Problems in the nutritional assessment of black individuals. Nutritional assessment of American Negro (Black) individuals of largely-African ancestry is complicated by differences that transcend socioeconomic status (SES). These include smaller size at birth but greater size from 2 to 14 years, advanced skeletal development ("bone age"), advanced dental development, a larger skeletal mass and bone "density" and a lesser rate of adult bone loss in the Black female from age 40 on as shown in a variety of bone-losing situtations, including renal osteodystrophies. Thus, appropriate dimensional and radiographic and radiogrammetric measures must be employed. Differences in hemoglobin concentration approximating 1.0g/100ml and in hematocrit levels also indicate the need for population-specific standards, otherwise gross errors will be made in calculating the per cent "deficient" and "low". Since self-assignments to racial categories are commonly used, the problem of racial identification is minimal. Failure to employ appropriate standards will result in underestimating the dimensional, radiographic and radiogrammetric effects of undernutrition in Blacks after the 2nd year, underestimating adult bone loss to a large degree, but overestimating the severity of hematologic responses from the 1st year through the 9th decade.


Health care and disease prevention through genetic counseling: a regional approach. The Colorado-Wyoming Regional Genetic Counseling Program has demonstrated the feasibility and utility of providing genetic counseling services over a very large area of the Rocky Mountain Region. A basis for preventing genetic and congenital disorders has been established and the patient care provided has been as comprehensive, sophisticated and effective as for any genetic counseling clinic operating in a medical center, with the added advantage of being accessible to a much larger and less financially able patient population. Utilization data and consumer assessment of the values of this service confirm these impressions.


The front line health worker: selection, training, and performance. Iranian villagers with basic literacy were recruited, selected, trained, and deployed as Village Health Workers (VHWs) to rural areas of Iran. VHW clinical visit records and activities logs were analyzed to determine levels and nature of effort achieved in the field. Within six months of deployment, the number of patient visits to VHW treatment services constituted 53% of the target population. Within ten months of deployment, the number of family planning acceptors rose from 8% to 21% of the population at risk. Improvements to water supplies have been effected in 50% of target villages. Sanitary improvements have been made to 35% of the houses and 88% of toilets in those villages. Demographic characteristics, class rank, and place of residence of VHWs appear unassociated with village differences in levels of achievement. However, availability of material resources and actual time spent by VHWs on the job may be factors influencing the differences in outcome between villages.


An introductory course in prescription drugs for community health workers developed by a systems approach. A 16-hour introductory course in prescription drugs for community health workers was developed by a systems approach. It featured an emphasis on: (1) learning the broad indications, side effects, and adverse reactions of the 30 most commonly prescribed drugs in the outpatient clinic, and (2) aiding the workers in patient education. Teaching materials were simple and inexpensive. An evaluation based on a pretest of the course's objectives compared to a final test documented the success of the instruction.


Renal involvement in patients with hepatosplenic Schistosomiasis mansoni. In a prospective study of renal involvement in 100 consecutively hospitalized patients with hepatosplenic schistosomiasis mansoni, 15 exhibited persistent proteinuria of varying degree, which in 6 instances was accompanied by hypertension. Nine patients had the nephrotic syndrome. The most common glomerular lesion in this group was membrano-proliferative glomerulonephritis. Surgical biospy obtained during splenectomy in 15 patients without clinical evidence of renal involvement showed glomerular lesions in 6 instances. Focal proliferative glomerulonephritis was the most common lesion in this group. The detection of silent glomerular lesions in patients with Schistosoma mansoni infection suggests that the glomerular alterations may precede clinical manifestations of renal disease.


Mycobacterium ulcerans (Buruli) skin ulceration in Nigeria. Twenty-two of 24 cases of Mycobacterium ulcerans infection in Ibadan are reviewed. The patients included Africans, Caucasians, and Indians. There were no differences between races in the manifestations of the disease. The average age of the patients was higher than that in other reports in the literature. The fact that most cases were originally wrongly diagnosed reemphasizes the need to search for M. ulcerans in cases of "tropical" ulcer that fail to respond to adequate therapy. Early recognition and surgery are the mainstay of treatment. Comexazole seems more effective than clofazimine in the treatment of these ulcers.


Cryptococcal granuloma (toruloma) of the central nervous system in a patient with schistosomiasis. A case of cryptococcal granuloma of the brain and lung is described in a Nigerian woman who also had Schistosoma haematobium infection.


Chromomycosis: a clinical and mycologic study of thirty-five cases observed in the hinterland of Rio Grande do Sul, Brazil. Data on thirty-five patients with chromomycosis seen in the hinterland of the State of Rio Grande do Sul (Brazil) are reviewed. Atypical lesions were found in 28.5% of the patients. The lesions were localized on the upper limbs and face in 14.2% and 8.5% of the patients, respectively. The clinical aspects and mycologic diagnosis of chromomycosis are discussed, and an account is given of its regional distribution in Rio Grande do Sul.


Dengue outbreaks in Guánica-Ensenada and Villalba, Puerto Rico, 1972-1973. Epidemics of dengue fever occurring in Puerto Rico in 1963 to 1964 and 1969 were caused by dengue-3 and dengue-2 (DN-2) viruses, respectively, but endemic dengue transmission has never been documented on the Island. Since the 1969 epidemic, a surveillance system has detected DN-2 activity on the Island during each of the years 1970 through 1973, which suggests endemic persistence of the virus. This report describes the investigation of localized outbreaks of DN-2 in Guanica-Ensenada (1972) and Villalba (1973), and presents epidemiological, serological, and virological data from the outbreaks. Analysis of geographic distribution of dengue activity in Puerto Rico in recent years indicates that the DN-2 transmission in 1970 to 1973 may represent a long tail-off of the 1969 epidemic rather than the emergence of a truly endemic situation.


Experimental transmission of trivittatus virus (California virus group) by Aedes trivittatus. The mosquito, Aedes trivittatus, when fed through a membrane a trivittatus virus dosage of 10(3.4) to 10(5.5) suckling mouse LD50/0.03 ml of blood, transmitted the virus to suckling mice. Virus multiplication indicative of a biological vector occurred in this species. When Aedes vexans and A. triseriatus ingested similar doses of trivittatus virus, both the infection and transmission rates were low and virus multiplication was poor. These results, added to evidence based on virus isolations from mosqito populations in nature, indicate that A. trivittatus is the primary vector of trivittatus virus in the north central United States.


Studies on x-ray induced chromosomal translocations in Anopheles albimanus. III. Effect of the release of translocation males on the dynamics of cage populations. Anopheles albimanus males carrying an Y-autosome translocation were continuously released into a cage population at a ratio of 1:5 in favor of translocation males. The release caused a significant decrease in the absolute density of cage populations. Virtually complete replacement of wild type Y chromosome by translocated Y chromosome was observed after four generations. The results obtained from the cage experiments encourage actual field trials for the control of this vector species.


Microfilaria of Wuchereria bancrofti in bone marrow smear. Microfilariae of Wuchereria bancrofti were detected in seven cases of anemia in persons with asymptomatic filariasis. In three cases microfilariae could not be detected in the blood. Their presence in bone marrow may indicate the ability of microfilariae to cross the vessel wall.


The prevalence of toxoplasmosis on Pacific Islands, and the influence of ethnic group. The prevalence of Toxoplasma dye-test antibody was determined in inhabitants of a number of Pacific islands, in Melanesia, Micronesia and Polynesia, and on Taiwan. With the exception of one island in French Polynesia, two Hawaiian islands, and Taiwan, Toxoplasma antibody prevalences were high, ranging between 84% and 100% in the adult populations tested. On the Hawaiian islands of Oahu and Hawaii, populated by several ethnic groups, and where about 50% of the total adult populations were estimated to have been infected with Toxoplasma gondii, a marked variation in prevalence of infection by ethnic group was observed. The lowest prevalence in the Hawaiian islands estimated at about 15% to 20% in adults, was observed in Japanese. On Taiwan, only 6% of adult ethnic Chinese and 1% of aborigines tested had Toxoplasma antibody.


Angiostrongylus cantonensis: lymphoid cell responsiveness and antibody production in rats. Angiostrongylus cantonensis-infected rats were examined for the presence of antigen sensitive lymphocytes, as assessed by the in vitro uptake of tritiated thymidine by cells of various lymphoid organs (cervical, mediastinal and mesenteric lymph nodes, spleen and periphereal blood), following stimulation by adult worm antigen. The lymphoid cell response of rats to A. cantonensis appeared to be local in nature in that significant responses were noted only in the cervical lymph node cells during the first 4 weeks of infection. The responses of spleen cells to phytohemagglutinin gradually declined as the infection progressed and this reduced responsiveness was statistically significant during the period of 5 to 10 weeks of infection. Homocytotropic antibody, demonstrated by 72-hour homologous passive cutaneous anaphylaxis, was detected throughout 2 to 17 weeks postinfection with a peak response at the 5th week of infection. The antibody was heat labile and sensitive to reduction by 2-mercaptoethanol and alkylation. Hemagglutinating antibody was first observed 5 weeks after infection and high titers occurred throughout 6 to 17 weeks postinfection.


Clinical observations on eosinophilic meningitis and meningoencephalitis caused by Angiostrongylus cantonensis on Taiwan. One hundred and twenty-five patients with eosinophilic meningitis or meningoencephalitis were studied in southern Taiwan in 1968 and 1969. The majority of patients had mild to moderate disease, but several had severe manifestations. Four patients died and three others had severe permanent sequelae such as blindness. Young adult Angiostrongylus cantonensis were recovered from nine patients, at autopsy in one, and from the cerebrospinal fluid of eight who survived. The clinical manifestations of cases of proven etiology were similar to those of cases from which parasites were not recovered and it is believed that the latter also were the result of infection with A. cantonensis.


Clinical and laboratory changes consequent to diethylcarbamazine in patients with onchocerciasis. This controlled study assesses the effect of a single oral dose of diethylcarbamazine (DEC) in a Guatemalan population with light infections of Onchocerca volvulus. From 8 to 24 hours after DEC, microfilariae were found with increased frequency in the urine, blood, and sputum, while the number of microfilariae per mm2 of skin decreased. The onset of signs and symptoms of reaction coincided with the appearance of microfilariae in the body fluids. Motile microfilariae were noted in the anterior chamber of the eye after the administration of diethylcarbamazine. Medication with corticosteroids appeared to reduce the symptoms of reaction without changing the laboratory results.


