The prerequisites for local lysolecithin formation in the human gallbladder. II. Studies on the positional specificity of the phospholipase A activity. The positional specificity of the phospholipase A in human gallbladder epithelium was studied by using biosynthetically radioabeled diacylphosphoglycerides as substrates. Diacylphosphoglyceride in 14C-palmitic acid-labeled, autoclaved E.coli was hydrolyzed under the formation of monoacylphosphoglyceride and fatty acid that were both radiolabled. In contrast, diacylphosphoglyceride in 14C-oleate-labeled bacteria was hydrolyzed so as to give radiolabel in the fatty acid only. Since 14C-palmitate occupies predominantly the 1-acyl position and 14C oleate the 2-acyl position of the major E. coli diacylphosphoglycerides, these findings suggest that: 1) the phospholipase attacks and 2-position of diacylphosphoglycerides, and 2) a complete deacylation of diacylphosphoglycerides in the gallbladder wall is brought about by the combined action of phospholipase A2 and lysophospholipase, the latter being able to hydrolyze the 1-acyllysophosphoglyceride. It appears, therefore, that the biochemical preequisites for a local formation and degreadation of lysolecithin in the gallbladder itself are met by the positional specificity of theenzymes present. This finding further substantiates the hypothesis that lysolecithin is an adjustable mediator of aseptic cholecystitis.


Standardized ("trifixed") diet in the study of chronic malabsorption syndromes. 143 patients (70 patients with Crohn's disease, 11 with ulcerative colitis, 40 with an intestinal by-pass operation, 9 with non-tropical sprue, 10 with short bowel syndrome, and 3 with other gastrointestinal disease) were studied during a metabolic regime including a fixed oral supply of 70 g fat, 800 mg calcium, and 200 mg oxalate. Faecal fat, 47Ca-absorption, 14C-oxalate absorption, and renal oxalate excretion were measured, and in the majority of patients a 14C-glyco-cholic acid breath test was also performed. 14Ca-absorption was practically identical (r = 0.92), whether determined by whole-body counting or from the accumulation of absorbed 47Ca in the skeleton of the underarm. 14C-oxalate absorption and renal oxalate excretion agreed well (r = 0.85). Steatorrhoea correlated weakly with renal oxalate excretion (r = 0.63, p less than 0.001), whereas no correlation was present between faecal fat and calcium absorption or between oxalate and calcium absorption under the constant conditions prevailing during the study. It is recommended that a "trifixed" regime with absorption studies of fat, calcium, and oxalate be undertaken previous to therapy that aims at a reduction of steatorrhoea or hyperoxaluria or an improvement of calcium absorption in chronic malabsorption syndromes, not least because therapy of these categories of patients most often continues for years.


Urolithiasis in chronic inflammatory bowel disease. In a selected material of 228 patients with chronic inflammatory bowel disease (CIBD) the incidence of urolithiasis was 15% (95% confidence limit 11-21). The tendency to urolithiasis is significantly correlated to small-bowel resection and its extent and to obstruction in the urinary tract. On the other hand, there is no definite correlation to the duration or extent of the bowel disease. The significant correlation between urolithiasis and ileal resection is in agreement with the hyperabsorption of oxalate as an important cause of stone formation demonstrated by others. That local factors too play an essential role in the formation of urinary calculi is apparent from the increased incidence of urolithiasis in obstruction of the urinary tract. The incidence of urolithiasis was particularly high (22-25%) among patients with ileostomies. The few and negligible symptoms of and sequelae to, urolithiasis in CIBD encourage a conservative attitude.


Gastroesophageal sphincter pressure and serum gastrin studies following food intake before and after vagotomy for duodenal ulcer. Gastroesophageal sphincter pressure (GESP) and serum gastrin concentration (SGC) were determined in the basal state and after a protein meal in 6 patients with duodenal ulcer (DU) 6 patients after parietal cell vagotomy (PCV) 6 patients after selective gastric vagotomy plus drainage (SGV + D), and 6 patients after selective gastric vagotomy plus precise antrectomy (SGV + A). No  correlation in the resting state between GESP and SGC was observed. After food ingestion, DU patients showed a sustained rise in GESP which lasted up to the end of the experiment. The vagotomized patients, however, showed no rise in sphincter pressure after food intake--rather a tendency to decrease in pressure occurred. On the contrary, SGC rose significantly after food ingestion in patients with SGV + D or PCV, while in DU patient this rise was less significant. Patients with vagotomy and antrectomy showed no rise in SGC. These results do not suggest that SGC and extrinsic vagal innervation in the resting state play a significant role in the maintenance of the tone of GES. After food ingestion an interaction may occur between intact vagal innervation and rise in SGC in order to obtain an adequate rise in GESP.


Relation of gastroesophageal sphincter pressure and esophageal contractile waves to age in man. Gastroesophageal sphincter pressure (GESP) and contractile waves of the esophagus were measured in 113 normal subjects ranging in age between 2 months and 74 years. The amplitude and duration of the peristaltic waves of the thoracic esophagus were similar in both children and adults. Resting GESP pressures were dependent upon age. In children under one year, high pressures were recorded. The high pressures gradually diminished until between 15 and 24 years, whereafter they remained at similar values up to 65 years. After this age, a further decline in pressure was observed. The importance of these findings are discussed.


The effect on intestinal calcium absorption of somatostatin in man. Somatostatin has been detected in the gastrointestinal tract and has been shown to have wide actions on gastrointestinal function. Using an isotope method with 51Cr as a stool marker, we have examined the absorption of 47Ca in 9 healthy volunteers with and without infusion of cyclic somatostatin  (250 microgram/h for 2 hours). Both serum and faecal measurements show reduced 47Ca-absorption during somatostatin infusion, net absorption falling from 53.0 +/- 14% without to 40.4 +/- 13% with somatostatin. Possible explanations are discussed with special emphasis on the possibility of an inhibition of active calcium transport, which may be a more general mode of somatostatin action.


Comparison of juice obtained during duodenal aspiration and cannulation of the main pancreatic duct after stimulation with exogenous secretin in man. The exocrine pancreatic secretion obtained by endoscopic cannulation was compared with that obtained by a conventional duodenal tube after exogenous secretin. The flow rate, bicarbonate output, and amylase output in response to secretin was larger during duodenal aspiration than when collecting during endoscopic cannulation. The majority of samples collected from the duodenum contained bile, whereas those from the pancreatic duct were, with few exceptions, colourless. In all patients the bicarbonate concentration was lower in the duodenal aspirate than in the pancreatic juice. In 5 of the 7 patients, however, the concentration of amylase was higher in the duodenal aspirate than in juice collected by endoscopic cannulation. In these patients the quantitative difference found could not therefore solely be explained by non-quantitative collection of juice from the pancreatic duct and/or contamination of bile, intestinal juice, and gastric juice in the duodenum. Augmentation of the response to secretin by the presence of bile and pancreatic juice in the duodenum and inhibition by the endoscopic cannulation of the pancreatic duct are discussed as alternative explanations.


Simultaneous recording of gastric and duodenal electrical activity. A method for simultaneous recordings of the gastric and duodenal smooth muscle electrical activity is described. Three pairs of silver electrodes are arranged along one side of a double lumen intestinal tube, which is fixed to the mucosal wall by suction. The slow pacesetter waves (BER) and the fast spikes accompanying motor activity are recorded on separate channels, together with registrations of intraluminal pressure variations and respiration.


Urinary oxalate excretion related to ileocolic surgery in patients with Crohn's disease. Urinary oxalate excretion was studied in healthy subjects and before and after surgery in patients with Crohn's disease. Urinary oxalate excretion in relation to the length of diseased or resected ileal segment in patients subjected to restorative and colectomy procedures, as well as in relation to faecal excretion of fat and bile salts and to urinary excretion of vitamin B12 and calcium, was also studied. The studies were performed in patients on a free diet or standard hospital diet and on a high-oxalate and/or high-fat diet. When patients subjected to ileal resection in conjunction with minor colonic resection were studied on a high-oxalate diet, urinary oxalate excretion increased with length of ileum resected and correlated with faecal fat excretion and urinary excretion of vitamin B12 but not with faecal excretion of bile salts. Increasing the dietary fat intake in these patients further increased urinary oxalate excretion. Although urinary oxalate excretion increased somewhat in colectomized patients on a high-oxalate diet, indicating an increased absorption of dietary oxalate, this increase showed no correlation either to faecal fat or bile salt excretion, or to urinary excretion of vitamin B12. The result are consistent with the "solubility theory". A diet low in fat and oxalate and high in calcium is recommended in patients with hyperoxaluria.


Effects of short-time somatostatin infusion on the gastric and intestinal propulsion in humans. The effect of short-time somatostatin infusion on gastric and intestinal propulsion of an oral glucose load was examined in healthy subjects by means of a multiple indicator dilution technique. The early gastric emptying rate was enhanced by somatostatin, indicating delayed gastric inhibition. After withdrawal of the somatostatin infusion, the late gastric emptying rate was decreased and the intestinal propagation rate markedly slowed. The effect of long-time somatostatin infusion has to be examined to analyse the nature of the events described.


The effect of sterculia bulk on the viscosity of stomal output from twelve patients with ileostomy. The addition of 15g of sterculia bulk (Inolaxol) to the daily food patients with ileostomy increased the viscosity of the stomal output by roughly 100%. The clinical result of this change was beneficial in 9 out of 12 patients in terms of diminished bandaging difficulties. Adding bulk to the diet of patients with ileostomy may thus facilitate the management of the stoma by increasing the viscosity of the output.


A prospective comparative study of clinical and pathological characteristics in Icelandic and Danish patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. II. Histological results. The occurrence of gastritis in antral and body mucosa is compared in an Icelandic and a Danish group of patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. In all 93 Icelandic and 88 Danish patients were examined. All signs of antral gastritis were more frequent in Icelandic than in Danish patients, but only the incidence of superficial inflammation and decreased mucus content in surface and crypt epithelium differed significantly. In body mucosa pseudopyloric metaplasia was more frequent in Iceland and occurred equally freqeuntly in all three diseases. A statistically significant correlation was found between macroscopic gastritis and occurrence of antral superficial inflammation and between smoking and superficial inflammation and decreased mucus content in the pyloric biopsy specimen. The presence of histological gastritis was not correlated to the intake of alcohol and salicylic acid, nor to the presence of pain at the time of investigation.


