Boerhaave's syndrome: The importance of early diagnosis and treatment. Boerhaave's syndrome, spontaneous esophageal rupture, is associated with a 70% survival with surgical intervention. Mortality and morbidity are increased in direct proportion to the time between diagnosis and appropriate surgical intervention. Sepsis, hypovolemia and shock are the predominant causes of morbidity and mortality in Boerhaave's syndrome. Two cases of Boerhaave's syndrome are presented which were diagnosed rapidly, and were managed surgically, resulting in survival of the patients. A review of the literature is also presented with emphasis on the clinical and roentgenologic methods of diagnosis of spontaneous esophageal rupture. Particular attention is given to the fact that early diagnosis and treatment will unquestionably reduce the morbidity of this syndrome.


Breast cancer presenting as an axillary mass. Experience with breast cancer presenting as an axillary mass in 42 patients has been reviewed according to initial clinical findings, treatment and survival. In the absence of an obvious inflammatory lesion, an axillary node may prove to be the first sign of breast cancer. It has been demonstrated that such a node should be biopsied and if positive for adenocarcinoma, a radical mastectomy performed presuming other primary sites have been ruled out. The survival rate after surgery in this group of patients is better than in those who present with a palpable breast mass and have axillary metastases.


Postoperative deep vein thrombosis in the lower extremity amputee: A prospective study with Doppler ultrasound. The incidence of postoperative venous thrombosis and pulmonary embolism was assessed in 87 patients undergoing 96 major lower extremity amputations for ischemia. Prospective surveillance for deep leg vein thrombosis was carried out by Doppler ultrasound in 35 patients. There was no instance of major leg vein thrombosis and only one episode of a small non-fatal pulmonary embolus in a patient suffering trauma to the amputation stump after discharge from the hospital. This study suggests that clinically significant venous thromboembolism following current techniques of lower extremity amputation is not as common as previously reported. Doppler ultrasound is the most suitable technique for surveillance of venous thrombosis in these patients.


Spontaneous rupture of the common bile duct. Spontaneous rupture of the common bile duct is an extremely rare condition. Only 11 cases have been reported in the world literature. An unusual case of this complication is reported and the possible etiology and pathogenesis are discussed.


Long-term results of brachial thrombectomy following cardiac catheterization. The late results of brachial thrombectomy following cardiac catheterization were evaluated in 20 patients. All patients had a radial pulse present and no symptoms or signs of ischemia of the hand at the time of discharge from the hospital. Late evaluation of these 20 patients revealed 8 in whom the long-term results were classified as failure of the thrombectomy. Four of these had intermittent claudication of the involved arm and hand. None had any tissue loss and four had no symptoms referable to the failed thrombectomy. The one patient who refused surgery had claudication of the affected arm. The mean period of followup was 20.8 months. The rate of failed thrombectomies was twice as high in females than in males. Prolonged time of cardiac catheterization (over 4 hours), delay in diagnosis of more than 24 hours, and omitting the use of systemic heparinization at the time of diagnosis are three factors that appear to increase the likelihood of late failures.


Portal diversion for portal hypertension in early childhood. Twenty-three children under 6 years of age with portal hypertention were treated by portal diversion. Fourteen had cavernomatous transformation of the portal vein and 9 had an intrahepatic block due to cirrhosis (8) or congenital hepatic fibrosis (1). Portal-systemic shunts were central splenorenal in 20 patients, side-to-side portacaval in 2 and mesocaval in one. In 20 of the 21 peripheral shunts, the veins used for the anastomosis were less than 10 mm in diameter. There was no operative mortality. Thrombosis of the shunt occurred in 3 children (13%) and was responsible for recurrent bleeding in one who was treated later with success by a mesocaval shunt. The two other children with a thrombosed shunt are waiting, at the present time, for a mesocaval anastomosis. The volume of blood flowing through the shunt was small initially and the fall in pressure gradient was slight: therefore intraoperative angiography appeared to be a better way to assess the patency of shunts done at an early age than pressure or flow measurements. The figures recently reported by Clatworthy, with a mortality rate of 12% directly or indirectly related to repeated hemorrhage, are for us a forceful argument for early adequate management of portal hypertension in children. Until now, portal-systemic shunts have been complicated by a high frequency of thrombosis and have given discouraging results. Our results suggest that it is possible to perform portal diversion successfully on diminutive veins (down to 4 mm). From this experience early portal diversion appears to represent the treatment of choice for portal hypertension in childhood.


Medical disorders in a small Caribbean island. An analysis of the disease of adults in Dominica in 1972 and 1973. An analysis was undertaken, for the first time, of the total picture of the medical disorders of adults on a small Caribbean island. At present non-infectious diseases, especially diabetes and hypertension, are of major improtance. Parasitic infestation of the gut occurred in 50-60% of the hospital population. The pattern of diseases indicates that the island is in a transitional stage of its medical development, and that resources need not be directed to the curative as well as to public health programmes. The impact of peculiarities of local geography and customs are discussed as contributing to some of the more unusual diseases of the Caribbean.


Culture of Schistosoma haematobium in vivo and in vitro. The maximum rate of development of Schistosoma haematobium in the hamster was determined by examination of the most advanced worms recovered at short intervals throughout the course of development. In culture S. haematobium developed at the same rate as in the hamster up to day 31 when pairing first occurs and male worms produce some spermatozoa. In vitro males formed some spermatozoa but pairing did not take place and, probably for this reason, females did not complete sexual maturation as occurs in the host between days 57-65. Somatic growth continued in vitro and at 70 days male worms had achieved almost the same length as in the hamster at this time. The culture medium, previously used for S. mansoni, consisted of equal volumes of serum and Earle's balanced saline with a final concentration of 0.25% lactalbumin hydrolysate, 100 units/ml penicillin, 100 mug/ml streptomycin and 1% rbc. The best culture results were obtained with one particular human serum; seven other human sera gave a wide range of growth support. The samples of baboon, rhesus monkey or foetal calf sera tested provided little or no growth support but prolonged survival was possible in all the sera.


Absence of liver toxicity in 2723 patients treated with hycanthone in St. Lucia. This report is submitted not to refute the occurrence of any toxicity but to record that in St. Lucia, given reasonable care in administration and careful follow-up, we have not yet encountered jaundice, liver necrosis or other serious side effects.


Social aspects in the changing epidemiology of malaria in the highlands of New Guinea. The increase in movement of people both within the highlands of New Guinea and also to and fro between holo- and hyperendemic lowland areas and the highlands by policemen and semi-skilled personnel in one direction and by labourers in the other, together with a great increase in potential breeding sites, were virtually inevitable consequences of the development process as the intense communalism and geographical isolation of the highland people was broken down. Prior to the "opening up" of the highlands, evidence suggests that malaria had existed in an endemic and very unstable form in only a few lower altitude areas and in the populations of the perimeter villages who had contact with lowland areas. This paper traces the changes in the distribution and determinants of malaria that occurred pari passu with the development process in the highlands of Papua New Guinea between 1930 and 1970.


A new design of membrane feeder incorporating an electrical blood stirring device. A selection of the literature illustrating the origin and development of membrane feeding devices is reviewed. A new membrane feeding device-incorporating an electrical stirrer is described and its mode of operation explained. The sedimentation of red blood cells within a membrane feeding device, and the consequent hazard to arthropod feeding, is prevented by the use of the redesigned feeding unit and electrical blood stirrer. The mosquito feeding rate and mean blood meal size (mg) were unaffected by the action of the stirrer when compared to those in an unstirred control. Mosquitoes, bugs, ticks and tsetse flies have been fed sucessfully using the apparatus.


Epidemiological patterns of cutaneous leishmaniasis in Panama. I. Epidemics among small groups of settlers. Epidemic of cutaneous leishmanniasis among a small group of people established in a Panamanian forested area was studied. The first settlers arrived in June 1971, and by June 1973 there were 37 persons, 33 of whom had no previous history of the disease. Epidemiological surveys were made in June 1973 and March 1974. The disease developed in 14 (42.4%) of the 33 susceptible persons by June 1973, with an exposure time ranging from one to 14 months. The last case occurred in April 1973, and no new cases were observed during the ensuing 11 months. Two (15.4%) of 13 dogs examined were found with cutaneous leishmaniasis, but none of 41 feral mammals studied, mainly terrestrial rodents, was infected. Four leishmanial strains characterized, three from patients and one from a dog, were identified as Leishmania braziliensis. Phlebotomine sandfly population composition was studied and the probable vectors involved in the transmission to man were determined.


Epidemiological patterns of cutaneous leishmaniasis in Panama. II. Incidental occurrence of cases in non-endemic settlements. Epidemiological studies on cutaneous leishmaniasis were carried out in a settlement in the Bayano region, Republic of Panama, during 1971-72. This settlement was established about 12 years earlier for the purpose of cattle raising by small groups of settlers. The primary forest was cut and cleared and the area planted with grass. The presence of active cases of cutaneous leishmaniasis among humans and animals, both domestic and ferals, was investigated. In addition, phlebotomine sandflies were collected to determine their species composition. In 1971, nine of the 161 persons interviewed had active lesions; all but one of the patients were males and of these seven were adults. Five (9%) of 55 dogs and one (3%) of 33 feral mammals examined also were found infected. Strains of the parasite infecting both humans and animals were characterized as Leishmania braziliensis. About 60% of the sandflies collected belong to four man-biting species previously incriminated as vectors of human cutaneous leishmaniasis in Panama. The extensive pasture, together with periodic applications of insecticides in the houses by the antimalarial agency in this country, provided an effective barrier against transmission within the settlement itself. However, both humans and dogs acquired the disease during excursions into the surrounding forest. No new cases were found in 1972.


A new method of external cardiac massage to improve diastolic augmentation and prolong survival time. Experiments were performed on 50 dogs to determine the reason for unsatisfactory survival rates following closed-chest cardiac massage and to help develop new means for increasing survival following acute myocardial infarction and other causes of cardiac arrest. A new technique, named the countermassage method, was subsequently developed. Coronary and carotid flows after use of countermassage following cardiac arrest were increased 1.4 and 2 times, respectively, in contrast to flows obtained during manual closed-chest cardiac massage. These increases brought flows up to normal levels. We also tried to determine whether survival could be extended by this method to facilitate clinical treatment such as defibrillation or placing a temporary pacemaker catheter under fluoroscopic control, which are hard to accomplish during the brief time permitted by conventional closed-chest cardiac massage.


