An emergency medical care facility: program characteristics and patient attributes.

The objectives of this research were: (1) to describe the programmatic structure and characteristics of an emergency medical care facility that is a satellite clinic of a community hospital; (2) to describe the types of illness treated, and (3) to characterize the patients who used the facility. One-half of the presenting patients were treated for traumatic conditions; a major factor of clinic use for such patients was proximity. For patients with nontraumatic illnesses, the clinic was used when private physicians were unavailable. Almost 20% of all presentations resulted from referrals, suggesting acceptance of the clinic by private practitioners in the area. Previous users had more tenuous relationships with private physicians than did initial users and no difference was found between initial and previous users in the amount of nontraumatic illness. Patient attributes of high mobility, lower socio-economic status, and younger age were associated positively with frequent clinic use.


Contraindications to the repositioning of fractured or dislocated limbs in the fields.

Supracondylar fractures of the femor or humerus and fractures of the radius, ulna, tibia or fibula, plus crush injuries of the limbs, most likely should not be manipulated in the field because of the potential for traumatizing adjacent nerves, veins and arteries. An emergency splinting system that allows immobilization without repositioning has been developed. Furthermore, fractures in or about the elbow, wrist, knee, or ankle should not be subjected to reduction in the field, unless there are compelling reasons to justify the risk of producing significant additional trauma. Conservative immobilization without repositioning may yield a more positive prognosis for the patient.


Posthypoxic ascites: a cause of post-traumatic abdominal distention.

A previously unreported etiology for post-traumatic abdominal distention was observed in a 5-year-old girl who suffered only head trauma and a prolonged period of hypoxemia. When there is a rapid accumulation of peritoneal fluid containing a high concentration of protein but negative for amylase, no evidence of blood loss, plus abnormal serial liver enzyme studies and the need for placement of large volumes of fluid, posthypoxic ascites should be suspected. Peritoneal aspiration confirmed the diagnosis and treatment was supportive. Because early operative intervention is necessary in pancreatic ascites and treatment is supportive for posthypoxic ascites, it is imperative to differentiate them.


Phenformin and lactic acidosis in a diabetic and a nondiabetic.

Two patients, each with a history of taking "diabetes pills," which proved to be phenformin, presented to the emergency department. The first, a 56-year-old female diabetic, on daily medication was symptomatic. The second, a non-diabetic 21-year-old man had attempted suicide using his grandmother's phenformin tablets. Both patients had lactic acidosis. The causal role of phenformin is discussed and the need for early recognition and aggressive treatment is stressed.


The elusive artery: found by sound.

The Doppler flow probe can be used to locate blood vessels in patients with shock or severe burns. The technique, which uses an ultrasonic signal, is described.


Call for help: an algorithm for burn assessment, triage, and acute care.

Because of the Medical College of Georgia Burn Treatment Center frequently received patients with extensive burns who had been badly managed locally, we devised an Algorithm to provide health care professionals a logical method for assessment, triage and obtaining help. Limited experience suggests that the Algorithm does, in fact, accomplish these ends but that continued evaluation of its efficacy is necessary.


Cleansing the traumatic wound by high pressure syringe irrigation.

The purpose of this study was to examine the influence of the fluid dynamics of syringe irrigation on the efficacy of wound cleansing and the infection rate of experimental wounds. The pressure experienced by a surface following wound irrigation was directly proportional to the pressure within the syringe and the size of the needle. High pressure syringe irrigation effectively removed bacteria from the surface of the wound. This reduction in the wound bacterial count resulted in a decrease in the infection rate of tissues. Low pressure irrigation with an asepto syringe did not significantly cleanse the wound of its bacterial contaminants and had no demonstrable clinical merit. On the basis of these studies, high pressure syringe irrigation is being employed routinely in our emergency department for the care of traumatic wounds.


Pneumomediastinum in heroin and marijuana users.

During the past three years, more than 500 patients were seen with mediastinal or cervical emphysema or both the Ben Taub General Hospital Emergency Center. In all but 15 there was a history of recent trauma or antecedent respiratory conditions with repeated sustained intrabronchial pressure, such as asthma. These 15 patients had a common history of repeated sustained Valsalva's maneuvers during marijuana smoking or during intravenous injections of heroin. The results of esophagography, bronchoscopy, and esophagoscopy were normal in these 15 patients. Conservative management consisted of close observation and re-evaluation for possible causes of secondary pneumomediastinum. All recovered without sequelae with resolution of the pneumomediastinum within 2 to 5 days. Radiographic and physical findings in primary pneumomediastinum resulting from prolonged intraalveolar hyperpressure are similar to those seen in patients with trauma or spontaneous rupture of the esophagus.


Esophageal obturator airway: use and complications.

The esophageal obturator airway, in lieu of placement of an endotracheal tube, has been found to be an effective and reliably safe means of providing an artificial airway. By occluding the esophagus, it prevents gastric dilatation and aspiration. However, it is not totally without hazard. Two cases of pharyngoesophageal trauma are reported: a high esophageal tear found at post mortem examination and a pyriform sinus laceration noted on admission to the hospital. The authors recommend conservative treatment for cervical esophageal perforations and surgery for thoracic esophageal perforations. Despite these complications, the authors feel the esophageal obturator airway is safe and effective for use by those unskilled in direct endotracheal intubation when participating in cardiopulmonary resuscitation.


Health services research as a management tool in the emergency department.

Researchers at Johns Hopkins University School of Medicine, with a grant under section 1205 of the Emergency Medical Services Systems (EMSS) Act of 1973 from the National Center for Health Services Research (DHEW), are doing three research projects pertaining to the quality and effectiveness of care and management in the emergency department. Project 1 concerns assessing the impact of categorization of facilities and ambulance and communication improvements on the use of emergency departments and ambulances. Project 2 assesses the impact of triage nursing, patient exit interviews, patient advocacy, nursing audit, walk-in clinics and education of asthmatic patients on emergency department care. Project 3 investigates the effect of specific clinical procedures on patient outcome.


Inpatient and emergency department utilization: the effect of distance, social class, age, sex, and marital status.

This study attempted to measure whether patients using two hospital services -- inpatient facilities and the emergency department -- were representative of the population. It sought to confirm the assumptions that, if patient demands were uniform and there were no barriers to emergency department use: (1) emergency patients would closely represent the population in the geographic service area of the hospital, and (2) factors such as distance from residence, age, marital status, social class, and sex, would be relatively uniform between inpatients and emergency patients. The first assumption was supported by the results of the study. Concerning the second, the 0- to 19-year-old group had a high emergency department utilization and low utilization of inpatient facilities when 35- to 65-year-old group had a lower emergency department and a higher inpatient usage pattern. The 65-year-old and over group had two and one-half times as many inpatient admissions as their number in the general service area would suggest. More men than women used the emergency department. Separated and divorced people were heavy users of the emergency department whereas widows heavily used inpatient facilities. Social class was not found to be significantly different among those using the inpatient service or emergency department.


Methadone overdoses in a New York City hospital.

Charts of the 81 methadone overdose patients admitted to Morrisania City Hospital from the Emergency Department during the eight month period between June, 1973 and January, 1974 were reviewed. There were 87 overdose cases in the 81 patients. All were treated successfully with naloxone hydrochloride administered intravenously. Four patients had pulmonary edema. In more than half, liver and muscle function studies showed abnormalities. Ninety percent (79) of the overdoses were associated with a combination of methadone and other non-opiate drugs, including alcohol.


Common childhood bacterial infections.

Acute bacterial infections are a common cause of pediatric visits to the emergency department. The diagnosis and treatment of pharyngitis, otitis media, pneumonia, urinary tract infection, acute bacterial lymphadenitis and gastroenteritis are reviewed. The authors propose the use of a limited number of antibiotic agents including penicillin, ampicillin, erythromycin, lincomycin, cephalexin, a sulfonamide and tetracycline to improve efficiency and quality of care and to allow physicians to become familar with the drugs' characteristics, indications, dosage and side effects.


Compound depressed skull fracture.

Although compound depressed skull fractures are common and their management and diagnosis have been described at length, their occurrence following dog bites is unusual. The case of an 18-month-old infant with this injury as a complication of multiple dog bites in the facial and head regions is described with the treatment employed. The necessity of searching for skull fractures in children following dog bites in this region is emphasized.


Physostigmine treatment of anticholinergic poisoning.

Physostigmine salicylate, a centrally acting cholinesterase inhibitor, is effective in rapidly and dramatically reversing the effects produced by anticholinergic drugs. Three case reports of successful use of physostigmine are presented. Since physostigmine is a tertiary amine that allows for passage of the drug into the central nervous system, it can reverse both the peripheral and central nervous system effects of anticholinergic poisoning. The adverse effects and contraindications of physostigmine use are discussed.


Public entry into emergency medical services systems.

The problems of public access to emergency medical services systems can decrease the effectiveness of emergency care. Much of the public is unable to recognize signs of serious illness, such as myocardial infarction, and dose not know how to obtain emergency medical help. In addition, emergency facilities and personnel are used for more non-emergency care than true emergency cases. Suggestions for the improvement of public access to emergency care include the use of telephones for triage and for providing information; ambulatory centers for non-emergency care; physician extenders such as paramedics or midwives, and improved systems of alerting emergency personnel that an emergency exists.


Assessing the quality of care by house staff in a mucicipal hospital emergency department.

The hypothesis that the results of process measures of the quality of care would be improved in a busy municipal hospital emergency department by using a medical record audit and reviewing findings with house staff and those responsible for their training was tested over a one year period and, tentatively, rejected. Out of 21 audit items, 14 showed no significant change. Of the remaining seven, only three items showed significant improvement. Other mediating factors are related to quality of care in this setting such as patient/staff ratios, supervision, the focus of training programs, the physical plant, staff attitudes, behavior and questions of control.


Brown recluse spider bites: five cases with a review of the literature.

