Cardiorenal effects of lidocaine and procaine amide in the conscious dog. Simultaneous measurements of hemodynamics, arterioventricular (AV) conduction, and renal functioner were obtained in conscious dogs. Catheters were implanted for the long-term measurement of central aortic, right ventricular, and pulmonary artery pressure. AV conduction was assessed following surgical implantation of multipolar electrode plaques in the area of the bundle of His, as well as on the epicardium of the right and left atria and ventricles. Renal function was assessed utilizing standard techniques. Following control measurements, lidocaine, 1 mg/kg, or procaine amide, 10 mg/kg, was administered intravenously. Subsequently, serial measurements were obtained for a 90-min period. No significant changes in hemodynamics were observed following either drug. Procaine amide produced a significant increase in heart rate and a minimal increase in QRS duration associated with a decrease in low right atrial to His bundle conduction time. However, no significant changes in cardiac conduction were observed after lidocaine administration. Renal function was unaffected by lidocaine but significantly depressed by procaine amide, as demonstrated by a decrease in GFR and effective renal flow. In summary, acute administration of procaine amide significantly alters renal function in the conscious dog with minimal effects on AV conduction and hemodynamics.


Neonatal changes in renal blood flow distribution in puppies. The intrarenal distribution of blood flow was studied in 31 newborn mongrel puppies from 18 h to 70 days using xenon washout and krypton autoradiography. Mean renal blood flow increased from 0.39 plus or minus 0.05 ml/g per min (SE) the 1st wk to 2.06 plus or minus 0.12 ml/g per min at 6 wk. During the 1st wk of life renal cortex was perfused homo-geneously at 0.88 plus or minus 0.19 ml/g per min (SE) and accounted for 35 plus or minus 4% of the renal blood flow. During the 2nd wk a narrow, rapidly perfused zone of outer cortex was identified which was perfused at 3.35 plus or minus 0.26 ml/g per min, received 19.53 plus or minus 5.05% of the total renal blood flow, and represented 15 plus or minus 4% of the mass of the total cortex. The inner cortex and outer medulla at this time received 53.40 plus or minus 4.12% of the flow at 1.07 plus or minus 0.08 ml/g per min. Outer cortical flow increased with age reaching adult values by about 6-10 wk when the rapidly perfused area represented 40 plus or minus 8% of the cortex. These changes are parallel to the results of previously reported studies with microspheres in newborn puppies and are compatible with the well established maturational changes noted in neonates of several species. They represent the first gas-washout studies in animals during the first 6 wk of life.


Myocardial performance during hemorrhagic shock in the pancreatectomized dog. Myocardial performance was evaluated in nine pancreatectomized and 12 nonpancreatectomized dogs by measuring left ventricular pressure (LVP), maximal dP/dt (max dP/dt), left ventricular end-diastolic pressure (LVEDP), pulmonary arterial pressure (PAP), aortic pressure (AoP), and lead II of the electrocardiogram during standardized hemorrhagic shock. Cardiac output (CO) and hematocrit were determined before hemorrhage, after 4 h of oligemia, when postinfusion mean blood pressure declined to 60 mmHg. Left ventricular function curves were obtained, by varying preload, in control dogs and 2 h after reinfusion of the shed blood in those dogs subjected to shock. Both groups of dogs showed identical responses to the shock procedure. In the immediate postinfusion period, LVP, max dP/dt, LVEDP, and mean blood pressure returned to near-control values, while PAP was significantly elevated. The postinfusion decline (after 60-90 min) in AoP was accompanied by a similar reduction in LVEDP. Left ventricular performance in hemorrhagic shock did not differ significantly from that seen in control dogs. In addition, there was no electrocardiographic indication of myocardial ischemia. The data indicate that terminal hemorrhagic shock need not be accompanied by myocardial depression whether or not the pancreas is intact.


Adenosine metabolism in cultured chick-embryo heart cells. Adenosine, a coronary vasodilator, in involved in the regulation of coronary blood flow, but the mechanism (s) of vasodilation especially with respect to the influence of dipyridamole and aminophylline are not clearly understood. Cultured cardiac cells of 16-day-old chick embryos were used as a model for the mammalian heart. Hypoxia produced a twofold increase in the production of adenosine and its metabolic products in this preparation, indicating that the source of adenosine in the hypoxic heart is the myocardial cell. Neither dipyridamole (1 times 10-minus 6M) nor aminophylline (1 times 10-minus 5M) blocked the release of adenosine from the myocardial cells, but dipyridamole aminophylline was without effect. These data suggest that dipyridamole exerts its vasodilator effect by blocking the uptake of adenosine into the cells, thereby increasing its extracellular levels and the concentration of adenosine in the vicinity of coronary resistance vessels. The mechanism whereby aminophylline attenuates the vasodilation produced by adenosine is not known. However, aminophylline does not interfere with the release or uptake of adenosine.


Prostaglandin F and E levels during endotoxin-induced pulmonary hypertension in calves. Prostaglandin F and E (PGF and PGE) concentrations in sequential blood samples obtained simultaneously from the pulmonary artery (PA) and pulmonary vein (PV) during endotoxin-induced pulmonary hypertension in calves were determined by radioimmunoassay. Three groups of calves were studied. In nine control calves in which no endotoxin was given PA pressure and PGF and PGE concentrations in four pairs of samples taken at 0, 5, 15, and 45 min did not change. In 17 calves given 1 mg E. coli endotoxin, PGF concentrations were increased significantly in the PV and to a lesser degree in the PA in the 15-and 45-min samples. The increased PGF concentration in the 15-min sample corresponded to an increased PA pressure of 74 plus or minus 4 mmHg (mean plus or minus SE). In three of the endotoxin-treated calves studied a second time and three separate calves indomethacin pretreatment completely blocked the hemodynamic effect of endotoxin as well as PGF release. PGE concentrations did not change in either group. These data suggest that endotoxin-induced pulmonary hypertension may be mediated by PGF, a known pulmonary pressor agent in the bovine, and that blockade of this effect by indomethacin may be due to inhibition of prostaglandin synthesis and/or release.


Phrenic and recurrent laryngeal discharge patterns and the Hering-Breuer reflex. In decerebrate, spontaneously breathing cats, whole-nerve recordings of efferent phrenic (Phr) and recurrent laryngeal (Lar) discharge were analyzed with an average-response computer. The Phr inspiratory (I) burst starts abruptly and has an augmenting discharge pattern which reaches a maximum at the end of the I phase. The Lar I burst starts before onset of the Phr burst (median delay 40ms), reaches an approximately constant level till the end of the I phase. These differences are functionally appropriate for the differing respiratory roles of the innervated muscles (diaphragm and glottis dilators). The Hering-Breuer reflex, produced by occulsion at minimum lung volume (start of the I phase), lengthens the I phase and disinhibits I discarge, but differently for Lar and for Phr activity. Lar activity was increased almost from the start of the I phase. In contrast, occlusion produced no change in the Phr augmenting pattern (slope of activity increase) for most or all of the I phase, indicating that normally vagal inhibitory input shuts off Phr activity in a trigger-like manner.


Localization of thirst and antidiuretic osmoreceptors by intracranial injections in rats. Eighty-six intracranial cannula placements in 51 rats were tested with unilateral, 2-mul injections of a 0.60-osmol/kg solution, sucrose dissolved in isotonic sodium chloride. To assess antidiuretic hormone (ADH) release, a water diuresis was induced and spontaneous urinations were collected and analyzed for sodium by flame photometry. On alternate test days the 0.60-osmol/kg solution was injected into sleeping rats, and latencies to drink and volume drunk were recorded. Injections at 42 placements elicited neither drinking nor adtidiuresis on two separate test days each; at 15, both antidiuresis and drinking on at least two of three tests each; at 19, drinking but not antidiuresis; at 10, antidiuresis but not drinking. Positive drinking and ADH placements were not distinctly separated. They clustered in the bed nucleus of the stria terminalis, the preoptic areas, and the anterior portions of the hypothalamus. Placements in the medial forebrain bundle and dorsal to the anterior hypothalamic area elicited thirst but not ADH release for the most part. Placements nearest the supraoptic nucleus were weak or negative for ADH release. Central nervous system osmo-receptors exist and seem not to be the neurosecretorycells. Thirst osmoreceptors and antidiuretic osmoreceptors seem to be contiguous, but distinct.


Myo-inositol transport in the central nervous system. Free myo-inositol (inositol) transport into the cerebrospinal fluid (CSF), brain, and choroid plexus and out of the cerebrospinal fluid was measured in rabbits. In vivo, inositol transport from blood into choroid plexus, CSF, and brain was saturable with an apparent affinity constant (K-t) of approximately 0.1 mM. The relative turnover of free inositol in choroid plexus (16 percent/h) was higher than in CSF 4percent/h) and brain (0.3percent/h) when meausred by tissue penetration of tracer [3-H]-labeled inositol injected into blood. However, the passage of tracer inositol was not greater than the passage of mannitol into brain when measured 15 s after a rapid injection of inositol and mannitol into the left common carotid artery. From the CSF, the clearance of inositol relative to inulin was saturable after the intraventricular injection of various concentrations of inositol and inulin. Moreover, a portion of the inositol cleared from the CSF entered brain by a saturable mechanism. In vitro, choroid plexuses, isolated from rabbits and incubated in artificial CSF, accumulated [3-H-labeled myo-inositol against a concentration gradient by a specific, active, saturable process with a K-t of 0.2 mM inositol. These results were interpreted as showing that the entry of inositol into the central nervous system from blood is regulated by a saturable transport system, and that the locus of this system may be, in part, in the choroid plexus.


Shivering and nonshivering thermogenic responses of cold-exposed rats to hypothalamic warming. The concurrent neural control of two thermoregulatory responses, shivering thermogenesis (ST) and nonshivering thermogenesis (NST), was investigated in chronically implanted cold-exposed rats. The effects of heating the preoptic/anterior hypothalamus (POAH) on shivering and on the rate of oxygen consumption (Vo2) were measured in these unanesthetized animals. With ambient temperature maintained constant (at some value between 10 and 16 degrees C), warming the hypothalamus 2-3 degrees C resulted in a significant decrease in Vo2 (Psmaller than 0.001) and an increase in shivering (Psmaller than .01), these responses being reversed on cessation of hypothalamic warming. These results are consistent with the proposal that, in the cold-exposed animal, elevated POAH temperatures directly inhibit NST even though shivering may increase (possibly as a compensation for the decrease in nonshivering heat production). They also rule out the possibility that, in the rat, signals from cutaneous and hypothalamic thermoreceptors are integrated in an indentical manner by the neural controllers for ST and NST.


