Delirium after cataract surgery: review and two cases. The authors define the delirium seen after cataract surgery on the basis of Dupuytren's original description and review studies using the criteria they set up on this basis. They then present prospective data on 2 patients with postcataractectomy delirium and 25 patients who did not experience this delirium. The data suggest that delirium after cataract surgery represents anticholinergic toxicity.


The impact of normal volunteers on a psychiatric research unit. Normal subjects were admitted to a psychiatric unit devoted to the study and treatment of affective illness. Initially the authors were concerned about the difficulties volunteers might have living with psychiatric patients. However, the volunteers adjusted with relative ease, while the patients' depressive symptoms were exacerbated. Their confrontation with the volunteers "normality" triggered an acute awareness of their underlying sense of failure. This response is analogous to depressed patients' reactions before discharge, when they struggle not only with their special vulnerability to separation and loss but with inevitable challenges to their fragile self-esteem during reintegration into the outside world. The presence of normal volunteers highlighted these issues and led to increased therapeutic work and considerable resolution.


Whatever happened to psychiatry? The deprofessionalization of community mental health centers. The authors describe the dichotomy in the concept of community mental health centers. One view regards the community mental health center as a service provider for underserved populations, and another holds that it is an agent of social change. Deprofessionalization of community mental health centers has resulted from this lack of clear purpose, curtailment of funds, and conflicts over authority, service delivery, and control of the centers. Deprofessionalization has led to a decline in the number of psychiatrists in community mental health centers and a potentially negative impact on the quality of patient care.


Plasma growth hormone: effect of anxiety during flooding in vivo. The treatment of phobias by rapid in vivo exposure to the feared situation was accompanied by an increase in plasma growth hormone levels on at least one of two occasions in 8 of 11 subjects. The average growth hormone response was greater on the second occasion, even though subjective anxiety was less. Plasma growth hormone was not elevated during the subjects' adaptation to the laboratory. Strong subjective and behavioral anxiety responses failed to elevate plasma growth hormone levels in some subjects. The probability of a growth hormone response was the same whether or not baseline levels were elevated prior to exposure.


Acid-base and electrolyte disturbances in anorexia nervosa. The literature on anorexia nervosa largely ignores the acid-base and electrolyte disturbances that may accompany this condition. In an attempt to assess the magnitude of these disturbances in anorexia nervosa the authors reviewed the laboratory profiles of 7 patients with the disease who were consecutively admitted to a hospital over a period of 8 years. Several acid-base and electrolyte disturbances were observed; the most frequent was chloride-responsive metabolic alkalosis. The authors suggest that all patients with anorexia nervosa receive diagnostic studies for these disturbances, including ECG and urinary electrolytes when necessary, so that abnormalities can be diagnosed and treated appropriately.


The relationship of early maternal separation to borderline personality in children and adolescents: a pilot study. The author compared 14 child and adolescent borderline patients, diagnosed by the criteria of Gunderson and Singer (1), with a control population for history of separation from the mother or significant caretaker before age 10. The borderline patients experienced a statistically greater number of separations than the psychotic controls, the nonpsychotic psychiatric controls, and the nonpsychiatrically-referred delinquent controls before age 5 but not between ages 5 and 10. The author concludes that the study provides statistical support for the theoretic role of disruption of the early infant-mother bond in borderline pathology.


The development of an acute short-term inpatient child psychiatric setting: a pediatric-psychiatric model. The authors describe the establishment of a unit for children that emphasizes the integration of the pediatric model of acute, short-term inpatient care with the psychological and developmental perspective of the psychiatric model. Of the 145 children admitted during the first year, more than 33% manifested aggressive or hyperactive behavior and 25%, depression or suicidal behavior. Eighty-five percent were discharged to their homes or previous residences after an average length of stay of 24 days. The authors suggest that similar units established in children's hospitals or general hospitals could help meet the urgent need for acute inpatient psychiatric care of children in this country.


Adolescents' adjustment to chronic hemodialysis. The author compares the adjustment of 18 adolescents on chronic hemodialysis to that of 63 adult patients on hemodialysis. The adolescents tended to comply less well with the medical regimen, their vocational rehabilitation was significantly lower, and their social activities were more restricted. The adolescents suffered more from the changes in body functioning and appearances. They were more hostile and overtly aggressive but seemed to have fewer psychiatric complications and, especially, less suicidal ideation. The author suggests that chronic disease is especially difficult for adolescents to handle because it creates stress in areas already problematic for this age group.


Juvenile firesetters: do the agencies help? In an attempt to find out what was being done for juvenile firesetters in their metropolitan community the authors reviewed the records of the local fire marshal, juvenile court, and psychiatric clinic. They found that the various agencies involved with 69 juveniles over a 3-year period were unable to coordinate their efforts and were largely unsuccessful in controlling the firesetting. Because the families of firesetters seem to have many other social problems, the authors recommend early inpatient assessment and possible referral to foster homes or residential treatment settings for juvenile firesetters.


The Mini-Mental State Test and computerized tomography. In order to evaluate the clinical usefulness of the Mini-Mental State (MMS) test, the authors had 63 patients complete the test after undergoing computerized tomographic (CT) scans of the brain. Patients with positive CT scans scored significantly lower than those with negative CT scans. Further analysis showed that cerebral atrophy was more closely related to cognitive impairment than focal cerebral lesions only. The authors conclude that the MMS can discriminate organicity in some instances but that further refinement and modification of its subtests are needed for maximum usefulness.


Adjustment of a group of Vietnamese people to the United States. The authors collected data on 50 Vietnamese families living in Baton Rouge, Louisiana, by individual and group interview questionnaire. They also used interviews of all of the Vietnamese people who came to the local community mental health center and studied the records of the center and other local social agencies for sociodemographic data. They define a number of specific sociological stresses encountered by Vietnamese refugees but conclude that basically these people are adjusting well without losing their cultural identity.


Peer review of group therapy: Washington, D.C., 1972-1977. The author discusses the evolution of psychiatric peer review in Washington, D.C. In its first six years (1972-1977) the Washington Psychiatric Society Peer Review Committee evaluated 146 cases, 23 (16%) of which focused on group therapy. Eight of these cases (35%) were partially or fully denied. Most of the cases involved outpatients with neuroses or character disorders who were treated in combined group and individual therapy. The author presents specific cases illustrating group therapy issues and peer review decisions. He discusses the benefits and liabilities of peer review and emphasizes its importance as a flexible, clinically sensitive, confidential, and meaningful process.


Life events, coping, stress, and depressive symptomatology. The author presents data on the relationships between life events, coping resources, and depressive symptomatology. A probability sample (N = 517) was interviewed three years apart. Respondents with high life-event scores had significantly more depressive symptomatology than those with low scores. Those with personal, familial, and interpersonal resources had significantly less depressive symptomatology than those without such resources in both the low- and high-life-event groups. The best predictor of Time 2 depressive symptom scores was Time 1 symptom scores; losses and resources were also statistically significant factors. These findings demonstrate the complex interrelatedness of life events, coping resources, and depressive symptomatology.


Life events at the onset of bipolar affective illness. The authors assessed the occurrence of stressful life events before the initial or subsequent episodes of affective illness in a group of 79 bipolar I manic-depressive patients who were attending a lithium clinic. About half of the patients recalled a life event in the 3-month interval before their initial episode; postpartum onset was prominent among these events. Few patients recalled life events for subsequent episodes. Finally, history data did not differentiate patients who recalled life events and those who did not. These data may be useful in assessing environmental antecedents of populations at risk for bipolar illness.


Childhood depression: interpersonal interactions and depressive phenomena. The author discusses the impact of parental disability, particularly parental depression, on children. Depression in children, which takes different forms according to the child's developmental level, may mirror or be a response to similar affect in a parent. Clinicians need to take note of the relationship between child and caretaker and of the various manifestations of childhood depression in order to avoid underdiagnosing this disorder.


The psychopathology of suicide: a clinical model approach. The author hypothesizes that certain types of persons at high risk for suicide constitute definable clinical models, that the process of arriving at a suicidal outcome involves elements unique to each model, and that these elements can be considered manifestations of psychopathology. This approach is investigated using two models: "Males Under Forty" and "Stable with Forced Change." The results indicate statistically reliable differences between the models in the distributions of estimated risks for persons who subsequently committed suicide compared with those who did not. The implications of the associated highrisk variables as reflections of psychopathologic processes are considered.


Depression simulating organic brain disease. The authors report four cases of depression manifesting as organic brain syndrome in adult nongeriatric patients. The correct diagnoses in three cases were made by a psychiatrist's or resident's empathic response to the patient, and in the fourth by the patient's history of depression. The authors state that only by maintaining a high degree of suspicion and trusting one's empathic response to the patient will unusual presentation of depression be recognized.


Depression in the wives of nuclear submarine personnel. The authors compared levels of depression among 24 wives of nuclear submarine personnel under conditions of husband-presence and husband-absence in a crossover research design. The wives had significantly higher depression scores under conditions of husband-absence on both the Zung Depression Scale and the Multiple Affect Adjective Checklist. The results are discussed in terms of the tremendous stresses imposed on the wives as a result of the nuclear submarine deployment schedule and the failure of the Navy and the spouses to recognize and reward the wives for their efforts.


Depression in Viet Nam veterans and civilian controls. In order to investigate the long-term psychological consequences of Viet Nam combat, the authors located and personally interviewed a group of 571 randomly selected Viet Nam veterans and 284 matched civilian controls 3 years after the veterans returned to the United States. In the veterans they found a weak association between combat and subsequent depressive symptoms, but the association did not persist after controlling for preservice factors. The incidence of depressive symptoms and syndromes was similar when veterans were compared with nonveterans. Results are contrasted with a 12-month follow-up study of the same veterans in which a stronger association between combat and later depression was found.


