I.

,
.


REPORT OF THZ DIRECTOR 03' TYE ?ICH'ITAL.

April 1922.

During ths ger?oa slma the last roprt wes written no

fundamental changes have been nado ?.n the gmzraL &an cf work or

in the chief problems engaging tha attention of the hospital staff.

The loss of an unusually large number of the meirbars of the staff

to accept academic positions elsewhere delayed progress to some ex-

tent during the early part of the winter.  bloreovsr, much of Dr

Binger'e ti;ne wan occupied with the trip to South America and Dr

Lundegaard and Dr Linder did not arrive until February.  However,

the hospital now has a fairly large staff of vio&ers, and the orgap

ization of the work ie more satisfactory than it has baen for some

time.

     Following the deprture of Dr Austin, Dr idorgan acted as

resident ph,ysician until the arrival of Dr Lundsgaard, and he carried

out the duties of resident in a very efficient man&r.  As he was,
the only assistant engaged in the care and study of &tier& with
. acute respiratory dishsea', tkie number `of these ijatients who'cculd'6~ I "
admitted V&E `nac&sariiy limited. ' Nevertheless, `during th& eiidmi.i   ' -

of influarha `it was' $,o$sible .      *
                to study a.numbar of patients sufferhi;

from this 'condition, and information'regarding the .ciitical features      '.

and evidence relating to.etiology ware obtained.   Considerable at-

tention is being given to the stuay'of the disturbances of respira-
tion in'psleumonia, and the oxygen c`bamoer, v&ich was built last ye,o.r
in V&d 6, is proving to be of much tise in this study..   It is ba-
lid'ded that through its employment a number of important quastione


rdlating to the @athology of res-niration rray be solved.

     Much atten:ion io now being given in the hospital to ths
study of nephritis and it Is hnped that In ths Imediate future,  tLC-

tlve pogrsse will be natie In this investigation,  Dr Lundsgaard,
Dr Edgar Stiltin ani Dr Linder are giving their entire t3n;o to this
wdrk and Dr Van Slyke is also LW& iptareated anr? Is g?.vhg it Me

time ar.d attention.

The following reports Indicate the character of studies

which are being carried an In the laboratories and vmrds at-d describe

the results which have reaently been obtained.

Acute Rheumt~a Fever.

Dr Swift, Dr Miller and Dr Boots.

     Aa the phy0iOiE~i8 of the city are becoming accustomed to
apply to the hosyital for the artpission of their patients suffering
from this dlseaee, the study of acute rhe--tic her has been facil-
itated by a fair supply of clinical material, . One difficulty is
that the p&&&e tire often not referred until several days have
elapsed following ths onset of the acute disease.   In the consldera-.
tlon of acute dis&eee in ,&&al, eSp$aially from the vieffpbin% OP
eticllogg; the desirability ai seeing the patie& at the one& !Le
self-evidend.  Ar we are continuing to &serve all of the patients
who hatie been under our cape ?or the past two yiara, and to readnAt
to the hosgjtal any of `km showing eliidence bf recurrenth,  we have
a better opportunity tb e'ke `&es@ tia?ly etages.

    %?I& value of d de&led and prol&qed clinical study of a
compiriati+ely era$ll grtip of jpiients suffering frgm a disease of


                                                                           t
                                                      . I ;*
                                                                         
                                          Phi

   such obscure nature is becoming more and n?ore auidensc.   Fro= our ob-

   serparti 0x1~ we are gaining the impression t'nat In roany patients the

   natur> nf "the rheurr;etic 5nfection" IY similar to that seen in syph,-

    iliST   there ard alternate 28ri@ds of activity and titemy.   In

   many of the patients It 1~ hard to erplaix, the recurrcmx of rhea-

   tic manifeetations on my other grmnd.   The uar!.oue so-called We.-

   cific anti-rhsmatic rmediee - such as sallcyle.tes or &to@33 and

   related compounds - s88m to act in niuct the fame manner a8 do keuf-

   ficieqt do888 of mercury awl iodirteo in eyphilis: they control the

   rymptoms snd aigne of the disease, but do not completely eliminate

   the stiologk agent.  These anti-rheumatic remedies em of value in

   making the patiept more comfortable and in preventing the severe gen-

   ore1 depression due to pralanged active lntoxicat%on; Mnu the petisn*

   is aeaisted in building ug his general resietancs.  It' `e8tNIM to US
w
   that rercovery is brought about in a manner eimllar to that seen in

   tubetculoele; the patient's own reaationtto the lnfectlon bqings

   about the cure,. .                                  .

        In .this connegtioa. the. .wUght charts of' our mtfeqte havq

   been of cmu~dereble inbemt:~ ,aa long as the psttenta continue tp
                                                                          .
  lose weight or fail .to regain the weight loot during the "8% ;/fBtageti,
                          i        .

   O$ the diSBB94, tier8 i8 little ti3ndeWy. t4l@W&3 oo@bte `re~ov=y,

   an4 relaptm ..f requeqtJy aoour.  Relapses are :ofteir heralded, bfr a

   renewed 10s~. of tight, and are practically efwaye accompanied by

    eimllar lo~see,  Attention. to the, proper. .nowlshment of these

   patient8 Is, .$+efpre, rqast. important :in treatmeht.  . it tis aeumei

   to us that 8 detailed study of this phass..of therapy might be of vkl;

   ue, for. the prevalent viewpoint. of "fanal infeetiohP and the` relief


@ovided by salLcylates &s directed the ettent?on &phycIcJ.anP ar%Y

from other general mrsnlfestationu of infection.

    During the past few months i new feature has 3~3 broxht

to our at.tention:  ~pany of the patients have shown an acute rhInitIs

w;?`;h many ffne punctate hemorrhages In the naeal mucosa.   This IriG;

have heen a feature of the recent epi%xnic of l'Influenza"; ths nasal

UIucOBa, nevertheless, tight easily have been tie point of e?trRnC9 04

the viros of xheurnqtic fever.   From these clinical observatirna We

were led to attempt Inooulation of monkeys by placing the lltrersi se-

cretionr from rheumatic patients with rhinitis Into the noses of mm-

keys, following the scarification of the earface of the turbinates

and IUWkl 8OptUUk.  The nosee of these animals were also packed with

cotton soaked with aaeel eeoretlcmr from ptients.   It VKW hoped

that the reeulting rhinitls In the monkeye mI&t allow the supposed

~Iru8 of rheumatic fever to enter the circulation.   At the aame time

the loge of the mdnkeye were Immersed daily in cold nater In order to

lower the resietanoe of the kn?ee and ankles anb thus favor the Im-

plantation of iaisction.  Thue far these srpeer5ments have failed to

educe aray of the ordinary mmlfeetations of rheumatio fever in the

monkeys.

     A detailed etudy ie beirg uade of the evolution and reaot'er;,

of the arthritis In wtlente treated with large amounts of antipneu-

moCOCCua eerum.  No detailed re&orts of studiee of this fox% of

polyarthritis are available; they are of value because a number of

observers have claimed that the polyarthritie of rhatic fever 5s
an anaphylactia manifestation or a phenomenon of hypersensativanesfl,

Wherever possible Joint fluid Is withdrawn from the serum diseaee


                                                                     ( /   -w

   patients to compre it with similar f1xA-l from pettents 4 th rxx%@*"

     tic fever.  A 35t.aiJed study of the cyt,ol.cgy' of the fluid iI1 both

    c9ndI tione ie jn progrecrs,

         Drs Boots and Cu2 J.en have coxiplote& a e tudy of tha recc-

    tica of the jo!.nt flucda from patj.ents with varicus forms of at-thri-

     tia.   meat-9 dete~i~tionq mro mM6:   !i) to compare the rem:ti.m
   of the exudates of the rarious form;l or a3hrjt.~lr; (2) t-J dti'ixlmI-?e
   If an acidity existed In infUmed joints of rhemtIc fever FatI.eJtS
   cufficisnt to permit the liberation of free salicylic acid follow%

    aalicylate therapy.

        It bed been eqgested for b number of years that the SPe-

   cific action of salicylatos In this dfseaee might be due to the lib-

   er8tIoa of free aalicylia acid In Inflamed tissuea.   Most of the

   dsterminrrtione were -de by the calorimetric method recently de-

.    scribed by Cullen for determining the hydrogen Ion concentration of

     the blood.  Rhere a sufficient ampuz$ of exudate could be obtained

   frcm the joint the electrom$ric method vlss uried.

        Hydrogen ion coaceatratione in 27 joint exudateo were de-

   termined; 16 of theae were from Inflamed joints of patisnte ill with
   aauto rheumtia fever; 7 from patientrr with arthrit+ of undetermined
  ki6in; 2 frw. joipts definitely infected with pyogenic bacteria; i
  and 1 of the fluids was an effusion int'a the knee joint of 8 patient
  w$ta aSrrked myocardial i&affIcIency,

          Retits: -  The reaction of the joint erudates from
   patients With acute rhewjpsitIc fever were all slightly alkaline; the11
                                     ' *
   &drown ion concentration varied in pH from 7.2 to 7.38.   Exudates

   from psfIent8 with chronic arthritio varied In pH from 7.27 to 7.4.


