Search

1) Eleven courses of intravenous ACTH by continuous infusion were given to 10 patients with severe bronchial asthma. 2) The total dose ranged between 10 mg. and 210 mg. given over a period of one to nine days. 3) Seven patients obtained excellent remissions lasting up to six weeks. The others obtained partial remissions only. There was no complete therapeutic failure. 4) One patient who demonstrated clinical resistance and eosinophil escape with i.m. ACTH responded promptly to i.v. ACTH. 5) Antibiotics should be administered concomitantly, particularly to those patients with bronchitic manifestations, to combat possible depressed resistance to infection produced by ACTH.

The study described here was undertaken to compare further three recently reported micro-niacin tests using both freshly isolated and stored cultures of various types of mycobacteria. When performed on the fresh cultures, it was observed that all of the human-type tubercle bacilli yielded slightly to intensely positive tests, whereas, all of the other strains, with two exceptions, gave either negative or doubtful results. As the period of incubation increased, there was a corresponding increase in both the number and degree of positive results. The bovine-type tubercle bacilli exhibited slightly positive results with each test after the 10, 14, and 21 day periods, respectively. When used on cultures of human-type tubercle bacilli from seven to ten days old, the sensitivity of the tests was observed to be as follows: (1) the benzidlne-cyanogen bromide and the o-tolidine-cyanogen bromide tests were slightly better than the aniline-cyanogen bromide method with four of the strains tested; (2) the aniline-cyanogen bromide and the o-tolidine-cyanogen bromide methods were slightly better than the benzidine-cyanogen bromide technic with six of the strains tested; and (3) the aniline-cyanogen bromide and the benzidine-cyanogen bromide procedures were slightly better than the o-tolidine-cyanogen bromide test with 47 of the strains tested. When used on the cultures of human-type tubercle bacilli from 14 to 21 days old, however, the sensitivity of all three niacin tests was virtually the same. When performed on the stored cultures, it also was observed that all of the human type tubercle bacilli exhibited slightly to intensely positive results irrespective of the period of storage or the dryness of the cultures. The drug resistant organisms yielded similar results to those of the drug susceptible strains. With two exceptions, all of the other mycobacteria exhibited either negative or doubtful tests. In the bovine group of tubercle bacilli, all of the cultures yielded slightly positive results at each test period. In the Battey group of organisms, 7 out of 100 cultures exhibited slightly positive results within the 50 to 156 week test periods. The sensitivity of each niacin test under these conditions was virtually the same. The tests are simple, efficient, safe, and economical. Reproducible and consistent results can be obtained on cultures as old as three years. In most instances, the results exhibited by human tubercle bacilli are sufficiently different in character from the results produced by other mycobacteria to enable a clear-cut differentiation of these organisms. For greater effectiveness, it is recommended that the niacin test be used in conjunction with other differential procedures.

