The effects of hypothermia on myocardial oxygen consumption and transmural coronary blood flow in the potassium-arrested heart. Hypothermia remains the primary adjunct employed to lower cellular metabolism during various cardiac procedures. In these experiments, left ventricular myocardial oxygen consumption (MVO2) and transmural blood flow (TBF) were measured during cardiopulmonary bypass with the range of temperatures used clinically. Determinations were made in empty beating normothermic hearts and after potassium cardioplegia at 37, 32, 28, 22, 18, and 15 degrees (K+ = 15--37 meq/L: Hct 25 volumes %). Oxygen content of the total coronary sinus collection was compared with a large volume arterial sample using a Lex-O2-Con-TL analyzer (vs Van Slyke, R = 0.98). Transmural blood flow was measured at each temperature using microspheres (8 microns), and perfusion was maintained at 80 mmHg. Asystole (37 degrees) alone decreased MVO2 from 5.18 +/- 0.55 to 1.85 +/- 0.20 ml O2/min/100 g of left ventricle or approximately 65% (p less than 0.001). With progressive cooling to 15 degrees an additional 82% decrement in oxygen uptake occurred during asystole (p less than 0.001). During asystole at 37 degrees the decrease in MVO2 was reflected mainly by a large decrement (p less than 0.01) in TBF (1.27 +/- 0.19 to 0.74 +/- 0.17 ml/min/g of mean left ventricular flow). However, with cooling below 32 degrees, the arteriovenous oxygen difference narrowed progressively (p less than 0.001) while TBF paradoxically returned to control levels. Endocardial/epicardial flow ratios were not altered by cooling. These data not only confirm earlier reports describing a sequential drop in MVO2 with incremental myocardial cooling, but also establish MVO2 levels for perfused hearts arrested by potassium at lower temperatures (18--15 degrees). Moreover, as transmural blood flow becomes independent of metabolic necessity during hypothermia, coronary autoregulation appears to be impaired, possibly affecting detrimental tissue over perfusion.


Infusion of the branched chain amino acids in postoperative patients. Anticatabolic properties. Postinjury metabolism is characterized by breakdown of muscle protein as substrate for energy production and gluconeogenesis and by the resultant loss of lean body mass and weight loss. The branched chain amino acids (BCAAs) which are principally oxidized by the skeletal muscle have been implicated in recent in vitro and in vivo studies as having special anticatabolic and regulating effects in skeletal muscle. We studied the anticatabolic effects of the BCAAs in 35 patients undergoing operative injury of moderate severity. In a prospective randomized and blinded manner patients were infused for five days starting immediately after surgery with either 5% dextrose or 5% dextrose with an amino acid solution containing 22, 35 or 100% BCAAs. All patients survived and there were no major postoperative complications. Mean hospital stay was 17 days for patients receiving amino acids and 19 days for patients receiving 5% dextrose only (p = ns). All three groups receiving amino acid solutions were in nitrogen equilibrium or in a slight positive nitrogen balance, while the group receiving 5% dextrose only was in a mean negative nitrogen balance of 6.6 +/- 0.6 gN/day. The differences between the three groups receiving amino acids were slight and not significant. Weight loss was 2 +/- 0.7 kg in the 5% dextrose group, 1 +/- 0.7 kg in the 22% BCAAs group, 0.5 +/- 0.5 kg in the 35% BCAAs group and the 100% BCAAs group gained 0.4 +/- 1.8 kg. Blood chemistries in the different groups and during the study period remained within normal limits except for ammonia levels rising significantly in the 5% dextrose group and SGOT levels rising in the 22% and 35% BCAA groups. With mild variations the plasma amino acid patterns in all groups were similar to the normal pattern, even in the 100% BCAAs group receiving an unbalanced amino acid solution, suggesting the complete cessation of amino acid efflux from muscle, the muscle depending solely on the exogenous supply of BCAAs to satisfy its metabolic requirements. The results suggest that early nutritional suppport in the postoperative period will result in nitrogen equilibrium and that the infusion of the three BCAAs only in the postoperative state is as effective in preventing muscle catabolism as other more balanced amino acid solutions. In the postinjury state balanced amino acid solutions rich in BCAA may prove beneficial.


[Total ureteral rupture caused by closed abdominal injury in polytraumatized patients]. The authors present a case of complete ureteral rupture, after closed, abdominal traumatism in a patient suffering from multiple traumatisms. They point out the slight number of cases published in the literature as well as the frequency of its delayed diagnosis due to few or no symptoms, particularly when associated with visceral ruptures or bone fractures which may conceal the picture. They recommend the I.V.U. for all patients with multiple traumatisms once they have recovered from the state of shock, as a simple exploration but which provides a great deal of information. They also advise conservative treatment even in cases with a delayed diagnosis.


[Conservative therapy of urolithiasis].

[Conservative therapy of urolithiasis]. Some common conservative treating methods of urolithiasis are critically discussed. Based on physico-chemical relationships of solubility and cristallisation of stone-forming compounds our own methods of conservative treatment of urolithiasis is presented.


Typhoid perforation of the bowel. Experiences in 78 cases. Seventy-eight patients ranging from four to 65 years of age were treated for typhoid perforation of the bowel. Sixty-one patients (78%) were males. The average time from perforation to admission was 56 hours. The mortality rate was 32% and was adversely influenced by the duration of illness, duration of perforation, shock, uremia, encephalopathy and fecal peritonitis. Forty-nine patients were treated by closure of the perforation, resection or miscellaneous procedures; the other 29 by closure of the perforation combined with an end-to-end ileotransverse colostomy. Although mortality was the same in both groups, those undergoing bypass had a significantly smoother postoperative course.


Initial treatment of sigmoid volvulous by colonoscopy. The initial management of acute, nonstrangulated sigmoid volvulous is to attempt proctosigmoidoscopic, rectal tube, or barium enema reduction and evacuation. If unsuccessful emergency surgery is necessary. The flexible colonoscope offers an additional therapeutic modality to effectuate preoperative reduction of the twisted sigmoid colon if attempts with conventional methods fail. Three cases of acute sigmoid volvulous are presented which illustrate for the first time successful reduction of acute sigmoid volvulous by colonoscopy after failure of the usual methods of treatment. Instead of emergency surgery all of these patients had elective resection with primary colocolostomy. Patients with acute sigmoid volvulous refractile to reduction by conventional modalities should have an attempt at flexible colonoscopic reduction.


Megacolon in the elderly. Ischemic or inflammatory? Ischemic colitis has been previously described in three forms: transient, strictured, and gangrenous. A fourth form of presentation in the elderly is characterized by signs of an acute abdomen, massive colonic dilatation, and systemic toxicity. Bloody diarrhea may be seen prior to the onset of dilatation. Ischemia should be considered as an etiologic factor in "colitis" in the elderly patient with segmental dilatation particularly if it follows a "low flow state." The rectum is usually uninvolved. Barium enema may confirm segmental involvement and later demonstrate stricture. Three patients with ischemic megacolon are presented. The diagnosis was suspected preoperatively in only one. In contrast to ulcerative colitis, these patients show a more abrupt onset and run a fulminant course. In patients who recover, there is lower relapse rate than young patients with ulcerative colitis. When resection is indicated, all attempts should be made to spare the rectum. Loop ileostomy and decompressive colostomy offer an excellent temporizing measure to assist the patient through the acute phase of the illness.


Evaluation and complications of 107 staging laparotomies for Hodgkin's disease. From 1971--1975, 107 staging laparotomies for Hodgkin's disease were performed at the University of Wisconsin Hospitals. Forty-one per cent of patients with abnormal abdominal lymphangiograms preoperatively had abdominal nodes which were negative for Hodgkin's. Thirteen per cent of patients with negative preoperative lymphangiograms had positive nodes at staging laparotomy. Twenty-nine per cent were upstaged by laparotomy, i.e. assigned to a less favorable stage (II A to III A), and 11.2% were downstaged. There were no surgical mortalities. Minor surgical complications occurred in 14.9%, and major ones in 3.7%. We conclude that surgical staging for Hodgkin's disease is valuable in making an accurate diagnosis and, hence, in determining the most effective treatment.


Regeneration of human liver after hepatic lobectomy studied by repeated liver scanning and repeated needle biopsy. Regeneration of the residual lobe of the liver after hepatic lobectomy in humans was studied by repeated liver scanning in seven noncirrhotic and three cirrhotic patients. Each patient was studied for several months during the study which lasted from 1-12 years. Regeneration was apparent in noncirrhotic liver remnants following hepatic lobectomy. In the case of a long standing, space occupying lesions such as benign giant cysts, the liver remnant would complete its regeneration process rather early, usually within a few months of hepatic lobectomy. In hepatoma cases, however, regeneration of the residual lobe after hepatic resection usually took five or six months for completion. On the contrary, no definite increase in the size of the liver remnant was seen on repeated liver scanning in cirrhotic patients. Histologic study of the residual lobe was repeated on needle biopsy specimens in two noncirrhotic and four cirrhotic patients. Regenerative hyperplasia of liver cells with large hyperchromatic, or double nuclei never seen in the preresection liver appeared in the liver remnant five, 11, and 27 days after hepatic lobectomy in noncirrhotic patients. In cirrhotics, however, there were no histologic changes between the preresection liver and the postresection remnant studied three, five, 15, 40 days or even two years and 8 months after hepatic lobectomy.


Carcinoid tumors of the appendix. Mesoappendiceal extension and nodal metastases. Carcinoid of the appendix occurred in 92 of 400,000 surgical pathology specimens covering 70 years, and followed previously reported incidences by age, sex, symptoms, size, localization and histology. Invasion of the mesoappendix occurred in 13 cases, and in two of these, a reoperative ileocolectomy demonstrated regional node metastases. No distant metastases or fatalities appeared. Tumor size correlated with mesoappendiceal invasion. Carcinoid invasion of the mesoappendix may provide a valuable marker for more distant tumor spread, and justify an aggressive surgical approach in selected patients.


