[Additional pacemaker indications].

[Additional pacemaker indications]. In addition to the widely accepted criteria for the implantation of a permanent pacemaker (bradyarrhythmias combined with syncope, cardiac decompensation, angina pectoris etc.) ther are borderline situations where the decision for a pacemaker is less easy: 1) marked bradycardia with only minor symptoms, 2) syncope without appropriate electrocardiographic abnormality, 3) bifascicular blocks, 4) tachyarrhythmias refractory to medical therapy. In connection with these situations, 3 syndromes are discussed with particular reference to the indication for pacemaker: A) hyperactive carotid sinus reflex syndrome, B) sick sinus syndrome, C) fascicular block. A pacemaker is a fairly safe method of therapy (although with some complications) which should not only be used as a last resort (e.g. in severe Adams-Stokes syndrome) but in patients whose condition may improve after a pacemaker implantation or be prevented from getting worse. Patients with pacemakers have a mean survival rate of 80-90% after 1 year and of 50-60% after 5 years.


[Heart disease and pregnancy].

[Heart disease and pregnancy]. The normal cardiovascular adjustments to pregnancy and the hemodynamic disorders attendant on various acquired and congenital cardiac defects is pregnancy are reviewed. The incidence of the various cardiovascular complications during pregnancy is discussed in relation to each individual type of heart disease. The modern diagnostic and therapeutic possibilities offered by cardiology mean that an increasing number of patients with cardiac defects can look forward to safe pregnancy and childbirth.


[Primary and secondary Raynaud's syndrome]. In the light of practical considerations a distinction is necessary between vasospastic and occlusive disease of hand and finger arteries. The vasospastic condition is usually termed Raynaud's disease and leads to recurrent ischemic attacks affecting the fingers, with early onset in life. In most instances, organic occlusions of peripheral arteries develop without initial vasospastic symptoms (exception: patients with collagen vascular disorders). Measurements of finger blood flow reported in this review show that vasospastic Raynaud's disease may be considered a variant of physiologic flow behavior in young women. Only in severe cases do cold stimuli precipitate long-lasting periods of non-measurable finger flow (venous occlusion plethysmography with finger strain gauges). In 109 personal observations the possible etiologic factors involved in organic finger artery occlusions are analyzed. They include a broad spectrum (arteriosclerosis obliterans, endangitis obliterans, collagen vascular disease, thrombocytosis, chronic occupational trauma, cryoglobulinemia). Therapy is directed at the underlying disease and the specific situation. In cases with severe ischemic symptoms, sympathectomy, intraarterial injections of reserpine, and treatment with Ancrod or fibrinolytic agents should be considered.


[Experiences with Dotter's percutaneous recanalization of chronic arterial occlusions]. Since 1971 141 patients (mean age 66 years, range 46-85 years) with chronic occlusions of the pelvic (19) and superficial femoral popliteal arteries (122) have been treated by the percutaneous recanalization technique first described by Dotter and Judkins in 1964. Since 1974 we have employed a modification of the original Dotter technique. The occluding material is removed with a double-lumen distensible catheter introduced over a guide wire. Primary success was achieved in 117 (83%) patients. Re-occlusions occurred in 18 patients after 6 months and in 5 patients in the second half of the first year, giving an overall patency rate of 75%. Up to now no further re-occlusions of dilated arterial segments have been observed. Indications for this treatment as compared with vascular surgery are discussed.


[Drug interactions].

[Drug interactions]. Beneficial and adverse interactions between drugs may occur in connection with any process that influences the pharmacokinetic and pharmacodynamic behaviour of a given drug and thus affects its therapeutic or toxic action. In dealing with drug interactions and their consequences, a uniform mode of classifying and reporting drug interactions based on clinical relevance appears to be needful.


[The heart in myasthenia gravis. Electrocardiographic, cardiodynamic and kinetocardiographic aspects in 18 cases]. Eighteen patients with myasthenia gravis, second-stage (A or B) according to Ossermann and Genkins, and of young age, were examined as outpatients from the cardiological point of view. Clinical and radiological examination of the heart and large vessels revealed no pathological features. Electrocardiographic abnormalities (including one case of ventricular preexcitation syndrome and one of subepicardial ischemia) were detected in three patients (16,6%). Among the various left ventricular systolic time intervals, only the deformation time was somewhat off normal limits in some cases, but the difference was not statistically significant. In over one-third of the cases, conversely, the kinetocardiogram revealed paradoxical systolic outward movements, indicative of myocardial dyskinesis or dissinergy. The essential normality of systolic time intervals in the presence of manifest abnormalities of the kinetocardiographic curve may be explained by the smallness of hypokinetic or dyskinetic areas, whereby the ejection fraction was not reduced. In general, the ECG and kinetocardiographic tracings showed no tendency to change under the effect of orally administered pyridostigmine.


[Aminoglycoside antibiotics from a clinical viewpoint]. Indications, side effects, dosage and pharmacokinetic properties of gentamicin, tobramycin, sisomicin, kanamycin and amikacin are reviewed. Different aspects of aminoglycoside antibiotics in combination with beta-lactam antibiotics are briefly discussed. Finally, the indications for the assay of serum levels of aminoglycosides are listed. Gentamicin, tobramycin and sisomicin appear to be very similar with regard to in vitro performance, clinical efficacy and pharmacology. Ototoxic and nephrotoxic side effects are observed - in decreasing order of frequency - with sisomicin, gentamicin and tobramycin. The advantage of amikacin is its stability against enzymatic inactivation, which should make it an agent of first choice against aminoglycoside-resistant gram-negative bacteria.


[Therapeutic use of antimycotic substances]. Since secondary deep mycoses are frequently seen in internal medicine nowadays, increasing interest has been focused on antimycotic therapy. This report deals with the limited available range of antimycotic substances which can be administered systemically. Since severe adverse effects are often observed with Amphotericin-B, the most effective antifungal agent, the advent of three new systemic antifungal drugs (Clotrimazole, Miconazole, 5-Fluorocytosine) has proven to be a real advance in our therapeutic approach to deep mycoses. To avoid unwanted side-effects, combined therapy with low doses of Amphotericin-B and another antimycotic agent promises to become increasingly important.


[Lung biopsy in interstitial pulmonary processes]. The value of open lung biopsies for the diagnosis of diffuse interstitial lung fibrosis is discussed. Except for few cases, e.g. granulomatous processes, needle biopsies are not a reliable method. In diffuse lung fibroses of unknown etiology which are not related to systemic diseases such as collagen diseases, combined electronmicroscopy and EDAX (Energy Dispersive X-ray Analysis) may reveal pneumoconiotic lesions due to unperceived mineral-dust exposure.


[Lung biopsy in interstitial pulmonary processes]. The techniques for lung biopsy are briefly described. In diffuse interstitial lung disease only open lung biopsy provides sufficient material for histological examination. In view of the severity of this diagnostic intervention the indication must be established restrictively: before biopsy it is essential to rule out all systemic diseases which may also produce interstitial lung disease. Furthermore, open lung biopsy should be considered only if a therapeutic prospect exists.


[Primary aldosteronism].

[Primary aldosteronism]. The syndrome of primary aldosteronism is caused either by an aldosterone-producing adenoma or by idiopathic bilateral adrenal hyperplasia. Hypokalemic hypertension is the leading symptome of the disease. Diagnosis is by the combination of abnormally high and non-suppressible aldosterone values with undetectable or low renin values unresponsive to postural changes or salt restriction. Patients with aldosterone-producing adenoma normally show a fall in plasma aldosterone in response to posture and ACTH-dependent circadian rhythm of aldosterone, whereas bilateral hyperplasia is characterized by postural increases in plasma aldosterone and an ACTH-independent diurnal aldosterone rhythm. These creteria serve to differentiate between adenoma and hyperplasia. An aldosterone-producing adenoma can be localized by veinography, determination of aldosterone concentration in both adrenal veins and by 131I-cholesterol scintigraphy. In our hands the determination of aldosterone in blood from both adrenal veins is the most efficient procedure. In interpreting the results, however, rhythmic and sudden changes in adrenal hormone secretion should be considered. In cases where no adrenal venous blood is obtained, 131I-cholesterol scintigraphy may be used to localize adenoma. In patients with aldosterone-producing adenomas unilateral adrenalectomy should be performed, whereas patients with idiopathic bilateral hyperplasia should receive antihypertensive therapy. As rare instances of primary aldosteronism, a case of aldosterone-producing carcinoma of the adrenal cortex and a case of presumably unilateral adrenal hyperplasia are reported.


[Diagnosis and quick diagnosis of breast neoplasms by means of fine needle puncture biopsy]. The technic, advantages and limitations of the fine needle method for diagnostic purposes in pathologic alterations of the breast are discussed. Our own results bear out the value of the method for rapid diagnosis: puncture of 252 breast tumors and 78 mastectomy scars revealed 37 and 41 suspect or malignant alterations respectively. No false positive diagnoses were recorded. The rate of false negative results was 7.3% in breast tumors and 9.9% in mastectomy scars.


[Diagnostic methods for the exploration of the female breast]. The diagnostic methods for exploration of the female breast (self-examination, clinical examination, mammography, xero-radiography, thermography, open biopsy, and aspiration biopsy smears) are briefly discussed. Their advantages and disadvantages emerge in their application for the detection of breast disease.


[Directions for mammography from a radiological viewpoint]. A significant decrease in mortality due to breast cancer is feasible only by earlier diagnosis. The decisive screening method is mammography, which permits identification of a malignancy in its earliest stages. Indirect and direct signs of malignancy exist whose detection necessitates biopsy. Radiological examination of the tissue sample permits evaluation of the adequacy of excision and thus renders possible specific histological examination of the region of interest. Pneumocystography is a method for simultaneous diagnosis and therapy of benign cysts.


[Which uric acid value is in need of treatment?]. Asymptomatic hyperuricemia should be treated only if the plasma uric acid levels are around 10 mg/100 ml or more on several determinations. In addition, patients on a purine-free diet who excrete more than 600 mg uric acid per 24 h should be treated. In both cases, treatment is intended to be prophylactic against gouty nephropathy. At present there is no evidence that primary hyperuricemia alone is a risk factor for early atherosclerosis and especially coronary artery disease. However, more attention should be paid to the accompanying risk factors such as obesity, hyperlipoproteinemia, diabetes mellitus and hypertension.


