Thromboelastographic distinction of malignant from benign breast masses: a preliminary report. Thromboelastography is a newly applied tool for the detection of carcinoma. By comparing the thromboelastograph (TEG) of fresh whole blood (native) to that of blood to which celite has been added (celite activated), enhanced clotting is manifested which allows identification of individuals harboring carcinoma. Twenty women, obtained in a random sampling, entering the North Carolina Baptist Hospital for biopsy of breast masses were studied with routine clotting tests and TEGs preoperatively. TEG prediction of the biopsy result was correct in 16 of 20 patients (P less than 0.05). Thromboelastography may be a useful adjunct in screening for carcinoma in the evaluating persons with masses of unknown histology.


Pebble ingestion: an unusual form of geophagia. Reported is a case representing an unusual form of geophagia, in which ingestion of pebbles by a 27-year-old mentally retarded woman resulted in impaction and complete filling of the colon with pebbles. Conservative therapy was successful in clearing the stones by the sixth day of treatment; however, a follow-up visit approximately six weeks later revealed that the patient was again ingesting pebbles.


Use of salt bridge in rhythm analysis.

Use of salt bridge in rhythm analysis. Filling a catheter with electrolyte solution converts it to a conductor and allows the safe recording of an electrogram from near or within the right atrium. This technic is very useful in localizing the internal position of a cardiac catheter and particularly in rhythm analysis. Four cases are presented to review the value of this salt bridge technic.


A pediatric residency program revisited. There have been few assessments of residency programs by graduates; therefore, to investigate a practical means of evaluating programs we asked former trainees to relate aspects of their training to present professional needs. Former residents in the Duke pediatric program from 1960 to 1972 were asked to evaluate various aspects of their training. The overall training program was rated favorably, as were most deficiencies were identified in ambulatory pediatric care, such as surgery, dermatology, psychiatry, and radiology. Analysis according to respondent's period of participation in the program and current professional activity revealed little variation in patterns of response. This survey method provides an inexpensive means of monitoring inadequacies in residency programs and provides data to initiate changes.


Evaluation of posterior fossa lesions by computer assisted tomography (CAT). Valuable neuroradiologic information can be obtained with routine examination of the posterior fossa by computer assisted tomography (CAT). The diagnosis can be difficult in the posterior fossa due to the relatively small size of the compartment and its proximities to large bony masses and air in the mastoid cells. However, many lesions can be accurately diagnosed when close attention is given to anatomic detail and the frequent use of contrast enhancement. We introduced a new CAT classification of posterior fossa neoplasms.


Bleeding, clotting, and functional disability following Beall prosthetic mitral valve replacement. The incidence of fatal and nonfatal thromboemboli and bleeding episodes was compared in 53 patients who received sodium warfarin and in 17 successive patients who received no sodium warfarin after Beall mitral valve replacement. Actuarial curves showed that by 12 months postoperatively patients not receiving sodium warfarin had a greater incidence of emboli (P less than 0.01). This significant difference remained when the combined incidence of emboli and hemorrhage was considered (P less than 0.05). Deaths due to emboli or hemorrhage, however, were not statistically different in the two groups. The quality of control of prothrombin times (percent of prothrombin times two to two and a half times control) did not significantly influence the incidence of ebmoli although the numbers were small. However, fatal and nonfatal hemorrhagic episodes which did occur were almost invariably associated with prothrombin times greater than three to eight times control. Results of pre- and post-operative graded treadmill exercise tests in 39 patients receiving a Beall mitral valve replacement showed significant postoperative improvement in exercise tolerance. Nevertheless, the patients' postoperative working capacity was only 55% to 57% of that of age- and sex-matched sedentary controls. The present study supports the use of sodium warfarin therapy and strict anticoagulation control in Beall mitral valve replacement patients. It also documents a significant residual impairment in physical working capacity.


A controlled clinical trial of two local agents in postepisiotomy pain and discomfort. Postepisiotomy pain can be an annoying complication for physicians and nurses to manage after an otherwise uneventful delivery. A controlled prospective study was conducted in 100 parturients to test the relative efficacy of two agents. Of 50 patients given a mucoadhesive foam containing a local anesthetic plus a corticosteroid, 82% reported relief of pain and discomfort and 86% demonstrated resolution of edema. Of the 50 patients using a spray containing a local anesthetic plus and antiseptic agent, 40% reported relief of pain and 30% demonstrated resolution of edema.


Treatment of patellar fractures by partial patellectomy. Results of treating 238 transverse, longitudinal, and osteochondral fractures of the patella are reviewed. Of these, 89 patients had partial patellectomy and extensor mechanism reconstruction. After an average follow-up of four years, functional results have been excellent; there have been no late patellectomies and traumatic arthritis has not developed. Total patellectomy is recommended only when the entire patella is so severely comminuted that none of it can be used as part of the extensor mechanism of the knee.


The outpatient treatment of refractory hypertension with minoxidil. Minoxidil is a potent orally administered vasodilator under investigation for use in severe hypertension. Fifteen patients with moderate to severe hypertension refractory to conventional antihypertensive drugs were treated with minoxidil on an outpatient basis. Propranolol and furosemide were administered concomitantly to control reflex tachycardia and fluid retention. Good blood pressure control was achieved in all but one patient with the average supine mean arterial blood pressure falling from 140 mm Hg with conventional drugs to 106 mm Hg with minoxidil (P less than 0.0005). The major side effects of fluid retention (9/15), hirsutism (15/15), and tachycardia were adequately controlled in all but one patient. We conclude that minoxidil will be a valuable drug in the outpatient management of refractory hypertension.


Nonunion of fractures of the proximal humerus: a method of treatment using a modified Moe plate. Treatment of nonunion of fractures of the proximal or middle third of the humerus by use of a modified Moe plate is described. We have found this treatment to produce more favorable results than other methods using either internal or external immobilization. Simple modification of an existing mechanically sound device has led to a very useful instrument for the internal fixation of this type of fracture.


Scar carcinoma: prognosis and treatment. A 30-year experience with 31 cases of squamous cell carcinoma arising in scars is reviewed. Mean age of the patients was 58 years. Average time from injury to diagnosis was 23 years. The male to female ratio was 4:1. Tumors were well differentiated in 23 cases and poorly differentiated in eight cases. Three-year survival rate was 94% for patients with well-differentiated lesions, but only 38% for those with poorly differentiated ones which were more likely to metastasize. Implications of these findings are discussed in relation to therapy.


Endocarditis treated with clindamycin: relapse and liver dysfunction. Clindamycin was used to treat six patients with endocarditis because of allergy to penicillin in five, and an unfavorable clinical response to methicillin in one. Only one patient had an uneventful cure with clindamycin. Two had hepatotoxicity which resolved rapidly after clindamycin was stopped. Two patients, one of whom had an aortic prosthesis, had completed four to six weeks of clindamycin therapy when clinical relapse occurred and blood cultures were again positive for a clindamycin-sensitive isolate. A fifth patient had peptostreptococcal endocarditis. Despite a favorable initial clinical and bacteriologic response, blood cultures taken on the 20th day of therapy again grew the Peptostreptococcus. This relapse pathogen had become resistant to clindamycin and was 100-fold less sensitive than the initial isolate. The few conditions in which clindamycin is indicated for therapy of bacterial endocarditis are outlined.


Investigating the contacts and suspected contacts of tuberculous patients in New Orleans. The New Orleans Health Department still investigates the contacts and suspected contacts of patients with tuberculosis, although it has stopped some tuberculosis control programs as unproductive. To determine whether contact investigation is worthwhile, in 1974 we sampled 1,110 men, women, infants, and children who had proved (391) or suspected (719) contact with a tuberculous patient. Nineteen percent (215 out of 1,110) of these contacts examined had tuberculous infections (reflected by positive skin tests). Seven (0.63%) also had pulmonary tuberculosis. We concluded that contact investigation effectively identified residents of New Orleans who were at risk of tuberculosis and the program should be continued.


Pseudocholinesterase deficiency: an additional preoperative consideration in outpatient diagnostic procedures. Because pseudocholinesterase deficiency is an unusual anesthetic complication which requires specialized equipment and postanesthetic management and nursing care for successful treatment, it takes on added significance when it occurs in the ambulatory surgical patient. It emphasizes the fact that while operative procedures performed in the ambulatory surgical setting may be of comparatively minor magnitude, this does not in any way render them minor anesthetic procedures.


Testing for the Tay-Sachs gene in the Atlanta Jewish population. In May 1975, three mass screening clinics for the asymptomatic Tay-Sachs carrier were held in Atlanta, Georgia. Ninety percent of the 2,330 adults screened were of Ashkenazi Jewish ancestry. One hundred seventy-six people were identified as possible carriers, 145 returned for retesting, and 74 were diagnosed as carriers. The Tay-Sachs heterozygote frequency estimated from this tested population was 0.043 or 1 in 23. Retesting of all possible carriers and assessment of their first-degree relatives were emphasized as saids in diagnosis of the carrier state. Our results indicated that the hexosaminidase A values in the white celll lysates used for the retest procedure provided a more reliable diagnosis of the carrier state than did enzyme values obtained from screening sera alone. Test results from first-degree relatives in all cases supported the assigned genotype of probands.


Visual field status in the management of chronic angle-closure glaucoma. A retrospective analysis of the case histories of 40 patients with chronic angle-closure glaucoma yielded 31 eyes without visual field loss and 26 eyes with field loss. Peripheral iridectomy was highly successful in cases without field loss. Trabeculectomy was significantly more successful (93%) than iridectomy (64%) in treating cases with field loss. It is suggested that the choice of surgical procedure in this syndrome be dictated in part by the character of the visual field.


The cephalosporin antibiotics in pediatric practice. The efficacy of the cephalosporins against gram-positive cocci and some of the gram-negative bacilli together with their relative safety make this family of antibiotics potentially useful in treating pediatric infections, particularly in instances of penicillin hypersensitivity. Newer cephalosporins have broadened the antimicrobial spectral range and may offset some of the previous drawbacks to their use in children. Of potential interest to the pediatrician is the highly active inhibitory effect against Hemophilus influenzae by cefamandole, one of the newer cephalosporin congeners.


Addison's disease secondary to North American blastomycosis. Reported is the fifth known case of Addison's disease due to adrenal involvement by North American blastomycosis (Blastomyces dermatitidis infection). The fact that amphotericin B therapy precipitated an addisonian crisis suggests that patients with disseminated blastomycosis should have their adrenal function and reserve evaluated before undergoing systemic chemotherapy.