Rapid effects of insulin on uridine metabolism in mammary gland explants. A study was made of the early actions of insulin on uridine metabolism in mammary glang explants. A stimulation of both labeled uridine uptake and its incorporation into RNA was demonstrated as early as 15 min after addition of insulin to medium bathing the tissue; these effects persisted for several hours. The metabolic fate of [3-H] uridine to UMP, UDP, and UTP was observed, whereas insulin had no effect on the quantity of 3-H present as uridine or uracil in these tissues. Further studies were performed in which insulin was also shown to have a rapid stimulatory effect on the incorporation of [32-P] phosphate into RNA; however, the uptake of the labeled phosphate was not affected by insulin. Experiments were also carried out to determine whether  the effects of insulin on labeled uridine uptake require ongoing RNA and protein synthesis and whether uridine incorporation depends on concomitant protein synthesis. Incubation of explants with antibiotics which inhibit protein synthesis resulted in the complete suppression of the effects of insulin on labeled uridine uptake and its  incorporation into RNA. In contrast, the effect of insulin on labeled uridine uptake does not appear to require ongoing RNA synthesis, since this effect persisted when RNA synthesis was significantly reduced by the presence of actinomycin D.


Modulation of carotid sinus baroreceptor reflex by sciatic nerve stimulation. In anethetized, immobilized, and vagotomized cats we analyzed the effect of sciatic nerve stimulation (SNS) on the relationships between intrasinus pressure (ISP) and arterial pressure (AP) and between ISP and heart rate (HR). At each of seven ISP levels between 60 and 240 mmHg, AP and HR before and 20 s after the onset of SNS were plotted against ISP to obtain the ISP-AP and ISP-HR relationships before and during SNA. SNA caused increases in AP, HR, and total peripheral resistance (TPR) and a decrease in cardiac output (CO). SNS raised the equilibrium pressure (the value of AP at which AP equaled ISP), but it significantly (P smaller than 0.005) decreased the slope (or gain) of the ISP-AP relationship at ISP's between 90 and 150 mmHg. SNS also significantly (P smaller than 0.05) diminished the gain of ISP-HR relationship at ISP's between 120 and 210 mmHg. Modulation of the gain of ISP-AP relationship was ascribable to that of CO but not of TPR. We conclude that in vagotomized cats 1) SNS attenuates the sensitivity of AP and HR responses in the carotid sinus baroreceptor reflex, and 2) the inhibition of the reflex AP response was caused by modulation of the reflex CO response.


Effect of prolactin on lipoprotein lipase in crop sac and adipose tissue of pigeons. The effect of prolactin on lipoprotein lipase activity of crop sac, omental adipose tissue, and esophagus was studied in adult female pigeons. Prolactin injected for 4 days, 1 mg/day, increased lipoprotein lipase activity from 17 to 177 U/g in crop sac and from 68 to 118 U/g in adipose tissue, but had no effect on the activity in esophagus, 4 U/g. (10 = 1 mumol of chylomicron triglyceride hydrolyzed to free fatty acid and glycerol per hour.? Prolactin increased the weight of crop sac from 1.4 to 7.2 G. The effect of prolactin on lipoprotein lipase activity and weight of crop sac occurred mostly during the 3rd and 4th days of treatment, whereas the effect on the activity of adipose tissue occurred later, during the 4th day of treatment. Crop "milk" collected from pigeons injected with 2 mg of prolactin daily for 4 days contained a small amount of lipoprotein lipase activity, 12 U/g, is smaller than 10% of that found in crop sac. The finding of markedly increased lipoprotein lipase activity in crop sac of prolactin-treated pigeons suggests that blood triglyceride may be used by crop sac for the formation of crop milk lipid.


Magnesium effects in rabbit ventricle.

Magnesium effects in rabbit ventricle. Ten to twenty millimoles per liter Mg did not affect 42-K exchange in control isolated blood-perfused rabbit septa, but abolished acetyl strophanthidin (ACS)-induced net 42-K loss (constant heart rate) without attenuating the mechanical response. In six septa ACS-induced net K loss was reduced from 159.3 plus or minus 45 to 43.5 plus or minus 35 mumol/kg tissue water (P smaller than 0.05) by increasing Mg from 1.0 to 20 mM without a change in inotropic response. Ten to twenty millimoles per liter Mg did not reverse ACS inhibition of 42-K5 tissue uptake. In eight septa 16 mM K doubled the efflux rate for 42-K in 1mM Mg. Twenty millimoles per liter Mg abolished this effect. Sixteen millimoles per liter K increase 42-K effluent counts by 99.5 plus or minus 18.5 percent of control in 1.0 mM Mg, but by 44.9 plus or minus 14.1 percent (P smaller than 0.001) in 20 mM Mg. Mg inhibited 42-K exchange at sites that became rate limiting after ACS treatment. These sites were activated by 16mM K. ACS inotrophy was not quantitatively related to net K loss. The Mg effect during digitalis exposure did not result from reversal of ACS inhibition of NA-K-ATPase activity but from a separate effect on K efflux.


Effect of angiotensin II and an angiotensin II inhibitor on renin secretion in the dog. This study examined the effect of angiotensin II (AII) and (Sar-1Gly-8) AII, a competitive inhibitor of AII, on renin release in anesthetized dogs. An intravenous infusion of AII (25 ng/kg per min) raised BP 24 mmHg and lowered plasma renin activity (PRA) from 18.8 plus or minus 2.8 to 6.2 plus or minus 1. 3 ng/ml per h (P smaller than .001). When the intravenous infusion of AII inhibitor (1.0 mug/kg per min) was superimposed on the AII infusion, PRA rose from 6.5 plus or minus 22 to 12.3 plus or minus 3.6 ng/ml per h (P smaller than .02). Renal hemodynamics, BP, and urinary sodium excretion (UNaV) reverted toward pre-AII control values. A small dose of AII inhibitor (0.1 mu/kg per min) was then infused into one renal artery in animals receiving the constant intravenous infusion of AII. Renin secretion rate (RSR) increased significantly, not only in the infused kidney, but also in the contralateral kidney. In the latter there were no changes in renal hemodynamics or UNaV, and RSR was unimpaired by denervation of that kidney. The results suggest that the AII inhibitor blocks both the vascular and the renin-suppressing actions of AII and that the latter effect is more susceptible to inhibition.


Heart rate response to sympathetic stimulation before and after sodium pentobarbital. Heart rate response to electrical stimulation of the right stellate ganglion of vagotomized cats was studied before and after the administration of sodium pentobarbital. The increase and decrease of heart rate with the initiation and cessation of sympathetic stimulation  could be accurately described by separate exponential time functions. The time constants of rise and decline, the maximum steady-state heart rate, and the time between cessation of stimulation and initial decrease of heart rate (lag) were functions of the frequency and voltage of stimulation. The main effects of sodium pentobarbital were: 1) to prolong the rise of heart rate by 20-30 percent (P smaller than 0.0001),2) to prolong the decay of heart rate by 36-56 percent (P smaller than 0.005), and 3) to decrease the resting heart rate. The effects were observed 10 min after administration of the drug and lasted at least 4 h.


Fibrinogen levels after inflammation or endotoxin in normal and hypophysectomized rats. The hypothesis that pituitary hormones are required for increased fibrinogen synthesis after inflammation or endotoxin was tested by measuring plasma fibrinogen concentrations after inflammation or endotoxin in normal and hypophysectomized rats. Animals were divide into groups receiving no exogenous adrenal steroids, low-dose adrenal steroids, or high-dose adrenal steroids. Hypophysectomy failed to prevent fibrinogen levels from rising after intramuscular turpentine (mean 240 mg/100 ml prior to and 556 mg/100 ml 24 h after turpentine). Steroids did not suppress this rise. Endotoxin, 5 mug/100 g, caused a marked rise in fibrinogen in normal rats at 24 h (mean 296 mg/100 ml before endotoxin and 554 mg/100 ml after endotoxin). This dose of endotoxin killed hypophysectomized rats within 12 h. Hoevr, if hypophysectomized rats were protected with high-dose adrenal steroids, then 5 mug of endotoxin per 100 g caused the same fibrinogen rise as in normal rats (mean 299 mg/100 ml before endotoxin and 587 mg/100 ml after endotoxin). Aparently, pituitary hormones are not necessay for increased fibrinogen synthesis after either inflammation or endotoxin in the rat.


Effect of infusion of insulin into portal vein on hepatic extraction of insulin in anesthetized dogs. Hepatic extraction of insulin was examined in anesthetized dogs before and after constant infusion of insulin (20 and 50 mU/min) with use of samples from the portal vein, mesenteric vein, left common hepatic vein, and the femoral artery. In 19 dogs, measurement of portal vein insulin concentration indicated an overall recovery of 110% of the insulin infused. The range varied from 9 to 303%, indicating the potential for serious error in sampling the portal vein. Equilibrium arterial insulin concentrations were achieved 20 min after starting the infusion. Prior to insulin infusion, hepatic extraction of insulin averaged 4.56 plus or minus 0.43 mUmin, representing an extraction coefficient of 0.42 of the insulin presented to the liver. The proportion of insulin extracted by the liver did not change significantly during insulin infusion despite a 10-fold increase in portal vein insulin concentrations. During the infusion of insulin, a significant proportion of the extraheptic clearance of insulin occurred in the mesenteric circulation. Infusion of insulin was associated with a significant increase in insulin extraction by tissues other than the liver and splanchnic beds. Initially, hepatic glucose output average 36 plus or minus 3 mg/min; by 20 min after insulin infusion, it was 16 plus or minus 5 mg/min. Despite continuation of insulin infusion, hepatic glucose output returned to control values even though arterial glucose concentration continued to fall. Hepatic glucose output increased with termination of insulin infusion.


Micropuncture study of uric acid transport in rat kidney. Free-flow micropuncture studies were perfromed to evaluated uric acid transport in the rat kidney. In all studies (a-minus 14C) uric acid and (methoxy-3H) inulin wereadministered. A simple two-step, column-chromatographic technique was utilized to separate (2-minus 14C) uric acid from its labeled oxidation product in plasma, urine, and tubular fluid. Tubular fluid collections were obtained from the early-and late-proximal tubule under control conditions and during subsequent volume expansion induced with 0.9 per-cent sodium chloride. These studies indicate bidirectional, possible active, uric acidtransport in the proximal tubule undr control conditions, with net reabsorption evident early and net decretion apparent late in this nephron segment. In association with volumeexpansion net uric acid reabsorption and secretion both decreased. No significant nettransport was evident beyond the accessible portion of the late-proximal tubule in either experimental state.


