Simulation study of QRS-T waves based on an eccentric spherical model of the heart. The relationship between the difference in the action potential duration in the myocardium and the T wave investigated by a mathematical model of the electrical activity of the heart. In this study we constructed an eccentric spherical model which duplicates the ventricles except for the interventricular septum. Our model is assumed to be composed of the working myocardium and the excitation conduction system which is uniformly distributed on the endocardial surface. The ventricular gradient was defined as a linear decrease (beta msec/cm) of the duration of the action potential from the endocardium to the epicardium according to the concept proposed by Wilson. Theoretical analysis based on this model strongly suggest that the ventricular gradient of 10-40 msec/cm accounts for the normal QRS-T angle since vectorcardiographic analysis have revealed that the QRS-T angle closely correlates with the angle (theta) between the directions of the propagation waves of depolarization and repolarization. The QRST waves in the standard limb and chest leads were calculated from the sum of the time-varying dipoles derived from the action potential, assuming that the heart was in a homogenous conducting medium. Simulated QRS-T waves were compatible with the clinically observed electrocardiograms not only under normal conditions but also with changes in the spacial position of the heart and the wall thickness. Positive T waves were obtained in the left precordial leads when the ventricular gradient was more than 20 msec/cm and when the amplitude of T wave increased with the transmural gradient. Our model also indicates that differences in the velocities of the excitation wave in the conduction system and the working myocardium may affect the polarity of the T wave.


Effects of diltiazem hydrochloride on renal hemodynamics and urinary electrolyte excretion. Dilitazem hydrochrolide, a potent coronary dilator, was administered in 18 patients to evaluate its effect on renal hemodynamics and urinary electrolyte excretion. Renal blood flow (RBF), glomerular filtration rate (GFR), and cardiac output were determined in 8 ambulatory patients by means of external counting of radioisotope dilution before and 3 or 4 weeks after the medication. Althoug RBF tended to increase after the therapy, there was no statistically significant change in RBF, GFR and cardiac output. Renal fraction of cardiac output (RBF/CO) showed a significant increase by 29.5% after the therapy, indicating that the renal vascular resistance decreased to a greater extent than the extrarenal vascular resistance. Standard renal clearance was performed in 10 inpatients whom 60 mg of dilitiazem was administered orally. Renal plasma flow (RPF) showed an average increase by 15% 3 hr after the administration of the drug, which was not, however, statistically significant. There was no certain trend for GFR and filtration fraction. Urinary sodium excretion (UNaV) began to increase one hr and reached its peak 2 hr after the medication in 9 out of the 10 patients. It may be concluded that diltiazem has a direct inhibitory action against the renal tubular reabsortion of sodium, although the participation of renal hemodynamics can not be denied.


Implication of renal prostaglandin E in urinary sodium excretion. To investigate the role of renal prostaglandin in the regulation of sodium metabolism, ruinary prostaglandin E excretion, an indicator of renal prostaglandin synthesis, urinary sodium excretion, plasma renin activity and urinary aldosterone excretion were measured in 84 normal subjects and 55 patients with essential hypertension on ad lib intake of sodium. The excretion rates of urinary prostaglandin E were 736.8 +/- 32.2 ng/day in normal subjects and 394.3 +/- 28.7 ng/day in essential hypertensives. The excretion rate was significantly decreased in essential hypertensives (P less than 0.001). A significant positive correlation was found between urinary sodium excretion and urinary prostaglandin E excretion in normal subjects (r = 0.39, P less than 0.001), and in essential hypertensives (r = 0.62, P less than 0.001). There was no correlation between the renin-angiotensin-aldosterone system and urinary prostaglandin E excretion in normal subjects as well as in essential hypertensives. The present data show that renal prostaglandin might be involved in the renal handling of sodium, and prove the possibility that the decrease of renal prostaglandin synthesis is one of the etiological factors in essential hypertension.


Effect of salt loading and calcium antagonist on the pressor response to angiotensin infusion in the rat. Elucidation of mechanisms of angiotensin tachyphylaxis will be necessary for explaning the continuous vasocontricting action of angiotensin in the vascular smooth muscle, which might be closely correlated to the high blood pressure in renin-dependent or vasoconstricting hypertension. From the results obtained sodium loading rats showed not only augmented pressor response to angiotensin but also inhibiting the appearance of its tachphylaxis under the infusion of Ca-antagonist dose enough to suppress the response to angiotensin in the rats of water drinking. Speculated mechanisms about this phenomenon has been discussed.


Storage form of renin in the dog kidney. A large part of renin was revealed to be stored in the remin granules as a soluble but hard to release form. Over 70% of the total renin in the granules could be released when the granules were ruptured by hypo-osmotic shock. Renin release from the isolated granules was limited within 20% of the total renin during incubation at 37C in an isotonic medium. 2. Without mechanical or osmotic shock renin granules were quite stable in a cold isotonic solution. Renin release from the isolated granules was not so much influenced by addition of cations which significantly stimulate renin release in vivo. Some cellular components may be required for the release process of renin from the granules as a mediator. 3. The molecular weight of the stored renin in the granules was shown to be 43,000 which was the regular size. Acidification of the extract of the renin granules altered neither molecular size of renin nor renin activity.


Effects of synaptic plasma membranes on release of acetylcholine from synaptic vesicles. The influences of synaptic plasma membranes on release of acetylcholine (ACh) from synaptic vesicles isolated from rat brain were examined. In the presence of ATP, Mg++ and Ca++ but absence of cytoplasm from the nerve endings, the synaptic plasma membranes did not increase ACh release indicating absence of a stimulating factor which is known to be present in the cytoplasm. In presence of ATP, Mg++, Ca++ and the cytoplasm, the synaptic plasma membranes inhibited ACh release from the synaptic vesicles in high K+ medium, though not in high Na+ medium. Binding of Ca++ by the synaptic plasma membranes was dependent on ATP, inhibited by Na+ and stimulated by K+. Thus, the synaptic plasma membranes may inhibit ACh release in high K+ medium due to reduction in the concentration of free Ca++.


Brainstem acetylcholine sensitive neurons activated by cutaneous impulses in cats. In order to determine the cholinoceptive mechanism associated with cutaneous inhibition of jaw-closing and lumbar motoneurons, the area related to the inhibition produced by stimulation of the superficial radial nerve was identified by a lesion within the pontomedullary reticular formation and effects of drugs upon neurons were studied within this area. The cutaneous inhibition, as tested by the inhibition of monosynaptic reflex activity of jaw-closing and that of hindlimb spinal motoneurons was completely abolished by lesion of the medial portion of the pontomedullary reticular formation, but was little affected by lesions of the lateral portion. Intravenously administered physostigmine (0.15--0.30 mg/kg) excited 11 of 21 neurons whereas electrophoretic ACh (90 nA) excited 26 and inhibited 4 of 96 brainstem neurons located in this area. Eight of 11 physostigmine, and 4 of 26 ACh excited neurons were reticulospinal neurons with axonal conduction velocities of 20--40 m/sec. From results presented here together with those reported previously, these physostigmine sensitive and ACh excited brainstem neurons, reticulospinal and non-reticulospinal neurons, could be cholinoceptive interneurons of the polysnaptic inhibitory pathway, from the superficial radial nerve to jaw-closing and hindlimb spinal motoneurons.


Enhancement of 5-hydroxytryptamine-induced contraction of the guinea pig ileum by a new sulfur compound, tripropylsulfonium bromide. In the presence of tripropylsulfonium bromide (TPS) (1 X 10(-4) g/ml), a new compound, the phasic contraction of the isolated guinea pig ileum to 5-hydroxytryptamine (5-HT) (5 X 10(-7) g/ml) was consistently enhanced ("TPS effect"). TPS alone increased moderatley the spontaneous movement of the ileum. When the contraction height was calculated as the percentage of that to 5-HT alone, such was observed in the "TPS effect" to be 167.1 +/- 3.6% (mean +/- S.E., n = 80). TPS did not enhance the contraction due to acetylcholine or histamine. The "TPS effect" remained unaffected in the presence of dibenzyline (1 X 10(-7) g/ml), was abolished by morphine(1 X 10(-6) g/ml), tetrodotoxin (2 X 10(-8) g/ml) adenosine (3 X 10(-6) g/ml) and atropine (1 X 10(-7) g/ml) and was not observed under anoxic conditions. Eserine (1 X 10(-8) g/ml) strengthened the "TPS effect" markedly. It is concluded that this effect may be the result of the potentiating effect of TPS on the action of 5-HT through the M receptors, possibly by the facilitation of the acetylcholine-liberation from the nervous tissue.


Interaction of benzyl alcohol with human erythrocytes. The uptake of benzyl alcohol by human erythrocytes and its binding to cell membranes were examined in vitro relation to its hemolytic actions. The hemolysis induced by benzyl alcohol was found to be time-, dose- and temperature-dependent. Little or no hemolysis was observed until the concentration of benzyl alcohol increased over a certain level. Radiotracer studies revealed that in contrast to the rapid cellular uptake which was independent of temperature, the binding of benzyl alcohol to membranes increased gradually with time and was dependent mainly on the temperature. The critical hemolytic levels of the alcohol bound to membranes were estimated to be about 500 nmoles/mg protein. The results obtained herein suggest that the process of hemolysis induced by benzyl alcohol depends on the binding of the alcohol to erythrocyte membranes.


Choleretic properties of ursodeoxycholic acid and chenodeoxycholic acid in dogs. Choleretic effects and properties of ursodeoxycholic and chenodeoxycholic acids given orally were investigated in comparison with dehydrocholic acid in conscious dogs with cholecystectomy. Ursodeoxycholic acid as well as chenodeoxycholic acid increased the bile flow and the concentrations of phospholipid, cholesterol and bile acids in the bile. After administration of either ursodeoxycholic acid or chenodeoxycholic acid, a great amount of each bile acid appeared in the bile. Ursodeoxycholic and chenodeoxycholic acids increased the outputs of phospholipid, cholesterol and bilirubin in the bile. On the other hand, dehydrocholic acid markedly decreased the concentrations and outputs of all the above materials in the bile, despite a considerable increase in the bile flow. After administration of dehydrocholic acid, 3alpha, 7alpha-dihydroxy-12-keto-cholanoic acid appeared in the bile instead of dehydrocholic acid. The results suggest that ursodeoxycholic and chenodeoxycholic acids are transported into the bile from the hepatic cells where they produce a choleresis due to the bile acid-dependent mechanism. Dehydrocholic acid is metabolized in the liver and the metabolites produced hydrocholeresis.


