Relationship between arsenic intake and internal malignant neoplasms. An attempt has been made to assess the carcinogenic effect of arsenic intake by analyzing a group of patients who were treated with arsenic for various skin diseases in the 1930s. When compared with the expected incidence of malignant internal neoplasms, based on figures obtained from the Danish Cancer Registry, a significant increase in the incidence of internal malignant neoplasms was observed in females with multiple basal cell carcinomas. A group comprising 53 patients with arsenic keratoses presented a considerable increase in the incidence of internal malignant neoplasms. However, these patients were so specifically selected that no regular statistical analysis can be made of this group. It may be said that arsenic has a carcinogenic effect even in the relatively small doses applied in dermatological therapy.


Diaper area granuloma of the aged.

Diaper area granuloma of the aged. Nine women, aged 77 to 89 years, suffered from diaper dermatitis, and many granulomas were seen in the genital or gluteal region restricted to the lesion of dermatitis. Because these granulomas resembled granuloma gluteale infantum of Tappeiner and Pfleger, we propose to call this condition diaper area granuloma of the aged.


Effects of occlusive tape systems on the mitotic activity of epidermis. With and without corticosteroids. This study was designed to elaborate on the effects of occlusion and corticosteroids on human epidermal mitotic activity. The experimental variables included tape delivery systems that afforded total, partial (50%), or no occlusion to normal human skin. In some experiments, hydrocortisone, flurandrenolide, betamethasone, betamethasone valerate, and fluorometholone were added to these tape systems. Using demecolcine cream, biopsies were taken, and mitotic figures were determined. Results suggest that potent antimitotic effects occur with semiocclusive and nonocclusive tapes that contain corticosteroids, and that total occlusion is not necessary for this physiological effect. This suggests the possibility that the presumably better tolerated nonocclussive and partially occlusive systems might be used as dermatological drug delivery systems.


Photochemotherapy of psoriasis (PUVA) without specialized equipment. High intensity long ultraviolet light (UV-A) systems along with oral methoxsalen (8-methoxypsoralen [8-MOP]) have been dramatically successful in clearing long-standing psoriasis. Since this equipment is beyond the reach of many dermatologists, we have examined alternate ways of achieving the benefits of PUVA photochemotherapy. A total of 24 patients with psoriasis have been treated with ordinary fluorescent blacklights in a conventional Zimmerman cabinet. Fourteen patients' conditions (58%) were cleared completely and the conditions of three (12%) were more than 80% improved. We used higher doses of 8-MOP, starting with 50 mg, and increased the dosage further in 15 cases. In five instances, 80-mg levels were given. With certain modifications, it may be possible to attain satisfactory therapeutic results with ordinary equipment. Higher doses of 8-MOP may be necessary to compensate for the lower irradiance light source in some instances. However, wide-spread use of PUVA therapy cannot be recommended at this time until the long-term effects of this treatment become known.


Atopic dermatitis, impaired cellular immunity, and molluscum contagiosum. A substantial elevation in the level of serum IgE (7,000 to 19,000 ng/ml) was noted in a man with atopic dermatitis and chronic molluscum contagiosum. Cell-mediated immunity (CMI) was depressed in vivo (cutaneous anergy), whereas in vitro tests showed normal numbers of "T" rosette-forming lymphocytes, a normal phytohemagglutinin-P-elicited lymphocyte transformation response, and lymphocyte transformation reactivity to the antigens streptokinase-streptodornase and purified protein derivative. Accumulated evidence suggests that patients with atopic dermatitis may have, associated with an elevated serum IgE level, a functional defect(s) in CMI that is greater in vivo than in vitro. This functional defect may impair host defense and account for the chronic molluscum contagiosum infection present in this patient.


Lymphangioma circumscriptum. A case with deep lymphatic involvement. Lymphangioma circumscriptum is a rare disorder that is localized to the skin. To our knowledge, involvement of deeper lymphatic structures has been reported on only two prior occasions. Our patient had typical lymphangioma circumscriptum of her inner thigh, which was associated with deep lymphatic involvement and enlargement of the extremity. We report this case to alert others to this disease entity.


Mycosis fungoides involving the brain and optic nerves. In a patient with long-standing plaque-stage mycosis fungoides, eye pain, a visual field defect, decreased acuity, and a swollen optic disc developed. A lymphomatous infiltrate consistent with mycosis fungoides was found in the brain at craniotomy and in the optic nerves at autopsy. Ten months elapsed between the presenting symptoms and death and during this period the patient's symptoms were controlled with prednisone therapy. The optic nerves as well as the brain can be involved with mycosis fungoides.


Reticular pigmented anomaly of the flexures. Reticular pigmented anomaly of the flexures (Dowling-Degos' anomaly) is a rare, benign, new genodermatosis that has recently evolved from independent observations and studies by several dermatologists. Because of its favorable prognosis, differentiation of this benign disorder from acanthosis nigricans, a cutaneous marker of possible or existing internal malignant disease, is highly important. Careful clinical appraisal of the eruption in correlation with the characteristic microscopic features makes the diagnosis simple and straightforward.


Varicella-like infection due to herpes simplex. Hepes simplex usually presents with fairly characteristic skin lesions that are localized to small area. A less well appreciated presentation for herpes simplex is a varicelliform eruption that may be difficult to differentiate from chickenpox. We treated a patient with such an eruption who had systemic lupus erythematosus and was receiving oral prednisone. We also review seven other cases from the literature of varicella-like herpes simplex and discuss the role played by immuno-suppression in herpetic infections.


Inflammatory linear verrucose epidermal nevus. We treated three patients with inflammatory linear verrucose epidermal nevus. The lesions were either verrucose or psoriasiform and all had an inflammatory component. Histologic features included psoriasiform acanthosis with spongiosis and parakeratosis. Features that distinguish this entity and the differential diagnoses are discussed.


Uveitis, poliosis, hypomelanosis, and alopecia in a patient with malignant melanoma. Bilateral uveitis, poliosis, hypomelanosis, and alopecia (Vogt-Koyanagi-Harada syndrome) developed spontaneously in a 57-year-old woman following operation for metastatic malignant melanoma. She has been disease-free for 8 1/2 years in spite of a highly unfavourable prognosis. Within the framework of current concepts of cell-mediated and humoral immunity in patients with malignant melanoma, activity of the host's immune system is postulated for the destruction of normal melanocytes in the skin, hair follicle, and uveal tract, as well as for the favorable outcome.


Contact dermatitis to homomenthyl salicylate. Two patients with follicular dermatitis were found to have a contact sensitivity to homomenthyl salicylate, a sunscreening chemical present in a commercially available suntan lotion. One patient did not use the product, but her boyfriend did, and contact between the two individuals resulted in a follicular dermatitis developing in her. A second patient with contact dermatitis to homomenthyl salicylate also had a follicular eruption. Both patients appear to represent true allergic sensitivities.


Residence under an airport landing pattern as a factor in teratism. An analysis of all Los Angeles County birth records for the years 1970, 1971, and 1972 reveals a higher incidence of reportable birth defects in those census tracts lying wholly or partly within the 90 dbA loudness contours under the landing pattern at Los Angeles International Airport than in the rest of the County. While not proving that noise is responsible for the increase in teratism, these results point to a potentially important physical environmental effect with significant public health implications.


The occupational hazards of formulating oral contraceptives--a survey of plant employees. In May 1976 an investigation of a factory in Puerto Rico which formulates oral contraceptives revealed that during the previous 12 months five of the company's twenty-five employees (20%), and twelve of the company's thirty female employees (40%) had experienced symptoms associated with hyperestrogenism. The affected males had gynecomastia and three of them also reported a history of decreased libido or impotence. The affected females each had had at least one episode of intermenstrual bleeding during the preceding 12 months. There was an estimated relative risk of 4.3 for intermenstrual bleeding in nonclerical female employees compared with matched controls who did not work at the plant. Elevated levels of plasma ethinyl estradiol were twice as frequent in the two highest-risk job categories compared with the rest of the factory population, but the difference in prevalence of elevated levels was not statistically significant (P = 0.08). Wide variations in mestranol concentration were noted in the environmental dust samples. Prompt consideration should be given to establishing health standards for persons occupationally exposed to estrogens in view of the possible long-term sequelae of such exposure.


Neutrophil chemotaxis in rheumatoid arthritis. Effect of D-penicillamine, gold salts, and levamisole. The effect of therapeutic concentrations of D-penicillamine, sodium aurothiomalate, and levamisole on in vitro neutrophil chemotaxis and random migration in normal subjects and patients with rheumatoid arthritis was studied. D-penicillamine produced no changes. Sodium aurothiomalate produced dose-related reductions in chemotaxis in normal subjects and in patients who had a good clinical response to gold therapy, while patients who had failed to respond to gold showed a minimal nondose dependent reduction. Levamisole produced dose-dependent stimulation of chemotaxis, a greater effect found with the patients cells. Neutrophil chemotaxis improved to normal values in most patients responding to several months of D-penicillamine treatment but showed an immediate and marked stimulation in patients treated with levamisole.


Mesothelioma and asbestos in the Province of Quebec, 1969-1972. All records of patients who died of mesothelioma in the Province of Quebec during the period 1969-1972 were collected and reviewed. Asbestos exposure in this group was compared with that in two control groups, one of persons dying of accidental causes and the other of those dying of cardiovascular disease. The mortality rate for mesothelioma was estimated at between 2.3 and 2.8 per million per year. Men were affected twice as frequently as women, this difference being related exclusively to pleural mesothelioma. The incidence in urban regions was much higher than in rural areas, and areas involved in mining showed an incidence in the expected range. Thirty-four percent of the patients with mesothelioma and only 2% of controls had histories of direct exposure to asbestos. This exposure was related to asbestos processing and not its production. No woman gave a history of occupational exposure to asbestos. It appeared that chrysotile may be less related to the production of mesothelioma than other types of asbestos fibers.


Synovial cysts in juvenile rheumatoid arthritis. In a case of juvenile rheumatoid arthritis with large synovial cysts, cyst fluid aspiration was performed to relieve pain, but recurrence was prevented with salicylate therapy alone. The mechanism of formation of synovial cysts is discussed.


