Methacholine and histamine inhalation challenges in asthma: relationships to age of onset, length of illness, and pulmonary functions. Levels of airways hyperreactivity, as indexed by methacholine and histamine thresholds, were determined for hospitalized asthmatic patients using the serial concentration, constant-breath method. Airways hyperreactivity was categorized into low and high based on a split of the sample of subjects tested. These categories were unrelated to pulmonary function measurements obtained throughout hospitalization. Patients having high airways hyperreactivity to histamine or methacholine were admitted for intensive inpatient care at a young age, had an earlier age of onset, and had asthma of longer duration than patients having low airways hyperreactivity. These latter results suggested that relatively greater airways hyperreacticity is more likely to be associated with early onset of the illness.


Influence of small atmospheric ions on the airways in patients with bronchial asthma. The influence of artificially generated atmospheric ions is studied in 15 patients with bronchial asthma. A slight but significant (at 5% level) improvement in the lung function was demonstrated in nine patients during positive as well as negative ion exposure, but the patients' subjective votings of the air quality did not show any changes due to ion exposure. No change in the histamine threshold of the airways in six patients with bronchial asthma was demonstrated during exposure to ions. Further controlled studies with electro-aerosols are needed.


Periodic respiration. The capnographic interpretation. Different type of periodic respiration are difficult to distinguish clinically although their identification may influence the diagnosis, prognosis and treatment. Often other forms of abnormal respiration are mistaken for periodic. Four capnograms are shown illustrating (1) true Cheyne-Stokes respiration, (2) irregular "pseudo-periodic" respiration a) after fentanyl, and b) in the presence of a brain tumour and (3) regular respiration interspersed with deep sighs which was diagnosed clinically as Cheyne-Stokes respiration. A plea is made for the routine use of capnography in order to provide a visual record of respiration.


[The influence of ethanol, dithiocarb, diethylmaleate and phenobarbital on the metabolic elimination of halothane in rats (author's transl)]. Rats exposed to halothane (100 ppm) in a closed allglass-system eliminate halothane from the atmosphere of this system with a half-life (t0.5) of 0.99 h. In 24 h-fasted rats t0.5 was prolonged to 1.24 h. A single oral load of 4.8 g/kg ethanol as well as a 15% ethanol solution instead of drinking water for 28 days did not alter the metabolic elimination of halothane. On the other hand, ethanol (4.8 g/kg p.o.) applied 5 min before exposure to halothane markedly prolonged t0.5 to 3.79 h. Pretreatment with phenobarbital (80 mg/kg i.p. for 4 days) shortened t0.5 significantly to 0.79 h. Inhibition of the mixed-function oxidase system by dithiocarb (100 mg/kg i.p.) or diethyl maleate (1 ml/kg i.p.) markedly prolonged t0.5 to 7.53 and 1.57 h. respectively. The observed modifications of the halothane metabolism may be of interest in relation to the problem of halothane-induced hepatotoxicity.


[Inject-ventilation in bronchoscopy (author's transl)]. Jet ventilation initially described by Sanders has been modified and improved for use with the Storz bronchoscope. Theoretical and technical performance are discussed and the mechanical and physiological properties are dealt with e.g. FiO2, driving and endotracheal pressure, expiratory CO2 concentrations, blood gas analysis, pulmonary artery pressure and electrocardiographic changes. Using this method prolonged diagnostic and surgical procedures, such as cauterisation of bronchial adenoma, removal of foreign bodies from the airways especially of small children and bronchial toilet in status asthmaticus, are rendered free from problems for the anaesthetist. We believe that the inject ventilator is a very useful addition to endotracheal surgery.


[Effects of various anaesthetics and relaxants on vascular smooth muscle (author's transl)]. The effects of various injectable anaesthetics and relaxants on the pressure-diameter relations of isolated segments of the rat tail artery were investigated in vitro. The wall of this vessel contains about 75% smooth muscle fibres. Measurements were made before and after the induction of a virtually maximum constriction of the vascular segments which was produced by 1 mg/ml noradrenaline. When added to pure Tyrode's solution all the agents used did not markedly influence the pressure-diameter curves. However, the noradrenaline-induced constriction of the vessels was inhibited to varying degrees. This effect was most evident after thiopentone which caused the diameter to increase by 50%. After pentobarbitone, the increase in diameter was found to be less pronounced (15%). Administration of methohexitone was followed by lesser relaxation of the arterial smooth muscle resulting in a maximum increase in diameter of 7%. After alphathesin (CT 1341) and propanidid, the arterial segments dilated about 20%, after etomidate and 4-hydroxybutyrate about 10%. The muscle relaxants suxamethonium and d-tubocurarine induced dilations of 10 to 15%, alcuronium and pancuronium, however, of less than 5%. The results presented here concur with those of experiments in vivo in which the influence of narcotics and relaxants on the peripheral resistance was studied. This indicates that the dilatation of peripheral resistance vessels seen after the administration of such agents is not exclusively caused by a neurally mediated inhibition of the vascular tone. The direct action of these substances on the vascular smooth muscle may often contribute to their complex haemodynamic effects.


[The continuous longtime measurement of intra-cranial pressure (author's transl)]. Epidural measurement is a suitable method for monitoring variations in cerebral pressure during intracranial operations and postoperative treatment. A short description is given of the technical equipment. Various possibilities for monitoring intra-cranial pressure are demonstrated in some examples.


[Test of an improvised anaesthesia system for newborn infants (author's transl)]. Anaesthesia for newborn infants is rarely undertaken in hospitals which have no paediatric surgical department. Using the usual anaesthetic equipment for children on newborns involves many hazards, mainly because of the small respiratory volumes of these little patients, the danger of large deadspace and the high resistance of valves in the equipment. A resuscitation bag for newborns proved to be easy and safe as anaesthesia apparatus, if connected to the output of the anaesthetic machine. Blood gases and respiratory volumes were measured in 17 newborn infants (body weight 1,600 g to 5,280 g) during anaesthesia using endotracheal tubes, masks, controlled and spontaneous respiration.


[Spinal anaesthesia using bupivacain--clinical experience of more than 6000 cases (author's transl)]. The following report of our experience using isobaric Bupivacaine 0.5% in 6,228 operations (intrathecal technique) will consider the intra operative period. In 55.8% of cases the lower extremities were operated upon and in 44.2% the lower abdomen. In 1,487 cases (23.9%) side effects/complications were evident and a classification of such is as follows: anaesthetic technique 5.29%, cardiorespiratory 15.69%, operator/operative technique 6.13%. The percentage remained relatively constant irrespective of age but a higher pre op risk classification (A.S.A. System) resulted in a marked increase in the above figures. The principal side effects encountered were as follows: Bradycardia 7.5%, hypotonia 6.3%, insufficient analgesia 3.9%, extrasystoles 2.9%. Grave complications occured in 0.15% and within this group 4 patients died intraoperatively; a relationship with the mode of anaesthesia has not been proven.


[Evaluation of brachial plexus block. Comparison between supraclavicular and interscalene approach (author's transl)]. A scheme for evaluating brachial plexus block was developed, which is based on anatomical structures and which utilizes simple neurological examination techniques. It facilitates the localization of the tip of the cannula near the plexus, gives an idea of the spread of the local anesthetic in the region of the trunks and cords, gives well timed judgement on the success of the block and allows a comparison of the development of the block when using various techniques. Using this scheme, the development of the block was examined following use of the supraclavicular and interscalene approach. With the supraclavicular technique, motor as well as sensory blockade of all nerves of the brachial plexus occurred with about the same frequency; with the interscalene technique, the centre of the block affected the caudal nerves of the cervical plexus and the cranial nerves of the brachial plexus. Following both approaches, the blockade developed from proximal to distal areas, the motor blockade preceding the sensory blockade.


[Changes of carbohydrate and fat metabolism under spinal anaesthesia or neuroleptanaesthesia and operation (author's transl)]. The effects of spinal anaesthesia neuroleptanaesthesia and surgery on the metabolism of carbohydrates and fats were investigated in two groups of 11 young, metabolically healthy patients, undergoing trauma surgical procedures. For both groups the determined parameters glucose, lactate, glycerol, ketone-bodies, NEFA and insulin remained, during the operative and early postoperative phase, within the physiological range without any marked differences. Both anaesthetic procedures seemed to be equally suited for these operations; therefore other criteria should be used as a basis for the selection of the anaesthetic management.


Subarachnoid block with an anaesthetic mixture containing dextran. Cytologic changes in the cerebrospinal fluid. The present study included 22 patients who received an anaesthetic subarachnoid injection of 1.0--1.2 ml Dixidextracaine-70 (a mixture of xylocaine 40.0 mg+cinchocaine 10.0 mg+Dextran-70 60.0 mg+distilled water ad 2.0 ml), associated with adrenaline in a final concentration of 1/10000. Before and 24--168 hours after administration of the subarachnoid anaesthesia, 2.0 ml of cerebrospinal fluid was collected for quantitative and qualitative determination of the cellular elements and for physical and bacteriological examinations. No bacteriological contamination or qualitative and quantitative alterations of leucocytes in the cerebrospinal fluid were found after the administration of anaesthetic-dextran mixture. It is concluded that the association of Dextran-70 with xylocaine and percaine, as well as with adrenaline, for lengthening the duration of the subarachnoid anaesthesia has no acute irritative effect upon the central nervous system and its membranes in the course of seven days following its administration.


Studies in man with a constant-rate infusion of tubocurarine. Tubocurarine (dTC) was administered to twenty patients by intravenous infusion at a predetermined constant rate, and the twitch responses recorded at stimulus intervals of 10 seconds (0.1 Hz). In half the group dTC plasma concentrations were measured both during and following the infusion. This provided data for derivation of the pharmacokinetic parameters, two plasma concentration-response curves and the dose-response curve. The mean effective dTC plasma concentration for 50% paralysis during the infusion (onset) was 0.93 micrograms/ml, but was lower post-infusion (offset) (0.54 micrograms/ml, p less than 0.001). The steady state dTC plasma concentration which should produce 95% paralysis was predicted to lie between 0.95 and 1.67 micrograms/ml. In the range 20 to 80% paralysis the slopes of the two (log) concentration-response lines were similar, although steeper than the associated (log) dose-response regression line, the test for parallelism showed no statistical difference. Combination of the plasma concentration-response curve with pharmacolkinetic models was used to predict the time course of paralysis in patients with normal and impaired renal function. Dose-response curves for the other 10 patients were also constructed to stimulus frequencies from 0.02 to 5 Hz. In the range 20 to 80% paralysis the regression lines appeared to be parallel. The results were pooled for all patients at a stimulation rate of 0.1 Hz, giving a mean effective dose of dTC at 95% paralysis of 0.53 mg/kg, and an ED50 of 0.22 mg/kg.


