Cholinergic neuronotrophic factors: intraocular distribution of trophic activity for ciliary neurons.

Chick ciliary ganglionic neurons require an interaction with their peripheral targets for survival during a critical period of their embryonic development in vivo. It has recently been shown that survival of these neurons in dissociated cell cultures is supported by extract from whole chick embryo. In this study, an assay system based on microwell cultures of ciliary ganglionic neurons was used to demonstrate that a very rich source of trophic factor for them is the intraocular target tissues they innervate. Out of 8000 trophic units present in a 12-day embryo, 2500 were contained in the eye. A subdissection of the eye showed its activity to be localized in a fraction containing the ciliary body and choroid coat, with a specific activity almost 20-fold higher than that of the whole embryo. This selective intraocular distribution at a time when survival or death of ciliary ganglionic neurons is decided in vivo suggests that this soluble factor may be involved in the normal development of the ciliary ganglion.


Goldfish retina: a correlate between cone activity and morphology of the horizontal cell in clone pedicules.

In the cone pedicules, the digitations of horizontal cell process lateral to the synaptic ribbon disappear after dark adaptation. This disappearance is correlated with the loss of color opponency and cone function shown in ganglion cell recordings in isolated retinas. Cone function and color-opponent responses are restored by reapplying background light.


Automatic classification of electroencephalograms: Kullback-Leibler nearest neighbor rules.

A prototypic problem in screening of electroencephalograms in the automatic classification of stationary electroencephalogram time series is treated here by the Kullback-Leibler nearest neighbor rule approach. In that problem, the category or state of an individual is classified by comparison of his or her electroencephalogram with those taken from other individuals in the alternative categories. The Kullback-Leibler nearest neighbor classification rules yield a statistically reliable estimate of the smallest possible probability of electroencephalogram misclassification with a relatively small number of labeled sample electroencephalograms. The automatic classification of anesthesia levels L1 and L3, respectively the anesthesia levels insufficient and sufficient for deep surgery, is treated by machine computation on the electroencephalogram alone.


Hyperthermia and local anesthetics: potentiation of survival of tumor-bearing mice.

Lidocaine infusion of a CA755 mammary adenocarcinoma growing in the hind leg of BDF1 mice results in a significant increase in the animals' survival when combined with heating for 1 hour in a 43.5 degrees C water bath. This ability of local anesthetics to prolong survival following hyperthermia is consistent with the hypothesis that increases in membrane fluidity influence sensitivity to heat. In view of the extensive clinical experience with local anesthetics, the delay between clinical application and the observation that they potentiate the action of hyperthermia in animals may be reduced.


Non-A, non-B hepatitis: ultrastructural evidence for two agents in experimentally infected chimpanzees.

Two different ultrastructural alterations were observed in liver cells of chimpanzees inoculated with plasma derived from two different patients with non-A, non-B hepatitis. During the acute phase of illness in one group of four chimpanzees, peculiar tubular structures, composed of two unit membranes with electron-opaque material in between, were observed in the cytoplasm of hepatocytes. In contrast, these structures were never detected in the liver cells of the second group of five chimpanzees that received the second inoculum, However, nuclear changes, usually associated with aggregates of 20- to 27-nanometer particles, were found in hepatocytes of the latter animals. Although these particles resembled viruses, they were not as uniform as small virus particles often appear. In five other chimpanzees inoculated with non-A, non-B hepatitis material not known to be related to the first two inocula, cytoplasmic structures were found in four, and nuclear structures were found in the remaining one. Thus, all 14 chimpanzees inoculated with transmissible non-A, non-B hepatitis agents could be classified as having either nuclear or cytoplasmic changes. These observations add support to epidemiologic data suggesting that there may be more than one agent of non-A, non-B hepatitis.


Erythrocytes: a new cell type for the evaluation of insulin receptor defects in diabetic humans.

Human erythrocytes have specific insulin receptors. When studied in an insulin radioreceptor assay, erythrocytes from adult-onset, nonobese diabetic subjects bound at least 42 percent less insulin than the normal subjects at insulin concentrations from 0.1 to 100 nanograms per milliliter. The diabetic subjects had 190 insulin receptor sites per cell as compared with the 380 insulin receptor sites per cell for the normal subjects. The deficit of insulin binding in the diabetic subject was thus associated with a fewer number of insulin binding sites per cell with little or no change in affinity. The erythrocyte is a readily available cell for the evaluation of cellular insulin receptor activity.


Feeding and behavioral activation in infant rats.

Three-day-old rats that were separated from their mothers and deprived of food were found to be capable of feeding either from small puddles of milk or when milk was infused into the front of their mouths. Such feeding was accompanied by a dramatic increase in behavioral activity and only occurred in a warm environment. These data demonstrate that neural systems for ingestive behavior are present at birth and suggest the existence of feeding-related arousal or motivational systems.


Medial septal lesions retard classical conditioning of the nicitating membrane response in rabbits.

Lesions of the medial septum were produced in 7 of 14 rabbits prior to classical conditioning of the nictitating membrane response. Lesions significantly altered the hippocampal electroencephalogram, attenuated conditioned hippocampal unit responses, and slowed the behavioral rate of acquisition. The contrast of the behavioral results with those of studies of massive septal or hippocampal ablation suggests a functional subdivision of the septo-hippocampal system in learning.


Host defense against Neisseria meningitidis requires a complement-dependent bactericidal activity.

Some individuals, with severe or recurrent infection with Neisseria species, have been identified as lacking a component in the terminal attack sequence of complement (complement components 5 to 9). The relevance of the terminal attack sequence to various phases of host defense was tested with the use of the C-11 strain of meningococci and human serum genetically deficient in complement component 8 (C8-D). The C8-D serum was comparable to normal serum in supporting ingestion and intracellular killing by leukocytes but was not bactericidal in the fluid phase unless reconstituted with C8. Thus, serum complement-dependent bactericidal activity may be especially critical for the host's defense against invasive Neisseria species.


Transmitter-specific retrograde labeling in the striato-nigral and raphe-nigral pathways.

Injecting radioactive transmitters into the rat substantia nigra led to retrograde neuronal labeling either in the dorsal raphe nucleus, after 3H-labeled serotonin injection, or in the caudoputamen, after 3H-labeled gamma-aminobutyric acid injection. This differential labeling in projections whose transmitter has been established provides the basis for a histochemical tracing method indicating both connectivity and transmitter specificity of neural pathways.


Hybrid ape offspring of a mating of gibbon and siamang.

The serendipitous mating of a male gibbon, Hylobates moloch, and a female siamang, Symphalangus syndactylus, has produced two female offspring born 1 year apart. The hybrid karyotype of 47 chromosomes comprises the haploid complements of the parental species, 22 for the gibbon and 25 for the siamang. Chromosomal G and C banding comparisons revealed no clear homologies between the parental karyotypes except for the single chromosome in each species containing the nucleolus organizer region. The lack of homology suggests that the structural rearrangement of chromosomes has played a major role in the process of speciation for these lesser apes.


Visually guided locomotion: psychophysical evidence for a neural mechanism sensitive to flow patterns.

Inspecting a radial flow pattern depressed visual sensitivity to changes in the size of a small test square, but only when the square was located near the focus of the flow pattern. The result suggests that precise visual judgments of one's direction of forward motion with respect to the outside world may be mediated by an already known neural organization sensitive to changes in the size of small objects.


Noradrenergic innervation of cerebral cortex: widespread effects of local cortical lesions.

The trajectory of the intracortical noradrenergic fibers has been characterized by histochemical analysis following the production of cortical lesions in the rate. A large group of noradrenergic fibers enters the cortex at the frontal pole and proceeds caudally through the deep layers of dorsolateral cortex. Branches arise from these longitudinally directed fibers and form a uniform pattern of innervation throughout lateral cortex. Because these fibers travel long distances rostrocaudally within the gray matter, a large area of cortex can be deprived of noradrenergic innervation by a relatively small lesion of frontal cortex. The medial and lateral cortex can be selectively and differentially denervated of noradrenergic fibers, and there is a medial to lateral topographic relationship between deep longitudinally running fibers and overlying cortex.


Opiate antagonists: a role in the treatment of hypovolemic shock.

The opiate antagonist naloxone has been used to treat shock following acute blood loss in conscious rats. Naloxone treatment rapidly increased mean arterial pressure and pulse pressure in this new shock model. More importantly, these blood pressure changes were sustained and survival was significantly increased with maloxone as compared with placebo treatment. From these findings, it may be inferred that endorphins may play a role in the pathophysiology of hypovolemic shock. It is suggested that narcotic antagonists may prove to be of therapeutic value in the treatment of shock.


Sucrose consumption early in life fails to modify the appetite of adult rats for sweet foods.

Male rats consumed a diet containing 0, 12, or 48 percent sucrose on days 16 to 30 of life. Thereafter, they had simultaneous access to all three diets until day 63. No relationship was detected between sucrose consumption early in life and subsequent preference for sucrose. The onset of puberty was associated with a decreased appetite for sucrose among animals of both sexes.


Ketone bodies are selectively used by individual brain regions.

Close study of 3-hydroxybutyrate uptake by brain suggests that its metabolism is limited by permeability. Furthermore, the permeability characteristics vary from region to region; areas known to have no blood-brain barrier show the highest rate of utilization. The results imply that rather than substitute fuels, ketone bodies should be considered supplements which partially supply specific areas but are incapable of supporting the entire energy requirement of all brain regions.


Erythrosin B inhibits dopamine transport in rat caudate synaptosomes.

Erythrosin B is a member of a class of fluorescein dyes that are suggested to elicit hyperkinesis when ingested by susceptible children. We found that erythrosin B inhibits dopamine uptake in rat caudate synaptosomes "uncompetitively" in the 10- to 800-micromolar range. Half maximal inhibition of uptake occurred at 45 micromolar. Uncompetitive inhibition denotes a decrease in efficacy of the dopamine membrane transport mechanism with an increase in affinity of dopamine to the carrier. Erythrosin B also decreased nonsaturable binding of dopamine to the synaptosome membrane. The inhibitory action of erythrosin B on dopamine uptake is consistent with the hypothesis that erythrosin B can act as a central excitatory agent able to induce hyperkinetic behavior.