The i;H Gf `thi: joint effusion from the .a~j ent, ,vj th m~ocL.~di?~l ~CSYS-

ficiency w?Ls 7.33.  An exL3ate aspiratzd firm :hc bee Infzctsd

with S+;tp:rlo.~occus aureu- ilad a pII cf 6.63, 3:~ that frcr 2 `mar,

lrlfectec witn StT~$~CCGCCiS hen;olyticus 3.5 3150 acid, having a 2I-i

of 6.13.  These ro7iult.s SA:CN that all th3 exxiates we'*0 slightly al-

kaline oxcekt those fro:.. joints fr,fccr:td :iitir ,go;.xii: b:iCt:lTil-

      Since 3 djfinit:ly acicr .r,d~:~ is noz;;;arrj ior C.4 liocir-

atlon of salicylic acid from a salicylnte salt, ale skIc3 all tha

Joint exudates from acute rheumatic fever &atients wera slf&tlY

alkaline, it is highly imdrobable that fred sallcylic acid can dx-

ist in these Joint fluids follo*rlrq the atiinistratlon of salicy-

la tes .

     During tha psst winter the ptients wIU acuts rhacIllatic

fever h&e been treated with tolysln, ~,tiich IS thz trada m.38 of tha

Geman gresration "neoato>han" and known also in this country as

`b30cinchoya~~1.  Recently many raports have apyeared in meiical
literature calling attantion to the marked therapeutic and sli.ght

toxic effects of this drug in various forms of arthritis.   As we
have detailed studies of patients treated with salicylates, it was
thou&G advisable to carry out similar studies with the new drug It1

:

order to be able to state definitely :vnather there is a distinct ad-

vantage in using either peasration.   Ten stients have been treat-

ed.  The results are more easily lnterpeted if the -+tients are

divided into two classes:  the arthritic and the cardiac. Tha firs-:

tyEe is `characterized by a sevitra 2olyarthtitis with moderate or c3
cardiac involvement; the second, by marked cardiac disease and litti,

or no arthritis.


      Arthritic ty$e:  Five patients, p.i.1 Gd-titn7, wer-3 tr;a+:t?d.

The dose during tha first twenty-fnlr ho-us va5e.L from O.b! 50 5.22 Of

of a grac? per kilo body veigct; on :.ua folio:-Lnl; `Ltly c'. aC.n.i.`!sr:

larger, or mllar dose :ELS r;ivez accordl r.g *, 3 the app2raxc of tax-

fc spptomr,; nnd fo.- tile xs; t;io or thraa ;dsekB :ne (~CIT~&C ~93 grad..

ual ly dimlni ah&.

amelioration of the

improvement dQzl not

' ic action has been nyarked in all of tao +tients; in %a, the tCWr-
sturd fell from 104' to 96O F.   The differancs between toxic acd

                         4

therapeutic dose soems to be greater +&an it is with sal?.cyl.ates;

hence the drug has been dinAnished or d.iscontinued before severe tOx-.

lc eymptoms have appeared.  All of the _uatients showed karke.3 sTfl@t-

   lng on tha first da, 7' of a&rdnlsfra:lon; two had rxbusea; ncna hare

   vomltad; tlnnitus, deafness, vertigo, have &en absent or only slf.gn5.

   The urine of two of tha patients showed a slight incrZitso in albumin
s

and caats;`no markad or dsrmanent toxic effect on the kidneys has

been observed.

     Cardiac type:   Four patients, all children were treated;

the dosags varied between 0.13 and 0.26 of a gram per kilo body

weight per day.   In each case there xas a fall of temperature to sub-

normal within eighteen hours; this maeffmrked antipyretic action of

the drug In children la noteworthy.

In both children and adults it has been possible to ndn-

tain a normal temperature with smaller doses of the drug than were

administered on the first day; in several cases tn which the dr-.q

WLS discontinued or decreased too rapidly there has been a return. c9


cutaneous nodules were due to the srtscnc:> of l~rv'1.1 folsls srd
possibly adult male ;amiites.   The pttripz I'deitj s reaction ydckly

kills the worn a;?& insures that it is re3joved fxm tna body xitnout

bring able to ccntinus !.ts aztivlty.   Tns b?is'.er, ii1 t.\e ??arly

tion of one e&-s to `;hs exterra.1 aorid m.:re they rsm in i;oji t:m YO

infect new bob:%.  Tie harti oeen unable to find a.3~ rdfsrtnce tc ary

exactly Eimilnr e-213 of para3itism.   w fres a3ul t male wcrm has

not bees! founti..  Fa this rzmon ?+ ha.8 not 1~n LlosHib?.e fo :la:;s$..

aif? f"". Trichosoub~ cut&bneLm.

Dr Van Rlyke.

     The aozk begun a mar a~;;, in collaboreticn with the li;tbcr-

atory of L. J. fIenderson to obtain tits on the reqi?atxy ch?ngx
in blood was coutii-xed by Cullen ar,d kus';in until thay Left, tind


.

.

: *

since then by Hastings, Heidelberger and Neill.

      The react ions, the quantitatdve relations of which form

the object of the study, are represented in the accompanying diagram,
presanted chiefly as used in a publication last year (The CO2 car-

riers of the blood.  Van Slyke, Physiological Reviews, I.)

Pl.asma.

> H2C03 + Na Protein d,

H Protein + NaHCO2 .

(2) B2C03 + NaCl '=,

NaHCOg + HCl ;

H2CO3 <

02:

zed Cell
w.

H2C03+

-) 02 e

3

(L) HCl + K2HP04-
    KH2PO4 + KC1
(4) 2 HC1 + 2 KHbOz `T

2 KCl+  hXbO2
   HHb + 09

is, H2COS + KLHI-'04-
  m-so3 + KE~PO4

(6) 2 E2C03 + 2 KHbO2,

  2 KHCO, + c abO2
       ZHb + 0s
c

     $11 6 reactions are forced from left to right by increase
in H2C03, which results in fomtion in the plasma of NaHCOa from z
sources (Reactions 1 and 2), and in the cells from 2 other sources

(Reactions 5 and 6).  The acidification of hemoglobin that results
from H2CO5 increase results in partial loss of 02, as indicated by

the last stages of Reactions 4 and 6.   On the othe9 hand, increase
                                                                .


1
i

! .
I

.
i  0

I
t*

through 6 and 2 sets H2C03 free.   By these yeactions oxygen pushes

CO2 out of the blood in the lungs, and CO2 pushes oxygen out in the
tissues to the assistance of both CO2 excretion and of O2 absorption

and utilization.   It does not appear that our understanding of the

normal resplrsLtor7 krocesees ~i.11 be as complste as is attainable,

nor our knowledge of the abnormalitl~a in ?.L~easo, unt 3. the o-anti-

tatlve relationship of the above reactions are worked out, and the

technique to do so seems now to be available.   A certain amount of

data hao already been collected, but as the results are still incom-

plete, we shall report them later &en they permit mors comprehensive

  oonclueJ.ons.  The indicated ratie, in the final stage cf C?a*tions

4 and 6, of 1 molecule of oxygen freed for 2 molecules of hemoglobin

set free from combination with alkali is approxlmte, and ths q;lanf3-

tatlve relations of the other reaetions have beast apprDxime.ted, but
we hope to fix them closer with the technique for control of 02 and

10 co2 tension, for blood gas azzJ.yses, and for blood electrolyte deter-

minations, which is now in we.

     In connection with this work 3r Heidelberger has devised a

new technique for the preparation of crystalline, electrolyte--free

hemoglobin.  He -has found that hemoglobin under proper Conditions

can be readily made to crystallize from watar solution by saturating
with a 4 to 1 mixture of CO2 and oxygen.   The crystals, which come

out almost instantly, can be purified by redissolving In alkaii, an&

recrystallizing with the gas mixture, and are finally freed from

electrolyte by rapid dialysiii through collodion tubes.  By this

means crystalline hemoglobin has been obtained frea from electrolyte.:


i

and with its full oxygen capacity.   It is doubtful that this has

been accomplishad by previously available ma+chods.

     Dr Heidelbergor hae at the same tive mde dafi:lite advan-

ces in the purifCcn?ion of the substance discovered by Avery in the

urine of czrta!.n pn3umcnia ;Eatic?nts, which forms yrecipitates with

epeciflc an:ip3oumxr-ccu;c, 93x2.  The detailo till be reported*by

Dr Avory.

     Xise I1~1le.r :~a: ftnichec! an ;z,vesti~ation of the behavior
of the d!.ffcrent prstcln precipitanto used in studying blood and Pro-

tein n1=rrts.  The precipltanta inc!udo dicric, trlchloracetic, meta-

*oe$Aoric, and tungotlc acids, co~lclfial iron, mercury salts, and

alcoir91.  The amino and peptide nitro&ena wore determined in the
filtrate8 from blood with and'withouf `ihe adtitlon of known'amounte

of amino acid and psytone nlt;rogen.   Ihe action of the yreclpttarts

on llF1tt.s peptone solut:onj was aleD ct.dit:d, In order to ascertain

which ones remove most completely the !nt&raediate protein products,

ana &ich remove the protein with a mindmum of the intermediates.
The data 0.otained will enable fature investigators to `choose precip-
itanfa ad.ayted to their ea&cial objects in a &y that has not here-

tofore been possible.  !?~e Immediate objezf of thfa work &S t0
                                                                    .

ascertain conditions for studying the abeor-&ion of intermediate "
product8 along with tb3 amino acids during iprotein digestion.   We
hope to attack this problem, &ich is an un!?inished portion of the

study of the fate of protein digestion products,

      Miss Hj.ller has also been preparing a supply of. the unkncwu

amino acid discovered in the hexone baqe frection of gelatin, for

future work on its cons titutfcn.


11.                                      ---..--_  --_ci.s . . _ .- - ..-- - -  . .   -- -

,

? :*

c .

. .
f  hii.

