Season of birth in the population of Norway, with particular reference to the September birth maximum. The monthly number of births in Norway fluctuates between a maximum in January-May and a minimum in October-December. This cyclic seasonality is assumed to be of biological origin, but indirectly it is influenced by social factors and consequently tends to vary a great deal. There is a secondary birth maximum in September, corresponding to a peak of conceptions during the traditional festivities around Christmas and New Year. It is shown that this maximum is much less variable within the country studied, though it probably varies from one country to another in relation to the impact of the mid-winter traditions. The January-May birth maximum is known to be higher in schizophrenia than in the general population, while no such difference is observed in Norway for the September birth peak. It is felt that there is a fundamental difference between the two birth maxima and a corresponding difference between schizophrenic patients and the general population. Minimal paranatal brain damage of seasonal origin is suggested as an explanation.


Seasonality of mania: a reappraisal.

Seasonality of mania: a reappraisal. Some recently published data on the seasonal incidence of mania are re-examined. The reanalysis confirms a strong, seasonal trend in females, but also demonstrates a similar trend in males; the latter results is at variance with an earlier finding which showed no seasonal pattern in males. A simple harmonic curve would describe the data extremely well in both sexes, and the parameters of these curves (the amplitude of variation and the time of maximum incidence) are very close for males and females.


Cannabis and the peripheral nervous system. The possible ill-effects of cannabis on the peripheral nervous system were examined in 27 male subjects with respect to their motor and sensory nerve conduction. They were classified by their previous cannabis use into casual and heavy users. The nerve conduction studies were done after a baseline period of five days and then repeated after a three-week period during which the subjects could acquire and smoke standardized cannabis cigarettes. The casual users smoked a mean of 54-3 and the heavy users a mean of 109-5 cigarettes during the smoking period. No deterioration of peripheral nerve function could be demonstrated.


Symptom changes in chronic schizophrenic patients on a token economy: a controlled experiment. An 18-month controlled experiment was conducted into the effects of a token economy programme on the ward behaviour and symptoms of chronic schizophrenic patients. An experimental group received tokens dependent upon appropriate behaviour, while a matched control group on the same ward received every aspect of the ward programme similarly except that tokens were not dependent upon their behaviour. Regular assessment showed that both groups improved substantially in social withdrawal. Over twelve months of treatment the experimental group improved no more than the control group. There were no symptomatic changes. The conclusions were that token economy is a treatment affecting withdrawl and social behaviour rather than symptomatology, and that factors other than reinforcement by tokens were responsible for the main changes.


The repetitiveness of self-poisoning and self-injury. A year's cohort of 690 suicide 'attempters' was followed for two years in order to monitor further attempts leading to referral to the general hospital. Eighteen per cent were involved in one or more repeat episodes, 16 per cent within the first year. More repeats occurred within the first three months than in the rest of the 21 months, and a large majority of repeats occurred within the first year. Study of a smaller cohort of 141 persons gave information about the frequency and timing of previous attempts. Forty-five per cent had made previous recognized attempts and 10 per cent previous unrecognized attempts. Sixty persons reported 166 previous attempts. Of previous attempters 32 per cent made two or more attempts within a three-month period. Three types of repeaters are suggested: (a) the chronic, habitual repeater; (b) the individual who repeats several times within a short period, and (c) the 'one-off' very occasional repeater.


The immediate and enduring effects of the inquest on relatives of suicides. A survey of relatives' experience of coroners' inquests on suicides is reported. The survey was conducted shortly after the inquest and gave results similar to those of a survey which took place some years after the relevant inquests. Both surveys show that the inquest aggravates the distress resulting from bereavement by suicide. Implementing the Brodrick Report and preventing the publication of inquest reports in the press would relieve some of this additional distress.


Male transsexualism in Singapore: a description of 56 cases. A psychiatric investigation on 56 cases of male transsexuals in Singapore revealed a prevalence of I in 25,000. Eighty-two per cent were prostitutes and 83 per cent had completed secondary education. All were unmarried, and 35 per cent were co-habiting with men. Fifty-eight per cent had felt they were females before the age of 5, 65 per cent cross-dressed before the age of 10, and by the age of 20, 57 per cent were completely cross-dressed of whom 73 per cent were receiving female sex hormones. Their mean IQ was 105. Thirty-two (58 per cent) underwent sexual reassignment surgery. There was no report of psychiatric complications. It was concluded that transsexualism as described by different authors may not refer to the same condition. Aetiologically, these cases did not appear to be determined by early childhood experience.


Outcome in psychotherapy evaluated by independent judges. To overcome common limitations in assessing the outcome of psychotherapy, the following method was used: independent assessment by teams of experienced psychotherapists; individualized measures of outcome; and videotaped clinical interviews to allow the judges to rate, at one sitting, a patient's clinical state before and after eight months of therapy. Agreement between the judges' ratings was low both for the severity of the clinical state and for its outcome. Possible reasons for this low agreement are discussed.


