Doppler ultrasound examination of pathologically enlarged lymph nodes.

Pathologically enlarged lymph nodes have been examined with a commercially available 10 MHz continuous-wave Doppler flowmeter. Many enlarged lymph nodes gave rise to significant Doppler-shift signals indicating increased blood flow. The signals have been spectrum analysed and the large diastolic flow components suggest that there is considerable arterio-venous shunting within lymph glands involved in leukemia, lymphoma and carcinoma. It also seems that the signals tend to diminish in response to treatment. The Doppler signals have been used in an imaging system to produce a vascular map of the region of the enlarged gland. It is suggested that these findings might be applicable to the detection of neoplastic tissues in less accessible sites.


The effect on dosimetry of changing from the lithotomy to the supine position in treating uterine cancer with the Cathetron and external radiotherapy.

Uterine carcinoma can be treated by combined external and intracavitary irradiation. With an afterloading technique intracavitary irradiation is given with the patients in the lithotomy position. External irradiation is given with the patient in the supine position. A lead shield is used with the external fields to cover the tissues which are close to the intracavitary sources and receive high doses. The positions of the intracavitary sources seen on radiographs taken when the patient is in the lithotomy position are transferred to films taken with the patient in the supine position. From the latter the position and profile of the shield are calculated. It is shown that a reliable transfer of the positions of the sources and determination of the necessary shielding cannot be achieved in this way. It is therefore concluded that both intracavitary and external irradiation should be carried out with the patient in the supine position.


A computerized three-dimensional treatment planning system utilizing interactive colour graphics.

A new computerized radiation treatment planning system has been developed to aid in three-dimensional treatment planning. Using interactive colour graphics in conjunction with a DPD 11/45 computer, the system can take multiple transverse contours and construct a perspective display of the treatment region showing organ surfaces as well as cross-sectional contours. With interactively selected orientations, the display allows easy perception of the relative positioning of the treatment volume and neighbouring anatomy. For external beam treatment planning, interactive computer simulation is used to select diaphragm sizes which best conform to the target area while avoiding sensitive structures. Dose calculations for the selected beams are carried out on multiple transverse planes. The calculational planes and surfaces are displayed in perspective with radiation dosage displayed in an interactively manipulated colour display. Altogether the system provides an easy assessment of the volume to be irradiated, interactive selection of optimal arrangements of treatment fields and a means for visualizing and evaluating the resulting dose distributions.


The dose in water surrounding point isotropic gamma-ray emitters.

A Monte Carlo method has been used to calculate the dose distribution around point gamma-ray emitters in water. Five gamma-ray emitting radionuclide, 60Co, 137Cs, 192Ir, 198Au and 226Ra, which are commonly used in radiotherapy interstitial implants have been considered. The results are in substantial agreement with those derived using a combination of experimental and theoretical data.


Lack of correlation between villus and crypt damage in irradiated mouse intestine.

It has been observed that scanning electron microscopy is a more sensitive indicator of mucosal damage at low radiation dose levels than conventional quantitative crypt counting techniques. Three different fractionation schedules were subjected to investigation by both of these methods to try to elucidate some features of irradiation damage to the whole of the intestinal mucosa, at dose levels commonly used in clinical practice. Despite variations in the qualitative observations, there was a marked difference in two of the schedules between damage expressed as crypt counts and that described by the qualitative techniques. In the first case high crypt numbers were associated with severe mucosal damage, whereas the second schedule produced a reduced crypt count in association with low damage to the surface mucosa. A third schedule produced results in which there was a general agreement between low crypt numbers and considerable surface mucosal damage. However, observations were made of mucosal formations not previously seen on damaged mucosal surfaces. These resembled the appearance normally associated with the gut of patients suffering from coeliac disease. Variations in the qualitative observations were seen in all the schedules so that their interpretation in terms of perturbation of cellular kinetics is difficult.


OER and RBE for negative pion beams of different peak widths.

Experimental data on survival curves for pion because of different peak widths under aerobic and hypoxic conditions are reported. Metabolic depletion of oxygen by the Chinese hamster cells (line V79) was used to obtain hypoxia. The results indicate that the RBE at the beam entrance (plateau) is approximately 1.0. When the Bragg peaks were broadened to widths of 1.3, 7.8, and 10.5 cm (at the 80% dose level), the RBE (50% cell survival) at the peak centres was 1.7, 1.6, and 1.2, respectively. The OER at the entrance was 2.4 compared with about 2.9 for X rays. The OER was independent of the survival level at which it was measured. The OER at the peak centres at widths of 1.3, 7.8, and 10.5 cm was 2.1, 2.4, and 2.2, respectively. These results indicate that, although the RBE at the centre of the 10.5 cm wide peak was significantly lower than at the centres of the 1.3 and 7.8 cm peaks, the OER values are similar for all peak widths used in this study.


Selective angiography in renal and peri-renal inflammatory lesions: correlation with histopathology.

We have correlated the angiographic and pathological findings in renal and peri-renal inflammatory disease in acute, sub-acute and chronic phases. In all stages of renal infection, the renal vasculature is attenuated. This corresponds in acute inflammation to vasospasm, acute vascular necrosis and post glomerular peritubular capillary congestion. In sub-acute inflammation, the reduction in vascularity is due to peri-vascular fibrosis and intimal and medial hyperplasia. In chronic infections, the renal vessels are completely destroyed and replaced by fibrotic tissue. In contrast to this, peri-renal inflammatory disease leads to vaso-dilatation and enlargement of the renal capsular arterial complex, and of retroperitoneal arteries. If both renal and peri-renal inflammation occurs simultaneously, a discordance between the renal cortical and capsular arterial filling results: this striking phenomenon is highly suggestive of inflammation, and extremely rare in tumours. Three types of inflammatory vascularity are described, two of which can be easily distinguished from tumour vascularity. An inflammatory blush, slow emptying of vessels and a mottled nephrogram with loss of cortical definition are highly suggestive signs of renal inflammation. It is concluded that angiography is a sensitive and accurate method for the early diagnoses of renal and peri-renal flammatory conditions.


Bronchial artery embolization in the control of massive haemoptysis.

Bronchial artery embolization is a useful palliative treatment for life-threatening haemoptyses where surgery is contra-indicated. Patients presenting with haemoptyses complicating cystic fibrosis and aspergilloma have been embolized. Control of haemoptysis was achieved in the former, but late recurrence of haemoptysis in the latter led to asphyxiation.


Pancreatic ultrasound--a systematic approach to scanning technique.

The pancreas remains one of the more difficult organs to visualize but ultrasound can be successful in nearly 90% of patients. A systematic technique for identifying and delineating the pancreas is described and has been verified on over 500 patients to date. The success of the technique depends on an accurate knowledge of the vascular relations of the pancreas and on correct adjustment of the ultrasound equipment. This paper is intended to help ultrasound practitioners achieve both these ends.


NSD and cell survival.

The relation between the NSD concept and cell survival in fractionated irradiation is established; the slope of Strandquist's lines is related to the shape of survival curves for the given type of cells and radiation. A new parameter, CBE, derived from TDF for determining cumulative biological effect is proposed.


Urinary inhibitors of calcium phosphate formation: the inhibitory activity of normal and artificial urines.

Eelven urine samples from normal subjects inhibited the formation of calcium phosphate. In all cases the activity of the urine was identical with that of an artificial urine having the same concentration of urea, creatinine, sodium, potassium, magnesium, calcium, ammonia, sulphate, chloride, inorganic phosphate, citrate, isocitrate and pyrophosphate, and the same pH.


Diuresis renography and morphology in upper urinary tract obstruction.

The results of a combined study of 25 patients with idiopathic hydronephrosis are presented. Diuresis renography was performed pre-operatively and surgically removed specimens of the renal pelvis and ureter were examined by light and electron microscopy. There was good correlation between the results of these 2 methods of assessment which have defined 2 broad categories of patients with renal pelvic dilatation. These findings are discussed with particular reference to the clinical value of diuresis renography.


The intravenous urodynamogram.

Modifications to the intravenous urogram are described. It is suggested that the time has come to rationalise the standard procedure. If an evaluation of the lower urinary tract is required, the voiding films may be modified to provide an intranvenous urodynamogram. If an evaluation of the upper urinary tract is directed at a specific question, then the number of spot-films can often be reduced.


The role of internal urethrotomy in the prevention of urethral stricture following transurethral resection of prostate.

Urethral stricture is the commonest late complication of transurethral prostatectomy. Although internal urethrotomy is widely practised to prevent structures, there are no reports of any controlled trials of the procedure. A prospective trial of internal urethrotomy, using the Otis urethrotome, in 210 consecutive transurethral prostatectomies is presented. Patients were divided into 2 groups, those undergoing urethrotomy before TUR ("Trial group") and those undergoing TUR without urethrotomy ("Control group"), and they were followed for a minimum of 6 months. The incidence of stricture in the control group was significantly greater than in the trial group (P less than 0.01). Analysis of all other variables revealed no difference between the 2 groups and it is concluded that internal urethrotomy does prevent stricture formation and that it should be undertaken routinely before transurethral resection.


Conservative treatment of carcinoma of the penis.

Sixty-five cases referred to one hospital between 1964 and 1977 were studied. Forty-one presented in Stages 1 or 2 and when treated by the Iridium mould technique gave a 12/13 (92.3%) crude 5-year survival rate, an improvement over the results of previous methods of treatment, including partial amputation. In Stage 3 radical amputation gave an 89% 5-year survival rate. Node dissection was reserved for inguinal nodes in Stages 1, 2 and 3 which failed to resolve after treating the primary tumour. Undifferentiated tumours and those with the microscopic "cord" pattern of growth did badly.


Experience wiht vasovasostomy: operative technique and results.

