral lesions and 11 percent of non-antral lesions. Distant metastases developed in 30 percent of antral cases and 35 percent of non-antral cases. Five-year survival was 32 percent (35 percent determinate) for the total group. The more advanced the staging of the antral lesions, the worse the prognosis. Best survival figures were in the areas of preoperative radiotherapy and surgery at 38 percent (43 percent) and surgery alone at 56 percent (59 percent).


The medical and surgical approach in management of the unilateral opacified antrum. The approach to the diagnosis and treatment of the patient with the unilateral opacified maxillary antrum presents a challenging problem. A total of 55 patients have been completely followed over a six-year period. Medical management, immediate, and delayed surgical intervention are discussed over a broad array of cases. Approximately one-half of those cases not requiring immediate surgical intervention recovered on medical management alone. The requirements for eventual surgical intervention and the results are discussed in the remaining cases.


Mediastinal dissection--1976: indications and newer techniques. Head and neck neoplasms may invade the mediastinum by direct extension or metastases to the tracheoesophageal or jugulo-subclavian lymph nodes. The clavicles and manubrium are a barrier to adequate resection in this type of disease. In 1962, the senior author reported six mediastinal dissections for stomal recurrences after laryngectomy. Later techniques for staging the removal of manubrium and clavicles and preparing the regional flaps were devised to avoid major complications arising from operating in this area which usually had prior treatment with radiation and/or surgery. Over 60 transsternal radical neck dissections have been performed in the past 20 years. We have in the past evaluated the morbidity and survivals in stomal cases and present here our revised indications and techniques.


The applied anatomy of thyroglossal tract remnants. Recurrences after surgery for thyroglossal cysts and fistulas were common until, in 1920, Sistrunk described his technique for removing the whole thyroglossal tract. Since that time there has been considerable argument concerning the exact path taken by the tract particularly in relation to the hyoid bone. In an attempt to elucidate this problem, studies have been made of embryos at varying stages of development, of serially step-sectioned adult larynges and of surgical specimens. These studies suggest that the thyroglossal tract occupies a constant and embryologically predictable position in relation to the hyoid bone and they support the rationale of Sistrunk's procedure.


Seventy-six cases of presumed sudden hearing loss occurring in 1973: prognosis and incidence. A sudden hearing loss (SHL) research clinic to which 30 members of an ENT Society refer patients, accumulates information about incidence, prognosis, recovery patterns, and treatment of SHL. The diagnostic protocol includes laboratory, audiometric, and radiologic studies; patients are followed for a minimum of 10 months. Among 76 patients seen in 1973, the diagnosis of idiopathic SHL was retained in 52; more specific diagnoses were established in 24. The incidence of SHL in the general population is estimated at 10.7 cases per 100,000. Although the therapeutic protocol was individualized, all patients with idiopathic SHL were advised to restrict dietary sodium, to discontinue use of stimulants, and were given instructions regarding activity. Twenty-six patients received prednisone. Results indicate that prednisone may have a beneficial effect when administered before the 10th day of SHL. Increasing age, hypertension, diabetes, and severe vertigo were found to be poor prognostic indicators. Outcome was significantly better in patients seen early in the course of their illness than in those seen later. Possible etiologic factors include vascular dysfunction and inflammatory response. Further studies of controlled series are needed to establish standards for diagnosis of SHL and its recovery pattern.


Leukocyte antigens and disease: III. Association of HLA-B8 and HLA-BW 15 with insulin-dependent diabetes in three different population groups. The distribution of 20 HLA antigens in 382 diabetic and 184 control subjects of white, Mexican-American, and black ancestry was studied. In all three populations, the incidence of antigens BB and BW15 was higher in the insulin-dependent diabetics than in the controls. The differences fell short of statistical significance when corrections were made for the number of antigens studied. When the results of previous studies were combined with our own, there was a highly significant association of insulin-dependent diabetes and the antigens BB and BW15 in the white population. It seems highly likely that this association would also hold true for the Mexican-American and the black diabetics if a sufficient number of patients were studied.


The effects of prolonged fasting on plasma triglyceride kinetics in man. Studies were undertaken to examine triglyceride turnover in obese humans on isocaloric balanced diets and during prolonged (3-5 wk) fasting. The data were related to plasma concentrations of insulin (IRI), glucagon (IRG), and free fatty acids (FFA) and to blood ketone concentrations. The triglyceride turnover rates were also related to the plasma triglyceride concentration. This relationship was the same in the obese on isocaloric balanced diets as that we have previously observed in lean humans on similar diets. The relationship between triglyceride turnover and concentration changed during prolonged fasting in a way that suggested that triglyceride removal was impaired. This viewpoint is consistent with the known effects of fasting on adipose tissue lipoprotein lipase activity. In another group of fasted obese, refed with a hypocaloric diet, the relationship returned toward normal. In addition to the impaired triglyceride removal, prolonged fasting resulted in a decrease in triglyceride production. This decrease occurred despite an increase in plasma FFA. After 3-5 wk of fasting the IRI was about 50% of the initial value, while the IRG was the same as the initial value. While triglyceride production fell during fasting, the blood ketone concentration rose. Others have seen similar changes in ketones and triglycerides in livers perfused with medium in which the ratio of insulin to glucagon fell. The rate of triglyceride production was not related to body weight. However, regardless of nutritional state, it was positively related to the basal plasma insulin levels. These data indicate that, in man as in animal preparations, insulin may regulate hepatic triglyceride production.


Cerebrospinal fluid glycine in nonketotic hyperglycinemic: effect of treatment with sodium benzoate and a ventricular shunt. In three infants with nonketotic hyperglycinemia, glycine was increased three-to fourfold in plasma, 13- to 28-fold in lumbar spinal fluid, and was higher yet in ventricular fluid. Oral sodium benzoate lowered cerebrospinal fluid (CSF) glycine by greater than 40%, but did not change the abnormal plasma: CSF ratio. An adult control, made hyperglycinemic with oral glycine, had a normal plasma: CSF ratio. Treatment of one patient with sodium benzoate from birth did not prevent mental retardation; the degree of brain stem depression was a function of CSF glycine in another patient. The persistance of glycine elevation in CSF, although therapy maintained normal concentration in plasma, appears to be caused by overproduction in brain and limitation of the high-capacity lumbar spinal reabsorptive mechanism. Treatment through lowering of CNS glycine by use of a ventricular shunt was explored.


Acute effects of bovine growth hormone on renal calcium and phosphate excretion. To evaluate the acute effects of bovine growth hormone upon renal hemodynamics and urinary electrolyte excretion, clearance studies were performed in intact and thyroparathyroidectomized dogs, receiving either vehicle alone or bovine growth hormone. Growth hormone had no effect when compared to controls upon glomerular filtration rate, renal plasma flow, or clearance of sodium, calcium, and phosphate either in the presence or absence of parathyroid hormone. It is concluded that acute changes in circulating growth hormone levels do not play an important role in calcium and phosphate homeostasis. The data suggest that previously described antiphosphaturic and hypercalciuric actions of growth hormone are not due to direct acute renal tubular effects but may be the result of indirect effects of chronic growth hormone administration.


Urinary excretion of methylarginine in human disease. Methylated amino acids are excreted in urine upon degradation of some tissue proteins. The urinary excretion ratios of NG,N'G-dimethylarginine (syn-DMA) and NG,NG-dimethylarginine (unsym-DMA) were studied in healthy adults and in patients with various diseases. The normal ratio of sym- to unsym-DMA in urine was 0.98 and ranged from 0.71 to 1.33; ratios were not significantly different in multiple sclerosis, cerebrovascular accident, cancer, and systemic lupus erythematosus. However, patients with liver, disease, including chronic active hepatitis, were found on average to have a significantly altered ratio of 0.79, range 0.49-1.30, owing to an increase in the excretion of unsym-DMA. Hence measurements of the urinary excretion of dimethylarginine could become a useful aid in assessing recovery of liver cells in patients with chronic liver disease.


