Phenformin and ethyloestrenol in recurrent venous thrombosis. Altogether 75 patients, 60 of whom had recurrent idiopathic deep venous thrombosis, 10 recurrent superficial thrombophlebitis and 5 retinal venous thrombosis, were given a combination of 100 mg phenformin and 8 mg ethyloestrenol a day for periods varying between 3 and 48 months (mean 16.2). Initially, all the patients had an abnormally low plasminogen activator content in the walls of superficial veins and/or a decreased capacity to release plasminogen activator from the vein walls on venous occlusion of the arms. The combination elicited a significant increase in the spontaneous fibrinolytic activity and in the local fibrinolytic activity during standardized venous occlusion of the arms (assayed on fibrin plates) after treatment for 3 months (p less than 0.001). These activities then remained normal throughout the observation period. In 65 of the 75 patients studied, the plasminogen activator level in the vein wall (histochemically assayed by the method of Pandolfi) was abnormally low intitially. The level had increased significantly after treatment for 3 months (p less than 0.001). After treatment for 12 months all the patients except 2 were normal. The patients in this material had had 2-20 episodes of venous thrombosis, the most recent 5 years before the institution of treatment, in spite of dicoumarol treatment. During treatment 9 thrombotic episodes occurred; in 5 of these patients the fibrinolytic activity of the vessel wall was not normal at the time of the recurrence. Except in 1 patient, who developed lactic acidosis, the side-effects were not severe.


Effects of medium chain triglycerides on portal and arterial levels of insulin, FFA and glucose in patients with pancreatic disease. Trioctanoin has been given orally to six patients with pancreatic disease and the effects on the portal and arterial levels of insulin, free fatty acids (FFA) and glucose have been investigated. The serum levels of insulin and FFA rose significantly in portal blood but not in arterial blood after trioctanoin. The glucose level in portal as well as in arterial blood remained unaffected by the fat ingestion. The implications of these findings are discussed.


The role of lymphography in the investigation of patients with fever of unknown origin. Lymphography has been performed in 21 patients with fever of unknown origin. In 8 of the patients, lymphography was positive, demonstrating retroperitoneal lymphoma. The value of lymphography before planning a laparotomy is stressed.


Hypothyroidism with subacute pseudomyotonia--an early form of Hoffmann's syndrome? Report of a case. A 25-year-old man was admitted to the hospital because of painful muscle cramps and action myospams of subacute onset and 6 weeks' duration. No myotonia could be demonstrated objectively and his deep tendon reflexes showed no prolongation of the relaxation phase. Serum creatinine was raised but creatinine clearance was normal. Serum levels of aldose, CPK, ASAT and ALAT were increased but ordinary light microscopy revealed no histological signs of muscle disease in a quadriceps biopsy. ECG showed a prolonged PQ interval and flat T waves in the left precordial leads. Laboratory tests of thyroid function revealed intensive hypothyroidism, and high titers of circulating thyroid antibodies were demonstrated. During 2 1/2 months of thyroid therapy, the muscle symptoms gradually disappeared completely and the patient could return to work. By that time the serum enzymes and the ECG had normalized. Despite the lack of objective signs of myotonia, we consider that the very dominant subjective muscle symptoms, severe enough to prevent the patient from performing his ordinary manual work and completely reversible on thyroid therapy, justify the designation of hypothyroid myopathy. The question is raised whether the case represents an early form of Hoffmann's syndrome.


Serum cholesterol and triglyceride concentrations of Finns and Finnish Lapps. I. Basic data. Serum cholesterol and triglyceride (TG) concentrations have been studied in six Finnish population groups in South and East Finland and in one group of Finnish Lapps in North Finland. Altogether 11626 Finns, aged 15 or above and 828 Lapps of all ages were studied. Serum cholesterol and TG concentrations of the Lapp children were higher in the age group 0--4 than in the age groups 5-9 and 10-14. Mean serum cholesterol of girls aged 0-9 was higher than that of the boys. The sex and age dependence of mean lipid values in the adults were in several respect similar to those observed in other industrialized populations. The serum cholesterol mean rose with age to reach a maximum in age group 50-59 in men, in age group 60-69 in women. Among the adults, women had lower cholesterol means than men only in age groups 30-39 and 40-49. The serum TG distribution was markedly skewed, and logarithmic transformation brought it closer to normal. Maximal log(TG) values (greater than 12 hours' fast) were attained by men aged 30-39 and by women aged 60-69. Men had considerably higher TG levels than women in middle-aged groups. Of all the sex and age groups studied, the men aged 30-39 had the most skewed cholesterol frequency distribution. Up to this age variability in men's cholesterol values were also increased, as reflected by an increasing S.D. As to women the cholesterol S.D. increased until the age of 60-69. In all the age groups above 14 years, the variability of TG values was larger in men than in women, but it was not age dependent.


Auscultatory measurement of blood pressure performed by the doctor on duty. A review is presented of the measurements of blood pressure on admission of 600 patients to the wards in a department of general medicine. Three doctors each examined 200 patients, distributed over two periods with an interval of one year. Large differences were found between the doctors as regards the distribution of the BPs, particularly the diastolic pressures. On the other hand, no differences were observed in the distributions during the two periods as far as the individual doctors were concerned. Great preference was shown for zero as the terminal digit and also for certain BP values. It is concluded that the observer introduces a considerable subjective factor in measuring the BP by auscultation. Correct performance of this simple procedure requires meticulous instruction.


On the use of renal angiography and intravenous urography in the investigation of renovascular hypertension. The value of renal angiography for revealing renovascular changes has been investigated in 126 patients with hypertension, and in 102 of them a comparison was made with i.v. urography. It was concluded that i.v. urography does not reveal renovascular changes and thus the primary investigation should be renal angiography, in some cases followed by urography in the same session.


Changes in plasma and extracellular fluid volume during long-term treatment with alpha-methyldopa in 11 thiazide-treated patients with essential hypertension. In eleven patients with essential hypertension, plasma volume (T-1824) (PV), extracellular fluid volume (82Br-distribution space) (ECFV), blood pressure (BP) and the ratio plasma to interstitial fluid volume (PV/IF) have been determined three times before treatment, after more than two months of thiazide treatment and after three and six months of combined thiazide-alpha-methyldopa (AMD) therapy. During combined treatment, PV/IF showed a significant increase, whereas PV and ECFV did not change significantly. Compared to values during thiazide therapy, PV and PV/IF increased, whereas ECFV was unchanged. BP was reduced significantly after thiazide treatment and showed a further significant fall when AMD was added. Based on the results and a review of the literature, it is concluded that AMD acts by interfering with the normal sympathetic activity, thereby producing a reduced venomotor tone and increased venous capacity. The concomitant reduced venous return of blood to the heart is suggested to contribute to the antihypertensive effect of AMD by means of a decreased cardiac output.


Serum cholesterol and triglyceride concentrations of Finns and Finnish Lapps. II. Interpopulation comparisons and occurrence of hyperlipidemia. Only small differences in serum cholesterol means and somewhat larger, but still modest differences in log(TG) means were observed, when seven Finnish population groups were compared. Semiurban and industrial groups had the highest triglyceride levels. Cholesterol levels tended to be lower in South Finland than in East or North Finland and lowest in semiurban population groups. Between 15-59 years of age, rural Finns of both sexes had higher and after this age lower cholesterol means than the Finns in the other population groups. The highest cholesterol levels below the age of 60 were observed in a rural population group in East Finland. The Finnish Lapps and the rural Finns had nearly identical serum lipid levels in spite of the differences in genetic background and way of life. The serum lipid concentration means were quite similar to those reported from the other Nordic countries, Denmark, Norway and Sweden. The differences between the populations of the Nordic countries are no larger than those observed between the Finnish population groups. However, no population in Scandinavia or elsewhere can confidently be said to have higher serum lipid levels than the Finns. The similarity of the lipid levels observed in different areas in Finland and in the larger Nordic area is remarkable in view of the large differences in the incidence of coronary heart disease and in mortality rates. It is conceivable that part of the variations in disease rates is attributable to differences in the prevalence of hyperlipidemias, although the present study does not prove this hypothesis. Such differences could occur in spite of similarities in the lipid concentration means. Prevalences of hyperlipidemias in Finland are given.


A trial of a new adrenergic beta-receptor blocker, ICI 66.082, in the treatment of hypertension. From a survey of 1250 males, 40-60 years of age, 25 mildly to moderately hypertensive patients have been offered treatment with the new beta-blocker ICI 66.082. Before and during the trial, data were obtained on resting BP and pulse rate, BP, pulse rate and ECGs during near maximal exercise, and various ventilatory function tests. In 15 patients, satisfactory BP control was obtained with ICI 66.082 alone, 25-100 mg twice daily. In 5 patients, the addition of hydralazine or a diuretic was necessary for satisfactory response. In 2 patients satisfactory control was not achieved and 3 patients were excluded for various reasons. Although BP and maximal pulse rate fell markedly during exercise, the total work capacity was not significantly reduced. No deleterious effect on ventilatory function was noted.


Production of auxins by bacteria isolated from the roots of pine seedlings (Pinus silvestris L.). Qualitative and quantitative studies were carried out on the production of auxins by Coryneform bacteria, the only bacterial types isolated from roots of pine seedlings. Almost all isolates were capable of producing auxins in tryptophan containing media. In media without this amino acid only trace or no auxins were produced. Most of the bacteria studied synthesized auxins located on the chromatograms run with isopropanol, ammonia, water (10:1:1 v/v) at Rf 0.3--0.5. Moreover substances with Rf values 0.05--0.2 and 0.8--1.0 were produced by some strains. No plant growth inhibitors detected with the Avena coleoptiles biotest were produced by the bacteria studied.