Depressed mood and subsequent physical illness. The authors describe the results of a matched case-control analysis in which 82 pairs of subjects were selected from a large-scale community study carried out in two general populations. Cases were those of persons hospitalized during an interval between two interviews for an illness starting during that interval or persons who died during the interval. Controls were persons with no new illnesses or hospitalizations during the interval. No relationship between measures of depressive symptomatology or depressed mood and subsequent physical illness was shown. This result corroborates the findings of prospective studies in more selected populations and suggests that it is unlikely that depressed mood is related to subsequent physical illness.


Depression: new evidence in support of biological differentiation. The authors studied monoamine metabolism in patients with bipolar (manic-depressive) and unipolar depressive illness and in normal control subjects under strict dietary conditions before and during administration of carbidopa, a peripheral decarboxylase inhibitor. They found that unipolar depressed patients excreted higher amounts of 3-methoxy-4-hydroxyphenylglycol (MHPG) and 5-hydroxyindoleacetic acid (5-HIAA) in the drug-free period and while receiving carbidopa and significantly less tryptamine only after carbidopa administration. Plasma tryptophan levels differed in the three groups. The authors state that their research design reveals changes in serotonin and nonrepinephrine metabolism in unipolar depressed subjects that distinguish this group from normal and bipolar depressed subjects, suggesting a reduced CNS uptake of tryptophan in unipolar depression.


The 24-hour dexamethasone suppression test in a clinical setting: relationship to diagnosis, symptoms, and response to treatment. Of 54 male psychiatric patients undergoing dexamethasone suppression tests in a clinical setting, 40% of those with a major depressive disorder showed escape from suppression over the 24 hours after dexamethasone administration, while all of the patients with schizophrenia, neurosis, alcoholism,and drug abuse showed normal pituitary-adrenal suppression. Only 10% of the depressed patients showed resistance to suppression 8 hours after dexamethasone administration. There was no difference between depressed patients who did and did not show escape from suppression in type of previous episodes, family history, symptoms, or medication. However, those who showed escape tended to respond better to treatment and to be rated as having a more severe depression. The theoretical and clinical implications of these findings are not yet clear.


Facial muscle electromyography in depressed and nondepressed hospitalized subjects: a partial replication. Imagining happy events, sad events, and the events of a typical day led to measurable electromyographic (EMG) changes in the corrugator muscle of the face in both depressed and nondepressed subjects. The depressed and nondepressed subjects could not be differentiated on the basis of muscle activity, whether depression was defined by a self-rating scale, an adjective checklist, or research criteria. Previous investigators have observed differences in the facial EMG patterns of depressed and nondepressed subjects who were not hospitalized; the authors suggest that such changes are a consequence of a general psychological stress state rather than of depression specifically.


Diagnosis and lithium treatment of affective disorder in the retarded: five case studies. The authors report on five institutionalized retarded patients who had symptoms strongly suggestive of manic-depressive illness and who showed significant symptom reduction in a single-blind placebo-controlled three-year trial of lithium. The number of illness episodes was reduced, and symptoms decreased in all major illness dimensions. These findings indicate that major affective disorder can be both diagnosed and treated in individuals with primary mental retardation.


Depression treated with imipramine and ECT: the DeCarolis study reconsidered. The authors reevaluate a large prospective Italian study (437 patients) that compared high-dose imipramine with ECT treatment in the treatment of depression. The superiority of ECT was evident among patients with endogenous depression, and especially evident among those with delusional depression (83% improved with ECT versus 40% with imipramine) and depressions defined as severe (83% versus 35%).


Lithium maintenance: factors affecting outcome. The authors reviewed the charts of 61 manic-depressive outpatients maintained on lithium for 6--75 months for relationships between clinical outcome and various demographic, clinical, and pharmacological variables. Good outcome (50% reduction in episode frequency) did not correlate with any demographic or most natural history variables. A history of frequent episodes was correlated with decreased episode frequency but not with a lower percentage of prophylaxis failure during follow-up. A nonsignificant trend toward decreasing episode occurrence with increasing duration of lithium maintenance was present. Depression occurred considerably more frequently than manic episodes at adequate maintenance plasma lithium levels. More medication noncompliance was found among patients who experienced both manic and depressive relapses.


The delineation of an MMPI symptom pattern unique to lithium responders. The author attempted to determine whether the Minnesota Multiphasic Personality Inventory (MMPI) would be sensitive to a symptom pattern unique to lithium-responsive patients regardless of diagnosis. Statistical analyses of the MMPI scores of lithium responders, lithium nonresponders, and a group of patients receiving other psychotropic drugs revealed that the depression, psychasthenia, mania, and social introversion scale scores significantly differentiated the lithium response and lithium nonresponse groups. No strong indications of significant difference were found between the MMPI scale scores of the lithium nonresponse and psychotropic groups. The results suggest that there is a lithium-responsive syndrome that exhibits a distinctive symptom pattern regardless of its varying phenomenological features in different individuals.


Exacerbation of psychosis by tricyclic antidepressants in delusional depression. The authors describe three patients with delusional unipolar depression whose delusional thinking worsened markedly following administration of tricyclic antidepressant drugs. The patients had met Research Diagnostic Criteria for major depressive episode and had no evidence of schizophrenia or mania. Since tricyclic antidepressants are known to exacerbate psychosis in schizophrenic patients, it is sometimes suggested that the exacerbation of psychotic thinking in depressed patients indicates schizophrenia. The authors suggest that such an exacerbation does not in itself indicate schizophrenia but may occur in patients with an affective disorder who are prone to depressive delusions. The authors discuss the use of antipsychotic medication in this patient group and present a neurochemical hypothesis to explain the interaction of the drug with the illness, which results in exacerbation of psychotic thinking.


The quantitative measurement of depression and anxiety in male alcoholics. Depression and anxiety have been reported to be commonly associated with alcoholism. Most attempts to clarify this relationship have suffered from a patient selection bias in that only those alcoholics who sought treatment were studied. The authors performed quantitative measurements of depression and anxiety in a group of 48 men referred for treatment solely on the basis of excessive drinking. The prevalence of depression and anxiety as measured by both the Zung and Hamilton scales was lower than that shown in previous studies. The results of this study indicate that problems in young, healthy male alcoholics.


Bipolar illness: factors in drinking behavior. Alcohol use and abuse was investigated in 73 patients with bipolar I manic-depressive illness who were attending a lithium clinic. Alcohol-related problems were identified in 7 of the male and none of the female patients. Family data revealed a higher morbid risk for alcoholism among relatives of patients with drinking problems than among relatives of patients without drinking problems. Morbid risks for affective disorder for these two groups of relatives were similar, suggesting that alcoholism among relatives of patients with bipolar illness is not solely "genotypically" related to the affective disorder.


Are all recently detoxified alcoholics depressed? Reports of the prevalence of depression among alcoholics vary from 3% to 98%; the authors attribute this variation to the use of different diagnostic criteria. They used clinical diagnosis, the Hamilton Depression Rating Scale, the Zung Self-Rating Depression Scale, and the MMPI to diagnose 35 men recently withdrawn from alcohol. The percentages of depression diagnosed were 8.6%, 28%, 66%, and 43%, respectively. The authors point out that the Hamilton, Zung, and MMPI scales are not diagnostic of depression in themselves and that accurate diagnosis of depression in alcoholics will reduce inappropriate treatment of nondepressed alcoholics and ensure careful treatment of the truly depressed.


Family rituals and the recurrence of alcoholism over generations. There have been relatively few attempts to identify environmental factors in the transmission of alcoholism across generations. Using the framework of family systems theory, the authors examined the extent of change in family rituals in 25 families in which at least 1 parent was or had been an alcoholic. They found that families whose rituals were altered during the period of heaviest parental drinking were more likely to evidence transmission of an alcohol problem to the children's generation than families whose rituals remianed intact.


Short-term spatial memory deficits in men arrested for driving while intoxicated. In the light of the fact that ethyl alcohol can cause damage to the brain, especially in the area of motor control, a study of the incidence of alcohol-related neuropsychological impairment in individuals arrested for driving while intoxicated (DWI) would be of great value. The authors report on 100 DWI offenders given a Memory-for Designs Test: 33% of the offenders were in the borderline range for organicity and a further 24% were in the critical range. Although they advise caution in interpreting these data, the authors point out a number of implications their analyses have for those interested in alcohol-related highway safety programs.


Craving for alcohol in sober alcoholics. The craving for alcohol experienced by 46 abstinent alcoholics was investigated with a structured interview, a personality inventory (the neuroticism Scale Questionnaire), and a mood state adjective checklist (Profile of Mood States). It was found that craving is a continuum, not an all-or-none phenomenon. The intensity of craving was positively correlated with the trait anxiety of the subject and inversely correlated with the duration of abstinence from alcohol. A large proportion of the craving was precipitated by environmental factors and relieved by psychological methods. A variety of mood changes accompanied carving. Only one mood state, anger-hostility, significantly differentiated subjects who experienced mild craving from those reporting severe craving.


Drug abuse among alcoholic women.

Drug abuse among alcoholic women. Of 293 women in an alcoholic treatment center, two-thirds have received prescriptions for drugs of potential abuse, usually hypnotic and antianxiety drugs. One-third of the women admitted abusing substances; 80% of these subjects got prescriptions for potential drugs of abuse while actively abusing. These figures are alarming in light of the lack of evidence that antianxiety drugs, hypnotics, and stimulants are effective in treating alcoholics and drug abusers. Drug-misusing women in this sample reported more suicide attempts and early antisocial problems and had received more psychiatric care than nonabusers. The authors urge that hypnotics, antianxiety drugs, and stimulants almost never be prescribed to outpatient alcoholics and that analgesics be prescribed only with great care.


