Grey-scale ultrasonography in the differential diagnosis of jaundice. One hundred fifty patients with cholestatic jaundice were studied prospectively by grey-scale ultrasonography. All patients had a diagnosis established by subsequent biopsy, autopsy, or surgery. Using the presence or absence of a dilated biliary tree as the criterion, the intrahepatic or extrahepatic nature of the jaundice was correctly differentiated in 145 of 150 patients, an accuracy of 97%. All 64 of the patients with intrahepatic jaundice were correctly identified. Five of the 86 remaining patients, each of whom had gallstones, were misdiagnosed. In eighty-two patients (54.7%), the specific etiology was diagnosed. Ultrasound is an accurate method for the evaluation of jaundice and would appear to have a definite value as a screening procedure before proceeding to more invasive studies.


Traumatic popliteal arteriovenous fistula. Diagnostic methods and surgical management. The popliteal vessels rank second only to the external iliac system as the most frequent site of acquired arteriovenous communication. Direct trauma to the popliteal space is by far the most common cause, and surgical intervention is usually required to manage the defect. We present a recent illustrative case following meniscectomy. To our knowledge, the occurrence of an arteriovenous fistula complicating knee surgery has not been reported previously. This case outlines the potential value of B-mode ultrasound in diagnosis and the use of intraoperative angiography in assessing the adequacy of primary vascular reconstruction. Earlier experience of this vascular abnormality--six additional cases since 1941--is reviewed.


Internal retrovesical hernia producing intestinal obstruction. Report of a case. A patient with clinical signs of complete intestinal obstruction was found at celiotomy to have a loop of small intestine caught in the narrow opening of a defect located in the transverse peritoneal fold of the urinary bladder and extending into the retrovesical space. This report aims at bringing attention to internal retrovesical hernias, an entity scarcely mentioned in the literature, as a possible cause of small bowel obstruction.


Saccular atherosclerotic aneurysm of the superior mesenteric artery. We report on the successful surgical resection of an aneurysm of the superior mesenteric artery. The saccular nature of the aneurysm and evidence of celiac axis occlusion in this patient posed an additional challenge in the successful surgical treatment.


Diagnostic, prognostic, and therapeutic nerve blocks. During the past three quarters of a century, nerve blocks have been used with varying success as a primary treatment technique for patients with acute and chronic pain. However, practicing dolorologists soon realized that, in certain individuals, anesthetic blocking of noxious, peripheral afferent sensations did not always amelliorate pain complaints and at times even exaggerated them. The recent advent of the multidisciplinary approach to the management of pain, including neurosurgical procedures, new drugs, electrical stimulation and psychosocial intervention, has helped to clarify the indications for, limitations of, and disadvantages of the use of nerve blocks. The purpose of this article is to place nerve blocks in proper perspective and to define their role among the many methods currently available for the evaluation and control of severe pain.


Neurosurgical control of chronic pain.

Neurosurgical control of chronic pain. The neurosurgeon can play a significant role in the management of chronic pain. This potential is all to often unrealized or distorted by a lack of knowledge about patients who are suffering from chronic pain. Patient selection is the most important determinant of successful surgical therapy. Patients with chronic pain due to a neoplasm should be offered prompt, definitive neurosurgical intervention. Neurosurgical therapy is less likely to be successful if the pain is secondary to benign disease; tic douloureux is an exception to this rule. If chronic pain behavior is not primarily due to noxious peripheral input, surgery is unlikely to yield any long-term benefit. Augmentation of input by skin stimulation or electrical stimulation of various regions in the peripheral and central nervous system may become important therapeutic procedures for the neurosurgeon.


Obturator hernia: an elusive diagnosis.

Obturator hernia: an elusive diagnosis. Obturator hernia is an uncommon problem that occurs predominantly in elderly, debilitated women. The diagnosis should be suspected in such patients who have evidence of small bowel obstruction, often initially intermittent, and who complain of pain along the anteromedial aspect of the thigh. We present experience with three patients that characterizes the difficulties in diagnosis and treatment. Most patients require resection of the incarcerated bowel. Mortality is variable and is related to the condition of the patient.


Mediastinal masses in infants and children. In a group of 93 pediatric patients with mediastinal masses, three quarters of them were diagnosed because they were symptomatic. Approximately one half of the masses were malignant, and of neurogenic or lymphomatous origin. Neurogenic tumors predominated before the age of 4 years, while lymphomas were most common beyond age 4. Two thirds of the malignancies were potentially curable by surgery, irradiation, and chemotherapy; 54% of the patients were salvaged. Enteric duplications, ganglioneuromas, bronchogenic cysts, hemangiolymphangiomas, thymic cyst, and teratomas were the most frequently occurring benign masses. Simple excision was uniformly effective in these lesions.


The profunda femoris-popliteal artery bypass. The profunda femoris artery can be used for the origin of a femoropopliteal bypass in cases of previous aorto femoral bypass graft, short saphenous vein, and other less common conditions that render the common femoral artery unsuitable for proximal anastomosis. Fourteen profunda-popliteal bypass procedures were performed in 12 patients between 1973 and 1976. The indications for surgery were incapacitating claudication in seven, and rest pain or tissue necrosis in five patients. Electromagnetic flow measurements at operation in ten patients indicated a mean graft blood flow of 146 +/- 51 ml/min. The mean Doppler ankle/wrist pressure ratio improved from 0.48 +/- 0.11 preoperatively to 0.87 +/- 0.14 postoperatively, while the plethysmographic mean pulse volume increased from 1.1 +/- 0.6 microliter to 2.4 +/- 0.4 microliter. Thirteen of the 14 grafts remain patient at one to three years' follow-up. The profunda-popiteal bypass is an effective alternative to standard femoropopliteal bypass in cases where the common femoral artery is not available for proximal graft anastomosis.


Treatment of carcinoma of the sigmoid colon and upper rectum. A comparison of local segmental resection and left hemicolectomy. We report a retrospective study of 107 cases of carcinoma of the sigmoid colon and upper rectum treated for primary cure at the University of California at Los Angeles Hospital between 1955 and 1970. Excluded from this analysis were patients treated by abdominoperineal resection, local excision, fulguration, or abdominoperineal pull-through procedures. Ninety-one patients were treated by local segmental resection and 16 by left hemicolectomy. Both groups were similar in regard to patient age and general health, lesion size, location, and pathological Duke's classification. Five-year survival was 70.3% after local segmental resection and 56.3% after left hemicolectomy. Hospital mortality was 1% after the former and 6.2% after the latter. Rate of recurrence after local segmental resection was 41% of that seen after left hemicolectomy, while complications were one-third as great. The present results after local segmental resection are comparable to the results reported in the literature when hemicolectomy was the procedure used. The data presented suggest that local segmental resection is an effective cancer operation for carcinoma of the sigmoid and upper rectum, and is fraught with a lesser morbidity and mortality than a radical left hemicolectomy.


Ipsilateral blindness: a complication of carotid endarterectomy. We report on three patients in whom ipsilateral blindness developed following carotid endarterectomy. Fundoscopic examination of the retina documented ischemia and the visual field defects were permanent. In one patient, the internal carotid artery was patent and thought to be the conduit for embolization to the eye. Two patients had chronic occlusion of the internal carotid artery, and blindness resulted from atheromatous emboli to the eye through the external carotid artery in one and from postoperative thrombosis of the external cartoid artery in the other. Our experience calls attention to this infrequently reported complication of carotid endarterectomy and emphasizes the importance of the external carotid artery, especially when the internal carotid artery is occluded.


Control of hepatic bleeding with microfibrillar collagen. Microfibrillar (Avitene) is a new absorbable topical hemostatic agent whose mechanism of action is platelet entrapment and activation of platelet clotting factors. It adheres to moist tissue surfaces to form a firm, flexible hemostatic coagulum. It has been used clinically in 36 patients with hepatic bleeding of diverse etiology, including bleeding from the gallbladder fossa, lacerations, resectional surfaces, biopsy sites, capsular denudations, and hepatic tumors. Although not intended to control major hemorrhage were major vessel ligation or resection is properly indicated, its topical use for diffuse small vessel bleeding may be life-saving. It is exceptionally useful in such conditions as cirrhosis and in thrombocytopenic or thrombasthenic coagulopathies. One treatment failure out of 36 occurred.


Noninvasive methods for evaluation of extracranial cerebrovascular disease. A comparison. Sixty-five patients with clinical evidence of carotid occlusive disease were evaluated by the Doppler ophthalamic test, ophthalmodynamography, and oculopneumoplethysmography prior to angiography. Clinical assessment was accurate 68% of the time, with 32% of patients having no arteriographic evidence of significant disease. The sensitivity of the noninvasive tests was dependent on the extent of the carotid stenosis. When the extent was greater than 60% of the cross-sectional diameter, the Doppler ophthalmic test was accurate 54% of the time; the ophthalmodynamography test, 61% of the time; and the oculopneumoplethysmographic test, 97% of the time. In lesions encompassing 50% to 60% of the vessel diameter, the Doppler ophthalmic test was accurate 15% of the time; the ophthalmodynamography test, 17% of the time; and the oculopneumoplethysmographic test, 10% of the time. With less than 50% stenosis, none of the noninvasive tests detected atherosclerotic lesions. Although many diseased vessels were missed, the low incidence of false-positive tests enhanced the usefulness of these methods in augmenting the accuracy of clinical evaluation.


Subphrenic abscess. The new epidemiology. Recent changes in the etiology, topography, and bacteriology of subphrenic abscess are identified in 93 patients treated between 1955 and 1975. Gastric and biliary tract operation account for 52% of abscesses. Appendicitis is now responsible for only 8% of subphrenic infections, in contrast with the 40% of previous reports. Colonic surgery (19%) and trauma (8%) are increasing in importance. Left-sided abscesses occur in 40%, and multiple space abscesses in 20% of patients. The bacterial flora consists of multiple strains of aerobic and anaerobic organisms. Since 1970, the aerobes have been Escherichia coli (96%), Klebsiella (21%), and Proteus (38%); anaerobes include Bacteroides (83%), cocci (50%), and clostridia (50%). The mean interval from the preceding operation until drainage of the subphrenic abscess was 5.5 weeks. Overall mortality was 31%, with higher mortalities for multiple space involvement (39%) and for abscesses developing after emergency procedures (35%). Recommendations based on this data are: (1) antibiotics selected should be effective against anaerobes, and (2) transperitoneal drainage is frequently indicated because of the increase in multiple abscesses and the need to evaluate the first operation.


