BRITISH MEDICAL JOURNAL
841
31 MARCH 1979
When seeing is believing
as lysergide, and in the withdrawal of alcohol and similar depressants of the central nervous system. Lowe, G R, British journal of Psychiatry, 1973, 123, 621. s Herridge, C F, Lancet, 1960, 2, 949. 3 Davies, D W, British J0urnal of Psychiatry, 1965, 111, 27. 4 Maguire, G P, and Granville-Grossman, K L, BritishJournal of Psychiatry, 1968, 114, 1365. 5 Johnson, D A W, Practitioner, 1968, 200, 686. 6 Hall, R C W, et al, Archives of General Psychiatry, 1978, 35, 1315. 7Lishman, W A, Organic Psychiatry. Oxford, Blackwell, 1978. 8 Hudgens, R W, et al, Journal of the American Medical Association, 1966, 198, 81. 9 Longo, V G, Pharmacological Reviews, 1966, 18, 965. 10 White, A C, and Murphy, T J C, British.7ournal of Psychiatry, 1977, 130, 104. 1
A hallucination is a false perception with no external stimulus, and should be distinguished from an illusion, where there is a distortion of perception. Normal people may experience hallucinations, especially when falling asleep or when waking up, and any sense may be affected. The most common hallucinations in mentally ill patients are auditory "voices," reported most frequently in schizophrenic patients. Visual hallucinations are also common. In one study' of mental patients with hallucinations the visual ones were elicited about as frequently as auditory hallucinations in manic-depressive and schizophrenic patients and in patients with "organic" disturbances; only in paranoid patients were visual hallucinations relatively uncommon. Indeed, visual hallucinations are often present in psychiatric patients but may be overlooked after brief or superficial interviewing. Among less obviously psychotic patients, however, visual hallucinations have more definite implications. Psychiatrists are well aware that physical illness may present as psychiatric disease. Herridge2 found that half of a series of 209- patients consecutively admitted to hospital with psychiatric illness had some physical upset, and in only a few patients was this irrelevant to the psychiatric condition. Similarly, Davies3 reported a 42% incidence of physical disease related to initial psychiatric complaints. In another survey of 200 consecutive inpatients4 the incidence of physical illness was one in three: 70% of these illnesses were considered severe, and half were unknown to either the patient or his doctor. Johnson found a lower incidence (12%) in 250 consecutive admissions.5 In a large-scale studyy6 reported last year from Texas 658 consecutive psychiatric patients presenting at a suburban community mental health centre underwent a detailed evaluation, including a thorough physical examination. Each patient completed a symptom check list. Almost 10% of patients reported fouir or more symptoms, and of these 600 showed evidence of disease supported by laboratory tests, compared with only .3% of' patients free from physical symptoms. Over three-quarters of the illnesses in the group with symptoms had been previously unrecognised. Of the total sample, almost' 10% had a medical condition thought to be definitely or probably responsible for the psychiatric symptoms. The most frequent medical diagnoses were cardiovascular and endocrine disorders, follolwed by infection, pulmonary disease, gastrointestinal disorders, blood diseases, central nervous system abnormalities, and malignant disorders. Visual hallucinations, distortions, and illusions were found to be the best symptoms in discriminating between medically produced and functional psychiatric disorders. In these outpatients, in contrast to psychotic inpatients, physical illness should be suspected in those who complain of visual hallucinations. Many medical conditions are associated with visual hallucinations, among the more common being infection (especially in the elderly) and cardiovascular impairment. Hallucinations tend to be commoner in acute organic reactions due to drugs or metabolic abnormalities than after trauma or anoxia.7 Thyroid dysfunction should be especially sought. Drug-induced phenomena usually start as heightened visual perceptions and finally become organised visual hallucinations. Psychotropic drugs such as the tricycic antidepressants8 and anticholinergic agents9 are well known to produce these effects. Bromocriptine, a dopamine agonist, has also been reported to induce visual hallucinations.10 Nevertheless, the most extreme instances are seen with the hallucinogens, such
