[Lateral ventricle tumors. (Part 2) -Neuroradiological analyses of 30 cases- (author's transl)]. In the first report, the clinical manifestations of 30 cases of the lateral ventricle tumor were reviewed. This report summarizes neuroradiological findings of the same 30 cases, in which 26 cases were examined by cerebral angiograms and 3 cases by CT scan. For the radiological analyses, the tumors of the lateral ventricle are classified into two groups, as follows: 1. Intraventricular tumors arise in the projection of the choroid plexus, the tela and the ependyma and grow in the lateral ventricle. 2. Paraventricular tumors arise from the wall of the neuroglia not only bulge into ventricle, but in addition infliltrate the substance of the surrounding brain. Following conclusions are obtained. (1) Unilateral hydrocephalus, which is shown clearly by vascular displacements in subependymal veins, is demonstrated in both tumors groups. (2) There are different findings on the feeding arteries, the draining veins and the tumor stains between two tumors groups. (3) In the intraventricular tumors groups, the anterior choroidal artery supplying the tumor is its the plexal segments and atrial segments. (4) On the other hand, the paraventricular tumors group, the anterior choroidal artery supplying the tumor is its the superior penetrating branch to the cerebral parenchyma. (5) Cerebral angiograms can reveal the definite signs of the intraventricular mass, but it is sometimes difficult to evaluate whether its space occupying lesions infiltrates the cerebral substance below the wall of the lateral ventricle, or not. (6) CT scan is useful neuroradiological method in the different diagnosis between two tumor groups, and CT scan provides and anantomical diagnosis rather than a histological one. (7) The accurate diagnosis of the tumors of the lateral ventricle can be demonstrated by both cerebral angiograms and CT scan.


[On-off mechanism of shunt system due to slit ventricle (author's transl)]. We report two cases of high shunt dependency, which were first thought to be shunt independent arrested hydrocephalus. Though their shunt systems didn't seem to work, symptoms of rapid increasing intracranial pressure were observed after obstruction or replacement of shunt tube. Their ventricles looked so small like a slit on CT scan and PVG that the apex of the ventricular tube were easily obstructed by a ventricle wall. This is the reason why we misjudged them to be shunt independent arrested hydrocephalus. The cause of slit-like ventricles was overflow of CSF fluid due to the low pressure valve and the siphon effect. In general, after the shunt operation, most of the cases with thickening of cerebral mantle show the shunt dependency. Especially the cases showing rapid and marked thickening of the cerebral mantle are highly shunt dependent. Therefore, we must observe such cases carefully, in which the ventricle becomes small. Short interval follow-ups by CT scan after the shunt operation are quite necessary in order to observe the ventricle size. Easy and reliable judging method to know whether the shunt system is working or not is required to be developed.


[Aneurysmal bone cyst of the skull -a case report- (author's transl)]. Aneurysmal bone cyst of the skull is rarely seen. There are 29 reported cases in the literatures as far as we could collect. We reported an additional case of aneurysmal bone cyst of the skull which originated from the right parietal bone of 4-year-old boy. We have summarized these 29 cases. The age incidence in this series is from 14 month-old to 31 year-old. There are 11 cases under the age of 10. In most cases clinical symptoms are palpable mass or headache and exophthalmos. Eyeball displacement and proptosis are also the symptoms when this disease occurs at the orbital roof. According to the characteristic radiographic appearance, it is "blown-out pattern with a shell of periosteal new bone over the mass or soap-bubble appearance". However in our case the radiological finding was osteolytic. It is possible to remove totally when this lesion occurs in the cranial vault, but only curettage may be performed when the skull base is involved. Total removal is the best treatment. Radiation therapy is usually done in the recurrent cases. It is necessary to follow up for at least 4 years because of the rarity of recurrence beyond 4 years after the initial treatment. We also described the other differential diseases and pathogenesis of this disease.


[The diagnosis of lumbosacral lipomeningocele by computed tomography (author's transl)]. A case of 2-month-old girl with lumbosacral lipomeningocele was reported. She was admitted for evaluation of a large soft mass in the lumbosacral area, initially noted at birth. On examination, the tumor was 7 cm in diameter and 3 cm in height. The upper part of a mass was cystic. Plain X-ray films revealed bifid lower lumbar and sacal vertebra. Spinal CT scans revealed a mass and bifid spine. An area with EMI units, 2.4+/-4.2, at L4 level and another with EMI units, -52.9+/-5.5, at L5 level were seen extending from within the canal to the subcutaneous tissue. The former was identified as water and the latter as fat. The preoperative diagnosis of lipomeningocele was made. Operation was performed under the operating microscope. A meningocele sac contained no neural element and it's surface was adhesive to lipoma. Lipoma involved cauda equina and conus medullaris in the canal. We removed the extraspinal lipoma with meningeal sac and a part of the intraspinal lipoma to avoid neurological deficit. We consider, like many authors, that intraspinal lipoma should be operated as early as possible with the help of surgical microscope. Early diagnosis is necessary. Myelography is valuable but caution is needed at time of lumbar or cisternal puncture. But spinal computed tomography is noninvasive and allows for precise diagnosis without contrast myelography. CT scan is extremely useful in diagnosing congenital abnormality of the spine.


[Actinomycotic brain abscess -case report- (author's transl)]. Actinomycosis of the central nervous system is rare. There has been considerable discussion as to whether it can be primary, but several cases have been reported occasionally. Authors presented a case of cerebral actinomycosis involving primarily the right frontal lobe through an obsolete stick wound. Patient is a 18-year-old man and when he was 8 years of age, he received right frontal penetrating injury due to fall on wire about 3 mm in diameter. Wound had healed sustaining any abnormal effect to note. Eleven years later, he was admitted to our institution because seizure attack characterized by automatism, and plain skull X-ray showed intracranial frontal calcification. EEG, angiography, RI scan and CT scan were performed. At operation, a granuloma was found and total removal was performed. The histological examination showed actinomycotic brain absess. Patient was treated with antibiotics and he returned to the previous occupation. Primary actinomycosis of the central nervous system was discussed with previously reported cases in the literature.


Concentration and metabolism of serotonin in selected brain areas during pregnancy and lactation in the rat. Serotonin (5-HT) and its major metabolite, 5-hydroxyindole acetic acid (5-HIAA), were assayed in hypothalamus, hippocampus, and cortex during selected stages of pregnancy and lactation in the rat. No changes in 5-HT were observed in any of the brain areas analyzed. However, concentrations of 5-HIAA in hypothalamus and hippocampus, though not in cortex, showed marked changes during the immediate postpartum period. The significance of these changes is discussed in terms of possible hormone-neurotransmitter relationships.


Effects of exogenous acetylcholine upon adrenal 17-hydroxycorticosteroid secretion of intact and head X-irradiated dogs. Adrenocortical response to exogenous acetylcholine (Ach) was investigated, under anesthetized conditions, in intact, hypophysectomized and head X-irradiated dogs. Intravenous injection of Ach (1 mg/kg b.w.) to intact dogs resulted in marked increases in the secretion of 17-hydroxycorticosteroids (17-OHCS) by the adrenal gland. The maximum response was seen at 10 min after the injection and a return to preinjection levels tended to occur by 60 min. This effect was abolished completely by hypophysectomy. In dogs whose heads had been irradiated with 200 and 1,000 R of X-rays 1 day previously, a considerably lower response to Ach was found; 17-OHCS output at the time when the secretion had been maximum was 44--53% less than that in non-irradiated dogs.


Evolution of vasopressin levels in the hypothalamo-posthypophysial system of the rat during rehydration following water deprivation. Correlation with ultrastructural aspects in the posterior lobe. Evolution of the (arginine)-vasopressin (AVP) content of the supraoptic (SON), paraventricular (PVN) and suprachiasmatic nuclei (SchN) and of the posterior lobe of the hypophysis (PLH) has been studied in rats at successive stages of rehydration after 4 days deprivation of drinking water. Particular attention has been focussed on short periods of rehydration. Evolution of the AVP content of the hypothalamo-posthypophysial system (HHS), the blood serum AVP concentration and osmolalities of serum and urine were compared. Variations of the AVP content in the different hypothalamo-hypophysial structures, are parallel. A marked depletion of AVP is observed after 2 and 4 days of dehydration. The AVP content of the PLH and of the hypothalamic nuclei shows two dramatic and short increases 15 min and 3 h after the onset of rehydration; these results are discussed in relation to the known physiological regulation mechanism of the HHS. In the PLH depleted by dehydration, reloading with neurosecretory granules (NSG) begins to be noticeable only after 24 h of rehydration, so that it does not seem to account for elevations of the AVP content occurring earlier. These could be related to a marked increase of the smooth endoplasmic reticulum (SER) network taking place in axons and nerve endings before the NSG reloading.


Biological and radioimmunological evidence for melanocyte stimulating hormones (MSH) of extrapituitary origin in the rat brain. The possible existence of extrapituitary melanocyte stimulating hormone (MSH) in various regions of the rat brain has been studied in intact and hypophysectomized rats. Using a sensitive and specific radioimmunoassay (RIA), alphaMSH has been found in a number of brain regions in intact rats. The standard curves of synthetic alphaMSH and the dilution curves for pars intermedia nervosa (PIN), pars distalis (PD), hypothalamus and thalamus extracts were strictly parallel. The alphaMSH concentrations were measured in PIN (6,225 +/- 962 ng/mg wet tissue); PD (12.5 +/- 1.41 ng/mg); pineal (380 +/- 29 ng/g wet tissue); hypothalamus (645 +/- 161 ng/g) and thalamus (33.3 +/- 5.26 ng/g). In rats hypophysectomized for 1 or 2 months, the highest concentrations of immunoreactive alphaMSH were found in pineal (353 +/- 140 ng/g wet tissue), hypothalamus (85.8 +/- 14.1 ng/g) and thalamus (39.8 +/- 13.9 ng/g). Hypophysectomy significantly reduced hypothalamic MSH content and concentration but did not alter MSH concentration in pineal and thalamus. From these results, we conclude that hypothalamic alphaMSH is, in part, of hypophyseal origin while pineal and thalamus alphaMSH does not originate from the pituitary. After Sephadex G-25 gel filtration, synthetic alphaMSH and PIN extracts showed a single peak of both bioactive and immunoreactive alphaMSH. In the same conditions, extracts from the 5 brain regions studied in hypophysectomized rats chromatographed as a single peak of immunoreactive MSH but as 2 peaks of apparent bioactive MSH, 1 concident with synthetic alphaMSH and the other far after the salt volume. We conclude that alphaMSH is found in a number of brain areas and its presence after hypophysectomy would indicate synthesis within the central nervous system.