Sensitivity of the canine pancreatic intraductal pressure to subclinical reduction in cholinesterase acitivity. As a continuation of work from this laboratory on anticholinesterase induced pancreatitis, a study of the relationship between reduced serum cholinesterase activity and changes in pancreatic intraductal pressure was undertaken. Pharmakokinetic studies in three dogs revealed rapid reduction in serum cholinesterase activity following an IV bolus dose of the cholinesterase inhibitor 0,0-diethyl-0-(2-isopropyl-6-methyl-4-pyrimidinyl)phosphorothioate. Following each dose of cholinesterase inhibitor, stable levels of cholinesterase inhibition were reached in 30 minutes. In four dogs the pancreatic duct was perfused from the tail of the ventral pancreas and intraductal pressures measured. A total of 25 mg/kg of the cholinesterase inhibitor was given in 5 mg/kg doses 30 minutes apart, and serum cholinesterase measured 30 minutes after each dose. Mean pressures were established over a 15 minute interval. Linear regression analysis of 23 data points revealed a significant (p < 0.001) cumulative dose-related increase in pancreatic intraductal pressure [Pressure (cm saline) = 14.2 + 1.03 x Cumulative Dose (mg/kg)] and significant (p< 0.001) negative correlation between serum cholinesterase activity and intraductal pressure [Pressure (cm saline) = 48.0 - 0.057 x Esterase Activity (mU/ml)]. These data suggest that, in dogs, reduced cholinesterase activity is directly related to increased pancreatic intraductal pressure, and it may be a factor in the pathogenesis of pancreatitis.


The undescended "parathymus". An occasional cause of failed neck exploration for hyperparathyroidism. Arrested descent of the inferior parathyroid gland ("parathymus") during embryologic development may leave the gland stranded high in the neck. Adenomas of such undescended glands are a rare cause of primary hyperparathyroidism, but they may not be uncommon among patients who have already had a failed cervical exploration. Unless the surgeon is aware of this entity, he will probably overlook it. If one is to find these tumors, it is necessary to extend the dissection upward above the superior pole of the thyroid gland, sometimes as far as the angle of the jaw. Adenomas of undescended "parathymus" glands were encountered in seven patients during a recent 20 month (May 1975 through December 1976) surgical experience encompassing 414 primary operations and 27 reoperations for hyperparathyroidism. These tumors were found at initial exploration in one patient and at reoperation in six patients. The individual case histories are presented to illustrate the difficulties posed by this anatomic variant.


Comparison of estrogen receptor levels in primary and regional metastatic carcinoma of the breast. The estrogen receptor (ER) level in carcinoma of the breast is a useful predictor of response to hormonal therapy. Metastatic disease may not have the same level of ER as the primary. In a series of 37 patients who had simultaneous ER determination in both primary neoplasm and regional nodal metastasis there was 81% agreement. The true ER character of the tumor would have been missed in seven patients if only the primary tumor had been sampled. The possible reasons for this discrepancy are discussed. We feel that the nodal metastatic deposit may reflect the true nature of the ER status because it represents a purer concentration of tumor cells as well as representing the aggressive element of the tumor.


Anoxic hypothermic cardioplegia compared to intermittent anoxic fibrillatory cardiac arrest. Clinical and metabolic experience with 1080 patients. Appropriately applied, hypothermic cardioplegia allows an excellent surgical setting that can significantly reduce the myocardial ischemic injury resulting from anoxia. One thousand eighty adult and pediatric patients underwent a variety of corrective cardial surgical procedures utilizing cold potassium cardioplegic solution injected into the coronary arteries via the aortic root. Myocardial septal temperature was maintained at 18--20 degrees during arrested time. This group of patients was compared to a group of 220 patients that underwent intermittent normothermic ischemic arrest to perform cardiac surgical procedures. Significant reduction in morbidity, mortality, perioperative myocardial infarction was noted in favor of the cardioplegic group. Metabolic coronary sinus blood analysis in the group undergoing surgery with cardioplegia revealed favorable changes in myocardial lactate and oxygen extraction.


Seeding arterial prostheses with vascular endothelium. The nature of the lining. Arterial prostheses seeded with autogenous vascular endothelium demonstrate a well-organized, cellular, inner lining. To determine the nature of the lining cells, six animals underwent replacement of the infrarenal aorta with Dacron prostheses. During the preparation of three such grafts, endothelium was scraped from the saphenous vein with a steel wool pledget, suspended in chilled Sack's solution, and mixed with blood used to preclot the graft. This suspension was omitted from the three control grafts. After six weeks, the grafts were removed, rinsed and examined. Fluorescent Factor VIII related antigen (F VIII-RA) strongly stained the lining cells. Silver nitrate Haütchen and electron microscopy preparations revealed a lining pattern characteristic of vascular endothelium. Endothelial cell-specific Weibel-Palade bodies were identified in the lining cell cytoplasm. Masson's trichrome staining revealed a relatively collagen-poor connective tissue within the seeded fabric. Transmission electron microscopy disclosed vascular smooth muscle cells between the seeded graft fabric and the lining cells. Vasa vasorum, arising from the outer capsule, penetrated the fabric to supply the inner capsules of the seeded grafts. It is concluded that the cells lining seeded canine arterial prostheses are true vascular endothelium supported by vascular smooth muscle cells, that the lining contains minimal connective tissue, and that vasa vasorum develop. Unseeded control grafts lacked these features.


Hemostasis in massively transfused trauma patients. Twenty-seven patients requiring massive transfusions were studied prospectively to determine whether administration of stored, modified whole blood induced a primary disorder of hemostasis evidenced by generalized microvascular oozing. Platelet counts fell in proportion to the number of units of blood transfused. In contrast, the levels of factors V and VIII correlated poorly with the units of blood transfused, 85% of the total variation in the levels being due to influences other than transfused blood. Levels of all other clotting factors were unrelated to the number of units of blood given. Eight patients developed abnormal bleeding. The cause appeared to be dilutional thrombocytopenia in five patients, and DIC in three. In six of the eight, bleeding was controlled with platelet concentrates alone. Two patients were given cryoprecipitate also. The most useful laboratory test for predicting abnormal bleeding was the platelet count. Fibrinogen levels should be followed as an aid in the diagnosis of DIC. The BT, PT, and PTT were not helpful in assessing the cause of bleeding, unless they were greater than 1.5 times the control value. We recommend that any patient receiving massive transfusions who develops diffuse microvascular bleeding be given platelet concentrates. Platelet counts as high as 100,000 may be required to control bleeding from surgical wounds. It is not necessary to supplement transfusions of stored, modified whole blood with fresh blood or fresh frozen plasma.


Pathologic identification of poor prognosis stage I (T1N0M0) cancer of the breast. Twenty to 40% of Stage I(T1N0M0) cancers of the breast recur in ten years. This is an attempt to identify those patients in whom the disease is likely to recur. On the basis of a study of the histologic changes in the tumor and treatment failures poor prognosis was associated with several histological characteristics: poor cytologic differentiation; lymphatic permeation; blood vessel invasion and invasion of the tumor into the surrounding soft tissue. This classification was then applied to 363 cancers of the breast seen over a five year period and followed three to eight years. There were 203 Stage I (T1N0M0) tumors in the group. Ninety-four of the 203 Stage I tumors had one to four of the above histologic characteristics; 109 had none. Among the 109 patients characterized as good risks there were two treatment failures (2%). In the group of 94 with any high risk histologic features there were 47 treatment failures (50%) which were statistically significant (p = 0.001). The histologic changes had a cumulative effect on the degree of malignancy of the tumor. Pathologic changes in the tumor identified those patients whose Stage I (T1N0M0) tumors were likely to recur.


Risk reduction in gastric operations for obesity. Although nearly devoid of late complications, gastric operations for obesity have resulted in 4.7% early postoperative perforations. For patients over 39 years of age who perforated, the first 11 patients died and the last 9 survived. Perforations are equally common in upper stomach, anastomosis, and lower stomach. They have become more frequent with the 50 ml upper stomach volume and 12 mm stoma that are required to assure optimum weight control. Perforation is as common with gastroplasty as with gastric bypass. If it occurs, it is normally within the first ten postoperative days. Acute dilatation and rupture of the stomach can happen if all the nasogastric tube holes are in the jejunum after gastric bypass. Erosion of the stomach by the hard end of the nasogastric tube has occurred when the tube was positioned in the upper stomach. This paper is dedicated to the prevention of death by early recognition and aggressive management of perforation and by prevention of perforations through careful attention to the details of these operations and early postoperative care.


Stapled cystograstrotomy. A method of treatment for pediatric pancreatic pseudocyst. An uncommon complication of pancreatic inflammatory disease or pancreatic trauma in children is the development of a pseudocyst. The English literature records less than 100 cases in children and emphasizes that surgical intervention is the indicated form of treatment. The authors have had experience with nine pediatric patients suffering from pseudocysts in a seven year period. All except one were successfully treated by internal drainage; the other spontaneously resolved. Four had cystogastrostomy using a stapler. This method is discussed as far as indications, technique, advantages and complications.


Evidence for a pyloro-cholecystic reflex for gallbladder contraction. We studied the effect of graded antral distension on gallbladder contraction both when gastrin release was promoted (alkaline distension) and when gastrin release was blocked (acid distension) in five dogs provided with innervated antral pouch, chronic bile fistula and gastric fistula. Graded distension of the antrum caused graded gallbladder contraction as evidenced by bilirubin output even when gastrin release was completely suppressed. This nongastrin mechanism of gallbladder contraction is abolished by parenteral atropine and by transthoracic truncal vagotomy. These observations provide evidence for a cholinergic, pyloro-cholecystic reflex for gallbladder contraction that is dependent on intact long vagal pathways. Similar reflex mechanisms have been shown to be initiated by antral distension and to cause pancreatic enzyme secretion (pyloro-pancreatic reflex) or acid secretion from the oxyntic gland area of the stomach (pyloro-oxyntic reflex). It would appear, therefore, that the antrum plays a central role in the integration of upper gastrointestinal function not only through the hormone gastrin but also through neural reflex mechanisms.


