- Email: [email protected]
NEONATAL STAPHYLOCOCCAL INFECTION
1042 On Feb. 28, 1961, three months after subtotal gastrectomy, the patient was readmitted to hospital with haematemesis and melxna. This time the attacks of abdominal pain were even more severe than before, and on account of a supposed jejunal ulcer or perforation a second operation had to be performed on March 11. In the periduodenal region, enlarged lymph-nodes, as well as a large inflammatory mass, were found in the region of the retrocolic gastrojejunal anastomosis. A cavity in the mass communicated with a perforated jejunal ulcer. A second gastric resection was performed, but 16 hours after the operation, despite vigorous treatment with blood, electrolytes, and antibiotics, the patient died. Necropsy revealed an active ulcer in the sutured end of the duodenum and in the resected jejunum. In the mesentery, around the pancreas there were several enlarged lymphnodes. The body of the pancreas contained a well-circumscribed tumour. Microscopic sections of this pancreatic tumour confirmed its islet-cell origin. There was evidence of tumour metastases-just as at the first operation-in the
peripancreatic lymph-nodes. Postgraduate School of Medicine, Budapest, Hungary.
D. LEHOCZKY.
PNEUMOCYSTIS CARINII PNEUMONIA ASSOCIATED WITH HYPOGAMMAGLOBULINÆMIA RESPONDING TO PENTAMIDINE
SIR,-The first
recovery from Pneumocystis carinii associated with hypogammaglobulinsemia as a pneumonia result of treatment with pentamidine has just been reported by Marshall et al. We describe here a second case. Unfortunately, the condition cannot be diagnosed with certainty in life without lung biopsy. In our patient the diagnosis was based on clinical and radiological findings that seemed to us to accord closely with those described in patients in whom the diagnosis had been confirmed post mortem.23 We were fortunate to hear of Dr. Marshall’s experience and to have his advice. The patient, a boy, was born on June 19, 1963, of healthy
parents. He has two sisters and a brother, whose y-globulin is normal, and there have been no early deaths in male children. He had developed normally until six weeks before he was admitted to hospital on Dec. 13, 1963, weighing 14 lb. 12 oz. (6-7 kg.) with a persistent " cold "-i.e., he was slightly catarrhal and had a dry cough, but his condition gave no cause for alarm. A week before admission his respiratory rate had increased; his rectal temperature was between 99° and 100°F, feeding distressed him, he had an infrequent cough, and there was a tinge of cyanosis. The child was admitted to hospital as a case of early pneumonia that had failed to respond Over the next five days the to oxytetracycline at home. cyanosis increased, and the child had a tachypnoea of 100 and more to the minute, with slight intercostal recession, a cough, a temperature seldom above 100°F, and an increasing need for oxygen. The only abnormal signs in the lungs were fine crepitations at both bases and extending into the axilloc. These varied from day to day. The chest X-ray showed widespread, confluent, fluffy opacities in striking contrast to the paucity of physical signs in the lungs. The heart was normal in size, and there was no clinical or electrocardiographic evidence of a
congenital cardiac lesion. Investigations.-The white-blood-cell count was 22,400 per c.mm. with neutrophils 5%, eosinophils 2%, and lymphocytes 93%. Later counts varied from 13,000 to 23,000 with a differential averaging 25% neutrophils and 75% lymphocytes. Trypsin was present in the stool to a dilution of 1 /320, and the fingerprint sweat test was normal. A throat swab grew enterococci and Streptococcus viridans; repeated gastric aspiration revealed no tubercle bacilli and subsequent cultures were sterile. The Mantoux was negative at 111000. 1. Marshall, W. C., Weston, H. J., Bodian, M. Arch. Dis. Childh. 1964, 39, 18. 2. Bird, T., Thomson, J. Lancet, 1957, i, 59. 3. McKay, E., Richardson, J. ibid. 1959, ii, 713.
