The Journal of the Philippine Medical Association

Media

Part of The Journal of the Philippine Medical Association

Title: The Journal of the Philippine Medical Association
Issue Date: Volume 52 (Issue Nos. 9-10) September-October 1976
Year: 1976
Language: English
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extracted text: Journal of the PHILIPPINE MEDICAL ASSOCIATION NURSES' AND PATIENTS' WEAR • OPERATING ROOM AND WARD LINEN ACCESSORIES eTABLE CLOTH Available in various colors and sizes. Special Fabric Specification for 180 thread count are available. The most complete line of high-quality hospital linen. See or call us at: GTI GARMENTS INTERNATIONAL CORP. (Linen Division) f Rodriguez Ave. Ext., Libis. Murphy. Quezon City • Telephone Numbers 79-67 96 • 78-79-11 to 23 • 79-89-55 • P O Box 2470, Manila Persantin® antithrombotic Availability: ampoule 10 mg/2 ml. 25 mg. tablets 75 mg. tablets prevents the formation of arterial thrombi packs of 25’s packs of packs of Boehringer Ingelheim (Phil.) Inc. Illlllll I P.O. Box 2159 MCC . BOEHRINGER J klNGHHEIM / w a Makati. Rizal Effectively improve zoronary blood flow in zoronary insufficiency igure 1 was taken before and Fig. 2 was taken alter the administration of 5 mg. ISORDIL sublingually, iignificantly, the artery is filled slightly more distally, and its diameter is incieased after administration of the drug Sewell, W.H.: The Medical and Surgical Management of Coronary Insufficiency, a motion picture, on file at Ayersrj Current investigations suggest that the symptoms of coronary insufficiency (angina pectoris in particular) result from inadequate oxygen supplies to the heart. The disparity between oxygen required and oxygen available can be resolved by improving :oronary artery flow and by reducing myocardial oxygen requirements. ISORDIL does both. ISORDIL dilates coronary arteries and collateral blood vessels, improving coronary alood flow, and markedly reduces venous return, resulting in decreased cardiac output and myocardial oxygen requirements. Presentation: - slo. 1100-Sublingual 5 mg., bottles of JOO tablets Jo. 1101-10 mg., bottles of 100 tablets to. 1102-Tembids * LA. 40 mg., bottles of iCO tablets •Trademark for Sustained Action Tablets ISORDIL isosorbide dinitrate effective in theory effective in feet, effective in clinical practice 17M * «CU$TCIt£O J A Trademark Dx: Bacterial bronchitis caused by susceptible strains of Streptococcus (Diplococcus) pneumoniae Ifc: Rest, fluids, decongestants, and an oral antibiotic consider Keflex cephalexin Monohydrate when oral antibiotic therapy is indicated Keflex, a member of the cephalosporin family, is available in three convenient oral forms. Four years of clinical use have established Keflex as a useful antibiotic. When considering oral antibiotic therapy for your next patient with bacterial bronchitis, * think of Keflex. *Caused by susceptible strains of Str. pneumoniae. Please see back for prescribing information. Keflex cephalexin monohydrate Description: Keflex is a semisynthetic cephalosporin antibiotic intended for oral administration. It is 7-(D-a-amino-a-phenylacetamido)-3-methyl-3-cephem-4carboxylic acid, monohydrate. Actions: Human Pharmacology-^^ is acid stable and may be given without regard to meals. It is rapidly absorbed after oral administration. Following doses of 250 and 500 mg., average peak serum levels of approximately 9 and 18 mcg. per ml. respectively were obtained at one hour. Measurable levels were present six hours after administration. Over 90 percent of the drug is excreted unchanged in the urine within eight hours. Peak urine concentrations are approxi mately 1,000 mcg. per ml. during this period following a 250-mg. dose. Microbiology— In-vitro tests demonstrate that the cephalosporins are bac tericidal because of their inhibition of cell-wall synthesis. Keflex is active against the following organisms in vitro: Beta-hemolytic streptococci Staphylococci, including coagulase-positive, coagulase-negative, and penicil linase-producing strains Diplococcus pneumoniae Escherichia coli Proteus mirabilis Klebsiella sp. Hemophilus influenzae Neisseria catarrhalis Note—Most strains of enterococci (Streptococcus faecal is) and a few strains of staphylococci are resistant to Keflex. It is not active against most strains of Enterobacter sp., Pr. morganii, and Pr. vulgaris. It has no activity against Pseudomonas or Herellea species. When tested by in-vitro methods, staphylococci exhibit cross-resista nee between Keflex and methicillin-type anti biotics. Indications: Keflex is indicated for the treatment of the following infections when caused by susceptible strains of the designated microorganisms: Respiratory tract infections caused by D. pneumoniae and group A betahemolytic streptococci (Penicillin is the usual drug of choice in the treatment and prevention of streptococcal infections, including the prophylaxis of rheu matic fever. Keflex is generally effective in the eradication of streptococci from the nasopharynx; however, substantial data establishing the efficacy of Keflex in the subsequent prevention of rheumatic fever are not available at present.) Otitis media due to D. pneumoniae, H. influenzae, staphylococci, strep tococci, and N. catarrhalis Skin and soft-tissue infections caused by staphylococci and/or streptococci Genitourinary tract infections, including acute prostatitis, caused by Esch, coli, Pr. mirabilis, and Klebsiella sp. /Vote—Culture and susceptibility tests should be initiated prior to and during therapy. Renal function studies should be performed when indicated. Contraindication: Keflex is contraindicated in patients with known allergy to the cephalosporin group of antibiotics. Warnings: before cephalexin therapy is instituted, careful inquiry should BE MADE CONCERNING PREVIOUS HYPERSENSITIVITY REACTIONS TO CEPHALOSPORINS AND PENICILLIN. CEPHALOSPORIN C DERIVATIVES SHOULD BE GIVEN CAUTIOUSLY TO PENICILLIN-SENSITIVE PATIENTS. SERIOUS ACUTE HYPERSENSITIVITY REACTIONS MAY REQUIRE EPINEPHRINE AND OTHER EMERGENCY MEASURES. There is some clinical and laboratory evidence of partial cross-allergenicity of the penicillins and the cephalosporins. Patients have been reported to have had severe reactions (including anaphylaxis) to both drugs. Any patient who has demonstrated some form of allergy, particularly to drugs, should receive antibiotics cautiously. No exception should be made with regard to Keflex. Usage in Pregnancy— Safety of this product for use during pregnancy has not been established. Precautions: Patients should be followed carefully so that any side-effects o unusual manifestations of drug idiosyncrasy may be detected. If an allergic re action to Keflex occurs, the drug should be discontinued and the patient treatec with the usual agents (e.g., epinephrine or other pressor amines, antihistamines or corticosteroids). 1 Prolonged use of Keflex may result in the overgrowth of nonsusceptible organ isms. Careful observation of the patient is essential. If superinfection occur during therapy, appropriate measures should be taken. Positive direct Coombs tests have been reported during treatment with thi cephalosporin antibiotics. In hematologic studies or in transfusion cross-matchini procedures when antiglobulin tests are performed on the minor side or in Coomb: testing of newborns whose mothers have received cephalosporin antibiotics befon parturition, it should be recognized that a positive Coombs test may be due t< the drug. Keflex should be administered with caution in the presence of markedly im paired renal function. Under such conditions, careful clinical observation am laboratory studies should be made because safe dosage may be lower than tha usually recommended. Indicated surgical procedures should be performed in conjunction with antibiotic therapy. As a result of administration of Keflex, a false-positive reaction for glucose ii the urine may occur. This has been observed with Benedict’s and Fehling’s solu tions and also with Clinitest® tablets but not with Tes-Tape® (urine sugar analyst paper, Lilly). Adverse Reactions: Gastrointestinal—The most frequent side-effect ha been diarrhea. It was very rarely severe enough to warrant cessation of therapy Nausea, vomiting, dyspepsia, and abdominal pain have also occurred. Hypersensitivity—Allergies (in the form of rash, urticaria, and angioedema have been observed. These reactions usually subsided upon discontinuation o the drug. Anaphylaxis has also been reported. Other reactions have included genital and anal pruritus, genital moniliasn vaginitis and vaginal discharge, dizziness, fatigue, and headache. Eosinophilia neutropenia, and slight elevations in SGOT and SGPT have been reported. Administration and Dosage: Keflex is administered orally. Adults—The adult dosage ranges from 1 to 4 Gm. daily in divided doses. Thi usual adult dose is 250 mg. every six hours. For more severe infections or thos caused by less susceptible organisms, larger doses may be needed. If daily dose of Keflex greater than 4 Gm. are required, parenteral cephalosporins, in appropriate doses, should be considered. Children-The usual recommended daily dosage for children is 25 to 50 mg per Kg. divided into four doses. Keflex Suspension > ml. 250 mg./5 ml. q.i.d. Vi to tsp. q.i.d. q.i.d. ¥2 to 1 tsp. q.i.d. q.i.d. 1 to 2 tsp. q.i.d. 1 In severe infections, the dosage may be doubled. In the therapy of otitis media, clinical studies have shown that a dosage c 75 to 100 mg. per Kg. per day in four divided doses is required. In the treatment of beta-hemolytic streptococcal infections, a therapeutic dosag of Keflex should be administered for at least ten days. How Supplied: Pulvules® Keflex® (cephalexin monohydrate, Lilly), equivalent ti 250 or 500 mg. cephalexin, in bottles of 24 and Keflex, for Oral Suspension, equi valent to 125 mg. cephalexin per 5-ml. teaspoonful, in 60 ml.-size packages. ” ELI LILLY (PHILIPPINES) INCORPORATED MAKATI. RIZAL, PHILIPPINES K4-3-76 from the skin’s point of view... a new perspective in topical steroid therapy dramatic clinical results confirm ■ new high in patient responsiveness without occlusive dressings Results from a major, continuing program of clinical trials initiated in 1968 ...conducted on a world-wide basis by leading clinical investigators in both double-blind controlled and open studies...involving thousands of patients with a variety of allergic and inflammatory dermatoses... confirm the unique dermotropic activity of new DIPROSONE. 95.8%" patient response ■ clinical “cure” rate unsurpassed by other steroids ”1309 patients with psoriasis and other allergic, inflammatory dermatoses were treated B.I.D. without occlusion. Treatment was continued until clinical "cure" was achieved or, in the majority of studies for a period of three weeks + The following results are from a program of double-blind controlled studies comparing new DIPROSONE with nine leading topical steroids...treatment B.I.D. was evaluated in 1528 patients with psoriasis and other allergic, inflammatory dermatoses.1 clinical "cure” or marked improvement moderate improvement slight improvement no improvement D1PROSONE.... (371 patients) ..4.0% (15 patients) 17.2% (64 patients) 8.3% (31 patients) Other topical steroids........... (365 patients) ..6.0% (22 patients) 40.8% (149 patients) 26.6% (97 patients) 70.3% (261 patients) 26.6% (97 patients) in psoriasis PACKAGING: DIPROSONE Cream, 10 gm. tube DIPROSONE Ointment, 10 gm. tube DIPROSONE.... (406 patients) ..2.7% (11 patients) 7.4% (30 patients) 3.4% (14 patients) Other topical steroids........... (386 patients) ..4.7% (18 patients) 17.3% (67 patients) 10.9% (42 patients) t Medical Research Files. Schering Corporation. U.S.A. SCHERING CORPORATION (PHILIPPINES) INC. P.O. BOX 238 COMMERCIAL CENTER MAKATI, RIZAL 3117 86.4% (351 patients) 671% (259 patients) in other steroid-responsive dermatoses subsidiary or SCHERING CORPORATION U. S. A. KENILWORTH, NEW JERSEY ‘TRADEMARK DIP-1 -75J-PH-(Cl) JOURNAL OF THE PHILIPPINE MEDICAL ASSOCIAIION CONTENTS Volume B2 Nos. 9-10 September-October 19 7 8 EDITORIAL The Responsibility of Medical Schools Augusto J. Ramos, M.D. 249 ORIGINAL ARTICLES The Coconut Water Egg Malachite Green Medium (CEM) for the Isolation of Mycobacterium Tuberculosis V. Basaca-SevBla, M.D., >I.P.A., Jo sue S. Sevilla, D.D.M., PotencianaC. Faraon, D.D.M., Celeste L. Fernando, A.B. and Josefina A. Uvero, B.S. Pharm. The Effects of Glycopyrrolate on the Motor Functions of the Esophagus Higino C. Laureta, M.D. Trace Elements in Relation to Cardiovascular Disease Benjamin dela Cruz, M.D., Luningning Lansangan, B.S., Gloria Asprer, B.S. and Revelinda Paradero, B.S. Clinical Experience with Transfer and Direct Turhor-Specific Immunity in the Treatment .of 24 Advanced Cancer Patients with Observations on "Post Surgical" Immunoprophylaxis and Local Immunotherapy Rodney A. Gomez M.D., FACS, FPCS, FICS, FrCC TREASURER'S REPORT Statement of Receipts & Disbursements 319 Hilarion C. de Dios, M.D. RE-ENTERED AS SECOND CLASS MAIL MATTER AT THE MANILA CENTRAL POST OFFICE ON OCTOBER 29, Wl. JOURNAL OF THE PHILIPPINE MEDICAL ASSOCIATION AUGUSTO J. RAMOS, M.D. Editor-in-Chief HIGINO C. LAURETA, M.D. Associate Editor IHLARION C. DE DIOS, M.D. Business Manager EDITORIAL BOARD CORNELIO G. BANAAG, JR., M.D.......... .................. EMMANUEL M. ALMEDA, M.D.................................... AVENILO P. AVENTURA, M.D. ... ........................ MANUEL N. BORJA, M.D. ............................ .. EDUARDO R. de la CRUZ, M.D. . .......... .............. CARMELO V. ENCARNACION, M.D. ...................... ENRIQUE L. ESQUIVEL, JR., M.D. .......................... FELIX A. ESTRADA, M.D.............................................. ROMEO V. FAJARDO, M.D................................ ........ ROMAN S. IBAY, M.D. .................................................. PERPETUA REYES-JAVIER, M.D................................ JESUS C. de JESUS, M.D................................................ PERPETUA S. LACSON, M.D............................ ........... LEON R. LOPEZ, M.D. ........ ......................................... ROMEO C, MONTES, M.D.............................................. TEODORO P. NUGUID, M.D. .................................... FRANCISCO M. PASCUAL, SR., M.D.......................... JOSE M. PUJALTE, M.D. ............................................ PEDRO M. REYES, M.D.................................................. ERNESTO S. RIVERA, M.D.......................................... RENATO Q. SIBAYAN, M.D........................................ BENIGNO M. SULIT, JR., M.D. .............................. ENRIQUE V. TALENS, M.D. ...................................... JOSE G. TAMAYO, M.D.................................................... TITO N. TORRALBA, M.D. ............................................ Psychiatric Otolaryngology Cardiovascular Surgery Oncology Family Medicine Public Health Urology Pediatrics Ophthalmology Pediatric Sugery Dermatology Pulmonary Sugery Hematology Radiology Compensation Medicine Colon Rectal Surgery Pharmaceutical Industry Orthopedics Surgery Pathology Neurosurgery Anesthesiology Military Medicine Obstetrics & Gynecology Rheumatology NOTE: The individual members of the Editorial Board represent their respective specialty. Introducing... The new eye opener... GAftAMKIN EYE DROPS CLEARS UP external eye infections caused by a wide range of ocular pathogens The eye opener... in bacterial conjunctivitis WIDE GRAM-NEGATIVE SPECTRUM AND GRAM-POSITIVE ACTIVITY CAftAMSCIN EYE DROPS Clears up conjunctivitis and other infections of the external eye and adnexa due to susceptible strains of gram-negative H. influenzae, E. coli, K. pneumoniae, M. lacunata, Enterobacter aero genes (formerly Aerobacter\ H. aegyptius and Neisseria sp., including N. gonorrhoeae. Clears up conjunctivitis and other infections of the external eye and adnexa due to susceptible strains of gram-positive staphylococci and strepto cocci, including D. pneumoniae. Clearsup infections of the external eye and adnexa due to problem organisms: P. aeruginosa (certain strains) and Proteussp. (sensitive strains— both indole-positive and -negative). Clears up infections ** of the external eye and adnexa generally without sensitivity reactions and irritation. No significant organism resistance to date.t Garamycin Eye Drops available in 5 ml. plastic bottle; also available in ointment form, 3 gm. tube. **due to susceptible organisms, t Th is may occur in the future. Resistance to gentamicin has been produced (with difficulty) in vitro by repeated exposures. <37 RCHFRING CORPORATION (PHILIPPINES) INC. * subsidiary of SCHERING CORPORATION U.S.A. I * Your prescription for tomorrow’s ,1 | vitamin . . . TODAY 1 LEFORTAN 1 TABLETS/SYRUP LECITHIN.FORTIFIED ■ Vitamin-Mineral Formula with Lysine BIOMEDIS, INC. it’ PR0ST1GMIN REDOXON ROMILAR RONICOL TIMESPAN ROVIGON SARlDON SUPRADYN SYNKAVIT VALIUM VlTAMINETS AROVIT AIROL AZO-GANTRISIN BACTRIM BENERVA BEPANTHEN CALCIUM-D-REDOXON DEHYDROEMETINE DECLINAX EPHYNAL FLUORO-URACIL ELEVIT LIBRAX Congratulations from... Roche Pharmaceuticals, Inc. 2252 PASONG TAMO MAKATI. RIZAL a sister company of F. Hoffmann-La Roche & Co., Ltd. BASLE, SWITZERLAND manufacturer and distributor of quality pharmaceuticals and bulk chemicals- products of research and technical expertise-in over 100 countries worldwide. ROCHE is considered one of the largest pharmaceutical manufacturers in the world. GANTRISIN LAROOOPA ELEVIT LIBRAX LITRISON LIBRIUM LIMBITROL MADRIBON MADOPAR MESTINON MOGADON AROVIT AIROL AZO-GANTRISIN BACTRIM BENERVA BEPANTHEN CALCIUM-O-REDOXON DEHYDROEMETINE DECLINAX EPHYNAL FLUORO-URACIL NOBRIUM PENTRIUM THE ULTIMATE IN CONVENIENCE AND THERAPEUTIC BENEFITS Celestone Repetabs (betamethasone repeat-action tablets) long-acting oral corticosteroid is desired Today’s most active systemic corticosteroid... in a specially designed long-acting form Celestone Repetabs * (betamethasone repeat-action tablets) higher degree of safety □ possesses a greater marginof safety in both short-term and long-term administration/7,8 comprehensive therapeutic benefits □ rapid and sustained symptomatic relief in allergic or inflammatory conditions15 □ enhanced gastric tolerance due to delayed absorption of follow-up dose15 □ prolonged activity makes middle-of-the-night doses unnecessary, allows patients the benefit of uninterrupted sleep matchless treatment convenience □ simplifies prescribing regimens. Repeat-dose, prolonged action tablet ensures adequate daily medication □ ideal for patients who find multi-dose regimens difficult or inconvenient □ ideally suited for hospital use. Dosage convenience simplifies administration of medication References: (1) Juarez, L.: M6d. Pr£ct. 245:4, 1965. (2) Villanueva, L. and Guillen, J.: Medicina 43:372, 1963. (3) Caruso, A. C., et al.: M6d. Pr^ct. 226:1, 1964. (4) Chavez, A.: Bol. Mex. Reumat. 3(1):43, 1963. (5) Quiroz, F., et al.: Bol. Mex. Reumat. 