     As pr6ser.t Lhe is engaged on a method for determining

blood fat in the piasrra of nephritics .  In the type of nephritis

known as neshrusiu:  chs most abnormal fat tor in the composition of

the blood a.p$ears to ke the hi& "at content.   Since ;ve are direct,-

ing especial attenj.+xi tow%ds this class of patients, and pri.sent
blood fat math&s ara oit.hor unzatisf&ctory in accuracy (the A.&-

elometrlc) or r::qu'.re cons irlernbl 9 axJuM'3 of blood (gravimetric)

the possibility of findtng a technjqde that will yield reliable re-

sults oc am311 amount8 of material seems to justify the attempt.

      fn connection \ti th our studies of acidosis two theoretical

papers have been prepared, one of which, entitled "The nornd and

abnr,r,ral var:stl.on of the acid-bnse balance of the blood" has been

publiahsd.   In it the demonstration tas been rude on the baais of

facts found in this azvi other Laborator!.cs, that associated with

each condition of hi&, nortls~l, oA. J,UW `Llood bicarbonate may be e.

high, normal, or low PH.  Q..~m ars thus 9 possible and actually
ob%srved combinations of B3CQ and pH, of ~&ic,h only 1 ie normal,
viz. t&t in which both pH an.d BHCO3 are normal.   Fach of .the
other k conditions indicates a specifio abnormality either in the

me'tibolic processes by which non-volati?.e ncide are fomed ati ex-

creted, or in thei respiratory prooeaess by which the CO2 tension in

the bLood is regulated.  For the general diagnosis of an abnormg.1

condition, determinations of both ths $3 and bicarbonafe existing

in the circulating blood becomes cbvfously necessary, although in

special conditions abnormality in one factor is so characteristic,

such as ?he 1~ MC03 in d-labetfc acidxis I that the other c-1 be

---


neglected.  In connec ;lon :vlth our nephritic 2er7ic3, the aatar-

mination of the acia-bare balcnce by combinerl ,Y ami ISiX estina-

tion has already proved of clinical value.

     Z'or the pJ eJtlrtaticrn on p1a~rr.a a method simpler t&n t&e

slectromatric and .mo:a rccurate than yrev!.oua colorim3tric oneo be-

came necessary.   If xx8 sup~lisL In tile ;orm of an improved cJlori-

metric technique by Cullen.   Eo founi t;?iLt If $ssma is diluted

with 20 volumes of naut*1 saline solution, 7ithout loss of CO2, tha
pH deternllned colorioratrlcally at a0 ;4iti; 3henol.sulfone~ht;lalein as

indicator is identical with tha electrorietric, and increasas by 0.01
for each degree balont 38'.   Colorimetrlc determinations performed

at room tempelusture, nrlth tha indicated correction, agree with the
electromepric estimation performed at 38' with an average difference

of only 0.02 pR.   The method has already been used in experimental

work on dogs, and Is be:ng emgloyeri clinically with m&ritic patienta.
It is about to be employed by Dr Neil1 in a study of the, at present,

somewhat confused question of the atate of tha acid-base balance in

pnqxr2onls. (

     The other theoretical pape r is on the subjact of buffer

measurement, tana the buffer values of sneak aoids, bases, and ax&hot-

eric substances, of various dissociation oonstants.   bespite the
vmrk that has been done with buffers, these relationshiys hava not
heretofore been xorked out; in fact, there has not even been a unit
for expressing buffer effect in qualitative numerical terms.   As

such a unit we have used the amount of strong al%ali or acid required

to cause unit. cnani;e of pH.  On this basis, a solution poes3ssss a
buffer value of 1 when the yH chaixes at ths rate of 1 unit p29r graj1'


mui-ralect of aided Etrong acid cr alkali .   bdatheiz3tiCai~y eX-

pressed, the buffer value of a solution is cl B , v,hen d3 is the in-
                           d 2H

cremont of added strong base (NaGi or KOid) , d &I the ~cco~~r~yirg

increment of pH.  From the quantitative known relationships, form-

ulated act jrding to rhe rmss Law, of hyCir:.on concentration Co the

s ible to dsrlve by means of tha diffcrontlal ca!.culus a genenl

equation expressing the buffer value of any buffer solution, viz.

                               I
Buffer value , d B . 2.3 `KC iid
         1                +  !;H+ 1 + [OI-ij \
          d pH    ,(K + [H+j j2

For weak acids as buffers, R = <,  the acid dissociation constant.
For weak bases X t 10-l'

            Kb   , .vhere Xb is the dissociation constant of

the buffer base.  For solutiorx near anough to neutrality so that
&+I a.nc?. $i)  are relatively negligible, viz. betv?een pH 3 and $9.

11, a zone covering nearly a&l biological solutions,the equation sim-

pilfies to

    Buffer value = , d B z 2.3 KC CHil
                  d PH  m+ + (H-9 )2

As is evident, the effectiveness of a given buffer
every (H"f .  The ef%ctiveness of every buffer at

the same curve, which reaches its maximum ken Km

and becomes insignificant when the P&tic H
                  pq falls

is different for

outside the limits

100
1  and 1 ) that is, when -10;: R differs from &H by more than 2
      100
units.  Pelt its maximum effectiveness, v4~en K* (IX'] any buffer is


half in the form of free Luffer acid or bask, hall in tile form of its

ealt.  At. this point Lh9 V?IU? cf 2n F/i 9OlU~5OlA (Akere c: = 1) of I
the buifer is 2 3 K2 =
    z*z 2.2.  = 0.575.  'b3 L~O~6CUhr commtration,

and hence the molecular weigllt, of (L di.ssolved buft'er may be ascer-

tained by dlT;ding U.%5 by the rbzieroed max!mum d d   ta lue .   me
                               d PI:

a

,

J A@

r;H change, (d PHI.
   The [Hq of maximum buffer value a Iso jrxiicateti the 6lsso-
ciation conetant of the buffer acid or b368, slncs at this point !>g

- K.

c For buffers containing more "c&n 1 buffer grouti (polyvaien,

weak acids or basee,
       .       or amphoteric substsnczs) the buffer value is tne
sum of the buffer values of the different grousa .

    The above principles are being applied by Dr Hest$ngs to a
8tudy of hemoglobin, and have already yi3Idad restllta,
    The question was Maently raf.sed by iham, of England, AS
te *ether elestrcme*rfc pE est$mationc on CO2-containiry; 861u~tiorls
                                  ,
are valid.  Evans 02#.sx+I that some acii is famed by rsduotior- of
CO2 B the electrodoa, and causes &he pH to be rPsrkedIy too 10~.
Cullen and Hastings have checked the m?,ttcr ug carefW.ly on phos$stJ
solutions with a?d ~ithous CQP, and found theoretical results !.n bc th
cask,  They beliwe Evans could. not have been suff icientlg accu.r*at


i 59.

in regulating the CO, tensions in 111s elactroc?ss.

     The study of nephritis is ba!.ng continued by Dr Edgar

Stillnan, who tns now bean joined in this problem by 3r Luncis@ard

and Dr Linder.  It is our intention to p rform on e considerable

number of atienta &yslcal examinations, blood an-?iyees, and func-

tional tests, accord:ng to a routine wLic> will be establlskcd

chiefly on the basis of the data alroad;* avail.ab!a from Stillman's

work, to follow the clinical histories of the cases arxi rageat these

examinations at Intervals, and to use the data thus gained in obtain-

ing eventually as logical a claerlflcatlon of nearltls as may be

poesible, and of treatment according to classification.   It la in-

tended tiile these data are balng accumulated by relatfvely short

obsarvation yarlode on a fairly large numbar of ne2hrltlcs of all
kinds, to attack one at a time certain s~ociflc droblen;s that arise

in connection with the study.  For exaqla, as already stated, the
abmxm&ly high blood fat of patients of +,ha so-called "nephrosis"

type raises the question of the mture of tha metabolic dlsturbanca

dliuh causes the Lipelmle.  Absorbed fat Is normally either.burned or
deposited in the body's fat depots so ragidly that it never rise8 %n
the blood to the heighte found in these patients.   The question is
Pre-ntd 68 e Netbr such~pitiente fail to burn fat 88 tipidly .&s
                  .;
nOrm& indivldu&, gnd we have prepared to obtain data on it by
means of total metabolism experfments following fat f ceding.

Another epeoff ic questlon is whether in so-called hydremias

there is really a dilution of the blood, with increased total blood

volume, or whether the low protein content of the blood Is due to

decrease fn tbs total blood protein content of the body, tit&out , -


,L c' .

increase in blood volume.   we hops i:o cbu,ti in in~orzzat!.on on tnls

point by mans of the available bLooc. ~c,l*.c?ra nztl:~~~?%.

Heart Discs.

Dr Cohn alrd_Dr Levy.

C&Lnidine . -

     The study of puttiding which vo cczenced last year has

been continued.  At that time our experiments on dogs were designed

to show the effect of this drug on the behavior of the heart, from

the point of view of the circulation as a whole.   We showed that

sxrall doses (0.01 to 0.04 grams) lowerd the blood yreseure distinctI;,

for a brief period of time and that a srtial recovery cnly took

place.  Of greater Importance was the fact that at the 5ame time a

favorable effect on the contractile ~o:iver of the ventricular muscle

took place.  This vas m8aSUr8d after opening the cheet in the mid
line, by means of the Roy and Adami myxardiograph which gives an in-
d8x of the shortening that takes place between the base and apex of

the oentr/cles .  The question arose a8 to whether this effect, which

S8emj to be important, did not result from th8 marked fall in blood   1

pressure.  fn order t9 elucidate this goint we c&pared this effect

with the result, in identical preparations, after bleed.$ng and after

the injection of histamine.'  We fcund that when the blood pressure
was lowered to the e&me degree by these procedures as with quinidine,

a similar increase in theheight of the contraction wave did not

occUr,O or if it did occur, that it wag a t8mmrary effect, quite ur.-
like the continued change in this respect that we had seen with Q"-~TI

idine.  MeajWhile experiments on hemorrhage in dogs, $e rformed b,!