Magnesium-neurohypophyseal hormone interactions in contraction of vascular smooth muscle. The contractile responses of helically cut rat aortic strips to neurohypophyseal hormones and synthetic analogues in the presence and absence of 1.2 mM external magnesium ions [Mg++]o was studied. These experiments demonstrate that 1) [Mg++]o potentiates the contractile actions of a variety of neurohypophyseal peptides on vascular smooth muscle. 2) [Mg++]o can alter both the ED50s (i.e., hormone-receptor affinities) and intrinsic activities (or maximum contractile responses) of these molecules on vascular muscle. 3) The amino acid moieties in positions 1, 2, 3, and 8 of the vasopressin molecule interact, differentially, with [Mg++] to produce contraction of vascular muscle. 4) The length of the side chain, and basicity, in position 8 of the vasopressin molecule are probably important in Mg potentiation in mammalian vascular muscle. 5) Interaction of Mg with an aromatic group in position 3 might be critical for potency of vasopressin hormones of mammalian vascular muscle; the ED50 for oxytocin is not shifted to lower concentrations in the presence of [Mg++]o. Collectively, these data suggest that Mg probably acts at more than one site in vascular smooth muscle in the production of neurohypophyseal peptide-activated contractions. In addition, the present findings indicate that the Mg dependence of these peptides on at least one vascular muscle, rat aorta, is a direct function of the rat pressor potency of the molecules.


Local ventricular repolarization changes due to sympathetic nerve-branch stimulation. Functional distributions of individual cardiac nerves distal to the stellate ganglia were determined in 30 open-chest, anesthetized dogs by mapping sites of refractory-period shortening during stimulation of the nerves. On the right, recurrent cardiac nerve stimulation produced marked shortening of refractory periods in the interventricular septum, and lesser changes on the anterior heart surface. On the left, ventromedial cardiac nerve stimulation shortened refractory periods in a similar distribution, but changes were not marked as with the recurrent cardiac nerve. The other left-side nerve that produced repolarization changes, the ventrolateral cardiac nerve, produced marked refractory-period changes on the posterior heart surface. Its distribution showed little overlap with that of the ventromedial or recurrent cardiac nerves. T waves inverted in an electrocardiographic Y lead during recurrent cardiac and ventromedial cardiac nerve stimulation, while ventrolateral cardiac nerve stimulation increased the positivity of T waves in that lead. The cardiac distributions of individual nerves documented in this study provide an anatomical basis for localized alterations in ventricular electrophysiologic properties.


HMOs and health education.

HMOs and health education. HMOs, by their stated purpose and nature, have a necessary and central involvement with health education. The specific characteristics of any HMO determine the extent and quality of health education. An HMO has the responsibility to identify its educational objectives, as well as the educational components of any of its other objectives. The more professional the educational guidance, the better it is integrated into the organization, and the greater its financial and administrative support, the more likely will be the success in achieving objectives. In brief, every HMO has the need and potential for a health education effort. The extent and quality of that effort will reflect the mix of administrative philosophy, organizational characteristics, the degree to which professional educators are involved, and the amount and stability of financial support.


Parental failure and consequences for children. The drug-abusing mother whose children are in foster care. The developmental progress of children of drug-abusing mothers was assessed in a study of foster children. Cognitive abilities and personal adjustment appeared to be normal but significantly poorer school adjustment patterns were observed. Such children are disproportionately locked into foster care.


Radiological practice in Hiroshima and Nagasaki: trents from 1964 to 1970. Use of X-ray in Hiroshima and Nagasaki from 1964 to 1970 was assessed according to numbers of films consumed, and the radiographic, fluoroscopic, and photofluorographic examinations performed. Except for chest photofluorography, a steady increase in the use of medical X-ray since Workd War II is demonstrated.


Pulmonary embolism associated with surgically proved deep venous thrombosis. In a prospective study, thrombosis of the femoral or popoliteal veins was discovered at operation in nine of eighty-one patients requiring amputation of a lower extremity for arterial insufficiency. One week postoperatively, all nine patients had evidence of pulmonary embolism on the lung scan. Embolization was documented by arteriography in two patients and at autopsy in a third patient. In none of these patients was there clinical evidence of venous thrombosis prior to operation. Two of the subjects with proved thrombosis died during study, a mortality of 22 percent, whereas the mortality for the entire group was 10 percent. It is concluded that the deep venous system of patients requiring amputation for ischemia should be examined carefully at operation. These patients have a high incidence of deep venous thrombosis and the discovery of thrombus at the time of operation places them in a particularly high risk group.


Surgical management of 100 consecutive abdominal aortic aneurysms. One hundred consecutive elective abdominal aortic aneurysmorrhaphies were performed at Walter Reed Army Medical Center from 1966 to 1973. The overall hospital mortality was 3 percent. There were no operative deaths in patients with aneurysms smaller than 9 cm. In view of our favorable overall statistics, we recommend elective abdominal aortic aneurysmorrhaphy in all cases unless there is severe associated cardiac and pulmonary disease. Preoperative carotid endarterectomy is recommended for symptomatic cerebrovascular insufficiency or for asymptomatic carotid brutis and/or hemodynamically significant carotid stenosis. When necessary, associatedgastrointestinal procedures can be accomplished without increased risk of infections.


Glucose intolerance after massive liver resection in man and other mammals. The relationship between changes in glucose tolerance and in mitochondrial phosphorylative activity was studied after massive liver resection. In rabbits twenty-four hours after hepatectomy, when the phosphorylative activity in the mitochondria of the remnant liver was enhanced maximally, the blood glucose level did not increase significantly after glucose administration. Forty-eight hours after hepatectomy, when the phosphorylative activity decreased to a submaximal level, the blood glucose level increased gradually but without a return toward normal. About six weeks after partial hepatectomy, mitochondrial function returned gradually to normal levels and the glucose tolerance test results returned to within normal limits. Considering the previous report that an enhancement of mitochondrial phosphorylative activity is required for a later increase in nuclear DNA synthesis, it was suggested that the plateau pattern, with hypoglycemia, and the gradual increase, with a prolonged return toward normal, in the glucose tolerance test are indicative or marked enhancement of mitochondrial phosphorylative activity preceding an increase in nuclear DNA synthesis. The changes in the glucose tolerance test results in hepatectomized rabbits also were observed in rats and in man; however, they were more rapid in rats and slower in man. From these results it was suggested that the glucose tolerance test is very useful in the evaluation of the stage of regeneration in the liver remnant after massive liver resection.


Primary hyperparathyroidism in children. Three cases of primary hyperparathyroidism in children are presented and the literature reviewed. Symptoms of nausea, weight loss, and personality changes are more common in children than in adults with this disease. Children may have the diagnosis delayed because of failure to consider hyperparathyroidism. Surgery has been demonstrated to be most effective in treating this condition.


The thyroid nodule. View from the community hospital. Most operative procedures, including those on the thyroid, are performed in community hospitals but reported on from large medical centers. For comparison, therefore, 651 patients who underwent operation for nodular goiter in a community hospital over a twenty-one year period are analyzed. The incidence of carcinoma in patients undergoing operation for nodular goiter increased from 8.7 per cent in the early years to 20.4 per cent in the past four years. The value of frozen section study and thyroid scanning is documented.


Immunologic reactions after experimental cryosurgery to the reproductive system of the male rabbit. I. The humoral response. Single cryoinjuries to the accessory reproductive organs and to the gonads of normal adult male rabbits elicit antibody responses in 35.8 and 11.9 per cent of the cases, respectively. The antibodies display agglutinating and precipitating properties against extracts of the organ that underwent the freezing injury, but do not react in the presence of extracts of other organs of the rabbit. Repeated cryoinjuries raise both the percentage of reacting animals (up to 100 per cent after four successive cryostimulations, in some cases) and the titer of the humoral responses, which, in addition, endure longer in blood than do responses to single stimuli. These humoral phenomena are the expression of immunologic reactions mounted by the host animals against "self" components, regarded, however, as "nonself" by their surveillance apparatus.


Gallstone ileus. Review of the literature and presentation of thirty-four new cases. An analysis of thirty-four patients with gallstone ileus is integrated with a review of the literature on the subject. Surgical treatment was carried out in thirty-two patients, with an overall operative mortality of 19 per cent. Three patients were treated by one stage enterolithotomy, fistula repair, and cholecystectomy without operative mortality, emphasizing the merit of one stage treatment in selected, well prepared patients. A 6 per cent incidence of carcinoma of the gallbladder was noted in this series of patients.


Recurrent inguinal hernia. Follow-up study of 100 postoperative patients. This review of recurrent inguinal hernia evaluates the possible causes of recurrence and the most effective operative procedures for successful repair. Emphasis is placed upon precise dissection technic so that whatever fascia is available after the primary operation may be utilized for the subsequent repair. A detailed study is devoted to the histologic features of fascia, emphasizing its lack of vascularization as the possible reason for its strength and permanency throughout life. In operations for recurrent inguinal hernia, rectus sheath pedunculated grafts should be used more frequently, and in extreme cases cord excision may be required. A follow-up study of one hundred postoperative cases, with a failure rate of 7 per cent, is presented.


Surgery of left paraduodenal hernia.

Surgery of left paraduodenal hernia. The clinical presentation, embryologic and etiologic factors, and repair of left paraduodenal hernia are presented. A new operative procedure for cure of left paraduodenal hernia is presented that deals effectively with the sac and predisposing arch containing the inferior mesenteric vein without section of the vein. Repair is based upon the embryologically normal anatomy with restoration of the inferior mesenteric vein to its normal retroperitoneal position. This procedure has been successfully utilized in a case in which the paraduodenal hernia of small bowel was encountered concomitantly with a perforated duodenal ulcer.


Strangulated diaphragmatic hernia. A clinical study. Symptoms, signs, and definitions of strangulation and incarceration in diaphragmatic herniation are surveyed, and four patients with strangulated diaphragmatic hernia are reported on. Although the symptoms may be uncharacteristic, the diagnosis is easily made, if kept in mind. X-ray examination of the chest, possibly supplemented by a barium meal, usually indicates the diagnosis. The mortality rate in our series was high, similar to the findings in other series in the literature. Since approximately half of the cases of incarcerated and/or strangulated diaphragmatic hernia are due to overlooked traumatic diaphragmatic rupture, we stress the importance of diagnosing and treating such rupture promptly to reduce the mortality rate. Strangulated diaphragmatic hernia is a clinical entity on the borderline between the fields of thoracic and general surgery. The disorder is often overlooked or improperly treated, possibly because most units have limited experience with this particular phenomenon.


