The values of some plasma components during the early phases of fracture healing in man. A study of plasma components during the early phases of fracture healing in man showed no specific changes except a change of C-reactive protein to positive and a slight but non-significant increase of the plasma hydroxyproline.


The penetration of lincomycin into normal human bone. Determination of penetration into compact bone, spongy bone and bone marrow. The penetration of lincomycin into normal bone was studied in 10 patients with fracture of the neck of the femur, a separate determination being made of the lincomycin concentration in serum, bone marrow, spongy bone and compact bone. The concentration of lincomycin in bone marrow was found to be at the same level as that in the serum. The concentration in spongy bone amounted in most cases to 50 to 75 percent of the concentration in the serum, whereas the concentration in compact bone varied from 0 to 15 percent of that in the serum.


Treatment of chronic osteomyelitis by transplantation of autogenous omentum with microvascular anastomosis. A preliminary report. Free omental transplantation with vascular anastomosis was attempted in three clinical cases as a new method of treatment for chronic osteomyelitis. The bone cavity produced by debridement was completely eliminated by the transplanted omentum. Furthermore, the omentum, because of its biological characteristics, formed good vascular anastomoses with the adjacent bone tissue. Although sufficient time has not yet elapsed to prove the existence of healthy bone regeneration and therefore, further evaluation for a longer period is necessary, this therapeutic method would seem to have considerable potential in the treatment of chronic osteomyelitis.


Correction with growth following diaphyseal forearm fracture. In 25 children with fracture of the shafts of the forearm an average angulation deformity of 20 degrees was recorded when the fracture had healed. At follow-up, which took place after the cessation of growth, and angulation deformity was reduced by half; there was, however, a large individual variation. Both severe and less severe deformities were found to be corrected. Correction was more likely in younger children than in older children, though again there were exceptions to this rule. The most common dysfunction recorded was a decreased pronation-supination. This was not very closely correlated with angular deformity.


Posterior interosseous nerve paralysis caused by fibrous band compression at the supinator muscle. A report of four cases. Four cases are reported of paralysis of the posterior interosseous nerve, caused by compression of the nerve between the Arcade of Frohse and the two heads of the supinator muscle. All four cases were treated by decompression with excellent results.


Surgical treatment of acromioclavicular dislocation. The results of surgical treatment of 17 patients with complete acrominoclavicular dislocation are presented. The operative procedure described is technically easy, gives good results, has few complications which often follow operations using metallic fixation devices. A second operation to remove fixation devices is avoided.


Ring total hip replacement in osteoarthrosis. A follow-up is given of the results of 40 arthroplasties with the non-cemented, vitallium-to-vitallium bearing Ring total hip prosthesis in 37 patients with osteoarthrosis. Operative indication was an intolerably painful and stiff joint. The surgery was performed by two specialists in orthopaedics. Point scors according to a modification of merle d'Aubigné's classification showed excellent or at least good results in 52.5 per cent, and fair results in 27.5 per cent of the operations. One prosthesis was removed because of deep infection. The mortality rate was zero. In 20 per cent the total score was between 0 and 7, signifying little or no improvement. Loosening was the main problem even although it was in many cases well tolerated by the patients.


False aneurysm of the external iliac artery following hip endoprosthesis. A false aneurysm developed from the external iliac artery within the pelvic cavity following total hip surgery when methylmethacrylate cement had been used to fix the cup. The aneurysm was probably caused by a cement spicule which had entered the pelvis and had come into contact with the external iliar artery.


Girdlestone's operation: a follow-up study. A study was made of 43 patients (48 hips) operated for diseases of the hip using Girdlestone's method. The follow-up time ranged from 2.5 to 13 years. For assessment of the post-operative results the following parameters were taken into consideration: pain, range of movement, gait and the patient's opinion. These were studied separately and in relation to the type of disease, the patient's age, and the time which had elapsed since the operation. Pain decreased in a considerable number of patients and range of movement and gait improved. The patients were generally in favor of the operation, and felt it had had a beneficial effect on their condition.


Lower extremity amputations in the county of Aalborg 1961-1971. Population study and follow-up. All lower extremities amputations in the county of Aalborg, Denmark, during the period 1961-1971 were analysed. During this 10-year period the amputation rate did not increase. Those requiring amputation were predominantly arteriosclerotics followed by diabetics. The diabetics underwent amputation 3 years younger on average than the arteriosclerotics, but it was more often possible to preserve the knee in diabetics. There was a far higher rate of successful prosthetic fitting among patients in whom the knee had been preserved. Despite a high mortality, also beyond the first postoperative months, prosthetic fitting was of such psychological and social value, that every effort should be made to amr homes. This was the most positive finding in the present study.


Stress radiographical measurement of the anteroposterior, medial and lateral stability of the knee joint. A hydraulically operated machine for applying well-defined forces to the knee joint is described. The measurement of anteroposterior as well as lateral and medial stability in the knee joint is based upon roentgenograms exposed while the forces are being exerted on the patient. The advantage of the radiological measuring method over methods using external measurements is the elimination of inaccuracies due to displacements of the soft tissues of the limb. The accuracy was evaluated by test/retest examination of 50 healthy subjects. The radiographs were measured at random after cessation of examinations in the gonylaxometer. The accuracy is +/- 1.2 nm for medial/lateral, +/- 2.4 nm for drawer sign. Diagnostically the difference between the two knees must exceed 2.0 nm (collateral instability) or 3.1 nm (drawer) to exceed standard values. The standard values for the different ligament laxities are given. The applied force to be used for evaluation of medial/lateral stability is recommended to be 9 kg, and for anteroposterior stability between 20 and 30 kg.


The subchondral bone in osteoarthritis and rheumatoid arthritis of the knee. A histological and microradiographical study. Specimens of the joint surfaces of the tibia from patients with OA and RA were exposed were examined for bone mineralization, bone formation, osteoid tissue and bone resorption. Judging from the appearance of the osteoblasts in OA the sclerotic changes are  mainly focal with relatively little osteogenesis. No osteoclasia was seen in the sclerotic areas. Breakdown of the mineralized cartilage is followed by the development of cysts with highly cellular connective tissue with high osteoblastic activity and osteoclasia. Osteoid tissue is relatively sparse. The changes in RA are more diffuse with a more active osteoblastic activity and widespread zones of osteoid tissue as well as resorption by osteoclasts. It appears as if the increased uptake of 85Sr in OA is more dependent on the occurrence of relatively inert osteosclerosis than on a rapid turnover of the bone tissue.


Segmental tibial shaft fractures.

Segmental tibial shaft fractures. A series of 54 cases with multiple fractures of the tibia is reported. Sixty-eight per cent of the group were pedestrians hit by a car. Fifty-two per cent were open fractures. Osteosynthesis was performed in 33 cases, whereas 21 were treated conservatively. Plate osteosynthesis was accomplished in 23 cases, seven had intramedullary nailing, and two were treated by Hoffman's external fixation device. Only one patient sustained a severe complication, viz., deep wound infection and osteomyelitis; however, even this infection was transient. All fractures healed except those sustained by two patients who died within 3 months; these deaths were, however, without any causal relationship to the osteosynthesis. One patient had a traumatic vascular lesion concomitant with the fracture, and his leg was amputated 3 days after the injury. Another patient had his leg amputated 1 year after his accident, in this case also because of injury to the vessels and nerves. It was concluded from the present series that segmental or multiple tibial shaft fractures do not entail more complications nor do they exhibit a slower rate of union than simple tibial shaft fractures if the treatssue injury.


Aneurysmal bone cyst of the talus.

Aneurysmal bone cyst of the talus. Aneurysmal bone cysts localized in the talus are extremely rare. Such a case is described and the histological findings are analysed in relation to those in aneurysmal cysts in general. The pathomechanism of the lesions is discussed.


Psychiatric disorder in children with birth anomalies. A retrospective follow-up study. A group of 273 children and adolescents, aged 8 to 19 years, who had been treated for a congenital malformation during their 1st month of life, were studied using psychiatric interviews with the child and at least one of his parents. The child was also given a Wechsler intelligence test. The rate of psychopathological disturbance was as high as 49% (the classification used included organic brain disorder and mental retardation). Developmental deviations, psychoneurotic disorder and reactive disorder were the commonest types of disturbance (in 18, 17, and 11% respectively). Eleven percent were suffering from organic brain disorder and 8% had an IQ of no more than 50. The malformed children were compared with 509 children from the general population in terms of behaviour disturbance as rated by their teacher. Approximately one child in five in both groups presented behaviour problems, and behaviour was labelled as antisocial in 10% of children in both groups. The two groups of children did not differ significantly in regard to the family's social class, annual income, father's educational background, or the number of children in the family, but the parents of the malformed children had recieved psychiatric treatment more often than the control group parents.


Specific reading retardation, hyperactive child syndrome, and juvenile delinquency. The purpose of the study was to ascertain the extent to which a specific reading retardation leads to criminal development in adolescent and to what factors such development is due in these cases. For this purpose, 224 adolescents with a specific reading retardation were investigated. A relatively large number of these (12.1%) were prone to criminality between the ages of 15 and 20 years, whereas the severity of the specific reading retardation did not seem to contribute to this propensity. Symptoms of hyperactivity, on the other hand, seemed to contribute to criminal behaviour.


Psychic disorders among pre-school children in a geographically delimited area of Aarhus county, Denmark. A study was undertaken concerning prevalence of psychic disorders among 175-5 to 6-year-old, pre-school children randomly selected from the general population in the municipality of Aarhus and the island Samsø of Aarhus County, Denmark. Deviant behaviour was arbitrarily defined, with a symptom considered aberrant if it occurred in 10% or less of the children studied. Mental health of the children was assessed by (a) the number of deviant symptoms, (b) opinions of the parents and (c) the personal assessment of the author, who interviewed all the families. Thirty-five probands (20%) showed good adjustment, 113 (65%) were coping well with only minor symptoms, and 27 children (15%) were poorly adjusted. A high prevalence of psychosomatic, behavioural, and emotional symptoms was observed, some of them more frequently among boys than girls. No significant difference was found between urban and rural children. The need for psychiatric help even among supposedly normal, pre-school children is discussed and emphasized.


