Cytotoxic lymphocytes in infectious mononucleosis D.C. OSBORN, PH D. R.A. Fox, MB, MRCP; L.A. FERNANDEZ, MD, FRcP[c], FACP; J.M. MACSWEEN, MD, FRCP[C] G.R. LANGLEY, MD, FACP, FRCP[C]
Seven patients with a clinical diagnosis of infectious mononucleosis (IM) and detectable heterophil antibodies were found to have peripheral blood lymphocytes that were cytotoxic for lymphoid cells containing Epstein-Barr virus from a patient with Burkitt's lymphoma. The cytotoxic lymphocytes persisted in the peripheral circulation for up to 45 days. Patients who had had IM I to 5 years previously lacked such cytotoxic lymphocytes. Patients who had signs and symptoms of IM but no detectable heterophil antibodies lacked cytotoxic lymphocytes. The lymphocytes of one patient with IM showed progressive diminution of cytotoxic ability after prednisone treatment. On a trouve que sept patients ayant un diagnostic de mononucleose infectieuse CMl) avec presence decelable d'anticorps heterophiles possedaient tous des lymphocytes p6ripheriques cytotoxiques pour des cellules lymphoides contenant le virus Epstein-Barr et provenant d'un patient atteint d'un lymphome de Burkitt. Les lymphocytes cytotoxiques se sont maintenus dans Ia circulation peripherique pour une periode allant jusqu'a 45 jours. Des patients qui avaient eu une Ml I a 5 ans auparavant n'avaient pas de lymphocytes cytotoxiques. Les patients qui presentaient des signes et sympt8mes de Ml sans anticorps h6t6rophiles decelables n'avaient pas non plus de lymphocytes cytotoxiques. Les lymphocytes d'un patient souffrant de Ml ont manifeste une diminution progressive de leur caractere cytotoxique apres traitement a Ia prednisone.
phoid cells from a patient with Burkitt's lymphoma.' This cell line contains EBV and can be stained by an immunofluorescence technique for viral protein in the plasma membrane of the cell. Patients and methods
Thirteen students aged 19 to 26 years attending the student health services clinic of Dalhousie University were selected for study on the basis of a clinical presentation compatible with a diagnosis of IM. For each patient a Paul-Bunnell test for heterophil antibodies was performed as well as a blood smear to identify atypical lymphocytes. From each patient 10 ml of blood was collected by venipuncture into tubes containing heparin. Lymphocytes were isolated on Ficoll-Isopaque gradients,4 to be used as "effector cells" against EBV-containing lymphoid cells from a patient with Burkitt's lymphoma - the "target cells" - 2 million of which had been incubated for 1 hour at 370C with 50 .Ci of radioactive chromium (51Cr). One million effector cells were incubated at 370C with 50000 51Cr-labelled target cells in a
Pattengale, Smith and Perlin1 reported that atypical lymphocytes in the peripheral blood of patients with infectious mononucleosis (IM) have characteristics of T (thymus-dependent)-lymphocytes. They suggested that these uninfected lymphocytes may be a factor in the immune response to the etiologic agent of the disease, the Epstein-Barr virus (EBV), which infects only B ("bursaequivalent")-lymphocytes.2 In this paper we report our observation that lymphocytes from patients with IM were cyto toxic for the 3PJ HR1K line of lymFrom the department of medicine and Clinical Research Centre, Daihousie University, and Camp Hill Hospital, Halifax Reprint requests to: Dr. D.C. Osborn, C-Mi Clinical Research Centre, Daihousie University, 5849 University Ave., Halifax, NS B3H 4H7
1118 CMA JOURNAL/DECEMBER 4, 1976/VOL. 115