New method for evaluating bronchomotor and bronchosecretory activities: Effects of prostaglandins and antigen. We devised a new method for measuring responses of canine airway musculature, bronchosecretion and bronchial vasculature simultaneously, in situ, and investigated the effects of prostaglandins F2alpha and E2 and antigen-antibody reaction by using this model. The right bronchial artery was perfused with blood at a constant flow under artificial respiration. Airway musculature response was measured as a change in ventilation overflow with a modification of the Konzett-Rössler method; the airway secretory activity was measured with our stopper method for secretion volume and with the glass plate method for viscosity. Close intraarterial injections of prostaglandin (PG) F2alpha, 0.01--10 microgram, into the right bronchial artery produced bronchomuscular and vascular constrictions, while those of PGE2, 0.01--3 microgram, produced dilatation in a dose dependent manner. A close intraarterial injection of 1 mg protein of ascaris suum antigen to dogs with positive skin reaction produced bronchoconstriction and vascular dilatation. Thirty min intraarterial infusions of PGF2alpha, 0.3--3 microgram/min, and ascaris antigen, 0.03--0.3 mg protein/min, resulted in a dose-dependent increase in the volume of airway secretions, while those of PGE2, 0.1--1.0 microgram/min, did not alter the secretory activity. These findings indicate that prostaglandin F2alpha in relatively high doses increases both bronchomotor tone and bronchosecretory activity, as does antigen-antibody reaction with ascaris antigen, and that the present method is useful for evaluating effect of drugs on the respiratory tract.


Antihypertensive and antidiuretic effects of 3-hydrazino-6-[N, N-bis (2-hydroxyethyl) amino]-pyridazine (L 6150) in rats. 3-Hydrazino-6-[N,N-bis (2-hydroxyethyl)amino]-pyridazine (L 6150) has been reported as an antihypertensive vasodilator drug. We determined antihypertensive effect of L 6150 for 11 weeks in spontaneously hypertension due to clipping (CLIP). The effects of hydralazine (HZ) and ecarazine (EZ) were also determined for comparison. L 6150, HZ, and EZ showed antihypertensive effects in SHR, DOC and CLIP hypertensive rats. These drugs increased heart rate in SHR and DOC rats. In CLIP hypertension heart rate tended to be higher for 9--10 weeks after the treatments. These treatments diminished incidence of the vascular disease in DOC and CLIP. We also determined renal effects of L 6150, HZ and EZ in normal rats. These drugs decreased urine volume, and excretion of osmotically active solutes, Cl, Na, and K for 180 min after bicarbonate saline load. It is concluded that L 6150 is an antihypertensive drug with characteristics of the vasodilator in rats.


Effects of 2-(4-(2-imidazo[1,2-a]pyridyl)phenyl) propionic acid (Y-9213) and anti-inflammatory drugs on erythrocytes, polymorphonuclear leukocytes and lysosomes in vitro. 2-(4-(2-Imidazo[1,2-a]pyridyl)phenyl)propionic acid (Y-9213) with analgesic, antipyretic and anti-inflammatory activities significantly inhibited hemolysis of rat erythrocytes. Activity of Y-9213 (100--500 micrometer) on hemolysis was more potent than that of phenylbutazone, and less potent than that of indomethacin. The spontaneous release of enzymes from rat liver lysosomes by incubation alone was significantly inhibited by Y-9213 (1--100 micrometer) to the same degrees as phenylbutazone or tinoridine hydrochloride. Release of enzymes from the lysosomes by addition of phospholipase C (PLC, 0.03 units/ml) was slightly inhibited by Y-9213 (10--100 micrometer) and phenylbutazone (100 micrometer). Dexamethasone, prednisolone, hydrocortisone and tinoridine hydrochloride (1--10 micrometer) inhibited more potently the PLC-induced release than the spontaneous release. Y-9213 (1--100 micrometer) inhibited considerably the release of enzymes from intact lysosomes of rabbit polymorphonuclear (PMN) leukocytes. The release of enzymes from the PMN leukocyte lysosomes preincubated at 37 degrees C for 15 min was strongly inhibited by dexamethasone, prednisolone and hydrocortisone (1--100 micrometer), but not by Y-9213, phenylbutazone and indomethacin (100 micrometer). Y-9213 (0.1--10 micrometer) also inhibited significantly the phagocytic secretion of lysosomal enzymes from PMN leukocytes without affecting phagocytosis of the particles. Activity of this agent was similar to that of phenylbutazone, and less active than that of indomethacin, dexamethasone or prednisolone. Our results suggest that Y-9213 may stabilize membranes of erythrocytes and lysosomes and inhibit phagocytic secretion of lysosomal constitutents from PMN leukocytes.


Influence of tracheal muscular tone on the initiation of cough reflex. We devised a canine blood-perfusion preparation which made feasible administration of drugs directly at the local tracheal site. The hypothesis of Salem and Aviado on cough mechanism that a local airway constriction induced by stimuli may be a trigger in stimulating cough receptors was investigated using this preparation. Close intraarterial injections of acetylcholine (ACh) and histamine did not elicit a cough although intense tracheal constrictions were evident. The cough reflex elicited by electrical stimulation of the mucosa of isolated upper trachea in situ was accompanied by a slight systemic hypotension, tracheal vasodilatation and tracheal muscular constriction. The latter two changes occurred after a time lag following coughs. Close intraarterial infusions of isoproterenol and papaverine caused a prominent tracheal dilatation, but did not suppress the coughs. Pretreatment with atropine sufficiently inhibited cholinergic tracheoconstriction but had no effect on the electrically induced coughs. Furthermore, an augmentation of the tracheal muscular tone produced by an infusion of ACh did not enhance the cough reflex. In light of our observations, the aforementioned hypothesis should be reconsidered.


The involvement of catecholamine in scopolamine-induced locomotor activation and rotational behaviour in mice. Scopolamine-induced locomotor activation was studied in comparison with the responses to apomorphine and methamphetamine in mice. The responses to scopolamine and methamphetamine were markedly depressed by the pretreatment with the catecholamine synthesis inhibitor, alpha-methyl-p-tyrosine, while the activation response to apomorphine was not affected. p-Chlorophenylalanine did not affect the response to scopolamine. Phenoxybenzamine reduced the responses to scopolamine and methamphetamine, but did not affect the apomorphine response. Propranolol did not affect the responses to the three agonists, scopolamine, apomorphine and methamphetamine. Antipsychotic drugs haloperidol and pimozide reduced the responses to the three agonists. Haloperidol was especially effective in this regard. These results suggest the involvement of catecholamine in the locomotor activation produced by scopolamine. In the rotational behaviour model which is sensitive to dopamine receptor stimulating agents, effects of the three agonists were studied. Scopolamine produced the ipsilateral rotation in mice with unilateral striatal 6-hydroxydopamine-induced lesions. Methamphetamine induced the ipsilateral rotation, while apomorphine produced the contralateral rotation. The rotations induced by three agaonists were suppressed by pimozide. The results indicate the participation of dopamine in the scopolamine-induced rotational behaviour in mice.


Effects on atrio-ventricular conduction of propranolol, pindolol and carteolol in the dog heart in situ as assessed by automated devices. In open-chest dogs the heart rate was controlled at 150 beats/min and drugs were given intravenously. Propranolol (30 microgram/kg--1 mg/kg) prolonged the atrioventricular (A-V) conduction time and functional refractory period of the A-V conduction system (FRP) by blockade of the existing tone of the sympathetic nerves to the heart. The prolongation of the two parameters by the non-specific depressant action of propranolol was evident only at 3 mg/kg. Propranolol (3--30 microgram/kg) shortened the A-V conduction time in the heart deprived of the vagal and sympathetic tone, suggesting some sort of sympathomimetic effect. Pindolol in a wide range of doses (0.3--300 microgram/kg) exerted virtually no effect on the A-V conduction time and FRP, and its non-specific depressant action was apparent only at 3 mg/kg. Carteolol slightly prolonged the A-V conduction time and FRP only in low doses (1--10 microgram/kg), and in high doses (30 microgram/kg--1 mg/kg) it shortened the two parameters, reflecting its predominant sympathomimetic action.


Familial spastic paraplegia-clinical and pathologic studies in a large kindred. Clinical studies of members of a six-generation kindred of familial spastic paraplegia support the diagnostic distinction of a pure form of this autosomal dominant disease. Onset was in the fourth decade or later and symptoms were those of progressive gait difficulties with lower limb spasticity and weakness. Sensor, cerebellar and cranial nerve changes were absent. Pathologic changes in one member were confined to the lateral corticospinal tracts and in the fasciculus gracilis.


Acute right ventricular overload: an echocardiographic clue to pulmonary thromboembolism. Serial echocardiographic changes and angiographic correlation are presented in a patient with multiple pulmonary emboli. Interval development of right ventricular dilatation and paradoxical septal motion coincided with a clinical event which was proven angiographically to represent pulmonary thromboembolism. Echocardiographic findings suggested right ventricular pressure and/or volume overload. The differential diagnosis of this finding when acute is limited; pulmonary embolism is a prominent consideration. Echocardiography performed after the patient received anticoagulant therapy showed a complete return to normal. Echocardiographic evidence of right ventricular overload, particularly when acute, may indicate the presence of a pulmonary embolism, and may be clinically useful in selected cases.


[Psychophysiological correlations in paroxysmal forms of cardiac rhythm disorders]. Fifty-two patients with paroxysmal disorders of cardiac rhythm were under observation for periods of 6 months to 3 years. Paroxysmal supraventricular tachycardia was registered in 16, ventricular tachycardia in one, paroxysmal cardiac fibrillation in 35. The method of comprehensive examination of personality (modified MMPI test, Cattell's and Hekhausen's tests) made it possible to reveal certain characteristic features of the personality and the actual psychic condition of all patients. Treatment with modern psychotropic agents (predominantly tranquilizers) improved the course of arrhythmia considerably in most patients; a tendency to normalization of the psychic condition was noted simultaneously. The possible mechanisms of the effect of psychotropic agents on the course of arrhythmias are discussed.