Pyogenic meningitis in Ibadan, Nigeria. A 15-month prospective study. Between January 1976 and March 1977, cerebrospinal fluid samples from 2130 patients at University College Hospital, Ibadan, Nigeria were examined, 130 patients were shown to have pyogenic meningitis. The commonest causative bacteria were Streptococcus pneumoniae (53.8%), Haemophilus influenzae (23%), Neisseria meningitidis (7.7%) and Klebsiella spp. (3%). Most of the infections occurred in very young children: 47% of all patients were under 1 year of age, and 69% were under 5 years old. The overall case fatality rate was 30% (Strep. penumoniae infection 28.6%, H. influenzae and N. meningitidis infection both 20%). All 4 patients with klebsiella infection died. There was a noticeable increase in the incidence of Strep. pneumoniae strains showing resistance to tetracycline, between 1974 and 1976, and this was attributed to the widespread use and abuse of the antibiotic among the general population. Two strains of H. influenzae were found to be resistant to ampicillin; such strains have not previously been reported from Nigeria. The results of the study support the use of a combination of ampicillin and gentamicin in the initial treatment of pyogenic meningitis in Ibadan.


Metronidazole treatment of liver abscess due to bacteroides fragilis. A 67-year-old woman with a liver abscess due to Bacteroides fragilis was treated with metronidazole 0.4 g orally every 8 h for 6 weeks. There was a rapid clinical improvement even though no surgical drainage was performed. By the indirect immunofluorescence technique using the patient's own strain as an antigen the antibody titer declined from 5120 to 80 in 6 months, suggesting eradication of the infecting agent.


Serum Q fever antibodies in Swedish UN soldiers in Cyprus--reflecting a domestic or foreign disease? Swedish soldiers from 2 battalions serving in Cyprus 1975 and 1976 were tested serologically for Coxiella burnetii phase 2 complement-fixing antibodies. 2.7% were positive. Although none of the seropositive soldiers had been seriously ill abroad, the titers are considered to emanate from an infection in Cyprus as there is no evidence of domestic Q fever from a survey of 1390 Swedes.


Early diagnosis of tick-borne encephalitis (TBE) by demonstration of specific IgM antibodies. The demonstration of specific IgM antibodies after separation of immunoglobulins was used for the early diagnosis of tick-borne encephalitis (TBE). The separation was done by sucrose-gradient density ultracentrifugation and IgM antibodies were demonstrated with the hemagglutination-inhibition (HI) test. IgM antibodies were found in 9/11 sera taken within 3 days after onset of clinical symptoms and in all sera (37/37) taken 4--15 days after onset of the disease. Most sera (22/24) were still IgM positive 3--6 weeks after onset of the disease. After this period of time IgM antibodies could no longer be defected. The demonstration of IgM antibodies also proved valuable in confirming the diagnosis in several cases where no antibody rise was found neither by the complement-fixation (cf), nor by the HI test.


Effect of osmium tetroxide and 198Au in normal and arthritic rabbit knee joints. Antigen-induced arthritis (AIA) was induced in adult rabbit knee joints, using ovalbumin as antigen. After 4 weeks, intra-articular injections of 0.3 ml 1% osmium tetroxide or 100 muCi 198Au were given. The same injections were also given to normal animals. The animals were observed for up to 12 weeks. In the normal animals, no affection of articular cartilage could be seen by light microscopy. In the arthritic animals, however, severe destruction of articular cartilage was seen. The degree of destruction in the osmium tetroxide-treated animals was similar to or even worse than that of the controls, whereas the 198Au-treated animals showed a lesser degree of destruction than both controls and osmium tetroxide-treated animals. Autoradiograms, using 3H-thymidine, showed affection articular cartilage in all groups, i.e. both normal and arthritic.


Acetylation phenotype in rheumatoid arthritis. The acetylation rate of INH was studied in 39 patients with RA; 20 patients with cardiac arrhythmia served as controls. Statistically, no significant difference was observed between the groups. The percentages of rapid acetylators in the RA and control groups were higher (59 and 55%, respectively) than the reported incidence in the Finnish population, 44% (11). The polymorphic acetylation phenotype was not correlated with either clinical parameters of RA or with sensitivity to gold salts.


Endoscopic evaluation of the effect of azapropazone on the gastric mucosa. The gastro-intestinal tolerance of azapropazone, a new non-steroidal anti-inflammatory agent, was studied endoscopically in 14 volunteers with no past history of gastro-intestinal disease. This study shows that gastrointestinal tolerance to azapropazone given in a daily dose of 1200 mg for a period of 31 days is good. Istolated erosions with mild hyperemia were found in 2 subjects only. No subjective symptoms were noted during the period of the study.


Tissue atrophy and subcutaneous edema of the rheumatoid hand. A roentgenographic study of soft tissues. Soft tissue radiography of the hands using a mammographic immersion technique was performed on 119 patients having definite or classical rheumatoid arthritis and on 123 controls of matching age, sex and professional distribution. The grade of soft tissue atrophy in the hands was visually estimated from the radiographs and the combined cortical thickness of the second metacarpal shaft and skin thickness of the lateral side of the hand were measured. The stage of chronic edema in the absence of synovitis was estimated. Local bone cortical thickness and skin thickness have a highly significant correlation to the estimated atrophy grade. Soft tissue atrophy of hands is a sign which appears in chronic rheumatoid arthritis, especially in elderly females and has a clear correlation to the number of other irreversible radiographic signs in the hands. The incidence of moderate or advanced atrophy was 21% in rheumatoid patients. Chronic edema was found in 16%, mostly in connection with atrophic changes. A lymphatic origin of this sign is suggested.


Psychological aspects of rheumatoid arthritis vis-à-vis osteoarthrosis. Using objective techniques (M.M.P.I; M.H.P.A.; ANAM; S.T.A.I.), a transverse investigation of two groups of arthritic patients (35 rheumatoid arthritis and 30 oesteoarthrosis) was carried out. The Rheumatoid Arthritis (RA) patients evidence greater depression (p less than 0.02), while the osteoarthrosis (OA) patients had higher levels of manifest aggressivity (p less than 0.01) and more somatic preoccupation (p less than 0.02). The RA group had a higher incidence of loss of a family member as a preceding life event (p less than 0.05), and a greater incidence of psychopathological problems in infancy (p less than 0.05). These findings were used to construct an interpretative hypothetical model which represents a starting point and a stimulus for future research.


Pulmonary functions and responses to exercise of patients following cranio cerebral injury. To assess the causes of excessive fatigue among patients who have recovered from cranio-cerebral injury (CCI) nineteen patients and fourteen healthy controls underwent pulmonary function testing at rest and cardiopulmonary evaluation during two submaximal exercise work-loads. Total lung capacity, vital capacity and forced expired volume were reduced by 25--40% among the patients. Functional residual capacity was normal. No improvement was elicited by inhalation of Ventolin and bronchoconstriction could thus be excluded. The above pattern may result from either decreased compliance of the chest wall or from weak (or non-coordinated) respiratory musculature. Exercise heart rate, minute ventilation and ventilatory equivalent were higher, and O2 pulse lower, among the CCI patients compared with the controls. This indicates lower circulatory and ventilatory efficiency during exercise among the patients, possibly due to habitual hypoactivity and detraining.


The physical, psycho-social and vocational effectiveness of a sheltered workshop for brain-damaged war veterans. This two-year investigation of the rehabilitation effectiveness of a sheltered workshop for severely brain-damaged war veterans who had been deemed non-feasible for the Ministry of Defense's usual rehabilitation services, included: (a) a multi-disciplinary staff, (b) adapted jobs, (c) client involvement in workshop management and maintenance, (d) client earnings and (e) social activities. Brain-damaged war veterans from the Tel Aviv area constituted the experimental group. Persons with similar neurological impairment, cognitive, emotional disabilities and social handicaps constituted the control group. In interviews at the beginning and end of the research period, the rehabilitation workshop members and the families expressed a significantly greater increase in satisfaction with a variety of major life activities than did members of the control group and their families. It would appear that sheltered work can increase the brain-damaged persons' satisfaction with major life activities by ameliorating the personal, social and vocational dysfunction that accompanies and aggravates the consequence of brain damage.


Dynamic features of standing and their correlation with neurological disorders. Standing posture is a result of complex activity of the human control system. Irregularities of postural control may be expected to result in deviations from normal standing. In the present study a ballistic monitoring technique was employed to establish criteria for assessment of postural disorders. Two "Kistler" force plate dynamometers were used to measure changes in the weight bearing components of each foot and displacement of the center of pressure of each foot. The patterns were analysed separately, and it was found that each of the monitored parameters demonstrated three modes of oscillation--termed Tremor, Ataxia and Sway. Statistical analysis conducted on three groups of subjects (normals, post-C.V.A. hemiplegics and brain injured) revealed significant intergroup differences in movement patterns. Good agreement was found between the interpretation of the ballistic features and the clinical diagnosis.


Dynamic load in the human knee joint during voluntary active impact to the lower leg. The aim of the study was to get an insight into the nature of the dynamic load in a joint caused by impacts of physiological magnitude to the distal part of an extremity of normal, live human subjects. A method was developed for the calculation of two components of the impulse reaction (parallel and perpendicular to the lower leg) as a measure of the dynamic load in the knee. A theoretical model regarding the lower limb as a double pendulum was chosen and equations developed. Five subjects were studied during kicking situations and the components of the impulse reaction were calculated. With a normal kicking motion pattern the direction of the components of the impulse reaction in the knee joint caused by the impact to the lower leg are usually distal and anterior. The impulse reaction thus tends to cause a traction of the lower leg from the thigh and an anterior displacement of the proximal part of the lower leg in relation to the distal part of the thigh. Anatomical structures which can prevent this displacement are discussed.


