The prevention of bypass enteritis after jejunoileal bypass for morbid obesity. The symptoms of bypass enteritis are disabling sequelae in many patients after jejunoileal bypass. This is a preliminary report of efforts to devise a valve to prevent reflux into the bypassed intestine after jejunoileal bypass. Valve I (42 cases) was formed by dividing the ileum, everting the proximal end as one matures an ileostomy, and inserting this into the distal ileum. Only 12 of these valves were competent. Valve II (six cases) was formed by dividing the ileum and merely inserting the proximal bowel into the distal, allowing it to evert spontaneously as with an unmatured ileostomy. In two cases the valve was competent, but four cases became obstructed and this valve is mentioned only to be condemned. Valve III (19 cases) is similar to an isoperistaltic Kock valve, except that the intussuscepted ileum is first divested of its mesentery. All such valves have been competent. All 33 patients with a competent valve have been free of the stigmata of bypass enteritis, whereas 54% of 156 patients showed the symptoms of enteritis after conventional jejunoileal bypass.


The comparative survivals of alcoholics versus nonalcoholics after distal splenorenal shunt. Survival after distal splenorenal shunt in appreciably better in nonalcoholic patients than in alcoholics. This increase in survival does not appear to be dependent upon the state of biochemical liver function or the severity of changes in liver histology since these latter were similar for both groups. We suggest that the poorer survival of alcoholics may be related to continuing alcohol toxicity, and that a possible reason for the failure to demonstrate this difference in survival after portacaval shunts may be due to the harmful effects of total portal diversion on the liver.


Comparison of the results of resection, bypass, and bypass with exclusion for ileocecal Crohn's disease. Controversy continues regarding the optimal surgical treatment of Crohn's disease involving the ileum and cecum. Over 43-years, 161 patients underwent primary surgery for this disease at The New York Hospital-Cornell Medical Center. Resection was performed in 115 patients, bypass with exclusion in 25, and side-to-side ileotranverse colostomy in 21. Overall recurrence rates were 25% for resection, 63% for bypass with exclusion, and 75% for simple bypass. Expressed as 15 year follow-up, recurrence rate were 65% for resection, 82% for bypass with exclusion, and 94% for simple bypass. Much of the difference in final outcome was accounted for by early recurrence or by persistent disease in the two bypass groups. This amounted to 21% for the bypass with exclusion and 45% for simple bypass as compared to 3% for patients who had resection. Conclusions from this review are that 1) resection can be performed with a morbidity and mortality equivalent to either of the bypass procedures; 2) the recurrence rat following resection is significantly lower than bypass with exclusion or simple bypass, and amounts to about 4% per year; 3) continuing disease in the bypassed loop accounts for a high percentage of reoperations in the bypass groups, while appearance of new disease is the usual problem following resection; 4) resection is the surgical treatment of choice for ileocecal Crohn's disease.


The surgical aspects of chronic mucosal inflammatory bowel disease (chronic ulcerative colitis). The surgical aspects of chronic mucosal inflammatory bowel disease were reviewed by comparing the experience at our institution between two periods, one a decade later than the other (1961-1965 and 1971-1975). The striking findings were a marked decrease in the incidence of carcinoma and toxic megacolon and a marked increase in use of one-stage proctocolectomy with either Brooke ileostomy or Kock pouch. There was, in addition, a corresponding decrease in the operative mortality for elective cases, from 2.4 to 1.3%; yet the operative mortality for emergency cases remained relatively stable at about 25%. The reason for the decrease in the incidence of carcinoma and toxic megacolon appears to be on the basis of selection outside of our institution, in that fewer of these cases are being referred.


Urinary tract complications with rectal surgery. The possibility of urinary tract injury should always be considered in the course of anterior resection or combined abdominoperineal resection of the lower colon and rectum. Controlled studies of ureteral and other injuries and fistulas cannot be made; but fortunately, unanticipated damage to the lower urinary tract does not occur often. The surgeon operating in the pelvis should be aware of the problems rarely encountered and should be capable of their management. If a urologic surgeon is available, consultation often is desirable. Prompt intraoperative recognition is most important so remedial procedures can be carried out immediately. Delay in recognition and treatment jeopardizes the patient's course and the function of the urinary tract. Postoperative urinary tract infections should be diagnosed early so prompt treatment can be instituted.


Reassessment of intraoperative decisions: why operations for cancer of the large bowel fail. A program developed for the intraoperative judgement decisions commonly faced in cancer of the colon and rectum has been published and has been found to correlate frequently with the management carried out in a cancer hospital and on the ward services of university programs in city/county and Veterans Administration hospitals. Those patients whose management varies with the recommendations of the program are subject to statistically significant excess risk of dying in the hospital and excess risk of failure of ultimate control of their malignant process. It is our opinion that this program is not only useful in demonstrating the explicit nature of surgical judgement but is also useful to the operating surgeon as an indication for the need for consultation or reassessment of his obwervations.


Management of pancreatic trauma.

Management of pancreatic trauma. Since 1950, 300 patients sustaining pancreatic injuries have been managed. Three-fourths of the injuries were due to penetrating trauma with a 20% mortality and one-fourth due to blunt trauma resulting in an 18% mortality. The pancreatic injury was responsible for death in only 3% of patients. Early onset of shock resulted in 38% mortality whereas only 4% of normotensive patients died. No patient died of an isolated pancreatic injury. Sepsis was the second most common cause of death following hemorrhage. Preoperative serum amylase was elevated more frequently following blunt trauma than penetrating trauma, but did not correlate with injury. There has been a tendency toward more frequent use of distal pancreatectomy for simple penetrating injuries without obvious ductal violation which increases operative time, blood loss and possible intra-abdominal abscess since resection usually requires splenectomy. Patients considered for an 80% distal resection are better managed with a Roux-en-Y limb to the distal pancreas since three patients developed diabetes following an 80% or greater resection. A conservative approach consisting of Penrose and sump drainage is adequate for most injuries.


Results of elective duodenal ulcer surgery in women: comparison of truncal vagotomy and antrectomy, gastric selective vagotomy and pyloroplasty, proximal gastric vagotomy. This study provides a retrospective comparative analysis of results in 90 women patients who underwent three different elective operations for intractable duodenal ulcer disease. Group I (30 patients) underwent truncal vagotomy/antrectomy (TV + A); group II (30 patients) gastric selective vagotomy/pyloroplasty (GSV + P); and Group III proximal gastric vagotomy (PGV). There were no operative deaths among the 90 patients. No patient after TV + A has developed a recurrent ulcer. Two recurrent ulcers developed after GSV + P, and one gastric ulcer occurred after PGV. Dumping, diarrhea, and reflux gastritis were lower after PGV than with TV + A and GSV + P. Follow-up studies have been from six months to ten years. The clinical results among the three groups of women patients compare favorably with results obtained in a recent prospective randomized study using the identical operative procedures in three groups of men patients operated upon for intractability. There was no statistically significant difference between women and men after similar operative procedures, but the postgastrectomy sequelae were less after PGV in both women and men patients.


The role of peritoneal lavage in severe acute pancreatitis. Encouraged by reports of the therapeutic efficacy of peritoneal lavage in small series of five or six patients with acute pancreatitis, we have evaluated this treatment in 24 patients with "severe" pancreatitis. One hundred and three patients with "severe" pancreatitis (28% mortality) were separated from 347 with "mild" pancreatitis (0.9% mortality) by previously described early objective signs. Early treatment (Day 0-7) of "severe" pancreatitis included peritoneal lavage through catheters placed nonoperatively in 18 (Group A) and by catheters placed at laparotomy in six (Group C). Early treatment of nonlavaged patients with "severe" pancreatitis was by standard nonoperative measures in 61 (Group B) and included early operation in 18 (Group D). Lavage was continued for 48-96 hours, usually using 36-48 L/24 hours of balanced isotonic dialysate fluid, and was uncomplicated. Lavage led to striking immediate clinical improvement and no lavaged patient (Groups A and C) died during the first 10 days of treatment of pancreatitis. By contrast, 45% of deaths in nonlavaged patients (Group B and D) occurred during this early period, usually from cardiovascular or respiratory failure. Although lavage reduced mortality in subgroups of patients, ultimate overall survival was no affected (Group A, 83%; B, 84%; C, 33%; D,33%). Late peripancreatic abscesses caused most deaths in lavaged patients. These data show that peritoneal complications of severe acute pancreatitis and dramatically reduces early mortality. Lavage does not prevent the late local sequelae of peripancreatic necrosis.


A clinical evaluation of the surgical treatment of anorectal malformations (imperforate anus). The surgical correction of anorectal malformations remains a serious problem despite their relatively frequent occurrence. Our surgical experience with 90 patients, seen in the past ten years, includes abdominal-perineal or sacro-abdominal-perineal repair in 28 patients, complete perineal anoplasty in 13 patients, and "cut-back" perineal anoplasty in 38 patients. Secondary surgical procedures for "fecal reservoir syndrome" (seven patients), revision for stricture (11 patients) and excision of redundant mucous membrane (ten patients). The observations made from this clinical study are: 1) The importance of thorough urological and neurological evaluation of "high" abnormalities and the value of the cremasteric and bulbocavernosus reflexes as indicators of sacral innervation. 2) Increasing satisfaction with the "cut-back" anoplasty as a definitive procedure or as a temporary stage in low recto-vaginal or recto-vestibular fistulas. The technique for the "cut-back" is improved by the use of Burow's triangles and the use of nonabsorbable sutures. 3) The advisability of the complete perineal anoplasty with posterior positioning of the anus and construction of a perineal body in patients with low recto-vaginal and recto-vestibular fistulas. 4) A concern over the functional capacity of the distal bowel segment in high abnormalities. This is emphasized by the experience with six secondary resections of the rectosigmoid or left colon for "fecal reservoir syndrome." 5) Heartening results with secondary operations for stricture and redundant mucous membrane which suggest the desirability of an earlier surgical approach to these complications.


