A computer-based reporting system for bone marrow evaluation. A computerized system of reporting results of bone marrow examination has been implemented at The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, since 1975. All results are entered via the keyboard of cathode-ray tube (CRT) consoles and are instantly available to the attending physician in CRTs strategically located throughout the institution in patient-related areas. Differential counts are available within two to three hours after aspiration. Description of clot sections and smear, diagnosis, and differential diagnosis are completed within 24 hours. Permanent reports are also printed by the computer at regular intervals during the day. The physician can ask the computer for results on a given day or for a cumulative summary displayed in tabular or plot form. This system has proven efficient and rapid, not only for direct reporting of bone marrow examination results but also for storage and retrieval of patient information.


An evaluation of the overestimation of serum albumin by bromcresol green. Repeated observations have shown that the bromcresol green method overestimates serum albumin. Random patient serum samples were analyzed by a bromcresol green method using the Technicon AutoAnalyzer and by serum protein electrophoresis using cellulose acetate. The mean AutoAnalyzer value was 4.29 g/dl and the mean protein electrophoresis value was 3.68 g/dl (r = 0.915, slope = 0.869, y intercept = 1.090 g/dl where bromcresol green is on the Y axis, n = 166). Studies of the interference of proteins other than albumin in the bromcresol green method using the Technicon AutoAnalyzer showed that alpha globulins produce approximately a third, beta globulins a ninth, fibrinogen a fifth and hemoglobin equal the color intensity with the bromcresol green reagent that a comparable weight of albumin produced. In the bromcresol green method using the Du Pont ACA the interferences were even greater. At present, serum protein electrophresis is the most reliable method generally available to measure serum albumin. A modified bromcresol green method or immunoassay may eventually prove to be the method of choice.


Substitution of a non-hazardous chromogen for benzidine in the measurement of plasma hemoglobin. Because of the possible carcinogenicity of benzidine, a plasma hemoglobin method that substitutes reagents now used in other methods and poses no similar hazard is presented. It is comparable to the benzidine method in ease and time of accomplishment.


The microscopic appearance of a sodium-potassium exchange resin in histologic sections. The histologic appearance of Kayexalate, an ion-exchange resin, in bronchioles and alveolar spaces is described. Aspiration of this material occurred as a terminal event in an infant who suffered neonatal asphyxia and meconium aspiration. A solution of Kayexalate prepared for comparison appears to be identical to that found in the lung sections.


Haemophilus aphrophilus cholecystitis.

Haemophilus aphrophilus cholecystitis. Cultures from the gallbladder and blood of a 60-year-old man with acute cholecystitis grew Haemophilus aphrophilus. This organism, an unusual isolate in clinical specimens, is most frequently seen in patients with either endocarditis or brain abscesses. Haemophilus aphrophilus may be distinguished from Eikenella corrodens and Actinobacillus actinomycetemcomitans on the basis of colonial morphology and the biochemical tests for oxidase and catalase production and fermentation of lactose, sucrose, glucose, mannitol, xylose, and trehalose.


The relationship of paroxysmal ventricular tachycardia complicating the acute phase and ventricular arrhythmia during the late hospital phase of myocardial infarction to long-term survival. The long-term prognosis of paroxysmal ventricular tachycardia (PVT) complicating acute myocardial infarction remains unevaluated. Significant ventricular arrhythmia in the patient after infarction is said to carry a poor prognosis with regard to survival. To evaluate these two important aspects of myocardial infarction in man, 56 patients with documented myocardial infarction had Holter monitoring performed during the initial 24 hours and prior to hospital discharge. In 38 of the 45 survivors, Holter monitoring was repeated an average of 19 months after infarction. There were eight cardiac deaths during follow-up. Data analysis revealed that of 18 patients with PVT during the acute phase, one died during follow-up and 17 survived long-term. Even though the incidence of complex PVCs prior to hospital discharge and at long-term follow-up was higher in patients with PVT during the acute phase than in those without PVT, survival appeared unaffected. Thus, PVT during the acute phase of myocardial infarction and complex PVCs at the time of hospital discharge are not incompatible with long-term survival.


Repeat hemodynamic determinations in borderline hypertension. Repeat hemodynamic determinations were performed in 37 young men with borderline hypertension. The duration of the follow up study was 47 +/- three months. At each determination, those with borderline hypertension were compared to a group of matched normal subjects. Blood pressure increased from the first to the second determination, but the increase was significant only for systolic (P less than 0.001) and mean (P less than 0.01) arterial presssures. Cardiac index and heart rate, which were initially increased, decreased significantly (P less than 0.02; P less than 0.01, respectively) and decreased to normal values; total peripheral resistance increased (P less than 0.01); blood and plasma volumes decreased (P less than 0.01). At the first determination, the cardiac index-heart rate correlation was significant (P less than 0.01) and the cardiac index-blood volume correlation was not. At the second determination, on the contrary, the cardiac index-total blood volume correlation was significant (P less than 0.001) whereas the cardiac index-heart rate correlation was not. The study provides evidence that patients with borderline hypertension, over a short-term period, show (1) a greater increase in systolic than in diastolic pressure, (2) a return of cardiac output toward normal values through a decrease both in heart rate and blood volume, and (3) an increased importance of volume factors in the cardiac output control.


Outbreak of toxoplasmosis in a family and documentation of acquired retinochoroiditis. An outbreak of toxoplasmosis in one household is described. It demonstrates the potential for a common source infection with Toxoplasma gondii to cause multiple cases. Six of seven members of a household investigated for toxoplasmosis demonstrated high antibody titers consistent with recent infection; five of these members (83%) were symptomatic. The most common manifestations were fever and lymphadenopathy, which developed from seven to 18 days (mean 11 days) after a common source ingestion of infected meat. Since inadequately cooked lamb, pork and beef are probably the most common sources of infection in the United States, outbreaks of multiple cases may occur more frequently than is generally appreciated. As more outbreaks of febrile illnesses are examined, especially in families and closed communities, it is likely that more common source epidemics of toxoplasmosis will be recognized. Retinochoroiditis is an unusual manifestation of adult acquired toxoplasmosis. In the index case in this epidemic the patient manifested vision threatening retinochoroiditis 129 days after infection with toxoplasmosis. He represents the ninth well-documented case of toxoplasma retinochoroiditis associated with adult acquired disease.


Pseudomonas maltophilia pseudosepticemia. During a 17 month period, 25 hospitalized adult patients had blood cultures reported as positive for Pseudomonas maltophila. Review of the hospital records suggested that these were contaminants and that blood for coagulation studies and for cultures that were subsequently positive had been drawn simultaneously. The source of contamination appeared to be black-top evacuated collection tubes used for coagulation studies in adults. Cultures of the liquid anticoagulant tubes yielded a pure growth of greater than 10(5) colony forming units (CFU)/cc of Ps. maltophilia on blood agar. Mock trials demonstrated that following venipuncture by syringe, inoculation of contaminated black-top tubes prior to inoculation of blood culture bottles would yield false-positive blood cultures (pseudosepticemia). One patient being treated for streptococcal prosthetic valve endocarditis and having frequent coagulation studies with blood obtained via direct venipuncture into evacuated collection tubes was found to have superinfection of his prosthetic valve with Ps. maltophilia at autopsy. Prosthetic valve infection may have occurred after reflux of contaminated anticoagulant from an evacuated collection tube directly into the vein. Contaminated evacuated collection tubes are a potential source of confusion in the diagnosis of infection as well as a potential source of true infection.


Morbidity of staging laparotomy in Hodgkin's disease. The morbidity of exploratory laparotomy and splenectomy in Hodgkin's disease was determined at three institutions--a university hospital, a major university affiliated hospital and a large community hospital. Of the 90 patients who underwent exploratory laparotomy, 33 (37%) sustained a major or minor complication within two weeks of surgery. Seventeen patients (19%) sustained a minor complication and 16 patients (18%) a major complication. There was no mortality. A higher complication rate occurred in patients more than 28 years of age (p = 0.01), and in patients with advanced clinical stage when age was controlled (p = 0.05). We suggest that prior to performing an exploratory laparotomy in a given patient, the necessity of the procedure be weighed against its potential hazards.


Capturing clinical expertise. A computer program that considers clinical responses to digitalis. The administration of digitalis by experienced cardiologists has been examined and a prototypical computer program has been developed which captures portions of their expertise. The new program first constructs a patient-specific model upon which to base the determination of dosage and then uses feedback information about a variety of clinical aspects of the patient's response to modify its recommendations. The model reflects both the program's knowledge of pharmacokinetics and those special features of the patient's condition which may alter his response to therapy. The program makes assessments of the therapeutic and the toxic effects of digitalis on the patient, and bases its subsequent recommendations on the "therapeutic-toxic" state which best describes the evolving clinical situation. A clinical trial was performed in which the program "followed" a series of patients managed by clinicians on a cardiology service. That trial demonstrated the feasibility of this type of program in dealing with acutely ill patients, even those who have increased sensitivity to the toxic effects of digitalis. Each patient in the trial in whom toxicity developed had received more digitalis than would have been recommended by the program. This approach to automated clinical consultation should eventually provide a technology for the distribution of clinical expertise.


Oxacillin hepatitis. Two patients with liver biopsy, and review of the literature. Hepatotoxicity associated with intravenous sodium oxacillin therapy is reported in two drug abusers cured of staphylococcal endocarditis. Coincident with the administration of oxacillin, marked increases in hepatic transaminase were observed and liver biopsy showed nonspecific hepatitis. Upon cessation of oxacillin therapy, liver enzyme values returned to(ward) normal. Reports of oxacillin-associated changes in hepatic enzyme levels are reviewed; further observation of oxacillin-associated hepatotoxicity is warranted.


Methamphetamine intoxication. A speedy new treatment. This communication describes the use of droperidol in methamphetamine poisoning. Droperidol antagonizes the central stimulatory effects of amphetamines producing a person who is indifferent to environmental stimuli, calm and cooperative. Coupled with an acid diuresis, causing a fivefold increase in the urinary concentration of methamphetamine and recovery of 66% of the ingested drug, a seriously intoxicated patient showed rapid improvement.