Effect of TLV levels of SO2 and H2 SO4 on bronchial clearance in exercising man. Pulmonary mucociliary function was assessed following exposure to industrial threshold limit values (TLV) of sulfur dioxide (5 ppm) SO2) and sulphuric acid mist (1 mg/m3 H2SO4). Bronchial clearance was measured in two sets of ten healthy exercising non-smoking adults under control and exposure conditions. A 99mTc-albumen saline aerosol (MMD 3 micrometer) was inhaled as a bolus in late inspiration under controlled conditions to produce reproducible deposition in large airways. Lung retention of radioactivity was quantified using a gamma camera and computer analysis. Clearance was significantly faster (P less than .05) on exposure to both SO2 and H2SO4 compared to control values. Maximum mid-expiratory flow rates (MMFR) were significantly reduced (P less than .01) on exposure to SO2 (mean decrease 8.5%), but only slightly reduced for H2SO4 (1.4%). The speeding in clearance was probably an irritant response in both cases. For SO2 the response appeared predominantly reflex, while H2SO4 showed evidence of a direct effect.


Antigammaglobulin (rheumatoid factor) activity of human IgG subclasses. A sensitive radioimmunoassay has been applied to the study of rheumatoid factor activity of IgM and IgG subclasses in serum and synovial fluid of patients with rheumatoid arthritis. Although rheumatoid factor activity was found in all four subclasses, its distribution was not the same as that of the total subclasses in normal sera. Results are discussed in relation to the possible clinical value of measuring IgG rheumatoid factor in sera and synovial fluids of patients with rheumatoid arthritis.


Mortality among individuals occupationally exposed to benzene. The mortality experience of 594 individuals occupationally exposed to benzene was investigated using a retrospective cohort design. Three hundred thirty-five of the employees began working in benzene areas prior to 1950, which provided a sound data base from which to examine latency. Data derived from work histories and industrial hygiene records permitted estimation of exposure intensities and cumulative dosages for each employee. No mortalities directly attributable to benzene exposure were observed. Several cases of leukemia and other blood disorders were noted and discussed.


Altered phospholipids in human rheumatoid synoviocytes. A specific cytochemical reaction for freely available phospholipids has shown a raised concentration of such phospholipids in the lining cells of human synovial membranes removed from rheumatoid joints. Quantitative measurement, by microdensitometry, of the amount of reaction-product per cell showed that the rheumatoid synoviocytes contained almost three times the amount of free phospholipids present in the equivalent nonrheumatoid cells; statistically the difference was highly significant. Evidence from studies in which the bound phospholipids were 'unmasked' by methanol-chloroform confirmed the view that the increased content of freely available phospholipids was related to altered lipid-protein binding rather than to an increase in total phospholipids.


Ankylosing spondylitis and inflammatory bowel disease. I. Prevalence of inflammatory bowel disease in patients suffering from ankylosing spondylitis. To establish the prevalence of inflammatory bowel disease in ankylosing spondylitis (AS), 79 AS patients underwent detailed medical screening, including sigmoidoscopic and roentgenological examination, 48 had gastrointestinal symptoms and the others did not. In 3 patients a diagnosis of Crohn's disease was made which was previously established. In all other patients inflammatory bowel disease could be excluded. The prevalence of inflammatory bowel disease in this series of patients with AS therefore was 3.8%.


Ankylosing spondylitis and inflammatory bowel disease. II. Prevalence of peripheral arthritis, sacroiliitis, and ankylosing spondylitis in patients suffering from inflammatory bowel disease. To establish the prevalence of peripheral arthritis, radiographic sacroiliitis, and ankylosing spondylitis in patients with inflammatory bowel disease, 58 consecutive patients suffering from ulcerative colitis (UC) and 51 with Crohn's disease (CD) underwent a detailed rheumatological examination. In addition, all patients were screened for the presence of the antigen HLA B27. Peripheral arthritis was found in 14 (8 UC, 6 CD) patients (12.8%); radiographic sacroiliitis was diagnosed in 11 (5 UC, 6 CD) (10.1%), of whom 10 were asymptomatic; and ankylosing spondylitis was diagnosed in 2 UC and 2 CD patients (3.7%). 18.9% of the UC and 3.9% of the CD patients were HLA B27 positive. One of the 11 patients with radiographic sacroiliitis and 2 of the 4 with ankylosing spondylitis had the HLA B27 antigen. Peripheral arthritis, radiographic sacroiliitis, and ankylosing spondylitis are apparently frequent manifestations in patients suffering from inflammatory bowel disease. Asymptomatic radiographic sacroiliitis in these patients appears to differ from idiopathic ankylosing spondylitis, both clinically and genetically. Evaluation of subjective rheumatological complaints, necessary for a confident diagnosis of ankylosing spondylitis, according to the New York criteria is difficult during a flare-up of the inflammatory bowel process, as was shown in 4 CD cases with marked limitation of lumbovertebral function and chest expansion, but no radiological abnormalities of the SI joints.


Ankylosing spondylitis and inflammatory bowel disease. III. Clinical characteristics and results of histocompatibility typing (HLA B27) in 50 patients with both ankylosing spondylitis and inflammatory bowel disease. A study was made, in co-operation with several gastroenterology and rheumatology centres, of the clinical and genetic characteristics (HLA B27) of 50 patients suffering from both inflammatory bowel disease (38 Crohn's disease (CD), 12 ulcerated colitis (UC)) and ankylosing spondylitis (AS), the latter diagnosis being established according to the New York criteria. 20 CD (52.6%) and 8 UC (66.7%) patients were HLA B27 positive. The presence of HLA B27 was studied in relation to clinical parameters, such as first occurrence of symptoms of AS or inflammatory bowel disease (IBD), a history of peripheral arthritis, iridocyclitis, and a positive history of AS or IBD. Our patients were found to have heterogeneous clinical features: on one side of the spectrum a group of cases was distingiushed with the typical characteristics of idiopathic AS, often being HLA B27 positive. On the other side a smaller group of HLA B27 negative patients was observed, with severe intestinal inflammatory pathology, lacking most of the typical clinical features of idiopathic AS ('secondary' form of AS). Finally, between these two extremes a group of patients was found with less pronounced clinical or genetic characteristics. These different clinical and histocompatibility patterns suggest a mixed aetiopathogenesis of AS in IBD patients. Such a 'syndrome' of AS might harbour both idiopathic AS and forms of AS 'secondary' to the intestinal inflammatory pathology.


Assessment of rheumatoid inflammation in the knee joint. A reappraisal. Subjective pain score, clinical assessment, 99m technetium joint uptake, infrared thermography, and thermistor skin temperature measurements were evaluated and compared in patients with rheumatoid knee treated with intra-articular hydrocortisone. In 11 patients with definite and classical rheumatoid arthritis, 10 of whom had unilateral knee involvement, the affected knee joints were assessed by the above techniques before and at intervals after treatment of up to 14 days. The anti-inflammatory property of the steroid therapy was shown by all the assessment parameters, values having decreased significantly from the pretreatment values. However, the only parameter still showing a statistically significant decrease on the 14th post-treatment day was 99mTc joint uptake. Correlations were obtained between the two clinical measurements assessed by a physician i.e. pain score and index of joint inflammation. Both of these also correlated with the 99mTc joint uptake but not with skin temperature measurements. Using the clinical assessments as a yardstick, 99mTc joint uptake seemed to provide a useful index of changes in disease activity in the group as a whole. However, skin temperature measurements by infrared thermography and by the thermistor were of considerably less value.


A family with primary protrusio acetabuli. The family of a child who developed symptoms and flexion contractures with protrusio acetabuli rapidly between the age of 8 and 11 was examined. The mother and one sib showed limitation of hip movements, while radiological criteria for protrusio were found in the mother and 4 of the proband's 8 sibs; only one had complained of pain. At the age of 16 the proband underwent bilateral total replacement arthroplasty; histologically the changes were those of fibrocartilaginous replacement and osteophyte formation.


A second study of tensile fatigue properties of human articular cartilage. The tensile fatigue properties of the collagen fibre meshwork in normal human articular cartilage were measured by subjecting isolated specimens of post-mortem femoral head cartilage to cyclic tensile stress. The results of the study showed (1) that the collagen fibre meshwork is fatigue prone and (2) that its fatigue strength decreases rapidly with age. Extrapolation of the data to physiologically possible stress levels suggests that tensile fatigue failure of the collagen meshwork could occur in life.


Neck movements in ankylosing spondylitis and their responses to physiotherapy. Cervical spine movements were compared in 35 patients with ankylosing spondylitis (AS) and matched controls. In AS there were limitations of all movements and particularly of lateral flexion. These limitations could not be correlated with any particular features of AS except radiological involvement of the lower apophyseal joints. In 25 patients there were significant improvements in all measurements after 3 weeks of intensive inpatient physiotherapy. After discharge the patients were encouraged to perform unsupervised physiotherapy and in 11 patients seen at 3 months the improvements in neck movements were either maintained or increased further. In contrast no changes in movements were found in 9 patients assessed 3 weeks and immediately before starting physiotherapy.


Serum copper and related variables in rheumatoid arthritis. Serum copper, caeruloplasmin, iron, iron-binding capacity, and antioxidant activity were measured in 120 normal subjects and in 189 patients with rheumatoid arthritis. Both serum copper and serum caeruloplasmin were significantly raised in rheumatoid disease in both sexes. A significant inverse relation was found between serum iron and serum copper, and a strong direct correlation between serum antioxidant activity and caeruloplasmin.


Synovial fluid copper and related variables in rheumatoid and degenerative arthritis. Copper, caeruloplasmin, transferrin, albumin, and total protein were measured in the serum and synovial fluid of 40 patients with rheumatoid arthritis and 40 patients with osteoarthrosis. A raised synovial fluid copper and caeruloplasmin have been found to be characteristic of rheumatoid effusions. The relation between copper and caeruloplasmin in synovial fluid differs from that in serum. Synovial fluid caeruloplasmin was increased disproportionately in relation to other plasma proteins present in rheumatoid effusions.


Rheumatoid arthritis in population samples in Iraq. A prevalence survey for rheumatoid arthritis was carried out during the summer of 1975 in persons aged 16 years and over in areas of Iraq representative of differences in geography and ethnicity. Definite rheumatoid arthritis was observed in 1% of the 6999 individuals studied, but differences in occurrence rates in relation to various associated characteristics were not detected. It is concluded that present rheumatological services in Iraq have not developed in response to the magnitude of the existing burden. Morning stiffness was reported fairly frequently by individuals without rheumatoid arthritis, but the significance of this observation is not easy to determine. Raynaud's phenomenon was also recorded, but comparative evaluation of the findings is not possible.