Incidence of antibiotic-related diarrhoea and pseudomembranous colitis: a prospective study of lincomycin, clindamycin and ampicillin. An existing intensive drug monitoring system was used to study the occurrence of pseudomembranous colitis and diarrhoea in 100 patients treated with lincomycin and clindamycin. In order to give perspective to the results an equal number of matched patients treated with ampicillin were also studied. The incidences of diarrhoea in both groups were similar (11% in the lincomycin-clindamycin group and 8% in the ampicillin group). One patient developed pseudomembranous colitis associated with two prolonged courses of lincomycin therapy. The results suggest that the risks associated with the use of lincomycin are acceptable if the drug is given for the approved specific indications.


The nature of the problem in a Sydney suburban population. The importance of trauma as a cause of disability and death in a suburban population has been documented. Nearly 10% of all hospital admissions and 50% of all casualty attendances at major hospitals in a city region were due to accidents. It was shown that the majority of injuries are due to sporting, work-related and domestic accidents and not to traffic accidents. It is believed that attention should be directed toward the identification of more detailed causes of domestic, sport and work accidents, to the education of the public and authorities concerned with these hazards and to the application of preventive measures involving the concept of "engineering out".


Gait rehabilitation for an arm amputee.

Gait rehabilitation for an arm amputee. This report is concerned with a male motor bike rider who was injured in a collision with a semi-trailer in June 1974. As a result of his injuries he had his right arm amputated, his right knee restricted, and his right foot partially amputated and pinned. This article presents the subsequent management of the patient which was aimed at achieving an acceptable foot and preventing further breakdown in other body linkages. The design of appliances and treatment were carried out by the physiotherapist, the chiropodist, and the bioengineer.


An unusual complication of corticosteroid therapy for sarcoidosis. This report describes the rapid development of an amoebic liver abscess in a patient receiving prednisone by mouth for hypercalcaemia associated with sarcoidosis. The diagnosis and treatment of amoebiasis in this setting are discussed.


Some considerations concerning institutional placement of retarded children. The question whether retarded children should be institutionalized is discussed in the light of how, on the one hand, children can be successfully cared for at home and, more extensively, the serious problems that often arise at home. Institutions are not seen as the dreaded places they are often believed to be, and the frequent advantages to the retarded children of institutional care are discussed.


Dysprosium-159 for transmission imaging and bone mineral analysis. The suitability of the intense Kalpha x rays of terbium emitted in the electron-capture decay of 159Dy for use in transmission imaging and bone mineral analysis is investigated. It is found that this radionuclide offers all the advantages of radiations from 210 Pb and none of the disadvantages inherent in the use of the latter. Yields of the Kalpha and Kbeta x rays of terbium and the 58-keV gamma rays emitted in 159 Dy decay are determined using a high-resolution Si(Li) photon spectrometer. Attenuation coefficients for these photons in gadolinium (critical) absorber are measured in a narrow-beam geometry. For Tb Kbeta x rays, whose average energy is only about 0.4 keV above the K edge or Gd, our experimental attenuation coefficient is about 10% less than the theoretical value given by Storm and Israel. Transmission images of regular and irregular bones obtained using 159Dy are presented.


Experimental tests of proton beam localization. The depth of penetration of heavy charged-particle therapy beams is sensitive to the density of tissues traversed. Maximum depth of dose contours will vary appreciably as the beam passes through bone, muscle, lung, and air or gas. Calculations suggest that beam activation of the short-lived positron-emitting isotope 15O in vivo will permit localization of proton therapy beams with resonable detected-event density and dose. Preliminary tests of this method indicate that the beam can be located at depth with a typical dose of 15 rad, using a large field-of-view positron camera on-ling. This technique is also applicable to other heavy charged-particle beams, negative pions, and heavy ions.


Scattered radiation from a neutron collimator. Fast-neutron beams are being employed in radiotherapy trials and associated radiobiology studies at numerous centers in the U.S., Europe, and Japan. Since collimated beams of various sizes and shapes are employed, it is desirable to know the composition of the scattered radiation component contributed by the collimator. A simple method is shown for deducing the field composition in terms of a three-component model, from measurements made with three ionization chambers (tissue-equivalent, graphite, and magnesium). The dose contributed by the scattered radiation in the present example was found to be predominantly due to fast neutrons indistinguishable from those in the primary spectrum (from 35-MeV D+ on Be). This method may prove useful for measurements in phantoms as well.


Response of tissue-equivalent ionization chamber to 15-MeV neutrons. The calibration (in rad/nC) of an air-filled tissue-equivalent ionization chamber for neutrons of 15-MeV average energy was determined by measuring absolute fluences and calculating the kerma per unit fluence. The neutron calibration determined from the gamma-ray calibration and application of the Bragg-Gray relation was found to be 4% higher than that based on the fluence measurement. Additional data were taken to obtain calibration factors with tissue-equivalent gas; the same difference betwen the two methods was observed.


Changes in histologic and biochemical indexes of bone turnover after bilateral nephrectomy in patients on hemodialysis. Evidence for a possible role of endogenous calcitonin. We studied the effects of bilateral nephrectomy on bone metabolism in 27 patients on maintenance hemodialysis. After nephrectomy plasma alkaline phosphatase fell rapidly in 10 patients whose preoperative plasma levels had been higher than normal. This fall was associated with a transient decrease in osteoblast counts of iliac-bone biopsies. A fall in plasma phosphate and a rise in plasma immunoreactive calcitonin also occurred, but calcium and immunoreactive parathyroid hormone levels did not change. Alkaline phosphatase levels remained unchanged in a control group of 17 patients on dialysis who had undergone an operation other than nephrectomy. In 26 nonsurgical patients on dialysis, immunoreactive calcitonin was inversely related to osteoblast counts. Rises in immunoreactive calcitonin may be partly responsible for the transient decreases in bone turnover after bilateral nephrectomy. Low levels of endogenous calcitonin may allow an increase in bone turnover in chronic renal failure.


Erythropoiesis in familial erythrocytosis. We found primary erythrocytosis in two male siblings with hematologically normal parents. To clarify the abnormalities in erythropoiesis, we studied erythropoietin production in the older sibling as well as in vivo and in vitro responses of bone marrow to various stimuli. His erythropoietin excretion after a 1000-ml phlebotomy increased by 0 to 11 units per day. In liquid-suspension culture, erythropoiesis was prominently augmented by erythropoietin and unstimulated erythropoiesis was greater and more prolonged than normal. Numbers of erythroid colonies rose in methylcellulose culture without exogenous erythropoietin, and cloning increased with added erythropoietin. Anti-erythropoietin antibody substantially decreased erythropoiesis in vitro. Increased bone-marrow erythropoiesis was also demonstrated in murine diffusion chambers. The principal abnormality in this familial erythrocytosis appears to be a greatly expanded erythropoietic precursor pool that is responsive to erythropoietin in vitro and in vivo. This abnormality is analogous to the functional erythropoietic defect in typical polycythemia vera.


Magnetic enhancement of electron dose distribution in a phantom. We have measured the effect of a 10-kG magnetic field on the dose distribution of electrons in a polystyrene phantom. Isodensity plots and depth-dose curves are presented for 22- and 28-MeV electron beams with and without the magnetic field applied. The measurements show that magnetic fields as low as 10 kG can produce a substantial modification of the absorbed dose distribution. When compared with the zero-magnetic-field distribution of the same energy, the magnetic field significantly improves the Dmax- surface dose ratio and increases the fall off in dose past the Dmax region.


Fast Fourier digital quantum mottle analysis with application to rare earth intensifying screen systems. The advent of fast Fourier techniques has greatly facilitated the digital analysis of noise power spectra (Wiener spectra) by circumventing the need for the autocorrelation function. We are now able to Fourier analyze film data at about the same rate the microdensitometer-computer system can collect it (1000 points/sec). The new technique has been applied to the analysis of the quantum mottle of several rare earth intensifying screen systems confirming earlier estimates from our pilot studies that such screens are capable of reducing exposure by a factor of about 2 with imaging parameters comparable to those of conventional calcium tungstate systems.


Decision analysis to evaluate lymphangiography in the management of patients with Hodgkin's disease. We used decision analysis to explore the role of lymphangiography for staging Hodgkin's disease. Factors included were status of the patient before the test, accuracy and mortality of lymphangiography, mortality of laparotomy and effectiveness of selected treatment. We analyzed hypothetical cases with varying probabilities being in Stages I+II, III and IV to determine the population in which indication for laparotomy would depend upon results of lymphangiography. Calculations made for asymptomatic patients revealed that the diagnostic usefulness of lymphangiography is restricted to patients either with a relatively low probability of Stage IV or with a very high probability of Stage IV disease. This population is further restricted as false-positive and false-negative results of lymphangiography increase.


