Electron microscopic study on the testicular interstitial cells in the mouse.

The interstitial tissue of the mouse testis contains, besides mature and immature Leydig cells, fibroblasts, occasional plasma cells and a considerable number of macrophages abutting on the Leydig cells. Mature Leydig cells extend filopodia into dilated portions of the intercellular space. Along the cell surface deep hollows are frequently formed which contain numerous filopodia protruded from the plasma membrane limiting the hollow. This unique structure is tentatively designated the "basal infolding-like structure." Abundant SER is classified into the tubular and vesicular forms. The former is composed of interconnected tubules which may form flattened, partially fenestrated cisternae in some areas. The latter form is composed of vesicles of variable sizes. The tubules probably transform into the vesicular form, possibly reflecting the functional phases of Leydig cells. Thus, among vesicles, patches of tubules with smaller calibers may be detectable. Membranous whorls composed of concentric lamellar stacks of flattened, partially fenestrated cisternae of the SER are frequently observed, enclosing a mitochondrion, lipid droplet or microbody in their center. A typical annulate lamellae are occasionally found in the cytoplasm or in the whorl which is continuous to the membranes of the ER. Small foci of the RER are detected and sometimes dilations of its cisternae are observed. Polysomes are distributed not only in the RER foci, but also throughout the cytoplasm intervening among the SER membranes. Mitochondria possess tubular cristae and occasionally contain sparse ribosome-like granules. Out of several Golgi complexes dispersed in the cytoplasm, the juxtanuclear one contains a diplosome and an occasional solitary cilium. Relatively numerous microbodies are scattered in the cytoplasm. Lipid droplet content varied strongly from cell to cell, probably suggesting variable intensities of steroid synthesis. In the peripheral cytoplasm, large vacuoles were found, probably derived from the testosterone-containing SER. These possible secretory vacuoles occurred close to the plasma membrane, suggesting emiocytotic release of the contents. The basal lamina was restricted to certain areas of the plasma membrane.


Blood supply of the rat periodontal space during amelogenesis as studied by the injection replica SEM method.

Distribution of blood vessels at the labial periodontal space of the rat lower incisor teeth was studied, using Mercox-resin vascular casts, which were coated with gold-palladium and observed in a scanning electron microscope (SEM). Three different layers were identified in the vascular bed of the periodontium. In the inner layer the enamel organ was supplied by a blood capillary network that changed from a circular mesh to a ladder-like pattern during amelogenesis. The middle layer was supplied by small arteries and arterioles. Small arteries originated from the inferior alveolar artery; arterioles, arising from them, became blood capillaries. In the outer layer, the sinusoid veins continued with the blood capillaries which ran into the proximal and the distal sites of the inner layer. This venous layer is located near the alveolar bones. As capillary networks change in pattern during amelogenesis, the circular mesh is considered convenient to provide the required materials for the proliferation and differentiation of inner enamel epithelial cells as well as for early enamel matrix formation, whereas the ladder pattern seems suitable to supply numerous organic or inorganic materials for the advanced enamel matrix formation and calcification.


Traumatic rupture of the thoracic aorta.

Fifteen patients with blunt traumatic rupture of the aorta, secondary to automobile accidents, that occurred less than seven days prior to admission were treated between 1967 and 1976. The diagnosis was suspected on the basis of roentgenographic evidence of upper mediastinal widening. Aortography demonstrated a localized deformity and dilation of the aorta isthmus just distal to the subclavian artery in all but one patient whose lesion occurred in the mid-descending thoracic aorta. The salvage of one of five patients with free rupture by the prompt institution of total cardiopulmonary bypass has prompted us to begin each operation with the capability of using either left heart bypass or cardiopulmonary bypass. An associated rupture of the right atrium of one patient was successfully controlled. Nine of 12 patients survived the operation, eight were discharged from the hospital, and six were alive and well as least one year later.


Fluid replacement in patients with large-area, full- and partial-thickness burns.

The importance of fluid replacement therapy in large-area, full- and partial-thickness burns has become widely recognized in the past 35 years. Experimenters have proposed various intravenous solutions and various ratios of fluid to body weight and percentage of body area burned. The importance of colloid and plasma during the early resuscitation phase has been questioned. The role played by age, by physical condition, and by individual response to injury in determining the patient's therapeutic needs has also been widely recognized. All physicians should bear in mind the need for careful observation of the patient in association with an understanding of the pathophysiology involved in treating burn shock.


On the malignant potential of acquired short esophagus.

Esophageal adenocarcinoma developed in an esophagus lined with columnar epithelium. The malignant potential of columnar metaplasia complicating long-standing gastroesophageal reflux and the implications of surgical management of acquired short esophagus are discussed briefly.


Discontinuity between the heart and the pulmonary circulation. Its management with the use of a valved external conduit.

The Hancock conduit that contains a porcine xenograft valve has been used in part of the cardiac repair of 22 patients with complex congenital heart disease. Five patients had a severe form of tetralogy of Fallot; six had pulmonary atresia; five had transposition of the great vessels, ventricular septal defect (VSD), and pulmonic stenosis; five had truncus arteriosus; and one had "corrected" transposition, VSD, and pulmonic stenosis. The hospital mortality was 2/22. This conduit has proved a satisfactory method to establish right ventricular-pulmonary artery continuity.


Pharmacology of sulfadiazine silver. Its attachment to burned human and rat skin and studies of gastrointestinal absorption and extension.

The attachment of Ag110-labeled sulfadiazine silver (AgSU) to the burn wound of humans and full and partial thickness scald burns of rats was studied over time. The duration of Ag adherence to burned skin and the absorption and organ distribution of ingested AgSU was studied. Peak attachment to human burns was 1% of the administered dose in 24 hours. Rat wounds showed greater attachment. Dissections of the wounds showed 81% to 98.7% of this attachment to be in the most superficial layers of cells and no silver was observed in organs of surface-treated animals. Duration of attachment after one application was until wound slough with percent attachment dropping from 5% to 1.7% over that time. Oral ingestion resulted in substantial silver deposition, particularly in liver and lungs. Clearance occurs in three weeks. The basic function of AgSU may be through the slow release of silver into the superficial wound environment.


Esophageal atresia. Critical analysis of 39 cases.

Knowledge of the factors that affect morbidity and mortality in the treatment of congenital malformations of the esophagus should result in better planning of their surgical management with increased likelihood of success. In 39 infants studied, associated anomalies, low birth weight, and postoperative respiratory complications were the factors responsible for morbidity and mortality. Infants with associated anomalies had a longer hospitalization than those with none, a mean of 17 vs 12 days.


Bilateral internal carotid artery aneurysms.

Two patients were treated for bilateral internal carotid artery aneurysms. One had resection and restoration of continuity on the right side nine years after ligation of the left internal carotid artery. The second had sequential resection and reconstruction of both vessels. Complications of carotid aneurysms include embolization, rupture, and thrombosis. Preferred treatment is resection with reconstitution of the flow. Patients with carotid aneurysms should be investigated for similar lesions on the opposite side. Patients who have had one carotid aneurysm treated should be followed up for the possible occurrence of a contralateral aneurysm.


Pathophysiology of bends and decompression sickness. An overview with emphasis on treatment.

Current concepts in the pathophysiology of decompression sickness are reviewed. Mild, moderate, and severe forms of this syndrome resulting from gaseous and lipid emboli are described. Therapy is aimed at restoring or specifically treating each alteration. Plasma volume deficit is restored by colloidal re-expansion. Decompression sickness is partially treated when recompression alone is used. Blood lipid alterations are managed by use of antilipemic agents. Dextran is mentioned. Divers at depths of 61 m display changes in hematocrit, platelet, and blood lipid profiles. Cord paralysis may occur from bubbles in the vena cava. Retrograde migration blocks the venous circulation of the spinal cord. Ultrasonic devices can detect "silent" bubbles during decompression. Recompression, when available, is a lifesaving treatment for diving accidents involving saturation diving. Air embolism is discussed. Monitoring emboli by EEG and fundoscopy are reported.


Gastric lymphoma vs adenocarcinoma. A diagnostic problem.

The prevalence of gastric lymphoma is increasing relative to gastric carcinoma. The differentiation between these two diagnoses can be difficult, but it is important from the standpoint of treatment and prognosis. These case reports illustrate that the results of gastroscopy, biopsy, and cytology may be misleading. If there is any question at the time of exploration, a biopsy and frozen section should be obtained before proceeding further or before closing the abdomen without resection. The pathologic diagnosis will determine the operation and postoperative treatment to be carried out.


Segmental aortic occlusion: An unusual lesion found in menopausal women.

A subgroup of patients with aortoiliac atherosclerosis are perimenopausal women in whom the lesions are confined to the midportion of the terminal aorta. The lesions occur in relatively small, though not hypoplastic, vessels, and it is speculated that the relatively small size of the terminal aorta functions as a long stenosis with resultant predisposition to atheroma formation. Other etiologic factors are not identified except for smoking. Endarterectomy results in satisfactory restoration of distal arterial flow. Recurrence has not been observed but the question exists as to whether replacement of the small segment with a larger prosthesis may be more appropriate in view of the possible etiology described.


The role of surgery on ambulatory patients in one teaching hospital.

The development of a program of one-day surgery for ambulatory patients in one hospital was stimulated by overloaded operating room facilities and a long waiting list of patients for hospital admission. This concept has received enthusiastic reception by the surgical staff and the number of operations has increased to over 7,500 per year. All of the surgical specialty services use the surgical day care unit, although the number of cases suitable for ambulatory surgical treatment varies greatly on the various services. There have been no deaths and about 1% of patients have been admitted to the hospital from the surgical day care unit for a variety of reasons that are summarized.


Alteration of oxygen tension and oxyhemoglobin saturation. A hazard of sodium bicarbonate administration.

