Preservation of normal cortical vasculature in ischaemic renal failure in the dog. Ischaemic renal failure in the dog was studied by clamping one renal artery for 2 hr in 18 animals. Total renal blood flow was measured for 3 hr after this and only reduced by about 30%. Fine detail renal angiography showed a normal cortical perfusion pattern. Urine flow rates and creatinine clearances from these kidneys, however, were found to be grossly impaired over this period. Seven days later the angiogram of the oliguric kidney remained normal. Two-hour unilateral renal ischaemia in the dog leads to a form of acute renal failure with a striking disparity between glomerular perfusion and clearance, arguing agains a primary circulatory defect.


The natriuretic effect of p-aminohippurate in man. The effects of p-aminohippurate (PAH) on electrolyte clearances were measured in 8 human volunteers. At plasma PAH levels used to measure renal plasm flow, the only significant increase was in sodium clearance, while with PAH levels used to measure maximum tubular secretion, the clearances of sodium, potassium and phosphorus were all significantly increased. The antriuresis combined with a depression of free water clearance and the absence of a chloruresis led to the conclusion that PAH- changed the anion composition of the filtrate delivered to the ascending limb, thus interfering with coupled Na+ reabsorption. This finding must be taken into account when electrolyte excretion is being measured during PAH infusion. A similar mechanism may operate in patients with chronic uremia whose endogenous hippurate level is increased.


Topography of human urokinase activity in renal tissue. Frozen sections of human kidneys were studied with a modified technique after TODD [22] )fibrinogen slides). Urokinase activity could be demonstrated in the juxtamedullary region (venae arcuatae, venae interlobulares, vasa recta) and in the epithelium of the calyces. Urokinase activity was specifically blocked by highly purified urokinase antibodies.


Management of peritonitis and bowel perforation during chronic peritoneal dialysis. Peritonitis and bowel perforation are the most serious conditions of peritoneal dialysis. This paper reports our experience with these two complications among 87 patients who were admitted to our porgram during a 3.5-year period and were treated with chronic peritoneal dialysis for periods up to 38 months (average 9 months). Approximately 6,000 dialyses were performed. Peritonitis occurred seven times in six patients (0.1%) and five patients had six episodes of bowel perforation (0.1%). All patients were successfully managed with conservative treatment, consisting of continuous peritoneal dialysis and intraperitoneal and systemic antibiotics. Careful aseptic technique seems to be the only necessary factor in prevention of peritonitis.


Renal histologic and ultrastructural findings in psychogenic polydipsia and diabetes insipidus. The renal biopsies of 15 patients affected by polydipsia syndromes were examined under light and electron microscopes. The authors contend that the observed renal lesions (dilatation of the glomerular loops, tubular hypertrophy and vacuolization, and basal membrane swelling) are the morphologic result of tubular hyperfunction in the service of ion reabsorption. This, in turn, is secondary to the increased GFR.


The increasing incidence of melanoma.

The increasing incidence of melanoma. A study of our hospital records has confirmed a striking increase in the number of melanoma cases. An examination of the New York State statistics demonstrates a 202 percent increase in the case rate from 1950 to 1971. The Connecticut statistics extending from 1935 to 1972 show an age-adjusted incidence rate increase of more than 300 percent for men, and more than 600 percent for women. An increased frequency of melanoma has been reported also for Texas, Canada, Australia, England and Wales. The available information on melanoma deaths and mortality rates fails to suggest that these lesions are biologically less significant than those so designated in the past. There has been no change in preferential sites of melanoma location in either sex, despite the increased incidence of the disease reported from these many geographic areas. The cause of the increased incidence remains obscure.


The blister and the second degree burn in guinea pigs: the effect of exposure. A reproducible partial-thickness burn was inflicted on 100 albino guinea pigs. With the blister intact, the evaporative water loss from the burn surface was essentially the same as from normal unburned skin. When the blister was removed, the rate of water loss was initially more than 100 times normal, and it remained 20 to 50 times the normal rate throughout the first week. This high rate of water loss was associated with an increasing depth of wound destruction (from dehydration) and a thickening of the overlying crust. Microscopic examination showed that previously viable dermis was incorporated in this crust. The depth of dermal loss was negligible when the blister was left intact, and improved healing resulted. We believe it is important to leave burn blisters intact, whenever possible.


Correlation of endoscopy and double-contrast radiography in the early stages of ulcerative and granulomatous colitis. Early radiological changes in ulcerative colitis include (a) finely granular mucosa due to hyperemia and edema, (b) mucosal stippling due to adherence of barium to superficial ulcers, and (c) coarsely granular mucosa due to ingrowth of granulation tissue. In granulomatous colitis, early changes include discrete, superficial ulcers, often against a background of normal mucosa, seen best en face. All of these changes can be demonstrated by the double-contrast technique. The radiological and endoscopic findings were in agreement in 95% of the examinations in the authors' series. The importance of the technical aspects of the examination is stressed.


Internal mammary lymphoscintigraphy. The rationale, technique, interpretation and clinical application: a review based on 848 cases. Internal mammary lymphoscintigraphy is a noninvasive reproducible technique which correlates well with the anatomic pattern of lymph node distribution. A study of 848 patients via radiocolloid injection established a normal internal mammary lymph node distribution and detected deviations from this pattern. A review of these cases is followed by a discussion of the clinical application of this technique, especially in carcinoma of the breast.


Acute cerebral vascular accident associated with hyperperfusion. Cerebral radionuclide angiography can demonstrate decreased or normal radioactivity in the affected region during the arterial phase in patients who have sustained a cerebral vascular accident and thus enhances the diagnostic specificity of the static brain image. In an occasional patient, however, a seemingly paradoxical pattern of regional hyperperfusion with a return to normal or subnormal perfusion following the acute phase has been observed. This phenomenon, called "luxury perfusion," has been defined using intra-arterial 133Xe for semiquantitative cerebral blood flow measurements and should be kept in mind as a potentially misleading cerebral imaging pattern.


Brain image manifestation in the patient with cavernous sinus occlusion. Radionuclide findings in a case of cavernous sinus occlusion by an intracavernous aneurysm are described. A brain image obtained 10 minutes after injection of 99Tc pertechnetate shows diminished activity in the area of the right cavernous sinus and increased activity in the area of the right sylvian veins; these are attributed to abnormal venous blood flow and may serve as a sign of cavernous sinus occlusion.


The sensitivity and specificity of 99mTc-sulfur colloid liver imaging in diffuse hepatocellular disease. The sensitivity and specificity of 99mTc-sulfur colloid liver-spleen imaging in diffuse hepatocellular disease and the significance of image patterns found in these diseases are presented. By visually quantifying the image alterations found in biopsy-proven cases of diffuse hepatocellular disease and analyzing the correlation between the histological diagnosis and the quantified image alteration (individually and by groups), the 99mTc-sulfur colloid liver-spleen image was found to be highly sensitive (83%). Relative discriminatory values were derived for each image finding and a specific image pattern was found in cirrhosis.


Cystourethrography procedures in children. Evaluation of benefits versus dose. Cystourethrography was used by the referring physician in 53 children with urinary tract disease. The benefits of this technique were evaluated using Bayesian methods. Prior and subsequent odds of the accuracy of the clinical diagnosis being affected by the radiological procedure were estimated. Marked benefits were found in 12 cases, which were used as the basis for the most conservative estimate of benefits. The genetic benefit-risk ratio is 140 for boys and 8.3 for girls. The somatic benefit-risk ratio is 10,000 for boys and 4,200 for girls.


Reflux and trapping.

Reflux and trapping. Although functional ureteral obstruction results in a decrease in the rate of antegrade urine flow, urine may still traverse the obstructed segment in a retrograde direction. Decreased musculature is found in the obstructing area. The combination of these processes results in reflux with trapping. This process has been demonstrated radiographically at both the ureterovesical and the ureteropelvic junctions.


Intrahepatic rupture secondary to duct exploration demonstrated by cholangiography. Seven cases of iatrogenic rupture of the intrahepatic bile ducts were demonstrated on T-tube and/or operative cholangiography. This brings the total of documented case reports to 17. All patients had hepatic duct exploration with either the Fogarty balloon catheter and/or the biliary spoon and/or the biliary forceps and/or Bakes dilators. These extravasations usually occur from the right hepatic duct. The recognition of this entity is important because potentially serious complications may occur. Most of the previous cases of intrahepatic extravasation ascribed to excessive pressures of injection were probably surgically induced.


Spondyloenchondrodysplasia. Enchondromatomosis with severe platyspondyly in two brothers. Two brothers affected by enchondromatosis with marked involvement of the spine including platyspondyly were followed for 12 years. Both brothers were of short stature and normal intelligence. Vertebral involvement in multiple enchondromatosis is very rare. To our knowledge, marked generalized platyspondyly has not been described in the literature as part of this condition. At present, this form cannot be placed within any previously described category. A new term--spondyloenchondrodysplasia--is proposed for this condition which may either be a subform of multiple enchondromatosis or an entirely different and distinct entity.


Radiographic changes in children following cardiac surgery performed by splitting the sternum. The incidence of radiographic changes in the chest following a sternal split for cardiac surgery is examined. These changes include: (a) an indiscinct sternal cortex; (b) elevation of the cardiac silhoutte above the diaphragm; and (c) uneven heights of the medial clavicular ends.


Metaphyseal giant-cell tumor in a girl of 14. A case of giant-cell tumor in the radial metaphysis of a 14-year-old girl is reported. 3.5% of these tumors are detected in patients younger than 15 years of age, when closure of the cartilaginous growth plate occurs. A significant number of the 14% of giant-cell tumors detected in patients younger than 20 may originate in a metaphysis during adolescence and become symptomatic only after long bone epiphyseal involvement.


Jugular venous ectasia in children. A report of 3 cases and review of the literature. Three cases of jugular venous ectasia in children were diagnosed preoperatively by selective venography. These rare lesions appear to be congenital dilatations of the veins and should not properly be called aneurysms, as their histological structure is normal. A typical history and complex of physical findings are associated with this entity. It is important to include it in the differential diagnosis of neck masses in children.


Clinical evidence of intestinal absorption of Gastrografin. Experimental evidence suggests that Gastrografin in the neonatal gastrointestinal tract leads to hypertonic dehydration by two mechanisms: loss of water from the circulating blood volume, and absorption of osmolarly active substances across intact, normal mucosa of the gastrointestinal tract. Clinical documentation of absorption of Gastrografin is presented. Renal excretion of contrast material was seen following its use in the treatment of meconium ileus.