Psychiatric problems in women admitted to an alcoholic detoxification center. The authors studied 293 consecutive female admissions to a public detoxification facility. One-half had a primary diagnosis of alcoholism; the rest had primary diagnosis of affective disorder (14%), antisocial personality (14%), drug abuse (6%) or did not meet the criteria for alcoholism (13%). Each subgroup had unique social backgrounds and characteristic histories of involvement with alcohol, drugs, and antisocial problems. The primary alcoholic woman in the detoxification center resembles the primary alcoholic man in the same setting. The authors underscore the importance of socioeconomic strata and primary versus secondary diagnosis in understanding the prognosis for alcoholics.


Interpersonal attractiveness and clinical decision in alcoholism treatment. The authors investigated the interactive contribution of patient characteristics and staff perceptions of the patient to decisions concerning the provision of continued alcoholism treatment following an initial 2-week evaluation period. Staff perceptions contributed significantly more to an individual's acceptance or rejection than did patient characteristics. A high interpersonal attractiveness rating also led to a significantly more positive evaluation of the patients' level of intelligence, knowledge of current events, morality, and adjustment. The present results and research findings with general psychiatric populations are compared.


Development of an information system: a means for improving social work practice in health care. The Johns Hopkins Hospital has developed a social work information system involving seven referral problem categories based on problems as identified by the referral source, ten problem categories for social work service, identified by the social work person after interview, and ten social work service categories similarly identified. The latter two categories include contracts with patients and expected outcomes together with categorization of actual outcome. Analyses of the coded data allow for more effective management of social work services and permit social work departments to compete for scarce resources, to comply with external regulations and accountability demands, and to assure quality service. In addition they provide a firm data base for research. The problem and service categories were tested for reliability by comparing the independent categorizations of 159 and 154 cases respectively by six social work persons, two each at three different levels of experience. Reliability levels were found to be satisfactory. The development of this system and the method of reliability testing are described and believed to be applicable to other systems.


The Ottawa County project: a report of a tuberculosis screening project in a small mining community. Following a retrospective review of tuberculosis cases reported from Ottawa County, Oklahoma, from 1969 through 1973, a selective tuberculosis screening project was implemented. Screening of a "target group" of the population, 519 former miners, greater than or equal to 50 years of age, resulted in the discovery of abnormal chest X-rays in 182; (103 with silicosis, 36 with silicotuberculosis, 12 with inactive tuberculosis, and 31 with other abnormalities). Eighty-five of these persons had positive tuberculin skin tests. Preventive therapy was recommended for 50, and 36 completed the prescribed course of treatment. Eight new bacteriologically confirmed cases of tuberculosis were found and treated. A large number of persons (1,904) residing in the same area who were not part of the target group were also screened for tuberculosis. This group contained a large number of positive tuberculin reactors but very few were candidates for isoniazid preventive therapy. Thirteen persons in this group had abnormal chest X-rays consistent with inactive tuberculosis but 12 had been identified and given preventive therapy before the project began. These data suggest that selective approaches to screening for tuberculosis in a community which are based on an in-depth retrospective review of the tuberculosis case register can be highly successful.


Longitudinal changes in blood lead level in children and their relationship to season, age, and exposure to paint or plaster. Children screened for lead poisoning in the Brownsville district of New York City in either summer or winter were followed with blood lead tests for approximately six months to one year from screening to measure longitudinal changes in blood lead level and to identify some determinants of the changes. Only minimal evidence was found of the hypothesized summer rise in blood lead level, while the predominant trend seemed to be for blood lead levels to display statistical regression to the mean. In children found to have low to intermediate blood lead levels (less than 55 microgram/100ml) at screening, variables which were found to predict a rise in blood lead level of 10 microgram/100ml or greater from winter to summer were under age three and/or exposure to paint or plaster.


Canonical correlation analysis: potential for environmental health planning. There is a challenging need to identify the relationships between environmental quality and health status. It may be especially important to be able to isolate key variables which can be consolidated into a few indices of environmental conditions as they are related to health. Such indices might be used to identifying associations among groups of variables, such as specific geographic area. The indices may also provide insights into environmental health relationships which are worthy of further epidemiological investigation. Canonical correlation analysis is a multivariate statistical technique which provides a means of identifying associations among groups of variables, such as health and environmental measures. The technique can produce weighted indices of environmental conditions as they are related to health within a city or region. This paper describes what canonical correlation is, and outlines how it might be used for these purposes. An illustrative application based on data collected for Philadelphia, Pennsylvania is also presented.


Ambient carbon monoxide levels and acute cardiorespiratory complaints: an exploratory study. Over a 92-day seasonally excessive period of ambient carbon monoxide (CO), chief cardiorespiratory complaints (CRC) of a nontraumatic origin were identified from each of 8,556 patient encounters at the Emergency Room of Colorado General Hospital. Excessive numbers of CRC were seen above a CO level of 5 ppm for the 24-hour mean and 11 ppm for the one hour mean maximum ambient CO (p less than 0.05 for both). Increasing relative risk was shown by comparing daily numbers of CRC with its mean in two-day trend analyses with both ambient CO measures above and below these thresholds. Other ambient pollutants were generally low during the winter period studies. These findings suggest an association between health effects and lower levels of CO than has been previously reported.


The hidden price tag: participation costs and health planning. The citizen participation program of the Los Angeles County Health Systems Agency represents one of the most ambitious efforts at implementing the public involvement provisions of PL 93-641. The first year of this program is discussed and analyzed through a participation costs theoretical framework. Specific costs which are inherent in the organizational design and introduced by the implementation procedures adopted are identified and discussed. Levels of participation after one year of operation are examined and found consistent with the high cost of participation in this program.


A retrospective and prospective study of serial CEA determinations in the early detection of recurrent colon cancer. The results of the present study emphasize the importance of minimizing the time delay between a significant elevation in CEA and a second-look operation. Equally important are the frequency of serial determinations, a thorough understanding of the limitations of the assay, and careful evaluation of the clinical condition of the patient.


Massive cecal dilation: pseudoobstruction versus cecal volvulus? Seven patients with acute and progressive abdominal distension secondary to massive cecal and right colon ileus are analyzed. Five had pseudoobstruction of the colon and two had cecal volvulus. Two of the patients with pseudoobstruction and one with cecal volvulus died from preexisting diseases. Pseudoobstruction of the colon is not a rare complication of elderly, sick, bedridden patients. Differential diagnoses include cecal and sigmoid volvulus and acute gastric dilation. Initial conservative therapy is warranted if no peritoneal signs are present. If the cecal diameter is more than 12 cm, colonoscopic decompression with a fiberscope should be attempted. If unsuccessful, tube cecostomy will provide curative, life-saving therapy even if taenia splitting is present. Perforation or widely scattered areas of necrosis make resection mandatory.


Colon interposition for benign esophageal disease. Our experience for the past seven years with colon interposition is reviewed. Colon interposition resulted in all patients being relieved of symptoms and satisfied with their result. Colon interposition for nondilatable benign esophageal stricture was shown to be efficacious. In patients undergoing colon interposition for a failed esophagomyotomy, excellent or good results were obtained in a thirty month follow-up period with no operative failures.


Acute appendicitis during pregnancy.

Acute appendicitis during pregnancy. Case reports (1970--1977) of thirty-five pregnant women with acute appendicitis were reviewed. Eighty-eight per cent had symptoms less than 24 hours and were operated on within 12 hours. No maternal or fetal loss occurred. Morbidity and mortality should be minimal if, when appendicitis is suspected in a pregnant woman, immediate operation is performed.


Acute perforations of the sigmoid colon secondary to diverticulitis. Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.


Aneurysms of the extracranial carotid artery. Twenty-one years' experience. Aneurysms of the extracranial carotid artery are an uncommon but potentially serious problem, usually due to rupture or thromboembolic events. Thirty-seven aneurysms of the extracranial carotid artery were seen in thirty-four patients from 1956 to 1977. The ages ranged from twenty-nine to ninety-two years, with an average of fifty-nine years. There were twenty-three males and eleven females. Nineteen (51 per cent) were false aneurysms, sixteen (44 per cent) atherosclerotic aneurysms, and two (5 per cent) posttraumatic aneurysms. All patients presented with evidence of a mass in the neck, and only five (15 per cent) had neurological symptoms related to the aneurysm. Surgery was performed on twenty-eight carotid aneurysms. Resection and patch angioplasty was employed for eighteen aneurysms, resection with graft replacement for six, and resection and ligation of the internal carotid artery for four. Postoperative neurologic deficits developed in three patients (11 per cent), and one of these died. There was one other operative death due to acute myocardial infarction (operative mortality, 7 per cent). Nonoperative treatment was employed when the patient had other associated high risk disease or a small asymptomatic aneurysm.


Comparison of changes in intestinal length and circumference after 90 per cent bypass and 90 per cent resection. Compensatory hypertrophy was compared in rats that had undergone 90 per cent small intestinal resection and rats that had undergone 90 per cent small intestinal bypass. Increases in intestinal length and circumference occurred rapidly in both groups and were virtually identical. Lengthening was more pronounced in the jejunum; increase in circumference was greater in the ileum. Increases in length and circumference of the appendix were seen in both experimental groups. These studies suggest that compensatory hypertrophy can occur in patients after either intestinal bypass or resection, and that patients with bypasses have a less difficult postoperative course because of their preexisting obesity.


Parietal cell autoantibodies and hypergastrinemia in achlorhydria and the Zollinger-Ellison syndrome. Parietal cell autoantibody (PCA), basal gastrin, and calcium-stimulated gastrin were measured in twenty patients with achlorhydria, in eight patients with the Zollinger-Ellison syndrome, and in fifty control subjects. In twelve patients with achlorhydria with a spared antrum, PCA was positive and basal gastrin was elevated. In contrast, eight achlorhydric patients with antral gastritis had negative PCA and significantly lower basal gastrin levels. Patients with the Zollinger-Ellison syndrome did not demonstrate positive PCA despite elevated levels of basal gastrin, nor was PCA present in normal controls. This study suggests that certain achlorhydric states are caused by an autoimmune response, particularly if antral function is spared.


