["The first duty of every physician is to be humane..."]. / "Enhver Laeges første Pligt er at vaere menneskekjaerlig..."--medisinsk etikk for 100 år siden.

In 1901 the Russian physician V.V. Veresajev published his book Zapiski vratsja (A doctor's notes). A Norwegian translation was out the next year. The book treats ethical problems in medicine and is critical of several aspects of medical practice. The article contains passages from the book, with comments.

[Manuscripts don't burn]. / Manuskripter brenner ikke.

Mikhail Bulgakov (1891-1940) studied at Kiev University and qualified in medicine in 1916. He worked as a doctor for a few years, then chose a literary career. All his life he was sceptical to the Soviet system and used his satire against the regime. Because of that he met difficulties as an author and could not publish anything after 1927. He worked on his main work, The Master and Margarita, from 1928 until his death. The novel was not published in his lifetime. In 1966-67 an abridged and censored edition appeared. Not until 1973 was a complete edition published in Moscow, and it soon became a cult book in Russia. In the major part of The Master and Margarita, the scene is in Moscow between the two world wars, with Bulgakov using his own experience. Through subtle irony and wild humour he exposes the imperfections of this society. To obtain this, he employs the Devil with his suite of strange figures. The book is also a love story between the Master and Margarita. The Master is writing a novel about Pontius Pilate, and this narrative runs parallel to the Moscow story, so that the book puts an eternal perspective on human frailty.

[Anton Chekhov--a self-deceiver?]. / Anton Tsjekhov--en selvbedrager?

The Russian author and doctor Anton Chekhov (1860-1904) died from tuberculosis in 1904. He had his first haemoptysis in 1884. In spite of continuing symptoms he did not let himself be examined by colleagues until he had a severe haemorrhage in 1897. He was then hospitalized, and extensive bilateral pulmonary tuberculosis was diagnosed. Even after that, he did not take his disease seriously. His attitude has been taken as an example of a doctor's self-deception. Almost 4,500 of Chekhov's letters has been published. In this article, the letters and contemporary memorial literature are used to illustrate the development of his disease and his ambivalence towards it. His self-deception was not that massive; there is a strain of uneasiness in his reports of his symptoms.

Potentials of a new laser guidance system for percutaneous musculoskeletal procedures.

Early experience using a new laser guidance device to assist CT-guided percutaneous musculoskeletal procedures is presented. We describe six cases, which demonstrate typical musculoskeletal applications of laser guidance. In our experience laser guidance for these procedures resulted in improved accuracy with no significant increase in biopsy time when a short learning period is considered. Other musculoskeletal procedures may benefit from laser guidance in preference to current standard CT-guided techniques, particularly when precision and accuracy are essential.

Comparison of conventional and computed radiography: assessment of image quality and reader performance in skeletal extremity trauma.

RATIONALE AND OBJECTIVES: Reader performance and image quality wee assessed for standard film, computed film, and computer monitor radiography viewing formats in the evaluation of skeletal extremity trauma. MATERIALS AND METHODS: Three radiologists and three orthopedic surgeons interpreted 27 skeletal radiographs obtained with equivalent technical parameters. Readers evaluated standard film, computed film, and computer monitor formats randomly for fracture and soft-tissue abnormalities. Sessions were videotaped, and eye motion was recorded. RESULTS: No statistically significant differences were found between image formats for true-positive or false-positive findings of trauma indicators. Findings were classified as false-negative based on eye position fixation times. Search errors (lesion not fixated) accounted for 21.7%, 20.6% and 17.1% of false-negative errors with the computer monitor, computed film, and standard film formats, respectively. Combined recognition errors and decision errors were 78.3%, 79.4%, and 82.9%, respectively. Viewing times were longest for the computer monitor images (P < .001). Image quality, contrast, and sharpness were rated highest for computed radiographs (P = .001). Radiologists had a higher true-positive decision rate than orthopedic surgeons (P = .03). CONCLUSION: No statistically significant differences were seen in reader performance among viewing formats. The computed film format received the highest quality rating, and workstation viewing times were longest.

Traumatic thoracolumbar facet instability: characteristic imaging findings.