Therapeutic value of arthroscopy.

Therapeutic value of arthroscopy. Thermography before and after joint irrigation at arthroscopy showed no significant improvement of inflammation in 14 patients. Subjectively, those with chondrocalcinosis did best.


Neutrophil chemotaxis in ankylosing spondylitis, Reiter's disease, and polymyalgia rheumatica. Neutrophil chemotaxis was found to be normal in 14 patients with ankylosing spondylitis, in 10 patients with Reiter's disease, and in 8 patients with polymyalgia rheumatica.


Cholestatic jaundice caused by D-penicillamine. D-penicillamine is not generally considered to cause hepatic damage. Cholestatic jaundice developed in a patient with rheumatoid arthritis 4 weeks after penicillamine was added to his regimen, and he died in acute renal failure. The probability that penicillamine caused the cholestasis is discussed.


Effect of glucagon and blood transfusion on liver metabolism in hemorrhagic shock. Treatment with glucagon in addition to blood transfusion was compared with blood transfusion alone after one hour of hemorrhagic shock in the rat. In liver tissue Na+ increased and K+ decreased during haemorrhagic shock. After treatment the initial values were restored equally in both groups within ten minutes. Incubation of liver slices in cold Krebs' solution resulted in a pronounced increase in Na+ and decrease in K+, the values being partially restored to initial levels after subsequent incubation at 37 degrees. Thirty minutes after treatment the liver slices obtained from rats given glucagon showed a more normal ion composition after leaching and rewarming than slices from rats not given glucagon. ATP decreased and glucose and lactate increased in liver tissue during hemorrhagic shock. These variables were partially restored 30 minutes after treatment. No difference between the treatment groups was noted. Animals trreated with glucagon were, however, more efficient in reducing the elevated blood lactate level. The results suggest that the use of glucagon in the treatment of hemorrhagic shock might be of benefit for cellular function in the liver.


Jejunal inhibition of gastric acid secretion induced by hypertonic glucose in duodenal ulcer patients before and after truncal vagotomy. The effect of intrajejunal infusion of hypertonic glucose on pentagastrin-stimulated (0.5 microgram/kg-hr) gastric acid secretion was studied in eight duodenal ulcer patients before and three to five months after truncal vagotomy. Preoperatively mean acid output was reduced from 44.0 +/- 3.1 meq H+/hr to 29.2 +/- 2.9 meq H+/hr (p less than 0.05), whereas no consistent changes were found postoperatively, suggesting that jejunal inhibition of gastric acid secretion induced by hypertonic glucose primarily is under vegal control. Furthermore, the study shows that glucose induced jejunal inhibition of acid secretion seems to be less pronouced in duodenal ulcer patients than previously found in healthy subjects.


Incidence and surgical importance of the posterior gastric artery. In a series of 61 adult cadavers, the posterior gastric artery was found in 38 (62.3%), originating from the superior aspect of the mid-third of the splenic artery. The posterior gastric artery, running behind the parietal peritoneum of the omental bursa, produced a peritoneal fold before reaching the posterior wall of the superior portion of the gastric body, near the cardiac region, and the fundus. Its high incidence, hidden origin, deep course, and distribution make this artery very important for surgical procedures relating to the stomach, pancreas, spleen, and celiac region. It may be crucial, especially if partial gastric resection of splenectomy have obliterated other gastric vessels.


Aneurysm of anomalous subclavian artery: an unusal cause of dysphagia lusoria in childhood. An 11-year-old female child with Down's syndrome presented with increasing dyspnea and dysphagia. Radiologic studies demonstrated a false aneurysm of an anomalous right subclavian artery which was compressing both trachea and esophagus. The etiology of this aneurysm most probably related to an unsuccessful cardiac catheterization two years prior to this admission. Proximal and distal ligation of the anomalous sublavian artery was accomplished through a right thoracotomy and the patient has remained asymptomatic.


Pulse pressure wave analysis in the diagnosis of aorto-iliac disease. The severity of aorto-iliac disease has been evaluated by direct pressure recording at the time of translumbar aortography. Pulse wave analysis confirmed the radiological appearance of 35 aorto-iliac segments and in one further segment, identified a normal haemodynamic pattern in the presence of marked degenerative disease. The method is safe, accurate, simple and relatively inexpensive.


Factors predicing survival after portacaval shunt: a multiple linear regression analysis. The predictive value of 15 pre- and peroperative parameters upon survival after portacaval shunt was analyzed in a retrospective investigation of 134 elective operations. A multiple linear regression model was used. Survival was measured at three different points of time: one month, one year and five years after the operation. Survival at one month was influenced by the parameters bilirubin/s and ascites only. Survival at one year was influenced by albumin/s, sex, bilirubin/s, BSP, heart disease history and ascites Survival at five years was influenced by albumin/s, alkaline phosphatase/s, history of alcohol abuse, and globulin/s. These findings indicate that prediction of survival after portacaval shunt is an intricate process and that considerable improvement of the child criteria is possible.


Hepatofugal portal blood flow in hepatic cirrhosis. A variety of indirect techniques has been claimed to provide evidence of spontaneous reversal of portal blood flow in hepatic cirrhosis but the existence of the phenomenon has been doubted by some who do not accept the validity of the indirect evidence. There are few reports of the demonstration of hepatofugal portal flow by selective hepatic arteriography, which is the only acceptable technique. We report three patients with histologically confirmed cirrhosis in whom hepatofugal portal blood flow was unequivocally demonstrated by arteriography, in whom no surgical portosystemic shunt had been performed and in whom there was no evidence of the Budd-Chiari Syndrome or hepatoma, situations accepted as associated with reversed portal blood flow. Theoretical considerations suggest that shunt surgery for bleeding esophageal varices should not be ruled out on the grounds of hepatofugal portal flow. However, end-to-side portacaval anastomosis and distal splenorenal shunt might predispose to the early redevelopment of esophageal varices when reversed portal flow is present. Side-to-side portacaval and conventional splenorenal shunts might be preferable in having less effect on hepatic parenchyma perfusion than when orthograde portal flow in the case.


Critical operative management of small bowel obstruction. The records of 238 patients with the diagnosis of small bowel obstruction at the University of Illinois Hospital from 1967 through the spring of 1976 were reviewed. Mortality, intra-operative management, and clinical findings were evaluated. Previous reports list a mortality of gangrenous small bowel obstruction, secondary to hernia and/or adhesions, as greater than 20%, although in this series, the mortality was 4.5% in patients with gangrenous small bowel obstruction. The present data reveal a 60% incidence of wound infection in patients in whom an enterotomy (iatrogenic, decompressive or resective) was made and the subcutaneous tissue and skin closed, and it is therefore recommended that the wound be left open in these situations. Although a variety of individual clinical findings have been advocated as diagnostic aids in patients with small bowel obstruction, this review suggests that attention to a combination of "classic" findings, i.e., leukocytosis, fever, tachycardia and localized tenderness, portends a situation in which conservative observation is safe--namely, the absence of all four findings. The presence of any one or more of these findings mandates early operative intervention.


Venous angiography and the surgical management of subcutaneous hemodialysis fistulas. Venous angiography of subcutaneous arteriovenous (A-V)) hemodialysis fistulas involves venous injection of radiographic contrast material which spreads throughout the venous system and into the arteries via the A-V anastomosis when blood flow to the extremity is temporarily occluded. Direct arterial cannulation is avoided. Subsequent restoration of blood flow with rapid sequential roentgenograms differentiates arteries from veins and identifies direction of fistula blood flow. A 44 month experience with 125 consecutive studies in 82 patients was performed with a 0.8% complication rate. Indications for fistulography included insufficient blood flow during dialysis (67%), cardiac failure (10%), aneurysms (6%), sepsis of undertermined site (6%) and other (77%). Roentgenographic findings identified vascular stenoses or occlusions (45%), malpositioned dialysis needles (11%), aneurysms (9%), unsuitable veins for dialysis (6%), absence of septic origin (5%), abnormal flow rates or patterns (5%), technically unsuitable studies (2%) and normal or baseline studies (17%). Information useful in planning clinical management of the patient was obtained in 88% of studies and fistular operations were performed in 65 patients (52%). Venous fistulography can be an effective and safe method of evaluating and planning correction of A-V dialysis fistula complications.


Myocardial oxygen delivery after experimental hemorrhagic shock. The two components of myocardial oxygen delivery, coronary blood flow to capillaries and diffusion from capillaries to mitochondria, were studied in six dogs, (1) prior to shock, (2) after three hours of hemorrhage shock at a mean systemic arterial pressure of 40 torr, (3) after reinfusion of shed blood, and (4) during the irreversible late posttransfusion stage. There was a maldistribution of left ventricular coronary flow during late shock consistent with subendocardial ischemia. Cardiac performance was significantly impaired after resuscitation and all dogs became irreversible. Total and regional left ventricular coronary blood flow and myocardial oxygen delivery to capillaries were significantly greater than preshock values in (3) but not different from preshock values in (4). However, the myocardial oxygen diffusion area to distance ratio was significantly lower than preshock values in (3), and slightly lower in (4). These data suggest that myocardial oxygen diffusion may be impaired in the early post transfusion period, (3). Accordingly, the probable etiology of left ventricular dysfunction and possibly irreversibility after resuscitation from hemorrhagic shock is subendocardial ischemia during shock with either post-resuscitation impairment of myocardial oxygen diffusion, or in cellular oxygen utilization, or both.


Gastrocutaneous fistula: etiology and treatment. Gastrocutaneous fistula is an infrequent but serious surgical complication which has received little attention in the recent literature. The current report analyzes 13 patients with this complication. The fistula most commonly occurs in the fundic portion of the greater curvature of the stomach and is usually a result of unrecognized iatrogenic injury or associated with severe left upper quadrant inflammation and external drainage. Clinical recognition occurs when the patient develops left subphrenic sepsis or drains gastric content. The fistula is best documented by upper gastrointestinal contrast studies and usually responds to wide drainage and supportive treatment in the presence of benign disease. Oral alimentation apparently need not be delayed until complete fistula closure.