Knee muscular moment, tendon tension force and EMG during a vigorous movement in man. With injuries to the components of the extensor apparatus of the knee as a background, it is interesting to investigate the magnitude of forces acting on these components, i.e. m. quadriceps femoris, the quadriceps tendon, patella, lig. patellae and tuberositas tibiae, during a vigorous but physiological movement. By means of the dynamic laws of mechanics the muscular moment of force with respect to the bilateral knee axis during kicking was calculated in 6 normal subjects. It was found that the maximum extending muscular moment in the knee occurs very early in the movement, when the initial flexion changes into extension, and thus long before the ball is hit. The peak of quadriceps EMG activity coincides with maximum moment. The EMG peak of the antagonistically acting hamstrings comes later, nearer to when the ball is struck. The greatest extending muscular moment obtained during the swing phase of kicking was surprisingly high, 260 Nm, corresponding to a tension force in the patellar tendon of 5200 N or about 7 times body weight. These values are discussed in relation to tendon strength.


The population study of women in Göteborg 1974--1975--the second phase of a longitudinal study. General design, purpose and sampling results. A study of a population sample of women in Göteborg aged 38--60 years was carried out in 1968--1969. This population sample has been re-studied during the years 1974--1975. Altogether 1302 women participated in this second study, which means 89.1% of those studied in 1968--1969 and 80.3% of those initially sampled. Twenty-six women had died during the interval between the two studies, more than half of them from neoplastic disease. Information is given about those who had moved or were inaccessible at the time of the second study or who refused to participate. The performance of the examination is described and research projects are outlined.


A survey of criminal homicide in Nigeria. Reports on 500 cases of murder were extracted from the case records of the Federal Supreme Court of Nigeria. Offenders were nearly always men and the victims were males in 64% of cases. The weapons were most often machetes or cutlasses. The killer and the victim were often related or were friends; only 8% were strangers. In 42% of cases, financial motives were involved.


Some aspects concerning admittance to and accommodation in geriatric institutions housing persons with varying degrees of need for care. On the basis of an account of the mortality and changes in the need for care over a 2-year period among independent persons and patients requiring care in De Gamles By, Copenhagen, an assessment is made of the movements of patients and the need for care in a model of a geriatric institution. This model includes both purpose-built residential apartments for independent persons and places for dependent patients requiring nursing care. It is shown that the accommodation for the latter patients rapidly becomes occupied by the independent persons from the residential apartments who subsequently need nursing care. Thus, the places in the nursing section are blocked for the admittance of dependent persons living in the community outside. This situation arises when there are equal numbers of both types of accomodation. Where the number of residential apartments is greater than the number of places in the nursing section the care function must be transferred to the residential apartments, and this is regarded as impracticable.


Minimum variability in the need for care in geriatric institutions. Based on an account of the need for nursing care in the entire patient population in De Gamles By, Copenhagen, on January 15, 1967, and again on January 15, 1969, it is shown that the need for care varies considerably, despite a policy of admitting only independent persons. The consequences of this variability for the size of the nursing staff required are discussed, together with some aspects of admittance policy.


A new method for investigating the relation between change and initial value in longitudinal blood pressure data. I. Description and application of the method. The relation between change and initial value is of great interest in longitudinal studies. With variables containing random errors (short-term intra-individual variations and measurement errors) the directly computed relation is however, biased by the regression towards the mean phenomenon. Earlier proposed solutions of the problem are unsatisfactory. In this paper the regression towards the mean phenomenon is described and a new method is proposed by which the error caused by the regression towards the mean is avoided. The method is applied to a set of longitudinal blood pressure data. It is shown that the observed, biased relation in this case is significantly negative, while the correct relation obtained with this method is significantly positive. Since random errors are present in most biological variables, similar erroneous conclusions may easily be drawn also in other cases if the regression towards the mean phenomenon is not corrected for. In this analysis, random errors constitute 65--80% of the observed blood pressure change. To reduce this dominance, recommendations about study design for future studies of change/initial value relationships are given.


[Should patients with portal hypertension undergo surgery?]. There is a noticeable similarity between the surgery of cancer and that of portal hypertension secondary to hepatic cirrhosis. The problems associated with the basic disease and with the surgical techniques used for its treatment are such that therapy should be determined by selection criteria, both when bleeding occurs and between bleeds. Highly experienced internists and surgeons are required and it is therefore advantageous if portal hypertension patients are referred to and concentrated in a small number of specialist centers. There the decision to operate should continue to be based on predetermined criteria, bearing in mind the patient's basic disease. If cirrhosis is in the foreground, as is so often the case, long-term social care should receive greater emphasis than hitherto in planning postoperative management.


[Clinical approach to the diagnosis of persistent diarrheas]. The differential diagnosis of chronic diarrhea is often difficult and necessitates a two-step evaluation: (1) classification as to the clinical type of diarrhea (accelerated transit time, lesional, metabolic); (2) once the type of diarrhea is ascertained, search for the causative factor. The clinical classification is within the general practitioner's capability, whereas step two is more a matter for the specialist.


[Pathology of colonic polyps].

[Pathology of colonic polyps]. Recent developments in the field of polyps of the colon are discussed. The WHO classification represents a definite improvement. Apart from standardization, non-neoplastic polypoid changes of varying etiology and hamartomatous polyps are clearly distinguished from neoplastic, non-malignant adenomas. The various changes are outlined briefly in their essential characteristics. Clear-cut differentiation from early invasive cancer is of considerable importance for practical therapeutic purposes. Focal carcinoma within an adenoma is referred to only if invasion through the muscularis mucosae is established, while all other changes confined to the mucosa are termed adenomas with focal epithelial atypia. With regard to the relation between adenoma and cancer of the colon, recent results on topographical distribution of adenomas through the colon are of considerable significance. From serial studies of biopsy and autopsy specimens on the one hand, and from assessment of colon carcinoma incidence compared with mortality rates in carcinomas of different localizations on the other, it is evident that special attention should be given henceforward to adenomas, possible precursors, and carcinomas in the upper segments of the colon.


[Double-contrast radiologic examination of the colon and rectum]. Double contrast (DC) barium enema is used at many centers as a routine technique for examination of the colon. However, simple contrast enema remains an efficient alternative easy to perform. DC may be performed in a direct manner in a single operation. The contraindications are few (severe colitis, risk of perforation). DC has proved advantageous for detection of polyps and study of inflammatory diseases of the colon. In granulomatous colitis in particular, it contributes to better analysis and differential diagnosis of the lesions, and surveillance of their evolution.


[Chlamydia peritonitis: a disease of young females]. Serological evidence of recent infection with Chlamydia trachomatis was found in 9 of 11 young women with acute peritonitis or perihepatitis proved by laparoscopy. High antibody titres to chlamydiae without laboratory evidence of gonococcal infection were present in 5 of these 9 patients, while the other 4 had evidence of simultaneous gonococcal infection. C. trachomatis may play an important part in peritoneal inflammation previously attributed only to gonococci.


[Arteriovenous fistulae following liver puncture biopsy]. 5 cases of arterio-venous fistula secondary to needle biopsy of the liver are reported. In 4 cases the lesion was a chance radiologic finding during arteriography and did not require a surgical procedure. In two cases spontaneous closure of the fistula was demonstrated by a second arteriography. Only in the fifth case did development of portal hypertension require a surgical procedure, ligature of the right hepatic artery being performed.


[Comparison of the biliary excretion of the radiographic contrast media Iotroxamate and Ioglycamide in the dog]. Biliary excretion of iotroxamat (ITX) and ioglycamide (IGL) in cholecystectomized dogs fitted with a Thomas duodenal cannula is compatible with saturation kinetics exhibiting maximal excretory velocities of 2.23 +/- SD 0.18 and 1.22 +/- 0.19 mumol/min/kg, respectively. While biliary excretion of ITX obeyed classical Michaelis Menten kinetics, the data obtained with IGL suggested a more complex process. The choleretic effects of both contrast agents (23.6 +/- SD 2.29 and 25.8 +/- 2.21 microliter of excreted substance) were comparable. On the basis of these results and in view of the similar toxicity of the two contrast agents in animals, it may be expected that ITX will have advantages over IGL for intravenous cholangiography.


[Volvulus of the colon].

[Volvulus of the colon]. Twenty-two cases of volvulus of the colon are reported. The conservative and surgical methods of treatment are discussed. It should be emphasized that a preliminary X-ray study of the colon with Gastrografin is necessary to identify the nature and site of obstruction and any associated lesions.


[What is the contribution of colposcopic polypectomy?]. Coloscopic polypectomy saves patients with polyps of the colon from diagnostic laparotomy and also serves for the diagnosis and in the majority of patients even therapy of early colonic cancer. Complications are rare and most can be controlled by endoscopy. Recurrences of the polyp are possible, and therefore, follow-up is necessary.


[Conservative therapy of acute ulcer hemorrhage using somatostatin. Pilot study]. Somatostatin (SST) infusion was used to treat severe upper intestinal hemorrhage in 10 patients with peptic ulcer disease. Bleeding ceased in all patients 4-8 h after start of infusion. In one case bleeding recurred when SST infusion was discontinued; SST was given again and the hemorrhage definitively halted. Another patient suffered a recurrence while under SST infusion and had to be operated upon. SST appears to be effective in controlling hemorrhage from peptic ulcer, though further studies are required.


[Effect of somatostatin on the endogenous release of secretin and pancreatic polypeptide in the dog]. In dogs with chronic duodenal and gastric fistula the effect of somatostatin (SST) on the endogenous release of secretin and pancretic polypeptide (PP) was investigated. The release of secretin following intraduodenal acid administration was significantly reduced by SST. While PP increased significantly after a test meal, its release was completely suppressed by SST.


[Radiotherapy of esophageal neoplasms. Review of the 1st post-therapeutic year]. The first post-therapeutic year in 33 patients with esophageal cancer treated by radiotherapy alone is analyzed. Effectiveness of treatment was measured by clinical symptoms, radiological findings, and autopsy results. Out of a group of 33 patients, 36.4% showed no subjective or objective symptoms 1 year after commencement of therapy. Based on our own experience and the literature, the concept of therapy in esophageal cancer is discussed.


