The treatment of benign thyroid disease. The treatment of benign forms of thyroid disease is reviewed. Endemic goiter is a public health problem preventable by the addition of iodine to the food or water supply. Endemic and familial goiters are treated with replacement doses of I-thyroxine, as are sporadic colloid goiters and goiters resulting from chronic thyroiditis. Hyperfunctioning autionomous nodules without thyrotoxicosis and cystic nodules require no specific therapy. Prophylaxis against diffuse or nodular goiter after radiation to the head or neck for therapeutic purposes with thyroxine replacement therapy is debatable. All forms of hypothyroidism, including incipient types, require replacement thyroxine therapy, but this should be undertaken cautiously in older patients and in those with evidence of ischemic myocardial disease. Myxedema coma requires vigorous treatment and detailed supervision because of dismal mortality rates. Iodine 131 is the treatment of choice in diffuse toxic goiter, but alternative forms.


Treatment of malignant thyroid disease.

Treatment of malignant thyroid disease. Surgery is the primary form of therapy in the management of malignant thyroid disease. A near-total thyroidectomy is the preferred approach. Radioactive iodine is used for supplementary ablation therapy and for definitive therapy in differentiated tumors of papillary or follicular cell type. Thyroid-stimulating hormone (TSH) is administered in conjunction with radioactive iodine therapy, since tumor uptake appears to be directly related to endogenous TSH levels. Therapeutic doses of radioactive iodine range from 100 to 200 mCi of 131 I depending on tumor distribution. Adequate thyroid hormone replacement therapy resulting in the suppression of TSH is of considerable value in the prevention of tumor recurrence. Due to the possibility of late recurrence, patients should be followed for indefinite periods by means of diagnostic imaging studies at 1-2 yr intervals. Despite 30 yr of experience, the therapeutic efficacy of radioactive iodine remains controversial. However, in recent years, there has been mounting evidence indicating increased survival and decreased tumor recurrence in radioactive iodine-treated patients. External radiation therapy is reserved for anaplastic carcinoma and lymphoma, and adenocarcinomas that are refractory to radioactive iodine. Chemotherapy experience is limited; however, some reduction in the size of metastatic lesions has been observed after the administration of adriamycin.


Comparison of media for dissemination of information about cancer in rural communities. A study was done in Orangeburg County, South Carolina, to compare the effectiveness of the various mass media--television, radio, and newspaper--for the dissemination of educational material about cancer. Effectiveness of these media in reaching certain subpopulations defined by race, sex, income, and population density was also examined. The newspaper was found to be generally more effective than other media. This superiority held for almost all subpopulations. Furthermore, it was found that certain subpopulations differed from others in the extent to which they were reached by a particular medium.


Caustic burns of the esophagus: ten-year results of aggressive care. In 1967, care of esophageal burns from caustic substances was altered to include immediate esophagoscopy, high doses of steroid, and follow-up dilatations plus cine-esophagograms as needed. Previously, this area averaged six repairs of esophageal stricutre each year. Since 1967, there have been no esophageal strictures in 100 patients.


Traumatic rupture of the thoracic aorta. Aortic transection secondary to blunt trauma is not an uncommon injury. Prompt recognition and treatment of the injury is required to salvage patients with this type of injury. Ten patients with transection of the thoracic aorta at the isthmus have been treated in the past two years at our institution. There have been two operative deaths, one delayed hospital death, and seven survivors. We believe the use of a temporary shunt of heparin-bonded polyvinylchloride during the repair of the aorta offers significant advantages over other methods which have been described.


Treatment of metabolic alkalosis with intravenous hydrochloric acid. Severe alkalosis requires aggressive treatment. Twenty patients at the Talmadge Memorial Hospital have been treated for metabolic alkalosis by infusion of dilute hydrochloric acid through a central venous line. The treatment was effective and there were no major complications. Intravenous hydrochloric acid is preferred to other modes of therapy for refractory alkalosis, especially in the presence of hepatic or renal failure.


Effect of lidocaine anesthesia on pattern of ventilation and pulmonary function tests. The pattern of ventilation (consisting of tidal volume, frequency of breathing, minute ventilation, peak inspiratory flow rate, inspiratory time, mean inspiratory flow rate, and inspiatory time ratio) and pulmonary function tests (consisting of spirometry, lung volumes, and airway resistance) were measured in ten conscious, healthy subjects before and after anesthesia of the airways achieved by inhalation of lidocaine, to determine the role of the vagus nerves in the control of eupneic breathing. No significant change was found in the pattern of ventilation or in pulmonary function tests after airway anesthesia. These results are consistent with the observation that the vagus nerves do not play an important role in the control of eupneic breathing in humans.


Safety and efficacy of micronized estradiol vaginal cream. Fifty-four postmenopausal patients with atrophic vaginitis satisfactorily completed one to two months' therapy with daily intravaginal application of 0.2 mg of 17 beta-estradiol in a cream base. No significant alterations were noted in the hematologic biochemical, and urine analyses. A number of response criteria showed significant improvement (P less than .01), including the severity rating for atrophic vaginitis, the maturation index of vaginal cells, the frequency and severity of hot flashes, the presence of vaginal dryness and itching, dyspareunia, skin flushing, and the severity of sweating episodes. The incidence of side effects was low and included breast tenderness and abdominal cramping.


Major venous anomalies complicating retroperitoneal surgery. Transposition of the inferior vena cava, duplication of the inferior vena cava, circumaortic renal collar, and retroaortic renal vein constitute the four most common major venous anomalies occurring in the retroperitoneum. Recent clinical cases are presented to review the embryogenesis, incidence, and clinical importance of these anomalies and to alert the unfamiliar surgeon to their possible existence. A high index of suspicion on the part of the surgeon is required to prevent inadvertent injury to these anomalous veins and to avoid significant hemorrhage during retroperitoneal surgery.


Amenorrhea secondary to voluntary weight loss. Obese patients who voluntarily reduce to a normal weight may develop secondary amenorrhea. Six young women who dieted to lose from 13 to 50 pounds, including four from an obese weight, were evaluated because of absent cervical mucus ferning, hypoestrogenic vaginal smears, and failure to have withdrawal menses from a progestogen. Serum FSH values were normal in all, while four had normal serum LH and two had low serum LH levels. T4 and/or T3 uptake was normal in all. The pituitary-adrenal axis was apparently intact since baseline urinary steroids were normal as was the response to both ACTH and metyrapone. Fasting serum growth hormone was markedly elevated in two and slightly elevated in three, with the other patinet demonstrating an unusually high response to glucagon/propranolol in the 30 minute specimen. These endocrine findings are similar to those observed in patients with anorexia nervosa, but the weight loss is entirely voluntary and there was no associated psychiatric abnormality.


Incidence of sepsis in neonates with clinical respiratory distress. Respiratory distress is the most frequent symptom initiating referral to neonatal intensive care centers. Previous reports have indicated that 40% of infants with sepsis proved by blood culture had respiratory symptoms as their clinical presentation. In this prospective study there were 145 consecutive infants referred because of respiratory distress. Two-site blood cultures were collated with all other clinical and laboratory data to confirm a diagnosis of septicemia. There was a 4.8% incidence of bacteremia, and clinical and laboratory parameters confirmed septicemia in 3.5% of infants studied. Sixty percent of these infants had group B streptococcal sepsis, and 80% had leukopenia. The low incidence of confirmed septicemia in infants referred because of respiratory distress suggests that antibiotic therapy should not be routine.


Use of transverse Kirschner wires in comminuted facial fractures. Although most facial fractures can be well managed with open reduction and direct wiring of the fracture sites, this treatment is inadequate for some comminuted fractures and further fixation is required. At Charity Hospital in New Orleans transverse Kirschner wires have been routinely used to stabilize the zygoma in these cases. Although this technic has been described previously, its indications, advantages, and limitations are not widely appreciated. Eight recent cases are presented to demonstrate the technic, and alternative methods of treatment are discussed.


Fungus balls of the urinary tract.

Fungus balls of the urinary tract. Fungus balls of the urinary tract are rare and usually associated with infection by Candid albicans. Since 1968 five patients seen at the Medical College of Virginia Hospitals presented with this peculiar manifestation of candidiasis. Summaries of their epidemiologic clinical, pathologic, and mycologic data are presented. All Candida fungus balls involved the upper collecting system and were detected by radiography and confirmed by culture and/or pathologic section. Two of the five patients completely recovered. Three patients were treated with flucytosine and/or local irrigation with a polyene antifungal agent. Two recovered and the third died of probable bacterial sepsis. One patient was treated successfully with surgical removal of the fungus ball and a brief period of local irrigation with amphotericin B (AMB). The fifth patient recovered after 28 days of parenteral AMB. Predisposing factors and pathogenetic mechanisms are discussed, and a rational approach to therapy is outlined.


Evaluation of the gallbladder by gray scale ultrasonography. A review of the results of the evaluation of the gallbladder by gray scale ultrasonography in 52 patients is presented. When the gallbladder was successfully identified by ultrasound (46 patients) the detection of stones was 98% accurate. When the gallbladder was not identified (four patients), a contracted gallbladder containing numerous stones was found at operation. The left lateral decubitus position proved very helpful in displaying the gallbladder when it could not be identified in the standard supine position. Ultrasonic evaluation of the gallbladder is of most value in the patients who have had unsuccessful radiographic studies.


Treatment of Goodpasture's syndrome with immunosuppression and plasmapheresis. A 14-year-old boy with Goodpasture's syndrome induced by anti-glomerular-basement-membrane (gmb) antibody exhibited declining renal function, in association with a progressive increase in the level of serum anti-GBM antibody. Treatment with prednisone, cyclophosphamide, and plasmapheresis was associated with rapid disappearance of the serum anti-GMB antibody and temporary stabilization of renal function.


Simultaneous open prostatectomy and inguinal herniorrhaphy. We report our results in 18 patients who had simultaneous open prostatectomy and inguinal herniorrhaphy between 1969 and 1976, and present our criteria for patient selection, operative technic, and postoperative results. The incidence of postoperative wound infection and recurrent hernia was 5.6% and 0 respectively, which compares favorably to results of herniorrhaphy and prostatectomy performed separately. The historic development of this procedure and the results of previously reported series are reviewed.


Chronic recurrent angina.

