`
`TH E
`
`JOURNAL
`OF THE
`
`PHILIPPINE MEDICAL ASSOCIATION
`
`VOLUME 42
`
`JULY, 1966
`
`
`
`
`NO. 7’
`
`The amhnz’s discusxes fizz:
`pmctica! uses a! in:—
`man tmmiozic JEEEII‘IIJWIIMZS in surgery and mezhads of
`pmparmiwz.
`
`Human Amnion: The Establishment of an Amnion flank"
`and its Practical Applications in Surgery
`BENVENUTO R. DIRO‘,’/M.D.F GEORGE G. EUFENIIO. AIDA”
`
`ind MARIO S, DE VILLA, Mi)?“
`
`IN TRODUC T1 ON
`
`After two years of cliniczfl exper-
`ience,
`the authors found eat that
`iwo of the: most
`impm‘tam prac-
`tical uppiications of human am—
`niotic membranes in surgery are,
`namely: (I) Its use as a bioiogic
`dressing in the local treatment of
`Secand dogma thermal burns and
`(2) Its use as a dressing in donor
`sites where
`split-thickness
`skin
`grafts were obtained. Because: of
`1wa mm practica¥ uses,
`the au-
`11101’3 decided t0 establish an arm
`niun
`bank similar
`to that of a
`M.m-. «QMNK
`
`bluud or bone bank in order to an—
`ticipate:
`the influx of
`iarge num-
`bers of burned patients at any one“
`time: and at the same time to pro-
`vitic-z The ”grafts" to Other physi-
`cians on request.
`
`Studies on how to prepare and
`how to steriliw the potentiaily in—
`fected amniotic membranes, and
`ways of preserving the membranes
`were made. The different preserv—
`ative solutions were tried and bac‘
`wriologic culture studies made at
`regular
`intervals. Histologic Stu»
`dim: of the preserved feta} mem«
`
`'"" Associate Professor, Callege of Medicine, UR; Chief, Section of Plastic Sur-
`gery. Department of Surgery UPPGH Medical Center.
`W Instructor in Surgery. College of Medicine. U.P.; Consultant. Departmant 0f
`Sammy zmci Cancer Institute. UP~PGH Medical Center.
`“1’ Assismnt, Instructor in Surgary. millage of Medicine, UP; Resizient
`gery. fiPvPGH Medic-a} Center.
`
`in Sun
`
`MTF EX.1018,P9.1
`
`MTF Ex. 1018, pg. 1
`
`

`

`358
`
`HUMAN AMNIONwBifie, at.
`
`“all.
`
`)7le $223
`
`brancs wen: also done from the
`third day up to the twentieth day.
`
`MATERIALS
`
`The amniotic membranes ware
`
`‘obtaincd from the Department of
`Obstetrics mlZ
`the same hospital.
`Practically} all
`the membranes 0b—
`mincc‘l were from those cases via
`
`the vaginal deliveries. Amniotic
`membranes obtained in cesarean
`
`section cases had becn prefcrrccl
`bccatxssc they are relatively sterile
`compared to those obtained via
`the vaginal route.
`
`In this study, the: different solut
`lions utilized for the preservation
`{of the amniotic; membranes were:
`‘(ll sterile normal saline solutions
`(2) bcnmlkonium Chloride 1:1000
`
`(3) sodium hypochloritc
`dilution,
`1:4{3 dilution,
`(4)
`saline Solution
`(400 CC) with 500,000 units Of
`
`aqueous: penicillin and one gram
`«of streptomycin $ulfatc and (5) 521.
`line solutian (400 cc) with one
`gram of kanan'xycin sulfate. The
`preserved ”grafts" were kept in a
`blood bank refrigerator.
`
`The clinical material consisted of
`
`40 bum patients admitted to the
`charity wards of the hospital from
`March, 1964
`to December, 1965.
`Thurs were 6 cases of "old burns”
`and 34 cases of
`”recent burns”.
`
`(Figure ll
`FIG. 1. CASES OF THER‘MAL BURNS
`TREATED WITH FETAL BERKIBRAWE
`
` Clasasification
`0ch bums
`Recent burns
`
`. Not of Cases
`f
`B
`‘
`34
`
`
`
`
`
`By ”()ltl bumfi" it is meant those
`that haw not yet healed and have
`
`Bx!
`clevelbpcd granulation tissue.
`“recent btims",
`it
`is referred m
`those in which thc burned sites
`
`wcm still ”raw and 007..ng and have
`not dcvnloped any granulation tis—
`sue yet. The “recent burn" cages
`were treated locally with the am-
`mimic: membranes; within 24 to 48
`lmurs after admission to the hos-
`
`In the series, 31 cases were
`pital.
`of second degree and 3 cages wcrc
`of third degree burn. Eighteen an
`363 were caused by scalding.
`15
`cases were due to flames find one
`case was clut:
`to electrical bums,
`
`PROCEDURE
`
`The fetal membranes
`
`(amnion
`
`and chorion) were separated frcun
`the placental
`tissue by cutting
`along its placental edge. The mem-
`branes were cleaned of blond un-
`
`der running tap water The am—
`nion was; then separated {150m the
`chorlon manually.
`Thu amniotic
`membrane was next rinsed in Ste»
`
`rile saline Solution and placed in
`the preservative solution. The am~
`niotic membranes were kept
`in
`\tvidcvnmutlwd bottles
`containing
`the: preservativeg, properly cover
`ed, labcllcd and placed in a blood
`bank refrigerator at a temperature
`of 4 degree ccmigradc. Howcvcr,
`household refrigerator can also be
`used.
`
`studics
`culture
`Bacteriologic
`were made at regular intervals to
`tfctcrminc the clllcacy of the. differ-
`ent preservatives used for
`the
`”grafts”.
`
`The amniotic membrane })1‘C5L:I‘\’~
`cd for various pcriodg of time l’mm
`the “Trash Slaw" up to out: month
`old have been 125ml
`in the treat-
`
`ment (Figure. 2’)“
`
`MTF Ex.1018,P9.2
`
`MTF Ex. 1018, pg. 2
`
`