3(3):32, 1963. (6) ^ans-Solci, L.: A.I.R. 7:174, 1964. (7) Quereilhac, M. H.: Rheumatologie 6.331, 1964. (8) Frankel, D. B., et al.: Ann. Allergy 20:649, 1962. SCHERING CORPORATION (PHILIPPINES) INC. a subsidiary of SCHERING CORPORATION U.S A. P. O. BOX 238 COMMERCIAL CENTER. MAKATI, RIZAL D-708 KENILWORTH. NEW JERSEY ‘T.M. REG. PHIL. PAT. OFF. CE (R)-76J-PH (Cl)-1 Nerisona outstanding among today’s leading topicals the superior, new dermocorticoid from Schering AG Berlin/Bergkamen rapid onset of action excellent efficacy in psoriasis available in 3 bases for the 3 types of skin conditions Nerisona Cream Nerisona Ointment Nerisona Fatty Ointment corticoid preparations for the topical treatment of inflammatory and allergic skin conditions Composition 1 g of the respective Nerisona preparation contains 1 mg (0.1%) diflucortolone valerate. Indications All skin conditions responsive to topical corti coid treatment, such as contact dermatitis, contact eczema; occupational eczema; vulgar, nummular, degenerative and seborrhoeic eczema; dyshidrotic eczema; eczema in varicose syndrome (but not directly onto ulcers); anal eczema; eczema in children; neurodermatitis; psoriasis; lichen ruber planus et verrucosus; lupus erythematosus discoides; first-degree burns, sunburn; insect bites. In these indications, the choice of the appro priate preparation (cream, ointment, fatty ointment) is determined by the characteristic appearance respectively the stage of the skin condition: Nerisona cream, with its base of high water and low fat content, in weeping skin copditions and for application on moist, exposed or hairy skin areas. Nerisona ointment, with its base of balanced fat/water content, for nearly all stages of inflammatory and allergic skin conditions. Nerisona fatty ointment, with its anhydrous base, for dry skin conditions or chronic stages. Contra-indications and risks Tuberculous and syphilitic processes in the area to be treated; virus diseases (vaccinia, smallpox, chicken-pox). Topical steroids should not be used extensively during the first trimester of pregnancy, i.e. in large amounts or for prolonged periods. Possible side-effects As with other corticoids, the following reactions may occur when Nerisona is applied to large skin areas (about 10% of the body-surface or more) and/or for prolonged periods (more than 4 weeks), particularly when the fatty ointment or occlusive dressings are used: local con comitant symptoms such as skin atrophy, telangiectasias, striae and acneiform skin conditions as well as systemic effects of the corticoid due to absorption. Please note In bacterially infected dermatoses and/or mycosis, an additional specific therapy is necessary. When Nerisona is applied to the face, it should not come into contact with the eyes. Dosage and administration Generally, the appropriate Nerisona preparation is applied twice, if necessary 3 times daily, initially, in a thin layer. After clinical improve ment, one daily application is often sufficient. In infants and children up to 4 years of age, duration of treatment should not exceed 3 weeks, particularly when Nerisona is applied to skin areas covered with napkins. If the skin dries out too much under prolonged use of Nerisona cream, a transfer to a prepara tion with a higher fat content (Nerisona oint ment or Nerisona fatty ointment) is recom mended. For detailed information on Nerisona please consult our scientific literature. Presentation Nerisona cream, Nerisona ointment and Nerisona fatty ointment: Tubes of 5,10 and 30g Schering AG Berlin/Bergkamen Berlimed Philippine Corp. P O. Box 331, Commercial Center Makati, Rizal No. 3117 s' 46 708 U 823 I SEPT. PHARMA INDUSTRIES, INC. PROMO DIVISIONS BTH FLR. ZUELLIG BLDG. BUENDIA AVE.. MAKATI. RIZAL P. O. BOX 604, MANILA PHILIPPINE MEDICAL ASSOCIATION OFFICERS 1976-'77 SAMUEL M. TANCH0CO, M.D. President LINO EDRALIN LIM, M.D. President-Elect ERNESTO P. CRUZ Vice-President fa Luzon ANTONIO C OPOSA,, M.D. Immediate Past-President CESAR G. ESTALILLA, M.D. Vice-Pretident for Visayas BELTANI A. CLEMENTE, M.D. Vice-President for Mindanao-Sulu ERNESTO V. FERREOL, M.D. National Secretary HILARION C. DE DIOS, M.D. National Treasurer COUNCILORS-AT-LARGE FELIX J. JARDENICO JR., M.D. CONSORCIA B. LOPEZ, M.D. PRIMITIVO D. CHUA, M.D. DISTRICT COUNCILORS TRIUNPO N. BANGUG, M.D. Cagayan Valley EDWIN N. ARGONZA, M.D. Central Luzon ESPERANZA I. DE CASTRO, M.D. Rizal WINIFREDO R. SANTOS, M.D. Southern Tagalog GEORGE L. BOCAR, M.D. Eastern Visayas FACUNDO TRAIN, M.D. Western Visayas FRANCISCO A. MANZANARES, M.D. Southeastern Mindanao SALVADOR T. DEGOLLA CI ON, M.D Northwestern Luzon JAIME F. LAYA, M.D. Manila RENE G. SANTOS, M.D. Central Tagalog ROMULO P. NACIONAL, M.D. Bicol SAMUEL D. TROCIO, M.D. Central Visayas SIXTO I. BATITANG, M.D. Northeastern Mindanao RICARDO LI. OCHOTORENA, M.D. Western Mindanao ANTONIO CABALLERO, M.D North Central Mindanao When the question is high potency vitamins, only, YOU are the expert! Help your vitamin - deficient patients get nutritional support for the many stresses of today PLURAXIN T.M. REG. PHIL. PAT. OFF. developed thru research by winthrop deploys the two first primary or major agents line drugs considered the for tuberculosis infections. buttressed with INH & PAS B-COMPLEX VITAMINS » management of tuberculous paits usually consists of the use of ndard or conventional drugs—isozid (INH), sodium-p-amino saliite (PAS) and streptomycin.or the /er compounds such as prothionide.ethionamideandethambutol. ile the new compounds have their i advantages, they also have their 1 set of disadvantages. They are only expensive but are also revely toxic. ly administration of INH and 5 provide the most effective com ation in the chemotherapy of tuculosis. Dinacrin combines them into a formula and in optimum con centration that will insure speed in the reversal of infectiousness. The formula of Dinacrin provides marked benefits for tuberculous pa tients. Greater antimicrobial activity of INH is assured which is the funda mental element in the chemotherapy of tuberculosis. There is considerable speed in the reversal of infectiousness. Dinacrin reaches the tubercle bacilli in the deepest tissues and organs. Even if resistance has already de veloped towards INH, the clinical status of the patients can still be maintained or even improved through out the entire period of administration. 500 mg HOW SUPPLIED: .. 10 mg Box of 100 caplets 12.5 mg 10 mcg. Each caplet contains: Isonicotinic acid hydrazide..... Sodium-p-amino salicylate..... Bt (Thiamine mononitrate)..... B6 (Pyridoxine hydrochloride) B12 (Cyanocobalamin)............ Dinacrin i * indicated for intensive oral chemotherapy of pulmonary and extra-pulmonary tuberculosis including: 1. Pulmonary tuberculosis, all forms, from minimal tu berculosis to uncomplicated cavitary disease. 2. Miliary (disseminated)tuberculosis.tuberculous men ingitis, and genito-urinary tuberculosis (preferably with concomitant streptomycin regimen). 3. Tuberculosis of the skin, oral cavity and lymph nodes. 4. Tuberculosis of the bones and joints (possibly with surgical intervention in advanced cases). NEW HOPE THROUGH SUPERIOR TUBERCULOSIS CHEMOTHERAPY THE against FEW MANY For Mild to Moderate Pain DOLOXENE COMPOUND (propoxyphene, acetylsalicylic acid, phenacetin, and caffeine, Lilly) Each Pulvule contains 50 mg. of propoxy phene napsylate (equivalent to 32 mg. of propoxyphene hydrochloride), 227 mg. of acetylsalicylic acid, 162 mg. of phenacetin, and 32.4 mg. of caffeine. USUAL ADULT DOSAGE: 2 Pulvules every four hours as needed for pain. ft Joint Pain For Significant Analgesia DOLOXENE COMPOUND-65 Each Pulvule contains 100 mg. of propoxy phene napsylate (equivalent to 65 mg. of propoxyphene hydrochloride), 227 mg. of acetylsalicylic acid, 162 mg. of phena cetin, and 32.4 mg. of caffeine. USUAL ADULT DOSAGE: 1 Pulvule every four hours as needed for pain. Head Pain 4? | I For Pain Relief Only DOLOXENE (propoxyphene napsylate, Lilly) Each Pulvule contains 50 mg. of propoxy phene napsylate. USUAL ADULT DOSAGE: 2 Pulvules every four hours as needed for pain. I Visceral Pain For Fever and Pain DOLOGESIC-32 (propoxyphene nap sylate and paracetamol, Lilly) Each tablet contains 50 mg. of propoxy phene napsylate (equivalent to 32 mg. of propoxyphene hydrochloride) and 325 mg. of paracetamol. USUAL ADULT DOSAGE: 2 tablets every four hours as needed for pain. $Muscular Pain ILOSONE (erythromycin estolate, Lilly) DESCRIPTION: Erythromycin is produced by a strain of Streptomyces erythraeus and belongs to the macrolide group of antibiotics. It is basic and readily forms salts with acids. The base, the stearate salt, and the esters are poorly soluble in water and are suitable for oral administration. ILOSONE is the lauryl sulfate salt of the propionyl ester of erythromycin. ACTIONS: Erythromycin inhibits protein synthesis without affecting nucleic acid synthesis. Some strains of Hemophilus influenzae and staphylococci have demonstrated resistance to erythro mycin. Culture and susceptibility testing should be done. If the Bauer-Kirby method of disc susceptibility testing is used, a 15-mcg. erythromycin disc should give a zone diameter of at least 18 mm. when tested against an erythromycinsusceptible organism. Orally administered erythromycin estolate is readily and reliably absorbed. Because of acid stability, serum levels are comparable whether the estolate is taken in the fasting state or after food. After a single 250-mg. dose, blood concentra tions average 0.29,1.2, and 1.2 mcg. per ml., respectively, at two, four, and six hours. Following a 500-mg. dose, blood concentrations average 3,1.9, and 0.7 mcg. per ml., respec tively, at two, six, and twelve hours. After oral administration, serum antibiotic levels consist of erythromycin base and propionyl erythromycin ester. The propionyl ester continuously hydrolyzes to the base form of erythromycin to maintain an equilibrium ratio of approxi mately 20% base and 80% ester in the serum. Further, the propionyl ester contributes to the activity of the drug through additional hydrolysis to the base at the bacterial cellular level. After absorption, erythromycin diffuses readily into most body fluids. Only low concentrations are normally achieved in the spinal fluid, but passage of the drug across the blood brain barrier increases during meningeal inflammation. In the presence of normal hepatic function, erythromycin is concentrated in the liver and excreted in the bile; the effect of hepatic dysfunction on excretion of erythromycin by the liver into the bile is not known. Less than 5% of the orally administered dose is excreted in active form in the urine. Erythromycin crosses the placental barrier, but fetal plasma levels are low. INDICATIONS: streptococcus pyogenes (Group A Beta-Hemolytic)— Upper and lower-respiratory-tract, skin, and soft-tissue infections of mild to moderate severity. ALPHA-HEMOLYTIC streptococci (Viridans Group)- Short-term prophylaxis against bacterial endocarditis prior to dental or other operative procedures in patients with a history of rheu matic fever or congenital heart disease who are hyper sensitive to penicillin. staphylococcus aureus— Acute infections of skin and softtissue which are mild to moderately severe. Resistance may develop during treatment. diplococcus pneumoniae— Upper and lower-respiratory-tract infections of mild to moderate severity. mycoplasma pneumoniae (Eaton Agent, PPLO)- In the treat ment of primary atypical pneumonia when due to this organism. treponema PALUDUM— Erythromycin is an alternate choice of treatment of primary syphilis in penicillin-allergic patients. In primary syphilis, spinal-fluid examinations should be done before treatment and as part of follow-up after therapy. corynebacterium diphtheriae — As an adjunct to antitoxin, to prevent establishment of carriers, and to eradicate the organism in carriers. corynebacterium minutissimum - In- the treatment of erythrasma. entamoeba histolytica - In the treatment of intestinal amebiasis only. Extraenteric amebiasis requires treatment with other agents. listeria monocytogenes— Infections due to this organism. CONTRAINDICATION: ILOSONE is contraindicated in patients with known allergy to erythromycin estolate. WARNINGS: The administration of erythromycin estolate has been asso ciated with the infrequent occurrence of intrahepatic cholestasis. Hepatic dysfunction, with or without jaundice, has occurred, chiefly in adults. It may be accompanied by malaise, nausea, vomiting, abdominal colic, and fever. In some instances, severe abdominal pain may simulate the pain of biliary colic, pancreatitis, perforated ulcer, or an acute abdominal surgical problem. In other instances, clinical symptoms and results of liver function tests have resembled findings in extrahepatic obstructive jaundice. Laboratory findings have been characterized by abnormal hepatic function test values, peripheral eosinophilia, and leukocytosis. If the above findings occur, discontinue ILOSONE promptly. Initial symptoms have developed in some cases after a few days of treatment but generally have followed one or two weeks of continuous therapy. Symptoms reappear promptly, usually within forty-eight hours after the drug is readminis tered to sensitive patients. The syndrome seems to result from a form of sensitization, occurs chiefly in adults, and has been reversible when medication is discontinued. Safety of this drug for use during pregnancy has not been established. PRECAUTIONS: Because erythromycin is excreted principally by the liver, caution should be exercised in administering the antibiotic to patients with impaired hepatic function. SIDE-EFFECTS (also see WARNINGS): The most frequent side-effects of erythromycin preparations are gastrointestinal (e.g., abdominal cramping and discomfort) and are dose-related. Nausea, vomiting, and diarrhea occur infrequently with usual oral doses. During prolonged or repeated therapy, there is a possibility of overgrowth of nonsusceptible bacteria or fungi. If such infections arise, the drug should be discontinued and appro priate therapy instituted. Mild allergic reactions, such as urticaria and other skin rashes, have occurred. Serious allergic reactions, including anaphylaxis, have been reported. DOSAGE AND ADMINISTRATION: adults— The usual dosage is 250 mg. every six hours. This may be increased up to 4 Gm. or more per day according to the severity of the infection. children— Age, weight, and severity of the infection are important factors in determining the proper dosage. The usual regimen is 30 to 50 mg. per Kg. per day in divided doses. For more severe infections, this dosage may be doubled. If administration is desired on a twice-a-day schedule in either adults or children, one-half of the total daily dose may be given every twelve hours. streptococcal infections- In the treatment of group A betahemolytic streptococcal infections, a therapeutic dosage of erythromycin should be administered for at least ten days. In continuous prophylaxis of streptococcal infections in persons with a history of rheumatic heart disease, the dosage is 250 mg., twice a day. When ILOSONE is used prior to surgery to prevent endocarditis caused by alpha-hemolytic streptococci (viridans group), a recommended schedule for adults is 500 mg. before the pro cedure and 250 mg. every eight hours for four doses after ward; for children, 30 to 50 mg. per Kg. per day divided into three or four evenly spaced doses. primary syphilis— A regimen of 20 Gm. of erythromycin estolate in divided doses over a period of ten days has been shown to be effective in the treatment of primary syphilis. amebic dysentery — Dosage for adults is 250 mg. four times daily for ten to fourteen days; for children, 30 to 50 mg. per Kg. per day in divided doses for ten to fourteen days. OVERDOSAGE: symptoms— Nausea, vomiting, and diarrhoea. treatment— General management may consist in supportive therapy. ELI LILLY (PHILIPPINES) INCORPORATED MAKATI. RIZAL. PHILIPPINES Published Under the Supervision of The Executive Council JOURNAL of the Philippine Medical Association J PM A VOL. 52, NOS. 9-10 SEPT.-OCT., 1970 EDITORIAL THE RESPONSIBILITY OF MEDICAL SCHOOLS If Medical Schools are to pursue their commitment and assume their important role in the progress of medicine in our country, their responsi bility to strive for and maintain quality basic medical education is of para mount concern. The maximum of efforts must be exerted continuously to provide Medical Schools with a competent faculty, adequate facilities for laboratories and research, and a well organized training hospital. An academic environment must exist and be preserved. It is probably be cause of these existing factors that medical students become more motiv ated, eventually successful graduates and grateful as well as loyal alumni. These alumni as a potent body may in turn contribute voluntarily and gen erously to support and further improve the Medical Schools. It is a well known fact, that institutions of higher learning such as Medical Schools abroad particularly in the advanced countries, are fortunate recipients or substantial funding and aid from their alumni, philantrophists, and founda tions who are truly and fully convinced of the schools' excellence and un doubted role in the progress and leadership of their country. Their own governments also contribute generously in this partnership. The future professional career of medical students is to a great extent dependent on the quality of basic medical education he had undergone. Inadequate basic education simply leads to mediocrity. It is not the few who become successful, but, the greatest number who are. 249 250 Ramos Sept.-Oct., 1976 J,P. M. A. The faculty must be well chosen and encouraged, for the quality of medical education is dependent on the quality of its. faculty. This is a critical and serious problem in our country. It cannot be overemphasized that the backbone of any institution of learning is its faculty. A medical school or any institution for that matter is only as good as its faculty. There is no substitute for a competent, responsive, and progressive faculty. In the not distant future, the standard of medical service and health care delivery will reflect the effects of what basic medical education our present undergraduates had. Whatever it maybe, our Medical Schools must provide the answer. A. J. RAMOS, M .D. For patients under pressure from anxiety Ativan m mg. (lorazepam, Wyeth) now truly your key to successful management of anxiety ■ helps regulate blood pressure in stress-induced hypertension' ■ completely compatible with standard antihypertensive thera pies: reserpine, hydralazine, meth yldopa, furosemide1 ■ no effects on antihypertensive or cardiotherapeutic regimens were observed, nor was there any evi dence of changes in orthostatic cir culation, as occasionally reported with some benzodiazepines ’ 1 Carballo. R. ef al. "Clinical Investigation With a New Anxiolytic. WY-4036. Lorazepam." La Prensa Midica Argentina 59:28 (1972) 1076-80. 2 Khorana, A. B. "Lorazepam, a New Benzodiaze pine. in Psychosomatic Disorders." Journal of the Association of Physicians of India 22:2 (February 1974) 173-8. 3. Hdffkes. H. "Effect of Lorazepam on Standard Therapies," Arztliche Praxis 24 (1972) 2871-4. Ativan & 1 mg. (lorazepam, Wyeth) for a wider range of anxiety states effective in improving patient’s physical and emotional condition helps regulate blood pressure in stress-induced hypertension clinical trials' show: systolic diastolic 173.3 Ativan per se Furosemide & Ativan (45 days) Furosemide per se (30 days) Average blood pressure (mm Hg) ORIGINAL ARTICLES The Coconut Water Egg Malachite Green Medium (CEM) for the Isolation of Mycobacterium Tuberculosis * • First Prize PMA-Abbott Research Award on Basic Science 1976. V. BASACA-SEVILLA, M.D., M.P.A., ** JOSUE S, SEVILLA, D.D.M., *** POTENCIANA C. FARAON, D.D.M., ** CELESTE L. FERNANDO, A.B. ** and JOSEFINA A. UVERO, B.S. Pharm. ** TUBERCULOSIS in all forms is the sec ond leading cause di deaths in this coun try, fourth in causing disease and the number one disease killer of our child ren. On its early diagnosis depends its cure and control and an assured healthy people. Toward this end, government and private agencies have joined efforts in the detection and treatment of in fectious cases as well as the institution of preventive measures. The most util ized tools of detection are sputum mi croscopy and x-ray. While sputum mi*The Process and Product is covered by Philippine Patent No. 9768 awarded First prize (Pharmaceuticals and Chemical Ca tegory) Invention Contest on the 10th Na tional Philippine Inventor's Week, April 9, 1976. ••Division of Laboratories, Bureau of Re search and Laboratories, Department of Health, Manila. ***Phi lippine Atomic Energy Commission. croscopy lias been the least expensive and most efficient tool in mass case de tection, there is still need for other lab oratory tools in the more scientific stu dy of detected cases. The isolation of Mycobacterium tuberculosis is one of the more reliable aids in the diagnosis of symptomatic cases with negative spu tum for acid fast bacilli, For those cas es under therapy with apparently no cli nical or bacteriological improvement, a bacteriological work-up is necessary to determine sensitivity or resistance to the drug being used, or where a possible change of drug is contemplated. For those where actual identification of the infecting organisms is necessary, a bac teriological work-up is the only tool. Today less than 10 clinical laboratories all over the country can afford to con tinuously and regularly do the routine bacteriological isolation of Mycobacte251 252 Basaca-Sevilla, et aL Sept.rOct., 1976 J. P. M. A. rium tuberculosis. Currently these lab oratories are utilizing a medium princi pally composed of eggs or other protein sources, mineral salts and a dye. With the exception of eggs and the distilled water, the reagents and chemicals that make up the formulas have to be pro cured from abroad entailing difficulties like irregular supply, increased dost, and because too few laboratories are using the special medium, there is very little interest to make the purchase from ab road. The formula of the medium currently in use for the isolation of M. tuberculo sis may be one of the following: 1. Lowenstein-Jensen medium, modified KH2PO4 ........................................................................ 2.4 gm. MgSO4.H2O .............................................................. 0.24 Magnesium citrate .................................................... 0.60 Aspargine .................................................................. 3.6 Glycerol ........................................................................ 12 ml. Malachite green 2% aq. solution ............................ 26 ml. Potato flour ............................. 30 gm. Distilled water .................................... 600 mL Eggs (fresh, whole) .................................................. 1000 ml. 2. Lowenstein-Jensen medium, modified Mineral salt solution KH2PO4 .................................................................. 4.0 gm. MgSO4 .................................................................... 0.4 Magnesium citrate ............... 1.0 Aspargine ................ 6.0 Glycerol ................................................................. 20.0 ml. Distilled water .................................................... 1000.0 ml. Complete formula Mineral salt ........................................................ 300.0 ml. 2% malachite green .......................................... 10.0 ml. 10 beaten eggs, approx. ................ ......... 500.0 gm. 3. American Trudeau Society (ATS medium, modified) Potato peeled and diced .................... 140 gm. Glycerol, reagent grade 2% ............. 335 gm. Egg yolk (fresh) with) 3 white ....... -.... 