A method of closed-chest cannulation of the left atrium for left atrial-femoral artery bypass. A large-bore polyvinyl catheter was devised for passage into the left atrium by means of a modified transseptal catheterization technique. This was performed without difficulty using both pulsatile and nonpulsatile bypass in the closed-chest animal as well as in 3 terminally ill patients. Blood was drained from the left atrium and returned to the femoral artery through an extracorporeal circuit. The shock syndrome produced by coronary embolization in dogs was successfully managed in this fashion. The results of the clinical trials were encouraging. Assisted left heart circulation using a closed-chest left atrial-femoral artery bypass seems feasible by this technique.


Bilateral atrial myxomas. Preoperative diagnosis and successful removal. A case of bilateral atrial myxomas is presented. The diagnosis was made preoperatively with the aid of echocardiography and cineangiography. The use of the echocardiogram in the diagnosis of this lesion is emphasized.


Hypoglycemic coma associated with benign pleural mesothelioma. A case of hypoglycemic coma and benign pleural mesothelioma is described. Serum insulin levels, as measured by insulin radioimmunoassay, were appropriately suppressed and consistent with hypoglycemia. Assay of the tumor showed insulin to be undectable. The mechanisms for hypoglycemia probably included increased glucose consumption by the tumor and, more important, the inhibition of lipolysis and hepatic gluconegenesis caused by tumor release of L-tryptophan and its metabolites and/or possibly nonsuppressible insulin-like activity, soluble in acid-ethanol(NSILA-s).


Upward displacement of the diaphragm after lung resection. Upward diaphragmatic displacement was performed in 53 patients after massive lung resection for tuberculosis or bronchiectasis and the data are presented. This technique provides ample room for expansion of the remainder of the lung; it also avoids overexpansion, activation of tuberculous foci, and relapse of bronchiectasis. Diaphragamatic displacement can be used for liquidation of a remaining infected cavity. In children with massive bronchiectasis it serves to conserve two unaffected segments and avoids pneumonectomy. During pneumonectomy in children it prevents significant shift of the mediastinum and progression of scoliosis.


A study of the validity of the task inventory method of job analysis. To enhance the efficient utilization of health providers, medical care researchers are increasingly concerned with the measurement of task performance. One job analysis methodology that is widely used is the task inventory technique, characterized by retrospective self-reporting. The purpose of this study was to validate the task inventory method by using the observational technique. Two data collection instruments were developed, a Task Inventory and an Observer Check List; both contained the same set of task statements. Trained observers shadowed 13 primary care physicians in their offices for one week recording the frequency and duration of task performance on the Observer Check Lists. At the end of the week, the 13 physicians completed a Task Inventory indicating how often they had performed each task in their offices and how long it normally took. The observers' and physicians' respective sets of data were analyzed to determine the degree of agreement. The results indicate that the agreement is not sufficient between the task data obtained by the two different methods to conclude that one is substitutable for the other. The validity of the Task Inventory method is therefore not supported by the results.


The use of an information system for community health services planning and management. The challenge of delivering health care on a more cost-effective and equitable basis has led to the formation of new kinds of organizations, which in turn require new kinds of management information systems. The system described in this article is used for planning resource allocation and monitoring the overall performance of Livingston Community Health Services, Inc., a rural community-owned health service designed to provide comprehensive care to a geographically defined target population. The Health Services Data System processes information on performance and productivity, effectiveness with respect to the target population, and billing and financial activities. Input consists of the results of a community census and two household surveys, patient registrations and patient services operating data, and financial data. Besides billing patients automatically, the system integrates financial, demographic, and health services utilization data to generate monthly summaries for the administrators, medical director, and community board. The article discusses several examples of these summaries, stratifying utilization by geographic location of residence, age, income, and race.


Vector resolution: a new tool in health planning. Vector resolution represents a new method for analyzing consumer data and comparing patterns for a variety of consumer services. The vectors are derived from a measurement of frequency of use and a geographic direction from the origin of the group to the point of service. Although the data presented were drawn from a probability sample survey of southern Utah rural households, the methodology may be readily applied to data derived from a variety of sources.


Cost analysis of regionalized versus decentralized abortion programs. A detailed cost analysis has examined the fiscal benefits from regionalizing abortion services. Benefits were found to be virtually insignificant and not to outweigh problems of program visibility and patient accessibility incurred in such regionalization. The study covered 14 hospitals' abortion programs providing both first trimester and second trimester abortions and analyzed each program's total cost and six component costs for first trimester and second trimester procedures separately. The results of this study were employed for program planning by the New York City Health and Hospitals Corporation in its operation of abortion services.


The role of prescriptions in therapy.

The role of prescriptions in therapy. The aim of the present study was that of discovering whether the prescription of drugs displaces other forms of therapy. The method adopted was that of behavior simulation. Doctors were requested to provide therapeutic proposals regarding a standard set of patient cases described in questionnaires sent to them. These cases were formulated in such a way that in the author's opinion they could easily, and perhaps best, be treated without drugs. Nevertheless, most of the cases were treated with drugs, thereby indicating the important role of drug therapy as a means of treatment. In particular, psychic disturbances were often treated by drugs. Frequently, drugs represented the only treatment offered, and no alternative form of treatment was suggested.


Epidemiological definition of the cohort of diseases associated with diabetes in Southwestern American Indians. A computerized health records system has facilitated an analysis of the correlated illness of a segment of population afflicted with a chronic disease. Taking the existence of clinical diabetes as a starting point, the total illness experience of 635 diabetics, as shown by clinic utilization data, has been compared with an age-sex-geographically matched control population. The comparisons show that, overall, diabetics cause a caseload rate more than double that of nondiabetics. In 17 out of 22 broad health problem areas, the diagnosis caseload rates for diabetics varied from 1.3 to 3.7 times greater than the rate for matched, non-diabetic controls. Workload (physician visit and hospital days) comparisons showed even greater disparity. Some of the comparisons confirm statistically the clinical impressions of diabetologists over the past years. Some of the findings are not reflections of orthodox clinical opinion. The results contribute to further elucidation of the natural history of this disease. They also indicate the need for the development of comprehensive clinical management programs for groups of interrelated conditions found in persons with chronic disease such as diabetes.


Physician's working hours and patients seen before and after national health insurance: "free" medical care and medical practice. Surveys were made of a sample of physicians before and after the introduction of a national health insurance plan in Montreal, Canada. Although the number of physicians in active practice seemed unaffected by the plan, their average working day was reduced 1.5 hours. Declines ranged from 0.3 hours for general internists to 2.7 hours for general surgeons. The average daily volume of services by physicians in the area also declined because of a decline in telephone consultations, and home and hospital visits. Office visits increased sharply. Changes in the type of services were clearly related to the fee schedule adopted by the government, with large declines in services for which payment was probably inadequate in relation to physician's time required. If the fee schedule reflected actual collections prior to the health insurance plan, then gross physician income increased as the result of redirecting services to better paying activities.


The orginization of medical practice and practice orientations among physicians in prepaid and nonprepaid primary care settings. Data are presented on office-based general practitioners and pediatricians working in varying practice settings. Fee-for-service physicians spend more time in direct patient care activities than those in prepaid practice, and devote more time to each patient. The data suggest that the patient load characteristic of general practice in prepaid groups encourages a more assembly line practice which is less responsive to patients than the pattern characteristic of fee-for-service practice. Prepaid physicians work during scheduled hours and may deal with increased load by processing patients more rapidly. Fee-for-service physicians tend to respond to increased demand by working longer hours. The responsiveness of primary care physicians to patient problems seems to reflect primarily their social orientations to medical practice and the time pressures they face. Varying practice settings result in different techniques of coping with the pressures of practice. Data are also presented on sociodemographic and professional characteristics of primary care physicians in varying settings, workload, use of diagnostic and laboratory procedures, social orientations to medical practice, satisfactions and dissatisfactions, and attitudes toward sociopolitical aspects of medical care. Suggestions are offered for improving the responsiveness of prepaid practice.


Postgraduate training and work experience of non-ECFMG certified physicians in the U.S. Data on postgraduate training and work experience of a sample of 850 Foreign Medical Graduates (FMGs) taking the January 1973 ECFMG examination in the U.S. are presented. It was found that 485 (57%) of the respondents had specialty training and, of these 485, 59 per cent were certified in a specialty. In addition, 81 per cent reported that they had worked as a physician prior to entering the U.S. The proportions with specialty training and work experience varied by country of medical education and year of graduation. The proportions with training or experience among those not currently employed in the health system are significantly lower than among those employed in the health field. Of the 186 respondents who reported passing the ECFMG examination, 92 per cent plan further training and 84 per cent of this group plan to specialize. More detailed information on the length and content of this training and work experience for different groups of FMGs is needed.


A core city problem: recruitment and retention of salaried physicians. The professional and personal characteristics of all physicians recruited into a large urban governmentally sponsored health system were evaluated and correlated to staff retention and loss. The results were tabulated for 84 physicians, approximately 90 per cent of the physician work force, over a three-year period. Eighty per cent resided in either Denver or the state of Colorado prior to entry. This is further reflected in a significant percentage being enrolled in the local medical school or training programs prior to entry. These facts suggest a possible source of manpower for beginning programs. Twenty-six per cent came from private practice, 32 per cent from the military and 14 per cent from the Public Health Service. The turnover rate averaged 6.2 per cent per year, with 4.4 per cent being initiated by the physician and 1.8 per cent leaving because of administrative pressure. Data from other studies are reviewed. Factors which appear to influence retention positively were residency training (pediatricians), sex (females), age (over 38) and those with team experience. These factors suggest directions as to the type of physician who, if recruited, tend to reduce turnover. The establishment of a group practice atmosphere with rewards for clinical skills and the offering of unusual specialty opportunities are proposed as positive factors in the retention of staff.