A survey of consultant psychiatrists' attitudes to their work, with particular reference to psychotherapy. Ninety-six out of 137 consultant psychiatrists working for the majority of their time in the London area outside academic units returned questionnaires concerning attitudes to their work. Analysis of the 88 fully completed questionnaires suggested the existence of four relatively discrete but overlapping patterns of psychiatric practice in the Regions concerned, of which two largely excluded individual psychotherapy. These findings are discussed in relation to the education in psychotherapy of trainee psychiatrists working in mental hospitals.


Oxygen cost and energy expenditure of running in trained runners. The oxygen cost and energy expenditure of submaximal treadmill running was evaluated in 9 male distance runners. The oxygen consumption--running speed relationship was highly significant (r = .917) and linear over the entire aerobic range. The caloric cost of 0.97 Kcal/kg/k was in close agreement with values found in the literature and was independent of running speed. The caloric cost per unit distance and time increased with acceleration in running speed. The slope of the regression line of oxygen consumption on running speed appear to measure a different component of efficiency than the fractional utilization coefficient of aerobic capacity. There is apparently a wide variation in the oxygen cost of running in trained runners.


Responses of adult women to programmed exercise. A group of eighty healthy women was studied following two months of programmed exercise (3 x 15 mins/per week) at 60 to 80 percent of age-predicted maximum heart rate. Physical work capacity corresponding to a heartrate of 170 bts. (PWC-170) was determined using a bicycle ergometer. Anthropometric and lung function variables were also ascertained prior to (T1) and following training (T2). The post training measurements of this exercise group, compared with measurements of a sedentary control group, displayed significant changes in PWC-170, resting systolic blood pressure and fat index. There were no significant changes in vital capacity, forced expiratory volume in one second (FEV1), strength and perceived exertion measures (RPE). The implication of these findings are discussed.


A study of potential Olympic swimmers: I, the starting point. Physiological and anthropometric profiles of a group of successful young swimmers are presented. Anthropometrically the swimmers appear to fall within fairly narrow limits but are physically more mature than their peers. Physiologically there is greater diversity within the group representing perhaps the varying demands of the swimming events practised. All values for the physiological parameters measured are high compared with children of similar ages. For the future it is hoped to relate performance in swimming to the variables measured and to assess any changes which occur thus perhaps colouring the profiles presented here.


A study of the physical working capacity of Gaelic footballers and hurlers. The possible contribution of endurance fitness to performance in the Gelic games, football and hurling, has been investigated. Two groups of 15 players were compared. The first consisted of members of teams reaching interprovincial finals and the second were similar members of comparable but less successful teams. The measurements taken were: height and weight, skinfold thicknesses on the triceps, biceps, subscapular and suprailiac sites, and the physical working capacity at a heart rate of 170 beats per minute (PWC 170). The more successful players were found to be taller and heavier and to have a higher PWC 170. There was no difference in estimated percentage of fat. The difference in PWC 170 of the two groups remained after correction for the difference in body weight. A group of seven of the players who participated in two or more finals was studied longitudinally. In six of these subjects PWC 170 was higher at the time of these matches than before or after. These findings are discussed and it is suggested that endurance fitness is a factor contributing to performance in football and hurling.


Factors affecting performance during an endurance relay. A successful attempt by Edinburgh Athletic Club on the world record for the 24-hour 10-man x 1 mile relay is reported. The effects of a variety of factors on the performances of the athletes are assessed, and some physiological changes noted. In the light of these observations recommendations are made to help the planning of future record attempts.


Cranial chordomas.

Cranial chordomas. The clinical and radiological features of 44 cranial chordomas are recorded. Classical features of a mid-line partially calcified tumour, destroying the clivus and causing a soft tissue mass in the sphenoid sinus or nasopharynx were present in about half of the cases. The high incidence of unilateral bone erosion which occurred in nearly a third of the cases, the diagnosti1c significance of erosion of the tip of the clivus and odontoid peg and the not infrequent sclerotic bone reaction to the tumour, are stressed. Increased uptake of 99Tcm occurred in the five cases in which gamma encephalography was performed. Computed transmission tomography was valuable not only in showing the intracranial extension of the tumours and changes in the ventricular system, but also in outlining the extent of the mass within the skull base. Chordomas tend to displace the dura before transgressing it so that the subarachnoid space is usually patent adjacent to quite large tumours allowing the margins of any intracranial or spinal extension to be outlined at encephalography or myelography. Displacements of basal vessels are helpful in confirmation of the site and extent of the tumour. Narrowing of arteries by compression is not frequent but encasement is rare. Pathological circulation which has not been considered to be a feature of chordomas was shown in six cases.


Aneurysmal bone cyst of clavicle.

Aneurysmal bone cyst of clavicle. Two aneurysmal bone cysts are described. They presented difficulties in diagnosis because the patients were rather older than usual for this lesion and because of the uncommon location of the cysts. The nature of aneurysmal bone cysts is discussed.


Coronary xeroradiography.

Coronary xeroradiography. Xeroradiography is shown to be especially helpful in coronary arteriography. Comparatively low concentrations of contrast medium are sufficient to provide adequate diagnostic details in the image. Selection injection techniques yield exceptional resolution of small vessels. The possibility of obtaining adequate coronary arteriograms by aortic root injections, with its inherently lower risk to the patient, is examined.