Prospective study among male employees in industry. I. Prevalence of hyperlipoproteinemia. In a primary prevention study performed in an industrial preventive health center in Göteborg, Sweden, 676 male employees, aged 40-67 years, have been screened for the presence of elevated serum lipid/lipoprotein values, and the estimated prevalence of hyperlipoproteinemia (according to the cut points) was 25.8%. The hyperlipoproteinemias were distributed among the three major types, II A, II B and IV, as 12.8, 1.9 and 11.1%, respectively. The incidence of coronary heart disease (CHD) (n = 13), pathologic ECG at rest (n = 42), elevated systolic or diastolic BP, and overweight were compared between 128 males with hyperlipoproteinemia and 100 matched normolipidemic controls from the same population. Hyperlipoproteinemia type IV was most common in males aged 50 (48-52) years. In type IV the mean systolic BP was higher (p less than 0.05) than in the controls and overweight was more frequent, particularly in males aged 50 (p less than 0.05). There were, however, no statistically significant correlations among the variables, serum lipids (cholesterol and triglycerides), BP (systolic or diastolic) and body weight (expressed in relation to height) in type IV. CHD (p less than 0.01) were more common among males with hyperlipoproteinemia than in the controls. The data from the present and earlier studies suggest that hyperlipoproteinemia should be looked for in particular among males aged 50, among males with elevated systolic BP and/or overweight, as well as among males already presenting signs or symptoms of CHD or a pathologic ECG.


Induction of atrioventricular nodal reentrant tachycardia after atropine. Report of five cases. After intravenous administration of 0.5 mg of atropine sustained atrioventricular (A-V) nodal reentrant tachycardia could be produced in five patients who had no prior historical or electrocardiographic evidence of supraventricular tachycardia. During the control period single atrial echo beats could be demonstrated in four of the five patients, but no instance of sustained tachycardia occurred. Atropine, known to enhance A-V nodal conduction, allowed achievement of longer A-H intervals (Case 1) and provided the necessary balance of conduction and refractoriness within the A-V nodal reentrant pathways (Cases 1 to 5) to sustain A-V nodal reentry in these patients.


Progression of coronary artery disease in patients with stable angina pectoris. Arteriographic, ventriculographic and other correlation studies. Left ventriculography and selective coronary angiography with determination of resting left ventricular end-diastolic pressures and ejection fraction have been carried out twice on 25 patients with stable angina pectoris. The interval between the two angiographic studies varied between 7 and 16 months (mean 12.3). Progression of obstruction amounting to occlusion was found in 4 of 73 arteries studied (5%). No new lesions occurred. Resting end-diastolic pressures before and after ventriculography did not change during the observation period. Values for ejection fraction were also unchanged, but there was a tendency for them to decrease in patients in whom this parameter had been abnormal at the first catheterization.


Quantitative study of the supernormal phase of ventricular excitability in man. The supernormal phase of excitability of the human heart was studied by means of fixed rate endocardial pacing in 11 patients with acute and chronic bradyarrhythmias. Ten of the eleven patients manifested a supernormal phase. The duration of the phase increased with increasing intensity of subthreshold stimuli and ranged from 91 to 148 percent of the Q-T interval. Subthreshold stimuli of a wide range of intensity could elicit a full response. Two types of supernormal phase, early and late in relation to the cardiac cycle, were observed. The latter was attributed to the summation of subthreshold stimuli with either spontaneous phase 4 depolarization of a ventricular ectopic pacemaker or atrial depolarization potentials. Its possible connection with Wedensky facillitation was suggested. The ventricle was less excitable after an ectopic beat than after a normally conducted beat.


Long-term treatment with methenamine hippurate in recurrent urinary tract infection. Twenty-four patients with a history of recurrent urinary tract infection and in whom residual urine was considered to be a factor of importance for chronicity, have been treated for an average of 16 months with 1 g methenamine hippurate morning and evening. No patient had urinary calculus at the commencement of treatment and neither did any patient have an indwelling catheter. In patients without urinary tract infection or in whom abacteriuria was achieved with methenamine hippurate, the number of reinfections was reduced by approximately two thirds compared to periods prior to treatment. No patient was completely free from infection throughout the whole treatment period. However, in no case did bacteria with extensive resistance appear. When urinary tract infection was treated with methenamine hippurate, abacteriuria was achieved in only 6 of 14 patients. It would therefore seem that this agent is only of limited value for treatment of established infection. In the event of manifest infection it would appear appropriate to treat the infection primarily with antibiotics and to use methenamine hippurate for prophylaxis when abacteriuria has been achieved. No patient developed urinary calculus during treatment with methenamine hippurate and no deterioration of renal function or haematological change was observed.


Myxoedema coma.

Myxoedema coma. Myxoedema coma is a medical emergency, which must be treated immediately. Otherwise the mortality is high. It is important to administer L-triiodothyronine and corticosteroids early. If hypoventilation occurs, artificial respiration may be necessary. In the two cases of described here the outcome was successful, probably owing to quick substitution. The causes of myxoedema and the symptomatology are discussed.


Hereditary progressive atrioventricular conduction defect. New data on genetics, including an extensive pedigree and certain aspects of natural history, have been compiled on Family S, which is characterized by a hereditary progressive atrioventricular (A-V) conduction defect. Concordance analysis of heart block in affected parents and their offspring suggests as a working hypothesis transmission of diathesis for the defect by means of a Mendelian autosomal dominant factor. Regression of the defect in several relatives, including reversion from first degree heart block to normal A-V conduction, defies explanation at this time. However, rapport established with the unusually large (1,067 members) and cooperative kindred will permit longitudinal evaluation of these findings.


The degree of bone mineralization in chronic renal failure estimated from phosphorus/hydroxyproline ratio in bone biopsies. The degree of bone mineralization is the proportion between the contents of mineral and collagen in bone. As phosphorus (P) and hydroxyproline (Hypro) constitute a constant fraction of bone mineral and collagen, respectively, the P/Hypro ratio in bone tissue provides an estimate of the degree of mineralization. The P/Hydro ratio has been studied in bone biopsies from 42 patients with severe chronic renal failure. A few of them had a subnormal P/Hypro ratio and these patients corresponded to the diagnosis of classical osteomalacia or probably hyperparathyroidism. However, the mean bone P/Hypro ratio was significantly higher than normal, indicating a general tendency towards a higher degree of bone mineralization in patients with chronic renal failure.


Abnormalities of left ventricular function and geometry in adults with an atrial septal defect. Ventriculographic, hemodynamic and echocardiographic studies. Left ventricular function and motion in 12 adults with an ostium secundum atrial septal defect were analyzed utilizing biplane cineangiography. Values for left ventricular end-diastolic volume index, stroke volume index, ejection fraction, left ventricular end-diastolic pressure and mean rate of circumferential fiber shortening were compared with values in an age-matched group of 11 normal subjects. Comparisons of ventriculographic and echocardiographic data were also made in 5 patients and 10 control subjects. Cardiac index was smaller in patients than in the normal subjects (3.6 vs. 4.5 liters/min per m2, P less than 0.01). Although left ventricular end-diastolic pressure was similar (8 mm Hg in both groups), the end-diastolic volume index was significantly smaller in patients than in normal subjects (56 vs. 76 ml/m2, P less than 0.05). Stroke volume index was also significantly smaller in patients (40 vs. 52 ml/m2, P less than 0.01). The two groups had similar values for ejection fraction (65 +/- 2 percent [standard error of the mean] in patients vs. 68 +/- 2 percent in normal subjects), circumferential fiber shortening velocity (1.67 +/- 0.13 vs. 1.81 +/- 0.15 circumferences/sec.), heart rate (91 +/- 7 vs. 90 +/- 5 beats/min) and mean systemic arterial pressure (92 +/- 5 vs. 87 +/- 3 mm Hg). Early systolic bulging of the upper ventricular septum toward the right ventricle was seen in 10 of 12 patients with an atrial septal defect but in no normal subject. Echocardiographic data supported these findings. No other abnormalities of motion were consistently noted. It is concluded that the left ventricle of patients with an atrial septal defect is subnormal in volume and abnormal in sequence of contraction of the septum and is characterized by apparent decreased distensibility.


Phasic left ventricular blood velocity alternans in man. With the use of the Doppler ultrasonic flowmeter catheter, phasic instantaneous left ventricular blood flow velocity was measured by radiotelemetry in 28 subjects during pacemaker-evoked pulsus alternans. Blood velocity alternation was more manifest at faster pacing rates. Four patients demonstrated diastolic blood velocity alternans at the mitral valve. Discordant right heart pressure and left ventricular blood velocity alternation was recorded in three subjects. In one such patient, rate-related shifts of concordant and discordant left ventricular blood velocity alternans occurred. Intermediate or variant forms of alternation, comprising weak and strong beats in a ratio of 2:1, were noted in two subjects. This study provides the first comprehensive description of left ventricular blood velocity alternans in man. The observed phenomena may be related to an altered inotropic state or to beat to beat variations in end-diastolic fiber length.


Iron metabolism in porphyria cutanea tarda. The iron metabolism has been studied in 11 patients with porphyria cutanea tarda. Despite significantly increased amounts of iron in the serum and liver, the porphyria patients absorb not less but significantly more radioiron than normal controls. Whereas phlebotomy-induced iron deficiency stimulates the absorption in controls, no further stimulation is found in the porphyria patients. The plasma iron turnover is high in the porphyria patients, and some of this iron is probably deposited in the liver. The relationship between the high iron absorption, high plasma iron turnover, high liver iron, liver damage and uroporphyrin production in the liver is discussed. It is suggested that two concurrent genetic defects may cause porphyria cutanea tarda, one in iron absorption and one in porphyrin synthesis by damaged liver cells. The absorption of inorganic iron was higher than that of hemaglobin iron. The possible damage which fortification with inorganic iron could cause to the very small group of porphyria patients is discussed.