[Contribution to the formal pathogenesis of the classical seminoma. Early diagnosis from testicular biopsies?]. 13 cases of seminoma of the testes were investigated in detail by means of light microscopy using paraffin and semithin sections. Paraffin sections were the basis for diagnosis, therapy, and prognosis. In semithin sectins, even individual seminoma cells within the seminiferous tubules were recognized by characteristic cytological features. In semithin sections also the development of the solid tumor from intratubular seminoma cells was elucidated. On the basis of our findings, the following concept of seminoma spread may be advanced: intratubular seminoma cells invade the lamina propria and gain access to to the interstitial tissue. Subsequent to the migration of seminoma cells, the tubules are smaller in diameter and contain only Sertoli cells. The seminoma cells in the interstitial tissue increase in number and build up the solid tumor.


[Internal medical accidents during cross country skiing. Deaths and hospitalizations in the Upper Engadine]. Between January 1975 and March 1978, 15 cases of sudden death or hospitalized medical emergencies occurred during cross-country skiing in the Engadine region, comprising 3 sudden deaths, 9 myocardial infarctions, and 3 neurovascular accidents. The total number is small as compared to the number of people practising this sport. Among participants of the Engadine Ski Marathon, the incidence was 1 emergency per 40,000 skiing hours and 1 death per 120,000 skiing hours. Patients suffering from myocardial infarctions were all vacationers  from lower altitudes, in most whom several risk factors were present. Two cases of cerebrovascular accident demonstrate that competitive cross-country skiing may impose enormous stress on the cerebrosvascular system even in well-trained individuals.


[Postoperative reflux gastritis].

[Postoperative reflux gastritis]. Postoperative reflux gastritis is generally considered a definite clinical syndrome. It is the possible sequel to any gastric surgery suppressing pyloric continence. Incidence of this complication is still difficult to evaluate, whereas enterogastric reflux is often seen during endoscopy. 75 patients were studied clinically and endoscopically, and their gastric mucosa histologically, after gastric surgery. Results were compared to those in a 2nd group of patients whose reflux induced symptoms had been brought under control by endoscopically confirmed surgical correction of reflux. Enterogastric reflux is common (80%), but its effect on the gastric mucosa is observed endoscopically only when it is relatively marked (69%). Clinical suspicion of reflux gastritis is most often confirmed by endoscopy, but endoscopic reflux gastritis is symptomatic in only half of patients undergoing surgery. Foveolar hyperplasia is the only histological criterion related to reflux gastritis.


[Clinical application of the radiolabeled bile salt tolerance test]. The labeled bile salt tolerance test is the measure of the decrease in plasmatic radioactivity after intravenous injection of carboxyl-14C-labeled chenic acid. The label is distributed in the blood, taken up by hepatocytes and then secreted in the bile. The decrease in plasmatic radioactivity during the 4 h following the injection follows a bi-exponential curve. It has been studied in 6 normal subjects, 4 patients equipped with "T tube", 3 cases of acute viral hepatitis, 4 cases of hepatic steatosis, and 6 cases of hepatic cirrhosis. The first slope (b1) represents the hepatic uptake of the label. It is lowered in cases of viral hepatitis and in cirrhosis. The second slope (b2) represents hepato-biliary secretion of the label. It is lowered in patients equipped with a "T tube". From 100 min after the injection, the plasma concentration of radioactivity remains constant. This is the residual value (R), and it is very low in normal subjects. It is increased in cases of acute viral hepatitis and cirrhosis, indicating displacement of a fraction of the bile salt pool into peripheral blood. After a standard meal, the R value is not modified in the normal subject. In cases of steatosis and cirrhosis, a temporary peak may be seen, indicating recirculation of the label towards the periphery due to a porto-systemic shunt or a hepatocyte lesion.


[Correlations between inflammatory activity, immunoglobulins and complement components in the synovial fluid of patients with rheumatoid arthritis and arthrosis]. In 81 synovial fluids (39 from rheumatoid arthritis and 42 from osteoarthritis patients), levels of IgG, IgM, IgA, and complement components C3, C4, and C3-proactivator were estimated. Lactatedehydrogenase (LDH) was used as the parameter of inflammatory activity. With increased LDH activity, the concentrations of all immunoglobulins rose in both groups. In the complement components, this positive linear correlation was demonstrated only in the osteoarthritic group. In rheumatoid arthritis, the results were best demonstrated by means of a regression type curve of the 3rd degree (p less than 0.01). In low inflammatory activity there was a rise in the level of the complement components. With higher LDH activity (greater than 500 U/l), however, there was a drop in the curve and the positive correlation changed to negative.


[Drug induced agranulocytosis. Improved prognosis due to better supportive care]. A retrospective study of 61 episodes of agranulocytosis observed in 56 patients between 1958 and 1977 is reported. The diagnosis was based on peripheral granulocyte counts below 500/mm3 and further documented by bone marrow analysis. The aim of this study was to determine whether the new guidelines for supportive care introduced in January 1973 led to an improvement in overall prognosis in this disease. Therefore, the patients were divided into two groups: the first group included 39 episodes of agranulocytosis observed between 1958-1972 and the second group 22 episodes observed between 1973-1977. Standard supportive care administered in the latter group included reverse isolation (hand-disinfection and gown-change before patient contact, conventional hospital single room), the immediate initiation of an appropriate combination of antibiotics in infectious states and additional granulocyte transfusions in selected cases. The two groups compared were similar as to the extent of neutropenia and the frequency of severe infectious complications. On the other hand, patients of the first group showed more advanced recovery of myelopoiesis as compared to the second group at the time of hospital admission. Death due to infection was observed in 36% of episodes in the first group, but only in 9% in the second group. The supportive care introduced in 1973 thus appears to improve the prognosis of agranulocytosis to a substantial extent.


[The bronchospasmolytics salbutamol, fenoterol, terbutaline and reproterol. Their effects and side effects in asthmatics after inhalation with an electric nebulizer]. A double-blind crossover trial was conducted in 10 asthmatic patients for comparison of fenoterol with salbutamol, in 12 other asthmatic patients for comparison of reproterol with salbutamol, and in 15 other asthmatic patients for comparison of terbutaline with salbutamol. The following doses were given: 1.25 mg fenoterol, 2.5 mg reproterol, 2.5 mg terbutaline and 1.25 mg salbutamol. 5 drops of each of the inhalation solutions (in 2 ml of saline) were aerosolized by a powered machine and inhaled for 15 min. FEV1 was measured before, and 15 and 45 min after inhalation. Immediately before FEV1 the following parameters for side effects were also determined: 1. heartbeats per min, systolic and diastolic blood pressure; 2. minute ventilation, arterial PCO2 and oxygen consumption; 3. arterial SO2, PO2 and the alveolar-arterial O2-gradient (AaDO2). To estimate the selectivity of each of the 3 betastimulators the ratio (formula: see text) was established for each parameter and compared to that obtained with salbutamol. In further steps the ratio of all parameters for side effects was shown, then only that of the 3 most important side effects tachycardia, hypocapnia (PaCO2) and hypoxemia (PaO2). The following order of selectivity was found: 1. salbutamol, 2. fenoterol, 3. terbutaline, 4. reproterol.


[Familial mesomelial dwarfism (Nievergelt syndrome)]. Familial mesomelic dwarfism was first described in 1944 by K. NIEVERGELT, who reported on a father and 3 sons by 3 different mothers who had shortening of the middle segment limbs. in the present study the family described by NIEVERGELT in 1944 is reevaluated and the mode of inheritance investigated over a period of 3 generations. Six patients with mesomelic dwarfism were found out of 43 family members. Two patients, a son of the first patient with mesomelic dwarfism and his son, were seen at our institution. Both presented a rare deformity-combination of the upper and lower extremities. In the upper extremities radio-ulnar synostosis, asymmetrically shaped elbow joints, subluxations of the radial head and a deficient supination capacity of the forearm were diagnosed. The deformities were nearly symmetrical, but a slight predilection for the left forearm was noted. In the lower extremities atypical club-feet with supination of the forefeet, shortening of tibia and fibula and marked synostosis of tarsal and metatarsal bones were seen. The legs were rhombic and supination and pronation of the forefeet were severely reduced. Synostosis of the tibia and fibula and deformities of the toes were found in both patients. The mode of inheritance was considered to be autosomal dominant with high penetrance. It is concluded that familial mesomelic dwarfism is an autosomal dominant disease of the upper and lower limbs with atypical club-feet, marked radio-ulnar, tibia-fibular and tarsal synostosis and deformities of the elbow joints.


[Prognosis and therapy of multiple myeloma]. Criteria for the diagnosis of multiple myeloma and differential diagnostic considerations are presented. The indications for treatment are discussed. Combination of melphalan or cyclophosphamide with prednisone may be considered standard therapy today. This produces objective tumor regression in 50-70% of patients. The parameters for determining remission and their significance with regard to survival and tumor cell mass are discussed. The importance of supportive measures is stressed. Persistent problems and potential for improving present therapy are discussed.


[Diagnosis of latent late infections following total hip replacement]. The etiology, diagnosis and elucidation of non-manifest late infection following total hip joint replacement surgery are discussed on the basis of 22 patients who underwent further surgery in our clinic due to an infected prosthesis from 1974 to 1976. Non-manifest late infection is usually the result of contamination of the hip before, during or after surgery; only in a few isolated cases can the infection be considered to have originated from the bloodstream. There is a higher risk of infection in patients who have undergone previous hip surgery. The principal symptom of late infection is pain; as a rule there are no other clinical signs of inflammation. The generally increased blood sedimentation rate is the only laboratory test of diagnostic value. An important aid is x-ray of the hip, in which the infection is manifested by osteitis and loosening of the prosthesis. Arthrocentesis should be carried out in case of doubt and when systemic antibiotic treatment is envisaged. Special diagnostic procedures such as arthrography and scintigraphy cannot be recommended for routine examination.


[Frequency of drug prescriptions and their adverse effects in a medical department]. The enquiries carried out in our unit since 1971, in some 1600 patients who received in all more than 13000 drug prescriptions and who were observed during 3 periods whose total duration was 12 months, prompt the following conclusions. The number of adverse reactions in which the relationship of cause and effect with one or several drugs was either definite or probable amounted to 217, 2--3% among patients at admission and 5--11% of patients during their hospital stay. The average number of prescriptions per patient remained stable and the average number of drug reactions per 100 prescriptions varied from 0.6 to 1.6. Severe drug reactions occurred in 1.1% of patients at admission and 1.1% of patients during their hospital stay.