Non-organ specific autoantibodies in malignant diseases. A significant increase in non-organ specific autoantibodies is demonstrated in13 per cent of the sera from 202 patients with histologically proven malignancies, as compared with only 4 per cent of sera from 214 age and sex matched control patients. It appears that the incidence of autoantibodies is related to the histological type of the tumour but not to the presence or absence of tumour dissenmination. While the control group shows the expected increase in both incidence and titre of autoantibodies with increasing age, the malignant patients show no such pattern i.e. in cancer patients autoantibodies occur with equal frequency and at similar titres regardless of age. The absence of an age related increase in incidence and titre of non organ specific autoantibodies does not appear to have been reported previously. Our findings lend support to the hypothesis that cancer is associated with a breakdown of immunological surveillance, not only in old but also in young cancer patients. Thus the findings of non organ specific autoantibodies, especially to smooth muscle antigen, in an apparently healthy adult could be considered evidence of such a breakdown, carrying with it an increased risk of neoplasia.


Clinical bacteriology of cephazolin.

Clinical bacteriology of cephazolin. Cephazolin, the latest parenteral cephalosporin produced by substitution of heterocyclic groups on the 7-aminocephalosporanic acid (7-ACA) nucleus, became available for clinical use in the U.K. in 1974. Its history is traced from the original Sardinian mould (1945) through isolation of cephalosporin C (1953) and 7-ACA (1962) to its discovery (1969) and subsequent clinical use. Its mode of actionis examined and its bactericidal nature confirmed, MICs of over 500 common pathogens are used to define its spectrum. The cut-off point for sensitivity and resistance is taken as 20 mg. per l. With 30 mug. discs zone sizes less than or equal to 14mm. indicate resistance. The clinical relevance of MICs and attainable serum and urine levels is examined by relating them to clinical response in 12 patients. A disc study compares cephazolin with 4 other available cephalosporins, namely cephaloridine, cephalothinm cephalexin and cephradine. Many major discrepancies indicate that they are not interchangeable. The laboratory and clinical implications are discussed, including the need for local policy decisions regarding choice of preparation. The change from a parenteral to an oral form should be preceded by a sensitivity test against the causal organism. The validity of using a single representative disc is questioned and the use of phrases such as 'sensitive to the cephalosporins' deprecated. Cephazolin is potent, broad-spectrum and bactericidal and is potentially life-saving in serious hospital infections. The cephalosporins rival the aminoglycosides as 'best-guess' primary choice and are preferable in pregnancy, the puerperium and in pulmonary infections. Within the group cephazolin will seriously challenge or even oust cephaloridine and cephalothin.


Activity of cephazolin and other cephalosporins against Bacteroides fragilis. The antibiotic sensitivity of 50 strains of Bacteroides fragilis to four cephalosporin compounds, cephazolin, cephaloridine, cephradine and cephalexin is reported. Cephazolin was found to be the most active, 94 per cent of strains being susceptible to blood concentrations achieved on standard dosage, comparative findings with cephaloridine and cephradine were about 50 per cent, and only 22 per cent of strains were inhibited by cephalexin. The importance of infections due to bacteroides is discussed. Although not the treatment of choice, cephazolin, a view of its bacterial activity may be useful alternative for bacteroides infections but clinical trials are needed to confirm the laboratory results.


The serum half-life and urine concentrations of cephazolin sodium in patients with terminal renal failure: effect of haemodialysis. The serum and plasma half-life of cephazolin has been determined in 5 maintenance haemodialysis patients during a non-dialysis period and then again in the same patients during haemodialysis with a Meltec Maxi-Multipont dialyser using cuprophance membranes. The mean half-life during the non-dialysis period was 28.3 hours and fell to a mean of 4.97 hours during haemodialysis. Percentage recovery of cephazolin in the urine was markedly reduced in 4 maintenance dialysis patients although adequate urine concentrations of cephazolin were achieved for many sensitive organisms. A dosage schedule for patients with creatinine clearances of less than 5 ml. per minute and for maintenance haemodialysis patients is suggested.


Cephazolin treatment of pneumococcal pneumonia and urinary tract infections. Ten cases of pneumococcal pneumonia were treated with cephazolin 500 mg. q8h for at least 5 days. In every case therapy was accompanied by clinical improvement and eradication of the organism. Ten patients with E. coli bacteriuria (5 symptomatic) were treated with cephazolin 500 mg. q12h for 7 to 10 days. In every case the pathogen was eliminated during therapy but in one case bacteriologic relapse occurred following cessation of therapy. In 10 cases of bacteriuria caused by P. mirabilis, Klebsiella sp, Enterobacter, and Enterococcus, the urine became sterile during treatment, but relapse was common. Initial and final creatinine clearances obtained in 29 patients who received an average of 12.9 g. of cephazolin showed no tendency toward loss of renal function. Serial serum levels of cephazolin were determined following the first 500 mg. dose in 18 patients. The peak serum level occurred at one hour with a serum half life of approximately 2.2 hours. For 13 of these 18 patients serial serum levels were also obtained following the last dose of cephazolin. At this time the mean peak level occurred at 2 hours but again the serum half life was approximately 1.9 hours.


Comparative biliary concentrations of cephazolin and cephalothin in patients with biliary tract disease. The concentration of cephazolin in the serum, gall bladder bile, common duct bile, and gall bladder wall were consideredably higher than cephalothin especially with IV administration and indicate that cephazolin should be a useful antibiotic in the surgical treatment of acute cholecystitis.


Cephazloin sodium - an invivo and in vitro evaluation of 100 patients with urinary tract infections. A random group of 100 patients in a general hospital were treated with cephazolin sodium for proven urinary tract infections. Sixty-six per cent had conditions predisposing to urinary tract infection. Under these somewhat difficult conditions the original infecting organism remained absent from the urine of 75 per cent of the 70 patients followed in the 3rd to 6th week period. This compares very favourably with response to other antimicrobial agents currently used in urinary tract infections.


Cephazolin: clinical studies in obstetrics. A clinical evaluation of a new cephalosporin, cephazolin, in obstetric patients is presented. Sixteen cardiac patients received the drug prophylactically as antibiotic cover during labour. Eighteen patients with miscellaneous antenatal and puerperal infections received the drug as primary treatment. The data obtained indicate adequate serum and tissue levels with the dose used, and corresponding clinical response. The impression is of a safe and efficaceous drug in the described obstetric situations requiring antibiotic therapy. It may be given prophylactically and with confidence to the cardiac patient in labour.


Gating currents associated with sodium and calcium currents in an Aplysia neuron. In a voltage-clamped aplysia neuron (R15), depolarization beyond -30 millivolts produces an inward sodium current. Depolarization beyond -10 millivolts produces an additional inward calcium current with slower kinetics than the sodium current. When these ionic currents have been suppressed and capacitive currents subtracted out, a small outward displacement current can be seen with depolarizations beyond -30 millivolts. An additional, slower displacement current is seen with depolarizations beyond -10 millivolts. The currents have an exponential decay with an increase in rate per 10 degrees C increase in temperature of about 3 and are thought to be sodium and calcium gating currents.


Uptake of bovine serum albumin by rainbow trout from hypersmotic solutions: a model for vaccinating fish. Immersion of juvenile rainbow trout (Salmo gairdneri) in a solution containing either urea or sodium chloride at 1650 milliosmoles and 2 percent of bovine serum albumin (BSA) resulted in an uptake of BSA into the blood of the fish after a 3-minute exposure. Similar blood levels of BSA were also obtained by placing the fish in 1650 millosmoles of sodium chloride for about 2 minutes, and then immersing them in 2 percent BSA solution for 3 minutes. Uptake of BSA into the fish appeared to be primarily through the lateral line system and secondarily through the gills.


Insecticidal action of the phytohemagglutinin in black beans on a bruchid beetle. Black bean (Phaseolus vulgaris) phytohemagglutinin added to the normal diet of a bruchid beetle (Callosobruchus maculatus) that can eat phytohemagglutinin-free cowpeas (Vigna unguiculata) but not P. vulgaris seeds kills the bruchid larvae. Trypsin inhibitors, found in both P. vulgaris and V. unguiculata seeds, have virtually no effect on the bruchid larvae. The conclusion is that a major part of the adaptive significance of phytohemagglutinins in black bean and other legume seeds is to protect them from attack by insect seed predators.


DNA structure in sheared and unsheared chromatin. Shearing chromatin, by either sonication or vortex homogenization, introduces significant structural artifacts. These may be detected by the anomalously large increase in the number of ethidium bromide binding sites and the large alteration of the circular dichroism spectra of chromatin. Structural alterations are also suggested by the disappearance of differential light scattering after shearing.


Inherited retinal dystrophy: primary defect in pigment epithelium determined with experimental rat chimeras. Chimeric rats were produced by the aggregation of embryos of the pinkeyed, retinal dystrophic RCS strain with those of pigmented, normal rats. In the mosaic eyes, patches of neural retina with abnormal and degenerated photoreceptors were present only opposite patches of nonpigmented, mutant pigment epithelium. This indicates that the retinal dystrophy gene acts in the pigment epithelial cell rather than in the photoreceptor cell.


Phytohemagglutinin-induced lymphocyte transformation in humans receiving delta9-tetrahydrocannabinol. Eight otherwise healthy male chronic marijuana smokers were hospitalized for a period of 30 days. Initially they received placebo, then a sustained dose of 210 milligrams of delta9-tetrahydrocannabinol (delta9-THC) per day for 18 days, followed by placebo. Lymphocyte responses to phytohemagglutinin were examined during each of these periods. Neither the daily ingestion of marijuana extract containing 210 milligrams of delta9-THC for 18 days nor the history of chronic marijuana smoking had a depressive effect on the lymphocyte responses of these subjects to phytohemagglutinin.


Femoral tibial bypass grafts.

Femoral tibial bypass grafts. The results of 53 femoral to tibial artery bypass grafts have been reviewed. All were carried out in an attempt to salvage severely ischemic extremities which resulted from arteriosclerotic occlusive disease involving the femoral, popliteal, and tibial arterial systems as demonstrated by arteriography. Most grafts were done with autogenous vein; however, composite grafts comprised of a Dacron prosthesis and an autogenous vein and homologous veins were used in several patients. The initial salvage rate in these pregangrenous extremities was 74%. Fifty-two percent of the grafts remain patent at this writing, a period of 56 months in some instances. This study indicates that most patients with a severely ischemic extremity are candidates for revascularization and should have angiographic studies before amputation is considered.