Effect of adrenalectomy on temporal patterns of serum gonadotropin levels. To determine whether adrenocortical function influences rhythmic gonadotropin patterns in male rats, blood samples were obtained by rapid decapitation from control and adrenalectomized male rats at 3-h intervals over a 24-h period (14 h light/day, 4 a.m.--6 p.m.). Control animals showed periodicity in serum LH, prolactin (Prl) and corticosterone similar to that reported previously. Peak and trough serum levels of corticosterone and Prl occurred at 5 p.m. and 8 a.m. respectively whereas those for LH occurred at 11 p.m. and 11 a.m. Serum FSH levels did not vary with circadian periodicity. 15 days after adrenalectomy, serum LH levels continued to fluctuate with a circadian periodicity but showed a marked phase shift; peak LH levels were observed at 8 a.m. The absence of adrenal hormones did not result in altered FSH levels nor was the phase of the Prl rhythm significantly altered.


Effects of testosterone and orchiectomy on the development of gonadotrophs in neonatal rats with hypophysial stalk section. The development of gonadotrophs in newborn Sprague-Dawley rats subjected to a hypophysial stalk section (SS) by an electrical cauterization of the infundibulum of the hypothalamus was examined throughout the first 12 postnatal days. The electrical cauterization of the infundibulum was performed during 24 to 30 h after birth, and the pituitaries were studied by immunohistochemical procedures 11 days later. In several animals orchiectomy or an administration of testosterone propionate (TP) was performed simultaneously with the cauterization. The SS animals showed remarkable retardation in body growth and in pituitary development. In males the development of gonadotrophs was strongly suppressed in number and in size after the cauterization, whereas in females the suppression was less prominent. Orchiectomy promoted the development of gonadotrophs in the SS males, while TP administration suppressed it in the SS females. These findings indicate that there is sexual difference in the neonatal development of gonadotrophs even in the pituitary isolated from the hypothalamus and that testosterone inhibits the development of gonadotrophs at the level of the hypophysis during the neonatal period in rats.


Relationship between tachycardia, prolactin and growth hormone in conscious ewes. Brief episodes of apparently unprovoked tachycardia (increased heart rate, HR) lasting about 10--20 min were observed about one h after initiation of experimentation in 10 ovariectomized ewes which were fitted with indwelling vascular cannulae. The incidence of tachycardia episodes varied among ewes, but 99 of 215 (46%) sampling trials contained such an episode (mean HR increase = 34 beats/min). Approximately 30--40 min after maximum tachycardia when HR had returned to basal rates, both plasma prolactin (Prl) and growth hormone (GH) increased significantly from the nadir concentrations that had been observed around the time of maximum tachycardia and shortly thereafter. There were no changes in packed cell volume (PCV) and only brief changes in mean arterial blood pressure related to the tachycardia. There was a mild trembling behavior associated with many of the tachycardia episodes. The causes for the tachycardia are not known. Heparin administration did not seem to be involved, but physical stimulation inside the jugular vein, while not essential, may increase the incidence of tachycardia episodes.


Effects of age of blinding on rhythmic pituitary-adrenal function in female rats. These experiments were designed to study the effects of age of blinding on the circadian rhythm in pituitary-adrenal function in female rats. In the 1st experiment, the eyes were removed at 1 day of age and serial blood samples were obtained at 6-h intervals for 24 h at 45 days. In the 2nd experiment, rats were blinded at 1,26 or 60 days of age, and serial blood samples were collected at 4-h intervals for 44 h when the rats were 84, 112 and 142 days of age. Intact and sham-operated rats served as controls. Plasma corticosterone (cpd B) concentrations, measured fluorometrically, were used to assess pituitary-adrenal function. Blinding disrupted cpd B patterns in all groups on all occasions. However, steroid patterns of individual rats suggested the presence of free-running 24-h rhythms. This suggestion was supported by the results of aligning the steroid peaks of individual blinded rats. This procedure yielded group patterns of steroid levels which were comparable to those of controls. The periodic stimuli available to the blinded rats from intact rats in the same and adjacent cages did not synchronize this rhythm. These results suggest that the eyes and their central projections are not essential after birth for the development and maintenance of rhythmic pituitary-adrenal function; these structures appear necessary, however, for synchronization with light-dark cycles.


The development of the serum corticosterone rhythm in rats. The purpose of this study was to determine whether the sequence of changes that occur in the adrenal rhythm in maturing female rats (development of a peak, shift in acrophase and amplitude) requires experience with a photoperiodic stimulus or a change in ovarian status. The emergence of the serum corticosterone (CS) rhythm occured more quickly in adult rats placed in a 14 h light, 10 h dark (14:10) cycle at 50 days of age after rearing in constant light (LL) than in weanling rats placed in 14:10. Ovariectomy at weaning age did not alter the pattern of CS development in 14:10 although the amplitude of the peak was reduced even in 25-day-old rats. Adult rats reared in 14:10 held a population rhythm of CS longer after they were placed in LL than did weanling rats placed in LL. This difference was not dependent upon the presence of the ovaries since acutely and chronically ovariectomized (OVX) adult rats responded in a similar manner to adult controls. It can be concluded that the adrenal rhythm emerges as a function of age rather than as a result of a change in ovarian status. The capacity to synchronize serum CS to light-dark cycles develops in the absence of photoperiodic cues.


A characterization of the effects of pentobarbital on episodic LH release in ovariectomized rats. The effects of pentobarbital (PBTL) on pulsatile LH release in ovariectomized rats were studied and characterized. Unanesthetized rats were first bled continuously (50 microliter whole blood every 5-6 min) through indwelling right atrial cannulae for 1 1/2 h prior to PBTL injection (35 mg/kg). Animals were then bled for various periods of time during PBTL-induced anesthesia, as well as for 1 1/2-2 h after recovery of the 1/2 righting reflex. Whole blood was analyzed for LH by radioimmunoassay. PBTL administration initially inhibited pulsatile LH release for 1 1/2-1 1/2 h, after which episodic release resumed. For the remaining duration of anesthesia (3-3 1/2 h) episodic LH release was characterized by decreased mean blood LH levels, a decreased rate and magnitude of increase in blood LH levels for individual episodes, and a lengthened periodicity between pulses. However, though reduced, episodic LH release remained stable despite the continued influence of anesthesia. In the 1 1/2-2 h following recovery of the 1/2 righting reflex, only the periodicity of LH release returned to a pre-anesthesia interval. Mean blood LH levels and the rate at which blood LH levels changed during individual pulses remained reduced, and a slight fall occurred in the extent of the increase in blood LH levels during single LH episodes. The influence of PBTL on those brain regions responsible for controlling pulsatile LH release is therefore of longer duration than the effects of this anesthetic on central nervous system (CNS) areas, which when affected, results in loss of the 1/2 righting reflex.


Effects of pinealectomy of rams on secretory profiles of luteinizing hormone, testosterone, prolactin and cortisol. In a study of pineal gland influences on hormone secretory profiles, blood samples were collected at 20 min intervals for 26 h from 4 pinealectomized and 4 sham-operated rams which were subjected to a 14.5 h daily photoperiod. Plasma levels of luteinizing hormone (LH) and testosterone (T) underwent rapid pulsatile fluctuations in all rams. Pinealectomized rams produced more LH than the sham-operated rams and a similar trend was recorded for plasma T data, since T secretion closely followed that of LH. A nocturnal elevation of plasma prolactin (Prl) levels displayed by sham-operated rams was substantially abolished by pinealectomy. Also a rise in cortisol secretion during the morning hours recorded from 3 of the sham-operated rams was absent in 2 of the pinealectomized rams. The possible significance of the pineal gland in the regulation of secretion of these hormones is discussed.


Effect of pentobarbital on serum levels of LH, FSH and prolactin in long-term ovariectomized rats. The intraperitoneal (i.p.) administration of sodium pentobarbital (30 mg/kg) to long-term ovariectomized adult rats results in a prolonged depression of serum LH levels and in a biphasic decrease of serum prolactin (Prl) titers, but does not modify serum levels of FSH. Consequently, caution should be used when interpretating neuroendocrine results obtained in animals submitted to pentobarbital anesthesia.


Pattern of adenohypophyseal hormone changes induced by various stressors in female and male rats. Plasma modifications of adenohypophyseal hormones were investigated in groups of female and male rats stressed for 15, 30 min, 1, 2, 4 or 6 h, either by cold (4 degrees C), forced muscular exercise (FME), or immobilization. GH levels in both female and male rats were consistently decreased by the 3 stressing agents. Immobilization in the female and the 3 stressors in the male elicited an early secretory response of prolactin (Prl), while only in immobilized female rats plasma LH levels showed an early, short-lived increment. A more prolonged exposure to stress had an inhibitory influence on plasma Prl and LH levels in both sexes. FSH concentrations were not modified in females, but were decreased in male rats submitted to either one of the 3 stressors. In both male and female rats plasma TSH levels rose during cold exposure, while they were decreased by FME and by immobilization. Our data indicate that the character of the hormonal secretory response during stress is nonspecific. Indeed, to the exception of the specific stimulation of TSH release by cold, stress-induced hormonal changes are not related to the nature but rather to the intensity and duration of the stressing agent.


The effect of pinealectomy on the pattern of prolactin secretion in conscious freely moving male rats. Plasma prolactin (Prl) titers were determined by radioimmunoassay in conscious, freely moving male rats which had either had sham operations or had been pinealectomized. Values were determined during the day and during the night in animals on a reversed light cycle. During the day plasma Prl levels were low in both groups with small bursts and a tendency for greater elevation toward the end of the collection period at 17.00 and 18.00 h. There were only 2 significant effects of pinealectomy on these daytime values, one of which was a reduction in the elevation of Prl at 17.30 h. There were also more frequent very low values, less than 5 ng/ml, after pinealectomy. At night there was greater variation of plasma Prl in sham-operated rats and in general the animals showed a sudden elevation just prior to the time the lights were turned on. The values remained elevated for some time thereafter. After pinealectomy the elevation when the lights were turned on was slightly delayed and the responses were smaller in magnitude or even absent. There were significantly more high Prl values in the controls than in the pinealectomized animals in darkness and the area under the curve of Prl release, which was greater at night than in the daytime, was significantly lowered by pinealectomy.