OBJECTIVE: To review imaging patterns and injury mechanisms in patients with thoracolumbar facet instability (TFI). DESIGN: Imaging studies for thoracolumbar osseous injuries over a 2-year period were reviewed. Imaging findings, injury pattern and reported mechanism of injury were established for patients with TFI. PATIENTS: One hundred and ten patients with thoracolumbar acute, osseous injuries were studied. RESULTS: Eleven of 68 (16.2%) unstable thoracolumbar injuries demonstrated TFI. Seven (64%) of the eleven TFI patients were unrestrained occupants in a motor vehicle accident (MVA) and the remainder were involved in injuries dominated by blunt impact to the back. Only two (18%) had serious, permanent neurological deficits. CONCLUSION: TFI is a common injury pattern, particularly for unrestrained occupants in MVAs. Characteristic radiographic, CT and MRI findings are presented and correlated with the injury mechanism and clinical findings.

Demographic biases of scoring instruments for the results of total knee arthroplasty.

Four knee-scoring systems were used to evaluate 200 adult subjects who had no history of injury, abnormality, or treatment of the knees, hips, lower extremities, or spine. All subjects were in the age-range (fifty to 100 years; average, 65.5 years) typical of candidates for total knee replacement. In addition to a physical examination, complete demographic data were collected for each subject. The knee scores were normalized by dividing the observed score by the maximum possible score. The average normalized total knee score was 91 per cent (range, 22 to 100 per cent) according to the knee score of The Hospital for Special Surgery, 95 per cent (range, 10 to 100 per cent) according to the system of Hungerford and Kenna, 89 per cent (range, -7.75 to 100 per cent) according to a modification of the scoring system of The Knee Society, and 95 per cent (range, 26.5 to 100 per cent) according to the system of Hofmann et al. Demographic variables that had a significant negative correlation with the knee scores included advanced age (particularly of eighty-five years or more), a family income below the poverty level, and two major medical conditions or more. Observed differences in knee scores between different study groups that have not been matched for various clinically relevant factors are at least as likely to represent differences in the patient populations as they are to represent differences in the operative technique or the design of the implant.

Evidence of reinnervation of free patellar tendon autograft used for anterior cruciate ligament reconstruction.

We studied six adult male dogs to determine whether free patellar tendon grafts show evidence of reinnervation when used for anterior cruciate ligament reconstruction. Histologic return of neural elements and return of a somatosensory-evoked potential defined evidence of reinnervation. Before removal, the native anterior cruciate ligament was electrically stimulated with a bipolar electrode and a somatosensory-evoked potential was recorded from a scalp electrode. The ligament was excised and reconstructed using an autogenous patellar tendon graft. Somatosensory-evoked potential was attempted immediately after reconstruction. Histology for nerve endings was performed on the native ligaments. Each animal underwent repeat arthrotomy 6 months later. The grafts were isolated and somatosensory-evoked potentials were attempted. An evoked potential was seen in all six dogs before reconstruction. No graft demonstrated a somatosensory-evoked potential acutely; however, 6 months postoperatively, the somatosensory-evoked potential returned in two cases. Histology of native ligaments showed that 25% of the 100 sections evaluated contained neural elements. Of the receptors present, 89% were mechanoreceptors and 11% were free nerve endings. Histologic examination of the graft tissue 6 months postoperatively revealed that all six grafts also contained neural elements. Mechanoreceptors and free nerve endings were present in approximately equal numbers in the grafts. The results of histology and somatosensory-evoked potential demonstrate that in at least some cases, free patellar tendon grafts show evidence of reinnervation when used for anterior cruciate ligament reconstruction.

Differences in time to interpretation for evaluation of bone radiographs with monitor and film viewing.

RATIONALE AND OBJECTIVES: The authors evaluated how observers search hard-copy versus soft-copy images to determine why viewing times are longer for images displayed on a monitor. METHODS: Twenty-seven nonconsecutive bone-trauma computed radiographs were collected from the routine emergency practice. Eye positions of three bone radiologists and three orthopedic surgeons were recorded as they searched images on a view box and digital images at a workstation. RESULTS: Overall viewing time was longer for images displayed on a monitor. Time to first fixate a lesion and true-negative dwell times were significantly longer with the monitor than with the film. Absolute numbers of clusters and dwell times were greater for diagnostic image areas on the monitor than on the film. Twenty percent of the clusters for images viewed on the monitor were on the image-processing menu. CONCLUSION: The amount and type of information that is processed during search is different when images are viewed on a monitor rather than on film.