Brown recluse spider bites can cause ulcerations of the skin, intravascular hemolysis and death. Five clinical cases are presented with a summary of known pathological processes, clinical findings, and recommended methods of treatment. The possibility of systemic manifestation make the physician's knowledge of loxoscelism, early diagnosis and adequate treatment necessary.


Arthrography in penetrating injuries.

Arthrography in cases of trauma to joints may provide valuable information about joint disruption as well as the location of foreign bodies. Allergy to contrast agents and bleeding diathesis are the only contraindications. Four cases are presented that demonstrate the usefulness of this technique.


Extratemporal facial nerve injury.

Isolated traumatic facial nerve injury, frequently seen in wartime combat, may also be encountered among civilians. The clinical picture occurring as a result of such injury may be confusing because partial, or incomplete, damage to the peripheral nerve may mimic impairment of the central facial motor mechanism. In treating the patient with facial injury, life-threatening aspects of the injury must be assessed and stabilized first. Then, attention may be focused on the injured facial nerve, for which prompt surgical repair is the treatment of choice. Prior to surgery, the assessment of taste and hearing, as well as mastoid and skull x-ray films and electrodiagnostic tests are helpful in localizing the facial nerve injury.


Sudden cardiac death: a retrospective and prospective study.

Since the inception of mobile coronary care units (MCCU), patients with sudden cardiac death (SCD) saved by advanced emergency medical technicians (EMT-A) can be studied retrospectively and prospectively. Forty-eight cases of SCD found in ventricular fibrillation (VF) were successfully resuscitated. Only 32% had a myocardial infarction. Most survivors were New York Heart Association (NYHA) class I or II. All class IV survivors with severe congestive heart failure died within 45 days. All class II survivors had angina as the limiting factor. Of all patients with VF, 23% survived. Eighty percent of survivors were class I or II and have resumed previous lifestyles. No clear cut symptom complex was identified. Rescue response time was generally less than five minutes. Intracardiac medications were administered without complications. Empirical administration of sodium bicarbonate correlated poorly with arterial blood gas determinations.


Conversion of paroxysmal atrial tachycardia by facial immersion in ice water.

Based on the concept of the classic diving reflex, which produced bradycardia, a technique for treating uncomplicated, but symptomatic, paroxysmal atrial tachycardia was developed. This technique consists of facial immersion for 15 to 30 seconds in water at 10 C (50 F). Of ten patients 9 (90%) achieved rapid conversion without complications. This technique may be especially useful for those patients resistant to more conventional methods of inducing conversion of paroxysmal atrial tachycardia.


Physostigmine--its use and abuse.

Physostigmine salicylate, a cholinesterase inhibitor, has been shown to reverse the effects of certain drugs with anticholinergic properties. The paper provides a brief historical account of physostigmine, reviews the cholinergic drugs and their effects and suggests a management protocol based on physiologic criteria. Twenty-six overdose cases, recently treated with physostigmine, are summarized. The controversy regarding the etiology of seizures following physostigmine administration is discussed.


Anticholinergic poisoning from Jimson weed.

Jimson weed (Datura stramonium), is a wild growing herb that contains belladonna alkaloids. Recently there have been reports of intentional ingestion of Jimson weed by adolescents for psychedelic purposes. When seen in emergency department, these patients appear with physical signs of atropine-like poisoning, disturbances of thought and hallucinations. Diagnosis depends on a positive history, if available, and recognition of anticholinergic effects. Differentiation from lysergic acid diethylamide (LSD) ingestion and schizophrenia is important. Physostigmine, an anticholinergic agent, can reverse both central and peripheral manifestations of Jimson weed intoxication.


Physostigmine in tricyclic antidepressant overdose.

Acute accidental and suicidal overdosages are becoming common in emergency medicine. Physostigmine salicylate (Antilirium) is the only parasympathomimetic drug capable of reversing both the central and peripheral manifestations of the anticholinergic syndrome caused by overdosage of tricyclic antidepressant drugs. Physostigmine acts rapidly, within 5 to 20 minutes, dramatically reversing the toxic effects. Because of the short duration of action, intoxication may recur and repeated doses may be necessary. Four cases, successfully managed, are presented and the pertinent literature reviewed.


Hereditary angioneurotic edema treated by partial uvulectomy.

Hereditary angioneurotic edema (HANE) is a rare familial disease of C1 esterase inhibitor deficiency that produces recurring attacks of acute, circumscribed, noninflammatory edema. The technique of partial uvulectomy to treat HANE can reduce the mortality from this condition due to asphyxiation. Three cases in which partial uvulectomy was the successful mode of treatment are described.


Pulseless idioventricular rhythm during CPR: an indication for massive intravenous bolus glucocorticoids.

Five consecutive patients were initially resuscitated successfully from pulseless idioventricular rhythm with the use of 100 mg of dexamethazone administered by intravenous push after all conventional modes of management had failed. In this small series, two of the five patients are long-term survivors and the deaths of the other three patients are attributable to advanced underlying pathology. The possible mechanisms of action of the glucocorticoids are not conclusively known. There is a need for detailed laboratory study of Purkinje conduction and single-cell depolarization and mechanical patterns, under controlled settings approximating the clinical conditions.


[Differentiation of the effect of diuretic urine extracts on the renal medullary blood flow (author's transl)].

In sodium depleted rats urine extracts of hydrated healthy human volunteer cause an increase in water excretion of 52% (p less than 0.005) and in sodium excretion of 45% (p less than 0.005). Cardiac output of the volumen loaded rats increases from 465 +/- 104 ml to 528 +/- 128 ml/kg-min (p=n.s.). Rb86 is used as an indicator for renal hemodynamics. Compared with controls there is an increase in blood flow through the outer medulla from 1.57 +/- 0.65 to 2.28 +/- 0.61 ml/g-min, through the inner medulla from 0.75 +/- 0.30 to 1.01 +/- 0.30 ml/g-min, and through the papillary tips from 0.85 +/- 0.04 ml to 1.21 +/- 0.25 ml/g-min. The experiments show that the diuretic/natriuretic urine extracts influence the hemodynamics of the renal medulla.However, since the significance level of the enhanced medullary blood flow is only low (p less than 0.1) it is impossible to find out the direct site of action of the urine extracts.


[Pupillary reaction on tyramine- a parameter of uremic sympathicopathy (author's transl)].

Clinical tests, for instance pupillometry, Valsalvatest, and orthostatic tests show evidence of sympathicopathy in chronic renal failure (GFR: less than 30 ml/min). Hemodialysis does not improve the intensity or frequency of the alterations. Toxic effects of uremic toxins on the autonomic nervous system can be supposed.


[Corneal arcus and hyperlipoproteinemia (author's transl)].

In 60 patients with corneal arcus the incidence of hyperlipoproteinemia was examined by serum lipid and lipoprotein analysis. An elevation of the serum lipid, or lipoprotein contents was found in every patient. 52 patients showed a primary type II hyperlipoproteinemia, three had a type IV, and one a type V pattern. In three cases hyperlipoproteinemia was found to be secondary to a severe cholestasis. The results show that the occurrence of corneal arcus in nearly every subject under 50 years of age and in most subjects over 50 years of age is highly suggestive of the presence of type II hyperlipoproteinemia. Until atherosclerotic complications appear, the course of the type II hyperlipoproteinemia is lingering and shows poor symptoms. Therefore, corneal arcus is of special importance for the early detection of this type of hyperlipoproteinemia.


[Hemoperfusion by means of encapsuled charcoal for the treatment of exogenous and endogenous intoxications].

The method developed by Chang for using in collodion and albumin encapsuled charcoal as artificial cells for hemoperfusion has been studied in vitro. The capacity for the absorption of more or less dialysable exogenous substances (barbiturate, Diazepam, Parathion) and an endogenous toxic metabolite (p-hydroxyphenyl acetic acid) has been examined. With the absorption unit one can eliminate 80 to 90 per cent of the initial concentration of barbiturate, Diazepam and p-hydroxyphenyl acetic acid in about 90 min, of Parathion about 50 per cent in the same time, whereas bromide and ammonia are not absorbed. Attempts to avoid regional heparinisation by the incorporation of heparin into the capsule of charcoal granules were not successful. Assuming correct preparation of the hemoperfusion system, observance of steril precoutions and regional heparinisation, the use of the "detoxication shunt" is a promising means in the treatment of severe exogenous and endogenous intoxications which are not accessible by conventional therapeutic means.


[Metabolic differences between males and females and between normal and obese subjects during total fast].

In 24 normal and 24 obese subjects of both sexes circulating substrates (blood sugar, free fatty acids, ketone bodies) and hormones (insulin, growth hormone, pancreatic glucagon) were determined during 6 days of total fast. In normals the blood sugar fell to lower levels than in the obese. Plasma free fatty acids and ketone concentrations rose faster in normal than in obese subjects, and faster in females than in males. Plasma insulin concentrations declined to a greater extent in obese than in normal subjects. In all groups studied a significant increase of the pancreatic glucagon level within 1-3 days of fasting was observed, however, its rise occurred faster in normal females than in males. Growth hormone (GH) rose significantly in normal males but not in obese males. Following high overnight fasting values in some normal females  showed no significant increase in GH levels but significantly higher GH values than obese females after 1-6 days of fasting. After summarizing starvation-induced metabolic changes common to all study groups the respective differences found between males and females and between normal and obese subjects are discussed.


[Percutaneous dilatation of experimental coronary artery stenosis- description of a new catheter system].

A technical description of a catheter system is given for percutaneous dilatation of experimental stenosis in small ateries (e.g. left coronary artery). The system consists of two catheters: the first is positioned into the orifice of the small artery and guides the second, double-lumen-dilatation catheter into the artery. During the manipulation ischemia in the peripheral area is prevented by contineous perfusion with oxygenated blood taken from the femoral artery by a roller-pump. The catheter system was tested in canine experiments.


Appearance of keratitis in laboratory mice: influence of azathioprine and meticorten.