The effect of preceptorship and rural training programs on physicians' practice location decisions. This study analyzes the relationship between medical student participation in rural training programs, including preceptorships, and the decision to locate medical practice in rural areas. Data consist primarily of responses to questionnaires mailed in 1972 to all graduates of United States medical schools in 1965. Study findings indicate that the overall impact of such programs on practice location decisions is relatively slight, but is most pronounced with respect to urban-reared physicians in nonprimary care specialties. It was also found that a large proportion of urban-located physicians had seriously considered rural practice and that the reluctance of many physicians to locate in rural areas is linked to fear of professional isolation. The findings suggest that an increased orientation toward urban-reared students and dissemination of information on nonsolo practice opportunities in rural areas are means of increasing the effectiveness of preceptorships and other rural training programs in attracting young physicians to underserviced areas.


Content of care in rural primary health care practices. The data used in this study was collected by the original MEDEX project in Seattle, Washington. The original use of the data by the project was to measure changes in patient characteristics. The MEDEX-designed data collection system is compared with proposed systems for collecting nationwide ambulatory health care data collection effort is additional evidence that such data can be collected on a large scale, if the physicians and their ancilliary personnel are properly motivated. Analysis of the data yielded distributions such as patient age, sex, age by sex, diagnosis and dispositions, as well as the distributions of dispositions by diagnosis. These distributions are based on reports from over 11,000 physician-patient contacts during the summers of 1969 and 1970 by seven physicians in five rural practices located in eastern Washington State. These results are shown for each of the practices individually and for the combination of all practices, with the exception that the dispositions by diagnosis distributions are prepared for the combined practices only. Where appropriate, the results of this study are compared with the findings of Last and White4 and these results generally substantiate their findings. When differences are noted, explanations are proposed to account for the differences.


A work sampling study of midlevel health professionals in a rural medical clinic. A work sampling study was initiated to provide a comprehensive description of the tasks performed by midlevel health personnel in the rural component of an experimental medical care delivery system. The investigation determined the proportion of time spent on various activities by the staff members of a rural clinic which is linked to supervisory physicians in a distant urban medical center. Over 800 observations were recorded during ten randomly selected days in a two-month period on each of the three staff members. The family nurse practitioner spent one-third of her time in direct patient care activities with almost one-half of the day devoted to indirect patient care tasks. The laboratory aide allocated one-half of her day to providing direct patient services whereas the clerk-receptionist spent over 40 per cent of her day on patient records and billing. Work sampling results were considered within a comparative framework to qualitatively assess performance. The findings were coupled with proposed changes in administrative and medical policy to provide a quantitative basis for developing cost-reducing alternative staffing configurations.


The use of research in national health policy: an assessment and agenda. This article provides an assessment of health services research contributions to national health policy. An examination of disciplinary-based research identifies many of the shortcomings of such research and the need for a different structure for relating research to health policy. Some definitions are offered for such terms as "applied research," "disciplinary research," "policy analysis," and "policy research." A policy research model of sequential steps in problem-solving is suggested as a useful approach. A review of the federal role in health policy is developed to set the context for viewing past contributions as well as to suggest a strategy for maximizing the relevance and usefulness of research.


Preimbursement: a new concept for HMO planning. Federal endorsement of the HMO concept has resulted in broad understanding of a number of concepts unknown in fee-for-service medicine. As the concepts are adapted to particular circumstances, refinement can be expected. One such refinement, applicable to financial arrangements between the HMO and contracting providers, is discussed here.


The tympano-frontal shunt: a procedure for the treatment of chronic Eustachian tube insufficiency. Eight ears with complications due to chronic eustachian tube insufficiency had insertion of a silicone rubber tympano-frontal shunt tube between the mastoid antrum and the ipsilateral frontal sinus. A one-way valve designed to open at -10 mm H20 was placed on the tympanic end of the tube to minimize tube obstruction by ear secretions. Follow-up an average of 20 months post insertion showed six of the eight ears to have an aerated middle ear without fluid or tympanic membrane retraction or perforation.


Optimal treatment for the technically resectable squamous cell carcinoma of the supraglottic larynx. The charts of 431 patients with squamous cell carcinoma of the supraglottic larynx observed at the M.D. Anderson Hospital between January, 1954, and June, 1971, were analyzed. This study is concerned with those patients who had a technically resectable lesion. Emphasis is directed to the analysis of the effectiveness of primary irradiation instead of partial laryngectomy for those lesions which are technically suitable for a partial resection and to define the groups of patients which are best treated by combining surgery and planned postoperative irradiation. One hundred forty-seven patients with T1 and T2 lesions, selected exophytic T3 lesions of the suprahyoid epiglottis received irradiation for their laryngeal lesion. A satisfactory control of the laryngeal disease has been obtained with preservation of a normal voice ranging from 88.5 percent for T1 lesions to 60 percent for T4 lesion. Comparing the groups of patients who had surgery alone or postoperative irradiation an NED rate of 63 percent was found in the latter group which is clearly superior to the 37 percent found in the surgery only group. There is no difference for the five-year NED rates, because the patients who had surgery and postoperative irradiation had more advanced neck disease which is a cause for distant metastases. The incidence of recurrences above the clavicles is clearly less in patients having had surgery and postoperative irradiation than in those who had surgery alone. Correlating in the two groups, surgery only and surgery followed by planned irradiation, the surgical staging of the neck metastases with recurrences above the clavicles within 24 months after treatment, it was found that the planned combined treatment has reduced the recurrence rate from 45 percent to 15 percent in the N2 and N3 patients. Postoperative irradiation should be given routinely after resection for all T4 lesions and for any T3 lesion which extends to the pharyngeal wall(s), vallecula, base of tongue, and pyriform sinus. Postoperative irradiation should also be given for any patient whose nodal classification is greater than N1. Irradiation should be given within six weeks (preferably three to four weeks) after the surgical procedure. To achieve this goal, the operation need only remove grossly detectable disease.


The biomechanics of facial bone fracture. Selected facial bone locations were impacted to simulate clinical trauma conditions. Locations selected included the nose, zygoma, mandible, maxilla, and frontal bone. The experiment clearly delineate tolerance bands for the facial bones for both sexes. These data should permit the improved design of injury producing structures.


Diverting the paralyzed larynx: a reversible procedure for intractable aspiration. Some unfortunate patients suffer disorders which in one way or another, usually neurologically, severely restrict the larynx in its role as a protector of the lower airway. Aspiration ensues, and unless it can be successfully managed, repeated episodes of a violent pneumonitis may lead to terminal chest problems. In some patients, even the cuffed tracheostomy tubes of new and improved design do not adequately prevent aspiration over an extended time intervel, as evidenced by repeated bouts of aspiration pneumonia despite these cuffed tubes and despite optimal intensive care. For these patients with intractable aspiration, and in whom recovery is expected only after a prolonged period of time, we have suggested a diverting procedure which employs a tracheo-esophageal anastomosis, as an effective yet reversible solution. Such an anastomosis with concomitant tracheostomy allows aspiration of saliva and even food to occur through the malfunctioning larynx but diverts it back into the esophagus through the tracheo-esophageal anastomosis. In normal mongrel dogs we demonstrated that an end-to-side tracheo-esophageal anastomosis is well tolerated and can be performed without damage to the intrinsic larynx or recurrent laryngeal nerves. The tracheo-esophageal lumen remained patent and the anastomosis intact for as long as these animals were observed prior to reconstruction. The reversibility of the tracheo-esophageal anastomosis was demonstrated in these dogs by excising the anastomosis, repairing the esophageal defect, and restoring the continuity of the trachea by end-to-end anastomosis. Vocal cord motion remained intact, the dogs ate normally, and barked once again. A tracheo-esophageal anastomosis was performed in a 60-year-old white female who had suffered lower cranial nerve damage as a result of a large acoustic tumor and the excision thereof. Despite every effort to control aspiration, pneumonitis occurred and became fulminant. The diverting tracheo-esophageal anastomosis was performed with relative ease and was well tolerated by the patient. Aspiration was totally and dependably controlled, and no further chest complications occurred. Her nasogastric feeding tube was removed, and she ate a regular diet with very little difficulty. She gained in strength, became much more alert mentally, and is now taking care of herself in a nursing home. We are following her progress by indirect laryngoscopy and barium swallow examinations and at five months post anastomosis, we are possibly seeing the first signs of lower cranial nerve recovery. We hope that reconstruction and restoration of function will soon be possible.


Voice rehabilitation following blunt trauma to the larynx. Two case reports illustrate different ways for restoration of quality of the voice. In both instances the vocal cords were displaced by trauma and restored by surgical correction.


The safety of intubation in croup and epiglottitis: an eight-year follow-up. A series of 815 infectious croup (i.e., laryngotracheobronchitis) cases and 55 epiglottitis cases, encompassing an eight-year interval, is reviewed to determine the incidence of adverse effects of nasotracheal intubation used to manage upper airway obstruction. The racial, sex, and age distributions, in addition to modalities of treatment, are presented. The intubated cases (86 patients), representing 6.5 percent of all croup cases and 60 percent of all epiglottitis cases, are described in more detail with respect to presenting symptoms and physical findings. The average duration of intubation is 55 hours for epiglottis and 88 hours for croup. The incidence of immediate, reversible complications for the entire intubated series is 7 percent. The incidence of delayed, irreversible complications, as determined by: 1. noting any persistent post-extubation symptoms; 2. measuring peak expiratory flow rates; and 3. laryngeal polytomography, is 1.6 percent. The mortality secondary to intubation is 0 percent. The complication rate (1.6 percent) in this series of nasotracheal intubations is lower than the mortality (3.6 percent) in a large collective series of pediatric tracheotomies performed for airway obstruction in croup or epiglottitis. Other advantages of intubation vs. tracheotomy are described (i.e., shorter hospital stay, dilatatory effect of endotracheal tube). The authors conclude that nasotracheal intubation is safer than pediatric tracheotomy and should be considered the procedure of choice in the management of upper airway obstruction secondary to croup or epiglottitis.