Severe mental retardation among children in the county of Arhus, Denmark. A community study on prevalence and provision of service. An epidemiological census investigation on severe mental retardation among children under 15 years were carried out on July 1, 1970, in the community of Aarhus. Case finding procedures are described in detail. One hundred and seventy-one severely retarded children were found in total population of 233,162 with 50,667 children under 15 years. The age-specific prevalence rate was 3.38 per 1,000. About 20% of the severely retarded children are not registered in the Danish National Mental Retardation Service when they reached school age. One third of the children are under residental care, but only half of these are in subnormality hospitals while the other half reside in waiting homes. Among 64% living at home, two thirds receive day-care or training. Comparisons are made especially with two other prevalence surveys, one covering the same area, and the other identical in methods.


Electrophoresis of platelet monoamine oxidase in schizophrenia and manic-depressive illness. Monoamine oxidase is an important enzyme in the catabolism of biogenic amines and can be measured in human platelets. Platelet MAO has been reported to be reduced in schizophrenic and manic-depressive patients, though other reports are contradictory. The present study evaluated the possibility that qualitative genetic enzyme abnormalities of MAO could be responsible for the different enzyme activities of platelet MAO in different populations. However, polyacrylamide gel electrophoresis of platelet MAO from 10 manic-depressive, 12 schizophrenic, and 11 normal individuals did not reveal any genetic mutant forms.


Investigation of the orthostatic reaction after intravenous administration of imipramine, chlorimipramine, and inimpramine-N-oxide. Three age- and sex-matched groups of 10 patients were treated intravenously with imipramine, chlorimipramine, and imipramine-N-oxide respectively, in increasing doses from 25 mg to 150-175 mg given as single daily infusions during 1 hour. No systemic changes of heart frequency and blood pressure were found during the infusions in spite of the high dosage of tricyclic antidepressants given such a short period as 1 hour. The patients were examined regarding orthostatic reactions as well as ECG changes before, after 4-5 infusions and after 8-10 infusions. There were more orthostatic abnormalities and ECG changes in the patients treated with imipramine than in those treated with imipramine-N-oxide and there were practically no changes in the chlorimipramine group. However, no statistically significant orthostatic changes were found.


Pneumatonographic studies on normal and glaucomatus eyes. A new methodological approach, embodied in the pneumatonograph, has been used to study the intraocular pressure, intraocular pulse and aqueous humor dynamics of normal and glaucomatous eyes. Comparative measurements of intraocular pressure in seated subjects by the Goldmann instrument and the pneumatonograph indicate close agreement over a wide range of pressures. On changing from the sitting to the supine position, it has been found by pneumatonometry that there is a significant increase of intraocular pressure in all eyes. In glaucomatous eyes, this postural response ranged up to as high as 12 mm Hg. Comparison of Schiotz and pneumatonometric pressure measurements on supine patients showed that the Schoitz values are significantly lower. This discrepancy of the values is in keeping with recent studies indicative that the Schiotz calibration is in error by 3-6 mm Hg. The coefficient of outflow facility was measured by a procedure of applanation tonography employing pressure-volume relations for the living human eye. The range of values found for normal eyes was significantly different from those of glaucoma eyes. It is concluded that pneumatonography is a useful method for improving the effectiveness of glaucoma diagnosis and clinical management.


New aspects of contact lenses in ophthalmology. The introduction of the hydrophilic contact lens has been a significant advance in ophthalmology for the correction of ametropia, as well as for the therapy of corneal disease. The number of potential contact lens candidates has been greatly expanded by the introduction of both spin-cast and lathe-cut lenses composed of a variety of individual hydrophilic polymers. Myopia, hyperopia, presbyopia, aphakia and moderate astigmatism can be corrected with a reasonable degree of success with the present lenses. Even in keratoconus hydrophilic lenses offer a nonsurgical alternative, especially when combined with spectacle overcorrection. The introduction of hydrophilic bandages in the treatment of corneal disease has been an important addition to the therapeutic armamentarium of the ophthalmologist. When properly applied, these lenses can provide subjective relief of pain while serving to protect the damaged cornea from the traumatic action of the lids and desiccating effects of the atmosphere. The hydrophilic material is permeable to many topically instilled medications and tends to prolong the contact time of the drugs with the corneal surface. Proper fitting of the bandage lenses can eliminate superficial corneal irregularities and, thus, improve the visual acuity while treatment progresses. Medical indications for the use of this therapy include bullous keratopathy, dry eye syndromes, chemical burns, exposure keratitis, and neurotropic keratitis. A number of recurrent erosions and ulcerations have also responded to this form of therapy. Surgical indications include lacerations, postoperative lamellar and penetrating keratoplasty, and keratectomies. One of the most promising applications concerns their use in the postoperative management of alkaline burns. Best results have been obtained by constant wear of the bandage lens, with topical administration of steroids, antibiotics, and saline solution (hypotonic or hypertonic) as indicated. The possible deleterious effects of standard ocular medication containing preservatives has been overstated. Patients receiving medications without preservatives must be placed on prophylactic antibiotics to avoid secondary infection. In many cases, the therapeutic efficacy is closely related to the diameter and curvature of the bandage lens as well as the inherent physical properties of the polymers. With meticulous fitting and close observation complications have been minimal. In many instances the results have been dramatic, but even if unsuccessful the method provides a safe and relatively simple nonsurgical alternative in the treatment of severe corneal disease. Just as with older modalities, the ultimate success or failure depends upon the intrinsic nature of the disease process as well as reasonable therapeutic application based on a knowledge of the mechanics involved.


[Fluorescent angiography of the papillary region in glaucoma]. The results of fluorescent angiography show that the main blood supply to the papilla comes from the ciliary circulation in the region of the lamina cribrosa, generally from the posterior ciliary arteries and less frequently from Zinn's corona, in the prelaminar region, to a considerable extent from the peripapillary choroid membrane and in the retrolaminar part also from the recurrent branches of the peripapillary choroid membrane. It also emerges that the vascular supply of the papilla in this region is arranged by segments, which explains, for example, the formation of nerve-fibre bundle defects in glaucoma. Papillary irrigation and the peripapillary choroid membrane are extremely sensitive to an increase in intra-ocular pressure. All these results provide a good basis for the assumption that, in glaucoma, the main factor producing restriction of the field of vision and excavations of the papilla is defective irrigation of the papillary vessels, originating in the choroid membrane, with chronic ischemia of the papilla. Our own studies lead us to suspect that disturbances of irrigation can precede functional disorders. For several reasons, fluorescence angiography is ill-suited to routine diagnosis. In general, however, this method does underline the significance of disturbances of papillary irrigation in the origin of glaucoma damage.


Use of inverted telescopic corrections incorporating soft contact lenses in the (partial) correction of aniseikonia in cases of unilateral aphakia. Soft contact lenses have been successfully adapted to inverted telescope units used to restore effective binocularity to selected unilateral aphakic patients. Techniques for adapting such units to the patient have been outlined and results have been reviewed. Differences between hard and soft contact lens techniques have been contrasted. The practitioner is encouraged to utilize these methods when binocularity would be a clear advantage to the patient with unilateral aphakia. The author hopes to adapt these techniques to the treatment of infants and young children in the future.


[Intra-ocular optics and contact lens correction in unilateral aphakia]. After an explanation of intra-ocular optics, the first results of combined contact lens correction in 42 patients are reported. As opposed to the conventional type of contact lens treatment in monolateral aphakia, this method has four main advantages: 1. It enables practically identical sight in both eyes, thus providing the necessary conditions for binocular vision both at a distance and close-up. 2. The recovery of sensomotor haptics in both eyes prevents squinting, even in the case of incipient cataract of the other eye. 3. Premature lens extraction in the second eye can be postponed and delay in lens extraction in the first affected eye can be avoided. 4. In cases where dioptric aniseikonia is very marked, as in myopia, a bilateral spectacle-contact lens combination enables tolerable binocular vision to be achieved even without an aniseikonic lens. Our findings indicate that the conventional contact-lens correction of monolateral aphakia is never satisfactory in cases with a moderate to high degree of myopia and in all refraction defects in young patients. Echometry, objective measurement of aniseikonia and combined contact lens correction helps most of these patients to regain binocular vision, both close-up and at a distance. In practice, rules of thumb and principles can be established. Even without the aid of echometry and objective aniseikonic measurement, Rule 1 enables us to prescribe combined contact lens correction for 80% of all presbyopic patients, thus enabling them to regain comfortable binocular vision. We all know that monolateral aphakia is, unfortunately, no triumph of ophthalmological science, but rather a serious eye defect that we must correct as best we can. Conventional contact lens correction, delay in operation for cataract of the first affected eye, as well as premature operation of the second eye are, in many cases, of as little help to our patients as monolateral cataract spectacles, with occlusion of the healthy eye with normal or dark glass. In contrast, combined contact lens correction in many cases of monolateral aphakia enables the patient to regain binocular vision.


Frequent or complex ventricular ectopy in apparently healthy subjects: a clinical study of 25 cases. During 18 months, 25 asymptomatic apparently healthy subjects were consecutively studied because of electrocardiographic discovery of frequent (more than 3 beats/min) or complex (multiform, alternating or repetitive patterns) ventricular ectopy of unknown cause. History, physical examination, laboratory data, chest roentgenogram, vectorcardiogram, exercise testing, echocardiogram, His bundle electrogram and cardiac catheterization procedures were performed to detect cardiac abnormalities. Ventricular ectopy was studied with maximal exercise testing, 24 hour Holter recordings and antiarrhythmic drug regimens. The duration of ventricular ectopy ranged from 1 to 30 years (mean 6). Eighteen subjects had an apparently normal cardiac status, and seven had mild or suspected abnormalities. Ventricular ectopy was of predominantly right ventricular origin in 19 of 25 subjects, and disappeared during maximal exercise in 21 of 23 subjects. Characteristic frequent (mean 559 beats/hour) and complex (bigeminal, trigerminal or ventricular couplet) ectopic beats were consistently present in all subjects during a 24 hour diurnal cycle. Antiarrhythmic drug regimens were generally ineffective. Our data suggest that a clinical syndrome of frequent complex ventricular ectopy can occur in apparently healthy subjects. The etiology and natural history of this syndrome are undefined.