.

i&.&c and zys$er iqers reL;oytc,q i?. ,,~TLc\~ tG.~l. `1'1,t ert.',ngs uUll?;rable in
size to 0~:s kvero produced. z:ld Ln &i,:ll n.i~~ si.zs 3gd output cf the

heart were directly measured by X-re.y ?n;l cdrdiG-m?ters.   in these

axperiments 3s in ours, no cunp q-,es xaticec in the output of the

hear%.   Ye have Corroboration then that sz1rl3 bnmorrk%es of about

1 psr cert cf the b&?y wei&klt 920 ;lot tol! 5.J'?. ?-~y a r3kwqi: in wt$.It;

this IS the conclrsxoc to k~ich v;e :x:; 3,  ?:: J ~1.3 tl-,e q,v~nn ~d~ogradh,

which gave us a linear measure rather ~kr.:~~ il:e LU.~~C ons cf '.he car-

diometer.   l7e think we are t,h3 m;re ,iu;;;:i-.'.ied, s+nze havine, insti-
tuted this comparison w? th the effect of hi:;`;amine and of hemorrhage,

in concluding that there is an effect on '&,j contrhct:le power of

heart mscle, quite apart from any effect 01 blood pressure.   In

what manner the increase in the contractil,; power of the ventrlcl3 is

brought about we have r&t asccrtainzd.

     This year we have addressed ourselves more es$ecia!ly to

the effect of quinidins on certain functicns of the heart mnecle.    .(I

will be rememberdd Lhat in 1908 A. G. V!ysr showed that ?n med-,%a

                                                                           .
prepared in special v,ays pi single j.q &se oould be start&d at a glvelr
pain+. of a ring of Muscle tissue and that the imp~~s3 so started woxld

COUTSB around the ring, rat.urning to the joint at vrhirh it began and

would then contim around the ring again p8 rforming *Air c<rcui t 3.n-

defin5 tely.  Mayer believed that this w&s a type of cor,`xaction wavti

which, although obv!.ously possible, t,Le !!l;ructure of the organLam as

a whole, through its innervation, served to prevent, and that eimila*

circuits w8re not to be found in nature.  In 1913, '2.~2. Garrey awl.

G. R. Mines both amlied this suggestio:\ cf ikayer's in sxperi;iie~~.s >I

their own in Ioggerkead turtles and in log-fish.   Tnay were &la :.i

repeat his results and developed the tLoue;ht that t.his "circus" t:w


.

0 -

of impulse mvement lay at ti,? ~.,.t-x. 0: ",I.+ :.j.!.xillatory process as

it is 8een in marrmbllan cardiac 5i3sui.   It VJaS clear in their 0X-

perimente that a circus in order to continue required a ring or 1~6s

of tissue of euffioient size; ring8 or bits of tissue Hmich WeIB COO
                                                                **
small failed to rugpokt the circus.   Thnre are twa reason8 for

this,; fint, If the paths were too small, the impulse retied to its

rtarting flint to find the muscle it had just left in a refractory

6tate, uble to be rr-excited by the returning imgulre, and this

occurred irrsrpectivs of the rats at which the impulee wa8 propaga-

ted.  fn larger rings both theoe factors wera important; the rate

of aonduction and the duration of the refrectory period.   In elabo-

rate experiroents in dogs, Otis by recording action currents, found

that after he had induced fibrillation In the auricle@, he could

aatually Identify and &lot the locetion of the circus.   Later he was

able by using three suitable simultaneous leads In mm to show by the

method of Elnthoven that, during the progress of. a eingls eleotrio
wave rogreeentlng auricular activity in the fibrlllatory eta&, the
dirsotlozi of the aatidn current wheeled in (L taingle plmc thrck#
3600,  Thir 8wnM to be sstfefeotarg eoidenae of the lWr&& of .?

CirCu8mov8memta inman. -

   At this pobat we undertook our invertigations to esfeblieh
which fumtiOn6 of the heart amscle quiaidine affected iu termindting

the flbrillatory process in the auricles.   Our simwas to study tho

rata of conduction and of the refractory period; it wae obvimly

unneoerbary to determine the mass of tissue tnvolved.  We amployed

doga, under ether aneefhesti, given by the method of Melteer and

Auer.  We opened the chest in the medien and incised the pericardkw


J `.

b

? o ?

sufficiently to expose the right auricle cnl:*.   To the base, of: Lb.3

auricle, near the haad of the sirio-aurku~r node, was sewed the

wick of one non-polarizable electroae, tlra circuit of vihich through

one string galvanomater ws cnm$latad. by an indifferent electroae in-

serted in the skin.  To trre apex of the aurkcls, another wick ~8

sewed, the circuit 31' ?vhich through a second galvanometer was com-

pleted as in the first case.  The movements of the s trlngs of both

galvanometers were &otographed simlt%mously x. the sam fil5.

Since we knew the distance between the two cardiac electrodes and

oould calculate from the records the difference in time of the a&War-

ante of the action current at the two points of the cardiac surface,

we could calculate the Fate of conduction through the muscle.

     The refractory period we studied by stimulating the aurlc1e.s

with break shocks.  This us done by connecting the seconddry coil

of an inductorium with the right auricle by means of a pair of fish

hook electrodes which atayad per?anently in place.   The primary c$r-

ait ~8s closed by tha following device,   On the same shaft were

mounted three discs, on each of which there projected four knob

equally spaced, the whole driven by a motor belted to a pulley also

on the shaft,  As tha disc8 revolved, the knobs grssaed down keys

each closing a circuit.  The rata of etlmulation was varied .by

changing the speed of the motor .   The first dim controlled the `bay

of the primary circuit; the second one, eynchroncus with it, that of

a signal, the motions of the armature of which were photogratihsd on

the record; the thfrd controlled the secondary circuit and was so

timed that this circuit was short circuited when the primary clrcu? t

~a8 made and odened before the primary circuit was broken.   In tinis


.

vuay only break shocks were cou,municated to the zuriclos 'L~~oJ& the

fish hook electrodes.   To measure them the fibs vare projected on

a screen so as to magnify the cu~`~es.   The tima intarvals which a$-

pear on the films aro ordirates 0.04 second aprt.   ?.hen the E:`.l!ns

were projected the distance between the ordimtes was 30 m., so that

each mlllimetsr squalled 0.002.5 second.  Two errors are possible in

this measurment; f lrat, an error in the tuning fork xhlch controls

the time wheel, and second, Inequality in tha rate of motion of tnt?

film between two ordinates.   These are errors, however, ::`nich GO not

affect the third place of decimals.

    In estimating refractory periods the time between a given

P-wave or `wave of auricular activity and the stimulus, which could ba

eean ae a small sharp deZlection of the curve and which could be iden,

tifisd by the sigxsl, -8 roeaeured.   Certain stimuli were followed

by aurfcular responses; others failed to &roituce this effect.   !%en

these msasurements were arranged chronologically it was found that
they oould be separated easily into two gmups; one of no responses,

the other of raeponses,  The last msasurement of the group of no

ree2onae8, wao, of course, the measure of the refractory ~eriocL

Ihe resulta of the& 8x~erimsnte with quinidtne &ro a8

ti;nei bcarcaly changed, `but' it wa8 never raised.  This r&t so far
aa the theory of fibrillation ie concerned is anunfavorable result

or, at least, one v&lob doea not contribute to succeee in teralnatirg

a circus. . . On the refractory period the'effect was materially to ix.-

crease ite duration.  This did not occur uniformly, but did a0 In

the majority of casee.   This effect is favorable.   In certain


                                                                 '

                                                              f
                                                 `185

instances t`ne increase MS not great,  but in othe;s it. a".c/a71,sd. ts

b from 50 per cent to 100 per cent.   This increase is sufTiclE;n',, tak.

ing into consideration tha probatle length oi the circus, to r)VPrcom

the u,favorable eff3c.t on ti.2 rtite of condL;tl~n.   The increase in

duration or` tile refract cry 2oriod in in sin: of fact the more strik-

ing bacaLoe th6 rake of the hoart usuaily increases considerably after

giving +inidine and an increase in rate is associated .vith a fall,

not ir rise, as occurred hare, in this r3asurtiuar.t.

     Attention should be diroctod to the lack of unIfD:mity in

m ref3;lt.s.  These, it will be recallal, are paralk3l with the kc:

of unifordty rtiich has been encountered on giving quinidine =a

*pat idct ? o  Ti,ere siccees has follov,ed a&AnistratIon in about jo p.

cent only of the cases In vhich this rerrsdy has been admirlisteied.

&ring the course of these exprirtants, similar ones by &.xis have ap-

peared.  His differ f ram ours in that h8 has striven for uniformity

in results, 9liririnati2g the influence of two factors vhich might po-.

duce variations, namly,  tha rate of beat and the influence of the

vague nerves.  The rate he raintained uniform by rhythmic stirmla-

t ion; the vagi he eliminated by injecting atrapine;   Under the88

circumstances he obtained uniform results,  His experiments are

corroborative of ours in princi_~le .   %a two Set8 COnSidar8d to-

gether point to the factors b-&i& c;re perhags concerned in thj di-

vergent results seen in the clinical results dith this drug.
     we are COntinuing expriiments in this subject, with the
                                               .
Vi8W t0 88eing What t?Ae effect in the aCtiOn of quinidine is of

vague atiz2A~tion.  In view of tha well known effect of morphine i.ri

~stimulating the v&g23 .2&L3nisc, .w am trying this means first.