Effects of chemical stimulation of masseter muscle nociceptors on trigeminal motoneuron and interneuron activities during fictive mastication in the rabbit.

An electrophysiological study was carried out in sixteen decerebrate and paralyzed New Zealand rabbits to determine how a bolus injection of a nociceptor stimulant (hypertonic saline, 5%) into the masseter muscle influences the activity of the trigeminal motor circuitry during fictive jaw movements. Hypodermic needles connected to a syringe held in a computer-controlled infusion pump were inserted into the anterior deep layer of either the right or the left masseter. Twenty-three infusions of 50, 70 or 80 microl saline were made in fourteen animals at constant rates over 1 min. Eight control infusions of normal saline (0.9%) were made in a subpopulation of five animals in an identical manner. Fictive jaw movements were evoked before and after the infusions by repetitive electrical stimulation of the corticobulbar tract. Effects were assessed by extracellular microelectrode recordings made from the digastric motoneuron pool and from putative last-order interneurons in the oral subnucleus of the spinal trigeminal tract and adjacent structures. In comparison with pre-infusion control cycles, nociceptor stimulation caused significant slowing of the rhythm and a reduction of the area of the digastric motoneuron bursts in the majority of the animals (12/14). The decrease in cycle frequency was due almost entirely to a lengthening of the time between the digastric bursts. Changes usually began 1-2 min after the infusion and returned to pre-infusion values within 10-15 min. No significant effects were seen when isotonic saline was applied. Recordings were obtained from nine interneurons, eight of which had low threshold mechanosensitive receptive fields. One neuron was, in addition, excited by pinch. Eight were not active in the absence of motor activity and this did not change when hypertonic saline was applied. However, once fictive movements began, all started to fire rhythmic bursts of spikes. In five cases, there was a significant post-infusion increase in spike frequency, and three showed decreases. Seven showed significant post-infusion changes in mean phase and/or concentration of their firing within the movement cycle. Changes in the preferred phase of interneuronal firing were significantly correlated to changes in the phase of offset of the digastric burst. The present results provide evidence that the stimulation of nociceptors in a muscle slows the frequency of rhythmical movements in the absence of sensory feedback. They confirm that infusions into one muscle affect the output of its antagonist. The results also suggest that neurons in the oral subnucleus of the spinal trigeminal tract and adjacent reticular formation appear to participate in programming these changes in motor output.

[Anton Chekhov--physician and writer. Physicians in his novels]. / Anton Tsjekhov--lege og forfatter. Legene i hans prosa.

Anton Pavlovich Chekhov (1860-1904) was a doctor and a writer. He practised medicine in a rather sporadic manner throughout his life, and his main occupation was his authorship. His collected works comprise 581 items of a narrative type, 17 plays, a narrative and a treatise of his voyage to Sakhalin, a number of articles and about 4,000 letters. This paper describes the doctors who appear in 83 of his short stories and associated material, and shows how Chekhov's medical background influenced his writing.

Potentials of laser guidance system for percutaneous musculoskeletal procedures.

Early experience using a new laser guidance device to assist CT-guided percutaneous musculoskeletal procedures is presented. We describe six cases which demonstrate typical musculoskeletal applications of laser guidance. In our experience laser guidance for these procedures resulted in improved accuracy with no significant increase in biopsy time when a short learning period is considered. Other musculoskeletal procedures may benefit from laser guidance compared with current standard CT-guided techniques, particularly when precision and accuracy are essential.

Demographic biases found in scoring instruments of total hip arthroplasty.