Cardiovascular and subjective central nervous system effects of long-acting local anaesthetics in man. Intravenous infusions of etiodocaine 50, 75 and 100 mg and bupivacaine 75 mg were carried out over ten minutes in healthy young adult males. Cardiovascular sequelae were generally trivial at all doses. A collection of subjective central nervous system symptoms were described which may be regarded as early warning of impending local anaesthetic toxicity. Plasma concentrations of etidocaine were proportional to dose and ranged from 2 micrograms/ml to 5 micrograms/ml at the termination of the infusion. Plasma concentrations of bupivacaine were similar to those from the same dose of etidocaine but declined more slowly on cessation of infusion.


D-tubocurarine requirement during hypothermia. The effect of hypothermia on the action of d-tubocurarine (d-TC) was studied under carefully controlled experimental conditions. It was found that with computer controlled infusion, 60% less d-TC was required to sustain 75% muscle paralysis in cats, during steady-state, in vivo, when the temperature was changed from 37 degrees C to 30 degrees C. The corresponding relaxant consumption rates were 0.136 +/- 0.025 and 0.055 +/- 0.012 mg/kg/1/2 hr respectively. When there was no temperature change the maintenance dosage of d-TC remained constant for up to four hours denoting the equilibrium phase of the relaxant kinetics. Temperature transitions introduced dynamic changes in these kinetics and altered the constancy of the maintenance dosage.


Thrombus formation on catheters in new born lambs. Catheters were inserted into the aorta and inferior vena cava of newborn lambs by cutdown on the femoral vessels and directly into the umbilical vein. The lambs were killed after six days and the amounts of thrombus surrounding the cathethers were measured. Most catheters inserted into the umbilical vein looped within the liver and only a few passed directly into the portal vein or through the ductus venosus into the vena cava. On different types of catheters inserted via the femoral artery or femoral vein, there were significant differences both in the proportion with thrombus and the amount of thrombus. There were also significant differences in renal infarctions caused by different types of catheters.


Effects of heparin, aspirin and dipyridamole on thrombus formation on venous catheters. Heparin, aspirin and dipyridamole were given alone or in combination to groups of sheep which had polyethylene catheters inserted into facial and saphenous veins. Animals were killed after 3 or 9 days. Neither aspirin nor dipyridamole reduced the amounts of thrombus on the catheters at autopsy. Heparin reduced thrombus only when sufficient was given to reduce blood coagulation.


Intermaxillary fixation: how practicable is emergency jaw release? Intermaxillary fixation as part of management of facial fractures or following osteotomy for facial deformity presents unique problems to the anaesthetist. It is traditional practice to keep wire cutters available by the patient at all times to enable quick release of the jaws in emergency. The efficiency of release was tested by timing various members of the management team. The time taken to release the jaws was an average 35.3 seconds by experienced oral surgeons and an average 2 minutes 9 seconds by hospital staff involved in caring for these patients and was not a practical proposition for a lay person. Thus the value of releasing fixation is questionable in the initial care of obstruction or vomiting. Techniques of avoiding and managing these problems are discussed.


A new tube for microlaryngeal surgery.

A new tube for microlaryngeal surgery. A technique of anaesthesia for microlaryngeal surgery is described utilizing a new catheter and the venturi jet injector. Access and exposure for the surgeon are excellent and the laser can be used without special precautions. The central position and lack of movement of the distal end of the tube in the trachea prevent the potential complication of rupture of the trachea or of a bronchus.


Case report: althesin in status epilepticus. A case of status epilepticus, resistant to conventional anti-epileptic treatment is described. Althesin rapidly abolished the epileptic activity, and control was achieved by a continuous infusion of Althesin.


Replacement of fatty marrow by active granulocytopoietic bone marrow following transplantation of mammary carcinoma into mice. The development of granulocytic hemopoiesis in the fatty marrow of metatarsal bones and caudal vertebrae of adult mice was studied in histological sections for up to six weeks following subcutaneous innoculation of granulocytosis inducing mammary carcinoma. The initial events observed were increase and engorgement of fatty marrow sinusoidal vascular beds, accompanied by numerous lymphoid mononuclear cells in the sinusoids and in the stroma. Foci of granulocytopoiesis appeared admixed with lymphoid cells in the stroma and near the endosteum. Hyperplastic granulocytopoiesis eventually predominated in the marrow of these bones as well as the femoral and sternal marrow of tumor bearing mice. The morphological findings suggested the possibility of stem cell and progenitor cell migration into fatty marrow, but activation of dormant stem cells could not be ruled out. The prevalence of granulocytopoiesis in the entire skeletal marrow is of the marrow including lymphocytes, reduced production of the latter would imply serious compromise for the immune system of the tumor bearing animals.


Resorption of connective tissue in the gingiva of the mouse incisor. During eruption of the mouse incisor part of the periodontal ligament moves along with the tooth in occlusal direction and is degraded in the gingiva, just apically of the junctional epithelium. When studied with the electron microscope some connective tissue cells (fibroblasts) showed disorganization of both nucleus and cytoplasm. In other cells vacuoles were observed containing partly degraded cellular constituents. Sometimes within these vacuoles electron dense material with the appearance of clumped chromatin was observed. On the basis of this observation it is concluded that heterophagocytosis contributes to the process of fibroblast breakdown. The ultrastructure of these heterophagic cells resembled that of fibroblasts. Collagenous fibrils were observed within cytoplasmic vacuoles of fibroblasts indicating that collagen is phagocytosed and probably digested in the lysosomal apparatus. Part of the intercellular space was filled with a homogeneous material of moderate electron density, intermingled with some collagenous fibrils. Within some cells of the junctional epithelium partly degraded material was observed which may indicate that the epithelium contributes to the removal of residual products of connective tissue degradation.


Testicular seminoma in father and son. Case report of testicular malignancies occurring in closely related family members. Father and son had testicular seminomas. Father had right and son had bilateral malignancies: this is the 5. report of testicular malignancies occurring in fathers and sons. A review is made also of the literature on testicular malignancies occurring in closely related family members (26 reports only).


[Analysis of spermatozoa with flow cytophotometric determination of DNA]. Semen samples of fertility patients and fertile men were analysed by an improved technique of flow cytophotometry. The DNA-contents of mature spermatozoa were measured with a high level of accuracy. Besides spermatozoa, peaks of spermiogenetic cells and other seminal cells could be demonstrated. Complementary to the results of semen analyses the complex histograms of pulse cytophotometry investigations may give further informations on the nature of the underlying disturbances of spermatogenesis.


[Circadian rhythm of testosterone level in plasma. I. Physiologic 24-hour oscillations of the testosterone level in plasma]. The testosterone level in plasma is measured in 10 males by radioimmunoassay (RIA) at the following times: 07.00 h, 08.00 h, 09.00 h, 10.00 h, 13.00 h, 16.00 h, 19.00 h, 23.00 h and 03.00 h. A circadian rhythm can be noted. Peak levels are reached between 07.00 h and 10.00 h. At 19.00 h testosterone values reach their minimum and rise at night. In the morning between 07.00 h and 10.00 h testosterone levels seem to have a plateau. Between the morning and the evening the values show great differences.


Plasma testosterone, luteinizing hormone and follicle-stimulating hormone one day after vasectomy. Plasma testosterone, LH and FSH were measured in 20 healthy subjects prior to and one day after bilateral vasectomy. No significant change in these hormones was noted after surgery. These data suggest that the decrease in free testosterone index and FSH reported by others at one week post-vasectomy is probably not related to the effects of psychological stress, local anesthesia or surgical stress, either singularly or in concert. Further studies are indicated to evaluate the transient hormonal changes reported within the first few weeks following vasectomy.


Serum prolactin in male infertility.

Serum prolactin in male infertility. Hyperprolactinemia was found only in two out of 71 patients with male infertility and in none of 53 patients with impotentia coeundi indicating that hyperprolactinemia is of minor significance in these patients. There was only a weak negative correlation between hPRL and testosterone in oligozoospermic men. No correlation was found between hPRL and hLH, hFSH, sperm count and sperm motility. Nevertheless measurement of hPRL should be performed in all cases with hypogonadotropic hypogonadism, loss of libido or impotence since these symptoms may be signs of a prolactin-producing pituitary adenoma.


[Peculiarities and side effects of testicular biopsy]. Testicular biopsies were performed in hospital conditions on 451 patients by whom was diagnosed oligozoospermia (56,5%), azoospermia (41,9%), teratozoospermia (1,2%) and aspermia (0,4%). 95,5% of these biopsies were bilateral. Anatomic peculiarities as well as particularities and complications observed during the operations, and lastly postoperative complications were demonstrated in this contingent of patients. In order to obtain this result the clinical documents of the department of andrology of the university hospital Hamburg-Eppendorf were used. Adhesions of the tunical layers of the testis (28,3%), as well as hydroceles (35,7%), and increased vascularisation (20,9%) could be seen in the operation field. We considered as the most frequent intraoperative step a second skin cut (4,6%). In 3,0% of the cases it was not possible to obtain a testicular parenchyma. As complication during the operation the sliding of the epididymis was observed in 4,8%, and bleeding in 2,0% of the cases. The most frequent complication after operation was bleeding in the region of the skin's suture (1,2%). Patients who presented intraoperative complications bleeded most. Orchitis and epididymitis as postoperative complications were not observed. To prevent these complications the testicular biopsies should be done in hospital conditions by well experienced operation teams.


Intratesticular testosterone concentration in patients with disturbed fertility. 45 patients with azoospermia or severe oligozoospermia were studied. Testosterone and luteinizing hormone in plasma were in the normal range. Intratesticular testosterone values were higher the greater the degree of tubular atrophy was. Patients with testes of subnormal size (less than 12 ml) had significantly higher values than those with normal sized gonads. 31 out of 37 testes obtained by castration of patients with carcinoma of the prostate showed slight to severe disturbance of spermatogenesis. In this group no positive correlation was observed between the degree of testicular atrophy and intratesticular testosterone concentrations. Intact spermatogenesis was observed in testes with a testosterone content as low as 542 pg/mg tissue.