Congenital deformities of the middle and external ear. Congenital deformities of the external and middle ears were shown by tomography in 246 patients. Surgical exploration has been undertaken at some time in many of these ears. The appearance of the tomograms and their significance were reviewed in the light of the operative findings and the authors' experience of congenital ear lesions. In nearly every case a middle ear cavity could be demonstrated although this varied from a normally aerated middle ear and mastoid in association with an isolated unilateral atresia of the external auditory meatus to a small slit-like hypotympanum in patients with craniofacial abnormalities. The ossicles were nearly always present but deformed. The typical appearances of the ossicles and the frequently aberrant pathways of the facial nerve are described.


Technetium-99m-labelled diethyl-acetanilido-iminodiacetate: a new hepatobiliary agent. A preliminary report. A new hepatobiliary reagent 99Tcm diethyl-acetanilido-iminodiacetate has been examined in a small group of patients to evaluate its potential as a clinical reagent. The radiopharmaceutical accumulated readily in the hepatocytes and was rapidly excreted via the biliary system. It would appear possible to develop a dynamic test of hepatocyte function coupled with an evaluation of the patency of the biliary system. No adverse reactions were observed.


A survey of radiation doses to patients in mammography. The results are given of a survey of skin doses received in mammography by a phantom breast containing a simulated spherical tumour. The survey covered the 18 centres in New Zealand where mammography was carried out in 1976. The techniques used included xeroradiography, non-screen film and film with a back screen. If the best parameters for each technique were chosen, the "tumour" could be readily seen. Unfortunately this was not often the case and in practice only xeroradiography produced mammograms where the tumour was clearly seen in both the cranio-caudal and medio-lateral views. No centre produced a mammogram of the highest quality with an entrance dose of less than 1 rad. Within each technique there was a very wide range of entrance doses for the same quality of mammogram. At two centres with large workloads, the entrance doses to 11 patients were measured and, in general, the skin doses received by the patients were within 25% of those measured with the Rando phantom.


Delayed (degenerate) interfascicular nerve grafting: a new concept in peripheral nerve repair. Interfascicular nerve grafts allowed to undergo endoneurial tube emptying in situ before transfer have been compared with grafts transferred fresh in terms of structure and function. The sciatic nerve of the rat was the model and its structure and ultrastructure were superior following degenerate grafting. More importantly, electrophysiological studies showed that function in nerves repaired with degenerate grafts was significantly better than in those repaired with fresh grafts.


A non-invasive test of gastric function. Using 98Tcm a non-invasive test of gastric function has been developed which completely obviates the need for a nasogastric tube and which adds to the accuracy of existing tests by overcoming losses due to incomplete aspiration or gastric emptying. 99Tcm is handled by the stomach like Cl-, the gastric secretion of which is equal to that of H+. The value of the pentagastrin stimulation test in the presence of varied gastric pathology is discussed in relation to 50 patients. Other possible diagnostic uses of the test are evaluated and a method of carrying out an insulin test by a modification of the technique is described.


Postoperative pulmonary perfusion defects: their natural history, origin and significance. Unmatched perfusion defects occur during the early postoperative period. These defects can persist until the tenth postoperative day and their presence is not related to the transfusion of blood or to peripheral thrombosis detected by the 125I-labelled fibrinogen uptake test. It is suggested that prophylactic agents against deep venous thrombosis should be evaluated by using a combination of krypton ventilation-perfusion lung scans and 125I-labelled fibrinogen leg scans.


Breast screening and surgical problems.

Breast screening and surgical problems. The Edinburgh Breast Screening Clinic in its first year completed the initial screening examination of 3005 invited women, who were apparently in good health, aged between 40 and 60 years; 141 were referred for a surgical opinion; 70 women ultimately underwent biopsy and 9 proved to have carcinoma. The indications for biopsy are described together with methods of management of the various lesions.


The role of plastic wound drapes in the prevention of wound infection following abdominal surgery. A randomized controlled trial has been performed to assess the value of plastic wound drapes in the prevention of surgical wound infection. One hundred and forty-four patients undergoing abdominal surgery were allocated to one of three groups; a control group (A) in which standard cloth towels were applied to the abdominal wound, group B in which an adhesive plastic drape was added and group C in which a plastic ring protector was inserted into the wound. There were 26 cases (18 per cent) of wound infection. The wound infection rate in the plastic drape groups did not differ significantly from that in the control group. Bacteriological culture from a wound swab taken at operation was positive in 32 per cent of the cases. The presence of a plastic wound drape did not influence the positive culture rate. In 68 per cent of wounds which became infected the operative swab was positive as compared with 24 per cent in those not developing a wound infection. Thirteen of the 33 patients (39 per cent) with a positive wound swab subsequently developed a wound infection. In 10 of these 13 cases of infection the operative swab permitted an accurate prediction of the organism responsible for the subsequent infection.