Visualization of the bile ducts using focused ultrasound. The feasibility of using focused ultrasound for studying structures as small as biliary ducts and correlative radiological and ultrasonic studies of the common and larger hepatic ducts are presented. Patients whose bile ducts were visualized on intravenous or T-tube cholangiography or oral cholecystography underwent radiography with a metallic skin marker along the right anterior lower costal margin. The marker was then correlated with ultrasonic observations of multiple oblique scans parallel to the lower costal margin. The common duct could be identified in 15 of 21 patients. Ultrasonic visualization circumvents the problems of elevated serum bilirubin, iodine contrast media sensitivity, and pregnancy.


The evaluation of malignant gastric neoplasms by ultrasonic B-scanning. The results of ultrasonic B-scanning of 11 patients with malignant neoplasms of the stomach are presented, and the diagnostic accuracy of this technique and its advantages and limitations are discussed and illustrated with specific case reports. The use of ultrasound to complement other techniques in evaluating malignant gastric neoplasms prior to consideration for surgery or chemotherapy is outlined.


Ultrasound in the evaluation of anencephaly. Three cases of anencephaly diagnosed in utero by ultrasound are presented and the ultrasound diagnostic criteria for anencephaly are illustrated. The literature regarding anencephaly is reviewed and the malformation discussed. Diagnostic ultrasound should be used to screen high-risk patients for this fetal anomaly. In addition, all patients clinically suspected of possible fetal malformation or polyhydramnios should be examined by ultrasound.


Subclavian artery occlusion following radiotherapy for carcinoma of the breast. Four cases of subclavian artery occlusion occurring 5-17 years after irradiation for breast carcinoma are presented. Although arterial insufficiency is a rarely reported sequel to radiotherapy, it may be the cause of pain and disability in the upper extremity in a postmastectomy patient. Particular attention should be paid to the presence of a bruit over the subclavian and axillary arteries. Arteriography will often reveal a short, segmental lesion of the subclavian artery that frequently can be repaired surgically.


Short-course radiation therapy in the treatment of head and neck tumors. A pilot study undertaken to evaluate short-course, high-increment radiation therapy. This type of treatment was tolerated well by the patients, with a surprisingly low level of acute reaction to the regimen and few late complications. Tumor regression seemed to be earlier than might be expected and involved more than 50% of the tumor in over 75% of the patients following the fourth course of treatment. Preliminary results show that long-range survival rates are at least equivalent to those obtained with the conventional longer treatment regimen. In general, this seems to be a more economical and efficient method of treatment which entails less patient discomfort than the conventional method.


Carcinoma of the urinary bladder. Influence of dose and volume irradiated on survival. Two groups with comparable bladder carcinoma were selected from 249 patients treated with telecobalt therapy from 1955 through 1971. Group I received a mean isocentric dose of 6,060 rads in six weeks to an average volume of about 1,050 cm3 within the 90% isodose lines; Group II received a mean isocentric dose of 6,542 rads in six and one-half weeks to a volume of approximately 1,700 cm3. Overall five-year survival rates were 12.6% (+/- 5.4) in Group I and 25.5% (+/- 4) in Group II, with improvement being most marked in patients with advanced stages of disease. Results show that when the dose was increased and a larger volume of pelvic tissue was irradiated, the five-year survival rate improved.


Prospects for x-ray exposure reduction using rare earth intensifying screens. From measurements of screen-film sensitometry, Wiener spectra, and x-ray spectra, the speed, mottle, and quantum efficiency of several rare earth screen-film systems have been characterized. These systems offer exposure reductions of from two- to tenfold over conventional calcium tungstate systems. At the slower end, the noise (mottle) and resolution are comparable to what is available with conventional systems. Moreover, films designed to be used in such systems can be made with significantly lower silver content. As the speed advantage is increased from two- to genfold, however, the mottle also increases.


Comparison of image quality obtained with optical and radiographic magnification techniques in fine-detail skeletal radiography: effect of object thickness. High-resolution radiography may be done using either optical or radiographic magnification. In the former technique, industrial Type M film was used without screens and the image was viewed with 4-10X optical magnification. In the latter technique, RP film was used with Detail screens and 4X geometric magnification together with a microfocus x-ray tube having a nominal focal spot size of 50 mum. The imaging properties of both techniques were evaluated by means of H & D curves, modulation transfer functions, and Wiener spectra. It was found that for thin objects such as the hand, optical magnification provides better bone images than radiographic magnification; whereas for thicker parts such as the knee, radiographic magnification is superior.


Quantitative assessment of field uniformity for gamma cameras. Objective criteria for judging the uniformity of field floods are developed and the effects of the energy window and scatter material on uniformity are examined. There is a highly significant correlation (p = 0.99) between a 14% difference in average count among adjacent photomultiplier tube regions and observer detection of detuned areas. Similarly, a 10% average count difference is not significantly recognized as a nonuniform area. Results indicate that there is a complex interaction between uniformity, energy window (15-30% symmetrical) and 0-7.6 cm of tissue-equivalent scatter medium interposed between the flood source and the collimator. Quantitation of the flood should be performed to indicate which regions need retuning.


Angiography of the celiac artery using caudal or cephalic beam angulation. Celiac arteriography in the frontal projection with the tube angled 50 degrees toward the feet demonstrated an aneurysm which arose from the celiac artery and did not involve the splenic or hepatic artery. Angling the tube toward the feet (or toward the head is the celiac artery ascends) is recommended for evaluation of the celiac, proximal splenic, and hepatic arteries.


Interfacing a programmable desk calculator to a hard-wired data system. The primary disadvantage of hard-wired data systems for use in nuclear medicine is the fact that that the data contained in the memory bank are not accessible to the user and often must be processed mathematically before they can be employed in interpretation, particularly in dynamic studies. The authors describe a relatively inexpensive programmable device which can be used in conjunction with the data system and overcomes these limitations to a great extent.


A collimator for reduced radiation dose with improved visualization of soft tissues. The authors describe a collimator for use in diagnostic radiology. Clinical radiographs show enhanced soft-tissue detail through the use of interchangeable straight and curved wedge filters, and in situ dosimetry using a head phantom shows that the provision for asymmetric beam limitation results in reduction of absorbed dose.


A versatile cassette holder for upright radiographic studies in infants and children. The authors describe a new cassette holder which permits standard upright studies of infants and children. Its ease of attachment to and detachment from the table top facilitates versatility of studies in a busy pediatric radiography room. The design is simple, using commercial parts--a fluoroscopy table footrest and a wall-mounted cassette holder. The new federal radiation safety regulations permit the use of this device.


Evaluation of the nasolacrimal canal in the basal projection. The authors describe a new technique for visualization of the nasolacrimal canal in the basal projection. Cranial angulation of the x-ray tube by 14 degrees will project the canal anterior to the facial bones.


Pediatric enema tips.

Pediatric enema tips. The authors describe modifications of disposable rubber enema tips for use in infants and children. These should be used instead of a Foley balloon catheter to avoid distension and obscuration of the rectum as well as possible perforation of the rectum.


The new special names of SI units in the field of ionizing radiations. New SI units for ionizing radiations have been recommended by the internation Commission on Radiation Units and Measurements (ICRU). These are the becquerel (symbol Bq), equal to the second to the power -1, and the gray (symbol Gy), equal to the joule per kilogram. It was recommended that the roentgen be replaced as the unit of exposure by the coulomb per kilogram (C/kg), for which no new name was proposed. The ICRU recommends that the units rad, roentgen, and curie be gradually abandoned over a period of ten years and that preparatory steps to this end be taken as soon as possible by various national and international bodies in order to facilitate a smooth, safe, and efficient transition.


The choledochocele: correlation of radiological, clinical and pathological findings. Two cases of choledochocele are presented and 14 cases in the literature reviewed. Choledochocele is defined as a herniation of the common bile duct into the duodenum. This entity is distinguishable radiographically from duodenal diverticulum and duodenal duplication cyst by filling during cholangiography but not during upper gastrointestinal series. The duodenal diverticulum fills on upper gastrointestinal series but not on cholangiography. The duplication cyst will not fill with either method.


Multiple leiomyomas of the esophagus.

Multiple leiomyomas of the esophagus. Multiple leiomyomas of the esophagus are rare. These benign intramural, extramucosal tumors present a sufficiently characteristic appearance during a barium examination to suggest a specific roentgenologic diagnosis. Although leiomyomas may become quite large and cause considerable distortion of the esophageal lumen, they produce surprisingly few symptoms in most patients. Since these tumors have little if any malignant potential, surgical excision is necessary only in patients with significant symptoms. Four patients with leiomyomas of the esophagus are reported here, and the clinical and roentgenologic features of these tumors are reviewed.


The supraclavicular fossa.

The supraclavicular fossa. The presence of a supraclavicular fossa and the visibility of its floor on chest radiographs have been ignored in the radiological literature. In a study of 500 randomly selected chest radiographs, we could identify the floor of the fossa in 29% of patients. There is extreme normal variation in the visibility, depth, and symetry of the two sides. However, the fossa can occasionally stimulate a parenchymal lung abnormality such as a fluid level or an emphysematous bleb in the upper outer lung fields.


Radiographic chest abnormalities in adult hemophilia. The chest radiographs of 33 adult hemophiliacs were reviewed for possible pulmonary features of this disease. Only 7 patients showed no abnormalities; 12 patients exhibited scarring, fibrosis, and pleural thickening of the lung, interpreted as the sequelae of intrapulmonary hemorrhage or hemothorax. The remaining 14 patients demonstrated abnormalities of the pulmonary vessels, and 4 of them had evidence of hyperinflation. Possible etiologic factors are discussed.


Radiolucent mediastinal lipoma.

Radiolucent mediastinal lipoma. Intrathoracic lipomas are rare. A patient with a surgically proved mediastinal lipoma is described. The lesion presented as an asymptomatic radiolucent mass within the mediastinum and was detected on routine chest radiography.


Cavitary pulmonary nodules in systemic lupus erythematosus. Two cases of systemic lupus erythematosus with cavitary pulmonary nodules as a manifestation are presented. The literature concerning the radiographic manifestations of cardiopulmonary involvement in systemic lupus erythematosus is reviewed.


