Areas Of Rarefaction Research Articles

1266. The pumping theory of diffusion pumps: G Toth,Acta Phys, Hungar,20(1–2), 1966, 99–114

The determination of possible locations of brain damage caused by the generation of tensile pulses in the brain for axisymmetric impact is investigated. The head is modeled as a spherical fluid-filled shell and as a prolate ellipsoid of revolution. In the latter case both cavitating and noncavitating central fluids were used. The models are analyzed using a two-dimensional Lagrangian, finite difference computer computation. Results show rarefactions occur in the fluid both adjacent to and opposite to the loading point. The elliptical geometry increases the maximum tensile value and the occurrence of cavitation causes major modification of the levels in the rarefaction areas.

1270. A simple sensitive mercury manometer: V B Gerard,J Sci Instrum,43,1966, 194–195

The determination of possible locations of brain damage caused by the generation of tensile pulses in the brain for axisymmetric impact is investigated. The head is modeled as a spherical fluid-filled shell and as a prolate ellipsoid of revolution. In the latter case both cavitating and noncavitating central fluids were used. The models are analyzed using a two-dimensional Lagrangian, finite difference computer computation. Results show rarefactions occur in the fluid both adjacent to and opposite to the loading point. The elliptical geometry increases the maximum tensile value and the occurrence of cavitation causes major modification of the levels in the rarefaction areas.

To culture or not to culture?

The results of root canal therapy in 2,335 teeth after 6 months and 706 teeth after 2 years were studied statistically in an attempt to uncover a significant relationship between success of repair in teeth with and without areas of rarefaction, positive or negative cultures, method of filling canals, and other variables. 1. 1. Repair was successful in 82 per cent of the teeth in all categories. 2. 2. Among the root canals of teeth which in the previous visit had yielded a negative culture, 16.6 per cent yielded positive cultures immediately prior to filling of the canal. 3. 3. On the basis of roentgenographic evidence alone, the prognosis for successful repair was less favorable in teeth with areas of rarefaction, regardless of the bacteriologic status of the root canal (88.8 per cent success in teeth without areas of rarefaction, 77 per cent success in teeth with such areas). 4. 4. There was no statistically significant difference between success of repair in teeth yielding positive or negative cultures prior to filling. 5. 5. The lateral-condensation methods of filling canals yielded slightly better results than the single-cone method, but the difference was not statistically significant in all groups. 6. 6. Overfilling of the root canal gave the worst percentage of success (69 per cent), and canals filled flush with the apex showed the best results (87.4 per cent success). 7. 7. A 2 year follow-up gives a more significant evaluation of success than a 6 month follow-up in teeth without areas of rarefaction. In teeth with areas of rarefaction a 6 month follow-up period is as reliable as a follow-up period of 1 to 2 years after treatment for evaluation of success. 8. 8. Differences in successful results may be due to an individual investigator's technique of débridement and pus evacuation, filling, and diagnosis, as well as other factors, but are not based on culture results. 9. 9. Differences in degree of success in this study were dependent upon roentgenographic interpretation and not on other clinical factors.

A clinical, roentgenographic, and histopathologic evaluation of periapical lesions