The administration of sodium bicarbonate solution, which has been advocated for the treatment of metabolic acidosis, may have detrimental side effects. We evaluated oxyhemoglobin saturation and oxygen tensions in eight anesthetized swine before and after freshwater near-drowning and after a rapid intravenous infusion of 7.5% sodium bicarbonate solution (8 mEq/kg). After freshwater aspiration, arterial and venous oxygen tensions and oxyhemoglobin saturation decreased. Administration of sodium bicarbonate resulted in decreased venous and increased arterial, oxygen tensions. Arterial, but not venous, oxyhemoglobin saturation increased. These findings suggest that sodium bicarbonate caused a distinct leftward shift in the oxyhemoglobin dissociation curve, which could impair tissue oxygenation. Therefore, to avoid detrimental effects, sodium bicarbonate should be administered slowly and in a dose sufficient just to correct metabolic acidosis.


Gastric tissue prostaglandin levels. Effect of vagotomy.

To determine tissue prostaglandin levels in antrum and fundus and to examine the effect of vagotomy and distention on tissue prostaglandin levels, truncal and parietal cell vagotomies were performed on rats that were killed at 2, 4, and 6 weeks postoperatively with antral and fundic prostaglandin E1 levels being determined. The fundus has considerably higher levels of prostaglandin than the antrum. No differences after any type of vagotomy however, were noted. It cannot be concluded from this study that increased prostaglandin levels result from vagotomy.


Gallstone perforation and obstruction of the duodenal bulb.

A 69-year-old woman had a large gallstone eroded through the wall of the gallbladder and into the duodenum. The gallstone became fixed within the cholecystoduodenal fistula and produced a duodenal obstruction. At the time of the diagnosis of this problem, the patient had had a three-week period of epigastric pain and prolonged vomiting. She was treated by removal of the stone and cholecystectomy. The duodenal fistula was closed in two layers, and a gastrojejunostomy and a truncal vagotomy were carried out to protect the duodenal suture line. A leak from the duodenal closure developed on the fourth day, but this subsided spontaneously after 15 days with the use of sump drainage. Six months later, the patient is doing well and has a normal duodenum and gastrojejunostomy as shown by upper gastrointestinal barium study.


The impact of prophylactic measures on fatal pulmonary embolism.

Prompted by reviews showing no significant reduction in the overall incidence of fatal pulmonary embolism in recent years, we examined the incidence of this complication found on autopsy over the 15-year period between 1960 and 1974 in a Veterans Administration Hospital. During the first six years, when no specific prophylactic measures were practiced, 41 patients died of pulmonary embolism on the surgical service; whereas in the last nine years, when dextrans were used prophylactically in high-risk patients, 24 patients had fatal pulmonary embolisms. Of these 24 patients, 21 did not receive the recommended dosages of dextran. There were no significant differences in the average annual number of admissions and major operations, or in the rate of autopsy, between the two periods. We conclude that the prophylactic use of dextran in high-risk surgical patients is a practical, effective, and safe method to reduce the overall mortality from pulmonary embolism.


White clot syndrome. Peripheral vascular complications of heparin therapy.

Heparin sodium-induced thrombosis is insidious and difficult to diagnose. If untreated, it results in death or major amputation. We have treated seven patients with thromboses resulting from platelet aggregation induced by heparin. Four patients had acute arterial ischemia of the lower extremity, venous gangrene developed in two, and one patient had an occluded autogenous vein femoral popliteal bypass in the immediate postoperative period. The platelet count was noticeably reduced in affected patients. White platelet thrombi were noted in four patients, three of whom had acute arterial occlusion. A white thrombus was the cause of immediate failure of a femoral popliteal graft. Electron microscopic examination of these thrombi demonstrated predominantly fibrin platelet aggregates with an occasional entrapped WBC and a rare RBC. All patients receiving heparin therapy must have platelet counts performed regularly. If thrombocytopenia is detected, platelet aggregation studies are indicated. When abnormal platelet aggregation is noted, heparin therapy should be reversed with protamine sulfate and the patient treated with low-molecular-weight dextran and warfarin sodium.


Altered coagulation after albumin supplements for treatment of oligemic shock.

Coagulation and need for postoperative blood and plasma therapy were studied in 94 injured patients requiring massive transfusions (average = 14.4); 46 patients, by random selection, received supplemental albumin. Albumin therapy increased total protein concentration (6.4 vs 5.8 g/dL), serum albumin level (4.2 vs 2.9 g/dL), and plasma volume (3,895 vs 3,579 mL) but not RBC volume (1,520 vs 1,530 mL). During the initial five postoperative days, patients receiving albumin required more transfusions (7.1 vs 3.8) and plasma (455 vs 317 mL). This increased need for blood and plasma correlated with a significant decrease in fibrinogen (238 vs 405 mg/dL) and prolongation of the prothrombin time (2.6 vs 1.4 seconds). The partial thromboplastin time was prolonged and the platelet concentration was decreased in albumin-treated patients, but not significantly. Deficiencies in specific coagulation factors have not yet been identified but are being studied. Impaired coagulation is another potential hazard of supplemental albumin therapy, which is probably contraindicated in injured patients.


Vascular access: long-term results, new techniques.

Effective approaches to unique problems of vascular access in renal failure have evolved from a five-year experience with 840 angioaccess procedures. Standard techniques plus innovations have required only 0.62 operations per year per patient with an average access life of 1.6 years. Classical forearm external arteriovenous (AV) cannulas and internal AV fistulas provided vascular access in 392 patients, while 61 required more complex procedures due to failure of primary cannulas and fistulas, inherently small forearm vessels, and iatrogenic vessel loss. Secondary techniques include reverse fistula, vascular graft AV fistulas using expanded polytetrafluoroethylene (E-PTFE), and arterioarterial (AA) jump graft. Presently, the new renal failure patient receives a forearm radiocephalic AV fistula; the cannula is restricted to emergency or short-term hemodialysis and may later be converted to a subcutaneous fistula. The reverse fistula is attempted before using E-PTFE grafts. Upper extremity AV and AA loops can then be constructed de novo or from the reverse fistula.


The Hartmann procedure for complications of diverticulitis.

A Hartmann procedure was performed on 25 patients with complications of acute diverticulitis. Of the 20 patients in whom both stages were completed, 14 had a smooth course. Total hospitalization for both stages averaged 23 days. Mortality was 8%. The initial resection usually is not difficult. Subsequent reanastomosis is facilitated by an interval of at least three months between stages. The advantages of the Hartmann procedure are as follows: (1) The diseased bowel is removed at the first stage. (2) The risk of primary anastomosis is avoided. (3) Hospitalization and overall time of treatment are reduced. (4) Mortality is relatively low. The Hartmann procedure should be considered for a broader selection of patients with complications of acute diverticulitis.


Diagnostic and therapeutic colonoscopy. A critical review of 662 examinations.

The results of 662 therapeutic and diagnostic colonoscopic examinations were reviewed to assess the morbidity, clinical benefit, diagnostic accuracy, and indications for the procedure, with special emphasis on detection and endoscopic excision of small, occult, invasive cancers. Overall, the frequency of detecting occult lesions (19%), the (89%) ability to clarify questionable radiographic findings, and a substantial reduction in laparotomy-colotomy procedures required for removal of colonic polyps (88%), coupled with a low morbidity (3%) and low false-negative examination rate (1%) established colonoscopy as one of the most important advances in the management of colon disease in recent years. Although early experience suggests that small, occult, invasive carcinomas, when properly selected, could be adequately treated by endoscopic excision, larger series and longer follow-up periods are necessary to validate any conclusions regarding the decision to manage these lesions conservatively.


Gastric bypass in the operative revision of the failed jejunoileal bypass.

Fifty-five patients with failed jejunoileal bypasses underwent reanastomosis and gastric bypass at the same operation. One patient died of undetermined cause three months postoperatively. The 54 surviving patients were all relieved of their preoperative symptoms, and 40 patients achieved satisfactory weight control. Technical complications prevented weight loss in 13 patients: four were given pouches too large to be effective, and nine had late disruption of the staple line. Two patients gained weight despite the fact that their pouches were of appropriate size. Reanastomosis will reverse the side effects of jejunoileal bypass, and a properly performed gastric bypass at the same operation will afford protection against subsequent weight gain.


Systems of trauma care. A study of two counties.

Cases of motor vehicle trauma victims who died after arrival at a hospital were evaluated in both Orange County (90 cases) and in San Francisco County (92 cases), Calif. All victims in San Francisco County were brought to a single trauma center, while in Orange County they were transported to the closest receiving hospital. Approximately two thirds of the non-CNS-related deaths and one third of the CNS-related deaths in Orange County were judged by the authors as potentially preventable; only one death in San Francisco County was so judged. Trauma victims in Orange County were younger on the average, and the magnitude of their injuries was less than for victims in the San Francisco County. We suggest that survival rates for major trauma can be improved by an organized system of trauma care that includes the resources of a trauma center.


Creatinine clearance in critically ill surgical patients.

Standard tests of renal function (urine output, BUN, and serum creatinine) were compared with creatinine clearance values and with outcome in 131 critically ill surgical patients. There was a strong negative relationship between creatinine clearance and mortality. Of the 23 patients with a severe reduction of creatinine clearance (less than 20 mL/min), 17 died. In contrast, 23 of the 24 patients with a creatinine clearance of 100 mL/min or more survived. Urine output, BUN, and serum creatinine levels correlated poorly with creatinine clearance. A urine output of less than 30 mL/hr, a BUN level greater than 40 mg/dL, and a serum creatinine level greater than 2.0 mg/dL in all instances were associated with reduced creatinine clearances. However, more than half of all the patients with a normal urine output, BUN, or serum creatinine levels also had a reduced creatinine clearance.


Multiple adenomas of the parathyroids: do they exist?

Since Cope's original description of chief cell hyperplasia in 1958, there has been general agreement that this entity is the most common cause of multiple parathyroid enlargement. Whether or not multiple adenomas of the parathyroid glands ever occur has been seriously questioned. Criteria are proposed for defining the entity of multiple parathyroid adenomas in contrast with hyperplasia. With the use of these criteria, five patients with multiple adenomas were found in our last 300 cases of primary hyperparathyroidism.


Cancer of the parathyroid glands.

