Unilateral medial rectus recession for small-angle esotropia. Ten patients with small-angle esotropia of 18 prism diopters or less were treated with a unilateral medial rectus recession of 5 mm. Nine of the ten cases considerably improved; one showed only minimal improvement. There were no overcorrections, but two cases did show lateral incomitance with a greater correction on gaze in the field of action of the recessed medial rectus muscle. Two patients became monofixators after the surgery. These had been patients with accommodative esotropia who had decompensated and had surgery for the nonaccommodative portion of the total esotropia. When indicated, the recession of one medial rectus muscle is a safe and predictable procedure for small-angle esotropia. An average correction of 11.6 prism diopters was obtained at distance and one of 11.3 prism diopters at near.


Acute orbital cellulitis.

Acute orbital cellulitis. A review of 104 patients with acute orbital cellulitis during the past decade showed that the frequency of hospital admissions for this disease has increased recently. Roentgenograms showed paranasal sinus in 77 of 91 patients. Haemophilus influenzae and Diplococcus pneumoniae were recovered from the blood of 20 and 6 patients, respectively. Four children had concomitant H influenzae meningitis. Bacteremia was demonstrated in 29% and more common in those with extensive orbital involvement, those not receiving antibiotics at the time of culture, and those less than 2 years old. Some of the 26 patients with less extensive involvement were bacteremic (17%), had leukocytosis, or roentgenographic evidence of sinusitis. Most children received large doses of ampicillin sodium and methicillin sodium intravenously until signs and symptoms had almost abated. With this regimen, there were no orbital, ocular, or other complications.


Lamellar macular hole: a complication of cystoid macular edema after cataract extraction. A woman developed an inner lamellar macular hole and cellophane maculopathy as a complication of chronic cystoid macular edema following cataract extraction. Fluorescein angiography revealed a cystoid pattern of fluorescence in the paracentral area but no evidence of staining in the region of the hole. Following death, histopathologic examination of both eyes confirmed the clinical observations. Biomicroscopic examination and fluorescein angiography are of value in differentiating an inner lamellar macular hole from a full-thickness macular hole and from a pseudomacular hole caused by spontaneous contraction of an epiretinal membrane.


Effects of microwave radiation on the lens epithelium in the rabbit eye. These experiments were conducted to determine the effect of cataractogenic doses of microwave radiation at 2.45 gigahertz (GHz) on the lens epithelium of the rabbit. One hour before animals were killed, tritiated thymidine was injected into the anterior chamber of both eyes at postirradiation intervals varying from six hours to one month. Epithelial peels were made and autoradiographic techniques used to identify cells manufacturing DNA. Comparison of counts from both experimental and control epithelia revealed two patterns, depending on the presence or absence of vesicle strings. Those lenses without vesicle strings showed an initial pronounced suppression of mitotic activity followed by gradual return to normal levels. Those lenses with strings showed a precipitous rise in DNA synthesis on the fourth to fifth day after irradiation. This increased activity may be the result of lens hydration.


Battered child syndrome simulating congenital glaucoma. A 9-week-old child with "congenital glaucoma" was later found to have, in addition to enlarged corneas and elevated intraocular pressure, subluxated and cataractous lenses, hyphema, iridodialysis, angle recession, and vitreous hemorrhage, along with signs of gross parental neglect and physical abuse. To our knowledge, this is the first report in which a battered child with bilateral "congenital glaucoma" (probably caused by trauma) is described.


Anterior segment ischemia following the Jensen procedure. Anterior segment ischemia occurred in a 66-year-old patient following recession of one medial rectus muscle combined with lateral rectus muscle union to the vertical rectus muscles (Jensen procedure). The mechanism of this complication is explained as inadvertent strangulation of the anterior ciliary arteries during tying of the split lateral rectus to the temporal aspects of the vertical rectus muscles. Special efforts to preserve the integrity of anterior ciliary arteries in those portions of the vertical rectus muscles not involved in the muscle union should be made to avoid this complication.


[Experimental "hormonal tenolysis" by cortisone therapy (author's transl)]. To prevent tendons from postoperative proliferation and adhesion to surrounding structures is still a main problem in handsurgery. In addition to numerous modifications of atraumatic handsurgical techniques which have been developed some sporadic attempts are made by animal experiments and clinical trials in order to avoid postoperative adhesive tenosynovitis by hormone therapy. Because of the high doses of cortisone which are required this method of treatment is generally not accepted. Using a new method of postoperative fixation of flexor tendon sutures in rabbits the possibility of a "hormonal tenolysis" by extremely high doses of cortisone could be confirmed. In a following study it is planned to perform breaking experiments on tendons after hormone therapy in order to determine the upper limit of the therapeutical range of cortisone medication.


[Closed injuries to capsular and ligamentous structure of MP I joint--diagnosis and treatment (author's transl)]. 7 new and 9 old injuries of the MP I joint primarily involving the ulnar capsule and ligaments have been reevaluated for treatnent and results. In old cases, the operative result could be classified as excellent and good in 7, while 2 were considered as failures. These results have been used to discuss the mechanism and diagnosis of ruptures of the MP I joint ligaments. Primary surgical treatment of fresh ligamentous injuries is far superior than plastic reconstruction of old injuries.


[Some aspects concerning the problem of lesions of the ulnar collateral ligament of the thumb (author's transl)]. The authors report on their experience on 20 old lesions of the ulnar collateral ligament of the MP joint of the thumb. They used a modified technique according to Strandell.--Follow up investigations were made in an average range of 17.5 months after the operation. All the colateral ligaments were stable. The procedure is not to be used for heavy manual working persons. If there is an osteoarthritis in the MP joint, arthrodesis is the alternative method.


The treatment of chronic knee joint synovitis with radioactive isotops (author's transl). On the basis of 77 cases report is given on the treatment of chronic synovitis of the knee in rheumatoid arthritis with radioactive isotopes. Gold 198 and Yttrium90 have been applicated. During an observation period up to 6 years a follow-up on 46 knee joints has been carried out. Very good and good results could be achieved in 50% of these cases.


[Fundamental biomechanic problems on osteosynthesis (author's transl)]. By means of compression plate osteosynthesis, of the lateral tension band and of the treatment with external chucks the main demand for stability of osteosynthesises is derivated: by adjustified, in the resultant axial tension of the metal implantats is to produce only pressure in the entire fracture zone without detrimental osteosynthesis induced excentric powers. The joint biomechanic aspects of the three methods are worked out.


[Stresses on osteosyntheses of femur and tibia in early mobilisation (author's transl)]. The knowledge of post surgery strain is of fundamental significance for dimension and location of application of osteosynthesis. In the following  biomechanical research height and direction of moments of flexure will be determined that occur during sleep and/or anaesthesia without additional and at partially loaded early mobilisation with the muscle activity at course of doppel step at upright- and swing-leg position. Moments of flexure are calculated at frontal and sagittal level considering efficiency of weights of parts of the leg and their centres of gravity as well as bending efficiency of the active muscle groups. Thus, moments of flexure resulting important facts are found for dimenstion of osteosynthesis equipments.


[The vessel behavior of the bone following plate osteosynthesis and subsequent osteomyelitis. An experimental study at the dog tibia (author's transl)]. In this paper the revascularisation pattern of the dog tibia diaphyse following osteotomy and plate osteosynthesis with subsequent osteomyelitis is described at various stages. As compared to undisturbed plate osteosynthesis the differences and conformities in revascularisation are shown. It is attempted to interpret the vessel behaviour under clinical aspects.


[New aspects for enlargement of surgical x-rays (author's transl)]. Method of direct geometrical X-ray magnification technique are discussed in the light of new technical possibilities,--fine-focus, high speed screen--and- the value in surgical X-ray diagnosis for the fine bone structure changes is demonstrated using practical examples. Also mentioned are other methods for a quirering a better form of diagnosis--such as for example the harmonising method.


[Late results in hemialloarthroplasty of the hip (author's transl)]. This paper presents a study of long-term results of femoral head replacement. 104 patients with Moore prosthesis could be followed up for an average of 9 1/2 years. In cases of fractures and complications of trauma the results were excellent and good in 65%. Practically 100% poor results could be shown in patients with osteoarthritis


Stresses and functional adaptation of alloarthroplasty of the proximal femur in dogs using a selfcuring rippled prosthesis. A comparative biomechanical and morphological study (author's transl). A self-adhesive prosthesis for youth patients is developed by Mittelmeier that is implanted without bone cement. After an implantation term of 1 year in animal experiment (dog), an adapted femur is compared with the contra-lateral normal femur. Strain gauges are used to determine bone strain under load. Further is determined external and internal construction change after endoprosthesis. The construction changes found are in connection with the changed bone strength. A cancellous change of bone at entire area of stem of prosthesis is called a "metaphysation" of bone shaft.


[Biomechanical and clinical studies of the transnaviculo-lunar resection arthroplasty (Steinhäuser operation) (author's transl)]. In advanced injuries of the proximal carpal row there is a therapeutic alternative to other methods of treatment--the Transnaviculo-Lunar Resection Arthroplasty of J. Steinhäuser. This operation gives the possibility to form a new joint by removing the os lumatum and the proximal two thirds of the os naviculare. The result is a painless new wrist which has a good range of motion. Since 1968 six Steinhäuser operations have been performed by attending orthopaedic surgeons of the "Orthopädische Klinik München Harlaching" follow-up study reports this clinical and radiographic results as well as the biomechanical fundamentales of the new wrist. The objective clinical and radiographic criterions, the subjective satisfaction of our patients and the biomechanical stability of the new wrist have shown, that there is a good prognosis of the Steinhäuser operation.


[Further experiences with total hip arthroplasty. Clinical and roentgenographic results after 3--6 years following implantation (author's transl)]. Report on 236 re-examined total hip arthroplasties performed between 3 and 6 years before (69 Huggler-Weber I and 167 McKee-Farrar joints). 76% of the patients were satisfied with their results on the base of acceptable pain control, increased joint mobility and improved functional capacity. Negative estimations usually could be verified by clinical and roentgenographic findings, the main reason for failures being aseptic loosening of one or both of the implant components in a present rate of 17.8%. Additional failures were due to infectious loosening (2.7%) and pararticular ossification (1.3%). Aseptic loosening of Weber-Huggler implants (33%) occured three times as often as with McKee-Farrar joints and usually was confined to the acetabulum. The influence of different factors such as patient's age and previous surgery, preoperative roentgenographic findings, etiology of coxarthrosis and operative technique has been evaluated. It is concluded that the present way of implant cementation with acrylics offers no sufficient long term anchorage and total hip arthroplasty therefore presently should be confined to the elderly. However, the results may be improved by strict indication and proper surgical technique.


