[Mortality trends in Switzerland 1951-1977. Principal categories of the causes of death].

Analysis of age-standardized death rates for the main categories of deaths, over the period 1951--1977, shows a three-quarter fall in mortality from infectious diseases, a reduction of mortality from cardiovascular disease more accentuated in women (-46%) than in men (-23%) and a decrease in mortality from tumors in women only (-21%). Suicide rates slightly increased and mortality from accidents started to decrease in 1971, more markedly in men than in women. As regards the last category including all other causes of deaths, a decline in mortality of approximately a half in both sexes was observed. Calculation of the potential years of life lost between ages 1 and 70 (PYLL) reveals that in men, for the year 1977, 25% were due to accidents, 23% to tumours and 22% to cardiovascular diseases, whereas in women tumours came first (36%) and preceded cardiovascular disease (17%). Analysis of PYLL by individual cause of death shows, in decreasing order of importance, for men: motor accidents, suicide, ischaemic heart disease, other accidents, cancer of lung, cerebrovascular disease and cirrhosis of liver, and for women: suicide, breast cancer, motor accidents, other accidents, cerebrovascular disease, ischaemic heart disease and uterine cancer. Finally, life expectancy at birth increased, over the period 1951--1977, from 66.4 to 71.8 years in men and from 71.0 to 78.4 years in women, which ranks Switzerland third among the 10 industrialized countries studies.


[Progress and developments in insulin therapy].

BANTING and BEST revolutionized diabetes therapy with the discovery of insulin 57 years ago. Since then, progress in this area has been slow despite tremendous reseach efforts. The subcutaneous injection of a depot insulin does not provide optimal control of blood sugar. True progress has been brought about by intravenous insulin administration for the management of diabetic coma. The authors do not recommend ultra low dose therapy. The prognosis of diabetic coma is much better than 20 years ago, in particular because of much improved and continuous supervision of the circulation (CVP, ECG, K+ etc.). Pancreas and islet transplantation fail in man due to immunological rejection. The "artificial pancreas" with a glucose sensor is useful for research purposes, and for controlling blood sugar for a few days at most. The implantable glucose sensor is not yet in sight. The authors have treated diabetics successfully with a programmable flexible open loop infusion program. The basal insulin infusion rate can be varied from 0.25 to 2 U/h, and rectangular one hour extra insulin infusions between 2 and 10 U/h are superimposed by pushing a button on the steering unit. The pump automatically switches back to the basal rate after one hour. No hypoglycemic reactions have been observed in patients on ths program on the ward or at home. At present, technical problems with the catheter remain to be solved before this simple therapeutic approach can be applied routinely.


[Determination of capillary lesions during diagnosis by means of the tourniquet test of microangiopathies in diabetes mellitus].

Decreased capillary resistance is documented by a pathologic tourniquet test (Rumpel-Leede), which demonstrates the existance of microangiopathy in diabetics. Thanks to its simple and rapid execution the tourniquet test is suitable for early diagnostic assessment of the situation in the microcirculation. The longer the patients have had diabetes, the more frequently is the tourniquet test pathological. There is also a direct correlation between the type of therapy (as an index of the severity of the disease) and the accumulation of pathologic results in measurement of capillary resistance. In diabetics with hypertension, capillary resistance is always decreased to a pathologic degree.


[Changes in storage and oxydation of ingested glucose in obesity and diabetes mellitus].

Indirect calorimetric studies were performed during a 100 g oral glucose tolerance test in diabetic patients with varying degrees of endocrine pancreatic dysfunction and in a control group of normal subjects. In 3 obese diabetics the study was repeated after a 3 day protein sparing modiefied fast. In diabetic patients the results show alterations of oxidation and storage of carbohydrates, related to insulin secretion deficiency on the one hand, and to overweight on the other. Endocrine pancreatic insufficiency may account directly for alterations observed in individuals with decreased or absent insulin response to glucose load, wheras metabolic factors such as adipose mass, hepatic steatosis, and peripheral insulin resistance appear to be responsible for alterations in carbohydrate oxidation and storage in subjects with relative endocrine pancreatic insufficiency, particularly obese diabetics.


[Advantages and disadvantages of insulin therapy in elderly diabetics with asymptomatic hyperglycemia].

15 elderly diabetic patients with fasting blood glucose levels above 160 mg/100 ml, without hyperglycemic symptoms and previously treated with oral antidiabetic agents, were put on insulin. The change of treatment regimen was made in the outpatient department. Frequent clinical and laboratory controls were performed and the patients were given full instructions for injection technique and diet. On the insulin regimen a prompt and lasting improvement was observed in the metabolic parameters (blood glucose levels both fasting and after food intake, Hb A1c, serum insulin, glucagon and serum lipid concentrations). The so-called "asymptomatic" patients noticed a marked improvement in their general status and performance. Three months after insulin therapy was started 13 of our 15 patients preferred the insulin treatment to oral agents. However, weight gain and a tendency to hypoglycemia were noticed in less disciplined patients. In addition, considerable time was spent on instruction of the patients. Bearing these factors in mind, insulin therapy in elderly diabetics with so-called "sysmptomatic hyperglycemia" can be regarded as worthwhile.


[Mortality from diabetic coma at the Basle Cantonal Hospital during 2 consecutive observation periods 1968-1973 abd 1973-1978, using conventional insulin therapy and treatment with lose dose insulin].

163 patients were admitted to the Cantonal Hospital, Basel, during the decade 1968--1978 with severe diabetic ketoacidosis or non-ketotic coma. The hospital mortality rate was 28% in the first period (1968--1973) but decreased to 14% (p less than 0.025) in the second period (1973--1978). The lower mortality rate in the second period was due to diminished early mortality within 3 days after admission. The decline in the mortality rate during the second period was assumed to be due to a general improvement of treatment and possibly to a direct effect of low-dose insulin therapy. The latter conclusion followed from the fact that the remaining recompensation therapy, such as fluid and electrolyte replacement, was similar during both periods. However, in the non-ketotic patients low-dose insulin therapy resulted in a delayed fall in blood glucose and distinctly diminished potassium retention. The fatalities in the second period of treatment were mainly due to thromboembolic complications. This points to the need for a search for preventive measures against thromboembolism in order to resuce mortality in severe diabetic coma further.


[Hepatitis following acupuncture].

Three patients with hepatitis B are presented whose common source of infection was attributed to a physician practising acupuncture. The contamination appears to be due to repetitive use of the same needles for insertion. Among the different side effects of acupuncture, hepatitis B may thus be a serious complication if the needles used are not properly autoclaved.


[Delayed elimination of aminoglycoside antibiotics: importance for clinical use].

In 7 patients the elimination of amikacin (4), tobramycin (1) and gentamicin (2) in serum and urine was measured over several days after cessation of therapy. All three aminoglycosides showed multicompartmental pharmacokinetics with a terminal half life ranging between 46 and 150 hours. Using computer simulations, it is shown that slow drug accumulation in the body is to be expected during multiple dose therapy. Therefore, the indiscriminate use of these drugs should be avoided and the duration of therapy kept as short as possible.


Studies on a new antiarrhythmic drug changrolin-4-(3',5'-bis [(N-pyrrolidinyl) methyl]-4'-hydroxyanilino)-quinazoline.

Changrolin is 4-(3', 5'-bis[(N-pyrrolidinyl)methyl]-4'-hydroxyanilino)-quinazoline. It is a novel type of antidysrhythmic drug. It has been synthesized in 4 steps. According to our experiments, changrolin exhibited significant protective and therapeutic effects against experimental arrhythmias induced by aconitine or ouabain. It raised the electrical threshold of ventricular fibrillation. Intravenous injections in dogs and rabbits caused (i) a mild tachycardia followed by bradycardia; (ii) a prolongation of P-R interval and a widening of QRS complex in the electrocardiogram; (iii) a gradual hypotehsion; (iv) a slight weakening of cardiac functions; and (v) only moderate influences on the hearts of dogs and rabbits when the rate of infusion was less than 1 mg/min. Changrolin could be well absorbed by oral administration. Absorption appeared to be more rapid and complete by intramuscular injection. 14C-labelled changrolin was distributed mainly in the liver and the alimentary tract.


Application of stepwise cluster analysis in medical research.

A stepwise clustering algorithm, a method of multivariate statistical analysis, is suggested in this paper. The algorithm is designed for solving problems connected with stepwise regression. It is efficient not only in handling both continuous and discrete variables, but also in the nonlinear relationships between the variables. The above procedure was used in an attempt to find out the causal association of esophageal cancer with its precursors, i.e. nitrates and nitrites of nitrosamines, some of which are known to be carcinogenic. An analysis has been made of the correlation between esophageal cancer as well as severe epithelial hyperplasia of the esophagus and the concentrations of NO3- and NO2- in the drinking water. The samples used were collected from 495 wells in 49 production brigades of the Yaocun Commune in Linxian County, Honan Province. The result indicates that esophageal cancer is definitely connected with the levels of NO3- (summer) and NO2- (spring) in the drinking water. Severe epithelial hyperplasia is defintely connected with the contents of NO2- and NO3- in the drinking water collected in spring, autumn and winter. Our preliminary analysis shows that the stepwise clustering algorithm is a useful statistical method to be used for medical research.


Generation of unidirectionally propagated action potentials in a peripheral nerve by brief stimuli.

Single, unidirectionally propagated action potentials can be elicited in peripheral nerves by electrical stimuli of short duration. Propagation in one direction is blocked anodically by means of a quasi-trapezoidal stimulus wave form and a modified tripolar electrode configuration. Propagation in the other direction proceeds unhindered. This technique may be applicable to collision blocking of motor nerves for neural prostheses.


Metabolism of theophylline to caffeine in human fetal liver.

Caffeine (1,3,7-trimethylxanthine) is a biotransformation product of theophylline (1,3-dimethylxanthine) in the human fetus. Liver explants, obtained from human fetuses with gestational ages of 12 to 20 weeks, were incubated with theophylline and produced caffeine and, in lesser amounts, 1,3-dimethyluric acid and 3-methylxanthine. These findings suggest that the predominant pathway in theophylline metabolism in the fetus and newborn infant is the methylation reaction producing caffeine. This may contribute to the neonate's exceedingly slower elimination of caffeine relative to theophylline. Caffeine produced from theophylline may add to the pharmacologic effects of theophylline in newborn infants with apnea.