400 ml. 2% malachite green ................................................ 10 ml. 4. Petragnani medium a. Pasteurized, homogenized whole milk ... 275.0 ml. Potato starch {Fisher) ............................ 20.0 gm. Aspargine (Difco) ............ -................ 1^9 gm. b. Fresh whole eggs- ........... 10 Fresh egg yolk .................................................. 3 Glycerine .... ..................................... 30 ml. c. 2% aq. sol. malachite green 5. Middle-brook-Cohn 7H-10 agar Solution 1 Monopotassium phosphate, ACS .................... 15 gm. Disodium phosphate, ACS .............................. 15 gm. Distilled water .................................................. 250 ml. Mycobacterium Tuberculosis 253 Volume 52 Nos. 9-10 Solution 2 Ammonium sulfite, ACS .................................... 5.0 gm. Monosodium gllutamate .................................... 5.0 gm. Sodium citrate (2 H2O) USP .......................... 4.0 gm. Ferric ammonium citrate .................................. 0.4 gm. Magnesium sulfate (7 H^O) .......................... 5.0 gm. Biotin (in 2 ml. 10% ammonium hydroxide) .......................................................... 5-.0' gm Distilled water ............................... ..................... 250.0 ml. Solution 3 Calcium chloride (2 H^O), ACS .................. 50.0 mg. Zinc sulfate (7 H2O), ACS .............................. 100.0 mg. Copper sulfate (5 H^O), ACS.......................... 100.0 mg. Pyrodoxine HCL .................................................. 100.0 mg. Calcium panthothenate .................................... 100.0 mg. Distilled water ...................................................... 100.0 ml. Solution 4 Reagent grade glycerine Solution 5 Malachite green, 0.01% aq. sol. Solution 6 Albumin-oleate dextrose solution 50 gm. bovine albumin, fraction V in 900 ml. sterile saline Sodium oleate solution 50% aq. solution of dextrose A glance through the above formulas will reveal their varying complexity, the cost it will entail in their preparation, the time involved in the weighing of each constituent especially those where an analytical balance is required, the physical facilities for the preparation and the need for personnel of higher tech nical training. The preparation of for mula nos. 4 and 5 require more skill. Formula no. 3 or ATS medium is a more simple one, but still it makes use of po tatoes which have to be peeled and diced besides eggs. METHODS In answer to the need for maximizing the utilization of isolation and culture of M. tuberculosis in all laboratories, a new medium, the coconut waTer egg mala chite green medium (CEM) has been devised. It has the following formula: Coconut water .................. 300 ml. Whole eggs ........................ 10 (approx. 500 gm.) 2% malachite green Water from young green coconut is sterilized By boiling or autoclaved for 10 min * at 10 lbs. pressure. The eggs are cleansed thoroughly with soap and wa ter; rinsed well and soaked in 70% al cohol, and dried with sterile towel. The eggs are aseptically broken into a sterile conical flask or an Erlenmeyer flask with a pipette or glass rod. The flask is shaken to break up the eggs and the coconut water added with malachite green solution enough to produce a light green color of the mixture. The contents are shaken well to mix, then filtered through sterile gauze. The mixture is Sept .-Oct., 1976 J. P. M. A. 254 Basaca-Sevilla, et al. aseptically distributed into screw-capped test tubes and inspissated at 80° to 85°C one hour in a slanting position. The sputum swab culture method de vised by Nassau was followed in the evaluation of this medium for the isola tion of M. tuberculosis from sputum. The modified Lowenstein-Jensen medium, formula 2, was used as control. One or two sterile swabs are moistened with sterile distilled water and both held in one hand, dipped into the sputum sample and vigorously rotated, mixing well the sample. The swabs are then placed in tubes, two-thirds full with 5% sterile oxalic acid and allowed to stand at room temperature for 35 minutes. Then the swabs are transferred to another tube also two-thirds full with sterile 5% so dium citrate and allowed to stand in the solution for 10 minutes. Two slopes of CEM and of Lowenstein-Jensen me dia are inoculated with each sample. The swabs are firmly rubbed on each slope while the swab is being rotated. RESULTS Laboratory standard strains of Myco bacterium like H37Rv, M. xenopei, M. avium, M. kansasii, a Scotochromogenic strain, 607 strain, BCG strain and M. le prae murium have been cultured and maintained in CEM medium and M. tu berculosis have been successfully isola ted from sputum samples using CEM. Illustrations of these cultures may be seen in Plates 1—4. It has been noted that the growth of the Mycobacterium strains in CEM has been very good. The standard laboratory human Sara nac virulent strain H37Rv has maintained the rough characteristic of its colonies light buff color, somewhat dry in CEM as in the Lowenstein-Jensen medium. A Group II Scotochromogenic strain of the Runyon group of atypical mycobac teria has shown its moist, smooth, con fluent colonies with yellow to orange pigments in both CEM and LowensteinJensen media. Mycobacterium avium, a virulent avian tubercle bacilli, produced smooth glistening colonies with cream or buff non-photochromogenic confluent co lonies in both CEM and Lowenstein-Jen sen media. Another atypical mycobac terium Mycobacterium xenopei in both CEM and Lowenstein—Jensen media produced smooth, pale yellow non-photochromogenic, moist growth. Another lab oratory strain used by the NIST is strain no. 607 of Runyon Group IV which main tains its confluent, finely irregular, light buff colored colonies in CEM as in Lo wenstein-Jensen medium. Mycobacterium kansasii of Runyon Group I showed yel low pigmented somewhat rough colonies when exposed to light in both media. A-20, a strain of the Scotochromogenic group isolated locally from sputum did not lose its yellow orange pigmented colonies when grown in CEM. CEM was found as efficient as Lowens tein^ Jensen medium in the isolation of Mycobacterium from sputum samples; buff colored rough colonies were prod uced, At no instance were negative re sults obtained from CEM when Lowens tein-Jensen medium was positive for iso lation. Using the sputum swab culture tech nique of Nassau, contamination from other bacteria presented no problem in utilizing CEM or Lowenstein-Jensen me dium. CEM was provided by the authors to another independent worker and he was successful in growing both M. leprae mu rium and BCG strain. Volume 52 Nos. 9-10 Mycobacterium Tuberculosis 255 Plate I — Shows the characteristic growth of M. xenopei, M. avium, M. kansasii, H37Rv, H607 and a Scotochromogen strain in CEM and LJ media. Sept.-Oct., 1976 J. P. M. A. 256 Basaca-Sevilla, et al. Plate H — Shows a close-up of H37Rv and a Scotochromogen strain in both CEM and LJ media. Mycobacterium Tuberculosis 257 Volumo 52 Nos. 9-10 — I Plate III — Shows the isolates from a sputum sample (378) on different days after inoculation of CEM and LJ media. 258 Basaca-Sevilla, et al. Sept.-Oct., 1976 J. P. M. A. Plate IV — Shows the isolates from a sputum sample (379) on different days after inoculation of CEM and LJ media. Volume 52 Nos. 9-10 DISCUSSION CEM utilizes coconut water as its main and only source of mineral salts in addi tion to its nutrients like protdin and car bohydrates, to mix with whole eggs as a culture medium for a fastidious group of organism like the mycobacteria. It was definitely shown in this work that used with eggs it can support the growth of mycobacteria. Blauvett1 reported that non-cooked, non-sterilized coconut water from “ripe fresh fruit” added to ordinary nutrient agar and broth nearly doubled the cul ture qualities of the latter in growing Protein .................................................... Carbohydrates ........................... ...... Fats .......................................................... Calcium .................................................... Phosphorous .......................................... Mycobacterium Tuberculosis 259 Staphylococcus aureaus, B. faecalis alcalis alcaligenes, and B. welchii. Paguio et al2 in 1970 utilized coconut water me dium for the isolation of Vibrio cholerae. Agasan3 in 1975 has proven the sensiti vity of coconut water medium in detect ing coliforms in waters and foods and the growth of Salmonella, Shigella and Klebsiella in the same medium. Several workers have analyzed the composition of coconut water from young green coconuts. Peters4 gave the range of concentration of the im portant components of coconut water per 100 ml. as follows: 0.23 — 0,43 gm.% .............. 3.68. — 5.0 gm.% ............. 0.64. — 0.8 gm.% .............. 0.03 gm.% .............. 0.01 — 0.22 gm.% Pradera and his co-workers5 reported the mineral content of 100 ml. of coconut water as follows: Calcium ................. 29.0 — 46.0 mg. Chlorine .................................................... 105.0 — 160.0 mg. Phosphorous .............................................................. 5.5 — 9.0 mg. Potassium .................................................................. 134.0 — 220.0 mg. Child and Nathaniel6 reported the constituents to be: Water .......................................................................... Nitrogen .................................................................... Phosphoric acid ........................................................ Calcium oxide .................................................... Magnesium oxide .................................................... Iron .......................................................................... Total solids ................................................................ Red sugar as invert sugar...................................... Add. sugar as sucrose .......................................... total sugar ....................................................... ash ................................................................... Unidtentified organic solids .................................... Ascorbic acid (Vit. C) ............................................ Nicotinic acid .......................................................... Panthotenic acid ...................................................... Folic add ................................................................ 95.50% 0.50 0.60 0.69 0.59 0.50 mg. in 100 gm. 4.71 gm./lOO ml. ’0.80 gm./ * fi0 ml. 1.28 gm./lOO ml. 2.08 gm./lOO ml. 0.62 gm./100 ml. 2.01 gm./lOO ml 2.20 — 3.70 mgm./lOO ml. 0.640 microgram/100 ml. 0.520 niierogram/100 ml. 0.003 microgram/100 ml. Sept.-Oct., 1976 J.P. M. A. 260 Basaca-Sevilla, et al. Vanderbelt7 found the following Nicotinic acid Panthotenic acid Biotin Riboflavin Folic acid Pradera and his co-workers (5) made a thorough study of the amino acid con tent of the water and found them preGlutamic acid Arginine-1 Leucine Lysine Proline Aspartic acid Tyrosine Alanine Histidine Phenylalanine Serine Cysteine The present work has shown for the first time the full utilization of coconut water to support the growth of a fasti dious group of organisms not just the use of its “growth factor”. Quite a number of workers have Shown this growth factor as capable of stimulating growth of certain bacteria. Ramakrishnan, et al8 in 1958 has shown that coco nut water even at a dilution of 1 in 10,000 when used as a supplement to the ordinary medium for the cultivation of Mycobacterium tuberculosis showed maximum growth in 12 days only in stead of the usual 20 days. We failed to elicit any change in the growth period of the Mycobacterium in CEM compared Materials KH2PO4 MgSO4 Magnesium Citrate Aspargine Glycerol Distilled water Malachite green 10 eggs amount of vitamin B complex as: 0.64 microgram/ml. 0.52 microgram/ml. 0.02 microgram/ml. 0.01 microgram/ml. 0.003 microgram/ml. sent as peptones based on dry protein content of the water to be as follows: 9.76 — 14.50 gm.% 12.75 gm.% 1.95 — 4.18 gm.% 1.95 — 4.57 gm.% 1.21 — 4.12 gm.% 3.60 2.83 — 3.00 2.41 1.95 — 2.05 1.23 0.59 — 0.91 0.97 — 1.17 to Lowenstein-Jensen although in some cases growth has been more luxuriant in CEM especially in isolations from spu tum samples. Tn our particular work the growth factor in coconut water is only an incidental advantage when the water is utilized as a whole. Green coconuts can be procured any where especially in the provinces. The simplicity of the formula and prepara tion does not require much technical skill nor physical laboratory facilities which suit local conditions. A laboratory that is going to start a TB bacteriology service would need to invest in the following if it will utilize Lowenstein-Jensen medium: Cost P 42.00/lb. 56.70/lb. 45.00/lb. 150.00/100 gm. 95.00/480 co. 2.50/liter 50.00/25 gm 4.50 Volume 52 Nos. 9-10 However, if it will utilize CEM, the Green coconut 10 eggs malachite green So that it is very apparent that one has to have about P445.00 to start with the Lowenstein-Jensen medium and only about P56.00 or only 1/8 of the former, for CEM. With CEM, even if malachite green is not available, the medium can still be used. CEM is a medium that can be produced from materials loeally available. Since it is a cheap medium, the pre paration of CEM may be done at a cen tral laboratory and tubes of the medium dispensed to peripheral areas. Actual production of the media can even be done in a small laboratory. The tubes can be inoculated in the peripheral area using the sputum swab culture techni que of Nassau. The inoculated media are then transported to more developei laboratories where it can be incubated, observed and studied. Instead of screw capped tubes, ordinary tubes with rub ber stopper may be used, thus further lowering the cost of each slope. CEM keeps very well at room temperature for at least 3 months and sterile coconut water for about 6 months. The addition of malachite green improves the gross visibility of the colonies. The green co lor of the media brings out very well the colonial characteristics. CEM is an ideal medium for the iso lation of mycobacteria since it supports early and eugonic growth for small ino culum; enables easy recognition of or ganisms; is easily prepared and inex pensive; and keeps the growth of conta minating organisms to a minimum. CEM medium is most useful wherever tuber culosis is a problem; wherever there is Mycobacterium Tuberculosis 261 cost estimate would only be: P 0.30 — 0.70/nut depending on where you procure it 4.50 — if procured in the city 50.00/25 gm. need for a more scientific work-up of detected cases especially for antimicro bial studies; wherever there is a lack or shortage of technical skills and physical laboratory facilities; wherever there is difficulty in the procurement of chemic als and reagents produced or manufac tured in developed countries; wherever there is need to lower the cost of medi cal care delivery and wherever coconut is grown. GEM answers all these needs, which wiM not only be in the Philippines but in many developing countries where tuberculosis is a health problem. SUMMARY For the first time a coconut water egg malachite green medium (CEM), has been devised for the isolation of Myco bacterium tuberculosis. CEM utilizes all the coconut water as its main and only source of mineral salts in addition to its nutrients like protein and carbohydrates to mix with whole eggs as a culture medium for a fastidi ous group of organisms like mycobacte ria. Laboratory standard strains of mycobacteria fike H37Rv, M. xenopei, M. avium, M. Kansasii, a Scotochromo genic strain, No. 607 strain, BCG strain and M. leprae murium have been cul tured and maintained in CEM. Mycobac terium tuberculosis has been successfully isolated from sputum samples using CEM. CEM is simple and inexpensive nor does it require much technical skill and physical laboratory facilities to prepare. It is an ideal medium for the isolation of Mycobacterium since it supports early 262 Basaca-Sevilla, et al. Sept.-Oct., 1976 J. P. M. A. and encourage growth for small inocu lum; enables easy recognition of organ ism and keeps the growth of contaminat ing organisms to a minimum. It utilizes materials locally available. CEM will be most useful not only in the Philip pines but in other developing countries where tuberculosis is a health problem. ACKNOWLEDGEMENT Sincere appreciation is due to Dr. J. SSumpaico, Director of the Bureau of Re search and Laboratories, for his interest in making this study possible; our sin cere thanks to those who in one way or another helped in this study particularly to Mrs. Remedios Fernandez, Mr. Eduar do Fontanos, Mrs. Erlinda Villadelgado, Mr. Bernardo Fotruna and Mr. Sol Dungca; to Mr. Sofronio Tomandao for the photographic illustration in this paper; to Miss Victoria Sanchez for her patience in typing the manuscript of this article; to Dr. Tirso Banzon and Attys. Fermin Galang and Nicolas Tayao for helpful suggestions in the preparation of this ar ticle; to Dr. Eulalia Venzon of the NIST and Miss Esperanza Basaca. of the NSDB for valuable assistance in the li terature research; our special apprecia tion to Dr. Antonio Jacalne of the Ins titute of Public Health, U.P., for his interest and actual trial of the medium and encouragement to go through with the study. REFERENCES 1. Blauvett, LJM.C. Asheville, The Use of Non-Cooked, Non-Sterilized Coconut Milk as an Additional Nu trient Substance on Culture Media, J. Lab. Clin. Med., 24, 4, 420-423 (1938). 2. Paguio, A. and N. Lopez. Coconut Water Medium in the Laboratory Diagnosis of Cholera, J. Phil. Med. Asso., 46:429-439, 1970. 3. Agasan, A.L. Coconut Water as Culture Medium for the Detection of Coliforms in Water and Foods, Thesis (M.S.H.), Institute of Public Health, 1975. 4. Pieters, F.B. The Coconut In the Human Diet, Food and Nutrition Notes and Reviews, Phil. Sci., 83 (4), 1954 5. Pradera, E.S., E. Fernandez and 0. Calderin. Co conut Water — A Clinical and Experimental Stu dy, Am. J. Dis. Child., V, 64 (1942) 977-996. 6. Child, R. and Nathaniel, W.R.N. Utilization of Coconut Water, Tropical Agriculturist (Ceylon) V, 103 (1947) 85-89. 7. Philocoa Compilation on Coconut Water. 8. Ramakrishnan, T., Indira, M. and Sirsi M., J, Indian Institute Science, 4C (15) 1958. 9. Gomez, L.P. Isolation and Characterization of the Growth Factor in Coconut Water, Thesis (B.S. Chem.), issued as Philcoa Technological Research Bulletin No. 7, 1961. 10. Nassau, E. Sputum Swab Culture: Simple Method of Isolating Tubercle Bacilli for Sputum Tuber cle, Lond. (1958) 39, 18. 11. Gradwoht's Clinical Laboratory Method and Diag nosis, Vol, 2, seventh ed., Mosby. 12. Clinical Tuberculosis Essential of Diagnosis and Treatment, Am. College of Clinical Physicians, 1966. 13. Mycobacteria: Isolation, Identification and Sen sitivity Testing, 1968, Butterworths. 14. Philippine Health Statistics, 1973. 15. Jacalne, A. — personal communication. The Effects of Glycopyrrolate on the Motor Functions of the Esophagus * • *This study was supported in part by grants from the Rockefeller Foundation and A. H. Robins Cd., Inc., Richmond, Va. **Makati MediGal Center. „ ^Second. Prize PMA-Abbott Research Award on Basic Science 1976. HIGINO C. LAURETA, M.D. ** INTRODUCTION ATROPINE decreases the pressure at the high pressure zone (HPZ) at the gas troesophageal junction thereby compro mising its physiologic sphincter func tion. M Moreover, it inhibits esophageal peristaltic waves.3 These promote eso phageal reflux and produce esophagitis. This is particularly undesirable in a pa tient who suffers from esophageal reflux and chronic esophagitis. The effects of atropine on the motor functions of the esophagus are to be ex pected because the motor nerves of the esophagus, the vagi, are cholinergic nerves. The anticholinergic drugs that are used for the treatment of peptic ul cer can potentially produce the same ad verse effects on the motor functions of the esophagus as those by atropine. Whether these anticholinergic drugs actually produce these effects especially in the recommended dose is not known. The purpose of this study was to deter mine the effects of a potent anticholi nergic drug, glycopyrrolate, on the mo tor functions of the esophagus. MATERIALS AND METHODS Four young and healthy Pilipino vo lunteers, two men and two women, were tested for this study. The motor functions of the esophagus were studied by intraluminal pressure measurements. This method has been previously described.4 The pressure de tecting device consisted of three waterfilled polyethelene tubes (P.E. 190; in side diameter, 0.047 in., outside diame ter, 0.067 in.) 120 cm long, tied togeth er at the dital end so that the side open ings at the distal end were in tandem five cm apart. The tubes were attached to pressure transducers (Statham P32Db) and the pressures recorded on Grass polygraph. The apparatus was ca librated so that one mm Hg pressure produced one mm deflection oh the poly graph. The pressure recording tubing assemly was passed through the nose until the side openings of all three tubes at the distal end were in the stomach. Press ure recordings were made with the sub ject in the recumbent position. The tu bing assembly was withdiawn in stepwiise fashion at one half to one cm in263 264 Laureta terval. Pressure were recorded at the lower esophageal sphincter, body of the esophagus, and the upper esophageal sphincter. The responses to swallows of two ml of water were recorded at each level. The effects of both the injectable and tablet preparations of glycopyrrolate were determined. Two subjects were first tested with the injectable form and the other two with the tablet. In the subjects in whom the injectable form was first tested the normal pressures were first recorded then the tubing assembly was repositioned in the stomach. The recording were repeated half an hour after a subcutaneous injection of 1.5 mg glycopyrrolate, The same subjects were then instructed to take one tablet of glycopyrrolate 30 minutes before each meal and at bedtime for five days after which the intraluminal pressure record ings were repeated. The last tablet was given one hour before the pressure rec ordings were made. In the two subjects in whom the tablet was first tested the test was repeated with the injectable form at least five days after the last tablet was taken. The swallowing complex consists of a rise in the average baseline pressure and appears like a plateau and which may be preceded by a brief negative deflec tion, followed by a positive deflection which represents the peristaltic wave (J5g. 1). The amplitude of the peristal tic wave was determined by measuring the height of the wave from the mean resting pressure to the tip of the wave and expressed in mm Hg pressure. The velocity of a peristaltic wave was determined by dividing the distance bet ween the two catheter tips (five cm) by the time required for the peristaltic wave Sept.