Haematuria after closed trauma Patients who have haematuria after a blow to the back or abdomen may have only contusions (which account for most cases), major parenchymal lacerations, or shattered kidneys (critical injuries on the classification of Sargent and
Marquardt'). The amount of haematuria shows no correlation with the extent of the injury. Guerriero et a12 noted gross haematuria in onily 10 out of 33 patients with injuries to the renal pedicle; these 10 patients also had severe parenchymal damage. Both renal artery thrombosis and renal vein avulsion have been recorded in patients with no or only microscopic haematuria.-8 Gross haematuria after miniimal trauma should suggest the possibility of an underlying pre-existing abnormality such as
hydronephrosis. Excretion urography should be undertaken as an emergency in all cases. While the results may be normal in many patients with haematuria after closed trauma,7 any selective policy based on the severity of the haematuria will allow important and correctable lesions to go undetected in some instances.8 Excretion urography is also essential to establish function of the contralateral kidney. Occasionally a contused kidney will be found not to function on routine excretion urography; highdose urography combined with tomography reduces the risk oferror.9 Nevertheless, in most patients the results of excretion urography will be normal. Almost all of these patients will recover spontaneously on a conservative regimen and further immediate investigation is not warranted. Immediate selective renal angiography should be considered only in the few patients who have substantial abnormalities shown on excretion urography'0 (severe renal injury with grossly impaired .gr no function), since the technique defines the injury more clearly." 12 Retrograde studies should not be performed because of the great risk of introducing infection into the damaged kidney. Even the advocates of renal scanning'3 14 concede that angiography provides better anatomical detail once a major renal injury has been discovered. Angiography can also be used to predict the outcome of the injury in terms of renal function. A finding of obstruction to a main renal artery, for example, carries a poor prognosis. Patients with extensive renal ischaemia will require surgery, while those with only parenchymal injury are unlikely to need exploration.10 Indeed, the clinical management of patients with serious renal injury should be based on the assumption that conservative treatment will usually fail in those with substantial renal ischaemia and succeed in those with an intact arterial tree.
842
BRITISH MEDICAL JOURNAL
When a main renal artery occlusion is diagnosed early immediate exploration may be worth while. In those patients with occlusion of a major branch artery the exploration should be an elective procedure, ideally five to seven days after the diagnosis; this should preclude the development of secondary haemorrhage and the need for emergency exploration. Should bleeding persist for some weeks of conservative management angiography may again be needed. Possible causes needing to be excluded are the development of an arteriovenous fistula or a large pseudoaneurysm. The development of a major intrarenal haematoma is usually associated with severe renal crushing and ischaemia from tamponade. Exploration is often required, and nephrectomy is usually necessary. Whenever an exploratory operation is needed on a patient with an injured kidney control of the vascular pedicle is imperative15 before the haematoma surrounding the kidney or the disrupted parenchyma is disturbed. Once control has been achieved an orderly and adequate evaluation of -the injury becomes possible, and repair surgery to the vascular, parenchymal, or collecting systems or partial nephrectomy may be feasible rather than the sacrifice of an entire kidney.