Clinical applications of the threshold tracking pacemaker. The concept of automatic threshold tracking is the most recent adaptation of artificial cardiac pacemakers to physiologic needs. Earlier pacemaker innovations were primarily in the area of timing of impulse delivery, whereas more recent changes have focused on alteration of the amplitude and duration of the pacemaker stimulus. Matching of this stimulus to the cardiac excitation threshold is important because a stimulus greater than necessary is wasteful of battery energy and may produce arrhythmias, whereas a stimulus of less than threshold intensity fails to pace the heart. Because of the wide range of clinically encountered threshold levels it is impossible to design a fixed output pacer that is efficient and safe for all patients at all times. The threshold tracking pacemaker searches for and finds the threshold level, and adjusts its stimulus to just above this level. The device ensures an adequate safety margin of stimulation, but reduces the stimulus level to the lowest safe level possible. It is fully automatic, adjusts immediately to any threshold changes and is not dependent on manual alteration.


Surgical experience in patients with Marfan's syndrome, ascending aortic aneurysm and aortic regurgitation. Surgical treatment of cardiovascular complications in patients with Marfan's syndrome is usually recommended with apprehension since the systemic nature of the disease predisposes to early and late complications. To define the incidence of these complications, 30 patients were evaluated after surgical treatment of aortic insufficiency and ascending aortic aneurysm at the Texas Heart Institute. To provide a minimal follow-up period of 5 years, only patients operated upon during of before 1968 were included in this series. There were 9 female and 21 male patients aged 4 to 80 years (mean 44 years). Aortic insufficiency was treated by valvuloplasty in 3 patients and by aortic valve replacement in 27. Graft replacement of the ascending aorta was required in 23 patients, and the aneurysm was excised and the aorta repaired by direct anastomosis in 7. Two patients were lost to follow-up study; 12 of the remaining 28 (42.8 percent) lived 5 years or more. The hospital mortality rate was 20 percent (6 of 30); the causes of death included dissection or rupture of the aorta in three patients, congestive heart failure in two and pulmonary embolism in one. The 24 survivors lived from 5 weeks to 9 years. Follow-up data were available on 22 of these patients. Ten of these (45.4 percent) died of late complications. Seven died suddenly, four of these had redissection, one patient had occlusion of the right coronary artery, and two had ventricular fibrillation of no apparent cause. The remaining three died of noncardiac causes. Although the risk of ascending aortic and aortic valve surgery in patients with Marfan's syndrome is high, 42.8 percent of the patients in our series survived 5 years or more. We believe that surgery should be recommended for patients with Marfan's disease who have dissection of the aorta or severe aortic regurgitation, or both.


Echocardiographic findings of ventricular septal rupture in acute myocardial infarction. Echocardiograms were recorded both before and after the clinical appearance of an autopsy-confirmed interventricular septal rupture in a patient with an acute myocardial infarction. The major findings were related to the upper portion of the interventricular septum. Before rupture, this portion of the septum was relatively akinetic with a slight anterior motion during systole, whereas after rupture there was a marked increase in the amplitude of septal motion with abrupt posterior motion occurring with the onset of ventricular diastole.


Echocardiographic findings in Uhl's anomaly. Demonstration of diastolic pulmonary valve opening. The echocardiographic findings in a case of Uhl's anomaly, or congenital hypoplasia of the right ventricular myocardium, are reported. Diastolic opening of the pulmonary valve is described. Comparison is made with echocardiograms in Ebstein's disease of the tricuspid valve, and it is suggested that echocardiography can help in differentiating these two entities. In addition to the pulmonary valve finding, increased right ventricular dimension, delayed tricuspid closure and abnormality (prolapse) of the mitral valve were noted. The echocardiographic findings are compared with cardiac catheterization data.


Revascularization after 3 hours of coronary arterial occlusion: effects on regional cardiac metabolic function and infarct size. Two experimental series of closed chest dogs were compared: Group A (five dogs with 7 days of continuous occlusion of the proximal left anterior descending coronary artery); and Group B (six dogs with 7 days of reperfusion after 3 hours of acute occlusion of the same artery). Hemodynamic measurements, ventricular wall motion, coronary sinus blood flow and regional metabolism in both coronary occluded and nonoccluded segments of the left ventricle were measured sequentially. The infarct size was characterized by detailed histopathologic analysis. In the control dogs (Group A), mechanical and metabolic function remained severely depressed after 7 days of occlusion, and mean infarct size was 31.6 percent. In Group B, significant mechanical and metabolic dysfunction developed during 3 hours of occlusion and did not improve during the 1st hour of reperfusion. However, after 7 days of reperfusion, function returned to near preocclusion level. Mean infarct size was 14.2 percent, but in two of the six dogs infarct size was 43 percent and 23 percent, respectively. The study confirmed the unstable character of the early phase of reperfusion, attributed to cell swelling, edema and hemorrhages that resulted in inadequate coronary reflow, arrhythmias and functional derangements. Prolonged reperfusion for 7 days reduced mean infarct size and improved cardiac function.


Consequences of coronary arterial occlusion on remote myocardium: effects of occlusion and reperfusion. Focal necrosis (microinfarcts) and regional lactate derangements were observed in closed chest dogs in the nonoccluded (remote) posterior segments of the left and right ventricles after acute occlusion of the proximal left anterior descending coronary artery. Focal infarcts in the remote areas were observed in five of the six dogs with 7 days of occlusion of the left anterior descending artery and in six of seven dogs with 7 days of reperfusion after 3 hours of occlusion. There was a good correlation between the finding of microinfarcts and myocardial lactate derangements in the corresponding remote myocardium. No significant lactate derangements or microinfarcts were found in sham experiments. These findings suggest that ischemia of the remote myocardium frequently accompanies an acute coronary occlusion and may result in irreversible focal lesions.


The origin of the follicular capillaries in the human spleen. The major arteries which supply the follicular capillaries in the human spleen do not arise as they do in most mammals as lateral or radial branches from the central artery but come from penicillar arteries which penetrate the marginal zone and enter the follicle at various points around its circumference. Such arteries may have a very short course through the red pulp or they may pursue very long courses. Upon entering the follicle, these arteries branch a number of times, the branches remaining together in a tight array of parallel arterioles along with capillaries formed from them, the whole bundle being enveloped by a reticular fiber sheath. There is thus formed an arteriolar-capillary bundle. The whole bundle may branch. From the sides, especially from its central end, arterioles and capillaries radiate out to all parts of the follicle to terminate in the marginal zone or in the follicle itself.


An unusual type of cilium.

An unusual type of cilium. The connective tissue cells of the dentinal pulp of unerupted dog teeth possess occasional cilia. Internally there are 4 to 8 peripheral doublets and one central doublet. Nine peripheral doublets are observed only close to or near the basal body.


Creatine kinase isoenzymes. Predictive value in the early diagnosis of acute myocardial infarction. This is a prospective study of the value of the creatine kinase (CK) isoenzyme determination in the early diagnosis of acute myocardial infarction. The presence or absence of the MB isoenzyme was correlated with electrocardiogram and standard enzymes. The frequency of falsely positive and falsely negative results for CK-MB, electrocardiogram and each standard enzyme was calculated and, using the elements of conditional probability theory, their predictive values for the diagnosis of acute myocardial infarction were determined. Results indicate that CK-MB combines the best attributes of the electrocardiogram and standard enzyme tests: detectable MB isoenzyme activity by acrylamide slab electrophoresis has a predictive value for the diagnosis if acute myocardial infarction comparable to that of a positive electrocardiogram; absence of MB isoenzyme activity, in the 24 hour period following the onset of symptoms, excludes the diagnosis of acute myocardial infarction with a probability equivalent to that provided by normal standard enzyme results.


Idiopathic ventricular tachycardia. An intracardiac electrical, hemodynamic and angiographic assessment of six patients. Six patients with idiopathic paroxysmal ventricular tachycardia were investigated by external electrocardiography, intracardiac electrography and pacing, exercise testing, cardiac catheterization and coronary angiography.  All had normal hemodynamics and coronary arteries. His bundle electrography proved ventricular origin in five; one had no paroxysmal ventricular tachycardia during His bundle electrography. Treatment with diphenylhydantoin, 4.2 to 8.0 mg/kg/day, and propranolol, 0.8 to 2.7 mg/kg/day, appeared effective, well tolerated therapy in three, and procainamide and propranolol in one requiring medical treatment. Abstinence from tobacco and coffee abolished paroxysmal ventricular tachycardia in one of two who required no medication. The other has no recurrence of paroxysmal ventricular tachycardia since study.


Waterborne typhoid fever in Dade County, Florida. Clinical and therapeutic evaluation of 105 bacteremic patients. An extensive outbreak of waterborne typhoid fever occurred in 1973 at a migrant labor camp in Dade County, Florida. Blood cultures from 105 of the 188 patients with proved or presumptive cases of typhoid fever grew Salmonella typhi. The clinical and laboratory findings in these patients were reviewed. Fever, usually with temperatures above 38.8 degrees C and of the sustained type, was a primary manifestation of disease, although a majority of the patients also complained of headache and gastroenteric symptoms. Hepatic or splenic enlargement was present in 52 per cent and 42 per cent, respectively, whereas rose spots were detected in only 13 per cent. The total leukocyte count was normal in 74 per cent, but serum levels of liver and muscle enzymes were frequently elevated. Gastrointestinal, pulmonary and neurologic complications were infrequent; circulatory failure was not observed. Defervescence in response to antibiotic therapy was variable; however, the median response among 68 patients who received chloramphenicol was two days less than that in 34 patients treated with ampicillin. There was one possible treatment failure with ampicillin. The relapse rate of 10 per cent in chloramphenicol-treated patients was not significantly greater than the 3 per cent rate among those treated with ampicillin. Serologic studies for typhoid fever were of limited diagnostic value since the titer of agglutinins was 1:160 or higher in 49 per cent of the serums obtained before treatment, and a fourfold rise in titer occurred in only 24 per cent of 57 patients studied. The serologic response to chloramphenicol treatment did not differ from that to ampicillin.


Lung biopsy in immunocompromised hosts.