[Pitfalls of statistics as shown in a study on dysplastic hips (author's transl)]. In 97 cases of randomly selected children of an age from 5 to 16 weeks the angles of Hilgenreiner are determined. In relation to these findings also the influence of various factors such as hereditary anamnesis and untimely birth are observed. The so found data are compared with those published from Tönnis and Brunken. It seems that their data are higher than those in an average population. The necessity of an exact random test is pointed out.


[Ultrastructural changes of human skeletal muscle after tendon and nerve injuries. I. Fine-structural changes of the hand muscles after tendor injuries (author's transl)]. During reconstructive procedures performed 4--16 weeks after the tendon lesion the specimens obtained from the injured muscle have been examined by the authors. It was found that after the tendon injury inactivity atrophy develops and a condition of equilibrum could be observed at this time. The most important changes in the fine structure were seen in the contractile elements: there were atrophied, homogenized, fragmentated and ragged independently from the functional unities. The number of the mitochondria was considerably decreased, the sarcoplasmatic reticulum was increased, and the difference between the originally red and white muscular fibres was indistinct. The glycogen content of the musculature was decreased, or it disappeared completely. No pathological changes have been observed in the sarcolemme, the cell nuclei and the motor nerve end-plates.


[Ultrastructural changes of human skeletal muscle after tendon and nerve injuries. II. Fine-structural alterations of the hand muscles after injuries of the motor nerve (author's transl)]. The authors examined the fine structural alterations of the muscles after traumatic neurotomy. The most important changes were forro found on the contractile elements, especially atrophy, and fragmentation. The number of mitochondria and sarcoplasmatic reticulum decreased both the glycogen content of sarcoplasma increased. The motor end plates were complete destroyed. On the motor motor-neurons typical Wallerian degeneration could be seen.


[Malignant degeneration of fistulas in chronic osteomyelitis (author's transl)]. The malignant degeneration of a skin ulcer has been reported as early as in 1884. In spite of this, however, the danger of malignant degeneration of sinus tracts associated with recurrences of chronic osteomyelitis is still underestimated. This development is neither restricted to case histories of years and decenniums nor to elderly patients and may also involve any part of the skeleton. Usually patients become aware of suddenly increasing tenderness and purulation, "washed out" structures of osteolytic areas are demonstrable radiographically. Diagnosis is established by mandatory histological examination of sinus tracts. Amputation or exarticulation of the extremity involved including efferent lymphatic vessels and nodi has no alternative. Local measures are insufficient. Apparently the first 3 years are decisive as to the prognosis. The prophylaxis consists of the therapy of the original disease: radical debridement of the osteomyelitic focus and filling of the defect with autogenous cancellous bone grafts.


[The results of open reduction of distal tibial epiphyseal injuries (author's transl)]. This article contains a report of 16 open reductions of distal tibial epiphyseal injuries. The follow-up studies were carried out 1 1/2 to 6 years post-operatively. The results were excellent in all cases. A discussison of the surgical indications of these injuries is included.


[Fresh combination injuries of the knee joint--diagnosis and treatment (author's transl)]. The diagnosis of fresh combination injuries of the knee joint is difficult. It is under all circumstances mandatory, occasionally by employing general anesthesia, to establish a diagnosis and the extend of the injury to decide on a conservative or surgical approach. Partial ruptures of the capsule and ligaments may be treated conservatively, complete ruptures are a surgical must. Between 1963 and 1974 we operated on 35 knees in 34 patients after afresh combination injury of the knee joint. 14 patients (15 knees) could be followed between 2 and 10 years postoperatively. All patients were satisfied with the result and were participating in sports. The objective results were excellent in 2, good in 12 and sufficient in 1. Knee joint stability could be reestablished in all knees. Follow-ups of a similar group of 14 patients after reconstructive treatment of an old "unhappy triad" showed considerably poorer results both subjectively and objectively. We conclude that fresh complete ruptures of the ligamentous and capsular structures of the knee joint have to be surgically repaired immediately to prevent permanent damage.


[Fractures of the olecranon; late results (authors's transl)]. 140 fractures of the olecranon were treated (69 conservatively, 71 surgically), of whom 71 were followed up (28 conservative, 43 operated fractures). The fractures are classified in 4 groups (A. transverse fractures, B. oblique fractures, C. comminuted fractures and D. fractures associated with other injuries in the elbow joint). Each of these groups is devided into 3 types according to the displacement of the fragments. Good results by conservative treatment were always seen in fractures with separation of the fragments less than 2 mm. A relative indication for surgical treatment is displacement from 2 up to 10 mm. Only surgical treatment can prevent non-union in fractures with separation of the fragments more than 10 mm. A new sheme for classification of the results is proposed, and late results of the followed up cases are reported. Immobilization of the elbow in full extension is rejected in the conservative treatment. The internal fixation of prestress type by the Weber technique and the osteosynthesis with Spongiosa-screw are the preponderant methods actually used in surgical treatment.


Antibiotic prophylaxis in allo-arthroplastic hip joint surgery. Concentration assays in the wound exudate after parenteral administration of gentamicin. The indecation and the efficacy of antibiotic prophylaxis in endoprosthetic operations are discussed with reference to prospective studies. After parenteral administration of 80 mg gentamicin the antibiotic concentrations in the serum and in the wound exudate were studied for 2 to 6 hrs after administration. During this observation period the gentamicin concentrations in the wound exudate were about equal to those in the serum. A comparison of the concentrations after parenteral and after local administration of gentamicin showed much higher concentrations in the wound exudate when gentamicin was administered with the bone cement.


Acoustic reflex threshold measurement in hearing aid selection. Aided speech discrimination scores were obtained for 18 patients with sensorineural hearing loss. Monosyllabic word discrimination lists with a competing message of connected discourse at a signal-to-noise ratio of +10 dB were used as the test stimuli, and measurements were made at four hearing aid gain settings for each subject. One of the gain settings was determined by measuring the acoustic reflex threshold for filtered noise in the ear contralateral to the aided ear. Two other settings were at +/- 10 dB relative to the reflex threshold gain setting; the fourth setting was determined with a traditional approach. Mean speech discrimination scores were highest at the reflex threshold gain setting and similar at the other three settings.


Measurement of nasal air flow with a new apparatus. An apparatus for measurement of nasal air flow has been calibrated against pressure-flow curves obtained in a pneumotachograph. A very high degree of correlation and an error of less than 3% of baseline values resulted when the apparatus was tested in hay fever patients using nasal allergen challenge.


Postoperative deep vein thrombosis in otolaryngologic surgery. The aim of this study was to determine the incidence of postoperative deep vein thrombosis in otolaryngologic surgery. The diagnosis was made by clinical examination, a method using fibrinogen labeled with radioactive iodine (125I), and the Doppler ultrasound technique. Only one (11%) patient developed an asymptomatic deep vein thrombosis. This is in contrast to the incidence in general surgical patients, which varies between 28% and 51%. The difference was probably related to the minimal tissue trauma and early mobilization of the otolaryngologic patients.


Immediate and short-term complications of chronic ear surgery. Complications of chronic ear surgery in a series of 2,192 operations are reported. Inadvertent opening of the inner ear occurred in 18 cases, leading to deafness in six ears. Four ears became deaf without apparent cause, for a total of ten (0.5%). High-tone sensorineural losses resulted in 3% of the ears. Facial nerve paralysis occurred in ten ears; in one of these, a graft was employed during primary surgery. All patients had a good recovery. It is stressed that to keep the number of complications at a minimum, strict rules must be followed and sufficient supervision offered in chronic ear surgery in teaching institutions.


Electrophysiological study of Bell palsy: electrically elicited blink reflex in assessment of prognosis. The electrically elicited blink reflex was tested serially in 81 patients with Bell palsy. In 56 patients, the reflex returned before excitability of the distal segment of the facial nerve was lost, indicating recovery of conduction across the involved segment before distal degeneration. These patients generally showed a good clinical recovery within a few months after onset. The reflex latency, however, was considerably prolonged during the first month, suggesting demyelination or other pathologic change. The reflex latency was reduced considerably during the second month and returned to normal levels during the third or fourth months. In the remaining 25 patients, direct response to facial nerve stimulation became unelicitable before reflex responses returned, indicating distal degeneration of the nerve. In this group of patients, clinical recovery was prolonged and generally incomplete.


Cysticercosis in otolaryngology.

Cysticercosis in otolaryngology. Cysticercosis is not likely to be the first diagnosis the otologist has in mind when regarding tumors in the head and neck area. The fact that this disease may present a diagnostic and therapeutic problem is illustrated by three cases, appearing in the tongue, buccal mucosa, and midline of the neck, respectively. The local finding of a soft nontender mass, the typical calcifications in the soft tissues visible on roentgenograms, and the histopathological findings are described and illustrated. Attention is drawn to the fact that cerebral cysticercosis, which is a very grave disease, may cause tinnitus, nystagmus, and hearing disturbances.


Audiologic profile of noise-induced hearing loss. Audiologic results for 450 ears presumed to have uncomplicated noise induced hearing loss were analyzed to describe their typical profile and to quantify the characteristic audiometric notch. Data consisted of tonal and speech thresholds, speech discrimination scores, Bekesy tracings, and short increment sensitivity index scores, and tone decay at 4,000 hertz. In each case, the pattern of results indicated a cochlear site of lesion, although the only uniformly cochlear sign was the absence of a pattern of abnormal adaptation in Bekesy tracings. In each case, the audiogram could be approximated by a quartic equation. The mean difference between actual thresholds and those predicted by the best-fit quartic did not exceed 7.72 dB and was less than 5 dB for eight of the 11 frequencies for which comparisons were made. We propose the application of this characteristic to clinical practice and to automated hearing conservation programs.