Acute prolonged renal arterial infarction. Return of function after thromboendarterectomy. This report describes a case of complete occlusion of the right renal artery. Arteriography and intravenous pyelography demonstrated no kidney function. The occlusion was treated by endarterectomy, and eleven days later another intravenous pyelogram revealed that renal function had been restored. A review of the literature also suggests that acute occlusion (caused by embolism) or chronic occlusion (caused by atherosclerosis) should be treated surgically to perserve renal function, reserving nephrectomy only if that should fail.


Shortened small bowel syndrome. Mackby's operation. Intestinal infarction is a condition with a high rate of mortality. Progress in the fields of anesthesia, maintenance of electrolyte balance, and intensive postoperative care has made survival possible in a number of patients subjected to extensive resection of the small intestine. Many of these patients, however, later succumb to the effects of malabsorption. In this paper we report on a patient who has undergone massive intestinal resection, because of venous intestinal infarction, and Mackby's operation, with favorable results twelve months postoperatively.


Fournier's syndrome: synergistic gangrene of the scrotum. Progressive spread of necrosis in the skin and subcutaneous tissues of the scrotum is the key feature of idiopathic scrotal gangrene. The disease may present initially as an acute abdomen, but laparotomy should be avoided. Usually an anaerobic Streptococcus is found, acting in synergism with aerobic, frequently gram-negative, bacilli. As in other synergistic gangrenes, wide dibridement with drainage of all sinus tracts is required. Although the testicles are frequently bared, they are usually not necrotic and should not be amputated. Once the infection has resolved, a surprising amount of skin coverage, including coverage of the testicles, can often be obtained from the scrotal remnants.


Femorotibial bypass in the diabetic patient for salvage of the ischemic lower extremity. Severe ischemia of the lower extremity in diabetic patients without runoff in the popliteal artery should not deter an aggressive diagnostic and therapeutic approach. Femorotibial or femoroperoneal bypass can effect limb salvage and avoid primary amputation if distal small vessel patency can be demonstrated by arteriography.


Femoral arteriography in outpatients.

Femoral arteriography in outpatients. Sixty-four femoral arteriograms were taken on an outpatient, ambulatory basis in sixty-two patients. There were no complications. It is believed that this method, when applicable, should effect substantial savings in health delivery cost and medical manpower and should facilitate adequate follow-up examinations in certain cases.


Appraisal of operative treatment for chronic pancreatitis. With special reference to side to side pancreaticojejunostomy. A total of sixty-one operations were performed in sixty of seventy-one patients with chronic pancreatitis, with the following results. 1. The procedures used were side to side pancreaticojejunostomy in twenty-four patients, caudal pancreatectomy in ten, pancreaticoduodenectomy in six, total pancreatectomy in one, removal of pancreatic calculi in four, cystojejunostomy in two, biliary tract procedures in twelve, and drainage of pancreatic abscess in one. Operative fatality occurred in six patients, with fifty-four surviving operation. 2. Of fifty-three patients surviving operation (excluding the one who underwent only exploratory laparotomy), forty-seven (88 per cent) had relief of pain. With the exception of two patients with complicating cancer of the pancreas at the time of operation, of fifty-two patients surviving operation, thirty-nine (75 per cent) had satisfactory results at follow-up study. 3. Sixteen of twenty-four patients (66.7 per cent) undergoing side to side pancreaticojejunostomy had satisfactory follow-up results. 4. Comparison of pre- and postoperative body weight levels in twenty-one patients undergoing side to side pancreaticojejunostomy showed a postoperative loss of less than 10 per cent in seven, unchanged weight in two, and a gain in eleven patients, including five with more than 10 per cent gain. However, fat absorption examination in these patients showed no distinct postoperative improvement in digestion and absorption. 5. Histologic evidence in one patient at autopsy four years and eleven months after side to side pancreaticojejunostomy indicated improvement in fibrosis of the pancreas as compared with the findings at operation.


Diagnosis of chronic and postoperative osteomyelitis with gallium 67 citrate scans. The effectiveness of gallium 67 citrate in diagnosing the exacerbations of chronic osteomyelitis or postoperative osteomyelitis secondary to open reduction of fractures was tested in thirteen patients. This isotope demonstrated an area of infection in every case in which such an area existed. The control subjects consisted of patients with noninfected wounds after open reduction. In this group, gallium was not incorporated into the post-operative hematoma. No false-negative results were observed in our series, demonstrating that this element is useful in the early diagnosis of bone infections.


B-mode ultrasound scanning in the diagnosis of renal lesions. The use and value of a relatively new diagnostic modality, ultrasound, in the diagnosis of renal masses are discussed. Several examples are presented.


Prediction of intestinal viability using Doppler ultrasound technics. The determination of intestinal viability intraoperatively remains difficult. Intestinal blood flow can be demonstrated in the serosa and mesentery-bowel junction by use of the Doppler ultrasound flow detector. The presence of flow in these areas after an ischemic episode correlates well with ultimate viability of the intestine. This technic may be useful clinically to assist in determining viability and the limits of resection of previously ischemic intestine.


Diseases of the colon and rectum in Bolivia. A review of the surgical and autopsy records from two general hospitals in La Paz, Bolivia, discloses an incidence of colon and rectal disease, excluding hemorrhoids, of 0.6 per cent (138 of 22,361 surgical cases) and 2.5 per cent (16 of 640 consecutive autopsies). Acquired megacolon complicated by volvulus represented more than half of all cases in the surgical series. Ulcerative colitis, diverticular disease, and neoplastic polyps represented less than 10 per cent of the cases of colonic disease. Only ten cases of carcinoma of the colon were seen, whereas five cases of granulomatous colitis or ileocolitis were detected in the same surgical material. Among sixty-four lesions of the rectum, so-called retention polyps accounted for 54.5 per cent of the cases, with carcinoma next in frequency (25 per cent), and the remainder being different varieties of inflammatory conditions. In the autopsy material almost half of the cases were infectious conditions, followed by congenital malformations and complicated acquired megacolon. No case of diverticular disease of the colon or neoplastic polyps was seen, and there was only one case of cancer of the large bowel. Because of the high incidence of acquired megacolon and the low incidence of cancer, ulcerative colitis, adenomatous polyps, and diverticular disease of the colon, possible etiopathogenic factors of these conditions are discussed in comparison with their incidence in other developed and developing countries of the world.


Progressive hypovolemia leading to shock after continuous hemorrhage and 3:1 crystalloid replacement. Dogs subjected to arterial hemorrhage and infused with 3:1 volumes of lactated Ringer's solution became progressively hypovolemic, to the point of frank shock. Stability and normovolemia were restored only after additional fluid delivery, in a net ratio of 8:1. These were the mathematically predicted values that satisfied Starling's hypothesis.


Traumatic perforation of the sigmoid colon through schistosomal ulcerations. A case is presented in which the colon was perforated through a S. mansoni ulcer after blunt abdominal trauma. This is believed to be a unique situation. The colonic complications of schistosomiasis are discussed, and it is expected that they will be seen more frequently in the United States.


Carcinoma arising in a mesenteric cyst.

Carcinoma arising in a mesenteric cyst. A report is presented in which a mesenteric cyst underwent a malignant change. A survey of the origin, symptoms, and treatment of mesenteric cysts is also included. The histologic picture of the case is described, the origin of the cyst discussed, and a comparison made with the two similar cases reported in the literature.


Extending the usefulness of self-retaining retraction. Self-retaining retractors are a great aid in surgery since they assist in obtaining and maintaining the exposure necessary to accomplish the goal of surgery. The purpose of this retractor-retaining ring and clamp set is to increase the versatility of the self-retaining retractor and to make its advantages more generally available by a drastic reduction in cost. This is accomplished by using a simple, easily obtained clamp that can be adapted to the retractors presently available in any operating suite in combination with any of the three ring sizes to produce a self-retaining retractor that can easily accommodate variables such as the size of the patient and the type of operation.


A new filtered sump tube for wound drainage. A new filtered sump tube has been designed for drainage of collections of fluids from wounds without the danger of infection by airborne contaminants. A two-staged filter has been attached to the vent lumen that removes particulate matter and bacteria from the air that passes through the filter. A clinical evaluation of this tube confirms the superiority of sump drainage as compared with closed suction drainage in the removal of fluids from wounds or cavities.


Estimation of plasma diazepam. Critique of a method using gas-liquid chromatography and benzene extraction. Plasma diazepam can be reliably estimated using a simple benzene extraction and gas-liquid chromatography with griseofulvin as internal standard. This gives reproducible results within the clinical range of plasma levels. Storage at minus 20 degrees C is recommended but is not essential for the 1st week.


Methaemoglobinaemia following treatment dispensed by witch doctors. Two cases of potassium permanganate poisoning. Two cases of acute acquired methaemoglobinaemia following the ingestion of witch doctor's preparations, are presented. Chemical analysis of the ingested powder revealed a mixture of soot and potassium permanganate. Both patients were comatose and deeply cyanosed but the response to oxygen, methylene blue and vitamin C was good.


Respiratory failure following gastroscopy. A 61-year-old, bronchitic male developed respiratory failure due to a pneumoperitoneum following gastroscopy. The management of this case and the possible complications following gastroscopy are described and discussed.


An evaluation of the Lex-O2-Con oxygen content analyser. The accuracy of the Lex-O2-Con apparatus is compared with the classical method of Van Slyke & Neill (1924) and the inaccuracies introduced by the presence of volatile anaesthetics in the sample are evaluated. The absolute levels of oxygen content depend upon the flow rate of carrier gas through the instrument.


Twenty-two cases of autotransfusion.

Twenty-two cases of autotransfusion. Twenty cases of ruptured ectopic pregnancy and two cases of haemothorax which have been given autotransfusion by a simple technique are reported. No deaths or complications occurred. The advantages of autotransfusion particularly in circumstances where laboratory facilities are minimal are discussed. Haemoglobin levels before and after transfusion and other investigations are recorded.


[The metabolism of pancuronium in man].

