Studies on the Macroglobulins of Human Serum: III. Quantitative Aspects Related to Cold Agglutinins

Eighteen sera containing cold hemagglutinins were examined. IgM levelswere determined before and after absorption of this cold antibody. In 5 serawith M-components (immunologic type M kappa) 33 per cent, 93 per cent,93 per cent, 95 per cent, and 75 per cent of the total IgM was serologicallyactive—that is, lost after the absorption. In 12 sera with no M-component(polyclonal), 0-24 per cent of the IgM molecules had cold activity. One exception was noted in a serum from a patient with cold agglutinin disease containing no monoclonal M-component, but which lost 66 per cent of its IgMafter absorption with stromata. No correlation existed between cold agglutinintiter, total IgM-concentration, or per cent active IgM molecules. The resultsindicate a general qualitative difference between polyclonal and monoclonalcold hemagglutinins.

Submitted on April 20, 1966 Accepted on August 2, 1966     

The Influence of Hemoglobin Concentration on the Distribution Pattern of the Volumes of Human Erythrocytes

1. Studies of the volume distributions of normal human, canine, andchicken erythrocytes through the use of a Model B Coulter electronic particlecounter and plotter of 400 channel analyzer have confirmed that the instrument provides a true reflection of cell volume, independent of theconductivity of the medium, independent of the shape of the erythrocyte,independent of the buffers, and independent of the anticoagulants employed.

2. The non-Gaussian distribution pattern of normal human cells has beenconfirmed, but no evidence has been found for a distinct bimodal distributionpattern in cells which have been freshly collected, pipetted, and examined.

3. Swelling of human erythrocytes in 0.5 per cent NaCl alters the volumedistribution pattern to that of a normal distribution, and the distributionpattern of hemoglobin-free ghosts in 1 per cent NaCl is more nearly symmetric than that of normal intact red cells in 1 per cent NaCl.

4. The Gaussian distribution of erythrocyte volumes in 0.5 per cent NaClsuggests a normal distribution pattern for both the critical volume and ioniccontent of red cells.

5. The asymmetry of red cell volume distribution at the tonicity of plasmaappears related to higher intracellular osmotic activity in the smaller cells,based on the anomalous osmotic coefficient of hemoglobin. It is suggested,therefore, that skewing of the curve is related to asymmetry of the distributionpattern at the lower end of the volume spectrum, rather than the upper end.

Submitted on May 5, 1966 Accepted on August 2, 1966     

The binding of Cr 51 to hemoglobin. II. In vivo elution rates of CR 51 from Hb CC, Hb CS, and placental red cells

In vivo elution rates of Cr⁵¹ from red cells containing Hb C and fromplacental red cells containing large amounts of Hb F have been determined.These were found to be 1.8 and 0.85 per cent per day, respectively, and do notdiffer greatly from those of normal adult red cells. Therefore, no special correction factors for elution need be used in evaluating Cr⁵¹ survival curves inthese clinical situations. The in vivo elution rate of 3.5 per cent/day observedfor Hb C-S is significantly greater than that of normal red cells.

Submitted on December 1, 1965 Accepted on January 16, 1966     

Detection of glucose-6-phosphate dehydrogenase deficient heterozygotes

Heterozygotes for the Mediterranean type of severe G-6-PD deficiencywere investigated by a variety of tests.

The methemoglobin reduction test was most successful in detecting heterozygotes (about 80 per cent). Enumeration of methemoglobin containingcells on blood films (Kleihauer-Betke technic) did not improve these results.Quantitation of enzyme level was less successful (65 per cent), and determination of decolorization time by the BCB technic was least sensitivein heterozygote detection.

Methemoglobin reduction technics reflect a more indirect effect of themutant gene than enzyme assay. The superiority of these technics in heterozygote detection is probably caused by the genetically determined presenceof both normal and enzyme-deficient cells in G-6-PD deficient heterozygotes.Since methemoglobin reduction is carried out by individual cells, the population of enzyme deficient cells does not reduce methemoglobin, and thereforeeven a minority of deficient cells leads to abnormal test results. In contrast,enzyme assay is less successful for heterozygote detection, since measurementof enzyme level is carried out on hemolyzed red cells, where cellular mosaicismno longer exists.

An additional source of variation of enzyme levels in heterozygotes iscaused by the existence of genetically determined control of normal enzymelevel. Possession of a high capacity allele for G-6-PD activity may placea heterozygote in the normal range of enzyme activity.