Chronic recurrent angina. The natural history of variant angina is described in a patient with multiple exacerbations and remissions over a period of several years. Constant in-hospital electrocardiographic monitoring for 26 days documented 569 episodes of ST elevation, 89% of which were asymptomatic. Episodes ranged in duration from 15 seconds to 11 1/2 minutes, with 4% of episodes associated with premature ventricular contractions. Over the course of hospitalization, the episodes of ST elevation decreased in frequency and length, as did episodes of pain. During this period, a number of therapeutic agents, including propranolol, indomethacin, and chlorpheniramine were evaluated using double-blind crossover trials. No agent had a significant beneficial effect on the course of the disease, and there was an increase in the length of episodes with high doses of propranolol. Because of the great variability in the course of this disease, only double-blind crossover trials should be allowed to dictate the efficacy of therapeutic agents.


Health and nutritional status of Vietnamese refugees. There are presently more than 7,000 Vietnamese refugees living in the greater New Orleans area. This paper summarizes the health and information on nutrition now available regarding Vietnamese refugees living in the United States. It is hoped that this effort will add to the documentation of the health changes occurring in migrant populations, and also stimulate the development of programs which will improve the health of the Vietnamese refugees in the United States. Although information on both the national and local level is limited, the following problems are found frequently in the Vietnamese refugee population in this country: dental caries, skin infestations, lack of adequate immunizations, and tuberculosis. Very little information is available concerning dietary habits and their relation to growth and development. There is some evidence that American nutritional patterns are being superimposed on traditional Vietnamese patterns. Target areas for further research are suggested.


The importance of the doctor to the dying patient. The physician plays a central role in the emotional as well as the physical care of the dying patient. The concerns of the terminally ill cancer patient include (1) emotional response to the physical limitations of illness, (2) communication with significant others, (3) self-concept, and (4) resolution regarding impending death. Although a busy physician would not be able to spend much time talking with the patient about these concerns, the physician could communicate to the patient in just a few minutes an empathic understanding of the emotional crises the patient faces. Sometimes only a word or touch of the hand can covey the physician's support and understanding which are so meaningful for a terminally ill patient.


Idiopathic arterial calcification of infancy. Idiopathic arterial calcification of infancy is an uncommon disease of unknown etiology, characterized by calcification along the internal elastic membrane and intimal proliferation of almost all the arteries of the body. When the diagnosis is made premortem, it is usually done by radiographic demonstration of arterial calcification. Because of its edge enhancement effect, xeroradiography should be useful in detecting the soft tissue calcifications of this disease.


Familial gynecomastia without hypogonadism. A family, six members of which had gynecomastia without hypogonadism, is presented. Endocrine studies failed to show the specific nature of breast enlargement in the patients. Chromosomal studies using peripheral leukocytes resulted in normal findings. In one of the patients, chromosomal studies were done using breast tissue and fascia, and again no abnormalities could be detected. The mode of inheritance may be autosoma dominant with sex limitations; however, X-linked inheritance cannot be ruled out.


Noncirrhotic portal hypertension after arsenic ingestion. Five years after arsenic therapy, the patient described had noncirrhotic portal hypertension, for which he had splenectomy and anastomosis of the splenic vein to the left renal vein. During the 12-year postoperative period he had Bowen's disease (skin carcinoma), but has had normal liver function and no further gastrointestinal bleeding. Arsenic exposure in humans is common throughout the world and may lead to late complications such as noncirrhotic portal hypertension and skin carcinoma, as well as malignancies of the lungs, liver, and lymphatic systems. It may also lead to severe arteriosclerosis with involvement of the heart and extremities.


Urticaria subsequent to administration of influenza vaccine. Described is an 11-year-old girl who had a reaction including urticaria and asthma to influenza immunization. The urticaria lasted for nine days. This patient had no clinical sensitivity to egg and no skin test reactivity to egg, but she did show positive skin test reactions to influenza B and bivalent flu vaccine. Since passive transfer did not produce positive skin tests, it would appear that the reactions were not IgE-mediated. The patient has not had subsequent urticaria. The possibility exists of reactions to influenza virus antigens or bacterial or other contaminants of the vaccine. More complete and detailed information about "contaminants" in influenza (and other egg embryo) vaccines should be made available so that these factors can be taken into consideration in seeking the cause of reactions to these vaccines and in possibly preventing reactions.


Extravasation of contrast medium from traumatic laceration of the intracerebral internal carotid artery. A single case of traumatic laceration of the intracerebral internal carotid artery diagnosed by extravasation of contrast medium is presented. The patient had associated cerebral circulatory arrest caused by increased intracranial pressure. A similar documentation has been made in only three previous cases.


Isolated bronchial capillary hemangioma: a rare benign cause of hemoptysis. A 74-year-old male cigarette smoker presented with hemoptysis and a right upper lobe infiltrate. Fiberoptic bronchoscopy revealed a small (1 x 2 mm) benign-appearing lesion in the right upper lobe bronchus which, on biopsy, was a submucosal capillary hemangioma. This is an exceedingly rare tumor and, to our knowledge, hemoptysis from these lesions in the proximal bronchi has not been previously reported.


Stercoraceous perforation of the colon.

Stercoraceous perforation of the colon. Stercoraceous perforation of the colon is most often unsuspected and is usually diagnosed at operation or autopsy. Abdominal radiographs show large fecal masses in the rectum and sigmoid colon, and occasionally lying free in the peritoneal cavity. Free intraperitoneal air is present. We have reported a single case, with a discussion of the pathophysiology.


Alcohol-induced Cushingoid syndrome.

Alcohol-induced Cushingoid syndrome. A 35-year-old woman with alcoholic liver disease presented with physical stigmas and laboratory confirmation of Cushing's syndrome. With discontinuance of alcohol, her signs of Cushing's syndrome resolved and the urinary free cortisol and the urinary 17-hydroxycorticosteroid response to dexamethasone returned to normal. These findings broaden the spectrum of deranged glucocorticoid chemistry that can occur in alcohol-induced cushingoid syndrome.


Hernia of Morgagni's foramen presenting as asymptomatic pleural mass. An asymptomatic 64-year-old black man presented with an enlarging left pleural mass. Preoperative evaluation failed to reveal an etiology. At thoractomy omental fat was found along the diaphragm, extending to the left costophrenic angle, and protruding through a hernia of Morgagni's foramen. The omentum was replaced into the abdomen and the defect was repaired.


Prevalence of anti-HBc in Malaysian male blood donors and its correlation with DNA polymerase activity. A study of Kuala Lumpur blood donors for HBsAG, anti-HBc and DNA polymeraes showed that 5.5% in the sample population was positive for HBsAG, 50.1% for anti-HBc and 10.1% for DNA polymerase activity. There was no significant difference of the HBsAG among the Malay, Chinese and Indian groups. However, a significant difference was observed for the anti-HBc and DNA polymerase activity between the Indian and the Malay/Chinese groups. Both analysis were significantly lower in the Indians but there was no significant difference between the Chinese and the Malays.


Endemicity of cholera in Surabaya, Indonesia. As the seventh pandemic of cholera is caused by V. cholerae biotype El Tor, the former criteria for endemicity of cholera need to be reconsidered as regards their applicability in areas that are infected with cholera. As the mortality rate of cholera nowadays can be reduced to a very low level due to modern methods of treatment, it is suggested that the infection rates of cholera should be taken into consideration as criteria of cholera endemicity, i.e. 1. Five years persistence of cholera cases in a given area. 2. Five percent infection rate among family contacts of cholera cases. 3. Minimum infection rate of 1% in a vicinity where cholera cases occur. It was also found that in such an endemic area it is very difficult to eliminate V. cholerae infection from a locality, even when all family contacts are treated with the full dose of tetracycline.


Life expectancy in an aboriginal Malaysian population. A life table for an aboriginal Malaysian population, the Semelai, living in West Malaysia, was constructed using censuses from 1965, 1969, and 1974; and interview data from 1974. The life expectancy at birth for this population, 54.0 years, was compared to that of other Malaysian populations and selected Asian populations. This comparison indicated that the Semelai were at a disadvantage compared to the Malaysian populations, but in a favorable position when compared with the other Asian populations.


Parasite fauna of the house rat Rattus rattus diardii in Kuala Lumpur and nearby villages. One hundred and fifty one house rats, Rattus rattus diardii from five different localities, Jinjang, Dato Keramat, Kuala Lumpur, Sungai Besi and Selayang Baru, were examined for parasites. Nineteen species of parasites were recovered. Hymenolepis diminuta and Nippostrongylus brasiliensis are the predominant species. The dominancy of the parasite species in the rats differed in each locality: Hymenolepis diminuta in Dato Keramat and Kuala Lumpur; Nippostrongylus brasiliensis in Sungai Besi; Gongylomena neoplasticum in Jinjang and Selayang Baru. The influences of human habitats on the parasite fauna of house rats are discussed.


Tachypleus lysate test for endotoxin in patients with Gram negative bacterial infections. Amoebocyte lysate from the horseshoe crabs (Tachypleus gigas) which abounds in the Gulf of Thailand was used to detect endotoxin in patients with Gram-negative bacteremia, in patients with Gram-positive bacterial infections as well as in the control. The Tachypleus lysate test (TLT) was positive in 94.4% of 36 patients with Gram-negative bacteremia before initiation of antibiotic therapy. Only 4% of 50 healthy individuals were positive and all 7 patients with Gram-positive bacterial infections were negative. The threshold sensitivity of TLT was 0.625 micrograms endotoxin per ml of the plasma. In comparison with the commercial Limulus lysate test (LLT), the TLT was slightly more sensitive in exhibiting higher grade of reaction, eventhough the threshold sensitivity was the same.