The mobile clinic of St. Mary's health center--a functional plan. Specialized medical facilities tend to be concentrated in medical centers in metropolitan areas, which results in unavailability of adequate medical care to large portions of our population. One solution is a mobile unit, staffed by personnel representing several different disciplines (physicians, nurses, social workers, nutritionists, etc) and extending a health ministry beyond the confines of a medical center to medically deprived areas. The unit also has educational benefits as the medical and nursing students gain valuable experience by evaluating the patients and relating them to the environment in which they live. The mobile clinic allows for a workable situation in a congenial atmosphere without compromising the quality of health care.


Ferruginous (asbestos) bodies in the lungs of rural dwellers, urban dwellers, and patients with pulmonary neoplasms. The lungs of 100 consecutive patients at autopsy and of 24 patients with various pulmonary neoplasms were analyzed for the presence of ferruginous (asbestos) bodies. The population comprised both rural dwellers and urban dwellers, in contrast to previous similar studies involving only urban dwellers. More than 90% of both population groups had ferruginous bodies in their lungs. There was no apparent difference in the incidence or quantity of ferruginous bodies between the group with pulmonary neoplasms and the randomly selected group. These findings raise the possibility of more widespread asbestos dust contamination of environmental air than has been previously thought and indicate that rural as well as urban populations are exposed. The failure to demonstrate more ferruginous bodies in the lungs of patients with pulmonary neoplasms is in accordance with the view that asbestos acts as a cocarcinogen in this regard.


Ovarian conservatism.

Ovarian conservatism. Everyone is conscious of the prime role of the ovaries in making a female a "female." However, too little attention has been directed toward the systemic mechanism of estrogens that protects against coronary artery disease and osteoporosis. Exogenous estrogen appears to be almost as effective as the ovaries are in protecting a female from these diseases. The incidence of neoplasia in preserved ovaries after previous pelvic surgery is low. Emphasis has been placed on ovarian conservatism in the young female because a clearer benefit can be demonstrated in them than in postmenopausal females.


Malignant thymoma with penetration into the gastrointestinal tract: report of two cases. Two cases of thymoma, one epiithelial and one seminoma type are presented. In both instances, the thymoma infiltrated and later perforated the gastrointestinal tract by direct extension. One is the 30th reported case of thymoma with extrathoracic metastasis; this patient had metastasis to the bone marrow and kidney. Neither patient had myasthenia gravis associated with the thymic tumor.


Smoking among medical students.

Smoking among medical students. A survey of smoking habits of medical students was done using basic medical science graduate students at the same institution as a comparison group. Smoking status was not significantly related to sex, race, or academic classification. Knowledge of adverse health consequences of smoking was related to time spent in medical school and to whether or not the respondent smoked (ie. probable denial of knowledge of the adverse consequences among smokers). The respondent's smoking status was significantly related to familial and peer group smoking status and to peer group attitude. The most common reason given by quitters was "the media influence." The nonsmoker most frequently never began the habit because of fear of health consequences. Because of the finding that a small percentage of medical students still are not convinced of the dangers of smoking, it was suggested that increased educational emphasis on these dangers be included in the medical curriculum.


The perioperative management of pericardial tamponade. A case report of a patient with acute pericardial tamponade is presented. The etiology, pathophysiology, and management of cardiac tamponade is discussed. Preoperative management includes volume expansion, administration of catecholamines, and pericardiocentesis. Intraoperatively, monitoring should include continuous measurement of arterial and central venous pressures. Ketamine has been found to be very useful in these patients.


Femoropopliteal bypass for salvage and claudication: a comparison of long-term results. Seventy-seven femoropopliteal grafts placed for salvage were compared to 51 grafts placed for claudication. Patient profiles of age, preexisting cardiovascular disease, and risk factors were notably similar. Previous vascular procedures were twice as common in the salvage group. The accumulated graft patency in the salvage group of 77% at one month and 58% at two years is compared to 90% and 80% during the same risk intervals in the claudication group. The salvage group sustained 34 complications (44%) and nine deaths (12%), compared to one death (2%) and seven complications (14%) in the claudication group. One half of all grafts placed in diabetic males failed. Nearly half of all early failures were thought to be due to errors of patient selection. Though new technics are making more extremities potentially salvageable, this study suggests that improved patient selection will be necessary to lower high complication rates.


Delayed hypersensitivity skin testing for assessing anergy in the mid-south. Although skin testing with ubiquitous antigens is widely employed to assess delayed hypersensitivity, little is known about the effect of geographic location on the frequency of skin test reactions to given antigens. To assess skin test reactivity in the mid-South, 82 hospitalized patients and 68 normal controls had skin tests with six antigens: histoplasmin, mumps, tuberculin purified protein derivative (PPD), Candida, Trichophyton, and streptokinase-streptodornase. Ninety-five percent of normal and 79% of hospitalized subjects without immunologically related disease reacted to at least one of the antigens. A high rate of anergy was found in a clinical setting of debilitation and malnutrition. If subjects in poor condition also were excluded, 93% of hospitalized patients reacted to at least one antigen. Rates of reactivity increased with higher concentrations of antigen. To assess anergy in the mid-South, it is recommended that patients be skin tested initially with histoplasmin, mumps, and PPD antigens. If the patient does not react to any of these, streptokinase-streptodornase and Candida albicans (Dermatophytin "O") should be applied.


Eosinophilic gastroenteritis.

Eosinophilic gastroenteritis. Four patients with eosinophilic gastroenteritis are presented to illustrate the protean manifestations of this disorder. While the cause is unknown, the complications many, and the differential diagnosis often challenging, the treatment is simple and consists of low-dose, alternate-day administration of corticosteroids. Diagnosis depends on gastrointestinal biopsy, which usually can be obtained without surgery.


Gastric emptying of hypertonic glucose in diabetes mellitus and duodenal ulcer. Gastric emptying of hypertonic glucose liquid meals was studied in diabetes, duodenal ulcer, and hospitalized controls by means of the 10% glucose 30-minute test meal, with phenol red as nonabsorbable marker. Acid secreted into the meal was measured. Results revealed no significant difference in gastric emptying between controls and patients with duodenal ulcer and diabetes mellitus. Among diabetics, some individuals empty this meal more rapidly than normal. The results show that alterations of gastric emptying cannot account for the late peaks observed on oral glucose tolerance tests in diabetics, nor for any tendency toward reactive hypoglycemia in duodenal ulcer. They suggest that autovagotomy may occur in some diabetics.


Polydactyly: report of a large kindred.

Polydactyly: report of a large kindred. The occurrence of polydactyly in a 33-year-old woman with a patent ductus arteriosus stimulated a study of her family. Four generations of her kindred were examined. No other case of congenital heart disease was discovered, but a large number of individuals with polydactyly were found. Inheritance of this trait is autosomal dominant.


Metastatic carcinoma in histologic sections of aspirated bone marrow: a comparative autopsy study. The incidence of metastatic carcinoma in bone marrow was studied by two different approaches in 220 consecutive autopsies of patients with carcinoma: histologic sections of aspirates from the iliac spine, as usually done in living patients; and gross and microscopic examination of the thoracolumbar spine. Ten percent of the autopsies showed bone marrow metastases by the aspiration technic as contrasted with 34.5% by the autopsy technic. Three cases had positive bone marrow aspirates in the absence of metastases demonstrable by routine autopsy. The combination of autopsy and aspiration technics yielded an incidence of metastatic marrow involvement of 35.9%. Of patients with marrow metastases at autopsy, 25% also had positive aspirates. This study establishes a norm for the comparison of the efficiency of discovery of metastatic carcinoma by different modalities of clinical bone marrow sampling.


Pauciarticular juvenile arthritis.

Pauciarticular juvenile arthritis. Pauciarticular juvenile arthritis begins insidiously, involves no more than five joints, causes few systemic symptoms, and has a relatively mild course. The disease may recur at the same site or in previously uninvolved joints. It generally runs its course in four years. The authors believe that synovectomy is contraindicated in children suspected of having this mild form of arthritis unless joint destruction is evident or symptoms progress for more than three years.


Recent survey of infectious meningitis in adults: review of laboratory findings in bacterial, tuberculous, and aseptic meningitis. Infectious meningitis in adults was reviewed to establish the frequency of meningitis due to each causative agent and to reexamine the laboratory parameters that help to distinguish aseptic, bacterial, and mycobacterial meningitis. Aseptic meningitis occurred 2.2 times more often than bacterial and mycobacterial meningitis combined. The most common nonviral causative agent was the pneumococcus (23 cases) followed by the tubercle bacillus (11 cases) and the meningococcus (5 cases). Cerebrospinal fluid (CSF) Gram stain was the most useful study to rule in a bacterial cause: 89% of cases of bacterial meningitis had a positive initial Gram stain. Hyponatremia occurred in 73% of cases of tuberculous meningitis; hyponatremia combined with a negative Gram stain was highly suggestive of a tuberculous cause. One third of all patients with tuberculous and aseptic meningitis had a predominance of neutrophils in the CSF. No patient with aseptic meningitis had a CSF while count higher than 2,800 cells/cu mm or a CSF protein value higher than 250 mg/100 ml. Other reviews confirm this if cases due to lymphocytic choriomeningitis (LCM) are excluded. One patient with tuberculous meningitis in this series, and none of those cases reviewed, had a CSF white count higher than 1,200 cells/cu mm. Only 3.7% of the patients with aseptic meningitis had hypoglycorrhachia. Series reporting exclusively disease due to mumps and LCM have a higher frequency of hypoglycorrhachia.


Mikulicz's disease and Mikulicz's syndrome. The pathogenesis, clinical manifestations, and historical development of Mikulicz's disease and Mikulicz's syndrome are given. It is recommended that the term "Mikulicz's syndrome" be dropped to avoid confusion with the rare and well defined entity "Mikulicz's disease."


Neurilemoma presenting as a lump in the breast. A neurilemoma arising in breast tissue is reported. Neurilemomas are usually well circumscribed and non-invasive, but may be confused with cystosarcoma phylloides, particularly in frozen section. Pertinent pathologic findings are described, and the literature is reviewed. Only one case of neurilemoma in the breast has previously been reported.