Between 1972 and 1977 vasovasostomy to reverse a previous vasectomy for contraception has been attempted in 27 cases. The procedure was abandoned as a technical impossiblity in only 1 case. The first 17 have been studied and in these there have been 11 pregnancies, 10 of which have already come to term with the birth of normal children, including one set of twins. Of the remainder, 2 are known to have oligozoospermia and 4 have been lost to follow-up although 2 of these were euspermic when last heard of. In spite of the encouraging results it is considered that there are no grounds for altering the present basis of vasectomy counselling in which the operation is described as likely to be irreversible.


Oestrogen-induced renal carcinoma.

Oestrogen may be implicated as an aetiological factor in the development of some renal carcinomas in man. The development of a renal carcinoma in 2 patients who had been treated with low-dose oestrogen for periods of 3 and 3 1/2 years because of prostatic carcinoma is described. It is suggested that patients receiving prolonged oestrogen therapy should be evaluated for the presence of a renal carcinoma at regular intervals.


Vesicoureteric reflux with urethral valves.

A retrospective review was undertaken of 66 boys with posterior urethral valves with regard to incidence and prognostic significance of vesicoureteric reflux. The results indicate that: Regardless of the age of the patient, the existence of bilateral reflux at the time of presentation implies a worse prognosis than does unilateral or no reflux. Reflux which does not stop spontaneously after the valves have been destroyed is generally associated with a functionless and often dysplastic kidney; surgical cure of such reflux is therefore pointless. Reflux stops spontaneously after valve ablation when the involved kidney possesses useful function; surgical cure of reflux is therefore unnecessary. In some cases, however, it remains possible that reflux may continue to damage the kidney during the interval between relief of the urethral obstruction and spontaneous cure of the reflux. Nevertheless, the grossly dilated refluxing ureter is poor surgical material and it is concluded that the best chance of preserving renal function in the majority of boys with urethral valves and reflux lies in endoscopic fulguration of the valves, controlling infection and awaiting spontaneous reflux cure.


End-to-end ureteroileal anastomosis for ileal conduits.

In the "Y" anastomosis, both ureters are spatulated and joined together to form a single tube which is anastomosed to the proximal end of the ileum. This technique has several theoretical advantages which appear to be borne out in practice when the results of its use in 101 patients followed for up to 12 years are reviewed. Only 2 anastomotic leaks needed operative treatment and only 4 patients developed ureteroileal stenosis. Renal function remained unchanged or improved in 84% of the patients, and definite hydronephorsis or pyelonephritis developed in only 4% of the kidneys. These results show that this method of ureteroileal anastomosis is at least as good as, and possibly better than, other techniques.


Urinary incontinence in the female. The value of detrusor reflex activation procedures.

One hundred consecutive female patients with urinary incontinence were investigated with CO2 cystometry including detrusor reflex activation procedures such as postural change and ability to suppress self-induced detrusor contractions. Detrusor hyperreflexia was seen in 20 patients during bladder filling in the supine position, and in an additional 35 patients after detrusor reflex activation procedures. Four different types of detrusor hyperreflexia are described based on the cystometric findings. In 38 patients treated with parasympatholytics, 66% showed a good result independent of the type of detrusor hyperreflexia.


The effect on erection and orgasm of cystectomy, prostatectomy and vesiculectomy for cancer of the bladder: a clinical and electromyographic study.

Forty-three men who had been subjected to cystectomy and concomitant prostatectomy, vesiculectomy and urethrectomy were interviewed about their pre-operative and post-operative sexual activities at a mean of 3 (range 1 to 8) years after operation. Twenty-eight of the 38 men (74%) who had been sexually active continued to have some form of sexual activity, 21 of them achieving orgasm. Only 3 men had penile erection; 2 of them had been subjected to prostatectomy and 1 to prostatic resection. One of these men treated by prostatectomy had also had urethrectomy. Electromyographic registration from the striated external urethral sphincter, the bulbocavernosus muscle and the levator ani muscle showed normal duration of muscular contractions and length of interval between contractions after operation. The pattern of impulses during organs did not differ from that of normal men.


Gelatin foam and isobutyl-2-cyanoacrylate in the treatment of life-threatening bladder haemorrhage by selective transcatheter embolisation of the internal iliac arteries.

Three patients with severe haemorrhage from inoperable bladder cancer were treated by selective transcatheter embolisation of both internal iliac arteries. The technical details, results and a rare complication are described. Both gelatin foam and isobutyl-2-cyanoacrylate (IBC) are suitable embolic materials, but we prefer IBC when possible in patients with tumour.


The assessment of prostatic obstruction from urodynamic measurements and from residual urine.

One hundred and seventeen males over the age of 55 were investigated for possible prostatic obstruction. About half of the cases in this series could have been objectively classified as unobstructed or obstructed from the maximum flow rate alone. In about two-thirds of the cases obstruction could be satisfactorily assessed from the maximum flow rate together with the detrusor pressure at maximum flow. It was not helpful to combine these 2 measurements into a single urethral resistance factor. In the remaining one-third of the cases, obstruction could be objectively assessed only from a plot of detrusor pressure against flow rate throughout micturition. In many of these cases both the pressure and the flow rate were low and the main peculiarity was that the contractile power of the bladder was weak. Residual urine is a sign of an abnormality of bladder function rather than the direct result of urethral obstruction.


Lateral curvature of the erect phallus without chordee.

Three cases of lateral curvature of the penis during erection are described. In no case was there evidence of chordee. A corrective operation for this condition is described.


Primary malignant melanoma of the penis. Two cases and a review of the literature.

Two cases of primary malignant melanoma of the penis are reported and 35 cases from the world literature are reviewed. The tumour most commonly started in the glans penis and less frequently from the prepuce. The microscopic appearances were identical with those of tumours arising elsewhere in the skin. A comparison is made between the incidence of melanoma of the penis and melanoma occurring elsewhere on the body surface. Evaluation of the best treatment was difficult because the total number of cases was small and the methods of treatment and results so variable. It would seem that the prognosis of malignant melanoma of the penis is generally poor, although there are sufficient examples of long-term survival after total amputation in Stage I disease to suggest that this radical treatment is justified.


Tumours of the testis in Jamaica.

Malignant tumours of the testis are reported to be rare in negroes. All cases reported in the records of the University Hospital of the West Indies and the Jamaica Cancer Registry over the period June 1958 to December 1976 were studied. There were 26 cases, giving a world standardised incidence of 0.40 per 100,000 per year. This incidence is higher than that seen in African negroes but lower than that of negroes in North America. The peak age incidence is a decade later than that commonly seen in high incidence countries.


The pattern of spread and treatment of metastases in testicular seminoma.

The results of treatment of 199 patients referred to the Royal Marsden Hospital with testiclar seminoma from 1963 to 1975 are described. Of 190 previously untreated patients 16 (8.4%) have died of seminoma, 3 (1.5%) of teratoma and 9 (4.9%) of intercurrent disease. Of 121 Stage I patients the only death was due to a second testicular tumour. In orchiectomy and volume of abdominal node metastases. This was not, however, prognostically significant. Death from seminoma occurred in 6 out of 38 patients (15.8%) with nodal metastases less than or equal to 5 cm in diameter and 3 out of 16 patients (18.7%) with metastases greater than 5 cm in diameter; 2 of 8 Stage III patients died of seminoma. Thus radiation controlled nodal metastases in more than 80% of Stage I, II and III patients. In Stage IV patients and patients referred with disease relapse, 12 out of 16 patients died of seminoma. Chemotherapy experience is briefly reviewed. Cyclophosphamide as a single agent has produced a 50% response rate. There is no evidence to suggest a radiation-related increase in mortality from the group of long-term tumour-free survivors.


Genetic associations of transitional cell carcinoma.

A series of 101 cases of transitional cell carcinoma (TCC) was contrasted with a control series for several genetic parameters. Three genetic associations were demonstrated with the TCC patients having A gene frequencies, HLA B5 and HLA CW4 genes all higher than might be expected by chance. A classification of the natural history of the disease is used to show that the HLA frequencies vary with the more or the less severe forms of the disease.


The value of large volume selective arteriophlebography of the renal veins in the pre-operative assessment of renal carcinoma.

The accuracy of large volume selective arteriophlebography in demonstrating the main renal veins in 28 patients with renal carcinoma is presented. The diagnosis was shown to be correct at operation in 96% of examinations. It is suggested that the technique is valuable and safe and should form part of the routine pre-operative assessment of patients with renal carcinoma.


Familial renal hypouricaemia: two additional cases with uric acid lithiasis.

Two families are reported affected with hereditary renal hypouricaemia associated with uric acid lithiasis. The propositi of both families were found also to have hyperabsorptive hypercalciuria. Based on the study of the effect of pyrazinamide and probenecid on uric acid excretion in both propositi, it is suggested that the defect in uric acid reabsorption is most probably at the pre-secretory site.


False-negative saralasin responses in renovascular hypertension.

Blood pressure responses to the infusion of saralasin and plasma renin levels were measured in 31 hypertensive patients following preparation with frusemide. Five patients had unilateral renal artery stenosis, with renal vein ratios lateralising strongly to the affected side. Saralasin produced depressor responses in 3 of these but failed to evoke significant effects in the other 2, despite the fact that in both cases hypertension was subsequently alleviated by renal bypass surgery. A further period of more severe sodium depletion increased plasma renin levels and the depressor effect of saralasin, but did not help to differentiate renal artery stenosis from other forms of hypertension.


An ultrastructural study on the effects of warm ischaemia on the inosine-protected kidney.

Unperfused, saline-perfused and inosine-perfused rat kidneys were subjected to various times of warm ischaemia with and without resumption of blood flow. Tissues were examined with a transmission electron microscope. Inosine has a protective effect on the epithelial cells of the proximal convoluted tubules, where microvilli are less damaged by ischaemia than those of the proximal convoluted tubular cells of the control animals. Three is also a much higher ratio of autophagic vacuoles to lysosomes present in cells of inosine-treated kidneys, reflecting their ability to sequester and digest organelles damaged during ischaemia and thus protect themselves from degradation products. A major effect of inosine seems to be the preservation of the organelles and rush border of the cells of the proximal tubule during warm ischaemia.