Hearing loss in prosthetically treated adults with cleft palate. The effect of obturator treatment of cleft palate on middle ear disease and hearing loss has not been established. This study serves as an otologic and audiologic review of a previously reported adult population with cleft palate. A substantial improvement in hearing levels subsequent to obturation was demonstrated; however, it was believed to be based on stabilization of pathologic features of the ear with age. A statistically significant correlation of hearing level with length of use of prosthesis or with type of lesion could not be demonstrated. Results are compared with those reported on the only other adult population with cleft palate. Prosthetic management of cleft palates is not shown to be detrimental, as has been generally thought.


Outer hair cell loss and alterations in glycogen due to tobramycin sulfate. A total of 26 albino guinea pigs were treated with 200 mg/kg/day of tobramycin sulfate. Animals were killed at various intervals of up to three weeks after seven days treatment. Outer hair cell (OHC) loss of the organ of Corti was evaluated by surface preparation techniques, and glycogen was assessed with PATCO- and PAS-stained sections. We have concluded that permanent damage of OHCs is most prevalent in areas that normally have the least amount and the smallest granule size of glycogen. With treatment, these susceptible areas are the least responsive in terms of an early increase in glycogen production. Furthermore, by 21 days after seven days of treatment, these same areas will reveal an almost total loss of glycogen at a time when damage is maximal.


Measurement of the acoustic reflex without a pressure seal. Obtaining a hermetic seal in the external auditory canal is often a major obstacle in impedance audiometry. In the present study, the acoustic reflex threshold was determined for three groups of subjects, first with and then without a pressure-tight seal. It was found that for subjects with normal hearing or sensorineural hearing loss and normal tympanograms, 96% of the measurements obtained without a pressure seal were within 5 dB of those obtained with a seal. Among the subjects who exhibited negative middle ear pressure, the acoustic reflex could be measured consistently at the point of maximum compliance, while no response was observed without a pressure seal.


Yes-no test for nonorganic hearing loss. The Yes-No Test is a procedure that can be used in the diagnosis of nonorganic hearing loss in children. The test employs a pure tone audiometric technique in which the child is instructed to say "yes" when he hears the tone and "no" when he does not hear the tone. This article describes clinical findings in three cases involving nonorganic hearing loss in which the Yes-No Test was instrumental in determining the true organic hearing thresholds.


Laryngeal injury: a critical review.

Laryngeal injury: a critical review. Thirty consecutive cases of laryngeal trauma requiring open exploration are reviewed. Eighteen injuries were the result of blunt trauma and 12 resulted from penetrating wounds. Within the blunt trauma group, eight of 18 injuries resulted in a competent airway and a good voice, six with a good airway but a fair voice, and four with airway compromise. Of 12 patients with penetrating wounds, ten sustained a good airway and a good voice, two a good airway and fair voice. Substantial granulation tissue response, though occurring in only eight of the 30 patients, was present in three of the four patients with airway stenosis. The use of a stent, in association with a soft tissue graft when mucosal loss cannot be approximated primarily, does not predispose to such a response, but rather facillitates maintenance of a competent skeletal framework and prevention of soft tissue endolaryngeal distortion.


Neurilemomas of the infratemporal space: report of a case and review of the literature. We describe a case of a trigeminal neurilemoma in an adolescent girl. It primarily involved the infratemporal space and extended into the middle cranial fossa, and began with only ocular symptoms. The surgical management is emphasized, illustrating the approach to the infratemporal fossa through a wide osteotomy of the coronoid process of the mandible without the need for mandibular split.


Laryngeal spasm complicating pseudomyotonia. Pseudomyotonia is a syndrome characterized by progressive muscle stiffness, weakness, myokymia, hyperhydrosis, and wasting of muscle. It especially affects the distal aspect of the extremities. The electromyogram is characteristic, and shows continuous muscle activity at rest. We discuss a case that is believed to be the first recorded instance of pseudomyotonia complicated by airway obstruction secondary to laryngeal spasm. Treatment with phenytoin sodium resulted in rapid improvement of the peripheral symptoms and simultaneous resolution of the laryngeal spasm.


Bronchopulmonary levage to remove pulmonary casts and plugs. Therapy for such obstructive pulmonary lung diseases as alveolar proteinosis, pneumonia, asthma, bronchiectasis, and cystic fibrosis, ranges from medical therapy to inhalation therapy to direct bronchoscopy and irrigation. The basic pathophysiologic feature is the retention of mucous secretions and foreign material within the lungs and therapy directed to removal of these secretions. Bronchopulmonary lavage recently has been suggested as an effective tool toward resolution of these illnesses. The otolaryngologist, who is adept in endoscopy, is asked to perform bronchoscopic procedures with washings to aid in the alleviation of these obstructive pulmonary diseases. This paper deals with the effectiveness of massive bronchopulmonary lavage in the elimination of severe chronic obstructive pulmonary lung diseases.


Ventilating tubes in the middle ear.

Ventilating tubes in the middle ear. One hundred children from 1 to 14 years of age had serous otitis media, the manifestations of which were bilateral in all but four patients. Thus, 196 ears were treated with aeration of the middle ear by means of a short transmyringeal tube. The mean duration of the treatment was 3.4 years, and the mean observation time was 7.3 years. Of the ears treated, 79.1% regained normal hearing, though scarring of the tympanic membrane and smaller adhesions were observed. The result was not satisfactory in 20.9% of the ears treated, the hearing losses varying from 25 to 60 dB. In 7.7% (15 ears) chronic otitis media developed; in 5.6% (11 of the 15 ears) cholesteatoma was confirmed surgically. Adhesive processes were present in 11.2%.


Electrodermal response, delayed auditory feedback, and lengthened off-time procedures. Comparison of use for medical-legal audiological assessment. Results of conventional audiological procedures, lengthened off-time Békésy, and electrodermal response audiometry are compared with pure-tone delayed auditory feedback procedures for 100 subjects referred for medical-legal audiological evaluation. Specific attention is given to a new economical prototype unit for pure-tone delayed auditory feedback, to the comparison of results of special test procedures, and to the nonorganic hearing loss population.


Audiotympanometric findings in myasthenia gravis. Myasthenia gravis can be a difficult diagnostic and therapeutic problem. Our study on six patients consisted of pure-tone audiograms, tympanometry, and acoustic reflex tests. Positive findings in the myasthenia gravis patients prior to medication included hyperacusis and increase in the intensity of sound required to elicit an acoustic reflex. Following medication, the hyperacusis lessened and the intensity of sound required to elicit the acoustic reflex decreased. During follow-up of two of the patients we encountered cholinergic (overdosage) crisis in one patient and myasthenic (underdosage) crisis in the other patient. Muscle weakness can be a common factor in both conditions. The acoustic reflex test can differentiate between the two types of crises. We believe audiotympanometric tests can aid in diagnosis and treatment of myasthenia gravis patients.


Hearing aid evaluation. Clinical experience with a new philosophy. We report a new method of hearing aid evaluation with the underlying philosophy that evaluation of hearing aid performance is not an end in itself, but an integral part of the total rehabilitation of the hearing-impaired patient. This new method uses synthetic sentences and speech competition in varying "message-to-competition ratios (MCRs)" to evaluate patient performance with hearing aids. We report six illustrative cases and a follow-up survey of patient satisfaction with recommended hearing aids to relate our experience with this technique.


Endolaryngeal cryosurgery. An improved technique. Crysurgery is a tissue-destroying technique that has been difficult to use in the larynx except for small or superficial lesions. An improved technique for creating precise but large endolaryngeal lesions was developed and studied in dogs. Six animals each had one true vocal cord destroyed with a large closed cryoprobe introduced through a tracheostoma. The larynges were removed at intervals from four to 63 days and were examined grossly and histologically. This technique was found to be a safe and simple method for treating selected laryngeal neoplasms without external laryngeal surgery.


Lipomatous lesions of the parotid area.

Lipomatous lesions of the parotid area. Lipoma of the parotid gland is a rare lesion in adults and children, and appears most frequently in the fifth and sixth decades of life. Thirty-two lipomatous lesions of the parotid gland and periparotid area are reviewed. One lipoma occurred in a 7-year-old boy. The lesion shows a definite sex preference, with a male to female ratio of 10:1. The lesion shows no laterality preference. The most frequent preoperative diagnoses in our series were mixed tumor and Warthin tumor. In general, these lesions are soft, mobile, and painless and enlarge slowly. They are not associated with neurological deficits, skin changes, other salivary gland lesions, or with lipomas elsewhere in the body. The surgical management of this lesion should be the same as for any other parotid tumor with due regard for the presence of the facial nerve in the operative field. There were no facial nerve injuries in this series. If totally excised, these lesions show no tendency to recur.


Pachyonychia congenita with involvement of the larynx. Pachyonychia congenita is a genetic syndrome of epithelial dysplasia that is inherited as an autosomal dominant trait. Its unique involvement within the larynx of a 3-year-old boy prompted this brief report of its clinical behavior and management.


Removal of foreign bodies in the esophagus. An old device--a new procedure. Extraction of hard, spherical foreign bodies from the esophagus has been accomplished with the use of a Dormia basket in combination with esophagoscopy. The Dormia basket was originally designed for the extraction of stones from the urinary tract.


Malignant melanoma of the head and neck in children. Review of the literature and report of a case. Perusal of the literature revealed that until 1970, 13 children with malignant melanoma of the head and neck had been reported. This group includes two cases of melanoma that developed in a giant cell nevus, as well as one case of congenital melanoma. The biologic features of prepubertal melanoma appear basically analogous to those of the adult variety. Malignant melanoma of the auricle is described in a 2 1/2-year-old child. Surgical therapy was given, and BCG vaccination was used as an adjuvant. The patient is alive and free of signs of the disease 2 1/2 years following the operation. This appears to be the third reported case of malignant melanoma of the external ear in a child.


Gustatory rhinorrhea developing after radical parotidectomy-a new syndrome? We report a case in which a 76-year-old woman developed unilateral gustatory rhinorrhea on the operated side after a radical parotidectomy. This is believed to be a new and previously unreported phenomenon that is mechanistically similar to the Frye syndrome (gustatory sweating).