Simultaneous infection of the central nervous system with Cryptococcus neoformans and Mycobacterium intracellulare. A 46-year-old woman with cryptococcal meningoencephalitis also had Mycobacterium intracellulare isolated from her cerebrospinal fluid. She was treated with amphotericin B,5-fluorocytosine, and antituberculous agents (isoniazid and rifampin). She gradually improved and was well, except for residual neurologic damage, three years after discharge from the hospital. No evidence of significant underlying disease has been found.


Spontaneous subcutaneous emphysema of the neck and mediastinum. An unusual case of spontaneous subcutaneous emphysema and pneumomediastinum presumably caused by a laryngeal or hypopharyngeal tear during excessive phonation is presented. The patient was treated conservatively after a careful search for any causative factors. Observation, with parenteral ailimentation, intravenous antibiotics, and voice rest, is advocated for most cases. Tracheostomy and open repair or mediastinotomy are reserved for the unusually severe or unresolving case.


New behavioral data concerning the autoerythrocyte sensitization syndrome. A typical case of autoerythrocyte sensitization or the Gardner-Diamond syndrome was reviewed with respect to personality factors, hypnotic influence in general, the effect of controlled hypnosis under two variable conditions, and the measurement of certain psychophysiologic responses before and following hypnosis. In this case it was not possible to delineate a clear psychiatric syndrome and hypnotic suggestion induced the classical lesion only during the active phase of the disease. When the lesions were absent or quiescent, no changes in various psychophysiologic measurements taken were observed.


Ventricular tachycardia in a patient with the "Chinese restaurant syndrome". A 36-year-old man developed severe weakness, palpitation, and diaphoresis 30 minutes after eating wonton soup. On admission to the hospital he was found to have ventricular tachycardia. He was given lidocaine intravenously and the rhythm converted to normal with the three minutes. It was concluded that monosodium L-glutamate might produce potentially serious arrhythmias in susceptible persons.


Cholangiographic findings in agenesis of the gallbladder. A case of agenesis of the gallbladder and cystic duct and the cholangiographic findings are presented. We believe this to be the first case documented by intravenous cholangiography.


Peutz-Jeghers polyposis with metastasizing duodenal carcinoma. A case of Peutz-Jeghers polyposis associated with duodenal carcinoma but without cutaneous pigmentation was presented. Duodenal carcinoma is the most commonly associated neoplasm. The presence of vitiligo in this patient is coincidental. Of 14 reported cases of Peutz-Jeghers syndrome associated with intestinal carcinoma, in only two was the tumor shown to originate in the polyp. In our case, too, we believe the carcinoma developed independently.


Henoch-Schönlein purpura of the colon: an unusual gastrointestinal manifestation. Henoch-Schönlein purpura is a nontraumatic hemorrhagic diathesis with bleeding into the joints, skin, and viscera. An unusual case demonstrating radiographic changes in the colon has been presented. Transitory submucosal bleeding found in the colon appears to be similar to that which has been seen in the small bowel.


Endometriosis of the umbilicus.

Endometriosis of the umbilicus. A 39-year-old woman with a history of prolonged and excessive vaginal bleeding and bleeding from the umbilicus was found to have umbilical endometriosis. The umbilicus was excised following hysterectomy and bilateral salpingo-oophorectomy. Umbilical endometriosis should be considered in the differential diagnosis of umbilical lesions.


Raised serum transaminase levels in patients with rheumatic fever treated with salicylates. Of 11 patients with acute rheumatic fever, 9 were treated with a total daily salicylate dosage of 3,6 g or less, 1 patient required a total daily dosage of 5,4 g and another required 9,0 g daily. Six of the 11 patients had elevated serum transaminase levels, and all were asymptomatic. The elevated transaminase levels appear to bear a direct relationship to the serum salicylate level, and a serum salicylate level of 19,2 mg/100 ml appears to be the critical point. In 5 out of the 6 patients with elevated transaminases, the serum salicylate level exceeded 19,2 mg/100 ml, while in the 5 patients with normal transaminases the serum salicylate level did not exceed 19,2 mg/100 ml. Also, in 10 of the 11 patients eosinophilia was noted, but this decreased despite continued or increased salicylate administration. A narrow margin thus appears to exist between therapeutic serum salicylate levels and hepatotoxic levels, and serial serum transaminase estimations are advocated in patients on long-term salicylate therapy.


[Single treatment with repository steroid in non-articular sport injuries]. A single treatment with repository steroid (methylprednisolone acetate) was given to 300 sportsmen with minor non-articular soft-tissue injuries. The response to treatment was determined after 5 days. Fitness to participate in sport was used as a guide. The results were excellent in 133 (44%) patients, good in 103 (34%) and poor in 64 (21%). Owing to the generally satisfactory response and the few minor side-effects, there appears to be justification for this type of treatment in properly selected cases.


Studies on increases in growth rate of South African Black schoolchildren and their significance to health. Heights and weights of Black schoolchildren aged 8-14 years, at five rural and two urban centres, have been compared with data secured at these places 12-38 years ago. Significant increases have occurred, although heights and weights in general remain lower than international reference standards. In the mass, pupils have normal weight for height. Evidence suggests that Black schoolchildren experience a high level of everyday good health. This must be validated. Research is required to determine the precise degrees of morbidity and mortality prevailing in slower compared with faster growing pupils.


Organic acidosis in infants.

Organic acidosis in infants. Any child or adult who has persistent acidosis after apparently adequate treatment should be suspected of having an organic aciduria, as should any person with a large anion gap and acidosis. The possibility that some can presently be treated, makes early diagnosis urgent. Acidosis occurs in hypoperfused states, and treatment of the hypoperfusion with half- to two-thirds-strength of physiological saline with 40 mEq/1 of potassium may correct the acidosis without there being any need to use bicarbonate.


Non-occlusive ischaemic colitis in a South African black. A case report. A rare case of non-occlusive ischaemic colitis in a South African Black is described. The appearance of the bowel at an initial operation, and the histopathological changes demonstrated in the resected specimen after a subsequent operation, provide evidence for this diagnosis. The clinical presentation and radiological features which were also compatible with the diagnosis are presented. While the initiating mechanism remains obscure, it is suggested that ischaemia of the colon wall is likely to have been responsible for the final histopathological picture in this case.


Isoniazid-induced pellagra in a patient on vitamin B supplement. A patient who was treated with isoniazid and who developed pellagra is presented. Vitamin B supplements did not help, but the patient's condition improved when isoniazid treatment was stopped.


Traumatic lung cysts after penetrating chest injury. Report of three cases. Three cases of traumatic lung cysts after penetrating chest injury are described and distinguished from pulmonary haematomas. The literature on pulmonary haematomas and traumatic lung cysts is briefly reviewed.


Generalized surgical emphysema as an early complication of facial fracture: a case report. A case of multiple facial fractures complicated by subcutaneous emphysema, pneumomediastinum and pneumoretroperitoneum, in the absence of intra-abdominal, neck or chest injuries, is described.


The effect of carbachol on the gallbladder in Black and White subjects. The effect of carbachol on the gallbladder was assessed in 24 White and 24 Black volunteers. The results suggest that in Blacks the gallbladder empties to a signigicantly greater degree than it does in Whites after administration of carbachol. This fact may account, in part, for the lower incidence of cholelithiasis in Black populations. No difference in gallbladder contractility was found between men and women nor did gallbladder response appear to be influence by hormonal factors.


Western diseases in developing peoples: in search of a 'marker'. Phleboliths were sought in pelvic radiographs of some 1 500 patients of whom about half were White and half were Black. A marked difference was found, and many more phleboliths occured in the White group. It may be that the younger group of Blacks exhibit more phleboliths than do the older folk. Phleboliths may be found to serve as a 'marker' for a developing Western pattern of diseases.


The child in hosptial.

The child in hosptial. The characteristic emotional reactions of the young child upon admission to hospital, and the long-term effects on his personality, are described. Children's attitudes to anaesthesia, pain, surgery and immobilization are examined. Guidelines are give for the minimization of emotional trauma whenever possible.


Jaccoud's arthropathy: report of seven cases. Seven patients with severe rheumatic heart disease and joint deformities, in whom there were no signs of active arthritis, are described. The fulfill the criteria for the diagnosis of Jaccoud's arthropathy (or 'chronic post-rheumatic arthritis'). We postulate that hypermobility may be a predisposing factor in the development of the deformity. This rare condition should be distinguished from rheumatoid arthritis because of its relatively favourable prognosis.


Intermittent maple syrup urine disease: a case report. A case of intermittent maple syrup urine disease (branched chain keto-aciduria) in an 8-year-old girl is reported. The early detection of this rare disorder is important since control of branched chain amino acid intake may control metabolic abnormalities and prevent neurological damage.


Pulmonary disease associated with mycobacteria other than tubercle bacilli in miners. Five patients with lung disease caused by mycobacteria other than tubercle (MOTT) bacilli are described. Mycobacterium kansasii was the causative organism in 4 patients and M. scrofulaceum in 1 patient. The species were repeatedly isolated from sputum specimens cultured on Löwenstein-Jensen medium. The clinical features, mycobacterial isolations, bacteriological properties of the pathogens and the therapeutic problems encountered are discussed.


The fate of drinkers: a six-year follow-up study of a community survey. A study of the drinking habits of Coloured adults in 1963, and of a sample of the same population 6 years later, showed that drinking patterns had remained remarkably stable. Excessive drinkers tended to retain their drinking pattern. Very few ceased drinking on their own account and a negligible proportion came forward for treatment. Social drinkers and abstainers also tended to maintain their patterns of drinking--only a few became excessive drinkers. The mean age of excessive drinkers was lower than that of the social drinkers and abstainers. There was much less excessive drinking among women.


Gastric ulcer after the Nissen fundoplication: a complication of alkaline reflux. Four of a series of 40 patients who underwent the Nissen fundoplication to correct reflux oesophagitis developed gastric ulceration 24, 22, 15 and 13 months respectively after the procedure. The gastric ulceration is attributed to bile reflux, and the original oesophagitis to "alkaline" reflux. When severe oesophagitis results from "alkaline" reflux, a Roux-en-Y bile diversion operation with vagotomy and fundoplication should be considered.