Keratitis was noted in mice which were splenectomized and subsequently treated with immunosuppressive drugs. It was found that anaesthesia was the cause of the lesion and not the azathioprine or meticorten administration.


Decomposition of supplementary vitamin C in diets compounded for laboratory animals.

Processing may result in losses approaching 20% of the added vitamin C. The extent of these losses depends upon the process and is apparently related to temperature and moisture. Storage losses are also related to processing conditions, and no more than 50% of the vitamin C present in the diet immediately after 6 weeks. These results indicate that the current practice of including 1000 mg/kg of vitamin C in pelleted guinea-pig diets should be satisfactory, provided such diets are used within 6 weeks of manufacture and are stored during this period in conditions conducive to stability, that is dry, not exposed to direct sunlight and, preferably, with an even cool temperature.


Ammonia build-up in animal boxes and its effect on rat tracheal epithelium.

Some common laboratory species are now considered unsuitable for the study of the toxicity of inhalants because of the natural incidence of abnormal respiratory histology. Levels of ammonia commonly encountered in animal boxes and cages have been shown to cause histopathological changes in the tracheal epithelium of rats, and it is suggested that 'abnormal respiratory histology" could be a reflection of the standard of husbandry employed before and during an experiment.


Electron microscope study of experimental enteric infection in neonatal dogs with a canine coronavirus.

Neonatal dogs, inoculated orally with coronavirus 1-71, grown in canine kidney cell cultures, developed diarrhea and a severe enteritis characterized by atrophy of the villi, changes in the enterocytes, and accelerated epithelial cell loss. Electron microscopy of the mucosal epithelium, 4 days after challenge, showed that the virus penetrated into the enterocytes between microvilli, possibly by pinocytotic mechanism. In the enterocytes, virions were most often enclosed, singly or in groups, in cytoplasmic vesicles. They were less frequently found in the cisternae of the Golgi apparatus, the endoplasmic reticulum, or in the dilated perinuclear space and only rarely, free in the cytoplasm. Virions replicated by budding only on the smooth.membranes of the cytoplasmic vesicles. The infected cells showed a variety of cytopathic effects, some nonspecific, such as disruption of the microvilli, loss of density of the cytoplasm, presence of lipid inclusions, alteration of mitochondria, and dilation of the endoplasmic reticulum and Golgi cisternae and of the perinuclear space. Other cytopathic effects, characteristic of the coronavirus infection, consisted of formation of dense filamentous structures and of membrane-bound bodies. Progeny virions appeared to discharge into the gut lumen through the disrupted cell membranes of infected enterocytes still in situ or following their premature shedding.


Pulmonary responses of rats to ambient levels of ozone: effects of 7-day intermittent or continuous exposure.

Groups of Sprague-Dawley rats were exposed to ozone for either 8 or 24 hours a day for 7 consecutive days to evaluate morphologic changes of the respiratory system. Three levels of exposure (0.2, 0.5, and 0.8 p.p.m. of O3) were selected to simulate moderate to severe episodes of oxidant pollution in urban environments. Morphologic evaluation included light, scanning electron, and transmission electron microscopy. Biochemical parameters which were examined included succinate oxidase, glucose-6-phosphate dehydrogenase, and nicotinamide adenine dinucleotide phosphate-cytochrome c reductase activities. The results indicated that (1) exposure to concentrations as low as 0.2 p.p.m. for 7 days induced pulmonary damage; (2) there was a dose-dependent pulmonary response to the three levels of ozone which was quantitated by alterations in biochemical marker enzyme activities and observed morphologically; (3) proportionate differences were not observed in morphologic characteristics of the lesions or detected in biochemical parameters between rats exposed continuously for 7 days and those exposed intermittently for 8 hours a day for 7 consecutive days; (4) alterations in surface height and granularity of the cytoplasmic luminal projection of Clara cells were subtle changes which were dose-dependent, occurring even at the lowest ozone concentration, and best detected by scanning electron microscopy; (5) alveolar macrophage accumulation within proximal alveoli of alveolar ducts was the most readily detectable morphologic indicator of pulmonary damage; and (6) although the brunt of ozone damage was borne by the centriacinar region, there was damage to cilia and increased ciliogenesis occurring in the trachea and larger conducting airways following exposure of 0.5 and 0.8 p.p.m. of ozone.


Urinary kallikrein in experimental renal disease.

Urinary kallikrein excretion was studied in two types of experimentally induced renal disease: anti-glomerular basement membrane nephritis (20 rats) and aminonucleoside nephrosis (five rats) with appropriate controls (23 rats) for a period of 6 to 9 weeks following disease induction. In both models there was a prompt significant decrease (p less than 0.01 - 0.001) in urinary kallikrein excretion associated with proteinuria but unrelated to urinary sodium and potassium excretion and urinary volumes. In antiglomerular basement membrane nephritis the fall in kallikrein excretion occurred within the first 24 hours concurrent with the onset of proteinuria. In aminonucleoside nephrosis the decrease antedated the onset of proteinuria by 48 hours beginning within the first 24 hours following injection of the aminonucleoside. Kallikrein inhibitors were not demonstrable in the urines of diseased animals from either model. The mechanism of the decrease in kallikrein excretion in immune and nonimmune glomerular disease associated with proteinuria is unknown.


Effect of polyamines on the uptake of poly (2'-fluoro-2'-deoxyuridylic acid) by a mammalian cell line.

VERO cells can take up poly(dUfl)1 from the medium. The uptake involves surface adsorption and, most probably, intracellular penetration. Part of the poly(dUfl) is hydrolyzed during incubation with the cells but the hydrolysis products are not incorporated into de novo synthesized nucleic acids. The uptake is reduced by serum and stimulated by polycationic ionenes. The magnitude of stimulation depends on the structure of the ionene and the treatment regimen.


Substrate heterogeneity of component a of the human erythrocyte membrane.

Component a of the erythrocyte membrane is a specific substrate for endogenous protein kinase activity and its phosphorylation is significantly decreased under assay conditions in myotonic muscular dystrophy (Roses, A.D., and Appel, S.H.J. Membr. Biol 20:51-58 (1975)). We have demonstrated substrate heterogeneity of two fractions of component a separated by concanavalin A (Con-A) sepharose chromatography. The fraction of component a that is retarded by Con A and eluted with alpha-methyl-D-glucoside does not accept the transfer of phosphate from [gamma-32 P]  ATP as a substrate for endogenous protein kinase activity. The nonretarded fraction contains greater than 90% of the radioactive label. These experiments also confirm the carbohydrate heterogeneity of component a (Findley, J.B.C., J. Biol. Chem. 249:4398 (1974).


Drug-resistant mutants of Chinese hamster ovary cells possess an altered cell surface carbohydrate component.

Surface label experiments using the galactose oxidase-]3H]-borohydride technique reveal that cells from drug-resistant Chinese hamster ovary clones possess a surface carbohydrate component of apparent molecular weight 165,000 which is absent from wild-type cells. The component may also be demonstrated by [14C]glucosamine incorporation but not by [3H]leucine incorporation or by the lactoperoxidase surface labeling reaction.


Protein transport: a selective membrane mechanism.

Proteins are selectively sequestered by a number of cell types. However, only in oocytes is the process sufficiently aggravated and specific to be readily studied. In these cells certain serum proteins are taken up in proportions different from those found in the serum. In vitro incubations of hormonally stimulated and synchronous mosquito oocytes show that the only protein capable of initiating the transport process is the female specific yolk protein. Heterologous proteins such as IgG, bovine serum albumin, cytochrome C, and ferritin are inactive. The female specific protein is a phosphoglycolipoprotein. It is synthesized in the fat body, a liver analog in the insect, and passed into the serum before being transported into the oocytes. Preliminary kinetic analysis shows the uptake process to be specific with an apparent Km of about 10(-7) M. Glycolytic inhibitors stop protein uptake. The receptor-mediated binding steps in the transport process are most easily studied in the chicken because of the enormous amount of oocyte membrane available from a given oocyte and because up to 1 gm of protein is normally transported per day per oocyte. IgG and the hen specific phosvitin lipovitellin are two of the physiologically important proteins that are transported intact into the chicken oocytes. The uptake appears selective as shown by studies with iodinated proteins. Ferritin conjugated to IgG is shown by electron microscopy to bind to isolated plasma membranes only where coated pits have formed, whereas ferritin alone is not seen localized on any membrane surface. These very specialized regions of the membrane are similar to micropinocytotic pits but, in addition, possess on their cytoplasmic side dense ridges that form the coat. Transport involves binding to the coated pits, the pinching off of the pits, and the subsequent movement of the coated vesicles in the cytoplasm.


A scanning electron microscope study of concanavalin A receptors on retinal rod cells labeled with latex microspheres.

Con A-methacrylate microsphere conjugates prepared by a two-step glutaraldehyde reaction were used to label Con A-binding sites on bovine rod photoreceptor cells for visualization by scanning electron microscopy. A dense distribution of markers was observed on the surface of the rod outer segment, the inner segment, and the synaptic region. Disk membranes also appear to be heavily labeled with the Con A-microsphere conjugates. The Con A inhibitor, alpha-methyl mannoside, inhibited the binding of the conjugate to the surface of these visual cells.


Frozen section- frozen attitudes.

Patients with breast cancer who have clinically negative axillae, tumors 2 cm in diameter or less, and tumors with a moderate or low degree of anaplasticity are candidates for treatment by local excision and irradiation. A definitive histologic diagnosis should be made in all cases of breast cancer before a final treatment decision is made. This can be accomplished by needle or excisional biopsy. After a histologic diagnosis is established, the decision regarding treatment can be arrived at with the patient enering into the process. Those patients requiring mastectomy will be better able to cope with this, knowing why the operation was considered best for them. The elimination of frozen section diagnosis will free the patient from one of the great fears of the current treatment of breast cancer- subjecting herself to biopsy without knowing what the outcome will be. It will free the surgeon from the rigid sequence of frozen section followed by mastectomy and allow him to begin to rationally assign patients with proper criteria to conservative treatment, reserving mastectomy for those who do not meet these criteria.