Sinus bradycardia and atrial fibrillation associated with the Wolff-Parkinson-White syndrome. Thirty-three patients with atrial fibrillation associated with the Wolff-Parkinson-White (WPW) syndrome were studied to determine the relation of sinus bradycardia and atrial fibrillation. In seven patients the sinus rate was less than 40 beats/min and sinus nodal disease was considered a cause of the periods of bradycardia. Ventricular fibrillation of functional cardiac arrest was documented in four instances. Twenty-six patients demonstrated a type A and seven a type B WPW pattern during periods of sinus rhythm. Male patients predominated. The average age was 38.5 years among patients with a type A pattern compared with 25.3 years among those with a type B pattern. The shortest R-R cycle length in this group was 130 msec during a period of atrial fibrillation. Five thousand serial microscopic sections were studied in one patient who demonstrated ventricular fibrillation. Three anomalous pathways were located in this patient with the widest tract, 380 mu, containing about 400 muscle cells. Most of the sinoatrial node was replaced by collagen elastic fibers, and there was widespread destruction of the atria with a marked increase in fibrous connective tissue. Ventricular fibrillation or functional cardiac arrest is not a rare arrhythmia in patients with atrial fibrillation associated with the WPW syndrome and may be responsible for sudden death in patients with these arrhythmias. Hence, precise electrophysiologic studies and pharmacologic or surgical management, or both, are suggested to prevent sudden death in patients with short refractory periods associated with atrial fibrillation and the WPW syndrome.


Association of ostium secundum atrial septal defects with mitral valve prolapse. Severe prolapse of the mitral valve leaflets was seen at left ventricular angiography in 16 of 92 patients with a secundum type atrial septal defect studied prospectively from 1970 to 1974. The patients were aged 15 to 69 years; angioplasty or mitral valve replacement was carried out in nine. In 9 of 122 patients aged 15 to 55 years who were operated on for closure of a secundum type atrial septal defect between 1956 and 1969, mitral regurgitation due to prolapse but with intact chordae tendineae was seen at operation. In three of these patients chordal rupture was seen at a second operation 2 to 6 years later. The outlook in the syndrome of mitral valve prolapse may be less benign than is usually believed.


Ventricular monophasic action potential changes associated with neurogenic T wave abnormalities and isoproterenol administration in dogs. Changes in the duration of monophasic action potentials on the anterior and posterior walls of the dog ventricle were correlated with changes in T wave polarity and duration of the Q-T interval after (1) left stellate ganglion transection, (2) right stellate ganglion stimulation, and (3) administration of isoproterenol before or after these procedures. Left stellate ganglion transection and right stellate ganglion stimulation produced similar changes in T wave polarity, but the former prolonged and the latter shortened the Q-T interval. All procedures changed the duration of the monophasic action potential and the Q-T interval in the same direction. The reversal of T wave polarity induced by left stellate ganglion transection, right stellate ganglion stimulation or administration of isoproterenol after left stellate ganglion transection was associated with an average change of 13 to 17 msec in the difference between the monophasic action potential durations on the anterior and posterior ventricular walls. Isoproterenol restored to normal the neurogenic T wave abnormalities produced by left stellate ganglion transection and right stellate ganglion stimulation. The drug shortened the previously prolonged monophasic action potential more than the normal monophasic action potential, and the normal monophasic action potential more than the previously shortened monophasic action potential. This study confirms that the T wave is a sensitive indicator of relatively small changes (less than 20 msec) in the sequence of ventricular repolarization and explains the mechanism by which isoproterenol "normalizes" the primary T wave abnormalities.


Effect of amiodarone in the Wolff-Parkinson-White syndrome. The effect of amiodarone in the Wolff-Parkinson-White syndrome was studied with programmed electrical stimulation of the heart in 15 patients. All 15 patients had circus movement tachycardias; 7 also had atrial fibrillation. Programmed electrical stimulation was performed before and after 14 days of oral administration of amiodarone. The effective refractory period of the accessory pathway lengthened in an atrioventricular direction in all patients and in a ventriculoatrial direction in eight patients. The effective refractory period of the atrium and ventricle lengthened in 14 and 12 patients, respectively. After administration of amiodarone, circus movement tachycardia could no longer be initiated in five patients. The zone of tachycardia narrowed in four patients, did not change in two and increased in seven. The effect of amiodarone on initiation of circus movement tachycardia could be related to differences in effect of the drug and in the mechanism of tachycardia in individual patients. In all patients in whom tachycardias could still be initiated after treatment with amiodarone the heart rate during tachycardia was slower than before treatment. This slowing was caused by a decrease in conduction velocity of the circulatory wave in different parts of the tachycardia circuit. The effect of amiodarone in prolonging the refractory period of the accessory pathway makes this drug especially useful in patients with the Wolff-Parkinson-White syndrome and atrial fibrillation.


Patient-initiated rapid atrial pacing to manage supraventricular tachycardia. Patient-controlled rapid atrial pacing was used to manage 12 cases of recurrent supraventricular tachycardia refractory to drug therapy. The pacing system consists of an implanted receiver-lead system and an external patient-activated transmitter. In each case, brief periods (5 to 20 seconds) of rapid atrial pacing were effective in terminating the supraventricular tachycardia and resulted in a return to normal sinus rhythm. In three patients, occasional transient episodes of atrial flutter or atrial fibrillation preceded a spontaneous return to normal sinus rhythm. The pacing system was removed in one patient 13 months postoperatively because of persistent pericarditis; one patient died of an unrelated cerebral hemorrhage 13 months postoperatively. Successful management of supraventricular tachycardia has been maintained in the 10 remaining patients for 15 to 36 months (average 26.4). In more than 6,000 patient applications of rapid atrial pacing, there has been only one failure to convert the tachycardia. Successful application of permanent rapid atrial pacing requires (1) prescreening of patients with temporary external rapid atrial pacing to verify susceptibility to conversion of supraventricular tachycardia and absence of anomalous conduction pathways that may permit conduction of rapid pacing rates to the ventricles, and (2) assessment of the patient's ability to use the transmitter properly.


Permanent pacing in patients with transient trifascicular block during acute myocardial infarction. Patients with acute myocardial infarction and transient complete atrioventricular (A-V) block in association with right bundle branch block and left anterior hemiblock have a high incidence rate of late sudden death presumably due to recurrent A-V block. Over a 5 year period, 18 patients demonstrated right bundle branch block and left anterior hemiblock and had transient complete block during an acute myocardial infarction and survived to hospital discharge. Of six patients who did not have permanent pacing, five died suddenly (one was lost to follow-up) with a mean survival time of 2.4 months after hospital discharge. Twelve subsequent patients received permanent demand pacemakers and had a significantly improved prognosis with a mean survival time of 18 months (P less than 0.001). Six patients were still alive at an average follow-up time of 20 months. Prophylactic permanent pacing significantly improves the prognosis after acute myocardial infarction in this select subgroup of patients.


Fetal and infant death, twinning and cardiac malformations in families of 2,000 children with and 500 without cardiac defects. Analysis of family data on 2,000 children with a congenital cardiac malformation of unknown origin and 500 with an innocent murmur showed the incidence of twinning in probands, siblings and parents to be the same as in the general population. The mothers in the two groups of probands had the same incidence of spontaneous abortions and stillbirths. There was a small increase in infant mortality in siblings of probands with a cardiac malformation, but this could be accounted for by the increased incidence of cardiac malformations. The latter occurred in 1.4 percent of all siblings and in 1.7 percent of later born siblings. Complete concordance for malformation type occurred in 31 percent of affected siblings and 46 percent of affected parents, and partial concordance occurred in an additional 21 and 8 percent, respectively. Combined direct and indirect observations and calculations indicate that the risk of recurrent cardiac malformations is 1.4 to 3 percent in families in which one child was born with a cardiac malformation of unknown origin; no significant difference was evident for the various cardiac malformations.


Postoperative pathology of congenital heart disease. Complete and unselected data concerning the postoperative pathology of congenital heart disease are presented for the first time. This study was based on 2,365 autopsies performed at the Children's Hospital Medical Center, Boston, in the 9 years from 1966 through 1974. Of these, 586 autopsies (25 percent) revealed congenital heart disease--238 performed in medically treated patients (41 percent) and 348 in surgically treated patients (59 percent). Tetralogy of Fallot, including cases with pulmonary outflow tract atresia and other associated malformations, was the congenital heart disease most often encountered in the postoperative autopsy series (88 cases, 25 percent of that series). D-transposition of the great arteries, including cases with other associated anomalies, was second (54 cases, 15.5 percent). Early death (hospital mortality) accounted for 320 (92 percent) of the 348 surgical cases; late death occurred in 28 patients (8 percent). Causes of late postoperative death included arrhythmias, excessively small ventricular septal defect with tricuspid atresia, massive hemoptysis, rupture of the pulmonary artery, cyanotic spell, congestive heart failure and infection. Prophylactic penicillin is recommended for patients with the asplenia syndrome because of their probably enhanced vulnerability to fulmfulminating septicemia by encapsulated bacteria such as the pneumococcus. Completeness and lack of selection in reporting data are essential in the interests of perspective and comparability of findings.