Ectopic kidneys with and without fusion.

Sixty-one patients with renal ectopia have been reviewed. Most presented with a palpable mass, abdominal pain or microscopic haematuria. Thirteen patients were treated surgically, usually by nephrectomy; 17 required no treatment and 31 were treated symptomatically.


Effects of therapy with bendroflumethiazide in patients with recurrent renal calcium stones.

Forty-four patients with recurrent formation of calcium-containing renal stones were treated with bendroflumethiazide for at least 2 years. Prior to treatment each patient had formed, on average, one stone per year for 8 years; during treatment only 4 patients formed new stones. A reduction in urinary calcium excretion was seen in almost all patients irrespective of their initial urinary calcium level. The apparent clinical benefit was not related to pre-treatment urinary electrolyte levels. Side effects were slight: one patient developed symptomatic hyperuricaemia and in one case sustained hypercalcaemia was found. Long-term treatment with thiazides appears to be a safe and effective method for the prevention of recurrent calcium stones.


Dietary treatment of idiopathic hypercalciuria.

Eighty-eight urinary tract stone formers (74 men) with idiopathic hypercalciuria were treated by dietary calcium restriction alone. Short-term control of hypercalciuria was achieved in only 27 patients and all but 12 eventually escaped control. Failure of control was twice as likely in patients with severe hypercalciuria. Almost all patients lived in a hard water area. In such areas at least, attempts to control hypercalciuria by diet alone are likely to fail and early introduction of additional treatment is advisable. In most severe hypercalciurics, such treatment should be introduced from the start.


Transvaginal milking of lower ureteric stones into the bladder.

In a selected group of adult female patients, stones in the lower ureter were transvaginally milked into the bladder. The transvaginal milking of lower ureteric calculi into the bladder is easy and safe and is recommended in the poor surgical risk patient.


A trial of prophylactic radiotherapy for non-infiltrating bladder tumours.

In series of 56 cases of non-invasive bladder tumours there was a 61.8% recurrence rate after endoscopic treatment. In 29 cases a trial of prophylactic, very low dose (750 rad) radiotherapy was given; this was administered within a few days of the primary treatment. Twenty-seven cases received no radiotherapy. Over follow-up periods of 2 to 5 years there were recurrences in 12 of the irradiated group compared with 11 out of the 27 controls.


Detrusor instability following surgery for genuine stress incontinence.

Nnety-two female patients with genuine stress incontinence, and with otherwise normal bladder function, were treated by a colposuspension operation. Pre-operative and post-operative clinical and urodynamic assessments were performed on all patients. Following surgery 17 of them were found to have detrusor instability.


Vesicovaginal fistulae.

The aetiology, methods of repair and results are described in 616 patients with vesicovaginal fistulae (26 also had rectovaginal fistulae). The cure rate was 81%.


Complications of antifibrinolysis therapy after prostatectomy.

As part of a trial to compare the effectiveness of various agents which have been claimed to reduce blood loss after prostatectomy, tranexamic acid (AMCA) was given pre-operatively and post-operatively to 6 patients having routine transurethral resections. Three of these developed indissoluble intravesical blood clots which persisted until they were evacuated surgically 5 to 17 days after cessation of AMCA therapy. AMCA cannot be recommended for routine use after prostatectomy.


Acid phosphatase after examination of the prostate.

We report the effect of rectal examination of the prostate and transurethral resection of the prostate (TURP) on the serum level of tartrate labile acid phosphatase (TLAP) in 18 normal cases, 31 with benign enlargement of the prostate and 20 with carcinoma. Rectal examination had no effect on TLAP in normal patients, those with benign enlargement and those with carcinoma, either after 5 min or the following morning. TURP for both benign and malignant disease raised the TLAP transiently with a rapid return to normal. We believe that there is no justification for postponing estimation of TLAP following rectal examination.


The early results of treatment of stricture of the male urethra using the Sachse optical urethrotome.

Thirty-nine male patients with urethral stricture have undergone urethrotomy using the Sachse optical urethrotome. Post-operatively a urethral catheter was used for 24 to 72 h. The technique is simple, the stay in hospital is short and complications are uncommon. Eighty-two per cent of the patients are now symptom-free and further 13% are sufficiently improved to be able to void satisfactorily at follow-up varying from 4 months to 2 1/2 years (mean 12 months). The 2 patients in whom unsatisfactory results were obtained had long strictures. We feel that direct vision urethrotomy should be considered as a treatment for urethral stricture.


Balanitis xerotica obliterans.

Twenty patients with histologically proven balantis xerotica obliterans have undergone different forms of treatment; their progress has been reviewed and discussed. Balanitis xerotica obliterans involving only the foreskin was best treated by circumcision. The patients in whom meatal stenosis was present responded well to regular meatal dilatation, meatotomy followed by regular dilatation and, in advanced cases, to meatoplasty. At present there is no evidence to indicate that associated urethral strictures, proximal to the fossa navicularis, are due to balanitis xerotica obliterans.


Genitourinary tuberculosis: a 7-year review.

Since 1970 short course regimes of chemotherapy have been adopted for the treatment of 87 patients suffering from genitourinary tuberculosis. The response to chemotherapy, the effect of surgery, the importance of hypertension and the relapse rate have been studied. It is concluded that all cases of genitourinary tuberculosis will respond to a short intensive course of chemotherapy, which need not be given for longer than 6 months.


Nephroplasty in the management of hydronephrosis.

Seventeen patients with hydronephrosis were treated by nephroplasty and pyeloplasty. This combination proved to be a simple and effective way of reducing intrarenal dilatation and encouraging dependent drainage from the lower pole calices.


Family history of renal stones in a population study of stone-formers and health subjects.

Information on the family history of renal stone disease was obtained from over 2500 middle-aged men in a general health survey. A family history of stones was significantly more common among the stone-formers than amoung the controls, largely due to an increased frequency of stones among the fathers and brothers of the propositi. This study thus supports previous suggestions that genetic factors play a part in the predisposition to stone formation. An increased tendency was also noted, however, among the wives of those whose relatives had stones, which suggests that environmental factors are involved. Subjects with a family history of renal stones did not exhibit any particular characteristics in their laboratory profiles, but they appeared to be more prone to develop early and frequent recurrences.


The modified lumbotomy versus the oblique loin incision for renal surgery.

The time to full mobility and total analgesic requirements have been assessed in 40 patients undergoing renal surgery by the oblique loin incision or the posterior lumbotomy approach. By these criteria the lumbotomy group fared better than patients who had oblique incisions. We consider lumbotomy to be a valuable incision which should be in the repertoire of every urologist.


Benign tumours developing at the site of ureterosigmoidostomy.

Two cases of benign tumours complicating ureterosigmoidostomy are described. The latent period between diversion and the development of tumour is long and careful follow-up of patients with ureterosigmoidostomy is recommended. It would seem highly probable that adenomatous polyps developing at the site of anastomosis may, if undetected, undergo malignant change to adenocarcinoma. All of the tumours recorded following ureterosigmoid diversion have been associated with a nipple type ureterocolic anastomosis and mucosa-to-mucosa anastomosis may possibly prevent this complication.


Bladder augmentation--a long-term review.

Fifty-nine patients who had undergone augmentation cystoplasty were studied over a period of 18 years. The indications for the operation were a tuberculous contracted bladder in 51, interstitial cystitis in 7 and carcinoma in 1. The ileum was used in one patient, the colon in 16 and the caecum in 42. The results did not seem to be influenced by the segment of bowel and the long-term results of using the colon as bladder substitute were similar to those achieved by using the caecum. An excellent result has been achieved in 78% of the 49 surviving patients. Operative mortality was 5.1% (3 patients). Contraindications include progressive severe renal failure, enuresis and a history of previous psychiatric disturbance.


"Undiversion" with colocystoplasty for neurogenic bladder. A report of 2 cases.

The encouraging success of partial replacement of the bladder for interstitial cystitis and for contracted bladder due to tuberculosis, and the relative success of total bladder replacement for carcinoma, prompted an attempt to reconstruct a bladder in 2 patients with neuropathic bladders, who had problems with their ileal conduit and, thus, "undivert" them. Bladder reconstruction in these patients was performed using a modified technique of colocystoplasty. One of the patients has had 2 normal pregnancies since colocystoplasty.


Transection of the bladder as a method of treatment in adult enuresis nocturna.

Ten adults with enuresis were treated by bladder transection. Urodynamic assessment was carried out before and after the operation. No significant urodynamic changes were recorded following transection. However, good results were obtained in 5 cases and improvement in 2.


Acute phase reactant proteins in the clinical management of carcinoma of the bladder.

The levels of a number of acute phase reactant proteins have been measured in 250 patients with carcinoma of the bladder in all stages. Three of them, acid glycoprotein, antichymotrypsin, and C-reactive protein, frequently gave abnormal results in advanced disease. The levels of these 3 proteins in patients who were clinically tumour-free were not distinguishable from those from an age-matched control group. The levels in patients with T1 and T2 bladder tumours were sometimes elevated. In advanced disease, figures were commonly above the normal range.


Weight estimation of benign prostatic adenoma with urethral pressure profile.

An estimation of the weight of the benign prostatic adenoma by quantitative analysis of the urethral pressure profile has been correlated with the surgically removed specimen in 23 patients. It has been found that the length of the continence zone cane be used as an index of prostatic weight. After operation the length of the continence zone fell into the normal range of the age matched controls.


The effect of prostatectomy on urodynamic parameters.

Sixty per cent of men subjected to prostatectomy had unstable bladders. It was found that this was related to the presence of either an indwelling catheter or obstruction, but had little influence on the result of prostatectomy. The functional urethral pressure profile length did not correlate with the size of the prostate gland. Shortening of the prostatic plateau was always found, but the extent to which the plateau was reduced did not correlate with urine flow rates.