Staging laparotomy for Hodgkin's disease in children. Evaluation of the technique. The evaluation of a technique of laparotomy for the staging of Hodgkin's disease in childhood, including 52 operative procedures, is reviewed. A standard protocol, including splenectomy, multiple hepatic and bone marrow biopsies, and the routine sampling of at least six designated lymph node groups, was employed. It was demonstrated that the surgeon is unable to identify Hodgkin's disease by gross inspection and that the biopsy of node groups previously not included in routine laparotomy studies, ie, mesenteric and porta hepatis nodes is essential to staging in childhood. Stage was altered from stages I and II to stages III and IV in 35% of the patients. The incidence of abdominal recurrence following a negative laparotomy was 7%, and the incidence of post-splenectomy hyperacute infection was 4.5%. This study included minimal use of the lymphangiogram (33%), which accounted for the relatively larger group of patients in clinical stages I and II.


Bile leakage following percutaneous transhepatic cholangiography with the Chiba needle. Percutaneous transhepatic cholangiography (PTC) for jaundice of undetermined etiology was performed with the Chiba needle in 30 patients. Successful visualization of the biliary ductal system was accomplished in 26 patients (86.7%); two of six patients (33.3%) with normal biliary systems had ducts visualized, and the ducts were visualized in the 24 patients (100%) with obstruction. Bile leakage of 50 to 500 ml (average, 200 ml) was observed at laparotomy or autopsy in 12 patients (40%), nine (30%) of whom had symptoms of peritonitis. Six (20%) of these were transient and three (10%) progressed to an acute abdomen. Bacteremia occurred in seven patients (23.3%), in three (10%) it progressed to septic shock, with one death (3.3%). There were no complications in patients with nonobstructed ducts. This study suggests that PTC with the Chiba needle has little advantage over the larger sheathed needles, and surgical standby is indicated in suspected cases of obstructive jaundice.


'Routine' liver biopsy in upper abdominal surgery. Liver biopsy was done at the time of operation in 125 consecutive upper abdominal procedures to assess the incidence of unsuspected or undiagnosed hepatic abnormalities. Specifically excluded were hepatic lesions unexpectedly identified at laparotomy. Sixty-seven percent of the liver biopsy specimens were abnormal, the most frequent findings being fatty metamorphosis, cholestasis, triaditis, fibrosis, inflammatory infiltrate, cholangitis, cirrhosis, and hepatitis. The most frequent operation performed was cholecystectomy. In 63 patients with chronic cholecystitis, there was a 51% incidence of abnormal liver histology, while in nine patients with acute cholecystitis, the incidence was 78%. In 83% of all other operations, abnormal liver biopsy specimens were identified. Bile leakage, hemorrhage, and infection did not occur in this series, despite inclusion of patients with severe biliary obstruction, abnormal clotting factors, and intra-abdominal sepsis. New techniques of histochemical enzyme analysis and electron microscopy are expected to enhance the clinical correlation of occult hepatic lesions. We conclude that liver biopsy in a safe, informative adjunct to all upper abdominal procedures.


Popliteal artery injury following fracture or dislocation at the knee. Diagnosis and management. Fracture dislocations or dislocations of the knee can produce an arterial injury that may be difficult to evaluate clinically. Aggressive diagnosis and treatment can produce satisfactory results in both vascular and orthopedic situations if performed early after the injury. Five cases of popliteal arterial injury were seen from April 1974 to August 1976. Three cases were following posterior knee dislocation, one was a femoral fracture displacement, and one was a rotary tibiofibular displacement. Four of the patients had complete popliteal artery transection and one had intramural hematoma and spasm. Initial diagnosis of severe arterial injury, although suspicious on clinical grounds, was not conclusive. Use of a Doppler flowmeter and arteriography was essential for the diagnosis of arterial injury. Peroneal nerve injury was present in two of five patients. Vascular surgery was successful in all cases. Skeletal instability was corrected at the time of vascular exploration, usually through same incision. Leg compartment edema or hematoma was common, but responded to fasciotomy in all cases. Vein graft reconstruction was preferred to direct repair because of wall contusion and the need for additional vessel length over edematous and contused tissue. Acceptable knee stability was obtained from initial repair in all cases.


Peripheral atheroembolism: an enigma.

Peripheral atheroembolism: an enigma. Fifteen patients with peripheral atheroembolism were studied and followed up for from one to three years. Clinical recognition of this condition is often masked by its elusive presentation. Foot pain may be the very earliest symptom. Transient presentation is an important feature. Eventually, gangrene develops in the toes. Ankle pulses are present on physical examinations. Both aortography showing proximal ulcerative plaques and digital arteriograms revealing the sharp cutoff pattern of an arterial embolus provide diagnostic confirmation. The results of treatment were satisfactory in all instances following aortoiliac endarterectomy or Dacron graft interposition. In five patients wiht gangrenous changes, toe amputation was necessary.


Adenocarcinoma in the columnar-lined (Barrett) esophagus. Case report and review of the literature. As of 1975, forty-nine cases of adenocarcinoma arising in the columnar-lined lower esophagus (CLLE) were reported in the literature. We add three more cases, including the youngest male to our knowledge. All survived esophagogastrectomy and radiotherapy, but each had metastatic disease and a guarded prognosis. Review of the literature revealed a male/female ratio of 3:1 for this disorder with a mean age for men of 53 years, less than that for women, (61 women). Columnar-lined lower esophagus is seen in up to 11% of patients with reflux esophagitis and probably does not regress, once present. Adenocarcinoma later develops in 2.4% to 8.5%. The CLLE is not rare and should be followed up as carefully as any other premalignant lesion.


[Age and features of atherosclerosis and primary calcinosis of the tunica media of the major arteries of the pelvis and lower extremities (morphometric study)]. Morphometrical studies were done on 432 longitudinally dissected arteries of the pelvis and lower extremities from 216 fatalities in the age of over 40 years (151 men, 65 women). The atherosclerotic process was found to develop and progress most intensively in the common iliac and popliteal arteries, the third place in the average area of the intima involvement belonging to the femoral artery, while the external iliac and posterior tibial arteries were less affected. In one third of the arteries examined the primary calcinosis of tunica media was found. An inverse relationship between the area of atherosclerotic changes in the intima and the area of primary calcinosis in the media of the vessels was demonstrated. In the lower extremities arteries the fibrinoplastic type of morphogenesis of atherosclerosis was predominant and "complicated" lesions were relatively rare. These data may be the basis for specification of the morphological diagnosis of atherosclerosis and for selection of rational surgical treatment.


[Myocardial ultrastructure in experimental myxedema]. Total thyroidectomy was performed in 18 rabbits and the material obtained analysed. Nine rabbits with pseudo thyroidectomy served as controls. Basal metabolism, levels of cholesterol, lipoproteins, phospholipids, and ionic blood composition were studied in the experimental animals before the operation and during various periods following the operation; the ultrastructure of the myocardium in the course of myxedema was also studied. Drastic changes in the contractile structures, which apparently were a substrate of cardiac weakeness in this pathologic state, are described.


[Dialectic of the interrelationship between structure and function in biology and medicine]. The paper deals with some aspects of the dialectics of structure and function relationships in biological objects normally and pathologically. Idealistic and metaphysical concepts of the structure-function relationships (morphological idealism, holism, physiological idealism, functionalism) are critisized, and historical premises of these concepts are characterized. The principle of indissoluble unity and interconnection of changes in structure and function is emphasized, while the thesis of the primacy of function in the shaping of the form and the concept of functional diseases are rejected. Much attention is paid to the methodological principles of the study of structure and function based on the systemic approach to the investigation of biological objects from the point of view of structural levels and integratism. The groundlessness of the principles of reductionism and organicism in the solution of this problem is indicated. The connection of the concepts of structure and function with categories and laws of materialistic dialectics is dwelt on.


[Complex laboratory-morphologic study of allergic joint inflammation in rabbits]. During the period of sensitization and in the dynamics of the development of the articular allergic inflammation in rabbits there occured regular slowing down of the properdin activity, decrease in the compliment titres and increase in the blood plasma magnesium content. An increased liability of the basophilic leukocytes to damage and an elevated activity of acid phosphotase in lymphocytes of the peripheral blood were also noted. In the acute period of inflammation the synovial sheaths were found to be diffusibly infiltrated by the lymphoid-histocytic and plasma cells. Proliferation of synoviocytes and the appearance therein of the PAS-positive granules were observed. Weakening of the myocardial staining with Schiff's reagent was established. The processes of disorganization of the connective tissue in a joint and in the heart were closely conjugated and manifested themselves in mucoid and fibrinoid swelling, and changes in the PAS-reaction. Dissociation of the natural resistance of the organism was revealed: mobilization of the processes of immunogenesis and inhibition of the nonspecific link of protection. Decrease in the immunological reactivity was associated with formation of hypersensitivity of delayed type. Cosequently, arthritis developed in rabbits on the immune basis.


[Electron-histochemical identification and differentiation of the chemical composition of the supramembranous layer of kidney cells]. The supramembrane layer of cells in various parts of renal nephron in rats and dogs was determined with the help of colloid ferrum. The study of the chemical composition of the supramembrane layer of podocytes, epithelium of the distal tubules, thin segment, collecting tubules and endothelia of blood capillaries revealed in it the presence of carboxyl groups referring to sialic acid, the latter being bound with protein, not with lipids.