Anorectal closing mechanisms.

Anorectal closing mechanisms. The thrust of this contribution is contained in an analysis of the refined sealing devices which supplement the co-operative interactions between the anorectum and its surroundings. They include an active smooth-muscle complex which, with elastic tissue, is closely related to vascular anal cushions. These, when distended, plug the anal lumen and complete continence. Additional objectives are: (i) to draw attention to new concepts on the nature of haemorrhoids; (ii) to add illustrations to support the idea of tripartite sealing plugs in the form of anal "cushions"; (iii) to note discrepancies in the literature on the exact siting of the pectinate/dentate line in the anal canal which have a bearing on the theory of the anal cushion; (iv) to give reasons why the musculus submucosae ani should not be termed Treitz's muscle; (v) to review some morphological, pressure, motility and electromyographic sutdies of the neuromusculature of the anorectal region in normal subjects and in patients with haemorrhoids; and (vi) to add explanations and suggestions to fit the concept of the anal cushion into a broader framework of use to the surgeon.


New observations on the cholangiographic pseudocalculus defect: a case report. Contraction of the distal sphincter of the common bile duct (as distinct from the sphincter of Oddi) may produce a pseudocalculus defect. A typical case is described where the defect was thought to be a retained stone on T-tube cholangiography. The anatomy of the defect is emphasized by its persistence after sphincteroplasty. A diagnostic feature is the immediate abolition of the defect by hyoscine butylbromide (Buscopan, Boehringer Ingelheim).


Neutral steroid concentrations in the faeces of North American White and South African Black populations at different risks for cancer of the colon. To test the hypothesis that a high risk for cancer of the colon might be associated with high concentrations of neutral steroids in the colon and with breakdown of these compounds by intestinal bacteria, the faecal neutral steroid concentrations of 84 rural South African Black adults (a population at low risk for colonic cancer), and of 98 North American White adults (a population at high risk for colonic cancer) were compared. Not only were the concentrations of animal steroids higher in the faeces of the North Americans, but the chemical state of their faecal steroids was different from that of the Blacks. A high proportion of plant and animal steroids in the faeces of the Blacks was esterified to long-chain fatty acids, whereas in the faeces of the North Americans, most of the neutral steroids were free (non-esterified). There was considerable variation in the extent of cholesterol metabolism by the intestinal bacterial in the North Americans. This was not the case with the South African population, which was much more homogeneous with respect to cholesterol metabolism.


Peripheral neuromuscular changes in Parkinson's disease. The muscle, nerve terminal and end plates of 3 patients suffering from idiopathic Parkinson's disease have been studied electrophysiologically, histologically, histochemically and electron microscopically. No characteristic neuromuscular features of parkinsonism were discernible. Four additional patients suffering from idiopathic parkinsonism complicated by diabetes, myasthenia gravis and spinal atrophy were also studied.


The role of screening in the prevention of inherited disease in South Africa. It is now possible to screen for the presence of the carrier state of a number of inherited diseases. Such screening can alert one to the need for antenatal diagnosis where feasible, it can ensure that early treatment is given to affected infants, and it can assist carriers in reaching a decision about having children. Facilities for certain types of screening already exist in some centres in South Africa, and new techniques will be introduced in the future.


The value of pretherapy para-aortic lymphadenectomy for carcinoma of the cervix uteri. Pretherapy surgical staging in locally advanced carcinoma of the cervix uteri should not be routinely performed. In hospitals conducting therapy of patients with proved aortic node metastasis, differing dose time relationships in extended field therapy need to be established that have a lower complication rate and significant cure rate. Surgical staging should possibly be restricted to Stages IIIB and IV with the approximate respective 36 and 50 per cent incidence of para-aortic node metastases.


Treatment of squamous cell carcinoma of the floor of the mouth. Treatment of 88 selected patients with Stages I and II squamous cell carcinoma of the floor of the mouth by monobloc resection has produced a high five year cure rate. The death of one patient in the series postoperatively was considered a surgical one. Disability after such a procedure is minimal, and dental complications are not a factor. Elective irradiation of the neck is recommended in those instances of positive sublingual or submandibular nodes found in the monobloc specimen and in all patients with Stages III and IV lesions. Radiation therapy is recommended for highly anaplastic neoplasms, for instances when speech impairment is important, for lesions in the posterior limits of the floor of the mouth, for edentulous patients without bone invasion, for the treatment of recurrent lesions after operation and for synchronous multiple primary carcinomas of the head and neck if one of which is a carcinoma of the floor of the mouth.


Factors affecting prognosis in acute renal failure following cardiac operations. Twenty-five patients with acute renal failure following cardiac operations using cardiopulmonary bypass were analyzed retrospectively to identify predictors of survival or mortality. Age and the number of postoperative medical complications served as predictors of mortality, p less than 0.05. A low survival rate occurred if the patient was in the seventh decade of life. Nonsurvivors had a higher number of postoperative medical complications. However, only cardiac failure and bacteremia occurred in a significantly greater proportion of those patients who died, p less than 0.05. The presence of non-oliguric renal failure was associated with a 100 per cent survival rate, p less than 0.05. The mortality of these 25 patients was 28 per cent, which is lower than that generally reported. Although an extremely serious postoperative complication, acute renal failure following cardiac operations does not imply a hopeless prognosis. A vigorous therapeutic effort is warranted.


A morphologic study of the submucosa of the large intestine. The morphologic structure of human, rat and mouse submucosa is similar. The strength, natural tension and extensibility of the submucosa can be readily interpreted form the physical properties of collagen and its structural arrangement as a pliable honeycomb. The perforations allow blood and lymph vessels to reach the mucosa.


Banked autologous blood in total hip replacement. Transfusion of banked autologous blood was used in 61 patients requiring a total hip replacement. Up to 3 units of blood may be removed by phlebotomy within three weeks of the operation. Hemoglobin levels of less than 7 milligrams and hematocrit levels below 29 had no adverse effect on wound healing or resistance to infection. Autologous transfusion avoids many of the problems associated with homologous blood transfusion, especially serum hepatitis.


Closure of a postexstrophy prostatic fistula. A technique for closure of difficult prostatic fistulas has been used in two patients with exstrophy and epispadias. In this technique, a rotated, twisted full thickness skin flap is used. The tip of the flap forms the roof of the closed fistula and is made out of the epidermis. The pedical of the flap is buried, and therefore, the epidermis is removed, leaving only the dermal layer to be buried. Consequently, there is no tension on the fistula closure, and the chance of breakdown is vastly reduced. The long term results is these two patients has been excellent. In the older child or adult, this technique may provide the only consistent means for achieving such a closure. The technique is obviously adaptable to other situations in which a simple closure is plagued with secondary breakdown.


The technique of modified radical mastectomy. The functional and cosmetic results of this modified radical mastectomy are superior to those achieved by standard radical mastectomy. The incidence of lymphedema of the ipsilateral arm, which is one of the feared complications from a standard radical mastectomy, appears to be decidedly less.


A simplified approach to hepatic vein injuries. Hepatic vein injuries continue to be difficult and frustrating problems, presenting any surgeon with a formidable challenge. However, this simplified approach can be used successfully in many patients. It does not require extensive dissection and cannulation of the inferior vena cava, and it is more applicable for surgeons with limited vascular experience, who occasionally encounter an injury of this magnitude. Obviously, it is not suitable for all patients with hepatic vein trauma, especially those with extensive caval involvement which does require shunting and exclusion procedures. However, one should evaluate thoroughly the magnitude of the injury and strongly consider this simplified approach before selecting a technically more difficult method which may not be required and which may result in a fatal complication if not executed properly.


Twenty-three years of experience with sphincterotomy and sphincteroplasty for stenosis of the sphincter of Oddi. A 23 year experience with papillotomy, sphincterotomy and sphincteroplasty for stenosis of the sphincter of Oddi shows sphincteroplasty to be the best procedure, with 79% of the patients obtaining a good result. The procedure was done for a demonstrable organic change in the sphincter, often associated with acute cholecystitis in older patients, the postcholecystectomy syndrome in those in whom a long cystic stump had been left at the first operation or in patients with chronic recurring pancreatitis. The study included 138 private patients observed from two months to 22 years. There were four postoperative deaths, an operative mortality of 2.9%, as two patients had been operated upon twice. The poor results were associated with recurring attacks of pancreatitis not cured by the procedure or developing subsequent to it, probably being attributable to persistent obstruction of the terminal part of the pancreatic duct. The results suggest that sphincteroplasty, if performed on suitably selected patients, is a safe procedure which should give good results in more than 75% of the patients.


A biomechanical study of healing of skin incisions in rats during pregnancy. Wound healing during both pregnancy and the postpartum phase results in stiffer, but not stronger, wounds. The probable mechanism is a hormonally mediated enhancement of fiber maturation. This mechanism, however, remains to be verified by a more direct study of the molecular stability of the collagen fibers. This study was undertaken to analyze the influence of pregnancy on reparative processes in extragenital connective tissue by using skin wound healing as an experimental model. Wounds were induced on gestational days 1 and 20, respectively, and analyzed biomechanically ten or 20 days later. Twenty day old wounds in rats in the pregnant and postpartal groups were found to be stiffer and required less energy to be ruptured than did those produced in nonpregnant rats, whereas ten day old wounds in pregnant rats were not found to differ in strength and stiffness from those in nonpregnant rats. The findings are compared with other studies on changes in reproductive hormone levels, and a mechanism for the biomechanical differences found is suggested.


The value of laparotomy in staging of lymphoma. Seventy-one patients with lymphoma underwent staging laparotomy. Fifty of the patients had Hodgkin's disease and the remainder, non-Hodgkin's lymphoma. One patient died from pulmonary embolism on the tenth postoperative day, one required temporary assisted ventilation, one required reoperation for hemorrhage and six patients had infectious complications which responded to appropriate antibiotic therapy. Despite extensive noninvasive procedures, including bone marrow trephine biopsy and lymphangiography, in approximately 30% of the patients, the disease was restaged as a result of the operation. Since primary management of these diseases is critically dependent upon accurate staging, we conclude that, at the present time, this procedure is indispensible for proper management, as it contributes information not available from other currently used investigational techniques.