Effect of chronic treatment with prostaglandin E2 on male rat fertility. Adult male rats were treated with prostaglandin E2 (100 microgram/100 g body wt) during 60 days. Neither morphological alterations in genital organs nor modification in epididymal contractility were observed. Nevertheless, a significant diminution of fertility was registered. This was recovered after 30 days following the cessation of treatment. Since sperm maturation occurs in the epididymis, it is postulated that the decrease of fertility in our experiments was due to an incomplete maturation of germinal cells, induced by a reduction in the time taken by spermatozoa in passing through the duct.


[Shock in abruptio placentae (author's transl)]. In sixty abruptions of the placenta observed during eighteen months, a severe condition of shock was observed in thirty per cent of patients. This shock state is seen during the abruption or after delivery. It's essentially a question of hemorrhagic shock, the importance of hemorrhagy being often underestimated, if the drop of blood pressure and blood losses are only estimated. The measurement of central venous pressure and the research of metabolic acidosis are better indexes of shock. This shock is associated with hypofibrinogenaemia and with other symptoms of disseminated intra-vascular coagulation. Fibrinolysis is rarely observed (3 times). Presence of fibrin degradation products is frequent. Renal complications are observed only in 1/6 of cases, but are frequently severe (one case of renal cortical necrosis). Heparinotherapy does not confirm the hope be suscited and seems to be a frequent source of ehmorrhagic complications in African women. Perfusion of fibrinogen, if useful, can be another source of complications. Rapid transfusion is the more effective treatment of abruption placenta and probably the less dangerous with strict control of the central venous pressure.


[Aggravation following anaesthesia in a case of unknown lateral amyotrophic sclerosis (author's transl)]. A 66 year old man whose activity was almost normal underwent a lombar sympathectomy under general anesthesia (thiopental, gallamine, N2O). Immediately after recovery an acute respiratory distress became evident. It was due to a respiratory paralysis on which neostigmine had no effect. Neurologic examination showed the symptoms of an amyotrophic lateral sclerosis which had remained unknown so far. The respiratory paralysis persisted and one year later artificial ventilation is still necessary almost continuously. Two aspects of this very rare observation are discussed: first the cause and mecanisms of the aggravation of the neurologic disease following anesthesia, secondly the rather unusually important part played by the respiratory paralysis in this case of lateral amyotrophic sclerosis.


Antacid pulmonary aspiration in the dog. The amount of damage resulting from pulmonary aspiration of gastric contents is determined primarily by the acidity of the aspirate. Thus, it has been recommended that the pH of stomach contents of pregnant women be increased by the oral administration of antacids prior to anesthesia for delivery. This study was done to investigate the effects of antacid aspiration in dogs and compare these effects with those obtained by trials of aspiration of acid, saline solution, and alkaline saline solution. Mean PaO2 of the saline-treated group had decreased from 81 to 60 torr at 10 min, while that of the alkaline saline-treated group had decreased from 83 to 58 torr. Fractional intrapulmonary physiologic shunt (Qs/Qt) increased in these two groups, from 15 to 34 and from 16 to 42 per cent, respectively. The Qs/Qt had returned to control values in both groups by four hours, and the PaO2 had returned to control values by 24 hours. By contrast, the acid- and antacid-treated groups had decreases in PaO2 values from 77 to 34 torr and from 84 to 46 torr, respectively. Neither group had a return of PaO2 to pre-aspiration level by 24 hours. Likewise, the Qs/Qt increased significantly more in these two groups: 14 to 66 per cent in the acid-treated group and 13 to 47 per cent in the antacid-treated group. These changes persisted throughout four hours. The saline and alkaline saline aspirates produced little histologic damage. The acid aspirate produced hemorrhage, exudates, and edema. However, these changes were no longer present a month later. The antacid aspirate produced a marked bronchopneumonia that was still present as a chronic inflammatory reaction after a month. These findings indicate that antacids can cause pulmonary damage when aspirated.


[False diagnosis of post-operative massive pulmonary embolism. Nine observations (author's transl)]. After having studied nine observations about patients referred to them for embolectomy under CEC on suspicion of massive pulmonary embolism, the authors describe five differential diagnosis and how they can be reached. A low central venous pressure, an hypoxaemia sensitive to oxygenotherapy, a high pulmonary wedge pressure or the lack of diastolocapillary gradient, and, last of all, a real hypocoagulability attained by the use of low and daily doses of heparin must make one cautious. Yet, if a doubt should persist, an angiography and/or a scintigraphy will be asked for.


Myocardial ischemia during non-cardiac surgical procedures in patients with coronary-artery disease. The purpose of this study was to determine the incidence of ST-segment depression during anesthesia and operation. Graded exercise testing has demonstrated a high correlation between ST-segment depression and myocardial ischemia. Therefore, 11 patients without and 29 patients with known coronary-artery disease were monitored during surgical procedures with a commercially available exercise electrocardiographic monitor (Viagraph). Comparisons were made between this device, which monitored lead V5, and the standard operating room monitor, which monitored lead 11. Eleven of 29 patients in the disease group demonstrated significant ST depression. Nine of the 11 ischemic episodes were not recognized on the standard operating room monitor. Retrospective review of anesthetic records of those 11 patients with ST-segment depression revealed rate--pressure product values greater than 11,000 for ten of them. Postoperatively, three of the 11 patients with significant ST-segment depression had changing electrocardiograms compatible with ischemia. None of the control group demonstrated significant ST-segment depression. The incidence of ischemia was 38 per cent during anesthesia and operation in the coronary-artery-disease group. Lead V5 analysis is superior to lead 11 analysis in detecting ST-segment depression. The period in which intubation is performed is one of the highest-risk intervals during anesthesia and operation, particularly when it is associated with an increased rate--pressure product.


Studies of the possible role of brain endorphins in pentobarbital anesthesia and toxicity in mice. In an attempt to ascertain whether opiate receptors and brain enkephalins or endorphins are involved in pentobarbital anesthesia and toxicity, the effects of 1) two pure narcotic antagonists, naloxone and naltrexone, 2) morphine sulfate, 3) D-phenylalanine, an inhibitor of carboxypeptidase A, and 4) D-leucine, an inhibitor of leucineaminopeptidase, in combination with D-phenylalanine, were studied in mice. Both naloxone and naltrexone, (1, 5 and 10 mg/kg) administered subcutaneously to mice were unable to modify the duration of anesthesia when they were injected 5 min prior to a challenge dose (75 mg/kg) of pentobarbital (ip). The onset of anesthesia was unaltered by naloxone (1, 5 and 10 mg/kg) and naltrexone (1 mg/kg). Higher doses of naltrexone (5 and 10 mg/kg) delayed the onset of anesthesia slightly. Morphine (1, 2.5 and 5 mg/kg) given 30 min before pentobarbital did not modify the onset or the duration of anesthesia. D-Phenylalanine (250 mg/kg), and D-phenylalanine + D-leucine (250 mg/kg each) injected ip an hour before pentobarbital did not affect either onset or duration of anesthesia. Naltrexone (10 mg/kg, ip) given 5 min before pentobarbital did not alter the LD50 of the latter. The studies do not support a role of enkephalins or endorphins in pentobarbital anesthesia or toxicity, and suggest a need for caution in using narcotic antagonists in treating pentobarbital toxicity.


[Brachial plexus block anesthesia in the upper limb surgery (author's transl)]. This work, during a period of 2 years, has been carried out on 139 brachial plexus block anesthesias out of which --92 through axillary approach--47 through supraclavicular approach. Our failure rate was--6,5 p. cent in the case of the axillary block--10,6 p. cent in the case of the supraclavicular block. This gives us a failure average of 7,9 p. cent. Depending on the duration of the operation we have been using three kinds of drugs, always without adrelanine--Lidocaïne . . . 2 p. cent--Mepivacaïne . . . 2 p. cent--Bupivacaïne . . . 0,5 p. cent. We finally adopted two mixtures based on lidocaïne together with mepivacaine or bupivacaine keeping the same concentration but reducing to half the doses of these last two drugs. In our work, we have not noted any complication, and we think that a locoregional anesthesia, should, as far as it is possible, be used as a substitute for general anesthesia instead of being used when general anesthesia is contra-indicated.


Comparative pharmacokinetics of d-tubocurarine and metocurine in man. To compare the pharmacokinetics of d-tubocurarine and metocurine in man, concentrations of 3H-d-tubocurarine and 14C-metocurine (0,0,N-trimethyl-tubocurarine) in plasma, urine and bile were determined after intravenous administration of d-tubocurarine, 0.15 mg/kg (five patients), and metocurine, 0.05 mg/kg (five patients), in patients anesthetized with thiopental and nitrous oxide for cholecystectomy. Plasma disappearances of both drugs were triexponential, with mean terminal half-lives of 346 and 217 min for d-tubocurarine and metocurine, respectively. By ion-pair thin-layer chromatography, no metabolite of either compound was found in urine or bile. Renal excretions 48 hours after injection ranged from 46 to 95 per cent of the dose for d-tubocurarine and from 46 to 58 per cent for metocurine. Mean total-body clearances were 56 and 96 ml/min for d-tubocurarine and metocurine, respectively. Biliary elimination of d-tubocurarine was greater than that of metocurine: within 48 hours 11.8 and 2.1 per cent of the doses were excreted in bile, respectively. The observed differences in total-body clearances and volumes of distribution (V1) may be partly explained by greater protein binding of d-tubocurarine. The results indicate that biliary excretion is an alternative route of elimination for d-tubocurarine only. Also, d-tubocurarine is less dependent on renal excretion for its elimination, and probably is preferable to metocurine for use in patients with renal failure.