[Epithelial formula and relationship between the chief and parietal cells of fundal gastric glands in gastric and duodenal ulcer]. The fundic glands of 143 stomachs resected in connection with peptic ulcer, including those localized in the stomach (70 observations) and in the duodenum (73 observations) were studied. The number of epithelial cells in the longitudinal section of the fundic gland in ulcer of the stomach was most often in the range of 100 to 149 (in 37 cases of 70), in duodenal ulcer--150 to 199 (in 36 observations of 73). In patients with duodenal ulcer, as distinct from those with gastric ulcer, the epithelial formula of the fundic gland was characterized by a lower content of non-differentiated and mucous neck cells and by a greater number of chief cells, the hyperpepsinogenic cellular shift (a rise of the content of chief cells up to 50% and more) in them was observed 4-5 times more often. The ratio index of chief and parietal cells in gastric ulcer (in 75.7% of cases) was usually in the range of 1--1.9 (tentative norm) and only in some cases (in 18.6% of observations) it was higher. In duodenal ulcer an elevated index was observed in 54.8% of cases.


[Morphologic characteristics of a vagina created from the skin of the labia minora and majora]. The present work is dedicated to clinico-morphological study of artificial vagina formed by means of plastic surgery from the skin of the labia majora and minora in 65 patients with aplasia of the vagina. Histological investigation of biopsy material carried out in 30 patients from 12 days to 10 years following the operation showed that the skin taken from the region of the exterior genitalia and placed under conditions of artificial vagina underwent changes. A year after operation and later it acquired characteristics of the mucosa membrane of the natural vagina: the hair ceased to grow, sebaceous and sudoriferous glands atrophied. The vagina created by the technique applied proved to be wholesome, both anatomically and functionally.


Morphological changes of motor units in Duchenne's muscular dystrophy. We studied the intramuscular motor innervation in 19 muscle biopsy specimens from boys with Duchenne's muscular dystrophy and the fiber-type pattern was analyzed in nine biopsy specimens. The main change in motor innervation was a longitudinal displacement of motor end plates that could reach 10 mm and the presence of numerous unemployed axons ending freely within connective tissue. There was no increased collateral ramification of subterminal axons and the terminal innervation ratio was normal. The fiber-type pattern was characterized by a random variation of fiber diameters, a slight predominance of type 1 fibers, and an impared type differentiation in many fibers. The morphological data do not support the possibility of denervation and collateral reinnervation that could be related to the late component potentials found in Duchenne's muscular dystrophy.


Effects of aging on visual evoked responses. The effects of aging of visual evoked responses (VER) and critical frequency of photic driving (CFPD) was studied in 74 volunteers aged 18 to 79. The amplitude of VER to pattern reversal stimulation did not vary with sex or age. The latencies of the first major negative and of the first major positive defection of the VER were significantly delayed (P less than .001) with advancing age. This increase of latency probably reflects a slowing of conduction velocity in the optic nerve or optic pathways or both. CFPD, defined as the highest frequency of photic driving response expressed in flashes per second, showed an inverse correlation, decreasing with age in older subjects. Critical frequency of photic driving is the electrophysiological counterpart of critical flicker fusion, which is known to decrease with advancing age. These data support the concept that aging influences the functions of specialized sensory systems.


The spectrum of mild X-linked recessive muscular dystrophy. We present 19 patients from 12 families with mild (Becker) X-linked recessive dystrophy and compare them with previously described cases. Features in common in the majority of patients include onset after the age of 7 years, walking beyond the age of 20 to 30 years, mild hypertrophy of the calves, mild joint contractures, and high arched feet. Pshychometric tests, EEGs, and ECGs were usually normal. Muscle biopsy specimens showed a combination of features, some more characteristic of severe (Duchenne) X-linked dystrophy and others more commonly seen in limb girdle dystrophy. Although there was some variation in the severity between different families, within any one kindred, the clinical picture was quite similar.


Evaluation of recent cerebral infarction by computerized tomography. Twenty patients with cerebral infarction were observed with serial computerized tomographic (CT) scans. Seventy percent of those infarctions showed a mass effect that had disappeared in all patients by the eighth week after the ictus. In 63%, there was enhancement after contrast infusion, with a definite temporal relationship to the day of onset of the neurological deficit. Twenty percent of the patients initially had normal CT scans that became abnormal weeks after the stroke. Radionuclide scans were positive in the patients who showed contrast enhancement, and the area of abnormal uptake correlated well with the area of enhancement. The timing of the performance of the CT scan in relation to the onset of neurological deficit is an important factor to consider when evaluating the stroke syndrome with CT.


A study of confabulation.

A study of confabulation. Confabulation consequent to organic amnesia is a well-described clinical finding. A number of plausible theories of confabulation have been proposed, but the various claims and counterclaims have not been systematically tested. A standardized test battery that included four different kinds of questions plus measures of suggestibility and the tendency to utilize external cues was administered to ten amnesic patients who demonstrated varying degrees of confabulation. One additional patient, whose clinical condition changed dramatically during his hospital course, received the battery on a number of occasions. Differences among patients were found in overall performance, degree of confabulation, and ability to use cues. Hypothesized relationships between confabulation and suggestibility, degree of memory disorder, and degree of disorientation were not confirmed. However, confabulation proved to be strongly related to the inability to withhold answers, to monitor one's own responses and to provide verbal self-corrections. These results suggest a tentative model of the process of confabulation as well as a number of useful clinical signs indicationg recovery from amnesia.


Three-generation pedigree of a Möbius syndrome variant with chromosome translocation. We report the clinical and cytogenetic data on seven members of a family, spaning three generations, who showed congenital facial diplegia and finger contractures. Each affected member showed an identical chromosome abnormality, reciprocal translocation between chromosome 1 and 13. The concurrence of the clinical and cytogenetic defect in this family suggests a direct and possibly etiologic relationship.


Bilateral intracranial arterial aneurysms with a persistent trigeminal artery. A 62-year-old hypertensive woman had bilateral intracranial arterial aneurysms associated with persistent trigeminal artery. The presenting symptom of this patient was painless ophthalmoplegia. We review embryologic development of the circle of Willis as an explanation for the occurence of the trigeminal artery. We also discuss the high incidence of associated vascular malformations with these vessels.


Unilateral asterixis associated with a mesencephalic syndrome. Unilateral asterixis due to a focal brain lesion is a rare occurrence. Acute asterixis restricted to the left upper extremity appeared in a patient in association with signs of acute midbrain dysfunction, without changes in mental status or in the EEG, and in the absence of metabolic or toxic disturbance. Electromyography disclosed features typical of asterixis due to metabolic causes.


Early visual field disturbances in glaucoma. Twenty-two eyes of 22 patients with initially normaly visual fields developed glaucomatous field defects. In 13 of these, the development of the definitive field defect was preceded by a localized minor disturbance in the area where the defect appeared subsequently. In a control group of 22 ocular hypertensives without field defects, six eyes had localized disturbances similar to those that preceded the field defects in the study group. This type of minor localized disturbance may represent an early glaucomatous visual change detectable before the appearance of definitive scotomas.


Visual field changes in ocular hypertension. A computer-based analysis. A minicomputer system has been developed to digitize and store visual field data. In 110 cortiocosteroid-nonresponding subjects aged 10 to 75, the area of the i4e and i2e isopters and of the blind spot changed linearly as a function of age. Within this population the same visual field parameters were randomly distributed with respect to intraocular pressure. In 32 cortiocosteroid responders (increase in intraocular pressure to over 31 mm Hg after topical administration of corticosteroids) with normal visual fields, the central visual field area (i2e isopter) was reduced as a nonlinear function of IOP. Increases in IOP in excess of 8 mm Hg were required to produce significant mean reductions in central visual field area.


Untreated ocular hypertension. A long-term prospective study. A prospective study was designed to determine the course of ocular hypertension without visual field loss if untreated and to estimate the value of various clinical findings in prediction the course of ocular hypertension. Seventy-five patients with intraocular pressure greater than 21 mm Hg but without demonstrable visual field defects were followed up without glaucoma therapy for a minimum of nine years. While under observation, seven of 75 ocular hypertensives developed typical glaucomatous visual field defects. Both the sensitivity and the specificity of each clinical finding in the individuals who later developed visual field defects were determined, and none of the clinical findings was found to be a good predictive indicator.


Retinal stroke. Is the patient at risk?

Retinal stroke. Is the patient at risk? A follow-up study was performed to determine the general prognosis for health and life in 86 patients with retinal artery occlusion or ophthalmoscopically observed retinal cholesterol emboli, not subjected to surgery. Survivorship rates and incidence of subsequent cerebrovascular disease were calculated and compared to expected survivorship rate of an age-and sex-matched population. Results were as follows: the patient group with retinal stroke as a whole showed a statistically significant diminished survivorship rate from the third year onward; patients with retinal occlusions without visible emboli had a survivorship rate comparable to the matched control; but patients with visible emboli demonstrated a strikingly diminished survivorship rate. In the study group, the combined time corrected annual stroke mortality was 1,695 per 100,000 (four to five times greater than expected), but the largest single cause of death was cardiovascular disease.


Familial foveal retinoschisis.

Familial foveal retinoschisis. Three young women, offspring of a nonconsanguineous marriage of normal parents, manifested mild visual loss associated with a bilateral foveal dystrophy that resembled the macular involvement in juvenile sex-linked retinoschisis. Electrophysiologic and psychophysiologic tests showed less severe involvement than the gonosomal equivalent. An autosomal recessive inheritance is proposed.


Arterial vascular anomalies of the retina. The incidence of nonaneurysmal congenital anomalies of the retinal arteries was determined by ophthalmoscopic examination of the eyes of 2,100 consecutive healthy individuals whose ages ranged from 6 to 68 years. Unusual anomalies were triple branching, anomalous course, arteriolar-arterial crossing, unusual tortuosity, prepapillary loops, aberrant macular arteries, unusual supply of the optic disc, presumed total ciliary arterial supply of the retina, anomalous relationship with the central retinal vein at the optic disc, and pseudoaneurysm of a major retinal artery. Cilioretinal arteries are the commonest of the congenital vascular anomalies of the retina.


Retinal detachments after intraocular lens implants. Intraocular lenses are a challenge to the retina surgeon. Forty-three eyes with pseudophakia and retinal detachment were examined. Intracapsular and extracapsular cataract extractions had been performed, and different types of lenses had been implanted. The single most important factor for the successful repair of these pseudophakic detachments was visual access to the retina.


