The evolution of molar occlusion in the Cercopithecidae and early Catarrhines. Those Eocene prosimians which are possible catarrhine ancestors have four blade-like crests on each lower molar. Each crest shears in sequence across two upper molar crests. Occluding crests are concavely curved to hold the foods being sheared. Each of two medial lower molar crests bordering the principal crushing surface shear past single upper molar crests at about the same time the lateral lower molar crests contact the second rank of upper molar crests. Grinding and crushing areas are restricted to hypoconid, trigonid, and protocone surfaces. Oligocene catarrhine molars have increased crushing-grinding capacities and maintained but modify their shearing. As the crushing surface of the protocone expands and a crushing hypocone is added, the "second rank" upper molar shearing crests are functionally reduced. At the same time medial crests are increasingly emphasized so that the total shearing capacity remains virtually unchanged. Marginal shearing blades are straight edged; leading edges of occluding blades are set at different angles to the occlusal plane so that blades contact at only one point at any given time. Early Primates have separate crushing basins surrounded by shearing blades. Catarrhines tend to link explanding crushing surfaces anteroposteriorly into a continuous surface between all molars. A cladistic analysis based on both new and previously recognized characters indicates that: 1. Apidium may be more closely related to Aegyptopithecus than to Parapithecus; 2. cercopithecids are derived from a Parapithecus-related stock; 3. Oreopithecus could equally well have come from an Apidium or Aegyptopithecus stock.


Stress and the etiology of osteoarthritis. Although degenerative joint disease is an old and exceedingly common problem, clinical investigators have not reached a consensus regarding the etiology of this disease. Comparative osteological analysis of the knee, hip, shoulder, and elbow joints of 789 individuals from four human skeletal populations (Black and White Americans, Pueblo Indians, and Alaskan Eskimos) indicates that age of onset, frequency, and location of degenerative changes are directly related to the nature and degree of environmentally associated stress, as reflected by the variable life styles of the populations sampled. Eskimos have the earliest onset and most severe involvement for all four joints studied, the right side is usually more affected than the left, and Blacks are more frequently involved than Whites in the knee, shoulder, and elbow. Functional stress, when constant and severe in nature, becomes the primary focus of degenerative disease, but other background contributing agents such as age, sex, and hormonal influence must not be ignored.


Brief hospitalization: a two-year follow-up. The author present two-year follow-up data of a controlled study of 175 newly admitted inpatients who lived with families, comparing the relative efficacy of brief hospitalization (with and without transitional day care) and standard hospitalization (with all patients offered outpatient aftercare). The long-term results confirm the preliminary finding that brief hospitalization is preferable to longer term hospitalization for most patients. Briefly hospitalized patients spent significantly less time as inpatients and showed less psychopathology and impairment in role functioning. In contrast to preliminary findings, the long-term results indicate that use of day care reduced the number of inpatient days.


Dangerousness, confidentiality, and the duty to warn. The Tarasoff decision, by imposing on psychiatrists an obligation to warn the intended victim of threats made by a patient, but only under certain vaguely specified circumstances, may stampede psychiatrists into issuing such warnings to avoid possible legal liability no matter how remote the risk of harm may actually be. The authors suggest that the ill effects of such a reaction by psychiatrists--breach of confidentiality and the attendant erosion of trust and harm to the therapeutic alliance--can often be easily avoided by taking less drastic steps, some of which are illustrated by case presentations.


Platelet monoamine oxidase activity in schizophrenic patients. The authors studied platelet monoamine oxidase (MAO) activity in 29 schizophrenic inpatients and 26 schizophrenic outpatients during a 4-week double-blind trial of chlorpromazine with imipramine or thiothixene with placebo. The found that significantly more schizophrenic patients than normal control subjects had low platelet MAO activity after 4 weeks. Outpatients with low MAO activity were distinguished by increased behavioral activity and reduced social apathy. Inpatients with low MAO activity were distinguished by severity of illness and symptoms. Hallucinations were significantly more frequent among patients with low MAO activity. The authors suggest that platelet MAO activity might decline in some actively schizophrenic patients as part of the psychotic process.


Postsynaptic supersensitivity in schizophrenia. In the context of the dopamine hypothesis of schizophrenia, the authors examined postsynaptic dopamine (DA) receptor sensitivity in schizophrenic patients by means of a neuroendocrine strategy using the DA receptor agonist apomorphine and growth hormone (GH) release as the measurable postsynaptic event. The activity of platelet adenylate cyclase, an enzyme intimately associated with catecholamine receptor activity, was also studied following stimulation by prostaglandin E1 (PGE1). Patients diagnosed as having acute schizophrenia had significantly higher GH responses and adenylate cyclase activity than normal control subjects and patients diagnosed as having chronic schizophrenia. Chronic schizophrenic patients with and without tardive dyskinesia showed GH responses slightly lower than but not significantly different from those of control groups.


Psychiatric consultation: concepts and controversies. There are two major models of consultation in the field of psychiatry, differing in their goals, participants, settings, and methods. The psychiatric-therapeutic model entails provision of optimal care for the individual patient; the community mental health model involves provision of assistance to mental health caregivers. The author believes that to enhance the value of consultation the consultation should restrict his or her role to that for which he or she has been trained. Current social needs, coupled with a limited supply of consultants, suggest that psychiatric consultation should be provided within comprehensive health care systems. There is a pressing need to clarify the concepts of formulations concerning the criteria of outcome of psychiatric consultation so that evaluation of its effectiveness can be advanced.


Psychotherapy and pharmacotherapy: conceptual lenses. Of the many difficulties in maintaining an integration of psychotherapeutic and pharmacotherapeutic treatment, one of the most important is "the problem of bimodal relatedness", that is, the distinction between relating to the patient as a diseased organ or object of study and as a disturbed person. The authors identify the forces that act to inappropriately emphasize one mode or the other and discuss major difficulties that arise because of failure to maintain a bimodal relatedness. In a setting of combined therapy, maintaining and safeguarding the optimal relationship of collaborative subject-subject relatedness can prevent the emergence of problem destructive to effective psychiatric treatment and research.


Catecholamine metabolism during heroin use. The authors examined urinary levels of catecholamines and metabolites during a 10-day period of heroin use in 9 subjects. Catecholamine and metabolite excretion increased over baseline values on the first day of heroin use, but markedly different patterns of change emerged later. In contrast to the significant increase in normetanephrine and decrease in metanephrine excretion in all 9 subjects during heroin use, only 4 subjects showed an increase in 3-methoxy-4-hydroxyphenyl glycol (MHPG) excretion. Moreover, it appeared that the increase in MHPG excretion in this subgroup began on the day before heroin administration, which suggests the possibility of an anticipatory or conditioned response.


Ten years of inpatient programs for alcoholic patients. The author reviews the progress made during the past decade in making acute hospital facilities available to the alcoholic patient. He also describes the advances that have been made in the level of care provided by increasingly available detoxification centers. However, he finds that the needs of chronically and permanently disabled alcoholic individuals are still not being met by the mental health system.


Prognostic implications of various drinking patterns in psychiatric patients. The authors examined the drinking patterns of 198 first admission nonalcoholic psychiatric patients to determine the relationship among drinking behavior, severity of pathology, and prognosis. Heavy drinking in the psychiatric sample was not associated with increased levels of pathology and poor prognosis. To the contrary, among these nonalcoholic patients the abstainers and occasional drinkers showed the most severe pathology and poorest prognosis of all drinking groups.


Cognitive and interactive aspects of splitting. The author discusses splitting, the segregation of multiple inner schemata of self and others, from the points of view of cognitive structure, cognitive process, anad interpersonal transaction. A case example illustrates how one borderline patient shifted fluidly during therapy among four isolated and sometimes incompatible representations of the doctor-patient relationship. The author concludes that therapists working with borderline patients must be aware of atypical transference patterns and may have to introduce, as a special nuance of therapy, work to stabilize patients' realistic self- and therapist images before offering interpretations.


Voluntary and involuntary treatment of aggressive patients. The author describes his experiences in treating violent patients in group therapy. Problems include the divergent goals of therapist, patient, and society; the environmental limitations on incarcerated patients; countertransference issues; and magical expectations on the part of patients. Therapeutic goals must be somewhat limited with patients who are forced into therapy. It may be dangerous to "open up" such patients, especially when they face lengthy prison terms. The author suggests that distancing tactics be avoided with violent patients, who need to encounter another person who has dealt successfully with hatred, fear, and limitations.


Absorption rate, blood concentrations, and early response to oral chlordiazepoxide. Ten healthy male volunteers received chlordiazepoxide (CDX) hydrochloride or matching placebo with Maalox or water in a four-way single-dose crossover trial. Coadministration of CDX with Maalox did not change the completeness of CDX absorption but significantly slowed its rate of absorption and the rate of desmethylchlordiazepoxide (DMCDX) appearance. Self-rating of feeling "spacey" at 1.0 and 2.5 hours were significantly increased over baseline for CDX taken with water but not with Maalox. Increases in "spacey" feelings at 1.0 hours were highly correlated with 0.5-hour but not with 1.0-hour blood levels. Similar findings were observed for self-ratings of "thinking" slowed down. Thus certain subjective effects of antianxiety agents after oral dosage may depend on the rate of drug absorption and may be attenuated or eliminated if the absorption rate is reduced.


Norepinephrine and 3-methoxy-4-hydroxyphenyl glycol gradients in human cerebrospinal fluid. The presence of abnormal levels of 3-methoxy-4-hydroxyphenyl glycol (MHPG) in the cerebrospinal fluid (CSF) of some patients with affective disorders may indicate abnormal norepinephrine metabolism in these patients. The authors evaluated the relationship between norepinephrine and MHPG in CSF and found that both are present in increasing levels as more CSF is removed from the lumbar puncture needle. Norepinephrine and MHPG are closely related, although norepinephrine levels are more variable within and between subjects. Both norepinephrine and MHPG levels in CSF should provide important information about norepinephrine metabolism in affective disorders.