Five year survival after cryosurgery for carcinoma of the mouth. Sixty patients with carcinoma of the mouth in various stages of development were treated by cryosurgery. Its outstanding feature was conservation of bone which forms the oral cavity. Thirty-two of 60 patients survived for five years. The best results were obtained in patients with small to moderate sized carcinomas without cervical lymphadenopathy. Cryosurgery is especially suitable for the high surgical risk patient.


A ten year study of heparin therapy for thrombophlebitis in ambulatory patients. During the past ten years, we have observed 407 patients with thrombophlebitis using a standardized outpatient regimen including subcutaneously self-administered heparin therapy. A definite protocol for tapering and discontinuing anticoagulants was applied which allows a correlation between duration of heparin administration, decreasing heparin resistance and symptomatic improvement. In acute and subacute thrombophlebitis, this method induced symptomatic resolution within less than two months in half of the patients and within less than six months in 78%. The number of recurrences during the follow-up period was acceptable and the frequency of complications minimal. We conclude that, except in the most severe, toxic instances of thrombophlebitis or in suspected pulmonary embolism, hospitalization--complete bedrest and intravenously administered anticoagulants--is unnecessary and wasteful.


Eight years experience with civilian injuries of the colon. A chart review of 130 patients with colonic injuries treated between the years 1968 and 1976 were reviewed. Types of operative procedure, complication rate, mortality and hospital stay were tabulated. The patients treated by primary closure and exteriorized primary repair had a 2% mortality, while various staged procedures used in the remaining patients resulted in a 6% mortality. Complications were common in all types of repair and correlated with the severity of the injury. Primary closure of the injured colon can safely be accomplished in carefully selected patients. Staged procedures necessitate a secondary operation which we found to be relatively benign, and we continue to use staged operations in the majority of our patients with colonic injuries. This management protocol has resulted in a 4 to 6% over-all mortality.


Pregnancy in patients with a prosthetic heart valve. Pregnancy and delivery were analyzed in 23 women one to ten years after undergoing prosthetic heart valve replacement. The main points of management during pregnancy and delivery were cardiac management and management against thromboembolism. The functional status of the pregnant patients was grade I of the New York Heart Association criteria in eight, grade II in 13 and grade III and higher in two. There were seven patients during pregnancy and eight after delivery who required hospitalization and treatment for congestive heart failure. Thromboembolism was observed in two during pregnancy and puerperium. Five of the patients were not given anticoagulation therapy, but when thromboembolism developed, warfarin was administered. Warfarin therapy was given indefinitely to seven patients, and 11 were given massive dosages of dipyridamole. In the first two groups, four patients had episodes of thromboembolism.


The relationship between antral function and completeness of vagotomy. To assess whether or not a persistent antral response to meat extract stimulation is an indication of incomplete vagotomy, 29 patients with a duodenal ulcer who underwent operation had preoperative and postoperative acid studies as well as postoperative Hollander tests. In the preoperative tests, two groups of patients were delineated--antral and nonantral responders. Postoperative Hollander tests revealed three positive responses; in two patients with an early positive response, meat extract led to a significant increase in acid and gastrin response. In the patient with a late positive Hollander test, there was no response to meat extract. In two patients with proved stomal ulcers and negative Hollander tests, meat extract led to a significant increase in acid and gastrin output. These results suggest that an antral acid and gastrin response to meat extract indicate an incomplete vagotomy.


Management of carcinoid tumors of the gastrointestinal tract. Sixty-five patients seen at the Massachusetts General Hospital between 1951 and 1974 with carcinoid tumors of the gastrointestinal tract are reviewed. Sixty-two patients were operated upon, and only one carcinoid was discovered for the first time at autopsy. Although corrected actual five and ten year survival rates of more than 60% were attained, only one of 15 patients was alive five years after the discovery of liver metastases. Patients less than 60 years of age, with tumors of less than 0.5 centimeter in diameter and with no history of weight loss, survived best. Most rectal and appendiceal carcinoids were small, and there were no deaths in patients who had undergone local resection. Only 33% of the patients with small intestinal carcinoids survived for five years; none survived for more than one year after diagnosis of the carcinoid syndrome was made. All colonic carcinoids had metastasized by the time the operation was performed. Carcinoids of less than 0.5 centimeter in diameter located anywhere in the gastrointestinal tract can be managed by simple local resection. Tumors 1 centimeter in diameter warrant consideration of a more extensive operation. A radical excision usually is required for tumors of more than 2 centimeters in diameter, even in the presence of metastatic disease.


An experimental study of suture of colonic wounds in the rabbit. It would seem that, during the early phase of healing of a sutured colonic wound in the rabbit when a single layer continuous suture is used, silk results in a significantly stronger wound when compared with polypropylene, polyglactin 910 and chromic catgut of the same gauge, 000. Although at 14 days after operation, no significant differences in wound strength are apparent there appears to be some weakening at 21 days after operation. This is most marked with absorbable sutures, especially polyglactin 910. The mechanism of this is uncertain but may well be at a biochemical level related to collagen maturation. The strength of the suture line bears no correlation whatever to the degree of acute inflammatory reaction or fibrosis excited by the suture material upon histologic examination.


Hilar hepatojejunostomy in resection of carcinoma of the main hepatic duct junction. Two patients with carcinoma of the main hepatic duct junction had resection followed by reconstruction between a Roux-en-Y loop of jejunum and the hepatic tissue surrounding the bile ducts at the hilum of the liver. At 18 and 11 month intervals postoperatively, they are both free from known tumor recurrence and have normal serum bilirubin levels.


The gastric bladder: a continent reservoir for urinary diversion. A continent reservoir ("gastric bladder") has been developed as an alternative to ileal conduits after urinary diversion procedures. The reservoir is fashioned from vagally denervated gastric fundus and has antireflux ureterogastric anastomoses and a continent "neourethra," the latter which is easily catheterized to empty the contents; the main stomach retains vagal innervation. Continent reservoirs were prepared in six dogs, and Heidenhain pouches (without urinary diversion) were prepared in six control dogs. Effects of short-term and long-term exposure of gastric mucosa to urine and 1M, 2M and 4M urea solutions were studied. Basal and food-stimulated acid outputs were unaffected by prolonged exposure. Mucosal permeability to H+, Na+, K+ and Cl- after exposure to urine remained unaltered, but 4M urea solutions produced a temporary increase in permeability. Mucosal blood flow was unchanged. Reservoir capacity rapidly increased up to 2,000 ml without any change in serum electrolytes. No precipitation of uric acid occurred. No histologic differences were noted between the main stomach and the reservoir. Because gastric mucosa (especially when acidified) is relatively impermeable to ions, secretes rather than absorbs Cl-, and is unaffected by prolonged exposure to urine, a gastric pouch may be useful as a continent urinary reservoir while allowing the maintenance of normal serum electrolytes.


Motor function of the esophagus after repair of esophageal atresia and tracheoesophageal fistula. Eleven patients with previous esophageal atresia repair (TEF) underwent esophageal motility studies and were compared to 10 normal patients. The upper sphincters (UES) in the two groups did not differ in resting pressure, contraction pressure, or coordination. UES relaxation, was 100% in normal patients and 83+/-8% in the TEF patients (p less than 0.05). In the proximal esophagus, 100% of the TEF group showed a normal peristaltic wave, coupled with an abnormal nonperistaltic wave. The normal group did not show this type of contraction. In the middle esophagus, the mean peak pressure of 30.5+/-2.0 mm Hg was greater in controls than the 14.6+/-1.0 in the TEF group (p less than 0.001). Coordination was observed in 97+/-1% of the controls, while present in only 27+/-4% of the TEF patients (p less than 0.001). In the distal 10 cm of esophagus, peak contraction pressures were 43.3+/-1.6 in controls and 21.3+/-1.1 in the TEF group (p less than 0.001). Coordination was 94+/-1% in normal subjects and 66+/-4% in the TEF patients (p less than 0.001). The resting pressure in TEF patients was significantly higher at all three esophageal levels (proximal, mid, distal) than in normal patients. In both groups lower esophageal sphincter function did not show any significant difference, except for closing pressure, which was significantly higher in controls (39.9+/-6.8 mm Hg) than in the TEF groups (21.3+/-3.0 mm Hg) (p less than 0.02). These studies suggest that marked motility abnormalities occur in the repaired esophagus after atresia. These abnormalities are distinctly different from other motor disorders of the esophagus.


Mechanisms for oliguria in acute renal failure. Warm ischemic (90 minutes) acute renal failure (ARF) was evaluated in the dog and found to cause polyuric ARF in the injured kidney if the opposite normal kidney was removed. In contrast, if the normal kidney were left intact, oliguric ARF was noted in the injured kidney. To further evaluate the mechanisms for oliguria and polyuria, chronic reinfusion of urine from a normal kidney into the inferior vena cava (ureterocaval anastomosis) resulted in polyuria in the opposite warm ischemic injured kidney; whereas chronic reinfusion of urine into the portal vein (ureteroportal anastomosis) resulted in profound oliguria in the opposite injured kidney. In separate additional experiments, urine acutely infused into the inferior vena cava at a rate of 0.38 ml/minute caused a significantly greater diuretic and renal hemodynamic response than seen with urine infused into the portal vein. Acute infusions of urea solution (0.38 ml/minute) with the same osmolality of urine were completely devoid of diuretic and renal hemodynamic effects. These studies reveal that urine contains a powerful hemodynamic and diuretic factor which appears to convert oliguric to polyuric ARF following warm ischemic renal injury in the dog. This factor is not urea and can be destroyed by the liver.


Effect of corticosteroids on collagen synthesis. Contraction and epithelization are two phenomena of "wound healing" retarded by corticosteroids. It is unclear how these agents affect collagen synthesis and wound remodeling. The methods used by several authors to conclude that steroids inhibit collagen synthesis are questioned. Therefore, collagen synthesis was measured in cultured steroid-treated chick embryo calvaria, 5 day open wounds in treated rats, and intralesionally injected human keloids. Collagen synthesis was suppressed only by long-term administration of massive systemic doses of a sustained release form of methylprednisolone (Depo-Medrol). Large, intermittent doses of corticosteroids (triamcinolone and Solu-Medrol) did not alter collagen synthesis. Because human keloids become softer and smaller following intralesional administration of triamcinolone without lowering the normally high rate of collagen synthesis, we hypothesize that corticosteroids enhance collagen degradation.