Choline excites cortical neurons.

In cats under halothane or methoxyflurane, iontophoretic applications of choline are only eight times weaker than applications of acetylcholine in evoking firing of neurons in the sensorimotor region of the cerebral cortex. The action of choline is suppressed by atropine but not by two agents that block choline uptake (hemicholinium-3 and triethylcholine), and is not potentiated by an anticholinesterase (physostigmine). Choline therefore appears to excite cortical neurons by a direct action, which may be a significant component of its beneficial therapeutic effects.


Shifts in perception of size after adaptation to gratings.

After viewing a suitable grating of vertical stripes for 5 minutes, subjects overestimated the width of a rectangle by 6 percent. The shifts in perception of size occurred whether individual stripes in the grating were narrower than, equal to, or wider than the rectangle. Rectangle width was underestimated only if the grating stripes were extremely wide, with a spatial frequency lower than most of the effective amplitude spectrum of the rectangle. These findings (and complementary ones with horizontal gratings) suggest that the visual system codes size on the basis of spatial frequency components, rather than directly in terms of width.


Genetic resistance to aflatoxin in Japanese quail.

Progress was rapid in attempts to develop lines of quail resistant to acute aflatoxicosis induced by oral dosing with aflatoxin. After five generations of selection, 8- and 11-fold differences were present in mortality between two selected lines and their respective control lines. These quail lines should be of value in investigating the physiological basis of resistance to aflatoxin.


The radiology of rheumatoid involvement of the cervical spine.

The radiological features of cervical spine involvement in rheumatoid arthritis are described. These include atlanto-axial subluxation, in both the horizontal and vertical planes, sub-axial dislocation, erosions, and vertebral end plate sclerosis. Detailed radiological investigation, using inclined plane radiography, auto-tomography, tomography, and myelography may all be required to demonstrate the abnormalities. Disorders of mobility can only be assessed with dynamic views and fluoroscopy and the mechanics of these derangements vary depending on the type of subluxation encountered. The cumulative effects of the lesions conform to certain characteristic patterns and include marked reduction of neck height, disorders of mobility, and changes in the capacity of the spinal canal. The discrepancy between these changes and the clinical and neurological findings is discussed.


Ultrasound appearance of myositis ossificans.

Ultrasonic evaluation of a soft tissue mass of the thigh was performed and suggested the diagnosis of myositis ossificans. Correlation with routine radiographic studies is made, as well as with the follow-up radiographic examination.


Osgood-Schlatter's disease, an emphasis on soft tissue changes in roentgen diagnosis.

Osgood-Schlatter's disease is a well known entity affecting the adolescent knee. Radiologic examination of the knee has been an integral part of the diagnosis of this condition for decades. However, the soft tissue changes have not been appreciated sufficiently. Emphasis is placed on the use of optimum radiographic technique and xeroradiography in the examination of the soft tissues of the knee.


Pseudoaneurysm of the popliteal artery as a complication of an osteochondroma.

This is a report of mechanical compression and transection of the popliteal artery by an osteochondroma, documented angiographically and pathologically, in a patient hospitalized for endocarditis.


The value of traction during roentgenography of the wrist and metacarpophalangeal joints.

Traction on wrist and metacarpophalangeal joints during radiography produces 'vacuum phenomenon' due to the release of intra-articular gas. The resultant pneumoarthrogram clearly portrays the articular cartilage. Manual traction radiography of the wrist and the metacarpophalangeal joints has the following potential uses. 1. Detection of joint effusion; increased interosseous space during traction without release of intraarticular gas is indicative of joint disease with effusion. 2. Separation of the carpal bones; the traction separates the carpal bones and allows evaluation. 3. Differentiation of arthralgia from arthritis. 4. Evaluation of midcarpal, radiocarpal compartments, and the metacarpophalangeal joints can be performed before the secondary ossification centers are ossified. 5. Evaluation of the integrity of the joint cartilage.


Periosteal bone apposition in chondroblastoma.

Periosteal bone apposition in chondroblastoma of long bones is more frequent than generally recognized. This should not cause confusion in differential diagnosis. The findings does not seem to have prognostic significance.


Hypertrophy of the talar beak.

Hypertrophy of the talar beak is the product of traction of the insertion of the joint capsule. It is commonly seen in athletes and may be entirely asymptomatic despite its size. It should not be mistaken for spurring of the articular margin of the talus which is seen in tarsal coalition.


Angiography in myeloma (plasmacytoma). A correlated angiographic and histologic study.

Angiography was performed in ten cases of myeloma (plasmacytoma), of which nine were solitary on admission. All lesions were hypervascular bone tumors with extension of neoplastic growth into adjacent soft tissue. Contrast uptake of the tumors occurred regularly and usually was non-homogeneous. In nearly all cases irregular tumor vessels and early venous drainage was evident with arteriovenous shunting in three. Pathologic-anatomic correlation demonstrated 'tumor vessels' to be newly formed vascular spaces lacking the normal constituents of vessel walls. The contrast uptake presumably was caused by passage of contrast into the newly formed, slit-like capillary vascular spaces. Angiography usually permitted separation of myeloma from benign, hypervascular bone lesions. The procedure proved to be of particular value in indicating definite malignancy, since myeloma was considered initially as the probable diagnosis in only one of the series. It was not possible, however, to differentiate myeloma from other malignant tumors by plain radiography or angiography. Irreversible renal failure occurred in one patient after angiography.


Cutaneous myiasis in visitors to Central America.

Six cases of cutaneous myiasis occurred in three groups of visitors to Guatemala between February and May 1978. Attack rates ranged from 12% to 50%. Furuncular lesions were generally multiple and involved both exposed and usually unexposed areas of the body. Parasitic fly larvae recovered from two patients were identified as the botfly, Dermatobia hominis. Botfly infestation is endemic in areas of Central and South America and is acquired indirectly through the bite of carrier arthropods, including mosquitoes. Although reports of cases in North Americans visting endemic areas are rare, the condition is probably much more common in such persons than it is currently believed to be. A history of travel to Central or South America should suggest the diagnosis.


How and when to use barium for diagnosis of small bowel obstruction.

The diagnosis of intestinal obstruction is readily made when a patient presents with typical history and signs, and when plain films of the abdomen display characteristic findings. Some patients, however, constitute diagnostic problems because abdominal roentgenograms are still equivocal, even after repetition in four hours. In the unclear case, use of a barium meal will safely, promptly, and routinely prove or disprove small bowel obstruction. Intestinal obstruction in which the initial abdominal films tend to be either unrevealing or equivocal include high obstructions, including the superior mesenteric artery syndrome; presence of strangulation; partial small bowel obstruction; and fluid-filled proximal bowel. In intestinal obstruction, characteristic roentgenographic findings with use of barium meal are normal to rather rapid transit time to the point of obstruction; homogenous dilution of barium in dilated proximal loops; and inhomogenous, scattered, and fragmented collections of barium in the distal, collapsed loops.


Management of persimmon bezoars (diospyrobezoars).

Since 1946, 20 men and one woman aged 40 to 76 years (average 57) were operated upon for complications of diospyrobezoars. Shortly after eating persimmons, 11 (52.4%) had severe abdominal cramping, anusea, vomiting, and pyrexia. Twelve of 17 (70.9%) with gastric bezoars had hematemesis or melena caused by an associated gastric ulcer, while five (29.1%) had only moderate dyspepsia. In four (19.1%), the bezoar had lodged in the ileum, causing obstruction. Enzymatic therapy is indicated in those with minor symptoms. Gastrotomy or gastrotomy with bezoar removal and wedge resection of the gastric ulcer is recommended when enzymatic therapy fails, or when there is gastric outlet obstruction or marrise hemorrhage. Emergency exploration with removal is necessary when the persimmon bezoar causes ileal obstruction.


Results of corrective surgery for alkaline reflux gastritis.

Reflux alkaline gastritis and esophagitis have been incriminated as a source of symptoms in achlorhydric patients afer operation for duodenal ulcer. Documentation of such pathologic findings has increased due to widespread use of fiberoptic endoscopy. As reported in the literature, results of remedial operations have ranged from encouraging to excellent, and evaluations have been uniformly laudatory. Correlation of the extent of symptoms and of pathologic findings has been difficult, and our results have not been as good as those reported in the literature. During a six-year period, the diagnosis of bile reflux gastritis in 13 patients was based on a characteristic symptom complex, endoscopic appearance, and histopathologic confirmation. Either a Roux-en-Y gastrojejunostomy or a Tanner-Roux 19 was the corrective procedure. There was complete relief of symptoms in five patients (38%) and partial relief in four, but no apparent relief in four others. In at least three of the patients, chronic gastritis and/or esophagitis have persisted and have not improved despite biliary diversion. Tabulation of the results of 13 remedial operations for reflux alkaline gastritis disclosed that copmlete relief of symptoms was achieved in 50% of those who had the Roux-en-Y and in 20% of those who had the Tanner 19 procedure. Based on our findings, we recommend a cautious approach to the surgical management of alkaline gastritis.


Pancreatic and duodenal injuries: morbidity and mortality of surgical management.

A retrospective review of pancreatic injury is presented. Twenty-five cases in which the pancreatic injury was either the sole or major injury were selected from over 100 cases of pancreatic injury admitted during the period 1970 to 1977. Eight pancreatic injuries resulted from blunt trauma and 17 from penetrating trauma. Two methods of treatment were compared, drainage alone versus duodenal diverticularization and/or distal resection. There were no deaths. Of the 15 patients treated by drainage alone, 14 (93%) developed postoperative complications, as compared to 20% (two of ten patients) treated by diverticularization and/or distal resection.


Pelvic recurrence of cancer after abdominoperineal resection of the rectum.

