Cerebrospinal fluid lysozyme in bacterial and viral meningitis. The concentration of lysozyme (LZM) in cerebrospinal fluid was determined in 25 patients with bacterial meningitis, in 18 patients with viral meningitis and in 25 control patients who had other fibrile illnesses. The concentration of LZM was less than 1.5 microgram/ml in all control patients, and slightly to markedly raised in 10 patients with viral meningitis and in 11 out of 13 patients with untreated bacterial meningitis. The concentration of LZM was significantly different in the viral and bacterial meningitis patients (p less than 0.001). Most raised concentrations of cerebrospinal fluid LZM persisted for at least one week after the start of antibiotic treatment. The concentrations of LZM correlated well with concentrations of lactic dehydrogenase. These results show that the determination of cerebrospinal fluid LZM is a useful tool in the differential diagnosis of meningitis, particularly when the prehospital treatment with antibiotics may be responsible for a diagnostically misleading negative bacterial culture of the cerebrospinal fluid and altered cerebrospinal fluid cytology.


Factors influencing the occurrence of "on-off" symptoms during long-term treatment with L-dopa. "On-off" symptoms were found to have developed in 43 of 85 parkinsonian patients who had been treated with L-dopa for five years or more, the risk of such symptoms apparently being greater the younger the patient had been at the début of the disease and at the start of treatment. The dopa dose had been higher throughout the treatment in the patients developing "on-off" symptoms than in those maintaining an even effect, and, furthermore, the initial improvement had been more marked and dyskinesia had appeared earlier and in a higher frequency. The clinical observations in the present studies seemed to be related to some pharmacological findings, where different degrees of the nigrostriatal neuron degeneration and the efficacy of the remaining neurons could be of importance for a varying therapeutic response. It also seemed possible that a higher dopa dose could evoke "on-off" symptoms more easily than a lower one in thereto predisposed individuals. As the patients maintaining an even symptomatology during long-term treatment with L-dopa were older, and in particularly as they had dementia in a higher frequency than those developing "on-off" symptoms, the possibility of a more widespread neuron damage, influencing the clinical manifestation in these patients, had to be taken into consideration.


Four cases of long-standing diarrhoea and colic pains cured by fructose-free diet--a pathogenetic discussion. Four patients with a long history of abdominal swelling, colic pains and diarrhoea were cured by a fructose-free diet. They were all given an oral load of (14C) fructose and their expiratory excretion of 14CO2 was found to be significantly lower than that of control patients with similar symptoms. It is concluded taht the patients cured by a fructose-free diet might have a partial fructose malabsorption.


[Control of the course of iris tumors with the aid of fluorescence angiography]. The clinical and fluorescence-angiographical control findings of 79 iris tumours are reported. According to the angiographical pattern, these tumours could be divided into three distinct types which correlated to the histopathological findings, if available. Thus, a type I tumour tends to run a benign course; type II we regard as potentially malignant and type III as definitely malignant. Furthermore, an increase in tumour size can be more exactly determined by iris angiographical controls than by other methods of documentation.


Hyperpermeable disc capillaries in glaucoma. Nine subjects had leakage of fluorescein dye from the capillaries in the glaucomatous discs. Eight subjects had a solitary leakage and one had four points of leakage in the disc. The leakage was ordinarily found in the centre or the temporal margin of the glaucomatous optic disc. No common factors causing dye leakage from the optic disc capillaries appeared to exist in these subjects, except that they had reached a very advanced stage of glaucoma.


[Functional morphology of the cornea].

[Functional morphology of the cornea]. The corneal epithelium serves as a barrier between tear film and stroma and maintains a smooth corneal surface. The optical features of the cornea, namely refraction and transparence, depend largely upon the characteristics of the superficial corneal layers. Any lesion of this superficial cell coat facilitates the penetration of particles of even small diameter (virus, bacteria) towards the stroma. In fact, viral corneal diseases usually start in the epithelium, the virus being replicated in transformed epithelial cells. Corneal wounds are rapidly covered by migrating epithelial cells, invading the lesion from the border of the epithelial defect. Cohesion between epithelium and underlying stroma remains very weak unless regenerating epithelial cells have synthesized a basement membrane, allowing thus a firm attachment between epithelial hemidesmosomes and basement membrane. Recurrent erosions occur readily in the absence of epithelial basement membranes. Presumably, corneal epithelium is involved in the biosynthesis of fibrillar collagen of the superficial stromal layers. Corneal wound healing is delayed by a pathological epithelium. Corneal hydratation is controlled by the endothelium. It maintains a bulk flow of water towards the aqueous humor side against a pressure gradient and regulates the movement of metabolites. In the case of endothelial malfunction, the corneal stroma thickens due to a swelling of mucopolysaccharides. The endothelium synthesizes a very thick basement membrane (Descemet's membrane). In penetrating corneal wounds, Descemet's membrane is synthesized by the endothelium.


Progressive nature of myocardial injury in selected patients with cardiogenic shock. To determine whether the extensive myocardial injury associated with cardiogenic shock in some patients results from a progressive rather than a discrete massive insult, a study was made of 15 selected patients who had cardiogenic shock within 48 hours of admission, 5 patients with hypovolemic shock without myocardial infarction and 11 patients with myocardial infarction without shock. Peak plasma MB creatine kinase (CK) activity was significantly higher in the seven patients with cardiogenic shock associated with initial infarction (213 international units [IU]/liter) than in patients with shock and previous infarction (98 IU/liter) and in patients with uncomplicated myocardial infarction (125 IU/liter). A prolonged time to peak MB CK activity (averaging 26 hours) and a plateau of elevated MB CK activity were seen in patients with shock associated with initial infarction. Because shock itself did not slow the rate of apparent MB CK disappearance, results obtained suggest that cardiogenic shock associated with initial infarction in selected patients results from progressive myocardial damage underlying continuing release of MB CK into the circulation. The findings are compatible with the concept that, in these patients, cardiogenic shock reflects a vicious cycle of spreading myocardial injury, progressive compromise of cardiac function, exacerbation of ischemia and perpetuation of myocardial damage.


Anuloaortic ectasia: angiographic, hemodynamic and clinical comparison with aortic valve insufficiency. Thirty-five patients with angiographically diagnosed anuloaortic ectasia were compared with 18 patients with isolated aortic valve insufficiency to study differences between the presentation, hemodynamic or angiographic findings and clinical course in the two groups. The maximal aortic root diameter in anuloaortic ectasia was 7.6 +/- 2.4 cm (mean +/- 1 standard deviation) versus 4.2 +/- 0.6 in aortic insufficiency. Dissection was a common complication of anuloaortic ectasia (44 percent) but was not seen in aortic insufficiency. Neither the size nor the configuration of the aortic aneurysm was a reliable predictor of dissection. Despite surgical therapy, patients with anuloaortic ectasia have a worse prognosis than those with aortic valve insufficiency.


Value of the QRS complex in assessing left ventricular ejection fraction. The relation between electrocardiographic findings and the angiographic left ventricular ejection fraction and the augmented ejection fraction after a premature ventricular contraction was investigated in 73 patients with documented chronic coronary artery disease. The patients were separated into four groups according to the presence or absence of abnormal Q waves. Twenty-four patients had diaphragmatic myocardial infarction, 21 had anterior myocardial infarction, 15 had both and 13 had no myocardial infarction. There was no statistically significant differences in cardiac index, left ventricular end-diastolic pressure or number of coronary vessels showing critical narrowing in the four groups. The sum of R waves (in mv) in leads aVL, aVF and V1 to V6 (sigmaR) was correlated with the ejection fraction (EF) and the augmented ejection fraction (EFa). EF in percent = 6.6 sigmaR mv + 9.4 (no. =73, r = 0.61); and EFa in percent = 8.6 sigmaR mv + 11.0 (no. = 73, r = 0.77). Among patients with sigmaR of less than 4.0 mv, augmented ejection fraction was less than 0.45 in 73 percent; among patients with sigmaR of 4.0 mv or more the augmented ejection fraction was greater than 0.45 in 93 percent (P less than 0.001). Thus, the sigmaR, calculated from six precordial and two augmented leads in patients with chronic coronary artery disease, correlated with both ejection fraction and augmented ejection fraction. The electrocardiogram in patients with coronary artery disease may prove useful as a simple, readily available and noninvasive guide in the assessment of left ventricular function in patients with coronary artery disease.


Atrioventricular block: natural history after permanent ventricular pacing. The preimplantation status, postimplantation morbidity and causes of late mortality were summarized for 246 patients who underwent pacing for atrioventricular (A-V) block at the University of Michigan for the 14 years from 1961 to 1974. The survival rate at 1, 5 and 10 years was 88, 61 and 49 percent, respectively. Risk of death was greatest among patients with antecedent ischemic or hypertensive heart disease or congestive heart failure in the period before pacemaker implantation, patients older than 74 years at initial implantation and those receiving a pacemaker before 1965. Forty-two percent of the 109 deaths were related to apparent progression of underlying cardiac disease. Pacing system malfunction was a contributing documented cause of only 3 deaths. Even with permanent pacemaker implantation, patients with A-V block have a higher age-specific mortality rate than the general U.S. population. Survival improved steadily over the period of study. This change is attributed to apparent improvements in treatment of cardiovascular disease including more effective treatment of congestive heart failure and valve replacement for selected patients as well as elimination of immediate postoperative mortality.


Variability in sequential measures of left ventricular performance assessed with radionuclide angiocardiography. The variability of left ventricular ejection fraction, normalized mean ejection rate and regional wall motion was evaluated from first pass quantitative radionuclide angiocardiograms obtained with a computerized multicrystal scintillation camera. Three radionuclide studies separated by an average of 4.3 days were obtained in each of 20 patients. Ejection fraction and ejection rate obtained on the first, second and third studies did not differ significantly. The mean (+/- standard deviation) variability of sequential ejection fraction measurement was 4.4 +/- 3.6 percent, and of sequential ejection rate was 0.56 +/- 0.47 sec(-1). Variations in measurements were not related to fluctuations in heart rate or blood pressure. Variability in ejection rate was significantly greater in patients with normal function than in those with abnormal function. Regional wall motion analysis was constant in 19 of 20 patients. Thus, sequential quantitative radionuclide angiocardiography allows reproducible serial assessment of left ventricular performance that can be performed with a low level of intrinsic variability.


