Outcome of normal and dysfunctional labor in different racial groups. Spontaneous labor in patients of different racial groups has been studied relating progress and outcome to whether labor was dysfunctional as defined by the partogram and action line. Forty-three percent of primigravidas and 17.6 to 25.8% of multigravidas passed the action line and had a lower admission cervical dilatation and a longer observed first stage than those patients whose labor progress remained to the left of the action line. White and black primigravidas whose labor progressed to the right of the action line had lower 1 and 5 minute Apgar scores and delivered heavier babies than those to the left. The cesarean section rates were 1.6% and 1.4% (left) and 7.6% and 18.2% (right) in white and black primigravidas, respectively. The cesarean section rate was significantly higher in black primigravidas irrespective of the relationship to the action line due to the high incidence of the complications of hypertension such as fetal distress and abruptio placentae in those in normal labor as well as those in dysfunctional labor due to cephalopelvic disproportion in those patients whose cervimetric progress went to the right of the action line.


In vitro effect of dopamine and pimozide on human chorionic gonadotropin secretion. In human placental explants cultured in vitro, dopamine inhibited human chorionic gonadotropin (hCG) secretion into the culture media. In the control flasks, the level of hCG secretion was 751 +/- 215 mIU/gm of tissue. When 1 mM of dopamine was added, hCG levels decreased to 321 +/- 57.6 mIU/gm of tissue (n = 6, P less than 0.1)--5 and 10 mM of dopamine significantly inhibited hCG secretion. In contrast, 1 mM of pimozide enhanced hCG secretion by 1.8-fold compared to control levels (1,707 +/- 343 versus 3,117 +/- 0.005). This in vitro effect on hCG is similar to the effect of dopamine and pimozide on hCS secretion by placental explants.


Changes in the glycosaminoglycans distribution pattern in the human uterine cervix during pregnancy and labor. The glycosaminoglycans distribution pattern of uterine cervix samples obtained from 42 women of reproductive age was determined by means of proteolytic digestion and subsequent chromatographic separation. The following glycosaminoglycans were detected: chondroitin 4- and 6-sulfates, dermatan sulfate, hyaluronate, chondroitin, and keratan sulfate. The connective tissue of the uterine cervix shows a characteristic distribution pattern with regard to glycosaminoglycans which does not correspond to that found in any other tissue studied so far. Based on dry weight, the content of keratan sulfate increases during pregnancy while the concentration of chondroitin remains unchanged. The chondroitin sulfates and dermatan sulfate drop simultaneously. During labor chondroitin increases threefold. The hyaluronate content of the postpartum cervix is higher than that of the cervix in nonpregnant women. Both changes in the solubility of collagen as well as in the distribution pattern of the glycosaminoglycans seem to be related to cervical dilatation.


Fetal breathing movements and the nonstress test in high-risk pregnancies. Three hundred ninety-eight observations of fetal breathing movements (FBM) and the nonstress test (NST) were made in 223 patients. The presence of FBM was noted in a significantly higher proportion of tests with a reactive NST (88%) than a nonreactive NST (67%). Conversely, a significantly higher proportion of tests were reactive when FBM were present (82.6%) than when FBM were absent (49%). A significant relationship existed betweeen either test and the outcome of pregnancy as judged by the five minute Apgar score or the incidence of fetal distress in labor. Combining two normal tests did not improve the accuracy in predicting outcome; but the combination of both tests, when abnormal, produced a significant improvement in predicting fetuses likely to have an abnormal outcome. The combination of the normal with the abnormal test had a predictive accuracy similar to a single normal test in predicting a normal five-minute Apgar. This combination was associated with an incidence of fetal distress in labor intermediate between that seen with either the normal or abnormal test when alone. Neither a single test nor the combination of tests was helpful in identifying the small-for-gestational age (SGA) infants. These data indicate antepartum fetal evaluation may be improved when more than one biophysical variable is used.


The relative significance of human placental lactogen in the diagnosis of retarded fetal growth. The purpose of this prospective study was to determine whether serial maternal venous hPL determinations could identify pregnancies resulting in growth-retarded infants from a selected population at presumed high risk for IUGR. Our results demonstrated that mean hPL levels in IUGR outcome pregnancies were significantly lower than normal after 33 weeks' gestation. Mean hPL was also lower in some pregnancies resulting in normal-weight neonates with abnormally low PI or short CHL, suggesting that these neonates, despite normal birth weight achievement, may represent previously unsuspected.


Insulin and placenta: degradation and stabilization, binding to microvillous membrane receptors, and amino acid uptake. Human placenta possesses insulin receptors, yet whether insulin affects uptake of substrate or other placental functions is still controversial. A potential problem in the study of this issue is degradation of insulin by placental tissue. We found insulin degradation to be rapid and temperature dependent. At 10 mU/ml and 37 degrees C, 40% became trichloroacetic acid soluble within 15 minutes. Degradation was decreased by preincubation of tissue, followed by change of medium and by addition of 0.5% to 2.0% bovine albumin. Receptor assay with isolated microvillous membrane, which bound insulin with the characteristics of known target tissues, demonstrated biologically active insulin (5 to 6 mU/ml) to persist under incubation conditions. The presence of insulin did not influence the uptake of amino acids by the three neutral amino acid transport systems of the human placenta. Thus the transport of an essential fetal nutrient is is apparently independent of fluctuations in maternal insulin with dietary carbohydrate intake and disease.


Simultaneous determination of seven unconjugated steroids in maternal venous and umbilical arterial and venous serum in elective and emergency cesarean section at term. In order to assess specific gluco- and mineralocorticoid functions in both mother and fetoplacental unit in relation to the presence or absence of labor, serum levels of unconjugated aldosterone (A), corticosterone (B), deoxycorticosterone (DOC), progesterone (P), 17-hydroxyprogesterone (17-OHP), cortisol (F), and cortisone (E) were determined simultaneously. These levels were determined by specific radioimmunoassays in two groups of 24 paired maternal venous and umbilical arterial and venous samples obtained at term delivery by either elective (Group I, N = 8) or emergency (Group II, N = 8) cesarean section. In Group II, after spontaneous labor, mean maternal serum levels of all steroids investigated exceeded those found in Group I (not in labor). These increases were most pronounced (p less than 0.005) in F (74%) and DOC (106%) levels demonstrating stimulation of both the glucocorticoid (cortisol)--and the mineralocorticoid (aldosterone)--producing pathways of the maternal adrenals by spontaneous labor. Arteriovenous differences in umbilical steroid levels revealed in both groups the placental origin of P, 17-OHP, and E (p less than 0.05 to 0.005), with greater (more negative) mean AV differences after labor (Group II). The negative AV difference of DOC, B, A, and F found in Group I, however, decreased after labor and became even positive in the cases of B and F, reflecting the close relationship between spontaneous labor and the fetal adrenal's active production not only of the glucocorticoids B and F, but also, to a lesser extent, of the mineralocorticoids DOC and aldosterone.


Ocular myasthenia gravis mimicking pseudointernuclear ophthalmoplegia and variable esotropia. A 70-year-old man with known vascular disease, who had bilateral internuclear ophthalmoplegia, and an 18-month-old girl with a long-term variable esotropia culminating in a postinfectious oculopharyngeal neuropathy both responded with a positive edrophonium chloride (Tensilon) test, strongly suggesting the diagnosis of myasthenia gravis. Both subsequently received maintenance doses of neostigmine methylsulfate (Prostigmin).


Vitreous fluorophotometry in adult-onset diabetes mellitus. We studied the breakdown of the blood-retinal barrier in 83 patients with adult-onset diabetes mellitus, by using vitreous fluorophotometry. The patients were in good stable metabolic control and were receiving injectible insulin or oral hypoglycemic agents. Vitreous fluorophotometry readings were abnormally high but similar in both groups of patients, and no significant differences were found between those with and those without early background diabetic retinopathy. Significantly more patients taking oral agents were hypertensive, and significantly fewer of these patients had background retinopathy.


Localized conjunctival amyloidosis.

Localized conjunctival amyloidosis. We treated a patient with localized amyloidosis of the bulbar conjunctiva, which strongly resembled a neoplastic growth. Although the patient suffered from a long-standing, debilitating rheumatoid arthritis, suggesting the possibility of a secondary systemic amyloidosis caused by the chronic effusive process, no specific clinical evidence of systemic amyloidosis was noted. The ocular lesion was, therefore, classified as a primary localized amyloidosis. However, the simple recognition of amyloid in the ocular adnexa should not be considered a complete diagnosis. For such cases in which a prominent underlying systemic disease is present, a thorough medical evaluation and future follow-up should be ensured to rule out the possibility that this represents the initial manifestation of a potentially life-threatening secondary systemic amyloidosis caused by rheumatoid arthritis.


Extended-wear contact lenses in 525 aphakic eyes. Extended-wear contact lenses were fitted to 225 patients with monocular aphakia and 150 with bilateral aphakia. They were observed from three months to three years. Eighty-eight of the 195 eyes fitted with a Softcon lens became red and painful within 14 days during extended wear. The Hydrocurve lens was better tolerated in 55, but many patients had acute congestion, pain, and tearing. Deposits accumulated rapidly on the Sauflon-PW lens. Some 90% of all patients can be fitted successfully with the cellulose acetate butyrate lens or the silicone lens. The silicone coating of the silicone lens is lost or damaged in about 20% of the patients because of excess mucous accumulation.


Epithelial deposition of gold in the cornea in patients receiving systemic therapy. Epithelial gold deposits were demonstrated biomicroscopically in 13 of 15 patients receiving gold therapy for rheumatoid arthritis. Only one of six further patients who had received gold therapy in the past showed such deposits. Deposits appeared with a cumulative dose of sodium thiomalate exceeding 100 mg. The earliest appearance was after seven months of therapy and deposits were visible in one subject as long as nine months after therapy had stopped. The density of deposit does not appear to increase over the whole of the dose range, possibly as a result of the effect of epithelial turnover. No symptoms attributable to the deposit were encountered in any patient.