Abdominal drainage following appendectomy and cholecystectomy. Consecutive patients undergoing emergency appendectomy (283) or urgent cholecystectomy (51) were prospectively studied for the development of post-operative incisional or peritoneal sepsis. Severity of the original peritoneal infection was carefully recorded, while use of a Penrose dam to drain the peritoneum was randomized according to pre-assigned hospital number. Both aerobic and anaerobic cultures were taken from the abdomen at the time of operation as well as from all postoperative infectious foci. Results demonstrated no essential differences in incidence of wound and peritoneal infection following appendectomy for simple or suppurative appendicitis (187) or following cholecystectomy for acute cholecystitis (51). However, with gangrenous or perforative appendicitis (94), incisional and intra-abdominal infection rates were 43% and 45%, respectively, when a drain was used; yet only 29 and 13%, respectively, without a drain. These latter differences were significant (p < 0.001). In addition, intra-abdominal abscesses were three times as likely to drain through the incision than along any tract provided by the rubber conduit. Cultures revealed that hospital pathogens accounted for a greater proportion of wound and peritoneal sepsis after cholecystectomy and appendectomy for simple or suppurative appendicitis if a drain had been inserted than if managed otherwise. By contrast, a mixed bacterial flora was responsible for most infections following appendectomy for gangrenous or perforated appendicitis, irrespective as to use of a drain.


Intraperitoneal povidone-iodine in experimental peritonitis. Two experimental models were utilized to study the efficacy of intraperitoneal povidone-iodine in an established peritonitis. In both models, there was a 100% mortality in the povidone-iodine treated group. In laboratories which have reported favorable results, the animals were treated before peritonitis was allowed to develop. Clinical studies with povidone-iodine lavage have used dilute solutions which did not remain in the infected space. The effectiveness of this method was probably due to mechanical continuous irrigation. Our toxicity studies showed povidone-iodine to be fatal in normal animals in dosages exceeding 4.0 ml/kg. However, a dose of 2.0 ml/kg, which was nontoxic in normal animals, was fatal in animals with peritonitis. This study strongly suggests that the intraperitoneal administration of povidone-iodine can be fatal when the animal is compromised by peritonitis. The mechanism of this effect is unclear. On the basis of these studies, the intraperitoneal administration of povidone-iodine cannot be recommended for therapy of peritonitis.


Microsurgical composite tissue transplantation. Since 1974, 69 patients with extensive defects have undergone reconstruction by microsurgical composite tissue transplantation. Using this method, donor composite tissue is isolated on its blood supply, removed to a distant recipient site, and the continuity of blood flow re-established by microvascular anastomoses. In this series, 56 patients (81%) were completely successful. There have been eight (12%) failures, primarily in the extremities. There have been five (7%) partial successes, (i.e., a microvascular flap in which a portion was lost requiring a secondary procedure such as a split thickness graft). In those patients with a severely injured lower extremity, the failure rate was the greatest. Most of these were arterial (six of seven). These failures occurred early in the series and were thought to be related to a severely damaged recipient vasculature. This problem has been circumvented by an autogenous interpositional vein graft, permitting more mobility of flap placement. In the upper extremity, all but one case were successful. Early motion was permitted, preventing joint capsular contractures and loss of function. Twenty-three cases in the head and neck region were successful (one partial success). This included two composite rib grafts to the mandible. Prolonged delays in reconstruction following extirpation of a malignancy were avoided. A rapid return to society following complete reconstruction was ensured. Nine patients presented for reconstruction of the breast and thorax following radical mastectomy. All were successfully reconstructed with this new technique except one patient. Its many advantages include immediate reconstruction without delayed procedures and no secondary deformity of the donor site. Healthy, well vascularized tissue can now be transferred to a previously irradiated area with no tissue loss. This new method offers many advantages to older methods of reconstruction. Length of hospital stay and immobilization are reduced. The total number of operative procedures required in achieving the desired result is also less, thus decreasing the cost of hospital care.


Spontaneous rupture of the esophagus.

Spontaneous rupture of the esophagus. Spontaneous rupture of the esophagus remains a medical and surgical challenge. Its diagnosis is often missed or delayed resulting in increased morbidity and mortality, and controversy exists as to the mode of therapy for the cases seen later than 12 hours after rupture. During the last seven years, nine patients were treated at Grady Memorial Hospital. Four patients, "early group," were operated upon within 12 hours from the onset of their symptoms and five, "late group," were operated upon between 20-76 hours (average 41) after rupture. All four patients in the "early group" had primary repair of the rupture and two had, in addition, fundoplication. From the two patients with primary repair alone, one developed postoperative leakage at the esophageal suture line, which closed spontaneously; whereas, in the two patients with fundoplication, no leakage occurred. Three of the four patients recovered and one died from renal failure, gastrointestinal bleeding, and gastric perforation. In the "late group" one patient had T-tube drainage of the esophagus and died. Two had primary repair alone with one death and the other two had primary repair with fundoplication 20 and 76 hours postrupture and both recovered. The two deaths in the "late group" were due to leakage at the site of the rupture. This study suggests that even in patients diagnosed late as having rupture of the esophagus, primary repair can be implemented with reasonable success. Good mediastinal, pleural and gastric drainage, high levels of appropriate antibiotics, and provision of good nourishment are of paramount importance for the successful management of these desperately ill patients.


Inferior mesenteric artery stump pressure: a reliable index for safe IMA ligation during abdominal aortic aneurysmectomy. Fifty-two patients undergoing nonemergent abdominal aortic aneurysmectomy were prospectively studied to determine when the inferior mesenteric artery (IMA) could be ligated without subsequent development of ischemic colitis. Cannulation of the severed distal IMA for blood pressure measurement (IMA stump pressure) before and after aortic reconstruction was attempted in all and possible in 39 individuals. In 13 the IMA was thrombosed precluding pressure measurement. Prereconstruction and postreconstruction mean IMA stump and systemic arterial blood pressure measurements were computed and mean IMA/systemic pressure ratios were calculated. All patients underwent postoperative colonoscopy. One patient developed postoperative ischemic colitis. Her postreconstruction ratio was 0.37 and her postreconstruction mean IMA blood pressure was 33 mmHg, the only individual with a ratio and pressure less than 0.40 and 40 mmHg, respectively. Internal iliac arterial pulsations could not be restored in two patients. Although postresection indices were less than preresection indices in both, postresection indices were greater than 0.40 and 40 mmHg. In this study, if the IMA was thrombosed or if postresection pressures and ratios measured greater than 40 mmHg and 0.40 respectively, ischemic colitis did not develop following abdominal aortic aneurysmectomy. This simple test may prove useful in identifying patients at risk for developing postoperative ischemic colitis or if IMA revascularization is required.


Extra-anatomic bypass of the abdominal aorta: management of postoperative thrombosis. Extra-anatomic bypass of the abdominal aorta was performed in 25 patients too ill to undergo abdominal operation (Group I) and in 22 patients with graft sepsis or hemorrhage (Group II). The graft patency rate determined by life table analysis in Group I patients was 83.5% at one year and 60% at two years. The graft patency rate for Group II patients of 47% at one year was significantly lower than the patency rate for Group I patients (p <.01). Thrombectomy was attempted in 11 of the 18 grafts that occluded postoperatively. Patency was re-established by this method in nine grafts (82%), failures resulted in amputation. Recurrent occlusion of three thrombectomized grafts was treated by multiple thrombectomies with cumulative patencies up to 44.5 months. Thrombectomy was not attempted in seven occluded grafts. Two graft occlusions resulted in amputation of extremities. Contralateral axillofemoral grafts were performed in three of the patients, ipsilateral axillofemoral graft in one patient, and aortobifemoral graft in one patient. Thrombectomy is the treatment of choice for occluded extra-anatomic bypass grafts. It can be performed easily under local anesthesia. If unsuccessful, contralateral axillofemoral or femoro-femoral grafts are indicated to re-establish blood flow.


Hemoptysis and pulmonary aspergilloma: operative versus nonoperative treatment. The clinical experience with 42 patients with pulmonary aspergilloma evaluated at the Vanderbilt University Affliated Hospitals in a 22-year period was reviewed to determine the necessity and advisability of pulmonary resection. Twenty-nine patients (69%) had sustained one or more episodes of gross hemoptysis. Eleven of the 42 patients were treated operatively with lobectomy, wedge resection, or cavernostomy. Five of them had had hemoptysis preoperatively, but in only 1 patient was massive hemoptysis the primary indication for operation. The single death among these 11 patients occurred in the patient undergoing operation for control of massive hemoptysis. Nonoperative treatment was selected in 31 patients because of advanced chronic lung disease. Twenty-four of these 31 patients experienced 41 episodes of gross hemoptysis during observation periods up to 8 years (average, 32 months). Superimposed bacterial infection usually accompanied the episodes of hemoptysis, and medical therapy with bedrest, antibiotics, and postural drainage was successful in controlling the hemorrhage in 40 of the 41 episodes. One patient died from massive hemoptysis. On the basis of this experience, pulmonary resection for aspergilloma in patients with hemoptysis seems rarely indicated.


The effects of fiberoptic bronchoscopy with and without atropine premedication on pulmonary function in humans. Pulmonary function studies, including arterial blood gas analysis, were performed in 21 patients undergoing fiberoptic bronchoscopy. Eight received premedication with atropine and 13 did not. In the atropine-treated group there was no significant deterioration in pulmonary function immediately after bronchoscopy compared with baseline. Compared with the values obtained after topical lidocaine anesthesia, however, there was a decrease in peak expiratory flow rate (PEFR) (20 +/- 20%), forced expiratory volume in one second (FEV1.0) (11 +/- 12%), forced expiratory flow between 25 and 75% of vital capacity (FEF25-75) (22 +/- 16%), and forced expiratory flow at 75% of exhaled vital capacity (FEF75) (28 +/- 38%) and an increase in residual volume (RV) (16 +/- 19%). In the no-atropine group, postbronchoscopy values showed a decrease in PEFR (13 +/- 19%), forced vital capacity (FVC) (13 +/- )9%), FEV1.0 (14 +/- 16%), and oxygen partial pressure (Pa02) (11 +/- 9%) and an increase in RV (19 +/- 31%) and alveolar-arterial oxygen pressure gradient (deltaAaPO2) (91 +/- 129%) compared with baseline values. In this group also, topical lidocaine anesthesia resulted in a decrease in FVC compared with baseline. We conclude that the deleterious effect of bronchoscopy on pulmonary function is counterbalanced by the beneficial effect of atropine and that atropine is therefore a useful premedication for fiberoptic bronchoscopy.