Microfilarial periodicity analysis of the survey data from six localities in Indonesia. The survey data of microfilarial periodicity of 2 species of filariae Brugia malayi at 4 localities, Mahang and Lampihong in South Kalimantan, Bengkulu in South Sumatra, Palolo in Central Sulwesi, and the species of Brugia timori at 2 localities, Flores and Alor Islands in Nusa Tenggara were analysed by using Aikat and Das's modified statistical method. Nine cases at Mahang and five cases at Lampihong were recognized as same group of non-periodic B. malayi and 1 case at Mahang was considered to be nocturnal subperiodic B. malayi by their parameters estimated by the wave equation, the amplitude (a), the peak hour of microfilaria density (k) the periodicity index (D) and the test of equality for comparison of two series of data. The data of 9 cases from Bengkulu and 11 cases from Palolo were similarly analysed and recognized as the nocturnal periodic type of B. malayi. The data of 5 cases from Flores Island and 5 cases from Alor Island were also recognized as the nocturanal periodic type of B. timori. Thus, in these observations the non periodic strain of Brugia malayi was detected in South Kalimantan. Further studies on the principal vectors and their bionomics should be carried out.


Field evaluation of dimethoate as a systemic for the control of chigger mites in the Pescadores Island of Taiwan. A 0.25% concentration of dimethoate applied as a surface coat on bait grain was evaluated in an open field trial in the Pescadores Islands of Taiwan for the systemic control of chigger mites. Unsatisfactory levels of control were observed on all 4 species of mammals studied. Chigger control with systemics does not appear practical at this time.


Serum vitamin B 12 and folic acid levels in patients with fasciolopsiasis. Serum vitamin B12, serum and red cell folate concentrations and vitamin B12 absorption were studied in 100 patients with fasciolopsiasis. A mean value of serum vitamin B12 level in the patient group was found to be significantly lower than that of normal subjects and 14% of these patients had serum vitamin B12 level less than 100 pg/ml. Serum UBBC and TBBC levels in the patients were significantly higher than those of the normal subjects. Serum TCI and TCIII increased significantly while TCII decreased. Vitamin B12 absorption was found to be impaired in 3 of 9 patients studied. There was no relationship seen between serum vitamin B12 level and vitamin B12 absorption. The mean values of serum folate and red cell folate levels in the patient group were significantly lower than those of normal subjects. Fifteen of 100 patients (15%) had serum folate level less than 3 ng/ml, while all of them had red cell folate higher than 100 ng/ml. Serum folic acid binding protein levels (FABP) in these patients, were not significantly different from those of normal subjects.


Diagnostic value of buffy coat preparation in dengue hemorrhagic fever. Examination of the buffy coat preparation is a simple, rapid diagnostic aid for the early diagnosis of dengue hemorrhagic fever (DHF). The presence of many transformed lymphocytes, usually 20-50 per cent during the first few days of fever is a unique finding especially during a secondary infection. Similar findings are absent during the early phase of illness in other viral infections. The buffy coat appearance in DHF is also clearly different from those in patients with bacterial infections, which show many polymorphonuclear leukocytes containing toxic granules and vacuoles. The early buffy coat diagnosis in 320 cases of DHF correlated well with the later serologic diagnosis. The buffy coat diagnosis of secondary DHF was correct in 94.2% of cases as early as the third day of fever. This technique has proven to be clinically useful for early screening test of secondary DHF in Southeast Asian countries. The observation of many transformed  lymphocytes in the peripheral blood of DHF patients also offer some insight into the pathogenesis of this condition.


The study of intestinal immunity against V. cholerae: purification of V. cholerae El Tor haemagglutinin and the protective role of its antibody in experimental cholera. V. cholerae El Tor Ogawa strain O17SR grown on trypticase soy agar were extracted with 0.05 M cyclohexylamino propane sulfonic acid (CAPS) pH 9.5 at 37 degrees C for 1 hour. The bacteria were then removed by centrifugation and millipore filtration. The filtered fluid, after being dialysed against many changes of cold distilled water, was concentrated and passed through Sephadex G200 column. Three protein profiles were eluted out with 0.05 M Tris buffer pH 8.6. The haemagglutinin and the bacterial lipopolysaccharide (LPS) were confined to the first profile. They were subsequently separated by agarose gel electrophoresis. The haemagglutinin was found to be more anodic than the LPS. After homogenization of the gel strips containing the haemagglutinin followed by centrifugation at 9,000 g pure haemagglutinin was obtained in the supernatant. Rabbit aniserum against pure haemagglutinin contained protective antibodies against V. cholerae infection in the baby mouse model. Specific antibodies prepared from this antiserum was as protective as the antibodies directed against whole V. cholerae and heat stable somatic antigens of V. cholerae upon the same weight unit.


Scanning and transmission electronmicroscopy of Mekong Schistosoma eggs and adults. Eggs and adult males and females of Mekong Schistosoma were studied by scanning and transmission electronmicroscopy. The observation of the eggs by the scanning and light microscopy revealed fine shell fenestration and a prominent knoblike spine. There are marked differences between the surface structures of male and female as studied by scanning and transmission electronmicroscopy. The surface of the male schistosome is moderately rough while that of the female is relatively smooth. SEM reveals certain basic features such as spines in the oral sucker, minute spines and folds in the gynecophoral canal of the male, and general features of male and female tegumental surfaces. The observations of the cross sections of adult schistosomes by transmission technique revealed certain features such as spines or ridges, and mucin droplets on the surface, the smooth muscles lining the integument, the mucin-producing cells and numerous lipid droplets in the body of the Schistosoma.


Computed tomographic scanning and the lumbar spine. Part II: Clinical considerations. With the advent of computed tomography of the lumbar spine, the theories of a small number of pioneering physicians regarding the pathologic sequela of degenerative disc disease and the entities of central and lateral spinal stenosis have been translated into objective determinations which can now be observed by all. CT scanning has provided clinicians with a better appreciation of the diagnostic limitations of myelography and of the pathologic sequela of hemilaminectomy, dorsal-lateral fusion, and discectomy itself. Since the identification by CT scanning of the loss of disc volume, leading to lateral nerve entrapment and nerve compression resulting from fusion overgrowth, it has become clear that our present modes of therapy require comprehensive reevaluation. Because of the findings of CT scanning, dorsal-lateral fusion now appears to have a much reduced role in the treatment of degenerative disc disease and spinal stenosis. In an era in which unnecessary surgery is a matter of concern, CT scanning is an important means of ensuring that surgery will be undertaken only after thorough pathologic conditions.


The significance and principles of computerized axial tomography in idiopathic developmental stenosis of the bony lumbar vertebral canal. Computerized axial tomography (CAT) in cases of stenosis of the lumbar bony vertebral canal may demonstrate features of diagnostic significance in the shape of the canal and the bony structures surrounding it. The distinguishing features are the measurements. Standardized measurements of the midsagittal diameters at the cephalad and caudad borders of the laminas of the vertebral canal are proposed as a means of furthering both surgical and comparative studies. Identification of these borders in CAT scans is described, as is the procedure for taking measurements. One or two interlaminar, transarticular CAT scans are also made. In these scans, the midsagittal diameters cannot be measured because the ligamentum flavum forms the posterior wall in the midline. The scans may, however, demonstrate narrow lateral recesses and deformities of the articular processes and joint spaces. Errors in measurement of midsagittal diameters result from the inability of CT body scanners to show the angle between axial sections and the anterior vertebral canal wall, and from the partial volume phenomenon. The diameters are then too large. Errors in the angle of axial sections also lead to distortion in reconstructions of sagittal sections of the vertebral canal from the soft material obtained from axial sections. New precision designs are described. The principal indication for the intrathecal injection of water-soluble contrast media in CAT scanning is the determination of the thickness of the ligamentum flavum. Apart from its value in distinguishing various forms of stenosis, CAT scanning may also reveal inadequacies in surgical decompression.


Multiplanar computerized tomography in the normal spine and in the diagnosis of spinal stenosis. A gross anatomic-computerized tomographic correlation. The limitations of current diagnostic tools, including myelography, in localizing the anatomic lesion in spinal stenosis are well recognized. The purpose of this study is to investigate whether computerized tomography can more effectively define the normal and abnormal osseous structures compromising the boundaries of the spinal canal, nerve root canal, and intervertebral foramen. This study is a pathologic-radiographic correlation between CT scans and sections of spine specimens that were so scanned. The tomographic images investigated were multiplanar, that is, simultaneously presenting transverse, coronal, and sagittal images. Spine specimens were chosen to show how the technique applies to the normal spine, as wel as to selected specimens with spinal stenosis. The role of the discs and apophyseal joints in shaping the intervertebral foramina and lateral recesses is emphasized in both normal and abnormal specimens. This study shows that computerized tomography can precisely localize anatomic lesions and, by comparison of the image to the gross anatomic specimen, that it is a reliable portrayal of the anatomic fact.


The respiratory depressive effects of intravenous buprenorphine in patients in an intensive care unit. Buprenorphine hydrochloride, a new, potent, long-acting synthetic opiate analgesic, with partial agonist-antagonist activity, was administered intravenously to two groups of patients in an intensive care unit. Arterial blood was drawn for blood gas analysis before (control) and at regular intervals after drug administration, to determine the effects of intravenous buprenorphine on respiration in critically ill patients, each acting as his or her own control. Intravenous buprenorphine 0,4 mg (group I -- 10 patients) caused a significant reduction in mean respiration rate and an increase in mean PaCO2, but did not alter heart rate, PaO2 or base excess values. Intravenous buprenorphine 0,2 mg (group II -- 10 patients) was associated with a less significant reduction in the rate of breathing and elevation of PaCO2. Both 0,4 mg and 0,2 mg buprenorphine produced effective relief of pain, sedation, and reduction in restlessness, and allayed anxiety. Our results suggest that intravenous buprenorphine 0,2 mg can be safely recommended for the prolonged relief of postoperative pain in adults.


Multiple squamous carcinomas and the oesophagus. Attention is directed to the synchronous and sometimes delayed appearance of squamous carcinoma of the oesophagus with other head and neck squamous carcinomas. The rare occurrence of double carcinoma of the oesophagus is emphasized. Two cases of double carcinoma of the oesophagus occurred in a group of 383 patients who were investigated as part of an epidemiological survey (an incidence of 0,5%). A third case of double carcinoma of the oesophagus is additionally reported.


Observer bias and error in the integumentary clinical diagnosis of chronic anaemia. In 74 patients believed to have chronic anaemia, 1 541 individual clinical assessments of haemoglobin levels were made from various sites. By comparison with laboratory values, there were statistically significant differences in the majority. In most instances these were not clinically important. The conjunctivae, the oral mucosa and the tongue were the integumentary sites that seemed to give the most accurate clinical assessment, while the appearance of nail-bed, palmar creases and facies did not correlate with laboratory findings. Bias appeared to be a factor in clinical estimates. There was no evidence that experience made clinicians more accurate.