The psychological effects of isolation in protected environments. The authors questioned the directors of 13 protected-environment installations on the psychological effects of protected environment treatment. Psychological problems reported included anxiety, depression, sleep disturbance, withdrawal, regression, and hallucinations. Children seemed to adapt better than adults to protected environments. Respondents recommended the use of preentry orientation, structured recreation programs, steps to prevent time disorientation, and psychological support for both patients and staff to minimize the psychological effects of treatment in protected environments.


Consultation in the college setting.

Consultation in the college setting. The author discusses the relationship between patient care and consulting and the rapport that contact between college health service psychiatrists and other college personnel can engender. People in the college community learn how psychiatrists approach problems and what they can or cannot do. Psychiatrists learn how people in a college setting function and are thus better able to understand and help both patients and consultees.


The reaction of the family system to rapid therapeutic change in one of its members. The family system can accommodate itself only to a certain amount of change in one of its members without manifesting a need or reorganize itself. The family response to such a change in one of its members is documented via three case examples in patients who were in individual therapy.


Male and female: the significance of values. Women's personal values as well as societal values regarding them have been undergoing significant changes. This trend is supported by recent rapid technological advances reaching into home and working place, by the development of birth-control measures and of treatment for venereal diseases, and by women's easier access to education and careers.


Medical and nonmedical models in clinical practice and training. Dealing with the range of events encountered by mental health professionals requires both anatomic/physiologic and psychologic/behavioral viewpoints. These viewpoints belong to two different universes of discourse, and their languages are not mutually translatable. For responsible clinical practice, both medical and nonmedical models are necessary and neither model is sufficient.


Psychotherapy with the dying patient.

Psychotherapy with the dying patient. This paper develops and describes encounters with dying patients and their families and looks for consesus of patterns and responses of possible help in confronting this situation. It offers positive suggestions for those providing care for dying patients but also acknowledges that only an intellectual grasp of the situation is not sufficient qualification for caring for the dying.


Management of mourning of a dead or dying parent. A method for working through the mourning of the parent in psychoanalytic therapy is described. The method permits focusing on the patient's relationship to the imago as it manifests itself during the mouring. The internal shifting that results permits a reorganization of personality with far-reaching implications for adaptational change.


The theory and practice of psychiatry in India. A comprehensive overview of the past and present state of psychiatry in India, as well as of its successes and limitations, is presented. The dregree of awareness and acceptance by different sectors of the Indian population is discussed. The influence of religious beliefs and cultural practices is taken into account. The report also deals with morbidity in patients with various emotional disorders.


Sex differences in psychoanalytic treatment. Sex sterotypes, clinical observations, and psychoanalytic theory of sex differences are presented. Stereotypes show differences in areas of inhibition and clinical observations, differences related to the phallic and genital phases in psychosexual development. Divergent analytical views on the sexual development of boys and girls are discussed.


A one-year follow-up of two forms of brief psychotherapy. How do patients who had brief behavior therapy evaluate change in themselves as compared to those who had brief psychoanalytically oriented psychotherapy a year following termination of their treatment? Restults of the follow-up study reveal that over-all, patients rated themselves at one-year follow-up as improved over their status at three months after therapy but less so than at the time of termination of therapy. The form of therapy did not make a difference in the patients' evaluation of change.


Emotions and psychotherapies.

Emotions and psychotherapies. Psychotherapy is seen as a series of congnitive-emotional interactions whose emotional impact on the patient serves as the principal reinforcement at certain phase of therapy. This paper examines techniques of interaction common to all psychotherapies, and their relative importance in various types of psychotherapy.


The impotent king: secondary impotence refractory to brief sex therapy. Men with a grandiose self-concept may develop secondary impotence that does not respond to sex therapy. The impotence occurs in response to a more self-assertive stance taken by their wives. The more common form of impotence is also presented and contrasted with the "impotent king". Recommendations for treatment are made.


The uses of multiple causes of death data to clarify changing patterns of cirrhosis mortality in Massachusetts. Evaluation of death rates from cirrhosis of the liver in Massachusetts since 1950 indicate a changing pattern suggestive of a substantial increase in the frequency with which cirrhosis is being recorded as the underlying cause of death. By comparing the relationship between the frequency with which cirrhosis is mentioned on the death certificate with its occurrence as the underlying cause of death, it would appear that the increase in death rate represents a real change. Additional evidence is presented to indicated that the increase is occuring in the urban center of the state. Males aged 40-49 and females aged 50-59 have shown the greatest changes. In spite of similar changes occuring on the national scene, the increase appears to be substantially greater in Massachusetts. The evaluation of multiple cause of death as mentioned on death certificates can allow for assessment of significant co-factors contributing to a fatal outcome in a disease like cirrhosis of the liver.


Patient outcome as a measure of quality of nursing home care. One thousand males transferred from a general medical hospital into 40 community nursing homes were classified by their physicians as to expectations of outcome within six months and measured on physical functioning at the time of their transfer. They were followed up six months later and retested on functional status. Subjects were classified on follow-up as improved, the same deteriorated, or dead. They were also classified as discharged from the nursing home, still in the home, or readmitted to the hospital. Nursing homes were measured every six months on structural variables. Outcomes of the patients were related to the nursing home characteristics by multivariate analysis of variance, controlling for expected outcome, age, and diagnoses of cancer and chronic brain disease. Homes with more RN hours per patient were associated with patients being alive, improved, and discharged from the home. Better ratings on meal services were related to being alive and improved. A higher professional staff-to-patient ratio, better medical records, and more services were related to being discharged from the nursing home.


Motivational interventions in community hypertension screening. To evaluate different techniques intended to motivate community residents to have their blood pressures taken, five inner-city target areas with comparable, predominantly Black, populations were selected. A sample of about 200 households in each of four areas were subjected to different motivational interventions; in one of these four areas, households were approached in a series of four sequential steps. The fifth target area served as a control. Findings establish that home visits by community members trained to take blood pressure measurements (BPMs) in the home produces much larger yields of new (previously unknown) hypertensives than more passive techniques such as invitational letters and gift offers. Prior informational letters, including letters specifying time of visit, do not affect refusals or increase the yield. More "passive" motivational techniques yield a higher proportion of previously known hypertensives than the more "active" outreach efforts.


Tibial plateau topography.

Tibial plateau topography. A logical definition of the anatomy of the tibial surface, based on the shape of the tibial surface as measured in the laboratory, is presented. The relevance of these data to a better understanding of normal and pathological knee joint function is discussed. The thesis that the spine of the tibia is the major weight-bearing portion of the tibial surface can be supported by this contour study. The significance of the lateral plateau contour relative to the static stability of the joint contributed by joint apposition has been indicated. In addition, the path followed by the lateral femoral condyle during the "screw home mechanism" and caused by joint contour has been clearly demonstrated. We hope that this experimental evidence will establish itself as the basis for understanding the anatomy of the proximal tibial surface and that the nomenclature can be accepted to provide a common base for discussion of the tibial surface.


Popliteus tendon tenosynovitis.

Popliteus tendon tenosynovitis. This series of case suggests that the entity of tenosynovitis of the popliteus tendon is more common than once recognized. A high index of sucpicion and accurate palpation of the lateral aspect of the knee lead one to the diagnosis. Knowledge of this entity may prevent future misdiagnosis of tear of the lateral meniscus and unnecessary meniscectomy as experienced by Helfet, Holden, and myself. There is a definite correlation with activities requiring downhill walking or running. The runners invariably complained of the oneset of symptoms during downhill running rather than uphill running. Back packing enthusiastscomplained of no symptoms for several days after ascending into the mountains, only to experience the symptoms at the end of a long, rapid descent out of the mountains. The pathomechanics of this inflammation of the popliteus tendon is not fully understood. Preliminary analysis of gait movies suggests that in downhill running there is an increased vector to displace the weight-bearing femur forward on the relatively fixed tibia as the knee is increasingly flexed (Fig. 5). Previously mentioned EMG functional studies indicate that the popliteus muscle is active during this weight-bearing phase of gait and may act to retard the femur from forward displacement on the tibia in conjunction with the quadriceps. More specifically, it may help to retard the lateral femoral condyle from rotating forward off the lateral tibial plateau. Downhill running or walking therefore may cause increased stress on the popliteus muscle-tendon unit in an effort to decelerate the body weight against the altered angle of gravitational pull, with resultant tenosynovitis and symptoms. In this series there were no top flight competitive runners. The typical patient was a 31-year-old physician who was jogging 1 to 5 miles and decided to increase his pace and distance, particularly while jogging downhill. The average age of this series of patients (31 years) at the time of onset, coupled with the fact many of these persons were relatively sedentary until stressing the knee by increased activity, suggests that there will be an increasing number of these patients in the future as jogging and running are prescribed for cardiovascular system conditioning.


Mebendazole in the treatment of severe symptomatic trichuriasis in children. Mebendazole (methyl-5-benzoylbenzimidazole-2-carbamate), a new broad spectrum anthelmintic, cured 26 (74% out of 35 children) with severe symptomatic trichuriasis. Repeat course of therapy were necessary in some cases. The nine treatment failures all showed large reductions (82-99%) in egg counts. Thus, an overall satisfactory response was obtained in terms of complete parasite eradication in 74%, relief of symptoms in all, and significant reduction in worm load in the failures. In the recommended dosage of 100 mg twice daily for 3 days mebendazole failed to achieve a cure rate of 95% to 100% reported in asymptomatic individuals and those with light infections of Trichuris trichiura. It is probable that measures to control diarrhea before administering mebendazole in an increased, extended, or repreated dosage schedule will achieve a higher cure rate. The drug was well tolerated and completely free from any toxic effects.


Tibial shaft fractures in skiing.