`

`[‘3ng"? 3?
`
`HUMAN ammo}: éomb. of. al.
`
`35?;
`
`2. BURATION OF PRESERVr
`FIG,
`ATION BEFORE APPLICATION '0?
`FETAL MEEIBRANE
`
`,
`
`A"
`
`01‘. Cages
`: N0.
`Bunnie“
`8
`,,
`“Fresh” M Q
`15
`1 day
`3
`g
`5 days
`3
`E
`19 days
`2
`E
`14 Clays
`l
`:
`20 days
`2
`i
`30 Clays
`
`T O T ‘5‘ L THWWWEjfiwyWV'WW
`
`preserved
`old
`one-day
`The
`“grafts" were
`pl‘cforl'cd .b‘oausc
`there: is no cellular necrossis of the
`
`membrane and bacteriologic cu}!
`lure is negative if the proper pru—
`sorvativc is being used. Every day,
`new sin-sills were bcing preserved
`and those that were: mom 11mm 2
`weeks old were cliaoardod.
`
`After admission, the burned sites
`of the patient were cloancd with
`homclilorophono in
`sterile water
`and minimal dclnridcnwnt pcrform«
`ml. All the other modalities in the
`
`manugcmcm olr bums were also in-
`stiiulcd simultaneously. This pro.
`ccdum is
`preferably done in a
`standard operating room, although
`it can also be done in the trcab
`
`mom room. No general or local
`anesthetic wa5
`given
`specifically
`for tho local troalmwt. The sites
`that were usually dragged with the:
`amniotic mombranos wore the ox
`
`tremiiies and the anterior aspect
`of“
`the whole trunk,
`including the
`annular abdominal wall? Small
`
`loft without
`adjacent areas were,
`as
`controlo
`“gi‘:ii"ling" m son's
`Burned sites such as tho lam: anal
`the back were not dressed with
`
`amniotic membranes,
`
`the mcm»
`The application of
`l3l'?!¥l(?5é was ClUlH: in such 2} way that
`
`it uxtcnds beyond the borders of
`the bumal area to overlap the nor~
`mal skin. Care is taken to onsore
`no trapping of ail“ bubbles between
`the ”grail!” and the burned area by
`gentle pressing. The aclherence of
`the membrane to the burned area
`
`is better if the abovelwo precau-
`tions were observed. No dressing
`is necessary until the bum wound
`is healed.
`
`Daily observations were made
`and color pictures were taken at
`regular intervals until the healing
`was completed.
`
`Section biopsios of the “grafted”
`burned sites were taken atQinter‘
`vals in a few patients for histologic
`Studios.
`
`Preserved amniotic; membranes
`were: also used in dressing the do~
`nor
`sites where
`split-thickness
`skin grafts were taken. This me-
`thod was tried in six patients in
`which autografting was performed
`after radical cancer surgery. We
`believed that; this is probably the
`first
`time in the
`Philippines
`in
`which amniotic membrane is util-
`ized to dress donor
`site where
`skin graft wag obtained. The raw
`donor site was dressed with one
`layer of
`the amniotic membrane
`and this is left (>an without any
`dressing. The oozing of the: donor
`site slapped after the application
`of
`the amnion and the; wound is
`dry in the next 24 hours.
`
`celloplimw, papers
`Sicrilized
`won: also tried in dressing the sec
`ond degree bum wounds. How-
`L‘VL‘Y. unlike the: amniotic mom
`humus, the papers did not adhere
`to tho bum wound and they be-
`czimc corrugated in a few hours so
`
`MTF Ex. 1018, pg. 3
`
` 3 al
`
`walgeomx
`
`lE
`
`l
`
`g
`
`MTF Ex. 1018, pg. 3
`
`