Common bile duct and Oddi sphincter pressure before and after endoscopic papillotomy in patients with common bile duct stones. Pressures in the Oddi sphincter and common bile duct were determined before, immediately after and several weeks after endoscopic papillotomy. Fifteen patients were included in the study. Significant decreases in Oddi sphincter and common bile duct pressures were found and the decrease in Oddi sphincter pressure was to some extent dependent upon the length of the papillotomy.


Primary malignant duodenal tumors.

Primary malignant duodenal tumors. Fourteen patients with primary malignant duodenal tumors are studied. Twelve patients had adenocarcinomas and two patients had malignant lymphomas. Preoperative diagnostic procedures, such as radiographic study of duodenum with hypotonic duodenography, complete duodenoscopy with biopsy and artertiographic studies are discussed. Early diagnosis is the key for curative surgical treatment since these tumors seem to disseminate rather late. In patients with primary duodenal carcinoma the resectability rate was 66.7%-seven Whipple resections and one segmental resection. Only one patient in our series died after a Whipple resection. There was no mortality after other procedures. The five year survival rate was 14.2%. There is a definite correlation between regional lymph node involvement and survival time. The mean survival period after Whipple resection without lymph node invasion is 56.5 months in our series. The survival period after Whipple resection for adenocarcinoma with regional lymph node invasion (6 months) is identical to the survival after palliative internal derivations for duodenal adenocarcinoma (5.8 months). It is concluded that a positive peroperative frozen section of a regional lymph node should exclude resective procedures (except in patients who hemorrhage) because they have a higher mortality rate as derivative procedures. Fifty per cent of the patients treated for malignant duodenal lymphoma is tumor free two years after a radical surgical therapy combined with chemotherapeutical treatment from the early postoperative period.


A long-term follow-up of patients resected for benign esophageal stricture using the Inkwell esophagogastrostomy. A total of 45 patients have undergone an Inkwell esophagogastrostomy after resection of a benign esophageal stricture. Nineteen patients were available for a long-term follow-up study, showing evidence of gastroesophageal reflux in 16 patients. Due to the high incidence of reflux and subsequent morphologic changes, there was a not negligible late disability. The Inkwell esophagogastrostomy can no longer be recommended in the treatment of an underlying reflux-induced lesion, strictures included.


Effects of methylprednisolone on experimental pulmonary injury. We studied the effects of methylprednisolone on pulmonary function of unanesthetized dogs with oleic acid induced pulmonary edema observed over a four day period. Methylprednisolone (30 mg/kg) was administered to 11 dogs three and 24 hours after pulmonary injury. Eleven animals were untreated after pulmonary injury and served as controls. There was no difference between the two groups until 72 hours after injury, when the venous admixture of the steroid treated animals was 11 +/- 3% (SD) compared to 22 +/- 8% (p less than 0.001) in the untreated with respective PaO2 values of 76 +/- 6 torr and 64 +/- 8 torr (p less than 0.001). Light microscopic examination of the lungs 96 hours after injury revealed a marked proliferation of Type II pneumocytes in the methylprednisolone treated animals. We conclude that, in the oleic acid or fat embolism model of pulmonary injury, methylprednisolone significantly increases resolution of the pulmonary injury presumably by stimulation of active proliferation and maturation of Type II pneumocytes.


Revascularization of the ischemic canine hindlimb by arteriovenous reversal. Arteriovenous reversal (AVR) for revascularization of ischemic tissues has previously failed to meet theoretical, experimental, and clinical expectations despite recurrent trials. The efficacy of a new staged approach to AVR was tested against a canine ischemic limb preparation in which global ligation of ipsilateral collaterals inevitably led to limb gangrene. In 12 animals the complications of direct, single-stage end-to-end femoral AVR, inevitably accompanied by the development of extreme edema, were demonstrated. However, when the ischemic preparation was accompanied by a staged AVR, in which an initial end-artery-to-side-vein arteriovenous fistula was converted 1 week later to AVR by ligation of the central venous limb, 20 of 20 animals survived, and 19 of 20 were ambulatory long-term survivors with only mild edema. Serial angiograms at 1 week, 1 month, and 4 months demonstrated patency rates of 100, 84, and 63%, respectively. Histologic examination of animals electively killed from 4 to 24 months showed normal skeletal muscle histology, venous intimal thickening, and mild edema. In the acutely ischemic canine hind limb, a staged AVR can provide both viability and function with only mild edema formation.


Minor hemobilia. Clinical significance and pathophysiological background. Profuse hemorrhage into the biliary tract--major hemobilia,--is an alarming condition which attracts much attention. Minor hemobilia, often caused by gallstones or operative injury, is much more frequent, yet often neglected. Clinical observations indicate that minor hemobilia is not always an innocent condition with the blood remaining fluid and unobtrusively flowing into the intestine. Examples are given where clots from occult hemobilia have caused diagnostic errors or obstructed the bile flow, thus imitating gallstones for which they may be mistaken. Experiments have been performed to elucidate the pathophysiology of this clot formation: 1) A model of the biliary tract was constructed with bile flowing through it. When blood was injected forcefully to simulate a major hemorrhage, mixed clots of blood and bile were formed. When introduced gently, as in minor hemobilia, the blood flowed immiscibly to the lowest level where it formed a clot of pure blood. The clots dissolved under the influence of flowing bile, but remained intact when protected from the flow. 2) Mixed clots were mushy and dissolved spontaneously, while pure clots remained solid and stable. When clots containing increasing amounts of bile were incubated, increasing amounts of cleavage products of fibrinogen and fibrin were formed. 3) Blood clots were produced in gallbladders of 33 dogs. Pure clots remained solid and floating while mixed clots formed a mushy layer, strongly adherent to the mucosa. Both kinds of clots disappeared after two-four weeks, but remained if bile flow was diverted. These findings explain why under certain circumstances minor hemobilia acquires clinical significance by forming clots that may obstruct the flow or cause diagnostic errors. Successful dissolution of "retained stones" may occasionally have the simple explanation that blood clots, mistaken for calculi, have been fibrinolysed. Consequently, in biliary obstruction or when defects are found on cholangiography, the possibility of blood clots in the ducts should be considered even in the absence of overt gastrointestinal hemorrhage.


Survival of patients with aortic valve endocarditis. The prognostic implications of the echocardiogram. The clinical and prognostic implications of the echocardiogram were assessed in 32 patients with clinical aortic valve endocarditis. Seventeen patients had an echocardiographic diagnosis of a vegetation, a flail cusp, or a root abscess (group 1). Ten group 1 patients had embolic episodes. Eight group 1 patients were treated surgically and all survived, while nine group 1 patients were treated medically and two survived. Eleven patients had echocardiographic aortic valve sclerosis (group 2). One group 2 patient had an embolic episode. Six group 2 patients were treated surgically and four survived, while five group 2 patients were treated medically and three survived. Four patients had normal aortic valve echograms (group 3). One group 3 patient had an embolic episode. All group 3 patients were treated medically and survived.


Incidence and outcome of the respiratory distress syndrome in gram-negative sepsis. Twenty cases of the adult respiratory distress syndrome (ARDS) in 86 cases of Gram-negative bacteremia were identified. Features of Gram-negative bacteremia associated with the development of ARDS included a history of cardiac disease, hypotension, and thrombocytopenia. The mortality of patients with and without ARDS was 90% and 55%, respectively. The association of hypotension and thrombocytopenia with the subsequent development of ARDS suggests the possible role of endotoxin-induced coagulopathy in this complication.


Learning style in a primary care internal medicine residency program. Individual differences in learning style should be one factor that is considered in medical education program planning and instruction, and this can be accomplished by using Kolb's learning style inventory (LSI) in a primary care internal medicine residency program. Case accounts are presented to suggest how the LSI can be used to enrich teaching-learning encounters. To our knowledge, these case accounts are the first reports of an important use of knowledge about learning style, obtained through instruments such as the LSI. Other educational applications are suggested with respect to evaluation formats and choice of instructional methods.


Effect of parathyroidectomy on anemia in chronic renal failure. Fourteen patients with chronic renal failure underwent parathyroidectomy. Postoperatively, seven patients exhibited a rise in hematocrit reading, but seven others did not. Responders had more severe bone disease and lower initial hematocrit values than did nonresponders. Marrow fibrosis was slightly more prominent in responders. Current concepts of marrow erythropoietic inhibition in renal failure suggest a toxic serum factor as the cause. This report fails to support parathyroid hormone as the toxic agent directly responsible for marrow inhibition. Rather, parathyroid hormone may contribute to anemia in renal failure by causing marrow fibrosis, a process sometimes reversible by successful therapy of hyperparathyroidism.


Epidemiology of infectious syphilis at a tertiary hospital. In 19 of 20 patients in whom the correct diagnosis of primary or secondary syphilis was not obvious initially, a positive routine admission VDRL test result was the first indication of the correct diagnosis. A retrospective study during a one-month period to correlate hospital admissions by clinical service with required routine admission serologic tests for syphilis disclosed an overall compliance rate of only 37.1% (range, 94.6% to 8.0%). Of the 38 patients who did have a positive admission VDRL test result, 55.3% were falsely positive. The false-positive rate was slightly higher for weakly reactive titers than it was for higher titers. The routine serologic testing program uncovered 129 and 116 new cases of syphilis during 1976 and 1977, respectively. The decision to continue the routine admission VDRL screening program was made because the consequences of an incorrect diagnosis could be very great for an individual patient.


Bone marrow necrosis and degeneration.

Bone marrow necrosis and degeneration. Bone marrow necrosis, regarded as a rare finding in specimens from living patients, has been associated with a poor prognosis in patients with serious hematologic diseases and metastatic carcinoma. Two patients with extensive idiopathic bone marrow necrosis and a relatively benign course of illness were found. Therefore, we examined 500 consecutive bone marrow biopsy specimens that were obtained in a university hospital complex. Review of this material showed evidence of necrosis and degenerative changes of variable severity in one third of the biopsy specimens. It was found with approximately the same incidence in patients who underwent bone marrow biopsy for either neoplastic or nonneoplastic disorders; an increased prevalence was not observed in the group of patients who had received chemotherapy. Based on these observations, we believe necrosis and degeneration of the bone marrow is a commonplace finding that is frequently overlooked in a wide variety of acute and chronic disorders, and that requires further investigation to determine its clinical importance.