D IAGNOSIS of periapical areas of rarefaction has always been a problem to the oral surgeon and general practitioner. A review of the literature reveals few studieF of apical roentgenolucent areas in the last 10 years. These investigations have concerned themselves mainly with teeth that have had extensive restorative and endodontic treatment. A study was undertaken to (I) evaluate, roentgenographically and clinically, areas of periapical rarefaction in persons who have never sought definitive dental treatment and (2) evaluate histopathologically the specimens obtained from these areas. Periapical roentgenolucent areas are usually diagnosed as cysts, granulomas, or chronic periapical abscesses. However, a differential diagnosis including, among others, Paget’s disease, eosinophilic granuloma, fibrous dysplasia, HandSchiiller-Christian disease, and neoplasms should be kept in mind. Criteria for the roentgenologic diagnosis of periapical pathoses have received considerable attention in the literature. McCall and Wald4 have defined a cyst as a circumscribed radiolucent area, usually more than 3/S inch in diameter, sharply outlined, and bound by a thin, even, white line which represents a layer of cortical bone. A granuloma has been defined as a definite radiolucency without the presence of a white line and usually less than 3/s inch in diameter. A chronic periapical abscess appears as a diffuse radiolucent area, usually accompanied by resorption of the root end of the involved teeth. Stafne5 also stated that the roentgen image of a dental granuloma is generally not as definite or as well demarcated as the small, fully developed cyst. He further states that granulomas and radicular cysts of equal size cannot be distinguished roentgenographically from each other. Granulomas, however, seldom exceed 1 cm. in diameter. The accuracy and validity of roentgenologic diagnosis of periapical lesions

Roentgenologic and clinical evaluation of endodontically treated teeth

1. 1. Four hundred thirty-two endodontically treated teeth have been evaluated by roentgenogram from 1 year to nearly 5 years postoperatively. 2. 2. Of this number, there were 198 cases of vital pulp extirpation and 234 teeth in which the pulp had died and the root canal was infected. 3. 3. Of the vital pulp extirpation cases, 90.4 per cent were considered successful on x-ray checkup. 4. 4. Of the pulpless teeth, 89.3 per cent were successful, including those with small preoperative areas of rarefaction as well as those without such areas (putrescent pulp cases). 5. 5. Of 98 teeth with definitive areas of rarefaction, complete or progressive repair occurred in 85.7 per cent. The degree of repair was not altogether related to the size of the area in this series of cases. 6. 6. The percentage of successful results is higher in teeth treated with antibiotics (93.2 per cent) than in those treated with conventional medicaments (86.8 per cent). This may be due to lack of irritation from the antibiotics used. 7. 7. Of 94 cases in which root resection was performed, progressive or complete repair occurred in 95.8 per cent. These cases are in addition to the root canal treatment cases. 8. 8. There appears to be a direct relationship between age and repair of periapical damage, the greater percentage of repair occurring in the younger age group. 9. 9. Poorly filled root canals accounted for a large percentage of failures.

Congenital Bowing of the Tibia and Femur

1. The findings are described in a male infant, one day old, with congenital bowing of both tibiae amid the left femur, associated with syndactylism, hydrocephalus, and anomalies of the urinary tract. 2. Pathologically, the left femur and both tibiae showed narrowing of the diaphysis, anterolateral bowing, marked cortical sclerosis at the site of angulation, and periosteal thickening. 3. Cystic areas of rarefaction seen on the roentgenograms were the result of disruption of the normal trabecular pattern of bone rather than proliferation of connective tissue. 4. No evidence of fibrous dysplasia was encountered. 5. Neurofibromata, café au lait spots, or cutaneous nodules were not found.

An Operated Case of Enchondroma Tibiae in Which the Course of Healing was Followed with SR85

Sr metabolism in bone was investigated in a 66-yr-old man from whom a large tibial chondroma had been removed and the defect filled with bone chips. lnjection of Sr/sup 85/ was used to follow the processes of new bone formation and bone regeneration during the period of healing. In order to follow the course of healing from all aspects and to be able to verify any possible recurrence, histologic and radiologic examinations were also made. Doses of approximates 30 mu C Sr/sup 85/ were injected on 7 different occasions. Nine months after surgery it was then found that a few of the implanted chips were loose, but no macroscopic tissue reaction could be found around them. On tomography 14 months after the operation, some areas of rarefaction were found in the bone. On counting, moreover, an increased activity was found within these areas, which indicated an active process, so that the recurrence of tumor was considered to have occuried, but no macroscopic signs of recurrence were found. The biological half life of Sr/sup 85/ varied from 39 days early after injections were began to 55 days at a later period. These values of the biological half life are an expressionmore » of the speed with which the radioactivity disappeared from each counting point over the healthy and diseased tibiae. They have no general significince but do allow a comparison to be made between various periods of time for precisely that point at which they were counted. A test with Sr/sup 85/ 3 3/ 4 yr after the operation, indicating a considerably higher quantity of Sr/sup 85/ uptake in the operated leg than in the healthy leg, showed that the increased speed of bone renewal still existed on the side treated even after this long period. The presence of radioactivity in united chips and in loose chips suggests that the chips have undergone regeneration and reformed into bone specific to the body. (BBB)« less

The roentgen diagnosis of meningiomas of the sphenoidal ridge.