The homocytotropic and hemagglutinating antibody responses to Brugia pahangi infection in the multimammate rat (Mastomys natalensis). Homocytotropic and hemagglutinating antibody responses were followed in multimammate rate (Mastomys natalensis) infected with Brugia pahangi. Homocytotropic antibodies were detected by both active and passive cutaneous anaphylaxis using an antigen prepared from Dirofilaria immitis. The homocytotropic antibody response was first evident at 3 weeks after infection and increased progressively until after patency. It then waned gradually and was absent at 33 weeks after infection (or 20 weeks after patency). During this time microfilaremia continued to increase steadily. Homocytotropic antibody induced by the infection was heat (56 degrees C) labile, sensitive to 2-mercaptoethanol reduction, and was detected in the skin of recipients following a 72-hour latent period. Hemagglutinating antibodies to the infection were detected by the D. immitis antigen. These were present by 9 days after infection and persisted throughout the course of the infection. Only 2-mercaptoethanol labile antibody was detected during the prepatent period of infection.


The intensity and effects of infection with Schistosoma mansoni in a rural community in northeast Brazil. The intensity of infection with Schistosoma mansoni and its effects were investigated in a defined population living on three contiguous fazendas (subcounties) in a nonmalarious area of northeast Brazil near Salvador, Bahia. Quantitative stool egg counts (Bell technique) were performed on 363 of 417 individuals (90%) of all ages; physical examinations were done on 294 of 357 individuals (82%) 5 years of age and older. The maximum increase in prevalence was observed between the 1- to 4- and 5- to 9-year age groups, while the maximum increase in fecal egg count occurred between 5- to 9- and 10- to 14-year age groups. Highest egg counts were observed in the 10- to 14-year age group (geometric mean of 301 eggs per ml of stool) while the maximum prevalence (100%) was in the 20- to 24-year age group. In the fazenda with the lowest quantitative egg counts the age specific prevalence rates increased more slowly than in the fazendas with higher egg counts. In the study group nearly 50% of the total fecal egg output was accounted for by 22 individuals (6%) who had a mean age of 12.6 years. Egg counts for this selected group were all over 800 eggs per ml of stool with a mean of 1,514 eggs per ml of stool. In children under 15 years of age, the frequency of hepatomegaly and splenomegaly varied directly with the egg count; further, the degree of hepatomegaly was directly correlated with increasing egg counts. No splenic enlargement was noted in children not excreting eggs. In adults, on the other hand, neither splenomegaly nor hepatomegaly could be directly related to schistosomal infection per se. In children, neither the presence of infection with S. mansoni nor its intensity was reflected by altered anthropometric measurements. In the one fazenda tested the frequency of stools positive for occult blood correlated with increasing S. mansoni egg counts.


Echinococcosis in Arizona and New Mexico. Survey of hospital records, 1969-1974. In 1974, seven cases of human echinococcosis were diagnosed in Arizona and New Mexico. A retrospective survey of Arizona and New Mexico hospitals obtained data on ten additional cases reported for the 5-year period 1969 through 1973. Sixteen cases were diagnosed as Echinococcus granulosus infections and one as E. multilocularis infection. The latter infection was in an Eskimo from Alaska, where E. multilocularis is endemic. All of the 16 E. granulosus cases were probably acquired autochthonously; 14 were diagnosed in American Indians of the Navajo (8 cases), Zuni (4 cases), and Santo Domingo (2 cases) tribes; the remaining 2 cases were diagnosed in non-Indian women. This is the first published account of echinococcosis autochthonous to Arizona and New Mexico. Evidence suggests that the infection may have been introduced only relatively recently to the areas populated by the American Indians and that parasite transmission to humans is increasing.


Variation among geographic strains of Aedes albopictus in susceptibility to infection with dengue viruses. The comparative susceptibility to dengue virus infection of 13 geographic strains of Aedes albopictus was studied by feeding the mosquitoes on a virus-erythrocyte-sugar suspension. Significant variation in susceptibility for each of the four dengue serotypes was observed among the geographic strains. Mosquito strains which were more susceptible to infection with one dengue serotype also were more susceptible to the other dengue serotypes. There was a direct relationship between the amount of virus ingested and the infection rate in a given mosquito strain. A 100-fold difference in oral ID50 was noted between the most and the least susceptible strains. Crossing experiments between susceptible and resistant mosquito strains produced hybrid progeny with intermediate susceptibility. Susceptibility to infection by dengue 2 virus was decreased by selective inbreeding in one strain from 74% to 13% in two generations. Further selection, however, failed to produce a completely resistant line. It appeared that the actual "barrier" to infection was in the mosquito midgut.


Variation among goegraphic strains of Aedes albopictus in susceptibility to infection with chikungunya virus. Two types of variation were observed when the susceptibility of 16 different geographic strains of Aedes albopictus to oral infection with chikungunya (CHIK) virus was studied. One was differential susceptibility to infection with the virus. The other was variation in the quantity of virus present in infected mosquitoes after a standard incubation period. Mean virus titers of infected mosquitoes of different geographic strains varied almost 1,000-fold. Attempts to develop increasingly resistant or susceptible mosquito lines through genetic selection were unsuccessful. Infection rates did not change significantly despite 3 to 6 generations of selective inbreeding. In contrast, crosses between strains of high and low CHIK susceptibility yielded hybrid mosquitoes with infection rates and mean virus titers intermediate between those of the parent colonies. These data suggest that at least one factor controlling the susceptibility of A. albopictus to CHIK infection is genetic. Two lines of A. albopictus with a marked difference in susceptibility to oral infection with dengue viruses were equally susceptible to oral infection with chikungunya virus.


Vector competence of mosquitoes as a marker to distinguish Central American and Mexican epizootic from enzootic strains of Venezuelan encephalitis virus. Two epizootic strains of Venezuelan encephalitis (VE) virus from Central America and Mexico were transmitted by a colonized epizootic vector mosquito, Aedes taeniorhynchus, at higher rates than were two enzootic strains when the mosquitoes were infected by intrathroacic inoculation or feeding of virus. Differences in transmission rates also occurred with colonized Aedes aegypti, but were less marked. Following intrathoracic inoculation of A. taeniorhynchus or A. aegypti, epizootic strains grew to slightly higher concentrations in the mosquitoes than did enzootic strains. Intestinal thresholds of infection for A. taeniorhynchus were slightly lower for epizootic than for enzootic virus strains, but were essentially equal for A. aegypti. Only a small percentage of individual Culex pipiens quinquefasciatus mosquitoes supported growth of epizootic VE virus, and only 1 of 6 tested C. p. quinquefasciatus transmitted virus by bite. Thus, transmission and growth of virus in these Aedes mosquitoes distinguished between these epizootic and enzootic strains of VE virus.


Plasmodium brasilianum antigen for use in the indirect hemagglutination test. Antigen was prepared from Plasmodium brasilianum harvested from an infected spider monkey. This antigen was attached to aldehyde-fixed, human type O cells, and was tested against sera from human cases of P. malaria, P. vivax, P. falciparum, and P. ovale infection, and sera from noninfected persons. At dilutions of 1:16 or greater the antigen failed to react in sera from noninfected persons. It reacted at titers of 16 or above with sera from 85% of the persons with P. malariae infection, 83% with P. vivax infection, 70% with P. falciparum infection, and 70% with P. ovale infection.


Complications of nonoperative extraction of retained common duct stones. A morbidity of 5 per cent and no mortality occurred in 612 reported patients undergoing nonoperative extraction of retained common duct stones. Three patients with complications required reoperation, but morbidity and mortality with this new procedure of percutaneous stone removal is significantcantly less than that with operative reexploration of the common duct. The use of small caliber T tubes results in a greater rate of failure and entails more complications. A T tube of no less than number 14 French caliber should be used routinely [2]. Penrose drains should be placed separately from the T tube, and the T tube should be brought out through a lateral stab wound.


Nodal response in medullary carcinoma of the breast. From 1954 to 1970, ninety-five patients with medullary carcinoma of the breast were evaluated in terms of immunologic activity based on the histologic changes seen within the tumor and regional nodes. Each patient was studied for the degree of lymphocytic infiltration in the tumor as well as the extent of sinus histiocytosis present within the regional nodes. Contrary to what would normally be expected, those nodes with increased sinus histiocytosis were associated with the larger tumors. In addition, lymph node metastasis increased from 26 to 75 per cent as the degree of sinus histiocytosis became more pronounced. There was no evidence that increased lymphocytic infiltration in the tumor resulted in a statistically significant improvement in the five and ten year survival rates. Similarly, sinus histiocytosis activity did not seem to enhance the survival rate among this particular group of patients. There is a suggestion that a correlation exists between sinus histiocytosis and lymphocytic infiltration in the tumor and that, whatever the stimulus present, its effect is on both the lymph node and the degree of lymphocyte response within the tumor. The antigenic substance in the tumor, which initiates the immune response, possibly produces an abortive reaction, which may result in the induction of blocking factors rather then those factors necessary for destruction. It appears that histologic evidence of immunologic enhancement does not necessarily signify improved survival, at least with those patients having carcinoma of the breast.


Surgical management of epidermoid carcinoma of the anus. An analysis of twenty-six cases of epidermoid carcinoma of the anus from the University of Virginia Medical Center and 1,060 cases from the surgical literature has been presented. We believe this review justifies the following conclusions. (1) Considerable delay in diagnosis frequently occurs, adversely affecting the prognosis of patients with this disease. (2) Abdominoperineal resection remains the treatment of choice. Wide local excision is inadequate for most lesions, and should be reserved for lesions of the anal verge less than 2 cm in diameter with favorable histology, that is, low grade of malignancy. (3) Large lesions and those with a high grade of malignancy are associated with a poor prognosis, but even these patients may sometimes be cured with aggressive surgical excision. (4) Synchronous inguinal node metastases are associated with a poor prognosis, but an occasional patient may be cured by iliofemoral node dissection. (5) Iliofemoral node dissection is indicated for metachronous inguinal node metastases in the absence of distant spread. (6) Iliofemoral node dissection should not be performed if these nodes are not clinically involved with metastases. Approximately 70 per cent of these patients will not need this procedure and would therefore have this resection and its attendant morbidity unnecessarily.


