artery.6 All three vessels run the entire length of the spinal cord, but the anterior spinal artery is responsible for blood supply of the greater part of
its cross section. It is variably reinforced by several branches via the lateral spinal branches of the intercostal and lumbar arteries. The lower tho¬ racic and entire lumbar portions of the spinal cord are principally sup¬ plied by a large lumbar branch called the arteria radicularis magna that arises either above or below the renal arteries with equal frequency. Paraplegia after aneurysm resec¬ tion is not a technical complication. In one half of the reported cases, rup¬ ture of the aneurysm had occurred with substantial hypotension, sug¬ gesting diminished collateral flow to the arteria radicularis magna associ¬ ated with the infrarenal origin of that vessel as the probable explana¬ tion. Paraplegia occurs under elective conditions as well and is particularly tragic in this situation because as a disabling complication, it undermines
otherwise successful operation for serious disease. Brewer and his coworkers7 have recently suggested that preoperatiye warning of the pos¬ sibility of paraplegia constitutes a prerequisite for informed consent for operation on the thoracic aorta. We believe that paraplegia deserves wider recognition as a possible occur¬ rence following surgery of the ab¬ dominal aorta. an a
Gerald T. Golden, MD H. A. Wellons, Jr, MD
William H. Muller, Jr, MD
University of Virginia Medical Center
Charlottesville, Va 1. Golden GT, Sears HF III, Wellons HA Jr, et al: Paraplegia complicating resection of aneurysms of the infrarenal abdominal aorta. Surgery 73:91-96, 1973. 2. Michaelis L: Spinal cord ischemia associated with repair of a ruptured abdominal aortic aneurysm. Stroke
3:238-239, 1972. 3. Lentin M, Salis JS: Paraplegia as a complication of infrarenal aortic aneurysmorrhaphy. Vase Surg 6:224\x=req-\ 226, 1972. 4. Pasternak BM, Boyd DP, Ellis FH Jr: Spinal cord injury after procedures on the aorta. Surg Gynecol Obstet 135:29-34, 1972. 5. Bolton PM, Blumgart LH: Neurologic complications of ruptured abdominal aortic aneurysm. Br J Surg 59:707-709, 1972. 6. Suh TH, Alexander L: Vascular system of the human spinal cord. AMA Neurol Psychiat 41:659-669,1939. 7. Brewer LA, Fosberg RG, Mulden GA, et al: Spinal cord complication following surgery for coarctation of the aorta: A study of 66 cases. J Thorac Cardiovasc Surg 64:368-379, 1972.
Allergic Reactions To the Tine Test
To the Editor.\p=m-\Whilelocal allergic reactions to the tine test have been reported, there are, to the best of our knowledge, no reports of systemic al-
lergic reactions after administration of this test. Anaphylactic reactions to intradermal injections can occur. Bee stings and scratch tests for penicillin sensitivity have caused anaphylaxis
and death. We encountered a case that apparently involved an anaphylactic death resulting from the tine test.
test.
Report of a Case.\p=m-\A19-year-old youth, apparently in good health from birth, was being processed with a group of newly arrived recruits at a military camp for basic training. A minute or two after receiving the tine test, the recruit suddenly collapsed while waiting in line for a venipuncture. His respiration was slow and gasping. Artificial respiration was begun and an oral airway inserted. No pulse was obtained, and external cardiac massage was begun. The recruit was taken to the base hospital, where he was pronounced dead 30 minutes after collapsing. The only other substance given to the recruit prior to the tine test was a sugar cube saturated with poliomye¬
litis vaccine. A complete autopsy was performed. No abnormalities were found—either grossly or microscopically-that could account for the sudden death. A toxicologie examina¬ tion, with analysis for volatile, acid, basic, and neutral compounds, and heavy metals
yielded negative findings.
Comment—The old tuberculin tine an intradermal test for the de¬
test is
tection of tuberculin reactivity. It is a convenient screening method when testing large population groups. The test unit consists of a steel disk with four prongs, each 2 mm long, at¬ tached to a plastic handle. Each prong is dipped in a solution of old tubercu¬ lin containing 7% gum arabic (acacia) and 8.5% lactose as stabilizers. Ster¬ ilization of the test unit is by eth-
ylene
tine test. The possibility of an anaphylactic reaction to the po¬ liomyelitis vaccine was also consid¬ ered, but in view of the constituents of the vaccine and the mode of ad¬ ministration, this is believed to be much less likely as a cause of death than an allergic reaction to the tine
oxide gas.