Effects of morphine sulfate on dorsal-horn neuronal responses to graded noxious thermal stimulation in the decerebrate cat. Effects of morphine sulfate upon activity of the neurons of dorsal-horn lamina V as evoked by graded noxious thermal stimuli applied on the receptive field were studied in spinal cord-transected, decerebrate cats utilizing an extracellular microelectrode recording technique. All single units studied (n = 30) responded to noxious thermal as well as to noxious mechanical stimulation. Their spontaneous discharge frequency was 9.7 +/- 1.5 (mean +/- 1 SE) impulses/sec (IPS), the threshold skin temperature was 44.8 +/- 0.2 C, and a linear correlation existed between skin temperature and discharge frequency at 6.7 +/- 0.6 IPS/degree C. Morphine, 1 and 2 mg/kg, iv, suppressed spontaneous activity by 53 +/- 6 and 84 +/- 6 per cent, respectively; increased threshold skin temperature to 46.5 +/- 0.3 and 47.9 +/- 0.5 C, respectively, and maintained the linear correlation between skin temperature and discharge frequency but depressed the mean slope of the regression line to 4.5 +/- 0.7 and to 2.4 +/- 0.4 IPS/degree C, respectively. Naloxone, 0.02--0.04 mg/kg, iv, reversed all of these changes produced by morphine. The results of the present study are, to the authors' knowledge, the first demonstration of the suppressive effect of morphine on the spinal nociceptive neurons in Rexed lamina V as they respond to graded noxious thermal stimuli. These results may explain the analgesic action of morphine at the spinal level.


Effects of ketamine on nociceptive cells in the medial medullary reticular formation of the cat. Anatomic, physiologic and behavioral evidence suggests that the neurons in the nucleus reticularis gigantocellularis of the medial medullary reticular formation may act as a relay station for the transmission of nociceptive information from the spinal cord to higher brain centers. The nucleus reticularis gigantocellularis may also be the site of action of analgesic agents, such as ketamine hydrochloride. Utilizing extracellular microelectrodes in 23 decerebrate cats, the authors measured the effect of ketamine on neurons in the nucleus reticularis gigantocellularis that were excited by electrical stimulation of peripheral nerves. The frequency of spontaneous single-unit firing activity in the nucleus reticularis gigantocellularis was suppressed by 31 +/- 11 (mean +/- 1 SE) and by 62 +/- 7 per cent with ketamine, 1.0 and 2.5 mg/kg, iv, respectively. The frequency of evoked single-unit activity was suppressed by 57 +/- 9 and 79 +/- 5 per cent with ketamine, 1.0 and 2.5 mg/kg, respectively. Ketamine produces significant depression of single-unit activity of the cells in the nucleus reticularis gigantocellularis, suggesting that this may be an important site of its analgesic action.


[New light on the discussion about the therapeutic attitude during the first 72 hours in subjects highly burned. Study of 100 patients burned on 30 p. cent of body surface or more (author's transl)]. The quantity of given fluids was guided by the Evans rule but with no limitations of infusion above 50 p. cent of burns. Fluid was concentrated human serum albumine made isotonic by infusion through a Y pathway with 5 p. cent glucose, natrium (6 g/l) and carbo-hydrate for caloric needs. Under these conditions, clinical and biological parameters show the keeping of a good hemodynamic and hydroelectrolytic balance, with a level of blood proteins very near of the normal one, and a raise in body weight much lower than usually described in literature. Beyond this, the time needed to lower the body weight to its initial level is short and the quantity of infused liquid is much lower than that requisited by resuscitation utilising only cristalloid fluids for the first 24 hours.


Osmotic swelling effects on neural conduction. Local anesthetics administered intrathecally seen more effective when in hypobaric solution than when in hyperbaric solution. To test whether an unrecognized osmotic effect might be playing a part in this, sheathed vagus nerves of rabbit were incubated in electrolyte-deficient or electrolyte-free media of various degrees of hypo-osmolarity. The nerves gained weight over a period of 15 min. They lost nearly half their sodium, but very little potassium, within 5 min. Electrolyte depletion by incubation in sucrose solutions depressed the amplitude of the C-fiber component of the compound action potential more rapidly in hypo-osmotic than in iso-osmotic solutions. In iso-osmotic sucrose, 50 per cent depression developed in 61 +/- 12 min (mean +/- SD, n = 5), but in 0.6 iso-osmotic sucrose, 50 per cent depression was reached in 17 +/- 3 min (n = 5). Lidocaine, 100 microM (approximately 0.003 g/100 ml) in iso-osmotic sucrose was without observed effect; lidocaine, 100 microM in 0.6 iso-osmotic sucrose produced 50 per cent depression in 7 +/- 2 min (n = 4). Thus, osmotic swelling plus electrolyte depletion, but not electrolyte depletion alone, markedly intensified inhibition of conduction by lidocaine. All effects were reversible by returning the nerves to isotonic physiologic incubation medium. The results suggest that intrathecal osmotic swelling of neural tissue may contribute to the conduction block in hypobaric spinal anesthesia.


Cardiovascular responses to diazepam and midazolam maleate in the dog. Previous clinical studies establishing the efficacy of midazolam maleate (RO 21-3981), a new water-soluble benzodiazepine for induction of anesthesia, have not critically evaluated the effects of this agent on the cardiovascular system. The present study compares the cardiovascular effects of midazolam maleate and diazepam in conscious dogs. Systemic arterial, pulmonary arterial and central venous pressures, cardiac output, LVmax dP/dt, heart rate and regional coronary blood flow were measured 3 min following intravenous administration of diazepam (0.5, 1.0, and 2.5 mg/kg) or midazolam maleate (0.25, 1.0, and 10.0 mg/kg). Midazolam maleate increased heart rate 10--20 per cent with all three doses and decreased mean arterial blood pressure approximately 10--20 per cent at 1.0 and 10 mg/kg. Cardiac output was increased 10--12 per cent with all three doses of midazolam maleate, and LVmax dP/dt was decreased 13--16 per cent at the two higher doses. Diazepam at all three doses did not alter heart rate or mean arterial blood pressure. Diazepam, 1.0 and 2.5 mg/kg, produced significant (17 per cent) decreases in LVmax dP/dt, and 2.5 mg/kg produced a significant (10 per cent) increase in cardiac output. Neither drug in any dosage altered regional coronary blood flow, systemic or coronary vascular resistance, stroke volume, or stroke work. Maximum alterations in cardiovascular variables occurred with doses of midazolam maleate that are 10--15 times the recommended clinical induction dosage. It is concluded that in concentrations necessary for induction of anesthesia midazolam maleate has minimal effects on cardiovascular function.


Bupivacaine, 0.125 per cent, in obstetric epidural analgesia: experience in three thousand cases. Bupivacaine, 0.125 per cent, with epinephrine, 1:800,000, was administered to 3,000 women in labor. Administration was in the lumbar epidural space for the purpose of achieving satisfactory analgesia with minimal or no motor paralysis. The usual initial dose of 12.5 mg (mean 13 +/- 2 SD) resulted in good sensory analgesia in 83 per cent of the patients and lasted for about and hour (mean 58 +/- 16 min). The mean total dose used for labor and delivery was 55 +/- 20 mg and the mean dose per hour 23 +/- 13 mg. Satisfactory analgesia for labor and delivery was obtained in 92 per cent of the patients, and in 66 per cent there was no discernible motor blockade. In the 3,000 patients, there was no adverse reaction to bupivacaine or epinephrine. No patient had a total spinal block or neurologic sequelae, and no neonatal depression could be attributed to the anesthetic.


[Morphometric evaluation of osteoclasts in non-decalcified bone sections. Its value in the diagnosis of hyperparathyroidism]. The authors assessed the surface areas of osteocytic lacunae in non-decalcified bone sections using a histomorphometric method involving a device with an adaptable drawing on the microscope and a graduated sheet. In 7 cases of primary hyperparathyroidism proven surgically and in 8 cases of hyperparathyroidism secondary to chronic renal failure, there was significant periosteocytic enlargement in comparison with a group of 7 controls. This method involving non-decalcified bone sections makes it possible to use the same slides as for the quantitative study of bone volumes, and osteoid, osteoclastic and fibrous surface areas. It is thus of great interest in the positive histological diagnosis of hyperparathyroidism.


[Foetal pulmonary maturity: estimation by the palmitic/stearic acids ratio and by the Clements' test in amniotic fluid (author's transl)]. Two parameters have been used to estimate the foetal pulmonary maturity: Clements' test or bubble test and palmitic acid/stearic acid ration. The reliability and the limits of these tests have been studied in function of several pathological pregnancies and the gestations's age. A value greater than 5 for the P/S ratio was a good pronostic at any gestational age. A value lesser than 5 should be examined according to this gestational age. A negative Clements' test has to be confirmed by an another amniocentesis, while a positive test have been followed always by a mature newborn's birth.


[In vitro and in vivo stability of macroamylase (author's transl)]. A complex case of macroamylasemia in an alcoholic subject with chronic pancreatitis is presented here. The existence of a macroamylase, suggested by hyperamylasemia associated with low amylasuria and by values of the ratio amylase clearance/creatinine clearance lower than 1%, was confirmed by the profile of the amylase activity after filtration on gel of the patient's serum. The macroamylase activity of samples taken at various times over a period of seven months presents a variable characteristic: lowered at the beginning of the fourth month, it rose suddenly following a portal systemic encephalopathy, then became nil a fortnight later. This oscillating character found during the following months is not associated with the values of the serum amylase. The subject's pancreatic juice had no macroamylasic activity but the pancreatic amylase, in vitro, may be feebly linked to a constituant of the patient's serum. The nature of the protein associated with the amylase was not discovered. To in vivo variations of the macroamylase activity may be added the notion of in vitro variability for a sample conserved at -18 degrees C.


[Critical study of methods of estimation by an enzymatic method of serum triglycerides (author's transl)]. The authors describe a critical study of two entirely enzymatic methods of determination of serum triglycerides which differ mainly by the choice of hydrolytic agents: esterase and hydrolase by the Roche methods, lipase and esterase in the case of the Boehringer method. The estimation of the resulting free glycerol requires 3 sequential enzymatic reactions (glycerol kinase, pyruvate kinase, lactate dehydrogenase, ending by the measurement of the consumed reduced NAD. The study of the kinetics of the analysis in two stages is carried out using standard solutions of glycerol and with human sera of variable concentration; the optimal conditions of the reaction time and temperature are drawn up. The trials of repeatability and reproducibility from day to day were carried out together with evaluation of the precision. The method was compared with Beohringer's method (n = 50) using hydrolysis of alcoholic potash. The authors conclude on the use of the methods studied.


[Larsen's syndrome with associates malformations (author's transl)]. A rare polymalformative syndrome is described, consisting in multiple joints dislocations, peculiar face, deformations of the hands and feet, abnormal pattern of the palms creases and congenital heart defect. New findings not reported before were: choanal atresia, agenesia of the right kidney and gall bladder and hypoplasic male genitals.