-Oct., 1976 J. P. M. A. to traverse the segment (based on paper speed) as shown in Figure. 1. Only the waves that were Nearly progressive were employed in these calculations. The duration of a swallowing complex was measured from the time of initial deflection to return of the pressure to the baseline (Fig. 1). The duration of the peristaltic wave was calculated from the point of upsweep of the wave to the point where the downsweep reached the baseline. The number and percentage of swallows initiating peristaltic waves and fall in pressure at the lower sphincter were determined for each patient; Respiratory movements were recorded with a belt pneumograph. RESULTS The Normal Pressure Profile of the Esophagus. Sphincter Pressure. In these four normal Pilipinos the lower esopha geal sphincter (HPZ) was three to four cm long, the pressure gradually rising from the atmospheric pressure at the fundus of the stomach and abruptly drop ping to five mm Hg below the baseline fundal atmospheric pressure as it entered the chest through the biatus. The mean resting pressure at the peak of the HPZ was seven mm Hg (Fig. 2A). The lower esophageal sphincter responded to 79% of wet swallows with relaxation in the •usual manner as indicated by a drop in the resting pressure very shortly after a swallow (Fig. 3). The upper or pharyngoesophageal sphincter was five to six cm long and the mean resting peak pressure was 15 mm Hg (Fig. 2B). Unlike the lower sphincter the upper sphincter responded everytime to a wet swallow in the usual manner with relaxation indicated by a quick drop in pressure followed just as quickly with a contraction indicated by a Volume 52 Nos. 9-10 Esophagus 265 quick rise in pressure. Peristaltic Waves. The mean ampli tude, duration, and velocity of the peris taltic waves are shown in Figure 4. These varied throughout the length of the eso phagus originating just below the upper sphincter and dying out before reaching the lower sphincter. The amplitude, du ration, and velocity of a peristaltic wave paralleled one another,, i.e. the biggest wave was also the longest and fastest * The biggest waves were about 45 mm Hg with a mean duration of 3.8 seconds and mean velocity of five cm/sec were generated by the middle third of the eso phagus. The smallest waves were gene rated just beyond the distal periphery of the upper sphincter. Effects of Giycopyrrolate on the Mo tor Functions of the Esophagus. Sphinc -ter Pressure. The effects of glycopy rrolate on the lower sphincter are shown in Figure 2A and 3. When given by a single subcutaneous injection 1.5 mg of giycopyrrolate reduced the mean resting pressure of the lower sphincter by half. Only 26% of wet swallows initiated re laxation compared to the control of 79% (Figure 3). When given orally one mg before meals and at bedtime as recommended for five days the last tablet being given an hour before the pressure recordings were made there was no significant effect on the resting pressure. Sixty percent of wet swallows initiated response as com pared to the control of 79% (Figure 3). Whether given by subcutaneous inject ion or orally as above giycopyrrolate did not have any significant effect on the upper sphincter (Fig. 2B). Peristaltic Waves. Figure 5 shows the percentage of swallows initiating peris talsis in the four subjects tested. Eighty to 100% of swallows (mean of 94%) ini tiated peristaltic waves during the con trol studies. This dropped to 81-95% (mean of 87%) after five days of four tablets a day and 27-60% (mean of 45%) after a subcutaneous injection of 1.5 mg of giycopyrrolate. The effect of giycopyrrolate on the amplitude of peristaltic waves are shown in Figure 6. Both the tablet and inject able form reduced the amplitude of the peristaltic waves; the effect of the for mer was less and was confined to the middle third of the esophagus. Follow ing an injection of the drug the waves of the whole esophagus but particularly the distal two-third was affected and the waves that managed to appear were at most half as big as those during the con trol studies (Fig. 7). Figure 8 shows the effects of glycopyrrolate on the duration of the peristal tic waves. The duration of peristaltic waves in the distal two-third of the eso phagus decreased after both the tablet and injectable giycopyrrolate; the effects of the latter on the peristaltic waves were so profound to allow accurate meas urements (Fig. 7). TTiere was no significant effect of oral giycopyrrolate for five days on the ve locities of peristaltic waves as shown in Figure 9. TSie velocities could not be determined after the injection because the effects were so great that there were not enough measureable (Fig. 7). Swallowing Complex. Figure 10 shows the swallowing complexes during control periods and after five days of tablet giy copyrrolate. There was no significant ef fect although there was a consistent tendency of the swallowing complexes to be longer after oral medication espe cially on the distal two-third of the eso266 Laureta - phagus. This was associated with a dec rease in the duration of the peristaltic waves. DISCUSSION The resting and deglutition esophageal pressures obtained during the control studies in these four subjects are simi lar to those obtained by others using the same technique.5,6 The pressures were reproducible in the same subject. Not only the pressures but also the pro file are similar to those obtained else where.3 Locally only one published da ta using the same technique is avail able;4 the present data are similar to these. It has been shown that the motor func tions of the espohagus are profoundly af fected by atropine.1*3 The resting press ure at the lower sphincter was reduced and this was accompanied by acid re flux into the esophagus. The amplitude of the peristaltic waves in the distal twothird of the esophagus were reduced and the percentage of response in terms of initiation of waves to swallows was markedly reduced. These effects are to be expected because the motor nerves of the esophagus, the vagi, are choliner gic. Because of the foregoing any potent anticholinergic agent would potentially have the same effects. If these effects are produced two things can be expect ed to follow, namely, varying degrees of dysphagia and esophageal reflux. The dysphagia may not be troublesome but the reduction of pressure at the high pressure zone would incapacitate its phy siologic sphincter function and promote esophageal reflux and subsequently a troublesome esophagitis. This effect is very undesirable in a patient who, to begin with, has esophageal reflux for one reason or another. Sept.-Oct., 1976 J. P. M. A. A number of potent anticholinergic agents are commonly used in the treat ment of peptic ulcer. One of these is giycopyrrolate. The intramuscular in jection of 1.5 mg of giycopyrrolate red uced the volume of acid and pepsin out put by about 90% in patients with pep tic ulcer.7 It has also been shown cap able of suppressing the antral, small in testinal, and colonic motor activities.8*10 The present study showed that glycopyr rolate, like atropine, can markedly de press the motor functions of the esopha gus particularly when given in sufficient dose and parenterally; the high pressure at the physiologic sphincter was reduced by 50% and the number of peristaltic waves initiated by swallows by as much as 57%. Moreover, the waves that were initiated were likewise markedly red uced in amplitude. The subjects had to wait for six to eight hours before at tempting to eat because the food would not go down. However * when given by mouth in the recommended dose for five days the effects were significantly less; the high pressure at the physiologic sphincter was not affected and the re duction in the number of waves initiated was not significant and did not produce dysphagia in the subjects. Nonetheless, they complained of dryness of the throat and slight blurring of vision. The subjects tested in this study were healthy and young. Whether the same effects could be produced in older or, more importantly, those with esophageal disease like hiatal hernia or esophagitis due to esophageal reflux was not deter mined. Giycopyrrolate or any anticholi nergic agent should therefore be used cautiously in these patients. SUMMARY The resting and deglutition intralumi nal pressures in the lower and upper Volume 52 Nos. 9-10 sphincters and body of the esophagus were recorded in four healthy young Pilipino volunteers, two men and two wo men. The amplitude, duration, and ve locity of the peristaltic waves and the duration of the swallowing complex throughout the body of the esophagus were determined. The average resting peak pressure was 7 mm Hg at the low er and 15 mm Hg at the upper esopha geal sphincter. In these four subjects 79% of wet swallows initiated a relaxa tion of the lower sphincter; the upper sphincter responded to every swallow. The swallowing complex increased more or less linearly from 4 seconds just be low the upper sphincter to 12 seconds just above the lower sphincter. Ninety four percent of wet swallows initiated peristaltic waves. The amplitude, dura tion, and velocity of a peristaltic wave more or less paralleled one another, i. e. the biggest wave was also the long est and fastest. The peristaltic waves decreased toward the distal portion of the proximal 3rd then increased to its peak at the distal portion ©f the middle and the proximal portion of the distal third of the esophagus and decreased again and dying out before reaching the lower sphincter. The biggest waves were about 45 mm Hg, maan duration of 3.8 seconds, and mean velocity of 5 cm/sec. The same subjects were studied aja hour after an injection of 1.5 mg and again after taking one 1 mg tablet four times a day of giycopyrrolate for five days. The injection of 1.5 mg of gly copyrrolate had the following effects: 1. The resting pressure at the lower esophageal sphincter decreased 50% and only 26% of wet swallows initiated a re laxation. The upper esophageal sphinc ter was not effected. Esophagus 267 2. Twenty seven to 60% of wet swal lows initiated peristaltic waves. Of the peristaltic waves that managed to ap pear the amplitude were profoundly red uced especially in the distal two-third of the esophagus. The effects on the du ration and velocity of the waves could not be determined. 3. The effect on the swallowing com plex could not be determined because the peristaltic waves that were initiated could not be measured accurately. With four mg of giycopyrrolate by mouth per day for five days the follow ing results were obtained in the same subjects: 1. The resting pressures of both the lower and upper sphincters were not af fected. However, only 60% of the wet swallows produced a relaxation of the lower sphincter compared to 79% during the control test; the upper sphincter res ponded to all the swallows. 2. Eighty seven percent of the wet swallows initiated peristaltic waves (compared to 94% during control tests). The amplitude of the peristaltic waves particularly in the middle third of the esophagus were reduced but the reduc tion was not as profound as those prod uced by the injection of 1.5 mg. The duration of the waves particularly the proximal portion of the distal third and the distal portion of the middle third of the esophagus was likewise reduced. There was no effect on the velocity of the waves. 3. The swallowing complex increased slightly particularly in the distal twothird of the esophagus. Potent anticholinergic drugs like giy copyrrolate can potentially compromise the sphincter function of the lower eso phageal sphincter by decreasing the 268 Laureta Sept.-Oct., 1976 £ P. M. A. PNEUMOGRAPH SCC' 1 1 * ‘ i » i i SWALLOW Figure. 1. This strip of tracing shows the norma} response of the esophagus four to 14 cm above the lower sphincter to a swallow. The method in determining the amplitude, duration, and velocity of peristaltic waves and the swallowing complex is indicated. Volume 52 Nos. 9-10 Esophagus 269 MM HG 10 - A ---- ~<GLYCOPYFt^ S.c. *‘"»GLYCOPYR< TABLET? Figure »A. Mean pressures at the lower esophageal Sphincter of four normal subjects before and after giycopyrrolate 1.5 mg by subcutaneous injection and one mg tablet ,q.i.d. for five days. MM HG Figure 2B. Mean pressures at the upper esophageal sphincter of four normal subjects before and after giycopyrrolate 1.5 rag by subcutaneous ihjectton and one mg tablet g.i.d. for five days. Sept.-Oct., 1976 J.P. M. A. 270 Laureta □ CONTROL DUB GLYCOP YR., S.c. tagore 8. Percentage of swallows initiating fall in pressure at the lower eso phageal sphincter in four normal subjects before and after giycopyrrolate 1.5 mg by subcutaneous injection and one mg tablet q.i.d. for five days. SEC mm HG CA * ABOVE LOW8R SPH/NCTER "Pjgure 4 * Mean amplitude, duration, and velocity of peristaltic waves of the sophagus of four normal subjects. Esophagus 271 Volume 52 Nos. 9-10 Table 1. LOWER ESOPHAGEAL SPHINCTERIC PRESSURES IN NORMAL SUBJECTS BEFORE AND AFTER AN INJECTION OF ONE MG OF ATROPINE. Esophagel Sphincteric Pressures and Pulse Rates Before Atropine After Atropine Pressure * Pulse Rate Pressure * Pulse Rate Subject mm H per min mm Hg pre min A 14.0 77 1.5 101 B 8.0 62 1 5 118 C 11.0 68 3.0 102 D 4.0 63 1.0 109 E 9.5 68 2.0 111 •Mean of three pressure recordings. □ CONTROL fQD GLYCOPYR.t S.C. % E3 glycopyr., tablet sUBJects Figure 5. Percentage of swallows initiating esophageal peristaltic waves in four normal subjects before and after giycopyrrolate 1.5 mg by subcutaneous inject ion and one mg tablet q.i.d. for five days. 272 Laureta Sept.-Oct., 1976 J. P. M. A. CM ABOVE LOWER SPHINCTER Figure 6. Mean amplitude of esophageal peristaltic waves of four normal sub jects before and after giycopyrrolate 1.5 mg by subcutaneous injection and one mg tablet q.i.d. for five days. T i(7 13- * ir 4 ft x I 4. ? \ \ 3 \ 'S ' 1 1 ’ It 4 (I ■’■ fl < 7 r** '*-*3 rflB* X Figure 7. These tracings of one of the subjects show the normal responses of the distal esophagus to wet swallows (upper tracing) and one hour after a subcu taneous injection of 1.5 mg of giycopyrrolate (lower tracing). Volume 52 tics. 9-TO Esophagus 273 SEC 1 3 5 7 9 11 13 15 17 19 21 CM ABOVE LOWER SPHINCTER Figure 8. Mean duration of peristaltic waves of four normal subjects before and after giycopyrrolate one mg tablet q.i.d. for five days * CM / SEC CONTROL GLYCO'"'?., TABLET I 3 -«------------ ‘----------- L----------- 1----------- L_------- 1----------- 1 5 7 9 f| 13 15 |7 |9 Figure 9. Mean velocity of esophageal peristaltic waves of four normal sub jects before and after giycopyrrolate one mg tablet q.i.d. for five days. Sept .-Oct., 1976 J. P. M. A. 274 Laureta 13 5 7 9 II 13 15 17 19 21 CM ABOVE LOWER SPHINCTER Figure 10. Mean duration of swallowing complexes (S.C.) and esophageal pe ristaltic waves (P.W.) of four normal subjects before and after giycopyrrolate one mg tablet q.i.d. for five days. pressure at the HPZ. Potent anticholi- reflux or any problem affecting the disnergic drugs should be used with parti- tai esophagus. cular caution in patients with esophageal REFERENCES 1. Bettarello, A., S.G. Tuttle, M.l. Grossman, 1960. Effect of autonomic drugs on gastroesophageal re flux. Gastroenterology, 39:340-346. 2. Laureta, H.C., Unpublished data, see Table 1. 3. Kantrowitz, P.A., C.l. Siegel, and T.R. Hendrix, 1966. Differences in motility of the upper and lower esophagus in man and its alteration by atropine. Bull. John Hopkins Hosp., 118:476-491. 4. Laureta, H.C., 1966 Intraluminal pressure record ing in the study of the motor activities of the esophagus in health and disease. Acta Med. Phil., 2:228-231. 5. Code, C.F. and J.F. Schlegel. 1968. Motor actions of the esophagus and its sphincters. In C.F. Code, ed., Handbook of Physiology, Alimentary Canal, Vol. IV., Motility. American Physiological So ciety, Washington, * D.C., pages 1821-1838. 6. Texter, E.C., Jr., C-c Chou, H.C. Laureta, and G. Vantrappen, 1968. Physiology of the Gastrointes tinal Tract. The C.V. Mosby, Co., St. Louis. 7. Bitsch, V. and M. Kristensen 1966. Determination of peptic activity in gastric juice of patients with peptic disease before and after administration of glycopyrolate. Acta Med. Scand., 180:385-393. 8. Young, R. and D.C.H. Sun, 1962. Effect of gly copyrrolate on antral motility, gastric emptying and intestinal transit. Ann. New York Acad. ScL, 99:174-178. 9. Fleshier, B., 1962. The effect of giycopyrrolate on normal human small bowel activity. J. New Drugs, 2:211-214. 10. Kasich, A.M., and H.D. Fein, 1963. Experimental observations on the effects of giycopyrrolate on the acidity of gastric secretion and on the moti lity of the gastrointestinal tract. Am. X Gas troenterol., 39:61-68. Volume 32 Nq< 9-TO SEC Esophagus 273 1 3 5 7 9 11 13 15 17 19 21 CM ABOVE LOWER SPHINCTER Figure 8. Mean duration of peristaltic waves of four normal subjects before and after giycopyrrolate one mg tablet q.i.d. for five days * CM / SEC CONTROL GLYCO'"'?., TABLET I ‘-------------1------------ 1----------L_______L_ 3 5 7 9 H -L_---------1----------- 1------------1 13 15 17 19 Figure 9. Mean velocity of esophageal peristaltic waves of four normal sub jects before and after giycopyrrolate one mg tablet q.i.d, for five days. Sept .-Oct., 1976 J. P. M. A. 274 Laureta 13 5 7 9 II 13 15 17 19 21 CM ABOVE LOWER SPHINCTER Figure 10. Mean duration of swallowing complexes (S.C.) and esophageal pe ristaltic waves (P.W.) of four normal subjects before and after giycopyrrolate one mg tablet q.i.d. for five days. pressure at the HPZ. Potent anticholi- reflux or any problem affecting the disnergic drugs should be used with parti- tai esophagus. cular caution in patients with esophageal REFERENCES 1. Bettarello, A., S.G. Tuttle, M.l. Grossman, 1960. Effect of autonomic drugs on gastroesophageal re flux. Gastroenterology, 39:340-346. 2. Laureta, H.C., Unpublished data, see Table 1. 3. Kantrowitz, P.A., C.l. Siegel, and T.R. Hendrix, 1966. Differences in motility of the upper and lower esophagus in man and its alteration by atropine. Bull. John Hopkins Hosp., 118:476-491. 4. Laureta, H.C., 1966 Intraluminal pressure record ing in the study of the motor activities of the esophagus in health and disease. Acta Med. Phil., 2:228-231. 5. Code, C.F. and J.F. Schlegel. 1968. Motor actions of the esophagus and its sphincters. In C.F. Code, ed., Handbook of Physiology, Alimentary Canal, Vol. IV., Motility. American Physiological So ciety, Washington, * D.C., pages 1821-1838. 6. Texter, E.C., Jr., C-c Chou, H.C. Laureta, and G. Vantrappen, 1968. Physiology of the Gastrointes tinal Tract. The C.V. Mosby, Co., St. Louis. 7. Bitsch, V. and M. Kristensen 1966. Determination of peptic activity in gastric juice of patients with peptic disease before and after administration of glycopyrolate. Acta Med. Scand., 180:385-393. 8. Young, R. and D.C.H. Sun, 1962. Effect of gly copyrrolate on antral motility, gastric emptying and intestinal transit. Ann. New York Acad. Scl., 99:174-178. 9. Fleshier, B., 1962. The effect of giycopyrrolate on normal human small bowel activity. J. New Drugs, 2:211-214. 10. Kasich, A.M., and H.D. Fein, 1963. Experimental observations on the effects of giycopyrrolate on the acidity of gastric secretion and on the moti lity of the gastrointestinal tract. Am. X Gas troenterol., 39:61-68. Trace Elements in Relation to Cardiovascular Disease * * BENJAMIN DELA CRUZ, M.D.+, LUNINGNING LANSANGAN, B.S.+ GLORIA ASPRER, B.S.+ and REVELINDA PARADERO, B.S.