Opioid peptides may excite hippocampal pyramidal neurons by inhibiting adjacent inhibitory interneurons.

The atypical excitation by opiates and opioid peptides of hippocampal pyramidal cells can be antagonized by iontophoresis of naloxone, the gamma-aminobutyric acid antagonists bicuculline, or magnesium ion. The recurrent inhibition of these cells evoked by transcallosal stimulation of the contralateral hippocampus is blocked by enkephalin but only shortened by acetylcholine. The results suggest that the opioids excite pyramidal neurons indirectly by inhibition of neighboring inhibitory interneurons (probably containing gamma-aminobutyric acid). This mechanism may be pertinent to the electrographic signs of addictive drugs.


Sensitization in Aplysia: restoration of transmission in synapses inactivated by long-term habituation.

Long-term habituation of a simple withdrawal reflex in Aplysia leads to an inactivation of synaptic transmission between identified sensory and gill motor neurons that persists for more than 3 weeks. A single sensitizing stimulus rapidly reactivates both the depressed behavioral response and the inactivated synaptic transmission. Thus sensitization, a simple competitive form of learning, provides a mechanism whereby changing environmental demands can rapidly override the long-term memory of habituation.


Appetitive learning in 1-day-old rat pups.

One-day-old rat pups learned to probe upward into a terry-cloth-covered paddle when they were rewarded with small infusions of milk into their mouths. In the presence of two paddles, discriminable on the basis of odor and position in the test container, the pups learned to probe into the paddle that provided them with milk. These experiments demonstrate (i) that milk may serve as a reinforcer to deprived rat pups and (ii) that pups as young as 1 day are capable of appetitive learning.


Reversal potential for noradrenaline-induced hyperpolarization of spinal motoneurons.

By using two separate electrodes with tips inside a single feline motoneuron, current-voltage characteristics were studied during extracellular iontophoresis of noradrenaline. The usually observed hyperpolarization was accompanied by an increase in membrane resistance and became larger with polarizing and smaller with depolarizing currents. During large depolarizing current injections, the noradrenaline-induced potential reversed its direction, usually at a membrane potential of about -20 millivolts. These data are compatible with the concept that noradrenaline hyperpolarizes nerve cells by decreasing resting membrane conductances to sodium and potassium ions. The observation could also be explained by a nonspecific decrease in ion permeability that is associated with a hyperpolarization due to sodium pump activation.


Histofluorescence techniques provide evidence for dopamine-containing neuronal elements in canine kidney.

Changes induced by hydrochloric acid in the excitation spectrum of catecholamine fluorophores associated with the innervation of the canine renal vasculature show that there are neuronal elements at the glomerular vascular poles containing predominantly dopamine. In contrast, the catecholamine fluorescence in the periadventitial layer of the arcuate arteries is derived from norepinephrine. The dopamine-containing structures may represent the prejunctional counterpart to the pharmacologically identified dopamine receptors in the renal vasculature. As such, this system may be involved in the normal regulation of renal blood flow and renin release.


Iodide-induced hypothyroidism: a potential hazard during perinatal life.

The administration of iodide to pregnant and nursing rats induces hypothyroidism in the term fetus and neonatal rat through age 10 days as indicated by an increase in the serum concentration of thyroid-stimulating hormone and a decrease in the serum of thyroxine and triiodothyronine. Thyroid function returned to normal from age 18 through 60 days in spite of continued iodide administration, strongly suggesting that resistance to the inhibitory effect of iodide on thyroid hormone synthesis is developed at approximately 18 days of age. This perinatal rat model can be used to study the mechanisms responsible for iodide-induced hypothyroidism and goiter in human newborns whose mothers received iodide-containing medications during pregnancy.


Platelet aggregation induced by ultrasound under specialized conditions in vitro.

Human platelets were induced by 2.1-megahertz ultrasound to form aggregates around gas-filled pores in membranes immersed in platelet-rich plasma. The spatial peak intensities required were only about 16 to 32 milliwatts per square centimeter. Ultrasound generated by a medical Doppler device, whose intensity exceeded this, induced aggregate formation under the same conditions.


Dissociations between the effects of LSD on behavior and raphe unit activity in freely moving cats.

The hypothesis that the action of hallucinogenic drugs is mediated by a depression of the activity of brain serotonergic (raphe) neurons was tested by examining the behavioral effects of d-lysergic acid diethylamide (LSD) while studying the activity of raphe neurons in freely moving cats. Although the results provide general support for the hypothesis, there were several important dissociations. (i) Low doses of LSD produced only small decreases in raphe unit activity but significant behavoiral changes; (ii) LSD-induced behavioral changes outlasted the depression of raphe unit activity; and (iii) raphe neurons were at least as responsive to LSD during tolerance as they were in the nontolerant condition.


Should there be a commission on medical education?

In its premedical and preclinical phases our present scheme of education for medicine is intellectually deficient, wasteful of money and time, and in urgent need of overhaul. The author defines conditions under which a national commission might possibly set the educational process on the road to reform.


Albumin-deficient rat mutant.

An analbuminemic colony was established from Sprague-Dawley rats. Analbuminemia was inherited as an autosomal recessive trait. The rates of growth and reproduction of the mutant rats were no different from those of normal rats. Biochemically, the mutant was characterized by an extraordinarily low serum albumin content and a hyperlipidemia. Total serum protein in the mutant rat was similar to that of control Sprague-Dawley rats, with increased globulin. Serum cholesterol was inversely correlated with a decrease in albumin; the correlation coefficient for ablumin was --.92. These mutant rats may serve as a model of human familial analbuminemia and may also be useful in elucidating the functional roles of albumin.


Endogenous inhibitor of colchicine-tubulin binding in rat brain.

A competitive inhibitor of colchicine binding to tubulin has been found in rat brain. Most of the inhibitor is associated with microsomes but some inhibitor, with an apparent molecular weight of approximately 250,000, is found in the cytosol. Both the microsomal and cytosol inhibitors are heat- and trypsin-sensitive, indicating that a protein moiety is required for activity. The microsomes bind tubulin directly; the microsomal and cytosol fractions both inhibit microtubule assembly in vitro. The inhibitor may function in the living cell to bind and sequester non-polymerized tubulin. Regulation of tubulin attachment to microsomes could then control the concentration of cytosolic tubulin available for microtubule assembly.


Reptiles and mammals use similar sensory organizations in the midbrain.

Striking similarities were observed between the overlapping visual and tactile maps of the mammalian superior colliculus and of its homolog in reptiles, the optic tectum. This topographic pattern probably represents a plan of sensory representation that existed in ancient reptiles and that was retained during the evolution to mammalian forms more than 180 million years ago.


Thyroid hormone influence on the susceptibility of mice to audiogenic seizures.

Serum thyroxine levels peak earlier and are significantly higher in audiogenic seizure-susceptible DBA/2J mice than in seizure-resistant C57BL/6J mice during early postnatal life. The seizure susceptibility of DBA/2J mice is suppressed by administration of an antithyroid drug or by radiothyroidectomy, while the seizure susceptibility of C57BL/6J mice is enhanced by treatment with excess thyroxine.


Combination tones at frequencies greater than the primary tones.

The existence of audible combination tones at frequencies greater than the primary tones that generate them has long been problematic. With primary tones at frequencies f1 and f2, combination tones at f1 + f2 - f1, and other frequencies can be demonstrated and measured by using a contralateral probe tone to establish a binaural interaction with a given combination tone. The estimated amplitudes of these higher-frequency combination tones are generally 20 to 40 decibels below the amplitude of the primary tones.


Vascular disorders associated with thrombohemorrhagic phenomena.

This paper has attempted to summarize the more common disease entities which may be accompanied by or may lead to a disorder of hemostasis and/or thrombosis. It is to be emphasized that the vascular component of hemostasis is often overlooked by clinicians caring for individuals with disorders in hemostasis and thrombosis. It is hoped that this brief summary will alert clinicians that the vasculature is equal in importance to the coagulation protein system and to platelets in leading to a hemorrhagic or thrombotic diathesis.


Combined surgical and radiation therapy for invasive carcinoma of the cervix.

Results of combined surgical and radiation therapy for invasive carcinoma in 266 patients treated between 1945 and 1970 are presented. Treatment protocol included radical Wertheim hysterectomy, Taussig node dissection, and deep pelvic irradiation. All cases were staged according to the International Staging System. The five-year survival for patients with disease in stages I, II, and III was 80.5%. All of the 32 patients with cervical stump carcinoma or cervical carcinoma complicated by pregnancy survived. Of the 52 patients with lymph node metastasis, 55.7% survived.


Gastric carcinoma in young adults.

The clinical and pathologic characteristics of gastric carcinoma in patients younger than 30 are compared with those of patients 30 to 39 years of age. Patients in both age groups had similar symptoms, predominantly undifferentiated neoplasms, and poor prognoses. In both groups, there were significant delays in initiation of definitive treatment because of delays in diagnosis. In 80% of the patients, the malignancy extended beyond the stomach wall at diagnosis, adversely affecting their long-term survival. The 20% five year survival in both groups indicates the necessity of early diagnosis and aggressive treatment.


Filtration characteristics of the polyester fiber micropore blood transfusion filter.

The filtration characteristics of a new polyester fiber (Fenwal II) micropore blood transfusion filter were investigated. Filtration of stored human whole blood and packed cells resulted in return of screen filtration pressure (SFP) of the blood to normal. Increased filter weights verified removal of large amounts of debris and microaggregates from the blood. Filtration of large quantities of blood accomplished at very high flow rates did not adversely affect the composition of the filtered blood. We conclude that the polyester fiber (Fenwal II) micropore blood transfusion filter is effective in removing microaggregates from stored whole blood and packed cells. It has a high volume capacity, allows rapid flow, and is reliable during pressure transfusion.


Double contrast examination of the upper gastrointestinal tract.