Hyperfunctioning parathyroid carcinoma is a relatively rare endocrine tumor, accounting for approximately 1% of all cases of primary hyperparathyroidism. The diagnosis is suspected when the tumor is large, parathyroid hormone (iPTH) levels are high, and a palpable tumor is present in the neck. Patients who have recurrence of hyperparathyroidism several months after surgical treatment should be suspected of having a recurrent or persistent parathyroid carcinoma. At operation, a large invasive tumor is usually found. The fibrous, inflammatory-like reaction is the most characteristic indication of malignancy. Even in tumors with minimal invasiveness, the possibility of a carcinoma should be considered if the tumor has mitotic activity and a monotonous instead of a pleomorphic cellular population. If the surgeon can recognize the possibility of parathyroid malignancy and adequately treat the patient during the initial operation, more gratifying results should be obtained.


The continued importance of adrenalectomy in the treatment of Cushing's disease.

Eighteen patients with pituitary-dependent Cushing's disease have been treated during a ten-year period. Eleven of these received a total of 14 alternative forms of therapy in an attempt to control the clinical manifestations of Cushing's disease prior to adrenalectomy. However, no substantial improvement was noted in these patients, who included four receiving conventional pituitary irradiation, five receiving cyproheptadine, two receiving mitotane, and one each receiving metyrapone and phenytoin. One patient had an attempted transsphenoidal hypophysectomy that could not be accomplished because of hemorrhage. A complete remission of the signs, symptoms, and laboratory abnormalities of Cushing's disease occurred in all 18 patients following bilateral adrenalectomy. There was no operative mortality and morbidity was minimal. This experience confirms that bilateral adrenalectomy is a rapid, safe, and permanent means of reversing hypercortisolism and that it should remain an integral part of the treatment of Cushing's disease.


Experience with lobular carcinoma of the breast. Emphasis on recent aspects of management.

A total of 105 patients with lobular carcinoma of the breast were seen at two hospitals between 1966 and 1978. Mammography was found to be of limited value in the preoperative assessment of these patients. As reported by others, there was a high incidence of bilateral lobular neoplasia. In the patients with lobular carcinoma in situ for whom follow-up data were available, all were alive and well. In contrast to this, infiltrating lobular carcinoma was found to be as malignant a lesion as any other infiltrating breast cancer regardless of the operative procedure performed. These latter tumors were found to bind substantial levels of estrogen receptor proteins. From the information gained, it is suggested that early hormonal manipulation and/or chemotherapy may be advantageous in the patient with recurrent infiltrating lobular carcinoma in particular.


Reoperation for pancreatic cancer.

Over an eight-year period, 24 patients were referred following laparotomy at various community hospitals where their conditions had been diagnosed as "incurable pancreatic cancer." Seventeen of these patients' conditions were reevaluated and they underwent exploratory surgery again. In two patients, no cancer was found in spite of multiple biopsies. Nine patients underwent total pancreatectomy with no operative deaths, and two of them had localized primary ampullary cancer. Eleven of these 17 patients have survived 1 1/2 to six years. We conclude that reoperation in selected cases in which the condition was diagnosed as "inoperable pancreatic cancer" can have an appreciable salvage rate. We suggest that pancreatic exploration with a view to resection should be performed only in specialty centers where there is interest and expertise in the problem.


Gastroesophageal reflux in infants and children. Diagnosis and management.

Eighty-three infants and children underwent surgical correction of gastroesophageal reflux (GER) from 1973 to 1978. Fifty-four patients had coexistent brain damage (most commonly due to cerebral palsy), eight were previously treated for esophageal atresia, and four had gastroschisis or omphalocele repair. Clinical presentation included failure to thrive in 64 patients, vomiting in 59, and recurrent bouts of aspiration pneumonitis in 43. Barium roentgenography showed GER in 61 patients, whereas additional tests (particularly pH monitoring) were required for detection of GER in 22 patients. After failure of medical management, transabdominal Nissen fundoplication was performed in 80 cases and a Hill repair in three cases. The surgical mortality was zero, but there were five late deaths. Results were considered excellent in 54 patients, good in 22 patients, and poor in seven. Ten of 12 patients with preoperative stricture responded to dilation after fundoplication. Nissen fundoplication was a safe and effective antireflux procedure in 76 of the 83 cases.


Reassessment of simple cholecystostomy.

Cholecystostomy was performed on 22 patients with acute cholecystitis after partial (13) or complete (9) removal of gallbladder stones. One patient had complementary common-duct drainage. Early mortality occurred in two patients. Three patients with associated cholangitis but intraoperative reflux of cysticduct bile were all treated by cholecystostomy alone and survived. For the poor-risk patient with cholecystitis, cholecystostomy is effective. When there is associated cholangitis and documented cystic-duct patency, cholecystostomy is also sufficient. When accompanying cholangitis is associated with cystic-duct occlusion, choledochotomy and T tube drainage should be added.


Biliary decompression in hilar obstruction. Round ligament approach.

In some patients with biliary obstruction, access to the hepatic hilus is hindered by extensive tumor or by dense vascular scar tissue. In such patients, the biliary tract may be decompressed via the left hepatic duct away from the affected hilus. Access to the left hepatic duct in the left intersegmental plane is gained by dividing the round ligament, freeing it from the undersurface of the liver, and following it to its junction with the left portal vein. The left hepatic duct, which lies superior to the vein, is exposed by dividing the liver overlying the round ligament in the relatively avascular plane between the lateral and the medial segments of the left hepatic lobe. Decompression can be effected by simple tube drainage or, if the duct is large enough, by Roux-en-Y hepaticojejunostomy.


Esophageal atresia. A 41-year experience.

Since the first attempted repair in 1935, a total of 365 infants have undergone treatment for esophageal atresia with or without tracheoesophageal fistula. To evaluate the improvement in our results, we have divided our patients into four, approximately equal, time periods. The overall late survival has indeed improved during each of the four decades from between 36% and 53% to 68% in the last ten years. During this past decade, the group A risk infants (35 patients) had a 3% mortality, the group B (20 patients) had a 5% mortality, but the group C babies (22 patients) had a 41% mortality due to associated anomalies or severe prematurity. Anastomotic leaks and recurrent fistulas were each encountered in approximately 5% of the cases in all decades. Postoperative stricture has been encountered in 20% of the entire series and no esophageal replacements have been required.


Our first 35 patients studied five years after parietal cell vagotomy.

Parietal cell vagotomy without drainage (PCV) was performed on 35 patients. The patients were evaluated at regular intervals for 60 months. A recurrent ulcer developed in four patients. One patient was reoperated on, one patient refused an operation, and in two patients, the ulcers healed and remained healed for four years after withdrawal of ulcerogenic drugs. Another patient was reoperated on for pyloric obstruction. Diarrhea was reported by no more than one patient at any reporting period. The number of patients who reported dumping at the various time periods ranged from two to four. At the time of each patient's last interview, 33 were considered to have excellent or good results. PCV is a safe and effective operation for treatment of duodenal ulcer. Instructions in the technique are necessary to avoid errors that might unnecessarily occur and lead to poor results with first operations.


Effective surgical therapy of esophagitis. Experience with Belsey, Hill, and Nissen operations.

During the years 1971 to 1978, 252 patients needed surgical treatment of primary or secondary esophagitis. Major operations performed were 73 Belsey Mark IV repairs, 55 Hill repairs, and 129 Nissen repairs. In the group with primary reflux, barium swallow tests and endoscopy were useful in confirming the diagnosis in patients with typical symptoms; routine biopsy, lower esophageal sphincter, manometry or an acid infusion test did not add to diagnostic certitude. If symptoms were atypical, a biopsy was helpful but manometry and acid infusion were not. Mean symptom scores in this group of patients were improved by each of the "valve-building" operations. Intraoperative dilation after mobilization of the esophagus coupled with a valve-building operation was successful in managing 26 of 29 strictures. Reoperation after an operation failed carried appreciable morbidity and mortality but resulted in good control of symptoms. Addition of a Belsey or Nissen procedure to myotomy for management of primary esophageal motility disorders diminished symptoms and did not cause disabling obstruction.


Reoperation for disruption and recurrence after Nissen fundoplication.

This report deals with 25 failed Nissen operations. A method of classifying the type of failure is presented. Manometric studies document disordered motor activity in ten of these patients with return to normal activity after repair. With these difficult patients, intraoperative manometrics allowed a satisfactory antireflux barrier to be created with posterior gastropexy. Good to excellent results were achieved in 22 of 24 patients. A search of the world literature is presented with complications ranging from the well-known "gas-bloat" syndrome to potentially lethal fistulas.


Alkylation of RNA by vinyl bromide metabolites in vitro and in vivo.

[1,2-14C]Vinyl bromide was incubated with rat liver microsomes, NADPH, and polyadenylic acid, polycytidylic acid, or RNA, respectively. Part of the adenosine moieties in RNA or in polyadenylic acid were alkylated and labelled 1,N6-ethenoadenosine structures were formed. Part of the cytidine moieties were converted into 3,N4-ethenocytidine. In addition, a further unidentified cytidine alkylation product was observed which was not seen in experiments using [1,2-14C]vinyl chloride. When rats were exposed to [1,2-14C]vinyl bromide, radioactive ethenoadenosine and ethenocytidine were present in hydrolysates of liver RNA. A further alkylation product was observed in the RNA hydrolysates which did not occur in experiments using [14C]vinyl chloride. The data show that vinyl bromide metabolites alkylate nucleic acids; although in general in this respect vinyl bromide and vinyl chloride behave similarly, some differences are observed in the alkylation behaviour of both compounds.


Action of N-isopropyl-alpha-(2-methylhydrazino)-p-toluamide hydrochloride (procarbazine hydrochloride) in the germ tissue of mice: dominant lethal effects.

A study was carried out on the effects of N-isopropyl-alpha-(2-methylhydrazino)-p-toluamide (procarbazine, Natulan) in the dominant lethal test in the mouse. Male mice were dosed once and mated with fresh virgin females each week. The utilization of sperm, treated as spermatids or testicular sperm with 100-800 mg/kg, resulted in significant post- and pre-implantation death of embryos. Fertility was markedly reduced after the injection of 200 mg/kg of procarbazine and over. This is probably due to a cell killing effect, the most sensitive stages being differentiating spermatogonia, type A sermatogonia and resting primary spermatocytes. Total sterility was induced for several weeks with doses of 600 and 800 mg/kg. Up to 12 weeks after treatment the number of females with implants was still significantly lower than controls indicating a severe depletion of spermatogonial cells. The spectrum of effects correlates well with the drug's effect on nucleic acid and protein synthesis.