Tibial shaft fractures in skiing. A prospective study of all tibial shaft fractures produced during a single ski season in a Northern Vermont area is presented. Very little previous work concerning skiing-induced tibial fractures was present in the literature. Younger, lighter, and less skilled skiers are more frequently so injured. Spiral fractures account for 41.9% and boot top fractures for 37.9% of the total. Spiral fractures occurred by an internal rotation mechanism just as frequently as by external rotation, and were observed more frequently in slower moving skiers who were using shorter skis and lower, softer boots. Associated fibular fractures were commonly not observed in children. Tibial fractures occurring in skiing are the result of relatively low energy trauma. The level and type of fracture had little effect on healing time. With rare exceptions these fractures heal satisfactorily with nonsurgical techniques.


Transmammary passage of Strongyloides sp. larvae in the human host. The prevalence of infection with Strongyloides fuelleborni and hookworms (Ancylostoma duodenale and Necator americanus), and the possible transmammary passage of these parasites, was studied in the people of a village in Bulapé, Zaire, Africa. Stool examinations revealed that 34% of 76 infants under 200 days of age were infected with S. fuelleborni and 8% were infected with hookworms. Infection rates in the general population were 44% for S. fuelleborni and 90% for hookworms. The examination of milk from nursing mothers revealed the presence of Strongyloides larvae in one case. The finding suggests that S. fuelleborni may be transmitted via the milk in humans.


Arm wrestling fractures--a humerus twist. Fractures of the humeral shaft in various throwing sports is a well recognized clinical entity. The specific etiology remains uncertain. Competitors engaged in Indian and/or wrist wrestling, a sport receiving increased interest, also are known to sustain humeral fractures. It is thought that these particular fractures are the result of bending moment, axial compression, and torsional forces applied to the humerus. The position of the arm during the match appears to be critical in determining the fracture pattern and location. Closed treatment was successful in all reported cases.


Evaluation of the effect of different methods of control of soil-transmitted helminths in Khuzestan, southwest Iran. Three methods of control of soil-transmitted helminths, namely, sanitation, mass-treatment, and sanitation plus mass-treatment, were tried in 15 villages in Khuzestan, southwest Iran. Stool samples from the inhabitants of each village were examined both quantitatively and qualitatively just before starting each control method and again about 4 years later, except for the inhabitants of one village whose stools were re-examined 7 months after moving to a new settlement. Sanitation measures consisted of one latrine for each family and the provision of a sanitary water supply in each village. The drugs piperazine and bephenium hydroxynapthoate were administered alternately every 3 months. The reduction in rates of infection with Ascaris, hookworm, and Trichostrongylus spp., respectively, for the above mentioned methods were as follows: sanitation alone, 28%, 4% and 30%; mass-treatment alone, 84%, 73%, and 31%; sanitation plus mass-treatment, 79%, 69%, and 30% and in the newly constructed village, 76%, 21%, and 38%. In a control group corresponding reductions were 19%, 11%, and 31%. The percentage of egg reduction in persons still infected with these three parasites was, respectively, as follows: mass-treatment plus sanitation, 88%, 88%, and 53%; mass-treatment alone, 90%, 87%, and 37%; sanitation alone, 60%, 26%, and 0.6%; in the newly constructed village, 87%, 78%, and 39%; and in the control group, 29% increased 12%, and 24.5%. The significance of these findings is discussed.


Field trials with oxamniquine in a Schistosomiasis mansoni-endemic area. In Peri-Peri (Minas Gerais), an area endemic for Schistosoma mansoni, 591 inhabitants were examined. A coprological survey showed a prevalence of infection of 43.7%. After clinical examination 220 patients were distributed into three groups for treatment with oxamniquine; in Group 1, 19 children (2 to 15 years) were treated with a single oral dose of drug suspension around 20 mg/kg body weight; in Group 2, 47 children were treated orally with two 10 mg/kg doses with a 6- to 8-hour interval between them; in Group 3, 154 adults were treated with a single dose of about 15 mg/kg (capsules). The most frequent side effects were dizziness, drowsiness, and headache. No statistical difference in frequency of side effects was observed between Groups 1 and 2. Nevertheless, after treatment 32% of the patients in Group 1 complained of dizziness and 13% of headache, whereas in Group 2 the frequencies of these symptoms were 2% and 0%, respectively. Adults (Group 3) had a higher frequency of side effects, their chief complaints being dizziness and drowsiness. In Groups 1, 2, and 3, respectively, 73.7%, 62.2%, and 82.4% of the patients were cured. Statistical analysis did not show any difference in cure rates between children in Groups 1 and 2; however a significance was found when compared with the cure rate observed in adults, showing the drug to be more active in the latter group. In 61.8% of the 40 patients not cured a decrease of over 90% in the number of S. mansoni eggs/g feces was observed. From the data above oxamniquine seems to be an effective schistosomicidal drug suitable for use in endemic areas, although further studies are still needed.


Comparative effects of hycanthone in Schistosoma mansoni and Schistosoma japonicum. After in vitro hycanthone treatment followed by a 20-hour incubation in drug-free medium, Schistosoma mansoni were still resistant to labeling by a fluorescent analog of acetylcholine. S. japonicum, in contrast with the hycanthone sensitive species, showed prompt reversal of the blocking effects of hycanthone on fluorescent labeling. This finding suggests that differences in the reversibility of hycanthone may correlate with the usefulness of the drug in the therapy of schistosome infections by different species of parasites. Scanning electron microscopy has been used to demonstrate that hycanthone treatment causes degeneration of the integument of S. mansoni, but not S. japonicum, over a period of few days after in vivo exposure to hycanthone. The mechanism by which hycanthone causes this effect is not known.


Coagulation factor XIIa (activated Hageman factor) inhibitor from adult Schistosoma mansoni. An inhibitory activity for the contact phase of the intrinsic coagulation pathway was demonstrated in an extract of adult Schistosoma mansoni. Inhibition is apparently specific for the enzymatic activation of Factor XI (pre-PTA) by Factor XIIa (activated Hageman factor). This phenomenon offers an explanation for the schistosomal evasive mechanism of the host contact hemostatic defense system.


Immunological studies in human schistosomiasis. II. Antibodies cytotoxic for Schistosoma mansoni schistosomules. Complement dependent cytotoxic antibodies for Schistosoma mansoni schistosomules were studied in a Brazilian population. The sera of S. mansoni-infected patients gave a high percentage of cytotoxicity (63.4%) compared with sera from persons not infected (8.7%). The IgG class and the specificity of these cytotoxic antibodies are defined. The index of lethality appeared to be independent of the titers of other specific anti-S. mansoni antibodies. A statistical correlation was found between the index of lethality and both the severity of the disease and delayed hypersensitivity to S. mansoni antigen. The significance of cytotoxic antibodies in human schistosomiasis and their relevance to immunity in man are discussed.


Hydatid disease in New Zealand: an epidemiological study of transmission among Maoris. An epidemiological study was designed to determine the factors placing the Maori people of New Zealand at an unusually high risk of infection with Echinococcus granulosus. Using stepwise multiple regression techniques, it was shown that the most important determinant of the incidence rate of human hydatid disease was the proportion of Maoris in the local population. It was found that the Maori system of land tenure, based on the Maori land laws led to the formation of many small fragmented properties under multiple ownership, decreasing the incentive of individual Maori farmers to improve their farming methods. In addition, long-standing behavioral patterns, such as an easy familiarity with working dogs and the feeding of dogs on raw offal, were practices that changed slowly, thus contributing to the maintenance of high E. granulosus prevalence in dogs owned by Maoris. Those cultural and behavioral factors, together with poor dog control, exposed all members of the rural Maori community to an increased risk of infection with E. granulosus, with the result that the incidence rate of hydatid disease for all age-groups and for both sexes was strikingly higher in Maoris than in non-Maoris.


Glomerular pathology in leprosy. An electron microscopic study. Electron microscopic examination of renal biopsies from 19 patients with leprosy who had edema, proteinuria, or hematuria showed a proliferative glomerulonephritis in 12, amyloidosis in 2, and no lesion in 5. The proliferative glomerulonephritis was of different patterns: diffuse with or without exudation, focal, or mesangial. Subendothelial and/or subepithelial deposits were seen in five biopsies. Of the patients with glomerulonephritis, 3 had a reduced total serum complement level, 5 had erythema nodosum leprosum, 5 had evidence of recent streptococcal infection, and 2 had microfilariae in the peripheral blood. The significance of these findings is discussed.


Unisexual infections with Schistosoma haematobium in the white mouse. In unisexual infections with an Iranian strain of Schistosoma haematobium in white mice, female worms matured normally and deposited eggs in the liver but these eggs did not contain miracidia. Both female and male worms grew to more than half the length of corresponding mated worms in bisexual infections, and males acquired the normal number of testes.


Diagnostic laparotomy for fever or abdominal pain of unknown origin. Diagnostic laparotomy performed on twenty-four patients with FUO and twenty-seven patients with obscure abdominal pain resulted in a positive yield of 87 and 82 per cent, respectively. No deaths occurred in either group and the complication rate was minimal. These findings indicate that it is appropriate to include laparotomy in the armamentarium for diagnosis of the cause of FUO and abdominal pain.


Intramural hematoma of the gastrointestinal tract. Two hundred sixty cases of intestinal intramural hematoma and subsequent bowel obstruction have been reported in the world literature. These cases have been evaluated and seventeen additional cases are reported. Multiple etiologic factors are presented, with trauma and anticoagulant therapy being the most common. Barium x-ray examination is the single most reliable diagnostic study. The mode of therapy for intramural hematoma depends upon thorough evaluation of the patient. Patients on anticoagulant therapy are best treated by observation and cessation of anticoagulants. Should the patient fail to improve or become worse, then surgery may become necessary. When trauma is a factor, prompt operative intervention is indicated.