Measurement of atrial septal defect during cardiac catheterization. Experimental and clinical results. The size of experimental and clinical secundum atrial septal defects may be accurately measured during cardiac catheterization. The position of the defects in the septum and their distance from the aortic and mitral valves may also be ascertained. A balloon catheter inflated with radiopaque dye is used for the measurement. The volume of dye in the balloon has been correlated with its maximal diameter. Thus, a no. 8-10 French catheter filled with 10 ml of diatrizoate (50 percent) has a diameter of approximately 25 mm and a no. 8-22 French catheter filled with 40 ml of diatrizoate a diameter of approximately 43 mm. Persistent arrhythmias or other adverse effects of the procedure were not observed. There was a high correlation between balloon-measured atrial septal defects and those measured at necropsy in the animals or at operation in the patients. These measurements aid in determining whether an ostium secundum defect is of proper size and location to be closed transvenously and may also prove valuable in physiologic studies of atrial septal defects or other cardiac anomalies.


His bundle electrogram after intracardiac repair of tetralogy of Fallot. Analysis of data in 59 patients. His bundle electrograms were recorded in 59 patients after intracardiac repair of tetralogy of Fallot and were correlated with the postoperative electrocardiogram. Except for five patients with first degree atrioventricular block postoperatively all patients in Group A (those with either a normal electrocardiogram or solitary right bundle branch block) had a normal A-H interval (77.7 +/- 21.6 msec) (mean +/- standard deviation); all had a normal H-V interval (39.5 +/- 7.2 msec). Patients in Group B (bifascicular block) tended to have a normal A-H interval (97.2 +/- 26.2 msec) with a prolonged H-V interval (48.8 +/- 10.7 msec). Patients in Group C (trifascicular block) had prolongation of both the A-H (160.0 +/- 32.4 msec) and the H-V interval (58.8 +/- 10.6 msec) by comparison with control values. Patients in Group D (transient complete heart block) had a normal A-H interval (79.5 +/- 28.2 msec) but a prolonged H-V interval (57.8 +/- 16.4 msec), similar to that in Group C. A good hemodynamic result was associated with a normal H-V interval; a prolonged interval accompanied a poor result.


Wolff-Parkinson-White syndrome in the neonate. Of 16 infants who presented with paroxysmal supraventricular tachycardia in the neonatal period, 50 percent had an electrocardiographic pattern consistent with Wolff-Parkinson-White conduction, type A. It is suggested that infants have bypass pathways similar to or identical with a Kent pathway as part of normal maturation. Infants with paroxysmal supraventricular tachycardia have electrically active bypass tracts but these are documented in only about one half of the patients because of the short duration of recordings or because of concealment (the bypass tract conducts only in retrograde fashion). The activity of these pathways is enhanced by the predominant cholinergic innervation of the neonatal heart. Resolution of the arrhythmias and the Wolff-Parkinson-White pattern in most patients occurs because of anatomic maturation of the conduction tissue, development of adrenergic innervation and a decrease in cholinergic dominance. In some children, maturation is incomplete and the bypass fibers remain quiescent or become active under certain circumstances such as those associated with increased autonomic discharge. Extended surveillance is recommended for all infants who present with paroxysmal supraventricular tachycardia and the Wolff-Parkinson-White pattern.


Hemodynamics of postmyocardial revascularization hypertension. The evolution of hemodynamic variables during the development of postcoronary bypass hypertension was investigated with use of serial cardiac output determination (indocyanine green dye) in 17 patients. Seven of the 17 patients remained normotensive (Group I) during the follow-up period of 4 to 6 hours after operation, whereas 10 (Group II) had a steady increase in blood pressure (173/101 mm Hg +/- 5.9/2.4 [mean +/- standard error] from 132/78 +/- 4.0/2.5 mm Hg immediately postoperatively, P less than 0.001) during the same time interval. Patients in Group I had no significant change in cardiac output, total peripheral resistance or heart rate. In contrast, patients who became hypertensive had a significant increase in total peripheral resistance (47 +/- 2.9 units/m2 from an initial level of 38 +/- 2.5 units/m2, P less than 0.001) with no significant change in cardiac index (2.73 +/- 0.17 versus 2.66 +/- 0.25 liters/min per m2, P greater than 0.10). Their heart rate, which was rapid initially (102 +/- 3.7 beats/min), remained unchanged during the hypertensive episode (103 +/- 3.0 beats/min). The mean rate of left ventricular ejection was not reduced by the increase in pressure and even tended to increase further in all but one patient. Central venous pressure (measured in all patients) and left atrial pressure (measured in eight patients) remained constant throughout the study in both Groups I and II. The results suggest that the mechanism underlying this type of hypertension is a generalized hemodynamic disturbance possibly related to overall sympathetic overdrive rather than the result of improved cardiac performance induced by myocardial revascularization.


Coronary revascularization under age 40 years. Risk factors and results of surgery. Groups of patients such as the elderly, the diabetic and women have been studied to evaluate the effectiveness of coronary revascularization. In this report 77 patients under age 40 years undergoing coronary revascularization were studied. There was a high prevalence rate of predisposing factors. Sixty-eight percent reported a family history of heart disease and 27 percent a history of diabetes; 57 percent were hypertensive, 43 percent were overweight, 91 percent smoked, 5 percent were diabetic and 16 percent had abnormal glucose tolerance curves. Sixty-four percent had hypercholesterolemia (cholesterol 250 mg/100 ml) and 56 percent hyperlipidemia. Forty-four percent had had a previous myocardial infarction; 95 percent had angina pectoris, 12 percent preinfarction angina and 9 percent congestive cardiac failure. There were no operative deaths. The incidence rate of perioperative myocardial infarction (new Q waves in the electrocardiogram) was 4 percent. The mean length of of follow-up was 26 months (range 6 months to 5 years). The late mortality rate was 4 percent. Eight percent had a late myocardial infarction. Overall graft patency was 85 percent. Sixty-seven percent of patients were free of angina, and 17 percent were in improved condition. Seventy-one percent returned to work, while 29 percent remained unemployed. This study shows that in young patients, coronary revascularization is associated with low mortality and morbidity rates and that, despite the wide prevalence of predisposing factors, the prognosis and graft patency rate of these patients are similar to those of other groups.


Echocardiographic features of total anomalous pulmonary venous connection to the coronary sinus. Six infants with anomalous connection of the pulmonary veins to the coronary sinus were studied with single crystal echocardiography. The posterior left atrial wall echo was identified by its continuity with the left ventricular posterior wall echo during a sweep from the left atrium to the left ventricle. In five of the six infants an echo-free space measuring 7 to 9 mm was identified behind the posterior left atrial wall; this space was thought to represent the common pulmonary vein. In four of these five, and also in the remaining infant, a highly mobile linear echo with a double wave form per cardiac cycle was recorded behind the posterior aortic wall and anterior mitral leaflet echoes. Echocardiographic contrast studies after the injection of saline solution into the coronary sinus disclosed that this additional echo was produced by the anterior wall of the coronary sinus. The anatomic connection of the pulmonary veins were established in each patient with pulmonary cineangiography. In four of the six patients all four pulmonary veins were connected to the coronary sinus by way of a common pulmonary vein; in the remaining two patients three of four pulmonary veins were connected to the coronary sinus, while the left upper lobe pulmonary vein was connected to the left innominate vein. The coronary sinus was greatly enlarged in each patient.


Elective mapping and surgical division of the bundle of Kent in a patient with Ebstein's anomaly who required tricuspid valve replacement. A 14 year old girl with Ebstein's anomaly and Wolff-Parkinson-White syndrome without supraventricular tachycardia underwent closure of an atrial septal defect and tricuspid valve commissurotomy. Her postoperative course was complicated by her first episodes of recurrent debilitating paroxysmal supraventricular tachycardia. Severe tricuspid insufficiency with low cardiac output necessitated a repeat intracardiac operation. At reoperation the patient underwent successful tricuspid valve replacement with concomitent cardiac mapping and division of the bundle of Kent. In patients with heart disease requiring intracardiac repair who also have Wolff-Parkinson-White syndrome, elective surgical division of the anomalous bundle is recommended whether or not preoperative attacks of tachycardia have occurred.


Effects of cytochalasin B on the fine structure of organized endodermal cells of the early chick embryo. Fresh pullet eggs (White Leghorn) were incubated for 36 to 48 hours. The blastoderms were exposed to cytochalasin B (CB), 10 or 40 microgram/ml, for 2, 5, and 15 minutes prior to fixation by immersion in buffered chick Ringers solution containing CB, previously dissolved in dimethysulfoxide (DMSO), or by sub-blastodermic injection. Controls fixed in ovo possess relatively flat surfaces with bulges due to uptake of yolk. Numerous microappendages (blebs, microvilli and ruffles) are present, especially at cell margins. DMSO-controls present a similar cell surface except that small blebs are more prominent. The plasmalemmas of CB-treated endodermal cells possess numerous large blebs (2-10 micron in diameter), smaller blebs (0.2 micron) and microvilli. Cell dissociation occurs in selected areas resulting in rounded cells, devoid of microappendages, with peripheral processes. Transmission electron microscopic preparations of tissues similar to those used for scanning electron microscopy reveal that large blebs are filled with membranous material. Microfilaments are present but lack their normal subplasmalemmal arrangement. Microtubules and other cell organelles are apparently unaffected by CB. Evidence in this study supports the concept that cytochalasin B exerts its influence through alteration of the plasmalemma.