Cardiac rhabdomyoma: a clinicopathologic and electron microscopic study. Cardiac rhabdomyomas are rare tumors of infancy. In a series of 36 patients 78 percent were under 1 year of age, and only one patient was over age 15 years. Ninety percent of the rhabdomyomas were multiple and occurred with nearly equal frequency in the right and left ventricles. Although reportedly infrequent in the atria, rhabdomyomas involved either one or both atria in 30 percent of patients. In 50 percent of patients at least one of the tumor masses was intracavitary and obstructed 50 percent or more of one of the cardiac chambers or valve orifices. Symptoms referable to obstruction of intracardiac blood flow were present in nine patients, none of whom had tuberous sclerosis, and all of whom would appear to have been good surgical candidates. Histologically the rhabdomyomas were composed of classic "spider cells". Electron microscopic studies revealed scattered bundles of myofibrils ringing these cells and radiating toward the center; glycogen was present both free in the cytoplasm and within mitochondria. Distinct intercellular junctions resembling intercalated discs with well defined desmosomes and nexuses were present. Many of the cells contained leptofibrils, arranged either peripherally or in spiraled clusters in the center of the cell. Rhabdomyomas derive from cardiac muscle cells and appear to represent hamartomas rather than true tumors.


Surgical treatment of congenital unilateral pulmonary arterial stenosis with contralateral pulmonary hypertension. This report describes the diagnosis and surgical treatment of a 48 year old patient with congenital right pulmonary arterial ostial stenosis, no intra- or extracardiac shunts and systemic levels of pressure in the main and left pulmonary artery with pulmonary vascular obstruction in the left lung. Operation consisted of a bypass graft of 10 mm woven Dacron from the main pulmonary artery to the distal right pulmonary artery producing an immediate 50 percent reduction in mean left pulmonary arterial pressure. Late postoperative evaluation revealed equal perfusion of both lungs, maintenance of the reduced pulmonary arterial pressure and improvement from New York Heart Association functional class IV to class I.


Masked abnormal drainage of the inferior vena cava into the left atrium. A 6 year old boy with a large atrial septal defect, partial anomalous pulmonary venous drainage and unrecognized anomalous insertion of the inferior vena cava into the left atrium had cyanosis after closure of the atrial defect. Repeat study revealed direct drainage of the inferior vena cava into the left atrium with moderate arterial oxygen desaturation. At repeat operation an unusual positioning of the inferior vena cava was seen. After reopening of the atrial defect, the pulmonary venous and systemic venous drainage anomalies were identified. A Dacron patch was inserted so as to divert flow to the proper atrium. Repeat catheterization 3 months after operation revealed a normal heart with no obstruction; arterial oxygen saturation was normal. The child has continued to do well 3 years after operation.


Aneurysm of the atrial septum in tricuspid atresia: diagnosis during life and therapy. Massive aneurysmal dilatation of the foramen ovale was diagnosed angiocardiographically in a patient with tricuspid atresia. The angiographic findings are distinct for this condition, and the pathogenesis appears to be related to a restrictive atrial communication in the patient with obligatory right to left shunting at atrial level. The anatomic potential for atrial restriction in the patient with tricuspid or pulmonary atresia, intact ventricular septum and diminutive right ventricle necessitates balloon atrial septostomy at the initial diagnostic cardiac catheterization. In the patient with aneurysmal dilatation of the foramen ovale, satisfactory decompression may be achieved by Blalock-Hanlon atrial septectomy, open atrial septectomy, or, possibly, balloon septostomy.


Esophageal dysfunction and Raynaud's phenomenon in patients with scleroderma. The relationship of Raynaud's phenomenon (RP) to the degree of esophageal motility dysfunction was evaluated in 12 patients with scleroderma. Motility abnormalities of the smooth muscle esophagus were quantitated using a motility index (MI). MI of the scleroderma patients differed significantly from controls. No relationship was noted between the extent of motility abnormality and the duration or severity of the RP. A nearly uniform finding was the absence of coordinated esophageal peristalsis, occurring regardless of the duration or severity of the RP. The study demonstrates that it is not possible to predict the degree of esophageal motility dysfunction in scleroderma based on RP alone. The disease may have two different and independent pathogenetic components. One component is closely linked to RP and involves impairment of neuromuscular electrical transmission. The other component (independent of RP) involves progressive loss of muscle strength in the distal esophagus and in the lower esophageal sphincter.


The behavior of mucopolysaccharide in the pancreatic juice in chronic pancreatitis. In order to study whether or not mucosubstance increases occur in the pancreatic juice of patients with chronic pancreatitis, hexosamine was measured in duodenal aspirates during the secretin phase (S-40) following pancreozymin-secretin stimulation in 16 normal subjects, 37 patients with chronic pancreatitis, 6 patients with alcoholism, 13 patients with gallstones, and 11 patients with peptic ulcer. The hexosamine concentrations in the pancreatic secretions showed a negative correlation with the bicarbonate concentrations and volume output. Rises in hexosamine concentration were seen in alcoholism and chronic pancreatitis, especially in alcoholic pancreatitis. This is probably intimately related with the repeated ingestion of large amounts of alcohol over long periods of time. Since high hexosamine values are noted in the relapsing type of chronic alcoholic pancreatitis, increases in viscosity due to mucosubstance increases in the pancreatic juice are probably related with the recurrence of acute attacks accompanying ductal stenosis or obstruction.


A bioptic study of gastrointestinal mucosa in cholera patients during an epidemic in southern Italy. A histological biopsy study of gastric and jejunal mucosa of eight acute cholera patients during an epidemic in Southern Italy was carried out. The study demonstrated in all patients an intact epithelial lining of gastric and jejunal mucosa, a moderate degenerative process of enterocytes, presence of inflammatory lesions manifested by edema, vascular congestion, mononuclear cell infiltrate of lamina propria, and discharge of goblet-cells mucus. These changes reverted to normal in a few days. The authors emphasize that, contrary to cholera patients of Asiatic areas in whom an underlying chronic spruelike enteropathy is very common, the histological picture observed in Western patients may be considered more specific since Vibrio cholerae acts upon a normal intestinal mucosa.


Motility of the large intestine of piebald-lethal mice. In normal siblings of piebald mice, artificial fecal pellets were propelled by peristaltic activity through the large intestine in vitro and were expelled at the anal end. Peristalsis was blocked by lidocaine. Artificial fecal pellets were propelled in the dilated region of the megacolon, but were not propelled in the terminal hypoganglionic segment of the intestine of piebald mice. Retropulsion of artificial fecal pellets occurred in vitro in normal bowel obstructed by a ligature, in the bowel of piebald mice with a narrowed terminal segment, and in the intestine of mice with imperforate anus. The results indicate that the distended portion of the colon of piebald mice is capable of coordinated peristalsis and that accumulation of feces and megacolon are secondary to the terminal obstruction that results from absence of coordinated propulsive activity in the hypoganglionic terminal segment. Reverse peristalsis may be a general response to a distal obstruction.


Similar sensitivities of pancreatic and biliary secretion to cholecystokinin plus secretin infusion. The differing sensitivities of the gallbladder and pancreas to graded doses of CCK have been claimed as important in normal digestive events. As both secretin and CCK are thought to be released in response to normal feeding, we have reexamined the sensitivities of the gallbladder and pancreas to graded increases of CCK with a constant secretin background. Under such conditions the increase in output of pancreatic trypsin and bile salt occurred simultaneously, the dose-response curves being almost superimposable. Thus, under conditions more closely approaching normal postcibal events, the previously described differing sensitivities of the pancreas and gallbladder were not observed.


The effect of magnesium sulfate infusion on acid secretion and on serum gastrin concentration in a patient with gastrinoma. A patient with documented ZE syndrome responded to intravenous magnesium infusion by increased gastric acid output and increased serum gastrin concentration. A patient with acid hypersecretion but no gastrinoma had no substantial alteration in acid output or serum gastrin concentration following magnesium administration. This suggests that magnesium caused gastrin to be released from a gastrinoma.


Inhibition of gastric acid secretion by blood drawing from an indwelling venous needle. To investigate a possible inhibitory effect of blood drawing through an indwelling forearm vein needle on gastric acid secretion, 11 subjects were studied on four occasions each. The first session was for adapting the subject to the 3-hr collection of gastric juice. In 7 subjects the second through fourth sessions gave three conditions in balanced order: (1) an indwelling forearm vein needle and the withdrawal of 5 or 10 cc of blood every 20 min, (2) only a nonfunctional "dummy" needle implanted subcutaneously in the forearm skin, and (3) the control condition with no needle. In four additional subjects the sessions were identical except that condition (1) involved an indwelling forearm vein needle kept open by a slow infusion of saline solution and no blood was drawn. Phenol red recovery from an initial intragastric injection was measured in all. Results showed that blood drawing, but not saline infusion or venipuncture per se, inhibited gastric acid output.


Familial aggregation of urinary kallikrein concentration in childhood: relation to blood pressure, race and urinary electrolytes. Biochemical alterations that have been correlated with elevated blood pressure have not received extensive epidemiologic study because of the technical difficulties involved. Because the excretion of urinary kallikrein is reduced significantly in adult hypertensives, we have studied urinary kallikrein in a cohort of children in whom familial aggregation of blood pressure has been demonstrated. Casual specimens of urine were obtained in household surveys, and urinary concentration of kallikrein was determined in 601 children aged 5-18 years. The children were from 163 families, whose members also had their blood pressures measured. Familial aggregation of urinary kallikrein concentration was found by analysis of variance (F=3.45, p less than 0.001) even in these casual specimens and was demonstrable for black and white children analyzed separately. Urinary kallikrein concentration was significantly lower in black children than in white children (p less than 0.001) and was positively correlated with urinary creatinine and urinary potassium and inversely related to urinary sodium concentrations. Urinary kallikrein concentration also was being altered by season (being lowest in the summer) and by time of day (being highest in the morning). Families with the lowest mean kallikrein concentrations tended to have higher blood pressures than did families with the highest mean kallikrein concentrations, although the effect is small and subject to many variables.


The Yugoslavia cardiovascular disease study. II. Factors in the incidence of coronary heart disease. In a 7-year follow-up of 11,121 Yugoslav men first examined in 1964-1965 when they were 35-62 years old, it was found that the incidence of coronary heart disease (CHD) was one-fourth that of a comparable Framingham (USA) group. Incidence in rural men was only 59% of urban men. In both urban and rural groups, men with higher blood pressures had greater CHD incidence, and cigarette smoking was also associated with greater incidence. In the urban but not the rural groups serum cholesterol and weight/height were also CHD risk factors. Levels of serum cholesterol and weight were lower in urban Yugoslavia than Framingham and lowest in rural Yugoslavia. At the same levels of these characteristics Framingham incidence was 3 times that in Yugoslavia. At the very low rural levels of weight and blood pressure CHD incidence was the same in urban as rural Yugoslav groups.