Wound infection. Acute versus chronic cholecystitis. Wound infection in 239 patients who underwent cholecystectomy were analyzed retrospectively. Seventeen per cent of the patients with acute cholecystitis had wound infection compared with 8.9 per cent of patients with chronic cholecystitis. Bacteriology of wound infections revealed Staphylococcus aureus in 76.4 per cent of the chronic cholecystitis group and in 12.5 per cent of the acute cholecystitis group. Wound infection in the acute cholecystitis group involved gram-negative rods predominantly. Organisms were isolated from bile culture in 71.4 per cent of acute cholecystitis patients compared with 59.6 per cent of chronic cholecystitis patients. Of patients with positive bile cultures 11.3 per cent had wound infections compared with 6.8 per cent of patients with negative bile cultures. The most common organisms isolated from bile cultures with resultant wound infections were S epidermis, S aureus, and Klebsiella sp. Wound infection after cholecystectomy for chronic cholecystitis arises from external sources and not contaminated bile. Antibiotic therapy should be directed accordingly.


Estimated median survival times of patients with colorectal cancer based on experience with 9,745 patients. From the End Results Group file at the National Cancer Institute, 9,745 colorectal cancer patients diagnosed from 1965 through 1971 and classified as adenocarcinoma NOS were selected to evaluate the joint effect of various prognostic factors on MST. A technic was developed which enables a physician to estimate the MST for a patient with a given set of patient/disease characteristics. The results are also summarized in an appendix, allowing the physician to bypass the calculation and refer directly to the MST. These results will aid the physician in determining whether a patient is at sufficiently high risk to warrant adjuvant therapy. The survival experience of this broad historical group of patients with varying prognostic factors can also serve as a basis for comparison of results of studies on highly selected patients treated in various experimental ways.


Eelvated postoperative renal clearance of amylase without pancreatitis after cardiopulmonary bypass. Two postoperative cardiopulmonary bypass patients who had pancreatitis within a two week period provided the impetus for pursuing this study. Amylase-creatinine clearance ratios (ACCR) were measured in a series of ten thoracic surgery patients: six coronary artery bypass patients with cardiopulmonary bypass (cardiac group), and four exploratory thoracotomy patients (pulmonary group). These ratios were obtained in the preoperative, recovery room, and postoperative periods. Comparisons were made among the following data: clinical history, pre- and postoperative medications, intraoperative vital signs, drugs, and anesthetics. The preoperative mean ACCR was 3.34 per cent. All cardiac patients had a significantly elevated ACCR in the recovery room with a mean of 17.36 per cent (p less than 0.05). The ACCR had returned to preoperative levels by the second postoperative day in five of six cases. There were no elevated ACCR levels in the pulmonary group. All patients were asymptomatic for pancreatitis. The intraoperative course of the cardiac patients involved four common factors, besides cardiopulmonary bypass, which were not present in the pulmonary group. These similarities included transfusion of citrated fresh whole blood activated by calcium chloride, hypotension treated with ephedrine, administration of mannitol, and intraoperative morphine analgesia. The mechanisms of increased amylase secretion by calcium chloride or ephedrine administration and transient sphincter of Oddi constriction by morphine or the alpha-adrenergic response of ephedrine are considered with the theoretical implications toward pancreatitis. The background and significance of the ACCR are also analyzed, especially in association with the osmotic diuresis of mannitol and a subsequent low urine creatinine level.


Adaptive increase of respiratory enzymes in jaundiced patients. A biochemical analysis of mitochondrial metabolism was made on biopsy specimens of fifteen jaundiced patients. In all but three jaundiced patients the phosphorylative activity based on mitochondrial protein was within normal limits or higher. In nine jaundiced patients the concentrations of cytochrome a(+a3), as representative of respiratory enzymes, increased to more than 1.0 x 10(-10) moles/mg protein, as compared with 0.81 of normal mitochondria, and the relative concentrations of cytochromes, flavoproteins and pyridine nucleotides in relation to cytochrome a(+a3) level remained unchanged. In such patients the phosphorylative activity per unit of cytochrome a(+a3) decreased to approximately 50 per cent of controls, whereas it was within normal limits or greater in jaundiced patients with cytochrome a(+a3) less than 1.0 x 10(-10) moles/mg protein. It is suggested that respiratory enzyme concentrations increase to compensate for the inhibited phosphorylative activity of respiratory assemblies and to maintain the energy balance in the liver in jaundiced patients.


Thyrotoxicosis and pregnancy. Use of preoperative propranolol for thyroidectomy. Propranolol has been utilized safely and successfully in the preparation for thyroidectomy in four pregnant patients with thyrotoxicosis. No ill effects were noted in mothers or infants. No change in fetal heart function was noted while two mothers were receiving propranolol. The major advantage of propranolol over the thiourea drugs is the rapidity with which the patient can be prepared for operation. Preparation with beta blockage can be accomplished in five to ten days. This limited experience suggests that propranolol is probably the drug of choice for preparation of the gravid thyrotoxic patient for whom thyroidectomy is planned.


Indications and guidelines for mammographic examinations. The value of mammography in evaluating the asymptomatic patient has been clearly demonstrated by the HIP program, as well as the National Cancer Institute's breast demonstration projects. A one-third reduction in mortality from breast cancer in mammographically screened women has been substantiated. Nonetheless, questions concerning the long-term effects of repeated radiation exposure associated with mammography have been raised, and for this reason judicious selection of women is urged. In general, women who are asymptomatic or at high risk for breast carcinoma should be evaluated with a planned regimen. Mammographic guidelines and recommendations for attaining the greatest benefit at the lowest possible risk are suggested.


Minor forefoot amputation in patients with low ankle pressure. Ankle pressures were obtained using Doppler ultrasound in fifty-seven patients undergoing forefoot amputations. Contrary to other reports, no amputations healed with a pressure of less than 60 mm Hg.


Differentiation of acute hyperparathyroidism from severe hypercalcemia of malignancy. Acute hyperparathyroidism should be distinguished from severe hypercalcemia of malignancy. In the former condition parathyroidectomy is often of vital importance; in the latter, the malignant neoplasm should be treated surgically or with radiation or cytostatics. The differential diagnosis is sometimes difficult because some patients with acute hyperparathyroidism have coexisting carcinoma elsewhere. Two patients subjected to parathyroidectomy because of severe hypercalcemia secondary to malignant neoplasms are described and compared with twelve similar cases from the literature. In patients with severe hypercalcemia medical treatment should always be tried first. If acute hyperparathyroidism cannot be excluded, subtotal parathyroidectomy should be performed after medical preparation.


Distribution of 5-fluorouracil to body tissues compared after intraluminal, intravenous, and intramural administration in gastrointestinal cancer. The distribution of 5-fluorouracil (5-FU) to various potential metastatic sites has been investigated in stomach and colorectal cancer patients, using intraluminal, intravenous, and intramural routes of administration at the time of surgery. The best overall concentrations of 5-FU in systemic blood, portal blood, liver, draining lymph nodes, tumor, and locally in the bowel wall was obtained after intramural injection. The intraluminal route of administration resulted in poor overall distribution of 5-FU. Intravenous administration tended to give levels between those obtained from intramural and intraluminal routes. There was no complication of 5-FU therapy. On the basis of this study we conclude that the intramural route is the most satisfactory for adjuvant administration of 5-FU with surgery. This might be expected to give better results than those obtained in clinical studies using intraluminal and intravenous routes. A controlled trial of 5-FU using the intramural route is indicated in gastric and colorectal cancer to demonstrate whether or not clinical benefit can be obtained.


The management of stenotic and obstructive lesions of the aortic arch branches. The stenotic internal carotid can be managed in a variety of ways and number of tests can be utilized for assessing the collateral blood flow. Except in unusual situations, carotid thromboendarterectomy with or without a patch graft is generally employed. Although some surgeons use no protective shunt at all, or only upon specific indications, intraluminal shunting is utilized extensively. Our preference is to employ the customary Javid shunt technic except in unusual circumstances that suggest that added safety may be assured by shortening to a matter of seconds the period of interruption of carotid flow. In such cases, we believe the temporary axillary-internal carotid intraluminal shunt is of considerable value. Although mediastinal and thoracic procedures and bypass grafts delivering blood from the ascending aorta are not needed nearly as often as they were formerly, they are essential in certain cases. They yield excellent results and carry small risk. Carotid-subclavian grafts have proved quite valuable in restoring pulsatile flow to the subclavian and carotid systems. Our preference, however, because of technical simplicity, is the carotid-axillary bypass procedure. Subclavian-subclavian and axillary-axillary grafts have been employed successfully. When a carotid-axillary bypass is feasible, we would choose this method instead and reserve the others for unusual anatomic-pathologic situations.


Transverse colon volvulus associated with scleroderma. An unusual case of volvulus of the transverse colon associated with scleroderma is presented. The morphologic changes in the large bowel due to progressive systemic sclerosis, resulting in pseudo-obstruction, are considered in the etiology and pathogenesis of colonic torsion.


Necrotizing enterocolitis after cardiac surgery: a local ischemic lesion?. Necrotizing enterocolitis continues to be a perplexing problem in the newborn and, in particular, the premature. Its pathogenesis is controversial, although there are well established clinical risk factors. Three patients had necrotizing enterocolitis while under close clinical observation and monitoring, despite the fact that these patients were not at high risk for necrotizing enterocolitis. All three had necrotizing enterocolitis after hypothermia and total circulatory arrest--a complication which until now has not been reported. Because of the close monitoring, these patients provide a unique clinical setting which eliminates most of the etiologic factors that have been implicated in the pathogenesis of necrotizing enterocolitis. The onset of necrotizing enterocolitis shortly after total circulatory arrest and the selective ischemic organ damage observed suggest local perfusion inadequacy. The authors postulate that splanchnic vasoconstriction as a result of marked sympathetic stimulation contributes to this local ischemia and subsequent necrotizing enterocolitis.


Carcinoma on old frostbites.

Carcinoma on old frostbites. Two cases of carcinoma developing on old frostbite scars of the heel are presented. A short review of the subject follows, stressing the rarity of these "secondary" tumors and their general context within the skin cancers and the tragic experience of Greece with frostbite in the campaign of 1940-1941.