[Neonatal necrotizing enterocolitis (author's transl)]. Authors present analysis of 31 cases of necrotizing enterocolitis, which where treated medically as well surgically. Etiology is discussed and perinatal accidents are considered. An analysis of symptomatology and radiological study is made, both being deciding factors as to whether a surgical intervention is necessary. Medical treatment is commented as well as surgical and technical aspects. Mortality is sensibly diminished due to a better knowledge of the illness and to a closer cooperation between neonatologist and surgeon. It is important to point out sequelae which appeared in patients treated medically with intestinal stenosis localized in the colon.


A Legionella-like bacterium related to WIGA in a fatal case of pneumonia. An unusual bacterium serologically related to a "rickettsia-like agent," designated previously as WIGA, was seen in lung tissue from a patient who died of pneumonia of unknown cause. A fluorescent antibody conjugate prepared with the WIGA organism, isolated in 1959, was used to stain the lung tissue. Enormous numbers of fluorescent bacteria in the lungs of this patient confirm the pathogenicity of this unusual bacterium.


[Ventriculo-atrial vs. cerebral-peritoneal shunts in the treatment of hydrocephalus (author's transl)]. Results and complications during the first two years after shunting are compared in two groups of 100 consecutively operated hydrocephalus children having either ventriculo-peritoneal or ventriculo-atrial shunt. One of the major reasons for revision of both types of shunts was obstruction at the ventricular end. This accounted for 18 out of 72 atrial shunt revisions and 20 out of 51 peritoneal shunt revisions. Atrial shunts required 21 revisions because of problems with cardiac end and peritoneal shunts required 17 revisions because of problems with peritoneal end. 25 patients with atrial shunt and 12 with peritoneal shunts died to shunt-related complications during first two years of placement. After this comparative study author feels that peritoneal shunt should be first choice in most forms of hydrocephalus in children due to its lower incidence of revision, serious infection and morbidity.


Percutaneous transluminal angioplasty for renal artery stenosis in a solitary functioning kidney. In five patients with hypertension and marked impairment of renal function due to renal artery stenosis in a solitary functioning kidney, a nonsurgical technique, percutaneous transluminal angioplasty, was used to dilate the stenotic renal artery. Blood pressure improved in all five patients, and renal function improved in three. One patient subsequently died of multiple cardiovascular complications, and in one patient the procedure resulted in acute renal failure requiring hemodialysis. Although preliminary, this experience suggests that percutaneous transluminal angioplasty may provide an attractive alternative to surgery in severely ill patients at high surgical risk.


[Regional adenitis following BCG vaccination (author's transl)]. During a period of time close to four years, 239 children with regional lymphadenopathy following BCG vaccination have been treated. Early neonatal vaccination, individual sensitivity and possible mistakes in the dose of vaccine administered may all influence the development of pathological regional lymphadenopathy. In advanced cases, surgery is proposed as the most effective treatment for a rapid recovery. No cases of recurrence or fistulization appeared in our series.


[Congenital posterolateral diaphragmatic hernia with delayed clinical manifestations (author's transl)]. Two cases of late-appearing congenital posterolateral diaphragmatic hernia are described. Chest X-rays performed a few hours after birth were normal. The diagnosis was made 45 days and 18 months after birth. Authors call attention about this unusual presentation of Bochdalek hernia. A review of the literature is made.


Nephrotic syndrome: vasoconstriction and hypervolemic types indicated by renin-sodium profiling. Studies of 16 adults with nephrotic edema reveal a spectrum of disease, the extremes of which suggest two different pathophysiologic forms. Patients with the "classic" form--vasoconstriction or hypovolemic nephrosis--have high renin and aldosterone levels that are stimulated rather than suppressed by salt-loading but become lower before steroid diuresis. These patients have minimal lesion disease and, perhaps from diffuse capillary damage, tend to have hypovolemia with renin-induced vasoconstriction. Patients with the second, and heretofore undescribed, form--hypervolemic or overfilling nephrosis--have low renin and aldosterone values that rise normally after sodium depletion. Hypertension, mild renal insufficiency, hypervolemia, and steroid resistance with chronic glomerulonephritis are seen histologically. This form appears volume overloaded from impaired renal sodium excretion. In remission of either type, renin system deviations tend towards normal, but one form does not convert to the other. Renin-sodium profiling may help reveal the two forms and predict steroid responsiveness.


[Apple Peel syndrome: an uncommon form of intestinal atresia (author's transl)]. A case of Apple Peel syndrome in a 1,800 g. premature female infant is reported. In a two stage approach, the dilated proximal segment of the jejunum was treated with jejunoplasty and termino-terminal anastomosis. After 55 days of total parenteral nutrition, oral feedings were instituted with good tolerance and satisfactory weight gain. Five months postoperatively, her weight is 5,500 g. and is on a standard diet for her age.


[Enteric duplication associated to renal agenesia (author's transl)]. A case of ileum duplication associated to left renal agenesis is presented. In literature being consulted frequent associations between enteric duplication and several bone and genital-urinary tracts malformations have been found. Authors advise to make excretory urography whenever an enteric duplication is discovered.


Chronic nonparoxysmal sinus tachycardia in otherwise healthy persons. Seven patients had chronic, unexplained, nonparoxysmal sinus tachycardia. The clinical, electrocardiographic, and electrophysiologic characteristics of these cases are described. In each case electrocardiographic and electrophysiologic observations suggested that tachycardia was nonparoxysmal and due to increased automaticity of the sinus node (or of an automatic atrial focus located very near the sinus node). The mechanisms of increased sinus node automaticity in these patients were explored using drugs affecting the autonomic nervous system. In each patient these studies suggested a defect in either sympathetic or vagal nerve control of resting heart rate, with or without an abnormality of intrinsic heart rate. Data are also presented on baroreceptor reflex arc function in these patients.


Risk factors for doxorubicin-induced congestive heart failure. Potential risk factors responsible for development of doxorubicin-induced congestive heart failure were examined through retrospective analysis of 4018 patient records. The overall incidence of drug-induced congestive heart failure was 2.2% (88 cases). The probability of incurring doxorubicin-induced congestive heart failure was related to the total dose of doxorubicin administered. There was a continuum of increasing risk as the cumulative amount of administered drug increased. A weekly dose schedule of doxorubicin was associated with a significantly lower incidence of congestive heart failure than was the usually employed every 3-week schedule. An increase in drug-related congestive heart failure was also seen with advancing patient age. Performance status, sex, race, and tumor type were not risk factors. These data will enable clinicians to better estimate the risk/benefit ratio in individual patients receiving prolonged administration of doxorubicin. They also provide a basis for the investigation of less cardiotoxic anthracycline analogues or for designing measures to prevent doxorubicin-induced cardiomyopathy.


Photochemotherapy and psoriatic arthritis. A prospective study. We have studied the temporal relation between psoriasis and psoriatic arthritis in 27 patients receiving photochemotherapy for treatment of psoriasis. Patients were classified as either spondylitic or nonspondylitic. For spondylitic patients, psoriasis was difficult to control, arthritis did not improve, and skin and joint activity appeared to vary independently. In contrast, 67% of nonspondylitic patients receiving photochemotherapy treatment remained clear of psoriasis, with 49% mean improvement in articular index. There was an inverse relation between initial percentage of psoriasis and improvement in peripheral arthritis. These results suggest that aggressive management of psoriasis helps control synovitis in at least a subgroup of patients with psoriatic arthritis.


Cardiac ganglionitis associated with sudden unexpected death. In a postmortem study of the hearts of two young women who died suddenly and unexpectedly, we found a remarkably similar and distinctive ganglionitis, predominantly in the region of the sinus node. Both women had ventricular fibrillation at the time of collapse. Vesicular neuritis and older neural degeneration were present in other regions of the heart. Except for focal fibromuscular dysplasia of the sinus node artery and atrioventricular node artery of one heart, there was no other significant anatomic abnormality in either heart. The functional significance of this cardiac ganglionitis is unclear, but its location in and around the conduction system makes it a possible cause of the fatal electrical instability. Recognition that ganglionitis of the heart may be associated with sudden death should stimulate a number of additionally useful studies.


Cases of Lyme disease in the United States: locations correlated with distribution of Ixodes dammini. Lyme disease, defined by erythema chronicum migrans and sometimes followed by neurologic, cardiac, or joint involvement, is known to have affected 512 patients in the United States. The disease seems to occur in three distinct foci: along the northeastern coast, in Wisconsin, and in California and Oregon, a distribution that correlates closely with that of Ixodes dammini in the first two areas and with Ixodes pacificus in the last. The implicated tick, saved by six patients in the Northeast, was identified as nymphal I. dammini. Residence in or travel to endemic areas and history of tick bite may be important clues to diagnosis.


Canine blastomycosis as a harbinger of human disease. Blastomycosis occurred in six patients in five households. In each instance one or more dogs living with the family or living near the family also developed blastomycosis. The recognition of canine blastomycosis helped in the early diagnosis of human cases. Because both dogs and patients were probably infected at the same place, canine blastomycosis may be an important epidemiologic marker, alerting physicians to the possible presence of concomitant blastomycosis in humans.


Nitroprusside.

Nitroprusside. Sodium nitroprusside has proved to be the most effective and best-tolerated vasodilator drug available for the management of acute hypertension, heart failure, and other vasoconstricted states as well as for the induction of controlled hypotension during surgery. It dilates both arteries and veins, has a rapid onset and offset of action, and is almost uniformly effective in achieving the desired degree of dilation by careful dosage titration. The need for close monitoring of its intravenous administration and the potential toxicity of prolonged infusions limit its general use from periods of hours to a few days, but its unique and usually well-maintained vascular actions make it an ideal agent for short-term therapy and a potentially useful model for development of new, orally effective vasodilator drugs.


Geriatric medicine: whose specialty?

Geriatric medicine: whose specialty? The recommendation of the 1978 report of the Institute of Medicine, Washington, D.C., states that there should not be "a formal practice specialty in geriatrics." The United Kingdom has a comprehensive geriatric service based on a separate specialty of geriatric medicine. This speciality was developed before the National Health Service in 1948. The future of geriatric medicine is not clearly defined. It should continue, I believe, as a separate speciality but with deliberate policies to bring it back into "mainstream medicine." This will involve closer integration with family practice, internal medicine, and psychiatry. While I realize that the operation of the geriatric service in Edinburgh, where I work, could not simply be transplanted into an American setting, the principles of geriatric care ought to be applied within a specialist service if the increasing problems of the aging in American society are to be adequately met.