[The metabolism of pancuronium in man]. The metabolic disposition of pancuronium was investigated in man under clinical condition. Pancuronium and its desacetylated derivatives were determined in body fluids using the previously described bromophenol blue method (3). The metabolites were isolated by thin layer chromatography. One minute after the intravenous injection of a mg of pancuronium the drug reaches a serum concentration of 2,2 plus or minus 0,2mug/ml. As an exponential function the concentration curve then falls to half of the initial value during the first 30 to 60 min. The end of the neuromuscular block conincides with a concentration of 0,1 to 0,3 mug/ml serum which is reached about 2 hours after the injection. After 3 to 4 hours no more pancuronium can be detected in the serum. The renal elimination of pancuronium can be folowed up for 12 hours. On average half of the injected dose is recovered in the urine. 80% of this proportion is unchanged pancuronium and 20% desacetylated metabolites. The monodesacetylated derivatives of pancuronium are still pharmacologically active. The biliary excretion 24 hours after the administration of pancuronium accounts for 5 to 10% of the injected dose...


[The influence of inhalation anaesthetics on catecholamine secretion from the adrenal medulla in vivo]. The influence of chloroform and ether on the catecholamine (CA) secretion from the adrenal medulla was investigated in cats in order to compare these effects to those of halothane and methoxyflurane studied previously. The CA concentrations in the blood of the adrenolumbar vein were measured spectrofluorometrically. During inhalation of chloroform (1.0-1.5%) no significant changes of spontaneous CA secretion were observed; contrary to that, the secretion evoked by splanchnic nerve stimulation was decreased. During inhalation of ether (4.0-6.0%) spontaneous CA output was increased and the CA release evoked by splanchnic nerve stimulation was inhibited. The results differ qualitatively from those obtained with methoxyflurane and halothane; these anesthetics caused a pronounced inhibition of spontaneous CA output. The inhibition by ether of CA secretion evoked by splanchnic nerve stimulation was less pronounced than that caused by the other anaesthetics. By comparison of the effects of four inhalation anaesthetics we evaluated, which circulatory side effects depend on changes of CA output.


[Influence of halothane on the effects of endogenous and exogenous noradrenaline on the isolated rabbit heart perfused at constant pressure]. The influence of halothane on the release of noradrenaline from synpathetic nerve endings was studied in isolated rabbit hearts with an intact postganglionic sympathetic nerve supply. In addition we investigated the influence of this anaesthetic on the effects of noradrenaline released from the nerve endings or infused into the aortic cannula. Halothane did not alter the noradrenaline release evoked by electrical stimulation of the postganglionic sympathetic nerve fibres. Although halothane directly diminished the rate of the isolated rabbit heart, the positive chronotropic effect of noradrenaline was not influenced by this anaesthetic. The coronary flow decreased during application of halothane. Both stimulation of postganglionic sympathetic nerve fibres and noradrenaline infusion (250ng/min, lasting for 2 min) evoked a decline in coronary flow; the decrease in coronary flow caused by noradrenaline was markedly attenuated by halothane. This effect of halothane did probably not depend on alterations of the myocardial component of coronary resistance, but on the fact that the vasoconstrictor effect of noradrenaline on the coronary vessels was decreased by this anaesthetic.


[Telemetric ECG data (biorhythms) during operations under acupuncture analgesia in the People's Republic of China (author's transl)]. On an educational journey to China, we were able to record and accumulate electrocardiograms during operations under acupuncture analgesia with the aid of a self-developed apparatus. To elaborate this among others the amplitude of the QRS-complex as well as the time period between two cardiac cycles were electronically measrued and registered. With examples from the comprehensive material it is possible to draw the following conclusions: 1. The patients were in conditions ranging from restlessness and irritation to weariness and drowsiness. A condition similar to that resulting from narcosis must be excluded. 2. A pre-operatively undertaken strong psychological sedation by means of drugs can be excluded with certainty. 3. The massive reaction to events such as the washing out of the operative field refutes, at least partly, our concept of "Asiatic indifference". 4. Acupuncture is not able to depress reflexes. 5. Finally, the hypothesis that acupuncture has a stabilizing effect on the circulation is not valid.


[The peripheral perfusion pressure: a new non-invasive parameter for the circulatory monitoring of patients (author's transl)]. Heating of a skin area to a temperature of 42 degrees to 44 degrees C produces a certain physiological condition which induces maximal vasodilatation. Detailed experiments have shown that local peripheral vascular resistance of such an area remains constant for several hours. The flow in this area is proportional to the actual perfusion pressure. Relative flow was measured by means of a new type of electrode fixed to the skin like and ECG electrode, and compared with simultaneous intra-arterial blood pressure measruements. The changes in arterial blood pressure were also recorded by the skin electrode. This new parameter is defined as "peripheral perfusion pressure". It is appropiate for non-invasive continuous monitoring of the circulatory system of patients.


[A method for the symmetrical pre-stretching of cuffs of plastic tubes (author's transl)[]. We describe a method to prestretch symmetrically cuffs of plastic endotracheal tubes. The tracheal wall pressure will be lower than the capillary pressure of the mucous membranes in tow third of the cases, if correctly prestrecthed cuffs are used. The importance of using truly high volume low pressure cuffs with a cuff diameter of a least 25 to 30 mm is stressed.


Unilateral pulmonary oedema following re-expansion of pneumothorax. Unilateral pulmonary oedema is a rare complication in the routine management of spontaneous pneumothorax. Previous reports have emphasized excessive negative intrapleural pressure, rapid re-expansion of the lungs and bronchial obstruction as major factors in the pathogenesis. We have encountered four cases, and at least one of these factors have been absent in each case. Review of the literature, and our own experience suggests that the major factor is chronic and total lung collapse resulting in hypoxia and increased alveolar-capillary membrane permeability. Other factors which may be contributory are discussed.


A comparison of two heated water-bath humidifiers. The performance of two heated water-bath humidifiers was examined in terms of airway temperatures and humidities. These were the simple heated tank (Marshall and Spalding, 1953) and the Fisher and Paykel No. 328 (Spence and Melville, 1972), both of which had the potential to deliver gases at temperatures above 40 degrees C, and with a moisture content in excess of 50 mg/litre. The major advantage of the No. 328 was its heating wire in the delivery tube. This lessened or prevented condensation within the tube, and allowed the water bath to be maintained at lower temperatures. Independent heat controls for the water bath and the delivery tubing allow precision of humidities in the gases provided for inspiration through an artificial airway. When condensation is prevented, the temperature of the saturated gases leaving the humidifier limits the absolute humidity supplied. Monitoring and adjustment of airway temperature of the patient then allows selection of temperature and relative humidity in the inspired gas.


The biomedical engineer and the doctor.

The biomedical engineer and the doctor. The appearance of engineers with special training in biology has occurred only in the past fifteen years, and the spectacular contributions they can make to patient care have been confined mainly to the years since solid-state electronic circuitry became available. It is timely to review the relationships between them and the clinicians, and to indicate the growing interdependence they have on each other. The three points at which their interests converge most noticeably are: 1. in the collection, storage and display of data, 2. in the maintenance of electrical safety and the proper functioning of apparatus, and 3. in the design of electro-medical equipment.


The biomedical engineer in the hospital. The role of the hospital biomedical engineer is described with reference to design and development of equipment and its maintenance, provision of a technical advisory service, and teaching.


End-tidal carbon dioxide levels in the early detection of air embolism. Two cases of air embolism in patients anaesthetized in the sitting position are described. The emboli, though producing no signs and therefore probably small, were readily detected by the fall in the end tidal CO2 fraction. Techniques for the detection of air emboli are briefly reviewed.


A prospective study of coronary care in a rural city. The results of a two-year prospective study of myocardial infarction in a rural city is reported. In the under 70 years age group there was a 10 per cent mortality of patients whilst being nursed in the coronary care area. Later deaths after transfer to the general wards raised the overall hospital mortality rate to 15 per cent. These figures compare favourably with other series.


Acupuncture and placebo: Effects on delaying the terminating response to a painful stimulus. An experiment was performed to determine whether needles inserted into appropriate acupuncture points could delay onset of a pain-terminating response more than needles inserted as placebos into inappropriate points could. A heat source contained in a modified Hardy-Wolff-Goodell dolorimeter was used as a stimulus to produce pain on the posterolateral aspects of the left forearms of volunteer subjects. Subjects pressed a switch as soon as pain was experienced, and the latency between stimulus onset and response was measured to the nearest hundredth of a second. Response latencies were recorded before and after needling, which included electrical stimulation. Needles placed in specific acupuncture points called Ho-Ku and Wai-Kaun delayed onset of the pain-terminating response slightly more than needles inserted as placebos. Even with needles in appropriate acupuncture points, analgesia was slight and subjects still experienced pain.


Acupuncture compared with 33 per cent nitrous oxide for dental analgesia: A sensory decision theory evaluation. Responses to electrical stimulation of the tooth pulp were obtained in both baseline and test sessions for subjects receiving acupuncture, 33 per cent nitrous oxide, or control conditions. A signal-detection analysis across sessions showed that both treatment groups demonstrated reduced sensitivity to stimulation, and increases in bias against reporting strong stimuli as painful. (Key words: Acupuncture; Anesthetics, gases, nitrous oxide; Measurement techniques, sensory decision theory; Pain, sensory decision theory).


The renin--angiotensin--aldosterone system during cardiac surgery with morphine--nitrous oxide anesthesia. Ten consecutive adult patients undergoing elective cardiac surgery with extracorporeal circulation were anesthetized using morphine (1-3 mg/kg) and nitrous oxide. Pre-bypass plasma renin activity showed a 3.5-fold elevation (P smaller than 0.001) over baseline values. This correlated with maximal blood pressure elevation. Plasma renin activity remained elevated during bypass. High baseline aldosterone levels increased 3.4-fold (P smaller than 0.001) after 15 minutes on bypass and 4.0-fold by the end of bypass. Plasma potassium decreased from 3.9 mEq/1 before bypass to 3.2 mEq/1 (P smaller 0.0001) during bypass, and the fractional urinary excretion of potassium was 32 per cent before bypass with a mean of 34.4 per cent during bypass. Urinary output remained high during bypass despite a progressive decrease in glomerular filtration rate. Catecholamine levels showed no significant change. The data suggest that the renin-angiotensin-aldosterone system may play a role in blood pressure regulation during cardiopulmonary bypass and may result in the excessive urinary excretion of potassium and decrease in plasma potassium levels.


Plasma protein binding of thiopental in patients with impaired renal or hepatic function. Binding of thiopental to proteins in plasma from healthy, cirrhotic, and uremic subjects was studied using equilibrium dialysis. In plasma from healthy volunteers 28.0 plus or minus 0.9 per cent of thiopental was unbound. In plasma from patients with hepatic disease 53.0 plus or minus 2.1 per cent was unbound, while in patients with renal disease 55.7 plus or minus 1.5 per cent remained unbound. The decreased binding in uremia could not be explained completely by competitive displacement by nitrogenous end products or by hypoalbuminemia, although hypoalbuminemia may account for the decreased binding in cirrhotic patients.