subsequent course.-There was no response to penicillin, streptomycin, isoniazid, erythromycin, cloxacillin, or fusidic acid, which were tried at various times. The cyanosis became continuous, and respiratory distress so severe as to necessitate tube feeding. At this stage, one of us (T. S. R.) suggested the diagnosis of hypogammaglobulinxmia and pneumocystis infection. The zinc-sulphate turbidity was low at 1’5 units, and electrophoresis showed absence of y-globulin, Treatment and
Even after the administration of 1750 mg. of y-globulin over three days the serum level was only 100 mg. per 100 ml.-a level acceptable for inclusion in the Medical Research Council trial series.4 The patient received 170 mg. y-globulin weekly (0-025 g. per kg. body-weight), and antibiotics were con. tinued; but for the next month he remained deeply cyanosed except when asleep in the oxygen tent, the slightest moveThe temperature was seldom ment precipitating cyanosis. above 100°F, the respiratory rate reached 80 to 110 to the minute, and the boy’s fingers and toes gradually became clubbed. The anoxic capillary dilatation was so gross that the pulse could be recorded by simply feeling the tip of the child’s
finger or toe.
-
At this stage, twelve weeks after the onset of the prodromal symptoms, and six weeks after admission to hospital, treatment with pentamidine isethionate, as recommended by Marshall et al./ was begun. The boy was given 28 mg. a day by intramuscular injection for ten days (4 mg. per kg.). At first there was no change, but a week after the end of treatment his condition began to improve, and after two weeks the crepitations had disappeared, and he was able to come out of the tent all day without cyanosis. Three weeks after treatment had been stopped, the chest X-ray showed improvement, and by the fifth week the child was clinically cured and ready for home. Kent and Canterbury Hospital, T. S. RODGERS. Canterbury. Victoria Royal Hospital, M. H. K. HAGGIE. Folkestone.
NEONATAL STAPHYLOCOCCAL INFECTION
SiRjŃThompson et al. 5and Williamshave reported that neonatal staphylococcal disease is more frequent in males than in females. This increased frequency is more pronounced in skin disease. Thompson et al. and Gezon et al. have hinted that this may be related to circumcision, which was undertaken in 95% of the male infants in their series. Surveys in Geelong of staphylococcal infection in the newborn have already been reported. 9 10 Now a review of staphylococcal disease in the 14,717 infants born between July, 1957, and June, 1963, has shown the following:
The sex difference is of particular interest as a total prohibition of infant circumcision was instituted in this hospital in October, 1956, owing to the then alarmingly high incidence of staphylococcal disease in the newborn. This ban was not lifted until August, 1963. Consequently, between July, 1957, and June, 1963, no circumcision was performed in this hospital on males less than 2 weeks of age, and less than 1% of males were circumcised before 6 weeks of age. Further analysis of staphylococcal disease in these 14,717 infants showed that the incidence of staphylococcal disease was consistently higher in males, irrespective of their age:
Unlike Thompson 4. 5. 6.
7. 8. 9. 10.
et al. we have found no sex difference in Soothill, J. F. Proc. R. Soc. Med. 1962, 55, 395. Thompson, D. J., Gezon, H. M., Hatch, T. F., Rycheck, R. R., Rogers, K. D. New Engl. J. Med. 1963, 269, 337. Thompson, D. J., Gezon, H. M., Hatch, T. F., Rycheck, R. R., Rogers; K. D. J. Pediat. 1963, 63, 869. Williams, R. E. O. Lancet, Feb 1, 1964, p. 274. Gezon, H. M., Thompson, D. J., Rogers, K. D., Hatch, T. F., Taylor, P. M. New Engl. J. Med. 1964, 270, 379. Plueckhahn, V. D. Brit. med. J. 1961, ii, 779. Plueckhahn, V. D., Banks, J. Med. J. Aust. 1963, ii, 519.
1043 the rate of nasal or umbilical colonisation in infants up to 6 weeks of age. The frequency (%) of nasal and umbilical colonisation in male and female infants up to 6 weeks of age was as follows:
misleading. A normal small kidney and a larger normal kidney will give different absolute count-rates; but the rate of accumulation of activity in the two organs will be normal, and this is what distinguishes normality from abnormality.14 can
be
Montreal General Hospital, Montreal 25, Quebec, Canada.