Qualitative and quantitative morphologic study of Peyer's patches of the mouse after neonatal thymectomy and hydrocortisone injection. Peyer's patches in normal adult mice, neonatally thymectomized mice and mice injected with hydrocortisone were studied qualitatively and quantitatively by light microscopy. The patch was divided into germinal center, follicular area, parafollicular area and dome area. In normal mice, the volumetric ratio of the germinal center to the entire patch was 30.9%; that of the follicular area, 33.3%; that of the parafollicular area, 27.7%; and that of the dome area, 8.2%. Thymus-dependent small lymphocytes were 40% of small lymphocytes in the patch. Out of the total thymus-dependent small lymphocytes in the patch, 13% were included in the germinal center; 19%, in the follicular area; 62%, in the parafollicular area; and 6%, in the dome area. Hydrocortisone-sensitive small lymphocytes were 65% of the total small lymphocytes in the patch, the germinal center contained 9%; the follicular area, 84%; the parafollicular area, 2%; and the dome area, 5%. The epithelium over the dome area was invaded by numerous small lymphocytes. Forty-eight percent of lymphocytes within the epithelium over the dome were thymus-dependent and 67% were hydrocortisone-sensitive. It is concluded that Peyer's patch may be considered as a peripheral lymphatic tissue, functionally as well as morphologically.


A study on the blood vascular system of the lamprey gill filament. The blood vessels in the gill filaments of lamprey, Lampetra japonica, were studied with an electron microscope. Each gill filament is supplied by an afferent filament artery (afa) flanked by a pair of filament veins (fv), along the outer border of the axial plate, and an efferent filament artery (efa) along the inner, free border. Between these arteries are interposed the cavernous body and the blood lacunae. The marginal channel arises from the cavernous body, which leads to the afa, runs along the free border of the secondary lamella collecting oxygenated blood from the lamellar blood lacunae, and finally joins efa. This channel is considered to play an important role in the gill circulation as a bypass between afa and efa. Pillar cells were found only in the blood lacunae of the axial plate and the secondary lamellae. The basal lamina is generally absent on the vascular wall, but only a small amount of dense material could be seen on the basal surface of endothelial cells of afa and fv: this is regarded as an anchoring device between the cell and connective tissue fibrils. Fenestrations are generally absent in the endothelial layer but numerous gaps were seen in the wall of fv. Arterio-venus anastomoses were found between afa or the cavernous body and fv, and between efa or the collecting arteries of the efferent branchial artery and the peribranchial venous sinus. The anastomosing channel consists of the inner endothelial layer and the outer smooth muscle layer, which is thicker in the intermediate portion of the channel. The endothelial cells called "AVA cells" here are characterized by (1) dense cytoplasms, (2) apical microvilli and (3) basal cytoplasmic processes closely associated with smooth muscle cells.


The spiral constrictor of the gastroesophageal junction. The gastroesophageal region was reconstructed from the histological analyses of five human newborn infants. In addition, the nusculature of eight (3 newborn and 5 adult) human stomachs obtained from autopsies, with the lower one-third of the esophagus attached, was dissected with the aid of a binocular dissecting microscope. The muscularis mucosae, in the region of the gastroesophageal junction, exhibited no increase in thickness, nor was there any indication of special mucosal folds. In addition, the gastroesophageal junction contained no morphologic evidence that would support the existence of an anatomic sphincter (a localized thickening of circular muscle fibers). However, the obliquely arranged inner circular muscle fibers of the esophagus separated into fascicular bundles below the esophageal opening. Some of the fasciculi, as they descended, again became circular in shape and continued into the stomach, forming the middle circular muscle layer, while other fasciculi maintained their oblique course toward the left surface of the esophagus. These fasciculi, coursing on the anterior and posterior surfaces of the esophagus, crossed and interdigitated along the left surface of the esophagus in the region of the incisura cardiaca. After crossing, the oblique fasciculi descended into the stomach forming the inner oblique muscle layer. Based upon this description of crossing and interdigitating fasciculi, it is suggested that closure of the gastroesophageal junction may be due to contraction of spirally arranged muscle. Since the term "sphincter" generally implies a circular structure, it is proposed that the term "spiral constrictor" be considered in naming this anatomical arrangement.


Effects of therapeutic radiation on microstructure of the human mandible. Mandibular bone from eight patients who had received therapeutic radiation (6,000-7,200 rads) for intra-oral cancer was obtained at surgery (1 month to 9 years after radiation) and compared histologically with non-irradiated mandibular bone from five subjects. Measurements made on the internal remodeling process of cortical bone included the extent of internal surface and the fraction indicating resorption, and the proportions of osteones which were incomplete (less than 3/4 filled with matrix), complete, and plugged. Appreciable differences were observed in all parameters except plugged osteones. The findings suggested early cessation of osteogenesis, and somewhat later cessation of resopriton, without subsequent resumption of either process. The histologic appearance of the osteoblasts, osteoclasts, and osteones was in accord. Microfractures found in the irradiated bone were not seen to have healed. Radiation damage to the osteoprogenitor cells is postulated.


The luminal surface of thyroid cysts in SEM. Four of the five kinds of cells constituting the walls of thyroid cysts can be identified in the SEM. These are cuboidal cells, mucous cells, cells with large granules and ciliated cells. A correlation between SEM and TEM observations is attempted.


Elimination of multiple innervation in the developing avian superior oblique muscle (1). Motor endplates in the developing avian superior oblique muscle first appear on day 18 of incubation. Most of the endplates from this time through hatching (day 27) are innervated by multiple fibers. Each endplate in the post-hatching period is innervated by only one fiber. Time of elimination of multineuronal innervation does not correlate with the time of trochlear neuron loss; the former occurs much later in development. Removal of multiple innervation is therefore, not the cause of the naturally occurring neuron loss.


The use and application of autopsy in research. The only limit to the use and application of the autopsy in research is the imagination of the investigator. As pathologists, it would appear that we have really neglected this powerful tool in recent decades and have undersold the potentiality of this method. As we hope to have made evident by the foregoing discussion, the field of research utilizing autopsy tissues is truly as broad as medicine itself, and if developed properly, becomes an indispensable part of the fabric of on-going research in areas of carcinogenesis, environmental disease, atherosclerosis, and aging.


The autopsy--benefits to society.

The autopsy--benefits to society. The autopsy has immense value to society but only when it is performed by interested, experienced pathologists who are asking questions relevant to today's world and who are utilizing imaginative approaches to the development of data to answer these questions.


Caveat prosector: the pathologist and autopsy law. For more than five centuries autopsies have contributed to the improvement of health care. To support this purpose, society has modified the laws governing the dead body. While the police power of the state authorizes some autopsies, most are performed in hospitals and are governed by the common law as locally modified. The use of living tissues and organs from dead bodies has led to efforts not only to redefine death, but also to regulate tissue banking, transplantation, and experimentation. These legal and social constraints must be recognized and respected by the autopsy pathologist.


Clinical management of father-daughter incest. A critical reexamination. The professional literature relevant to child incest cases is reviewed. Four questions related to clinical management are examined. Although physical separation of the offending parent and child is typically recommended, there is insufficient evidence to support the belief that an incestuous relationship per se is inevitably harmful to the mental health of the child. It is suggested that exclusive focus on the sexual relationship can sometimes prevent the clinician from providing maximum assistance to the child and family. A representative case history is discussed.


Goldenhar's syndrome.

Goldenhar's syndrome. We present a report on 16 patients with Goldenhar's syndrome. The criteria we required for the diagnosis of Goldenhar's syndrome consisted of an eye abnormality (lipoma, lipodermoid, epibulbar dermoid, or upper eyelid coloboma) associated with ear, mandibular, or vertebral anomalies (two of the three). Although Treacher Collins' syndrome can be easily differentiated from Goldenhar's syndrome, the differences between Goldenhar's syndrome and hemifacial microsomia are more difficult to delineate.


Sickle cell anemia and transposition of the great vessels. A child with homozygous sickle cell disease and transposition of the great vessels had erythrocytosis associated with markedly increased plasma erythropoietin activity. Her clinical course was complicated by neurologic manifestations but not by recurrent sickle cell vasooculsive episodes. The fetal hemoglobin level which had been greater than 25% during the first two years of life gradually decreased to less than 10%. She died at 3 years of age of congestive heart failure and severe anemia. The only sickle cell painful crisis occurred during her terminal illness. It is likely that the high levels of fetal hemorglobin decreased sickling and thus allowed erythrocytosis to develop. Fetal hemoglobin may also have prevented frequent vaso-occlusive events despite the high hematocrit level.


Relationships between child-rearing styles and child behavior over time. We investigate the hypothesis that "authoritarian" styles of child rearing will lead to more home and school problems than will "accommodative" styles. One hundred thirty-five children have been followed up from age 2 into first grade. Follow-up observations show no significant differences between groups on any of the scores indicating malfunctioning for boys or girls at home or school. However, the home behavior of boys being raised with accommodative styles was described in more positive terms by their mothers than those raised with authoritarian styles. The accommodatively raisded girls were described in more positive terms by their first grade teachers. We found no evidence in this study that the permissive style is producing large numbers of "spoiled brats" nor that the authoritarian styles are producing large numbers of overly aggressive or inhibited children. The way parents handle authority relationships is not sufficientyl predictive of later problems to warrant any widespread attempts by physicians to change them. The physician should respect individual differences in child-rearing syle and only intervene where there is substantial evidence that a particular approach is having a harmful effect.


Retinoblastoma and subband deletion of chromosome 13. Two patients with retinoblastoma and an interstitial deletion of the long arm of chromosome 13 were studied using G-banded metaphase and prophase chromosomes. One patient showed several congenital defects, developmental retardation, and deletion of bands q14 and q21. The second patient showed mild developmental delay, a few minor congenital defects, and a loss of approximately half of band q14. On the basis of this study and nine others from the literature, it is now possible to tentatively assign a predisposition to retinoblastoma to deletion of a specific small region of chromosome 13.