Comparison of effect of narcotic and epidural analgesia on postoperative respiratory function. A prospective, randomized comparison was made of the value of meperidine versus epidural analgesia when used for the relief of pain after cholecystectomy in twenty patients without cardiopulmonary disease. Respiratory function was assessed the day before surgery and at 3 to 4 hours and 24 hours after operation by the bedside measurement of expiratory peak flow, vital capacity, and arterial blood gases. The two groups of patients were comparable as to age, height, weight, smoking habits, preoperative peak flow, vital capacity, and duration of operation. The arterial oxygen tension and oxygen saturation were significantly greater and carbon dioxide tension lower in the epidural analgesia group 24 hours after operation. At this time peak flow rates and vital capacity were not different. However, at 3 to 4 hours postoperatively, vital capacity was significantly greater in the epidural anesthesia group. This might account for the differences in arterial blood gases the following day. These findings suggest that epidural analgesia is valuable in the early postoperative period after upper abdominal surgery.


Operative treatment of appendix mass.

Operative treatment of appendix mass. From January 1972 to March 1974, thirty-four consecutive patients with appendix masses underwent acute appendectomy within 32 hours of admission. There was no death and no morbidity, except  local wound problems in six patients and drainage of pus from drain site in four patients. Twenty-four patients were afebrile without wound problems and could be discharged on the seventh postoperative day. Hospital stay ranged from seven to nineteen days with an average of nine days.


Abdominal angina. Intestinal absorption eight years after successful mesenteric revascularization. A woman with panmalabsorption and symptoms characteristic of abdominal angina underwent successful revascularization of the superior mesenteric artery. Laboratory studies obtained eight years postoperatively were compared with preoperative data. Her stool fat was reduced to 29 per cent of the preoperative quantity, although her dietary intake of fat was increased fivefold. The d-xylose tolerance test was increased to 346 per cent of the preoperative value, serum carotenes to 817 per cent, serum albumin to 172 per cent, hematocrit to 148 per cent, and cholesterol to 296 per cent. Her weight had risen from 69 to 122 pounds. We conclude that the panmalabsorptive defect associated with mesenteric vascular insufficiency is reversible and that the intestine may function normally for a prolonged period of time after revascularization.


Reoperation for amputation neuroma of the cystic duct. Two cases of amputation neuroma of the cystic duct are reported. In both instances, significant symptoms were totally relieved by excision of the neuroma. Review of the literature reveals at least twenty similar cases with the same results. Emphasis is placed on the importance of considering this diagnosis in postcholecystectomy patients after all the usual causes of right upper quadrant symptoms have been ruled out.


Extremity necrosis caused by indwelling arterial catheters. Four patients sustained tissue due to indwelling catheters, three of which were in radial arteries and one of which was in the dorsalis pedis artery, In one of the patients, septic thrombosis was demonstrated. The risk of such complications can be minimized by precannulation evaluation of the arterial circulation of the extremity, by proper care of the catheter when in place, and by careful observation for clinical evidence of infection, ischemia, and other treatable problems.


Hyperparathyroidism: ectopic parathyroid glands. A patient with a parathyroid adenoma located beneath the throid capsule and within a benign thyroid adenoma is reported on. To the best of our knowledge, this lesion has not previously been reported. This case points out the difficulties that may be encountered when it is necessary to locate a missing parathyroid gland in a patient with multinocular goiter. In this clinical setting there may be a role for use of the various technics recommended for preoperative localization of a parathyroid adenoma.


Neck mass caused by thrombus in the external jugular vein. Three cases of lateral neck tumors caused by thrombosis of the external jugular vein have been presented. Microscopic examination of the excised thrombosed veins revealed all of them to have a dilated architecture with somewhat degenerated vessel walls much like an aneurysm. Such a dilatation would cause some stasis and eddy currents and make the vessels more susceptible to thrombus formation. The final factor which induced these thrombi remains unknown. Indeed, when the interrelation of the factors discussed previously is considered, multiple etiologic factors appear most likely. Some form of minor trauma, although not documented, would still seem the most likely cause of thrombosis of a vein in a patient with no previous symptoms. In case III, trauma of inflammatory changes in a mass already noted to be present for some time could have induced thrombosis within the dilated vessel. Thrombosis of the external jugular vein is yet another lesion in the extensive differential diagnosis of a mass in the lateral neck.


A suture-tightening technic for delayed wound closure. A method is described that allows the tightening of standard suture materials for skin approximation of open wounds. The need for wire sutures in such circumstances is therefore unnecessary. The technic has been applied in delayed primary or secondary wound closure, and in the tightening of loosened ties or retention sutures.


A technic for restoring intestinal continuity after left hemicolectomy for cancer of the distal colon and rectum. Retroileal retroperitoneal transplantation of the transverse colon allows additional length for safe colorectostomy after left hemicolectomy in patients with short proximal colonic remnants.


Sliding lock modification of standard tissue forceps. This report describes a modification of the standard thumb forceps to provide a simple locking mechanism. This increases its usefulness in many surgical procedures. Certain advantages are presented and the instrument is illustrated and described.


A constant pressure infusor.

A constant pressure infusor. A device for maintaining a constant pressure in a pressure infusor is described.


Ketamine and the oculocardiac reflex. Dysrhythmia in pediatric strabismus surgery: the role of intravenous atropine. Fifty children in the age-group 1.75-10 years, admitted for cure of strabismus, were anaesthetised with intramuscular ketamine. Half the patients, at random, were given intravenous atropine, while anaesthetised, 5 minutes before operative interference. ECG recording of Lead 2 showed an oculacardiac dysthythmic response to muscle pull in 19 of the 25 unatropinised patients. The atropinised patients failed to show evidence of muscle induced dysrhythmia in any of the subjects (0%) The 25 control traces in the atropinised subjects showed no dysrhythmia after 5 minutes, but the possible immediate transitory dysrhythmic effects of atropine in the presence of ketamine anaesthesia is the subject of further study.


[The effect of Fentanyl and Althesin on haemodynamics, inotropism of the heart and myocardial oxygen consumption in man (author's transl)]. The acute effect of Fentanyl and Althesin upon haemodynamics, inotropism of the heart and myocardial oxygen consumption has not been studied in man so far. Healthy premedicated pateints (n = 16) were lightly anaesthetized with nitrous oxide-oxygen (ratio 2:1), 0.3 Vol.-% forane and 0.3 Vol.-% halothane respectively. In order to avoid any interference with respiratory depression all subjects were normoventilated via an orotracheal tube. In a circulatory steady state a single dose of 0.01 mg/kg Fentanyl (n = 7) and 0.075 mg/kg Althesin (n = 9) respectively was injected intravenously within 20 sec. After the application of Fentanyl there was a delayed (5th min) fall in blood pressure by 23%, which was due to a reduction in total peripheral resistance (12%) and in cardiac output (thermodilution technique) by 13%. The decrease in cardiac output was the result of a bradycardia (18%). Considering heart rate, pre- and afterload simultaneously, the fall in max dp/dt (catheter-tip manometer) by 20% could not be explained as a decrease in myocardial contractility. The altered haemodynamics led to a decrease of the myocardial oxygen consumption (control 6.4 ml O2/min x 100 g) by 31%. The energy demand of the heart was quantitatively calculated using the formula of the complex haemodynamic parameter developed by Bretschneider. Immediately after the administration of Althesin the cardiac output rose on account of tachycardia slightly, while stroke volume (19%), total peripheral resistance (32%) and mean arterial pressure (24%) reacted reversely. Since heart rate increased (11%), preload remainded unchanged and afterload decreased, the fall in dp/dt max (20%) has to be understood as a moderate reduction in myocardial inotropism. The energy demand of the heart decreased only initially by 15%. The clinical implications of the results were discussed.


[The effects of sodiumnitroprusside and trimethaphan induced hypotension on haemodynamics and myocardial oxygen consumption (author's transl)]. The influence of controlled hypotension (mean arterial pressure 60 mmHg) induced by sodium nitroprusside and trimethaphan on systemic circulation and myocardial oxygen consumption was studied in 7 anaesthetized closed chest dogs. The hypotensive effect of both drugs was primarily mediated by a reduction in total peripheral resistance. No change in cardiac output was observed. Stroke volume decreased in the presence of tachycardia. Left ventricular max dp/dt remained unaffected during sodium nitroprusside hypotension and was reduced by trimethaphan. Max dp/dt, load data and heart rate indicated that trimetaphan possesses negative inotropic properties. Sodium nitroprusside induced a hyperperfusion of the heart with a marked decrease in myocardial arteriovenous difference in oxygen. Myocardial oxygen consumption remained unchanged. Trimethaphan, on the other hand, induced only small increments in coronary blood flow and a rise in the arteriovenous difference in oxygen of the heart. This resulted in a higher myocardial oxygen consumption (+16%). Cardiac efficiency was lessened by trimethaphan and remained unaffected in the presence of sodium nitroprusside. As sodium nitroprusside neither affects myocardial oxygen consumption nor alters myocardial contractility, we conclude that sodium nitroprusside has advantages over trimethaphan in the management of controlled hypotension and in the therapy of hypertensive crisis and cardiogenic shock.


Nephrotoxic effect of methoxyflurane anesthesia. A case report. A patient with normal preoperative hepatic and renal laboratory findings was exposed to relatively low concentrations of methoxyflurane during a routine anaesthetic procedure. For at least 12 postoperative days, the patient showed unusually high level of inorganic serum fluoride; his urinary excretion of fluoride and oxalic acid were also increased. However, he had no clinical signs of nephrotoxicity. This observation suggests that some patients with presumably normal renal function may have a low threshhold for the nephrotoxic effects of methoxyflurane.


[Reduction of apparatus deadspace in pediatric anaesthesia (author's transl)]. The size of inhalation equipment deadspace in infant anaesthesia is of critical importance. While endotracheal intubation reduces anatomical deadspace, the added deadspace of the tube connector tends to increase the overall deadspace by 6 to 10 ml. In order to ensure optimal gas exchange at minimal respiratory effort a new tube was designed which separates inspiratory gas down to the level of the vocal cords and maintains rapid gas flow by a Venturi injector. In controlled air ventilation this tube improves arterial pO2 by 15% and reduces tidal-volume 35% compared to Magill tubes of equal size.


The temperture inside carbon dioxide absorbers. The temperature changes which occur when soda lime is used to absorb carbon dioxide were measured simulated clinical conditions. The temperature reached in the circle absorption system was found to vary with the room temperature; with a room temperature of 24 degrees C, all brands of soda lime tested reached 40 degrees C in the centre of the circle system. The 'to and fro' absorber achieved a central temperature approximately 5 degrees C higher than in the circle absorber. Temperatures at the periphery were always lower than those measured at the centre of the system. It is still advisable to avoid the use of trichloroethylene in the presence of soda lime and the absence of a safety lock on new anaesthetic machines is regrettable.