Prostaglandins in middle ear effusions.

Prostaglandins in middle ear effusions. Although otitis media with effusion is usually a self-limiting disease, there are certain cases in which there appears to be chronic progression of the disease with serious sequelae. It has been demonstrated that there are biological mediators of inflammation in the middle ear that are capable of producing mucous membrane pathologic features. Some of these mediators of inflammation may be the prostaglandins. These cyclic fatty acids have been found in ten consecutive middle ear fluids in concentrations that are usually higher than the corresponding serum or plasma. It is suggested that prostaglandins may play an active role in maintaining the inflammatory response in the middle ear in otitis media with effusion.


Causes of recurrent laryngeal nerve paralysis. The recurrent laryngeal nerve in its course from the brain stem to the larynx follows a path that brings it in proximity to numerous structures. These structures can interfere with its function by pressure or by disruption of the nerve caused by disease invading the nerve. The various causes of recurrent laryngeal nerve paralysis that I have observed during the past 24 years are reported. In 134 patients with recurrent laryngeal nerve paralysis, the left recurrent nerve was most commonly involved. Malignant neoplasms of the lung and pulmonary tuberculosis were the most frequent causes of the paralysis.


Cranial polyneuritis and Bell palsy.

Cranial polyneuritis and Bell palsy. In view of the specific nature of the clinical and neurologic findings in Bell palsy and other acute benign cranial neuritides, the neural component of cutaneous herpes simplex, the predilection of the herpesvirus for sensory nerves, and intrinsic behavior and immunologic interreactions of the herpesvirus within ganglion cells, it is suggested that (1) the entity that has been termed "idiopathic facial paralysis" be recognized as an acute benign cranial polyneuritis; and (2) other acute benign cranial neuritides be recognized as formes frustes of Bell palsy.


Functional anatomy of tensor palati and levator palati muscles. An experimental study of the modus operandi of tensor and levator palati muscles over the Eustachian tube was conducted in two dogs. The tensor palati muscle is divisible into four functional units: (1) anterior part, vertical fibers; (2) middle part, oblique fibers; (3) posterior part, horizontal fibers; and (4) posterior-most part, osseous origin. Though the levator palati passively fixes the medial lamina and narrows the pharyngeal ostium, it dilates the lumen of the isthmus by two mechanisms: (1) rectification of the isthmus "kink" by bringing the cartilaginous and osseous segments into a stright line; and (2) pushing away the surrounding soft tissue pressure that is being exerted over the medial wall of the tube (not protected by cartilage). The peculiar absence of the medial cartilaginous lamina near the isthmus is attributed to the following: (1) freedom of movement of cartilaginous tube; (2) better anchorage of tubal cartilage passively by levator palati; (3) "kinking" of canal; and (4) compression of the lumen.


Patulous Eustachian tube. A new treatment with infusion of absorbable gelatin sponge solution. For the treatment of abnormally patent Eustachian tube, we had previously employed repeated tubal insufflation of salicylic acid-boric powder (1:4) through a Eustachian tube catheter. Such treatments, however, usually were associated with uncertain results and numerous complications. Therefore, treatment of this condition was changed to employment of an infusion of absorbable gelatin sponge solution directly into the Eustachian tube. Twenty-two ears in 16 patients recovered successfully when this method was used.


Vocal cord fixation in laryngeal carcinoma. The 1962 TNM classification (T, tumor and extent; N, regional lymph node metastasis, M, distant metastasis) did not emphasize vocal cord fixation in staging. In the revision of 1972, lesions with partial fixation were classified T2, stage II, and those causing fixation were T3, stage III. The therapeutic results in 39 patients with fixed cords revealed a determinante five-year survival of 41% and an absolute of 23%. These statistics support the validity of the 1972 classification. Careful evaluation of vocal cord mobility prior to selection of therapy is stressed.


Oscilloscopic analysis of the stapedius muscle reflex in brain stem lesions. An oscilloscopic analysis of several features of the stapedius muscle reflex was carried out in a group of normal subjects and in patients affected by dysfunction at the brain stem level due to a pathologic lesion or temporary reduction by small doses of barbiturates. Under these conditions, the increased latency and reduced amplitude of the reflex, but particularly the reduced velocity and, not infrequently, the step-like pattern of the tracings, are considered to be data of considerable value in disorders of the brain stem structues.


Pseudosarcomas of the pharynx and larynx. Pseudosarcoma of the pharynx and larynx has remained an enigma both to the pathologist and clinician since its original description by Lane in 1957. These lesions are usually polypoid growths that microscopically present very bizarre appearances beneath a squamous cell carcinoma. Eight cases of pseudosarcoma of the larynxand pharynx were observed. These occurred almost twice as often in males as females, with an average age of 56 years. Most were extralaryngeal lesions, and in all cases surgical excision was the primary therapeutic modality. A thorough review of the literature summarizes the clinical and pathologic characteristics of these lesions. There is strong clinical evidence against the traditional belief of the benign course of these lesions, and we recommend that they be treated aggresively like any other carcinoma of the head and neck.


Neonatal screening for detection of deafness. To assess various methods of early detection of deafness, a longtudinal study of infants born in the Jerusalem area was performed. The 17,731 newborns were tested by an acoustic signal generator hearing test (Apriton), and the "at risk" for deafness register was applied to them. Twenty-five children were identified as deaf, 14 with severe or profound hearing loss and 11 with moderate or moderately severe loss. The screening hearing test did not prove to be sensitive enough for detection of deafness in newborns, and, therefore, is not considered valid for screening purposes. The at risk for deafness register, which in our program covered 20% of the entire newborn population, proved to be to expensive and impractical; a restricted register, including approximately 7% of the newborns, is suggested.


Myxomas of the head and neck.

Myxomas of the head and neck. Myxomas are benign mesenchymal tumors that occur rarely in the head and neck. When they do occur, they are prevalent in the jaws and occur less frequently in the subcutaneous tissues. We report ten new cases and review the clinical, structural, and behavioral characteristics of myxomas arising in various head and neck locations. All ages are affected. The most common initial complaint is the presence of a slow-growing mass. The sarcomas, especially liposarcomas and fibrosarcomas, rank high in the differential diagnosis of myxomas. These tumors are stubborn infiltrators. When a capsule is present, it is usually incomplete and insufficient to contain the tumor. Treatment is by wide surgical excision. The high recurrence rate previously reported is probably due to incomplete excision and is higher when enucleation or curettage are used. Long-term follow-up is mandatory since recurrences may develop several years after treatment.


Pneumocele of the maxillary sinus. Report of a case. The first two cases of pneumocele of the maxillary sinus have been recently published. The expanded antrum produced a different initial complaint in each case. A third case, with yet another initial problem, middle ear effusion, is now reported. The roentgenographic and operative findings and the therapeutic effect of decompression by antrostomy would suggest that this is a specific disease entity, presumably due to a check valve obstruction of the sinus ostium.


Rhinosporidiosis.

Rhinosporidiosis. A case of nasal rhinosporidiosis occurred in a 73-year-old man who has lived all his life in the United States. The lesion was treated surgically, and he remains free of disease four years later.


Goldenhar syndrome. Associated with submandibular gland hyperplasia and hemihypoplasia of the mobile tongue. We report of a case of Goldenhar syndrome with submandibular gland hyperplasia and hemihypoplasia of the mobile tongue. This association has not been noted in the literature. A vascular abnormality or hemorrhagic phenomenon occurring during embryogenesis have been proposed as an explanation for the spectrum of defects seen in this syndrome. Congenitae hearing loss, when it occurs in Goldenhar syndrome, is usually unilateral and conductive in nature; however, inner ear defects may be more common than previously recognized.


Cardiac monitoring during exercise tests in the horse. 2. Heart rate responses to exercise. Data on resting heart rates, pre-exercise heart rates, the anticipatory rises before exercise, the influence of speed of work and recovery heart rates have been presented. Some observations on differences in the heart rate response on slow and fast working days are also recorded. In conformity with other workers, a linear relationship between heart rate and working speed within the range of 400-800 metre/min was observed. When the speed of work was between 400-800 metre/min, horses with resting ECG's classed as abnormal had significantly higher heart rates than those regarded as normal. It was also observed that the abnormal animals showed lower heart rates than a small number classed as borderline. The significance of these findings is discussed and the need for further work indicated.


Osteodystrophia fibrosa in horses at pasture in Queensland: field and laboratory observations. Horses grazing manily Cenchrus ciliaris and/or Panicum maximum var. trichoglume pastures on over 30 properties in southern central Queensland developed lesions of osteodystrophia fibrosa. Horses on individual properties in coastal Queensland grazing Setaria anceps, Brachiaria mutica or Pennisetum clandestinum also developed the disease. Ill-thrift, lameness, and fibrous swellings of nasal bones, maxillae and mandibles were observed. Calcium and phosphorus levels of pasture were normal but all the above pasture species contained oxalates which were suspected of causing the disease.


Squamous-cell carcinoma of the vulva in Merino sheep. Squamous-cell carcinoma of the vulva was observed in 3.1% of Merino ewes up to 3 years old. It is suggested that this high incidence of tumours was related to increased exposure of the perineal region to direct sunlight. It occurred in a group of sheep where short docking of tails and a radical surgical procedure to reduce cutaneous myiasis (Mules' operation) both led to greater exposure of the perineal region. The perineum was also subject to scarring from the operation and to application of organophosphate compounds to control cutaneous myiasis.


Piroplasmosis in buffaloes and its serological diagnosis based on a homology between buffalo and bovine immunoglobulins. Babesia argentina, Babesia bigemina and Theileria mutans were transmitted experimentally from water buffaloes (Bubalus bubalis) to splenectomised Bos taurus calves. Buffaloes were positive to an indirect fluorescent antibody test for B. argentina when reagents of bovine origin were used. The formation of similar patterns during immunoelectrophoresis suggested a homology of buffalo and bovine serum proteins, particularly IgG.