[Diagnostic value of hemodynamic and angiographic studies in right medioventricular subinfundibulaire stenosis (author's transl)]. Two cases are reported of right medioventricular subinfundibular stenosis with intact intraventricular septum. This rare congenital malformation, also known as "double chambered right ventricle", and usually associated with an intraventricular communication, can only be diagnosed with certainly on the results of hemodynamic and angiographic studies which demonstrate the abnormal medioventricular muscle bands. A steep intraventricular pressure gradient was noted in the first patient who was operated upon successfully. The second patient developed progressively increasing stenosis which underlines the need for long-term observation of cases in which there is little initial obstruction. Particular types of electrocardiographic recordings, not previously reported, were present in both cases; in one there was an unexplained long QT interval; in the other a first degree nodal atrioventricular block with atrial arrhythmia, requiring the implantation of a cardiac stimulator.


[Polyneuropathy and dysglobulinemia presenting 36 months before an angio-immunoblastic lymphadenopathy (author's transl)]. We report a patient with angio-immunoblastic lymphadenopathy (A.I.L.) with pulmonary localisation. The symptomatology of the A.I.L. was dominated by a polyclonal increase in gammaglobulins and a neuropathy 35 months before the generalized lymphadenopathy. We discuss this unusually long prodromal period and the nature of the neuropathy.


[Cardiac localization of Hodgkin's disease (author's transl)]. Two cases of specific cardiac affection during the course of Hodgkin's disease, of which one involved all three layers, illustrate the diagnostic difficulties in such cases. These are related to the latency period before clinical manifestations appear and the more frequent possibility of iatrogenic affection, especially during treatment with adriamycin and/or radiotherapy. Surgical biopsy of the pericardium is essential for establishing the diagnosis and prescribing treatment, the results of which are often satisfactory.


[Sydenham's chorea in Tunisia: a report on 65 cases (author's transl)]. Sydenham's chorea was observed in 65 patients in Tunisia during the period 1971-1976. The average age of onset was 10.8 years, and girls were affected twice as often as boys. Sydenham's chorea is a seasonal disorder; it usually develops between the months of november and march, and its frequency is closely related to that of Bouillaud's disease. A study of the past history of infections disease or rheumatic disorder (ARF), and biological tests for inflammation (sedimentation rate, blood fibrin levels, antistreptolysins O, and culture of throat swabs), showed that it is possible to distinguish cases of true chorea occurring alone from those in which it is associated with a rheumatic affection. These facts are discussed in the light of the data published in the literature. The authors conclude that sydenham's chorea and acute rheumatic fever are but two unrelated expressions of a streptococcal infection. Anti-inlammatory treatment with corticoids, therefore, is only indicated in the presence of signs of rheumatic affection.


[Specificity of function of a psychiatric unit in a general hospital (author's transl)]. The recent creation of a psychiatric unit in the hospital Broussais gives rise to reflection on what, according to the authors, could constitute the originality of such a treatment unit. It should not be used to satisfy all the requests for psychiatric care within the hospital itself, nor act in parallel with the specialized psychiatric departments established as such in psychiatric or general hospitals. The presence, however, of a group of psychiatrists working as a team in a general hospital, and having several beds for their own autonomous use, should enable the first approach to be made, under the best conditions, to pathological disorders produced by psychological disturbances which are not immediately recognized by the patient: somatic manifestations of anxiety or depression, psychosomatic disorders, behavioural problems such as alcoholism, or even suicide attempts. This clinical function cannot be dissociated from the daily therapeutic approach of the health team or from the conception of medical psychology training based on the true needs of general practitioners. It is also the starting point for a close collaboration with physicians and basic scientists in the field of medical research.


[Cholestatic hepatitis during treatment with I.N.H. and rifampicin: arguments in favour of the hepatotoxicity of rifampicin (author's transl)]. It is generally accepted that hepatitis occurring during treatment with INH and rifampicine results from the hepatotoxicity of INH metabolites. A case is reported of cholestatic hepatitis occurring during such treatment, in which there was a previous history of an isolated hepatic affection. The administration of INH and rifampicin caused cholestasis alone, which reoccurred after rifampicin administration only. No immuno-allergic phenomenon has been shown to be involved in rifampicin toxicity. This observation suggests that rifampicin may be hepatotoxic itself, especially in patients with previous hepatic affections.


[Double malformation discovered during investigations for hypertension; single pelvic kidney and occipitovertebral joint malformation (author's transl)]. A young Portuges eman with a spastic gait was found to have a kidney lying below the bladder. This was the only kidney present and its blood supply was derived from a renal artery which was also the only one present. This renal abnormality was associated with a major malformation of the occipitovertebral joint (occipitalization of the atlas, total occipito-atlanto-odontoid dissociation above the line of the digastric). The possible relationship between these two affections is discussed.


[Acute mitral incompetence of ischemic origin (author's transl)]. Clinical findings and results of treatment in 17 patients with acute mitral incompetence are described. The lesions were secondary to a recent myocardial necrosis causing severe cardiac failure (shock, or acute left ventricular failure), and the presence of mitral incompetence was confirmed by right catherization (15 cases) and/or left ventricular angiography (13 cases). The anatomical lesions are described in 14 cases: rupture of the posterior mitral papillary muscle in 7 cases, and acute dysfunction of the muscle in 7 other cases. Eight patients were treated by an intra-aortic balloon to assist circulation, and 14 were given vasodilators (phentolamine, trinitrin) associated in 5 cases with positive inotropic drugs. Surgical treatment was given (mitral valve replacement) in 7 cases. The respective effects of vasodilators and circulatory assistance are discussed, as well as the indications for, and results of urgent surgical treatment (6 successes in 7 operations).


[A comparative study of three procedures used for studying bronchopulmonary bacterial flora (author's transl)]. Three methods of taking samples of bronchopulmonary secretions; transtracheal aspiration (TT), sputum collection, and fibro-aspiration, were compared in 43 patients with severe pneumopathies. There was no significant difference in the number of times a pure or dominant germ was isolated by using the three procedures in these 43 cases. In contrast, however, there was a significantly lower number of polymorphous flora and more sterile samples observed when using TT than with the other two methods. When antibiotics are given 1 to 7 days before taking the samples, there is a significant reduction in the number of cultures having a germ in the pure state.


[The traveler without luggage. A case of lost identity in an adolescent (author's transl)]. Loss of personal identity is a difficult problem which is relatively rarely encountered in psychiatric practice. A case is reported of an adolescent of 15 years of age with total amnesia over a period of two months. His true identity was discovered only after his photograph and story had been published in a widely-read daily newspaper. Following a discussion on the possible etiological mechanisms involved, two problems remained unresolved: the difficulty of establishing a psychopathological basis for a loss of identity, and the prognostic uncertainty inherent in restoring the adolescent's identity.


[The cost of alcoholism in a hospital medical department (author's transl)]. The authors evaluated the costs involved when alcoholic patients were admitted to a hospital medical department. Costs which were identical for all patients, such as basic services and hospitalization fees, were discounted, and only those for individual investigations and treatment were calculated. These costs were then compared with the average daily costs for non-alcoholic patients in the same department over the same period. The results are discussed in relation to other similar studies.


[Recovery after treatment for cirrhotic ascites : a study of 90 cases. Frequency of arterial hypertension (author's transl)]. Thirty patients with alcoholic cirrhosis, ascitic during 13.6 +/- 13 months (mean +/- S.D.) were cured of ascites and followed up during 2 to 9 years (4.3 +/- 2.7 years). Twenty six were compared with a same number of cirrhotics, matched for age and sex, who died during the year after the first admission. Many biological data show statistical difference. Nevertheless no valuable prognosis can be predicted in an individual case. The clinical improvement is associated with major, sometimes total biological recovery. Other complications of cirrhosis (gastro-intestinal bleeding, hepatoma) may occur (7 cases with 5 deaths) or alcoholic hepatitis if alcohol withdrawal is stopped (3 cases, 2 deaths). Some associated diseases look unexpectedly frequent: diabetes (4 cases), obesity (9), nodular lipomatosis (14 cases) whose frequency looks higher than that can be calculated for a similar group of healthy subjects.


[Psychotropic effects of a new beta noradrenergic receptor blocking agent, acebutolol, in psychotics (author's transl)]. In a pilot, phase II open trial, 32 psychotics, aged between 19 and 54, whose illness was evolving from between 1 and 25 years, and was not improved with classic treatments, were given daily 200 to 1 400 mg of acebutolol orally, in three divided doses. Following global clinical evaluation and scores of BPRS, in 18 patients was observed a mild improvement, in 2 a clear one, in 2 others a clear improvement with partial social rehabilitation and in 2 a clear improvement with long lasting social rehabilitation, while 6 patients showed no improvement. Acebutolol could be considered as a mild or partial neuroleptic and its action as amphidromic or double.


[Role of the digestive microflora and of the crystalline structure of starch in digestion and dietary efficiency in the chicken. Study of tropical tubers]. The influence of microflora in the utilization of starches, the X ray pattern which was of A or B type, was studied by balances and carcasses analysis with growing axenic or holoxenic chickens, put in isolators. Five tropical tubers were used : Manihot utilissima and Dioscorea dumetorum of A-type, Dioscorea cayenensis and alata and Canna edulis of B-type. They were introduced in isoenergetic (4,460 Kcal/g D.M.) and isoproteic (18 p. 100) diets. The A-type starches are entirely digested (95 p. 100) and the B-type are poorly digested (40-60 p. 100). The first ones induced a better growth than the second. The influence of digestive microflora changes with the two types of tubers used. With A-type starches the microflora lowered the feed intake, the growth and the energy and protein efficiency respectively--25 and--10 p. 100. When the diet included tubers with B-type starches, the low digestibility of starch and the low metabolisable energy in the diets induced poor growth and retentions. The results are discussed in relation with the starch breakdown into glucose, lactic acid and volatile fatty acids.


[Specific problems posed by carbohydrate utilization in the rainbow trout]. Carbohydrate incorporation in trout diets arises problems both at digestive and metabolic levels. Digestive utilization of carbohydrate closely depends on their molecular weight. In addition, in the case of complex carbohydrates (starches), different factors such as the level of incorporation, the amount consumed and the physical state of starch influence the digestibility. The measurement of digestibility in itself is confronted with methodological difficulties. The way the feces are collected can affect the digestion coefficient. Dietary carbohydrates actually serve as a source of energy. Nevertheless, above a certain level in the diet, intolerance phenomena may appear. The question that arises now is to establish the optimal part that carbohydrates can take in the metabolizable energy of a given diet.