In vivo choroidal thickness measurement. We developed a system that permits exceptionally accurate measurements of human choroidal thickness in vivo by means of ultrasound. With minicomputer techniques, the complementary functions of the time and spectral domains of reflected sound can be used to permit measurements accurate to less than 20 mu at 10 MHz center frequency. Even more accuracy can be obtained with higher center frequencies. Choroidal thickness has been found to exceed that previously reported, with typical values of 420 mu found at the posterior pole. Even greater values are seen in regions outside the macula.


Effects of monomeric methylmethacrylate on ocular tissues. Toxic effects of high doses of monomeric methylmethacrylate were demonstrated in rabbit eyes. These effects were not related to surgical manipulation. Monomeric methylmethacrylate caused limbal hyperemia, corneal edema, corneal neovascularization, iris engorgement, anterior chamber inflammation, iris atrophy, and cataract. The doses of monomeric methylmethacrylate needed to produce these lesions were much higher than the amount of monomer available for leaching out of implanted intraocular lenses.


Prospective observation of vascular anastomoses between the retina and choroid in recurrent toxoplasmosis. Prospective angiographic observations demonstrated the formation of both choroidoretinal arteriolar anastomoses as well as retinochoroidal venular anastomoses in the ocular fundus of a young man with recurrent ocular toxoplasmosis.


Prevention and treatment of symblepharon. Symblepharon after acute conjunctival injury can be prevented by separating  the raw surfaces for one to two weeks, until re-epithelialization takes place. We have used a soft contact lens and a conjunctival ring without a corneal center, or lined the eyelid and palpebral conjunctiva with plastic. This often eliminates the need for mucous membrane grafts. Symblepharon can interfere with intraocular surgery and disrupt cataract incisions unless they are divided and separated at the time of surgery.


Observations on the development of the anterior chamber angle with reference to the pathogenesis of congenital glaucomas. Abnormalities in neural crest cell migration may have a role in the pathogenesis of the congenital glaucomas, with or without changes in the gonioscopic appearance of the anterior chamber angle. Neural crest cells also contribute to the bones of the face, dental papilla, cartilage, bone, and meninges; this may explain the association of craniofacial, dental, and upper spinal malformations with some of the congenital glaucomas.


Ocular hypotensive action of labetalol.

Ocular hypotensive action of labetalol. Labetalol has a unique and profound effect on the IOP of rabbits, in contrast to pure beta-adrenergic blockers which have little or no effect in this animal. Its action cannot be satisfactorily explained by simple alpha and beta-adrenergic blocking activity. In the concentrations used, it failed to block the action of a beta-adrenergic agonist (isoproterenol), the action of an alpha-adrenegic agonist (norepinephrine), and its own hypotensive action was neither blocked nor potentiated by the alpha-adrenergic blocker phenoxybenzamine. However, the beta blocker, timolol, did reduce the action of labetalol. These observations and the reduced response to labetalol after cervical sympathectomy, suggest that labetalol's ocular hypotensive effect may occur through some mechanism other than alpha or beta blockade.


Birth order and parental age in microphthalmos and other ocular diseases. We compared the distribution of birth order and maternal and paternal ages of blind school children throughout Japan with that of the total Japanese population of the corresponding age groups and with that of a subgroup of children with acquired blindness. The number of first-born children with microphthalmos was smaller, and the number of second-, third-, or fourth-born children was larger, as compared with the control groups. The differences were highly statistically significant by chi-square test. There was a less pronounced indication of birth order effect in amblyopia, congenital cataract, and optic nerve atrophy, which involved more first-borns than in the controls. The distribution of maternal age was also different from the control group in microphthalmos, congenital cataract, corneal opacity, and optic nerve atrophy. Less mothers in their 20s and more in their 30s produced children with these conditions. We believe this finding may be partly related to the rapid decline in infant mortality and in the incidence of congenital blindness in Japan.


Vessels of intraocular malignant melanomas. The vessel walls of six malignant choroidal melanomas were thin; only thin basal membranes and narrow endothelial linings could be observed with the electron microscope. The endothelium was even absent in some places. Tumor cells were released into the bloodstream through disruptions of the vessel walls in the epithelioid and spindle cell B type tumors.


Association of HLA antigens and primary open-angle glaucoma. HLA testing of 55 patients with primary open-angle glaucoma revealed no increased frequencies of any of 17 HLA-A and 29 HLA-B antigens. However, the subgroup with a known family history of primary open-angle glaucoma had an increase in the frequency of the HLA-B12 antigen (48%). Intrafamily studies might further define the strength and importance of this association.


Pars plana vitrectomy in ocular trauma.

Pars plana vitrectomy in ocular trauma. Visual improvement was achieved in 62% of 100 consecutive patients with ocular trauma treated by pars plana vitrectomy. Anterior segment injuries had a better prognosis than posterior segment injuries, and retinal detachment was a poor prognostic sign. Patients undergoing vitrectomy during the two weeks after injury had a better visual prognosis than those who had delayed vitrectomy. Pars plana vitrectomy has increased the recovery rate in traumatized eyes which previously were deemed inoperable and frequently were enucleated. Most such eyes have intraocular fibrocellular proliferations, resulting in traction retinal detachments, cyclitic membranes, and phthisis, as documented in clinicopathological and experimentally produced specimens of penetrating ocular trauma. Vitrectomy can interrupt this sequence, if performed one to 14 days after injury, by removing the vitreous scaffold onto which proliferation occurs, together with the elements of hemorrhage, damaged lens, vitreous, and foreign material which may incite proliferation. We believe four to ten days after injury to be the optimal time for vitrectomy to avoid the hazards of immediate intervention, while removing damaged tissue before serious sequenlae occur.


Cataracts and macular degeneration.

Cataracts and macular degeneration. The intraocular lens restores general vision and some degree of independence and mobility to patients with dense cataracts and macular degeneration. The patient, however, must be repeatedly warned that fine central vision, particularly reading, will not be possible after the surgery. An aphakic spectacle leaves such patients a narrow band of vision when superimposed over the macular lesion, and contact lenses are too small for the patient to manage insertion without help.


Estimates of genetic correlations among clinical measures of the eye. In a quantitative genetic investigation of seven clinical tests, five pairs were significantly correlated: (1) cover test measures and corneal power, (2) corneal power and divergence recovery points, (3) convergence and divergence recovery points, (4) divergence break and recovery points, and (5) convergence break and recovery points. Common genes may account entirely for the gene influence on cover test measure; thus, parents who are above the population mean for corneal power will have offspring with a tendency toward an exodeviation (phoria). The two convergence amplitudes may depend on the same gene differences, whereas the two divergence amplitudes only partly reflect a common function, suggesting that they may be indexing somewhat different underlying physiologic mechanisms.


Myelinated retinal nerve fibers associated with ipsilateral myopia, amblyopia, and strabismus. Four patients had extensive unilateral myelinated nerve fibers associated with ipsilateral myopia, amblyopia, and strabismus. Their profound visual impairment, exotropia, and the early age onset of symptoms indicated that the amblyopia may have been organically caused. Prognosis is poor for even partial correction but good results have been obtained with intense therapy that includes full correction of the refractive error in each eye and extraocular muscle surgery if cosmetically necessary. In patients with axial myopia, images of a similar size will be produced by placing a lens of the correct power at the spectacle plane. In younger patients, a contact lens should not be used to correct the refractive error because it creates an undesirable anisometropia. Younger patients who have parafoveal fixation and no strabismus respond best to amblyopia therapy.


Penalization in the treatment of amblyopia. Penalization is a useful alternative to occlusion therapy in amblyopia of mild and moderate degrees and in preserving therapeutic gains made by previous occlusion treatment. Penalization at near, total, and alternating penalization are more valuable than penalization at distance. Because penalization does not prevent the development of visual deprivation amblyopia, unilateral atropine therapy must be used carefully in treating patients in an age group susceptible to occlusion amblyopia.


An en bloc technique for the resection of anterior uveal tumors. We modified trabeculo-iridocyclosclerectomy in a technique for en bloc excision of anterior uveal tumor. A trabeculectomy-type of approach was used, which allowed excision of a rectangular block of sclera, cornea, and trabeculum with attached uveal tissue containing the tumor.


Metastatic disease from untreated uveal melanomas. Few ophthalmologists or pathologists have observed uveal melanomas that metastasized before they were recognized and treated. In an effort to characterize those melanomas that have produced metastatic disease before the tumor-containing eye was enucleated, we have collected a series of 29 cases for review. These have generally involved older subjects (median age 65 years) who had large tumors that had been symptomatic for long periods before being recognized. A disproportionately large percentage showed extraocular extension. Although the data support the thesis that uveal melanomas are typically slow-growing tumors that show local infiltrative properties but little tendency to produce metastatic disease unless treated by enucleation of the eye, it is possible that the available information is possibly biased by our methods of acquisition of data. Much pertinent information is lost because the cases usually do not come to the attention of ophthalmologists or ophthalmic pathologist. This missing link in our knowledge of the natural course of untreated uveal melanomas is one of several factors that make it impossible to determine whether the overall effects of enucleation have been beneficial or harmful in the management of this disease.


Extended-wear contact lenses and intraocular lenses for aphakic correction. We evaluated extended-wear soft contact lens use in 128 aphakic eyes of 113 patients, 44 of whom had been unable to wear conventional contact lenses; 116 eyes (91%) have been successfully fitted and have worn the extended-wear lenses without significant complication. Eleven patients were unable to wear the lens or had to be discontinued for transient lens-related problems. In 103 eyes successfully fitted the lens is removed for cleaning less often than monthly. Ninety six of the 116 eyes fitted have visual acuity as good as, or better than, with aphakic correcting spectacles. The results obtained with the extended-wear soft contact lens are similar to those obtained with intraocular lenses, except for the recent high incidence of inflammation seen after intraocular lens insertion when using ethylene-oxide-sterilized lenses.


The microbial flora in extended-wear soft contact-lens wearers. Of 857 cultures of material collected from the eyelids, conjunctivae, and contact lenses of 51 extended-wear soft-contact-lens wearers, 44 (5%) grew potential pathogens. The aphakic patients wearing contact lenses had fewer recoverable pathogens (24 of 295 or 8%) than a group of preoperative cataract patients (63 of 295 or 21%). On five occasions, positive cultures accompanied clinical symptoms, and on three occasions, repeated cultures grew the same potential pathogen.