Photosensitivity papules--a cutaneous sign of systemic disease: erythropoietic protoporphyria. Erythropoietic protoporphyria is an unusual autosomal dominant syndrome characterized by increased deposits of protoporphyrin in erythrocytes, liver, feces, and skin. Symptomatic chronic cutaneous papules in sun-exposed areas, cholelithiasis, cirrhosis, hepatic failure, and anemia are manifestations of this systemic disorder. Treatment of cutaneous symptoms is with oral beta-carotene, but there is no effective control for internal manifestations.


Adverse effects of transfusions.

Adverse effects of transfusions. The risks of morbidity and mortality associated with transfusion are so great that no transfusion should be given until it is decided that it is absolutely necessary and then only with the utmost care. The unfavorable effects of transfusion reviewed are: hemolytic reaction; bacterial contamination; febrile reaction due to leukoagglutinins; urticaria; anaphylaxis; problems associated with the transfusion of excess potassium, ammonia, and acid; transmission of hepatitis, cytomegalic inclusion disease, toxoplasmosis, and malaria; pulmonary insufficiency; air embolism; and circulatory overload.


Macrocheilia due to lymphangiectasia.

Macrocheilia due to lymphangiectasia. A case of symmetrical, diffuse macrocheilia due to lymphangiectasia is presented. No primary cause for this case or for many other pathologic forms of macrocheilia has been established. Tranverse mucosal wedge resection of the lip with mucosal advancement, however, is a satisfactory method of treatment.


Recurring spontaneous pneumothorax associated with menses. A case of catamenial pneumothorax in a 34-year-old woman is presented. Typically recurrent, right-sided pneumothorax associated with menses occurs in a 30- to 40-year-old woman with endometriosis. The right-sided occurrence is attributed to the frequency of congenital perforations of the right hemidiaphragm. Aberrant endometrial tissue is thought to gain access to the right hemithorax and cause pneumothorax with the menstrual slough. Therapy consists of ovulation-suppressing drugs or thoracotomy with pleural ablation for recurrent pneumothoraces. The physician should be aware of the syndrome to make a proper diagnosis.


Intramural hematoma of the duodenum.

Intramural hematoma of the duodenum. A case concerning a patient with an intramural hematoma involving the first and second portions of the duodenum was presented with a brief review of etiology, pathogenesis, clinical features, and management. An intramural hematoma usually occurs after blunt trauma, manifesting clinically as a high small bowel obstruction with a palpable mass. Roentgenograms usually confirm the diagnosis and treatment in simple evacuation of the hematoma.


Leiomyoma arising adjacent to a maxillary tooth socket: an intraosseous leiomyoma presenting as an odontogenic lesion. An intraosseous leiomyoma involving a maxillary tooth socket is described and previous reports of oral leiomyomas are reviewed. This is the first case report of an intraosseous leiomyoma. Although theoretically it could be of odontogenic origin, the tumor probably arose from vascular smooth muscle or bone.


Colitis cystica profunda.

Colitis cystica profunda. The 50th reported case of colitis cystica profunda, with coexisting carcinoma in situ, was found. The diagnosis was made after a second excisional biopsy. The lesion was excised locally, and no recurrence has been observed one year after operation.


Weber-Christian disease after weight loss. Weber-Christian disease has no known cause and is characterized by a febrile, recurrent, nonsuppurative panniculitis occurring preferentially in young, obese women. The present case is of interest in that it occurred in a young, obese woman after she lost 18.2 kg (40 lb) in eight weeks. It is only speculative as to whether the sudden weight loss precipitated the Weber-Christian disease. However, since Weber-Christian disease is an obscure disease with metabolic and autoimmune overtones, such a hypothesis is not unrealistic in a predisposed individual.


Neoplasia of the colon: a late complication of ureterosigmoidostomy. A case of carcinoma of the sigmoid colon arising 26 years after ureterosigmoidostomy for a benign condition is presented. This is the 31st reported instance of neoplasia complicating ureterosigmoid diversion. Possible etiologic mechanisms include surgical trauma, constant irritation of the transplanted ureter, alteration of local tissue dynamics, and urine carcinogenesis.


Ichthyosiform scaling in association with lymphoma. A patient is described who developed ichthyosiform scaling in association with localized Hodgkin's disease. The scaling subsequently cleared following initial successful radiotherapy of the tumor. The scaling has not returned with two recurrences of the lymphoma during a five-year period.


Death due to fluorocarbon inhalation.

Death due to fluorocarbon inhalation. The abuse of inhalation of aerosol preparations containing fluorocarbons as the propellant is a potentially lethal act. I report a death believed due to inhalation of an aerosol propellant.


Systemic lupus erythematosus: unusual presentation with gastric polyps and vasculitis. A case of SLE with the unique association of gastric polyps and vasculitis is reported. Gastrointestinal symptoms, surgical indications, and complications of SLE with gastrointestinal involvement are reviewed. The unusual patterns of ileus or lupus peritonitis secondary to mesenteric vasculitis must be differentiated from a true surgical emergency. Corticosteroids may be expected to produce rapid clinical improvement in the two former instances. Surgical exploration is reserved for those cases with clinical or radiologic evidence of uncontrollable hemorrhage, bowel perforation, or mesenteric infarction.


Metastatic carcinoma in meningioma.

Metastatic carcinoma in meningioma. A case of adenocarcinoma of the lung metastatic to two of three parasagittal meningiomas is presented. This is the tenth reported case of carcinoma metastatic to a meningioma.


Choledochoduodenostomy: an answer to some biliary surgical problems. In the presence of a primary stasis stone, ampullary obstruction, and a massively dilated common bile duct, choledochoduodenostomy should be considered. Because of infrequent need, surgeons may hesitate to utilize this valuable procedure; however, it may be the most expeditious and safest method of treating complex biliary problems. Neither ascending cholangitis nor stasis in the remaining distally obstructed duct appear to be a problem if an adequate stoma is established. A case report was included to emphasize the problem and the solution.


Chronic arachnoiditis after a pantopaque study of the posterior fossa. Reported is a case in which chronic arachnoiditis resulted as a complication of using Pantopaque in studying the posterior fossa. The possibility that prophylactic intrathecal injections of methylprednisolone acetate while performing Pantopaque myelography help avoid serious complications is discussed.


The mortality and morbidity of laryngectomy. Experiences with 147 laryngectomies, 49 with en bloc neck dissection, are presented. One patient died, and 36 suffered postoperative complications serious enough to delay rehabilitation and to prolong hospitalisation.


A forward view of health services in South Africa. This article is an exposition of health services, past, present and future, in the Republic of South Africa, with particular reference to the Black homelands and their development in the fields of personal health services, nutritional services and laboratory services. It also deals with manpower resources and medical aid.


Acute leukaemia and allogeneic granulocyte support. Infusion of functional allogeneic granulocytes is rational therapy in pyrexial patients with severe neutropenia when combined with appropriate antibiotic administration. On the basis of our first year's experience we endorse this approach, but emphasise the need for further critical evaluation of these cells, and present an approach to placing this procedure on a more scientific basis.


Treponemal depigmentation, with special reference to yaws. Depigmentation of the skin at characteristic sites occurs in all the treponematoses, but it is seen most commonly in older persons who have had yaws in infancy or childhood, especially when treatment has been inadequate to prevent this tertiary manifestation. A total of 689 cases are recorded from the former Belgian Congo.


The role of Mycoplasma in human infertility. Seminal fluid from males complaining of infertility was examined for the presence of T-mycoplasmas and Mycoplasma hominis. No significant difference, with regard to the presence of mycoplasmas, was found between the seminal fluid which had normal cytology and seminal fluid of which the cytology was deemed pathological. Colonisation was shown to be an evanescent phenomenon, and female consorts often had different mycoplasma flora to the males. No positive role of mycoplasmas in the pathogenesis of infertility could be shown.


Multiple therapist groups in a day-patient setting and some aspects of group geography. The pros and cons of multiple therapist groups are considered from both the patient's and the therapist's points of view. Some aspects of group geography and how this may affect group activity, are examined. The significance among selected patients of preferential seating and how activity in the group varied with this, is discussed.


Induction of labour in Black patients.

Induction of labour in Black patients. The results of a prospective study of induction of labour in 175 Black patients are presented. They show that induction of labour in Blacks, even when performed with optimal care, is more hazardous than in other population groups, owing to an increased proportion of patients of high parity and an increased prevalence of cephalopelvic disproportion. The factors affecting the outcome of induction, the safety of induction and the criteria for a safer induction are discussed.


Abdominal paracentesis in the diagnosis of ruptured ectopic pregnancy. A prospective study of the use of abdominal paracentesis in the diagnosis of suspected ectopic pregnancy was carried out. Paracentesis was performed in 189 patients, of whom 132 were subsequently shown to have ectopic pregnancies. Paracentesis confirmed the diagnosis in 90,9% of cases, but when this was corrected to exclude cases where no intraperitoneal haemorrhage was present, the success rate rose to 96,3%. We believe that this simple, harmless, bedside procedure has value in aiding and confirming the diagnosis of ruptured ectopic pregnancy.


Rupture of the uterus: the preventable factors. A review of 50 cases of ruptured uterus revealed that important measures to prevent this serious complication are: good antenatal care; careful attention to patients who have had a previous Caesarean section; the correct management of cephalopelvic disproportion in the multigravida; the recognition of the serious hazards of internal version in the management of transverse lie; and careful attention to detail in the use of oxytocin in the multigravida. The factors that were regarded as critical in maintaining a low maternal mortality rate in rupture of the uterus are also reviewed.


Intra-amniotic use of urea and prostaglandin F2 alpha to induce labour in pregnancies complicated by death of the fetus. A simple, safe and efficient method of inducing labor in patients in whom pregnancy is complicated by intrauterine death of the fetus is described. The technique involves a single intra-amniotic infusion of 30 mg of prostaglandin F2alpha with 60 g of urea. Fourteen pregnancies complicated by intra-uterine fetal death (ranging in duration from 1 to 7 1/2 weeks) were successfully terminated by this method. Side-effects and complications were minimal. It is submitted that this method provides the obstetrician with a valuable addition to his therapeutic armamentarium. If correctly employed, it provides rapid delivery with minimal risk of discomfort to the patient.