Simultaneous recording of electroretinogram and visual evoked response. Focal stimulation under direct observation. A system has been tested that allows simultaneous recording of the retinal response (electroretinogram [ERG]) and the occipital response (visual evoked response [VER]) with focal photic stimulation of the retina under direct observation of the fundus. A helium-neon gas laser is used as a stimulus source. The laser is chopped either by a pen motor or a rotating disc. The laser is attached to a biomicroscope through which the examiner can observe the fundus of the subject during the entire recording session. The optically clear contact lens is made with a flat surface that neutralizes refraction due to the cornea, thereby allowing fundus observation by microscope. Two metal wires mounted inside and outside of the lens serve as the electrode for the ERG. Graticules consisting of concentric circles and radial lines are projected onto the subject's fundus, providing a pattern that the examiner can use to determine the exact location to be stimulated in the fundus. With proper adjustment of stimulus and background illumination, local ERG and VER can be recorded simultaneously by stimulating the macula.


Clinicopathologic correlations in diabetic retinopathy. II. Clinical and histologic appearances of retinal capillary microaneurysms. One eye of a 21-year-old patient with proliferative diabetic retinopathy was available for clinicopathologic correlation. The fluorescent spots in a fluorescein angiogram were correlated with the changes in color fundus photographs and with the corresponding histologic findings in a trypsin digest preparation of the retina. A round, regular fluorescent spot was the most reliable diagnostic indicator of retinal capillary microaneurysms, although some microaneurysms appeared as irregular fluorescent spots, tiny fluorescent spots, or dark silhouettes with or without fluorescent halos. Very large fluorescent spots correlated with very large irregular pouches that may represent intraretinal neovascularization. Fluorescein angiography was considerably more sensitive than color fundus photography for the detection of retinal capillary microaneurysms.


Deep ocular socket reconstruction.

Deep ocular socket reconstruction. A technique to reconstruct totally contracted sockets forms spacious, deep ocular fornices to accommodate ocular prostheses. Fixation of the midperiphery of mucous-membrane-lined, custommade conformers to the superior and inferior orbital rims secures the posterior periphery of the conformer deep in the orbit. The method restores the normal anatomy of the ocular fornices that not only extends to the orbital rims but also penetrates deeply into the orbit along its roof and floor. The procedure contrasts with conventional, frequently unsuccessful methods of socket reconstruction that form fornices only to the superior and inferior orbital rims without extending posteriorly into the orbit. Using this technique, we reconstructed deep, spacious sockets in five patients with serious socket contracture, allowing the patients to retain cosmetically acceptable artificial eyes. The principles advocated apply to all contracted sockets.


Margins of safety in lateral orbitotomy. Five adult cadaver half skulls were used to study the bone cuts of the lateral orbital wall in performing the lateral orbitotomy. Measurements were taken of the anterior vertical opening, the anteroposterior opening, and the distance to the middle cranial fossa. The vertical opening at the anterior aspect of the lateral orbital wall ranged from 18 to 22 mm. The anteroposterior exposure averaged 18 mm when the thick and thin portions of the bone were removed. The distance from the anterior rim to the middle cranial fossa averaged 31 mm on both the superior and inferior cuts. Hence a distance of approximately 12 to 13 mm separated the posterior aspect of the orbitotomy from the middle cranial fossa.


An improved method of fitting resultant prism in treatment of two-axis strabismus. A new chart determines resultant prism power and angle when correction of combined horizontal and vertical deviation with a single prism, set at an angle intermediate between horizontal and vertical, is desired. The chart is based on a derivation so weighted as never to permit a vertical error greater than one tenth as large as the associated horizontal error, with use of commercially available sizes of plastic Fresnel-type prisms. This weighting takes into account differences in horizontal and vertical fusional reserves. A compass rose facilitates proper alignment of the prisms.


Oblique saccadic eye movements. Independence of horizontal and vertical channels. Horizontal and vertical components of oblique saccadic eye movements are dynamically independent. That is, they have independent dynamic trajectories determined by either the presence, or the absence, as well as the magnitudes of dynamic overshoot, glissades, overlapping saccades, and closely spaced saccades. Temporally, oblique movements manifest varying degrees of independence, for the two components can begin and end either together or separately. Purely horizontal saccades (ie, between two points on a horizontal line) usually show crosstalk demonstrated by extraneous, transient, vertical components. Therefore, saccades are very seldom linear or straight; the trajectories are usually curved.


New insights in the human orbital connective tissue. Result of a new anatomical approach. Exenteration and dissection of the collapsed specimen has so far been standard procedure in the anatomic study of the orbital contents. If, as in surgery, the orbit is approached through the palpebral aperture and its connective tissue is kept extended in the framework of the oribital walls, hitherto unrecognized septa of connective tissue are found, containing vessels, nerves, and smooth muscular tissue. No anatomic evidence was found for the existence of a common muscle sheath behind the globe, subdividing the orbit into central and peripheral surgical spaces. The study of serial sections of complete orbits shows a definite structural organization and constant pattern of this connective tissue system. The relations of the eye muscles and the eyeball with these connective tissue structures, the periorbit and the enclosed fat cushions, are of interest with reference to normal motions of the globe.


Simultaneous bilateral fluorescein angiography. Two fundus cameras were used in the development of a setup for bilateral fluorescein angiography. The indications for this method are listed and examples of simultaneous fluoroangiograms are given. This technique allows the simultaneous study of hemodynamics in the carotid artery, the study of intraocular and anterior eye segment circulatory disturbances, and it is time-saving in bilateral pathology.


[Etiopathogenesis of loosening after total hip replacement (author's transl)]. We analyzed 30 cases of loosening of different hip-totalendoprotheses (Weber-Huggler, Müller-Charnley, McKee-Ferrar and Brunswick), intraoperative known as aseptic loosening. Especially is shown that also by those protheses with a part of polyäthylen there is the same histological picture as by those protheses of Weber-Huggler with the head of polyester: "the aggressive Granuloma". There is only a gradually difference and the "maligne Osteolysis" was not so excessive.


[Treatment of Smith fractures (author's transl)]. A full description of the different types of Smith fractures following Thomas classification is given, together with the guidelines of treatment of each type. Conservative treatment is usually sufficient for types I and III, provided that reduction is anatomic and stable. The indication for internal fixation is given for all type II and unstable type III fractures. An exact description of the volar buttressing technique with the AO-T-plate is presented.


[The importance of the radiological angle between talus and calcaneus in patients with congenital clubfoot (author's transl)]. A reduction of the angle between the longitudinal axes of talus and calcaneus in the lateral X-ray view of a clubfoot is a sign of persistent supination of the subtalar joint and not due to anatomical changes of the bone. Correction of this deformity by closed manipulation produces a normal angle between talus and calcaneus. The angle between talus and calcaneus can thus be used as a guide for adequate correction of the subtalar deformity.


[The autonomous quadrant-syndrome (author's transl)]. The quadrant-syndrome (Q.S.) is a functional disturbance of the vegetative system, characterized by the distribution of subjective and objective lesions to a quarter of the body (quadrant). The neurological  aspect of the Q.S. varies so much in character, that it may mistakenly be considered to be psychogenic in origin. All qualities of peripheral nerve function can be affected singly or collectively and in varying degree. The duration of illness cannot be predicted; it may last from some weeks up to more than 10 years. The patients age seems to play some role in the duration of the syndrom. On account of symptomatological and pathogenetical similarities with the dystrophy of Sudeck and the causalgic state, it appears that the Q.S. would be observed more frequently, if its characteristic principle of distribution to a quarter of the body is taken into consideration. Out of the many possible causes of this syndrom the common lesions of the extremities are pointed out. These peripheral lesions act as focus, which affects a specially predisposed central vegetative nervous system. A case report is given of an 18 year-old girl suffering from a median nerve compression in the elbow region (pronator teres syndrom) and developing a Q.S. with complete anaesthesia and analgesia. Six weeks after surgical decompression of the median nerve, she was free of symptoms and remained free of symptoms after a follow up control six months later. Besides sanitation of the peripheral focus, sympathectomy is critically discussed, and the possibility of preventive treatment in common lesions of the extremities is ventilated.


[The lateral splitting of the knee joint capsule for treatment of chondropathia patellae (author's transl)]. This is a report on the results of the lateral splitting of the knee-joint capsule for treatment of chondropathia patellae. The operative procedure is described. Pains relative to the patella syndrome, chondropathia patellae, forms of dysplasia of the patella and lateral dislocation of the patella are regarded as indications. 50 knee-joints were post-examined. 26% were without complaints, 54% showed improvement, 10% no change, 10% deteriorated. These results are comparable to those of other, more intensive surgery. Representing a comparatively minor operation, the lateral splitting of the capsule is therefore particularly recommended for young patients.


Subchondral cancellous bone in osteoarthrosis and rheumatoid arthritis of the femoral head. A quantitative histological study of trabecular remodelling. Thirty-three femoral heads taken from patients undergoing total hip replacement for osteoarthrosis and rheumatoid arthritis have been examined in undecalcified, plastic-embedded sections, using a quantitative histological methods. The characteristic change of trabecular remodelling in the subchonfral cancellous bone of the femoral heads was that total osteoid surface in the medial osteoarthritis (medial O.A.) and rheumatoid arthritis (R.A.) was significantly less than in the proximal osteoarthrosis (proximal O.A.) (P less than 0.01). Resorption surface was slightly greater in R.A. than in proximal O.A. (P less than 0.05). Bone area in the deep area was not different in each group. In the superficial area it was significantly less in medial O.A. than in proximal O.A. (P less  than 0.05). The average width of trabeculae was slightly less in medial O.A. and R.A. It is suggested that subchondral trabecular remodelling may be a basic pathological process of general importance in the evolution of these diseases.