`

` i iii3
`
`fiT'é'EJAmmNI—Iynochlorite
`(Milieu) 1:40 Dilutioz-
`
`: Negatiw {
`‘
`
`Negative: i Negative 3 Negative i Positive
`‘
`E
`i
`(10%?
`
`tiv.‘ Pe‘niéifiin Aqueous
`500,000 Units Strepm-
`mvcin 1.0 Gram in
`400 cc NSS
`
`V Kanamycin Emirate 1.6
`Gram in 4131) cc NSS
`
`;Negm:ive
`
`Negative ; Negative ‘ Negative 3 Positive.
`‘
`g
`{10%)}
`
`
`‘ Nega‘ix’“
`
`Nééaiive i‘Negative : Negative . Negative
`
`MTF Ex. 1018,1394
`
`360
`
`HUMAN AMMON «Difia, ct. at.
`
`3am arm,
`Juiy‘
`I966
`
`that {issue fluid accumulated in
`
`different tiny areas which later be-
`came badiy infected. This proced-
`ure was discarded after 10 trials.
`
`OBSERVATIONS AND
`DISCUSSION
`
`the fetal
`The various layers of
`membranes; had been tried and the
`
`and result is practically the same,
`whether
`it
`is zu/nnimi alone. C310—
`i‘ion alone, or combined :imniuri
`
`and Chorion (Figure 3).
`
`‘1. DIFFERENT LAYERS OF
`FIG.
`FETAL MEMBRANES USED
`
`Layers
`EOld Burnsé Recent Bums;
`WM...-WWWEW.W, , ”,MMELWWW
`Amnion
`5
`‘
`31
`i
`,
`
`Chm-ion
`Amnion 6.:
`Chorion
`
`:
`
`i
`
`i
`
`1
`
`D
`
`1
`
`2
`
`
`
`
`
`6 _,T nta ,1. 1 , wwéémmw
`
`the authors pm
`Nevertheless,
`Famed 10 use the amnioiic mem-
`
`the fuliuwing reasons:
`for
`brain:
`(1} It is the: layer of the fetal 11mm“
`brain: {hat most cloaely resembles
`the skin being a direct cantinuzp
`
`{ion of the: femi integumcm along
`thc umbificai cord; (2) It can eas—
`iiy be Obtained with a minimum
`of
`contact with
`{he maternal
`
`(3) It is fairly 513011;; and
`biaoci:
`can easily be handled; and (4)
`IL
`is; highly stretchable and can,
`(:0-
`vcr a wide surfaca.
`Amnimic mcmbmncs obtained
`i'mm cesarean
`section masses; are
`
`preferred over those obtained via
`the vaginal mute bacausc of the
`potential
`infection in the normal
`vaginal deliveries. However,
`in 21
`bzwmriologic cuitm‘e study of am—
`nimic fluid in 84 cesarean sectimn
`
`211, 18 cases
`cases by Esgucrrm at
`0:" 21.4301: of the series showed 130*
`siiivc cultures and the predominant.
`organisms were those found nor—
`maily in the vagina, namely: 31mp—
`tococci, Staphylococci, and 111010-
`bacilli."
`
`the
`The fallowing mbic slmws
`rcsulis in tin: culture find}; of the
`prescrved
`amniotic membraneg
`using {he diffcmm prewrvaiivc so-
`quigms‘ Bacterioiugic culiure sub
`dies were made at: one, three, sae
`van, fourteen and thiry days inter-
`val (Figure 431
`
`FIG 4. RESULTS IN CULTURE OI“ PRESERVED AMI‘IIOTIC NIEMBRASM
`Kind of Suiution
`Used {or
`
`I’ressrvation
`
`.
`
`1 clay
`
`I. Sterile Narnia} 521-
`line fiolution (Control)
`
`‘Positive
`190%..)
`
`””11. Bénzaikonium Chloride
`1:1000 Dilution
`
`Positive
`{10%)
`
`'
`
`CULTURE
`> any;
`7 dam i,
`14 days ; W315(153;:
`Positive.
`E
`i
`( 1003 1) 3
`1 Positive
`I
`£40132»;
`
`‘
`
`’
`
`A
`
`Positive ;
`imam
`
`11
`
`y
`
`MTF Ex. 1018, pg. 4
`
`