                                   --T&j

                                                ;
                                                               .

Ynaixxxi t Is2
        -*

     l,'!e bve continued tk,;d investigation 02 ii;s XCl.an-sm of

the r.eart in cases of rheumatic fever stuaiea by Dr S:vift.   Trl i

ckia~as whlcn **ere found last yaar we contirrue to find.   -1; p.;3 ? L  f ccra

day to day altaratlo2.s in tne col;duction interval bet,x&l aT1?Clc?.es

and ventriclas take Jnce, inaicsting yro`ccbly cont!nuow ii-t.r.ngs lr:

or damage to the aurlculo-ventricular system.   Ii.2 t i4rwsentl.;
                                                                .

PDnges in the ventricular complexes  0 f the elestrocarciio~Pw~ ay$ear,

mic.kk indicate tnti occurrence of a disr?ase prozess in th3 v>rtricL?s

of such a nsture as to interfere with the nor1131 pro,ri3gation >f thl:

axcltatian impulse.
     It is, of coxse, already known t&t heart block, pa?tial
or complete, Is occasionally ancounterzd in this disease, but for
the ~ontlnuous variation fros day to da;- in most cases, ;ve were not

prepared.  It se3n.a to us not improbable that -.wight may ba attwhsd
to these findings In our study of cardiac involvemant in rh.rwnatlsm

and that evidsnce of thi: sort should be considered In making prog..

noses.

    llhese frequen% alterations In the behavior of the heart,
have sugsested a study of the limits of variation of behavior in

normal persons.  Wa are now engaged in collecting such informtion.
we hake bean at pains to find s lx &ndivlduals whose health is sound
and whose electrocardiograms correspond to an ideal of normality.
me intend to photograph the three usual leads simultaneously and
have arranged thrae galvanomaters for this purpose.   In no other
-Y can we be CXMain of estimations of the directton of tha an,t,i.lp
current and of its progress of the excitation WW~ through %he


.
r

)

.' I 1)

heart.  In view of the fact that ressirat ion al ;ers tile Ynrm of the

curves, we ?,;avu a.rrai.se-1 to record sircultanooasl:r o-1 tho eiectrocard-

logra&ic f ilffi a c-uve of tie resp%ratz>ry cxcirsions.   These r3s-

rir&tol`y CUVJS are to be ci;rvtis of tke acu) tidal air.   The

inlivid;uals ar3 to b2ea%e into a spiro.ietur.   The L'3'ltmCts of the

spiroi tr?: ue co..Te;ed to a p!.ston re3 )r;l,r; this rr:c:rder *.I; con.

r.ected ;vit'n a second ,icton recorder, t'r,o :zt:ots of t;;~ .lovdr oi

which are &otogra,hea.  A change 01' esch 100 cc. of ,Ir Ln the

qirosleter is Bipgallad and &otogra$ie.!.   This is ~ccoqlished as

follows:  as the clown of the sgiroirster rises and falls its scale

FOintdr passes over a series of contacts Groperly spaced, so complat-

ing the si@nl circuit,  At the ~LLU tiae the curve of respiratory

motion Is being inscribed.  A coqarison of this curve, &i 21 by

;-3ins of thd signal permits an estiuta of khe VO~ULIB of the ti&l

Bfs, :vith the electrocardiogram ~111 allosv us to draw conclusions of

the effect of &aaes of respiration on the cardiac curve.   "Ihe 68

curve8 a2e to be taken dally for a period of 10 days.   V?a ought then
to be k% possession of data &lch will give exact information on thd
degree of uniformity of behavior of a group cf nor-al individuals.
In terms of these findings we shoxld be abh to tell how great a de-
viation kom normal the rheumtic ;patients exhibit.

clinical Studies of Culnidlne.

The introduc%ion of quinidine into clinical mdicim may

perhaps be regarded as the ma&t important adv,ance in the drug therq-r
of heart disease since Withering's account of the foxglove jn 3.`18.i;
for it Is unique as a pharzacothera$eut ic age:lt in that it ser &s t 3

restore to nor-1 a disturbed @yslologic LUX&.XI~~~.   It has also


furnished a valuable means of studyir,g the nature of the 2-i Aurbance

which is at the basis of fibrillation and flxtter of the auicles.

Ir. Yliy 152;. b ;crelimil;nr;r report was published on "Restor-

ation of the nor:21 cardtic mechaniu in awicular fibrillation by

Quinidine".  In that pitier, four cases were described,- in two of

vblch it was possible to restore the  sinu s rhythm by oral administsa-

tion of this drug.   Iking the ynst ye;&-, twenty-txo pat lents with

auricular fibrillation have been treated.  In dine (40.9 per cent)

the normal rhythm has been restored for varying lengths of t irrb.   A

detailed study of these caaee hae been made.

     The drug has been adrcinistered by mouth k gelatin capsules.

After a preliminary dose of 0.2 to 0.4 gm. to test for idiosyncrasy

to member6 of the cinchona group, 0.4 gm, have bee:1 given three time
at intervals of two hours on the first day; four tiues at similar in-

tervals on the second day; five times at similar intervals on subee-

q-dent days.  Re&a&atioh pi rhykH!n has ohcuiT6d for the most part
da thb firoi or sUbon day o? treatrmnt.   It has, In general, been

Putile to continue beyond five days of qulnidine therapy.

&adach&, tinnitds, epigaetrio discomfort, diarrhea and

palpitation have been among the unsleaaant symptoms attending qukil- ;-

dine ad&nistrat ion.  %ese are ore frequently observed in patients

in &om it is not possible to tiestore the norm1 rhythm than in those

in whom the desired effect Is accomplished,
   By wan8 of fre&nt electrocardiogra@ic records,  al tera-

tions in the cardiac mechanism have been carefully observed.   The

first effect has usually been acceleration of ventricular rate.   This


.

has been followd in a rxdxr OJ? pat, ier.t;s by occasional pezztxe

beats of ventricLlsr crigir..   The I;ra;,s;t,iolml uschanistis in Lhe

cormr;n or&r of their ;i~;litiar~:,ce wore:  cohrs6r f iorillat ion, dimot-

ing retard.xticr. of aurit->&iirr rate; input? ilLtter; flLtte2, and nor-

ual rhythm.  I-3 cze ,;at?el.t the transition from auricalar flutter to

norm1 rhythm. wa9, ?I~. good fort-we, &otogra&ed in the second lead.

`&e change was rathe; abrui,t, in that thsre was a short period of

altering aurimlar aotivity, slon3n~ of ventricular rate for several
beats, a relatively long period of asystole of both auricles and

ventricles, and then prompt resumption of sinus rhythm.   Altarations

in the form and direct ion of the T-WLVIZI of tha electrocardiogram have
&en observed after quinidine vbich are similar to the changes de-
Fcribed after the a-i&ration of digitalis.   Intra-ventricular

block, sine-auricxlar block and alterations in the form of the ventric-

ular complex `nave also bean sam.  Digltaiization prior to quinidin-

ization was not essential for success in therapy; I'or in the same

individual a normal mechanism was restored on one occasion with ven-

tricular rate of 180, sna at another time, after the administration

of digitalis, with the ventricular rate ranging from 90 to 100.
of digitalis, with the ventricular rate ranging from 90 to 100.

     Of great significknce for the clinic were certain,toxic ef-
     Of great significknce for the clinic were certain,toxic ef-
fects of the drug. Satferal sudden and unexplained dejaths have been
fects of the drug. Satferal sudden and unexplained dejaths have been

reportad by Foqpe tent observers.
reportad by Foqpe tent observers.  In one of cm patients ib was clear
                   In one of cm patients ib was clear

that heart failure was indvced following a simple tahycardia result-
that heart failure was indvced following a simple tahycardia result-

ing from qUnidine.
ing from qUnidine.   In several others,
            In several others, ver&riculax tachycardia was
                        ver&riculax tachycardia was

seen after doses ordinarily regsrdad US within therapeutic range.
seen after doses ordinarily regsrdad US within therapeutic range.
This mechanism assumes Lportance if it is borne in mind that in dogs
This mechanism assumes Lportance if it is borne in mind that in dogs
po&aor& by digitalis or stroyjlantiin it is not infrequently the
po&aor& by digitalis or stroyjlantiin it is not infrequently the


`&.,
.I
.. Tm-

~ecuraor of .ventrictilar fibrillation ~~lcl Jeath.   It is, t?23refore,

wise for the present to csr;; act the ad.Anist:aticr. of ~~inidine

*,vith t& satiant in be1 in a hospitcLl, &n, ,reiarubly controllad by

i'            the hormal rhythm for as long as nine months.

gra&ic racords.

       The reas0r.s fc2 Q-A variable oL;tcolra oi thara?y are not

clear. Tke .-.otal r';.;, tiu, hds been restored in a. va.?iety of organic

heart ConLltions, anti t,i;ora$y has faiiad in castta ~tiich, on clinical

ax-inat ion, differea in nc :v;y frol.. tiow in tY.8 first group.   It

has been thought that a long duration of the fibrlllatory Grocess IS

wfavorabla and that the rownt occurence of this abzorrzlity tends

to favor restoration of the sinus rhythe.   `Ihis criterion is, how-

evar, not vall;l, for the norrztl nechaziss has been restorei irk a

Htiant  who has oeen known to fibrillate for as long as saven years.