The influence of pineal ablation and administration of melatonin on growth and spread of hamster melanoma.

Removal of the pineal organ resulted in increase in the growth of transplanted melanoma in hamsters. Administration of melatonin, which is the priniciple indole found in pineal tissue, to pinealectomized animals abolished this effect. Therefore it was concluded that the effect of pinealectomy on tumor growth is due to a lack of endogenous melatonin. Administration of large doses of melatonin (4 mg/day) to intact animals, however, did not influence the rate of tumour growth, indicating that the drug has no direct effect on tumor growth and that the changes produced by melatonin deficiency is perhaps due to complex reaction involving centers in the hypothalamus and brain stem. Certain morphologic changes were noted in the pineal organs of animals treated with exogenous melatonin. Although the biologic significance of these changes is not clear, study of the electron micrographs indicates that the pinealocytes of the melatonin-treated animals are in a state of increased activity.


Immunocompetence and spontaneous regression of metastatic renal cell carcinoma.

Spontaneous remission of pulmonary metastases from renal cell carcinoma was correlated with a positive response to dinitrochlorobenzene (DNCB). When first seen, the patient was DNCB negative and a chest radiograph showed nodular densities in the right lung and left midlung. Six months after sensitization, the patient had a positive response to DNCB and no evidence of lung metastases. Three mo later, the patient developed brain metastases although X-ray examination showed no pulmonary nodules. A diminished response to DNCB noted over the next several months and chest X ray verified the return of pulmonary metastases.


Possible factors in remote metastases in female breast cancer.

The association of metastases (M) with age of patient, stage of disease, the gross and microscopic characteristics of the primary tumor, its physical location, the postradiational status of the breast, the extent and level of histological nodal involvement, the type of surgery practiced, and the host's biological environment are analysed. The authors conclude that the critical factor in systemic dissemination in female breast cancer is the extent and level of metastatic nodal involvement. Though the association between stage of disease, character of tumor (T), and histology are significant, the cruicial factor seems to be the nodal involvement. Systemic metastases are significantly higher in inner quadrant tumors. Possible methods of circumventing this dissemination are discussed.


Differences in potentiation of melanoma growth by absorbable and nonabsorbable suture.

This study demonstrates that various suture materials have different influences on tumor take and growth. When used in an area containing 10(5) or greater tumor cells, all suture types studied potentiated tumor growth. At subclinical tumor cell doses- that is, 1,000 or fewer cells that do not normally grow to a clinically detectable tumor- silk and steel increased tumor occurrence. In comparison, monofilament nylon, polyglycolic acid, and chromic suture did not potentiate tumor growth. This phenomenon of increased tumor growth associated with certain suture types appears to be related to the physical characteristics of the suture involved, although the interaction of the chemical breakdown products of the suture material with the local tumor cells is under investigation. The type of suture material used may play a significant role in the subsequent development of local recurrence of cancer.


Mesenchymoma: a review of literature and report of two cases.

Both benign and malignant varieties of the mesenchymoma have been described. Previously reported cases of mesenchymoma in the head and neck are rare. Two cases of mesenchymoma occuring intraorally are  reported here. In each case local excision has affected apparent cure, for periods of 12 yr and 8 mo, respectively. Local excision is advocated as the primary treatment for such lesions occurring in the oral cavity. Although recurrences in areas other than the oral cavity tend to undergo malignant changes, this phenomenon has bot been demonstrated in lesions occurring in oral tissues.


Prognostic significance of peripheral lymphocyte counts and carcinoembryonic antigens in colorectal carcinoma.

An association between pretreatment lymphocyte counts and 5-year prognosis was noted in colorectal cancer. Among 188 patients with 5-year follow-up significant difference in survival rates in relation to lymphocyte counts was noted: 61% for patients with counts greater than 2,000/cm, 30% for those with counts less than 1,000/cmm, and 58% for the intermediate group. Similar differences were also noted within groups with Dukes' B and C lesions and in elderly patients. Highly significant differences were noted in women. Those with Dukes' B and C lesions with counts greater than 2,000/cmm had an 81% survival rate, compared to 50% for those with lower counts X2 = 6.81 P LESS THAN 0.01. Women had significantly higher lymphocyte counts and higher survival rates than men. An inverse correlation was noted between pretreatment lymphocytes and simultaneously determined carcinoembryonic antigens. These observations indicate that lymphocyte counts may be of prognostic value in colorectal cancer when used in association with carcinoembryonic antigens.


The regional lymph node question. To treat or not to treat: the pros and cons.

The question of whether or not to extend treatment to the regional lymph nodes when treating malignant disease remains unanswered. The clinician must individually approaise the pros and cons and derive a satisfactory treatment plan for each patient. Six reasons which are generally stated as indications for regional lymphadenectomy and seven potential arguments against lymphadenectomy are presented.


Comparison of the inotropic action of morphine and ketamine studied in canine cardiac muscle.

This study compares the inotropic action of morphine sulfate and ketamine hydrochloride on isolated canine right ventricular trabeculae. The heart was removed from 19 mongrel puppies weighing 5 to 9 kilograms and placed in Krebs-Ringer bicarbonate solution. The bathing solution contained 1.3 mM. of Ca2+ and was bubbled with a gas mixture of 95 per cent oxygen and 5 per cent carbon dioxide. At Lmax (i.e., the peak of isometric force-length curve) morphine even in large concentrations (up to 1 mg. per milliter) produced no significant direct inotropic effect. At the lower concentrations tested there was a minor but not significant increase in contractile performance, whereas at the highest concentration used there was a minor but not significant depression in contractility. In these same muscles lower concentrations of ketamine had a significant positive inotropic action, but a concentration of 200 mug per milliliter, which is approximately equimolecular to 1 mg. per milliliter of morphine sulfate, caused a profound depression in contractile performance. In the presence of a beta-blocking agent and in reserpine-pretreated muscles, low concentrations of ketamine, which had only a positive inotropic action in the normal muscles, now caused depression of contractile performance. The positive inotropic action of ketamine is thus indirect and mediated via adrenergic influences. At each concentration studied the direct inotropic action of ketamine was exclusively negative. Because of this bimodal inotropic action seen when adrenergic mechanisms are intact, we conclude that caution must be exercised when ketamine is given to patients previously treated or still under the influence of drugs having adrenolytic properties. Caution is also necessary when ketamine is used in patients having diminished cardiac adrenergic reserves as in congestive heart failure.


Human skin burns induced by defibrillator default current.

The attachment of various types of electronic instrumentation to a patient can lead to hazardous interactions. Component malfunction in a single piece of equipment connected to a patient may be totally innocuous. However, the same fault occurring in an identical piece of equipment functioning as one component in a network of monitoring and electrosurgical equipment can result in severe burns or even electrocution. This paper describes interaction between a defective defibrillator paddle and an electrosurgical unit. Burns and ventricular fibrillation resulting from this malfunction and interaction are described in detail and the electrical circuits are analyzed.


Successful total repair of complicated cardiac anomalies with asplenia syndrome.

A one-stage total repair was successfully accomplished in a Japanese girl, 7 years, 8 months old, who had asplenia syndrome with vixceral heterotaxia, isolated levocardia, and complicated cardiovascular anomalies; double-outlet right ventricle with d-malposition of the great arteries (anterior aorta, posterior pulmonary trunk), complete form of endocardial cushion defect, total anomalous pulmonary venous drainage, pulmonary stenosis, sinus venosus type of atrial septal defect, patent ductus arteriosus, bilateral superior venae cavae, and inferior vena cava draining into the left-sided atrium. A routine cardiopulmonary bypass, consisting of ligations of the patent ductus arteriosus and right superior vena cava, was followed by direct and patch closure of atrial and ventricular septal defects. An internal conduit was inserted to drain the systemic venous blood from the left ventricle to the pulmonary artery. Thus a total repair is physiologically possible in such complicated cardiovascular anomalies with an asplenia syndrome. One year after this operation the child is well and attends school daily.


Delayed timing of heart and arterial sounds in patients with implanted pacemakers.

We have recorded the timing of the heart sounds and the arterial sounds with reference to the onset of each cardiac cycle in 16 patients before and after implantation of a pacemaker prosthesis, and in an additional 18 patients after pacemaker implantation only. The interval between the QRS complex and the Korotkoff sound at diastolic pressure (QKd) is markedly prolonged, from 206 to 294 msec., a change corresponding to 10 standard errors of the mean difference. Likewise, the Q-Korotkoff interval at systolic pressure (QKs) is prolonged from 329 to 414 msec. The interval between the QRS complex and the onset of the first sound (S1) is prolonged by approximately 90 msec., whereas the interval between the QRS and the second heart sound (S2) is prolonged by 70 msec. We noted an associated increase in heart rate, a slight decrease in systolic pressure, an increase in diastolic pressure, a decrease in pulse pressure, and a slight decrease in the  deltaP/deltat at the brachial artery measured indirectly and noninvasively.


Persistence of biologic activity after disappearance of propranolol from the serum.

In order to evaluate the duration of the biologic effects of propranolol after the drug was discontinued, we evaluated a variety of noninvasively determined hemodynamic parameters. Significant depression was found in the heart rate (18 per cent), cardiac output (13 per cent) (determined echocardiographically), and the triple product of blood pressure, heart rate, and systolic ejection time (16 per per cent) during administration or propranolol (200 mg. per day) to 9 normal volunteers. Significant depression of these parameters was present 12 hours after discontinuing the drug. By 12 hours, serum propranolol levels had returned 90 per cent toward their base line; however, at the same time, the heart rate and cardiac output had returned only 19.4 and 14.3 per cent toward their base-line values, and the triple product had returned 41 per cent toward its baseline. By 36 hours no biologic effect was seen. Thus if propranolol were discontinued 2 days prior to cardiac surgery, no significant biologic effect would remain to complicate the patient's postoperative course.