Effective treatment of self-injurious behavior through a forced arm exercise. A forced arm exercise was investigated as a means of eliminating head-hitting in two children. During sessions restraints used to manage subjects were removed. After a baseline measure, required practice of repeated vertical arm movements was made contingent upon each response. Later, this procedure was combined with reinforcement under a differential reinforcement of other behavior schedule. Arm exercise alone produced a substantial decrease in head-hitting, while the combination treatment engendered near-zero levels. Subsequently, reduction of head-hitting was extended to several contexts by regular ward staff. This type of treatment appears as effective with self-injurious behavior as it is with stereotyped behavior.


Effects of attributions for success and failure on the performance of retarded adults. Seventy-two TMR adults were given success and failure experiences at a coding task, as well as one of three causal attributions (ability, effort, or task difficulty [ease]). The data revealed that causal ascriptions interacted with outcome in influencing speed of performance and that success enhanced performance only when coupled with an ability ascription. The data suggested that some of the contradictions in the success-failure literature may be due to differential causal attributions elicited across the various investigations. The implications of these data for training programs also were discussed.


Test of the generality of Bobrow and Bower's comprehension hypothesis. In a test of the generality of the comprehension hypothesis, EMR children were assigned, following pretraining measures, to experimental(n = 24) and control (n = 12) conditions. The experimental group was given intensive training with both self-generated and supplied links, while the control group participated in the same training format but without mediational instruction. Posttraining measures strongly supported the applicability of the comprehension hypothesis to the associative learning of EMR children. Superior associative learning and greater comprehension occurred under generate as compared to supplied conditions.


Facilitative effect of mnemonic strategies on multiple-associate learning in EMR children. The efficacy of mnemonic strategy training for multiple-associate learning was examined. Following pretraining measures of multiple-associate learning and general memory skills, 33 young EMR children were randomly assigned to one of three conditions: imagery, rote repetition, or control. Each group participated in a story and game program for 5 hours over a 2-week period, which, depending on condition, involved intensive training in the use of either imagery or rote repetition or no direct mnemonic training. Posttraining measures of children who received mnemonic training showed marked improvement, with imagery being superior (p less than .01) to rote repetition.


Role of strategy in reading by mentally retarded persons. Mentally retarded individuals who could read were tested on their ability to pronounce words and produce meaningful associates. Analyses of their responses indicated an overuse of a strategy of memorizing works as a way to recognize words in print and an inability to consider work meanings in terms of abstract referents. A comparison of these results with responses given by nonretarded children suggests that retarded persons use cognitive strategies that lead to inefficient reading and even interfere with the development of effective reading skills.


Low-income children's attitudes toward mentally retarded children: effects of labeling and academic behavior. Effects of the label "mentally retarded" and academic competence on low-income sixth-grade children's attitudes toward peers were examined. Attitude was defined in terms of children's affective feelings and behavioral inclinations. The results showed that low-income children expressed more favorable attitudes toward a competent than an incompetent child and, paradoxically, toward a labeled than a nonlabeled child. The data also revealed that an academically incompetent child who was not labeled as retarded evoked negative attitudes, especially from boys, whereas an incompetent child who was labeled as retarded evoked positive attitudes. The findings were discussed in terms of the pros and cons of the current trend toward delabeling.


Group decision-making by mentally retarded adults. The effects of group discussion and decision-making on subsequent individual decisions of mentally retarded residents of group homes were studied. Meeting in groups of four, the subjects discussed and attempted to make group decisions of 6 of 12 interview questions (experimental) but did not discuss the remainder of the questions (control). Between the pretest and the posttest, there was a significantly greater increase in the quality of answers to the experimental than to the control questions. Also, leadership status moderately correlated with individual participation rates and initial task competence but not with verbal intelligence.


Effects of contingency management of academic achievement and conduct of mentally retarded Arab students. An experimental group of 11 mentally retarded Arab children were involved in a contingency-management program based on successful completion of academic work. A control group of retarded children with approximately equal mean CA and mean IQ scores was exposed only to the regular teaching routine. Results indicated that academic achievement was greatest in Phase B an ABA design. In addition, the experimental group made achievement gains beyond that of the control group, and there were some generalization effects stemming from the treatment phase. Also, good conduct, although not directly manipulated in the study, was observed in the three phases of the study. Subjects in the experimental group displayed more attending behavior and decreased their amount of nonattending (e.g., looking out the window) and disruptive behavior (e.g., shouting) during the treatment phase. The results also indicated that contingency management is a viable technique for retarded children living in a culture substantially different from that in the United States.


Stability of territorial and aggressive behavior in profoundly mentally retarded institutionalized male adults. Previous research has documented that institutionalized profoundly retarded male adults are territorial and aggresive. The present study represents a follow-up on the same group of males. Results demonstrated that the behavior initially observed remained highly stable across the 19 months since the previous study.


Reducing self-injurious behavior by facial screening. Self-injurious behavior has been treated with a variety of techniques with varying degrees of success. Some techniques that have generally been effective, such as response-contingent shock punishment, are not always permissible to use; thus, other methods must be investigated. A multiple-baseline design was used to evaluate facial screening (covering a subject's face with a terrycloth bib) as a means of reducing a retarded person's self-injurious behavior. Facial screening applied intermittently by teachers in three special education classroom was successful in eliminating self-injurious behavior.


Sperm procurement and analysis in Jewish law. Whether, and how, a husband whose marriage has proved barren may procure a sample of his semen for a fertility test is a question that has often been discussed in rabbinic writings. It is permissible according to most rabbis to obtain sperm from the husband both for analysis and for insemination, but a difference of opinion exists as to the method to be used in the procurement of it. Masturbation should be avoided if at all possible and coitus interruptus or the use of a condom seem to be the preferred methods. Since many important legal and moral considerations, which cannot be enunciated in the presentation of general principles, may weigh heavily upon the verdict in any given situation, it seems advisable to submit each individual case to rabbinic judgment, which, in turn, will be based upon expert medical advice and other prevailing circumstances.


Serum prolactin, gonadotropins, and estradiol in menstruating and amenorrheic mothers during two years' lactation. Serum prolactin, LH, FSH, and estradiol were measured in single blood samples collected from 465 nursing mothers in Central Africa (Kivu, Zaïre) during the first 2 postpartum years. Lactating mothers were hyperprolactinemic during 15 to 18 postpartum months. Both serum prolactin and FSH were higher in amenorrheic than in menstruating nursing mothers; the difference was more apparent during the first than during the second year. Mean serum LH and estradiol were significantly higher in menstruating then in amenorrheic nursing mothers during the second postpartum year but not during the first. There was a significant association of hyperprolactinemia with amenorrhea. Furthermore, postpartum, the incidence of amenorrhea declined parallel to that of hyperprolactinemia.


Endogenous levels of prostaglandin F2alpha and its main metabolites in plasma and endometrium of normal and dysmenorrheic women. The concentrations of prostaglandin F2alpha 15-keto-13, 14-dihydro-PGF2alpha, and 13,14-dihydro-PGF2alpha were determined in plasma and in endometrial specimens taken from both dysmenorrheic and normal women at the time of their menstruation. The estimations were carried out by means of the gas chromatography-mass spectrometry method. The plasma levels of 15-keto-13,14-dihydro-PGF2alpha in dysmenorrheic women ranged between 32 and 105 pg. per milliliter, which are significantly higher than the corresponding levels in eumenorrheic women, 20 to 33 pg. per milliliter. On the first day of menstrual bleeding the concentration of PGF2alpha in the endometrium was approximately 4 times higher (300 to 2,600 pg. per milligram) in cases of dysmenorrhea than in normal subjects. Treatment with either oral contraceptives or prostaglandin synthetase inhibitors lowered the concentrations significantly and the majority of patients became symptom free.


Hysteroscopic management of intrauterine adhesions. Sixty-six patients who had the presumptive diagnosis of Asherman's syndrome underwent hysteroscopic evaluation and treatment. In 65 patients, hysteroscopy was performed on an outpatient basis under local anesthesia. In all but five patients, complete lysis of adhesions was accomplished during the initial hysteroscopy. Uterine perforation occurred in two of the 66 patients. The extent of the intrauterine adhesions correlated with the patients' presenting menstrual patterns, but not with prior hysterosalpingography. Of the patients who have completed surgical and hormonal therapy, 98 per cent have normal spontaneous menses. Follow-up examination of the endometrial cavity was normal in 32 of 34 patients. Seven of ten patients who wished to conceive and who had no other infertility factors have done so. The pregnancies have been uncomplicated. Hysteroscopy is the method of choice to diagnose, classify, treat, and follow-up patients with Asherman's syndrome.


Cervical and vaginal bacterial flora: ecologic niches in the female lower genital tract. The bacterial flora of the cervix and vaginal vault were compared by obtaining duplicate specimens for quantitative bacteriologic studies in 14 patients electively admitted for hysterectomy. There were a total of 137 isolates from the 28 specimens, including 71 aerobes and 66 anaerobes. Aggregate data showed that the flora of the two sample sites were similar by both qualitative and quantitative analysis. However, individual comparison of paired specimens showed considerable differences in that 75 of the 137 isolates were recovered from only the cervix or vaginal vault. Additional studies showed that neither low concentrations of bacteria nor the culture techniques accounted for these differences. It is concluded that most women harbor distinctive bacterial populations in the cervix and vaginal vault.


The cervical polyp: a new diagnostic and therapeutic approach with CO2 hysteroscopy. CO2 hysteroscopy for diagnosis of cervical polyps was performed in 36 patients. The polyps could be located under direct vision and their attachments were found to be deeper than what is seen in regular inspection. A relatively high number of endometrial polyps were found. It is advised that the polyps be surgically removed by cutting the stem at its attachment followed by a curettage.


Promethazine hydrochloride: use in patients with Rh isoimmunization. Twenty-two babies born to 21 mothers were treated prenatally for varying periods of time with promethazine hydrochloride in doses of 150 mg. per day. Seven of the 22 babies required intrauterine transfusions. With the exception of positive clinical impressions in some cases, specific ameliorating effects of the drug in this group could not be demonstrated.