Open abdomen liver biopsy by a modified one-second technic. With the purpose of facilitating liver biopsy during upper abdominal procedures, an adaptation of the percutaneous one-second needle biopsy technic is proposed. A simple device, consisting of a three-way deviator, allows the utilization of the standard needles for percutaneous biopsy. The entire procedure requires from 10 to 30 seonds. Large caliber needles from 1.6 to 2.0 mm are recommended. Complications are practically nonexistent.


An adjunct to mammoplasty: the pectoral muscle flap. The pectoralis major muscle has overcome many of the complications of augmentation mammoplasty after subcutaneous mastectomy. It places the implant deep to prevent skin slough and irregularities in skin surface contour. The flap eliminates abnormal implant posture when the pectoralis major is contracted. The short (5 to 7 days) staging of the procedure allows sealing of the pocket from external innoculation of bacteria while preventing unretrievable skin and nipple shrinkage.


Total gastrectomy with esophagojejunoduodenal anastomosis reestablishing duodenal circuit. A modified Roux-en-Y anastomosis. A simple modified Roux-en-Y anastomosis--esophagojejunoduodenostomy with circuit duodenal loop (circuit Roux-en-Y anastomosis) after total gastrectomy--has been performed in ten consecutive patients without any operative death or complications. The simplicity and safety of this procedure may well be more worthwhile than other forms of alimentary tract reconstruction.


A nonoperative approach to subcutaneous removal of stubborn sutures from wound granulomas. A simple device for grasping, cutting, and extracting sutures from subcutaneous granulomas has been used in more than fifty patients. It is especially useful in removing sutures embedded deeply beneath the skin level in obese patients.


"Soft" angled bulldog clamp for carotid control. A bulldog vascular clamp was modified to reduce both weight and clamping force, and to permit easy use in the control of delicate vessels such as the internal carotid artery during carotid endarterectomy. The final instrument (Codman and Shurtleff, Inc, Randolph, MA) retains a simple design.


Gastric cancer. Contemporary aspects.

Gastric cancer. Contemporary aspects. Records of 403 patients with gastric cancer seen between 1957 and 1966 at the Lahey Clinic Foundation have been analyzed. While the operability rate was 94 per cent and the resectability rate was 58 per cent, the cure rate was only 11 per cent and was unchanged from the previous decade. Significant correlation occurs with location, clinical type, histologic type, size of tumor, and number of lymph node metastases. The surgical approach is aggressive in exploration and in treating extensive but resectable cancers but is conservative for the average cancers and does not include resection of spleen, omentum, pancreas, and total stomach if possible. The histologic differentiation into diffuse and intestinal varieties provides additional prognostic information as well as clues to the etiology of varieties of gastric cancer.


Selection of patients with lymphedema for compression therapy. Seventeen patients with lymphedema were treated with intermittent external pneumatic compression. Two patients with hemodynamically significant venous obstruction showed no response to therapy. The response of the remaining fifteen patients varied with the degree of subcutaneous tissue fibrosis. Xeroradiographic estimates of tissue compressibility provided valuable prognostic information. Intermittent external pneumatic compression is an effective nonsurgical method of treatment in patients selected by xeroradiography.


Biplane translumbar aortography for evaluation of peripheral vascular disease. Complete evaluation of the aortoiliac femoropopliteal system is necessary for the proper evaluation of lower extremity peripheal vascular ischemic disease. We have used a modified infrarenal translumbar approach since it is both safely and rapidly performed. An analysis of 212 consecutive cases (the last 182 with translumbar technic) revealed that 72 per cent of patients had significant atherosclerotic involvement of the aorta or one or more common or external iliac arteries, 43 per cent had significant bilateral involvement, and it was judged that retrograde femoral catheterization would have been difficult or impossible in 38 per cent. Biplane aortoiliac evaluation was added in our last seventy-nine studies. This provided additional diagnostic help in thirty-six of these cases and revealed an abnormality not otherwise visible in six of these patients. There were no serious complications in this series.


Natural history of the leg amputee.

Natural history of the leg amputee. For 173 patients undergoing major leg amputations, the operative mortality was 13 per cent. The ratio of below-knee (BK) to above-knee (AK) amputations was approximately unity. Of the 150 patients who survived amputation, 93 were given prostheses. Amoung the latter group, 76 per cent of the unilateral AK amputees and 90 per cent of the unilateral BK amputees had a successful rehabilitation. For those patients who had to be converted from BK to AK unilateral amputations, 40 per cent experienced successful rehabilitation, and for those who had either bilateral BK or bilateral mixed amputations, 45 per cent were successful. The most common contraindications to granting prostheses were debility and dementia. The mean time interval from first amputation to latest observation was 3.5 years (range, 5 weeks to 13.5 years). At three years 49 per cent of the patients survived and at five years 31 per cent survived. Despite major impediments, satisfactory rehabilitation is accomplished frequently enough to justify optimism for a considerable number of geriatric amputees.


Managment of thoracic empyema.

Managment of thoracic empyema. Over a ten year period, 102 patients with thoracic empyemata were treated at Boston City Hospital. Only three patients died from the pleural infection while twenty-six succumbed to the associated diseases. Priniciples of management include: (1) thoracentesis; (2) antibiotics; (3) closed-tube thoracostomy; (4) sinogram; (5) open drainage; (6) empyemectomy and decortication in selected patients; and (7) bronchoscopy and barium swallow when the etiology is uncertain.


Considerations that lower pancreatoduodenectomy mortality. To aid in case selection for pancreatoduodencetomy and to gain information on the technical management of this operation and its complications, records of 279 patients who were treated for neoplasm or pancreatitis by this procedure between the years 1957 and 1975 were reviewed. The overall operative mortality was 12.5 per cent and was 10.7 per cent for the years 1969 throught 1974. The use of vagotomy did not prevent postoperative bleeding from the stomach, and the use of a stent did not make a statistically significant difference in morbidity or mortality. Postoperative hemorrhage is an ominous complication and is best treated conservatively until blood loss cannot be replaced. Preoperative serum bilirubin levels above 20 mg/100 ml indicate a two-stage operative procedure as does the presence of right upper quadrant sepsis. The resection of malignant disease of the duodenum and lower bile duct is followed by a high mortality and requires total pancreatectomy if a satisfactory pancreatojejunostomy cannot be constructed.


Predictability of healing of ischemic leg ulcers by radioisotopic and Doppler ultrasonic examination. In a prospective study of twenty-six patients with ischemic ulcerations of the lower extremity, the predictive reliability with regard to spontaneous wound healing of diabetes, pedal pulses, ankle blood pressure (ABP) as measured by doppler ultrasound, and "leg ulcer scan" as performed by the intra-arterial injection of radioactive albumin was evaluated. The results suggest that only the leg ulcer scan is significantly reliable in predicting the likelihood of spontaneous healing. The following format for the evaluation of the ischemic leg ulcer is therefore suggested: (1) If pedal pulses are present, a three week trial of conservative therapy is indicated before further evaluation. (2) If the doppler ABP is 50 mm Hg or less, the ulcer will not heal spontaneously. (3) Leg ulcer scan is indicated: (a) in the absence of pedal pulses if ABP is less than 50 mm Hg; (b) in the presence of pedal pulses if there is no evidence of spontaneous healing after three weeks of conservative therapy.


The clinical effectiveness of selective portal shunts. The use of four types of selective portal shunts designed to avoid postshunt encephalopathy has been reviewed. The incidence of hospital mortality and recurrent hemorrhage from varices among 187 reported cases have been comparable to standard portacaval shunts. The incidence of postshunt encephalopathy among 154 survivors with patent shunts followed from two to ninety-six months has averaged 8 per cent but with significant differences between the types of operation. The most effective has been the left gastric vein to vena cava shunt followed by the distal splenorenal shunt, the modified central splenorenal shunt, and the central splenorenal shunt, with success in avoiding encephalopathy in direct proportion to the number and size of postoperative collaterals between the persistently hypertensive portal system and the decompressed splenic system. The development of such collaterals inlong-term survivors, especially after the splenorenal shunts, may contribute to an incidence of late encephalopathy approaching that of nonoperative patients.


Myocardial depression during sepsis.

Myocardial depression during sepsis. The cardiac response to volume loading was evaluated in fifty severely septic patients. After a rapid infusion of albumin or whole blood the cardiac index (CI) and left ventricular stroke work  index (LVSWI) were recorded as the pulmonary arterial wedge pressure (PAWP) increased. Initial values of PAWP, CI, and LVSWI were similar in both the nineteen surviving and thirty-one nonsurviving patients. Surviving patients, however, demonstrated greater increases in CI and LVSWI as PAWP rose. Nearly half of both patient groups developed decreases in CI and LVSWI as the PAWP continued to increase. These downslopes occurred at relatively low PAWP and are taken as evidence of an abnormality of myocardial function in both survivors and nonsurvivors. The lower upslope of the performance curves in nonsurvivors indicates myocardial depression or a negative inotropic effect. Cardiac ischemia, acute respiratory failure, and high affinity red cells were found to diminish the cardiac response to volume loading, whereas hepatic and renal failure were associated with a good CI and LVSWI response.


Total blood washout and exchange. A valuable tool in acute hepatic coma and Reye's syndrome. Total body washout (TBW) was accomplished thirteen times in twelve patients, with response in five and survival in three. TBW can be done without apparent harm to patients and is less laborious and more rapidly effective than repeated exchange transfusion. Early application of TBW in stage III to stage IV hepatic coma may increase survival and possibly prevent progression of metabolic derangements. Patients with stage III to IV Reye's syndrome probably should have TBW promptly, without time-consuming attempts at exchange transfusion. Based on our experience, further application of TBW is warranted in coma due to acute hepatic failure and stage III to IV Reye's syndrome.


Detection of hepatic metastases from cancer of the breast. The liver scan and CEA assay were employed as a composite to increase the accuracy with which hepatic metastases from breast cancer may be detected. The number of false-positive interpretations was markedly reduced in this selected groups of patients. Other combinations of tests were examined and found less effective. In view of the potential benefits found in this study, it appears worthwhile to extend the principles applied here to other groups of patients at different stages of this disease and with other primary tumors.