Antral patch esophagoplasty. A new procedure for acid-peptic esophageal stricture. Antral patch esophagoplasty is a new procedure for intractable fibrous stricture of the esophagus secondary to acid-peptic reflux. A full-thickness patch of gastric antrum, supplied by a pedicle based on the left gastroepiploic vessels, is inserted, mucosal surface to lumen, into the opened stricture. A fundoplication is done below the esophagoplasty to prevent reflux. The functional results were excellent in five of six patients. The procedure may have application also in other types of benign esophageal stricture.


Gastric patch esophagoplasty: an experimental study. To determine whether the use of pedicled full-thickness gastric patches would be feasible and safe in esophageal reconstruction, studies were undertaken in eleven dogs. The results demonstrate that patches containing parietal cell mucosa are likely to produce localized adjacent esophagitis. Patches containing antral mucosa do not produce esophagitis and are not associated with a subsequent increase in circulating serum gastrin levels.


A longitudinal study of tryptophan involvement in hepatic coma. Previous cross-sectional studies have demonstrated that hepatic coma is associated with abnormally high levels of plasma free tryptophan. Establishment of a more definitive relationship between this biochemical abnormality and hepatic coma requires an evaluation of biochemical changes in individual patients as they undergo alterations in the function of their central nervous systems. The present report is an evaluation of tryptophan and substances believed to influence its entry into the brain in six patients whose clinical status progressed from hepatic coma to complete recovery. Consistent significant decreases in plasma free tryptophan and free fatty acids were demonsrated to occur as the patients recovered. No consistent changes, however, were found in the plasma levels of the amino acids which have been reported to compete with tryptophan for transport across the blood-brain barrier, except for leucine which was significantly decreased in all six patients upon recovery from coma. Assay of lumbar cerebrospinal fluid for both tryptophan and the serotonin metabolite, 5-hydroxyindoleacetic acid (5-HIAA), showed no consistent changes as the patients recovered from hepatic coma.


Aortic dissection: surgical and nonsurgical treatments compared. An analysis of seventy-four cases at the University of Virginia. During the eleven year period from 1965 to 1976, aortic dissection was diagnosed in seventy-eight patients treated at the University of Virginia Medical Center. The seventy-four cases that comprise the present report were confirmed by aortography, surgery, or autopsy. Forty patients (54 per cent) were surgically treated by interruption of the origin of dissection and insertion of a Dacron prosthesis. The remaining thirty-four (46 per cent) were treated according to the Wheat regimen or by nonspecific supportive measures. The overall survival at one year was 28 per cent. One year survival for patients with type I dissections treated surgically was 19 per cent compared with 8 per cent one year survival for nonsurgically treated patients. Sixty per cent of patients with type II dissections treated surgically were alive at the end of one year, whereas no patients with type II dissection treated nonsurgically survived beyond one year. Half the patients with type III dissections treated surgically were alive at one year compared with 35 per cent of those nonsurgically treated. These data suggest that surgery is the treatment of choice for all types of aortic dissections, but particularly for type II. Patients with type I dissections have a very poor prognosis regardless of therapy.


Screening for significant carotid stenosis by ocular pneumoplethysmography. Carotid stenosis is significant when the resulting lumen is 50 per cent or less of the diameter of the vessel distal to the carotid sinus. The ocular pneumoplethysmograph can detect these stenoses with an accuracy of 97 per cent.


Doppler assessment of the inferior epigastric artery flow patterns as a screening test for aortoiliac obstruction. A simplified technic utilizing the ultrasonic directional flowmeter for the detection of hemodynamically significant aortoiliac obstruction is described. The method is based upon the presence of a reversed flow pattern along the inferior epigastric artery in patients with aortoiliac obstruction. Correlation with angiographic findings was made in the twenty patients reported on in this study. In twelve patients with severe or complete iliac artery obstruction, reverse epigastric flow was present, whereas in the remaining eight without significant obstruction to arterial flow, the inferior epigastric arterial flow direction remained normal.


Detection of deep venous thrombosis by impedance plethysmography. Ninety-eight limbs in sixty-seven patients supected of having lower extremity deep venous thrombosis were evaluated by physical examination, venous impedance plethysmography (IPG), and venography. Diagnosis based on physical signs commonly associated with deep venous thrombosis was false-positive in 43 to 66 per cent and false-negative in 26 to 73 per cent when compared with evidence obtained by venography. The overall accuracy of IPG was 94 per cent, with false-positive results occurring in 10 per cent and false-negative results in 4 per cent. IPG is sufficiently accurate to be considered a reliable screening test for lower extremity deep venous thrombosis.


Pyomyositis. Review of 205 cases in 112 patients. A study of pyomyositis, a pyogenic infection of the muscle, in 112 patients is presented. The etiologic role of suggested factors remains unclear. Early recognition and aggressive management with antibiotics, incision, and drainage usually lead to rapid resolution. Accordingly, the clinical findings are presented, and criteria for diagnosis are suggested.


The variability of estrogen receptors in metastatic breast cancer. Estrogen receptor protein (ERP) concentrations were determined by the sucrose diffusion method in primary tumors and one or more metastases in twenty-nine patients with breast cancer. Concurrence of ERP concentrations between primaries and at least some metastases was found in 76 per cent of cases. Multiple metastases were assayed in ten cases, three of which demonstrated highly variable concentrations. It was concluded that clinically significant differences in ERP concentrations often exist between primary breast cancers and their metastases as well as between different metastases from the same tumor, accounting for the lack of responsiveness of some ERP-"positive" tumors and for mixed responses to hormonal or endocrine therapy. Assay of an isolated metastasis may be no more reliable in predicting overall patient benefit from therapy than assay of the primary itself.


Spontaneous gastric rupture in the newborn. Spontaneous rupture of the stomach during the neonatal period is the most common type of nonobstructive perforation. The clinical manifestations include severe abdominal distension, vomiting, and respiratory distress. However, diagnosis is based on an upright x-ray film of the abdomen which shows the "saddle" of "football" sign due to massive pneumoperitoneum. The fatality rate is still quite high. Success in treatment depends on early diagnosis and immediate surgical intervention.


Spontaneous rupture of spleen in leukemic reticuloendotheliosis. Leukemic reticuloendotheliosis, or "hairy cell leukemia," is a neoplasm of the reticuloendothelial system. It is characterized by the presence of many "hairy cells" in blood, marrow, lymph nodes, and spleen; by anemia, leukopenia, thrombocytopenia, and often, by massive splenomegaly. Three such patients with spontaneous rupture and one patient with multiple infarctions of the spleen all had spleens which were large, congested, and diffusely infiltrated by "hairy cells." The lacerations in all three ruptured spleens were located in areas of extensive infarction. Indications for splenectomy in this disease include hypersplenism, severe cytopenia, hemodilution, splenomegaly with severe pressure symptoms, massive splenomegaly, rupture, or infarction.


Massive air emboli from intravenous infusion pump: etiology and prevention. A case of massive air embolus secondary to use of an intravenous infusion pump is presented. The pump is unable to detect air entering the intravenous line if the air enters distal to the air detection device. A simple solution is presented.


The use of intraluminal intravascular balloon occlusive shunts in vascular surgery. Intravascular shunts are primarily utilized to prevent cerebral ischemia during carotid artery surgery. However, an intraluminal intravascular balloon occlusive shunt tube is described which may be used to perfuse extremities during bypass procedures, repair of arteriovenous fistulas, and traumatic lacerations of sizable arteries and veins.


Operative management of radiation injuries of the intestinal tract. A review of forty cases of radiation-induced gastrointestinal injuries is presented. Based on this experience and reports in the literature, preoperative management and operative technics are discussed. The increased risk of radiation bowel injury is recognized in patients who have had previous operations. Preradiation contrast studies are advised to identify trapped loops of intestine in the pelvis. Small bowel resection is recommended with localized segments of disease. Bypass operations are preferable to avoid any extensive dissections. Bypass operations have anastomotic dehiscence rates similar to those of resections. Proctocolitis is usually managed by diverting colostomy, with resection in a few favorable cases or with treatment failures. Most rectovaginal fistulas are managed by permanent colostomy. Small bowel fistulas are best treated by bypass with partial or total exclusion rather than by primary resection. Vigorous preoperative and postoperative nutritional support and evaluation are vital because of the poor healing qualities of irradiated bowel. Multiple operative procedures should be anticipated because the natural history of radiation bowel injury is slowly progressive.


Intrahepatic cholangiojejunostomy: a new simplified approach. A simplified technic for performing intrahepatic cholangiojejunostomy has been described, which can be utilized to bypass proximal biliary tract obstruction where the usual methods of choledochoenteric decompression are not possible. This technic has been performed nine times in seven patients, with a mortality of 30 per cent. In all but the two patients who died of liver failure in the immediate postoperative period, jaundice and pruritus were relieved. There was one wound infection and one instance of stenosis of the anastomosis which responded to dilatation.


A technic for pancreatobiliary sphincteroplasty. A technic for pancreatobiliary sphincteroplasty providing accurate approximation of tissues in a bloodless field has been presented. It is suitable and adaptable to the common duct with duodenum, as well as pancreatic duct with common duct.