Sample mass determination using Compton- and total scattered excitation radiation for energy-dispersive x-ray fluorescent analysis of trace elements in soft tissue specimens. Compton profiles and total scattered intensities have been measured to determine the total sample mass, analyzed by an x-ray probe energy-dispersive analyzer. Under photon excitation, fluorescent x rays are emitted from the trace elements in a biological matrix. From incident radiation, the number of photons which are Commpton and elastically scattered by low-atomic-number elements is directly proportional to the total specimen mass. Tissue specimen masses have been measured from Compton intensities using Zr Kalpha and Ma Kalpha excitation x rays and mass calibration standards based upon carbon scattering. This procedure has been extended to include lower-energy excitation radiation, such as Cu, where the resolution of an energy-dispersion system requires that the total scattered intensity be used to determine the sample mass. Trace element weight-fraction concentrations are determined from this scheme with precisions of 1% in 2%, relying only upon information contained in the energy-dispersive x-ray spectrum. By adjusting for the difference between tissue and corbon scattering the accuracy of the elemental weight-fraction concentrations is brought to within 10% of elemental concentrations measured by atomic absorption spectroscopy, for samples weighing up to 25 mg. In the case of heavier samples, absorption corrections are necessary to achieve this accuracy.


Comparison of convolution and ray-tracing methods for computing small blood vessel images in angiography. Two methods for computing x-ray images of small blood vessels in angiography are presently available, namely, convolution and ray tracing. The convolution method, which is simpler and more powerful than the ray-tracing method, is based on the assumption that blood vessel imaging is isoplantic, whereas ray tracing is considered to provide correct images. In this study, the approximation error (difference between two images, normalized by the maximum value) due to nonisoplanatic imaging was determined by computation of blood vessel images according to both methods. The approximation error for geometric conditions normally encountered in angiography was less than 0.01. It is concluded that an approximation error of this magnitude is negligible and that the convolution method can be applied instead of the ray-tracing method for the computation of images of small blood vessels.


Modulation transfer function of the EMI CT head scanner. The two-dimensional modulation transfer function [MTF(vx, vy)] has been determined for the EMI CT head scanner by measuring the point spread function (PSF) in different locations in the field of view. This PSF was obtained by scanning a fine wire supported perpendicular to the tomographic slice. Based on these MTFs, the resolving power of the EMI scanner was found to be 3.1 line pairs/cm. Our results also verify the symmetry of the system response and the uniformity of the system resolution.


The toxicity of the non-ionic watersoluble contrast medium metrizamide (Amipaque) in selective vertebral angiography. An experimental study in rabbits. Selective left vertebral angiography was carried out in 21 rabbits comparing the toxic effects of meglumine iothalamate (Conray meglumine), meglumine metrizoate (Isopaque Cerebral) and metrizamide (Amipaque). The iodine concentration for all 3 media was 280 mg/ml. General convulsions were seen in many of the animals with all 3 media. The convulsions occurred at higher doses and were milder with metrizamide than with the 2 other contrast agents. Bradycardia was also seen with all 3 media and there was no statistical significant difference between them in this respect. The mortality was approximately 50% with both meglumine iothalamate and meglumine metrizoate, while no animals died following angiography metrizamide.


Experimental evaluation of watersoluble contrast media for myelography. An experimental method for testing contrast media for myelography was developed and used to compare three watersoluble contrast media, iocarmate meglumine, iothalamate meglumine and metrizamide after suboccipital myelography in 120 rabbits. A further 71 rabbits served as controls. Iocarmate and iothalamate caused vigorous convulsions; metrizamide did not. Examination of the CSF revealed an acute pleocytosis after installation of the contrast media and after cisternal puncture with injection of hypertonic saline. Histological examination of the spinal cord, nerve roots and meninges revealed pathological changes in 1 or 32 unoperatec controls (3%). Leucocyte infiltrations were found in the meninges, nerve roots and spinal cord of about 20% of the animals after myelography, after cisternal puncture without injection or with injection of hypertonic saline. There were no significant quantitative differences between the experimental groups. Degenerative changes were seen only after myelography. No meningeal fibrosis was demonstrated. An abnormal leucocyte count in the primary CSF influenced the incidence of histological changes, indicating that only rabbits with CSF cell counts within normal limits should be used in future experiments.


Fenestration of the middle cerebral artery. Three cases of angiographically demonstrated fenestration of the middle cerebral artery are reported. The incidence of demonstration of fenestration of the middle cerebral artery by angiography is 0.26%. Its clinical significance is discussed briefly.


Early filling of veins in the parietal region. The early filling of the parietal veins is not always pathognomonic for a lesion in this region. The parietal region is probably an area of special sensitivity where we can recognize circulatory disorders even if the primary pathology is located elsewhere.


Computerized tomography and encephalography. This preliminary paper compares encephalography and computed tomography as regards the duration of the examinations, the technical difficulties and their diagnostic values. Some examples are reported to demonstrate the complementary importance of the two techniques.


Computer tomography for lesions of the craniovertebral region. The images obtained by computed tomography constitute a new and interesting approach to lesions of the craniovertebral region. The criteria of basilar invagination must be systematically checked in routine examination. The main interest of CT scanning is the simultaneous view of the bony structures as well as the central nervous system in a completely innocuous way.


[Spontaneous bilio-biliary fistulae. Experience in 18 cases]. Six cholecyst-hepatic, nine cholecyst-hepatic-choledochic, and three cholecyst-choledochic spontaneous fistulae were observed in subjects (89% females) aged 28-76 (average 52) yr, forming 0.9% of a series of bile duct operands. Lithiasis is seen as the origin of these forms. A large calculus wedged in the gallbladder basis leads, due to decubitus, to symphysis between the basis and the main bile duct. Later, infection results in necrosis of the walls and gives rise to the fistula. The symptoms are not pathognomonic. Clinical diagnosis is virtually impossible and the condition is usually an unexpected surgical discovery. The only sound management consists of elimination of the fistula and calculus and reestablishment of free bilio-enteric transit. Anterograde cholecystectomy (including section of the organ in nearly every case) may or may not be accompanied by papillotomy. The fistulae is sutured or a bilio-enteric diversion is provided. Personal experience suggests that Y-diversion to the jejunal loop according to Roux is preferable to choledocho- or hepatico-duodenostomy. Very good results are usually obtained and mortality is low at 5-9%.


[Hypertrophic pyloric stenosis in the adult. Presentation of 4 cases]. 4 cases of hypertrophic stenosis of the pylorus, an infrequent benign  disease often associated with gastro-duodenal lesions and characterized by narrowing and lengthening of the channel owing to hypertrophy-hyperplasia of the circular muscular fibres, are reported. Aetiopathogenesis, diagnosis and therapy, namely always gastric resection, are discussed.


[Intestinal complications during a course of vascular reconstructive surgery. Case reports]. Twenty-one cases of gastro-enteric complications during aorto-iliac-femoral reconstructive surgery carried out from 1965 to 1973 in the Department of Surgery of University in Milan are studied. Causes, frequence, clinical data and medical and surgical procedures are discussed.


[Our experience in the surgical therapy of recurrent varicose veins]. After outlining the advances made by surgical technique in the radical treatment of varices veins of the lower extremities, the causes of recurrences are attributed to inadequate operating technique, an error of indication or to treatment of so-called arterial varices of Pratt. Personal experience with 435 operations for varices of the lower extremities carried out from 1971 to the present is reported. 33 cases of relapses or incomplete outcome were observed. The operating report on the occasion of the 2nd intervention showed persistence of the bulb of the internal saphenous vein with all or some of the collateral branches in 22 cases. In 4 cases the recurrence was due to failure to treat insufficiency of the external saphenous vein, and in the remaining 7 cases the cause was insufficient treatment of the communicating veins of the leg.


[Hypothesis on the embryologic moment in arising of the cystic dilatation of the choledodochus]. It is felt that congenital cystic dilatation of the common bile duct and duodenal stenosis with annular pancreas begin at the same moment during embryonal life in the light of an observation of these deformities in a sibship.