Human prostatic lymphoscintigraphy. A preliminary report.

A simple method for demonstrating prostatic lymphatic drainage by transrectal injection of 99mTc labelled antimony sulphide colloid into the prostatic capsule has been developed. This technique may be readily applied in clinical practice with obvious potential in the assessment and follow-up of patients with carcinoma of the prostate.


Fracture of the penis with laceration of the urethra.

Two patients are described with severe injury to the penis sustained during sexual intercourse. The literature is reviewed. A conservative approach to management with suprapubic urinary diversion led to acceptable results.


Prophylactic vasectomy.

A prospective study of the value of vasectomy with prostatectomy is presented. Vasectomy significantly reduced the incidence of epididymitis after prostatectomy in the presence of pre-operative urinary tract infection and prolonged indwelling urethral catheterisation.


Fournier's gangrene.

Twenty-five cases of gangrene of the scrotum and penis have been analysed. The anterior scrotum or the whole scrotum were the areas most frequently involved. The results of seminal analyses showed marked oligozoospermia during the infective period. Haemolytic streptococcus was the most common organism. The aetiology of the disease is reviewed and "infective gangrene of the scrotum and penis" is considered to be a more suitable diagnostic label than Fournier's gangrene.


Giant hydronephrosis.

A case of congenital, unilateral giant hydronephrosis containing 42 1/2 litres of urine in an adult male is reported. Diagnosis and management are discussed. Because of the possible effects of sudden abdominal decompression, a plea is made for a two-stage procedure. The hydronephrosis is first decompressed slowly by drainage and nephrectomy is then performed after the patient's cardiorespiratory and alimentary systems have been stabilised.


A new look at the arterial supply of the bile duct in man and its surgical implications.

The blood supply of the human bile duct has been re-evaluated using high resolution resin casts prepared from 24 fresh human cadavers. The refined technique used yielded casts of all vessels, including capillaries, and produced a clear picture of the blood supply of the human bile duct for the first time. The arterial supply of the supraduodenal duct was shown to be axial, with the main vessels, which have been named the 3 o'clock and 9 o'clock arteries, running along the lateral borders. The retroportal artery, which has not been described by previous workers, was present in all complete casts and was a major source of the axial blood supply to the supraduodenal duct in 32 per cent of them. The major importance of this new knowledge of bile duct blood supply may well lie in the understanding of the aetiology of postoperative bile duct strictures and in their prevention. An explanation is proposed for the long strictures sometimes seen after minimal surgical trauma to the bile duct, based on damage to the small vessels supplying the duct; guidelines to prevent such damage are presented. Ischaemia of the bile duct may also explain some of the biliary problems that have followed human liver transplantation and other procedures involving biliary anastomosis, such as Whipple's operation.


Exploration of the common bile duct: a comparative study.

The results of a retrospective comparative study of 122 patients who underwent explorations of the common bile duct in a district general hospital over a 5-year period are presented. Seventy-eight patients had a supraduodenal choledochotomy, 32 had a transduodenal spincterotomy and 12 had a combination of both procedures. Particular attention was paid to postoperative complications in relation to the grade of the surgeon performing the operation and also to the age of the patient. A total of 78 (64 per cent) patients had definite stones in the common bile duct. Of these patients, 7 (9 per cent) were subsequently shown to have retained stones, all having been operated on by registrars. Registrars also did more negative explorations than consultants. Nine patients (7.4 per cent) died, all but 1 of them being over the age of 70 and 4 of them having had a combined procedure. We conclude that transduodenal exploration should be avoided in patients over 70, particularly when added to a supraduodenal exploration.


Renal function and other factors in obstructive jaundice.

Renal function and other factors that possibly affect the outcome of operation were measured in 24 patients with obstructive jaundice and in 15 non-jaundiced controls. The preoperative features that were associated with a poor postoperative recovery from obstructive jaundice were a raised serum fibrinogen/fibrin degradation product concentration, infection, hypoalbuminaemia and a low glomerular filtration rate. Preoperative serum fibrinogen/fibrin degradation product concentrations were raised in 4 of the 6 jaundiced patients who died after surgery but in none of the controls, in whom there was no mortality. In the jaundiced patients there was a greater incidence of postoperative renal impairment than in the controls. All patients were given mannitol during operation. Further mannitol was required after surgery in 13 of the 24 jaundiced patients in order to maintain urine flow rate despite adequate intravenous fluids being given. In contrast, only 1 of the 15 control patients required post operative mannitol. It is emphasized that repeated doses of mannitol can lead to a profound natriuresis and adequate intravenous saline should be given.


Acute pancreatitis in Hong Kong.

A series of 311 Chinese patients with acute pancreatitis admitted to Queen Mary Hospital, Hong Kong, over a 10-year period is reviewed. Biliary tract disease was associated with pancreatitis in 52.4 per cent of patients and 77.9 per cent of them had stones, mud or parasites in the common bile duct. Fever and jaundice were present in 55 per cent and 41.2 per cent of patients respectively. Because of the prevalence of recurrent pyogenic cholangitis among the indigenous population, emergency operation, with the aim of common duct decompression, was conducted in 54.3 per cent of patients during the acute episode, with a mortality rate of 14.8 per cent. Five of 142 patients (3.5 per cent) died whilst on conservative treatment and all 5 had haemorrhagic pancreatitis. The overall mortality rate was 9.6 per cent. Exploration of the common bile duct, which was carried out in 57.4 per cent of patients in the acute phase, was not associated with a higher mortality than when laparotomy alone was performed, and 19 patients had sphincteroplasty without any death. Subtotal pancreatectomy was performed in 2 patients with haemorrhagic pancreatitis with 1 death.


Haemorrhagic cholecystitis.

Two cases of haemobilia due to haemorrhagic cholecystitis are presented; only 28 other cases have been described. As there are so many more dramatic causes and treatment for haemobilia it is important for the surgeon to recognize that a common operation will suffice for this rare condition. In both cases bacteria were grown from the bile and it is to be hoped that bile culture will be recorded more commonly in future in cases of this interesting condition.


Primary hydatid cyst of the gallbladder.

An unusual case of hydatid cyst of the gallbladder is presented. The difficulties in diagnosis are discussed. There is no other report of such a cyst in the world literature.


Splenic cysts: a review of 6 cases.

Benign cysts of the spleen are rare. Six cases have been managed in this hospital in the past 25 years. The history, physical findings and investigations are reviewed. It is suggested that splenectomy is the treatment of choice as it carries a low morbidity and mortality.


H2-antagonists in the treatment of recurrent ulceration after vagotomy.

Twenty-two patients with recurrent ulceration following vagotomy with and without a drainage procedure have been treated with histamine H2-antagonists and followed for up to 3 years. Four of a group of 6 patients responded to a single therapeutic course. Ten of 16 patients assigned to long term maintenance treatment remain symptom-free. Cimetidine may be an alternative to further surgery in the treatment of some patients with recurrent ulceration after vagotomy.


The excretion of alkaline ribonuclease by children undergoing surgery.

The excretion of alkaline ribonuclease has been measured in the urine of two groups of children after major operations. The excretion was significantly increased in all patients after open operations on the heart and in many of those who were operated on soon after birth for anomalies in the intestine. It is suggested that these elevations may indicate a disturbance of pancreatic function.


The role of thrombolytic therapy in the management of phlegmasia caerulea dolens.

Two cases of phlegmasia caerulea dolens with peripheral venous gangrene treated with streptokinase are presented. Both patients had excellent results, beyond expectation. The literature is reviewed and the symptomatology, aetiology, pathogenesis and current thoughts on treatment are discussed.


The morbidity of carotid endarterectomy.

The results of 72 carotid endarterectomy operations carried out by three consultant surgeons were analysed. Thirty-eight operations (32.8 per cent) were performed in patients with mild or resolving stroke and 33 operations (45.9 per cent) in patients with transient ischaemic attacks and/or amaurosis fugax. Five patients (7 per cent) died in the early postoperative period, 2 as a result of strokes and the others from cardiac causes. Seventy-six per cent of patients had a satisfactory long term result, remaining free from storke, blindness or recurrent transient ischaemic attacks over the follow-up period of 1--7 years. There were 10 patients (13.8 per cent), including 2 who died, who developed early postoperative neurological deficits; 4 (5.5 per cent) had transient defects and 6 (8.3 per cent) had permanent deficits. Of these patients, 4 had proved occlusions of the reconstructed artery. In 3 patients, cerebral embolization during operation was suspected as the cause. There were, in addition, 2 asymptomatic patients whose reconstruction was shown to be occluded on follow-up postoperative angiography. The continued absence of symptoms, therefore, is no guarantee that the reconstruction is patent and some more objective method of assessment is necessary if the results of carotid endarterectomy are to be critically analysed. The incidence of neurological deficits could, it is believed, be reduced by greater experience with the operation, the routine use of peroperative intra-arterial shunting and peroperative angiography to confirm the patency of the reconstruction.


The clinical relevance of radiologically revealed Paget's disease of bone (osteitis deformans).

Radiological and hospital records of 400 patients with Paget's disease that was shown radiologically have been examined in an effort to establish the clinical significance of the disease. Twenty-eight per cent of the patients were considered to have symptoms related to their disease, the most frequent symptom being bone pain, deformity and fracture. It appears that Paget's disease may predispose to the formation of urinary calculi. Malignant change and neurological and cardiovascular complications are rare, and osteitis deformans does not appear to predispose to osteoarthrosis.


Distribution of plasma-bound hydroxyproline in breast cancer, benign breast disease and healthy females.