Clinical observation on brittle diabetes. The brittleness of 100 severe diabetics was calculated as the mean of differences of blood glucose between two consecutive days at four time points (fasting, one and two hours after breakfast, and two hours after lunch). Mean daily difference (MDD) had a unimodal distribution; 15 patients with a MDD greater than 100 mg/100 ml were classified as most brittle. There was no correlation between MDD and insulin requirement. The brittle diabetics received 26 to 48 units of insulin/day. The insulin-resistant patients had low MDD values. No difference was found between seven patients with brittle diabetes and seven stable matched controls in insulin-binding capacity or total insulin. In two groups of six patients each with brittle diabetes, it was found that the stable dosage caused less brittleness than a sliding-scale regimen and that routine injection of 4 units of regular insulin before meals slightly decreased the mean diurnal glycemia level but increased the number of hypoglycemias. In two brittle diabetics, the blood glucose level was stabilized on intravenously administered insulin infusion, and in these patients, meals caused only a moderate hyperglycemia.


Contrast media-induced oliguric renal failure. Seven patients had acute oliguric renal failure after intravenous urography (2), celiac arteriography (2), or cardiac angiography (3). Diatrizoate meglumine was the contrast media used in all of the cases. These patients had an average age of 63 years and six were 55 years of age or older. Diabetes mellitus, negative fluid balance before the procedure, underlying renal insufficiency, and hypertension were common, being present in three, four, five, and six of the patients respectively . Anuria or oliguria occurred within 24 hours of the procedure and persisted from 36 to 96 hours (72 hours average). The serum creatinine level rose significantly in all of the patients and reached a peak in two to seven days after the procedure. In six patients, recovery was complete by two to three weeks. The seventh patient experienced only partial recovery. These cases taken together with a mounting number of recent reports suggest that contrast media-induced oliguric renal failure is more common than generally believed. Diabetes mellitus, older age, and underlying renal insufficiency seem to be important predisposing factors.


Hyperpigmentation of pernicious anemia in blacks. Report of three cases. We investigated three black women who had anemia and skin hyperpigmentation. They were found to have pernicious anemia (PA) and normal adrenal functions. To our knowledge, this is the first report of skin hyperpigmentation of PA in black patients. This report reemphasizes the similarities in clinical features of PA and Addison's disease.


Decreased insulin requirement in acute renal failure in diabetic nephropathy. Twelve of 13 diabetics with azotemic nephropathy experienced exacerbation of renal failure and decreased insulin requirement after coronary angiography utilizing radiographic contrast material. The single patient who did not develop acute renal failure had no evidence of decreased insulin requirement. Eleven of 12 patients had decreased insulin requirement: mean  decrement in insulin dose, 40%; mean decrement in fasting blood glucose level, 33%; mean decrement in peak blood glucose level, 42%. The 12th patient underwent peritoneal dialysis against hypertonic glucose without need of an increased insulin dose. Eight of 11 patients experienced a total of 19 insulin reactions; one patient was hypoglycemic continuously, despite infusion of glucose and discontinuation of insulin. The decrement of insulin requirement was not proportional to the rise in either serum creatinine or potassium concentrations. We suggest that when acute renal failure occurs in diabetics, decreased insulin requirement should be anticipated and the insulin dose lowered.


Typhoid fever. Studies of blood coagulation, bacteremia, and endotoxemia. Patients with typhoid fever were studied to determine whether disseminated intravascular coagulation (DIC), circulating bacteria, and endotoxemia were responsible for the signs and symptoms of their illnesses. Coagulation tests in 28 patients detected thrombocytopenia in 17, hypofibrinogenemia in nine, and elevated titers of fibrinogen-related antigens in 20. Repeated testing during convalescence showed a return toward normal values. Intestinal bleeding, however, did not correlate with abnormalities of coagulation tests. Thus, DIC occurred commonly but appeared to be a subclinical event in these patients. In 25 patients with positive blood cultures for Salmonella typhi, quantitative cultures detected from less than 10 to 9 x 10(2) bacteria/ml. Limulus tests for endotoxin in plasma were negative in all 21 patients tested. These results indicated that the concentrations of circulating bacteria and endotoxin in typhoid fever are lower than in other Gram-negative bacterial infections and suggested that circulating bacteria and endotoxin do not play a major role in the pathogenesis of typhoid fever.


Factors predicting for response and survival in adults with advanced non-Hodgkin's lymphoma. Knowledge of the prognostic factors that characterize a disease can assist in planning and analyzing clinical trials. The present study was conducted to determine the characteristics related to response and survival in patients with stage III and IV non-Hodgkin's lymphoma who were treated with combinations of cyclophosphamide, vincristine sulfate, and prednisone. Considering each characteristic individually and using stepwise regression analysis, tumor bulkiness, prior therapy, sex, and pretreatment lymphocyte count were selected as the four most important prognostic variables. Tumor architecture (diffuse or nodular pattern) and cell type, hemoglobin level, and symptoms although not important in predicting response were found to be  important in predicting survival. The hemoglobin level had only marginal importance in predicting response. Factors found not be important were age, stage, symptoms, cell type, nodularity, marrow involvement, prior extensive radiotherapy, and bone involvement. A logistic regression equation has been derived that can be used to predict response rate.


Myoglobinuria associated with herpes-group viral infections. Two cases of myoglobinuria were associated with herpes-group viral infection (herpes simplex and Epstein-Barr). Muscle atrophy and acute renal failure were important complications. No evidence of direct invasion of muscle fibers by virus was found, nor was the severity of myoglobinuria correlated with histologic appearance of muscle.


Ultrasonic guidance for renal biopsy.

Ultrasonic guidance for renal biopsy. B-mode ultrasonic guidance was used to perform 76 percutaneous renal biopsies. Renal tissue was obtained from 73 (96.1%) subjects with adequate tissue for interpretation or diagnosis in 72 instances. Major bleeding complications occurred in four (5.3%) patients. Ultrasound has proved to be a safe and effective means of guiding physicians performing renal biopsies. In addition, it has many advantages over other techniques.


Septic shock with Micrococcus luteus.

Septic shock with Micrococcus luteus. Micrococcus luteus is considered a non-pathogenic saprophyte of human skin and eye. Disease in man caused by this organism is not recorded in medical literature. We present a case of septic shock cause by M luteus. The value of this report is to document the pathogenicity of coagulase-negative staphylococci in patients without valvular heart disease, surgically implanted artifificial prosthetic devices, or polyethylene intravenous catheters.


[Microcirculatory bed of the serous membranes in hypertension]. In hypertension, all the components are affected in the microcirculatory bed of serous membranes: arterioles, precapillaries, capillaries, postcapillaries, venules, lymph capillaries and postcapillaries. Convolution of microvessels, formation of loops, skeins, torsions along the longitudinal axis, deformation of walls (folds and angularity of the contours, multiple unilateral and bilateral protrusions and invaginations, sacciform and cylindrical microaneurisms, multiplication of venules) are observed. In the control material collected from subjects who had died of various traumas vascular changes in serous membranes are poorly manifest or absent indicating a relative specificity of the microvessel involvement in hypertension. The results of the study are in accord with known from literature descriptions of changes in the microcirculatory bed of the eye conjunctiva observed in biomicroscopy in patients with hypertension which confirms the generalized nature of MCB involvement in this disease.


[Structural changes in the vessels of the heart in different hemodynamic disorders in the coronary basin]. Coarctation of the aorta was created in 15 and stenosis of the pulmonary arteri in 20 puppies. In the first experimental defect the blood inflow into the coronary basin increased, in the second the outflow from it was disturbed. The proposed method of complex histomicrometria was used to study changes in coronary vessels of various calibers. In both disorders of the coronary hemodynamics, hypertrophy of tunica media of arteries of all levels, an increase in their walls of the amount and power of obliquelongitudinal muscles, and hypertrophy of muscle-elastic sphincters in the openings of side branches going from small arteries were observed. Signs distinguishing one defect from the other were found at different levels of the vascular system of the heart. Their emergence is associated with hypertrophy of one or another part of the heart and features of the coronary hemodynamics inherent in each defect.


[State of the vascular bed of the lungs and pleura in congenital heart defects with hypovolemia of the lesser circulation]. The status of the vessel bed of the lungs and pleura in congenital heart diseases with hypovolemia of the pulmonary circulation was studied. Morphological manifestations of adaptative changes in the vessels of microcirculation of these organs were found. The importance of the discovered changes in the maintenance of hemodynamic homeostasis under conditions of deficiency of blood inflow into the pulmonary artery is demonstrated.


[Biopsy of the mucosa of the lower lip for purposes of diagnosing Sjögren's syndrome]. Thirty biopsies of the lower lip mucosa from patients with clinical and subclinical manifestations of Sjögren syndrome were studied. The results indicate characteristic morphological changes in small salivary glands. The dynamics of these changes consists in progressive lymphoid infiltration of the gland tissue and includes 4 stages: I--weak lymphoid infiltration, II--focal lymphoid infiltration, III--focal-extensive lymphoid infiltration, IV--diffuse lymphoid infiltration, that is, lymphomatosis. In parallel with the progressive lymphoid infiltration there occur sclerosis of the stroma, atrophy and loss of parenchyma of the salivary glands in which the chemical composition of the secrete is changes as confirmed by tests done for mucus. The results obtained and data from literature permit a conclusion that Sjögren syndrome is a generalized autoimmune disease underlain by the disturbance of immunological homeostasis.


[Morphofunctional aspects of the experimental effect of hyperbaric oxygenation on the myocardium of the healthy organism]. Changes in the myocardium arter numerous treatments with hyperbaric oxygenation (HBO) (PO2 3 technical atmospheres, time of saturation--45 min) were studied by morphological, histochemical and enzymohistochemical methods in 50 rabbits. Three stages were found to occur in the development of these changes: 1) functional-morphological changes (1--3 seanses of HBO), 2) early morphological changes (4--5 seanses), 3) marked morphological lesions (6--8 seanses). The first three treatments produce reversible changes on the part of metabolic processes (a reduction in the content of glycogen and changes in the activity of oxidoreductases: succinate-, malate- and lactate dehydrogenase). Morphological signs of oxygen toxicity in the form of disorders in hemodynamics and microcirculation, and dystrophy of cardiomyocytes appear after 4 seanses of HBO and increase with further treatment. The experimental data permit to recommend short HBO courses (1--3 seanses) for therapeutic application.