Esophageal intubation in the management of perforated esophagus with stricture. Insertion of a Celestin tube was employed in the treatment of 5 elderly patients who sustained perforations of the thoracic or abdominal esophagus during dilation of benign or malignant strictures. Two perforations treated within 24 hours were closed by direct suture in addition to intubation. There was a delay of 24 to 48 hours between the occurrence of the perforation and treatment in the other 3 cases. Only 1 of the latter patients subsequently developed pleural effusion, and this responded to drainage. One patient died 3 weeks after intubation; there was no evidence to suggest continued leakage through the perforation. The Celestin tube appears to be effective in sealing off esophageal perforations while healing occurs and merits consideration in the management of esophageal perforations associated with stricture in elderly patients when more radical treatment is not envisaged.


Late results of triple valve replacement: a 14-year review. Forty-eight patients have undergone simultaneous triple valve replacement at our institution over the past 14 years. This series was reviewed as a baseline for comparison with more recent tricuspid valve reparative procedures and to assess the natural history of advanced rheumatic heart disease with surgically corrected valvular lesions. Survival was 81% at one month and 32% at 14 years, not significantly different from results with double valve replacement during the same period, and not related to whether the tricuspid involvement was organic or functional. Forty-three percent of the late deaths were clearly valve related, a percentage which would undoubtedly be lowered with currently available prostheses. Functional class was determined in 13 of the 17 current survivors (mean follow-up, 10.3 years), and was improved over preoperative functional class in all but 3 patients. Three patients died of progressive congestive heart failure despite normally functioning prostheses; the reasons for these deaths are open to speculation.


Intraoperative changes in coronary resistance during aortic valve replacement. Coronary vascular resistance was investigated in 10 patients undergoing aortic valve replacement using continuous constant-pressure coronary perfusion at 32 degrees C. After coronary flow was initiated, resistance was low but increased steadily until it reached a certain resting level. The plateau was attained faster after a short period of anoxia than after a longer period. The initial postischemic resistance was dependent on the duration preceding anoxia, being of the same magnitude after short and moderate periods of anoxia but significantly higher after a long period. This resistance difference between the groups lasted for the whole perfusion. The total coronary resistance and flow reached a plateau in 30 minutes, while resistance increased threefold but flow decreased to half of the initial postanoxia flow. Our results indicate the importance of initiating coronary perfusion soon after aortic cross-clamping to avoid increase in the initial vascular resistance and subsequent inadequate myocardial flow.


Current results with construction and interruption of the Waterston anastomosis. The Waterston anastomosis was constructed in 21 infants and neonates between 1973 and 1977. Sixteen neonates were 1 week old or less and 8 were less than 24 hours old. There were 2 operative deaths, giving a hospital survival of 90%. There were 3 late deaths. All surviving infants received satisfactory palliation except 1 who required a Potts anastomosis one year later. During the same time interval, 9 other patients who had had a Waterston anastomosis underwent complete intracardiac repair. Seven of them had significant angulation of the right pulmonary artery necessitating patch reconstruction. All patients survived operation, and follow-up pulmonary angiograms demonstrated only a slight persistent narrowing of the right pulmonary artery in 2 patients. We conclude that the Waterston anastomosis can be constructed with a low operative mortality even in the severely cyanotic neonate and that it can be taken down at the time of complete repair with minimal morbidity and no mortality even if it has significantly angulated the right pulmonary artery.


Massive mitral regrgitation from chordal rupture and coronary artery disease. The precise mechanism that causes spontaneous rupture of chordae tendineae remains unknown. That it may occur in patients with no disease other than underlying or associated coronary artery occlusion has not been previously reported. Six patients with chordal rupture were found among 600 patients who underwent operation for mitral regurgitation in a 6-year period. All 6 patients without exception underwent simultaneous mitral valve replacement and coronary revascularization. The salient clinical features of these patients are summarized, and 1 case is reported in detail.


Improved myocardial performance in postoperative cardiac surgical patients with sodium nitroprusside. Myocardial performance in the immediate postoperative period was studied 49 cardiac surgical patients treated with nitroprusside alone. With a thermodilution catheter positioned in the pulmonary artery, cardiac output was calculated and cardiac index, systemic vascular resistance index, and stroke work index were derived before after treatment with nitroprusside. The drug was a administered to all patients because of elevated systemic vascular resistance index. Based on their mean arterial pressure and cardiac index before treatment, the patients fell into two groups. Group I patients (N = 25) had elevated mean arterial pressure and normal cardiac index. Group II patients (N = 24) had normal mean arterial pressure and subnormal cardiac index. Nitroprusside administration resulted in a significant reduction of systemic vascular resistance index in all patients. In Group I the mean arterial pressure was lowered significantly while cardiac index increased only slightly. In Group II there was no change in arterial pressure, but cardiac index improved significantly. The results not only confirm that nitroprusside is effective in managing postoperative hypertension, but also demonstrate that in patients with postoperative left ventricular failure, the drug can improve cardiac output by reducing systemic vascular resistance without significantly lowering arterial blood pressure.


Decompression of the heart with siphon drainage. A simple technique for inducing intracavitary hypothermic cardioplegia and decompressing the left heart through the ascending aorta is presented. The technique is based on siphon drainage, which eliminates the dangers of air embolism.


A simplified cardiac cannulation technique. A technique for venous cannulation, left heart venting, and aortic root cannulation is described. It is simple and tidy and permits full mobility of the cannula with minimal manipulation and no blood loss.


Closure of the complicated patent ductus arteriosus. A technique for closure of the complicated ductus arteriosus is described which has proved both simple and safe. The technique embodies the use of profound hypothermia, low flow, and direct suture of the pulmonary end of the ductus arteriosus through a pulmonary arteriotomy. No operative deaths have occurred among 4 patients so treated, and no complications from air embolism or hemorrhage have been encountered.


Delayed mediastinal infection after ventricular aneurysm resection. A patient developing delayed mediastinal infection following ventricular aneurysm resection and double coronary bypass is presented. The source of sepsis was infection of a ventriculotomy incision that had been closed with Teflon-felt buttresses. Diagnosis was established by an increasing opacity on the lateral chest roentgenogram with a stable sternal wound. Treatment was ultimately successful only after removal of the infected Teflon and replacement by simple mattress closure. The need to remove the infected foreign body was clearly established by the initially unsuccessful attempt at simple debridement.


Traumatic subarachnoid-pleural fistula.

Traumatic subarachnoid-pleural fistula. A patient with a traumatic subarachnoid-pleural fistula successfully managed by closed tube thoracostomy is presented. Management of this patient differed significantly from that previously reported for similar cases.


Possible sites of temperature-dependent changes in sensitivity of the positive inotropic and chronotropic responses to sympathomimetic amines by comparisons of the temperature optima for a range of agonists. The temperature optimum for the positive inotropic response of guinea-pig isolated atria to single submaximal doses of isoprenaline was 25 degrees C. This was well separated from that for rate responses (37.5 degrees C). This separation was not due to changes in catechol-0-methyl-transferase or phosphodiesterase activity since it occurred with orciprenaline alone and in the presence of theophylline. The rate optima for aminophylline, histamine, glucagon, ouabain, calcium chloride and dibutyryl cAMP were essentially the same as for isoprenaline. The temperature-dependences therefore lie at a common ultimate pathway leading to the rate response. The site of temperature-dependence of the inotropic response to isoprenaline is not at the common contractile mechanisms since its optimum differed from those of ouabain and CaCl2. Activity of cAMP and its production were also eliminated as possible sites from differing optima of aminophylline, histamine and dibutyryl cAMP. The temperature-dependence may lie at the beta-adrenoceptor itself, possibly adenyl cyclase. This may be shared by glucagon although tachyphaylaxis made its optimum difficult to determine.


In vitro analysis of Ca-antagonistic effects of prenylamine as mechanisms for its cardiac actions. Ca-antagonistic properties of prenylamine were studied using isolated guinea-pig and canine cardiac preparations. Prenylamine is a weak Ca-antagonist compared to nifedipine, verapamil and diltiazem. Lower doses of prenylamine slightly increased the tension, but higher doses decreased the tension of both the guinea-pig and canine cardiac preparations. It decreased the tension while maintaining the action potential of the normal guinea-pig atrial preparation and decreased both the tension and Ca-action potential of the depolarized guinea-pig atrial preparation. Similar to antiarrhythmic agents, prenylamine also decreased the max dV/dt of the normal guinea-pig atrial action potential.


Effect of lorcainide, a new antiarrhythmic compound, on the changes in heart rhythm induced by intravenous injection of adenosine-5'-diphosphate in rats. In rats, the intravenous injection of 1 mg/kg A.D.P. (adenosine-5'-diphosphate) results in transient thrombocytopenia, bradycardia and arrhythmias. Pre-treatment of the animals with the antiarrhythmic compounds lorcainide, aprindine, procaine (1.25, 2.5, 5 mg/kg i.v.) and xylocaine (5, 10, 20 mg/kg i.v.) before A.D.P. injection results in a reduction of bradycardia and a faster normalization of heart rate. All 4 compounds were equipotent in this respect, but the higher dose of xylocaine used should be stressed. The duration of irregular heart rhythm after A.D.P. injection was significantly shortened by all 4 compounds. Peak thrombocytopenia after A.D.P. administration is reduced only by lorcainide and the highest dose of aprindine, with two dose levels of xylocaine, but is not reduced by procaine. Suloctidyl (50 mg/kg orally) had no effect on any of the parameters registered. From this study we conclude that the normalization by the compounds of cardiac rate and rhythm disturbances after A.D.P. is due to their direct antiarrhythmic effect rather than to inhibition of platelet aggregation.


Ouabain-induced potentiation of Ca2+-contraction in the depolarized vas deferens of guinea-pig. The effect of ouabain (10(-5) M) on the Ca2+-evoked phasic contraction was examined in various depolarized vas deferens of the guinea-pig. Ouabain-induced potentiation of the contraction occurred in muscle depolarized with 40 mM K+, but not in muscle depolarized with 0 mM or 137 mM K+. Furthermore, this potentiating effect of ouabain was investigated in the presence of Mn2+ and Mg2+, each of which has an inhibitory effect on Ca2+-contraction. It was strongly inhibited by Mn2+, but unaffected by Mg2+. From these findings it is suggested that ouabain facilitates Ca2+-entry, which is accompanied by the spike generation.