Survival with severe hypernatremia.

Survival with severe hypernatremia. In a 74-year-old woman, excessive insensible water loss developed secondary to a period of hot, humid weather, associated with an underlying inability to obtain adequate water replacement. On admission to the hospital she was comatose, clinically dehydrated, and had laboratory values consistent with a water deficit of approximately 30% (9 L) of body water. Serum sodium concentration was 202 mEq/L. Serum osmolality was 430 mOsm/L. The patient remained comatose for seven days, during which time she was vigorously treated with fluids, and she gradually recovered. This case represents what we believe is a unique report in the literature of the severity of hypernatremia developing via this pathogenic mechanism and survival in an adult with this degree of disturbance of sodium and water homeostasis.


Recurrence after a surgically induced remission. In December 1976, an 18-year-old woman had symptoms typical of Cushing's syndrome. Laboratory evaluations and roentgenograms documented pituitary-dependent Cushing's disease in a patient with a pituitary microadenoma. In May 1977, she underwent transsphenoidal pituitary exploration. A 2-mm pituitary microadenoma was removed. The patient improved, and laboratory evaluation documented remission of the disease. In June 1978, she again complained of symptoms compatible with Cushing's disease. Laboratory evaluation confirmed a pituitary-dependent hypercortisonism. This case report marks the first recurrence of Cushing's disease in a patient previously cured by transsphenoidal resection of a pituitary tumor.


Complete degradation of carbohydrate to carbon dioxide and methane by syntrophic cultures of Acetobacterium woodii and Methanosarcina barkeri. Methanosarcina barkeri (strain MS) grew and converted acetate to CO2 and methane after an adaption period of 20 days. Growth and metabolism were rapid with gas production being comparable to that of cells grown on H2 and CO2. After an intermediary growth cycle under a H2 and CO2 atmosphere acetate-adapted cells were capable of growth on acetate with formation of methane and CO2. When acetate-adapted Methanosarcina barkeri was co-cultured with Acetobacterium woodii on fructose or glucose as substrate, a complete conversion of the carbohydrate to gases (CO2 and CH4) was observed.


Gender identity change in transsexuals. Follow-up and replications. An apparently successful change in gender identity of an adolescent transsexual was reported several years ago. Gender-specific motor behavior, appropriate sex role social behavior, cognitive sexual activity, and finally sexual arousal patterns were defined, measured, and sequentially modified. In this report, a 6 1/2-year follow-up is presented and the application of a similar therapeutic package to two additional cases is described. In the first case, sweeping changes in gender identity, sex-role behavior, and sexual arousal patterns were observed. In the second of these cases, rigid feminine gender was given up, but the patient chose to retain homosexual arousal. Social adaptation was satisfactory. These findings and other recent developments point to the possibility of psychosocial intervention as an alternative to surgery in the treatment of transsexualism.


Sex reassignment. Follow-up.

Sex reassignment. Follow-up. Although medical interest in individuals adopting the dress and life-style of the opposite sex goes back to antiquity, surgical intervention is a product of the last 50 years. In the last 15 years, evaluation procedures and surgical techniques have been worked out. Extended evaluation, with a one- to two-year trial period prior to formal consideration of surgery, is accepted practice at reputable centers. Cosmetically satisfactory, and often functional, genitalia can be constructed. Less clear-cut however, are the characteristics of the applicants for sex reassignment, the natural history of the compulsion toward surgery, and surgery's long-term effects. The characteristics of 50 applicants for sex reassignment, both operated and unoperated, are reported in terms of such indices as job, education, marital, and domiciliary stability. Outcome are reviewed. The results of long-term follow up data are discussed in terms of the adjustments of operated and unoperated patients.


Centerfold. An essay on excitement.

Centerfold. An essay on excitement. A woman who poses for soft-core pornography reports that she has never felt she belonged to her body, that she is and wants only to be an erotic product manufactured by a team of specialists for the use of a viewing audience of males, that since age 5 she has been a nude dancer, and that she has no other material existence except in this form. She is, then, a fetish. Her success illustrates the hypothesis that erotic daydreams in pronography represent fantasies of revenge in which the consumer imagines he is degrading--dehumanizing--women.


Nonverbal behavior and thought processing. Generally, clinicians assessing mental status interpret patients' nonverbal behavior in terms of its discharge, expressive, interactional, or neurological properties. The present study addresses the conceptualization of hand movement behavior as related to central cognitive processes, and attempts to identify encoding-related motor behavior by comparing the hand movements of subordinate bilingual subjects in situations of dominant- and nondominant-language and low- and high-imagery verbalization. Compared to the parallel dominant-language situation, subjects verbalizing in their nondominant language produced more speech-primacy and groping hand movements. Also, in comparison with the verbalization about a high-imagery topic, when the subjects encoded a low-imagery topic they displayed more pointing movements. Unless they are aware of these movements, clinicians evaluating bilingual patients may interpret an increase in encoding-related motor activity as reflecting psychopathology. Apart from this psychodiagnostic significance, hypothetical implications of these findings for the study of aphasia and information processing mechanisms are discussed.


Cerebral lateralization and personality style. Hysterical and obsessive-compulsive style subjects, as determined by a modified Rorschach test and the Wechslar Adult Intelligence Scale Comprehension subtest, were questioned in a face-to-face format where lateral eye movements were surreptitiously observed. Only right-handed subjects were used. It has been argued that lateral eye movements index immediate hemispheric activation after questions--the first such eye movement being a direction opposite to the putatively activated hemisphere. There was significantly more left-looking among the hysterical subjects than among the obsessive-compulsive style subjects.


Adaptational problems of Vietnamese refugees. I. Health and mental health status. The forced migratory influx of Vietnamese to the United States has raised questions regarding the resettlement process, the effect of culture shock, the refugees' coping behavior and adaptabilities, and their health and mental health status. We report the two-year results of ongoing research on the Vietnamese refugees based on the use of the Cornell Medical Index (CMI). The responses on the CMI on the first (1975) and second (1976) administrations indicate a high and continuing level of physical and mental dysfunction. The second administration also revealed significant shifts in dysfunctions as well as exposing factors that related to these dysfunctions, ie, age/sex interactions, marital status, family groupings, and public assistance. The follow-up CMI also showed an increase in anger and hostility with concomitant reductions in feelings of inadequacy.


Multimodality treatment. A one-year follow-up of 84 hyperactive boys. This study reports findings at the end of the first year of a three-year prospective study of 84 hyperactive boys. A multidimensional approach to evaluation and an individualized multimodality treatment plan commensurate with each child's disabilities was used. Treatment plans were implemented by members of the research staff working together as a coordinated therapeutic team. Measures of the child's behavior at home and at school, academic performance, delinquent behavior, and emotional adjustment were obtained initially and at one year. Results suggest that the combination of a clinically useful medication with appropriate psychological treatments simultaneously directed to each of the child's many disabilities is associated with an unexpectedly good outcome. Whether this will continue to be true when these children are followed up over a longer period of time awaits further investigation.


The laminar and size distribution of commissural efferent neurons in the cat visual cortex. The laminar and size distribution of commissural efferent neurons were studied in the cat visual cortex including area 17, 18, 19 and the lateral suprasylvian cortex (the lateral wall of the middle suprasylvian gyrus) by means of retrograde transport of horseradish peroxidase. Single or multiple injections of the enzyme were made unilaterally along the medial part of the lateral gyrus (the adjoining parts of area 17 and 18) or along the lateral wall of the middle suprasylvian gyrus. In the contralateral cerebral cortex (area 17, 18, 19 and lateral suprasylvian cortex) the majority of peroxidase labeled commissural efferent neurons was identified in layer III with a smaller population in other layers except layer I. The size distribution of labeled cells of layer III showed that all sizes of neurons contribute to interhemispheric connections, ranging from small cells which are comparable to those predominating in layer III of the acommissural medial area 17 to the characteristic large pyramides of layer III at the area 17/18 boundary. There was a certain difference in the pattern of size distribution of commissural efferent neurons of layer III between area 17, 18, 19 and the lateral suprasylvian cortex. Labeled neurons in area 17, 18, 19 showed a dominant peak in the histograms of cell size, while in the lateral suprasylvian cortex they were more evenly distributed in a wide size range.


The Merkel cell in the labial ridge epidermis of the anuran tadpole. II. Electron microscope observations on the appearance and differentiation of the Merkel cell. The appearance and cytodifferentiation of the Merkel cell were studied electron microscopically using the developing labial ridges of Rana japonica. The most primitive Merkel cell was identified with specific cored granules with an average diameter of about 90 nm. Such a primitive Merkel cell was found in the basal layer of the primitive labial ridge epithelium. As the primitive labial ridge continued to mature, the primitive Merkel cell accumulated an increased number of the specific granules, developed digital shaped cytoplasmic processes and came into contact with nerve fibers. When the labial ridge was sufficiently developed the cell showed typical morphological features of the mature Merkel cell except for a small accumulation of tonofilament-like structures and glycogen particles. It was also observed that the position of the Merkel cell in the epithelium changed from the basel layer to the third basal layer during development. On the other hand, it was difficult to find the Merkel cell in the mesenchymal layer of the developing labial ridges. From the results, it was suggested that the cytodifferentiation of the Merkel cell in the labial ridge of an anuran tadpole occurs within the epithelium.


Ultrastructure of intercellular junctions in the rat exocrine pancreas stimulated by pancreozymin. Intercellular junctions in the exocrine pancreas, through which pancreatic enzymes may leak out from the lumen into the intercellular spaces, were studied in the rat by means of electron microscopy using tannic acid as a tracer and freeze-fracture methods as well as conventional thin sections. In thin sections and freeze-fracture replicas from the pancreas stimulated or not stimulated by exogenous pancreozymin, tight junctions were located between adjacent cells of the acinus or duct at the level just below the lumen. Observation of freeze-fracture replicas revealed that the number of strands or furrows in the tight junction did not differ significantly between the two groups but the width of the tight junction area was narrower and the distance between neighboring strands or furrows in the junction was smaller in the stimulated pancreas than in the control pancreas. Tannic acid, the molecular weight of which is smaller than that of pancreatic enzymes, could not pass beyond the tight junction area into the lumen. This study suggests that the pancreatic enzymes can not leak out from the glandular lumen into the intercellular spaces by dissociation of intercellular junctions even if the pancreas is stimulated by a high concentration of pancreozymin.