The use of spectrograms in the evaluation of vocal cord injection. The utilization of voice spectrography can be an important adjunct to the assessment of vocal cord function by both laryngologists and speech pathologists. It is especially useful in determining the effectiveness of vocal cord Teflon paste injection procedures. Dysphonic characteristics are made visible, and their improvement can be monitored. As such, spectrographic analysis should be considered as a useful tool for the laryngologist.


Penetrating neck wounds: selective exploration. This study of 223 patients with penetrating neck wounds justifies individualizing surgical treatment. Twenty-four percent was selected for neck surgery. In spite of selective rather than mandatory neck exploration, the mortality rate related to the neck wound in this series was three percent. This compared favorably with the experience of others employing mandatory exploration. There were no deaths in our series attributable to selective observation.


Frontal sinus disease. III. Experimental and clinical factors in failure of the frontal osteoplastic operation. The surgical approach to frontal sinus disease has been subject to much variation. Experimental evidence for new treatment modalities is quite limited. Frontal osteoplasty, while probably the best procedure to date, has up to a 25 percent failure rate. Possible complications include recurrent disease, incomplete bony obliteration (Macbeth technique), infection of the adipose implant, frontal bossing or depression, and laceration of the dura. Four experimental groups were designed using the canine frontal sinus model. Results indicated that stripping the mucosa in a normal sinus with intact periosteum and a patent nasofrontal duct will not consistently lead to normal mucosal regeneration. Second, the additional factor of removing the periosteum (as in osteoplasty by osteoneogenesis), leads to partial fibrous obliteration complicated by mucocele formation. Third, sinus obliteration by osteoneogenesis was much more consistent with concurrent closure of the nasofrontal duct. Fourth, intentionally leaving a strip of mucosa leads to failure of obliteration by osteoneogenesis 100 percent of the time. Finally, bony-fibrous obliteration increases with time but is still incomplete after one year. In light of these results, fat obliteration with closure of the nasofrontal duct is probably more reliable than obliteration by osteoneogenesis.


Mucosal melanomas of the head and neck.

Mucosal melanomas of the head and neck. Malignant melanomas arising from the mucosal areas of the head and neck are rare. When such neoplasms are encountered, the problem of their management is often poorly resolved. Cases of primary malignant melanoma of the maxillary sinus, the nasopharynx, oral cavity and laryngo-pharynx are presented and the results of treatment analyzed. Much of the difficulty in therapy is due to an incomplete understanding of the mechanisms which determine survival. A brief discussion of melanoma immunology is presented. Surgery (including cryosurgery) remains the primary therapy when possible. The role of chemotherapy, immunotherapy and radiation therapy in such lesions cannot be clearly delineated at this time.


Trigeminal neurinomas.

Trigeminal neurinomas. Trigeminal neurinomas may produce atypical facial pain, loss of facial sensation, facial palsy, hearing loss, nystagmus, or vertigo, and thus may be confused with nasopharyngeal carcinomas or acoustic neurinomas. The diagnosis can be made by the clinical presentation together with radiographic features showing widening of the foramen ovale and/or smooth destruction of the anteromedial portion of the peterous apex. Tomography, pneumoencephalography, angiography, and other diagnostic procedures are sometimes helpful. Treatment is removal by transtemporal craniotomy and offers an excellent prognosis.


Density of goblet cells in chronic secretory otitis media: findings in a biopsy material. In 30 ears from 24 children with chronic secretory otitis the density of goblet cells and of glands was determined on biopsies from the anterior part of the promontory. The goblet-cell and gland density proved to be highly increased in all cases, with marked individual variations. The median density of goblet cells was 142 cells/field, corresponding to 8,000 cells/mm-2. This substantiates the fact that in chronic secretory otitis the mucous secretion is a product of goblet cells and mucous glands and confirms the secretory pathogenesis of the disease.


An absorbent, non-adherent nasal pack.

An absorbent, non-adherent nasal pack. A modification of an absorbent, non-adherent material (Telfa) is described for use as an anterior nasal packing. The ideal nasal packing should fulfill certain criteria. It should be easy to introduce and remove, contour to the nasal cavity to exert a tamponade effect, and should not prolapse or react unfavorably with the mucous membranes of the nose. The advantages of Telfa as a nasal packing is discussed and compared to previously described materials in this regard. During the past three years this pack has been used in over 800 patients for anterior epistaxis, septal and rhinoplastic surgery. The results have been extremely satisfactory, and the authors suggest their use in these cases.


Effect of noradrenaline on triglyceride and glycogen concentrations in liver and muscle from man. Fifteen male subjects aged 21-29 were given noradrenaline infusions for 4 hr. The noradrenaline infusions started at a rate of 0.1 mug/kg/min and were increased stepwise at hourly intervals. Blood was sampled before and at hourly intervals during and after the noradrenaline infusions. Needle biopsies were taken from the femoral muscle in 10 subjects and frim the liver in 8 subjects before and after the noradrenaline infusion. The concentrations of FFA in lasma and of beta-hydroxybutyric acid in blood were markedly elevated during noradrenaline infusion. The concentrations of plasma TG and blood glucose were slightly elevated. In liver the TG concentration increased from 23.1 to 32.7 mmole/kh (p smaller than 0.001). It was estimated that the de novo synthesis of TG in the liver could have required about 30% of the plasma FFA entering the slanchnic region. In muscle the TG concentration was 3.6 mmole/kh lower after the noradrenaline infusion (p smaller than 0.001). No change was found in the concentrations of cholesterol and phospholipids in muscle or of cholesterol in liver. The glycogen concentration in muscle did not change during noradrenaline infusion. The decrease in liver glycogen concentration was of the same order of magnitude as previously observed in fasting man. The results suggest that noradrenaline was without major net effects on the metabolism of glycogen in liver and muscle.


Peripheral metabolism of bovine parathyroid hormone in the dog. Four dogs were infused with highly purified bovine parathyroid hormone until constant levels of immunoreactive hormone were attained in the circulation. Simultaneous samples of plasma were then obtained from the aorta, from hepatic, renal, and femoral veins, and later from a pulmonary artery and the left ventricle. Radioimmunoassay of these samples revealed mean arteriovenous differences of -23% across the liver and -19% across the kidney. No significant differences were found across the lung or lower extremity. After termination of the infusion the disappearance rate of immunoreactive hormone in external jugular-venous blood was multiexponential: the predominant initial T 1/2 was 4, 6, and 8 min, and the terminal component was 60, 54, and 99 min. respectively, in 3 dogs.


Removal of insulin by perfused rat liver: effect of concentration. The kinetics of insulin removal by isolated rat liver were investigated by measuring the rate of disappearance of insulin from the perfusate during recycling perfusion and by comparing the extraction of insulin over a wide range of constant arterial hormone levels during nonrecycling perfusion. In the recycling studies, insulin was removed from the perfusing medium at a uniform rate between 5 and 45 min. The reaction velocity constant, or hepatic clearance, during this period of uniform disappearance averaged 1.8 ml/min and represented 34% of the volume flow through the liver. In the nonrecycling flow-through studies at constant arterial insulin concentration, an initial period of accelerated hepatic uptake of insulin was seen. This period lasted for 3 to 7 min, was seen at every level of arterial insulin concentration, and was followed by a period of constant hepatic insulin removal. The hepatic removal rate during the period of constant uptake increased in a linear fashion until arterial insulin concentration reached 500 muU/ml and attained a maximal value at concentrations over 800 muU/ml. These findings indicate that the time course of hepatic insulin uptake by the perfused rat liver consists of two phases-an initial rapid phase, possibly associated with insulin binding, followed by a sustained rate of insulin removal, which probably represents insulin utilization and degradation. The rate of hepatic insulin removal was found to be proportional to arterial insulin concentration overa range of 20 to 500 muU/ML. Above this concentration, hepatic removal processes became saturated, reaching a maximal value of 183 muU of insulin per gram of liver per minute.


Fatty acid synthesis by human adipose tissue. The effect of age and nutritional status on the synthesis of fatty acids from a variety of labeled substrates by human adipose tissue in vitro was investigated. The results of this study clearly demonstrate that, although human adipose tissue is able to oxidize glucose to CO2, its ability to incorporate glucose-carbon into long chain fatty acids is negligible. Although the utilization of acetate for the synthesis of fatty acids by adipose tissue is substantial in the presence of glucose and insulin, its physiologic significance in human under normal dietary conditions is questionable. That the capacity of human adipose tissue is limited is further supported by (1) a negligible incorporation of pyruvate-3-14C (up to 25 mM concentration in the incubation medium) into fatty acids, (2) a lack of stimulation in lipogenesis by human adipose tissue after refeeding a diet high in carbohydrate and very low in fat to a previously starved human, and (3) an extremely low activity of pyruvate carboxylase and ATP-citrate lyase in adipose tissues from humans of varying ages. The activities of other key lipogenic enzymes, glucose-6-phosphate dehydrogenase, 6-phosphogluconate dehydrogenase, and NADP-malate dehydrogenase, are also low. These enzymes can be stimulated in human adipose tissue after a fasting-refeeding regimen. The activity of phosphoenolpyruvate carboxykinase is also very low in human adipose tissue,and it is suggested that a pathway of glyceroneogenesis may not play a significant role in human adipose tissue. In light of our results, together with previous reports, it is possible to conclude that the capacity of human adipose tissue to utilize a dietary carbohydrate for the synthesis of fatty acids is extremely low and that the liver plays a major role in the biosynthesis of endogenous fatty acids from dietary carbohydrate in the human.