We consider that Thompson et a1.5 have opened up a surprising and extremely exciting aspect for investigation into the epidemiology of staphylococcal disease in the newborn. Department of Pathology, Geelong and District Hospital,
Geelong, Victoria, Australia.
V. D. PLUECKHAHN JOAN BANKS.
TELEVISION AND MEDICINE
SIR,-In his report on the recent meeting of the Television Viewers’ Association, your Correspondent (May 2) makes some curious observations on an excerpt from a programme on the structure of the liver. The sentence " Viewers south of the border, or even in the east of Scotland, would appreciate at least the suggestion that the subject was not finally closed, and the possibility of error " (my italics) reveals the kind of prejudice which we treat indulgently when it is displayed by the supporters of professional football teams, but it makes strange reading in The Lancet. I imagined that these extravagances would be the preface to a catalogue of serious blunders committed by my colleague on this S.T.V. programme. In fact the only indictment your Corre" spondent can muster is this: The speaker’s facts appeared to be wrong, or at any rate disputable, in one small respect " (my italics). Readers may well feel that this sentence is a notable achievement in terms of anticlimax.
I hope, Sir, that you will allow me to extend to your anonymous Correspondent a cordial invitation to come to Glasgow. It would be a pleasure to offer the hospitality of my department to enable him to give a lecture on the structure of the liver. Alternatively he might prefer to address us on the art of teaching through the medium of television. The outcome of these academic exercises might well merit a further report in the colums of The Lancet. Department of Materia Medica and Therapeutics,
University of Glasgow.
STANLEY ALSTEAD.
RADIOISOTOPE LOCALISATION FOR RENAL BIOPSY SIR,-With reference to the article by Dr. Telfer and
others (Jan. 18) we would make the following comments: If they are using a detector to pick up the maximum concentration, then they must by necessity be near the centre of the kidney. There is a danger in using this area because of the
proximity to the hilum and its vessels. We have had no difficulty with X-ray localisation in the prone position using a metal grid placed on the back plus a firm non-radiopaque support (’Collo’ block) under the abdomen.ll At present we are using radioisotope scanning, and we should like to correct some misconceptions regarding their hazard. The dose to the patient is not 50 rads per 100 uC radioneohydrin-2o3lig but 5 rads, according to Greenlaw and Quaife.l2 McAfee and Wagner 13 claim about 13 rads per 100 fLC 203Hg. If there is concern about radiation to the patient then the newer isotope, radioneohydrin, tagged with "’Hg may be used. The dose to each kidney is approximately 1 rad per 100 C. Telfer et al. also state that by determining the maximal count-rate over each kidney after injection the functional-capacity will be obtained. This is partiallv true but 11 12. 13.
Kaye, M. Canad. med. Ass. J. 1956, 75, 480. Greenlaw, R. H., Quaife, M. Radiology, 1962, 78, 970. McAfee, J. C. in Proceedings of a Symposium at the Medical Division of the Oakridge Institute of Nuclear Studies, October 22-26, 1962.