[Results of implanting aortic valve xenografts into the tricuspid position]. From 1968 to 1976 transplantation of the tricuspid valve was performed on 47 patients with combined form of rheumatic heart disease. Hospital mortality was 36%. The follow-up period in 30 cases ranged from one to 7 1/2 years. Ten patients died in the late postoperative periods, only in one of them the cause of death was associated with incompetence of the transplanted valve. According to the findings of dynamic clinical follow-up, the function of the transplant in the other patients was quite satisfactory; at the same time, peculiarities of the phonocardiographic picture of valves treated by different methods were revealed.


[Surgical treatment of mitral stenosis]. Open and closed methods of mitral commissurotomy are appraised in comparison. Open correction of mitral stenosis was performed under conditions of extracorporeal circulation, closed correction was accomplished by the instrumental method from right and left approaches. The advantages of open mitral commissurotomy in complicated forms of the disease (intraatrial) thrombosis, calcinosis, restenosis, concomitant regurgitation) are demonstrated. The indications for both methods of surgical treatment are substantiated and recommendations for their effective application are given.


[Late results of mitral valve prosthesis]. The late results of mitral valve prosthetics were studied in 100 patients one to six years after surgery. Survival which was estimated by the actuarial method was 79.4% (15 patients died 2 to 34 months after the operation). The data obtained confirm the effectiveness of mitral valve prosthetics by means of the Soviet made MKch--25 and MKch--27 protheses. The operation ensures normalization of hemodynamics. Thromboembolic complications and bacterial endocarditis still present a serious problem. Patients with an implanted mitral valve prosthesis should be kept under dispensary surveillance.


[Diagnosis of paravalvular fistulae after mitral valve prosthesis]. The phonocardiography method is appraised and the correlative dependence of the data yielded by it is compared with the hemodynamic values in the diagnosis of paravalvular fistulas following mitral valve prosthetics in 11 patients. It was revealed that the duration of the interval from the sound of aortic closure to the sound of mitral opening is in close reverse relation (r = -0.61) with the level of the mean pulmonary-capillary pressure: the shorter the interval, the more severe is the disorder of hemodynamics in patients with paravalvular mitral insufficiency and the higher is the mean pulmonary-capillary pressure. Paravalvular fistulas in the 11 patients examined were manifested by the development of a systolic murmur.


[Analysis of the hemodynamics in patients with artificial mitral valve insufficiency]. Hemodynamic disorders which developed in 12 patients with artificial mitral incompetence were studied. A method developed in the clinic of analysing the findings of catheterization and cine-angiocardiography was used. The method of analysis of single-plane ventriculograms makes it possible to estimate the volume of blood regurgitated into the left atrium to an accuracy of several millilitres. The degree of artificial incompetence is determined from the relative regurgitation which is estimated by dividing the volume of returned blood flow by the total volume of ventricular ejection. It is concluded that the "malignancy" of the course of artificial incompetence is determined by a sharp reduction of the effective cardiac output (to 33--50% of the normal volume) against the background of rapid rapid exhaustion of the left ventricular myocardum.


[Anatomical and functional assessment of mitral stenosis using echocardiography before and after commissurotomy]. In 36 patients with pure mitral stenosis verified during catheterization and operation the results of echocardiography were compared with the operative findings. The changes in the mitral echogram and the degree of valve calcification before commissurotomy were studied. The hemodynamic changes in pulmonary circulation were approximately appraised by determining the degree of delay of the EF interval on the echogram of the anterior cusp of the mitral valve. Significant conformity between the dimished rate of diastolic movement of the anterior mitral cusp and the degree of mitral stenosis was established. The importance of the advancement of the posterior mitral cusp to the front of the horizontal line passing through point C of mitral valve closure in the appraisal of the degree of its stenosis is underscored.


[Quantitative analysis of the phonocardiogram configuration for determining the degree of aortic regurgitation in patients with combined acquired heart defects]. A phonocardiographic index for determining the presence and severity of aortic regurgitation in patients with complex combined valvular diseases is suggested. This index comprises the relation between the amplitudes of the early diastolic murmur and the second sound and the relation between the maximum oscillations in early and late systole. The first two parameters are measured from a phonocardiogram recorded from the site where the early diastolic murmur is registered best(left third or fourth intercostal space at the sternum), the last from the site where the systolic murmur of aortic origin is recorded best (right second intercostal space). The differences in the value of the index between 4 groups of patients with different degree of aortic regurgitation are statistically significant (p less than 0.05). The index makes it possible to distribute according to the phonocardiogram all patients into 4 groups with 17% classification error and 2 groups of practical importance (with and without marked regurgitation) with 5% error.


[Clinical anatomy of the heart in combined rheumatic heart defects]. Contrast cardioangiograms of 46 patients with combined rheumatic diseases of the heart were studied. Essential changes were found in the clinical anatomy of the heart. In accordance with these changes, the points of maximum sound and the zones of the spread of the murmurs in tricuspid valvular disease and mitral stenosis were displayed to the left, which should be borne in mind during physical examination of the heart and phonocardiography.


[Late results of closed methods of the surgical treatment of multiple valvular rheumatic heart defects]. The late results of surgical treatment of 178 patients with follow-up periods of 6 months to 8 years are analysed. The late results were much worse in stage IV disease, marked calcinosis of the valves, concomitant mitral or tricuspid regurgitation, intraatrial thrombosis, as well as in cases with a combination of these complications. Analysis of the actuarial curve showed that unfavourable dynamics of the remote outcomes were usually associated with inadequate aortic or tricuspid commissurotomy. It is underscored that a change in the surgical tactics in the direction of aortic valve prosthetics and correction of tricuspid valve defects and complicated forms of mitral stenosis under conditions of extracorporeal circulation is necessary.


[Late results of closed mitral commissurotomy]. The remote results of closed mitral comissurotomy were studied in 400 patients during a follow-up period of 7 years. The results were appraised on the basis of the stage of hemodynamic disorders (classification proposed by A.N. Bakulev and E.A. Damir), disability, and working capacity. Five years after the operation good remote results were noted only in 58% of patients, which is explained by inadequate correction of the defect by the closed method due to the frequently encountered gross morphologic changes in the valve cusps. For greater objectivity in the assessment of the remote results it is suggested to use the term "without objective improvement" instead of "satisfactory results" because the former reflects the patient's condition and the state of hemodynamic disorders in greater measure.


[Indices of the sympathetic-adrenal and hypophyseal-adrenocortical system reactions in myocardial infarct patients during physical rehabilitation]. Changes in the content of hormones of the cortical and medullary layers of the adrenals in 40 patients with myocardial infarction were studied during physical rehabilitation. Increased activity of the sympathetico-adrenal and hypophyseal-adrenocortical systems after therapeutical gymnastics was revealed. The greatest shifts in all indices were noted in the first and fourth movement regimens. Changes in the blood hormone content were most obvious. The importance of studying hormones during rehabilitation of patients by means of exercise therapy is discussed. Fluorometry was employed in tests for adrenal hormones in blood and urine and for determining their concentration.


[Instructions with prophylactic therapy (author's transl)]. Jurisdiction demands thorough information to be given to the patient concerning kind, extent and possible complications of diagnostic, therapeutic and prophylactic procedures.--Uncertainty prevails because reliable rules on the mode of instruction do not exist and if they would, such instructions could often affect the patient. Examples of problems of prophylactic treatment and questions to the legal experts concerning necessary instructions to be given to the patient are presented.


[Prophylaxis and explanation (author's transl)]. The doctor-patient contract results from the logical actions. As well as treating the patient to the best of his knowledge and capability the doctor has the subsidary obligation of explanation. This must be done so that the patient can estimate risks himself. There is no legal basis for the extent of the explanation. Typical complications are to be mentioned--but not all possible complications. But "what is a typical complication" is controversial. The less urgent the treatment, the more comprehensive the information. The responsible doctor must do the explaining himself--he may delegate this only in the case of professional hindrance because of other urgent cases. The content of the explanation should be written and countersigned by the patient. For minors and legally incapacitated the parents or the responsible persons must give their consent.


[On the legal situation associated with prophylactic measures in ophthalmology (author's transl)]. Every medical procedure (diagnosis, prophylaxis, treatment) is in German law an assault and must be preceded by evidence of actual consent of the patient. Is this consent not present, then the requirements for a legal process are there. The doctor has freedom of choice of treatment, but he must explain to the patient possible side-effects and complications i.e. enlighten the patient. A significant proportion of damage- and criminal processes are due to incomplete explanation. The kind, form and complications of a procedure must be mentioned understandibly--the complications independent of their incidence. The guidelines resulting from processes are vague and ambiguous. Formed notes with confirmation by a witness are advisable. The value of an explanatory booklet seems doubtful.


[Detachment surgery without drainage (author's transl)]. Detachment surgery without drainage was introduced in 1953 by Custodis and modified by Lincoff. In this method the retinal hole determines the surgical procedure. Subretinal fluid will disappear by fixating an explant the sclera under tension in the area of the hole. The size of the explant depends upon the size of the retinal hole. Radial orientation of the buckle proves to be an optimal tamponade for a horseshoe tear. The change from traditional extensive circumferential buckles and cerclages to radial orientation of the buckle in the area of the hole is to be considered as a logical evolution in detachment surgery. From 1970--1977 there were treated 1000 consecutive detachments with cryopexy and elastic episcleral sponges. Non drainage was done in 93% of the time. The extension of the detachments ranged in 84% of the time from over 1 to 4 quadrants. The surgical procedure, however, consisted in 96% of the cases in segmental buckles with a preference for radial orientation. Cerclage was found to be useful in 4% of the time; an aphakic detachment was no longer an indication per se for an encircling procedure. Reattachment occured in 83% of the cases after one operation and in an additional 8% after reoperation. The complications with this procedure were minor, extraocular and reversibel. In 2,7% of the time an infection was observed around the explant. After removal of the buckles infection disappeared in every eye, re-detachment did occur in none of the eyes.