Lead-induced leukocytosis in female mice.

Lead acetate was shown to stimulate a striking leukocytosis in young adult female mice. The effect was manifest 4 days after lead injection and continued throughout the following 4 days. At the higher treatment level, lead induced an increase of 300% for both monocytes and neutrophils. The leukocytosis was due primarily to the elevated levels of neutrophils as suggested by a decrease in the ratios of peripheral agranulocytes to granulocytes. No differences from normal leukocyte cytology were observed in blood samples collected from animals receiving lead.


1,3-Bispyridinium-dimethylether mono- and dioximes: synthesis, reactivating potency and therapeutic effect in experimental poisoning by organophosphorus compounds.

Nine bispyridinium oximes containing two pyridinium rings linked by dimethylether were synthesised. Each compound had on one of the pyridinium rings a hydroxyiminomethyl group in position 2 or 4, while the other ring was unsubstituted or had a methyl or a hydroxyiminomethyl group in position 2 or 4. The reactivating potency and therapeutic effect of the oximes were tested on two organophosphates: O,O-dimethyl-2,2-dichlorovinylphosphate (DDVP) and O-ethyl-S-(2-diisopropylaminoethyl)-methylphosphonothioate (VX). The reactivation was measured on human erythrocyte acetylcholinesterase and the therapeutic effect was evaluated on male albino rats. The oximes with a hydroxyiminomethyl group in position 4 in the pyridinium ring were good reactivators of both phosphorylated and phosphonylated acetylcholinesterase. They were also very effective given together with atropine against VX and DDVP poisoning. The compounds are almost as effective as PAM-2, but PAM-2 is less toxic.


The interaction between ethanol and manganese in rat brain.

The effect of combined administration of ethanol and manganese on the brain tissue of rats was investigated to evaluate the role of alcohol ingestion in inducing susceptibility to manganese poisoning. Ethanol and manganese alone and the combination of the two were administered orally daily to the rats for 30 days. Almost identical increase in the brain contents of manganese in rats receiving the metal alone and in combination with ethanol indicates that ethanol administration does not influence the accumulation of manganese in that organ. The copper contents of brain also increased to almost the same extent in these two groups. Synergistic effect of ethanol and manganese was noticed on increasing the activity of ATPase and RNase while marked antagonistic effect was observed on the activity of MAO. The mechanism and the significance of these neurochemical alterations occurring after the administration of ethanol and manganese have been discussed.


[Nerve ultrastructure of the arteries of the brain stem].

Ultrastructure of the nerve apparatus in the arteries of the brain base has been studied in cats. The structure of peri- and adventitial nerves has been investigated electron microscopically. Three types of efferent axons and four types of synaptic vesicles (small agranular and granular, large granular, large electron opaque vesicles) have been revealed. Vesicle-containing axons in the brain arteries approach the external smooth muscle cells of about 80 nm. Terminal axonal dilatations possessing direct and mediated connections with muscular cells of the middle tunica have been revealed.


[Quantitative study of the capillaries in a secreting salivary gland (electron-microscopic and morphometric analysis)].

Regularities in structural rearrangement of epithelium of blood capillaries in the rat parotid salivary gland have been studied under various functional conditions of the organ. The data obtained demonstrate that secretion is accompanied by dilatation of anuclear segments of capillary endothelium, decreasing thickness of endotheliocytes, rise of hematocrit number by adding the total area of the capillary fenestrated surface, the form factor of intraendothelial contacts and decreasing length of the contacting cytolemmas. Since extreme values of the metrical parameters studied have been revealed during the phase of the secrete excretion, a suggestion is made that increasing hydraulic permeability of the metabolic vessels with subsequent transport of the fluid to the terminal parts of the gland create the conditions promoting to reach the threshold level of pressure in acini that is necessary to overcome high resistance of nerrow intercalated sections for the secretion to reach the ducts.


[Effect of venous congestion on the microcirculatory bed of rat adrenal glands].

Early effect of experimentally induced venous congestion on the rat adrenals is evident in dynamical changes in the microcirculatory bed of the glands. As morphometric data demonstrate, the greatest changes take place in blood vessels of the cortical substance: the capillary diameters are dilated in all the zones, the thickness of the wall in subcapsular and capsular arterioles increases at the expense of hypertrophic smooth muscle elements. Subsequently, venous-arteriolar reaction develops, with capillary diameter approaching the initial size. The data obtained are discussed.


[Form of branching of pulmonary air pathways in the canine lung].

The degree of regularity in bronchial dichotomy has been studied in 5 corrosive preparations of the dog bronchial tree by the method of E. R. Weibel. It has been demonstrated that a high degree of regularity is specific for the dog lungs that makes 0.82 +/- 0.12 regarding small and large diameters. Approximation in distribution of bronchi having the diameter of 3--3.5 mm in 1--9 generations by means of binomial distribution gives a good result. The greatest bronchial rate with the diameter mentioned above has been registered in 5--7 generations. Theoretical data are presented to demonstrate the necessity in regularity of bronchial branching in order to maintain an optimal gaseous exchange in lungs.


[Tendinous fibers in the periosteum and bone].

The relation of muscles and  bony skeleton studied in the work demonstrates a rather complex mechanism of connections existing between tendinous elements and periosteum and bone. Investigation on fixation of muscular tendons to the skeleton has demonstrated that in some cases tendinous filaments plait into the periosteum and terminate in it, while in other cases not all the tendinous  filaments terminate at the level of the periosteum, but some of them penetrate into the bone. Thus, it has been demonstrated for the first time that tendinous filaments penetrate into the compact substance of the bone.


[Quantitative characteristics of cells formed during early postnatal ontogenesis in the cytoarchitectonic layers of the parietal region of the cortex in normal mice and following brain injuries].

By means of computer analysis, size distribution of neurons and glial cells together with the label of 3H-thymidin labelled cells were studied in cytoarchitectonic layers of the field 1 in the mouse parietal cortex injected with the isotope on the 5th day of life and killed 1 month later. In some animals, 3 days before 3H-thymidin injection, the parietal region in the right hemisphere was perforated. The labelled cells were subdivided into 2 groups according to their size: astrocytes (A) and small gliocytes (mg). Labelled A and mg  were stated to be rather evenly distributed along the cytoarchitectonic layers in the field 1. The trauma performed resulted in increasing amount of the labelled A and MG in the operated hemisphere. Uniformity in distribution of the labelled A and mg, occupying the position of satellites, did not change considerably at the trauma, in spite of general quantitative increase of the labelled glial cells. One month after the trauma, body dimentions of the mice labelled with A and mg did not considerably differ from those of intact animals, while the size of nerve cells increased. Thus, neurons in the parietal cortex of a growing brain respond to brain trauma with hypertrophy of cell bodies, and glial populations--with increase of their number.


[Histometric changes in the liver of inbred rats during prevention of hypokinesis].

An experimental investigation on morphological changes in the liver under prophylaxis of hypokinesia has been performed in genetically uniform material--150 premature rats of August and Wistar lines. The prophylaxis has been carried out at hypokinesia as the background produced by training in the treadban and at the combination of the latter with a pharmacological stimulator. The experiment has been performed for two months. In histological preparations of the liver the number of hepatic lobules, hepatocytes and stellate reticuloendotheliocytes per unit of the tissue area have been determined. Nuclear diameters, width of hepatocytes and sinusoid blood capillaries have been measured. Significant histometric changes in structural components of the liver have been stated after 60 days of hypokinesia with decrease of the organ. Prophylactic measures applied with hypokinesia as the background produce certain positive effect, though it is not the same in different indices and in different strains of animals.


[Electron microscopic study of the innervation of the heart conduction system in rats].

A systemic quantitative electron microscopic analysis on innervation of the sinus node, the atrioventricular node, the bundle of His and its pedicles within the interventricular septum has been performed in intact hearts of mature rats. The data have been obtained on the size of nonmyelinated and myelinated nerve fibres, efferent and afferent terminals within different parts of the cardiac conductive system, their interconnection with specialized cardiomyocytes have been described. Application of certain methods for electron microscopic investigation on the innervation of mammalian cardiac conductive system has been discussed.


[Several indices of the morphofunctional state of the normal kidney and kidneys following lymph drainage disruption].

The size of the renal body in convoluted parts of proximal and distal nephrons has been studied in normal dogs and after section and ligation of the efferent lymphatic vessels in 4 series of experiments (85 dogs). Observations have been made 12 h, 3 and 10--150 days after the operation. Histological, histochemical and morphometric methods have been applied; the level of residual nitrogen has been estimated. In early days of the experiment, the disturbance in lymph drainage has been found to result in edema and albuminous saturation of the connective tissue stroma, granular distrophy of the epithelium in the convoluted tubules of the kidney. After 40--150 days of the experiment, diffuse sclerosis of the connective tissue stroma of the medullar substance and of the pyramids develops. Alterations and disorders in the organ's function on nitrogen discharge are especially pronounced when lymph drainage is disturbed in one kidney, and the other kidney is removed. In such a case, the processes of compensatory hypertrophy are delayed. Morpho-functional alterations are less pronounced after lymph drainage disorders in the compensatory hypertrophic kidney.


[Histochemical and cytologic changes in the liver in experimental poisoning and subsequent pregnancy].

In 275 white rats chronic intoxication was produced by injection of amidopyrine acetaldehyde and chloraldehyde derivatives for 4 months. Histochemical and electron microscopic investigations of the liver under the experimental conditions and subsequent pregnancy revealed certain changes in nucleic metabolism, glycogenolisis, in the content of sulfhydryl, disulfide, carboxylic groups of protein molecules. Decrease in activity of enzymes of Krebs cycle and pentosophosphate cycle proved the deep changes in hepatocytes at the level of oxidation-reduction processes and protein synthesis. Ultramicroscopic changes in the nucleus, in cytoplasmic network, mitochondria and local degenerative alterations determined the level of morphologic reconstructions in connection with the intoxication. As the liver performs a number of vital functions and is closely connected with regulatory systems of the organism, morphofunctional shifts in the organ affect unfavourably the system mother--fetus.