Cell surface antigens in a rat colon cancer model: correlation with inhibition of tumor growth. Chemically induced bowel tumors in Wistar/Furth (W/F) rats possess surface antigens analogous to those demonstrated in humans with colon carcinoma. To determine if these in vitro tumors markers have any in vivo significance, tumor isograft challenge experiments were performed. Groups of animals received three immunizing doses of 10(7) cells from chemically induced colon carcinomas NG-W1, DMH-W49, or DMH-W9 or small-bowel adenocarcinoma DMH-W7. Control rats were immunized with a noncross-reacting, virally induced mammary fibroadenoma A9-W1. Six weeks after immunization, all animals were challenged with 1 X 10(5) or 3 X 10(4) colon carcinoma NG-W1 cells. None of the NG-W1-immunized animals developed tumors after either NG-W1 challenge dose. In contrast to this strong protection by "private" tumor rejection antigen (TRA), protection by common or "tissue type specific" antigens was evident only if tumor volumes were measured. Twenty-two days after low-dose NG-W1 challenge, mean tumor volume (m) in animals immunized with colon tumor DMH-W9 (m=0.25 cu cm) and DMH-W49 (m=0.17 cu cm) were less (p less than 0.05) than in animals untreated (m=1.0 cu cm) or immunized with mammary fibroadenoma A9-W1 (m=0.9 cu cm). Embryonic antigens also may function as weak TRAs. NG-W1 challenge tumor volumes in fetal-gut-immunized (m=0.9 cu cm) and whole embryo-immunized animals (m=0.9 cu cm) were less (p less than 0.05) than in fetal-kidney-immunized (m=2.5 cu cm) or adult-colon-immunized animals (m=1.8 cu cm). Low-dose NG-W1 challenge tumor volumes were less (p less than 0.01) in multiparous females (m=0.3 cu cm) than in either untreated (m=1.2 cu cm) or age-matched virgins (m=1.4 cu cm). In vitro tumor markers in this model may serve an important function in vivo as TRAs.


Pancreatic secretion in hamsters with pancreatic cancer. Pancreatic secretory abnormalities develop in most persons with pancreatic cancer and have been attributed to ductal obstruction. These experiments investigated whether abnormal secretion results instead from carcinogen-induced changes in the secreting cells. Fifty male Syrian Golden hamsters (40 to 100 grams) received weekly injections of di-isopropyl-nitrosamine (250 mg/kg, subcutaneously), and survivors and age-matched controls were studied after 3.5 to 6.5 months of treatment. Pancreatic secretion was stimulated by secretin or cholecystokinin (2 units/kg, intravenously, as a bolus). After each stimulus four 15-minute collections of pancreatic juice were analyzed for HCO3- and Cl- or total protein, amylase, trypsin, and chymotrypsin. The organs were examined histologically. Pancreatic ductal adenocarcinoma developed in 30% of the animals at 5 months, 56% at 5.5 months, and 100% at 6.5 months. The animals without cancer either had hyperplasia of the duct epithelium or were histologically normal. The histologic appearance of acinar tissue and protein secretion were normal in all groups. The tumors did not obstruct the major ducts. In all treated animals the pancreatic secretory response to secretin was of low volume, low maximal [HCO3-] and HCO3- output, and low [Cl- + HCO3-]; these changes progressed with time. The secretory abnormalities antedated the appearance of the neoplasms and were not caused by obstruction.


Does intermittent coronary perfusion offer greater myocardial protection than continuous aortic cross-clamping? There has been considerable controversy concerning the relative merits of intermittent coronary perfusion vs. continuous aortic cross-clamping for cardiac procedures requiring ischemic arrest. Using the isovolumic ventricular balloon model and "stop-freeze" biopsy techniques, myocardial contractility (LV dp/dt max, length-tension, and force-velocity relationships) and metabolism (adenine nucleotides, creatine phosphate, and glycogen) were studied in 46 intact dogs supported by normothermic cardiopulmonary bypass and subjected to either 60 minutes of continuous ischemic arrest or to four 15-minute intervals of ischemia each followed by 5 minutes of reperfusion. Following ischemia the hearts were reperfused for 30 minutes and defibrillated after the first 10 minutes. There were no significant differences in either metabolic parameters or contractile function between the groups. Although partial regeneration of adenosine triphosphate and glycogen occurred during reperfusion, only creatine phosphate achieved normal values and the end result was no difference between the two techniques. These data indicate that 5 minutes of coronary reperfusion between consecutive episodes of ischemic arrest affords no greater intraoperative protection of the myocardium than does continuous aortic cross-clamping.


Acute pancreatitis with hyperlipemia: studies with an isolated perfused canine pancreas. Clinical evidence suggests that in many settings hypertriglyceridemia can initiate an episode of acute pancreatitis. Hydrolysis of triglycerides by pancreatic lipase with the local release of large quantities of free fatty acids (FFAs) has been proposed as the pathogenetic mechanism. To gather information to evaluate this mechanism an isolated, ex vivo, perfused pancreatic preparation was used. Control preparations remained normal in gross appearance, gained little weight (18 gm), extracted oxygen and glucose and released carbon dioxide, and continued to secrete during a 4 hour perfusion period. Serum amylase remained normal (972 CU/100 ml) as did FFAs (1.11 mEq/liter). When triglycerides were added to the perfusate to increase the serum triglycerides to 1,600 mg%, the glands became edematous, hemorrhagic, and gained considerable weight (52 gm) during the 4 hour perfusion period. Serum amylase became markedly elevated (2,624 CU/100 ml), as did the serum FFA (29.19 mEq/liter). When FFAs were added directly to the perfusate, the glands became edematous, hemorrhagic, and gained weight (90 gm), but did so much more rapidly than when triglycerides were added. These studies add support to the concept that hypertriglyceridemia can initiate pancreatic injury. Furthermore, they suggest that the mechanism may be through the release of FFAs.


Direct measurement of arteriovenous anastomotic blood flow after lumbar sympathectomy. Absolute blood flows through hind limb capillaries and arteriovenous anastomoses (AVA) were determined by the radioactive microsphere technique of relative shunt measurement combined with direct (electromagnetic) measurement of femoral artery flow. Hemodynamic parameters were measured before and after laparotomy, after unilateral lumbar sympathectomy, during reactive hyperemia, and during alpha adrenergic blockade in normal and sympathectomized hindlimbs of six anesthetized dogs. After sympathectomy arteriovenous (A-V) shunting increased from 3.8 to 32.1% (p less than 0.05). AVA flow increased from 4 to 54 ml/minute (p less than 0.01), while capillary flow was unchanged. Nonsympathectomized limbs did not demonstrate these changes. During reactive hyperemia, capillary flow increased more than 100% (p less than 0.03) in both normal and sympathectomized limbs, while AVA flow was unchanged. After phentolamine (5 mg, intravenously), AVA flow increased from 2 to 19 ml/minute (p less than 0.01) only in nonsympathectomized limbs. Phentolamine mimicked surgical sympathectomy effects in nonsympathectomized limbs, with paw temperature, femoral flow, A-V O2 difference, A-V shunting, AVA flow, and capillary flow equal to sympathectomized limbs after phentolamine administration. In the acute canine model, increased blood flow after sympathectomy is due to increased nonnutritive AVA flow, with no change in total hindlimb capillary flow, both at rest and during reactive hyperemia.


The relative importance of incompetent communicating veins in the production of varicose veins and venous ulcers. To investigate the possible anatomic and hemodynamic reasons for the variability in response to surgery for venous insufficiency (a 50% ulcer recurrence rate following ligation of incompetent perforating veins), we performed phlebography and venous pressure measurements in 109 legs of 77 patients and in 30 healthy volunteers. Patients were divided into five groups: saphenofemoral incompetence alone (group 1), saphenopopliteal incompetence (group 2), incompetent lower leg communicating veins alone (group 3), calf communicating veins and saphenous incompetence (group 4), and postthrombotic limbs (group 5). Patients in groups 1 through 4 had phlebographically normal deep veins. As compared to the normal controls (68%), preoperative pressure measurements revealed a significantly smaller pressure fall during exercise (deltaVPex) in all groups, which was the least marked in groups 3 (26%) and 5 (17%). These latter two groups failed to increase their pressure fall with thigh tourniquet. deltaVPex 3 months after operation demonstrated normalization in groups 1, 2, and 4 (52%, 57% and 59% respectively). Groups 3 and 5 improved little following surgical ligation. Whenever saphenous vein incompetence coexists with lower leg communicating vein incompetence, the former appears to be the dominant cause of the pressure abnormalities. Based on venous pressure measurements and phlebography, patients with normal deep veins and who increase their deltaVPex with a thigh tourniquet should respond favourably to orthodox surgical ligation of the saphenofemoral or saphenopopliteal junction. By contrast, if no change in deltaVPex is noted in patients with incompetent perforating veins and the deep veins look abnormal on the phlebogram, then ligation of the incompetent communicating veins would appear to be associated with a high recurrence rate.


The nature of failure of pulmonary adaptation to atelectasis. The ability of the lung to decrease blood flow to an atelectatic lobe and to increase flow to normal after reinflation was investigated with a model using left lower lobe atelectasis (LLLA) in the dog. The change in the shunt fraction QS/Qt with continuing LLLA was assumed to represent a change in blood flow to the LLL. With LLLA the Qs/Qt rose from 0.112 to 0.172 and then decreased to 0.119 by the end of 2 hours at the rate of -17%/hour. Reversal of atelectasis for varying times demonstrated that the pulmonary vasoconstrictive response persisted for at least 4 hours after reinflation of LLLA. With LLL ischemia for 1 and 2 hours followed by LLLA, Qs/Qt decreased, but at a rate less than the controls, whereas after hemorrhagic shock with venous reinfusion and LLLA, the Qs/Qt did not decrease. When hemorrhagic shock was followed by arterial reinfusion, 60% had a normal response to LLLA; 40% did not. There was no difference in PVR in these two groups. Pulmonary extravascular water in both groups was the same as in controls. Infusion of NE after 3 hours of LLLA caused Qs/Qt to rise from 0.125 to 0.248, comparable to the value immediately after onset of LLLA. EPi had similar results. Catecholamines may restore blood flow to the atelectatic lobe by causing a maximum generalized pulmonary vasocontriction or by overexpansion of the pulmonary blood volume secondary to peripheral vasoconstriction and thereby abolish any differential in pulmonary vascular resistance across the lung. The early hypoxemia of adult respiratory distress syndrome may arise not on the basis of any intrinsic lung pathology but rather as the result of a normal response of the lung to increased catecholamines.