Records of 122 patients with carcinoma of the rectum treated by abdominoperineal resection at M. D. Anderson Hospital and Tumor Institute between 1967 and 1972 were reviewed with regard to local pelvic recurrence and survival. Local recurrence rates for men were: stage IB, 14%; II, 23%; and III, 21%; and for women: IB, 6%; II, 15%; and III, 35%. Forty-one percent of the male patients and 54% of female patients had nodal metastasis at the time of their initial operation. The high pelvic recurrence rates in women may lend support to consideration of a posterior exenteration in all female patients with advanced carcinoma of the rectum.


Small cell carcinoma of the lung: results of combination chemotherapy and radiation therapy.

A retrospective study of 244 patients treated for small cell carcinoma of the lung from Jan 1, 1971 to Dec 31, 1976 revealed that 34% of patients, with local-regional disease who received radiation alone survived one year (median survival, seven months), and 53% with local-regional disease survived one year (median survival, 12 months) when treated with combination chemotherapy and radiation. The one-year survival for patients presenting with metastatic disease was 14.5% (median survival, five months) when treated with radiation alone and 50% (median survival, 11 months) when treated with combination chemotherapy and radiation. Although combination chemotherapy and radiation will prlong the disease-free interval in patients with small cell carcinoma of the lung, more than 90% will develop evidence of progressive disease within two years.


Comparison of staphylococcal and nonstaphylococcal endocarditis in narcotic addicts.

In a 54-month retrospective review, we compared the clinical features of 26 narcotic addicts with staphylococcal endocarditis (group 1) and ten other addicts with nonstaphylococcal endocarditis (group 2). The admission temperature and the respiratory rate of patients in group 1 were significantly higher (P less thn .05 and less than .02 respectively) than those of patients in group 2. Group 1 also differed from group 2 in the following variables: (1) bilateral multiple pulmonary infiltrates in 46% vs none in group 2; (2) greater incidence of symptoms referable to the central nervous system (50% vs none in group 2); and (3) gastrointestinal symptoms of vomiting, diarrhea, or constipation in 62% vs 10% in group 2. Serious cardiovascular, renal, and other complications were more frequent in staphylococcal endocarditis. Tricuspid regurgitation occurred with equal frequency in both groups and was of no value in differentiating staphylococcal from nonstaphylococcal endocarditis.


Colposcopy in anorectal disease.

The colposcope was introduced into colon and rectal surgery for the evaluation of anal and perianal disease. The standard technics of gynecologic colposcopy were used. The indications included evaluations of pruritus ani, condyloma, mass lesions, unexplained bleeding or pain, and follow-up of patients previously treated for carcinoma of the anus or lower rectum.


Tuberculous peritonitis.

Tuberculous peritonitis is an uncommon disorder and is often not considered on initial evaluation of ascites. A negative 5-TU PPD test, a normal chest roentgenogram, or a low level of ascitic fluid protein may erroneously direct attention away from tuberculosis. Failure to thoroughly evaluate nonmalignant exudative ascites, especially in alcoholics, is a common diagnostic pitfall. TB peritonitis should be considered in the differential diagnosis in every patient who presents with ascites, fever, and abdominal pain, particularly when alcoholism, a lung lesion, weight loss, or cirrhosis is also present. Percutaneous needle biopsy of peritoneum, followed by peritoneoscopy if necessary, may preclude the need for laparotomy. Antituberculous drugs, when conscientiously taken, afford a rapid response with a cure in most patients. Case material on four patients is presented.


Clearance of lidocaine by hemodialysis.

Because little has been known regarding the dialyzability of lidocaine, we studied the clearance of this drug by hemodialysis. The dialysance of lidocaine was found to range between 10.6 to 21.3 ml/min. Lidocaine-urea extraction ratio averaged 11%. Because of the low therapeutic and even toxic plasma levels, the amount of drug removed by dialysis is negligible. Therefore, dose adjustment is unnecessary during dialysis, and dialysis appears to be of little help in the treatment of lidocaine toxicity.


Esophageal perforation in an infant: repair with a pleural flap.

Most esophageal perforations regardless of cause, should be treated surgically. Since anatomic features of the esophagus make even small rents difficult to close, a variety of technics have been developed. Flaps of pleura have been used in adults, but to our knowledge this technic has not been previously described in infants. We used a local pleural flap for successful closure of a large esophageal perforation in a 2-week-old infant. Rapid healing occurred without stricture.


Citrobacter freundii meningitis in an adult.

We have described the first case of an adult patient with Citrobacter freundii meningitis, which was successfully treated without administration of intrathecal aminoglycoside.


Agranulocytosis during combined procainamide and phenytoin therapy.

We have presented two cases of agranulocytosis occurring in patients receiving a combination antiarrhythmic regimen. As multiple drug therapy for ventricular arrhythmias becomes more commonplace, increased scrutiny should be given to agents chosen, in an effort to prevent any possible adverse interactions. When future cases are encountered, the acetylator pheontype should be determined. This information would aid in assessing the predicative value of the acetylator phenotype in the development of agranulocytosis. Due to the inherent danger, neither patient was rechallenged with procainamide nor phenytoin.


Lithium carbonate therapy for granulocytopenia in a patient with myelofibrosis and septic arthritis.

We report a patient with myelofibrosis, granulocytopenia, and septic arthritis, in whom lithium carbonate induced a more appropriate granulocyte count. Further evaluation of the use of lithium carbonate in granulocytopenic states seems warranted.


Value of bone scan in primary sternal osteomyelitis.

Roentgenographic examination of the sternum is particularly difficult and offers little clinical assistance in the early stage of acute osteomyelitis. With only a few cases of primary sternal osteomyelitis reported, there are almost no data available regarding the role of bone scan in the diagnosis of this lesion. The present case illustrates the usefulness of the scan both in diagnosis and management of sternal osteomyelitis.


Giant pheochromocytoma with sarcoidosis.

We describe a case of an asymptomatic patient with a huge left abdominal mass, which at operation was found to be a cystic pheochromocytoma weighing over 3,000 gm. A dignosis of sarcoidosis was established simultaneously, with the discovery of sarcoid granulomas in abdominal nodes and within the tumor mass itself. This is only the second observation of coexistent sarcoidosis and pheochromocytoma, and with the paucity of related literature, we conclude the association is probably fortuitous.


Hyperglycemia and diabetic coma: possible relationship to diuretic-propranolol therapy.

Two patients developed diabetic coma when taking a combination of a thiazide diuretic and propranolol. On subsequent follow-up one patient is taking no insulin and has been maintained on hydrochlorothiazide; the other patient required insulin on two occasions when challenged with a propranolol-thiazide combination, but not when the thiazide was discontinued or replaced with furosemide. These reports suggest the possibility that the risk of developing hyperglycemia and diabetic coma with this combination may be greater than when taking diuretics alone. The mechanism is probably multifactorial.


Splenic infarction in a white man with sickle cell trait.

We report the third case of splenic infarction from sickle cell trait in a young white man traveling through mountains. Apparently the hypoxemia at 10,800 feet, along with a relatively high hemoglobin S concentration of 40%, interacted with the known conditions of splenic blood flow to cause sickling and infarction, even though our patient was not exercising. The optimal management for this rare complication of sickle cell trait remains unknown, but surgery may not be required for either diagnosis or therapy.


Asymptomatic cecal stenosis after necrotizing enterocolitis.

Survival of infants with necrotizing enterocolitis may be complicated by intestinal stricture(s) as a result of healing of ischemic segments of bowel. An asymptomatic cecal stenosis not visible on barium enema was identified at operation for reestablishment of intestinal continuity. Infants recovering from acute necrotizing enterocolitis deserve continued surveillance for mechanical and functional abnormalities of the gastrointestinal tract. Patency of the intestinal lumen distal to the ostomy site should be clearly demonstrated by the surgeon when continuity is reestablished.


Pigmentation of the tongue and mucous membranes associated with cancer chemotherapy.

Hyperpigmentation of the tongue and buccal mucosa was observed after administration of conbination chemotherapy containing doxorubicin. The pigmentation lessened after discontinuation of doxorubicin, suggesting this drug as the possible causative agent.


Renal vein thrombosis associated with nephrotic syndrome and gold therapy in rheumatoid arthritis.

In this case of renal vein thrombosis secondary to a nephrotic syndrome, we postulate renal disease resulted from gold therapy. We know of no previous report relating gold toxicity and renal vein thrombosis. It should be emphasized that with increasing use of gold, proteinuria and nephrotic syndrome may be more common than once suspected and, when present, predispose to the development of renal vein thrombosis.


Isolated central nervous system histoplasmosis.

A solitary localized Histoplasma infection of the central nervous system, a "histoplasmoma," may mimic a neoplastic brain tumor clinically and radiographically and should be considered in a differential diagnosis of localized central nervous system mass lesions.


Pseudoneurilemoma of the spinal canal.

Two cases are presented with the myelographic appearance of an intradural tumor believed to be neurilemoma. In one instance the defect was undoubtedly caused by a cicatrix which developed over a period of years, consequent to postoperative spinal fluid fistula. In the second case a herniated disk at the L2-3 level was mistaken as artifact and its true nature was revealed only at operation seven years later. It was suspected to be neurilemoma because of the myelographic appearance and persistence of the lesion.


Severe tracheal stenosis after brief endotracheal intubation.

The most serious complication of endotracheal intubation is ischemic mucosal necrosis and subsequent stenosis caused by excessive cuff pressure. An instance of tracheal stenosis occurring after only 72 hours of intubation is presented. Resection of the stenotic segment with primary end-to-end anastomosis was curative. There has been no recurrence after six months.


Percutaneous transhepatic cholangiography to diagnose carcinoma of the ampulla of Vater.

A case of carcinoma of the ampulla of Vater was diagnosed preoperatively by percutaneous transhepatic cholangiography using the Chiba needle. A dilated pancreatic duct is a radiologic sign diagnostic of early ampullary carcinoma.


Spontaneous retroperitoneal bleeding during acute hemodialysis.

We report a case of spontaneous retroperitoneal bleeding in a patient requiring acute hemodialysis. Both hemodialysis and peritoneal dialysis are either contraindicated or will worsen the problem. Prompt surgical intervention was life-saving.


Problems of diagnosis of disseminated intravascular coagulation (DIC).