Left ventricular and biventricular extracardiac conduits.

The insertion of an extracardiac conduit from the right ventricle has gained extensive success during the past decade. This report concerns the application of such a conduit from the left ventricle. Its use in four types of anomalies is described: (1) left ventricular outflow hypoplasia, (2) transposition of the great arteries with ventricular inversion and associated pulmonary stenosis, (3) complex anomalies involving double-outlet right ventricle wherein construction of an intracardiac tunnel is not feasible, and (4) transposition of the great arteries with intact ventricular septum and severe pulmonary stenosis. The correction of the last two mentioned anomalies involves the insertion of two parallel conduits, one from each ventricle to its appropriate great artery. The transposition anomaly may alternatively be corrected by combined Mustard repair and a left ventricle-to-pulmonary artery extracardiac conduit.


Postperfusion coronary ostial stenosis: incidence and significance.

In a study of 117 consecutive aortic valve replacements in which selective coronary perfusion was routinely employed, four patients developed coronary ostial stenosis (3.5 per cent). Continuous selective coronary perfusion was performed by use of Mayo balloon catheters with individual measuring of pressure and flow. All 4 patients developed progressive symptoms of angina pectoris within 6 months of the original operation, after uneventful recoveries. All 4 were found to have lesions in the left main coronary ostium and required a coronary bypass. Two made uneventful recoveries and are presently asymptomatic, whereas 2 died in the immediate postoperative period. The literature indicates that the reported incidence of this complication varies from 1 to 5 per cent. Furthermore, the mortality rate for reoperation in these patients is higher than that for those undergoing uncomplicated coronary bypass without an antecedent procedure. Our experience confirms the lethal nature of this complication and the necessity for reoperation once the diagnosis is established. The development of these dangerous lesions must be taken into account in the prevailing controversy between the most effective methods of myocardial protection during aortic valve replacement.


Program for managing chronic pain. I. Program description and characteristics of patients.

A program for the management of patients with treatment-resistant pain involves behavior modification, physical treatment, medication management, and counseling. The first 50 patients were characterized by pain of many years' duration, multiple operations, treatment failures, prolonged disability, compensation factors, and dependency on medication. In addition, they demonstrated loss of intellectual efficiency and were more psychologically deviant than the general medical population. Management problems were encountered in the following areas: patient acceptance, drug seeking, complicating psychopathology, complicating physical disorders, group dynamics, family reactions, and staff morale. Fifty-four percent of patients achieved moderate to marked improvement.


Suprasellar extension of tumor associated with increased cerebrospinal fluid activity of growth hormone.

The diagnosis of hormonally active acromegaly has been aided by the radioimmunoassay for human growth hormone (hGH). We report a case in which baseline plasma hGH levels were elevated minimally and partial suppression during the glucose tolerance test occurred. Subsequent hGH assay of the cerebrospinal fluid, however, confirmed active acromegaly and correctly predicted suprasellar extension of the tumor.


A volume-displacement plethysmograph to measure limb blood flow in the newborn infant.

An instrument is described that measures limb blood flow in newborn infants by venous occlusion plethysmography. The plethysmograph is filled with air and a pneumotachygraph measures the volume displaced during venous occlusion. The response of the system is linear for flows over the range 1 to 100 ml/min and the frequency response to a square wave pressure change is 22 Hz with a 95% response time of 0.5 second. The average flow in the forearm of 10 normal newborn infants was 5.9 ml/min per 100 ml of tissue.


The primary surgical treatment of carcinoma of the breast: a changing trend toward modified radical mastectomy.

To study the effectiveness of a trend at the Mayo Clinic toward modifying the standard radical mastectomy, the 5-year survival of 873 women treated surgically for breast cancer from 1965 through 1968 was evaluated. The observed survival of 534 patients treated by the standard radical mastectomy was 85% when nodes were negative and 56% when nodes were positive. For 339 patients treated by the modified radical mastectomy, the observed survival was 80% and 48% when axillary nodes were negative and positive, respectively. In order to accomplish a more significant analysis of cancer risk and results of the two operative procedures, a relatively homogeneous group of 541 patients was established from the total group. In this homogeneous group, the observed survival of 336 patients treated by the standard radical mastectomy was 86% when nodes were negative and 66% when nodes were positive. For 205 patients treated by the modified radical mastectomy, the observed survival was 84% and 66% when axillary nodes were negative and positive, respectively. When patients were further analyzed and compared according to the extent of axillary-node involvement, age at the time of treatment, grade, size, location, and histopathologic type of tumor, and the use of postoperative irradiation, survival was essentially the same, irrespective of the type of mastectomy performed.


Patho-physiologic findings after chronic tryptophan deficiency in rats: a model for delayed growth and aging.

Long-Evans female rats three weeks, three months and 13-14 months of age were placed on tryptophan-deficient diets for periods ranging from a few months to nearly two years. Growth was interupted during the period of tryptophan-deficiency, but when the animals were returned to a complete diet, they gained weight and grew to normal size. Ability to reproduce, as indicated by litter production, was present at 17-28 months of age in rats which had been deprived of tryptophan, whereas no controls over 17 months of age produced any offspring. Other signs of delayed aging in the experimental group included, at advanced ages, greater longevity, as well as later onset in the appearance of obvious tumors, and better coat condition and hair regrowth. Many of these effects were also seen in pair-fed controls (fed a diet equal in amount to that eaten by the tryptophan-deprived rats, but with 1-tryptophan added). It is hypothesized that tryptophan deficiency delays growth, development and maturation of the central nervous system (CNS), in particular, by decreasing the levels of the neurotransmitter serotonin, for which tryptophan is the necessary precursor. In a parallel experiment, chronic treatment with d, 1-parachlorophenylalanine, an inhibitor of brain serotonin synthesis, from weaning until adulthood, also inhibited growth (body weight) and delayed sexual maturation (age of vaginal opening). These observations suggest that diets deficient in tryptophan or restricted in calories can affect maturation and aging by interfering with CNS protein synthesis, or neurotransmitter metabolism, or both.


Morphological changes in aging cell lines of Paramecium aurella. I. Alterations in the cytoplasm.

Electron microscopical examination of aging P. aurelia revealed that definitive changes occur in the cytoplasm of old cells. There was an increase in the number of mitochondria and lysosomal bodies as well as the appearance of large dense bodies and autophagous vacuoles. The mitochondria were altered morphologically and many appeared to be coalesced with lysosome-like bodies and were also observed to be degenerating within autophagous vacuoles. The large dense bodies were considered to be similar to the lipofuscin or age pigments reported in other aging cells. The relationship of the large dense bodies to the lipofuscin pigments and their probable origin are discussed as is the involvement of the cytoplasm in the aging death process in P. aurelia.


Ovarian development in athymic nude mice. IV. The effect of PMSG and oestradiol on the growth of the oocyte and follicle.

Retarded follicular and oocyte nucleolar growth rates in ovaries of 1 month old congenitally athymic nude mice are restored by pregnant mare serum gonadotrophin (PMSG). By contrast oestradiol-17beta depresses follicular growth rate in phenotypically normal (control) mice to levels found in nude littermates. Paradoxically, oestradiol-17beta stimulates nucleolar growth rate in control mice, but not nudes, to levels found in PMSG treated groups. These results are discussed in relation to the position of the thymus gland in the pituitary/ovarian axis and the mode of action gonadotrophin upon oocyte and follicular growth in the pre-puberal mouse ovary.


13. Studies in rating the physical, mental, and social dysfunction of the chronically ill aged.

It is difficult to separate what might be considered the normal from the dysfunctional aspects of aging in the physical, mental, and social areas, and wide variation occurs in the way persons age, with and without chronic illness. One cannot, and would not want to, disentangle these interrelated areas, but they are often measured as if they were independent of each other. Any assessment of the total functioning of an individual must take into account the subject's own perception of his health or functional status which, in addition to the cultural influences and feedback from the environment, interact to produce total adjustment. There is some indication that self-assessments of health may be a reliable predictor of more detailed functional assessments. Lastly, there is a plea for the study of a multidimensional approach including objective and subjective physical, mental, and social measurements related to patient outcome. With currently available statistical methods, it may be possible to reduce the number of variables needed for assessment of the total person to a few that uniquely describe overall status.


16. Recent studies using a global approach to measuring illness.

Global measures of illness are designed to measure the performance of a health service as a whole and the contribution of its various components. Such measures convert data about the outcome of medical care into information for use in planning at all administrative levels including the highest levels of government. This is achieved by means of a classification of states of illness applicable to all patients, whatever their diagnosis and symptoms, and of a scale which places valuations as perceived by society on the defined states. The valuations of changes in the states of individuals during treatment or over a period of time can then be summed for heterogeneous populations. By adjusting the valuations of future changes for time preferences it may be possible to take into account prognosis, and by placing a valuation on death, mortality and morbidity data can be combined. The properties appropriate to the classification and scale are defined and problems encountered in their derivation are discussed. Examples are presented of the application of one global measure to a group of medical specialists and to population data for the United Kingdom.


28. The nursing home project of the Iowa Health Services Data System.

The long-term care project of the Iowa Hospital Association has demonstrated the feasibility and utility of a multipurpose data system for nursing homes and related institutions. Important features of the Iowa system are emphasis on the needs and constraints of those providing care and collecting the data; prior establishment of specific criteria for the content of the system; the use of three related forms (admission, evaluation, and discharge) to produce current reports; and ease, flexibility, and transferability. A significant byproduct of the demonstration project was improved record keeping and patient care planning by the 14 participating facilities. Major problems encountered were lack of experience on the part of nursing homes and external regulatory agencies in defining their data needs and using data effectively, and financial support. Contribution to cost by external agencies in return for data and a major commitment to educational programs, both initial and continuing, are seen as essential to the success of long-term care data systems.