Postabortal and postpartum tetanus. A review of 19 cases. The occurrence of postabortal and postpartum tetanus over a 7 1/2-year period at Groote Schuur Hospital, Cape Town, is reviewed. Of all the women between the ages of 15 years and 50 years who were admitted with tetanus, 34,7% were admitted after abortions. The mortality rate was 15,8%, which appears to be the lowest thus far reported. Possible methods of preventing postabortal tetanus are discussed.


Comparison of oral prostaglandin E2 and intravenous oxytocin for induction of labour. A carefully controlled, prospective study was undertaken in 100 patients to compare orally administered prostaglandin E2 capsules with intravenous oxytocin in the induction of labour at term. Orally administered prostaglandin E2 induced labour in slightly more patients than did intravenous oxytocin (48 out of 50 v. 45 out of 50) and a larger trail is in progress to evaluate this observation further. Mild gastro-intestinal symptoms occurred in 28% of the patients when oral prostaglandin was given. However, the oral route is more convenient and more comfortable for the patient and the administration requires less adjustment by the nursing staff.


Treatment of anovulation with human menopausal gonadotrophin. A method is presented of gonadotrophin administration and serum 17beta-oestradiol monitoring for the treatment of anovulation. Four of the 6 patients treated have conceived without any undesirable effects due to hyperstimulation. The advantages of this method of treatment and monitoring are discussed.


Scanning electron microscopy of normal uterine cervix, carcinoma in situ and squamous cell carcinoma. Preliminary findings. Colposcopically directed punch biopsy specimens of the uterine cervix were taken from women in whom Papanicolaou smears indicated cytological abnormalities. Half of each specimen was processed for scanning electron microscopy and half for light microscopy. The surface morphology of normal cervical, metaplastic and frankly carcinomatous epithelia and epithelia of carcinoma in situ, as seen under the scanning electron microscope, was compared with the appearance revealed by Papanicolaou smears, and haematoxylin- and eosin-stained sections.


Misconceptions and miscarriages in multiple choice questions. A modification of the standard format of multiple choice question (MCQ) examinations, recently introduced in certain medical schools in this country, is decribed. The scheme allows for the variation of marks allocated to different in the paper, depending upon the relevance, importance and degree of difficulty of each question. However, the manner in which this new system is being implemented in some cases transgresses some fundamental principles of MCQ examinations. The consequence of this is that the average mark for the class is unintentionally low, with the good students separated from the main body of the class by a disproportionate number of marks. In addition, the examination lends itself to abuse by the enterprising student who is familar with the system of mark allocation.


Clinical aspects of monocomponent insulins in the treatment of diabetes. Conventional insulins, even if recrystallised many times, are found to contain several peptides on gel electrophoresis and are immunogenic. Antibody formation, insulin allergy, fat atrophy, fat hypertrophy and insulin bumps are thought to be largely caused by the impurities rather than by the insulin itself. 'Monocomponent' insulin has recently been prepared in the laboratories of Novo industries Ltd. Theoretically, this insulin should not cause the above complications. A combined clinical trial of monocomponent insulin has been carried out in Johannesburg and Cape Town on 24 patients with diabetes of diverse aetiology, who required insulin. The results of the trial may be summarised as follows: Monocomponent insulin appears to be very effective in patients with insulin allergy, adipopathy, and possibily in some patients in whom diabetes is not controlled with large doses of insulin. The monocomponent insulins deteriorate on storage at room temperature and yield monodesamido insulin. This de-amidation may be associated with persistent circulating antibodies to insulin and pro-insulin and with failure to reduce insulin requirements, but does not interfere with improvement in allergy or adipopathy. Long-standing diabetic patients, who are qell controlled with conventional insulin, are unlikely to gain therapeutic benefit from monocomponent insulin, and may even deteriorate or lose smooth metabolic control.


Multiple colonic stricture formation and amoebiasis. A case report. Case reports of multiple colonic strictures resulting from amoebiasis are uncommon in the literature. Such a case is presented and the diagnosis and management are discussed.


Sideroblastic anaemia associated with iron overload treated by repeated phlebotomy. Iron overload with prominent skin pigmentation and hepatic parenchymal siderosis is reported in a patient with refractory sideroblastic anaemia. Failure to reverse the sideroblastic changes or the anaemia with conventional therapy prompted us to use a graded phlebotomy programme. The rising haemoglobin level in spite of repeated venesections is support for this approach in selected patients with this diagnosis.


Dissecting aneurysm of the aorta. A report of four cases. Four cases of dissecting aneurysm of the aorta are discussed. The clinical diagnosis depends on awareness, suspicion, an association of certain preceding conditions and an understanding of the varied manifestations. Sudden, sharp chest pain, aortic valvar involvement and peripheral arterial occlusion are practically diagnostic. A widening of the aortic arch, the exclusion of myocardial infarction electrocardiographically, and an aortogram are helpful in the diagnosis. A dissecting aneurysm of the aorta is an emergency requiring early diagnosis and surgical treatment to improve the survival rate of 10%. Medical treatment is to be preferred for the chronic type of dissection.


Alcohol, aspirin, depression, smoking, stress and the patient with a gastric ulcer. It would seem that a gastric ulcer is the product of an interaction between chronic gastritis, the acid (and pepsin) of the gastric juice, and one or more precipitating factors. In a group of 194 consecutive patients with gastric ulceration particular note was made of whether they smoked, drank alcohol, used salicylates, were depressed or had experienced recent stress. There was an extraordinarily high incidence of depression among White women.


Personal experience.

Personal experience. Three attacks of infective endocarditis with consequent emergency surgery to the aortic and mitral valves leave their mark. These are the impressions of a physician at the receiving end of his medical environment, an experience which entailed 4 periods of hospitalisation in 2 hospitals.


Onchocerciasis and the skin.

Onchocerciasis and the skin. In areas of low prevalence of onchocerciasis, and in persons with low intensities of infection, the skin manifastations are of more frequent occurrence and of greater importance than the ocular complications. In addition to pruritus and erythema around the site of the bites, depigmentation of characteristic appearance is common.


Plasma cholinesterase variants - an unexpectedly high incidence of the silent allele. The silent allele is one of the rarer plasma cholinesterase variants. In a series of 9 South African families with an inherited abnormal cholinesterase, the silent allele occurs in 5. In 2 it is the only abnormal allele present while in 3 it occurs with the 'atypical' (dibucaine-resistant) form. Identification of the single silent allele requires full family studies, since its inhibition characteristics are those of the other allele present, normal or abnormal.


The isolation of Botryodiplodia theobromae from a nail lesion. Botryodiplodia theobromae not known to produce onychomycosis was repeatedly recovered from a healthy woman with evident lesions in a toe nail. Mycelial fragments were observed in the scales and the fungus was isolated in cycloheximide-free culture media. The report indicates that many fungi, hitherto considered non-pathogens, may still be able to colonize a vaiety of human tissues.


Freeze-fracture replication of cultured Pityrosporum orbiculare. Skin scrapings from a patient with Pityriasis versicolor were plated on a bile salt medium containing 10% glycerol (for cryoprotection) and Pityrosporum orbiculare was harvested for freeze-fracture replication. Resting and budding cells were senn. The overall pattern of indentation of the plasma membrane towards the cytoplasm was well revealed as a spiral arrangement of major indentations with minor ones disposed more or less at right angles. Hexagonally-arranged particles were not observed. Mitochondria were elongated with constrictions at intervals, and the fracture face of the limiting membrane directed towards the exterior exhibited linear arrays of particles. An unusual type of organelle was also present, viz: a membrane-limited vesicle with regularly-spaced depressions or "dimples".


In vivo development of spores of Absidia ramosa. Approximately 10(6) spores of Absidia ramosa were inoculated intravenously into normal and cortisone pretreated mice. At subsequent time intervals the liver, lungs and kidneys were removed and examined for fungal localization and growth. In normal mice, spore germination and continued hyphal growth was restricted to the kidneys-evidence of germination not being visible until around 30h post inoculation. Cortisone therapy allowed germination of spores in the lung and kidney by 7h but subsequent hyphal growth in the lung was severely restricted compared with the kidney where extensive hyphal growth occurred. Germination of spores in the liver of cortisone treated animals was slow, not becoming apparent until about 40h after inoculation. These results suggest that host defence mechanisms in the form of phagocytosis as well as biochemical inhibitors and/or lack of suitable stimulators are important in preventing germination of introduced fungal spores. Once germination has occurred, it appears that additional as yet undetermined factors play a role in allowing continued growth of the fungus.


Animal ringworm in upper Egypt.

Animal ringworm in upper Egypt. One thousand nine hundred and twenty animals (cattle, buffalo and sheep) and 60 humans suspected of ringworm were investigated in Egypt. Clinical and mycological aspects of the disease are described. Trichophyton verrucosum was the commonest dermatophyter on all species examined. Only T. mentagrophytes was isolated once from soil in the region of the clinical cases.


Cutaneous geotrichosis in the red flamingo (Phoenicopterus ruber). In three flamingos (Phoenicopterus ruber), which died showing extensive necrotic inflammation of the skin of the webs and the legs, the presence of abundant mycelium and arthrospores was shown in the altered dermis and epidermis. From all the lesions Geotrichum Candidum was isolated in pure culture. Inoculation of suspensions of the fungus into domestic chickens and mice produced granulomas or more purulent nodules with central growth of abundant mycelium. From 20 of 28 experimental animals, G. candidum was reisolated from the lesions in pure culture 2 weeks after the inoculation. It is suggested that alteration of the skin by e.g., prolonged contact with pondwater, the presence of small wounds and the advanced age of the birds, acting as predisposing factors may be necessary in establishing this disease.


Cutaneous infection of a porcupine (Erethizon dorsatum) by Aureobasidium pullulans. Aureobasidium pullulans was repeatedly isolated from a cutaneous infection of a porcupine (Erethizon dorsatum). Tissue sections revealed fungal filaments similar to those of A. pullulans. This is the first reported association of A. pullulans with a natural infection of either wild or domesticated animals.


Pemphigus vulgaris and disseminated coccidioidomycosis. A Mexican-American patient with pemphigus vulgaris developed fatal disseminated coccidioidomycosis while on immunosuppressive therapy with systemic corticosteroids and azathioprine. Immunosuppressed patients should be carefully monitored for coccidioidomycosis as well as other systemic mycoses.