total volume of 1 ml of medium 199 plus glutamine, containing 20% heatinactivated fetal calf serum. After 3 hours' incubation the suspension was centrifuged and the supernatant was assayed for '1Cr released from the target cells. The amount of 51Cr released from cells that had been repeatedly frozen and thawed was taken as 100%. One patient was treated with prednisone, 10 mg/d for 2 days, beginning the day after the first assay. Two subsequent tests of lymphocytes were performed 3 and 7 days after cessation of treatment. The following control studies were done: (a) lymphocytes from healthy laboratory personnel were used as control effector cells; (b) EBV-containing target cells were incubated alone; (c) lymphocytes from healthy laboratory personnel were used as control target cells for both IM and control effector cells; and (d) lymphocytes from three patients who had had confirmed IM 1 to 5 years previously were used as effector cells against both EBV-contaming and control target cells. Heterophil antibody titres were measured in patients and controls by the method of Davidsohn and Henry.5
Results
Data for the subjects whose lymphocytes were tested are presented in Table I. For the seven patients with heterophil antibody titres of at least 1:40 the percent release of 51Cr induced by their lymphocytes was greater than the mean release (19 ± 2.0%) induced by control effector cells from healthy laboratory personnel (P K 0.01; Student's t-test, two-tailed). The release of 51Cr decreased after prednisone treatment in patient 3; by 7 days after treatment the release was not significantly greater than control values, although the heterophil antibody titre remained positive. For six patients, ill and febrile but without detectable heterophil antibodies, the mean release of 51Cr induced by their lymphocytes was 20 ± 1.4%, a value not significantly different from control values. Mean release of 51Cr from EBV-contaming target cells incubated without effector cells was 10 ± 3%. Mean release of 51Cr from lymphocytes not containing EBV was the same (21 ± 2.3%) when both IM and control lymphocytes were used as effector cells. Lymphocytes from the three patients who had had confirmed IM 1 to 5 years previously induced a mean release of 51Cr of 21 ± 2% from EBVcontaining target cells, compared with a mean release of 20 ± 2% from control target cells, even though these three patients had positive serum EBV titres. Discussion
Royston and colleagues6 and Svedmyr and Jondal7 have reported that lymphocytes from IM patients are specifically cytotoxic for cells containing EBV. Our study confirms that observation. Lymphocytes from seven patients with clinical signs and symptoms of IM and detectable heterophil antibodies were cytotoxic for EBV-containing target cells. No control lymphocytes showed such cytotoxicity. Jondal and Pross8 have reported nonspecific cytotoxicity of lymphocytes containing Fc (crystallizable fragment)/ C3 receptors to a number of cell lines. In our assay the mean release of 51Cr from target cells when control lymphocytes. were used as effector cells was greater than the mean release when the target cells were incubated alone; this may reflect nonspecific cytotoxicity of lymphocytes since lymphocytes bearing Fc/C3 receptors were not removed from the cell populations we tested. However, the increased cytotoxicity observed with lymphocytes from patients with IM must reflect a specific reaction against EBV-containing cells since substitution of non-EBV-containing target cells resulted in the same levels of 51Cr