31 MARCH 1979
Cardiomyopathies in negroes
endocarditis parietalis fibroplastica. Thrombus in the ventricles may be prominent, when the condition is called "obliterative" cardiomyopathy. It is in endomyocardial fibrosis that the greatest regional variations exist-though this is the rarest type of cardiomyopathy. For example, the South African study found only eight patients, and four ofthese were Negroes.4 Obliterative cardiomyopathy was diagnosed in only one black patient and in three white women. Endomyocardial fibrosis is much more commonly encountered in other parts of Africa, such as in Uganda, where it accounts for 14% of patients dying from cardiac failure.8 Most often (51%) there is biventricular disease, with only the left ventricle affected in 38%/ and lone right ventricular disease in only 11%h of a series of 173 patients suffering from endomyocardial fibrosis.9 The signs and symptoms depend on which ventricular chamber or chambers are affected: mitral or tricuspid valve dysfunction may occur or constrictive pericarditis may be mimicked. When endomyocardial fibrosis was first identified it was thought to be confined to the equatorial region of Africa, but since then it has been reported from India,'0 Ceylon," Brazil,'2-14 Venezuela,15 and Colombia.'6 The other restrictive type of cardiomyopathy, L6ffler's endocarditis parietalis fibroplastica,'7 was thought to be confined to temperate zones. Clinical and pathological similarities have been established'8 19 between this condition and endomyocardial fibrosis; and there is now persuasive evidence that the two conditions belong to the same pattern of disease, in which eosinophils are implicated in the cause of endomyocardial damage.'8 20) Dilated (congestive) cardiomyopathy appears to be the most common and the restrictive-obliterative type the rarest form of cardiomyopathy, with the hypertrophic type in an intermediate position. Nevertheless, the incidence in absolute numbers has not yet been established for any of these cardiomyopathies, with the exception of a single report from Sweden giving an incidence of five patients with the congestive form per 100 000 population per year.2' Ugandan Africans appear to be unusually susceptible to endomyocardial fibrosis, but environmental factors are thought to play an important part in its cause.2223 Though the evidence is patchy, the conclusion to be drawn from it is that despite recent population movements no increase in endomyocardial fibrosis or any other type of cardiomyopathy seems likely in Britain.
Defined as "heart muscle disease of unknown cause,"l1 2 cardiomyopathies have been classified into the dilated (congestive), hypertrophic, and restrictive types on the basis ofhaemodynamic and structural changes.1-3 Cardiomyopathies spare neither race nor ethnic groups, but their world-wide distribution shows distinct regional variations. Now that the British population includes representatives of all racial groups, should we expect any increase in the prevalence of cardiomyopathies ? This is unlikely. In a recent survey from South Africa4 the relative frequency of the various types of cardiomyopathies was compared in "Caucasian," "coloured," and "black" patients. Of a total of 333 patients, 214 had the dilated (congestive) type and the three groups were affected equally. This type of disease is also not infrequent in subtropical and tropical regions.5 6 By contrast, hypertrophic cardiomyopathy has been reported in Negroes only rarely7 and the South African survey4 confirmed the unequal distribution of this type: the condition was diagnosed in 35 coloured and 72 Caucasian patients but in no Negroes. The third type of cardiomyopathy, the restrictive type, includes both endomyocardial fibrosis and Loffler's
Goodwin, J F, Circulation, 1974, 50, 210. Oakley, C M, Postgraduate MedicalJ7ournal, 1975, 51, 271. 3 Olsen, E G J, British Medicine, 1978 7 June, 53. 4 Beck, W, Postgraduate Medical_Journal, 1978, 54, 475. s Stuart, K L, and Hayes, J A, Quarterly Journal of Medicine, 1963, 32, 99. 6 Falase, A 0, British Heart Journal, 1977. 39, 671. Lewis, B S, et al, South African Medical_Journal, 1973, 47, 599. 8 Davies, J N P, and Ball, J D, British Heart3Journal, 1955, 17, 337. 9 Shaper, A G, Hutt, M S R, and Coles, R M, British Heart3Journal, 1968, 30, 391. Samuel, I, and Ankesaria, X J, IndianJ7ournal of Pathology and Bacteriology, 1960, 3, 157. Nagaratnam, N, and Dissanayake, R V P, British Heart Journal, 1959, 21, 167. 12 Fagundes, L A, Revista do Instituto de Medicina Tropical de Sao Paulo, 1963, 5, 198. 13 Andrade, Z A, and Guimaraes, A C, British Heart Journal, 1964, 26, 813. 14 Guimaraes, A C, et al, American 1974, 88, 294. 1i Suarez, J A, and de Suarez, C, Acta Cientifica Venezolana, 1967, 18, 98. 16 Correa, P, et al, American Heart3Journal, 1963, 66, 584. 1 Loffler, W, Schweizerische Medizinische Wochenschrift, 1936, 17, 817. 18 Brockington, I F, and Olsen, E G J, American HeartJournal, 1973, 85, 308. "Bell, J A, Jenkins, B S, and Webb-Peploe, M M, British HeartJournal, 1976, 38, 541. 20 Oakley, C M, and Olsen, E G J, British Heart Journal, 1977, 39, 233. 21 Torp, A, Postgraduate 1978, 54, 435. 22 Connor, D H, et al, American Heart3Journal, 1967, 74, 687. 23 Connor, D H, et al, American Heart_Journal, 1968, 75, 107.