`

`Valuer:
`Na
`1?
`
`4?
`
`HUs‘l’IAN fll‘INI‘)N-‘Difiu. El}. 31‘
`
`361
`
`The latter three solutions used
`
`in this study appeared to be the
`lacs: preservéiivcs For the amniotic
`membrane.
`
`The first 24 hours after the ap-
`plication of the
`amnion is quite
`critical as far as adherence oi Llw
`membrane to the burnod site is
`
`is impcrativc to al»
`It
`concerned.
`low the overlapping portion of the
`membrane to dry up fast so that it
`will adhere and seal
`the burned
`
`area. The scaling will minimize, if
`not coz‘npletcly control the oozing
`of tissue fluid.
`It usually takes 24
`to 48 hours for the membrane to
`
`be firmly adherent
`sue.
`
`to the burned
`
`recent
`of
`Among the 34 cases
`bums treated locally, all of them
`had relief of pain and control of
`oozing and developed no allergic
`reaction secondary to the ”grafts?
`(Figure 5).
`
`(FIGURE 5. POSTGRAF‘TZNG OBSERVATIONS
`
`()bsnrvations
`
`No. of £2359}:
`
`Percentage
`
`Relief of Pain
`
` oi
`
`oozing;
`
`Nazgmiw: Allergic Reaction
`
`34
`
`32.1
`
`34}
`
`i
`
`.
`
`100 a, z.
`
`1 (309’s
`
`100", "a
`
`,
`
`Upon application of the: ”graft”,
`the patient experienced immediate
`relief of pain There is no known
`exact explanation regarding this
`phenomenon. The mechanism is
`probably not a chemical process
`like local anesthetics which require:
`some time to take effect. One: plau-
`sible explanation is that
`it could
`be duo to the soothing effect of the
`soil mucoicl surface of the mem-
`brane protecting the nerve endings
`from the irritant
`factors which
`may be only the surrounding air.
`The: process
`therefore
`could be
`mechanical as allorded by the nor—
`mal protectivo epidermis.“
`
`cd site without any ‘px‘ossurc band-
`age or: dressing.
`It is probably due
`to 2m augmentation of the plasma
`on the raw surface
`causing
`tin:
`sealing. The
`coagulating
`Fibrin
`tlicn
`invades the; meshes of {ill}
`
`membrane and prevents passage of
`tissue Fluid {lirough it and at
`the
`same time making it adhere to the
`raw surface.
`The importance of
`this observation cannot be ovorenm
`
`phasized when it was estimated by
`Nvlcu and Wallonius that a‘ moan
`of 2.89 grams of protein. per 24
`hours is lost from an area of gra-
`nulating bum wound equal to one
`per cent of the body Surface.“
`
`The: cossation of oozing of tissue
`fluid altar the application is; pro
`bably not due to a mechanical ocn
`elusive process, since
`the mom-
`’hmm is Simply laid over the bum-
`
`The crusts; formed in the ”graft-
`cd" areas remained dry and gross~
`1v fret: from infection. During that:
`first live (lays, ilk: crusts gradually
`thickened to about 2 millimeters
`
`MTF Ex. 1018, pg. 5
`
`MTF Ex. 1018, pg. 5
`
`