Prevention, diagnosis, and treatment of pancreatic abscess. Since pancreatic abscesses are a highly lethal complication of acute pancreatitis, factors influencing the genesis of major peripancreatic infection (MPI) were analyzed in 330 patients with pancreatitis. MPI developed in 28 (8.5%). Management of MPI was reviewed in 35 patients, including seven admitted with MPI. Etiology and severity of pancreatitis influenced MPI frequency. MPI was common in postoperative pancreatitis (39%), compared with alcoholic (6.6%), biliary (3.6%), or other causes (15%). "Severity" of pancreatitis was estimated by 11 early prognostic signs, which were reported previously. With fewer than three signs, MPI developed in 2.7%, three to five signs, 32%; more than five signs, 50%. Treatment of pancreatitis also influenced MPI. Early laparotomy increased MPI incidence from 1.6% to 23% in mild pancreatitis and from 24% to 67% in severe pancreatitis. Early oral feeding also appeared to predispose to MPI. Prolonged nasogastric suction and avoidance of early operation reduced MPI incidence from 16% in the first 100 patients to 5% in the next 230 patients. Outcome of MPI reflected severity of underlying pancreatitis. Mortality with fewer than three signs was 14%; with three to five signs, 65%; with more than six signs, 100%. Mortality was only 26% in 19 patients treated with radical sump drainage of the entire peripancreatic retroperitoneum, compared to 75% of 16 patients treated with conventional local drainage. In summary, MPI is related to etiology and severity of pancreatitis as quantified by early signs. Early laparotomy for pancreatitis increased MPI. Treatment of MPI with wide sump drainage appears more effective than local drainage.


Operative management of penetrating vascular injuries of the thoracic outlet. A five year experience with 20 patients who had penetrating vascular injuries of the thoracic outlet was reviewed. A median sternotomy with extension into the right neck was used to explore six patients with right subclavian vascular injuries. With injuries to the origin of the left common carotid artery, repair was accomplished through a median sternotomy combined with a left anterior thoracotomy in one patient and through a left posterolateral thoracotomy in the other. Injury to the left subclavian vessels occurred in five patients and was exposed through a left anterolateral thoracotomy combined with a supraclavicular incision in four patients and through a supraclavicular incision with clavicular resection in one patient. Axillary vessel trauma generally was managed with an extrathoracic incision only. The two deaths in this series were due to postoperative respiratory complications (mortality rate of 10%). Twenty arteries were repaired and all were patent on follow-up examination. Associated neural and venous injury caused significant morbidity in 28% and 10% of patients, respectively. As a result of this experience we continue to recommend an extended median sternotomy for repair of right-sided cervicothoracic vascular injury. Anterior or posterolateral thoracotomy combined with a supraclavicular incision is advocated for trauma to left-sided vessels of the thoracic outlet. When possible, injured veins should be repaired rather than ligated.


Pulsatile buttock masses: gluteal and persistent sciatic artery aneurysms. A case of persistent sciatic artery aneurysm in a 65-year-old woman was treated by exclusion and reconstruction with a saphenous vein graft. When cases such as this present as pulsatile buttock masses, arteriography is the most important diagnostic aide. It will indicate when the circulation must be reconstructed and when it is safe to simply ligate an aneurysm.


The production of an unusual tissue reaction in rabbit bowel injected with Crohn's disease homogenates. Recent reports have suggested a transmissible factor in the etiology of Crohn's disease, which had yet to be confirmed. The specificity of the transmission was tested with a disease control of ulcerative colitis as well as normal bowel. Twenty New Zealand White rabbits received inoculum of tissue homogenates from the terminal ileum of normal, ulcerative colitic, and Crohn's disease patients. This inoculum was injected into the wall of the ascending colon and the animals were examined after one year. Changes were noted consistently only in those animals receiving the Crohn's disease inoculum. These changes consisted of thickened bowel wall with increased mucosal folds, thickened mesenteric fat with some creeping, irregular areas of thin colonic mucosa, and hyperplastic mesenteric lymph nodes. The terminal ileum distant from the inoculum site was smooth with atrophic changes only in the Crohn's inoculated group of animals. These animals also had discrete collections of macrophages in colon or sacculus, mucosal and submucosal edema, and chronic inflammation of the colon. However, the characteristic features of Crohn's disease were not reproduced.


Detection of deep vein thrombosis with an automatic electrically calibrated strain gauge plethysmograph. A new strain gauge plethysmography was developed to permit accurate electrical calibration and automatic calculation of limb blood flow from a panel meter. This instrument was used to quantitate maximum venous outflow (MVO) in both limbs of 20 normal volunteers and 387 limbs of 195 patients with clinically suspected leg vein thrombosis. The MVO of normal subjects averaged 45 +/- 18 cc/minute/100 cc of calf tissue (mean +/- 1 SD). In 69 limbs with deep vein thrombosis documented by Doppler ultrasound and/or phlebography, the MVO averaged 17 +/- 13 cc/minute/100 cc, which was significantly less than that of normal limbs (p less than 0.001). Only three of 31 limbs with venous thrombosis above the knee  had MVO above 20 cc/minute/100 cc, the lower limit of normal, for a diagnostic sensitivity of 90%. The specificity of a normal MVO in excluding deep vein thrombosis was 81%, with only a 1% rate of false-negative diagnoses above the knee. This automatic strain gauge plethysmograph has the attribute of providing rapid quantitation of limb venous hemodynamics which facilitates noninvasive diagnosis and follow-up assessment of venous disease.


Demonstration of lymphocyte blastogenesis--inhibiting factors in sera of melanoma patients. The proliferative response of lymphocytes obtained from a healthy volunteer to the mitogens phytohemagglutinin (PHA) and concanavalin A (Con A) was evaluated in the presence of sera from 101 patients with malignant melanoma and 75 normal controls. A significant decrease in blastogenic response was observed in the presence of sera from melanoma patients. Sera from patients with advanced disease were particularly inhibitory, suggesting that the circulating immunosuppressive factors were either tumor derived or tumor induced. Our observation that sera from patients who failed to display a delayed cutaneous hypersensitivity reaction to 2,4-dinitrochlorobenzene (DNCB) are more inhibitory to mitogen stimulation than sera from patients who react to this contact allergen suggests that DNCB skin testing may identify an immunological defect mediated by circulating humoral factors.


Cardiorespiratory and sympathoadrenal responses during weaning from controlled ventilation. Weaning from controlled ventilation was attempted in 20 patients who were ventilated with volume constant ventilators for at least 24 hours before study. Measurement of alveolar to arterial oxygen tension differences on 100% oxygen (Aa DO2 1.0) in patients who failed to wean (nonweaners, n = 10), showed a mean AaDO21.0 at 5 minutes after beginning to wean of 388 +/- 56 mm Hg (SEM), and right-to-left shunt (QS/Qt) of 21% values which were significantly different from control (p less than 0.025) and significantly different from ten patients who weaned (p less than 0.005). Since rises in QS/Qt were not accompanied by increased pulmonary capillary wedge pressure, the increased QS/Qt was most likely due to acute atelectasis and not left ventricular failure. These data suggest that patients who fail an initial period of weaning should be placed on positive end-expiratory pressure during subsequent weaning attempts. Significant increases in cardiac output and atrial PCO2 occurred in both groups. Assessment of urinary catecholamine excretion during weaning suggests that sympathoadrenal stimulation often is intense and usually is greater in those patients who weaned successfully. Increased arterial PCO2 may be the mechanism for sympathoadrenal stimulation and rises in cardiac output (r = 0.39, p less than 0.01) during weaning.


The ascitic leak: a case presentation. Management by paracentesis and saline--albumin reinfusion. Postoperative ascites, particularly if infected, poses a difficult clinical situation for the surgeon. Concomitant use of salt and water restriction and diuretics will control most cases. However, in those patients who do not respond, paracentesis with a peritoneal dialysis cathether together with concomitant infusions, cubic centimeter for cubic centimeter, of saline-albumin or fresh frozen plasma will insure a sufficient intravascular volume to enable adequate renal perfusion, decrease intra-abdominal pressure to allow adequate respiratory mechanics, and decrease potential losses from around drainage tubes. Thus the cirrhotic patient may recover more easily from the insult of the nonhepatic surgical procedure. A case is presented demonstrating this technique.


Peripheral atheromatous embolization following blunt abdominal trauma. A 65-year-old man sustained blunt abdominal trauma in an automobile accident which resulted in severe acute ischemia of the right lower leg and foot. Complete arteriography showed extensive aortoiliac arteriosclerosis and embolic occlusion of the distal right popliteal artery. Prompt embolectomy accomplished limb salvage and confirmed the diagnosis of traumatic artheromatous embolization.


Highly selective vagotomy in the treatment of duodenal ulcer in a teaching hospital. A one-to-three year follow-up relating results to the number of operating surgeons, their surgical experience, and training conditions. In the present series, highly selective vagotomy (HSV) was used in the treatment of duodenal ulcer and the patients were followed up 1 to 3 years after operation. Three months after operation, 57% of the patients had positive insulin tests (early and late positive). Ulcer recurrence rate was approximately 6.5%, whereas 18% of the results were judged to be therapeutic failures. The operations were done during the period of introduction of the method in a general surgical department of a teaching hospital, when the enthusiasm was great and the experience of the individual surgeon with HSV was small. The moderately poor results in this series are thought to be due to too many surgeons operating on a rather limited number of patients. Unrelated to this situation, a statistically significant increase in the frequency of positive insulin tests during the observation period was found, giving an incidence of 80% positive tests 2 years after the operation.


Lymphatic disruption in varicose vein surgery. In order to investigate the possibility of lymphatic disruption occurring during varicose vein surgery, lymphangiography performed by a modification of the Kinmonth technique was done in seven patients before and after standard surgical ablation of primary varicose veins. All seven patients demonstrated marked disruption of lymphatics. Extravasation of lymphangiogram contrast medium at the calf level and at the thigh level precluded demonstration of the groin lymphatics. It is concluded that lymphatic disruption attends varicose vein removal and such lymphatic damage contributes to postoperative leg edema.


Erythrocytes cultured from bone marrow.