Systemic and uterine hemodynamic responses to dopamine in pregnant and nonpregnant sheep. The systemic and uterine hemodynamic effects of dopamine were studied in nonpregnant and near-term pregnant, unanesthetized, chronically instrumented sheep. Dopamine was administered by constant intravenous infusion in doses ranging from 2 to 40 microgram per kilogram per minute. A hypertensive effect was consistently observed when doses greater than 5 microgram per kilogram per minute were given. The rise in pressure was accompanied by a rise in the systemic vascular resistance and an increase in the cardiac output; the increment in the latter was greater in the pregnant than in the nonpregnant animals. Uterine blood flow increased consistently despite some rise in uterine vascular resistance; uterine fraction of cardiac output either remained unchanged or increased slightly. Venomotor construction, reflected by a rise in central venous pressure, occurred at all dose levels. These hemodynamic properties of dopamine may be explained partly on the basis of its combined beta- and alpha-mimetic action, as well as through redistributions of flows and resistances among various regional vascular beds.


Plasma levels of ampicillin in pregnant women following administration of ampicillin and pivampicillin. A single dose of ampicillin as been reported to produce lower plasma levels in pregnant than in nonpregnant women. In the present study plasma and urine levels oa ampicillin were studied in pregnant women following administration of multiple oral doses as well as single doses of 0.35 Gm. of pivampicillin and 0.5, 1.0, and 2.0 Gm. of ampicillin. Assays for levels of ampicillin were performed by means of a disc-agar-diffusion method. Multiple doses of ampicillin resulted in plasma levels and recovery in urine similar to those after a single dose. Mean plasma levels were low. A dose of 1.0 Gm. of ampicillin resulted in plasma levels in pregnant women comparable to those reported earlier by us in nonpregnant women following a dose of 0.5 Gm. A dose of 0.35 Gm. of pivampicillin resulted in plasma levels considerably lower than those reported by others in nonpregnant subjects, but plasma levels and recovery in urine were as high as those produced in pregnant women by 0.5 Gm. of ampicillin.


Human fetal breathing movements and gross fetal body movements at weeks 34 to 35 of gestation. Human fetal breathing movements in utero at 34 to 35 weeks' gestational age were measured using a real-time ultrasonic scanner. Fetal breathing movements were episodic and occurred 31.8 per cent of the time. Aanalysis of continuous recordings in 10 fetuses from 09:00 to 17:00 hours demonstrated that the percentage of time spent breathing per hour was greater in the afternoon than in the morning. The number of gross fetal body movements was also greater in the afternoon than in the morning. The percentage of time spent breathing was significantly greater during the hour following the noon meal than during the hour preceding the noon meal. It was concluded that real-time ultrasonic scanning permits identification of fetal breathing movements and that between 09:00 and 17:00 hours the character of these movements is related to the time of the day and to the ingestion of food by the mother.


Concentrations of 24,25-dihydroxyvitamin D and 25-hydroxyvitamin D in paired maternal-cord sera. Mean serum concentrations of 24,25-dihydroxyvitamin D (24,25(OH)2D) and 25-hydroxyvitamin D (25OHD), measured by competitive radioassays, were significantly higher in maternal serum than in cord serum of term infants in both black and white subjects. There were positive correlations between maternal and cord levels of both metabolites of vitamin D. Serum concentrations of 24,25(OH)2D and 25OHD were significantly lower in white pregnant subjects than in nonpregnant women. In utero levels of 24,25(OH)2D and 25OHD probably reflect maternal stores of these metabolites.


Spontaneous abortion and the use of sugar substitutes (saccharin). The hypothesis that the use of saccharin may increase the risk of spontaneous abortion was tested in a case-control study. Women who had had spontaneous abortions were compared with women who had been delivered after 28 weeks' gestation. Women with a history of diabetes were excluded from the analysis. The use of sugar substitutes during pregnancy was similar in cases and controls: 5.5 per cent of cases and 5.8 per cent of controls reported using sugar substitutes. The power of the analysis to detect a twofold increase in the frequency of use of sugar substitutes in cases as compared to controls was approximately 81 per cent. The analysis effectively controlled for all known potentially confounding variables: that is, age at last menstrual period, history of previous spontaneous abortions, smoking during pregnancy, and usual weight were controlled in the analysis.


Effects of maternal and fetal plasma from toxemic patients on the vasomotility of the human umbilical artery. Maternal and fetal plasmas from patients with specific hypertensive disease of pregnancy (SHDP) are shown to have a greater vasoconstrictive effect on perfused human unbilical artery than plasma from normal parturients. The vasomotility of isolated segments of artery was determined by measuring perfusion pressure at constant flow rate. The differences were demonstrable with plasmas and artery segments from the same parturients and also when plasma from patients with SHDP and arteries from normal parturients were used. These results, which show that plasmas from SHDP patients have a larger vasoconstrictive effect on human umbilical artery than normal plasma, support and extend the suggestion that there may be humoral mechanism which participates in the physiopathology of SHDP. This humoral factor can be detected with human umbilical artery from both normal and SHDP parturients.


Spontaneous human lymphocyte-mediated cytotoxicity against tumor target cells. IV. The suppressive effect of normal pregnancy. The effects of pregnancy and other donor characteristics on spontaneous lymphocyte-mediated cytotoxicity (SLMC) were studied. Sex, age, and stage of the menstrual cycle had no significant effect on the SLMC of the control donors, the SLMC was significantly lower in pregnant donors in the second or third trimester. However, this lowered level of activity was still within the 95 per cent confidience limits of the normal population and parity had no cumulative effect. At delivery, fetal cord blood lymphocytes possessed substantial cytotoxic activity, further evidence that the fetus is immunologically competent at birth. The relevance of these data to the immunologic coexistence of the mother and fetus is discussed.


Maternal circulatory response to a single dose of ritodrine hydrochloride during orthostasis in normal and hypertensive late pregnancy. Placental blood perfusion, the maternal heart rate, and arterial blood pressure were measured before and after a single intramuscular dose of ritodrine hydrochloride during orthostasis in 11 healthy pregnant women, 10 pre-eclamptic patients, and 11 pregnant patients with essentially hypertension. There was a slight increase in placental blood perfusion in the healthy subjects and a significant rise in the pre-eclamptic patients and the women with essential hypertension. The heart rate increased significantly in all groups. No greater changes in the systolic and diastolic blood pressures were observed. The clinical significant of the results is discussed briefly.


The effects of hexoprenaline, a beta 2-sympathomimetic drug, on maternal glucose, insulin, glucagon, and free fatty acid levels. Hexoprenaline, an adrenergic beta 2-receptor agonist, was administered as a 10 microgram intravenous bolus to 9 women in the third trimester of pregnancy. The maternal plasma glucose, serum immunoreactive insulin, plasma immunoreactive glucagon (IRG 30 K), and free fatty acid (FFA) concentrations rose significantly at different times following the bolus injection. Thc serum insulin level increased first and reached a peak at 10 minutes, before the rise in plasma glucose, which reached a maximum at 30 minutes, suggesting that beta 2-receptor stimulation affects insulin secretion directly and not via a rise in the glucose level. Plasma glucagon and FFA levels also rose despite the rise in glucose levels. We therefore conclude that beta 2-receptor stimulation has direct actions on insulin and glucagon release and  on glucose and FFA metabolism. The possible fetal sequelae due to these changes in the maternal metabolic milieu are discussed in relation to the use of a 10 microgram intravenous bolus of hexoprenaline as a measure in the treatment of acute fetal distress.


Clinical application of a scoring system for evaluation of antepartum fetal heart rate monitoring. Five hundred-seven passive tests (PT's) on 260 patients and 133 oxytocin challenge tests (OCT's) on 97 of these patients were reviewed. The tracings were categorized according to a proposed modified scoring system based on baseline fetal heart rate (FHR), variability, accelerations and decelerations of FHR, and fetal activity. The scoring system was compared with the usual criteria for fetal compromise currently employed in PT's and OCT's and was found to be superior in accuracy. The usefulness of antepartum FHR monitoring as evaluated throuth the scoring system is discussed. It is concluded that passive testing can largely replace the OCT.


Functional significance of the zonal morphologic differences in the normal human placenta. A morphometric study. Previous investigations have shown that the human placenta is a complex organ with different zones, each with a unique morphology. These zonal morphologic difference have been related to a probable blood PO2 gradient operating in the intervillous space. This study describes zonal variations in the vertical plane of the placenta by the application of different morphometric parameters. It demonstrates morphologic changes, which suggest that zonal differences may be the result of a physiologic adaptation of the placenta, which is dependent upon its structural relationships with the maternal tissues. This adaptation found in various areas of the placenta increases its functional efficiency.


Determination of fetal lung maturity by fluorescence polarization of amniotic fluid. The degree of fluorescence polarization (P value) of 1,6-diphenyl-1,3,5-hexatriene has been shown to be an excellent indicator of the lecithin/sphingomyelin (L/S) ratio in laboratory prepared liposomal dispersions. In order to test the validity of this technique in amniotic fluid, the L/S ratio and P value of 161 amniotic fluid specimens were determined. In 127 the P value was less than or equal to 0.336 and the L/S ratio was greater than or equal to 2. In 26 the P value was greater than 0.336 and the L/S ratio was less than 2 (P less than 0.05). The amniotic fluid P value is affected by blood or meconium but not by surgical lubricants or bilirubin. We concluded that the degree of fluorescence polarization of amniotic fluid indicates fetal lung maturity as reliably as the L/S ratio. However, this method has important technical and practical advantages that make it more applicable for a clinical laboratory.


Positive correlation of optical density at 650 nm. with lecithin/sphingomyelin ratios in amniotic fluid. In this study, we have attempted to correlate optical density measurements of amniotic fluids with L/S ratios. We may conclude, with over a 98 per cent accuracy, that fluids having optical density readings of 0.15 and above, at 650 nm. will have an L/S ratio over 2.0. Fluids having optical density readings up to 0.05 will have L/S ratios of about 1.3. Finally, amniotic fluids having optical densities greater than 0.05 and less than 0.15 will have L/S ratios of approximately 1.5.


