Talocalcaneonavicular joint arthrography for sustentacular-talar tarsal coalitions. Sustentacular-talar tarsal coalitions can be difficult to detect radiographically. The sustentacular-talar articulation is a part of the talocalcaneonavicular joint. Thus, arthrography of this joint, combined with tangential views of the sustentaculotalar articulation (Harris views), provides a new and simple method to detect or exclude talocalcaneal tarsal coalitions.


New grid design for a fluoroscopic spot film device. A new grid design for a fluoroscopic spot film device is presented. Fluoroscopy is achieved with a conventional low ratio grid, while spot filming is done with a high ratio criss-cross grid. The result is a low patient radiation dose during fluoroscopy, while the high ratio grid during spot filming provides a significant increase in subject contrast.


Bifurcation level of the aorta: landmark for pelvic irradiation. The position of the aortic bifurcation in women in relation to the lumbar vertebral bodies was determined in 100 pelvic arteriograms to provide some help in teleradiation therapy planning for pelvic malignancies. It was found that in order to cover the area of the aortic bifurcation, the radiation field should extend to the top of the body of the fourth lumbar vertebra.


A new technique for urethrography.

A new technique for urethrography. The male urethra can be demonstrated following intravenous urography by having the patient void against the partial obstruction produced by a penile clamp. The clamp is useful for both the normal or stenosed male urethra.


A simple afterloading applicator for intracavitary irradiation of carcinoma of the nasopharynx. A simple, disposable afterloading applicator for intracavitary irradiation of carcinoma of the nasopharynx has been found useful as a supplementary radiation boost to the primary site. Hopefully, local tumor control can be enhanced by employing this technique.


A new calculator for radiotherapy treatment planning. Comparison of speed and costs of the programmable desk calculator and the minocomputer reveals that although the desk calculator is slower, most operations are simple dose and treatment time calculations in which the turn-around time is essentially immediate. Assuming a five-year equipment capitalization of the initial $24,000 cost and $1,700 per annum maintenance charge with a workload of 800 plans per year, the cost per plan is about $8.00. This does not include programmer salaries.


The characterisation of Campylobacter sputorum subspecies mucosalis isolated from pigs. A comparison is made between the recognised subspecies of Campylobacter sputorum isolated from humans and cattle and the previously unrecognised catalase negative vibrios isolated from porcine intestinal adenomatosis. The characters of the porcine strains warrant their inclusion within the species Campylobacter sputorum. Differentiation between all three is possible in the laboratory and we propose that, in addition to the recognised subspecies, sputorum and bubulus, the pig strains be accorded subspecies rank and called mucosalis. Other porcine strains characterised as C coli formed a heterogeneous group but could be differentiated from porcine C sputorum strains by their pigment and catalase production, sodium chloride tolerance, antigenic and a number of other characters.


A radiographic study of rostral tooth development in young Friesian cattle. Twenty-nine British Friesian cattle fed the same diet, slaughtered at various weights and including bulls, steers (castrated males) and females (heifers) were examined. The stage of their rostral tooth development was recorded both visually and radiographically. Insufficient animals were present in each sex and slaughter weight treatment group to allow any comparison between them. When the data for each sex were compared, no statistically significant differences were seen between the mean ages at which bulls, steers and heifers attained each stage of dental development as determined from their radiographs. The results for all 29 cattle were then combined. This combined data showed a relationship between age and those stages of tooth formation which could be differentiated by examination of the X-ray films. As most phases of tooth formation occurred within well defined limits, it is suggested that radiographs of rostral tooth development might be used to estimate the age of cattle.


The rate of mitotic division in regenerating epithelium in the dog. An account is given of the changes which took place in the rate of mitotic division of the epithelial cells, over and around healing unprotected circular full-thickness excised skin wounds in the thoracic and metatarsal regions of the dog. The rate of division increased during the first 24 h and the maximum rate in the epidermis around the wound was reached after two to six days when 4-7 to 6-0 per cent of the cells were dividing. Mitotic figures were seen in the migrating epithelium on the second day. As the mitotic rate in the epidermis around the wound became less the rate in the newly-formed epidermis over the wound increased.


An interaction between diet and blood group upon serum alkaline phosphatase activity in lambs. Serum alkaline phosphatase activity was studied in groups of lambs fed diets containing different amounts of wheat grain and lucerne hay with different levels of supplementation with formaldehyde treated casein-sunflower seed. Total serum alkaline phosphatase activity increased more in groups fed 100 per cent wheat or 67 per cent wheat 33 per cent lucerne than in those fed 33 per cent wheat 67 per cent lucerne or 100 per cent lucerne. Supplementation of the diets with the casein-sunflower seed preparation resulted in an increase in the heat resistant proportion of serum alkaline phosphatase activity. This effect was more apparent in lambs of the r blood group (R-r-i blood group system) than in R lambs. These finds are discussed in relation to the relative heat resistance of tissue isoenzymes of alkaline phosphatase.


Treatment of crenosomiasis in dogs.

Treatment of crenosomiasis in dogs. Dogs were infected with the lungworm Crenosoma vulpis. The efficacy of four drugs in the treatment of the disease was examined using a controlled test. Levamisole and diethylcarbamazine proved to be highly effective.


Physiological variations in levels of 2,3-diphosphoglycerate in horse erythrocytes. The levels of 2,3-diphosphoglycerate (2,3-DPG), which affects the transport of oxygen by haemoglobin, were examined in horse blood. Resting levels of erythrocyte 2,3-DPG were established in thoroughbred horses, and levels of 2,3-DPG together with haemoglobin levels, were examined in a variety of conditions. A negative correlation was observed between erythrocyte 2,3-DPG and haemoglobin levels. Mares had higher erythrocyte 2,3-DPG levels was observed during training, and this variation may have a significant effect on haemoglobin oxygen transport. Erythrocyte 2,3-DPG levels were not affected by age or exercise.


Studies on tibial dyschondroplasia in ducks. A high incidence of tibial dyschondroplasia was present naturally in a variety of strains of ducks. The incidence was higher in heavy strains than in light strains and both incidence and severity were markedly reduced by early restriction of growth rate. The incidence and severity differed somewhat in groups of ducks of the same strain and growing at the same rate on two different commercial rations. The abnormality was not dramatically reduced by feeding a ration containing a high bicarbonate mineral mix. The histological development of the lesion is described and possible aetiologies discussed. Despite the high incidence, tibial dyschondroplasia seldom caused significant economic loss.


The effect of Imidocarb treatment on Babesia in the bovine and the tick (Boophilus microplus). Treatment of calves with 5 mg/kg Imidocarb (3,3-1-bis-(2 - imidazolin - 2 - yl)carbanilide dipropionate) given intramuscularly 14 days before and 14 days after exposure to Babesia infected Boophilus microplus larvae rendered the next generation of larvae incapable of transmitting Babesia infection. When administered to calves 14 or 28 days before tick exposure, the drug prevented the development of clinical babesiosis; the larval progeny of ticks  reared on the calf which was treated 28 days before infestation were infective. Treatment of a calf 42 days before exposure to infective larvae did not prevent the development of a Babesia parasitaemia but appeared to reduce the severity of infection.


Corynebacterium bovis as a pathogen in rabbits. A Corynebacterium identified as Corynebacterium bovis has been isolated from a chronic testicular abscess and the lung of a laboratory rabbit. The strain, on intravenous injection, reproduced a similar disease in the inguinal and vulval region of an experimental rabbit. Sera from both animals showed increasing titres of agglutinating antibody for the isolated Corynebacterium and for kaolin particles sensitised with the phosphatide antigen of Mycobacterium tuberculosis. It is suggested that the pathogenicity of C bovis for dairy animals be re-evaluated in view of the uncertainty in the literature.


Effect of changes in ambient temperature on maternal plasma and allantoic fluid from chronically catheterised ewes during the last two months of pregnancy. At ambient temperatures of 17-22 degrees C hypoglycaemia (plasma glucose levels smaller than 45 mg/100 ml) in pregnant sheep was associated with rising potassium concentrations in allantoic fluid, while at temperatures below 12 degrees C glucose levels were higher and coincided with falling potassium values. It is suggested that the fetus is sensitive to changes in maternal glucose balance induced by variations in anbient temperature, and this indicates the need to consider the environmental temperature in metabolic studies of fetal sheep.


Chronic catheterisation of the aorta and umbilical vessels of fetal sheep. Methods for cathetersing the fetal aorta and tributaries of the umbilical vessels are described by which daily samples of fetal blood were obtained for up to 53 days and up to 42 days, respectively. This represents a considerable advance on previously reported techniques.


The use of mouse protection tests in the diagnosis of caseous lymphadenitis in sheep. Mouse protection tests gave promising results in the diagnosis of caseous lymphadenitis in sheep especially those presenting no external lesions. The test was specific since sera of infected sheep were capable of neutralising Corynebacterium ovis toxin while sera of healthy sheep failed to do so. Better results were obtained with 1-0 ml than 0-5 or 0-25 ml serum of infected sheep to neutralise 2 MLD of the toxin through mice.


Some implications of ternary diffusion in the lung. Diffusion in the lung normally involves three gases and the governing laws are Stefan-Maxwell equations rather than the more familiar Fick's law. A simple gas film model is studied mathematically to (1) demonstrate that the rate of diffusion of a component gas may be zero even though its concentration gradient is not zero (known as "diffusion barrier"), that the rate of diffusion of a component gas may not be zero even though its concentration gradient is zero ("osmotic diffusion"), and that a component gas may diffuse against the gradient of its concentration ("reverse diffusion"); (2) compare the discrepancy between results obtained by binary and ternary laws separately; (3) determine the importance of ternary diffusion at high pressure. The findings from the model study suggest that the effects of ternary diffusion may not be pronounced when air is breathed under normal conditions, but the behavior of helium mixtures deviate significantly from that described by binary diffusion laws.