Pichia norvegensis sp. nov.

Pichia norvegensis sp. nov. A new yeast species Pichia norvegensis Leask et Yarrow is described as the perfect state of Candida norvegensis (Dietrichson) van Uden et Farinha ex van Uden et Buckley. Strains of this species were isolated on 3 occasions from human vaginas. This species differs from other Pichia species that assimilate glucose but not galactose, sucrose, maltose, lactose, D-mannitol and D-glucitol by assimilating cellobiose.


Light resistance in geophilic dermatophytes. The effect of repeated illumination by ultraviolet or visible light on slide cultures of Trichophyton ajelloi and Microporum cookei was studied. Under UV light, germination was inhibited, spores were damaged and destroyed, growth was suppressed and the hyphae were killed. Inhibition was dependent on exposure time and wavelength. Lethal doses for the far UV range were as high as 1 300-1 700 mW sec/cm2 for T. ajelloi and 2 300 mW sec/cm2 for M. cookei. The same effect was caused by the complete UV region but the far UV range was most effective. One exposure, however long, was not sufficient to kill the inoculum but this was effected by smaller doses when repeated 4 times at daily intervals. Under visible light, germination of the spores and growth of the young hyphae were inhibited. Depending on the exposure time and wavelength used, inhibition of 8 to 76% of controls grown in darkness were noted. The inhibition degree was increased up to lethality when the mycelium was sensitized by means of eosin. The coefficient of variation increased regularly up to very high values following exposures to sublethal doses of light...


Antibiotic sensitivity of the yeast and mycelial phases of Histoplasma capsulatum. Cycloheximide and chloramphenicol in combination have a greater effect on yeast cells of Histoplasma capsulatum than on the mycelial phase of this fungus. In contrast, clotrimazole was found to be more effective against mycelia. Miconazole produced a pronounced effect against both phases wheras tolnaftate was only slightly active. Sulfadiazine and griseofulvin were completely inactive against both phases. The differential sensitivities of the 2 phases of H. capsulatum to various antibiotics can be useful in studying the transition of the dimorphic fungus from 1 phase to the other.


Congenital posterolateral diaphragmatic hernia. The infant who is born with a posterolateral diaphragmatic hernia who becomes symptomatic at or soon after birth requires urgent care. Surgical reduction of the diaphragmatic hernia must be accomplished quickly. Respiratory and metabolic acidosis must be treated appropriately. The parents should be informed of the gravity of their infant's problem and reassurred by appropriate explanation of the nature of the defect and the therapeutic requirements. If the infant dies, the parents are in need of empathy, reassurance, and adequate explanation so that they do not have lingering doubts regarding the etiology of the anomaly and the adequacy of the therapy. If the infant lives, the medical team can share the feeling of a job well done.


Hirschsprung's disease.

Hirschsprung's disease. Hirschsprung's disease or aganglionic megacolon is an anomaly caused by the absence of ganglion cells in the myenteric plexus of the distal colon. It produces intestinal obstruction or lethal enterocolitis in the neonatal period and constipation of varying degree in the older child. The diagnosis can be made by history alone and confirmed by physical findings, barium enema, motility studies, and rectal biopsy. Colostomy may be a life saving measure in the newborn, to be followed by a definitive pull-through procedure before the age of 1 year. Operative correction consists of various techniques all of which aim for excision of the aganglionic segment with preservation of the internal anal sphincter. The major pitfall of these procedures is a too perfectly preserved sphincter which remains spastic and still produces obstruction. Some damage to this muscle must be accomplished either during the procedure or postoperatively by bouginage in order to obtain a satisfactory result.


Omphalocele.

Omphalocele. From a historical curiosity at the turn of the century, today omphalocele and gastroschisis can be corrected with good results, thanks to innovative techniques and better understanding of the newborn. Associated anomalies consist mainly of malrotation, Meckel's diverticulum, intestinal atresia, congenital heart defects, and genitourinary abnormalities. Nonoperative management in certain centers has been sucessful for the very large omphaloceles with an intact sac; however, a secondary procedure is necessary. In the past 10 years, the use of Silastic sheeting and total parenteral nutrition has allowed early repair of even the most severe cases, with excellent end results and low mortality.


Imperforate anus.

Imperforate anus. Sucessful treatment of the child with imperforate anus yields an individual with satisfactory continence and a healthy urinary tract. These goals are achieved by accurate evaluation of the newborn, optimal technical results, and conscientious follow-up. The infant born with one of these malformations frequently has a serious associated anomaly which also requires early specific diagnosis and management. When the bowel has passed through the puborectalis in utero, the deformity can often be definitively treated in the neonate by dilations or anoplasty. However, if a urinary or high vaginal fistula is present, or if the anomaly is of the supralevator type, definitive surgery is best postponed some months and the neonate given a colostomy. We have found the sacroabdominoperitoneal approach to be the most satisfactory pullthrough procedure for the supralevator lesion. The children with high, supralevator anomalies have higher mortality rates and, in one out of four cases, have suboptimal fecal continence. They require the utmost in technical skill and continuing care if they are to lives free of social stigma. The mortality rate in all other types is low and the functional continence uniformly acceptable.


A clinicopathologic study of hepatic dysfunction following shock. Nineteen patients who had profound hypotensive shock were studied to correlate the light and electron microscopic appearances of the liver with the clinical and biochemical evidence of hepatic dysfunction. Despite the multiple etiologic factors that can result in jaundice in these patients, a fluctuating pattern occurs which enables the correlation of a bilirubin peak with the predominating etiologic factor. Immediately after shock, there was enzymatic and light and electron microscopic evidence of hepatocellular damage, resulting in a  jaundice peak on the eighth to tenth day after the shock episode. This was followed by repair and regeneration of the liver as well as an increase in cholestatic enzyme levels. Later, bilirubin peaks occurred when hepatocellular function was further decreased or overloaded against this background of dysfunction related to the episode of shock. Recovery of hepatic function could continue or be delayed by intercurrent disease, particularly systemic infection. Support of hepatic function, similar to that available for pulmonary and renal failure may, in the future, be used to effect the prognosis of these patients.


Fecaloma simulating colonic neoplasm.

Fecaloma simulating colonic neoplasm. Large, discrete fecal masses in the colon may be confused with neoplasms, particularly if they are relatively immobile. The radiologic features of such masses generally permit their true identification.


Laboratory observations and clinical implications of monitoring the effect of heparin by bioassay. Laboratory and clinical experience in the monitoring of circulating heparin concentration of bioassay shows that the whole blood clotting time and the activated partial thromboplastin time differ in their reflection of the state of anticoagulation. The decay of biologic activity may be as short as 30 minutes in one patient or as long as 360 minutes in another. This fact may drastically affect patient response to the drug. Safe and rational clinical heparinization is dependent upon periodic monitoring of the circulating heparin concentration. The success of this method was illustrated in two representative patients.


The pathogenesis of diarrhea after bypass of the small intestine. Certain aspects of the pathogenesis of the diarrhea after bypass procedures of the small intestine for obesity have been evaluated. In the late postoperative period, a significant increase occurred in fecal weight and in fecal bile salt and free fatty acid output. There was a significant direct correlation between fecal weight and fecal bile salt output. There was no significant correlation between fecal weight and fecal fatty acid output. This suggests that, after bypass procedures of the small intestine, bile salts play a more significant role in the pathogenesis of diarrhea than do free fatty acids.


Genetic heterogeneity and familial carcinoma of the breast. The particular patterns of familial aggregations of cancer in the several families reported from our clinical resource suggest that multiple genotypes explain their diversity of cancer susceptibility. This knowledge could be of value in improving cancer control. We postulate that each particular genotype functions in concert with differential carcinogenic interactions, including a possible oncogenic virus, contributing to carcinogenesis in the susceptible patient. This reasoning is consistent with a concept of genetic heterogeneity as an explanation for familial carcinoma of the breast. This phenomenon is not unlike the current explanation for the genetics of the mucopolysaccaridoses, the lipidoses and several other major disorders of man which show genetic heterogeneity.


Arteriovenous fistulas for dialysis using modified bovine arteries. Arteriovenous fistulas were created on 21 occasions in 18 patients using an interposed segment of processed bovine carotid artery. In 18 fistulas, there were loops in the femoral region, and in three, they were created in the forearm. Seventeen of 21 fistulas developed a useful patency, with useful patency being achieved in 16 of the 18 patients. This patency is impressive, since it provided life-saving vascular access in these patients who previously had had failure of multiple standard shunts or fistulas. However, there was a high incidence of complications, with 17 of 21 fistulas developing some complication. Ten fistulas spontaneously occluded, but flow was restored in six. Seven significant infections occurred in fistulas of the thigh, with one patient eventually dying from complications. In two patients, major hematomas developed, and in six patients, false aneurysms developed, four of these false aneurysms being clearly associated with infection. Venograms were useful in the arm for demonstrating patency of the vein to be used for the arteriovenous fistula. The bovine interposed segment is a useful alternative in patients with difficult vascular access problems for hemodialysis but should be reserved only for such patients.


Noninvasive prevention of thrombosis of deep veins of the thigh using intermittent pneumatic compression. Intermitten venous compression promotes cyclic emptying and refilling of the veins and sinuses of the legs. It prevents stasis and formation of thrombi while the patient is on the operating table and during recovery. Once the patient is ambulatory, the system is discontinued. While the system is in use, thromboelastography, venous impedance plethysmography and venography, when indicated, are used to monitor the system. The intermittent pneumatic compression system is safe, simple and practical to use for almost all patients. There was no evidence of deep vein thrombosis or pulmonary embolism in 123 patients, as determined by an absence of clinical signs, a negative impedance plethysmogram and a negative venogram.