Competitive antagonism between calcium and antibiotics at the neuromuscular junction. The neuromuscular blockade produced by the amino-glycosidic-aminocyclitolic antibiotics streptomycin and kanamycin and its reversal by calcium was quantitatively studied in the isolated phrenic nerve-diaphragm preparation of the rat. The low dose-response curves obtained presenting no significant deviation from parallelism are highly suggestive of a competitive type of antagonism between those substances. The streptidinic moiety of streptomycin showed the same properties as the original antibiotic. Streptomycin and kanamycin decreased the amplitude of intracellularly recorded e.p.p.'s of the toad sartorius muscle in a manner quite similar to that described for magnesium ions which suggests an interference of the antibiotics with the cooperative interaction of calcium ions with specific receptive sites at the presynaptic membrane of the neuromuscular junction.


The inhibitory action of ketamine on the rat's gastric secretion. Ketamine exhibited effects on gastric acid secretion total acidity and acid output. Reduction of secretion by ketamine did not appe,r to be significantly different from values obtained with atropine or hexamethonium. In addition to atropine- and hexamethonium-like effects, ketamine also appeared to decrease gastric secretion through a potentiating activity on the sympathetic nervous system. When sympathetic activity was potentiated by cocaine, the antisecretory effect of ketamine appeared to be significantly reduced, compared with that of atropine. Furthermore, after alpha- or alpha- and beta-blockade, ketamine produced similar decreases in secretion, although maximum inhibitory effect was obtained after beta-blockade. Potentiation of adrenergic activity by ketamine seemed to be mediated through alpha-receptors. Histamine H2 receptors did not appear to be involved in the antisecretory action of ketamine.


Competitive antagonism between calcium and aminoglycoside antibiotics on guinea-pig intestinal smooth muscle. Streptomycin and related aminoglycoside antibiotics and magnesium ions antagonize in a competitive manner the contractile response elicited by calcium ion on the potassium-depolarized guinea-pig ileum. The inhibitory potency decreases in the following way: gentamicin greater than magnesium greater than neomycin greater than streptomycin=streptidine greater than kanamycin. Streptomycin was also found to reduce the uptake and to increase the efflux of 45Ca. To explain these effects two alternative mechanisms are proposed: 1) a competition of the antibiotics with calcium ions for binding sites of a transport system which carries the activator ion to the myoplasm, and 2) an interaction of the antibiotics with membrane sites that regulate calcium permeability with a consequent reduction of calcium passage to the cell.


Studies on the anti-inflammatory activity of creatine. Creatine is an aminoacid which has been found to posses anti-inflammatory activity. It is orally effective in modifying the inflammatory response in all of the test models employed. It does not produce gastrointestinal ulceration in the effective doses. In common with many of the nonsteroidal anti-inflammatory agents creatin exhibits analgesic activity. Anti-inflammatory activity is comparable to that of phenylbutazone and merits further studies.


Roentgenologic, immunologic, and therapeutic study of erosive (inflammatory) osteoarthritis. The terms erosive or inflammatory osteoarthritis refer to an inflammatory condition of the interphalangeal joints of the hand. In this report, observations of 15 patients with erosive osteoarthritis are described. The principal clinical features are symmetrical synovitis of the interphalangeal joints of the hand, the knees, and the first carpometacarpal, interphalangeal, and metacarpophalangeal joints. The principal roentgenographic features are productive and destructive osseous changes. These changes, found particularly at the interphalangeal joints of the hand, consist of both central and peripheral articular erosions and cysts associated with adjacent osteophyte formation. Serologic abnormalities commonly found in rheumatoid arthritis are rarely encountered. In two thirds of the patients, the synovial fluid is noninflammatory; in the remainder, it is mildly to severely inflammatory. The injection of intra-articular corticosteroids predictably results in decreased synovitis but does not seem to affect the subsequent development of erosions.


Fiberoptic bronchoscopy in nonhospitalized patients. Fiberoptic bronchoscopy is employed extensively in the examination of patients with pulmonary disease. As demonstrated in this large series, the procedure can be performed safely and efficiently on an outpatient basis, with the use of only topical anesthesia. Discomfort is minimal and readily accepted by most patients. Bronchial biopsies of suspected neoplastic lesions can be performed without difficulty. Outpatient bronchoscopy in an appropriate clinical setting can hasten the medical evaluation without compromising patient care.


Improving hypertension detection and referral in an ambulatory setting. A paraprofessional aide working in an urban hospital's ambulatory clinics encouraged nurses to take and record blood pressures; he then contacted patients with elevated pressures who were not referred by clinic staff or who did not return for follow-up of their own accord. Blood pressure recording by clinic staff increased during the intervention from 54% to 68% of patients seen. Appointment keeping increased with intervention from 13% to 73% of those eligible for referral. The yield of hypertensive patients initiating management increased from a control level of 7% to 22% of total patients eligible for referral. Thus, a health aide can be effective in improving detection and referral of hypertensive patients at low cost.


Thoracic and pulmonary abnormalities in multiple myeloma. A review of 958 cases. Review of the records of 958 patients with multiple myeloma disclosed thoracic skeletal or pleuropulmonary abnormalities or both in 443 patients (46%). The abnormalities were an initial finding on 25% of the chest roentgenograms. The most common finding, exclusive of plasmacytomas, was thoracic skeletal abnormality in 28% (the initial finding in 15%)--osteolytic lesions being the most frequent abnormality. Localized or diffuse pulmonary infiltrates, most often caused by infections, were present in 10%. Four patients had a diffuse infiltrate thought to be caused by a plasma cell infiltrate (proven in one). In 113 patients, plasmacytomas were seen (intramedullary 102, extramedullary 11)--as an initial finding in 8%. Fifty-eight patients (6%) had pleural effusions. Eight patients with pleural effusion caused by myeloma are added to the eight cases reported in the literature.


Coagulation and complement studies in Rocky Mountain spotted fever. A patient with laboratory-acquired Rocky Mountain spotted fever (RMSF) and concomitant influenza virus infection was studied from the third day of clinical illness. The course of his illness was marked by petechial rash, thrombocytopenia, and elevation of fibrin split products. No evidence of complement activation was observed. Plasma proteins were elevated in a pattern characteristic of the "acute phase reaction." The patient recovered completely, and vascular collapse or clinically important disseminated intravascular coagulation had developed. In febrile patients who had influenza or a clinically similar noninfluenzal respiratory syndrome, no changes in coagulation, complement, or plasma proteins developed. We conclude that aberrations in the patient's laboratory values reflected RMSF, and that complement played no critical role in his illness.


Decreased taste and smell acuity in cirrhosis. The sensory modalities of taste and smell were evaluated in eight patients with cirrhosis that was proved by biopsy specimens and in 13 control subjects. Additionally, the following serum levels were determined in these same subjects: zinc, copper, magnesium, calcium, manganese, and selenium. Fourteen concentrations each of sucrose, sodium chloride, urea, and hydrochloric acid were used to evaluate taste acuity. Smell was evaluated with 11 concentrations each of nitrobenzene, thiophene, and pyridine. These studies show that decreased acuity of taste and smell occurred in conjunction with cirrhosis in the patients who were tested. There were no trace element abnormalities that consistently correlated with decreased acuity in perception of the individual test substances.


Aseptic necrosis of bone in systemic lupus erythematosus. Relationship to corticosteroid therapy. The relationship of corticosteroid therapy to the development of aseptic necrosis (AN) in 365 patients with systemic lupus erythematosus (SLE) was investigated. Seventeen patients (4.7%) were identified as having AN. The dosage of corticosteroids ingested during the initial period of therapy in patients with AN was tabulated and compared with that of 25 SLE control patients. There was a substantially greater dose of costicosteroids ingested in the first one, three, and six months of therapy in the patients with AN than in the control SLE group. Severity of disease and duration of therapy were not found to correlate with AN. Total corticosteroid dose was virtually identical in both groups. Thus, high initial corticosteroid dosages in patients with SLE seem to be associated with the development of AN.


Benign retroperitoneal emphysema associated with upper gastrointestinal endoscopy. It is important to realize that retroperitoneal emphysema may be seen as a complication of upper gastrointestinal endoscopy. Because of the increased frequency of endoscopic and associated procedures, it is important to realize that these striking roentgenographic findings may be associated with a benign clinical condition that will resolve with expectant management alone. Clinically, we might be forced to differentiate this complication with pathological perforation from the original lesion or with free perforation by the instrument depending on the clinical conditions.


Septic arthritis caused by Enterobacter agglomerans. A case of septic arthritis was caused by Enterobacter agglomerans, an association that to our knowledge has not been described previously. The right knee joint of a previously healthy 11-year-old boy became infected when the organism was introduced through the overlying skin by a contaminated wooden splinter. Conservative management with antibiotic therapy and repeated arthrocenteses was successful. Enterobacter agglomerans is a known plant pathogen, and a relationship between human infections caused by this organism and contact with plants is well recognized. The patient described here demonstrates that, when given a suitable set of environmental circumstances, E agglomerans can cause infection in man, including septic arthritis.


Exacerbation of renal failure associated with doxycycline. Doxycycline has been considered a safe broad-spectrum antibiotic for patients with renal failure. Although doxycycline possesses many of the metabolic properties of the tetracycline group, toxic blood levels usually do not occur because of the drug's unique extrarenal route of excretion. We report here a patient with stable chronic renal failure whose renal function acutely and reversibly deteriorated coincident with a 14-day course of doxycycline. Review of the literature suggests that occasional patients may have impairment of the nonrenal excretory pathway for doxycycline. We speculate that these patients are at risk for developing nephrotoxic levels of this antibiotic.


Malignant hyperthermia. An allergic reaction to thioridazine therapy. A case of allergic rash associated with malignant hyperthermia (body temperature of 41 C) occurred in a patient who had been taking 400 mg of thioridazine hydrochloride (Mellaril) daily for two days. The condition responded well to supportive measures and immediate discontinuation of the drug use.


Successful treatment of cryptococcal meningitis with intraventricular miconazole. A patient with cryptococcal meningitis retractory to amphotericin B was treated primarily with intraventricular miconazole. All parameters of disease improved, and the patient was dischared after four months of therapy. In selected persons with cryptococcosis, it may be possible to successfully utilize intraventricular miconazole in the absence of concurrent intravenous medication.