Respiratory frequency control during external elastic loading and chest compression. Experiments were conducted to determine if extravagal (i.e. chest wall) respiratory mechanoreceptors are involved in the control of respiratory frequency during steady-state external elastic loading (EEL) and chest compression (CC) in the anesthetized (Dial), vagotomized cat and dog.  Frequency versus PaCo2 curves obtained by breathing CO2 mixtures were compared with curves obtained during elastic loading  and chest compression.  There was no significant difference between the CO2  and EEL curves in cats or dogs indicating there is no extravagal mechanoreceptor information contributing to the control of respiratory frequency during EEL. Comparison of curves obtained with chest compression and CO2 breathing show that dogs respond to chest compression with an extravagal (i.e. involving chest wall mechanoreceptors) neural reflex increase in frequency.


Role of the red cell membrane in oxygen uptake. The rate at which red blood cells take up O2 or CO as measured in a rapid reaction apparatus is considerably less than predicted from solution of the equations for diffusion and chemical reaction in a layer of hemoglobin solution about the same thickness as the red cell. Nicolson and Roughton (1951) showed that this discrepancy could be accounted for by postulating that the red cell membrane is an important barrier to gas uptake. Sinha (1969) measured the rate of O2 uptake by single red cells located near a gas-plasma interface. The equations for diffusion and chemical reaction of O2 in a membraneless layer of hemoglobin solution for conditions that correspond to Sinha's experiments are solved. The calculated time course of O2 uptake fits the experimental data sufficiently well to suggest that the resistance of the red cell membrane to O2 diffusion is not an important limiting factor. Also analyzed in this way is the data of Carlson and Comroe (1958). The author finds that calculations predict a faster rate of CO uptake by biconcave disc shaped red cells than was observed experimentally, but that calculations for sphered red cells agree well enough with experimental data that membrane CO permeability may not be primary in limiting CO uptake by spherocytes.


Vagal modulation of respiratory control during exercise. Vagal modulation of chemical control of ventilation during rest and exercise was studied in 15 anesthetized mongrel dogs. Arterial chemical stimuli--hypoxic, hypercapnic or a combination of both, increased ventilation by increasing both rate and depth of breathing during rest and exercise in the intact dogs. After bilateral vagotomy chemical drive increased ventilation mostly by depth and little by rate. The ventilatory response to the chemical drive, therefore, reached a plateau when tidal volume approached its maximal value ata relatively unchanged breath frequency. Muscular exercise, however, largely restored frequency response in the vagotomized animals. Since the rate response to chemical stimuli but not to exercise was impaired by vagotomy, we concluded that hyperpnea of exercise could occur through a mechanism not shared by the chemical control of ventilation. The relationship between tidal volume and breath cycle during chemical stimulation was modulated by the volume related vagal reflex. During exercise, another mechanism, presumably bulbo-pontine, is activated to influence the relationship independent of the lung volume.


Hyperoxic hyperventilation in carotid-deafferented cats. Ventilation when breathing air and during exposure to hyperoxia (PAO2 equal to 400-450 mm Hg) was studied in unanesthetized cats before and after carotid sinus nerve section (chemo-deafferentation). Chemo-deafferentation resulted in lowered values of measured ventilation, tidal volume, and respiratory frequency, during air breathing PACO2 increased by an average of 7.9 mm Hg. In intact animals, ventilation after 10 minutes of exposure to hyperoxia was similar in magnitude and pattern to that measured during air breathing. Exposure of chemo-deafferented animals to hyperoxia resulted in an increased ventilation, due entirely to augmented tidal volume. Increased ventilation was accompanied by a decrease in PACO2. This response to hyperoxia developed gradually duringa 3-4-minute period, the rise in ventilation and fall in PACO2 invariably stabilizing by 5 minutes. It is concluded that carotid body chemoreceptor activity is essential for the maintenance of normal values of ventilation and PACO2 in unanesthetized cats. In addition, central mechanisms responsible for tidal volume production may, in the absence of carotid body afferent input, be depressed by the PO2 characteristic of normal arterial blood. The significance of these findings to the chemical control of breathing is discussed.


Hypoxia-induced tachypnea in carotid-deafferented cats. Ventilation while breathing air and in response to hypoxia was studied in unanesthetized cats after carotid body chemo-defferentation. Hypoxic exposure (FIO2 equal to 0.07-0.12) of chemo-deafferented animals rapidly produced a high frequency, low tidal volume tachypnea. Tachypneic breathing, although usually associated with an increased expired ventilation, was accompanied by an increase in PACO2. In contrast to intact cats, behavioral arousal during hypoxic exposure was not observed after chemo-deafferentation. The response to milder hypoxia (FIO2 equal to 0.14-0.16) occurred with an increased latency, and there resulted a less marked depression of tidal volume and stimulation of respiratory frequency. Elevation of PACO2 to 5 mm Hg above the resting value, by addition of CO2 to the inspired gas, prevented the appearance of tachypnea upon subsequent reduction of FIO2 from 0.21 to 0.07. Depletion of central catecholamine stores, by administration of reserpine, did not prevent the tachypneic response to hypoxia. Following administration of anesthesia (pentobarbital, 30 mg/kg, IP), hypoxic exposure (FIO2 equal to 0.10) led to depression of both respiratory frequency and tidal volume, resulting in apnea within 1.5 minutes. It is concluded that hypoxia (FLO2  equal to  0.07-0.16) acts, in a concentration-related manner, as a powerful stimulant to central respiratory frequency generation and as a depressant of the tidal volume in the unanesthetized cat.


Carbon monoxide elimination.

Carbon monoxide elimination. The elimination rates of carbon monoxide in anesthetized, spontaneously breathing dogs were determined following acute inhalation of varying amounts of this gas. Blood levels of carboxyhemoglobin (COHb) induced ranged between 5 and 43%. Following the administration of carbon monoxide, the decline in arterial blood %COHb was biphasic. The decline in the blood %COHb level could be described as an initial distribution curve which was exponential in nature, followed by an elimination curve which was linear for 90 min. Prediction equations for elimination of CO from blood according to the initial levels of COHb are presented. Animals having low (5-16%) and high (20-43%) COHb levels eliminated 50% of their total load in 190 plus or minus 6.4 and 134 plus or minus 5.3 min, respectively.


Respiratory effects of pneumotaxic center lesions and subsequent vagotomy in chronic cats. Ventilation was monitored in awake and anesthetized cats breathing air or CO2 mixtures, both before and after lesions in the pneumotaxic center region and after subsequent bilateral vagotomy. Cats with pontile lesions had, relative to intact state, a prolonged inspiratory duration and an increase in tidal volume and expiration duration. The changes seen on the spirogram differed quantitatively according to the region of the pneumotaxic system which was destroyed. After subsequent bilateral vagotomy, respiratory phases and tidal volume were greatly increased. These results indicate that the pneumotaxic center would control the sensitivity of Breuer-Hering reflex and that the inspiratory activity is released by the successive suppression of the two inspiratory-inhibitory mechanisms, i.e., the pneumotaxic center and the vagal pulmonary afferents.


Stress-strain relationships during uniform and non uniform expansion of isolated lungs. Stress-strain relationships in various directions were determined on isolated rabbit and cat lungs both during unrestrained and restrained expansion, the latter approximating the condition of cylindrical deformation. Under this condition the distortion due to the weight supported at the lung surface was also studied. Experimental data did not fit the equilibrium equations for a continuum solid, except for relatively small distortions of lung parenchyma. On the contrary, over the full range of lung distortions they fitted a model made up by a three-dimensional network of interconnected springs. While distortions produced even at relatively low lung volumes caused substantial changes of surface pressure distribution, the distorting effects of the weight were negligible under this respect. These results support the conclusion that pleural surface pressure distribution in rabbits, cats and dogs is mainly due to the lung distortion caused by the mismatching between lung and chest wall inherent shapes, while that caused by the lung weight plays only a minor role.


[What was the condition in 1972 of patients operated by Voss' method between 1959 to 1966?]. The authors describe the condition in 1972 of patients who were operated on by the Voss technique between 1959 and 1966 and who had been studied first in 1967. Four patients out of 10 remained satisfactory for 6 to 10 years after surgery but the progressive deterioration in the results shows that this operation does not withstand the test of time and that it has a very weak pathogenic basis.


[Articular complications of Kahler's disease. Results of a survey of 1953 cases of plasmocytic myelomas]. The authors confirm the great rarity of joint complications in patients with Kahler's disease. Among the records of 1953 cases the following complications were the only one found: 2 cases of proved articular amylosis, 2 cases of probable articular amylosis, 3 cases of possible articular amylosis, 20 cases of arthropathy that were impossible to classify, 27 cases of compression of the median nerve in the carpan canal, 6 cases of gouty arthritis, and 3 cases of septic arthritis. The data on symptoms obtained in the course of this enquiry are in conformity with the data in the literature. Articular amylosis often takes on the appearance of a polyarthritic syndrome of progressive installation and extension, involving in particular the hands and the wrists, but sometimes involving in a symmetrical bilateral manner the elbows, the shoulders, and the knees. The affected joints are swollen, stiff, and painful. Local signs of inflammation are, however, often absent. The deformations characteristic of rheumatoid arthritis do not develop. The joints do not show radiological signs for most of the time. In addition, it is not possible to detect the rheumatoid factor in the serum. The arthropathies can also assume an oligo-articular topography. Articular discharges are very frequent: they are usually of a mechanical nature. Whatever the clinical appearance, an exact diagnosis can be established only by means of anatomo-pathological examination of the synovial membrane or of certain para-articular amyloid nodules. Myelomas complicated by amyloid articular deposits are often light chain, with only little increase in the erythrocyte sedimentation rate, discrete hyperproteinaemia, moderate medullary plasmocytosis, and rare or limited radiological lesions. The carpal canal syndrome is either isolated or included within the framework of a polyarthropathy. Compression of the median nerve is due to amyloid infiltration into the synovial sheath of the tendons of the finger flexors, proof of which is not always easy. Gout is rare despite the frequency of hyperuricacidaemia caused by renal insufficiency. Septic arthritis is often caused by renal insufficiency. Septic arthritis is often caused by pneumococci to which those with a myeloma appear particularly suceptible.