Primary and secondary pulmonary artery neoplasia mimicking acute pulmonary embolism. Two cases of rare pulmonary neoplastic lesions (primary pulmonary artery sarcoma and pulmonary carcinosarcoma) directly involving the pulmonary artery and presenting with findings mimicking acute pulmonary embolism are discussed. Although this represents an unusual presentation for these two lesions, they should be included in the differential diagnosis of acute pulmonary embolism in patients presenting with somewhat atypical clinical, isotopic, and radiological features. Serial lung scans followed by angiography will prove useful in arriving at the correct diagnosis.


Pitfalls in knee arthrography.

Pitfalls in knee arthrography. Sources of error in performing and interpreting knee arthrograms are discussed. Normal anatomic structures and technical factors can simulate tears in most areas of both the medial and lateral menisci. These pseudotears, as well as unrecognized true tears, occur more commonly in the posterior horn of the medial meniscus. Inferior meniscal recesses and coronary ligament irregularities of the posterior medial meniscus often represent incomplete tears. Diagnostic, etiologic, and therapeutic aspects of these recesses, or pseudorecesses, are discussed. Excessive intra-articular positive contrast medium may become localized and simulate a loose body in the joint.


Osteoblastic bone metastasis in Zollinger-Ellison syndrome. The authors describe a case of osteoblastic metastasis in a patient with Zollinger-Ellison syndrome resulting from the presence of a pancreatic tumor, which they believe is the first such case documented. Following a total gastectomy for hyperacidity in a 53-year-old woman, a gradually enlarging liver was treated with steptozotocin. Radiation therapy to the areas of bony metastases resulted in complete alleviation of pain.


The radiological spectrum of acute pyelonephritis in adults and adolescents. Excretory urograms of 40 patients with a clinical and laboratory diagnosis of acute pyelonephritis were reviewed. Eleven (28%) had abnormal urograms attributable to the acute disease process. Of the 11 abnormal patients, 7 had obvious urographic abnormalities, while in 4 the findings were few and subtle. The most common findings were renal enlargement, decreased density of contrast material, delayed calyceal appearance time, and dilatation of the collecting system; of these, the last two most frequently correlated with the clinically abnormal side.


Plain-film findings in severe pseudomembranous colitis. Plain-film abdominal changes in 5 patients with severe antibiotic-related pseudomembranous colitis were found to be strikingly similar and distinct from those seen in other colitides. These consisted of moderate gaseous distension of the colon and unusual wide transverse bands of thickened bowel wall associated with giant "thumbprinting" which was universal in distribution, with minimal or absent small-bowel abnormalities. While the radiographic findings were not pathognomonic, they were highly suggestive of advanced pseudomembranous colitis when combined with the clinical data. Prompt recognition of this entity by the radiologist is extremely helpful in management, since such patients frequently present with physical findings of an acute abdomen requiring surgery.


Cervicovertebral phlebography: pathological results. Cervical phlebography via the femoral vein approach was done in patients with spinal tumors, cervical radiculopathies, and myelopathies. Tumors originating from or extending into the spinal canal readily compress and obstruct the epidural venous plexus. Because of the lateral position of the epidural veins, the foraminal veins are deformed when cervical roots are compressed in the intervertebral foramina by spondylosis of the uncinate processes or lateral disk herniation. In congenitally narrow canals without significant spondylotic bars, the epidural veins were not opacified. Nonfilling of veins was also seen when the canal was narrowed by multiple spondylotic bars. With a few or even a single spondylotic bar, the epidural veins opacified but this was interrupted at the affected levels. When a significant spondylotic bar was associated with a narrow canal higher up, filling of the epidural veins at the level of the bar was completely arrested.


Evaluation of the neurotoxicity of water-soluble myelographic contrast agents by electrophysiological monitors. The effects of subarachnoid injection of Conray (methylglucamine iothalamate) and its dimer (methylglucamine locarmate) in various concentrations were compared using electrophysiological monitors of the cortical evoked response (CER) and the H-reflex. Significant concentration-dependent differences were noted in the H-reflex, less marked with the dimer. No significant difference in the CER was noted. This differential alteration in neurophysiological parameters was independent of changes in blood and cerebrospinal fluid pressure, implying that these water-soluble contrast media have a direct toxic effect on the nervous system, possibly situated in the larger (group 1) root fibers.


Hydatid cyst of the skull: report of four cases. Four new cases of cranial echinococcosis are presented and the literature is reviewed. Young males are most commonly affected. Early cases present as an expansile osteolytic lesion in the diploe. The more advanced forms manifest as multilocular or unilocular destructive lesions with adjacent soft-tissue masses. Two patients with unilocular hydatid cysts recovered completely after surgery. One youth with the multilocular form died four months after operation. The other patient is well two years after surgery. The location, anatomical forms of the lesion, and the importance of early diagnosis are stressed.


[Normal value of ventilatory work of breathing (author's transl)]. Ventilatory work of breathing is defined as a variable referring to the mechanics of the breathing function of the lung, ascertainable from the alveolar pressure-breathing volume diagram. Information on the resistance of the respiratory canal can be obtained. The ventilatory respiration of 93 healthy persons at spontaneous resting breath frequency (15 +/- 3 min) was investigated, with the aid of a body plethysmograph. A mean value of 2.21 g-cm/ml (s = 0.92) was obtained. A dependence on age and sex could not be statistically proved. The value of 4.0 g-cm/ml (= 2s) is discussed as a limit to a pathological increase. With a rise in breath volume, relative weight and also, marginally, the spontaneous resting breath frequency, a significant increase of ventilatory work of breathing in normal persons must be anticipated. A so-called index of ventilatory work of breathing (breath volume/alveolar pressure changes under defined conditions) correlates significantly with ventilatory work of breathing and can thus be regarded as an orientating value for the resistance of the respiratory canal. Its mean value amounts to 3.10 cm/cm, with a SD of 1.12.


Comparison between pathological and biochemical investigations on an experimental model of fibrosing alveolitis. Subcutaneously injected Freund's adjuvant caused a fibrosing alveolitis in guinea pigs. This model served to compare biochemical and morphological parameters. The phospholipids were quantitatively extracted from lung tissue, separated and estimated. The fatty acid composition of lecithin was analysed. We observed a correlation between the histologic alterations and the content of phospholipids. A constantly higher phospholipid content was measured in the affected lungs in comparison to the normal ones; however, the composition of the phospholipids changed. The close correlation between the course of the inflammation and the biochemical pattern seems to indicate a function-correlated control of lung metabolism.


Correlation between lung function and tracheobronchial collapse. In 30 unselected male patients, bronchoscopic aspect and lung function parameters (notch in FEV1, FEV1/FIV1%, discrepancy between airways resistance and FEV1, club-shaped resistance curves) were correlated to determine the validity of lung function in the diagnosis of a central bronchial collapse. There were no strong correlations; only the club-shaped resistance curve and FEV1/FIV1% less than 60 were a little more often seen in the presence of central bronchial collapse. It is concluded from these results, and with regard to the known results from bronchial pressure measurements, that the functional parameters mentioned above are good indicators of a flaccid tracheobronchial system but not typical for a central bronchial collapse alone. Additional methods (bronchoscopy, bronchial pressure measurements) are needed to locate the major pressure drop and to select the adequate therapy (conservative in the case of pure peripheral or most mixed situations, chirurgical in special cases with pure central bronchial collapse). The reactions of a collapsible tracheobronchial system to bronchodilating drugs are described and their help in location of the major pressure drop is discussed.


Smoking and blood oxygen tension in healthy middle-aged males. The blood oxygen tension (PaO2) was measured using a Clark-type microelectrode on 'arterialised' capillary blood samples obtained from 74 sitting subjects; these were asymptomatic and spirographically normal men aged 42-63 (average 53.7) years. The mean PaO2 of smokers (83.8+/-6.0 mm Hg) was slightly, non-significantly lower as compared to non-smokers (85.5+/-4.9 mm Hg). The trend towards lower mean values with increase in current cigarette consumption or amount smoked in life did not result in significant differences between smoker sub-groups. The lower normal limit for the whole group was 73.3 and the average PaO2 85.3 mm Hg. Though no significant influence of tobacco use could be demonstrated, the histogram of specific subjects shows a bi-modal distribution in smokers, suggesting the existence of a sub-group (about one third of the smokers) who tend to have lower PaO2s, possibly as a consequence of sub-clinical 'small airway disease'.


Effect of acute hypoxia on blood serotonin in human beings and rats. The object of this study was to see if the blood level of 5-hydroxytryptamine (5-HT) increased under acute hypoxic stress in human beings and rats. Soldiers who had been stationed at high altititudes 2-7 months prior to study were selected. 17 had suffered from pulmonary oedema and the remaining eight, who had not developed the condition, acted as controls. The technique of YUWILER [18] with suitable modifications was used for estimation of 5-HT. No significant change in 5-HT levels was observed either in subjects or controls. Rats exposed to simulated high altitude for 6 h also did not show any significant change in blood 5-HT levels.


Comparative studies on the effect of oxygen high pressure (OHP) on different species; with special reference to the organ preservation. Different species of animals (warm-blooded, poikilotherms and cold-blooded) were exposed to oxygen high pressure (OHP) (1-4 ata) for 2-8 h. OHP revealed (a) a different vulnerability in various species; (b) an inverse correlation between basal oxygen consumption and their vulnerability; (c) the critical point of the toxic effect of OHP in normothermia was an exposition time of 2 h with 2 ata OHP; (d) morphological changes of lung, CNS and vessels -- intense folding of alveolar septa with cell hyperplasia and hypertrophy; (e) electron-microscopical demonstration of damaged endothelial cells with total or partial occlusion of the capillaries.


Postbulbar peptic ulceration of the duodenum. One hundred and twenty patients operated upon for peptic ulcer diathesis had intraluminal digital examination of the duodenum seeking post-bulbar ulcers. Twelve such ulcers were found, an incidence of 10 per cent. In six of these patients, the postbulbar ulcer was an unexpected finding, and in two patients, a second ulcer was present. A review of the patients with postbulbar ulcers revealed that these patients had severe ulcer symptoms that responded poorly to medical management. Our patients were treated by truncal vagotomy and an outlet procedure. In ten patients, the anterior duodenotomy was extended to include the stenotic area. A Jaboulay gastroduodenostomy was performed in one patient, and duodenoplasty with pyloroplasty in another patient. These 12 patients were observed from one to six years. There were no deaths. Two patients had temporary gastric atony and one patient had a dumping syndrome. Three patients have had possible recurrence of the ulcer, reoperation being required in one patient. It is possible that unrecognized postbulbar stenosis may be a cause of recurrent peptic ulcer following some surgical procedures. To recognize these ulcers, we believe that the duodenum should be inspected by intraluminal palpation in all patients operated upon for peptic ulcer disease.