Evidence for a physiologic role of pancreatic glucagon in human glucose homeostasis: studies with somatostatin. To study the role of glucagon in human glucose homeostasis, experimental glucagon deficiency was produced by infusing somatostatin (i. v. 250 mug bolus, followed by infusion of 500 mug/hr) in six normal subjects and in two hypophysectomized patients-an insulin-dependent diabetic and a nondiabetic. In normal subjects, somatostatin lowered plasma glucagon from a mean (plus or minus SE) basal level of 85 plus or minus 15 to 33 plus or minus 10 pg/ml, p smaller than 0.001. Concurrently, plasma glucose fell from 90 plus or minus 2 to 73 plus or minus 3 mg/100 ml, p smaller than 0.001. Serum insulin and growth hormone fell slightly during somatostatin infusion, while plasma free fatty acids rose. In both hypophysectomized patients, somatostatin lowered plasma glucagon and glucose levels. In all subjects, after stopping somatostatin infusions, plasma glucagon and glucose returned promptly to control values, while serum growth hormone did not change. In additional in vitro studies, somatostatin (1 mug/ml) had no effect on muscle glucose uptake. Since it is known that somatostatin has no direct effect on hepatic glucose production, these results suggest that the fall in plasma glucose during somatostatin infusion resulted from inhibition of glucagon secretion, thus providing evidence that this hormone plays a physiologic role in the maintenance of fasting euglycemia in man.


Increased sterol excretion with polyunsaturated-fat high-cholesterol diets. Previous studies have shown that polyunsaturated ruminant fats in the diets of human subjects cause an increase in cholesterol and bile acid excretion during the first 3 weeks of such diets. The present studies were designed to compare the effects of polyunsaturated (P) and conventional (S) ruminant fats at two levels of dietary cholesterol intake: a higher (HC) and lower (LC). Four study periods, each of about 3 weeks' duration, were conducted in 5 healthy subjects providing these dietary combinations: HCS, HCP, LCS, LCP. Neutral sterols and bile acids were measured in the feces, and sterol balances were calculated. Plasma cholesterol levels were significantly lower with P than with S diets at both HC and LC intakes. Changes attributable to differences in fatty acids and to differences in cholesterol intake appeared to exert independent effects. The major changes occurred in lipoproteins with density 1.019-1.045. Cholesterol absorption expressed as a percentage of the dietary intake was not significantly different with the four diets. Neutral sterol excretion of probable endogenous origin and bile acid excretion were significantly higher during the HCP than during the HCS periods, but the difference between LCP and LCS periods was less marked. Net sterol excretion was therefore significantly greater with HCP and LCP than with HCS and LCS diets, the differences being greater at HC than at LC intakes. Comparisons of diets with similar fatty acid but differing cholesterol intakes showed lower net sterol excretion with HCS than with LCS diets (presumably due to suppression by HC by cholesterol synthesis), but this difference was not seen between HCP and LCP diets. This finding, together with greater sterol excretion with HCP than with HCS diets, showed that enhanced sterol excretion with polyunsaturated fat was potentiated with higher cholesterol intake. This enhanced excretion was generally greater during the first than during the second 3-week period of polyunsaturated fat.


Evidence that parathyroid hormone is not required for phosphate homeostasis in renal failure. Varying degrees of renal failure were produced by surgical reduction of renal mass in normal dogs and in thyroparathyroidectomized dogs (TPTX) in whom serum calcium levels were maintained in the normal range by the administration of vitamin D. Both groups of dogs maintained normal serum phosphate levels in spite of progressive decreases in glomerular filtration rates (GFR). Furthermore, both groups of dogs were able to increase the fractional excretion of phosphate as GFR decreased. Thus the same renal response to loss of GFR was maintained in the complete absence of parathyroid tissue. Finally, stable serum phosphate levels and increased fractional excretion of phosphate in response to a decrease in GFR were also demonstrated in acutely TPTX dogs who were not receiving vitamin D. These results indicate that phosphate homeostasis can be maintained in renal failure in the total absence of parathyroid hormone secretion.


Plasma catecholamine response of coronary-prone subjects (type A) to a specific challenge. Plasma norepinephrine (NE) and epinephrine (E) were assayed in 15 men prone to develop coronary heart disease (type-A behavior pattern) and in 15 coronary-disease-resistant men (type-B behavior pattern) under resting, noncompetitive conditions and also immediately before, during, and after participation in a nonphysical competitive struggle. The average concentration of catecholamines was virtually the same in both groups under resting conditions. Under competitive conditions the NE concentration of the coronary-susceptible group rose an average of 30%, while that of the resistant group remained essentially unchanged. E concentration remained unchanged in both groups.


[Geographical distribution of leukemia. Study on the urban/rural relationship]. The geographical distribution of leukemia 69 soldiers of the German army died of leukemia between 1957 and 1970. Investigations were made with regard to their geographical distribution, in comparison to 1500 healthy soldiers. The percentage of leukemia patients, who lived in rural areas (villages up to 500 inhabitants) was 2.1 times higher. With regard to the birth-place this "rural provenance" was even more significant (3.6 times higher). This means: every fifth soldier, who died of leukemia, originated from a little village (of the control-group: every sixteenth). A local incidence ("clusters") was not found. The professions were of no particular significance. These findings raise the question if there exist risk factors in rural environment (domestic animals?).


[Clusters of Hodgkin's disease. Case report of two brothers]. Case report of two brothers who suffered from lymphogranulomatosis successively. Familiary clusters are rare and are in favour of infectious and of hereditary factors in the pathogenesis of Hodgkin's disease. The own observation is discussed in reference to the world literature.


[Pheochromocytoma in childhood. Report of a case of a familial type in an 8-year-old boy]. A case of right adrenal pheochromocytoma in an 8-yr-old boy and its successful surgical management are described. Clinical and statistical data are given for this form and its symptomatology and aetiopathogenesis are illustrated. Particular stress is laid on the occasionally misunderstood importance of the part played by continuous hypertension. Early diagnosis and surgery are essential to avoid the onset of serious cardiocirclatory complications.


Chronic myopathy associated with coxsackievirus type A9. A combined electron microscopical and viral isolation study. Virus-like crystalline structures in human skeletal muscles have been observed by many electron microspists, but no viruses have been isolated and identified in such cases. An 11-year-old girl who had had muscular weakness and physical retardation since early infancy died of pneumonia due to atrophy of diaphragmatic and intercostal muscles. Electron microscopy of these muscles revealed a heavy infiltration of picornavirus-like particles that measured 19 to 23 nm in diameter. Subsequent inoculation of primary human-amnion cells with a sonic-treated suspension of the patient's diaphragmatic muscle induced an enterovirus-like cytopathic effect. The isolate was identified with use of Lim-Benyesh--Meinick enterovirus typing serum pools as coxsackievirus Type A-9. This viral isolation supports the belief that the organized  electron-dense particles in human muscle are indeed virions.


Effects of oral alanine feeding on blood glucose, plasma glucagon and insulin concentrations in small-for-gestational-age infants. The effects of oral alanine feeding on glucose homeostasis were evaluated in 21 infants who were small for gestational age and 26 who were appropriate for gestational age. In the first 24 hours, basal plasma alanine concentrations were higher in the former. Oral alanine feedings produced a significant rise over baseline levels of plasma alanine and glucagon concentrations in both groups. The blood  glucose and plasma insulin concentrations also increased significantly in infants who were appropriate  but not in those who were small for gestational age. At 25 to 96 hours of age, plasma glucagon, insulin and blood glucose concentrations did not change after the alanine feeding in either group. These data indicate that in the normally nourished infant (appropriate forgestational age), gluconeogenic amino acid (alanine) enhances hepatic glucose output. This  phenomenon is not observed in the mainourished infants (small for gestational age), a point that may reflect decreased glycogen stores and ineffective gluconeogenic enzyme system in such infants.


The teaching hospital and primary care. Closing down the clinics. Hospitals have become major providers of primary medical care by default rather than design because of the decreasing availability of primary physicians in community practice. In 1972, Beth Israel Hospital in Boston closed its traditional general clincs and estblished a primary-care group practice--Beth Israel Ambulatory Care. The practice is staffed by teams of full-time salaried physicians, other health professionals and paraprofessionals, house staff and medical students. More than 25 per cent of patient visits are managed by nonphysicians. Subspecialty clinics have been relieved of primary-care case loads and limited to referral and consultative functions. In 1973-74, the cost per visit was $20.32. Patient-visit volume in primary care has increased from a figure of 29,144 in 1971-72 to 41,650 in 1973-74. Broken appointments have declined by one third.


Ventilatory control in myxedema and hypothyroidism. Alveolar hypoventilation is known to occur in myxedema. To clarify the role of hypoxic ventilatory drive and hypercapnic ventilatory drive in thyroid hormone insufficiency states, 10 patients with myxedema and seven with hypothyroidism (thyroid ablation) were studied before and after thyroid replacement. An index developed for hypoxic ventilatory drive was markedly reduced in myxedema: 17 plus or minus 4.7 (S.E.M.) (normal, 126 plus or minus 8.7) (P smaller than 0.01) and increased to 78 plus or minus 12.6 (p = 0.02) with thyroid hormone replacement. In the hypothyroid group this index was also depressed as compared to normal at 67 plus or minus 20 (p smaller than 0.01) and increased to 114 plus or minus 19 (p smaller than 0.02) with replacement. An index for hypercapnic ventilatory drive was depressed in myxedema, 0.69 plus or minus 0.01), but was not significantly depressed in hypothyroidism. With thyroid hormone replacement this index did not significantly increase in either group. We conclude that both myxedema and hypothyroid states produce depression of hypoxic ventilatory drive that is responsive to replacement therapy. This alteration in ventilatory control may contribute to the hypoventilation seen in myxedema.


Comparison of 125I fibrinogen count scanning with phlebography for detection of venous thrombi after elective hip surgery. A comparison was made of 125I fibrinogen count scanning and phlebography in 142 limbs of 83 patients without known prior deep venous thrombosis who underwent total hip replacement. A localized accumulation of fibrinogen located away from the hip wound represented a fresh thrombus in 25 of 29 cases (86 per cent).  However, of all the fresh thrombi demonstrated by phlebography, the fibrinogen scan detected only approximately 50 per cent.  Major reasons for failure to detect thrombi were the presence of the wound and the small size of some thrombi.  In defining whether or not fresh venous thrombosis was present in a given patient, the scan was accurate in three quarters of the cases.  We conclude that fibrinogen scanning is a useful examination in patients after elective hip surgery, but less accurate than previously reported.