The optical quality of currently manufactured intraocular lenses. We selected 95 intraocular lenses from ten lens manufacturers for a study of optical quality. Tremendous variation in resolution from a high of 313 line pairs per millimeter to a low of 40 line pairs per millimeter was seen. All of the lenses from eight manufacturers showed greater than 100 line pairs per millimeter resolution, the American National Standards Institute proposed minimum. Five of the 95 lenses had greater than 1.0 diopter error, whereas 79 of the 95 lenses had less than 0.5 diopter error from the stated power. With respect to toricity, there were 11 lenses with greater than 0.25 diopter (built-in astigmatism), however, no lenses showed more than 0.5 diopter astigmatism. Two lenses had a built-in double image, another clinically significant problem. We believe the optical quality of the lenses from some lens manufacturers cannot be guaranteed.


A glass intraocular lens.

A glass intraocular lens. We designed a glass and polyimide iris-plane, iris-clip intraocular lens. It is sterilized in the autoclave and weighs approximately 6 mg in water. The optic is 0.3 mm thick for a 19-diopter lens and the flexible haptic is 0.05 mm thick. Two identical haptics and the optic are joined mechanically to form the intraocular lens. The round spatula-like portion of an insertional instrument secures the intraocular lens by passing through two opposing flexible haptic loops and behind the optic. Fluid or air is irrigated through the cannula as the implant is inserted in order to protect the endothelium.


Sodium hydroxide sterilzation of intraocular lenses. Intraocular lenses of polymethylmethacrylate contaminated with various inocula of bacteria, spores, and fungi were sterilized by modifications of the Ridley method using sodium hydroxide. Positive cultures were obtained from iris-supported lenses contaminated with concentrations of approximately 1 x 10(6) organisms per milliliter after one hour in 10% NaOH. No positive cultures were obtained when lenses remained in 10% NaOH for three hours, a time corresponding to a 1 x 10(-6) probability of surviving organism. The NaOH method, when appropriately used, is an effective sterilization process for intraocular lenses.


Evaluation of timolol maleate combination therapy in chronic open-angle glaucoma. In an eight-week study, timolol maleate ophthalmic solution 0.25% was administered twice daily with either pilocarpine 2% four times a day, epinephrine 2% twice a day, carbachol 1.5% four times a day, or 250 mg of acetazolamide twice a day to 44 patients with chronic open-angle glaucoma. Compared to baseline readings on standard therapy alone, mean intraocular pressure was significantly reduced after addition of timolol maleate to each of the regimens. Mean facility of outflow was unaffected. No clinically significant ocular irritation or changes in visual acuity, pupil size, or vital signs were observed in any patient. Timolol maleate appears to be effective and well tolerated when administered with other antiglaucoma medications in patients with open-angle glaucoma.


Transient reversible cupping in juvenile-onset glaucoma. A 17-year-old man had marked glaucomatous cupping of his left optic nerve. Two days after trabeculectomy, the appearance of the disk changed dramatically, appearing full, rather than cupped. Over the next month, with normal intraocular pressure, the optic nerve resumed its preoperative excavated appearance.


Circumferential flow in Schlemm's canal. A model of Schlemm's canal was designed and analyzed mathematically. The effect of canal width on intraocular pressure was examined, and the pressure and flow distribution in the canal were calculated.


Trabecular and retrocorneal proliferation of melanocytes and secondary glaucoma. A 59-year-old woman with no evidence of glaucoma developed secondary open-angle glaucoma after an intracapsular cataract extraction complicated by vitreous and iris incarceration. Histopathologic and scanning and electron microscopic studies of the enucleated eye 22 years later revealed extensive proliferation of iris melanocytes across the trabecular meshwork and posterior surface of the cornea. Proliferation of iris stromal melanocytes over the trabecular meshwork may have caused secondary open-angle glaucoma.


Blepharoptosis after traumatic third-nerve palsies. We evaluated the clinical records of 16 patients with blepharoptosis secondary to direct traumatic third-nerve palsies. Most patients were involved in auto accidents, and had associated skull fractures. Of 12 patients who were followed up for at least one year, ten recovered completely. Over half of the patients had evidence of aberrant regeneration, which could be seen clinically as early as nine weeks after the trauma. Orbital localization of the third-nerve dysfunction carries an excellent prognosis for prompt, spontaneous recovery without aberrant regeneration. Surgical intervention in these cases should be delayed at least one year after the traumatic event, and longer if continued slow but progressive recovery is demonstrated.


Effect of isolated inferior oblique muscle myectomy in the management of superior oblique muscle palsy. Thirty-three patients with superior oblique palsy were treated with an inferior oblique myectomy temporal to the inferior rectus muscle. The mean effect of surgery was 11.91 +/- 1.38 in all positions of gaze and for all age groups. The operative result in both children and adults was the same. The mean effect of surgery correlated with the size of the preoperative hyperdeviation in the fields of action of both inferior and superior oblique muscles. Inferior oblique muscle myectomy was followed by return of normal function to the superior oblique muscle in 63% of cases. Ocular torticollis was eliminated in 90% of the patients. Persistent overaction of inferior oblique muscle was encountered in three patients. Postoperative underaction of the myectomized muscle was not observed in any of our patients. A myectomy is recommended as a primary procedure in patients with superior oblique muscle palsy when the direct antagonist is overacting and the hyperdeviation is 10 to 15 prism diopters or more in primary position or the fields of action of the paretic superior oblique muscle or the overacting inferior oblique muscle.


Mydriatic effect of anticholinergic drugs used during reversal of nondepolarizing muscle relaxants. Large doses of anticholinergic drugs (atropine, glycopyrrolate) produced mydriasis in a group of adults with no eye abnormalities except strabismus, though the usual intramuscular and intravenous doses of these drugs do not have this tendency. Such large doses are often given intravenously during general anesthesia to prevent the side effects of neostigmine methylsulfate, which is used to reverse the effect of nondepolarizing muscle relaxants. Neostigmine methylsulfate (Prostigmin) reduced the mydriatic effect when given intravenously in conjunction with atropine or glycopyrrolate. Mydriasis was more likely to occur in lightly pigmented eyes than in eyes with dark irides. Pilocarpine eyedrops instilled at the beginning of anesthesia caused miosis that persisted after the large intravenous doses of atropine or glycopyrrolate were given. To prevent an attack of acute angle-closure glaucoma in any patient who is to receive large doses of anticholinergic drugs during general anesthesia, miotic drug therapy should be continued before, during, and after anesthesia at the same frequency as when awake.


Pseudo-orbital apex syndrome.

Pseudo-orbital apex syndrome. A 48-year-old man had symptoms and signs of the orbital apex syndrome. All orbital and systemic studies were unrevealing . The computed tomoggraphy scan showed a cystic lesion external to the pons. The lesion proved to be a cholesteotoma originating in the peduncular fossa area, comprising the oculomotor nerve proximally and extending anteriorly in a finger-like projection to involve the ipsilateral optic nerve.


The measurement of the Bausch & Lomb Soflens contact lens by interferometry. A method is described for the measurement of the anterior and posterior radii of curvature and thickness or a soft (hydrogel) contact lens. The method is based on the observation of an interference pattern that is generated by two beams of light, one reflected from the surface of the lens and the other reflected from the surface of a comparison mirror. It was found that the maximum coefficient of variation for the measured values of the anterior and posterior radii of curvature was 2% and the minimum value was 0.6%. An accuracy of 1:10(3) for the radii of curvature and the center thickness of the lens is claimed.


Prism-ballasted and truncated spherical trial lenses as indicators of toric soft lens rotation. Fifteen refractive astigmats were fitted with prism ballasted and truncated plano, spherical lenses and prescription toric soft lenses. The initial rotation observed with each lens type did not differ significantly, indicating that trial sets of such spherical lenses may provide an effective method of fitting toric soft lenses.


The relationship between convergence insufficiency and school achievement. Schoolchildren (735) between the ages of 7 and 14 were examined for convergence ability. Nine percent had an objective near point of convergence of more than 10 cm and 10% had a subjective near point of convergence of more than 10 cm. The recovery point was greater than 15 cm for 9% of the subjects when measured objectively and 12% subjectively. The sample was analyzed with regard to age, sex, and IQ. There was no significant difference between children who showed convergence insufficiency and those who did not with regard to school results in their mother tongue and in their grade point average.


Factors affecting peripheral curve design. Factors associated with edge clearance in the contact lens-corneal relationship are peripheral curve radius and width, lens diameter, and corneal shape. The effect of each parameter is quantified, permitting an examination of current design practices. Recommendations are that minor adjustments be made by changing radius, that major adjustments be made by changing width, and that the peripheral curve radius should be steepened as the diameter increases.


Convergence and divergence show large and sustained improvement after short isometric exercise. There are conflicting reports on the effect of vergence training. In two studies using push up and prism vergence exercises the conflict is shown to result from differences in the constancy of effort. Improvement only occurs in exercises involving sustained effort in the direction being trained. The effect of alternating movements in both directions is small and inconsistent. Substantial longlasting gains in either convergence or divergence prism vergence scores can result from just 5 min of sustained effort at an angle halfway between the break and recovery points. Results for adults and children on motor-driven instruments are comparable and the scores obtained discriminate better than those from hand-turned instruments. The most likely physiological model involves potentiating processes which are specifically maximized by isometric exercise. Potentiation results in a positive feedback process, the effects of which are strong enough to precipitate strabismus and which might be deliberately manipulated in therapy of poor vergence control, if responses in the required direction can be induced.


Near retinoscopy and cycloplegic retinoscopy in early primary grade schoolchildren. Retinoscopy under cycloplegia with various agents can yield varied results. Additionally, cycloplegics and produce adverse local as well as central nervous system disturbances. A noncycloplegic near retinoscopy technique as promulgated by Mohindra is compared with cycloplegic retinoscopy on schoolchildren in early grades. Results obtained by a study utilizing the two techniques show that they yield similar objective measurements of refraction.