[Are salicoyl-like analgesics vitamin K antagonists? An interpretation of spontaneous subnormal Quick values]. Prolonged spontaneous prothrombin time values (subnormal Quick values of between 50--70%), such as are encountered frequently in the clinical laboratory, are discussed. The reason for these abnormal values may be traced in part to the ingestion of salicoyl-like analgesics. Acetylsalicylic acid must be considered a low-acting oral anticoagulant which behaves like a vitamin K antagonist. In connection with the frequent use of this substance its interference with the plasmatic blood coagulation system should be considered.


[Abdominal computer tomography].

[Abdominal computer tomography]. In computer tomography of the abdomen the amount of diagnostic information obtained depends on the organ system examined and correlates with the topographical anatomy. The information gained by this non-invasive method results from the demonstration of contour alteration and from inherent density differences. Although at this point in time, while the process of evaluation is still in progress, it is too early to formulate definitive guidelines on the indications for computer tomography of the abdomen, we suggest, on the basis of experience hitherto, that computer tomography of the adrenals and the pancreas is better than the previously known image-producing diagnostic methods. The overall diagnostic value of computer tomography of the liver and spleen, depending on the pathology in question, is apparently at least equal to sonography, nuclear medicine and angiography. Computer tomography of the gastrointestinal tract and the kidneys, when compared to other diagnostic radiographic and sonographic investigations, at present adds little information, and for this reason has limited application in these systems. In contrast to this is the highly instructive computer tomographic examination of the extrarenal retroperitoneal space.


Scottish health authorities revenue equalisation. A community medicine view of SHARE report. A working party was set up by the Scottish Home and Health Department to consider the system of allocation of money to health boards. The system advocated (SHARE Report) is predictable from the NHS structure and the analogous report (RAWP) in England. The Secretary of State has announced his decision to accept SHARE in general principle. In principle, the Report is to be welcomed as a first step toward rationalising the distribution of health service money. However, work already published suggests the assumptions in SHARE require examination. SHARE would encourage individual health boards to plan for their own populations although thereby the greatest improvement in health services in Scotland may not be achieved. The SHARE object of equal opportunity of securing access is open to various interpretations. Emphasis is laid on the recommendation in Report for a comprehensive examination of the inter-relationship of social circumstances (in particular, urban deprivation), morbidity and mortality.


Tourist hepatitis in the West of Scotland. During the 6-year period (1971-76) 971 patients were admitted with acute viral hepatitis to different infectious units in the West of Scotland. Of these, 30 (3%) patients had tourist hepatitis. The majority (80%) acquired the infection in the subcontinents of Africa and India or other tropical countries. The clinical spectrum of the illness in these patients ranged from mild to fulminant hepatitis. Fifteen patients were specifically asked about their immunisation history prior to their travel and none had immunoglobulin prophylaxis against hepatitis. Normal human immunoglobulin prevents clinical hepatitis A and should be given to all prospective travellers to Third World countries. In order to formulate a rational policy for prophylaxis, more data about the risk of contracting hepatitis in different countries is needed.


Need for reform in health professions accrediting. At least 50 vocational or professional groups, exclusive of specialties within categories, now provide a health service. Many have established accrediting procedures for maintaining educational standards, and the number is increasing. So great is the demand from the accrediting bodies that universities and academic health centers find that the cost in terms of money, time, and duplication of effort has become exhorbitant, and thereby a major problem in the management of educational institutions. The duplication of effort leads to fragmentation of the entire accrediting process, and this, in turn, fosters inadequate sharing of health professions educational experiences. A model is presented that would lessen the burden of accrediting on educational institutions and simultaneously permit testing of the feasibility of a multiprofessional accrediting mechanism.


Photoejection of electrons from flavins in polar media. Riboflavin and 12 of its derivatives have been shown to form solvated electrons under ultraviolet irradiation (253.7 nanometers) in various water-methanol solvent mixtures. The highest quantum yield of solvated electrons (about 0.03) was obtained for flavins containing tyrosine on a side chain in the isoalloxazine N-3 or N-10 position. The splitting of hydrogen atoms from excited flavin molecules was also observed. From the results presented here, it can be determined that the semiquinone transients are formed not only by way of the flavin triplet, as usually suggested, but also by the attack of the electrons and hydrogen atoms on flavin molecules in the ground state. This is important, because the flavin radicals remaining after the electron-ejection or hydrogen-splitting processes must also be considered in the subsequent reaction mechanisms. The electron-ejection process from electronically excited flavins has important implications in the photobiology of these compounds.


Left ventricular receptors inhibit brain serotonin neurons during coronary artery occlusion. Acute coronary artery ligation in pargyline-treated rats decreased serotonin and increased 5-hydroxyindoleacetic acid in the medulla and posterior hypothalamus. Lidocaine applied topically to the left ventricle completely prevented these alterations. No changes in serotonin were observed in the other brain regions examined. These data suggest a reflex inhibition of bulbar and hypothalamic serotonergic nerves by left ventricular receptors following acute coronary artery occlusion in the rat.


Cryoprecipitate reversal of opsonic alpha2-surface binding glycoprotein deficiency in septic surgical and trauma patients. Human opsonic alpha2-surface binding glyoprotein (alphs2SB-glycoprotein), a molecule having immunologic identity with an amino acid composition similar to cold-insoluble globulin, is concentrated in a cryoprecipitate of plasma. Septic surgical and trauma patients manifesting opsonic alpha2SB-glycoprotein deficiency and associated reticuloendothelial system dysfunction were treated by intravenous infusion of cryoprecipitate. This therapy restored circulating bioreactive and immunoreactive opsonin and improved their septicemia, pulmonary insufficiency, and duration of recovery. Cryoprecipitate infusion may offer a new approach to the treatment of septic injured patients in preventing multiple organ failure; measurement of immuno-reactive serum opsonic alpha2SB-glycoprotein may provide a noninvasive index of reticuloendothelial system function and patient status during servere sepsis that follows trauma.


Skin color and nutrient photolysis: an evolutionary hypothesis. Human populations native to areas of intense sunlight tend to be heavily melanized. Previous explanations for this relationship have invoked only weak selective pressures. To test the hypothesis that dark pigmentation may protect against photolysis of crucial light-sensitive vitamins and metabolites by ultraviolet light, folate was used as a model. It was found that exposure of human plasma in vitro to simulated strong sunlight causes 30 to 50 percent loss of folate within 60 minutes. Furthermore, light-skinned patients exposed to ultraviolet light for dermatologic disorders have abnormally low serum folate concentrations, suggesting that photolysis may also occur in vivo. Deficiency of folate, which occurs in many marginally nourished populations, causes severe anemia, fetal wastage, frank infertility, and maternal mortality. Prevention of ultraviolet photolysis of folate and other light sensitive nutrients by dark skin may be sufficient explanation for the maintenance of this characteristic in human groups indigenous to regions of intense solar radiation.


Terminal arbors of axons that have formed abnormal connections. Ther terminal arbors of individual retinogeniculate axons that have been induced to grow into an inappropriate geniculate layer have been revealed for light and electron microscopic study by being filled with horseradish peroxidase. After a unilateral ocular enucleation in kittens, single axons from the surviving eye show terminal arbors not only within their own geniculate layers but also in the denervated layers. The new, abnormal arbors arise from the terminal segments of arbors that lie within the nondenervated layer and make patterns of synaptic contacts that appear normal.


Lead exposure during infancy permanently increases lithium-induced polydipsia. Lead (200 milligrams per kilogram) was administered daily by intubation to Long-Evans rats on days 3 through 30 of life. Thirty to 180 days after cessation of lead administration, the lead-treated rats were consistently more polydipsic after lithium administration (2 millimoles per kilogram per day) than were pair-treated controls. Lithium increased the plasma renin activity equally in both the lead treated and the control groups. These data are evidence that there may be permanent neural changes induced by postnatal exposure to lead that are manifested by pharmacological challenge with lithium.


Human auditory frequency-following responses to a missing fundamental. Both a complex tone perceived as a 365-hertz "missing fundamental" and a 365-hertz pure tone evoked 365-hertz far-field frequency-following responses. Narrow-band masking noise centered at 365 hertz attenuated the responses to the pure tone but not to the complex tone. Results support the concept that perception of the missing fundamental is based on periodic neural activity.


Symbolic communication between two chimpanzees (Pan troglodytes). Through use of learned symbols, two chimpanzees accurately specified 11 foods by name to one another when the food item's identity was known by only one. They could not do this when denied use of the symbols. The chimpanzees then spontaneously requested specific foods of one another by name. Requests resulted in cooperative and reciprocal symbolically mediated food exchange.


Genetic basis of XX male syndrome and XX true hermaphroditism: evidence in the dog. Serological analysis of white blood cells from the members of a family of American cocker spaniels indicates that a form of abnormal sexual development, in which individuals with a female karyotype have testes or ovotestes, is caused by anomalous transmission of male-determining H-Y genes.


Stimulated DNA synthesis in frog nuclei by cytoplasmic extracts of temperature-sensitive mammalian cells. Cytoplasmic extracts of proliferating cells stimulate DNA synthesis in isolated nuclei of Xenopus laevis liver. When tested by the same assay, cytoplasmic extracts of resting cells are completely inactive. When cytoplasmic extracts are prepared from cell cycle-specific temperature-sensitive mutants arrestd in the G1 phase of the cell cycle by the nonpermissive temperature, they also fail to stimulate DNA synthesis in frog nuclei. The results indicate that, to stimulate DNA synthesis in isolated frog nuclei, essentially all information of G1 cells must be present.


Analysis of melatonin in human plasma by gas chromatography negative chemical ionization mass spectrometry. Three techniques have been used to measure human plasma melatonin: bioassay, radioimmunoassay, and gas chromatography--mass spectrometry (GC-MS). GC-MS is theoretically capable of the greatest specificity, but in general suffers from insufficient sensitivity. Negative chemical ionization, a new technique, provides a 150-fold increase in GC-MS sensitivity for electron-capturing compounds. Negative chemical ionization GC-MS permits routine measurement in human plasma of melatonin at a concentration as low as 1 picogram per milliliter.