G. A. POSEN M. KAYE L. ROSENTHAL.
ACID-BASE ANALYSIS
SIR,-There is
now considerable evidence that the choice of blood for acid-base studies may under many circumstances be venous rather than arterial-a fact pointed out by Dr. Searcy and his colleagues 15 and Dr. Gambino (March 28). Our data 16 further support this
hypothesis. Our study was undertaken to compare pH and Pco2 values of simultaneously drawn venous and arterial samples in a series of 200 patients during general anxsthesia. The patients were unselected females undergoing pelvic or perineal surgery during one or a combination of different inhalational anaathetics (cyclopropane, ether, nitrous-oxide/halothane, fluothane and
ether, nitrous-oxide/trichlorethylene, ornitrous-oxide/methoxyfluorane). Muscle relaxant drugs, generally either carbolonium (’ Imbretil’) or a succinylcholine infusion, were employed as needed for abdominal relaxation. Respirations were spontaneous in 57 patients, manually assisted in 24, and controlled by mechanical ventilator in the remaining 119. After establishing a steady state of general anxsthesia, a Riley needle inserted into either the brachial or radial artery of one arm, and an 18-gauge needle into the median cubital, cephalic, or basilic vein of the other arm. Simultaneous arterial and venous samples were drawn into heparinised syringes at a time that varied from 10 to 190 minutes after the commencement of anxsthesia, and under conditions of hypoventilation, hyperventilation, or normal ventilation. pH was determined by a Beckman model G pH meter, and blood-gas analysis was performed by the manometric technique of Van Slyke for oxygen and carbon-dioxide content, applying the Henderson-Hasselbalch equation and the nomogram of Singer and Hastings to calculate Pco,. In 211 determinations on these 200 patients, the arterial pH ranged from 7-16 to 7-64 with an arithmetic mean of 7-37 (s.D.0-11), the venous pH ranged from 7.15 to 7-63, with a mean of 7-36 (s.D.0’11); and the coefficient of correlation between the arterial and venous pH was 0-985. The arterial PC02 ranged from 17-3 to 78-9 mm. Hg, the arithmetic mean being 40-09 (s.D.j: 13-85); the venous Pc02 ranged from 17-7 to 78-2- mm. Hg, the mean being 42-20 (s.D._L 13-55); and the coefficient of correlation between the arterial and venous Pco2 was 0-978. It is worth noting that, in 67 of the paired samples, there was no difference in the observed arterial and venous pH value; in 68, the arterial-venous difference was 0-01 pH units; and in 47, the arterial-venous difference was 0-02 pH units. Thus in 182 of 211 paired samples, or 86-2%, the difference between the arterial pH and venous pH values was either nil or within the experimental error of the laboratory method (i.e., 0-02 unit). Similarly, in 9 paired samples, there was no difference in the observed arterial and venous Pc02 values; in 52, the arterialvenous Pco2 difference was between 0 and 1 mm. Hg; in 54, the arterial-venous PC02 difference was between 1 and 2 mm. Hg; in 46, the arterial-venous Pco2 difference was between 2 and 3 mm. Hg; and in 24, the arterial-venous PC02 difference was between 3 and 4 mm. Hg. Thus, in 185 of the 211 paired samples, or 87-7%, the difference between the arterial PC02 and the venous Pc02 values was either nil or within the experimental error of the laboratory method (i.e., 4 mm. Hg). There was, however, one disturbing feature of this study from the viewpoint of employing venous blood samples to monitor ventilation during anxsthesia. There were several instances was
14. McAfee, J. C., Wagner, H. N., Jr. Radiology, 1960, 75, 820. Searcy, R. L., Gordon, G. F., Simms, N. M. Lancet, 1963, ii, 1232. Little, D. M., Jr., Given, J. B., Walker, H. A. Anesthesiology, 1963, 24, 134.
15. 16.
peripancreatic lymph-nodes. Postgraduate School of Medicine, Budapest, Hungary.
D. LEHOCZKY.
PNEUMOCYSTIS CARINII PNEUMONIA ASSOCIATED WITH HYPOGAMMAGLOBULINÆMIA RESPONDING TO PENTAMIDINE
SIR,-The first
recovery from Pneumocystis carinii associated with hypogammaglobulinsemia as a pneumonia result of treatment with pentamidine has just been reported by Marshall et al. We describe here a second case. Unfortunately, the condition cannot be diagnosed with certainty in life without lung biopsy. In our patient the diagnosis was based on clinical and radiological findings that seemed to us to accord closely with those described in patients in whom the diagnosis had been confirmed post mortem.23 We were fortunate to hear of Dr. Marshall’s experience and to have his advice. The patient, a boy, was born on June 19, 1963, of healthy