[Ultrasonic investigations of the vitreous space in idiopathic retinal detachment (author's transl)]. 63 patients suffering from unilateral, idiopathic detachment of the retina were examined by the A-scan ultrasound method. A vitreous degeneration always appeared in eyes with detachment of the retina, and this was severe in 52 eyes. In the other eye the degeneration of the vitreous body was much smaller and in 11 eyes it was not at all proved by ultrasound. In 24 eyes with detachment of the retina the subretinal space could be examined and it was always acoustically heterogenous. The observations concerning acoustic characteristics of the vitreous body may be important in planning of operative treatment and prophylaxis.


[Diagnostic ultrasonography and X-ray computer tomography in space-occupying orbital lesions--a joint effort (author's transl)]. Diagnostic ultrasonography (A-and B-scans) and X-ray computer tomography are completely different in their physical bases. The yield, therefore, different informations in the examination of space-space-occupying lesions in the orbit. The informations which can be recorded from normal and pathologic tissues in the orbit are described in this paper. The value, but also the limitations, of the various diagnostic methods are demonstrated in clinical cases. The reliable diagnosis of unilateral, progressive pseudoprotrusion in high myopia by ultrasound exophthalmometry is described. Facilities and diagnostic value of ultrasonography and X-ray computer tomography in the localisation of orbital tumours and in the determination of their relationship to the orbital walls are discussed. The diagnostic management in intermittent exophthalmos, in orbital abscess and in Grave's disease is reported. The complete ophthalmic examination is followed by ultrasound exophthalmometry and--if indicated--A- and B-scan ultrasonography of orbital tissues. Computed X-ray tomography is indicated in all tumour-suspicious lesions within the orbit. The results of diagnostic ultrasonography and computed X-ray tomography may complete each other in a very helpful manner. The combined evaluation yields better results than the use of only one of these methods. In orbital varices we recommend, to supplement ultrasonography by venography and eventually arteriography. In diagnoses of orbital abscesses resulting from paranasal sinusitis it may usually suffice to combine ultrasound diagnosis with native X-ray examinations. Good interdisciplinary cooperation in diagnosis and therapy is mandatory in all patients with space-occupying orbital lesions.


[Fluorescence angiography as a basis for successful prophylactic and therapeutic light coagulation for diabetic retinopathy (author's transl)]. The fluorescence angiogramme served as a basis for the plan of treatment and as a criterion of treatment success in 192 patients with  diabetic retinopathy who underwent xenon-light coagulation between January 1971 and October 1972. In 64 patients this success could be statistically evaluated comparing the untreated partner eye according to the exact Fisher-test. The rate of success of light coagulation showed itself to be statistically highly significant (p less than 0.01%) with regard to retinal morphology and haemodynamics, but with regard to visual acuity only statistically barely significant (p less than 5%). For the influencing of the capillary occlusion process with light coagulation no statistical significance (p = 25.19%) was found, and for the influencing of the capillary permeation disturbances with light coagulation a slight statistical significancing of the capillary permeation disturbances with light coagulation a slight statistical significnace (p less than 5%) was calculated. For avoiding or hindering present or threatened new vessel formation with light coagulation we calculated a statistical significance of p less than 1%.


[Metastatic deposits of carcinoma in the choroid (author's transl)]. The authors report on choroid metastatic deposits from primary tumors of other organs with regard to a survey of the literature and personal observations. 85% of the choroid secondary growths occur after breast cancer in women with an average latency of 3 1/2 years. The ophthalmological appearances and the fluorescence-angiographical phenomena are discussed with regard to the differential diagnosis of melanoma and haemangioma of the choroid. The therapeutic procedure for secondary deposits of mamma carcinoma is considered.


[Metabolite changes and ulcer formation in the cornea. Experiments with acid burns of varying severity (author's transl)]. Acid burns with 0,25 n H2SO4 constantly cause mild corneal opacities. Burns with 2 n acid are too severe to be investigated for more than one week. Lactate and pyruvate levels drop in the aqueous and, less pronounced, in the cornea. A very similar decrease of glucose levels in aqueous and cornea can be found depending in its degree on the acid concentration used. In milder burns the levels return to normal within 2--3 weeks. The results can be explained by changes of the blood-aqueous barrier and of the rate of aqueous flow. It seems very unlikely that the metabolite changes cause the formation of corneal ulcers, as severe ulcerations can be found along with almost normal metabolite levels.


[The influence of Poly-HEMA and silicone contact lenses on corneal thickness (author's transl)]. The influence of permanent wear contact lenses (highly oxygen permeable silicone and less oxygen permeable highly hydrophilic Poly-HEMA) on corneal thickness was evaluated in 22 volunteers. Poly-HEMA lenses provoked a highly significant increase in corneal thickness not correlated with the fitting technique, while no significant variation in corneal thickness was observed under silicone lenses.


[Retinal detachment in the aphakic eye (author's transl)]. The picture of retinal detachment following cataractextraction is studied in 86 cases of aphakic detachment, and the hypothesis that two different forms of detachment exists is proposed. In order to study this hypothesis the time-interval, the refraction and the type of tear is analysed. The results seem to indicate that two forms are present. The first one, the so-called "non: aphakic" detachment, appears in the predisposed eye and will occur after a short time-interval. The other form, the "true" aphakic detachment appears at a later stage and though this form more often shows no clear-cut tear the prognosis seems to be somewhat better.


[Perimetry in glaucoma. Liminal and supraliminal stimuli (author's transl)]. With supraliminal, evenly moving targets absolute and relative glaucomatous visual field defects may be picked up as well as sensory alterations, even if static and kinetic perimetry seem to be normal. The method and their results in 53 eyes are described. Isolated findings in the nasal peripheral field are frequent and call for an accurate evaluation of this region in the search of early glaucomatous changes.


[On Harada's disease (author's transl)]. 2 cases of Harada's disease are reported: in one cases there was a most severe uveo-encephalitis, the other showed only ocular manifestation (according to Shimizu in about 95% of the cases), the diagnosis was made sure by fluorescence photography.


[Pyoderma vegetans of the eye-lid (author's transl)]. A cases of Pyoderma vegetans attacking only the outer skin of the eyelid and leaving free the conjunctiva is reported. The diagnosis of this rare condition, belonging to the pemphigus diseases, depends on clinical course and especially on histological investigation. The aetiology of Pyoderma vegetans still remains unknown, an immun-pathological mechanism is discussed.


[Reversible irregular corneal astigmation in disseminated neurodermatitis (author's transl)]. Neurodermitis disseminata may often involve the eyes. A case report is described with development of an irregular astigmatism of the cornea, which resolved spontaneously. Possibilities of transitory alteration of refraction are discussed.


[The Bifosolar Ideal light-protection spectacles (author's transl)]. Bifosolar glass is made without heating, therefore the phototropic material keeps unchanged its original light sensitivity. A further development of the Biofosolar glass leads to the "Bifosolar Ideal dual strenght glass". This can be used in reduced visual acuity by combining with additional corrections up to 8.0 dioptres. The author describes the manufacture and the technical data of the various Bifosolar glasses.


Breeding and reproductive physiology of the desert gerbil, Meriones crassus. Meriones crassus were bred under laboratory conditions. The mean gestation period was 21.6 days, with a range between 21 and 24 days. The mean litter size was 4.4. Mean litter size varied from 3.4 in October to 5.6 in April. Studies of vaginal smears revealed four phases of the estrous cycle, and the mean length of this cycle was 2--8 days. Most females experienced postpartum estrus, and the majority of postpartum matings were fertile. Mating was not observed during lactation. Implantation was delayed if the female suckled more than two young, and gestation was then prolonged to over 30 days. Young gerbils were weaned by the fourth week and attained adult size within 3 months from birth.


A mask for the artificial respiration of rats. A simple artificial respiration mask for rats was constructed from the drip chamber of an intravenous solution administration set. The mask was held in place by means of straps and a hole through which the maximillary incisors protruded. This mask permitted artificial ventilation during drug-induced respiratory paralysis, was easily and inexpensively constructed, and may be used with a variety of positive pressure respirators.


Surgical removal of the pyloric antrum in weanling rats. A method was devised for surgical removal of the pyloric antrum in 3-week-old rats. Contrary to published experiences with older rats, it was found that ligation of right and left gastroepiploic arteries was not necessary in young animals. Erythrocytes and fluids were routinely administered postoperatively, and recovered animals were denied access to water and food for 2 and 3 days, respectively. When the rats were fasted overnight prior to surgery, the recovery rate was 87% (27 of 31 attempted). Surgical sites were intact and showed minimal adhesions 2 months later. When overnight fasting was omitted, only 57% survived (8 of 14 attempted), because extensive manipulations were necessary to remove gastric contents, and this often produced shock.


An automatic apparatus for feeding successive meals to rats during predetermined time intervals. A method was developed to control the amount, composition and timing of four meals per day for laboratory rats. Food was weighed into cups and inserted under metal covers in cages. An apparatus was built and tested for retracting each cover and exposing the food at a predetermined time of day.


Isolation of Pasteurella aerogenes from the uterus of a rabbit following abortion. Pasteurella aerogenes was isolated from the uterus and peritoneal cavity of a rabbit which died 4 days after abortion. Histopathologic observations confirmed a bacterial infection. Mouse pathogenicity tests indicated that this organism was an opportunistic pathogen that might have been responsible for the stillbirths. The cultural and biochemical characteristics of this isolate were similar to those of the Pasteurella aerogenes isolated from swine. This is the first report describing the isolation of Pasteurella aerogenes from a rabbit.


Pathologic changes induced by an euthanasia agent. Dogs and cats killed by intravenous injection of either 0.3 ml/kg body weight T-61 or 100 mg/kg body weight pentoarbital and necropsied at less than 5 minutes or at 15 minutes after injection did not have gross or microscopic pathological changes. However, dogs and cats killed with T-61 at a dose of 1.0--1.5 ml/kg body weight and necropsied at 15 minutes after injection had significant gross and microscopic pathological lesions. Grossly, the lungs were severely edematous, did not collapse, and were deep red. Microscopically, the lungs had severe pulmonary edema and endothelial necrosis. Endothelial swelling of glomerular tuft vessels was also present. These lung and kidney lesions are classified as an euthanasia artefact.