Surgical treatment of congenital heart disease with special reference to the application of hypothermia. This report presents the results of operation for congenital heart disease using two different methods of hypothermia: (1) Immersion hypothermia alone. Of the 782 patients who underwent open-heart operations using this method the results were good in patients whose intracardiac surgical repair took less than one hour (average mortality rate, 5.6%). (2) Rapid extracorporeal cooling. Of the 269 patients with congenital heart diseases such as ventricular septal defect, tetralogy of Fallot, or atrioventricular canal with low cardiac reserve who underwent operation with mild to moderate hypothermia utilizing rapid extracorporeal cooling, the mortality was 11.2%. In the 151 patients with more serious defects, including the extreme form of tetralogy of Fallot, single ventricle, and truncus arteriosus, who underwent open-heart operations with deep hypothermia utilizing extracorporeal cooling, the mortality rate was 15.2%.


Mustard's operation for transposition of the great arteries complicated by juxtaposition of the atrial appendages. Six patients were seen with complete left-sided juxtaposition of the atrial appendages (LJAA) in a series of 366 consecutive Mustard operations for transposition of the great arteries. All 6 patients had situs solitus of the viscera and atria with concordant atrioventricular relationship. D-transposition was present in 3 patients and L-transposition in the other 3; all 6 had associated cardiac anomalies. The diagnosis of LJAA was first made at operation, although angiocardiographic recognition is possible. The size of the right atrium is small in the presence of this anomaly, and direct cannulation of the venae cavae and enlargement of the pulmonary venous atrium are therefore recommended.


Microporous expanded polytetrafluoroethylene arterial prosthesis for construction of aortopulmonary shunts: experimental and clinical results. A new microporous, expanded polytetrafluoroethylene arterial prosthesis was evaluated in dogs. The material appears to produce an adequate prosthesis for aortopulmonary anastomosis in animals and can conduct a high rate of blood flow. The graft has been used in 3 patients with pulmonary atresia aged 2 days, 2 months, and 6 months. Thus far all patients are well, growing, and have a loud shunt murmur. The desirable features of this type of anastomosis are presented.


Traumatic aortic rupture: roentgenographic indications for angiography. The principal radiological indication for thoracic aortography following blunt chest trauma has been a widened mediastinum on chest roentgenogram. The presence or absence of sixteen findings on 100 cm anteroposterior supine chest roentgenograms were noted and compared in 47 consecutive patients who underwent aortography following blunt thoracic trauma and 100 patients without trauma. On the basis of our data, we propose six radiological indications for thoracic aortography following chest trauma: mediastinum greater than 8 cm on 100 cm AP supine chest film; tracheal shift to the right; blurring of the normally sharp outline of the aorta; obliteration of the medial aspect of the apex of the left upper lobe; opacification of the clear space between the aorta and pulmonary artery; and depression of the left main bronchus below 40 degrees.


Left subcostal insertion of the sutureless myocardial electrode. This report describes the use of a left subcostal extrapleural supradiaphragmatic approach to the heart for myocardial sutureless electrode insertion. Electrode insertion by this approach has consistently produced low electrode thresholds, and the ability to insert electrodes into the left ventricle or septal area of the right ventricle is considered an advantage. This technique has now been used in 52 patients. Postoperative morbidity and complications have been minimal. The procedure appears to be well tolerated in the elderly, poor-risk patient and has been a useful technique for revision of failed pacemaker systems. We believe this procedure reduces the indications for permanent transvenous pacing.


Plasmacytoma arising in a pacemaker pocket. A 48-year-old man developed a plasmacytoma in the subcutaneous pocket of a titanium covered pulse generator that had been inserted sixteen months previously. The tumor represented a cutaneous manifestation of myelomatosis. The presence of a pacemaker may affect the detection and treatment of tumors arising in the region of pulse generator pockets. Possible cause-and-effect relationships are explored.


Embolization of disc occluder of a Wada-Cutter mitral prosthesis with survival. The second recorded survivor following emergency prosthesis replacement after embolization of the Teflon disc occluder of a Wada-Cutter mitral valve is reported. Difficulties encountered while attempting to locate the missing occluder are presented and a useful operative technique for aortic control is described. A plea is made for incorporation of a radiopaque material during manufacture of all future valve poppets.


Primary repair of esophageal atresia without staging or preliminary gastrostomy. Twenty-two neonates with esophageal atresia and a distal tracheoesophageal fistula were treated by primary repair. Only if an anastomotic leak was demonstrated was a tube gastrostomy for decompression with trangastric placement of a duodenal tube for feeding performed. Twelve newborns were classified as high-risk by the presence of prematurity with low birth weight (less than 2,250 gm), significant pneumonia, or obvious significant associated anomalies. There was one operative death and 1 late death. Three babies required a tube gastrotomy and duodenal tube for anastomotic leaks. All 20 survivors are symptom free and thriving. Progress in perioperative management of neonates with esophageal atresia may obviate the need for routine gastrostomy and for staging of high-risk newborns.


Prevention of increased hemoglobin-oxygen affinity in open-heart operations with inosine-phosphate-pyruvate solution. In a control group of 32 patients undergoing open-heart operation, erythrocyte 2,3-diphosphoglycerate (2,3-DPG) declined progressively during the course of perfusion from a prebypass mean of 17.00 to 11.29 mu M per gram of hemoglobin at the end of bypass. The decrease was greater than that attributable merely to dilution of the patients' cells with the 2,3-DPG-deficient donor cells used to prime the pump oxygenator circuit. Administration of 300 mg of allopurinol, to prevent the conversion of inosine to uric acid, every 8 hours during the 24 hours prior to operation in 11 patients did not prevent the 2,3-DPG decrease during heart-lung bypass: prebypass, 18.31; postbypass, 13.56 mu M/gm Hgb. The mean P50 for both these groups combined decreased from a prebypass mean of 25.7 to a postbypass level of 21.9 torr. A solution of 0.1 M inosine, 0.1 M pyruvate, and 0.066 M phosphate (IPP) in a dosage of 7.5 ml per kologram of body weight prevented the 2,3-DPG decrease: prebypass, 15.74; postbypass, 14.85. Administration of 15 ml per kilogram of IPP in 15 patients preserved 2,3-DPG: prebypass, 18.09; postbypass, 18.52. The P50 remained unchanged in this last group. The method of providing for myocardial oxygen requirements during bypass was not standardized, and therefore the protective effect of IPP against ischemic damage in patients undergoing aortic valve replacement or myocardial revascularization could not be evaluated. No deleterious effects of IPP were noted.


Phasic coronary flow: intraoperative evaluation of flow distribution, myocardial function, and reactive hyperemic response. Using visual inspection of phasic flow patterns and understanding their physical determinants, intraoperative decisions regarding flow distribution, function of revascularized myocardium, and collateral communications can be made. Mean flow measurements cannot provide this information. Systolic compressive forces across most of the normally contracting left ventricle limit systolic myocardial perfusion. Consequently, normal flow through the left anterior descending, left circumflex, and dominant right coronary artery (supplying the inferior left ventricle) is predominantly diastolic (greater than 60%) and remains so during reactive hyperemia. Representative examples from 100 consecutive revascularizations are presented showing that when more than 40% of flow is systolic in the right coronary artery, high mean flows (greater than 100 ml/min) may go predominantly to the right rather than the left ventricle; in the case of the left coronary artery, high mean flow may supply myocardium undergoing infarction or replaced by scar rather than normally contracting muscle. When more than 60% of flow is diastolic without reactive hyperemia, borderline mean flow (40 to 60 ml/min) may indicate lack of distal ischemia rather than fixed distal resistance.


Retrograde coronary capillary perfusion for prevention and reversal of cardiogenic shock in experimental myocardial infarction. The coronary sinus and coronary veins offer an access route for delivery of increased oxygen to ischemic myocardium surrounding the central dead zone of heart muscle in cardiogenic shock due to myocardial infarction. This investigation was conducted to determine if transvenous retrograde coronary capillary perfusion with oxygenated blood would prevent and reverse cardiogenic shock in experimental myocardial infarction produced by acute ligation of the circumflex and anterior descending left coronary artery in dogs. Cardiac output and systemic blood pressure were maintained near control values for up to 30 minutes when total left coronary ligation was accompanied by coronary retroperfusion. Conversely, both cariac output and systemic blood pressure fell to severe cardiogenic shocks levels within 2 minutes of total left cardiogenic shock levels within 2 minutes of total left coronary artery occlusion without retrograde flow or when retrograde flow was terminated 5 to 30 minutes following simultaneous coronary ligation and institution of retrograde flow.


Events related to microembolism during extracorporeal perfusion in man: effectiveness of in-line filtration recorded by ultrasound. Microparticle generation during cardiopulmonary bypass was monitored continuously in 60 adult patients who underwent open-heart operations. Echo-ultrasound transducers of 5 mHz frequency were interposed in a bubble oxygenator arterial line proximal and distal to a commercially available micropore filter. Ordinary perfusion events correlated with an increase in embolic counts and were recorded graphically. Calculation of filter efficiency revealed that all filters decreased measurable embolic counts. Platelet and leukocyte determinations and plasma hemoglobin values were not altered beyond limits ordinarily encountered during perfusion without filters. No patient in any filter group experienced postoperative respiratory distress, diffuse pulmonary infiltrate, or low PaO2. The 20 mu woven nylon mesh filter and the Dacron-wool filter showed greater than 90% effectiveness in removing recorded particles. Insertion of a cardiotomy filter did not appreciably alter recorded embolic counts distal to the arterial line filter.


Supravalvular stenosing ring of the left atrium. Two patients with supravalvular stenosing ring of the left atrium are described. In 1 patient with an associated ventricular septal defect and Wolff-Parkinson-White syndrome, the diagnosis of supravalvular stenosing ring was only suspected. This patient underwent correction but died 34 days after the operation because of pulmonary embolism. In the second patient a preoperative diagnosis was not made, and this contributed to his death following correction of tetralogy of Fallot. The association of these two anomalies is very rare. Differential diagnosis from other congenital anomalies producing obstruction of left atrial flow is discussed. The divergent microscopical features of the membrane in supravalvular stenosing ring of the left atrium and in cor triatriatum are described. The value of cardiac catheterization, angiography, and echocardiography as diagnostic aids is emphasized. The hazards of not recognizing and diagnosing this anomaly when associated with other cardiac malformations are pointed out.