Lung biopsy in immunocompromised hosts. Ninety-five lung biopsy procedures in 78 immunocompromised patients yielded treatable diagnoses in 35 per cent of the needle aspirates, 46 per cent of the cutting needle biopsies and 65 per cent of the open thoracotomies. Complication rates of bleeding or pneumothorax were comparable to those previously described in nonimmunocompromised patients. In patients with coagulation defects, the risk of having bleeding complications was high. Among 44 patients with primary lymphoma, 22 (50 per cent) had a lymphomatous infiltrate in the lung. Twenty-two patients with severe hypoxemia were studied and their mortality, although significantly greater than in the patients without hypoxemia, was marginally improved when a treatable lung lesion was found. The over-all recovery rate was 70 per cent when a treatable diagnosis was made in contrast to 25 per cent when there was no specific diagnosis. Hence lung biopsy, particularly by thoracotomy, appears to be a valuable procedure in immunocompromised patients who have otherwise undiagnosable lung lesions.


The prognostic and therapeutic implications of DNA:anti-DNA immune complexes in systemic lupus erythematosus (SLE). Serum samples serially obtained from 50 patients with systemic lupus erythematosus (SLE) were studied for antibody to deoxyribonucleic acid (DNA) and circulating DNA:anti-DNA complexes during the active and inactive phases of their disease. The patients were divided into four categories: Group I: six patients without clinical evidence of central nervous system (CNS) or renal involvement. Group II: three patients with CNS lupus. Group III: nine patients with normal urinalyses and glomerular filtration rates, but morphologic evidence of glomerular disease. Group IV: 32 patients with overt lupus nephritis. Elevated anti-DNA levels were observed in 16 of 18 patients (88 per cent) in groups I, II and III during active disease. This persisted in 14 (77 per cent) during remission. DNA:anti-DNA complexes were demonstrated in four of 18 (22 per cent) during active disease and disappeared in all but one patient with progressive disease. In 30 of the 32 patients (94 per cent) in group IV, DNA binding was increased during active disease; this persisted in 21 (70 per cent) despite remission. Complexes were observed in 25 of the patients in group IV (78 per cent) with active disease. In six of these patients, complexes have persisted; two have died, one has progressed to renal failure and the remaining three patients continue to manifest active disease. This study suggests that measurement of DNA:anti-DNA complexes provides a valuable additional index of disease activity and prognosis in SLE.


Bartter's syndrome. New insights into pathogenesis and treatment. Discussed here is a patient with normotension, hypokalemic alkalosis, hyperreninemia, hyperaldosteronism, juxtaglomerular cell hyperplasia and insensitivity to the pressor effects of angiotensin (Bartter's syndrome). The hyperreninemia and hyperaldosteronism were both suppressible with volume expansion. Hypokalemia was correctible both short-term with potassium chloride infusions and long-term with spironolactone. Nevertheless, the abnormal pressor response to infused angiotensin could not be corrected by these maeuvers, suggesting that this defect is likely to be of primary pathophysiologic significance. We found that potassium loading markedly stimulated aldosterone excretion. This may explain the inadequacy of potassium supplementation alone to correct the hypokalemia and the observed "escape" from the potassium conserving effects of spironolactone seen in patients with Bartter's syndrome. The administration of propranolol in large doses only partially suppressed the marked hyperreniemia of our patient and failed to prevent a subsequent rise in the renin level which was associated with spironolactone therapy. In contrast, suppression of the renin level to normal was demonstrated by sodium loading. It is suggested that patients with Bartter's syndrome be treated simultaneously with large doses of spironolactone and a high sodium intake.


Chromatin-positive Klinefelter's syndrome with undetectable peripheral FSH levels. An 18 year old phenotypic man is described with chromatin-positive Klinefelter's syndrome and undetectable peripheral human follicle stimulating hormone levels. The subject manifested chromosomal mosaicism consisting of three stem cell lines (45X; 46XY; and 47XXY). Testicular biopsy specimen showed germinal cell aplasia: the tubules were lined by Sertoli cells only, whereas the Leydig cells appeared normal. Serum human follicle stimulating hormone levels were undetectable and rose to only 5 mIU/ml after the administration of luteinizing hormone releasing hormone. Serum human luteinizing hormone varied between normal and moderately elevated values, and serum testosterone was in the low normal range. We discuss the features which distinguish this syndrome from isolated gonadotropin deficiency and from classic germinal cell aplasia. We suggest that the patient represents a new variant of Klinefelter's syndrome, with failure of human follicle stimulating hormone release secondary to prolonged hypersecretion.


The intrauterine device and tubo-ovarian abscess. During the past 4 years, 16 patients have been seen who developed a unilateral tubo-ovarian abscess while wearing, or soon after removal of, an IUD. None of the patients had gonorrhea. There appears to be a prodromal syndrome before abscess formation of 2 to 5 weeks during which the patient complains of vague lower abdominal pain, pelvic tenderness, and dyspareunia. A few patients had a rapid onset of symptoms. The device should be removed when prodromal symptoms arise and the patient should be treated with antibiotics. Should a tubo-ovarian abscess develop, surgical intervention is necessary.


Operative management of early invasive epidermoid carcinoma of the vulva. The clinical records and surgical specimens of 60 patients with squamous cancers of the vulva less than 2 cm in size (TI) were studied. Fifty-eight patients had stromal invasion 5 mm. or less in depth. Three of the 60 patients (5 per cent) had pelvic lymph node metastases; two of these three showed invasion of vascular channels; the third patient's tumor showed cellular anaplasia. In an effort to reduce patient morbidity in radical surgery for vulvar carcinoma, while achieving comparable survival data, an operative approach less radical than radical vulvectomy, inguinal dissections, and/or pelvic lymphadenectomy is proposed for selected patients.


Multiple primaries and gynecologic malignancies. An analysis was done on all gynecologic malignancies over a 13 year period to review the frequency and types of multiple primaries. A surprising spectrum of malignancy is seen and certain radiologic studies are of particular value. The time from occurrence of the various extragenital and genital tract cancers to the original gynecologic malignancy is shown. The per cent and types of malignancies that subsequently develop after a genital tract cancer are discussed.


Monitoring health care.

Monitoring health care. Health risk determinants in obstetrics and gynecology are readily obtainable from state birth records. This study demonstrates the manner in which these determinants may be used to assess health care delivery and monitor its progress. The over-all problem is quite complex. Some parameters are interrelated, while others are not. In addition, any specific parameter may be causally related to many different antecedents, acting singly or in combination. Hence, one must take care not to generalize about deficiencies in our health care systems and thereby propose simplistic, unworkable solutions. However, the study does clearly identify certain specific areas of risk which deserve greater attention than they have hitherto received from health care officials, physicians, and responsible citizens. We believe that the approach outlined in this paper offers a means to achieve unbiased, ongoing monitoring of health care, which may, in turn, be used in attempts to improve the delivery of health services.


Preliminary evidence of a role for prostaglandin F in human follicular function. Animal studies have shown that LH causes an increased synthesis of PGF by ovarian follicles both in vivo and in vitro. In lower animals, there is strong evidence that PGF acts as a mediator of certain LH effects, including maturation and extrusion of the ovum. Ovarian follicular tissue of 12 patients was halved or quartered and maintained in organ culture. Part of each follicle was exposed to gonadotropins throughout the culture period, while controls received no treatment. All tissues continued to synthesize PGF but in 11 cases the amount was greater in the gonadotropin-treated. It is concluded that PGF probably plays a role in human follicular function, including ovulation, and may act as a mediator of certain LH functions.


Regional chemotherapy--a comparison of pelvic perfusion and intra-arterial infusion in patients with advanced gynecologic cancer. Forty-patients with advanced gynecologic cancer were treated with two different regional chemotherapeutic techniques. They were divided into two comparable groups. Twenty were treated by isolated regional perfusion and 20 were treated by intra-arterial infusion. The simple technique of intra-arterial infusion had a much lower mortality rate and gave equally satisfactory results when compared with the more complicated "closed" pelvic perfusion method. This comparative study suggests that the further use of isolated pelvic perfusion should await improvements in techniques and the development of more rapidly acting drugs. Further efforts in the area of infusion should be directed toward the development of more rapidly acting drugs, the development of better tumor-cytotoxic drug sensitivity tests, better use of the newer knowledge of cellular kinetics, and improved techniques for accuracy in the placement of arterial infusion catheters. While it is felt that regional chemotherapy has a place in management, it is not being proposed as a substitute for surgery or radiotherapy in the patient who will benefit from orthodox treatment.


The madness of art.

The madness of art. The author finds a constant thread of what Benjamin Rush termed "tristimania" in works of great authors. The madness of art, Henry James's description of the need to transform and metamorphose personal experience by means of prose, poetry, or other artistic expression, is illustrated in the lives and works of many great writers. Psychotherapy as a means of dealing with depression in artists can be either rejected or used to advantage. The author posits that the most enduring works may be those of artists who have lived through their sadness to experience and control their rage against aging.


Patterns of illicit drug use in the Army. The authors collected detailed histories of illicit drug use in the Army in individual interviews with a stratified random sample of 262 enlisted men at six military posts across the United States. Approximately half of the sample (N equals 128) were classified as drug users; 90 of these individuals were identified as career multiple-drug users. Most of these subjects used a variety of drugs in frequently changing patterns. The authors emphasize the individualistic nature of drug use and question the appropriateness of an addiction model for most users of illicit drugs.


The lithium clinic: a new model for the delivery of psychiatric services. Advances in the diagnosis of recurrent affective disorders and consistently high levels of lithium prophylaxis have made it possible to treat manic-depressive disorders on an outpatient basis. The author describes the experiences and organization of a lithium clinic that has operated for 15 years. Utilizing the services of trained paramedicals and a small medical staff, the clinic has efficiently served a large patient population. The author suggests that centers using this model could serve the community by increasing the availability of specialized psychiatric care.


Mood changes in an alcoholism treatment program based on drinking decisions. The authors compared the amount of discomfort experienced by 18 alcoholic men who chose to drink and 43 alcoholic men who abstained from drinking during a 6-week treatment and research program. They found that the discomfort of the drinkers increased  but that the discomfort of the abstainers decreased. The increase in the drinkers' discomfort appeared to be more related to their having to make a decision about drinking than to the amount of alcohol actually consumed. This finding emphasizes the importance of the role played by environment in affecting the mood state of drinking alcoholics.