Hydralazine-induced tachycardia and sodium retention in heart failure. Hemodynamic and symptomatic correction by prazosin therapy. Severe tachycardia, ventricular ectopy, and sodium retention manifested by hemodynamic deterioration developed with hydralazine hydrochloride therapy in chronic coronary heart disease with congestive failure refractory to digitalis, diuretics, and nitrates. Coronary care unit admission with Swan-Ganz catheterization corrected hemodynamics by sodium nitroprusside treatment after hydralazine withdrawal. Satisfactory cardiac performance with oral long-acting nitrates were unsuccessful. However, the new oral vasocilator, prazosin hydrochloride, achieved considerable hemodynamic benefit by greatly reducing elevated left ventricular filling pressure and increasing severely depressed cardiac index to normal, accompanied by striking symptomatic improvement. Furthermore, long-term enhancement of cardiac dynamics and salutary functional status was maintained by ambulatory oral prazosin therapy for several months. This experience demonstrates the favorable alternative of prazosin nitroprusside-like actions over hydralazine-nitrate therapy in heart failure therapy and emphasizes prazosin's utility when untoward side effects to hydralazine develop.


Osteolysis with detritic synovitis. A new syndrome. A new pattern of osteolysis accompanied by detritic synovitis occurred in a 71-year-old woman. The patient had a severe, destructive, and multilating arthropathy of her hands, with distal phalangeal deformity. Radiographs outlined bone resorption of the appendicular and axial skeleton, with involvement of phalanges, metacarpals, metatarsals, clavicles, long bones, and spine. There was no notable occupational history nor laboratory evidence of hyperparathyroidism. Pathological evaluation revealed synovial ulceration and necrosis, and necrotic bone embedded with fibrotic synovium. This patient's abnormalities appear to represent a new pattern of osteolysis that can be distinguished from other disorders.


Neuromuscular disease in tertiary hyperparathyroidism. A 38-year-old woman with chronic renal failure had disabling proximal myopathy of the lower extremities. Investigation revealed "tertiary hyperparathyroidism". Neuromuscular evaluation, including clinical examination, electromyogram, and muscle biopsy, revealed neuropathic muscle disease. These findings are quite similar to the neuromuscular changes in primary and secondary hyperparathyroidism. This suggests that the same neuropathic mechanism may be present in all forms of parathyroid hyperfunction.


Antacid-induced osteomalacia and nephrolithiasis. A 36-year-old woman suffered from bone pain, muscle weakness, and renal stones after prolonged ingestion of antacids for esophageal reflux. Investigation disclosed hypophosphatemia, hypercalciuria, and osteomalacia by bone biopsy. All symptoms and abnormal laboratory findings reversed with a regimen of oral phosphate supplementation and cessation of antacid intake.


Adverse reactions to methicillin and nafcillin during treatment of serious Staphylococcus aureaus infections. Relative toxicities of methicillin and nafcillin were compared in 70 patients with serious infections caused by Staphylococcus aureus. Of the 29 patients treated with nafcillin, four had fever, rash, and leukopenia and 1 had absolute neutropenia. Of the 41 patients treated with methicillin, 16 experienced 27 reactions. In addition to fever and skin rash, neutropenia and urinary tract abnormalities were common. Methicillin and nafcillin are equally effective in treating S aureus infections, but methicillin was significantly and more frequently associated with adverse drug reaction that was nafcillin.


Hepatitis associated with high-dose oxacillin therapy. A prospective survey of liver function during oxacillin sodium therapy revealed five cases of drug-related abnormalities among 41 patients. In each instance, the serum transaminase level was increased from normal to greater than 100 units. The serum alkaline phosphatase level was mildly elevated and bilirubin levels remained normal. All of the patients were asymptomatic. Hepatic dysfunction was reversible on withdrawal of oxacillin therapy and substitution of a cephalosporin or clindamycin. The observed abnormalities in liver function were associated with a daily oxacillin sodium dose of greater than or equal to 12 gm as well as with heroin addiction and staphylococcal endocarditis.


Mucormycosis. A complication of critical care. Lethal nosocomial mucormycosis developed in three previously well individuals while they were receiving intensive care for acute hemorrhagic pancreatitis, for cardiogenic shock, and for a ruptured intra-abdominal aortic aneurysm. In two cases, the condition was first seen as progressive cavitary pneumonia refractory to antibacterial therapy; Mucoraceae was identified in all three patients only at autopsy. Each patient had received large doses of corticosteroids and broad-spectrum antibiotics, and all had suffered from respiratory failure, acute renal failure with acidosis, and severe hyperglycemia in association with total parenteral nutrition. Mucoraceae should be regarded as an additional nosocomial pathogen in the setting of advanced life-support care.


Partial exchange transfusion as treatment for hemoglobin SC disease in pregnancy. Serious infarctions and embolic events can complicate the course of pregnant patients with hemoglobin SC disease. In two cases, partial exchange transfusion preceded recovery in severely ill pregnant women with hemoglobin SC disease. There seem to be pathophysiological correlations for the observed clinical findings, and there are potential beneficial effects of partial exchange transfusion. Based on our experience, partial exchange transfusion should be considered as a means of reversing the often fatal complications attending hemoglobin SC disease and pregnancy. The exchange should be of sufficient volume to ensure a postexchange level of hemoglobin A of at least 30%.


Prevailing patterns and predictor variables in patients with acute tubular necrosis. The courses of 276 acute tubular necrosis patients referred for dialysis were reviewed in search for prognostic indicators. Sixty-three percent survived. Of 28 possible predictor variables, a posttoxic cause and nonoliguria were favorable, whereas myocardial infarction and peritonitis affected survival unfavorably. Total pareneral nutrition influenced survival favorably only in those with multiple complications or peritonitis. No single variable or combination predicted a lethal outcome. Since survivors were frequently restored to complete health, we advocate an aggressive therapeutic approach even in the face of multiple complications.


Sensitivity of the amylase-creatinine clearance ratio in acute pancreatitis. An elevated amylase-creatinine clearance ratio has been established as being highly specific for the diagnosis of acute pancreatitis. In the present study, the sensitivity of this test was compared to that of the serum amylase and the one-hour urinary amylase test in 29 patients with acute pancreatitis. Abnormal elevations of the amylase-creatinine clearance ratio were found less frequently than abnormal elevations of the serum and one-hour urinary amylases. Moreover, abnormal elevations of the amylase-creatinine clearance ratio showed less deviation from normal and values returned to normal sooner than those of the serum and one-hour urinary amylases. When compared to the serum amylase and the one-hour urinary amylase tests, the amylase-creatinine clearance ratio is a relatively insensitive test in patients with acute pancreatitis.


Pulmonary candidiasis. A clinical and pathological correlation. Thirty patients with systemic Candida infection underwent autopsy during a 13-year prospective study. Eleven patients had tissue-verified pulmonary candidiasis. Nine of these patients had hematogenous dissemination, as evidenced by multiple organ invasion; two had aspiration pneumonia with lung involvement only. Aspiration Candida pneumonia is rare. Pulmonary candidiasis usually arises from a focus of infection implanted during hematogenous dissemination. An infected indwelling venous catheter was the source of candidemia in six of these patients. Organisms in the lumen of pulmonary vessels caused a necrotizing vasculitis and appeared to invade the parenchyma from these areas.


Bronchial endometriosis and bronchiectasis. A possible relationship. A 60-year-old patient with cyclic hemoptysis for 30 years was found to have bronchiectasis that was not present when hemoptysis began. Thoracic endometriosis and its possible relationship to bronchiectasis are discussed.


Allopurinol-induced granulomatous hepatitis with cholangitis and a sarcoid-like reaction. A 36-year-old man had pain in both knees and an elevated uric acid concentration; his liver function was normal. Allopurinol therapy was started, 100 mg twice daily. After one month fever, lethargy, and severe polyarthralgia developed. On admission to our hospital liver function was abnormal, and a liver biopsy specimen showed granulomas with cholangitis and pericholangitis. He also had lymphopenia with a reduced number of T cells and granulomas in the bone marrow. One month after discontinuation of allopurinol therapy the patient was clinically well with normal liver function and a normal lymphocyte count. A repeated liver biopsy specimen showed normal liver tissue with no granulomas. The onset of the symptoms and findings shortly after the initiation of allopurinol therapy, and their disappearance after the discontinuation of therapy suggest a drug-induced hypersensitivity.


Metabolic products of microorganisms. 170. On the antibiotic activity of cladosporin. Cladosporin was isolated from the cultures of three species of the genus Eurotium. Cladosporin inhibited the growth of several fungi and at very low concentrations the growth of Bacillus brevis and Clostridium pasteurianum. Bacillus subtilis and most other Gram-positive bacteria were not sensitive. Gram-negative bacteria and yeasts were not affected by concentrations up to 100 microgram/ml. Dimethyl cladosporin showed only week activity against Bacillus brevis with the minimal inhibitory concentrations being a 100 times higher than of cladosporin. The incorporation of leucine and uracil into acid insoluble material in Bacillus brevis cells was completely inhibited by concentration of 0.5 microgram/ml cladosporin. The incorporation of thymidine was not affected at this concentration.


Effect of light intensity of vesicle formation in chlorobium. 1. Chlorobium limicola forma sp. thiosulfatophilum was cultivated at 22 and 22000 lux. 2. The content of bchl d on a protein basis in the low light intensity cultures was about twice that of the high light intensity cultures; 3. After growth at 22 lux the red bchl d peak was at c. 743 nm, while at the higher intensity this peak was at c. 732 nm; 4. Electron microscopy of thin sections of Chlorobium revealed that vesicle size was greater at the low light intensity than at the high. 5. This was confirmed by sucrose density gradient centrifugation of differentially 14C-labelled vesicles from cultures grown at the two intensities. 6. The optimum temperature for growth was about 35 degrees C. Incubation at the optimum temperature was particularly beneficial at high light intensity.