[Morphology of heart tumors in rats induced by methyl- and ethylnitrosourea]. The results of morphological examinations of 78 heart tumors in BD IX rats induced by methyl- and ethylnitrosourea (MNU, ENU) administered by various routes are described. After repeated intravenous or intraperitoneal injections of MNU heart tumors developed in 39--46% of the treated animals. The following localizations were found: left ventricle--55, right ventricle--7, both ventricles--12, other sites--4. In 51 (65.4%) of 78 cases there were early stages of tumor with a ribbon-like lining of the affected ventricle wall. They consisted of elongated stream-like-arranged tumor cells. Large tumor nodules protruding into the ventricular lumen usually showed considerable features of cellular and nuclear polymorphism. The heart tumors were classified as fibromas or neurinoma-like tumors, fibrosarcomas, and polymorphous sarcomas. Histogenetically, the neoplastic cells are probably derived from fibroblasts and Schwann cells.


Potentialities of the cytological method in diagnosing adenocarcinoma of the lung. Parallel cytological and histological studies were performed for 87 patients with pulmonary adenocarcinoma. Sputum, impression smears of the bronchial mucosa, aspirates from the bronchi, punctates of the tumor obtained transbronchially, pieces of tumor obtained at bronchoscopy, and operation material were examined. Considerable difficulties wre found in cytological diagnosis of adenocarcinomas due to degenerative changes in tumor cells, the presence of cells of the metaplastic columnar epithelium and marked anaplasia of tumor cells in adenocarcinoma with low differentiation. The frequency of diagnostic errors was 20.0--50.6% depending on the histological form of adenocarcinoma and the accompanying processes in bronchi. The cytological criteria improving the differential diagnosis of adenocarcinoma are presented. The validity of cytological diagnosis of adenocarcinoma does not depend on the nature of the material examined.


[2 cases of reticulohistiocytosis].

[2 cases of reticulohistiocytosis]. Excerpts from case histories and the results of morphological examinations of organs and tissues of a man of 17 with Letterer-Siwe disease and a man of 26 with Gaucher's disease are presented. Noteworthy is the fact of morphological similarity of eosinophilic granulema and Letterer-Siwe disease and transition of the former into the latter.


Ataxic hemiparesis. A pathologic study.

Ataxic hemiparesis. A pathologic study. Three stroke patients showed weakness and pyramidal signs on one side combined with a cerebellar-like ataxia on the same side. Pathologic study in each case showed an old infarct cavity in the basis pontis at the level of the junction of the upper one third and lower two thirds on the side opposite the neurologic deficit. The basilar artery was patent and the infarcts were probably the result of occlusion of penetrating arteries. This study demonstrates that a lesion of the basis pontis may be associated with a contralateral ataxia that is cerebellar in character. The designation ataxic hemiparesis is suggested for the syndrome.


Controlled use of cranial computerized tomography. This study attempts to assess the impact of computerized cranial tomography (CT) on clinical practice in a veterans hospital. A CT scan could be performed only if there existed a reasonable potential for the results to affect the patient's clinical course. We document many instances of how the 163 CT scans obtained during a one-year period aided patients. We quantitated one beneficial aspect by estimating the major neuroradiologic contrast procedures obviated by CT scan. Case-by-case review indicates 70 cerebral arteriograms and 58 pneumoencephalograms would have been performed had CT scanning not been available.


Glissadic overshoots are due to pulse width errors. Glissades are the slow, gliding eye movements often appended to the end of human saccadic eye movements. They have been used as an aid in diagnosing disease states, eg, multiple sclerosis and vascular lesions. Glissades are a consequence of a mismatch between the sizes of the pulse and step components of the pulse-step motoneuronal controller signals. This physiological and simulation study shows that glissadic overshoot is caused by pulse width errors and not by pulse height errors. This implies that the CNS can control the firing frequencies and recruitment of motoneurons more precisely than it can control the duration of the high-frequency motoneuronal saccadic burst.


Computerized tomography and auditory-evoked potentials. Use in the diagnosis of olivopontocerebellar degeneration. The pneumoencephalogram has been the only diagnostic test available to confirm the diagnosis of olivopontocerebellar degeneration during life. This study suggests that pneumoencephalography may be obsolete and that the diagnosis of olivopontocerebellar degeneration may be established by abnormalities seen during computerized tomography (CT) and by abnormal responses to auditory-evoked potentials (AEPs). The combination of CT scans and AEPs provides a completely nontraumatic method of diagnosis in olivopontocerebellar degeneration and eliminates the need for pneumoencephalography.


Tuberculous brain abscess. Report of a case and review of the literature. Tuberculous brain abscess is a rarely reported form of central nervous system tuberculosis. Fifty-seven cases were found in a review of the world's literature; only 16 met rigid diagnostic criteria. Tuberculous brain abscesses are devoid of the granulomatous reaction associated with tuberculosis. Histologically and clinically, these abscesses are similar to pyogenic brain abscesses. An analysis of 16 verified cases from the literature and one reported case showed that tuberculous brain abscesses usually present acutely, often in the third and fourth decades, commonly have a supratentorial location, frequently present with focal neurologic signs, and are associated with historical and laboratory evidence of tuberculosis. Tuberculous brain abscesses may be difficult to differentiate from pyogenic brain abscesses, tuberculomas, and tuberculous meningitis on the basis of clinical, laboratory, and roentgenographic information. Appropriate therapy includes adequate antituberculous chemotherapy and surgical excision.


Dominant spinopontine atrophy. Report of two additional members of family W. In five generations of Anglo-Saxon family W, 28 members were affected with dominant hereditary ataxia. In 1969, two members of this family were reported as prototypes of dominant spinopontine atrophy. We discuss two additional members of the original family, with one postmortem examination, including ultrastructual study. In contrast to previously accepted clinical generalizations, we found abolished tendon reflexes and flexion contractures of the lower extremities in patient 1 and onset of illness at the age of 18 years, palatal myoclonus, and optic atrophy in patient 2. Dementia was observed in both patients. Unlike in previous pathological reports, our patient 1 showed definite involvement of the cerebellum and mild degeneration of the inferior olivary nuclei. We conclude, therefore, that clinical and pathological distinction between dominant spinopontine atrophy and olivopontocerebellar atrophy is not clear and raises the question of the justification for regarding dominant spinopontine atrophy as a nosological entity.


Cebocephalus associated with trisomy 13-15 mosaicism. A case of cebocephalus occurred in association with a 10% mosaicism of trisomy 13-15. Both parents of the affected child had normal karyotypes. Cebocephalus has been associated with abnormal chromosomes such as a deletion of the short arm of chromosome 18 as well as the trisomy 13-15.


Recurrent disseminated vasculomyelinopathy. The monosymptomatic (recurrent infantile hemiplegia) and the polysymptomatic forms of disseminated vasculomyelinopathy that follow various infections and antigenic challenge to the nervous system were seen in two cases. These cases emphasize the importance of vasculopathy as the initial and obligatory component of the postinfectious and postimmunization neurologic syndromes as well as the clinical and pathological variability of the secondary effects on the nervous system. Recurrent infantile hemiplegia occurred in the first patient. In the second patient, after two episodes of postinfectious myelinoclastic encephalopathy, concurrent acute hemorrhagic leukoencephalopathy and an acute Guillain-Barré syndrome following swine flu vaccination developed.


Intracerebral arterial aneurysm in a newborn. Angiographic diagnosis of an intracerebral aneurysm in a neonate was made on the 13th day of life following persistent neurological symptoms that began at birth. Rupture of the aneurysm probably occurred within the first day of life. This unusual condition should be considered in newborn infants with unexplained neurological signs or intracranial hemorrhage.


Intermittent see-saw eye movements. Report of a patient in coma after hyperextension head injury. For 24 hours after an automobile accident, a 19-year-old comatose man exhibited spontaneous, intermittent, see-saw, rotatory, and downward eye movements with synchronous lid elevation. These unusual movements, which appear most closely related to nonpendular see-saw nystagmus and atypical ocular bobbing, probably resulted from the severe pontomedullary tegmental damage found at autopsy.


Cryptococcal meningitis. Cure despite cryptococcemia. Cure of cryptococcal meningitis accompanied by cryptococcemia was achieved with amphotericin B therapy. Cryptococcal meningitis is associated with substantial morbidity and mortality, especially when accompanied by evidence of extraneural infection. Experience with the patient reported suggests that associated cryptococcemia is not invariably associated with treatment failure.


Vitrectomy for complications of diabetic retinopathy. Pars plana vitrectomy was used to treat 134 consecutive eyes with complications resulting from proliferative diabetic retinopathy, including nonabsorbing vitreous hemorrhage, recent traction and rhegmatogenous retinal detachment, progressive fibrovascular proliferation, and early rubeosis iridis with recent vitreous hemorrhage. Vision improved after surgery in 65% of the eyes, was unchanged in 16%, and decreased after surgery in 19%. In 24% of the successful cases, vision of 20/50 or better was achieved. When all posterior cortical vitreous was removed, no preretinal fibrovascular growth occurred after surgery. Nonatrophic epiretinal fibrovascular membranes that were not removed usually underwent centripetal contraction after surgery, causing tangential traction on the adjacent retina. Rubeosis iridis was the most common postoperative complication in otherwise successful cases, and rubeosis underwent regression after scatter retinal photocoagulation in some eyes.


Immunosuppressive therapy for severe chronic uveitis. Twenty-five patients with severe, progressive, chronic uveitis who were poorly responsive or unresponsive to corticosteroid therapy received low-dose prednisone and cytotoxic immunosuppressive therapy. Azathioprine (2.0 to 2.5 mg/kg) or chlorambucil (6 to 8 mg) was combined with prednisone (10 to 15 mg) daily in a long-term therapeutic program. All 25 patients exhibited a therapeutic response. In 18 of 25 patients, complete quiescence of the inflammatory process was observed. The remaining seven patients showed a substantial decrease of uveitis with persistence of some inflammatory changes. Adverse side effects that resulted from this therapy were infrequent.