The treatment of colonic cancer presenting with intestinal obstruction. The factors affecting the prognosis of patients presenting with colonic obstruction caused by carcinoma were examined in a retrospective study of 66 patients undergoing emergency surgery for obstruction. The findings in these cases were compared with 176 patients with colonic cancer undergoing elective surgical treatment. Obstructed patients had a significantly higher surgical mortality (37.9 per cent) than elective cases (11.9 per cent). There was a significantly higher incidence of lymph node metastases in obstructed patients and those who survived surgery had a significantly lower 5-year survival rate (22.9 per cent) than elective cases (41.5 per cent). Primary resection of obstructing tumours was followed by a higher 5-year survival rate (31.8 per cent) than staged resections (7.7 per cent), but these operations were used selectively and the 5-year survivors following primary resection all had tumours of the proximal colon. Primary resection and anastomosis of the distal colon was associated with a surgical mortality of 50 per cent. Further progress in the cure of patients with obstructing cancer of the colon may be limited by the aggressive nature of the disease, but the use of primary resection in these cases should be examined in a prospective clinical trial.


Varicocele: a review of radiological and anatomical features in relation to surgical treatment. The patterns of venous drainage of the testis and scrotum have been evaluated in patients with varicocele by a variety of radiological procedures, including left renal venography, and at the time of operation by ascending venography and retrograde injection of contrast medium into prominent varicosities. These studies have allowed classification of the system of veins involved in the condition into several groups, including involvement of the internal spermatic vein alone, pure cremasteric varicocele, mixed internal spermatic and cremasteric varicosities in one or both systems with valvular incompetence or mere dilatation without apparent incompetence of valves. As a result, an anatomical approach to the surgical management of varicocele is suggested which attempts to place the operative treatment on a more rational basis appropriate to each case.


Closed renal trauma.

Closed renal trauma. A series of 76 cases of closed renal trauma is presented. The clinical and radiological features are described and the indications for conservative and surgical treatment discussed.


Neoplasms at the site of ureterocolic anastomosis. This paper discusses one of the more uncommon sequelae of ureterocolic anastomosis, namely the formation of tumours at the site of anastomosis. This is a very rare complication and until 1971 the literature recorded only 28 cases of this phenomenon. This present communication adds 2 more cases to the literature--a unilateral tumour and bilateral tumours at the site of anastomosis.


Carcinoma of the thyroid gland in Iran.

Carcinoma of the thyroid gland in Iran. Of the 1698 cases of thyroid disease seen during the 17 years 1956-72 in the Taj Cancer Institute, Tehran, 398 were cases of carcinoma, an incidence of 23.4 per cent. The factors involved in this high incidence of malignancy are discussed and the treatment of these patients is described.


Hiatus hernia repair combined with the construction of an anti-reflux valve in the stomach. An operation is described that combines hiatus hernia repair with the construction of an anti-reflux valve in the stomach immediately beyond the cardia. One hundred and ten patients treated by this operation, including 28 with panmural oesophagitis, have been followed up by clinical and radiographic assessment at yearly intervals for periods from a little over 1 year to over 5 years. Three patients had return of reflux symptoms, 2 of these being the only patients in the series with X-ray reflux at follow-up. The return of reflux in these patients appeared to result from anatomical changes that were probably caused, at least in part, by over-tight application of the stapling instrument used in the operation.


The effect of vagotomy on the lower oesophageal sphincter: a manometric study. The pressure profile of the gastro-oesophageal junctional zone was studied at rest and during abdominal compression in 26 duodenal ulcer patients after subdiaphragmatic truncal vagotomy with a drainage procedure. An 'early' group of 9 patients was investigated 10-14 days after surgery and a 'late' group of 17 patients more than 1 year after operation. Comparisons were made with 25 control subjects. The resting lower oesophageal sphincter pressures after vagotomy in both the early and late groups were similar to the levels of sphincter pressure in the controls. However, the increase in sphincter pressure always observed during absominal compression in normal subjects was significantly decreased by complete vagotomy, and the normal increase in the gastrosphincteric pressure gradient was not produced. All 26 patients were tested for completeness of vagotomy using the insulin/pentagastrin test. In 19 patients the vagotomy was complete and in 7 patients it was judged to be incomplete. A decrease in the gastro-sphincteric pressure gradient on manometric study of the lower oesophageal sphincter was interpreted as indicating complete vagotomy. Accurate correlation between secretory response and compression response was achieved in all patients with complete vagotomy and in 5 of the 7 patients with incomplete vagotomy.


Plasma gastrin concentration related to acid secretion during insulin hypoglycaemia. The release of gastrin by insulin hypoglycaemia was studied in man before and after vagotomy. Completeness of vagotomy was judged by the gastric acid response to the same hypoglycaemia, using several criteria including one that allows for pyloric losses and duodenogastric reflux. A total of 137 tests was performed on 10 subjects. The plasma gastrin concentration was found to rise in the preoperative studies and also in the postoperative studies no matter what type of vagotomy had been performed or what criteria of completeness of vagotomy were used. We concluded that gastrin can be released in response to hypoglycaemia in the absence of the vagus nerve.


Recurrence after proximal gastric vagotomy without drainage for duodenal ulcer: a 3-6-year follow-up. During the period December 1970 to August 1973, 99 patients with duodenal ulcer underwent proximal gastric vagotomy without drainage, and 93 per cent of the patients were followed up for 3-6 years after the operation. A proved recurrent duodenal ulcer was noted in 4.3 per cent and a strongly suspected recurrent duodenal ulcer in 2 per cent. It is suggested that this rate of recurrence on medium term follow-up is compatible with the continued use of proximal gastric vagotomy in the surgical treatment of duodenal ulcer.


