MYELOGRAPHY—Diagnostic Value in Lesions of the Lumbar Intervertebral Discs with a Variation in Technique

Myelography using pantopaque in greater than usual amount with a variation in technique, which is described, is believed to provide increased accuracy in differential diagnosis and precise localization of lesions in the lumbar spine. The need for multiple space exploration is eliminated and more detailed information concerning the size and shape of lesions is provided as compared to that secured by the use of 3 or 6 cc. of opaque medium and fluoroscopic examination alone. In 53 cases in which lumbar myelography was performed and the diagnosis verified or disproved at operation, there was a 5 per cent diagnostic error in 41 instances in which the method outlined was used, as compared with 17 per cent error in 12 cases in which only 3 or 6 cc. of radiopaque material and fluoroscopy alone were used. The accuracy of the procedure would appear to warrant its use in the evaluation of patients suspected of having abnormalities of the lumbar discs associated with nerve root compression.     

LABORATORY DIAGNOSIS OF TYPHOID FEVER—With Notes on Treatment

As indicated by a study of 41 cases of typhoid fever treated in three years, blood culture alone is often sufficient for the diagnosis of the disease if a large (30 cc.) specimen is used. Demonstration of the organism is the only completely diagnostic measure, but this was also achieved by the Widal reaction, by fecal or urine culture, or by aspirated bile culture, which in one case gave the only positive response.Chloramphenicol is the drug of choice in treating typhoid fever. Since only 25 per cent of patients develop immunity, immunizing injections should be started a week after therapy is discontinued.     

Laboratory diagnosis of typhoid fever with notes on treatment

As indicated by a study of 41 cases of typhoid fever treated in three years, blood culture alone is often sufficient for the diagnosis of the disease if a large (30 cc.) specimen is used. Demonstration of the organism is the only completely diagnostic measure, but this was also achieved by the Widal reaction, by fecal or urine culture, or by aspirated bile culture, which in one case gave the only positive response. Chloramphenicol is the drug of choice in treating typhoid fever. Since only 25 per cent of patients develop immunity, immunizing injections should be started a week after therapy is discontinued.     

ACUTE AND CHRONIC ASTHMA—Treatment with Theophylline in Hydro-Alcoholic Solution: Clinical Evaluation and Pulmonary Function Studies

A flavored solution containing 80 mg. of theophylline and 3 cc. of ethyl alcohol per 15 cc. was given orally to 31 patients with acute asthma to terminate the attack. Thirty patients with moderate to severe chronic asthma were alternated for three or four weeks on daily multiple doses of either the theophylline solution or a placebo.In the acute cases three-second Vital Capacity increased by 33.8 per cent and Maximal Breathing Capacity by 30.2 per cent in one hour after taking 60 cc. to 75 cc. of the theophylline solution. When placebos were given, both measures of lung function declined during the first half hour.Seventy-one and a half per cent of patients with acute cases felt moderate to complete relief of symptoms. In persons with chronic asthma the regular use of the theophylline solution did not change the frequency of asthma in most cases, but it decreased the severity in 59 per cent of cases. The values for three-second Vital Capacity and Maximal Breathing Capacity rose only a little.Gastric irritation was noted in one-third of the chronic cases and one-fourth of the acute cases. This could be reduced by appropriate measures.     

Needle biopsy in diagnosis of prostatic cancer

Four methods available for the diagnosis of carcinoma of the prostate-digital rectal evaluation, prostatic smear, needle biopsy and open perineal or transurethral biopsy-were studied and correlated.One hundred ten patients with clinical indications of cancer of the prostate were subjected to needle biopsy and open perineal or transurethral biopsy. Seventy of the same patients had prostatic smear examination. Using the open perineal biopsy or the positive transurethral biopsy as the standard, the accuracy of prostatic palpation, prostatic smear and needle biopsy were obtained.A high degree of correlation (74 per cent) was demonstrated between digital rectal evaluation and positive surgical biopsies in both early and late cases. There were 17 false positive clinical diagnoses. The prostatic smear showed an overall correlation of 45 per cent when compared with the results of positive surgical biopsy. The overall accuracy of needle biopsy was 73 per cent. However, in the last 39 cases, including eight in which the carcinomas were of groups A and B (curable), the needle accuracy was 100 per cent. When there is clinical indication of malignant disease of the prostate, needle biopsy of the lesion is warranted and should be done before definitive or palliative treatment is undertaken.     

Aspiration biopsy cytology, mammography and clinical exploration: a modern set up in diagnosis of tumors of the breast.