Meningiomas, which constitute about 15 per cent of all brain tumors, are among the few intracranial neoplasms which lend themselves to successful surgical removal. For this reason, any diagnostic assistance the roentgenologist can offer is of practical value. The roentgenogram alone will not always establish the diagnosis of meningioma. It is true that the roentgen findings are often so typical that no other diagnosis would be logical, but enough atypical cases are constantly occurring to bring out the fact that correct interpretation of the roentgenogram may depend on knowledge of the tumor itself, the history of the patient, and careful physical and neurologic examinations. Even with all this information at hand, the diagnosis is not always easy. There is need for close cooperation between the neurosurgeon, the neurologist, and the roentgenologist. Histogenesis That the histogenesis of meningiomas has long been obscure is obvious from the number of terms by which they have been known. Chapter I of Cushing and Eisenhardt's monograph on meningiomas (1) is devoted to the historical background of this tumor, and in this source the following terms appear: At first these tumors were thought to arise from the dura mater. Virchow called them sarcomas, but later adopted the term psammoma or sand tumor, because of the number of small concretions found within them. As they sometimes resembled epithelial cancer, the term epithelioma came into use. Later, epithelioma was replaced by endothelioma, since the term endothelium was employed to designate membranes of mesodermal origin lining body cavities, and the meshwork of the meninges was regarded as such a membrane. Mallory called the tumors arachnoid fibroblastomas because he thought they were made up of undifferentiated potential fibroblasts. Cushing arbitrarily coined the word meningioma as a nonspecific designation. The two terms fibroblastoma and meningioma are still used, but of the two, meningioma seems to be the more widely accepted. The identity of these tumors would be more obvious if the membrane from which they arise were known. The arachnoid villi are continuations of the arachnoid mesh into the lateral walls of the great dural sinuses. The arachnoid cells at the tips of the villi, directly below the vascular endothelium, are usually several layers in thickness, so that cellular caps over the villi are formed (2). The cells making up these villous caps resemble those found in meningiomas, and it is because of this striking similarity that meningiomas are thought to arise from the arachnoid (1, 3, 4). Further substantiation of this origin is found in the fact that meningiomas most frequently occur along the course of the dural venous sinuses. As part of the normal aging process, these arachnoidal villi become greatly enlarged, thickened, and even calcified, and are then known as pacchionian granulations (3). The roentgenologist is well aware of the areas of rarefaction or of increased density appearing in the inner table of the skull at the vertex and in the frontal and parietal regions due to these pacchionian granulations (5).

TOXIC REACTIONS DURING STREPTOMYCINSULFADIAZINE THERAPY OF BRUCELLOSIS

The toxic effect of streptomycin on the eighth cranial nerve has been well known since early in its clinical use. Published opinions indicate that the toxicity of streptomycin to the central nervous system is confined almost entirely to this nerve, predominately to its vestibular branch. 1 Nevertheless, a few isolated instances of other neurologic involvement have been reported. Hunnicutt and co-workers 2 have published a fatal case of toxic encephalopathy apparently caused by streptomycin. Postmortem examination revealed focal areas of rarefaction and necrosis throughout the brain. Finland and co-workers 3 reported a patient in whom severe vertigo, syncope and right-sided clonic convulsive seizures occurred on two occasions during the intravenous injection of streptomycin. In patients with meningitis receiving streptomycin intrathecally, neurologic disorders arising during the course of treatment ordinarily are attributed to the disease, but in some instances it is not unreasonable to suspect that the symptoms may be a