parents. He has two sisters and a brother, whose y-globulin is normal, and there have been no early deaths in male children. He had developed normally until six weeks before he was admitted to hospital on Dec. 13, 1963, weighing 14 lb. 12 oz. (6-7 kg.) with a persistent " cold "-i.e., he was slightly catarrhal and had a dry cough, but his condition gave no cause for alarm. A week before admission his respiratory rate had increased; his rectal temperature was between 99° and 100°F, feeding distressed him, he had an infrequent cough, and there was a tinge of cyanosis. The child was admitted to hospital as a case of early pneumonia that had failed to respond Over the next five days the to oxytetracycline at home. cyanosis increased, and the child had a tachypnoea of 100 and more to the minute, with slight intercostal recession, a cough, a temperature seldom above 100°F, and an increasing need for oxygen. The only abnormal signs in the lungs were fine crepitations at both bases and extending into the axilloc. These varied from day to day. The chest X-ray showed widespread, confluent, fluffy opacities in striking contrast to the paucity of physical signs in the lungs. The heart was normal in size, and there was no clinical or electrocardiographic evidence of a
congenital cardiac lesion. Investigations.-The white-blood-cell count was 22,400 per c.mm. with neutrophils 5%, eosinophils 2%, and lymphocytes 93%. Later counts varied from 13,000 to 23,000 with a differential averaging 25% neutrophils and 75% lymphocytes. Trypsin was present in the stool to a dilution of 1 /320, and the fingerprint sweat test was normal. A throat swab grew enterococci and Streptococcus viridans; repeated gastric aspiration revealed no tubercle bacilli and subsequent cultures were sterile. The Mantoux was negative at 111000. 1. Marshall, W. C., Weston, H. J., Bodian, M. Arch. Dis. Childh. 1964, 39, 18. 2. Bird, T., Thomson, J. Lancet, 1957, i, 59. 3. McKay, E., Richardson, J. ibid. 1959, ii, 713.
subsequent course.-There was no response to penicillin, streptomycin, isoniazid, erythromycin, cloxacillin, or fusidic acid, which were tried at various times. The cyanosis became continuous, and respiratory distress so severe as to necessitate tube feeding. At this stage, one of us (T. S. R.) suggested the diagnosis of hypogammaglobulinxmia and pneumocystis infection. The zinc-sulphate turbidity was low at 1’5 units, and electrophoresis showed absence of y-globulin, Treatment and
Even after the administration of 1750 mg. of y-globulin over three days the serum level was only 100 mg. per 100 ml.-a level acceptable for inclusion in the Medical Research Council trial series.4 The patient received 170 mg. y-globulin weekly (0-025 g. per kg. body-weight), and antibiotics were con. tinued; but for the next month he remained deeply cyanosed except when asleep in the oxygen tent, the slightest moveThe temperature was seldom ment precipitating cyanosis. above 100°F, the respiratory rate reached 80 to 110 to the minute, and the boy’s fingers and toes gradually became clubbed. The anoxic capillary dilatation was so gross that the pulse could be recorded by simply feeling the tip of the child’s
finger or toe.
-
At this stage, twelve weeks after the onset of the prodromal symptoms, and six weeks after admission to hospital, treatment with pentamidine isethionate, as recommended by Marshall et al./ was begun. The boy was given 28 mg. a day by intramuscular injection for ten days (4 mg. per kg.). At first there was no change, but a week after the end of treatment his condition began to improve, and after two weeks the crepitations had disappeared, and he was able to come out of the tent all day without cyanosis. Three weeks after treatment had been stopped, the chest X-ray showed improvement, and by the fifth week the child was clinically cured and ready for home. Kent and Canterbury Hospital, T. S. RODGERS. Canterbury. Victoria Royal Hospital, M. H. K. HAGGIE. Folkestone.
NEONATAL STAPHYLOCOCCAL INFECTION
SiRjŃThompson et al. 5and Williamshave reported that neonatal staphylococcal disease is more frequent in males than in females. This increased frequency is more pronounced in skin disease. Thompson et al. and Gezon et al. have hinted that this may be related to circumcision, which was undertaken in 95% of the male infants in their series. Surveys in Geelong of staphylococcal infection in the newborn have already been reported. 9 10 Now a review of staphylococcal disease in the 14,717 infants born between July, 1957, and June, 1963, has shown the following:
The sex difference is of particular interest as a total prohibition of infant circumcision was instituted in this hospital in October, 1956, owing to the then alarmingly high incidence of staphylococcal disease in the newborn. This ban was not lifted until August, 1963. Consequently, between July, 1957, and June, 1963, no circumcision was performed in this hospital on males less than 2 weeks of age, and less than 1% of males were circumcised before 6 weeks of age. Further analysis of staphylococcal disease in these 14,717 infants showed that the incidence of staphylococcal disease was consistently higher in males, irrespective of their age:
Unlike Thompson 4. 5. 6.