Some aspects of middle ear surgery.

Some aspects of middle ear surgery. An eclectic, modified radical technique for the treatment of advanced middle ear and mastoid disease is described. This technique is safe and makes the ear easy to inspect. The reconstruction technique, using heterografts, homografts or alloplastic ossicular prostheses, minimizes lateralization or the tympanic membrane and provides satisfactory hearing results. From my experience the concept of Mr Bondy of a basic, modified radical technique for advanced ear lesions has withstood the test of time, and all credit is due to him.


A follow-up study of cardiac patients. A preliminary report. Five hundred consecutive admissions to a coronary care unit were studied, and the information was used to gain insight into the patients' background. It was found that the patients did not return for follow-up investigation. Contributory factors could have been that the patients did not understand their disease, and/or that some medical or paramedical services need to be reorganized. Diagnoses and other associated factors were also studied and related to one another statistically, in order to obtain a clearer understanding of the disease process as it affects individuals admitted to a coronary care unit.


Permanent pacemaker implantation in the absence of a right superior vena cava. A case report. In a patient with syncope and sinus bradycardia the left superior vena cava drained into the right atrium via the coronary sinus. He underwent permanent transvenous pacemaker implantation via the tortuous left superior vena-caval route, and has continued to show normal pacing over an 18-month follow-up period. The problem of pre-operative recognition and the optimum means of permanent and temporary pacing in this condition are discussed.


Which benzodiazepine, why and how?

Which benzodiazepine, why and how? While no major differences with regard to psychopharmacological actions are to be found among the benzodiazepines, certain pharmacokinetic differences are known. These differences allow the benzodiazepines to be classified as cumulative or non-cumulative; the differences between these two groups are further dissected and evaluated, in an attempt to rationalize therapy with these agents.


The pathology of trachoma in a black South African population. Light microscopical, histochemical and electron microscopical findings. Conjunctival biopsy specimens from a Black South African population suffering from trachoma have been studied by light microscopy, histochemistry and electron microscopy. A wide spectrum of histopathological changes was noted at different ages. Large cystically dilated glands containing concretions were seen and histochemical and electron microscopical examination revealed that the concretion material consisted of the inspissated secretion of goblet cells and cell debris. The cell damage seen in trachoma may be caused by the release of lysosomal enzymes from inflammatory cells.


Does cimetidine alter the cardiac response to exercise and propranolol? The recent discovery of histamine (H) receptors in the heart raises the possibility that the H2-antagonist drug, cimetidine, used in the therapy of peptic ulcer, might have cardiac side-effects and might impair the cardiac response to exercise. In 10 normal subjects, cimetidine did not alter the normal heart rate and blood pressure response to treadmill exercise, nor was the effect of beta-blockade by propranolol exaggerated. Thus it appears that the use of propranolol is not necessarily a contraindication to cimetidine therapy, or vice versa. However, further trials on patients with ischaemic heart disease are required to exclude any additive effects of cimetidine and propranolol on the diseased heart.


Paroxysmal neurogenic hypertension and its prevention in patients with cervical spinal cord lesions. Ten patients with clinically complete cervical spinal cord transection of traumatic origin were studied. These subjects do not have supraspinal control of their sympathetic outflow and are prone to marked elevations of blood pressure during visceral and somatic stimulation. This is a result of reflex sympathetic activity via the isolated spinal cord. The arterial blood pressures and heart rates of these patients were recorded on separate occasions during elevation of the urinary bladder pressure and before and after treatment with propranolol, labetalol, phenoxybenzamine and guanethidine. Guanethidine seems to afford the best protection against the marked hypertension occurring during autonomic hyperreflexia. In contrast to the ganglionic blocking agents, it has no anticholinergic or CNS side-effects, and reflex sweating, a valuable indicator of an impending abdominal catastrophe, still occurs. The findings that negative inotropic drugs, i.e. propranolol, guanethidine and labetalol, reduce the marked elevations in pulse pressure which occur during acute bladder distension in quadriplegic patients, suggest that inotropic cardiac responses are mediated by cardiac sympathetic nerves which leave the spinal cord above the T5 level.


Mumps virus and ovarian cancer.

Mumps virus and ovarian cancer. Thirty-four patients with carcinoma of the ovary were compared with controls matched for age, sex and racial origin. Previous mumps infection was determined by taking a history from the patient, by complement fixation test and by estimating neutralizing antibody titre. No significant differences between the two groups were found for any of the three methods used to estimate previous exposure to mumps virus. Therefore this study did not confirm previous hypotheses that mumps infection confers a significant degree of protection against the development of ovarian cancer. A relatively small proportion of cases could possibly be due to lack of such protection, but in this study not more than 30% at the 5% fiducial limit.


Isolated fractures of the shaft of the ulna. Fractures of the shaft of the ulna are described and a simple classification is proposed. Statistics are analysed in respect of mode of treatment and time of healing, and the unique mechanism of direct trauma is discussed. This survey showed that operative treatment has no place whatsoever in the treatment of these fractures.


Cryosurgery for basal cell carcinoma of the head and neck. Thirty patients with 57 basal cell carcinomas of the head and neck underwent cryosurgery during the years 1971--1973. Treatment was performed in the outpatient clinic, and no premedication or local anaesthesia was required. Residual disease necessitating local excision was found in 4 patients at follow-up which extended over a period of 2 years. The technique proved to be simple and safe. However, since tissue was not available for histological control, rigid criteria for patient selection and a prolonged follow-up are required.


The use of ultrasound in the diagnosis of pelvic masses. Two hundred and two patients were referred to the ultrasound department for evaluation of a pelvic mass during 1977, and of these only 120 underwent an operation enabling a definitive diagnosis to be made. The diagnostic accuracy of ultrasound was compared with the final operative diagnosis. The great majority (98%) of pelvic masses could be detected, and ultrasound was accurate in predicting the antatomical site of a pelvic lesion in 88% of cases. Uterine lesions were precisely diagnosed in 87% of cases, but only 30% of adnexal conditions could be specifically recognized. Numerous situations in which ultrasound provided additional information of great clinical value were noted.


Endobronchial lipoma. A case report.

Endobronchial lipoma. A case report. An endobronchial lipoma of the right main bronchus causing obstructive pneumonitis and bronchiectasis in a 71-year-old White man is described. Tumourlets were also found in the fibrosed lung. Although the tumour is rare, it is of clinical importance because it can be treated successfully by local excision.


Computed tomography of infratentorial masses in children. Seventeen cases of infratentorial mass lesions (excluding abscesses) in children are reviewed. The findings after computed axial tomography (CAT) are described, as well as the changes that were revealed by plain radiographs of the skull. Ancillary investigations were performed in 11 cases, and their usefulness is assessed. The possibility of making a provisional diagnosis of the nature of the lesion based on CAT findings is discussed.


Displacement of the spinolaminar line--a sign of value in fractures of the upper cervical spine. The spinolaminar line is an important anatomical landmark easily visualized on the lateral radiograph of the cervical spine. Any displacement in this line may be an indication of subtle traumatic vertebral damage. This is particularly relevant to the upper cervical spine in which the complex anatomy and frequent absence of associated neurological deficit make diagnosis difficult. Two case histories are presented which emphasize the importance of evaluation of the spinolaminar line on the lateral radiograph after trauma to the head and neck.


A mannitol-bisacodyl regimen for radiological visualization of the colon. The effectiveness of a 20% solution of mannitol-bisacodyl for oral use in preparing patients for barium enemas was investigated, in an investigator-blind control situation. The results were evaluated and compared with other methods currently in use. No comparative study where mannitol had been used could be found in the world literature. The mannitol-bisacodyl regimen was found to be an acceptable and reliable method for colon preparation in a high percentage of cases. Side-effects and changes in electrolyte balance of body fluids were recorded. The regimen was found to be safe for use on any patient irrespective of race, age or clinical condition and is not contraindicated in cases of cardiac and renal failure.


Diagnosis and treatment of abdominal aortic aneurysm. A report of 82 cases. Resection for abdominal aortic aneurysm (AAA) is being performed with decreasing mortality and morbidity. A retrospective study on 82 consecutive patients with AAAs admitted during the period 1974-1977 shoowed that 66 had a non-ruptured aneurysm and 16 a ruptured aneurysm. The mean age of the patients was 66,7 years. Concomitant disease was frequent. Operative mortality aneurysms and 37% in the group with ruptured aneurysms.


An acquired inhibitor to factor XIII A case report. An elderly woman presented with a postoperative bleeding problem, and a presumptive diagnosis of factor XIII (fibrin-stablilizing factor) deficiency was made. However, on further testing, an inhibitor to factor XIII was detected. She was on isoniazid (INH) therapy at the time. INH has been implicated in other patients who have developed inhibitors to factor XIII, and it was felt that this was the reason for this patient developing the inhibitor. The patient subsequently died from a cerebral haemorrhage, a well-described complication of factor XIII deficiency.


Men and women: changing roles and social security. In the Social Security Amendments of 1977, Congress called for a study to examine ways to eliminate dependency as a factor in determining entitlement to spouse's benefits under the social security program as well as proposals to bring about the equal treatment of men and women. The report of the study undertaken in response to that change explores two options for making broad-scale changes--earnings sharing and the establishment of a double-decker benefit structure. The study was conducted by the Social Security Administration with assistance from the Department of Justice Task Force on Sex Discrimination and several other interested bodies. Public views were obtained from responses to the report of the HEW Task Force on the Treatment of Women Under Social Security and letters to the Advisory Council on Social Security. The Advisory Council is expected to make use of this report in its deliberations. The extensive excerpts that follow, which relate to the comprehensive options discussed, are taken verbatim from the summary of the report prepared by the Department of Health, Education and Welfare.


