The wrist in rheumatoid arthritis.

The wrist in rheumatoid arthritis. The wrist is the key joint of the upper extremity and is frequently seriously involved in rheumatoid arthritis. Surgery is often indicated to control the effects of the synovitis which often includes rupture of both flexor and extensor tendons. Early synovectomy is indicated. Tenosynovectomy, synovectomy, distal ulnar resection and transposition of the dorsal carpal ligament beneath the extensor tendons, has been effective in preventing rupture of the extensor tendons. The wrist also has an effect on ulnar drift of the fingers. Transfer of the extensor carpi radialis longus to the extensor carpi ulnaris is recommended in patients who do not have the ability to actively ulnar deviate the wrist. Wrist fusion has proven to be effective in patients with marked destruction, deformity or pain, or where there has been a rupture of both radial wrist extensors.


Juvenile aponeurotic fibroma. Report of three cases and a review of the literature. Three cases of a distinctive soft tissue fibrous tumor with spotty calcification demonstrate the lesion originally described by Keasby as Juvenile Aponeurotic Fibroma. The tumor tends to occur on the volar surface of the hands and feet in children and adolescents but may be seen in other areas in all age groups. Size rarely exceeds 3.0 cm. The tumors are fixed to the fascial layers. In previously reported patients pain was not described as an important factor, but both pain and tenderness were striking in all 3 of our cases. Microscopically the dominant feature is a fribrous stromal pattern of fusiform cells with inclusions of mast cells. Spotty calcification is a constant finding and appears to increase with duration of tumor. Local recurrence after excision and an aggressive histologic appearance may raise the question of malignancy. However, neither destruction of normal tissue surrounding the tumor nor metastases have occurred. Local exicision is the treatment of choice.


The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. The anatomical and functional details of the cruciate ligamants of the knee were studied on 20 cadaver knees and 24 fresh knees. Each anterior cruciate ligament was found to consist of 2 parts: a distinct anteromedial band (AMB) and a main posterolateral part. The exact geometry of the ligaments and their relationship to bony landmarks were recorded in detail. The state of the cruciate ligaments, i.e. tightness or looseness was recorded in the various positions of the knee as the basis for classification of the function of the various anatomical components. Selective cutting of the anterior cruciate ligament resulted in an increase of anterior drawer flexion and extension. External and internal rotation were increased in both flexion and extionsion. Hyperextension also was increased. It is suggested that the AMB of the anterior cruciate is responsible for the in anteroposterior drawer with flexion. The selective cutting of the posterior cruciate ligament demonstrated that it is important in the flexed knee and produces an.increased posterior drawer sign. Rotational stability was unchanged in extension, but altered in flexion after cutting the posterior cruciate.


Closed intramedullary nailing for ununited femoral shaft fractures. Fifteen cases of ununited diaphyseal fractures of femurs were treated successfully by intramedullary reaming and closed Küntscher nailing through the small gluteal incision. The equipment used is the same as for nailing fresh shaft fractures. The cases included 10 nonunions, 2 delayed unions and 3 miscellaneous problems. All but one case had been initially treated by open reduction with some form of internal skeletal fixation. Two cases had been treated by 2 open procedures befor the closed Küntscher nailing. No supplemental bone graft or external immobilization was necessary. Two cases were nailed successfully in the presence of infection, resulting in solid union and no recurrence of infection. Five nails have been removed after union and no refracture has occurred. No important postoperative complication or instances of the fat embolism syndrome were encountered. No rotational deformity or further shortening of the femur occurred. Postoperatively, the patients ambulated with protected weight-bearing as early as possible. The average hospital stay was 15 days. In general, the patients had a functional extremity even while the fracture lines were still visible on roentgenographs; all have returned to their previous work.


Tibial periosteal hemangioma.

Tibial periosteal hemangioma. A case report on periosteal hemangioma in the left tibia of an 11-year-old girl demonstrates roentgenographic thickening, sclerosis, and a smooth scalloping cortical depression in the bone. En block exicision of the defect, together with the markedly thickened periosteum, revealed a combination of cavernous and capillary bone hemangiomas.


Isolation of Vibrio parahaemolyticus from a knee wound. This is a case report of a contamination of an injured knee with an unusual organism, Vibrio parahaemolyticus, that is likely to occur in patients living in coastal areas but often overlooked. The infection apppears to be sensitive to a number of antibiotics and very likely cured, whether recognized or not as the proper organism.


Treatment of clubfoot by posterior capsulectomy. Posterior capsulectomy is a complete excision of the posterior tibiotalar and talocalcaneal capsule with a release of the distal tibiofibular connection. The operation is proposed for a resistant or relapsed clubfoot, where remaining equinus is the major problem. A follow-up of 29 operations showed that the average talocalcaneal angle became normal in the AP and lateral views. The best results were obtained with long postoperative cast immobilization, i.e. 6 months.


Shelf operation for congenital subluxation and dislocation of the hip. One hundred forty-one shelf procedures were performed on 120 patients who had congenital hip dysplasia or dislocation. Long-term follow-up evaluation of hip function revealed that about three-fourths of the patients had satisfactory results. Although some children less than 10 years old may have benefited, this age group has the highest percentage of failures of shelf operation. The shelf procedure provides a buttress of bone for later reconstructive surgery such as cup or total hip arthroplasty.


Pitfalls of proximal tibial osteotomy.

Pitfalls of proximal tibial osteotomy. Proximal tibial osteotomy for degenerative genu varus and valgus has an excellent success rate with proper patient selection and technical proficiency. The following are some infrequently recognized pitfalls. Excessive bone loss prevents two plateau weight-bearing after osteotomy, introduces a "teeter effect," and is therefore a contraindication. Patellofemoral arthritis may produce symptoms, particularly on stair climbing and necessitate secondary surgery. Varus and planning indicates postoperative articular surface obliquity in excess of 10 to 15 degrees another type of reconstruction is indicated. Secure fixation, closing wedge osteotomy, and non-displacement of the d-stal fragment prevent loss of correction. Peroneal nerve palsy may be avoided by careful surgical technique and postoperative dressings. Cracking the apical cortex and visualization of the plateau fragment will usually prevent fracture.


Experimental studies on the effect of chymopapain on nerve root compression caused by intervertebral disk material. Chymopapain degrades the nucleus pulposus portion of the intervertebral disk of rabbits. The degradation is not grossly visible until 15 days post-injection. Depolymerization of the chondromucoprotein and decreases in the ability of a disk to imbibe fluid, is, in effect, a "chemical decompression" of the nucleur pulposus. The enzyme must come into direct contact with the chondromucoprotein complex of the disk material, and to a significant extent also must reach the area of disk material adjacent to the herniated annulus. Rapid depolymerization of the chondromucoprotein complex on a biomechanical level, and "decompression" of disk material on a biomechanical level can be correlated with relief of pain in all types of disk herniation in human beings. A primary biochemical change in the disk material would lead to a secondary decrease in inflammation if the change led to a "decompression" of the chondromucoprotein. Since the primary effect of chymopapain is on the chondromucoprotein of the disk, beneficial results would not be expected if nerve root compression is due to bony impingement or scar tissue following previous surgery. Chymopapain did not seem to possess any anti-inflammatory properties when bone was used as an irritant under a nerve root. However, this was technically difficult to evaluate and the possibility that chymopapain may also interfere with a chemical mediator of pain or interfere directly with an inflammatory reaction secondary to root compression can not be excluded.


Comparison of the effects of steroid, aspirin and sodium salicylate on articular cartilage. Rabbit knee joints were compressed to produce cartilage degeneration in control and test animals who received intramuscular injections of prednisolone and aspirin or sodium salicylate by gavage. After three weeks of compression, animals were sacrificed and articular cartilage was analyzed grossly and histologically. Gross and histological specimens from salicylate treated animals showed less while the steroid treated rabbits showed more degenerative change. These data suggest that salicylate inhibits cartilage destruction while steroids enhance it.


Wood, an organic foreign body of bone. A case report. A case of an organic foreign body consisting of wood in bone is presented along with diagnosis and treatment. The unusual delay in noting the nature and extent of the injury was due to the radiolucence of the object and its lodging within the epiphyseal cartilage.


Tissue gas tensions and oxygen consumption in healing bone defects. A technique for measuring the gaseous environment during the reconstitution of a large bone defect is described. Extensive testing of this system over the past 10 years has demonstrated its validity in measuring the average extracellular tissue pO-2 and pCO-2. Histology of the tissue surrounding the tonometer was obtained and correlated with the gaseous measurements. New bone formation in the healing segmental bone defects has been shown to take place under hypoxic conditions. The oxygen consumption of the surrounding tissue was determined and correlated with the histology and tissue gas measurements. It was demonstrated that the oxygen consumption was not elevated during the period of new bone formation, reflecting a state of anaerobic metabolism. The hypoxic conditions persist until the vascularity increases to match the cellularity. Thephysiological role of oxygen in osseous repair is presented. The present technique as well as the previously published microelectrode technique have demonstrated bone formation in vivo can take place under hypoxic conditions but the mechanism is not known and requires further investigation.


Current trends in the treatment of the young adult with disabling hip disease. A survey. The otherwise physically fit young adult with unilateral disabling hip disease poses a treatment dilemma for the orthopedic surgeon. In an effort to gain some insight into current treatment trends for this group ten eminent hip surgeons were each sent case histories and pertinent X-rays of two otherwise fit young adults with disabling unilateral hip disease. Their treatment suggestions are analyzed following a review of the possible alternatives. Two features of the survey stood out: 1) For both patients a significant number of respondents favored total hip replacement; 2) John Charnley, who has been at the forefront in the development of total hip arthroplasty recommended that both patients wait until the total hip problems of component loosening and excessive wear are solved, (he predicts these solutions will come within the next five years) and then undergo total replacement. Ironically then, at a time when there may be a trend toward performing total hip replacement in otherwise fit young people with disabling hip disease, one of the prime developers of total hip replacement is calling for a moratorium on this course of action until the problems of total hip pertinent to young people are solved.


Osteoarthritis of the hip. A survey of treatment. Of 2,712 Board certified orthopedic surgeons selected from the directory of the American Academy of Orthopaedic Surgery, 1,683 (62.1%) responded to a mailed questionnaire concerning their preferred treatment for osteoarthritis of the hip in a specified active 53-year-old man. A Müller total hip arthroplasty was the most frequently performed operation in 1973; only 23 per cent of the respondents considered osteotomy the preferred treatment.