`

`362
`
`HUMAN ‘AMNION— Difm, et. a1.
`
`30mm, RMYA'
`Juiy. was
`
`and the color changed from serum
`yellow to brown. They became:
`slightly corrugated, hard and Lough
`thus affording 21 good protcciivc
`covering for ihc underlying deli
`cute healing skin. The dry crusts
`together with this membranes us-
`ually start to peel all with in thc
`iwclvcth to twentieth days after
`application. The healed skin in {he
`"grafted" arms showed {'10 differ-
`ence: from that {if
`the “ungrafted”
`or control areas. There were no
`Lliilercnccs observed butween heal
`Cd areas due to llama: bums or
`
`scalding.
`
`Then: is no allergic reaction ck»
`velopud in the patients secondary
`to the application of the:
`foreign
`membrane
`to
`the: burned site.
`There is no dificrcncc in the and
`
`result or during the ”grafted" pi":-
`riod whether the blood typing of
`the (101101" and that of the recipient
`lam-med patient were the same or
`not.
`
`Tim m’m‘limic membranes do not
`adhere to burned sites of those, of
`
`the third degree Or to the granula-
`tion tisguc of old bums~ The mem.
`
`brane easily peels off within 24 to
`48 hours after the application in
`these cases. After failures in many
`attcmpts of repeated applications,
`this procedure was finallv aha)»
`cloned.
`In 1962, Chardack, et all,
`
`reported the use of synthetic iva»
`ion surgical
`smmszc in the local
`treatment of 4 patients with third
`degree bums. They have shown
`that a ”take" could lac achieved on
`
`a granulatimz wound even with its
`implied surface,
`infcmion and it
`am be mmovml
`lraciionally and
`rapizzcrrcl
`iv}: zxiitogmi‘m without in
`
`tafferencc with the take of auto~
`
`grafts." We have no experience lo»
`wily with this synthetic substitute
`in treatment of third degree bums.
`
`the fresh
`(if
`Hismiogic studies.
`and preserved fetal membranes
`were made. There was cellular nev
`cmsis of the fetal membrane start
`
`ing from {he third day after pre-
`Sim-vation. Daiiy
`serial
`paraffin
`suction examinations of
`the pre—
`served fetal membrane revealed
`
`the cciluiar necrosis is pro
`{hat
`gi‘cxsiw martini; on the third day.
`However,
`according
`to Kirsch‘
`lmum and Hernandez that after 45
`
`to 60 clays, ceilulm‘ elements of arm
`nion stiii
`survive." Grossly,
`the
`membrane remained intact but ap~
`pcarcd thickened and mare siimy
`on proionged preservation.
`
`Biopsies; of the burned sizes ap-
`plication of
`tha fetal membrane
`at different periods of time reveal—
`ed ictz’zl membrane to be intact but
`
`richly invaded by phagocytic in—
`flammatory cclis.
`Epithelization
`from micmscopic islands of un-
`damaged skin nccurred underneath
`the. amniotic membrane. No vas-
`cularization ml: the fetal mmnbranc
`was; demonstrated.
`
`8 If 5421114 R Y AND CONCLUSIONS
`
`'l‘wo practical uses Of human
`1.
`amniotic membranes
`in surgery
`arc: (1) its use: in local treatment
`of second degree
`thermal bums
`and (2)
`its use. as; a drawing in
`cicmnr
`sites where split-thickness
`skin grafts; were taken. The clin-
`ical rcmiig were very satisfactory.
`
`2. An amnim bank skin to that
`:1 bluixi
`(21‘ 3.3mm bank was as-
`
`mi
`
`
`
`MTF Ex.1018,P9.6
`
`MTF Ex. 1018, pg. 6
`
`

`

`firm? 42
`
`H MAN AMNIt)N--Difio, at. a].
`
`:Lyea'nom boy, sustained second
`Fig. 6.
`degree bums due to 361110111157. Second day
`aftear application of amniotic: membrane.
`
`.
`,
`’
`‘
`h
`.
`53mg: patiem‘showmg drmd and
`’~
`F1g.
`hardened @1me cavermg on the 7th day
`after upphcanon.
`
`)3
`
`
`
`S3. Denor site of patient, in left thigh
`”fig,
`(‘iresged with amnion cm 'the saecond day at
`{er application. Splitthmknesa gmfits wmv
`(Hammad {mm this sxtefi
`
`MTF Ex. 1018, pg. 7
`
`
`
`
`E
`,
`ii
`
`i i
`
`.
`
`gi
`
`the mum
`
`
`
`r
`
`«
`
`..
`Same patient showing,
`8
`Fit"
`bum? wmmci mtet‘ ‘3 weaken
`
`
`
`
`
`
`f
`
`
`
`MTF Ex. 1018, pg. 7
`
`