Chronic intracerebral hematoma.

Chronic intracerebral hematoma. Twelve patients with chronic intracerebral hematoma are reported. This condition may be unrecognized as possibly being benefited by relatively simple diagnostic and therapeutic measures. The neurological symptoms and signs may be acute but may also be intermittent and progressive. The etiology is usually systemic hypertension, but trauma, coagulopathies, and obscure etiologies have been implicated. After diagnosis by computerized tomographic scan and/or arteriography, aspiration of the liquid hematoma usually results in improvement. It is hypothesized that recovery is hastened by removal of the hematoma. Often complete recovery ensues, but mild to severe neurological signs may persist depending on the initial damage.


Ring formation on computerized tomography in the postoperative patient. Ring formation with contrast infusion in computerized tomography has been described with various entities. The current report demonstrates its appearance in three postoperative patients from whom cerebral tumors had been removed. These examples of postoperative ring formation are compared with the ring formation in the scan of an unoperated patient with an intracerebral hematoma.


Endoscopic biopsy of intraventricular tumors with the use of a ventriculofiberscope. The results of endoscopic biopsy in 21 cases of intraventricular tumor are presented. The details of the equipment are given. Of the 21 tumors biopsied, there were 9 in the lateral ventricle, 2 in the thalamus, 6 in the anterior portion of the 3rd ventricle, and 4 in the pineal region. A correct histological diagnosis was made in 11 cases (52.4%). No serious complications were noted. The value of the procedure is discussed.


Cerebral revascularization: common carotid to distal middle cerebral artery bypass. A right common carotid to distal middle cerebral artery bypass utilizing a saphenous vein graft was performed in a patient with episodic cerebral ischemia and reversible ischemic neurological deficit. The patient was relieved of his symptoms, and there was improved motor function in the left hand. Postoperative angiography revealed flow through the graft with excellent filling of the middle cerebral circulation, both retrograde and antegrade. This bypass procedure provided an immediate source of high volume blood flow and thereby provided immediate protection to the hemisphere.


Cerebral herniation from ventricular dilatation after craniectomy: a method of treatment. Local cerebral herniation due to ventricular dilatation was observed in a patient who had had removal of a bone flap and whose dura had previously been left open. The explanation of this problem was suggested by experimental and clinical evidence relating the development of ventricular enlargement to loss of support of the brain. Such an explanation also suggested that head wrapping to buttress the brain and promote transependymal absorption of cerebrospinal fluid could reverse the condition. This treatment was employed with apparent success.


Intracranial vascular complications of choriocarcinoma. Choriocarcinoma is the most malignant of the tumors of chorionic tissue that (most commonly) arise from fetal tissues and invade the maternal vasculature. Two cases of choriocarcinoma are presented. One patient had a suprasellar mass in conjunction with a neoplastic carotid-cavernous fistula. The mass and the fistula disappeared after apparently successful radiation therapy and chemotherapy. The second patient had a ruptured arterial aneurysm associated with an intracerebral hematoma treated by evacuation of the hematoma and resection of the aneurysm. The vascular complications of this tumor are reviewed, and a management plan is suggested.


Intracranial teratocarcinoma in a child with anterior sacral and intrasacral meningocele. A very rare combination of two rare entities is reported. The patient had anterior sacral and intrasacral meningoceles, which were repaired at age 3 years, and 7 years later he presented with hypopituitarism due to a suprasellar teratocarcinoma. There has been no evidence of tumor recurrence in the 2.5 years since subtotal excision and radiotherapy (patient was last seen in 1977). Two aspects of the case are reviewed: the unusual nature of the spinal defect and the implications of its association with an intracranial tumor of developmental origin.


Large decompressive craniotomy in the treatment of acute subdural hematoma. A series of 42 patients who had large decompressive craniotomies for acute subdural hematoma has been reviewed with regard to long term results. Postoperative mortality (within 30 days of surgery) was 36%. Delayed but related deaths accounted for an additional 19% mortality, for a total mortality of 55%. Fourteen patients (33%) were able to return home, but there was a significant morbidity in terms of intellectual impairment, hemiparesis, and dysphasia. Recommended management includes establishment of an adequate airway, intravenous administration of mannitol, and performance of an emergency computerized tomographic (CT) scan before operation. A large decompressive craniotomy is performed, with removal of the blood clot, establishment of hemostasis, patch-grafting of the dura, and removal of the bone flap to allow the edematous, swollen brain to expand away from the brain stem. The mortality and morbidity will probably always remain high because in the majority of the cases significant structural damage to the cortical and brain stem structures occurs at the time of the injury.


Computerized tomography in Reye's syndrome: evidence for pathological cerebral vasodilatation. The authors present two children with Reye's syndrome who were studied with serial computerized tomographic (CT) scanning. Scans performed with contrast enhancement during the acute phase of this disease showed evidence of pathological cerebral vasodilatation. The possible mechanism for this vasodilatation and the increased intracranial pressure (ICP) seen in Reye's syndrome are discussed.


Cerebral arterial revascularization: the value of repeated angiography in selection of patients for operation. Three patients with occlusive cerebrovascular disease were evaluated for possible extracranial-intracranial arterial anastomosis. Cerebral angiography repeated at a later date revealed disappearance of the initial vascular stenosis or occlusion and development of extensive collateral circulation. It was concluded in these cases that surgical revascularization would not improve upon natural revascularization. Repeated angiography provides information of value to the physician who must make a decision about such surgical treatment.


Infrequent aneurysm surgery.

Infrequent aneurysm surgery. A study of 18 consecutive surgically treated intracranial aneurysms, with no mortality, is presented. The study extended over a period of 6 years, and this relatively infrequent surgery with acceptable results is the main feature of the study.


An analysis (time study) of service and education in a neurosurgery residency program. A time study analysis of the activities of neurosurgery residents, allocating their time to one of four categories (service, education, questionable, personal), indicates that the service-education percentage ratio is 44.65:37.34 during the week and 61.50:28.11 for the weekend. The distribution of activities within service and education categories identifies the extent to which a neurosurgery resident in this program is a student, although most of the "service" activities are those that a neurosurgeon must learn to perform efficiently in order to practice his specialty.


Regional cortical blood flow at craniotomy. Regional cortical blood flow was monitored at craniotomy in 32 patients with a thermal diffusion flow probe in an attempt to assess the effects of surgical conditions on flow. Changes in flow due to vascular manipulation, retraction, hypotension, and hyperventilation were readily apparent. Eleven patients with supratentorial tumors had intermittent measurements of cerebral blood flow; the expected differences in blood flow with halothane anesthesia and hyperventilation were observed. Fourteen patients with aneurysms were monitored continuously and demonstrated a reduction in flow during hypotension; in two of these cases, the reduction was to disastrously low levels. Flow reduction occurred secondary to branch occlusion by the aneurysm clip in a patient with three middle cerebral artery aneurysms and was corrected by changing the clip position. Direct measurement of regional flow may be of value in estimating the safety of temporary clips and the degree of hypotension that can be tolerated.


Evaluation of brain death by contrast-enhanced computerized cranial tomography. Four patients with clinical criteria of cerebral death were evaluated by computerized cranial tomography (CT). Upon intravenous infusion of meglumine diatrizoate, the intracranial vascular structures failed to enhance. Two of the patients also had electroencephalographic evaluation, and one patient underwent cerebral angiography, confirming the absence of cerebral blood flow. Contrast-enhanced CT may provide a contributory method in the establishment of cerebral death, in addition to elucidating the etiology of the ictus.


Mechanism and localization of speech in the parietotemporal cortex. Cortical stimulation of the supramarginal and angular gyri elicited dysphasia. Delays in verbal response, misnaming, and difficulties in speech production were also elicited from this region. In two patients speech arrest occurred when stimulation was extended into the occipital cortex and the cortex medial to the supramarginal gyrus, respectively. In a left-handed patient, with speech representation presumed to be in the right hemisphere, neither stimulation nor ablation of the angular gyrus resulted in dysphasia. After anterior temporal resections two patients exhibited dysphasia in association with cortical edema. In one of these an additional resection in the inferior temporo-occipital region produced a marked but transient dyslexia. Observations of the disintegration of speech function during stimulation suggest that such stimulation interferes with a search mechanism by which the nonverbal concept of a visual stimulus is linked to a specific word in memory that is then withdrawn for use. A review of autopsy specimens demonstrates how close the cortex bearing indispensable speech representation lies to the occipital pole and the parietal midline. Because the gyral pattern is obscured by the meninges and is subject to anomalies, elective resection in these areas should be preceded by cortical stimulation and functional mapping.


Preliminary experience with ultrasonic aspiration in neurosurgery. A new instrument utilizing ultrasonic energy to fragment and aspirate normal and pathological tissue has been evaluated for neurosurgical use. The instrument has been tested in several animal models to assess its efficacy and safety. The instrument has been used clinically in 38 cases for removal of meningiomas, acoustic neurinomas, and other tumors. Future modifications and applications are discussed.


Eight-year follow-up of experimental carotid-middle cerebral and carotid-basilar arterial bypass grafts and anastomoses. Fifty-one dogs were operated upon, and various microvascular bypass grafts and anastomoses were completed. Seventeen of these dogs were followed for 5 to 8 years. Of these, three had a carotid-middle cerebral arterial bypass graft, five had a carotid-basilar arterial bypass graft, five had a lingual-basilar anastomosis, and four had a sublingual-basilar anastomosis. Postoperative carotid angiograms showed patent grafts and anastomoses in all of the dogs. Except for slight to moderate enlargement of the donor artery in the lingual and sublingual-basilar anastomoses or minor irregularities in the carotid-middle cerebral and carotid-basilar arterial bypass grafts, no significant changes were noted. In five dogs with lingual-basilar anastomoses in which both internal carotid arteries were ligated, the mean blood flow of the lingual artery was increased to 1.1 to 2.4 times normal. This study shows that, when experimental arterial bypass grafts and anastomoses remain patent for a few weeks after the operation, they stay patent for years, and, depending on the need, the blood flow through the anastomosis may increase.