+ CARDIOVASCULAR disease may be con sidered as a public health problem in the Philippines. Reports of the Disease In telligence Center, Department of Health show that diseases of the heart has a five year average mortality rate of 35.2 per 100,000 population and constitute 5.1% of the total deaths in the Philip pines. In the search for the etiologic factors of cardiovascular disease one has to consider the role of trace elements. In our previous reports1 2 we reported an increase in the mean values of man ganese and copper and a decrease in the mean levels of zinc in the serum of pa tients with hypertension, old myocardial infarct and diabetes mellitus. Kanabrocki3 and Wacker4 also suggested the possible relationship of copper, zinc and manganese to cardiovascular disease. In the present report we shall present find ings on the concentration of copper, zinc and molybdenum in the heart, liver and •Supported in Part By The Cardiovascular Unit, World Health Organization.. Geneva, Switzerland. Biomedical Research Division, Philip pine Atomic Energy Commission, Diliman, Quezon City. •Second Prize PMA-Abbott Research Award on Basic Science 1776. kidneys of 20 normal male healthy sub jects that met accidental death and from 25 male patients who died of myocardial infarction. MATERIALS AND METHODS Samples that were analyzed for their trace elemental contents were taken from the anterior wall of the left ventri cle, the superior anterior surface of the right lobe of the liver, and the cortex of the kidney. During the collection of the samples, extreme care was taken to prevent metallic contamination with the use of glass or silica knives. Prepara tion of irradiation standards for copper, zinc and molybdenum, as well as the bio logical reference materials to check the accuracy of our analytical procedures has been previously described2. Prepa ration of the tissue samples for irradia tion and the determination of its trace metals contents by neutron activation technique has already been reported5. RESULTS AND DISCUSSION Figures I, II and III will show the gamma ray spectrum of zinc, copper and molybdenum in the heart, liver and kid ney. The results in Tables I to HI in dicate the values of copper, zinc and 275 Sept .-Oct., 1976 J. P. M. A. 276 dela Cruz, et al. molybdenum in the heart, liver and kid ney of normal male subjects that met accidental death. The results in Table IV show that the mean values of zinc, copper and molybdenum in the heart, li ver and kidneys of Pilipinos are agreeable to the mean values reported in litera ture. The results in Tables I to III also indicate that the normal values of cop per, zinc and molybdenum in the heart, liver and kidneys of the normal subjects do not vary with their age and occupa tion. Figures IV to XII will show the scattergram of zinc, copper and molyb denum levels obtained from heart, liver and kidney tissues of normal healthy sub jects and patients with myocardial infarc tion. The results in Table V indicate that the mean concentration of rinc in the heart and liver of patients who died of myocardial infarction, 28.85 4- 2.07 ug/g and 37.57 4- 8.38 ug/g respective ly were lower than the normal mean values of 30.35 4- 2.33 ug/g and 47.30 4- 7.72 ug/g. Our data on the decrease of zinc concentration in the infarcted heart tissue is in good agreement with the report of Wester6, who reported a significant decrease of zinc level in the injured heart tissues. This decrease might perhaps be related to the disap pearance of lactic dehydrogenase, a zinc enzyme from the infarcted heart tissue with an increase in the level of its ac tivity being observed in the serum of pa tients with acute myocardial infarction7. Zinc has been reported to be beneficial to cardiovascular health. Schroeder6 found that the administration of zinc will reverse the hypertensive effect of cad mium in rats. The mean level of copper in the liver of patients with myocardlai infarction of 3.95 4-. 0.82 ug/g was lower than the normal value of 5.01 l-9b ug/g. Hartman9 has reported the athe rogenic effect of copper. Reinhold10 found that a deficiency in copper would * also result in the ^defective synthesis o? collagen and elastin in the aorta anc. blood vessels. The mean concentration of molybdenum, 0.83 4-_ 0.13 ug/g, 0.76 0.36 ug/g and 0.74 4- 0.31 ug/g in the heart, liver and kidney respectively of patients with myocardial infarction were higher than the normal values of 0.32 4 0.13 ug/g. 0.52 4. 0.16 ug/g and 0.41 4 0.20 ug/g. Our data on the molybdenum content of the infarcted heart tissue does not agree with the re sults obtained by Wester7 who reported a decrease in the concentration of mo lybdenum in the injured heart tissue, and relate the concentration of this trace ele ment to the degree of fibrosis present in the infarcted heart tissue. The data that we have obtained our 5 years investigation indicate changes in the concentration of copper, zinc and molybdenum in the heart, liver and kid ney of cardiac subjects occuring in as sociation with myocardial infarction. We do hope that the tissue mineral concen tration changes that we detected will add significant data to the growing evid ence that certain trace elements are as sociated with degenerative cardiovascu lar diseases, such as hypertension, athe rosclerosis and their sequela. The re sults that we obtained would not only help in establishing the elemental com position of a “Standard Man” but this study might give us a due on the bio chemical assodation of the certain trace elements with cardiovascular disease, which would offer information of im portance in the control of this public health problem. SUMMARY Heart, liver and kidney specimens from 45 adult male subjects were an alyzed for their zinc, copper and molybVolume 52 Not. 9-10 Cardiovascular Disease 277 Energy, MeV Fig. 1 — Gamma-ray spectrum of Zinc, Copper and Molybdenum in Heart. Sept.-Oct., 1976 J. P. M. A. 278 dela Cruz, et al 64 1000 Counts/min 800 600 400 200 20 10 1208 0. 0 0.8 Energy, MeV Fig. 2- Gamma-ray spectrum of Zinc, Copper and Molybdenum in Liver 40 0. .0 * o.: 0, Volume 52 Nos. 9-10 Cardiovascular Disease 279 280 dela Cruz, et al Sept.-Oct., 1976 J. P. M. A. I II Fig. 4 — Scattergram of zinc levels obtained from heart tissues of normal sub jects and patients with old myocardial infarct. Volume 52 Nos. 9-10 Cardiovascular Disease 281 I II Fig. 5 — Scattergram of zinc levels obtained from liver tissues of normal sub jects and patients with old myocardial infarct. Sept.-Oct., 1976 J. P. M. A. 282 dela Cruz, et al I II Fij*. 6 — Scattergram of zinc levels obtained from kidney tissues of normal sub jects and patients with old myocardial infarct. Volume 52 Nos. 9-10 Cardiovascular Disease 283 i n Fig. 7 — Scattergram of copper levels obtained from heart tissues of normal sub jects and patients with old myocardial infarct. Sept .-Oct., 1975 i. P. M. A 284 dela Cruz, et al. I II Fig. 8 — Scattergram of copper levels obtained from liver tissues of normal sub jects and patients with old myocardial infarct. Volume 52 Nos. 9-10 Cardiovascular Disease 285 I n Fig. 9 — Scattergram of copper levels obtained from kidney tissues of normal subjects and patients with old myocardial infarct. Sept .-Oct., 1976 J. P. M. A. 286 dela Cruz, et al. I II Fig* — Scattergram of molybdenum levels obtained from heart tissues of normal subjects and patients with old myocardial infarct. Volume 52 Nos. 9-'O Cardiovascular Disease 287 I II Fl#. 11 — Scattergram of molybdenum levels obtained from liver tissues of normal subjects and patients with old myocardial infarct. Sept .-Oct., 1976 J. P. M A. 288 dela Cruz, et al. I II Fig. 12 — Scattergram of molybdenum levels obtained from kidney tissues of normal subjects and patients with old myocardial infarct. Volume 52 Nos. 9-10 Cardiovascular Disease 289 Table 1. VALUES OF ZINC IN HEART. LIVER AND KIDNEY OF 20 NORMAL MALE SUBJECTS: ug/g WET TISSUE Name Age Occupation : Cause of Death Heart : Liver : Kidney G. D. 40 Soldier : Vehicular accident 30.50 : 44.50 : 39.30 R. J. 10 Vendor : Stabbing 29.50 : 46.00 : 33.55 Unknown 40 N. A. : Gunshot wound 28.55 : 40.67 : 31.83 Unknown 40 N. A. : Stabbing 32.70 : 49.00 : 33.20 F. S. 43 Butcher Stabbing 30.07 : 45.40 : 33.89 K. S. 45 Businessman Stabbing 29.04 : 42.30 • 37.10 L. S. 15 Patrolman : Stabbing 30.50 : 57.45 : 31.64 F. C. 45 Scavenger : Vehicular accident 26.86 : 47.80 : 36.78 H. C. 1-5 Laborer Vehicular accident 29.64 : 28.13 : 35.48 J. B. i-5 Employee . Stabbing 29.64 : 54,41 : 35.03 A. P. 15 Driver : Vehicular accident 33.60 : 41.60 : 32.53 M. L. Employee Stabbing 35.29 : 30.66 : 37.69 N. C, 17 Driver : Vehicular accident 28.26 : 55.30 : 31.68 M. J. 43 Security : Gunshot 33.00 : 57.64 : 30.20 Guard A. T. 48 Employee : Vehicular accident :: 30.19 : 51.61 : 34.26 P. D. 48 Security : Karate blow :: 28.60 : 32.20 : 34.40 Guard S. T. 48 None ; Vehicular accident : 34.80 : 13.63 ; 40.27 A. D. 48 Employee : Gunshot : 27.82 : 46.90 : 37.69 M. L. 50 Realtor : Gunshot : 29.26 : 57.41 : 34.68 A. C. 54 Operator : Stabbing 1 «! 29.10 : 49.20 : 39.20 Table II. VALUES OF COPPER IN HEART, LIVER AND KIDNEY OF 20 NORMAL MALE SUBJECTS; ug/g WET TISSUE Name ; Age Occupation Cause of Death : Heart Liver Kidney O. D. 40 Soldier Vehicular accident 3.10 2.80 3.40 R J. 40 Vendor Stabbing 2.02 7.41 2.15 Unknown 40 N. A. Gunshot 2.19 8 <00 2.48 Unknown 10 N. A. Stabbing 1.62 3.10 2.00 F. S. 43 Butcher Stabbing 2.20 7.60 2.54 R. S. 45 Businessman Stabbing 2.43 6.20 2.99 L. S. 15 Patrolman Stabbing 3.20 5.66 2.01 F. C. 45 Scavenger Vehicular accident 4.54 5.49 2.72 H. C. 15 Laborer Vehicular accident 3.26 3.79 1.71 J. B. 15 Employee Stabbing 1.60 4.14 2.54 A, P. 45 Driver Vehicular accident 3.40 5.13 3.15 M. L. 16 Employee Stabbing 3.86 5.14 2.69 N. S. 47 Driver Vehicular accident 2.84 6.02 2.46 Security Gunshot 3.45 4.00 3.44 M. J. 18 : Guard A. T. : 48 : Employee Vehicular accident : 2.45 : 4.49 ! 2.15 P. D. : 48 : Security Guard Karate blow 2.30 : 5.90 : 1.10 S. T. . 48 : None Vehicular accident 3.62 : 5.32 3.51 A. D. 48 : Employee Gunshot 2.40 : 4.12 2.32 M. L. 50 : Realtor Gunshot 2.52 : 2.12 2.48 A. C. 54 : Operator Stabbing 3.52 : 3.75 : 3.19 Sept.-Oct., 1976 J. P. M. A. 290 dela Cruz, et al. Table IH. VALUES OF MOLYBDENUM IN HEART, LIVER AND KIDNEY OF 20 NORMAL MALE SUBJECTS ug/g WET TISSUE Name : Age : Occupation : Cause of Death Heart Liver : Kidney O. D. : 40 : Soldier : Vehicular accident : 0.15 : 0.12 : 0.48 R. J. : 40 . Vendor : Stabbing 0.23 : 0.87 : 0.60 Unknown : 40 : N. A. : Gunshot 0.21 : 0.47 : 0.25 Unknown : 40 : N. A. Stabbing 0.48 : 0.97 : 0.52 F. S. : 4i : Butcher Stabbing 0.70 : 0.56 : 0.51 R. S. : 45 : Businessman : Stabbing 0.54 : 0.65 0.57 L. S. : 45 : Patrolman : Stabbing : 0.31 0.2S : 0.20 F. C. : 45 : Scavenger : Vehicular accident : 0.31 : 0.29 : 0.12 H. C. : 45 : Laborer : Vehicular accident : 0.50 : 0.45 0.27 J. B. : 45 : Employee : Stabbing : 0.24 : 0.21 0.34 A. P. : 45 : Driver : Vehicular accident : 0.27 : 0.52 : 0.44 L. : 46 : Employee Stabbing 0.27 : 0.13 0.24 N. C. : 47 : Driver : Vehicular accident : 0.36 : 0.35 : 0.38 M. J. : 48 : Security : Guard : Gunshot 0.09 : 0.86 : 0.35 A. T. : 48 : Employee Vehicular accident : 0.37 : 1.22 0.94 P. D. : 48 : Security : Guard : Karate blow : 0.53 : 0.64 0.55 S. T. : 48 : None : Vehicular accident 0.26 : 0.28 0.27 A. D. : 48 : Employee : Gunshot 0.20 : 0.65 0.44 M. L. : 50 : Realtor : Gunshot 0.16 : 0.28 : 0.25 A. C. : 54 : Operator : Stabbing 0.26 : 0.52 : 0.40 Cardiovascular Disease 291 Volume 52 Nos. 9-10 K id n e y 14-67(5) CD in cd 8 o «“s co § 1 8 o fa Z—s ® s d > 00 in T—1 •** CD co CD i CD in r-i CO <+• fa s 2 fl co CO © CO 20 d r-< o in o d • * • • s CO CD 8 © fl ci d o •fl -H Hl -H s co in i-H o .in in co d co b; CD O'. 8 fa b-‘ T—i o ve + + +. •P4 o rH co J co o in b- m d TH co X CO co b- t-H +■> co d o fl O ■H -H .1 “1 s in X co co X co o (bl d •• co on fl me: fl fl © fl s fa © 75 © JD CJ Q< & >» fl o O N O § ® fl *4 ® > 2 • • *4 65 M to 9 fl •M a fa ® > •M J fa fl ® a •• •• * • CO co o o CD co co d o -H 41 CO in 1—* o m TH in co d co •• •• •• co CD CD t- o> i—1 t> 1—1 o +. +, + o 1—1 co co o in b-’ in d co X co co b- i—< co o d -H -H -H in X CO co 00 co d co d co E o c N T5 >» O % 292 dela Cruz, et al. Sept.-Oct., 1976 J. P. M. A. denum contents. The normal mean values of zinc, copper and molybdenum in the heart, liver and kidney of male adult Filipinos was determined and found be agreeable with the normal mean values reported in literature. The mean concentration of zinc in the heart and liver of patients who died of myo cardial infarction, 28.85 -4- 2.07 ug/g and 37.57 -k 8.38 ug/g respectively were lower than the normal values of 30.35 4- 2.33 ug/g and 47.30 + 7.72 ug/g. The mean level of copper in patients with myocardial infarction of 3.95 4- 0.82 ug/ g was lower than the normal value of 5.0i 1.96 ug/g. The mean concen tration of molybdenum of 0.83 4- 0.13 ug/g, 0.76 + 0.36 ug/g and 0/74 40.31 ug/g in the heart, liver and kidney respectively of patients with myocardial infarction were higher than the normal values of 0.32 4- 0.13 ug/g, 0.52 4-_ 0.1& ug/g and 0.41 -£ 0.20 ug/g. The results and importance of our in vestigation was discussed. REFERENCES 1. B. dela Cruz et ala “The Manganese Concentration in Red Blood Cells and Serum of Filipinos." Jour nal of the Philippine Medical Association Vol. 49, No. 6, pp. 313-320 June 1973. 2. B de1h Cruz’et al,’“The Concentration of Cop per, Zinc and Molybdenum in Serum and Red Blood Cells of Filipinos." The Journal of the Philippine Medical Association Vol. 51, Nos. 7-8 pp. 173-188 July-August 1975. 3. E. L. Kanabrocki dt at, Neutron activation studies of biological fluids, manganese and copper. I nt. J. Applied Radiation 15:175, 1964. 4. W. E. Wacker et el. The relation of copper to cerrloplasmin activity and zinc to malic and lac tic dehydrogenase activity in acute myocardial in farction J. Clinical Investigation 35:741, 1956. 5. B. dela Cruz et at, "Trace Elements in Heart and Other Tissues of Filipinos Determined by Neutron Activation Analysis". The Journal of the Philippine Medical Association. V. 47, pp. 90-98’ August 1971. 6. P. O. Wester, Trace Elements in Human Myocar dial Infarction determined by neutron activation analysis. Acta Med. Scand. 178:765, 1965. 7. F. Wroblenski and S. La. Doo, Lactic Dehydroge nase activity in blood. Pure Soc. Exp; Bini 90r 210. 8. H. A. Schroeder and J. Buckman, Arch, of Envir onment and Health 14 (1967) 693. 9. D. Harman, Circulation 28, 658. 10. J. G. Reinhold, Radioisotopes in animal nutritionand physiology. Vienna, International Atomic Ener gy Agency, pp. 267-232, 1964. Clinical Experience with Transfer and Direct Tumor-Specific Immunity in the Treatment of 24 Advanced Cancer Patients with Observations on "PostSurgical” Immunoprophylaxis and Local Immunotherapy RODNEY A. GOMEZ, M.D., FACS, FPCS, FICS, FPCC * INTRODUCTION UNTIL RECENTLY, concepts in the treatment of cancer in general have been centered on three major modalities, namely: Surgery, Irradiation, and Che motherapy. Mathe’1, however, has succintly emphasized that even the most witty combination of these time-tested approaches takes care only of approxi mately one-third of the total cancer cell population in the average tumor-stricken victim. There remains, therefore, even after a thorough treatment, the bigger, deceptive, and invisible enemy which must be handled and combatted continu ously by the immune defenses of the host down to the ‘“last cell” in a guer rilla type of “cell-to-cell” contact through the relentless cell-mediated vi gilance of a battered immunologic sys tem which manytimes has been rendered ♦Chief of Surgery, Doctors Hospital, Bacolod City. incompetent in the latter stages of the warfare. Because of repeated failures of these orthodox methods (mentioned above) to achieve acceptable cures and survivals, the pendulum of therapeutic posture in cancer has swung from one modality to the other, oftentimes with mixed feeling of confusion even among the sturdiest proponents of a particular modality. It should be emphasized that surgery, irra diation, and chemotherapy are by them selves immunosuppressive procedures and that although their initial effects are encouraging, the patient is frequently overwhelmed and overcome in the latter stages by unopposed and revitalized can cer cells. He, in effect * has become a vulnerable victim, for his defenses have been rendered immunologically impotent by the standard procedures. During recent years, with some knowl edge in human immunology, in a “last ditch” effort to salvage patient survival 293 294 Gomez in cancer, Immunotherapy has become a beaconing light to some workers. In its incipient stage, the fascination is great, but there is apparently little to offer to the despondent cancer populace. There is a dearth of local experience in this field as it is abroad. However, it is con ceded that the specialty of Cancer Im munology is gradually but steadily taking shape inspite of tremendous difficulties. It was only during the last decade that we were afforded a clearer understand ing of the Human Immune System relat ive to its behavior in the cancer victim as expounded by Gordon and Ford2 and by Dmodchowski and Bowen8. This has brought us an articulate definition of what actually takes place in the host with respect to tumor-specific antigen recognition, processing, specific cellmediated activation, and cytoeffector im mune response to tumors recognized as non-self that we are provided a means not only for a more effective immuno logic approach to the management of cancer but also to elucidate the basic question of how malignant cells manage to escape immunologic destruction. Through a gradual accumulation of the most recent information on the subject as exemplified by the work of Hellstrom4, we understand now the sluggish and often suppressed immune system of the ad vanced cancer patient in contrast to the heightened Immunity among non-cancer and cancer-reeovering patients. It is with this utter helplessness, impotence, and non-responsiveness of the immune defenses of the cancer victim, and the challenge brought about by the possibi lity of superactivation and utilization of the immune potentials of the non-caneer and cancer-recovering patients through specific and non-specific immunoactiva Sept.-Oct., 1976 J.P. M. A. tion that this work was conceived. The allergory is akin to a drowning man who cannot swim. Utterly helpless and doomed to die, he needs a rescuer in the person of a competent swimmer. In our country, the report of Villasor5 on the immunopotential effects of BCG in advanced cander in 1961 and 1965 was initially encouraging, but lasting results were not as dramatic. This however, was a giant step in cancer immunotherapy in our country. The trophoblastic hypothesis of Navarro6 in the midsixties was challenging and probed into the pos sibility of further investigation into the “riddle of cancer” in an effort to develop new concepts, diagnostic procedures, as well as methods of treatment. In retro spect, the discovery of Alpha Fetopro tein (AFP) by Abelev in 19637 and of Carcinoembryonic Antigen (CEA) by Gold and Freedman in 19658 as immunodiagnostic procedures may have mir rored themselves from the human chorio nic gonadotropin (HCG) test of Navar ro. Gomez® in 1967 reported on the “im munosuppressive nature of cancer, “the significance of lymphocytic infiltration at the tumor-host interface, and the possibility of “cancer rejection” in man. Subsequently, in the same year, immu nopotentiation techniques were initially employed by the same author1®. Lately, Pineda11 ingeniously elaborated on the employment of hemocellular transplant from a healthy syngeneic donor, alone ore combined with BCG administered to advanced cancer patients and reported some beneficial effects in at least two patients but with inconstant and unpre dictable results in others. It is the purpose of this treatise to present a non-heretofore described clinic al study on Transfer and Direct TumorSpecific Immunologic procedures in adVolume 52 Nos. 9-10 vanced human cancer with special at tention to effects on tumor regression, survival time, and mortality, as well as observations on immunoprophylaxis. The author is not aware of any similar stu dy undertaken in our country at this time of writing. MATERIAL AND METHOD Twenty-four patients with various types of malignant and potentially ma lignant tumors, most of them in the mod erately or far-advanced state form the material of this report. There were 7 males and 17 females with ages ranging from 3 to 63 years. Complete history, physical examina tion, pertinent X-rays, and blood counts, particularly the peripheral differential counts including atypical cells when present were routinely performed. Separ ate studies of leucocytic profiles on 53 cancer patients were also undertaken to determine the role of lymphocytes and other cytopathic effectors of cell-medi ated immunity. The patients were clinically grouped into three, namely: Group 1 —Patients whose tumors were adequately removed with no recurrence or spread at the start of the treatment, Group 2 — Pa tients whose tumors were adequately re moved previously but had recurrence or spread at the start of treatment, Group 3 — Patients whose tumors were not ade quately removed and who had recurrence or spread at the start of the treatment. Survival time was always calculated from the first visit or during the start of the immune treatment in all instances. Six patients were operated on between 1-2 years prior to immune treatment but survival times in these patients were counted not from the time of operation but from the immunotherapy. Cancer 295 IMMUNOLOGIC TECHNIQUES Therapeutic manuevers depending upon the presenting need were as fol lows: 1. Administration BCG alone given directly to the cancer patient par ticularly after adequate tumor re moval. In this sense, the thera py may be termed a 4‘Post-Sur gical” immunoprophylaxis. The BCG, given mainly as a recall an tigen and non-specific immunopo tentiator was given intracutaneously at the time of diagnosis at a dose of 0.5 to 1.5 cc similar to the technique of Villasor5 once or twice depending upon the ini tial Delayed Hypersensitivity Re action (DHR). When the first in jection produced a violent or sa tisfactory reaction (3 to 5 cm of initial redness), no second dose was given. When the DHR was poor or timid, a second dose was given 10-20 days after the first. The scarification techniques as ad vocated by Ma the * 1 was not used in this series, although this au thor is contemplating its use on future patients. 