Biochemical genetics of Chinese hamster cell mutants with deviant purine metabolism: isolation and characterization of a mutant deficient in the activity of phosphoribosylaminoimidazole synthetase. A new purine-requiring mutant of Chinese hamster ovary cells (CHO-Kl) is described. This mutant, Ade-G, grows on aminoimidazole carboxamide, hypoxanthine, or adenine. It complements all eight of our other previously described Ade- mutants. Biochemical analysis of de novo purine synthesis in whole cells suggests that Ade-G is capable of the first four reactions of de novo purine biosynthesis and that it synthesizes and accumulates phosphoribosylformylglycinamidine (FGAM). Direct enzyme assay in cell-free extracts confirms that Ade-G is defective in phosphoribosylaminoimidazole synthetase activity and does not convert FGAM to phosphoribosylaminoimidazole (AIR), the next intermediate in the de novo biosynthetic pathway.


Respiration-deficient Chinese hamster cell mutants: genetic characterization. We present here genetic experiments with a series of Chinese hamster cell mutants defective in oxidative energy metabolism. The mutations were all shown to be recessive in intraspecies hybrids. Thirty-five mutants were sorted into eight complementation groups, but one of these mutants failed to complement representatives of two distinct complementation groups. The possibility was raised that this is a cell carrying two mutations or a deletion. Because of the greatly different frequencies with which such mutants could be isolated from two different Chinese hamster cell lines, CCL16 (DON) and V79, the stability of representatives from each cell line was examined, and it was found that revertants could be obtained after treatment with mutagens, while spontaneous revertants appeared at unmeasurable or extremely low frequencies, with one exception. The mutant with a very noticeable frequency of spontaneous reversion was defective in mitochondrial protein synthesis, and the question arose whether the mutation was on the mitochondrial genome. A detailed fluctuation analysis of reversion rate and comparison with rates for other mutations was consistent with a nuclear mutation. This conclusion was supported by experiments involving fusions with cytoplasts.


Cytoplasmically inherited mutations of a human cell line resulting in deficient mitochondrial protein synthesis. A large number of mutants deficient in mitochondrial protein synthesis (mtPS-) have been isolated from the human cell line VA2-B by subjecting cells partially depleted of their mtDNA to mutagenic treatments thought to be specific for mtDNA. Each of these mtPS- mutants has less than 10% of the wild-type rate of mitochondrial protein synthesis, exhibits reduced cytochrome oxidase and rutamycin sensitive ATPase activities, requires high concentrations of glucose, and grows indefinitely in the presence of 100 micrograms/ml of chloramphenicol (CAP). Fusion of cytoplasts from seven mtPS- mutants to the nucleated thioguanine-resistant VA2-B derivative TG-6 has yielded numerous cybrid clones which grow in CAP plus thioguanine, whereas almost no clones have resulted from the fusion of nucleated mtPS- cells to TG-6 cells: these results suggest that the gene(s) coding for the phenotype of mtPS- cells is localized in the cytoplasm (mtDNA?).


Characterization of naturally occurring auxotrophic mammalian cells. In a previous study, several cultured cell lines were detected which are naturally occurring auxotrophs. In this investigation, the enzyme deficienceis involved are described. It is demonstrated that the Chinese hamster cell lines CHO(K1), YH21, RJK-36, and CHW-1102 are deficient in cystathionase and argininosuccinate synthetase. In addition, CHO (K1) and CHW-1102 were found to lack argininosuccinate lyase. CHW-1102 cells were also found to be unable to proliferate in medium containing branched-chain alpha-keto acids in place of the corresponding L-amino acids since CHW-1102 cells lack branched-chain aminotransferase.


Tourniquet infusion chemotherapy in extremities with malignant lesions. Tourniquet infusion chemotherapy involves the direct injection of a chemotherapeutic drug into the main artery of an extremity with prior application of an external tourniquet proximally on this extremity set at above the level of systolic pressure for ten minutes. Thus, the drug is not diluted and pushed by the blood into the venous circulation before diffusion into the tissues has occurred. This technique, applied in seven patients for a total of 40 instances, proved to be safe. Skin erythema and blisters, which are reversible, occur in the treated area. Complete clinical regression was achieved in all six patients with evaluable tumor, with high percentages of tumor necrosis. It was possible to avoid amputation in five of the seven patients treated. This technique appears superior to perfusion, but the long term permanence of regression has not yet been ascertained.


Retroperitoneal cross pelvic bypass grafts. An extraperitoneal retropubic cross iliac artery bypass graft is a safe alternative to an intra-abdominal aortoiliac bypass, axillofemoral bypass or subcutaneous femorofemoral bypass in the patient considered to be at high risk. This procedure may prove to be superior to subcutaneously placed grafts because the graft is less prone to trauma and infection. The circulation of the donor limb must be adequate to produce a significant increase in the rate of flow through the recipient limb. There was an early patency of the graft in 58 of 61 patients. There was patency of the graft at three years in 40 of 61 patients.


The value of bone scans in the management of patients with carcinoma of the breast. The bone scan has become a major staging and screening test for patients with carcinoma of the breast. The routine use preoperatively of bone scans to detect occult osseous metastases has been advocated to prevent radical operations on patients with Stage IV disease. Periodic use post-operatively of bone scans has also been advocated to detect metastic disease before the onset of symptoms. In view of the prevalence of this disease, the implications of this approach in terms of cost alone warrant consideration. All bone scans obtained of patients with carcinoma of the breast during a five year period were reviewed and the results correlated with the pathologic stage of the disease, the presence or absence of symptoms and pertinent clinical data. The sensitivity, specificity and predictive value of the bond scan was then analyzed for each group. Recommendations for the use of bone scans in patients with carcinoma of the breast are based upon these data.


Treatment of resistant lateral epicondylitis of the elbow by lengthening of the extensor carpi radialis brevis tendon. Resistant lateral epicondylitis remains a difficult therapeutic problem. Lengthening of the extensor carpi radialis brevis has proved to be a simple, yet effective, method for treating this problem. Sixteen of the 18 patients in our series are asymptomatic and rated as having excellent results. The result in one patient is rated as good. The one failure in retrospect represented poor patient selection. The results we obtained support the original conclusions of another investigator that this simple surgical approach to the problem can give lasting relief. The procedure can be done on an ambulatory outpatient basis. Minimal postoperative restrictions are involved, and this procedure is appealing in terms of time of disability and cost.


Ultrasonic detection and aspiration confirmation of intra-abdominal collection of fluid. In patients clinically suspected of possessing intra-abdominal abscesses, ultrasonic imaging is an effective way of detecting suspicious localized fluid collections. However, definitive diagnosis depends upon sampling the fluid collections, which can be most easily performed by percutaneous fine needle aspiration of the collection under ultrasonic guidance. Sixty-six patients suspected of having intra-abdominal abscesses had localized fluid collections demonstrated by ultrasonic scanning. The composition of the fluid was proved in 40 patients by percutaneous aspiration; in 26, by surgical drainage alone, and in 30, by both methods. The aspiration procedure is relatively painless, rapid and free of complications.


Management of chronic atlantoaxial dislocation. Twenty-two patients with chronic atlantoaxial dislocation have been treated. Of 13 patients with a reducible dislocation by skeletal traction, 12 underwent successful posterior infusion of the first, second and third cervical vertebrae. Of nine patients with irreducible dislocation, eight underwent surgical reduction and fusion through the transoral approach. The reduction was successful in all eight, but fusion was accomplished in four.


Vascular and orthopedic complications of knee dislocation. Experience with complete dislocation of the knee in 22 consecutive patients during a six year period was analyzed. Major vascular complications occurred in nine of 13 extremities with anterior dislocation, one of seven extremities with posterior dislocation and none of two extremities with lateral dislocation. Liberal use of trans-femoral ateriography for diagnosis disclosed significant arterial injuries in four of 15 limbs, despite postreduction pedal pulses which were apparently normal. Limb salvage was accomplished in 20 of 21 survivors and in eight of nine with associated vascular complications. All patients demonstrated severe instability of the ligamentous structures of the knee consistent with the type of dislocation. Posterior instability was severe in all patients, an indication of disruption of the posterior cruciate ligament in every instance. Adequate follow-up information was available on 12 knees that had primary ligamentous repair, ten of which were stable to stress testing. Postoperative immobilization was accomplished by external skeletal fixation, skeletal traction or long leg posterior plaster splint.


Distal splenorenal shunt for decompression of portal hypertension in children with cystic fibrosis. Apart from the sound physiologic basis for the distal splenorenal shunt as compared with the portacaval shunt and the conventional central splenorenal shunt, there are two important reasons why we think the use of this type of shunt is especially advantageous in children with portal hypertension secondary to cystic fibrosis. Firstly, the thick, fibrotic retroperitoneal area in the porta hepatis, where a portacaval shunt has to be constructed, can be avoided, which makes the distal splenorenal shunt the easier operation. Secondly, notwithstanding the relatively small-sized vessels, a wide anastomosis can be constructed with a high flow rate and, therefore, a minimal chance of shunt thrombosis.


Risk of infection in prolonged central venous catheterization. Classically, duration of infusion was thought to increase the rate of contamination by catheters. The results of this study show that this is not true and that, to the contrary, there is a definite difference in contamination rates between the basilic and the jugular and subclavian veins. The advantage of the basilic way which exists whatever the pathologic condition must undoubtedly determine the choice of this way of catheterization rather than any other.


Incidence of ischemic colitis following abdominal aortic reconstruction. The incidence of ischemic colitis following abdominal aortic reconstruction was determined by postoperative colonoscopy during a three year period. The over-all incidence of colitis was 11 of 163 patients who underwent elective or urgent reconstruction of the abdominal aorta for aneurysmal and occlusive diseases. The incidence of ischemic colitis for patients who survived resection of ruptured abdominal aortic aneurysms was higher, although the colonoscopy rate was lower. The incidence might have been even higher if all patients surviving resection of ruptured abdominal aneurysms had undergone colonoscopy.


Scintiscans in the evaluation of patients with malignant melanomas. In an attempt to define the role of scintiscanning in patients with a malignant melanoma, 349 liver, bone and brain scans in 136 patients have been reviewed. No patient with clinical Stage I or II disease was found to have occult metastases detected by scintiscans. All patients with proved positive scans demonstrated clinical symptoms consistent with the results of scintiscanning. Scintiscans in patients with a malignant melanoma are most effectively used to evaluate the symptomatic patient with Stage I or II disease and all patients with Stage III disease. Histologic verification of positive scans in patients with Stage I and II disease avoids unwarranted therapeutic decisions. There is, however, practical value in being able to predict accurately the absence of metastatic involvement. In only two of 249 examinations did the scans fail to detect metastases. A normal scan is a strong indicator of the absence of metastatic disease.