Constrictive pericarditis.

Constrictive pericarditis. A patient with constrictive pericarditis following an open-heart operation without sepsis is discussed. In the absence of sepsis, it has been widely held that this complication does not develop following an open-heart procedure. The fatal outcome in this patient could have been avoided had such an association been known.


A simple technique for obtaining Pap smears of the esophagus. A simple method for obtaining Papanicolaou smears of the esophagus is described. The procedure is easy to perform, does not require specialized equipment, and is a useful adjuvant to direct esophageal biospy.


A method of outflow tract reconstruction in tetralogy of Fallot with anomalous anterior descending coronary artery. An anomalous anterior descending coronary artery that arises from the right coronary and crosses the right ventricle outflow tract can compromise corrective operations for tetralogy of Fallot. The only safe method of outflow tract reconstruction reported until now is the use of a tubular graft from the right ventricle to the pulmonary artery. We report successful reconstruction of the outflow tract by placing a standard fabric path under the mobilized anomalous coronary artery. This technique should avoid the late complications of tubular conduits by preserving the natural posterior wall of the outflow tract for growth.


Patch closure of the ductus arteriosus: an improved method. An improved surgical procedure for patch closure of the ductus arteriosus under cardiopulmonary bypass is presented. A patch with a Fogarty catheter inserted through its center is used. The catheter is insinuated into the aorta through a pulmonary arteriotomy under normothermic cardiopulmonary bypass. An inflated intraaortic balloon is made to plug the orifice of the ductus using gentle traction on the catheter. The catheter may be slanted in any direction that is convenient to provide satisfactory visualization of the operative field.


Improved technique for bedside insertion of the Swan-Ganz pulmonary artery catheter. A method for inserting the Swan-Ganz pulmonary artery ballon has proved this to be a safe and efficient approach to hemodynamic monitoring of critically ill patients, frequently catheter utilizing direct subclavian venipuncture is presented. Our experience eliminating the need for bedside surgical procedures.


Possible role of histamine receptors in cardiovascular responses to 5-hydroxytryptamine in the chicken. Mepyramine (a selective H1-histamine receptor antagonist) and burimamide (a selective H2-receptor antagonist) specifically and equally modify the systemic hypotensive responses to both serotonin and histamine. Results suggest that both H1- and H2-histamine receptors in part mediate systemic arterial depressor and venous pressor responses to 5-HT in the domestic chicken.


Studies on the neuropharmacology of tert-butylurea in mice. Tertiary butylurea has been investigated neuropharmacologically in mice and rats, and the results indicate that the compound possesses a marked CNS activity. It exhibited a pronounced activity against pentetrazole-induced convulsions and lethality, but the protection against strychnine-induced convulsions and lethality, was only partial. A significant prolongation of pentobarbital sleeping time by a subsedative dose of tert-butylurea was also observed. Protection afforded by tert-butylurea against tremorine-induced tremors and the intensity of its analgesic activity were both of moderate degree. In a subsedative dose range, tert-butylurea exhibited motor incoordination and behavioral effects with a decrease in the minor and the major movements of animals, as apparent from the treadmill and activity meter experiments respectively. The compound, however, does not seem to be a potent sedative-hypnotic agent, although there is a fairly good margin of safety between the hypnotic and the lethal dose orally. The anti-pentetrazole activity of tert-butylurea suggests its possible effectiveness against 'petit mal' seizures and, therefore, calls for additional studies to evaluate the anticonvulsant activity of tert-butylurea.


Acute changes in ventilation and blood pressure induced by inhalation of tobacco smoke. Inhalation of cigarette smoke through a tracheal cannula was induced in cats anesthetized with pentobarbital. Smoking of tobacco cigarettes produced increased ventilation and systemic hypertension, which were found to be due to their nicotine content. Respiratory stimulation and the increase in diastolic pressure were abolished by acute section of 'buffer nerves', but the mediation of carotid nerves was more important than that of the vagi for evoking reflex hyperventilation. Tobacco smoking induced a marked increase in the frequency of chemosensory impulses recorded from the carotid nerves, an effect due to its nicotine content.


Respiratory and circulatory reflexes induced by nicotine injections: role of carotid body chemoreceptors. Intravenous and intracarotid injections of nicotine were delivered to cats anesthetized with pentobarbital. Low doses of nicotine were found to induce reflex hyperventilation and hypertension, mainly due to excitation of carotid body chemoreceptors. The frequency of discharge of carotid nerve chemosensory fibres was increased by nicotine in doses as low as 1 mug/kg when injected intravenously and 50 ng when injected into the carotid artery. Nicotine also activates vagal afferent fibres; some of them produce reflex excitation of the respiratory and vasomotor centres, but others provoke reflex inhibition. High doses of nicotine can act directly upon the medulla provoking acceleration or arrest of ventilation. Nicotine can also induce 'late' changes of b.p. (delay 5 sec or more) which are not mediated by the carotid or vagus nerves.


Cardiovascular tryptamine receptors in the chicken. The effects of "M"-receptor blockers (atropine and morphine), "D"-receptor blockers (dibenamine, dibenzyline, methysergide) and a ganglion blocking agent (mecamylamine) were studied to characterize cardiovascular tryptaminergic receptors in domestic fowl. This study showed the presence of both "M" and "D" tryptaminergic receptors (both mediating systemic hypotension) and also other "D"-receptors, which mediate arterial and venous hypertensive responses to 5-HT. There appear to be interactions of tryptaminergic, cholinergic and adrenergic mechanisms in the mediation of cardiovascular responses to 5-HT in chicken.


Haemodynamic effects of adenosine-5'-carboxylic acid-amide in the anaesthetized dog during normal respiration and hypercapnic acidosis. Adenosine-5'-carboxylic acid-amide (1 mug/kg/min) and adenosine (500 mug/kg/min), given in a 10-min infusion to anaesthetized dogs, produced qualitatively and quantitatively comparable cardiovascular effects, namely a marked increase in coronary blood flow and a generalized vasodilation, concomitantly with an increase in heart rate, left ventricular dp/dt, heart work, myocardial oxygen consumption, and pulmonary blood pressure; the pulmonary vascular resistance remained unchanged. Hypercapnic acidosis enhanced the coronary dilator effect of both compounds. These results indicate that adenosine and adenosine-5'-carboxylic acid-amide act at the same receptor sites.


[Age dependent differences in the pharmacokinetics of furosemide in rats]. After i.p. administration of 0,60 mg/100 g of furosemide, adult rats excreted 50 to 70% of this diuretic drug unchanged and 10% as desfurylmethylfurosemide. The renal excretion of furosemide is slower in 5- and 15-day-old rats. Age differences in absorption from the abdominal cavity or in the reabsorption rate in the kidney tubules can be excluded. The excretion of furosemide by the kidney is competitively inhibited by p-aminohippuric acid (PAH). The relative small inhibitory effect of PAH in young rats is caused by a smaller participation of tubular secretion in the renal excretion of furosemide in this age group. The half life time of furosemide is 83 min in 5-day-old rats and 47 min in 55-day-old rats. The distribution volume is 146% of body weight in both age groups. The concentration of furosemide in the kidney homogenate is higher in young rats than in adults. The slow renal excretion of furosemide in young rats is in accordance with the prolonged efficacy. The greater efficacy of furosemide in 5- and 15-day-old rats than in adults is caused particularly by differences in the conditions for diuretic effectiveness, especially by the retention of water and electrolytes in young rats.


Interaction of angiotensin II with noradrenaline and other spasmogens on rabbit isolated aortic strips. Angiotensin II in sub-contractor concentrations enhanced the contractions of rabbit isolated aortic strips to noradrenaline, potassium chloride, histamine, acetylcholine, isoprenaline and 5HT. The potentiation of noradrenaline responses by angiotensin II was independent of any effect of angiotensin II on neuronal uptake of noradrenaline. The sensitization of this tissue to spasmogens induced by angiotensin II occurred in reserpine-treated preparations and in normal tissues suspended in calcium-free bathing medium. Procedures which abolished the transfer of sodium ions across membranes such as substitution of fructose for glucose in the bathing medium, absence of potassium ions or treatment with ouabain each abolished the non-specific sensitization. The evidence suggests that angiotensin II may cause a non-specific sensitization of this tissue by inhibiting sodium transfer across the cell membrane.


Nature of the inhibition by amiodarone of isoproterenol-induced tachycardia in the dog. Inhibition of in vivo isoproterenol-induced tachycardia by i.v. amiodarone was studied in anesthetized dogs. Significant dose-response curves to isoproterenol could not be obtained in single animals because of the time-dependent lowering of the inhibitory effect of the drug. Single isoproterenol injections after amiodarone in 105 dogs allowed dose-response curves to be obtained. The slope of these curves decreased with increasing doses of amiodarone, and the maximal rate stimulation diminished also in a dose-dependent manner. These features are consistent with a non-competitive inhibition pattern. A mechanism of the beta-adrenergic antagonism developed by amiodarone is suggested.


Cycrimine on rat diaphragm.

Cycrimine on rat diaphragm. Cycrimine hydrochloride, an anti-Parkinson drug having central cholinolytic properties, was found to cause neuromuscular blockade in the isolated rat diaphragm preparation. The neuromuscular blockade by cycrimine remained unaffected in presence of neostigmine and tetraethylammonium. Lower concentrations of cycrimine potentiated the paralytic effect of d-tubocurarine. A similar paralytic effect of cycrimine was observed in the pharmacologically denervated rat diaphragm. Responses to acetylcholine administered by retrograde i.v. injection were found to be inhibited in presence of cycrimine. These results suggest that the neuromuscular blockade by cycrimine is produced by a postsynaptic direct effect on the muscle.