release as with control effector lymphocytes. For each of 13 patients we studied, the first assay was performed the day of the patient's first visit to the clinic. In patient 1 the cytotoxicity measured by the first assay was then only slightly greater than that of control lymphocytes but 13 days later it had increased to 33%; this suggests that the first assay was performed before the cytotoxic ability had matured. In three other patients in whom second assays were performed 4 to 45 days after the initial assays, the cytotoxicity was greater in the second assay than that of control lymphocytes. The heterophil antibody titre of patient 2 was undetectable when the second assay was performed, although the percent release of 51Cr was 39%. The lymphocytes of three patients who had had IM 1 to 5 years previously did not show cytotoxicity. This suggests that the natural immunologic course of IM includes the disappearance of heterophil antibodies with subsequent loss of the cytotoxic ability of lymphocytes. Our results also suggest that the cytotoxic ability is specific for the lymphocytes of IM patients with detectable heterophil antibodies. The lymphocytes of six patients with signs and symptoms compatible with those of IM but without detectable heterophil antibodies did not demonstrate more cytotoxicity than control lymphocytes. Since these patients did not have heterophil antibodies they probably did not have IM, although atypical lymphocytes were detected in peripheral blood smears from some. In the one patient treated with prednisone the cytotoxic ability of the lymphocytes decreased after treatment. Although we have not identified the specific cytotoxic cell, we have shown that a population of lymphocytes, presumably T-lymphocytes, are specifically cytotoxic for a cell line containing EBV. This cytotoxicity may be selflimiting along with IM and may contribute to the clinical manifestations of the disease. We thank Dr. William Kingston, director of student health services, Dalhousie University, for making patients available to us; Mr. Doug Gough, clinical virology laboratory, Pathology Institute, Halifax, for providing us with cultured lymphocytes; and Ms. Donalda Robson and Ms. Debbie Jennex for technical assistance. This study was supported by the Medical Research Council of Canada (grant MA 1197) and the National Cancer Institute of Canada. References 1. PAmNGALE
PK,
SMiTh
RW,
PERLIN
E:
Atypical lymphocytes in acute infectious mononucleosis. N Engi J Med 291: 1145, 1974 2. GREAVES MF, BROWN G, RIcKINsoN AB: Epstein-Barr virus binding sites on lymphocyte
subpopulations and the origin of lymphoblasts in cultured lymphoid cell lines and in the blood of patients with infectious mononucleosis. Clin Immunol Immunopathol 3: 514, 1975 3. Joi'ic.s JH, LEYRITZ M: The effect of hydrocortisone and bromodeoxyuridine (BUdR) on the Epstein-Barr herpes virus in human lymphoblastoid cell lines. Rev Can Biol 33: 135, 1974 4. FERNANDEZ LA, MACSWEEN JM, LANGLEY GR: Separation of T lymphocytes from normal individuals and patients with B lymphocyte chronic lymphatic leukemia. Immunology 28: 231, 1975 5. DAVID5OHN I, HENRY JB: Clinical Diagnosis, 14th ed, Philadelphia, Saunders, 1962, pp 284-90 6. RoYsroN I, SULLIvAN JL, PERLIN B, et al: Cell-mediated immunity in infectious mononucleosis: lymphocyte-mediated cytotoxicity of lymphoblastoid cells expressing Epstein-Barr virus antigens (abstr). Clin Res 23: 295a, 1975 7. SYEDMYR E, JONDAL M: Cytotoxic effector cells specific for B cell lines transformed by Epstein-Barr virus are present in patients with infectious mononucleosis. Proc Nail Acad Sci USA 72: 1622, 1975
8. JONDAL M, PRoss H: Surface markers on human B and T lymphocytes. VI. Cytotoxicity against cell lines as a functional marker for lymphocyte subpopulations. mt J Cancer 15: 596, 1975