In normal adult females, patients with benign breast disease and patients with breast cancer, hydroxyproline (OHPro) was found in the plasma attached to the protein fractions which were separated by Sephadex gel filtration. In addition, a distinct moiety, probably a protein sub-unit, containing substantial amounts of this imino acid, occurred in between gel filtration fractions III and IV. Quantitative differences in the OHPro content of these various fractions were observed in the groups of patients studied. Significant elevations in the peptide-bound OHPro (fraction IV) were found only in patients with breast cancer and the level appeared to correlate with the degree of advancement of the disease. Similar findings relate to the OHPro content of the sub-protein moiety which is found between gel filtration fractions III and IV. A reduced level of high molecular weight hyproprotein (fraction I) was found in the breast cancer group.


Midline cancer of the floor of the mouth: role of suprahyoid dissection.

Of 37 patients with squamous cell carcinoma of the floor of the mouth seen during a 5-year period, 28 were treated primarily by surgery. Ten of the 28 patients presented with midline cancers measuring between 1.0 and 3 cm (T1 and T2). Three of these patients had local excision only. Metastases to the submandibular lymph nodes later occurred in 1 of these 3 patients. The remaining 7 patients with midline lesions had wide excision of the tumour, marginal resection of the mandible and bilateral suprahyoid node dissection. Of these 7 patients 4 remained free of disease for periods ranging between 2 and 5 years. Two of these had lymph node metastases. These results suggest that en bloc excision of relatively small midline cancers (i.e. not exceeding 2 cm (T1) in largest diameter) with bilateral suprahoid node dissection gives effective control of these lesions.


Pancreatogram changes in patients with calculous biliary disease.

A successful pancreatogram was obtained at endoscopic retrograde cholangiopancreatography (ERCP) in 53 patients with calculous biliary disease. Twenty-eight patients presented with jaundice and 25 with pain. In both groups there was a high incidence of pancreatogram abnormalities (47 and 48 per cent respectively). These findings demonstrate that the pancreas is often abnormal in the presence of complicated calculous biliary disease even though there may be no recent clinical evidence of pancreatitis and suggest that asymptomatic chronic pancreatitis may be common. The clinical significance of the abnormalities is discussed.


Chronic relapsing pancreatitis: a review of 64 cases.

A collected series of 64 cases of chronic relapsing pancreatitis is reported. Analysis of this material reveals several points of interest. There is a difference in the aetiological spectrum in Britain when compared with reports from France and the United States. In particular, nearly half the British cases were idiopathic. The clinical presentation and the age and sex ratios also varied with aetiology. Endoscopic retrograde cannulation of the pancreatic duct was of little value in confirming a diagnosis of pancreatitis in the problem case. This investigation did, however, demonstrate that a widespread dilatation of the pancreatic duct was a minority finding. In those patients with alcoholic pancreatitis follow-up studies have shown that, if the addiction can be broken, there is a 75 per cent chance that pain will diminish or disappear with the passage of time. The main indication for surgical intervention was severe pain and this study has shown that if strict criteria are observed, a worthwhile relief of symptoms can be achieved. In particular, subtotal pancreatectomy produced good results in up to 85 per cent of cases, although with an appreciable short term postoperative morbidity.


Does obstructive jaundice adversely affect wound healing?

The effect of obstructive jaundice on wound healing has been investigated in an experimental study of abdominal wounds in rats following ligation and division of the common bile duct. Animals were jaundiced for 2 weeks before a second operation at which the abdominal wounds were made. The wounds in jaundiced and control animals showed no significant differences in mechanical strength during a 21-day period of study but there was a significant delay in the accumulation of collagen in the wounds of jaundiced animals. The findings suggest that the biochemical changes in the wounds of jaundiced animals did not interfere with wound repair and cast doubt on the thesis that jaundice has an adverse effect on wound healing.


The surgical treatment of axillary hyperhidrosis.

Axillary hyperhidrosis is a common condition and young people often suffer unnecessarily for many years in spite of the availability of good surgical methods for cure. We describe our own modification of Pettersson and Strömbäck's (1970) method of excision of the sweat glands. During the years 1972-6 218 axillary operations have been performed on 109 patients at the surgical clinic in Västerås for axillary hyperhidrosis. We reviewed 104 of these and found that 71 patients were completely satisfied and only 7 unsatisfied. Twelve patients wanted to be reoperated either because they still sweated or because they were unhappy with their scars. Thus, we found that overall the surgical methods are safe, simple and give good results.


Congenital chylothorax: report of unique case associated with 'H' -type tracheo-oesophageal fistula.

A case of congenital chylothorax associated with a congenital 'H'-type tracheo-oesophageal fistula is reported. The development of the thoracic duct is described and the possible embryological association with tracheo-oesophageal fistula is discussed. The management of the case is reviewed.


Absorption from the jejunum is increased by forward and backward pacing.

In 4 dogs a 75-cm segment of jejunum was isolated from the intestinal stream. Stimulating electrodes were implanted at each end of the segment and recording electrodes at intervals between. The two ends of the segment were fashioned as stomas on the anterior abdominal wall. After recovery, the electrical activity of the segment was continuously recorded, whilst a solution of 100 mmol/l glucose and 90 mmol/l NaCl was infused into the proximal stoma at 2.9 ml/min. Effluent from the distal stoma was collected in 5-min aliquots for three consecutive 30-min periods. In the second period electrical stimuli were given via either the proximal or the distal bipolar electrodes to entrain pacesetter potentials. Both forward and backward electrical pacing decreased the output of water, glucose and sodium from the jejunal segment, but the decrease was significantly greater with backward pacing. We conclude that pacing a segment of jejunum backwards with electrical stimuli produces a greater increase in absorption from the segment than pacing it forwards, a finding which has therapeutic implications in patients with the short bowel syndrome.


An experimental evaluation of segmental reversal after massive small bowel resection.

The technique of reversal of a distal segment of residual small intestine was applied to the management of massive resection. A controlled evaluation was carried out in dogs into the effects of segmental reversal on the proximal remnant after the distal 75 per cent of the small bowel had been resected. The variables studied were survival, body weight, glyceryl tri(palmitate-1-14C) absorption and mouth-to-caecum transit time. Animals subjected to resection alone had accelerated intestinal transit, poor absorption, serious weight loss and a high early mortality. It was clearly demonstrated that segmental reversal after resection produced marked and progressive delay in transit time from mouth to caecum, sustained improvement in fat absorption and body weight and enhanced survival.


Transcutaneous defunctioning colostomy.

The technique is described for constructing an occlusive tube colostomy which requires no second operative procedure for closure. The advantages of this method are discussed and it is recommended as a superior alternative to loop colostomy or caecostomy for defunctioning the unobstructed distal bowel.


The effect of levamisole on postoperative immunosuppression.

Cell mediated immunity was studied before and after surgery in patients with colorectal cancer. Thymus-derived (T) lymphocytes were enumerated and their non-specific activity was measured by assessing phytohaemagglutinin (PHA)-induced blastogenesis. Specific T lymphocyte activity was measured by leucocyte migration inhibition in response to purified protein derivative of tuberculin (PPD) and autochthonous tumour extract. One group of patients received levamisole postoperatively and the other group consisted of controls. There was a more rapid return to preoperative levels of leucocyte migration inhibition to both antigens by the levamisole group. However, levamisole administration had only a marginal effect on the postoperative depression of cell counts and did not restore depressed lymphoblast transformation.


Reduction in road fatalities and injuries after legislation for compulsory wearing of seat belts: experience in Victoria and the rest of Australia.

In 1970 the Government of the State of Victoria became the first in the 'western' world to introduce legislation for compulsory wearing of seat belts. Within 14 months the other Australian states followed. Seat belt wearing rates increased to attain 90 per cent in 1977. This paper presents an evaluation of changes during the period 1955--77 in the incidence of road crash fatalities and injuries for vehicle occupants in Victoria and the rest of Australia. The introduction of the legislation in Victoria and subsequently in the other Australian states coincided with significant and marked decreases in driver and passenger fatality and injury rates (numbers per 10 000 registered vehicles). The decreases were enough to reduce the total numbers of vehicle occupant fatalities and injuries for all post-legislation years in Victoria. The improvements have been maintained throughout the entire post-legislation period. The legislation did not apply to child passengers of less than 8 years of age and the frequency of seat belt or harness wearing among them remained low. These children did not share in the overall improvement for passengers. The Australian experience supports the view that legislation for compulsory wearing of seat belts is the single most effective method available for the protection of vehicle occupants in road crashes.


Vagotomy and pyloric dilatation in chronic duodenal ulceration.

A total of 101 patients suffering from duodenal ulcer underwent truncal vagotomy (TV) combined with pyloric dilatation (PD). They were followed up over six years, and the results were found to compare favourably with those in patients who underwent alternative surgical measures. Before any revisionary surgery 79 patients were classified as Visick grades I plus II. The incidence of recurrent ulceration was 4%. Side effects were noticeably less common than in patients in whom a drainage procedure had been performed, and overall results were compared with those reported for groups of patients treated by proximal gastric vagotomy. The combination of TV and PD is commended on account of its simplicity, safety, and effectiveness at a time when medical treatment for duodenal ulcer is becoming more specific and increasingly effective.


Proximal gastric vagotomy, fundoplication, and lesser-curve necrosis.

Out of 400 patients who underwent proximal gastric vagotomy (PGV), three developed lesser-curve necrosis (LCN) leading to perforation within the first seven days. In each case diagnosis was delayed but the patient survived after a second operation. In each an associated Nissen fundoplication had been carried out; we used the combined operation in only 33 patients. Delayed LCN occurred in a patient who had undergone splenectomy at the time of the PGV and in a fifth patient treated elsewhere who had also undergone fundoplication. These findings indicate that early postoperative gastric distension with gas, not readily voided after fundoplication, may aggravate local vascular factors and predispose to LCN. We suggest that PGV combined with fundoplication may be dangerous.


Renal function after long-term treatment with lithium.