Sargent, J C, and Marquardt, C R, Journal of Urology, 1950, 63, 1. Guerriero, W G, et al,Journal of Trauma, 1971, 11, 53. 3Peters, P C, and Bright, T C, Advances in Surgery, 1976, 10, 197. 4 Caponegro, P J, and Leadbetter, G W, jun, Journal of Urology, 1973, 109, 2
769.
Richie, J P, Bennett, C M, and Brosman, S A, Urology, 1975, 6, 481. 6 Bright, T C, White, K, and Peters, P C,Journal of Urology, 1978, 120, 455. 7McDonald, E J, jun, et al, American Journal of Roentgenology, 1976, 126,
5
739. 8 Griffen, W 0, et al, Journal of Trauma, 1978, 18, 387.
Mahoney, S A, and Persky, L, Journal of Urology, 1968, 99, 513. Moss, D I, and Freeman, R, Australian and New Zealand J7ournal of Surgery, 1977, 47, 462. Elkin, M, Meng, C H, and DeParedes, R G, American Journal of Roentgenology, 1966, 98, 1. 12 Lang, E K, et al, Radiology, 1971, 98, 103. 13 Koenigsberg, M, Blaufox, M D, and Freeman, L M, Seminars in Nuclear Medicine, 1974, 4, 117. 14 Berg, B C jun, Seminars in Nuclear Medicine, 1974, 4, 371. 16 LeVeen, H H, and Samellas, W, Journal of Urology, 1962, 88, 5. 9 10
2
Heart_Journal,
Medical_Journal,
841
31 MARCH 1979
When seeing is believing
as lysergide, and in the withdrawal of alcohol and similar depressants of the central nervous system. Lowe, G R, British journal of Psychiatry, 1973, 123, 621. s Herridge, C F, Lancet, 1960, 2, 949. 3 Davies, D W, British J0urnal of Psychiatry, 1965, 111, 27. 4 Maguire, G P, and Granville-Grossman, K L, BritishJournal of Psychiatry, 1968, 114, 1365. 5 Johnson, D A W, Practitioner, 1968, 200, 686. 6 Hall, R C W, et al, Archives of General Psychiatry, 1978, 35, 1315. 7Lishman, W A, Organic Psychiatry. Oxford, Blackwell, 1978. 8 Hudgens, R W, et al, Journal of the American Medical Association, 1966, 198, 81. 9 Longo, V G, Pharmacological Reviews, 1966, 18, 965. 10 White, A C, and Murphy, T J C, British.7ournal of Psychiatry, 1977, 130, 104. 1
A hallucination is a false perception with no external stimulus, and should be distinguished from an illusion, where there is a distortion of perception. Normal people may experience hallucinations, especially when falling asleep or when waking up, and any sense may be affected. The most common hallucinations in mentally ill patients are auditory "voices," reported most frequently in schizophrenic patients. Visual hallucinations are also common. In one study' of mental patients with hallucinations the visual ones were elicited about as frequently as auditory hallucinations in manic-depressive and schizophrenic patients and in patients with "organic" disturbances; only in paranoid patients were visual hallucinations relatively uncommon. Indeed, visual hallucinations are often present in psychiatric patients but may be overlooked after brief or superficial interviewing. Among less obviously psychotic patients, however, visual hallucinations have more definite implications. Psychiatrists are well aware that physical illness may present as psychiatric disease. Herridge2 found that half of a series of 209- patients consecutively admitted to hospital with psychiatric illness had some physical upset, and in only a few patients was this irrelevant to the psychiatric condition. Similarly, Davies3 reported a 42% incidence of physical disease related to initial psychiatric complaints. In another survey of 200 consecutive inpatients4 the incidence of physical illness was one in three: 70% of these illnesses were considered severe, and half were unknown to either the patient or his doctor. Johnson found a lower incidence (12%) in 250 consecutive admissions.5 In a large-scale studyy6 reported last year from Texas 658 consecutive psychiatric patients presenting at a suburban community mental health centre underwent a detailed evaluation, including a thorough physical examination. Each patient completed a symptom check list. Almost 10% of patients reported fouir or more symptoms, and of these 600 showed evidence of disease supported by laboratory tests, compared with only .3% of' patients free from physical symptoms. Over three-quarters of the illnesses in the group with symptoms had been