BOOKS continued from page 1071 PRESENT DIAGNOSIS AND TREATMENT OF SEPTI. CEMIA. ANTIBIOTICS AND CHEMOTHERAPY. Vol. 21. 1st InternatIonal Symposium, Madrid, Nov. 1974, held on XXVth Anniversary of AntibiotIcs S.A. and the Xth Anniversary of Tribuna Medica'. L.P. Garrod, H. Seneca, E. Jaweta and J. Fereres. 215 pp. lIlust. S. Kargar Medical and Scientific Publishers, Basal, 1976. $19.75 PREVENTION OF EMBRYONIC, FETAL, AND PERI. NATAL DISEASE. Vol. 3 of Preventive Medicine. Edited by RI. Brent and MI. Harris. 411 pp. Illust. US Government Printing Office, Washington, 1976. $8.20 PRINCIPLES OF ORTHOTIC TREATMENT. W.H. Bunch and RD. Keagy. 144 pp. illust. Grune and Stratton, Inc., New York; Longman Canada Limited, Toronto, 1976. $36.25 PROGRESS IN LIVER DISEASES. Vol. 5. H. Popper and F. Schaffner. 733 pp. lIlust. Grune and Stratton, Inc., New York; Longman Canada Limited, Toronto, 1976. $55.25 PROGRESS IN MEDICAL VIROLOGY. Vol. 22. Edited by J.L. Melnick. 230 pp. Illust. S. Karger AG, Basal, 1976. $46.00 PTOSiS. 2nd ad. Crowell Beard. 287 pp. Iliust. The C.V. Mosby Company, St. Louis, 1976. $34.15 RECENT ADVANCES IN RESPIRATORY MEDICINE. Vol. 1. TB. Stratton. 311 pp. Illust. Churchill Livingatone, Edinburgh; Longman Canada Limited, Toronto, 1976. $32.25 RECOGNIZABLE PATTERNS OF HUMAN MALFOR. MATION. MAJOR PROBLEMS IN CLINICAL PEDI. ATRICS. Vol. VII. 2nd ad. David W. Smith. 504 pp. illust. W.B. Saunders Company, Philadelphia; W.B. Saunders Company Canada Limited, Toronto, 1976. $19.05 REGULATION OF BLOOD PRESSURE BY THE CENTRAL NERVOUS SYSTEM. The Fourth Hahna. mann international Symposium of Hypertension. Edited by Gaddo Onasti, Michael Fernandes and Kwan Eun Kim. 484 pp. lIlust. Gruna & Stratton, Inc., New York; Longman Canada Limited, Toronto, 1976. $42.00 THE SCIENTIFIC JOURNAL: EDITORIAL POLICIES AND PRACTICES. Lois DaBakey. 129 pp. The CV. Mosby Company, St. LouIs, 1976. $10.45 SELF ASSESSMENT IN CLINICAL CARDIOLOGY. Vol. II. MS. Gordon. 349 pp. Year Book Medical Publishers, Inc., Chicago, 1976 SPEAK TO ME IN NUCLEAR MEDICINE. Philip Shtasel. 223 pp. lIlust. Harper & Row Publishers, Inc., Hagarstown, MD, 1976. $22.50
A TEXTBOOK OF EPILEPSY. Edited by J. Laidlaw and A. Richens. 389 pp. lIlust. Churchill Living. stone, Edinburgh; Longman Canada Limited, Toronto, 1976. $42.00 VASCULAR SURGERY. A GUIDE AND HANDBOOK. Gerald H. Pratt. 300 pp. illust. Warren H. Green, Inc., St. Louis, 1976
CMA JOURNAL/DECEMBER 4, 1976/VOL. 115
111.
Seven patients with a clinical diagnosis of infectious mononucleosis (IM) and detectable heterophil antibodies were found to have peripheral blood lymphocytes that were cytotoxic for lymphoid cells containing Epstein-Barr virus from a patient with Burkitt's lymphoma. The cytotoxic lymphocytes persisted in the peripheral circulation for up to 45 days. Patients who had had IM I to 5 years previously lacked such cytotoxic lymphocytes. Patients who had signs and symptoms of IM but no detectable heterophil antibodies lacked cytotoxic lymphocytes. The lymphocytes of one patient with IM showed progressive diminution of cytotoxic ability after prednisone treatment. On a trouve que sept patients ayant un diagnostic de mononucleose infectieuse CMl) avec presence decelable d'anticorps heterophiles possedaient tous des lymphocytes p6ripheriques cytotoxiques pour des cellules lymphoides contenant le virus Epstein-Barr et provenant d'un patient atteint d'un lymphome de Burkitt. Les lymphocytes cytotoxiques se sont maintenus dans Ia circulation peripherique pour une periode allant jusqu'a 45 jours. Des patients qui avaient eu une Ml I a 5 ans auparavant n'avaient pas de lymphocytes cytotoxiques. Les patients qui presentaient des signes et sympt8mes de Ml sans anticorps h6t6rophiles decelables n'avaient pas non plus de lymphocytes cytotoxiques. Les lymphocytes d'un patient souffrant de Ml ont manifeste une diminution progressive de leur caractere cytotoxique apres traitement a Ia prednisone.