Determination of endogenous concentrations of norepinephrine and dopamine and their rates of synthesis in a single mouse brain: biphasic effects of (+)-amphetamine. A method is described that possesses sufficient sensitivity to permit the simultaneous fluorometric assay of endogenous concentrations of tyrosine, dopamine and norepinephrine, and the measurement of the estimated rate of synthesis of 3H-dopamine and 3H-norepinephrine from 3H-tyrosine in a single mouse brain. (+)-Amphetamine elicited a biphasic effect reducing the estimated rate of synthesis of dopamine and norepinephrine at 5 mg/kg, while lowering the endogenous concentrations of these catecholamines and increasing their rates of synthesis at 15 mg/kg.


Inhibition by indomethacin and niflumic acid of catecholamine--uptake into rat hypothalamic and striatal synaptosomes. Niflumic acid and indomethacin showed to be inhibitors of catecholamine--uptake into rat striatal and hypothalamic synaptosomes. Whereas the inhibition by niflumic acid was non-competitive for both amines at similar Ki values, the action of indomethacin displayed differences between areas as well as amines: the potency of inhibition by indomethacin was greater in striatal than in hypothalamic synaptosomes irrespective of the amine; the type of inhibition by indomethacin was non-competitive for norepinephrine, but competitive for dopamine regardless of the brain area.


Distribution and retention of exogenously administered alkali metal ions in the mouse brain. A pharmacokinetic study of the distribution and retention profiles of Li+, Rb+ and Cs+ in the brain and blood was performed in male mice given single (acute) or repeated (semi-chronic) injections of the respective chloride salt solutions. The concentration of Li+ in whole brain and in cerebral cortex, striatum, hippocampus, diencephalon, brain stem and cerebellum were similar after acute and semichronic LiCl treatment. In contrast, semi-chronic RbCl and CsCl treatment resulted in greater accumulation of Rb+ and Cs+ in brain compared to the levels obtained after acute administration. The Li+ concentration in brain declined to negligible amounts at 48 hr after termination of acute or semi-chronic LiCl administration, while the Rb+ and Cs+ concentration in the brain remained elevated for up to 6 days after termination of semi-chronic treatment. Differences in the distribution and retention patterns of Li+, Rb+ and Cs+ also were observed in the brain regions examined. In the blood, the concentration of Li+ reached a peak soon after LiCl administration and then progressively declined while Rb+ and Cs+ concentrations showed a biphasic course with the highest levels obtained 48 hr after administration of the salt solutions. It is suggested that the differences observed in the pharmacokinetics of Li+ compared to Rb+ and Cs+ in the brain might be related to their duration of actions.


Physostigmine as a discriminative cue in rats. Rats, trained to respond differentially in a T-maze contingent upon the presence or absence of physostigmine (0.50 mg/kg), showed a reversal of drug responding when physostigmine (0.50 mg/kg) was given simultaneously with the anticholinergic ditran (dose range: 0.80-3.20 mg/kg). Testing the quaternary anticholinesterase neostigmine (0.50 mg/kg) resulted in no drug responding which indicates a central site of action for the physostigmine discrimination.


Normalization of abnormal T waves in ischemia. Inverted T waves due to coronary artery disease and previous myocardial infarction were observed to revert ot normal, upright position during ischemia in 38 patients. The normalization of inverted T waves was seen on the electroencephalograms of 19 patients during spontaneously occurring angina pectoris and of 11 patients when ischemia was provoked by treadmill exercise; for 8 patients, normalization occurred during the administration of isoproterenol hydrochloride and during the consequent episode of angina pectoris. The mechanism for normalization may be the algebraic sum of the extent of ST segment elevation and the amplitude of the T waves of acute ischemia plus the extent of preexisting ST segment depression and the degree of T wave inversion, to result in isoelectric ST segment and upright T wave. As with myocardial infarction, reciprocal changes may also be recorded. However, the reciprocal nature may be masked since either acute ST segment elevation of T wave inversion, or both, may not be recorded in the leads reflecting the ischemic area because of normalization.


Prognosis of patients permanently paced for sick sinus syndrome. In 39 patients (mean age, 66 years) treated for sick sinus syndrome (SSS) with pacemaker insertion, the long-term prognosis was studied. Fifteen patients (42%) died during the follow-up period of 6 to 59 months (mean, 25 months). Three patients were unavailable for follow-up. Eleven of the 15 deaths (73%) were cardiac-related, yet none could be associated with either an arrhythmia or pacemaker failure. Symptoms recurred or persisted after pacemaker insertion in 14 patients (mean age, 71 years), nine of whom died (31 deaths per 100 patient follow-up years). Twenty-two patients (mean age, 63 years) were asymptomatic after pacer insertion, six of whom died (11 deaths per 100 patient follow-up years). These follow-up results demonstrate a poor long-term prognosis in patients with SSS and persistent symptoms following permanent pacing.


Diabetes among men in a general population. Prevalence and associated physiological findings. A random sample of 281 men, aged 30 through 69, resident in the community of Tecumseh, Mich, was studied with the use of standard glucose tolerance tests, including serum insulin assays and fasting serum lipid concentrations. Diagnoses of diabetes and probable diabetes were made according to a modification of the criteria of Fajans and Conn. Prevalence of diabetes and probable diabetes was considerably higher among men aged 40 through 49 than among those aged 30 through 39, but it increased little in the 50-through-59 and 60-through-69 age groups. Lean nondiabetics and probable diabetics had similar mean systolic blood pressures and similar mean levels of serum cholesterol, serum triglycerides, and serum insulin, but fat probable diabetics had much higher mean serum lipid and serum insulin concentrations that fat nondiabetics. Adiposity grouping discriminated by variable levels less well between diabetics and nondiabetics.


Elevated plasma MB creatine phosphokinase activity. A specific marker for myocardial infarction in perioperative patients. Plasma MB creatine phosphokinase (CPK) activity is consistently elevated following myocardial infarction (MI). To determine whether elevations of plasma MB CPK activity is a specific index of myocardial injury, CPK and isoenzymes were assayed by a quantitative kinetic fluorometric technique in fresh organs obtained at surgery. Analysis of CPK isoenzymes showed myocardium to be essentially the only organ with MB CPK. Operative procedures included thoracic, neck, genitourinary, and orthopedic surgery. Total plasma CPK activity increased in all patients; however, MB CPK activity was not elevated. Thus, (1) the heart appears to be the only organ that is capable of liberating substantial amounts of MB CPK into plasma; (2) in spite of notably increased CPK activity after cardiac surgery, MB CPK activity is not elevated; and (3) increased MB CPK activity is a reliable index of MI in postoperative patients.


Bone marrow scan evaluation of arthropathy in sickle cell disorders. Twelve patients with sickle cell hemoglobinopathies and arthropathy were studied, using technetium Tc 99m sulfur colloid bone marrow scans. Eight of 12 had decreased marrow radionuclide activity adjacent to painful joints, suggestion obliteration of vessels supplying bone marrow. Four patients without marrow defects on scanning had causes other than infarction for their joint symptoms, viz, small fractures, postinfectious synovitis, degenerative arthritis, and osteochondromas. Roentgenograms never showed bony abnormalities in five patients with marrow infarctions, and, in three others, showed defects several months later than did the marrow scans. Bone marrow scans offer a sensitive and early diagnostic aid in sickle cell hemoglobinopathies with arthropathy.


Cushing syndrome with cyclical edema and periodic secretion of corticosteroids. A patient had a malignant carcinoid tumor of the lung. Cyclical edema was closely associated with periodic secretion of corticosteroids. Surgical excision of the tumor reversed the clinical and biochemical abnormalities.


Unexplained bronchopulmonary disease with inflammatory bowel disease. Six patients developed severe, unexplained, chronic bronchopulmonary disease from 3 to 13 years after the onset of nonspecific inflammatory disease of the colon. All had chronic bronchitis, bronchiectasis was diagnosed in four, and an obstructive type of pulmonary dysfunction was noted in five. Four of the six, including the two with only chronic bronchitis, had no history of smoking. There was an initial correlation between the pulmonary symptoms and the intestinal disease, except in two patients who developed overt pulmonary disease following total proctocolectomy. The frequent occurence of extraintestinal lesions has suggested that ulcerative colitis and regional enteritis are systemic disorders. Chronic unexplained bronchopulmonary disease may be another infrequent complication in such patients.


Incomplete distal renal tubular acidosis in hypomagnesemia-dependent hypocalcemia. The mechanism perpetuating hypocalcemia in the presence of hypomagnesemia is unknown. Two patients with this disorder had elevated immunoreactive serum parathyroid hormone levels and incomplete distal renal tubular acidosis. All abnormalities were corrected with magnesium replenishment. Postulated mechanisms include (1) parathyroid hormone activation in the serum or at the site of action dependent on magnesium, and (2) abnormalities in vitamin D metabolism that can be corrected by magnesium replacement.


Reversal of systemic manifestations of cryoglobulinemia. Treatment with melphalan and prednisone. In a patient with essential cryoglobulinemia with systemic, cutaneous, and neurologic manifestations and a mixed IgG-IgM cryoprotein, elimination of systemic and cutaneous disease manifestations, as well as notable reversal of neurologic impairment, followed therapy with melphalan. Levels of circulating cryoprotein decreased, but protein structure was unchanged by chemotherapy. Experience to date with alkylating agents suggests that this mode of treatment is the most effective currently available.


Survival after asphyxia secondary to gravel aspiration. A case of extreme asphyxia and acidemia secondary to mechanical obstruction of the tracheobronchial tree with sand and gravel is described. The roentgenographic appearance, clinical course, and management are emphasized. Survival with no neurologic sequelae after such profound physiologic disturbance has not, to our knowledge, previously been described.


Combination antibiotic therapy in staphylococcal endocarditis. The use of methicillin sodium-gentamicin sulfate therapy. The addition of gentamicin therapy in a case of S aureua endocarditis, in which the response to methicillin therapy alone was unsatisfactory, resulted in clinical improvement, enhanced serum bactericidal activity, and a bacteriologic cure. Gentamicin and methicillin were synergistic in vitro. Since the mortality in staphlococcal endocarditis remains exceedingly high, we suggest that the combination of a cell wall active antibiotic, such as methicillin, and an aminoglycoside may prove to be effective alternate theraphy for this disease.