Maternal and amniotic fluid 17 alpha-hydroxyprogesterone levels during pregnancy: diagnosis of congenital adrenal hyperplasia in utero. 17 alpha-Hdroxyprogesterone levels (17 alpha-OHP) were measured in 70 samples of amniotic fluid and 30 samples of maternal serum obtained at different stages of normal pregnancy and in samples of maternal serum and amniotic fluid from a pregnancy with the fetus affected with congenital adrenal hyperplasia. The mean level of 17 alpha-hydroxyprogesterone in the amniotic fluid from control pregnancies was 133.9 +/- 7.6 ng. per 100 ml. (range, 25.1 to 266.6 ng. per 100 ml). The levels were significantly higher in midpregnancy (157.4 +/- 8.4 ng. per 100 ml.) than in late pregnancy (79.2 +/- 6.8 ng. per 100 ml.) (p less than 0.01). Amniotic fluid 17 alpha-OHP levels in the affected pregnancy were significantly higher than the control levels. Mean maternal 17 alpha-OHP level during early pregnancy and midpregnancy was 259.5 +/- 22 ng. per 100 ml. and there was a two-to three-fold increase after 37 weeks (672.2 +/- 61 ng. per 100 ml.) The maternal 17 alpha-OHP levels in the affected pregnancy were significantly higher than the control levels after 34 weeks, but before 34 weeks, the level was within the range seen in control pregnancies. Measurement of 17 alpha-OHP levels in the amniotic fluid before 24 weeks and maternal serum after 34 weeks can be utilized for the prenatal diagnosis of congenital adrenal hyperplasia.


The impairment of progesterone-induced pituitary release of prolactin and gonadotropin in patients with hypothalamic chronic anovulation. Sequential administrations of progessively increasing amounts of estradiol benzoate (EB) for five days followed by 10 mg. of progesterone (P) elicited a prompt pituitary release of luteinizing hormone, follicle-stimulating hormone, and prolactin in normal women during the early follicular phase but not in women with normogonadotropic hypothalamic chronic anovulation with or without associated hyperprolactinemia. Since hypothalamic dopamine functions as an inhibitor for the secretion of both prolactin and gonadotropin, we postulate that sequential EB-P stimulation for simultaneous release of gonadotropin and prolactin may be mediated by a reduction of hypothalamic dopamine in response to progesterone. The failure of patients with hypothalamic chronic anovulation to respond to this sequential ovarian steroid feedback demonstrated in this study may indicate the presence of dopaminergic dysfunction and that this test may prove to be useful in delineating hypothalamic function in amenorrhea patients.


Benign glandular inclusions in para-aortic lymph nodes in women undergoing lymphadenectomies. Benign glandular inclusions in para-aortic lymph nodes are a relatively common occurrence. The chance of finding these benign glandular inclusions in the para-aortic lymph nodes is dependent on the intensity with which one searches. In our series of 106 para-aortic lymphadenectomies performed on patients with gynecologic malignancies, there were five patients in whom these benign Müllerian rests were found. Other series report up to a 40.8 per cent incidence of benign inclusions in nodes of patients with cervical cancer. They may have been either congenital or acquired. It is critical that these Müllerian tissues are not confused with metastatic disease. The significance of these benign glandular inclusions is discussed.


Tomographic diagnosis of pituitary microadenomas in Forbes-Albright syndrome (amenorrhea-galactorrhea). The present study documents a characteristic tomographic sellar abnormality in five patients with Forbes-Albright syndrome (ammenorrhea-galactorrhea) and surgically proved pituitary microadenomas. This abnormality, noted in patients with normal-sized sellae, consists of asymmetric erosion of the anterior inferior wall of the sella turcica. Utilizing the twin criteria of an elevated serum prolactin and characteristic sella abnormality, herein  described, previously unrecognized patients with pituitary microadenomas can be diagnosed and treated effectively.


Manpower for obstetrics-gynecology. I. Demographic considerations and practice work load. A cooperative study between the University of Southern California Division of Research in Medical Education and the American College of Obstetricians and Gynecologists represents one subset of a large-scale study of manpower supply in obstetrics-gynecology. A stratified random sample of all obstetrician-gynecologists was obtained from the AMerican Medical Association's "Master File of Physicians." A total of 879 respondents (56 per cent of the sample) completed a detailed, one-week log of practice activities and self-descriptive questionnaire. This initial report describes these physicians by practice arrangement as related to age and geography. Practice work load is identified by encounter time per patient, work hours per day and week, and variations related to geographic location and population served. The descriptive findings may have important implications for manpower planning.


Intrauterine fetal transfusion, 1965-1976, with an assessment of the surviving children. The need for IUT in the management of Rh hemolytic disease is likely to continue in the foreseeable future. Recent reports have been skeptical about the success of this procedure and the quality of the surviving infants. Of 84 fetuses who received 134 IUT's, over all, 35.7 per cent survived; 48.3 per cent of the nonhydropic group survived. Fifteen of the 23 survivors between 3 and 11 years of age received intellectual, academic, behavioral, health, and developmental evaluations. When compared to sibling and high-risk control groups, the study children showed no significant differences in intelligence quotients, arithmetic achievements, or reading achievements; their school performance is acceptable and none is presenting significant behavioral problems. Except for an excessive number of umbilical and inguinal hernias, there were no physical abnormalities that could be directly related to IUT.


Lymph gland metastases in invasive squamous cell cancer of the vulva. Cancer of the vulva has responded to surgical therapy. "The problem now is to decide in what way the results may be improved." A clinical series of 195 patients who had extended vulvectomy and bilateral inguinal and pelvic lymphadenectomy were systematically examined for lymph gland metastases in the inguinal and pelvic regions. Forty-one patients had metastases in these lymph glands. Lesion site, lesion size, and patterns of metastases were delineated in these 41 patients. ;ariations in the pattern of central (clitoral) and lateral (labial) cancers were recorded. Risk factors of 20.5 and 4.6 per cent respectively, was calculated for omitting bilateral inguinal and pelvic lymphadenectomy. The latter figure indicated that one of 20 patients would have had residual disease if pelvic lymphadenectomy had been omitted. With out present inability to determine accurately lymph gland metastases by nonsurgical means, trends from this study indicate that optimum therapy requires addition of pelvic lymphadenectomy to extended vulvectomy and bilateral inguinal lymphadenectomy.


Rehabilitation of patients with NCA (neurocirculatory asthenia) through a short term training program. Twenty-two patients, 18 years old, with the predominant somatic type of NCA, and a control group of 22 healthy subjects participated in a short term training course lasting three weeks. Following the training the NCA subjects showed a significant change in the systolic and diastolic blood pressure after 5 minutes of recumbency as well as in the systolic blood pressure after 5 minutes of standing, diastolic pressures during 50 W load and submaximal effort (100-150 W) - all the values being significantly lower following the training, except the diastolic pressure during 50 W load which was higher following the course. The prominent training effect was on the heart rate during light work loads (50 W) in which a decrease from a mean of 151.2 +/- 13.9 to 118.3 +/- 16.3 beats/min was recorded. This decrease indicates the better adaptation of the NCA patients to physical effort. Similarly, a significant increase in the mean VO2max from 31.5 +/- 6.1 to 37.7 +/- 5.9 ml O2/kg B.W./min was observed. No changes were recorded in the ECG after the short training course. Following the training all the symptoms typical of the NCA syndrome vanished. A short physical training of 3 weeks can start the procedure of rehabilitation of a well selected group of NCA patients with predominant somatic complaints. The rehabilitation must be continued throughout life by continued physical training.


Muscle stretch receptor hypersensitization in spasticity. Inapproprioception, Part III. The author's concept of Inapproprioception, which accounts for athetoid movements in terms of defective proprioceptive feedback (i.e., distortion of afferent signals representing limb position) is extended here to explain spasticity in cerebral palsy was well. Descending activation of gamma efferents supplying hypertonic muscles may be excessive, leading to hypersensitization of stretch receptors in those muscles (the exact distribution of muscles affected varying with the individual). The result is exaggerated reflex activation of alpha motoneurons in response to the slightest muscle stretch. Even passive tension due to gravitational forces, which is inescapable, results in excessive impulse discharge from sensitized stretch afferents and thus leads to reflex contractions simply in response to shifts in body position. The affected muscles shorten to a length corresponding to the elevated level of reflexly originating motoneuron discharge, manifesting excessive tone even in the contracted state. The distribution of hypertonicity thus induced usually follows a predictable pattern and can be modified using slow passive stretch of hypertonic muscles to relax them, followed by facilitated voluntary contraction to strengthen weak antagonists, and progressing to functional reciprocal usage of agonists and antagonists to achieve proper muscle balance. Application of this procedure leads to improved posture, balance and ambulation in subjects with spastic cerebral palsy.


Immunoglobulin (Gm) allotypes in a sample of Canadian Ashkenazic Jews. Gm typing on the serum specimens of 507 Ashkenazic Jews (pre-dominantly of Polish-Russian ancestry) from Toronto, Canada has established the presence of haplotypes Gm3;5, Gm1;21, Gm1,2;21, and Gm1,17;5, and the absence of haplotypes Gm1;13,15,16, Gm1;5,6, and Gm1;5,6,24 which have been found in other Jewish peoples. It is suggested that Ashkenazic populations have lower frequencies of haplotype Gm1,17;5 than non-European Jewish populations, and that some eastern European Jewish populations have acquired the Gm1;13,15,16 haplotype through gene flow from Central Asia. Thus Jewish populations show differences in the Gm system; many of the differences may be in the direction of similarities to neighbouring non-Jewish populations.