Revagotomy for recurrent peptic ulceration. A review has been made of 59 patients with recurrent peptic ulceration after incomplete vagotomy. Eighteen transthoracic procedures were performed, the remainder having abdominal revagotomy. An antrectomy was also carried out in 10 of these patients. An intact posterior nerve trunk was the most common operative finding and when either an anterior trunk or nerve strands only were present there was less likely to be an early positive insulin response (P = 0.033). Following incomplete vagotomy a longer period of symptomatic relief is obtained when gastro-enterostomy rather than pyloroplasty is used as the drainage (P less than 0.01). Completing the vagotomy by the abdominal route gave superior results to transthoracic revagotomy (P = 0.0015), the former procedure without antrectomy having no associated mortality in this series. Although the results of revagotomy and antrectomy are as good as those of transabdominal revagotomy alone, we recommend the latter more conservative treatment for recurrent ulceration after incomplete vagotomy.


Reappraisal of the left lateral decubitus X-ray in splenic rupture. The lateral decubitus view of the barium-filled stomach has been reassessed in a series of 42 patients with possible splenic rupture and compared with a group of 17 patients with splenomegaly. Displacement of the gastric fundus of more than 4 cm from the inner rib margin is highly suggestive of splenic rupture. Where doubt exists, the test should be repeated within a short while. Peritoneal lavage and a full blood count investigation both add to the diagnostic accuracy.


Bile composition in bilharzial hepatic fibrosis. At operation for haematemesis in bilharzial hepatic fibrosis, the gallbladder was always found to be diseased but devoid of stones. This led to a study of gallbladder bile composition in a group of bilharzial patients and comparison with a group of cholelithiasis patients. When values for biliary lipid composition were plotted on triangular coordinates, both groups fell well outside the line of maximum cholesterol solubility. The bilharzia group had significantly more cholesterol and less phospholipid than the gallstone group. The absence of stones in patients with bilharzial hepatic fibrosis was possibly due to their early demise and the suggestion is that, in this condition, it is the disease of the gallbladder itself which renders the bile lithogenic.


Umbilical pilonidal sinus.

Umbilical pilonidal sinus. A rare case of umbilical pilonidal sinus is reported--the only documented case of barber's pilonidal of the umbilicus. Possible mechanisms of formation are described. It is suggested that this possibility should be considered in cases of resistant or recurrent omphalitis. Definitive treatment consists of sinus excision with cosmetic umbilical reconstruction. Total omphalectomy is probably only justified for recurrence.


Stricture-plasty for tubercular strictures of the gastro-intestinal tract. Twenty stricture-plasties have been performed for multiple tubercular strictures of the gastro-intestinal tract in 9 patients, who in total had 35 strictures. The procedure has been found to be safe, simple and effective in relieving obstructive symptoms. It does not appear to carry the disadvantages of entero-anastomosis or multiple and/or massive resections in cases of multiple tubercular strictures of the small bowel.


Appendicectomy: an assessment of the advisability of stump invagination. Seven hundred and thirty-two cases of appendicectomy performed over a period of 5 years are reviewed to compare the incidence of complications and the length of the postoperative stay in hospital, depending on whether the appendix stump was simply ligated or was invaginated by purse string suture following ligation. No detrimental effects are noted following simple ligation, whereas patients who had stump invagination remained in hospital on average more than a day longer, mainly owing to a higher incidence of wound infection (16 per cent as against 6 per cent).


The Erlangen magnetic colostomy control device: technique of use and results in 22 patients. The evolution and general principle of the Erlangen magnetic ring colostomy device are described and its practical use illustrated by reference to a personal series of 22 patients treated with the device. Analysis of the functional results obtained in 13 of these cases, who were assessed after at least 3 months' trial, shows that only 3, or at most 4, could be considered to have achieved worth-while continence, but there are grounds for believing that these results might be improved a little by more stringent selection of patients for the procedure and by employing a more meticulous technique for implanting the rings.


Intestinal obstruction after excision of the rectum. Over a 5-year period, 33 patients underwent excision of the rectum in the same unit of Aberdeen Royal Infirmary. Six patients in whom the abdominal contents were allowed to fall into the denuded pelvis showed a uniform pattern of delayed intestinal transit. Two of the patients required reoperation and one died. A similar pattern was not seen in patients managed by other methods. Even if leaving the pelvic peritoneum open were to improve the likelihood of primary perineal healing, for which there is no good evidence, the risks are such that the practice must be regarded as unacceptable unless omentum is mobilized to occupy the pelvic cavity.


The finding of thrombus at carotid endarterectomy and its relationship to the timing of surgery. The clinical, angiographical, operative and histological records of 52 patients undergoing carotid endarterectomy for transient cerebral ischaemic attacks were reviewed. Thrombus or other friable material was present in 66 per cent of the 24 patients operated upon within 4 weeks of a clinical attack, but in only 21 per cent of the 28 patients in whom the time interval was longer. The data favour an embolic explanation for the clinical episodes and further suggest that thrombus formation on atheromatous stenosis and ulceration is intermittent.