The legal responsibility of the anaesthetist. The various ways in which an anaesthetist may come into contact with the process of the criminal and civil law have been discussed. Some comparisons have been made between the English Law and that of other countries. The need for vigilance by professional bodies representing medical practitioners in monitoring and making representations about proposed new laws is emphasised.


Postoperative pulmonary function. A comparison of ventilation with nitrogen or nitrous oxide during anaesthesia. Arterial blood-gases and lung volumes were measured in 48 patients before and after upper abdominal surgery. There was no significant difference between the results of 25 patients ventilated with oxygen and nitrogen during anaesthesia compared with a comparable group which received oxygen and nitrous oxide.


Terminal gas-exhaust valve for a passive disposal system. A one-way gas-exhaust valve for use in passive disposal systems is described. The valve is explosion-proof and it does not offer any resistance at gas flow rates of up to 30 litres/minute. The design of the valve minimises the influence of wind velocities on pressure fluctuation in the disposal system.


A comparison of the antibacterial properties of six local analgesic agents. The effect of six local analgesic drugs on bacterial growth is reported. Amethocaine proved to be the only effective antibacterial agent.


Electrolytes in surgical patients: the effect of pre-operative starvation and environmental temperature. Serum sodium, potassium and chloride values were measured before and after pre-operative starvation and after premedication in healthy subjects under going routine surgery, during both temperate and hot weather. No significant change in serum electrolytes occurred during temperate weather either after starvation or after premedication. In hot weather, when the subjects were sweating, a rise in serum electrolytes occurred, indicating fluid deficit of about 1-8 litres after a mean period of starvation of 11 hours; premedication with atropine and diazepam in these subjects was followed by a significant decrease in the serum electrolytes from the previous raised level after pre-operative starvation.


Possible dangers of anaesthesia in patients receiving fenfluramine. Results of animal studies following a case of human cardiac arrest. Following the report of the death of a patient concurrently taking fenfluramine, following routine general anaesthesia, a series of anaesthetised rabbits received injections of adrenaline or fenfluramine. There were abnormal electrocardiographic changes and phonocardiographic  evidence of altered heart activity in both groups, but the changes seen with fenfluramine were greater in number and less readily reversed with beta blockers and resuscitative drugs. This evidence may support an interaction between halothane and fenfluramine in man, and it is suggested that the latter drug be discontinued for a week prior to anaesthesia for elective surgery.


Response to a Valsalva manoeuvre before and after epidural block. In pregnant patients at term the cardiovascular response to a Valsalva manoeuvre has been evaluated in the lateral and supine positions, before and after epidural block (T8-S5). There was no difference in the pattern of response under these four conditions. After epidural block, there was a tendency to a greater degree of hypotension and a slower recovery. In labour such repeated hypotension could account for the increase in fetal acidosis when the second stage of labour is conducted in the supine position.


The effects of prolonged naso-endotracheal intubation in children. A study in infants and young children after cardiopulmonary bypass. The results of 458 prolonged nasotracheal intubations are described in 435 infants and young children up to 5 years of age after open heart surgery, in whom the upper airway was normal. No deaths occurred which could be attributed to the technique, and no tubes became obstructed. Sub-glottic stenosis did not occur when a loose-fitting endotracheal tube was used, and stridor after extubation was rare. If necessary, the technique can be used with safety for several weeks.


Setting up in private practice. A guide for the newly appointed consultant. If you are considering going into private practice under the present contract weigh up the cost, seek advice as to prospective earnings, join a partnership if you can, buy sound sensible equipment (second-hand if possible), insure for super-annuation and sickness benefits right away--it is both cheaper and safer. Agree a sensible NHS programme from the start using the advice of the BMA and the Association of Anaesthetists, and, when you are an established practitioner and a young colleague joins you, try to give him a helping hand and sound advice. The sine qua non of survival is co-operation.


Prolonged action of bupivacaine hydrochloride. This paper describes a case of prolonged action of bupivacaine hydrochloride following supraclavicular brachial plexus block with complete recovery.


An assessment of the TM3 gas differentiator. The TM3 Gas differentiator, a simple device introduced to differentiate between nitrous oxide and oxygen, was found to be capable of positively distinguishing between these gases when only they were known to be present. The differentiator gave nearly equal responses to nitrous oxide and carbon dioxide. Cyclopropane, halothane, methoxyflurane, trichloroethylene and nitrogen all produced smaller responses on the differentiator's built-in meter. This apparatus has proved in use to be a practicable and simple method of checking the composition of gases emerging from pipelines.


Prevention of venous blood gas embolism with blood microfilters. The efficacy of blood microfilters in removal of the gaseous emboli produced during the warming of blood for transfusion is demonstrated experimentally. It is suggested that when blood microfilters are used they should be placed distal to any blood warming device.


Simple alarm for quadriplegic patients.

Simple alarm for quadriplegic patients. An electrical alarm which can be operated by the tongue of a quadraplegic patient by contact with an electrode on the chin is described.


Medical equipment for an accident team.

Medical equipment for an accident team. Equipment assembled for use by an accident team is described. The aim is to provide independent lightweight units that a medical practitioner can easily carry yet which will contain the essential items which he may need. A complete list of equipment is included. Compromise is inevitable which makes planning difficult particularly if action is seldom needed. Some schemes may need alternative equipment and individual preferences must also be taken into account.


Apparatus for emergency anaesthesia outside main hospitals. The criteria which govern the design of anaesthetic equipment for emergency use away from a sophisticated operating theatre in a base hospital is discussed. A recently developed portable anaesthetic unit based on the air draw over principle and designed particularly for use with an obstetric flying squad is described and discussed.


Use of methohexitone, fentanyl and nitrous oxide for short surgical procedures. An anaesthetic technique for unpremedicated patients undergoing minor surgery is described. After the administration of atropine and fentanyl, anaesthesia was induced with methohexitone and maintained with nitrous oxide supplemented when necessary by further small doses of methohexitone. This technique provided good operating conditions and was free from major complications. Recovery was rapid and pleasant.


Adiposity and the pharmacokinetics of halothane. The effect of adiposity on the maintenance of and recovery from halothane anaesthesia. Thirty fit patients (15-70 years, 46-98 kg) undergoing body-surface operations were selected to include a wide range of adiposity (12-45% of total body weight estimated from measurements of skinfold thickness). They were anaesthetized with halothane and 70% N2O in O2. From measurements of total ventilation (ml min-1 kg-1) and of halothane concentrations in inspired (F1) end-tidal (FE') and 'mixed-spill' (FS) gases, the following parameters were calculated for 5-min intervals from 20 to 40 min after induction; the rate of uptake of halothane per percent inspired concentration (Vha1 ml min-1%-1) and the degree of equilibrium achieved with the inspired concentration, calculated as FE'/F1 expressed as a percentage. Multiple-regression analysis of the results for 19 patients, taking account of the effects of body fat, ventilation, age, and the blood-gas partition coefficient lambda of halothane for the individual patient, showed that Vha1 increased with adiposity (b=0-375, P=0-0019), and with ventilation (b=0-054, P=0-09) but decreased with increasing age (b=-0-258, P=0-006). The time intervals between the end of the anaesthetic and the achievement of four defined levels of recovery (response to painful stimulus obedience to a simple command, response to a question, orientation in time and space), were recorded. Multiple-regression analysis showed that recovery time increased with addiposity, duration of administration and end-tidal concentration at the end of the administration, and decreased with increasing age. All four effects were statistically non-significant at the first levels of recovery but all increased at the later levels and all eventually became significant.


Anaesthetists and the Common Market.

Anaesthetists and the Common Market. The Medical Directives of the E.E.C. are now in force. Those relating to basic registration and specialist registration in anaesthesia are considered. Problems arising from the implementation of these Directives are discussed together with their impact on British anaesthetists wishing to work in other E.E.C. States as well as on E.E.C. anaesthetists wishing to work here. Sources of further information are listed in the appendices.


Anaesthesia in the Guillian-Barré syndrome. A case report and recommendations. A large proportion of patients with the Guillain Barré syndrome show signs of involvement of the autonomic nervous system beside the better known motor and sensory features of this disease. These patients present a substantial anaesthetic risk because of autonomic dysfunction. We present here an illustrative case in which the administration of a low subarachnoid block resulted in cardiac arrest and offer suggestions for the anaesthetic management of such cases.


Laryngeal oedema due to hereditary angioedema. A case is reported in which a young man suffering from hereditary angioedema was admitted with severe airway obstruction due to groww pharyngeal and laryngeal oedema. Tracheostomy was necessary. The rationale of treatment with epsilon aminocaproic acid, tranexamic acid and fresh frozen plasma is discussed. The patient subsequently underwent dental extractions under general anaesthesia with tracheal intubation without complications.


Fatal anaphylactic reaction to tetracycline in the postoperative period. A case of anaphylactic reaction in the form of acute cyanosis, hypotension with sudden and unexpected death of a patient in the post-operative period following the administration of tetracycline is described. There was no history of previous exposure to the drug.


Toxic methaemoglobinaemia. A case of acute nitrobenzene and aniline poisoning treated by exchange transfusion. A case of severe toxic methaemoglobinaemia following ingestion of aniline and nitrobenzene is described. Important factors in treatment are discussed. These include, gastric lavage, the administration of methylene blue and exchange transfusion. The possibility of a late haemolytic reaction being a complication of methylene blue treatment is mentioned.


Bilateral nasopharyngeal tubes for outpatient dental anaesthesia. The successful use of nasopharyngeal intubation for minor dental outpatient surgery and conservation is described and discussed.


The immediate care of acute renal failure. This article does not attempt to answer all the questions which might arise with the immediate management of a patient with acute renal failure but an effort has been made to lay down some guidelines and discuss some of the points of controversy. It should be remembered that the management of acute renal failure is an exercise in intensive care and that maintenance of non uraemic homeostasis is but one part in the overall management of the patient.


Scientific and medical English.