Management of septic chemical abortion with renal failure. Use of a conservative regimen. The concept that hysterectomy is of value in the management of septic abortion induced by instillation of soap or phenolic antiseptics into the uterus is challenged. Nineteen out of 20 such cases with renal failure were managed with intensive antibiotic therapy, peritoneal dialysis and an absolute minimun of surgical intervention. Seventeen patients recovered, with normal renal function. Of the 11 known to be subsequently exposed to conception seven have achieved normal pregnancies.


Antenatal exposure to meprobamate and chlordiazepoxide in relation to malformations, mental development, and childhood mortality. In a follow-up study of 50,282 pregnancies (lasting at least five lunar months) and the offspring, malformations identified before the first birthday, or at death before the fourth birthday, were identified in 3248 children (6.5 per cent). A total of 1870 children exposed in utero to meprobamate or chlordiazepoxide were compared with 48,412 children who were not. No significant differences were found either overall or in specific outcomes; rates were also similar when exposures occurred during the first trimester or at other times during pregnancy. Deaths (stillbirth to the fourth birthday) occurred in 2227 children (4.4 per cent), and there was no evidence that antenatal exposure to either drug increased the death rate. Finally, as judged by mental and motor scores at the age of eight months, and intelligence quotient scores at four years, there was no evidence that the drugs cause brain damage.


Comparison of television and telephone for remote medical consultation. Television and telephone communications were randomly used to compare their effectiveness in allowing consultation between a hospital-based physician and remote nurse practitioners. Visits using television for consultation averaged 50 minutes as compared with 40 minutes for telephone. This difference was caused by longer work-ups before the consultation, longer delays after it was requested, and longer consultations, themselves, on television. However, television consultations resulted in significantly fewer immediate referrals of patients to hospital physicians: 6 plus or minus 1 as compared to 12 plus or minus 1 per cent (mean plus or minus S.E.M) OF ALL TELEPHONE CONSULTATIONS (P SMALLER THAN 0.005). Although no overall difference in satisfaction was documented between the results of television and telephone consultations, participants preferred the former for medical decision making and cited it for allowing more social interaction than telephone. These findings suggest that television may have its greatest value in remote sites where the sense of isolation is great and the need to reduce long-distance referrals offsets the costs of the system.


Vertical transmission of hepatitis B antigen in Taiwan. To determine the frequency of vertical transmission of hepatitis B antigen (HB5 Ag) from asymptomatic carrier mothers in Taiwan to their offspring, HB5 Ag was sought by radioimmunoassay and complement fixation. Of 158 babies born to carrier mothers, antigenemia developed in 63; 51 of these antigenemic babies had become antigen positive within the six months of life. Three inter-related factors were found to increase the risk that antigenemia would develop in the infant: a high maternal complement-fixation titer for HB5 Ag: presence of HB5 Ag in the baby's umbilical-cord blood: and antigenemia in siblings. In contrast to previous studies, these findings indicate that vertical transmission from carrier mothers frequently occurs, at least in Taiwan, and may partially explain Taiwan's high prevalence of HB5 Ag.


Impact of membership in an enrolled, prepaid population on utilization of health services in a group practice. Members of prepaid group-practice medical-care plans are believed to use more ambulatory, but fewer inpatient, services than populations served by fee-for-service practitioners. It is not known whether these differences are attributable to the prepayment aspects of the plan or to other circumstances. We studied the impact on use of services of only one factor-prepayment at the Marshfield Clinic, Wisconsin--with all other factors, including group practice, held constant. The findings were derived from the experience one year before, and two years after, the initiation of the prepaid program. Results showed that prepayment alone resulted in significant increases in both inpatient and ambulatory care (about 100 per cent in ambulatory-care visits, 75 per cent in hospital discharges, and 60 per cent in hospital days). These increases were far greater than comparable increases in the fee-for-service population served by the Clinic.


Angiography in the management of aneurysms of the abdominal aorta. Its value and safety. The course of 190 patients with aneurysm of the abdominal aorta who underwent preoperative aortography was reviewed to determine the safety and usefulness of that procedure. There were no serious complications; minor problems occurred in only four patients and did not affect operative therapy. In 21 patients, the clinical impression of aneurysm was found to be incorrect. Surgically important findings included suprarenal extension of the aneurysm in nine patients, and demonstration of stenotic lesions in the renal arteries (37 patients) or superior mesenteric artery/celiac axis (17 patients). Helpful findings were associated aneurysms (26 patients), multiple renal arteries (28 patients), and occlusive lesions in the lower extremities or aortocranial system in 82 and eight patients respectively. Such information was found useful in planning operative procedures and minimizing operative time and blood loss. In our experience, angiography in patients with aneurysm of the abdominal aorta is both safe and informative.


Percutaneous aspiration biopsy of the pancreas under ultrasonic guidance. Fine-needle aspiration biopsy for cytologic diagnosis was performed on seven patients suspected of having pancreatic tumors. A 23-gauge biopsy needle was accurately placed in the suspicious lesion under ultrasonic guidance. Six patients had tumors; of these, five had a definite cytologic diagnosis, and the sixth was suspicious of tumor. There was no morbidity associated with the procedure in these patients. Although fine-needle biopsy is not expected to prolong life in patients with pancreatic tumors, it does eliminate the need for more complicated, expensive, uncomfortable and hazardous diagnostic procedures. In many cases exploratory surgery may be obviated.


Lack of erythropoietic inhibitory effect of serum from patients withe congenital pure red cell aplasia. The serum from five children with congenital pure red cell aplasia demonstrated no erythropoietic inhibitory effect either in vivo in animals or in vitro. The significance of immunosuppressive therapy in this disease is discussed.


Health-care workers positive for hepatitis B surface antigen. Are their contacts at risk? To assess the hepatitis risk to patients exposed to HBs AG-positive health-care workers, 228 contacts were followed prospectively for six to nine months. Health workers included two physicians with chronic hepatitis, a chronic asymptomatic carrier nurse, a food handler with acute HBs Ag-positive hepatitis and a physician who was HBs Ag-positive for 25 days before the onset of acute hepatitis. Controls (167) consisted of identically followed patients who had not been exposed to an HBs Ag-positive health worker. No exposed or control patient acquired clinical hepatitis or HBs Ag. Isolated elevations in serum glutamic pyruvic transaminase occurred equally in both groups and did not correlate with serologic evidence for hepatitis B infection. One exposed patient demonstrated antibody seroconversion (anti-HBs), as did two of the controls. These data do not demonstrate hepatitis B transmission from HBs Ag-positive health workers to their patients. Restriction of such carriers is not warranted at present.


Structure of tobacco mosaic virus at 6.7 å resolution. The electron density distribution of tobacco mosaic virus has been determined to 6.7 A resolution by analysis of the X-ray diffraction pattern given by oriented gels of the virus. This has been achieved by separation of overlapping Bessel function terms by a technique analogous to crystallographic isomorphous replacement. The course of the polypeptide chain of the coat protein may be traced for a large part of its length.


Control of somite number during morphogenesis of a vertebrate, Xenopus laevis. During Xenopus embryogenesis and early growth, somite number stays close to a species-typical value for each morphological stage. This remains true even after operations on blastulae which lead to the development of abnormally small but otherwise complete early embryos, involving reduction in number of cells assigned to each somite. Evidence presented suggests that a body-position gradient may be involved, but in rather different ways at different stages, in controlling total somite number.


Positional signalling and specification of digits in chick limb morphogenesis. The interpretation of positional information can provide the basis for pattern formation in limb morphogenesis. The gradient in positional information along the antero-posterior axis, which is specified with respect to a localised boundary region, can be modified by grafting this region to successive positions along the axis. The pattern of digits obtained is consistent with a model based on diffusion of a labile morphogen and is thus similar to models proposed for the development of pattern in invertebrates.


[L-tubocurarine and pancuronium bromide in open heart surgery]. Comparison is made between 45 cases treated with d-tubocurarine and 60 with pancuronium bromide in open-heart surgery. Pancuronium displayed unmistakable advantages in the form of a more potent action, rapid commencement and long duration, dose flexibility and an almost complete absence of undesirable side-effects. In addition, it offered stability with respect to the cardiovascular system and enabled risk-free, deep muscle relaxation to be achieved even in subjects with complex cardiopathies, such as those with pulmonary hypertension, extreme hypoplasia or aplasia of the trunk of the pulmonary artery and patent ductus arteriosus, for whom a very high operative mortality risk exists when even minimal changes in cardiovascular parameters occur.


[Use in anesthesiology of a new beta-2-stimulator, Salbutamol. Original technic and considerations]. Notes on drugs relating to the adrenergic system are followed by an account of the chemical, pharmacological and clinical features of a new beta2-stimulant, Salbutamol. Employment of this drug to prevent bronchospastic crises in 10 asthmatic patients subjected to narcosis is reported. An original technique was used: oral administration preoperatively, inhalation in the immediate preoperative period, topically on the trachea, and inhalation and oral adminstration post-operatively. Satisfactory results were observed in all 10 cases and support for the use of Salbutamol in anaesthesiology is given.


[Enflurane-pancuronium combination: real progress toward greater safe conditions in general anesthesia]. The literature data and personal experience with high - and very high - risk patients show that the association of enflurane as anaesthetic and pancuronium as muscle-relaxant constitutes a positive advance in balanced general anaesthesia. Cardiocirculatory depression is not encountered; if anything, there is an improvement of homeostatic conditions. This results in increased safety, even for patients regarded as inoperable. Confirmation of the reasons for associating these two drugs has certainly been obtained. The method cannot, however, be employed indiscriminately, but, at least in theory, should be avoided in patients with serious hypertension or a myocardium that is particularly sensitive to endogenic catecholamine incretion. In hypotension, on the other hand, cases of imminent or frank shock, or situations where surgery cannot be postponed, the association is, paradoxically, a true pharmacological "support", backed up, of course, by other usual procedures. This contradiction of modern views concerning the peripheral circulation is only apparent, since the duration of anaesthesia is reduced; main aim in this period is the maintenance of sufficient circulation to the more important organs. Comparison with associations combining d-Tubocurarine, halothane and methoxyfluorane is still an open question as far as objective assessment of their usefulness is concerned. There can be no doubt, however, that the association of enflurane and pancuronium has eliminated a large sector of contraindications in the field of general anaesthesia.