Four hip scoring systems were used in evaluating 200 adult subjects who had no prior history of injury, pathologic condition, or treatment of the hips, knees, lower extremities, or spine. All subjects were in the age range typical of a total hip arthroplasty candidate (average age, 65 years; range, 50-100 years). In addition to a physical examination, complete demographic data were collected on each subject. Data were recorded on standardized flow sheets so that hip scores could be calculated; scores were normalized by dividing the observed scores by the maximum possible score. The average normalized total hip scores were Harris hip score, 90.8%; modified Harris hip score, 91.9%; Merle D'Aubigne score, 93.9%; and Hospital for Special Surgery hip rating 87.5%. Demographic variables that had a significant negative correlation with hip scores included advanced age (particularly past age 85), an income below the poverty level, and the presence of two or more major medical conditions. Differences in hip scores between different study groups that have not been matched for various clinically relevant factors ("case mix") are at least as likely to represent differences in the patient populations as differences in surgical technique or implant design. Hip scores may decline over the course of a 10- to 20-year follow-up period due to the change in a patient's age and/or medical condition rather than any factor relating to the hip arthroplasty.

Magnetic resonance imaging in coccidioidal arthritis.

OBJECTIVE: The authors assessed the MRI findings of appendicular coccidioidal arthritis. DESIGN: T1- and T2-weighted MR images of affected joints, both with and without intravenous gadopentetate dimeglumine, were performed in nine adult patients (ten studies) and evaluated by three masted readers, using a four-point certainty scale for: synovial abnormality, articular cartilage loss, subarticular bone loss, abnormal marrow signal, enhancement of osseous and articular structures, and assessment of disease activity. Findings were correlated with biopsy results or clinical course. RESULTS: Eight patients had active and one had inactive arthritis, involving the knee (five patients), ankle (two patients), and elbow (one patient). Synovial complex was the most common finding in active arthritis (P < 0.025). Cartilage and subarticular bone loss were seen 56% and 89% of patients with active disease, respectively. Abnormal marrow signal was uncommon (two patients). All cases showed synovial and/or osseus enhancement. CONCLUSIONS: MRI findings in coccidiodal arthritis are described. Enhancement of thickened synovium and erosions was seen after intravenous gadopentetate.

Current sonographic applications in orthopedics.

Until recently, few orthopedic indications for sonographic imaging have been widely accepted. Advances in technology and concerns about imaging costs are expanding the role of sonography in musculoskeletal conditions. In this pictorial essay we review normal musculoskeletal sonographic anatomy, selected current applications, and potential pitfalls.

Ultrasound evaluation of sacroiliac motion in normal volunteers.

RATIONALE AND OBJECTIVES: We demonstrated quantitatively, using ultrasound imaging, the passive range of motion of the normal sacroiliac (SI) joint. METHODS: Ultrasound images of the SI joints of 22 adults at rest and during a manual medicine maneuver designed to induce a passive range of motion in the SI joint were obtained. Differences between the baseline alignment of the SI joint and alignment during induced passive motion were observed and measured by six radiologists. RESULTS: Significant movement (> 2 mm) of at least one SI joint was demonstrated in 82% of the subjects using ultrasound recordings. Interobserver (r = .49 - .81) and intraobserver (r = .87) correlations were high. CONCLUSION: The results suggest that the range of passive SI joint motion is more than 2 mm, and may be up to 10 mm in some normal subjects, and that ultrasound imaging could be a useful method for assessing passive SI movement.

Ultrasonographic imaging of the hand and wrist in rheumatoid arthritis.

OBJECTIVE: To assess ultrasound findings in patients with rheumatoid arthritis affecting the hand and wrist compared to normal volunteers. DESIGN: Metacarpophalangeal and carpal articulations were imaged ultrasonically. Two readers reviewed static images for synovial, cartilaginous, and bony abnormalities using severity and probability scales. Ultrasound findings were correlated with disease activity. PATIENTS: Ten normal volunteers and 29 patients with known rheumatoid arthritis. RESULTS: Synovial abnormalities and erosions were most commonly identified in the rheumatoid hand and wrist (p < 0.01). Criteria used for normal and abnormal cartilage did not predict normal and disease states. Significant differences in synovial abnormalities and erosions were observed between the inactive and mildly active disease groups as well as the active and mildly active disease groups (p < 0.01). CONCLUSION: Ultrasound can detect abnormalities of the hand and wrist in patients with rheumatoid arthritis compared to normal volunteers. Normal articular anatomy is well demonstrated ultrasonically.