Abdominal aneurysm in South African Negroes due to intimomedial mucoid degeneration. Nine South African Negroes with abdominal aortic aneurysms due to intimomedial mucoid degeneration are described. These occurred in a younger age group than atherosclerotic aneurysms and with a female predominance. The aneurysms are not syphilitic in origin and are unlike atherosclerotic aneurysms. This form of abdominal aneurysm constitutes a distinct entity which is relatively prevalent in South African Negroes and which has hitherto received little or no emphasis and attention.


Deep venous thrombosis in patients having aorto-iliac reconstruction. The 125I-labelled fibrinogen test has been used to assess the incidence of deep venous thrombosis in 88 patients who had undergone elective aorto-iliac reconstruction. Deep venous thrombosis was detected in 18 (20.5 per cent). The results suggest that these patients merit prophylaxis.


Phenol lumbar sympathectomy for severe arterial occlusive disease in the elderly. Phenol chemical lumbar sympathectomy is an additional aid in the management of ischaemic rest pain and incipient gangrene. This technique was used in 132 elderly patients in Bath between September 1972 and March 1975 and the results are presented here. The patients were unfit for reconstructive arterial surgery. In this series an image intensifier was used in order to make the procedure safer. One hundred and twenty-six patients were available for review, their average age being 71.5 years. The average period of follow-up was 16.3 months. Of the 126 patients, 111 were not diabetic, and of these 45 (41 per cent) had satisfactory results while 17 (15.4 per cent) had persistent symptoms but had avoided amputation. Thirty (27 per cent) patients required amputation and 12 of these died as a direct result of this procedure. A further 19 patients in the non-diabetic group died during the period of follow-up. However, of the 15 diabetic patients, only 3 (20 per cent) improved whilst one patient with persistent symptoms avoided amputation. The remainder either died (8) or had an amputation (5) during the period of follow-up. Two died after amputation.


Submucosal arterial malformation of the stomach as the probable cause of recurrent severe haematemesis in a 16-year-old girl. A 16-year-old girl who had previously been in good health suffered recurrent life-threatening haematemesis. The cause of this bleeding appeared to be the spontaneous rupture of an abnormally large submucosal artery in the stomach. The site of bleeding was eventually localized by coeliac angiography via an indwelling percutaneous femoral catheter.


Congenital anal duplication: a cause of para-anal sinus. Four cases of recurring para-anal sinus originating, it is suggested, as congenital duplication of the anal canal, are described. The diagnosis depends upon the finding of columnar mucus-secreting epithelium in a sinus track which does not communicate with the bowel lumen. The sinus may or may not penetrate the levator ani muscle. Treatment should be by excision of the sinus, rather than by laying it open into the anal canal. If the sinus is superficial, the latter operation will result only in delayed healing and prolonged convalescence, but if it runs deep, there is a danger of causing incontinence or an extra-sphincteric fistula. Untreated lesions may eventually be the site of malignant change. This complication was not encountered in the present series.


Prospectively randomised trial of proximal gastric vagotomy either with or without pyloroplasty in treatment of uncomplicated duodenal ulcer. A consecutive series of 100 men with uncomplicated duodenal ulcer was randomly divided into two groups: one group of 52 underwent proximal gastric vagotomy (PGV), the other group (48) underwent PGV with pyloroplasty (PGVP). Preoperative peak acid output (PAOP) was measured in all patients. Those with a higher preoperative PAOP were significantly more likely to develop recurrent ulceration. Three patients developed recurrent ulceration after PGV and seven after PGVP. Dumping was both more common and more severe after PGVP than PGV. An overall satisfactory result was achieved in 92% after PGV and 81% after PGVP. We conclude that combining pyloroplasty with PGV has no appreciable advantages.


Maternal drug histories and congenital abnormalities. We obtained drug histories for the first trimester of pregnancy for 836 mothers of congenitally malformed babies and for an equal number of control mothers of normal babies from the same doctors' practices. There was an association between the use of a hormonal pregnancy test and the subsequent birht of a malformed baby. There was also a greater use of barbiturates by mothers of affected children compared with mothers of control babies, mainly accounted for by treatment of epileptic mothers with phenobarbitone. For all other drugs usage was similar in both sets of mothers.


Vitamin D supplements and 25-hydroxy vitamin D concentrations in the elderly. Serial 25-hydroxy vitamin D (25-OHD) concentrations were measured in long-stay geriatric patients treated with vitamin D. Comparison between a treatment and a control group showed that a daily dose of 500 IU vitamin D produced a significant increase in 25-OHD levels by two months. The supplement had a striking effect when the initial 25-OHD level was low and very little effect when it was high. 25-OHD levels in subjects on 2000 IU vitamin D daily were only marginally higher than those in subjects on 500 IU. A dose of 500 IU vitamin D daily should therefore produce adequate blood 25-OHD concentrations in most old people, and probably prevent most cases of osteomalacia in the elderly--though a large-scale study is needed to confirm this.