Osteoid osteoma of the hip in children.

Osteoid osteoma of the hip in children. In 31 children with osteoid osteoma lesions about the hip ranging in age from 2 to 16 years, there was an inordinate frequency of diagnostic delay with 16 patients having symptoms for more than 12 months. The clinical features were dominated by pain, limp, restricted hip motion and thigh atrophy. Twelve patients did not have classical night pain. Errors in diagnosis occurred in 22 instances. The roentgenographic appearance of most lesions consisted of a radiolucent central nidus encircled by sclerotic bone. Twenty-nine of the 31 patients were operated upon utilizing intra-operative roentgenograms and the nidus fully excised, with histological confirmation in 24 cases. All were relieved of preoperative symptoms. Two patients, who did not have surgical treatment, had pain for about one year and thereafter became pain free for 2 and 12 years. The sequelae observed at follow-up were meralgia paresthetica in 12 patients and mild asymptomatic leg length discrepancies in 7 patients. In view of these findings and since the process of apparent regression is slow and characterized by pain, blocked surgical excision of the lesion is the procedure of choice.


An improved technique for allogeneic hip joint implantations. A new technique which has been developed for the allogeneic hip-joint transplantation to enable minutely accurate processing of donor and recipient femoral head, neck, and hip-joints is dependent upon the manual skill of the surgeon. The donor and recipient parts had to be made congruent by free hand fitting. Even the most experienced surgeon cannot produce perfect form congruity of the whole contact surface between donor and recipient parts. The foregoing article presents new instruments and the techniques for 0.5 mm precision fit. An ideal fit of donor and recipient parts represents an important prerequisite for successful allogeneic joint implantations and accounts for improvement in previous results from such operations. Obviously, the cell-devitalized cold-conserved joints cannot produce optimum or permanent results, but can be implanted as an alternative to arthrosis in patients in vary young age groups. Further research on viable cartilage and bone in joint implantations await new advances in immunology and tissue typing.


Capital necrosis, metaphyseal cyst and subluxation in coxa plana. Three specific elements associated with a poor prognosis in Legg-Calvé-Perthes disease, i.e., capital necrosis, metaphyseal cyst and subluxation, have been selected for study to determine the effect of each on the end result. A retrospective analysis was made of 337 children who received non-weight-bearing treatment. Half of the patients were treated in abduction splints, over a third with bed rest and traction and the remainder with a variety of routines including sling and crutches, wheelchair or bed rest alone. The group was treated as representing a common pool of therapy and was analyzed statistically in this overall manner. End results were graded by the Knud Mose method (concentric circle matching plus epiphyseal quotient determinations). Good and fair results were combined into an acceptable category while the poor results were considered unacceptable. Femoral capital necrosis was present either segmentally or totally. A classification was devised of three grades of partial epiphyseal involvement and one of total necrosis. The patients with total necorsis (Group IV) had a higher percentage of poor results than those with segmental involvement (Groups I, II and III). The lowest percentage of poor results correlated with the least involvement of the femoral head (Group III). Total head involvement occurred in the unacceptable group one and one half times as frequently as it did in the acceptable group. Metaphyseal cyst formation exhibited a close relationship to the fragmentation of the capital epiphysis. It is suggested that the metaphyseal lesion itself is part of the overall necrotic process and that the "cyst" is resorption associated with revascularization as healing is taking place. We noted twice the frequency of metaphyseal cysts in patients with poor results in comparison to that found in the acceptable group. Subluxation is defined as loss of acetabular centration of the femoral head due to upward and outward displacement. Increased distance between the medial margin of the metaphysis and the lateral limb of the "tear drop" figure is practically a universal finding on early roentgenograms and was not considered "subluxation" in this prognostic evluation. In the series under study there were three times as many subluxations in the poor result group as in the group with acceptable results. A prognostic profile revealing three of the above-listed features was associated with a poor result and should constitute an objective basis of evaluation of new forms of therapy.


The magnesium load test: II. Correlation of clinical and laboratory data in neonates. Parenteral magnesium load tests were conducted on 91 infants less than one month of age, most of whom had marked hyperirritability and symptoms compatible with the diagnosis of electrolyte imbalance with relative or absolute magnesium deficiency. Most of the patients studied had a 40-hour test, with an eight-hour preload and a 32-hour postload collection of urine. Of 43 premature infants studied, only three retained less than 40 per cent of the load: one was untreated, one had low retention of a second load following a course of therapy, and the mother of the third had received magnesium within 24 hours of delivery. Of 48 full-term infants studied, ten retained less than 40 per cent of the load. These were asymptomatic or had minor problems. Irritability was common in both high and low retention groups. Ten per cent of the low retention group and 50 per cent of the high retention group manifested two or more of the nonspecific signs compatible with the diagnosis of magnesium deficiency; the difference was significant (P smaller than 0.025). Eleven premature and six full-term infants with very high initial retention received five or six intramuscular injections of magnesium, after which the magnesium retention was about 30 per cent lower than the initial value. For most patients, repletion therapy was given orally. Although low plasma magnesium values related to high magnesium retention, correlation on an individual basis was poor. The plasma calcium levels of three patients with combined hypomagnesmia and hypocalcemia failed to respond to calcium therapy and remained low until the plasma magnesium value was corrected. Magnesium appeared to be specific therapy for symptomatic infants found to be deficient. More males than females had sufficient symptoms to warrant study.


Anatomic restoration of congenital hip dysplasia in adulthood by total hip displacement. Congenital dysplasia, treated or untreated, produces a hip joint difficult to reconstruct and is even more difficult when coxarthrosis supervenes producing significant disability. Total hip replacement can be dramatically successful in these patients, and equals those with coxarthrosis without congenital dislocation. The acetabulum must be totally reconstructed and relocated as near as possible to its original orientation. Usually a small straight stem femoral component must be placed into a generally constricted femoral canal. A thoughtful preoperative plan including X-ray templates is absolutely essential for a successful reconstruction without postoperative complications.


The magnesium load test: III. correlation of clinical and laboratory data in infants from one to six months of age. A study of 64 infants from one to six months of age was made using the 32-hour parenteral magnesium load test. Most of the infants were studied for neuromuscular hyperirritability or other signs compatible with magnesium deficiency; some with unrelated problems served as controls. Magnesium retention below 40 per cent was found in 26 infants who presented with minor sign or signs that were otherwise explained, as by infection. Twelve who retained 72 per cent of the load were normal or small at birth, amply fed on demand, and grew at accelerated rates, increasing from the 50th to the 88th mean percentile by ten weeks, when they were "fat, hungry, jumpy babies," exemplifying the Mg deficiency syndrome of growth. Seven infants of 8.2 plus or minus 1 weeks had had one or more sudden, transient episodes that included: apnea, gasping, tonic or tonic-clonic fits, and flaccidity, often with pallor, cyanosis, eye signs, sweating, or tearing. Despite preload Mg in two, the group retained 88 per cent of the load. Mg appeared to be specific therapy in high retention groups. The signs are nonspecific but resemble premonitory signs and the type of episode that may occur in the sudden infant death syndrome (SIDS), suggesting a possible link between magnesium depletion and SIDS.


Infections in total hips secondary to a primary source elsewhere. This is a report of 3 cases in which a primary infection in a site other than a total hip led to infection in the hip itself. One hip infection appeared to arise in a tooth abscess, a second in the urinary tract, and one from the respiratory tract. All infections resulted in the necessity of removing the components of the total hip. It is suggested that patients who have had previous total hip replacement should be warned to consult their physician when the possibility of an infection is present, and that antibiotic coverage be given during this period of time. Cultures of infected sites should be made in patients who have had total hip replacements, in order that organisms and their sensitivity may be identified in the event that antibiotic therapy is needed, subsequently.


Fatal overdose from Bendectin.

Fatal overdose from Bendectin. A three-year old male ingested approximately 100 tablets of Bendectin. He developed tonic-clonic seizures followed by cardiac arrest. Toxicologic analysis yielded high levels of doxylamine, dicyclomine, and pyridoxine in blood, peritoneal fluid, and tissue homogenates. The antihistamine, doxylamine succinate appears to be the toxic constituent. Analytical methods used to document the case are herein described.


The pediatrician and the dying child. "Physician, know thyself". To deal with problems aroused in professional medical staff working with fatally ill children, a team of psychiatrics and oncologists not only deals with the problems of the children and their families, but also with problems of the medical staff themselves. Psychotherapy to the medical staff is offered only indirectly. The overriding difficulty which prevents the medical staff from maintaining role-appearance behavior is dealing with the theme of death. Often this is the hidden agenda behind a facade of other presenting problems. At times, the medical staff may be unable to deal with their own anger when conforted by demanding patients or hostile parents. At other times, medical staff will overidentify with the patient resulting in inappropriate role behavior. When medical results are poor despite good medical care, staff may feel inappropriately guilty. These issues can be dealt with means of a weekly mental health conference with the focus on the patient.


Plasma testosterone levels during chronic heroin use and protracted astinence. A study of Hong Kong addicts. The effects of heroin use and subsequent prolonged abstinence on plasma testosterone levels were examined in 31 male heroin addicts. Heroin (alone and in combination with methadone) significantly suppressed plasma testosterone levels. However, drug-induced testosterone suppression does not appear to be permanent in adult addicts. Recovery of testosterone levels to normal occurred after about one month of heroin abstinence.


Respiratory effects of delta-9-tetrahydrocannabinol. The respiratory effects of smoked marijuana and oral delta-9-tetrahydrocannabinol (delta9THC) have been studied in healthy males by assessing displacement of the respiratory response curve. Both cause slight respiratory depression, in some subjects it stimulates respiration. High doses of pentobarbital depress respiration but low doses apparently do not.