Effects of transfusion on surviving and nonsurviving postoperative patients. In the pretransfusion control period, generally, the cardiorespiratory values of the nonsurviving patients were worse than those of the surviving patients. Moreover, the responses of nonsurvivors to a standardized test of therapy generally were less than those of survivors. The increase in oxygen availability to the tissues after blood transfusion in nonsurvivors was almost as great as that of survivors, but the increase in oxygen consumed by nonsurvivors was only about one-half that of survivors. This is of particular importance in the critically ill patient, as reduction in oxygen transport represents a major physiopathologic problem in postoperative deaths.


Isotope angiograpy for detection of embolic arterial occlusion. Radionuclide angiography is a safe, noninvasive, easily performed and rapidly executed technique which will accurately demonstrate the presence of an acute occlusion of the arterial tree of the lower extremities. The diagnosis of embolic or thrombotic occlusion of the arterial circulation of the lower extremity in the critically ill patient often is not clear. Visualization of the arterial tree prior to any operation is advantageous, but these patients are invariably in such poor general physical condition that one wound prefer not to submit them to the invasive and time-consuming procedure of conventional contrast arteriography. Radionuclide angiography was performed in three patients who had an equivocal diagnosis of acute occlusion of the femoral artery. Acute occlusion was correctly diagnosed by this technique in all three patients.


Internal jugular venous autograft in extrahepatic portal hypertension. A 26 year old female with repeated episodes of upper gastrointestinal bleeding, secondary to extensive extrahepatic portal and superior mesenteric venous obstruction, was surgically treated by interposing an internal jugular vein autograft between a collateral channel and the inferior vena cava. The follow-up observation during a seven and one-half year period has shown no recurrence of bleeding, disappearance of esophageal varices and a widely patent graft with normal portal vascular pressures. The internal jugular vein is a readily accessible autogenous graft of adequate caliber that can maintain patency under rigorous conditions. Its use is recommended in constructing portal-systemic venous shunts in those instances of extrahepatic portal hypertension in which conventional shunts cannot be established or, if they can be established, are liable to closure.


Trace metal levels in cancer of the breast. Twenty sample pairs of cancerous and noncancerous tissue from the human breast were analyzed for trace metals. Samples were dissolved by wet digestion with ultrapure grade nitric and perchloric acids. The sample solutions was analyzed by conventional atomic absorption for calcium and magnesium. Ten other elements--iron, zinc, copper, lead, calcium, manganese, chromium, silver, strontium and aluminum--were determined in the solution by the graphite furnace technique. Magnesium and zinc levels were significantly higher in the cancerous than in the noncancerous tissue.


Abnormal motion of the mitral valve with pericardial effusion: Pseudo-prolapse of the mitral valve. The echocardiograms of seven patients with large pericardial effusions were found to show posterior motion of the mitral leaflets in systole as seen in prolapse of the mitral valve. Repeat echocardiograms after resolution of the effusion revealed normal mitral valve motion. None of the patients had clinical evidence of prolapsed mitral valve. We postulate that a posterior swing of the heart within the pericardial fluid occurring in late systole causes posterior displacement of the mitral valve simulating a prolapsed valve.


Reciprocal rhythm in patients with normal electrocardiogram: Evidence for dual conduction pathways. The present study refers to six patients in whom an A-V reciprocal rhythm could be documented; in four cases it took the form of sustained tachycardia. None of the patients showed any ECG feature of ventricular pre-excitation (PR interval of more than 0.12 sec. and normal QRS configuration). The extrastimulus method showed, at first, that the A-V conduction time of the premature beat varied only slightly with the decrease of the coupling interval. From a critical A1A2 interval there was a sudden lengthening of A2H2 preceding the occurrence of re-entrant beats. The curve of H1H2 responses reflected these changes, showing two distinct parts. The second part following the slowing of the impulse included the initiation zone of atrial echoes and of reciprocating tachycardia. These results suggest the existence of two A-V pathways, one fast and the other slow. The point at which the break between the two parts of the curve occurred might be related to the effective refractory period of the fast pathway. In the same way, when atrial pacing reached a critical rate, it induced an abrupt increase of AH in five cases. In the sixth patient, A-V conduction time remained unchanged up to 170 per minute. Ventriculoatrial conduction was always observed, the delay of which did not lengthen with the rate. In one case tachycardia could be induced by a premature ventricular beat without lengthening of the V-A time. It is concluded that in spite of a normal PR interval, the presence of dual A-V pathways may be  implied in the genesis of reciprocal rhythm.


Clinical study on the flow murmurs at the defect area of atrial septal defect by means of intracardiac phonocardiography. In order to study flow murmurs through atrial septal defects, right heart catheterization was performed on 48 patients of secundum type, four of primum type, and five of probe-patent foramen ovale, with the double-lumen phonocatheter of Lewis, at the tip of which barium titanate was mounted. The flow murmurs at the defect area were classified into three patterns: v murmur, atriosystolic murmur, and mid-diastolic murmur. V murmur was continuous, extending from late systole to diastole, of low to medium pitch, closely related to atrial v wave and augmenting with expiration. It had no significant correlation to the ratio of left-to-right shunt. It was recorded in 32 out of 48 cases of secundum type and one of primum type, but not observed in probe-patent foramen ovale. Atriosystolic murmur was noted in 17 of 48 cases of secundum type and one of primum type. It was connected with atrial a wave. Mid-diastolic murmur was found at the defect area in four subjects of secundum type. It was thought to be an independent entity from v murmur and to be another one due to shunt flow through the septal defect, since it had no relation to v wave but it was localized between v and a waves in the pressure curve of the right atrium. It is different in localization from mid-diastolic murmur due to relative tricuspid stenosis at the inflow tract of right ventricle.


Progressive improvement of His-Purkinje conduction during recovery from catheter-induced heart block. Complete heart block developed during HBE studies in a patient with left bundle branch block, after inadvertent catheter-induced trauma to the right bundle branch. Normal intraventricular conduction (HV interval) was documented during the initial part of the study, and was demonstrated to be markedly prolonged after the appearance of heart block. Conduction through the right bundle branch improved over a short period of time as manifested by steplike shortenings of the HV interval, until the original conduction velocity was re-established. This case strongly supports the concept that the His-Purkinje system is capable of varying its conduction velocity and further demonstrates that, in patients with bundle branch block, a prolonged HV interval indicates disease of the remaining bundle branch.


Development of mitral insufficiency following closure of ostium secundum atrial-septal defect. The development of severe mitral insufficiency after a successful closure of an ostium secundum ASD was encountered in four adult patients. This acquired postoperative lesion appeared nine years, three and a half years, two year, and two months following ASD repair. It was associated with deterioration of the excellent clinical improvement following closure of ASD, and was detected clinically by the appearance of a new apical holosystolic murmur. In one patient, pathologic examination of the mitral valve indicates insufficiency to be possibly due to rheumatic valvulitis. The cause of mitral insufficiency in the other patients is not clear. Multiple etiologies could be responsible for this unusual association.


Total anomalous pulmonary venous connection: Report of 93 autopsied cases with emphasis on diagnostic and surgical considerations. Total anomalous pulmonary venous connection (TAPVC) is failure of development of the common pulmonary vein, with consequent ersistence and enlargement of embryonic collaterals between the lungs and the systemic veins. In the great majority (91 of 93 autopsied cases, 97 per cent, no remnant of the common pulmonary vein was found, supporting the concept of agenesis or involution of the common pulmonary vein. Occasionally, a cordlike strand was found in the location of the common pulmonary vein (in three of 93 cases, 3 per cent), supporting the concept of atresia of the common pulmonry vein. The order of frequency of the various types of TAPVC was: left innominate vein ("snowman"), 26 perent cent; subdiaphragmatic, 24 per cent; coronary sinus, 18 per cent; right superior vena cava, 15 per cent; right atrium, 8 percent; mixed, 5 per cent; azygos, 2 per cent; and left supeior vena cava, 2 per cent...


Mitral valve prolapse in coronary artery disease. Mitral valve motion, left ventricular segmental contraction and severity of arterial stenosis were analyzed in 92 patients with coronary artery disease and 28 patients with "atypical chest pain" and normal coronary arterio-rams. Mitral valve motion was evaluated for the presence or absence of leaflet prolapse. Segmental contraction was evaluated by calculating the percent shortening of six chords of the left ventricle measured from right anterior oblique ventriculograms. The severity of disease in each coronary vessel (left anterior descending, left circumflex and right coronary) was graded on a scale of 1 (0 to 30 percent stenosis) to 5 (complete occlusion). Mitral valve prolapse was not suspected clinically but observed angiographically in 15 of 92 patients with coronary artery disease and in 5 of 28 patients with normal coronary arteriograms. In nine patients with coronary artery disease, the prolapse was restricted to the posterior leaflet, in five it was in both the anterior and the posterior leaflets and in one patient in the anterior leaflet only. Mitral regurgitation was noted in seven patients with coronary artery disease; it was mild in six and moderate in one. Among the patients with coronary artery disease, 12 of the 15 (80 percent) with mitral valve prolapse had left ventricular asynergy compared with 63 of the 77 (82 percent) without valve prolapse. The mean scores for severity of disease in the left anterior descending, circumflex and right coronary arteries were, respectively, 4.2, 2.5 and 3.2 in the patients with valve prolapse and 4.2, 2.2 and 3.5 in those without prolapse. In summary, there was no significant correlation between mitral valve prolapse and distribution of coronary arterial obstructions or abnormal patterns of left ventricular segmental contraction. There was a high frequency of mitral valve prolapse in patients with severe coronary artery disease and in those with normal coronary arteriograms and atypical chest pain.