[Radiographic study of the hand in 50 cases of primary articular chondrocalcinosis. Comparison with a control series of 100 subjects]. The authors analysed radiograms of the hands of 50 patients suffering from primary articular chondrocalcinosis (ACC) and compared them with those of 100 control subjects of similar sex and age. There were 40 women and 10 men, with an average age of 69.6 years (plus or minus 9.82). A chalky incrustation of the semilunar pyramidal interspace was observed in 40 percent of cases. The frequency of this incrustation was next in order of importance to incrustation of the triangular ligament which occurred in 52 percent of cases. The difference from the controls was highly significant (p less than 0.001). Voluminous geodes affecting one or more of the bone of the wrist were present in 20 percent of the patients with ACC and in 5 percent of the controls. The difference was significant (p less than 0.01). Chalky deposits were found in the soft tissues immediately next to a metacarpo-phalangeal articulation in 22 percent of the ACC patients but not in any of the controls. The difference was highly significant (p less than 0.001). These chalky deposits next to metacarpo-phalangeal articulations were always associated with chalky incrustation of the radio-carpal joint. As regards the radiological lesions, considered as being typical images of arthrosis and affecting the trapezo-metacarpal, metacarpo-phalangeal, and interphalangeal articulations, the chondrocalcinosis patients appeared to be more frequently affected than the controls, but the difference was not significant. On the other hand, a type of arthropathy occurs in ACC patients which also resembles an arthrosis radiologically but which was 5 times more frequent in them than in the controls and which in this series occurred without nearby trapezo-metacarpal arthropathy only in ACC patients (16 percent as against 0 percent in the controls: p less than 0.001); this was scapho-trapezial arthropathy. The finding of this kind of radiological lesion, particularly when it is not associated with lesions in the trapezo-metacarpal articulations should indicate the possibility of a diagnosis of ACC and should lead to radiological investigation of other sites.


[Needle puncture of the intervertebral disk foci in the bacteriological diagnosis of infectious spondylodiscitis. Technic and results]. Clinical, laboratory, and radiological data do not make possible a certain diagnosis of infectious spondylitis: errors are thus possible, even frequent, and are harmful to the patient. In order to ensure a certain diagnosis and to avoid exploratory surgery as far as possible, the authors propose systematic needle puncture of the inververtebral disk--a technique that is simple and inoffensive to carry out in all disks below T4, and that, in a series of 18 cases, gave a success rate of 2 out of 3 (11 positive results). The technique, the results and the factors essential for success are described and analysed.


[Cylindrical osteotomy of the upper extremity of the tibia with advancement of the patellar ligament. Biomechanical treatment of gonarthrosis]. The authors recall briefly the applications of Pauwel's theories concerning surgery in cases of gonarthrosis, which must be surgery to relieve restrictions on movement and not surgery to restore shape. They describe briefly the main biomechanical principles which must guide the pre-operative investigations and report their experience with a technique proposed by Blaimont and perfected by Maquet, the advantage of which is the exactness of the surgical correction. The technique is also useful in cases of femoro-patellar arthrosis. Among 120 osteotomies carried out using this method, the authors obtained very good or good results in 85 per cent of cases, and fairly good or poor results in 15 per cent of the patients. This method makes it possible to avoid in the great majority of cases recourse to total prostheses of the knee.


[The place of intertrochanteral valgus osteotomy (Pauwels II) in the surgical treatment of coxarthrosis. Biomechanical principles. Results. Apropos of a homogeneous series of 80 cases]. The authors report their experience of treating certain forms of coxarthrosis by valgus osteotomy (Pauwel's operation II). Their study was carried out on 80 patients in whom the disease was of sufficient duration. The authors recall the main principles of biomechanics that must be strictly applied following careful and detailed study of the radiological films and of the results of the pre-operative test: failure to do this will lead to failure in treatment. The cases that are usually improved by the Pauwels II operation are those arthroses with a flattened head or with gout, often dislocated. The authors describe the surgical technique and the postoperative treatment. They obtained very good or good results in 85 percent of cases, and unsatisfactory results in 15 percent of patients, mainly because of errors at beginning of the series. As with varus, osteotomy, these operations must be regarded as surgery to relieve restrictions on movement and not surgery to restore shape.


[Osteonecrosis, alcoholism and liver steatosis]. Ethylism represents at the present time one of the most frequent etiological factors of primitive osteonecrosis of the femoral head. In relation to a case of osteonecrosis of the femoral head associated with multiple bone infarcts in a chronic alcoholic, also presenting recurring jaundice, alcohol-sensitive hyperlipidaemia, and moderate anaemia, the authors review the role of fatty embolisms in the formation of primitive osteonecrosis of the femoral head. These fatty embolisms may be the result of alcohol-induced hyperlipidaemia, possibly an associated pancreatic disorders, or in particular of hepatic steatosis. A systematic histological study of 10 recent unselected cases of primitive osteonecrosis of the femoral head confirmed the extreme frequency of such embolisms (8 cases out of 10).


[Several synovial enzymes in rheumatoid arthritis]. The authors show that although the enzyme variations are nil or unimportant in the mechanical joint fluids, they are of some importance in the inflammation fluids, particularly in cases of rheumatoid arthritis. Of those studied so far, the variations are most notable in the dehydrogenases and the phosphatases, the variations being highly significant and related to one another and to the sedimentation rate.


Studies on a fraction of human gastric mucosa containing intrinsic factor isoproteins typical of mucosa. A mucosal fraction containing isoproteins of the vitamin B12-intrinsic factor complex with high isoelectric points (pH 5.95-6.52) was prepared, using DEAE-cellulose chromatography. It possessed biological and immunological intrinsic factor activity, and its molecular weight was about 2,000 daltons smaller than that of the isoprotein assembly of gastric juice. Neuraminidase digestion of the gastric juice complex produced a biologically active product containing the high pI isoproteins typical of mucosa. Thus the high pI fraction is deficient in sialic acid, apparently consisting of 'incomplete' molecules not yet ready to be secreted.


Platelet reactivity ex vivo and in vivo after acute and chronic treatment with sodium caprylate. The effect of sodium caprylate on platelet function and other hematological parameters was studied, using rabbits as experimental animals. Intravenous administration of caprylate resulted in a pronounced, although transient, inhibition of platelet reactivity as measured by the laser technique. A single oral dose of caprylate had no effect on platelet adhesiveness. Long-term oral administration of caprylate (2 and 3 weeks) to rabbits resulted in a progressive and significant decrease in platelet adhesiveness in these animals compared to that in a control group receiving saline. However, the platelet reactivity to laser damage was not changed after administration of caprylate for 3 weeks. Other hematological parameters such as hematocrit, plasma cholesterol, triglycerides, and ketone body concentrations were not altered by the treatment.


Factor V (proaccelerin) concentration in 1016 blood donors. The effects of age, sex, and ABO blood groups. Factor V (proaccelerin) concentration was measured in the plasma of 1016 regular and controlled blood donors. Age had a highly significant effect on factor V concentration. The median rose from 99 per cent at the age of 20 to 123 at the age of 60 years. Minor effects of sex and ABO blood groups were suggested. Interactions between these factors were found negligible. Accuracy and precision of the assay method and the use of percentiles in the laboratory reports are discussed. The results may support the hypothesis of relation between high concentration of coagulation factor V and predisposition to thrombosis.


Plasma aldosterone by radioimmunoassay determination in normal man and in patients on maintenance haemodialysis. The plasma aldosterone concentration was measured by a radioimmunoassay in which paper chromatography was used for separation of the steroids. The method had a low blank value (1.3 plus or minus 2.8 pg/ml), and the sensitivity was 6 pg/ml. The variation coefficients for interassay and intraassay determinations were 13.0% and 9.4%, respectively. An accuracy study on fixed amounts of unlabelled aldosterone added to pool-plasma gave a linear correlation (slope equals 0.9973). In a normal material, the mean plasma aldosterone concentration was found to be 120 pg/ml. In 26 patients on maintenance haemodialysis the mean plasma aldosterone concentration was 68 pg/ml, in the group of anephric patients 36 pg/ml, and in the non-nephrectomized group 91 pg/ml. There was a significant difference (P smaller than 0.01) between the two groups as well as between the total group of patients on maintenance haemodialysis and the normal subjects.


Increased metabolic turnover rate and transcapillary escape rate of albumin in long-term juvenile diabetics. The metabolic turnover rate and transcapillary escape rate of albumin were studied with 131I-labelled human albumin in nine patients with long-term diabetes mellitus. Retinopathy was present in all patients and nephropathy in four. Plasma albumin concentration and plasma volume were reduced (P smaller than 0.05). The previously reported decrease in the intravascular albumin mass in long-term diabetics was thus confirmed by an average of 59.0 g/m2 surface area, compared with a normal value of 71.7 g/m2-(minus18%) (P smaller than 0.005). The albumin metabolic rate was increased, the fractional disappearance rate being an average 13.2% of the intravascular albumin mass per 24 hr, compared with a normal value of 8.4% (+ 57%) (P smaller 0.001). The rate of synthesis was 7.7 g - 24 h-1 - m-2 in contrast to a normal rate of 6.2 g - 24 h-1 - m-2 (+24%) (P smaller 0.001). Total body albumin mass was decreased proportionally to the intravascular mass. Confirming previous observations, we found an increase in the transcapillary escape rate of albumin (fraction of intravascular albumin mass passing to the extravascular space per unit time) from a normal average of 5.6% - hr-1 to 7.4% - hr-1 (+32%) (P ssmaller than 0.001). This finding can best be explained by an increased microvascular permeability to plasma proteins. A positive correlation between the transcapillary escape rate and fractional disappearance rate of albumin was demonstrated ( r equals 0.74; P smaller than 0.01). This supports the concept that albumin is catabolized in connection with its permeation through the microvascular endothelium.


Effects of nicotine and inhalation of cigarette smoke on total body oxygen consumption in dogs. The effects on total body oxygen consumption of nicotine infused intravenously and of simulated cigarette smoking were studied in intact anesthetized dogs. Nicotine infusion and simulated cigarette smoking raised total body oxygen consumption by 9 plus or minus 2% (mean plus or minus S.E.M.; P smaller than 0.02) and 6 plus or minus 2% (P smaller than 0.05), respectively, and arterial concentration of free fatty acids (FFA) by 29 plus or minus 9% (P smaller than 0.05) and 12 plus or minus 3% (P smaller than 0.01). When nicotine infusion and simulated cigarette smoking were repeated during inhibition of lipolysis with beta-pyridylcarbinol, no rise in total body oxygen consumption occurred, although the mean aortic blood pressure and heart rate remained elevated to levels similar to those during intact lipolysis. It is concluded that the rise in total body oxygen consumption induced by intravenously infused nicotine or simulated cigarette smoking was probably mediated through increased mobilization and consumption of FFA.