1) In order to restore physiologic balance in the sick asthmatic, it is necessary to maintain a therapeutic balance. I have attempted to illustrate the various measures which are necessary to balance this therapeutic seesaw. 2) The therapeutic measures suggested are based largely on personal experiences in the management of 513 patients and have been correlated with extensive laboratory studies with a large variety of protecting drugs, employing a method of human assay (protection studies). 3) With this technique, a method of human assay of the relative value of new and accepted therapeutic agents for the relief of bronchial asthma is possible. This technique has afforded us the opportunity of making these studies under controlled conditions usually not present in the sick patient. A comparative study of the protective abilities of several bronchodilators against the effects of intravenous histamine and mecholyl-induced dyspnea and bronchospasm is presented. The role and limitations of epinephrine, aminophyllin and the antihistaminic preparations based on laboratory and clinical correlation is discussed. 4) The role of sedation with drugs and anesthetic agents is presented. The use of chloral hydrate and sodium bromide, demerol, demerol and scopolamine (a modified form of “twilight sleep”), ether and paraldehyde, and caution about the use of sprays or topical pontocaine and cocaine is discussed. 5) Supportive therapy including the replacement of water, glucose, electrolytes and blood plasma is discussed at length. There should be no standard “intravenous cocktail mixture”. It should be prescribed according to physiologic needs. Interrupted or continuous intravenouses containing aminophyllin may be of great value. Addition of Cytochrome-C, nicotinic acid, vitamin B. Complex or cevitamic acid to the infusion fluid has not proven of striking value. On occasion, relaxation followed the use of alcohol-dextrose solution in place of the saline-dextrose infusions. These effects, however, did not persist with repeated use. 6) The therapeutic use of gases is discussed: oxygen for the relief of anoxia and cyanosis; helium and oxygen mixtures for the relief of respiratory obstruction; positive pressure inhalations of oxygen or helium and oxygen for the management of pulmonary edema; carbon dioxide mixtures as expectorants (“bronchial catharsis”); and aerosols of bronchodilator drugs for the relief of bronchospasm or antibiotic drugs for the control of infection. 7) Considerable emphasis is placed on the value of bronchial evacuation. Evacuation of the bronchi may be accomplished by “bronchial catharsis,” positional drainage, bronchoscopic aspiration and endoscopic lavage. “Bronchial catharsis” in its physiologic sense can be observed with the use of expectorant drugs (e.g., iodides) and syrup of ipecac, Ipecac acts by substituting effective retching for ineffective coughing. 8) The role of infection in bronchial asthma and its management is discussed. Adequate levels of sulfonamides and antibiotics in the sputum, the tracheobronchial tree and the pulmonary tissues should be the primary aim in management. We have been unable to demonstrate any penicillin in the sputum of patients with suppurative lung disease following intramuscular penicillin. On the other hand, we have been able to demonstrate high sputum levels in the same patients following aerosol and endoscopic instillations. In normal subjects, we have also demonstrated adequate penicillin blood levels which persist for a longer period than those following intramuscular injection. These levels were highest when neosynefrin and pantopaque were employed as diluents in place of saline. 9) Paranasal sinus disease is responsible for the reinfection and recurrence of cough and wheezing in patients with bronchial asthma. These patients are more likely to have serious asthma and irreparable sino-bronchitic disease. Treatment should consist of the combined use of antihistaminic preparations and nasal penicillin therapy with the technique of intermittent negative pressure and replacement with penicillin aerosol, with judicious but minimal surgical assistance. 10) The antihistaminics although generally of limited value in the management of the asthmatic subject, may be of considerable value in the following: Orally for the relief of paranasal obstruction (allergy is the dominant factor in the maintenance of chronic paranasal sinus disease in the asthmatic); intravenously to restore the delicate histamine-sympathin balance in the epinephrine refractory state; and for sedative effects in the status state.

A new syndrome of heart disease has been presented that we have not found recorded in the literature heretofore. We prefer to call this the "straight back" syndrome. It may be described as a congenital straightening of the upper dorsal spine which decreases the anteroposterior diameter of the chest at this level. This results in compression phenomena which may either cause pseudocardiomegaly or cause mechanical murmurs. These murmurs are systolic in timing and would seem secondary to distortion or impingement of the great vessels. Simple physical examination will usually reveal the straight back syndrome. The degree of deformity may then be determined when lateral x-ray films are taken. The simple defects found in this syndrome may not be uncommon. Their recognition may prevent a common form of iatrogenic heart disease that has often interfered with employment, insurability and peace of mind.