Digital ischemia and gangrene preceding renal neoplasm. An association with sarcomatoid adenocarcinoma of the kidney. A 63-year-old woman had acute onset of rapidly progressive Raynaud phenomenon and digital gangrene. Prior to the detection of a sarcomatoid renal carcinoma, prominemt hypergammaglobulinemia, microhematuria, and weight loss were noted. Following nephrectomy, the patient showed improvement of the Raynaud phenomenon, with complete healing of digital ulcers and decrease of gama-globulin levels. Immunofluroescence studies demonstrated substantial deposits of IgG that lined the tumor cells in a linear and diffuse pattern. Electron-dense deposits were seen in the endothelium of arterioles int the tumor by electron microscopy. These findings suggest that antibodies to tumor antigens may have participated in the induction of digital vasculitis and Raynaud phenomenon.


Factor IX deficiency in Gaucher disease. An in vitro phenomenon. Low factor IX coagulant activity was demonstrated in a patient with Gaucher disease before and after splenectomy. The same abnormality was found in seven of ten additional patients studied. Possibly, abnormally retained sphingolipids inactivate or interfere with the action of certain procoagulants.


Natural history of male psychological health. V. The relation of choice of ego mechanisms of defense to adult adjustment. Ninety-five men, selected in college on the basis of health have been prospectively followed up for 30 years. Their adaptive styles have been isolated, labeled by the ego mechanisms of defense that their behavior reflects, and studied by semiquantitative techniques. A hierarchy of ego mechanisms was devised that ordered defenses along a continuum that reflected the following two dimensions: (1) immaturity-maturity and (2) psychopathology-mental health. The most important finding was that despite blind assessment, a scale reflecting the maturity of a subject's defenses correlated with scales measuring his objective psychopathology (r = -.35) and his objective adaptation to the external environment (r = .65). Highly significant shifts in defensive style occurred as individuals matured. In order to conceptualize the continuum that underlies mental health, identification of a person's dominant defensive styles may be superior to our current scheme of static unitary diagnoses.


Losing a symptom through keeping it. A review of paradoxical treatment techniques and rationale. The therapeutic technique of symptom prescription has been used by practitioners from a variety of clinical schools. This article reviews techniques based on learning theory, symptom redefinition, paradoxical intention, and directive therapy, among other approaches. A conceptual framework for understanding these various approaches is offered, utilizing data from psychoanalysis, learning theory, and interpersonal communication theory.


A comparison of process notes and tape recordings. Implications for therapy research. The basic contention of many researchers is that process notes are not suitable for objective study of psychotherapy. We focus here on our contrasting assumption that process notes may be effectively used for certain kinds of psychotherapy research, particularly that which deals with thematic shifts occurring over a period of time. To test this, three classes of taped memories were examined for thematic shifts: memories of the patient's father, mother, and repetitive memories. The taped memories were then compared with the memories recorded in the analyst's notes. Compared to the tapes, process note memories were fewer in number, significantly condensed, and introduced a variety of distortions into the data. In spite of these differences, judgments by independent raters indicated that in all three classes of memories, the analyst's notes reliably picked up pertinent thematic shifts.


Appropriate and background affect in facial displays of emotion. Comparison of normal and schizophrenic males. The hypothesis that normal subjects can express emotions more accurately than schizophrenics was tested by having judges match photographs of five posed affects with five emotion words for each of 16 normal and 16 schizophrenic male expressors. Discrimination accuracy was high, but the hypothesis was not confirmed. The results of a second study, in which separate measures of appropriate (intended) and "background" affect (eg, the rated intensity of anger displayed in a subject's nonangry poses) were provided, supported our expectation that discrimination accuracy is a function of both appropriate and background affect. The normal men tended to display more appropriate affect generally, and displayed more background happiness, while the schizophrenics expressed more background anger, sadness, and fear. Both intended and background affect, therefore, must be carefully considered in studies of emotional expressions.


Reactive psychoses and schizophrenia with good prognosis. Cross-national studies have indicated that American psychiatrists diagnose schizophrenia more often than others. Clinical, genetic, and follow-up studies suggest that many patients diagnosed as having acute schizophrenia might be more appropriately diagnosed as having affective disorder. Forty probands diagnosed in Aarhus, Denmark, as having reactive psychoses are compared with 28 probands diagnosed in St Louis as having schizophrenia with good prognosis. Clinical differences largely reflect diagnostic criteria, with the patients from the St Louis group frequently having diagnosable affective disorder. A smaller proportion, 39% of the patients from St Louis, could be considered for the diagnosis of reactive psychosis. This is additional evidence supporting the use of the diagnostic category, reactive psychoses. Patients ordinarily given the diagnoses acute schizophrenic episode and/or schizo-affective schizophrenia may be more appropriately diagnosed as having (1) affective disorder and (2) reactive psychoses.


Catatonia. A prospective clinical study. We studied 55 patients admitted during 14 months to two inpatient psychiatric units of a municipal hospital who exhibited one or more of the catatonic signs of mutism, stereotypy, posturing, catalepsy, automatic obedience, negativism, echolalia/echopraxia, or stupor. Only four of the 55 patients satisfied our research criteria for schizophrenia, whereas over two thirds had diagnosable affective disorders, usually mania. The eight catatonic motor signs were nonspecific and homogeneously distributed among the various research diagnostic groups, with the number and type of individual signs unrelated to short-term treatment outcome. A favorable treatment response was shown for the entire catatonic sample, with two thirds markedly improved or in remission at the time of discharge. These findings are consistent with those of other investigators of the catatonic syndrome for the past 100 years.


Serum dopamine-beta-hydroxylase activity in the affective psychoses and schizophrenia. Decreased activity in unipolar psychotically depressed patients. Serum dopamine-beta-hydroxylase (DBH) activity was studied in 125 psychiatric patients and 73 normal controls. Serum DBH activity in schizophrenic, bipolar manic, and neurotic depressive patients was not significantly different from that in controls. Although serum DBH activity in unipolar and bipolar depressed patients was also not significantly different from that in controls, the subgroup of psychotically depressed unipolar patients had significantly lower serum DBH levels than controls did. Serum DBH activity in bipolar psychotically depressed patients also tended to be low, but was not significantly less than in controls. Serum DBH activity in the patient group usually did not increase in the immediate period following successful treatment with drugs or electroconvulsive therapy, indicating that basal levels of serum DBH activity in psychiatric patients are not state-dependent. Low serum DBH levels in psychotically depressed patients must be verified in an independent group of patients before its significance can be appreciated. Our findings could be the result of the study of an atypical group of psychotically depressed patients.


Klinefelter syndrome in a military population. Electroencephalographic, endocrine, and psychiatric status. In a study of nine Klinefelter syndrome patients obtained from a military population, all were found to have normal electroencephalograms (EEGs), all were clinically euthyroid, and had normal thyroid function test results. All had normal verbal and nonverbal IQs and no evidence of neurologic dysfunction on psychological testing. There was a high incidence of personality maladjustment as indicated by both the Minnesota Multiphasic Personality inventory and individual psychiatric evaluation. No particular personality pattern appeared typical for the group as a whole. Neurologic dysfunction, as manifest by EEG abnormality, mental retardation, or neuropsychological test deficits, and hypothyroidism are not necessarily associated with Klinefelter syndrome. Likewise, although the incidence of personality disorders may be strongly associated with this disorder, no specific personality type appears especially characteristic of the syndrome.


Further studies on sex hormones in male homosexuals. Plasma estrone, dihydrotestosterone, luteinizing hormone (LH), and percentage-free testosterone levels were determined in 26 predominantly or exclusively homosexual males (20 to 33 years of age) and in an age-matched control group. Although the homosexual and control groups showed a broad overlapping for all hormonal factors measured, highly significant differences between the groups were found without exception. The medians of the homosexual group (control group) and the significance levels for the two-sample rank tests were as follows: estrone 3.07 (2.43) ng/100 ml, P less than .01; dihydrotestosterone 66.0 (49.2) ng/100 ml, P less than .01; percentage-free testosterone 10.7% (9.7%), P less than .02; LH 35.1 (24.9) ng/ml, P less than .001. These findings can in part be explained by the higher LH secretion in the homosexual subjects.


Effects of sleep deprivation on mood and central amine metabolism in depressed patients. Nineteen patients, each hospitalized with a major depressive episode, were deprived of sleep for one night. Ten patients responded with clear improvement in depressive symptoms; the substantial clinical change was transient, usually lasting one day. Those who responded had significantly higher initial depression ratings (P less than .01) and tended to be older than nonresponders who experienced mild increases in irritability, fatigue, and discomfort following sleep deprivation. Amine metabolites, 5-hydroxyindoleacetic acid (5HIAA), and homovanillic acid (HVA) were not substantially affected by sleep deprivation, although there was a significant interaction of clinical response and direction of 3-methoxy-4-hydroxyphenylglycol (MHPG) change. Sleep deprivation thus produces acute, but only transient improvement in a selected group of severely depressed patients; it appears to be an important tool in the study of the affective disorders.


Needle electromyography: its effect on serum creatine phosphokinase activity. The effect of needle electromyography on serum creatine phosphokinase (CPK) levels has remained unclear despite the diagnostic implications. Serum CPK was serially assayed for changes before and after electromyography (EMG) in two healthy persons and ten persons having low back pain, while they remained at total bed rest. Mean curves showed a peak at 6 hours post-EMG and a return to baseline 48 hours post-EMG. The mean peak value was 1.5 times the baseline. Only one sample exceeded the normal range and it was from a patient with frank positive waves and fibrillation potentials. Correcting for dilution of CPK released, by body weight and for total trauma, by number of needle insertions did not modify the results. The time course and magnitude of elevation of CPK parallel those reported for post exercise changes but are much less than those reported to follow myocardial infarction. In the differential diagnosis of myopathies, care must be taken to ensure that the combination of needle electromyography, exercise, diurnal variation and active denervation does not lead to a "false-positive" elevation of CPK above the normal range. Needle electromyography by itself should not induce a false-positive CPK level in a normal person and no significant changes in CPK levels are likely to occur within two hours after the study.


Spontaneous potentials in premature and full-term infants. Spontaneous potentials may be normally found in the electromyograms of premature and full-term infants. These potentials tend to disappear as the infants mature past three months of age. However, in some infants with cerebral or metabolic disorders these spontaneous potentials may persist. Their pathogenesis is obscure. The electromyographer must be aware of their existence in disorders unrelated to the lower motor neuron.