[Comparative characteristics of the cyto- and angioarchitectonics of the inferior olives and the dentate nuclei of the cerebellum during human prenatal ontogenesis].

The development of the inferior olives and the denticulate nuclei of the cerebellum and their capillary network were studied in human fetuses 4--10 months old. General regularities in the formation of the inferior olives and the denticulate nuclei of the cerebellum were stated. During prenatal ontogenesis, nuclear cytoarchitectonics becomes more complex that is especially evident after 7th month of the intrauterine development: the density of the neural cells arrangement decreases, while the density of the glia arrangement and that of the glial index increases. At the same time, essential alterations occur in the capillary network: int acquires three-dimensional structure, becomes longer with more complicated interrelations between the neural cells and the capillaries.


[Effect of articular cartilage resection on the growth and formation of the femoral and acetabular epiphyses].

Different parts of the articular cartilage were resected in 46 rabbits at the age of 2.5 months. The resected narrow stripe of the articular cartilage completely restored by the 60--90th day and the growth of the condyles was not disturbed. Resection of considerable areas of the articular cartilage on the condyles and on the femoral head was accompanied by a certain disturbance of the osseous tissue growth in these areas with  resulted impression of the condyles, deformation of the head and further formation of coxa vara. The removal of 1/3 of the articular cartilage of the cotyloid cavity resulted in a certain increase of its diamter, uneven development at the site of resection; the femoral head of this joint increased, its spherical shape was altered. The restored cartilage did not restore its original structure characteristic for a growing bone. The newly formed articular cartilage lost its ability to participate in endochondral bone formation during the growth of the animal.


[Effect of weightlessness and artificial gravitation on thyroid gland morphology].

The investigation of the thyroid gland was carried out in Wistar rats, SPF colony 4.5--13 h and 25 days after a 18.5 days flight on board the space biosatellite "Cosmos-936". In animals subjected to weightlessness, moderate symptoms of the thyroid hypofunction were observed, statistically significant decrease in number and volume of the nuclei in calcitonin-secreting cells (C-cells) was especially pronounced during 4.5--9 h after landing. Similar but less pronounced changes were observed in C-cells of the rats subjected to artificial conditions of space flight, besides weightlessness. The similarity of the changes in the animals of both groups made it possible to connect the increasing amount of C-cells and the morphological symptoms of their functional inhibition with the effect of weightlessness and hypokinesia. During the space flight, the animals were kept under the conditions of artificial gravitation on board the biosatellite and therefore morphological peculiarities specific for the earth conditions were preserved in C-cells and the thyroid gland. Thus, it was concluded that artificial gravitation prevented the development of the thyroid changes which appeared under the influence of weightlessness.


[Effect of artificial gravitation on the skeletal musculature of rats during space flights].

Comparative morphological and histochemical investigation of the rat skeletal muscles after a 18.5 days flight in the space ship "Cosmos-936" under conditions of weightlessness and artificial gravitation created by means of a centrifuge has demonstrated that weightlessness creates muscular atrophy, with fibres of different types affected in different muscles. The greatest changes take place in the soleus muscle. Metabolic disorders in the muscular tissue are manifested as an excessive deposition of glycogen and an increased content of phospholipids in it. The artificial gravitation favourably affects the state of the skeletal musculature preventing the development of metabolic disorders, though it does not completely avert the appearance of atrophic processes in it.


[Radioautographic study of a culture of fibroblasts after irradiation by a neodymium laser].

By means of radioautographic method, with 3H-thymidin application there were studied: mitotic activity, the number of DNA-synthesizing cells, growth fraction and population number of fibroblast culture irradiated with a single impulse of neodymium laser at energy density within 1 Dg/cm2--100 Dg/cm2. Under the influence of small doses of laser radiation (1--10 Dg/cm2) the number of dividing DNA-synthesizing cells increased, together with proliferative pool and the number of cells in the field of vision. At energy density of laser radiation equal to 50 Dg/cm2, and especially to 100 Dg/cm2 despite increased mitotic index and labelled cells index, registered during first hours of the effect, proliferative pool decreased and population growth rate lowered. These doses of laser radiation produced destruction of a rather large part of the cells in a monolayer.


[Electron microscopic study of the effects of thyroxine and exogenous RNA on cultured cells].

Dependence of thyroxin effect on the level of transcription and the influence of exogenous RNA synthesized by injection of thyroxin to animals was studied in culture cells electron microscopically. Thyroxin was stated to produce changes in nuclear structures, the development of endoplasmic network, increase in number of ribosomes, hypertrophy of the laminar complex. A partial blockade of transcription by actinomycine prevents the manifestation of thyroxin effect on the state of cell ultrastructures. Injection of RNA obtained from organs of rats treated with thyroxin to some extent imitates thyroxin action on the state of protein-synthesizing of the cell. The data were presented on the existance of some genetic link in the mechanism of thyroxin action affecting ultrastructural organization of the cell.


[Mineral saturation, ossification and synostosis of the hand bones in adolescents and youth].

The results on X-ray densitometric studies of the hand bones in adolescent and young people at the age of 10--17 years (369 persons in all) are presented in the work. Processes of mineralization, ossification and synostosis, as the investigation has demonstrated, are closely connected with each other. From the beginning of ossification in the pisiform and sesamoid bones of the first metacarpophalageal joint (11--12 years of age) up to the completion of synostosis in short tubular bones of the hand (15--16 years of age), a decrease of mineral salts is noted in osseous tissue. Hence, accumulation of mineral salts in skeleton of children and adolescent persons does not occur smoothly, but rather distinctly reflects those functional changes which take place in the adolescent organism when the genital glands begin their increased activity.


[Anatomical variants of the lymphatic vessels connecting the inguinal lymph nodes].

The study of anatomical variants of lymphatic vessels connecting inguinal lymph nodes was carried out on 56 corpses of adult persons of both sex whose deaths were not connected with lesions in the lymphatic system of the pelvis and lower extremities. The inguinal lymph nodes and their afferent and efferent lymphatic vessels were detected by the method of intradermal injection and by the method of direct injection into the lymphatic vessels. It was stated that groups of the inguinal lymph nodes, as well as the nodes in every group determined, can serve as nodes of different stages for afferent lymphatic vessels running from different parts of the body and organs.


[Intraspecies features of variants in the structure of the arterial bed in dogs and their importance for hindlimb transplantation].

As a result of detailed studies of the dog anatomy, the authors have concluded that besides generally accepted subdivision of these animals into flabby, rough, strong, lean and gentle types, it is reasonable to subdivide them according to the type of their habitus (brachy-, meso- and dolichomorphous types). In 95 fresh and fixed anatomical preparations, peculiarities of topographic-anatomical relations and morphometric indices of magistral arteries and their large branches have been studied in the pelvic girdle and a free hind extremity in mongrel dogs according to the type of their habitus. In dogs of mesomorphous type of habitus, quantitative parameters of the diameter and length of magistral arterial trunks in the hind extremity, as a well as the distance between their branches occupy an intermediate place when comparing the animals of brachy- and dolichomorphous types. The authors have come to the conclusion that dogs of the mesomorphous type of habitus are the most suitable to perform experiments on transplantation of extremities and for modelling different pathophysiologic conditions in the organ.


[Features of the structure of the cornea of fish].

Electron microscopy of the cornea have been performed in marine fishes. Some structural peculiarities in the cornea of prebottom-dwelling fishes have been demonstrated. In Gobius fluviatilis (Pallas), Gobius (Proterorhinus) marmoratus (Pallas), glossa Platichthys flesus (L) the cornea is double and there is an iridescent layer. It is stated that cells of the iridescent layer play an active part in the formation of the endothelial basal membrane. In Syngnathus nigrolineatus, according to its living conditions, the cornea has a rather simple composition and structure. In the cornea of fishes either epithelial or endothelial basal membrane (Gobiidae, Syngnathus nigrolineatus) or a wide electron opaque epithelial membrane (Blennius tentacularis) or else, besides this, the Bowmen membrane (glossa) can be formed.


[Dynamics of axonal degeneration in the neuronally isolated cerebral cortex].

The brains of 11 cats were studied after unilateral isolation of the cortex after M. M. Khananashvily (1961) by means of resection of the projection fibres connecting the cortex with subcortical formations. The character and peculiarities of axonal degeneration in the large hemisphere cortex, were investigated after Nauta and Fink--Heimer. It was found that distribution of degenerating terminals in every layer depended on the time when the material was taken for investigation. Maximal concentration of the degenerating fibres was observed 3--5--10 days after the operation, then a gradual decrease in density of degeneration in every cortical layer was observed. By the 9th month after the operation, the processes of axonal degeneration completely came to their end. The problem of retrograde and anterograde nature of the axonal degeneration in the cortex of the large hemispheres was discussed in the article and it was demonstrated that in the field 4 of the neuronally isolated cortex it is of mixed nature.


[Innervation of the microcirculatory bed of the human trigeminal nerve].

The investigation of film preparations and histological sections of human trigeminal nerves impregnated with silver nitrate and treated after Gomori, Falck--Hillarp demonstrated a rich innervation in the intraneural blood vessels. The most various and complex interconnections of the neural structures were noted in arterioles and venules of the node capsule, epineurium and external layers of perineurium of the trigeminal nerve branches. On the vessel walls of these layers, neural plexus were revealed. Sensitive innervation of the neural blood vessels mainly performed by posvalent tissue-vascular receptors. In the walls of intraneural vessels, adrenergic and cholinergic neural plexus are revealed.


A hemoperfusion column based on activated carbon granules coated with an ultrathin membrane of cellulose acetate.

A hemoperfusion system has been developed which makes use of activated carbon encapsulated with cellulose acetate. Studies have revealed that there are no stagnant flow regions in the column, there is minimal particle release and the coating is 30 A thick. The relationships between pore size, pore volume and surface area have been examined. Twenty-five patients in grade IV coma have been treated with the column for treatment of drug overdose or agricultural chemical poisoning; the clinical course of one meprobamate-poisoned patient is described in detail.


Thiols and hepatic coma.