Biomass yields of Chlorella from iron (Yx/Fe) in iron-limited batch cultures. The maximum biomass in iron-limited photosynthetic batch cultures of chlorella increased as the logarithm of the iron concentration. The growth yield from iron (UxFe) showed a marked inverse relation to the specific growth rate. The maximum biomass yield, g dry biomass/g iron consumed, was 7.5 X 10(3) with specific growth rate 0.108h-1; the minimum was 0.79 X 10(3) with specific growth rate 0.145 h-1. The maximum specific growth rate in the exponential phase of Fe limited cultures varied as the initial Fe concentration. Fe-limited growth made the cells adhere to a glass surface.


Functional capabilities of lower extremity amputees. One hundred thirty-four lower extremity amputees were evaluated from six months to 12 years postamputation by means of retrospective questionnaires. Patient population was similar to that of the "Amputee Census" in terms of sex, amputation level and cause of amputation. Information was gathered on activities generally considered essential for daily living, vocation and recreation, living arrangements and adjustments therein, as well as feedback on the patients' beliefs concerning what rehabilitation personnel should be doing to improve amputees' lifestyle. The relationship of functional outcome to age, amputation level, and cause of amputation was also evaluated. Results showed that most amputees did not resume a completely normal lifestyle and many modifications were made. The most popular recreational activities were fishing and swimming. Activities that amputees found most difficult were running and walking long distances. Patients requested better communication between professional staff and themselves. Below-knee amputees were significantly more independent than above-knee and bilateral amputees, but the differences between above-knee and bilateral amputees were statistically insignificant. Tumor patients did better than the other three etiologic groups. As age increased, functional independence decreased.


Rehabilitation outcome of patients with dual disability of hemiplegia and amputation. The records of 30 patients with the dual disability of hemiplegia and amputation were reviewed. Six factors noted to have influenced the success of rehabilitation were: (1) age; (2) sequence of onset of disability, whether amputation or hemiplegia first; (3) localization of dual disability, whether ipsilateral or contralateral; (4) side of hemiplegia; (5) level of amputation; (6) availability of prolonged hospital stay and training. The final functional status was better if: (1) the amputation preceded the CVA; (2) the amputation and hemiplegia were ipsilateral; (3) amputation and hemiplegia were both on the right side. The hospital stay of patients with dual disability ranged from 4 months to 1 year. Those who had disability on contralateral sides and those who had left hemiplegia required a more prolonged hospital stay.


Amputations resulting from electrical injury: a review of 22 cases. Twenty-two cases of electrical injury with a combined total of 43 major amputations are reviewed. Electrical injury resulting from contact with high-voltage current (greater than 1000 volts) commonly results in significant systemic damage. The purpose of this study was to develop statistical data on the rehabilitation and eventual outcome of these patients. Most of the injuries were job related and involved young male adults. Upper-extremity amputations were predominant, and more than 50% of the patients had two or more limbs amputated. In addition to major amputations, other obstacles to rehabilitation included skin burns and limitation of joint motion. The length of hospitalization in a rehabilitation facility for these amputees was greater than for patients with amputations due to other causes. Prostheses were fitted for 95% of the amputated limbs. At the follow-up stage of rehabilitation, 50% of the patients were either employed or pursuing career training or educational goals.


Orthostatic hypotension in amputees and subjects with spinal cord injuries. Orthostatic examinations were performed with a tilt table on 64 male volunteers, of whom 21 had sustained amputation of one or both lower limbs and 23 were paraplegic due to spinal cord injuries (SCI), with 20 healthy subjects as controls. Following tilting, signs and symptoms of fainting appeared in five of the SCI subjects, four of whom had spinal injuries above the level of D5. These phenomena appeared in only two of the controls and in none of the amputees. The mean systolic and diastolic blood pressures of the amputees at rest and standing were higher than those recorded in the other two groups. The mean pulse pressures were lower in the amputees than in the other two groups. The changes in the systolic, diastolic, and pulse pressures were more profound in those subjects with high spinal cord injuries than in subjects with lower cord injuries. ECG changes and fainting were more frequent among the SCI subjects than in the other two groups.


Videotape immediate playback: a tool in rehabilitation of persons with amputations. This study attempted to measure whether immediate videotape feedback would improve the degree of motor learning and ambulation performances of amputee patients. Twelve amputee patients were randomly assigned either to a control or to an experimental group. Subjects in the experimental group were videotaped during four sessions at weekly intervals and were permitted to view tapes to discuss their performances with the experimenter, to attempt to correct mistakes and to view the second effort again. Members of the control group were also videotaped at weekly intervals but they did not view the tapes or discuss their performances. Initial and final tapes of both groups were rated by a group of physicians and physical therapists on an Amputee Gait Rating Scale which consisted of objective behavioral measures of ambulation. Reliability of ratings was determined and difference scores between the groups were calculated. Results indicate that immediate television feedback is a valuable adjunct in the teaching process for the amputee patient.


Vibration influence on control of single motor unit activity. Effects of vibratory stimulation and maximal isometric contraction on a fine motor control task were evaluated in 17 human subjects. Electromyographic audiovisual feedback cues derived from two fine-wire bipolar electrodes, inserted to a depth of 12 and 6 mm respectively, were used to train the subjects to isolate a motor unit in the extensor carpi radialis brevis muscle. A specially designed compressed air driven vibrator providing vibratory stimulation with an amplitude of 2 mm and a frequency range of 120-160 cycles per second was applied to the muscle tendon. A significant decrease was found in the subjects; ability to isolate the pretest motor unit during and after continuous and interrupted periods of vibration and following a maximal isometric contraction of the extensor carpi radials brevis muscle. Individual variations in the subjects' responses to the forms of application of the vibratory stimulus, electrode preference and feedback specificity were observed. Results suggest that marked spatial recruitment of motor units, brought into action by the vibration stimulus or by the maximal isometric contraction, interfered with inhibitory mechanisms necessary to achieve isolation and control of a single motor unit. A therapeutic application of vibration, based on the marked spatial recruitment observed during and after vibration, is proposed for muscle reeducation.


Hand function after metacarpophalangeal joint replacement in rheumatoid arthritis. Hand function, determined by a standardized test, was compared before and after total metacarpophalangeal joint replacement with the Swanson Silastic rubber metacarpophalangeal prosthesis in patients with destructive rheumatoid arthritis. Two groups of rheumatoid patients were tested. Group 1 consisted of 10 patients who were examined 3 to 4 months after surgery. Group 2 included 11 patients who were evaluated 6 to 12 months postoperatively. Each group represented 43 prosthetic replacement procedures performed on 12 hands. Results indicate substantial postoperative improvement in tip prehension and grasp, while performance remained essentially unchanged for lateral prehension, pinch force, and power grip. A postoperative program of therapeutic exercises, functional hand activities and splinting is discussed.


Research trends in physical medicine and rehabilitation. Titles and abstracts of the 700 papers presented in the scientific sessions of the American Congress of Rehabilitation Medicine and American Academy of Physical Medicine and Rehabilitation from 1972 to 1976 were reviewed. There were 81 papers in 1972, 123 in 1973, 131 in 1974, 158 in 1975 and 207 in 1976. Two hundred thirty-seven (34%) of the papers were presented by 11 Research and Training Centers and 463 papers (66%) were presented by other institutions. One hundred fifteen papers were related to spinal cord injury, 84 to electromyography, 57 to stroke, 51 to muscle histology, physiology and chemistry, 49 to orthotics and 43 to urologic problems. Only six papers were related to cerebral palsy, only one to myelodysplasia, 4 to burns, 8 to cancer, 13 to human sexuality and 10 to prosthetics. It is believed that appropriate funding of research and an emphasis on the neglected subjects through seminars and courses may provoke the curiosity of the research and encourage him to do research in important areas other than the few which are currently most popular.


Stroke rehabilitation: evaluation of its quality by assessing patient outcomes. A modified version of an outcome-oriented quality-assurance system was used to assess the care received by patients, aged 21 to 60 years, with completed stroke, who had participated for at least three weeks in a rehabilitation program. Care for 110 patients was evaluated by comparing actual results with a set of standards for outcomes produced by practicing rehabilitation professionals using small-group estimation techniques. Outcomes were better than estimated, standards having indicated that 29% of patients should be capable of self-care, while actually 43% were. When 50 of the 110 outcomes were individually investigated; only 5% of the total study population were probably not functioning at an optimal level, and 3% more might reach optimal functioning if existing follow-up procedures were extended and made more routine. Since only an estimated 3 to 6 cases per year would be affected, the cost of instituting such care would not be justified. Participants concluded that assessment of outcomes justified continuation on the existing processes for stroke rehabilitation.


Sensory nerve conduction: effect of ultrasound. Bilateral antidromic sensory conduction measurements of the lateral cutaneous branch of the radial nerves of 5 men were performed at intervals before and for 15 minutes following ultrasonic application over a segment of the nerve. The ultrasound was applied over the area of the radial nerve for 5 minutes at a frequency of 1 MHz, continuous wave and using 1.5 watts/sq cm dosage. Nerve bed temperature was continuously recorded during the study via a subcutaneous needle thermistor probe. Eighty measurements were made of temperature latency, amplitude and duration of the nerve action potentials. Amplitude and duration of the nerve action potentials did not change following sonation. Latency and temperature values changed significantly following the application of ultrasound. The latencies decreased, indicating increased speed of conduction, as the subcutaneous temperatures increased. The ultrasound dosage used in this study increased the speed of nerve conduction.


H reflex latency in radiculopathy.

H reflex latency in radiculopathy. This study was designed to evaluate whether the H reflex latency obtained from the triceps surae following tibial-nerve stimulation was of value in detecting and differentiating S1 from L5 radiculopathy. Thirty-two patients were studied, 15 with a definite unilateral L5 radiculopathy and 17 with a definite unilateral S1 radiculopathy. Data revealed a mean H reflex latency difference of 0.03 msec (range--0.1 to 0.2 msec) between the affected and unaffected extremities for the 15 patients with L5 radiculopathy and of 2.9 msec (range 1.3 to 4.1 msec) for the 13 patients with S1 radiculopathy where an H reflex could be recorded. The H reflex was unobtainable in the affected extremity in four of the patients with S1 radiculopathy. It is concluded that H reflex latency testing is a valuable tool in helping to differentiate S1 from L5 radiculopathy.