29. The Multi-State Information System for Psychiatric patients.

The Multi-State Information System for Psychiatric Patients (MSIS) is a computer based, clinical and administrative management information system used by numerous mental health programs and facilities for patient and program management. Structured forms are used for the collection of core information on patients, on services rendered, on affiliated agencies, and on fiscal and administrative processes. A variety of output reports and general retrieval techniques are being used to help administer and evaluate patient care programs, monitor clinical and program management functions, refer clients to other service agencies, and review individual cases, as well as for administrative functions such as cost finding, rate setting, billing, and inventory control. MSIS is currently field testing an automated problem-oriented psychiatric record, and a goal-oriented record to be used with the mentally retarded is under development.


Policies to influence the spatial distribution of physicians: a conceptual review of selected programs and empirical evidence.

To increase the usefulness of existing physician location literature for policy evaluation, literature is grouped into intraurban and urban-rural studies. A conceptual overview of physician location literature is presented. Consensus results, if any, are discussed. A list of hypotheses suggested by the literature is then utilized in a discussion of economic social, prior exposure, and professional development incentives embodied in selected public and private sector programs. Programs are evaluated by type of incentive mechanism and geographic target area to determine if present program structures are based on a solid empirical foundation. This assessment indicates that, in general, use of prevalent location incentive mechanisms is not justified by a consensus of empirical evidence.


Distribution of private practice offices of physicians with specified characteristics among urban neighborhoods.

The office location of New York County physicians in private practice is determined for a verified subpopulation of the "Medical Directory of New York State" listing for the year 1970-71. Physicians are categorized by specialty status, medical schools attended, dates of graduation, and hospital affiliations. Multiple regression analysis is performed to relate numbers of physicians per Health Area (average population: 20,000) to demographic, economic, and medical care characteristics of the areas. There is considerable unevenness in the number of private physician offices among Health Areas (mean, 66; standard deviation, 173; range, 1 to 1,043). Multiple regression analysis shows a strong, positive association between practice location and median area income. The influence of population size on practice location is also found to be significant for many categories of physicians but less strong than that of income. Other independent variables are found to have a weaker to nonsignificant impact on practice location. Disaggregation of physicians into specified categories reveals differences in elasticity of location estimates that would have gone undetected had only the aggregated physician population been investigated. Itis concluded that policy decisions concerning physician distribution should be made on the basis of data on smaller areas than has been done in the past, and on specified categories of physicians rather than on aggregates.


United States foreign medical graduates in Connecticut: how they compare with foreign medical graduates.

This study contrasts the graduate training and subsequent careers of a cohort of United States-born foreign medical graduates (USFMGs) and foreign medical graduates (FMGs) who were in training positions in Connecticut in 1964 and who were located in 1971. The data suggest that although USFMGs were foreign-educated, they had certain advantages--both cultural and administrative--in hospital training positions which helped them to pursue different career alternatives than FMGs. However, the data further suggest that they retained characteristics of their foreign training which continued to differentiate them from United States medical graduates (USMGs).


Physician migration to the U.S.--foreign aid for U.S. manpower.

Data were obtained from the American Medical Association on Iranian physicians practicing in the U.S., and from the Iranian Medical Registry on U.S.-trained Iranian physicians who have returned to practice in Iran. There were 2,066 Iranian physicians practicing in the U.S. in 1972, 1,234 (60%) of whom were not undergoing any training. Only 600 of Iran's 9,535 physicians in 1972 had been trained in the United States. Thus, less than one-third of the specialists who have completed training in the U.S. have returned to practice in Iran. The specialist group with the highest rate of return is the combined surgery subspecialties (neurosurgery, thoracic surgery, orthopedic surgery, and plastic surgery). The specialist groups with the lowest rates of return were pathology, anesthesiology, and psychiatry. A comparison is made of the manpower problems Iran faces and the American problems in the area of physician manpower.


Unaccepted applicants to medical school as a health resource.

The career decisions of national samples of male and female unaccepted applicants to the 1971-72 entering U.S. medical school class are studied in order to determine whether the increasing number of unaccepted applicants is a potential manpower pool for alternative health occupations. The dominant response to rejection among respondents is reapplication to medical school in subsequent years, and the principal determinant of reapplication is receiving postrejection support (usually from family or friends) of the original career intentions. Most of the respondents who do not gain admittance to medical school on reapplications still aspire to doctoral-level degrees, but only half remain in the health area. Those respondents who had formulated contingency career plans in the professions and who had high science aptitude but low math aptitude tended to remain in the health area. A service orientation toward occupations is not associated with remaining in the health area.


Socioeconomic factors and maternal and child health care.

A sample of mothers was interviewed between 12 and 18 months after delivery of a liveborn infant. Data were gathered concerning planned parenthood, prenatal care, the child's care in the first year of life, and socioeconomic factors. Among socioeconomic variables, maternal education was found to be the single best parameter in terms of detecting differences within the sample with regard to levels of birth control, prenatal care, and child care.


Clinical experiences in hyoid arch transposition.

Autogenous hyoid bone grafts for the repair of subglottic stenosis have been used successfully in canine experiments. This technique was subsequently modified for human use, and the experience in six patients over the past year at Washington University is reported. In five of the six patients, satisfactory results were obtained. Several case reports are included, and the surgical procedure is described in detail.


Vocal cord injection in the treatment of acute and chronic aspiration.

The problem of maintenance of proper tracheobronchial toilet is frequently a determining factor in the morbidity and mortality of patients with vocal cord paralysis. Aspiration from an incompetent glottis can cause pneumonitis and its attendant complications. Standard management of tracheobronchial toilet in patients with vocal cord paralysis has involved direct or indirect suctioning of the trachea; however, only the symptoms and not the anatomic defect are treated by these measures. Largely due to the work of Arnold and Lewy, the technique of vocal cord injection has been advocated as a method of correcting the anatomic deficiencies in patients with vocal cord paralysis, and has been advocated in the past to prevent recurrent and chronic aspiration. This study has shown that vocal cord injection increases the ability to maintain maximum peak intraluminal air pressures following injection. It has also shown that there is an increased ability to maintain air flow by glottic closure following injection. Eleven patients were studied, each of whom has been evaluated separately in this paper. The use of vocal cord injection should be more widely used by otolaryngologists and chest disease specialists for treatment of physiologic problems as well as correcting vocal disturbances.


Supraglottic larynx and its pathology as studied by whole laryngeal sections.

The need for additional data regarding the behavior of carcinomas of the supraglottic larynx was recognized during attempts to identify candidates for supraglottic laryngectomy. The crux of the matter was whether supraglottic carcinomas remain confined at the supraglottic larynx. If some do not, can these exceptions be detected preoperatively? Information gained from whole-organ study of 40 larynges with such tumors showed that most tumors do remain confined to the supraglottic larynx; however, there are exceptions, and these are usually high-grade tumors. Preoperative biopsy demonstrating undifferentiation in a tumor suggests a potential for atypical behavior. Patients with these high-grade lesions are not candidates for supraglottic laryngectomy. Fortunately, most supraglottic carcinomas are well-differentiated, behave in a typical manner, and fulfill the expectations gained from the preoperative mucosal appearance. Supraglottic laryngectomy is, therefore, feasible and successful in carefully selected candidates. The conclusions of this study are the following: 1. Most supraglottic cancers behave as expected, being typically well-differentiated tumors that remain confined to the supraglottic larynx. 2. Exceptions to such behavior are exemplified by tumors manifesting submucosal extension some distance away from the main tumor mass, tumors invading the thyroid cartilage, second primaries, and tumors disseminating emboli away from the main tumor. 3. Present preoperative diagnostic measures still fail to detect tumors with atypical behavior. Subsequent supraglottic laryngectomy in patients with such tumors would, therefore, leave residual tumor. 4. Carcinomas exhibiting atypical behavior are characteristically undifferentiated and aggressive. 5. The epiglottis and pre-epiglottic space are easily invaded by supraglottic cancer. The pre-epiglottic space is removed during either supraglottic or total laryngectomy. 6. The thyroid cartilage is an excellent barrier to the spread of supraglottic cancers. Tumors that invade it penetrate the anterior commissure first. 7. The pitfalls in the selection of candidates for supraglottic laryngectomy are assessment problems in which the tumor mass makes it difficult to see its full mucosal extent. Inadequate biopsy may also fail to detect a tumor. 8. In the preoperative assessment of a patient with supraglottic carcinoma, supraglottic laryngectomy is contraindicated if the biopsy does show high-grade differentiation and if the tumor is situated near the petiole. 9. Undetected extension submucosally to the level of the glottis will result in some failures with conservation surgery of the larynx.


Surgical salvage after radiation for laryngeal cancer.

From January, 1962, through December, 1973, 1,084 patients with cancer of the intrinsic larynx were treated at the Mayo Clinic. Of the 1,084 patients, 136 were retreated after radiation therapy failed to cure their cancer (105 glottic, 30 supraglottic, and one subglottic cancers). Recurrence of glottic cancer was generally recognized later than recurrences in the supraglottic area; likewise, glottic cancers were more advanced at recurrence than supraglottic growths. When feasible, conservation surgery was carried out on both glottic and supraglottic growths. Unfortunately, many growths were too advanced for conservation surgery by the time recurrence was recognized. The concept of "radiate-and-watch" for early glottic and supraglottic cancers is designed to save larynges. The concept is not supported by this study.


The middle cranial fossa approach to the petrous apex.

Petrositis is still a very real complication of otitis media. The most striking diagnostic feature is facial and/or retrobulbar pain, and it is the most consistent symptom. External rectus paralysis was present in only one of the four cases presented in this series. Treatment is surgical. In order to spare the cochlea and give adequate exposure to the apical cells, the middle fossa approach to the petrous apex is presented, to be used alone or in conjunction with mastoidectomy.


Perichondritis of the ear.