Improving transverse colostomy function. Loop transverse colostomies as usually constructed without immediate mucocutaneous anastomosis function poorly even a year later, with diarrheal fluid output approaching 1 liter/day on a regular diet. In contrast, primarily matured end transverse colostomies produce an average of 750 cc/day at one month and 560 cc/day at nine to twelve months on a similar diet. A further reduction to 360 cc/day was achieved on an experimental 70 mEq sodium diet. It is suggested that end transverse colostomies with immediate maturation should be performed in all patients requiring a transverse colostomy for more than a very short time to markedly improve colostomy function.


Preservation of splenic function in adults and children with injured spleens. Mounting evidence supports efforts to preserve splenic function. This evidence indicates (1) that the problem of postsplenectomy sepsis warrants splenic preservation whenever possible, and (2) that the spleen, as a whole or in part, and its function, can be preserved in cirmustances which formerly seemed to necessitate removal of the entire spleen. Nine patients with splenic injuries in whom splenic function was preserved successfully are presented. Approaches to management of the splenic injuries included (1) nonoperative management, (2) hemostasis by application of microfibrillar collagen (Avitene), (3) partial splenic resection, and (4) preservation of accessory spleen. Since reliable prevention and treatment of postsplenectomy sepsis do not seem attainable in the near future, continuing efforts to preserve function of the spleen whenever possible, in patients with injured spleens, seem justified and desirable.


Assessment of operative risk with electrocardiographic exercise testing in patients with peripheral vascular disease. Doppler ankle blood pressures were performed inere obtained in 100 consecutive patients with peripheral arterial insufficiency after treadmill exercise. A twelve lead electrocardiogram was monitored during and after exercise. Despite a restricted ability to exercise because of peripheral vascular insufficiency, forty-six patients had ventricular dysrhythmia or ischemia, or both, usually without associated symptoms. Electrocardiographic monitoring during treadmill exercise proved a useful predictor of postoperative complications. Thirty-two vascular operations were performed in patients with no electrocardiographic evidence of ischemia. No patient had a postoperative myocardial infarction or died. Sixteen vascular procedures were performed in patients with ischemic responses on exercise electrocardiography. Six patients had postoperative myocardial infarctions, two of which were fatal. Electrocardiographic monitoring during treadmill exercise for peripheral vascular insufficiency in recommended (1) to assess the severity of coronary artery disease and the likehood of postoperative complications, and (2) as a precautionary measure to identify potentially dangerous dysrhthmias or ischemia during exercise before the development of clinical symptoms.


Lethal pancreatitis: a diagnostic dilemma. Clinical and pathological information from forty patients who died with pathologically severe acute pancreatitis was correlated. Patients were classified into four etiologic groups: those with biliary pancreatitis (11 patients), alcoholic pancreatitis (13 patients), idiopathic pancreatitis (10 patients), and renal failure (6 patients). Antemortem diagnosis was made in only 57 per cent of the patients studied. The diagnosis was determined before death in 91 per cent of the biliary patients but in none of the renal patients. Thirty-seven patients died from their first clinical attack of pancreatitis. Operation in patients with biliary pancreatitis failed when biliary decompression was not provided. Peripancreatic sepsis was a frequent lethal mechanism in patients with biliary pancreatitis, but renal and respiratory failure were more common in patients with alcoholic pancreatitis.


Intraoperative autotransfusion in major vascular surgery. The use of intraoperative autotransfusion provides a safe and cost-effective means of salvaging operative blood loss and reducing or eliminating the use of stored homologous bank blood with its inherent difficulties and risks. The risk of disease transmission or various reactions is minimized. Autotransfusion provides a readily available, more physiologic, and at times life-saving source of blood for patients with rare blood types or patients in whom time does not permit adequate cross-matching. This technique is acceptable to most sects of Jehovah's Witnesses, who normally refuse homologous blood. Our experience during the past six years with autotransfusion in major vascular surgery reveals a mean slavage equivalent to five units of blood loss, and avoidance of using any bank blood in almost half of elective patients. No significant problems occurred due to hemolysis, coagulation abnormalities, or particulate/air emboli, nor any morbidity or mortality specifically related to autotransfusion. We conclude that wider and more frequent use of autotransfusion technics is appropriate.


Increasing incidence of right-sided lesions in colorectal cancer. One hundred ninety-eight patients with 211 cancers of the colon and rectum underwent elective resection at the University of Vermont College of Medicine during the five year period 1971 through 1975. Analysis of this series demonstrated that 35 per cent of all cancers were located in the cecum and ascending colon, that a similar percentage were classified as Dukes' A cancers, that a synchronous cancer was present in 5.5 per cent of the patients and that diagnosis by rectal examination and sigmoidscopy was possible in only 32 per cent of the patients. Comparison of these results with published data during the past thirty years indicate that there is an increasing incidence of carcinoma of the right colon with an associated decrease in the incidence of carcinoma of the sigmoid colon and rectum. It is recommended that patients be screened by examination of the stool for occult blood rather than by rectal examination and sigmoidoscopy so that these proximal lesions can be diagnosed at an earlier stage. Preoperative evaluation of patients with distal colorectal cancer should include double contrast barium enema examinations and colonscopy to rule out synchronous right-sided lesions.


Bile gastritis without prior gastric surgery: contributing role of cholecystectomy. This study reports on ten patients with typical bile gastritis who had no prior gastric surgery. Clinical symptoms included burning epigastric pain unrelieved by food or antacid, episodic nausea, and vomiting of bile. In all patients the symptoms appeared after cholecystectomy, with (four patients) or without (six patients) transduodenal sphincterotomy; the symptoms were often initially attributed to chronic pancreatitis. Six patients had hypochromic, microcytic anemia. Eight patients had basal achlorhydria; stimulated acid secretion was low or absent in seven patients. Gastroscopic examination revealed gastritis, most prominent in the prepyloric antrum, and abundant bile lakes. Mucosal biopsy disclosed chronic gastritis. Although medical therapy failed, seven of eight patients treated by vagotomy, hemigastrectomy, and long Roux-en-Y gastrojejunostomy had immediate and sustained relief. Cholecystectomy appears to be a critical factor in the pathogenesis of bile gastritis in patients who have not had prior gastric surgery. Without the reservoir function of the gallbladder, the unregulated flow of bile into the duodenum probably promotes the access of bile to the unprotected gastric mucosa.


The Belsey operation for hiatal hernia: a twenty year experience. A twenty year experience with the Belsey operation for hiatal hernia repair demonstrated good to excellent results in 80 per cent of patients, a fair outcome in 15 per cent, and unacceptable results in 5 per cent of patients. Good results included the absence of reflux symptoms, pleasant swallowing, the preservation of a normal capacity for belching and vomiting, minimal flatulence, and a comfortable incision. Although most recurrent symptoms appear within five years after operation, symptoms first recur ten or more years after operation in 10 per cent of patients.


Is pulmonary angiography essential for the diagnosis of acute pulmonary embolism? The records of 158 patients who underwent pulmonary angiography for the presumed diagnosis of acute pulmonary embolism were retrospectively reviewed. Of the 111 patients in the category of high probability for pulmonary embolism based on clinical impression, 60 patients (54 per cent) had a positive pulmonary angiogram. Of the forty-seven patients in the low probability group, ten (21 per cent) had a positive angiogram. Forty-eight of the seventy-three patients (66 per cent) with a high probability lung scan had a positive pulmonary angiogram. Eleven of twelve patients (92 per cent) with a high probability ventilation-perfusion scan had a positive pulmonary angiogram, and two of eight patients (25 per cent) with a low probability ventilation-perfusion scan had a positive pulmonary angiogram. The mean PO2 of patients with a positive pulmonary angiogram was 64 mm Hg, and the mean PCO2 30 mm Hg. The mean PO2 of patients with a negative pulmonary angiogram was 63 mm Hg and the mean PCO2 34 mm Hg. Based on these data, we believe that the accuracy of pulmonary angiography in diagnosing acute pulmonary embolism is much higher than that of the clinical impression, arterial blood gas determinations, and lung scanning technics.


Surgical management of the chronic venous ulcer: the Rob procedure. Eighteen operations for venous ulceration were performed through a stocking seam incision with only one recurrence and minimal wound problems. The prolonged morbidity of venous ulcer disease can be alleviated with the method described. By a history and clinical examination followed by venography, a group of patients with venous ulcers can be identified who will benefit from an aggressive surgical approach.


A simple technic for predicting daily maintenance dose of warfarin. Warfarin anticoagulation data from forty-seven patients studied retrospectively was used to develop an algorithm for predicting daily maintenance dose of warfarin. A plot of prothrombin time versus cumulative warfarin loading dose was made for each of the forty-seven patients and the aera under the curve (AREA) measured from the baseline prothrombin time to a prothrombin time of 20 seconds. A linear correlation between the established daily maintenance dose of warfarin and AREA was derived regression analysis: Daily maintenance dose (mg/day) = 0.0465 x (AREA) + 1.5. The correlation was then used to predict daily maintenance dose in twenty-four patients studied prospectively. The mean prothrombin time for a seven day stabilization period after loading for all patients in the prospective study was 21.5 +/- 2.2 seconds and the seven day mean prothrombin time for each patient fell between 19 and 24 seconds. The results of the prospective study indicate that this technic is useful in the early, accurate prediction of a daily maintenance dose of warfarin.


Dural dimpling in the dog.

Dural dimpling in the dog. Indentation of the dura has been proposed as the cause of subatmospheric pressure in the extradural space, but has never been demonstrated directly in humans. In this study, radiographs have been produced showing dimpling of the dura by a needle tip lying in the extradural space in the dog. Pressure tracings demonstrate that advancement of the needle tip produces a progressive decrease in extradural pressure, and observations made using an image intensifier have confirmed that the pressure changes are proportional to the degree of dural indentation.


Amniotic fluid embolism. A report of three cases. Three patients showing the typical features of amniotic fluid embolism are described. Two survived the insult, while in the third the diagnosis was confirmed by post-mortem histological examination of the lungs.