Evidence for reinstatement of infants 12 to 14 months of age into routine measles immunization programs. The hemagglutination inhibition (HI) serologic responses of 851 measles-susceptible infants and children to the live, further-attenuated measles virus vaccine were evaluated over a ten-year period. The response by age at 23-day intervals was determined. Infants inoculated at 12 through 14 months of age demonstrated seroconversion rates by HI assay comparable to those in infants and children inoculated at 15 months of age or older. This finding does not support the recent recommendation that routine active immunization with measles vaccine should be postponed until 15 months of age. We emphasize the possible consequence of electively leaving infants 12 throught 14 months of age vulnerable to measles because of the current endemicity of this disease in the United States. We also present evidence for the reinstatement of infants 12 through 14 months of age into routine measles immunization programs and for the need to further evaluate the causes for vaccine failure in vaccines after the loss of maternal antibody.


Cystic fibrosis presenting with the meconium plug syndrome. The meconium plug syndrome (MPS) is a common cause of low intestinal obstruction in newborn infants. Usually, it is benign and not associated with other intestinal dysfunction. We describe the cases of three infants in whom there was intestinal obstruction consistent with the MPS and in which cystic fibrosis (CF) was later documented. We suggest that there is an association between the MPS and CF, and that the condition of all infants with the MPS be evaluated for the possibility of both Hirschsprung's disease and CF.


Biological bases of psychological sex differences. The mammalian process of sexual differentiation is briefly outlined. It is argued that in becoming girl or boy there are certain constraints and biases placed on the developing individual, some of these stemming from physiological bases, others from sensory-perceptual ones. These bases in turn affect the salience environmental factors for the two sexes. The different "behavioral styles" of boys and girls are thus a consequence of the transaction between the environment and these predispositions. The psychosexual anomalies are reviewed as instructive cases. Differences in neural organization and cerebral asymmetry are considered as further evidence of sexual dimorphism in humans.


Medical care of the athlete.

Medical care of the athlete. Atheletics involve many health hazards for children. The possibility for injury is present and participation means a calculated risk. To justify the risks, the benefits must outweigh the dangers. Sports, suitably engaged in, promote both physical and mental health. As pediatricians we become involved on two occasions: during the preseason examination to determine the child's fitness to participate, and when injury has occurred. Adequate examining means an understanding of what is involved to participate, promoting safety standards, and equitable competitive situations.


Evaluation of the professional communications of a pharmacist in a 45-bed rural hospital with comprehensive pharmaceutical services. The professional communications of a pharmacist providing comprehensive services were studied to determine the accuracy of the information provided, its usefulness to patient care and the level of expertise needed to respond appropriately. Data were collected by a diary technique for a four-month period. Patient charts were reviewed to collect clinical data needed to evaluate the appropriateness of the pharmacist's responses and to ascertain evidence that the information provided was implemented. The analysis classified the communications as either "clinical" or "pharmaceutical" in content. Practitioner panels of pharmacists and a physician assessed the communications for accuracy, relevance to the patient episode and level of pharmacy expertise necessary to communicate. Most communications with physicians were "pharmaceutical" in content. The most frequent information asked concerned dose or dosage schedule. Approximately one-third of the "pharmaceutical" communications could have been handled adequately by a technician. Only one communication should have required an extensive literature search for the pharmacist to respond. Less than half of the pharmacist's communications were pertinent to the patient episode and of clinical importance. Information from half of the communications was implemented in patient care within 48 hours. There did not appear to be any relationship between accuracy of response and implementation of information. It is not known whether the deficiencies identified apply to a large number of pharmacists. Hence, the bearing of the study on the cost-benefit of clinical pharmacy services is not clear.


The hospital pharmacist: master or victim of the environment? The results of an investigation into role perceptions and expectations of hospital pharmacists are reported. The Locus of Control Scale which taps a personality attribute associated with beliefs about personal control over the environment was administered to 443 practitioners and students. It was found that hospital pharmacists are significantly more internal (masters rather than victims of the environment) than pharmacy students, other students and the general population. Implications of this finding are discussed in light of changing roles of pharmacists in the delivery of health care and the evaluation of pharmacy education. It is suggested that hospital pharmacists are well suited to the role of change agent, but that certain cautions are indicated in selecting strategies for change.


Drug use in a day treatment center.

Drug use in a day treatment center. The medication therapy of participants in a day treatment center was reviewed and evaluated. Medication data from patient or family interviews, physician records, and center records were correlated. Prescription drug use was low (three to four medications per patient). However, when nonprescription drugs were included in the data, drug use was much higher (greater than 11 drugs/patient). Patient compliance was 90% or greater. Specific recommendations for drug use review and control in a day treatment center are given.


Use review of nutritionally complete liquid diets. A study was conducted to determine the manner in which semisynthetic fiber-free liquid diets and complete oral liquid diets were being used in a large teaching hospital, and to determine the influence of the establishment of a dietary formulary and guidelines on prescribing. A use review of the dietary formulations was conducted both prior and subsequent to the publication of the formulary and guidelines. Ninety-five patients were monitored on 22 adult medical, surgical, psychiatric and gynecological divisions. The inappropriate or questionable orders for all types of dietary formulations decreased from 65% to 52% after the publication of the formulary and guidelines. There was a significant decrease (p less than 0.005) in orders for semisynthetic fiber-free diets, from 34 to 4, after publication of the formulary and guidelines. The guidelines and formulary appeared to have caused the decreased use of the diet formulations and to have aided in eliminating less than optimal prescribing of the products.


Centralized intravenous admixture program for nine British hospitals. The development of a centralized i.v. admixture service for nine British hospitals is described. Emphasis is placed on strict aseptic technique. Production of admixtures is limited only to those situations where i.v. administration is positively indicated.


Management stretegy for the diffusion of innovation: unit dose drug distribution. The concepts of the change agent and opinion leader are explored as means to aid the pharmacists in affecting the diffusion of an innovation such as unit dose. A four-part model which describes one possible management strategy for the diffusion of innovation into the organization is presented. The effect of changes in the environment of hospital pharmacy, which may result in the recognition of performance gaps and thus stimulate the introduction of innovation, is discussed. Aspects of diffusion of an innovation--supplying the appropriate information, the knowledge function; creating a positive attitude toward the implementation of the innovation, the persuasion function; the adoption or rejection of the innovation, the decision function--are explained. The successful diffusion of an innovation requires a conscious management strategy, such as the four-component model discussed in this paper.


Computerized controlled drug inventory system. The development and use of a computerized system for controlled drug inventory is described. The system configuration, processing and report programs are discussed. The system is capable of producing reports on controlled drug prescriptions and receipts, current balances, and close-out inventory levels, as well as patient use and physician screens. This flexible system, developed with limited hardware, has the ability to provide up-to-the-minute accounting of controlled drugs.


Rationale for patient package inserts.

Rationale for patient package inserts. The need for patient package inserts (PPIs) is discussed in terms of the "consumers' right-to-know" and "patient health education" themes, as well as the premise that verbal means of communication are often inadequate. Some of the reasons for the frequent failure of verbal messages are reviewed by detailing the five stages through which any communication must be processed in order to be effective. Verbal information may be inadequate because: (1) patients are not exposed to necessary material, (2) they may not pay attention to the information, (3) they may not understand it, (4) the information may not be accepted as valid, and (5) patients may not remember the material. Written communication which must be processed through the same five stages also may be frequently inadequate. Therefore, PPIs must be viewed as reinforcing and augmenting verbal consultation, and both written and verbal forms are necessary. Consumer surveys and demonstration projects have shown that written communications are a desired and effective means for conveying additional prescription drug information to patients. The wide implementation of PPIs is apt to cause many problems for the pharmacists; however, it may also serve as a means to enhance the pharmacist's clinical role.


Harvey A. K. Whitney Lecture: Patient accountability--pharmacists' future. A philosophy of pharmacy practice is expressed, centering on service and accountability to the patient. To attain the goal of comprehensive pharmaceutical services, one must consider the factors of the environment and the characteristics of individual pharmacists. Aspects of the environment include support by the hospital administration and medical staff, and team cooperation among pharmacists and among all health professionals. Individual motivation to perform must be based on service to the patient. It is suggested that economic justification of pharmaceutical services should be a major goal of pharmacy organizations. The problem of employment opportunities for young pharmacists is discussed. The future of pharmacy practice is bright if pharmacists center their activity around the patient and become accountable for patient services.


Compliance clinic: an opportunity for an expanded practice role for pharmacists. The development and operation of a pharmacy-based clinic providing specialized services to noncompliant patients is described. Physicians refer patients who are not complying with their medication regimens to the pharmacy. The pharmacist interviews the patient to determine the reasons for noncompliant behavior and to reinforce the need for taking medications as directed. Special packaging, such as unit-of-use, may be used to encourage compliance. Medication calendars also are employed. The program has yet to be evaluated fully, but it is concluded that the compliance clinic has permitted the growth of comprehensive pharmacy practice.


Comparison of selected intravenous infusion pumps and rate regulators. Selected intravenous infusion pumps and rate regulators were compared to determine the relative advantages and disadvantages and to formulate guidelines for purchase of these devices. Three basic types of devices were studied: infusion rate regulators, nonvolumetric (peristaltic) infusion pumps and volumetric infusion pumps. Simple syringe-type infusion pumps were not studied. After use and close study of the devices, both in the laboratory and in the clinical area, desirable features were identified. Ideally, the infusion device should operate over a wide rate range, use standard administration sets, be easy to assemble and service, have an internal battery of good power for several hours, have appropriate malfunction alarms, have an automatic keep-open device in alarm situations, be accurate under a variety of situations, and be easy for the nurse to understand and operate. All devices tested were accurate within the limits claimed by the manufacturer, although a couple of models have features which can cause gross volume errors. Overall evaluation resulted in preference of some devices over others. Cost of infusion devices and administration sets can vary widely, and this should be a factor in the final choice of intravenous infusion equipment.