A total of five ears with perichondritis secondary to burns was treated using a method of excising cartilage. This treatment resulted in the need for general anesthesia, frequent repeat debridement and frequent loss of structure of the ear with subsequent deformity. The presentation, etiology, pathology and present modes of therapy are presented. Our experience stresses the importance of early recognition and treatment and further consideration for the use of drains with continuous antibiotic and proteolytic enzyme administration.


Management of the mastoid air cell system in chronic otitis media.

The influence of the Mastoid Air Cell System in Chronic Otitis Media is subject to much speculation. Does a mastoidectomy influence the surgical results following chronic inflammatory ear surgery? An understanding of the pathology associated within the mastoid air cell system is necessary before a discussion of the need for a mastoidectomy can be presented. Most mastoid air cell systems are sclerotic in chronic otitis media patients. The report summarizes one author's experiences with the influence of mastoidectomy upon surgical reconstruction for chronic inflammatory diseases of the ear. Emphasis is directed toward the eustachian tube rather than the mastoid air cell system.


Recurrent meningitis and labyrinthine gusher, related to congenital defects of the labyrinthine capsule and stapes footplate.

A congenital defect in the bony footplate of the stapes is now known to be a point of lowered resistance to extension of bacterial middle ear suppuration to the vestibule and thence to the meninges. Tomographic demonstration of the congenital pathologic condition of the ear permits the surgeon preoperatively to chart his surgical course. Despite antibiotic and chemotherapy, recurrent meningitis remains a serious disease as manifested by the death of two of the patients reported. The capacity for surgical correction of the congenital defect is manifested by one of our patients who has been free of meningitis for more than two years after surgery. If a congenital defect is considered in each case of recurrent meningitis, it is believed the mortality of this serious disease can be reversed.


Endolymphatic sac drainage for intractable vertigo (method and experiences).

This paper describes a method of endolymphatic sac decompression and drainage. The method emphasizes widely exposing dura, avoiding skeletonization of the posterior semicircular canal and draining the sac via a T tube. The results of this procedure in 75 patients, including statistics in 46 ears are discussed. In patients with unilateral disease good results were obtained in control of vertigo in 94 percent of patients and significant improvement in cochlear function in over 30 percent.


Chondrosarcoma of the larynx.

Cartilaginous tumors of the larynx are rare, and of those reported, most are chondromas. To date, approximately 157 cartilaginous tumors of the larynx have been reported, but only 37 have been chondrosarcomas. A review of the records of the past 25 years (1948-1974) of the Johns Hopkins University Hospital and the Greater Baltimore Medical Center was made and revealed only two previous cartilaginous tumors, both chondromas. A case of an exceptionally large chondrosarcoma of the larynx which appeared as a neck mass invading the thyroid cartilage in a patient with a six-month history of hoarseness is presented. A complete review of the literature was made which shows that most chondrosarcomas occur in middle-aged males originating most often from the posterior cricoid lamina, next from the thyroid cartilage. Misdiagnosis has been a problem with low-grade tumors, and although wide local excision has been stated as being the treatment of choice, the authors emphasize the need for more aggressive surgery because of the high recurrence rate discovered in the literature.


Respiratory function in infants with Arnold-Chiari malformation.

The respiratory pattern of each of eight infants with Arnold-Chiari malformation was studied, employing an especially constructed nosepiece for the pneumotachograph. The apparatus was developed, using the principle that infants are nose breathers. Respiratory function was normal in seven infants and abnormal in one. The respiratory pattern of infants with ACM should be critically reviewed upon observing any changes in breathing.


Parapharyngeal neurilemmoma of the hypoglossal nerve.

Although neurilemmomas are uncommon cervical neoplasms, they account for a significant percentage of parapharyngeal space tumors. These neoplasms may originate from any nerve traversing this space, but the vast majority arise from the vagus nerve and sympathetic chain. Satisfactory treatment of neurilemmomas consists of total excision which is best accomplished via an external approach. Immediate nerve grafting is advocated when a segment of cranial nerve must be sacrificed in order to achieve complete tumor removal. A case of a parapharyngeal neurilemmoma arising from the hypoglossal which required treatment in this manner is presented. Electromyographic studies performed 15 months postoperatively demonstrate reinervation of the lingual musculature via the nerve graft.


Primary osteoma of the sphenoid sinus.

Osteomas of the nose and paranasal sinuses are rather common benign tumors arising in the head and neck area. The sphenoid sinus is involved in various inflammatory and neoplastic conditions; however, an osteoma arising from the sphenoid sinus proper has not been reported in the available literature. This paper reviews, in detail, osteomas of the paranasal sinuses and their incidence, and a case of a sphenoid sinus osteoma is presented with radiological and pathological findings.


Systemic lupus erythematosus causing subglottic stenosis.

Acute lupus erythematosus has manifested itself in many ways. Symptoms most often pertain to polyarthritis, arthralgias, skin lesions and those attributed to lupus nephritis. Recently documented lesions have been seen in the nose and larynx. The following case report shows evidence of subglottic stenosis due to SLE.


First branchial cleft syndromes and associated congenital hearing loss.

We have recently encountered three cases of first branchial cleft syndromes, two of which had prominent hearing losses. The cases are described, and the literature pertaining to first branchial cleft syndrome is reviewed. Because of the frequent coexistence of various congenital anomalies, we feel that the prevalence of congenital otologic problems associated with a first branchial cleft syndrome may be greater than has previously been suspected.


Specialties and the specialty boards.

As specialism has developed in the United States, multiple specialty societies and specialty boards have been created. Although they, in a very realistic fashion, have established the general standards for the delivery of specialty care and for graduate medical education, they, with other national medical organizations such as the American Medical Association, the Association of American Medical Colleges, and the American Hospital Association, function with a considerable degree of independence. There is lacking a cohesive and integrated effort to develop unified attitudes, postures, and policies that represent the medical profession and the health care industry in general. Recently the Coordinating Council on Medical Education and the Liaison Committee on Graduate Medical Education have been established. These two agencies represent a significant attempt to integrate policies for medical education and to identify a single accrediting agency that will apply uniform standards to the process of accrediting programs of graduate medical education. The federal government for the past several years has had an increasing interest in the health care industry and medical education. Many legislative bills have been passed which have imposed more and more regulations on medicine and have established more bureaucratic control over the professional activities of physicians. Insidiously the medical profession is being socialized. If accountability for the public welfare cannot be exercised by medicine, at least in the perspective of the federal government, more and more legislation and regulation are inevitable. The pluralistic structure of organized medicine will ultimately be self defeating. Cohesive policies on behalf of the medical profession must be developed if leadership in medicine is to remain in the private sector. The Coordinating Council on Medical Education is unquestionably a significant attempt to demonstrate public accountability. It is, however, only the first step in the long and difficult process of developing cohesive national policies on behalf of organized medicine.


Human laryngeal reinnervation.

Bilateral vocal cord paralysis is fortunately an uncommon occurrence although the incidence of this injury secondary to external neck trauma is increasing. In general, a patient with this lesion is faced with the choice between adequate airway at the expense of a breathy, weak voice or a fairly good voice with the need for a permanent tracheotomy. In an effort to provide a better solution to this dilemma, an attempt has been made to develop a means of reinnervation of at least one vocal cord without the problems inherent in the usual nerve anastomosis techniques. After extensive preliminary work in dogs the nerve-muscle pedicle technique for reinnervation has been developed. In this procedure the branch of the ansa hypoglossi to the anterior belly of the omohyoid is mobilized and a small block of muscle containing the terminal branches is freed from the muscle proper. Using an approach similar to the Woodman arytenoidectomy, the posterior cricoarytenoid muscle is exposed, and its fibers are partially incised. The previously prepared nerve-muscle pedicle is sutured to it. In the first five patients subjected to this procedure, return of spontaneous abduction of the reinnervated vocal cord was noted between six and eight weeks post surgery. In no case was the voice weakened nor was there any problem with aspiration. All five patients have achieved sufficient airway so that exercise tolerance for daily activities is adequate without a tracheotomy. The physiologic and histologic background of this technique is discussed in detail.


A radiologic advance in the diagnosis of disorders of the larynx.

The cervical spine greatly reduces the usefulness of anteroposterior soft tissue radiologic examination of the larynx. Fractures of the laryngeal and cricoid cartilages are difficult to diagnose by soft tissue technique, and time-consuming laminagraphy is often required. A new technique for single exposure anteroposterior soft tissue radiography of the cartilages and airway is described. An esophageal cassette containing ultraspeed dental film placed in a retrolaryngeal position is shown to yield detailed radiographs of high contrast. The feasibility of this technique is illustrated by the presentation of radiographs from patients with laryngeal disorders. The new technique is compared with existing examinations available to the clinician and its application in other disorders of laryngeal cartilages and soft tissue is discussed.


Transposition of the lingual thyroid.

Lingual thyroid represents the only functioning thyroid tissue in the body in 70-80% of the cases, surgical ablation of which will produce hypothyroidism. Transposition of the lingual ectopic thyroid with its vasculary supply intact as a pedicle graft is presented. This seems to be the most locigal approach in preserving the viability and function of these ectopic tissues.


Postoperative chylous fistula prevention and management.

Postoperative chylous fistulas occur as a complication in 1-2% of all radical neck dissections. Twelve cases are reviewed herein. Chylous fistulas are more common with left neck dissections, but 25% occurred on the right side in this series. An intraoperative chylous fistula was recognized and treated in 75% of the cases which later developed a postoperative fistula. Postoperative fistulas may be divided into two groups: minor fistulas may be treated with pressure dressings and repeated aspirations; fistulas which do not respond to conservative management should be re-explored early and the fistula ligated.


Surgical pathology of cancer of the larynx and hypopharynx.