Sex pheromone of the tsetse fly: isolation, identification, and synthesis of contact aphrodisiacs. Sex pheromones isolated from the cuticle of the female tsetse fly, Glossina morsitans morsitans Westwood, release mating behavior in the male fly at ultrashort range or upon contact with baited decoys. Three active components were identified as 15,19-dimethylheptatriacontane, 17,21-dimethylheptatriacontane, and 15,19,23-trimethylheptatriacontane. Chemical and biological comparisons show that the natural and synthetic compounds are identical.


Gentamicin-resistant gram-negative bacilli in hospital patients. Part II. In vitro aspects including susceptibility to tobramycin and amikacin. A study of 259 clinical isolates of gentamicin-resistant Gram-negative bacili (GRNB) has revealed 99,2% crossresistance with tobramycin and 6,9% with amikacin. Resistance to all 3 drugs is transferable in vitro. Simultaneous transfer of resistance to ampicillin, carbenicillin, cephalothin, tetracycline, chloramphenicol, sulphonamides, co-trimoxazole, streptomycin and kanamycin was shown to occur, emphasizing the potential for the selection of aminoglycoside-resistant organisms by the use of many other drugs. All GRNB studied were multiresistant. While amikacin should prove useful for those infections caused by GRNB which require treatment, care should be exercised in its use, to minimize the emergence of large-scale amikacin resistance.


The immune response in iron-deficient children. Isohaemagglutinin titres and antibody response to immunization. The primary antibody response of iron-deficient children to diphtheria and typhoid immunization was measured. In 5 children immunized with diphtheria toxoid, there was no increase in antitoxin titre. Of 8 children who were given typhoid vaccine, 6 showed an increase in Salmonella typhi O agglutinin titre. All the iron-deficient children had normal isohaemagglutinin titres.


The role of community paediatrics in South Africa. Community paediatrics in South Africa is concerned with helping to identify the factors that retard realization of the full developmental potential of the nation's children. It is also concerned with the removal of such blocking factors. Paediatricians familiar with the orientation and methods of community medicine are suited to this task, which involves: (i) co-operation with all health, education and welfare organizations concerned with child care; (ii) taking part in the education of all child care professionals; (iii) taking part in the planning and organization of child care services; and (iv) being concerned with clinical care, particularly at primary care and rehabilitative levels.


Double fractures of the spine--an indication for routine radiographic examination of the entire spine after injury. Routine radiographic examination of the entire spine in 103 patients with traumatic spinal cord injuries has demonstrated double fractures of the spine in 5 patients. The incidence, clinical significance and mechanism of injury are discussed. The danger of overlooking the presence of a second spinal fracture in the paralysed patient and thus putting the patient at risk of increased spinal cored injury is stressed. A simple system of radiographic examination is described and routine radiographic examination of the entire spine in all patients who have sustained spinal cord injury is advocated.


Vitamin B6 and aspartate aminotransferase activity in chronic liver disease. Serum aspartate aminotransferase (AST) concentrations are commonly determined to detect hepatocellular damage. However, discrepancies between serum AST values and histological signs of active liver damage sometimes occur in patients with cirrhosis. The enzyme AST requires pyridoxal-5-phosphate (PLP) (active vitamin B6) as a co-enzyme to express its activity. Since approximately 90% of patients with severe cirrhosis are vitamin B6-deficient, it has been suggested that vitamin B6 supplements given to these patients might cause an elevation of falsely low serum AST concentrations. Treatment of 8 vitamin B6-deficient cirrhotic patients with pyridoxine hydrochloride (50 mg intravenously twice daily for 1 week) increased their serum AST concentrations from 121 +/- 18 (mean +/- SEM) to 136 +/- 26 lU/l, while treatment of a second group of 9 patients with the active co-enzyme PLP increased AST concentrations from 118 +/- 17 to 146 +/- 20 lU/l. Neither of these increases was statistically significant. Plasma PLP increased from 2,4 +/- 0,7 to 18,5 +/- 7,6 ng/ml after pyridoxine, and from 3,3 +/- 0,7 to 27,0 +/- 6,2 ng/ml after PLP supplementation. It is concluded that B6 deficiency is unlikely to be an important determinant of serum AST concentrations in patients with chronic liver disease.


Polyposis coli. The clinical spectrum in adults. Four patients are reported, to illustrate the wide spectrum of colonic polyps which may occur in multiple form in adults. Included are unusual cases of metaplastic and juvenile polyposis. The subject is reviewed, and the need for accurate histological diagnosis is stressed. The possibility that the difference between familial adenomatous polyposis and Gardner's syndrome may lie merely in the degree of expressivity of the associated extracolonic features is discussed. Surveillance of these patients for peri-ampullary neoplasms in the duodenum is considered. The interrelationship between familial adenomatous polyposis, juvenile polyposis and colorectal cancer is discussed.


Value of the mandibular radiograph in familial polyposis coli. Familial polyposis coli and Gardner's syndrome have identical colonic manifestations. Recent evidence has shown that both conditions are associated with occult osteomatous lesions in the mandible. We present 3 patients from 2 families with familial polyposis coli who, in addition to the colonic lesions, also had occult osteomatous mandibular lesions. The value and practical application of radiography of the mandible as an additional diagnostic aid in familial polyposis coli are emphasized.


Changes in serum electrolyte levels during marathon running. Serum electrolytes were measured in 18 well-trained, experienced long-distance runners before and after a standard marathon run (42 km), during which they ingested no electrolytes. Their sweat losses and water deficits after completion of the marathon were also measured. In 12 of the subjects, the percentage change in plasma volume and in total circulating plasma electrolytes was determined. There was a highly significant fall in serum magnesium concentration, with an increase in both potassium and sodium levels. Changes in total circulating plasma sodium and chloride were closely correlated with alterations in plasma volume. On the basis of these observations, it is recommended that athletes drink an augmented volume of fluid during marathon running, irrespective of the prevailing weather conditions. Supplementation of potassium and magnesium is contraindicated during long-distance running. Salt intake is unnecessary during races over the standard marathon distance. Subjective evidence for glucose supplementation is presented.


Neonatal Listeria monocytogenes meningitis. A case report. The clinical presentation, bacteriological results, treatment, and outcome of Listeria monocytogenes meningitis in a newborn infant are described. The neonatal listeriosis was of the late-onset variety, and the infant survived the infection, but hydrocephalus, which necessitated operative relief, developed. Although 2 cases of Listeria meningitis have previously been described in South Africa, and opportunistic listeriosis is known to occur here, this is apparently the first documented case of neonatal listeriosis in this country.


Genetic and congenital disorders. Knowledge and attitudes of the public, nurses and medical practitioners in South Africa. Knowledge and attitude studies with regard to genetic and congenital disorders were carried out on White women (2 500), nurses (826) and doctors (61). The studies indicated the need for public education and improved medical and paramedical training in human genetics. Education and training in human genetics. Education and training programmes should highlight the theoretical background, practical applications and available facilities.


Haematocrit values and blood viscosity in the newborn infant. The haematocrit values in 51 babies were studied to observe the possible variations due to the method and time of sampling and to relate these findings to blood viscosity. A good correlation (r = 0,9536) between haematocrit values of warmed heel capillary blood and of central venous samples was found. Prediction of venous value from a known sample of capillary blood can be made using regression lines and 95% confidence limits. The correlation between venous and unwarmed blood samples from the heel is not as good. A central venous haematocrit value of 65% or greater gave a 100% risk of the infant's blood being hyperviscous. Hyperviscosity occurred in 71% of infants with a capillary haematocrit value of 65 - 68% but the figure rose to 81% when the peripheral haematocrit value was 68% or more.


Acrodermatitis enteropathica--a zinc deficiency state. Successful therapy with zinc sulphate is reported in 3 children suffering from acroedematitis enteropathica.


Nutrition rehabilitation in Transkei. An evaluation. Children and their guardians who had been admitted to the nutrition rehabilitation units at Holy Cross Mission and Rietvlei Hospitals, Transkei, were followed up at their homes between 6 and 14 months later in order to assess the condition of the children, the knowledge gained by the guardians, and the changes implemented by them at their homes. Factors influencing these parameters are analysed and recommendations are made arising from the results obtained.


Blood viscosity in the normal newborn baby. A viscometer was tested and the results were found to be accurate and reproducible for the ranges encountered in neonates. The viscosity was determined in 80 cord blood samples and the mean and 2 standard deviations (2SD) were calculated at each shear rate. Changes in viscosity increased from birth to 12 hours, and then gradually decreased over the next 72 hours. The results are in keeping with the accepted normal values in the newborn.


The bacteriology of chronic destructive pneumonia. Thirty-four patients with chronic destructive pneumonia (CDP) were investigated bacteriologically and mycologically; specimens were obtained by transtracheal aspiration, percutaneous lung puncture, and open lung biopsy. Anaerobes were isolated in the absence of aerobes in 1 case while specimens from 9 patients yielded aerobes only. In 16 patients both groups of organisms were cultured. Streptococcus viridans was isolated in 12 cases and fungi in 2 cases. Specimens from 8 patients were sterile on culture. All patients had been treated with various antibiotic combinations before specimens were taken. Aerobes, particularly Gram-positive cocci, and anaerobes probably play an important synergistic role in the pathogenesis of CDP.


Pulmonary function in normal children aged 11-15 years. Prediction equations is forced vital capacity (FVC), forced expiratory volume in 1 second (FEVi), maximum mid-expiratory flow rate (MMFR) and peak expiratory flow rate (PFR) have been derived from a study of 367 asymptomatic Caucasian and Coloured (mixed race) children, aged 11--15 years, who did not smoke. Significant ethnic differences were found in FEVi, FVC, FEVi/FVC, and MMFR/FVC, but not in MMRF or PFR. The practical and epidemiological value of these observations is discussed.


[Disseminated herpesvirus hominis infection. A case report]. A case of disseminated Herpesvirus hominis (type I) in a 23-year-old White man with widespread eczema is reported. The grave prognosis of this disease is stressed.