The principles and technic of the double contrast examination of the esophagus, stomach, and duodenum are outlined. Use of the hypotonic agent glucagon improves evaluation of the stomach, but optimal visualization of the duodenum may require reexamination after its effect has worn off. The technic is able to show gastric erosions and linear ulcers, both of which are rarely recognizable with conventional examination. The characteristics of malignant gastric ulcers and the presence of fundal lesions are also better demonstrated on double contrast evaluation. Small esophageal carcinomas may be recognized on a double contrast barium swallow. Examples of each of these lesions are illustrated. Many ulcerating lesions are seen "en face" on double contrast, and not in profile, which may require relearning the interpretation of their appearances. For greatest accuracy the double contrast technic should be combined with the conventional examination. As this therefore becomes a more time-consuming examination, we advocate its use only in selected clinical situations rather than on a routine basis.


Cystic lymphangioma of the spleen.

Splenic cysts are uncommon, with fewer than 600 cases reported in the world literature. This report concerns a case of cystic lymphangioma of the spleen, consisting of a large splenic cyst with associated multiple, small, subcapsular cysts and lymphangiectasia. The cysts are lined by endothelium, and they conform to the characteristics of dilated lymphatic channels. Lymphangioma of the spleen is thought to arise from congenital obstruction of lymphatic flow, with subsequent dilatation of lymphatic channels. The diagnosis and treatment of splenic cysts are discussed and a new classification of splenic cysts is proposed.


Allergic reactivity of the Pikes Peak region.

Despite the introduction of many new species from other areas, a skin test survey of patients visiting our allergy office shows that the plants causing hay fever in this area continue to be the same as in years past. Each physician should evaluate potential allergens in his own area, as our survey reveals the inadequacy of commercially available regional allergy diagnostic and treatment sets.


Unicompartmental replacement for medial compartment gonarthrosis: preliminary report.

Unicompartmental replacement using the Marmor prosthesis was done in 40 knees (37 patients) with medial compartment gonarthrosis. Of the 27 available for follow-up, results were considered excellent in 18 cases and good in seven, while two cases were considered failures. Meticulous removal of osteophytes by intercondylar burring and accurate alignment of the femoral component of the tibial medial compartment with the axis of the normal medial femoral condyle are essential to success. Preservation of a good articular surface and early mobilization with excellent report indicate that unicompartmental replacement may be useful in the treatment of medial gonarthrosis.


Transient erythrocytosis during the neonatal period: possible neurologic compications.

Transient erythrocytosis during the neonatal period may result in serious complications. Among the well recognized problems are respiratory distress, acute heart failure, and death. Little attention has been ascribed to the neurologic complications of a high hematocrit level in the neonatal period. This report describes four pediatric patients with neurologic deficits presumably due to transiently high hematocrit levels during the neonatal period. The neurologic findings in these patients were consistent with the general diagnosis of cerebral palsy. We hypothesize that they may be representative of a group of patients with seizures, structural central nervous system defects, and/or mental retardation secondary to transient erythrocytosis. Moreover, prompt recognition and treatment of this hematologic finding may prevent the immediate or late appearance of such neurologic findings.


Critical care and anesthetic management of Reye's syndrome.

The encephalopathy of Reye's syndrome is frequently complicated by increased intracranial pressure (ICP) which may lead to death or severe neurologic sequelae. An understanding of the pathophysiology of increased ICP is necessary to prevent further increases in pressure and to reduce pressure while maintaining adequate cerebral perfusion. Four of seven children with Reye's syndrome and increased ICP survived after reduction of increased ICP by controlled hyperventilation and osmotherapy while being monitored with the Richmond intracranial bolt. Careful anesthetic and critical-care management, appropriate, reliable monitoring, and pentobarbital therapy may constitute the most successful therapy to date for patients with Reye's syndrome and increased ICP.


Lethal toothache: parapharyngeal cellulitis complicating dental infection.

Three patients with parapharyngeal cellulitis arising from dental infection were seen by the Medical Service over a period of ten months. Respiratory distress and/or pharyngeal discomfort prompted all patients to seek medical aid. The extent of infection within the parapharyngeal space, the potential for life-threatening complications, and the significance of the dental lesions were not appreciated initially in all cases. Despite early antibiotic therapy, one patient died and one incurred severe neurologic sequelae. Early recognition, use of antibiotics effective against anaerobic bacteria, and prompt surgical drainage are mandatory to prevent considerable morbidity and mortality. Control of the airway is the most important therapeutic maneuver leading to a favorable outcome.


Evaluation and prognosis in nonorganic failure to thrive.

The 70 children with failure to thrive (FTT) admitted to our hospital over the last five years were reviewed. After extensive evaluations, only 16% received a diagnosis of an organic disorder. In the nonorganic group, 45% of FTT was secondary to improper feeding and 52% was secondary to environmental deprivation. Thirty percent of the children were discharged without a diagnosis. Although there were some important differences between the groups, extensive laboratory data were of little value. Follow-up information revealed that while the children with FTT secondary to poor feeding technics uniformly did well, the outlook for the environmentally deprived group and unknown cause group was frequently poor.


Congenital lobar emphysema.

Congenital lobar emphysema is a rare disorder thay may present outside the newborn period. It is generally best treated surgically by excision of the affected lobe. We describe a 6 1/2-week-old infant in whom the initial auscultatory and roentgenographic findings were confusing and of no help in making the diagnosis. The etiology of congenital lobar emphysema remains unclear.


Gunshot wounds to the spinal cord.

A series of 59 patients with gunshot wounds to the spinal cord is presented. Seventeen injuries were cervical, 30 were thoracic, 11 were lumbar, and one was sacral. Twenty-nine patients had immediate complete sensorimotor loss of function, 18 had sensory or motor sparing below the cord lesions, and 12 had injury of the cauda equina. Thirty-nine patients were treated with decompressive laminectomy, four with local wound debridement only, three with cervical traction and subsequent anterior cervical fusion; 13 had only conservative therapy. Eleven patients had return to normal function and 20 patients had some degree of improvement. There was no significant difference in the outcome between patients operated on and those treated conservatively.


Coombs'-positive hemolytic anemia and ibuprofen.

A patient who developed an autoimmune hemolytic anemia during treatment with ibuprofen (Motrin) is described. Positive indirect Coombs' reaction was demonstrated with the patient's red blood cell eluate in the presence of the drug, supporting a drug-related immune hemolysis. The positive direct Coombs' reaction to anti-C3 antiserum strongly suggested that the immune hemolysis in this patient is probably mediated through complement alone; however, the presence of a small amount of IgG antibodies on the surface of the red blood cells which cannot be detected under conventional screening procedures cannot be completely excluded. Further studies, both clinical and laboratory, disclosed that the responsible ingredient in this particular instance appeared to be the orange dye coating of the Motrin-400 tablet rather than the ibuprofen itself.


Serum levels of estrone and estradiol after implantation of estradiol pellets.

Serum estrone, estradiol, progesterone, FSH, and LH levels were studied after the implantation of estradiol pellets in female volunteers in the reproductive age group. The estradiol pellets were implanted at six-month intervals. The first implant consisted of four pellets (25 mg each). Subsequent implants consisted of a reduction by one pellet as compared to the previous implant. The mean serum estradiol levels during the six-month period of implantation or at the end of six-month intervals were in the premenopausal range and did not differ significantly during the study. The serum estrone levels showed a tendency to increase with time even though the number of pellets implanted was decreasing, apparently a result of incomplete absorption of the implanted estradiol during the six-month period. The results of serum progesterone determinations and basal body temperature records indicate that the suppression of ovulation takes place most consistently during the second and subsequent months after estradiol pellet implantation.


Evaluation of extramural programs.

Extramural programs may be evaluated in terms of effectiveness in achieving their particular goals. The components of structure, process, and outcome are examined as related sets of program elements. Goals influence appropriate structure in organization, facilities, and manpower. Structure in turn influences process or activities which result in outcome. Outcome is considered in terms of goals. Each set of elements is examined by institutional faculty and administration, extramural faculty, and students. Where all agree that desired outcome variables are relevant to the goal(s) and are achieved, the program is "effective." Where outcome and goal are not compatible, process and then structure must be examined for appropriateness of each. When there is disagreement between groups about any element, a problem area in the program is specifically identified. The procedure for cyclic assessment may be used by a school or program for self-study or for periodic internal monitoring of problem areas. Use of this method has shown some characteristics common to different types of extramural programs.


Gallstone ileus masquerading as a gastric outlet obstruction.

We have described a patient with gallstone ileus who was initially believed to have a gastric outlet obstruction. Roentgenogram of the abdomen revealed a markedly distended stomach. None of the classic roentgenographic signs of gallstone ileus were present. Old age and diabetes mellitus probably contributed to her severe gastric retention.


Hemobilia complicating warfarin therapy.

This patient is the first case of endoscopically documented massive hemobilia exacerbated by inadvertent warfarin overdose. The true frequency of this disorder should become evident with the widespread use of endoscopy and a high index of suspicion.


A case of leprosy at Charity Hospital, New Orleans.

A 63-year-old black woman, admitted to Charity Hospital, New Orleans, for treatment of hypertension and congestive heart failure, was found clinically and histopathologically to have Hansen's disease. She had lived most of her life in Orleans Parish and had no known contact as a source of her infection.


Disseminated intravascular coagulation after surgical excision of cavernous hemangioma.

This report describes the clinical course of a child who had excision of several symptomatic cavernous hemangiomas. Disseminated intravascular coagulation resulted in severe postoperative bleeding. DIC was treated successfully with heparin.


Intestinal atony in progressive systemic sclerosis (Scleroderma).

A 27-year-old woman with a long history of scleroderma developed megacolon and severe fecal vomiting as a result of intestinal atony. Evacuation of fecal impaction with water-soluble contrast enema resulted in prompt relief of fecal vomiting and gradual return of bowel function.


Postspinal headache: use of epidural blood patch.

Epidural blood patch should be considered the treatment of choice for postoperative headache if oral fluids and bed rest provide no relief. There should be no hesitation in performing this procedure, provided there are no contraindications. The two important contraindications are (1) evidence of inflammation or infection on the back when the puncture is to be made and (2) septicemia. A representative case is presented.