Erythrocytes cultured from bone marrow. The long-range objective of this study is in vitro tissue culture of bone marrow stem cells to produce erythroid cells of sufficient volume for clinical transfusion. Bone marrow from dogs and patients was cultured in 29 experiments lasting up to 15 weeks. Peripheral erythroid cells from dogs were cultured in three control experiments. Optimal tissue culture media was NCTC 109 augmented with vitamin B12, erythropoietin (EP), folic acid, and 9% fetal protein in 60 mm glass Petri dishes. Additional media and Step III EP was added at 2 to 4 day intervals. Peripheral erythroid cells in culture all were dead within 4 weeks. Marrow erythroic cells in culture proliferated as demonstrated by (1) Fe59 incorporation into cells during culture, (2) H3 thymidine uptake into cultured cells, (3) microscopic evidence of mitoses, and (4) total erythrocyte concentration in cultures far exceeding that of peripheral culture controls. For as yet unexplained reasons the total mature red blood cell concentration in the culture media remained essentially constant throughout the studies. This is a first step in achieving the ultimate goal of bulk erythrocyte production from tissue culture.


Functional value analysis: a technique for reducing hospital overhead costs. Many administrators feel that the methodology suggested for functional value analysis could beneficially be applied to many aspects of hospital administration beyond overhead functions. Some base their comments on their own experience in applying approaches similar to FVA to non-overhead activities. Others--who have not yet used a similar technique--believe that FVA's discipline in methodology and in-depth participation of hospital personnel could produce results in areas such as radiology, laboratory, and nursing.


An inexpensive microphotometer system for measuring silver grain densities in autoradiographs. An inexpensive microphotometric system is described which will facilitate reading grain-dense areas in autoradiographic material. It is reliable, easy to operate and adaptable to most light microscopes with a dark field condenser. In addition to the microscope, the components include a photodiode, an operational amplifier and a digital mV meter. Data are presented to demonstrate the sensitivity of the system and to illustrate the differential variability between the microphotometer and the counting of grains by eye.


[Primary radiation therapy of sarcoma of the uterus (author's transl)]. We report 24 cases of sarcoma of the corpus uteri treated by sole irradiation. The 5-year-survival-rate was 20,8%. The prognosis seems to be poor in this group treated by sole irradiation. Only inoperable cases of sarcoma of the corpus uteri ought to be treated by radiotherapy alone.


Mutagenicity tests with irradiated food in the mouse. Male and female mice from BALB/c strain received normal food or food irradiated with a mean dose of about 2.85 Mrad of gamma-rays. Three different tests were performed on mice fed for one month with control or irradiated pellets: estimation of prenatal loss and examination of somatic and male germ cells for the presence of chromosome aberrations. The negative results obtained in the three tests demonstrate that ingestion of irradiated food has no mutagenic effects large enough to be detected by the methods which were used.


[Introduction in the problem of the time factor and its therapeutical significance (author's transl)]. Dependencies of biological radiation effects on time distribution of dose may result from a) restitution processes on all levels of effect and b) changes of radiation sensitivity by irradiation itself. In case of fractionated radiation therapy the following mechanisms are important: intercellular recovery, cell renewal, synchronization, reoxygenation and redistribution of cells within the cycle. It has to be proven whether and to what extent the particular processes differ in the radiation reaction of tumours on the side and of normal tissues on the other--so that these differences may be used for the development of optimal fractionation schemes. The Strandqvist concept of dose-time-effect relationship is to be considered as an approximation to complex biological conditions. From recent results of cell kinetic studies and of experimental tumour therapy one may expect that for various tumour types according to their specific growth-characteristics and radiation reactions individual modes of dosage may be developed in future in which the curative dose is lower than expected.


Repair in normal tissues and the possible relevance to radiotherapy. Between each fraction in radiotherapy, there is repair and recovery of both normal and neoplastic tissues. Several different types of repair have been identified. Some relate specifically to the effect of changing the number of fractions and others to the overall treatment time. Each will be discussed and particular attention will be paid to slow repair phenomena which have recently been the subject of much interest.


Reoxygenation of hypoxic tumour cells.

Reoxygenation of hypoxic tumour cells. The present status of our knowledge on the reoxygenation of hypoxic tumour cell during fractionated radiotherapy is reviewed. The phenomenon of reoxygenation does not eliminate the need for studies of hypoxic sensitizers or high LET radiation.


[Foundation of the Ellis-formula (author's transl)]. The Ellis-formula is used in radiation therapy to derive the nominal dose. This nominal dose is an index of effectiveness applicable to different fraction schemes. Its critical value, the standard nominal dose, corresponds to the tolerance of normal tissue. The Ellis-formula is first compared to the earlier equation of Strandqvist. The Strandqvist equation accounts only for the total duration of the irradiation series. In contrast, the dominant factor in the Ellis-formula is the dose per fraction; the total duration is of secondary importance. It is then explained how the so-called TDF-factor is applied to derive the nominal dose for the combination of two partial fractionation series. The usual way to account for an extended interruption in a fractionation schedule is also considered. The common generalozation of the Ellis-formula rests on approximations; it is also restricted to the combination of two partial series. In order to overcome the limitation a new numerical method is presented which provides nominal doses for irregular fractionation schedules. The procedure follows without additional postulates from the basic assumptions underlying the Ellis-formula. It does not apply to continuous irradiation.


Histological changes in the canine stomach following massive electron beam irradiation. The histologic changes induced by irradiation of the stomachs of dogs were examined one hour to nine months after irradiation. The irradiated area of the stomach progressed to ulcer formation by way of hyperemia and erosion; on the other hand, there were simultaneous signs of recovery. Regenerating epithelium appeared during the first week and migrated from the surface adjacent to the ulcer to the center of the ulcer. Subsequently the muscularis mucosae extended, and then the submucous coat was repaired. Regeneration of the nerve fibers around the muscularis mucosae seemed to reach its maximum three weeks after irradiation. These proliferating nerves degenerated with deepening of the radiation ulcer, but they were unexpectedly radioresistant and protrude from the surface of the ulcer into the necrotic surrounding tissues. It is concluded that the effect of irradiation on the alleviation of the pain of stomach cancer is not due to the degeneration of the nerves but to elimination of the stimulation of nerves on account of the radiation effect on the cancer cells themselves.


RBE values of d (16) + Be and d (50) + Be neutrons for chromosome rearrangements induced in mouse spermatogonia. The rate of reciprocal translocations induced in mouse spermatogonia by exposure to X-rays and to neutrons produced by 16 and 50 MeV deuterons has been estimated by scoring multivalent configurations in the descendant spermatocytes. In the X-irradiated group the yield of translocations increases from 2,1 per 100 cells after exposure to 100 rad to 5,7 after exposure to 300 rad. The dose-response relationship shows no statistical departure from linearity. After exposure to 50, 100 or 150 rad of d (16) + Be and d (50) + Be neutrons, the yield of translocations displays a humped curve. Up to this dose the RBE value decreases with absorbed dose and neutron energy.


Effect of alpha-methyldopa and alpha-methyl-m-tyrosine on the amount of noradrenaline in the heart and brain of irradiated rats. Effect of alpha-methyldopa and alpha-methyl-m-tyrosine on the amount of noradrenaline in the heart and brain of rats irradiated with 850 R was investigated. It was established that the application of alpha-methyldopa to the animals irradiated with 650 R caused significant decrease of noradrenaline stores in the heart and brain. Meanwhile, when alpha-methyldopa was applied to the animals irradiated with 850 R, there was no further decreasing of noradrenaline. The different effects may be tentatively explained: in animals irradiated with 650 R the processes of biosynthesis are still going on, while after the dose of 850 R, biosynthesis of catecholamine is badly damaged and the further inhibition of decarboxilase is probably impossible. Alpha-methyl-m-tyrosine caused, also, the strong discharge of noradrenaline storage in the heart and brain of irradiated animals. It is interesting to note there is no significant difference in inhibitory effect on animals irradiated with 650 and 850 R, respectively.


Monoamine oxidase activity in gamma-irradiated rat brains. The short-term effect of gamma-irradiation (single dose, 100 Gy = 10 000 rad) on tth monoamine oxidase activity in the rat brain was investigated. In contrast to other investigations virtually no changes in MAO-activity were found.


Repeat abortion in Denmark: an analysis based on national record linkage. The abortion registration system maintained by the Danish government permits an analysis of abortion incidence by individual. Using computer techniques to sort all the abortion records for the 15-month period from October 1973, when the abortion law was liberalized, through December 1974, it has been possible to determine the rate of repeat abortion and some demographic variables associated with it. Of the women who experienced induced abortion in the period under study, 2.92 percent had more than one abortion. Repeat abortion was found to be more frequent among women aged 20-34 and among women with a greater number of pregnancies, live births, and induced abortions prior to the change in law. A higher rate of repeat abortion was observed in urban areas. The overall rate of repeat abortion is consistent with a high level of contraceptive effectiveness.


Fertility decline in Barbados: some spatial considerations. Despite its small size, Barbados exhibits some striking regional differences in fertility levels, which persisted during a period of major fertility decline in the 1960s. Regression analyses are performed for 28 subregions, using sex ratio, male occupational structure, female education, and female employment for 1960 and 1970 as the independent variables. The spatial influence of the Barbados family planning program is also considered. The author argues that a concentration of family planning programs in areas of greatest accessibility and modernization contributes to spatial variations in fertility.


Successes and problems in family planning administration: experiences in two districts of Kerala, India. The administrative organizations of the Ernakulam and Malappuram Districts' family planning programs during 1970-74 and the ways they dealt with typical problems of program organization are examined. Lack of personnel, poor staff morale, inadequate supplies, and political and religious opposition to various contraceptive methods, especially sterilization, existed to varying degrees in both districts' programs. The Ernakulam experience, involving mass sterilization camps that were part of an overall district development program, documents the effectiveness of a strong central leader. The Malappuram program illustrates, in contrast, the handicaps of poor areas where development programs were just beginning and administrative resources were overtaxed.


Fertility and family planning in Hungary. Hungary's birth rate has been declining fairly steadily since World War II, and Hungarian population policy is aimed at increasing fertility to at least replacement level through social, health, and economic benefits to encourage childbearing. Figures for the mid-1970s indicate that birth rates have been rising. Whether these recorded increases may be permanent is examined through analyses of data on Hungarian fertility since 1900 and through retrospective and prospective surveys of family planning attitudes and practice. Both fertility statistics and surveys of family-size desires document a trend toward the two-child family and a birth rate too low to achieve the desired net reproduction rate of more than one. The surveys also show that family planning has become more prevalent in recent decades, and previously heavy reliance on abortion and traditional contraception is increasingly giving way to use of modern contraceptives.