Bow hunter's stroke.

Bow hunter's stroke. A case of suspected brain stem infarction (modified Wallenberg syndrome) due to vertebral artery injury in a bow hunter is presented. An anatomical review is presented to explain the neurological involvement, and recommendations are given for avoiding this syndrome.


Carcinoembryonic antigen in a metastatic brain tumor. A case is presented in which 10 ml of cystic fluid from a metastatic brain tumor contained a high concentration of carcinoembryonic antigen (CEA). The use of CEA as a prognostic indicator and adjunctive therapeutic monitor in tumors is reviewed.


Revascularization of the scalp by microsurgical techniques after complete avulsion. A total scalp replantation was performed after a complete traumatic avulsion of the scalp with skull fracture. Multiple arterial and venous anastomoses were required. Satisfactory healing occurred, and the patient has had a subsequent uneventful cranioplasty to fill a bony defect, with normal scalp healing.


Emission computed tomography.

Emission computed tomography. Emission computed tomography (CT) is a nuclear medicine visualization technique that yields an image of the distribution of a previously administered radionuclide in any desired transverse section of the body. Emission CT allows the safe, quantitative, three-dimensional measurement of regional radionuclide distribution in tissue. This approach is analogous to quantitative radioautography, with the added advantage of allowing in vivo studies.


[Proposed technic of drainage tunneling in marsupialization of hydatid cysts of the hepatic cupula]. Even though the present tendency is to make use of radical operations, such as pericystectomy, hepatic resection and lobectomy, in the surgical management of hydatidosis of the liver, marsupialisation is still the method of choince in a large and clearly defined number of cases. While usually simple, this operation may prove difficult and complex when used on cysts of the cupola, since it may often be necessary to mobilise the liver to a large extent and employ damaging approach routes. A description is offered of a particular technique for tunnelling the desinage tube which considerably simplifies marsupialisation in cases of this kind.


[Intermittent chronic occlusion of the duodenum caused by pheochromocytoma]. A case (63 y. old male) of intermittent duodenal obstruction is presented. Aortographic investigation showed a neoplastic mass in the right adrenal gland. At laparotomy the mass, histologically diagnosed as a pheochromocytoma, appeared to infiltrate the duodenal wall, displacing it upward. Though gastrointestinal disturbances have been frequently recorded in pheochromocytoma, as far as we know this is the first description of intermittent duodenal obstruction in this disease.


[Radiopaque hemithorax, with special reference to scintigraphic methods]. Radioopaque hemithorax is frequently observed. The various situations in which it may occur are examined aetiopathologically, along with the general and specifically radiological methods used for its investigation. Particular attention is given to the employment of radio-isotopes for this purpose and the methods involved. Results obtained with perfusion are noteworthy, and even more so those achieved with positive tracers such as 67Ga citrate and 57Co Blm, especially in the differential diagnosis of pleural effusion and mesothelioma through what is described as the "paradox effect".


[Lithium in the prevention of manic-depressive and schizo-affective psychoses]. The brilliant results obtained with lithium carbonate in the prophylactic treatment of manic-depressive (MDP) and schizoaffective (SAP) psychoses over almost five years are reported. The series includes 53 patients, 46 of them suffering from MDP and 7 from SAP. In the majority of cases, the lithium dose used was 900 mg/die and lithaemia was 0.564 +/- 0.0632 mEq/1. The parameters considered were the number of attacks, their intensity and duration; therapy, if any, with traditional psychodrugs (neuroleptics and antidepressants); the number of hospitalizations and their duration. Results were valuated by comparing an equal period of time before and during therapy with lithium. In MDP the number of attacks fell 74.25% and their duration by 83.14%; severe attacks responded better to treatment, with a reduction of 94%. The quantity of traditional psychodrugs used was reduced by 66.42%. The number of hospitalizations fell 75% and days admitted by 80%. In SAP the results were even better: the number of attacks fell by 87.5% and their duration by 94.7%; serious attacks disappeared completely and the quantity of traditional psychodrugs used fell by 57.06%. The number of admittances fell 75% and days in hospital by 97%.


[Contrast of the grey scale and stable B-scan in the ultrasonic visualization of the thyroid gland]. Thyroid echography can be profitably performed with the stable contrasted B-scan and the gray scale. Both methods are based on the possibility of recording weak echoes from structures inside the gland and so differentiate almost all lesions in a reliable manner. The echo-structural patterns permit the following distinctions to be drawn: uniform distribution of echoes in the normal, hypoplastic and hyperplastic-hypertrophic thyroid. Calcified areas in goitre give distinct, strong echoes, whereas in colloid-cystic goitre there are weak echoes mixed with small empty areas due the cysts. Cystic lesions, too, have empty areas that are well defined, with reinforcement of the posterior wall. In adenoma, there is a uniform, solid area, in which the echoes are evenly distributed internally and the borders are well defined with respect to the unimpaired parenchyma. In acute thyroiditis, the presence of oedema and areas of fibrosis offer sufficiently indicative signs. In tumours, the most typical features are the irregularity of the walls, the distinct attenuation of the beam and the presence of a few, irregular internal echoes. These pictures are almost always peculiar to each situations and thus make echographical investigation of thyroid not only useful, but also indispensable.


[Evaluation of transendoscopic retrograde cholangio-pancreatography in 151 jaundiced patients]. Endoscopic retrograde cholangiopancreatography was performed for possible obstruction of the extra-hepatic bile ducts in 151 patients with jaundice. The endoscope findings (9 cases) and the retrograde cholangiopancreatogram (127 cases) provided a final diagnosis in 131 cases. A correct surgical indication was obtaines in a further 5 cases (90% diagnostic success overall). In 19 cases, unnecessary exploratory laparotomy was avoided by the demonstration of normal extrahepatic ducts. No complications were noted. It is concluded that this technique is virtually free from risks and offers prompt diagnosis in subjects with jaundice. This, of course, has a significant influence on the subsequent treatment.


[Aneurysmal dilatation of the superior vena cava]. A case of aneurysmatic dilatation of the vena cava superior is presented. This lesion is rare and not commonly taken into consideration in the differential diagnosis of anterior mediastinal masses. Chest X-rays taken during inspiration and expiration and in the standing and reclining positions (particularly the second and fourth) revealed changes in the size of the mediastinal mass and pointed clearly to its venous nature. This deduction was then confirmed angiographically.


[Spinal and spinal cord injuries in aviation medicine]. The causes of vertebral lesions in the course of flying are listed. An account is given of the dynamic forces required to bring about vertebral fracture and their mechanism. Reference is made to the most common sites of vertebral injury in crashes, particularly in the case of helicopters, and during catapulted seat ejection. Lastly, sites of vertebral fracture in parachutists are discussed.


[Arthrotic manifestations secondary to repeated microtrauma in helicopter personnel]. Following aetiopathogenetic and anatomopathological examination of arthrosis, chronic microtraumatism, often below the threshold of subjective perception, is indicated as a component, aggravating factor in the disease. During flight, especially if the aircraft is a helicopter, these microtraumas (triggered by the varied motions of the craft and its vibrations) operate continually on joints and muscles and so, along with other factors of anatomical and biochemical nature, cause an aggravation to arthrosis in flying personnel, particularly in the vertebral tract.


[Behavior of impedance of the middle ear during rapid changes in barometric pressure]. The first results on the dynamic behaviour of middle ear impedenzometric variations starting from an altitude of 3,000 mt and descending constantly by about 1,500 mt/min to sea level, are reported. The research was carried out in a hypobaric chamber, under simulated flight conditions, using the equipment of the Aeronautics and Space Medicine Studies and Research Centre of the Air Force. Evaluation of the results obtained in subjects trained for rapid descents and in others not so trained suggests that the technique used is a useful aid in the diagnosis of the tubal conditions of subjects who are to be subjected to rapid ascents and descents.


[Means and methods of bone biopsy].

[Means and methods of bone biopsy]. Stress is laid on the usefulness of bone biopsy in rheumatology, endocrinology, haematology, etc. and percussion with a Bartelheimer or Westerman needle, and trapanation are discussed. Preference is expressed for the latter method and it is hoped that instruments capable of giving excellent results will be produced, so that deeper and more exact diagnostic and therapeutic conclusions can be drawn, especially in geriatric medicine.


[Cystic lymphangioma of the spleen associated with hypersplenism]. A rare case of cystic lymphangioma of the spleen accompanying hypersplenism syndrome is described. After stressing the importance of certain examinations such as arteriography and splenic scintigraphy in diagnosis the condition, the many ways in which cystic lymphangioma of the spleen may present clinically are reviewed; these go from asymptomatic to straightforward splenomegaly, with or without clinical signs, up to a clear-cut hypersplenism syndrome. The present case merits consideration for three reasons: 1) The absolutely exceptional nature of cystic lymphangioma of the spleen; 2) Exceptional association with hypersplenism syndrome; 3) Remission of the syndrome following splenectomy. It is concluded that, notwithstanding the condition's rarity, cystic lymphangioma of the spleen should be considered in the differential diagnosis of splenomegalic syndromes when these are also accompanied by hypersplenism.


[Anemia in chronic renal insufficiency]. Anaemia is common in renal insufficiency and has various causes: 1) depressed marrow production of red cells, probably due to reduced production of erythropoietin, though the possibility of direct marrow inhibition on the part of uraemic toxins cannot be ruled out, together with iron deficiency, as occurs in prolonged dialysis management; 2) greater red cell destruction attributable to extraglobular factors and other mechanisms (microangiopathy, drugs, etc.); 3) greater blood loss following thrombocytopenia, reduced platelet adhesivity and agglutinability, dialysis. The main premisses on which the treatment of anaemia of uraemic patients is based are discussed.


[Chromatographic fractionation of cholesterol esters in Morgagni's hepatic cirrhosis. Preliminary note]. The behaviour of plasma cholesteryl esters has been investigated in patients with liver cirrhosis (so-called Laennec's cirrhosis). Both absolute and percentage values of esters containing di-, tri- and tetra-unsaturated fatty acids were decreased below the normal range; however, the various esters groups showed unequal decrement rates. These findings may be the result of a low lecithin: cholesterol-acyltransferase (LCAT) activity, due either to depression of the enzyme syntesis in the liver, or to inadequate substrate supply (possibly related with an impaired fatty acid production and lecithin synthesis). A decrease of all ester fractions, or a selective one, could also be induced by the releasing of abnormal hydrolases from damaged liver tissues.