Daily urine volumes, plasma creatinine concentrations, and creatinine clearance were measured in 106 patients with unipolar and bipolar affective disorders attending a "lithium" clinic. Urine volumes exceeded 3.51 in only six patients, plasma creatinine concentrations exceeded 150 mumol/1 (1.7 mg/100 ml) in only five, and creatinine clearance was below 50 ml/min in 16. Renal function was assessed by measuring creatinine clearance and renal tubular function, including response to 20 hours of water deprivation, in a representative sample of 30 patients from the lithium clinic and 30 psychiatric patients matched for age and sex who were taking other psychotropic drugs. Creatinine clearance and tubular function, including urine osmolality after water deprivation, were not significantly different between the two groups. Urinary excretion of arginine vasopressin (AVP), however, was much greater in the lithium-treated patients, who therefore had a diminished tubular responsiveness to AVP. The findings do not support suggestions that long-term lithium treatment results in seriously impaired renal function, renal damage, and polyuria. Compared with other series, however, the patients were being maintained with low serum lithium concentrations, which apparently area as effective prophylactically as higher concentrations.


Disposable syringes for insulin injection.

Results of a questionnaire on use of glass syringes among diabetic patients showed considerable variation in methods of keeping the syringes and in the duration of their useful life. Thirty patients took part in an investigation in which each patient used the same disposable syringe in place of the glass syringe for up to two months. No clinical or bacteriological evidence of infection was found. Used in this way, disposable syringes were less expensive than glass syringes. They are lighter than glass syringes, less susceptible to damage, and more easily carried on journeys.


Survival of patients ventilated in an intensive therapy unit.

The survival of patients who were artificially ventilated in an intensive therapy unit (ITU) of a district general hospital was studied. The first 100 such patients admitted were followed up for at least four years. Of these, 67 survived treatment in the ITU, 47 were discharged from hospital, and 30 survived four years. (Survival in the ITU of patients who did not require ventilation was 89%.) The effects of age, duration of ventilation, and disease were studied, and a higher survival was found in children, in patients ventilated for under 24 hours, and in patients admitted with drug overdosage. Survival was poor in patients aged over 75 and in those who required ventilation after cardiac arrest or myocardial infarction or for chronic obstructive lung disease. The cost of a bed in an ITUs to be used to the greatest effect it is important to define those patients who are most likely to benefit from the facilities they offer.


Pneumoperitoneum associated with artificial ventilation.

Four adults injured in serious road-traffic accidents developed pneumoperitoneum after artificial ventilation. No case could be attributed to injury or to perforation of a hollow viscus in the belly, but doubt about this in one patient resulted in exploratory laparotomy. In three patients the origin of intraperitoneal air was considered to be leakage through minute ruptures in alveoli subjected to the stress of artificial ventilation, with air tracking to the mediastinum, pleural space, subcutaneous tissues of the neck and chest, and peritoneal cavity. The fourth patient later developed herniation of the stomach through a rupture in the diaphragm, the presence of a pneumothorax on the same side suggesting direct passage of air through the diaphragm. Pneumoperitoneum induced by artificial ventilation is probably more common than reports suggest and should be distinguished clinically and radiologically from that caused by rupture or perforation of a hollow viscus. This will reduce the number of needles laparotomies performed on patients who are already seriously ill.


Unknown primary adenocarcinoma: incidence of overinvestigation and natural history.

Out of 1300 patients referred to a medical oncology unit, there were 87 with metastatic cancer in whom a primary tumour site was not evident from the history and after physical examination and chest radiography had been carried out. An analysis of the investigations performed in these patients and their results showed that in only eight of the 87 patients did non-surgical investigations at presentation determine the primary site. In two patients it was identified by diagnostic laparotomy, and in a further 13 clinical follow-up led to recognition of the primary tumour site before death. Few investigations should be performed in patients in whom the primary site is known since they have a low yield, and in our population identifying the primary tumour did not improve the outcome or alter management. Treatable tumours should be excluded, and this may be done in most cases by simple blood tests, particularly those measuring acid phosphatase activity and other tumour markers.


Raised blood pressure and plasma noradrenaline concentrations in teenagers and young adults selected from an open population.

Plasma noradrenaline (PNA) concentrations were measured in 38 subjects aged 13-23, who were followed up for two to four years after an initial blood-pressure (BP) reading of 140/90 mm Hg or over was obtained, and in 39 age-matched controls from the same open population. Subjects who were hypertensive when the PNA concentration was measured had a significantly higher concentration (351 +/- SE 26 pg/ml) compared with their controls (248 +/- 29 pg/ml). Furthermore, in those subjects in whom the mean arterial pressure decreased by under 5% during the follow-up period the mean concentration was 363 +/- 27 pg/ml, compared with 271 +/- 29 pg/ml in their controls. PNA concentrations and systolic BP were positively correlated. A positive association between PNA concentrations and age was observed in the controls but not the subjects with hypertension, owing to the higher concentrations in younger hypertensive subjects.


Spinal-cord compression in myeloma.

Clinical records of 47 patients in whom spinal-cord compression was the presenting feature of plasma-cell myeloma were analysed retrospectively. Patients were referred during 1954-78. Median survival was 30 months and prognosis was best for those in whom the site of cord compression was the thoracic region. Early laminectomy and decompression followed by adequate radiotherapy resulted in complete or good partial response in over a third of patients who presented with complete paraplegia. Improvements in supportive care and more effective chemotherapy allow spinal-cord compression in myeloma to be treated promptly and vigorously, thus improving duration and quality of survival in a substantial proportion of patients.


Randomised comparison of methyldopa and oxprenolol for treatment of hypertension in pregnancy.

Fifty-three pregnant women with moderately severe hypertension were randomly allocated to treatment with methyldopa or oxprenolol. There were no significant differences between the groups in age, height, weight, parity, or stage of gestation at the start of treatment. The outcome of pregnancy was better in the group treated with oxprenolol, with greater maternal plasma volume expansion and placental and fetal growth. No intrauterine deaths occurred in either group, and antepartum fetal distress, detected by oxytocin challenge testing, was evident in only one patient, who received methyldopa. This infant, and one other in the methyldopa group, died in the neonatal period. No neonatal deaths occurred in the oxprenolol-treated group. Even in this small number of patients these results were considerably better than those in untreated women with hypertension of similar severity. Apgar scores in both groups were equivalent at birth, while blood sugar concentrations were higher in the oxprenolol group. Oxprenolol appears to be safe and effective in controlling hypertension during pregnancy. There was no evidence of harmful effects on the fetus, and oxprenolol may offer a selective advantage over methyldopa for fetal growth and wellbeing in utero.


Reasons for requesting radiographs in an accident department.

A prospective study of 500 patients was performed to determine the reasons for requesting radiographs in an accident and emergency department. Most examinations were requested either to confirm a clinically suspected abnormality or because of difficulty in excluding a significant bone injury on clinical grounds alone. Several requests were also made to reassure the patient. Medicolegal reasons were relatively few, and those made purely because the doctor feared litigation probably accounted for only 5% of requests. Undue emphasis on the medicolegal aspects of accident and emergency radiography in the United Kingdom is unhelpful in that it directs attention away from the real reasons for x-ray referral. Although a reduction in the number of x-ray examinations is desirable on the grounds of expense and radiation exposure it is likely to be obtained only by improving experience and acumen in the clinical assessment of injuries.


General anaesthesia in sickle-cell disease.

General anaesthesia was administered on 284 occasions to 200 patients with sickle-cell disease at one hospital during July 1958 to June 1978. No intraoperative but six postoperative deaths occurred. The management of anaesthesia may have contributed to two of the postoperative deaths. Clinically uneventful anaesthesia did not appear to provoke severe sickling crises or to be responsible for mortality, but a contribution to postoperative morbidity could not be excluded. A simple, careful anaesthetic technique and selective but not routine blood transfusion appears to be associated with minimal anaesthetic morbidity and mortality in patients with sickle-cell disease.


Whooping cough after stopping pertussis immunisation.

An epidemic of whooping cough occurred in a rural practice in Shetland, containing 144 children under 16. Before July 1974 all children were immunised against pertussis, but after that date immunisation was stopped. Of the 134 children studied, 93 had been immunised. Sixty-five of the children developed whooping cough. The incidence of infection was similar in those who had and had not been immunised. The incidence was also similar in those born before and after July 1974. There was no evidence to support the routine use of pertussis immunisation in rural Shetland.


Minor operations in general practice.

An analysis of minor operations performed in one general practice showed that one doctor doing an average of only four minor operations a week can save the area health authority over 15 000 pounds a year.


Raised serum human chorionic gonadotrophin concentrations in hyperemesis gravidarum.

Serum human chorionic gonadotrophin (HCG) concentrations were determined by radioimmunoassay with an antiserum specific to HCG beta-subunit in 42 patients with hyperemesis gravidarum and 115 women with normal pregnancies. Mean concentrations (+/- SE of mean) were higher in the women with hyperemesis gravidarum at 7-8 weeks (40.8 +/- 5.2 IU/ml v 22.1 +/- 1.4 IU/ml; P less than 0.001), 9-11 weeks (38.1 +/- 2.3 IU/ml v 27.1 +/- 2.1 IU/ml; P less than 0.0025), and 12-14 weeks of gestation (35.9 +/- 4.2 IU/ml v 25.1 +/- 1.7 IU/ml; P less than 0.005), but there was no difference between the two groups at 15-20 weeks of gestation. In the hyperemesis gravidarum group primigravid women had a higher (P less than 0.005) mean HCG concentration (41.8 +/- 4.0 IU/ml) than multigravid women (32.2 +/- 2.3 IU/ml). The results suggest a causal relation between a high serum HCG concentration and hyperemesis gravidarum.


Peer review of consultations in primary care: the use of audiovisual recordings.