Heat and stretch procedures: an evaluation using rat tail tendon. This study evaluated various methods of applying force to collagenous tissue at various temperatures to produce permanent elongation, using rat tail tendon as the tissue model. A materials testing machine was used to measure the forces applied and the resulting elongation produced by differing procedures. Short-term vigorous stretching and prolonged moderate stretching were compared at 37 C. The effect of heating tissue prior to applying force was evaluated, and the effect of using a prolonged application of low force was demonstrated. The data showed that the low force, long duration procedure was very effective at producing residual elongation. Elevating tissue temperature and maintaining it prior to applying force was found to cause significantly less damage; and finally, the lower loads applied at elevated temperatures for prolonged periods were found to produce significantly greater residual elongation.


Heat stress: comparison of short exposure to severe dry and wet heat in saunas. Sixty subjects, 33 males and 27 females, from 18 to 63 years of age, were exposed to two kinds of saunas: the Finnish sauna (dry sauna) with an air temperature of 80 to 90 C and a relative humidity of 50%, and the wet sauna with an air temperature of 45 to 50 C and a relative humidity of 100%. There was a rest period of one week between the two experiments. For the 60 subjects the mean duration in the wet sauna was 19.6 minutes and in the dry sauna it was 17.4 minutes. After 10 and 20 minutes of exposure in the wet sauna the mean rectal temperature was 38.1 and 38.5 respectively, the mean skin temperature 40.2 and 40.4 C, the respiratory rate 21 and 22.9 breaths/min, the pulse rate 113 and 135.4 beats/min, the mean diastolic pressure 76.1 and 71.9 mm Hg, and the mean systolic pressure 115.7 and 123.5 mm Hg. Comparing the different physiological parameters in both saunas showed significant differences only during the first 10 minutes: a greater drop in diastolic blood pressure, a higher increase in systolic blood pressure, and a greater rise in pulse rate in the dry sauna. After 20 minutes there were no significant differences between any of the above parameters. It is concluded that the heat strain and hence the risk in both saunas are similar and exposure in either sauna exceeding 10 minutes may be dangerous.


Wheelchair cushions designed to prevent pressure sores: an evaluation. Seven commercially available wheelchair cushions were tested for their ability to reduce reactive hyperemia in paralyzed patients. The cushions were evaluated daily for seven days on each of three patients. A Latin-square design was used to determine the sequence of evaluation on each of the days, and to control the effect of order of assessment. Patients sat on the cushions exactly 30 minutes after which the duration of any redness was measured with a stop watch. Before sitting on the next cushion, the patients remained off their buttocks for exactly 30 minutes. Data for the three patients were averaged, and an analysis of variance of the Latin-square showed no significant differences among the cushions.


Sex education and counseling program on a spinal cord injury service. A sex education and counseling program was designed for spinal cord-injured patients and their partners, and alternative approaches are briefly reviewed. Also notable is the importance of inservice training for staff working with the cord-injured.


Clinical applications of a standardized mobility test. Four patients with mobility problems were evaluated in relation to their performances on a standardized mobility test throughout the course of their rehabilitation programs. While each of the four cases demonstrates the value of an objective measurement of independent function, each also reflects individual points of merit. Clinical application demonstrated the test's ability to separate out areas of mobility deficit, evaluate forms of treatment, and indicate need for follow-up. Further, the sensitivity of the test in long-term follow-up of mobility problems was illustrated.


Graphical representation of neuromuscular function in spinal cord injury. Accurate determination of the location and extent of a spinal cord leson is essential to the ongoing therapeutic plans for a patient as well as for overall program evaluation in a spinal cord center. The interpretation of muscle function tests performed for this purpose is often complex due to the large number of muscles innervated in part by a single segment of the cord and the overlapping pattern of innervation. The aggregation of the individual muscle ratings by spinal cord root segment and graphic presentation of this information provides a convenient means to gain an overview of muscle function and follow changes in the cord lesion over time through serial test results. Two cases demonstrate some of the graphic patterns that result from complete and incomplete lesions from shortly after injury with both receding and advancing involvement of the cord demonstrated.


Cerebral palsy: predictive value of selected clinical signs for early prognostication of motor function. A prospective longitudinal study involving 233 children with cerebral palsy was carried out to select signs useful for early prognostication of ambulation. All patients were followed from the time they were 12 months old and their progress was observed until they reached the age of 3 to 11 years. The population consisted of 61 children having congenital hemiplegia, 37 having diplegia, 85 having spastic quadriparesis and 28 having the spastic-athetoid clinical type of cerebral palsy. In addition, there were 14 children with athetoid, 6 with ataxic and 2 with hypotonic cerebral palsy. Of the total population, 78.7% achieved some degree of functional walking. Findings indicated that the probability of ambulation was related to the clinical type of cerebral palsy. In some the ultimate functional outcome was rather uniform, as in those with congenital hemiplegic and ataxic types where the prognosis was consistently favorable or in those with hypotonic cerebral palsy in whom the outlook was poor. In spastic diplegic, quadriparetic, spastic-athetoid and athetoid types, on the other hand, expectations varied considerably. For this group of patients, sitting by two years was found to be a predictive sign of high reliability since all children who sat by this age eventually walked. For the group of patients not sitting by two years which included more than half of the eventual ambulators, suppression of obligatory primitive reflex activity between 18 and 24 months provided a sensitive indicator to distinguish the children who ultimately walked from those who would not be expected to do so. These data offer a possibility for predicting future ambulatory status by two years of age in those clinical types of cerebral palsy where difficulties of early accurate prognostication are most likely to be encountered. Observations also suggested that the presence of mental retardation adversely affects ambulation.


Abductor digiti quinti shuffleboard: a study in motor learning. The purposes of this study were as follows: (1) to refine prior studies by investigating one muscle which provided all the agonistic motion involved in a novel motor task, (2) the pinpoint the exact time during which motor activity contributed to the final task, (3) to study the electrical changes that occurred in that one muscle as it developed skill, and (4) to compare the results of this study with the previous studies in this series. The muscle chosen for this study was the abductor digiti quinti of the nondominant hand and the novel task involved propelling a small plastic disk into a specific target area. Electromyography and cinematography were used in data collection. No statistically significant differences were found in prelearning and postlearning data with regard to electrical activity, movement time or range of movement. These results support a hypothesis earlier proposed by Payton to the effect that all the the agonists which contribute to a skilled performance begin as a relatively undifferentiated mass of muscle; as learning takes place the various elements of this muscle mass are differentiated into prime movers and auxiliaries. The electrical activity remains essentially the same in the prime movers while a marked reduction is seen in the auxiliary muscles. A reinterpretation of several earlier studies is suggested.


Exercise effect on contractile properties of skeletal muscle in mouse muscular dystrophy. The purpose of this study was to determine the effect of a high repetitive exercise program, treadmill running, on the tetanic tension and rate of tension development of the slow twitch soleus muscle of normal plus dystrophic mice and their littermates. The exercise program used would be considered to be of mild intensity since it failed to produce any detectable histochemical or biochemical changes. In the noninvolved normal and littermate mice, there was no difference in maximum tetanic tension between the exercised and nonexercised control groups. In the normal mice (eight weeks of age), there was a significant decrease in rate of tension development for those exercised for five weeks compared to nonexercised controls. In littermate mice (seven weeks old) exercised for a four-week period, there was also a significantly lower rate of tension development compared to their nonexercised controls. In dystrophic mice (seven weeks old) exercised for only one to two weeks, there was significantly lower tension as well as rate of tension developed for the exercised mice when compared to nonexercised dystrophic mice. In dystrophic mice (six weeks old) exercised for one to two weeks, there was no difference in tension or rate of tension development when compared to nonexercised controls. In both six and seven-week-old littermate mice, also exercised for one to two weeks, this reduction in tension and rate of tension development did not occur. The average life span for the dystrophic mice used in this study is about 30 weeks. Of the nine exercised dystrophic mice scheduled for study at eight weeks, only one survived, suggesting that even the mild exercise used might have shortened their life expectancy.


Longitudinal unobtrusive measurements in rehabilitation. Most evaluation techniques in rehabilitation emphasize descriptions of patient capability during brief time intervals under relatively standardized conditions. This paper outlines a conceptual approach which emphasizes the importance of evaluating how patients actually perform under everyday circumstances during extended periods of time. The underlying strategy embodied in this approach consists of the following elements: (1) continuous monitoring of discrete activities over extended periods of time (hours to months); (2) data collection wherever the patient goes allowing nontest behavior patterns to be studied; and (3) unobtrusive, noninvasive, and ethically acceptable monitoring to minimize observer bias. Although numerous techniques can be used to obtain these kinds of measurements, recent advances in biomedical engineering make a technological approach both inexpensive and feasible for selected activities. In addition, unobtrusive instrumentation can help generate objective, quantitative information concerning actual patient behavior which provides a previously unavailable data base for evaluating individual patient progress, assessing program effectiveness and developing more relevant outcome measures. Two examples of studies which utilize longitudinal unobtrusive measurements are described and preliminary results are presented.


Skoraya Pomosch: Emergency Medical Service of the Soviet Union. The Emergency Medical Service of the Soviet Union as witnessed in 1975 shows evidence of central communication, organization, and planning. The Skoraya Pomosch has developed into an elite medical corps with general multispecialty emergency teams that include well-trained physicians and physicians' assistants, with emphasis on bringing medical care to the patient at the site of the emergency. At its optimum, it is an elite corps that is uniformly available and capable of response to minor emergencies as well as major community disasters. Chronic problems of inadequate equipment and inappropriate use of the system continue to plague the Skoraya as they do other aspects of Soviet medicine. Certain qualities, such as the central communication network, are probably adaptable to the United States' situation, but in general, we must continue to improve and devise our own emergency medical system.


Crohn disease and pregnancy.

Crohn disease and pregnancy. Seventy-eight women with Crohn disease, each having the physical capability and opportunity to bear children, were admitted to the New York Hospital-Cornell Medical Center during a 20-year period. Forty-two pregnancies occurred. Results are suggestive of overall decreased fertility with no significant difference according to site of disease. The outcome of the pregnancies was not unlike that of the general population. Pregnancy did not exert an adverse effect on the disease itself, but termination of pregnancy was associated with relapse of Crohn disease 24% of the time.