    The uuation of the effect after a single course of the -

Is extremely variable, ranging from a number of days to as long as

five months in our OVUA extjeriencs.  By properly spaced doses of the

drq given over long $riods of tir\s it has been possible to train`ta3.n

     All of the patients in &om the normal rrschanism was re-
' stored have been subj&tivoly improved,  In particular they we& no'
                                                                           *'

longer aware of the `act'ion of the heart, and the se&e of mbsternal
$res&e which is so often a'8ource of gompldnt, disappeared.< tiey

are relieved, furthermom,! of the necessity of continually taking

di,gitalis;  A number S&O have .been chronic $nvalids have been re-

stored .to working capacity?

     Teleroentgenogr@ic studies of the changes in the size of
. the he&t have in certain indiuiduals, revealed striking differences


during the ;ieriod of f ibriilation ani the per io,i of normal rhythm, in

the sense that ken fibrillation was $reser.t there itas an increase in

the size of the heart.  The dilatation occurring \*lfiile this arrhyth-

uiid is observed is, in all probability, an attetipt on the part of the

heart to -intoin afficielt ventricular o\;t$ct by increased length of

muscle f ibre.  An analcgoxx diminution in the size of the heart has

been observej. in +tients in -.-horn no alte;-ation of rhythm has taken

pldce but in xhon coqensetion has been restored follo*.ving the admin-

.

istrat ion of digitalis.

   Studies of the vital capacity have shown very sl'ight in-

crease following restoration of the norlral rhythm.  Great changes

were not to be ant iciwted for in all of these patient0 a fair degree

of cardiac compensatfon was brought about by rest, regulation of

fluid &take, digitalis administration, etc., prior to the &minis-

t rat Ion of quinidine .   The effects of atropine injected while the

auricles were fibrillating and again given when the normal rhythm

prexiled have been studied electrooardiograghically .   The results

have not as yet been critically analyzed.

Teleroentgenoprachic Studies of the SW of the Heart in F'neumonis,

     A ~eliminary report of these studies was presented last

year.  A techniwe for outlining the cardiac silhouette was he-

scribed at that tirm.  In brief, it was found that in a considerable

percentage of cases of lobar pnaumonia, and in a somewhat smaller per-
centags of cases of - bronchopneumnia, there was a significant in-

ureas6 in the size of the heart during the active stages of the
diBBaB& tith gradual return to a fairly constant level during con-
                    .
valtm*~tie~


`772

     ih atteqpf hx 0ti:c.r nde this your ':o !xike studies of .z

similar series of cxxs to r&ich digitalis ~3s ati,ninistercd.  Scir.2 ;-al

                                                   .

hundred plates have: besn rrade by'; the n;eazurcn.ents are not yet co10

plete.   It would CippeaA- frou tho wterial so far at hand that in

wtimts ivho irave rzcei;cI tittGute digitalis dosage, marked cardiac

dilatatlan doe3 aot occ1.r.  VbLefher this is to be regarded as a de-

sirable effect is no2 a,togothcr clear and depends in a measure upon

the interr tC'* .1jx~ wI:3.ch ir, pLt uyox the dilatation itself.   This

my be regarded as a conpnostory lengthening of the muscle fibre in

an attemZ:t to Eaintain v%tricular output during a period of stress
or w be looked upon as an evidence of poisoning of the heart mua-

de ~companying the pulmonary tifection,   Certainly there are in

the course of the ordinary pmumonia no outspoken manifestations of

heart f ai lure.  It has been shown in this laboratory that in the
norrmlly beating beart digitalis in therapeutic doses servee to in-

cream ventricular voluue output.   It has furthermore been shown

that in pneumonias the T-wave of the electrocardiogram is affeated In

ip IGBM~Z qu%te like that seen in ttBb absence of an infeqt ion,   The

marked grade of dilatation observed in certain -pee pf pmxnonia and
                                                              1
the very gradual return of the heart to Its usual size has led us to
believe that the enlargement in the cow88 of this disease ie evil . ,,

dence of a de,leterious or perhaps compnsatory effect.   Prevent ion
of such d&tat ion may be desirable,  But in any caee, if it can be

prevented by the administration of digitalis additional concrete evi-
dence is at hand to show that the d&g acts umn the heart mscle in

8 definitr and pramrably favorable rmnner in this dimmO

,


Studies on bsuitation.

Dr Binger.

Since October 1921 Dr Dinger `s'tir,.e has been s.+nt largely

in activities associated with the Anglo-tirican Physiological Expe-

dition to the Andes.   In October these consisted of accmlating

equipment for the exipedition end arranging details of transportation

and finances.  He was angaged too in a survey of the literature on

the L;hyslology of adaptation to low oxygen greswes.   Until the

  tin& of his departure on November 16th, he was occupied Mth prepara-
.

tion for work ~&ich he was plarming to take trp upon his return. !I'his

consisted in SQID~ modifications necessary in the lung volume method.

An elusive source of error Rich had troubled hicY for a year was dis-

covered and the error correctstd by somewhat changing the apparatus.

F'urtheruare the oxygen chamber had to be over-hauled, made more leak-

tight and improved in a variety of other ways to make it practicable

and economically feasible .

ti iJovember 16th, 1921, he sailed in company with the four

/             other American mabers of the axpedft ion on the Grace Line S.S.
/
i         Santa Teresa for Cal'lao Peru, vjhich ie the Port of Lirus.  They spent
j ,i:     the first wddk in Lima eetting up their laboratory.  Through the
I
           :
I                      courtesy of the Penrvian Corporation vWch operates the Central Rail-
                   .
!`a            road of Peru, they obtained a baggage oar, Rich, with the ald of a

             little carpentry, was converted into an excellent laboratory.   A
                *

3

freight car which the 13eruvian Corporation also furnished them served

as a store house for supplies.   These two cars were placed on a sid-

c

ing at Montearrati about tan r..inutes by train from Lima and as soon

as possible they started @king base line observations on themselves.


I                  The srime object of the expedition was a study of the &be-

I'

nonsna of adaptation to low oxygen jzess\;ros - Garticularly an
                                        o

inquiry into the question of mygen sacretion, a subject over which

there had been mch controversy and ~41ic.h they felt, with the methods

now at hand, could be definitely nettled.    This necessitated a

,

study of the varicn;s &asss of the problems concerned with hemato-

c

     .

respiratory tilctions of t:le body,

      First.- A study of the m3chanic8 of ventilation including

not only observations on the mirmtcj voluce of pulmnary vantilation,
but also studies In 1-g volurm, oxygen consumption, CO2 elimination
and alveolar oxygen and CC2 pressures.

       Second.- A study of the rate of diffusion of oxygen through

the alveolar epithelium.

     ThlrQ.
          - A study of the percentage saturation and oxygen

pressure of the arterial blood which was to be the critical test of

the oxygen secret ion theory.

       Fourth.
         - A study of the react ion of the blocd and particu-

larly of the oxyhemglobin dissociation curve and CO2 absorption

-s.

    `IhiS st3rieS of inveetigations was designed to stub the'.

~YS~O~Ogy of mspirat ion at all the salients now accsssibla.   !Che

problem of a2 pressure of the tissuee had to be left out became at
present there was AO method for sub an lnvestigat ion in the hum

subject.

      Besides these observations a number of collater&l observa-

tions were carried oUt concerned with pulse rate, circulation time,

bloo4 volaxrm, red blood cell count, fluid balance and acid base


                            3 7-5.

excrat ion.  Dr Birqor I c participation in the x&Qrk was concerrsa in

t'he main ~iti-; tha s t&dies in ventilation ;lril lung vclur~e, but Chiefly

,.vith thd construction or' the oxyhemglobin iissoctition curvzs and

                           .
ti,e CO2 abccrktion curves.

After t .;G ;GU~.E at ;IL[L~ the 3ri t ish rwrr,bzrs of the Ex2edi-

tion arrived, ~onnistini; of i/k. Barcroft ar.a ik. Doggart of Kings

Co liege , Gmbridgn, and Professor Jonathan i~~&ins of t'ne University

of klinburgh.  A tin aftez their arrival SOA of the +rty (Dr Eed-

f ie Id end D: Binger) proceeded by rail to Oroya (12,GOO ft.).   `Ihe

other8 followed in grad-1 stages,   All the rrambers of the expadition

..vere detained at Oroya from two to five days until the acute sym$toffis

of n-ountain si&leas, or "soroche" as it is called, had subsided. At

Oroya as well ds at Corro de Pasco where they made their permanent

headquarters, they were the guests of the Cerro de Pasco Copper Cor-

poration &ho exita-A& every courtesy ald hospitality to tharr.   They

renainad at Carro de PJSCO (14,200 ft .) for a little mora then three

weeks.  The mteria.1 for study they dividad into three groups; I,

thems e 1Ve 6 ; II, the snglo-saxon residents mostly engaged as mining

enginears; III, the indigenous populatian of Peruvian Indians and

Masistos, or half-breed Smish Indians.   These three classes made

an interesting and valuable material for study:  themselves, new er-

rivals; the angle-Saxons, resident intermittently for periods up to

five years , and the indigenous population Who had lived at altitudes

approxinlating 15,000 ft. often for many generations.   It was be lieveu

that ijny process of adaptation which was not initiated or comt;let*d

in themselves after 6hort exposure would surely manifest itself in

the nativas.


_ -   -      - __

     The ILore important rcsul.ts of their studies can be briefly

statad as foilows:-

     1. Cyanosi;; and unsaturation of the uterial bleed (15 to

20 her cant; were foma in L.eL.tarc cf all three groq6.