Metabolic activity of skeletal muscle in patients with peripheral arterial insufficiency. Effect of arterial reconstructive surgery. The metabolic capacity of leg muscles was determined in 12 patients with peripheral arterial insufficiency before and 6 months after vascular surgery. Succinic oxidase activity and the incorporation rates of glucose-carbon into glycogen, lipids, lacate, and CO2 were determined as a measure of metabolic capacity. Leg muscles from patients with intermittent claudication had high metabolic capacity, as shown previously. This capacity was reduced towards control values after successful revascularizations, while it remained unchanged if the surgery failed. In patients with gangrene the preoperative values of leg muscles' metabolic capacity were subnormal, and increased towards control values if surgery was successful. In 2 patients with limb gangrene the vascular surgery was only partially successful i.e. the gangrene threat was changed into intermittent claudication. In these 2 patients the metabolic capacity of leg muscles changed from sub- to supracontrol values. In 2 patients the vascular surgery failed, and the patients had no benefit from the operation. In these 2 patients the metabolic capacity of leg muscles remained unchanged. These results support the theory that changes in the amount of blood flow, i.e. the supply of oxygen and substrates to the leg, govern the level of metabolic capacity of the skeletal muscles. The results seem to justify the recommendation that reconstructive arterial surgery in patients with intermittent claudication ought to be followed by physical training to preserve the high metabolic capacity in the skeletal muscles.


The effect of circulatory occlusion on isometric exercise capacity and energy metabolism of the quadriceps muscle in man. Occlusion of the circulation to the quadriceps muscle for 20 min resulted in decreases in the muscle ATP and phosphorylcreatine (PC) contents of 1 and 32 per cent, respectively, and increases in ADP and AMP of 7 and 37 per cent. Decrease in PC was statistically significant after 4 min of occlusion, suggesting that the local intramuscular oxygen store was sufficiently depleted at this time as to be limiting to normal mitochondrial function. Pyruvate and lactate concentrations in muscle and the lactate to pyruvate ratio were significantly increased after 15 min of occlusion but not before. The calculated local oxygen store in the muscle was 2.0 mmol O2 - (kg dry muscle)-1. Local oxygen store depletion after 4 and 10 min of occlusion was estimated to be 40-50 and 90-100 per cent complete. Increasing time of pre-exercise occlusion resulted in decreased isometric endurance capacity. The observed decreases in endurance, however, were far greater than could be accounted for by any parallel decrease in the local muscle energy stores.


Static and functional morphology of the pathological platelets in primary myelofibrosis and myeloproliferative syndrome. Native and functioning platelets in patients with primary myelofibrosis and myeloproliferative syndrome were examined by transmission electron microscopy. Among various types of ultrastructural abnormalities in the platelets, three features were emphasized: hypoplasia of the surface connecting system (SCS) with few orifices, hyperplasia of the dense tubular system, and considerable variety in numbers of granule. Morphological analysis was made on platelets of these patients and of normal subjects. Functional morphology of the abnormal platelets was examined in the aggregate samples either by ADP or collagen and the effluent blood from platelet retention test. The abnormal platelets were more or less indifferent from the aggregates and underwent only to a slight degree the changes observed in normal platelets. They frequently retained their native, round, smooth-surfaced form without pseudpod, and did not show the inward shift of organelles; furthermore, they retained more granules than did normal platelets. From these morphological findings we speculated that these ultrastructurally abnormal platelets had an impaired release reaction as a result of the dysfunction of SCS in passing released substances, of the inability of microfilaments to constrict in expelling these substances and sometimes because of a lack of granules as the sources.


The role of the local health officer--why not a nurse? Examination of the role of the public health officer indicates that registered nurses with a master's degree in public health have, in many cases, more training and experience than physicians to function effectively in this role. It is suggested that, give the current physician shortage, the changes in scope of public health practices, and the use of other professionals capable of fulfilling the role, the selection of physicians as local health officers should be viewed as only one of several alternatives.


Breast cancer: a critical review of a patient sample with a ten-year follow-up. Records of 407 patients with primary breast cancer treated at the M.D. Anderson Hospital in 1958 and 1959 were reviewed with regard to patient characteristics, treatment, and results. These patients presented with relatively advanced disease (42% were inoperable on initial evaluation). Black and Chicano patients had significantly more advanced disease on admission than did white patients. Approximately 61% of patients received treatment appropriate to their clinical category indicating that multiple factors influence therapy selection. Absolute ten-year survival free of disease was 21%. Black and Chicano patients with early disease (categories 1 and 2) had significantly worse survival than did white patients. Problems with retrospective studies are multiple and limit the validity of conclusions. Randomized controlled studies are essential to answer critical questions.


Some marital-sexual concomitants of carcinoma of the cervix. The responses of 50 cervical cancer patients to questions about marital and sexual adjustment are discussed. The subjects were predominantly poor, white women from rural areas or small towns. They had to travel 50 to 150 miles to a hospital where half were treated by radiotherapy and half by surgery. Their interview responses suggest five phases in attitudes and feelings from the time of the diagnosis until six months after treatment. Of 30 subjects who had a sex partner available and who completed the third of four interviews, 70% had either as much or more desire for coitus after treatment than before illness, and 57% had coitus either as frequently or more frequently after treatment than before illness.


Experience with total hip replacement at Ochsner Clinic. Eighty-four patients had 97 total hip replacement procedures. Standard Müller components were used in the first 40 operations; the Aufranc-Turner acetabular component was used with the Müller-femoral component in the final 57 procedures. The trochanter was detached only in exceptional circumstances. Seventy-six patients with 87 replacements were followed up for 12 to 34 months. Complications, occasionally multiple, occurred in more than one third of our patients; thromboembolic disease was the most frequent. No significant wound complications occurred; there was no infection. In 71 replacements the results were excellent; in 15, good; and in 1 fair.


The sick sinus syndrome: treatment by permanent transvenous atrial pacing (a new approach). "Sick sinus syndrome" is characterized by alternating tachyarrhythmias and bradyarrhythmias, diverse origin, generalized conduction abnormalities, and symptoms of heart failure, systemic embolization, and syncope. Proper treatment requires demand atrial or ventricular pacing. A patient with this syndrome was treated with a new transvenous atrial electrode catheter which has successfully controlled her symptoms for 33 months with unrestricted physical activity and without further paroxysms of atrial arrhythmia.


Removal of nonmagnetic and magnetic intraocular foreign bodies with constant visualization. A method of removing intraocular foreign bodies, magnetic or nonmagnetic, that are invisible to ordinary viewing procedures is presented. Intraocular foreign bodies are associated with media which is opaque from the blood and debris of trauma. Early removal of nonmagnetic particles usually is impossible, while localization of magnetic foreign bodies changes with movement of the patient or the eyeball, causing wrong magnet application and additional intraocular damage. All of this is resolved by placing the inside of the eye on a "television screen" where the foreign body and the forceps are seen constantly in a two dimensional aspect, allowing removal of the object with minimal trauma.


Hammertoe surgery: waist resection of the proximal phalanx, a more simplified procedure. A technic for correcting hammertoe and other toe deformities by waist resection of the proximal phalanges of the toes effectively corrected these conditions in 95 patients and 466 toes. This procedure can be done quickly and easily with low morbidity. Through a very short incision over the waist of the proximal phalanx, a subperiosteal resection is carried out which permits settling of the resected bone ends together within the periosteal tube, resulting in bony union. The proximal phalanx is effectively shortened and the imbalance of the tendon length to the bony arch, which originally produced these deformities, is thereby corrected.


131-I rose bengal liver scanning in the differential diagnosis of neonatal jaundice. Results of a series of 2i liver scans with 131-I rose bengal in 21 patients who developed progressive jaundice in the neonatal period are described. Using the 131-I rose bengal scan alone, an attempt was made to separate the patients into two groups, the first with total bile obstruction (biliary atresia) and the second with only partial biliary tract obstruction (intrinsic liver disease). The diagnostic accuracy of the scan was 82%. An additional diagnostic criterion, the count radio, is suggested. The determination of this ratio requires no additional effort or expense and would improve the diagnostic accuracy of the scan used alone in this series of patients.


Goals and teaching methods of the urologic core curriculum at the University of Missouri, Columbia. Urology is a highly specialized surgical subspecialty, but most urologic patients present to the primary physician with variable signs and symptoms. As medical school educators, we are obligated to furnish the students with the knowledge and skills required to handle the patient's initial problem, and refer the patient to a urologic specialist at the optimal time. The Section of Urology, University of Missouri, Columbia, has developed a core urologic curriculum for junior and senior medical students. The goals and methods used to accomplish these goals are presented in conjunction with the goals for the Department of Surgery, University of Missouri, Columbia.


Practical approach to pediatric hearing problems. The identification and measurement of suspected hearing loss in pediatric patients presents a formidable challenge to the physician. Since he is responsible not only for determining the nature and extent of the hearing deficit, but also for overall management throughout the patient's learning life, an early and accurate diagnosis of the loss is mandatory.


Obstructive uropathy secondary to a false aneurysm in 12 years after abdominal aneurysmectomy. Long-tern follow-up of patients having abdominal aneurysmectomy and graft replacement will show that a considerable number develop false aneurysms at the anastomotic sites. This is the particularly true in situations in which silk suture was used for the vascular anastomoses. Successful management of this problem necessitates an awareness that unsuspected, asymptomatic ureteral obstruction can be a complicating factor. Preoperative work-up of all abdominal aortic problems should include an intravenous pyelogram. When evidence of ureteral obstruction is encountered, retrograde ureteral catheterization is important to precisely identify the point of obstruction and to aid in the ureterolysis at the time of operation. Inadvertent injury and contamination from an obstructed ureter is a situation which must be avoided when prosthetic grafting is anticipated.


Shunt surgery in Meniere's disease.