Acute generalized intravascular coagulation is regularly associated with fibrinolysis. Evidence of the clotting process includes thrombocytopenia, hypofibrinogenemia, prolongation of the prothrombin time (deficiency of factor V and fibrinogen) and of the partial thromboplastin time (factor VIII is also deficient). Evidence of fibrinolysis is elevation of fibrinolytic split products (FSP or FDP). A positive protamine gel results from both coagulation and fibrinolysis.


Dipyridamole in the treatment of dengue haemorrhagic fever.

Clinical studies in the treatment of 54 children suffering from DHF with a combination of dipyridamole and ASA as an adjuvant of our standard therapy consisted of fluid, electrolytes, blood, plasma and plasma expanders were evaluated. Heparin was administered in cases of DIC. It appeared that dipyridamole and ASA did not change the mortality significantly, but it prevented the progress of the severity of the disease from grade I and II to grade III and IV.


Investigation of coagulation abnormalities in patients with erythema nodosum leprosum.

Twenty erythema nodosum leprosum (ENL) patients were examined. Coagulation studies were carried out in 13 of them during their active stage and 7 in the latent stage. From these 13 patients, 6 were re-examined when the disease became latent. From these observations a conclusion can be drawn that there are coagulation abnormalities in the majority of ENL patients in the active stage and these abnormalities will return to normal values when the disease becomes latent.


Coagulopathy in nephrotic syndrome at the time of renal biopsy.

Two cases of nephrotic syndrome with coagulopathy were presented. The first case was due to acquired factor IX deficiency. The second case was due to unexplanable prolonged thrombin time.


Thrombo-embolism in minimal change nephrotic syndrome.

A case report of thrombo-embolism in minimal change nephrotic syndrome was presented. Autopsy revealed massive bilateral pulmonary emboli, edema and congestion, bilateral adrenocortical atrophy and left renal vein thrombosis. Thrombo-embolic phenomenon should be borne in mind during management and treatment of nephrotic syndrome.


Haemorrhage in neonatal hepatic necrosis due to herpes infection.

A case of early neonatal severe bleeding and persistent hypoglycemia with a fatal outcome is reported. The autopsy examination revealed the features of neonatal hepatic necrosis. Further study by the electron microscopy indicated the presence of herpes type particles in the nucleus and cytoplasm of the remaining liver cells. Serological study of the maternal blood, post partum, revelaed positive reaction to Herpes simplex virus type 2 at low titer. It is believed that intrauterine herpes infection was responsible for the severe hepatic damage manifesting in complex clinical findings.


Current status of spinal cord monitoring.

Spinal cord monitoring, as currently practiced, requires a source of sensory stimulus, transmitted through filters and amplifiers, to result in an enhanced signal, which is recorded and studied. Three techniques are under investigation. In one, the stimulation and responses are recorded directly from the dura. In another, the stimulus is applied to a peripheral nerve and the response is gathered from vertebral bone. The third utilizes responses in the form of cortical evoked potentials, with the stimulus applied to peripheral nerves.


Evoked spinal potentials as a monitor of spinal cord viability.

To determine the diagnostic and prognostic significance of evoked spinal potentials (ESPs), reproducible, compressive spinal cord lesions were produced in dogs under ESP monitoring. Both motor recovery and histologic findings were investigated in relation to the amplitude and persistence of the ESPs. Animals that had moderate, anterior compression (51% of canal width) in which the ESP was maintained had considerable motor recovery. Among animals that had submaximal compression (60%), motor recovery was good in those with persistent ESPs. The compression ratio at which ESPs terminated (67%) was termed the "electrophysiologic maximum tolerable compression." Continuous ESP expiration resulted in irreversible lesions and loss of motor recovery. Compressive spinal cord lesions of reproducible, graded severity were employed for the first time in our study of ESP. Persistence and amplitude were both useful in predicting not only the severity and extent of this type of lesion but also the recovery.


Diagnosis of the level and severity of cord lesion in cervical spondylotic myelopathy. Spinal evoked potentials.

Experimental and clinical studies were performed to measure the segmental spinal evoked potential (SEP) of the cervical cord after stimulation of the median nerve, to determine the location, severity, and outcome of cord lesion in patients who had cervical spondylotic myelopathy. The SEP in control subjects consisted of two waves, the primary reactive R-wave and the secondary reactive N-wave. The R-wave related to both the dorsal root potential and the funiculus posterior potential; the N-wave related to the post-synaptic potential in the spinal cord. In the early stages of cervical spondylotic myelopathy, the N-wave weakens or disappears at the level of lesion. Then, as damage progresses, the R-wave also weakens or disappears.


Spinal cord monitoring using evoked potentials recorded from feline vertebral bone.

A new recording method for continuous spinal cord monitoring has been developed at Rancho Los Amigo Hospital. Using peripheral nerve stimulation, spinal evoked potentials (SEPs) are recorded from cancellous bone of spinous processes. This neurologically noninvasive technique provides a highly reproducible and consistent signal, unaffected by biologic noise and surgical handling of the spinal column. Moreover, the evoked response is extremely sensitive to changes in functional integrity of the spinal cord. In experimental spinal cord injuries, produced by localized distraction of the spine, changes of the evoked responses were well correlated with the change in spinal cord function.


Spinal evoked potentials from the cervical spine.

Spinal cord evoked potentials were recorded from spinous processes of the lumbar, thoracic, and cervical levels of the spinal column of normal cats in response to direct stimulation of the sciatic nerve and subcutaneous stimulation of the posterior tibial nerve. The typical primary response was altered by changes in location, magnitude, and frequency of the stimulation. Further changes in the primary response could be associated with spinal level of observation. Reduction in amplitude and decrease in signal complexity with increasing frequency of stimulus indicated the loss of the slower components of the primary response of average evoked potentials. Sharp reduction of signal amplitude and increase in latency was evident as the recording moved from L1 to C3 and C2.


Somatosensory evoked potentials during decompression and stabilization of the spine. Methods and findings.

As part of a study to determine if decompressive surgery benefits patients who have incomplete lesions of the spinal cord, the somatosensory evoked potential (SEP) has been employed as an intraoperative spinal cord monitor. This procedure was used to see if decompression results in any rapid changes in spinal cord conductivity and to correlate these findings with the patient's subsequent clinical course. In addition to trauma, however, other factors also affect the SEP, and these must be recognized if intraoperative monitoring is to be successful. Frequency of stimulation, wakefulness, and anesthetic agents alter the wave-form and amplitude of the SEP. Using nitrous oxide, oxygen, meperidine (or morphine), and a muscle relaxant for anesthesia, and stimulating at frequencies of 1 or 2 per second, 11 patients with cervical or upper thoracic lesions have been monitored. There was no loss or diminution of an SEP and no patient was neurologically poorer afterwards. In 4 patients, the SEP "improved" soon after decompression. Clinical outcome, however, was not related to whether the SEP changed or remained the same. In total, 8 patients subsequently improved functionally and 3 did not.


Transoral microsurgical odontoid resection and spinal cord monitoring.

Four patients underwent transoral resection of the odontoid with utilization of microsurgical technique and spinal cord monitoring of somatosensory cortical evoked responses. All patients improved following surgery, and no operative morbidity or mortality was encountered. Spinal cord monitoring enhances the safety of the procedure and, reapplied at a later date, detects information of prognostic value.


Degenerative lumbar scoliosis.

Recent work on degenerative lumbar curves has focused on stable deformities with entrapment syndrome secondary to spondylotic compression. A review of our local experience with degenerative lumbar curves shows that approximately half of the 14 cases have had a less typical radiographic presentation of short reciprocating lumbar curves thought to be on the basis of asymmetric intervertebral osteochondrosis. In these latter cases, marked spondylotic ridging and intervertebral buttressing were absent; therefore, major decompressive surgery on the residual posterior elements may increase instability and hasten further collapse. Although most patients have had good relief of radicular leg complaints with decompressive procedures, several patients had persistent low-back pain that appeared to have a mechanical basis. In those instances of potentially increased postoperative instability or persistent mechanical back complaints, consideration should be given to augmenting decompressive procedures with Harrington instrumentation and fusion for these painful collapsing lumbar spines.


Symptomatic lumbar scoliosis with degenerative changes in the elderly.

Lumbar scoliosis with degenerative changes in the elderly presents with spondylosis, variable apophyseal joint arthrosis, laminar hypertrophy, and marginal osteophytos most prominent within the scoliotic apex. Resultant lumbar stenosis, alone or with ventral spurs and herniated discs as isolated or associated lesions, can produce disabling low-back and lower extremity pain, weakness, and neurogenic claudication relievable by appropriate decompressive surgery. Myelography is essential as a preoperative measure. Whether such scoliosis is superimposed on adolescent thoracolumbar scoliosis or arises anew in later life remains an open question.


The age, nutritional status and major diagnoses of outpatients at the Red Cross War Memorial Children's Hospital.

In 1961 a study of the age, sex, race, nutritional status and common diagnoses of children attending the Red Cross War Memorial Children's Hospital in Cape Town during one 12-month period was reported. A similar study was undertaken during two 2-week periods in 1972--1973. Comparison of the studies shows: (i) that a greater number of older children attended the hospital in 1972/1973; (ii) that the proportion of malnourished children whose percentage of expected weight for age was less than 66% had decreased from 8--10% to 5,5--6%; and (iii) that the overall pattern of disease had not changed appreciably, most of the children presenting with minor or preventable conditions.


An anti-drooling operation in cerebral palsy.

Persistent drooling in cases of cerebral palsy can be successfully controlled by a combination of bilateral parotid duct translocation and bilateral submandibular gland excision. Ten children are described who underwent this operation with satisfactory results. Apart from mile transient postoperative swelling of the cheek, there have been no postoperative complications. The importance of bilateral submandibular gland excision is stressed and the operative details are described. These include elevating a flap of buccal mucosa distally from the orifice of the parotid duct and then burying this strip beneath the buccal mucosa posteriorly to emerge in the pharynx just above the tonsillar fossa. The edges are then sutured to the mucosa of the pharynx. In time the parotid secretions pass into the pharynx via the newly created tube of mucous membrane. The technique is simple and the end result is satisfactory.