A study was designed to determine the influence of certain surgical pathologic findings on tumor spread and survival in patients with cancer of the larynx and hypopharynx. All patients with primary epidermoid carcinoma of the larynx and hypopharynx, treated by either surgery or preoperative irradiation and surgery, between 1955 and 1971 were included in the study. The patient population consisted of 791 patients all of whom were eligible for three-year follow-up. Information from a retrospective study of the surgical pathology reports regarding resection margins, size and differentiation of the primary tumor, histopathologic characteristics of the primary tumor and neck dissection, number, position and size of positive lymph nodes and post treatment staging, was correlated with tumor spread and survival.


Arytenoidectomy revisited.

The spectrum of disabilities attendant to laryngeal paralysis range from mild hoarseness to complete upper airway obstruction depending upon the static position of the paralyzed cord or cords. The most distressing disabilities are those of bilateral vocal cord paralysis in which both vocal folds are fixed in the midline resulting in severe upper airway obstruction. Clearly the most acceptable solution to the problem of persistent laryngeal paralysis is through the establishment of normal neuromuscular integrity by vagal repair or neural transfer techniques. While electromyographic evidence of reinnervation and some restoration of cord motion has been described, synchronous neuromuscular activity is, at best, unpredictable and generally unsuccessful. Successful reinnervation procedures depend in part on early repair and herein lies a disparity between experimental work and its clinical applicability. Given the realities of delays in diagnosis and the unpredictability of operative reinnervation of the paralyzed larynx, we rely on alternative methods of improving the compromised glottic airway consequent to bilateral recurrent nerve paralysis of the larynx. During the period 1962 through 1974, 23 patients with complete bilateral paralysis of the larynx have been treated by the posterior extralaryngeal approach originally described by Woodman. The following is a description of the operative technique utilized with technical modifications which we consider important in enhancing operative results.


Amyloid deposits in the trachea and esophagus ultrastructural confirmation.

The clinical details of two patients suffering from amyloid infiltration of the trachea and esophagus respectively are presented. The "amyloid tumor" in the trachea presented with dysphonia and a swelling in the lower subglottic region. Attempts at complete surgical excision of it were unsuccessful. The patient with esophageal amyloid presented acutely with dysphagia and features of dehydration and malnutrition. Systematized amyloidosis was discovered at autopsy, but no primary initiating cause for it was found. In both cases it was possible to confirm the diagnosis by electron microscopy. The current views on the composition, structure, causation and treatment of amyloid disease are reviewed.


Anesthetic management for carbon dioxide laser surgery of the larynx.

Fifty-one patients underwent 71 carbon dioxide laser procedures under general anesthesia for various intralaryngeal pathology. Anesthesia was induced with thiopental sodium, followed by succinylcholine to facilitate endotracheal intubation. For maintenance of anesthesia, 70% nitrous oxide was supplemented with halothane, enflurane or small doses of fentanyl. Succinylcholine, d-tubocurare or pancuronium were used to maintain muscular relaxation of jaw, pharyngeal and laryngeal muscles for a smooth lasing procedure. Small diameter (16-22 Fr.), red rubber, cuffed endotracheal tubes provided maximum working space, facilitated the controlled ventilation and reduced the explosion hazard of the anesthetic gases. Safely eyeglasses were used by all the personnel in the operating room against accidental injury to the cornea by the laser beam. Anesthetic management provided excellent operative conditions with maximum safety to the patient and the personnel in the operating room.


Cricopharyngeal myotomy in amyotrophic lateral sclerosis.

Reported herein is the experience of the authors with 38 amyotrophic lateral sclerosis (ALS) patients for whom cricopharyngeal myotomy was performed. The major surgical objectives were facilitation of swallowing and amelioration of the tendency of these patients to aspirate ingestants and secretions. In the group of these patients in which the follow-up information has been adequate, 64% were improved and 36% experienced no significant benefits. The authors' surgical indications, methods of anesthesia, surgical technique, and postoperative care are described.


Arterial blood gas determination in patients with anterior packing.

Twenty-two healthy males ranging in age between 18 and 43 years were studied by arterial blood sample obtained before nasal surgery and again after complete bilateral nasal obstruction produced by nasal packing. Five of these patients had a third sample drawn after pack removal. The pO2 dropped from a preoperative mean of 85 mm Hg to 74 mm Hg. This difference is statistically significant; pCO2 did not change between the two measurements. This result is attributed to hypoxia caused by acute total nasal obstruction. It suggests that anterior packing alone may cause a clinically important hypoxia in patients with inadequate pulmonary reserve and that these patients merit close observation when bilateral anterior packing is placed. The early removal of anterior packing in patients where possible seems indicated. Supplemental O2 (40%) for patients over 40 years of age requiring nasal packing is practiced at this Center.


Examination of the vestibular system by short-time accelerations.

Short accelerations, lasting for the split part of a second can be produced by the chair rotating with uniform speed in such a way that the chair will change its direction after each turn of 360 degrees. The accelerations of alternating directions produce ampullopetal flows in the right and the left labyrinth alternately. The nystagmus elicited will be finished during the rotation of the chair with uniform speed, thus during the stimulus-free period. The short acceleration rates render possible the multiple dosage of identical stimuli as well as the gradual increase of the intensity of the stimulus. Since the stimulus produces ampullopetal flow in the right and the left labyrinth alternately the central vestibular equilibrium will not be changed. The author applied acceleration stimuli of 20, 30, 40 and 50 degrees/sec2 doses to 20 healthy male subjects and studied the manifestations of the nystagmus elicited.


The importance of panographic and dental evaluation for lesions of the antrum.

A large dentigerous cyst which displaced the antrum and partly eroded its bony walls was interpreted as a malignant neoplasm in routine sinus films. The true nature of the process was readily apparent in a panographic view which showed an unerupted third molar lying horizontally above the apices of the first and second molars. This case is an excellent demonstration of the important role of panographic views in the differential diagnosis of maxillary sinus lesions.


Human stapes crura: surface bone architecture: scanning electron microscopic findings.

Human stapes crura obtained at the time of stapedectomy for clinical otosclerosis have been studied after removal of the mucosal and periosteal layers by treatment with hydrogen peroxide and ultrasonification. With the scanning electron microscope, four basic architectural patterns are evident: honeycomb, fibrillar, compact and pitted. The significance of these patterns is as yet unclear, but they do appear to be in intimate relationship one to another and perhaps are varying stages in a single process.


Hemangiomas of the salivary glands.

Five salivary gland hemangiomas in adults are reported. The feasibility of preoperative diagnosis on clinical and radiologic grounds is emphasized. Adult hemangiomas are of the cavernous type and can be differentiated from infantile capillary hemangiomas clinically as well as histologically. Cavernous hemangiomas in the adult should be treated by surgical excision.


An endolaryngeal method of vertico-lateral transposition of the vocal cord for bilateral abductor paralysis.

An endolaryngeal method of vertico-lateral elevation and fixation of the vocal fold in the treatment of bilateral recurrent laryngeal nerve paralysis is described. In 62 patients on whom this operative procedure was performed, a considerable improvement in respiration at the same time as almost unchanged phonation has been obtained in 61 cases. The results are illustrated by sonograms and respirometric examinations. Laryngograms demonstrate the function of the newly created glottis.


Paget's disease and sensori-neural deafness: temporal bone histopathology of Paget's disease.

Four cases with Paget's disease of the temporal bone are presented to illustrate the pathogenesis of the associated deafness. One case illustrates the combination of severe deafness due to bilateral otosclerosis with probably asymptomatic bilateral Paget's disease. One case with advanced Paget's disease presents features to explain early stages of sensori-neural deafness before actual cellular invasion of the inner ear. One case of profound deafness due to Paget's disease presents a different stage of cellular invasion of the inner ear by the disease on each side. One case illustrates invasion of the internal auditory meatus by Paget's disease with infiltration of the acoustic division of the nerve and profound deafness.


Otitis media with effusion: specific antibody activities against exotoxins in middle ear effusions.

Findings of recent immunologic studies on otitis media with effusion indicate that antibodies in middle ear effusions can either originate from serum and/or from local production in the middle ear cavity and Eustachian tube. Determination of specific antibody activity of different immunoglobulin classes in effusions and sera against certain bacterial antigens may aid in a better understanding of the pathogenesis of otitis media with effusion. A radioimmunosorbent assay was employed in the present study to determine specific antibody activity against streptolysin or staphylolysin. Although these antibody activities were mainly limited to IgG and IgA class antibodies in effusion as well as in serum, it was also found that SIgA of various types of the effusion possesses the antibody activity against these exotoxins. Findings of this study suggest that a local immunity functions in the middle ear cavity of patients with otitis media with effusions and that bacterial infection may contribute to the development of middle ear effusion in certain cases.


Intracranial carotid catastrophies encountered by the otolaryngologist.

Arteriographic studies are utilized to illustrate the presence and document the results of arterial ligation on three intracranial carotid aneurysms. All three aneurysms resulted from trauma, surgical and otherwise, and all presented as otolaryngologic dilemmas. All were successfully controlled by a combined Otolaryngological and Neurosurgical Team employing varying combinations of intra and extra cranial arterial ligations. None developed significant neurological impairments. The two major indications for common or internal carotid ligation are the resection of neoplasm and the control or prevention of hemorrhage. Sixty percent of patients undergoing elective carotid ligation survive these procedures without evidence of neurological sequelae. This uncompromised survival is based upon the presence or rapid development of collateral circulation to the cerebrovascular bed. Further arteriographic studies are employed to illustrate the development of intra and extra cranial collateralization to the internal carotid artery after surgical interruption of the ipsilateral common carotid. The major collateral circuits demonstrated via a case report are as follows: a. from the vertebral artery to the external carotid and hence to the internal carotid; b. from the posterior communicating artery to the internal carotid; and c. from the ophthalmic artery to the internal carotid.


Cerebrospinal fluid rhinorrhea via the fossa of Rosenmuller.

Traumatic cerebrospinal fluid fistulas in children are not rare as described by Harwood-Nash and Caldicott, North, and Simpson. Those involving the sphenoid bone apparently are rare, particularly in early childhood.