Experimental production of longitudinal smooth muscle cells in the intima of muscular arteries. Longitudinal smooth muscle cells were produced in the intima of muscular arteries in order to determine their method of development. Longitudinally arranged smooth muscle cells are present regularly in the intima of muscular arteries in man. Although absent in mesenteric arteries of the rat, layers of these cells were formed in these arteries after the insertion of a ligature through the mesentery. The resulting damage to, and subsequent repair of the arteries in the fibrotic area around the ligature apparently induced the development of longitudinal, intimal smooth muscle cells. When the mesentery was fixed to the diaphragm in such a way that it followd its respiratory movements with intermittent stretching of the mesenteric arteries, intimal smooth muscle cells developed only when the ligature through the mesentery caused local damage. Intermittent stretching as such had no effect.


Energy dispersive x-ray microanalysis of mitochondrial deposits in sideroblastic anemia. Energy dispersive x-ray microanalysis was used to analyze mitochondrial and lysosomal iron-containing deposits in sideroblastic anemia. Although it has been previously known that these deposits contain iron by inference from Prussian blue staining, the possible presence of other cations as well as the nature of the anions present has not been identified. The results show that the mitochondrial deposits in erythroid cells have peaks for iron and phosphorus indicating that they do not represent calcifications which commonly occur following injury and that the  principal anion may be phosphorus. Studies of hemosiderin and ferritin aggregates in lysosomes of macrophages in the same bone marrow samples again reveal similar peaks for iron and phosphorus. The results also indicate the probable similarity of mitochondrial and macrophage deposists although ferritin itself was never identified in the mitochondrial deposits. The results illustrate the potential of this method for diagnostic and investigative pathology.


Functional, biochemical, and morphologic changes in alveolar macrophages following thoracic x-irradiation. Alveolar macrophages lavaged from mice at various times after 1800 rads of thoracic x-irradiation were compared to control mice. Determination of their numbers, size distribution, glass adherence, latex particle uptake, cytochemistry, morphology, protein, phospholipid, and hydrolytic enzyme composition showed that defective bacterial uptake and clearance, which has been demonstrated by other workers, may be related to a transient decrease in their numbers rather than activity. A decrease in numbers is explainable on the basis of a population of radiosensitive precursors in the lung interstitium. The work load in the alveolar space may prolong the duration of their residence in the alveoli as well as increase their size and content of hydrolytic enzymes and ingested surfactant components.


Freeze-fracture of membrane fusions in phagocytosing polymorphonuclear leukocytes. Freeze-fracture of rabbit polymorphonuclear leukocytes in the process of phagocytosing yeast cells shows changes in storage granule and phagosome membranes essentially similar to those described in mammalian secretroy cells during exocytosis. These changes consist of the clearing of intramembrane particle from limited zones of the fusing granule and phagosome membranes. After the completion of fusion, which leads to the incorporation of storage granule membrane into the phagosome membrane, particle-free patches are no longer visible, but the phagosome membrane contains some loose aggregates of particles. These data suggest that intracellular membrane fusion in polymorphonuclear leukocytes occurs through interaction of protein-depleted areas of the involved membranes.


Leprosy and ABO blood groups.

Leprosy and ABO blood groups. 250 patients of Lepromatous and Non-lepromatous Leprosy were studied. The statistical analysis showed that there is no relationship between the blood groups and Lepromatous or Non-lepromatous Leprosy. The results are discussed in comparison with the work of other authors.


Syndrome of crocodile tears caused by lepra bacilli. A case of the syndrome of crocodile tears as a result of tuberculoid type of leprosy is reported to lend support that the syndrome may be caused by this disease after a long period of its onset.


Effects of noise and rhythmic stimulation on the speech of stutterers. This study was designed to investigate the effects of noise and rhythmic stimulation on stutterers' vocal fundamental frequency, vowel duration, and vocal level, and the relation these variables have to one another and to stuttering during noise and rhythmic stimulation. Measurements of speech variables were obtained from audio and graphic-level recordings and from narrow- and broad-band spectrograms. Results indicated that stuttering was significantly reduced during noise and rhythmic stimulation with the reduction during rhythmic stimulation being significantly greater than the reduction during noise. Decreases in stuttering were correlated with increases in vowel duration during both conditions for seven of nine subjects. We interpret our findings to suggest that temporal changes in speech production are related to the decrease in stuttering that occurs during noise and rhythmic stimulation.


Toward measuring how well hearing-impaired children speak. Average intelligibility scores for a group of 37 hearing-impaired and two normally hearing adolescents were determined by 50 normal listeners and were compared with nine acoustically measured speech variables. These nine variables included measurements of consonant production, vowel production, and prosody. Regression analysis of the variables showed that three of the speech variables bore a multiple correlation of 0.85 with measured intelligibility scores. Two variables alone, the mean voice-onset-time difference between /t/ and /d/ and the mean second-formant difference between /i/ and /c/, accounted for about 70% of the variance in the intelligibility scores. To cross-validate the reliability of these correlations, intelligibility scores were subsequently predicted for another group of 30 hearing-impaired adolescents and then compared with intelligibility scores as determined by another group of normal listeners. For this second group, the correlation between measured intelligibility scores and predicted scores was 0.86, which indicates that the reliability of the predicting variables is high. Five of the nine variables correlated more highly with measured speech intelligibility than did pure-tone audiometric thresholds. The average speech intelligibility of all 67 hearing-impaired subjects was 76%.


Experimental acquisition of wh-questions in language-disordered children. Twenty-four language-disordered children were trained, through modeling with a problem-solving set, to produce a question form involving a wh- word-who, what, or where-in a structure requiring either auxiliary is or auxiliary does. Results indicated the subsequent use of the trained auxiliary across wh- words and, to a lesser extent, the subsequent use of untrained as well as trained wh- words. These results suggest that the training of one multioperation structure may result in the acquisition of two partially independent linguistic operations. Such patterns of acquisition could result in an increase in the efficiency of language training.


Vocal roughness and jitter characteristics of vowels produced by esophageal speakers. Audiotape recordings of sustained vowels produced by nine esophageal speakers were subjected to acoustic and perceptual analysis. Results indicated that (1) the magnitude of vocal jitter present in the vowels was substantially larger than that observed in normal speakers and speakers with laryngeal/vocal disturbance, (2) listeners could reliably rate the severity of vocal roughness in the vowels, (3) voices of esophageal speakers were characterized by varying degrees of vocal roughness, and (4) mean fundamental frequency, mean jitter, or jitter ratio measures did not serve as useful predictors of the perceived severity of vocal roughness. These findings are interpreted to suggest that the mechanism esophageal speakers employ to regulate fundamental frequency is substantially different from that employed by normal speakers and that the identity of physical variables underlying the perception of roughness severity in naturally produced human speech is not well understood.


Some waveform and spectral features of vowel roughness. Acoustic wave-period variation (jitter) and acoustic wave-amplitude variation (shimmer) associated with vowel phonations representing a range of vocal roughness were investigated. Twenty normal-speaking adult males phonated each of the vowels /u/, /i/, /v/, /a/, and /ae/, first normally and then with simulated abnormal vocal roughness. Twenty hoarse adult males, each presenting a medically diagnosed laryngeal pathology, also produced each of the five test vowels. To provide a measurable presentation of the frequency and amplitude variations of interest, each recorded vowel was band-pass filtered to isolate the fundamental frequency component. Relations of the jitter and shimmer indices (obtained from the filtered vowel waves) to acoustic spectral noise levels and to roughness ratings for the vowel phonations were studied. The findings supported the hypothesis that increases in vowel acoustic wave variability (estimated by period or amplitude variation or both) are associated with increases in vowel spectral noise levels and perceived vowel roughness. The findings also suggested, for most of the vowels studied, that cyclic peak amplitude variation may provide a better index of perceived roughness than cyclic period variation. Vowel spectral noise levels, however, may provide a more clinically useful indicant of vowel roughness than the waveform variability indices derived from the filtering procedure employed in this study.


Correlates of psychological dimensions in talker similarity. This investigation identifies correlates of psychological dimensions in talker similarity. Twenty adult male talkers recorded a monosyllabic word, and 13 acoustic measurements were made from spectrograms of each talker's production. All possible pairs of voices were presented to 11 adult listeners for similarity judgments via a paired-comparison paradigm. A four-dimensional INDSCAL analysis of the similarity ratings was employed to derive psychological dimensions of talker similarity. Correlations between the acoustic measurements and the INDSCAL dimensions revealed that fundamental frequency and word duration were moderately correlated with two of the psychological dimensions. The other two dimensions were not convincingly correlated with any of the acoustic measurements, but are best described as representing voice quality and talker age. A listener's familiarity with the talkers did not seem to influence his judgment of voice similarity.


Variation in perioral reflex amplitude prior to lip muscle contraction for speech. The purpose of this study was to examine variations in the amplitude of the perioral reflex that may occur during the reaction time interval before voluntary muscle contraction for speech. Four normal adults produced the syllable /wi/ as quickly as possible in response to a low level electric shock while electromyographic recordings of the orbicularis oris inferior muscle (OOI) were made. During the reaction time interval a precise mechanical stretch was applied at the corner of the mouth to elicit the first component of the perioral reflex. Analysis of the resulting data revealed a significant increase in perioral reflex amplitude occurring between 30 and 50 msec before the onset of voluntary OOI contraction. It is concluded that the observed increases in reflex amplitude were the result of increased excitability of brainstem interneurons and/or motoneurons mediating the perioral reflex. The central mechanisms underlying such excitability increases and their significance for understanding speech motor control are discussed.


Acoustic-reflex dynamics for pulsed signals. Contralateral acoustic-reflex measurements were taken for 10 normal-hearing subjects using a pulsed broadband noise as the reflex-activating signal. Acoustic impedance was measured at selected times during the on (response maximum) and off (response minimum) portions of the pulsed activator over a 2-min interval as a function of activator period and duty cycle. Major findings were that response maxima increased as a function of time for longer duty cycles and that response minima increased as a function of time for all duty cycles. It is hypothesized that these findings are attributable to the recovery characteristics of the stapedius muscle. An explanation of portions of the results from previous temporary threshold shift experiments on the basis of acoustic-reflex dynamics is proposed.