Immobilization of fractures of the zygomatic bone with an antral pack. Reduction and fixation of malar complex fractures has been emphasized and re-emphasized. Simple methods of reduction for complicated fractures are still advocated with clinically poor results. The necessity for a three point fixation and overcorrection for the complex fracture is emphasized. While it is true that simple fractures may be reduced by simple techniques, these simple methods cannot be applied to more comminuted fractures.


Results of early operations on cerebral aneurysms. In 625 cases of cerebral aneurysms operated upon from 1971, those in which operation was performed within the first week after subarachnoid hemorrhage had the highest mortality. However, a closer analysis of these cases revealed that the results of surgical treatment were significantly different with each day. The mortality rates resulting from operation on the first and second days were low in comparison with the remaining days of the week. To evaluate the differences, the cases are presented and the best timing of surgery is discussed.


A simplified method of CT assisted localization and biopsy of intracranial lesions. A simplified technique available to most neurosurgeons is described for using computerized tomography (CT) to localize and/or biopsy intracranial lesions. Illustrative cases are presented.


Epidural hematomas of the posterior fossa. The authors report four cases of epidural hematoma of the posterior fossa. The presenting signs and symptoms are discussed. Emphasis is placed on the need for early recognition and treatment and the fact that concomitant supratentorial lesions may be present. The radiologic findings are discussed, and special note is made of the value of computed tomographic (CT) scanning. Suboccipital craniectomy may result in complete recovery, even in moribund cases, once the lision is suspected and treated.


Cryptococcal granuloma presenting as an intracranial mass. A case of cryptococcosis of the central nervous system presenting as an intracranial space occupying lesion is described. The world literature and epidemiology of this unusual disease are surveyed. Problems in the diagnosis and the use of modern diagnostic techniques are discussed. The authors suggest that cryptococcosis should be included in the differential diagnosis of an intracranial space occupying lesion.


Intracerebral chondroma.

Intracerebral chondroma. Intracerebral chondroma is an extremely rare condition. A case of a parasagittal intracerebral chondroma with no meningeal attachment is reported. The clinical and histological findings are described and a review of the literature is presented.


Eosinophilic granuloma of the second cervical vertebra. The occurrence of eosinophilic granuloma in the body of the second cervical vertebra of a young adult male is presented. The necessity of making a histologic diagnosis and prevention of vertebral instability led to operative intervention. Treatment consisted of posterior fixation of the spinous processes of the second and third cervical vertebrae with size 0 wire. Through a transoral approach the lesion was curetted, and bone chips were placed in the vertebral defect. The patient remains well, and disease-free, after 36 months.


Thrombosis of the superior sagittal sinus associated with idiopathic thrombocytosis. An unusual association of thrombosis of the superior sagittal sinus and idiopathic thrombocytosis is reported. Etiology, clinical and radiological findings and therapeutic approach are discussed.


The acute abdomen in patients with ventriculoperitoneal shunts. A rationale for management of the patient with an acute adbomen and a ventriculoperitoneal shunt is presented in relation to eight patients. In two patients peritonitis was due to perforation of an abdominal viscus, not shunt related, and six were due to infections of ventriculoperitoneal shunts. Resolution of abdominal symptomatology occurs within six hours after the distal end of the shunt catheter is removed from the abdomen and placed in a drainage bottle. In four of these six, infection was limited to the peritoneal end of the catheter. The ventricular fluid was sterile.


Intraperitoneal pseudocyst after ventriculoperitoneal shunt. A case with intraperitoneal pseudocyst as a complication of a ventriculoperitoneal shunt is reported. The pathophysiology, diagnosis and treatment are discussed.


Treatment of ruptured and unruptured internal carotid artery aneurysms. A consecutive series of 95 patients with a total of 131 intracranial cerebral aneurysms came under observation from 1972-1978. Of these, 78 patients had operations for 106 aneurysms. Over half of the patients (41) had operations for an aneurysm of the intracranial internal carotid artery; there were 16 incidental "asymptomatic" aneurysms also found. There was no surgical mortality in this group. Medical treatment, including bed rest, antihypertensive treatment and administration of epsilon amino caproic acid followed by microsurgical obliteration of the aneurysm offers the best results for the treatment of ruptured and unruptured aneurysms.


Malignant cardiac myxoma with cerebral metastases. Two cases of cardiac myxoma with secondary involvement of the brain and death are reported. In one case, tumor emboli to the middle cerebral artery caused massive cerebral infarction, while in the other case true cerebral metastasis developed in the cerebrum and cerebellum, with rapid demise ensuing in both patients. It is emphasized that an emergency exists in cases ihat prompt echocardiography and computerized tomography of the brain are indicated. The second case represents the only instance of cardiac myxoma behaving as a true malignant neoplasm with actual invasion of the neural tissues recorded in the literature.


The standardization of experimental impact injury to the spinal cord. The biomechanical criteria for standardization of experimental impact injury to the spinal cord are derived. The theory is verified experimentally using cats. The undesirable effect due to heavy impounders is discussed. A falling mass of 20 gm and a small impounder 5 mm in diameter with a mass of 0.1 gm are recommended, leaving the momentum of the falling body to be controlled for different degrees of trauma.


Facial myokymia.

Facial myokymia. Facial myokymia is an uncommon form of dyskinesia, usually resulting from a lesion in the brain stem. The electromyogram is typical. A case is reported. The condition was due to an astrocytoma of the brain stem.


Abdominal aortic coarctation and segmental hypoplasia. Functionally significant, nonatherosclerotic, noninflammatory, concentric and tubular stenoses of the abdominal aorta, 4 to 16 cm in length, were encountered in five male and five female patients 11 to 49 years old. Seven patients were younger than 19 years of age. Aortic branch stenoses were common, affecting splanchnic vessels in seven patients and renal arteries in eight patients. The pathogenesis of the aortic constrictive lesions remains unknown, but it may be related to developmental error or aortic growth arrest. Existence of multiple renal arteries in 70% of these patients lends support to the developmental hypothesis. Intimal fibroplasia characterized stenotic aortic tissue. Severe hypertension was common, with the mean preoperative arterial pressure being 200/119 mm Hg. Thoracoabdominal bypass was undertaken in eight patients, being combined with renovascular reconstruction on five occasions. Two patients underwent patch graft aortoplasty with bilateral renal revascularization. Therapeutic results were classified as excellent six times and as good four times. Single-stage arterial reconstructions are the preferred method of treatment for abdominal aortic coarctation or segmental hypoplasia with associated aortic branch disease.


Progressive essential iris atrophy, Chandler's syndrome, and the iris nevus (Cogan-Reese) syndrome: a spectrum of disease. Progressive essential iris atrophy, Chandler's syndrome, and the iris nevus (Cogan-Reese) syndrome are considered to be variations of a single disease process, which is characterized by abnormalities of the cornea, anterior chamber angle, and iris. In each variation, the typical patient is a white woman with unilateral disease, negative family history, and an onset of symptoms in early to middle adulthood. Since the membrane theory of Campbell suggests that the disease is a fundamental abnormality of the corneal endothelium, rather than the iris, the term "iridocorneal endothelial syndrome," as proposed by Yanoff, may be an appropriate inclusive term for the spectrum of disease, although further study of the pathogenesis is needed. For each variation of the disease, corneal edema and secondary glucoma are both treated primarily by medical or surgical reduction of the intraocular pressure, although penetrating keratoplasty is occasionally required for cases with advanced corneal edema.


Hepatic artery ligation.

Hepatic artery ligation. The use of hepatic artery ligation (HAL) in various clinical situations is illustrated by presenting a series of eight patients. The indications for HAL included ruptured hepatic tumors, spontaneous liver rupture, delayed hemorrhage after liver trauma, hematobilia, hepatic artery aneurysm, and hemorrhage after liver biopsy. Conventional methods of hemostasis had been used in some of these patients, but failed to control hemorrhage. The reasons for the relatively late adoption of hepatic artery ligation in treating liver hemorrhage are discussed and placed in proper prospective. Hepatic artery ligation has been shown to be such an effective method of controlling hemorrhage from the liver that other methods, such as packing and mass suture, which are unsafe and ineffective, should be abandoned. Major resection should be done only when an entire lobe of the liver is reduced to pulp or when exposure and repair of the retrohepatic vena cava are necessary.


Peritoneal mesotheliomas.

Peritoneal mesotheliomas. Eight cases of peritoneal mesothelioma have been seen at the University of Missouri Medical Center and affiliated hospitals since 1940. The incidence for our patient population is 0.24 cases per 100,000 patients. The nonspecific symptoms, physical findings, x-rays, and laboratory results usually preclude an early establishment of the diagnosis. The diagnosis was eventually established at laparotomy in seven cases and at autopsy in one. Only the benign mesothelioma was resectable; that patient is doing well 10 months after operation. The survival interval of the patients with malignant peritoneal mesotheliomas averaged 3 months, with the two patients who received chemotherapy surviving 3 and 6 months, respectively.


On understanding the optics of intraocular lenses. The optical considerations of intraocular lenses can be understood, using only the formulae and principles taught in a typical basic science course in ophthalmology. Some of the more common optical problems associated with intraocular lenses are presented and the methods for their solutions are illustrated and explained.


Correction of hypersplenism following distal splenorenal shunt. The effect of splenorenal shunt on hypersplenism was assessed in 47 patients with splenomegaly, 26 of whom had significant thrombocytopenia or leukopenia. Of 16 patients with thrombocytopenia, platelet count returned to normal in 15 (94%) following operation, an improvement which was statistically highly significant (P less than 0.001). Of 16 patients with leukopenia, leukocyte count returned to normal in 11 (69%), also a highly significant improvement (P less than 0.001). Dramatic relief of hypersplenism occurs in the majority of patients following splenorenal shunt. Thrombocytopenia is more consistently corrected than is leukopenia. The etiology of liver disease appeared not to be a factor, but leukopenia was corrected more consistently in alcoholic than in nonalcoholic patients, while there was no difference in the postoperative response of thrombocytopenia to the operation. Long-term follow-up in 26 patients demonstrated sustained improvement in 57% of patients with preoperative leukopenia and 78% of patients with thrombocytopenia. Since significant improvement in leukopenia and thrombocytopenia will occur following the distal splenorenal shunt, hypersplenism is not a contraindication to this procedure.