Genetic variation in transferrin alleles of rhesus macaques, Macaca mulatta. The rhesus macaque displays an extensive polymorphism at the transferrin locus. A principal components analysis describes the variance and covariance of alleles at the transferrin locus in eight widely dispersed sample populations. Using an eigenvectorial representation of the covariance matrix and systematically approximated geographical locations the distribution of populations and transferrin alleles is compared. Alleles with high variance prove to be the determining factor in the placement of populations in a "genetic map" and provide a means for interpreting the low congruence of genetics and geography found.


Growth trends among male Bods of Ladakh--a high altitude population. A random sample of 274 native male Bods of Ladakh ranging in age from 11 to 19 years, living in Leh (Ladakh) at mean altitude of 3,514 metres, was studied. The pattern of growth of this sample was compared with the sea level Indians. The results indicate that: (1) The so called adolescent spurt is not well defined among Bod highlanders. (2) Bods grow faster than plain dwelling Indians and are taller and heavier at the age of 19 years. (3) The highlanders exhibit greater chest circumference than the lowland norms. This finding, similar to those among Andean natives, supports high altitude hypoxia's role in human growth and morphology.


Prevalence and possible etiology of dental enamel hypoplasia. Two hundred black and white adult human skeletons and 200 living black and white children from the greater Cleveland area were examined for evidence of enamel hypoplasia. Enamel hypoplasia, present in varying expressings (pits, lines and grooves), was found to be more prevalent in both skeletal samples, than in the living groups. In the majority of cases, sex differences between white and black males and females through time and space are highly significant for all tooth catagories. Regardless of the mechanisms behind it, prevalence of enamel hypoplasia for both white and black group has significantly declined through time. No evidence suggesting specific etiologies responsible for enamel hypoplasia can be found. In the majority of previously published reports, the etiology is still idiopathic. The reduction in the prevalence of enamel hypoplasia in the groups examined through time may be related to improved nutritional conditions and the elimination or decline of childhood diseases that have been implicated in this condition.


Multivariate dental allometry in primates. Disagreement is current over the question of whether relatively large teeth in some large primates are a natural outcome of growth trends instead of an indication of intrinsic differences. A cross-primate survey of dental scaling relative to skull (and inferred body) size is given in this study, using a principal component technique to measure the multivariate growth relation between two sets of data: dental size and cranial size. Cheek teeth are strongly positively allometric in restriced taxonomic groups, especially in cercopithecoids. Conversely, the allometry drops to an almost linear proportional growth relation when variation in diet is controlled.


Artificial cranial deformation and the increased complexity of the lambdoid suture. Studies examining an association between artificial cranial deformation and the presence of wormian bones in the lambdoid suture have been inconclusive. Cranial deformation, however, does not seem to have a direct effect of increasing the sutural complexity of the pars lambdica of the lambdoid suture and also increasing the mean number of lambdoidal wormian bones, given their presence.


A new method for assessing the sex of fragmentary skeletal remains: femoral shaft circumference. A simple discriminant function using midshaft femoral circumference for the determination of sex has been tested with 114 skeletons from the Libben Site, Ontario County, Ohio. The results have been shown to be 85% consistent with other, accepted means of determining sex. Femur circumference an be an aid to the sexual identification of poorly preserved and fragmentary skeletal remains.


Aging in the lumbar spine. II. L1 and L2. The bodies of the first and second lumbar vertebrae, like those of L3 and L4, show a significant trend toward lowering and broadening with age. Superior, inferior, and midbody transverse breadths increase, but there is little or no increase in endplate "flaring" with age. There is essentially no change in the relationship between anterior and posterior heights, but as reported for L3 and L4, there is a sexual difference in the amount and type of wedging of the bodies of L1 and L2. Posterior wedging (posterior height less than anterior height) of these vertebrae is about twice as common in females as in males. Whites of both sexes show a statistically significant relationship between age and increased biconcavity of the endplates. Black females, but not the males, show a similar trend, especially in L1.


Aging in the lumber spine. III. L5.

Aging in the lumber spine. III. L5. The fifth lumbar vertebra, like the other units of the lumbar spine, shows a significant trend toward lowering and broadening of the body with age. In most individuals the pedicales of L5 arise from the lateral surface of the body, rather than posteriorly as in the other lumbar vertebrae, and the increase in body breadth is very often associated with the formation of reinforcing columns of bone between the bases of the pedicles and osteophytes bordering the inferior endplate. In L5 midbody breadth shows a greater gain than endplate breadths, so "flaring" is decreased with age, a change that is statistically significant in Black males and White females. This vertebra shows no significant change in endplate biconcavity or posterior wedging with age.


Changes in somatotypes of European males between 17 and 24 years. In order to examine the possible changes in somatotype of young males, 14 boys who had been somatotyped annually from 11 to 18 years by the Health-Carter anthropometric rating method were re-somatotyped at 24 years. The analysis focused on years 17, 18 and 24. Discriminant analysis, somatotype dispersion indices and distances, and the I-index were used to analyze the data. The findings showed a significant shift in somatotype from ectomorphmesomorph towards endo-mesomorphy between 17 and 24 years. This shift was greater than that observed by Zuk ('58), and was in the same direction. It is hypothesized that the somatotypes of males become more endo-mesomorphic from 17 years to the mid-twenties.


The blacks of Panama: their genetic diversity as assessed by 15 inherited biochemical systems. Panama's black citizens are culturally and historically divisible into two groups, the Spanish-speaking coloniales and the English-speaking anglos or afro-antillanos. Until recently these groups have been geographically as well as culturally isolated one from the other, although both are predominantly of West and Southwest African origin. Assessment of the genetic diversity within-villages and within language groups reveals as much, possibly somewhat more, diversity in 15 inherited biochemical markers within villages and language groups as that which obtains between villages and language groups. A number of rare variants at the 6-phosphogluconate dehydrogenase, lactate dehydrogenase, and esterase D loci were encountered and are described.


Mineral analysis of ancient Peruvian hair. Ancient Peruvian hair has been excavated from a series of archaeological sites on the Peruvian coast. After careful cleaning, examination by scanning electron microscopy revealed most of the samples to be in a state of preservation comparable to modern hair. No evidence of pathological conditions was observed. Trace metal composition was determined by atomic absorption and flame emission spectrophotometry and nitrogen by Kjeldahl analysis, producing the following results: (1) nitrogen is lost with time, while all other tested minerals except zinc and copper showed irregular increases; (2) relatively high chromium levels may indicate that diabetes was not present in the samples; and (3) no consistent trend in the ratio of calcium to strontium was found through time and across corresponding dietary shifts.


Linkage disequilibrium in Bougainville Island. Linkage disequilibria are estimated for three 2-locus systems in 18 samples from Bougainville Island, Solomon Islands. The systems are haptoglobin, acid phosphatase and MN blood group. The disequilibria are estimated two ways: by maximum likelihood (ML) and by the covariance between the non-alleles. Though seven of the 52 ML estimates are statistically different than zero, none of the covariance estimates are significant. We conclude that because linkage disequilibrium for loosely linked loci is a small quantity and because the sample sizes for most populations studied by anthropologists are small, linkage disequilibrium will not be a useful parameter for the study of natural selection in these populations.


Inheritance of tooth size in Australian aboriginals. The purpose of this study was to clarify the question of inheritance of tooth size, with particular reference to the role of the sex chromosomes. Data were obtained from the dental casts of Aboriginals living at Yuendumu in the Northern Territory of Australia, who had participated in a longitudinal growth study extending over 20 years. The compilation and verification of comprehensive genealogical records gathered over a number of years enabled the analysis of family data. Product-moment correlation coefficients between different full-sibling and half-sibling pairs were calculated for permanent tooth size. Values of individual and average correlation for both mesiodistal and buccolingual tooth diameters conformed with the theoretical correlations expected assuming polygenic inheritance. However, no evidence of sex chromosomal involvement was found.


Variation in dental occlusion and arches among Melanesians of Bougainville Island, Papua New Guinea. II. Clinical variation, geographic microdifferentiation and synthesis. Patterns of geographic microdifferentiation for dental occlusion and the size and shape of the dental arches are described for 14 villages on Bougainville Island, Papua New Guinea. Occlusal variables, such as overjet, overbite, molar relationships, crowding or spacing, and malalignment vary less among villages than do arch length and width. Arch length and width decrease in size from north to south. The pattern of biological distance among villages for occlusal variables and arch size correspond poorly to anthropometric, linguistic, geographic and migrational distances. The value of occlusal variables and arch size for discriminating among populations, the biological interpretation of multivariate data and the objectives of research on geographic microdifferentiation are discussed.


Genetic basis of a-b, b-c and c-d ridge counts on human soles. The mechanism of inheritance of ridge count of plantar interdigital areas has been studied among Brahmans of Sagar town of Central India. The correlation coefficient between ridge counts in various family relationships lend support to the concept of an additive genetic model.


The adult psychiatrist in the medical environment. To function effectively in the medical environment a psychiatrist must be comfortable with the skills and values of medicine. He or she must nurture his or her original knowledge in this area with an ongoing learning program. Certain problems are uniquely encountered in this environment. The psychiatrist must understand that various psychiatric disorders may be masked by or may mask somatic complaints. He or she must expect to deal with threatened and threatening patients. Most important, the psychiatrist must understand that to be effective he or she must make a commitment to involvement.


Stages of onset of schizophrenic psychosis. On the basis of a review of the literature describing the process of schizophrenic illness, the authors conclude that schizophrenic psychosis is one stage in a process of psychological and biological breakdown that has a specific structure and a characteristic unfolding consisting of the sequential appearance of hierarchically ordered, distinguishable, and recognizable psychological states. They present on illustrative case history of a patient who was able to describe her feelings during the process of decompensation to schizophrenic psychosis and two case histories of patients whose decompensations were rated according to the authors' State of Illness Rating Scale.


Clinical relevance of anthropological and cross-cultural research: concepts and strategies. The author presents a method through which findings from anthropological and cross-cultural research can be applied to problems affecting patient care. The clinical social science approach emphasizes the distinction between disease and illness and cultural influences on the ways "clinical reality" is conflictingly construed in the ethnomedical models of patients and the biomedical models of practitioners. The relevance of such research extends beyond special clinical concerns arising from ethnic differences to ubiquitous problems that result from cultural influences on all aspects of health care. Consultation-liaison psychiatry is a particularly appropriate vehicle for introducing clinical social science into medical and psychiatric teaching and practice.