[Value of a low-calorie diet in the diagnosis of Gilbert's syndrome]. Reduction of the calorie intake to 400 per day was employed in clinching the diagnosis in a case of Gilbert's disease admitted in the course of remission. This diet, in fact, results in a marked increase in serum bilirubin concentration. The non-conjugated form, in fact, reached values 5 times greater than those observed initially, within 24 hr after commencing the diet. Unlike other cases reported in the literature, this increase occurred in spite of an initially normal blood bilirubin level.


[Aspects of glycolipid metabolism during chronic renal insufficiency. Effects of dialytic treatments of short duration (3-4 hours on alternate days)]. The main indices of glycolipid metabolism were examined during and after dialysis in 11 patients receiving chronic treatment. Each dialysis period lasted 3-4 hr and was carried out on alternate days with individual machines and Coil UF2, Coil UF100 and Dasco SP75 dialysers. The liquid contained 35 mEq/l sodium acetate and 2 g glucose and flowed at 500 cc/min. Heparin was injected in the arterial line in a single initial dose. During treatment, there was an increase in free fatty acids and a decrease in serum triglycerides. Blood sugar and insulin were unchanged. The first 4 hr after treatment were marked by decreased fatty acid and increased trigylceride values. Blood sugar and insulin were again constant. The part played by sodium acetate and heparin in these changes is discussed.


[Study of a group of families with high incidence of schizophrenia]. The pedigrees of six schizophrenics' families presenting a very high percentage of sick subjects, (near to 50%) are studied. The data obtained allow to think to an hereditary transmission of the mental disease, in these families, as an autosomal dominant character; the responsible gene may have a reduced penetrance and a variable expressivity. The comparison of these data with those obtained from other schizophrenics' families support the hypotesis of an unomogeneus genetic basis for schizophrenia and also the supposition that a severe mutation of the principal gene has occurred in the studied families.


[Treatment of coronary insufficiency with a combination of 2 nitro-derivatives. Controlled pluricentric clinical trial]. The effectiveness of an association of two nitroderivatives (Stenodylate) was compared with that of its individual components. The association was found more effective in the relief of both subjective and objective symptoms in 118 cases of coronary insufficiency. In addition, it was well tolerated and would appear to be indicated in the management of this form.


[Therapy of cholesterol lithiasis with chenodeoxycholic acid (Chenoxyl)]. Chenodesoxycholic acid (500-750 mg/day Chenoxyl) was employed over a period of 9 months in the treatment of 40 patients with radiotransparent calculi in a functioning gallbladder and 8 with choledochal lithiasis. Radiological examination and complete hepatological exploration were carried out before and after the treatment in all cases. Complete dissolution was obtained in 6 and 2 cases respectively, with reduction of size in 13 and 2, and no change in 21 and 4. No significant variations were notes in the blood lipid picture or in liver function. There were no cases of diarrhoea.


[Oral loading test with a preparation which frees iron gradually in the intestine. Behavior of blood iron and transferrin]. Blood iron, total transferrin, iron-bound transferrin and transferrin iron saturation percentage were determined in non-anaemic subjects after oral administration of 1 and 2 tablets of a commercial preparation (Ferro-grad) containing ferrous sulphate and ensuring slower release of iron in the intestine. After 1 tablet, blood iron and transferrin saturation reached their peaks after 4 hr and returned to start levels after 10 hr. Higher increases were achieved, though later, with 2 tablets and the return to start levels presumibly occurred within 14 hr. There was a slight increase in total transferrin 2 hr after 1 tablet and values remained high throughout the experiment. When 2 tablets were given values fluctuated considerably, with minima coinciding with maximum blood iron values.


[Hemostatic changes in the course of different chronic hepatopathies]. The following tests were performed in 15 cases of chronic aggressive hepatitis (CAH), 12 of cirrhosis, and 8 of other forms of chronic disease: liver function, thromboelastogram, prothrombin time (PT), partial thromboplastin time (PTT), determination of factors I, II, V, X and XIII, euglobulin and FDP lysis, and platelet count, shape and agglutinability. At least one haemostasis alteration was observed in nearly every case, the most common being in the thromboelastogram, PTT, prothrombin, and platelet shape and agglutinability. Defects were most marked in cirrhosis and comparison with CAH was significant in the case of PT and factor V. Fibrinolysis was increased in 60% of the CAH group and rarely elsewhere. Haemorrhage was noted in 7 cases of cirrhosis and 1 of CAH. On each occasion, it was more dependent on the serious nature of the disease, rather than defective haemostasis.


[Drug combinations in the treatment of primary arterial hypertension]. A number of pathogenetic moments have been identified in primary or essential hypertension in recent years. Marked variations have been noted in plasma volume, cardiac output, neurosympathetic tone, the renin-angiotensin system, and the aldosterone-adrenal neurosympathetic regulation system. Biological and clinical studies have underscored the action of the individual hypotensive drugs at present available commercially and their synergic or, in some instances, antagonist effects when associated. The fact that the disease has different stages and that different points of attack can be chosen is an ecouragement to the combination and simultaneous employment of two or more hypotensive drugs. Known associations, such as reserpine (with or without sympathicoplegics) or vasodilators and the diuretics, are examined, together with more recent combinations, such as propranolol, hydralgine and the diuretics, and spirolactone and the diuretics.


[Recent studies on the in vivo and in vitro activity of gentamicin]. The effect of gentamycin was investigated at the University of Modena Phthisiology and Respiratory Diseases Department. In vitro activity against most pathological Gram-positive and Gram-negative bacteria was observed. A dose of 4-5 mg/kg proved very effective in cases of bacteria-induced bronchopneumopathy. The drug was also active against penicillin-resistant staphylococci and Gram-negative bacteria with a known resistance to ordinary antibiotics.


[New orientations in the treatment of proclaimed tetanus: use of continuous peridural anesthesia]. Notes on the typical infectious and toxis picture associated with tetatus and the physiopathological aspects of the disease are followed by the presentation of continuous C8-L2 peridural anaesthesia, giving antalgic relief and partial motor block, as a primary form of therapeutic management. A classic two catheter technique is employed and fractioned doses are used so as to exploit the action of the local anaesthetic absorbed by the patient over several days. Sedation of the orthosympathetic leads to reduced catecholamine production, hypometabolism and cardiac sedation. Analgesia and relaxation are achieved by blocking the local and general spasms typical of the disease. Success with the method in serious cases is mentioned and its use in all forms is recommended.


[Anatomical and surgical notes on the morphology of Hunter's canal]. The morphology of Hunter's canal was examined, together with behaviour of the sheath of the femoral vessels and the relations between this sheath and the walles of the canal. A search was made for morphological and anatomotopographical features capable of explaining early and intense degenerative arteriopathy and the reasons why this is a level of choice for segmentary forms. The extent, constitution and behaviour of the adductor canal are explained. It is shown that, under normal conditions, the sheath is independent of the canal walls. Mechanical influences on the corresponding segment of the artery may be attributable to early inflammation or sclerosis of the cell milieu of the adductor canal.


[Medical treatment of obliterating peripheral arteriopathies, especially arteriosclerosis]. The efficacy of medical treatment of peripheral obliterating arteriopathies on an aetiopathogenetic basis in the light of diabetes and atherosclerosis is discussed. The pros and cons of management with vasoactive drugs exercising a dilatatory action of choice on the metarterioles and the arteriolocapillary sphincters are summarised, together with the possibilities offered by such drugs. A example of the short-term effects of chorionic gonadotrophin in atherosclerotic forms is presented. Such effects include the improvement of arteriolocapillary flow and the correction of dyslipidaemia. It is suggested that chorionic gonadotrophin can be successfully associated in consecutive courses with vasoactive drugs and anticoagulants to obtain long-term success, even in cases treated for ten years.


[Hyperparathyroidism in pregnancy].

[Hyperparathyroidism in pregnancy]. A case of adenoma-based hyperparathyroidism operated at the 4th month of pregnancy (third reported case) is described. The clinical picture was extremely flimsy and diagnosis was formulated exclusively on the observation of the characteristic alterations in the calcium-phosphorus metabolism. The validity of examining renal phosphate excretion for the diagnosis of hyperparathyroidism is considered and proposed evaluation indices (P.E.I. of Nordin and Fraser; I.P.E. OF Nordin and Bulusu) are discussed. The gravity of foetal prognosis in hyperparathyroid women is sufficient justification for surgery during pregnancy.


[Respiratory function in liver cirrhosis. Spirometry, blood gas analysis and radioisotope study with Xenon 133]. The literature data concerning respiratory function in cirrhosis of the liver are cited and reference is made to the results of a spirometric, gas analysis and 133-Xenon investigation of this parameter in 38 patients. Spirometry pointed to slight ventilatory incapacity of the restrictive type. Arterial gas analaysis showed respiratory alkalosis, usually accompanied by metabolic acidosis and slight hypoxyaemia. Examination with 133-Xe indicated that hypoxyaemia was not due to a shunt effect, since there was no excess of perfusion with respect to district ventilation. It was clear, on the other hand, that the pulmonary capillary reserve was almost exhausted. Such complete perfusion of the capillary bed may be due to increased cardiac output and, in part, to reduction of the respiratory surface caused by raising of the diaphragm and hypoventilation of the lung bases.


[Demonstration of 2 experimental models of pure chronic erythroblastopenia]. Two experimental models for pure red cell aplasia (PRCA) were established.  In the first one, administration of PRCA serum IgG in normal mice induced a sustained inhibitory effect on erythropoiesis, a progressive decline of the hematocrit values and an inverse rise of erythropoietin (Ep) levels in serum.  Thus, the physiopathological pattern of PRCA type I (or A) was established,  In the second model a rabbit producing anti-Ep crossreacting with endogenous Ep was subjected to  a booster injection of Ep.  The rise of the immune response was associated with decrease of Gct values and disappearance of erythroid precursors from marrow smears, and its subsequent decline with reticulocytosis and regression of the anemia, thus reproducing the physiopathological pattern of PRCA type II (or B).