The effect of intravenous domperidone on the resting lower oesophageal sphincter pressure in dogs and baboons.

Domperidone (Motilium), a dopamine receptor blocking agent, increased the resting tone of the lower oesophageal sphincter in 15 dogs and 6 baboons. It is therefore a potentially useful drug in the management of gastrooesophageal reflux due to incompetence of the lower oesophageal sphincter.


A critical look at geriatrics in a teaching hospital. Part II. The remedy.

Measures to improve the organization of geriatric care in South Africa are recommended after a study of overseas methods. The necessity for a geriatric unit in a teaching hospital is stressed, for the specific purposes of education of medical and paramedical personnel, and the linkage of hospital and community facilities.


Albumin metabolism in health and disease.

Studies performed at the University of Cape Town on the metabolism of albumin have been reviewed. The control of albumin metabolism in protein energy malnutrition, in acute exposure to alcohol and after partial hepatectomy in the rat is discussed.


Familial symptomatic porphyria in South Africa.

Seven members from 3 generations of a family investigated for evidence of symptomatic porphyria (SP) were found to be affected in varying degrees by the disease. Four had cutaneous lesions, while all 7 had biochemical abnormalities diagnostic for SP in their excreta, plasma or hepatic tissue. The results were obtained using the highly sensitive technique of quantitative fluoroscanning after separation of the porphyrin methyl esters by thin-layer chromatography. This clear case of familial SP is rare in South Africa where the high incidence of the sporadic form of the disease is well documented. This study indicates that SP occurs in the following two forms: (i) the sporadic type, usually found as an uncommon associate of chronic liver disease; and (ii) the rare familial type, inherited as an autosomal dominant trait.


Porphyria and the dangerous life-threatening drugs.

The dangerous life-threatening drugs have been identified in 153 acute attacks in 138 porphyric patients by establishing a consistent temporal relationship between the administration of a specific drug and the development of an acute attack. The drugs so identified have been supplemented by a number of others found to be porphyrogenic by testing with a recently devised rat model. Lists of the dangerous and the safe drugs have been compiled.


Activation of uroporphyrinogen decarboxylase by ferrous iron in porphyria cutanea tarda.

Uroporphyrinogen decarboxylase was measured in the presence of ferrous iron, using mitochondria-free rat liver extracts as enzyme source. The activity of the enzyme was found to be increased at concentrations of ferrous iron from 0,01 mM, with maximal activity exhibited from 0,1 mM. Enzyme kinetics indicate that uroporphyrinogen decarboxylase reversibly binds ferrous iron, with a binding constant of approximately 5 x 10(4) mol-1. It is proposed that the effect of phlebotomy on patients with porphyria cutanea tarda is to mobilze storage iron in the liver to the active ferrous form, which activates hepatic uroporphyrinogen decarboxylase, the enzyme which is defective in this syndrome, with resultant clinical and biochemical remission.


Gycosuria as an indication for glucose tolerance testing during pregnancy.

The indications for and results of all glucose tolerance tests (GTTs) performed at the Antenatal Clinic, Groote Schuur Hospital, Cape Town, over a period of 1 year, and the indications for a GTT in the first 80 newly diagnosed diabetics over a 4-year period are analysed. Out of 558 GTTs, only 17 tentative diagnoses of 'gestational diabetes' were made. The most rewarding single indication for a GTT was repeated glycosuria, which was an indication in 61 out of the 80 newly diagnosed diabetics. A combination of two indications in the same patient was related to twice as many abnormal GTTs as a single indication, while reported previous diabetes or hyperglycaemia certainly merited confirmation. Reasons for repeating GTTs are discussed, as well as the management of 'borderline' and 'potential' diabetics. It is emphasized that 'diabetes' or 'hyperglycaemia' diagnosed during pregnancy is not equivalent to a definite diagnosis of diabetes in the non-pregnant state.


Choriocarcinoma and invasive mole. A review of 10 years' experience.

Experience gained in the management of 24 patients with choriocarcinoma and invasive mole admitted to Groote Schuur Hospital, Cape Town, during the past 10 years is analysed. Three high-risk patients died and 21 patients recovered without any known recurrence, giving a 'cure' rate of 87%. The modes of presentation, methods of diagnosis, and treatment, including cytotoxic therapy and the place of hysterectomy, are discussed. Patients with choriocarcinoma require special facilities, including beta-subunit human chorionic gonadotrophin assay, ultrasonography and arteriography, together with skilled treatment, and a plea is made for the referral of all patients to special treatment centres.


Benign tumours of the larynx.

Over the 8-year period 1971--1978, 743 benign lesions of the larynx, of which 551 were pseudotumors and 192 were benign neoplasms, were surgically treated at Groote Schuur Hospital. In comparison, during the same period 402 malignant tumours of the larynx were also seen. The commonest benign lesions were vocal cord nodules, almost exclusively found in women, and the vocal cord polyp, predominantly found in men. The various specific pathological entities encountered are discussed.


Cystic pulmonary hamartoma simulating posterolateral diaphragmatic hernia.

Posterolateral diaphragmatic hernias and cystic hamartomatous malformations of the lung can cause actue respiratory distress in the immediate postnatal period. The clinical and radiological features of these two conditions can be similar. Owing to misdiagnosis, the surgical approach was inappropriate in 2 of 26 patients diagnosed as having posterolateral diaphragmatic hernias on admission. During the same period, 5 cases of congenital cystic lung disease were treated surgically. Three of these patients were admitted in severe respiratory failure within 48 hours of birth, and in 2 of these cases the wrong diagnosis was made. The clinical features of these two easily confused congenital anomalies are discussed, and the main differentiating points on the chest radiographs are presented.


Ocular aspects of learning disabilities in children.

A total of 160 children were investigated to establish the role of ocular problems in children with learning disabilities. Thirty-eight per cent were found to have associated ocular problems. Eight per cent (8%) of these showed improvement in scholastic achievement after the elimination of the ocular defect. When there was evidence of brain dysfunction, correction of errors of refraction or muscle balance problems failed to improve scholastic achievement. A multidisciplinary approach to the problem is mandatory.


Congenital dislocation of the hip. Management at the Princess Alice Orthopaedic Hospital.

The importance of early diagnosis of congenital hip instability is emphasized and the ultimate goal of treatment defined, and the management of congenital dislocation of the hip as practised at the Princess Alice Orthopaedic Hospital and the University of Cape Town is reviewed.


Management of pituitary tumours at Groote Schuur Hospital from 1966 to 1978.

From 1975 both trans-sphenoidal and transcranial operations have been utilized for visual pathway decompression or removal of small functioning adenomas. The particular surgical route is selected on the basis of the size, situation, shape and secretory capacity of the tumour, the state of vision, and the state of the patient. Radiotherapy is given to all non-secreting tumours and all invasive or surgically uncontrolled secreting tumours. All patients are managed in a combined clinic where radiotherapists, endocrinologists, ophthalmologists and neurosurgeons function together.


Costs in a clinical pharmacological laboratory.

As a measure of the efficiency of service provided to the Groote Schuur group of hospitals by the Department of Clinical Pharmacology, certain costs were analaysed. The approximate annual cost of routine analytical work was R40 000 $45 000 or 22 000 pounds). The average cost per assy was R9,50 ($11,30 or 5,50 pounds). Closer examination of data showed that the cheapest assays are those done in large batches using an off-line analytical technique such as thin-layer chromatographic densitometry.


Biochemical aspects of neutrophil chemotaxis.

Solutions of crude casein contain a chemotactic peptide with a molecular weight of 2 200 daltons. As in the case of other cytotaxins, this compound displays hydrophobic properties. Partially purified casein cytotaxin stimulated the disproportionate oxidation of glucose-1-carbon, from which we infer that hexose monophosphate shunt activity is increased in cells exposed to cytotaxin. No evidence could be found to support the suggestion that cytotaxin stimulation leads to activation of latent cellular esterases.


The Cape Town Psychiatric service.

A comprehensive psychiatric service for the city of Cape Town and a large rural catchment area in the southern and central Cape Province is described to show how the psychiatric facilities and services of the Department of Health, the Cape Provincial Administration and the University of Cape Town function together as an effective, co-ordinated whole. The principles on which this is based are described, namely, planning on the basis of what one multidisciplinary team can achieve, the development of specialized therapeutic units at different hospitals, and co-ordination of clinical activities by the Department of Psychiatry of the University of Cape Town. Emphasis is placed on community psychiatry. The different units and their functions are described, as well as teaching and research activities.


Need determination in AFDC program.

This study summarizes the State policy with respect to the determination of need in the Federal-State program of AFDC. The areas discussed are the individual State definitions of need, the content of need standard, the types of persons included in the payment, the amount of income and resources allowed recipient families, the method of determining need, and a comparison of State food allowances with the Department of Agriculture cost figures. The cumulative effect of these policies on payments is also explored. The information in the report is based on data assembled for the biennial report of program plan characteristics early in 1978.


Tax impact from elimination of the retirement test.

The OASI eligibility provisions include a retirement test (or earnings test), and in 1979 aged beneficiaries who are under age 72 give up $1 in current benefits for each $2 of annual earnings above $4,500. If the retirement test were eliminated, total OASI payouts would increase because aged workers would no longer forfeit benefits. Aged workers also might increase earnings or delay retirement if this penalty on work effort were removed. Increased earnings would generate additional OASDHI taxes and individual income taxes. This article examines the fiscal effects on OASI benefit payouts and increased tax receipts if the retirement test were eliminated.


Educational and economic characteristics of student beneficiaries: black-white differences.

This article compares black and white student beneficiaries under the old-age, survivors, and disability insurance (OASDI) program during the 1972-73 school year from the standpoint of differences in economic and educational characteristics. The role that OASDI played in enabling students to continue in school full time is studied. The findings show that relatively more blacks were in the student beneficiary population than in the general student population; they were also overrepresented among students attending high school. Blacks were disadvantaged with respect to the educational attainment of their fathers and in terms of total family income. They also had lower-grade-point averages and those in high school were older than their white counterparts. Black high school students nevertheless planned to continue their education and to attend 4-year colleges in about the same proportion as whites. The total amount of educational income of black students was greater than that of white students, but the members of the latter group received more from loans and miscellaneous sources. Grants were the most important source of educational income for blacks. About half the student beneficiaries said they could continue full time in school without benefits and a third said they could not.