Value of Holter monitoring in assessing cardiac arrhythmias in symptomatic patients. Holter electrocardiographic monitoring in 55 symptomatic patients with syncope, palpitations or dizziness uncovered significant arrhythmias in 30 patients (55 percent). By providing an observation period of at least 24 hours including a period of sleep, the procedure aided detection and diagnosis in both symptomatic and asymptomatic patients of transient arrhythmias or conduction abnormalities not documented by routine electrocardiograms. Bradyarrhythmias accounted for the majority of arrhythmias recorded in 21 or 30 symptomatic patients (70 percent); 15 had sinus bradycardia (35 to 55 beats/min) alone and 6 also had long episodes of sinus arrest of up to 5 seconds. Two had sinus bradycardia with periods of atrioventricular block with Wenckebach phenomenon. Five patients had a tachycardia-bradycardia syndrome; three had other episodic arrhythmias and one had pacemaker failure. In 15 (60 percent) of the 25 patients without arrhythmias, monitoring did not document the cause of symptoms. Holter monitoring is of considerable value in assessing the efficacy and adequacy of drug treatment, especially in patients with known heart disease, and in detecting pacemaker malfunction. However, very long periods of monitoring may be needed to make a diagnosis in those with only sporadic symptoms.


Successful correction of total anomalous pulmonary venous connection in a 2.5 kilogram premature neonate. A 16 day old 2.5 kg premature infant with total anomalous pulmonary venous drainage to the coronary sinus was successfully treated with use of profound hypothermia and total circulatory arrest. To the best of our knowledge, this neonate is the smallest to successfully undergo correction of this anomaly. A plea is made for a more aggressive approach in early recognition and assessment of these critically ill infants, followed by early surgical correction.


Supravalvular mitral stenosis associated with tetralogy of Fallot. The association of tetralogy of Fallot with supravalvular mitral stenosis is a rare anomaly that has been reported only once previously. The difficulty of preoperative diagnosis is emphasized. Although left-sided obstructive lesions in association with tetralogy of Fallot are rare, their recognition is imperative since these are surgically correctable anomalies and potentially lethal, as proved in this case and the one previously reported.


Effects of electrical countershock on serum creatine phosphokinase (CPK) isoenzyme activity. Total and MB serum creatine phosphokinase (CPK) activity levels were measured serially in 30 patients treated with direct current electrical countershock, 17 patients with acute myocardial infarction and 25 normal subjects. In addition, serial determinations of total and MB CPK in serum were performed in 11 closed chest anesthetized dogs subjected to 10 repetitive countershocks at 15 second intervals with a delivered energy of 240 joules per countershock. Less than 4 milli-international units (mlU)/ml of MB CPK was found in the serum of normal subjects. Patients with myocardial infarction whose elevated total CPK levels were comparable with those of patients treated with cardioversion had a usbstantial rise in MB CPK activity, with peak values averaging 39 +/- 6 mlU/ml (mean +/- standard error). Fifteen of the 30 patients treated with countershock had elevated total CPK activity that peaked within 4 hours. In this group, MM CPK elevations accounted for the overall rise in CPK activity. In two patients, modest elevations of MB CPK (11 and 13 mlU/ml, respectively) were observed after cardioversion. In all 11 dogs total CPK increased after countershock, peaking to 1,888 +/- 410 MLU/ml within 6 hours. Six dogs had increased MB CPK activity (52+/- 6 mlU/ml) and myocardial necrosis demonstrable histologically 4 days later. The results indicate that (1) myocardial damage in dogs produced by intense, repetitive countershock is associated with increased serum MB CPK; and (2) countershock as conventionally used in patients does not generally produce myocardial damage and serum MB CPK elevation. Although release of MB CPK into serum occasionally occurs after countershock, perhaps reflecting myocardial damage, the elevations appear to be modest. Thus, electrical countershock does not obscure the diagnosis of myocardial infarction or impair quantitative assessment of the extent of myocardial damage based on analysis of serum MB CPK activity.


Upsloping S-T segments in exercise stress testing. Six year follow-up study of 438 patients and correlation with 248 angiograms. A 6 year follow-up study of 438 patients who underwent maximal treadmill stress testing revealed the following annual incidence rate of coronary events (death, myocardial infarction or onset or progression of angina pectoris): 13 percent in 84 subjects whose stress test produced 2 mm downsloping S-T segment depression, 9 percent in 230 subjects with 2 mm horizontal S-T depression and 9 percent in 124 subjects who had an upsloping S-T segment with 2 mm S-T depression measured 0.08 second from the J point. Coronary angiograms were obtained in another group of 248 subjects who underwent maximal treadmill stress testing. They revealed major (greater than 50 percent) obstruction of two or three vessels in 67 percent of 62 subjects with a downsloping S-T pattern on the stress test, in 60 percent of 116 subjects with horizontal S-T depression and in 57 percent of 70 subjects with upsloping S-T depression. Patients with an upsloping pattern of S-T depression during stress testing had the same incidence of coronary events as those with a horizontal pattern of S-T depression. Upsloping S-T depression should not be confused with isolated J point depression. Subjects with an upsloping segment also had the same incidence of major two or three vessel disease as those with horizontal depression. Subjects with a downsloping pattern has a slightly greater incidence of coronary events and major two or three vessel disease.


Changes in regional vascular resistance after myocardial infarction in the dog. The possibility that failure of vascular resistance to increase during hypotension in cardiogenic shock is a generalized phenomenon affecting many vascular beds was investigated in anesthetized dogs subjected to coronary arterial embolization. Blood flow in the carotid, mesenteric and renal vascular beds was monitored. Efferent vagus nerve stimulation, which, through bradycardia, produces hypotension of cardiac origin without myocardial damage, was associated with reflex vasoconstrictor responses in the carotid and mesenteric vascular beds; no change in resistance occurred in the renal vascular bed. In marked contrast, vasoconstriction failed to occur in any of the vascular beds in response to the hypotension produced by coronay embolization. These responses to cardiogenic shock mimicked those seen after ganglionic blockade, in which hypotension of partly cardiac origin was produced and reflex vasoconstriction blocked. The data support the previous hypothesis that myocardial infarction is associated with reflex inhibition of the reflex vasoconstrictor response to hypotension.


Cardiovascular effects of long-term cigarette smoking and nicotine administration. The nature of the cardiovascular risk in cigarette smokers has not been characterized. To compare the relative effects of long-term smoking and nicotine administration on the cardiovascular system, 18 month old beagle littermates were prepared with a permanent tracheostomy. They were classified into three groups: I, seven control dogs; II, nine dogs that smoked seven cigarettes/day; and III, eight dogs that received an equivalent amount of nicotine. After a period of up to 22 months, the animals were catheterized under anesthesia for assessment of left ventricular function and volumes by indicator-dilution technique. Heart rate, stroke volume, left ventricular end-diastolic pressure and volume and intraventricular conduction times did not differ significantly in the three groups. Left ventricular ejection fraction was 44 +/- 3 percent (mean +/- standard error of the mean) in the control group, 35 +/- 3 percent in the dogs that smoked cigarettes (P less than 0.05) and 27 +/- 3 percent in those given nicotine (P less than 0.01) despite similar values for end-diastolic variables in the three groups. The first derivative of left ventricular pressure (dP/dt) normalized for pre- and afterload was 2.4 +/- 0.2 cm/sec -1 in the control group, 1.41 +/- 0.12 in the cigarette-smoking group (P less than 0.005) and 1.34 +/-0.08 in the nicotine group (P less than 0.01). Although mean aortic pressure was significantly elevated in both the smoking (127 +/- mm Hg) and nicotine (127 +/- 10 mm Hg) groups, there was no significant correlation with the contractility indexes. Reduction of afterload to normal levels did not affect the abnormal ventricular performance. Hypertrophy, inflammation and abnormalities of cell ultrastructures were not present, and myocardial lipid and cation composition were normal. Since interstitial fibrosis was evident in both experimental groups, an alteration of elastic elements may be operative. These cardiovascular abnormalities appear to be predominantly dependent on the nicotine of cigarettes.


The quiz electrocardiogram: a new diagnostic and research technique for evaluating the relation between emotional stress and ischemic heart disease. To evaluate possible cardiovascular effects of emotional stress, a specially designed 12 minute tape-recorded stress quiz was administered to 43 subjects while blood pressure and the electrocardiogram were monitored. For the entire group, the heart rate and blood pressure rose from respective control levels of 76 beats/min and 136/87 mm Hg to a mean during the quiz of 87 beats/min and 158/94 mm Hg. This difference was highly significant. Of the 43 subjects, 33 were classified as executives and 10 as nonexecutives. There were three groups of executives: control and angina with and without a history of hypertension. Both groups of executives with angina responded with a significantly higher heart rate than that of the executive control group. Blood pressure response was significantly greater in executives with angina and hypertension than in the other groups. Heart rate and systolic blood pressure responses to the quiz were lower in nonexecutives with angina than in executives with angina. During the quiz, 10 of 14 executives with angina had S-T segment depression greater than 0.5 mm; of these, 7 evidenced greater than 1.0 mm depression, andin 3 of these the depression was greater than 1.5 mm and in 2 greater than or equal to 2.0 mm. None of the executive control subjects had S-T depression greater than 0.5 mm Among nonexecutives, 2 had S-T depression greater than 0.5 mm but none greater than 1.0 mm S-T depression. Seventeen of the patients also were given a bicycle exercise tolerance test. There was a significant correlation between S-T depression in response to exercise and to the quiz (r = 0.63; P less than 0.01). The quiz electrocardiogram is presented as a new research technique and diagnostic test for evaluating the relation of emotional stress to ischemic heart disease.


Abdominal bruits in renovascular hypertension. A study of 87 patients surgically treated for renal arterial stenosis revealed that upper abdominal bruits were heard more frequently in patients whose stenosis was due to fibrous disease than to atherosclerosis. A diastolic bruit in a patient with fibrous disease of the renal artery usually indicated a favorable surgical result. Conclusions regarding the prognostic value of diastolic bruits in atherosclerotic renal artery disease must be deferred until a larger number of patients with this finding can be studied. When hypertension of less than 3 year's duration was combined with presence of a diastolic bruit, 17 or 18 patients had a favorable surgical outcome. An abdominal bruit should be carefully sought for in all patients evaluated for hypertension; when found, should be characterized acurately, because of the important diagnostic and prognostic information it may provide.