[Total knee replacement using the Walldius hinge joint (author's transl)]. 45 Walldius knee joints have been reevaluated an average of 3 years after implantation. 75% were considered good to excellent when compared with the preoperative situation. Most failures were due to infection (11%). The end result depends largely on the condition of adjacent joints which frequently prevent a major improvement in walking ability inspite of a successful implantation of a Walldius prosthesis. The Walldius hinge joint was prefered over other designs because of its large weight-bearing flanges. It can absorb static forces better without sinking into the tibial or femoral shafts. Inspite of a resection of 3 cm, a fusion is still possible if necessary. The use of cement is emphasised to prevent migration of the prosthesis and fracture of the shafts. Inspite of a high complication rate the prosthestic replacement of a severely destroyed knee joint by a Walldius hinge is a promising procedure.


[Observations of ultrastructural changes on prepared homologous tendon transplants in humans (author's transl)]. Authors have investigated the ultrastructural morphology of transformation of homologous human tendon transplants. Tenoblasts and mast cells were found next to collagenous fibres originating in the transplant and disintegrating in the voluminous ground substance. The formation of new collagen tissue was of different grades; areas of only a few fibres and areas with oriented fibres were both present. Twenty months after implantation parts characterised by apparently mature structure were found as well as abundant new fibre formation and mast cells.


Tympanostomy tube protection with ear plugs. Protection by ear plugs from water-borne infection was evaluated in 35 patients with "tympanostomy" tubes, tympanic membrane perforations, or mastoid bowls. Stock and custom-made ear plugs were found to be equally effective up to four months during a period of frequent swimming and bathing activities. Infections were only noted to occur in those patients who did not follow instructions on appropriate use of the plugs.


Stabilization of comminuted zygomatic fractures with external suspension apparatus. An external fixation device using a suspension bar fashioned from dental compounds is described. The finished appliance resembles a drawer pull from which the fractured malar eminence is suspended. The apparatus is recommended for the treatment of comminuted, unstable zygomatic fractures where conventional means of stabilization have proved unsatisfactory or undesirable and where passive traction is desirable. Appliances fashioned from lightweight dental compounds offer the maxillofacial surgeon a safe, effective, and highly versatile means of stabilizing facial fractures.


Sleep apnea, hypersomnolence, and upper airway obstruction secondary to adenotonsillar enlargement. The authors examined four children with substantial adenotonsillar enlargement that caused intermittent severe upper airway obstructive episodes, documented by all-night polygraphic monitoring of sleep and respirations. Previously unreported complications of severe adenotonsillar enlargement that were demonstrated included prolonged obstructive apneic episodes and disturbed sleep patterns. The children also exhibited daytime hypersomnolence. Polygraphic sleep studies after adenotonsillectomy confirmed improved sleep patterns and relief of the obstructive episodes. None of our patienqs had developed pulmonary hypertension, cor pulmonale, or other reported complications of prolonged upper airway obstruction, all of which may have been averted by early diagnosis and treatment.


The epidermis of the drumhead in some otologic conditions. In a study of the behavior of the keratin layer of the drumhead epidermis in some otologic conditions, a marker dye was applied to the tympanic membrane, and migration and/or desquamation of the dotted spots observed. Decelerated migration with desquamation in situ was observed during the quiescent phase of recurrent otitis externa, with or without myringitis. The same findings were observed in most cases of chronic secretory otitis media and its sequelas (retraction pockets, atrophic membranes, and scarring). The remnants of drumhead with keratotic and hyperplastic changes in the middle ear cleared themselves of the dye very slowly.


Nasal obstruction from facial palsy.

Nasal obstruction from facial palsy. Nasal obstruction due to a collapsed nasal ala occurred in 2% of our patients with facial paralysis. The denervated dilator nasal muscles allow the ala on the paralyzed side to collapse leading to increased resistance to inspiration. This symptom was further aggravated by preexisting external and nasoseptal obstructing deformities. Nasal obstruction from facial paralysis was corrected with septorhinoplasty techniques in three patients and by lateralization of the ala with a facial sling in another.


Neonatal sound deprivation affects brain stem auditory nuclei. CBA/J mice deprived of airborne sound stimulation during postnatal development have smaller globular cells in the ventral cochlear nucleus and smaller neurons in the medial nucleus of the trapezoid body than do normal control mice. The sound deprivation in these mice is similar to that experienced by persons with pure congenital conductive hearing losses. Even more profound central neural changes were found in auditory nuclei in the brain stem of a congenitally sensorineural deaf human.


Ranula and the sublingual salivary glands. The term "ranula" is poorly understood and is frequently applied to a variety of cystic structures in the head and neck. Ranulas classically are cysts of salivary gland origin, usually the sublingual glands, of which two varieties are described: a simple, epithelial lined cyst resulting from ductal obstruction, and a pseudocyst without epithelial lining resulting from extravasation of saliva that dissects through the tissue planes of the neck and may appear as a neck mass. Four cases are presented that illustrate the difficulties in diagnosis; treatment consists of meticulous dissection of the thin-walled sac in continuity with the excision of the sublingual glands that are the origin of these lesions.


A comparison of three hearing aid evaluation procedures for young children. The evaluation of hearing aid performance with young, nonverbal children traditionally consists of a comparison between aided and unaided thresholds. Alternative evaluation procedures include those that provide an estimate of the speech spectrum area that is potentially audible to the child with amplification. This study compared the hearing aid performance results for ten hearing impaired children evaluated with a sound field procedure and two speech spectrum methods. Results obtained for three hearing aids demonstrated no differences in hearing aid recommendation between procedures for children with only mild-moderate hearing loss. For children with severe to profound losses, however, the sound-field audiogram was found to overestimate what is potentially audible to the child.


Mucous glands in nasal polyps.

Mucous glands in nasal polyps. A total of 102 nasal polyps from 52 patients were stained by the PAS-alcian blue whole-mount method, and mucous glands were studied quantitatively. Glands were found in all polyps but in many of them only a few. The density is very low, considerably lower than in the nasal mucosa. The glands are tubular, of different shape and size, but differ widely from those in the nose and are formed from the surface epithelium after the polyp has attained a certain size. They do not issue from the nasal mucosa. The glands degenerate and distend. Thus, cysts in the polyp are degenerated, mucus-filled glands.


Diagnosis of hearing loss in infancy by electric response audiometry. The assessment of hearing by electric response audiometry (ERA) in 88 children under the age of 3 years was compared with the final assessment of hearing by other means made six months to four years later. A reliable decision was available in 78 patients. The ERA was correct in 64 patients (72.7%) and was incorrect in 14 (15.9%). In ten patients (11.4%), the reliability could not be determined. The incidence of errors was much greater in the 23 children who were given pentobarbital (39%) than it was in 55 not given this drug (9%). All of the errors associated with pentobarbital were the incorrect diagnosis of a loss of hearing. Three of the five errors in patients not given pentobarbital were the false diagnosis of a hearing loss in infants recovering from meningitis.


An evaluation of predicting hearing loss from the acoustic reflex. Three different formulas used in predicting hearing level from acoustic reflex data have been suggested. Acoustic reflex information is also used in predicting slope of hearing loss. Seventy-four normal and hearing-impaired persons were tested, and predictions of level and slope of hearing were compared with pure tone hearing thresholds. The results indicate that the Niemeyer-Sesterhenn and Jerger unweighted formulas yield comparable results and are preferable to the Jerger weighted formula. Predictions of slope of hearing loss are equivocal.


Gardner's syndrome and chondrosarcoma of the hyoid bone. There appears to be a total of five cases of chondrosarcoma of the hyoid bone (not all associated with Gardner's syndrome). The case reported herein is one that was first reported in the literature on Gardner's syndrome and the second reported instance of a patient with Gardner's syndrome who had a malignant bone tumor.


Psychological effects of symptoms associated with labyrinthitis. a case study. The psychological effects of postviral labyrinthitis in a patient who had been undergoing intensive psychotherapy are reported. The mildness of the physiological symptome was in contrast to the magnitude of the psychological consequences. The general psychological effects of illness on the patient are differentiated from the specific psychological correlates of vertiginous symptoms. The factors that contributed to the psychological effects and the psychological impact of these symptoms are discussed. There is a special potency to the cited effects in patients with specific personality characteristics.


A liquid nitrogen turbinate probe for hypertrophic rhinitis. A new liquid nitrogen turbinate probe for freezing of the free edge of the inferior turbinate in cases of chronic hypertrophic rhinitis has been designed.


Salivary gland choristoma of the middle ear. We discuss the eighth reported case of a benign salivary gland tumor in the middle ear. The lesion was a smooth lobulated mass and was found to be intimately associated with the tympanic portion of the facial nerve. Recommended treatment is biopsy without attempting removal. This concept of management is supported by a report of a similar case with a 15-year follow-up.


Salivary gland choristoma of the middle ear and mastoid. We report a choristoma larger than those previously reported. Its possible causes are discussed.


Curved lateral osteotomy for airway protection in rhinoplasty. Lateral osteotomies performed posteriorly enough to avoid step-like prominences at the sides of the nose may allow medial displacement of bone to impinge on the airways. This obstruction near the floor of the nasal passageway is prevented by leaving a triangular piece of bone at the pyriform aperture intact just superior to the level of the inferior turbinate. A curved lateral osteotomy, as described here, cuts bone posteriorly only where aesthetic narrowing is required in rhinoplasty. Techniques providing the recommended curved or angulated lateral osteotomies with osteotomes are demonstrated in the cadaver and in patients.


Myringoplasty as an office procedure: a new technique. An office technique uses preserved dry temporalis fascia homograft to close eardrum perforations smaller than subtotal. A follow-up on 36 patients who under-went this technique revealed a 64% success rate and 11% partial success rate. If the patients whose eardrum remnants were atrophic or scarred with or without calcareous deposits (11 cases) were excluded, the success rate becomes 76% and the partial success rate 8%. This technique is therefore recommended for patients whose eardrum remnants are healthy because it is simple and it saves time and money. In case of failure, the situation does not become worse and a regular myringoplasty may then be performed.