[Trans-sheath laparotomy of the rectus muscle in appendectomy]. Reference to personal experience covering 2035 appendicectomies is referred to in an account of the technique of transvaginal laparotomy of the rectus muscle. Here the sheath of the rectus and the peritoneum are incised at different levels and in different directions. The outside border of the sheath is not touched and the muscle is displaced medially, without section or displacement of the muscle fibres. If required, the operation can be extended upwards or downwards into a pararectal incision without departing from the context of the sheath. The technique is easy and gives ample vision. Closure is simple, rapid and cosmetically satisfying. The resulting solidity of the wall means that laparocele does not occur.


[Osteopetrosis (Albers-Schönberg disease). I. Clinico-radiological and pathogenetic aspects]. An account is given of recent clinical and radiological findings with respect to Albers-Schönberg disease. Reference is made to its hereditary transmission modality and clinical picture (skeletal lesions and haematological distress), and to its radiological aspects. Suggestions are made with respect to the aetiopathogenesis of disease. Stress is laid on the as yet undefined mechanism of "genotypical condensing dysplasia". The relation between osteopetrosis and thyrocalcitonin is discussed, though no definite conclusions could be drawn from the hormone levels determined in a personal series.


[Osteopetrosis ( Albers-Schönberg disease ). II. Personal contribution]. Five cases of marble bones in two families living near Brescia are presented. Case 1 (42-yr-old female) was a typical malignant form with deep and extensive eburnation, many pathological fractures, concomitant osteitis and the formation of many fistulae, massive spleen enlargement and infarct, and marked anaemia with clear signs of extra-medullary haemopoiesis. The patient died 5 yr after her first admission. Two of her brothers had had an identical, fatal form. Case 4 (28-yr-old male) was much the same: virtually general osteosclerosis despite the difference in age, marked spleen enlargement, a history of fractures, serious anaemia and extramedullary haemopoiesis. Benign pictures were seen in cases 2 and 3 (73- and 68-yr-old females). In case 5 (25-yr-old male), typical bone condensation was the only significant pathological sign. It is suggested that this, too, may be seen as a "benign" form.


[Epidemiological study on chronic bronchitis with special reference to various occupational environments in a sample of the population from the town of Pistoia]. The results of an epidemiological study of chronic bronchitis are examined with particular regard to the influence of occupational environment on the disease. The damaging effect of organic and inorganic dusts, because of the irritation they cause and the possibility of allergic sensitization, is pointed out. The importance of smoking in the onset and development of chronic bronchitis is also stressed.


[New aspects of the relation between work and pulmonary tuberculosis]. Two new aspects of the relation between work and T.B. are considered: T.B. secondary to psychologically stressing work, and as the result of contagion due to the presence of subjects with poorly marked T.B. symptoms in the work environment. Notes on preventive medicine are offered in the light of a personal series.


[Analysis of membrane proteins in pernicious anemia and various primary and secondary erythropathies]. A study of membrane proteins in pernicious anaemia and other haemolitic and anhaemolytic erythropathies is reported. Cellulose acetate and acrylamide gel electrophoresis was carried out and acid, neutral and basic amino acid contents were determined. Relatively specific alterations were noted. Chromatographic analysis of the amino acids suggested that in pernicious anaemia, as in other conditions, structural changes take place in the red cell membrane, though these may be confined to certain sectors. A constant alteration related to the concomitance or otherwise of erythrocyte hyperhaemolysis, however, could not be discerned.


The effect of fetal monitoring on the incidence of cesarean section. To determine whether routine fetal monitoring inevitably increases the cesarean section rate, we studied the pertinent literature and analyzed the cesarean sections performed at Evanston Hospital during the last 8 years. Many authors have found a slight to moderate increase in cesarean section rates, whereas others have found no change or a decrease. At Evanston Hospital, the primary cesarean section rate has increased from 2.6% in 1968-1969 to 6.9% in 1974-1975. Only 19.2% of this increase is due to increased fetal distress; the magnitude of the increase is due to changes in other factors, notably, breech deliveries (29.5% of the increase) and "dystocia" (60.2% of the increase). The incidence of cesarean section is controlled by several complex variables, only one of which is fetal monitoring. To describe the fetal monitors as the cause of the increased cesarean section rate is to ignore these other equally profound changes in obstetric technic and philosophy.


Pregnancy complicated by clinical diabetes mellitus. A study of 600 pregnancies. In a consecutive series of 600 pregnancies (618 infants) in 300 clinically diabetic patients, treated in Dublin, Ireland, the maternal mortality was 0 and the loss of viable infants was 9.5%. Therapeutic abortion and sterilization were not practiced. The cesarean section rate was 23%. The major causes of perinatal loss were hyaline membrane disease and congenital malformations. Recent routine estimation of the L/S ratio in amniotic fluid led to a reduced incidence of respiratory distress syndrome and a consequent improvement in perinatal mortality. At a very early stage in pregnancy diabetic patients should be referred to a center in which physician, obstetrician, nurse, and pediatrician operate as a team. Strict control of diabetes is essential.


Early labor initiation with oral PGE2 after premature rupture of the membranes at term. Two groups of healthy women at term, who were not in labor 3 hours after premature rupture of the membranes, were studied. In one group labor induction with oral prostaglandin E2 (PGE2) was begun 3 hours after rupture, and in the other group intravenous oxytocin induction was begun 12 hours after rupture. PGE2 was successful in initiating active labor in 88% of women treated. Of the women who were observed for 12 hours, one-half began labor spontaneously during that time. Women in whom labor was induced with PGE2 given 3 hours after rupture of the membranes had a shorter interval of rupture to delivery, a lower cesarean section rate, and shorter postpartum hospitalization. Although significant bradycardia did not occur in fetuses of those women given PGE2, 10% of infants whose mothers were receiving oxytocin were delivered by cesarean section for this reason. It is concluded that oral PGE2 is safe and effective for induction of labor in women with premature membrane rupture. The benefits, to both mother and fetus, of a shorter latent period are discussed.


Fetal lung maturation. III. The amniotic fluid cortisol/cortisone ratio in preterm human delivery and the risk of respiratory distress syndrome. Cortisol and cortisone have been measured in amniotic fluid samples obtained within 24 hours of deliver of 50 premature infants. When expressed as cortisol/cortisone ratios, the ratio tends to rise with advancing gestational age, although statistical significance is not attained. Both cortisol concentration and the cortisol/cortisone ratio are significantly lower in the amniotic fluid of infants who develop respiratory distress syndrome than in those with mature lung function (cortisol ratio: 19.2 +/- 10.3 ng/ml vs 26.1 +/- 9.4, P less than .02; cortisol/cortisone ratio: 1.2 +/- 0.6 vs 2.0 +/- 0.8, P less than .001). These findings also hold in the subgroup of infants less than 32 weeks' gestation but not in those infants at or beyond the 32nd week. The amniotic fluid cortisone concentration is significantly lower in infants born after spontaneous labor beginning with rupture of the membranes as opposed to after contractions or bleeding (13.2 +/- 3.6 ng/ml vs 16.3 +/- 6.1, P less than .05), although the cortisol concentrations and the cortisol/cortisone ratios are not significantly different.


Sinusoidal fetal heart rate pattern and severe fetal anemia. This report describes a case of a sinusoidal fetal heart rate (FHR) pattern encountered in a fetus at 34 weeks' gestation during antepartum fetal stress testing because of maternal hypertension. Delivery of the fetus was accomplished, and the newborn was found to be severely anemic and hypotensive due to a massive fetomaternal transfusion. Some pathophysiologic mechanisms are suggested, and the clinical significance of this finding is discussed.


Divergent biparietal diameter growth rates in twin pregnancies. Twenty-eight twin pregnancies were monitored by serial ultrasonic cephalometry from 30 or 31 weeks' gestation. The rates of growth of the individual twins as determined by biparietal diameters were similar in 11 cases (39%) and divergent in 17 (61%). When the rates of growth were divergent, the lesser rate was always below the mean for singleton pregnancies, and the incidence of small-for-gestational-age babies was 18 of 34 (53%). It was apparent that the greater the difference in biparietal diameters within the 2 weeks preceding delivery, the higher the risk of a small-for-gestation-age baby being delivered. No comment could be made on the growth rate prior to 28 weeks except that at diagnosis there was little or no difference in biparietal diameters.