Unusual Bone Lesions in an Infant, Probably Osteitis Tuberculosa Multiplex Cystoides

The following case, in a Chinese infant, is reported because of peculiar lesions of uncertain etiology involving many bones of both hands and forearms. It terminated in complete recovery without special treatment except for a liberal addition of oranges to the diet. Case Report J. Y., Chinese male, was born at full term, the second child of a family of four. He was weaned at the age of four months and received thereafter a diet composed mainly of sterilized cow's milk and flour paste. Orange and tomato juice were added after the age of three months but were not available when the infant was nine months old. By the end of November 1939, at the age of eleven months, some swelling of the left middle finger, thought to be chilblains, was noticed. In addition, the child was likely to cry when handled, caught cold easily, was fretful, and slept poorly. At about the same time, there was an attack of fever accompanied by moderate swelling of the right submaxillary region, which lasted for two weeks. The left middle finger subsequently became more swollen and tender, but with no signs of infection, and a month later the right middle finger and the dorsum of the right hand also became swollen. The patient was then brought to the hospital for observation, at the age of fourteen months. The infant was well developed and well nourished. The skin and mucous membranes were pale. The teeth and gums were in good condition There was no jaundice, nor were petechiae or signs of bleeding anywhere discoverable. The heart and lungs appeared normal. The liver was not enlarged. The spleen was just palpable. There was firm swelling of the left second and third fingers, right middle finger, and dorsum of the right hand. There was no adenopathy. The red cell Count was 3,900,000; white cell count 12,750 (polymorphonuclears 40 per cent, lymphocytes 50 per cent, monocytes 7 per cent, eosinophils 3 per cent). The blood platelet count was 130,000 per c.mm. Kahn and Ring tests were negative, and the stools were negative for blood and ova. The first x-ray examination of the left hand (Fig. 1), on Feb. 16, 1940, two and a half months after the onset of symptoms, showed some widening of the shaft of the proximal phalanx of the third finger with a few tiny punched-out areas of rarefaction distally. The outline of the distal two-thirds of the same bone seemed slightly irregular. The middle phalanx of the same finger and the proximal phalanx of the fourth finger appeared slightly expanded. The x-ray diagnosis was indeterminate. Because of probable lack of vitamin C in the diet, and in view of some of the clinical signs and symptoms, the possibility of infantile scurvy was entertained. This suspicion was subsequently strengthened by a strongly positive capillary resistance test and the presence of many red blood cells in the urine. It was then decided to increase the vitamin C intake through the addition to the diet of three or four locally grown oranges daily.

Roentgenographic Changes in Bone Infections Treated with Penicillin

The recent generalized use of penicillin has stimulated interest in the treatment of infections of all types with this biological agent. We have had the opportunity of using penicillin in approximately 25 cases of bone infection, both acute and chronic, with varying results. In general, the period of active infection has been shortened and the clinical results have been gratifying. The following case summaries and illustrations demonstrate what we believe to be the typical changes occurring in bone infections susceptible to treatment with penicillin. Certain of these cases represent old chronic infections, and in these the response was by no means dramatic, although in the majority there was a decrease in drainage, with improvement in the general physical condition of the patient. In some of the cases it was possible to do elective surgery concurrent with the administration of penicillin, with no extension of the infection. In the acute cases which proved susceptible to penicillin, clinical improvement preceded the roentgenographic signs of healing, and the patient became clinically well. We do not feel that it is by any means established that in bone infections treatment with penicillin is a substitute for adequate drainage, when necessary, or for other surgical procedures which have proved of benefit in the past. In a few of these cases the clinical response was so rapid that surgical drainage was not instituted. Not all of the patients showed a prompt response to the penicillin, but in those which did, certain bone changes occurred. Case Reports Case I: E. M. B., an 11-year-old boy, was admitted to the clinic March 14, 1944, with pain in the right knee of three days' duration. Examination showed tenderness over the upper fourth of the right tibia with a slight soft-tissue swelling below the medial condyle anteriorly. There was a slight increase in joint fluid, and motion in the knee was guarded and painful. The temperature on admission was 101°, the white blood count 14,000; urinalysis showed ketone bodies. The roentgenograms were negative (Fig. 1, A). The administration of penicillin was instituted on admission: 1,000,000 units were given intramuscularly, 10,000 units every three hours. The patient's temperature rose to 103° on the first day, and until the fourteenth day it continued to show an afternoon elevation to as high as 102°. It then returned to 98.6° and remained normal thereafter. Roentgenograms made March 24, after 800,000 units of penicillin had been given, showed a localized area of rarefaction in the tibial shaft adjacent to the epiphyseal line (Fig. 1, B). The patient was discharged from the hospital on the fifteenth day, with a normal temperature and a leukocytosis of 12,800. The upper end of the tibia was painless.