Scientific and medical English. Ten historical extracts are quoted to show that the problems of jargon and indifferent English in scientific and medical writings have been with us for a long time. One improvement is that criticisms printed in the correspondence columns of medical journals have become less abusive.


Efferent arterioles in the cortex of the rat kidney. Although a number of morphological studies have investigated the vascular system of the rat kidney, minimal data are available on the detailed anatomy of the efferent arterioles located throughout the cortex of the kidney. In the present study, the renal vascular system was filled with Microfil and the various efferent arteriole patterns were examined extensively. The efferent vessels of the entire cortex appear to form three major patterns which in turn divided the cortex into three separate regions: the outer, middle and inner cortex. The efferent arterioles of the outer cortex leave the glomerulus and run perpendicular to the kidney capsule. However, as the efferent arterioles ascend, they may show three variations in the way they branch: (1a) the efferent arteriole does not branch until directly beneath the capsule, (1b) the efferent vessel begins to divide into its major branches 100-200 mum below the surface of the kidney and (1c) the efferent vessel has only a short course before giving off many side branches. In the middle cortical area, the branches of the efferent arteriole run lateral to the glomerulus. However, the efferent arterioles of the inner cortex have a few branches which run lateral to the glomerulus while most of them descend into the medulla as vasa rectae. The unique morphological features of the efferent arterioles of the outer cortex are of particular interest in light of the functional data which suggests that the reabsorption of fluid by peritubular capillaries may indeed regulate the rate of net tubular sodium reabsorption.


Ultrastructure of the cat sublingual gland. The sublingual gland of the cat consists primarily of branched secretory tubules that open into an abbreviated duct system. The simple epithelium that composes the secretory tubules consists of an admixture of mucous and serous cells, with the former predominating. Some secretory tubules are capped by a serous demilune. Regardless of position, almost all serous cells have prominent basal folds and border on at least one intercellular canaliculus as well as on the tubule lumen. Serous cells possess an extensive array of irregular, distended cisternae of rough-surfaced endoplasmic reticulum that frequently contain dense intracisternal granules. Serous granules are relatively few in number and rarely show evidence of substructure. Mucous cells, which lack basal folds, contain an apical mass of secretory material in the form of partially fused droplets. The duct system is somewhat less ordered than in most major salivary glands; secretory tubules empty into structures resembling intercalated ducts or may be in direct continuity with ducts intermediate in morphology between intercalated and excretory ducts. The absence of striated ducts noted in this study may be correlated with the high sodium content of cat sublingual saliva. The main excretory duct of the sublingual gland closely resembles that of the cat submandibular gland in terms of morphology, but exhibits little of the transport functions reported in the latter duct.


Integrated actions of masticatory muscles: simultaneous EMG from eight intramuscular electrodes. In 29 normal persons with complete dental arches, the muscular activity of the temporalis, masseter, medical pterygoid, anterior belly of the digastric, mylohyoid and geniohyoid muscles was studied electromyographically with bipolar fine wire electrodes during various mandibular movements--both resisted and unresisted. Action potentials were recorded on FM magnetic tape and each experiment was also videotaped. Temporalis muscle was active during centric closing of the jaw with either contact of the teeth, or against resistance; during free lateral movements to the ipsilateral side, either against resistance or occlusal contact; during incisor gum chewing, molar gum chewing on ipsilateral or contralateral sides, during normal mastication; and during forceful centric occlusion. Activity occurred in the masseter and medial pterygoid muscles during the following movements; closing the jaw slowly either without occlusal contact or with occlusal contact and against resistance; free lateral movement to contralateral side, either against resistance or with occlusal contact; protraction of the jaw either without occlusal contact or with occlusal contact; swallowing either saliva or water; incisor gum chewing with either the ipsilateral or contralateral molars; normal mastication; and during forceful centric occlusion. Activity occurred in the digastric, mylohyoid and geniohyoid muscles during the following movements; opening of the jaw either slowly or maximally against resistance; closing the jaw against resistance; free lateral movement to ipsilateral and contralateral sides, either against resistance or with occlusal contact; protraction against resistance of the jaw either without or with occlusal contact; swallowing saliva and water; and protraction of the tongue. They work in antagonism (reciprocally) during gum chewing and normal mastication.


Ultrastructure of gallstones produced in mice fed a high cholesterol diet. Mice fed a high cholesterol-cholic acid diet for two to six months develop gallstones; these were studied by transmission electron microscopy after glutaraldehyde-digitonin fixation. Examination of the contents of mouse gallbladders presents views of layered structures and surrounding amorphous material. We interpret these images of gallstones to suggest that they may arise by cohesion of material rich in cholesterol to form more ordered structures. Gallbladder contents of mice fed the diet for five to six months were found to contain occasional crystals and rectangular areas similar to those observed in thin sections of human gallstones (unpublished observations). Recent findings that human gallstones can be dissolved with chenodeoxycholic acid are discussed, with reference to their applicability to studies of gallstones in mice.


Ultrastructural localization of peroxidase in leukocytes of rat bone marrow and blood. The differentiation of leukocytes in the bone marrow and blood of normal adult male rats was studied by electron microscopy and peroxidase cytochemistry. Tissue samples were fixed in glutaraldehyde, or paraformaldehyde-glutaraldehyde, and incubated in a peroxidase medium containing 3,3'-diaminobenzidine and H2O2 ad pH 7.6. Mature cells of blood were identified, and then the earlier stages of maturation in bone marrow were analyzed. In immature cells of four cell lines, neutrophils, monocytes, basophils, and eosinophils, peroxidase is synthesized and could be demonstrated in the rough endoplasmic reticulum (RER), Golgi complex, and in cytoplasmic granules. Later in maturation, reaction product for peroxidase could not be found in RER or Golgi complex, indicating that peroxidase synthesis had ceased. In two cell lines, neutrophils and monocytes, peroxidase-negative granules were formed, and the mature cells contained two populations of cytochemically distinct granules. All granules of mature eosinophils were peroxidase-positive. In mature basophils, some granules were clearly peroxidase-positive; others displayed variable density, making interpretation uncertain. Mast cells were never seen in blood, but were abundant in bone marrow; peroxidase was never found in their granules by either electron microscopic cytochemistry or a variety of light microscopic methods. Hence, these cells differ from basophils, not only in morphology but also in the enzyme content of their granules.


The influence of progestin and androgen on the fine structure of the male reproductive tract of the rat. I. General effects and observations on the testis. The combination of a progestin and androgen has received attention as a possible male contraceptive. The progestin is thought to reduce gonadotropin release and suppress spermatogenesis, while the sex accessory organs and male characteristics are maintained by the simultaneous administration of testosterone. In the present study, the histology and ultrastructure of parts of the male reproductive tract of rats treated with medroxyprogesterone (Provera, Upjohn) (1 mg/100 g body weight/day) alone and combined with testosterone (15, 30, or 100 mug/100 g/day) were studied following treatment for up to 16 weeks. The testes and epididymides of rats administered Provera alone or Provera and testosterone weighed less than those of control rats. The weights of the accessory glands of rats treated with Provera were greatly reduced; it was possible to maintain them at approximately control levels by simultaneously administering sufficient testosterone (100 mug/100 g body weight/day). The fertility of some of the animals was tested by caging them with female rats, and none of the treated rats tested in this way was fertile. Similar microscopic alterations were present in the testes of animals administered Provera alone or Provera and different levels of testosterone. Spermatogonia, spermatocytes, and early spermatids were abundant in treated rats and did not show ultrastructural changes. However, many degenerating or necrotic spermatids of the cap phase (approximately stages 6-7) and later were present. Late spermatids of the acrosome and maturation phases were rare. Some necrotic spermatids were surrounded by Sertoli cells, and parts of spermatids lay within lysosome-lyke structures in the cytoplasm of Sertoli cells. Many large lipid droplets were also present in Sertoli cells of treated rats. Leydig cells were smaller in treated animals than in control rats. The results suggest that germ cells can develop up to cap phase spermatids but then undergo degeneration. These alterations in spermatogenesis may be responsible in large part for the antifertility effect of the progestin and androgen combination. Some rats were permitted to recover following the end of treatment. The microscopic appearance of the testis returned to normal within three to six weeks, although epididymal alterations persisted in some animals six weeks after the end of treatment. By 9 to 12 weeks after the end of treatment the reproductive organs had a normal microscopic appearance in all the rats studied.


The influence of progestin and androgen on the fine structure of the male reproductive tract of the rat. II. Epididymis and sex accessory glands. Young adult male rats were administered medroxyprogesterone (Provera, Upjohn) alone and in combination with testosterone,as has been done to inhibit male fertility. The histology and the fine structure of several segments of the epididymis, the ventral prostate, and the seminal vesicle were studied at intervals after treatment for up to 16 weeks. The epididymides of treated animals weighed less than those of control rats. Microscopic alterations in the epididymis were similar in rats treated with Provera alone and in those animals that received Provera and testosterone, but the changes varied with the segment of the epididymis. In the middle segment in the caput epididymidis, the normally abundant luminal sperm were absent but the epithelium retained its normal ultrastructural features. In the terminal segment in the cauda epididymidis, different changes were observed in the proximal and distal portions. In the proximal cauda epididymidis, the lumen was small, irregular in outline, and virtually devoid of sperm. The light cells of the epididymal epithelium in the proximal cauda contained extremely large numbers of dense bodies resembling lysosomes, which occupied most of the supranuclear and basal cytoplasm. In contrast, in the distal part of the cauda epididymidis, the epithelium had a normal appearance but the lumen was filled with debris, sperm, and spherical masses of cytoplasm that were apparently derived from germ cells. It is suggested that the clearing of the lumen of the proximal cauda epididymidis may reflect the greater activity of light cells of the epididymal epithelium in that region. Although alterations in spermatogenesis may be most important in the antifertility effect of progestin and androgen, these alterations in epididymal sperm and epithelium may also play a role. The weights of the prostate and seminal vesicles of rats treated with Provera (1 mg/100 g/day) were greatly reduced compared to those of control rats. Although there was considerable variation, in many specimens treated with Provera alone the epithelium of the prostate showed a change from a columnar to a cuboidal or squamous shape, and there was a reduction in the size and abundance of organelles involved in the formation of secretions. The microscopic structure of the seminal vesicle of rats treated with Provera was less severely affected than the prostate. Although the seminal vesicle epithelium of Provera-treated rats was generally not as tall as in control animals, the cells possessed parallel cisternae of rough endoplasmic reticulum, secretory vacuoles, and an active-appearing Golgi apparatus, suggesting that they continued to be able to form secretions in the presence of Provera. The weights of the sex accessory glands were maintained at control levels by the administration of testosterone, 100 mug/100 g/day, along with the Provera. A normal fine structure was present in the epithelium of both the prostate and seminal vesicle of rats administered this amount of testosterone in addition to Provera...