Effect of smoking marihuana and of a high-nicotine cigarette on angina pectoris. The purpose of this study was to determine the effect of smoking marihuana and of high-nicotine cigarettes on exercise-induced angina pectoris. Smoking 1 marihuana cigarette increased the resting product of systolic blood pressure times heart rate 54%, increased the venous carboxyhemoglobin level, and decreased the exercise time until angina 50% in 10 patients with angina pectoris. Smoking 1 high-nicotine cigarette increased the resting product of systolic blood pressure times heart rate 36%, increased the venous carboxyhemoglobin level, and decreased the exercise time until angina 23%. Smoking either marihuana or high-nicotine cigarettes decreases exercise performance until angina by increasing myocardial oxygen demand and by decreasing myocardial oxygen delivery. Smoking 1 marihuana cigarette decreased the exercise time until angina more than smoking 1 high-nicotine cigarette (p less than 0.001).


First-pass metabolism of imipramine in man. The systemic availability of orally administered imipramine (IP) varied from 29 to 77% in 4 subjects. The decrease in availability was due to an excess in metabolism after oral administration. This first-pass metabolism did not correlate with plasma half-life, apparent clearance, or the rate of metabolite excretion in urine. There was close correlation with the excess in formation of demethylated metabolites after oral administration, which suggests that the first-pass metabolism is mediated by demethylation, but does not correlate to the total rate of demethylation.


Placental transfer to diazepam and its disposition in the newborn. Diazepam (DZ) placental transfer in pregnant women at term, following single or repeated drug administration by various routes, was evaluated. DZ and its metabolite N-demethyldiazepam (NDZ) were constantly present in umbilical cord plasma at concentrations comparable to the mother's shortly after drug administration. N-methyloxazepam (MOX) was detected in cord plasma only in a limited number of cases following chronic DZ treatment. Postmortem analysis of fetal tissue concentrations showed accumulation of NDZ in heart and lungs. Differences in NDZ concentrations between venous cord (VC) and arterial cord (AC) plasms suggest metabolic degradation of DZ in the fetus. The DZ apparent plasma half-life in the newborn was found to be longer (31 plus or minus 2 hr) than previously observed in infants and children. The low drug clearance appears to be linked to reduced urinary excretion of hydroxylated metabolites, suggesting limited capability to dispose of DZ in the newborn.


Pharmacodynamics of minoxidil as a guide for individualizing dosage regimens in hypertension. The antihypertensive effect of minoxidil was studied in 6 patients with varying degrees of hypertension. Their baseline mean arterial pressure (MAP bi) ranged from 122 to 197 mm Hg. Single oral doses between 2.5 and 25 mg were administered in sequence and the time-course of hypotensive action was followed. We have reported previously that when the peak lowering of MAP is linearly regressed against log dose, both the dose-response slope (M) and threshold dose (Dt) are positively correlated with the MAP bi of individual patients. This investigation focuses on the temporal pattern of effect. It was found that the hypotensive effect of minoxidil declined linearly with time at a rate consistent with an average effective biologic half-life of about one day. The rate of decline of effect was apparently independent of dose but was dependent on MAP bi. Since both response to and duration of effect of minoxidil are functions of MAP bi, there is an abvious need to individualize dosage regimens based on the severity of disease. Using pharmacodynamic parameters, guidelines for loading dose, maintenance dose, and dosing frequency as a function of the degree of hypertension are suggested. Loading dose requirements were found to increase with MAP bi while maintenance doses were largely independent of the severity of the disease. Frequently of dosing was found to range from 3 times a day in very severe hypertension to once a day in moderate hypertension.


Pharmacokinetic studies of tolmetin in man. The pharmacokinetics of the new anti-inflammatory agent tolmetin have been studied after its oral administration to normal subjects and to patients with rheumatoid arthritis. Plasma concentration-time data were fitted to a one-compartment open model. Following single oral doses, no basic differences in rates of drug absorption and elimination were found between normal subjects and arthritic patients. For the 12 subjects studied, the overall mean elimination rate constant was 0.839 hr-1, corresponding to a plasma half-life of 0.83 hr. The drug was rapidly absorbed and had a mean apparent volume of distribution of 0.098 l/kg. Plasma levels and pharmacokinetic parameters of tolmetin in arthritic patients after multiple dosing were smaller to those after a single dose.


Correlation of peak aortic and carotid flow acceleration during coronary occlusion in conscious baboons. 1. Peak blood flow acceleration measured in the common carotid artery was compared with peak flow acceleration measured in the ascending aorta of three baboons. 2. The response to occlusion for 60s of the circumflex branch or the anterior descending branch of the left coronary artery was investigated. 3. Both accelerations decreased approximately to the same extent. Peak aortic flow velocity, stroke volume and cardiac output also decreased but to a smaller extent. 4. It is concluded that peak aortic flow acceleration is a sensitive index of myocardial function during acute coronary occlusion in conscious primates and that peak carotid flow acceleration is an indirect measure of myocardial performance under the same conditions.


Triglyceride, free fatty acid and carbohydrate metabolism in hyperlipaemic (type IV) and normolipaemic subjects on carbohydrate- of fat-rich diets. 1. Five patients with hyperlipoproteinaemia type IV and five normolipaemic controls were maintained on diets containing either a fat or a carbohydrate content of approximately 60%. Leg exchanges of triglycerides, free fatty acid (NEFA), glucose and other metabolites were measured in the basal state. The metabolic response to an intravenous glucose load and the turnover of intravenously infused (14C)oleic acid were determined. Individual fatty acids were analysed in plasma NEFA and very-low-density lipoprotein triglyceride. 2. No differences were detected between patients and controls with regard to leg uptake of triglyceride or NEFA on either diet. On shifting from a fat-rich to a carbohydrate-rich diet, the control subjects showed reduced values for arterial NEFA and for NEFA turnover, accompanied by a lowered release of NEFA and glycerol from the leg. In patients, on the other hand, the arterial concentration and turnover of NEFA remained unchanged and the release of glycerol from the leg increased. Glucose administration gave a less-pronounced fall of arterial NEFA on either diet in the patients and the incorporation of (14C)oleic acid into triglycerides after glucose administration was more marked than in the controls. 3. No difference in net uptake of triglyceride by the leg was demonstrable between patients and controls. 4. it is concluded that hyperlipaemic patients show an altered metabolic response to a carbohydrate-rich diet, possibly contributing to the development of a hyperlipaemic state, and that acute glucose loading results in a greater incorporation of circulating NEFA into very-low-density lipoproteins in these patients.


Assessment of urine-concentrating ability in man: effect of fludrocortisone and urea in enhancing response to vasopressin. 1. Healthy subjects, given a long-acting preparation of vasopressin intramuscularly, excreted a significantly less concentrated urine than when subjected to fluid deprivation for 28 h. 2. When fludrocortisone, a potent mineralocorticoid, was given in addition to vasopressin the urine was not significantly less concentrated than after fluid deprivation. 3. Oral urea-loading also enhanced the urine-concentrating power of vasopressin but its effect was less marked than that of fludrocortisone. Oral urea did not increase further the urine concentration achieved by combined fludrocortisone and vasopressin. 4. Renal concentrating power was assessed in fourteen patients with renal disease and impaired concentrating ability. Fludrocortisone significantly enhanced the urine concentration achieved by vasopressin alone and the resultant urine was not significantly less concentrated than that achieved by fluid deprivation. 5. The action of fludrocortisone in enhancing the urine-concentrating effect of vasopressin is similar to that of aldosterone and is probably due to the increased sequestration of solute in the renal medulla, caused by increased reabsorption of sodium chloride in the ascending limb of the loop of Henle. 6. In the clinical assessment of renal concentrating power, the combined use of fludrocortisone and vasopressin has potential advantages over established methods.


The selective inhibition of chenodeoxycholate synthesis by cholate metabolites in man. 1. Seven normal volunteers took 0-28--0-42 mmol (100--150 mg) of deoxycholate by mouth. This resulted in a reduced proportion of chenodeoxycholate in bile and an increased proportion of deoxycholate. Cholate was unchanged. 2. Cholate and chenodeoxycholate pools and rats of synthesis were determined in four of the subjects by simultaneously labelling each pool with 14C-labelled bile acids. The chenodeoxycholate pool and rate of synthesis decreased after deoxycholate administration. Cholate synthesis and pool size did not change appreciably. 3. The proportion of deoxycholate in bile samples of sixty-two subjects with intact enterohepatic circulation was found to be inversely related to the proportion of chenodeoxycholate in bile, but not to the cholate. 4. It is suggested that inhibition of chenodeoxycholate synthesis by deoxycholate, the principal bacterial product of cholate, regulates the size of the chenodeoxycholate pool independently of the total amount of bile salt.


Human platelet monoamine oxidase activity in iron-deficiency anaemia. 1. The activity of monoamine oxidase, when assayed with four substrates, was significantly lowered in platelets prepared from the blood of patients with iron-deficiency anaemia. 2. Treatment with oral iron preparations restored platelet monoamine oxidase activity to normal in those patients whose serum iron concentrations also returned to normal. 3. Platelet monoamine oxidase activity remained low if treatment failed to restore serum iron concentration to within normal limits.


The effect of age on deoxyribonucleic acid synthesis in rat adipose tissue. 1. Rats of four different age groups were injected intraperitoneally with labelled thymidine and killed 1, 7 or 12 days later. 2. The epididymal fat-pads were separated into fat-cells and stromal elements by collagenase digestion. 3. The incorporation of labelled thymidine into the deoxyribonucleic acid (DNA) of both fractions was greatest in the 6-week-old animals. Uptake was significantly decreased in 12- and 15-week-old animals and was lowest in 22-week-old rats.


Role of saline consumption in the prevention of deoxycorticosterone hypertension in rats by central 6-hydroxydopamine. 1. The mechanism by which pretreatment of rats with intracisternal 6-hydroxydopamine prevents the onset of deoxycorticosterone hypertension has been studied. 2. Rats pretreated with central 6-hydroxydopamine increase their consumption of 0-17 mol/l sodium chloride--0-03 mol/l potassium chloride ('saline') less than normal rats when implanted with deoxycorticosterone. 3. Intact rats restricted to the equivalent consumption of saline of rats pretreated with 6-hydroxydopamine develop hypertension despite this restriction. 4. It is suggested that the prevention of deoxycorticosterone hypertension by central 6-hydroxydopamine does not depend on reduced saline consumption.