Arterial endothelial changes after ischemia and perfusion. The effects of six hours of ischemia and six hours of perfusion with 10 per cent dextrose and water solution, Sacks' solution and Intralipid on the endothelium of common femoral arteries in dogs were examined by light and by scanning electron microscopy and compared with normal arteries. Arteries that were ischemic or perfused with 10 per cent dextrose and water solution or Sacks' solution showed a flattening of the normal linear convolutions and extensive crater formation, with fragmentation and even complete loss of endothelial cells in many areas. The more severe changes occurred in perfused vessels. Fibrin and platelets covered the luminal surface in many areas in which there was extensive injury to the endothelium. Light microscopy revealed thickening of the internal elastic membrane and intimal fibrosis. Results of biopsies performed two weeks after perfusion showed slight, although incomplete, improvement in the structure of the endothelium. Arteries perfused with Intralipid had thickening of the intima with a proliferation of plump cells orientd linearly over the surface but with an absence of craters. Results of present studies confirm the observations of other investigators that injury to endothelial cells may be produced by ischemia and that perfusion with various solutions may produce an even more severe alteration in structure of the endothelial cell which does not return to normal within two weeks. The origin of new endothelial cells is not demonstrated by this study.


Role of preoperative bone scan in carcinoma of the breast. Although a skeletal scan is an effective means of detecting early metastatic deposits from carcinoma of the breast, its indiscriminate use in screening patients with early tumors does not seem justified because of the low yield of abnormal results. Selection of patients for this procedure should be based on the size of the tumor and the clinical stage of the disease. It is extremely unlikely that patients with a T1 lesion will have an abnormal skeletal scan. A preoperative scan in indicated for T2 lesions in patients with a central or medial quadrant mass, inflammatory carcinoma, palpable axillary lymph nodes or other clinical evidence suggestive of spread beyond breast tissue. All patients with T3 and inoperable tumors should have a bone scan prior to therapy to define the extent of the disease. A routine postoperative scan at six month intervals may be considered only in patients with large primary lesions and involvement of regional lymph nodes.


The coagulation and fibrinolytic response to splenectomy. The responses of the coagulation and fibrinolytic systems in nine patients with Hodgkin's disease undergoing splenectomy and lymph node mapping have been compared with those in nine patients undergoing elective upper abdominal operation for benign conditions. Differences have been noted in base line levels of fibrinogen, prothrombin, partial thromboplastin time and euglobulin lysis time. Platelet count increases were exaggerated following splenectomy, but other parameters of coagulation activity behaved similarly in the two groups. There is no evidence from this study to support the suggestion that blood coagulability is increased more markedly following splenectomy than it is after other upper abdominal operations.


Percutaneous biopsy of carcinoma of the pancreas guided by angiography. Histologic verification of the angiographic diagnosis of carcinoma of the pancreas may be achieved by percutaneous, transperitoneal fine-needle aspiration biopsy. The method was used in conjunction with the angiographic procedure in 29 patients with tumors of varying size down to 3 centimeters in diameter. Positive diagnosis was obtained in 22. Complications were not encountered. Since the method is simple and harmless it is recommended whenever histologic verification is desired.


Experimental aneurysms.

Experimental aneurysms. Aneurysms were produced experimentally with vein patch grafts on the carotid artery in the neck in rats. Aneurysms created at the bifurcation of the common carotid artery had a greater tendency to enlarge than did those on the trunk of the common carotid artery. Four aneurysms on the carotid trunk thrombosed; none did so at the bifurcation. The aneurysms ruptured in nine cases, more often when they were covered with oxycell than when they were not. Experimental aneurysms were also produced on the middle cerebral arteries in dogs.


Inhibition of cell-mediated immunity in patients with brain tumors. The immunocompetence of patients with glioblastomas, but not patients with astrocytomas, is altered. In vitro testing demonstrates an inhibitory factor in the serum of patients with glioblastomas which impairs lymphocytic responsiveness. The degree of this impairment appears important in relation to the clinical course.


Hemicraniectomy in the treatment of acute subdural hematoma: a re-appraisal. Although acute subdural hematoma continues to be one of the more common conditions neurosurgeons are called upon to treat, mortality rates continue to be quite unsatisfactory. Hemicraniectomy with wide decompression of the swollen brain was devised for the condition in 1971 (JNS 34:70-76). Initial results were quite encouraging with a 40% overall survival rate, 28% of the patients returning to normal activity. Since this original report, an additional 50 patients have been treated with only a 10% total survival rate and a 4% functional survival rate. Retrospective analysis of our cases over the past three years reveals that patient's age, status of preoperative neurologic examination, angiographic findings and appearance of the brain at operation, all have no statistical correlation with survival. These statistics will be presented and discussed. The failure of hemicraniectomy and extensive clot removal to significantly increase the functional survival rate in this condition implies that in a majority of patients with "acute subdural hematoma," primary brain stem and possibly subcortical injury are present, neither of which is amenable to radical therapy. The operation of hemicraniectomy should be restricted to those patients who enter hospital, obtunded but without demonstrable brain stem dysfunctionn, only to deteriorate subsequently because of increasing hemispheric edema and/or subdural clot.


Alcoholic cerebellar disease and seizures. Forty-eight chronic alcoholic patients with a clinical picture consistent with midline cerebellar disease were evaluated regarding alcohol related seizures. These seizures were noted in about 15% of this patient group. This seizure incidence approximates that in the severely alcoholic hospitalized population. Thus, the midline cerebellar degeneration does not appear to influence the seizure diathesis in the chronic alcoholic.


Complications of ventriculo-vascular shunts: computer analysis of etiological factors. The charts were reviewed at 323 patients who underwent a total of 578 ventricular shunting procedures at the Vancouver General Hospital, the original procedure having been done between 1960 and 1970 inclusive. There were 503 ventriculoatrial shunts, 38 ventriculo-peritoneal shunts, 34 Torkildsen procedures and three other procedures. The complications of the 503 ventriculo-vascular shunts, and the technique variables that might be related to these complications, were subjected to computer analysis.


Epidermoid of the fourth ventricle: discovery by computerized tomography. A case of fourth ventricular epidermoid is presented. The initial diagnosis was considered to be multiple sclerosis. Computerized axial tomography demonstrated the lesion without enhancement.  Since fourth ventricular epidermoids may present in a variety of ways, the value of computerized tomography is emphasized.


Carotid-ophthalmic aneurysms.

Carotid-ophthalmic aneurysms. Carotid-ophthalmic aneurysms have intimate relationships with the ipsilateral optic nerve and other neighboring structures. Direct operation for treatment of these aneurysms has been considered particularly hazardous and difficult. Therefore, some authors have recommended an indirect operation (carotid artery ligation in the neck) as the procedure of choice. A Consecutive series of eight patients with carotid-ophthalmic aneurysms in presented; a direct operation was performed in seven instances. There was no operative mortality and the morbidity was very low. The direct attack seems to be  reliable, and is recommended.


Arteriovenous malformations of the splenium of the corpus callosum: microsurgical treatment. Ten patients with arteriovenous malformations (AVM) involving the splenium of the corpus callosum are presented. All were treated by microsurgical techniques with no mortality and minimal morbidity. The diagnosis and operative technique is described, and these AVMs are compared with those involving the anterior and the middle portions of the corpus callosum.


Peripheral nerve injury from implantation of chronic stimulating electrodes for pain control. Complications of implantable stimulating electrodes for pain control are becoming recognized. We present two cases of peripheral nerve injury related to placement of peripheral nerve stimulating electrodes and discuss the relevant literature.


Spontaneous cerebrospinal fluid otorrhea. A case of spontaneous cerebrospinal fluid otorrhea with recurrent meningitis is reported. The route of cerebrospinal fluid leak was through the internal auditory meatus. The cerebrospinal fluid otorrhea was stopped by packing the meatus with muscle and Gelfoam.


Computerized tomography correlated with CSF protein concentrations. The authors present a case of hydrocephalus complicated by ventriculitis in which it was possible to correlate the numerical printout of sequential computerized tomograms (CT-Scans) with cerebrospinal fluid protein concentrations obtained by direct ventricular puncture. Different protein levels were unambiguously associated with changes in the absorption numbers on the scan but they did not bear a simple linear relationship to one another. The value of the numerical printout in diagnosis and follow-up is discussed.


Aqueductal occlusion by midline arteriovenous malformation. An adult presented with signs of chronic obstructive hydrocephalus. Angiography showed an arteriovenous malformation in the region of the posterior diencephalon and mesencephalon with venous drainage into the vein of Galen. Pneumoencephalography demonstrated obstruction of the aqueduct. This case affirms the need to consider the presence of an arteriovenous malformation in adults who present with signs of aqueductal stenosis.


Extracranial meningioma presenting as lytic skull lesion. A meningioma that had replaced the outer table of the skull and thinned the inner table but had no intracranial extension appeared as a solitary lytic lesion on routine roentgenograms of the skull. It was removed without complications.


Occipital artery-posterior inferior cerebellar artery anastomosis. In a 58-year-old man who suffered a stroke and had multiple and extensive extracranial arterial occlusions, an anastomosis was completed between the right occipital artery and the right posterior inferior cerebellar artery. Cerebral angiograms performed two weeks post-operatively showed patent anastomosis and partial improvement of the posterior circulation.


Microsurgical anterior cervical myelotomy. Cervical myelotomy utilizing the anterior approach and the operating microscope in a patient with an acute spinal cord injury is described. The procedure overcomes the technical difficulties previously encountered. The ease with which the hemorrhagic gray matter may be separated from the normal gray and surrounding white matter is emphasized.


Experimental cervical myelopathy: autoradiographic studies of spinal cord blood flow patterns. The cervical spinal cord was compressed at one (C5) or two (C4,C5) levels in eight awake dogs by advancing screws through the vertebral bodies into the spinal canal until minimal limb weakness occurred. Ischemia of the cervical cord was produced by ligation of vertebral and spinal arteries in four anesthetized dogs, of which two had previously undergone cord compression at two levels. The neurological and histological findings were studied. By means of antipyrine [14C]autoradiography, qualitative changes of blood flow in dogs with compression and/or ischemia of the cervical spinal cord were compared to flow patterns in normal dogs. The authors conclude that the neurological and histological changes produced by spinal cord compression, ischemia and their combination correlate with altered patterns of blood flow within the cervical spinal cord.


Severe epistaxis caused by traumatic aneurysm of cavernous carotid artery. A case of cavernous carotid aneurysm presented with unilateral blindness, orbital fracture and recurrent, severe epistaxis of delayed onset. Traumatic origin of aneurysm is confirmed by repeat angiographic studies.