Nerve conduction impairment in patients with respiratory insufficiency and severe chronic hypoxemia. Sixteen patients with chronic respiratory insufficiency and severe hypoxemia were studied to determine the effect of chronic respiratory insufficiency on peripheral sensory and motor nerve conduction. When matched with a control group, a statistically significant slowing (from p less than 0.02 to p less than 0.001) of nerve conduction was noted in the motor median, ulnar peroneal, and tibial nerves and also in the sensory median nerve. The peripheral neuropathy was probably due to chronic hypoxemia.


Surgical treatment of pressure ulcers.

Surgical treatment of pressure ulcers. The authors' philosophy and regimen of treatment, based on experience with 103 pressure ulcers in 75 patients, are presented. This experience illustrates that the problem of pressure ulcers can be managed well by the application of sound surgical principles in a community hospital with a rehabilitation unit. With some simplification, the standard treatment procedures can be applied easily in this setting.


How do normal subjects learn a simple adaptative task: how and why do paranoid schizophrenic patients fail? The authors studied the behavior of normal subjects and paranoid schizophrenic patients in a simple problem-solving situation. The schizophrenics were divided into two sample groups, one of individuals under treatment and the other of individuals not under treatment. The learning process involved in this problem-solving situation is very similar to an instrumental conditioning, and can be understood by means of the following assumptions: (1) the subjects use decision functions in reacting to the stimuli, although they may be not fully aware of this; (2) learning is the result of successive transformations of these decisions in the course of time; (3) the changes have specific probabilities and are related to (a) those responses which are made to the latest stimuli, and (b) a differential probability for decision functions which were effective, or only interrupted painful reinforcement, or were completely ineffective. In schizophrenics further factors of importance were (1) an 'inertia' factor and (2) the rigidly continued use of unsuccessfuly or only partially successful decision criteria. The authors used a systems theory based on Galois field theory and a calculus of operators specifying three groups of subjects. A computer program based on thses hypotheses was tested in a stimulation experiment. The statistical evaluation of the results showed a congruence between the theoretical approach and the experimental data.


[Interrater reliability of amp symptoms (author's transl)]. Two psychiatrists examined 48 patients (25 depressed and 23 schizophrenic). Each documented the symptoms on AMP sheets 3 (psychopathologic symptoms) and 4 (somatic signs, first column only). The study deals with 139 AMP symptoms. Seventy could be judged concerning symptom exists/does not exist. Of these 70 symptoms, 45 showed a good or moderate interrater reliability. Specific symptoms had a better reliability than nonspecific. Symptoms described by the patients had a better reliability than those judged by the doctor alone. The results indicate that expanded use of the AMP system in its present form is problematic. Work on a new version of the AMP system has already begun.


Intravenous cholangiography in the diagnosis of acute cholecystitis. We reviewed our experience with intravenous cholangiography in the evaluation of 70 patients with suspected acute cholecystitis. Twenty-one of these patients had visualization of the biliary ducts without opacification of the gallbladder, a roentgenographic finding that was considered diagnostic of acute cholecystitis. Twenty of the 21 patients were noted to have acute cholecystitis during exploratory laparotomy. The remaining patient had a normal gallbladder, but was found to have a liver abscess. Opacification of the gallbladder with evidence of gallstones was found in eight patients; all had acute cholecystitis. Visualization of the gallbladder without gallstones was found in 22 patients, revealing no acute cholecystitis in this group. Many of these patients were admitted to the hospital with a primary diagnosis of acute cholecystitis and were spared an unnecessary surgical exploration. Nineteen patients had nonvisualization of the gallbladder and biliary ducts. This roentgenographic finding may be caused by acute intra-abdominal conditions other than cholecystitis and caution is warranted in its interpretation. This test has been found to be a reliable adjunct in the work-up of patients with suspected acute cholecystitis.


Reduction of free water clearance with cephalic venous hypertension. A laboratory model was developed in the dog to quantitate the effects of cerebral venous hypertension on inappropriate antidiuretic hormone (ADH) secretion. When cerebral venous pressure was abruptly increased during continuous water loading, there was a sharp rise in urine osmolality within 30 minutes. Urine osmolality continued to increase during, and ten minutes after, the period of hypertension. On lowering cerebral venous pressure, the osmolality returned to baseline within 60 minutes. The effects could be extended for at least three hours and presumably longer. A 50% response threshold for this ADH effect occurred at a cerebral venous pressure between 18 and 19 cm of water. The effect correlated with plasma ADH levels. The study paralled documented clinical observations. The results are discussed in light of the recognition and management of surgical states where increased cerebral venous pressure might produce a severe antidiuretic effect.


Renal failure in ascites secondary to hepatic, renal, and pancreatic disease. Treatment with a LeVeen peritoneovenous shunt. Renal failure occurs in ascites of diverse causes. Functional renal failure (the hepatorenal syndrome) in cirrhotic patients is usually progressive and rapidly fatal. Insertion of a LeVeen shunt significantly reduces weight, as well as abdominal girth, and improves preoperative urine flow (488 vs 2,318 ml/24 hr; P less than .001) and natriuresis (12 +/- 15 vs 45 +/- 33 mEq/liter; P less than .003). The shunt should not be inserted in patients with alcoholic hepatitis (bilirubin level greater than 8 mg/100 ml). Ascitic fluid should be discarded at the time of surgery in patients with impaired cardiac function, a bleeding diathesis, and when liver function is more severely deranged.


Anomalies encountered during varicose vein surgery. During 5,050 stripping operations for varicose veins, three noticeable deviations from the normal anatomy were encountered. In two patients (0.04%) the long saphenous vein entered the femoral vein completely separate from its branches, which joined to form a common trunk before emptying into the femoral vein. In one patient (0.02%), the femoral vein and artery were transposed in the region of the fossa ovalis. In one patient (0.02%), a long saphenous artery was encountered. It arose from the femoral artery just proximal to the origin of the deep femoral artery and accompanied the long saphenous vein along the medial aspect of the upper thigh. In some patients, a large venous cluster overlying the fossa ovalis was encountered, usually the result of a congenital venous anomaly. Surgical problems can be minimized if the possibility of these congenital anomalies is always considered.


Allograft vein arterial bypass.

Allograft vein arterial bypass. Untreated allograft saphenous veins used for arterial bypass failed in ten of 11 cases. The precise cause of failure was uncertain, but immune reactions of the recipient against the allograft seemed to be related to failure.


Calcified ballbladder (porcelain gallbladder). Calcification of the gallbladder wall, otherwise known as porcelain gallbladder, is a relatively rare disease and is frequently asymptomatic. Symptoms suggestive of biliary disease are often absent in patients with this manifestation. Since the condition is uncommon, it is important to recognize the clinical as well as the roentgenographic characteristics of the disease because of the high frequency (22%) of adenocarcinoma in the porcelain gallbladder. To our knowledge, no pathognomic sign of symptoms of the disease have been reported so far. Of five cases of porcelain gallbladder reported, carcinoma of the gallbladder was discovered in one patient. This disease seems to appear mostly in the sixth decade of life and is more prevalent in women. Diagnosis is made in most cases by a simple flat plate of the abdomen, and workup should include other roentgenographic examinations to exclude calcification of other viscera or the thoracic wall. Surgery should not be delayed even if the patient is asymptomatic since the occurence of carcinoma in porcelain gallbladder is remarkably high.


Radioimmunoassayable plasma vasopressin associated with surgery. Plasma vasopressin concentration was measured by radioimmunoassay before, during, and after anesthesia and surgery in ten subjects. During the short period between the onset of anesthesia and the start of operation, small elevations of vasopressin level were noted. Surgery itself was associated with significant elevations of up to 82 pg/ml. Highest levels of vasopressin were noted with major intra-abdominal surgery and lowest levels with limb surgery. The immediate postoperative period was marked by plasma vasopressin levels that were often higher than during surgery itself. Levels gradually fell to their preoperative state after three to four days. The elevated levels of vasopressin can be associated with oliguria and excessive water retention. Among the possible mechanisms for the stimulus to vasopressin secretion are pain, stress, positive pressure respiration and anoxia. This study confirms by radioimmunoassay the changes in plasma vasopressin level with surgery that have been previously described by bioassay.


Long-term results of operative therapy for aortoiliac disease. Over a period of 11 1/2 years, 140 patients were operated on for aortoiliac disease; 81 had coexisting superficial femoral artery occlusions (combined segment disease). Patients with combined segment disease were older, had twice the incidence of diabetes, and significantly more rest pain and gangrene on presentation. Aortic bifurcation grafts were placed in 114 patients. Relief of rest pain and threatened gangrene was uniformly good. However, relief of claudication was significantly poorer in patients with combined segment disease. There were 11 "late" thrombotic graft occlusions. Six grafts with distal anastamoses to the external iliacs failed because of limb outflow problems, while five grafts to the common femoral position exhibited more diffuse problems. Late graft failures were due to progression of disease and not problems intrinsic to the grafts. Cumulative patency rates were 98.0% at one year and 94.6% at three years.


Gastric secretory response to intravenous amino acids in eviscerated dogs. Eight dogs, four with intact vagi and four with vagotomy, were studied to see if the gastric secretory effect of intravenously administered L-amino acids is mediated by a gastrointestinal (GI) hormone or hormones. Intravenous infusion of amino acids produced a significant secretory response in denervated and in innervated stomachs. When the known sites of formation of GI hormones were removed by resection of antrum, duodenum, pancreas, jejunum, ileum, and colon, the gastric stimulatory effect of amino acids was not changed significantly in denervated stomachs but was greatly increased in innervated stomachs. We conclude that amino acids have a direct effect on parietal cell secretion that is not dependent on the intermediary release of a stimulatory hormone, and that evisceration enhances this effect in dogs with intact vagi.


Immunological enhancement of rat small intestinal allografts. In an attempt to evaluate whether survival of rat intestinal allografts could be extended by the administration of enhancing serum, Lewis-Brown Norway small intestine was transplanted to Lewis recipients, using microsurgical techniques. Only multiple injections of serum, administered on alternate days, resulted in a prolongation of survival by a few days. Neither graft irradiation nor a single injection of antiserum was effective in increasing survival time of the transplanted intestine. Clinical trials of intestinal transplantation from cadaver donors will probably have to await a clearer understanding of various methods of altering host responsiveness to foreign tissue. At the present time, central venous nutrition offers the best solution to the patient with an insufficient length of small intestine.