`

`‘mswm .11;
`NC,
`7
`
`HUMAN AMNIONMDifiO, at. a}.
`
`365
`
`mblished in the hospital and its 01:»
`jcctivcs discussed
`
`3. Mctlmds ml preparation and
`sterilization of that amniotic mum-
`
`lumncs bclorc its; 115::
`and dismissal.
`
`is pmsunmd
`
`4‘ Diil'umm preservatives Wen:
`{rival for {lie storage of the amnian
`21ml lmcicriologic culture studies
`wsrc rmule at regular intervals for
`as long; as 30 days after prescrvm
`lion. Three of
`the recommended
`
`(1)
`golutions were:
`pt‘cscrvaiiyc
`sodium l'lypm:hluritc 1:40 dilutim’l
`(2) sterile sczlim: sulutiun {400 (.325)
`
`with 500,090 units of aqueous pi:-
`miciliin (mil 0m: gram of
`strcptov
`mycgin sulfate 21ml (3,) sterile saline
`solution (400 CC) with om: gram of
`lmnamycin sulfate.
`
`5‘ The \‘m‘iuus layers of the. {6"
`m! s‘ncn‘zbmncs, 17ml} fresh and put»
`served, ware used in the local treat—
`ment
`of" 40 patients with recent
`and old burns in the charity wards
`of ihc 1103911211. Th“ umniun alarm
`is;
`the preferred on" as.
`21 biologic
`dressing in lhc local
`treatment Of
`scczmd dugzm'
`thermal bums in
`this; Manly.
`
`(3. Clinical observatim‘m such as
`
`control of waxing
`relief of pain,
`and negative allergic rcactinn af—
`{or application of
`{he amniotic
`membrane. were: discussaci.
`
`in
`7, The {lumimn of healing
`second (16ng burnt; was practicalv
`lv tin: same bem'ccn thoac burned
`areas that were dressed with am‘
`H in)! ii:
`mcmaztmc and {huge
`that
`
`wrrc lrczuccl by mpugurc mctl‘md.
`me'cwr. {his relief of pain and the
`(retinal of maxing; Warn: awe; of” ilk:
`most émpcn‘tsz (zlaxcrvmimns maul:
`
`on burned sites after amnion 21;»
`plication. Only one application of
`ilk? amnion is (10:16: and no dress;-
`
`bum
`ihc
`uniil
`ncccssmy
`ing;
`wound is healed which usually
`takes 2 weeks.
`
`8. The: use of amniotic mem-
`branes in lucal treatment of burns
`
`uf third degree and g‘anulution of
`old burns is nut successful“
`
`9‘ Daily paraffin section examim
`ations of the preserved amniotic
`mcmbranc i‘écvcaled cellular necro-
`
`sis starting on the third day and
`the nccmsis is progressive up to
`film twentieth day.
`
`the
`of
`Studies.
`l0. Hismlogic
`burned sites after amnion applica-
`tion were made and discusised.
`
`REFERENCES
`
`1. Bourne, 6.: The Microscopic Ana»
`toms: of the Human Amnion and
`Chorion. The American Journal of
`
`Obstetrics and Gynmology, 79:1070,
`June. 1960.
`
`‘2. Brown, J. B. and Fryer, M. P. Post;
`mortem Homogmfts
`to Reduce
`Mortality in Extensive Bums, J. A.
`M. A. 156:1163, Nov. 20, 1954‘
`
`3, Chardack, W., Martin. M., Jewett.,
`T. and. Bayer, 13.:
`Synthetic Sub‘
`stitute for Skin:
`Clinical Exper‘
`lance with Their Use in Treatment.
`()5 Burns, Plast. and Reconstmct.
`8mg. 30554-567, Nov. 1962.
`
`4. Difm, B., Eufemio, (3., Villa de, M.,
`Rcysio-sz, M. and Jurado R; The
`Use
`of Fetal Membrane Homo—
`:{mfts in the Local Management of
`Burma The Philippine Journal of
`Surgery and Surgical Specialties,
`20:128, Jammryf’ebruary, 1965.
`
`Etsguerm, A, Yambao, G., Sega, R.
`«4113:2113. C, and Limson, 1:3,:
`Am-
`rfiolic‘: Fluid Culture at; the Time of
`Ceaarmn 89013031. The Journal of
`
`MTF Ex. 1018, pg. 8
`
`MTF Ex. 1018, pg. 8
`
`