Underreporting of cancer in medical surveys: a source of systematic error in cancer research. Systematic errors occur in the reports of disease frequency derived from health surveys based on questionnaire interviews. Five hundred and thirty-three persons with clinically and histologically confirmed disease in a case-control study of cancer were interviewed in their homes by carefully trained interviewers using a standardized questionnaire interview schedule. Comparisons of the information obtained by interview about past history of cancer with cancer registry and hospital medical record information about the same people revealed serious underestimates of correct frequency and wide variation in the rates of correct reporting. The findings reported here and elsewhere add support to an essential requirement in medical survey research: the completeness and accuracy of responses in health interview surveys must be verified and the methods of verification must be reported before the results can be interpreted with confidence.


Life events and subsequent illness.

Life events and subsequent illness. The objective was to examine for relationships between stress, as measured by life events, and hospitalization or death during the following 6 to 12 months, using a case-control design. As part of the Community Mental Epidemiology Program, life events data for the preceding year were gathered on a random sample of the population at two sites, and health data for the interval between interviews were collected at follow-up. A case is defined as anyone becoming ill and being hospitalized or dying during the interval between interviews. Each case was individually matched by several variables to a control who had neither been sick nor hospitalized. There were no significant demographic differences between cases and control in either site or between sites. When life events were examined by various scoring methods, there were no differences between cases and controls. This finding is important since most longitudinal studies that have shown a positive relationship between life events and subsequent illness have had methodologic limitations or have been based on healthy, young, male populations who generally did not become seriously ill during the study period. The results of this study plus the lack of generalizability of previous findings and their somewhat conflicting results raise serious questions about the etiologic relationship of life events to subsequent illness.


Providencia stuartii, a hospital pathogen: potential factors for its emergence and transmission. The emergence of Providencia stuartii as a hospital pathogen in a burn unit was demonstrated by routine infection surveillance. The organism was initially recognized in a burn wound and subsequently in urine or sputum. Compared to controls, those patients harboring P. stuartii were similar in age and percentage of body surface burned and were more likely to have been in one of the two burn unit rooms, (p less than 0.02). Infection with P. stuartii was independent of duration in the Intensive Care Unit or Burn Unit, and of number of visits to hydrotherapy or operating rooms (OR). Once patients were colonized with P. stuartii they had greater morbidity than non-colonized patients as evidenced by longer stays in the unit and increased visits to the OR for debridement. P. stuartii was isolated from air samples (5/14) more commonly than from the hands of personnel. In vitro tests suggested that extensive use of parenteral gentamicin and replacement of the antibacterial topical cream sulfamylon by silver sulfadiazine favored the emergence of P. stuartii over Pseudomonas aeruginosa as the predominant colonizing organism.


Three tests for randomness of attack of social groups during an epidemic. It is suggested that investigation of the attack of social units can be more illuminating of an epidemic process than the usual study of secondary attack rates of individuals. Three tests for detecting non-random differences in the occurrence of a disease between two groups of social units are presented. In each method the number of units attacked (X) in one of two groups of units is considered, rather than the number of individuals attacked. The tests are: (a) to use the Monte Carlo method, computer simulation of the epidemic process, to obtain an empirical distribution to which the observed value of X is compared; (b) to obtain the exact distribution of X; (c) to standardize X and compare it to the standard normal distribution. The three approaches are compared using data obtained from an epidemic of variola minor in two schools and the differences between the results are trivial. However, for large samples the only feasible approach is the Monte Carlo method.


The mechanism of increase in total lung capacity during acute asthma. In order to investigate the mechanism underlying the increased total lung capacity (TLC) observed during an acute asthmatic attack, we measured respiratory mechanics in a specially trained, exercise-induced, asthmatic. During the acute attack his TLC (determined plethysmographically) increased from 7.8 to 9.2 liters. The static pressure-volume curve of the lung shifted to the left and expiratory compliance increased from 0.24 to 0.55 liter/cm H2O. There was a parallel shift of the static pressure-volume curve of the chest wall resulting in an increase in the outward recoil of this structure. The maximum inspiratory pressure-volume curve of the total respiratory system was shifted so that the inspiratory muscles were able to generate greater pressures at any given lung volume during the attack. The findings indicate that the increase in TLC during acute bronchospasm results from the combination of loss of lung recoil, increased outward recoil of the chest wall and increased strength of contraction of the inspiratory muscles.


Neurologic involvement in seven patients with Behçet's disease. Of 25 patients with Behçet's disease seen in five years at the Mayo Clinic, seven had central nervous system involvement. The mean interval from onset of Behçet's disease to central nervous system involvement was 1.3 years, and the mean period of observation thereafter was 3.8 years. All patients had headache and fever during or preceding exacerbations of the central nervous system disease, and all had cerebrospinal fluid pleocytosis (white cell counts ranged from 6 to 490/mm3) with predominant lymphocytosis. The mean cerebrospinal fluid protein level was 55 mg/dl, and gamma globulin was less than 15 per cent in six patients. Results of cerebrospinal fluid, lesional and serologic studies for bacterial, fungal and viral agents were negative. Clinical findings included corticospinal tract disease (five patients), cerebellar ataxia (four patients), pseudobulbar palsy (three patients) and transient ocular palsies (three patients). All these occurred in concert with the systemic phases, especially aphthosis. Corticosteroid therapy was used in six patients, cyclophosphamide therapy in two and azathioprine therapy in two. The neurologic manifestations tended to recur when dosages of the drugs were lowered and established central nervous system damage could not be reversed. The case histories suggest that steroids, when used promptly and in sufficient dosage (up to 60 mg prednisone), are effective in reducing or preventing progression of central nervous system disease. Three patients died, one from Pneumocystis carinii infection, one from neurologic disease and another from presumed myocardial infarction. The central nervous system involvement in Behçet's disease should be diagnosed earlier, and it can be if attention is given to other systemic criteria, that is, aphthous stomatitis, aphthous genital lesions, cutaneous vasculitis, uveitis and synovitis.


Hereditary antithrombin III deficiency. Effect of antithrombin III deficiency on platelet function. Antithrombin III (AT III) is the main physiologic inhibitor of thrombin, and activated factors X and IX as well. Normal levels of AT III appear to be necessary to maintain blood fluidity and to prevent thrombosis. Four families with AT III deficiency and recurrent venous thromboembolism have been reported on. We present an additional family with AT III deficiency and a high incidence of thromboembolism. AT III levels were determined by both a functional and an immunologic assay. Results of platelet function tests, not previously reported in persons with AT III deficiency, were found to be normal. Following gel filtration, the platelets were very sensitive to thrombin. Thrombin-induced platelet aggregation appears to be dependent on a balance between the amount of thrombin and AT III present.


Irreversible acute renal failure in idiopathic nephrotic syndrome. In five adult patients (aged 44 to 74 years) with idiopathic nephrotic syndrome, irreversible acute renal failure developed. Prior renal disease, associated systemic illness or occlusion of major renal vasculature was not present. All patients continued to excrete large amounts of proteins (8.6 to 15 g/24 hours) despite a minimal glomerular filtration rate and severe oliguria. One patient died after five months without recovering renal function. Four patients have required hemodialysis for a period of 12 to 58 months. The failure to recover renal function could not be explained by the light microscopic findings. It is suggested that the irreversibility of the renal failure may be related to either permanent alterations in renal blood flow or ultrastructural changes, or to both. Clinically, adult patients in whom acute renal failure develops during the course of idiopathic nephrotic syndrome seem to have a grave prognosis. Protracted oliguria or irreversible renal failure can be expected to occur.


Comparative effects of lidocaine and procainamide on acutely impaired hemodynamics. Controversy exists regarding the relative safety of intravenously administered lidocaine and procainamide to patients with acutely impaired hemodynamics. Accordingly, their effects were studied in 15 such patients, 14 with acute myocardial infarction and one with cardiomyopathy and severe congestive heart failure. All had elevated levels of pulmonary capillary wedge pressure (greater than 15 mm Hg) and/or low cardiac index (less than 2.5 liters/min/m2). Patients were given lidocaine, a 100 mg bolus followed by a 3 mg/min infusion and, after at least a 30 minute recovery period, procainamide, a 100 mg bolus over 2 minutes followed by a 20 mg/min infusion for 20 to 25 minutes. Hemodynamic measurements were compared early and late in the infusion of each drug. Small, clinically insignificant differences were observed in the hemodynamic responses to the drugs, and no clinically significant deterioration occurred with either. Conventional therapeutic doses of intravenous procainamide can be administered by this regimen, to patients with acute myocardial infarction complicated by cardiac failure or low cardiac output, without producing deleterious hemodynamic effects.


Echocardiographic detection of fungal vegetations in Candida parasilopsis endocarditis. A case of primary Candida parasilopsis endocarditis in a heroin addict involving the aortic valve is presented. Abnormal echoes in the aortic root during diastole and in the aortic valve during systole and diastole produced by fungal vegetations were found. The demonstration of fungal vegetations by echocardiography in the absence of positive blood cultures and systemic embolization is a useful diagnostic tool which should be utilized when fungal endocarditis is suspected.


Tuberculous arthritis: A report of two cases with review of biopsy and synovial fluid findings. Two cases of tuberculous arthritis with synovial fluid findings are presented, and the major series with culture results and synovial fluid analyses are reviewed. Synovial fluid cultures are positive for tuberculosis in almost 80 per cent of proved cases. Specimens obtained by open synovial biopsy are positive by histology or culture in over 90 per cent of proved cases. Little experience with closed needle biopsy has been published. About one-fifth of the patients with tuberculous arthritis will have a positive synovial fluid acid-fast smear for tubercle bacilli. The tuberculous synovial effusion invariably has an elevated protein level, fair to poor mucin clot formation and usually a low joint fluid sugar level. The synovial fluid white cell count is usually in the range of 10,000 to 20,000 cells/mm3, but it varies widely. Most fluids exhibited a predominance of polymorphonuclear leukocytes. The importance of bacteriologic or histologic study of the synovial fluid and membrane in establishing the diagnosis is emphasized. In general, this disease is different from tuberculous involvement of serous membranes both in the frequency of positive cultures and in the difference in cellular response.