An approach to aesthetic rhinoplasty in the non-caucasian nose. The problem of augmenting the nasal dorsum and columella in the exaggerated Negroid or Oriental nose is presented. Augmentation of the nasal dorsum is routinely performed using polyamide mesh. The lengthening and lowering of the short and sometimes retracted columella and narrowing of the alar bases is performed by making a columellar splitting incision and extending it along the alar sills. A septal cartilage graft is sewn into the new columellar space, and the alar sills are advanced into the columella, thereby lengthening the columella and changing the axis of the nares. The columellar advancement is done after the dorsal implantation is performed, and the projection of the tip is advanced to whatever amount necessary to aesthetically match the dorsal profile line.


Tympanoplasty: medial grafting using Williams' microclips. A technique for medial grafting that evolved in Alaska over a period of about five years has been used by the author at the Dartmouth-Hitchcock Medical Center for over two years. The technique is one whereby fresh temporalis fascia is placed medial to the tympanic membrane remnant and fastened to that remnant with stainless steel wire microclips. This technique has resulted in a success rate in excess of 94% in the Alaskan "bush." In a private practice setting, the success rate has been slightly better than 97%.


Geniculate neuralgia and facial nerve sensory systems. Although it is only a small ganglion, the geniculate ganglion subserves several different sensory systems with sensory fibers distributed to different parts of the head. The ganglion innervates chemoreceptors and phasic mechanoreceptors on the front of the tongue. In addition, the ganglion supplies mechanoreceptors of the hair follicles on the inner surface of the pinna and deep mechanoreceptors of nasal and buccal cavities. The ganglion also innervates chemoreceptors on the soft palate. No neurophysiological evidence was found for sensory innervation of the facial musculature. In considering neuralgias of geniculate ganglion origin, it is necessary to examine the loci of sensory projections of the ganglion and the possible effects of inflammation on pulse discharge patterns of sensory neurons.


Masking level differences in central nervous system diseases. The relationship between the tonal masking level difference performance and the behavior of the "sensitized speech tests" according to Bocca and Calearo, were studied in subjects with normal hearing who were suffering from CNS diseases. The results have shown that pathological masking level difference values are present in all cases with pathological sensitized speech tests, and are related principally to the following two conditions: (1) the bulbo-pontine lesions and (2) the central hearing functional asymmetry. In subjects with normal hearing who have CNS diseases, pathological tonal masking level differences indicate the existence of central hearing pathways lesions.


Venous aneurysms of the parotid gland.

Venous aneurysms of the parotid gland. Venous aneurysms of the parotid gland are rare lesions that have distinctive clinicopathologic features. Clinically, they appear suddenly and manifest as masses in the parotid area. Characteristically, these masses are compressible, fill on release of pressure, and increase in size when the head is lowered below the heart and when the Valsalva maneuver is performed. Also, venous aneurysms are nonpulsatile. Definitive diagnosis, however, requires phlebography. Pathologically, these lesions represent aneurysmal dilatation of a segment of a vein and are frequently thrombosed. Surgical excision is the treatment of choice.


Adenoid squamous cell carcinoma of the oral cavity: report of the first case arising in the tongue. A case of adenoid squamous cell carcinoma arising in the tongue is presented. This histologic variety of squamous cell carcinoma originates almost exclusively in the skin, and the few examples of oral mucosal lesions have heretofore been restricted to the lip. In the oral mucosa, the neoplasm should be differentiated from several types of adenocarcinoma of salivary origin. Surgical excision in our case was followed by rapid local recurrence and death. This behavior is in contrast to the generally favorable prognosis of analogous cutaneous and lip neoplasms, and may indicate a more aggressive course in lesions of lingual origin.


Soft tissue ameloblastoma in a 92-year-old woman. Ameloblastoma is a rare epithelial neoplasm that most commonly is found within the bony structure of the jaw. Soft tissue ameloblastomas are rarer. Only nine well-documented cases are found in the reviewed world's literature. It is our purpose to report the clinical and morphological features of a gingival ameloblastoma in a 92-year-old woman.


Temporal summation of the acoustic reflex. A signal-averaging technique was used to minimize acoustic reflex measurement system noise while preserving temporal fidelity. In normal listeners, the interaction of signal intensity and signal duration was explored at visual detection threshold (VDT) and at varying suprathreshold signal levels. Reflex amplitude increases, with signal intensity, at a rate which changes as a function of signal duration, a finding which complicates the interpretation of temporal summation data based on VDT. A theoretical model is proposed to explain the complex interactions of signal intensity, duration, and band width on the amplitude of the acoustic reflex.


Post pill amenorrhoea--how much of a problem? Presumably, post-Pill amenorrhoea reflects a mechanism whereby a hypothalamus "switched off" by the Pill does not switch on again when therapy is stopped. In Australia the incidence of post-Pill amenorrhoea appears to be in the vicinity of 1 in 200 for a six months duration and 1 in 400 for over 12 months. The only clearly defined feature of women who are likely to develop the syndrome is previous cycle irregularity--cycles consistently longer than 35 days. There is indication that nullipara and women with gross weight fluctuation may also be more likely to be affected. In management, skull X-ray is mandatory and if galactorrhoea is present, serum prolactin can be of diagnostic importance. Otherwise, the deciding factor is whether there is a desire or not for pregnancy.


Contraception in the over 40 age group.

Contraception in the over 40 age group. Fertility sharply declines in the 45-50 age, but simple and effective contraception is still desired. The Pill offers this plus the advantage of cycle control and alleviation of vasomotor symptoms. Lowest oestrogen content is preferred and combined with this, norgestrel has the theoretical advantage of reversing undesired oestrogen effects. If the Pill is continued in the 40 + age group, it can be safely discontinued when the age of 50-52 is reached. It must be kept in mind that side effects of the Pill or intrauterine device related to bleeding may mask pelvic disease. Regular check ups including full history, breast and pelvic examination should be carried out.


Determination of hearing threshold for single frequencies from the acoustic reflex. With preactivation, the threshold of stapedial reflex activity can be lowered by 20-30 dB. From these measures of the normal and reduced reflex threshold, an extrapolation may be performed down to the hearing threshold. Thus, the hearing threshold can be determined for every single frequency from 0.125 to 4 kHz if the reflex is elicitable up to 8 kHz.


Contraception in the puerperium.

Contraception in the puerperium. Choice of contraception in the puerperium is complicated by the normal factors of lactation, involuting uterus and emotional lability. The individual's previous contraceptive experience is important, and new agents and techniques change current practices. In the puerperium, failure for IUDs is increased, and tubal ligation has more hazards. During lactation the standard combined oral contraceptives are not advised, but the microdose progestagen-only pill may be a most satisfactory agent-changing to more routine methods when menstruation starts. In a population of normal women, progestagen-only therapy may show about a 25 per cent dropout because of an unacceptable bleeding pattern, but there is a small group of women who appear to be well suited by this form of oral contraception.


Low-level frequency-following response.

Low-level frequency-following response. In man, the scalp-recorded 'Frequency-following response' (FFR) can be well observed only at fairly high levels of stimulation. As a consequence, it is difficult to ascertain whether the low or the high-frequency channels of the peripheral auditory system mediate this response. It is shown that the sensitivity of the recording method is considerably increased when the averaged recorded waveform is subjected to frequency analysis. Results from experiments with high-pass masking noise become unequivocal and they suggest that the low-level FFR is caused by nervous activity arising in the apical part of the cochlea and mediated by the low-frequency in the brain stem.


Electro-cochlear potentials elicited by sinusoidally modulated signals. Responses of the guinea pig cochlea to amplitude-modulated stimuli were measured with the aid of a gross electrode. The dynamic characteristics of this part of the auditory system was studied by varying several parameters of the applied signal. The signals used as carriers in our experiments were either white noise or pure tones of 1 and 4 kHz. The modulation frequency, dynamic and intensity characteristics were determined by varying the modulating frequency, the modulation depth and the intensity of the applied signal. To get an idea about possible non-linear aspects of the system under investigation, we always computed the Fourier transform of the response data and plotted the amplitude of the various harmonics and the phase of the fundamental separately as functions of the signal parameter in question. The greatest response was always found at a modulation frequency of about 200 Hz, with a relatively gradual rise up to this frequency and a sharper drop above 200 Hz. The phase of the fundamental changes very rapidly at frequencies above Hz. The distortion is mainly second-harmonic and has a maximum about 1 octave lower than the fundamental. The carrier frequency and the intensity of the stimulus were not found to have a great influence on the frequency characteristic. For small modulation depths, the system is nearly linear; at higher intensities and modulation depths saturation occurs, coinciding with a relative increase in the intensity of the second harmonic with respect to the fundamental.


Dependence of the temporary threshold shift on the immediately preceding exposure to noise. Temporary threshold shift (TTS) measured immediately after exposure to noise here called TTSi, is surely more difficult to determine in audiological testing, than the usual TTS2, but in its dependence on the preceding exposure, it is useful in defining criteria for auditory fatigue, for damage and for normal adaptation to noise exposure of short durations. A few results selected from a study using improved methods of measuring TTSi confirm the point of view of others in defining regions and limits of normal hearing and auditory fatigue.


Effects of subtle mid-frequency auditory dysfunction upon speech discrimination in noise. Earlier studies have indicated mid-frequency auditory dysfunction and depressed ability to discriminate speech in noise among noise-exposed listeners with high-frequency hearing loss. The present study was designed to determine whether mid-frequency dysfunction contributed to the depressed speech discrimination performance. Normal listeners, and noise-exposed and older listeners with high-frequency hearing loss listened to word lists presented in competing 'cocktail party' noise under unfiltered and low-pass filter conditions. In the low-pass filter condition the performance of the noise-exposed listeners was superior to that normal listeners, indicating that mid-frequency auditory dysfunction on the part of noise-exposed listeners does not contribute to their difficulties discriminating unfiltered speech in noise. The performance of the older listeners was below that of the two other groups in both filtered and unfiltered conditions, indicating greater difficulty discriminating speech than would be predicted only on the basis of high-frequency hearing loss.