Family planning attitudes and practices in rural eastern Nigeria. A survey was conducted in August 1974 in 16 Ngwa Igbo villages in the East Central State of Nigeria to determine the attitudes and practices of currently married women with regard to fertility and contraception. The results revealed that 50-60 percent of wives had ever used traditional contraceptives (abstinence, prolonged lactation, and rhythm), although data suggest that some of these methods may have been used for purposes other than contraception. Ever-use of modern contraceptives (pill, IUD, and tubal ligation) was shown to be very low and the desire for many children very strong. Nearly 80 percent of the women interviewed, however, expressed a willingness to attend a family planning clinic if one were accessible to them. This finding suggests that a significant interest in family planning services exists in Ngwa Igbo.


The rural health worker as a family planning provider: a village trial in Iran. The impact of the Kavar Village Health Worker Project on contraceptive knowledge, attitudes, and practice was studied 14 months after health workers were deployed in this pilot project in rural Iran. Results showed that knowledge and use of the pill were significantly higher in the project villages than in control villages, where the pill was supplied by a nonresident rural midwife: 28 percent of married women of reproductive age were using the pill in project villages compared with 15 percent in control villages. The sex of health workers did not appear to affect the proportion of pill acceptors or length of use. Attitudes toward contraceptive use, however, did not vary significantly between project and control villages.


Cow's urine poisoning in Nigeria: cardiorespiratory effects of cow's urine in dogs. "Cow's urine" concoction (CUPR) is a traditional remedy for convulsive seizures in Nigeria. Its administration has been associated with severe poisoning, sometimes with a fatal outcome in Nigerian children. Recently, we showed that several of the components of the concoction are toxic. We have demonstrated in the present study certain cardio-respiratory effects of cow's urine concoction in dogs. On the cardiovascular system, an initial bradycardia followed by tachycardia and a biphasic effect on blood pressue characterized by a fall followed by a rise were demonstrated. Progressive hypotension following repreated administration of CUPR was also shown in all experimental dogs. On the respiratory system, a short period of respiratory arrest and/or respiratory depression, followed by tachyponoea with associated hypoventilation of the lungs, were observed. The possible explanations for the observed cardiorespiratory effects of the concoction were discussed. On the basis of our findings, an hypothesis is advanced for the possible mechanisms of the neurological sequelae and/or death following cow's urine poisoning.


Schistosomiasis mansoni: blockage of cercarial skin penetration by chemical agents: i. naphthoquinones and derivatives. Skin penetration by Schistosoma mansoni cercariae may be blocked by 1,4-and 1,2-naphthoquinones applied topically. Of 23 naphthoquinone derivatives synthesized, 15 afforded almost complete protection when applied in solution to the tails of mice 24 hours before exposure to cercariae. On the basis of present evidence the 5-carbon atom side chain present in naturally occurring lapachol seems to be important for activity, and this is in accord with the previous observation that effective protective agents are liposoluble. Topically applied cercarial penetration inhibitors are presently the only prophylactic agents available for use in the field.


Serological survey for congenital toxoplasmosis among 4,136 pregnant women. A prospective seroepidemiological survey for latent congenital toxoplasmosis was carried out among 4,136 women and 3,787 of their offspring in and around Montreal. The indirect immunofluorescent antibody test was used to titrate specific IgG and IgM antibodies and results were standardized in international units. The prevalence of antibodies was 40-8% for the mothers and 36-4% for the babies. Mean annual seroconversion rate was 0-95%. Thus, 30 women would have been expected to acquire toxoplasmosis during pregnancy: two cases only were observed and the reasons for it are discussed. Four cases of congenital toxoplasmosis were diagnosed serologically (0-1%), none of them showed any signs of illness. Preventive treatment was administered to 12 of 52 pregnant women suspected of a recently acquired infection.


The influence of above-optimal constant temperatures on South African Biomphalaria pfeifferi (Krauss) (Mollusca: Planorbidae). The effects of constant above-optimal temperatures on the hatching, growth, survival, fecundity and development of the ovotestis of Biomphalaria pfeifferi from Komatipoort, South Africa, have been studied and compared with observations reported on B. glabrata. While rates of gametogenesis at 25 degrees C and ambient temperature (mean 22-8 degrees C) were similar, they were slightly accelerated at 27 degreesC. Fecundity and survival at 27 degrees C were considerably reduced and at 29 degrees C hyperthermia was pronounced.


Man-biting species of Chrysops meigen, Culicoides latreille and Simulium latreille in Ethiopia, with discussion of their vector potentialities. Human filariasis and its vectors are little known in Ethiopia. Wuchereia bancrofti is confined to the western lowlands and cannot be the aetiological agent of elephantiasis in the highlands. Onchocerca volvulus is widespread in the south-western highlands. Loa loa and Dipetalonema perstans are reported here for the first time and appear to be uncommon. Studies were conducted in 1973, mostly near Jimma in Kaffa Province, on potential vectors of all but the first of these parasites. Among Simuliidae, the only blackflies of apparent medical importance were S. woodi ethiopiense and a possibly new member of the S. damnosum complex. The former is less seasonal and much less numerous than the latter, but may be more widespread and important along smaller and higher streams. Onchocerca larvae were recovered from "damnosum", but not from the small number (46) of ethiopiense examined. In August, at the height of the rainy season, the biting-rate of ethiopiense at 1,710 m altitude on the Gilgil Ghibe river reached 9.5/man-hour at 10-1100 hours and about 12/man-hour at 14-1600 hours. At the same time and place, the attack of "damnosum" reached a midday climax of about 1,800/man-hour; this peak could be delayed or suppressed by rain. Another possibly anthropophilic blackfly, S. dentulosum, tended to become most common in December afer the rainy season had passed, but proved incompetent to bite man successfully. The only feasible loiasis vector found in Ethiopia was Chrysops streptobalius; however, this tabanid was not closely associated with man. Up to 34/man-day were caught in watermeadows by the Gojeb river (altitude 1,160 m) in October. Man-biting species of Ceratopogonidae in various parts of Ethiopia were Culicoides fulvithorax, C. grahamii, C. kingi and C. milnei. The first two of these were anthropophilic in lowlands, but apparently not so in highlands. C. milnei was extremely abundant biting man highlands. C. milnei was extremely abundant biting man and domestic animals both indoors and outdg cycle was irregular, usually displaying a succession of ill-define nocturnal peaks; sometimes it attacked in daylight. Up to 35,000 C. milnei per trap-night were caught in light traps. Most of the females entering light traps in a stable were already engorged with blood. It seemed  very likely that C. milnei would prove to be of veterinary importance. No firm indication was obtained as to what may transmit D. perstans in Ethiopia.


Metabolism by the rabbit of intravenously administered adenine. A study was made of the metabolism by the rabbit of adenine administered intravenously at a dose of 35 mg/kg with 100 micronCi of 8-14C-adenine. The infused adenine was removed from the blood in two phases, first by diffusion into the tissues and second by metabolic reactions throughout the body. The adenine equilibrated within a few seconds equally between plasma and red blood cells and between them and kidney, liver, duodenum, lung and heart. Diffusion into skeletal muscle was much slower and into brain slowest. The more gradual disappearance of adenine from blood, and from the rest of the body, with a half-life of about 20 minutes and with complete removal by two hours, was predominantly along three pathways, leading to, after four hours: 1) 74 per cent in adenine nucleotide (mostly AMP, ADP, and (ATP); 2) 12 per cent as unchanged adenine in the urine; and 3) 11 per cent as a mixture in almost equal parts of 8-oxyadenine and 2,8-dioxyadenine in the urine. Conversion of adenine to adenine nucleotide, probably by initial reaction with phosphoribosyl pyrophosphate and adenine-phosphoribosyltransferase, was at widely different rates in the organs with duodenum, kidney, liver, and lung high and heart, red blood cell, skeletal muscle and brain relatively low. Sites of formation of the two oxyadenines, probably by action of xanthine oxidase, were not determined.


Formation of oxyadenine metabolites in the rabbit after intravenous administration of adenine. Adenine, 8-oxyadenine, and 2,8-dioxyadenine were analyzed, by Dowex-50 column chromatography, in rabbit urine four hours after IV infusion of the following doses of adenine in mg/kg: 2, 4, 8.75, 17.5, 35, 70, 140 and 210. The average excretion in mole percentage of the dose was: adenine, 11.1; 8-oxyadenine, 6.1; and 2,8-dioxyadenine, 6.2. The percentage of excretion of 8-oxyadenine and of 2,8-dioxyadenine was unrelated to the dose of adenine. At doses of adenine of 35 mg/kg and above more than 80 per cent of the 2,8-dioxyadenine in the urine was in the form of microscopic pale yellow spherical particles. The particulate 2,8-dioxyadenine was found in the kidney in a very small amount at the dose of 70 mg/kg and in much greater quantities at 140 and 210 mg/kg.


Metabolism by man of intravenously administered adenine. A study was made of the metabolism by a human subject of adenine administered intravenously at a dose of 10 mg/kg with 200 micronCi of 8-14C-adenine to learn how similar and different the results might be from those obtained by a much more extensive study by this Laboratory on the rabbit. A rapid initial disappearance of radioactivity from the blood was followed by a slower loss with a half-life of about an hour. The first was probably due to diffusion into the extravascular fluid and the second to metabolism in the tissues. Fifteen per cent of the radioactivity infused was excreted in the urine during the first three hours as unchanged adenine and another 8 per cent was excreted during the first six hours as a mixture, in almost equal parts, of 8-oxyadenine and 2,8-dioxyadenine. Radioactivity in the urine after the second day, starting at 1.5 per cent of the dose per day and declining steadily to 0.5 per cent at three months, was predominantly in uric acid, reflecting turnover of the adenine which had entered body pools of purine nucleotide. Approximately 2 per cent of the injected radioactivity was incorporated into red blood cell AMP, ADP and ATP, each of which, by the second day, had the same specific radioactivity, which then decayed at a rate of 1.3 per cent per day. The results were remarkably similar to those obtained in a previous study on the rabbit. A variety of clinical observations and tests on blood and urine showed no abnormalities attributable to the infusion with adenine.