Predicting fetal death by measuring oestrogen:creatinine ratios on early morning samples of urine. Total oestrogens were measured, on a creatinine basis, by a fully automated method in 75 000 early morning specimens of urine from 5429 women. Among the 5241 pregnancies in which the oestrogen:creatinine ratio was normal there were 11 fetal deaths (0-21%). But there were 57 fetal deaths (30-3%) among 188 patients with ratios below the fifth centile. When delivery took place before the ratio decrease to below the fifth centile a live baby was born in every one of 59 pregnancies. Apart from its effectiveness in predicting fetal death, the test has a high degree of precision and can be performed swiftly, and cheaply. For these reasons the assessment of fetoplacental function by measuring the urinary:creatinine ratio could become a convenient and inexpensive part of antenatal care that could be extended to every pregnant woman without making many further demands on obstetricians' time.


Antibiotic treatment of abscesses of the central nervous system. Samples of intracranial pus and serum from 32 patients were assayed to determine the concentrations reached in them of penicillin, ampicillin, cloxacillin, cephaloridine, gentamicin, chloramphenicol, fusidic acid, and lincomycin. Metronidazole had not been given. Penicillin penetrated abscesses reasonably well, but other beta-lactam antibiotics did not. The penetration of chloramphenicol was erratic. Aminoglycosides penetrated poorly, but lincomycin and fusidic acid penetrated well. Assay of sulphonamides and co-trimoxazole in pus was unreliable. These studies indicate that treatment of abscesses of the central nervous system should be considered according to the site and the likely antecedent cause. Abscesses of sinusitic origin, usually in the frontal lobe, yield penicillin-sensitive streptococci. Penicillin is the drug of choice. Abscesses of otitic origin, usually in the temporal lobe, yield a mixed flora, often including anaerobic bacteria. Multiple antibiotic therapy is indicated. Abscesses of metastatic or cryptogenic origin yield streptococci or mixed cultures, and multiple therapy is appropriate while awaiting the bacteriological results. Spinal and post-traumatic abscesses yield Staphylococcus aureus, and fusidic acid is the drug of choice.


Effect of preoperative anaesthetic visit on anxiety. Anxiety levels measured in patients who received preoperative reassurance about anaesthesia from a member of the hospital staff were significantly lower than those in a control group given no such support. Anxiety levels in patients who read a booklet designed to reassure about anaesthesia were less significantly reduced. Owing to the increasing work load in the operating theatre many anaesthetists can no longer afford the time to visit patients preoperatively. This study shows that either this trend should be reversed or the role of reassurer should be assumed by someone else, possibly the anaesthetic nurse. For optimal effect, the visits should be combined with use of the booklet. Unless such measures are taken, up to three million people each year may be being denied any form of reassurance before surgical treatment.


Association of polymyalgia rheumatica and giant-cell arteritis with HLA-B8. Histocompatibility antigens were determined in 30 patients with temporal arteritis, 27 patients with polymyalgia rheumatica, and 216 normal blood donors. HLA-B8 was significantly more common in patients with polymyalgia rheumatica (59%) and temporal arteritis (50%) than in the controls (27%). The findings of HLA-A10 in 26% of the patients with polymyalgia rheumatica compared with only 10% of the controls may be associated with the suggested immunological pathogenesis of the condition.


Bacteriological study of otogenic cerebral abscesses: chemotherapeutic role of metronidazole. In nine consecutive patients with otogenic cerebral abscesses a mixed growth of aerobic and obligate anaerobic bacteria was isolated from the pus in five patients, and in the remaining four obligate anaerobes were the sole isolates. The commonest obligate anaerobe isolated was Bacteroides fragilis, which was present in all but one patient. The patients were all treated with metronidazole for the anaerobic organisms and with appropriate chemotherapy against the aerobic organisms isolated. All the patients recovered and only one was left with a neurological deficit. As otogenic cerebral abscesses constitute a major proportion of all cerebral abscesses, the use of metronidazole against obligate anaerobic bacteria, which tend to dominate in such abscesses, should reduce the high mortality from this condition.


Arrangements for special and intensive care of the newborn. All the special care baby units in three Thames health regions completed a one-day census on the number of infants in the unit, staffing, and facilities. The results were assessed in the light of the recommendations of an expert group set up by the Department of Health and Social Security. Although the provision of cots (6.1-6.9 per 1000 live births) was more generous than the estimated need and the occupancy rate (59--63%) lower than suggested, some units did not have adequate trained nursing cover at night, some did not have resident paediatricians, and some lacked essential equipment. Some small units, on the other hand, had very expensive equipment that was probably underused. Relating this provision to the regional statistics on babies needing special care showed that there was room for the rationalisation of facilities for their care. Factors that should be considered in planning such care include the size of the child-bearing population, the percentage of infants of low birth weights, and the proximity of specialist paediatric and maternity units and pathology facilities. It is also essential to monitor the effectiveness of the care by assessing the outcome in babies admitted to special units, especially those of low birth weight.


Treatment of hepatic hydatid disease with mebedazole: preliminary results in four cases. Mebendazole was given to four patients with hepatic hydatid disease. In three patients hydatidosis had remained after surgery, and in the fourth it could not be treated surgically. Mebendazole was given orally in maximum doses of 400-600 mg three times a day during courses lasting 21 to 30 days. Ultrasonic echotomography showed a complete regression of the intrahepatic cysts after four to 13 months in all four cases. In three patients the course of treatment had to be repeated. Mebendazole also induced clinical improvement and a progressive lowering of the concentration of specific IgE of Echinococcus granulosus. During treatment circulating blood levels of specific immune complexes of antigen 5 were increased. These observations indicate that mebendazole has a lethal effect on E granulosus cysts in primary hydatid disease in man and that the efficacy of chemotherapy can be assessed with ultrasonography and by measuring changes in the concentration of specific IgE of E granulosus and circulating immune complexes.