Cimetidine affords protection equal to antacids in prevention of stress ulceration following thermal injury. A prospective, randomized, double-blind, endoscopic study is described in which the efficacy of cimetidine (13 patients) is compared to that of antacids (14 patients) in the prevention of stress ulceration following severe thermal injury. Each treatment modality was equally effective in the prevention of acute gastroduodenal disease and its associated complications. Both cimetidine and antacids produced a near elimination of duodenal disease and markedly reduced the severity of gastric disease when compared to that of untreated historical controls. Lack of major side effects and ease of administration make cimetidine an attractive alternative to antacid therapy in the prophylaxis of stress-induced gastroduodenal disease in the thermally injured patient.


Duodenal perforation in blunt abdominal trauma. Ten patients with duodenal perforation secondary to blunt abdominal trauma are reviewed. All 10 patients survived. Most of the injuries were related to motor vehicle accidents. Early recognition requires a high index of suspicion because preoperative signs and symptoms tend to be nonspecific and x-rays are usually not helpful. A careful exploration of the duodenum at laparotomy including both the Kocher maneuver and the Cattell-Braasch exposure is essential. Suitable methods of surgical repair are numerous, but those providing for restoration of normal gastrointestinal tract continuity are preferred.


Endoscopic retrograde pancreatography in the surgery of pancreatic pseudocysts. Endoscopic retrograde pancreatography (ERP) was performed on 83 patients with 99 pancreatic pseudocysts (PCP). ERP was successful in 76 patients; in the other seven PCPs were found at operation. Five characteristic ductal patterns are described and illustrated. The PCPs were situated in the head (51 patients), body (21 patients), tail (20 patients). Thirteen PCPs were less than 2 cm, 50 were between 2 and 5 cm, 29 greater than 5 cm. There were multiple PCPs in 13.2% of patients. ERP was a more accurate diagnostic measure than ultrasonography or upper gastrointestinal roentgenograms, revealing the lesion in 89% of patients. Eight patients with pancreatic ascites had the causative PCP demonstrated prior to operation. Three patients had pancreatic pleural effusions; two with effusions on the right had PCPs of the tail. Five patients had spontaneous connections between a PCP and the stomach (four patients) or duodenum (one patient). Rational surgical planning for the management of PCPs is greatly facilitated by preliminary reconnaisance by ERP.


Necrotizing anorectal and perineal infections. Sixteen cases of spontaneous necrotizing infection of the anorectum and perineum are described. Thirteen patients had clostridial infections and three had infections with nonclostridial organisms. Six patients were diabetic and two had leukemia. All 16 patients presented with pain, tenderness, swelling, and crepitation. Four had an ominous black spot on the scrotum or posterior labia. Shortly after initial recognition by the patient, all infections rapidly disseminated to include all surrounding areas such as the external genitalia, the anterior abdominal wall, and thighs. Treatment consisted of radical debridement and antibiotics; hyperbaric oxygen was used in the clostridial cases. Ten of the 16 patients survived. Delayed diagnosis and delayed treatment were the primary factors responsible for death.


Further clinical observations on the pulmonary effects of paraquat ingestion. Five patients are reported who developed evidence of acute lung damage after proved ingestion of paraquat. In two the lung changes resolved; in one an aspiration pneumonia occurred, which was successfully treated, while two developed fatal pulmonary oedema. These pulmonary complications after paraquat intoxication appear more common than the progressive pulmonary fibrosis previously described. It is suggested that acute pulmonary oedema is a response to large doses, usually of Gramoxone, that subclinical lung changes result from small doses, usually of Weedol, and that pulmonary fibrosis occurs after intermediate doses. Preliminary data on plasma paraquat concentrations suggest that these are of value in prognosis.


Effective time of the forced expiratory spirogram in health and airways obstruction. We have calculated the effective time (t eff) of the forced expiratory spirogram in healthy non-smokers, in patients with simple chronic bronchitis, and in patients with chronic obstructive lung disease. Effective time was obtained by dividing the area underneath the forced expiratory spirogram by the forced vital capacity (FVC) and is equal to the time constant of lung emptying if the FVC-time curve is a single exponential. In 75 healthy non-smoking adults, t eff showed a linear increase with age but no difference between the sexes. In 37 patients with low forced expiratory volume in one second (FEV1)/FVC ratios, t eff, as expected, was increased. In 19 subjects with simple chronic bronchitis and normal FEV1/FVC ratios, t eff was longer than or at the upper limit of 2 SE above the mean for healthy subjects of the same age. A comparison of t eff with FEV1/FVC suggested that in most normal subjects and patients the forced expiratory spirogram was a multiple exponential and that t eff was a more sensitive index for the evaluation of airway obstruction than the FEV1/FVC ratio.


Transit-time analysis of the forced expiratory spirogram during clinical remission in juvenile asthma. The mean transit time (MTT), coefficient of variation (CoV), and index of skewness (IoS) of transit times of the forced expiratory flow/time curve have been compared with maximal mid-expiratory flow (MMEF), flow at 75, 50, and 25% of vital capacity (V75, V50, and V25), and the ratio of forced expiratory volume in 1 second (FEV1) to vital capacity (VC) in 51 asthmatic children judged on clinical grounds to be in remission. In 19 children all eight indices were normal. Of the remaining 32, MTT was normal in 5, V50 in 11, V75 in 12, and FEV1/VC and MMEF in 13 each. MTT was significantly more sensitive in detecting abnormality when other indices were normal, and abnormalities in MTT were of significantly greater magnitude when present. In 12 patients with at least one abnormal index given salbutamol aerosol, MTT was not more sensitive than MMEF, V25, FEV1/VC, or V50 in detecting change.


The pulmonary endothelial cell.

The pulmonary endothelial cell. The surface of the endothelial cells of the pulmonary trunk of the Wistar albino rat was studied by means of silver preparations and by scanning and transmission electron microscopy. This surface is the site of cytoplasmic projections and the opening of caveolae which together appear to be features associated with the active metabolic rôle of the pulmonary endothelial cell.


Binding and ingestion of human lactoferrin by mouse alveolar macrophages. 59Fe-labelled human lactoferrin was found to be preferentially ingested by mouse alveolar macrophages (MAM) when compared to 59Fe-labelled human transferrin. The cells bound and ingested 125I-labelled iron-saturated and iron-free lactoferrin. The latter was digested faster (t1/2 = 5.8 hours), however, than the iron-saturated compound (t1/2 = 10.5 hours). The constant elimination of the Fe-lactoferrin complex by alveolar macrophages could enhance the bacteriostatic effect of lactoferrin in the pulmonary secretions.


Hypoxaemia in chronic obstructive bronchitis. Arterial blood gas tensions were studied for six years in 85 patients (59 men, 26 women, mean age 58.8 years) with hypoxaemia associated with chronic bronchitis. All patients who died had a precipitous fall of arterial oxygen tension (PaO2) breathing air. In patients dying within two years of the first appearance of ankle oedema the mean rate of fall of PaO2 was 0.11 kPa/month. Patients who survived two years appeared to deteriorate more slowly (0.017 kPa/month) until some months before death, when they too deteriorated rapidly. Hypoxaemic patients with obstructive airways disease suffer a terminal rapid decline in arterial oxygen tension, which probably indicates real pathological change in the lungs and has important implications for long-term domiciliary oxygen treatment.


Serial pulmonary function tests in progressive systemic sclerosis. Serial pulmonary function tests were performed on nine patients with progressive systemic sclerosis over a mean period of ten years. Abnormality was seen to develop both early and late in the course of the disease, and the earliest abnormality observed was impairment of the transfer factor. Deterioration of some aspect of pulmonary function was noted in each case, evidence of restriction or air trapping being seen with equal frequency. Two patients died, both of causes unrelated to their pulmonary involvement, and even pronounced early involvement of the lungs did not necessarily imply a bad prognosis.


Carcinoma of the lung in Lancashire coalminers. The prevalence at death of carcinoma of the lung in miners and ex-miners has been compared in those with and without pneumoconiosis at necropsy. The prevalence of 11.4% in the group as a whole is no greater than that in the male population in North-west England. Carcinoma of the lung was present in 62 (13.1%) of those without pneumoconiosis and in 52 (9.8%) of those with pneumoconiosis. The mean age at death of those with pneumoconiosis was 71.3 years so that they cannot be said to have died before the age at which they would have developed carcinoma. Those with progressive massive fibrosis whose mean age at death was 72 years had the lowest prevalence of carcinoma of the lung at all ages--8.4%. For reasons stated in the text this is inevitably a biased sample. The number of those without pneumoconiosis is probably lower than the true figure because the deaths of miners and ex-miners in whom there is no suspicion of lung disease may not have been reported to the coroner or to the pneumoconiosis medical panel. There appears to be no positive link between carcinoma of the lung and pneumoconiosis. There is a surprisingly high number of smokers and ex-smokers among these miners, and this appears to have more relevance to the prevalence of carcinoma of the lung than does pneumoconiosis.


The pulmonary angiographic appearance of pleurisy associated with subdiaphragmatic inflammation. In two patients who had recently undergone major abdominal operations and were later suspected of having pulmonary emboli, pulmonary angiography showed no evidence of embolism, but in both cases one of the hemidiaphragms was clearly outlined by contrast material. It is suggested that subdiaphragmatic inflammation was responsible for this unusual appearance.


Melanotic spinothoracic schwannoma.

Melanotic spinothoracic schwannoma. A dumb-bell mediastinal melanotic schwannoma is described, and the rarity of this type of tumour emphasised. The tumour was resected by simultaneous laminectomy and posterior thoracotomy. The patient is well four years after operation. The pathology of the tumour is described and the origin of melanotic cells is discussed.


Technique for the management of anterior flail chest. A technique for the management of anterior flail chest consisting of osteosynthesis and the positioning of two long Kirschner wires behind the sternum in the form of a St Andrew's cross is described. The procedure is easy to perform, the patient is ambulant early, and the results are good.