CHOLESTEATOMA WITH FISTULA INTO THE LABYRINTH: Report of a Case in Which the Roentgenologic Findings Were Confusing

In the case to be reported, cholesteatoma with fistula into the labyrinth on the left side was diagnosed clinically, and the diagnosis was proved correct at operation. Roentgenographic examination of the mastoid processes, however, revealed indefinite, if any, evidence of disease on the left side but marked evidence of abnormality on the right side. The case is reported to illustrate that roentgenographic evidence of chronic disease of the ear may at times be misleading. ( a ) Roentgenogram of left mastoid process showing no evidence of abnormality; the dehiscence in the left epitympanum is not readily seen in the reproduction; ( b ) roentgenogram of the right mastoid process, showing sclerosis of the bone and an epitympanic area of rarefaction, which was interpreted as a cholesteatoma. especially if not carefully correlated with the clinical manifestations of the disease. REPORT OF CASE A 37 year old married woman came to the Mayo Clinic on Sept.

Clinico Pathological Conference

C. D. (Case A40,933), a five-year-old white boy, was first admitted to the hospital in February 1940, with a history of pain in the joints and recurrent fever of seven months' duration. During this time he had been treated for acute rheumatic fever, without improvement. Onset of the pain had been in the right knee and right lower leg, and the knee joint had been moderately swollen and tender. Subsequently, similar episodes occurred involving the other knee and both ankles and elbows. Symptoms subsided after several weeks but recurred in spite of bed rest and salicylates. It was noted that each episode was associated with tenderness along the shafts of the adjacent long bones. Past history and family history were not contributory. Physical examination on admission showed a pale, under-nourished, under-developed boy with slightly swollen tender knees and elbows. Temperature was 99.8°, pulse 100, and respirations 20. The positive findings were marked pallor of the mucous membranes, a blowing systolic murmur at the cardiac apex, and limitation of motion of the elbows and knees due to pain. There was exquisite tenderness along the shaft of each tibia from the knee to the ankle. There were no enlarged lymph nodes and no abdominal organs or masses could be felt. Laboratory examinations showed a hemoglobin of 50 per cent (S) with 2,800,000 red blood cells. The white blood cells numbered 2,000, of which 68 per cent were adult lymphocytes. The Wassermann reaction was negative and blood chemistry and urinalysis were normal. A biopsy of the sternal marrow was performed. Roentgen examination of the skeleton showed numerous punched-out areas of rarefaction in the skull, pelvis, and the diaphyses of the femora and tibiae. All the long bones showed a striking, smooth, regular periosteal proliferation extending along the shafts. (Figs. 1, 2, 3.) During the next two months the patient remained chronically ill, and enlargement of the liver, spleen, and lymph nodes appeared. Dr. Belk: Before proceeding to a discussion of the differential diagnosis, I think we should be told about therapy, inasmuch as this patient's response to therapy has diagnostic significance. Dr. Taylor: This little boy was given supportive therapy, including iron and vitamins and numerous small transfusions during the eight months before his death. Roentgen radiation in divided doses totalling 300 r, given with an intermediate-voltage unit, proved specific in relieving bone and joint pain. In addition, small doses (10 r) of whole body irradiation at 70 cm. at weekly intervals seemed to maintain the child in fairly good health during most of the summer before his death. With the coming of October, the patient began to lose ground steadily in spite of treatment. Subcutaneous ecchymoses and a persistent neutropenia developed. The week before death, the white count was 300 with absence of polymorphonuclears. This agranulocytosis was associated with generalized furunculosis.