2. Tumor — Specific Antigen (TSA) administered directly to the pa tient. This was either given alone or in combination with BCG. This maneuver was also given as a “post-surgical” immunoprophy laxis. The TSA was either allo geneic, syngeneic, or autologous in origin. No typing compatibility was required for allogeneic (non related) TSA as long as the can cer cell type was similar. Tumor-specific Antigens which are actually protein complexes were usually 296 Gomez given subcutaneously either fresh or treated with mitomycin as recommended by Mathe’1. In this series we prefer the former and sometimes use a little ether to reinforce antigen identification. Mi tomycin inactivation was used only in 2 patients (cases 12 and 24). The TSAs were obtained by simple venipuncture in the following manner: (a) As solubilized antigen (detached from the cell) taken from the se rum of the same or another can cer patient (same blood type and tumor) as defined by Pilch and Golub12 and demonstrated clinical ly by Griffiths18. (b) As cell-bound antigen either from the same or another patient with the same cancer cell type from co elomic cavity fluids which were positive histologically for cancer, or from resected tumors or in volved nodes. The antigens from resected tis sues were minced in a sterile man ner in the operating room, and ground before subcutaneous im plantation through an incision se parate from the main operative wound. Those obtained from body fluids and sera were injected si milarly mixed with bacterial prod ucts or enzymes such as polyva lent bacterial vaccines, varidase, or BCG. Part of the resected tu mors was submitted for biopsy and another part was stored in the freezer for future antigenic uti lization. 3. Transfer Immune Factors in form of serum and white blood cells or whole blood administered to the cancer patient subcutaneous ly from a sensitized human donor preferrably but not necessarily Sept.-Oct., 1976. J. P. M. A. syngeneic (related) and of the same blood type as the patient. Sensitization consisted of the do nor having received either TSA as described above, or TSA-BCG combination, or BCG alone when TSA was not available. Transfer Immune Factors were given perio dically, at first 2 times a week for 2-3 weeks, then weekly for 1 month then once every 15 to 30 days, there-after when signs of clinical remission appeared. This was sus tained for a total average of 15 to18 transfers. In this set-up, Transfer Immun ity consisted of the following pos sible constituents, namely: (a) Transfer Factor (TF) as ori ginally demonstrated by Law rence in 195514. (b) Immune RNA is also a pos sibility as demonstrated by Mannick and Egdahl15 and confirmed by Sabadini and Sehon16. This factor, however, is mainly obtained from ani mals (rodents, sheeps, mon keys) rather than humans and is easily inactivated by tissueribonuclease. (c) Serum Factors — (1) Unblocking Serum Factor (USF) — described by Hellstrom, et al1*1 which abrogates the “blocking” of cell-mediated tumor immunity among cancer patients also earlier re ported by the same work ers4. (2) Antibody — Dependent Cellular Cytotoxic factor (ADDC) also called the •'arming” antibody, lym— Voiume 52 Nos. 9-li phocytedependent antibo dy, and “Synergistic” cy totoxicity as recently in vestigated by MacLennan19 and Perlma».in19 4. Local Immunotherapy in cases of cutaneous and subcutaneous can cers either as a local recurrence or metastatic spread to he subcu taneous tissues. In this series an ointment consisting of a combina tion of fibrinolysin and desoxyri bonuclease was applied locally on the cutaneous and subcutaneous tumors daily as abvocated by Kelin20 In cases of metastasis, or when adequate solid tumor removal was impossible because of extensive growth or spread, inductive che motherapy usually with cyclo phosphamide with or without ste roids was initially utilized to red uce tumor burden to at least 105 cells (Mathe’1), or to shrink the lesions to not greater than 1 cm. per cluster even when multiple as advocated by Southam21 to render these residual cells vulnerable to eventual immunologic maneuvers. When initial chemotherapeutic induction has been achieved, or when peripheral lymphocytic po pulation has significantly been red uced to levels below 5,000, the drug was promptly withdrawn and transfer or direct immunity was administered and periodically given until host resistance has been overhelmingly potentiated. As soon as immunotherapy was started, chemotherapy was abso lutely omitted so as not to offset positive immune responses. Cancer 297 Radiotherapy was utilized only in three instances: one for ovarian suppression in a breast cancer, one for recurrent epidernoid skin cancer, and the other, for a neck mass in reticulum cell sarcoma. Chemotherapy and radiotherapy, there fore. were only adjunctive and inductive modalities and were not necessary in the treatment. High dosages of amino-acids and ino sine were given during the whole period of the treatment to potentiate immune cell regeneration and immunoglobulin synthesis as part of a multimodality con cept of treatment ip cancer. For Transfer Immunity, only healthy donors were selected having the same blood type and preferrably but not ne cessarily related (syngeneic) with the patient. The donors usually received TSA with BCG combined, or BCG alone. Full knowledge of the procedure was required and consents were signed by both donor and patient. The cases in this series re flected only those whose families or friends fully consented to the procedure since great difficulty was encountered in the process. A separate group of 33 patients with various types of advanced cancer who had either surgery or chemotherapy but without immunotherapy as described herein was used as control. RESULTS Of the 24 patients, 21 were operated on but only 14 had adequate removal of their tumors, one of whom was a huge recurrent breast tumor which was treat ed like a primary lesion. Eight of these patients had no demonstrable spread or recurrence at the time of immunotherapy while six showed either recurrence or systemic spread. Five patients had 298 Gomez only exploration and biopsy, while two had primary surgery leaving distant me tastases unaltered. Three patients were diagnosed mainly by unequivocal radiolo gic signs (see table 1). The diagnoses of the different tumors are listed in table 2. These were ob tained prior to immunologic treatment. Nine patients had ductal infiltrating car cinomas of the breast, two had chorio carcinoma, and two had reticulum-cell sarcoma. The remaining eleven had one diagnosis each, namely: primary neuro genic cancer of the right lung (neurilem moma), adamantinoma, bronchiolar car-1 cinoma, lung carcinoma (radiologic), tongue carcinoma (epidermoid), medias tinal cancer (radiologic), adenocarcino ma of the pancreas, ovarian carcinoma, esophageal carcinoma (radiologic), giant cell tumor of the humerus with fracture, and epidermoid skin carcinoma, interor bital area. For detailed information of the clinical materials see Plate 1. TUMOR EFFECTS Specific cytopathic effects on tumor of patients whose malignancies were ade quately removed are seen on table 3 and demonstrated the following: (1) Dramatic dissolution of pulmonary, subcutaneous, cutaneous, nodal metastasis or recurrences and ef fusions with stabilization of bone lesions in 3 patients: 2 with breast carcinnoma, 1 with choriocarcino ma (see figures 1, 2, and 3). (2) Intermittent or partial dissolution and growth slowing of recurrent cutaneous and pectoral incisional lesions in 1 patient with recurrent breast cancer one year after ra dical mastectomy, and a recurrent ovarian carcinoma removed 1 1/2 years previously. Sept.-Oct., 1976 J. P. M. A. (3) Absence of recurrence in seven patients with adequate removal of: breast cancer in four, adaman tinoma in one, giant cell tumor in one, and tongue cancer in one. One of the breast cancers in this group was huge local recurrence 24 months after a pervious radical procedure. There was no recur rence 9 months after a second ope ration with subsequent immuno therapy. (4) Marked slowing of bronchiolar cancer adequately removed 24 months previously, and an epider moid skin cancer removed one year previously. Tumor effects on patients whose malignancies were either inadequately removed or not removed at all were noted as follows: (1) Moderate to marked slowing of: a massive neurogenic pulmonary growth, an esophageal cancer with temporary remission and restored ability to swallow, and two breast cancers, one of whom is still alive after 72 months. (2) Progression of tumor growth was ob served in: one lung cancer with me diastinal extension, one pancreatic cancer, one choriocarcinoma, two reticulum-cell sarcomas, and one mediastinal cancer. SURVIVAL TIME Survival times calculated from the first visit or at the start of immunothe rapy are seen in table 4. Group 1 con sisting of 8 patients had a survival time range of 9-96 months with a mean of 35.87 months. As of this moment seven of eight patients (87.5%) as still alive. Volume 52 Nos. 9-10 Group 2 consisted of 6 patients with a survival time range of 6-60 months and a mean of 27.16 months. Five of six patients are still alive (83.33%). Group 3 had only two patients: One survived 30 months, the other only two months, a mean survival time of 16 months. Both patients have died. Group 4 consisted of 8 patients with a survival time range of 1 to 72 months with a mean of 12.25 months. All have died except one (12.5%). Of the total 24 patients, 13 are alive ( * 54.1%) at the time of writing. The overall mean sur vival time was 24.16 months. The Control Group consisting of 33 pa tients with their respective organ can cer listed in table 5 had an age range of 4 to 78 years. 17 were males and 16 were females. The mean survival time were 2.7 months (range 1-18 months). One female patient with a sluggishly growing ductal breast cancer survived 18 months. All patients died at the end of the follow-up. RESULTS OF IMMUNOLOGIC PROCEDURE — The result of the immunologic proced ures employed are seen in table 6. BCG was used alone on cases 2, 3, and 4 of Group 1. Only one had eventual recur rence and died (66.6%). TSA alone was used on cases 1,6,7,8,12,13,15 and 24. Six of eight patients (75%) are still alive, four from Group 1, one from Group 2, and one from Group 4. Transfer Immunity utilizing only BCG which alone was available at each parti cular instance was used on cases 9,11,16, * 17,18,19,21 and 23. Only 2 of 8 patients (25%) are alive, all from Group 2. Transfer Immunity utilizing BCG and Cancer 299 TSA to sensitize the donor plus direct employment of TSA and BCG on the pa tient was used on cases 5,10,14, 20, and 22. Three of the five patients (60%) are alive, one from Group 1, and 2 from Group 2. POST-SURGICAL “IMMUNOPRO PHYLAXIS” This was done on 8 patients in Group 1, on one patient in Group 2, on one pa tient in Group 3, and on three patients in Group 4. Only 7 patients (7 of 8 patients or 87.5%) all in Group 1, are alive, giving an overall survival rate of 53.84% for all groups. TSA was used in 6 patients, TF was used in 4, and BCG in 3. The results are seen in table 7. Interestingly, two cases (1 and 7) with low malignancy (adamantinoma and giant cell tumor) had no recurrence 30 and 47 months after therapy, respective ly. Lymphocytic Profiles Of the 53 patients separately studied for peripheral lymphocyte profiles, 36 were terminal cases while 17 were in the process of clinical remission. Of the ter minal subjects, 13 had lymphos below 10%, 8 with lymphos between 10-15%, 8 had between 16-20%, 5 had 21-30%, while only 2 had over 30%. Of the remitting cases, no patient had below 10% count, 10-15% count, or 16-20% count. Eleven had counts between 21-30% while 6 pa tients had over 30%. The results can be viewed in table 8. Atypical lymphos as an expression of blastogenic responses were observed on two patients. In one of these, a significant eosinophilia was observed (35%). The same patient had a dramatic dissolution of metastatic le sions. Examples of unfavorable and fa vorable lymphocyte responses are seen in table 9. 300 Gomez This author was able to observe sig nificant lymphocytic increases with ino sine and essential amino-acids in con junction with immunotherapy. In one remitting patient (case 14) for instance, an initial count of 25% on 8-2-75 in creased to 37% on 8-16-75 without signi ficant change in the total WBC. A si milar observation was seen in cases 9, 10, 17, and 23 who were maintained on these adjuvants throughout the length of their treatment. Local Immunotherapy Local Immunotherapy with combined fibrinolysin and desoxyribonuclease was uwsed in the cutaneous and subcutaneous lesion on cases 9, 10, and 14. Case 9 had intermittent flattening while cases 10 and * 14 had dramatic disappearance reflect ing also probably not only local but also systemic immune responses resulting from TSA and TF. DISCUSSION The study of cancer has often fascin ated surgeons, pathologists, radiologists, and biologists alike. Surgeons often ca pitalize on the excisional approach and have been able to prolong survival times in cases of purely localized malignancy. When the extent of the lesion is precari ous, the long term results are poor and it becomes the duty of the chemothera pist and radiotherapist to render adju vant aid at a stage when host resistance has obviously waned. Frequently, the latter two modalities enhance rather than check tumor growth particularly when doses are inadequate because of their in herent capacity to further immunosup press biologic defenses in the same manher that surgery does to the patient, the difference being that surgery produces a rebound immunologic response probably because of tumor burden reduction as Sept.-Oct., 1976 J. P. M. A. hypothesized by Simmons * 2. It is now known that the above men tioned modalities can only cure about one-third of the cancer patients when treating perceptible disease!. This leaves a considerable amount of imperceptible tumor cells which comprises the residual, insiduous, and upredictable enemy. This is that particular state of affairs that brings recurrence and eventual demise of the immunobiologically helpless can cer patient. Many-times, one would only hope that the left-over cell burden would not exceed the capacity that can be handled by the existing immune defense in a particular patient. It is in this concept that a multimodality approach to cancer treatment has been advocated by Haskel23. The role of immunotherapy in the treatment of cancer although slow in its development, has lately gained momen tum with a better understanding of “bio logic immunodynamics”. The finding by this author in 19671° of the immunosup pressive behavior of cancer as revealed by absence or scanty lymphocytic infil tration at the tumor-host interface has given insight into the need of some ma neuver that would bring about a po tentiation of the host resistance. Expe rience has shown that most patients with advanced cancer and, therefore, with considerable tumor burden have an al most absolute refractory immunosup pression not responsive to ordinary non specific immunostimulants such as BCG or other bacterial vaccines as advocated by Villasor5, or to non-sensitized hemoCellular transplant as reported by Pine da11, hence, the unpredictability of these immunologic procedures. In advanced cancer patients with sev ere immunosuppression, intracutaneous Volume 52 Nos. 9-10 BCG did not produce a reaction (7 pa tients) even after repeated inoculations, showing obvious anergic status. In some patients with minimal immunosuppress ion, however, hemocellular transplant it self could be beneficial probably because of Hellstrom’s USF. This is one of the components (serum factors) this author relied on during transfer immunization. Physiology of the Immune System There are unequivocal evidences to show that immunity of tumors are exer cised by the Cellular or Lymphocytoid Division rather than by the Plasmacytoid Division of the Immune System as amply described by Gordon and Ford24. The schema of the Physiology of the Immune System is seen in figure 4. The sensitized T-lymphocyte which has mat ured through the thymus and, therefore, thymus oriented is the obvious cytopathic effector, However, if the T-lymphocyte is not tumor-specifically sensitized, then the USF is non-effectual since the unop posed cytopathic effector mechanism has no specific direction or target cell. For this reason, non-specific hemotransplant is of no physiologic value. The most Ideal and rational approach is tumor specific sensitization and/or transfer im munity from a healthy, syngeneic, speci fically sensitized donor. The Plasmacytoid or Humoral Division which is represented by the B-cell or bursa oriented cell, so called because in the chicken these cells are derived from the hindgut bursa of Fabricius, is in man derived from the lymphoid follicles of the Peyer’s Patches and probably the appendix. These plasmacytes elaborate immunoglobulins or serum antibodies which are mainly responsible for immune responses in bacterial infections, foreign body and allergic reactions. They seldom Cancer 301 take part in tumor immunity. More over, by creating antigen-antibody com plexes with tumor receptor sites, they may actually enhance tumor growth pro ducing the so-called “Serum Blocking Factor” SBF) earlier reported by Hellstrom4 (see figure 5). This is the more plausible explanation of cancer patients who inspite of high titres of tumor anti bodies are unable to “reject” their own tumor lending credence to the hypothesis of the immunosuppressive behavior of cancer in its autonomous stage10. Tumor-Specific Antigen One of the various new properties which characterize cancer cells is the ac quisition of protein complexes which have not been present or defined in the cell prior to malignant change. The exis tence of these TSA in both animal and human tumors has been recognized for years3. The malignant cell may carry a variety of antigens, either intracellu lar or at the cell surface. These an tigens may be recognized as “foreign” or “non-self” by the host’s immune system, and an immune response may be mount ed specifically against the antigens and against the tumor cells that bear them. The immune response is usually believed to be cell-mediated (Lymphocytoid Divi sion) and the mechanics is similar to a transplantation rejection process. It is to be emphasized here that the cancer cell is distinct from the antigen itself. It is therefore, with practical importance that we distinguished our approach in securing the TSA into the so called “so lubilized” or cell-free, and the “cell bound” antigens, the former obtained by simple venipuncture, the latter by sur gical excision, aspiration of coelomic fluids, or biopsy. Griffiths13 has shown that cancer cells 302 Gomez abound in the blood in 42 of 70 patients (60%) even among silent, localized colo nic cancers. It is obvious, therefore, that the score could be up to 90% when it comes to cell-bound antigens in cases of full-blown metastatic cancer. This au thor, moreover, predicts an almost 100% availability in the peripheral blood in ca ses of solubilized antigens. In the fu ture, it will be an expedient plan to set up a bank of fresh frozen cancer tissues of various types as a vaccine pool similar to the one described by Mathe’ 1 at the Institute of Cancer and Immunogenetics in France. In this report, the author has introd uced specific immunization by way of immunoprophylaxis, cancer suppression, and transfer immunity with the end in view of a well-directed specific immune response. From the data presented, there was no recurrence of the tumor 30, 21, IS, 9, 42, 47, and 96 months, res pectively, in Group 1, all patients being presently alive (100%). One patient aged 30 (case 6) suffered no recurrence and is alive 42 months after initial surgery and immunization inspite of one pregnan cy during the follow-up period. There was only one patient (case 2) whose growth slowed (24 months) but devel oped metastases and died. There were two patients in group 2 with TSA im munization. One had a dramatic disso lution of pulmonary metastases and is alive today 60 months after initial im munization (see figure 2). The other pa tient had growth slowing of an epider moid carcinoma of the interorbital skin but latter died of cerebral spread 24 months after immunotherapy. One pa tient in Group 3 and one in Group 4 had marked slowing of growth, but eventual ly, of the 8 patients with direct TSA ad ministration in all groups, six (75%) are Sept.