Cost of a cardiac surgical and a general thoracic surgical patient to the National Health Service in a London teaching hospital. The cost of the inpatient stay for a typical aortic valve replacement and for an oesophagectomy were determined by recording and costing every aspect of the patients' care from admission until discharge. This method of cost calculation was found to be satisfactory and could be used by other centres to allow comparisons between hospitals or countries. At St Thomas's Hospital in 1977 the cost of a cardiac operation was 2755 pounds, an oesophagectomy 1870 pounds, and a general surgical operation 564 pounds.


Assessment of respiratory function in patients with chronic obstructive airways disease. The reproducibility of some respiratory function tests and a simple self-paced walking test were assessed in 13 patients with stable chronic obstructive airways disease by making observations on six occasions at two to three weekly intervals. The coefficients of variation of the various tests were as follows: forced expiratory volume in one second, +/- 14.8%; forced vital capacity, +/- 11.1%; transfer factor (single breath carbon monoxide), +/- 15%; total lung capacity, +/- 8.8% by helium dilution and +/- 8.3% by body plethysmography; increase in heart rate and minute ventilation for an increase in oxygen uptake of 0.5 1 min-1, +/- 19.4% and +/- 16.3%; distance covered in a 12-minute walking test, +/- 8.2%. The 12-minute distance increased significantly over the first three studies. The considerable variations in the result of these tests in subjects with apparently stable clinical states and without changes in treatment should be considered when assessing the results of changes in treatment.


Bronchodilator effects of antiasthmatic cigarette smoke (Datura stramonium). In 12 asthmatic patients with mild airway obstruction we have measured the effect on specific airway resistance (sRaw) of inhaling the smoke of one Datura stramonium cigarette. In 11 patients sRaw decreased substantially after the cigarette, the mean maximal decrease being 40% at the 30th minute. In seven patients the subsequent inhalation of 200 micrograms salbutamol caused no further decrease in sRaw. In the remaining four patients salbutamol induced a larger decrease in sRaw than the cigarette smoke. The inhalation, however, of a synthetic anticholinergic agent (SCH 1000, 600 micrograms) proved as effective as salbutamol in these patients. In one patient the cigarette smoke and SCH 1000 produced only a negligible amount of bronchodilatation whereas the bronchial obstruction was reversible with salbutamol. Minor side effects were observed in six patients after the cigarette.


Hydropneumopericardium and oesophagitis: a non-fatal case. Hydropneumopericardium is a very rare and usually fatal complication of peptic oesophageal ulceration. The patient reported here survived and the report resembles one previously made about a child. In both patients failure to show the fistula radiologically or on endoscopy suggests that rapid spontaneous healing had occurred, and that this was responsible for survival.


Effect of hyperlipidaemia on pulmonary diffusing capacity for carbon monoxide. There is conflicting evidence on the effect of hyperlipidaemia on pulmonary diffusing capacity for carbon monoxide (DLCO or TLCO) in man. We have measured the carbon monoxide transfer factor per unit alveolar volume (TLCO/VA or KCO) by the single breath method in 25 patients with hyperlipidaemia, and in three normal subjects before and after infusions of an intravenous fat emulsion, Intralipid. Non-smokers with hyperlipidaemia had normal levels of TLCO/VA, whereas some of the smokers showed a slight reduction. In neither group was there any correlation of TLCO/VA with serum triglyceride or cholesterol concentrations. A reduction in triglyceride concentrations of up to five-fold produced by plasma exchange (three studies in two patients) or by dietary manipulation (one patient) had no significant effect on the levels of TLCO/VA. Intralipid infusion in three normal subjects caused a four- to five-fold increase in serum triglyceride concentration but had no effect on TLCO/VA. We conclude that moderate degrees of hyperlipidaemia have no effect on pulmonary diffusion.


A double-blind trial of bromocriptine in steroid dependent asthma. The pilot study of Newman Taylor et al (1976) in which, by adding bromocriptine to the full medical treatment, they improved the symptoms of three out of four asthmatic patients, prompted us to carry out this study. Bromocriptine is a dopaminergic agonist that is used in acromegalic patients, as well as an inhibitor of prolactin in doses of 5 to 20 mg a day. We decided to use 15 mg a day, which is usually without major side effects.


Peak flow rate records in the diagnosis of occupational asthma due to colophony. Peak expiratory flow rate (PEFR) has been measured hourly from waking to sleeping in 29 workers with respiratory symptoms exposed to the fumes of soft soldering fluxes containing colophony (pine resin). Thirty-nine records of mean length 33 days have been analysed, and the results compared with the occupational history and bronchial provocation testing in the same workers. From plots of daily mean, maximum, and minimum PEFR, recurring physiological patterns of asthma emerge. The most common pattern is for asthma to increase with each successive working day. Some workers have an equivalent deterioration each working day. Regular recovery patterns taking one, two, and three days are described. The combination of a three-day recovery pattern and a late asthmatic reaction on Monday results in Monday being the best day of each week. Assessment of these records has shown them to be specific and sensitive, provided the worker was not taking corticosteroids or sodium cromoglycate during the period of the record and that bronchodilator usage was kept constant on days at home and at work. The results of the PEFR records correlate well with bronchial provocation testing, and provide a suitable alternative to this for the diagnosis of mild to moderate occupational asthma. The records are of particular use for screening symptomatic workers whose symptoms appear unlikely to be related to work.


Factors influencing the prevalence of asthma among first degree relatives of extrinsic and intrinsic asthmatics. The prevalence of asthma, hay fever, and eczema was examined in first degree relatives of extrinsic (atopic) and intrinsic (non-atopic) asthmatics attending the asthma clinics of the Brompton Hospital and the Doncaster Royal Infirmary. In both the Doncaster and Brompton populations the prevalence of asthma, hay fever, and eczema was significantly higher among relatives of extrinsic than among relatives of intrinsic asthmatics. Furthermore, the prevalence of these traits tended to be higher among siblings of extrinsic probands with one or both parents affected than among siblings of probands with neither parent affected. Most importantly, the prevalence of asthma among first degree relatives was positively correlated with the prevalence of hay fever or eczema or both among relatives and with the degree of atopy in the probands. These findings are consistent with the results of previous investigations in which the expression of asthma was shown to depend on a genetic predisposition to the trait as well as exposure to environmental provoking agents. We further suggest that the presence of atopy in genetically predisposed individuals increases the risk of developing asthma.


Postnatal lung growth after repair of diaphragmatic hernia. The lungs of two patients who died eight months and 64 months after repair of a left-sided diaphragmatic hernia on the first day of life were examined. Lung volumes were appropriate for the size of the children, and the ratio of right lung volume to left lung volume was also normal in both patients. The lungs, however, were grossly abnormal with evidence of enlargement and destruction of respiratory tissue. The left lung was affected more than the right in both subjects. In one patient the total number of alveoli in the lungs was similar to that of normal children of the same age, but this was because the right lung had more than twice as many alveoli as the left lung. It appears that alveolar multiplication is impaired after repair of diaphragmatic hernia. The number of bronchioles was reduced in the infant with very few alveoli, and there may have been too few bronchioles in the other patient.


Relationship of bacterial and viral infections to exacerbations of asthma. Fifty-one asthmatic patients were followed for up to 18 months. During this time 111 exacerbations of wheeze were recorded. Involvement by pathogenic respiratory bacteria and viruses was looked for directly by culture and indirectly by antibody studies. Proof of infection was found in only 12 (10.8%) of the 111 exacerbations. Only eight patients provided sputum samples. Potential bacterial pathogens were found in four. Viruses were isolated in four of 27 exacerbation specimens; significant rises in specific viral antibody titres occurred in three. Six patients developed precipitating antibody to respiratory bacteria over the study but only one in relation to an exacerbation. The study therefore indicated that the great majority of exacerbations of asthma in these patients were not due to respiratory tract infection.


Ventilatory function in the Eisenmenger syndrome. Ventilatory function and carbon monoxide transfer factor were studied in nine adult patients with post-tricuspid intracardiac defects and the Eisenmenger syndrome. A consistent mild defect of ventilatory function was found, with raised residual volume and closing capacity and reduction of other lung volumes and maximal expiratory flows. Maximal expiratory flow was particularly reduced at low lung volumes. One of the four subjects in whom pressure-volume studies were performed showed loss of normal elastic recoil at low lung volumes. A significant poorly ventilated space was excluded since the volume of distribution of helium during a 10 second breath-hold at full inspiration was close to plethysmographically measured total lung capacity. Carbon monoxide transfer factor, after correction for haemoglobin concentration, was 77% of predicted normal values. Sequential assessment of carbon monoxide transfer factor might be useful in the early diagnosis of pulmonary vascular disease in infants with large intracardiac defects, since it is likely to be raised early due to high pulmonary blood flow and will fall with the development of pulmonary vascular disease.


Relationship between bronchial and arterial diameters in normal human lungs. In order to find an objective method for measuring narrowing of small airways, eight lungs from four people without lung disease were inflated and fixed at 25 cm of water pressure. Eight to nine blocks were taken at random from each of six parasaggital slices from each lung, sectioned, and stained. The size of the bronchioles (airways without cartilage) in relation to their accompanying arteries was determined. The internal bronchiolar diameter was compared with three different arterial diameters (the internal, external medial, and external adventitial). The ratio of the internal bronchiolar diameter to the external adventitial arterial diameter was constant between lungs (0.62 +/- 0.02) and independent of the method of inflation or the position within the lungs. This ratio may provide a useful index of bronchiolar narrowing in disease.


Lung function in healthy British women.

Lung function in healthy British women. The forces expiratory volume, total lung capacity, transfer factor (diffusing capacity), and their subdivisions have been measured in 113 healthy British women aged 27 to 74 years of whom 47 were current smokers and 66 were lifetime non-smokers. The results have been analysed in terms of age, stature, mass, body fat, and smoking. In addition to their relation to stature and to age, the inspiratory capacity was positively correlated with indices of body muscle while the residual volume, expiratory reserve volume, and total lung capacity were inversely correlated with the percentage of body mass that is fat or with mass divided by the square of stature. The inverse correlation between total lung capacity and age was apparently due to the quantity of body fat increasing with age. The transfer factor and its subdivisions were inversely correlated with smoking. In this study the forced expiratory volume and vital capacity were independent of both fat and smoking; the transfer factor was independent of the physiological response to exercise. The results provide reference values for lung function in British women.