Intercostal pulmonary hernia.

Intercostal pulmonary hernia. In five cases of intercostal pulmonary hernia, the hernia occurred following blunt chest trauma in two cases, after tube thoracostomy drainage in two, and following rib resection in one. Surgical repair was accomplished in three cases with good results, while in the remaining two the hernia underwent spontaneous regression.


Basilar pneumonia simulating acute appendicitis in children. Twelve children with acute abdominal pain, which was suspected of being acute appendicitis, were subsequently found to have lower lobe pneumonia. Diagnostic barium enema or operative exploration failed to demonstrate any appendiceal abnormality. The abdominal symptoms and the ileus subsided soon after the initiation of antibiotic therapy. Contrary to common belief, it was observed that left-sided pneumonia is capable of mimicking appendicitis almost as frequently as right-sided pneumonia. Since the likelihood of acute appendicitis accompanying pneumonia is small, operative intervention is rarely indicated and should be undertaken only after careful and intensive investigation.


Tracheal stenosis. A method of dilation with use of the fiberoptic bronchoscope. Tracheal stenosis is not an uncommon sequel of prolonged endotracheal intubation. In some cases, immediate reconstruction is not feasible. We use the flexible fiberoptic bronchoscope and a lucent, tapered endotracheal tube for tracheal dilation. The fiberoptic bronchoscope is passed through a special T connector into the endotracheal tube and used to guide the tube under direct vision through the stricture.


Peripheral nerve division for relentless ischemic foot pain. During a three-year interval, 12 multisensory peripheral nerve divisions in ten patients were performed for intractable ischemic foot pain. The two major indications, after concluding that revascularization was impossible, were (1) the presence of localized, dry, and contained acral gangrene in patients who were not candidates for a lesser amputation and (2) patient or family refusal of a limb amputation.


Improvement in blood flow through a critical arterial stenosis by defibrination with ancrod. Using electromagnetic flow probes, cardiac output and hind limb blood flow were measured in dogs in which one hind limb had been rendered ischemic. Four dogs served as controls; seven were defibrinated by intravenous infusion of ancrod, 1 unit/kg, over a 30-minute period. In both groups, hematocrit readings remained constant, but cardiac output fell (this was attributed to barbiturate anesthesia), as did flow in the normal hind limb. In the controls after three hours, flow in the ischemic hind limb had decreased by 34%, but in the treated animals it had increased by 20%. The difference was statistically significant (P less than .001). The selective increase in blood flow in the ischemic limb may be explained by the greater reduction in blood viscosity at low shear rates achieved by defibrination.


Direct injection into the gallbladder in dogs, using ultrasonic guidance. Direct injection into the gallbladder can be accomplished with the guidance of the ultrasonic aspiration transducer. Possible bile peritonitis is a limiting factor, but not necessarily a complication that contraindicates the procedure. Some modifications of the procedure may be necessary, and further investigation into this potentially valuable procedure is indicated.


Influence of enteral oxygen administration on the slow electrical activity of the intestine and stomach. Thirty-eight starved cats, anesthetized with pentobarbital (Nembutal) sodium, received enteral administration of oxygen and other gases; the effect on intestinal motility as expressed by electrical activity was measured. Oxygen caused a notable increase in amplitude and frequency of slow electrical waves, while carbon dioxide and nitrogen caused no visible alterations. Phentolamine hydrochloride and propranolol hydrochloride together with atropine sulfate decreased the amplitude and frequency of oscillations to near zero; subsequent administration of enteral oxygen caused a notable increase in electrical activity, while enteral carbon dioxide produced no alterations. On the basis of our previous observations that enteral oxygen enhances oxygen and blood delivery to the gut wall, we suggest that the rise in stomach and intestinal electrical activity during enteral oxygen administration in conditions of surgical stress may be associated with an increase in oxygen and blood delivery to the gut wall.


Manometric evaluation of an artificial intestinal valve. A new type of intestinal valve was constructed by telescoping the proximal portion of the intestin into the distal portion. The length of telescoped intestine was expressed in relation to its diameter. Various lengths of intestine were tested in 29 dogs. Valvular function was evaluated under pentobarbital sodium anesthesia, with open-tip catheters perfused at a rate of 5 mul to 6 mul/sec. An intestinal valve, made by telescoping two diameter lengths of the intestine, yielded the most similar results manometrically to those of the ilecolonic junction. Mean isoperistaltic and antiperistaltic pressures were measured to be 25.0 +/- 2.0 and 39.0 +/- 3.8 cm H2O in the valve, and 20.4 +/- 2.2 and 39.7 +/- 5.1 cm H2O in the ileocolonic junction. No alteration of the valvular function was found in the long-term follow-up study.


Species differences in response to renal ischemia. Different species appear to tolerate different amounts of renal ischemia. It is suggested that all kidneys are equally susceptible to ischemic damage, but that the whole animal response varies between species. Mice, rats, rabbits, and pigs were subjected to bilateral nephrectomy. Large animals had relatively smaller kidneys and survived longer than smaller animals. Therefore, the larger the animal, the more time available for recovery of a kidney damaged by ischemia. This adequately explains the apparent species differences in susceptibility to renal ischemia, which are only seen when the kidney is expected to support life immediately. Simple relationships are described, relating metabolic rate, body size, and survival time with no renal function.


Obstructive jaundice and renal masses.

Obstructive jaundice and renal masses. An 82-year-old patient with obstructive jaundice secondary to simple renal cyst also suffered pain and vomiting from partial duodenal obstruction. The symptoms were relieved by aspiration of 1,750 ml of fluid. This reaccumulated over a five-year period when aspiration again relieved his symptoms, which then only consisted of epigastric fullness. Review of the literature shows jaundice to be an extremely rare symptom of renal cyst.


Primary repair in transection of duodenum with avulsion of the common duct. In combined pancreatoduodenal trauma, the surgeon usually chooses a diverting or resectional procedure at substantial risk. Simple closure of the duodenum and transposition of the common duct was accomplished at early operation in an 18-year-old boy who had almost complete transection of the duodenum with avulsion of the ampulia of Vater from blunt abdominal trauma. Transgastrojejunostomy and use of Chaffin tubes were discontinued prior to discharge from the hospital three weeks later. The postoperative course was complicated only by a brief pancreatitis. The excellent result persists more than two years later. In similar anatomic situations, consideration might be given to this operative approach.


Pseudomembranous colitis treated with completely diverting ileostomy. A seriously ill patient with pseudomembranous colitis of obscure origin responsed promptly to a completely diverting ileostomy. The ileostomy was successfully closed three months later when the colon appeared to be normal. In an unusually severe case of pseudomembranous colitis, where operation is required and where pseudomembranous colitis is the sole operative finding, a completely diverting ileostomy should be considered rather than a more extensive procedure.


Incomplete membranous obstruction of the inferior vena cava. Hemodynamic measurements and correction by balloon membranotomy and surgical resection. This report discusses a patient with chronic liver disease and portal hypertension, initially thought to be caused by chronic bile duct obstruction or chronic hepatitis B. For evaluation of portal hypertension, hepatic vein catheterization was performed, disclosing incomplete membranous obstruction of the inferior vena cava at the level of the diaphragm--the probable cause of the liver disease. The obstruction was corrected by balloon membranotomy and surgical resection of the membrane. Hepatic vein catheterization in patients with chronic liver disease and portal hypertension allows detection of this lesion as well as evaluation of hepatic and portal hemodynamics.


Ectopic pelvic spleen.

Ectopic pelvic spleen. We are reporting the first, to our knowledge, ectopic pelvic spleen demonstrated preoperatively by means of a liver-spleen scan and a selective splenic arteriogram. Symptoms, consisting of crampy pain in the lower part of the abdomen exacerbated by standing or stooping, were relieved by splenectomy in this 19-year-old woman. Splenopexy, which has been advocated in the past, has no place in the management of this rare and interesting congenital variant. Laxity or failure of development of the phrenicosplenic and gastrosplenic ligaments is thought to account for the splenic descensus.


A simple effective technique for performing intraoperative cholangiography. This simple, effective technique for performing intraoperative cholangiography uses a smooth-tipped side port cannula that is easily threaded into the cystic duct. Performance of intraoperative cholangiography is expedited by this method and artifacts commonly produced during cholangiography are avoided.


Spontaneous rupture of the spleen. An unusual complication of anticoagulant therapy. A 44-year-old man, who had been taking warfarin sodium because of a previous myocardial infarct, suddenly developed abdominal pain and signs of peritoneal irritation, requiring exploratory laparotomy. The spleen was ruptured. There were not any systemic diseases nor antecedents of trauma that could be considered predisposing factors for the apparently spontaneous rupture of the spleen. The only abnormality recorded was an elevated prothrombin time. Thus, a coagulopathy produced by the anticoagulants appeared to be the only possible predisposing factor for his splenic rupture.


The sink action of cerebrospinal fluid volume flow. Effect on brain water content. Effects of changes in serum osmolarity on volume flow of fluid into the cerebral ventricles of cats were measured by ventriculocisternal perfusion with mock cerebrospinal fluid (CSF), mock CSF containing acetazolamide, or a 30 mOsm/liter sucrose solution. Serum osmolarity was altered by intravenous infusion of a sucrose solution ranging between 10 and 650 mOsm/liter changing volume flow. For all perfusion fluids, regression lines relating volume flow to infused solution osmolarity were parallel. After infusion of a 10 mOsm/liter solution, brain water content increased. One hour after infusion, volume flow returned to normal, although serum was still hypotonic. Gray matter water content was still elevated; white matter returned to normal. The results suggest that the source of increased volume flow is the brain, and that the CSF acts as a sink, limiting excess water accumulation during water intoxication.