The various tests were also applied to subjects with the mild Greek typeof G-6-PD deficiency. Males with this mutation had enzyme levels varyingbetween 12-45 per cent of the mean of normal males. Methemoglobin reduction test results were considerably less abnormal in hemizygotes with themild type of Mediterranean deficiency than in heterozygotes with the severedeficiency. Fewer heterozygotes with the mild deficiency were detected.

Submitted on February 4, 1966 Accepted on May 31, 1966     

Hematologic Effects of Splenic Implants

1. Splenectomy in the rat results in a marked elevation in the number ofcirculating leukocytes and platelets.

2. Transient suppression of the leukocytosis may result from the presenceof a 10 per cent splenic implant, either free in the peritoneal cavity or enclosed in a Millipore diffusion chamber.

3. Marked and persistent suppression of postsplenectomy thrombocytosisresults from the presence of a 10 per cent splenic implant, whether freeor enclosed in a 0.45 µ Millipore diffusion chamber.

4. The results provide indirect evidence of a humoral substance producedby rat spleen which influences platelet levels; presumably this substanceacts by suppressing thrombopoiesis.

Submitted on April 28, 1966 Accepted on August 26, 1966     

Malic and Lactic Dehydrogenase Isozymes of Normal and Leukemic Leukocytes Separated on Glass Bead Columns

Five LDH and two MDH isozyme bands were obtained with acrylamidegel electrophoresis of leukocyte extracts. Normal lymphocytes showed a hightotal H-LDH (heart type) activity (67 per cent) with 25 per cent in LDH-1and only 3.5 per cent in LDH-5. Lymphocytes from chronic lymphatic leukemia(CLL) and lymphosarcoma leukemia (LSA-LL) had less LDH-1, and moreLDH-3 and LDH-4, than normal lymphocytes. The H-LDH fell to 60.5 per centin CLL and 56 per cent in LSA-LL. PMN leukocytes had low H-LDH activity(38.8 per cent) with 3.3 per cent in LDH-1 and 25.8 per cent in LDH-5. Inmyelogenous leukemia, myeloblasts had the most LDH-1 and H-LDH, whilemature PMN had the least. PMN leukocytes isolated from CLL, LSA-LL, andmyelogenous leukemia had LDH patterns like the normal. Monocytes fromacute monocytic leukemia were low in LDH-1 and LDH-5, but had a high totalenzyme content. They evidently were rich in LDH-2, 3, and 4.

Lymphocytes had less MDH-1 (60 per cent) than PMN leukocytes (78 percent). In CLL, lymphocyte MDH-2 increased. In myelogenous leukemia,myeloblasts had the most MDH-2 and mature PMN the least. Monocytesfrom monocytic leukemia contained a little more MDH-2 than PMN leukocytes.

In general, white cell immaturity and/or ability to divide was associatedwith high levels of LDH-1, total H-LDH, and MDH-2.

Submitted on May 5, 1966 Accepted on June 26, 1966     

The Intravascular Lifespan of Monocytes

Monocytes, defined as peroxidase positive mononuclear cells in the peripheral blood of healthy rats, were labeled by frequent intermittent injections oftritiated thymidine. About 25 per cent of the monocytes were labeled within 1day and 82 per cent in 8 days. Both labeled and unlabeled monocytes disappeared from the circulation in accordance with an exponential function with ahalf-time of about 3 days. Mean grain counts increased asymptotically towarda limit reached in 4 or 5 days. The monocyte turnover rate in the rat is in theneighbourhood of 3.6 x 10⁶ cells per day.

It is concluded that monocytes leave the circulation at random and not as aconsequence of senescence. It is probable that they are the product of a celllineage consisting of about 3 generations from the primitive precursor to themature form, and that the average generation time is about 24 hours. Becauseof the rapid appearance of large numbers of labeled cells, it is unlikely thatthey are derived from lymphocytes which acquire label much more slowly.

Submitted on October 27, 1965 Accepted on January 31, 1966     

Colorectal carcinoma: A decade of experience at the Lahey Clinic

Summary Carcinoma of the colon and rectum is the commonest visceral malignancy in this country today. Uncorrected fiver-year survival rates (1967–1971) for Dukes' A, B, and C lesions were 81 per cent, 62 per cent, and 33 per cent respectively, and are essentially the same as those observed in the previous five-year period (1962–1966). The actuarially corrected five-year survival rates for Dukes' A, B, and C lesions for the ten-year period (1962–1971) were 95 per cent 90 per cent, and 55 per cent. Further improvement in these statistics depends on bringing the patient to operation with less advanced disease and possibly on supplementing resection with other modalities of therapy.     