Psychosocial aspects of mastectomy: I. the women's perspective. The authors administered a questionnaire to 41 women who had had mastectomies to investigate aspects of the procedure itself, pre- and postmastectomy adjustment, effects on sexual relationships, and the influence of age. Although most women reported good overall adjustment, there were strong indications of psychological suffering (suicidal ideation, increased use of alcohol and tranquilizers, etc.). Psychological intervention may be called for in many cases, and age, support systems, and premorbid functioning may be indicators of the amount and type of intervention needed. Counseling is particularly important before surgery, since this was viewed as the period of maximum stress by most women. Further research with larger, more random samples and postsurgical control groups is indicated to determine more precisely the factors related to adjustment to mastectomy.


The borderline adult: therapeutic alliance and transference. The author suggests that successful therapy with borderline patients requires the initiation, strengthening, and maturation of the therapeutic alliance as well as the working-through of the patient's difficulty with separation-individuation from the past. He defines a borderline transference as the activation and alternative projection on the therapist of the patient's primitive, split, positive, and negative object relations part-units. In the process of therapy confrontation and, later, interpretation bring these part-units to the patient's awareness, where they can be worked through and the separation-individuation process failure repaired. The therapist who deals with borderline patients must have both personal maturity and professional skill.


A profile of Asian-American psychiatrists. Of 367 respondents to a survey of Asian-American members of the American Psychiatric Association, fewer than 16% were American-born U.S. medical graduates, and 41% of the patients treated by this sample were minority group members. These findings have important implications for training. Asian psychiatrists have recently emerged as the largest visible multiethnic minority group within American psychiatry, and increased attention to this group may lead to its more appropriate utilization in this country.


The education and training of Asian foreign medical graduates in the United States. Asian physicians represent a growing majority among foreign medical graduates practicing psychiatry in the United States. The training of this group requires continued study and planning. Particular attention should be given to curriculum enrichment programs, the acculturation process, and role models and supervision.


Service delivery issues in Asian-North American communities. The authors describe some of the sociocultural factors (e.g., moralistic, religious, psychological, and familial characteristics) that influence the help-seeking behavior of Chinese psychiatric patients in North America. They propose a replicable approach for investigating sociocultural patterns relevant to service delivery to Chinese in other communities.


Research priorities in Asian-American mental health delivery. The author cites statistics which show that Asian-Americans underutilize mental health services. He suggests that more research is needed regarding the effects of such mental health delivery factors as language difference, familial reaction, community education, cultural changes, cross-cultural misdiagnosis, and therapeutic method.


Psychiatric disorders in a U.S. urban community: 1975-1976. The authors point out that new findings in psychiatric genetics and psychopharmacology support the heterogeneity of psychiatric disorders. They present data on the current rates of specific psychiatric disorders, using a recently developed diagnostic technique in a survey conducted in New Haven, Conn., during 1975-1976. The survey showed that depressive disorders are the most common diagnoses.


Evidence for genetic inheritance of primary affective disorder in adoptees. Offspring of psychiatrically disturbed and normal biologic parents, adopted away at birth, were followed up as adults. The psychiatric status of the adoptees was determined by adoptive parent and adoptee interviews. The incidence of depression was significantly higher in the affective-parented adoptees (3 depressed of 8 adoptees) than in the remaining adoptees whose biologic parents had other psychiatric conditions or were apparently psychiatrically well (8 depressed of 118). The results suggest a genetic factor in affective disorders.


Phantom bite syndrome.

Phantom bite syndrome. Despite repeated treatment failures, some individuals seek bite correction from a succession of dentists. Their pathological narcissism focuses on their bite, in a manner reminiscent of phantom limb phenomena. The dentist's diagnosis and treatment are manipulated until the patient claims them a failure and consults another dentist. The author suggests that this behavior represents a defense against paranoia and severe personality disorders.


ECT in metropolitan New York hospitals: a survey of practice, 1975-1976. Of New York psychiatric facilities surveyed, 83% used ECT. Five percent of patients in university and private nonprofit hospitals, less than 1% in public hospitals, and 21% in private for-profit hospitals received ECT. Practices and procedures were remarkably uniform, except that less than 17% of units used unilateral ECT. Training programs were minimal and unplanned. Differences in incidence of use result from staff training, public antipathy, and economic factors.


Contamination of the home environment by patients treated with Iodine-131: initial results. We have employed twin sodium iodide radiation detectors to analyze iodine-131 transfer from thyroid patients to their families. Unlike previous studies of this problem, we measured thyroid radioiodine activity directly and are able to detect as little as 92 pCi of iodine 131 in adult thyroids. As in previous studies, we have also measured direct radiation exposures of family members with wristband thermoluminescent dosimeters. Thus far, we have studied seven families with 17 persons. Eleven of these are children under age 16. Direct radiation exposure of family persons from proximity of these radioactive patients ranged from 0.17 to 126 mR per day (natural background radiation amounts to approximately 0.35 mR per day). The maximum activity of iodine-131 in family thyroids ranged from less than 92 pCi to as high as 110,000 pCi and resulted in thyroid dose equivalents of 4 to 1330 mrem. Based on recent estimates of thyroid cancer, the latter dose equivalent could possibly double the risk of thyroid malignancy in children over what is expected normally. Such a risk implies the addition of 10 induced cases to the 10 naturally occurring cases per million people per year.


Laceration of the median nerve from skiing. Increased numbers of injuries to the upper extremity are being seen since improved equipment is available to protect the lower extremity. Three patients, who are excellent skiers, have been seen in which significant structures of the wrist were lacerated by the sharp outer edge of the ski. Well fitted leather gloves or mittens designed to protect the palmar surface of the wrists are recommended during skiing. We must now focus our attention to design better protection for the more vulnerable upper extremity during the sport of skiing.


Occult osteomalacia in American (U.S.A.) patients with fracture of the hip. Low-grade osteomalacia, detectable only by quantitative histological measurement, was present in eight of 31 femoral heads from normocalcemia American patients having intracapsular fracture of the hip. The histological changes were of a much lower degree than those observed in overt clinical osteomalacia. Further, regional differences between the osteoid content of the proximal femur and iliac crest were demonstrated in 13 age-matched controls. In these, the osteoid content of the femoral bone averaged only 30% of that in the iliac crest.


Lipoadenoma of the parathyroid gland.

Lipoadenoma of the parathyroid gland. An unusual parathyroid adenoma containing abundant adipose tissue is described in four patients. In one patient, hyperparathyroidism was documented; in another, studies were incomplete but the adenoma was probably functioning. Prior reports of similar lesions have been called "parathyroid hamartoma or parathyroid adenoma with myxoid stroma," and some of these also have been shown to be functional. They may create diagnostic difficulties because of the presence of adipose tissue, a feature associated with normal parathyroid glands.


Treating "cauliflower ear" with silicone mold. Acute hematoma of the ear (cauliflower ear) can be satisfactorily treated with aspiration and the use of the silicone mold to prevent reaccumulation of the blood or serum in the ear. Advantages of the silicone mold over other dressings appears to be ease of application, patient acceptance, and prevention of reoccurrence of reaccumulation of the hematoma.


Adenosquamous and squamous cell carcinoma of the colon. Adenosquamous and squamous cell carcinomas of the colon are uncommon tumors; only 28 have been previously reported. In a review of 5,969 colonic adenocarcinomas (excluding anorectal cancers). I identified six carcinomas with squamous features. This is a frequency of 0.1% relative to the incidence of "usual" adenocarcinomas of the colon. An association of squamous neoplasia in the colon and chronic ulcerative colitis is noted.


Injury prediction in the young athlete: a preliminary report. Joint flexibility and laxity as measured by 5 indices among 2,300 West Point cadets demonstrated no statistical relationship to joint injuries, or the need for surgical intervention resulting from injuries sustained in general athletic competition involving the ankle, knee, shoulder, or elbow. Similarly, no relationships were seen in a high school and collegiate football team. Parameters of flexibility vary significantly among different athletic population groups as related to age, sex, and type of athletic activity in which the individual is participating. In that part of the study conducted during the 1975 football season, the 16PF showed some potential for predicting injuries. However, stronger relationships between predictor and criterion variables must be established in the future before injury predisposition counseling is a possibility. Hopefully, continuing study will bring this into being and will extend to younger and younger individuals and other population groups. This would facilitate the development of an injury profile index to assist in the counseling of athletes into sports where their individual traits are protective and beneficial, rather than detrimental.


Giant-cell containing "fibrous" lesion of the sacrum. A roentgenographic, pathologic, and ultrastructural study of three cases. Three similar and unique, predominantly osteolytic lesions are reported in young patients between the ages of 4 and 19 years. Progressive back pain and neurologic deficits were the principal clinical features. The initial roentgenographic impression was that of a malignant tumor either primary or metastic. Despite incomplete resections of a firm, intraosseous and extradural tumor, healing has occurred during the follow-up interval with one interim exception. A spindle-cell stroma containing a variable number of giant cells was the consistent microscopic finding. Ultrastructural studies of one case revealed that the mononuclear spindle cells and giant cells contained cytoplasmic microfilaments similar to those of the myofibroblast. The possible relationship of this tumor to nodular fasciitis and desmoplastic fibroma is hypothesized in the light of the role of the myofibroblast in the fibromatoses and nodular fasciitis.


Pulmonary resection for metastatic neoplasms in the lung. Experience at the Massachusetts General Hospital. Cumulative survival in a series of 142 patients undergoing 163 pulmonary resections for metastatic malignant disease is 30% at five years, a statistic that is slightly higher than survival for 820 cases of resection for primary lung carcinoma at the same institution (26%). Removal of pulmonary metastases continues to be a relatively safe approach with hospital mortality of 1.2% and low operative morbidity. Unfavorable predictors, if primary disease is under control, are limited. The primary ones include extent of disease requiring pneumonectomy, melanomatous disease, and appearance of the metastasis antedating knowledge of the primary. An aggressive approach to removal of pulmonary metastases merits continued consideration.