[Phagocytic lymphocyte-like elements (PLLE) and irradiation in vitro]. The peripheral blood of rats contains lymphocyte-like phagocytes after intracardial injection of India ink. In vitro irradiation of whole blood (1000 r - 60Co), causes marked reduction in whole lymphocytes but does not modify the number and morphological integrity of the phagocytes, which can therefore be held to be comparatively radioresistant: as such, they could belong either to the mononucleate phagocyte system or to the lymphatic system (T4 lymphocytes). Since T-lymphocytes are not capable of phagocytosis, the former hypothesis would appear the most probable.


[Metabolism of somatotropin in severe liver diseases. Influence of the therapeutic administration of a liver extract]. Metabolic Clearance Rate (MCR) and half life of 125I Human Growth Hormone (HGH) have been studied in hepatopathic patients. A clear reduction of MCR and a prolongation of HGH half life have been found in all patients examined. After a 30 day therapy with crude liver extract (F.U. VIII ed.) both MCR and HGH half life have shown a tendency towards normalization. These findings are in agreement with the marked improvement of the clinical state of the patients and with the normalization of the laboratory indexes.


[Hyperplasia of the adrenal medulla].

[Hyperplasia of the adrenal medulla]. A case of arterial hypertension due to suprarenal medulla hyperplasia is reported. Having accepted the existence of this form, the problem of its recognition is stressed, in the presence of catecholamine pathology, even though the type or site of its anatomo-pathological substrate cannot be identified, explorative surgery and possible removal of the suprarenal glands can be indicated.


[An atypical case of subacute sclerosing panencephalitis (SSPE), (with special reference to psychiatric and psychological evaluations)]. An atypical case of subacute sclerosing panencephalitis is described, with particular reference to its psychiatric and psychological aspects in the light of the neurological and laboratory data: slow-gamma electrophoresis of the spinal fluid, periodic delta signs in the EEG over about 6 yr, 1/160 blood titre of anti-measles virus antibodies. The history displayed an ingravescent dementia course and the patient's continuing survival for more than 11 yr makes the case the longest recorded in the literature. Both the psychiatric-psychological and neurological symptoms had occurred in distinct stages. It is suggested that neurological recrudescence was responsible for the pattern of symptomatological stabilisation followed by sudden relapses. The symptoms regarded as characteristic of the terminal stage have not yet appeared, especially on the neurological side.


[Low-calory dietetic treatment of gross obesity]. Reference is made to 96 grossly obese subjects classed as "resistant" to medical treatment and examined as possible candidates for surgery. 31 were eventually subjected to jejunal-ileal bypass. The main difference between these patients and those with slight or average spontaneous obesity was not so much their weight, but its self-maintenance. Weight patterns did not reflect calorie intake, though they pointed to a change in the energy balance when taken as a whole. In some cases that proved resistant both to severe hypocalorific treatment and the by-pass, no reason could be found for the discrepancy between calorie intake and the maintenance of weight. Some correlations between weight and certain endocrine, biohumoral and genetic features offer an idea of the metabolic orientation in gross obesity, but they fail to provide a satisfactory pathogenetic explanation.


[Carbohydrate metabolism in gross obesity]. Results obtained in an investigation of two groups of obese and grossly obese subjects are presented. Poorer carbohydrate tolerance was noted in the latter. Blood insulin patterns after oral glucose loading, however, were less easy to interpret. Overall, the values were much the same in the two groups. Nevertheless, analysis of the curves showed that the grossly obese displayed a later peak.


[Behavior of adipose tissue cellularity in gross obesity]. Adipose tissue cellularity was studied in relation to the degree of obesity. It was found that mild obesity is essentially linked to a simple increase in adipocyte size, whereas gross obesity involves considerable hyperplasia of adipose tissue with at least twice the normal number of adipocytes. Prognostic and therapeutic conclusions are drawn from these personal data.


[Surgical treatment of severe obesity. Criteria of choice of operation. Personal technic]. The criteria underlying the choice of operation in a given case and the personal technique adopted are described. The technique in question is a personal modification of end-to-side jejuno-ileal bypass codified by Payne. To minimize reflux into the blind loop, a number of technical steps are considered indispensable: 1) fluted section of the jejunal stump; 2) isoperistaltic construction of the anastomosis and, particularly, 3) the creation of a single or double valve system upstream from the anastomosis by spiral introflexion of the mucosa using seroserous stitches parallel and perpendicular to the ileal lumen. Other techniques in use are reported. These are held to be extremely interesting but are not yet supported by a long enough follow-up.


[Historical development of the surgical treatment of gross obesity]. Reference is made to the experimental preliminary remark and the first, clinical observations underlying the surgical management of severe obesity, together with the techniques employed, starting with the jejunal-colic by-pass of Payne et al. This, however, led to serious liver damage and electrolyte imbalance, whereupon Payne et al. proposed end-to-side and Scott end-to-end jejunal-ileal by-pass. The end-to-end variety has been used with excellent results in 33 cases. Mason's gastric and gastroplastic techniques is till now unfrequently used. An account is also given of experimental ileo-cholecystostomy and biliopancreatic by-pass. In agreement with most other workers, a preference is expressed for the end-to-end jejunal-ileal by-pass as the most suitable technique available at present.


[Jejuno-ileal bypass in the treatment of severe obesity: transverse or vertical approach?]. The criteria applicable to the selection of the approach route in the surgical management of essential gross obesity by means of a jejunal-ileal by-pass are discussed. Median vertical and transverse incision are compared in the light of early and late hypoxaemia in the immediate postoperative period; postoperative acidosis and alkalosis; rapidity; exposure; extendibility; tightness; postoperative pain; cosmetic results. A preference for the vertical approach is both stated and justified.


[Kinetics of loss of body weight after intestinal by-pass]. Changes in body weight (absolute and percent), overweight index, and body surface area were examined in 27 grossly obese subjects after jejunal-ileal by-pass. Curves were steeper and linear for 3-4 months and then flattened out for the remainder of the twelve-month period of observation. They were parallel to each other even when a division was made between patients weighing more and less than twice their ideal weight. This shows that if a person weighs more than 120 Kg his weight loss curve will depend on the time that has elapsed since surgery. It is virtually independent of the start value.


[Short-term tolerability of 2 types of termino-terminal jejuno-ileal bypass]. The short-term tolerability of two types of end-to-end jejuno-ileal bypasses with different distal ileal loop lengths was evaluated. A comparison was made for 20 days of the behaviour of the main parameters influenced by the malabsorption syndrome thus induced. It was found that the operation involving a greater loss of small intestine was burdened with a greater number of discharges per day, an increase in total water loss, and an elevatem operative risk. This was compensated by more rapid and more evident loss of weight. Evaluation of the real meaning of the inversion of the A:G ratio observed in the short term with this type of operation was postponed to allow a longer follow-up period to run.


[Pulmonary aspergillosis. Presentation of an anatomo-clinical case of lobitis]. A case of pulmonary aspergillosis in an elderly, wasted patient is described from the clinical and anatomopathological points of view. The different ways in which pulmonary aspergillosis presents in humans are reviewed and the different factors favouring onset of the disease, which has become commoner in recent years, are considered. Finally, stress is laid on the anatomoclinical aspects of the case which, unlike those typical of aspergillosic pneumonia, also presented cavital zones.


[Use of the duodenum in demolition surgery of the stomach. Reconversion gastroduodenostomy in post-resection syndromes following Billroth II operations]. Stress is laid on the importance in digestive and absorptive physiology. The methods used for the re-insertion of the duodenum in the digestive circuit in the surgical correction of servious post-Billroth II syndromes are explained. Direct duodenal reconversion by means of the transformation of gastrojejunostomy into gastroduodenostomy is recommended in the light of results obtained in 25 cases of p.o.p.u., dumping syndrome, inflammation of the anastomosis, and ALS. It is suggested that jejunal interposition should be kept for cases in which the particular shortness of the gastric stump makes simple re-insertion of the duodenum into the stomach impracticable.


[The antisteatosic activity of 2-MPG (Thiola). Study with the (BSF) dynamic test and with liver biopsy before and after the treatment]. The short-term therapeutic effect of 2-MPG has been studied in 12 patients suffering from chronic liver disease of prevalent steatosic type. The drug was administered in a dose of 2.5 g. for 20 days. Patients were submitted to hepatic needle biopsy and BSF load test, with compartmental analysis before and after treatment. A marked reduction in steatosis and a statistically significant fall in BSF retention at the 45th minute, with increase in conjugation and excretion of colorant, was observed in 11 patients.


[Genital tuberculosis and sterility].

[Genital tuberculosis and sterility]. The incidence of genital tuberculosis in its active and silent forms in determining in female procreational incapacity can be evaluated at about 5.03% (0.27% in active phase, 4.76% latent): these figures come from the extensive series of three Milan marriage sterility centres covering some thirty years of clinical and out-patient work (a total of 294 patients with specific genital diseases, of whom 16 in developmental phase and 278 latent). Chemotherapy, which always involves a variety of medicaments (prevalently streptomycin-isoniazide-etambutol association or rifampicin-isoniazide) can consist of the following approaches, depending on disease characteristics: - attach therapy - particularly in initially exudative forms, in acute and subacute evolutive phase and in the acute recurrences of chronic, drug-sensitive forms - using massive doses for two-three months; - basic therapy - indicated in chronic and stationary periods - with simultaneous administration of the chosen drugs and breaks in the treatment, for a period of at least six-eight months; - consolidation therapy - to be carried out even when the cure is apparently complete so as to avoid relapses - with periodic cycles lasting at least ten-twelve months. The experience can be considered highly encouraging because, quite apart from clinical cure, gestation occurred in only six cases and these gave rise to eutocic deliveries.