Hormonal studies in pregnancy. III. Unconjugated esterone and estradiol in mother and fetus at delivery in IUGR. The levels of unconjugated estrone and estradiol in maternal vein serum during labor, in cord artery serum, and in cord vein serum were measured in normal pregnancy and in pregnancy complicated by intrauterine growth retardation. The mean level of unconjugated estrone and estradiol in maternal vein serum was significantly lower in the group with intrauterine growth retardation than in the normal patients (P less than 0.001 and 0.025, respectively). The mean unconjugated estrone and estradiol level in the cord vein was lower only in the most severely growth retarded subgroup. There was no difference seen in the cord artery values between the groups.


Clinical aspects of the polycystic ovary syndrome. One hundred and one patients with polycystic ovary syndrome (PCO) were treated during an 11-year interval. Sixty-seven cases were classified as typical PCO with enlarged ovaries of probable ovarian origin (Type I) and 34 as atypical PCO of probable adrenal origin (Type II). Fifty-five patients were treated for anovulatory infertility with clomiphene citrate or other endocrine therapy as indicated. There was a 91% ovulatory response and 51% conception rate from therapy in cases of Type I PCO. In Type II PCO, adrenal suppressive therapy resulted in a 55% ovulatory response. Our data support the concept that anovulation of ovarian origin as seen in PCO Type I responds to clomiphene therapy, while anovulation secondary to adrenal hyperandrogenization should be treated by adrenal suppressive therapy.


Maternal mortality due to ectopic pregnancy. A review of 102 deaths. Ectopic pregnancy represents an increasing proportion of direct maternal deaths which has reached 10%. Between 1950 and 1974 there were 102 deaths from early ectopic pregnancy reviewed by the Michigan Maternal Mortality Committee. These cases were analyzed by status on admission and compared to a control series treated at a medical center. Patients with ectopic pregnancy were older than women delivering live infants. There were no differences in age, gravidity, or parity between the study patients and controls. The study patients were slightly further advanced in pregnancy. Pain was the major presenting symptom. Marked delays occurred between first symptom, first consultation, and diagnosis. Seventy-five percent of the deaths were considered preventable. Hemorrhage was the leading cause of death. The estimated mortality of ectopic pregnancy is between 2 and 4/1000.


Conservative surgery for endometriosis in the infertile couple. Sixty-five infertile patients with moderate or severe endometriosis were treated with conservative surgery. Acosta's classification was used to demonstrate the extent of disease. In 48 women whose partners were normally fertile, 65% conceived, and in 17 whose partners were deficient, 35% achieved pregnancy. The extent of disease, age at the time of surgery, and length of infertility prior to surgery appeared to be significant factors. To intelligently give a prognosis prior to surgery and to achieve maximum pregnancy yield from the surgery, it is important to perform conservative surgery for endometriosis within the context of a complete infertility evaluation.


Vaginal hysterectomy in obese women.

Vaginal hysterectomy in obese women. The influenced of obesity in vaginal hysterectomy was examined by comparing the characteristics and outcome in 108 patients who weighed 200 pounds or more with matched controls weighing less than 200 pounds. Obese and nonobese subjects were similar in age and surgical indications, though overweight patients, who averaged nearly 60% above standard weight for height and age, were more likely to have hypertension and diabetes mellitus. Both operating time and operative blood loss were greater in obese patients, presumably because of more frequent employment of vaginal repair in this group. However, obese and nonobese patients did not differ significantly with respect to mortality (none in either group), postoperative febrile morbidity (62 and 56%, respectively), or postoperative hospitalization in excess of 12 days (19 and 16%, respectively). Thus, obesity does not seem to impose additional risks in vaginal hysterectomy, in contrast to abdominal hysterectomy in which the increased morbidity relates to wound infection.


Reducing the hospital stay following vaginal hysterectomy. A rapidly increasing waiting list in a new National Health service district general hospital made it necessary to explore measures to reduce the length of hospital stay of gynecologic inpatients without lowering the standards of medical care. Three years of experience with patients undergoing vaginal hysterectomy after January 1972 is described. During this time, 290 vaginal hysterectomies were performed and combined with pelvic floor repair in 194 cases. The average hospital stay for such patients was 12.7 days in 1971 before this study was commenced; since then this has been reduced progressively to 7.2 days with a corresponding increase in the number of such operations carried out annually. The effects of routine chemoprophylaxis and a modified technic of vault closure are discussed.


The false negative smear. II. The trapping effect of collecting instruments. One hundred and sixty-six conventional instruments of cell sampling used in gynecologic cytology were investigated after collecting tumor cells and normal squamous cells in vitro. Histologic preparations as well as scanning electronmicroscopic observations of wooden spatulas and cotton swab applicators revealed that despite smearing the material onto a slide, a large number of tumor cells remained trapped in the frames of such instruments. Five percent of the smears obtained showed no tumor cells. Similar results were obtained in preliminary observations in gynecologic patients having cervical atypias. The possibility was entertained that wooden spatulas and cotton swabs may be a source of some of the false negative results in gynecologic cytology.


Evaluation of abnormal cervical cytology. The results from cytologic, colposcopic, and histologic studies in 376 patients are analyzed and compared to previous reports. Cytologic results correlated within 1 degree of the histologic diagnosis in only 67% of cases. Colposcopic impression correlated with the final histologic diagnosis in 78% of cases. Directed biopsies were exceedingly accurate (99.3%) when the entire transformation zone was visualized. When the entire zone was not visualized, 7 cases of invasive carcinoma were discovered among 59 cone biopsies. It is concluded that cytology should be used only as a screening tool and colposcopy as a directional aid in obtaining biopsies and defining the need for endocervical curettage. When the entire zone is visualized, directed biopsies are dependable and cone biopsies may be avoided. When the upper zone is not visualized and the endocervical canal is involved by significant dysplasia or carcinoma in situ as diagnosed by directed biopsies and/or endocervical curettage, cone biopsy is mandatory prior to definite therapy.


The prevalence of cervicitis, reserve cell hyperplasia, squamous metaplasia, and cervical dysplasia in Jewish women. The prevalence of cervicitis, reserve cell hyperplasia, squamous metaplasia, and dysplasia was studied in Jewish women and compared to that reported elsewhere in non-Jewish populations. The study was based on a histologic review of 250 women whose cervices were clinically either normal or presented with minor changes, and of 50 cases of squamous cell carcinoma. The findings indicate that the prevalence of the above-mentioned histologic features in the 2 groups of Jewish women is similar to that observed in comparable groups of non-Jews. It thus appears that in a majority of Jewish women the histologic spectrum leading to cervical cancer unexplicably stops at the dysplastic stage. On the other hand, the results of this study may possibly cast doubt on the well-documented evidence establishing dysplasia as a pre-cancerous lesion. For further elucidation of these problems cytologic studies in matched Jewish and non-Jewish populations will be carried out.


Pelvic lymphadenectomy in women with carcinoma of the clitoris. Thirty-three women with carcinoma of the clitoris underwent surgical therapy, and 12% subsequently developed pelvic recurrence. However, none of the 18 patients without initial evidence of inguinal node metastases developed a pelvic recurrence. Of the 15 women with initial evidence of inguinal node metastases, 26.6% developed pelvic recurrence. It is, therefore, concluded that the addition of the routine use of pelvic lymphadenectomy to radical vulvectomy and bilateral inguinal lymphadenectomy in women with carcinoma of the clitoris is not warranted and that only those patients with histologically proven inguinal node metastases should undergo pelvic lymphadenectomy. If pelvic node metastases are documented, it is suggested that such patients receive postoperative pelvic irradiation.


Invasive adenocarcinoma of the uterine cervix. A series of 33 infiltrative adenocarcinomas of the uterine cervix treated during the period from 1965 to 1970 is assessed and compared with a previous series from this institution and with series reported in the literature. The findings indicate that adenocarcinomas constitute and increasing proportion of cervical carcinomas and in this series make up 9.6% of all cervical carcinomas as compared with a previous figure of 5.5%. Five patients in the series were 32 years of age or less, and all had been receiving oral contraceptives for varying periods of time prior to the diagnosis of carcinomas. Radical surgery or irradiation treatment followed by extrafascial conservative hysterectomy in appropriate cases may offer increased survival for operable stages of adenocarcinoma, particularly in the presence of bulky lesions.