Prolonged Q-T interval syndrome. Sudden cardiac arrest during anaesthesia. A review of the literature concerning the causation of prolonged Q-T interval syndrome is presented. A fatal case, 50 years of age, with this rare entity is also reported, in whom a sudden cardiac arrest occurred 46 min after induction of anaesthesia. An outline for the successful anaesthetic management of patients with prolonged Q-T interval syndrome is suggested.


Malignant hyperthermia susceptibility. Management during pregnancy and labour. A case of pregnancy complicated by malignant hyperthermia susceptibility is reported. Serum CPK and electrolyte concentrations were measured during pregnancy and labour. Labour and delivery were managed successfully under epidural analgesia using plain bupivacaine 0.5%.


Anaesthetic pollution in the dental out-patient surgery. Five factors influencing pollution in the dental surgery are considered. Despite leakage from round the mask and from the mouth, scavenging can remove the majority of expired anaesthetic. The effectiveness of scavenging can usefully be monitored with a Wright respirometer. Spillage of anaesthetic vapour at induction and at the end of anaesthesia must be avoided. In addition to scavenging, pollution levels are minimised if a Boyle's type machine is used and excessive fresh gas flow avoided. Room ventilation, e.g. extract fans in windows, is vital in reducing pollution levels in the surgery. Room size and non-uniformity of ventilation must also be considered.


Anaesthesia for microsurgery of the larynx using a carbon dioxide laser. Microsurgery of the larynx using the carbon dioxide laser is becoming popular and provides many advantages. The anaesthetic management described here has proved successful in clinical use. Anaesthesia is induced with thiopentone and maintained by nitrous oxide and oxygen with or without halothane. Muscle relaxation is maintained using a continuous infusion of suxamethonium. Emphasis is laid on the need to protect the tracheal tube against the fire risk from the laser beam.


The current practice of endobronchial intubation. A study of the current usage of endobronchial intubation in thoracic anaesthesia was made following the distribution of questionnaires to fifty thoracic units in the United Kingdom. From the 144 replies received from forty-eight units, it is clear that single-lumen endobronchial tubes and blockers are never used by a majority of anaesthetists. The use of the double-lumen tube is almost routine for all types of surgery, the Tobertshaw tube being the most frequent choice. Included in the discussion, is a brief review of the development of endobronchial intubation, illustrating the probable influential factors.


A continuing saga of piped medical gas supply. The development and present position of British Standards relating to Piped Medical Gas Supplies is considered with particular reference to the recommendations of the reports of the Kent and Canterbury and Westminster Inquiries.


[Efficacy of low doses of heparin to postoperative changes of blood gases after abdominal surgery (author's transl)]. Arterial hypoxaemia near critical values may occur during the postoperative period after surgery under general anaesthesia. Mainly alterations of ventilation/perfusion ratio seem to be the cause for this disorder. In this study we examined the effect of low-dose-heparin in improving pulmonary perfusion and consequently reduction of postoperative hypoxaemia. In 22 elderly patients both male and female we found no significant differences in oxygen tension compared to a control group of 19 patients. In both groups duration and degree of postoperative hypoxaemia were equal with minima on the first respectively second postoperative day. As in both groups there were no significant differences in other parameters further influencing oxygen supply--such as haemoglobin, haematocrit, pH and mean arterial blood pressure--we do not believe that disturbances of perfusion caused by microembolism are mainly responsible for postoperative hypoxaemia. Likewise low dose heparin seems to have no effect on postoperative hypoxaemia.


[Controlled clinical trial "blind" versus aimed fibrebronchoscopic suction in mechanically ventilated patients (author's transl)]. In patients treated with ventilation therapy only 60% of blind suction catheters reach the desired position. In ten patients the routinely performed blind suction was replaced by aimed bronchoscopic suction. Blood gas analyses before and after aimed and blind suction favoured the former. Also the arterioalveolar oxygen tension difference showed a good response to aimed suction. There is a broad spectrum of indications for fibreoptic bronchoscopy in every care unit dealing with mechanical ventilation.


[Doltron ESA 1000. A new apparatus for electrostimulation-anaesthesia (author's transl)]. The Doltron ESA 1000 apparatus is a constant current stimulator which delivers positive and negative rectangular pulses. On account of the safety precautions built in, which satisfy international standards, and adequate software this device appears suitable for electrostimulation anaesthesia.


Distribution of surface coat material on nasal folds of mouse embryos as demonstrated by concanavalin A binding. 3H-concanavalin A and the concanavalin A-horseradish peroxidase staining technique were used to study the distribution of surface coat material on the epithelium of the nasal folds and nasal groove of mouse embryos. In stages shortly before and during epithelial fusion concanavalan A stained or labeled material was present at apical surfaces of epithelial cells of the nasal groove and nasal folds. Silver grains, representing bound 3H-concanavalin A, were counted in defined areas of the nasal groove and presumptive fusion area in both anterior and posterior regions of the nasal folds. For both stages examined there was a significant increase in the amount of 3H-concanavalin A bound by presumptive fusion areas in posterior regions of the nasal folds as compared with anterior regions; i.e., the atact between the nasal folds. This finding is consistent with results from investigations of palatal shelf and neural fold fusion which suggest that increased synthesis of surface coat material is associated with adhesion and fusion of epithelial folds and shelves.


An electron microscope study of crystal calcium carbonate formation in the mouse otolith. The ultrathin sections of the developing otolith of mouse fetuses 15.5 days to 20 days after birth were observed with the aid of the electron microscope. The first step of otolith formation is an aggregation of organic clusters observed in the sacculus of the 15.5-day fetus. These organic structures are modified and assume a hexagonal shape in the 17.5-day fetus. The unmineralized stages of the otolith referred to as the preotolith, serve as the template for future development. One day after birth, at either end of the preotolith, minute tube-like structures develop in which needle-shaped crystallites are initiated. Crystallites continue to develop throughout the hexagonal template which gave rise to a structure containing many regularly arranged needle-shaped crystallites. Based on the present observations, the mouse otolith is considered a multi-iso-oriented crystal.


Localization of a highly specific neuronal protein, serotonin binding protein, in thyroid parafollicular cells. A highly specific serotonin binding protein (SBP) has been found in serotonergic neurons in both brain and gut. This protein has an extremely high affinity for serotonin and may be a storage protein. Serotonin is found in many endocrine cells, including parafollicular cells of the sheep thyroid, as well as in neurons. SBP is also present in sheep thyroid. The present study was done to localize the protein in the gland. Thyroid glands were divided into five segments. Concentrations of serotonin and SBP, as well as parafollicular cell volume were measured in each. Serotonin was assayed by enzymatic conversion to melatonin using tritiated S-adenosylmethionine. SBP was assayed by molecular sieve chromatography on sephadex G-50. The relative volume of parafollicular cells was obtained by stereological analysis of electron micrographs. Experiments were also done to demonstrate these cells by histofluorescence and radioautography following incubation with tritiated 5-hydroxytryptophan. Good correlations were found between serotonin and SBP concentrations, and parafollicular cell volume. These peaked in the rostro-central portion of the gland and were minimal at the poles. We conclude that thyroid SBP is probably localized in parafollicular cells.


Short-term effects of androgen withdrawal on the structure of different epithelial cells in the rat epididymis. Rat spermatozoa are highly dependent on the milieu of the normal epididymis for their maturation and survival, and die within a few days after androgenic support of the epididymal epithelium is withdrawn. The immediate changes in the ultrastructural organization of the epithelial cells of the rat epididymis, 2, 4, 6 and 14 days following castration have been monitored by morphometric analysis of localized regions of the caput and cauda epididymidis. While castration results in greater endocytosis by principal cells (Moore and Bedford, '79), many of their early structural changes following androgen withdrawal (disappearance of vesicles from the cell apex, reduction in rough endoplasmic reticulum, a drop in the volume of the Golgi cisternae and increase in lysosome content) seem indicative of inhibition of a secretory function. By contrast with the regressive response of the principal cell, the ultrastructure of clear cells in the cauda and of apical cells in the caput region appeared unchanged up to 14 days after castration. The implications of this evidence for specialized functions, and the suggestion of a differential androgen dependence among major cell types of the epididymal epithelium, are discussed briefly.


The differential absorptive activity of epithelial cells of the rat epididymus before and after castration. Horseradish peroxidase introduced into the lumen of the rat epididymis was taken up by the columnar cells of the epithelium by five minutes and more so after longer periods. The apical cells and particularly the clear cells in the caput and cauda epididymis, respectively, showed significantly greater endocytotic activity than the principal cell in both locations. Within 14 days after castration, however, such differences in absorptive activity among the various cell types were essentially obscured because of increased endocytosis by the androgen-deficient principal cells. The results are discussed briefly in terms of the function of different epithelial cell types and secretory/absorptive activity in the epididymis.


Renal regeneration following d-serine induced acute tubular necrosis. Regeneration of the ray kidney was observed for six days after inducing acute tubular necrosis of the proximal pars recta with d-serine (80 mg/100 g body weight. Regenerating cells appear by two days post-treatment, and re-epithelialization of the nephron is completed within six days, with the most mature cells approaching normal morphology. Regeneration originates from viable cells adjacent to the necrotic zone which divide and follow a template provided by the intact basement membrane. Transient, cytoplasmic regenerative activity among developing tubular cells is characterized by the presence of large, irregularly shaped nuclei, prominent nucleoli, abundant ribosomes and lysosomes, and abnormal mitochondrial configurations. Microfilaments appear to be involved in the formation of apical microvilli and the basal labyrinth of plasmalemmal convolutions. These data suggest that d-serine induced acute tubular necrosis of the proximal pars recta may be followed by rapid, patterned regeneration along an intact basement membrane, and that microfilaments are involved in differentiation of cellular morphology.