Persecutory delusions: a cybernetic model. The authors propose a cybernetic model for the formation and maintenance of persecutory delusions. During the formation of persecutory ideation, the threat of loss of control over the self or others interacts with predictions of control from others. This interaction may result in feelings of alien control followed by persecutory explanations. Since the persecutory explanations provide the individual with a new goal of resisting others' influence in order to prevent being controlled, they reduce the threat of loss of self-control. This is how persecutory delusions are maintained.


Basic concepts in family therapy: a differential comparison with individual treatment. The author presents basic differences between the approaches of family therapy and of the individual therapies on three dimensions: personality development, symptom formation, and the approach to producing therapeutic change. Family therapy bases its view of these factors in psychotherapy on the idea that they are determined by the family's functioning as an interderdependent transactional unit; the individual therapies base their views of these factors on the idea that they are determined by the dynamic intrapsychic functioning of the individual alone.


Psychotherapy of borderline patients: the influence of theory on technique. Although the treatment of borderline patients has attracted increased attention, there is little agreement on the basic nature of the disorder or the proper techniques for its treatment by analytically oriented psychotherapy. The author states that treatment based on the idea that the borderline patient achieves therapeutic gains by raging against an accepting therapist for a prolonged period of time is not so effective as treatment based on the recognition of specific ego defects as the core pathology. He suggests that the therapist be active in the treatment of borderline patients and not permit gross and unproductive distortions of the therapeutic relationship.


Patients' and observers' assessments of process and outcome in group therapy: a follow-up study. A six-month follow-up investigation of process and outcome in group therapy was conducted by the authors and patients in two therapy groups. The results indicated that although there were discrete stages in the therapeutic sequence, acceptance was the most beneficial process variable for both groups.


The use of a written summary in group psychotherapy supervision. Clinical supervision is an important feature of the education of the group therapist. The authors describe the application of a summary written by trainee cotherapists in their supervision. They found that the summary, which is supplied to the patients as well as to the supervisor, serves several functions that contribute to improved quality of clinical supervision and training of group therapists.


Psychotherapy patient transfer: secondhand rose. The author uses the analogy of the marketplace to examine the dynamics of the transfer of psychotherapy patients in university clinic settings. The outgoing therapist is the seller, the prospective therapist the buyer, and the patient the commodity--the secondhand Rose. Marketing techniques that are used in this buyers' market allow no active patient participation and are therefore antithetical to the tenets of psychotherapy. The author suggests early clarification of therapeutic goals, assignment of therapists on the basis of patient choice, and explanation of time frames and limits as means for ameliorating the problems he describes.


Issues in developing psychotherapy groups for preschool children in outpatient clinics. A survey of 10 randomly selected clinics indicated that only 1 offered group psychotherapy for preschool children. Reasons given for the lack of such programs resembled the resistances encountered in the authors' clinic. The authors describe the solutions they found in creating and running therapy groups for preschool children and in integrating parent counseling with this treatment. It is suggested that professional groups provide in-service training opportunities in this area to counteract resistances resulting from clinic staffs' perceived lack of experience and expertise.


Controversy in medicine and psychiatry.

Controversy in medicine and psychiatry. Factual and ethical controversies confront physicians in medicine as well as in psychiatry. If psychiatrists can impart a perspective on these controversies and their growth-stimulating quality to medical students and thereby increase their tolerance for uncertainty, they will aid them in becoming better physicians and will perhaps also remove one reason for their disinterest in psychiatry.


Positive therapeutic response to lithium in hypomania secondary to organic brain syndrome. A 57-year-old man with no personal or family history of manic-depressive disease developed symptoms of hypomania after a cerebrovascular accident and surgical trauma to the brain. The patient responded well to lithium carbonate treatment over a 2-year period. Although this therapy is contraindicated in cases of organic brain syndrome, the authors suggest that it should be considered in the management of hypomanic behavior following organic brain dysfunction.


Prolonged psychosis attributed to phencyclidine: report of three cases. After ingesting street drugs sold as "PCP," "THC," and "methadone," three young men developed schizophreniform psychoses, analgesia, anesthesia, and amnesia for the psychotic state. Except for their unusually long duration of 2 to 4 weeks, these reactions resembled phencyclidine psychoses. The authors are aware of other phencyclidine-related hospital admissions but could find no information on phencyclidine in recently published handbooks on drug abuse.


The chief resident as reluctant staff therapist. The author discusses the interactional process between the chief resident and ward staff, with reference to Bion's theory of group functioning. He concludes that the primary task of the chief resident is to serve as psychotherapist to the staff, and that this in not a chosen role but derives from the staff's wish for such a leader.


Overview: the right to treatment--comments on the law and its impact. The constitutional right to treatment has now become an accepted premise of litigation in the United States. It lacks only the imprimatur of the Supreme Court. The author presents a brief description of the history of right to treatment cases and comments on the problems and possibilities the law holds for psychiatry. He warns that psychiatric institutions must be aware of the costs and benefits of such litigation and must obtain skilled legal counsel to advise them of their rights and obligations. He calls on psychiatry as a profession to participate in right to treatment litigation and to attempt to shape legal standards so that future generations of psychiatrists can provide appropriate care to patients.


The phasing out of mental hospitals in the United States. The authors view the current wave of closing state mental hospitals against the background of trends in mental health services during the past 20 years. Although a small number of hospitals has been totally closed, the overall number of institutions has remained stable due to the opening of new hospitals, and many states will be forced to consider phasing out additional hospitals in the immediate future. The closing of hospitals is a social phenomenon that involves the lives and welfare of patients, personnel, families, and the community and poses a substantial political and logistical challenge. The authors make a few suggestions for those who are contemplating closing hospitals in the future.


Diagnostic subgroups of affective disorders and their urinary excretion of catecholamine metabolities. Previous reports have indicated that some depressed patients excrete less than normal quantities of 3-methoxy-4-hydroxyphenyl glycol (MHPG). The authors present data indicating that a subgroup of depressed patients who excrete less than normal quantities of MHPG may be identified by the application of explicit clinical criteria. They found no significant difference in the excretion of normetanephrine (NM), metanephrine (M), and 3-methoxy-4-hydroxymandelic acid (VMA) among any of the diagnostic subgroups or between each patient group and a healthy comparison group. However, depressed patients diagnosed as having primary affective disorder and bipolar illness excreted significantly less MHPG than did the healthy comparison group.


Growth hormone catecholamines in affective disease. The authors studied growth hormone (GH) release after insulin-induced hypoglycemia (HI) in relation to urinary MHPG, the major metabolite of central norepinephrine. There was a significant linear correlation of urinary MHPG levels and GH peaks after HI in unipolar depressed patients and in manic patients; however, GH peaks in manic patients shifted downward on the GH axis in comparison to the unipolar depressive patients. The authors suggest that such shifts in the GH response may occur as a result of abnormalities of other neurotransmitter systems also known to facilitate GH release.


A hierarchy of drug use in adolescene: behavioral and attitudinal correlates of substantial drug use. The authors studied drug use in a representative sample of suburban junior and senior high school students. They found high levels of drug use overall and a substantial amount of drug involvement among junior high school students. They also found that drugs were used in clusters, that there was a distinctive age-related pattern of drug use, and that the progressive-step therory of drug use was not confirmed. A number of behavioral and attitudinal variables correlated with a tendency toward a high level of drug use. The implications of these findings include the need for targeted drug education and prevention programs and a differentiated approach to the study of drug use among adolescents.


History and analysis of a leaderless group of professional therapists. The authors describe the experiences of a group of 11 psychiatrists and psychologists who met for 3 years with the initial purpose of providing peer supervision in group therapy. The group became a basic assumption dependency group in which all members had both realistic and magical expectations for help with their personal lives, and a resulting attempted transformation into a leaderless therapy group was a failure. The authors indicate that the experiences of this group illustrate some of the functions of group-leader interaction in allowing group and individual growth.


Season of birth in schizophrenia and neurosis. National studies in Scandinavia and in England and Wales have shown that schizophrenic patients are born significantly more often in the early months of the year than would be expected from comparison with the general population. The author examines additional evidence from England and Wales and discusses possible sources of technical error. Although there is currently no evidence of a causal association between season of birth and schizophrenia, he suggests that this possibility should be given consideration.


Cortisol, growth hormone, free fatty acids, and experimentally evoked affective arousal. Eight male volunteers who viewed selected control, suspense, and erotic films experienced significant changes in affect that were limited to fatigue, anxiety, and sexual arousal, respectively. All subjects showed free fatty acid elevations with the suspense and erotic films and those subjects with the most anxiety and sexual arousal showed cortisol elevation with the suspense and erotic films, respectively. Growth hormone elevations occurred independently of cortisol elevations and were not clearly related to film or affect. Thus, activation of the pituitary-adrenocortical and sympathetic nervous systems appears to occur not in relation to a specific dysphoric state but rather with nonspecific affective arousal.


The coordination of mental health services at the neighborhood level. The neighborhood health center is becoming a major locus of mental health care delivery. Because of their strategic position at the neighborhood level, mental health care systems in the comprehensive health center locus have been able to develop linkages with both general health and community mental health systems to provide a broad continuum of coordinated health and mental health care. Four models identified in a survey of 19 neighborhood mental health programs are described. The authors suggest that persistent problems in coordination of care between neighborhood mental health and other caregiving systems would be considerably alleviated by a fiscal reimbursement scheme that rewarded integration rather than fragmentation of care.


A comparison of two methods of diagnosing hysteria. The authors compare the syndrome of hysteria, defined as or indicated by a specified response to a 55-item symptom checklist previously used by Guze and other researchers, with the definition of hysterical personality in the second edition of APA's Diagnostic and statistical Manual of Mental Disorders (DSM-II). When 20 control subjects and 10 hysterical personalities (DSM-II) were given the Perley-Guze test, the results showed a close correlation between positive scores on the symptom checklist and the DMS-II diagnosis. The authors comment briefly on the theoretical usefulness and practicality of the test and note some difficulties in administration.