Comparative effects of protracted protein deprivation on the DNA synthetic and mitogenic actions of phytohemagglutinin and concanavalin A in vivo on the lymphocytes of the rat. The increase rate of DNA synthesis and mitotic activity in popliteal lymph nodes following subplantar injection of PHA was significantly reduced in rats subjected to a protein-free diet given for 9 weeks. On the contrary, the lymph node responses to Con A were higher with latter diet than with a balanced 18% casein diet. On the other hand, PHA reduced the weight and proliferative activity of the thymus, and probably also increased the emigration of thymocytes in protein deprived rats, while Con A was devoid of any effects. Thus, mainly the activity of the PHA-responsive subset of T lymphocytes and thymocytes appeared to be disturbed after protein deprivation. According to previous work, this subset was formed of high theta, cortisone-sensitive celles.


Blindness due to illicit use of topical cocaine. A drug abuser developed simultaneous bilateral corneal ulcerations after the use of topical cocaine. One eye was enucleated because of secondary angle-closure glaucoma and the other developed a dense central corneal scar.


Ocular and orbital metastatic carcinoma. One hundred cases of metastatic carcinoma to the eye and orbit were reviewed. Fifty-nine patients were female and 35 were male. The average age of the females was 60 years and the males 52 years. Breast carcinoma was the most common primary in the females and lung carcinoma in the males. The left eye and orbit were involved more frequently than the right (30 to 27). The choroid and the orbit were the most common site of metastasis.


Central retinal artery spasm.

Central retinal artery spasm. Central retinal artery spasm, a seldom witnessed ocular sign, has been recognized in one eye of a patient complaining of transient monocular blindness. Removal of an ulcerative atheromatous plaque of the carotid artery on the same side as the eye with central retinal artery spasm resulted in complete disappearance of symptoms. No other signs of ocular pathology were noted in addition to the central retinal artery spasm. Central retinal artery spasm occurring in both eyes simultaneously may be the mechanism explaining the visual loss of amaurosis fugax. Physiologic mechanisms associating brief episodes of monocular blindness and carotid artery obstructive disease with atherosclerosis are discussed. The possibility of central retinal artery spasm initiating occlusion of the same vessel is mentioned.


Endothelial cell morphology and corneal deturgescence. In a series of 46 patients accepted for cataract removal and intraocular lens implantation, 23 showed visibly obvious variation in endothelial cell size (polymegethism) according to specular microscopic examination. In this group, mean increase in postoperative corneal thickness was 52.7% on the first postoperative day, 35.4% on the third, and 18.0% after 4 weeks. Mean corneal swelling was consistently and significantly less in the 23 patients exhibiting apparently normal endothelial cell patterns (homomegethism). In homomegethous corneas, preoperative cell density was significantly correlated with age (inversely) and postoperative cell loss (directly). Preoperative cell density in polymegethous corneas showed significant, direct correlation with age, suggesting that endothelial cell density may remain relatively constant in this condition. There was no correlation with postoperative cell loss. Significant differences in endothelial functional capability identified within each morphologically-defined group indicate a structure-function continuum. Since 15 homomegethous corneas and only one polymegethous cornea returned to preoperative thickness within 4 weeks, it appears clinically valid to use morphological criteria in predicting functional capability.


Ischemic retinal alterations in cardiac arrest. Retinal ischemia caused by systemic hypotension produces significant functional and morphological symptoms. Animal experiments were carried out in dogs to study the retinal alterations during cardiac arrest created by artificial pericardial tamponade which lasted for 1 to 9 minutes. The main parameters of the blood circulation were recorded with a multichannel recording system and serial fundus photographs were made. The retinas, after a prompt enucleation of the eye, were studied by light and electron microscope. The retina and arterial walls became cloudy during the circulatory arrest, which were reversible, if the blood circulation was recreated not later than 4 minutes. Ultrastructural alterations can be seen in the retina after 4 minutes. Mitochondrial destruction of the ganglion cells and bipolar cells as well as edema of Muller's cells are the first consequence of the circulatory arrest, which is followed by disintegration of the capillary endothelium and destruction of the inner segment of the photoreceptor cells. These observations suggested that during circulatory arrest serious ultrastructural destructions occur both in the retina and retinal capillaries which explain the definitive diminution of retinal functions.


Bullous retinal detachment associated with renal failure: case report. A case of bilateral bullous retinal detachment in a patient with long-standing disseminated lupus erythematosus is presented. Although several authors have reported the presence of bullous retinal detachment in association with chronic renal disease, in no other case have the ocular findings preceded the onset of frank renal failure. The etiology of nonrhegmatogenous detachment and uveal effusion in association with chronic renal disease was discussed and the possible contributory role of hypertension, electrolyte imbalance, and renal glomerular malfunction was investigated. The additional finding of late onset bilateral keratoconus is, in all probability, unrelated to the patient's retinal findings, though it is a major factor in her present visual morbidity. The purpose of this paper is twofold. First-ly, to alert the ophthalmologist to the possible development of bullous retinal detachment in patients with chronic renal disease, and secondly, to alert the internist to the possibility of impending renal failure in patients with such bilateral nonrhegmatogenous detachments.


Endophthalmitis in a pediatric population. A study of 22 consecutive cases of suspected endophthalmitis in children disclosed that 68% (15/22) were male with a mean age of 7.4 years. In contrast to adult populations, 86% (19/22) followed trauma in this series. Cultures were performed in 18 cases yielding positive results in 8 cases. Anterior chamber paracentesis was positive in 6/10 attempts, vitreous cultures in 1/4, and wound cultures in 2/7. Gram-positive organisms were recovered in 75% (6/8) of the cultures, stressing the importance of coverage for these organisms before culture results are known. Although cultures should be obtained as soon as possible, the initiation of antibiotics beforehand should not deter one from obtaining cultures as 75% (6/8) of patients with positive cultures had preculture antibiotics. Fourteen patients were diagnosed within 48 hours of the precipitating event, and all of these cases followed trauma. Three of 7 patients with positive cultures and 1 of 10 patients with negative cultures had final visual acuities of 20/200 or better. The lack of correlation between a positive culture and a poor visual outcome suggests that the final visual acuity depends not only on the endophthalmitis, but also on the extent of trauma.


Retrospective ocular study of patients receiving oral 8-methoxypsoralen and solar irradiation for the treatment of vitiligo. A retrospective ocular study of patients receiving oral 8-MOP and exposure to solar irradiation for the treatment of vitiligo is presented. Fifteen patients between the ages of 20 and 40 years of age were selected who had been under therapy for 5 to 23 years. No ocular abnormalities were found.


Progressive hemifacial atrophy (Parry-Romberg syndrome): report of two cases. We describe 2 cases of progressive hemifacial atrophy (Parry-Romberg syndrome) with typical facial and ocular involvement. Ocular manifestations in these 2 cases include enophthalmos, due to fat atrophy, decreased corneal sensitivity, episcleritis, and band keratopathy. The slowly progressive changes were documented in one case over a 40 year period. Both cases were unilateral with limitation of the lesions at the midline.


An evaluation of 8-0 polyglycolic acid braided synthetic absorbable suture in cataract surgery. This study describes the operative and postoperative performance of 8-0 polyglycolic acid braided suture, trademarked Dexon "s", in cataract surgery. The evaluation consists of a clinical comparison of 8-0 Dexon to the same suture in 7-0 size in 109 cataract surgical procedures. The 8-0 Dexon, like 7-0, gave high tensile strength, good knot security, batch-to-batch uniformity, relatively good pliability, and provoked minimal reaction while disappearing at a predictable rate of around 35 days. When compared to 7-0 Dexon, 8-0 produced less tissue drag, fibrillation, and reaction, while providing better pliability. However, the smaller suture possessed less tensile strength, and had an increased tendency to cut through tissue when tied too tightly.


Corneal retraction and intraocular lens implantation. A corneal retractor has been developed which when used after intraocular lens insertion insures against endothelial intraocular lens touch during the maneuvers of clipping or suturing various intraocular lenses to or through the superior iris.


Autoimmune sensorineural hearing loss.

Autoimmune sensorineural hearing loss. The author proposes the existence of a new entity, autoimmune sensorineural hearing loss, on the basis of diagnostic study and treatment experience with a series of 18 patients. In each case the clinical pattern did not fit with known entities and thus seemed to merit distinctive categorization. In the one patient in whom tissue was available, a vasculitis was evident, a feature of autoimmune disease. All patients responded to treatment for an autoimmune disease, namely, chronic cortisone and cyclophosphamide therapy. The author suggests that all otolaryngologists should be aware of the possibility of this condition, because it is one of the few forms of sensorineural deafness for which we have a treatment.


The combined computerized tomography-sialogram. A technique to differentiate deep lobe parotid tumors from extraparotid pharyngomaxillary space tumors. The preoperative differentiation of a deep lobe parotid tumor from a parapharyngeal tumor is important to the surgeon in determining the correct surgical approach. The combined parotid sialogram and CT scan provide more information than either study alone, and we feel that a reliable preoperative differentiation can be made on this combined study.


Cricopharyngeal myotomy in pharyngeal paralysis. Cineradiographic and manometric indications. A brief outline of the causes and symptoms of hypopharyngeal paresis is followed by a discussion of the diagnostic possibilities of manometry and cineradiography. It was found that the pharyngoesophageal sphincter mechanism remains intact in the case of complete paralysis of the hypopharynx. When there are severe symptoms of dysphagia, myotomy of the pharyngoesophageal sphincter is to be considered on the basis of these diagnostic findings. This procedure can lead to substantial improvement of the symptoms. Sphincterotomy yielded very favorable results in five out of nine patients, two of whom are discussed in some detail by way of illustration.


Effect of cholinergic drugs on the perilymphatic oxygen tension. The effect of the intravenous injection of cholinergic drugs on perilymphatic oxygen tension (PO2) was measured using the polarographic method in 20 cats. Acetylcholine, pilocarpine and neostigmine produced minimal but statistically significant changes in perilymphatic PO2. Atropine and scopolamine did not influence the PO2 of the perilymphatic space. The reported results show that under normal conditions the cholinergic receptors of the vestibular vessels have little effect on the permeability of arterial PO2.