Potencies of doxapram and hypoxia in stimulating carotid-body chemoreceptors and ventilation in anesthetized cats. The effects of doxapram on carotid chemoreceptor activity and on ventilation (phrenic-nerve activity) were tested before and after denervation of the peripheral chemoreceptors in cats. Doxapram was found to be a potent stimulus to the carotid chemoreceptors; the stimulation produced by 1.0 mg/kg doxapram, iv, equalled that produced by a Pao2 of 38 torr. Doxapram also increased phrenic-nerve activity in doses as low as 0.2 mg/kg, iv. After denervation of the peripheral chemoreceptors, doxapram in doses as large as 6 mg/kg failed to stimulate ventilation. It is concluded that (in anesthetized cats) doxapram in doses of less than 6 mg/kg increases ventilation by direct stimulation of the carotid, and, probably, the aortic, chemoreceptors, not by a direct effect on the medullary respiratory center.


Hemodynamic consequences of the combination of isoflurane anesthesia (1 MAC) and beta-adrenergic blockade in the dog. The hemodynamic response to the combination of isoflurane (1 MAC) and propranolol (0.5 mg/kg) was studied in 12 intact ventilated dogs following basal anesthesia with chloralose-urethane. When propranolol was administered during isoflurane anesthesia, stroke volume was maintained with a higher pulmonary capillary wedge pressure (3.2 plus or minus 0.7 mm Hg to 6.3 plus or minus 1.4 mm Hg), while systemic vascular resistance remained unchanged. When isoflurane was administered to the previously beta-adrenergically blocked dog, there were declines in systemic pressure and cardiac output (P smaller than 0.01) and in pulmonary arterial pressure and stroke volume (P smaller then 0.05), without change in systemic vascular resistance. When isoflurane was subsequently discontinued, these changes were reversed, and in addition, systemic vascular resistance increased (P smaller than 0.05). These data indicate that isoflurane has pharmacologic properties compatible with a peripheral beta-adrenergic stimulating action.


Effects of anesthetics on ponto-geniculo-occipital waves from the oculomotor nucleus of the cat. Effects of anesthetics and doxapram on pontogeniculo-occipital (PGO) waves from the oculomotor nucleus were studied in acute experiments in cats paralyzed by gallamine triethiodide. The anesthetic agents studied in the present experiment (thiopental, ketamine, Innovar, nitrous oxide, and halothane) decreased, while doxapram increased, the total number of PGO waves. As the doses of anesthetics increased, PGO waves were abolished, but they returned to control levels or below control levels when the concentrations of anesthetics were decreased. The results indicate that the anesthetics studied inhibit the activity of the central mechanism associated with the oculomotor system. PGO waves may prove a useful index of the level of anesthesia.


Increased serum bromide concentration after halothane anesthesia in man. Seven healthy male volunteers received 6.6 plus or minus 0.5 (SE) per cent-hours of halothane-oxygen anesthesia without surgery. Serum bromide concentrations increased from 0.6 plus or minus 0.1 before anesthesia to 2.9 plus or minus 0.2 mEq/l on the second day after anesthesia. On the ninth day serum bromide was still elevated to 2.5 plus or minus 0.1 mEq/l. These bromide concentrations represent psychoactive levels and may account for previously recognized prolonged changes in mood and intellectual function after halothane. Plasma and urinary fluoride concentrations did not increase significantly.


Soda-lime dust contamination of breathing circuits. A case report of soda-lime dust contamination of the breathing circuit of an anesthesia machine causing bronchospasm in a patient is presented. Various factors in absorber design and increased dusting of soda lime due to high-flow techniques and lack of wetting are described. A modification of the Fraser-Sweatman absorber leading the fresh gas into an area free of dust accumulation has resulted in near-complete elimination of the problem.


The anesthetic effect of air at atmospheric pressure. Nitrogen has recognized narcotic potential at hyperbaric pressures. No narcotic effect of helium has been demonstrated at any pressure. We evaluated the effect of nitrogen in air at one atmosphere on human performance by comparing it with helium-oxygen using a four-alternative divided-attention task that requires rapid response to auditory and visual signal changes. There was a 9.3 per cent decrease in response time when subjects breathed helium-oxygen, a signigicant change (P less than 0.001). This change could not be ascribed to practice since the order of presentation of gases did not have a significant effect. It concluded that the nitrogen in ambient air slightly but measurable impairs human performance compared with a non-anesthetic gas such as helium.


Neuromuscular blocking effects of succinylcholine in infants and children. The neuromuscular blocking effects and recovery times following two doses of succinylcholine on a weight basis were evaluated in 16 infants and 16 children. Infants had less profound neuromuscular blockade than children at both 0.5 and 1.0 mg/kg doses. Succinylcholine, 1 mg/kg, in infants produced blockade equal to that produced by 0.5 mg/kg in children; at these equipotent doses there was no statistically significant difference between the times to recover to 10 and 90 per cent neuromuscular transmission in the two groups. However, the rate of recovery from 50 per cent neuromuscular transmission to 90 per cent neuromuscular transmission was 69.1 per cent/min in children, as opposed to 46.4 per cent/min in infants. When dosage was calculated on a surface area basis, there was a linear relationship for infants and children as a single group between the log dose and the times to recover to 50 and 90 per cent neuromuscular transmission. Similarly, there was a linear relationship between the log dose (mg/m2) and the maximum intensity of neuromuscular blockade.


Intravenous delta9-Tetrahydrocannabinol: Effects of ventilatory control and cardiovascular dynamics. Delta9-Tetrahydrocannabinol (THC), the active component of marijuana, was studies to determine whether it might be useful for preanesthetic medication. Ten healthy subjects received THC intravenously in logarithmically spaced incremental doses. Four subjects received a total cumulatine dose of 135 mug/kg and four others, 201 mug/kg, Two of the ten subjects discontinued the study because of anxiety reactions. Ventilatory minute volume at a controlled elevated CO2 tension, 48 plus or minus 2 (SD) torr, changed minimally with TCH, -0.49 1/min/50 per cent increase in dose. TCH shifted the ventilatory response to CO22.7 torr destrad at 20 1/min without a change in slope. Dose-related tachycardia was the most marked cardiovascular effect. Heart rates increased to more than 100/min in five of six subjects. Cardiac index increased from 4.04 plus or minus 0.62 1/min/m-2 before TCH to 6.92 plus or minus 2.34 1/min/m-2 after 134 mug/kg. Mean arterial pressure increased slightly, and total peripheral resistance fell. The cardiovascular changes suggest beta-adrenergic stimulation. Intense mental effects and anxiety prohibited higher THC doses.


Decamethonium and serum potassium in man. Decamethonium and succinylcholine were used to study the effects of depolarizing muscle relaxants on serum potassium in 60 patinets, free of neuromuscular disease, during major orthopedic surgery. Significant increases in serum K+ were found after administration of decamethonium or succinylcholine in the usual clinical doses. The abnormal elevations of serum K+ found in patients with burns, massive trauma, or muscle denervation are thus accentuations of the process that occurs in normal man following use of these depolarizing drugs. The administration of any depolarizing agent to these abnormal patient groups would, therefore, appear contraindicated.


Newborn blood levels of lidocaine and mepivacaine in the first postnatal day following maternal epidural anesthesia. Distribution and elimination of lidocaine and mepivacaine were studies in 114 subjects after obstetric epidural anesthesia, Epinephrine significantly lowered the concentrations of lidocaine in the mothers' circulations by about 33 per cent, and the concentrations of mepivacaine by about 22 per cent. It also significantly altered their concentrations in the newborns' circulations at delivery and in the first 4 hours after birth. More mepivacaine than lidocaine crossed the placenta. The mepivacaine concentration in the cord blood was 36 to 47 per cent higher, and the mean fetal to maternal ratio for mepivacaine without epinephrine was 0.64, in contrast to 0.52 for the equivalent lidocaine group. Of importance was the long persistance of either drug in the newborns' circulation. Detectable levels of lidocaine and mepivacaine were present until 8 and 24 hours after birth, respectively. Pharmacokinetic models revealed that the long-term rate of disappearance of lidocaine was approximately three times as fast as that of mepivacaine. Computed half-times averaged 3 hours for lidocaine and 9 hours for mepivacaine.


Neurokinetics of lidocaine in the infraorbital nerve of the rat in vivo: Relation to sensory block. The kinetics of neural uptake and efflux of lidocaine hydrochloride were studies by means of a standardized technique for blocking the intraorbital nerve of the rat, using a palatal jig. Following injection of 14-C-labeled local anesthetic, groups of ten animals were saccraficed at incipient recovery from sensory block or at othertimes. The nerves were weighed and assayed for radioactivity. The lengths of nerve containing high levels of lidocaine varied inversely with the times elapsed since onset of block. In experiments where a fixed quantity (2 mg) drug was injected, the incidence of block 2 hours later was concentrated-dependent, occuring in 80 per cent of animals after 2 per cent, in 40 per cent after 1 per cent, and in none after 0.5 per cent lidocaine. Epinephrine, 1:200,000, prolonged by 80 per cent the block effected with 0.2 ml of 1 per cent lidocaine. At the onset of recovery the neural contents of lidocaine at the sites of injection were 484 plus or minus 404 ng/mg of nerve in epinephrine-treated nerves, and 274 plus or minus 218 ng/mg in nonepinephrine-treated nerved (N.S., P greater than 0.05). Quantitative comparisons of in-vivo effectiveness of local anesthetic solutions can be made with this technique.


Lidocaine effects on brain mitochondrial metabolism in vitro. Both lidocaine and anoxia inhibit rapid axonal transport. In an attempt to elucidate the mechanism of this action of lidocaine, its effect on mitochondrial respiration was studies. The local anesthetic produces a dose-dependent inhibition of oxygen consumption (50 per cent inhibition at 8mM) by porcine brain mitochondria when glutamate, but not when succinate, serves as the substrate. This indicates electron transport is blocked at the NADH dehydrogenase level. Potent uncoupling of oxidative phosphorylation is observed with both substrates. All of the effects are readily reversible upon removal of the anesthetic. It is concluded that lidocaine apparently inhibits rapid axonal transport by depressing oxidative metabolism.


Normal hemoglobin-oxygen affinity.