Prevention of dermal ischemia after thermal injury. One percent methylprednisolone acetate was evaluated as a pharmacologic agent in the prevention of dermal ischemia following burning. Standardized partial thickness burns were inflicted on guinea pigs. Burned guinea pigs were separated into five groups; one was treated with topical steroid, one with systemic steroid, one with both, one with emollient base without steroid, and one served as an untreated control. Histology and depth of dermal ischemia were evaluated by india ink perfusion technique. Untreated controls showed progressive dermal ischemia with complete absence of india ink-filled vessels in the dermis by 24 hours. Topical steroid alone improved dermal perfusion as suggested by relative levels of india ink filling. Topical steroid in the dosage used does not potentiate infection in standard burn wound sepsis models. Preservation of dermal appendages was seen secondary to improved dermal microcirculation with a ninefold increase in hair follicles in treated guinea pigs compared with controls.


Condyloma. A new epidemic.

Condyloma. A new epidemic. Condyloma acuminatum of the anus is an increasingly frequent disease that may require a combination of therapies. Large bulky lesions can be reduced with topical freezing, cautery, or the scapel. Topical chemotherapy with podophyllum resin can be supplemented with cancer chemotherapeutic agents. Many of these drugs probably act, at least in part, by stimulating a strong local cellular immune reaction. Dinitrochlorobenzene was used to eradicate lesions that had been resistant to treatment with podophyllum resin. 5-Flourouracil was used as a control. All 23 patients studied were initially skin tested with both agents and randomized to either treatment group. All but one of the dinitrochlorobenzene-treated patients had excellent regressions. Immunotherapeutic agents, such as dinitrochlorobenzene, warrant further study as adjuvant therapeutic agents for this disease.


Excision of pulmonary and renal aspergillomas. Its use in treating chronic granulomatous disease of childhood. Renal and pulmonary Aspergillus granulomas in two 6-year-old boys with chronic granulomatous disease were treated by nephrectomy and lobectomy as well as intravenous amphotericin B and granulocyte transfusion. After lobectomy two smaller pulmonary aspergillomas resolved with medical therapy. The second child's condition improved after nephrectomy, but he died with disseminated Aspergillus infection. This experience suggests that surgical excision of localized Aspergillus granulomas in conjunction with specific antimicrobial therapy provides temporary clinical improvement and may prevent further blood-borne dissemination of the fungus.


Preoperative angiographic diagnosis of small bowel leiomyomas. Two patients with gastrointestinal (GI) tract bleeding underwent preoperative selective visceral arteriography that demonstrated small-bowel tumors compatible with leiomyoma. A review of the material indicates that 42% of patients with small-bowel leiomyomas also have GI tract bleeding. Arteriography is valuable in obtaining a preoperative diagnosis.


Salt and water balance before and after peritoneojugular and portacaval shunts. Renal salt and water handling were studied in a patient who had refractory ascites that were due to alcoholic liver disease. The patient underwent a peritoneojugular shunt that was followed eight weeks later by a portacaval shunt. Ingestion of a 10-mEq sodium diet and albumin infusion had no effect on sodium balance but increased free water clearance before and after the operative procedures. After peritoneojugular shunt, free water clearance and sodium excretion increased. After portacaval shunt, free water clearance decreased and sodium retention occurred.


Intraoperative measurement of common duct resistance. Biliary tract resistance was measured in 142 patients at the time of cholecystectomy, using a simple technique in which contrast media is infused through the cystic duct at a fixed flow rate. A sharp demarcation exists between the resistance of patients with normal and abnormal common bile ducts. A resistance of less than 2.5 units was found in only one patient with a common duct abnormality, and the test was improperly performed in that case. Two patients with normal common ducts had resistance values of greater than 2.5 units, for a false-positive rate of 1.63%. Overall, the technique gave accurate results in 97.9% of the cases studied.


Abortive infection of influenza virus in Ehrlich ascites tumor cells. Unusual fragility of virus particles. Noninfectious virus particles were produced in Ehrlich ascites tumor cells infected intraperitoneally with fowl plague virus. The PFU yield of virus per cell was less than 0.1 and the ratio PFU/HA units in the progeny virus was less than 10(3). The virus particles had the same morphology and size as egg-grown virus but were more fragile. They were disrupted by centrifugation through sucrose and caesium chloride gradients, but this disruption was avoided by fixing the particles with formaldehyde before centrifugation. Analysis of polypeptides by SDS-PAGE showed that ascites-grown virus particles contained reduced amounts of matrix protein compared with egg-grown virus.


[Development of neuron-capillary interrelationships in the nuclei of the anterior portion of the human hypothalamus during ontogenesis]. Three periods in the formation of the spatial arrangement of the neuronal nuclei have been stated: 1) from the prenatal period, infancy including--pronounced decrease in the density of the neuronal cells arrangement; 2) from the childhood up to adolescence--relative stabilization in the hypothalamic cellular composition; 3) mature and old age--secondary decrease in the dencity of the neuronal cells arrangement. Certain peculiarities in the nuclear capillary composition and in their neuronal-capillary relationships have been revealed: during the prenatal ontogenesis, the dencity of the neuronal cells arrangement decreases and their size increases that is followed by decrease in their capillary loops. In postnatal ontogenesis no proportional relationship between the dencity of neuronal cells arrangement and that of capillary network in the nuclei of the anterior hypothalamus was noted.


[Microcirculatory bed of the human trigeminal nerve]. Studies of film preparations from the sheaths of the human trigeminal nerve impregnated with silver nitrate demonstrated all the parts of the microcirculatory bed to be situated in the soft sheath of the root, in the capsule and stroma of the trigeminal ganglion, in epineurium and in the outer layers of perineurium of the nerve branches. In the internal layers of perineurium, pericapillaries, capillaries and postcapillaries are present; in the sheaths surrounding the root fibers and in endoneurium, there are only capillaries. Ontogenic peculiarities in the microcirculatory pathways of the trigeminal nerve are noted; varieties in arterio-venular anastomoses are described. The data obtained and those available in literature make it possible to conclude that the circulatory bed of epineurium and the external layers of perineurium possess the greatest compensatory-adaptive resources. The microcirculatory bed of the internal layers of perineurium and, especially, those of endoneurium possess the least compensatory resources.


[Establishment of the capillary-receptor connections of laminar bodies in the hand muscles of fetuses and newborn infants]. The first findings of capillary-receptor connections of the laminar bodies in the hand short muscles are related with 5--6 months of embryogenesis. These connections become gradually more complex by the time of birth and in early postnatal life. Arterial portions of the capillaries penetration to the laminar bodies, arrange along the border of the internal cone and the external capsule and within the internal cone itself, along the course of the axonal cylinder. Venous capillary loops form a dense network on the surface of the laminar bodies. In the group accumulations of the laminar bodies (reflexogenic zones) the capillary network is denser than in identical areceptor zones  of the hand muscles.


[Effect of prostaglandin F2alpha on several morphofunctional characteristics of mouse embryos during the pre-implantation period of development]. Prostaglandin F2alpha in vivo and in vitro effects were studied in mouse embryos at different developmental stages. Inhibiting effect of this factor on cell reproduction (cleavage) was demonstrated, and in vivo experiments the process of the embryo release from the zona pellucida was also investigated. The studies were carried out in a large statistically significant material with an adequate mathematical processing of the data obtained. The critical point of the greatest sensitivity in the embryo to prostaglandin F2alpha effect was determined--the morula stage (16 cells).


[Critical period in the work of the form-inducing apparatus of the lens in chick embryos, detected after chloramphenicol application]. The inhibitor of protein synthesis chloramphenicol (2 mg/egg) was applied to elucidate the critical period in the chicken lens development. Chloramphenicol injected before incubation and at 24, 30 and 48 h of incubation did not prevent the formation of parts in the lens-inducing apparatus (the optic vesicle, and the presumptive lens ectoderm), but the injection at the stage of 24--30 h of incubation resulted, in many survived for 5--7 days of incubation, in lack of the lens. Therefore, it is possible to speak about a disturbance in the activity of the inducing apparatus during the period of determination, or about a critical period of the lens development.


[Ultrastructural characteristics of the incretory granules of the EC- and ECL-cells of the gastrointestinal tract]. At least three varieties of EC-cells differing in their density, form and fine structure can be revealed at the ultrastructural study of EC- and ECL-cells of the intestinal tract. Different forms of the incretory granules of the ECL-cells and heterogenous ultrastructural organization of their dense contents in man and animals make is possible not only to distinguish several forms of these cellular elements, but to speak of their specific peculiarities. It is not impossible that the ultrastructural peculiarities revealed in the incretory granules of the endocrine cells explain differences in the nature of histologically active substance which they produce.


[Histochemical characteristics of the secretory cells of gastric glands compared]. The work is dedicated to complex histological studies of the secreting cells in the gastric fundal glands, in their comparative aspect. In the representatives of Amphibia, Reptilians and birds, histochemical differentiation of oxyntopeptic cells was demonstrated to be independent on the peculiarities of the animal nutrition. In mammals, histochemical characteristic of the carbohydrate component in the glandular secreting cells depends on the type of nutrition.


[Reactive-destructive changes in the nervous elements of the capsule of the hip joint in coxarthrosis]. Specimens of the hip joint capsule were obtained during surgical treatment in 56 patients suffering from different kinds and stages of coxarthrosis. Neuronal elements of the capsule were stated to undergo reactive-destructive changes. Demyelinization of the capsule nerve fibers seems to be one of the causes producing painful sensation in the affected joint at coxarthrosis. Displastic and idiopathic coxarthrosis produces the destruction of less degree with preservation of the capsule nerves for a longer period; traumatic coxarthrosis with an aseptic necrosis of the femoral head is followed by a more profound destruction and the development of the disease is of shorter duration.


[Results of a microscopic study of several remains of the internal organs of Shandrin's mammoth]. The survived portion of an organ which topographically can be considered as a part of the lung, as well as a section of muscular tissue, perhaps that of the heart, has been studied. Under weak systems, the portion resembles the lung, spaces resembling alveoles, alveolar ducts and alveolar saccules are seen. "Alveolar" walls are stained dark grey by different methods; "alveoles" contain yellow granules, ferric components are not detected in them. The intestinal wall and that of the large vessel in the mesenteric cavity preserves a fibrillar carcass, fibrillar ultrastructure corresponding to collagen.