previously unrecognised. Of the total sample, almost' 10% had a medical condition thought to be definitely or probably responsible for the psychiatric symptoms. The most frequent medical diagnoses were cardiovascular and endocrine disorders, follolwed by infection, pulmonary disease, gastrointestinal disorders, blood diseases, central nervous system abnormalities, and malignant disorders. Visual hallucinations, distortions, and illusions were found to be the best symptoms in discriminating between medically produced and functional psychiatric disorders. In these outpatients, in contrast to psychotic inpatients, physical illness should be suspected in those who complain of visual hallucinations. Many medical conditions are associated with visual hallucinations, among the more common being infection (especially in the elderly) and cardiovascular impairment. Hallucinations tend to be commoner in acute organic reactions due to drugs or metabolic abnormalities than after trauma or anoxia.7 Thyroid dysfunction should be especially sought. Drug-induced phenomena usually start as heightened visual perceptions and finally become organised visual hallucinations. Psychotropic drugs such as the tricycic antidepressants8 and anticholinergic agents9 are well known to produce these effects. Bromocriptine, a dopamine agonist, has also been reported to induce visual hallucinations.10 Nevertheless, the most extreme instances are seen with the hallucinogens, such
Haematuria after closed trauma Patients who have haematuria after a blow to the back or abdomen may have only contusions (which account for most cases), major parenchymal lacerations, or shattered kidneys (critical injuries on the classification of Sargent and
Marquardt'). The amount of haematuria shows no correlation with the extent of the injury. Guerriero et a12 noted gross haematuria in onily 10 out of 33 patients with injuries to the renal pedicle; these 10 patients also had severe parenchymal damage. Both renal artery thrombosis and renal vein avulsion have been recorded in patients with no or only microscopic haematuria.-8 Gross haematuria after miniimal trauma should suggest the possibility of an underlying pre-existing abnormality such as
hydronephrosis. Excretion urography should be undertaken as an emergency in all cases. While the results may be normal in many patients with haematuria after closed trauma,7 any selective policy based on the severity of the haematuria will allow important and correctable lesions to go undetected in some instances.8 Excretion urography is also essential to establish function of the contralateral kidney. Occasionally a contused kidney will be found not to function on routine excretion urography; highdose urography combined with tomography reduces the risk oferror.9 Nevertheless, in most patients the results of excretion urography will be normal. Almost all of these patients will recover spontaneously on a conservative regimen and further immediate investigation is not warranted. Immediate selective renal angiography should be considered only in the few patients who have substantial abnormalities shown on excretion urography'0 (severe renal injury with grossly impaired .gr no function), since the technique defines the injury more clearly." 12 Retrograde studies should not be performed because of the great risk of introducing infection into the damaged kidney. Even the advocates of renal scanning'3 14 concede that angiography provides better anatomical detail once a major renal injury has been discovered. Angiography can also be used to predict the outcome of the injury in terms of renal function. A finding of obstruction to a main renal artery, for example, carries a poor prognosis. Patients with extensive renal ischaemia will require surgery, while those with only parenchymal injury are unlikely to need exploration.10 Indeed, the clinical management of patients with serious renal injury should be based on the assumption that conservative treatment will usually fail in those with substantial renal ischaemia and succeed in those with an intact arterial tree.