A rating scale was designed to measure performance in interviewing techniques in primary care. Peer review of audiovisual recordings of their consultations showed that a group of experienced general practitioners achieved significantly higher scores on the rating scale compared with a group of similarly experienced general practitioners who did not observe their recordings. The higher scores were obtained at the expense of longer consultations. The traditional five-minute appointment system in general practice needs to be reconsidered if an improved interviewing technique results in a more favourable outcome.


Spread of steroid-containing foam after intrarectal administration.

The spread of a steroid-containing foam from the rectum was studied in eight normal controls and eight patients with ulcerative colitis proved by biopsy. A standard dose of foam was labelled with technetium-99m adsorbed on to microspheres of Amberlite resin. Immediately after the foam was administered the extent of spread varied considerably, though in no instance did it extend beyond the rectosigmoid. Further scans at 120 and 240 minutes showed no further spread. It is concluded that a steroid-containing foam has a topical effect only on the rectal mucosa.


Improved glucose control in maturity-onset diabetes treated with high-carbohydrate-modified fat diet.

Fourteen patients with established maturity-onset diabetes were treated as outpatients with a high-carbohydrate-(about 60% of total daily energy requirements)-modified fat diet (ratio of polyunsaturated fatty acids to other fatty acids greater than or equal to 1:1) for six weeks. Commercially available and acceptable cereal foods and tuberous vegetables high in both digestible and non-digestible carbohydrates were used. Simple sugars were restricted. Compared with their usual, low-carbohydrate diabetic diet this diet resulted in a fall in basal plasma glucose concentration (average of values measured at 0300, 0500, and 0700), mean preprandial plasma glucose concentration (average of values measured at 0800, 1230, and 1730), and percentage of glycosylated haemoglobin. Modifying dietary fat also decreased the fasting plasma cholesterol concentration. The findings suggest that it is no longer justifiable to prescribe a low-carbohydrate diet for maturity-onset diabetes.


An epidemiological study of oral contraceptives and breast cancer.

During 1968-77, 707 women aged 16-50 years with newly diagnosed breast cancer and 707 matched controls were interviewed at eight teaching hospitals in London and Oxford about their use of oral contraceptives. Eighty-six of the patients with breast cancer were matched with controls with gall-bladder disease; these subjects were omitted from the main analyses, which thus related to 621 case-control pairs.The results were reassuring. A few statistically significant differences in oral contraceptive use were found between the breast cancer and control groups, but the data were subdivided in many ways, so that some "significant" differences would have been expected to occur by chance. The only subgroup in which the evidence for a positive association between pill use and breast cancer was at all convincing comprised women aged 46-50 years, but trends in those aged 41-45 were by and large in the opposite direction and results of combined analysis gave no cause for concern.Information on clinical stage was available for 487 patients with breast cancer treated before the end of 1975. Those who had never used oral contraceptives had appreciably more advanced tumours at presentation than those who had been using the pill during the year before detection of the lump, while past users of the pill occupied an intermediate position. This difference in staging was reflected in the pattern of survival. Oral contraceptives may have had a beneficial effect on tumour growth and spread, though diagnostic bias could not be definitely excluded.


Effects of manufacturing oral contraceptives on blood clotting.

In monitoring the effects of industrial exposure resulting from the pharmaceutical manufacture of oestrogen-progestogen combinations by coagulation studies acceleration of some clotting tests was found. The most pronounced changes were in workers most closely associated with the industrial process. Less pronounced changes were found in women employees not closely concerned with the processing and may have been secondary to the postmenopausal bleeding to which they were prone. A safer work procedure elaborated by the Employment Medical Advisory Service was monitored by clotting studies for over a year but the three most highly exposed subjects showed no substantial improvement.


Asthma due to industrial use of chloramine.

Seven brewery workers developed asthmatic symptoms after using chloramine (chloramine-T) powder as a sterilising agent. They gave positive weal and flare reactions to skin-prick tests with solutions of chloramine at strengths that caused no reactions in unexposed controls. The symptoms did not recur once the men had been removed from areas in which chloramine was handled. As well as causing irritant effects, inhaling dry or liquid aerosols of chloramine may cause sensitisation, with workers being prone to allergic asthma on reexposure. In view of this, measures should be taken to ensure that chloramine is not inhaled.


Long-term parenteral exposure to mercury in patients with hypogammaglobulinaemia.

Patients with hypogammaglobulinaemia commonly receive regular long-term replacement therapy with a concentrate of pooled normal human immunoglobulin G (IgG) containing an organic mercury compound (thiomersal) as a preservative. In 26 such patients the total estimated mercury dosage received ranged from 4 to 734 mg (mean 157 mg) over treatment periods of six months to 17 years (mean 6.5 years). Nineteen patients (73%) had raised urine mercury concentrations, but no correlation was found between urine mercury and the age of the patient, the IgG dose, or the duration of treatment. Urine mercury concentrations are often used to control exposure and evaluate risks in exposed subjects. Hence most patients with hypogammaglobulinaemia are theoretically at risk from mercury exposure, although no clinical evidence of toxicity is yet apparent.


Relation between medicines sweetened with sucrose and dental disease.

The teeth of 44 children aged under 6 years who had been taking syrup medicines regularly for at least six months were compared with those of a control group of 47 children of similar ages. Dental disease was assessed by measuring dental caries, dental plaque, and gingivitis. The children who were receiving sucrose-based medicines had significantly more carious teeth and gingivitis. It is concluded that sucrose-based medicines continuously administered to children cause dental caries and gingivitis. Liquid medicines for children should be either unsweetened or sweetened with non-cariogenic substances.


Costs of unnecessary tests.

The relative importance of the history, examination, and routine and special investigations has been assessed in the diagnosis and management of 630 medical outpatients. The history was the most important factor in both diagnosis and management in cardiovascular, neurological, respiratory, urinary, and other miscellaneous problems, and decided 56% of all diagnoses and 46% of all management. Examination findings were of more limited value, accounting for only 17% of diagnostic and 17% of management decisions overall. Routine haematology and urine examinations were of minimal value, contributing to less than 1% of all diagnoses. Special investigations decided most of the diagnoses and management in alimentary and endocrine problems, but were less helpful in problems affecting all other systems. If a local survey in the Trent Region reflected the pattern of medical outpatient practice nationally, then pounds 1.25 million could be saved annually if routine investigation was discontinued on all patients whose problem had already been diagnosed on the basis of the history and the clinical examination.


Anaerobic axillary abscess.

Fifty-two patients with axillary abscesses were seen during two years. Staphylococcus aureus was isolated from 34, anaerobic bacteria from 12, and skin flora from five; in one case the pus was sterile. Seven patients with hidradenitis suppurativa had recurrent infection with abscess formation, which was bilateral in three. Anaerobes were isolated in five of these cases and skin flora alone in two. Anaerobes are secondary invaders in this condition, and histological examination shows that the primary abnormality is obstruction of pilosebaceous follicles and apocrine glands, associated with keratin plugging of the follicles. Chemotherapy offers little hope of cure, although metronidazole removes the offensive smell of the discharge. Radical surgery is usually indicated.


Hospital outbreak of trimethoprim resistance in pathogenic coliform bacteria.

In an investigation of outbreak of infection caused by coliform bacilli with plasmid-mediated trimethoprim (TMP) resistance many patients were found to be asymptomatic carriers of TMP-resistant coliform bacilli. Analysis of factors predisposing to rectal carriage of these organisms showed that the most important was previous treatment with co-trimoxazole, a sulphonamide, or ampicillin. The outbreak was controlled by a policy restricting the antibiotics given. Geriatric units are an important source of hospital infection. When an outbreak occurs the logical sequence of steps to be taken is to monitor cases, identify the outbreaks, analyse the causative factors, plan corrective action jointly with laboratory staff, and monitor the outcome.


Induction of labour using prostaglandin E2 pessaries.

The routine method of induction at Queen Charlotte's Maternity Hospital is now by the use of prostaglandin E2 pessaries. The first 502 consecutive patients thus induced are presented: the caesarean section rate for a failed induction with an unfavourable cervix has fallen to 2%. The prostaglandin E2 pessary is highly efficient and acceptable for all cases in which a simple amniotomy will not suffice.


Comparative trial of volunteer and professional treatments of dysphasia after stroke.

A study of the treatment of dysphasia after stroke compared the progress of two groups of disabled patients. One received conventional treatment from qualified speech therapists and the other from non-professional volunteers. Methods of assessing communication difficulties were also compared and the impact of aphasic illness on families examined. No important differences in the results of treatment were seen between the two groups. The volunteers, however, often had to assume some of the responsibilities of social workers, and transport to hospital created practical and economic problems. It is concluded that the two forms of treatment provide essentially the same benefit, although doubt must still remain because relatively few patients were studied.


Methodology of monitored release of a new preparation: buprenorphine.

The analgesic agent Temgesic (buprenorphine) was made available under monitored release regulations for one year, which yielded data from 1736 doctors on 9123 patients. An analysis of 17 120 administrations of the drug confirmed the results of the pre-licensing clinical studies encompassing data from nine British hospitals on 483 patients. No important new adverse effects attributable to the product were observed, and apart from giving reassurance, the usefulness of monitored release is questioned in the light of the relatively small amount of additional information arising from it.


Postoperative analgesia: a comparison of intravenous on-demand fentanyl with epidural bupivacaine.

In a randomised trial postoperative pain relief was provided by either epidural injections of bupivacaine or an infusion of fentanyl adjusted by the patient to achieve adequate pain relief. Both techniques produced satisfactory analgesia without respiratory depression after peripheral arterial surgery. The technique of infusing intravenously a potent analgesic in a dose adjusted by the patient appears to offer several advantages in postoperative care.


Gutter treatment for ingrowing toenails.