Interlaboratory variability in determination of plasma antiepileptic drug concentrations. The usefulness of plasma antiepileptic drug concentrations in treatment of epilepsy has been established, and many laboratories provide this service. A "blind" survey utilizing pooled patient plasma samples was conducted among 197 laboratories in the United States and Canada to establish the interlaboratory reproducibility. Three "patient specimens" containing different amounts of phenobarbital, phenytoin (diphenylhydantoin), primidone, and ethosuximide were employed; 112 laboratories reported results within five weeks. The average cost for analyzing four drugs in a single sample was $43.27. Half of the laboratories reported results outside +/- 1 standard deviation of the mean of five reference laboratories. Wide interlaboratory variability must be considered by the practicing physician. Until certified antiepileptic drug standards in a biologic matrix are available from the National Bureau of Standards, a volunteer quality control program among laboratories is needed.


Rapid regular respiration in unconscious patients. Respiratory frequency has been studied by strain gauge and impedance pneumography in a group of unconscious patients suffering from a variety of medical conditions, and has been compared with breathing in control subjects during wakefulness and sleep. Seventeen of 25 comatose patients had breathing patterns amenable to computerized statistical analysis of respiratory rate which demonstrated abnormalities in all patients studied. Unconscious patients breathed more rapidly and regularly than controls. Rapidity of respiration was not consistently associated with any specific central nervous system lesion, and was usually accompanied by coexistent pulmonary disease. Increasing regularity of respiration correlated well with deepening of coma and accurately reflected ultimate outcome even when other clinical signs were unchanging.


Experimental arthrogryposis caused by viral myopathy. Immobilization of the embryo has been postulated to cause the joint deformities in arthrogryposis multiplex congenita (AMC). Experimental damage to the motor neurons or pharmacologic blockade of neuromuscular transmission has previously resulted in typical joint changes of AMC. In the present investigation, we have studied the effects of paralysis produced by a viral myopathy on joint development. Coxsackievirus A2 was injected intravenously into chick embryos on the seventh day of incubation. Within 48 hours, severe myositis and paralysis resulted. Electron microscopical and immunofluorescence techniques demonstrated virus in muscle cells. Within three to four days after infection, the muscle had virtually disappeared. Ankylosis of joints, corresponding to that seen in human AMC, occurred. This study shows that primary myopathy with paralysis can produce arthrogrypotic joint deformities. The possibility of a viral etiologic factor in some human cases of AMC should be considered.


Myoclonus in familial restless legs syndrome. Eighteen members of a family were affected over a span of five generations with the restless legs syndrome, transmitted as an autosomal dominant trait. Ten patients had myoclonus. The propositus, a 57-year-old man, suffered from repeated, intense, asymmetric flexion jerks of the lower extremities, alternating with fidgeting and friction movements of the legs; all occurred at night prior to sleep and severely interfering with it. The patient's movements ceased with the onset of stage 1 sleep, while in his brother, the motor activity persisted in stages 1 and 2 of sleep.


Ophthalmoplegia and dissociated nystagmus in adetalipoproteinemia. A characteristic pattern of acquired exotropia, progressive paresis of the medial rectus muscles, and dissociated nystagmus on lateral gaze was found in three patients with abetalipoproteinemia. Study with electronystagmography of the eye movements of one patient revealed abnormally slow voluntary saccades and slow or absent fast components of vestibular nystagmus, optokinetic nystagmus, and jerk-type, disassociated nystagmus. Defects in central nervous system centers generating saccadic eye movements are postulated.


Migratory white-without-pressure retinal lesions. Nine patients had white-without-pressure retinal lesions. These lesions were seen in areas of vitreoretinal adhesions. The configuration and location of these lesions changed over variable periods of time. The cause of this pecular migration is unknown, but may be related to separation and re-creation of vitreoretinal adhesions. The migratory nature of white-without-pressure areas has not, to our knowledge, previously been reported in the literature.


Treatment of Behcet disease with chlorambucil. A follow-up report. In Behcet disease the eyes are involved in most cases, and progression to blindness is almost the rule. When the central nervous system is involved, the prognosis for life is grave. In a preliminary report, 11 patients had the disease arrested as a result of treatment with chlorambucil. Some of these patients had long-term follow-up and are included in this report. Nine others received the same treatment, resulting in arrest of the disease in eight and pronounced improvement in one. Long-term follow-up, in some patients for more than five years after arrest of the disease, has not disclosed any recurrence. These results may appear more important if it is noted that blindness in Behcet disease occurs an average of 3.36 years after onset of eye symptoms.


Herpes simplex keratitis in a developing country. Natural history and treatment of epithelial ulcers in Tunisia. Herpes simplex keratitis was found to be a common ophthalmic problem in Tunisia. Dendritic and geographic ulcers were complicated by deep stromal keratitis in 31% of patients, two thirds of whom were known to have been treated previously with corticosteroids. Herpes simplex virus was isolated from 41% of patients from whom corneal material was cultured. To develop an effective program for management of epithelial herpes in developing countries, treatment with idoxuridine was compared with debridement and patching. Average healing time for 31 ulcers treated with idoxuridine was 13 days, with three treatment failures; average healing time for 20 ulcers treated with debridement and patching was five days, with one failure. Debridement and patching of herpetic ulcers was an efficient way to treat herpes simplex keratitis within the context of overall medical care in Tunisia.


Developing eye in an ovarian teratoma.

Developing eye in an ovarian teratoma. A malignant teratoma of the ovary was resected in a 14-year-old girl. Within the tumor, a partially developed eye was found.


Senile mecular degeneration. A clinicopathologic correlation of two cases with neovascularization beneath the retinal pigment epithelium. The histopathologic findings in two cases of senile macular degeneration were correlated with the premortem clinical studies, from the onset in both cases and through the disciform stage in one case. In case 2, the postmortem eyes were obtained only one month after ophthalmoscopic, fluorescein angiographic, and fundus photographic studies were performed, all on the same day. Our report not only adds to the few clinicopathologic correlations of the lesions in senile macular degeneration reported in the literature, but also presents the first reconstruction to scale of subretinal pigment epithelial (sub-RPE) neovascularization. Our results confirm the diagnosis of sub-RPE neovascularization and serous detachment of the retinal pigment epithelium. Drusen were correlated as to number and general location but not individually. Serous detachment of the neurosensory retina was found histopathologically but not clinically.


Ocular findings six years after intravitreal silicone injection. A case of giant retinal tear treated by injection with dimethicone 350 (medical fluid silicone) was observed for six years before enucleation. About four months after the injection, signs of anterior segment ischemia were evident. A year after the injection, an injury resulted in displacement of dimethicone 350 into the anterior chamber. Enucleation was done because of pain.


Cellular blue nevus of the sclera.

Cellular blue nevus of the sclera. An isolated cellular blue nevus of the sclera was discovered and removed during a retinal detachment operation. Such benign tumors may be misdiagnosed clinically as an extension of a melanoma of the choroid or histologically as melanoma.


Corneoscleral cautery. Pathology and technique. The filtration procedures of trephine, iridencleisis, and corneoscleral cautery are compared to show the superiority of the latter. Pathologic vertification of the three operations suggests the reason for success. Several changes in the original technique as described by Schele are suggested.


Intermittent vs continuous steroid administration. Efficacy in experimental conjunctivitis. The development of techniques for the continuous administration of drugs to the eye raises the question of whether a conjunctivitis can be controlled by continuous low rates of steroid release, or whether large, intermittent doses of steroid, as provided by eyedrops, are necessary. Efficacy of the two modes of drug administration was evaluated in a conjunctivitis model produced in immunized rabbits by daily topical ocular challenge with antigen. The acetates of hydrocortisone and prednisolone were released from a drug delivery system inserted in the cul-de-sac of the eye or were provided in eyedrops. The model was sufficiently sensitive to differentiate between the effectiveness of hydrocortisone and prednisolone. The continuous delivery of either steroid from the drug delivery system was as efficacious, or more so, than the corresponding steroid dose given as eyedrops.


A Ganzfeld stimulator for electroretinography. The design of a ganzfeld stimulator for electroretinography affects both clinical results and ease of operation. Several advantageous design differences from a recently described ganzfeld stimulator are (1) close proximity of the flash electrode to the surface of the sphere to increase the intensity and uniformity of the stimulus; (2) provision for interposing color filters in the background light; (3) use of a diffusing filter in the background light; and (4) placement of the stimulus flash anteriorly to avoid uneven illumination of the retina. Details of construction are proveded for two models and the specific advantages of each design are noted.


Hypotension and bradycardia following intraocular acetylcholine injection. Report of a case. A possible systemic reaction to acetylcholine chloride injected into the anterior chamber of the eye occurred in a 65-year-old patient who had a cataract extraction while under general anesthesia. Following cataract extraction, 20 mg of acetylcholine chloride was injected into the anterior chamber of the eye. Immediately following injection, hypotension and bradycardia (48 beats per minute) occurred.


Retinal vascular changes of incontinentia pigmenti. Of 19 patients with incontinentia pigmenti, seven had a bizarre retinal anomaly that consisted of a zone of abnormal arteriovenous connections and preretinal fibrotic tissue at the temporal equator, with no perfusion peripheral to it. In one patient, the vascular changes progressed and required photocoagulation. This retinal lesion may represent an early stage of the pseudoglioma that so commonly is reported with this skin disease. Incontinentia pigmenti should be considered in the differential diagnosis of retinal vascular disease in girls and women of any age.


Visual field changes in branch retinal 'vein' occlusion. The visual field defects in 20 consecutive patients who had branch retinal "vein" occlusions included arcuate nerve fiber bundle scotomas, central scotomas, paracentral scotomas, and segmental peripheral constriction. The role of retinal arteriolar insufficiency in the production of these field defects is discussed. The available evidence suggests that the term "branch retinal vascular occlusion" is a preferable term to describe such clinical findings.


Disciform degeneration of the macula. II. Pathogenesis. Of 84 patients with unilateral disciform macular degeneration, 36 were followed up for one to four years (average, 22 months). The fellow eye in 13 cases developed disciform lesions during that follow-up period. A significantly greater number of drusen were found in the fellow eyes of patients with unilateral disciform macular degeneration than in the eyes of a comparable control group of patients (P less than .001). Furthermore, the eyes with unilateral disciform macular degeneration that developed disciform lesions in the other eye were characterized as a group by a significantly larger number of drusen than those that did not. We postulate that drusen are precursors of disciform macular degeneration in fellow eyes and are probably manifestations of the same exudative process.