Problems in general anaesthesia. Emergencies and trauma. Emergencies resulting in death of the patient are sufficient reason for insisting on only medically qualified people giving anaesthetics. Unlike in most other specialities, complications in anaesthesia usually will not await the arrival of the expert. Trauma provides the anaesthetist with some of his most testing occasions. Most problems are related, as with emergencies, to basic derangements of respiratory and circulatory physiology However, there is a steady progression with severe trauma cases that is not a common feature of the ordinary anaesthetic disaster. Respiratory problems are either of obstructive origin or due to failure to generate respiratory muscle activity. Circulatory problems, in the vast majority of cases, consist of low cardiac output because of relatively deficient circulatory blood volume. Overload of the circulation resulting in acute pulmonary oedema is often feared but uncommonly seen. Another cause of failure of output of the heart lies in the heart itself, either because heart muscle is not contracting well enough--myocardial failure, or because of disorder of rhythm.


Problems in general anaesthesia. Dental. Administration of general anaesthetics in the dentist's surgery is widely practised in Australia. There is considerable demand for this service, and those doctors who supply it fill a very real need. Where medical practitioners fail to supply this service, dentists are forced to use sedation techniques and may be tempted to push these beyond the limits of safety.


Problems in general anaesthesia. Geriatrics. Elderly patients are at considerable risk during and following general anaesthesia due to the physiological changes which occur with age, the fact that they commonly undergo major surgery, and that there is a high incidence of associated cardiovascular and respiratory disease. This paper attempts to emphasize important points that the anaesthetist should be looking for, and to explain why. Pathological states, although common in this age group, will not be mentioned; the dicussion will apply only to healthy aged patients.


Problems in general anaesthesia. Paediatrics. Many general practitioners are involved in anaesthesia and consequently, from time to time are called upon to anaesthetize children. This paper is aimed at provideing information on the differences between adults and children, and indicating how recognition of these differences will prevent many of the problems that may occur in paediatric general anaesthesia.


Cardiac arrest.

Cardiac arrest. Cardiac arrest is easily recognized clinically and requires immediated cardiopulmonary resuscitation (CPR) by well trained personnel. The importance of prophylaxis is emphasized in high risk patients. The ABC regime of CPR and the technique of blind defibrillation are recommended in the management of cardiac arrest. Good results may be expected with ventricular fibrillation associated with some correctable factor or myocardial infarction. With a satisfactory CPR technique and prompt resuscitation, the incidence of complications is low.


General anaesthesia in general practice. Several important physiological parameters may vary during the course of an anaesthetic. The administration of safe general anaesthesia demands the constant recognition of these variations by continual monitoring with simple are unsophisticated apparatus. This article reviews these physiological parameters, and the use of monitors on the anesthetic machine, the patient and the anaesthetist.


The isolated practice.

The isolated practice. The isolated practice can be developed into a satisfying and rewarding way of life. Contact between the doctor and his patient is intimate and lasting. I believe that a doctor should be motivated by God's great Commandent, "Love one another", and that it must be easier to achieve this because of the continuing close contact.


General management of the diabetic child. An acute onset with polyuria and polydipsia is the pattern of onset for something approaching 90 per cent of child diabetics. Their management, then, must include insulin and diet together with education of the parents in how to use these measures.


Acute infections of the respiratory tract in children. Although respiratory infections are the commonest childhood diseases, they remain some of the most poorly understood. With identification of viruses as the causes of most respiratory diseases as well as controlled epidemiological studies, the understanding to acute respiratory infections is gradually increasing. Problems still exist, however, in clinically differentiating bacterial from viral infections and in evaluation the host-organism interaction.


Using the psychiatrist.

Using the psychiatrist. The change in the practice of psychiatry has been sufficiently marked and sufficiently recent to generate uncertainty as to the psychiatrist's function, and particularly how he might best be used by other doctors. This article examines some issues relevant to the psychiatrist's function as a clinical consultant, as a contributor to preventive psychiatry, and as a mental health consultant in relationship to community medicine in general, and the family doctor in particular.


Psychological disturbance in a general practice setting. One hundred consecutive patients who consulted a general practitioner in Sydney with a new complaint completed the General Health Questionnaire (GHQ), a self-administered instrument designed to assess psychological dysfunction. Although all patients presented somatic symptoms as their principal complaint, 39 per cent scored positively on the GHQ. A direct relationship between severity of psychological disturbance as clinically assessed and GHQ score was observed, while the relationship between the clinically assessed severity of physical dysfunction and GHQ score was an inverse one. At the 10 week follow-up, psychological morbidity had fallen to 23 per cent, a figure akin to a Sydney general population norm. Some implications of these findings are discussed.


Behaviour modification.

Behaviour modification. The first part of the article outlines how behaviour, both normal and 'abnormal', is a learned phenomenon and briefly looks at the various contingencies of learning that determine which behaviours develop. Many types of psychological disorder can be accounted for by such an approach, and several examples of how behavioural disorders develop are outoined. Finally, a rationale for treating certain types of these behavioural disorders is presented.


Interpersonal communication.

Interpersonal communication. A significant number of patients consulting general practitioners have emotional and behaviour problems in addition to, or rather than medical problems. Many such difficulties involve, or are a function of inadequate interpersonal relationships. The article begins by examining the relationship of assertion to interpersonal communication and its role in interactions with other people. The behavioural aspects of assertion, as well as its relationship to social anxiety, are also discussed. Assertive training as a behaviour modification technique for teaching assertion is described and the evidence for its efficacy briefly reviewed. The relevance of assertion and assertive training to community health is discussed.


Counselling the disturbed family.

Counselling the disturbed family. The article begins by considering the various ways in which behavioural and psychological problems may be present in a family setting. Three broad areas where such problems may arise are considered. These are; firstly, interpersonal relationship difficulties within the family system as a whole; secondly, where one family member is selected as a 'symptom bearer', and thirdly, where some form of family crisis arises. A rationale for treating these problems is presented; the ultimate goal being that the persons concerned learn new skills so that they themselves can cope with their difficulties.


Acute pharyngitis, tonsillitis and tonsillectomy. Respiratory infections are the most common group of diseases experienced in the community and treated by doctors. Tonsillitis and pharyngitis, sometimes referred to together as acute sore throat, are among the most common of the individual respiratory infections.


Chronic pain syndromes in the elderly.

Chronic pain syndromes in the elderly. In this paper the painful syndromes of temporal arteritis, polymyalgla rheumatica, glaucoma, trigeminal neuralgia, post-herpetic neuralgia, and temporomandibular joint dysfunction have been described. These conditions occur commonly in the elderly. The dangers of blindness occurring in temporal arteritis or polymyalgia rheumatica, the importance of early diagnosis in glaucomatous headache, the value of Tegretol in trigeminal neuralgia, the paucity of therapeutic agents in post-herpetic neuralgia and the value of dental treatment in tempor-mandibular joint dysfunction have been stressed.


Spinal osteoporosis in the aged.

Spinal osteoporosis in the aged. Spinal osteoporosis is a common condition in the elderly. Its aetiology is unknown although endocrine and metabolic factors appear to be involved. The diagnosis is relatively straight-forward but treatment is unsatisfactory. In this article the author discusses the disease as a whole and presents his views on the management of the condition.


Human amino acid excretion during and following an extended airborne alert. The urinary excretion of free amino acids was measured in 15 men who participated in a continuous airborne alert for an extended period of time. These men made up one of three teams which took turns so as to assure that at least one team remained airborne in an EC-135J aircraft at all times during the 96-h alert. The team making up the test group herein reported was airborne for 8.5 h on each of four successive days; flights were flown during the daytime. The data strongly suggest that the participants experienced anticipatory stress during the early part of the first two flight days of the alert, after which the excretion of amino acids was virtually unaltered. Additionally, amino acid excretion during the 24-h period following the alert was essentially in accord with baseline values established for another groups of subjects.


Recurrent heat exposure: effects on levels of plasma and urinary sodium and potassium in resting and exercising men. Heat acclimatization was induced in a group of healthy young men by walking on a treadmill (5.6 km/h, 49 degrees C/27 degrees C dry/wet bulb, 90 min/day, 7 d) and confirmed by observing significantly reduced final rectal temperatures and heart rates on the seventh day of exercise in the heat. A second group of men, paired for maximal oxygen consumption and body weight, remained sedentary under identical environmental conditions. While the mild exercise combined with the severe heat conditions induced significant hyperkalemia (p less than 0.02, minimal significance) on both the first and final days, there did occur an attenuated response with significantly (p less than 0.01) reduced plasma K+ after 45 min on the seventh day when compared  with first day levels. No significant inter- or intragroup differences in plasma Na+ content of 24-h urine samples showed that men exercising in the heat retained an increased ability to conserve Na+, while sedentary individuals consistently displayed increased excretion of Na+. Thus, we concluded that even the mild exercise described herein effected hyperkalemia at each sampling time, but the level of hyperkalemia was attenuated after acclimatization, and while Na+ was conserved in the exercising men, no such adaptive processes occurred in sedentary individuals.


Catecholamine excretion in T-37 flight training. Catecholamine excretion was determined for eight USAF student pilots during three basal and four T-37 training conditions. When viewed as the dependent variable, catecholamine excretion patterns support the conclusion that the Basic Cockpit Training Emergency Procedures unit was not stressful. The remaining lesson units, including Power-on-Stall  and Spin-Recovery, First Solo, and Instrument Check lesson units, resulted in a pronounced stress response. When catecholamine excretion data were interpreted for psychological significance, it was concluded that the lesson unit which included Power-on Stalls and Spin-Recoveries created the highest arousal, anxiety and apprehension. Student pilot observations supported this interpretation. The relative excretion of epinephrine and norepinephrine showed changes accompanying pilot training which may be interpreted as demonstrative of successful coping behavior.


Theoretical analysis of altitude tolerance and hemoglobin function. The potential effect of changes in the position and shape of the oxyhemoglobin dissociation curve (ODC) in modifying altitude tolerance is quantitatively analyzed and discussed. The most frequently used criteria for oxygen affinity, the position or P50 of the ODC (oxygen pressure at 50% saturation) is shown to have slight influence on tissue oxygenation in terms of arteriovenous oxygen difference under steady-state, hypoxic-hypoxia conditions. Conversely, changes in the shape of the curve, also expressed as the cooperativity or heme-heme interaction, could substantially modify oxygen transport under these conditions. Published observations are reviewed which suggest that hemoglobin cooperativity is not normally invariant.