The use of bethanechol chloride with tricyclic antidepressants. The author describes the use of bethanechol chloride to relieve side effects, including salivary inactivation, constipation, and bladder inhibition, which result from the anticholinergic action of tricyclic antidepressants. He suggests that the use of cholinergic medication during antidepressant therapy may extend the use of the tricyclics to patients who find anticholinergic side effects especially troublesome.


Conspiracy of silence: psychiatric counseling with students at high risk for academic failure. The authors examined the academic records and counseling histories of 132 freshman students at a state university who sought psychiatric counseling. They found that most students with poor previous academic performance were not helped academically by brief (crisis intervention) psychiatric counseling. They also found that many couselors resisted confronting such students with their academic inadequacies.


Delirium tremens in a nine-year-old child. The authors report a case of delirium tremens in a 9-year-old American Indian boy, who was later found to have been drinking steadily for 3 years prior to his emergency admission for agitation and delirium. The authors suggest that the use of alcohol by children is an activity that may be more common than most physicians realize.


Suicide rate of callers to a poison information service. The authors assessed the frequency of suicide subsequent to calls to a poison information center in a follow-up study. The 8 confirmed suicides out of 2,177 calls yielded a rate of 66.8 per 100,000 population--significantly higher than that for the general population. In addition, 15 possible or probable suicides were identified. The authors note that poison center callers seem to constitute a pool of significantly suicidal persons and reaffirm the premise that poison centers and suicide centers should coordinate their efforts.


Affect, mood, emotion, and feeling: semantic considerations. There is considerable variation in the use of words that describe emotional experience and expression. The author illustrates this semantic problem by reviewing the use and definitions of the terms "affect," "mood," "emotion," and "feeling" in some classical and contemporary works of psychiatry and psychology. He concludes that these words refer to distinct pscychological phenomena and suggests that they be used clearly and carefully to facilitate communication about emotions.


Early and late obstruction of the small bowel after abdominoperineal resection. A series of patients with early or late obstruction of the small bowel after abdominoperineal resection is studied. Immediate intervention is recommended in patients with early obstruction; adhesions and defects of the pelvic floor are the most common etiologic factors in this group. Recurrent pelvic carcinoma with associated obstruction of the small bowel is the primary etiologic factor in patients with late obstruction. Bypass operation provides the best palliation. Simple adhesions continue to be a significant etiologic factor. No obstruction related to spaces created by colostomy was encountered.


Colostomy. Intraperitoneal or extraperitoneal closure? Forty-three patients who underwent intraperitoneal closure of colostomy are reported on. Complication rates of 4.6 per cent for wound infection and 4.6 per cent for fecal fistulas appear significantly lower than the 10 to 21 per cent complication rates reported for colostomy closure using other technics.


Smooth muscle tumors of the stomach.

Smooth muscle tumors of the stomach. A series of fifty-one smooth muscle tumors of the stomach seen at the Massachusetts General Hospital over a twenty year period is reviewed. Virtually all benign tumors were asymptomatic and were discovered in the course of autopsy or an unrelated operation. Malignant tumors frequently caused symptoms. Contrast studies and endoscopy, although they confirmed the presence of the lesions, were of limited value in differentiating between benign and small malignant tumors preoperatively. Eighty-two per cent of the malignant lesions were well circumscribed, and 57 per cent of patients with gastric leiomyosarcomas survived at least five years after resection. Benign tumors may be treated by local resection, but malignant tumors should be resected widely, with involved adjacent organs if technically feasible.


Current status of heparin dissolution of gallstones. Experimental and clinical observations. Investigation of the use of heparin in bile indicates that it has the ability to disperse suspended particles. Clinical experience using a heparinized saline flush in forty-three patients with retained gallstones demonstrated disappearance of the stones in thirty-one of the patients. On this basis we would recommend this treatment for further clinical trials in patients with retained common duct stones.


Lumbar sympathectomy in the treatment of peripheral vascular occlusive disease. Ten year study. A study of the results of lumbar sympathectomy in the treatment of peripheral vascular occlusive disease has been presented. Results continue to be encouraging in properly selected patients, as they have been since 1947.


Iliofemoral thrombophlebitis associated with central nervous system pathology. It is very uncommon for acute thrombophlebitis to develop in children without an identifiable predisposing cause. During a ten year period at a children's hospital, central nervous system disease was observed in four of eight children with iliofemoral thrombophlebitis. This association suggests that a thorough neurologic evaluation should be carried out in any child with acute thrombophlebitis.


Prevention of cerebral infarction in the dog by intact omentum. Three groups of dogs underwent total occlusion of the right middle cerebral artery close to its junction with the internal carotid artery. Dogs that had omentum placed on the brain prior to occlusion of the middle cerebral arterial withstood this deprivation of normal cerebral blood flow in a statistically significant manner when compared with dogs that had no omental protection or had omental placement on the brain simultaneous with middle cerebral artery occlusion. These results raise the possibility that use of the intact omentum might be another technic for revascularization of the brain in patients with transient cerebral ischemic attacks or brain dysfunctions secondary to diminished cerebral blood flow who presently are not candidates for routine surgical procedures for cerebral revascularization.


Inadequacy of steroids in the treatment of severe hemorrhagic shock. Massive doses of methylprednisolone were given to dogs prior to severe, lethal, hemorrhagic shock. An untreated group of dogs subjected to hemorrhagic shock served as controls. No persistent significant differences were seen in cardiac output, mean arterial blood pressure, superior mesenteric artery flow, and survival. Calculated total peripheral resistance tended to be lower in the treated dogs and was significantly lower after reinfusion of shed blood. Pretreatment with methylprednisolone did not prevent plasma elevations of the lysosomal enzymes, cathepsin D and beta-glucuronidase. Stabilization of hepatic lysosomes in treated dogs subjected to hemorrhagic shock was not evident. The results failed to indicate significant salutary effects of methylprednisolone sodium succinate in this lethal hemorrhagic shock model.


Moderate hemodilution technic in surgical procedures. Blood electrolyte balance in patients undergoing operation for gastric and duodenal ulcer. Studies to determine selected blood electrolyte concentrations showed no disturbances in serum sodium, chloride, and copper concentrations during and after moderate hemodilution to 30 per cent of hematocrit. Sudden significant decreases in serum potassium, magnesium, and total calcium concentrations at ten minutes after hemodilution were the result of physical dilution only and did not have negative effects on organs, especially the heart. We observed a significant decrease in serum iron concentration with a gradual return to the control value; we cannot explain this phenomenon because it resulted neither from dilution nor blood loss. Our results require that caution be exercised and that the dilution fluid employed be changed when more significant hemodilution (below 30 per cent of hematocrit) is intended, so that suspected, more intensive sudden alterations in electrolyte concentration are prevented.


Renal artery stenosis: a complication of needle puncture for manometry. Case of subintimal dissection with spontaneous resolution. After aortorenal bypass for renovascular hypertension secondary to atherosclerosis of the renal artery of a solitary left kidney a high-grade stenosing lesion developed distal to the site of insertion of a Dacron graft. In the immediate postoperative period the blood pressure was restored to normal, but one week later hypertension recurred. An arteriogram disclosed an area of stenosis 1 cm distal to the site of insertion of the graft in the renal artery. During the next year, serial arteriograms were made, renal function remained normal, and hypertension gradually abated. One year after the discovery of the postbypass stenosis, an arteriogram showed disappearance of the constricting lesion. The postoperative stenosis was, in all probability, caused by subintimal dissection secondary to needle puncture for strain gauge manometry.


Gastric aneurysms: unusual lesions with lethal potential. Extravisceral gastric aneurysms are rare lesions infrequently producing symptoms prior to life-threatening intraperitoneal rupture. Elective resection is indicated in those unusual cases diagnosed preoperatively. Ruptured visceral aneurysms should be included in the differential diagnosis of obscure intraperitoneal hemorrhage. In contrast, intramural gastric aneurysms produce massive hematemesis managed successfully in two cases by subtotal gastrectomy. Acknowledgment: I wish to thank Doctors Stephen A. Ockner and John Cacciamani for the kind referral of their patient and Doctor Edito Cabal, St. Louis Veterans Administration Hospital, who performed the arteriography.


Myelolipoma of the adrenal gland. Angiographic findings and review of the literature. Myelolipoma of the adrenal gland is a rare tumor. It has been surgically excised in only five cases, including the one described in this report. However, review of the literature reveals a total of one hundred thirty cases. Although more than 96 per cent of these lesions were found incidentally at autopsy and more than half could be appreciated only microscopically, it is clear that these tumors can grow sufficiently to become symptomatic, undergo hemorrhage, and require operation. The clinical angiographic and pathologic features of myelolipoma are described. Although endocrine function of this tumor has never been demonstrated, related experimental evidence of others is summarized because it suggests that complete endocrinologic evaluation of patients with suspected myelolipoma is indicated. Despite the rarity of the tumor, we believe that the radiologic and clinical features of myelolipoma that we have described may allow preoperative diagnosis in the future.


Unique case of mesenteric fibrosis in multiple polyposis. A massive mesenteric fibroma in a patient who had had subtotal colectomy for familial polyposis necessitated resection of all but the proximal 3 to 4 feet of small bowel. The patient is alive and well with few stigmata of short bowel syndrome. Acknowledgment: We wish to thank CAPT Malcolm L. Cowen, USN, MC, Chief of the Department of Pathology, for histopathologic photomicrographic study and extensive laboratory data.


Alternate technic for operative cholangiography. Occasionally the cystic duct cannot be cannulated for cholangiography. A technic of cholangiography via a fine needle is described that allows similar injection of dye. The needle must be secured to prevent dislodgement during the procedure.