phoid cells from a patient with Burkitt's lymphoma.' This cell line contains EBV and can be stained by an immunofluorescence technique for viral protein in the plasma membrane of the cell. Patients and methods
Thirteen students aged 19 to 26 years attending the student health services clinic of Dalhousie University were selected for study on the basis of a clinical presentation compatible with a diagnosis of IM. For each patient a Paul-Bunnell test for heterophil antibodies was performed as well as a blood smear to identify atypical lymphocytes. From each patient 10 ml of blood was collected by venipuncture into tubes containing heparin. Lymphocytes were isolated on Ficoll-Isopaque gradients,4 to be used as "effector cells" against EBV-containing lymphoid cells from a patient with Burkitt's lymphoma - the "target cells" - 2 million of which had been incubated for 1 hour at 370C with 50 .Ci of radioactive chromium (51Cr). One million effector cells were incubated at 370C with 50000 51Cr-labelled target cells in a
Pattengale, Smith and Perlin1 reported that atypical lymphocytes in the peripheral blood of patients with infectious mononucleosis (IM) have characteristics of T (thymus-dependent)-lymphocytes. They suggested that these uninfected lymphocytes may be a factor in the immune response to the etiologic agent of the disease, the Epstein-Barr virus (EBV), which infects only B ("bursaequivalent")-lymphocytes.2 In this paper we report our observation that lymphocytes from patients with IM were cyto toxic for the 3PJ HR1K line of lymFrom the department of medicine and Clinical Research Centre, Daihousie University, and Camp Hill Hospital, Halifax Reprint requests to: Dr. D.C. Osborn, C-Mi Clinical Research Centre, Daihousie University, 5849 University Ave., Halifax, NS B3H 4H7
1118 CMA JOURNAL/DECEMBER 4, 1976/VOL. 115
total volume of 1 ml of medium 199 plus glutamine, containing 20% heatinactivated fetal calf serum. After 3 hours' incubation the suspension was centrifuged and the supernatant was assayed for '1Cr released from the target cells. The amount of 51Cr released from cells that had been repeatedly frozen and thawed was taken as 100%. One patient was treated with prednisone, 10 mg/d for 2 days, beginning the day after the first assay. Two subsequent tests of lymphocytes were performed 3 and 7 days after cessation of treatment. The following control studies were done: (a) lymphocytes from healthy laboratory personnel were used as control effector cells; (b) EBV-containing target cells were incubated alone; (c) lymphocytes from healthy laboratory personnel were used as control target cells for both IM and control effector cells; and (d) lymphocytes from three patients who had had confirmed IM 1 to 5 years previously were used as effector cells against both EBV-contaming and control target cells. Heterophil antibody titres were measured in patients and controls by the method of Davidsohn and Henry.5
Results
Data for the subjects whose lymphocytes were tested are presented in Table I. For the seven patients with heterophil antibody titres of at least 1:40 the percent release of 51Cr induced by their lymphocytes was greater than the mean release (19 ± 2.0%) induced by control effector cells from healthy laboratory personnel (P K 0.01; Student's t-test, two-tailed). The release of 51Cr decreased after prednisone treatment in patient 3; by 7 days after treatment the release was not significantly greater than control values, although the heterophil antibody titre remained positive. For six patients, ill and febrile but without detectable heterophil antibodies, the mean release of 51Cr induced by their lymphocytes was 20 ± 1.4%, a value not significantly different from control values. Mean release of 51Cr from EBV-contaming target cells incubated without effector cells was 10 ± 3%. Mean release of 51Cr from lymphocytes not containing EBV was the same (21 ± 2.3%) when both IM and control lymphocytes were used as effector cells. Lymphocytes from the three patients who had had confirmed IM 1 to 5 years previously induced a mean release of 51Cr of 21 ± 2% from EBVcontaining target cells, compared with a mean release of 20 ± 2% from control target cells, even though these three patients had positive serum EBV titres. Discussion