Stability of carbenicillin and oxacillin frozen in syringes. The stability of carbenicillin disodium and oxacillin sodium following storage in syringes for three months at -20 C was studied. Employing a spectrophotometric assay, it was found that carbenicillin (2500 mg/ml) and oxacillin (200 mg/ml) remained stable in both glass and plastic syringes for three months when frozen at -20 C. Stability was not altered by storage in either glass or plastic, nor by the size of the syringe used. Although the results were favorable, additional evidence is necessary before the practice of freezing reconstituted carbenicillin and oxacillin in syringes is advocated.


Study of particulate matter in carbenicillin disodium using scanning electron microscopy and microbeam x-ray spectrography. A scanning electron microscopy membrane filtration study was conducted to determine the particulate contamination of samples of carbenicillin disodium which had been manufactured by bulk filling and by lyophilization. The bulk-filled product contained more contaminating particles than the lyophilized product. In both products, the number of particles increased logarithmically with decreasing particle size in the range measured (exceeding 0.1 micron). X-ray spectrographic analysis of particles larger than 0.5 micron revealed that the major particulate contaminates in both products were composed primarily of elements below atomic number 10. It is concluded that packaging of carbenicillin disodium by lyophilization of a solution results in significantly less submicrometer particulate contamination than packaging by sterile bulk filling of spray-dried powder.


Review of gentamicin therapy based on pharmacokinetics. The feasibility of using pharmacokinetic estimations of drug serum levels to evaluate gentamicin use was explored. A consecutive series of 40 adult patients who received nonprophylactic "piggyback" gentamicin therapy was retrospectively evaluated. Traditional factors in the evaluation of antibiotic use, such as identity of microbe and sensitivity to antibiotic, were monitored. Additionally, peak and trough drug serum levels were computed for each patient. These were compared with toxic serum levels and minimum inhibitory concentrations as reported in the literature. Certain factors, such as duration of therapy and existence of alternate antibiotic therapy, suggested less than optimal therapy in the study patients. However, computed serum levels revealed that the patients experienced both safe and effective peak and trough gentamicin levels. Only with the use of pharmacokinetic estimations of drug serum levels could a comprehensive conclusion be reached regarding the appropriateness of therapy. Gentamicin therapy was generally rational in the study group. The use of pharmacokinetic principles in the calculation of serum levels may be a useful tool in drug use studies.


Tested tips for interviewing technician applicants. Suggestions for pharmacists interviewing technician applicants are given. An outline of methods to make interviews more productive and suggested questions to be discussed is presented.


ASHP guidelines for scientific research in institutional pharmacy. For institutional pharmacy to continue to be successful it must be able to adapt to an ever-increasing rate of change. The best type of scientific thinking will be required to attempt to understand these changes and to keep the profession relevant.


Overview: foundations of cultural psychiatry. The authors demonstrate the significance of adding the cultural dimension to basic psychiatric concepts. They point out the areas in which the work of anthropology and social psychology are relevant to psychiatry, including understanding mental health and illness, child-rearing practices and their effects on personality, cognition, family and social networks, sex roles and behavior, alcohol use, communication, and therapy. They also present some of the major conceptual foundations of cultural psychiatry, which include ethnography, emic and etic approaches, the cross-cultural approach, and the study of subjective culture.


A new method of classification for psychophysiologic disorders. The authors suggest that there are a number of shortcomings in DSM-II's classification system for psychophysiologic disorders, which lists this group of disorders as a distinct group of diseases different from other organic diseases. They propose a new, multiaxial method of classification in which the clinician could indicate the role of psychological factors in the initiation, exacerbation, or maintenance of any physical disorder. This method would make it possible for the first time in psychiatric nomenclature to indicate a clinical judgment of the importance of psychological factors in all physical disorders rather than focusing on a small group of illnesses traditionally regarded as psychosomatic or psychophysiologic.


Cocaine hallucinations.

Cocaine hallucinations. The author reviews the literature on hallucinations that occur as a result of acute and chronic administration of cocaine. He examined the phenomenology of cocaine hallucinations in a group of 85 recreational cocaine users, 15 of whom reported hallucinatory experiences in visual, tactile, olfactory, auditory, and gustatory modalities. He discusses a new phenomenon of "snow lights" in terms of initiating a progression of symptoms leading to the classic "cocaine bugs." He also points out the similarity of cocaine hallucinations to entoptic phenomena and migraine hallucinations, which suggests a common mechanism of action based on CNS excitation and arousal.


Utilization and cost of mental illness coverage in the Federal Employees Health Benefits Program, 1973. The authors examine the utilization of mental illness benefits under the Blue Cross/Blue Shield and Aetna plans for federal employees; the latter plan sharply cut back its mental illness benefits in 1975. In 1973 mental illness benefits represented 7.4% of all payments under the Blues plan and 12% under the Aetna plan. The benefit for mental illness treatment under the Blues averaged $12.52 per person covered and was 7.3% of the total benefits for all conditions. Younger enrollees and their spouses tended to receive mental illness benefits primarily for outpatient treatment and children and older adults for hospitalization. These data raise key questions for claims review and peer review activities.


The bent twig: psychiatry and medical education. The authors note that an increase in psychiatry's involvement in the selection and education of medical school students, which historically has been limited and problematic, would benefit both the discipline and the profession in general. There is evidence indicating the need to pay attention to personal attributes in medical education, particularly in light of the incidence of problems in physicians (e.g., addiction, alcoholism, and suicide) that fall within psychiatry's area of expertise. Active participation by psychiatry in medical education might also help combat the cynicism that seems to develop during training and might contribute to consideration of ethical issues and to the fostering of emotional maturity.


Observations on the theoretical bases for seclusion of the psychiatric inpatient. Contemporary controversy concerning the seclusion of psychiatric inpatients is focused primarily on the issues of civil rights and behavior control. The author believes that we are in danger of losing sight of the therapeutic aspects of this treatment modality. He offers a brief review of the theoretical and clinical rationale for seclusion.


Prediction of individual dosage of nortriptyline. The authors describe a technique that enables a physician to determine individual patient dosage requirements for nortriptyline from a single 24-hour blood sample. Because the technique reveals immediately those patients at the extremes of dosage ranges, toxicity and the need for time-consuming titration of the dosage regimen can be avoided.


Lithium erythrocyte/plasma ratio as a predictor of response. The authors measured RBC/plasma lithium ratios in 33 patients with primary diagnoses of unipolar depression (N=20), bipolar depression (N=9), schizo-affective psychosis (N=2), and alcoholism (N=2). Subjects rated as having marked or moderate improvement at follow-up (average = 17.1 months) tended to have high ratios (greater than or equal to .41), whereas all 9 patients rated as minimally improved were in the low-ratio group. Although further research with larger samples, controls, and longer follow-up is necessary, the results suggest a predictive value for the RBC/lithium ratio.


The evolution of psychiatric services in a health maintenance organization. The authors describe a prepaid mental health service program in which outpatients referrals were 34.7 per 1,000 members per month, the hospital admission rate was .80 admissions per 1,000 members per year, and the average length of hospital stay was 5.03 days. They offer several explanations for their finding that the costs for mental health services in this program appear lower than those in fee-for-service programs.


Children of dialysis patients and selection of dialysis setting. The authors interviewed hemodialysis patients, their families, and medical staff and found that some patients preferred dialysis at a medical facility, which allowed them to appear more "normal" before their children. Patients with more social support involved their children in dialysis at home. The author suggests that social support is of primary importance to the outcome of home dialysis and should be considered by physicians in the assessment of patient's suitability for home dialysis.


The failure to detect low IQ in psychiatric assessment. The authors assessed the IQs of 188 hospitalized psychiatric patients and found that 27 (14.4%) had IQs of 85 or less. However, the psychiatric records of 22 of the patients with low IQs showed that only 5 contained any mention of level of intellectual functioning. These findings suggest that a variable of major importance for diagnosis and treatment planning is often ignored.


Dystonia: a disorder often misdiagnosed as a conversion reaction. The authors studied the records of 84 patients who had idiopathic torsion dystonia. Thirty-seven cases had originally been misdiagnosed as primarily psychiatric illness. Only 1 patient presented with dystonic movements that were clearly part of a more general psychiatric disorder. The authors believe her to be the first reported patient whose dystonia is undeniably of psychogenic origin.


The decision to hospitalize.

The decision to hospitalize. The authors explored determinants of psychiatric hospitalization in four Manhattan general hospital emergency rooms and found that although the nature and severity of a patient's problem played the most important role in the decision to hospitalize, the facility involved was also a determining factor. The findings are discussed in relation to policy concerning staffing and organization of emergency room services and future studies of service delivery in this area.


Becoming an administrator: the vicissitudes of middle management in mental health organizations. Middle management has been a conceptually neglected and operationally abused position in the administrative hierarchy of mental health organizations. The position is viewed as a preparatory exercise for executive responsibility, and frequent changes disrupt service delivery. The author describes the responsibilities, hierarchical role relationships, rewards, and constraints of middle management positions. Health care professionals must actively seek and retain these positions if they wish to maintain their place in directing the work of mental health institutions.


Effects of social disincentive policies on fertility behavior in Singapore. Five social disincentive policies were implemented by the Singapore government in 1973 to augment its fertility reduction program. The policies involve increasing delivery charges in government hospitals, school admission priority for children, maternity leave, priority in allocation of government housing, and income tax relief. In a two-year prospective study, 1,010 married abortees (study group) and 943 married parturients (comparison group) were questioned to determine their awareness and understanding of these policies, and whether the policies influenced their decision concerning their present pregnancies or would influence future decisions. Except for the tax policy, these disincentives were known to a fairly large proportion of the women studied. Knowledge was positively related to education level. Four of the five disincentives have, to varying degrees, influenced the women's decisions concerning their present pregnancies and may do so in future pregnancies. The two most widely known and most influential disincentives are those affecting school admission priority and accouchement fees.