Central auditory function in stutterers. Central auditory function was assessed in 10 stutterers and 10 nonstutterers. Performance of the two groups was compared for seven audiometric procedures including acoustic reflex threshold, acoustic reflex amplitude function, performance intensity function for monosyllabic phonetically balanced (PB) words, performance intensity function for Synthetic Sentence Identification, Synthetic Sentence Identification with Ipsilateral Competing Message, Synthetic Sentence Identification with Contralateral Competing Message, and the Staggered Spondaic Word test. Relative to the control group, the performance of the stuttering group was depressed on three procedures--the acoustic reflex amplitude function, Synthetic Identification with Ipsilateral Competing Message, and Staggered Spondaic Word test. As a group, the stutterers presented evidence of a central auditory deficiency. The pattern of test results suggests a disorder at the brainstem level. The subtlety of the deficiency is emphasized.


Measurement of attack-release times in compression hearing aids. A system for measurement of attack-release times in hearing aids with automatic-gain-control circuitry is described, with a view toward implementing that portion of the ANSI S3.22-1976 Standard in which parameters for these measurements are specified. Signal generation is accomplished by using a phased-array loudspeaker arrangement designed to produce transient-free pulsed acoustic sinusoids. Output waveforms are captured by a commercial transient recorder, and are displayed in either an oscilloscopic or graphic mode. A specific means of calculating attack and release times is recommended whereby variously shaped output waveforms are amenable to the basic protocol outlined in the ANSI Standard.


Presentation by order of difficulty of test tasks to persons with aphasia. To determine the effects of arranging test tasks by order of difficulty, two test forms were administered to each of 20 patients with aphasia. The two test forms were split halves of the Porch Index of Communicative Ability. One of the test forms, Form EH, was presented to each patient with the subtests arranged for the individual subject in an order from easy to hard. The other test form, Form HE, was administered to each subject in the hard-to-easy order. There was no significant difference between the performance of the subjects on the Form EH and their performance on Form HE.


Intraoral air pressure during the production of /p/ and /b/ by children, youths, and adults. Peak intraoral air pressures produced by 12 children (age four to six years), 12 youths (age 10 to 12 years), and 12 adults (age 19 to 46 years) were measured during the production of /p/ and /b/ in 12 stimulus words placed in a carrier phrase. Mean pressures produced by children and youths were similar but significantly higher than those for adults. Pressures associated with /p/ were significantly higher than those associated with /b/ across all age groups. Mean pressures associated with the intervocalic context were significantly higher than for the postvocalic context. An inverse relationship was found between age and variability of intraoral pressure, and the variability of pressure associated with /b/ was greater across all age groups than that associated with /p/.


Inflectional morphemes in the manual English of young hearing-impaired children and their mothers. Spontaneous sign-language samples were collected in a controlled interactive situation from 20 young hearing-impaired children and their mothers. Inflectional morphemes in the samples were described by cher attributes and classified for syntactic function within utterances. Inflectional morpheme productivity did not increase significantly with age; mean manual English morphemes per utterance did increase with age. The first six inflectional morphemes used by the children studied were the same as those used by normal-hearing children. A good predictor of the child's use of inflectional morphemes was the mother's use of these morphemes.


Comprehension of inflectional morphemes by deaf children exposed to a visual English sign system. A test of morpheme-based concepts was administered to 67 deaf children who were exposed to Seeing Essential English (SEE). Results indicated that these children show the following order of acquisition for the inflectional morphemes tested: plural -s, past tense -ed, present progressive -ing, possessive -'s, third person present indicative -s, comparative -er, superlative -est, and present perfect -en. There were no effects of sex, age, or school from which the subjects were selected. The main contribution to the subjects' performances were their lengths of exposure to SEE.


Relation between sound intensity and the latency and amplitude of the brainstem auditory evoked response. This study investigated the relation of peak amplitude and latency to signal intensity for the brainstem auditory evoked response (BSAER). One thousand clicks were presented to obtain each averaged response. Responses were obtained to clicks presented at sensation levels of 15, 20, 30, 40, 50, 60, and 70 dB. Five adult males who demonstrated normal hearing served as subjects. Latency and amplitude for various wavelets were plotted against signal intensity. A consistent trend of decreased peak latency occurred with increased signal intensity. Contrary to previous reports, the amplitude of Wavelet V showed a linear growth with increased signal intensity.


Effects of signal rise time and frequency on the brainstem auditory evoked response. Two experiments studied the effects of signal rise time and frequency on the brainstem auditory evoked response. In Experiment 1, five different rise times were presented, fast (10 microseconds), 0.5, 1, 2.5, and 5 msec at a center frequency of 1000 Hz at three sensation levels, 20, 40, and 60 dB. As rise time was increased, response amplitude and detectability decreased and response latency increased. In Experiment 2, tonal pips were presented at 250, 500, 1000, 2000, 4000, and 8000 Hz at 40-dB sensation level. Although the effects of frequency and signal rise time were confounded, no frequency effect was apparent.


Drinking patterns in Western New York State. Comparison with national data. A survey of 1041 adults in Western New York State revealed many of the general associations between drinking patterns and selected sociodemographic factors seen nationwide, but the absolute rates of heavy drinking were consistently higher.


Drinking patterns of greater Boston adults. Subgroups differences on the QFV index. A survey of the Boston metropolitan area correlated drinking patterns with sex, age, race, marital status and social class; findings were compared with previous studies in Boston, San Francisco and nationwide.


Tribal affiliation and prevalence of alcohol problems. Differences in tribal culture, history and settlement may explain why Indians in eastern Oklahoma have lower rates of alcohol-related arrests and deaths than do Indians in the western part of the state.


Attitudinal and normative variables as predictors of drinking behavior. In a study of three groups of subjects, attitudes toward drinking were positively related to drinking behavior, and personal, but not social, normative beliefs were useful predictors of drinking.


Effect of intravenous infusion of ethanol on plasma glucose, lactic acid and pyruvic acid concentrations in miniature swine. Fructose, infused intravenously with ethanol, alleviated ethanol-induced hypoglycemia in adult miniature swine at all concentrations tested. Increases in plasma lactic acid and pyruvic acid concentrations also were found.


Lower dominance ranking associated with delay in development of aversion to ethanol in mice. Mice with a slower development of aversion to 3% ethanol solutions were slower to develop aggressive combat skills. Plasma testosterone levels did not decrease in another similarly treated group.


Effect of ethanol on carbohydrate metabolism. II. Influence on glucose tolerance in diabetic rats. A single moderate dose (0.4 g per kg of body weight) of ethanol given orally with a glucose load resulted in exaggerated glucose intolerance and inhibition of glucose mediated-insulin response in mildly diabetic rats.


The alcoholic's spouse, children and family interactions. Substantive findings and methodological issues. Literature on the personality characteristics of spouses of alcoholics, on the psychosocial status of children of alcoholics and on alcoholic-spouse and alcoholic--family interactions is reviewed.


Correspondence between reports of problem drinkers and spouses on drinking behavior and impairment. Correlations between patients' and spouses' reports of drinking were modest when relatively precise measures of drinking were used but stronger when more global measures were used.


Empirical derivation of a partial personality typology of alcoholics. Based on data from the 16 Personality Factor Questionnaire, personality profiles were derived allowing partial classification of 65 to 70% of a group of alcoholics into three categories.


Evaluation of a Salvation Army alcoholism treatment program. The functioning and participation of 97 men in a treatment program were analyzed in what was judged to be a cost-effective program for Skid Row alcoholics.


Arrests, readmissions and treatment following release from detoxication centers. Six months following discharge from a detoxication center, almost half of the 522 men studied were arrested, more than half were readmitted to detoxication centers, more than a third entered residential treatment and a quarter began outpatient treatment.


The impact of training on career mobility of alcoholism counselors. A follow-up study. Graduates of a training program for alcoholism counselors were more likely to remain in the field of alcoholism treatment than were rejected applicants, but the training did not enhance their career satisfaction and advancement.


Social drinkers' self-regulation of alcohol intake. When drinkers attempted to reproduce a particular drug state, the average difference between the two blood alcohol concentrations was 0.013%.


Alcohol-related acts of violence: who was drinking and where the acts occurred. Most of the alcohol-related acts of violence studied were martial or other common assaults, the former usually occurring in a private residence after the offender or both spouses had been drinking and the latter likely to occur anywhere after the victim had been drinking.


Control orientation and disulfiram.

Control orientation and disulfiram. Alcoholics electing to take disulfiram were significantly more externally oriented, as measured by Rotter's Internal-External Locus of Control Scale, than were alcoholics not electing to take disulfiram.


Impact on traffic safety of the introduction of Sunday alcohol sales in Perth, Western Australia. An analysis of the number of persons killed and casualty accidents in the 3 years before and after the introduction of Sunday sales of alcoholic beverages in Perth, Western Australia, indicates that the new laws had a detrimental effect on traffic safety.


Use of breathalyzer scores in the evaluation of persons arrested for driving while intoxicated. Because of their moderate correlation with Breathalyzer measurements of blood alcohol concentration, self-reports and clinical judgments of alcohol consumption are unreliable.


Tracheobronchial mucoepidermoid carcinoma. Clinicopathological features and results of treatment. Mucoepidermoid carcinomas of the tracheobronchial tree are extremely uncommon and, as a result, opinions regarding their natural history are conflicting. In an effort to determine whether the tumors are aggressive or relatively benign, we have collected seven well-documented, previously unreported cases from among 4,250 primary pulmonary carcinomas and 116 bronchial adenomas. The two tracheal and five endobronchial lesions presented here include one high-grade and six low-grade tumors. Curative resections were performed, including segmental tracheal resections in two patients, lobectomy in three patients, and pneumonectomy in two patients, and the follow-up is complete to the time of this report. Long-term survivals ranging from 5 to 23 years, averaging 12.8 years, have been achieved in the six patients with a low-grade carcinoma. The one high-grade variant proved fatal within 28 months of diagnosis despite two surgical attempts at control and radiotherapy. It is concluded that these tumors exhibit a spectrum of virulence with low-grade lesions amenable to long-term surgical cure. The optimum treatment of high-grade lesions remains problematical.