Therapy for disseminated coccidioidomycosis with transfer factor from a related donor. A 17 year old caucasian woman in whom disseminated coccidioidomycosis developed with culture positive meningitis during her third trimester of pregnancy was treated with amphotericin B and subsequently with transfer factor prepared from her father's peripheral lymphocytes. Clinical response and in vivo and in vitro immunologic data indicated that this transfer factor afforded a significant contribution to her survival whereas previous therapy with transfer factor from an unrelated donor provided only transient immunologic reactivity. This experience suggests that transfer factor prepared from a related donor with positive responses to C. immitis may be more efficacious than that prepared from an unrelated donor.


Allopurinol hypersensitivity. Granular deposition of IgM at the dermal-epidermal junction. A patient with allopurinol hypersensitivity, manifested by fever, lymphadenopathy and a severe erythematous, morbilliform, maculopapular rash was studied. On immunofluorescent staining of the patient's skin, heavy granular deposits of immunoglobulin M (IgM) were found at the dermal-epidermal junction. Transformation of the patient's lymphocytes could not be effected by a variety of combinations of allopurinol, allopurinol metabolites and serum. These data suggested that the hypersensitivity reaction caused by allopurinol had immune complex deposition as the central feature in pathogenesis. The predominance of IgM may provide a distinctive feature from the deposits generally seen in systemic and discoid lupus erythematosus.


Potencies of oral contraceptives.

Potencies of oral contraceptives. Oral contraceptives are combinations of estrogens and progestogens or, in the case of the mini-pills, progestogens alone. With specific test procedures in laboratory animals or human subjects, it is possible to assign potency evaluations to the components relative to the progestational, estrogenic, or antiestrogenic activities of the progestogen or to the estrogenic potencies of the estrogenic component. It might even be possible to quantify the synergistic effects of the estrogen on the progestational agent. Unfortunately, however, it is impossible now to amalgamate such assay results into single estimates of the potencies of the combinations (either the combination products per se or the combination tablets of sequential products). For example, an over-all estrogenic potency of a combination preparation would involve the integration of contributions form the estrogen itself plus the estrogenic products of metabolism of the progestogen minus the antagonistic effect of the progestational agent, if any. These factors cannot now be quantified independently, much less merged into a single figure of clinical significance. Further, even if it were possible to produce such an estimate, it is unlikely that the evaluation would be meaningful in relation to any putative side effect or adverse reaction, i.e., the alleged thrombogenic effects of oral contraceptives cannot currently be related directly to any measure of potency that will allow prediction of these clinical conditions from laboratory models. Any evaluation of the potential of a given contraceptive to produce a specific side effect will depend upon data generated with specific regard to that adverse reaction and the individual product in question.


Cyclic changes of cervical mucus enzymes related to the time of ovulation. I. Alkaline phosphatase. The concentration of alkaline phosphatase in cervical mucus was serially determined during a menstrual cycle in five normal ovulatory women and correlated with the time of ovulation as monitored by the basal body temperature and radioimmunoassay of serum lutenizing hormone (LH), progesterone, and estradiol. The activity of alkaline phosphatase decreased significantly at midcycle just prior to the LH surge and began to rise after ovulation. Self-detection of cervical mucus alkaline phosphatase may provide a practical method of ovulation prediction.


Effect of oral contraceptives on nutrients. III. Vitamins B6, B12, and folic acid. The interactions of oral contraceptive agents (OCA's) with vitamins were studied in a large population of women. In the upper socioeconomic groups, higher incidences of abnormal clinical signs related to vitamin deficiencies were seen in OCA users than in the control subjects. Plasma pyridoxal phosphate and red cell and serum folate were lower in subjects using OCA's in the upper socioeconomic group as compared to levels in the control subjects. Reduction in erythrocyte glutamic oxalacetic transaminase (EGOT) activity and elevation in the EGOT-stimulation test were observed in subjects using OCA's in both upper and lower socioeconomic groups. These observations suggest a relatively deficient state with respect to vitamins B6 and folic acid in OCA users. No significant effect on serum vitamin B12 was observed as a result of OCA administration.


Endometrial suction biopsy: appraisal of a new instrument. With the use of a completely self-contained, pre-evacuated, and disposable suction apparatus, endometrial suction biopsy was performed in 250 patients presenting with abnormal uterine bleeding or for an infertility evaluation. The instrument's components and performance features are described, as well as the distribution of tissue diagnoses. Biopsy provided tissue sufficient for diagnosis in 90 per cent of cases where tissue was obtained. In the postmenopausal subgroup, hyperplastic transformation was seen in 28/71 (39 per cent) women, and occult adenocarcinoma was diagnosed in another nine (12 per cent). Over-all instrument performance was very good.


Endocrine-metabolic response to acute starvation in human gestation. During a 72 hour fast in pregnant women, significant decrements in the maternal plasma glucose concentrations, accompanied by a significant increase in the plasma placental lactogen (hPL) concentration, occur. At the same time, utilization of glucogenic amino acids, principally alanine, takes place. The mean postprandial glucose concentration in pregnancy is significantly lower than that of comparable nonpregnant women (70.5 +/- 1.7 versus 79.5 +/- 1.3 mg. per 100 ml., p less than 0.001). There appears to be a significant sparing effect on the maternal plasma glucose concentration during acute fasting which may be mediated through hPL. Concentrations of amniotic fluid and fetal plasma glucose from women undergoing fasting decrease in a manner parallel to that of the mother. Fasting provokes a mean rise in plasma hPL of 33.2 per cent over basal levels. This rise is still evident 72 hours after refeeding, after which it gradually returns to pretest concentrations. The infusion of alanine or arginine to pregnant women at the end of the fast produced increments in the peripheral maternal glucose concentration. The response was much greater with alanine than with arginine, demonstrating the increased gluconeogenic potential of this amino acid. The increment in human growth hormone (hGH) following alanine infusion was significantly greater than that observed after arginine administration. Hypoaminoacidemia was present in nonpregnant and pregnant women in response to fasting, but the decline was greater in pregnancy. Acute fasting in the first half of gestation appears to produce significant alterations in carbohydrate metabolism evidenced by profound hypoglycemia, hypoinsulinemia, and hypoaminoacidemia. This maternal deficit can be reflected in fetal substrate concentrations. The effect of these changes on fetal growth and development is speculative at this time.


Fluctuation of fetal hemoglobin in sickle-cell anemia. A reduction of morbidity and mortality rates in homozygous sickle-cell patients was found in those with high fetal hemoglobin (HbF) levels. This factor would lead one to believe that an adequate amount of this substance would be protective to a patient with this hemoglobinopathy. This study utilizing pregnant and nongravid females, as well as males, followed for long periods of time indicates that the HbF level fluctuates with crisis. Some patients had low HbF levels with many crises and others had high amounts of HbF with no crises. However, many patients with high levels on one occasion demonstrated a decrease in HbF levels when crisis occurred. More importantly, no patient had high levels of HbF during a crisis although the amount was elevated before and after the episodes. The possible explanation and ramifications of this finding are discussed.


Actions of the uterine relaxant, fenoterol, on uteroplacental hemodynamics in human subjects. The action of fenoterol, a uterine relaxant of the adrenergic beta-mimetic group of drugs, has been investigated on placental, myometrial, and cardiac blood pools. 113mIndium was injected intravenously and the blood pools were measured by recording gamma activity externally. In eight cases with oxytocin-induced labor, fenoterol inhibited the typical blood pool changes of labor, i.e., contraction-synchronized decrease of placental and myometrial blood pools with increase in cardiac blood pool. Furthermore, fenoterol produced an increase in placental and myometrial pools with corresponding decrease of cardiac blood pool. These changes were observed consistently. In four other cases, of which three had spontaneous labor, similar effects were observed. The possible mechanisms of hemodynamic action of fenoterol, with reference to uterine relaxation, are discussed.


Ultrastructural observations of the human uterine smooth muscle cells during gestation. At term pregnancy, the myometrium consists of bundles of smooth muscle cells bound together by varying amounts of connective tissue. Each bundle contains both dark and light muscle cells. During uterine contractions it is believed that the smooth muscle cells become darker, decrease in volume, and exhibit changes in diameter. This is accompanied by widening of the interspaces and by a decrease in the areas of cellular contact. Between contractions, there are more light cells which become arranged closer to each other and exhibit large areas of interdigitation. The significance of these observations in the mechanism of uterine contraction and retraction is discussed. Cell believed to be modified smooth muscle cells occupy the myoendometrial junction and the decidua basalis. They are irregular in shape, poor in myofilament content, and rich in other cytoplasmic organelles and form a loosely arranged layer of cells between the myometrium and the trophoblast. The possible functional significance of these cells is also discussed.


Instantaneous fetal heart rate monitoring by electromagnetic methods. Fetal magnetocardiography (FMCG) is a new complementary external method for accurate antepartal FHR recording. Because of the low magnetic noise level required it is not yet suitable for routine hospital use. Fifty-six simultaneous FMCG and external FECG measurements were made in order to compare these methods for instantaneous FHR recording. The error of the FHR value obtained with the instrumentation described is less than 1 per cent. Our results show that FMCG can be used for FHR processing from week 30 of gestation until term. Thirty-five of the measurements were done during this period. From these, a readable FHR curve was obtained in 21 cases with FMCG and in 12 cases with external FECG. The maternal complexes were always present in the FECG, but in only 15 of the recorded FMCG's.