SUMMARY The present investigation was undertaken to study further the usefulness of a three-day phenolphthalein sulfatase test for the differentiation of the rapidly growing M. balnei, M. fortuitum, and saprophytic acid-fast bacilli. Two different test methods were compared. It was found that, with the liquid medium test technique and a 0.0005M concentration of the enzyme substrate, tripotassium phenolphthalein disulfate, all of the M. fortuitum strains could be differentiated from all of the other mycobacteria. With a substrate concentration of 0.002M all of the saprophytic mycobacteria could be separated from all of the M. balnei and M. fortuitum strains and most of the M. balnei organisms could be differentiated from most of the M. fortuitum strains. With the solid medium test procedure and a substrate concentration of 0.000125M, all of the M. fortuitum strains could be differentiated from all of the other mycobacteria. With a substrate concentration of 0.0005M all of the saprophytic mycobacteria could be separated from all of the M. balnei and M. fortuitum strains and most of the M. balnei organisms could be differentiated from most of the M. fortuitum strains. On the basis of the present findings, the liquid medium test technique has proved somewhat more useful than the solid medium test method because of the more clear-cut results which have been obtained in the majority of the tests performed. Additional study will be required before this can be determined definitely. Thus far, the phenolphthalein sulfatase test has proved to be a rapid and useful screening tool for the differentiation of these three groups of mycobacteria.

SUMMARY The pulmonary heart disease syndrome is a multiform complex whose evolution is determined by the natural history of the underlying disorders. It should be recognized that considerable physiologic derangement may long precede the clinical evidence of heart failure and that the recognition of this fact has significant therapeutic implications. The development of the syndrome is essentially determined by the interplay of physiologic factors such as hypoxia, pulmonary arteriolar resistance and cardiac output, acting upon varying degrees of established curtailment in the effective areas of the pulmonary vascular bed. Some highlights in therapy are discussed.

1. It is suggested that the numerous chest-wall syndromes involving painful costal cartilage be identified by the term "Rib syndrome," to indicate a single entity or process. 2. Selections from 50 cases of the "Rib syndrome" are presented, some of which illustrate the interrelationships of the numerous acute types of chest wall conditions as one entity. Nine cases of the acute type of rib junction pain showed eventual transition into the chronic nodular type previously known as "Tietze's syndrome," suggesting an origin for this previously baffling condition. 3. The etiology of the "rib syndrome" appears to be occupational and due to a sprain or strain of the rib junction in many cases. The patient is usually unaware of local tenderness until it is found by the examiner. Biopsies and x-ray films are usually normal and unrevealing. 4. Treatment consists of local splinting, local heat and oral salicylates. The more severe cases respond best to local injections of procaine and cortisone mixtures. 5. The "Rib syndrome" appears to be a common condition that is frequently confused with diseases of heart or lungs. The diagnosis is easily confirmed when point compression over the involved costochondral junction or other painful cartilage exactly reproduces the patient's complaints.

1) The simple portable air pressure device is described which safely produces positive and negative phase pressures (exsufflation with negative pressure) without disturbing the circulatory hemodynamics during the brief periods of therapeutic application. 2) The pressure characteristics in the face mask obtained with this unit are recorded,—during a single cough and during a series of coughs. 3) The rapid expiratory air flows created are sufficiently capable of eliminating the accumulated pulmonary secretions in a variety of pulmonary and nonpulmonary diseases. We are presently applying this form of therapy in a series of patients with bronchiectasis, atelectasis of varied etiology and postoperative retention of pulmonary secretions. 4) A detailed case history is presented of the application of the device in a patient with a large atelectatic-cystic area of lung. Copious expectoration followed a series of “coughs” with the apparatus and a large cystic area was successfully evacuated. 5) Control settings added to the basic unit, to permit the use of wider pressure ranges during both positive-negative phases, are presently being explored for the purposes of resuscitation in general.