Effect of sodium bicarbonate on aspirin-induced damage and potential difference changes in human gastric mucosa. Two aspirin tablets in 100 ml fluid will produce microscopical damage to the human stomach. A study was performed to determine whether a small amount of sodium bicarbonate (equivalent to one-third of a teaspoonful of baking soda) could protect against this damage. Sequential gastric biopsy specimens were taken from 15 healthy subjects before, during, and after intragastric instillation of one of the following isotonic solutions: saline; sodium bicarbonate; 600 mg aspirin suspended in sodium bicarbonate; and aspirin suspended in saline. On a separate day the same solutions were instilled, but gastric transmucosal potential differences were monitored. Light microscopy and scanning electron microscopy of the biopsy specimens showed occasional mucous degranulation of mucosal surface cells, but no cell damage during instillation of sodium bicarbonate. Light microscopy studies 10 minutes after aspirin in saline showed damage in 20% of surface cells, with focal areas of cellular disruption and microscopic erosions, but only 3.4% of cells were damaged after aspirin in bicarbonate and there were no erosions. Electron microscopy showed a damaged honeycombed appearance of surface epithelium after aspirin in saline and a normal cobblestone appearance after aspirin in bicarbonate. Aspirin dissolved in bicarbonate failed to induce the usual fall in potential difference.These findings indicate that sodium bicarbonate in amounts equivalent to one-third of a teaspoonful of baking soda protects the gastric mucosa against aspirin-induced damage and prevents the usual fall in potential difference after aspirin.


Survivors of ruptured abdominal aortic aneurysm: the iceberg's tip. In four and a half years 25 patients in one community suffered a ruptured abdominal aortic aneurysm. Eleven died at home, nine died without operation in hospital, and only five had the aneurysm removed. There were four survivors. A further seven patients might have lived had they had a prompt operation. The average operative mortality for ruptured aneurysms among series reported in British journals is 53%, but the survivors are a small minority of the total number of people in the community whose aneurysms rupture. No basis could be found for the view that replacing an aortic aneurysm with a straight graft (while leaving behind aneurysmal common iliac arteries) lowers the operative mortality. On the contrary, oversimplifying the operation may be hazardous.


Practical approach to problems of the parturient diabetic in developing countries. Improved management of diabetic pregnancies at Lautoka Hospital, Fiji, in 1976 resulted in a neonatal survival rate of 100%. Management included attempts to control the maternal blood glucose concentrations with insulin and delaying delivery until there was enough surfactant in the liquor to ensure a viable infant. The techniques are simple to use and require only minimal technological facilities.


Investigations on reactivity of sera in endemic syphilis from Bosnia 20 years after treatment. Sera from 225 patients who 20 years earlier had been infected with endemic syphilis and adequately treated with penicillin (PAM 4.8-6 megaunits) at various stages of the disease, were investigated for serological reactivity by the fluorescent treponemal antibody absorption (FTA-ABS), treponemal haemagglutination, and Venereal Diseases Research Laboratory tests. Specific antibodies were found in a large percentage of cases and their presence may be assumed to depend on persisting specific antigen which stimulates their synthesis.


Tetracycline treatment for non-specific urethritis. The conclusions, where pertinent, of the 10 papers on the treatment of non-specific urethritis which have appeared in the British Journal of Venereal Diseases between 1971 and now are reviewed. Recent studies purport to argue, but in fact assume, that tetracyclilne treatment for non-specific urethritis is both effective and desirable; current practice agrees with this assumption. To prove effectiveness, studies over much longer follow-up periods would be necessary. These studies should compare results not only of different methods and doses of tetracycline, of different regimens, and of different types of the drug; they should also compare results over a prolonged period with placebos and with other drugs, for instance those outside the antibiotic range and with no suspected side effects. Only then would it be reasonable to hold a firm view on the desirability or the effectiveness of the treatment. With patience and properly conducted experiments results may emerge to justify some view. At the moment the data are ill-assembled although voluminous and fail to support conclusions that have any clarity or force; moreover they are so haphazard that they cannot be compared with one another. Some venereologists are sceptical about treatment, some advocate the administration of one single dose, others say the four- or five-day regimen is preferable, and so on up to those who maintain that the 21-day regimen is the best. The coexistence of such mutually incompatible, firmly-held views may well suggest that the whole system of investigation put together to validate such views is quite inappropriate. That would be a radical thesis, and perhaps none the worse for that. What is not a radical thesis, however, is that at present the whole system of data and argument is in disarray.


Plasma levels after a single oral dose of 1.5 g ornidazole. Administration of a single oral dose of 1.5 g ornidazole to volunteers produced plasma levels which remained above the mean minimal trichomonicidal concentration for between 54 and 72 hours. A subjective feeling of dizziness was observed by all volunteers, but it was not possible to make a correlation between this and the drug levels in this study.