Evaluation of the contraction stress test before 33 weeks' gestation. The value of the contraction stress test (CST), although well documented in late pregnancy, has been questioned earlier in gestation. We have evaluated the reliability of the CST in 102 patients tested before 33 weeks' gestation. Eighteen patients with a positive CST had a significantly higher incidence of abnormal urinary estriol excretion (60% of patients), low Apgar scores (44%), growth retardation (39%), and perinatal mortality (277/1000) than did 84 women without a positive CST. Two stillbirths and 3 neonatal deaths occurred in the positive CST group. None of the neonatal losses was due to unnecessary premature intervention. Four patients with a positive CST showed no signs of fetal compromise, a false positive rate of 22%. Delivery was safely delayed an average of 6.1 weeks in patients without a positive CST. These findings demonstrate the predictive value of the CST and support its clinical application early in the third trimester.


Deflexion of the fetal head in breech presentation. Incidence, management, and outcome. The deflexion attitude of the fetal head in 223 consecutive breech deliveries was radiologically evaluated and classified into four grades. Additional x-ray pelvimetry was performed on all primiparas (136 cases). Extended (35 cases with deflexion angle of 90 degrees or less) and hyperextended (2 cases with angle of more than 90 degrees) variants were found in 16.4%. In the cases of hyperextension, the patients had elective cesarean section, while in cases of other variants they were delivered vaginally in the absence of other indications to cesarean section. The overall cesarean section rate was 17.5%. No cases of perinatal mortality were recorded. Two hundred and sixteen babies had a 1-minute Apgar score of 7--10, 6 had a score of 4--6, and 1 had a score of 2. Only 1 of the 7 asphyxiated babies was of the group of 35 patients classified as having an extended variant. These favorable results confirm the importance of the radiologic assessment of the deflexion angle as a clinical tool.


Infectious morbidity following cesarean section. Comparison of two treatment regimens. During a 4-month period 265 women delivered by cesarean section were studied to determine what effect membrane rupture has on the incidence and severity of postoperative infection. There was a definite correlation between the duration of ruptured membranes and the incidence as well as severity of postoperative infections. Only 29% of women with intact membranes subsequently developed endometritis with pelvic cellulitis, in contrast to 85% of those whose membranes were ruptured for less than 6 hours. Wound and pelvic abscesses were encountered in less than 1% of women delivered with intact membranes, yet these complications developed in over 30% of women with membranes ruptured for less than 6 hours. The incidence of septicemia was four times greater in those women whose membranes were ruptured for less than 6 hours. Women with endometritis were treated with one of two empirical antimicrobial regimens chosen randomly. Intravenous penicillin and tetracycline was found to be as effective as, and perhaps slightly more effective than, the combination of intravenous penicillin and intramuscular tobramycin.


The effect of maternal blood sugar levels on fetal activity. Nonstress testing of the fetal heart rate is an antepartum test for fetal well-being utilizing the fetal heart rate response to fetal movement. Performing the test during times of maximum fetal movement should reduce the time required for the test. In this study, fetal activity was evaluated before and during a 3-hour glucose tolerance test to determine the effect of maternal blood glucose levels on fetal activity. Fetal activity was monitored by a nurse at the bedside throughout the study, utilizing both the patient's perception of fetal movement and the recording of fetal movement by the tokodynamometer. Fetal activity increased significantly during the first 30 minutes after maternal ingestion of 100 g glucose and was significantly greater during the last 10 minutes of this time interval. No correlation could be found between absolute levels of glucose at any measured level and fetal activity.


Umbilical cord and neonatal cortisol levels. Effect of gestational and neonatal factors. To evaluate the effect of the type of delivery, gestational age, maternal dexamethasone treatment, and neonatal complications on the serum cortisol levels in early infancy, a total of 92 neonates were investigated with 611 cortisol determinations (specific radioimmunoassay after Lipidex chromatography). Umbilical cord blood samples were taken immediately after delivery and capillary blood samples from the infant's heel 30--60 minutes after delivery and at 8:00 AM and PM on the second, fourth, and sixth days of life. Umbilical cord cortisol concentration after elective cesarean section was lower than after emergency cesarean section or after normal vaginal delivery, while neonatal cortisol values did not show any correlation with the type of delivery. Prematurity did not affect neonatal cortisol levels. In postterm infants the activation of cortisol production was retarded to some degree. After maternal dexamethasone therapy, neonatal cortisol concentration decreased 30--60 minutes after delivery, but from the second day on it was at the same level as in infants without maternal therapy. Respiratory distress syndrome, especially in fatal cases, caused an elevation in neonatal cortisol levels, while hyperbilirubinemia did not have an effect on plasma cortisol concentrations of the neonates.


Sinusoidal fetal heart rate pattern associated with alphaprodine administration. Sinusoidal fetal heart rate patterns were observed in 42.5% of a group of 40 women who had received alphaprodine (Nisentil) for relief of labor pain. Analysis showed that the pattern appeared approximately 19 minutes following alphaprodine administration and persisted for approximately 60 minutes. In a control group of 18 patients who did not receive narcotic analgesia, and intermittent sinusoidal pattern was observed in one patient. All babies with sinusoidal heart rate during labor had 1-minute Apgar scores of 7 or greater except two in the study group. Both these neonates had low Apgar scores directly associated with complications at delivery. All 5-minute Apgar scores were 7 or greater, and there were no perinatal deaths.


Diphenylhydantoin teratogenicity in man. A case is presented of fetal teratogenic damage from an unusually high maternal dosage of diphenylhydantoin, 600 mg daily, to a 40-kg woman throughout pregnancy. The anomalies included narrowed ends of the fingers and toes; aplasia of the nails on the other fingers and toes; aplasia of the distal phalanges of the fingers and toes; a broad, depressed nasal bridge; anteverted nostrils; prominent upper lip; coarse, profuse scalp hair; pilonidal sinus; and simian crease of the left hand. At the age of 7 months, ossification of the distal phalanges of both middle fingers appeared, the anterior fontanel was small, brain development was retarded, cranial asymmetry was marked, and the fingertips showed a pattern of low arch dermal ridges.


Regulation of amniotic fluid volume and composition in the ovine fetus. To determine the role of fetal swallowing in the control of amniotic fluid volume and composition and fetomaternal sodium transport, 4 ovine fetuses of 101--129 days' gestation had their esophagi surgically occluded. Amniotic and fetal vascular cannulas were implanted at the same time in these fetuses and in four intact controls. There was no difference between the amniotic sodium or potassium of these two groups over the next 3 weeks, at which time cesarean section was performed and the volume of amniotic fluid measured. Hydramnios did not result from esophageal atresia. Twenty-four hours after injection of 24Na into the amniotic fluid, the percentages of the dose in the fetal/maternal compartment were similar in intact and esophagus-ligated fetuses.


Hormonal content of plasma and endometrium of women taking oral contraceptives. A total of 134 women were studied, 75 of whom were using cyclic steroid contraception (ethinyl estradiol, 0.05 mg plus norgestrel, 0.5 mg) and 59 of whom had normal ovaulatory cycles. By radioimmunoassay techniques simultaneous determinations were made of total estrogens (TE) and progesterone (P) in both plasma and endometrium and of FSH and LH in plasma, covering all days of the pseudomenstrual and true menstrual cycles. As expected, the ovulating women showed a midcycle peak of plasma TE and an increase in plasma P thereafter, while no cyclic variations were observed in the treated group. Correlations of endometrial concentrations of TE and P with plasma  FSH and LH levels are discussed. In 13 of the 75 treated women elevations of endometrial P concentrations were present, presumably demonstrating the "escape phenomenon." The possible future value of endometrial hormone determinations is suggested.


Granulosa cell tumors. A clinical review of 61 cases. Sixty-one patients with granulosa cell tumors of the ovary were treated in the A.M. Evans Clinic of the British Columbia Cancer Control Agency between 1944 and 1974. Their treatment and follow-up are reviewed, and while the 5-year survival rate was 78%, the 15-year rate fell to 50%. The material suggests that the trend to total hysterectomy and bilateral salpingo-oophorectomy has improved the prognosis, but other explanations are, of course, possible as this is a historical comparison.


Screening for the patient at risk for postpartum depression. A simple, accurate, and practical device was designed for detecting the woman at risk for postpartum emotional disorder (PED). Women attending the Sainte-Justine prenatal clinic were requested to complete a 19-item "yes/no" type of questionnaire. Each patient was classified for presence or absence of PED according to preestablished criteria. The responses of the patients classified as having emotional disorders were compared to the "normal" group. Thirteen percent developed PED. Six items showed predictive value: 1) admission of often feeling unloved by husband; 2) admission of feeling that pregnancy is undesired; 3) past history of postpartum depression; 4) being single or separated; 5) admission of marital problems; 6) admission that pregnancy was unplanned. The presentation of these items as part of a routine patient prenatal history questionnaire would constitute a means of identifying the woman at risk to develop PED and preventive measures could be taken.


Mass visual screening via television.

Mass visual screening via television. Videotaped programs that could be used for screening of visual acuity and of visual fields by means of broadcast television have been developed and tested. The tests are designed to be effective regardless of the size of the viewer's television screen. Inevitably, false-positive and false-negative results would occur, which would have to be carefully explained at the time the tests were broadcast.


A multispecialty approach to the excision and reconstruction of eyelid tumors. An ongoing study indicates that the Mohs' fresh tissue technique of tumor removal followed by eyelid reconstruction may be the most efficacious management of eyelid malignancies. Forty-seven recurrent, invasive or large eyelid and canthal tumors were excised by this method followed by eyelid reconstruction. The advantages of this approach are (1) a high cure rate, (2) conservation of tissue, (3) reduced operating room time, and (4) maximum utilization of specialty training.


Eyelid reconstruction by the semicircle flap technique. The semicircle flap technique of eyelid reconstruction is a modified lateral advancement-rotation flap. The procedure combines the use of selective lysis of the limbs of the lateral canthal tendon with a semicircular skin-muscle flap confined to the region of the lateral canthus within the boundary established by the lateral eyebrow and the arc it defines. Reconstruction of one half to more than three fourths of the lower or upper eyelid can be accomplished without borrowing tissue from the eyelids, nose, ear, or mouth. Large forehead, brow, or cheek flaps are elininated, as is the need for closure of the palpebral fissure during the early healing course. The procedure has been used in the reconstruction of 36 lower eyelids and five upper eyelids in 40 patients, with a follow-up period of six months to six years. The usual indication for the use of this procedure is reconstruction of a central, marginal lid defect following the excision of a neoplasm. However, it may also be useful in cases of tissue loss caused by trauma, or for severe lid malpositions for which major kid reconstruction is necessary. The early and long-term cosmetic and functional results have been gratifying.