Indirect traumatic rupture of the globe. Indirect rupture of the globe was found to be a rare injury, more common in males (P less than .01), and having a tendency to involve the left eye. Severe chemosis, a  hyphema, and hypotony were usually present, but the intraocular pressure was elevated in three eyes. Of the 50 ruptures in this study, 41 were at the equator or anterior to it (P less than .01), and 37 were parallel to the equator. Thirty-three of the 41 anterior ruptures were located in the superior half of the eye. The nasal-superior quadrant between the limbus and spiral of Tillaux, the temporosuperior quadrant between the spiral of Tillaux and 5 mm posterior to the equator, and the temporosuperior quadrant between the limbus and spiral of Tillaux were the three most common areas involved, in decreasing order of frequency. A theory has been described to explain this distribution. The absence of a hyphema (P less than .001), the presence of a rupture of 9 mm or less (P less than .01), and the use of cryotherapy or diathermy at the wound edge at the time of closure of the rupture (P less than .01) were all good prognostic signs. The visual outcome was light perception or worse in 45 of the 50 ruptures, but every effort must be made to preserve the eye rather than to remove it.


Sympathetic ophthalmia. A long-term follow-up. Seventeen cases of sympathetic ophthalmia have been followed up for as long as 23 years (average 10.6 years). Sixty-five percent of those patients treated with corticosteroids retained a visual acuity of 20/60 or better. Complications were frequent and included secondary glaucoma, cataract, exudative retinal detachment, and choroidal scarring. Uneventful cataract extraction was difficult to manage, requiring frequent changes in the steroid dosage, and in one patient two glaucoma procedures. The duration of steroid therapy was quite variable and ranged from a few months to six years or longer. Relapses were common and several occurred many years after the initial episode had resolved. If the histopathologic picture were moderate or severe, the clinical course most often would be difficult and protracted.


Treatment of intermittent exotropia.

Treatment of intermittent exotropia. To study the long-range results of surgically treated intermittent exotropia, 100 consecutive patients have been followed up for an average of 6.1 years. In all cases, the initial procedure was bilateral recession of the lateral rectus muscles. The overall functional cure rate was 78%. To accomplish this result, 27 patients were operated on a second time, 21 for undercorrection and six for overcorrection. A number of patients cooperated very poorly or were lost to follow-up while still under treatment. Had these patients been eliminated from the series, the cure rate would have been greater than 90%. In this study, bilateral recession of the lateral rectus muscles corrected the distant measurement more than the near measurement only with the divergence excess type of deviation. Also, this procedure was not notably more effective with divergence excess than with basic-type intermittent exotropia.


Sympathetic uveitis after trauma and vitrectomy. A case is describes in which the earliest clinical manifestations of sympathetic uveitis that occurred after trauma and pars plana vitrectomy were confined primarily to the retina, retinal pigment epithelium, and choroid posteriorly, and resembled focal lesions of acute posterior multifocal placoid pigment epitheliopathy. Similar focal lesions were noted on gross examination of the enucleated inciting eye. Histopathological examination revealed that these lesions were caused by focal choroidal granulomas and overlying Dalen-Fuchs nodules. Sympathetic ophthalmia was also noted in four other patients in whom the condition developed after trauma and vitrectomy.


Cryptogenic unilateral paralysis of the superior oblique muscle. Fifteen patients spontaneously developed paralysis of one superior oblique muscle, which remained unexplained after an initial evaluation. Follow-up evaluation showed that all of the patients' conditions were improved. Twelve of the patients had enjoyed spontaneous, functional recoveries within four months. Three had residual diplopia that was relieved by prisms. No patient subsequently developed evidence of any local or systemic disease that could explain the ophthalmoplegia. One patient suffered a recurrence 3 1/2 years after his first episode that lasted three months and spontaneously cleared.


Retinal involvement in thoracic-pelvic-phalangeal dystrophy. A patient with typical thoracic-pelvic-phalangeal dystrophy has survived to the age of 11 years with no pulmonary problem except a single episode of pneumonia at the age of 5 years. She has no evidence of renal disease. An associated ocular lesion resembled Leber's congenital amaurosis clinically but was different on electrophysiologic testing.


Oncocytic adenocarcinoma of the lacrimal sac. A well-differentiated, oncocytic adenocarcinoma of the lacrimal sac recurred locally in a patient during a period of 13 years. This appears to be the second documented instance of such a neoplasm.


Human albinism. Light and electron microscopy study. The eyes of a 13-year-old leukemic boy with the attributes of tyrosinase-negative oculocutaneous albinism were obtained for light and electron microscopic study. Repeated examinations had failed to reveal WBCs with giant oxidase-positive granules, and leukemic involvement of the fundus never occurred. Light microscopic examination of horizontal and vertical sections through the retina confirms earlier reports that the fovea is absent in albinos. The synaptic apparatus of the photoreceptor terminals appears abnormal. The rough endoplasmic reticulum of the retinal pigment epithelial cells is sparse though the presence of phagosomes suggests that phagocytic function is intact. Suggestions as to the importance that the morphological findings may have on albino visual function are made.


Choroidal Osteoma.

Choroidal Osteoma. Choroidal osteomas caused visual symptoms in four healthy young women. A positive 32P test led to enucleation and histopathologic confirmation of the diagnosis in one patient. The characteristic ophthalmoscopic findings in these patients included the following: (1) slightly and irregularly elevated, yellow-white, juxtapapillary, choroidal tumor and well-defined geographic borders; (2) diffuse and mottled depigmentation of the overlying pigment epithelium; and (3) multiple small vascular networks on the tumor surface. A diffuse mottled pattern of hyperfluorescence in the area of the tumor occurred during the early and later stages of angiography. The tumors were ultrasonically dense, and the orbital tissue behind them was rendered silent. The tumors were visible on routine orbital x-ray films and computerized tomograms. The latter study demonstrated the tumors as having the consistency of normal bone.


Clinically stationary choroidal melanoma with extraocular extension. A malignant melanoma of the choroid was observed for three years because of an erroneous diagnosis of disciform macular degeneration. No lateral or vertical growth was noted during the observation period, but significant extrascieral extension was discovered at the time of radioactive phosphorus uptake test and enucleation.


Peripapillary choroidal melanomas. Extension along the optic nerve and its sheaths. We reviewed 26 cases of peripapillary melanoma, 21 (80.8%) of which extended into the optic nerve or its meningeal sheaths. Most melanomas that extended into the optic nerve were necrotic and of the mixed or epithelioid cell type; all invaded the overlying retina and occurred in blind eyes with secondary glaucoma. The extension of melanoma cells into the subarachnoidal space was only influenced by the presence of the melanoma around the optic nerve head (peripapillary). The prognosis of these patients was highly dependent on the presence of orbital extension. A long piece of optic nerve should be excised when eyes with peripapillary melanomas are enucleated.


The effect of phacoemulsification on corneal endothelial cell density. Seventy-six patients who had undergone unilateral phacoemulsification of cataracts had their endothelial cell density (ECD) measured by specular microscopy. When compared with the unoperated contralateral eye, there was a mean decrease in ECD of 33.8%. Ten patients who had undergone unilateral intracapsular cataract extraction had a mean decrease in ECD of 14.9%. Cataract extraction by phacoemulsification appears to be more traumatic to the corneal endothelium than is intracapsular extraction.


Endothelial trauma and cell loss from intraocular lens insertion. Eighty-six patients who underwent intraocular lens implantation in one eye, with no surgery in the contralateral eye, were examined by specular microscopy. The mean endothelial cell density (ECD) was 39.5% lower in the operated eye. The loss of ECD was roughly proportional to the endothelial trauma from the intraocular lens at the time of surgery.


Ischemic optic neuropathy in cavernous sinus thrombosis. Visual loss is uncommon in thrombosis of the cavernous sinus. A patient observed closely in the acute stages developed high introcular and intraorbital pressures. Although the retinal vasculature remained patent, total unilateral blindness occurred within 48 hours. To our knowledge this is the first documented case in which ischemic optic neuropathy caused blindness in a patient suffering from cavernous sinus thrombosis.


Meningiomas and aneurysms of the cavernous sinus. Neuro-ophthalmologic features. A series of 16 patients with unilateral ophthalmoplegia due to mass lesions of the cavernous sinus was analyzed; there were six cavernous meninglomas and nine intracavernous aneurysms. All meningiomas were characterized by painless, insidiously progressive partial nerve palsies, as were half of the aneurysms; the remaining aneurysm patients experienced acute painful episodes. Pharmacologic pupillary tests failed to confirm a coexisting Horner syndrome in the majority of cases with anisocoria. Although plain skull films were unremarkable or misinterpreted as normal, bone tomograms, computerized axial tomograms, radionuclide scans, and cerebral angiograms established the diagnosis in all cases. Because cavernous meningiomas show slow progression and are surgically inaccessible, craniotomy is advised only if the visual pathways or brain stem is compromised. Intractable pain appears to be the only distinct indication for intervention with cavernous aneurysms.


Perineural optic nerve changes in endocrine orbitopathy. A-scan ultrasonographic measurements of the differences between nerve and dural diameters of the retrobulbar optic nerve were made in 55 eyes of 30 patients with endocrine orbitopathy. This measurement was found to be enlarged in all cases. Extraocular muscle thickness measurements were also made ultrasonically in these eyes, and the degree of intervaginal distension was found to increase with increasing extraocular muscle involvement. These findings were consistent whether the patients were hyperthyroid, hypothyroid, or euthyroid clinically, and the findings occurred in the absence of any detectable functional optic nerve compromise. The cause of this subdural perineural enlargement remains unknown.


Cataracts induced by topical dexamethasone in diabetics. Eleven diabetic patients were treated with unilateral topical dexamethasone for 14 to 36 months in an attempt to control their retinopathy. Cataracts developed in the treated eye of nine patients, compared with only one cataract in an untreated eye.


Multiple-slit illumination of the optic disc. A modification to a photo slit-lamp illuminator adds detail to the human optic disc surface by projecting onto it a pattern of fine parallel lines. These stripes curve as they traverse the disc, and its surface contour is revealed. Application of this technique may improve the reliability of methods used to quantitate disc topography.


New diagnostic and surgical gonioprism.

New diagnostic and surgical gonioprism. A modification of Zeiss' four-mirror goniolens for static and dynamic indirect gonioscopy in the office and during surgery has been designed. The lens is also used for determining the position of the haptics of anterior chamber-fixated intraocular lenses at the time of placement. Advantages of this lens compared with Zeiss' lens are discussed.