Assortative mating in lesser snow geese (Anser caerulescens). Assortative mating occurs in the dimorphic lesser snow geese in the wild. Mixed matings between the blue and white phases are much less frequent than would be expected by chance. Evidence from marked birds in field conditions indicated that mate choice was correlated with familial color. Birds from white families usually chose white mates, birds from blue families usually chose blue mates, and birds from mixed families chose mates of either color. Similar results were obtained under captive conditions when offspring from foster families with particular parental and offspring color combinations were allowed to choose mates. Both parental color and sibling color appeared to influence mate choice. The bird's own color did not appear to be important in mate choice in either field or experimental conditions, and in those cases where male and female parents differed in color neither parental color was more influential than the other in determining offspring mate choice. The results provide the first evidence, to our knowledge, that mate selection based on familial appearance operates intraspecifically in the wild.


Cerebral lateralization and spatial ability. Frequencies of three cerebral dominance genotypes who show right or left ear superiority on a verbal dichotic listening test and left or right field superiority on a tachistoscopic lateral field test of perceptual dominance are deduced. A hypothesis is offered relating direction of cerebral dominance, as defined by genotype, to degree of lateral specialization and perceptual ability, and a theoretical distribution of subjects according to spatial-perceptual ability and lateralization is derived. This distribution corresponds almost exactly with empirical data, thus confirming the proposed correlation between lateralization and spatial-perceptual capacity.


Editorial: Myocardial sarcomeres and the functioning mammalian heart. Previously the length-tension properties of the isolated papillary muscle have been related to myocardial sarcomere lengths. Though past studies have relied upon fixed material, recentlly, living muscles have been used. Sarcomere lengths have now been measured on the same specimens in both living and fixed material and the sarcomere length at optimum muscle length established. These lengths are extremely uniform. Studies on the sarcomere lengths through the wall of the left ventricle have also been carried out. Surprisingly sarcomere lengths were relatively uniform from endocardium to epicardium over a wide range of intraventricular pressures. Furthermore, enddiastolic sacarcomere lengths were 91% to 94% of optimum sarcomere length over a physiologic pressure range. Since the papillary muscle in function has been shown to shorten by 23% (to 70% of optimum sarcomere length), these results suggest that the papillary muscle uses the entire ascending limb of the length-tension curve during function.


[Hemodynamics and myocardial contractility in experimental tourniquet-shock]. A reproducible tourniquet-shock has been produced in hind limbs of dogs by unilateral and bilateral extremity ischemia. The following parameters have been measured for analysing the function of the cardiovascular system: mean aortic pressure, heart rate, cardiac output, intraventricular pressure and left ventricular pressure. From these data the stroke volume, stroke work, total peripheral resistance and the parameters of heart contractility dp/dtmax, dp/dtmax:IP and t-dp/dtmax were derived. During the ischemic period all circulatory parameters did not change in comparison to the controls. A tourniquet-shock developed upon recirculation of the ischemically stressed extremity which was more pronounced after bilateral than after unilateral hind leg ischemia. After release of the tourniquet all animals with unilateral tourniquet survived an observation period of 5 hours duration, whereas 6 out of 8 dogs with bilateral tourniquet died of heart failure. Upon release of the tourniquet, the cardiac output raised up to 140% of the normal value: the abruptly decreasing aortic pressure was fully compensated by a tachycardia from 100 to 190 (beats/minute). The parameters dp/dtmax:IP and t-dp/dtmax indicated a distinct increase of the left ventricular contractility in the early tourniquet-syndrom. Already after 30 minutes an increasing circulatory depression developed indicative of the decrease in aortic pressure, and enddiastolic pressure. At the same time an increase of heart rate and total peripheral resistance occurred. The parameters of left ventricular contractility did not change markedly during the course of shock except for the final stage.


Continuous recording of local myocardial function in normal and ischemic myocardium. Experiments in anaesthetized open chest dogs are described in which intramyocardial pressure was determined by two methods, both suitable for long time experiments. By means of a Fogarty catheter in connection with a normal transducer the intramyocardial pressure can be measured. With this method the pressure gradient from epicardial to endocardial muscle layers is demonstrated. Insertion of catheter tip manometers leads only to small trauma of the myocardium. This method allows the determination of systolic and enddiastolic tissue pressure together with the dp/dtmax and dp/dtmin. Measurements were performed in normal and in ischemic areas of the myocardium. In the ischemic parts of the myocardium all parameters descline, while in the normal, non ischemic areas the parameters increase, thus demonstrating overactivity, which compensates for the loss of myocardial function in the ischemic parts. The overall function of the heart as a pump remains nearly unaffected. On release of the coronary ligature the negative changes in the ischemic myocardium are rapidly restored. During the phase of reactive hyperemia the parameters measured in the ischemic area even increase above the control values.


[A slide ruler and nomogram for calculations in cumulation kinetics of cardiac glycosides (author's transl)]. 1. Substance I, whose elimination we can approximate with an exponential function, is active in the organism. 2. At a given moment substance II with the same onset of action whose elimination we also can approximate with an exponential function but different from substance I, starts to be added at regular intervals. 3. The relative levels of the two substances can be added up. 4. The optimal dose-scheme for the most regular effect is to be sought. According to the relations derived in repost (5) published previously a slide ruler and a nomogram are constructed by the authors for that purpose. The scales are described as well as how to work with them. Some examples are included. The slide ruler and the nomogram are suitable for some further calcaulations in cumulation kinetics, which is briefly mentioned. These expedients are mainly meant for the application of cardiac glycosides. The same principle can be used in all cases to which the assumptions mentioned above apply.


Human Herpes simplex encephalitis (cellular events). Electron microscopic demonstration of herpes viral particles in cerebral tissues obtained at autopsy was easily accomplished. Analysis of the structural abnormalities in this case offers support for the proposed mechanisms of cellular injury in herpes simplex encephalitis. Interference with synthesis of nucleic acids and glycoproteins which has been suggested by in vitro studies correlates well with the structural abnormalities of endoplasmic reticulum cisternae and changes in nuclear membranes, described in the case reported herein.


The determination of the myocardial extracellular space in the cat in vivo: a comparative methodological study. The myocardial extracellular space (ECS) was determined in cats in vivo by means of the ECS indicators, inulin and sulfanilic acid and, additionally, as glucose space. Experiments were carried out in cats subjected to bilateral kidney ligation (single injection) and in intact cats (single injection or infusion of indicator). The heart was clamped by instant deep-freezing in situ; this technique was compared, in renally-ligated cats, with excision and subsequent freezing of the heart in liquid nitrogen. The myocardial blood content was significantly decreased, and the myocardial lactate concentration significantly increased in excised, as compared with in situ-clamped hearts. Renally-ligated cats showed marked hypotension. The mean myocardial blood content was also significantly lower than in intact animals. A highly significant correlation was found between myocardial blood content and blood pressure for all experiments with instant deep-freezing. The mean inulin ECS value in renally-ligated cats was 22.7 +/- 1.5 ml. In accordance with the fact that the ECS is dependent on the tissure blood content, the corresponding values in intact animals were significantly higher, 25.9 +/- 2.5 ml (single injection) and 26.3 +/- 3.9 ml (infusion), calculated per 100 g tissue wet weight. Similar values were obtained for the glucose and sulfanilic acid ECS. If the interstitial space, an expression independent of the tissue blood content is used as space parameter, no significant differences were found under any of the present experimental conditions.


Cardiovascular effects of high doses of thiamine (vit B1) in the dog with special reference to myocardial oxygen consumption. The purpose of this study was to determine the reactions of the cardiovascular system with special reference to myocardial oxygen consumption (MVO2) after the administration of graded doses (up to 2.4 g/kg) of thiamine. The data obtained indicate that thiamine: 1. Decreases mean peripheral pressure up to 25%. 2. Decreases LVEDP, left ventricular pressure, and LV dP/dtmax up to 10%, 15%, and 20% respectively. 3. Reduces pulse rate up to 25%. 4. Reduces coronary sinus blood flow up to 31%. 5. Reduces myocardial oxygen consumption up to 45%. The reduction in LVEDP, LVP, and LV dP/dtmax could be antagonized by dextran or norepinephrine infusion. It is suggested that thiamine blocks alpha-receptors which leads to pooling of blood with a concomitant reduction in pre- and afterload of the heart. The effect on MVO2 suggests that thiamine, the essential coenzyme for the formation of high energy substrates reduced the metabolic needs of the heart. The drug warrants further investigation for the treatment of myocardial ischemia.


Structural analysis of pulmonary vascular changes in a case of infantile calcifying arteriopathy. In a well documented case of ACI, the pulmonary vessels were subjected to light microscopy, radiography, electron microscopy and X-ray microanalysis. The analysis of calcified foci in the walls of large and medium pulmonary arteries demonstrated a marked correlation between the deposits of calcium and phosphorus and the number of elastic fibers. The interpretation of our observations is in favour of a congenital defect of elastic fiber formation in the vascular walls, followed by calcification. Massive accumulation of calcium in the vascular walls was associated with tissue destruction, fragmentation of fibers and formation of irregular calcified foci which provoked a foreign-body reaction.


Effect of cerium on the rat liver: an ultrastructural and biochemical study. In rats, liver steatosis and necrosis were induced by cerous chloride (CeCl3) and the evolution of these changes was examined. By electron microscopy, 17 hours after CeCl3 treatment, dilation, disorganization and degranulation of the rough endoplasmic reticulum (RER) were noted with an increase in the number and electron density of lysosome-like bodies. In addition, nuclear chromatin showed showed a marked focal electron density, and the nuclear membrane appeared to be interrupted. At 24 hours, the RER was markedly dilated and degranulated, with free ribosomes aggregated in the cytoplasm. The Golgi cisternae appeared to be empty. There was an increase in the number and size of lipid droplets, with depletion of glycogen. At 48 hours, a massive proliferation of smooth endoplasmic reticulum (SER) vesicles occurred. Large lipid droplets were scattered throughout the cytoplasm, while the mitochondria displayed mild changes. By the 8th day, the number of lipid droplets returned to normal; no abnormalities were detected in the other cell organelles. Biochemically, the total hepatic ATP levels fell significantly by the 12th hour, dropping to a minimum by the 48th hour. The liver was gradually depleted of glycogen within the first 48 hours, while hepatic triglycerides increased rapidly, reaching a peak at 96 hours. Exogenous administration of adenine, ATP (adenosine triphosphate), or tryptophan completely prevented CeCl3-induced mortality; hepatic fat accumulation and necrosis were markedly decreased. Glucose, dl-methionine, and choline had no protective effect. It appears that a defect in hepatocellular lipoprotein synthesis and/or release may be responsible for lipid accumulation.