"No-touch" cryosurgical enucleation: a minimal trauma technique for eyes harboring intraocular malignancy. Current surgical approaches for cancer are emphasizing minimal trauma--the so-called no-touch technique of tumor removal. Tumor seeding through the circulatory system seems reasonable, particularly with friable and necrotic tumors. Attempts to reduce metastatic seeds should originate with the original procedure. Enucleation of nontumor eyes with simultaneous intraocular manometry has shown which surgical maneuvers elevate intraocular pressure and how ocular massage can be avoided. Our surgical procedure involves a delicate surgical technique coupled with transscleral cryocoagulation to immobilize the tumor's blood supply.


Relative frequency of ultrasound diagnoses in patients referred for ophthalmic ultrasound. An ultrasound diagnostic coding system was developed that permitted entry of diagnoses into a programmable calculator, thus permitting rapid information retrieval of patients with a specific diagnosis or diagnoses as well as the number of patients with a specific diagnosis. Cataract, vitreous opacity, trauma, choroidal disease, and retinal detachment were the most common diagnoses made. Only 7.2% of the patients had a normal ultrasound, indicating that ultrasound examination is a test probably underutilized by ophthalmologists.


Reliability of orbital diagnostic tests: ultrasonography, computerized tomography, and radiography. A series of 342 patients with unilateral exophthalmos underwent orbital diagnostic studies including ultrasonography, computerized tomography, radiographic studies, and vascular contrast studies. Each test was found to have diagnostic capabilities that complemented other studies depending upon the specific disease process involved. No one test was entirely adequate without supplementary information from the other tests. Radiographic studies demonstrated bony abnormality in 50% of the tumor cases, but in only 28% of the entire series of exophthalmos cases. Computerized tomography demonstrated diagnostic soft tissue abnormality in 86% of tumors, 43% of inflammatory diseases, and an overall yield of 62% positive results. Ultrasonography proved the most versatile test for evaluation of orbital soft tissues, with 80% positive results for tumors, 87% for inflammatory disorders, and 78% overall accurate orbital diagnosis. Erroneous tumor diagnosis of 7% with computerized tomography and 3% with ultrasonography were corrected by combining these two studies, because they tend to err in opposite directions. Combination of ultrasound and CT scan resulted in a 98% correct diagnosis of all types of orbital diseases.


Orbital hematoma secondary to frontal sinusitis. A 30-year-old woman had an orbital hematoma with frontal sinusitis. This complication of infection in the paranasal sinuses has not been previously described, but is explainable in anatomic terms. On computed tomographic scanning, the degree of enhancement with contrast infusion was striking and may aid in future diagnosis of this condition.


Macular circulation and the flying corpuscles phenomenon. The entoptic phenomenon of the flying corpuscles (FLC) consists of the perception of one's own leukocytes flowing in the perifoveal capillaries. A method has been developed to investigate the type of motion of the FLC, their relative number and speed, and their distribution over the central visual field. The results in 38 patients with disease affecting the macula correlated well with the clinical findings obtained by ophthalmoscopy, visual field tests, and fluorescein angiography. The test is noninvasive, inexpensive, easy to perform, and provides information on the perifoveal retinal circulation and on macular function.


Hyperornithinemia and gyrate atrophy of the choroid and retina. The diagnosis of hyperornithinemia and gyrate atrophy (HOGA) depends upon the presence of five characteristic features: (1) typical chorioretinal lesions, (2) high myopia, (3) cataracts, (4) hyperornithinemia, and (5) autosomal recessive inheritance. We have seen three patients and described four new findings: (1) decreased whole blood glutamic acid, (2) low normal intelligence, (3) hepatic mitochondrial changes, and (4) urinary excretion of ornithine methyl ester. Investigations of amino acid metabolism in vivo are consistent with the presence of a defect in ornithine keto-acid transaminase.


Follow-up studies of suspicious choroidal nevi. The fundus photographs and fluorescein angiograms of 255 consecutive cases of choroidal nevi were reviewed. Sixty-one cases (24%) were selected as suspicious on the basis of strict preestablished criteria including greatest single diameter, elevation, degree of disruption of the retinal pigment epithelium, and presence of subretinal fluid. Fifty of these 61 had adequate four-year follow-up. The remaining 194 cases, labeled as nonsuspicious, were usually small, relatively flat, slate-grey nevi which failed to meet the criteria for being suspicious. Of the 50 suspicious choroidal nevi followed four years, five (10%) showed photographic evidence of growth 4 to 30 months after the last examination. In contrast, none of the 194 nonsuspicious cases demonstrated growth. On the basis of these results, recommendations are made for the management of suspicious choroidal nevi.


Living retinal nematode (filarial-like) destroyed with photocoagulation. A motile worm creating tracks upon the pigment epithelium of the retina was observed in each of two patients. The fundus findings resembled pseudoretinitis pigmentosa. Unilateral macular degeneration resulted in one patient. The worm was a nematode, probably a filaria. This report represents the third and fourth intraocular filariae found in the United States. To our knowledge, it is the first report of living, intraretinal filarial-like worms destroyed by photocoagulation.


Bilateral retinal artery and choriocapillaris occlusion following the injection of long-acting corticosteroid suspensions in combination with other drugs: I. Clinical studies. Two well-documented cases of bilateral retinal artery and choriocapillaris occlusions with blindness following head and neck soft-tissue injection with methylprednisolone acetate in combination with lidocaine, epinephrine, or penicillin are reported. One case had only a unilateral injection. The acute observations included hazy sensorium, superior gaze palsy, pupillary abnormalities, and conjunctival hemorrhages with edema. Follow-up changes showed marked visual loss, constricted visual fields, optic nerve pallor, vascular attenuation, and chorioretinal atrophy. The literature is reviewed, and possible causes are discussed.


Bilateral retinal artery and choriocapillaris occlusion following the injection of long-acting corticosteroid suspensions in combination with other drugs: II. Animal experimental studies. An experimental dog model was used to reproduce the clinical picture of bilateral arteriole and choriocapillaris occlusion from a unilateral intracarotid injection of long-acting corticosteroids combined with other drugs including lidocaine, epinephrine, and penicillin. All five known long-acting corticosteroids, when combined with 1:1000,000 epinephrine, elicited vasoconstriction followed by dilatation of the retinal vessels with particulate material occlusion of the retinal vessels and choriocapillaris associated with small retinal hemorrhages. The fluorescein picture is described. The particles were identified by polarization as the long-acting corticosteroid.


Failure of femoral component in total hip arthroplasty: a case study--failure analysis. Marked bending prior to fatigue failure of the femoral component of a total hip arthroplasty points out the necessity for proper valgus placement of the prosthesis in the femoral shaft, especially in large active patients. This failure also indicates the need for limiting activities in such a patient.


Distraction pinning for radial metaphysis fractures. Comminuted fractures of the distal radial metaphysis are inherently unstable. Reduction can be obtained utilizing traction, and then the fracture stabilized by placing pins proximal and distal to the fracture and incorporating these pins in a short-arm cast. The results of 36 patients treated in this manner were analyzed. An excellent result was achieved in 78% of the cases.


Computed tomography in the measurement of femoral anteversion. A new technique using computed tomography for measuring femoral anteversion is presented, with advantages over prior techniques. Computed tomography allows the visual portrayal of the cervical axis to be superimposed upon the diacondylar axis for direct goniometric measurement of the anteversion angle. Beyond its accuracy, the procedure requires no complicated positioning framework and can be done in a brief span of time.


Leg length discrepancy: how much is too much? A survey of 74 skeletally mature patients with leg length discrepancies of 1.5 cm or more revealed that patients with less than a 2.0-cm discrepancy did not consider their short leg to be a problem in any way. As the amount of discrepancy increased, there were more problems, although there was no critical "cutoff" point. Some patients functioned well athletically with discrepancies of over 2.5 cm. A survey of pediatric orthopedists reflected the wide variety of opinion regarding indications for equalization of leg length discrepancy noted in the literature. It is concluded that there seems little indication for equalization of discrepancies less than 2 cm. For larger amounts of discrepancy, "clinical judgment" still must be weighed on an individual basis, as individual variation among patients with leg length discrepancy confounds any precise classification of functional disability.


Equinus contracture following Bryant's traction. A case of a 14-year-old girl with both foot and hip sequelae secondary to the use of Bryant's traction at the age of 2 years, 8 months, is presented. It serves as a reminder of the dangers of Bryant's traction, which should be used with discretion, if at all.


Auditory screening.

Auditory screening. Hearing screening is one of the most viable techniques in the health screening arena. The procedures are sufficiently valid and flexible to meet the requisite goals at any age level. The yields are easily great enough to justify the relatively small expenditures for screening programs. When one considers that the proper identification of hearing loss can create fulfillment in life that would not otherwise have been possible, it is evident that these programs should be implemented universally.


Audiometric bone conduction.

Audiometric bone conduction. Audiometric bone conduction test data are obtained with a unit that permits comparison with a recognized standard because the unit can be calibrated to operate within specified limits. Proper calibration of the unit is necessary if the equipment is to be accurate. Two procedures can be helpful in determining the need for calibration: the average loss method and the input voltage measurement method. Neither should supplant calibration, but each offers a means of checking the output of the unit. Confidence in auditory test data is increased when there is a high degree of consistency among the various tests; the availability of several different tests in the audiometric series can be used to an advantage then in a determination of consistency. An additional opportunity to ascertain the existence of consistency is present when tuning fork tests are employed as part of the total evaluation. The use of a masking stimulus in the nontest ear simultaneously with the presentation of the test tone to the test ear can be extremely useful in defining the type as well as the extent of the hearing loss. Presentation of the test tone and the masking stimulus in controlled discrete steps is the key to the interpretation of masking results.


Speech audiometry.

Speech audiometry. Two aspects of speech audiometry, namely, the speech reception threshold and the speech discrimination scores, have been discussed in the light of their development and present day administration. Evidence was presented to forego the concept of phonetic balance in discrimination test messages for the preferable attributes of familiarity and equated list difficulty. Campbell's redistribution of the W-22 word lists was proposed as an available solution to one of these parameters. Some delineation of the single "maximal" discrimination score's relation to the prediction of the hearing impaired individual's ability to understand continuous discourse was offered. Diagnostic implications of speech audiometry were not treated.