     2. In no case was the arteriai oxygen tension fomd to be

higher than the 0; tonsion in the alveolar air - or than could be

accounted for by simple diffusion.

     3. A shift to the left of the oxyhemoglobin dissociation

curve ~8s found In all the ascbers examined of the threa groups.

    4. A shift downward of tho CO2 absorption curves was found

in  thmse lve s ,

.

5. It was found that the value of the diffusion constant

es determined by the technique of Marie Krogh was the best index

available to determine tiich rrembere of the expedition would suffer

from soroche.

     A full report of these findings has been given in Mr.

Barcroft Is Lowell Institute LeeWres and will be included in the re-

port of the expedition tiich will be wblished by the Royal Society

in its proceedings.  k number of valuable and interesting anthropo-

metric measuremnts were made particularly of the size and shape of

the thorax and in this the portable X-ray outfit was of great  service.

     The expeditipn left Cerro ds Pasco on January 12th, climb-
ing Carlos Franiiada to the height of 17,500 ft. on Jariuary 13th, and

sailed from Lima on the S.S, Ebro of the Pacific Steatiflavigation

Company, on January '15th.  The ho-ward voyage was spent in figuring

data and writing up the work, as well as in s&king further sea level

observations.  .,They -rived in New York on January 31st, being


Q

dakyad three &ys by a severe storrh..

Sir,c,e Dr Bir,gar's r3t'l;rn he has bean encaged uith invasti-

g3tix.s Of ventilation in c~s3s of lobar Gntwnia a13 cbservations

c0cc,s Q&J" II `;lOOJ iLli`LL-c living in the oxygen ciIa&ber for 15

&A;JB.  idI 3X~C3tX33 of this brat icn rasirod a revision of the ven-

tiL5t ion oysteui - :artimlsiy of CO2 ri3ri.oVal.   Besides it was

~O-GJ ueeirable to eibpltfy tho n~ch;lni 26~1 arrangeribnts so that now

a8 si stance.

Dr Bir,ger plans to continue this study until the pneumonia

stshson is over and then to taktr u$ again the work with heat wtients.
.
The t;m problems ore intiaately associated and can profitably be

approached with similar technique.  `Ihe next stage in the soktlon

of the problem relates to the function of pulu~nary epitheliu, to

the passage of gases into and from the blood a8 in the case of moun-

t&l sickness.  Following this, there is the problem of the constl-

tution of the blood in respect to the transpdt of gases.   And then

COTPBS the effect of the constitution of the blood on the central

riervcue sys tern.  Associated with these problems connacted with the
                                                                           :`.,>,

blood, the mechanism @ whiuh peripheral (pulmonary) influences are
                                                                           i

conveyed to the central nervous sys tern mst be studied.  T&l u.n&

lying idea is to determine what disturb - the character of breathing,

&at the disturbed character of breathing does to the organism and

how it and its effects can be remdied.

     Ihe work on temperature , under taken with Dr Clark, had to
ba discontinued owing to Dr Binger's trip to Peru.   A method for


accurate tem$eratuv daterir.inations to be IS&M in this investigation

has beef1 +blisl;od by Dr Clark.

Dr Avery, Dr Ibrgaq md Dr E. G. StillriaG.

Prior to the recent work of Bla;te

and Cecil on the experi-

rental tjroducticn of acute resp'iratory disease in monkeys, there was

little definite knowledge concerning the pathogenesie of the various

types of weumcnia, in spite of the fact that the pathology of this

group of disaassa has been known for many yaara.  For example, there

has been little accurate inform& ion concerning the primary pathways

of infection, the initial point of bacterial invasion of the lungs,

the character and location of the earliest lesions or the methods by

  .

which lnf ect ion spreads thrmat the lungs and consolidation devel-

opa.  `Even more important from the epidemiological atandpoint, it

has not been definitely known which of the varWus organisms con-

cerned in the production of pneumonia are capable of ini tiatlng an

infection wlthout the assistance of the other contributing etiologi-

.

aal factors.  2228W.3 questions, & ich might appear corqparat ively

.
1      sir@% in the case of lobar pmmon ia duw to pneumococcus alone, be-

.

corce Wry complex in tie case of the secondary pneumonias of maaeles

. .

and influenza.

The work of Blake and Cecil indicates that in pneux~coccus

lobar pmumonia, infection takes

tory tract; that pneumococci are

of the- healthy upper respiratory

place solely by way of the respira-

2ncapable of initiating an infection

rnm~us membrane and that these cocci

ms t gain access to the looter respiratory tract through the


4

`19a.

intervention of soas other factor or factors which break dcwn the

norrx;rl defensive mxhnism before infection can be initiated.  These

BXkb. Ariadntal results are in pcccrd with those of clinical investi-

eation.   It has been S'LCN~ that the majority of cases of lobar

peuMnia are ca~6ed 'by the highly parasitic pe~~~~cocci, Types 1

and II, axi fu;tZa imre ,  that these tyras ara not found in the mouths

of nornal i.naividLbla, b\lt cnly in the secretions of those sick with

thd dtsease and occaeionally in the mouths of persons inttitely in

contact with the sick.  The importance of the mere presence of the

organiBms, therefore, as far aa lob&r pneumonia aseociated with theee

special types of organlams is concerned, bdcoaa very great.   It is

hardly conceivable, however,  that even in these cases the ume arriv-

al of these vimlant Nraeitic pneumococci Fn the mouths of indivld-

uals Is the only factor concerned, for If it ;vere, lobar pneumonia
        .

bnuld obviously be very reswily transmissible and assume the charac-
ters cif an ipidemic disease.  Why it dues not ordinarily do so finds

partial explanation atileast in the experimental facts preVicualy x+e-

ferned to,- that a hig& parasitic ~eunococcus is incapable of in-+
                     t

citing lung infection in a very susceptible animal unlese it is able

.

to ga'+n access to the lower respiratcry tract by factora entirely

unrel&ed to the bacteria themselves.   What souie of #ime factors

are, are aatters of comum but experimentally unstipported observation,

such as exyosuTe, fatig32, ata., and probably cost inqortant, mild

upper respiratory tract infections such as corrmon colds, all of which

are as-d to operate ira breaking d0v.n the no-1 defensive me&an-

ism which guards the lower respiratory tract.

With the hope of determining more accurately the nature


.

                        ' i -j@.
                                                              : '.

and effect of certak, of these factors on the tjroducticn of ;~~-LLC-

CDCCXS dnf ectio; of ths lungs, thd ,York of the b&CL,-iological lab-

oratories of the hos,,iLl has td;d b twofold direction.

     One ,roblcL; hzs been thd attump; to induce experimentally

in ~ninsls respiratory infection Gth pne%ococcus under conditions

.

ar9 cZorsely kprroxioat'ag `the natural infection in nnn.   Normal

animals, and ~-`lic.zls .reviously subjected to procedures designed to

ls39r rdsistanca, have been irxpooe;i in suits; lo cha:..iers to an atmos-

pher9 sprayed with virulent pneumococci.   At vary ir,,-  intervals after

exposure 60~9 of the anirrals knave baen killed and their lungs and .:

other viscera cultivated for the presence of ~9umococci, *&I19

othor animals have been kept under observation for evidences of sub-

sequent infect ion.  Tnese procadxxes have already yielded certain

facts concerning the nschanisu of infection, and the fate of virulent

microorganisms irqLnt9d on the res&rUtory UUCOSB of normal suscepti-

ble ai-1s.

    The i9oond problem of investigation concarns the kinds and
nature of the microbial agents associated with the mild upper respi-
ratory infections, which &ve already bean referred to as probably

the most important of the contrititing etiolo&al factors in the
                                                                    .
caus&ion of pneumonia.   Because of the advance in our kno;vledge of

the respiratory flora

perim9ntal studies of

patients, the present

tempt to isolate from

already mde by Olitsky end Gates in their exA,`>

the nasopharyngeal secret ions from Wluenza

work has concerned itself largely With the at-

the upper resLGirbtoL-y tract of normal inLivid-

uais and of persons sxffering from acute respiratory infections,

microorganism identical with or ClO691y allied t0 tne anaerobic


group oi which 13. seuao6inte.s srobahly represents the type.

     !Ihe first of these srobleras, nmly, that having to do

with the prod-dction in animals of ~ne;imococcus infect ion by asgira-

tion and t'ne fclctcrs L;fl;lcncing air-borne infect ion is being in-

                   1
vestigated by Cr &. G-.  sti;h!in.  Xicc end guinea pigs .@re &laced

in a2ecially :o:.str;lcted metal chamcers and spreyed with cultures of

pneumococc i,  `the vi,rulmce of ttiich for the test anials had been

previously proved by the intraperitoneal inoculation of other ani-

uals.  Of the 147 mice used in these spraying experirrents, 33 were

killed and autopsiel at intervals of from * to 48 hours after spay-

ing.  ~euocococci of the same type ;rere recovered frory the lugs
of all of the 12 mice autopsidd within 1 hour of spraying.   After

this period the incidence of recovery of pneumococci from the lags

rapidly decreases,  Of the retraining 114 mice which were sprayed
and allowed to live, all survived for 10 days with the exception of
5 Vcnich died with ~eumococ~s septicemia.   These observations af-
   .
ford evidence that virulent pneticocci may Beach the lungs through
tiaiation, but that in all but a relatively few animsls these in-

haled organism are effectively disposed of.   The anatomical and

imuunity reactions concerned in this defensive rrschanism are now     1

being investigated.  In many experismnts various attempts w0re made
to reduce the resistance of the experimental animals, both before
and after exposure to infection, b such methods as chilling, ether-
izat ion, intraperitoneal inject-ion of foreign sera.   In no instance,

however, did these meawlres materially alter the course of events

already described.