-Oct., 1975 J. P. M. A. alive between 24 to 96 months after im munotherapy. Deaths in Groups 2 and 3 merely reflect the factor of tumor bur den which runs pare’ pasu’ with tumorinduced immunosuppression and is often times a decisive element in determining immunologic victory or defeat. It has been conceded by cancer im munologists that tumors with sizes over 1 cm. are difficult to disintegrate immu nologically. The experience in this se ries, however, have shown that metasta sis as big as 1 inch even when in multi ple clusters all over the body dissolved dramatically as early as one to two months time as exemplified by cases 10, 11, 12, and 14 (see figures 1, 2, and 3). Some big solid tumors may pose as im penetrable barriers, although a “second set” type of homograft-like rejection may occur similar to the “Gell’s perivascular islands” of Jones25 which can cause an acute ischemia, necrosis, and dissolution regardless of tumor size. The specificity of tumor antigens to induce corresponding specific reaction is exefnplified by the work of Hellstrom and associates26 who observed inhibition of various tumor cultures by autogenous or allogeiieic leukocytes from patients with the same type of tumor in 88 to 91% as against 3 to 7% of normal cell cultures. Most interestingly, leukocytes from can cer patients caused destruction of allo geneic tumor cells of the same type but not tumors of other histologic types. The recent clinical trial by Marcove, et al27 of autogenous vaccines in the treatment of osteogenic sarcoma merits attention. Southam21, in his experiments in mice observed that tumor-takes of transplant ed methylcholanthrene-induced sarcoma were only 50% less'in immunized than non-immunized animals. Experience in Volume 52 Nos. 9-10 man although not well controlled, showed that reduction of takes was not more than 50% of control values, and to get approximately to that degree, it takes a ratio of 1,000 leucocytes to 1 tumor cell for an effective cell-to-cell contact. The preparation of the tumor-specific antigen itself deserves mention. Accord ing to Southam21, the most effective form of tumor vaccine is the intact tumor cell, either viable, or metabolically alive but treated with chemicals, bacterial prod ucts or irradiation to prevent cell propa gation but retains as well as reinforces its antigenicity as suggested by Rios and Simmons38. This author suspects that in big solid tumors antigenicity is nil if the host-tumor interface remains as a thick barrier leaving no means of “immunolo gic exchange” between the tumor and the host, thereby perpetuating unchecked tumor growth. When the tumor eventual ly finds its way to the blood stream, im munosuppression has gone too far for the host to take care. Thick TSA tis sues when not comminuted adequately and attenuated as described prior to sub cutaneous implantation may produce a “take” which occurred in one patient in earlier experiments. The lesson was learned and subsequently corrected. When severe immunosuppression has prevailed, TSA alone may be too weak to evoke a response. The use of TSA in combination with BCG becomes an al ternative. This is a simpler method de void of moral and donor problems when compared with Transfer Immunity. Re cent reports by Powles28 showed drama tic results among patients with acute myelogenous leukemia using stored viable tumor cells plus BCG. Fefer, quoted by Simmons22 described 12 patients who re ceived subcutaneously their own leuke mic ceils, lethally irradiated in vitro with Cancer 303 10,000 rads plus intravenous infusions of peripheral lymphocytes from a normal identical twin. Complete remissions occured in 87% of cases with six patients having complete remission at 11 to 44 months without chemotherapy. The cultured cell-BCG immunization techni que of Sokal and Aungust29 is merely a variation. Recently, Rosato30, et al used Vibrio cholera neuraminidase as an adjunctive treatment with monthly injections of autochthonous tumor cells to 25 patients with various types of cancer. Six who received the full course of 6 injections are all alive without clinical evidence of progression more than 8 months after the start of treatment. It is clear, therefore, that the TSA may need some sort of immunopotentiation in the more advance ype of cancer with severe im munodepression. The adjunctive treat ment apparently reinforces the TSA by causing a DHR through the following mechanisms, namely: 2) production of a less rigid cell surface structure allowing easier membrane deformation and pha gocytosis of the TSA by macrophages, b) unmasking of antigens allowing greater recognition, and (c) facilitation, and accessibility of antibodies to antige nic receptor sites on the surface of the cancer cell. Employing cytotoxici ty assays in vitro using autologous tar get cells grown in tissue culture, Rosato30 observed cytolysis without tumor en hancement or “blocking” effect in 4 of 5 patients in whom this was measured, In this series, TSA combined with BCG was not used alone but in conjunction with Transfer Immunity by reason of exi gency. Of 5 patients where this was used (case 5, 10, 14, 20, and 22), 3 or 60% are alive. The non-response of pa tients in group 4 (cases 20 and 22) was 304 Gomez due to overwhelming tumor load and im munodepression . Transfer Immunity Lawrence14 in 1955 was the first to report on the rtansfer of delayed hyper sensitivity responses to tuberculin and other antigens in man with dialyzable extracts of human peripheral lymphocy tes. This was termed the “Transfer Fac tor” (TF). In 1960, specific accelerated rejection of skin homografts in man were found to be mediated by this factor by the same authors31. Although its use has been confirmed in non-cancer immune deficiency diseases such as Wiscott-Aldrich syndrome, its more dramatic role in recent years has been focused on malig nancy. It is similar but distinct from Immune RNA of Pilch and Golub12, the difference being on the fact that the for mer is obtainable from the lymphocytes of man while the latter mostly from that of animals and is, moreover, inactivated by tissue ribonuclease while the TF is not. Ribonuclease, however, can be in activated in turn by low molecular weight dextran. Southam21 refers to Lawren’s TF as “Instructional Immunotherapy” for al though it does not contain the antigen to which immunity is conferred, nor is an tigenic of itself, it somehow transmits Information which “instructs” the reci pient’s immune system to respond to the same antigen which sensitized the donor. The appeal then for such non-antigenic material for immunotherapy is obvious based on the assumption that healthy do nors who have built up immune resis tance to a wide variety of cancer cells could offer their leucocytes to the can cer recipient who is unable to defend himself against the malignancy. This was precisely the concept utilized by this Sept.-Oct., 1976 J. P. M. A. author in this treatise. With the ad ministration BCG to the donor, he ac quires a heightened, non-specific immu nity, but with the addition of TSA, he develops, in effect, a specific, hightened immunity when transferred “instructive ly” to the cancer patient and confers not only a recall DHR but also a specific cytotoxic instigator to a remarkable deg ree. When using transfer elements including serum instead of just only leukocytes as originally used by Lawrence14, this au thor also availed of two serum factors aside from the possible availability of Immune RNA. The serum factors, pre viously mentioned are: (1) USF of Hellstrom, and (2) ADCC factor of MacLennan and Perlmann. Two patients, in Group 2 where trans fer BCG was used are both alive (cases 9 and 11) 41 and 12 months, respective ly. The rest of the patients who received transfer BCG all died, one belonging to Group 3 and five from Group 4. One of the above survivors (Case 11) had dramatic dissolution of abdominal spread and ascites. The over-all effectivity for all groups with transfer BCG was a poor 25% reflecting severe refractory immu nosuppression. In comparison, the ef fectivity of 50% for combined Transfer and Direct Immunity utilizing TSA plus BCG for both approaches seems encour aging and should be used more often in advanced cases. It is observed however that transfer BCG was used more often than transfer TSA. The reason is re luctance on the part of the donor in ac cepting the procedure for fear of cancer propagation. However, the argument it self is not valid, first, because the TSA is initially deactivated by pre-treatmenx as previously described, and second, be * cause of the concept of Immunologic Volume 52 Nos. 9-10 Surveillance in healthy individuals as ad vanced by Burnet32. Survival Time and Mortality The mean survival time in this series of 35.8 months in Group 1 and 29.2 months in Group 2 is indeed encouraging. For example, in Group 1 we had a su perextended survival of 96 months in one patient and over 40 months in two, and the rest between 9-30 months with only one death. The mean survival among patients given autologous tumor cells treated with Vibrio cholera neuramini dase after surgery by Takita, et al, as quoted by Simmons22 was only 17.4 months. Although the mean survival time in Group 2 was only 29.2 months, the long est survivals for this group were 60 and 41 months, respectively. The rest had between 12 to 24 months with only one death at the end of the follow-up. Group 3 and 4 did not fair well (16 and 12.2 months mean, respectively), although one patient who is still alive has a 72-month survival time. These results speak co gently for themselves when compared with the 33 control patients without im munotherapy who had a mean survival time of 2.7 months, all of whom have died. Comparison with the BCG group of Villasor5 (see table 10) which had 7 sur vivors out of 43 patients (16.2%) at 24 months, the survival in this series were 10 out 24 patients alive 24 to 96 months (41.6%), while the actual number of living patients is 13 (54.1%) which is highly significant. The results in Group 1 and 2 are inspiring and should invite more attention and study as well as em ployment of bigger and adequately con trolled series. It is, moreover, obvious from this data that tumor burden is a Cancer 305 critical factor if immunotherapy is to succeed. The poor results in Groups 3 and 4 are witness to this fact. Lymphocytic Responses The study of peripheral lymphocytes in this series deserves mention since they are the principal agents of immunity against tumor cells. As early as 1922 MacCarty33 has already mentioned the significance of lymphocytic infiltration around breast cancers as a determinant in host rejection of the tumor and a favorable prognostic sign relative to sur vival. It is unfortunate that this obser vation was discredited for half a century before eventually gaining some support. Evidences have shown that lymphocy tes become significantly reduced in a good number of patients whose progress is dismal. As a matter of fact, the dec rease or increase of the lymphocyte popu lation is of prognostic significance which will presage whether the patient is go ing to succumb to the disease or get well in the not too distant future. In the authors * personal unlisted experience, the forst and most accurate prognosis were on those patients whose lymphocyte counts slumped below 10% pare’ pasu” with very high total WBC counts be yond 15,000. The appearance of atypical cells in two patients (cases 10 and 18) was sug gestive of blastogenic repsonse which according to Pilch and Golub12 is indic ative of prior sensitization of lymphocy tes to tumor antigens. This may, there fore, be interpreted to represent detect ion or recognition of TSA by the host. The appearance of significant eosino philia in one patient (also with atypical lymphos) with dramatic tumor dissolu tion indicated either the presence of a Sept.-Oct., 1976 J. P. M. A. 306 Gomez foreign agent, an allergic reaction, or an antigen-antibody repsonse. By elimina tion, the latter may be the most likely mechanism to explain this occurrence. This antigen-antibody phenomenon has been amply expounded by WetherleyMein34 who claimed that eosinophils are involved in the initiation of antibody syn thesis. It appears that antigen-antibody complexes could be phagocytosed by eosinophiles. Defense against pathogenic effects of immune complexes by eosiphiles is significant in the light of Hellstrom’s SBF * . Other functions of the eosinophiles are fibrinolytic activity and histamine inactivation whose relation ship to cancer is still unknown. <<Post-Snrgical” Immunoprophylaxis Cancer Immunoprophylaxis in the strict sense of the word refers to immu noprocedures performed on the non-cancer patient to prevent a future occur rence of the actual cancer. In this stu dy the term immunophylaxis was used rather loosely and was preceded by the word “post-surgical” to qualify succinct ly what this author had in mind. The word was used only with respect to those patients who had actual removal of the tumor and were given either BCG, TSA, both, or with TF. From the figures in this study, immu noprophylaxis was effective only when the tumor was adequately removed. The figure of 87.5% effectivity (7 of 8 pa tients) clearly justifies the procedure, al though a bigger series would be more convincing. Moreover, immunoprophy laxis may be effective even with tumors of low malignancies as seen in two pa tients. To date, only two other human experiments had been done aside from this present series. One was by Bjorklund35 who inoculated small groups of elderly men with a vaccine containing a mixture of human tumor cell in the hope that the resulting homograft immunity would inhibit the development of future cancers. Up to the present, however, no follow-up reports had been published. The flaw in this experiment, however, is that the prophylaxis was made late in life, although it can be opined that this is the age when tumors occur more fre quently and, therefore, demands preven tion. The other study was a collabora tion between the group from Sloan-Ket tering Institute, and that from Ohio State University Medical School36 with the pri mary objective of studying homograft re jection phenomena and TSA. In that experiment, nearly 300 volunteers in the Ohio Penitentiary received living tissue culture cell homografts of various hu man cancer cell lines. Long-lasting ho mograft immunity directed toward TSAs was demonstrated in these men. The follow-up was between 14 to 20 years, and although it was difficult to trace every body because of frequent change of abode, those who were account ed for ten years or more from the time of inoculation (about one-third of the original number) showed only two known cases of cancer (2%). Although no conclusion was possible, immunoporphylaxis, either post-surgical or the true preventive measure is a fascinating pro cedure which will do doubt find its place in our future conduct with cancer-prone patients. Local Immunotherapy The subject of local immunotherapy for superficial lesions merits attention. Klein, et al20, in his experiences with basal-cell and breast cancer (recurrent) as well as mycosis fungoides using locally applied dinitrochlorbenzene (DNCB), streptokinase-dornase, and PPD showed eradicaVolume 51 Nos. 9-10 tion of skin cancers in 95% in a grousa of 90 patients. The mechanism is brought about by DHR to haptens of re latively small molecular weight produ cing selective antitumor effects against malignant and premalignant epidernal lesions and lead to their eradication. Of three patients where local immunothera py was used m mis series, all responded with either flattening or complete disap pearance of cutaneous and subcutaneous lesion (100%). The Donors The donors selected for transfer im munity were preferrably of the same blood type and related to the patient. This is merely to avoid the usual problem with histocompatibility antigens encount ered with non-syngeneic donors during subsequent transfers. The experience here, however, has shown that non-related isotyped donors did just as well with excellent results even -after over 12 trans fers (cases 10 and 14). A history of hepatitis not only in the prospective do nor but also in the patient is an abso lute contraindication to transfer immu nity. TSA in this case is the logical re course. Adjunctive Therapy The discussion of immunotherapy will not be complete without certain factors which may be responsible for adequate lymphocyte production. Protein is one of the most vital raw material which can accelerate cell production. Preferrably, this should be in essential amino-acid form when assimilated by the patient in order to facilitate prompt synthesis without undergoing too much digestive work when introduced orally. Interes tingly, amino-acids in contrast to the usual natural complex protein, passes through the gut into the portal system Cancer 307 to the liver frflftte without ®iuch ado and there undergo rapid protein synthe sis. It is even more effective when ad ministered intravenously. Hypoproteinemia is a common obser vation among advanced cancer patient probably because ot nausea, inanition, poor absorption, and deficient protein synthesis. This results in poor body re sistance and immunodepression. Patients given amino-acids, however, regain their serum protein values and, consequently also, their lymphocyte and antibody ca pacities, and frequently experience some kind of remission. The role of Inosine in reversing lym phopenia either after chemotherapy, ra diotherapy, or because of cancer immuno suppression itself has been firmly estab lished by Kondo and Aoyama87 in 1965. Lymphocyte regeneration is probably by way of the Inosine-RibosephosphateAMP-ADP-ATP pathway facilitating nu cleotide and protein synthesis even un der conditions of hypoxia. In this series at least 20% of the cancer patients were brought to satisfactory lymphocytic le vels either after inductive chemotherapy or during the immediate cost-surgical period. This phenomenon cannot be ex plained solely by the effect of immuno therapy alone. SUMMARY Twenty-four patients with various types of cancer were given transfer and Direct-Specific Immunizations which at times were reinforced with BCG under conditions of exigency. The patients were grouped as follows: Group 1— Tu mors adequately removed, no metastasis or spread, Group 2 — Tumors adequate ly removed previously but with existing spread or metastasis at time of immu notherapy, Group 3 — Tumors not adeCancer 309 Vnlunvt 52 Nm. 9-10 Volume 52 Nos. 9-10 Cancer 311 PHYSIOLOGY OF THE IMMUNE SYSTEM X V ..............AFFERENT ] CENTRAL > LIMBS ------------ EFFERENT J FIGURE 4 quately removed, with local or systemic spread, Group 4 — Tumors not removed, with local or systemic spread. In group 1, all are alive except one (7/8. or 87.5%) between 9 to 96 months (mean 35.8 mo.) with recurrence of tu mor only in one patient. In Group 2 (6 patients), four had dramatic dissolution of the spread and recurrence, two had growth slowing and all are alive except one (5/6 or 83.3%) 6 to 60 months. (mean 27.1 mo.). In Group 3 (2 pa tients), all died with a mean survival time of 16 months. In Group 4 (8 pa tients), only one is alive (12.5%) after 72 months, with a mean survival time of 12.2 months. Control studies in 33 advanced cancer patients without Im munotherapy revealed a mean survival time of 2.7 months, with no living pa tient after that period. Survival time was calculated from the first visit or inSept.-Oct., WTb J. P. M. A. 312 Gomez FIGURE 5 stitution of immunotherapy and not from the previous operation. Compari:on with Villasor’s series was discussed. In cluded in this study was an experience with local immunotherapy for cutaneous lesions. Tumor burden was a critical factor as shown in Groups 3 and 4. The results in Groups 1 and 2 were encouraging and invite more attention, study and employ ment of bigger semes. “Post—Surgical” Immunoprophylaxis W’as discussed relative to its effectivity (7/8 or 87.5%) in Group 1 and an over all survial rate of 53.8% for all groups. The role of lymphocytes as cytopathic * effectors of cell-mediated immunity as well as the prognostic significance of its peripheral population has been empha sized. The presence of atypical cells and significant eosinophilia in some patients and their relationship to antigenic recog nition and tumor antigen-antibody inter action was mentioned. Finally, the rege nerative potential of Amino-acids com bined with Inosine in conjunction with Immunotherapy was revealed by improve ment in lymphocyte levels which cannot to explained solely by immunotherapy alone. Volume 52 Nos. 9-10 Cancer 313 Plate 1. TRANSFER AND DIRECT TUMOR-SPECIFIC IMMUNITY. SPECIFIC TUMOR EFFECTS AND SURVIVAL Group 1 — Case Age Sex Cancer Tumor Effects Survival Time in Months Present Status 1 50 F Jaw NR 30 A 2 51 F Lung MS 24 D 3 50 F Breast NR 21 A 4 53 F Breast NR 18 A *5 54 F Breast NR 9 A 6 38 F Breast NR 42 A 7 3 M Bone NR 47 A 8 63 M Tongue NR 96 A * second operation for local recurrence Group 2 — 9 55 F Breast PD 41 A 10 36 F Breast DD 20 A 11 52 F Ovaries PD 12 A 12 22 F Trochoblast DD 60 A 13 48 F Skin MS 24 D 14 47 F Breast DD 6 A A. With Surgery-.......... ................... •.................... (21) 1. Adequate Tumor Removal ......... 14 Group 3 — 15 16 54 52 F F Breast Prophoblast MS PG 30 2 D D Group 4 — 17 50 F Lungs MS 10 D 18 58 M Lungs PG 2 D 19 7 M RES PG 5 D 20 58 M Pancreas PG 3 D 21 62 M Esoph. PD 3 D 22 61 F RES PG 2 D 23 60 M Mediast. PG 1 D 24 55 F Breast MS 72 A Legend: NR—No recurrence, MS — Marked slowing of growth, PD—Partial dissolution, DD — Dramatic dissolution. PG—Progression of growth, RES — Reticulo-endothelial system D — Dead, A — Alive Plate 1. CLINICAL MATERIAL C I a s s ification No. of Patients a) no spread ................................ 