The gutter treatment for ingrowing toenails consists of introducing a small guard along the side of the toenail and requires only three outpatient attendances. The gutter is left in place for eight to 12 weeks and then removed by the patient. Two studies were carried out to establish the long-term results of the method. In one, a preliminary retrospective study, 13 out of 25 patients who had received the gutter treatment were cured after one year compared with five out of 15 patients in whom the toenail had been avulsed. In a randomised prospective study 20 out of 36 patients (56%) treated by the gutter method were cured after one year compared with 27 out of 32 (84%) in whom the wedge resection procedure had been used. The gutter treatment demands little skill and may be carried out in general practice. It gives an excellent cosmetic result with immediate pain relief and does not compromise further surgery should this be required, thus fulfilling the main requirements for the primary treatment of choice.


Maternal smoking habits and congenital malformations: a population study.

Maternal smoking habits in 67 609 singleton pregnancies were examined. The overall incidence of congenital malformations was 2.8% in both non-smokers and smokers. On analysing congenital defects according to individual systems there was no significant difference in the incidence of malformations according to the number of cigarettes smoked, except for neural tube defects. Further analysis, taking social class into account, showed that neural tube defects were less common in non-smokers in social classes I and II. This study suggests that maternal smoking does not have teratogenic effects in the offspring, except in the case of neural tube defects, where the effect is at most modest.


Autonomic neuropathy in rheumatoid arthritis.

Patients with seropositive and seronegative rheumatoid arthritis (RA) and age-matched controls were investigated for the presence of autonomic neuropathy. Significantly more patients with RA had abnormal autonomic function, suggesting that autonomic neuropathy occurs more commonly in RA than hitherto suspected. The existence of an autonomic neuropathy may be an important complicating factor in rheumatoid disease and may lead to increased morbidity and mortality.


Needle aspiration of the breast with immediate reporting of material.

Needle aspiration with immediate cytological reporting has been practised in a breast clinic for one year. Patients benefit by receiving immediately the provisional diagnosis and, when indicated, appointments for metastatic surveys. Close co-operation between surgeon and cytologist has resulted in increased skill in aspiration, better preparation of samples, and greater accuracy in interpretation of reports. Since 5% of clinically benign lesions have proved malignant, even on immediate reporting, we would recommend cytological examination of all breast lumps.


Ultrastructural study of satellite lymph nodes in syphilitic rabbits.

In an electron microscopy study of lymph nodes from syphilitic rabbits plasmablasts and plasma cells were unequivocally identified in germinal centres. Up to 20% of the plasma cells possessed unusual cytological features. Paracortical hypoplasia was shown to be associated with actively phagocytic histiocytes. These findings may reflect morphological correlates of the aberrant immune regulation which has been observed in infection with Treponema pallidum.


Treatment monitoring in syphilis using the autoanalyser.

Treatment monitoring in syphilis using the automated Reiter protein complement fixation test and the automated reagin test was investigated over a two-year period. Clearly defined response patterns were demonstrated in primary and secondary syphilis and, to a lesser extent, in latent syphilis, thus facilitating the assessment of treatment and the identification of treatment failures and reinfection. No obvious treatment failures were detected in those patients receiving penicillin, but two failures were noted in a group of patients with secondary syphilis treated with doxycyline. The combination of two automated tests overcame some of the disadvantages inherent in the use of a single reagin test.


Rapid presumptive diagnosis of gonococcal urethritis in men by the limulus lysate test.

In an evaluation of the limulus assay as a method for detecting endotoxin in urethral exudates, positive results of urethral samples at a 1/200 dilution were obtained from 73 out of 73 patients with culture-positive gonococcal urethritis while negative results were obtained from 26 out of 27 patients with cuture-negative urethral specimens. A specimen from one patient, which gave negative results on Gram stain and culture, gave positive results to the limulus test. The overall accuracy of the limulus test for predicting culture results was 99% (p less than 0.001). Thus, in preliminary studies of otherwise healthy men, the results of the limulus assay correlated with those of biological methods for diagnosing urethral gonorrhoea; the test may, therefore, be of use in identifying cases of nongonococcal urethritis.


Clinical pharmacological studies of amoxycillin: effect of probenecid.

In a study of eight, healthy adult volunteers given 3 g amoxycillin with or without 1g probenecid, significantly higher peak plasma levels of amoxycilin were recorded in the presence (34.96 microgram/ml) of probenecid than in its absence (22.72 microgram/ml). When plasma levels were plotted against time the mean area under the curve was significantly greater for subjects given probenecid than for those given amoxycillin alone. These findings suggest that 3g amoxycillin plus 1g probenecid provide better bioavailability than 3g amoxycillin alone. The plasma levels obtained were several times higher than the minimun inhibitory concentrations (MICs) of most strains of gonococci. Plasma levels in excess of the MICs for most strains were maintained for eight hours with both regimens, but the higher levels in the presence of probenecid support the better clinical results previously reported with this regimen.


Reinfection with disseminated gonococcal disease.

A 20-year-old prostitute was admitted to hospital with joint pains and a macular and pustular rash on the fingers and feet on two occasions. Disseminated gonococcal infection was diagnosed and successfully treated.


A retrothalamic system of collateral fibers from the cerebral peduncle.

Ramón y Cajal described a sizeable bundle of collateral fibers from the cerebral peduncle and called it 'faisceau de Forel'. This bundle has been consistently ignored by recent authors, possibly because of the difficulty to visualize it in transversal section. It is described here as the fasciculus prerubralis, or FPR. It originates at the level of the transition from the nucleus subthalamicus to the substantia nigra. In sagittal-stained sections of the mouse brain stained with the rapid Golgi method it can be seen following an ascending and nearly vertical course. It arches caudalwards, and appears to terminate in the rostral tegmentum. In the cat, Nauta-stained material proved that the corticofugal fibers which contribute to this system originate preponderantly, if not exclusively, in the pericruciate gyrus. Following lesions in this cortical area one could observe, in addition to the degenerating fibers of this bundle, another system of degenerating direct cortico-tegmental fibers which coursed toward the rostral tegmentum. It is not clear whether this second degenerating system resulted from the encroachment of passing fibers in the subjacent internal capsule. The tegmental prerubral collateral fibers from the cerebral peduncle were observed in mouse, rat and cat. Possibly, they could represent a general feature of the mammalian nervous system.


Neurochemical and histochemical studies of the effect of a lesion of the nucleus cuneiformis on the cholinergic innervation of discrete areas of the rat brain.

The innervation sites of the dorsal tegmental acetylcholinesterase (AChE)-containing pathway were examined in rats by combining histochemical and biochemical techniques. A lesion was placed in the nucleus cuneiformis (midbrain reticular formation) and brains were examined after 4 days survival for changes in AChE staining and choline acetyltransferase (ChAT) activity in discrete brain areas. An ipsilateral projection appears to exist to the anterior thalamic nuclei, lateral portion of the medial thalamic nucleus, parafascicular nucleus, pretectal nucleus, posterior thalamic nucleus, and deep layers of the superior colliculus. A possible bilateral innervation to the reticular nucleus of the thalamus and the dorsal and ventral lateral geniculates was found. The parallel use of AChE histochemistry and measurements of ChAT activity in discrete nuclei will be useful for future evaluation of cholinergic pathways.


The effect of penicillin on the release of gamma-aminobutyric acid from cerebral cortex slices.

Penicillin is known to block the depressant action of GABA on cortical and spinal neurons. In this study we examined the effect of penicillin on the release of endogenous amino acids from rat cerebral cortex slices. The principal finding was that penicillin blocked the potassium-stimulated release of GABA, a calcium-dependent process. It did not block the veratridine-stimulated release of GABA, a calcium-independent process. It did not affect the release of other putative transmitter amino acids. Inhibition of GABA release from nerve endings may explain in part the ability of penicillin to depress synaptic inhibitory mechanisms.


Localization of lumbar epaxial motoneurons in the rat.

In the rat, lateral longissimus and the lumbar transverso-spinalis muscles are lumbar trunk muscles, and participate in the lordosis reflex (female sexual posturing). Medial longissimus, the remaining major lumbar epaxial muscle, is a muscle of the proximal tail-tailbase. To allow an analysis of the motor control of lordosis, motoneurons for these muscles must be localized. Horseradish peroxidase (HRP) was injected into lumbar epaxial muscles of female rats. Following injection into medial longissimus, labeled cells were found posterior to the lumbar enlargement, ventrolaterally in the ventral horn. Following injections into lateral longissimus or into lumbar transverso-spinalis muscles, most labeled cells were found on the medial side of the ventral horn, extending through and anterior to the lumbar enlargement. Injections into lumbar transverso-spinalis muscles at more posterior levels led to more posterior locations of labeled cells. The distributions of the labeled cells agree with previous observations on innervation of the muscles. Additionally, the spinal cord was scanned for sites at which microstimulation produced visible twitches of medial longissimus or transverso-spinalis muscles. Locations of low threshold twitch sites were consistent with conclusions based on the HRP findings.


A critical period in the development of tectal neurons in the chick, as revealed by early enucleation.

To further study the existence of a critical trophic period in the development of the chick optic tectum, during which the presence of retinal synapses is essential to the continued growth of tectal neurons, we have unilaterally enucleated embryos between stages 14--20 and allowed survival until stages 35--43. If the critical trophic period is between stages 40--44, as previously reported, then we reasoned that early removal of the eye might not have any effect on tectal development until the critical period. We assessed tectal neuron survival by staining for degeneration in the efferent projections of tectal neurons. In early enucleates, degeneration was present from stages 37--43, and the severity of the degeneration was much reduced in comparison to animals enucleated during the critical period. These findings substantiate the proposition that there is a critical period late in chick tectal development. However, because the degeneration in tectal projections is less intense than in animals enucleated during the critical period, we suggest that the early enucleation has permitted axons from the remaining eye to be routed to the deafferented tectum, where they may help to sustain a portion of the tectal neurons through the critical period. Moreover, the somewhat earlier appearance of degeneration in tectal efferent pathways of early enucleates suggests that a subtle trophic relationship between retina and tectum may exist prior to stage 40, even though this relationship is not revealed when enucleations are performed later, as between stages 35--40 (ref. 17).