Treatment of Hereditary Spherocytosis in Peromyscus by Radiation and Allogeneic Bone Marrow Transplantation

An inherited disease of the bone marrow identical in its pathophysiologyto human hereditary spherocytosis has been described in the deer mouse,Peromyscus maniculatus. As Peromyscus are not inbred and of distinct individually-specific histocompatibility, they provide an experimental model system for the use of hemopoietic allotransplantation in the treatment of hereditary diseases of the erythron. Ninety adult mice were exposed to otherwise 100per cent lethal doses of x-rays and then inoculated intravenously with 20 to60 million nucleated marrow cells. Marrow was transplanted on a one-to-onedonor recipient basis in four combinations of phenotypes: normal to normal;spherocytic to normal; spherocytic to spherocytic; and normal to spherocytic.Mortality and pathology were similar in all groups. Thirty per cent of the hostsdied as a direct result of the irradiation within 20 days. Another 30 per centsubsequently succumbed to secondary disease presumably of graft-against-hostorigin, bringing the overall mortality to 60 per cent at the end of 10 weeks. At3 months, however, the hematologic status of the survivors, nearly withoutexception, was of donor phenotype: Genetically spherocytic recipients of normalmarrow contained normal red cells; conversely, wild type recipients of spherocytic marrow had assumed the mutant phenotype. Evidence of chronic grafthost interaction was obtained. By 7 months, six mice in the spherocyticto normal transplant group had reassumed the host hematologic phenotype, but only one animal in the normal to spherocytic group reverted to themutant phenotype.

Submitted on May 24, 1966 Accepted on July 18, 1966     

Reutilization of DNA Breakdown Products from Lymphocytes in Lumen of Intestine

Migration of a very large number of lymphocytes (211.8 x 10⁶ per day)into the intestinal canal of rats, which weighed about 100 Gm., was found.Lymphocytes in the lumen of the intestine were 80.2 per cent small, 15.9 percent medium and 3.9 per cent large. Any recycling of instilling cells intothe intestine could not be observed. Lymphocytes labeled with H³-thymidine,obtained from both thymus and mesenteric lymph nodes of donor rats, werewashed and injected into the intestine of recipient rats. H³ activity of the bloodand thoracic duct lymph plasma after administration of labeled lymphocytesshowed that DNA breakdown products from the lymphocytes in the gut wereabsorbed and transferred by way of both the portal vein and the thoracic duct.Evidence that the activity was actually incorporated into the DNA of proliferating cells of the recipient was demonstrated by autoradiographic means.

Submitted on July 15, 1965 Accepted on October 8, 1966     

Surgical treatment of pulmonary tuberculosis in Greenland

Surgical treatment of pulmonary tuberculosis in Greenland. Follow-up of 1, 143 patients operated on for pulmonary tuberculosis at Queen Ingrid's Hospital, Godthåb, during the years 1954–1966. In particular the main group consisting of 785 resected patients is reviewed. Overall operative mortality was 1.0 per cent. At follow-up 2–12 years after surgery 104 (9 per cent) had died, and 1, 039 were in good health. Of the survivors 78 per cent were fully and 12 per cent partially fit for work while 1 per cent were unfit. Of the 1, 039 survivors 95 per cent were back at work within one year after surgery; 90 per cent had resumed their old occupation while only 6 per cent had changed occupation because of the tuberculosis. There was a close relationship between impaired work capacity and the nature and extent of the operation. By Greenland standards housing conditions of the survivors were satisfactory for 80, unsatisfactory for 5 and poor for 14 per cent.     

Eight hundred and seventy-five cases of bacterial meningitis. Part I of a three-part series: clinical data, prognosis, and the role of specialised hospital departments

Between 1966 and 1976, 875 patients with bacterial meningitis were treated at the Department of Infectious Diseases, Rigshospitalet. Among 495 patients admitted directly to the department, fatality rates were 0.4 per cent for meningococcal infections (including septicaemia), 3.7 per cent for haemophilus meningitis and 8.7 per cent for pneumococcal meningitis. The total fatality rate for directly admitted patients was 3.8 per cent, and 4.0 per cent had sequelae on discharge. Patients transferred from other hospitals often had complications, and their fatality rate (20.1 per cent) was markedly higher than that for directly admitted patients, but not significantly higher than that for patients treated elsewhere in Denmark (17.6 per cent). The low fatality at a specialised unit may reflect an open and swift admission procedure and the preparedness of staff familiar with the management of meningitis. During the first five years after discharge, the relative death risk was increased among meningitis patients but later declined to that found in the general population.     