Shunt surgery in Meniere's disease. This is a clinical study of the results of endolymphatic sac shunt surgery for Meniere's disease in 28 patients. Postoperative audiometric results and clinical evaluation of vertigo and tinnitus were analyzed to determine the effectiveness of this form of treatment. Although this is a small study and the time interval since operation is of only moderate duration (6 to 46 months), the results are encouraging: 79% of the patients showed improvement or stabilization of hearing as well as control of vertigo.


Perforation of duodenal stump ten years after partial gastrectomy. Described is a patient who developed spontaneous perforation of the duodenal stump of a Billroth II anastomosis done ten years ago. This catastrophe is thought to have resulted from acute afferent-loop obstruction, a rare but recognized late postgastrectomy complication. The patient died of hemodialysis disequilibrium syndrome.


Spontaneous pyeloduodenal and renocolic fistulas. Twenty-seven previously reported cases of pyeloduodenal fistulas are reviewed and the first case of a simultaneously occurring pyeloduodenal and renocolic fistula is reported. Pyeloduodenal fistulas appear to result from an inflammatory process originating in the kidney, frequently are associated with calculi, and are best managed surgically with nephrectomy and closure of the fistula.


Arm ischemia due to fibromuscular hyperplasia of the axillary artery. A case of fibromuscular hyperplasia of the left axillary artery is reported. The lesion was bypassed using autogenous saphenous vein. At present writing, nine months after grafting, excellent pulses are present in the arm and the patient has been completely relieved of the ischemic symptoms.


Renocolic fistula.

Renocolic fistula. A case of left renocolic fistula secondary to chronic pyonephrosis has been reported. Neprectomy, excision of the fistulous tract, and closure of the colon is the treatment of choice. This was accomplished in this case with excellent results.


Retinal sparing in diabetic retinopathy. Asymmetrical involvement of the retinas in diabetic retinopathy is rare. The cause of this "sparing" of one retina is important in terms of the possibility of coexisting or superimposed ocular or vascular disease. Asymmetrical retinal involvement also reflects a pathophysiologic element in the progression of diabetic retinopathy, namely, the concept of net retinal vascular pressure as it affects the degree of observable retinal disease in diabetics. An illustrative case was presented, along with a review of similar cases reported in the literature.


Rupture of the gallbladder after blunt abdominal trauma. The diagnosis of traumatic injury of the gallbladder may only be discovered at the time of celiotomy. The patient initially may be asymptomatic; later, he may develop nausea, vomiting, or paralytic ileus. Hemoconcentration, leukocytosis, and biliurea all have been observed, but are inconstant findings. However, increasing abdominal distention without a change in hematocrit value, jaundice, dark urine, or acholic stools accompanied by a rising bilirubin level should aid in diagnosis. Although the treatment of traumatic rupture of the gallbladder may be altered to fit the clinical situation and degree of anatomic disruption, most authors agree that cholecystectomy is the method of choice.


Fertilization of the eggs of bivalve mollusks with different insemination conditions. Eggs of the bivalve mollusks Ostrea gigas, Spisula sachalinensis, and Mactra sulcataria taken from the ovary and placed in sea water are capable of maturation: the nuclear membrane dissolves and polar body I is released. The percentage of such spontaneously ripening eggs differs widely in different females and apparently characterizes the degree of roe maturity. The fertilization rate of roe containing a small percentage of spontaneously maturing eggs increases considerably during holding in sea water and remains at a high level for several hours. Maximum percentage fertilization can be obtained only over a narrow range of sperm concentrations in suspension for the species studied. A concentration of 10-6 or 10-7 sperm/cm-3 is usually optimum; a decrease or increase in sperm concentration by an order of magnitude (in comparison with the optimum level) reduces percentage fertilization. It was shown that sperm in suspensions with concentrations above the optimum level are activated to a lesser extent and their speed of movement is less than at high dilutions.


Distribution of neoblasts and mitoses during the asexual reproduction of the planarian Dugesia tigrina (Girard). The neoblast distribution in the prepharyngeal portion of the body remains unchanged during the asexual reproduction of planaria. During the first few days after fission, the number of neoblasts decreases in the portion of the body immediately adjoining the site of daughter zooid detachment and considerably increases in the regenerative bud. Starting with the fourth day after division, there is an increase in the number of neoblasts in the region of future fission, which can be regarded as one preparatory mechanism for the next fission. The mitosis distribution pattern is just the reverse: the regions of the body with the highest neoblast density are characterized by a low mitotic index or no dividing cells at all. The neoblast and mitosis distributions in the daughter zooid during its asexual reproduction cycle duplicate those observed in the maternal zooid.


Incorporation of labeled amino acids into proteins of the cell organelles of muscle tissue during the restoration of the regenerative capacity of the limbs of axolotl, suppressed by x-irradiation. The incorporation of labeled amino acids into the total proteins of muscle tissue and cell organelles during the regeneration of limbs of axolotls and after the suppression of the regenerative capacity by x-irradiation and its experimental restoration were investigated. In the case of suppression of the regenerative capacity of the limbs by x-irradiation, the protein synthesis in the muscle tissue is impaired. The intensity of the incorporation of labeled amino acids into the proteins of a homogenate of muscle tissue, nuclei, mitochondria, and the mitochondria-free fraction is reduced in comparison with normal regeneration. Under the influence of biopreparations (a salt extract from a homogenate of the rat gastrocnemius muscle), a restoration of protein synthesis, processes of differentiation, and the formation of regenerates was observed. C-14-lysine was incorporated most intensively into the proteins of the mitochondria-free fraction and nuclei at the spatula stage (exceeding this index in the series with irradiation of the limbs without treatment with the biopreparation by 5 and 7-fold, respectively).


Connection between the mitochondria and endoplasmic reticulum in oocytes of loach (Misgurnus fossilis L.). A considerable number of mitochondria (10-20 percent) are closely connected with the granular endoplasmic reticulum at the early stages of oogenesis in loach. The number of ribosomes on sections of the endoplasmic reticulum turned toward the mitochondria is considerably greater than on other sectors of the membranes. The work discusses the role played by contacts between the mitochondria and the granular endoplasmic reticulum in the biogenesis of oocyte mitochondria at the early stages of oogenesis.


The effect of the splotch gene on the parameters of the cell cycle in the brain and spinal cord of mouse embryos. The parameters of the cell cycle were determined in 10-day-old mouse embryos, homozygous for the splotch (Sp) gene, by the radioautographic method with H-3-thymidine. Normal embryos (+/+)with a similar genetic environment were used as the control. In the brain and spinal cord of Sp/Sp embryos the mitotic indices were more than twice as high as those in +/+ embryos. The rate of cell proliferation increased identically in both the dorsal and ventral parts of the neural tube. The generation time of the brain and spinal cord cells of Sp/Sp embryos was 8 h and that of normal embryos 9 h. The Sp gene decreased the duration of the S phase 1.5 h (25 percent). In addition, this gene increased the duration of the G(1) phase 0.5 h. The Sp gene evidently acts in the G(1) phase, as a result of which the duration of this phase increases while that of the S phase decreases considerably. This leads to an increase in the rate of cell proliferation and to the development of abnormalities of the CNS of homozygous embryos.


Incorporation of H-3-thymidine into mitochondrial DNA of quail oocytes and eggs. The amount of mitochondrial DNA and its synthesis were investigated in quail oocytes during the last 20 days of their growth. As the oocyte grows the amount of DNA in it increases rapidly, but at the end of oogenesis the increase in the amount of DNA lags considerably behind the rate of increase in the volume of the oocyte. As the oocyte grows the incorporation of H-3-thymidine into mitochondrial DNA decreases. The synthesis of mitochondrial DNA in cells of the quail embryo in early stages of development takes place at the same rate as the synthesis of nuclear DNA and far more rapidly than is more inhibited by ethidium bromide and mitomycin than the synthesis of nuclear DNA.


Change in myoglobin content in rabbit and chicken muscles in ontogenesis. The accumulation of myoglobin in the muscles was studied in the ontogenesis of rabbits and chickens. A connection was found between the myoglobin content and the degree of the functional load of the muscles in different age periods. Myoglobin appears first in the myocardium. In the femoral muscles of chick embryos myoglobin is first found on the 16th day of incubation. Myoglobin is not detected quantitatively in the masseter and femoral muscles of the rabbit during prenatal development. The myoglobin content is highest in the gizzard of a mature hen.


Presence of modified fibroblasts in ischemic contracture of the intrinsic musculature of the hand. Biopsies of fibrotic interosseous muscles were obtained from three patients with ischemic contracture of the intrinsic muscles of the hand. Control biopsies were taken from normal contralateral interossei and from normal interossei crushed three weeks earlier. Examination of the specimens from the affected muscles under the electron microscope demonstrated large numbers of modified fibroblasts with ultrastructural features of both fibroblasts and smooth muscle cells. The atypical fibroblasts observed resembled myofibroblasts seen in contracting wounds, Dupuytren's contracture, stenosing tenosynovitis, and idiopathic carpel tunnel syndrome. Biopsies from normal muscle and crushed normal muscle contained normal fibroblasts and smooth muscle cells but no modified fibroblasts. Active contraction of modified fibroblasts could be responsible for progressive muscle shortening seen in intrinsic contracture.


Surgical management of shotgun injuries of the face. The surgical reconstruction of patients with self-inflicted gun blast injuries to the face requires the most efficient management. There was a uniform pattern of tissue loss in the patients studied. The repair sequence was subjected to a retrospective analysis to indicate the most efficient co-ordination and return to a functional state. Emphasis must be upon the principle of initial salvage of as much bony structure as possible. Primary flap transfer or early mobilization of flaps for soft tissue repair are desirable in speeding restoration.