Fluorescence microscopic and enzyme histochemical studies of the innervation of the human spleen. The innervation of the human spleen was investigated by the fluorescence method for adrenergic nerve fibers (52 cases) and the enzyme histochemical method for cholinergic nerve fibers (27 cases). The spleens examined were removed by laparotomy chiefly for gastric cancer. Adrenergic nerve fibers were demonstrated at the medioadventitial junction and the media in the trabecular arteries, whereas they occurred at the medioadventitial junction in the central and penicillar arteries. They were not found in the trabecular and pulp veins and venules, sheathed capillaries, avascular trabeculae, white and red pulp, and capsule. Nerves containing only a few adrenergic fibers and nerves without adrenergic fibers occurred close to the trabecular arteries. It was also demonstrated that nerves close to the trabecular arteries contain cholinergic fibers. The present study first verifies histochemically that the human spleen is innervated doubly by adrenergic and cholinergic nerve fibers.


Pairing of spermatozoa in the epididymis of the opossum (Didelphis virginiana): a scanning electron microscopic study. Spermatozoa of the opossum, Didelphis virginiana, were taken from three different regions of the epididymis and examined by scanning electron microscopy, phase-contrast and dark-field microscopy. It has been demonstrated that marked morphological changes occur in spermatozoa during their passage through the epididymis. In the first segment or head of the epididymis, spermatozoa are non-motile and the long axis of their nuclei is perpendicular to that of the tail. The nucleus is V-shaped with a thick and a thin arm. At the junction of the two arms. At the junction of the two arms, where the arms join, the articular fossa receives the capitulum of the connecting piece which attaches the head of the spermatozoon to the tail. Spermatozoa from the central region of the epididymis show a re-orientation of the nuclei which now lie parallel to the long axis of the tail. Both paired and unpaired spermatozoa are found and show an increase in motility. In the caudal region of the epididymis all spermatozoa are paired. Pairing occurs as a result of the close apposition of adjacent cell membranes covering the acrosomes of the larger arms.


Specific lamellar structures of agranular endoplasmic reticulum in the senile mouse adrenal cortex. In the adrenal cortex of old mice, lamellar bodies of various shapes frequently appear in the zona reticularis cells. These structures consist of electron dense plates, about 20 nm in width, closely piled at regular distances of about 25 nm. Each plate displays two sheets of unit membranes enclosing a dense material and with several clear spaces between them. These paired membranes usually terminate in round saccules at both ends, but occasionally continue to the tubules of surrounding agranular endoplasmic reticulum. Saccules in several rows, in combination with a part of the lamellae, may be arranged cirularly in the cytoplasm. From these observations, it is proposed that the lamellar body is composed of a cup-shaped mass of flattened cisternae of the agranular endoplasmic reticulum and each of the cisternae is attenuated and closed except at their marginal sacculations. The concentric or horseshoe-shaped profile of the lamellar body observed in this study is accounted for by different section planes through the cup-shaped structure.


A bioceramic endoprosthesis for the replacement of the proximal humerus. In patients with malignant tumors in the region of the shoulder, radical resection can avoid amputation in most instances. To improve the function of the arm, endoprosthetic replacement of the defect is desirable. A three-component endoprosthesis made of a bioceramic material (aluminium oxide) was designed, implanted without bone cement. Fast anchorage to bone is achieved by using a conical sleeve, fixed upon the previously conically reamed humerus shaft. A stable primary fit is always feasible. Subsequent bone in growth into grooves inside the conical sleeve provides a permanent anchorage of the endoprosthesis. The authors experiences are based on implantations of 38 endoprostheses. The original diseases were primary malignant bone tumors in 19 patients, one case of "solitary" plasmocytoma and metastases into the proximal humerus in 16 patients. In two women, resection was made because of posttraumatic subcapital humeral pseudarthrosis. The follow-up study includes only those 27 cases operated on at least one year ago. 12 of the 14 patients with primary tumors have been surviving for 12-55 months (range 27.4) without signs of metastases or recurrent disease. Seven patients with metastases died of their original diseases after 7.7 months on the average. Owing to extensive resection of the shoulder musculature the mobility in the shoulder joint is considerably reduced. All the patients have good movement of the elbow joint and free function of the hand.


Improvements in total hip prosthesis implantation technique. A cement-proof seal for the lower medullary cavity and a dihedral self-stabilizing trochanteric osteotomy. The anchorage of the femoral component of a total hip prosthesis can be improved by the following two refinements to the surgical technique: 1. The femoral medullary cavity is plugged with a bone core taken from the excised femoral head or with a polyethylene bung. The plug prevents the bone cement from being displaced distally into the lower part of the medullary cavity. It contains a small hole through which blood can escape, thus preventing the latter from accumulating in the upper part of the medullary cavity and impairing the bond between the cement and the bone wall of the cavity. 2. The greater trochanter is no longer sliced off with a single cut in one plane but is now removed by dihedral osteotomy, i.e., by making cuts in two planes which intersect each other so as to form a ridge. On compressing this osteotomy by tension band fixation all movement between the fragments is eliminated, including that in the parasagittal plane which results from flexion and extension of the hip. In this manner loosening and pseudarthrosis of the osteotomy are prevented.


Special instruments and prosthetic cups for the removal and replacement of a total hip prosthesis. In the course of replacing more than 500 total hip prostheses over a period of five years the authors have developed a new set of instruments for the removal of the defective prosthesis and cement and for improved anchorage of the new prosthetic cup. The set comprises: 1. A set of special chisels and an axially guided drill for removal of the old cement from the femur. These instruments greatly simplify the latter procedure. 2. A new type of prosthetic cup with a weight-bearing collar. This cup is used for cases in which the amount or structure of the acetabular bone is such that it will not support a conventional cup. 3. A new type of drill with a flexible drive and easily exchangeable drill bits for cutting anchorage holes in otherwise inaccessible parts of the acetabular bone.


Behavior of the extensor pollicis longus tendon in experiment. Several experimental rupture tests of the extensor pollicis longus tendon proved that a rupture of a tendon caused by experiments is located in a region in which the rupture is mainly found clinically as well. By using a newly developed Silicon impression system it can be proved that in the course of a tendon there is always a certain place which has the smallest cross section. This is more or less identical with the location of the rupture. Thus, ruptures of the extensor pollicis longus tendon can be experimentally simulated.


[The significance of tomography in the x-ray diagnosis of coxarthrosis (author's transl)]. Authors have made besides routine roentgenograms tomograms too in 50 patients with coxarthrosis of various severeness. For an assessment of the diagnostic value of tomography the routine roentgenograms and the tomograms were analysed comparatively. The investigations have shown that the tomography may give in certain cases great help in the judgement of progression and in the correct indication of operative methods in hip surgery.


Total subperiosteal resection treatment of solitary bone cysts of the humerus. The solitary bone cyst is most frequently located in the upper arm and the average age of the affected patients is between 7 and 9 years, thus perceptibly lower than in cases where solitary bone cyst occurs elsewhere, where the average age is 15. The tendency towards recurrence before 10 years of age is twice as great as the tendency after that age. Investigation of the results obtained from the treatment of 26 patients suffering from solitary bone cyst of the humerus showed a recurrence rate of 55% after curettage and filling-in of the defect with cancellous bone grafts, whereas after total subperiosteal resection and bridging the defect with an autologous tibia graft the corresponding recurrence frequency was 7%. The average duration of the plaster cast fixing period after resection treatment was 18 days longer than after curettage, but the low rate of recurrence in the first-mentioned case makes up for this disadvantage. It is absolutely essential to retain the periosteum in cases of cyst resections. The defect is bridged over by an autologous tibia graft, but fibula grafts are also suitable for bridging the defect. Osteosyntheses are not necessary with latent cysts. In the case of active cysts screws, wire loops, Kirschner wires, and thin Küntscher nails can be used as temporary stabilisation means. Plate osteosyntheses constitute an exception. Complete removal of the cyst by resection is the most certain prophylactic method against recurrence, and hence the most reliable form of treatment of the solitary bone cyst of the humerus.


An alternate method for posterior fixation in anterior and inferior atlanto-axial dislocation. A modification of common methods is described for fixation of anterior and inferior atlanto-axial dislocation (AAD and IAD). In AAD a wire is passed around the atlas arch and knotted around the spinous process of the axis in a way that a figure 8 arrangement is achieved as seen in the lateral view. In IAD a wire is passed through holes in the occiput and knotted around the spinous process of the axis. A rectangular bone graft is inserted between the occiput and the spinous process of the axis, thus preventing further inferior dislocation. In both methods methyl methacrylate and bone grafts are as a rule added for further long-time stabilization. The methods have been used in 15 cases of AAD and in three cases of IAD. On radiologic examination with attention focused on the immediate postoperative fixation the follow-up time has been three months. The long-time results of fixation have been recorded with a follow-up time of six years. The fixation proved to be satisfactory in 14 patients with AAD and in the three patients with IAD. The clinical results were good in the 14 patients with AAD and in the three with IAD.


[The creeping post-operative hip joint empyema (author's transl)]. The case histories of 10 patients with chronic empyema of the hip joint following nailing of the femoral neck, respectively following intertrochanteric osteotomy are being described. With only a few exceptions their post-operative course showed no signs of infection. After an interval of between 5 weeks and 2 years their condition deteriorated rapidly. By the time the patients returned to hospital, usually, the joint was already destroyed or septic luxation had occurred. Because of their poor general condition only resection of the femoral head was possible. As an alternative to continuous suction drainage, the implantation of PMMA chains seems to have advantages.