Gaucher's Disease

Gaucher's disease is a somewhat rare familial disturbance of the cellular metabolism in the reticulo-endothelial cells and histiocytes, characterized by an accumulation and retention of the cerebroside kerasin. Thannhauser and his associates (1) explain this deviation from the normal lipid metabolism as an imbalance of intracellular enzymes concerned with the disintegration and synthesis of sphingomyelin and kerasin within the cell and a resulting accumulation of kerasin. The clinical manifestations may be enlargement of the spleen, liver, and sometimes the lymph nodes, pigmentation of the skin, pinguecula-like lesions of the conjunctivae, thrombocytopenia, and frequently a leukopenia. There may be pain in some portion of the osseous system caused by destructive infiltration of the cerebrosidic reticulosis of the bone marrow, and osseous involvement may be the earliest and continue to be the predominating manifestation of the disease. An accompanying fever and leukopenia are usually present. It is of the predominantly osseous type with which this case report deals. Risel (2) was the first to note macroscopic bone changes in Gaucher's disease and described the spongiosa at the upper and lower ends of the femur dotted with rather small, thick, whitish areas, arranged in a stellate form either in nodes or streaks or in a net-like manner. These areas represented deposits of Gaucher cells. The first complete x-ray studies were made by Klercker (3) and Junghagen (4) in 1926. The earliest as well as the most consistent type of change usually occurs as a widening of the lower ends of the femur, just above the condyles (Fischer's sign). This is followed by areas of rarefaction with intermingled areas of sclerosis and a resulting club-shaped conformation. The severe pain over this region when the changes begin to take place, accompanied by fever, makes it easy to confuse this condition with acute osteomyelitis. A history of some preceding trauma can almost always be obtained and, despite the low-grade fever and lack of leukocytosis, operation may be performed. The finding of a sterile pus from which no organism can be grown, coupled with the other findings atypical of acute osteomyelitis, may help to throw doubt on this diagnosis. Once operation has been done, drainage may continue for months. Bony changes occur frequently in the humerus, tibia, fibula, radius, ulna, and ribs. Changes have also been described in the pelvis and skull. Of those cases described in the literature, the most common changes in the long bones include general osteoporosis, large areas of destruction of the spongiosa, and as a late manifestation punched-out areas in the bone with irregular thickening of the cortex. Pathological fractures have been noted in long bones with a destructive lesion. Similar destructive changes in the head of the femur may result in a deformity which must be differentiated from Legg-Perthes' disease, tuberculous coxitis, and chronic osteomyelitis.

REGIONAL OBSTRUCTIVE PULMONARY EMPHYSEMA IN INFANTS AND IN CHILDREN

Pulmonary cavitations appear roentgenographically as areas of rarefaction with diminished lung markings, usually bounded by annular shadows of increased density. If cavities are partially filled with fluid, air-fluid levels are present that shift with changes in position of the patient. In the early days of roentgenology it was believed that such areas were caused only by pulmonary destruction, and they were diagnosed as either pulmonary abscess or tuberculous cavitation. 1 Later it was demonstrated that such shadows could also originate in the pleura and might represent the loculation of air, with or without fluid, in the pleural space. 2 When large pulmonary cavities have been present in roentgenograms of young infants, congenital cysts of the lung have usually been invoked to explain their formation. 3 More recently, substantial evidence has appeared which indicates that localized obstructive emphysema is an important factor in the production of cavernous lesions in the lungs.