7. 8. 9. 10.
et al. we have found no sex difference in Soothill, J. F. Proc. R. Soc. Med. 1962, 55, 395. Thompson, D. J., Gezon, H. M., Hatch, T. F., Rycheck, R. R., Rogers, K. D. New Engl. J. Med. 1963, 269, 337. Thompson, D. J., Gezon, H. M., Hatch, T. F., Rycheck, R. R., Rogers; K. D. J. Pediat. 1963, 63, 869. Williams, R. E. O. Lancet, Feb 1, 1964, p. 274. Gezon, H. M., Thompson, D. J., Rogers, K. D., Hatch, T. F., Taylor, P. M. New Engl. J. Med. 1964, 270, 379. Plueckhahn, V. D. Brit. med. J. 1961, ii, 779. Plueckhahn, V. D., Banks, J. Med. J. Aust. 1963, ii, 519.
1043 the rate of nasal or umbilical colonisation in infants up to 6 weeks of age. The frequency (%) of nasal and umbilical colonisation in male and female infants up to 6 weeks of age was as follows:
misleading. A normal small kidney and a larger normal kidney will give different absolute count-rates; but the rate of accumulation of activity in the two organs will be normal, and this is what distinguishes normality from abnormality.14 can
be
Montreal General Hospital, Montreal 25, Quebec, Canada.
We consider that Thompson et a1.5 have opened up a surprising and extremely exciting aspect for investigation into the epidemiology of staphylococcal disease in the newborn. Department of Pathology, Geelong and District Hospital,
Geelong, Victoria, Australia.
V. D. PLUECKHAHN JOAN BANKS.
TELEVISION AND MEDICINE
SIR,-In his report on the recent meeting of the Television Viewers’ Association, your Correspondent (May 2) makes some curious observations on an excerpt from a programme on the structure of the liver. The sentence " Viewers south of the border, or even in the east of Scotland, would appreciate at least the suggestion that the subject was not finally closed, and the possibility of error " (my italics) reveals the kind of prejudice which we treat indulgently when it is displayed by the supporters of professional football teams, but it makes strange reading in The Lancet. I imagined that these extravagances would be the preface to a catalogue of serious blunders committed by my colleague on this S.T.V. programme. In fact the only indictment your Corre" spondent can muster is this: The speaker’s facts appeared to be wrong, or at any rate disputable, in one small respect " (my italics). Readers may well feel that this sentence is a notable achievement in terms of anticlimax.
I hope, Sir, that you will allow me to extend to your anonymous Correspondent a cordial invitation to come to Glasgow. It would be a pleasure to offer the hospitality of my department to enable him to give a lecture on the structure of the liver. Alternatively he might prefer to address us on the art of teaching through the medium of television. The outcome of these academic exercises might well merit a further report in the colums of The Lancet. Department of Materia Medica and Therapeutics,
University of Glasgow.
STANLEY ALSTEAD.
RADIOISOTOPE LOCALISATION FOR RENAL BIOPSY SIR,-With reference to the article by Dr. Telfer and
others (Jan. 18) we would make the following comments: If they are using a detector to pick up the maximum concentration, then they must by necessity be near the centre of the kidney. There is a danger in using this area because of the
proximity to the hilum and its vessels. We have had no difficulty with X-ray localisation in the prone position using a metal grid placed on the back plus a firm non-radiopaque support (’Collo’ block) under the abdomen.ll At present we are using radioisotope scanning, and we should like to correct some misconceptions regarding their hazard. The dose to the patient is not 50 rads per 100 uC radioneohydrin-2o3lig but 5 rads, according to Greenlaw and Quaife.l2 McAfee and Wagner 13 claim about 13 rads per 100 fLC 203Hg. If there is concern about radiation to the patient then the newer isotope, radioneohydrin, tagged with "’Hg may be used. The dose to each kidney is approximately 1 rad per 100 C. Telfer et al. also state that by determining the maximal count-rate over each kidney after injection the functional-capacity will be obtained. This is partiallv true but 11 12. 13.