Temporal bone histopathology in deafness due to cryptococcal meningitis. This paper reports on a patient who survived an attack of cryptococcal meningitis eight years prior to his death. A bilateral sensorineural hearing loss had been noted a short time before the patient was admitted to the hospital, and was the only complication after he recovered from the disease. Histopathologic study of the temporal bones showed a similar pattern of pathology in both ears, the most striking finding being a severe loss of spiral ganglion cells in Rosenthal's canal, and of cochlear nerve fibers in the osseous spiral lamina and internal auditory meatus. The vestibular nerve was mostly free from pathology. The organ of Corti was atrophic but the hair cell population appeared to be almost normal. A slight number of cryptococci were observed in limited areas of the cochlear and the saccular nerves in the internal auditory meatus. The severe pathology of the cochlear nerve was compatible with audiologic evaluations, which pointed to a retrocochlear lesion. Thus, this case demonstrates some characteristic aspects of cryptococcal infection of the temporal bone: The primary site of invasion was the cochlear nerve in the internal auditory meatus and the modiolus, leading to the loss of ganglion cells and nerve fibers, while the vestibular nerve appears to have been resistant to infection.


Role of periosteum on the fate of pedicle osteocutaneous grafts. Recent studies on the fate of pedicle osteocutaneous grafts have shown that they remain viable and may be actively involved in the mechanics of bone repair. This communication reports on a series of experiments aimed to clarify the role of periosteum in the survival of pedicle-assisted bone grafts. Osteocutaneous grafts were developed in dogs in such a manner as to isolate the implant from normal recipient bone. Free bone grafts were used as controls and a group of pedicle periosteal grafts were studied as potential sources of bone formation. Specimens were evaluated at regular intervals over a 40-week period. The pedicle bone grafts maintained their viability and developed vigorous osteoneogenesis. The process was progressive and eventually resulted in partial substitution of the original graft by new bone of periosteal origin. The free bone grafts were resorbed and no bone formation was obtained in pedicle periosteum specimens. The study provides clear evidence that under experimental conditions no bone contact is needed to maintain the viability of pedicle osteocutaneous grafts. It also shows that the periosteum has the leading role in the restructuring process of these grafts.


Photoplethysmography in the prediction of experimental flap survival. A standard photoplethysmograph, modified to differentiate between arterial and venous vasculature in skin tissue, has been used to measure arterial supply in 100 unipedicle skin flaps in 25 pigs. A datum transform from a light intensity scale to a relative arterial blood density scale has been introduced and empirically labelled the vascular coefficient (VC). Statistical analysis of the VC data shows a significant difference between necrotic and surviving flap group mean data as early as 24 hours. Additional analysis in which a normal ogive was fitted to the sample VC data distributions suggests that statistically significant predictions of the probability of eventual flap necrosis can be made using VC measurements obtained immediately postoperatively. It is concluded that the modified photoplethysmograph in conjunction with the VC data transform, constitutes a usable measuring technique for skin flap viability prediction in the experimental animal.


Hearing and age: research challenges and the National Institute on Aging. Just as the ear trumpet once symbolized the elderly, so do contemporary approaches to hearing loss in the aged reflect many of the major themes in geriatrics and gerontology today. This paper begins by describing the National Institute on Aging (NIA) with particular emphasis on activities relevant to hearing in the elderly. Next, several areas of research interest, including the typology of presbycusis and related conditions, the epidemiology of auditory impairment in old age, the design of testing and research, and the rehabilitation of the hearing-impaired elderly, are addressed. The NIA and the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) are coordinating their efforts to stimulate investigation of these and related topics.


Effects of neonatal conductive hearing loss on brain stem auditory nuclei. Both postnatal auditory deprivation and experimentally produced conductive hearing losses in mice result in incomplete maturation of most brain stem auditory neurons. The affected groups are: octopus cell, globular cell, small spherical cell, and large spherical cell groups in ventral cochlear nuclei; and the lateral superior olive and medial nucleus of the trapezoid body of the superior olivary complex. When 45 days of auditory deprivation are followed by 45 days of normal acoustic stimulation, there is incomplete maturation of neurons in: multipolar cell, globular cell, small spherical cell, and large spherical cell groups in ventral cochlear nuclei; lateral superior olive and medial nucleus of trapezoid body in superior olivary complex; and central nucleus of inferior colliculus. A critical period exists when adequate sound stimulation is needed for full development of these neurons.


[Pyoderma gangrenosum and haemopathy. Report of three cases (author's transl)]. The authors report three personal cases of phagedenic pyoderma associated with hemopathy. Studying twenty-five other cases, described in the reviews, the question can be debated on three levels: 1) The clinical characteristics of hemopathic pyoderma remain non-specific. However blisters, pustules, and even vegetating lesions occur very often; 2) the etiology of hemopathy is subject to change; acute leukaemia or myeloproliferation syndrome. During the polyglobulars associated with pyoderma, anemia and myelofibrosis appear quite constantly; 3) finally on the pathogenic level, the recent works tend towards the hypothesis of a damage in the functioning of the polymorphonuclears hence displaying the increase in the inflammation during phagedenic pyoderma.


[Treatment of alopecia areata with D.N.C.B. (author's transl)]. The results of treatment of 16 cases of alopecia areata with dinitrochlorobenzene (D.N.C.B.) are reported. The chemical is applied to the scalp once a week, beginning three weeks after sensitivation (patch-test 1/50). We have available to us a battery of D.N.C.B. solutions of various concentrations (11 solutions ranging from 1/20,000 to 1/25). The concentration used varies at each application with the desired result being a contact dermatitis. In the 16 cases studied, 4 were classified as good results, 8 as poor and 4 as failures. Hairgrowth begins with three weeks following the first D.N.C.B. application to the scalp. Good prognostic signs include the facility in sensitizing the patient as well as the intensity of this reaction. The reasons for this treatment's efficacy being as yet unknown, the standardization, as well as the actual technique are, at the present time difficult and hazardous.


Trends and profiles in stapes surgery.

Trends and profiles in stapes surgery. Stapedectomy has become recognized as the procedure of choice in the surgical treatment of clinical otosclerosis. Based on results obtained in stapes surgery performed in 1977, profiles were established for hearing improvement, vertigo, tinnitus, chorda tympani injury and temporary threshold shift of high tones. Tympanometric and stapedial muscle reflex tests in cases of proved clinical otosclerosis also are discussed. The profiles indicate that stapedectomy performed on a regular basis and under ideal conditions is highly successful for the improvement of hearing. The incidence and probable causes of complications are presented and discussed. This study reveals, however, that the number of new patients with otosclerosis has decreased steadily since its peak in 1964. Should the number of surgical cases continue to diminish, it may be impossible for the practicing otologist to maintain sufficient expertise for the performance of an occasional stapedectomy. Also, it may become impossible to provide sufficient experience in otosclerosis surgery for all trainees in otolaryngology.


[Cowden disease: report of 8 cases in 2 families (author's transl)]. These 8 cases of multiple hamartoma syndrome are the first reported in Switzerland. Two men aged respectively of 65 and 28 years presented a cobblestone appearance of the gingiva and of the tongue ("pebbly tongue"), which suggested Cowden disease. This diagnosis was confirmed by the discovery of numberous skin lesions, a thyroid goiter, gastrointestinal polyposis, and a mild skelettal dysmorphosis. The older patient had a grade one carcinoma of the bladder; his son and his daughter presented the syndrome, which was also discovered in the family of the second patient (his father, his brother, his sister and one of her daughters). The ultrastructural study of two skin biopsies demonstrated anomalies of the fibroblasts and collagen fibers.


[Iridium 192 interstitial radiotherapy of carcinoma of the penis. Carcinologic results, dermatologic evaluation (about 87 cases) (author's transl)]. 87 cases of epidermoid carcinoma of the penis treated by Ir 192 interstitial radiotherapy are studied. The 5 years survival rate, estimated on a 51 patients group, is 61 p. 100. Among these 51 patients, 12 had a local recurrence. The post-radiotherapy early reaction is estimated on a 79 patients group, with a mean duration of 3, 4 months. The early reaction is correlated to tumor size and not correlated to number of radio-active lines. The later dermatologic evolution is studied in 59 patients. In 22 cases, the scar remained supple, without any further local change. Local changes occurring in the 37 other cases are studied in their clinical aspect, signification and frequency. Of 34 patients followed longer than 40 months, 14 had local complications with 4 cases of local recurrence. The carcinologic reliability of this method is similar to that by surgery. It seems however it must be restricted to tumors limited to glans penis.


Necrotizing ("malignant") external otitis histopathologic processes. The histologic findings in a serially sectioned temporal bone, from a patient who succumbed to brain abscess secondary to necrotizing ("malignant") external otitis, are described. The mechanism of invasion of the ear canal appears to be due to local bone necrosis. This in turn extends to the submucosal vasculature of the pneumatic spaces. The infective process extends submucosally, establishing one or several sites of bone destruction. The lumen of the pneumatic space is not involved. In this process, the periphery of the fibrous inflammatory tissue formation is the site of active bone destruction. In pneumococcal petrositis, the peripheral fibrous elements are protective. The process in malignant external otitis may extend directly to adjacent central nervous system structures inoculating the structure with Pseudomonas. Development of Pseudomonas brain abscesses can be slow, allowing for new bone closure of the site from which the infection spreads as demonstrated in this specimen. Therefore, apparent local control of the disease can be established while a central infective process progresses.


[Cutaneous lesions of malignant histiocytosis. About five cases (author's transl)]. Five cases of malignant histiocytosis are reported. They associate specific cutaneous lesions with the other much more classical symptoms of the illness; fever, weight loss, lymphadenopathy, splenomegaly, hepatomegaly. The principal clinical and histological findings observed during the course of the illness in these patients are described. In a review of the literature concerning this rare but now well individualized illness, 34 cases of malignant histiocytosis associated with cutaneous lesions are found among which 24 were studied on a clinical and histological point of view. The principal characteristics of the cutaneous eruption are presented: clinical characteristics with the most frequent nodular aspect of the lesions, but also histological features with the relative specificity of the disposition of the infiltrate whose cytological features will not be forgotten to analize. Nevertheless, the diagnostic will often be established by the histological analysis of the lymph node biopsy or sometimes of biopsy of the other affected organs. These cutaneous lesions might also be in several cases of some prognostic interest.