Myositis ossificans following total knee replacement. A report on two cases. Two cases of myositis ossificans involving the quadriceps femoris muscle are described following total knee replacement arthroplasty. This condition appears to be a very rare complication of this operation. One case was helped by ultrasound therapy.


The effects of dynamic loading on intracalcaneal wood implants and on the tissues surrounding them. The dorsal parts of the calcanei of rabbits were resected and replaced with similarly-shaped implants made of ash wood. In each case the Achilles tendon was reinserted into the projecting part of the implant so as to subject the latter to the dynamic loads generated by use of the limb. The implants were removed from some of the animals after 5 weeks and from the others after 14 weeks. They were evaluated by preparing undecalcified microtome sections and ground sections which were examined by light microscopy and microradiography. Some of the animals underwent vital staining so as to produce polychromatic sequential labelling of the calcaneal specimens. In the area of insertion of the Achilles tendon soft tissue grew into the larger pores of the wood and, in some cases, differentiated into cartilage. Every implant remained stably anchored in the calcaneus. In every animal the intracalcaneal part of the implant became surrounded by new bone which was in direct contact with the surface of the implant and which also formed in the pores of the wood, even all rabbits loaded the operated foot. The formation of new bone in and around the implants demonstrates the basic feasibility of using ash wood as an isoelastic implant material in bone.


Differential diagnosis of ruptures of the lateral ligaments of the ankle joint. Ruptures of the lateral ligaments of the ankle joint occur very frequently in young persons and this subject is therefore one which deserves more attention. Once a fracture or avulsion of a ligamentary insertion has been excluded the nature and extent of the ligamentary lesion should be precisely assessed. The only objective criterion of rupture of a ligament is demonstrable instability of the joint. Since the anterior talo-fibular ligament is always found to be torn immediately following supination-inversion injury to the ligaments the talar drawer sign will be demonstratable both clinically and radiologically in such cases. This test causes almost no pain and can be carried out without anesthesia. The radiological visualization of ligamentary instability with the aid of a simple jig which stresses the ankle joint provides diagnostic information which is definitely superior to that obtained from an a-p roentegenogram of the stressed joint. This conclusion was reached by statistical analysis of 384 roentgenograms.


[Crystallographic investigation of distraction callus (author's transl)]. Physical examination using electron diffraction and thermogravimetry was performed on the distraction callus of six metacarpal bones of sheep. Brushite was observed in this callus beside apatite, and the number of crystals found was less than in physiological nature bone. From the crystallographic point of view the distraction callus was found similar to the callus known in fracture healing.


Syndromes of compression of the median nerve in the proximal forearm (pronator teres syndrome; anterior interosseous nerve syndrome). Entrapment of the median nerve in the proximal forearm is seen in two forms: the pronator teres syndrome, and the anterior interosseous nerve (or Kiloh-Nevin) syndrome. Both syndromes are rare, and they comprised approximately 1% of the compression syndromes of the upper limb which were treated operatively by the authors. The symptoms, signs, etiologies, and intraoperative findings are discussed. It is pointed out that certain of the clinical features may resemble those of irritation of the median nerve by a supracondylar process or Struthers' ligament. Although both proximal median entrapment syndromes have a favorable prognosis when treated non-operatively, the authors recommend operative treatment in cases in which there is no perceptible improvement following 8 weeks of non-operative treatment, since this is likely to speed and enhance recovery. Nine cases of the pronator teres syndrome (8 treated successfully by operation, 1 failure) and 2 cases of the anterior interosseous nerve syndrome (both fully recovered) are added to the cases reported previously in the literature.


Femoral neck fractures following surface replacement. A femoral neck fracture following surface replacement of the hip has been studied and five potential causes of failure were noted. These consisted of; removal of a hip nail during surgery, use of a too small femoral cup, initial reaming in varus, notching of the femoral neck, and failure to completely seat the cup.


Functional recovery from cancer surgery: estimation of expectations. Level of expected functional recovery from colostomy, laryngectomy and mastectomy was established by the Delphi technique. One hundred fifteen cancer rehabilitation experts responded to 2 rounds of questionnaires and provided their judgments regarding degrees and timing of recovery in 14 functional, physical and psychological areas. Feedback of first round judgments was provided in the second round and 85% agreement was set as the standard for consensus. The mastectomy patient is expected to have the quickest recovery with former level of functioning reached in most areas by 3 months postdischarge. The colostomy patient is expected to be functioning normally in most areas by 6 months postdischarge. The laryngectomy patient is expected to be functioning normally in most areas by 12 months postdischarge. Some functions were judged to have the same rate of recovery for all 3 patient types; for example, the experts agreed that for the 55-year-old patients described in the case abstracts, sexual activities would not reach the preoperative frequency until 12 months postdischarge.


The pedynograph: a clinical tool for force measurement and gait analysis in lower extremity amputees. The pedynograph is a simple, inexpensive piece of equipment which can be used in the clinical setting to monitor amputee gait. Strain gauges applied to the pylon of a modular prosthesis and incorporated in an appropriate electrical circuit provide measurements of axial load which are displayed on an oscilloscope during ambulation. Preliminary experience with the described equipment has shown that it is of value in monitoring and regulating weight bearing in patients with healing or maturing stumps or impairment of stump sensation. Gait and prosthetic problems can be analyzed, their correction documented and a permanent record of amputee performance provided.


Orthotic devices for serratus anterior palsy: some biomechanical considerations. The pathomechanics of serratus anterior palsy are reviewed to provide a physiological basis for designing an effective brace. The problems involved in the practical application of the brace and the effectiveness of the brace in controlling the biomechanical dysfunctions are discussed. Two modifications of the basic brace and their effects on the patients' shoulder functions are presented. The main benefit of scapular bracing is control of scapular winging, while loss of active scapular rotation and medial scapular displacement cannot be effectively corrected.


Pressure distribution and skin temperature effect of the ROHO wheelchair balloon cushion. This study evaluated the effectiveness of the ROHO Balloon Wheelchair Cushion in distributing pressure on the skin over the ischial tuberosities in healthy subjects. Surface skin temperatures over the ischial tuberosities and thighs of the subjects were also measured. Pressure recordings were obtained by placing a pressure sensor between the wheelchair cushion and the skin overlying the ischial tuberosities. For comparison, pressures were recorded while the same subjects sat on a 4-inch foam cushion supported on a plywood board. Skin surface temperatures on the 2 cushions were recorded on separate occasions under the ischial tuberosity and the posterior thigh during a 30-minute test period. The results indicate no important difference in resting pressures when the subjects sat on either the 4-inch foam cushion or the balloon cushion. Neither was there an important difference in pressure when the cushion was inflated to greater than the manufacturer's recommendations or when it was covered with a commercially designed cover. The average increase in skin temperature over the tuberosity was 1.9C and over the thigh, 2.6C.


Involuntary single motor unit discharges in spastic muscles during EMG biofeedback training. The apparent involuntary single motor unit discharges observed in many extremity muscles of spastic patients necessitate monitoring raw electromyography during training sessions. The clinician should note that electronic components of some biofeedback instruments may amplify and distort these units so that the feedback, whether by meter or by variable pitch tone, may erroneously be perceived by the patient as a high level of muscle tension.


Below-knee orthosis: a wrap-around design for ankle-foot control. Control of foot and ankle positions with orthotic appliances is generally more difficult to accomplish in children with spastic than flaccid paralytic disorders. Our new design for a custom molded plastic ankle-foot orthosis has proven superior to other designs in most applications. The appliance is vacuum molded from very thin polypropylene plastic and innerfaced with a foam material (Aliplast). The limb is enclosed completely in plastic with an anterior opening secured by several Velcro straps. Although the material is soft and pliable, the circumferential support provides remarkably rigid control of the limb. The orthosis has been successfully applied to children with polio, meningomyelocele and all forms of spastic and athetoid cerebral palsy. In addition to superior limb control, another advantage appears to be reflex inhibition of abnormal motor tone in may spastic patients. Patients have preferred this orthosis to those previously worn probably due to greater comfort. The limitation of adjustability of dorsiflexion can be compensated by heel or sole shoe lifts. Excessive heat created by the "wrap-around" design can be reduced by a thin cotton sock extended above the orthosis.


Psychosocial factors associated with pressure sores. To determine if psychosocial factors, not purely mechanical aspects, play an important part in the incidence of pressure sores, 141 subjects were tested on 3 psychosocial measures. Results indicate that differences exist among groups in pressure sore history and psychosocial measures. Contrary to the expectations of a mechanical skin problem model, quadriplegics as a group (rather than paraplegics) had a history of fewer pressure sores. Two variables, the subject's responsibility in skin care (RESPON) and his satisfaction with the activiities of life (SATIS), were significantly associated with the incidence of decubitus ulcers. The combination of RESPON, SATIS, and the total positive score from the Tennessee Self-Concept Scale in multiple linear regression accounted for (1) 26% of the pressure sore history in the total sample, (2) 40% in the paraplegic group, (3) 69% in the paraplegic with help group, and (4) 41% in the paraplegic without help group. The histories in the quadriplegic groups and subgroups did not show reliable associations with the 3 variables. SATIS contributed most in accounting for the incidence of pressure sores. The level of injury and these psychosocial factors are thus related to the incidence of pressure sores.


Conceptual style and life satisfaction following spinal cord injury. The major purpose of this study was to explore the relationship between conceptual style and life satisfaction following a physical loss. It was predicted that conceptual abstractness is positively associated with life satisfaction. Fifty-four men between the ages of 18 and 41 who were paraplegic or quadriplegic, because of a spinal cord injury that occurred at least 18 months prior to the interview, were asked to complete questionnaires designed to measure their conceptual styles and their satisfaction with various aspects of their lives. The data suggest that: the respondents were generally satisfied with life; dissatisfaction was frequently greatest in family and other intimate relationships; and physical trauma may trigger changes in conceptual style in the direction of greater complexity and abstractness. The predicted positive association between conceptual abstractness and life satisfaction was supported in several instances by the data.