Comparative orthostatic responses: standing vs. head-up tilt. In both physiologic and clinical studies, standing is often loosely equated with head-up tilt(HUT) although the cardiovascular effects of these variants of orthostasis have not been formally compared, except for heart rate. The effects of HUT and standing were measured noninvasively in male volunteers satisfying identical criteria for age and normal status. In both postures, there were significant increases in heart rate, pre-ejection period, isovolumic contraction time, and the ratio of pre-ejection to ejection period, and significant decreases in ejection period and ejection time index. All of these changes were greater for standing than for tilt. Pulse transmission time changed significantly (-14%) only with tilt. We conclude that head-up tilt and standing are rather comparable but not physiologically identical forms of orthostasis.


Altitude tolerance in rats in relation to carbohydrates and fats in their diet. Rats were exposed to simulated altitudes of 3658, 4877 and 7620 m, 5 h/d for 30 d, at ambient temperature of 28 degrees C. Voluntary food intake, growth rate, and survival time were measured under effects of commercial diet (50% CHO, 4% fat and 24% protein), high fat diet (52% fat), and high carbohydrate diet (75% CHO). The results showed that altitude-exposed rats on high CHO diet had improved growth rate, but lowered survival time on their subsequent exposure (at the end of a 1-month period) to severe hypoxia (5% oxygen). The animals on high fat diet had very poor growth rate, as they ate very little amount of it voluntarily, either at sea level or under high-altitude conditions. These rats, however, had tremendously increased resistance to severe hypoxia (survival time greater than 60 min as compared with greater than 12 mins of those on commercial or high CHO diet).


Two years of routine patient movement in the U.S.A. (Jan. 1974-Dec. 1975). During a 2-year period, Jan. 1974-Dec. 1975, a total of 102,547 routine patients were aeromedically evacuated from an originating medical facility to a destination hospital within the Continental United States (CONUS). It is the policy of the Department  of Defense (DOD) that, in both peace and war, the movement of patients of the Armed Forces shall be accomplished by airlift when airlift is available and conditions are suitable for aeromedical evacuation, unless medically contraindicated. The DOD Regulation 4515.13-R states that a routine patient will be delivered to the destination hospital within 72 h after pickup from aerial ports or from the originating CONUS medical facility. During this 2-year period, 66% of all patients moved were delivered to their destination hospital the same-day they were picked up and 93% of all patients were delivered to their destination hospital within the 72-h DOD criteria for routine patients. In order to reach the destination medical facility, many patients had to remain overnight (RON) at an aeromedical staging facility (ASF). Contributing factors were weather, aircraft maintenance problems, expiration of the crew duty day, patients originating overseas, and patients moving out of originating areas and requiring a second mission to reach the destination hospital.


Suicide by aircraft: a case report.

Suicide by aircraft: a case report. A 36-year-old pilot took his plane on a brief, unauthorized flight that ended in a high-speed vertical crash next to the runway. A retrospective "psychological autopsy" yielded strong presumptive evidence of an unrecognized depression in a man with manipulative and mildly antisocial characteristics. His withdrawal from his usual patterns of behavior was, instead, regarded as a desirable return to "normal" behavior. This case report includes comments on the role of the psychological autopsy in aircraft accident investigation, anniversary reactions, the use of psychiatric diagnosis to support the agreed-upon decision on the desired disposition, some aspects of subintentional suicidal behavior, a brief review of the literature on suicide by aircraft, and consideration of the role of the flight surgeon in preventing such occurrences through early recognition of depression.


Cambodian airlift.

Cambodian airlift. To  reduce the presence of U.S. military personnel in Cambodia, the Air Force, in September, 1974, completed negotiations with  a civilian contractor to continue the emergency airlift of supplies and ammunition to that country. As the Khmer Rouge threat increased on the Cambodian capital, Phnom Penh, the airlift was expanded and the supply sorties increased. Because fatigue was a potential medical problem for the crews--they were required to fly excessive hours with little time off between 13 Jan. and 13 March, 1975--a flight surgeon was assigned to the company. The flight surgeon monitored the men by subjective evaluation, several physiological and hematological measurements, and anonymous questionnaires. Although none of the factors correlated with subjective fatigue or performance decrement, recommendations for aircrewmen flying emergency airlift operations in the future were made based upon this unique experience.


Aeromedical support of flying safety programs. One of the most significant responsibilities of the flight surgeon is support of flying safety programs. This discussion reviews the prerequisites necessary to provide such support and then considers activities the flight surgeon can accomplish in enhancing flying safety programs.


Physicians and airline medical emergencies. Physician passengers on airlines are frequently called to assist the flight crew if an emergency medical situation arises. There have been numerous studies and reports pertaining to medical emergencies inflight, the various aspects of crew responsibility and reaction, and the types of emergency medical supplies available. This paper is to present the comments and opinions of physicians who have been called upon to assist the flight crew during inflight emergency medical situations. The background information is presented followed by statistics as to types of conditions encountered; physicians' responses; physicians' comments as to airline emergency medical supplies; flight crew, airline, and airport responses to medical emergencies and suggestions from physicians as to what significant changes may be indicated.


Complexities of human factors in aviation. Statistics continue to show an increased incidence of serious aircraft accidents where the cause has been attributed to "human factors", although the factors themselves have not always been specifically determined. This paper is an attempt to outline some of the stress factors which may cause a pilot to react improperly in a given situation and thus set in motion a train of events potentially leading to an accident.


Inabilities as an immunoadjuvant of cell walls of the group B peptidoglycan types and those of arthrobacters. The cell walls from several bacterial species whose peptidoglycans are the group B types (Schleifer and Kandler) and those of two arthrobacters were shown to be inactive or only weakly active as an immunoadjuvant in both induction of delayed-type hypersensitivity and stimulation of circulating antibody levels to ovalbumin when administered to guinea pigs as a water-in-oil emulsion, in sharp contrast to the adjuvant-active cell walls of the group A peptidoglycan types which were previously studied. The possible reason for the inabilities as an adjuvant of these cell walls was discussed in relation to the chemical structures of peptidoglycans.


The mode of hydrolysis of a glycan portion of Micrococcus lysodeikticus cell walls by endo-N-acetylglucosaminidase or endo-N-acetylmuramidase isolated from crude barley beta-amylase. Micrococcus lysodeikticus cell walls were digested with a pI 6.8 endo-N-acetylglucosaminidase or a pI 9.5 endo-N-acetylmuramidase. The digests were further treated with a N-acetylmuramyl-L-alanine amidase of Flavobacterium L-11 enzyme to remove the peptide portion. The products were fractionated by gel filtration and ion-exchange chromatography, and the glycan portion of fractions were analyzed for their average amino sugar chain lengths. The following results were obtained. 1. The glycan portion of the main products in the pI 6.8 enzyme digest consisted of (-N-acetylmuramic acid-N-acetyl-glucosamine-)2-3. 2. The glycan moiety of the pI 9.5 enzyme digest was mainly composed of (-N-acetylglucosamine-N-acetylmuramic acid-)3-4. 3. The glycosidic linkages around the muramic acid 6-phosphate residues which linked to a special structure through a phosphodiester bond were rather refractory to the glycosidase action of both pI 6.8 and 9.5 enzymes.


Gelation of the amoebocyte lysate of Tachypleus tridentatus by cell wall digest of several gram-positive bacteria and synthetic peptidoglycan subunits of natural and unnatural configurations. Water-soluble adjuvant-active fractions prepared by digestion of the cell walls from several gram-positive bacteria with an endo-N-acetylmuramidase (Mutanolysin) were shown to gelate the amoebocyte lysate of Tachypleus tridentatus, the Japanese horseshoe crab. This finding was further extended by examination of the clotting activities on the amoebocyte lysate of a synthetic N-acetylmuramyl-L-alanyl-D-isoglutamine and related compounds, either adjuvant-active or -inactive, demonstrating that there are in general close correlations between the abilities to initiate lysate gelation, immunoadjuvancies and pyrogenicities, although there are some exceptions.


The hemoglobins of Artemia salina. IV. A model for genetic control of hemoglobin 1, hemoglobin 2, and hemoglobin X. Two loci account for all genetic variation resulting in difference in electrophoretic mobility in three hemoglobins (Hb1, Hb2, and HbX) in the hemolymph of the brine shrimp. Four alpha alleles and nine beta alleles have been studied. In shrimps of all genotypes and in electrophoresis in media with varying degrees of molecular sieving, Hb2 is approximately equidistant from Hb1 and HbX. A shrimp heterozygous at both loci has a three-banded Hb1, a four-banded Hb2, and a three-banded BbX. We conclude that Hb2 contains n alpha-polypeptides and n beta-polypeptides. Hb1 contains 2n alpha-polypeptides. HbX contains 2n beta-polypeptides. During electrophoresis, the three native hemoglobins undergo reversible dissociation to n subunits. Subunits with the same charge reassemble to migrate as molecules of the same size as the native molecules. Although there is no evidence for an additional polypeptide in the three hemoglobins, we cannot exclude such a possibility. If it exists, it is under three constraints: (1) it must be present in equal amounts in each of the three hemoglobins; (2) it must have the same molecular weight as the alpha- and beta-polypeptides; and (3) it must be free of genetic variation (detectable by electrophoresis).


The hemoglobins of Artemia salina. V. Genetic variation in hemoglobin 1, hemoglobin 2, and hemoglobin 3. Electrophoretic mobilities of three hemoglobins (Hb1, Hb2, and Hb3) were studied in 15 populations of brine shrimps. Genetic segregation data support the model that Hb2 contains n alpha-polypeptides and n beta-polypeptides; Hb1 contains 2n alpha-polypeptides- Hb3 contains neither alpha- nor beta-polypeptides. There is no evidence of linkage of alpha and beta loci with each other or with the locus (or loci) which governs Hb3 or with the nonhomologous portion of the sex chromosomes. Hemoglobins of different populations may be hybridized in vitro by incubation at high temperature. Reversible dissociation to subunits which contain only one (alpha or beta) polypeptide occurs at 40 C (for Hb1) and at 50 C (for Hb2).