842
BRITISH MEDICAL JOURNAL
When a main renal artery occlusion is diagnosed early immediate exploration may be worth while. In those patients with occlusion of a major branch artery the exploration should be an elective procedure, ideally five to seven days after the diagnosis; this should preclude the development of secondary haemorrhage and the need for emergency exploration. Should bleeding persist for some weeks of conservative management angiography may again be needed. Possible causes needing to be excluded are the development of an arteriovenous fistula or a large pseudoaneurysm. The development of a major intrarenal haematoma is usually associated with severe renal crushing and ischaemia from tamponade. Exploration is often required, and nephrectomy is usually necessary. Whenever an exploratory operation is needed on a patient with an injured kidney control of the vascular pedicle is imperative15 before the haematoma surrounding the kidney or the disrupted parenchyma is disturbed. Once control has been achieved an orderly and adequate evaluation of -the injury becomes possible, and repair surgery to the vascular, parenchymal, or collecting systems or partial nephrectomy may be feasible rather than the sacrifice of an entire kidney.
31 MARCH 1979
Cardiomyopathies in negroes
endocarditis parietalis fibroplastica. Thrombus in the ventricles may be prominent, when the condition is called "obliterative" cardiomyopathy. It is in endomyocardial fibrosis that the greatest regional variations exist-though this is the rarest type of cardiomyopathy. For example, the South African study found only eight patients, and four ofthese were Negroes.4 Obliterative cardiomyopathy was diagnosed in only one black patient and in three white women. Endomyocardial fibrosis is much more commonly encountered in other parts of Africa, such as in Uganda, where it accounts for 14% of patients dying from cardiac failure.8 Most often (51%) there is biventricular disease, with only the left ventricle affected in 38%/ and lone right ventricular disease in only 11%h of a series of 173 patients suffering from endomyocardial fibrosis.9 The signs and symptoms depend on which ventricular chamber or chambers are affected: mitral or tricuspid valve dysfunction may occur or constrictive pericarditis may be mimicked. When endomyocardial fibrosis was first identified it was thought to be confined to the equatorial region of Africa, but since then it has been reported from India,'0 Ceylon," Brazil,'2-14 Venezuela,15 and Colombia.'6 The other restrictive type of cardiomyopathy, L6ffler's endocarditis parietalis fibroplastica,'7 was thought to be confined to temperate zones. Clinical and pathological similarities have been established'8 19 between this condition and endomyocardial fibrosis; and there is now persuasive evidence that the two conditions belong to the same pattern of disease, in which eosinophils are implicated in the cause of endomyocardial damage.'8 20) Dilated (congestive) cardiomyopathy appears to be the most common and the restrictive-obliterative type the rarest form of cardiomyopathy, with the hypertrophic type in an intermediate position. Nevertheless, the incidence in absolute numbers has not yet been established for any of these cardiomyopathies, with the exception of a single report from Sweden giving an incidence of five patients with the congestive form per 100 000 population per year.2' Ugandan Africans appear to be unusually susceptible to endomyocardial fibrosis, but environmental factors are thought to play an important part in its cause.2223 Though the evidence is patchy, the conclusion to be drawn from it is that despite recent population movements no increase in endomyocardial fibrosis or any other type of cardiomyopathy seems likely in Britain.