Postural fluid retention in patients with idiopathic oedema: lack of relationship to the phase of the menstrual cycle. 1. Water and electrolyte excretion was measured in the follicular and luteal phases of the menstrual cycle in seven patients with idiopathic oedema and in four post-menopausal patients with this condition. 2. In contrast to previous findings in healthy women, the reduction in urinary flow and sodium excretion on being tilted to the upright position was not significantly different in the follicular and luteal phases in pre-menopausal patients and there were no significant differences between pre- and post-menopausal patients. 3. The percentage increase in packed cell volume on standing was significantly greater in patients with idiopathic oedema than in normal subjects in the luteal phase of the menstrual cylcle. 4. It is postulated that the enhanced retention of electrolytes and water in response to tilting in patients with idiopathic oedema is a compensatory mechanism for the decreased effective blood volume at that time.


Isolation, characterization and function of cord-blood transferrin. 1. Transferrin was isolated from umbilical cord blood by means of gel filtration on Sephadex G-150 and ion exchange chromatography on DEAE-Sephadex A-50, and its properties were compared with those of transferrin isolated from human adult blood. 2. Both glycoproteins were able to bind a maximum of two atoms of iron per molecule and have very similar amino acid and carbohydrate compositions. 3. The molecular weight of cord-blood transferrin, assessed by equilibrium centrifugation, was 78200, and its sedimentation velocity appeared to be 5-2S. 4. Cord-blood transferrin and adult blood transferrin were found to be immunochemically identical. 5. No differences could be detected between the transferrins in their capacities to deliver iron to immature erythrocytes derived from rat bone marrow, which indicates that the rapid transport of iron across the placenta cannot be explained by differences between foetal and maternal transferrin.


Factors affecting the metabolic production of methylguanidine. 1. Methylguanidine administered orally to normal volunteers was almost completely recovered in the urine, indicating that it is absorbed in the gastrointestinal tract and is not converted into other compounds. In normal persons at least, its urinary output therefore corresponds to its metabolic production rate plus the amount ingested. 2. In normal persons, diets based on foods not containing methylguanidine (e.g. vegetarian, protein-free and milk-egg) caused a fall in the urinary output of methylguanidine as compared with the output of the same subjects on a free diet. Conversely, higher amounts of methylguanidine were excreted on a diet rich in broth and in boiled beef, which contain large amounts of methylguanidine formed from the oxidation of creatinine, caused by boiling. 3. Oral administration of creatinine to normal volunteers induced an immediate and marked increase in urinary excretion of methylguanidine, and the ingestion of [methyl-14-C]creatinine by uraemic patients was followed by the urinary excretion of labelled methylguanidine. These findings indicate that creatinine is partly converted into methylguanidine in both normal and uraemic subjects and accounts for the high metabolic production of methylguanidine in patients with renal failure, in whom the body pool of creatinine is high. 4. Creatinine, incubated at 38 degrees C for 24 h in Krebs bicarbonate solution (pH 7-38) through which was bubbled oxygen with 15% carbon dioxide, was partially oxidized to methylguanidine. This raises the possibility that even in vivo such a conversion may occur "non-enzymatically".


A comparison of the effects of incubation on cells containing haemoglobin S or haemoglobin A. 1. A centrifugal packing technique has been used to investigate the effect of incubation on the flexibility of erythrocytes containing normal (Hb A) or sickle-cell (Hb S) haemoglobin. The effects on cell morphology and on the reversibility of morphological changes were also investigated. 2. The two types of cell reacted similarly to incubation. Sickling of the Hb-S was shown not to be responsible for the production of irreversibly deformed cells in these circumstances. 3. It is concluded that for both cell types the membrane inflexibility, cellular deformation and morphological irreversibility induced by the incubation were due to metabolic depletion.


Protein synthetic activity of membrane-bound and free ribosomes from parathyroid glands of dogs. 1. Membrane-bound and free polyribosomes were isolated from parathyroid glands of normal dogs by a discontinuous density-gradient technique. 2. The conditions necessary for optimum incorporation by bound and free ribosomes of [3-H]-phenylalanine into protein were determined for assays in vitro directed by both endogenous messenger ribonucleic acid (mRNA) and polyuridylic acid [poly(U)]. 3. When the specific cofactors were available in optimum amounts, the rate of incorporation of amino acids into protein was directly proportional to the number of ribosomes present. This applied to assays directed by endogenous mRNA and poly-(U). 4. The results indicate that it is possible to isolate and directly study the protein synthetic activity of membrane-bound and free parathyroid ribosomes.


Efficiency of utilization of urea nitrogen for albumin synthesis by chronically uraemic and normal man. 1. The relation between endogenous urea metabolism and albumin synthesis has been studied in ten patients with chronic renal failure and in four normal subjects, after single intravenous injections of [14-C]urea,[15-N]urea and 125-I-labelled albumin. 2. The rate of urea synthesis was determined from the dynamics of plasma [14-C]urea specific radioactivity and the rate of urea metabolism was estimated from the relative rates of urea synthesis and urea appearance in urine and body water. Deconvolution analysis of plasma [15N]albumin enrichmevt and 125-i-labelled albumin radioactivity yielded the cumulative incorporation of 15-N into total exchangeable albumin and enabled calculation of the absolute rate of urema nitrogen utilization for albumin synthesis. 3. Although the mean absolute rate of urea degradation in uraemic patients (3-7 mmol/h) was higher than in normal subjects (2-3 mmol/h) there was no significant positive correlation between urea degradation and plasma urea concentration. 4. In uraemic subjects, there was a significant positive correlation between urea synthetic rate and urea degration rate. 5. The rate of utilization of urea nitrogen for albumin synthesis was low, but was very much higher in uraemic subjects (mean 83-8 mumol/h) compared with normal subjects (mean 6-4 mumol/h), as was the provision by urea of the nitrogen required for albumin synthesis in uraemic subjects (2-37%) compared with normal subjects (0-13%). 6. The efficiency of utilization of urea nitrogen for albumin synthesis was higher in the uraemic patients (1-3%) than the normal subjects (0-2%), and was higher in those patients with chronic renal failure who received a 30 g protein diet than those on 70 g of protein. A significant negative correlation was noted between efficiency of urea nitrogen utilization and the rate of synthesis of albumin. 7. These studies suggest the presence of a mechanism for the conservation of urea nitrogen in chronic renal failure which is unrelated to the extent of urea degradation, and which can only be partly explained by the higher proportion of intraluminal gut nitrogen derived from urea.


The relationship of body fat content to deep muscle temperature and isometric endurance in man. 1. The relationship between body fat content, isometric endurance and deep muscle temperature was assessed in eight male and female volunteers trained to static effort. 2. Muscle temperature, measured in the belly of the brachioradialis muscle, was found to be directly related to the subject's body fat content. 3. Associated with a reduction in body fat content, there was a marked decrease in deep muscle temperature and an increase in isometric endurance of the hand-grip muscles; no change in strength was noted. 4. Conversely, an increase in body fat content resulted in an increase in deep muscle temperature and a decrease in isometric endurance. 5. When muscle temperature was stabilized before and after weight loss by immersing the forearm in water at 37 degrees C, a reduction in body fat no longer influenced endurance. 6. It was concluded that the change in isometric endurance associated with either loss or gain of weight can be accounted for entirely by the changes in muscle temperature.


Effect of immunization against angiotensin II on blood pressure and on plasma aldosterone in the rabbit. 1. Rabbits were actively immunized aganist angiotensin II (AII). 2. Basal plasma aldosterone concentration was 0-058 plus or minus 0-027 pmol/ml (20-7 plus or minus 9-6 pg/ml) (mean plus or minus SD) in immunized and 0-056 plus or minus 0-021 pmol/ml (20-2 plus or minus 7-5 pe. When the endogenous formation of AII was stimulated by frusemide, by haemorrhage or by feeding with low sodium diet, a significant increase of plasma aldosterone was observed with no difference between immunized and non-immunized animals. 3. In non-immune rabbits, the average mean arterial blood pressure rose 13 mmgHg during the infusion of AII (5 pmol min--1 kg-1) and 27 mmHg during the infusion of 50 pmol min-1 kg-1. In contrast, there was no clear increase in blood pressure in the immunized animals. The blood pressure rose in immune animals (15 mmHg) and in non-immune animals (36 mmHg) during the infusion of 200 pmol min-1 kg-1 ALL. Plasma aldosterone rose in all animals in response to each of the three infusions with no significant difference between the two groups. 4. It is concluded that the immunization against ALL blocked only the pressor effect of the peptide but had no clear influence on the response of plasma aldosterone to increased ALL. Differences between the affinities of the adrenal and vascular AII receptors may explain these findings.


Effects of inhaled prostaglandins E1, E2, and F2alpha on the airway resistance of healthy and asthmatic man. 1. Changes in specific airway conductance after the inhalation of aerosols of prostaglandins (PG) E1, E2, and F2alpha were investigated in healthy and asthmatic subjects. 2. Inhalation of 155 nmol (55 mug) of PGE1 or 156 nmol (55 mug) of PGF2 resulted in consistent minor bronchodilatation in healthy subjects, but in asthmatic patients airway conductance increased significantly, along with subjective improvement. Isoprenaline (988 nmol; 550 mug) inhalation resulted in a similar increase in conductance to that obtained after these two prostaglandins, whereas a control aerosol had no effect. In contrast to the isoprenaline aerosol, both PGE1 and PGF2 were highly irritant to inhale. It was concluded that this made them unsuitable for therapeutic use. 3. Prostaglandin F2alpha inhalation resulted in a dose-related bronchoconstriction in healthy and asthmatic subjects. Asthmatics were approximately 150 than were the healthy subjects but there was very wide and significant variantion in the sensitivity of the asthmatic subjects. In contrast the asthmatic subjects were only 8-5 times more sensitive to histamine than the healthy subjects with less variation in response of individual subjects. The reasons for the hyper-reactivity of asthmatic subjects to PGF2alpha is unknown and no correlation could be drawn between increased sensitivity and age, type of asthma, or treatment. 4. The effects of disodium cromoglycate, flufenamic acid, atropine methonitrate, PGF2 and isoprenaline on PGF2alpha-induced bronchoconstriction were investigated in healthy subjects. Prostaglandin E2 reversed PGF2alpha-induced bronchoconstriction, as did isoprenaline, but prior treatment with the other drugs had no effect in preventing bronchoconstriction.