Bone Rarefaction after Trauma to Large Joint Regions without Fracture

LOCAL regressive soft-tissue changes after an acute trauma without fracture to a large joint region are fairly common and familiar. For instance, it is recognized that a violent wrench, blow, or bump to the knee can lead to severe and disabling local muscle atrophy. Occasionally, the latter is even associated with the presence of one or more small areas of rarefaction in the spongiosa near the joint. Very rarely, without having induced a fracture, an acute trauma to a large joint region instigates, in addition to soft-tissue changes, an impressive degree of bone rarefaction. In these cases, the rarefaction extends far along one or all of the bones entering into the formation of the joint, and involves both the spongiosa and the cortex. That this sequence of events can occur at all does not seem to be well known. Cases presenting rarefaction of long bones after trauma (without fracture) to large joint regions are analogous in many respects to cases showing rarefactions of hand or foot bones after trauma (n...

Extensive Bone Metastasis in Carcinoma of the Breast

Early removal of carcinoma of the breast, followed by deep x-ray therapy and general treatment, helps toward cure and to keep patients alive longer than the employment of only one method. We should avail ourselves of every means to educate the public to seek frequent, thorough examinations, and to obtain medical advice as soon as any abnormal condition or symptom is noted. Since we know that fear is a powerful factor in preventing many persons from consulting a doctor, we do well to explain patiently and explicitly that a policy of putting off the seeking of such examination can result only in letting a tumor, if present, get a head start. If the individual's fears should, happily, prove to be groundless, the sooner they are relieved the better for his general wellbeing. I report two cases, commenting upon them in conclusion. Case 1. A. B., white female, unmarried, 39 years of age, first came to my attention in 1926 when she entered the North Chicago Hospital to have a carcinoma of the left breast removed. The operation was a radical one, the left breast with adjacent axillary and supraclavicular lymph glands being removed. The wound healed promptly and the patient made an uneventful recovery. She remained in apparent good health until December, 1929, when “shooting pains” extended to the left hip. Dull in character at first, they became progressively more intense. In the latter part of January, 1930, she was unable to support her weight on the left leg. She entered Grant Hospital on Feb. 7, 1930. Except for the above-mentioned mastectomy four years previously, the patient's personal, like her family, history was essentially negative. Physical examination revealed a moderately well nourished individual. The head, neck, heart, lungs, and abdomen were essentially negative. There was marked tenderness over the left hip. The reflexes appeared to be normal. The laboratory examination of the blood showed: red blood cells, 4,360,000; white blood cells, 8,000; hemoglobin, 75 per cent, with a normal differential count. The blood calcium was 9.8 mg.: the urine was negative. Roentgen Examination.—Films of the skull, both femurs, and the pelvis showed some rare-factions and elevations of the calvarium, rare-fied areas in the upper third of the left femur, and similar areas in the pelvis. Films made at a later examination showed small areas of rare-faction in the left shoulder and the left scapula. Clinical Course.—There was a gradual, steady loss of vitality. When the patient entered the hospital she was able to sit up in a wheel chair, but within a few months she was confined to bed. Pain developed in both shoulders, and a marked muscular atrophy from disuse occurred. The metastatic growths were controlled to some extent by x-ray therapy but new growths appeared in the left shoulder and along the lower right ribs. A mass was palpable in the abdomen to the left of the epigastrium, and the liver enlarged.