Stage II endometrial adenocarcinoma. Memorial Hospital for Cancer, 1949-1965. Of 617 patients receiving initial therapy for endometrial adenocarcinoma from 1949 to 1965, 90 patients were retrospectively assigned to Stage II (FIGO) by reviewing preoperative, operative, and pathologic findings. In 66 patients (73%) the cervical spread of endometrial cancer was occult and detected only microscopically in the hysterectomy specimen, whereas in the other 24 (27%) it was detected clinically prior to surgery. The survival rate for patients with occult cervical involvement was better (61%) than in those patients with gross cervical spread of tumor (48%), but the difference was not statistically significant. When the surgical specimen revealed that the only spread was to the cervix, those having only occult spread had a better 5-year corrected survival rate (89%) than those with grossly detectable spread (57%). Spread of tumor beyond the uterus occurred in over one-third of the patients with each kind of cervical spread. Study of lymphadenectomy specimens in 31 patients revealed a similar incidence of lymph node metastases for both groups: 25% in those with grossly detectable spread and 21% in those with occult spread. Only 1 of the 7 patients with positive pelvic lymph nodes had clinically positive paraaortic nodes in addition to the positive pelvic nodes. Thus, only 1 of the 31 patients having the stnadard pelvic lymph node dissection was found to have paraaortic metastasis, as it was routine to sample only clinically positive paraaortic lymph nodes. These data suggest that in Stage II endometrial adenocarcinoma both gross and occult cervical involvement have a relatively bad prognosis and require aggressive therapy.


Single agent vs combination chemotherapy in the treatment of ovarian cancer. One hundred and eight patients with Stage III or IV epithelial ovarian cancers were randomly allocated to treatment with either melphalan or the combination of Actinomycin-D, 5-fluorouracil, and cyclophosphamide (ACFUCY). Those patients receiving the ACFUCY combination had a higher objective response rate and a statistically significantly lower progression rate. The ACFUCY combination gave a higher incidence of severe toxicity.


Midtrimester abortion by intraamniotic prostaglandin F2alpha. Safer than saline? Published reports disagree on the risks of intraamniotic prostaglandin F2alpha (PGF2alpha) for midtrimester abortion. To evaluate the safety and efficacy of intraamniotic PGF2alpha, we compared 1241 PGF2alpha and 10,013 saline abortions performed during the 13th to the 24th menstrual week. The results were reported in the Joint Program for the Study of Abortion/CDC, a multicenter prospective study. PGF2alpha abortions required less time (P less than .001) but had higher rates of major complications (P less than .01), antibiotic and operative treatment of complications (P less than .001), and readmission to a hospital (P less than .001). These findings challenge the current contention that PGF2alpha is safer than saline as an abortifacient.


Basal cell epithelioma of the vulva.

Basal cell epithelioma of the vulva. A case of basal cell epithelioma of the vulva is reported. Basal cell epitheliomata of the vulva are less rare than commonly thought. They are easily misdiagnosed and the proper treatment may thus be delayed.


Early pregnancy on the diaphragm with endometriosis. The source of hemorrhage in a young woman who required emergency laparotomy for intraabdominal bleeding was found to be a very early primary pregnancy implanted on the undersurface of the right diaphragm, far behind the dome of the liver. Immediately adjacent to this lesion were three tiny foci of endometriosis. This coincidence suggests that the site of nidation may have been a focus of ectopic endometrium rather than peritoneum.


Passage of mannitol from mother to amniotic fluid and fetus. Ten pregnant women and three pregnant sheep received mannitol intravenously. The results show that during late pregnancy this substance appears in amniotic fluid, and when the fetus is alive, its concentration increases with time, reaching values which are higher than those simultaneously obtained in maternal plasma. The experiments performed in sheep show that in fetal urine the concentration of mannitol reached values 10 to 20 times higher than those found in fetal plasma. This supports the hypothesis that the fetal kidney has an important role in the transference of this type of substance from the mother to the amniotic fluid.


Epidemiologic studies of measles, measles vaccine, and subacute sclerosing panencephalitis. Histories obtained in 350 of 375 clinically cofirmed cases of subacute sclerosing panencephalitis (SSPE) reported to a national registry showed that 292 patients had measles and 58 had no history of measles. Forty of the latter patients received live, attenuated measles virus vaccine. In patients with a history of measles, measles illness occurred before age 2 years in 46%, and a mean of 7.0 years before onset of SSPE. In contrast, there was no relationship of SSPE with age at vaccination in 35 of the 40 patients historically associated with measles vaccine, and SSPE occurred a mean of 3.3 years after vaccination. Based on estimated national measles morbidity data and national measles vaccine distribution data, the risk of SSPE following measles vaccination (0.5 to 1.1 cases/106) appears to be less than the risk following measles (5.2 to 9.7 cases/106). Because live measles vaccine is highly effective in preventing measles illness and a high proportion of children in the United States have received measles vaccine, these data are consistent with the observed downward trend in SSPE incidence since 1969.


Osteoid osteoma in children and young adults. Osteoid osteoma is a relatively common benign tumor of bone which occurs most often in adolescents and young adults. The pattern of the pain with its characteristic response to aspirin and the roentgenographic findings make the clinical diagnosis easy and virtually certain. An example is presented to help the pediatrician become familiar with the tumor and its diagnosis.


Frequency and etiology of gross hematuria in a general pediatric setting. Since the frequency of gross hematuria in general, unselected, pediatric outpatient settings has not been reported, we reviewed all patients with this symptom or sign at a pediatric emergency walk-in clinic during 24 consecutive months. Of a total of 128,395 patient visits, gross hematuria was proven in 158 (1.3/1,000 visits). Fifty-six percent of all patients had readily apparent causes for their gross hematuria. Twenty-six percent of all hematuric patients had documented urinary tract infections, but only 9% had apparent glomerular disease.


The early childhood development of 17 boys with sex chromosome anomalies: a prospective study. Seventeen boys with sex chromosome anomalies were identified at birth and followed up developmentally for two to five years. The 17 included 12 boys with 47,XXY, four with 47,XYY, and one with 46,XY/XXY mosaicism. None had major disabilities in physical, intellectual, or emotional growth. Some of the boys with 47,XXY were characterized as tall, inactive, poorly organized in motor functions, placid, and delayed in language; two of the four with 47,XYY were impulsive at 1 year of age. These deviations from normal were relatively mild; the boys were not found to be at high risk for grossly abnormal development in the early years.


Blood volume changes in patients with cystic fibrosis. Simultaneous red blood cell (RBC) and plasma volume determinations were obtained in 16 patients with cystic fibrosis (CF) and moderately severe pulmonary involvement. Hypervolemia with an increase in both RBC and plasma volumes was observed. Changes in blood volume were marked when values were indexed by weight but less significant when indexed by height. Decreasing systemic arterial oxygen saturation was associated with a progressive increase in RBC mass, hematocrit value, and hemoglobin level and a decrease in mean corpuscular hemoglobin concentration. RBC and total blood volumes were highest in patients with cor pulmonale and congestive heart failure. However, the compensatory polycythemic response in patients with CF was inadequate when compared with the response to hypoxemia in patients with cyanotic congenital heart disease. The insufficient oxygen-carrying capacity may compromise tissue oxygen delivery and necessitate treatment.


Prolonged continuous monitoring of intracranial pressure in severe Reye's syndrome. Evidence from both clinical and pathological investigations suggests that increased intracranial pressure (ICP) is a significant factor in the mortality of patients with Reye's syndrome. This, coupled with a critical review of our previous 22 patients, which failed to document the efficacy of exchange transfusion, led us to include continous ventricular pressure monitoring in the supportive care of children with Reye's syndrome. To date, three children, ages 3 to 5 years, have been managed with continuous ICP monitoring. All had stage IV coma by both clinical and electroencephalographic criteria. Peak blood ammonia concentrations were 1,036, 316, and 56micronug/100 ml; all had elevations of serum glutamic oxaloacetic transaminase level, prothrombin time, and creatine phosphokinase level as well. Rapid, unprediatble increases in ICP occurred for many days in all children. Therapeutic measures most successful in controlling ICP were the intravenous administration of mannitol and hyperventilation. Elevations in ICP occurred despite serum osmolality as high as 418 mOsm and following oral administration of glycerol. Rapid increases in ICP also resulted from routine manipulation of the patients (e.g., postural drainage). Exchange transfusion, used in two of the three patients, increased ICP in one child and had no effect in the other. All three children have achieved complete recovery and are doing well 6 months after their illness. Our experience with these children suggests that vigorous supportive therapy, including careful monitoring of ICP, should be used as a basis of comparison when evaluating claims of specific treatment in Reye's syndrome.