Total body potassium and body fat estimation in relationship to height, sex, age, malnutrition and obesity. 1. Total body potassium was estimated by 40-K measurement with a high-sensitivity whole body counter in normal individuals over a wide age range and in patients who were obese or were grossly wasted as a result of various conditions which restricted food intake. 2. Potassal males and females, but when individuals of different age groups were matched for height, a significant fall in total body potassium with increasing age was observed only in males. Total body potassium of females was about 75% that of males of similar height when young, the sex difference decreasing with ageing. In the normal population, total body potassium was significantly correlated with height and with weight; regression equations for various relationships are given. 3. Fat-free mass was estimated from total body potassium, values of 65 and 56 mmol of potassium/kg fat-free mass being used for males and females respectively. Body fat estimated by this method correlated well with skinfold measurements over a wide range of body weight but in malnourished individuals having inadequate food intake there was considerable fat-free mass from total body potassium appear unsatisfactory in malnutrition. Considerable differences between expected and observed values of total body potassium were found in muscular individuals and in normal individuals who were thin but whose body weight was relatively constant. 4. The patients with malnutrition were low both in body fat as estimated by skinfold thcikness and in total body potassium estimated on the basis of height. Plasma potassium was, however, normal and potassium supplements did not increase the total body potassium. 5. Total body potassium of obese individuals was not significantly different from that of normal weight individuals on the basis of height. Total body potassium fell on weight reduction with a very low energy diet of 1260 kJ (300 kcal.) daily but changed little with a 3300 kJ (800 KCAY POTASSIUM WAS BEST PREDICTED FROM THE INDIVIDUAL'S HEIGHT. For those whose body weight was less than expected, the use of weight gave the best prediction but the error was considerable when the weight deviation was large.


Oestrogen hypertension in rats.

Oestrogen hypertension in rats. 1. A large dose of oestrogen elevated the blood pressure in male Westar rats. 2. Plasma renin substrate and renin activity increased significantly but plasma renin concentration was unchanged. 3. The increase in blood pressure induced by oestrogen was significantly reduced by salt loading, plasma renin concentration was suppressed and the increase in plasma renin activity was reduced. 4. The increase in plasma renin activity induced by the increase of plasma renin substrate concentration may play a role in oestrogen-induced elevation of blood pressure.


Effect of parathyroid extract on renin release in the dog. 1. A rapid increase in plasma renin activity occurred in dogs after intravenous administration of parathyroid extract. 2. This was not seen after injection of a purer parathormone preparation, or the solution used to dilute the parathyroid extract or calcitonin. 3. A vasoactive compound in parathyroid extract appears to provide the most likely explantation of this effect.


Fibrous osteodystrophy with facial hyperostosis in a dog with renal cortical hypoplasia. A five-month-old Great Dane had abnormally small kidneys with narrow cortices and a reduced total number of glomeruli. In the renal cortex, subcapsular nests of primitive structures were associated with radiating streaks of fibrosis and were interpreted to be the result of interference with terminal development. The animal had secondary parathyroid hyperplasia and generalized fibrous osteodystrophy. The most severe skeletal lesions were present in the face and jaws where exuberant proliferation of fibrodystrophic bone had caused boney enlargement with focal hemorrhage and brown node formation.


Sphaerophorus necrophorus: laboratory model for the evaluation of chemotherapeutic agents in mice. Severe necro-purulent lesions were induced in mice following parenteral inoculation of Sphaerophorus necrophorus. Gross and histological changes observed in the lung, liver, and foot pad of infected mice were similar to those occurring naturally in cattle. The lesions could be prevented, cured or significantly reduced by the administration of chemotherapeutic agents such as sulfonamides, potentiated sulfonamide and antibiotics. The application of this novel laboratory model infection in the primary evaluation of potential antibacterial agents is discussed.


Astrocytoma in a dog causing convulsions. An adult, male, 7 Kg. dog was presented because of a convulsion. This progressed and interictal signs became apparent. A slight left spastic hemiparesis was present with a normal gait and posture. A partial left visual deficit with intact pupillary reflexes became evident. All signs were referable to a right cerebral lesion. Necropsy revealed an astrocytoma in the right cerebrum compressing the internal capsule and optic tract.


Duration of Brucella ovis infection in ewes. Twenty Romney Marsh ewes, some 5 to 40 days pregnant, were inoculated with a strain of Brucella ovis onto the scarified mucous membrane of the vagina. Establish of infection was ascertained by recovery of the organisms from blood; supramammary and inguinal lymph nodes; the vagina, after initial disappearance of the organism from this organ; and the complement fixation tests. The bacteremia was transitory or intermittent, but organisms could not be recovered from blood, or any other tissue examined, after 98 days of infection. Abortions or placentitis were not observed. It is recommended that in countries where sheep breeding is aseasonal a sexual rest of infected ewes for at least 4 months must be part of any program for the control and eradication of ram epididymitis.


Leiomyoma of the tunica vaginalis in a dog. A benign neoplasm of smooth muscle origin was found in the tunica vaginalis testis of a 13-year-old male Miniature Poodle. The leiomyoma had caused hydrocele and atrophy of the corresponding testis. It consisted of bundles of interwoven smooth muscle cells with elongated nuclei and areas of hyalinization.


Neurofibrillary accumulation in a puppy. A diffuse neuronal intracytoplasmic accumulation of a fibrillar material is described in a 12-week-old puppy with signs of progressive neurologic disease. Electron microscopic examination revealed fibrils about 120A in diameter aggregated in the perikaryon and processes of neurons primarily in the brain stem.


A serum enzyme test to detect pulmonary capillary injury. Lung converting enzyme (LCE) was extracted from normal human lung obtained at autopsy. The specificity of the enzyme preparation was confirmed in vitro by incubation with Angiotensin I (AI) and paper chromatographic identification of reaction products. A method was developed for assay of the enzyme preparation in human serum using tritiated Angiotensin I (H-3A-I) as substrate. Enzyme activity is quantitated by scintillation counting the radioactive end product tritiated dipeptide histadylleucine (H-3His-leu). Serum from the authors and pooled serum from the hospital laboratory caused less than 3.5% conversion of H-3A-I to H-3His-leu. Serum from two patients with severe lung damage caused a maximum 20% conversion of H-3A-I to H-3His-leu. Percent conversion in these patients correlated with clinical and laboratory evidence of lung dysfunction.


Cardiac function determined by echocardiogram. Echocardiographic analysis with a strip recorder gives an accurate assessment of cardiac function, easily obtainable at the bedside of the critically ill. Ejection fraction and velocity of circumferential fiber shortening (Vcf) are the two most accurate measurements of cardiac function. The diameter of the minor axis of the left ventricle is measured in systole (Ds) and diastole (Dd). Systolic volume is (Ds)-3, diastolic volume is (Dd)-3, ejection fraction is (Dd)-3-(Ds)-3 divided by (Dd)-3, Vcf is Dd-Ds divided by Dd times LVET.


The Mayo Lung Project for early detection and localization of bronchogenic carcinoma: a status report. The Mayo Lung Project (MLP) is a screening program designed to detect bronchogenic carcinoma at a curable stage. Screening tests include chest roentgenograms, three-day "pooled" sputum cytology studies, and lung-health questionnaires. These are being applied every four months to a study population of outpatients who have a high probability of developing lung cancer. Initial patient acceptance of the screening program has been excellent. Small asymptomatic lung cancers have been detected both roentgenographically and cytologically. The two procedures have complemented each other with little overlap. Chest roentgenography has proved most useful in diagnosing peripherally situated cancers, whereas sputum cytology studies have been most effective in identifying early squamous cancer involving major airways. At present, more cancers have been detected roentgenographically than cytologically, but the cytologically detected cases appear to have a better prognosis. Roentgenographically occult cancers have been localized with regularity, although the localization process is complicated. Theoretically, vigorous application of radiologic and cytologic screening, combined with optimum use of localizing procedures and treatment, could increase the five-year survival rate among lung cancer patients to nearly 50 percent. However, the actual survivorship attained will ultimately be determined by currently imponderable factors such as patient acceptance of longterm screening, frequency of multicentric respiratory cancers, and incidence of noncancerous smoking-related diseases, especially chronic obstructive pulmonary disease and ischemic heart disease.


Esophageal disease as a cause of severe retrosternal chest pain. During one six-month period 11 patients were referred with a diagnosis of coronary artery disease, because of recurrent episodes of severe, prolonged retrosternal chest pain necessitating from one to seven hospital admissions per patient for "suspect myocardial infarction". In no instance was this diagnosis proved by electrocardiogram or serum enzyme changes, but 7 of the 11 patients had abnormal resting electrocardiograms. Selective coronary arteriograms were normal in 10 patients and revealed nonobstructive coronary artery disease in the 11th patient. Esophageal studies revealed hiatus hernia in 9 and mild to severe disordered motored activity of the esophagus in all 11. Acid perfusion into the esophagus reproduced the chest pain in nine patients and in the other two, the hiatus hernia was incarcerated. On direct questioning, all patients indicated that the pain was worsened by lying down and bending over, and in eight patients there was a history of pharyngoesophageal or gastroesophageal dysphagia. In this day when the problem of chest pain with normal coronary arteries is very topical, our report emphasizes the need to consider symptomatic esophageal disease in the differential diagnosis of this problem.


Pleuroscopy and pleural biopsy with the flexible fiberoptic bronchoscope. Diagnostic pleuroscopy has been performed under local anesthesia in nine patients using a gas sterilized flexible fiberoptic bronchoscope inserted through a 1 to 2 cm chest incision into the pleural space. Pleuroscopy in one patient excluded recurrent neoplasm on the pleural aspect of a bronchopleural fistula. Another patient had a pleuroscopic biopsy of the lung, which was the only method successful in diagnosing a metastatic renal carcinoma. The other seven patients were studied for pleural effusions which were undiagnosed after study of pleural fluid and/or Abrams needle biopsy. In four of them pleural implants of carcinoma were visualized and proved by biopsy. Three patients had negative pleuroscopy, two of these also being negative at subsequent thoracotomy. One was not explored because of extrathoracic metastases. The procedures were performed with minimal patient discomfort and no serious complications.


Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura. A comparison was made of the efficacy of pleural needle biopsy and pleural-fluid cytopathology in the diagnosis of pleural tumor in a group of 271 patients. A malignant tumor involving the pleura was present in 95 cases. Needle biopsy alone provided a diagnosis of tumor in 53 instances, and cytopathologic preparations were diagnostic in 69 patients. A diagnosis was established on either the biopsy or cytopathology, or both, in 86 cases (90 percent). These results indicate the value of using both biopsy and fluid cytology in the evaluation of pleural effusion, which often is due to involvement of the pleura by malignant neoplasm.


Sequential atrioventricular pacing as a stress test. Evaluation of left ventricular function in second-degree AV heart block developing during atrial pacing. Advanced or second-degree atrioventricular (AV) heart block pre-existing or developing during atrial pacing (AP) at low heart rates of smaller than 130 per minute, limits the value of AP to stress the left ventricle. When Wenkebach type AV block is present, the heart rate can be increased by administration of atropine before atrial pacing or by right ventricular pacing. Atropine, however, occasionally may cause serious supraventricular or ventricular arrhythmias, and high rate right ventricular pacing is not tolerated by many patients with left ventricular dysfunction because of the absence of the atrial contribution. Twenty-eight out of 101 patients with angina pectoris (27.7 percent) developed second degree AV heart block during atrial pacing studies performed for evaluation of left ventricular function. In 8 of the 28 patients, sequential AV pacing (SP) was performed successfully, with the heart rate being increased to 150-167 per minute. In 4 of the 8 patients, left ventricular dysnfunction was demonstrated during and immediately after SP. Typical angina pectoris developed in two of the four patients during SP, one of whom proved to have normal coronary arteriogram. Sequential AV pacing is an alternative method to increase the heart rate for the purpose of stressing the left ventricle when advanced degree or second-degree AV heart block pre-exists or develops during right atrial pacing. In some patients the method of SP might be preferable to administration of atropine or to ventricular pacing.


Preliminary experience with the use of a programmable pacemaker. One hundred sixty-four patients, in whom new externally programmable pacemakers had been inserted, were studied over a two year period, beginning July, 1972. Following implantation, the rate and current output of this pacemaker could be changed at any time by a non-invasive technique involving electromagnetic pulse trains emitted by an external "programmer". In 89 percent of the patients it was possible to reduce battery output by half, implying greater longevity of the pacer in these cases. In 15 percent of the patients, manipulative control of the pacemaker rate was employed and found beneficial.


Value and pitfalls of the lateral lung scan. Two hundred eighty-one of 443 lung scans composed of anterior, posterior, and lateral projections (done in our hospital) demonstrated defects. In 3.9 percent of them (11 cases), the defects were delineated in the lateral views only, while in 29.2 percent (82 cases), the lateral views either outlined additional defects not appreciated on the straight views, or showed more extensive lung involvement. In the majority of instances, 56.6 percent (159 cases), the lateral views showed comparable findings and also tended to segmentally localize the defects better. However, in 10.3 percent (29 cases), defects present on the straight projections were not detected on the lateral views. Various causes that could give rise to artefactural abnormalities in the lateral lung scan and therefore inhibit its proper interpretation, are reviewed and discussed. Despite these problems, the lateral may be the only view to demonstrate abnormalities and, in fact, frequently provides additional useful information.


Asynchronous breathing movements in patients with chronic obstructive pulmonary disease. An electromagnetic ventilation monitor was used to record the separate anterior-posterior movements of the chest and abdomen during the breathing cycle in 30 patients with chronic obstructive pulmonary disease (COPD) and in 10 normal subjects. In all normal subjects and 17 COPD patients, the chest and abdomen movements were syndhronous and in phase with the flow of air as measured with a spirometer. In 13 COPD patients chest movement was synchronous with the flow of air, but the abdomen moved inward suddently near or at end inspiration and then outward during a variable part of expiration. Compared to COPD patients with a normal breathing pattern, those with asynchronous breathing movements had poorer ventilatory mechanics and 10 of the 13 were dependent on assisted ventilation. Nine of the 13 patients with asynchronous breathing have died in a 10 month period, a significantly higher mortality than in those with normal breathing.


Platelet aggregation: effects of cardiopulmonary bypass. This study was designed to determine whether reduction in platelet aggregate microembolization during the first 30 minutes of cardiopulmonary bypass is due to thrombocytopenia or to decreased ability of platelets to aggregate. The total volume of platelet aggregates induced in blood by adenosine diphosphate (ADP) was measured with a Coulter counter. The volume of platelets in blood was calculated by multiplying hemocytometry platelet counts by the mean platelet volume. Immediately before cardiopulmonary bypass, the total volume of aggregates induced in blood by ADP (2muM) was reduced when compared to normal donors because of (1) a slight fall in the volume of platelets, and (2) reduction in the percentage by volume of platelets which aggregated. After 30 minutes on bypass, the volume of both platelets and aggregates fell, but a greater percentage of platelets aggregated. This indicates that reduction of platelet aggregate formation during cardiopulmonary bypass is due to thrombocytopenia. It also suggests that anesthesia, surgical trauma and heparinization alter platelet reactivity more than cardiopulmonary bypass.


Flexible fiberoptic pleuroscopy: pleural and lung biopsy. While diagnostic procedures are available to explore most of the body cavities for diagnosis and treatment, examination of the pleural cavity remains difficult, mainly because the negative pressure in the pleural cavity makes direct examination impossible without collapsing the lung. The ability to diagnose pleural and pulmonary disease by conventional techniques, such as blind pleural and lung biopsy, cytology of bronchial washings and brushings, radiologic techniques or cultures is limited and frequently fails to provide an accurate diagnosis. Exploratory thoracotomy, with a relatively high complication rate, remains the method of choice in many cases. We have devised a new technique for exploring the pleural cavity under direct vision while avoiding lung collapse, using a modified flexible fiberoptic bronchoscope introduced into the pleural cavity through a specially designed cannula.


Precordial ST segment mapping. A sensitive technique for the evaluation of myocardial injury? Myocardial ischemic injury was created acutely in pigs by a closed-chest technique utilizing an intracoronary balloon occluder for the interruption of flow in the left anterior descending coronary artery and ST-segment elevation was followed over a two hour period using an 18 lead precordial map. In an experimental group of 10 animals, occlusion was carried out within the left anterior descending coronary artery 8.3 plus or minus 0.5 cm distal to the origin of the main left coronary. Mean ST segment elevation (ST) showed a peak rise of 0.16 mV 10 minutes after occlusion. The balloon was moved proximally 1.6 plus or minus 0.2 cm giving a significant secondary rise of 0.16 mV within 5 minutes, despite indications of a generally small area of additional myocardial involvement, as judged from anatomic distribution of additional vessels occluded as well as a lack of significant change in hemodynamic parameters. In a control group of 5 additional pigs, a single distal occlusion at 6.4 plus or minus 0.9 cm from the origin of the main left coronary was produced by an identical technique. The ST rose to a peak of 0.20 mV at 15 minutes and was followed by a steady decline. Unlike the experimental group, no additonal rise in ST was seen. The technique of precordial mapping thus appears to be a sensitive index of myocardial injury. In addition, it appears from this study that the magnitude of ST elevation is a direct reflection of the extent of myocardial injury.


Pulmonary blastoma: report of two cases. Pulmonary blastoma is a rare primary malignancy of the lung originating from multipotential pulmonary blastema. Two cases of this tumor are reported emphasizing lack of correlation between the microscopic appearance and the clinical course. There are no specific clinical features that differentiate this tumor from the more common lung neoplasms. Surgical resection is the preferred treatment; the merits of radiotherapy and chemotherapy have not yet been established. Prognosis after adequate resection appears no better than for other pulmonary malignancies.


A new plastic operation for pectus excavatum: sternal turnover surgical procedure with preserved internal mammary vessels. The so-called turnover operation for pectus excavatum in older age groups has been disappointing due to postoperative complication such as fistual formation with necrosis of bones and muscles. Thus, the need of preserved vascular pedicle to the sternum was stressed in this type of operation. A new sternal crossover operation keeping the bilateral internal mammary vessels preserved was developed and satisfactorily applied on three clinical cases. The results indicate that this method is a useful sternal crossover procedure for patients over 15 years of age.


Distal propulsion of vena cava umbrella by cardiac massage. Distal propulsion of a 28 mm umbrella filter from vena cava to femoral vein occurred in a 75-year-old woman during external cardiac massage. After cardiac massage, filter position must be checked roentgenographically. Optimal management of distal migration might include placement of a second umbrella to prevent recurrent emboli and proximal migration of the dislodged umbrella.


Hyperacute radiation pneumonitis.

Hyperacute radiation pneumonitis. We present a patient who developed radiation pneumonitis only eight days after beginning therapy. The pneumonitis responded dramatically to prednisone on four occasions, which was a helpful point in the differential diagnosis.


Ill-effects of cardiac resuscitation: report of two unusual cases. Two mishaps associated with closed-chest cardiac resuscitation are presented. One-pneumoperitoneum-became evident during life, created considerable diagnostic difficulty, and evoked treatment that possibly hastened the patient's death. The other-cardiac puncture-appeared at autopsy and its mechanism may be unique.


A cutaneous manifestation of untreated disseminated histoplasmosis. We present a case of histoplasmosis with skin manifestations occurring 17 years after initial diagnosis. The clinical manifestations of disseminated disease are discussed. Amphotericin B administered through an A-V shunt resulted in prompt resolution of the skin lesions.


Congenital atrial flutter.

Congenital atrial flutter. Two cases of congenital atrial flutter, one of which was documented electrocardiographically before birth, are reported. In both patients sinus rhythm was restored with digoxin treatment; in one patient the transition was preceded by various arrhythmias. No cardiac malformation was found in either case, and no materal disease occurred during pregnancy. Both mothers had received medication during pregnancy, but its role as a causative factor is questionable.