Duration of intubation and ICU stay after open heart surgery.

One hundred four consecutive patients undergoing open heart surgery were studied to determine the duration of intubation and ICU stay associated with an anesthetic management protocol designed to avoid prolonged postoperative respiratory depression. The results document the feasibility and safety of early extubation and shortened ICU stay in patients having operations for ischemic and acquired valvular heart disease. Patients with complex congenital heart defects require significantly longer periods of respiratory support and intensive care.


Variant angina in the setting of hypothyroidism and beta blockade: a proposed mechanism.

Coronary artery spasm can occur in the presence of excessive alpha-adrenergic tone. A decrease in protective coronary vasodilator substance and enhanced alpha-adrenergic responsiveness, which occurs in the setting of hypothroidism and beta blockade, predisposes to coronary artery spasm. The case presented supports these concepts.


Analysis of factors influencing the renin-aldosterone system in a patient with Bartter's syndrome.

The response to indomethacin of a patient with Bartter's syndrome and proximal tubular sodium wasting is described. The patient had evidence of excessive prostaglandin activity (elevated urinary prostaglandin E metabolite [PGE-M] excretion) which returned to normal with indomethacin therapy. Indomethacin administration corrected the defect in proximal tubular sodium resorption, but suppressed plasma renin activity and urinary aldosterone excretion only when sufficient dietary sodium was available to allow for extracellular fluid volume (ECFV) expansion. We conclude that the proximal tubular defect in sodium resorption may have been caused by excessive prostaglandin activity and that the sustained hyperactivity of the renin-aldosterone system was mediated by ECFV depletion.


Air embolism from mechanical ventilation in respiratory distress syndrome.

Three cases of air embolism secondary to mechanical ventilation in premature infants with respiratory distress syndrome are presented, and its mechanism is discussed. A plausible mechanism for air in the hepatic veins occurring in most of these cases is also discussed. Many sudden unexplained deaths in premature infants on mechanical ventilation may be due to air embolism, which should be recognized as a component of neonatal "air-block syndrome."


Pathologic fractures of long bones.

Sixty-two cases of pathologic fractures occurring in 53 patients treated at Scott and White Memorial Hospital from 1966 to 1976 are reviewed and analyzed with regard to type of neoplastic lesion, location, mode of therapy initiated, functional stability of therapy selected, and average length of survival after orthopedic procedure. Pertinent literature is reviewed, and our results are compared with those of other series.


Follow-up study on hemiarthroplasty of the hip.

This follow-up study on hemiarthroplasty of the hip evaluates the effectiveness of the treatment in various hip conditions. A total of 169 hemiarthroplasties of the hip were performed at the Medical College of Georgia from 1966 to 1972. Fifty-two patients were available for follow-up study in 1975. Hips were evaluated by Harris' hip evaluation method. The patients were divided into various diagnostic groups. The hips with idiopathic avascular necrosis followed by the hips with fresh fractures showed the best overall results. The results were not as good when the acetabulum was damaged, but acetabuloplasty was beneficial in these patients. In view of the complications of the total hip reconstruction and greater functional demand, a more conservative approach in younger patients is discussed. The hips with rheumatoid and degenerative joint disease did poorly with hemiarthroplasty.


Vascular access for cancer chemotherapy.

A persistent problem in caring for patients receiving long-term intravenous chemotherapy for cancer is the maintenance of access to the vascular system. At Emory University Hospital between January 1975 and December 1977, 48 cancer chemotherapy patients had upper-arm bovine arteriovenous fistulas created for vascular access. The heterografts were inserted from the distal brachial artery to the proximal brachial vein under local, regional block, or general anesthesia. Grafts were functioning satisfactorily in 81% of the subjects at the time of death or at termination of treatment. The mean duration of useful graft patency for the entire group was 4.6 months, with a range of 0 to 27 months. Thrombosis of the graft was the most frequently encountered complication; infection and bleeding occurred infrequently. Reoperation was required in 35% of grafts, of which one half were salvaged. No mortality was attributable to the operative procedures or to the presence of a chronic arteriovenous fistula.


Secondary renal neoplasms: an autopsy study.

The records of 11,328 autopsies performed on patients who died of malignant disease between March 1944 and August 1974 were reviewed, and 816 cases (7.2%) demonstrated renal metastases. The most common primary tumors in decreasing order of frequency were lung, breast, skin (melanoma), and tumors of the genitourinary, gastrointestinal, and gynecologic tracts, respectively. Generally metastases were hematogenous, multiple, bilateral, less than 3 cm in diameter, and located throughout the renal parenchyma. Associated metastases were usually present in many other organs. Because methods to detect renal lesions depend upon their size, clinical recognition of renal metastases will be largely limited to that 10% which are greater than 3 cm in diameter.


Factors influencing the occurrence of advanced cervical carcinoma.

The continued occurrence of advanced cervical carcinoma (stage II, III, IV) was studied. Patients were evaluated with regard to age, racial origin, socioeconomic status, geographic distribution, and presenting symptoms. Particular emphasis was placed on the role of screening in disease detection. The disturbing finding was that of the 170 patients reviewed, disease was diagnosed by screening examination in only 20 patients. Furthermore, 62 patients were not diagnosed even though they were exposed to the health care system. Factors which influence obtaining Pap smears are discussed, with suggestions as to how to enhance use of the Pap smear.


Colposcopy in gynecologic practice.

We review the role of colposcopy in the setting of a private gynecologic practice and present the data regarding 418 patients. The practicality and propriety of using colposcopy to evaluate patients with abnormal results of cytology, gross cervical lesions with or without postcoital bleeding, or a history of intrauterine exposure to diethylstilbestrol are discussed. The follow-up of small groups of patients treated with cryosurgery for intraepithelial neoplasms is presented.


Group III atypical mycobacterial infections.

We retrospectively and prospectively examined the clinical presentation, course of disease, and response to therapy in 63 patients whose mycobacterial isolates were identified as Runyon group III atypical mycobacteria. All of the patients except four had pulmonary disease similar to typical pulmonary tuberculosis. The others had scrofula or abxcess. There was a male predominance and whites were slightly more frequently infected in our series. Forty-six percent of the patients were from rural Oklahoma. Skin testing and chest roentgenography were important, but culture of the organism appeared to be the only productive method of distinguishing the atypical disease from typical tuberculosis. Eighty-one percent had an associated disease. The isolates showed a very high rate of primary drug resistance, and this was reflected in the difficulty in controlling the infection.


Classic migraine with cerebral cortical infarction causing permanent hemianopia.

A patient with typical classic migraine, including clear-cut visual auras, who had been followed up clinically for more than 15 years developed permanent right homonymous hemianopia. The underlying cause of this clinical syndrome was established by computerized axial tomography as vascular infarction or ischemia, involving the contralateral visual cortex.


Postoperative beta irradiation in the treatment of pterygium.

High recurrence rates are reported after surgical treatment of pterygia. With the use of beta irradiation, the recurrence rate drops dramatically. This paper describes technic and dosage used in a group of patients receiving postoperative beta irradiation. Two thirds of these patients, however, had at least two surgical procedures. A recurrence rate of 3.5% was observed, with no apparent morbidity.


Tendon rupture after local steroid injection.

Thirteen patients who developed 15 ruptured tendons subsequent to injection of a depository steroid in or about the tendons are described. Eight were treated surgically. Ruptures were encountered in three Achilles tendons, two supraspinati, one lateral epicondylar attachment at the elbow, eight tendons of the long head of the biceps at the shoulder, and one anterior tibial tendon. Measures designed to lessen this complication are described. In most cases triamcinolone hexacetonide was used as the depository steroid, mixed with procaine or lidocaine. Patients with this complication who were not treated surgically were the older patients who had ruptures of the tendon of the long head of the biceps.


Inguinal herniorrhaphy: reduced morbidity, recurrences, and costs.

Costs, morbidity, and recurrences have been reduced in the repair of inguinal hernias. In 18 months 135 repairs were done using local anesthetics, prompt ambulation, and minor variations in the Shouldice technic. Men and women aged 22 to 84 years were operated upon. No recurrences have been reported, and urinary catheterization has not been necessary. Significant savings are available by abbreviated hospital stay. The majority of patients require only 24 hours for repair of a unilateral inguinal hernia and the observation period following it. The same basic repair is used for direct and indirect sliding hernias. Rebuilding the floor of the inguinal canal is essential. Postoperative pain has been minimal. Use of long-acting local anesthetics has proven helpful.


Combined oral L-dopa and propranolol for growth hormone provocation.

A convenient test of growth hormone (GH) provocation using oral doses of L-dopa and propranolol (L + P) is compared with insulin-induced hypoglycemia (IIH) in 28 children and adolescents with short stature. In eight of these children, growth hormone deficiency was diagnosed when GH failed to rise above 7 ng/ml. The GH levels of the remaining GH-responsive children were significantly higher after administration of L + P (P less than .05) when compared with IIH given before L + P on the same morning or on a separate day.


Physician attitudes toward relicensure: the simulated patient option.

Primary care physicians in one Southern city were asked to return a mail questionnaire stating their attitudes toward relicensure issues. Respondents overwhelmingly preferred continuing education as the method of creditation for relicensure, but as a second choice preferred the simulated patient procedure to formal examinations. Nearly one half of the respondents agreed to participate in a pilot study of this method. The MD author received more positive replies than the PhD author, possibly because different segments within well matched subsamples were motivated to respond.


Practice monitoring as a means to direct individual continuing medical education.

Methods of practice monitoring currently available and requiring little of the physician's time are discussed. The application of these tools to direct individual continuing medical education efforts and to examine and improve patient care are illustrated from my experience and that of the Department of Family Practice of the Medical University of South Carolina.


The complete health checkup: fad, fiction, or fact.