[Suxamethonium-induced hyperkalaemia in patients with severe intraabdominal infections (author's transl)]. A serious danger to the circulation following the administration of suxamethonium is known to occur in patients reacting with an abnormal release of potassium. So far the following groups of patients have been found to be at an increased risk: burns, multiple trauma, tetanus, neurological disorders, uraemia. As a result of our investigations patients with severe intraabdominal infections are also to be regarded as at risk. Four of ten patients with this diagnosis have shown an increase of serum-potassium of more than 2.5 mequiv/l following suxamethonium injection in spite of a prophylactic small dose of nondepolarizing relaxant. The predisposing factors are high fever of over a week's duration and a leucocytosis of more than 10,000/cu. mm. A possible hypothesis and pathogenesis of the abnormal efflux of potassium is discussed. Prophylaxis consists of using only nondepolarizing relaxants in these cases. When there is a special indication for suxamethonium the potassium increase can be lessened if the patient is given a small dose of nondepolarizing relaxant prior to the administration of suxamethonium.


Adsorption of anaesthetic vapours on charcoal beds. The adsorptive properties of four charcoals have been examined in relation to their value as adsorbents in filters attached to an anaesthetic trolley. Data for four anaesthetics have been obtained. The test conditions (flow rate, concentration, humidity) were those relevant to the application, and the effect of variation of these conditions was also studied. The air flow resistance of the charcoals was measured. Basic data are thus provided for the design of suitable adsorbers. The performance of two prototype anaesthetic adsorbers has been measured.


Effects of sodium nitroprusside during the excision of phaeochromocytoma. A case report is presented which illustrates the use of sodium nitroprusside to control blood pressure levels during neurolept anaesthetic technique for removal of phaeochromocytoma. In this case the evanescent action of nitroprusside was advantageous since when the drug was discontinued elevation of blood pressure gave rise to suspicion that further catecholamine-secreting tumour was present. In all, four such tumours were removed from this patient.


Circadian rhythm in DNA synthesis in mouse thymus: effect of altered lighting regimens, restricted feeding and presence of Ehrlich ascites tumor. A circadian rhythm in the incorporation of tritiated thymidine into DNA of the mouse thymus has been described. This same rhythm in animals bearing an 8-day Ehrlich ascites tumor (EAT) was altered in its phasing, wave-form and over-all 24-hour mean; the most striking alteration seen in four out of five studies was a reduction in the over-all DNA synthesis rate in tumor-bearing animals. Mice subjected to an altered light-dark cycle did not show a complete phase shift in their thymus DNA rhythm within two weeks, but during this time the rhythm in the mitotic index of their corneal epithelium completely phase shifted; the presence of the tumor had no effect on this latter rhythm. In mice subjected to a daily 4-hour restricted feeding schedule, the rhythm in DNA synthesis in the thymus became synchronized in that the peak occurred toward the end of the 4-hour restricted feeding span in both tumor and non-tumor-bearing animals. The rhythm in the mitotic index in the cornea was not phase shifted or altered by the restricted meal timing. The DNA synthesis rhythm in the normal thymus demonstrated a phasing similar to (1) the rhythm in the length of survival time in untreated mice challenged with EAT and (2) the rhythm in DNA synthesis in the normal spleen.


Cell differentiation in the terminal tubule of fetal rat submandibular gland in organ culture. Submandibular glands from 17-day-old rat fetuses were maintained in organ culture for five days in a medium consisting of Eagle's MEM (87%), horse serum (10%), and chick embryo extract (3%). Each day of the culture period explants were incubated for the demonstration of peroxidase activity and processed for light and electron microscopic observations. In some experiments cultures were exposed to 3H-thymidine one hour prior to fixation and incubation for the demonstration of peroxidase activity. Labelling index was determined using radioautographs of 1 mu Epon-embedded sections. At the time of explantation the submandibular gland rudiment consisted of undifferentiated epithelial cells arranged in cords. On day 3 of culture two additional cell types could be distinguished: terminal tubule cells and proacinar cells. The proacinar cells were characterized by peroxidase activity in their granules and cytoplasm. By day 4 acinar cells begin to appear. On the fifth day of culture the four cell types of the terminal tubule were present in the following proportions: undifferentiated cells, 44%; terminal tubule cells, 19%; proacinar cells, 31%; acinar cells, 6%. These results indicate that the cytodifferentiation of the secretory unit of rat submandibular gland in vitro is comparable to the differentiation in vivo.


Quantitation of ultrastructural changes in the mouse pineal in response to continuous illumination. Adult male mice were exposed to either alternating illumination or constant illumination for 70 days. Light and dark pinealocytes were compared as to distribution within the gland and ultrastructure. Quantitative studies with the electron microscope revealed a significant reduction in pinealocyte size and Golgi complex size in constant light treatment, as well as a marked but nonsignificant reduction in the concentration of lipid droplets and irregular vacuoles. Under constant light treatment the cross-sectional area of pinealocyte pericapillary terminals and the number of granulated vesicles per terminal decreased significantly. A greater number of mitochondria appeared swollen, with rarified matrix and reduced numbers of cristae, with constant light treatment. These results provide ultrastructural correlation with the known reduction of pineal weight, protein synthesis and antigonadotrophic activity that is seen with constant light treatment. The marked decrease in concentration of pinealocyte granulated vesicles in constant light treatment gives morphological support to the theory that these vesicles contain antigonadotrophic secretory material.


A freeze-fracture study of sarcoplasmic reticulum from fast and slow muscle of the mouse. Sarcoplasmic reticulum (SR) of fast extensor digitorum longus (EDL) and slow soleus (SOL) muscles of the mouse was examined by freeze-fracture techniques. A distinctive feature of sarcoplasmic reticulum from the EDL is the presence of hillocks on the A-face within the terminal cisterns. These hillocks are usually arranged in a single row which is deployed parallel to the long axis of the adjacent T-tubule. Center-to-center spacing of hillocks within a row is about 70-75 nm. Hillocks are also found scattered within the collar region. The EDL of ten week mice was characterized by sheet-like terminal and intermediate cisterns, the latter being replaced in 37 week animals by thin tubular longitudinal elements of the SR which contain no hillocks or dimples. Hillocks occur only occasionally in SR from 10 or 20 week SOL muscle. In such cases the hillocks occur singly rather than in rows as in the terminal cisterns of EDL. The predominant form of SR in the SOL contains no hillocks. Total particles in the A-face of EDL-SR (2996 particles/mu2; S.D. = +/- 287) slightly exceeded that of SOL-SR (2558 particles/mu2; S.D. = 274 8 NM). Packing density of 8 nm particles was slightly higher for EDL (750/mu2) VS. SOL (700/mu2). The possible significance of these features of SR in fast and slow muscle is discussed.


Folliculogenesis in the ovary of the mature mouse: a radioautographic study. Studies on the growth sequence of follicles in mature mice four to six months old were conducted by giving the three injections of 16 muCi tritiated thymidine (3H-T)/gm body weight at four hour intervals over a period of eight hours. Subsequent radioautographic analysis on ovaries obtaine d 1,3,5,9, and 17 days after the last injection showed an overall follicle growth time of 17 to 19 days. The duration of the different follicle stage times were also estimated from radioautographic data. Intense 3H-T incorporation was noted in the developing antra and zona pellucida of follicles of animals sarcrificed on e and three days after treatment suggesting that these areas serve as precursor storage sites during development. Oocytes of follicles in early antrum formation also showed juxtanucleolar 3H-T incorporation concomitantly with rapid and massive oocyte and follicular growth. The findings further indicate that the earliest follicular cells surrounding the oocyte originate at some distance from the developing primordial follicle.


Dobutamine for inotropic support during emergence from cardiopulmonary bypass. Dobutamine, a recently introduced derivative of dopamine, is reported to retain inotropic properties with less pronounced chronotropic and arrhythmogenic effects than isoproterenol. The drug was evaluated in two doses, 5 mug/kg/min and 10 mug/kg/min, in two groups of ten patients each, during emergence from cardiopulmonary bypass. A third group of five patients was studied similarly with isoproterenol, 0.02 mug/kg/min. Cardiac index increased 16 and 28 per cent eith the two doses of dobutamine, respectively, and 9 per cent with isoproterenol. Heart rate, in contrast, increased 6 and 15 per cent with dobutamine (not significant) and 44 per cent with isoproterenol (significant). Dobutamine seemed to associated with fewer arrhythmias than isoproterenol. It is concluded that dobutamine, 5-10 mug/kg/min, is suitable for use during emergence from cardiopulmonary bypass and may possess advantages over isoproterenol.


Microbial flora of the larynx, trachea, and large intestine of the rat after long-term inhalation of 100 per cent oxygen. Effects of long-term inhalation of 100 per cent oxygen on the microbial flora of the rat larynx, trachea, and large intestine were studies. Rats were kept 14 days in an atmosphere of 100 per cent oxygen after being conditioned to high oxygen concentrations by exposure to three cycles of 100 per cent oxygen (two days) alternating with 40 percent oxygen (two days). Controls were kept under similar conditions in normal atmosphere. Rats were sacrificed, and at necropsy laryngotracheal swabs and fecal material from the large intestine were obtained and cultured for bacteria and fungi. Streptobacillus moniliformis, the predominant microorganism in the upper tracheas of controls, was not isolated from the oxygen-treated rats. Alpha-hemolytic streptococcus and Staphylococcus albus were present in control rats, but were found less frequently in rats exposed to oxygen. Pseudomonas and Proteus, infrequently isolated from controls, were predominant and sometimes the only microorganisms isolated from oxygen-treated rats. The data indicate that prolonged exposure of the rat to 100 per cent oxygen shifts the microbial flora in the upper respiratory tract from mainly gram-positive to mainly gram-negative bacteria. In contrast, there was no significant difference between the microbial flora in large intestines of control and oxygen-treated rats. The possibility that similar changes may occur in man should be considered when prolonged oxygen therapy is contemplated.