Beneficial effects of atropine in the pre-hospital phase of coronary care. The current widespread interest in early (pre-hospital) coronary care has raised questions regarding the safety and efficacy of the use of atropine in these circumstances. Although reports from early coronary care systems have been favorable, serious questions of safety have been raised on the basis of experimental animal studies and isolated case reports. A sample of the experience of a large scale emergency coronary care system in Columbus, Ohio has therefore been reviewed. A group of 70 patients who, during the early phases of myocardial infarction, exhibited bradyarrhythmia (less than 60 beats/min) was identified. When this group was further categorized on the basis of arterial pressure at the time of initial observation, patients with normal or elevated blood pressure had low mortality rates whether treated with atropine or not. In patients with hypotension the mortality rate was 75 percent without therapy, and 25 percent with therapy. Indeed, when normal hemodynamics were restored, the mortality rate was only 11 percent. Unexpected ventricular fibrillation occurred in 1 of 45 treated patients and 2 of 25 untreated patients. Although the study was not controlled, the data strongly suggest that atropine is both beneficial and safe for use in treating bradyarrhythmia and hypotension in the early phase of acute myocardial infarction.


Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence of absence of asynergy. The relation of minor and major axes of the left ventricle was determined in 100 left ventriculograms performed in the right anterior oblique projection. This relation taken over a wide range of volumes was used to derive a theoretically correct equation for determination of ventricular volume by echocardiography. The final equation was: V =[7.0/2.4 +d] (D3), where V = volume and D = the echocardiographically measured internal dimension. In 12 patients without asynergy, this equation accurately and directly calculated end-systolic and end-diastolic volumes whether the left ventricle was small or large. However, in 12 patients exhibiting left ventricular asynergy the correlation between angiographically and echocardiographically determined volumes was poor. Thus, caution is recommended in the use of time-motion echocardiography to calculate ventricular volumes in patients with coronary artery disease and possible left ventricular asynergy.


Results of surgery for congenital supravalvular aortic stenosis. Of eight children aged 3 to 15 years with surgical correction of severe supravalvular aortic stenosis, 6 were evaluated 7 to 44 months later by repeat cardiac catheterization and aortography. Prosthetic patch angioplasty was performed in all cases. Preoperative systolic gradients ranged from 40 to 90 mm Hg (average 70); postoperative gradients ranged from 0 to 20 mm Hg (average 11). The postoperative anglographic appearance of the ascending aorta was near normal in all six patients, and none had new aortic valve insufficiency. These results of surgery for supravalvular aortic stenosis are judged to be excellent.


Pericarditis caused by Histoplasma capsulatum. Sixteen patients with pericarditis caused by Histoplasma capsulatum were studied. Fourteen were less than 30 years old, and no patient had an underlying illness or was receiving immunosuppressive therapy. All patients experienced a flu-like prodromal illness lasting from 2 weeks to 4 months. Pneumonitis or hilar adenopathy, or both, was found in 12; pleural effusion, uncommon in primary pulmonary histoplasmosis, was found in seven patients. Pericardial fluid, pleural fluid and bone marrow cultures yielded no growth. All patients demonstrated a fourfold or greater change in complement-fixing antibody titers. No patient had disseminated disease, and only one required treatment with ampholericin B. The illness ran a protracted course, and in six patients symptomatic pericarditis recurred. Ultimately all recovered. Ten patients were restudied 6 months to 12 years after recover. Only one patient had pericardial calcification, and none had constrictive pericarditis. This form of granulomatous pericarditis, unlike that caused by Mycobacterium tuberculosis, appears to carry a good prognosis.


Electrophysiologic demonstration of bilateral anomalous pathways in a patient with Wolff-Parkinson-White syndrome (type B preexcitation). Pre- and postoperative electrophysiologic studies are described that were suggestive of two (right- and left-sided) anomalous atrioventricular (A-V) connections in a patient with type B Wolff-Parkinson-White syndrome and intractable arrhythmias, who underwent epicardial mapping and successful surgical ablation of the right-sided anomalous pathway. The presence of the right-sided anomalous pathway capable of both antegrade and retrograde conduction was suggested by the following observations: (1) Type B preexcitation on the surface electro-cardiogram; (2) maximal preexcitation and minimal stimulus-delta with low lateral right atrial pacing; (3) epicardial mapping of the atria and ventricles; and (4) disappearance of ventricular preexcitation after surgical ablation of the right-sided anomalous pathway. The presence of an additional left-sided anomalous pathway capable of only retrograde conduction (concealed on the surface electrocardiogram) was sugg-sted by the following observations: (1) Left to right retrograde atrial activation sequence during reentrant tachycardia and ventricular pacing at rapid rates and with coupled ventricular pacing postoperatively; (2) spontaneous conversion of wide ORS tachycardia utilizing the anomalous pathway for antegrade conduction to narrow QRS tachycardia with significant slowing in rate; and (3) smooth antegrade A-V nodal conduction curves with echo zone postoperatively. The demonstration of bilateral anomalous pathway in patients with preexcitation has important electrophysiologic and surgical implications.


Termination of pregnancy with double prostaglandin impact. With the "double PG impact" (DPGI) technique in 100 sedated first- and second-trimester volunteers, pregnancy was terminated successfully in 99 with a total extraovular PGF2alpha dose of 19.0 +/- 1.5 mg. in 16.9 +/- 0.9 hours. Two thirds of the patients received only the initial dose of 11.6 +/- 0.5 mg. of PG and aborted in 12.9 +/- 0.7 hours without requiring supplemental treatment. Only mild and transient side effects and 14 indicated curettages were recorded. Excepting one gravida (who failed to abort), plasma progesterone in 99 patients decreased at 3 hours after DPGI from 32.5 +/- 1.7 to 22.7 +/- 1.2 ng. per milliliter (P less than 0.001). The rate of progesterone withdrawal and IAT showed a close relationship and the first-trimester patients aborted at a lower progesterone level than the second-trimester patients (P less than 0.001).


Intravascular coagulation in obstetrics: Serial dilution protamine sulfate test throughout labor. Serial dilution protamine sulfate tests (SDPS) were performed in 191 women during labor. It was found that 27 per cent of women with uncomplicated pregnancies and 42 per cent with complicated pregnancies had positive SDPS tests, the highest incidence being between three and six hours of labor. These findings support the previous report of a physiologic disseminated intravascular coagulation in pregnancy but make the SDPS test of little value in obstetric cases.


Amount and distribution pattern of soluble fibrin monomer complexes during the early puerperium. Soluble fibrin monomer complexes (SFMC) were determined in 12 patients following delivery, 2, 4, 6 days and 3 months post partum. Quantitative gel filtration (1 per cent agarose) of the beta-alanine-precipitated plasma samples yielded the relative (per cent of the total fibrinogen content) and absolute (milligrams per 100 ml. of plasma) amount of SFMC. During the early puerperium the amount of SFMC remained essentially constant, with average postpartum values of 6.3 +/- 1.2 per cent and 27.6 +/- 9.1 mg. per 100 ml. (mean and standard deviation). Three months after delivery the level of SFMC was significantly (p less than 0.001) decreased (3.3 +/- 1.3 per cent and 8.4 +/- 3.4 mg. per 100 ml.). The quantitative estimation of SFMC in the early puerperium as presented in this study indicates that a state of hypercoagulability can be evaluated by measuring the thrombin-mediated catabolic products of fibrinogen.


Indomethacin induces rat uterine contractions in vitro and alters reactivity to calcium and acetylcholine. The initial contractions of uteri in vitro from castrated, estrogen-treated rats, were markedly diminished following replacement with fresh bathing medium. Indomethacin and aspirin (10(-5) to 10(-4)M) strongly stimulated such quiescent preparations and reduced their subsequent responsiveness to Ca++. Reintroducing the initial bathing medium (which contained prostaglandin-like material), or adding prostaglandin F2alpha to the fresh medium, initiated uterine contractions and restored responsiveness to calcium ion. Injections of indomethacin into castrated, estrogen-treated rats reduced initial in vitro uterine motility, abolished production of prostaglandin-like compounds, and prevented either indomethacin, aspirin, or Ca++ from stimulating uterine contractions. Uterine responsiveness to acetylcholine in vitro was significantly reduced in rats pretreated with indomethacin.


Cortisol in amniotic fluid and cord blood in relation to prenatal betamethasone load and delivery. The influence of maternal corticosteroid administration on the cortisol concentration in fetal blood and amniotic fluid (AF) was studied in women receiving betamethasone for prevention of IRDS. Thirty-four pregnant women in danger of spontaneous or induced preterm delivery were treated with 12 mg. of betamethasone daily for 3 days. AF was obtained by amniocentesis on the day before and the day following the betamethasone treatment and by amniotomy at delivery; cord arterial and venous blood was taken at delivery. Corresponding samples were obtained from 17 pregnant control subjects. All samples were analyzed in duplicate for cortisol by radioimmunoassay. The basal AF cortisol level rose with gestational age. The AF cortisol concentration fell from the basal value of 24.5 +/- 1.8 to 5.4 +/- 0.4 ng. per milliliter 3 days after the start of treatment, and it remained low at delivery if the treatment-delivery time was less than 1 week. An almost significant positive correlation (r = 0.543) was found between the cortisol concentration in cord arterial blood and AF. The cortisol concentration in cord blood in the controls was 108.2 +/- 14.3 ng. per milliliter in the arteries and 106.4 +/- 18.6 ng. per milliliter in the vein. Also, the cord blood cortisol level was depressed in betamethasone had been given within one week before delivery. The multifactorial influence on cord blood cortisol level prevents interpretation of the results as support for the concept that the human fetal adrenal is involved in labor initiation. The duration of gestation was not altered by the betamethasone treatment. The analysis of cortisol in the easily accessible amniotic fluid is suggested for estimating the function of the fetal adrenal cortex.


Serum levels of a placental protein during gestation in the baboon. A placental specific protein (Sp-1) isolated from human placentas was used to establish a radioimmunoassay for measurement of a baboon protein in the sera of pregnant baboons. No reaction was observed with any known pituitary or placental hormone in this assay system. Levels of Sp-1 were detected at 17 to 18 days of gestation and reached high levels by the end of the first trimester of pregnancy. A slow increase in serum levels continued thereafter until parturition. Disappearance of Sp-1 post partum was very slow and required 26 to 34 days to become undetectable in the serum. No function or role of Sp-1 in pregnancy has been suggested, but possible use of its measurement for detecting abnormal placental function deserves investigation.