Transcervical thymectomy in myasthenia gravis. Since 1967, transcervical thymectomy has been the procedure of choice for all patients with nonthymomatous myasthenia gravis and a selected group of patients with thymomatous myasthenia gravis operated upon at the Mount Sinai Hospital. A total of 180 transcervical thymectomies have been performed. In 12 patients, a pre-existing tracheostomy was present. Morbidity was minimal, limited to three instances of bleeding, five of pneumothorax, one of self-limited chylothorax, and one wound infection. One postoperative death from an unrelated cause occurred in 1967. The postoperative course has been smoother and the management of the myasthenia gravis considerably easier than those following transthoracic approaches. Consequently, routine elective tracheostomy at the time of thymectomy has been abandoned. The average period of hospitalization does not exceed one week. As a result of the minimal risk involved, indications for thymectomy now include all patients with generalized myasthenia gravis, and the procedure is performed earlier in the course of disease. Postoperative electromyographic findings show immediate improvement in the majority of patients operated upon during the first year in which symptoms occur. Transcervical thymectomy arrests the progress of the disease, decreases the mortality rate, and has long term results equal to those of transthoracic approaches. Earlier remissions, fewer germinal centers, and a smaller number of thymomas were noted in patients operated upon early in the course of the disease. A decrease in neoplasms outside the thymus gland  and in neonatal myasthenia gravis was also noted following thymectomy.


Fiberoptic bronchoscopy following thermal injury. In a series of 25 burned patients, 15 had inhalation injury as evidenced by fiberbronchoscopic examination. The criteria for post-thermal pulmonary injury were airway edema and inflammation, mucosal necrosis and presence of soot and charring in the airways. This technique of direct visualization of the pulmonary tree can be performed easily, without complications, and provides an objective means for the early diagnosis of inhalation injury in burned patients and prompt institution of treatment.


Further experience with circle tube nephroureterostomy urinary diversion. Circle tube nephroureterostomy as an alternative method of urinary diversion has now been used in 80 patients, representing a wide variety of clinical problems. The technique offers several advantages over nephrostomy or intubated ureterostomy. Additional extensive experience with the procedure has substantiated the initially favorable impressions.


Acute vascular compression of the duodenum following cast application. It is suggested that only those patients in whom symptoms begin within two weeks after application of the cast should be included in the cast syndrome. Early diagnosis with prompt treatment in the form of replacement therapy and a nasogastric tube is important. Operation should be reserved for those patients in whom conservative treatment fails or the cast cannot be removed.


Oral glucose tolerance in patients with jaundice. A glucose tolerance test was performed on 21 patients with jaundice. The glucose tolerance patterns were principally classified into a parabolic pattern characterized by the return toward normal within 120 minutes and a linear pattern with long-standing increase for more than 120 minutes. Of these, 13 patients showed the parabolic pattern and tolerated the operation well. The other eight patients showed the linear pattern. Of the latter, four patients died within three weeks postoperatively, and the others died without leaving the hospital following operation. From the results, it was suggested that the parabolic glucose tolerance pattern is indicative of compensated damage to the liver, while the linear glucose tolerance pattern shows critically decreased hepatic functional reserve. Experimentally, the close relationship between the severity of the derangement of metabolism in the mitochondria of the liver and the degree of glucose intolerance was studied in rats and rabbits with jaundice subjected to the ligation of the common bile duct. In rats with jaundice in which the phosphorylative activity is significantly higher than that in the mitochondria from the tissues of the liver deprived of endogenous insulin through portal blood, the parabolic patterns develop. In rabbits with jaundice in which the phosphorylative activity is considerably lower than that in the mitochondria from tissues of the liver deprived of endogenous insulin, the linear pattern occurs. It was suggested that the two distinct patterns in patients with jaundice are closely related to the severity of the derangement of the phosphorylative activity of the mitochondria.


Arterialization of the liver in combination with a portacaval shunt in the dog. A dog preparation has been developed combining an end-to-side portacaval shunt with arterialization of the hepatic portion of the portal vein through an anastomosis between the inferior branch of the splenic artery and the stump of the portal vein. In this dog preparation, total hepatic blood flow, perfusion of the intrahepatic portal vein, and sinusoidal pressure remained within the preoperative range in the majority of the dogs. The data presented indicate that arterialization of the liver, under those conditions, resulted in no histologic damage or atrophy of the parenchyma of the liver and was effective in achieving significant prolongation of life and prevention of most of the adverse metabolic sequelae that follow a portacaval shunt in dogs. The indocyanine green extraction was restored to normal. The extraction of ammonia was impaired in all dogs with shunts; however, a significantly better ammonia extraction was seen in dogs with arterialization of the liver. It is being postulated that the dual perfusion of the liver through the hepatic artery and the portal vein is essential for the maintenance of the normal morphologic and functional states of the liver in dogs. The avoidance of hyperfusion of the sinusoidal bed with arterial blood is the most critical factor in preventing morphologic damage of the liver if arterialization of the portal vein is used.


The value of biliary endoscopy.

The value of biliary endoscopy. The value of biliary endoscopy was determined in 100 consecutive patients undergoing choledochotomy. Using a compact, rigid, right-angled choledochoscope with a rod-lens optical system the biliary tract was inspected for residual stomes following conventional exploration. Completion operative cholangiography and postoperative T-tube cholangiography were performed in all patients. Of 52 patients undergoing primary choledocholithotomy, the duct was cleared of all calculi in 51. A small residual stone was found by postoperative cholangiography in one patient. Exploration revealed no calculi in the ducts of the remaining 30 patients. Biliary endoscopy was of benefit to the surgeon in the majority of patients. In 17 patients, calculi missed by standard exploration were detected; in five of these, the calculi could be retrieved only under endoscopic control. In 11 patients, interpretation of operative cholangiograms was aided, while in three the endoscopic findings clarified operative strategy. The use of biliary endoscopy did not increase the postoperative morbidity or mortality rates beyond those oridinarily encountered in choledocholithotomy. Current experience indicates that the new choledhchoscope overcomes limitations of previous endoscopes and should serve as the definitive diagnostic tool for operative biliary endoscopy. The addition of this technique to the armamentarium of the biliary surgeon will play a significant role in overcoming the age-old problem of the retained common duct stone.


Nongenital pelvic tumors found at gynecologic operations. Sixty-nine nongenital pelvic tumors were foudn unexpectedly at gynecologic operations performed between 1960 and 1969, during which period 60,930 patients were examined in the gynecologic departments. The two largest groups of tumors were those of the colon, 18 instances, and retroperitoneum, 15.


The posterior approach to rectal anastomoses. The posterior approach to the rectum provides excellent exposure for benign lesions which are too high to be excised through the anus but too low to be excised transabdominally. As an adjunct to low anterior resection, it broadens the scope of the procedure without compromising the requirements of a proper operation for cancer.


Technique and results of fifty-five open renal biopsies in children. Amodification of the Hamburger technique of renal biopsy has been used to obtain 55 biopsies in 47 high risk children. The kidney is exposed through a vertical 2 to 3 centimeter incision just caudad from the 12th rib. The speciimen is taken with a biopsy-needle under direct vision. Specimens obtained nine to 93 glomeruli suitable for examination, and all were suitable for diagnosis. There were no significant complications, and all patients had recovered completely within 24 hours.


Comparison of two methods of postoperative pulmonary care. A new apparatus for postoperative pulmonary care was compared to one in common use. Vital capacity, a common clinical indicator of pulmonary status in the postoperative patient, was used as an index of improvement or deterioration. In patients using the device with increased dead space and expiratory pressure, there was a significantly greater increase in vital capacity than in those of the group who used blow bottles. Since increased vital capacity is indicative of improved pulmonary function, it is suggested that the use of the dead space-expiratory pressure device should result in a decreased incidence of postoperative pulmonary complications.


Pulmonary edema in patients with sepsis. Fifteen critically ill patients with sepsis, 12 of whom had significant pulmonary dysfunction develop, were investigated with regard to changes in pulmonary capillary pressure, in serum oncotic pressure and on roentgenograms of the chest. It could not be shown that the pulmonary edema, which is a major characteristic of the septic lung lesion, was due to changes only in oncotic and hydrostatic pressures. Nor was there evidence that increased capillary permeability was the sole explanation of the edema. A significant relationship was found which consisted of increasing severity of the lung lesion, decreasing serum oncotic pressure and increasing pulmonary pressure. When patients with sepsis require resuscitation with fluids, the administration of moderate amounts of albumin along with monitoring of pulmonary capillary pressure appears to be a rational approach to therapy.


Evidence of nonvagal neural stimulation of canine gastric acid secretion. In this study, we confirmed our original findings that central vagus stimulation is significantly associated with a subsequent increase in gastric mucus secretion. Central vagus stimulation following phenoxybenzamine hydrochloride administration was associated significantly with protracted elevations in secretory volume and titratable acid. We were unable to conclude that phenoxybenzamine itself in several pharmacologic dosages was associated with an increase in titratable acid. The acid secretory responses could be abolished by transection of the splanchnic nerves. Electrical stimulation of the peripheral part of the splanchnic nerve following administration of phenoxybenzamine was also associated with significant increases in secretory volume and titrable acidity. These secretory responses were not blocked by atropine but were diminished by burimamide. It is concluded that, in the dog, a largely heretofore unsuspected second neural pathway exists which is capable of influencing gastric acid secretion.


Acute cholecystitis.

Acute cholecystitis. The mortality rate for acute cholecystitis was 9.4 per cent. Those patients who underwent cholecystostomy had a mortality rate of 27.3 per cent, cholecystectomy 2.2 per cent, cholecystectomy and choledochotomy 7.4 per cent. Factors found to have an adverse effect on mortality in acute cholecystitis included sphincterotomy, perforation or gangrene of the gallbladder and cholagitis. Cholecystectomy is the operation of choice in acute cholecystitis in the absence of or history of jaundice or evidence of a common duct stone or cholangitis. Operative cholangiography and pressure and flow measurements through the cystic duct are advocated to avoid a retained common duct stone. Cholecystostomy should be reserved for the critically ill patient or a patient who deteriorates during operation, and it should be done only if the operator visualizes clear bile returning through the cystic duct.


Associated diagnoses which complicate rehabilitation of the patient with bilateral lower extremity amputations. Cardiopulmonary problems were the most common limiting factor in the rehabilitation of 42 bilateral lower limb amputees. Diabetes mellitus and local stump problems, most common in below knee amputees, delayed rehabilitation but, subsequently, obtained the highest goals. Thirty of the 42 amputees finally were self sufficient; the average time required was 30 weeks to maximum benefit.