Hearing impairment: a family crisis.

This paper reviews the initial crisis for hearing impaired children and their families from the perspective of the clinician who must assess their adjustment at the point of entry into a school for the deaf. The use of crisis theory as it relates to the special needs of this client group is discussed.


Visual impairment: facing possible blindness.

Blindness real or threatened often constitutes a major crisis for the eye patient. This paper discusses the use of crisis intervention during the acute phase of medical care to support the coping patterns of the patient and his family and prepare them for the rehabilitation tasks ahead.


A study of person-environment fit among the chronically ill.

The ecological perspective is gaining acceptance in social work thinking. This approach focuses on the interaction of people and situations. An important ecological concept is person-environment fit; that is, the congruency between people needs, capacities, and aspirations and the resources demands and opportunities in their environment. The study described in this article explored the empirical manifestations of this concept among a group of chronically ill persons. The results suggested that there are several categories of person-environment fit that are important to people. The concept also appears to have potential usefulness for research on social work practice.


Head and neck cancer: a threat to life and social functioning.

This paper deals with the crisis of cancer and the communication loss faced by the laryngectomized patient. It considers the particular issues for the patient and his family and how the use of crisis intervention can reinforce the coping patterns of the patient and his family.


Comprehensive care of the chronically ill cancer patient: an inter-agency model.

The article identifies continuity of care between hospital and community as the key element of comprehensive health care for the chronically ill cancer patient. It describes the collaborative effort of the Michigan Cancer Foundation and the Metropolitan Detroit Cancer Control Program to provide this continuity. The structure, process, and outcome of the inter-agency model is presented and illustrated through case example. The authors believe that this model is applicable to treatment of persons with other chronic diseases which require frequent hospitalization.


Social work and primary health care: an integrative approach.

An interinstitutional, interagency Consortium has been formed in Houston to develop an innovative service model and provide interdisciplinary primary care/mental health training. The Houston Consortium Program integrates mental health professionals and trainees into the primary care framework of a neighborhood center serving a low-income, predominatly Mexican-American population. The introduction of mental health, psychosocial, and cross-cultural perspectives to complement the long-standing physiological concerns of health professionals fosters an holistic approach to patient care. The social workers' full participation as members of primary care teams builds upon their traditional training to provide them the experience and skills required to function effectively in the expanded coordinative capacity of health/mental health manager as defined by the President's Commission on Mental Health. It is anticipated that Consortium Program can serve as a heuristic model in the development of a nationwide pattern of comprehensive care.


Collaboration, consultation and referral in an integrated health-mental health program at an HMO.

The paper describes interactions between primary care physicians (PCP's) and mental health clinicians (MHC's) in a "team collaborative model." A study of the interactions showed there were about two consultations a day with PCP's for each MHC, that they were largely unscheduled, took place mostly in PCP or MHC offices or in corridors, and increased in frequency over a two-year period. Role definition was a continuing process; PCP's and MHC's each learned through repeated discussions what to expect from the other in patient care. It is found that a model with close working arrangements between PCP's and MHC's is of therapeutic value for that large population of emotionally disturbed patients seen often by PCP's much less often by MHC's.


Anesthetic considerations in surgery for gastrointestinal disease.

We have attempted to present a brief overview of current considerations in anesthesia for surgery of gastrointestinal disease as practiced at our institution. Many considerations remain unexplored owing to limitations of space. We have deliberately concentrated upon antecedent and concurrent therapy encountered in the treatment of the surgical patient. The potent drugs introduced in the past decade have produced infinite potential for drug interactions--some serious, some not so serious, and some which are desirable. We hope we have generated further reader interest in this mushrooming problem of modern medicine confronting the anesthesiologist and surgeon in the perioperative period.


The albatross syndrome--how to prevent it.

While no single test or historical feature will allow the physician to predict the patients who will have poor results from ulcer surgery, certain factors may alert the physician to a possible poor result and encourage careful re-evaluation of the need for surgery. Any patient with intractable pain should be assessed carefully in an attempt to establish the cause of the intractability, and this assessment should include endoscopy. The endoscopist may help to identify those patients with structural disease that is too minimal to explain the intractable complaints. Careful attention should also be given to the evaluation of the patient's personality, work record, and relationship to spouse, family, and friends. Patients who have previously been disabled by other medical problems such as low back injury should be approached with caution. While newer procedures in ulcer surgery may alter the incidence of standard postgastrectomy complications it will not alter the incidence of the albatross syndrome, which is more directly related to the selection of the patient rather than the selection of the surgeon or surgical procedure.


Spontaneous cure of dural arteriovenous malformation in the posterior fossa.

A 28-year-old male with spontaneous disappearance of dural arteriovenous malformation in the posterior fossa ten years after onset is reported. Ligation and excision of the right occipital artery brought about no marked changes in clinical manifestations and the post-operative angiogram. Over nine years after that operation, pulsatile tinnitus disappeared suddenly without any obvious cause and the dural arteriovenous malforamation was absent on the angiogram. The frequency of such an occurrence and some possible mechanisms involved are reviewed and discussed.


Traumatic intracranial hematomas in hemophiliac children.

Three cases of traumatic acute subdural hematoma in hemophilia A children underwent surgical interventions. There were two functional survivors and one death. The management of intracranial hematoma in hemophiliac patients is discussed.


Intracavernous giant aneurysm associated with Marfan's syndrome.

A case of intracavernous giant aneurysm associated with Marfan's syndrome is reported. The patient was treated with a superficial temporal artery-middle cerebral artery bypass and a ligation of the internal carotid artery in the neck. Although they are common in aorta and pulmonary artery, the vascular abnormalities in Marfan's syndrome are very rarely reported in intracranial arteries. The patient also had an aberrant internal carotid artery which presented as a red mass behind the eardrum.


Umbilical fistula as a complication of ventriculo-peritoneal shunt.

Two cases of CSF umbilical fistula in children with ventriculo-peritoneal shunt are reported. In the first at exploratory laparotomy there was a persistent umbilical vein and in the second a diffuse perivisceritis. Only three cases of this complication of ventriculo-peritoneal shunt have been reported in the literature.


Intracranial introduction of a nasogastric tube in a patient with a pituitary tumor.

This case report describes the complication of intracranial introduction of a nasogastric tube in a patient with a pituitary adenoma.


Postoperative complications in 1,000 cases of intracranial aneurysms.

Clinical analysis of postoperative complications was made in 1,000 cases of intracranial saccular aneurysm. Psychological symptoms, motor disturbances, and aphasia were observed in 107 cases (11.5%), 74 cases (7.1%) and 20 cases (2.1%), respectively, in 939 discharged cases. Water and electrolyte disturbances and gastro-intestinal bleeding were found in 60 cases (6.0%) and 19 cases (1.9%), respectively, in 1,000 surgically treated patients including those that died during hospitalization. Psychological symptoms were most apt to develop in cases of vertebrobasilar artery aneurysm, multiple aneurysms and anterior communicating aneurysm. It appeared that the poorer the preoperative grade, the higher the incidence of psychological symptoms. These developed most frequently in patients operated on the third to seventh days after the subarachnoid hemorrhage. The postoperative psychological symptoms improved in 63% of 107 cases. The occurrence rates of other complications were also studied.


Intranasal approach to the sella turcica.

A transseptal approach to the sella turcica is described which is entirely intranasal and avoids the sublabial incision. The first incision is unilateral along the caudal edge of the septum, and the second incision is made across the base of the nasal columella. This allows the speculum to open the width of both nasal chambers, giving adequate exposure. The septal cartilage is either preserved or resected except for a caudal strut. The difficult dissection of mucosa from the nasal floor and maxillary crest is avoided. This technique is rapid and straightforward and results in a cosmetically acceptable scar.


Multiple giant aneurysms.

A case with four unusual aneurysms is presented. On the right were a ruptured small middle cerebral artery aneurysm and a giant carotid-ophthalmic artery aneurysm. On the left were two giant internal carotid artery aneurysms: one at the ophthalmic artery and one at a ventral or paraclinoid position. All four aneurysms were clipped. The patient returned to her household duties.


Intracranial meningiomas related to external cranial irradiation.

Three cases are presented of meningiomas following small-dose external cranial irradiation in which several features clearly indicate a causal relationship between radiotherapy and tumour development. In two of them, multiple meningiomas followed X-ray treatment for Tinea capitis. The length of the latent period separates meningiomas following high-dose irradiation, usually administered for intracranial tumours, from those which followed small-dose irradiation. Therefore the oncogenic mechanism seems to act differently in the two groups. This demonstration that multiple meningiomas can occur in patients irradiated for Tinea capitis should enable other similar cases to be recognized.


The value of serial computerized tomography in the management of severe head injury.

A consecutive series of 107 comatose patients with head injury was studied with regard to the proper role of serial computerized tomography for clinical management and as a research tool for studying the pathophysiology of severe head trauma. In this prospective study patients had serial CT scans on days 1, 3, 5, 7, 14, at 3 months, and at 1 year (day 1 is the day of admission). In seven instances CT scanning was responsible for detection of late intracranial lesions requiring surgical decompression two weeks to one year after injury. No surgically significant lesions were, however, detected by routine scanning on the pre-determined days in the early post-trauma period that had not already been signalled by changes in the neurological status, intracranial pressure, or volume pressure response. It is concluded that for purposes of clinical management, additional scans should be obtained in the following circumstances: 1) 1 day post-craniotomy, 2) no improvement by day 3, 3) at 2-3 weeks, and 4) at 3 months. All other scans should be obtained as needed. As a research tool, serial CT scanning is of value in studying post-traumatic hydrocephalus, delayed intracerebral hematomas, and intraventricular hemorrhage.


Supratentorial arteriovenous malformation presenting with cerebellar dysfunction.