8 b) with spread .............................. 6 2. Inadequate Tumor Removal .............................. 2 3. Exploration or biopsy only .................................. 5 B. Radiologic Diagnosis Only .............................................................. ( 3) Total 24) Sept.-Oct., 1976 J. P. M. k. 314 Gomez Table 2. DIAGNOSES OF MATERIALS Tumor No. of Patients Duct Carcinoma, Breast ........................................................ 9 Choriocarcinoma ........................................................................ 2 Reticulum-Cell Sarcoma .......................................................... 2 Esophageal Carcinoma (radiologic) .................................... 1 Neurogenic Sarcoma, Lung .................................................... 1 Giant Cell Tumor, humerus with fracture.......................... 1 Adamantinoma ............................................................................ 1 Epidermoid Skin Cancer .......................................................... 1 Bronchiolar Carcinoma, Lung ........................................... 1 Lung Carcinoma (radiologic) ................................................ 1 Tongue Epidermoid Cancer .................................................... 1 Mediastinal Cancer (radiologic) ............................... 1 Adenocarcinoma, pancreas ......................................... 1 Ovarian Carcinoma .................................................................... 1 TOTAL 24 Table 3. SPECIFIC TUMOR EFFECTS WITH TRANSFER AND DIRECT TUMOR-SPECIFIC IMMUNITY Classification No. of Patients A. Tumors Adequately Removed .............................................. (14) 1. Dramatic dissolution .............................................. 3 2. Intermittent or partial dissolution .................. 2 3. Absence of recurrence .......................................... 7 4. Marked slowing of growth ........................... 2 B. Tumors Inadequately or Not Removed .................. (10) 1. Moderate to marked growth slowing.................. 4 2. Progression of tumor growth .............................. 6 TOTAL.............. 24 Table 4. SURVIVAL TIME AND EFFECTIVITY RATE Group No. of patients Range-mo. Mean-mo. Survival Ratio % Alive. 1 8 9—96 35.87 7/8 87.50 2 6 6—60 27.16 5/6 83.33 3 2 2—30 16.0 0/2 0.00 4 8 1—72 12.25 1/8 12.50 AU Groups 24 1—96 24.16 13/24 54.10 Control 33 1—18 2.7 0/33 0.00 Volurrie 52 Nos. 9-10 Cancer 315 Table 5. ORGAN CANCERS IN 33 CONTROL PATIENTS — Organ Site No. of Patients Lungs 9 Breast 7 Liver 4 Skin and Subcutaneous Tissue 3 Colon, Rectum 2 Cervix 1 Pancreas 1 Esophagus 1 Intestines 1 Bone Marrow 1 Muscle 1 Bone 1 Pleura 1 TOTAL................ ................ 33 Agents Used Table G. Case IMMUNOLOGIC PROCEDURES Group Tumor Effects Result % Alive A) BCG Alone 2 1 MS Dead 3 1 NR Alive 2/3 (66.6%) 4 1 NR Alive B) TSA Alone 1 1 NR Alive 6 1 NR Alive 7 1 NR Alive 8 1 NR Alive 6/8 (75%) 12 2 DD Alive 13 2 MS Dead 15 3 MS Dead 24 4 MS Alive C) TFusing BCG 9 2 MS Alive 11 2 DD Alive 16 3 PG Dead 17 4 MS Dead 2/8 (25%) 18 4 PG Dead 19 4 PG Dead 21 4 MS Dead 23 4 PG Dead D) TF Using TSA +BCG 5 1 NR Alive 10 2 DD Alive 3/5 (60%) 14 2 DD Alive 20 4 PG Dead 22 4 PG Dead Legend: DD-Dramatic dissolution, NR-No recurrence, MS-Marked Slowing, PG—- Progression of Growth. 316 Gomez Sept.-Oct., 1976 J.P. M. A. Table 7. IMMUNOPROPHYLAXIS Group No. of Patients Alive % Dead 1 8 7(87.5%;) 1 2 1 0 (0%) 1 3 1 0 (0%) 1 4 3 (biopsy only) 0 (0%) 3 Total 13 7(53.84%) 6 Table 8. LYMPHOC/TE PROFILES IN 53 CANCER PATIENTS A. Terminal Patients (36 Patients) Lymphocyte Count: Below 10% 13 10—15% 8 16—20% 8 21—30% 5 over 30% 2 B. Remitting Patients (17 Patients) Lymphocyte Count: Below 10% 0 10-15% 0 16—20% 0 21—30% 11 over 30% 6 Table 9. UNFAVORABLE AND FAVORABLE RESPONSES RELATIVE TO LYMPHOCYTIC PROFILES AMONG CANCER PATIENTS (a) Unfavorable — (.untreated) (1) Patient E.T., 33 yrs., F — Breast Cancer Initial Counth — WBC — 17,000 lymphos—14 Eost-2 Subseq. Count — WBC — 19,000 lymphos— 7 Ebs-0 Result: died (2) Patient R.T.. 40 yrs., M — Lung Cancer Feb. 3, 1967 — WBC — 13,500 lymphos — 19 Eos-1 Feb. 14, 1967 — WBC — 25,000 lymphos — 9 Eos-1 Result: died (b) Favorable — (With Immunotherapy) Patient L.S.. 36 yrs, F (Case 10) — Breast Cancer Jan. 19, 1974 — WBC — 17,000 lymphos — 3 Eos-11 March 29, 1974— WBC — 17,000 lymphos — 25 Eos-35 atypical Result: (lymphos seen) Dramatic Tumor Dissolution, Alive Table 10. COMPARISON BETWEEN SPECIFIC AND NON-SPECIFIC IMMUNOTHERAPY Workers No. of Patients Survival Time Survivors % Villasor 43 at 24 months 7 16.2 This Author 24 24—96 months 10 41.6 (do) (do) 6—96 months 13 54.1 (present survivors) Volume 52 Nos. 9-10 BIBLIOGRAPHY 1) Mathe , G.: Current status of immunotherapy of human cancers: leukemias, lymphomas, solid tu mors Med. Prog. 2,5:17-24, May 1975. 2) Gordon, B.L., and Ford, D.K:: Essentials of Im munology, p. 1-19, F.A. Davis Co., Phila, Pa., 3rd printing, 1972. 3) Dmodchowski, L., and Bowen, J.M.: Current trends in basic immunology as applied to the problem of human neoplasia. Am. J.CI. Path 62,2: 167-172, Aug. 1974. 4) Hellstrom I., Sjogren, H.O., Werner, G., et al: Blocking of cell-mediated tumor immunity by sera from patients with growing neoplasms. Int. J. cancer 7:226-237, 1971. 5) Villasor, R.P.: The clinical use of BCG vaccine in stimulating host resistance to cancer, J. Phil. Med. ASS. 41,9:619-632, Sept. 1965. 6) Navarro, M.: Personal communication 7) Abelev, G.I.: Alpha-fetoprotein in oncogenesis arid its association with malignant tumors. Adv. Can cer Research 14:295-358, 1971. 8) Gold, P, and Freedman, S.O.: Specific carcinoembryonic antigens of the human digestive system. J. Exp. Med. 122:467-481, 1965. 9) Gomez, R.G.: The Immunosuppressive Behavior of Cancer and the Hypothesis of Cancer Rejection in Man: The Significance of the Tumor-Host Inter face. J. of Phil. Med. Asso. 43,8:689-714, Aug. 1967. 10) Gomez, R.G.: The Immunosuppressive Nature of Cancer and Cancer Rejection in Man. First Prize Scientific Paper award, Phil. College of Sur geons' Annual Convention Dec. 1968. 11) Pineda, J.B.: Hemocellular Transplant plus BCG, Pulse Phil. 8,2:2, Feb. 1973. 12) Pilch, Y.H., and Golub, S.H.: Lymphocytemediated Immune Responses in Neoplasia Am. J. Cl Path. 62,2:184-211, Aug. 1974. 13) Griffiths, J.D., Mckinna, J.A., et al: Carcinoma of the colon and rectum: Circulating malignant cell * and five survival. Cancer 31:226 * 236, 1973. 14) Lawrence, H.S.: The transfer in humans of de layed skin sensitivity to streptococcal M substance and to tuberculin with disrupted leucocytes. J. Cl. Invest. 34:219-230, 1955. 15) Mannick, J A., and Egdahl, E.H.: Transformation of non-lmmune lymph node cells to a state of transplantation immunity by RNA. Ann. Surg. 156:356-365, 1962. 16) Sabadini, E, and Sehen, H.: Acceleration of allo graft rejection by RNA from sensitized donors. Int. Arch. Allergy 32:55-63, 1967 17) Hellstrom, I., Hellstrom, K.E., Sjogren, H.O.: Se rum factors In tumor-free patients cancelling of blocking of cell-mediated tumor Immunity. Int. J. Cancer 8: 185-191, 1971. 18) MacLennan, I.C.M., Loewi, G., Harding, B.: The role of Immunoglobulins In lymphocyte mediated cell damage in vitro. Immunology 18:397-404, 1970. 19) Perlmann, P., Perlmann, H.: Contactual lysis of antibody-coated chicken erythrocvtes by purified lymphocytes. Cell Immunol. 1:300-315, 1970. Cancer 317 20) Klein, E., Holtermann, OA., Case^ R.W., et al: Responses of Neoplasms to Local Immunotherapy. Am. J. Clin. Path 62:281-289, 1974. 21) Southam, C.M.: Areas of relationship between Immunology and clinical oncology. Am. J. Clo Path. 62,2:224-242, Aug. 1974. 22) Simmons, R.L.: Tumors in "what's new-in sur gery SGO 140:220-224, Feb. 1975. 23) Haskel, C.M. Silverstein, M.J., et al: Multimo dal ity cancer therapy in man; a pilot study of adriamycin by arterial infusion. Cancer 33:1485, 1974. 24) Gordon, B.L., and Ford, D.K.: Basic Aspects of immune Responses-Physiology of the Immune Sys tem, F.A. Davis Co., 3rd printing, p. 5-10, 1972, Phila., Pa. 25) Jones, C.S.: Transplantation and Immunity. SGO 6, 120:1317-1336, June 1965. 26) Hellstrom, I., Hellstrom, K.E., Sjogren, H.O., et al: Demonstration of cell-mediated immunity to human neoplasms of various histological types. Int- J. Cancer 7:1-16, 1971. 27) Marcove, R.C., Southam, C.M., et al: A clinical trial of autogenous vaccines in the treatment of osteogenic sarcoma (in Mathe' and Weiner-lnvestigation and Stimulation of Immunity in Cancer Patients; Vol. 1 (Springer, Verlag CNRS, Heidel berg, 1974). 28) Powles, R., Kay, H.E.M., et al: Immunotherapy of acute myeloblastic leukemia in man, (In Mathe' and Weiner-Investigation and stimulation of Im munity in Cancer Patients, Vol. 1 (Springer, Ver lag, CNRS, Heidelberg, 1974). 29) Sokal, J.E., and August, C.W.: Immunization with cultured cell-BCG mixtures (in Mathe' and WelnerInvestigation and stimulation of Immunity in Can cer Patients, Vol. 1 (Springer, Verlag, CNRS, Heidelberg, 1974). 30) Rosato, F.E., Brown, A.S., et al: Neuraminidase immunotherapy of tumors In man. SGO 139,5:675682, Nov. 1974. 31) Lawrence, H.S., Rapaport, F.T., et al: Transfer of delayed hypersensitivity to skin homografts with leucocyte extracts In man. J. Clin. Invest. 39:185-198, 1960. 32) Burnet, F.: The concept of Immunological surveil lance Prog. Exp. Tumor Res 13:1-27, 1970. 33) MacCarty, W.C.: Factors which influence longe vity In cancer. Ann. Surg. 76:9, 1922. 34) Wetherley-Meln, G.: The significance of eosino philia, The Practitioner, 204:805, June 1970. 35) Bjorkland, B.: Commented on by Southam, C.M. JAMA 180:343-344, 1962. 36) Itoh, T., and Southam, C.M.: Isoantibodies of human cancer cells in healthy recipients of cancer homotransplants. J. Immunol 91:468-483, 1963. 37) Kondo and Aoyama: The effect of Inosle on In cells survival following irradiation. Kobe J. Med. Sc. 11:31, 1965. 38) Rios, A., and Simmons, R.L.: Experimental can cer Immunotherapy using a neuraminidase-treated nonviable frozen tumor vaccine. Surgery 75:503, 1974. Lactogen "fulbproiein" The ideal follow-up formula. Protein needs increase in relation to a baby’s age and weight. And because the non-milk part of the diet is usually a most unreliable source of protein, the milk given to growing babies should compensate with an adequate supply of protein. Lactogen “full-protein” is the ideal follow-up formula. At full strength, Lactogen “full-protein” contains 3.24g of cow’s milk protein per lOOcc. By contrast, most humanized formulas provide only 1.5 to 1.7 grams of cow’s milk protein per 100 cc. So when a mother starts baby on weaning foods, make sure he gets the protein he needs at his age. Prescribe Lactogen “full-protein”. The ideal follow-up formula. Complete — with a full range of vitamins and iron in physiologically appropriate quantities. Nestle’ o rCi g £ PHILIPPINE MEDICAL ASSOCIATION NORTH AVENUE, Q .C . Statement of Receipts & Disbursements March 16— September SO, 1976 (With Comparative Figures for July August & September) ss ss rH K» s? § £ £ § § § 8 S o oi 606 o o 1 o S t* CM 1 xp ft I CO 8 ih of o 8 8 Ci s s <0 in S 3 s co 85 £ o 8 CO T—1 8 8 8 8 o o O rH r-< CM ci S § 1 oi T CM in o CD GJ t § ! o 1 jH r-5 £ 3 CM in CM I> in O in rd r-l 00 CD cm o 00 t* rH b- 00 CM 03 CM r-< t-H CM T—1 CD * “ C0 * “ rH CM CO in in in r * co d 00 S3 CM rd CM in § s g O CD in co rr co o o O o d d 00 . d cd . pi d o in o i> 00 1 3 133 1 1 1 8 s 00 * “ 00 * “ CM rH cm“ 'O c PHILIPPINE MEDICAL ASSOCIATION North Avenue, Quezon City Cash on Hand & In Banks & Short Term Investments September 30, 1976 Petty Cash ........................................................................................................... Cash on Hand .................................................................................................... CBTC-c/a (General Fund) .............................................................................. CBTC-s/a ............................................................................................................... PNB-s/a ............................................................................................................... CBTC-s/a ............................................................................................................... Bank of America — s/a ................................................................................ CBTC-c/a (Matef & DBP Fund) ................................................................ CBTC Time Deposit (Matef & DBP Fund) .................................... . Pasay City Rural Bank .................................................................................. Pasay City Development Bank-Time Deposit (Matef & DBP Fund). . FNCB-Time Deposit (Matef & DBP Fund) ............................................ CBTC-s/a (WMA Fund) .................................................................................. CBTC-s/a (PMA Building Fund) .................................................................. CBTC-s/a (PMA Special Fund) .................................................................... PNB-c/a (PMA Special Fund) ................................................................... CBTC-s/a (Dr. Romeo Y. Atienza Memorial Fund) CBTC-s/a ( Narciso-Perez Fund) ................................ CBTC-s/a ........ ~ ‘ ~ ~ - CBTC-s/a CBTC-s/a CBTC-s/a CETG-s/a CBTC-s/a (Culture & Arts Project Fund) ................................................ (PMA Medical Indigency Project Fund) ................................ (Population Council Fund for Family Planning Project) .. (PMA Medicine Week Celebration Fund) ............................ (Weight Reduction Clinic Fund) .............................................. (PMA FAPHEPI FUND) P 300.00 4,027.99 105,354.47 1,749.90 3,622.95 3,878.49 39,763.50 * 79,972.97 38,302.99 20,000jOO 23,497.11 32,850.00 41,579 63 22,460.00 4,516.01 2,000.00 4,000.00 3,619.99 3,326.59 4,89546 2.775.86 3,062.17 1,040.13 110.16 H46J0637 Money market placements — Matef & Issue Date FNCB P.N. No. 018574 8/ 4/76 FNCB P.N. No. 018533 7/27/76 DBP Maturity Date 11/ 4/76 10/26/76 Interest Rat© 13% 13% P343,161.60 363,076.17 706,237.77 Money market placements — General Fund & PMA Physicians Fund FNCB P.N. No. 8/ 4/76 10/ 4/76 121/2% 1846,040.16 FNCB P.N. No. 7/27/76 10/26/76 13% P224,643.19 570.683.35 Pl,723,627.49 RESERVE FOR — Matef & DBP Fund .................................................................................. 900,384.52 WMA Fund ................................................................................................ 41,579.63 PMA Physicians’ Fund ............................................................................ 186,204.32 PMA Building Fund .................................................................................. 165,804.26 PMA Special Fund .................................................................................... 6,516.01 Dr. Romeo Y. Atienza Memorial Fund .............................................. 4,000.00 Narciso-Perez Fund .................................................................................... 3,619.99 Culture & Arts Project Fund .................................................................. 933.09 P5MA Medical Indigency Project Fund .................................................. 5,375.46 PMA Abbott Research Award Fund .................................................... 11,396.94 BMA Abbott Scientific Speakers’ Fund ................................................ 6,538.36 PMA Medicine Week Celebrations fund .............................................. 2,881.72 PMA Weight Reduction Clinic Fund .................................................... 1,040.13 Calamity & Disaster Fund ...................................................................... 22,417.15 Population Ooundl of New York fund (for PMA Family Planning Forums & Seminars) ............................................................................ 2,775 86 PMA FAPHEPI Fund .............................................................................. 110.16 Journal Operating fund .......................................................................... 90,136.07 General Operatin fund & other reserves ............................................ 271,913.82 H,723,627.49 *US $5,680.50 deposit recorded in the books at the conversion rate of P7.00 to UJS. $1.00. HILARION C. DE DIOS, M.D. National Treasurer PREPARED BY: (Sgd) JOSEFINA B, CRUZ Accountant 323 Republic of the Philippines Department of Public Works and Communications BUREAU OF POSTS Manila SWORN STATEMENT (Required by Act 2580) The undersigned, HILARION C. DE DIOS, M.D., Business Manager of the JOURNAL OF THE PHILIPPINE MEDICAL ASSOCIATION (title of publication), published Bi-monthly (frequency of issue), in English (language in which printed), at Quezon City (office of publication), after having been duly sworn in accordance with law, hereby submits the following statement of ownership, management, circulation, etc., which is required by Act 2580, as amended by Commonwealth Act No. 201, NAME ADDRESS Editor: AUGUSTO J. RAMOS, M.D.............................. North Avenue, Dil., Q.C. Associate Editor: HIGINO C. LAURETA, M.D............ North Avenue, DU., Q.C. Business Manager: HILARION C. DE DIOS, M.D......... North Avenue, DU., Q.C. Owner Publisher: PHILIPPINE MEDICAL ASS‘N. ... North Avenue, DU., Q.C. Printer: SISON'S PRINTING PRESS .......................... 536 Quezon Blvd., Q.C. Office of Publication: PHIL. MEDICAL ASS’N............. North Avenue, DiL, Q.C. If publication is owned by a corporation, stockholders owning one per cent or more of the total amount of stocks: Bondholders, mortgages, or other security holders owning one per cent or more of total amount of security: In case of daUy publication, average number of copies printed and circulated of each issue during the preceding month of ........................................... 19........... 1. Sent to paid subscribers................................................................ , - ., - 2. Sent to others than paid subscribers ...................................... -____________ Total ______ ____ _____________ In case of publication other than daily, total number of copies printed and cir culated of the last issue dated, JULY-AUGUST, 1976. 1. Sent to paid subscribers .............................................................. 10,000 X Sent to others than paid subscribers ...................................... 200 Total...................... 10,200 (SGD.) HILARION C. DE DIOS, M.D. Business Manager SUBSCRIBED AND SWORN to before me this 7th day of October, 1976 at Manila, the affiant exhibiting his/her Residence Certificate No. A-3876454 issued at Quezon City on Jan. 13, 1976. (SGD.) LUTS F. TOLENTINO Postal Inspector NOTE: This form is exempt from the payment of documentary stamp tax.fc The more physiologic replacement solution... NORMOSOL-R pH 7.4 A balanced multiple electrolyte fluid with the same pH as blood 1. Normosol-R pH 7.4 has the same pH as blood or extracel lular fluid, and is more physiological than the pH 6.5 of lactated Ringer’s. 2. When needed for immediate replacement of circulating blood volume in hemorrhagic shock, pending administra tion of blood, Normosol-R pH 7.4 is preferable to lactated Ringer’s. In this circumstance there is a tendency for the blood lactate to be increased. Lactated Ringer’s may ag gravate this condition. Normosol-R pH 7.4 does not contain lactate as its bicarbonate source. 3. Nevertheless Normosol-R pH 7.4 provides 50 mEq. of bi carbonate precursor. This is nearly twice as much as in lactated Ringer’s. Approximately half is acetate, a rapidly available source of bicarbonate. The remainder is glu conate, a slowly available source. When the acetate has been expended, the more slowly metabolized gluconate provides a reserve. 4. Unlike lactated Ringer’s, Normosol-R pH 7.4 provides magnesium, to guard against iatrogenic magnesium de ficiency. 5. The sodium content of Normosol-R pH 7.4 is identical with that of normal plasma, whereas that of lactated Ringer’s is 10 mEq./L. less. 6. The Normosol formula contains no calcium. It thereby avoids the precipitation of calcium salts that may occur when other drugs are added. HOSPITAL PRODUCTS DIVISION A Division of Abbott Laboratories COMBINED ATTACK ON BRONCHITIS COMPLICATED BY UNPRODUCTIVE COUGH CLEARSTHE INFECTION CLEARS THE MUCUS An aggressive, combined attack on bronchitis complicated by unproductive cough. ERYBRON combines ERYTHROCIN® and bromhexine. The result is potent therapy with unsurpassed safety. At sufficient dosage levels, ERYBRON is: 1) Bactericidal against the bacterial pathogens most often seen in infectious bronchitis: Streptococcus pyogenes, Mycoplasma pneumoniae, Diplococcus pneumoniae, and many strains of Staphylococcus aureus, Bordetella pertussis, and Haemophilus influenzae, and 2) mucolytic against the bronchial secretions that are thick, viscid, and extremely difficult to cough up. ERYBRON is available in Filmtab® Tablets for simple b.i.d. and t.i.d. dosage regimens and in granules particularly suited for pediatric and adult use. a PHARMACEUTICAL PRODUCTS DIVISION A Division of Abbott Laboratories (Philippines) Mandaluyong, Rizal