Kaye, M. Canad. med. Ass. J. 1956, 75, 480. Greenlaw, R. H., Quaife, M. Radiology, 1962, 78, 970. McAfee, J. C. in Proceedings of a Symposium at the Medical Division of the Oakridge Institute of Nuclear Studies, October 22-26, 1962.
G. A. POSEN M. KAYE L. ROSENTHAL.
ACID-BASE ANALYSIS
SIR,-There is
now considerable evidence that the choice of blood for acid-base studies may under many circumstances be venous rather than arterial-a fact pointed out by Dr. Searcy and his colleagues 15 and Dr. Gambino (March 28). Our data 16 further support this
hypothesis. Our study was undertaken to compare pH and Pco2 values of simultaneously drawn venous and arterial samples in a series of 200 patients during general anxsthesia. The patients were unselected females undergoing pelvic or perineal surgery during one or a combination of different inhalational anaathetics (cyclopropane, ether, nitrous-oxide/halothane, fluothane and
ether, nitrous-oxide/trichlorethylene, ornitrous-oxide/methoxyfluorane). Muscle relaxant drugs, generally either carbolonium (’ Imbretil’) or a succinylcholine infusion, were employed as needed for abdominal relaxation. Respirations were spontaneous in 57 patients, manually assisted in 24, and controlled by mechanical ventilator in the remaining 119. After establishing a steady state of general anxsthesia, a Riley needle inserted into either the brachial or radial artery of one arm, and an 18-gauge needle into the median cubital, cephalic, or basilic vein of the other arm. Simultaneous arterial and venous samples were drawn into heparinised syringes at a time that varied from 10 to 190 minutes after the commencement of anxsthesia, and under conditions of hypoventilation, hyperventilation, or normal ventilation. pH was determined by a Beckman model G pH meter, and blood-gas analysis was performed by the manometric technique of Van Slyke for oxygen and carbon-dioxide content, applying the Henderson-Hasselbalch equation and the nomogram of Singer and Hastings to calculate Pco,. In 211 determinations on these 200 patients, the arterial pH ranged from 7-16 to 7-64 with an arithmetic mean of 7-37 (s.D.0-11), the venous pH ranged from 7.15 to 7-63, with a mean of 7-36 (s.D.0’11); and the coefficient of correlation between the arterial and venous pH was 0-985. The arterial PC02 ranged from 17-3 to 78-9 mm. Hg, the arithmetic mean being 40-09 (s.D.j: 13-85); the venous Pc02 ranged from 17-7 to 78-2- mm. Hg, the mean being 42-20 (s.D._L 13-55); and the coefficient of correlation between the arterial and venous Pco2 was 0-978. It is worth noting that, in 67 of the paired samples, there was no difference in the observed arterial and venous pH value; in 68, the arterial-venous difference was 0-01 pH units; and in 47, the arterial-venous difference was 0-02 pH units. Thus in 182 of 211 paired samples, or 86-2%, the difference between the arterial pH and venous pH values was either nil or within the experimental error of the laboratory method (i.e., 0-02 unit). Similarly, in 9 paired samples, there was no difference in the observed arterial and venous Pc02 values; in 52, the arterialvenous Pco2 difference was between 0 and 1 mm. Hg; in 54, the arterial-venous PC02 difference was between 1 and 2 mm. Hg; in 46, the arterial-venous Pco2 difference was between 2 and 3 mm. Hg; and in 24, the arterial-venous PC02 difference was between 3 and 4 mm. Hg. Thus, in 185 of the 211 paired samples, or 87-7%, the difference between the arterial PC02 and the venous Pc02 values was either nil or within the experimental error of the laboratory method (i.e., 4 mm. Hg). There was, however, one disturbing feature of this study from the viewpoint of employing venous blood samples to monitor ventilation during anxsthesia. There were several instances was
14. McAfee, J. C., Wagner, H. N., Jr. Radiology, 1960, 75, 820. Searcy, R. L., Gordon, G. F., Simms, N. M. Lancet, 1963, ii, 1232. Little, D. M., Jr., Given, J. B., Walker, H. A. Anesthesiology, 1963, 24, 134.
15. 16.