Strength of thin chemtempered lenses: static load testing. Static load tests were conducted on heat-tempered and chemtempered plano white crown glass lenses from five different optical laboratories. With both ball-on-ring and ring-on-ring loading, chemtempered lenses considerably thinner than 2.0 mm were found to be as failure resistant as 2.0-mm-thick heat-tempered lenses. A similar result was obtained previously using the drop-ball test. It is shown that the theory of brittle fracture can be used to relate the results of different tests and provides a rational basis for comparing the relative performance of chemtempered and heat-tempered lenses.


A versatile multi-input device to study the Pulfrich effect. A versatile multi-input device based on an x-y recorder was designed for the study of the Pulfrich effect. Because the device provided constant velocity of the target, a rectangular Pulfrich effect was observed rather than the traditional elliptical effect. The instrument permits study of the response induced when the input is changed in a variety of ways.


Calibration of the ERG photostimulus with standard photometer and photodiode. A method for quantifying the ERG photostimulus is presented. The units of measure are reasonably straightforward and yet consistent with laws of photochemistry and psychophysics. Application of these laws facilitates measurement with readily available photometric instrumentation.


Central gyrate atrophy: a case report.

Central gyrate atrophy: a case report. Central gyrate atrophy is a rare ocular finding with a unique pathogenesis and fundus appearance. This entity results in total atrophy of the large and small vessels of the choroid and concomitant changes in the outer layers of the retina. A case report is presented to demonstrate the clinical appearance of this lesion and its relationship to the pathogenesis.


Infrared recording retinoscope for monitoring accomodation. An optometer (infrared recording retinoscope) that provides high resolution measurements of accommodative changes of the eye has been developed. The instrument employs the principle of retinoscopy to monitor changes in the refractive state of the eye. Infrared radiation is scanned across the eye to provide a moving retinal source as in retinoscopy. An electro-optical system replaces the observer in determining the direction and amount of apparent motion in the pupil of the patient. The optometer is sensitive to accommodative changes of 0.12 D over a range of 12 D. The response of the instrument is faster than the most rapid changes of accommodation, and measurements are unaffected by pupil changes or by small eye movements.


Fluorescein as an aid in pachometry.

Fluorescein as an aid in pachometry. Precision of measurement of apparent corneal thickness with the Haag-Streit lamp depth measuring attachment is significantly enhanced by staining the precorneal film with sodium fluorescein before measuring.


An accessory fill-in flash for the Nikon photo-slit lamp. High-quality slit lamp photographs require a balance between slit beam exposure and exposure of surrounding ocular structures. Proper exposure of surrounding ocular structure is difficult to obtain with the Nikon photo-slit lamp. The purpose of this research was to design an accessory fill-in flash for this slit lamp, which would provide proper exposure of over all ocular structures. In addition, this paper describes the procedures used to obtain proper exposure values and provides an exposure table for this accessory flash unit.


Malpractice insurance at optometric institutions. The optometric educator needs insurance against malpractice suits. A survey was made of the policies available at twelve schools and colleges of optometry in the United States. The object of this survey was to compare the various protections offered by the optometric institutions and also to inform the educators of what is available to them. It was found that coverage and premiums vary considerably between the institutions. At only one of the twelve schools and colleges of optometry responding to this survey were faculty members required to pay for their own policies, but to avoid undue risk, two other colleges highly recommended that their faculty purchase their own coverage. Implications of the low number of claims brought against optometric teaching facilities and other factors are discussed in light of the "malpractice insurance crisis."


The theory and computation of optical modifications to the cornea in refractive keratoplasty. The optical theory of keratophakia employing implant lenticules with a refractive index different from that of the cornea is presented. This generalized theory also embraces keratophakia employing donated stromal lenticules and keratomileusis, with equal accuracy. The method of solution of the formulas is indicated. The effects of the various parameters upon the radius of curvature to be applied to the cornea are illustrated and discussed.


A comparison of three methods for determining the reading addition. Three subjective determinations of the reading addition required by each of 10 subjects were obtained in this study with the use of a cross cylinder grid target, a variable color, near-point, grid target and an ordinary reading card. All three methods gave similar results. In addition, there was no change in the measurement when the color of the horizontal and vertical lines was reversed on the variable color, near-point, grid target.


Prevalence and management of divergence excess. The prevalence of divergence excess was assessed from the records of 250 consecutive patients attending a binocular-vision clinic. The 67 cases in the sample showing divergence excess were subdivided into the following groups: (1) secondary to operations for esotropia (8 cases); (2) anisometropic amblyopes (14 cases); (3) basic (14 cases); (4) convergence weakness (13 cases); (5) divergence excess (18 cases). Treatment methods placed heavy emphasis on physiological diplopia. Of the 18 in the divergence excess category, 14 began treatment, 10 showed a satisfactory outcome, two achieved some improvement, and two discontinued treatment on their own. Divergence excess seems to respond well to nonsurgical treatment.


Prevalence of the Hudson-Stähli line of the cornea. The prevalence of the corneal Hudson-Stähli line among 400 eyes was found to range from 5.3% of the eyes of patients aged 11-20 years to 100% of eyes of patients aged 81-90 years. In 87.3% of patients over 50 years of age corneas were affected; this percentage is considerably higher than previous estimates. Up to the age of 60 years it occurs more frequently in men than in women.


The incidence of cone epiphyses and ivory epiphyses of the hand in Nigerian children. Radiographs of the left hand of 594 children from Ibadan, Nigeria were inspected for skeletal anomalies to determine differences in the incidence of cone and ivory epiphyses for the rich and poor children and differences in incidence for four hemoglobin types. Ivory epiphyses ovvurred more often in children in the lower socio-economic class and children with hemoglobin AA. The cone epiphyses observed in Hb SS children were primarily a result of bone infarcts, while cones in children of other hemoglobin types appeared to be normal variants. The incidence of ivory epiphyses was higher in the Nigerian children than in American black children in the Ten-State Nutrition Survey. The incidence of cone epiphyses was much lower than those reported for other normal populations.


A multinational Andean genetic and health program. VIII. Lung function changes with migration between altitudes. Studies of lung function in high altitude populations have suggested the influence of hypoxic environment on the development of this characteristic independent of confounding variables such as ethnicity and habitual exercise. However, often the effect of altitude on vital capacity is greater in children than adults, suggesting that more than developmental adaptation is operative. Also selective migration could account for the similarity of migrants and permanent residents at a destination altitude. To explore these problems we studied the lung function (FVC, FEV1, PFR) of 377 individuals who had migrated between altitudes in northern Chile. Migrant measurements were adjusted to those of permanent residents of appropriate age, sex and height at the altitudes of origin and destination. The measurements were then related to ethnicity (Spanish-Aymara ancestry), occupation and permanence, the latter combining information on both age at migration to and length of stay at a destination altitude. Upward migration was associated with increased chest depth, FVC and FEV1, but not height or other chest measurements. Downward migration had no significant effect. The flow-dependent test PFR was so sensitive to observer variability and occupation that it was difficult to establish its relationship to permanence. Unlike the body measurements, lung function measurements (especially PFR) tended to deviate from permanent controls at the origin altitude in a direction suggestive of selective migration, nor was permanence itself independent of ethnicity and occupation. Because of these difficulties the question of developmental adaptation in lung function may not be answerable in cross-sectional studies like the present and previous efforts, but rather in longitudinal investigations in which the control is the individual him/herself.


Monthly changes in the gain and loss of growth in weight of children living in Guatemala. Monthly increments of weight growth for a sample of 246 Guatemala City private school children are analyzed for the presence of a seasonal pattern in rates of growth. Neither a seasonal pattern nor any other periodic rhythm is found. It is observed that a significantly greater number of children aged 5.0 to 6.9 years experience their minimum annual growth rate during the dry season, with up to 60% of them losing or not gaining weight in any one month. Patterns of diet, exercise and disease cannot explain this trend. A possible association between minimum weight growth and maximum growth in height is discussed.


Some neurophysiologic aspects of individual behavior. The author provides a brief primer of the biologic processes in the brain that produce affect and implement communication. These neuroanatomic and neurophysiologic processes are presented in broad configuration rather than in detail and as distributive systems rather than just as localized mechanisms. The basic viewpoint is that of a continuum between the biologic processes within the brain and their manifestation as behavioral phenomena expressed in, and visible to, the culture. The primary focus is not clinical but on neuroanatomy and neurophysiology as basic medical sciences for psychiatry.


Normal neuropsychological abilities of alcoholic men in their late thirties. The neuropsychological performance of alcoholic men in their late 30s (mean age, 37 years), some of whom has been abstinent for 3 weeks and others for 18 months, was compared with that of a group of men who drank occasionally. There were no differences between the alcoholic groups and the comparison group that could not be attributed to normal aging. The number of years of alcoholism or estimated lifetime alcohol use, dietary adequacy, and medical or blackout history did not relate to neuropsychological impairment. The authors suggest that a simple "dose-effect" relationship between alcohol use and cognitive decline cannot be assumed.


Midlife concerns of women: implications of the menopause. Midlife has received recent attention but is still difficult to define. Women's developmental phases are most appropriately understood as different from men's, with a complex integration of biological context, family development and roles, and individual development. Menopause has been considered a determining event, and a variety of symptoms have been attributed to menopausal changes. Emerging data indicate that menopause does not appear to be responsible for most of the symptoms. Midlife stresses are the result of a combination of personal, family, social, and biological variables, with postmenopausal development an important phase.


Choline chloride treatment of memory deficits in the elderly. Eight elderly patients with mild memory impairment were given choline chloride, a drug that increases brain acetylcholine concentrations. After 16 g/day of choline for 7 days, average memory performance was not different from performance during pre- and postcholine placebo treatment, although the patient with the poorest baseline performance improved considerably on choline.


Adaptive strategies and recovery from rape. The authors conducted a follow-up study of 81 rape victims to analyze the effect of adaptive or maladaptive response to rape on recovery over a 4-6 year period. They found that victims recovering fastest used more adaptive strategies, including positive self-assessment; defense mechanisms of explanation, minimization, suppression, and dramatization; and increased action. Victims who had not yet recovered had more maladaptive mechanisms, such as negative self-assessments, inaction, substance abuse, and action on suicidal thoughts.