The ritual of the annual physical examination is scrutinized with respect to its clinical value. The periodic physical examination is not usually a health examination, because it does not include all components that affect a person's total health. The annual physical examination is usually not of importance to the physician unless disease is discovered. Seldom is the examination used as an opportunity to reinforce behaviors which have kept the patient healthy. It has been suggested that physician extenders be used to deliver primary care services, including comprehensive health examinations, with physicians used as backup. Laymen should not have to seek out specialists to give them examinations for each system of the body. Comprehensive health care should be available and accessible to all segments of the public with an emphasis on greater self-responsibility for maintaining one's health and enhancing one's wellness.


Adolescent pregnancy.

This paper reviews the literature of the past seven years concerning adolescent pregnancy. Social and motivational factors leading to pregnancy are discussed and weighed. Obstetric aspects of adolescent pregnancy are reviewed as well as the repercussions of this event. Goals and objectives are proposed, including: (1) assurance of health education, including family life and sex education, in all private and public schools, from elementary grades through high school; (2) assuring that family planning services are available, accessible, and acceptable to all school-aged individuals who desire such services; (3) assuring availability of inexpensive, or free, and easily accessible pregnancy testing, backed up by counseling about alternatives available to the pregnant school-aged woman; (4) assuring that pregnant adolescents have alternatives to childbirth, ie, abortion services, foster care services, adoption services; (5) assuring that pregnant adolescents receive optimal prenatal care, including social and other support services as well as medical care, and that their families are involved in the care process; (6) assuring that school-aged individuals and their families receive postnatal and follow-up care that includes social and other support services as well as medical care.


Blind-ending branch of a bifid ureter.

An example of a blind-ending branch of a bifid ureter in a woman presenting with a urinary tract infection is reported. Definition, diagnosis, and treatment of this anomaly are discussed.


Iatrogenic superior vena cava syndrome with spontaneous improvement.

We describe a patient in whom superior vena cava syndrome developed after central venous catheterization and infusion of caustic medications. The diagnosis was proven by venography. Because anticoagulant therapy was contraindicated, the patient was clinically observed and the syndrome improved spontaneously. Follow-up venographic examination was normal.


Rate-related left bundle branch block secondary to intra-his block.

A 67-year-old man who had chronic aortic valvular disease with first degree AV block and rate-related left bundle branch block on the surface electrocardiogram was studied by His bundle electrography. During conduction with narrow QRS complexes, the first degree block was AV nodal in origin. With spontaneous heart rate acceleration a QRS pattern of left bundle branch block emerged, and the His electrogram revealed split His potentials. This report adds strong support to the evolving concept that left bundle branch block, in some cases, actually may be secondary to block anatomically localized to the His bundle.


Endocarditis involving a left ventricular apicoaortic valve-bearing conduit.

Fatal infectious endocarditis involving a left ventricular apicoaortic valve-bearing conduit occurred in a 20-year-old man. Risk factors included early postoperative wound infection, broad spectrum suppressive antibiotic administration, and inadequate dental prophylaxis against infectious indocarditis. Palliative therapy included intravenous antibiotic administration and removal of the conduit. Lessons learned are discussed.


Septicemia during antibiotic therapy in neutropenic patients.

Two patients with acute leukemia developed septicemia while receiving antibiotic therapy. In both cases, the microorganism grown from the blood was sensitive to the drugs the patients were receiving. Areas of colonization by the same organisms were found at autopsy in the necrotic spleen and in the necrotic colonic mucosa. Septicemia developing during antibiotic therapy can indicate colonization of necrotic organs and appropriate diagnostic and therapeutic measures may be necessary.


Acute hyperthyroidism precipitated by trauma.

An adolescent girl presented to the emergency ward with a fracture of the femur and subtle indications of acute hyperthyroidism which progressed. The diagnosis was confirmed and treatment was instituted. In the care of acute trauma, the less obvious signs of an endocrinopathy must not be overlooked.


Primary liver amyloidosis producing obstructive jaundice.

Liver amyloidosis is very rare but is relatively common within the group of amyloid diseases. Jaundice seldom accompanies this condition. Since the results of liver tests are often abnormal, liver amyloidosis cannot be diagnosed by symptoms alone. Diagnosis is provided only by liver or rectal biopsy. We have described an elderly woman with vague digestive symptoms for several months and jaundice for two weeks before hospitalization, and in whom exploratory laparotomy showed amyloidosis causing obstructive jaundice.


Systemic lupus erythematosus: an unusual cause of bilateral hilar lymphadenopathy.

Systemic lupus erythematosus is usually not associated with bilateral hilar adenopathy. We report a young woman with arthralgias, fever, pleuritic pain, peripheral and hilar lymphadenopathy, high titer ANA, and a low serum complement. Transbronchial lung biopsy revealed interstitial pneumonitis. SLE should be considered an unusual cause of hilar adenopathy.


Pneumothorax complicating acute asthma.

The association of asthma and pneumothorax in hospital practice is examined. The association varies from 1:300 to 1:1 000 acute asthmatics admitted to either a specialized or general unit. The clinical details of 18 patients with further reference to associated parenchymal lung diseases are discussed.


Contact dermatitis of the eyelids.

A series of White women seen in a dermatological private practice were investigated for causes of dermatitis of the eyelids. Patch tests were done with test substances of known allergenicity used as ingredients of vehicles of cosmetics and medicaments and also with substances which could be conveyed to the eyelids by the fingertips from distant sites. Patients were also patch-tested and usage tests were done with cosmetics currently used on the face, nails and hair. The commonest cause of the contact allergic dermatitis of the eyelids was a variety of facial creams.


Physiotherapy present and future.

The medical profession has been slow to recognize the advances in recent years in the practice of physiotherapy. The physiotherapist now undergoes a long period of training but is still struggling for recognition and appropriate reward in South Africa. The increasing complexity of physiotherapy has led to the formation of specialist groups, but the future of the profession must now lie with prevention as well as with therapy and rehabilitation. The increasing involvement of physiotherapists overseas in ergonomics and occupational health and safety is described.


Gangrene of the penis after circumcision: a report of 3 cases.

Three patients with gangrene of the penis after Xhosa ritual tribal circumcision are reported. A review of complications which may follow circumcision is given.


Dilatation and curettage.

A retrospective study was undertaken in which the histopathology reports on 1,000 specimens of endometrial curettings were reviewed in order to assess the value of pathological examination of the endometrium. In this series the reports were of use in only one-half of the specimens submitted. A seemingly high proportion of specimens was unsuitable for histological assessment. The main factors contributing to the pathologist's inability to provide a useful report appear to be inadequacy of the specimen and a lack of information regarding the clinical and menstrual history. Alternative methods of endometrial sampling are also briefly reviewed.


Serum complement concentrations, nutritional status and the outcome of measles and measles pneumonia.

A prospective study of children with measles has shown a significant association between malnutrition and a poor prognosis. Levels of a number of complement components bore no relationship to the severity of the disease or to its prognosis. Some of the children with acute measles had depressed serum concentrations of factor D, Clq or C3, but complement deficiency does not appear to be implicated in the heightened susceptibility to secondary bacterial and viral infection so commonly found after acute measles.


Hypertensive heart disease and cardiomyopathy in blacks. Diagnostic confusion.

Four Black South African patients, representative of a larger group, are described in detail. The common features were long periods of observation, multiple hospital admissions in both normotensive and hypertensive cardiac failure, hypertensive retinopathy and good renal function. All had been diagnosed as having cardiomyopathy. Two of the patients in a normotensive phase became hypertensive after responding to therapy for heart failure. One patient with malignant hypertension showed the features of idiopathic cardiomyopathy at necropsy. These cases are regarded as evidence in favour of the hypothesis that many cases of cryptogenic heart disease (cardiomyopathy, congestive cardiomyopathy, idiopathic cardiomegaly) are in fact cases of hypertension presenting with normotensive cardiac failure.


Myelography using water-soluble contrast media as an outpatient procedure.

Established practice as reported in the literature is that all patients undergoing myelography with water-soluble contrast media are admitted to hospital for observation after the procedure. However, I believe that if the examination is expertly performed and with due consideration to the factors influencing the effects of contrast media used in myelography, it can be done as an outpatient procedure in most cases.


Discography simplified.

Discography, which is the direct injection of a radio-opaque medium into the nucleus pulposus, provides a useful adjunct in the diagnosis and investigation of pain related to the spine and is planning surgery of the spine. However, the procedure is little used in South Africa and this article serves to discuss its value and to describe new modifications.


The effect of oxygen and paraquat on the 14C-glucose oxidation of rabbit alveolar macrophages and lung slices.

In this study, we measured the effects of different concentrations of paraquat (0,01 mM and 1,0 mM) on the 1-14CO2 and 6-14CO2 production of rabbit lung slices and isolated alveolar macrophages, in 20% and 95% oxygen phases respectively. A 95% oxygen phase induced an increase in the 6-14C-glucose oxidation of contorol lung slices over a 3-hour period, while the increased activity of the pentose pathway over the first 2 hours started to decline during the third hour of incubation. Paraquat (1,0 mM) in 20% oxygen caused a consistent increase in the 6-14CO2 production by lung slices, but in a 95% oxygen phase gradually inhibited the 6-14C-glucose oxidation over a period of 3 hours. The pentose phosphate pathway was highly significantly stimulated by 1,0 mM paraquat in 20% and 95% oxygen over 3 hours. When isolated alveolar macrophages (viability 95%) were incubated in a 20% and a 95% oxygen phase respectively, both the 6-14C-glucose and 1-14C-glucose oxidation rates were significantly inhibited by 1,0 mM paraquat after 1 hour. Our results confirmed the initial increase in glycolytic metabolism induced by paraquat, but also inhibited by paraquat when lung slices were incubated in a 95% oxygen phase. The fact that the glucose metabolism in alveolar macrophages is more sensitive to paraquat exposure than that of cells in lung slices may be related to the genesis of the intra-aveolar pulmonary lesions described in the literature.


The statutory noise level in South Africa.

Noise legislation in South Africa was introduced in 1974. However, in industry, compliance with the recommended maximum equivalent noise level of 85 dB(A) is poor. The subject of noise exposure is reviewed briefly and a tentative proposal for a temporary raising of the statutory limit is put forward.