Boston, Massachusetts Sarcoidosis, when entertained as a possible diagnosis today, has a vastly more extended significance than when the term “Sarcoid” was first used by Boeck’ in 1899 to describe the skin lesions. Sarcoidosis is more and more frequently considered in the differential diagnosis of obscure systemic illness. The present, most widely accepted, concept of sarcoidosis is that it is essentially a systemic disease which may involve not only skin and subcutaneous tissue, but also lymph nodes, eyes, bones and viscera, especially the lungs. The characteristic, although non-specific, microscopic lesion of sarcoidosis is a granuboma composed of nests of epithelioid cells.2’ � In the later stages, giant cells of either the Langhans or foreign body type are often present; the latter frequently contain inclusing bodies of round (Schaumann) or stellate (“asteroid”)4 configuration. In systemic sarcoidosis, such granulomata may be found in almost any organ or tissue, but they have a predilection for skin, lymph nodes, spleen, liver, lungs, salivary glands, bone and eye. The granulomata may be contiguous, but are rarely confluent, and they almost never caseate in the manner which is characteristic of tuberculosis. The granuloma of sarcoidosis has a cycle of variable duration, beginning with the appearance of perivascular inflammatory cells, progressing to the formation of an epithelial granuloma, which eventually disappears or is replaced by fibrosis, about a core of collagenous hyaline material. Generally, a number of granulomata of about the same stage will be found in a given specimen. The principal pulmonary complications and sequellae of sarcoidosis that are found at post mortem examination include fibrosis and cyst formation; only rarely is there cavitation, bronchiectasis or emphysema. Tuberculosis is found in 10 per cent or more of clinical cases and with

In previous studies’-3 it was observed that the thioglycollate, peroxidase, neutral red, and serpentine cord tests were useful for group differentiation of M. tuberculosis, atypical acid-fast bacilli, and saprophytic mycobacteria. The present investigation was undertaken to determine further the differential potential of these procedures, and to ascertain whether the niacin test4’5 could also be used to help in the differentiation of these groups of organisms. Materials and Methods

Summary A simple ruler-graph device has been described for use with single determinations of the vital capacity on a recording drum apparatus. This permits the rapid determination of the volume of air ejected during each second of the vital capacity tracing on a graphic record. The same record also affords an opportunity for analyzing the contour of the graph for evidence of trapping or change in mid-position. These time relationships enhance the value of the simple vital capacity determination. The relative efficacies of bronchodilator preparations in relieving the bronchospasm of the patient with bronchial asthma or pulmonary emphysema can be determined readily with this technique. This method was compared with the vitalometer. Both methods yield comparable values. The ruler-graph method, however, affords additional significant data, easily obtained by employing the apparatus which is generally in use in laboratories studying pulmonary function.

1)Clinical studies and biological assays of a new penicillin preparation (Diethylaminoethyl-ester-hydroiodide) were carried out in patients with pulmonary diseases. 2)Clinical results were encouraging and mostly evident in the relief of cough, the decrease and change in character of the expectoration and control of temperature. 3)Penicillin sputum peak levels were consistently much higher than those obtained in the blood serum. 4)The conversion of bacterial flora lagged behind the clinical results. The appearance at the end of treatment of new bacterial flora, though frequent, did not alter the beneficial clinical results. 5)Neo-penil appeared to be an effective penicillin preparation for pulmonary diseases, whenever a higher local concentration of the drug in the diseased lung was desired.

and similar compounds is based on a phenanthrene nucleus, whereas Noscapine is an isoquinoline derivative (related to papaverine). It is readily absorbed after oral or parenteral administration, disappears rapidly from the blood stream, and only traces appear in the urine. Its fate is unknown. It has been referred to as the least toxic of the opium alkaloids in mice, rats, and man. Up to 3 grams by mouth have been given to man with only minor side reactions. Chronic toxicity studies did not demonstrate any cumulative effects. No depressant action on respiration or the central nervous system has been observed up to toxic doses; stimulation may appear with higher doses. The effects of Noscapine on the gastrointestinal tract were insignificant. No effects on secretory activity and minimal effects on gastrointestinal movements were reported. Occasionally emesis and constipation were noted only with large doses. No significant analgesc action was observed. Potentiation of morphine analgesia with antagonism to side effects have been reported, but not definitely established. The parenteral use of Noscapine has been limited because of local pain. In experimental cough in animals and man, it was described as effective as codeine. No tolerance to the drug developed. Finally, although no antihistaminic action was found, it did inhibit the “allergic cough” in sensitized guinea pigs exposed to aerosols of specific antigen. It did not, however, prevent anaphylactic shock after injected antigen. In a study centering about the experimental production of cough in normal and asthmatic subjects, small doses of Narcotine (5 and 15 mg.) were demonstrated to have greater anti