[Functional anatomy of the venous inflow in the human fetal heart (author's transl)]. Heart and cardiac veins of human fetuses (85-190 mm C.R. length) were dissected in situ by dorsal or ventral access. The atrial wall was partially removed. Muscle tissue and blood vessels were studied histologically. The pattern of the blood vessels (except the pulmonary veins) and their opening into the heart is presented synoptically. The following terms are discussed: posterior caval channel, sinus venarum, torus Loweri, atrial septa, and foramen ovale, respectively. Also discussed is the architecture of the muscles of the right atrium in systole and diastole. A correlation has been made with corresponding physiological data.


[Congenitally corrected transposition of the great vessels throughout ventricular inversion (author's transl)]. Congenitally corrected transposition of the great vessels is a cardiac anomaly in which the pulmonary artery and the aorta are transposed in relation to one another but in which the flow of blood is maintained in the physiologic direction. In this condition there is a concomitant inversion of the ventricular chambers. 8 patients--5 adults and 3 children--with this condition have been reviewed with special attention to clinical symptoms and electrocardiographic and roent-genologic features. The anomaly is of importance because it is much more common than formerly believed. Frequently associated cardiac defects are correctable by surgical procedures. Therefore a preoperatively firmly established disgnosis is necessary by angiocardiography and heart catheterization.


Adrenocortical suppression and myocardial infarction in non-arteriosclerotic (virgin) and arteriosclerotic (breeder) rats. Non-arteriosclerotic, virgin and arteriosclerotic, breeder rats were treated with aniline to suppress adrenal steroidogenic capacity and responsiveness to the stress of acute myocardial infarction. After two weeks of aniline treatment, some of the non-arteriosclerotic and arteriosclerotic animals were given two injections of isoproterenol, spaced 24 h apart, to induce massive myocardial infraction. On the 3 rd day, when myocardial necrosis reaches its zenith, the animals were sacrificed. Aniline-induced adrenal insufficiency caused increased mortality, absence of congestive heart failure, cardiac and adrenal enlargement but no evidence of the characteristic intense catabolism and increased corticoid production which attends acute myocardial infarction. Serum enzymes, e.g., SGOT, SGPT and LDH, triglycerides, but not glucose, free fatty acids and cholesterol, became acutely elevated in animals treated with aniline and isoproterenol. Animals developed a fatty liver, beta cell degranulation, post hypophy-sectomy-like changes in their adrenal cortices, unusually severe infarction, marked distention of intermuscular spaces, frequent foci of dystrophic calcification and cartilaginous metaplasia of the papillary muscles. It is believed that aniline-induced adrenal suppression altered the usual pathophysiologic response to acute myocardial infarction.


Hemodynamically-induced increase in soluble collagen in the anastomosed veins of experimental arteriovenous fistulae. External jugular veins that had been subjected to the hemodynamic stresses produced by experimental arteriovenous anastomosis developed 2% increased total protein contents and 17% increased collagen contents. When the stressed veins were homogenized and extracted with saline solutions, statistically significant increases in the saline-soluble proteins and in the saline-soluble collagen (87% and 267%, respectively) were observed. Increased amounts of low molecular weight peptides were found in the extracts. A fraction of these peptides could be degraded by Clostridium collagenase. The saline extract also contained proteins which resembled by their amino-acid composition the acidic structural proteins of the connective tissues. Additonally, in 3 dogs so tested, changes were found in the hydroxylation and glycosylation of lysine from gelatin extracts as well as in the lysine and desmosine contents of the insoluble elastin fractions. This is the first demonstration of a hemodynamically induced increase in the saline solubility of connective tissue proteins in the absence of dietary manipulations.


Chronic smoking in an animal model. Effects on clotting and fibrinolysis. The effects of chronic smoking upon fibrinogen turnover and other clotting parameters, were studied prospectively in an animal model maintained on a chronic program for a period of 18 months. The animal received the equivalent on a weight basis of 11/2 packs of cigarettes daily, smoked by a human subject with the weight of 70 kg. The obtained results suggested significant enhancement of the coagulation mechanism in the smoking animals developing over the period of observation particularly when combined with high lipid diet.


Studies on the distribution of lipids within fibrous plaques. The present report is an attempt to determine the nature of the circulation of lipids within fibrous plaques by studying the pattern of lipid distribution within the plaques. The material was obtained from aortas from 405 mammals and birds dying in the Oklahoma City Zoo. Analysis of the pattern of lipid distribution in 187 lipid containing aortic fibrous plaques suggested that most of the lipids entered the plaques at the shoulders and circulated from there toward the centers, usually in the outermost layers of the plaques.


Individual cigarette usage: self-reported data as a function of respondent-reported data. The interview method was used to collect data from living respondent-subject pairs regarding cigarette usage of the subject; the nonsmoker subject was explicitly not studied. Several different measures of usage were tested. The mean correlation coefficient between subject-reported data and the corresponding respondent-reported data was 0.86; that is, at least 70% of the variability in subject-reported data can be accounted for from information obtained from an appropriate living respondent closely associated with the subject. Selected regression equations are presented for estimating cigarette usage of a subject from data provided by a respondent.


Cigarette smoking and atherosclerosis in autopsied men. The association of cigarette smoking and atherosclerorosis was investigated in 1320 autopsied men, 25--64 years of age. Aortic and coronary lesions were evaluated visually in coded specimens and objectively by analysis of radiographs. Using schedules that had been tested on pairs of living persons, interviewers obtained estimates of cigarette smoking habits of the deceased men from surviving relatives. Data were analysed for black and white men in the total sample of cases and also in groups according to the presence (selected disease group) or absence (basal group) of diseases thought to be associated with smoking (emphysema, lung cancer, etc.) or with coronary heart disease (myocardial infarction, hypertension, diabetes, stroke, etc.). Atherosclerotic involvement of aorta and coronary arteries was greatest in heavy smokers and least in nonsmokers for both races in the total sample of cases, the basal group and the selected disease group.


A nicotinic acid ester and experimental atherosclerosis: no significant effect of treatment with niceritrol (pentaerythritoltetranicotinate) on cholesterol in aorta of rabbits previously fed with cholesterol-enriched diet. The influence of niceritrol on cholesterol in serum, liver and inner aorta of 115 rabbits was studied during a period where a cholesterol-enriched diet was given and during two succeeding periods after which cholesterol addition to the diet was discontinued. Niceritrol given together with cholesterol for 6 weeks reduced significantly the concentration of cholesterol in serum and liver, but not in the inner aorta. During 16 weeks decrease of serum cholesterol after discontinuation of cholesterol feeding no significant effect of niceritrol was observed on the decrease in serum and liver cholesterol or on the concentration of cholesterol in inner aorta. When serum cholesterol had normalized 16 weeks after discontinuation of cholesterol feeding, addition of niceritrol to the diet for the following 16 weeks did not significantly affect the concentration of cholesterol in liver and inner aorta. Animals in all groups were injected intravenously with an equal amount of [3H] cholesterol 3 weeks before discontinuing cholesterol feeding. Niceritrol did not significantly affect the amount of accumulated labelled cholesterol in inner aorta. The present results indicated that niceritrol had no significant effects on metabolism of cholesterol in inner aorta of the hypercholesterolemic and previously hypercholesterolemic rabbits.


A classification of fistula-in-ano.

A classification of fistula-in-ano. A classification of anal fistulas is presented, which is the result of an analysis of 400 cases treated over the past 15 years, based on the pathogenesis of the disease and the normal muscular anatomy of the pelvic floor. Four main types were found but numerous variations of each occur, which are described. It is hoped that this will alert the surgeon to the various complex situations that he may encounter.


Family studies in cancer of the colon and rectum. Family histories were obtained from 209 patients undergoing treatment for cancer of the colon or rectum at St Mark's Hospital. Death certificates were obtained for parents and siblings who had died. Among these, the number of deaths from cancer of the bowel was more than three times that expected for a comparable group from the general population. There are three principal features which, if present in an index case, are associated with the likelihood that other members of the family will also have had cancer of the large bowel. These are, first, the presence of multiple benign or malignant tumours in the large bowel, secondly, a history of previous primary carcinoma or adenoma of the large bowel and, thirdly, early age of onset of carcinoma of the bowel.


Familial cancer of the gastro-intestinal tract. A family with a high incidence of early onset gastrointestinal carcinoma is described. Individuals from four generations have been proved to have had the disease. The management of individuals as yet unaffected is discussed and a regime for follow-up suggested.


Tetronic 701-a novel hypocholesterolaemic agent. The Tetronic series of polymeric surface-active agents were screened for hypocholesterolaemic activity in rats fed on a semi-synthetic hypercholesterolaemic diet. Only Tetronics 701 and 702 were active and the former was further investigated. Tetronic 701 lowered serum and liver cholesterol in rats fed on a semi-synthetic diet, with or without cholesterol, but not in rats fed on stock laboratory diet. A dose-related growth depression was observed. The compound was hypocholesterolaemic in chicks and rabbits fed on cholesterol-containing diets. The uptake of a single dose of cholesterol into liver and serum was inhibited in rats given Tetronic 701. Tetronics 701 and 702 were effective in precipitating cholesterol from mixed micelles in vitro. Non-hypocholesterolaemic Tetronics were inactive in this respect. A series of tetraesters of tetronic 701 were prepared and tested in rats fed on a semi-synthetic hypercholesterolaemic diet. Several were hypocholesterolaemic and the tetrabenzoate was of especial interest in that it depressed growth less than did Tetronic 701 itself.