[Periaticular metastatic calcifications in uremic patients]. Metastatic periarticular calcification was observed in 18 per cent of a series of 61 patients receiving haemodialytic treatment for from 3 months to over 5 yr.  Calcium deposits occurred more frequently in the 1st and 2nd yr of treatment.  The factors responsible included the plasma calcium-phosphorus product, non-optimal calcium and magnesium ion concentration in the dialysis bath, and secondary hyperparathyroidism.  Tests for the diagnosis of parathyroid hyperfunction in the uraemic subject are described.  The therapeutic criteria adopted in the prevention and management of calcification are also discussed.


[Coronary cardiopathy].

[Coronary cardiopathy]. Results obtained with selective coronariography, ventriculography, left catheterisation and the measurement of systolic times were compared in a series of 110 patients.  Evaluation of vascular alterations with the aid of a coronary index showed that their entity was closely related to the incidence of asynergia and the extent to which left ventricular function was compromised.  Index values were proportional to decrease of the DP/DT ratio, increased telediastolic pressure, lengthening of the pre-ejection phases and shortening of left ventricular systole.  The physiopathological and clinical significance of these results is discussed.


[Arrhythmia in the course of myocardial infarct.  Our year's experience in a coronary unit]. Personal experience with arrythmia in 57 out of 132 cases of myocardial infarct treated over a period of one yr. in a coronary unit.  The ECG and biohumoral enzyme pictures gave clear indications of infarct in all 132 cases.  The various types of primary stimulus formation or conduction arrhythmia observed in these 57 patients are examined in relation to the site and extent of infarct.  The treatment modalities are described.  Mortality was less than 10 per cent in the entire series, with 3 per cent deaths due to serious rhythm disturbances.  It is concluded that the introduction of coronary units has primarily contributed to the reduction of infarct deaths by their effective treatment of arrhythmia.  Earlier admission to such units would lead to further reductions in mortality.


[Respiratory autogenic training (RAT) in the psychosomatic training of physicians]. The Author, after having described the nature of the relationship between the physician and the patient and the various possibilities that are available for their communication and the obstacles that hinder it, specifically analyzes the different phases that are necessary for the physician's psychological formation and the possibilities that the "respiratory autogenic training", practiced in a group, can offer to the expierence of the Baliant groups.


[Analogies between psychotic experiences and those lived during respiratory autogenic training relaxation]. Comparative study of a dissociative experience of the bodily scheme lived in a group relaxing session (R.A.T.) comparable to certain somatic pains found in a schizophrenic situation. Such psychopathological experiences, usually considered by doctors as in themselves averse and without meaning, can be transferred from the emotive level to the rational level using the "Ontoanalytic" method and in this way be a valid contribution to the psicological formation of the doctors in as much as a more syntonic, human and staisfying doctor-patient relationship ensues, as Balint indicated.


[Psychosomatic effects of respiratory autogenic training relaxation]. The effects of R.A.T. relaxation, as we have been able to verify during an experiment conducted by a group of doctors of various specialisations at the Catholic University of Medicine in Rome, allow recovery of the availability to recognize ones' self in others and others in one's self, and to overcome the manipulation situation which persists in groups of competitive training. In groups which undergo R.A.T. relaxation, it in fact happens that the participant, in the same degree to which he trains himself to overtake his own psychosomativ hallucinations, is able to free himself from certain substitute and negative mechanisms of the mind, can better adhere to or separate himself from his body or from the environment thus obtaining as a result the re-organisation of the emotional economy at the disposal of the Ego. Such an experiment can evidently turn out to be quite formative and useful for the successive approach between doctor and patient.


[Archetypic and mythological images detectable in respiratory autogenic training relaxation]. The author, after having described the procedure to thor, after having described the procedure to study the phenomena during the Respiratory Autogenic Training, points out the dynamycs which intervene among affective state, the fase of partial objects and coscience state. Therfore the A. analyses the function of the archetype and the relationship between implicit and explicit meaning.


[The role of hypnosis in present-day obstetrics]. There is a present need for the insertion of psychology in teaching and medical practice so that full value and respect can be given to the patient's human side. Psychological assistance during pregnancy is reviewed and a brief account is given of early hypnotic techniques in the Soviet Union. Here, however, note is taken of the fact that attention was initially paid to symptoms alone and not their causes. As these techniques spread throughout Europe, they gradually lost touch with hypnosis and moved into the realm of teaching thus becoming completely ineffective. At present, more complete and more advanced hypnotic techniques are used. These throw particular light on the psychological causes of tension in pregnancy and are suitably backed up by instruction relating to the various problems encountered during gestation.


[Hypnosis: fundamentals of futuro-genesis]. The future lies continously in the womb of the present. In every "today" one of the critical factors on which the configuration at any given conjuncture is the creativity of the intellectual and managerial élite. This creativity is to a great extent dependent on the fluidity of unconscious associative processes. These, in their turn, are decisively influenced by affective factors in the widest sense. Since, as will be shown later, hypnosis can be conceived in the manner of a "quid" identical with emotion, it inevitably follows that it must be treated as a basic element that is always present in and intimately bound up with the continous process that, at every moment, are producing the future.


[Hypnosis: logic and cybernetics].

[Hypnosis: logic and cybernetics]. Fundamental notions concerning cybernetics, as derived from the systematic application of logic to questions of communication and control, are illustrated. Particular attention is given to the concepts of "system" "structure" and "dynamics" and it is shown that these concepts ensure that better and more exact understanding and forecasting of reactions in organised beings can be obtained. Turing to hypnosis, it is made clear that a trance is the execution of a momentarily proposed programme; it is not the result of a generalised mechanical action, but is preordained and geared to various situations. The difficulty that the hypnotised subject finds in aciting against his own interests, or against moral priniciples, can be seen, for example, as a consequence of pre-programming. Another result is given moment and a given type of person. Since cybernetis has proved useful in psychology, the hope is expressed that it can be included as a teaching subject for those who learn, practise and teach hypnotism.


[Methods and relationships in hypnotism]. Hypnotism is as much an intensive and intrapersonal relationship as a state of awareness. It is therefore necessary to know how to induce this state, so that the therapeutist can achieve the best results. Ways in which this can be done are described and particular hypnotherapeutic methods that enable the technique to be managed with success are explained. Special attention is given to the concepts of relationship and suggestion. Purification and verbal catharsis under hypnosis are described, along with abreaction as a therapeutic instrument. Cases of free and selective association are presented, together with others illustrating strategic techniques for manipulation between subject and object. Personal methods are defined in the sense of suitable mechanisms enabling the hypnotist to establish what can be seen as a true state of equilibrium between himself and his patient.


[Methods and relationships in hypotism]. Hypotism is as much an intensive and intrapersonal relationship as a state of awareness. It is therefore necessary to know how to induce this state, so that the therapeutist can achieve the best results. Ways in which this can be done are described and particular hypotherapeutic methods that enable the technique to be managed with success are explained. Special attention is given to the concepts of relationship and suggestion. Purification and verbal catharasis under hyponosis are described, along with abreaction as a therapeutic instrument. Cases of free and selective association are presented, together with others illustrating strategic techniques for manipulation beteen subject and object. Personal methods are defined in the sense of suitable mechanisms enabling the hypnotist to establish hat can be seen as a true state of equilibrium beteen himself and his patient.


[Hypnosis within the framework of psychotherapy]. Apart from special cases, hypnosis cannot be used to combat symptoms, nor to give the patient something he does not yet have. That it cannot be employed, as in the preanalytic period, as a means of interpretation and psychological exploration is clear from what is said by Anna Freud. After discussion in deep analysis during wakefulness, and in the light of the psychodynamic concepts of psychoanalysis, of the what interpretat to be given to the dynamic process of the symptom, we can exactly repeat this interpretation in a hypnotic trance. It is vulnerable, like hypnoid states (emotion, fear, anxiety, anger, fatigue, surmenage, transition from wakefulness to sleep) in which a psychic pathological process may easily start due to "difference of level, blank in the consiousness" and absent "abreaction". This vulnerability and increased tendency to accept has been encountered in hypnoid states as in artificially induced trances, and gives a much more rapid entrée to the patient's integration process. The interpretation of the dynamics of his symptom, once accepted, becomes an active force, and produces effects that would, in any event, have been produced if the integration process had occurred normally, without the acceleration provided by hypnotism, leading to resolution of the symptom. What is involved, therefore, is acceleration of the psychoanalytic process.


[Ophthalmoplegia in dermatomyositis].

[Ophthalmoplegia in dermatomyositis]. A case in which apparently myasthenic ophthalmoplegia had been observed more than six years prior to the onset of dermatomyositis is reported. The clinical picture is described and the possibility of a partially common pathogenesis for both forms is mooted. It is suggested that initial local disturbance of neuromuscular transmission was eventually followed by "aggression" against the muscle fibres.


[On some aspects of activation of tissue lipolysis by mechanical factors]. An analysis of the effect of the ordinary physical factors acting on living beings on the splitting of adipose tissue triglycerides is reported. Massage was usually responsible for activation of lipolysis, or at least for an increase in blood glycerol and NEFA. If carried out for some time and repeated over a period of days, it appears capable of maintaining chronically enhanced lipolysis. The possible causes of these effects are discussed and particular stress is laid on the release of catecholamines by tissue nerve endings. Partial confirmation of this can be seen in the fact that activation of lipolysis can be depressed by administering beta-blocking drugs. The data also suggest that non-neuroendocrine mechanisms may exert a more immediate action on cell metabolism. Such mechanisms are concerned with a sector of cell life about which little is yet known, wherein every biological process is the result of phenomenon dependent on molecular physics.