Gonadal dysgenesis in a phenotypic female with an XY chromosomal constitution. A phenotypic female with an XY karyotype and pure gonadal dysgenesis is described. Bilateral streak gonads may be found in patients with features of Turner's syndrome and also in phenotypic females without the somatic abnormalities described in Turner's syndrome. Mixed gonadal dysgenesis refers to the presence of a unilateral streak gonad and contralateral testis in a phenotypic female. Dysgenetic gonads are more liable to undergo malignant change, especially in patients with an XY karyotype, and in those with mixed gonadal dysgenesis. Laparotomy and removal of the dysgenetic gonads is indicated in patients with an XY karyotype. If a 46,XX chromosomal pattern is present, the malignant potential is probably less, but laparotomy is still indicated to enable a prognosis to be given regarding fertility.


Atrial fibrillation in acute pancreatitis. A report of two cases. Atrial fibrillation is one of the rarer cardiovascular signs complicating acute pancreatitis and may lead to diagnostic difficulties. Two patients who developed this arrhyrhmia during the acute phase of their pancreatic disease are described. Therapy was primarily directed at the pancreatitis and both patients reverted to sinus rhythm within 8 hours before recovering.


The magnitude of the asthma problem in Cape Town. The magnitude of the asthma problem in Cape Town, as reflected by cases presenting to a large hospital, is described. The need for better facilities to treat acute asthma and to provide supervised interval therapy is discussed. A plea is made for the more widespread use of well-established simple beside aids in the assessment of the severity of asthma and the response to therapy.


Oestrogen receptors in tumours of breast cancer patients. Oestrogen receptors were measured in the cytoplasmic fraction of tumours from patients with breast cancer. Receptors were detected in 48% of patients, and 52% showed no receptors. A follow-up study of a small group of patients on hormone therapy is reported.


In vitro enzyme activity of commercially available pancreatic enzyme extracts. An in vitro study was performed to measure the enzyme activity in commerically available preparations of pancreatic enzyme extracts. Particular attention was paid to lipase content, because lipase deficiency is the most clinically relevant enzyme deficiency. Individual preparations varied greatly with regard to enzyme content, and Cotazym and Viokase proved the most effective preparations of those tested.


The effect of oral magnesium chloride therapy on the QTc and QUc intervals of the electrocardiogram. The effect of magnesium, given orally as enteric-coated magnesium chloride tablets, on the ECG of 25 randomly selected patients was investigated. Each patient, who served as his own control, was given 4--6 tablets, each containing 0,5 g MgCl26H2O, at night for periods varying from 6 weeks to 2 years. Findings included (i) a statistically significant decrease in OTc and QUc intervals; (ii) a progressive shortening of QTc and QUc intervals with continuing therapy; (iii) reversion to normal of ECG abnormalities, especially of ST segments and T waves.


Length of survival after cardiac resuscitation in an intensive care unit. Seventy-four patients were admitted after cardiac resuscitation to a general intensive care unit; 19, of whom 14 were neurologically normal, were utimately discharged from hospital. It is suggested that elderly patients, those who have had prolonged resuscitation, and patients with a combination of hypothermia, coma, dilated pupils, and apnoea have a very poor prognosis. It is doubtful whether such patients benefit from admission to an intensive care unit.


Infection of the common bedbug (Cimex lectularius L) with hepatitis B virus in South Africa. A total of 1 368 bedbugs of the species Cimex lectularius L were collected mainly from huts in villages or on farms at 6 localities in the northern Transvaal. They were tested in pools of 10 for the presence of hepatitis B surface antigen (HBsAg). None of 20 pools from Pietersburg was HBsAg-positive, but 32 out of 120 pools from the 5 other localities were HBsAg-positive. Estimated infection rates per 1 000 bugs were 17,1 (Messina), 24,9 (Waterpoort), 28,4 (Letaba), 54,5 (Potgietersrus) and 67,0 (Louis Trichardt), with an overall rate of 30,6. Seventeen out of 57 pools of the engorged bugs (infection rate 34,8) and 14 out of 62 pools of the unengorged bugs (infection rate 25,3) were HBsAg-positive. These very high infection rates, even in unengorged bugs, suggest that C. lectularius could be a vector of hepatitis B virus in the Transvaal, and that the varying degrees of infestation could explain the markedly different HBsAg-positive frequencies previously shown in sera collected from different population groups in that province.


Unreduced obturator dislocation of the hip. A case report. A patient with a late unreduced obturator dislocation of the hip is reported and the literature reviewed. The diagnosis was confirmed by vaginal examination. An open reduction was necessary and it is suggested that this is best achieved through an anterior approach.


The significance of the tuberculosis infection risk and its application in Pretoria. The value of the infection risk index for the determination of the TB situation and for the planning and evaluation of specific control measures is discussed. From tuberculin studies performed on schoolchildren in Pretoria since 1972, the annual risk of contracting a TB infection or of reinfection has been determined for all races in Pretoria; it is 0,05% for Whites, 0,53% for Coloureds, 0,68% for Asians, and 0,64% and 1,05% for Blacks in Atteridgeville and Mamelodi respectively. A downward trend of the risk could be shown for all population groups.


Prevalence of Toxoplasma antibodies in Southern Africa. An indirect fluorescent antibody survey of the prevalence of Toxoplasma antibodies was carried out on sera from 4 regions of Southern Africa (Natal, Eastern Cape, Western Cape, and South West Africa and Botswana). The overall prevalence of seropositivity at a titre of 1/16 or higher was 20% (of 3379 sera tested), the highest prevalence occurring in Blacks (34%) and Indians (33%) of Natal, and the lowest in San (Bushmen) (9%) and Whites (12%) of South West Africa and Botswana. Differences in prevalence in these areas, and between different ethnic groups, are discussed and compared with previous studies in Southern Africa. Climatic factors affecting prevalence and transmission are compared in relation to cyst and oöcyst survival. The marked differences in prevalence between the San (9%) and the Negroid Dama (27%), both inhabiting the arid Kalahari Desert, are discussed with reference to the lifestyles of these groups.


A community approach to trachoma control in the Northern Transvaal. Trachoma represents the largest single cause of preventable blindness in the Black population of the Northern Transvaal. Epidemiological and cultural considerations indicate the necessity of community involvement in trachoma control at the household level. Involvement of the community by means of groups of voluntary health workers (care groups) has proved to be effective and acceptable to the local inhabitants. These groups, who form part of the comprehensive health system, integrate trachoma control into the primary health care activities of the area.


Spina bifida and anencephaly in the Cape. In the first phase of a programme for the prevention of neural tube defects at a population level, information has been obtained concerning 285 infants born with open neural tube defects. As in other parts of the world, the months of conception of affected infants clustered in the second quarter of the year and the majority of the parents were members of lower income groups. In the years 1975-1977, the incidence of anencephaly and spina bifida in White South African patients was similar to that generally encountered in Western Europe. However, in the non-White populations the separate and combined incidence were significantly lower. It is emphasized that these are preliminary figures and that they might be subject to ascertainment biases.


[Aspects of the treatment of postoperative oliguria]. The importance and differential diagnosis of postoperative oliguria are discussed. A plea is made for the recognition of undesired postoperative antidiuretic hormone (ADH) secretion as a separate entity in the aetiology of postoperative oliguria. Five patients are described who suffered from postoperative oliguria and in whom the diagnosis of undesired ADH secretion was made. The successful treatment of this condition with diphenylhydantoin is emphasized.


Sterilization--the vaginal route revisited. With the use of strict selection criteria it was found that 86 of 161 women who required interval sterilization could be sterilized vaginally. The superiority of vaginal sterilization was demonstrated by the reduction in postoperative hospital stay (from an average of 5,5 days for abdominal sterilization to 1,8 days for vaginal sterilization). Febrile responses to sterilization were reduced from 53,5% to 18,6%, and major complications fell from 17,3% to 1,2%.


Delayed flow of patients in a Black hospital. Two hundred consecutive patients who were discharged from a ward in a Black hospital were studied with reference to delay of flow through a system. Problems are discussed, e.g. that of the young patient, admitted at night, who awaits radiography and investigations. Because he is unable to give consent, he must wait for an operation until appropriate staff and consent are available. He recovers, may have to wait for a surgical appliance, is discharged and may then have to wait several more days before relatives collect him. The unique problems in Black hospitals can be alleviated, inter alia, by departmental admission protocols, outpatient liaison education officers, more even distribution of medical manpower, improved hospital transport systems and overnight stay wards incorporated in a more active outpatient system to replace the present sorting system.


Inguinal hernia containing a paramesonephric (Müllerian) duct in an adult male. A case report. This article describes the extremely rare contents of a right indirect inguinal hernial sac in an adult male, namely a paramesonephric duct. Radiological investigation at operation by means of 'salpingography' demonstrated the connection of this 'uterus' with the prostatic utricle. 'Salpingohysterectomy' was performed. Sex typing of the patient determined him to be a male. His family history revealed siblings with intersex features; the prenatal determination of sexual identity is discussed and reference made to the fate of the mesonephric (Wolffian) and paramesonephric (Müllerian) remnant.


Lumbar puncture--an innocuous diagnostic procedure? The correct technique and indications for lumbar puncture are described. Possible and probable complications are discussed. The need for early recognition and consultation when complications arise is emphasized.


Porphyria variegata--studies of an affected couple and their children. Porphyria variegata affects approximately 1 in 200 Afrikaans-speaking people in South Africa. This paper reports the first case of a marriage between 2 people with porphyria variegata and describes investigations carried out on their 2 children, who do not exhibit any signs of the disease. The wife had suffered 1 miscarriage at 4 months' gestation.


Prevertebral soft-tissue swelling as a sign of undisplaced fracture of the odontoid process. Marked evanescent swelling of the prevertebral soft tissues has been found in 2 patients with undisplaced fractures of the odontoid process. In one patient the significance of the swelling was appreciated only in retrospect and after shift had occurred at the fracture site. The experience gained from this patient alerted the radiologist and the clinician so that any further damage could be averted in the second patient. All patients with head injuries require radiography of the cervical spine. Soft-tissue swelling anterior to the atlas should be viewed in a serious light.