Management of the upper extremity with absent pulses after cardiac catheterization. Thirty-one patients had a delayed loss of brachial artery and radial artery pulse after cardiac catheterization; eleven of the patients had early embolectomy or a vein patch graft and 82% of these had immediate restoration of pulse and remained asymptomatic. Early surgery failed in two patients, requiring late vein bypass grafting for claudication. Twenty patients did not have early surgery, eleven (55%) remaining asymptomatic and nine (45%) developing ischemic symptoms. Five of these nine patients (25%) required late vein bypass grafting for severe claudication. Of the fifteen patients who lost their pulse and did not undergo surgery, the average Doppler forearm pressure immediately following the occlusion was 50 mm Hg (pressure index=0.46). The average Doppler pressure measured at the time of follow-up was 80 mm Hg (pressure index = 0.61). Early local surgery is highly successful in patients who lose their radial artery pulse after cardiac catheterization. Conservative nonoperative therapy may be successful but often results in late ischemic symptoms that may require late vein bypass grafting.


Macroamylasemia and other chronic nonspecific hyperamylasemias: chemical oddities or clinical entities? Seventeen patients with chronic hyperamylasemia were studied using standard clinical and laboratory parameters, amylase/creatinine clearance ratios, and polyacrylamide gel electrophoresis of serum amylases. These patients, none of whom had evidence of pancreatic disease or other specific source for the elevated serum amylase, fell into three groups: (1) Normal serum isoamylase profile and normal amylase clearance (6 patients). We postulate that the generalized hyperamylasemia may be due to reduced extrarenal catabolism of amylase, a previously undescribed phenomenon. (2) Macroamylasemia and very low amylase clearance (9 patients). Seven of the nine patients had recurrent epigastric pain. Evidence for an autoimmune basis is discussed. (3) Salivary-type hyperamylasemia and low amylase clearance (2 patients). This entity may really be macroamylasemia in which the macroamylase complex dissociated during analysis. Chronic hyperamylasemia is often not of pancreatic origin. The assumption that the pancreas is at fault, especially if there is abdominal pain, may cause morbidity due to gross overtreatment.


In pursuit of the unknown primary.

In pursuit of the unknown primary. The case histories of sixty-seven patients were reviewed to evaluate the contribution made by various x-ray and laboratory studies to the diagnosis and treatment of systemic metastases from unknown primary tumors. When used as screening procedures, radiographic contrast studies were rarely helpful unless the test was indicated by appropriate symptoms. The large number (8 of 27) of misleading ultrasonic scans rendered that study a major source of confusion. Inadequate tissue samples were another cause of confusion and delay. Even with adequate tissue samples, a definitive pathologic diagnosis could be assigned to only forty-five of the sixty-five patients who underwent biopsy. After extensive diagnostic evaluations, only thirty-one of the sixty-seven patients received chemotherapy for specific diagnoses. Objective remissions were seen in four of thirty-one recipients of specific chemotherapy and one of five patients treated without a primary diagnosis. The same patients would have received the same therapy had the diagnostic workup been limited to x-ray studies of symptomatic systems, adequate tissue sampling, and appropriate pathologic examinations followed by treatment of the "most treatable" disease.


Survival and limb salvage in patients with infected arterial prostheses. A series of 590 cases with a 2.5% rate of infection of arterial prostheses is presented. When one of the anastomoses was in the inguinal area, the incidence of prosthetic infection was higher. Two infections not involving the anastomotic site healed with conservative management. The three patients with aortoduodenal fistulas died. The long-term survival was 62%, and the amputation rate was 31%. During the last two years, a more aggressive surgical approach of total removal of the infected prosthesis and its replacement with an extraanatomic bypass has been instituted. With this approach, only one death and one amputation has occurred in six patients.


Detection and treatment of recurrent cancer of the colon and rectum. A series of 177 patients with recurrent colorectal cancer treated at the Massachusetts General Hospital is examined retrospectively. Two thirds of recurrences were observed by the second postoperative year, and 15% of patients were asymptomatic. Pelvic recurrences were usually attributable to rectal or sigmoid tumors, whereas right-sided carcinomas frequently spread to the liver. The commonest methods of clinical discovery of recurrence included findings of abdominal and pelvic masses, hepatomegaly, and positive chest films. The average survival after discovery of recurrence was only eleven months, but 23 patients having reresections for cure lived an average of thirty-three months. Seven patients (30%) undergoing reresection for cure represented probable cures. Chemotherapy with intravenous 5-FU provided poor palliation, but radiotherapy gave satisfactory relief of symptoms in approximately 50% of patients, particularly those with rectal or low colon lesions. A program of follow-up is offered since there is evidence that even the symptomatic patient may be well palliated or even cured by surgical resection of the recurrence or palliative therapy.


Adjuvant radiation therapy in colorectal carcinoma. A series of sixty-five patients with adenocarcinoma of the rectum and rectosigmoid is reviewed. Thirty-two patients had surgery alone, fourteen patients underwent postoperative radiation therapy, and nineteen patients underwent preoperative radiation therapy. A moderate dose program of 4,000 to 4,500 r was used. The postoperative treatment group had a higher incidence of stage C lesions and a higher recurrence rate, but there were no statistically significant differences in survival. Postoperative radiation therapy in patients with stage C lesions did not prolong life and is of little benefit. The preoperative treatment group tolerated the radiation very well, and there were no major complications. Eight patients underwent anterior resections in irradiated fields. Two minor anastomotic leaks subsequently healed spontaneously. There were no pelvic recurrences in the preoperative treatment group, and the incidence of lymph node metastases was 26% as opposed to 41% in controls. We conclude that preoperative moderate dose radiation is not associated with increased risk of morbidity or mortality. It may be useful in reducing the incidence of lymph node metastases and pelvic recurrence. The effect on survival is not determined in this study.


Anastomotic dehiscence after low anterior resection of the rectum. Thirty-two patients who had anastomoses to the extraperitoneal rectum underwent radiographic contrast studies about two weeks after operation in order to determine the incidence of anastomotic dehiscence. No extravasation occurred in the sixteen anastomoses in which the middle hemorrhoidal arteries were intact, but partial disruption occurred in four of seventeen (24%) anastomoses in which the middle hemorrhoidal arteries were sacrificed. Since not all patients with anastomotic dehiscence after low anterior resection are symptomatic, the incidence of anastomotic breakdown will be under-estimated unless x-ray studies are performed. More data are required for a better understanding of the technical features of operation which will reduce the incidence of leakage from anastomoses to the extraperitoneal rectum.


Acute fulminating transmural ileocolitis after small bowel bypass for morbid obesity. A personal series of small bowel bypass operations for morbid obesity is presented. The importance of careful considerate follow-up by the operating surgeon is stressed. The development of acute fulminating transmural ileocolitis, Crohn's disease, in a patient twenty-two months after such surgery is reported and considered merely a dangerous coincidence, combining an acute colonic disease with a short small intestine.


Screening for lower extremity deep venous thrombosis. An improved plethysmographic and Doppler approach. Noninvasive screening of the lower extremities for deep vein thrombosis was performed bilaterally on 1,118 patients. Impedance plethysmography alone was used in 868. Venography in 135 revealed an accuracy of 88%, with a false-negative rate of 5.3% and a false-positive rate of 18.6%. A combined ultrasonic Doppler and modified impedance technic was used in 250 patients. Venography in forty revealed an accuracy of 95%, with a false-positive rate of 10% and no undetected thrombi. The combined technic, emphasizing the more accurate modality in three anatomic areas, has proven sensitive, specific, and reliable as a screening test for deep venous thrombosis.


Computerized discrimination of microemboli in extracorporeal circuits. A computerized ultrasonic particle detection system is capable of identifying microemboli in the 10 to 350 microgram. Data show that appropriate computer analysis of the reflecting signals allows discrimination of size and type of emboli. All extracorporeal circuits have microemboli with a large variation in size and number, depending upon the apparatus and how it is run.


Noninvasive intraoperative monitoring: a prospective study comparing Doppler systolic occlusion pressure and segmental plethysmography. Seventy-two limbs in forty patients underwent Doppler systolic ankle pressure and Pulse Volume Recording (PVR) amplitude measurements intraoperatively. Control patients and patients undergoing abdominal aortic aneurysm (AAA) resections showed no significant decrease in Doppler systolic ankle/brachial pressure ratio (DSAB). PVR measurements were slightly decreased after declamping in the AAA patients. Femoropopliteal bypass was associated with a prompt increase in PVR and DSAB levels. In contrast, postreconstruction values in the extraanatomic (EA) and aortofemoral (AF) bypass groups were dependent upon the patency of the femoropopliteal segment. Intraoperative monitoring provides a quantitative assessment of the immediate success of arterial surgery.


Management of penetrating heart wounds.

Management of penetrating heart wounds. The records of ninety-two patients treated between 1965 and 1976 at the Boston City Hospital for penetrating wounds of the heart were reviewed and the results were compared with a previous series of twenty-five patients admitted to the same institution between 1956 and 1964. The annual incidence rose from 2.8 cases during the first period to 8.0 during the more recent years. Gunshot wounds increased in frequency in the second period. The overall mortality was similar in the two series. However, there were more complex wounds and agonal patients subjected to immediate emergency room thoracotomy during the second phase of this experience. The salvage rate in the latter group of patients gradually improved and averaged 24% between 1965 and 1976. These data indicate that an aggressive approach, including the use of immediate thoracotomy, to the agonal patient with a heart wound will be rewarded with salvage of some patients.


Plastic mesh repair of incisional hernias. During eight years polypropylene mesh was used in fifty-three patients for the repair of difficult incisional hernias. There was no operative mortality, and the mesh has been uniformly well tolerated. To date, recurrences have been observed in six patients (11.3%), a distinct improvement over the era before mesh was used. Greater attention to the details of mesh fixation may further lower the recurrence rate.


Hydatid disease of the liver.