Pure gonadal dysgenesis with an XY chromosomal constitution (Swyer's syndrome): Report of two cases. Two cases of Swyer's syndrome, characterized by rudimentary streaks in association with a 46,XY chromosome karyotype are reported. Both individuals were tall, with sparse axillary and pubic hair, and breasts were undeveloped in one and well developed in the other (she had some estrogen therapy). One had infantile but otherwise normal external genitals, while the other had poor development of labia majora and no clitoris. The vagina in each was normal, with a small cervix and uterus, and vaginal smears of the preadolescent type. Urinary 17-ketosteroids were normal, while gonadotropin levels were elevated. The gonadal streaks were extirpated, and histologic examination revealed the presence of fibrous stroma but no ova or follicles. Scattered clumps of Leydig cells and mesonephris remnants were found in one patient. Both patients responded well to cyclic hormonal therapy, i.e., menstrual withdrawal bleeding and breast development.


Testosterone metabolism in endometrial cancer. Plasma testosterone (PCT), metabolic clearance (MCRT), and production rates (PRT) of testosterone and conversion ratio of testosterone to androstenedione (CRppTA) were performed on 11 patients with endometrial cancer and on a control group of five postmenopausal women. The PCT, MCRT, and PRT of patients with endometrial cancer are in the normal postmenopausal range. The conversion of testosterone to androstenedione in patients with endometrial cancer was significantly decreased.


Studies on the cytodynamics of human endometrial regeneration. I. Scanning electron microscopy. Stereoscopic morphologic studies on regenerating cyclic endometrium indicate that endometrial repair lasts 48 hours, beginning between cycle Days 2 to 3 and ending between cycle Days 4 to 5. During this period, endometrial repair is focused on the neoformation of surface epithelium and is initiated only when and where the zona basalis is denuded from the overlying secretory spongiosa. The surface epithelium is derived from a simultaneous proliferation of dual origin: first from the exposed ends of basal glands and second from the persistent and intact surface lining of cornual and isthmic regions, bordering the denuded areas. The lack of estrogen-dependent morphologic alterations (mitosis and ciliogenesis) in the uterine mucosa during the regenerative period suggests that the initial factors and cellular processes operating in endometrial reconstruction are purely a reflection of tissue repair and are independent of cyclic hormonal stimuli.


Psychometric testing as a basis for counseling patients choosing a method of contraception. A retrospective survey. To investigate the merits of using psychometric testing as a predictive adjunct to counseling patients in the choice of a contraceptive method, 134 family-planning patients using an oral contraceptive for one year or longer completed the Neuroticism Scale Questionnaire. Clinic records of these patients were examined to determine consistency of contraceptive usage. Patients who were inconsistent in contraceptive usage scored significantly higher on the anxiety and emotional immaturity for inconsistent users. Results of this study provided support for the findings of two similar studies but failed to provide support for others. However, the over-all predictive ability of the questionnaire scores proved to be low. Further study is recommended.


Amenorrhea following oral contraception. A prospective study was done on 326 nulliparous women who ceased oral contraception. Follow-up was obtained on 311. The mean age was 20.3 years (S.D. 2.5). Eighty-nine per cent began menstruating within 60 days after stopping therapy, and only 7 took 180 days or longer to menstruate. Late menarche strongly correlated with post-pill amenorrhea (PPA), but continous length of time on oral contraceptives and type of oral contraceptive showed no significant relationship. The incidence of PPA was 2.2 per cent. All women did eventually menstruate spontaneously, the longest period of amenorrhea being 540 days.


Infertility following wedge resection of the ovaries. Seven cases of polycystic ovarian disease were investigated by laparoscopy and endocrinologic tests after failure of ovarian resection to restore fertility. One case of bilateral and two cases of unilateral ovarian atrophy were recorded. In all seven patients the common features were extensive perivarian and peritubal adhesions. Four of the six patients amenable to cure were submitted to reconstructive surgery; three of them conceived and had normal deliveries. The present observations support the plea to relegate the surgical approach to a minor position in patients with Stein-Leventhal syndrome and stress the importance of meticulous surgical technique in the performance of ovarian surgery. Laparoscopic investigation is mandatory in all cases of unsuccessful ovarian resection.


Vaginal agenesis.

Vaginal agenesis. Vaginal agenesis is not rare. Many ingenious procedures have been devised for its correction; some are simple, and some are complicated. Not enough emphasis has been placed on the emotional aspects when patients with this problem are treated. Proper timing of the operation and selection of the best procedure are discussed. We feel that procedure of choice is the simplest, least dangerous one which will give good results in the individual patient. Rather than using the same routine procedure in each patient, we fitted the treatment to each patient. Our experience, particularly with the simple vulvovaginoplasty technique, is given. Postoperative support and encouragement are needed to have a successful outcome.


Myocardial performance and N2O analgesia in coronary-artery disease. Inhalation of 40 per cent N2O by nine patients who had occlusive disease in two or more coronary arteries with elevation of left ventricular end-diastolic pressures (LVEDP) significantly decreased arterial pressure (average 5 per cent) and myocardial contractility as measured by dP/dt/CPIP (average 14 per cent), and increased LVEDP (average 21 per cent). N2O had no significant effect in four patients who had angina without angiographically demonstrable coronary arterial disease. It is concluded that N2O depresses myocardial function in patients who have occlusion of the coronary arteries and impaired left ventricular function.


Sodium nitroprusside and cerebral blood flow in the anesthetized and unanesthetized goat. The effects of dodium nitroprusside (SNP) on total, ipsilateral cerebral blood flow (CBF) in the unanesthetized and anesthetized goat was evaluated under four conditions: 1) bolus injection of SNP into the cerebral circulation via the temporal artery; 2) continuous infusion of SNP into the temporal artery in amounts too small to affect the peripheral circulation (0.57-1.14 mug/kg/min); 3) intravenous infusion of SNP; 4) continuous intravenous infusion of SNP with a bolus injection af angiotensin. Small doses (20, 40, and 80 mug) of SNP injected directly in the cerebral circulation of the awake goat produced immediate increases of 21 +/- 8, 36 +/- 8, and 48+/- 10 per cent, respectively, in CBF lasting 1 to 3 min without causing peripheral cardiovascular changes. The effects of SNP were attenuated by 1.5 per cent halothane anesthesia. Continuous infusion of SNP into the temporal artery in amounts too small to cause peripheral cardiovascular effects produced sustained increases in CBF averaging 31+/- 8 percent; CBF returned to preinfusion values upon cessation of infusion. Intravenous infusion of SNP in both anesthetized and unanesthetized animals in recommended clinical dosages (3-8 mug/kg/min) produced hypotension but did not significantly alter CBF. However, upon injection of angiotensin (1.43 mug/kg), both peripheral blood pressure and CBF increased sharply, suggesting that SNP may impair autoregulation of CBF. The results of this study indicate that SNP dilates the cerebral vascular system in a way that is probably similar to its effects on other vascular beds.


Halothane-induced porcine malignant hyperthermia: metabolic and hemodynamic changes. Metabolic, hemodynamic and neuroendocrine responses to halothane were measured in five normal and five malignant hyperthermia-susceptible (MHS) swine. Constant-volume ventilation was used. There was no therapeutic intervention. In NHS animals, blood lactate concentrations increased first, and the initial increases appeared to be non-hypoxic in origin. Lactate concentrations increased progressively to more than 20 mum/ml. Whole-body oxygen consumption increased almost twofold, and hind limb muscle oxygen consumption increased almost threefold. Extrapolated increases in muscle oxygen consumption accounted for about 55 per cent of the increase in whole-body oxygen consumption. Respiratory and metabolic acidosis, marked hyperkalemia, and increases in catecholamines and temperature occurred secondarily and were accompanied by progressive circulatory failure.


Metabolism and renal effects of enflurane in man. The metabolism and renal effects of enflurane were studied during and after anesthesia in ten surgical patients without renal disease; ten control patients received halothane. Enflurane was metabolized to inorganic fluoride with a mean peak serum level of 22.2 +/- 2.8 muM four hours after anesthesia. Urinary inorganic and organic fluoride excretions were increased but oxalic acid excretion was not, suggesting that the latter is not an enflurane metabolite. Postanesthetic renal function, including the response to vasopressin, was normal in both groups. During enflurane anesthesia renal blood flow, glomerular filtration rate, and urinary flow rate were 77, 79, and 67 per cent of control values, respectively. In this study of patients without renal disease, metabolism of enflurane to inorganic fluoride was insufficient to cause clinically significant renal dysfunction.


Inhibition by cyclopropane of release od norepinephrine, but not dopamine-beta-hydroxylase, from the guinea-pig vas deferens. Like halothane, cyclopropane reduces stimulation-induced release of norepinephrine, but not release of dopamine-beta-hydroxylase, from the isolated guinea-pig vas deverens. The dissociation between transmitter release and enzyme release in the presence of cyclopropane may be the result of either an increase in the affinity of norepinephrine for binding sites on the vesicular membrane produced by cyclopropane, or a direct effect of cyclopropane on a mechanism of release of norepinephrine that could be controlled independently of release of dopamine-beta-hydroxylase.


Porcine malignant hyperthermia: effect of dantrolene sodium on in-vitro halothane-induced contraction of susceptible muscle. Halothane-induced contractures in isolated muscle fibers from swine susceptible to malignant hyperthermia (MHS) were significantly less when fibers were incubated in KRB plus 6.2 x 10(-6) M dantrolene sodium prior to the administration of 4 per cent halothane. Administration of dantrolene sodium at the time of maximum contraction to NHS fibers in which contractures had been induced by halothane significantly increased the rate of relaxation of these fibers compared with similar fibers not treated with dantrolene sodium. This study indicates possible prophylactic and therapeutic value of dantrolene sodium in malignant hyperthermia and suggests that the previously reported effectiveness of dantrolene sodium in preventing and treating halothane-induced contractures may be due, at least in part, to its direct effect on muscles.