Local
allergic
test have been
reactions to the tine
reported. These
reac¬
tions are similar to those observed af¬ ter administration of old tuberculin or purified protein derivative (PPD) in the intradermal test. Such reac¬ tions are rare and usually consist of a wheal or flare at the test site. This al¬ lergic reaction occurs either immedi¬ ately after the test or within the first 24 hours and then fades promptly (personal communication, Lederle Laboratories, December 1974). Local allergic reactions to the gum arabic may also occur. In view of the circumstances lead¬ ing up to death and the absence of any anatomic or toxicologie cause of death, one might reasonably consider that the death was due to an anaphy¬ lactic reaction to a constituent of the
Vincent J. M. DiMaio, MD Southwestern Institute of Forensic Sciences Dallas
Col Richard C. Froede, MC, USAF Armed Forces Institute of Pathology Washington, DC
Cardiac Unusual
Pacing: An Complication
To the Editor.\p=m-\Recently,in converting a bipolar endocardiac transvenous pacing system to a unipolar epicardial one,
we
encountered
an
unusual
com-
plication we had not seen previously. After placing a single epicardial lead (Medtronic model 6919), the original left infraclavicular pocket was again used for the generator together with an immediately adjacent subcutaneous pocket for the new indifferent lead. Pacing was established at a low threshold and with good R wave sensing. Six hours later, pacing was lost. On inspection of the wound, an air pocket could be felt over the indifferent lead. This was aspirated and a pressure dressing applied, with immediate recapture of the rhythm. Cardiac pacing has continued without incident
since
that
time.
Suction
drainage may have obviated this tentially dangerous complication.
po-
Paul A. Kennedy, MD
George H. Cohen, MD
Burlingame, Calif
A
Surgeons'
FDA?
To the Editor.\p=m-\Thedialogue (232:35, 37, 1975) concerning the equal treat-
ment of drugs and operations has several interesting implications when carried to its conclusion. If there were an FDA for the surgeon, perhaps the artisans of the trade could buy advertisements in the journals to promote their latest technique. Then, a new breed of detail man would have to be developed so that they could be trained to provide "sample operations." I'm sure that the "surgeons' FDA," in its infinite wisdom, could come up with some method of regulating "over-the-counter" operations.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/29/2015
Kenneth G. Davis, MD Marianna, Ark
its cross section. It is variably reinforced by several branches via the lateral spinal branches of the intercostal and lumbar arteries. The lower tho¬ racic and entire lumbar portions of the spinal cord are principally sup¬ plied by a large lumbar branch called the arteria radicularis magna that arises either above or below the renal arteries with equal frequency. Paraplegia after aneurysm resec¬ tion is not a technical complication. In one half of the reported cases, rup¬ ture of the aneurysm had occurred with substantial hypotension, sug¬ gesting diminished collateral flow to the arteria radicularis magna associ¬ ated with the infrarenal origin of that vessel as the probable explana¬ tion. Paraplegia occurs under elective conditions as well and is particularly tragic in this situation because as a disabling complication, it undermines
otherwise successful operation for serious disease. Brewer and his coworkers7 have recently suggested that preoperatiye warning of the pos¬ sibility of paraplegia constitutes a prerequisite for informed consent for operation on the thoracic aorta. We believe that paraplegia deserves wider recognition as a possible occur¬ rence following surgery of the ab¬ dominal aorta. an a
Gerald T. Golden, MD H. A. Wellons, Jr, MD
William H. Muller, Jr, MD
University of Virginia Medical Center
Charlottesville, Va 1. Golden GT, Sears HF III, Wellons HA Jr, et al: Paraplegia complicating resection of aneurysms of the infrarenal abdominal aorta. Surgery 73:91-96, 1973. 2. Michaelis L: Spinal cord ischemia associated with repair of a ruptured abdominal aortic aneurysm. Stroke
3:238-239, 1972. 3. Lentin M, Salis JS: Paraplegia as a complication of infrarenal aortic aneurysmorrhaphy. Vase Surg 6:224\x=req-\ 226, 1972. 4. Pasternak BM, Boyd DP, Ellis FH Jr: Spinal cord injury after procedures on the aorta. Surg Gynecol Obstet 135:29-34, 1972. 5. Bolton PM, Blumgart LH: Neurologic complications of ruptured abdominal aortic aneurysm. Br J Surg 59:707-709, 1972. 6. Suh TH, Alexander L: Vascular system of the human spinal cord. AMA Neurol Psychiat 41:659-669,1939. 7. Brewer LA, Fosberg RG, Mulden GA, et al: Spinal cord complication following surgery for coarctation of the aorta: A study of 66 cases. J Thorac Cardiovasc Surg 64:368-379, 1972.