Diabetic diarrhoea and steatorrhoea. A case report and review of the literature.

A case of severe diabetic steatorrhoea is presented in a young Black male with poorly controlled diabetes, symptomatic peripheral neuropathy, evidence of autonomic neuropathy with gastroparesis and raised faecal fat excretion. A pancreatic function test was negative as were tests of small-bowel structure and function. There was resistance to all therapy. The literature on diabetic diarrhoea and steatorrhoea has been reviewed, and it is concluded that they are expressions of the same entity which remains a clinical problem for which there is at present no effective management.


A time series aggregation model for predicting the incidence of syphilis.

The incidence of infectious syphilis is much different from the number of reported cases in any given year; therefore, an estimate of the incidence is needed to formulate effective control programs for the future. A time series aggregation model that predicts the incidence of syphilis was developed. The model accounts for the number of treated but unreported cases, and it provides estimates of incidence for different age and racial groups. As an illustration the model was applied for estimation of the incidence of syphilis in the city of Chicago, Illinois. A sensitivity analysis revealed that a 10% variation in input parameters would cause an error of smaller than or equal to 4.1% in the estimates of incidence.


Management of genitourinary trauma.

The spectrum of genitourinary injuries seen in a small community hospital over the past three years is presented. With the exception of the obvious ureteral injury, the key factor in management is adequate x-ray diagnosis. This allows the physician to estimate the type and extent of injury. In the clinically stable patient, renal injuries can be managed conservatively. However, in our experience a major renal injury is usually associated with major intra-abdominal injury and these patients require exploration. Bladder injuries may be diagnosed with a cystogram, and repaired. Posterior urethral injuries may be managed initially by simple insertion of a suprapubic tube.


Analysis of routine data describing morbidity from gonorrhea.

A system was developed for the collection, coding, and processing of data from routine reports describing morbidity caused by gonorrhea. These data are coded centrally, and tables that provide information about the age, sex, race, source of care, and geographic and temporal distributions of the population affected by gonorrhea are generated. Applications of the system are described; these include study of distribution of the disease, trends in utilization of facilities, seasonal trends in incidence of the disease, and several features of recidivism in the Denver (Colorado) metropolitan area. This system has potential as a tool for evaluation of disease control efforts in any standard metropolitan statistical area.


Blood banking in the small hospital.

This represents an attempt to briefly outline the type of blood bank and transfusion service we at Montrose Memorial Hospital have developed and utilized to supply our blood needs. Basically it is a system based on a fairly large list of known, pretested, and available donors who can be contacted quickly to supply blood upon demand. Only bare minimum stock supplies are maintained. The major problem is waste of blood, but Montrose experience continues to fall below the average for rural areas. Although the starting and maintaining of this walking blood bank was and is a complicated involved, and somewhat tedious process, we have been happy with the results and have been able to supply in an adequate fashion the blood requirements of an isolated yet extremely active population with a sophisticated medical community.


Management of popliteal artery injuries.

In a series of seven popliteal artery injuries including two concomitant popliteal vein injuries and three knee dislocations, only one failure occurred. With appropriate training of emergency medical technicians and adequate supportive services such as blood banking and arteriography, the vascular surgeon in a small hospital setting can manage peripheral vascular trauma with acceptable results.


Should vascular surgery be done in the small hospital?

This article presents our successful experience with vascular surgery at the Montrose Memorial Hospital. Before a decision is made to ban vascular operations from all but referral hospitals, hard data from additional small community hospitals concerning their experience must be obtained. Surgeons from small community hospitals should be urged to analyze and objectively report their results with vascular procedures before national guidelines are formed.


Nontraditional education for surgeons.

Some of these programs would not work in every rural (or urban) practice. A partnership practice helps considerably. The ability to step into a medical center position with patient acceptance has been important. We feel that many similar opportunities exist--we have more planned--for other surgeons, and should be utilized. Both our geographic isolation and our small medical community have given us a sense of need for continuing education that is perhaps more acute than that of the urban-based private practicing surgeon. However, one has only to look about at most university surgical grand rounds and to note the paucity of surgeons  practicing in those urban communities to realize that the feeling of isolation of the rural surgeon may be a very positive and beneficial force in his continuing education.


Effect of regenerated endothelium on collagen content in the injured artery.

Collagen content and intimal thickness were measured in endothelialized and nonendothelialized zones of the aorta in rabbits for 30 days after a standard embolectomy balloon injury. A large increase in collagen content and intimal thickness were seen in the arterial wall covered by regenerating endothelium. In areas devoid of endothelial coverage, minimal intimal thickness occurred; no measurable increase in collagen content was measured. Interaction between arterial smooth muscle cells and regenerated endothelium appear to be necessary for collagen accumulation and intimal thickening after arterial injury and repair.


Jejunoileal bypass and the defunctioned bowel syndrome.

Sixty-six patients who had a jejunoileal bypass with ileosigmoidostomy for intractable obesity were reviewed. Thirty-three patients had sudden, severe, upper pain develop in the abdomen with distention from one to four years after the original operation. All 33 patients had a repeat laparotomy from one to six years after the initial bypass procedure. In every instance, a dilated, hypertrophied defunctioned ileum was found proximal to the ileosigmoidostomy. In 11 patients, an ileosigmoid volvulus was present. In every instance, the ileosigmoid anastomosis was dismantled and an end-to-side ileotransversostomy performed. In one patient, an ileal volvulus developed proximal to the ileotransversostomy because of an inadvertent technicality and this was corrected by reoperation. The remaining 32 patients have been asymptomatic since the ileosigmoidostomy was converted to ileotransversostomy. To date, in more than 200 primary operations for morbid obesity, the ileum has been drained into the transverse colon. None of these patients have had obstruction of the defunctioned small bowel develop.


The indications for transcervical mediastinoscopy in patients with small peripheral bronchial carcinoma.

A series of 80 patients with roentgenographic evidence of bronchial carcinomas 3 centimeters or less in size was analyzed as to the incidence of mediastinal lymph node metastases. Forty patients underwent transcervical mediastinoscopy prior to thoracotomy and 40 patients did not. Three patients with large cell undifferentiated carcinoma had mediastinal lymph node metastases which could be detected by transcervical mediastinoscopy. None of the 40 patients who did not undergo mediastinoscopy had palpable evidence of mediastinal lymph node metastases at thoracotomy. The survival rates for the two groups of patients were similar. On the basis of this study, we have concluded that mediastinal exploration is not routinely indicated in patients with peripheral T1, N1, M0 lesions.


Intratumor bacillus Calmette-Guerin therapy for chest wall recurrence of carcinoma of the breast.

Intratumor bacillus Calmette-Guerin administration is effective for treating chest wall recurrence from carcinoma of the breast in selected patients. Our results suggest that bacillus Calmette-Guerin therapy can be used alone, with systemic chemotherapy, hormonal therapy or in previously irradiated tissue. It represents local treatment for local disease that is well tolerated. Intratumor bacillus Calmette-Guerin treatment is a useful clinical method for the treatment of local chest wall disease.


The influence of cortisol on wound healing of the skin and distant connective tissue response.

The effect of moderate dosage cortisol treatment on healing wounds and on the response in skin distant to the wounds was investigated. The stress-strain characteristics of a skin wound and intact skin specimens were examined. Also, skin thickness, water content and collagen content were measured. Cortisol treatment resulted in reduced extensibility and increased stiffness for ten day wounds, but unchanged failure energies; for 20 day wounds, failure energies were reduced, indicating reduced ability to withstand rupturing forces. Thus, the mechanical properties of healing wounds under moderate dosage, long term corticosteroid treatment were found to be slightly impaired. A systemic effect of wounding at day 10 resulted in decreased stiffness and increased collagen content of the skin distant to the wound.


Open diagnostic peritoneal lavage in blunt trauma victims.

Open diagnostic peritoneal lavage was 97.8 per cent accurate for diagnosis of intra-abdominal injury in 2,072 blunt trauma victims. The only significant injuries missed were in certain patients with a ruptured hemidiaphragm, renal trauma and extraperitoneal bladder rupture. However, these injuries were identified by other means. False-postive lavage results are generally a consequence of technical error and can be minimized by careful surgical technique. Hemoperitoneum must be explained for all patients to prevent needless morbidity and mortality. Only diagnostic tests of proved value in blunt abdominal trauma should be used and risk to the patient must be minimized. We currently rely upon diagnostic laparotomy to evaluate hemoperitoneum in patients with a weakly positive lavage result confirmed by a second infusion. With this policy, approximately one of every four to five laparotomies was for injuries not requiring surgical therapy; and, the over-all morbidity rate and mortality was 12 and 3.5 per cent, respectively, in this group. By using open diagnostic peritoneal lavage in essentially all blunt trauma victims, we have had no deaths from either unrecognized intra-abdominal injury or delayed treatment.


Surgical implications of acid ingestion.

Ingestion of mineral acid may be accidental or intentional. This form of corrosive usually sears the esophageal mucosa only to produce major injury to the stomach. The prepyloric antrum is almost always injured, but the fundus and cardia may be involved if the stomach is empty at the time of ingestion. Clinically, significant esophageal injury occurs in less than 20 per cent. Initial treatment is supportive, with early operation reserved for patients with severe ingestion in whom gastric necrosis rapidly ensues. In the more typical patient, however, late gastric outlet obstruction still makes surgical therapy mandatory. Subtotal gastrectomy with Billroth I reconstruction is usually possible and is the treatment of choice. Total parenteral nutrition is a useful adjunct.


Anorectal supralevator abscess-fistula in ano.

Small percentages of anorectal abscesses and of chronic fistula in ano are supralevator, resulting from a high intermuscular abscess caused by infected anal glands or chronic ulcer of the anus. The disease is not to be confused with a pelvic abscess caused by other factors. The recommended treatment is internal sphincterotomy to permit drainage at the site of perforation in the longitudinal muscle into the rectum. On rare occasions, in critically ill patients, additional drainage of the pelvic abscess may be necessary through the fossa ischiorectalis or by a lumbar-retroperitoneal space approach.