Battered parents: a new syndrome.

Battered parents: a new syndrome. The authors identify a new syndrome of family violence--parent battering. Relevant dynamics include individual characteristics of the parent batterer, distortions in the generational authority hierarchy, the role of secrets and denial, and cultural influences. The authors conclude, on the basis of their clinical work with these families, that this subtype of family violence is distinct from child and spouse abuse.


The psychiatrist as medical backup: ambiguity in the delegation of clinical responsibility. When the psychiatrist functions as medical backup, i.e., in a setting of delegated clinical responsibility, a number of problems may arise, originating from factors in the patient, in the physician, in the staff member to whom responsibility is delegated, and in the setting itself. The authors delineate these problem areas through case examples and discuss the implications for multidisciplinary training.


Termination initiated by the therapist: a countertransference storm. Termination of psychotherapy has been infrequently examined in the literature and often ignored by many training programs. Not only are criteria and techniques for termination not often discussed, but termination as a therapeutic opportunity has been neglected. The authors present two cases of psychotherapy termination initiated by the therapist and point out that countertransference phenomena, potentially destructive, are the major aspect separating psychotherapy termination by mutual agreement and termination initiated by the therapist. Careful, regular, and attentive supervision for therapists in training is essential to counterbalance the intensified countertransference reactions involved.


The incidence of seizures among children with autistic symptoms. The authors examined 183 children with autistic symptoms and found that the age-specific incidence rates of seizures in this sample were between 3 and 28 times the rates for children in the general population. The subjects classified as totally autistic were at high risk of developing seizure from early childhood well into adolescence, but especially so at puberty. The partially autistic children had an increased risk of seizures only up to age 10. The authors suggest that the high incidence of seizures at puberty observed in this study may be specific to children with total autistic symptomatology and may represent a distinct pathological process associated with autism.


Temporal disorganization and primary affective disorder. The authors used a self-rating scale of thinking process disorganization to measure degree of temporal disorganization in a group of 38 rigorously categorized psychiatric inpatients. Patients diagnosed as having primary affective disorder, depressed type, were significantly different from those with either a character disorder or schizophrenic diagnosis; both schizophrenic and character disorder groups showed variable temporal disorganization scores, and the primary affective disorder group showed consistently high levels of temporal disorganization. Diagnosis was more important than symptom measures in relationship to temporal disorganization scores.


A comparison of two unilateral ECT electrode placements: efficacy and electrical energy considerations. The authors compared the treatment outcomes and ECT energy requirements of 10 patients treated with the Muller unilateral placement method (secondary electrode in the frontal position) with those of 10 matched patients treated with the unilateral placement described by d'Elia (secondary electrode lateral to the vertex). Both groups showed a similar dramatic clinical improvement after ECT; however, the mean watt seconds required for the Muller method was nearly four times that for the d'Elia procedure. The treating physicians reported that the patients treated by the d'Elia method had fewer anterograde and retrograde memory disturbances and that they were alert and oriented sooner after ECT.


Breaking the cycle in abusive families.

Breaking the cycle in abusive families. The tendency for the cycle of abusive and neglectful parenting to be transmitted across generations has been well documented. The authors report on 40 families who broke this family pattern. The mechanisms for change used in these families included reliance on a broad network of resources, a degree of self-differentiation, an attitude of realistic optimism, and the ability to marshall extra resources to meet crisis situations. The authors recommend further study of such exceptions and a more hopeful approach to the problem of abusive families.


Footedness of left- and right-handers.

Footedness of left- and right-handers. The performance on a simple tapping task of the hands and feet of left- and right-handers was tested. Right-handers tapped faster with their right hand and right foot. Left-handers tapped faster with their left hand and right foot. Thus, footedness follows handedness in right-handers but not in left-handers. Left-handers showed smaller left/right differences than right-handers in both hand and foot performance. These data are in loose agreement with the modified genetic theory of handedness proposed by Annett (Hand preference and the laterality of cerebral speech, Cortex, 1975).


Characteristics of men most likely to respond to an invitation to be screened. Some of the characteristics of men, with known risk factors, who were most likely to respond to an invitation to be screened in a national randomized clinical trial to prevent heart disease were determined in 18,872 men, 35-57 years of age, members of the Kaiser Foundation Health Plan of Oregon. Demographic characteristics and risk factor variables (blood pressure, blood cholesterol, and cigarette smoking levels) were abstracted from medical records. The men were ranked high priority or low priority according to level of risk. All age-eligible men in the health plan received at least one invitation to be screened, with high-priority men receiving more invitations. Despite concentrated efforts to bring them in, less than one-half the high-priority men were screened. Participants were older and wealthier than non-participants, and more likely to have more dependents and to routinely use medical services. Whether or not a man received a medical care service within the preceding two years was a powerful discriminating variable in both the univariate and multivariate analyses reported. The findings suggest that health care programs serving a stable population group should give more consideration to screening in routine medical care.


Utilization of prepaid dental health care by students in health professional schools. Utilization of prepaid dental health care was studied, involving health professional students in an open panel program at the University of Alabama Medical Center. Major barriers to treatment were eliminated and optimal conditions for utilization established. Annual utilization ranged from 44-61 per cent during the period extending from 1969-70 to 1975-76. The majority of enrollees treated sought care from the Student Dental Health Plan (SDHP) clinic, rather than from private practitioners. Thirteen per cent of recent graduates presented for treatment at least once each year during their tenure as students, 57 per cent sought care in more than one year, and 24 per cent did not seek care at all. It was concluded that factors other than cost, accessibility, and educational level operate to prevent total utilization of prepaid dental health care in a young adult age group.


Presence of observers at patient-practitioner interactions: impact on coordination of care and methodologic implications. In this study in an urban practice, the presence of a neutral observer at follow-up visits enhanced the extent to which practitioners recognized problems which patients had in a previous visit. This improvement was limited to those problems which initially had been mentioned by patients as requiring follow-up. Follow-up of problems initially mentioned by practitioners as needing follow-up was not improved by the observer unless the problem was also mentioned by the patient. Investigators whose information about practitioner-patient interaction depends upon the presence of an observer should be aware of this and possibly other effects. Although routine involvement of a neutral observer in patient-practitioner interactions is probably undesirable, selected deployment of observers or similar alternatives may be useful in situations where practitioner-patient communication is inadequate.


Voluntary coordination as a strategy of plan implementation for health systems agencies. Health planning agencies are faced with the difficult mission of guiding change within a large complex social system whose power is dispersed. Initial short- and long-range plans have been established as frameworks, and now the major focus is implementation. Regulation (non-voluntary coordination) and voluntary coordination are the major means of implementation. Voluntary coordination is a significant strategy for consideration by Health Systems Agencies (HSAs). It may interact with regulation as a competitor, substitute, or complement. Because of limited regulatory powers, HSAs are dependent upon voluntary coordination as a major means of influencing behavior. Conflict, a major feature of voluntary coordination, has the potential of being used as a constructive means for dialogue; negotiation and bargaining may become positive approaches to arriving at decisions. Legitimized community authority is the primary source of authority in a strategy dominated by voluntary coordination as contrasted to state or federal mandates in a regulatory strategy. Knowledge of the environment within which the HSA operates will assist HSA staff and board to arrive at rational and realistic decisions.


Hazards in the hospital: educating the workforce through its union. The hospital workforce is exposed to many occupational hazards of which most hospital workers are unaware. The author and another health educator, both employed with the California State Department of Health, conducted occupational health and safety educational sessions for the membership of a hospital workers' union. These sessions taught nonprofessional workers how to recognize hospital hazards, how to eliminate or minimize these hazards, and informed workers of their legal rights under the California Occupational Safety and Health Act. We first had to convince the union health and safety officer that we had skills and information which would be of benefit to the union. Once that hurdle was crossed, we encountered some difficulty conducting an adequate needs assessment and including the target population in the planning of the educationals. Two series of educational sessions for rank-and-file members were conducted and were enthusiastically received by those attending, with a request for more sessions.


Blizzard morbidity and mortality: Rhode Island, 1978. The total number of outpatient visits to 10 hospital emergency rooms declined 64 per cent and emergency admissions 35 per cent immediately after the February 1978 blizzard in Rhode Island; both quickly returned to normal levels. Three days after the storm, admissions for myocardial infarction increased markedly. Total mortality and ischemic heart disease deaths showed a considerable increase for the five-day period following the blizzard. The physical and psychological stress of the blizzard probably precipitated cardiac deaths in susceptible individuals.


Vaccine failures in the epidemiology and control of measles. Data were employed from confirmed measles case reports and an immunization survey to estimate the apparent effectiveness of measles vaccine in Los Angeles County in 1976. We evaluated the age-specific proportions of our case load arising from persons erroneously thought to possess immunity. Thirty five per cent of our cases claimed to have had prior measles vaccination, and over 60 per cent of these reported having written records. Since community measles control programs rely on immunization records as the principal screening tool, the shortcomings observed need to be recognized.


A vitamin profile of heroin addiction.

A vitamin profile of heroin addiction. Circulating thiamine, riboflavin, nicotinates, folates, vitamin B12, B6, A, and carotenes of 149 heroin addicts aged 17-60 years were compared to 204 healthy subjects not using drugs or vitamins. Only 24 per cent of the addicts had no evidence of hypovitaminemia; 45 per cent and 37 per cent had vitamin B6 and folate deficit respectively, whereas deficits of thiamine, vitamin B12, riboflavin, and nicotinate were recorded for 13-19 per cent of the addict population; impaired liver function in addicts did not influence these results.


The psychological effects of differential treatment of a high risk sample in a randomized clinical trial. A study was carried out using 616 participants in a randomized clinical trial at the Harvard MRFIT (Multiple Risk Factor Intervention Trial) Clinical Center, to test if there were differences in the psychological dimensions of anxiety, depression, and functional heart symptoms in groups given different levels of treatment in a CHD (Coronary Heart Disease) Intervention Program. A theoretical framework was given to justify a number of hypotheses as to the induction of adverse psychological effects. At the end of two years in the MRFIT Program there were no significant differences between the special intervention group (SI) and the usual care group (UC) in the selected psychological variables.