Midsystolic clicks originiating from tricuspid valve structures: a sequela of heroin-induced endocarditis. In two patients who had been heroin users, loud midsystolic clicks developed during infective endocarditis involving the tricuspid valve. The sounds were loudest along the left sternal border, exhibited an increase in intensity during inspiration and were associated with right atrial gallop sounds and with murmurs of tricuspid regurgitation. This constellation of clinical events suggests that the midstystolic clicks emanated from tricuspid valve structures as a result of disordered function of the chordae tendineae. Prolapse of the tricuspid valve has recently been demonstrated angiographically to accompany similar abnormalities of mitral valve motion in certain patients with the click-murmur syndrome. The participation of the tricuspid valve in the generation of the auscultatory finding is unclear, but the cases herein reported suggest that the tricuspid valve is capable of producing these findings.


Pericarditis of acute myocardial infarction. Forty patients with acute myocardial infarction and pericarditis (AMI-P) were encountered over a three-year period. The incidence of AMI-P was 7.2 percent (40 of 554 patients). Fifty consecutive patients with acute transmural infarction without pericarditis (AMI-C) were used as a control group. There were no significant differences between the AMI-P and AMI-C groups regarding age, sex, infarct location, hospital stay or mortality. Painful symptoms of pericarditis were experienced by 37 patients (92 percent), all of whom had developed symptoms by the fourth hospital day. The pericardial friction rub lasted three days or less in 34 patients (85 percent), but an occasional rub could be heard for up to eight days. Twenty patients with AMI-P (50 percent) developed pleural effusions and/or parenchymal pulmonary infliltrates. Twenty-eight AMI-P patients (70 percent) were thought to have had congestive heart failure (CHF) on the basis of their symptoms and physical findings. Radiographic examination could confirm only 13 cases of CHF among the 28 patients in whom the diagnosis was made clinically. Glucocorticoids were given parenterally to 31 of the 37 patients (84 percent) who had symptomatic pericarditis and was felt to be effective in ameliorating painful symptoms. Followup data was obtained on 28 of the 32 surviving patients. Five patients (15 percent) had seven episodes of the postmyocardial infarction syndrome (PMIS). Pericarditis is generally a shortlived complication of acute myocardial infarction. Pleural and parenchymal pulmonary abnormalities are common and probably account for the tendency to "overdiagnose" CHF in patients with AMI-P. PMIS appears to occur more frequently in patients who have had pericarditis at the time of the acute myocardial infarction.


Cough dynamics in the post-thoracotomy state. A series of 24 adult male patients undergoing thoracotomy were found to have a reduction in their cough pressures in the immediate postoperative period to 29 percent of their preoperative values. Cough pressures still averaged only 50 percent of control values one week following surgery, with slow return toward normal over the ensuing three weeks. Pain associated with the surgical wound appeared to be primary factor in the patients' inability to cough effectively. The degree of impairment appeared to be related to the extent of the procedure, pressures being altered less in those with limited incision thoracotomies. Ultrasonically nebulized water mist was found to be effective in all but one patient in inducing significantly higher cough pressures and more effective sputum expectoration. Its use should be considered as a simple method of inducing more effective coughs in the postoperative patient.


Severe pleural restriction: the maximum static pulmonary recoil pressure as an acid in diagnosis. Three patients with pleural restriction are presented in detail. One patient had had a right pneumonectomy and died of ventilatory failure due to left-sided restrictive pleurisy. The second patient had neoplastic pleural effusion and inactive tuberculosis. The third patient had systemic lupus erythematosus with bilateral restrictive pleuritis. The physiologic picture was similar in the three cases, with marked decrease of lung volumes, increase of the RV/TLC ratio, absence of airways obstruction, decrease of the Dco and decrease of dynamic lung compliance. In addition, each of these three patients and others with severe pleural restriction had a lower than normal maximum static pulmonary recoil pressure (Pmax). Since in pulmonary restrictive disease, the Pmax was found to be elevated, it was a useful test for distinguishing pulmonary restriction from pleural restriction.


Mortality prediction in adult respiratory insufficiency. The results of treatment of acute respiratory insufficiency in the adult must be quantitated before indications for innovative treatment (such as extracorporeal oxygenation) can be defined. A method for retrospective and prospective data collection based on a graph of A-a gradient and time was evaluated in 45 patients. From this graph a pulmonary insufficiency index (PII) can be calculated which correlates well with mortality in this series. The mean PII of surviving patients was 0.84 and the highest value was 2.75. The mean PII of patients who died with pulmonary insufficiency was 15.9; the lowest value was 6.0. Using this method with a larger data base, it will be possible to predict mortality based on PII facilitating the study of ongoing management and innovative treatment methods.


Silent anomalies of the urinary tract and congenital heart disease. Postangiocardiographic screening of infants and children with congenital heart disease for silent anomalies of the urinary tract yielded an incidence of 7.7 percent in 260 so studied. The incidence was 29 percent in 21 babies who came to autopsy and had been studied at catheterization but without this screening. Patients with atrial septal defect had the highest incidence of urinary tract anomalies, while those with ventricular septal defect and tetralogy had an average incidence. Some of the lesions discovered were potentially significant even though silent. They were found with sufficient frequency to warrant routine use of this screening technique at cardiac catheterization.


Left ventricular approach for recording His bundle potential in man. The electrical potentials of the His bundle (HB) were recorded from the left ventricular endocardial surface in 28 patients ranging from 16 to 63 years of age. In 14 of the patients the left bundle branch (LB) potentials were also obtained. Placement of a bipolar electrode catheter tip toward the interventricular septum, right at and also 1 to 2 cm below the aortic valve, resulted in stable recordings of both potentials in successive cardiac cycles even at performing atrial or HB pacing from the right heart. The following intervals were measured in milliseconds (msec): P-A, A-H, H, H-V, LB, and LB-V. The average values in 12 patients (average age 26 plus or minus 7 years and average heart rate 90 plus or minus 16 beats per minute) with normal A-V conduction were as follows: P-A 28 plus or minus 7, A-H 76 plus or minus 16, H 19 plus or minus 3 and H-V 45 plus or minus 6 msec. The average values for LB and LB-V in 10 of these 12 patients were 15 plus or minus 3 and 25 plus or minus 3 msec respectively. Validation of the His bundle electrogram (HBE) from the left ventricular endocardial surface was based on simultaneous recordings of the intracardiac electrograms from both left and right sides of the heart in 18 patients. The individual average values for the intervals obtained from both sides of the heart in these patients were statistically not different, except that the H potential was slightly longer in duration fr  m the left heart (P equals 0.05). Among these, 16 showed simultaneous onset of the H potentials, and the LB-V and RB-V conduction times from comparable points were almost the same. Indications for the left sided electro-physiologic studies include the following situations: (a) inability to record H from the right of the heart; (b) giant right atrium; and (c) possibly during atrial fibrillation.


Pericardial cyst ten years after acute pericarditis. A case of pericardial cyst development in the years after an episode of acute pericarditis is reported. The method of diagnosis allowed confirmation of the condition without thoracotomy. These aspects of the case are relevant to the genesis of pericardial cysts in general and establish ultrasound and subsequent contrast roentgenography are advocated as adequate means of diagnosis in this condition.


A technique for unknotting an intracardiac flow-directed balloon catheter. Described is an unusual complication occurring during right-sided cardiac catheterization using a 7F flow-directed balloon catheter. During an attempt to direct the catheter from the main pulmonary artery into the pulmonary wedge position, the tip became entangled in a loop of catheter and knotted. Initially, all attempts to unknot or remove the catheter failed. A movable core guide wire was passed through the major lumen of the catheter, resulting in the immediate unknotting of the catheter, thus allowing its withdrawal.


Recurrent myxosarcoma of left atrium.

Recurrent myxosarcoma of left atrium. The surgical treatment of cardiac myxosarcoma is reviewed with emphasis placed on palliative response to radiation therapy. A case of primary myxosarcoma of the left atrium in a 16-year-old girl is presented. The tumor was surgically removed in October, 1967. Recurrently myxosarcoma was removed in August, 1968, at which time involvement of the pulmonary veins and the pericardium was noted. Subsequent to postoperative radiation therapy, the patient remained symptom-free for more than three years. Death occurred 4 1/2 years after the original operation from local and systemic recurrence of the tumor.


Acute obstruction in cancer of the colon and rectum. Results after operations for acute obstruction of the large intestine due to cancer were analyzed during a 10-year period and compared with the results after operations for nonobstructive tumors during the same period. The following conclusions could be deduced: 1) Cancer is more often obstructive in the colon than in the rectum. Cancers of the splenic flexure are relatively more often obstructive than cancers in other parts of the colon. 2) Postoperative morbidity (and probably mortality) is higher and the five-year survival shorter in patients with obstructive cancers of the large intestine than in those without obstruction. Obstructive Dukes' A tumors are very few. 3) The early morbidity and mortality after acute cecostomy are probably not higher than after acute transversostomy, if the cecostomy wound is left open. The cecostomy carries a risk of peritoneal contamination. 4) Cecostomy does not relieve obstruction in 5-10 per cent of the patients, while transversostomy seems always to be effective. Emergency exploratory laparotomy for obstructive cancer of the large bowel instead of a blind cecostomy reduces the number of patients who need two operations by 10 per cent. 5) Hernias are frequent at the sites of previous spontaneously closed cecostomies. 6) Antibiotic bowel preparation seems not to be effective shortly after decompressive colostomy.


Factors influencing survival with complete obstruction and free perforation of colorectal cancers. A review of 26 years' experience in the management of patients with obstruction and perforation of the colon due to carcinoma at Hôpital Notre-Dame, Montréal, is reported. We try, in the present paper to identify the factors responsible for the very poor prognosis in complete obstruction and free perforation of colorectal cancers. As we are comparing these complicated cancers with a larger group of uncomplicated cancers, our results are analyzed by the chi-square test.


Adenomatous polyps of the ileocecal valve: report of three cases. Lesions of the ileocecal valve are uncommon and include various inflammatory diseases, submucosal fatty infiltration, edema, and neoplasia. Of the neoplastic lesions, adenomatous polyps are distinctly rare, despite their frequency in the remainder of the colon. Three patients with adenomatous polyps of the ileocecal valve are added to the seven previously reported cases. One had a large pedunculated polyp, another had polyps resulting from familial polyposis, and the third had circumferential adenomatous polypoid hyperplasia and the ileocecal-valve syndrome. Although many lesions of the valve produce the characteristic symptoms, the diagnosis of the ileocecal-valve syndrome is seldom made. Most ileocecal-valve lesions are incidental findings on barium-enema studies and may be carefully followed. The indications for operative intervention are suspicion of malignancy and the presence of troublesome symptoms. If malignancy is likely, a right colectomy should be done. Segmental resection is the procedure of choice for the ileocecal-valve syndrome. Adenomatous polyps may require simple polypectomy, segmental resection, or even subtotal colectomy. Following recognition of these unusual disorders the exact management is individualized.