Hepatic and renal amyloidosis in association with schistosomiasis. A case report. The association of systemic amyloidosis with schistosomiasis is rare. This report concerns a 47-year-old Black woman who presented with the nephrotic syndrome, with some unusual features. Ova of Schistosoma haematobium were seen in a rectal biopsy specimen, and amyloid material was shown in renal and hepatic biopsy specimens.


Health status among low-income elderly persons: rural-urban differences. This research compares the health status of low-income elderly persons in rural and urban areas. Using data from the Social Security Administration's 1973 national survey of low-income aged and disabled, the study demonstrates that the prevalence of many chronic disorders and impairments is significantly greater among the rural aged than for their cohorts in more urban areas. These differences persist after controls for age, sex, and race are introduced. No significant differences between rural and urban elderly were apparent in the utilization of health services. The determinants of chronic health status of the elderly have already occurred, by and large, and an explanation of disorders and impairments cannot be found by examining current sociodemographic status. Such an explanation is contained in the accumulated effects of years of residence in differing social, economic, and physical environments.


Colonic endoscopy in perspective.

Colonic endoscopy in perspective. Sigmoidoscopy is an easy procedure and should be utilized more frequently. Barium enema examination is incomplete without sigmoidoscopy. Flexible fiberoptic sigmoidoscopy may have a role in the detection of disease of the descending, sigmoid, and rectosigmoid colon. The necessity for its routine usage remains to be determined. The control of colonic polyps by colonoscopy has been the greatest contribution to date by the fiberoptic instrument. Colonoscopy has improved the accuracy of diagnosis of colonic disease and, in certain instances, is helpful in the early detection of cancer of the colon. Colonoscopy complements the use of barium enema examination. Colonoscopy only for the purpose of confirmation of clinical or radiological diagnosis is often unnecessary. While the benefits of endoscopy are obvious, there are definite practical and technological limitations to its use. Complications, although infrequent, are major. Indications for colonoscopy must be clear and findings interpreted with knowledge of the limitations.


Modern management of hemorrhoids.

Modern management of hemorrhoids. Hemorrhoids require therapy only when they cause symptoms. Early symptoms troubling the patient only occasionally are readily managed by dietary measures that increase the intake of fluids and fiber, such as bran, often supplemented by hydrophilic bulk-forming colloids, so that a bulky, soft stool is produced regularly. Rubber band ligation is the treatment of choice for small or moderate sized hemorrhoids with minimal prolapse, whether or not they bleed. Such bands should be applied to the mucosa at the anorectal junction and not directly to the hemorrhoidal tissue. Patients with large prolapsing or acutely thrombosed hemorrhoids are best managed by a closed type of hemorrhoidectomy. This technique is effective and safe and has great advantage with rapid healing and minimal postoperative care, which provides the patient with the maximum comfort. Complications are few and, in particular, anal stenosis or stricture is rare. Hemorrhoids occurring in association with other conditions require specific treatment only if they are responsible for symptoms in their own right, distinct from the associated condition. Other treatments discussed are effective but have particular disadvantages that make them unsuitable for routine use. Moreover, they offer no advances on the treatment regimens proposed.


Symposium on colon and anorectal surgery. Pruritus ani: a practical approach. Pruritus ani is a symptom of diverse cause and varied presentation which will respond in most cases to measures directed at keeping the anal area clean and dry. The role of the surgeon is to evaluate the patient to determine the status of the problem and to rule out threatening conditions, to educate the patient in his responsibility for continuing care and prevention, and to prescribe initial therapy to relieve symptoms. Follow-up evaluation is necessary to intensify treatment for the unresponsive patient, to diagnose further or identify the candidate for surgery, and to refer the patient with uncontrolled pruritus exhibiting a dermatosis for dermatological diagnosis and therapy. The crux of this practical management rests in the control of perianal moisure, the elimination of which gives an enfilading effect to therapy.


Anal eroticism.

Anal eroticism. A delineation of the medical problems associated with anal sexual eroticism has been presented. Our method of approach to both the patient and the various disease states has been described. Treatment of the most commonly encountered condition, condyloma acuminata, has been detailed. Precautionary measures to be taken and possible diagnostic pitfalls have been mentioned.


Exposure and manipulation of rectal lesions. The methods of treatment for benign tumors of the rectum are by local removal or local destruction. The benign status of the tumor must be determined histologically or by gross morphology before treatment is instituted. The approaches are either transanal or by posterior proctotomy. The following procedures have been employed with excellent results for the past 30 years at the Ferguson Clinic: (1) transanally, by local excision, local destruction, or snare removal; and (2) by the posterior proctotomy approach for benign tumors that could not be removed transanally because of size or inaccessibility. A "two scope technique" first devised in 1969 has been used with great success since.


Fibromuscular dysplasia of the cervico-cephalic arteries. Six cases of fibromuscular dysplasia of the cervical and cephalic portions of the internal carotid arteries, including their intracranial branches are reported. It should perhaps be pointed out that one of the cases was from the Sudan. As far as we know, the condition has never before been reported in a male African. The condition was associated with an intracranial aneurysm in four of our cases. To our knowledge only three autopsied cases of fibromuscular dysplasia involving intracranial arteries are on record. In our six cases the diagnosis was based on angiographic evidence, and three of the cases, two with intracranial involvement, were verified post mortem.


Glossopharyngeal schwannomas.

Glossopharyngeal schwannomas. Glossopharyngeal schwannomas are rare entities. Our recent experience with three such cases treated successfully, suggests that recognitton of this tumor as a discrete entity is both desirable and feasible. Although this tumor shares with the far more common acoustic schwannoma the presenting symptom of hearing loss, it may be distinguished by an elicitable history of hoarseness, demonstration of abnormal palatal function and absence of expected findings upons standard radiographic examination of the petrous bones and internal auditory canal. We have found that identification of this tumor may be accomplished with currently available diagnostic technics, including computerized tomography. The authors review the literature and report their experiences regarding preoperative assessment, operative technic and the postoperative course.


Traumatic bitemporal hemianopsia and diabetes insipidus. Bitemporal hemianopsia and diabetes insipidus are infrequently occurring complications of closed head injuries. Porter and Miller found 18 cases of posttraumatic diabetes insipidus among more than 5000 patients with nonfatal closed head injuries. Of these, five also manifested damage to the optic chiasm. In 1971 Laursen surveyed the literature regarding traumatic bitemporal hemianopsia and found associated diabetes insipidus in 26 of 50 patients for whom information on this was given. Both conditions were present in a patient seen at Walter Reed Army Medical Center.


Intracranial aneurysms in early childhood. A case of an aneurysm of the middle cerebral artery in a 17-month-old child has been presented and the literature on the problem reviewed. A total of 27 aneurysms in young children (under two years of age) has been found. The characteristics that define this group of patients are: a greater proportion of aneurysms of the middle cerebral artery and its branches and of the vertebrobasilar system; greater size of the aneurysms; and frequent pseudotumor syndromes. The surgical prognosis in this group of patients is excellent. The physical and pathophysiological characteristics of these aneurysms appearing in early childhood are described.


Computed tomography with giant intracranial aneurysms. Five patients with giant intracranial aneurysms were studied by computed tomography. Secondary intracranial changes such as hemorrhage, cerebral infarction and communicating hydrocephalus are easily demonstrated by computed tomography. In addition, computed tomography provides precise information concerning the actual size and location of large but partially thrombosed or calcified aneurysm to better advantage than angiography.


En bloc removal of large bilateral olfactory groove meningioma. With careful pre-operative angiographic evaluation, reversible intra-operative external carotid occlusion, controlled hypotension, steroids, osmotic diuretics, and early control of nutrient arteries, the en bloc removal of a large bilateral olfactory groove meningioma is feasible in some instances. Dissection around the tumor is facilitated by shrinkage of the tumor, as its nutrient vessels are occluded. Ligation and division of the venous drainage is left until the end. This technique may be particularly valuable in poor risk patients, as  it may considerably reduce blood loss and operating time, without sacrifice of brain.


Intimal dissection of the superficial temporal artery. Three patients who underwent superficial temporal-middle cerebral artery anastomosis demonstrated a dissection of the intima of the superficial temporal artery at operation. The fact that this abnormality had not been appreciated previously in surgical series and that it and other anatomical variants may account for "technical failures" of anastomoses is elucidated. The authors describe their successful technique for suturing the intimal flap.


Cervical hematomyelia as cause of death after mild head injury. A 55-year-old black man died the day after an automobile accident during which his forehead struck the car's windshield. He was not rendered unconscious. At routine autopsy no cause of death was found by the pathologist. Postmortem neurosurgical consultation disclosed hematomyelia and associated damage of the cervical spinal cord. Review of the literature disclosed that such changes in the spinal cord may be caused by hyperextension injuries of the cervical spine. These findings have been observed both clinically and experimentally. This report deals only with cases of "central cord" trauma without roentgenologic evidence of bony disruption.


Complete obliteration of a carotid cavernous fistula with sparing of the carotid blood flow using a detachable balloon catheter. A detachable balloon catheter system is described which has several distinct advantages over pre-existing methods of "intervention radiology". It is anticipated that further refinements in this technique will continue to expand the uses for this procedure.


Intracranial saccular aneurysms in the first three decades. To examine the characteristics of cerebral aneurysms in juvenile patients, 39 patients less than 30 years old were chosen from our 1,000 patients with saccular aneurysms who had undergone an intracranial operation on their aneurysm. The frequency, clinical features and surgical results in these young patients are discussed.


Emergency occlusive techniques.

Emergency occlusive techniques. Emergency occlusive therapy may be indicated in the management of acute arterial injury or expanding arteriovenous fistula. Intra-arterial occlusion may be performed at the time of diagnostic angiography. Selective placement of catheters permits percise diagnosis and management. We wish to report eight cases to demonstrate the efficacy of different occlusive agents. No adverse reactions were noted in this series of patients. We feel that emergency occlusive therapy is rapid and safe. It may facilitate and occasionally obviate surgical management.


Multiple intracranial aneurysms: identifying the ruptured lesion. The problems associated with the identification of the source of bleeding in multiple intracranial aneurysms are discussed, and the contribution towards diagnosis of each method of examination and investigation are evaluated, special emphasis is laid on the use of CAT scanning and electroencephalography as additional aids in localisation.