Allergic Reactions To the Tine Test
To the Editor.\p=m-\Whilelocal allergic reactions to the tine test have been reported, there are, to the best of our knowledge, no reports of systemic al-
lergic reactions after administration of this test. Anaphylactic reactions to intradermal injections can occur. Bee stings and scratch tests for penicillin sensitivity have caused anaphylaxis
and death. We encountered a case that apparently involved an anaphylactic death resulting from the tine test.
test.
Report of a Case.\p=m-\A19-year-old youth, apparently in good health from birth, was being processed with a group of newly arrived recruits at a military camp for basic training. A minute or two after receiving the tine test, the recruit suddenly collapsed while waiting in line for a venipuncture. His respiration was slow and gasping. Artificial respiration was begun and an oral airway inserted. No pulse was obtained, and external cardiac massage was begun. The recruit was taken to the base hospital, where he was pronounced dead 30 minutes after collapsing. The only other substance given to the recruit prior to the tine test was a sugar cube saturated with poliomye¬
litis vaccine. A complete autopsy was performed. No abnormalities were found—either grossly or microscopically-that could account for the sudden death. A toxicologie examina¬ tion, with analysis for volatile, acid, basic, and neutral compounds, and heavy metals
yielded negative findings.
Comment—The old tuberculin tine an intradermal test for the de¬
test is
tection of tuberculin reactivity. It is a convenient screening method when testing large population groups. The test unit consists of a steel disk with four prongs, each 2 mm long, at¬ tached to a plastic handle. Each prong is dipped in a solution of old tubercu¬ lin containing 7% gum arabic (acacia) and 8.5% lactose as stabilizers. Ster¬ ilization of the test unit is by eth-
ylene
tine test. The possibility of an anaphylactic reaction to the po¬ liomyelitis vaccine was also consid¬ ered, but in view of the constituents of the vaccine and the mode of ad¬ ministration, this is believed to be much less likely as a cause of death than an allergic reaction to the tine
oxide gas.
Local
allergic
test have been
reactions to the tine
reported. These
reac¬
tions are similar to those observed af¬ ter administration of old tuberculin or purified protein derivative (PPD) in the intradermal test. Such reac¬ tions are rare and usually consist of a wheal or flare at the test site. This al¬ lergic reaction occurs either immedi¬ ately after the test or within the first 24 hours and then fades promptly (personal communication, Lederle Laboratories, December 1974). Local allergic reactions to the gum arabic may also occur. In view of the circumstances lead¬ ing up to death and the absence of any anatomic or toxicologie cause of death, one might reasonably consider that the death was due to an anaphy¬ lactic reaction to a constituent of the
Vincent J. M. DiMaio, MD Southwestern Institute of Forensic Sciences Dallas
Col Richard C. Froede, MC, USAF Armed Forces Institute of Pathology Washington, DC
Cardiac Unusual
Pacing: An Complication
To the Editor.\p=m-\Recently,in converting a bipolar endocardiac transvenous pacing system to a unipolar epicardial one,
we
encountered
an
unusual
com-
plication we had not seen previously. After placing a single epicardial lead (Medtronic model 6919), the original left infraclavicular pocket was again used for the generator together with an immediately adjacent subcutaneous pocket for the new indifferent lead. Pacing was established at a low threshold and with good R wave sensing. Six hours later, pacing was lost. On inspection of the wound, an air pocket could be felt over the indifferent lead. This was aspirated and a pressure dressing applied, with immediate recapture of the rhythm. Cardiac pacing has continued without incident
since
that
time.
Suction
drainage may have obviated this tentially dangerous complication.
po-
Paul A. Kennedy, MD
George H. Cohen, MD
Burlingame, Calif
A
Surgeons'
FDA?
To the Editor.\p=m-\Thedialogue (232:35, 37, 1975) concerning the equal treat-
ment of drugs and operations has several interesting implications when carried to its conclusion. If there were an FDA for the surgeon, perhaps the artisans of the trade could buy advertisements in the journals to promote their latest technique. Then, a new breed of detail man would have to be developed so that they could be trained to provide "sample operations." I'm sure that the "surgeons' FDA," in its infinite wisdom, could come up with some method of regulating "over-the-counter" operations.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/29/2015
Kenneth G. Davis, MD Marianna, Ark