Effects of in Vivo Hyperoxia on Erythrocytes: V. Changes of RBC Glycolytic Intermediates in Mice after in Vivo Oxygen under High Pressure

During prehemolytic exposure of mice to 100 per cent oxygen, changes inglycolytic intermediates were observed. Red cell ATP and hexosemonophosphate compounds were increased and fructose 1-6 diphosphate, triose-phosphates, ADP and TPN were decreased. These changes were not affected bysplenectomy or tocopherol status of the animals.

Submitted on April 4, 1966 Accepted on August 6, 1966     

Leiomyosarcoma of the rectum

Summary A case of leiomyosarcoma of the rectum is described. Medical literature was reviewed and 96 cases were encountered. Increased constipation, localized rectal pain and rectal bleding are the most constant symptoms. The tumor was discovered by digital examination in 84 per cent of the cases. Local excision was followed by a recurrence rate of 86 per cent. On the basis of this experience, we believe that leiomyosarcoma of the rectum is best treated by radical surgical removal. Read at the meeting of the Pennsylvania Society of Colon and Rectal Surgery, Philadelphia, Pennsylvania, September 11, 1966. Resident in Proctologic Surgery.     

Diagnosis of “asbestosis”: Observations from a longitudinal survey of shipyard pipe coverers

In 1972, to study slight manifestations of pulmonary fibrosis due to asbestos, we evaluated 101 shipyard pipe coverers and 95 control subjects whom we had examined in 1965 and in 1966. Although these workers had been exposed to low levels of asbestos, “asbestosis” was diagnosed in the first survey 11 times more often among pipe coverers than among control subjects. In 1972, clinical, roentgenologic and physiologic tests for monitoring workers were evaluated with respect to (1) ability to separate pipe coverers from control subjects, (2) consistency from the initial to the final survey, (3) predictive value in 1966 with respect to health in 1972 and (4) relationship to duration of exposure. Basilar rales, irregular opacities on chest film, and reduced vital and diffusing capacity were more common in pipe coverers in both surveys. These findings tended to be abnormal in 1972 in those workers in whom they were present in 1966, whereas dyspnea and clubbing were inconsistently found. The predictive value of a single abnormality was minimal, whereas the prognosis was poor in the nine pipe coverers who had three or more of these criteria in 1966. “Asbestosis” was considered present when three or more of the following were present: (1) bibasilar fine rales, (2) irregular x-ray opacifications (International Labour Organization, University of Cincinnati Classification [ILO/UC] 2/1 or more), (3) forced vital capacity (FVC) less than 80 per cent predicted, (4) single breath diffusing capacity (Dsb) less than 80 per cent predicted. There was only one false positive, a worker with significant heart disease. Clusters of findings appear more important for monitoring exposed workers than single findings. An incidence of 1.1 per cent/year of asbestosis, despite an 80 per cent reduction in the total quantity of asbestos used, emphasizes the importance of environment control.     

Comparative Response of Normal Human Thymus and Lymph Node Cells to Phytohemagglutinin in Culture

Human thymocytes, in short-term tissue culture, show a proliferative activity distinct from that observed by either lymph node or blood lymphocytes.As expected, the behavior of lymph node lymphocytes in culture is very similar to that of peripheral blood lymphocytes. The only difference betweenthese 2 groups of cells was the finding of spontaneous proliferation by normal lymph node cells after 3 days in culture without phytohemagglutinin(PHA).

Whereas blood and lymph node lymphocytes show a negligible uptake ofH3T in the basal state, approximately 10 per cent of thymus cells incorporateH3T, indicating significant autonomous proliferation. This is unaffected byPHA and is unassociated with globulin synthesis as judged by immunofluorescent technics. After 3 days in culture, there are significantly more transformed cells and more cells which incorporate H3T into DNA in thymus cellcultures containing PHA than in the control cultures. However, the labelingindex of stimulated thymus cultures is less than either the basal rate of proliferation of thymocytes or 3-day cultures of PHA stimulated blood and lymphnode lymphocytes. These observations suggest that the normal human thymuscontains at least two populations of lymphoid cells: a major component whichshows autonomous and unsustained proliferative activity and does not respondto PHA, and a second and probably minor cellular component which transforms and proliferates in response to PHA.