Defined as "heart muscle disease of unknown cause,"l1 2 cardiomyopathies have been classified into the dilated (congestive), hypertrophic, and restrictive types on the basis ofhaemodynamic and structural changes.1-3 Cardiomyopathies spare neither race nor ethnic groups, but their world-wide distribution shows distinct regional variations. Now that the British population includes representatives of all racial groups, should we expect any increase in the prevalence of cardiomyopathies ? This is unlikely. In a recent survey from South Africa4 the relative frequency of the various types of cardiomyopathies was compared in "Caucasian," "coloured," and "black" patients. Of a total of 333 patients, 214 had the dilated (congestive) type and the three groups were affected equally. This type of disease is also not infrequent in subtropical and tropical regions.5 6 By contrast, hypertrophic cardiomyopathy has been reported in Negroes only rarely7 and the South African survey4 confirmed the unequal distribution of this type: the condition was diagnosed in 35 coloured and 72 Caucasian patients but in no Negroes. The third type of cardiomyopathy, the restrictive type, includes both endomyocardial fibrosis and Loffler's
Goodwin, J F, Circulation, 1974, 50, 210. Oakley, C M, Postgraduate MedicalJ7ournal, 1975, 51, 271. 3 Olsen, E G J, British Medicine, 1978 7 June, 53. 4 Beck, W, Postgraduate Medical_Journal, 1978, 54, 475. s Stuart, K L, and Hayes, J A, Quarterly Journal of Medicine, 1963, 32, 99. 6 Falase, A 0, British Heart Journal, 1977. 39, 671. Lewis, B S, et al, South African Medical_Journal, 1973, 47, 599. 8 Davies, J N P, and Ball, J D, British Heart3Journal, 1955, 17, 337. 9 Shaper, A G, Hutt, M S R, and Coles, R M, British Heart3Journal, 1968, 30, 391. Samuel, I, and Ankesaria, X J, IndianJ7ournal of Pathology and Bacteriology, 1960, 3, 157. Nagaratnam, N, and Dissanayake, R V P, British Heart Journal, 1959, 21, 167. 12 Fagundes, L A, Revista do Instituto de Medicina Tropical de Sao Paulo, 1963, 5, 198. 13 Andrade, Z A, and Guimaraes, A C, British Heart Journal, 1964, 26, 813. 14 Guimaraes, A C, et al, American 1974, 88, 294. 1i Suarez, J A, and de Suarez, C, Acta Cientifica Venezolana, 1967, 18, 98. 16 Correa, P, et al, American Heart3Journal, 1963, 66, 584. 1 Loffler, W, Schweizerische Medizinische Wochenschrift, 1936, 17, 817. 18 Brockington, I F, and Olsen, E G J, American HeartJournal, 1973, 85, 308. "Bell, J A, Jenkins, B S, and Webb-Peploe, M M, British HeartJournal, 1976, 38, 541. 20 Oakley, C M, and Olsen, E G J, British Heart Journal, 1977, 39, 233. 21 Torp, A, Postgraduate 1978, 54, 435. 22 Connor, D H, et al, American Heart3Journal, 1967, 74, 687. 23 Connor, D H, et al, American Heart_Journal, 1968, 75, 107.
Sargent, J C, and Marquardt, C R, Journal of Urology, 1950, 63, 1. Guerriero, W G, et al,Journal of Trauma, 1971, 11, 53. 3Peters, P C, and Bright, T C, Advances in Surgery, 1976, 10, 197. 4 Caponegro, P J, and Leadbetter, G W, jun, Journal of Urology, 1973, 109, 2
769.
Richie, J P, Bennett, C M, and Brosman, S A, Urology, 1975, 6, 481. 6 Bright, T C, White, K, and Peters, P C,Journal of Urology, 1978, 120, 455. 7McDonald, E J, jun, et al, American Journal of Roentgenology, 1976, 126,
5
739. 8 Griffen, W 0, et al, Journal of Trauma, 1978, 18, 387.
Mahoney, S A, and Persky, L, Journal of Urology, 1968, 99, 513. Moss, D I, and Freeman, R, Australian and New Zealand J7ournal of Surgery, 1977, 47, 462. Elkin, M, Meng, C H, and DeParedes, R G, American Journal of Roentgenology, 1966, 98, 1. 12 Lang, E K, et al, Radiology, 1971, 98, 103. 13 Koenigsberg, M, Blaufox, M D, and Freeman, L M, Seminars in Nuclear Medicine, 1974, 4, 117. 14 Berg, B C jun, Seminars in Nuclear Medicine, 1974, 4, 371. 16 LeVeen, H H, and Samellas, W, Journal of Urology, 1962, 88, 5. 9 10
2
Heart_Journal,
Medical_Journal,