Regional versus systemic heparinization.

In 12 mongrel dogs, the comparative effectiveness of systemic versus regional heparinization was studied after injecting 100 units per kilogram of heparin into a systemic vein or regionally into an artery. Activated plasma thromboplastin time was used to monitor the heparin activity, and the coagulability of blood in the general circulation was compared with the coagulability of blood in the excluded circulation distal to the vascular clamps. Both methods of heparinization were found to be equally effective. Heparin injected regionally rapidly achieves a uniform distribution in the excluded, as well as the general, circulation and, as such, cannot be called regional. There was no difference in coagulability of blood in the general circulation compared with the blood in the excluded circulation. Results of this study suggest that regional heparinization is, in fact, systemic heparinization.


The treatment of locally advanced carcinoma of the colon and rectum by a surgical procedure and radiotherapy postoperatively.

Following resection of locally advanced carcinomas of the rectum and colon, 95 patients received moderate dose elective radiotherapy either to an inverted T field or the entire abdomen. In 27 instances, carcinomas invaded adjacent structures and were incompletely resected. Fifty-seven patients had tumors of the rectosigmoid and had either an abdominoperineal or an anterior resection. Thirty-five patients had a mean follow-up period of 26 months. Three of 35 carcinomas recurred locally, 26 of 35 patients are alive without disease. Thirty-eight patients had carcinomas of the colon and had either a partial or hemicolectomy. Thirty-one had a mean follow-up period of 24 months. Five of 31 carcinomas recurred locally. Seventeen of 31 patients are alive, without disease. Sixty-six of 95 patients have survived two years free of disease. One death occurred from radiation enteritis. Radiotherapy postoperatively for patients at a high risk of failure resulted in a low incidence of local recurrence.


Measurement of toe temperature for assessing the severity of acute circulatory failure.

The temperature gradient between the ventral surface of the first toe and the ambient temperature was measured and compared with established hemodynamic measurements in 71 critically ill patients. Thirty-two patients had acute myocardial infarctions, 21 patients had primary bacteremia and 18 patients had primary hypovolemia which followed acute blood loss. The temperature gradient served as a more predictable indicator of survival or fatality than either arterial pressure or cardiac index in each group of patients. Patients who improved after treatment and survived had increases in the toe minus ambient temperature gradient to more than 4 degrees C., whereas a gradient of less than 3 degrees over an interval of 12 hours was typically observed in patients who subsequently died. These observations indicate that the toe minus ambient temperature gradient provides a valuable, inexpensive and noninvasive monitor of tissue perfusion in critically ill patients.


Reconstruction of the breast after mastectomy for cancer.

General surgeons are taking a more active role in the treatment of all the problems which face the patient who undergoes mastectomy. For many of these women, an important part of their adjustment is achieved by reconstruction of the breast. The number of women requesting reconstruction of the breast after mastectomy is increasing, and more women faced with mastectomy are asking their general surgeons for information about the procedure. It is hoped that as reconstruction of the breast becomes more widely appreciated, women will be encouraged to perform more frequent self-examinations and to seek earlier treatment of carcinoma of the breast. It is tempting to speculate that one ultimate benefit may be an improvement in the survival figures associated with this disease.


Assessment of anastomotic blood supply by Doppler ultrasound in operations upon the colon.

Doppler ultrasound was used to determine whether or not colonic anastomoses have sufficient blood supply for healing to occur. Experimental anastomoses placed at, or 1 centimeter from, the last audible arterial signal healed; those placed 2 or 3 centimeters distally had a high incidence of disruption. Results were statistically significant by chi-square analysis, p less than 0.05. Clinical parameters of intestinal viability would not have predicted anastomotic failure.


Treatment for melanoma of the lower extremity with intralesional injection of bacille Calmette Guérin and hyperthermic perfusion.

Twenty-seven patients with locally recurrent melanoma of the lower extremity were treated during a six year period. Recurrences were noted with primary lesions, at Clark's level II, III, IV or V, greater than 1.7 millimeters in depth of invasion and included intransit metastases, satellitosis, subcutaneous metastases and combinations of the three. Median time to recurrence was 12 to 14 months whether or not lymphadenectomy had been performed or lymph node metastases were present. Local recurrence was treated initially with intratumor bacille Calmette Guérin; 20 of 27 patients had complete or transient disease control and 14 patients were alive at 1.5 to 55.0 months. More responders reacted to dinitrochlorobenzene and purified protein derivative skin tests, although these parameters did not predict response to therapy. If intratumor bacille Calmette Guérin therapy did not control local disease or if the disease progressed toward the upper third of the thigh, patients underwent hyperthermic perfusion with L-phenylalanine mustard. Nine patients underwent ten therapeutic perfusions with objective response in seven of nine, with five being alive at two to 65 months. Intratumor bacille Calmette Guérin therapy and subsequent hyperthermic perfusion in bacille Calmette Guérin failures are rational treatment alternatives for locally recurrent melanomas of the extremity.


Carcinoembryonic antigen levels as an indicator for reoperation in patients with carcinoma of the colon and rectum.

The experience from the University of Minnesota with routine reoperations in cancers classified as Dukes' C suggests only a small minority of patients found to have asymptomatic recurrences will benefit from an additional operation. Also, morbidity and mortality will be significant. The presence of a rising carcinoembryonic antigen level following a potentially curative operation has been suggested as a more selective indicator for reoperation. Unfortunately, carcinoembryonic antigen levels are a far more sensitive indicator of hepatic metastases, the group usually not helped by operation. Patients with local-regional recurrent carcinoma of the colon and rectum--the group most likely to benefit from reoperation--often have normal carcinoembryonic antigen levels. The importance of patient selectivity for reoperation and the usefulness of the Astler-Coller staging system to define risk factors are stressed.


The surgical treatment of choledochal cyst.

Eleven consecutive infants and children with choledochal cyst were evaluated for operative resection of the cyst as the primary surgical therapy. Total excision and biliary reconstruction by choledochojejunostomy was successfully performed in nine patients. Simple intestinal drainage of the cyst was used in two instances because of severe liver disease. Four patients had coexisting biliary malformations. In all five infants, biopsy of the liver was consistent with biliary atresia. In addition, the extrahepatic bile ducts proximal to the cyst were obliterated in two infants. The findings suggest that pathogenesis of choledochal cyst may be different in infants than in older children. The indications for excision of the cyst in four patients were due to complications from earlier internal drainage procedures. In most patients, including all those having had a cystoenterostomy earlier, resection was done from the inside of the cyst, thus minimizing the danger of injury to the neighboring vascular structures. There were no operative deaths, and morbidity was minor. The traditional operation for a choledochal cyst has been internal drainage of the cyst into the intestine. Because of the high incidence of late complications and the frequent association of major co-existing biliary malformations, the procedure should be reserved for highly specific indications. Total surgical excision is the procedure of choice for a choledochal cyst.


Chronic changes in the walls of experimentally produced aneurysms in sheep.

Twenty-seven saccular aneurysms were fashioned on the common carotid arteries of sheep using the venous transplants with a side-to-side anastomosis. The vessels were examined at varying intervals up to eight months postoperatively. The venous sacs exhibited severe phlebosclerosis of rapid progression and gross loss of muscle, and elastica was most prominent at the fundus. Some aneurysms leaked, some contained mural thrombus and several exhibited minimal quantities of lipid. The histologic changes were similar to those in man and experimental models entailing severe hemodynamic stress and can be regarded as atherosclerotic in nature.


The short saphenous vein.

If an incompetent short saphenous vein is overlooked during an operation, varicosities invariably recur. A flush saphenopopliteal venous ligation is essential, since it is difficult to eliminate marked valvular insufficiency at this site by injections of a sclerosing solution. The prone position affords excellent exposure of the saphenopopliteal junction. Since the anatomy varies greatly, a flexible approach is desirable. If the anatomy is straightforward and the junction is close to the popliteal space, a transverse skin incision affords excellent exposure and heals well. Although it does not heal as well, a vertical or S-shaped incision is advisable in more complicated instances because it provides better exposure. If all valvular insufficiency is corrected at operation and the patient checked annually so that any new varices can be eliminated by injections, the leg should remain free of varicose veins.


Cardiovascular effects of methyl methacrylate monomer.

Although cardiorespiratory human sensitivity to circulating methyl methacrylate monomer remains unknown, it is clear that the blood levels responsible for cardiocirculatory alterations in intact dogs are not obtained after insertion of acrylic cement in long bones in clinical practice. Circulating monomer considered as the sole causal factor for the hemodynamic changes described during orthopedic method is highly questionable.


Gram-positive peritonitis in patients with infected ventriculoperitoneal shunts.

Patients with infected ventriculoperitoneal shunts may, in some situations, present with prominent abdominal signs and symptoms and no neurologic complaints. As a consequence, the correct diagnosis may be confused initially, and the appropriate therapy may be dangerously delayed. Definitive diagnosis is established by percutaneous tap of the shunt reservoir and analysis of the ventricular fluid. If the offending organism is gram-positive, externalization of the shunt combined with systemic and intraventricularly administered antibiotics, without laparotomy, is the treatment of choice. If gram-negative organisms are identified, exploratory laparotomy is indicated to rule out a ruptured viscus. In establishing the correct diagnosis and determining the appropriate therapeutic priorities, the co-operative efforts of the general, as well as the neurologic, surgeon are required.


The rejuvenation of the anal sphincteroplasty.

Anal incontinence, as a result of traumatic lesions upon the anal sphincter, is a devastating problem. Direct approximation by appropriate repair may not produce the appropriate animation of the anal sphincter and return of function. The transfer of the gracilis muscle for anal sphincteroplasty, which was initially described for neurogenic dysfunction, is recommended for repair and reconstruction of traumatic and dysfunction. The use of this technique in two patients with anal incontinence following trauma proved to be helpful in alleviating the problems of the patients. A diverting colostomy is used prior to the repair of the anal sphincter. Physical therapy regimens of the reconstructed anal sphincter by the muscle transfer is done prior to closing of the colonic stoma and restoring normal continuity and function of the lower part of the alimentary tract.