The influences of changes in temperature on intestinal lymph flow and relationship to operations for carcinoma of the intestine. The effect of cooling, freezing and warming temperatures on the flow of lymph from the intestines was studied in dogs. When intestinal temperatures were dropped to an average of approximately 40 degrees F., an immediate decrease in lymph flow occurred to a mean value 33 per cent of control levels. With rewarming, lymph flow increased rapidly, rebounding to a level almost twice as great as that in controls. When the intestines were subjected to hypothermia to the point of freezing, lymph flow decreased immediately with flow rates dropping to only 6.6 per cent of control levels. Techniques for achieving freezing in these studies were inefficient, and uniform freezing was not always obtained. Again, with rewarming there was an immediate rise in lymph flow to levels significantly above those in controls. In hyperthermic studies to temperatures of 103 degrees F., a biphasic reaction was noted with an initial increase in lymph flow averaging 71 per cent higher than that in controls followed rapidly by a drop in lymph flow significantly below control levels. These experiments demonstrate that hypothermia, particularly below freezing temperatures, may rapidly decrease and virtually stop lymph flow from an intestinal segment. This suggests that hypothermia might be useful as an adjunctive measure in the operative management of patients with carcinomas of the gastrointestinal tract.


Use of peritoneal lavage in the diagnosis of experimental acute pancreatitis. Twenty-four dogs were divided into five groups. Under pentothal sodium anesthesia, those in the control group received no further manipulation; another group underwent laparotomy only; and dogs in the last three groups had induced pancreatitis, intestinal ischemia and duodenal perforation, respectively. An analysis was made of serum and peritoneal lavage fluid in the dog of each group at 30 minute intervals for four and one-half hours. Parameters which were significantly elevated in dogs with pancreatitis compared with other groups included fluid amylase, lactate dehydrogenase, proteolytic activity and intestinal alkaline phosphatase and serum amylase. We judge that these biochemical differences in the lavage fluid, when taken with the physical characteristics of the fluid and the clinical symptoms, can significantly aid the clinician in arriving at the diagnosis of acute pancreatitis.


Technetium bone scanning as an aid in the diagnosis of atypical acute osteomyelitis in children. Technetium bone scanning is a simple, safe and accurate method for the diagnosis of acute osteomyelitis in children whose presenting clinical findings are atypical of bone infection. Bone scanning was effective in the localization of the exact site of osteomyelitis, thus facilitating needle aspiration as well as subsequent surgical decompression. Tehcnetium bone scanning is a diagnostic technique for determining bone infection in children who are unable to communicate adequately or in those whose signs have been modified by previous inadequate antibacterial therapy.


Flow through the bile duct after cholecystectomy. The human bile duct has no intrinsic motility, but following cholecystectomy, flow through the bile duct is governed by the intraductal pressure generated by the liver, by the resistance to flow through the duct and sphincter at the terminal end of bile duct and by intraduodenal pressure. Pressure-flow experiments were performed upon 50 patients with biliary T-tube drainage following cholecystectomy and choledochostomy; nine patients had also undergone transduodenal sphincterotomy. Saline solution was introduced into the bile duct at controlled pressures, ranging from zero to 30 centimeters of water, while recordings were made of the flow rate of saline solution, intraduodenal pressure and respiratory movements. Although the flow rate of saline solution increased as its perfusion pressure was increased, three types of variation in flow were also recorded: rhythmic arrests of flow, occurring four to eight times per minute, believed to be due sphincteric contractions; nonrhythmic arrests of flow, lasting up to one minute, believed to be due to sphincteric contraction, and variations in flow associated with changes in intraduodenal pressure. The resistance to the flow of saline solution and the variations in flow rate were also similar in the patients who had undergone sphincterotomy. This study supports the view that sphincteric activity is present followingcholecystectomy, that the choledochal sphincter has rhythmic activity which differs from that of duodenal motility and that sphincter probably opens and closes continuously in a rhythmic manner during fasting periods in patients who have undergone cholecystectomy.


Quantitative morphologic assessment of immunoreactivity in regional lymph nodes of patients with carcinoma of the breast. The main quantitative problem in the pathologic evaluation of carcinoma of the breast is how to appraise host resistance. To study this in 107 patients with radically excised carcinoma of the breast, the axillary lymph nodes were weighed, the average sinus histiocytosis was estimated, and the plasma cells in the medullary cords were counted and expressed as a plasma cell index. The product of the lymphoid weight, the average sinus histiocytosis and the plasma cell index multiplied by 0.1 is called the hyperplasia index, which expresses quantitatively the cell mediated immunity and the humoral immunity in the axillary lymph nodes. The hyperplasia index was correlated with the metastatic tumor weight in the primary tumor with blood vessel invasion, lymphoid infiltration and volume of the tumor. There was a significant inverse relationship, p smaller than 0.001, between the hyperplasia index and the ratio of metastatic tumor weight to lymphoid weight. A significant direct relationship was found in the women with blood vessel invasion and low hyperplasia index values with increased metastatic tumor weight ratio to lymphoid weight, p smaller than 0.01. In patients without metastatic lymph nodes, there was a direct relationship between high hyperplasia indexes and lymphoid infiltration of the frank tumor, p smaller than 0.05. The hyperplasia index is considered a quantitative morphologic evaluation of the regional host defense reaction in the axillary lymph nodes, reflecting the antigenic strength of the tumor and the immune response to it.


Cystadenoma of the pancreas.

Cystadenoma of the pancreas. Five patients with cystadenoma of the pancreas were seen during a period of 22 years at this institute. This rare benign tumor occurred predominantly in middle age women, with the presenting symptoms of pain and an epigastric mass, but without a history suggestive of pancreatitis or abdominal trauma. Selective celiac and superior mesenteric antiography is helpful in establishing the diagnosis. If this cystic tumor is not recognized and adequately treated, the surgeon may miss the opportunity for cure. Cystadenoma should be suspected when a cystic mass arising from the body or tail of the pancreas is encountered without evidence of metastases. Although surgical extirpation is the preferable treatment, undue risks should not be undertaken because of the slow growth rate of this benign tumor. Due to the known association of this tumor with other malignant lesions, diabetes mellitus as well as multicystic tumors of the liver and kidneys, these patients should be thoroughtly investigated.


The effect of suture materials on healing wounds of the bladder. The healing pattern of bladder tissue and its response to various suture materials were studied and compared with data reported previously on skin, stomach and colon wounds. Tensile strength, biochemical data and histologic reactions were used as parameters of wound healing measurement. The healing pattern of urinary bladder wounds resembles that observed for stomach and colon. However, wounds of the urinary bladder wall regain strength equal to unwounded bladder wall within 21 days, whereas wounds of stomach and colon do not achieve more than 70 per cent of unwounded tissue strength after 120 days. The rate of collagen synthesis in bladder wounds reaches a peak at five days and returns to that of normal unwounded tissue by 70 days. Colon and stomach wounds, on the other hand, showed elevated rates of collagen synthesis even at 120 days. As with colon and stomach, absorbable sutures appear to lower the strength of both the wound and unwounded tissue. However, in stomach and colon this effect is only observed during the first 21 days of healing; in the bladder it persists throughout the 120 day observation period. No histologic evidence of smooth muscle regeneration was seen in bladder wounds. Noncollagenous protein synthesis was not increased in the wound, also suggesting smooth muscle regeneration does not occur. Silk and Mersilene sutures produced the greatest tissue reaction; if the sutures were exposed in the lumen of the bladder, stone formation was observed. This was not observed with monofilament polypropylene sutures. Plain catgut produced the least tissue reaction, but both plain aions comparable with chromic catgut but were regularly absorbed between 28 and 70 days. Since the bladder is well healed by 21 days, polyglactin-910 may be an ideal suture for use in the bladder.


Experience with detailed surveillance of nosocomial infection. Infection rates have been determined in a 332 bed university hospital using an efficient surveillance program. This computerized program analyzed, summarized and returned infection reports in six days. The efficiency rate of this system was 80 per cent as determined by prevalence survey. The mean nosocomial infection rate for the 12 month study period was 10.8 per cent. Neurology, medicine, neurosurgery, surgery and urology ahd the highest attack rates. Urinary tract infections composed 44 per cent of the total and predominated on seven of the 11 services. Escherichia coli predominated in infections of the urinary tract, surgical wounds and blood and ranked third in respiratory infections. Escherichia coli, klebsiella, pseudomonas and proteus mirabilis accounted for 61 per cent of the isolates. There is a need for efficient reporting of hospital infections to establish effective preventives.


Intraoperative demonstration of the mesenteric lymph channels. The mesenteric lymphatic channels are readily demonstrated at laparotomy by injecting methylene blue directly into the mesenteric lymph nodes. Flow through the lymphatic system can be augmented by temporarily compressing the superior mesenteric vein.


Technical details in the surgical correction of extrahepatic biliary atresia. As in any new operation, what appear to be minor variations in surgical methods may be crucial to the success or failure of the procedure. Extended biliary drainage has been achieved in infants with extrahepatic biliary atresia by adherence to the details of the surgical technique just described. To date, results appear to be better in those infants having the definitive operation at the time of the initial exploration. Consequently, it appears that surgeons undertaking operative exploration should be able to carry out the porticoenterostomy procedures.


The hemodynamics of portal hypertension revisited: determinants and significance of occluded portal pressures. We bring up to date our series of direct measurements of portal flow and pressure in patients with cirrhosis of the liver. In 153 patients the portal flow averaged 447 plus or minus 350 ml. Hg per minute and the portal pressure 28.5 plus or minus 4 mm. Hg (approximately 387 mm. H2O). Both quantities compare favorably with our previous measurements in smaller groups of patients. In 80 of our patients we had also measurements of pressure on the hepatic and splanchnic sides of a clamp occluding the portal vein. Nine of these patients had an hepatic occluded portal pressure higher than either or both the free portal pressure and the splanchnic occluded portal pressure. Of these nine patients with reversed pressure differences, two had stagnant portal flow and the remaining seven had forward flow into the liver measuring from 80 to 1,116 ml. Hg per minute.