Influence of parasitism on secretin-inhibited gastric secretion. This study tested the hypothesis that the inhibitory action of secretin on gastrin-stimulated gastric acid and pepsin secretion is comprised in animals harboring intestinal stages of the parasite Trichinella spiralis. Pentagastrin-stimulated acid and pepsin secretion, and the influence of secretin on these processes, were measured in dogs prepared with gastric fistulas and Heidenhain pouches. Dogs were studied before and after infection with 10(4) T. spiralis larvae/kg body weight. Gastric secretion was stimulated by constant intravenous infusion of pentagastrin, 1 microgram/kg per hour. Exogenous secretin inhibited pentagastrin-stimulated acid and pepsin output from both the main stomach and Heidenhain pouch in infected as well as in the uninfected dogs. Identical inhibition was observed in uninfected dogs during duodenal infusion with HCl to release endogenous secretin. In contrast, duodenal stimulation with HCl did not inhibit acid and pepsin secretion in dogs tested during the 1st week following infection. Results support the conclusion that the regulatory effect of secretin on gastrin-stimulated gastric secretion is impaired during the early phase of infection, and is due to depressed synthesis or release of secretin from duodenal mucosa.


Damage to Trichinella spiralis newborn larvae by eosinophil major basic protein. Purified eosinophil major basic protein damaged newborn larvae of Trichinella siralis when added to in vitro cultures. Damaged larvae were stiffened, immobile, and showed a granular appearance by light microscopy. Larvae in control cultures and in cultures containing equimolar concentrations of other basic proteins failed to exhibit such damage.


Schistosomiasis haematobia in coast province Kenya. Relationship between egg output and morbidity. Several studies of schistosomiasis haematobia in Africa have revealed a correlation between intensity of infection as measured by urine egg counts and severity of disease as determined by intravenous pyelography. The present study consisted of a survey of 390 school children in the coastal area of Kenya involving a single egg count, and intravenous pyelograms in a stratified random sample of 69 children; the results showed a greater prevalence of urinary tract disease in those with higher intensities of infection. This survey was then followed by a more detailed study in which nine consecutive daily egg counts were done on 121 children; 17 of these children, subdivided into three groups with different intensities in infection, were given intravenous pyelograms. The results were similar in the 11 children with minimal and moderate counts (averaging, respectively, less than 1 egg and 167 eggs/10 ml urine daily), with approximately 30% having bladder or renal abnormalities. In comparison, all of the six children with heavy counts (averaging 1,288 eggs/10 ml urine daily) had bladder lesions and five of them had renal lesions.


Ovaries and adrenals in murine Schistosomiasis mansoni. III. Morphology and function of the adrenals in acute infection. In mice with acute Schistosoma mansoni infection lipoid depletion was found in the zona fasciculata of the adrenal cortex without any other major histological alterations of the adrenals. Schistosomiasis did not influence the weight of the adrenals, or the cortisol level of the blood serum as determined by radioimmunoassay. The changes in morphology and function of the ovaries in the same infected animals reported earlier point to the vulnerability of the gonads in schistosomiasis mansoni, which may be a consequence of partial hypopituitarism.


Resistance to tick-borne Francisella tularensis by tick-sensitized rabbits: allergic klendusity. Mammals become hypersensitive to ticks that feed upon them. That hypersensitivity was thought responsible for an observation that a large number of Francisella tularensis-infected Dermacentor variabilis failed to infect a rabbit previously exposed to ticks of that species. In a series of tests of that hypothesis, rabbits sensitized to ticks were often significantly more resistant than control animals to tick-borne tularemia. The conditions that determine the klendusity are thought to be variable and complex but the phenomenon must be of importance in the epidemiology of some arthropod-borne agents.


Higher venereal infection and transmission rates with La Crosse virus in Aedes triseriatus engorged before mating. Infection of colonized female Aedes triseriatus by La Crosse (LAC) virus occurred more frequently when females were inseminated by infected males after the females engorged blood (49% of 39) than when mating took place before engorgement (4% of 554). Salivary transmission of LAC virus to mice also was more frequent in females venerally infected after engorgement on a normal mouse (35% of 34) than in females mated before engorgement (2% of 49). LAC virus was transovarially transmitted by 40% of 10 females mated by infected males, and in 64% of 279 progeny reared from eggs of second or later ovarian cycles.


Aedes triseriatus and La Crosse virus: lack of infection in eggs of the first ovarian cycle following oral infection of females. La Crosse (LAC) virus filial infection rates were 0% for 279 first ovarian cycle larvae, 43% for 380 second ovarian cycle larvae, and 58% for 363 third ovarian cycle larvae from orally infected mosquitoes representing 14 Wisconsin populations of Aedes triseriatus. LAC virus was not detected in 72 pools representing 2,250 first ovarian cycle larvae, while 35 pools and 16 pools each containing 30 second and third ovarian cycle larvae, respectively, were all positive for LAC virus. Similar results were obtained when the extrinsic incubation period temperature was 25 degrees C, 27 degrees C, or variable (17, 23, and 29 degrees C for 8 hours each). LAC virus was not detected in 240 second ovarian cycle larvae in which the bloodmeal for the first ovarian cycle was non-infectious. Infection was not detected in 337 first ovarian cycle larvae from female mosquitoes that had been injected intrathoracically with LAC virus concomitantly with receiving a non-infectious bloodmeal. After an extrinsic incubation temperature of 25 degrees C, LAC virus was discovered in dissected mosquito ovarian tissue 7 days postfeeding on an infectious bloodmeal. The epidemiological implications of these findings are discussed.


Sterlizing and packaging males of Anopheles Albimanus Wiedemann for field release. Technology was developed for sterilizing and packaging as many as 1 million male Anopheles albimanus Wiedemann per day for field release. The average sterility produced in the males during a 1.5-year period was 98.9%. Mortality due to transport of the males in specially developed cages averaged 4.5% for 72-hour-old adults and 2.5% for 24-hour-old adults. The average mortality due to transport and field exposure of pupae was 1.2 to 9.8%, depending on the technique used.


Dermatitis caused by cercariae of Orientobilharzia turkestanicum in the Caspian Sea area of Iran. Cercarial dermatitis is very common among rice farmers in the Caspian Sea area of Iran. The characteristic eggs of Orientobilharzia turkestanicum were found in the feces of a plowing bull. Fifty-six percent of uninfected Lymnaea gedrosiana maintained at 24-25 degrees C produced cercariae, identical to those from natural infections, 21 days after exposure to the miracidia obtained from the feces of the bull. Cercariae of O. turkestanicum from naturally infected L. gedrosiana produced dermatitis on the arm of one of us.


Biological control of schistosome transmission in flowing water habitats. Marisa cornuarietis was evaluated in Puerto Rico for control of schistosome transmission in flowing water. A population of Biomphalaria glabrata and their schistosome infections disappeared after introduction of 20,000 M. cornuarietis to an endemic stream, while in nearby untreated streams the B. glabrata population remained stable and the schistosome prevalence increased. This method cost U.S. $0.10 per capita for over a year of protection, 5%-10% of the cost of chemical control.


Cultivation of dengue virus type 2 in baby hamster kidney cells in serum-free medium. Propagation of dengue virus type 2 (New Guinea C strain) was performed using a shaker culture of baby hamster kidney cells (BHK-21) cultivated in serum-free modified Waymouth medium. Maximum virus titer varied from 10(8.3) to 10(8.8) plaque forming units/ml after incubation of BHK-21 cells in suspension culture at 37 dgrees C for 40-48 hours post-infection.


Plexiform neurofibroma of the head and neck. Ten patients with plexiform neurofibroma of the head and neck were observed at M.D. Anderson Hospital between 1956 and 1978. The clinical presentation and the long-term follow-up of the most interesting cases are presented. This is a chronic disease that causes cosmetic and functional deformity because of the size or the position of the tumor, or both. No patient exhibited malignant transformation. Because all of the disease cannot be removed, the surgical procedures should not be radical but should be designed to relieve symptoms or improve cosmesis.


Feasibility of total thyroidectomy in the treatment of thyroid carcinoma: postoperative radioactive iodine evaluation of 140 cases. The objective of this study was to evaluate our experience with so-called total thyroidectomy. Fifty cases (the retrospective group) had been operated on before the start of the study and had been on thyroid replacement therapy; this was discontinued, thyroid-stimulating hormone was administered, and iodine-131 studies were performed. Ninety cases (the prospective group) were evaluated 3 or more weeks postoperatively with no thyroid hormone having been administered. All patients were given 50 microcuries of iodine-131 and uptake studies were performed 24 hours later. All the patients were evaluated at a time when it was believed that practically all circulating hormone secreted by the thyroid gland before its removal had been metabolized or excreted from the body. If the patients with iodine-131 uptakes only in the region of the pyramidal lobe are considered to have had total thyroidectomy, we find that 85.7% of the patients studied had an uptake of less than 1.5%, and 96.4% had an uptake of less than 2.5%. There is increasing evidence to indicate that total thyroidectomy is the procedure of choice in the treatment of differentiated thyroid carcinoma. The present study indicates that with proper technique, total resection of the thyroid gland is feasible in nearly all cases of thyroid carcinoma.


Tumors arising in accessory parotid tissue. A summary is presented of our experience with 23 patients who had accessory parotid tumors, comprising 1% of all primary parotid neoplasms seen during a 40 year period. Although more than half of the tumors proved malignant, adequate excision was usually curative. We prefer to approach these tumors through an extended cheek-flap incision. Once the lesion is exposed, either local excision or resection in conjunction with subtotal parotidectomy can be performed, depending on the clinical findings.


Use of surgery and postoperative radiation in the treatment of advanced squamous cell carcinoma of the pyriform sinus. Forty-seven patients with very advanced cancer of the pyriform sinus were treated with surgery and immediate postoperative radiation in a planned sequential manner. Eradication of the cancer above the clavicles was obtained in 81% of the patients, with a treatment mortality of 8%. Most of the patients' tumors were resected with primary closure, which obviated the need for complicated reconstructive procedures. The survival rate of 23% at 2 years and the high rate of distant metastasis reflect the aggressive biologic behavior of this cancer. The need to find an adjuvant treatment that will act upon the systemic spread of this cancer is obvious.