Protein supplementation in the management of degenerating liver function after jejunoileal bypass.

Five patients who began to have signs of degenerating liver function develop after jejunoileal bypass were treated with protein supplementation, either on an outpatient or inpatient basis, making use of preparations orally and intravenously. Subjective as well as objective evidence of improving liver function was obtained, and all patients have survived. It is important to maintain a high protein intake postoperatively. The most useful tests for assessing the status of liver function in these patients have been serum albumin, serum bilirubin and prothrombin time.


A peroperative technique for determining the extent of gastrectomy.

An easy, quick and practical way to determine the magnitude of gastric resection during operation consists of determining the length of the lesser and greater curvatures with a Nélaton's catheter. According to the extent of gastrectomy, different denominations should be used. If a precise antrectomy is desired, the physiologic antrum-corpus border should be determined.


Trigeminal neuralgia: compression of the trigeminal nerve by an elongated and dilated basilar artery.

A patient with trigeminal neuralgia caused by direct compression by an elongated basilar artery of the 5th nerve at the zone of entry of its sensory root into the pons is presented. Rhizotomy of the portio major is a treatment of choice in such a case instead of simple microsurgical decompression. The elongated basilar artery is very firm and not readily movable with manipulation.


Quadriplegia associated with narrow cervical canal, ligamentous calcification and ankylosing hyperostosis.

The occurrence of three pathological entities of the cervical spine--ankylosing hyperostosis, calcification of the posterior longitudinal ligament, congenitally narrowed cervical canal--in a single patient is reported. This combination of pathology led to a severely narrowed cervical canal and a spine with abnormal mobility at non-fused levels. Minor trauma to the patient resulted in permanent quadriplegia.


Primary intraventricular oligodendrogliomas.

Two cases of primary intraventricular oligodendrogliomas which were successfully removed by a transventricular approach using microtechniques are presented. Oligodendrogliomas in this location are very rare. The literature is reviewed.


Intravasation of pantopaque during myelography.

Two cases of venous intravasation of Pantopaque during myelography are described. A brief summary of world literature is made. Features of the present two cases lead to suggestions and precautions useful in preventing or ameliorating this unwanted event.


Lipoma of the corpus callosum.

A case of corpus callosum lipoma with presumptive diagnosis is presented. Review of the literature disclosed 84 cases with such diagnoses. Lipoma of the corpus callosum is a rare intracranial lesion, perhaps congenital and often asymptomatic, but can present with seizure disorder, headache, mental changes, paresis or paralysis. Twenty-one patients had been operated upon. Surgical treatment seems to be of no value in this disease.


Localization of intracranial lesions from CT scans.

Accurate localization of intracranial lesions from data derived from CT scans is necessary in the planning of surgery or radiotherapy. Several methods have been described previously. This report describes a simple method for localization which has many advantages over other methods without loss of accuracy.


Primary rhabdomyosarcoma of the tentorium with peculiar angiographic findings.

Primary intracranial rhabdomyosarcoma is extremely rare, only nine cases have been reported in the world literature. To differentiate it from medullomyoblastoma, rhabdomyosarcoma should be devoid of neuroblastic elements. A case of rhabdomyosarcoma of the tentorial region in a 17-year-old boy is reported. Carotid angiograms demonstrated a peculiar neovascularity. Multiple cytologic preparations of CSF repeatedly contained rhabdomyosarcoma cells and CSF dissemination in the spinal subarachnoid space was documented at autopsy. The literature is reviewed.


Chiasmal compression from metastatic cancer to the pituitary gland.

A case of chiasmal compression and panhypopituitarism from carcinoma of the breast metastatic to the pituitary gland is presented. A review of the subject of metastatic disease of the pituitary emphasizes the paucity of clinical involvement in most cases. Posterior pituitary insufficiency is the most common manifestation, with anterior pituitary involvement being much rarer, and chiasmal compression the least common.


Aneurysm and arteriovenous malformation of the spinal cord.

A case is presented in which microsurgical technique was used to excise an intramedullary vascular lesion of the spinal cord. This kind of vascular pathology is uncommon. In this case, a radical excision of the malformation was obtained using the microscope. What appeared to an associated intramedullary aneurysm was totally removed.


Calcified subdural hematoma in the elderly.

A 71-year-old patient with asymptomatic calcified subdural hematoma is presented. Review of the pertinent literature indicates that the lesion should be left untreated when incidentally found or not associated with progressive neurological symptoms and signs.


Intramedullary thoracic schwannoma.

A case of intramedullary thoracic schwannoma in a 40-year-old woman without signs of von Recklinghausen's disease is reported and the hypotheses as to its origin are discussed. The literature covering 11 other cases is reviewed.


Spontaneous ventriculo-cisternostomy.

A case in which obstructive hydrocephalus was relieved by spontaneous ventriculo-cisternostomy is presented and the pertinent literature reviewed. Management of acquired obstructive hydrocephalus by percutaneous stereotactic or endoscopic third ventriculo-cisternostomy is discussed.


Subacute bilateral epidural hematomas in an infant.

Subacute bilateral epidural hematomas in a two-year-old girl are presented. No similar case in this age group has been reported. CT scans may increase the detection of bilateral epidural hematomas in children in the future. The diagnostic and therapeutic characteristics of epidural hematoma in children are discussed.


Unusual cerebral tuberculoma.

The unusual occurrence of a cerebral tuberculoma is herewith reported. The first manifestation of the tuberculous infection was an optic perineuritis. Treatment of the "papillitis" with steroids was followed by Jacksonian seizures--the signature of the tuberculoma. Surgical excision has produced a cure.


Spontaneous subarachnoid hemorrhage complicated by communicating hydrocephalus: epsilon amino caproic acid as a possible predisposing factor.

An increased incidence of communicating hydrocephalus following subarachnoid hemorrhage has been observed on the neurosurgical service at Vanderbilt University Hospital during the past four years. This increase parallels the time interval during which epsilon amino caproic acid (Amicar) has been used in the preoperative regimen for intracranial aneurysms to prevent recurrent hemorrhage. Radiographic studies of 48 patients with subarachnoid hemorrhage not receiving Amicar were compared with 46 similar patients treated with this antifibrinolytic agent. In the series not treated with Amicar, a 17% incidence of dilated lateral ventricles was found, with 10% of the series being symptomatic from their hydrocephalus. A total of 43% of patients in the group treated with Amicar demonstrated dilated ventricles, with 31% of the group clinically symptomatic. Mechanisms of action of Amicar possibly implicated in this increased incidence of hydrocephalus are discussed.


Ganglioglioma of the medulla oblongata.

A patient with signs and symptoms suggestive of symptomatic Arnold-Chiari malformation was encountered. Neuroradiologic investigation revealed the presence of a medullary tumor, which later proved to be a ganglioglioma. A review of the literature suggests that this presentation is typical of medullary gangliogliomas. It is proposed that the pathophysiology of this lesion renders it amenable to decompressive therapy via suboccipital craniotomy.


Cervical spinal angiography in midline spondylosis and herniations of intervertebral discs.

Three patients with clinical evidence of cervical myelopathy and degenerative osteoarthritis or herniation of intervertebral disc were studied with angiography. Angiography yielded information regarding the level of the most significant lesion better than did Pantopaque myelography when multiple lesions were present. Angiography also aided in differentiating hard central osteophytic from soft tissue encroachment on the spinal cord caused by herniation of a disc or thickening of the posterior longitudinal ligament. An occasional patient with cervical discogenic myelopathy suggested at multiple levels by myelography may benefit from the localization offered by angiography.


Meningiomas confined to the optic canal and foramina.

We present two cases, each with a small meningioma arising from the sheath of an optic nerve in the canal. Both cases demonstrate the paucity of clinical and radiographic signs occurring with these tumors. The diagnosis must be strongly suspected when a middle aged white woman slowly and progressively loses vision in one eye in the absence of remission or other neurological findings. We review similar cases reported in the literature that have been proven by biopsy.


Meningioma of the anterior part of the third ventricle in a child.

The authors present a rare case of a meningioma in the anterior part of the third ventricle in a 10-year-old boy which was successfully removed through a right-sided transventricular approach. The literature is reviewed.


Use of hyaluronidase in the central nervous system.

Hyaluronidase, an enzyme which depolymerizes the mucopolysaccharide hyaluronic acid, appears to be tolerated by the human central nervous system and in the anterior chamber of the rabbit eye. Two patients with hydrocephalus and meningomyelocele had their condition curtailed by intraventricular injections of hyaluronidase, and in a third patient its use permitted delay of shunting. It was apparently effective in preventing a reaccumulation of cystic fluid in an intramedullary neurofibroma, and in reversing adverse effects of adhesive arachnoiditis of the spinal cord. Hylauronidase seems worthy of further investigation in disorders of the central nervous system.


Acoustic neurinoma in a child.

A very large acoustic neurinoma in a ten-year-old girl is reported. The diagnosis was based on the clinical findings and the CT scan. The pertinent literature is reviewed.


Intracranial arteriovenous malformations in the Chinese.

A series of 32 intracranial arteriovenous malformations in the Chinese is retrospectively studied. Their salient clinical, radiological and morphological features are presented together with their eventual outcome. Contrasting features from reported western series are compared.


Superficial temporal arteriovenous fistula.

A case of post-traumatic arteriovenous fistula involving the superficial temporal artery is reported. The traumatic episode antedated the clinical manifestation and diagnosis by 28 months. The salient feature of the physical examination was the presence of a pulsatile mass with detectable bruit. This lesion, which was confirmed by angiography and computerized tomography, was treated by direct excision.


Intranasal meningoencephalocele with recurrent meningitis.

Two patients presented with repeated bouts of meningitis. RISA cisternography established the diagnosis in both cases. An intranasal meningoencephalocele was the cause of these infections. Frontal craniotomy and section of the peduncular connection of the meningoencephalocele and sealing of the bony defect was successfully performed in both cases. Postoperative investigations showed complete cure.