Efficacy of screening for cervical cancer: a review. Cytologic screening for cervical cancer currently enjoys wide acceptance, but there remains controversy in the literature concerning its efficacy in prolonging life. On the basis of a literature review, several conclusions are reached: 1) Cervical screening can identify women who are at greater-than-average risk of developing invasive cervical cancer by detecting asymptomatic lesions that would frequently progress to invasion if left untreated; 2) Therapy based on confirmed positive smears can reduce the incidence and mortality rates of invasive cervical cancer, as shown by declining rates in many centers that had constant or increasing rates before screening began, lower rates for geographic areas and occupational groups having less screening, and lower rates among screened women than unscreened women; and 3) Attempts to estimate the amount of life prolongation attributable to cervical screening have not yet yielded reliable figures, because of difficulties with the models or data used. However, in view of the available evidence, it is suggested that incomplete data should not prevent a vigorous continuation of screening where it is already extensive, and an escalation where it is not.


The Woodlawn mental health studies: tracking children and families for long-term follow-up. Elementary school children in a large public urban school system (Chicago) can be tracked into adolescence, together with their families, by using student numbers established by the Chicago Public Schools. This paper reports on the linkage between a psychiatric follow-up study and the data bank of the Chicago Public Schools. The authors were able to find information about the location and grade placement of 87% of an urban ghetto neighborhood's first grade children after a seven to ten-year lapse in contact. The children about whom information was found did not differ from those missing in the early measures of their school achievement and psychological wellbeing. However, first grade measures of school success of failure did relate to grade placement of children ten years later, as did first grade ratings of bizarreness.


Treating obesity in children and adolescents: a review. Researchers and health practitioners are becoming increasingly concerned with the problems associated with obesity among children and adolescents. Obesity tends to persist into adulthood and to be associated with a variety of physical and psychological problems. Treatment approaches used to date are generally impotent, but some promising short-term results have been achieved with some forms of dietary counseling, exercise programs, total environmental management, and behavior therapy. But even with these strategies, clinically significant weight loss is rare and advances during treatment are rarely maintained. Radical departures from current treatment strategies are needed in the form of more structured and intensive treatments, family involvement, and training in problem solving. Closer adherence to sound scientific methodology might at least provide a foundation from which more effective treatments might be developed.


An outbreak of bovine cysticercosis in California. Approximately 4.75% of the animals sent to slaughter from a southern California feedlot during a 9-mo period were found to be infected with the cysticercus of Taenia saginata. An investigation of possible transmission sources revealed that the feedlot was the most likely site of infection. One feedlot worker was found to be infected with T. saginata, and the pen infection patterns and other physical relationships indicated that he was the source of infection. The following recommendations were made: 1) treatment of the infected worker; 2) education of employees as to the mode of transmission and personal hygienic practices; 3) addition of sanitary facilities; 4) maintenance of animal source and destination records; 5) inauguration of a surveillance program to include parasitologic examination of employees prior to employment and periodically thereafter; and 6) restriction of unauthorized personnel from critical areas.


Vibrio parahaemolyticus enterocolitis in Bangladesh: report of an outbreak. In March 1974 eight men in Chandpur, Bangladesh, experienced an illness characterized by severe abdominal cramps, nausea, vomiting and bloody diarrhea with onset 20 min to 9 h (median 2.5 h) after eating one of two fish dishes at a restaurant. Rectal cultures from all eight grew Kanagawa-positive strains of Vibrio parahaemolyticus (serotype O3K5) that were negative in the Sereny test for invasiveness and the Y-1 adrenal cell and infant mouse assays for enterotoxin production. The short incubation, severity of abdominal cramps and grossly bloody stools distinguish this illness from that usually associated with V. parahaemolyticus infection in the United States.


Trachoma in a rural South African community. The prevalence of trachoma was studied in a representative sample of family units from a rural community. Evidence of current or previous infection was found in 82% of the total population, but there was a relatively low prevalence of intense upper tarsal disease. Most children acquire the disease within the first 3 yr of life, these primary infections having a tendency towards spontaneous cure without complications. The prevalence of active disease and potentially blinding sequelae is higher in elderly females than in males of the same age. Clinical and microbiological evidence suggests that trachoma is transmitted primarily within households in this community, the main source of infection appearing to be children of pre-school age. Chlamydiae were isolated from the eyes of children with intense upper tarsal disease, but not from elderly persons with similar clinical signs.


An epidemic of yellow fever in central Brazil. 1972-1973. I. Epidemiological studies. An epidemic of jungle yellow fever occurred in Goiás State, Brazil, between December 1972 and March 1973. Laboratory confirmed cases were observed in 36 counties located in the central and southern parts of the State. Seventy-one cases were proved, of which 44 were fatal. The diagnosis was made on the basis of pathology, serology, and virus isolation. Besides yellow fever, malaria and viral hepatitis were present, and in two fatal cases there was malarial pigment in the liver in addition to the specific lesions associated with yellow fever virus infection. The fact that male patients strikingly outnumbered females (9:1) and that young adults were predominantly affected indicates that transmission occurred mainly inside or adjacent to the forests. The lack of cases in urban areas can be attributed to the absence of Aedes aegypti in these areas. Yellow fever complement-fixing antibody in high titers was found in 18 of 1,201 (1.4%) persons living in eight counties of the affected area. This finding suggests that at least 21,000 persons out of the 1.5 million rural inhabitants of the three districts where the epidemic occurred had been infected by the virus. The epidemic subsided following an intensive vaccination campaign, and the last four cases were observed in March 1973.


Production of adjuvant-induced ascitic fluid in the white rat. A simple method of inducing ascites in the laboratory white rat by intraperitoneal administration of Freund's complete adjuvant is described. Female rats were found to produce ascitic fluid more reliably than males with an average volume yield of 60 ml per rat. The performance of immune rat ascitic fluids in complement fixation, hemagglutination-inhibition, neutralization and immunodiffusion tests was found to be excellent.


Laboratory studies of transovarial transmission of trivittatus virus by Aedes trivittatus. Aedes trivittatus were experimentally exposed through a membrane to a concentration of trivittatus (TVT) virus in dog defibrinated blood of 10(3.4)-10(3.5) SMICLD 50/0.025 ml. Transovarial and transstadial transmission was demonstrated. Fifty-five percent of the infected mosquitoes tested transovarially transmitted TVT virus. TVT virus was isolated from 16% of the F1 generation progeny examined, including 19% of the larvae, 23% of adult females, and 10% of adult males.


Venereal transmission of La Crosse virus from male to female Aedes triseriatus. Horizontal transmission of La Crosse (LAC) arbovirus in colonized Aedes triseriatus was first observed in mating cages. LAC antigen was visualized by fluorescent antibody technique in multiple organs of 5 (2.5% of 198 females dissected after contact in mating cages with males, with a transovarial infection rate of 31%. Venereal transmission of LAC virus was demonstrated by limited contact induced mating. Antigen was detected in bursal contents of 35 (53%) of 66 females dissected within 24 h after induced mating by males previously infected by intrathoracic inoculation. Antigen was observed in ovaries, heart, gut, salivary glands, or other organs in 13 (3.4%) of 379 females dissected 1 to 14 days post-mating. LAC virus was isolated from infected males, from contents of the bursa copulatrix of females following mating, and from dissection remnants of 6 of the 13 females in which disseminated antigen had been observed. Venereally infected females were shown to be capable of transmission of LAC virus by bite to mice and to eggs.


Treatment of giardiasis with tinidazole. Fifty-five patients, 51 males and 4 females heavily infected with Giardia lamblia were treated with a single 2 g dose of tinidazole (four tablets); 53 were cured. Of 20 other infected patients kept under the same conditions and given four placebo tablets, 18 continued to pass cysts or trophozoites in the stools during the whole 3- to 4-wk follow-up period in hospital. There were no side effects attributed to the drug.


In vivo effects of mebendazole and levamisole in the treatment of trichuriasis and ascariasis. The anthelmintic drugs mebendazole (Vermox) and levamisole were tested in patients for their possible ovicidal effects on the eggs of Trichuris trichiura and Ascaris lumbricoides. The patients studied were 20 Africans of Sierra Leone, and 11 children of Nassau, Bahamas. Egg counts were made before treatment, and for 5 consecutive days following treatment. Eggs were incubated in 2.5% aqueous potassium dichromate and percentages of larval development were determined. Mebendazole completely inhibited the development of the eggs of T. trichiura by day 3 of the follow-up period. The ovicidal action of mebendazole on the eggs of A. lumbricoides was determined to be 64.8% by day 5 of the follow-up study. Levamisole had little (11.6%) ovicidal action on the eggs of T. trichiura and no ovicidal activity for A. lumbricoides.


A case of occipital gnathostomiasis in Thailand. A large subcutaneous nodule present for 2 mo was removed from the occiput of a 26-yr-old Thai man and found to contain a male Gnathostoma spinigerum. Aside from the occipital location, a noteworthy feature of the case was the long stationary persistence of the stable, non-tender nodule.


Leptospirosis in zoo workers associated with bears. Leptospirosis due to Leptospira interrogans serovar icterohaemorrhagiae was diagnosed in two zoo animal keepers. The implicated source of infection was bear cubs that had microscopic agglutination antibody titers to leptospires of the Icterohaemorrhagiae serogroup.


Present status of kala-azar in Iran.

Present status of kala-azar in Iran. Sporadic cases of visceral leishmaniasis have been reported from all parts of Iran except the deserts and very arid zones in the southeast. About 120 cases have been reported up to the present time, the majority from the mountainous areas of the southwest. Most patients (76%) have been children under 10 years of age. The probable reservoirs of infection are wild carnivores, infection of man and dog being accidental. During a survey conducted in the Caspian area and northeastern part of Iran in 1970, 20 jackals and 10 foxes were shot; examination of smears from bone marrow and spleen showed the infection in a jackal (Canis aureas) and in a fox (Vulpes vulpes). On the basis of epidemiological evidence, Phlebotomus major is the probable vector of kala-azar in Iran.