Biphasic respiratory depression after fentanyldroperidol or fentanyl alone used to supplement nitrous oxide anesthesia. Either fentanyl or Innovar (fentanyl, 0.05 mg/ml, and droperidol 2.5 mg/ml) was administered to supplement nitrous oxide anesthesia for operations on 29 patients. Both fentanyl and Innovar depressed the slope of the rebreathing CO2 response curve during operation to 42 per cent +/- 6 (mean of all intraoperative values, +/- SE) of the awake control value. Following the last injection of drug but with continuation of operation, the slope increased such that it was 77 per cent +/- 8 of control on the patients' arrival in the recovery room. The slope continued to increase to a peak of 103 per cent +/- 9 of control. Soon therafter respiratory depression recurred, as indicated by a decline in the slope to 55 per cent +/- 5 of control, with a subsequent gradual return to 85 per cent +/- 8 of control 230 minutes after the last injection. This biphasic response occurred in 90 per cent (26 of 29) of the patients treated either with fentanyl alone or with Innovar. Full recovery appeared to be more rapid with Innovar than with fentanyl alone. Droperidol did not augment and may have attenuated fentanyl-induced respiratory-depression.


Early and late relative potencies of pancuronium and d-tubocurarine in man. In ten patients anesthetized with halothane and nitrous oxide, d-tubocurarine or pancuronium was infused continuously for 80 minutes to produce a constant 90 per cent depression of twitch tension. For the first 30-minutes period, 8.2 +/- 0.32 and 1.09 +/- 0.06 (mean +/- SE) mg/m2 of d-tubocurarine or pancuronium, respectively, were required, and for the last 30-minutes period (50 to 80 minutes of infusion) 2.1 +/- 10.10 and 0.41 +/- 0.02 mg/m2 were required, giving potency ratios of 8.2/1.1, i.e., 7.4, and 2.1/0.41, i.e., 5.1. The difference in potency ratios in the first and last 30-minutes periods implies that potency values determined by single-injection techniques inadequately describe the relative requirements for sustained paralysis. The mean ratios between that amount of relaxant representing tissue uptake and that amount representing metabolism and renal excretion during the first 30 minutes were 3.06 +/- 0.28 for d-tubocurarine and 1.63 +/- 0.19 for pancuronium. The significantly higher ratio for d-tubocurarine implies that its tissue uptake relative to metabolism and renal excretion is greater than that for pancuronium. The higher ratio for d-tubocurarine may be partly explained by its greater binding to plasma and tissue proteins.


Bulk oxygen and nitrous oxide delivery systems: design and dangers. A survey of hospitals with anesthesia residency training programs was undertaken to determine the frequency and types of complications encountered with the use of bulk supplies of oxygen and nitrous oxide. Of the responding hospitals, 98 per cent dispense oxygen from a central source and 80 per cent dispense nitrous oxide from a central source. Nearly a third of the hospitals responding reported the occurrence of serious or potentially serious accidents related to their bulk gas delivery systems. In three instances accidents resulted in patient deaths. More than half of the reported incidents were decreases in oxygen pipeline pressure, often resulting in insufficient delivery of oxygen for clinical use. Most complications related to pipeline accidents could have been prevented by observance of National Fire Protection Association regulations. Anesthesiologists should be familiar with these regulations and should understand the designs of gas delivery systems in their institutions.


Lidocaine and increased respiratory resistance produced by ultrasonic aerosols. Respiratory resistance significantly increased from 5.0 to 8.0 cm H2O/1/sec in anesthetized patients who were given ultrasonically nebulized water for 20 minutes via an endotracheal tube. Intravenous administration of lidocaine failed to reverse the provoked increase in resistance. In another group, respiratory resistance significantly increased from 5.8 to 7.5 cm H2O/1/sec in response to nebulized water despite prior and con-current intravenous administration of lidocaine. In a third group, initial respiratory resistance was 5.6 cm H2O/1/sec and did not increase during a 20-minute challenge with intratracheally administrered ultrasonically nebulized 2 per cent lidocaine. In a final group, resistance was increased from 5.0 to 6.9 cm H2O/1/sec with nebulized water. When challenge was continued with nebulized 2 per cent lidocaine, resistance remained elevated for about 10-12 minutes. It then decreased and returned to its initial control value at about 17 minutes, despite continuing lidocaine aerosol administration. Lidocaine, when administered intratracheally as an aerosol, both prevented and reversed provoked increases in respiratory resistance. Intravenously administered lidocaine was ineffective. Intratracheal administration of ultrasonically nebulized lidocaine might be another useful technique for management of bronchoconstriction in anesthetized patients.


Ethanol and contraction of venous smooth muscle. Low concentrations of ethanol (17 mM) inhibited development of spontaneous mechanical activity (vasomotion) in isolated rat portal veins. Low concentrations of ethanol potentiated, however, contractions induced by epinephrine, but not those induced by angiotensin or potassium. Higher concentrations of ethanol, such as those associated with surgical anesthesia (100-170 mM), resulted in almost complete suppression of spontaneous contratile responses. These higher concentrations of ethanol: a) attenuate contractions induced by epinephrine, angiotensin, and potassium (K+); b) cause noncompetitive displacement of the dose-response curves of these vasoactive compounds; c) attenuate calcium (Ca++)-induced contractions of K+-depolarized portal veins; d) relax drug-induced, as well as Ca++-induced, contractions of portal veins. The profound depressant actions of ethanol are not mimicked by alpha-adrenergic, histaminergic, cholinergic, or serotonergic blocking drugs, nor are they attributable to actions on beta-adrenergic receptors. The direct vasodepressant actions of ethanol on isolated venous smooth muscle may play a significant role in alcohol-induced peripheral vasodiatation seen in man and animals.


Nitroprusside-induced cyanide poisoning: antidotal effect of hydroxocobalamin. Sodium nitroprusside was investigated as a potential source of cyanide poisoning, Whole-blood cyanide determinations were performed on arterial samples from baboons receiving nitroprusside while anesthetized. There was a statistically significant increase in cyanide levels, as well as development of tachyphylaxis and severe metabolic acidosis. Hydroxocobalamin (vitamin B12a) infused simultaneously with nitroprusside significantly lessened the increase in cyanide levels and eliminated the development of metabolic acidosis. Nitroprusside can cause cyanide intoxication in the baboon, and hydroxocobalamin appears to be an effective antidote.


A systematic approach to the evaluation of immunological disease patterns. An approach to the detection and investigation of immunological disease patterns is presented in the form of a relationship of etiology to disease and the major diagnostic procedures available to evaluate the etiological agents. The presentation is made in the form of a preamble which outlines the mechanisms of each class of dysfunction. Four tables are included which serve to amplify and detail the format of approach and the immune mechanisms.


Allergy and learning disabilities in children. Allergic children suffering from learning disabilities, hyperactivity, fatigue, incoordination and irritability who were treated by conventional allergic methods showed a marked improvement in ability to learn, reduction of hyperactivity and incoordination, and ability to perform intelligence tests. The objective neurological studies showed no consistent changes as a result of one year of allergy therapy.


Comparison of skin tests and RAST in the diagnosis of atopic hypersensitivity. Prick, intracutaneous tests and the radioallergosorbent test (RAST) were performed with 12 common allergens in 50 consecutive patients who required skin testing during an allergy investigation. Results of prick test and RAST showed agreement in 82.7% of tests but positive prick tests were much commoner than positive RAST tests. When intracutaneous tests were required to obtain a positive skin test, agreement between skin test and RAST fell to 66.5%.


Allergy and recurrent urinary tract infections in childhood. II. Fifty selected patients with recurrent urinary tract infections and allergy problems were treated with a comprehensive allergy regime. The results demonstrated that the recurring urinary tract infections ceased or were distinctly alleviated by treatment of the presenting allergic condition. Of the 50 patients 42 were definitely benefited.


Diabetes mellitus and insulin in an aspirin sensitive asthmatic. The infrequency of diabetes mellitus and asthma in the same individual is re-examined. The antagonism between epinephrine and insulin, as suggested by Konig in 1935, is indeed accurate. The assays done by the Eli Lilly Research Department revealed no in vitro effect of insulin on the CAMP and GMP level of mast cells as occurs in liver cells. It is felt that this effect is probably an in vivo effect produced via the vagus nerve and alpha-adrenergic receptor system stimulation. This would explain the mechanism of aggravation of asthma by excess insulin. Dr. Petersen's studies, the negative intradermal skin tests to insulin and the absence of change on either beef or pork insulin usage by our patient all point to a nonatopic factor in the aggravation of the asthma of this patient. In the uncommon occurrence of asthma and diabetes in the same patient, insulin dosage should be considered as a factor in all such asthmatics who do not respond well to conventional therapy. Two additional asthmatics who also have diabetes did improve with cessation of nocturnal asthma by a reduction of their evening dose of insulin. A high fat, low carbohydrate diet, as suggested by Abrahamson to avoid dietary hyperinsulinism, is certainly worth considering in patients with nocturnal asthma. If patients cannot be made to follow a diet requiring frequent feedings high in protein and fats and low in carbohydrates, another approach suggests itself. Abrahamson was able to relieve the patients who developed nocturnal asthma with hypoglycemia by having them drink a glass of milk. Assuming other causes have been eliminated and a patient awakens each day at 3:00 a.m., an alarm clock could be set at 2:00 a.m. Milk or a milk substitute in milk sensitive patients could be taken at 2:00 a.m. to raise the blood sugar and hopefully prevent the asthma associated with hypoglycemia. Also to be noted is the ubiquitous use of tartrazine in so many drugs, including those used to relieve asthmatic symptoms. Inasmuch as tartrazine so frequently aggravates the aspirin sensitive asthmatic, it would be wise for pharmaceutical companies to become cognizant of this fact and delete tartrazine from their antiasthmatic preparations.


Cardiopulmonary effects of enflurane and isoflurane in the dog. The cardiopulmonary effects of 2 new inhalant anesthetics, enflurane and isoflurane, were studied in nonsedated, previously instrumented, awake dogs. Base line values were determined, and anesthesia was induced and maintained with the drug being studied. Enflurane depressed cardiopulmonary function to a greater extent than isoflurane. The depression of cardiopulmonary function from both agents increased with increasing depth of anesthesia. Enflurance produced muslce twitching, but isoflurane did not.


Cell-mediated immunity and age at vaccination associated with measles inoculation and protection of dogs against canine distemper. The antibody-mediated immune response (AMIR) of dogs to measles and canine distemper viruses has been described. However, there is little information on the cell-mediated immune response (CMIR). The AMIR and the CMIR of dogs to canine distemper and to measles were examined. The CMIR was determined for 6 weeks by measuring the 3H-thymidine uptake by immune lymphocytes in the lymphocyte transformation test. Concurrently, canine distemper and measles virus serum-neutralization antibodies were measured by a microtitration serum-neutralization test. Dogs vaccinated with canine distemper virus had a CMIR and an AMIR to canine distemper. However, measles virus-vaccinated dogs had only a CMIR to canine distemper. A CMIR in the absence of an AMIR indicates that cell-mediated immunity is the most important immune mechanism in protecting measles virus-vaccinated dogs against canine distemper. Development of CMIR and AMIR to canine distemper and measles antigens depended on the age of the dog at the time of vaccination. Adult and juvenile dogs had immune responses to both canine distemper and measles. Neither virus, however, elicited an immune response in neonates.