Submitted on August 25, 1966 Accepted on October 24, 1966     

Surgical results in 657 patients with colorectal cancer

Six hundred fifty-seven patients with colorectal cancer who were operated upon at the Second Department of Surgery, Helsinki University Central Hospital during the period 1966 to 1975 had a 40.5 per cent crude five-year survival rate and 54.2 per cent relative (corrected) rate. The survival rates of patients with Dukes' A lesions were 80.7 per cent, Dukes' B, 61.6 per cent, Dukes' C, 40.4 per cent, and Dukes' D, 2.7 per cent. One hundred two patients (15.5 per cent) underwent emergency operations; 91 were occlusive cancers, eight were perforations and three were cancer bleedings. The operative mortality for the whole series was 6.5 per cent (4.7 per cent in elective and 16.7 per cent in emergency operations). A definite improvement of the five-year survival rates could be seen in both the colonic and rectal cancer series. This was due to earlier detection of the disease, reflecting a decreasing number of palliative operations. Patients at high risk for colorectal cancer (inflammatory bowel disease, inherited intestinal polyposis, cancer family syndrome, multiple colorectal cancers, and neoplastic polyps) might benefit from more effective cancer surveillance and prophylactic surgery to find and treat cancers in earlier stages, to prevent recurrences, and to facilitate follow-up. The controversial findings on postoperative adjuvant therapy presented in this study indicate the need for further controlled studies to define the patients who really benefit from it.     

Alcoholism Treatment in Trinidad

Of a total patient population of 152 in Trinidad treated in 1965 through a program of build up, emetine, education and group therapy, 115 were followed up approximately one year following treatment. Thirty-three per cent were discovered to be abstinent or very largely sober, and 52 per cent were drinking. A further study was undertaken to ascertain how many of the abstinent and sober remained so at the end of seven years, and in 1973, of the 45 located,49 per cent remained abstinent entirely, or were largely sober, 35per cent were drinking, and 11 per cent were dead through alcohol related problems. The remainder could not be traced. No evidence supports the proposition that membership in A.A. is the best insurance for ultimate sobriety. Nor is treatment by any one particular means–either emetine alone, or emetine plus active A.A. membership subsequently–insurance for successful outcome. This study also fails to substantiate certain studies that suggest that the best predictor of subsequent sobriety and successful achievement in life is abstinence after either six months or one year. In the Trinidad sample almost 50 per cent had returned to alcohol, at least half of them relapsing early after the 1966 follow-up.     

The influence of cell type and lymph node metastases on survival of patients with carcinoma of the lung undergoing thoracotomy.

We studied 202 cases of bronchogenic carcinoma treated surgically between January 1, 1966 and December 31, 1970. Over all, adenocarcinoma was the most common cell type (36.1 per cent). Of 151 patients whose carcinomas were successfully resected, and who lived for at least 30 days postoperatively, 88 had lymph nodes free of cancer. Not surprisingly, 5-year survival was related to lymph node metatases and cell type. The best over-all 5-year survival rate was for large cell carcinoma; it was 52.0 per cent without nodal involvement. Similar figures for epidermoid carcinoma were 29.0 per cent over all, and 26.3 per cent without lymph node involvement; for adenocarcinoma, 19.3 per cent over all, and 32.0 per cent without nodal involvement. For the entire group of 151 patients, the 5-year survival rate was 27.8 per cent over all, and 36.4 per cent without nodal metastases. Among resected patients with mediastinal lymph nodes positive for cancer, the 5-year survival rates were 1 of 10 patients with large cell carcinoma, 1 of 19 patients with adenocarcinoma, and 3 of 12 patients with epidermoid carcinoma. This suggests that in patients with epidermoid carcinoma, the presence of mediastinal lymph node metastases is not, in itself, an absolute contraindication to resectional therapy.     

The changing face of Hodgkin's disease.

The changing outlook for patients with Hodgkin's disease has been documented in 346 patients seen in a general hospital during the period 1966 through 1977. Disease-free survival after salvage therapy, actuarially calculated, has proved to be a useful statistical approach to a disease in which patients who have a relapse can be cured by a second mode of treatment. The most recent figures indicate that at five years 87 per cent survive, 85 per cent are free of disease after salvage treatment, and 69 per cent are free of disease since initial therapy.For those without symptoms, 95 per cent survive seven years, 92 per cent are disease-free after salvage at that time, and 75 per cent are disease-free from first treatment. Extension below the diaphragm is a rare event in the asymptomatic patient with a negative staging laparotomy, and combination chemotherapy has proved effective both as salvage treatment after recurrence and as primary therapy (together with adjuvant radiation) for those with disease above and below the diaphragm. The failure of radiation to control mediastinal lymphoma is the major problem remaining in patients without symptoms.The treatment of symptomatic subjects, particularly those with disease above and below the diaphragm, is less satisfactory, and most of the mortality in Hodgkin's disease in the five years after diagnosis occurs in these patients. Many are not cured by the MOPP combination and it is unclear whether other drug combinations will provide a satisfactory alternative. However, the risks of treatment-induced leukemias, second solid neoplasms and fulminant sepsis require caution in the indiscriminant use of combined treatment with drugs and irradiation.