The plasma concentrations of methane and ethane thiols have been determined during the course of acute liver failure by a gas-chromatographic technique, and a prognostic evaluation is possible using this analysis. Further, the effects of some therapeutic measures, notably hemoperfusion, on the thiol levels have been investigated. It is concluded that these toxins, which are to a large extent covalently protein-bound, are extremely difficult to remove in an extracorporeal liver support system. Since the cause of the pathological thiol concentrations is probably the elevated plasma methionine levels associated with severe liver disease, it is suggested that the most hopeful course of action against the accumulation of thiols in the body might be a preventative therapy involving the normalization of methionine at an early stage of the disease.


Albumin-coated Amberlite XAD-7 resin for hemoperfusion in acute liver failure. Part II: in vivo evaluation.

Albumin-coated Amberlite XAD-7 has been previously shown to be blood compatible in in vitro hemoperfusion experiments whith human blood. In this study, the preliminary results are reported on single hemoperfusions with albumin-coated XAD-7 resin in four patients with acute liver failure. The mean platelet count was 116+/-SE 16.3% of the initial arterial value and the mean white cell count was 96+/-SE 6.5% of initial at the end of four hours of hemoperfusion. Removal of bilirubin, phenols and substances in the middle molecular weight range by the resin was demonstrated. These preliminary results suggest albumin-coated Amberlite XAD-7 resin to be blood compatible and capable of removing protein-bound and middle molecular weight substances from patients with acute liver failure. Further clinical evaluation of repeated resin hemoperfusion is required to determine whether this treatment will be beneficial to patient survival.


Dialysis/hemofiltration in schizophrenia: a journey by night and cloud.

Hypotheses for the etiology of schizophrenia are discussed and related to possible treatments utilizing artificial kidney systems. For hemofiltration particularly, a theoretical framework is presented for treatment planning. Emphasis is placed on the necessity of using rigid diagnostic criteria for patient selection. Results are reported on two "strict" schizophrenic patients after a series of hemofiltration treatments. One patient showed no clinical improvement after seventeen treatments and died subsequently in a mountaineering accident. Though clinical improvement was noted in the second patient (22 treatments in four months), it is unjustifiable to attribute this solely to hemofiltration. Increased family and medical staff attention towards the patient is sufficient explanation for all changes noted in the patient's symptomatology. Chemical analyses so far have failed to detect any endorphins, normal or abnormal, in the hemofiltrates of either the two patients or two normal controls (sensitivity 30 pmol/L).


Effects of glucose dehydrogenase in converting urea and ammonia into amino acid using artificial cells.

A microencapsulated multienzyme system containing urease, glutamate dehydrogenase and glucose dehydrogenase has been used to convert urea and ammonia into an amino acid. The effect of two different glucose dehydrogenases was studied in detail. High-specific-activity glucose dehydrogenase requires minimal cofactor and glucose and can greatly facilitate the further development of this approach for possible clinical applications.


Biochemical, hematological and histological changes in a fulminant hepatic failure rat model for artificial liver assessment.

Galactosamine-induced fulminant hepatic failure rats have been used as a model for statistical assessment of liver support systems. The present study reports in detail the biochemical, hematological and histological changes in these animals. They have been used to study statistically the effects of ACAC charcoal hemoperfusion, cross-circulation and liver perfusion on long-term survival in fulminant hepatic failure.


Present status of the hemofiltration/molecular separation artificial kidney.

The hemofiltration/molecular separation (HFMS) artificial kidney concept, first proposed over a decade ago, involves continuous ultrafiltration from the blood stream followed by cleansing of the filtrate, with subsequent return to the body. Thus, the system is completely self-contained and portable. During recent preclinical trials on nephrectomized canines, HFMS was better than hemodialysis (HD) in several important ways. First, the removal or clearance of middle molecules was better with 0.34 m(2) HFMS than with 1 m(2) HD. Significant phosphate clearance was achieved, and the removal rate for creatinine was the same as that for urea. This uniform clearance extends to even higher molecular weight solutes and could potentially result in improved patient response. It mimics the real kidney, whereas membrane-limited dialysis undergoes a logarithmic decrease of clearance with molecular weight. This is due to the fact that solute transport through the membrane involves solution into its matrix followed by diffusion, and solute diffusivity decreases with molecular volume. In order to achieve this potential for hemofiltration-based systems, however, there are stringent requirements on both the membrane and the plasma proteins allowed to accumulate on the membrane surface.


Low-dose heparin in routine hemodialysis monitored by activated partial thromboplastin time.

To evaluate the use of the activated partial thromboplastin time (APTT), as measured by the Coag-A-Mate semi-automatic unit, in lowering the dosage of heparin in stable chronic hemodialysis patients, four protocols for anticoagulation were utilized. Ten patients were dialyzed five times with each protocol. In protocol I, clotting time was performed baseline, 2 and 4 hours and in protocol II, baseline and every 30 minutes, with heparin administered by bolus to keep the clotting time at 2-2 1/2 times normal. In protocols III and IV the APTT was performed every 30 minutes, with heparin given by bolus in protocol III and infusion in protocol IV, to keep the APTT 1 1/2-2 times normal. Protocol I required 6000 +/- 543 U of heparin with the dose decreasing significantly to 3694 +/- 158 U in protocol II, 2634 +/- 139 U in protocol III and 2013 +/- 117 U in protocol IV (P less than 0.05- less than 0.001). Three episodes of clotting occurred, one in protocol III and two in protocol IV. There was no bleeding, and clearances of urea, creatinine, phosphate and uric acid at 1 and 5 hours were similar in all protocols. APTT, as measured by the Coag-A-Mate unit, provides a simple means of lowering heparin requirements in routine dialysis patients.


Heparin allergy accompanying acute renal failure.

A generalized cutaneous hypersensitivity reaction to a porcine heparin preparation was observed in a patient during the course of acute renal failure. Immunological studies, including gel diffusion and immunoelectrophoresis, suggested that the reaction was to a contaminant of the heparin and involved both IgG and IgE antibodies.


Biological reactors as renal substitutes.

The concept of using natural biological reactors for renal support has been investigated. Normal urine was used as the source of urinary wastes. Quantities of nitrogenous wastes approaching those produced in renal failure patients have been removed in batch reactors. Mixed strains of microorganisms are required. While further studies are required, it is conceivable that biological reactors can be useful in combination with other technologies in the design of future treatment modalities for renal failure.


Plasma administration to defibrinogenated dogs during extracorporeal circulation.

Plasma, in an amount corresponding to 0.05 gm fibrinogen/Kg of body weight, was administered during one hour to defibrinogenated dogs subjected to extracorporeal circulation. Four blood filters included in the extracorporeal circuit were removed one by one at 30-minute intervals. The prefilter pressures rose gradually during the whole experiment. Scanning electron microscopy of the filter surface revealed equal amounts of deposits before, during and after the infusion of plasma. Only minimal amounts of fibrin were found on the filter surfaces by immunoelectrophoresis. Mean arterial pressure, arterial blood gases, fibrinogen concentration, platelet count and leukocyte count were followed before, during and after plasma infusion and showed no significant changes. Thus, it is possible to administer limited amounts of plasma to defibrinogenated dogs subjected to extracorporeal circulation.


Use of plasma polymerization for preparing silicone-coated membranes for possible use in blood oxygenators.

The plasma polymerization of hexamethylcyclotrisiloxane (D3) and octamethylcyclotetrasiloxane (D4) over the microporous polypropylene membrane Celgard 2400, over polypropylene filter membranes, and over glass slides was investigated. The rate of polymer deposition was dependent upon the location of the substrate materials in the reaction vessel. The increase in weight of all the substrates was linear with the time of reaction, indicating a uniform polymerization rate. The rate of polymer deposition over polypropylene filters was found to be 2.27 micrograms/cm(2)/min for both D3, and D4, whereas over the glass slides it was 1.53 and 1.87 microgram/cm(2)/min for D3 and D4, respectively. The coated Celgard membranes showed better blood compatibility that Silastic sheeting or glass.


Pathogenesis of transient ischemic attacks within the vertebrobasilar arterial system.

Regional cerebral blood flow (rCBF) was measured by xenon 133 inhalation in 36 patients with vertebrobasilar arterial insufficiency (VBI), three patients with brain stem infarction, and 15 age-matched normal controls before and after inducing postural hypotension. Probes mounted over the suboccipital area by means of a helmet were used to measure rCBF over the brain stem and cerebellar regions. When lying flat, rCBF values measured over both cerebral hemispheres and the brain stem-cerebellar regions in patients with VBI were not significantly different from normal controls. Unlike carotid transient ischemic attacks, regional flow reduction rarely persisted for three weeks after transient ischemic symptoms in patients with VBI. When postural hypotension was induced, rCBF became significantly reduced in patients with VBI whether or not they were treated with papaverine. Dysautoregulation was restricted to vertebral, basilar, and posterior cerebral arterial distribution in patients with VBI of 1 to 12 months' duration, but was more widespread and involved both cerebral hemispheres in long-standing VBI. Hemodynamic factors and dysautoregulation appear to play a part in the pathogenesis of symptoms of VBI.


Wernicke's and global aphasia without alexia.

It has been proposed that the comprehension of written language requires transcoding from the visual (grapheme) to the auditory (phoneme). It has also been proposed that visual word images can be comprehended without grapheme-phoneme transcoding. We describe three aphasic patients with left hemisphere impairment who had poor speech comprehension but could comprehend written language. One of these patients had a subsequent right hemisphere lesion and lost his ability to read. We propose that the right hemisphere in some individuals may be capable of extracting semantic information from iconic images (ideogram) without phonological processing.


Dominant language functions of the right hemisphere? Prosody and emotional gesturing.

Two patients lost the ability to impart affective qualities to their speech following lesions in the right hemisphere. Arguments are given to support the idea that the right or "minor" hemisphere has a dominant role in modulating the affective components of speech. The anatomical organization of the cortical areas subserving affective speech in the right hemisphere seem to be similar to the organization of cortical areas subserving propositional speech in the left or "major" hemisphere.


Visual-motor adaptation. Quantitative demonstration in patients with posterior fossa involvement.