Intraocular sulfur hexafluoride and octofluorocyclobutane. Effects on intraocular pressure and vitreous volume. Partial vitrectomies were performed on rabbits and the amount of vitreous removed was replaced with either 100% sulfur hexafluoride (SF6), 100% octofluorocyclobutane (freon-C318), 40% SF6, or air. Intraocular pressure and vitreous volume were determined. Replacing 40% of the initial vitreous volume with either 100% SF6 or 100% octofluorocyclobutane caused an increase over 20 mm Hg in the IOP with an associated loss of the remaining vitreous, whereas replacement with 40% SF6 or air caused no significant increase in IOP. Replacement with 40% SF6 caused a significant loss of the remaining vitreous, whereas the air replacement did not result in a vitreous loss. The experiments were repeated substituting only 20% of initial vitreous volume with 100% SF6 and 100% octofluorocyclobutane. Using this amount of SF6 and octofluorocyclobutane, the IOP did not increase but an associated vitreous loss occurred equal to twice the amount of SF6 injected and three times the amount of octofluorocyclobutane injected.


Intraocular irrigating solutions. A comparative study of BSS Plus and lactated Ringer's solution. Isolated human corneas maintained normal corneal thickness and endothelial ultrastructural integrity throughout a three-to four-hour period of perfusion of BSS plus to the endothelial surface. By comparison, only one of six human corneas perfused with lactated Ringer's solution was able to maintain normal thickness and ultrastructural integrity. The other five corneas perfused with lactated Ringer's solution showed various degrees of endothelial cell breakdown and corneal swelling during three hours of perfusion. The results of these studies suggest that BSS plus is a better solution for maintenance of human corneal endothelium during long-term (one- to three-hour) surgical procedures.


An improved method for practice vitrectomy. Practice is essential for acquiring the skills necessary for the delicate technique of pars plana vitrectomy. An improved animal model is presented for the beginning surgeon and the assistant to learn basic as well as advanced vitrectomy techniques. A stepwise scheme progressing from simple vitrectomy in the phakic rabbit eye to complicated situations is introduced. Fluorescein staining helps in visualization of the normal vitreous. Double perforating injuries are created to simulate complicated vitreoretinal problems. Methods for learning manipulations with two instruments in the eye are described.


Radiation effects on microvascular anastomosis. Three groups of rats were studied. Group 1 rats received 6,000 R of irradiation, group 2 rats received 4,000 R, and group 3 rats acted as a control. Four weeks following irradiation, the femoral artery of each rat was cut and reapproximated using microvascular surgical techniques. Four weeks after surgery, the same femoral artery was evaluated for patency. There was no notable effect of irradiation on the patency of subsequently performed anastomosis of these small (1 mm in diameter) muscular arteries. Radiation effects were obvious on histological examination, but the anatomical and physiological alterations apparently were not severe enough to cause early thrombosis after microsurgical manipulation of these vessels.


The long tracheostomy tube. Alternative management of distal tracheal stenosis. The incidence of tracheal strictures has greatly increased, and even in the most controlled clinical setting, the treatment of this problem requires sophisticated surgical management. We present an alternative method of management that was initially used to secure a temporary airway in young and debilitated patients. This technique has provided both immediate relief of the airway obstruction and definitive long-term correction of the stenosis, with a low complication rate.


Basal cell tumors of the parotid gland.

Basal cell tumors of the parotid gland. We present two patients with parotid tumors; one had a basal cell adenoma, and the other had a malignant tumor of uncommon morphologic features that was diagnosed as basal cell carcinoma. Both tumors showed morphologic similarities: peripheral, palisading, nests-like arrangements and organelle-poor cytoplasm. This suggests the same cell of origin.


Reversible sudden deafness in early acquired syphilis. Although congenital syphilis is a well established cause of hearing loss, early acquired syphilis is frequently overlooked in the differential diagnosis of sensorineural deafness. This is due, in part, to a decrease in the incidence of syphilis and to the advent of penicillin in previous years which reduced this complication to a clinical rarity. However, with the increase in new cases of syphilis in the past decade, early acquired syphilitic deafness is being seen with increasing frequency. Along with it is the syndrome of early syphilitic meningitis with sudden sensorineural deafness. This potentially reversible condition should be considered in sexually active patients in whom sudden deafness develops. Early diagnosis and treatment are essential for maximum recovery of hearing.


The brow-lift operation in a man.

The brow-lift operation in a man. Various techniques of brow elevation, including their advantages and limitations, are discussed. Since there are no lines immediately above the eyebrow, the direct brow-lift operation results in a scar that cannot be camouflaged with makeup by a man. The approach via temporofrontal scalp produces limited and temporary brow elevation, and the scars may eventually become visible with hairline recession in men. A technique of the brow-lift operation in a man via the natural, horizontal forehead crease above the eyebrow has been found to be very effective. The complications have been minimal, the resulting scars have been unnoticeable.


Congenital choanal atresia. Anatomic, physiological, and therapeutic aspects, especially the endonasal approach under endoscopic vision. In four cases of congenital bilateral choanal atresia, endonasal perforation using a modified surgical technique was employed with satisfactory results. In each patient, a polyethylene tube was inserted into the nasal cavity and left in place for varying lengths of time; a period of three months is recommended. This calls attention to a lenient, safe, and relatively easy operative technique that can be applied as soon as the anomaly is detected. By this technique, sufficient nasal respiration, which is of vital importance to the newborn, can be established.


Burn perforation as a method of middle ear ventilation. Eardrum perforation caused by burn is well known to have a tendency to resist closure. This unfavorable tendency to resist closure. This unfavorable tendency can be turned to the benefit of patients with severe, Eustachian tube dysfunction. Pressure equalization of sufficient duration can be produced by making a burn perforation of the tympanic membrane. Multiple, small perforations placed closely or a large perforation of about one eighth of the tympanic membrane will remain patent and equalize pressure across the tympanic membrane for a period greater than three months. The procedure is of a minor nature comparable with myringotomy or with the removal of a plugged clot from a tube.


Ultrastructural features of spiral ganglion cells. A study of patients with hearing loss of varying origins. Fresh specimens of the acoustic nerve that were obtained during vestibular neurectomy or acoustic neuroma removal were studied for structure of the spiral ganglion cells. These were large, round or oval cells with many cytoplasmic organelles and were surrounded by Schwann cells. Schwann cells formed a single layer or perikaryal sheath and the cells were thus unmyelinated. In one case the specimen contained part of the spiral ganglion, but in six others spiral ganglion cells were found outside of Rosenthal's canal, among the myelinated nerve fibers. In three cases the ear was deaf due to cochlear insult, but the nerve fibers and ganglion cells showed no retrograde degeneration. The neurophysiologic features of the cochlear nerve should be considered because unmyelinated ganglion cells may have a different conduction capacity in comparison with thickly myelinated cells.


A self-administered history questionnaire for cosmetic facial surgery candidates. The collection of information concerning a patient's history is every bit as important in the evaluation of candidates for cosmetic surgery as it is in any other branch of medicine. Consequently, a self-administered questionnaire was developed to save time and to ensure thoroughness. The questionnaire helps elicit a patient's motivations and expectations, and also satisfies some of the requirements of the legal doctrine of informed consent. A particularly noteworthy feature of the form is the "Personal Inventory" section, which attempts to "red flag" patterns of psychogenic conditions in prospective patients.


Incidence of Ménière's disease.

Incidence of Ménière's disease. The incidence of Ménière's disease in Sweden for the year 1973 has been calculated as one case in a population of 2,163. This gives an overall incidence of 46/100,000. Extrapolating the Swedish incidence data to the population of the United States, there should have been 97,000 cases of Ménière's disease treated as inpatients or outpatients during the year 1973. The incidence in the United States of Ménière's disease, cochlear type, is considered to be even higher. In addition, the Swedish statistic for some other disorders, including otosclerosis, are reported. For otosclerosis, the yearly incidence in Sweden is 12/100,000 or one case in a population of 8,414. This could be extrapolated to 25,000 patients with clinical otosclerosis in the United States for the year 1973. By comparison, Ménière's disease, by stringent diagnostic criteria, is approximately four times as common as clinical otosclerosis. It is also more common than all laryngeal carcinomas, all salivary gland tumors, both benign and malignant, as well as acute epiglottitis and acute nephritis.


Allograft stapes-incus assembly. A new ossiculoplasty. In 45 patients with absence of the stapedial arch, including 24 with a history of radical surgery and without ossicles, the head of an allograft stapes was placed on the patient's footplate and on top of this an incus body, either as allograft or autograft. The results of this assembly, judging by different methods of analysis, are the same as in 45 ears having approximately the same pathologic condition treated by an autograft or allograft incus as the columella between the footplate and eardrum. The allograft stapes-incus assembly is an alternative method to the commonly used incudal columella, particularly in patients previously subjected to radical surgery in whom all ossicles are absent.


Nasopharyngeal rhabdomyosarcoma. A clinical perspective. Embryonal rhabdomyosarcoma of the nasopharynx is an uncommon tumor occurring almost exclusively in children. The clinical characteristics of 56 previously reported cases are analyzed and four patients recently treated at the UCLA Center for the Health Sciences are described. Special attention has been given to the prognosis of these tumors as it relates to current methods of treatment.


The mastoid air cell system in ear surgery. Despite the overall high success rate of myringoplasty, the long-term results in ears with preoperative dysfunction of the Eustachian tube and with a small mastoid air cell system are disappointing. In this communication, we report an 83% healing rate after myringoplasty that included mastoidectomy with posterior and anterior tympanotomy in a selected group of patients with poor tubal function and small mastoids.


Transport of antibiotics into the canine sinus. Experiments with penicillin G and erythromycin. Complete and consistent occlusion of the nasofrontal duct of the canine sinus was achieved by introducing acrylic through a trephinated opening in the nasal dorsum. This surgical procedure resulted in the isolation of the frontal sinus, without impairing the integrity of the cavity. In this experimental canine model, potassium penicillin G and erythromycin lactobionate were absorbed into the blood equally well when placement was either in the intramuscular (IM) space or in frontal sinus cavity. When different concentrations of these antibiotics were injected into the IM space, peak blood levels occurred between one and two hours; however, peak sinus levels, following IM introduction, did not occur until four hours. The peak ratios show that between 4% and 20% of penicillin, and 1% and 12% of erythromycin in the blood is transferred across the normal sinus membrane.