In an atten& to trace the sthway of infect ion from a


.

                 #                             -m%-

known portal cf entry Dr Stiltin has injected kneuxrococci into the

reritracheel tissues, and beneath the nasal mxosa of guinea pigs

and follo*xed by cu;ltuyal rret%ods toe route of invasion to the lungs.

Of the anirra;s icjected 31 lera killed in frofil 1 to 3 days after in-

fect ion end &a-cL;occsci `:Jdre recovered by cultural nathods as follow

fro= the trazi;eL LTLCOB~ 4 +r cdat, rdritracheal lymI!hatic nodes

50 per cant, s;ieen 45 ier cent, imxt Is blood 35 dar cent, and

lungs 32 jer cent.  F?mxococcl were Isolated Jirectly f ran the

lungs in 4 anirrals in &~ich the heart's blood ws sterile,   fi number

of guinea pigs similLZly injected survived.   Several of these SC-

vivors wera sacrificed 3 to 5 days ELfter infect ion and in no instance

`mre pneumococci recovered at exto;sy.   This xork has bean cO~$,li-
                                                         I

catsd by the occurrence in 67 per cent of the pigs autopsied of Gram

negative bacilli of two distinct varieties.   These secondary orgd-

isms have been recovered almost excl-~sively frog the lungs end often

from lungs xhioh apijeared'entirely nornal on gross insyection. These

orgmiauis probably belmg to a group similar to the Gram negative

.

bacilli which have bdm cl&scribed by previous investigators ai the

cause o,D apontaneow epidemics of weumonia in guinea pigs. t ..I -

     The second problem, namely tha study,of the anaerobic fil-.
ter-pa8sing group of Gram negative organisms associated zith mild%

upper respiratory tract Infections is being investigate8 by Dr Avery

and Dr Morgan.   In this study ive have been fortunate in having the

hearty cooperat ion of Dr Oli tsky and Dr Gates, those im&or tant con-

tributions have added mch to the kno:Nledge of a hithtito unrecog-

nized group of microorganisms of the respiratory flora.   Several

weeks were spent in becoming fmiliar xrith the biologic characteris-

.


                                             .

/

tics 0;' a strain of Bacterium 2nmxrosintes originally isolated by
Dr Olitsky and 2r G&tee ~JI ti-a +nJen.ic of infkenza in 1918-13.        ii Iii
                                                                           !I,

During the racznt a9iJef.i~ of acv.ta r'3sLJir~tcry disease opportunity

was ir fforded to +.t i:lto r,ractichl sexice the technique and rmthcds

developed by :kese investigators for the isolation of O~gEUliEill6 from

the filtered JLI ui:.Itered nasosharyngeal secret ions of patients SE.`..

fering frorj so-called irfkmza.  From 5 cases in which the cliniCa.

diagnosis of acucte influenza was rrade, positive cultxres of 0rg;nisffis
                                                                 .

tividantly closely allied to B. pneurcosintes hava been recovered froffi

the nasokharyngeal washings in 4 lnstawas.   These strains have

certain chxactere which aid in identifying thea, *.vlth the group or`

orgtiislUs cf ,Nfiich B, pneumosintes serves as a type.   All posses~~

in co&on the follo:ving characteristics:  they are SK& 1, Gram nega-

tive bacilli, Strictly anaerobic, and were cultivated directly from

the filtrates of nasopharyngeal washings after passage through Berk-

efeld candles "V" - that is they were filter-passing in the form in

  &WA they existed before artificial cultivation. .           .

.

.        Variations in morphology and cuittiral reactions suggest

that these strains differ in certain .Characters from the type culture

1               of B, ~eumosintes.  Further study of the cultural and Ixoiunological

properties of these recently isolated organisms ie' necessary, haw-
,ever, before any certain opinion can be given as to their identity

with the original strain.  ft is interesting that in two' instances

a positive culture was obtained by primary isolation from filtered

washings directly on blood agar plates by the use of an anaerobic

jar, tIxs eliminating the possibility of chanca contamination from

kidney tissue, ascitic fluid, or animal passage.   Whatever reIat ion


                                             :: `:
                                                      .          `,
                                           `i-jL& .

these strain6 and others ttat nay bo sLbscquont:y isolated Cay bear

to one another or to the original B. pnaumosintes, and whatever rray

eventualiy be iravt3.i s;j to their c;ics31 relationship to acute respi-

ratory disease, &.3ra is little doubt that they constitute a group

of organisu,s hithczto unkno.vn.  It is worthy of note that by iden-

tical methods of st=ldy of ptixtures of the sputum and nasopharyngeal
secretions from 8 pat idnts suffering from acute lobar pneumonia of

pmmrmcoc~s origin, organisms of this n8.v ty$ have not been en-

countered in a single instance.

*ific Solukle Sutsttnce of Pneumococcbs.
             - ---
    In conjunction with Dr Heidelberger a study is being con-

tinlied on the chemical nature of the soluble, specifically precipi-

.

table substance which is excreted in the urine of patients suffering
from pneumonia of pneum~coccus origin.  !@is active substance de-
rived from the infecting organism passes the kidney unchanged in
specificity and appears in the urine in a form cvhidh reacts only with
antipneumococcus serum of the same type as that of the infecting pneu-

mococcus. '  It was soon found that this specifically reacting subs
o stance is not protein in nature,
  .               tha3 it is stabie in bdiling solu-

tions, that it is not dialysable, and is precipitated from solution

                                                                  `> : " ;.a:`
- by acetone and alcohol.  The methods of isolation and purification

of the material now being studied depend. on these facts.  Proteins -

are removed by boiling the urine with dilute acetic acid and the

neutralized and concentrated filtrate is poured into 10 volumes of

acetone, the aqueous solution of the resulting 2recipitate is dialyzad.

unt 11 salt-f me, and reprecipitated first with acetone and then wi'h

absolute alcohol.  The product so obtained contains _nract ically no

                        . .


free amino nitrogen, but rjn hydrolysi:, yLel2.s about 50 per text Oi
the total nitrogen as an;ino nitrogen ard 20 per cer,t as aummia.
     A produzt with practically idzr.tioal proi;erties is ob-

tained by dissolving zvJshod ~ne-~~~~ococci in antiformin and purifying

as in the case of -&inn.  It has recently been found that a further
inactive fraction can be removed by precipitating fractionally with

acetone.  The active substance is not precipitated by asrcuric
chloride in neutral solution and is therefore not a polypeptide or

proteose.

     The eerologic type specificity of this reacting substance
' ranaim unimpaired by these chemical procedures; this fact affords
a delicate biologic test for detecting the active substance through-
out the varicue chemical manipulations incident to the search for

it8 structural constitution.  It is hoped that further study may

reveal the chemical nature of this substance, with &ich the type

epecificity of pneumococcus ie so intimately bound.

Accessory Growth Substances in Plant Tlssuu.
    The study of the proper the of blood upon ~Mch depend6

the' ability of the so-called hemglobinophilic bacilli to grow in
  .           .
this nradium, hae shown that these properties are related to at
least two factors which can be separately studied.   Both of these
factors are present in plant tissue, (potato and banana), and ster-
ile,unheated plant tissue can replace blood in the cultivation of

B. influenzae.  These observations have now been extended; yellow

and vdzite turnip, carrot, beet, parsnip, and sweet potato, when
added to fluid media have been found to possess the same growth


.

stjmlating action as &ite potato.

Dr. Morgan and Dr. Avexy have found that these vegetable tissue8 not

only permit the cultivation of tha so-called htnoglobinophilic organisms,
but that they also greatly favcr the growth of other entirely unrelated

orgmleme.  For inetance, in the r,asr of ?nm3mococcus, not only i8 there a

marked acceleration of growth, b,& a seeding too mlmat e in i tsalf to Witdate
growth in plain broth alone, will amply suffice to inducz abundant multipli-

cation in the same medium to tiich small pieces of e&rile, unheated vegetabt0

have bema added.  Moreover, in the plant tissue medium the zone of hydrogen
Ion concentration within which growth can be initiated ia considerably extend-
ed beyond the acid and alkaline limits of the optimal zenge in ordtiry

bouillon.  fn addition oertain other ba.cterla, VW& ordinarily fail to grow

in the presence d free ox;rgen, multiply in CA metium containing fresh plant
tissue even theugh no precautions are taken to exc1ud.e air. It $8 evident,

therefore, that the presence 11' media of certain substanoos contained in fresh

plant tissue not only euspliee the necessary factora for growth of' the

hewglobinophilio bacilli but furniehee the necsssary reqpitemonte for the
Cultiuation of o%hes bacteria &ich multiply only under certain restricted
                    .
Condltiona.  One..wcla oondit.tion is the reacttin of @e medium v&i033 in the

presence of plant ;issue may be made to vary over a much wider zone without

referding gtewth; enothw coruiition $8 oxygen tension *ich similarly SSermS to
require for eens.l,tive organfsma xt~~ch less accurate control in the pr6SWe Of

plant tissue than 3n its absence.

%0 BxBQt xIa%ure of then. substances contained in plant tissue U. rhich

these Broper3%% depend is not yet d&mined, but the studiss so far made,
Wggeat that they ate related to the prg8wo of oertain oxidizing and reduc-
ing aa?iymee in fresh plant t issuea, as well as to the pre60?Ut0 of so~a~ll~

accessory food eIibsta.nW.