Short-term visual-motor adaptation to magnifying spectacle lenses was studied in normal subjects and in patients with nonacute posterior fossa lesions. When normal subjects, looking through magnifying lenses, pointed open loop to targets without viewing their hands, they initially underestimated the distance (magnification effect). After a 20-minute close-loop training or adaptation exposure period during which they viewed the performance of their hands, a modified visual-motor scheme evolved, compensating for about half of the lens-induced pointing error (adaptation effect). Removal of the lenses after adaptation caused open-loop, overshooting pointing errors (adaptation after-effect). Four patients with remission of cerebellar signs showed normal visual-motor adaptive performance, evidence of ability to recalibrate gain. One patient with persisting cerebellar ataxia was unable to recalibrate gain during close-loop visual-motor training. His history of transient palatal myoclonus implicates a role for the cerebellar-olivary system in calibration of visual-motor gain.


Bilaterally recorded brain stem auditory evoked responses. Their asymmetric abnormalities and lesions of the brain stem.

Simultaneous bilateral recordings (C3 to A1 and C4 to A2) of brain stem auditory evoked responses have been studied in 67 supratentorial lesions, nine midbrain lesions, 21 intrinsic pontine lesions, and 23 extrinsic compressions of the pons. The responses in supratentorial lesions showed completely normal records. In midbrain lesions, wave V was specifically altered. As wave 1 has been shown to be a far-field seventh nerve potential, and wave V the midbrain potential, waves II to IV can be inferred to originate in the central auditory pathway between the seventh nerve and the midbrain. Alterations of waves II to IV correlated well with localization of pontine lesions, and asymmetric alterations of the bilaterally recorded responses were associated with unilateral lesions of the brain stem auditory pathway and/or lesions of the crossed auditory projections.


Visual evoked responses in pernicious anemia.

We describe three newly diagnosed and untreated cases of pernicious anemia (PA) with clinical features suggestive of subacute combined degeneration. Visual evoked responses (VERs) were evaluted in all three patients. In each instance, delayed responses were obtained, suggesting that involvement of the visual pathways may be an early and perhaps not uncommon manifestation in PA, even in the absence of clinical stigmata of visual impairment. The need for excluding PA in cases of myelopathy with impaired VERs is stressed.


Acute anterior myelitis complicating West Nile fever.

A healthy young man developed acute anterior myelitis resembling the "polio syndrome." He had visited an area (the Gulf of Suez) in which West Nile fever is endemic prior to his illness. The course of his febrile illness, the spinal fluid findings, and complement fixation antibody titers established the diagnosis of West Nile fever. Meningoencephalitis is a serious, and previously the only known, complication of this usually benign febrile illness. This is the first report, to our knowledge, of another neurological complication, namely acute anterior myelitis.


Delayed meningitis following stapes surgery.

Perilymphatic fistulae, developing even years after stapedectomy, open a communication between the perilymph and middle ear. These fistulae constitute a potential pathway for flora of the middle ear to invade the subarachnoid space by way of the cochlear aqueduct. Our patient developed pneumococcal meningitis 14 months after stapedectomy. The history of stapedectomy in a patient with meningitis is an indication for reexploration+ion of the operative site. The appearance of fistula symptoms in patients who have had stapedectomy indicates a high risk for development of intracranial infection.


Electroencephalographic absence status with minimal behavior change.

Difficulty in correlating EEG abnormalities with clinical seizures is emphasized in this case report of an epileptic patient with electrical status epilepticus and normal behavior. In addition, the usefulness of dichotic listening tests in the identification of subtle perceptive and expressive impairments is illustrated in this same patient at a time of noncompliance with anticonvulsant therapy.


Conservation surgery in laryngeal cancer and its role following failed radiotherapy. A histopathological and clinical study of 32 cases.

The partial laryngectomy specimens from 32 patients with laryngeal carcinoma were histologically examined by the technique of whole organ sectioning. Twenty-three of these patients had previous irradiation therapy. We identify local criteria for performing conservation laryngeal surgery based on clinical and histopathological studies. These criteria are borne out as success or failure, and outcome could be accurately predicted when adhered to. The salvage rate for patients receiving conservation surgery after failed radiotherapy was 60%, while 43% retained a functional larynx.


Quantitative relationships of the ototoxic interaction of kanamycin and ethacrynic acid.

We determined the range of doses of kanamycin sulfate and ethacrynic acid that results in an ototoxic interaction in guinea pigs. In addition, we determined the time interval between the administration of the two drugs that is needed to produce this interaction. In all cases, the magnitude of the ototoxic lesion was determined by measuring the cochlea's ability to generate both the sensitivity and intensity functions of the ac cochlear potential. In addition, the cochlear pathologic conditions, as determined by counting the number of missing hair cells in the organ of Corti, was found to correlate highly with the ac cochlear potential data. The dosage range of ethacrynic acid during which the interaction occurs is very narrow, while the dose range of kanamycin is very large.


Argon laser in human tympanoplasty.

We describe the use of an argon laser in human tympanoplasty. The laser was used in two different ways: (1) to stop the bleeding of small vessels in the external auditory channel and eardrum remains; and (2) to spot-weld the new eardrum graft in the proper position. Seven operations were performed. We report the results.


Management of the flap tracheostomy. An experimental study.

The flap tracheostomy was studied in 25 adult canines to further investigate its best management. Tracheostomies were performed by employing the inverted U flap incision in the trachea. After decannulation, the flap was either formally resewn to the trachea, bluntly dissected from the surrounding soft tissues, or left in place. The time required for epidermal closure over the tracheostomy site was measured, along with fixation of skin to soft tissues in the area. Histologic examinations were made, and tracheal dimensions were calculated on sections through the stomal area. More rapid skin closure and less soft tissue fixation occurred in animals that underwent resuturing or release of the tracheal flap. In all groups, cartilage viability and regrowth were noted. Tracheal diameters were maintained in all groups, but smoother contouring was seen with resuturing. Additional support for the flap tracheostomy is provided from this animal experimentation.


Nasolacrimal obstruction after maxillary sinus and rhinoplastic surgery.

Transient nasolacrimal obstruction is a common complication of maxillary sinus, as well as rhinoplastic surgery. Permanent epiphora, however, is unusual. This communication describes 11 patients with surgical injury to the lacrimal drainage system, which necessitated dacryocystorhinostomy for correction. Seven of these cases occurred subsequent to nasoantral window procedures, three occurred after rhinoplasty, and one resulted from a partial maxillectomy. It has been shown that the two areas most vulnerable to inadvertent surgical injury are the nasolacrimal sac, located just beneath the medial canthal ligament, and the ductal ostium in the inferior meatus. We discuss the relevant anatomy of the nasolacrimal apparatus, in addition to surgical methods for avoiding injury to the system. We also describe the currently applied techniques for diagnosing and managing lacrimal obstruction and review the literature.


Neurogenic sarcoma of the head and neck.

We discuss our experience in the diagnosis and management of seven cases of neurogenic sarcomas of the head and neck. These uncommon tumors, which affect all ages, arise most frequently from the brachial plexus, sympathetic chain, and the cranial nerves or their branches. An enlarging mass is the most common initially appearing symptom. Diagnosis may be difficult and rests heavily on gross evidence of a relationship between the tumor and its nerve of origin. Histologically, the lesions are composed of spindle cells with varying degrees of pleomorphism in a pattern that is frequently undistinguishable from fibrosarcomas. Ultrastructural studies may be helpful in establishing the neurogenic origin of these tumors. Neurogenic sarcoma of the head and neck has an extremely poor prognosis. Surgery remains the cornerstone of treatment, although radiotherapy is important for palliation.


Auditory dysfunction with facial paralysis.

A series of 58 patients with idiopathic facial paralysis were studied to determine if a concomitant cochlear or eight nerve auditory dysfunction could be identified with traditional audiologic tests. Results indicated that only those patients with a facial nerve lesion, proximal to the stapedius branch, experienced reduced tolerance for loud sounds, reduction of speech discrimination at high-intensity levels, and abnormal loudness growth. Such findings suggest that changes in auditory function, accompanying facial nerve paralysis, are a mechanical effect due to absence of stapedial action. Site of lesion tests in this sample failed to demonstrate eighth nerve dysfunction and, thus, does not support a theory of polyneuropathy that involves the auditory nerve.


Evaluation of frontal sinus fractures.

Forty-six instances of frontal sinus fracture were reviewed to determine the factors that are important in the initial clinical and radiologic evaluation. Associated injuries, the appearance of the forehead, and roentgenographic studies were all considered. Polytomography is the most accurate diagnostic technique and is justified in all patients. The otolaryngologist must examine all roentgenograms personally, with particular attention paid to the nasofrontal duct region and to the magnitude of depression of fracture fragments.


Abscess of the lingual tonsil.

Abscess of the lingual tonsil is an unusual entity that may cause diagnostic difficulty. The pathophysiologic mechanism of formation was correlated with normal posterior tongue histology in a case of lingual tonsillar abscess.


Calcifying odontogenic cyst of the maxilla.

Large cystic lesions of the maxillary sinus may initially manifest with malocclusion, cosmetic deformity, or both. Their origin may be odontogenic or nonodontogenic. Proper diagnosis of these cysts immeasurably aids in adequate (nonmutilating) treatment. A recent case of a calcifying and keratinizing odontogenic cyst that initially manifested as a facial mass exemplifies the need for adequate clinical and histological diagnosis to ensure appropriate treatment. Fewer than 35 cases have been reported since the original description in 1962.


A technique for stroboscopic examination of the vocal folds using fiberoptics.

An improved fiberoptic laryngoscope is connected to Timcke's stroboscope. The laryngoscope gives a magnified view of 2x and is prefocused from 5 cm to infinity. The combination of the stroboscope and the laryngoscope gives an excellent slow-motion view of the vocal fold movement.


Persistent pharyngeal membrane.

A 39-year-old man was examined for a severe speech impediment that was first noted in early childhood. Otolaryngologic examination demonstrated a membranous structure confluent from anterior pillar and from the soft palate to the base of the tongue. A review of the literature reveals this to be a persistent pharyngeal membrane, which is a rare congenital anomaly.


Voluntary nystagmus masquerading as Tullio's Phenomenon.