Critical tests and safety studies on trichlorfon as an antiparasitic agent in the horse. Three series of critical tests were completed on a combined total of 46 horses to determine the efficacy of single doses of trichlorfon against bots, ascarids, pinworms, and large strongyles. Different formulations of trichlorfon were administered by tubing intragastrically, mixing with the daily grain ration, injecting intramuscularly, or pouring on the back at dose rates between 20 and 100 mg/kg. Administration by feeding tended to be more efficacious for removal of bots and less toxic to the horese than administration by stomach tube. In many of the tests, trichlorfon was given in the grain ration at the dose rate of 40 mg/kg of body weight, and the aggregate average removals of 2nd and 3rd instars of Gastrophilus intestinalis and Gasterophilus nasalis in the 3 series of tests were between 97 and 100%. Removal of Parascaris equorum was equally efficacious with both the intubation and the grain feeding methods of dosing, and at the dose rate of 40 mg/kg, the aggregate averages were 99 and 100% in the 3 series. Removal of Oxyuris equi was variable--aggregate averages were between 11 (1 infected horse in the initial series) and 96 (5 infected horses in the 3rd series) to 100% (7 infected horses in the 2nd series). Large strongyles, Strongylus vulgaris and Strongylus edentatus were almost completely refractory to the 40-mg/kg dose rate of trichlorfon. Dose rates of 40 mg/kg and less were generally well tolerated by the critical test horses. Higher dose rates (60 and 80 mg/kg) administered by stomach tube induced moderately severe to severe colic and diarrhea, whereas a dose of 80 mg/kg given in the feed resulted in only a transient softening of the feces. Likewise, 5 consecutive doses, 1 week between doses, of a bolus formulation given at the rate of 80 mg/kg to 4 horses were well tolerated. Clinical trials involving a total of 2,294 treatments of trichlorfon at dose rate of 35 to 40 mg/kg in pregnant and nonpregnant mares, stallions, suckling and weanling foals, yearlings, and horses in training on 38 farms in central Kentucky did not cause notable adverse clinical effects.


Influence of prednisolone on intravascular granulocyte kinetics of calves under nonsteady state conditions. The influence of prednisolone on granulocyte kinetics in calves was evaluated under nonsteady state conditions, using chromium-51 as a cell label. The kinetic pattern observed was similar to that described for persons. Interpretation of results indicated that alteration from steady state to granulocytosis was the result of an increase in input from the storage pool and that shifts occurred in the distribution of cells between the marginating and circulating pools during the period of rapidly changing kinetic patterns. Granulocyte kinetic variables of a calf under induced physiologic stress demonstrated a kinetic pattern similar to that of the calves given prednisolone. There was a rapid enlargement of the total granulocyte pool size and a greater than twofold increase in clearance halftime compared with those in calves of a similar age group.


Experimentally induced Mycobacterium avium serotype 8 infection in swine. Five of 6 swine experimentally inoculated with Mycobacterium avium serotype 8 had microgranulomas in the cervical or mesenteric lymph nodes at necropsy 92 days later. In vivo tuberculin skin reactivity and in vitro lymphocyte immunostimulation responses were evaluated at 10 and 12 weeks after the pigs were inoculated. Positive responses were obtained on both tests in inoculated pigs, whereas test results in noninoculated pigs and pigs given killed bacterial cells were negative. Mycobacterium avium serotype 8 was isolated at necropsy from the cervical or mesenteric lymph nodes of each of the pigs inoculated with viable microorganisms and from the 2 pigs kept in the pen with inoculated swine. Mycobacteria were not isolated from tissues of the noninoculated swine or those given killed cells.


Electron microscopic studies of estrogen-induced ciliogenesis and secretion in uterine tube of the gilt. The time required for occurrence of estrogen-induced uterine tubal (oviductal) ciliogenesis and for differentiation of secretory cells was studied, utilizing electron microscopy procedures. Sixteen cycling gilts were ovariectomized; 3 to 4 months later, 12 principal gilts were each given subcutaneous injections of 17 beta-estradiol in 0.5 ml of corn oil at the rate of 200 mug/day, and 4 control gilts were given injections of corn oil only at the rate of 0.5 ml/day. Two principals each were killed on days 1, 2, 3, 4, 5, and 7 after start of treatment. The epithelial heights were low and completely atrophied 3 to 4 months after ovariectomy. Uterine tubal cilia were absent in all the control gilts. Cytologic changes were not seen in the atrophied epithelium of ovariectomized gilts 1 day after estradiol treatment, but definite proliferative elements consisting of an extensive fibrillar meshwork encrusted with granules (60 to 80 nm) were observed in close association with the nuclear envelope and in the apical cytoplasm after 2 days of estradiol treatment. By day 3, enlarged electron-opaque granules referred to as condensation forms, undergoing various stages of depletion, were closely associated with radially arranged procentrioles. These associations have been referred to as generative complexes. The presence of many generative complexes indicates that maximal production of basal bodies can be expected after 3 days of treatment with estradiol. The depletion of the condensation forms produced hollow spheres with thin walls as the procentrioles grew in length and assembled their microtubules. Enlarged mature-appearing basal bodies were abundant in the cytoplasm after 3 days of estradiol treatment. These bodies aligned themselves linearly along the luminal surface of the cell. Small ciliary buds were then formed above the cell surface, and ciliary filamentogenesis occurred in the bud. Motile cilia were observed on day 3, but cilia numbers increased markedly between day 4 and days 5 and 7. Procentrioles were generated from the diplosomal centriole after 2 days of estradiol treatment. These observations have provided evidence for both ancentriolar and centriolar basal body replication in the ciliated cells of uterine tube of the gilt. Maximal secretory cell differentiation occurred after 3 days of estradiol treatment. Hypertrophy of cytoplasmic organelles was evident on day 3, but the number of secretory granules and amount of rough endoplasmic reticulum increased markedly on days 5 and 7. Close association of secretory granules, Golgi apparatus, and endoplasmic reticulum was evident after estadiol treatment. These data indicate that both ciliated and secretory cells are sensitive to estrogen.


Efficacy studies on Haemophilus gallinarum bacterin preparations. Broth cultures inactivated and potentiated by selected methods were tested in chickens for efficacy against homologous and heterologous challenge inoculation, using 2 serotype A strains of Haemophilus gallinarum. Although the 2 strains were within the same serotype, they failed to cross protect. One dose of thimerosal-inactivated bacterin was protective against homologous challenge, but 2 doses of formalin-inactivated bacterin were required. A bivalent bacterin protected chickens well against 1 strain, but not the other, at the 1-dose level.


Evaluation of radioiodinated human serum albumin in the dog for assessment of hemodynamic function. Radioiodinated human and dog serum albumins, each labeled with a different radioisotope of iodine (125I and 131I, respectively), were injected intravenously into dogs. Plasma volumes and plasma clearance half times were used for the comparative evaluation of the 2 radiopharmaceuticals. After repeated injections in a 6-week period, differences in these values could not be demonstrated. Plasma volumes obtained with both radioiodinated serum albumins compared favourably with the previously reported values in dogs.


A procedure for pulmonary lavage in mice. A method for the pulmonary lavage of mice is described. The procedure includes exsanguination of anesthetized mice by severting the renal artery, inserting a tracheal catheter in situ, and repeatedly injecting and aspirating 0.9% sodium chloride solution. Protein was recovered from the cell-free lavage fluid even after a given mouse was lavaged several times. The major part of the protein, however, was obtained with 1-ml washes repeated 3 times. Approximately 0.563 mg of protein was recovered by the procedure from a 29-g mouse. Four lavages per mouse yielded approximately 2.9 x 106 free cells.


Intestinal infection of neonatal dogs with canine coronavirus 1-71: studies by virologic, histologic, histochemical, and immunofluorescent techniques. Enteritis induced in neonatal dogs by oral inoculation of coronavirus 1-71 was studied by virologic, histologic, histochemical, and immunofluorescent antibody methods. The enteritis, accompanied by diarrhea, developed in 4 to 7 days and was characterized by atrophy and fusion of intestinal villi and deepening of crypts, increase in cellularity of the lamina propria, flattening of epithelial cells, and discharge of goblet cells. Intra-epithelial enzyme activities generally were depressed. Specific immunofluorescent antibody reactions were present in villous epithelium of the duodenum starting on postinoculation day 2 and of the ileum on day 4. Epiehtlium of the colon showed no reaction. Virus was present in the feces for 6 to 9 days and was recovered from the small and large intestines from day 2 through day 10. The infection was not fatal and was self limiting; the diarrhea stopped between 1 and 2 weeks. The intestinal mucosa also started recovering by the end of week 1, proceeding caudally from the duodenum.


General anesthesia with methoxyflurane given intravenously to the dog. Dogs were anesthetized with liquid methoxyflurane administered intravenously by gaseous diffusion through sealed medical grade silicone rubber tubing placed in the femoral vein. A similar catheter placed in the other femoral vein and connected to a pressure transducer measured the increase in intraluminal pressure due to methoxyflurane diffusion into the 2nd catheter from the bloodstream 20 seconds after the catheter was flushed with room air. These pressures were plotted against venous blood methoxyflurane concentration, as determined by gas chromatography, for increasing lengths of anesthetic-administering catheter exposed to the bloodstream.


Pregnancy termination in dogs with novel nonhormonal compounds. Resorption of the products of fertilization was induced in bitches given (subcutaneously) single or multiple doses of the nonhormonal compounds L-10492 and L-10503 during the first half of gestation; also resorption or expulsion of the conceptus was induced when these compounds were given during the latter part of pregnancy. The smallest doses were required at a time immediately after implantation of the fertilized ova in the uterus. Effectiveness and appearance of side effects were dose-dependent. These consisted of decreased appetite, loss of body weight, and diarrhea (feces sometimes containing streaks of blood). Bitches which had aborted returned to estrus within normal intervals of time, exhibited normal mating behavior, and were fertile. They had normal deliveries and lactation, and the pups were normal. The mechanism of action does not involve effects on nidation and the compounds were not luteolytic, but probably involved the uteroplacental complex.