Six hundred and two mammary tumors were examined clinically, by mammography and cytology, with a histologic checkup following surgical biopsy. There were 247 cases of malignoma and 355 benign cases. The limited reliability of the individual methods is demonstrated, and it is shown that their combined use can improve the diagnosis. More malignomas are detected, and preoperative diagnosis is made more safely. If all three methods yield identical results, as was the case in 50.2% of the malignant and 32.7% of the benign lesions, the probability of diagnostic error is less than one per cent. With a malignoma thus established, surgical treatment may follow immediately, or irradiation can be started. In benign cases a surgical biopsy may be foregone and further developments may be awaited with due provision for regular control. If the three methods yield conflicting or doubtful results, elucidation by surgical biopsy and histology is indicated.     

NEEDLE BIOPSY OF THE LIVER—General Considerations

Needle biopsy of the liver provides concrete diagnostic information that cannot be as readily obtained in any other way. This report reviews 401 liver biopsies in 312 patients.The major indications for use of this procedure are: To determine the cause of an obscure liver enlargement; to establish the cause of jaundice; to distinguish between malignant disease and cirrhosis of the liver; to determine when hepatitis has subsided; and to evaluate the results of treatment. At times, systemic disease that has not been recognized by other means may be diagnosed by this technique. There is risk in performing this test, and the 0.25 per cent mortality in this series compares favorably with that reported from other clinics. Where the diagnosis by biopsy could be compared with observations at operation or autopsy, the correct diagnosis was made by biopsy in 85 per cent of cases. Greater accuracy was obtained by two or more biopsic examinations in one case then by single biopsy.In several cases in which surgical operation was considered, biopsic information made it unnecessary, and vice versa.     

CONSIDERATIONS OF POSTOPERATIVE ELECTROLYTE AND FLUID REPLACEMENT

The most important postoperative fluid considerations are maintenance of adequate urinary output, of blood volume, and of extracellular and interstitial cell water and electrolytes.Normal urinary output is between 1,000 and 1,500 cc. daily. A fluid intake of 2,000 cc. of 5 per cent dextrose in distilled water, plus 500 cc. of normal saline solution, will insure this amount of urinary output.The use of 5 per cent dextrose solutions in distilled water provides fluid, retards the protein catabolism of the body, and spares electrolytes.Irradiated plasma is the only intravenous solution which will adequately supply protein in amounts to maintain nitrogen equilibrium. Protein hydrolysates in the absence of adequate caloric intake do not provide enough protein for nitrogen balance.The role of the potassium ion is ordinarily not a consideration in postoperative fluid management. It becomes a consideration in the presence of a large amount of drainage from wounds or abscess cavities, nasogastric suction, or intestinal fistulae. It also must be given attention in cases in which parenteral administration of fluids is necessary for a prolonged period.     

Ectopic pregnancy; early diagnosis,clinical errors and conservative operation

This report of eight years' experience with extrauterine pregnancy by a single gynecologist is an exposition of how the diagnosis was made or why it was missed. Of 26 diagnoses of ectopic pregnancy, five were false (20 per cent); and in three cases (10 per cent) the diagnosis was not made promptly-a total error of 30 per cent. Ectopic pregnancy will be discovered earlier if obstetric patients are always examined shortly after missing the first menstrual period.A palpable adnexal mass was present in 19 of 21 ectopic pregnancies (90 per cent). A mass was palpable in only one of five cases erroneously diagnosed as ectopic pregnancy (20 per cent).Decidual casts were passed by four patients, two of whom did not have ectopic pregnancy. If two gynecologists do not agree on the question of extrauterine pregnancy, a third opinion should be sought or culdoscopy employed. Enucleation of the conceptus and salvage of the oviduct is advocated.     

Carminomycin study in breast cancer]

Karminomycin was used for the treatment of cases with disseminated cancer of the mammary gland in doses of 5 mg/m2 of the body surface intravenously every day for 5 days (15 patients) or 6 mg/m2 twice a week for 2-3 weeks (30 patients). Partial remission or diminution of the tumor size at least by 50 per cent was observed in 26 and 17 per cent of the patients respectively. The remission duration was from 2 to 6 months. With the use of the shortperiod scheme the frequency of the direct side reactions increased. Leucopenia as a side effect was registered in 100 and 40 per cent of the patients and thrombocytopenia was registered in 18 and 3 per cent of the cases respectively.     