Risks of facial plastic surgery in an otolaryngology program. By reviewing 680 rhinoplasty, facelift, blepharoplasty, otoplasty, and chin implant procedures that were performed during a two-year period by UCLA Head and Neck Surgery (Otolaryngology) residents, we have found that the rate of major and minor complications compares favorably with that rate achieved by physicians in practice who have reported their results in the literature. Three hundred and sixty-eight rhinoplasties resulted in 1.6% major complications, 14.4% in minor complications, and 5.2% in revision surgeries. One hundred fourteen facelifts had 5.3% major complications, and 24.5% had minor complications. One hundred fifty-six blepharoplasties had no major complications, and 7.7% had minor complications; 21 chin implants resulted in no major complications, and 9.5% resulted in minor complications; and 21 bilateral otoplasties had no major complications, and 14.3% had minor complications, with 4.8% revisions.


Mycotic infection of the temporal bone.

Mycotic infection of the temporal bone. Herein is a histopathologic study of the temporal bone changes in three patients with fatal systemic fungal infections. All three patients were compromised hosts who failed to respond to adequate chemotherapy. Interestingly, one patient with cryptococcosis had a unilateral hearing loss as the sole manifestation of cerebral cryptococcosis. The most common histopathologic change consisted of a fungal infiltration of the nerves in the internal auditory canal, with moderate infiltration of the sense organs of the membranous labyrinth.


The anatomy of the nose. External support. The anatomy of the nose is poorly defined, even in standard anatomical texts. Wide disagreement exists regarding the interdigitation of the supporting cartilages, the articulation of these cartilages with the nasal bones, and the contribution of each of these cartilages to the support of the external nose. An understanding of this nasal anatomy is essential to the facial plastic surgeon. The authors describe the fundamental anatomical structure of the adult nose based on gross and microscopical observations and serial sections in 31 cadaveric noses. Tables of cartilage measurements and variation, plus appropriate drawings define the anatomy encountered. Structural variations are common and can be predicted by external appearance in selected cases. To discuss relationships of importance in the surgical alteration of the nose in rhinoplasty, anatomical findings are compared to descriptions in the surgical and anatomical literature. Preservation of essential support and physiological function is stressed.


Aryl hydrocarbon hydroxylase inducibility in laryngeal carcinoma. The chief carcinogens of tobacco smoke--the polycyclic aromatic hydrocarbons--must be activated in the cells to exert their carcinogenic effect. This activation is carried out by the enzyme system aryl hydrocarbon hydroxylase (AHH). Mitogen-stimulated, human lymphocyte studies of AHH activity indicate wide individual variation, which is under strict genetic control. The venous blood samples from 90 patients with a laryngeal carcinoma were assayed, and a significant overrepresentation of patients with genetically high AHH inducibility was demonstrated. Our results suggest the possibility of identifying those tobacco users at higher genetic risk for developing carcinoma of the larynx.


Simultaneous recurrent multiple chemodectomas. We report a case of concomitant, recurrent carotid body tumor and recurrent bilateral glomus jugulare tumors, with extensive intrajugular-venous extension. The patient's family history confirms the previously reported familial occurrence of chemodectomas. The value of preoperative angiographich evaluation is emphasized in establishing a diagnosis and formulating a therapeutic approach. Recurrence of chemodectomas after appropriate therapy, although unusual, was present in all three previously treated sites in this patient.


Lymphoepithelioma of the vocal cord.

Lymphoepithelioma of the vocal cord. Lymphoepithelioma is a predominantly nasopharyngeal tumor with some incidence elsewhere in the pharynx. Occurrence in other sites is unusual. This report presents an example of a lymphoepithelioma arising in the vocal cord. The basal cells of the squamous epithelium lining the tonsillar crypts bear a close resemblance to the cells of this tumor, and they are intimately related to lymphoid tissue. It is our belief that lymphoepitheliomas arise from the basal zone and that the basal layer of epithelium even further afield might on occasion produce the lesion.


Congenital deafness and spontaneous CSF otorrhea. Two patients with congenital deafness had spontaneous CSF otorrhea and recurrent bacterial meningitis. A careful workup, including tomograms, is especially important in the treatment of the closed type of CSF otorrhea. At operation of our patients, the leak was found to be at or near the oval window. The stapes was removed, and muscle was packed into the defect. The profuse flow of CSF was believed to be secondary to a wide-open cochlear aqueduct in the first case, and to an abnormal communication between the internal auditory meatus and the vestibule in the second case. These findings were the bases for the recurrent bacterial meningitis.


Operating table for guinea pig ear surgery. This communication describes the construction and method of use of an adjustable operating table. The small table was designed especially to immobilize guinea pigs for experimental ear surgery.


Inhalation anesthesia with methoxyflurane for guinea pig ear surgery. Anesthesia with methoxyflurane is ideal for long-term middle ear experiments on guinea pigs. This communication describes the use of a conventional pediatric anesthetic circuit that delivers a mixture of methoxyflurane and air by a face mask; it is effective, safe, and simple to use.


Foreign bodies in the ear, nose and throat. Foreign bodies in ear, nose and throat orifices should not be hastily removed. Inaction is the order of the day, with the exception of the larynx and trachea which have to be rapidly assessed, and the FB removed as a life saving procedure.


Earache and glue ear.

Earache and glue ear. In most cases, the cause of an earache is obvious. If the cause is not apparent after careful inspection, a systematic approach to the associated causes and sites of referred pain is necessary. Glue ear is the most frequent cause of hearing loss in children. The diagnosis, investigation and management have been described. Recurrent earache from pressure change or from recurrent middle ear infection is an important clue to the presence of a glue ear.


Blocked, runny or stuffy nose.

Blocked, runny or stuffy nose. The blocked, runny or stuffy nose is purely a symptom caused by a multitude of complaints. Whether the discharge be serous or mucoid is not necessarily important, but more so is the transition from mucoid to purulent. Where signs and symptoms of so many causative pathological agents are so similar, a better understanding of nasal function coupled with a more thorough examination of the nasal cavity and indeed of the whole patient, is the only way to come to an accurate diagnosis.


Reconstructive surgery of the nose.

Reconstructive surgery of the nose. Reconstruction of the nose either for disease or deformity is often a complex procedure. The methods used follow time-honoured plastic surgical principles. Modifications of and improvement on existing methods continue to appear, and will continue to do so as long as the art of plastic surgeon develops further, and the challenge of a difficult deformity remains. It has been said that once the surgeon has completed his first 1,000 rhinoplasties, he may begin to have some understanding of the subtleties of the procedure. No-one has performed this operation with patience, care and what skill he imagines he has developed over the years, only to find that on removing the plaster the result is less than pleasing, would seriously challenge this statement.


Hoarse voice.

Hoarse voice. Various causes of hoarse voice are briefly discussed in this article. As it is not possible to give a detailed account of all the causes of this important condition affecting the larynx, any patient with persistent hoarseness of more than four weeks' duration should have his larynx thoroughly examined. The head mirror, suitable light source, laryngeal mirror, spirit lamp, pierce of gauze and a local anaethetical spray is all that is required to carry out a mirror examination of the larynx.


The diagnosis of asthma.

The diagnosis of asthma. There are three steps in establishing the diagnosis of asthma in a child presenting with recurrent wheezing or recurrent coughing. The first is to decide whether the symptoms are due to asthma, the second is to consider possible aetiological factors--mainly to reassure the parents that there is nothing particular in this area that need be done--and the third is to determine what is the pattern of airways obstruction. Is it purely episodic or alternatively, are there periods where it persits? In younger children, clinical evidence alone is all that is available to decide whether the respiratory symptoms are due to asthma, and to determine its pattern. In older children, pulmonary function tests are very helpful.


The allergist's concept of asthma.

The allergist's concept of asthma. Asthma is a disease characterized by bronchial hyper-reactivity which leads to airway obstruction of varying degree. Numerous factors are able to induce the obstruction; amongst theses, allergy is prominent and the asthma/allergy relationships listed in Table 1 are generally accepted. Thus, although asthma is not necessarily an allergic disease, all asthmatic patients deserve a full allergic investigation aimed at either finding or excluding a relevant allergen.


Characteristics of hepatic alanine-glyoxylate aminotransferase in different mammalian species. Mitochondrial extracts of dog, cat, rat and mouse liver contain two forms of alanine-glyoxylate aminotransferase (EC 2.6.1.44): one, designated isoenzyme 1, has mol.wt. approx. 80 000 and predominates in dog and cat liver; the other, designated isoenzyme 2, has mol.wt. approx. 175 000 and predominates in rat and mouse liver. In rat and mouse liver, isoenzyme 1 activity was increased by the injection in vivo of glucagon, but not isoenzyme 2 activity. Isoenzyme 1 was purified and characterized from liver mitochondrial extracts of the four species. Both rat and mouse enzyme preparations catalysed transamination between a number of L-amino acids and glyoxylate, and with L-alanine as amino donor the effective amino acceptors were glyoxylate, phenylpyruvate and hydroxypyruvate. In contrast, both dog and cat enzyme preparations were specific for L-alanine and L-serine with glyoxylate, and used glyoxylate and hydroxypyruvate as effective amino acceptors with L-alanine. Evidence that isoenzyme 1 is identical with serine-pyruvate aminotransferase (EC 2.6.1.51) was obtained. Isoenzyme 2 was partially purified from mitochondrial extracts of rat and mouse liver. Both enzyme preparations were specific for L-alanine and glyoxylate. On the basis of physical properties and substrate specificity, it was concluded that isoenzyme 2 is a separate enzyme. Some other properties of isoenzymes 1 and 2 are described.


Articular-cartilage proteoglycans in aging and osteoarthritis. The composition of macroscopically normal hip articular cartilage obtained from dogs of various ages was studied. Pieces of cartilage with signs of degeneration were studied separately. In normal aging, the extraction yield of proteoglycans decreased; the keratan sulphate content of extracted proteoglycans increased and the chondroitin sulphate content decreased. The extracted proteoglycans were smaller in the older cartilage, mainly owing to a decrease in the chondroitin sulphate-rich region of the proteoglycan monomers. The hyaluronic acid-binding region and the keratan sulphaterich region were increased and the molar concentration of proteoglycan probably increase with increasing age. The degenerated cartilage had higher water content and the proteoglycans, as well as other tissue components, gave higher yields. The proteoglycan monomers from the degenerated cartilage were smaller than those from normal cartilage of the same age, and hence had a smaller chondroitin sulphate-rich region and some of the molecules also appeared to lack the hyaluronic acid-binding region. Increased proteolytic activity may be involved in the process of cartilage degeneration.