Improving the efficiency of wound drainage catheters. We have modified the most commonly utilized wound drainage system to further reduce the incidence of postoperative accumulation of fluid under the skin flaps. This modification allows more efficient removal of debris, loose tissue fragments, and clots from the wound catheters and insures a constant negative pressure in the system. These maneuvers lengthen the usefulness and improve the efficiency of the catheters and have reduced the incidence of fluid accumulation.


Hürthle cell carcinoma of the thyroid.

Hürthle cell carcinoma of the thyroid. Even though Hürthle cell carcinoma is a distinct histologic entity, the clinical course of these patients is similar to that of patients with follicular carcinoma of the thyroid and they should be so treated. This review covers a study of thirty-five previously untreated patients with Hürthle cell cancer of the thyroid.


Carcinoma of the thyroid with description of a new scanning technic. A statistical analysis of 193 patients with thyroid carcinoma encountered at Vanderbilt University Hospital from 1925 to 1974 is reported, from which the following conclusions are drawn: (1) Papillary thyroid carcinoma is an extremely favorable lesion that when grossly limited to one thyroid lobe can usually be managed successfully by ipsolateral total lobectomy. (2) Cervical lymph node enlargement in patients with papillary carcinoma requires lymph node dissection. When feasible, the spinal accessory nerve should be preserved. (3) Failure to cure papillary and follicular thyroid carcinoma is influenced by advanced age, inadequate local extirpation, and unresectability of the carcinoma. (4) Prophylactic lymph node dissection is rarely indicated in the treatment of follicular carcinoma. A new isotope scanning procedure, developed at Vanderbilt University Hospital, promises to be helpful in preoperatively differentiating benign  from malignant solitary thyroid nodules.


Preservation of parathyroid glands during total thyroidectomy. Improved technic utilizing microsurgery. An improved technic for total thyroidectomy, utilizing magnification, is described. A method of preservation of the parathyroid glands with intact blood supply has been developed. The completeness of total thyroidectomy has been confirmed in 91 per cent of patients studied by postoperative radioactive iodine scan.


Metastasis of metastases.

Metastasis of metastases. Metastasis of metastases was demonstrated experimentally. Mice whose primary tumors were amputated after the development of pulmonary metastases were placed into parabiosis with normal syngeneic partners. Metastases were demonstrated in the nontumor-bearing partners despite their development of passive immunity. Immunizing the nontumor-bearing partner prior to joining into parabiosis was not protective against the formation of metastasis.


Penetrating injuries to the neck. Pitfalls in management. One hundred patients with penetrating injuries to the neck were evaluated. The safest, most expeditious method of managing a penetrating injury to the neck is still prompt surgical exploration. Patients with positive physical examination have definite indications for surgerymin our series, 93 per cent of these patients had significant injuries. Patients with negative physical examinations are still optimally treated with neck explorations. The mortality of this series was 2 per cent. In specific situations, nonoperative management of penetrating injuries to the neck may be useful. This modality, however; should not be construed as "conservative" management. Specific pitfalls noted include inadequate neck exploration, failure to completely examine the patient, and being unprepared for exploration outside the neck.


Tumors of the facial skeleton in children. Growth patterns after maxillectomy and mandibulectomy. Thirteen children who had major extirpative surgery of the maxilla or the mandible were followed up an average of five years postoperatively. They ranged in age from three months to eleven years. Facial and oral photographs, cephalograms and cephalometric analysis, and plaster dental models were used to document longitudinal and cross-sectional growth patterns; Our experiences in this limited number of cases has indicated the following: (1) Extensive extirpation of facial bones may be performed in children without significantly jeopardizing function or growth. (2) The roots of healthy teeth may be resected without fear of their noneruption or early loss; loss of sensation with continued viability is the rule. (3) The use of an iliac bone crib with particulate grafts has proved a highly successful means of reconstruction of the mandible in children. (4) Particulate bone has proved to be an effective means of reconstructing large contour defects of the mandible caused by enucleating large tumors in children.


Reoperative parathyroid surgery.

Reoperative parathyroid surgery. Reoperative parathyroid surgery is associated with a high mortality and morbidity. Morbidity consists of uncorrected hypercalcemia, hypoparathyroidism, and recurrent nerve injury. Initial operative failure is most frequently a result of not identifying four parathyroid glands. On reoperation, parathyroid glands are most often found in the neck and are usually hyperplastic. It is recommended that before attempting rexploration for parathyroid disease, all the patient's records especially the operative note and the previous pathology material should be reviewed. Preoperative localization by selective venous catheterization is of great use in the management of this type of patient.


A medial approach to thyroidectomy.

A medial approach to thyroidectomy. Thyroidectomy initiated by transecting the isthmus and peeling the lobes laterally away from the midline exposes the three vital elements of thyroid anatomy, namely the vessels, the recurrent laryngeal nerves and the parathyroid glands, by an almost bloodless dissection conducted at a distance from these vital structures. Part or all of the lobe or lobes can be removed while the parathyroid glands and recurrent laryngeal nerves remain clearly under view at all times.


Experience with 1,360 primary parotid tumors. Experience with 1,360 primary parotid tumors seen at the Mayo Clinic during two fifteen year periods, 1940 through 1954 and 1955 through 1969, is reviewed. A comparison of histopathologic classification, type of treatment indicated, recurrence rates, and survival in the two periods reveals considerably greater understanding of all factors in the later fifteen year period. The relatively high mortality still encountered among patients with high grade malignant tumors of the parotid glands indicate the nature of the challenge still to be met. Based on the data in this study, it is our opinion that superficial or total conservative parotidectomy is best employed primarily for benign tumors and that the shift to more radical operative procedures should continue in the management of malignant tumors, especially those that are less well differentiated. For experienced surgeons, exceptions might be the small superficially located tumors or the tumors in the lower pole of the gland such as Warthin's tumors. Local excision with removal of a margin of parotid parenchyma might be justifiable in such cases.


Combined craniofacial resection for malignant disease. A combined craniofacial approach has been employed in nineteen patients with tumors involving the base of the skull. Monoblock resection of the temporal bone, anterior fossa, or anterior and middle fossa can be achieved with acceptable mortality, even in cases of advanced cancer that recurs after radiation. Immediate reconstruction with a full thickness flap was routinely employed to provide improved cosmesis and to minimize the risk of intracranial infection.


Squamous cell carcinoma of the oral tongue in patients less than thirty years of age. Eleven patients less than thirty years of age who had squamous cell carcinoma of the oral tongue were treated at the M. D. Anderson Hospital from 1956 to 1973. The overall survival was 45 per cent. Many of the usual concomitant factors, such as heavy smoking, drinking, and poor dental hygiene were absent. Poorly differentiated, or grade III, squamous cell carcinoma was present in 48 per cent of the patients and indicated a poor prognosis regardless of the type of treatment. The primary lesion of the tongue was controlled in nine of the eleven patients. Recurrent cancer of the neck was observed in four patients. The selection of treatment in each case must be based on the various factors such as the size of the primary lesion, its histologic aspects, and the presence of nodal disease, and not on any emotional or subjective factors.


Preoperative irradiation for squamous cell carcinoma of the head and neck. Does it improve five year survival or control figures? 1. A well defined group of patients have been studied. 2. Composite operation resulted in a 56 per cent five year disease-free survival rate. 3. Treatment of recurrent disease with irradiation increased the five year survival to 61 per cent. 4. Preoperative irradiation for squamous cell carcinoma of the intraoral cavity, stage III, is unwarranted unless this treatment plan can produce five year end results better than 61 per cent.


Carcinoma of the glottic larynx.

Carcinoma of the glottic larynx. During the years 1955 through 1964, 535 patients with histologically proved squamous cell cancer of the glottic larynx were recorded in the Tumor Registry of the Memorial Sloan-Kettering Cancer Center. Of these 521 were treated and form the basis of this report. All were retrospectively staged. Possible etiologic factors were tabulated associated diseases recorded, and results of treatment evaluated. In this almost wholly surgically treated series, the determinate five and ten year survival rates for previously untreated patients were 81.5 and 80 per cent, respectively. The incidence of cervical lymph node metastases increased and the prognosis worsened with increasing stage of disease. The previously treated patients had a much worse prognosis than did the primary patientsmcancer of the glottic larynx is eminently curable if detected early and treated adequately.


Carcinoma of the pyriform sinus.

Carcinoma of the pyriform sinus. Ninety-one consecutive patients with carcinoma of the pyriform sinus were treated surgically during a ten year period from 1964 to 1973. Two of the ninety-one patients died postoperatively. The absolute five year survival was fifteen to fifty-nine patients or 25.4 per cent. One of the survivors had bilateral cervical metastases at the time of initial operation.


Cervicofacial actinomycosis.

Cervicofacial actinomycosis. Cervicofacial actinomycosis is a disease that is currently encountered as a pseudotumor entity or cold abscess. The frequent use of antibiotics in treatment of masses in the cervicofacial region may either delay its appearance or disguise the diagnosis. The surgeon must be highly suspicious when making the diagnosis since precautions in handling the biopsy specimens are necessary. Treatment consists of incision biopsy and drainage or aspiration to establish the diagnosis, followed by prolonged penicillin therapy. In those patients allergic to penicillin, clindamycin should be the initial drug of choice. Either medication must be administered for a prolonged period of time, even after the disease is clinically controlled.


Mucosal changes in the trachea and main bronchi of newborn infants after naso-tracheal intubation. Permanent sequelae of nasotracheal intubation are uncommon, but acute ulceration and squamous metaplasia occur. Histological sections from the trachea and main bronchi were examined in 12 infants. A nasotracheal tube had been inserted during the first two weeks of life of these infants and had been in place for more than one week. In four cases the patient died some time (7 to 108 days) after extubation. Similar sections from patients who were not intubated, intubated only for attempted resuscitation, or intubated for several hours were studied for comparison. The sections were classified according to the degree of mucosal loss and metaplasia, and the extent of the lesions was estimated. Squamous change was seen in most sections from all 12 patients with the exception of one who died 57 days after extubation. Some respiratory epithelium was seen in all patients. In the eight patients who died while intubated, the changes were more marked in the right main bronchus than the left in seven, and more marked in the lower trachea than the upper in five. In the two patients intubated for several hours, in addition to mucosal loss, early metaplasia was seen. It is suggested that mucosal loss is replaced by the squamous metaplasia, and that trauma caused by suction catheters in the lower trachea and right main bronchus is more extensive than that due to the endotracheal tube itself.