A young patient with classic clinical presentation and radiological findings of an arteriovenous malformation subsequently developed a spontaneous occlusion of the straight sinus. Although the lesion was supratentorial, thrombosis of the straight sinus and cerebellar cortical veins resulted in signs and symptoms of cerebellar dysfunction. Successful surgical excision was performed with good results.


Microsurgical anatomy of the anterior choroidal artery.

The anatomy of the anterior choroidal artery was studied in 25 adult brains (50 cerebral hemispheres). The point of origin and the distribution of this artery were determined. The surgical and clinical implications of these findings are discussed.


Delayed cerebral radionecrosis following treatment of carcinoma of the scalp: clinicopathologic and ultrastructural study.

A 56-year-old female was found to have cerebral radionecrosis four and one-half years following betatron therapy of a carcinoma of the scalp. Angiographic findings revealed irregular narrowing of the pericallosal artery in the site of the lesion. The patient has resumed full activities with no new neurological findings in the six years following radical extirpation of the lesion. Fourteen similar cases are reviewed. Ten of the twelve patients who underwent radical surgery were cured. Radical extirpation soon after making the diagnosis of cerebral radionecrosis appears to be the treatment of choice. Characteristic ultrastructural findings of abnormal vessels are discussed.


Middle meningeal--middle cerebral artery anastomosis for cerebral ischemia.

A new technique of anastomosing the middle meningeal artery to a cortical branch of the middle cerebral artery is described. A case is presented in which the operation was technically successful and the immediate clinical result was good. Long-range follow-up is necessary and a larger series will be needed for study before the merits of the technique can be judged adequately. The advantages and disadvantages of this technique are described, as well as possible indications and future studies.


Cerebellar retraction: significance and sequelae.

Does cerebellar retraction during operations in the posterior fossa contribute to increased morbidity and mortality, and if so, what are the critical factors involved? In order to answer these questions, graded retractor pressures of 10, 20, and 30 mm Hg were applied for one hour to the cerebellar hemispheres of dogs in the sitting position. It was noted that the amount of mechanical pressure and the difference between systemic perfusion pressure and retractor pressure were important determinants of the outcome. The mechanism of damage from retractor pressure is discussed.


Hypertrophic pachymeningitis dorsalis.

A young man developed a paraplegia of relatively sudden onset. A myelogram revealed an obstruction at the T8 level. Laminectomy at T7-9 disclosed a remarkably thick dura mater compressing the spinal cord. Microscopic examination of the dura mater was suggestive of syphilitic granulation tissue. Serum and CSF samples examined for evidence of syphilis were strongly reactive.


Chronic subgaleal haematoma.

A case is reported of a chronic subgaleal haematoma resulting from repeated head trauma during epileptic fits. The haematoma, which was organized and partially calcified, complicated the diagnosis and treatment of an underlying subdural haematoma.


Cerebrospinal fluid hypotension secondary to traumatic rupture of lumbosacral meninges.

Cerebrospinal fluid hypotension as a result of meningeal rupture due to injury is described. Nonsurgical therapy was followed by a good functional recovery.


Progressive multifocal leukoencephalopathy: cerebral mass lesions.

In 9% of reported cases, progressive multifocal leukoencephalopathy presents clinically and radiographically as a focal cerebral mass lesion. Initial misdiagnosis may occur, leading to surgery for suspected malignancies. The electroencephalographic, radiologic, and histopathologic findings in such cases are discussed.


Vascular malformation of the medial posterior choroidal artery.

A case is presented of a vascular malformation of the medial posterior choroidal artery in the vicinity of the posterior part of the third ventricle successfully obliterated via the supracerebellar-infratentorial approach.


Germinomas in the cerebral hemisphere.

Three patients with germinomas developing in the frontal lobe are reported. Common to the three cases, long-standing pyramidal signs were observed and the tumors simulated a cystic glioma containing xanthochromic fluid. The site of origin of these germinomas and the relation to suprasellar germinomas are discussed.


Reproductive function in temporal lobe epilepsy: the effect of temporal lobectomy.

We have examined sexual and reproductive changes in 25 patients (11 men and 14 women; mean follow-up 13 years) with temporal lobe epilepsy who underwent temporal lobectomy. Five men and two women had sexual dysfunction preoperatively, in particular, decreased libido. This improved after temporal lobectomy in three of these patients. One woman developed a partial Klüver-Bucy syndrome. Reproductive dysfunction was present in one man (oligospermia) and in ten women (four had the onset of seizures either at pregnancy or menarche; four had increased frequency of seizures during menarche or pregnancy, and two had amenorrhea). The man fathered two children post-operatively, and an appreciable improvement in both the seizure activity and the reproductive dysfunction was noted in the majority of the women.


Evaluation of the plasma scalpel for intracranial surgery: a pilot study.

The plasma scalpel, a new type of thermal knife, was investigated to determine its utility in neurosurgery. A series of 23 dogs underwent cortical resections comparing the use of the plasma scalpel with conventional bipolar cautery. Tissue heating, blood loss, speed of coagulation, wound healing and pathological change associated with use of the plasma scalpel were studied. The device was found to be effective, safe and faster than bipolar cautery. At present, several technical problems, including the large size of the handpiece and the blast effect of the plasma beam, preclude preliminary human clinical trials.


CT scan of retroperitoneal hematoma with neuropathy.

A hematoma in the left iliacus muscle induced by anticoagulant therapy and causing a femoral neuropathy was demonstrated by CT scan. The scan returned to normal after the surgical evacuation of the hematoma. Other possible uses of the CT scan to demonstrate neurological lesions in this region are discussed.


Metastasis of prostatic adenocarcinoma simulating a falx meningioma.

A 56-year-old man, with known metastatic carcinoma of the prostate, presented with a single Jacksonian seizure. Examination revealed a tumor of the falx cerebri which demonstrated many characteristics of a meningioma. Although exceedingly rare, the tumor proved to be a meningeal metastasis of the prostatic adenocarcinoma. The relevant literature is reviewed.


Opacification of the lumbar epidural venous plexus during myelography.

Opacification of the regional epidural venous plexus is an untoward circumstance of myelography. The following case reports demonstrate the epidural veins and the transient pulmonary symptoms that resulted.


Radiological features of holoprosencephaly.

Three cases of alobar, semilobar, and lobar types of holopresencephaly are reported. Their neuroradiological features and differential diagnosis are described.


Spinal epidural cavernous hemangioma.

A case of spinal extradural venous hemangioma is presented. Its initial manifestation simulated a herniated intervertebral cervical disc. The probable precipitating mechanism of its presentation in producing radicular pain and its successful surgical extirpation are discussed.


Effects of nifedipine of pial arteriolar calibre: an in vivo study.

In cats the response of individual pial arterioles to perivascular microapplication of the Ca++-antagonistic drug nifedipine was studied using the image-splitting technique developed by Baez. It has previously been shown that the coefficient of variation for repeated measurements of pial vessel diameter using this system is 1%, under conditions of steady arterial pressure and blood gas tensions. All investigated pial arterioles invariably responded with a dilatation at an injected nifedipine concentration of 10 microM. The dilatatory response was inversely proportional to the resting vessel calibre, i.e., arterioles less tham 70 microns responded with a significantly stronger dilatation as compared with arterioles greater than 100 microns in diameter. In experiments where a minor subarachnoid hemorrhage was made by the injection micropipette injuring capillaries just before the perivascular microapplication of nifedipine, a dilatatory response invariably ensued in spite of the perivascular blood which in itself constricted the arterioles under examination.


Acute cerebral revascularization: part I. Cerebral ischemia experimental animal model.

Thirty-two mongrel dogs divided into two groups were subjected to a transorbital occlusion of the middle cerebral artery (MCA) or a combined transorbital MCA and cervical internal carotid artery (ICA) occlusion. Clinically apparent deficits were present in the MCA group in 18% of cases and in 73% of MCA/ICA cases. Pathologically, 55% of MCA cases and 73% of MCA/ICA cases had demonstrable areas of infarction. The incidence and severity of clinical deficits as well as the location and extent of pathological infarction were significantly greater (p less than 0.05) with the MCA/ICA group than in the MCA group. The mortality rate and frequency of pathologically apparent infarcts were not statistically different p greater than 0.05. No hemorrhagic infarctions were seen in any case.


Balloon embolization of a giant aneurysm using a newly developed catheter.

A new catheter with a releasable balloon has been developed for the controllable embolization of intracranial vascular lesions located beyond many arterial curves such as the carotid siphon. Embolization is accomplished by introduction of the balloon to the lesion, followed by inflating the balloon with a polymerizable liquid. After this liquid sets to a gel, the catheter is twisted off to detach the balloon at a specially designed joint. This balloon catheter has been used clinically to embolize an aneurysm of the middle cerebral artery.


The importance of early diagnosis and treatment of the meningiomas of the planum sphenoidale and tuberculum sellae: a retrospective study of 105 cases.

Delay in the diagnosis of meningiomas of the tuberculum sellae and planum sphenoidale is detrimental to the patient in terms of visual recovery, morbidity and mortality. Early accurate diagnosis of these tumors is possible through the use of computed tomography which is recommended for all patients with unexplained impairment of vision. In this article 105 cases of meningiomas of the planum sphenoidale and tuberculum sellae are reviewed. In only five cases was the diagnosis made within three months of the onset of the symptoms.


Surgical treatment of arteriovenous malformations of the posterior fossa.

Nine cases of arteriovenous malformations of the posterior fossa were operated upon, using microsurgical techniques. The excision was radical in eight patients. Seven of them, as well as the sole patient who had a partial removal of the malformation, returned to their previous occupations without neurological signs. In one case the preoperative deficit was unchanged. Some lesions that appear to penetrate the brain stem actually lie on its surface and can be dissected through an extrapial plane of cleavage. Extension of the malformation into the cerebellar peduncles requires dissection of the tangle and opening of the IVth ventricle.


Syringomyelia presenting as a mass lesion of the conus medullaris.

A case is presented of a young girl with syringomyelia presenting as a mass lesion of the conus medullaris. Computerized tomography of the cerical spinal cord revealed asymptomatic extension of the syrinx to that level. Seven other similar cases are reviewed, and suggestions made for preoperative diagnosis of this unusual entity.