Preparation of biological tissues for electron microscopy by freeze-drying. A dependable method for freeze-drying tissues for electron microscopy has been developed. Thin slices of fresh tissue were frozen by bringing them into direct contact with a polished copper bar at liquid nitrogen temperature. The tissue was transferred to a copper specimen block equipped with a thermocouple and heating circuit for accurate control of the environmental temperature of the tissue, and evacuated in a glass freeze-drier using clean high vacuum techniques for keeping the system free of hydrocarbons. The tissue was dried by increasing the temperature of the specimen block 10 degrees C each hour while monitoring the rate of water removal from the tissue with a partial pressure analyzer. The dry tissue was fixed with OsO4 vapor, vacuum embedded in a low viscosity epoxy resin, sectioned, stained, and viewed with the electron microscope. Tissue processed in this manner exhibits excellent morphological preservation at both cellular and organellar levels without prefixation or the use of cryoprotective agents. The results of the experiments using the partial pressure analyzer indicate that small blocks of tissue can be dried in a short time at low temperature.


The thyroid gland of the woodchuck, Marmota monax: a morphological study of seasonal variations in the follicular cells. The morphology of the thyroid gland of the woodchuck, Marmota monax, was studied during the four seasons of the year. In the spring the thyroid is extremely heterogenous in appearance. Some follicular cells appear quite active. They contain a well defined Golgi apparatus, abundant large colloid droplets and pseudopodia but few, if any, apical vesicles. Other less active cells have poorly defined rough surfaced endoplasmic reticulum and lack a well developed Golgi apparatus. They do not contain apical vesicles or colloid droplets. Summer thyroids have uniformly small follicles which are lined by high cuboidal cells containing numerous mitochondria, apical vesicles, abundant rough surfaced endoplasmic reticulum, and lipid droplets but few colloid droplets. There is extensive lateral and basal infolding of the cytoplasmic membranes in these cells. In the fall and winter the follicles are larger than in the summer and contain more colloid. Numerous heterogeneous dense bodies appear in the cytoplasm of the follicular cells in the fall and increase in number in the winter when there is an obvious sparsity of such glycoprotein synthetic organelles as Golgi apparatus and rough surfaced endoplasmic reticulum. These morphologic changes are compared with previous studies of thyroid structure and function in other animals and are correlated with the seasonal physiologic activities of the woodchuck.


Reproductive strategy of winged and wingless morphs of the aphids Sitobion avenae and Metopolophium dirhodum. The reproduction of apterous and alate morphs of the aphids Sitobion avenae and Metopolophium dirhodum is compared on the basis of fecundity in 5- and 10-day periods of adult life. Apterae of both species are consistently more fecund than alatae of comparable weight, producing about three more nymphs on average in any 5-day period. The reproductive differences are related to the number and quality of embryos at eclosion and to ovulation rates, both of which in turn appear to be linked to wing-muscle maintenance. These relationships between weight, embryos and reproduction may be used to predict a newly moulted adult aphid's fecundity, a method which may facilitate the assessment of resistance to aphids in new cereal varieties, by obviating lengthy recording of reproduction. The strategies by which alatae of these and other aphid species minimize the difference between their fecundity and that of apterae are discussed.


Oxygen therapy: appropriate use of nebulizers. Control of the inspired O2 concentration requires both an appropriate O2 fraction from the nebulizer and an adequate flow of gas to the patient. We evaluated the O2 fraction and total flow of commercially available nebulizers operated under conditions commonly encountered in clinical use. Total gas flow O2 fraction, and back pressure were measured in 8 commercially available nebulizers. Measurements were made with no outlet tubing ,with 72 inches of dry corrugated plastic tubing, and with 72 inches of corrugated plastic tubing partially occluded with water. Nebulizers were studied individually ,and in parallel sets of 2 and 3, at both 40% and 70% O2 settings. Total flow was always lower and O2 fraction higher than that predicted by the manufacture under all experimental circumstances. As the outlet resistance of the nebulizers increased, the O2 fraction increased and the total flow decreased. The O2 fraction was, in addition, increased with the addition of each nebulizer in parallel. Currently available nebulizers have operating characteristics that do not permit the easy administration of accurate O2 therapy.


The effects of posture on venous admixture and respiratory dead space in health. Alveolar-arterial PO2 difference ([A-a]PO2), venous admixture, and physiologic dead space were measured in 24 healthy men and women 23 to 72 years of age in the sitting and supine positions, breathing air, breathing O2, and breathing O2 in deep breaths. In the supine (but not the sitting) position, (A-a)PO2 and venous admixture, breathing both air and O2, were more highly correlated with the difference between closing volume and expiratory reserve volume than with age. The change in (A-a)PO2 and venous admixture from sitting to lying was related to the change in closing volume minus expiratory reserve volume, during both air and O2 breathing. These results confirm previous work on the contribution of gravity-dependent airway closure to the air-breathing venous admixture. They further indicate that the same mechanism is important when O2 is breathed, and it may account for most of the alveoli that close during O2 breathing because of critically low ventilation perfusion ratios. Physiologic dead space in the supine position may be predicted by subtracting 12.5% from the normal sitting value for the same tidal volume and respiratory frequency.


On line determination of lung volumes by plethysmography and digital computer. This report describes a method of obtaining lung volumes on line with a minicomputer and whole body plethysmograph. The results of this approach were compared with standard methodology for a wide range of values and found to be in good agreement. This system can be readily implemented using standard hardware and laboratory techniques. Its advantages are its accuracy ,rapidity of data analysis, and retrieval; through the latter it allows for an assessment of such factors as variability of subject performance.


Penetration of inhaled pollen into the respiratory tract. The pathophysiologic mechanisms of pollen-induced asthma have heretofore remained unclear, because pollen particles have generally been considered too large to penetrate into the lower respiratory tract. Such grains are therefore believed to be unable to induce an immunologic response in the lower respiratory tract. Nevertheless, experimental curves of particle penetration into the respiratory tract indicate that a small percentage of large-sized particles may penetrate into the peripheral areas of the lungs. Under the conditions of our study, a radioisotopic method using labeled pollen grains was not effective in detecting the very small number of grains expected to be found in the lung. We used another simpler and more effective method derived from techniques used by palynologists in the detection of pollen grains in sediments. According to our results, which showed pollen grains normally present in tracheobronchial secretions and in lung parenchyma, we can safely assume that inhaled pollen does penetrate into the distal lower respiratory tract. At present, we do not know the precise number of pollen grains necessary to trigger a response, and we do not know the behavior of these grains with regard to the mucous membranes of the small bronchi and the alveoli. It is important to determine whether these grains have an effect on these areas and whether a direct mechanism is involved in the genesis of pollen-induced asthma.


Diagnosis of asbestosis by transbronchial biopsy. A method to facilitate demonstration of ferruginous bodies. The diagnosis of asbestos-associated pulmonary fibrosis was established in 3 patients by finding ferruginous bodies in transbronchial lung biopsies. Ferruginous bodies may be difficult to identify in histologic preparations when they are not oriented parallel to the plane of tissue section or when camouflaged by anthracotic pigment. We describe a simple method to enhance diagnostic sensitivity by digesting biopsy tissue and examining the filtered residue for ferruginous bodies.


Cutaneous infection due to mycobacterium szulgai. A patient on long term corticosteroid therapy for sarcoidosis developed a cutaneous infection due to Mycobacterium szulgai. No evidence of visceral infection with the organism was found during life or at autopsy. The spread of the infection to multiple skin sites probably occurred by autoinoculation.


Deaths and complications associated with transbronchial lung biopsy. A questionnaire requesting information about complications resulting from transbronchial lung biopsy was sent to 178 directors of respiratory disease training programs in the United States and Canada. Ninety-six questionnaires (54%) were returned, listing 5,450 transbronchial lung biopsy procedures. Thirteen deaths were directly or temporally related to the procedure. Nine patients died from hemorrhage. Eight of these patients had underlying diseases or were receiving drugs known to affect hemostasis. One also had pulmonary hypertension. One patient died from a tension pneumothorax that rapidly progressed more than two hours after the procedure. Analysis of the exact data, which were available for 2,628 procedures, indicated that pneumothorax, hemorrhage exceeding 50 ml, and death occurred in 5.5, 1.3, and 0.20% of procedures, respectively.


Rhabdomyolysis and shock after intravenous amphetamine administration. Five patients who had injected intravenous (i.v.) phenmetrazine or methamphetamine developed marked prostration resembling septic shock, disseminated intravascular coagulation, rhabdomyolysis with myoglobinuria, and azotemia. Soon after injection, four noted chills, fever, sweats, nausea, and abdominal cramps. Within hours, they developed vomiting, myalgias, paresthesias, headache, and orthostasis. Cardiorespiratory arrest, accelerated bleeding, and noncardiac pulmonary edema were observed in one patient. From 4 to 11 litres of saline were required in the first 24 h to maintain blood pressure and urine output, suggesting that shock resulted from massive loss of intravascular volume into necrotic muscle. Recognition of this syndrome and treatment by aggressive volume replacement led to the recovery of all five patients.