Carcinoma of the lip.

Carcinoma of the lip. (1) Carcinoma of the lip occurs predominantly in men in their seventh and eighth decades of life. (2) Epidermoid carcinoma is the most common malignant lip tumor. (3) Metastases to cervical lymph nodes are uncommon. (4) Elective neck dissection is not indicated. (5) Therapeutic radical neck dissection can benefit the patient in the presence of proved suprahyoid lymph node metastases. (6) The five year survival rate for epidermoid carcinoma of the lip is higher than the rate for epidermoid carcinoma of other sites in the oral cavity or pharynx. (7) Local recurrence does not correlate with the size of the primary tumor. (8) Initial treatment failures can frequently be salvaged surgically.


Carotid arterial hemorrhage after radical head and neck surgery. From 1960 to 1974, 63 patients treated by the Head and Neck Service of Memorial Hospital underwent carotid arterial ligation for control of actual or threatened carotid rupture. Twenty-one of these patients died without leaving the hospital. Fourteen of these deaths were the direct result of carotid ligation or hemorrhage. Five of the surviving patients suffered permanent neurologic damage. Factors predisposing to carotid rupture included a history of radiation, advanced disease, the presence of an oral or pharyngeal suture line in continuity with a dissected neck, and the postoperative development of skin necrosis or fistulas. Because elective carotid ligation did not prevent the consequences of carotid rupture and because reestablishment of vascular continuity is almost never possible, all attempts should be made to avoid the conditions that are precursors to this most serious complication of radical head and neck surgery.


Sublabial approach to the nasal and nasopharyngeal cavities. A sublabial transnasal degloving approach to the mid-face, nasal cavity, septum, paranasal sinuses, and nasopharynx is described. This approach provides adequate exposure and ample facility for management of tumors in these areas. The pterygomaxillary space and infratemporal fossa ard readily accessible for hemostasis and management of tumor extensions. Children, adolescents, and women with benign and low-grade malignant tumors of these areas are the ideal candidates for this procedure. Twenty-six patients have been managed in this fashion, with no major complication. The cosmetic results have been excellent. This approach to the mid-third of the face, nasal, paranasal, and nasopharyngeal cavities should receive more attention and use.


Construction of a neolarynx after radiation and laryngectomy. We have developed a technique for forming a new larynx from a cervical "bucket handle" flap to replace the larynx after laryngectomy in patients who have had radiation of the neck. Experience with the technique in six patients suggests that it is more successful than previous procedures used in such patients and may offer some advantages as a general technique of laryngeal construction. The procedure is designed to preserve speech and swallowing without aspiration, but translaryngeal breathing is sacrificed and respiration requires a permanent tracheostomy tube.


Anaesthesia and the Valsalva manoeuvre. A test of circulatory responses in neurosurgical patients including those in the sitting position. The four phases of the Valsalva manoeuvre were studied before and after anaesthesia had been induced with a technique of either spontaneous breathing or controlled ventilation of the lungs. The Valsalva manoeuvre was found to be an unreliable predictor of a patient's ability to tolerate the upright or sitting position for neurosurgical procedures. However, a false negative response is more likely to occur than a false positive response.


The measurement of occlusion pressure during anaesthesia. A comparison of the depression of respiratory drive by methohexitone and etomidate. Occlusion pressure (Po max) was used to indicate the depression of respiratory drive following rapid administration of methohexitone 0.5 mg/kg and etomidate 0.067 mg/kg to fourteen patients under stable light anaesthesia. Methohexitone produced considerably more respiratory depression than etomidate, the difference probably being clinically significant. Po max is the maximum sub-atmospheric pressure generated in the trachea when inspiration is prevented by occlusion of the airway, at functional residual capacity. The factors concerning the use of this simple, non-invasive technique during anaesthesia are discussed, and suggestions made for producing consistent, useful, measurements.


Relief of pain after surgery. A comparison of sublingual buprenorphine and intramuscular papaveretum. Sublingual buprenorphine (0.4 mg) and intramuscular papaveretum (20 mg) were compared in sixty patients after abdominal hysterectomy. Though slower in onset of effect the sublingual tablets proved effective for pain relief and appeared to have a longer duration of action. The only side-effects of note were nausea and vomiting which occurred after both treatments. Haloperidol was tried as a long acting antiemetic and appeared successful.


Postoperative analgesia after circumcision. A randomized comparison between caudal analgesia and intramuscular morphine in boys. A randomised blind comparison between caudal analgesia (1.5 mg/kg bupivacaine) and intramuscular morphine (0.15 mg/kg) is reported. Forty boys were studied. Caudal analgesia is shown to be significantly better than morphine by means of a linear analogue scale designed to quantify behaviour immediately after operation.


The effects of ketamine on the canine coronary circulation. Systemic and coronary haemodynamic measurements have been made in six healthy greyhounds anaesthetized with trichloroethylene. The administration of ketamine in bolus doses of 5 mg/kg, 10 mg/kg and 5 mg/kg followed by an infusion 0.1 mg/kg/min was found to be accompanied by a decrease in arterial pressure and an increase in cardiac output produced by an increase (84%) in stroke volume. Coronary blood flow increased greatly as did myocardial oxygen consumption and there was no change in myocardial oxygen extraction.


Detection of venous air embolism. A clinical report using end-tidal carbon dioxide monitoring during neurosurgery. A clinical report on the detection of venous air embolism during neurosurgery is presented. The use of end-tidal CO2 monitoring is described.


Complications of guided blind endotracheal intubation. The complications observed in twelve patients undergoing guided blind nasotracheal intubation are presented. The commonest was minor bleeding, followed by difficulty in hooking the cannula out of the nostril. These complications are minor enough to justify the more frequent use of the technique in patients with intubation problems.


[Coagulation problems associated with massive blood transfusions. An experimental study (author's transl)]. During storage banked blood show changes as far as function and concentration of their corpuscular and plasmatic ingredients are concerned. Antihaemophilic globulin (factor VIII) and pro-accelerin (factor V) in particular lose their activities so quickly that only very few activities still remain after a storage period of 3-5 days. In connection with existing primary diseases but also in trauma and shock a dilution-coagulopathy caused by insufficient supply of factors VIII and V can develop during massive transfusion, and this especially with banked blood already stored over a longer period of time. Therapy of this disturbance of coagulation consists of substituting the missing coagulation factors under heparin protection.


[High doses of thiopental for therapy of post-ischaemic anoxia of the brain. A case report (author's transl)]. The case of a 7-year-old child is presented, who suffered circulatory arrest during induction of anaesthesia for surgery for a posterior fossa tumour. A brain ischaemia lasting 6 minutes duration had to be assumed. After restoration of circulation, 825 mg ethiopenta were administered in order to ameliorate a possible post-ischaemic anoxia of the brain according to a protocol by Safar [18]. 11 hours after circulatory arrest the child awoke. Except for a more pronounced left sided hemiparesis and paresis of the left n. abducens no additional neurological deficit was observed compared to the neurological status before induction of anaesthesia.


[Pneumothorax caused by anaesthesiological manipulations (author's transl)]. Pneumothorax may occur following procedures such as the insertion of a subclavian catheter, intercostal blockade, supraclavicular brachial plexus blockade, endotracheal mechanical ventilation or assisted ventilation of the newborn by the "pulmarca" method. The incidence of pneumothorax was investigated over a 2 1/2 years period. Measurements to prevent, reduce and treat this complication are discussed and suggestions on the aetiology of bilateral pneumothorax in the newborn are described.


[Functional evaluation of "tekatest", a test equipment for halothane-vaporizers (author's transl)]. The results of investigations on the reliability of a commericially available test equipment for anaesthetic vaporizers based on the Rotameter principle (s.c. "Tekatest") are reported. In prototype devices scattered differences up to 27% between the results obtained by the Tekatest and those derived from gas chromatography and mass-spectrometry were noted; in a somewhat improved version an unidirectional error of about 24% became evident. Up to now, therefore, this test equipment cannot be recommended for recalibration of vaporizers in clinical use.


[Effects of dopamine-droperidol interaction on renal function in rats (author's transl)]. The influence of dopamine and droperidol on the glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) was examined in twelve groups (N = 8) of male wistar rats using the double isotope method with a partially-shielded whole-body counter according to Oberhausen. No alterations of GFR and ERPF could be elicited in normovolaemic rats given dopamine 2--4 micrograns/kg/min (i.v.) alone or in combination with droperidol 0.3 mg/kg. The administration of 10 micrograms/kg/min dopamine alone was followed by a significant (p less than or equal to 0.05) reduction of the ERPF, this effect being abolished by the concomitant use of both drugs. In tourniquet shock dopamine administration or the combined use of dopamine and droperidol produced a significant rise in arterial blood pressure and the renal functions described above. The results in the present study indicate that dopamine infusions will be effective in the presence of froperidol.


[Medial AV-nodular rhythm observed during an endolaryngeal micro-surgical intervention (author's transl)]. A case of therapy resistant junctional nodal rhythm in the course of a microsurgical laryngeal operation is reported. The interaction of possible reflex mechanisms is discussed. Attempts to reverse the electrocardioscopic findings with drugs were unsuccessful. Diminuation of the mechanical irritation caused by the operation-laryngoscope resulted in immediate return to sinusrhythm.


[The computerized anaesthetic record of the 'Universitätsklinik Köln' (author's transl)]. Some of the main arguments are presented which led us to develop our present anaesthetic record. This record system and a part of its voluminous code is described. The new version provides for the documentation of arbitrarily complicated status, which are due to the preoperative condition of the patient. Furthermore, the course of aneaesthesia and its effects upon the patient can be numerically recorded in a detailed fashion. The punching is affected by a small rate of error only.


[General anesthesia in patients with sickle cell disease (author's transl)]. From pathogenic datas about sickle cell disease, the authors enumerate precautions that should be taken during pre, per- and post-operative periods. These conclusions have been established according to previous publications and according to a personnel serie of 31 general anaesthesias, 11 of which on patients with sickle cell disease.