Calcium transport and the secretory ameloblast. The distribution of calcium in the enamel organ of the rat incisor was investigated using potassium pyroantimonate for ultrastructural localization of calcium. Substantial amounts of precipitate occurred in the intercellular compartment of the enamel organ and modest deposits were observed in specific organelles of the secretory ameloblast. Mitochondria, nuclei granular endoplasmic reticulum, Golgi vesicles and secretory granules consistently contained small deposits of pyroantimonate. Complexing of calcium by the pyroantimonate was confirmed by EGTA decalcification and scanning electron microscope energy dispersive X-ray analysis. The observed distribution is discussed in light of potential for an intercellular pathway of calcium transport as well as controlled movement of the ion along the synthetic and secretory route followed by organic components of enamel.


Scanning electron microscopy of developing photoreceptors in the chick retina. Photoreceptor morphogenesis in the sensory retina of chicks of 2 to 20 days incubation age was studied by scanning electron microscopy (SEM) and correlative transmission electron microscopy (TEM). At 9.5 days spherical inner segments extend into the subretinal space (optic ventricle). They are randomly arranged with chiefly smooth surfaces and contain centrioles, polyribosomes and microtubules. Microvilli project primarily from Müller cells. By the twelfth day immature ellipsoid and myoid regions have formed. Microvilli are abundant on the lateral surfaces of inner segments and extend over the entire spherical surface by the fifteenth day. Occasional cilia with surrounding depressions at their bases were also observed. Inner segments are more symmetrically arranged due to close proximity of photoreceptor cells. Inner segments elongate during the sixteenth day; many display a transitional ovoid form. Microvilli become less numerous but some persist as calycal processes. By the eighteenth day, conical shaped outer segments appear. Thereafter, all photoreceptor cells are comparable to those in the mature retina. Abundant microvilli on the external surface of the sensory retina suggest a supportive role in supplying adequate nutrition to the sensory retina during morphogenesis. The establishment and continual development of the ellipsoid and myoid appear to be primarily responsible for the elongation of photoreceptor cells.


The guidance of optic axons in the developing and adult mouse retina. Previous studies in chick embryos (Goldberg, '77) indicated that unidirectional guidance of retinal axons toward the optic nerve is restricted to the vitread portion of the ganglion cell fiber layer (GCFL) of the retina; random fiber growth was noted after deflection of the optic axons sclerad to the GCFL. The present study on mice confirms these observations. Silver-stained flat mounts of retinal colobomas were examined. Many optic axons in colobomas do not exit normally from the eye, but travel randomly when deflected sclerad to the GCFL. Newborn mouse axons grew around retinal lesions in a highly directed manner. Such axons were always situated in the vitread portion of the GCFL. The unidirectional guidance found in newborn mice was absent in adults. Deflected adult axons traveled randomly regardless of their level within the GCFL. We propose that defective guidance largely accounts for failure of axonal regeneration in the adult mouse retina. The inability of the adult axons to fasciculate (adhere to one another and form fiber bundles) suggests that impaired cellular adhesivity may be part of the mechanism of regenerative failure.


Cell death during detachment of the lens rudiment from ectoderm in the chick embryo. The distribution and cytological characters of physiological cell death associated with formation of the lens vesicle in the chick embryo was studied by means of vital staining, light and electron microscopy. We have established a constant pattern of cell death which differs in some aspects from that reported for mammals and amphibians. The necrotic process is observed initially in the dorsal part of the lens cup (stage 15). The necrotic area progressively surrounds the lens pore as invagination proceeds (stage 16) and at stage 17 is located in the zone of fusion of the invaginated lens. After detachment of the lens (stages 18, 19 and 20) dead cells appear in the ectoderm, in the superficial epithelium of the lens vesicle and in the space between both structures. Ultrastructurally we observe isolated dead cells in different stages of degeneration and in phagocytosed cells. Phagocytosis is carried out by the neighboring healthy epithelial cells. Phagocytic activity was detected concomitant with the beginning of the necrotic process. Cell fragments were occasionally detected within the lens cavity.


Fine structure of the oxynticopeptic cell in the gastric glands of an elasmobranch species (Halaelurus chilensis). Gastric mucosa of an elasmobranch species was examined by electron microscope. The gastric glands contain one form of cell whose fine structure is similar to the cell that secretes both hydrochloric acid and pepsinogen of the amphibian gastric glands proper. The oxynticopeptic cells are characterized by: (a) a luminal surface with long projections of cytoplasm having dilatations in their thickness; (b) a tubulo-vesicular system in the apical cytoplasm; (c) a great number of mitochondria, some of which are of great length; (d) a well developed granular endoplasmic reticulum and a conspicuous Golgi apparatus; and (e) a large nucleus with a conspicuous nucleolus. A fourth part of the cells are binucleated. Physiological implications of some of these ultrastructural features are discussed.


Distribution of glycogen in prefusion human palatal epithelium. Various stages of embryonic human secondary palatal development were examined for the presence of epithelial glycogen. Utilizing periodic acid-Schiff's reagent staining of thick plastic sections and osmium ferrocyanide enhancement of thin sections, dramatic changes in epithelial glycogen distribution were noted during palatogenesis. Prior to fusion, the epithelium destined to adhere in the midline exhibited a marked diminution of glycogen in the superficial cell layer. This cell layer was composed of slender dense cells and cuboidal cells undergoing lysis. Adjacent nonfusing epithelium was markedly different and contained large glycogen reserves in its superficial cell layer. Glycogen may play a role either as precursor for specific adhesive macromolecules or as a physical agent capable under the influence of appropriate enzymes of causing cell lysis.


Scanning electron microscopy of frozen sections: a method for studying selected planes in small specimens. A procedure for studying small biological specimens with the SEM, using frozen sections of fixed material is described. Controlled fixation schedules and convenient handling of sections insure optimal preservation of cell shape and size. The greatest advantage of the method presented is to allow scanning through any desired plane of the specimen, even in those planes parallel to an epithelial face. SEM of frozen sections is thus helpful for the study of cell distribution and organization within a tissue.


Degeneration of mouse oocytes in response to polycyclic aromatic hydrocarbons. Destruction of mouse oocytes in primordial and small primary follicles in response to treatment with 3-methylcholanthrene (MC) was studied at the ultrastructural level. Four-week old C57Bl/6N (B6) strain mice received a single injection of 80 mg/Kg MC in corn oil intraperitoneally. Controls received only corn oil. Ovaries from animals were prepared for light and electron microscopic examination at specified intervals after treatment. The number of primordial follicles remained constant in control animals. In contrast, their number decreased significantly (P less than 0.01) by three days, and they were depleted by seven days after MC treatment. Subtle degenerative modifications were noted in the ooplasm of primordial follicles two days after treatment. These changes consisted of vesiculation of mitochondrial cristae, increased electron density of the mitochondrial matrix, myelin structures in lipid droplets and in mitochondria. More advanced stages of degeneration of primordial follicles were characterized by further vesiculation or disappearance of mitochondrial cristae, chromatin clumping, and increased density of the ooplasm. Small primary follicles had undergone similar initial degeneration as primordial follicles. In more advanced stages of degeneration nuclear and cytoplasmic contents condensed, endoplasmic reticulum, Golgi complex and mitochondria swelled, small vesicles and multivesicular bodies appeared. In the most advanced stages of degeneration of small primary follicles it appeared that small portions of the oocyte were engulfed by the surrounding follicular cells. It is concluded that exposure of B6 mice to a single dose of MC results in atresia of oocytes in primordial and small primary follicles. Ultrastructurally, these degenerating oocytes of treated mice looked much like the spontaneously atretic oocytes in untreated animals.


Morphologic variations and aging in the atrioventricular conduction system of large breed dogs. The microscopic anatomy of the atrioventricular node, bundle of His, both bundle branches and surrounding fibrous cardiac skeleton was studied in 40 large breed dogs of various ages. In the AV conduction system of all dogs over five years of age there was an increase of fibrous connective tissue, an infiltration of adipose tissue, loss of conduction fibers and focal fibrosis extending from the central fibrous body. Fibrosis was seen in the summit of the interventricular septum posterior to the AV node in dogs of all ages. Chondroid metaplasia was consistently observed in the central fibrous body and the root of the aorta in large breed dogs, including ten Doberman Pinschers of all ages. This metaplasia varied from a few chondroblasts and chondrocytes to mature chondrocytes with mineralization. Bone formation was seen in eight dogs. These changes appeared in close approximation to the cardiac conduction system above the bundle of His. No degenerative changes were seen in the AV bundle. Approximately one-half of the large breed dogs five years of age and older had thickened medial and intima proliferation in the small coronary arterioles supplying the AV node. The results of this study suggest that the presence of cartilage and bone in the central fibrous body is a normal occurrence in large breed dogs at all ages.


Scanning electron microscopy of bronchiolar neuroepithelial bodies in neonatal mouse lungs. Scanning electron microscopy of the bronchiolar neuroepithelial bodies (NEB's) in the neonatal mouse lungs was undertaken and correlated with the accompanying transmission electron microscopy. The NEB's appeared as isolated organoids along the entire length of the bronchioles, and often were located at the branching points. The boundary of the NEB's was outlined by the ciliated and Clara cells. Both granulated cells and modified Clara cells participated in the formation of the NEB. The modified Clara cells covered most of the surface of the NEB leaving only small oval areas for the exposed surfaces of the specialized cells which contained numerous cytoplasmic granules. Short and regular microvilli projected from the exposed surfaces of the granulated cells, while only sparse microvilli of irregular length were seen on the surfaces of the modified Clara cells. This scanning electron microscopy of the NEB's further established these organoids as separate morphological entities. In addition, the findings that the NEB's could be easily identified with the scanning electron microscope and subsequently dissected out for further studies would help future investigations of their functions which are not clearly known.