Degradation of adenine nucleotides by the soleus muscle in hemorrhagic shock. Our previous studies have shown a salutary effect of adenosine triphosphate-magnesium chloride (ATP-MgCl2) administered to animals in shock. The presence of adenine nucleotide converting enzymes on cell surfaces and the ability of nucleotides to act at the cell surface have been recognized also. To investigate the fate of administered or externally applied ATP and to determine whether it would be subjected to increased degradation with shock, the soteus muscles from rats subjected to hemorrhagic shock and from control animals were incubated in the presence of ATP, adenosine diphosphate (ADP), or adenosine monophosphate (AMP) with MgCl2. Comparable degradation of the added nucleotides was observed with both control muscles and those from bled animals. Adenylate kinase activity was detected to the same extent in the medium after incubation with both groups of muscles, but other enzymes were not, suggesting that the latter enzymes were located on the exterior surface of the muscle cell. Thus with shock there was no increase in the breakdown of the nucleotides by the enzymes on the muscle surface (ATPase, AMPdeaminase) or the cellular enzyme, adenylate kinase.


Mortality rate following lower limb arterial embolectomy: causative factors. The series reported includes 85 patients who underwent arterial embolectomy for 101 embolic events. The over-all hospital mortality rate following embolectomy was 41 percent. The etiological factors for this high mortality rate are analyzed. The group includes 58 patients who had arteriosclerotic heart disease and 27 patients with rheumatic valvular disease. The mortality rate encountered in the arteriosclerotic group of patients was 52.9 percent, whereas that in the rheumatic group of patients was 18 percent. The major cause of death was cardiorespiratory failure (51 percent). Factors which weighed heavily on the final outcome were previous myocardial infarction, hypertension, diabetes, cardiac decompensation, and rhythm disturbances. Limb salvage was accomplished in 51 patients (60 percent). Amputation was performed in 17 patients (20 percent).


Fat and solid filtration in clinical perfusions. The purpose of this study was to define the fat filtration characteristics of a packed polyester wool filter when used alone in the cardiotomy suction (12 cases) and the arterial lines (10 cases) during clinical hemodilution, extracorporeal circulation. The pressure gradient-flow relationship and the efficiency of removal of fibrin microparticles were first ascertained in vitro. Total fat was extracted from the polyester wool with a Soxhlet device. Whole blood and plasma lipids were measured before and after bypass. The results showed a 23 mm. Hg pressure drop across a wool filter with a water flow rate of 5 L. per minute and a 40 to 52 percent efficiency for fibrin microparticles 15 to 250 mu. The total lipid extracted from the cardiotomy filters averaged 376 plus or minus 72 mg. compared with 512 plus or minus 95 mg. in the arterial line filters, although there was no statistically significant difference. Additionally 245 plus or minus 101 mg. of nonlipid material were extracted from the arterial line filters. The postperfusion whole blood contained a higher concentration of lipid than the preperfusion blood when corrected for dilution. It was concluded that significant quantities of solids, two thirds of which were fat, were removed by packed polyester wool filters during total body perfusions. Most of the fat was derived from the cardiotomy suction system. The amount of filtered fat and solids increased with perfusion time. These findings endorse the concept of cardiotomy filtration during extracorporeal circulation.


An attempt at forming an effective gastroesophageal mucosal valve. A technique for the prevention of esophageal reflux has been studied in dogs and successfully applied to two patients. It consists of stripping the distal 2 to 3 cm. of the esophagus of its musculature and then closing the muscular gap, thus infolding the mucosa of the denuded segment. Experimentally and clinically the mucosal valve thus formed has proved effective in preventing reflux without producing obstruction.


Jejunal absorption of bile salts after resection of the ileum. Malabsorption of bile salts plays a major role in the pathogenesis of diarrhea after resection of the ileum, but the diarrhea usually improves with the passage of time. To test the hypothesis that this improvement may occur as a result of increased absorptive capacity for bile salts in the jejunal remnant, everted sacs of jejunal remnants were prepared 3 months after ileectomy. The mean serosal to mucosal concentration ratio of taurocholate found in the experimental jejunal sacs was increased approximately 70 percent over the mean ratios of normal and sham-resected jejunal preparations (p smaller than 0.05). This change may be a manifestation of cellular adaptation in transport function, suggesting that the scope of intestinal adaptation in short gut syndrome goes beyond morphological hypertrophy and hyperplasia.


Patient selection and improved technical factors in small-vessel bypass procedures of the lower extremity. Thirty-two small-vessel bypasses were constructed as limb-salvage procedures. The one month patency rate was 72 percent and the one year cumulative patency rate was 55 percent. Preoperative, intraoperative, and postoperative angiography was performed in most cases and the results correlated with the ultimate fate of the graft. Preoperative angiography is critical in determining the location of a suitable small vessel, including the peroneal artery, and the quality of the runoff. Intraoperative angiography is required to delineate correctable intraoperative defects usually appearing at the distal anastomotic area. Additionally, failure to demonstrate runoff or a pedal arch can help support a decision not to re-explore a graft should early closure occur. Postoperative angiography is essential to validate clinical success with graft patency and function. It also serves to discover potential graft defects that might otherwise lead to closure and potential limb loss. Selected cases of failed small-vessel bypass grafts may be salvaged by thrombectomy with or without graft revision. Small-vessel bypass is generally contraindicated if there is extensive tissue necrosis and infection extending into the proximal foot. In cases where the necrotizing infection is localized, particularly to the forefoot, then open drainage, debridement, or amputation should be performed together with small-vessel bypass. Finally, the risks indigenous to small-vessel bypass procedures demand optimal patient selection and exquisite operative technique.


The effect of vagal stimulation on gastrin release and acid secretion. Canines with vagally innervated fundic pouches and chronic esophageal fistulas were subjected to sham feeding experiments during which pouch acid output and peripheral serum gastrin levels were measured. These dogs then underwent construction of vagally innervated antral pouches. The sham feeding experiments were repeated after recovery. Preoperatively sham feeding provoked a substantial increase in acid output accompanied by a small serum gastrin increase which did not achieve statistical significance. After creation of the innervated antral pouches, sham feeding evoked an acid secretory response similar to control values. Serum gastrins, however, increased nearly 500 percent in response to sham feeding. Our data support the concept that direct vagal stimulation of the parietal cell mass is the major mechanism by which sham feeding increased acid secretion.


Autogenous vein bypass grafts: biological effects of mechanical dilatation and adventitial stripping in dogs. To evaluate whether mechanical vein dilatation and stripping of adventitia at the time of harvest may adversely alter the long-term fate of autogenous vein grafts, dogs were subjected to reversed femoral vein interposition grafting with either normal veins, mechanically dilated veins, or adventitially stripped veins. Vein segments taken before grafting and veins exposed in situ but not grafted served as controls. Animals were killed at 3 months, and five vein segments in each category were evaluated for gross and microscopic changes. All grafts subjected to arterial interposition displayed marked neointimal proliferation and fibrosis of the media and adventitia. Notably, both dilated and stripped veins appeared to be similar and were indistinguishable from normal veins that had been subjected to arterial interposition for the same duration. Veins exposed in situ but not subjected to arterial flow remained essentially normal. Adverse alterations attributed to vein dilatation or adventitial stripping were not apparent and should not be invoked in the mechanism of graft failure at 3 months' duration.


Platelet response to regional and systemic shock. Hemorrhage in dogs to 30 mm. Hg did not produce platelet aggregation. Significant platelet aggregation was shown in stored blood delivered through the standard blood administration set, in the splanchnic circulation in endotoxic shock, and in the inferior vena cava following three hours of aortic cross-clamping. Pulmonary trapping of platelet aggregates could not be shown by serial screen filtration pressure measurements.


Extrathoracic axillary-iliac bypass substitution of a resected descending thoracic aorta. Resection of a dissecting aneurysm of the descending thoracic aorta (Type III) was accomplished in a uremic patient on hemodialysis with reconstruction of blood flow through extrathoracic bilateral axillary-subclavian-iliac Dacron grafts. Review of the literature revealed no similar operation reported before. Other potential uses for this operation, such as infected aortic grafts and resections of the arch and descending thoracic aorta in high-risk patients, are discussed. Despite complete rehabilitation of this patient 10 months after operation, the application of this procedure must await longer term follow-up. The operative procedure described thus far was applied only in one patient and should be considered only in special circumstances, as discussed.


Replacement of portal vein during pancreatectomy for carcinoma. Three patients are described in whom the portal vein, surrounded but not penetrated by pancreatic carcinoma, was resected and replaced by an expanded Teflon (Gore-Tex) tube. One patient, who has survived 32 months without recurrence of disease, had a radiographically patent graft at 2 and 17 months after operation. A second survivor has a patent graft at 8 months. The third patient died 10 days after operation with an open prosthesis. Excision of involved portal vein during pancreatoduodenectomy for carcinoma of the pancreas is justified in the absence of metastases. Vein grafting is the best means of portal vein reconstruction. Gore-Tex appears to be a suitable prosthesis when the portal vein must be sacrificed. Its clinical success in terms of patency substantiates previous experience in experimental animals.


Evaluation of palliative resection in advanced carcinoma of the stomach. A retrospective study of 140 patients with adenocarcinoma of the stomach seen at Roswell Park Memorial Institute during a 5 year period revealed that 112 patients were TNM Stages III or IV. A palliative resection of the stomach was done in 39 patients; the other 73 did not undergo resection. Patients who had palliative resection for stages III and IV carcinoma of the stomach had a prolonged mean survival rate, as compared with those with similar stage of disease who did not have palliative resection, regardless of an additional treatment such as feeding procedures, gastroenterostomy, chemotherapy, and radiation therapy. This significance was noticed regardless of age, sex, and histological differentiation of the tumor. Chemotherapy significantly increased the survival rate in the unresected group but failed to show this effect in the resected group.


Saphenous nerve entrapment simulating vascular disorder. Saphenous nerve entrapment may cause a painful syndrome simulating vascular disorder of the leg. The anatomical relationship of the saphenous nerve is described to explain the pathogenesis of the syndrome. The clinical features, diagnosis, and results of treatment of 32 patients are reported. The differential diagnosis of the syndrome is discussed. It is concluded that entrapment of the saphenous nerve should be considered when other known syndromes are unable to explain the symptomatology.