Evaluation of the accuracy of a new ultrasonic fetal heart rate monitor. An indirect Doppler fetal monitoring system has been developed and validated by computer comparison of simultaneous fetal heart rate (FHR) with Doppler and scalp ECG of high-risk patients during labor. The difference in measurement of FHR averaged 0.3 b.p.m., and 93 per cent of the Doppler FHR measures were within 10 b.p.m. of the ECG FHR. If interinstrument difference is discounted, 96 per cent were within 10 b.p.m. All types of decelerations and variability were well approximated. Doppler FHR from the instrument described may be relied upon as valid clinical information and may be obtained from over 90 per cent of labor patients with 93 per cent accuracy.


Sigmoidovesicocutaneous fistula complicating diverticular disease of the colon. A sixty-six year old diabetic male had a draining sinus tract from the lateral portion of a fourteen year old left herniorrhaphy scar. The diagnosis of sigmoidovesicocutaneous fistula was confirmed by a sinogram and the patient was treated in one stage with left hemicolectomy and resection of the fistula site from the dome of the bladder. To our knowledge this is the first report of a sigmoidovesicocutaneous fistula.


Femoral neuropathy complicating anticoagulant therapy. A twenty-six year old white male on long-term sodium warfarin (Coumadin therapy for recurrent thrombophlebitis had sudden onset of severe groin pain, right iliac hematoma, and a femoral nerve palsy. A review of the twelve previously reported cases of this hemorrhagic complication indicates that immediate surgical decompression may be necessary to prevent residual disability.


Superficial lymph node infarction.

Superficial lymph node infarction. A case of spontaneous superficial lymph node infarction points up the rarity of the lesion as well as the necessity to include its consideration in the differential diagnosis of groin masses.


Clinical significance of pancreatic ascites. Recurrence of pancreatic ascites in a patient after two courses of peritoneal lavage suggested pancreatic ductal disruption as the etiolgy, and this was confirmed at operation. Peritoneal lavage in two other patients with pancreatic ascites without ductal disruption or cysts was associated with resolution ascites. The use of peritoneal lavage in patients with acute or chronic pancreatic ascites may guide the selection of those requiring early surgical treatment.


A "Bikini" incision for appendectomy.

A "Bikini" incision for appendectomy. An incision is described for adaptation to the young female requiring an appendectomy. The incision is designed to allow the use of brief bathing suits and to preserve the normal contoured appearance of teh abdominal wall.


Repair of extensor tendon injuries of the hand. We have presented methods for treating extensor tendon injuries from the interphalangeal joint to the wrist and the musculotendinous junction in the forearm. Early and proper splinting in the treatment of extensor tendon injuries is more important than a specific method of surgical repair. We emphasize the need for prolonged splinting, up to eight weeks in distal injuries. Immobilizing the finger in full extension or hyperextension is necessary at the distal and proximal interphalangeal joints. Correct splinting is mandatory in any method of treatment. Reconstruction of the extensor mechanism is difficult and the results are unpredictable.


Use of the stapler in skin closure.

Use of the stapler in skin closure. The AutoSuture skin stapling instrument reduces operating room time and provides adequate skin closure for a wide variety of plastic surgical procedures.


Long-term results from use of fascia lata as arterial graft. Of twenty-four dogs, fifteen survived up to two years after aortic replacement with fresh fascial graft. Surviving dogs underwent hemodynamic study and cineaortography. Histology of the graft was examined after the dogs were sacrificed. Length of the graft used is an important factor for both dog survival and graft hemodynamics. The shorter the aortic segment replaced the better the chances for long-term graft patency.


Gallbladder disease in children and adolescents. Seventy-nine patients, twenty years old or younger, with cholecystitis underwent cholecystectomy during a five year period at Santa Rosa Medical Center. There was a considerable delay in diagnosis in many cases. Etiologic factors differed with race and age; however, the disease appears to be quite similar in adolescents and adults. Hemolytic disease was present in all five blacks but in none of the remaining seventy-four patients. Patients younger than ten years of age are more likely to have congenital anomalies or infectious etiologies for the gallbladder disease. Cholecystectomy was associated with minimal morbidity and no mortality in this series. Cholecystitis should be considered early in the child or adolescent with unexplained abdominal pain, and oral cholecystograms proved to be a safe and reliable method of diagnosis.


Abdominal pain of unknown etiology.

Abdominal pain of unknown etiology. The influence of age, sex, duration of symptoms, and exploratory laparotomy on prognosis of adult patients with abdominal pain of unknown etiology was assessed in a retrospective review. Patients with incomplete diagnostic evaluation were excluded. Of the sixty-four patients studied, forty-six were female. Lack of improvement of symptoms in the follow-up period was 67% in females and 22% in males (p less than 0.05). Younger patients tended to have higher improvement rates. Of the patients whose duration of symptoms was less than fourteen days, 65% were improved and 25% were subsequently diagnosed, as compared with 14 and 9%, respectively, of those whose symptoms had been present for more than ninety days (p less than 0.05). Laparotomy did not influence rate of improvement and established a diagnosis in only one of twenty-three patients explored. It is concluded that few of these patients are likely to benefit from laparotomy, especially adult females whose symptoms have been present for more than three months.


Late precancerous changes and carcinoma of the gastric stump after Billroth I resection. Carcinoma of the gastric remnant after resection for benign ulcers is regarded as a rare complication after Billroth I resection. In seventy-four patients reexamined by gastroscopy and multiple biopsies ten to twenty-two years after gastric resection four cases of cancer of the gastric stump were diagnosed and the patients operated on. Another eight patients had regenerative polyps and one patient had a tubular adenoma. The histologic findings in gastroscopic biopsy specimens from the gastric stoma and fundus are compared. Possible precancerous changes and etiologic aspects are discussed briefly. Repeated gastroscopy is recommended starting about ten years after gastric resection for benign ulcers.


Ambulatory inguinal hernia repair compared with short-stay surgery. Two groups of patients operated on for inguinal hernia, one outpatient group and one inpatient group, are compared with respect to subjective distress and immediate postoperative complications. The groups were chosen at random and matched for sex and age. A large number of those who received treatment as outpatients suffered marked distress during the first postoperative days. Some form of intermediary or light nursing should be tried out for the outpatients so that if necessary they can stay the night after operation at the hospital. The number of postoperative complications was equal in the two groups. With suitable patient selection and with a small number of reserve places in a light-care ward, the majority of inguinal hernia operations can be performed on outpatients, resulting in a considerable economic saving and shorter waiting time.


Diaphragmatic hernia as a long-term complication of stab wounds of the chest. The suggestion that early exploratory operation be performed in all patients with stab wounds of the left lower chest in whom the diaphragm is likely to be injured is examined in detail. The incidence of stabs in this situation is reported on an analysis of 1,000 consecutive cases of stab wounds of the chest. Thirteen cases of diaphragmatic hernia as a long-term complication of stab wounds of the chest are discussed.


Frey's syndrome after parotid surgery.

Frey's syndrome after parotid surgery. The operative records of seventy-one patients who had parotid surgery carried out in the ten year period from 1964 to 1973 were reviewed. Forty-one (67%) of the operations were suprafacial parotidectomies. Of the fifty patients who agreed to reassessment in a special clinic, seventeen had a noticeable degree of Frey's syndrome, and of these fourteen were submitted to further investigations. Minor's test in these fourteen patients showed the greater auricular nerve to be involved in six patients, the ariculotemporal nerve in four, and both nerves in two. The results in two patients were inconclusive. Because the starch test reveals only the distribution of the gustatory sweating, a useful adjunct is described for investigating Frey's syndrome. By blocking of the contralateral greater auricular nerve in the neck and mapping out of the anesthetized area, its sensory distribution is demonstrated. We conclude that it is manifestly unwise to avulse the auriculotemporal nerve if the sweating occurs in the distribution of the greater auricular nerve.


Treatment of cholecystitis: cholecystostomy or cholecystectomy? Nine hundred ninety-two consecutive patients with cholelithiasis and cholecystitis are reported on. In Finland, these diseases seem to affect women more often than men as only 18% in the present series were men. The frequency of these diseases increases with advancing age and reaches its peak in patients sixty to sixty-five years of age. Therapy always consisted of cholecystectomy. The incidence of minor technical complications varied from 1.1% in group I to 4.5% in group III (6.1% in group IIB). Postoperative nonfatal complications varied from 2.0% in group I to 5.2% in group III (8.1% in group IIB). The age-adjusted duration of postoperative hospitalization was about eight days (in group IIB, nine days. In groups I and II one patient died whereas in group III two died. The mortality varied from 0.2% in group I to 0.6% in group III (1.2% in group IIB). The overall mortality for this series was 0.5%. On the basis of this analysis and the good results, I have concluded that cholecystectomy is the preferred therapy for cholecystitis at all stages when all coexisting diseases and water and elctrolyte imbalances have been treated.


Factors influencing patency of femoropopliteal artery bypass grafts. An analysis of 276 femoropopliteal bypass procedures performed in 264 patients at the Columbia-Presbyterian Medical Center over the past two decades showed a direct relationship of graft patency to preoperative popliteal artery runoff. Fuctional results were better than patency results. Sympathectomy and anticoagulation did not improve graft patency. The risk of amputation is outweighed by the benefits of restoration of blood flow to the ischemic extremity by a byass procedure.


Villous adenoma of the duodenum. A case report and review of the literature. A case of villous adenoma of the duodenum, with focal in situ carcinomatous changes, has been described with a review of forty-two other case reports from the world literature. Occult bleeding, resulting in anemia, and vague obstructive symptoms appear to be the most common presenting findings. The average age was 56.4 years, which was seven years younger than the average age for villous tumors of the colon. Adequate radiologic studies should establish the diagnosis preoperatively. These tumors obtain relatively large size before causing significant symptoms. Approximately one third showed carcinomatous changes, and approximately one half of these were in situ changes. Local segmental resection for duodenal villous tumors is desirable when possible. However, in areas where this is not feasible, local mucosal excision is acceptable for benign tumors and for those with in situ carcinoma. If invasive carcinoma is found in the excised specimen, pancreatoduodenectomy is recommended. Insufficient evidence is available to adequately evaluate survival for malignant villous tumors of the duodenum, but the available data suggest that the survival after treatment of malignant villous tumors is comparable to other malignant lesions originating in the duodenum.