Endobronchial lymphoscintigraphy (EBLS). New diagnostic modality. A safe, simple method of visualizing deep intrathoracic lymph nodes and determining regional tracheobronchial lymphatic drainage with colloidal radionuclides has been developed. The tracer is injected submucosally via a bronchoscope and lymph node scanning is performed at least 2 hours later. The technique was developed and tested in seven canine experiments. Endobronchial lymphoscintigraphy (EBLS) has been performed in 43 patients undergoing routine bronchoscopic examination. 99mTc phytate, 198Au colloid, and 99mTc antimony sulfide have been used; the last appears to have been the most satisfactory. The primary lymphatic drainage from selected sites of the tracheobronchial tree could be determined. Up to five lymph nodes have been visualized, with an average of 2.1 lymph nodes seen in those patients with lymph node visualization. Four patterns of lymphatic drainage were seen; ipsilateral ascending, contralateral ascending, descending, and no spread of injected colloid. In some cases cervical and celiac lymph nodes were seen. In combination with conventional diagnostic methods, EBLS in many cases clarified the extent and nature of underlying disease.


Tracheal growth and healing.

Tracheal growth and healing. Studies of tracheal growth in the rat, puppy, and human being indicate that there is a linear relationship between body weight and tracheal cross-sectional area. Each tracheal cartilage grows continuously, and there appear to be no growth centers. Each cartilage enlarges by proliferation of chondrocytes on the convex surface and resorption of cartilage on the concave surface. Vertical incisions in the trachea heal by fibrous union without interruption of growth. These studies indicate that there is no optimal age for surgical repair of subglottic stenosis, since growth is constant and is not interrupted by vertical incisions in the tracheal rings.


Reasonable surgery for thoracic neuroblastoma in infants and children. Neuroblastoma is the most commonly encountered soft tissue malignant tumor of childhood. Over the past 30 years we have treated 180 patients with neuroblastoma. Sixty-five percent had primary abdominal tumors and 20 percent (41 patients) had primary chest tumors. For the 22 patients under the age of 2 years, the 2 year survival rate was 87 percent. There were 19 patients who were 2 years of age or older, and of these only seven patients have survived 2 years after the diagnosis was made. The vast majority of these patients were treated with surgery (debulking type procedure) and postoperative radiation and chemotherapy. Patients with the most differentiated tumors had a remarkably good survival rate, with no deaths. However, the tumors with lesser differentiation did not stratify enough focus to draw conclusions as to survival. Staging correlated the least with survival when compared to age or grading. The 2 year survival rates for patients with Stage I, II, III, IV, and IV-S disease were 75, 82, 100, 17, and 80 percent, respectively. In conclusion, 41 cases of documented primary thoracic neuroblastoma are reviewed, with follow-up from 2 to 27 years (average 9.3 years). We have concluded from this experience that age is the main determining factor influencing survival. Heroic and/or radical surgery is contraindicated in this disease.


Effect of pulmonary microembolism on arteriovenous shunt flow. The effects of acute pulmonary hypertension on the fraction of cardiac output shunted through pulmonary arteriovenous communications have been studied in dogs as a possible cause of hypoxia following pulmonary embolization. Pulmonary artery pressure was increased twofold and then fourfold above control values by embolization of the pulmonary vascular bed with polystyrene microspheres. Quantitative measurements of arteriovenous shunt were determined from the fraction of 50 mu radioactively labeled microspheres injected into the inferior vena cava which passed through the pulmonary circulation into systemic vascular beds. There was no increase in the fraction of pulmonary blood flow passing through pulmonary arteriovenous connections, 50 mu in diameter or greater, with pulmonary microembolism when FIo2 was 1. There was a small increase in arteriovenous shunt fraction when pulmonary artery pressure was increased with an FIo2 of 0.21. Physiological shunt measured by the oxygen technique did not increase with pulmonary embolism, but total venous admixture rose significantly. Postmortem gravimetric measurements of lung water indicated pulmonary edema. We conclude that anatomic arteriovenous shunt channels have little physiological significance after pulmonary microembolism in the dog lung. The major cause of hypoxia immediately after pulmonary microembolism is ventilation/perfusion imbalance, probably caused by pulmonary edema.


Sequential evaluation of DNCB reactivity in patients with primary lung cancer. Correlation with prognosis. Delayed hypersensitivity reactions before therapy in 137 patients with lung cancer and in 50 patients with benign thoracic lesions were evaluated by 2,4-dinitrochlorobenzene (DNCB) contact sensitization using the patch test. Ninety-eight percent (49/50) of control patients and 46 percent (62/137) of patients with lung cancer were sensitized by 250 mug of DNCB. There was an excellent correlation between the initial reactivity to DNCB and resectability. In patients with resectable lung cancer, preoperative DNCB reactivity has no prognostic value. However, an excellent correlation was found between postoperative reactivity and 2 year survival, i.e., conversion from unresponsive to responsive status was observed on sequential testing. In 15 of 74 patients with resectable disease, the conversion was noted postoperatively, and among 12 patients followed for 2 years, only two patients had died. Conversion from a reactive to nonreactive status to DNCB occurred only in the terminal stage of the disease. From these observations, we found that, in order to evaluate the afferent limb of cellular immunity in patients with lung cancer who have once expressed reactivity to DNCB, one must use some new sensitizing agents which show no cross-sensitivity with each other thereafter.


Assessment of the isolated right atrium as a pump. The ability of the hemodynamically isolated dog right atrium to pump against a resistance equivalent to normal pulmonary artery pressure was tested in an in vivo preparation. At a preload of 10 mm. Hg, the right atrium reached a peak systolic pressure of 18.2 mm. Hg (+/- 1.3 S.E.M.) against an afterload of 12 mm. Hg, but it could eject a flow only equivalent to 53 percent (+/-6) of the dog's cardiac output (n = 6). At a preload of 15 mm. Hg, a peak systolic pressure of 21.5 mm. Hg (+/- 0.8) was recorded against an afterload of 17 mm. Hg, but again, only 55 percent +/-5) of the dog's cardiac output was ejected. It appears that the cardiac output from the nonhypertrophied right atrium is limited by the strength of the right atrial contraction and the physiological limits imposed by the venous driving pressure.


Use of microporous expanded polytetrafluoroethylene grafts for aorta-pulmonary shunts in infants with complex cyanotic heart disease. A report of seven cases. Seven cyanotic infants in our institution have undergone central aorta--pulmonary artery shunt operations with a microporous expanded polytetrafluoroethlene (PTFE) graft. All of these patients have had pulmonary atresia, in four cases associated with endocardial cushion type defects. Four patients have had excellent palliation for up to 13 months. Congestive heart failure and kinking of the pulmonary artery, frequently seen with other types of central aorta-pulmonary shunts, have not been a problem. Until further experience is gained with this procedure, however, we reserve its use to the occasional cyanotic infant in whom neither open-heart repair or the Blalock-Taussig shunt is feasible.


Use of temporarily placed epicardial atrial wire electrodes for the diagnosis and treatment of cardiac arrhythmias following open-heart surgery. We retrospectively assessed our experience with the use of bipolar atrial epicardial electrodes in 70 consecutive patients following open-heart surgery. These patients, representing 1 month's experience on one of our cardiac surgical services, are a random sample of our total experience with more than 6.000 patients in whom we have routinely placed such electrodes. The atrial wire electrodes were used diagnostically and/or therapeutically in 57 patients a total of 139 times. In only 13 patients were the atrial wires not used for any reason. Atrial electrograms were recorded 63 times in 34 patients, 41 times to establish a diagnosis of an arrhythmia and 22 times to confirm the diagnosis of an arrhythmia originally suspected from interpretation of a standard or monitor electrocardiogram (ECG). Atrial pacing was used to treat abnormalities of rhythm or conduction or both in 75 instances in 49 of the 70 patients. Because of their great utility in the diagnosis and treatment of arrhythmias, we conclude that routine placement of atrial wire electrodes at the time of operation is indicated regardless of the nature of the open-heart procedure or the preoperative rhythm.


Quantitative evaluation of myocardial ultrastructure following hypothermic anoxic arrest. Thirty-six anesthetized mongrel dogs were subjected to systemic hypothermia and anoxic cardiac arrest while on cardiopulmonary bypass. Myocardial fine structure in the left ventricle was evaluated by quantitative analysis in the subepicardial, mid-myocardial, and subendocardial layers. The specimens were obtained by a transmural myocardial biopsy method. Graded hypothermia was employed at 36 degrees, 30 degrees, 28 degrees, 25 degrees, and 22 degrees C. The aorta was cross-clamped for 30 minutes at 36 degrees, 30 degrees, 28 degrees, and 25 degrees C. or for 45 minutes at 25 degrees and 22 degrees C. Observations indicated that pathological changes of the myocardial fine structure were significant after anoxic arrest in the normothermic group. Lesions were most extensive in the subendocardial layer after normothermic anoxic arrest, whereas hypothermia below 30 degrees C. preserved the myocardium throughout all layers without difference in pathological changes in the fine structure among the layers. Mitochondria and glycogen granules in the mid-myocardial layer and the subendocardial layer were best preserved with hypothermia at 25 degrees and 22 degrees C. after 30 minutes or 45 minutes of anoxic arrest, and dogs in these groups had a survival rate of 100 percent. Quantitative analysis of ultrastructural changes induced in these experiments suggest that a safe duration of anoxic arrest at 22 degrees to 25 degrees C. is between 30 and 45 minutes.


Effect of intra-aortic balloon pumping on nutrient coronary flow in normal and ischemic myocardium. The effects of intra-aortic balloon pumping (IABP) on myocardial flow distribution were studied in 50 dogs. Cardiac output was controlled by right heart bypass. In each dog the following parameters were measured with and without IABP during normal coronary perfusion and after regional ischemia was induced by anterior descending coronary vein flow by timed collection, and endocardial/epicardial flow ratios by a previously reported thermal washout technique. In nonischemic myocardium, IABP significantly (p less than 0.05) increased mean coronary sinus flow 11.5 percent +/- 5.8 percent (S.D.) and the mean endocardial/epicardial ratio, 17.3 percent +/- 0.28 percent. In the regionally ischemic myocardium, IABP significantly (p less than 0.05) increased mean segmental coronary vein flow 13.9 percent +/- 1.23 percent but decreased the endocardial/epicardial ratio 29.9 percent +/- 1.1 percent. We conclude that in the dog, IABP enhances subendocardial blood flow in perfused but not in ischemic myocardium. Contrary to common suppositions, the increase in collateral blood flow with IABP preferentially supplies epicardial layers in segmental ischemic zones, but may be shunted from the subendocardium.