Nystagmoid eye movements elicited by humming loudly was initially misdiagnosed as Tullio's phenomenon (abnormal acoustical stimulation of the vestibular apparatus owing to labyrinthine fistula). Further workup lead to a final diagnosis of a form of voluntary nystagmus characterized in some reports as "hysterical mystagmus". Some of the characteristics of this example of voluntary nystagmus differed from generally accepted descriptions.


Alteration of oxidative enzymes (LDH and MDH) in perilymph after noise exposure.

Chinchillas were exposed to noise (123 dB, 1/2 h, 700--2800 Hz). The activity of lactate dehydrogenase (LDH) and malate dehydrogenase (MDH) was studied immediately after exposure or 1, 7, 14, 21, or 28 days later. LDH activity in perilymph doubled immediately after exposure, gradually decreasing to control values in about a month. The activity of MDH not only doubled immediately after the exposure but continued to rise for at least another 24 h, reaching a peak value of 3.5 times normal at 24 h. The activity was still 1.6 times normal even after a month of recovery. The enzyme activity of serum and CSF remained within the control range throughout the experimental period except for an initial increase of serum enzyme activity due to anesthetic. The results demonstrate that the morphological changes induced by a noise exposure that is known to produce permanent threshold shift (PTS) are reflected in a significant elevation of oxidative enzymes in perilymph. Possible mechanisms of the elevation of enzymes in perilymph are discussed.


Brain-stem responses of the cat and interaural attenuation.

The early auditory evoked responses have been studied in bilaterally hearing cats, and in animals with hereditary unilateral anacusis. Cross-over stimulation of the hearing ear occurs at an interaural attenuation of 50--50 dB, and all six waves of the responsare present at supra-threshold stimulus levels.


Electron microscopical and histochemical studies of outer hair cells in acoustically exposed rabbits.

After acoustic exposure, in the infranuclear region of the basal turn histochemically the lactate dehydrogenase activity increased more than normal. In the lower half of the second turn of this region, small vesicles, free ribosomes and coated vesicles decreased in number and cytoplasmic matrix become lower in electron density and lactic dehydrogenase activity decreased. Small vesicles were found to be preferentially distributed in the presynaptic side of the afferent nerve endings. Movement of these small vesicles leads to the speculation that small vesicles have close relationship to the afferent nerve endings.


[Time resolution ability in dichotic hearing experiments (author's transl)].

Concerning auditory analysis of speech signals time resolution is one of the most important ability of the hearing system. In psychoacoustic experiments with dichotic represented bursts of noise the detection and time resolution of short changes of interaural time delay and noise coherence are investigated. The results of normal and pathological binaural hearing are discussed and compared to other auditory time analysis experiments.


[The influences of hyperbaric oxygen (OHP) on the normal inner ear of guinea pigs. Simultaneous registrations of cochlea microphonics (CM) and nerve potentials (AP) (author's transl)].

Guinea pigs were treated with 3 bar oxygen pressure in a hyperbaric chamber and CMs and APs were simultaneously registrated. The results depended on the kind of the usual anesthesy. If nembutal i.p. was used, the CMs and APs had been increased significant shortly after oxygen pressure reached 3 bar (CMs increased more than APs). If urethane i.p. was used, the CMs and APs increases not so significantly. These results are traced back to the different effect of the both anesthetic drugs on the blood flow in the brain. Oxygen toxicity in the inner ear was observed after OHP of 3 bar more than 30 min but only by APs. The CMs didn't show any signs of oxygen toxicity under the same conditions during 60 min and more.


Simultaneous recording of fast and slow auditory evoked potentials (slow-fast-simultaneous-ERA, SFS-ERA).

In order to reduce measurement time we have used part of the interstimulus interval of the slow cortical responses to record fast brain stem responses. For this purpose we reconstructed a programmable audiometer and preamplifier which are controlled by a computer. These, with 1/4 ms-click and tone-burst stimulation simultaneously gained fast and slow responses, not only give a frequency-related view of the threshold and the kind of hearing loss--because of amplitude and latency--, but also in some cases--because of differences between both responses--give ideas of the possible location of the hearing impairment through the auditory pathways. The audiological value of this new method is discussed and explained by giving examples of two interesting cases, one central-neural hearing loss and one questionable aggravation.


Cochlear otosclerosis. A continuing fantasy.

Sensorineural hearing loss without an associated conductive loss cannot be attributed to otosclerosis.


Speech audiometry by a speech synthesizer. I. A preliminary report.

A preliminary report on speech test results with a portable, text-to-speech synthesizer is presented. The differentiation scores achieved at speed 80 words/min vary. So far the best mean differentiation scores in normal material are 75%. The increase of the presentation level improves the differentiation score, as does the decrease of word speed and training. The future and present uses of this system are discussed. These include: devices for the handicapped, e.g. to produce speech for the mute, man-machine communication through speech in industry control, data processing systems and uses in audiological diagnostics. The study is continued.


The effect of the click repetition rate on the latency of the auditory evoked brain stem response and its clinical use for a neurological diagnosis.

The effects of click repetition rate on the latency of the auditory brain stem responses (BSR) and its possible use as a clinical diagnostic tool of the brain stem disorders were investigated. When the click rate was increased, the latency of the BSR waves was prolonged. The latency of the later response components increased more than that of the earlier response components. This method was applied to the clinical cases with brain stem disorders. A case with a IVth ventricle epidermoid tumor showed a marked latency prolongation and disappearance of the waves at higher repetition rates. An explanation of the latency shift in the normal subjects and the abnormal responses of the patient to repetition rate is attempted.


Surgical treatment of the infected preauricular sinus.

Preauricular sinus is a frequent occurring congenital abnormality (circa 0.25% in the white race), but gives mostly no symptoms. In a certain amount of cases symptoms can arise as recurring purulent secretion or a preauricular abscess. If the disease is recognized an adequate therapy can be accomplished. Sometimes the disease is not recognized and diagnosed as a sebaceous cyst or a furunculus. Also, if the sinus is recognized, it is necessary not to underestimate the disease. In several clinical studies a recurrencerate of 15--33% is quoted. Singer published in 1966 a technique of extirpation of the infected preauricular sinus with excellent results. This technique was adopted with addition of the use of the operating microscope. In nine patients with an infected preauricular sinus extirpation in toto was accomplished in a silent period. Under these nine patients were two recurrences after previous inadequate surgery. After a minimal follow-up of 2 years the patients were symptom-free. The quoted technique of extirpation of the infected preauricular sinus in toto seems to be an improvement for the therapeutic armamentarium.


Reliability of slow vertex response audiometry in young children with sensorineural hearing loss.

In order to supplement our previous report on the reliability and validity of slow vertex response (SVR) audiometry, the detectability of the response, the agreement among scorers and test-retest reliability were studied in 6 children aged 2-4 years who have sensorineural hearing loss of 60-75 dB for the test frequency (1 000 Hz). Mean percentage of positive response increased from 20.6 to 62.2% as stimulus intensity was increased from 60 to 80 dB. Such a sharp increase in the detectability of the response at a level of stimulus intensity close to the auditory threshold of the subjects was not observed in normal children. The results indicate that SVR audiometry is more reliable and valid in children with sensorineural hearing loss than in normal children.


How do you recognize allergy?

A suggested basic approach to the diagnosis of allergic diseases, which involves the characteristics of allergic diseases themselves, is presented. Using these characteristics as basic guidelines in investigation, not only should the condition be diagnosed but main cause or causes and triggering factors should be demonstrated in individual patients. Investigational procedures ranging from history, and including simple skin tests and more sophisticated immunological investigations, are briefly analyzed and it is stressed that if a really adequate allergic investigation of all patients with suspect allergic disease is carried out in an effort to demonstrate and subsequently control all causes and triggering factors, then development of chronic disease, sometimes intractible to our standard methods of therapy, could well be prevented in many cases.


[Auditory fatigue in man. Comparison of recovery at threshold and above threshold].

Using a 1 000-Hz pure tone, a TTS2 of 20 dB was produced in a group of subjects. Recovery from this TTS was studied at 1 500 Hz and the measurements were extended to 320 min to encompass the course of recovery, The recovery of the temporary impairment of threshold was plotted concurrently with that of the temporary masked threshold shift (TMTS) of the 1 500 Hz tone in the presence of a 700 Hz masking tone. This technique provided an indirect measurement of loudness loss at 10. 20, 30, 40, 50 and 60 dB SL. The time required for complete recovery depended upon whether one measured TTS or TMTS; the longest recovery times were, in respect of the masked threshold, at low sensation levels.


Critical bandwidth in patients with a hearing loss induced by salicylates.

During a slight temporary salicylate-induced hearing loss, the normal loudness difference between broad-band noise and narrow-band noise was markedly reduced at all levels, except the highest. The critical band, measured at 1 kHz by means of a loudness summation method, appeared to become wider in 9 out of 16 subjects, to a degree roughly proportional to the degree of hearing loss. However, some discrepancies in the data and a rather large intersubject variability of the loudness estimates were present. The localization of the mechanism which forms the basis for the critical band concept is discussed in view of the results.


An overall approach to treatment of allergic disease.

Allergy as a scientific term, and clinical allergy are two different things. Confusion as to what is meant by 'allergy' depends significantly on an illogical omission to name a level of reactivity which pertains to a cell or tissue prior to augmentation of that level by an allergic reaction. Hyper-reactivity is suggested as a term denoting raised non-specific reactivity pertaining to the inherent reactivity of cells, as distinct from excessive reactivity induced by specific antigenic enhancement. Some of the implications of discrimination between these qualities have been mentioned so far as impact on the assessment and treatment of clinically allergic subjects is concerned.


Hearing results after vestibular neurectomy.

After a general review of the actual histopathological concept of Menière's disease, a review of the results, as concerns hearing, of the selective section of the vestibular fibers by the suboccipital approach, and of vestibular neurectomy by the middle fossa approach is made. From our personal experience in performing 247 neurectomies from November, 1969 to July, 1976 as treatment for peripheral vertigos of different etiologies, auditory function was followed-up in 78 cases of Menière's disease, with a postoperative control, between 2 and 6 1/2 years. In 51% of these cases the preoperative threshold was preserved, hearing improved in 32%, and deteriorated in 17%. Possible mechanisms by which vestibular neurectomy can favorably influence hearing are considered, with special mention of the neurovegetative theory.