Clinical applications of the auditory brain stem response. The auditory brain stem response is a powerful new tool for the detection and quantification of hearing impairment, especially in the pediatric population. It gives exact information about the functional status of the cochlea and brain stem pathways. The technique distinguishes recruiting from nonrecruiting losses, predominantly high frequency from flat losses, and retrocochlear from peripheral disorders. The recent introduction of bone conducted stimuli should soon permit the unambiguous separation of conductive and sensorineural losses.


Spinal cord injuries as a result of motorcycle accidents. The orthopaedic and neurological lesions of 21 cases of spinal cord injuries as a result of motorcycle accidents are reviewed. The thoracic spine and spinal cord were the site of injury in 76% of cases. Eight-one per cent of the thoracic injuries showed complete neurological lesions. A mechanism of injury is postulated.


Tropical paraplegia: a case of transverse myelitis, probably caused by schistosomiasis mansoni. In tropical regions transverse myelitis may be caused by involvement with schistosoma or the eggs of this organism. Although 200 million people seem to be infected with this disease, involvement of the spinal cord is rare. A case of a 15-year-old boy is described and some literature reviewed.


Traumatic rupture of the aorta and paraplegia. During the past 10 years, 15 traumatic ruptures of the aorta isthmus have been diagnosed. The most likely mechanism is that of a brutal deceleration. Three patients developed a complete mid-thoracic flaccid paraplegia. One died in a few hours of a complete rupture, the second after a few days from renal insufficiency, the third 12 days after, having been operated upon on the same day of the accident. All had associated lesions. Diagnosis can be very difficult in these patients, especially in the first few hours. Paraplegia is here considered as an aggravation ischaemic symptom with anuria and loss of blood circulation in the lower limbs. In delayed cases the vascular mechanism of the infarction of the spinal cord is discussed, either by compression of the intercostal arteries or by direct compression of the aorta itself. In our cases, the most likely mechanism is that of an obstruction of the lumen of the aorta by a torn inner coat. These patients must be transferred as quickly as possible to a cardiovascular surgical unit and operated upon immediately. Three cases of preoperative, rapidly progressive paraplegia with neurological recovery after the operation, have been reported in the literature.


Three unusual cases of spinal cord injury in childhood. Three cases of unusual traumatic spinal cord injuries are reported. The cases were referred to the neurosurgical unit of Nancy, one tetraplegia and one paraplegia caused by transfixing wounds which were overlooked after the injury. The transfixing wound caused an associated meningitis with tetraplegia, and in the second case the initial small plural effusion associated with paraplegia even, in a very short while, evoked a possible diagnosis of leukaemia amongst others, until the knowledge of trauma had been ascertained, the child being then immediately transferred to the neurosurgical unit. Spanking, in the last case, was the cause of an important luxation of T12-L1, at first with a complete paraplegia, and was associated with the fact that the child was only seen a few days after by a doctor and immediately referred. The child made a full recovery from his paraplegia.


Proceedings of the Annual Scientific Meeting of the International Medical Society of Paraplegia held at Stoke Mandeville from 28-30 July 1977 (Part II). Fracture dislocation of the cervical spine: a critique of current management in the United States. The author has been asked to review the hospital records and X-rays of 12 patients from various regions of the United States who have sustained fracture dislocations of the cervical spine. In no instance was the initial care considered to be appropriate. No patient was significantly improved by treatment although only 17% had apparent complete transverse cord syndromes on admission. Sixty-seven per cent of the patients became worse. In the latter group there were three patients who were admitted with either no neurological deficit or only minimal pyramidal signs. All of these three patients became tetraplegic as a consequence of their not being immobilised or placed in traction during periods of many hours to several days after admission. There is little evidence that the treating physicians understood the need for immediate immobilisation, proper examination, steroid therapy, adequate safe radiological examination, expedited traction, postural adjustments, or follow-up examination. After-care was poor, leading to excessive complication. Two patients were transferred in deteriorating condition to other hospitals without safeguards and with adverse result. The availability and the performance of neurological surgeons during the first critical hours after injury was generally suboptimal. Although all of the patients were admitted within an hour of injury only three were seen by a neurosurgeon within 2 hours of admission. Three patients were seen between 36 hours and 8 days. The remaining six patients were examined between 4 and 36 hours and at an average of 12 hours. Skeletal traction was instituted on an average of 11 hours after admission excluding one case of delay for 9 days. Only two patients had adequate reduction within 28 hours. Steroids were given to eight patients at an average of 6 1/2 hours following admission but usually in inadequate dosage. Five laminectomies and six anterior fusions were eventually performed. Two patients had both operations. One patient subsequently expired. No patient had a surgically remedial lesion or showed postoperative favourable change in cord function. Five operated patients developed spine deformity, persistent dislocation, spinal canal stenosis or instability. This care was generally attested to meet proper standards and to represent the treatment ordinarily rendered when academic and qualified neurosurgeons gave testimony regarding it. Neither the funding of care and research, nor the adopted codes governing treatment in accredited hospitals, nor accepted teaching would appear to have influenced the substandard of care provided these patients. Other statistics confirm this to be a prevailing circumstance.


Neurological recovery distal to the zone of injury in 172 cases of closed, traumatic spinal cord injury. The Southwest Regional System for Treatment of Spinal Cord Injury (Good Samaritan Hospital and St Joseph's Hospital, Phoenix, Arizona) treated 325 cases of traumatic spinal cord injury during the period June 1970 through December 1975. Of these, 172 met the study population criteria of the cases reported by Frankel et al. (1969) in their paper 'The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia'. These cases are compared with those reported by Frankel et al. (1969). Cases were divided into neurological categories. The demography of the two study populations was amazingly similar as was the neurological results. The means for the reported neurological changes show that the average recovery for patients treated at Stoke Mandeville was slightly greater for each neurological category; however, this difference was statistically significant only for cervical cases (P less than 0.01). One of the differences in the treatment given by the two centres was that the Southwest Regional System performed surgery on 39% of its cases and Stoke Mandeville none. The Southwest Regional System's non-operated cervical cases showed less average neurological recovery than Stoke Mandeville cervical cases (P less than 0.001). Comparison between the Southwest Regional System non-operated cases and operated cases revealed no significant differences within any neurological category. The average neurological change reported by both centres was relatively small, documenting that from the onset of injury the majority of people sustaining spinal cord injury are committed to living with paralysis, in most cases severe, for the rest of their lives.


Actual concept of osteoporosis in paraplegia. The osteoporosis which appears in paraplegics below the neurological lesion has been studied in 100 patients with the following parameters: quantitative X-rays, urinary hydroxyproline excretion, kinetic study of calcium metabolism by 45Ca, serum phosphorus and calcium, parathormone and calcitonin radio-immunoassay, quantitative histology, density fractionation of bone and amino-acid composition of fractionated bone analysis. All our results show that the important bone resorption occurring very early in the paraplegia is immediately followed by an increase of the bone repair. This osteoporosis below the neurological lesion in paraplegia represents an unbalance between the synthesis and the resorption of bone which possesses a large degree of activity. Furthermore, we demonstrated that the collagen of this bone is underhydroxylated. Following the quantitative X-rays and intraosseous phlebography results we have considered the aetiopathogenesis of this osteoporosis. It seems that vascular modifications due to the lesion of the autonomic nervous system play an important role and furthermore we believe that immobilisation represents only a minor factor in the aetiology of this osteoporosis.


Hypercalcaemia in adolescent tetraplegic patients: case report and review. The paper presents the case history of a 15-year-old boy with traumatic tetraplegia who developed hypercalcaemia within 6 weeks of injury. The condition was initially controlled by the infusion of intravenous fluids in large amounts and by the administration of calcitonin. After 3 weeks, calcitonin became ineffective. Eventually the hypercalcaemia responded to cortisone administered in low dosage. The endocrinologic implications of this observation are discussed.


A relationship between the composition of the urine and that of urinary tract calculi in spinal patients. Chemical analysis was carried out on 42 urinary phosphatic calculi obtained from 14 spinal cord patients (two to seven stones per patient) and on small samples taken from different sites in a further 17 large phosphatic calculi. In 'early' stones (removed up to 30 months after onset of the cord lesion) the ratio of calcium to magnesium was significantly higher than in 'late' stones. Samples taken from sites nearer to the centres of calculi contained more calcium and less magnesium than did those from more peripheral sites. This change in the composition of urinary calculi with time corresponds with the known alterations in urinary calcium and magnesium following spinal cord injury.


Epidemiology of spinal cord injury in the Rhône-Alpes Region, France, 1970-75. Three hundred and fifty-one cases of traumatic spinal cord injuries concerning only inhabitants of the Rhône-Alpes region have been collected at Henry Gabrielle Hospital. Incidence and prevalence are discussed, as well as male/female ratio, causes of accidents, and their relationship to sex, race, age, vertebral level, associated injuries and profession.


Past history and degree of depression in paraplegic individuals. The purpose of this study was to attempt to collect sufficient data to substantiate the clinical impression that the degree of depression in the paraplegic and his past history are correlated. It was hypothesised that the poorer the past history, the greater the degree of depression in paraplegic individuals. This study was conducted on ten paraplegic subjects from the Spinal Cord Clinic at Columbia Presbyterian Medical Center, Department of Rehabilitation Medicine, based on data obtained from the administration and scoring of the Depression Scale (D-scale) of the Minnesota Multiphasic Personality Inventory (MMPI) and by the clinical observation by the consulting psychiatrist with the Spinal Injury Clinic. Past history was assumed measurable as 'favourable' to 'poor' by the use of an original questionnaire. The results of this investigation suggested a relationship between a paraplegic individual's past history and the degree of depression. The study was deemed significant in presentation of an original past history questionnaire and in the prediction of future difficulties in the rehabilitation of paraplegics so that preventive measures could be instituted.


Incidence of traumatic paraplegia and tetraplegia in Norway: a statistical survey of the years 1974 and 1975. A survey based on interviews with all Norwegian hospitals, 62 in number, showed that in 1974 and 1975 respectively 65 and 66 traumatic spinal cord and cauda equina lesions were treated in Norway, a total of 131 or 16 . 5/million inhabitants/year.