Arachnoid cysts of the middle cranial fossa. Arachnoid cysts of the middle cranial fossa may present clinically in several different ways. They may remain asymptomatic throughout life, or may cause only local bulging of the skull, with or without exophthalmos. Expansion of the cyst may occur through a ball-valve mechanism of its membrane in communication with the general subarachnoid space leading to increased intracranial pressure with or without localizing neurological deficits. Finally, such cysts are associated with increased vulnerability to the effects of head injury, resulting in hemorrhage either into the cyst or external to the cyst to form a subdural hematoma. Recognition of these various manifestations is essential to proper treatment.


Pellet-gun brain wound complicated by Clostridium Perfringens meningitis. A ten-year-old male was hospitalized for a pellet-gun wound to the brain. He developed Clostridial meningitis within eighteen hours in spite of radical debridement and prophylactic antibiotics. However, successful recovery was obtained with high levels of penicillin and chloromycetin antibiotic therapy.


Neurogenic intermittent claudication and stenosis of the lumbar spinal canal. Neurogenic intermittent claudication is briefly reviewed and correlated with twenty consecutive cases of lumbar spinal canal stenosis. Irreversible damage may occur if surgical decompression is unduly delayed. A unilateral decompression may be sufficient in carefully selected cases.


A practical method for measuring hydrodynamics of cerebrospinal fluid. A method for measuring the formation and absorption rates of cerebrospinal fluid is described which can be carried out relatively rapidly and with a minimum of expensive apparatus. It has been found particularly useful in the evaluation of patients with hydrocephalus.


Surgical and angiographic localization of spinal arteriovenous malformations. Three cases of spinal arteriovenous malformation are reported which illustrate that localization of intra- and extramedullary components are not always adequately assessed by spinal angiography alone. One large malformation, primarily dorsal to the spinal cord, was not seen on angiography. A second lesion thought to be intramedullary and unresectable as judged by angiography was found at surgery to be primarily dorsolateral and was resected. The third malformation was thought to be extramedullary on angiography, yet had a major intramedullary component at surgery and was not resected. We conclude that surgical exploration of all spinal arteriovenous malformations should be performed despite the angiographic appearance.


Convulsions subarachnoid haemorrhage and death following myelography with meglumine iothalamate 280. A case is presented of convulsions, subarachnoid haemorrhage and death following the use of meglumine iothalamate 280 for myelography. The patient was suffering from sciatica but had no pre-existing symptoms of other neurological disease. This case dramatically illustrates the dangers inherent in the use of meglumine iothalamate 280 for myelography.


Epidural venography in the diagnosis of lumbar disc disease. Epidural venography is a simple and effective technic in the diagnosis of herniated intervertebral discs. The procedure may be performed in the outpatient department using percutaneous transfemoral catheterization. Our experience in 87 cases suggests that epidural venography is superior to Pantopaque myelography at the L5-S1 level, comparable to, and in some cases superior, at the L4-L5 level. The epidural venogram was abnormal in 33 cases. The findings were confirmed at operation in 25 of these. The remaining eight patients are being followed or are awaiting surgical treatment. Twenty of the 25 cases had had normal Pantopaque myelograms. Fifty-four of the 87 cases were considered to be normal.


Acute spinal epidural hematoma secondary to aspirin-induced prolonged bleeding. A case of acute and spontaneous spinal epidural hemorrhage is described in which there was no history or evidence of trauma, conventional anticoagulant therapy, hemophilia or vascular anomalies. A recent history of excessive ingestion of an aspirin-containing medication was obtained and the clinical and laboratory picture of an aspirin-induced bleeding disorder was documented. We have discussed the mechanism and hematological considerations of the syndrome of aspirin induced bleeding.


Aneurysm rupture during angiography: does acute vasospasm occur? Thirty-two cases of rupture of an aneurysm during angiography were reviewed to determine whether there is an immediate, acute phase of intracranial arterial spasm in human beings. Unfortunately, in the 11 instances of major extravasation into the adjacent subarachnoid spaces (the cases most likely to demonstrate arterial spasm), the arteries either were not filled or were obscured by the escaping contrast medium. In 13 patients who demonstrated arterial spasm, the vasospasm definitely (5), probably (6), or possibly (2) was related to a prior episode of bleeding. There was no evidence of arterial spasm in the other eight cases. Therefore there is no definite proof from the present investigation that an acute phase of intracranial arterial spasm occurs following rupture of an aneurysm.


Cerebral tuberculoma localized by EMI scan. A case of isolated supratentorial tuberculoma is described. The patient had a left facial palsy, left hemiplegia, and left proprioceptive and stereognostic deficits with negative studies until the lesion was delineated with computerized axial tomography (EMI scan). The characteristics EMI scan is helpful in delineating the nature and precise location of the lesion prior to surgery.


Monitoring and control of intracranial pressure in non-traumatic encephalopathies. Fifteen patients with non-traumatic encephalopathies underwent continuous monitoring of intracranial pressure. These included 11 children with Reye's syndrome, two with viral encephalitis, one with mushroom poisoning, and one with hypoxia from drowning. Elevated intracranial pressure was treated with decadron, hyperventilation, hyperosmolar agents and in some cases hypothermia and barbiturates. The results are discussed.


An apparatus for quantitating experimental spinal cord trauma. An apparatus is described for producing experimental contusion of the spinal cord and simultaneously monitoring the degree of trauma: velocity of spinal cord deformation, impulse and energy. This is accomplished by modifying an existing trauma apparatus by the addition of a displacement transducer, an induction coil triggering device and oscilloscope. With variability in the mechanics of the trauma apparatus and biological variations in each animal (i.e. differences in the visco-elastic properties of the spinal cord, etc.) and in different kinds of animals, this apparatus will more accurately quantitate the trauma delivered to each spinal cord and, thereby, form a better basis for correlation of amount of injury, degree of neurological dysfunction and efficacy of various methods of treatment.


The use of expanded microporous polytetrafluoroethylene for limb salvage: a preliminary report. Initial laboratory and clinical evaluations of a new prosthetic material, expanded microporous polytetrafluoroethylene (PTFE), for small vessel replacement is promising and encourages further clinical trial. Frequently the autogenous saphenous vein is not available for bypass procedures, and alternative arterial substitutes have not proved reliable for replacement of small vessels. In this study, 15 patients with impending loss of limb and no available saphenous vein underwent revascularization of the lower extremity with expanded microporous PTFE grafts. Thirteen of 15 patients now demonstrate viable extremities with a resulting over-all early patency and limb salvage rate of 87 percent for this series. Follow-up ranges from one to 8 months. Seven patients had diabetes mellitus and eight had atherosclerotic heart disease. Nine grafts crossed the knee joint. In all patients arterial runoff was poor. Six patients had previous femoropopliteal bypasses, five with autogenous veins and one with Dacron velour. Two patients had multiple previous operations that failed, first with autogenous vein and later with fabric grafts. The current limb salvage and patency rate of 87 percent in high-risk patients suggests that expanded PTFE may be the prosthesis of choice when an autogenous vein is not available and possibly an equally good substitute when the venous autograft is available.


A modified method for the repair of esophageal atresia with tracheoesophageal fistula. Forty patients with esophageal atresia with tracheoesophageal fistula were operated upon during a period of 2 years, 39 of them with the end-to-side anastomosis technique. According to Waterston's classification, the survival rate was 91 percent for Group A (11 patients), 60 percent for Group B (15 patients), and 14 percent for Group C (14 patients). A prospective study carried out with the first 30 patients showed that the partial removal of the mucosa of the lower esophagus, just distal to its junction with the trachea, reduced significantly the incidence of recanalization of the tracheoesophageal fistula.


Tracheomalacia in association with congenital tracheoesophageal fistula. Tracheomalacia is an important cause of morbidity and death following correction of congenital tracheoesophageal fistula and is a well defined syndrome which requires recognition and appropriate treatment. The symptoms and signs allow division into mild, moderate, and severe groups. When the clinical features suggest the presence of tracheomalacia, endoscopy should be carried out in order to confirm the diagnosis and document the severity. Mild and moderate cases can be managed conservatively; efficient and regular physiotherapy is the mainstay of treatment. Severe cases warrant consideration for the operation of tracheopexy which may be lifesaving and will certainly reduce the period of hospitalization and will simplify management.


Lady Luck.

Lady Luck. When a patient with no distance complaints is unable to read with comfort, a shift in the cylinder axes should be among the first things considered. A simple technique for measuring the axes is described, interpretation of the measurements is discussed, and various therapeutic approaches are suggested.


Influence of a synthetic prostaglandin analog on pancreatic secretion. Effects of a synthetic prostaglandin analog-16--16-dimethyl prostaglandin E2, methyl ester (16-diMe-PGE2)--on pancreatic secretion were evaluated in seven dogs with chronic duodenal fistulas. Graded doses of 16-diMe-PGE2 were administered intravenously (0.1, 0.3, 0.5, and 1.0 mug per kilogram, intraduodenally, or intragastrically (15, 30, 50, 100 mug per kilogram) with the pancreas in the resting state or in response to (1) secretin and (2) secretin with cholecystokinin-pancreozymin. Profound and prolonged inhibition of volume and bicarbonate concentration of secretion occurred in the resting and stimulated gland. ED50 was 0.31 mug per kilogram intravenously (1/75 the ED50 for PGE1) and 25 mug per kilogram intraduodenally. As with PGE1, stimulation of enzymes occurred, even with doses that were subthreshold for inhibition of volume and HCO3. Like PGE1, 16-diMe-PGE2 has a dual action on the intact canine pancreas (stimulation of enzymes and inhibition of volume and electrolytes), but is much more potent, has a prolonged action, and is active intraduodenally and intragastrically. Nonsteroid inhibitors of endogenous prostaglandin synthesis did not alter these effects.


Vascular compression of the duodenum: Presentation of ten cases and review of the literature. Ten cases of vascular compression of the duodenum are presented, and 125 cases in the literature since 1962 are reviewed. More common in women than in men, the lesion may result from supine immobilization, wearing body cast, or a rapid weight loss. In about one third of the patients, no predisposing factor can be found. Diagnosis is best made by cinefluoroscopy. Although conservative measures will provide relief in a few patients, most will require surgery. Section of the suspensory muscle and relocation of the duodenojejunal junction will relieve the symptoms in many patients. Duodenojejunostomy will be required in some others. Complete relief can be expected in all but a very few patients. Those who have developed neurotic eating habits from years of discomfort may not show immediate improvement. Untreated vascular compression of the duodenum may be chronic or may become acute with fatal results.