CEA, ZGM and EMA localization in cells of pleural and peritoneal effusion: a preliminary study

Carcinoembryonic antigen (CEA), the zinc glycinate marker (ZGM) and epithelial membrane antigen (EMA) have been described as epithelial or tumour markers of varying specificity. These antigens were studied by immunoperoxidase localization in selected cell blocks of 62 pleural or peritoneal effusions and compared to cytological findings and review of the clinical records. By cytological criteria, 25 of the cell blocks were positive for malignancy, 30 negative, and 7 inconclusive. CEA, ZGM, and EMA by immunoperoxidase staining were localized on the cell surface and often in the cytoplasm of malignant cells, in 11/25 (44 per cent), 17/25 (68 per cent) and 22/25 (88 per cent) of the positive cell blocks respectively. Ten (40 per cent) of these cases were positive for all three antigens, 7 (28 per cent) for two, and 6 (24 per cent) for one. Of the 7 cases which were inconclusive on routine cytological reporting, 5 were positive for at least one marker. In 3 of the 5 a diagnosis of malignancy was confirmed, and in the other two was strongly suspected as malignant on clinical grounds. Macrophages were sometimes positive for one or more markers (but showed cytoplasmic staining only) and mesothelial cells in some cases stained positively for EMA but were always negative for CEA and ZGM. Localization of the 3 antigens in cells of malignant effusions was compared with their localization in the primary tumours in 9 cases. Localization corresponded for CEA in 7 of 9 cases, for EMA in 8 of 8 an for ZGM in only 2 of 9. Effusion fluid levels for CEA were compared with the cytological and immunocytochemical findings in 30 cases. Mucin stains performed on the cell blocks were also compared with the immunoperoxidase findings.     

ECTOPIC PREGNANCY—Early Diagnosis,Clinical Errors and Conservative Operation

This report of eight years'' experience with extrauterine pregnancy by a single gynecologist is an exposition of how the diagnosis was made or why it was missed.Of 26 diagnoses of ectopic pregnancy, five were false (20 per cent); and in three cases (10 per cent) the diagnosis was not made promptly—a total error of 30 per cent.Ectopic pregnancy will be discovered earlier if obstetric patients are always examined shortly after missing the first menstrual period.A palpable adnexal mass was present in 19 of 21 ectopic pregnancies (90 per cent). A mass was palpable in only one of five cases erroneously diagnosed as ectopic pregnancy (20 per cent).Decidual casts were passed by four patients, two of whom did not have ectopic pregnancy.If two gynecologists do not agree on the question of extrauterine pregnancy, a third opinion should be sought or culdoscopy employed.Enucleation of the conceptus and salvage of the oviduct is advocated.     

LAMINECTOMY FOR HERNIATED INTERVERTEBRAL DISC

In a study of 59 patients surgically treated by various surgeons for relief of herniated lumbar intervertebral disc accompanied by symptoms that persistently recurred or had become resistant to conservative therapy, it was noted from review of hospital and office records that laminectomy either greatly relieved or entirely abated symptoms in 83 per cent of the cases.Postoperative complications reported by the surgeons who did the operations consisted of one death and five wound infections. Contrast myelography and electromyography, used in almost all cases in the series, appeared to be valuable adjuncts in the diagnosis of herniated lumbar intervertebral discs. The most common site of the lesion in this series was between the fourth and fifth lumbar vertebrae. Strain upon lifting was the most commonly reported precipitating factor.     

Investigation of an Operator Method in the Analysis of Biological Tracer Data

Some factors affecting the usefulness of a linear operator in the analysis of tracer data were evaluated. Application of the operator to a sum of two exponential components resulted in the separation of the rate constants with an accuracy of 10 to 15 per cent if they differed by a factor of at least 2 and the error in the data was about 2 per cent. A factor of 4 was necessary if the error in the data was 6 per cent, and of 6 if the error was 10 per cent. The ratio of amplitudes varied from near unity to equality with the ratio of rate constants. However, if the ratio of amplitudes was greater than the ratio of rate constants the method would not resolve the rate constants. Application of the operator to a sum of three exponential components was also considered.     

Determining the site of brain tumors; the use of radioactive iodine and phosphorus

By tests using radioactive iodine combined with diiodofluorescein, the site of tumors was correctly determined in 61 per cent of 39 cases of tumors of the cerebral hemispheres. In 19 cases where the focal radioactivity was increased 24 per cent or more over that of the surrounding area, there were no errors in localization. Fifteen patients with expanding intracranial lesions were tested at operation with radioactive phosphorus and 14 lesions were correctly localized. This procedure in which the needle probe was used was found of great value in rapidly locating and outlining the area of involvement.     

DETERMINING THE SITE OF BRAIN TUMORS—The Use of Radioactive Iodine and Phosphorus

By tests using radioactive iodine combined with diiodofluorescein, the site of tumors was correctly determined in 61 per cent of 39 cases of tumors of the cerebral hemispheres. In 19 cases where the focal radioactivity was increased 24 per cent or more over that of the surrounding area, there were no errors in localization. Fifteen patients with expanding intracranial lesions were tested at operation with radioactive phosphorus and 14 lesions were correctly localized. This procedure in which the needle probe was used was found of great value in rapidly locating and outlining the area of involvement.     