The practicality of the Congo Red test, or is your vagotomy complete? The use of Congo Red testing for adequacy of vagotomy in a variety of clinical situations is described. Its intraoperative use is presented for the first time, thus allowing the surgeon immediate documentation of the completeness of his vagotomy and hopefully averting incomplete vagotomy, the single most common cause of ulcer recurrence after vagotomy-pyloroplasty.


Prevention of complications after liver trauma. Treatment of 681 cases of liver trauma during the past ten years at the San Francisco General Hospital was reviewed. The mortality was 14.7 per cent and the morbidity rate 18.9 per cent. The complications relating specifically to liver injury were bleeding subphrenic or subhepatic abscesses, intrahepatic abscess, biliary fistula, and liver failure. These complications and the recommended management of the liver injury are discussed.


Lower extremity atheromatous embolization. Eleven patients with lower extremity atheromatous microembolization are described. The diagnostic feature of sudden, often repetitive, episodes of focal ischemia, patent major arteries of the legs, and arteriographic demonstration of nonocclusive atheromas of the proximal arterial tree are characteristic. Successful removal of the causative lesion in these patients has prevented further ischemic episodes.


The natural history of Meckel's Diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel's Diverticulum found in King County, Washington, over a fifteen year period. To determine the natural history of Meckel's diverticulum, 202 case records of proved disease of Meckel's diverticulum were retrieved, covering a fifteen year period, from all the hospitals of King County, Washington (population, 1,143,800). Using the figure of 2 per cent incidence of Meckel's diverticulum, we calculated that a Meckel's diverticulum has a 4.2 per cent likelihood of causing disease during a lifetime, decreasing to zero with old age. Using previously published mortality and morbidity figures, we calculated that to save one patient's life from the complications of Meckel's diverticulum, it would be necessary to remove approximately 800 asymptomatic Meckel's diverticula. This would be likely to incur a significant amount of postoperative morbidity from postoperative intestinal obstruction and infection. We suggest that the prophylactic removal of Meckel's diverticulum is rarely, if ever, justified.


Operative endoscopy in the management of biliary tract neoplasms. Operative endoscopy of the biliary system has been employed with ever increasing frequency at the UCLA Hospital during the last three years. In addition to its established value with respect to disclosing unsuspected stones in the bile ducts, choledochoscopy has been of great value in terms of more accurate diagnosis and staging of periampullary and bile duct neoplasms. It has been observed that many biliary tract carcinomas are multicentric in origin and that cholangiography is not adequate to identify small intrahepatic ductal lesions. More than one cell type of bile duct carcinoma may be present in the same patient. Choledochoscopy should be used in addition to the conventional criteria for resectability in all patients with ductal or periampullary carcinoma. Use of this technic will spare some patients needless radical procedures and should improve long-term cure rates by identifying those patients with truly localized disease for curative resections.


Intimal injury from arterial clamps.

Intimal injury from arterial clamps. Preliminary experimental data have been presented indicating that intimal injury of some degree is a virtually constant finding at the site of application of any arterial occluding clamp. These injuries vary from intimal distortion to complete fracture into the media of the vessel. The degree of injury appears directly proportional to the amount of pressure exerted through a given clamp. Atherosclerotic arteries are particularly subject to severe degrees of intimal injury. Preliminary observations suggest that heparin is not helpful in preventing platelet aggregation and initial thrombus formation at intimal injury sites. The problem of anticoagulation at such injury sites is being studied further.


An evaluation of the Mobin-Uddin umbrella in the prevention of pulmonary thromboembolism. A vena caval umbrella was implanted in twenty-eight patients for the prevention of recurrent pulmonary embolism. Eighteen of these patients were catastrophically ill at the time of reimplantation. Thirteen patients died after implantation, one from a recurrent pulmonary embolus originating in the vena cava. There have been two additional recurrent nonfatal emboli. Three of the thirteen long-term survivors had significant lower extremity edema. Our experience and that of others indicates that the inferior vena caval umbrella is comparable to other methods of incomplete interruption in terms of effectiveness, morbidity, and mortality. Its unique technical advantage is the simplicity of insertion in severely ill patients in whom abdominal surgery is undesirable.


The computer as an unbiased medical investigator. Experience on an active surgical service. An adaptable on-line computer system for entry, retrieval, and analysis of medical discharge summaries has been developed and applied in the Trauma Service of a busy city hospital. Each summary occupied 5 to 10 minutes of the physician's time and compared favorably in cost to the standard dictated summary. While the average dictated summary contained 15 +/- 7 relevant facts, the machine-generated summaries were found to have 53 +/- 20 relevant facts. The summaries are well organized, easily comprehensible, and a duplicate copy can be obtained at any time by using the patient's name or number for identification. To date, 495 discharge summaries have been entered and reside in the memory of the computer. Statistical analysis from the data base is done by the computer, thus eliminating human prejudice. It provides facility for rapid and accurate retrospective studies as well as pattern-of-care and individual case review.


Staging of Hodgkin's disease: a surgical perspective. Staging laparotomy, consisting of splenectomy and biopsies of liver, lymph nodes, and bone marrow, is a very useful adjunct in the workup of a patient with Hodgkin's disease. In this series of 400 patients, 1.0 per cent required reoperations for complication, 3.7 per cent had major complications, and 14.0 per cent had minor complications from the operation. Further evidence of Hodgkin's disease was discovered in 42.0 per cent of the cases and a change from the clinical to the pathologic stage occurred in 27.5 per cent of these cases. The surgeon's task in the treatment of Hodgkin's disease and other malignant diseases is to document and mark the areas of involvement so that accurate and appropriate therapy can be given, while morbidity and mortality are minimized.


Asymptomatic primary hyperparathyroidism. With the advent of automated equipment for blood chemistry determinations, many patients are presenting with asymptomatic or "biochemical" hyperparathyroidism. In the present series, of 136 patients operated on for hyperparathyroidism, fifty-three were considered asymptomatic. In fifty-one patients, parathyroid pathologic conditions were found; in one patient, it is probable that an adenoma had been missed, and in the other, it is presumed that an error in diagnosis was made. We recommend that surgical exploration be considered as an acceptable alternative to watchful waiting for patients with asymptomatic hyperparathyroidism.


Evaluation of recurrent duodenal ulcer after vagotomy-pyloroplasty. Seventy-five antrectomies were performed for recurrent duodenal ulcer after 1,515 vagotomy and drainage procedures. Eighty-four per cent of proved recurrences at reoperation were associated with positive acid secretory tests. Seventy-eight per cent of recurrences occurred in patients with intact vagal trunks. Incomplete vagotomy is implicated as the cause of recurrence.


Injuries to the phrenic nerve resulting in diaphragmatic paralysis with special reference to stretch trauma. Traumatic interruption of the phrenic nerve causing diaphragmatic paralysis occurs much more commonly than realized. Patients present with symptoms referable to the respiratory, gastrointestinal, or cardiovascular systems as a result of anatomic displacement of the respective organ (eventration). Symptoms often occur shortly after the injury but may be delayed for many years; consequently, prolonged follow-up of these patients is essential. If patients are symptomatic after trauma, judicious observation is dictated, since many will experience gradual return of normal diaphragmatic function over the succeeding six to twelve months. In those who remain significantly symptomatic, thoracotomy and imbrication of the eventration is a simple and effective surgical procedure.


Mucoid degeneration of the mitral valve. Clinical review, surgical management, and results. Forty-four patients exhibiting myxomatous degeneration of the mitral valve were reviewed. The clinical features, pathologic findings of the valve excised, surgical treatment, and results are presented. The complexity of the clinical pathologic findings are discussed. Despite the technical difficulties encountered in the surgical treatment of myxomatous degeneration of the mitral valve, the long-term surgical results are excellent.


Compound fractures of the pelvis.

Compound fractures of the pelvis. A retrospective study of sixteen patients with pelvic fractures compounded through the perineum, rectum, or vagina showed a mortality of 50 per cent. The cause of death in seven of the eight patients was sepsis and multisystem failure. The initial surgical management of these patients must include complete diversion of the fecal stream so that pelvic and systemic sepsis may be prevented.


Alkaline reflux esophagitis after total gastrectomy. Esophagoduodenostomy and loop esophagojejunostomy with or without enteroenterostomy may not be the optimal reconstructive procedures after total gastrectomy because of esophagitis and dumping. More effective esophagointestinal anastomoses have been described [1,3,4,8,9,12]. We have had good success using a Roux-en-Y esophagojejunostomy with and without a jejunal pouch after total gastrectomy for the Zollinger-Ellison syndrome and agree that a jejunal pouch associated with Roux-en-Y esophagojejunostomy as described by Hunt and Lawrence is an excellent reconstructive procedure [1,13]. Several reports using this type of procedure have emphasized the absence of alkaline reflux esophagitis and the ability of their patients to maintain ideal weight [1,2,8].


The role of varicocele in male fertility. In summary, seventeen infertile men with varicocele in whom no other cause for infertility could be identified, were studied before and following varicocele repair. Morphologic alterations were the most common abnormality noted in the seminal fluid with all subjects demonstrating increased numbers of tapered or amorphous spermatozoa. Ligation of the varicocele resulted in improvement in one or more of the seminal fluid abnormalities in thirteen of the seventeen patients. Seven patients achieved a pregnancy. No single seminal fluid parameter was identified which was of predictive value in determining those subjects who would demonstrate improvement following varicocele repair.


Selective retrograde venography of the internal spermatic vein: a conclusive approach to the diagnosis of varicocele. Selective retrograde catheterisation of the left internal spermatic vein at its orifice in the renal vein was carried out in 25 patients suspected of varicocele. When contrast medium is injected, the patients with varicocele, standing in the erect position, present a retrograde filling of the varicose spermatic vein, in contrast to the absence of such reflux in normal men. The venography is indicated for diagnostic and therapeutic purposes and it is the only available, non-surgical technique to prove the existence of a disturbed venous flow in the testicular region.