The Warren operation for anal incontinence caused by disruption of the anterior segment of the anal sphincter, perineal body, and rectovaginal septum: report of five cases. The use of the Warren vaginal flap operation for repair of a traumatic deformity consisting of disruption of the perineal body, anterior segment of the external anal sphincter, and lower half of the rectovaginal septum is described. Modifications described in this article include use of the jackknife position to give better exposure and epinephrine infiltration to give a bloodless field. The incidences of infection and recurrence appear lower than with the layer technique.


Atraumatic splenic rupture simulating ruptured sigmoid diverticulitis: report of a case and review of the literature. A case of atraumatic rupture of the spleen originally presenting as ruptured sigmoid diverticulitis is described. The underlying disease was found to be myelofibrosis. Although progressive splenomegaly is always associated with this disease, spontaneous rupture of this organ is not reported in the literature. We also reviewed the literature in regard to unusual presentation of splenic rupture and we could not find any case simulating acute sigmoid diverticulitis. It is suggested that awareness and familiarity with this disease may enable the surgeon to suspect this diagnosis when dealing with an unusual acute abdominal emergency.


Clinical experiences at St. Mark's Hospital with multiple synchronous cancers of the colon and rectum. We have reviewed the experience of St. Mark's Hospital with double synchronous cancers of the large intestine. This occurs in 3.5 per cent of cancer resections, and in 75 per cent there are associated benign neoplasms. Patients with double or treble cancers fare much the same as those with single cancers, and the prognosis appears to be surprisingly favorable, even when the second growth is comparatively advanced. The second lesion, however, is usually not palpable at operation, and full clinical and radiologic investigation is therefore essential before any resection is undertaken for cancer of the colon or rectum.


Stercoral necrosis of the cecum in an incarcerated right inguinal hernia: report of a case. A rare case of stercoral ulcers of the cecum in an incarcerated inguinal hernia is described. Local resection was followed by an uneventful recovery.


Entrapment of the colon following diaphragmatic injuries: report of eight cases. With a rise in the incidence of severe injuries, we are seeing increasing numbers of patients with colonic entrapment occurring at the sites of diaphragmatic injuries. The initial injury might have occurred recently or it might have occurred as long as 25 years before. Blunt trauma, stabbings, and infection accounted for the initial trauma in our patients. Acute symptoms implicate the cardiorespiratory system as a result of interference with respiration and the filling and function of the heart. Acute or chronic gastrointestinal symptoms may suggest intestinal obstruction or functional bowel disorders. The proper diagnosis of colonic entrapment depends upon a high index of suspicion and proper studies. Chest x-rays, fluoroscopy, barium-enema examinations and contrast studies of the upper gastrointestinal tract are essential. Acute cardiorespiratory enbarrassment necessitates prompt surgical intervention. When subdiaphragmatic injuries are suspected, an abdominal incision is necessary. In long-standing cases where the abdominal viscera are intact, the thoracic approach is preferable. At times, the combined thoraco-abdominal incision may be preferable. Diaphragmatic injuries resulting in colonic entrapment occurred most often in the left hemidiaphragm, which is relatively unprotected. In seven of our eight patients, the left diaphragm was the site of herniation. The liver on the right side serves to protect this area from herniation. Only the largest defects permit displacement of the liver into the right chest. Only one of our patients had such a defect. Patients with long-standing cardiac or gastrointestinal symptoms suggestive of colonic entrapment should have a THOROUGH MEDICAL evaluation before any operative treatment is advised. We have reviewed the cases of eight patients in whom infection, stabbings and blunt trauma resulted in diaphragmatic herniations with subsequent colonic entrapment. The splenic flexure of the colon protruded through the defect in three of our eight patients. The transverse colon was located above the diaphragm in five.


Lateral subcutaneous internal sphincterotomy for chronic anal fissure, an outpatient procedure. We have adapted the lateral internal sphincterotomy technique for the repair of chronic anal fissure to a strictly office or outpatient procedure. The early cure rate in this review of our first 200 patients was very good - well in excess of 98 per cent. Complications were exceedingly minor, the considerable cost to the patient of hospitalization and time off from work has been saved, and patient acceptance has been excellent.


Tumors of the appendix.

Tumors of the appendix. An analysis of 101 tumors of the appendix is presented. During the period under study (from 1949 to 1972), 8,699 appendectomies had been performed. Only 17 of the 101 tumors were malignant. In this group, there were two primary carcinomas, 12 metastatic carcinomas, and three lymphomas. Most of the tumors (84) were benign, including 43 carcinoids, 32 mucoceles, five neuromas, two leiomyomas, and two villous adenomas, Some of the clinical and pathologic features of carcinoids, adenocarcinoma, and mucoceles are discussed. The most significant observation in this study is the statistically significant evidence that, even without associated acute appendicitis, mucoceles 2 cm or more in diameter probably do cause clinical symptoms, which may be alleivated by appendectomy.


Gracilis muscle transplant for correction of traumatic anal incontinence: Report of a case. We report a case of traumatic anal incontinence successfully treated by the transplant of a gracilis muscle sling, using the technique described by Pickrell et al. in 1952. Although gracilis muscle transplant has been used in the treatment of congenital anal incontinence, its use in traumatic cases has not been widely accepted. Instead, many techniques offering uncertain results have been employed. We believe that Pickrell's technique is a worthwhile procedure in the presence of traumatic anal incontinence, particularly with noniatrogenic large perineal wounds, and that establishment of a temporary colostomy immediately after the injury, together with use of surgical steel sutures and antibiotics, is very helpful in averting posttransplant infection.


[Diagnostic and prognostic value of endomyocardial biopsy in patients with congestive cardiomyopathy (author's transl)]rdiomyopathy(author. Endomyocardial biopsies were obtained from the right ventricle in 25 patients with the clinical diagnosis of congestive cardiomyopathy. The biopsies were subjected to virological and histological studies (light and electronmicroscopy) and the findings correlated with clinical data. Abnormal morphological findings were present in all patients. The presumed clinical diagnosis was confirmed in 19, the morphological changes not being consistent with the clinical diagnosis of CCM in six patients. Electronmicroscopy revealed cardiac storage disease in one patient and pathological changes secondary to previous myocarditis in the other five. Clinical follow-up studies of the five patients apparently confirmed the morphological results, because in no case was there clinical deterioration, three patients in fact being in a fairly normal cardiac state at present. Using a morphological scoring system, the 19 patients with morphologically confirmed diagnosis of CCM were subdivided into two groupds, those with four points or less (group I, n equal to 9), and those with five pints or more (group II, n equal to 10). During a mean follow-up period of nearly 12 months the first group had a low mortality rate (n equal to 2), while the other had a high one (n equal to 6). The occurrence of signs of degeneration and mitochondrial alterations, in particular, was associated with a poor clinical prognosis. This differentiation into two groupds could not be achieved by clinical means alone. Type B3 Coxsackie virus was isolated from one biopsy, but no patient had significant serological evidence of virological infection.


[Localization of the conduction defect in complete A-V block by means of His bundle electrograms (author's transl)]. The localization of the conduction defect in so-called complete A-V block can be established by electrocardiography only indirectly and unreliably. In principle the region of the atrio-ventricular junction, i.e. the A-V node and the bundle of His, may be involved just as well as the two branches. Analysis of the configuration of the QRS complex in the electrocardiogram is unreliable, particularly in cases with bundle branch block, because any pattern can arise from the appropriate site of a tertiary focus of stimulation in one of the two ventricles. Recording His bundle potentials (His bundle electrogram) enables differentiation. In eleven personal observations and 151 cases collected from the literature of complete A-V block the analysis with this method showed that the so-called A-V block in the majority of cases (63%) is actually due to bilateral bundle branch block. In the other 37% an A-V junctional block was present. This type of block could be differentiated by means of His bundle electrograms into an A-V nodal block and His bundle block.


[Labile repolarization changes in the ECG of patients without heart disease (author's transl)]. Nine patients with suspicious repolarization (ST-T segment) changes in the ECG were further investigated. Each had ten different additional ECG tests (after various degrees of exercise, and orciprenaline, amylnitrite, glucose, potassium chloride, and propranolol injections). The ECG changes became normal in all patients, orciprenaline and propranolol injection providing optimal results. Clinical investigation, left-heart angiocardiography and coronary angiography were normal in all. The questionably abnormal repolarization distrubances were, therefore, judged to be benign. As both beta-stimulation and beta-blockade normalized the ECG it can be safely assumed that the ECG changes were induced by autonomic nervous system factors. Cardiac catheterization appears, therefore, not indicated in each case and a potential iatrogenic heart disease can be avoided by relatively simple means.


[The effect of tilidine on left-ventricular function of the human heart (author's transl)]. The effect of tilidine (Valoron, 1.5 mg/kg) on left-ventricular function was measured in ten patients undergoing diagnostic cardiac catheterization. In the course of thirty minutes after administration there was a small fall in systemic arterial pressure, decrease in cardiac output, cardiac index and stroke volume, as well as a change in the isovolumetric inotropic state. Haemodynamic and inotropic changes were small in amount, varying between 3.4 and 14.5% of basal values. This study indicates that tilidine, while having a powerful analgesic effect, has only a mild contractility-inhibiting action. Tilidine is thus a useful alternative as an analgesic in cardiac pain.


[The surgical treatment of cerebral ischaemia due to extracranial arterial occlusion(author's transl)]. Results of reconstructive vascular surgery in 352 patients (aged 3 to 75 years) with extracranial arterial occlusions (295 of internal carotid artery) with intermittent symptoms or minor neurological defects are reported. Advantages of reconstructive surgery in the prevention of recurrence are: (1) further cerebrovascular episodes more frequently affect the non-operated side or brain-stem; (2) neurological recovery is quicker and more complete in operated than conservatively treated patients. However, reconstructive surgery, while preventing further cerebrovascular episodes, does not influence definite neurological defects.