Intracranial pressure: monitoring and normalization therapy in children. The clinical course of 42 children with intracranial pressure monitoring was reviewed. Intracranial hypertension was documented in a variety of diagnostic categories. Therapy was titrated to maintain a baseline intracranial pressure of less than 15 torr (mm Hg), and to decrease the frequency of spontaneous and reactive pressure waves. Ventricular drainage, controlled hyperventilation, intravenous glycerol osmotherapy, therapeutic hypothermia, and barbiturate loading were employed as needed to achieve those goals. Survival was significantly related to average and peak intracranial pressure levels and to the degree of serum hyperosmolality that developed during therapy.


Gram-negative cerebrospinal fluid shunt-associated infections. Twenty hydrocephalic children with cerebrospinal fluid (CSF) shunts over an 11-year period were seen with Gram-negative central nervous system (CNS) infections. Seventeen infections were with single organisms and three were mixed. Sixteen of 20 (80%) of the infections occurred within five months of shunt surgery. Complete shunt removal or replacement in a new site plus systemic and intraventricular antibiotics resulted in a 100% (9/9) cure rate. Systemic and intraventricular antibiotics alone or in combination with incomplete shunt removal generally were unsuccessful. Significant morbidity and mortality were associated with these infections. Of the 18 patients with follow-up data, seven (39%) died with the infection, four (22%) sustained definite CNS damage, three (17%) were retarded after infection but their preinfection status was unknown, and only four (22%) patients escaped without definite sequela. Early recognition and appropriate therapy, hopefully, will improve the current bleak prognosis


Postnatal head shrinkage in small infants. The front-occipital circumference, frontooccipital and biparietal diameters, degree of suture overriding and weight were measured daily during the first week of life in 50 infants of birth weight under 2,000 gm. In a second similar group of 21 infants, fronto-occipital circumference, weight, and sodium balance were measured daily during the first week of life. Head volumes were estimated from the circumference and diameters of the head. The parameters of head size and derived volumes changed maximally and significantly in the direction of intracranial shrinkage around 3 days of age. The degree of shrinkage was significantly correlated (P less than .005) with the degree of weight and cumulative sodium losses, and decreasing gestational age. We postulate that postnatal head shrinkage results from shift of sodium and water outward from the intracranial cavity as a transient phenomenon during the first week of life. The significance of head shrinkage is discussed.


Erythromycin prophylaxis for pertussis.

Erythromycin prophylaxis for pertussis. A neonate admitted to the newborn nursery was found to have bacteriologically proven Bordetella pertussis whooping cough, and two of seven infants exposed to this child became infected. Erythromycin administration to the seven infants apparently prevented further infection as well as the appearance of clinical disease in the two infected infants. This limited experience supports previous reports of the efficacy of erythromycin in preventing B. pertussis infection and disease in susceptible children.


Cholestyramine therapy and intestinal obstruction in infants. Two infants are reported who developed partial intestinal obstruction following cholestyramine therapy for intrahepatic cholestatic syndromes. The hazards of this potential side effect of cholestyramine therapy are emphasized.


[Radiological exploration of the Budd-Chiari syndrome. Study of 13 cases]. Using 13 cases of Budd-Chiari syndrome, the authors describe their method of radiological investigation in order to reach a positive and sometimes aetiological diagnosis. Hepatic venous thrombosis can be confirmed only on the basis of findings at hepatic phlebography. Cavography, which precedes retrograde catheterisation of the hepatic veins, provides only presumptive evidence and sometimes reveals total thrombosis of the inferior vena cava. Coeliac and superior mesenteric, or even hyperselective hepatic arteriography, is of great value if there is inversion of the portal flow. Otherwise it only leads to a suspicion of the diagnosis, and makes it possible to determine the state of the portal trunk and to seek an aetiology.


[Digestive origin of Campylobacter septicemias]. Whilst the animal origin fo human Campylobacteriosis is generally accepted, its epidemiology remains ill understood. Animal contact prior to a Campylobacter septicaemia is only rarely found. The frequent occurrence of episodes of diarrhoea immediately prior to the onset has led to a suspicion of a digestive portal of entry. Our aim is to provide incontrovertible proof of this hypothesis, reporting the results of systematic stool examinations for Campylobacter in the stools as well as 5 new cases of septicaemia.


[Primary dissecting aneurysm of the renal artery with hypertension]. Dissecting aneurysms of the renal artery are the most common site of peripheral dissections without aortic involvement. The problems posed by this condition are analysed in the light of a personal cases and 52 in the literature. The onset in a young man of sudden loin pain followed shortly after by hypertension is suggestive of obstruction of a renal artery. The diagnosis can be confirmed only by arteriography, if the findings are sufficiently clearcut, which is not invariably the case. Surgical treatment gives good results and our own case clearly indicates the immediate and definitive relief of hypertension by nephrectomy. However the decision regarding surgery must take into account the possibility of recurrent peripheral lesions and of the possible reversibility of hypertension under the influence of medical treatment.


[Periodic oscillating respiration outside of comatous stages]. A periodic oscillating breathing was observed in 11 subjects during study of their pulmonary function. All these patients were male and more than 50 years old. A cardiovascular disease was clinically evident in eight of them. Arterial hypoxemia was found in five subjects and a light hypocapnia in three. Analysis of oscillating rhythms first, revealed unexistence of ventilatory pauses between periods of deep breaths in some subjects and secondly, showed existence of permanent or discontinuous periodic rhythms. Breath by breath changes in ventilation were essentially induced by oscillations in tidal volume. Discontinuous oscillating breathing appeared after forced maximal inspiration and this periodic rhythm was frequently associated with sights. This periodic breathing began or persisted under progressive hypoxia but disappeared under normobaric hyperoxia. These data are discussed in terms of changes in the ventilatory control system and in central regulation of breathing patterns.


[Is it possible to treat uremia by hemofiltration? Initial clinical results obtained with a poly-acrylo-nytril membrane]. Following to work of Quellhorst, the authors used an RP6 haemodialyser as an ultrafilter and exchanged 20 litres of plasma ultrafiltrate against 18 to 20 litres of physiological solution during 200 sessions of 4 to 5 hours in 5 patients with uraemia, over a period of 3 to 10 months. The technique is simple and tolerance excellent. The possibility of a new approach to the treatment of uraemia without dialysate makes a large clinical trial worthwhile.


[Idiopathic cyclic edema: disorders in water elimination accentuated by orthostasis]. Forty patients suffering from idiopathic oedema were studied. The disturbance in water excretion is characterised by a delay in excretion of a water load (20 ml/kg body weight), an inability to decrease urinary osmolarity below 137 mOsm/1 standing (normal: 60 mOsm +/- 25) and an inability to increase free water clearance: 2.36 +/- 2 ml/mn/1. 73 m2 (normal value: 6.8 ml/mn/1.73 m2) in the upright position. This problem of water excretion related to orthostasis defines and characterises the syndrome, the clinical picture of which is well known. The disturbance suggest a fault in the regulation of anti-diuretic hormone whilst the aldosteronism often described would seem to be inconstant and secondary to diuretic therapy too often prescribed without supervision.


[Coronary insufficiency in the female: possible effect of menopause]. A population of 239 women suffering from chronic coronary disease was divided into two groups according to whether or not they had sustained a myocardial infarction. For the 226 post-menopausal women, the type of menopause (natural or artificial) and their age at its onset were determined, together with the age of onset of the infarction or angina, and possible correlations with other risk factors in atherosclerosis. Whilst the average age at the time of artificial menopause was markedly less than that of natural menopause, the age of onset of coronary complications was comparable regardless of the type of menopause, this applying to both groups. Contrary to a classically accepted opinion, early menopause would not appear to favourise the premature development of atherosclerotic coronary problems, and, in addition, would not appear to affect other coronary "risk factors".