Normal hemoglobin-oxygen affinity. Hemoglobin-xoygen affinity is known to vary in a number of disease states. The authors measured the continuous affinity of blood from healthy subjects and, using mathematical data reduction techniques, calculated coefficients for rational function models of average normal affinity, plus or minus 2 standard deviations, and 95 per cent confidence limits. Average normal P50 was 27.10 torr, with a two-standard-deviation range of 25.85 to 28.35; P50s of the 95 per cent confidence limits were 26.69 and 27.53 torr. The affinity usually accepted as standard lay between or very near to the 95% confidence limits of normal throughout its range. It is concluded that the range of normal affinity is narrow and that, for most practical purposes, standard affinity adequately represents normal affinity. There should be little difficulty in distinguishing from normal the shifts that occur in certain disease conditions.


Determining patency of palmar arches by retrograde radial pulsation. The patency of palmar arches must be ascertained before radial-artery cannulation is performed. A simple test in which digital pulsation is felt after proximal occlusion of the radial artery has been devised for that purpose. The method is reliable, does not require active patient cooperation, and can be carried out in all clinical situations where the radial artery can be felt.


Comparison of proteolytic enzyme activity in pulmonary alveolar macrophages and blood leukocytes in smokers and nonsmokers. Proteolysis (or more specifically, elastolysis) of the lung may be involved in the pathogenesis of pulmonary emphysema. To investigate the human alveolar macrophage as a potential mediator of lung damage, elastase-like esterase and protease activity was determined in these cells as well as in alveolar lavage fluid and in peripheral blood leukocytes. Bronchoalveolar lavage was used to obtain alveolar cells and fluid in normal volunteers who were divided into two groups according to cigarette smoking history, nonsmokers and smokers. Results of these studies revealed that human alveolar macrophages possess a high activity of both elastase-like esterase and protease. Furthermore, the alveolar macrophages of cigarette smokers has a significantly greater elastase-like esterase and protease activity than those of nonsmokers. When the 4- to 5-fold increase in the number of macrophages found cigaretts smokers is taken into account there was approximately 10 times more elastase-like esterase activity and 18 times more protease activity within macrophages in the alveolar spaces of cigarette smokers' lungs. This makes the alveolar macrophage a poten potential source of proteolytic enzymes in man.


Predictability of the radioallergosorbent test (RAST) in ragweed pollenosis. The radioallergosorbent test was compared with currently accepted allergy diagnostic techniques in ragweed-sensitive and unselected patients. The radioallergosorbent test was positive in 28 of 30 patients with proved histories, positive scratch tests, and positive nasal provation tests to ragweed. The radioallergosorbent test was also positive in 69 per cent of 40 clinically sensitive patients whose diagnoses were corroborated by scratch tests alone. In unselected patients evaluated by intracutaneous testing with short ragweed extract, 10 minus 3 g per ml, the incidence of positive radioallergosorbent test scores was reduced to 43 per cent. No false positive results were encountered in these studies. A good relationship was observed between radioallergosorbent test scores and the maximal tolerable dose of ragweed administered during a course of "rush" immunotherapy in clinically allergic patients. These results suggest that the radioallergosorbent test has several unique advantages in assessing clinical sensitivity to ragweed.


Open thoracotomy for pneumothorax in cystic fibrosis. The results of open thoractomy and pleurectomy or pleural abrasion for 17 episodes of pneumothorax in patients with cystic fibrosis were compared with the results of observation, closed thoracostomy, and closed thoracostomy with sclerosing agents. Open thoracotomy had the advantage of insuring prompt resolution of the pneumothorax. A small incision minimized postoperative morbidity. The average hospital stay was 15 days after open thoracotomy and 19 days after closed thoracostomy, with or without sclerosing agents. Complications of all treatments were infrequent. A limited symptomatic recurrence was observed in 2 of 17 pneumothoraces successfully treated with open thoracotomy. Recurrence also occurred in 1 of 8 treated with observation, 3 of 9 treated with closed thoracostomy, and 1 of 14 treated with closed thoracostomy and sclerosing agents. A loss of vital capacity was usually noted 4 to 18 months after resolution, regardless of treatment. Forty per cent of patients in both operative and nonoperative groups survived 3 years. In our experience, open thoracotomy can be used safely for treatment of unresolved or recurrent pneumothorax and warrants further evaluation as a primary therapy for pneumothorax in patients with cystic fibrosis.


Functional abnormalities in young asymptomatic smokers with special reference to flow volume curves breathing various gases. Functional abnormalities have been described in healthy, asymptomatic young smokers. Fifteen subjects between 22 and 30 years of age, who smoked but were completely asymptomatic, were compared with 10 nonsmokers of the same age group using lung volumes, maximal expiratory flow rates, closing volumes, and maximal expiratory flow volume curves breathing air and a helium-oxygen mixture. Lower maximal mid-expiratory flow rates, higher closing volumes, and significant differences in flow volume curves with the helium-oxygen mixture were found in smokers. Special attention was given to the volume expressed as percentage of vital capacity at which the flows with air and the helium-oxygen mixture were equal for each subject ("equal-flow volume"). This volume was found to be significantly higher for smokers than nonsmokers. The authors offer explanations for these differences and suggest that smoking may alter compliance, as reflected by abnormal closing volumes, and resistance of the small airways as determined by differing responses in flow rates after helium-oxygen breathing at low volumes.


Response to exercise in upper airway obstruction. Mild excerice in 7 patients with upper airway obstruction but without diffuse lung disease caused a mean decrease in arterial oxygen tension of 11 mm Hg. Exercise hypoxemia disappeared after surgical removal of obstruction in 3 patients tested. Exercise hypoxemia due to relative alveolar hypoventilation was observed in 4 normal subjects with external combined inspiratory and expiratory resistance. Analysis of mechanics of air flow through an orifice suggests that exertional dyspnea is caused by manifold increase of airway resistance during exercise; acute respiratory failure might be precipitated by further minimal reduction in airway lumen once it has reached a diameter of 8 mm. Clinicians should be alert to the possibility of upper airway obstruction in any symptomatic patient who has had tracheal intubation or in patients with obscure wheezing, especially on exercise.


Extrapulmonary tuberculosis in Oklahoma, 1965 to 1973. Three hundred seventy cases of extrapulmonary tuberculosis were reported to the Oklahoma State Department of Health between January 1, 1965 and December 31, 1973. The annual number of cases reported showed no tendency to decrease with time. A greater proportion of cases reported in recent years had bacteriologic confirmation. When compared to the distribution of all newly diagnosed cases of tuberculosis in the population, a greater proportion of newly diagnosed cases of extrapulmonary tuberculosis occurred in nonwhites. This was especially true to tuberculous meningitis, tuberculous lymphadenitis, and miliary tuberculosis. Possible reasons for the failure of the number of newly reported cases of extrapulmonary tuberculosis to decrease in recent years are presented.


Antibiotics as an aid in the prevention of infections after peripheral arterial surgery. Patients having arterial reconstructive operations appear to have a comparatively high attack rate of hospital-acquired infections. A protocol for administration of antibiotic prophylaxis to such patients was designed to minimize major adverse effects while evaluating the effect on attack rate of hospital acquired infections. Short intensive therapy with an appropriate antibiotic during a period of time surrounding the operative procedure itself is emphasized. The attack rate of nosocomial infections declined from approximately 12 to approximately 3 per cent and wound infections occurred in only seven of 811 patients. Administration of antibiotics according to this protocol appears to reduce the expected attack rate of nosocomial infections.


Treatment of surgical infections with tobramcin. A survey of the safety and effectiveness of tobramycin, a newly developed aminoglycoside antibiotic, was assessed in 116 septic surgical patients. For comparison, the final 52 cases were randomized with 51 similarly infected patients who were treated with gentamicin. The two antibiotics gave equally good results when evaluated bacteriologically and clinically. Nevertheless, gram-negative infections appeared more likely to be susceptible to tobramycin than to gentamicin. No toxicity to the liver or bone marrow was observed. Although there were 13 cases of nephrotoxicity and 4 of ototoxicity, only one instance of such an adverse drug reaction could be attributed to parenterally administered aminoglycoside alone. In fact, topical neomycin and established renal damage caused by prior episodes of shock or dehydration appeared to be significantly more responsible for such adverse effects.


Mechanism of heightened tumor immunity induced by cryosurgery. Sarcoma-bearing mice treated with cryosurgery demonstrated significantly greater tumor immunity (as measured by lymphocytoxicity assays) than untreated tumor-bearing mice (p less than .001). However, cryosurgically treated mice did not show greater cytotoxicity than tumor-bearing and tumor-amputated mice which were treated with frozen exogenous tumor antigen. These results suggested that the mechanism by which cryosurgery stimulates systemic tumor immunity is through the release of antigen from the neoplasm. Thus, tumor-bearing mice treated with cryosurgery in these experiments underwent definitive ablative therapy while at the same time they received active tumor immunotherapy.


Projectile injuries from rotary power lawn mowers. Two case reports of projectile injuries to bystanders from rotary power lawn mowers are presented. The surgeon must think in terms of entrance and exit wounds and tentative trajectory. Roentgenograms are invaluable. Treatment follows the same surgical principles that are applicable to civilian gunshot wound.


Upper gastrointestinal fiberendoscopy: an analysis of 100 consecutive procedures. Upper gastrointestinal fiberendoscopy has significantly advanced the diagnostic and therapeutic capabilities of physicians as seen in this study of 100 consecutive examinations. The indications for this procedure in the areas of diagnosis, confirmation follow-up, and treatment are reviewed and evaluated. Materials and methodology are described.


Silastic and gelatin film sheeting in tympanoplasty. In 78 patients, representing 10% of the most severe case of chronic otitis media and in whom the mucosa from the promontory had been removed or severely damaged, the promontory was covered in one-stage mastoidectomy-tympanoplasty with a large piece of thin silastic or of Gelfilm. The results in the silastic group, comprising 50 patients, and in the Gelfilm group, comprising 28 patients, were compared on the basis of various criteria. The results proved better in the Gelfilm group. In particular, the percentage of recurrent perforations was considerably lower than in the silastic group. In one-stage operations, which we prefer, it is therefore recommended to use Gelfilm rather that silastic.


Structure of the avian tectorial membrane. The avian tectorial membrane is a thick massive-appearing structure permeated by cavities, which probably facilitate the diffusion of endolymph. As revealed by scanning and transmission electron microscopy, the cavities are arranged in a characteristic honeycomb-like pattern and each hair bundle is enclosed in an alveolus. The open ends of the alveoli show the impressions of sensory hairs on one side. The rims about the cavities are attached to the microvilli of the supporting cells by means of fibrous material. These morphological aspects are compared with those reptiles and mammals, and the functional significance of the fibrillar anchors is discussed.