`

`HUMAN Ai‘bflHON w Dim}, at. 21!.
`
`mun, RM A.
`Joly, 1966
`
`Manila Medical Society, 3:152165,
`July~AugusL 1965.
`
`6. Crolmtein, M. and Baxter, H; Fetal
`Tissue Homogmfts, Annals Of
`the
`New York Academy of Balance, ‘73:
`584, 1958.
`
`q
`
`Kirschbaum, S. M. and Hernandez,
`$1.:
`Use of Ammon in Extisnsive
`
`Burns, Excepta. Medica, N. p. 21
`Third International Congress of
`Plastic Surgery, Washington, DC.
`1963.
`
`‘8. Merril, J.: Tissue Transplantation,
`Annals of
`Internal Mediating.
`55:
`848, Nov. 1961.
`
`Some Basic Con»
`‘9. Ocampo de, 3.:
`siderations on Tissue
`and Organ
`Transplantation,
`The
`Philippine
`Journal of Surgery and Surgicm
`Specialties, 16:139. MayJune, 1951.
`
`If). Pigeon, J.: Tim Treamlen‘a of Set}
`and Degree Bums wit; Amniotic
`Membranes. The
`Journal of
`the
`Canadian Medicaid Association. 33:
`{Milnéf‘}, Oct, 15, 1960.
`
`1}. Sta. Romana, (3.: Skin fiomografit‘
`mg, The Philippine Journal 0f Surv
`gery and Surgical Spmziaities,
`16:
`152, MayJune, 1960.
`
`1:2. Steriing, 3.: Use of Amniotic Mem-
`brane to Cover Surface Detects due
`to Flame Burns. The American
`J0uma1 of Surgery, 91.534042, June,
`1956.
`
`13, Wooctrufl‘. M.: The Use 0! Human
`Amnion in Surgery, The Trans-
`;flantation of Tissue and Organs.
`Charles C. Thomas. Fublisher. Ban:
`nerstone House, Springfieid. mi‘
`£10135. 3;). 249-255.
`
`THE UMBILICAL CORD COMPLICA~
`'1‘1ONS OF TRUE KNOTS, NUCHAL
`(12011.5 AND CORDS AROUND THE
`BODY
`Speflacy, W. N, Graven, H.
`and Fisch. P. 0. Am. J. Obst. £5 6331100.,
`94211736, {£er 15. 1968.
`
`The authors found that out of 17.1%
`deliveries.
`from 15
`instimtmns,
`true
`knots occurred in 1.05 per cent, mmhai
`coiIS occurred in 2&6 par cent. and word
`mmmd, the body in 12.0 per mm. These
`
`related to
`com complications are not
`mammal age. parity 0r comeuital mat
`fmmations but umxally they are long
`cards. There was 31':
`increaseci maid
`mice of abruptio placentae with cords
`around the botiy. The apgar score was
`inwm at.
`(me: minute Wham the catch:
`mam puiled tightly around Hm neck
`mam when they were loose. Stiilbirth
`cmiiveries were associamd Wm 21 higher
`immense of true cord knots.
`H. ACOSTA-SISON
`
`VARECELLA INFECTION CONTRkCT-
`ED IN U’I‘ERQ: SEX INCIDENCE AND
`INCUBATION PERIOD w Raine. D. N.
`Am. J, Obst. 3: Gynecz. 94:11:14, Agaril
`‘15,
`3966.
`
`Thy. author smdiad 36 infants who
`had vmrécena in micro.
`Six deaths on»
`curred among the 13 inmnts in whmu
`dim rash appeared hmween me 5511 and
`mm (33:; of lib: and :12] 0f.
`them were
`
`In m2» instance did any M the
`fumams.
`1‘?
`infants born with the rash subse‘
`
`quenuy die.
`Of the 32 infanta in whom the sex is:
`known. mm: 9 are boys.
`The usual
`incubation period is 14 to
`‘31 days. But in same cases the mm,»
`hation period is as ghort as S to 7 days.
`It. is iikmv thaf the infant infected in
`ufero carries with it maternal antibodv.
`H. ACCIS'I‘AuSISON
`
`MTF Ex. 1018, pg. 9
`
`MTF Ex. 1018, pg. 9
`
`