86 mg/100 ml. Bone marrow aspiration showed normal cellular marrow, with 30% plasma cells, plasmablast cells, and megaloblastoid erythropoiesis. The patient was treated with intra¬ venous fluid, hydrocortisone, and furosemide, and recovered uneventfully from acute hypercalcemia and acute renal fail¬ ure. Melphalan and prednisone therapy was started and he died after a short pe¬ riod from aspiration pneumonitis. At autopsy, there was a pathological fracture of the sternum with diffuse infil¬ tration with sheet of plasma cells often separated by fine trabeculae (Fig 2), with widespread myelomatous lesions.

gated by papaverine. Interestingly enough, I have had two patients, both of whom were approximately 71 years old, female, and white and had long-standing classical Parkinson disease that responded well to levodopa therapy, and both of whom suffered not only reversal of response but also reappearance of adventitious movements when inadvertently given papaverine by their family physicians. In both instances, gait difficulty increased markedly, rigidity and bradykinesia definitely increased, and there was a definite deterioration in handwriting. Speech also deteriorated. Indeed, the only difference between these two patients and the woman reported by Dr. Duvoisin would seem to be the return of adventitious movements to a significant degree. I have no explanation for this phe¬ nomenon, but its relation to the ad¬ ministration of papaverine, at least in these two well-documented cases, was unquestionable, as a return of the beneficial effects of levodopa was noted in each instance approximately five to six days after the cessation of

papaverine therapy. Certainly, personal

Figure 2. A pathological fracture of the ster¬ nal bone is an extremely rare compli¬ cation; however, its occurrence should arouse suspicion of multiple mye¬ loma.' Ivan P. Law, MD Walter Reed Army Medical

Center

Washington,

Veterans Administration Wilmington, Del

1.

Snapper I, Kahn

tol 1:87-143, 1964.

AI:

Donald M. Posner, MD

Canaan, Vt

Chloramphenicol-

Hospital

Multiple myeloma. Sem Hema-

Antagonism of Levodopa By Papaverine To the Editor.\p=m-\Ithought it might be worthwhile commenting on Dr. Duvoisin's note (231:845, 1975) concerning the antagonism of levodopa by papaverine. I have come across roughly one patient per year in whom the beneficial effects of levodopa have in some way been inadvertently ne-

one

and

Fever

To the Editor.\p=m-\Thereport of chloram-

phenicol-resistant Salmonella typhi in Saigon (231:162, 1975) emphasized the poor clinical response of patients infected with chloramphenicol-resistant strains of S typhi to chloramphenicol alone. Chloramphenicol-resistant typhoid fever has also been noted in Bangkok, Thailand, with evidence of in vitro and in vivo resist-

to chloramphenicol.1-3 During 1974, thirty-two percent (22 of 67) of the S typhi strains from Children's Hospital, Bangkok, were ance

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chloramphenicol. Forty-

percent (9 of 22) of these chloram-

phenicol-resistant strains were resistant to ampicillin also (minimal inhibitory concentrations > 128\g=m\g/ ml). Ampicillin has been ineffective therapy in patients with S typhi isolates resistant to ampicillin and chloramphenicol. One such patient receiving 150 to 200 mg/kg/day of ampicillin intravenously remained febrile, in a toxic condition, and had positive blood cultures after seven days of therapy. Recovery occurred following therapy with trimethoprimsulfamethoxazole. All of the S typhi

isolates have been sensitive to trimethoprim-sulfamethoxazole, and this drug has been effective therapy. We wish to emphasize that chloramphenicol-resistant typhoid fever is present in other parts of Southeast Asia, and that in vitro and in vivo re¬ sistance to ampicillin occurs as well. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. MAJ Richard M. Lampe, MC, USA Chiraphun Duangmani, MD US Army Medical Component SEATO Medical Research Laboratory Pethai Mansuwan, MD

experience

could lead me to agree strongly with Dr. Duvoisin that papaverine should not be administered to patients with parkinsonism. I might go one step further in my belief that papaverine really does not have any place in the treatment of cerebral arteriosclerosis, as I have never been convinced that it has any significant effect on intracerebral vasculature, except perhaps indirectly and adversely by means of "shunting" blood away from the brain to peripheral structures.

Ampicillin-Resistant Typhoid

DC

Charlotte Jones, MD

resistant to

Children's Hospital

Bangkok, Thailand Mansuwan P: Chloramphenicol-resistant Salmonella typhosa. N Engl J Med 289:1203, 1973. 2. Lampe RM, Mansuwan P, Duangmani C: Chloramphenicol-resistant typhoid. Lancet 1:623-624, 1974. 3. Oonsombat P: Chloramphenicol-resistant typhoid fever. Siriraj Hosp Gazette 26:1548-1554, 1974. 1.

Lampe RM,

Paraplegia After Surgery For Abdominal Aortic Aneurysms To the Editor.\p=m-\In1973, we reported two cases of paraplegia following the resection of aneurysms of the infrarenal abdominal aorta, and we were able to find reports of an additional 17 cases in the literature.1 Since that time, this complication has occurred in another patient in our institution, and five separate, additional cases have been reported.2-5 We have also received letters from surgeons throughout the country about paraplegia following aneurysm resection. This complication, although not mentioned in standard surgical textbooks, is more common than has been appreciated. The blood supply to the spinal cord is tenuous at best, coming from both the two-part anterior spinal arteries and the single posterior spinal

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

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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. Kenneth G. Davis, MD Marianna, Ark