A case of primary amebic meningoencephalitis. Light and electron microscopy, and immunohistologic studies. A 56-year-old alcoholic developed primary meningoencephalitis and died 3 weeks later. Autopsy revealed multiple areas of necrosis and acute and granulomatous inflammation in the brain and pancreas. Trophozoites and cysts were discovered in the brain and trophozoites alone in the pancreas. Morphologic studies revealed some parasitic features described as characteristic for Naegleria, but clinical, histological and immunohistological features favored in Acanthamoeba infection. This study calls for caution in the use of pure morphological criteria for the differential diagnosis of Naegleria and Acanthamoeba in humans. Cultural characteristics, immunohistology and serologic tests are probably more reliable for differentiating these parasites.


Strongyloides stercoarlis--hyperinfection. A case of severe Strongyloides stercoralis infection is described in a patient with renal failure due to bilateral cortical necrosis. Because thiabendazole, the drug of choice in strongyloidiasis, is primarily excreted by the kidneys, alternative therapy with a mebendazole was instituted. Although the patient eventually died as a result of the renal failure, successful therapy with mebendazole was well demonstrated.


An unusual outbreak of hookworm disease in North India. An unusual outbreak of hookworm disease occurred after a game of "kabaddi" (a local game which results in much body contact with the ground) in 27 young males from one village. It was characterized by an immediate incapacitating dermatitis, followed by severe pulmonary symptoms. Progressive weakness, abdominal pain, weight loss and anemia developed within a few months. Ancylostoma duodenale was found in all except four patients who had received antihelminthic treatment. Specific treatment for hookworm resulted in complete clinical recovery. Features of the outbreak were: 1) the hitherto unrecorded mode of infection; 2) severe dermatitis; 3) pulmonary symptoms lasting more than 3 mo; 4) abdominal symptoms suggestive of subacute obstruction starting 4-6 mo after exposure; and 5) severe disability with weight loss for a period of 1 yr until specific treatment was administered.


Larvae of Anisakidae in marine fish of coastal waters near Jakarta, Indonesia. Three species of marine fish were collected from the waters around Seribu Islands, near Jakarta, Indonesia, and examined for nematode larvae of the family Anisakidae. Larvae were found in 719 (49%) of 1.459 Rastrelliger kanagurta, 445 (50%) of 884 Decapterus russelli, and 217 (41%) of 531 Sardinella sirm. Larvae from a subsample of 150 infected fish, 44 R. kanagurta, 86 D. russelli, and 20 S. sirm, were examined microscopically and only Anisakis type I and Terranova type B larvae were found. In all three species of fish the Anisakis larvae predominated. The Anisakis larvae found in these fish are a potential source of infection for humans in Indonesia; however, human anisakiasis has not yet been reported from this country.


Immunization of mice with cobalt-60 irradiated Schistosoma mansoni cercariae. Parameters of immunization of mice with 60Cobalt-irradiated Schistosoma mansoni cercariae are described and related to protection against subsequent challenge infection. Such immunization was found to be dependent on dose of irradiation, number of immunizing cercariae, and number and time course of infections. Low levels of resistance were obtained with low irradiation doses, in contrast to previous studies in mice. In general, resistance increased with increasing irradiation doses, up to approximately 48-56 Kr. Maximal resistance (70-80%) was induced by a single exposure to 250-500 cercariae, irradiated at a dose rate of 2 Kr/minute to a total dose of 56 Kr, administered percutaneously 4-6 wk prior to challenge. Challenge could be delayed for at least 15 wk after immunization without a decrease in resistance. The resistance obtained was not attributable to a delayed migration of challenge worms.


Effect of immunization on migration of Schistosoma mansoni through lungs. Schistosoma mansoni schistosomula migrate through the lungs of infected mice; peak recovery occurs 6 days following infection. When cercariae were irradiated at 60Cobalt doses of 24 to 64 Kr, the number of schistosomula recovered from lungs 6 days after infection decreased in a dose-dependent fashion. The pattern of lung migration of schistosomes irradiated at 56 Kr prior to infection was similar to that of nonirradiated schistosomes, but greatly reduced numbers were recovered. When mice were immunized by a single infection with 56 Kr attenuated cercariae 6 wk prior to challenge, the pattern of challenge migration through the lungs was altered. The number of schistosomes recovered increased rapidly between 2 and 6 days post-infection, and showed a plateau between 8 and 10 days with peak recovery occurring 10 days post-infection. This peak recovery was reduced in comparison to that of non-immunized mice, but did not account for all of the reduction observed at the adult worm stage.


Hydatid disease screening: Sanpete County, Utah, 1971-1976. Between 1971 and 1976 approximately 20% (2,265) of the population of Sanpete County, Utah, was screened for hydatid disease (Echinococcus granulosus) by intradermal, indirect hemagglutination, and bentonite flocculation tests. Of 34 persons who had follow-up chest radiographs and radioisotope liver scans, 6 were found to have asymptomatic hepatic cysts. If a participant who had pulmonary cysts and negative screening tests were included, the prevalence of asymptomatic hydatid disease would be 3 per 1,000. During the same period, 82 (148 per 1,000) of 553 dogs successfully purged and examined had E. granulosus infections. Human cyst carriage was associated with dog ownership, particularly of infected dogs or in conjunction with sheep raising as the main livelihood. Combinations of immunodiagnostic tests were more efficacious in identifying cyst carriers than the tests used singly. Limitation of screening to high risk groups (e.g., sheep raisers with dogs) can reduce costs without reducing yield. Optimum management of the cyst carrier awaits further information on the natural history of asymptomatic hydatid disease.


Insulin-induced attenuation of glucose-stimulated gastric inhibitory polypeptide secretion. Administration of exogenous insulin before and after intraduodenal glucose results in blunting of the GIP response to glucose. Physiologic levels of serum insulin were attained. Therefore, the present study suggests the existence of negative feedback regulation of GIP release by endogenous insulin (pancreatico-GIP axis).


Prophylactic intraperitoneal povidone-iodine in alimentary tract surgery. In controlled experiments intraperitoneal povidone-iodine significantly reduced the mortality of mice (p less than 0.01) and rats (p less than 0.01) with induced peritonitis. Povidone-iodine irrigation of the rat colon before and after anastomosis did not interfere with healing or inhibit peritoneal adhesion formation. However, a newly formulated povidone-iodine solution containing increased PVP significantly reduced adhesion formation in a controlled study in rats.


Mesenchymal tumor hypoglycemia: the effect of a tumor tissue extract on the insulin and glucagon secretion from the isolated perfused porcine pancreas. Severe fasting hypoglycemia and hypoinsulinemia occurred in a sixty-six year old woman with an intrahepatic mesenchymal tumor. An extract from the tumor was potent in inhibiting the arginine-induced glucagon secretion from the isolated perfused porcine pancreas. This observation supports the theory recently advanced that mesenchymal tumor hypoglycemia in some cases is due to a still unknown factor secreted from the tumor, which directly inhibits pancreatic glucagon secretion.


Incidental cholecystectomy during major abdominal surgery in the elderly. Forty-four elderly patients with an average age of seventy-eight years were found to have cholelithiasis during unrelated major abdominal surgery. Thirty-nine of them underwent incidental cholecystectomy, one had cholecystostomy, and four had no surgical treatment of their gallbladder disease. Of the thirty-nine patients with an incidental cholecystectomy, none died and only sixteen had nonfatal complications. Of these complications, only one was clearly related to the cholecystectomy and resolved spontaneously. The results compare favorably with other reports of similar procedures in elderly patients. Incidental cholecystectomy does not seem to significantly alter the mortality and morbidity of elderly patients undergoing major abdominal surgery. We advocate incidental cholecystectomy for cholelithiasis in elderly patients as long as the gallbladder is easily accessible and the condition of the patient warrants the additional procedure.


Pancreatic pseudocyst: management in fifty-four patients. The management of pancreatic pseudocyst was reassessed in fifty-four patients: only sixteen (30 per cent) regressed with nonoperative management; six (11 per cent) died of septic complications; and thirty-two (64 per cent) eventually required operation. Most pseudocysts did not regress with nonoperative therapy, thus emphasizing the need of serial clinical and ultrasonic examination at frequent intervals to detect nonresolution or complications requiring earlier operation than previously advocated.


The role of percutaneous liver biopsy in the pretreatment evaluation of pancreatic adenocarcinoma. Percutaneous liver biopsies were performed on twenty-two patients with locally unresectable adenocarcinoma of the exocrine pancreas within a median of six weeks of laparotomy. Three patients (13 per cent) had positive biopsies obtained either blindly or at peritoneoscopy. Of these three patients, two had elevations in either alkaline phosphatase, direct bilirubin, or hepatic transaminase levels, and one of these two patients had an abnormal liver-spleen scintigram. Liver biopsies are recommended for all patients being evaluated for pancreatic resection either pre- or intraoperatively.


Relationship between postoperative temperature and survival in patients resected for colorectal cancer. The present study suggests that the prognosis of patients undergoing resection for colorectal carcinoma might be improved if there is an increase in body temperature during the postoperative period.


Surgical morbidity after mastectomy operations. The records of 146 consecutive patients with mastectomy operations over a three year period were reviewed. Of these, ninety-three (63.6 per cent) had one or more complications secondary to surgery. There were 175 complications, of which complications, of which 107 (73.2 per cent) were wound-related. Seroma formation occurred most frequently but was of minor consequence. The incidence of flap necrosis was 19.1 per cent, with cellulitis or suppurative infection appearing in thirteen patients. Immediate postoperative edema of the arm was fairly rare (2.7 per cent) and appeared related to delayed wound healing. Postoperative complications after total, modified radical, and radical mastectomy present problems unique from those seen after other major surgery, in that local complications predominate. The very nature of the procedure, with the creation of large thin skin flaps, extensive axillary dissection, and an open wound for a prolonged period of time, predisposes to wound morbidity.