Consecutive water provocative tests in normal and glaucomatous Beagles. Water provocative tests were evaluated in normal and glaucomatous Beagles. Schiotz tonometry was performed before water was administered (50 ml/kg) by stomach tube and for the next 90 minutes. The mean increase in Schiotz tonometric values in normal dogs ranged from 3.1 to 8.6 mm of Hg and in glaucomatous dogs, 7.3 to 19.9 mm of Hg. Beagles with glaucoma had progressive, gradually increased responses to water provocative tests.


Immunization against feline calicivirus infection. Forty-three cats (experiments 1 and 2) were vaccinated (2 doses, 27 and 30 days between doses) with the F-9 strain of feline calicivirus by the intramuscular route. There was no untoward response in any of the cats to the administration of the vaccinal virus nor was there spread of the virus from 20 vaccinated cats to nonvaccinated cats held in contact during the next 6 months (experiment 2). The vaccinated cats developed serum-neutralizing antibodies that were increased further after the 2nd vaccination. The level of serum-neutralizing antibodies was related to the quantity of vaccinal virus administered. Twenty-three cats vaccinated with the F-9 strain were protected to a significant degree when challenge exposed to virulent calicivirus strain FPV-255 (experiment 1).


Feline caliciviral disease: experimental immunoprophylaxis. An attenuated feline calicivirus (FCV) was administered intramuscularly to specific-pathogen-free cats. Vaccination did not cause signs of illness. Oropharyngeal replication of attenuated FCV was not detected, nor was there evidence of virus transmission to contact-control cats. Antiviral neutralizing antibody was present in the serum of all vaccinated cats 7 days after they were given the 2nd intramuscular dose of immunogen. Vaccinated and control cats were challenge exposed to aerosols of a virulent FCV strain. All controls developed severe pneumonia and died within 7 days after this challenge exposure. In the vaccinated cats, signs of illness were absent or minimal; pulmonary lesions were milder and less extensive than those in the control cats. Feline calicivirus was isolated from ocular, nasal, and oropharyngeal swabbings from both control and vaccinated cats after viral challenge. Results indicate protective immunity to FCV disease can be induced by intramuscular administration of an attenuated FCV.


Large monocytoid cell in mononuclear cell fraction of bovine blood. Sodium metrizoate-ficoll separation of bovine mononuclear cells from peripheral blood yielded a granulocyte-free leukocyte population with an average recovery of 76%. A high proportion of the separated cells were of large size and monocytoid in appearance. This cell type was observed in a much smaller percentage in mononuclear preparations separated from defibrinated blood.


Phenotypic differences in female Ostertagia circumcincta as demonstrated by isozymes hydrolyzing alpha-naphthyl acetate. According to results of disc gel electrophoresis of homogenates prepared from individual female nematodes of the species Ostertagia circumcincta and subsequent staining of gel preparations, a maximum of 5 isozymes, hydrolyzing alpha-naphthyl acetate, were present. On the basis of resolution and mobility, these isozymes could be classified as 2 slow and 3 fast bands. Phenotypic differences were observed in the intensity of individual bands, as well as in the presence (or absence) of bands.


Isolation and metabolism cage system for newborn pigs. An isolation system was designed and constructed for isolating normal and infected newborn pigs. The system consisted of an outer cage fitted with a biological diffusion filter and a dunk bath entry system and an inner metabolism cage to contain the pig. When tested with S-13 bacteriophage, the isolation and metabolism cage system was at least 99% efficient in preventing the entry or escape of microorganism. A total of 267 Escherichia coli-infected newborn pigs have been isolated in these units, with no cross contaminations.


Erythropoiesis and erythrocytic survival in dogs with cyclic hematopoiesis. Erythrocytic survival and ferrokinetic studies were carried out in dogs with cyclic hematopoiesis. The serum iron values varied during different phases of the cycle. The highest values occurred when the bone marrow predominantly contained granulocytic cells. The erythrocytic survival and the remainder of the ferrokinetic variables were comparable to those in normal dogs of a similar age.


Effect of monensin on experimental infections of Eimeria ninakohlyakimovae in lambs. Two nearly identical experiments were conducted to determine the effects of the coccidiostatic compound monensin on Polled Dorset lambs experimentally infected with oocysts of Eimeria ninakohlyakimovae. Prophylactic medication at a dose level of 1 mg/kg of body weight was started 2 days before inoculation and prevented diarrhea and reduced oocyst production. Therapeutic medication at a dose level of 2 mg/kg, started with the appearance of signs of infection, reduced oocyst production below that of nonmedicated controls but did not eliminate diarrhea. Weight gains of medicated lambs were less than those of noninoculated, nonmedicated controls in both experiments. Apparently monensin, at the dose levels used, reduced oocyst production but also prevented weight gains as high as those in inoculated nonmedicated controls.


Cystine aminopeptidase activity (oxytocinase) in pregnant guinea pigs: normal and infected with Campylobacter fetus. The cystine aminopeptidase (CAP) activity was determined in plasma from guinea pigs at various stages of gestation and in pregnant guinea pigs infected with Campylobacter fetus subspecies intestinalis. The CAP activity decreased with length of gestation, which is in contrast to the changes in activity in persons. Infected guinea pigs near the time of abortion can be distinguished from normal guinea pigs on the basis of plasma CAP activity, if the plasma samples are taken 1 to 2 days before abortion. Among pregnant guinea pigs at the same stage of gestation, CAP activity was lower for infected than for normal pregnant animals. This test might be used to indicate probable disruption of placentation and the onset of abortion in the guinea pig.


Miliary tuberculosis in two infants after nursery exposure: epidemiologic, clinical, and laboratory findings. Two infants born 4 days apart, and cared for in the same nursery, developed miliary tuberculosis at 2.5 and 5.5 months of age, respectively. A search for a source case among household contacts failed to reveal anyone with active tuberculosis. An epidemiologic study of nursery personnel revealed a nurse's aide with cavitary tuberculosis. Examination of 1,647 infants (98.9 per cent of all infants cared for in the nursery during the 10.5-month period preceding the discovery of the source case) failed to reveal any other infected children. Recommendations are made for tuberculosis control programs among nursery personnel that should be carefully and persistently followed.


Ventilatory defects in atypical mycobacteriosis. A comparison study with tuberculosis. Two hundred thirty-two patients infected with Mycobacterium kansasii and 120 patients infected with M. intracellulare who were admitted to the East Texas Chest Hospital between 1965 and 1974 were individually matched according to age (+/- 5 years), sex, and extent of disease with an equal number of patients infected with M. tuberculosis. The ventilatory function in these patients was compared. The frequency of obstructive ventilatory defect, defined as forced expiratory volume in 1 sec less than 70 per cent of forced vital capacity, was greater among M. kansasii patients (68.9 per cent of 232) than among M. tuberculosis patients less than 80 per cent of predicted, was greater among M. intracellulare patients (68.3 per cent of 120) than among M. tuberculosis patients (57.5 per cent of 120). Above age 40, obstructive ventilatory defects tended to be more common in M. kansasii patients, whereas restricted ventilatory defects tended to be more common in M. intracellulare patients when compared with the same age group of M. tuberculosis patients. As expected, ventilatory function values among the M. tuberculosis groups decreased as extent of disease increased. In contrast, among the M. kansasii and M. intracellulare groups, these values were poorly related to the extent of disease; values were relatively low even with minimal extent of disease. It is suggested that the increased ventilatory defects among the M. kansasii and M. intracellulare patients could be accounted for by coexistent lung disease.


Water as a source of potentially pathogenic mycobacteria. The mycobacterial flora of 321 water samples was explored to evaluate the role of this part of the environment as a possible source of human mycobacterial disease. The samples included natural waters, waters treated to make them suitable for drinking, and waters in contact with animals. Water from the city aquarium contained the greatest abundance of mycobacteria, with an average of 3.5 strains per sample. The highest yield of positive cultures came from samples in contact with zoo animals and with fish. The majority of the isolated strains were slowly growing mycobacteria; 80 were Mycobacterium gordonae, and 34 of thse belong to a new serotype. Forty-seven cultures were members of the M. avian-intracellulare-scrofulaceum complex, of which 11 were typable by agglutination. From this study and from the work of others, it is concluded that water may be contaminated with potentially pathogenic mycobacteria and thus may serve as a source of human disease.


Evaluation of a temperature-sensitive influenza virus in elderly and chronically ill subjects. A temperature-sensitive influenza virus, influenza A/Hong Kong/68-ts-1 (E), was administered to 18 elderly subjects and to 18 chronically ill subjects. Clinical reactions were infrequent (n = 3), mild, and afebrile. Vaccine virus was recovered from 5 subjects. Serum-neutralizing antibody responses to A/Hong Kong/68 antigen were detected in 13. Serum hemagglutination inhibiting antibodies were detected in 6 to A/Hong Kong/68 antigen and in 7 to A/England/42/72 antigen. Nasal antibodies were detected in 3. Using any criteria, a total of 17 patients developed evidence of infection, and occurrence of infection was related to concentration of serum antibody before inoculation. Transmission of vaccine virus may have occurred to one of 10 uninoculated subjects. In the presence of a naturally occurring outbreak of influenza A/England/42/72, 15 ts-1 (E) vaccines and 17 of 42 persons who had received parenteral vaccine became ill. Evidence of infection with influenza virus was obtained in 8 of the former and 10 of the latter group.


The effect of acute, intensive cigarette smoking on maximal expiratory flows and the single-breath nitrogen washout trace. The effect of acute, intensive cigarette smoking on forced vital capacity and the single-breath expired N2 trace was studied in 82 smokers. There were significant decreases in the "effort-dependent" tests, such as peak flow and 1-sec forced expiratory volume, but no change in the more "effort-independent" tests, such as maximal mid-expiratory flow and maximal expiratory flow at 25 per cent of the vital capacity. Closing volume was unchanged in absolute terms and as a percentage of vital capacity. Closing capacity was unchanged in absolute terms and as a percentage of total lung capacity, but there was a significant increase in the slope of Phase III of the N2 washout curve after the acute smoking session. The tests of function that changed significantly after acute, intensive smoking were the ones that improved in 52 subjects who modified their smoking habits. The data suggest that acute, intensive cigarette smoking may be associated with an increase in resistance to air flow in the larger airways or a reduction in effort, and with increased nonuniformity of intraregional distribution of ventilation.