Sphenopalatine (nasal) ganglion: remote effects including "psychosomatic" symptoms, rage reaction, pain, and spasm. Many articles implicate the nasal ganglion in the production of remote symptoms and discuss treatment. Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others. All these symptoms appear to have 2 common denominators. They are mediated by the autonomic nervous system and at least in some instances can be "psychosomatic." The sphenopalatine ganglion (SPG) is a major autonomic ganglion located superficially in the pterygopalatine fossa, with major afferent distribution to the entire nasopharynx and important connections with the trigeminal nerve, facial nerve, internal carotid artery plexus of the sympathetic nervous system and, as shown in the rat, direct connection with the anterior pituitary gland. This paper presents arguments supporting the following hypotheses: 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered.20


Electromyographic insertional activity in normal limb muscles. A mechanical electrode inserter was used to allow reproducible electromyographic (emg) electrode insertions. The electrical activity provoked by the mechanical insertion was recorded and quantitatively analyzed in the anterior tibialis, the extensor hallucis longus, and the extensor digitorum brevis of unimpaired human subjects. No statistically significant differences were found among these muscles in the total duration of sharp spike activity or in the duration of sharp spike activity following cessation of needle electrode movement. There was a statistically significant reduction in the total duration of mechanically-provoked electrical activity in the extensor digitorum brevis when compared to the anterior tibialis using the technique employed in this study. There was a statistically significant increase in time following the onset of needle electrode movement until the initiation of sharp spike activity in the extensor hallucis longus as compared to the anterior tibialis. Abnormalities are present in the extensor digitorum brevis muscle of clinically unimpaired subjects. Endplate spikes can be recorded as positive-shaped potentials in the endplate zones of muscle. Nonreproducible positive-shaped potentials of unknown etiology are seen to occur singly or in pairs following insertional activity in normal muscle. When examining muscle for the early evidence of provokable positive sharp wave and fibrillation potentials, care must be taken not to mistake normal characteristics of insertional activity for pathological abnormalities.


EMG needle electrodes: electrical impedance. The electrical impedance of samples of stainless-steel monopolar needle electrodes and concentric electrodes from 3 manufacturers were measured in 154mM saline solution using sine-wave excitation at 4 frequencies from 10Hz to 10kHz. Current densities of less than 2.5x10(-5) amp/cm2 were used. Measurements on both needle and fine-wire electrodes were also made in live rats. Linear dimensions of the exposed tips were measured from which the areas of exposure were calculated. Surface areas of the monopolar needles varied between 0.06 and 0.15mm2. Presoaking of the electrodes for 20 minutes in saline solution containing a small concentration of a wetting agent produced a sixfold to twentyfold reduction in impedance. The average impedance magnitudes of the monopolar electrodes ranged from 1.4 megohms (Momega) at 10Hz to 6.6 kolohms (komega at 10kHz. The phase angle of the impedance due to the capacitive component of the needle-electrolyte impedance ranged between -45 and -71 degrees. The reduction in impedance resulting from presoaking and the concomitant reduction in electronic noise would be an advantage in observing lowamplitude potentials.


Vocational development and adjustment of adolescents with cystic fibrosis. Adolescents with cystic fibrosis were compared with normal adolescents of the same age and educational grade on several measures of vocational development and adjustment. The cystic fibrosis group in ages 12--16 and in grades 7, 8, and 9 scored lower than their normal counterparts in measures of vocational and educational plans, and were less realistic than normals in considering their limitations and financial constraints. In contrast, the cystic fibrosis group at nearly all age and grade levels scored significantly higher on strength of commitment to vocational choice, work values, and awareness of occupational information. Compared to 4 additional handicapped groups already studied, adolescents with cystic fibrosis scored favorably. They not only plan to work but also hold strong work values compared to normals. Rehabilitation programs should emphasize preparation for a career and the development of educational and vocational plans while the adolescent is still in high school.


Arthritic hand response to pressure gradient gloves. Five women with osteoarthritis and 10 with rheumatoid arthritis and finger joint involvement wore a pressure gradient glove, a control glove, or no glove in a randomly assigned sequence. All were outpatients. Each patient wore the assigned glove nightly for 1 week, after which a battery of subjective and objective data, including number of tender joints, ring size, grip strength, palmar temperature, and hand function were obtained. In all, 105 separate examinaion sessions were completed over 7 visits, with each hand serving as its own control in the experimental design. The palmar skin temperature was elevated in both patient groups when either a pressure gradient or control glove was worn. In patients with rheumatoid arthritis, the only significant difference was that the pressure gradient glove reduced ring size when compared to the control glove or no glove. No differences were detected in the patients with osteoarthritis.


Neonatal spinal cord injury.

Neonatal spinal cord injury. In this review of the prognosis of patients having neonatal spinal cord injury, findings in 3 patients and 11 case histories from the literature are evaluated as to obstetric complications, clinical and pathologic examinations, and follow-up data from 2 to 12 years, or until death of the child. Eight of the 14 patients died: 4 at less than 3 months of age, 3 between 3 months and 1 year of age, and 1 at 3 1/2 years of age. Six children survived for more than 2 years for follow-up examination. Survival is dependent on the level of the lesion, with cervical lesions being almost incompatible with life. The quality of survival for those with levels of C8-T1 and below depends on the child's multiple medical complications.


Dysphagia associated with cricopharyngeal dysfunction. In protracted forms of dysphagia associated with neuromuscular dysfunction, myotomy of the upper esophageal sphincter has been suggested. The literature, however, is unclear about the indications and outcome of this procedure. In this article, 3 cases are presented of dysphagia associated with the failure of relaxation of the cricopharyngeus during swallowing. Two patients had brain stem infarctions and the 3rd had an inflammatory disease of the brain stem. In all patients, barium swallow revealed aspiration of contrast material into the trachea with failure of relaxation of the cricopharyngeal sphincter. Indirect laryngoscopy demonstrated partial paralysis of one or both vocal cords. In one, an emg of the laryngeal muscles showed normal results. A complete evaluation by the speech pathologist failed to reveal abnormality of the oral musculature in all patients. All patients required gastrostomies for their nutritional needs. Therapeutic modification and control of rate, quantity and consistency of food along with counseling for prevention of aspiration. Oral feeding, without aspiration, was achieved in the 3 patients within the treatment period, allowing removal of the gastrostomy. Cricopharyngeal myotomy, therefore, was not necessary in these patients, despite the long duration of the swallowing problem.


[Effects of oxygen inhalation therapy on blood and phonomechanography in patients with heart disease, lung disease and cardiorespiratory insufficiency]. Arterial PaO2 and some phonomechanographic indices were studied during and after a period of 40-60-100% oxygen breathing in fourteen patients (six with pulmonary insufficiency, four with cardiac disease and four with cardiorespiratory insufficiency). Arterial PaO2 was measured at the beginning, every five minutes during and many times after the ventilation. Myocardial performance was also measured by sistolic time: isovolumetric contraction time, left ventricular expulsive time, preejection pressure, deformation time. The authors discuss the modifications of these indices and the clinical involvement of O2 breathing.


[Mexiletine, a drug with anti-arrhythmic action. Experimental research on the cardiovascular system]. It was shown experimentally that mexilithene possesses anti-arrhythmic activity with slight depression of sino-carotid baroreceptorial and glomo-carotid and gangliar chemoreceptorial activity and catecholamine uptake. Hypotensive and bradycardizing effects were only noted when high per kg doses were used. The drug did not display vascular alpha- and beta-adrenolytic, anti-muscarinic and anti-histaminic activity.


[Changes of plasma renin activity during perfusion with dextran 40. Functional study; statistical evaluations and cl-nical considerations]. Changes in RAP, AP (max and min), Ht and R.R. induced by daily perfusion with 250 and 500 ml Dextran 40 in a 10% isotonic solution were examined in two groups of patients with peripheral obstructive arteriopathy. Systemic AP showed no appreciable changes, whereas RAP and Ht fell in direct proportion of the dose given. This effect tended to disappear after 96 hr. Administration of this plasma volume extender 4 days per week is recommended.


[Relations between immunological and enzymatic parameters in viral hepatitis]. The results of a study showing correlations between the behaviour of complement serum level, the presence of antigen Au, variations in serum immunoglobulin and the behaviour of transaminases in the cases of hepatitis examined are reported. It was found that the reduction in complement level during the initial stage of the disease coincides directly with antigenaemia positivity, increased IgM production, large increases in transaminase activity and inversion of the SGOT/SGPT ratio.


[Ectopic pancreas in the duodenum].

[Ectopic pancreas in the duodenum]. Aberrant pancreas to the duodenal site is a by no means simple problem of diagnosis as it is only rarely that X-ray, gastroscopy or biopsy suggest it. The case of aberrant pancreas in the duodenum, simulating a peptic lesion, is reported. Following an anatomo-pathological study, the typical aspects of the case are stressed.


[Zieve's syndrome. Case report].

[Zieve's syndrome. Case report]. The Zieve's syndrome consists of the transient association of cholestatic jaundice, hemolytic anemia, hyperlipemia, in a chronic alcoholic. The Authors, after a short introduction regarding physiopathological problems, describe and subsequently examine on the clinical ground a recent personal observation, which had been mentioned for the rarene-s of this disease.


[Behavior of plasma androgens in cases of adrenal pathology]. Following chromatographic separation, the RI method has been used to examine the behaviour of plasmatic androgens in a group of normal subjects, in two patients with Addison's disease and two patients with hypercorticoadrenalism, due respectively to corticoadrenal adenoma and bilateral adenomatous hyperplasia. A significant reduction in adrenal androgens was observed in patients suffering from Addison's disease. The most interesting information, however, was the paradoxical reduction in DHEA and delta 4-A in patients with corticoadrenal hyperfunction.


[A case of primary hyperparathyroidism. Clinical contribution]. The authors discusses some clinical, laboratory and instrumental problems of a reported case of primary hyperparathyroidism caused by adenoma from the point of view of medical literature. Nethertheless the lack of the specificity of the clinical manifestations and the slowly progressive evolution of this disease, primary hyperparatiroidism must be suspected in the presence of his most common multifarious complications. The finding of hypercalcemia in these conditions and from screening procedures requests parathyroid functional tests and exclusion of other causes of which chiefly pseudohyperparathyroidism may be difficult to be differentiated. The early diagnosis and correction of the parathyroid lesion avoid further damage and regression of many preoperatory complications.