Stroke associated with carotid endarterectomy. Between 1966 and 1976, eleven strokes occurred in association with 509 carotid endarterectomies performed at Walter Reed Army Medical Center. Contralateral carotid arterial occlusion with unilateral stenosis, bilateral carotid stenoses, or multiple extracranial (with or without intracranial) stenoses were present in all patients in whom stroke developed. Preventable technical factors contributing to or directly causing stroke were identifiable in six of the eleven patients. Better appreciation of the high risks associated with the above arteriographic patterns and elimination of technical mishaps should lead to an improvement in our already respectably low stroke rate of 2.2 per cent.


Amputations in peripheral vascular occlusive disease. One hundred consecutive patients undergoing major lower extremity amputations were critically analyzed over a five year period. The results of surgical care and the degree of success of rehabilitation were determined. The number of patients with peripheral vascular occlusive disease who require major lower extremity amputations appears to be increasing and they continue to present a challenge to the surgeon.


Effectiveness of reoperation after late failure of femoropopliteal reconstruction. Eighty-two femoropopliteal reconstructions were performed on sixty-six consecutive patients. Of seventeen late failures, thirteen were secondarily reconstructed. Clinical and angiographic studies demonstrated the reasons for failure in all patients except one. Seven patients were improved and six unimproved by reoperation. The best results were obtained when an inflow problem was found and there had been a long duration of initial patency.


Debridement: an essential component of traumatic wound care. The harmful influences of devitalized tissue on wound defenses are documented and the importance of wound debridement in the care of the traumatic wound is stressed. All devitalized soft tissues damaged the host's defenses and encouraged the development of infection. The capacity of divitalized muscle, fat, and skin to enhance infection was comparable. The infection-potentiating effect of skin was enhanced by exposing it to a dry thermal injury. The mechanisms by which devitalized soft tissue enhanced infection are several. The devitalized soft tissue acts as a culture medium promoting bacterial growth. In addition, the devitalized tissue inhibits leukocyte phagocytosis of bacteria and subsequent kill. Finally, the anaerobic environment within the devitalized tissue may also limit leukocyte function.


Cervico-occipital pain and its surgical treatment: the myth of the bony millstones. The proposal was made in 1949 that occipital neuritis/neuralgia was frequently of traumatic origin. The hypothesis was advanced that the C2 sensory root lay unprotected between the lateral masses of the atlas and axis and was vulnerable to squeezing on extreme extension or rotation of the head. This conjecture converted a hitherto banal neurologic affliction into the sequela of a banal trauma. Hence, it has been exploited in the diagnosis and treatment of whiplash injuries as well as for headaches of unknown origin. Evidence is presented that the original anatomic proposition was erroneous and that the C2 root is not exposed and is not vulnerable. Indeed, a survey of the "worst" traumatic and pathologic disruptions of the craniospinal junction shows that although they would be expected to injure the C2 root, in fact, they do not. The theory as well as the operations based upon it, particularly intradural section of the C2 root, should be abandoned.


Serum gastrin levels in the differential diagnosis of recurrent peptic ulceration due to retained gastric antrum. If recurrent peptic ulceration follows partial gastrectomy with Billroth II reconstruction, retained antrum on the duodenal stump may be the culprit. Moderate hypergastrinemia and a high basal acid output (BAO) to maximal acid output (MAO) ratio on gastric analysis should alert the clinician. Careful filling of the afferent loop on barium meal or technetium 99m scanning may verify the diagnosis. The secretin provocative test may be helpful in distinguishing retained antrum from the Zollinger-Ellison syndrome by eliciting a decrease in serum gastrin levels in patients with retained antrum and an increase in serum gastrin levels in patients with Zollinger-Ellison syndrome.


Gangrene of the stomach: a case of acute necrotizing gastritis. Of the several causes of gastric necrosis, the rarest is acute necrotizing gastritis which appears to be a variant of phlegmonous gastritis. In acute necrotizing gastritis all four major gastric vessels are patent, but gastric gangrene occurs secondary to an over-whelming necrobiotic infection. The case presented herein is of unusual interest because it appears to be only the third reported case of acute necrotizing gastritis with overt gangrene of the stomach. Review of the literature on suppurative gastritis emphasizes the rarity and high morbidity of acute necrotizing gastritis; the patient reported on in this study, however, survived after subtotal gastrectomy and antibiotic therapy. It is our opinion that debridement by gastrectomy must be performed in those patients with transmural, diffusely infected, nonviable gastric tissue.


Common bile duct stricture repair with serosal onlay technic. To our knowledge this is the first reported patient in whom the technic of serosal onlay for biliary stricture was applied successfully. The approach proved easy and satisfactory, and we plan to continue its use in similar cases.


Transabdominal bone biopsy during staging laparotomy for Hodgkin's disease. A bone marrow biopsy is one of the recommended components of the exploratory laparotomy performed for the staging of Hodgkin's disease. A simple method is described for obtaining a full thickness biopsy of the ilium via the laparotomy incision using the Cloward drill.


Pilonidal cyst: an operative approach.

Pilonidal cyst: an operative approach. An operative technic is presented which has been used on fifty-four patients with pilonidal cyst. This technic has resulted in primary union and complete healing within six weeks in 89 per cent of cases. The use of an incision that crosses the vertical gluteal fold at an angle and eliminates the suture line in the gluteal fold has been beneficial in all patients on whom it was used.


The axillary artery to axillary vein bovine graft for circulatory access: surgical considerations. The bovine graft axillary artery to axillary vein fistula provides a simple method of circulatory access. This method is reserved for patients in whom Cimino arteriovenous fistulas or looped grafts have failed. The grafts are easy to cannulate, flow is excellent, and the patients adapt to it very promptly.


Restoration of pharyngoesophageal continuity with a replaceable prosthetic conduit: a new method. Treatment of carcinomas of the upper aerodigestive tract by high dose radiation and wide surgical resection result in large tissue defects. When the inferior pharyngeal constrictor and the cricopharyngeus muscles are removed, a replaceable prosthetic conduit can be used effectively to reestablish pharyngoesophageal continuity. This prosthesis can be readily fabricated and obviates the need for extensive reconstructive operations in suitable candidates.


Observations on the pathogenesis and management of pulmonary hypertension. Experimental subclavian-pulmonary and aorta-pulmonary anastomoses were performed in attempts to produce progressively increasing pulmonary vascular changes and to observe their sequential development. At six weeks after anastomosis there was medial hypertrophy, at eight weeks total involvement of the artery, and at eleven weeks severe pulmonary vascular disease, total decrease in the number of capillaries, and complete obstruction of the lumen. These pathologic changes are compared with the normal course of events in the fetal and postnatal lung. A series of patients with patent ductus arteriosus, single ventricle, and a large ventricular septal defect were studied and categorized into three phases according to the severity of their clinical symptoms. A method for producing pulmonary artery stenosis in the laboratory as applied to a three month old infant is discussed.


The effect of added bran to the diet on the saturation of bilein people without gallstones. Bran was added to the diet of eleven volunteers without gallstones, and its effect on bile saturation, bile acid profile in bile, and serum cholesterol and triglycerides was determined. Bile cholesterol saturation was decreased after two months of feeding bran to those female subjects who had supersaturated bile. Bran may be effective in decreasing the lithogenic potential of bile in people without gallstones, and further studies on its place in the prevention of gallstones in susceptible individuals are indicated.


Bacterial contamination of the biliary tree after choledochostomy. Secondary exogenous contamination of bile after choledochostomy could be an important cause of long-term morbidity if infection persists after removal of the T tube. Surprisingly, documentation of the frequency of conversion of sterile to infected bile after choledochostomy has rarely been recorded. Patients undergoing exploration and T-tube drainage of the common bile duct between July 1966 and January 1975, in whom intraoperative and postoperative cultures of bile were available, were studied. Postoperative cultures were obtained from five to forty days after operation. Of ninety-five patients available for study, contamination developed postoperatively in previously sterile bile in 44 per cent. The common duct bile contained bacteria at operation in 42 per cent and remained sterile throughout in 14 per cent. The most common secondary contaminants were klebsiella group and Escherichia coli. The fate of the contaminating organisms in a biliary tree without anatomic abnormalities is unknown. Two cases are presented which suggest that persistent infection may linger in the biliary tree for many years and give rise to pigment calculi. Since bacterial cannot be eradicated so long as a foreign body remains in the common duct and because such bacteria may cause symptoms even in an anatomically normal biliary tree, we suggest that a closed system of biliary drainage be employed and that appropriate antibiotic therapy be instituted for seven to ten days after removal of the T tubes.


Anaerobic metabolism and wound healing: an hypothesis for the initiation and cessation of collagen synthesis in wounds. The implanted cylinder model was used to measure LDH activity and lactate and pyruvate concentrations in the extracellular fluid of wounds and wound tissue. Total LDH activity corresponded directly to lactic acid concentration and inversely to oxygen availability. LDH isoenzymes in wound fluid were in an anaerobic pattern soon after injury and evolved toward the aerotic pattern as oxygen supply more nearly matched metabolic capacity. Lactate levels in the wound space are elevated soon after wounding and remain elevated far above those in blood. These data again indicate that wound metabolism is characterized by a relatively poor oxygen supply. Current data from several sources indicate that lactate found in the hypoxic area of the wound may stimulate collagen synthesis in fibroblasts lying in the high lactate environment. We postulate that elevated concentration of lactate in wounds is a major signal for collagen synthesis and repair.


Total gastrectomy.

Total gastrectomy. Total gastrectomy is indicated principally for Zollinger-Ellison syndrome and for potentially curable gastric cancer. The diagnosis of cancer should be verified by biopsy before the resection is performed, and the margins of resection should usually be examined by frozen section. Of the various reconstructions, Roux-en-Y esophagojejunostomy gave the best long-term results.


"CRAB" chemotherapy. Curative, relieving, adjuvant, and basal. A selection of patients with a variety of tumors treated effectively by chemotherapy followed by radiotherapy or surgery or both is presented. The best success has been achieved with lesions not previously treated by radiotherapy or surgery and which have no fixed lymph node masses. Where possible, we prefer to administer chemotherapeutic agents by direct infusion into the regional artery supplying the tumor mass.