Sedative drug surveys in coma: how reliable are they? Routine blood tests of comatose patients for drugs that depress the CNS are highly desirable, but techniques of analysis are not well standardized and the results do not correlate well with clinical condition. Determining the role of sedative drugs in coma requires a high degree of suspicion and sound clinical judgment.


Family planning and the primary care physician. Family planning has become an important issue in modern life. The physician must be prepared to advise patients on the advantages and risks of both old and new methods and to determine which method is most acceptable and will therefore be most effective.


Toward a Biocommunications Network.

Toward a Biocommunications Network. Development and implementation of the Biocommunications Network in the Memphis region have relied on sharing of resources among hospital libraries. Implied in this system is the recognition that all health care professionals have a right of access to health sciences libraries.


Management of tuberculosis: altered role of the primary care physician. Increasing incidence of tuberculosis is being reported in some areas, even though greater precision in diagnosis and greater reliability in treatment have been achieved within recent years than were previously possible. The Mantoux test is a convenient office procedure that should be done more often. Patients with active tuberculosis can now be treated on an outpatient basis with little morbidity or social or economic disruption.


Thyroid nodules--benign or malignant? 1. Diagnosis. Radioisotope scanning is an invaluable aid in determining whether a palpable thyroid nodule is benign or malignant. In many cases, however, precise diagnosis is impossible without needle biopsy or surgical exploration.


Thyroid nodules--benign or malignant? 2. Management. On radioisotope scanning, thyroid nodules present one of five characteristic patterns. A "cold" nodule is most likely to be malignant and often necessitates surgery and functional ablation. However, any nodule that is growing and insuppressible probably should be removed.


Effects on hypothalamic and telencephalic NE and 5-HT of tegmental knife cuts that produce hyperphagia or hyperdipsia in the rat. Knife cuts in the coronal plane through various aspects of the midbrain tegmentum produced hyperphagia, hyperdipsia, or no effect on ingestive behavior. All of the cuts significantly depleted NE and 5-HT from hypothalamus and forebrain. The brains of hyperphagic or hyperdipsic animals did not differ from those of normophagic and normodipsic animals with respect to hypothalamic NE or 5-HT or telencephalic NE. Both hyperphagic and hyperdipsic animals had significantly lower concentrations of 5-HT in forebrain than rats which sustained similar cuts in the tegmentum which did not affect ingestive behavior.


Shock induced ethanol consumption in rats. Two experiments are presented which describe the temporal and volumetric changes in ethanol consumption by rats exposed to recurring schedules of inescapable random shock. The animals in Experiment 1, which had a choice between ethanol and water, increased their voluntary ethanol consumption immediately after the shock schedule. The postshock changes occurred with both 5% and 10% V/V ethanol, were specific to the presence of shock and were not reflected by measures of total daily ethanol intake. Experiment 2 exposed rats to extended 22 hr stress sessions, during which each animal had four simultaneous fluid choices available: water, saccharin 0.1% W/V, ethanol 5% V/V, and ethanol 10% V/V. Temporal intake patterns for both 5% and 10% ethanol showed pronounced peaks for the interval immediately following the shock schedule. A shift of intake from 5% to 10% ethanol was also demonstrated with increasing time under shock, while saccharin and water intake decreased. The results are interpreted as a relationship between voluntary ethanol intake and escape from the consequences of stress.


Interactions between delta9-tetrahydrocannabinol and phencyclidine hydrochloride in rats. delta9-Tetrahydrocannabinol (THC; 2.5, 5.0, 10.0 mg/kg, PO) impaired avoidance and rotarod performance, and caused bradycardia and hypothermia. Phencyclidine (PCP; 1.25, 2.5, 5.0 mg/kg, IP) impaired avoidance and rotarod performance and caused a marked increase in photocell activity. When combined, the depressant properties of each drug were enhanced and the stimulation of photocell activity cg/kg THC and its interactions with PCP followed subacute treatment for six days, whereas many of the effects of PCP were enhanced after subacute treatment with a dose of 2.5 mg/kg. Open-field behavior was affected by each drug alone and in combination in a similar way as photocell activity, but the depression caused by their interaction was greater; both drugs caused an increase in urination. Response rates on an FR-10 schedule of food reinforcement were decreased by 2.5 mg/kg PCP, but not by 5.0 mg/kg THC; the combination caused greater response suppression than either drug alone. The functional interactions between THC and PCP were not related to changes in the concentrations of 14C or 3H in plasma or brain derived from 14C-delta9-THC and 3H-PCP, respectively.


A method for sleep depriving rats.

A method for sleep depriving rats. A method is described for sleep depriving up to 12 rats at a time by placing them in two large rotating cylinders. EEG data, previously unavailable for rats treated in this manner, show that total sleep time was significantly reduced from 47.0% to 3.8% of a 24-hr period. There was no selective reduction of REM or non-REM sleep.


A logic circuit for identifying and reinforcing operant response durations. A simple circuit useful for the study of response duration and timing response in operant behavior in rats was described. Important features of the circuit include: a logic function to identify respondings with the preregistered duration, elimination of the premature reinforcement by the feeder operation during lever-pressing behavior, reinforcement after the complete release of the lever, simple design and inexpensive construction. Experimental results with and without the present circuit were also given.


Effects of central norepinephrine depletion on the initiation and maintenance of maternal behavior in the rat. The catecholaminergic neurotoxin, 6-hydroxydopamine (6-OHDA), was used to test the hypothesis that increased transmission across selected noradrenergic synapses is involved in the initiation of maternal behavior. Specifically, 6-OHDA was infused intraventricularly either two days before parturition or four days after parturition. Control animals were infused with the vehicle alone. Among prepartum animals, NE depletion of more than 30% of control levels interfered with the initiation of maternal behavior. Among lactating animals, similar degrees of NE depletion had no significant effect on the maintenance of maternal behavior. Thus, NE appears to be involved in the initiation of maternal behavior, but not in the maintenance of the behavior once that behavior is established.


Influences of genotype and sex on behavioral tolerance to nicotine in mice. Spontaneous motor activity in a Y-maze was measured in DBA/2Ibg and C57BL/6Ibg mice which had received nicotine or saline injections three times a day for two, four or seven days. Both genotype and sex influenced the development of tolerance to nocotine's effects on spontaneous motor activity, with DBA males requiring the longest exposure to nicotine and C57 males requiring the shortest drug exposure for tolerance development. DBA and C57 females developed behavioral tolerance equally after two days of pretreatment, but the C57 females showed a greater degree of tolerance after seven days of injections than did the DBA females. The development of behavioral tolerance in DBA males after four days of nicotine pretreatment was associated with the development of behavioral tolerance in DBA males after four days of nicotine pretreatment was associated with the development of drug dispositional tolerance, with minimal evidence for a change in nervous system sensitivity. Drug dispositional tolerance in DBA females, C57 males and C57 females, however, did not seem to affect spontaneous motor activity.


Effects of marihuana on reaction time and short-term memory in human volunteers. Twenty-seven adult male marihuana smokers volunteered to participate in a hospital research ward study for a 31-day period. Following five days of baseline acclimatization, subjects could purchase and smoke marihuana cigarettes on a free choice basis for a period of 21 consecutive days. The marihuana smoking period was followed by a concluding five-day baseline. Measurements of simple reaction time, choice reaction time and short-term memory were carried out during the entire study. Analysis of variance revealed no statistically significant differences between control and marihuana performance; however, a correlational analysis showed that individual subject performances on all three tasks were significantly correlated from test session to test session during control conditions but not during marihuana smoking conditions. Findings are discussed in relation to attentional and motivational factors associated with performance on the three tasks.


Taste aversion disruption by drug pretreatment: dissociative and drug-specific effects. Disruption of taste aversion learning following the administration of the same drug prior to and during conditioning (intra-agent disruption) was shown to be greater than disruption following the administration of one drug prior to conditioning and another during conditioning (inter-agent disruption). Comparable dosages of ethanol and lithium chloride served as unconditioned stimuli. Inter-agent disruptions are attributed to a dissociation of conditioned and unconditioned stimuli, while intra-agent disruptions are attributed to both a dissociative effect and drug-specific effects. Intra-agent disruption was correlated with an independent measure of tolerance, suggesting tolerance constitutes at least a portion of the drug-specific effects.