[Methods of treatment of tumors of the soft parts and bones of the limbs and extremities. Analysis of case records]. 218 patients examined for localized cancer of the extremities (50% benign, 50% malignant) are reported. The incidence is considered by sex and age. Demolition surgery was carried out in 35 patients and 27 locoregional treatment with antiblastics and radioactive isotopes was employed. Conservative surgery was used in 158. Operative mortality was less than 1% (2 cases out of 218) and did not reach 6% if amputations and disarticulations alone are considered. There were no deaths in cases submitted to radiochemotherapy and inguinocrural hymphadenectomy. The series includes a 15-years survival for giant-cell tumour of the femur treated with radioactive microsphores, an 11-years survival for a popliteal melanoma submitted to radiocolloid infiltration, a 9-year survival for femoral osteosarcoma for which hip disarticulation was carried out and a 4-year survival for a recurrent rhabdomyosarcoma of the hip operated by hemipelvectomy.


Further definition of antibiotic use and abuse in the surgical setting. Surveys of the use of antimicrobial agents were conducted at three university-affiliated teaching hospitals to ascertain the current use of antibiotics associated with surgery and to compare this use to the presently accepted standards. The survey included 300 consecutive surgical patients representing three surgical specialities. Evaluation was based on accepted therapeutic criteria with respect to the presence of an infection, appropriate in vitro antibiotic sensitivity testing, and recognized forms of prophylaxis. The results of our survey disclosed that although nonuse was usually appropriate, more often than not use of antibiotics was inappropriate. Errors, in order of frequency, included (1) misjudgments in attempted prophylaxis of operative wound infection, such as failure to use preoperative administration or use in clean operations without implanted foreign bodies, such as prosthesis, and (2) attempted treatment of undefined and undiagnosed fever.


Choledocholithiasis associated with acute cholecystitis. A retrospective review of the records of 1,507 patients with a diagnosis of cholecystitis was conducted for the five-year period, 1972 to 1977. Of this group of patients, a histopathologic diagnosis of acute cholecystitis was established in 154 patients (10.2%). Common duct calculi were detected in 17 of these 154 patients, an incidence of 11%. Preoperative evaluation by means of serum bilirubin and alkaline phosphatase levels and intravenous cholangiography was unsatisfactory for consistent demonstration of choledocholithiasis in the presence of acute cholecystitis. Intraoperative cholangiography was found to be the most reliable method for detection of common duct calculi and was successfully employed in 14 of 17 patients with choledocholithiasis. The remaining three patients had palpable stones.


Ultrasonography and tumor-associated antigens. The concept of combining noninvasive tests in the screening for pancreatic cancer. A total of 134 patients suspected of having pancreatic cancer were given preoperative ultrasonic examinations. A total of 54 cases had a final diagnosis of pancreatic cancer histologically confirmed. The diagnostic sensitivity and specificity of the ultrasonographies were 76% and 91% or 87% and 74%, depending on whether doubtful results were called abnormal or normal. "Doubtful" results were defined as those that stated that pancreatic cancer was "possible" or "could not be excluded." When these results were divided into abnormal and normal groups on the basis of the patients' preoperative serum carcinoembryonic antigen and pancreatic oncofetal antigen levels, the sensitivity and specificity of the combined tests may prove to be a more accurate means of screening patients for pancreatic cancer than ultrasonography alone.


Physical characteristics of implanted polytetrafluoroethylene grafts: a preliminary report. Despite the widespread clinical use of polytetrafluoroethylene (PTFE) grafts, few reports dealing with their physical properties have appeared in the literature. In the past 20 months, 17 such grafts have been implanted into 15 patients threatened with limb loss, with an 88% immediate graft patency. Postoperatively, all patients underwent periodic evaluations; arteriograms were obtained in four. The effect of knee flexion on graft function was also studied. All grafts were found capable of withstanding cuff pressures in excess of 300 mm Hg without occlusion. With 90 degrees flexion, the grafts kinked crossing the knee joint but a pressure gradient or decrease in pulsatile blood flow did not develop. This remarkable resistance to external compression should render these grafts especially valuable for extra-anatomic bypass.


[Long-term results of 2 continuous series of total hip prostheses of the McKee-Farrar metallo-metal type and the Charnley metallo-plastic type]. Two continuous series of McKee-Farrar type metal-metal and Charnley type metal-plastic prostheses have been examined. Results are analysed and complications examined ten years after the operation. The McKee-Farrar prostheses showed inferior results in all parameters and a markedly higher incidence of late complications compared to the Charnley prostheses.


[The role of digital storage in radiological studies based on fluoroscopic technics]. In recording radiological images obtained by fluoroscopic techniques on permanent support, digital storage, when compared with other methods, shows several interesting features, especially in order to reduce the X-ray dose and to allow for using economical hard copies. In the paper a system is described, for which it is possible to predict competitive cost in the near future; such system is based on a 512 X 512 X 6 bits digital memory, continuosly refreshed and on a software package oriented to handle radiological images. Examples of images referring to typical body segments (stomach, skull, chest) are reported.


Doxycycline in the prevention of hepatic dysfunction: an evaluation of its use following jejunoileal bypass in humans. A prospective randomized study was carried out to evaluate doxycycline hyclate in the prevention of hepatic dysfunction following jejunoileal bypass for morbid obesity. Forty-five patients were entered into the study and were observed for a year or more. Patients received either 100 mg of doxycycline hyclate twice daily on postoperative days 5 through 10 and then 100 mg daily for six weeks, or no drug. At six weeks, 12 weeks, and 12 months after the operation, biochemical levels were measured. After one year all patients had a liver biopsy. Doxycycline, in the regimen, was not demonstrated to be of value in the prevention of hepatic dysfunction in these patients. A lack of correlation was demonstrated between the biochemical definition of hepatic dysfunction and liver histopathology.


Long-term results of esophagomyotomy for achalasia of esophagus. Modified Heller's esophagomyotomy for achalasia of the esophagus was done in 145 patients at Henry Ford Hospital, Detroit, from 1951 to 1977. Information on current symptoms was obtained for 121 patients from a detailed questionnaire that was sent to all patients, from personal interviews, or from data obtained from patients' clinical records. Average period of follow-up was 85 months. Actuarial analysis of postoperative symptoms showed an incidence of reflux of 24% after one year and 48% after ten years; incidence of relief of dysphagia was 89% of all patients after one year and 81% after ten years. Continual surveillance of patients after esophagomyotomy must be stressed. Dissatisfaction with the results of this procedure prompted us to recommend that an antireflux operation be performed at the time of the initial procedure.


Is there postdefecation bacteremia?

Is there postdefecation bacteremia? An investigation was done to determine the incidence of postdefecation bacteremia. A study of 82 healthy volunteers was done. Among 164 predefecation cultures, only one (0.6%) from an anaerobic flask was positive for microorganism, which was identified as Staphylococcus epidermidis. In only two of 328 (0.6%) postdefecation cultures did microorganisms grow, which were shown to be Propionibacterium acnes. The results of this study suggest that either bacteremia after defecation does not occur or is a rare event in healthy individuals.


Early failure of expanded polytetrafluoroethylene in femoral vein replacement. Grafts of expanded 30-mu fibril length polytetrafluoroethylene (PTFE) were inserted as segmental femoral vein replacements in nine dogs. The contralateral femoral vein served as a control, receiving a graft from each dog's right external jugular vein. Graft patency was monitored for 24 weeks postoperatively with serial venograms and venous pressures of the operated limbs. All expanded PTFE grafts and one autogenous graft thrombosed within 24 to 48 hours. Significant venous hypertension in the extremities receiving the PTFE grafts persisted for six months.


Polypoid lesion of the stomach: resection through the fiberoptic endoscope. Endoscopic removal of gastric polyps was done in six patients. Because most gastric polyps are benign and the malignant neoplasm is limited to the polyp without distant metastasis, local excision should be the treatment of choice.


Renal cell carcinoma occurring with contralateral adrenal metastasis: a clinical and pathological trap. Because renal cell carcinoma occasionally occurs in manifestations referable to a single metastatic lesion, there is a risk that a metastasis will be mistaken for the primary tumor. Histologic examination can compound the confusion, particularly when a clear cell carcinoma of the kidney metastasizes to an organ, such as lung, liver, adrenal, or skin, where clear cell tumors may occur as primary lesions. Although advanced renal cell carcinoma not infrequently involves the adrenal gland, the clinical and pathologic setting establishes the tumor in the adrenal as a metastasis. Two patients are described to illustrate what is to our knowledge the heretofore undescribed occurrence of renal cell carcinoma as a metastasis to the contralateral adrenal gland.


Lower extremity arterial insufficiency after long-term methysergide maleate therapy. Its evaluation with Doppler ultrasonic velocity detector. Iatrogenic ergotism is the primary source of ergot intoxication. The patient whose case is reviewed had migraine headaches and received methysergide maleate for 13 years. She had, in July 1977, severe claudication of the lower extremities. Measurements of the peripheral arterial circulation were made using the Doppler ultrasonic velocity detector. The extent of disease and subsequent reversal were documented using arteriographic examination. Initial measurements showed the patient was able to walk for one minute and 34 seconds on a treadmill (2 mph, 10% grade) before stopping because of claudication. Symptoms cleared after drug withdrawal and repeated testing produced no claudication. The calculated index (posterior tibial/arm pressure) increased from a mean of 0.22 to 0.74 during the eight-month period following discontinuance of methysergide therapy with no recurrence of migraine headaches. A review of the literature is also presented.


Perforated appendicitis in an incarcerated inguinal hernia. Although perforated appendicitis in an incarcerated hernia is an uncommon condition, the clinical manifestations vary from relatively benign to much more serious, depending on whether the septic process is limited to the hernial canal and sac or if there is intraperitoneal contamination. The patient described in this report had minimal symptoms other than a slightly tender, irreducible inguinal hernia. He easily tolerated resection of the appendix and contiguous inguinal tissues, with a primary repair of the inguinal hernia.