Needle biopsy of the liver; general considerations

Needle biopsy of the liver provides concrete diagnostic information that cannot be as readily obtained in any other way. This report reviews 401 liver biopsies in 312 patients. THE MAJOR INDICATIONS FOR USE OF THIS PROCEDURE ARE: To determine the cause of an obscure liver enlargement; to establish the cause of jaundice; to distinguish between malignant disease and cirrhosis of the liver; to determine when hepatitis has subsided; and to evaluate the results of treatment. At times, systemic disease that has not been recognized by other means may be diagnosed by this technique. There is risk in performing this test, and the 0.25 per cent mortality in this series compares favorably with that reported from other clinics. Where the diagnosis by biopsy could be compared with observations at operation or autopsy, the correct diagnosis was made by biopsy in 85 per cent of cases. Greater accuracy was obtained by two or more biopsic examinations in one case then by single biopsy. In several cases in which surgical operation was considered, biopsic information made it unnecessary, and vice versa.     

Action of antibiotic combinations with furacilin on the synthesis of proteins and nucleic acids in intact NAG-vibrio cells]

Furacillin in combination with such antibiotics as tetracycline, levomycetin or neomycin inhibited the synthesis of proteins in the cells of NAG-vibrios. Combination of 8 gamma/ml of furacillin and 0.125 gamma/ml of tetracycline inhibited the protein synthesis by 58.8 per cent, 8 gamma/ml of furacillin and 0.5 gamma/ml of levomycetin inhibited the synthesis by 61 per cent, 8 gamma/ml of furacillin and 4 gamma/ml of neomycin inhibited it by 59.5 per cent. At the same time furacillin alone in concentrations of 16 and 8 gamma/ml inhibited the protein synthesis by 69.1 and 37 per cent respectively, tetracycline alone in doses of 0.25 and 0.125 gamma/ml inhibited it by 51.3 and 34.7 per cent respectively, levomycetin alone in doses of 1 and 0.5 gamma/ml inhibited it by 54.4 and 33.2 per cent, enomycin in doses of 8 and 4 gamma/ml inhibited it by 54.4 and 22.6 per cent respectively. Therefore, when the above antibiotics were used in combination with furacillin the inhibitory effect of the drugs on the protein synthesis was summarized. When furacillin was combined with tetracycline or levomycetin in the above concentrations, the inhibitory effect on RNA synthesis (42 or 32 per cent respectively) was lower than that of furacillin alone (50.5 per cent). When furacillin was used in combination with neomycin, the inhibition of RNA synthesis increased up to 69 per cent. The increase in the inhibitory effect was also noted with respect to the synthesis of DNA. Combination of furacillin with tetracycline, levomycetin or neomhcin decreased the synthesis of DNA by 79.7, 85 or 85.8 per cent respectively as compared to the inhibitory effect of 8 gamma/ml of furacillin equal to 61 per cent.     

Results of irradiation in cancer of the lip,tongue and ear

CANCER OF THE LIP: The primary lesion can be controlled by irradiation in approximately 80 per cent of cases. For lesions with metastases there is only about a 25 per cent chance of five-year arrest (irradiation of the primary lesion followed by excision of involved nodes). CANCER OF THE TONGUE: Lesions in the anterior two-thirds are controllable by irradiation in about 50 per cent of cases if the nodes are not involved; the salvage is only about 15 per cent if the nodes are involved (nodes treated surgically). Lesions in the posterior third of the tongue are seldom controlled in the author's experience. CANCER OF THE EAR (AURICLE): Five-year arrest of basal-cell lesions should be attained by irradiation in about 80 per cent of cases; of squamous-cell lesions in about 60 per cent. If the lesion is extensive, radiation does not offer a superior cosmetic result to operation and entails danger of late chondronecrosis. Therefore extensive lesions are probably best treated surgically. In either event, it appears probable that results of irradiation can be improved by the use of more adequate fields and greater fractionation.     

Poikilocytosis in Cancer Patients

The incidence of poikilocytosis in 100 patients with cancer of various organ systems was found to be 12 per cent. Poikilocytosis was more frequently seen in patients with adenocarcinoma of the gastrointestinal tract and with inoperable metastatic carcinoma than in patients with other malignant lesions. Anemia was associated in three cases, but in nine instances the patient was not significantly anemic at admission. Two of these patients may have been dehydrated. Uremia was not a factor in any of the cases.Fifty per cent of the patients exhibiting poikilocytosis died or were in a terminal condition within one month after the observation was made, as compared with 21 per cent of the patients who did not have evidence of poikilocytosis. These findings show that poikilocytosis may occur in cancer patients without anemia or uremia; and they indicate that its presence is an unfavorable prognosis sign.