[On some aspects of activation of tissue lipolysis by electric factors]. Like mechanical stimulation, electrical stimulation can nearly always activate lipolysis, as evidenced by increased blood glycerol and NEFA. The interpretation of this phenomenon is discussed and importance is attached to catecholamine mediation, since administration of a beta-blocking agent is sufficient to cause a significant reduction in the extent of the phenomenon. Other mechanisms can possibly be sought in the muscle fibres present in subcutaneous tissue, whose contraction induces increases blood lymph flow. While electrical stimulation of adipose tissue fragments in vitro gave no appreciable results, it is still possible that electrical impulses act even more intimately by means of direct physical modification of the more elementary metabolic mechanisms.


[Hemorrhagic complications during therapy with carbenicillin in 2 cases of acute renal insufficiency]. During the treatment of two patients with acute renal insufficiency with carbenicillin for Pseudomonas aeruginosa sepsis haematemesis, melaena and omnipresent petechiae were observed. Suspension was followed by rapid regression and the normalisation of clotting. Attention is drawn to haemorrhage as clotting. Attention is drawn to haemorrhage as a possible complication of carbenicillin management in patients with acute renal insufficiency.


[Gastric adenomatosis. Case reports and attempted new pathogenetic interpretation]. Two cases of gastric adenoma with lymphocyte infiltration of the basal stroma are reported. Diagnosis was based on gastroscopic, radiographic and histological data. The more significant findings are illustrated. The various theories relating to the aetiopathogenesis of this form are discussed and the possibility of its being an autoimmunitary phenomenon is examined.


[Selective pancreatic scintiscanning in the diagnosis of pancreatic diseases]. Pancreas scintiscanning using electronic image subtraction has proved useful in the diagnosis of pancreatic disease. Confirmation of this was found on comparison of the scintiscan picture and the surgical picture on gross inspection in 50 cases. Findings indicative of pancreatitis, cysts and tumours are illustrated, together with those given by scintiscanning of pancreas alterations occuring in the course of diseases affecting nearby organs.


Ultrasonic cephalometry: Its use in estimating fetal weight. Data on 100 consecutive patients delivering within 1 week after ultrasonic cephalometry measurement were reviewed to assess the weight-predicting potential of three known formulas. With Thompson's formula, 78% of infant weights fell within a range of 350 g, the absolute mean error for the 100 cases being 267 g. Excluding cases of fetal malnutrition, when the biparietal diameter (BPD) obtained was 8.3 cm or more, all newborn babies weighed more than 2000 g, and with a BPD of 8.7 cm or more they all exceeded 2500 g. Ninety percent of newborn babies in whom the in utero BPD was 9.1 cm or more weighed more than 3000 g. These values compared very favorably with those from other series and, thus, demonstrate the usefulness of this type of assessment.


Diagnosis of congenital fetal abnormalities by sonography. Sonographic examinations were performed on 13 patients whose fetuses had the following congenital malformations: anencephaly (4 cases), hydrocephaly (4), obstruction of the renal excretory system (3), iniencephaly (1), and sacrococcygeal teratome (1). In 7 cases the initial diagnosis was made by sonography, in 6 cases by radiography. Sonography was valuable a) in the detection of discrepant growth between fetal chest and head and b) in the recognition of fetal soft tissue abnormalities. It is concluded that sonography is a valuable aid in the diagnosis of congenital fetal anomalies.


Comparison of uterine contractions in spontaneous and oxytocin- or PGF2alpha - induced labors. Labor contractions in 20 patients in spontaneous labor and 40 others who reveived either PGF2alpha or oxytocin for stimulation of the active phase of labor were statistically analyzed during 1 hour of labor. Measurement criteria were the frequency, intensity, and duration of contractions. Statistical analysis failed to reveal any significant difference in contractions in the three groups, suggesting that oxytocin and PGF2alpha-induced contractions and spontaneous contractions appear to be indistinguishable.


Intrauterine pressure monitoring with a balloon-tipped catheter. Clinical experience with the latex and new estane balloons and a short and flexible guide is described. The extraovular balloon as an intrauterine pressure sensor is compared to the open-ended transcervical intraamniotic catheter, and the balloon is considered superior in many respects. The transcervical extraovular water-filled 0.8-ml estane balloon is recommended for use in place of the open-ended transcervical catheter in all clinical situations in obstetrics in which there is a need for monitoring intrauterine pressure.


Hormonal changes associated with Danazol therapy. During a 6-month course of treatment of endometriosis with Danazol,  a synthetic derivative of 17alpha-ethinyl testosterone, the following hormonal changes were found. Plasma LH remained essentially unchanged but FSH concentration was consistently in the low normal range. Plasma estradiol, especially after the fourth week of therapy, dropped to levels that did not exceed 30 pg/ml throughout the 6-month period of therapy. Plasma progesterone concentration was consistent with follicular phase levels. In the months after discontinuation of Danazol, all hormone parameters were strongly suggestive of normal ovulatory cycles. Danazol did not displace estradiol bound by endometrial cytosol.


Suction drainage as an alternative to prophylactic antibiotics for hysterectomy. A technic is described for suction drainage of the retroperitoneal space. Its use is evaluated in 150 private patients undergoing vaginal or abdominal hysterectomy and compared with 150 private control patients. This technic resulted in an average of 40 cc of fluid (range, 10-200 cc) being suctioned from the retroperitoneal space. With this technic febrile morbidity decreased from 26 to 11% for abdominal hysterectomies and from 32 to 8% for vaginal hysterectomies. Information is offered to explain the physiology of posthysterectomy infections, the effectiveness of prophylactic antibiotics, and the paradox of a febrile morbidity higher for vaginal than for abdominal hysterectomies. The risks in using prophylactic antibiotics routinely are stated, and suction drainage is suggested as a preferable alternative.


Meckel's diverticulum.

Meckel's diverticulum. The embryology and clinical implications of Meckel's diverticulum, the most common gastrointestinal anomaly, are presented from the viewpoint of the obstetrician-gynecologist. The complications and clinical management are discussed.


Vaginal evisceration.

Vaginal evisceration. Although vaginal laceration following sexual trauma is a well-reported entity, vaginal evisceration appears to be a rare occurrence. This paper presents 2 cases of vaginal evisceration recently managed at the Bronx Municipal Hospital Center and a review of the literature. Etiologic factors and management are discussed.


Endometrial cytohistology by aspiration technic and by Gravlee Jet Washer: a comparative study. An office procedure of intrauterine aspiration yielded a 99% diagnostic accuracy in 100 patients admitted for either curettage or hysterectomy. After correlation with surgical diagnosis, no false-positive or false-negative results were found. The method provides tissue for cell blocks adequate for histologic diagnosis of endometrial adenocarcinoma and its precursors. The major advantage of this technic in comparison with the Gravlee Jet Washer is its low cost. Moreover, in this study, it proved to be less painful, superior for cell block preparation, and yielded more satisfactory specimens. As a screening procedure for asymptomatic patients at risk, this intrauterine aspiration technic holds promise and must be evaluated by further studies.


Intraamniotic urea for induction of midtrimester pregnancy termination: a further evaluation. Forty percent hyperosmolar urea solution was used intraamniotically to induce midtrimester pregnancy termination in 508 patients. The mean injection-abortion interval was 43.4 hours in those patients aborting within 7 days (85.8% of the total group); 76% of the group aborted within 72 hours. Complications from the procedure included endometritis, hemorrhage, and nausea and vomiting; 29.3% of the patients required operative completion of the abortion (placental removal 12 hours after passage of the fetus). There were no cases of hypernatremia, cardiac arrest or collapse, clinically evident coagulopathies, nor cervical lacerations. This study supports the conclusion that urea is a safer intraamniotic solution than hypertonic saline for midtrimester pregnancy termination.


Effect of oral contraceptives and IUD's on the copper in human cervical mucus. The copper content of normal human cervical mucus varies during the menstrual cycle. It is lowest at midcycle when the copper content decreases sharply; When oral contraceptives are used, levels of copper in the mucus show a general increase, this being especially evident at midcycle when the normal decrease in levels is not observable. In addition, with oral contraceptive used, levels in mucus disappears. Copper content of the mucus in also noticeably higher in users of copper IUD's and slightly higher in users of plastic (non-copper-bearing) IUD's than in normal controls, Mucus samples from copper IUD users consistently have the highest copper content in all phases of the menstrual cycle. It is concluded that the presence of copper assists in preventing pregnancy.


Emotional reaction to sterilization.

Emotional reaction to sterilization. Ninety-four patients sterilized by tubal occlusion were interviewed at the time of hospitalization for surgery and followed at scheduled intervals for a 2-year period. There were no serious problems, medical or psychologic, and all but 3 patients were pleased and satisfied at the end of 2 years. There were no technical failures. Psychosomatic symptoms do develop. They are more prominent and persist longer in the younger age group. Patients having these symptoms are those who had difficulty with contraceptive technics, have a limited understanding of the sterilization procedure, and continue to question its permanency. The need for preoperative evaluation and counseling is emphasized.


Effect of povidone-iodine on Herpes genitalis. Ten patients with vulvovaginal and cervical herpesvirus infections were treated with a regimen of external and intravaginal povidone-iodine preparations. In all but 1 case, the expected duration of symptoms and healing time were shortened. The response of cervical lesions was especially remarkable. The findings of this pilot study warrant further controlled clinical investigation.


Vulvar carcinoma with hypercalcemia.

Vulvar carcinoma with hypercalcemia. Hypercalcemia associated with nonmetastatic malignancy has been reported most frequently with lung or kidney tumors, while among gynecologic malignancies, the ovary has been the most common primary site. The pertinent clinicopathologic features of 2 cases of nonmetastatic vulvar carcinoma producing hypercalcemia are described in the present report. Including 3 previously reported cases, the vulva is seen to be the second most common site in the female genital tract for production of this paraendocrine syndrome. The clinician should be aware of the association of hypercalcemia and mental confusion with bulky vulvar tumors, so that surgery will not needlessly be delayed in a futile attempt to correct the hypercalcemia medically,