Relationship of constitutional factors and cigarette smoking to decrease in 1-second forced expiratory volume. A 5-year prospective survey of 34 subjects with mild chronic bronchitis revealed marked individual variation in the annual rate of decrease in the forced expiratory volume in 1 sec. The mean annual decrease in the 1-sec forced expiratory volume was 0.046 +/- 0.057 liter. Although the annual decrease in the 1-sec forced expiratory volume was greater among smokers (0.056 +/- 0.061 liter per year) than non- and ex-smokers (0.016 +/- 0.021 liter per year; P less than 0.005), differences in tobacco consumption did not account for the individual variation. This variation was related, instead, to 3 phenomena believed to indicate the presence of host susceptibility to chronic bronchitis. These phenomena were bronchial reactivity to methacholine, ventilatory responsiveness to isoproterenol, and sputum eosinophilia. The correlation between the rate of decrease in 1-sec forced expiratory volume and the degree of methacholine reactivity was 0.76 (P less than 0.001); the correlation between the decrease in 1-sec forced expiratory volume and ventilatory responsoveness to isoproterenol was 0.45 (P less than 0.01). Deterioration of 1-sec forced expiratory volume was appreciably greater among those with sputum eosinophilia (0.062 +/- 0.06 liter per year) than among thse without eosinophilia (0.017 +/- 0.033 liter per year P less than 0.01). The progression of abnormality appeared to depend on an interaction between cigarette smoking and individual susceptibility. Even minimal tobacco consumption led to serious ventilatory deterioration when methacholine reactivity was high, whereas heavy smoking produced little effect on the decrease in 1-sec forced expiratory volume when methacholine reactivity was slight.


Mechanisms of maximal expiratory flow limitation in clinically unsuspected emphysema and obstruction of the peripheral airways. We studied the determinants of maximal expiratory flow in 7 patients in whom surgical lung specimens showed evidence of mild emphysema or obstruction of the peripheral airways. All the patients showed frequency dependence of dynamic lung compliance and low maximal expiratory flow. Lung elastic recoil pressures were reduced at all lung volumes in 4 of 5 patients with emphysema but were normal in 2 patients with obstruction of the peripheral airways. Maximal flow-static recoil curves showed a high intercept in the pressure axis when the slope between 50 per cent and 30 per cent of vital capacity was extrapolated to zero flow (transmural pressure in the flow-limiting segment) in all patients. The slope of these curve represents the conductance of the segment that extends from the alveoli to the flow-limiting segment and includes the latter. Conductance of this segment was higher than normal in 4 patients with emphysema and borderline low in one, and low in one patient with obstruction of the peripheral airways and borderline low in the other. Increased transmural pressure in the flow-limiting segment was interpreted as being due to peripheral location of collapsible flow-limiting segment and, in part, limiting maximal expiratory flow. The results also suggested that flow limitation in emphysema may occur without physiologic evidence of increased resistance of peripheral airways when, in fact, bronchiolitis is present on histologic examination.


Removal of endobronchial foreign body by fiberoptic bronchoscopy. A relatively large foreign body (ham bone) was seen in the left upper lobe bronchus of a 25-year-old woman and was successfully extracted with the use of a standard fiberoptic bronchoscope. Although the removal of foreign bodies by the fiberoptic bronchoscope has serious technical limitations, the use of this instrument should be considered when the foreign body is not within range of the rigid bronchoscope.


Observations of the pathology of clubbed fingers with special reference to mast cells. Mast cell counts were made, in tissue samples of normal and clubbed fingers obtained at autopsy, to investigate the possibility that mast cells act as an intermediary in the development of finger clubbing. Quantitative measurements of the composition of the tissues of the normal and clubbed nail bed were also made. The only significant difference in mast cell numbers in clubbed fingers was a decrease in mast cells in the tissues just superficial to the nail. The appearance of the mast cells was normal. The porportion of blood vessels and other tissues was not significantly different from normal.


A study of a new bronchodilator: carbuterol. A new oral bronchodilator, carbuterol, was studied in 9 subjects who had reversible airway obstruction. In addition to the spirometric changes, serial arterial blood gas determinations were done to see if the drug induced hypoxemia. Two- and 4-mg doses were compared with the placebo. There was a significant bronchodilating effect with the 4-mg dose beginning 30 min after administration of the drug. Maximal improvement of forced expiratory volume in 1 sec was observed at 4 hours, with a 42 per cent increase from the baseline. No significant hypoxemia was observed. The drug was considered an effective bronchodilating agent, with the effect lasting longer than 4 hours.


Biliary ascariasis.

Biliary ascariasis. Biliary ascariasis, rarely noted in the western literature, is a common condition in other climates. An increase in infestation may occur with travel to these countries. With the changes in biliary function which follow common duct exploration, invasion can occur in the affected individual. Treatment involves antispasmodics, antihelminthetics, and prevention of superinfection. Surgical intervention is reserved for specific indications of failure of medical therapy.


Carcinoma of the pancreas.

Carcinoma of the pancreas. Study of hospital records of 146 patients with carcinoma of the pancreas from 1952 to 1971 revealed that 74 per cent had had abdominal pain and 65 per cent jaundice. Abdominal pain was the commonest symptom of carcinoma of the head as well as of the body and tail. Diabetes mellitus was four times as common among the patients with carcinoma of the pancreas as among the population in general. The interval between the onset of symptoms and diagnosis of the disease was the same in both decades of the 20-year period, but the survival time after operation was longer in the second 10-year period. Pancreatoduodenectomy was possible in only four of the 138 patients operated on, and one of them died postoperatively. The three patients who survived the operation survived significantly longer than the 87 in whom an anastomosis had been established between the bile ducts and the intestine. Forty-one patients were subjected to surgical exploration only. No difference in survival time was found between the two last-mentioned groups.


Effective surgical palliation of giant compressive bullous emphysema (vanishing lung syndrome): long-term follow-up. Giant compressive bullous emphysema is rare. The three major considerations for operation involve a breathless patient with giant bullae occupying more than one-third of one lung field who has a positive pulmonary arteriogram revealing diminished blood flow to the involved lung. Finally, we think that the survivors in our series, eight long-term postoperative patients alive one year to 14 years, supply gratifying evidence that surgery can provide effective and safe palliation.


A combined surgical approach in the management of achalasia of the esophagus. The treatment of achalasia at the present time is far from being ideal. The results of pneumatic dilatation have not always been impressive and the risk of esophageal perforation is real. Modified Heller operation has succeded in relieving obstructive symptoms in the majority of patients with achalasia. However, the reported incidence of reflux esophagitis following Heller myotomy is four to 37 per cent. In 25 patients with achalasia followed up to 10 years after Heller myotomy, nine patients had symptomatic reflux and three patients developed esophageal strictures. We believe the addition of an anti-reflux operation should be considered in all patients undergoing operation for achalasia and especially those patients with preoperative symptoms of reflux.


Duodenal varices.

Duodenal varices. Upper gastrointestinal bleeding from isolated duodenal varices is a rare occurrence. We report the case of a patient with idiopathic duodenal varices in whom the diagnosis was established preoperatively by endoscopy. The patient did not have esophageal varices or portal hypertension, and he was treated by exicising the varix with a full thickness of duodenal wall. Bleeding has not recurred. Duodenal varices as well as duodenal ulcer and gastritis must be considered in evaluating a patient with cirrhosis and upper gastrointestinal bleeding.


Mobile cecal syndrome in the adult.

Mobile cecal syndrome in the adult. The mobile cecal syndrome is primarily a disease of children. However, it may be present as a precursor of frank cecal volvulus in approximately 50 per cent of the cases. Symptoms are intermittent colicky right lower quadrant pain with tenderness over McBurney's point and hyperactive high-pitched bowel sounds during the attack. After the attack, the patient is asymptomatic. Three cases of young women with mobile cecal syndrome are presented to illustrate the clinical course and surgical therapy. The mobile cecal syndrome should be considered in the differential diagnosis of right lower quadrant pain from obscure causes.


Perineal wound healing after abdominoperineal resection. The healing of the perineal wound after proctectomy depends on the disease, the presence of perianal infection, and the technique of management of the perineum. Experience shows that when the perineum is left open, healing by secondary intention is accompanied by a significant morbidity, extended hospitalization, continued disability, prolonged postoperative drainage and an occasional persistent perineal sinus. The patients required daily care of the perineum for two to 12 months. The wound healed slower in patients with inflammatory disease of the colon. Within six months the perineum healed in 58 per cent of the patients with inflammatory disease and 70 per cent of the patients with carcinoma. After one year, healing had taken place in 98 per cent of the patients. It is necessary to leave the perineal wound open in the patients with perineal sepsis, contamination and uncontrollable hemorrhage. For the other patients, there should be some attempt to close the perineum and obtain primary healing of the wound.


Tetanus in a patient with a uterine tumor. A 45-year-old woman developed tetanus in a necrotic 5 Kg leiomyoma of the uterus; she was treated successfully by a combined surgical and anesthesiology team. A hysterectomy was performed despite the considerable controversy in the older publications. This literature was reviewed, and it was noted that there have been only two previously published cases of uterine tetanus other than in a post-abortal situation. The practical aspects of the management of severe tetanus are tabulated.


Serum lipid levels in angiographically defined coronary artery disease. To evaluate the association between serum cholesterol and triglyceride levels and angiographically determined coronary artery disease, two selected groups of 100 patients each were compared. The coronary artery disease group had significantly higher serum levels of both cholesterol and triglyceride. However, several types of analyses based on the quartile distribution of serum levels of cholesterol and triglyceride showed that the serum cholesterol level was more significantly associated with coronary artery disease than was the triglyceride level. This was especially true in relation to multivessel disease, the most severe form of coronary artery disease, and most marked in men. Association with coronary artery disease appeared to be continuous, rather than being related to any critical serum level, thus re-emphasizing the need to distinguish between desirable and average levels of serum cholesterol in countries with a high dietary intake of saturated fat.


Atrial septal defect: echocardiographic observations. Studies in 120 patients. Previous studies on small numbers of patients have indicated a high incidence of increased right ventricular dimension and abnormal ventricular septal motion in patients with atrial septal defect. However, recent evidence suggests that septal motion may be normal in as many as 46% of patients with atrial septal defect when observed at proper levels. We have analyzed the echocardiograms of 120 patients with sinus venosus or secundum atrial septal defect in an attempt to define sensitivity of the foregoing two echocardiographic abnormalities. Right ventricular dimension index was increased in 98% of patients. When both sides of the ventricular septum were analyzed, abnormal ventricular septal motion was observed in 87% of patients. It is important to observe both right and left septal echoes at all levels. Other measurements and observations were made when possible and are included in the study.