[Supra-umbilical laparotomies and perturbed pulmonary blood oxygenation (author's transl)]. Pulmonary blood flow and ventilation were studied in twenty three patients after supra-umbilical laparotomy by means of samplings of blood gases and expiratory air content, spirometry, and pneumotachography. Although ventilatory perturbations predominate (notably, a lessened tidal volume and an amputation of the residual functional capacity they are found in conjunction with perfusion anomalies, an shown by the study of O2 and CO2 ductances). The PCO2/PO2 diagram of Rahn and Fenn further illustrates these perfusion alterations; in addition, it gives an impression of the metabolic orientation of the patients in the early post-operative period. Several physiopathological notions are derived from the study, as well as some therapeutic proposals.


[Humoral and cellular immunity and sepsis in intensive care (author's transl)]. Different parameters of humoral and cell mediated immunity were studied in 17 patients with sepsis. There is an important decrease of CH 50 (82 p. cent of patients) and variations of serum complement according with activation of alternative pathway in gram negative and gram positive septicemia. The cellular immunity is never normal: the stimulation index of lymphocyte proliferation under the influence of P. H. A. is lower than 3. There is less than 50 p. cent of T lymphocytes forming rosettes. With cure of sepsis a discrimination is observed between patients with transient decreased immunity and those with persistent lower responses.


[Post-operative necrotising enterocolitis. One case cured by hyperbaric oxygenotherapy (author's transl)]. About one case of necrotising enterocolitis following an extra-peritoneal and aseptic operation, it seems that a post-operative ileus, by the ischemia of mucous membrane and the swarming of anerobics that it involves, seems to be responsable of this dreadful complication. The macroscopic and deceiver aspect of intestine to an early re-operation can impeed this diagnosis. The hyperbaric oxygenotherapy seems to be a perceptible adjuvant treatment.


[Malignant syndrome in burned children. Nosologic and therapeutic approach]. A malignant syndrome was observed in 7 children less than 3 years old; the extent of burn was between 5 and 25 p. cent. This syndrome appeared between the second and the fifth days. It was characterized by fever, autonomic disorders and finally coma. The clinical, biological and anatomical features look like the syndrome of Reye. The use of dopamine before coma allowed healing.


[Shock during necrotic amoebic colitis (author's transl)]. Two varieties of conditions of shock may be isolated during necrotic amoebic colitis (13 cases). Eight patients present a simple hypovolemic shock secondary to wastage by diarrhea and perilesional oedema with globular, protein, alcaline and potassic deficiency. Its prognosis is relatively good, after vascular infilling and corrections of metabolic disorders. Five other patients present real toxi-infectious shock resulting from widespread tissue necrosis with auto-intoxication associated with septicemic complications. Its prognosis is frankly bad. The treatment is far more difficult. The use of cardiovascular analeptics, such as dopamine, after an infilling failure, is not always sufficient to re-establish the situation. The exeresis of necrotic tissues is an indispensable condition to remove the cause of the shock before septicaemic generalisation.


[Defence of Swan-Ganz catheters during surgical intensive care (author's transl)]. It is difficult to apprehend certain precarious hemodynamic states with classical parameters alone; the help of a flow-directed pulmonary artery catheter is necessary in order to define the disease accurately and reach a rational therapy. The problem is easily solved by the use of a Swan-Ganz catheter. The authors have selected 50 observations to help them make clear the indications of this method in surgery and traumatology: it appears necessary to use this method not only in specialized surgery such as valvulary surgery under CEC, but also in the treatment and prevention of non-cardiogenic pulmonary oedema and in emergency or bleeding surgery on patients suffering from cardiac disease or renal failure.


[Hypertensive accident in a surgical patient with unsuspected pheochromocytoma (author's transl)]. Death may follow anesthetic incident in unsuspected pheochromocytoma. They may lead to hypertensive crisis with cerebrovascular accident and severe arythmias or acute left heart failure with pulmonary edema. We report a case illustrating these problems and in which death has followed. Analysis of the 18 cases recorded in world litterature demonstrates a mortality rate of 85 p. cent. The accident can occur in association with surgery, anesthesia and certain, even minor, investigatory procedures. However if the crisis is recognized and appropriatly treated, the patient may recover before irreversible shock occurs.


[Abortion and the use of anaesthesia. Observations after two years' experience (author's transl)]. The authors give an account of their experience of anaesthesia in 380 abortion cases. Two kinds of technique were used: --paracervical block: 10.2 p. cent of the cases, only one complication; --narco-analgesia: considered to be essential. Dextromoramide was the principal analgesic used, chosen for its pharmacodynamic properties. Three narcotic drugs used successively in conjunction with this were: propanidine, with this drug per-anaesthetic complications and post-operative vomiting proved excessive, C.T. 1341 considerably reduced the frequency of these complications, disodic penthiobarbital did not give rise to any problems.


[The advantages and disadvantages of different methods of access to the internal jugular veins (author's transl)]. The authors have made a critical study of the respective advantages and disadvantages of the various methods of access to the internal jugular vein. These have been classified under 3 headings: frontal access, lateral access and rear access. They outline their experience of the technique described by Boulanger and Delva in 1977. This method of access seems to be favoured on two scores, its simplicity and the absence of immediate serious complications. These encouraging results lead them to advocate this as the technique they would choose especially in urgent cases.


[Deep hypotension induced by sodium nitroprusside in neurosurgery. I.--Systemic hemodynamic effects (author's transl)]. The systemic hemodynamic effects of deep hypotension (MAP: 38 +/- 6 mm Hg) induced by sodium nitroprusside (S.N.) were studied in 20 patients who underwent surgery for cerebral aneurysm. The hemodynamic measurements were performed four times.: (1) during the preoperative period, (2) during stable anesthesia just before hypotension, (3) during stable hypotension, (4) 20 minutes after stopping nitroprusside. All patients were mechanically ventilated with a constant tidal volume and rate. Parameters for acid-base balance and Pa O2 were also recorded. Nitroprusside produces arterial and venous dilatation which results in a decrease of afterload and preload. The mean dosage of S. N. was 18 mcg/kg/mn. Systemic vascular resistances decreased by 62 p. cent. Mean arterial pressure decreased by 53 p. cent; it reached 40 mm Hg. Fall in preload resulted in a decrease in pulmonary wedge pressure by 28 p. cent. This fall in preload produced a decrease in stroke index according to Frank-Starling's mechanisms. However tachycardia allowed a rise in cardiac index by 20 p. cent. Increase of pulmonary wedge pressure at 8-10 mm Hg by blood volume expansion maintains stroke index at control level. Under these conditions the elevation of cardiac index is due to tachycardia. Cardiac rhythm disorders (wandering pace-maker, nodal rhythm) are observed in 5 patients after having stopped nitroprusside.


Tolerance to nitrous oxide analgesia in rats and mice. The purpose of these experiments was to characterize the nature of tolerance to the analgesic action of nitrous oxide. Analgesia was assessed in rats using a tail-flick latency test and in mice using an abdominal constriction test. Rats and mice were exposed to nitrous oxide, 75 per cent, the balance oxygen, continuously for 16--18 hours. On re-exposure to nitrous oxide 30 min later, these animals were found tolerant to nitrous oxide in that the analgesic response was decreased by at least 50 per cent. Animals tolerant to nitrous oxide were not tolerant to morphine. Morphine (0.25--1.5 mg/kg) produced equal degrees of analgesia in control and nitrous oxide-tolerant mice and rats. In contrast, rats made tolerant to morphine by repeated daily injections of as much as 400 mg/kg subcutaneously or by subcutaneous implantation of morphine pellets (75 mg, twice) showed a decreased analgesic response to nitrous oxide. Thus the cross-tolerance between nitrous oxide and morphine appears unique in that it is unidirectional.


Comparison of a chloroprocaine--bupivacaine mixture with chloroprocaine and bupivacaine used individually for obstetric epidural analgesia. Continuous lumbar epidural anesthesia was instituted in 49 healthy parturients who were randomly assigned to three treatment groups: 14 patients received chloroprocaine, 3 per cent; 19 received bupivacaine, 0.5 per cent, and 16 received a mixture containing chloroprocaine, 1.5 per cent, and bupivacaine, 0.375 per cent. Observations relating to the characteristics of the anesthetic block and to maternal and fetal well-being were made by a trained nurse observer. Times to onset of analgesia, times to maximum block, and adequacies of analgesia were similar in all groups. Bupivacaine lasted significantly longer than chloroprocaine or the mixture (68 versus 50 and 52 min, respectively, for the first injection), and caused the least motor block. No clinical superiority could be demonstrate for the mixture as compared with bupivacaine or chloroprocaine used individually. There was no sign of material or fetal toxicity with any of the three treatment regimens.


An animal model of halothane hepatotoxicity: roles of enzyme induction and hypoxia. Exposure of phenobarbital-pretreated male Sprague-Dawley rats to halothane, 1 per cent, for two hours under conditions of hypoxia (FIO2 0.14) resulted in extensive centrilobular necrosis within 24 hours. Accompanying the morphologic damage were an increase in serum glutamic pyruvic transminase (SGPT) and a decrease in hepatic microsomal cytochrmoe P-450. Glutathione levels in the liver were unchanged. Phenobarbital-pretreated rats anesthetized with halothane, 1 per cent, at FIO2 0.21 had only minor morphologic changes at 24 hours. Hepatic injury was not apparent in any non-phenobarbital-induced rat or in any induced animal exposed to ether at FIO2 0.10 or to halothane at FIO2 0.99. There was a 2.6-fold increase in the 24-hour urinary excretion of fluoride in those rats in which extensive centrilobular necrosis developed. The in-vivo covalent binding to lipids of 14C from 14C-halothane also was increased markedly when 14C-halothane was administered intraperitoneally to phenobarbital-induced rats maintained hypoxic (FIO2 0.14) for two hours. These results support the authors' hypothesis that halothane is metabolized to hepatotoxic intermediates by a reductive or non-oxygen-dependent cytochrome P-450-dependent pathway. This animal model of halothane-induced hepatotoxicity may be clinically relevant. A decrease in hepatic blood flow during halothane anesthesia may decrease the PO2 available to hepatocytes and thus direct the metabolism of halothane along its reductive, hepatotoxic pathway.