Severe pseudomembranous colitis after lincomycin and clindamycin. Four cases of severe pseudomembranous colitis following the use of lincomycin and clindamycin are described; 2 required emergency total colectomy and 2 died. Cases of such gravity after the use of these drugs have not been previously reported. On hundred and fifty-six orthopaedic cases where clindamycin and lincomycin were used postoperatively are reviewed; 34 had diarrhoea (22 per cent), and 3 of the severe cases occurred in this group. The diagnosis of pseudomembranous colitis may be difficult as the latent period from initiation of drug therapy to commencement of diarrhoea may be as much as 18 days, and that from cessation of drug therapy may be as much as 11 days. The value of early sigmoidoscopy in cases of diarrhoea of obscure aetiology is emphasized, and the characteristic sigmoidoscopic and histological appearances of pseudomembranous colitis are described. As these drugs may produce a lethal condition it is suggested that they should be used with appropriate discretion, especially in the elderly female who appears to be most at risk.


Symptomatic hypoglycaemia, liver glycogen depletion and cirrhosis following jejuno-ileal bypass for gross obesity. A new complication following jejuno-ileal bypass for gross obesity is described. The patient suffered from hypoglycaemic attacks which were associated with total depletion of liver glycogen together with a progressive micronodular cirrhosis. Increased dietary protein and calorie content relieved her symptoms, restored liver glycogen but had no effect on the development of the cirrhosis over the next 12 months.


Chronic intussusception in children.

Chronic intussusception in children. Three children with chronic intussusception are reported together with a review of the literature. Neither the palpation of a mass nor the passage of blood per rectum was necessary for the diagnosis. Weight loss was seen in each case and 1 child was investigated for malabsorption. In all 3 children there was a delay in diagnosis, and it is suggested that a chronic intussusception should be considered more frequently in children with persistent abdominal symptoms for which no cause can be found. Although a barium enema was helpful diagnostically, it did not result in the reduction of the intussusception. The problem of a recurrence after a reduction and its subsequent management is discussed.


Splenectomy in childhood: a review in England and Wales, 1960-4. An investigation was carried out of 821 children under the age of 16 years who were subjected to splenectomy in England and Wales during the 5 years 1960-4. A postal follow-up study provided satisfactory information concerning 96 per cent of these. Excluding early postoperative deaths, practically all the cases were followed up for 2 years or more and 70 per cent for more than 5 years. Forty-nine children had died since operation, 32 from underlying disease and 17 from infection. Fifty children (6 per cent of the survivors) had major infections considered to be due to the primary condition aggravated by splenectomy. Seven died, all from the primary disease. Sixteen children (2 per cent) developed septicaemic illnesses and 10 died. In these the effect of splenectomy was considered to be the primary factor. Fourteen of the 16 had been operated on in the first 4 years of life. Practically all the serious infections occurred within 3 years of operation and pneumococcus was the organism most frequently implicated. Ninety per cent of the splenectomies in childhood were performed for accidental injury, congenital haemolytic anaemia or idiopathic thrombocytopenic purpura. Accidental injury to the spleen rarely occurs in very young children, and in the other two conditions splenectomy can usually be safely delayed untile over the age of 3 years. If this is achieved it is estimated that the unavoidable risk of dangerous infection is less than 1 per cent. One in 10 splenectomies will be carried out for severe and potentially fatal illnesses and in this situation the risk from operation is of secondary importance. Many such conditions carry increased susceptibility to infection per se or because corticosteroids or other immune suppressants are used in their management. It is recommended that splenectomy be avoided if at all possible during the early years of life. It is further recommended that prophylactic penicillin be administered for 3 years following operation whatever its indication and whatever the age of the patient. If the underlying condition itself carries risk of infection more active and more prolonged prophylaxis may be indicated.


Some observations on gallstones and bile composition. A series of 31 consecutive patients undergoing surgery for gallstone disease has been studied and the composition of the gallstones and bile from the gallbladder and common duct determined. As a result of the stone analysis by the X-ray powder diffraction method, the patients were classified according to whether their stones consisted of cholesterol, calcium salts or a mixture of the two. The mean composition of the common duct bile for the groups with cholesterol and mixed stones was just outside the micellar region of cholesterol solubility. The gallbladder bile from the cholesterol group of stone-formers was also supersaturated, but the gallblader bile from the group of mixed stone-formers was undersaturated with respect to cholesterol. None of the patients forming gallstones of calcium salts showed any abnormality in the cholesterol content of their bile.


Retained common bile duct calculi.

Retained common bile duct calculi. A method of elimination of gallstones remaining in the common bile duct after exploration of the duct is described. The retained stone is flushed through the common duct sphincter into the duodenum using rapid infusion of normal saline via a T tube. The method is quick and simple and is recommended as the first step to take in the management of this discomforting group of patients. The method is not without potential morbidity and should only be carried out under carefully controlled conditions.


Operative cholangiography: criteria which make exploration of the common bile duct desirable. The purpose of this study was to evaluate the individual criteria and combination of criteria examined by operative cholangiography which make exploration of the common bile duct desirable. The overall accuracy of exploration of the common bile duct (89 per cent) was similar to that of previous series. In the normal group the accuracy of the criteria established by Le Quesne (1960) is confirmed. The most reliable criteria in the abnormal cholangiograms were the presence of single or multiple filling defects in the common bile duct, the absence of free flow of contrast medium into the duodenum and an abnormality of the terminal narrow segment. Measurements to aid assessment of free flow into the duodenum are suggested. In 34 of 40 positive explorations the common bile duct diameter was 14 mm or less; 10 common bile ducts which contained stones were less than 10 mm in diameter. Excess filling of the intrahepatic ducts was often impossible to judge in the abnormal group and was the least valuable criterion. Attention is drawn to the advantage of an immediate radiological report.


Pancreatic pseudocysts.

Pancreatic pseudocysts. Twenty-seven patients with 32 pancreatic pseudocysts have been seen during the past 10 years at St George's Hospital, London. Two of the pseudocysts were found in unusual positions--one in the right inguinal canal and the other one in the porta hepatis. Approximately half of the pseudocysts in this series followed biliary-induced pancreatitis. The various clinical presentations are reported and the surgical treatment is discussed. Internal drainage is the most effective treatment and in the majority of cases transgastric cystogastrostomy via a tube is the procedure of choice. One death occurred, an overall mortality rate of 3-1 per cent.


Curling's ulcer: a rare condition.

Curling's ulcer: a rare condition. A case of Curling's ulceration of the duodenum in a child with 50 per cent burns, requiring operative arrest of the bleeding, is reported, and this condition is reviewed. Inquiry among the surgical units treating burns in Great Britian showed that only 18 cases of alimentary bleeding had been seen in the course of treating some 32 500 patients. The incidence in Europe and Australia appears to be of the same order, but there is a much higher incidence in some burns units in North America. Possible reasons for these differences are examined. The occurrence and treatment of Curling's ulcer in childhood are considered.


Pleural empyema in association with renal sepsis. Five cases of pleural empyema in association with perinephric abscess or renal infection are presented. This represents 4 per cent of a series of 122 pleural empyemas, or 30 per cent of empyemas with subdiaphragmatic aetiology. It is suggested that the renal tract should be investigated in all cases of recurrent or non-resolving pleural empyema of uncertain aetiology.


Delayed arterial embolectomy: a plea for a more active surgical approach. In a series of 18 patients delayed embolectomy of the limb was performed 8-63 days after embolism had occurred. Three patients died (2 of them after amputation), and 7 limbs were amputated after surgery. In 10 instances blood flow was fully restored by the operation. Analysis of the 18 cases leads to the conclusion that the success of delayed embolectomy where neuromuscular function is intact depends primarily on surgical technique. Direct embolectomy by local or regional exposure of the obstructed arterial level is shown to produce better results than conventional (distant) balloon catheter embolectomy by proximal incision. This is thought to be due to increased mural adherence of the embolus, with secondary thrombus formation after a delay of 8 days or more. A plea is therefore made for a more aggressive surgical attitude to delayed arterial embolization. Provided that preoperative arteriography has localized the obstructive level and that the patient's general condition allows major vascular surgery, direct removal of the embolus and secondary thrombi by open exposure of the obstructed artery is recommended.


Bypass grafting to the anterior tibial artery. Four patients with severe ischaemia of a leg due to atherosclerotic occlusion of the tibial and peroneal arteries had reversed long saphenous vein grafts to the patent lower part of the anterior tibial artery. Two of these grafts continue to function 19 and 24 months after operation respectively. One graft failed on the fifth postoperative day and another occluded 4 months after operation. The literature on femorotibial grafting has been reviewed. The early failure rate of distal grafting is higher than in the case of femoropopliteal bypass, but a number of otherwise doomed limbs can be salvaged. Contrary to widely held views, grafting to the anterior tibial artery appears to give results comparable to those obtained when the lower anastomosis is made to the posterior tibial artery.


Leiomyosarcoma of the right common iliac artery: a case report. A case initially diagnosed at laparotomy as having a phaeochromocytoma was re-explored after negative biochemical tests and found to have a leiomyosarcoma of the right iliac artery.


Elevation of plasma bromide levels in patients following halothane anesthesia: Time correlation with total halothane dosage. Plasma bromide concentrations of 25 patients were determined before and after halothane anesthesia. A high correlation (r greater than .70) between exposure to halothane in MAC-hours and plasma bromide levels 24, 48 and 72 hours later was found. Peak bromide levels occurred 48-72 hours after anesthesia in 16 patients (64 per cent), and ranged from 52 mug/ml (0.65 mEq/l) to 180 mug/mo (2.25 mEq/l). Bromide levels remained elevated for prolonged periods (at least 22 days in some patients). Possible sedative or psychoactive effects of increased plasma bromide levels are discussed.


Hypoxia and halothane metabolism in vivo: release of inorganic fluoride and halothane metabolite binding to cellular constituents. Fluoride release and covalent binding of halothane metabolites were studied in rats pretreated with phenobarbital and anesthestized with halothane in the presence of high (40 per cent) and low (7 per cent) oxygen tensions. The purpose of producing hypoxia was to promote the reductive pathways involved in the metabolism of halothane. Halothane anesthesia under hypoxic conditions caused a significant elevation in the plasma fluoride concentration. There was also a greater than three-fold increase in covalent binding of 14C-halothane metabolites to microsomal lipids in hypoxic rats. The lipid/protein binding ratio in control animals averaged 0.76, while hypoxic animals had a binding ratio of 3.24. The findings demonstrate that defluorination of halothane does occur during hypoxic conditions. It is hypothesized that the products produced by this reductive metabolic pathway are also potentially more hepatotoxic than the oxidative metabolites, based upon the increased covalent binding of halothane metabolites under hypoxic conditions.