Visual suppression of vestibular nystagmus after cerebellar lesions. Visual suppression of calorically induced vestibular nystagmus was observed following discrete lesions of various structures in the cerebellum. Unilateral lesions of the flocculus resulted in a complete loss or a significant reduction in visual suppression when the quick phase of the nystagmus was directed to the ipsilateral side of the lesions, and bilateral flocculus lesions caused a bilateral loss of suppression. Nodulus lesions resulted in a loss of suppression, and this loss tended to recover in time. Lesions of the dentate nucleus resulted in a very short term loss of suppression. Extirpation or lesions of the uvula, vermis, para-flocculus, cerebellar cortex, or the fastigial or interpositus nuclei had no observed effect on the visual suppression of vestibular nystagmus. The results of this study suggest that the flocculus and nodulus function as intermediators through which the visual system can modify or alter vestibular reflexes. Also, this phenomenon, that is, loss of visual suppression after the flocculus and nodulus lesion, is very useful to diagnose the localized lesion in the cerebellum.


Chordomas: nasopharyngeal presentation and atypical long survival. Atypical clinical and pathological features of a cranio-cervical chordomas have prompted a review of these neoplasms at the University of Michigan Medical Center. Contrary to prior investigations, 92% of the spheno-occipital chordomas reported in this study clinically presented with a nasopharyngeal or intranasal mass. This high incidence indicates the requirement for an otorhinologic examination on all patients presenting with the neuro-ophthalmologic syndrome and roentgenologic findings characteristic of chordomas in this anatomical region. Special attenion is called to a histologically distinctive variant of chordoma - the "chondroid chordoma.' Apparently restricted to the cranio-cervical region, this variant has been associated with long survival.


A tympanometric pressure swallow test for assessment of eustachian tube function. Normal Eustachian tube function is necessary for maintaining healthy middle ear conditions. A tympanometric pressure swallow test is proposed which can be used to assess Eustachian tube function behind an intact tympanic membrane. In general, after recording a baseline tympanogram, mechanically created positive and negative air pressures are created in a hermetically sealed ear canal causing increased pressure on the middle ear air cushion. The patient is then asked to swallow. Preliminary clinical findings in ears with apparent normal Eustachian tube function show that a shift in the peak pressure point of the tympanogram occurs when the tympanogram is recorded again, implying that the Eustachian tube opens and equalizes middle ear air pressure. Positive canal pressure swallow maneuvers show a peak pressure shift to a negative value, whereas negative pressure swallow maneuvers show a peak pressure shift to a positive value.


Effect of microaerosol inhalation on the pattern of breathing. Microaerosol stimulation of the trachea and bronchi appears to have no effect on the pattern of breathing. However, laryngeal stimulation with microaerosol produces consistent changes characterized by slowing of the inspiratory effort. The reflex response can be abolished by either bilateral superior laryngeal nerve section or topical anesthesia of the laryngeal mucous membranes. Nasal stiumulation with saline microaerosol results in marked slowing of inspiration. This response can also be blocked by topical anesthesia of the nasal mucosa. The decreased breathing rate results from both increased t insp. and t exp. During inspiration the build-up phrenic discharge activity, the phrenic slope, decreases. The phrenic peak, however, remains unchanged. The nose and larynx, therefore, appear to play significant roles in the modification of the breathing pattern in response to a nonirritating solution delivered as a microaersol. Slower breathing, relexly produced in the human being by such a method, might benefit partial airway obstruction by reducing turbulence and therefore the work of breathing. It is speculated that in a marginally competent upper airway, this benefit might be a critical factor in survival.


Disconjugate eye movements during electronstagmographic testing in patients with known central nervous system lesions. A tacit assumption underlying current ENG testing is that the eyes move conjugately. However, considering the intricate neuroanotomical pathways within the ocular motor system in addition to the elaborate vestibulo-ocular connections, we think it reasonable that disconjugate eye movements may result with certain CNS lesions. Recently we have employed independent eye movement measuring techniques in order to assess the movement of each eye separately during our ENG valuations. The preliminary work has revealed that disconjugate eye movements occurred even with extra-axial lesions which spared the medial longitudinal fasciculus. These data may be valuable for the neurotologist with regard to differential diagnosis and prescription of a treatment plan for the patient. The eye movement patterns of patients with confirmed CNS lesions and other interesting findings are presented.


Giant cell tumor of the spenoid bone.

Giant cell tumor of the spenoid bone. The clinical features of the giant cell tumor of the sphenoid bone have been discussed and a case report has been added to the fourteen cases reported in the literature. Such cases may first report to an ophthalmologist, an otolaryngologist, a neurologist, or an internist. They should consider this condition in a patient who complains of headache, ocular symptoms such as diplopia, and diminution of vision progressing to complete blindness. The presence of multiple cranial nerve palsies involving II, III, IV, V, and VI nerves in various combinations and the sellar erosion in the lateral x-ray of the skull are quite suggestive of this tumor which should be confirmed by biopsy. The telecobalt therapy appears to give the best results.


Brain step tumor and otoneurologic manifestations: report of a case with autopsy. The otoneurologic findings in a 30-year-old male patient who died of a brain stem tumor have been correlated with the histopathology of the temporal bones and brain. The patient was examined on two occasions. A sensorineural hearing loss, which was moderate in the right ear and mild in the left ear, was found. Abnormal vestibular function, indicative of central pathology, was also demonstrated. The right side of the medulla oblongata and pons was largely replaced by the tumor. The cochlear and vestibular nuclei and their connecting fibers were involved with the tumor. Histopathological changes were more prominent in the right cochlea and VII nerve than in the left and were minimal in the vestibular portion of the labyrinths. The otoneurological finding suggested a central nervous system (CNS) lesion, and the morphologic observations confirmed the central origin of the symptoms and signs. Manifestations of lesions of the central auditory and vestibular pathways are discussed.


Tachyphylaxis to the action of topically applied corticosteroids. A previously unrecognized pharmacological event, acute tolerance to the vasoconstrictive action of topically applied glucocorticosteroids, has been discovered in human skin. Thus, potent topical glucocorticosteroids will cause vasoconstriction when first applied to human skin but with subsequent applications the production of vasoconstriction rapidly diminishes. However, after a rest period of a few days, the same initial vasoconstrictive effect may be produced again, but this will also disappear if the steroid is again continued topically. These observations have important applications to optimum timing in the clinical topical use of glucocorticosteroids for maximum therapeutic advantage.


Multiple basal cell carcinoma and internal malignant tumors. One hundred ninety-six patients with multiple basal cell carcinoma were studied to clarify the relationship between multiple basal cell carcinoma and internal malignant neoplasms. No substantial deviations between the expected number and the observed number of cases of internal malignant neoplasms were found. On examination of patients who had histories of arsenic intake, a markedly high number of internal tumors were found in women but not in men. The figures are too low to prove that arsenic treatment can cause an increase in the incidence of internal malignant neoplasm, but they do indicate that more comprehensive studies are needed.


Adamantinoid basal cell epithelioma. A histological variant. Twenty-three instances of a histological variant of basal cell epithelioma are presented for the first time in the American literature, to our knowledge. This variant has been termed adamantinoid basal cell epithelioma because of its histological resemblance to adamantinoma (ameloblastoma) of the oral cavity.


Multiple primary cutaneous melanomas.

Multiple primary cutaneous melanomas. Of 1,444 patients with primary cutaneous melanomas, 57 (3.9%) developed more than one. Most had two primary lesions but one had six. Every effort was made to insure that all melanomas were primary tumors. Most patients developed new primary melanonas within five years of the original operation, but an appreciable number developed them many years later. In the largest group, second and subsequent primary tumors developed in different areas of the body at later times. The subsequent tumors were not diagnosed at an earlier biological stage than the original tumors. Patients with primary cutaneous melanoma should be made aware of increased risk of developing another primary melanoma and physicians should do careful examinations for new primary melanomas as well as for recurrences of the original melanoma.


Psoriasis on tumor.

Psoriasis on tumor. Indicators of the relative contribution of epidermis and dermis to the pathogenesis of psoriasis may be obtained from clinical observation. We studied a case of clinically characteristic and histologically identifiable plaque of chronic psoriasis occurring over transitional cell carcinoma metastatic to the dermis. The tumor substantially replaced the usual fibrous structure of the dermis, showing that a normally structured dermis is not requisite for the presence of psoriasis.


Candidiasis and multiple endocrinopathy. With oral squamous cell carcinoma complications. A 26-year-old man having multiple endocrinopathy (pernicious anemia, hypothyroidism, hypoadrenocorticism, gonadal failure, and diabetes mellitus) and chronic candidiasis developed several rapidly growing primary tumors on the oral mucosa. Histologically, the tumors appeared to be very well differentiated squamous cell carcinomas. Yet, in spite of all therapeutic attempts, the tumors rapidly progressed and within eight months resulted in disseminated carcinomatosis and death. At autopsy the patient was found to have had a miniscule dysplastic thymus. It is postulated that in chronic candidiasis and polyendocrinopathy a defect may exist in immunologic cellular surveillance for recognition and destruction of aberrant cells.


The importance of being visually literate. Observations on the art and science of making a morphological diagnosis in dermatology. Morphology (or living gross pathology) is being neglected in contemporary dermatology. It is high time for a renaissance of the teaching of the art and science of seeing, so that students, residents, and physicians can learn about basic morphological changes in the skin, the raison d'etre of the speciality of dermatology. How do we see? How can what we see be recorded? What do these recordings tell us when applied to morphological diagnosis? Basing my arguments on the studies of Thomas and others, I will discuss the significance of how much a physician actually sees, the effect of certain emotional states and blind spots, the ability to synthesize visually, and the influence of prior knowledge.


Survey of malpractice claims in dermatology. A statistical survey of malpractice claims asserted against dermatologists was made. The subject matter of the claims was divided into eight major categories: (1) drug reactions, (2) x-ray burns, (3) poor cosmetic result following surgery, (4) poor cosmetic result following medication, (5) failure to diagnose cancer, (6) improper diagnosis, (7) infection from treatment, and (8) miscellaneous. The study showed that a group of "serious" damage cases, which accounted for 34% of total claims, generated 94% of total dollar losses. The problem areas for malpractice claims appeared to be drug reactions, cosmetic chemosurgery, and failure to diagnose cancer.