Multiple Myeloma

Case 1. E. S., aged 49 years, white, a printer by occupation, consulted one of us (V. W. K.) on Feb. 1, 1935. He complained of weakness, shortness of breath on exertion, and pain involving the lower dorsal and upper lumbar segments of the back. This symptom-complex was ushered in in May, 1934, when he experienced a sudden pain in the back in the region of the floating ribs. Since then his symptoms have gradually increased in intensity till now he has difficulty in moving about freely and in getting out of bed. He has had a cough for the past six months but there is no expectoration. Coughing, sneezing, and breathing deeply aggravate his pain. He has lost no weight yet is unable to work because of weakness. He has a whitish precipitate in the urine which is more noticeable toward the end of micturition. Clinical examination reveals a very pal e, well developed male, six feet in height, weighing 180 pounds. His pulse rate is 99 ; temperature 96; systolic blood pressure 132, diastolic 98. The blood coun t reve als 10,500 white blood cells, 4,180,000 red blood cells. The hemoglobin is 58 per cent. The differential blood count is as follows: small lymphocytes, 22 per cent ; large lymphocytes, 2 per cent; po1ymorphonuclears, 75 per cent ; large mononucl ears, 1 per cent . Chemical examination of the blood reveals 166 mg. of cholesterol per 100 c.c.; 68 mg. sugar per 100 cc.; 15 mg. calcium per 100 c.c., which is an increase from the average normal amount of 9 to 12; phosphorus 3 mg. per 100 c.c., which is a relatively low normal amount. The Wassermann reaction is negative. Gastric analysis reveals the following: Fasting—0 free HCl—18 c c., total acidity 10 30 minutes—0 free HCl—112 c.c. , total acidity 6 1 hour—0 free HCl—20 c.c., total acidity 5 The phenolsulphonphthalein intravenous kidney function test reveals 14 per cent at the 15-minute interval, 13 per cent at 30 minutes, and 15 per cent at one hour. The water test is shown below. There is 0.7 per cent urea present at the first hour and 0.9 per cent at the second hour, whereas there normally should be over 2 per cent of the 15 grams given. The urine is cloudy, acid in reaction, and contains 10 per cent albumin. The albumin is of the BenceJones variety. In sharp contradistinction to the urine, the blood contains only a small percentage of Bence-Jones albumin. The x-ray examination reveals multiple punched-out areas of rarefaction involving the ribs and sternum. The upper thirds of the radii are markedly osteoporotic. The lower ends of the femora contain tiny rarefied areas. The nght fibula shows several demineralized areas extending from the medullary canal outward into the cortex. The skull is peppered with punched-out atrophic areas varying in size from a bird shot to a silver dollar.

OSTEOCHONDRITIS OF THE HEAD OF THE FEMUR

The exact etiology of osteochondritis of the head of the femur 1 is still undetermined. Various theories of the cause of this disease have been advanced, the most reasonable of which may be considered under the headings of infection, trauma, embolism and maldevelopment. The evidence in favor of infection as the etiologic agent is based on a few bacteriologic studies. Legg 2 scraped tissue from a large area of rarefaction in the neck of the femur of a patient suffering from this disease and found that staphylococci grew in cultures from the material so obtained. Kidner 3 obtained staphylococci from the granulation tissue found in necrotic areas in the metaphyseal region of the upper end of the femur in a similar case. McWhorter 4 likewise found the staphylococcus in a single case. Phemister 5 removed part of the upper femoral epiphysis after curetting the interior, and obtained no microbic growth

BRAIN CHANGES IN MALIGNANT ENDOCARDITIS

Histologic examination of the central nervous system in malignant endocarditis reveals a rather common involvement of the brain which is The present study comprises twelve cases of malignant endocarditis that were placed at my disposal by Dr. R. H. Jaffe from his necropsy material at the Cook County Hospital and one case of rheumatic endocarditis from the Research and Educational Hospitals of the University of Illinois. They all showed manifest circumscribed, as well as diffuse, lesions which, though they varied to some extent, had certain common features which will be described. REPORT OF CASES Case 1. —Malignant endocarditis of several months' duration following rheumatic endocarditis; glial nodules in the pons, optic thalamus and subcortical white matter; diffuse glial proliferation; areas of rarefaction around blood vessels; degenerative changes of ganglion cells; hyperemia and mild perivascular infiltration of the pons; hyperplasia of the leptomeninges. History. —A white man, aged 42, a goldsmith,