Localization of molecular halothane in phospholipid bilayer model nerve membranes. The molecular motion and distribution of the inhalation anesthetic halothane (2-bromo-2-chloro-1,1,1-trifluoroethane) in a phospholipid bilayer model nerve membrane preparation was studied using fluorine nuclear magnetic resonance. Bilayers containing stable free radicals at known depths were studied to measure possible localization of halothane within certain areas of the bilayer. Bilayer suspensions containing manganese ions in the aqueous phase were used to test the partition of halothane between the aqueous and lipid phases. It was found that halothane rapidly achieves complete exchange throughout the bilayer and the surrounding aqueous phase. The results provide experimental evidence against the formation of anesthetic clathrates hypothesized by Pauling and Miller in their theories of anesthesia.


Duration of halothane anesthesia and neuromuscular blockade with d-tubocurarine. Cumulative d-tubocurarine dose-response curves were determined in 35 unpremedicated adult surgical patients. In five awake patients with and five awake patients without ulnar nerve block the median effective doses of d-tubocurarine necessary for 50 per cent depression of twitch tension (ED50) were 8.3 and 9.1 mg/m2, respectively. The presence of an ulnar nerve block did not significantly alter ED50, which suggests that the central nervous system has little influence on the d-tubocurarine dose-response curve. The ED50's of d-tubocurarine were 4.8, 4.5, 2.5, 3.2, and 3.8 mg/m2 in patients anesthetized with 1.0 to 1.3 per cent alveolar concentrations of halothane for 10, 20, 40, 80, and 160 minutes, respectively. It is concluded that duration of anesthesia has no effect on neuromuscular blockade by d-tubocurarine.


Myocardial depression by nitrous oxide and its reversal by Ca++. The effects of 50 per cent nitrous oxide on isometric contractile force of electrically stimulated cat papillary muscle suspended in a Tris-buffered solution at five concentrations of Ca++ ranging from 1 to 15 mM were studied. Compared with an equal concentration of nitrogen, or with pure oxygen, nitrous oxide caused a highly significant reduction in contractile force, averaging 22 per cent at 2.5 mM Ca++. This reduction in force, like that caused by halothane, could be antagonized by increasing [Ca++] in the bathing medium. However, the reductions in force caused by equinarcotic concentrations of halothane and nitrous oxide are significantly different in magnitude, suggesting that the mechanisms of anesthetic action in the central nervous system and in the myocardium may not be the same.


The medical malpractice problem, and some possible solutions. The solutions to the problems of medical malpractice and malpractice insurance coverage are primarily in the hands of state legislatures. Legislation enacted has been primarily palliative, to assure continued availability of professional liability insurance. Unfortunately, no limit can be placed on the costs of such coverage. Unfortunately, too, no long-term solution has been forthcoming. Any long-term solution must encompass some method or methods of reducing injuries to patients and at the same time changing the system from defense of the physician to compensation of the patient. If such changes are not forthcoming, physicians will become uninsurable and the private practice of medicine as we now know it will disappear in this country.


Massive left atrial thrombus complicating mitral stenosis with atrial fibrillation: results of surgical treatment. Thirty-five patients with massive atrial thrombus complicating mitral stenosis and atrial fibrillation were treated surgically. The mean age in this series is lower than that reported in the West. Furthermore, the incidence of preoperative embolic manifestations has been less frequent in our experience. We believe it is desirable to document the presence of a thrombus by selective left atrial cineangiography. Surgical treatment was accomplished with an acceptable mortality. The vital role played by the use of low-molecular-weight dextran and early anticoagulation in decreasing the incidence of postoperative cerebral embolism is emphasized. Follow-up data in the survivors has shown excellent functional status with no late embolic phenomena in any subject.


Surgical treatment of postinfarction ventricular aneurysm. We have operated on 62 consecutive patients for postinfarction ventricular aneurysm since coronary bypass grafting became available. Analysis of hemodynamic and angiographic data reveals that the prognosis of operation is favorable if mean pulmonary artery pressure is less than 45 mm Hg and cardiac index is greater than 2.0 L/min/m2; such factors as the preoperative New York Heart Association Functional Class, number of coronary grafts, aneurysm size, left ventricular end-diastolic pressure, and coronary score were not closely related to the outcome of operation. Hospital mortality was 6.5% (4 patients) and late mortality, with a mean follow-up of two years, was 11% (7 patients). The prognosis among survivors was good: 82% (46) achieved NYHA Class I or II status, whereas 87% (54) had been in Class III or IV preoperatively. Concomitant vein grafting with aneurysmectomy did not significantly enhance operative or late survival, nor did it add appreciably to the risk of operation. Long-term benefits of revascularization in addition to aneurysmectomy are expected but not yet proved.


Communication between the pulmonary and systemic circulations. Communications between the pulmonary and systemic circulation occur normally and also in association with a number of pathological entities. On the basis of recent experience I believe that this phenomenon occurs more frequently than has previously been appreciated and may assume significant clinical importance in many cases. This report reviews the spectrum of the phenomenon of systemic-pulmonary vascular connection, particularly with regard to its occurrence and recognition in the adult age group. A number of illustrative cases are reported and the pertinent literature is reviewed.


Myocardial protection during aortic valve replacement. The results following aortic valve replacement (AVR) were compared in 40 patients in whom the myocardium was protected by topical hypothermic arrest or continuous coronary perfusion with sustained electrical fibrillation (Group A) and 40 similar patients in whom the hearts were also continuously perfused but were kept in the beating state (Group B). The operative mortality was not greatly different between the two groups, being 10 and 5%, respectively. The postperfusion cardiac performance was strikingly different, however. Seventeen patients (43%) in Group A required inotropic support, while this was necessary in only 1 patient (3%) in Group B. In this instance, recurrent ventricular fibrillation persisted despite attempts at reversion. These data show that the myocardium is preserved best during AVR when continuous coronary perfusion is used and the heart is maintained in the beating state.


Aortic valve replacement without left heart decompression. Conventionally, during aortic valve replacement the left ventricle is vented to achieve a dry field, remove air, and prevent ventricular distention. This report demonstrates the feasibility of performing aortic valve replacement without cannulation of either the left ventricle or the left atrium. The technique has been utilized in 54 patients with 1 early death due to pulmonary embolism and 1 late death presumably secondary to ventricular arrhythmias.


A temporary catheter-tip aortic valve: hemodynamic effects on experimental acute aortic insufficiency. A catheter-mounted polyurethane cusp was designed to act as a temporary prosthetic aortic valve in the ascending aorta. Acute aortic insufficiency was created in 15 dogs by transventricular tearing of the two aortic valve leaflets with a wire hook. Hemodynamic variables were measured during aortic insufficiency and with the prosthetic valve in place. Comparison of the values showed that the prosthesis functioned as a competent aortic valve. Aortic diastolic pressure increased by 62 +/- 42%, pulse pressure was lowered by 44 +/- 9%, and left ventricular end-diastolic pressure decreased by 45 +/- 18%. Neither cardiac output, coronary blood flow, nor peak systolic pressure was significantly altered. The observed hemodynamic improvement and the simplicity of the design and application suggest that the prosthetic aortic valve may be applicable in the temporary treatment of decompensated aortic insufficiency.


The source of coronary perfusion during partial bypass for extracorporeal membrane oxygenation (ECMO). The proper siting of cannulas to return oxygenated blood to patients on long-term membrane oxygenator support is as yet undecided. This experimental study on adult sheep shows the problems of obtaining perfusion of the coronary arterial tree when blood is returned to the ascending aorta. Our 11 experiments demonstrate that the coronary arterial tree is perfused with blood ejected from the left ventricle except during very high bypass flows (85% bypass) or when the aortic valve is rendered incompetent.


The effect of simultaneous administration of levarterenol and phentolamine on renal blood flow. The effect of simultaneous administration of levarterenol and phentolamine upon renal blood flow was studied over a 3-hour period in 22 mongrel dogs. The infusion of levarterenol alone produced a fall in renal blood flow that ranged from 28 to 58% from the baseline value. When both drugs were administered simultaneously, renal flow fell only 17 to 22% from baseline (p less than 0.05). From these studies we conclude that the simultaneous administration of levarterenol and phentolamine in optimal ratios maintains renal blood flow near baseline levels.


A technique for direct measurement of left atrial pressure after cardiac operations. A grooved director bent to a "hockey stick" configuration serves as an effective catheter guide to assure accurate placement of a left atrial pressure measuring catheter.


A method for insertion of a stented xenograft valve in the atrioventricular position. To facilitate the insertion of prosthetic valves, holders are available which keep the poppet out of the area of suture insertion or keep the open ends of the struts occluded. No such holders are available for use during insertion of xenograft valves, and it seems unlikely that one could be used, for danger of damage to the valve leaflets. To obviate this problem, we have brought the flexible struts together with a suture at the time of insertion. The struts assume their original open position upon cutting the suture.


Measured tricuspid annuloplasty: a rapid and reproducible technique. A technique for repairing the tricuspid valve that involves principles successfully used in operative repair of the mitral valve is described. A measured orifice produces competence but not obstruction and eliminates the trial-and-error aspects of annuloplasty. The procedure can be performed with the heart beating, though it can be transiently fibrillated so that the suture may be tied without tension.


Sternal staple: simple and rapid device for closure of median sternotomy. A new device for rapid and secure closure of median sternotomy has been developed, clinically proved, and found to be an excellent additional tool for the armamentarium of the thoracic surgeon.


Peristernal closure of median sternotomy using stainless steel bands. Peristernal closure of median sternotomy incisions with interrupted stainless steel bands has proved to be a rapid and safe method for achieving solid internal fixation in approximation of the sternum. The method is particularly useful for obese patients undergoing sternotomy. There have been no instances of wound dehiscence using this technique, and several other advantages over standard forms of sternal closure are apparent. The method is a useful addition to the cardiac surgeon's armamentarium.