Intraepidermal cell surface fine structure: preservation and examination at high resolution. Morphological and functional studies on cell surfaces have been limited largely to cultured cells because of injury wrought to cells of solid tissues by commonly employed mechanical, enzymatic, or chelator dispersal methods. By using the staphylococcal epidermolytic toxin we avoided this problem; the toxin cleaves the intercellular spaces of human and mouse squamous epithelia without ultrastructural evidence of cytotoxicity. We studied the cell surface topography of neonatal mouse epidermis obtained two hours after injection of highly purified epidermolytic toxin. Immediately after sacrifice intraepithelial surfaces were exposed while the animals were immersed in fixative. Specimens were either freeze-fractured or embedded for transmission electron microscopy, or were critical-point-dried prior to platinum/carbon replication for transmission and scanning electron microscopy. Replicas could be prepared for transmission electron microscopy only if they were first stabilized with parloidion and then cleaned with both bleach and 40% chromate. By using these four complementary morphological methods (freeze-fracture, scanning electron microscopy, transmission electron microscopy of surface replicas, and standard thin sections), we could positively identify external membrane structures. The convoluted surface was studded by tenuous microvilli, scattered 15-20 nm particles, and hemispherical desmosomal mounds. Desmosomal plaques displayed randomly arrayed 15-20 nm globular particles comparable in distribution and density to particles observed in freeze-fractured desmosomes, and suggesting that desmosomal integral membrane particles span the external leaflet of the plasma membrane.


Action of cinnarizine on the hyperviscosity of blood in patients with peripheral obliterative arterial disease. Cinnarizine, a drug capable of improving blood flow, was studied for its action on blood viscosity and its main components in patients affected by peripheral obliterative arterial diseases (POAD). Both acute and chronic administration of the drug diminished the increased whole-blood viscosity in patients, without affecting plasma and serum viscosity, hematocrit, plasma fibrinogen concentration, and plasma osmolality. Since cinnarizine also led to a significant increase of peripheral muscular blood flow, it was hypothesized that this action may be due to an increased deformability of the red cells, and may play a considerable role in the therapeutic approach to POAD.


Influence of raised venous pressure on the flow properties of blood. This study posed the question of whether the blood flow properties from the anticubital and ankle vein of healthy subjects varied under different hydrostatic conditions. The blood flow properties from the vena cubitalis and the ankle vein do not vary to any greater degree during lying, whereas during standing the blood viscosity, plasma viscosity, hematocrit, and plasma protein concentration increase significantly. Furthermore, they are significantly higher than in venous blood taken from the arm at the same time. The oxygen partial pressure in venous blood from the arm is significantly higher than in the ankle venous blood after 5 minutes of standing. These results show, among other things, that under the various hydrostatic conditions present in different body regions, the blood flow properties differ considerably. From the pathophysiologic point of view, it is important that during standing the return of blood is made even more difficult because of the increased blood viscosity resulting from fluid loss from the intravascular space to the interstitium.


Comparison between reactive and exercise hyperemia in normal subjects and patients with peripheral arterial disease. Reactive and exercise hyperemia were compared in healthy men and in patients with PAD. In both patients and normals the calf blood flow of reactive hyperemia was recorded after a 5-minute ischemia. Exercise hyperemia was measured in normals after variable work loads (30 and 50 kg) and immediately after the occurrence of pain in patients with PAD. In healthy limbs the first and peak flows of exercise and reactive hyperemia are similar. The recovery time for basal flow is prolonged after exercise. However, reactive and exercise hyperemia differ significantly when arterial obstruction due to arteriosclerosis obliterans is present. First flow and peak flow are higher and recovery time more prolonged after exercise. It is also likely that the control mechanisms of the two hyperemic reactions are different. Muscular exercise, when protracted until pain occurs, can produce a metabolic and circulatory adjustment other than that of ischemia. There is experimental evidence to support this hypothesis.


Changing diastolic closure rates (E to F slopes) in a patient with mitral stenosis: a case report. A patient with mitral stenosis and atrial flutter was found to have a normal diastolic closure rate (E to F slope). Following cardioversion, the typical echocardiographic features of mitral stenosis were found. After various interventions that increased heart rate, however, the diastolic closure rate increased. This report demonstrates, therefore, that the E to F slope is not always a fixed value in mitral stenosis and that under certain conditions it may even appear to be normal.


Oral challenges in inhalant antigens in asthmatics. Nine asthmatic children were sensitive to a variety of antigens by skin testing and bronchial inhalation challenges. On two separate occasions they received the antigens sublingually at 2.5 to 50 times the dose received by bronchial challenge. There were no subjective symptoms or objective changes in pulmonary function measurements following the oral challenges.


Skin response to histamine in systemic lupus erythematosus. A comparative study of skin responses to histamine in systemic lupus erythematosus (SLE) patients and in a control group suggests that although there are individual differences in response, the SLE patients responded sooner to 1:100 dilution. Since the test did not result in any ill effect it is concluded that existing clinical methods of testing and treatment of SLE patients having allergies are safe from the viewpoint of the histamine effect.


House dust, mite (D. farinae) and cockroach allergy in a midwestern population. By using three different skin testing techniques and RAST, this study explores the relationship among house dust, mite (Dermatophagoides farinae) and cockroach allergy in atopic patients in the Kansas City area. Results suggest that the cockroach antigen may be as important as the mite in the etiology of house dust allergy in this population.


Air pollution analysis used in operating an environmental control unit. A simple, fast and reliable method was developed to measure the origin and daily and seasonal variations of selected air pollutants in the Brookhaven Environmental Unit. None of the pollutants that were measured surpassed its threshold limit value. The average concentrations of the pollutants that were measured could be considered as preliminary standard for environmental units in hospitals as long as material analysis for outgassing is used simultaneously.


Atopic skin test re-evaluated. V. The wheal-flare ratio of skin reactions to extracts of grass pollen, Dermatophagoides pteronyssinus and to histamine and compound 48/80. Some formulas are given for the relationship between the sizes of wheals and flares of skin reactions to three allergen extracts and to histamine and compound 48/80. Only compound 48/80 shows a somewhat different wheal/flare relationship.


Atopic skin test re-evaluated. VI. Skin reactions to compound 48/80 and histamine in patients with atopic and non-atopic chronic respiratory complains and in normal volunteers. Using a perfected technique for skin testing, no difference was found between skin reactions to either histamine or compound 48/80 in atopic and non-atopic patients or in healthy volunteers. The correlation of the size of the skin reactions to both compounds was only slightly lower than the correlation of the duplicates, which indicates that compound 48/80 can be used as a control extract in skin testing. The skin reactions to this compound are read after 15 minutes, just as those to inhalant allergens.


Unsuitability of bakery work for a person with atopy: a study of 234 bakery workers. A disease of the atopic group was established in 25% of bakery employees investigated: 9% had asthma, 25% allergic rhinitis and 5% atopic eczema. The definite role of flour dust as an allergen maintaining asthma was established in 14 of 21 bakery employees with asthma. The onset of asthma in bakery work occurred after an average of 4.2 years of exposure to flour dust. The study revealed that 71% of the bakers suffering from an atopic disease had close relations with a history of atopic disease, whereas the corresponding percentage for the healthy group was 17. The results indicated that no person with current atopic disease or earlier signs of one should be given employment in the bakery branch. A relative bar to employment appears to be also the occurrence of these forms of diseases in the applicant's close relations.


Discriminate diagnostic peritoneal lavage in blunt abdominal injuries: accuracy and hazards. The diagnostic peritoneal lavage for hemoperitoneum in blunt abdominal injuries is a safe test, and its high accuracy reported in unselected consecutive cases, is maintained equally in the clinically equivocal patients, the very group where one is expected to relay more decisively on the results of the D.P.L.


An analysis of cerebral bood flow systemic base deficit accumulation and mean arterial pressure as a function of internal cardiac massage rates. The effect of varying rate of internal cardiac massage on the cerebral blood flow equivalent (CBF/CMRO2 = (Formula: see text), where CBF = cerebral arteriovenous oxygen difference, CMRO2 = Cerebral metabolic oxygen consumption, and (Formula: see text), = cerebral; arteriovenous oxygen content difference) was investigated in the dog. Also, systemic base balance and mean arterial pressure were analyzed as functions of rate. Nine dogs 14-27 kg in weight were subjected to rates of 14-200 compressions per minute. For rates between 14 and 200 per minute, there was no significant rate-related effect on the parameters monitored.


Malignant schwannoma: report of a case mimicking lumbar disk disease. Primary neurogenic retroperitoneal tumors in the adult are rare. This case presentation reviews an unusual history of a patient who presented with pain and neurologic deficits suggesting lumbar disk disease but who was unrelieved by laminectomy and disk removal. Later he was found to have a malignant schwannoma arising from the right L nerve root. Experience such as this reminds physicians that when the result of treatment is not as expected the original diagnosis must be questioned.


Shotgun wounds of the abodomen: revisited. A review of one hundred and sixty-seven patients with penetrating abdominal injuries caused by firearms showed that 17 patients (11%) had shotgun wounds. Nine patients were treated nonoperatively, whereas eight patients had immediate exploratory laporotomy. An analysis of shotgun wounds of the abdomen is presented to outline the principles in management. Factors influencing conservative versus operative treatment are discussed. Magnitude of the clinical problems have been illustrated by means of 4 cases.


Solitary rectal ulcer progressing to pseudo-cloaca: a case report. A 57 year old diabetic patient is reported with the progression of a solitary ulcer of the anterior rectal wall which resulted in destruction of the posterior bladder wall, and subsequent pseudocloaca. The patient was successfully treated by colonic and urinary diversion. The etiology of this condition remains obscure. A review of the literature on this uncommon lesion is discussed.