Royston and colleagues6 and Svedmyr and Jondal7 have reported that lymphocytes from IM patients are specifically cytotoxic for cells containing EBV. Our study confirms that observation. Lymphocytes from seven patients with clinical signs and symptoms of IM and detectable heterophil antibodies were cytotoxic for EBV-containing target cells. No control lymphocytes showed such cytotoxicity. Jondal and Pross8 have reported nonspecific cytotoxicity of lymphocytes containing Fc (crystallizable fragment)/ C3 receptors to a number of cell lines. In our assay the mean release of 51Cr from target cells when control lymphocytes. were used as effector cells was greater than the mean release when the target cells were incubated alone; this may reflect nonspecific cytotoxicity of lymphocytes since lymphocytes bearing Fc/C3 receptors were not removed from the cell populations we tested. However, the increased cytotoxicity observed with lymphocytes from patients with IM must reflect a specific reaction against EBV-containing cells since substitution of non-EBV-containing target cells resulted in the same levels of 51Cr
release as with control effector lymphocytes. For each of 13 patients we studied, the first assay was performed the day of the patient's first visit to the clinic. In patient 1 the cytotoxicity measured by the first assay was then only slightly greater than that of control lymphocytes but 13 days later it had increased to 33%; this suggests that the first assay was performed before the cytotoxic ability had matured. In three other patients in whom second assays were performed 4 to 45 days after the initial assays, the cytotoxicity was greater in the second assay than that of control lymphocytes. The heterophil antibody titre of patient 2 was undetectable when the second assay was performed, although the percent release of 51Cr was 39%. The lymphocytes of three patients who had had IM 1 to 5 years previously did not show cytotoxicity. This suggests that the natural immunologic course of IM includes the disappearance of heterophil antibodies with subsequent loss of the cytotoxic ability of lymphocytes. Our results also suggest that the cytotoxic ability is specific for the lymphocytes of IM patients with detectable heterophil antibodies. The lymphocytes of six patients with signs and symptoms compatible with those of IM but without detectable heterophil antibodies did not demonstrate more cytotoxicity than control lymphocytes. Since these patients did not have heterophil antibodies they probably did not have IM, although atypical lymphocytes were detected in peripheral blood smears from some. In the one patient treated with prednisone the cytotoxic ability of the lymphocytes decreased after treatment. Although we have not identified the specific cytotoxic cell, we have shown that a population of lymphocytes, presumably T-lymphocytes, are specifically cytotoxic for a cell line containing EBV. This cytotoxicity may be selflimiting along with IM and may contribute to the clinical manifestations of the disease. We thank Dr. William Kingston, director of student health services, Dalhousie University, for making patients available to us; Mr. Doug Gough, clinical virology laboratory, Pathology Institute, Halifax, for providing us with cultured lymphocytes; and Ms. Donalda Robson and Ms. Debbie Jennex for technical assistance. This study was supported by the Medical Research Council of Canada (grant MA 1197) and the National Cancer Institute of Canada. References 1. PAmNGALE