Hemodynamic response to ganglionic blockade with pentolinium during N2O-halothane anesthesia in man. Hemodynamic and blood-gas variables were studied before and after pentolinium tartrate administration in six patients anesthetized with nitrous oxide-halothane and maintained at PaCO2 35-40 torr. Measurements were made prior to induction of anesthesia; before and 10, 20, and 60 minutes after administration of pentolinium (0.3 mg/kg); 15 minutes after return of arterial blood pressure to control values. Mean arterial blood pressure (MAP) was significantly decreased at 20 (P less than 0.02) and 60 (P less than 0.001) minutes, in association with significant decreases in systemic vascular resistance (SVR) (P less than 0.05 and P less than 0.005). At 60 minutes MAP was significantly lower than that at 10 minutes (P less than 0.01). Cardiac output (CO) was increased (P less than 0.05) after 10 minutes secondary to a significant increase in heart rate. Neither variable changes significantly thereafter. CO and HR were significantly lower (P less than 0.01) 60 minutes after pentolinium than at 10 minutes; both returned to 10-minute values after intravenous administration of atropine. Changes in stroke volume (SV) and mean right atrial pressure (MRAP) were not significant. Whole-body O2 uptake (VO2) was not significantly altered by pentolinium. However, a substantial diminution of myocardial O2 consumption (MVO2) was deduced from a significant decrease in the heart rate-arterial systolic pressure produce (HR X ASP). Fifteen minutes after return of MAP to control levels, SVR was 11.5 per cent lower, while CO was still significantly higher (P less than 0.02) than control values. Following ganglionic blockade with pentolinium during halothane-N2O anesthesia, HR is a valuable index of changes in CO, while the HR X ASP index may be utilized to evaluate changes in MVO2. Assessment of myocardial performance during controlled hypotension is possible by the use of routinely available measurements.


Familial hyperparathyroidism. Description of a large kindred with physiologic observations and a review of the literature. Sixty-nine out of a kindred of 100 members covering five generations were examined and studied, and 34 were hypercalcemic. Sixteen subjects were believed, on the basis of laboratory and clinical observations, to have primary hyperparathyroidism. Eight patients were subjected to exhaustive study to identify polyendocrine involvement before neck exploration. No coexisting endocrine abnormalities were found; operation showed multiparathyroid gland involvement in most instances. Measurement of immunoassayable calcitonin and assessment of renal and gut function were carried out in 37 subjects to search out possible causes of "reactive" parathyroid gland hyperfunction. While no such cause-effect relationship was noted for this kindred, 16 of the subjects so tested had serum calcitonin content below the assay limits of sensitivity. What role this apparent lack of calcitonin played in the development of hyperparathyroidism (or vis versa) needs clarification.


Lidocaine in Wolff-Parkinson-White syndrome with atrial fibrillation. Atrial fibrillation in the Wolff-Parkinson-White syndrome may be life-threatening because of the extremely rapid ventricular rates that can occur over the accessory pathway. An 18-year-old man with Wolff-Parkinson-White (type B) syndrome developed episodes of syncope due to atrial fibrillation. In studies during hospitalization the administration of lidocaine immediately slowed the ventricular response by abolishing antegrade conduction over the accessory pathway. The role of lidocaine and other antiarrhythmic drugs in the management of arrhythmias in the Wolff-Parkinson-White syndrome is discussed.


A new look at peptic ulcer.

A new look at peptic ulcer. There have been notable advances in knowledge about peptic ulcer recently. Gastrin-producing tumors have been recognized as a rare cause of ulcer, and multiple physiologic defects have been found in duodenal ulcer, including excessive release of gastrin after food intake, increased sensitivity to gastrin, and decreased inhibition by low pH. The tendency of gastric ulcer patients to reflux duodenal contents into the stomach may have pathogenetic significance. Two new classes of drugs strongly inhibit acid secretion in man: chemically modified prostaglandins and histamine analogues which block the action of histamine on acid secretion. Their value in treating ulcer is now being assessed in clinical trials. A new operation for duodenal ulcer shows promise: only those vagal fibers innervating the acid-secreting part of the stomach are severed, thus obviating the need for a drainage procedure and decreasing some of the undersirable side effects of earlier operations.


Respiratory morbidity in rubber workers: II. Pulmonary function in curing workers. Pulmonary function tests were conducted on 121 curing and 189 control workers in 1972; 87% of the 1972 cohort was resurveyed one year later. The curing workers were subdivided into high and low exposure groups on the basis of environmental sampling. Cross-sectionally, in the 1972 cohort, the residual forced vital capacity was significantly decreased (P greater than .01) among the the heavily exposed workers (266 ml). Longitudinally, the mean one-year loss of forced expiratory volume in one second (FEV1.0) (173 ml/yr) in the curing workers with more than ten years of exposure was significantly greater (P less than .01) than in the control groups. Pulmonary function tests before and after a day's work were conducted on 29 curing-room workers. The eight heavily exposed curing workers had a significant decrease (P less than .05) in FEV1.0 of 115 ml. Our findings are sufficient to conclude that heavy exposure to curing fume affects pulmonary function. We recommend reduction of exposure and further longitudinal studies, especially in regard to those most heavily exposed.


Use of disposable products in surgical practice. Disposable products today are an important part of the multibillion dollar health devices industry. A few heavy-usage and low-usage examples of disposable products used by surgeons are chosen to demonstrate that in a 1,000-bed hospital, economy is rarely, if ever, a reason for converting from reusables to disposables. The actual reasons are more closely related to individual preference, availability, convenience, dependability, safely, and, in some cases, manufacturer's promotion. In a 24-hospital study of surgical apparel, it was found that only caps, masks, shoe covers, and other small items approached partly in cost between disposable and reusable items, where as the per-use cost of reusable larger items such as gowns and drapes was still much lower than that of their disposable counterparts. However, each hospital must make its own decisions based on all factors, not on economy alone.


Climate and environment change in patients with chronic airway obstruction. Psychological, clinical, and pulmonary physiological measurements were studied in ten patients with weather-sensitive chronic airway obstruction during one month in Gothenburg, Sweden, and immediately after for one month in the Canary Islands, a change to a drier and warmer climate. All patients improved according to psychological tests and claimed to be better. Objective measurements including peak expiratory flow rate, airway conductance, static lung volumes, and elastic lung recoil showed improvement in eight of ten patients, a change that we believe is due to the effect of climate.


Experience with 21 pancreaticoduodenectomies. Twenty-one patients underwent pancreaticoduodenectomy-19 for neoplasia and two for benign disease (operative mortality, 9.5%). Anastomotic leakage occurred in three patients (14.3%); in two it was biliary and in one it was pancreatic. Vagotomy was not employed and there were no instances of stomal ulceration. Four patients (21%) operated on for malignant neoplasm are free of disease from five to ten years since surgery, and two more are in good health for less than five years (total, 31.6%). The presence of an involved regional lymph node is not a contraindication to curative or palliative resection in either carcinoma of the ampulla of Vater or carcinoma of the pancreas.


The diagnosis of deep venous thrombosis. Fallibility of clinical symptoms and signs. One hundred twenty-four patients, with 133 involved extremities having the clinical diagnosis of deep venous thrombosis of the lower extremity, were studied by phleborheography and phlebography. Seventy-two limbs were proved to have deep venous thrombosis and 61 to have no evidence of thrombi in the deep veins. Classic symptoms of muscle pain and muscle tenderness, swelling, and the presence of a positive Homans sign obtained by dorsiflexion of the foot were found to occur with approximately equal frequency in those limbs with and without deep venous thrombosis.


Follow-up study of patients treated by X-ray epilation for Tinea capitis; resurvey of post-treatment illness and mortality experience. This is the second follow-up study of 2,215 persons who during childhood between 1940 and 1959 had been given x-ray therapy for tinea capitis and of 1,395 persons well matched for age, sex, and race who were treated for the same disease during the same period without the use of x-ray therapy. The major finding of the study was an excess incidence in the irradiated cases of tumors of the head and neck including the skin, brain, thyroid, and parotid. However, between the groups there was no difference in death due to malignant neoplasms or any other cause. Among white patients, a 40% excess of treated psychiatric disorders was observed in the irradiated group, but there was no difference among blacks.


Surveillance techniques for respiratory illness. The data presented represent a pilot study to determine the most efficient method of detecting the frequency and severity of respiratory illnesses in a defined population of children. Home surveillance telephone calls, parent-completed diaries, and monitoring of school absence lists were used. Detailed questionnaires were used to investigate reported illnesses. No one method of surveillance provided accurate estimates of respiratory morbidity in young children, and physicians' records were not reliable enough to be used as the sole source for data validation. Use of multiple sources for surveillance, however, provided illness rates comparable to those obtained in other community surveillance programs.


Drug prevention of postoperative deep vein thrombosis. A compararative study of calcium heparinate and sodium pentosan polysulfate. Deep vein thrombosis and its sequel, pulmonary embolus, are possibly the greatest threats to recovery after surgical operation. In a randomized, controlled clinical trial in which the 125I-fibrinogen uptake test, Doppler ultrasound, and phlebography were used for diagnosis, it was found that low doses of calcium heparinate administered subcutaneously and sodium pentosan polysulfate intramuscularly were effective in preventing deep vein thrombosis (DVT), postoperatively. The incidence of DVT was as follows: 9% in the group treated with heparinate; 15% in the group treated with sodium pentosan polysulfate; nad 51% in the untreated control group.


Arteriovenous fistulas constructed with modified human umbilical cord vein graft. Arteriovenous (AV) shunts were created using modified umbilical veins in baboons. The shunts consisted of veins removed from human umbilical cords tanned by either dialdehyde starch or glutaraldehyde 2% and surrounded with a polyester fiber mesh. Twelve fistulas were constructed employing the femoral or axillobrachial vessels. Six of the seven straight axillobrachial shunts remained patent for up to four months during the period of study. One of two loop fistulas and three femoral AV fistulas thrombosed because of kinking. There were no infections, mural disruptions, or aneurysm formations. Anglogram results and histologic studies confirmed the maintenance of graft function, morphologic appearance, and tolerance to repetitive punctures.


Doppler jugular flow velocity to differentiate cardiac tamponade from failure. Jugular venous flow velocity (JVFV) was analyzed by the directional Doppler velocity detector in an experimental model to distinguish postoperative acute cardiac tamponade from myocardial failure in eight dogs. Cardiac tamponade was produced by infusion of saline solution into the pericardial cavity; acute myocardial failure was created by temporary occlusion of the left anterior descending artery and circumflex coronary artery. A decrease in mean arterial pressure of only 10% was associated with a decrease in JVFV of 30% +/- 6% (mean +/- SE) in the tamponade group compared to 10% +/- 2% in the myocardial failure group. The difference was statistically significant (P less than .005) and persisted to severe levels of hypotension. An increase in venous pressure to 8 mm Hg resulted in a decrease in JVFV of 41% +/- 11% in the tamponade group. Thus, there is an early notable decrease in JVFV in tamponade, which allows differentiation from myocardial failure.