Benign intracranial hypertension: clinical features and diagnosis using computed tomography and treatment.

A series of 28 patients presenting with benign intracranial hypertension is reported. The diagnosis was based on normal CT scanning appearances, including ventricular size, and it is stressed that no further neuroradiological investigations were required. Conservative treatment is shown to be effective in the majority of patients. It is, however, suggested that surgical intervention in the form of a shunting procedure (lumboperitoneal in our cases) might prove necessary, if vision remains in jeopardy.


Modified suction system for neurosurgery.

A new system providing suction for neurosurgical operations is presented. It is designed so that the amount of suction is readily controllable and provides adequate suction for the removal of fluid and blood clots without damage to the nervous tissue. The device also allows the surgeon an unrestricted view of the operative field.


Coexistence of posterior inferior cerebellar artery aneurysm and arteriovenous malformation fed by the same artery.

A saccular aneurysm of the posterior inferior cerebellar artery and an arteriovenous malformation in the cerebellum fed by the same artery are reported. Clipping of the neck of the aneurysm and total removal of the arteriovenous malformation were performed successfully in one operation.


Intracerebral arteriovenous malformation angiographically resembling a dural malformation.

A case of intracerebral arteriovenous malformation with a purely external carotid contribution is presented. This case is not only rare, but also instructive in terms of the pathogenesis of the dural arterial supply to the intracerebral arteriovenous malformations.


Experimentally induced cerebral aneurysms in rats: part IV--cerebral angiography.

Carotid angiography was performed in our model rats with cerebral experimental aneurysms. Major vessels at the base of the brain and the cerebral aneurysms were well visualized by a single injection into one carotid artery.


An aneurysm of the proximal anterior cerebral artery at the olfactory bulb.

The authors report a very rare case of ruptured intracranial aneurysm at the olfactory bulb. The aneurysm was located at the tip of an abnormal loop of the proximal anterior cerebral artery and was buried in the olfactory sulcus. Preoperative examination revealed hyposmia.


Giant serpentine aneurysms: a separate entity.

Giant intracranial aneurysms containing a tortuous vascular channel appear, to some extent, different from other giant aneurysms. Their particular features are outlined in the present report which concerns a case of a small fusiform aneurysm of the posterior temporal branch of the middle cerebral artery evolving over five years into a giant serpentine aneurysm. Successful and complete removal of this lesion was achieved.


Progressive visual loss associated with peculiar disc swelling.

A patient with progressive visual loss associated with swelling of the disc presented the classic clinical picture of Leber's optic neuropathy. The hereditary patterns, diagnostic characteristics and natural history of the disease are discussed. Although there is no efficacious treatment for Leber's optic neuropathy available at this time, correct diagnosis is important for purposes of genetic counseling and avoidance of unnecessary neuroradiologic and surgical procedures.


Pelvic hemodynamics after aortoiliac reconstruction.

Changes in blood flow to the pelvis were monitored by measurement of penile blood pressures before and after 38 aortoiliac vascular reconstructions. An increase in penile pressure was noted in 14 patients (37%), a decrease was seen in eight patients (21%), and no change occurred in 16 patients (46%). These changes could have been predicted by matching arteriograms to the surgical procedure performed. Preoperative impotence was present in 27 patients (17%). In this group a postoperative increase in penile pressure was associated with restoration of erectile capability in eight of 11 patients. Only one of 10 patients with an unchanged penile pressure regained sexual potency. In contrast, none of the eight patients whose penile pressures decreased had recurrence of erectile capability. Six of these patients had end-to-end aortobifemoral grafts, and concurrent external iliac disease prevented retrograde flow to the internal iliac vessels.


Pseudoaccommodation and progressive addition lenses.

The limitations of traditional multifocal lenses to replace normal ocular accommodation are well known. The recent development of progressive addition lenses circumvent many of those problems, furnishing smoothly varying power in desired amounts for various distances and allowing freedom from distracting lines. Optical characteristics, screening considerations, prescribing and fitting requirements, and the advantages and limitations of progressive addition lenses are discussed.


Ocular malingering and hysteria: diagnosis and management.

Confronted with a claim of poor vision in the absence of any apparent pathology, the ophthalmologist must consider the possibility that the patient is malingering or hysterical. The authors define four categories of such patients, and recommend diagnostic approaches for each. Specific diagnostic tests are described, as are methods of managing patients once the diagnosis of malingering or hysteria has been made.


Late appearance of arterial emboli: diagnosis and management.

Although the occurrence of an arterial embolus is usually a cataclysmic event prompting emergency presentationand early diagnosis, we have managed 22 patients who presented more than 48 hours after the onset of symptoms. The diagnosis was apparent in only six patients. The remainder had subacute limb ischemia, and arteriography was used to help delineate the diagnosis in 14 of these patients. In most instances arteriograms were atypical of chronic occlusive disease, rather than diagnostic of arterial emboli. Embolectomy was performed a mean of 13 days after the onset of symptoms, with retrieval of thromboembolic material in all instances. Two patients died (mortality rate of 9%), and the limb salvage rate for the 25 limbs explored was 88%. Among 22 lower extremity embolectomies, foot pulses were restored in 13 patients (59%), and four patients (18%) had viable extremities without pulses. Adjunctive arterial reconstruction was required in three patients.


Interference of lead with implantation in the mouse: a study of the surface ultrastructure of blastocysts and endometrium.

Implantation chambers, trophoblast and uterine luminal surfaces were examined on days 5 and 6 of pregnancy by electron microscopy in mice with implantation failure due to an intravenous injection of 75 ppm of lead chloride on day 4. Attachment of the trophoblast cells to the surface of the endometrium and closure of the uterine lumina had failed to occur. Uterine epithelial cells in implantation chambers and along the lumina were covered with abundant microvilli. This appearance is similar to that seen in mice in experimental delay of implantation before the oestrogen-induced attachment of the blastocyst has occurred. It may therefore be assumed that lead has in some way interfered with the activity of ovarian steroid hormones on the endometrium. No significant changes were observed in surface ultrastructure of the blastocysts from the lead-treated and control groups.


Sensitivity patterns for the induction of homeotic shifts in a favorable strain of mice.

In an effort to develop a prescreening system that is sensitive, is compatible with in-vivo administration of presumptive teratogens, and utilizes morphological endpoints, we are studying the induction of homeotic shifts in the axial skeleton. Our earlier work had demonstrated the existence of critical periods for certain such shifts, even though the (C57BL x NB)F1 hybrid used was not entirely suitable for this purpose. Using 100 R X-rays on successive days during the period of major organogenesis, we have now analyzed the sensitivity pattern of the BALB/c, since this strain normally straddles thresholds for the position of axial borders. Mortality, birthweight, and skeletal anomalies were analyzed, in addition to the homeotic shifts. --Day 9 1/4 postconception was clearly the most sensitive stage for the production of posterior shifts at the thoraco-lumbar border and the lumbo-sacral border, and for increases in the number of sternebrae and costo-sternal junctions. Anterior shift could be induced three days later, on day 12 1/4, but this was confined to only one of the four characters, the thoraco-lumbar border. There are a number of indications that, at given stages during the study period, BALB/c embryos correspond developmentally to chronologically somewhat earlier stages of two strains studied previously. The present results do not support the hypothesis that factors influencing the quantitative skeletal characters act by way of body size. --Since homeotic shifts can be produced by a number of mechanisms and are obvious indications that developmental interference has occurred, and since such shifts are easy to score and convenient to analyze quantitatively, our identification of a highly suitable strain and of stages of maximum sensitivity in this strain should aid in making the system useful in the prescreening for chemical teratogens.


Role of vitamin E in the etiology of spontaneous hemorrhagic necrosis of the central nervous system of fetal hamsters.

The intraperitoneal inoculation of pregnant hamsters with vitamin E during the first half of gestation reduced the severity or eliminated the occurrence of grossly observable effects of spontaneous hemorrhagic necrosis (SHN) of the central nervous system in their offspring and improved the pre-weaning viability of their litters. The addition of corn oil (16%) or linoleic acid (8%) to a ration associated with the occurrence of SHN in fetal hamsters enhanced the incidence and severity of the disease, and these effects were moderated by inoculation of the dams with vitamin E. Experimental data indicated that, among multifactorial contributions to the cause of SHN in hamsters, vitamin E availability and levels of dietary polyunsaturated fatty acid played a significant and interrelated role.


Early human pregnancy with the intrauterine contraceptive device in situ: incidence of heteroploidy.

An indirect method, based on placental morphology, was used to establish the incidence of heteroploidy in early human pregnancy and to determine the possible effect of the IUR on its occurrence. The non-IUD-wearing control population, comprised of 5,779 healthy fertile women undergoing therapeutic abortion for socioeconomic reasons, yielded an incidence of heteroploidy of 0.83% as compared with an overall incidence of 46.7% in our group of spontaneous aborters. In contrast heteroploidy was never detected pathologically in IUD-associated spontaneous and therapeutic abortions. It was concluded that the IUD significantly prevented the development of heteroploid conceptuses. the biological and clinical significance of these findings was discussed.


Some effects of continuous low-dose congenital exposure to methylmercury on organ growth in the rat fetus.

Congenital low-dose exposure of rat fetuses to methylmercury produced smaller offspring without anatomical abnormalities. The present study explored the mechanisms of the smallness of fetuses. The pregnant rats were given methylmercury water (25 ppm) from day 1 of pregnancy continuously until day 20 of gestation. There was a negative correlation of fetal weight and maternal and fetal mercury burden. The whole organ DNA and protein content of the livers and kidneys in the experiments were significantly lower than the control (P less than 0.05) indicating that there were fewer cells per organ in the mercury exposed fetuses. When the data were compared on a per gram of tissue basis, there was no significanct difference, indicating that the number and size of the cells of each were not diminished. The incorporation of 3H-thymidine into fetal tissue DNA was also substantially lower in the experimental group indicating decreased proliferative activity. We conclude from this study that, at least for some major organs, the decreased size in the mercury exposed fetuses is due to fewer cells in the organs due to decreased proliferative activity.