PK,
SMiTh
RW,
PERLIN
E:
Atypical lymphocytes in acute infectious mononucleosis. N Engi J Med 291: 1145, 1974 2. GREAVES MF, BROWN G, RIcKINsoN AB: Epstein-Barr virus binding sites on lymphocyte
subpopulations and the origin of lymphoblasts in cultured lymphoid cell lines and in the blood of patients with infectious mononucleosis. Clin Immunol Immunopathol 3: 514, 1975 3. Joi'ic.s JH, LEYRITZ M: The effect of hydrocortisone and bromodeoxyuridine (BUdR) on the Epstein-Barr herpes virus in human lymphoblastoid cell lines. Rev Can Biol 33: 135, 1974 4. FERNANDEZ LA, MACSWEEN JM, LANGLEY GR: Separation of T lymphocytes from normal individuals and patients with B lymphocyte chronic lymphatic leukemia. Immunology 28: 231, 1975 5. DAVID5OHN I, HENRY JB: Clinical Diagnosis, 14th ed, Philadelphia, Saunders, 1962, pp 284-90 6. RoYsroN I, SULLIvAN JL, PERLIN B, et al: Cell-mediated immunity in infectious mononucleosis: lymphocyte-mediated cytotoxicity of lymphoblastoid cells expressing Epstein-Barr virus antigens (abstr). Clin Res 23: 295a, 1975 7. SYEDMYR E, JONDAL M: Cytotoxic effector cells specific for B cell lines transformed by Epstein-Barr virus are present in patients with infectious mononucleosis. Proc Nail Acad Sci USA 72: 1622, 1975
8. JONDAL M, PRoss H: Surface markers on human B and T lymphocytes. VI. Cytotoxicity against cell lines as a functional marker for lymphocyte subpopulations. mt J Cancer 15: 596, 1975
BOOKS continued from page 1071 PRESENT DIAGNOSIS AND TREATMENT OF SEPTI. CEMIA. ANTIBIOTICS AND CHEMOTHERAPY. Vol. 21. 1st InternatIonal Symposium, Madrid, Nov. 1974, held on XXVth Anniversary of AntibiotIcs S.A. and the Xth Anniversary of Tribuna Medica'. L.P. Garrod, H. Seneca, E. Jaweta and J. Fereres. 215 pp. lIlust. S. Kargar Medical and Scientific Publishers, Basal, 1976. $19.75 PREVENTION OF EMBRYONIC, FETAL, AND PERI. NATAL DISEASE. Vol. 3 of Preventive Medicine. Edited by RI. Brent and MI. Harris. 411 pp. Illust. US Government Printing Office, Washington, 1976. $8.20 PRINCIPLES OF ORTHOTIC TREATMENT. W.H. Bunch and RD. Keagy. 144 pp. illust. Grune and Stratton, Inc., New York; Longman Canada Limited, Toronto, 1976. $36.25 PROGRESS IN LIVER DISEASES. Vol. 5. H. Popper and F. Schaffner. 733 pp. lIlust. Grune and Stratton, Inc., New York; Longman Canada Limited, Toronto, 1976. $55.25 PROGRESS IN MEDICAL VIROLOGY. Vol. 22. Edited by J.L. Melnick. 230 pp. Illust. S. Karger AG, Basal, 1976. $46.00 PTOSiS. 2nd ad. Crowell Beard. 287 pp. Iliust. The C.V. Mosby Company, St. Louis, 1976. $34.15 RECENT ADVANCES IN RESPIRATORY MEDICINE. Vol. 1. TB. Stratton. 311 pp. Illust. Churchill Livingatone, Edinburgh; Longman Canada Limited, Toronto, 1976. $32.25 RECOGNIZABLE PATTERNS OF HUMAN MALFOR. MATION. MAJOR PROBLEMS IN CLINICAL PEDI. ATRICS. Vol. VII. 2nd ad. David W. Smith. 504 pp. illust. W.B. Saunders Company, Philadelphia; W.B. Saunders Company Canada Limited, Toronto, 1976. $19.05 REGULATION OF BLOOD PRESSURE BY THE CENTRAL NERVOUS SYSTEM. The Fourth Hahna. mann international Symposium of Hypertension. Edited by Gaddo Onasti, Michael Fernandes and Kwan Eun Kim. 484 pp. lIlust. Gruna & Stratton, Inc., New York; Longman Canada Limited, Toronto, 1976. $42.00 THE SCIENTIFIC JOURNAL: EDITORIAL POLICIES AND PRACTICES. Lois DaBakey. 129 pp. The CV. Mosby Company, St. LouIs, 1976. $10.45 SELF ASSESSMENT IN CLINICAL CARDIOLOGY. Vol. II. MS. Gordon. 349 pp. Year Book Medical Publishers, Inc., Chicago, 1976 SPEAK TO ME IN NUCLEAR MEDICINE. Philip Shtasel. 223 pp. lIlust. Harper & Row Publishers, Inc., Hagarstown, MD, 1976. $22.50
A TEXTBOOK OF EPILEPSY. Edited by J. Laidlaw and A. Richens. 389 pp. lIlust. Churchill Living. stone, Edinburgh; Longman Canada Limited, Toronto, 1976. $42.00 VASCULAR SURGERY. A GUIDE AND HANDBOOK. Gerald H. Pratt. 300 pp. illust. Warren H. Green, Inc., St. Louis, 1976
CMA JOURNAL/DECEMBER 4, 1976/VOL. 115
111.