Hydatid disease of the liver. Our experience in the surgical management of hydatid disease of the liver in 212 patients over the past eighteen years is reviewed. The most frequent postoperative complications and mortality rates of elective and emergency procedures are presented, and the more frequently utilized operative technics are described. In the great majority of patients conservatism was the rule in excision of solitary or multiple cysts. It is important to establish whether or not hepatic cysts communicate with the biliary tree. In these cases, enteroanastomoses (such as cystjejunostomy or cystgastrostomy) may be utilized depending on the position of the cyst. Any associated biliary disease (such as lithiasis or fibrosis) should be taken care of at the same time. External cystic drainage (marsupialization) is contraindicated because of the high incidence of chronic external biliary fistula, secondary hemorrhage, sepsis, and postlaparotomy hernia. In those patients in whom the cyst has penetrated the diaphragm and communicates with the lung, treatment should be carried out in one stage whenever possible.


Primary malignant tumors of the small intestine. A twenty-two year experience with thirty patients. A review of thirty cases of primary malignant small bowel tumors is presented. Chronic obstruction was the presenting symptom most frequently encountered, with an acute abdomen from perforation of the tumor next in frequency. Adenocarcinoma and carcinoid were about equally encountered, and more than half of all tumors were found in the ileum. Three patients are alive and well, two are alive on chemotherapy, and all others are dead. Five of these died of other causes. Of twenty-seven patients explored for symptomatic small bowel cancers, only one is alive free of tumor. Malignant small bowel tumors are difficult to diagnose early and have a poor prognosis.


Diagnostic value of the portable chest x-ray technic in pulmonary edema. The ability of the portable chest x-ray film to define the amount of physiologic shunting and the severity of noncardiogenic pulmonary edema was evaluated in thirty-seven observations of eleven patients. Ten of the eleven patients were suffering from acute respiratory failure. The radiologic assessment of the amount of pulmonary edema and the severity of left ventricular failure were compared with the physiologic shunt fraction, tracer-measured lung water, and pulmonary arterial wedge pressure. The radiologic scores for edema did not predict the shunt fraction or tracer measurements of lung water. The radiologic score for congestive failure correlated with the wedge pressure but not well enough to be clinically useful. Five per cent of the x-ray results were false-positive and 11 per cent false-negative. Results indicate that the portable chest x-ray technic does not provide quantitative information regarding cardiopulmonary function. It is especially hazardous to accept an x-ray diagnosis of congestive failure as the cause of pulmonary edema.


Anticholinergic drugs in anaesthesia. A survey of their present position. A survey was carried out amongst anaesthetists in the United Kingdom and Ireland regarding the use of anticholinergic drugs. Sixty-two per cent of these anaesthetists use these drugs routinely in premedication. The drugs are nearly always atropine or hyoscine and are used mainly for reducing secretions and protection against vagal stimulation. A longer-acting drug was desired by 22% and 60% would like to use an orally effective anticholinergic drug. Though quite a number of minor side effects are high-lighted, the majority do not consider these serious enough to stop routine use. There is now a tendency amongst many anaesthetists either not to use these drugs routinely or use them less often, more rationally and in reduced dosage.


The interaction of halothane and pancuronium bromide. A study in dogs. The interaction of halothane and pancuronium is demonstrated in the dog tibialis anterior-sciatic nerve preparation. The results show a dose related effect of halothane on the recovery index and the 50% recovery times. These results are compared to other reports and possible mechanisms are discussed.


Circulatory effects of labetalol during halothane anaesthesia. Labetalol is a drug possessing both alpha and beta adrenergic receptor blocking properties. Its possible use in induced hypotension during halothane anaesthesia has been investigated. It causes a satisfactory decrease in arterial pressure unaccompanied by tachycardia. The circulatory effects of the drug during halothane anaesthesia, both with spontaneous and controlled respiration, have been measured and compared with those of halothane alone. In patients anaesthetised with 1% halothane, labetalol, with both spontaneous and controlled ventilation, was associated with a reduction in MAP from 71.5 mmHg to 54.0 mmHg (P less than 0.001) and 66.8 mmHg to 50.4 mmHg (P less than 0.001) respectively. This reduction was associated with decreases in Qt of 18% and 12% respectively. In the presence of labetalol, with 3% halothane and spontaneous respiration, the depressant effects of the anaesthetic on the heart became rapidly apparent: Qt was reduced by a further 28%. In patients not receiving labetalol, the depressant effects of 3% halothane were frequently countered by the positive inotropic effects of hypercarbia.


Hazards of central venous pressure monitoring. In shock syndromes, cannulation of the central veins has become standard practice. The procedure, although valuable, is not completely innocuous. Fatal complications as a result of perforation of the sinus coronarius with resultant cardiac tamponade, and a laceration of the subclavian artery are described, in addition to the previously reported complications encountered during such monitoring. It is of vital importance that the procedure be prescribed and supervised only by those who are thoroughly skilled in its use and that there be awareness of the early symptoms of cardiac tamponade when a venous catheter is in situ.


Anaesthesia for bronchoscopy. A laboratory study using the Nuffield lung ventilator with the injector technique. The control module of the Nuffield (A-P) Anaesthetic Ventilator was found to be an efficient means of automatically controlling the ventilation of the lungs through a bronchoscope during a series of laboratory experiments. The relationships between lung characteristics (compliance and airway resistance) and the driving flow rate through various injectors on the final oxygen concentrations and tidal volumes delivered were determined. A 14 gauge injector provided the largest tidal volumes with the least entrainment of air.


Cardio-respiratory effects of nitrous oxide:oxygen:halothane anaesthesia administered to dental outpatients in the upright position. The cardio-respiratory responses of fifty-three healthy dental patients receiving 30% oxygen with nitrous oxide and halothane whilst seated upright are reported. A high degree of sympathetic autonomic activity was noted with considerable lability of the blood pressure and pulse rate. Hypoxaemia caused by respiratory obstruction, unrecognised by the anaesthetist, occurred in approximately 20% of patients at the time of insertion of the prop or pack and during removal of teeth.


Method of measuring blood loss.

Method of measuring blood loss. An easy rapid method of calculating blood loss during paediatric surgery using an osmolality dilution technique is described. Known volumes of whole blood packed red blood cells and plasma were measured in the laboratory using this method. A statistical analysis of the results suggest that this technique would be useful for measuring blood loss in the operating theatre.


Directional spinals in obstetric analgesia. Directional characteristics of spinal injections delivered via a 22 gauge Whitacre needle were confirmed in twenty-one obstetric patients undergoing elective Caesarean section. Caudad injection was inadequate for elective Caesarean section, while cephalad or lateral injection provided good sensory levels for the duration of the surgery. It is speculated that along with the low incidence of postspinal headache and ease of administering the block with a more rigid 22 gauge needle, low dose caudally directed injections may provide a superior means of administering saddle block analgesia for obstetric patients.


Anaesthesia for mediastinoscopy.

Anaesthesia for mediastinoscopy. The hazards associated with anaesthesia and surgery for mediastinoscopy are reviewed. A successful general anaesthetic technique in a series of twenty cases is described. Recommendations are put forward about the anaesthetic management of patients undergoing this investigation.


[Epidural anesthesia with bupivacaine 0.75% in comparison with bupivacaine 0.5% and mepivacaine 1.5% with adrenaline (author's transl)]. 147 patients undergoing low laparotomies, perineal operations and operations on the lower limbs were given bupivacaine 0.75%, bupivacaine 0.5% or mepivacain-adrenaline 1.5% for epidural anaesthesia. The anaesthesia was most effective after bupivacaine 0.75%. In this group the intensity and duration of both sensory analgesia and motor block were more prolonged. No serious complications occurred. No increase in toxicity, when using bupivacaine 0.75% (total dose of 128 mg) for epidural anaesthesia, has been shown in this clinical trial.


[The use of nerve stimulators for nerve blocks (author's transl)]. The clinical experience using peripheral nerve stimulators for nerve blocks is described. This method has the advantage that the patient cooperation is not required. In addition injections of local anaesthetic agents can be placed more accurately and therefore the total dose may be lowered. Thus successful injection is more probable and the possibility of an inadequate block, a Wedensky block, is diminished. 301 therapeutic blocks and 195 blocks for clinical anaesthesia are described.


[Physiology and pathophysiology of subarachnoid and epidural block (author's transl)]. The most important patho-physiological changes following subdural or epidural blockade are seen in the central nervous system and cardiovascular system. Preganglionic sympathetic blockade is the main reason for these changes. Sympathetic blockade is followed by a decrease in peripheral vascular resistence and alterations in the arterial and venous circulation. Hypotension occurs frequently and is thus of great interest in clinical anaesthesia. Differences in the degree of nerve block are not only seen when comparing spinal and peridural blockade but also relate to the different pharmacodynamic properties of local anaesthetics. These pharmacodynamic differences are very pronounced when the new long acting local anaesthetics bupivacaine and etiodocaine are compared in respect of motor and sympathetic denervation. All severe patho-physiological changes following subdural and peridural blockade are predictable and can be avoided by proper prophylactic treatment.


[The effect of methohexital, fentanyl, droperidol, and chloralose on the aortic baroceptor discharge of decerebrated cats (author's transl)]. The effect of methohexitone, fentanyl, droperidol and chloralose on the response characteristics of aortic barorecptors was studied in decerebrated cats. The conclusions rest on the analysis of the drug effect on the stimulus-response curves of individual baroceptor fibres of the aortic region relating the average discharge rate (spike/s) to the average aortic arch pressure which was altered over wide ranges by a balloon catheter located in the thoracic aorta. The stimulus response curves were shifted to higher activities by methohexitone and less obviously also by droperidol. Contrarywise, chloralose and fentanyl shifted these curves to lower activities. Thus, the first two drugs increase the afferent receptor drive and favour the development of arterial hypotension, whereas the last two decrease the afferent receptor drive and act to stabilize the arterial pressure. Interestingly, at comparable depth of anesthesia arterial blood pressure levels tend to be lower with the first kind of anaesthetics as compared with the last.