The final F.F.A.R.A.C.S. examination.

The final F.F.A.R.A.C.S. examination. The development of the Final Examination of Fellowship of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons is described from its inception in 1956 to the present. A statistical analysis was made of the examinations in 1969 and 1970. The correlations between marks for essay questions, within the multiple choice examination and between clinical examinations were low, suggesting that the reliability of these tests was unsatisfactory. At this same time, applied anatomy was added to the subjects in this examination. The examination was restructured with more emphasis on the oral and multiple choice examination and the marking system was revised. Continuing analysis has shown higher correlations between and within most parts of the examination. The correlations for the essay marks have remained lower, but essays have been retained in an attempt to assess and encourage the skills involved. Feedback of teaching and learning information obtained from analysis of the examination is provided to Regional Education Officers and Supervisors of Training.


Post operative pulmonary dysfunction: an historical review. The development of current understanding of post operative pulmonary dysfunction is outlined and discussed.


Acute respiratory failure in acute pancreatitis. The respiratory complications of acute pancreatitis are discussed, with particular reference to the incidence, pathophysiology and management of acute respiratory distress.


Anaesthesia for electroconvulsive therapy. The results of a prospective study of 3,500 Anaesthetics for electroconvulsive therapy is presented. Minimal differences were observed between thiopentone and methohexitone. Propanidid and Diazepam were found to be unsuitable induction agents. Other findings included minimal serum potassium elevation and a low incidence of post treatment muscle pains. The place of the single-handed operator and the place of unmodified electroconvulsive therapy is questioned as being unacceptable practice.


Thiopentone anaphylaxis--case report.

Thiopentone anaphylaxis--case report. A case history is presented of a man who developed angioedema of his head and neck during anaesthesia for his 11th cystoscopy within four years. Thiopentone was always used to induce his general anaesthesia. An intradermal skin test with 1 : 100 dilution of 2-5 per cent thiopentone was positive and subsequent anaesthesia without thiopentone was straightforward.


Successful use of intra-aortic balloon counterpulsation in the treatment of refractory intraoperative cardiogenic shock. Intra-aortic balloon counterpulsation (IABC) has been used successfully in the treatment of shock following myocardial infarction. This report describes eight patients who developed medically refractory cardiogenic shock following cessation of cardiopulmonary bypass and who were treated with IABC. None of the eight became balloon dependent and seven of eight (87.5%) left the hospital doing well. The treatment of refractory intra-operative cardiogenic shock represents a new and additional indication for IABC.


Treatment of oral carcinoma with selective therapy for the individual patient. A series of 121 patients with carcinoma of the lower oral cavity seen at the British Columbia Cancer Institute during the years 1963 to 1969 has been reviewed. We have evidence of improved treatment results over a previous series of patients treated between 1953 and 1962. The results are as satisfactory as other reported treatment policies in which either surgery or radiation is used exclusively. Careful follow-up of all patients is essential. When recurrence or metastatic disease is recognized early, further treatment can still result in cure. The criteria for case selection of the individual patients are outlined.


An alternative to routine operative cholangiography. The use of the Fogarty biliary balloon catheter has added to the safety of common duct exploration. Review of our own series seems to support this concept. With this adjunct adn a careful anatomic dissection of the biliary system, one can decide to do cholangiography or common duct exploration based on carefully considered clinical factors when stones are suspected. Perhaps neither need to be done in many instances. Without trying to question the virtures of operative cholangiography, we believe that it can be used selectively rather than routinely.


Nonpenetrating trauma of the abdominal aorta with partial vessel occlusion: report of two cases. Two cases of blunt trauma of the abdominal aorta are reported. In both there was lacreation of the intima and development of intimal flaps with only partial occlusion of the aorta. Immediate recognition in one allowed prompt repair of injured tissue. Delayed recognition in the other, while not life-threatening, did prolong disability  and did necessitate vascular tissue replacement with prosthetic graft. Audible bruit and palpable thrill are diagnostic signs that, if sought for in the emergency room and operating room examinations of the traumatized abdomen, will yield early recognition of this lesion.


Hamartoma of the spleen: a manfestation of tuberous sclerosis. An unusual case of tuberous sclerosis is presented in which splenomegaly and abdominal pain predominated. The clinical manifestations of the disease are discussed, and the generalized hamartonmatous nature of the diseases is emphasized.


Therapeutic splenectomy.

Therapeutic splenectomy. An eight-year experience at Charity Hosptial and Touro Infirmary indicates that 10 percent of splenectomies were performed for reasons other than trauma or malignancy. Fifty-nine per cent of therapeutic splenectomies were done for congenital spherocytosis or idiopathic thromboytopenic purpura. All patients having spherocytosis and 57 per cent having ITP had favorable response following splenctomy. Seven surgical death occurred following 69 splenectomies (mortality 10%). Three deaths were from pulmonary emboli, three from hemorrhagic disorders and one from peritonitis. Eighteen postopertive complications occurred, the most frequent being thromboembolic disease. Prophylactic anticoagulants were not used in any patient.


Intussusception in the adult.

Intussusception in the adult. Intussusception in the adult is an uncommon condition usually with a chronic history but it may occasionally present as an acute process. The clinical picture is most often that of a large or a small bowel obstruction. When the intussusception begins in the small bowel, a benign causative factor is found most frequently, whereas intussusception of the colon is most often secondary to a malignant lesion. Idiopathic causes occur rarely as compared to the pediatric age group. The treatment of adult intussusception is surgical.


Chicken bone herina: an unusual presentation of a Richter's hernia. An unusual case of a perforated Richter's hernia in which is presented with abscess cavity contained a chicken bone. Richter's gernia is difficult to diagnose before strangulation occurs. The surgeon must be prepared to follow small bowel resection with a second operation for definitive repair of the hernia.


Five years' treatment of Parkinson's disease with levodopa. Therapeutic results and survival of 100 patients. One hundred patients with Parkinson's disease, who started taking levodopa before the end of 1968, have been assessed after 5 years. Forty-seven patients are still being followed on levodopa, and half of them are at least 25% better than at their pretreatment evaluation. However, the average functional rating is returning toward baseline from its remarkable improvement at 1/2 to 2 years. Abnormal involuntary movements, rapid oscillations in motor performance, postural instability, and dementia have become the major adverse effects. Thirty-two of the 100 patients have died. Life-table analysis shows an excess mortality of 1.9 compared with the U.S. population, a figure that is lower than the 2.9 reported before levodopa's use. Despite its inability to cure Parkinson's disease, levodopa provides symptomatic relief for a prolonged time and it remains the single most effective medication for the illness.


On the role of sexual behavior in the spread of hepatitis B infection. There is a significant excess of serologic evidence of hepatitis type B infection in two high-promiscuity populations: patients with venereal diseases and their unrelated sexual contacts (15% to 18%) and male, but not female, homosexuals (37% to 51%). Spouses of asymptomatic chronic carriers of antigen had a higher prevalence (26% to 28%) than spouses of noncarriers (10% to 11%); however, the prevalence in the former is relatively low when compared with rates seen in other relatives of carriers. Persons who had a higher-than-average probability of exposure to potentially infective partners or whose patterns of sexual behavior made such exposure more likely (large numbers of sexual partners, long duration of homosexuality, involvement in predominantly anal intercourse) were found to have serologic evidence of hepatitis B more frequently than those with other patterns of sexual behavior. This study showed a strong association between serologic evidence of type B hepatitis and patterns of sexual behavior. However, whether or not transmission of hepatitis type B virus occurs through vaginal intercourse could not be ascertained.


Absence of echocardiographic abnormalities of the anterior mitral valve leaflet in rheumatoid arthritis. Thirty-five consecutives patients with classic or definite rheumatoid arthritis underwent echocardiography to evaluate the motion of the anterior mitral valve leaflet. Adequate echocardiograms were obtained in 31 patients. All 31 patients showed normal valve motion and a normal EF slope. If meticulous technique was not observed, a falsely low value for the EF slope was obtained and a normal slope was found when the method was improved. This study shows that echocardiographic abnormalities of the anterior mitral valve leaflet rarely, if ever, occur in patients with rheumatoid arthritis, provided that careful attention to recording method is observed.


Echocardiographic manifestation of "false" mitral stenosis that was. An unusual normal posterior direction of motion of the posterior mitral valve leaflet echo during diastole was detected in a patient whose clinical and hemodynamic data confirmed the presence of significant rheumatic mitral stenosis after other conditions causing echocardiographic pattern of "false" mitral stenosis were ruled out. The finding of normal direction of motion of the posterior mitral valve leaflet when associated with abnormal EF slope of the anterior mitral valve leaflet does not rule out the existence of significant mitral stenosis.


Interaction of chronic daily warfarin therapy and rifampin. To evaluate the interaction between the antibiotic rifampin and the anticoagulant warfarin during chronic therapy, eight normal subjects were given daily doses of warfarin for 21 days to achieve therapeutic hypoprothrombinemia. Daily blood samples were analyzed for one-stage prothrombin activity and for warfarin content spectrophotometrically and chromatographically. One month later, the same warfarin dose was repeated plus rifampin, 600 mg a day orally. For the last 10 days of every experiment, there was a highly significant lessening of both the hypoprothrombinemic effect (P less than 0.001) and the blood levels of warfarin (P less than 0.001). No significant difference in the warfarin levels was found between the spectrophotometric and chromatographic methods. It is concluded that rifampin markedly decreases the hypoprothrombinemic effect of warfarin during long-term therapy by enhancing its elimination from plasma. This conclusion was reinforced by finding increased amounts of warfarin metabolites in urine and stool.