False aneurysm of the left ventricle. Surgical treatment. The clinical and pathological features in three cases of false aneurysm of the left ventricle are reported. In two instances the condition developed after myocardial infarction, and in the third case a mycotic pseudoaneurysm developed after purulent pericarditis. All three patients were in intractable heart failure before urgent operation. The correct diagnosis was established preoperatively by angiography. In all three cases the aneurysms were successfully resected and the left ventricle reconstructed. An aggressive surgical approach is warranted in the management of this lesion.


Mediastinal masses of vascular origin. A review. Vascular lesions must be considered in the differential diagnosis of mediastinal masses. Knowledge of the vascular anatomy of the mediastinum and the clinical setting, as well as an awareness of key radiographic features, should suggest the vascular origin and guide appropriate diagnostic imaging. Although angiography is used most often, radionuclide flow studies and computed tomographic scanning may also be useful.


Effect of cross-clamp time, temperature, and cardioplegic agents on myocardial function after induced arrest. To evaluate the importance of time, temperature, and cardioplegia on the ability of the canine myocardium to maintain functional and ultrastructural integrity following induced arrest, we studied 220 dogs by varying myocardial temperature (34 degrees, 24 degrees, and 11 degrees C.), arrest time (0 to 120 minutes), and cardioplegic agents. Change in left ventricular function (LVF) was defined as the arithmetic difference in the center of mass between prearrest and postarrest LVF curves and was expressed as percent recovery of left ventricular stroke work. Left ventricular biopsies were obtained for semiquantitative electron microscopic analysis. After 90 minutes of cross-clamping, only hearts protected with combined hypothermia (H) and potassium-induced cardioplegia (K) significantly recovered prearrest function (24 degrees C.--80 percent, 11 degrees C.--99 percent). Hypothermia (H) alone for 90 minutes was less protective (24 degrees C.--49 percent, 11 degrees C.--59 percent). H preserved 84 percent of function after 60 minutes and 91 percent after 45 minutes. Normothermic arrest resulted in only 39 percent return of function at 45 minutes but could be extended with potassium-induced cardioplegia(K) to 78 percent at 60 minutes and 54 percent at 90 minutes. The addition of procaine plus HK improved protection over HK alone (95 percent versus 80 percent) but by itself was not effective. Neither hydrocortisone nor pretreatment with glucose-insulin-potassium, branched chain amino acids, or propranolol increased the protective effect of HK plus procaine. Inadequately protected groups (normothermia or H without K) showed more myocytic and capillary endothelial damage than the HK groups. No technique of myocardial protection studied completely preserved LVF, but the combination of HK plus procaine resulted in maximal recovery of LVF following cross-clamping for up to 120 minutes.


Surgical correction of chronic postembolic obstructions of the pulmonary arteries. Following episodes of pulmonary embolism, the presence of thrombi in the pulmonary arteries leads to severe respiratory insufficiency and chronic right heart failure. We have operated upon 16 such patients, nine men and seven women from 23 to 68 years of age. All had severe dyspnea, 14 had chronic cor pulmonale, six had mental disturbances with syncope, and four had severe cardiac failure. The presence of clots was demonstrated by pulmonary angiography, and the permeability of the distal arterial bed was ascertained by selective injection of the bronchial arteries. In all cases but two a lateral thoracotomy was used so that the obstructed arterial branches could be approached distally. The inferior vena cava was always ligated to prevent recurrences. There were six operative deaths, three from cardiac failure, one from acute pulmonary edema, one from hemothorax, and one following a pyothorax. Ten patients are surviving after 6 months to 10 years. One is still limited because of significant pleuropulmonary sequelae. Six are enjoying good results with marked improvement in their functional limitations, a significant drop in the pulmonary artery pressure, and radiological permeability of previously obstructed arteries. Three are excellent condition--completely asymptomatic.


Conservative management of uremic pericardial effusions. Although there has been a recent trend toward early operative treatment of uremic pericardial effusions unresponsive to intensified dialysis, this approach may be unnecessarily aggressive. Review of 787 patients in our chronic dialysis program since 1969 has shown 54 patients (6.9 percent) to have developed 56 episodes of large pericardial effusion. All were managed by increasing the frequency of dialysis. If the effusion failed to diminish or if life-threatening signs of tamponade developed, pericardiocentesis was performed. In 63 percent (35/56) the effusion resolved with increased dialysis. In 37 percent (21/56), pericardiocentesis was performed, with 57 percent (12/21) requiring only one aspiration. During a mean follow-up of 34 months (2 to 100 months) only 5.5 percent (3/54) have undergone operation: one partial pericardiectomy incidental to pulmonary decortication and two pericardiectomies for late (3 months and 5 months, respectively) constriction. There were five complications of pericardiocentesis: one pneumothorax, one pneumoperitoneum, one costochondritis, and two myocardial punctures without sequelae. The one death related to pericardial effusion in this series occurred in a home-dialysis patient who arrived in the emergency room moribund. Our experience suggests that the great majority of uremic pericardial effusions can be effectively controlled with simple needle aspiration by experienced personnel and that pericardial resection is usually not necessary.


Role of angiography in cervicothoracic trauma. The role of angiography in cervicothoracic trauma is controversial. Since 1967 the policy at San Francisco General Hospital has been to use liberal indications for angiography in hemodynamically stable patients with either penetrating or blunt cervicothoracic trauma. The 304 patients in Group 1 had emergency angiographic evaluation: 102 had penetrating cervical wounds: 202 had thoracic injuries-71 penetrating and 131 blunt trauma. During the same time period, 72 patients (Group II) had cervical or thoracic vascular injuries and underwent operative treatment without preoperative angiography. Sixty-six patients in Group 1 had significant vascular injury. Thirty patients with penetrating cervical injury had 38 vascular lesions. Thirty-six patients with gunshot or blunt chest trauma had 43 vascular lesions. Group II patients had two main indications for operation: exanguinating hemorrhage (45 patients) or suspected vascular injury, usually associated with hemorrhage (27 patients). Angiographic results were useful whether abnormal or normal. In cases with adnormal findings operative treatment was specific and improper incisions were avoided. In cases with normal angiographic results, clarification of the vascular status avoided unnecessary operations and permitted concentration of therapeutic effort upon the main clinical problems of the patients.


Esophagectomy without thoracotomy.

Esophagectomy without thoracotomy. Blunt esophagectomy without thoracotomy has been performed in 26 patients: four with benign disease and 22 with carcinomas involving various levels of the esophagus (10 cervicothoracic, one upper third, five middle third, and six distal third). Continuity of the alimentary tract was restored by anastomosing the pharynx or cervical esophagus either to stomach (19 patients) or to a colonic graft (seven patients). Esophageal resection and reconstruction were performed in a single stage in 25 patients, and the esophageal substitute was positioned in the posterior mediastinum in the original esophageal bed in 24 patients. There were no deaths directly related to the technique of blunt esophagectomy. Average intraoperative blood loss was 1,350 ml. for the entire group, 1,650 ml. for those requiring concomitant laryngectomy and 1,050 ml. for those undergoing esophagectomy without laryngectomy. Complications in these patients included pneumothorax (eight), transient hoarseness (five), pleural effusion (five), anastomotic leak (four), subphrenic abscess (one), and cerebrovascular accident (one). The five deaths were due to pheumonia (two), innominate artery rupture (two), and pulmonary embolus (one). Blunt esophagectomy without thoracotomy is safe and is far better tolerated physiologically than the combined transthoracic and abdominal operations more traditionally used for exophageal resection and reconstruction.


Gastroesophageal fundoplication for the management of reflux in infants and children. Gastroesophageal reflux (GER) has been recognized with increasing frequency as the source of a wide variety of symptoms in infants and children. During the past 8 years at the UCLA Hospital, 74 patients under 18 years of age have been identified as having sufficiently severe symptomatic reflux to warrant gastroesophageal fundoplication. Although repeated emesis was the most common primary symptom, failure to thrive was a major symptom in 20 patients, repeated pneumonia in 18, asthma in five, and dysphagia owing to stricture in 12. Nine patients with previously repaired esophageal atresia had severe reflux. Serious neurologic disorders were present in 14 children. The diagnosis of reflux in the majority of symptomatic children was established by combining the findings of an abnormal esophagogram, Tuttle test, esophageal manometry, and esophagoscopy with biopsy. Six infants experienced repeated symptomatic GER although results of all diagnostic studies were normal. Each of the patients had undergone an unsuccessful trial of medical management before the decision to operate was made. Transabdominal Nissen fundoplication with gastrostomy was performed on each of the 74 children (28 under 1 year of age). Each of the strictures was successfully managed by postoperative dilatations. No death and no major complications occurred, but six patients experienced transient dysphagia and four had delayed gastric emptying. Every patient has been relieved of clinical reflux, and the pulmonary status in each, including the asthmatic children, has been markedly improved. On the basis of this favorable experience with 74 patients, we believe that an aggressive surgical approach should be taken in the management of symptomatic GER in infants and children who fail to respond to an adequate trial of medical management.


Gastroplasty and fundoplication in the management of complex reflux problems. Between 1963 and 1976, 220 patients with complex reflux problems were managed by combining a modified Collis gastroplasty with a Belsey type of partial fundoplication. All patients had one or more of the following complicating conditions considered indications for the combined operation: peptic stricture (104), esophagitis and shortening without stricture (25), one or more prior hiatal repairs (65), massive herniation (33), and motor disorders associated with reflux (26). Ninety-six percent of the patients were evaluated by personal interview from 1 to 15 years after repair. The operative mortality rate was 0.5 percent. The incidence of significant symptomatic reflux requiring medical therapy was 3 percent and the incidence of troublesome dysphagia was 11 percent. No patient has required further operation for the relief of recurrent symptomatic reflux. Two patients required additional operation for severe residual dysphagia. Twenty patients managed by this repair were evaluated by preoperative, intraoperative, and sequential postoperative esophageal pressure studies. The mean postoperative pressure of 21.4 mm. Hg was more than double the preoperative value. Two publications from other centers reported on similar groups of patients managed by gastroplasty and partial fundoplication, evaluated by preoperative and postoperative esophageal pressures. In these latter publications, the percentage increase in postoperative lower esophageal pressure was significantly less than in our study, and a much higher incidence of symptomatic reflux was recorded. We suggest that the differences in postoperative pressures observed in account for the pronounced differences in the quality of results obtained.