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One particular leviathan
CORRESPONDENCE
The Reply: As emphasized in Langevitz and Buskila’s letter, the major role for colchicine is in the prevention of recurrent episodes and the amyloidosis of FMF [l-3]. Our report (Am J Med 1989; 86: 356-357) described a patient who developed severe toxicity after receiving intravenous colchicine for an apparent exacerbation of FMF. I was asked to examine and manage this patient at the time of the clinical deterioration of her condition, several days after colchicine therapy was initiated. The purpose of our report was to highlight the clinicopathologic features of colchicine toxicity. It is not our intent to imply that intravenous colchicine is part of the usual treatment of acute episodes of FMF. To the best of my knowledge, this patient had no pre-existing hepatic or renal disease. RICHARDJ. SIMONS,M.D. The Milton S. Hershey Medical Center Hershey, Pennsylvania 17033 1. Goldfinger SE: Colchicine for familial Mediterranean fever. N Engl J Med 1972; 287: 1302. 2. Zemer D. Revach M, Pras M: A controlled trial of colchicine in preventing attacks of familial Mediterranean fever. N Engl J Med 1974; 291: 932-934. 3. Zemer D. Pras M. Sohar E, Modan M. Cabili S. Gafnr J: Colchicine in the prevention and treatment of the amyloidosis of familial Mediterranean fever. N Engl J Med 1986: 314: 1001-1005.
ONE PARTICULAR
LEVIATHAN
To the Editor: I thought the article “One Particular Leviathan” by LaCombe (Am J Med 1989; 86: 319-321) was touching and interesting. I would like to comment on his discussion of the
drug Prontosil. This was an early sulfonamide and wasgiven intravenously. I remember very well that one of the effects of Prontosil was a diffuse reddening of the entire body. But by the 194Os,when Dr. LaCombe was in Great Britain, in the United States Army during the Second World War, Prontosil was certainly not the only sulfonamide available. Several others were obtainable by that time and each was far more effective than Prontosil, such as sulfanilamide, sulfapyridine, and sulfathiazine. I am sure that these drugs were available for his fiancee, who had diabetes and sepsis. SELVAN DAVISON, M.D.,F.A.C.P. Manhattan Medical G~OUD New York, New York 10021 Submitted
April 7. 1989,
and accepted
June 6. 1989
The Reply: I guessthat I had better state at the outset that I only write fiction. That said, I must also add that where history of medicine comes into my stories, I make every attempt to be as factual as possible. For “One Particular Leviathan,” I used Cecil’s 1941 edition of A Textbook of Medicine, to research use of sulfonamides and the treatment of diabetes mellitus in the late 1930s. Dr. Davison is entirely correct that many of the sulfonamides were available in the 1940s. However, the old doctor in the story joined the British Medical Corps in 1939 to serve as physician for British soldiers. In the story, his fiancee died in 1939. From what I can gather from Cecil’s text [l] and from other references as well [2-41,
September
1989
Prontosil and the other sulfonamideswere not widely available or widely used in America until after 1939. More than this I cannot say, and would certainly defer to Dr. Davison. He was there, and I was not. Historical fact aside, “One Particular Leviathan” is a love story, a story of missed opportunity, and a story of conflict between reason and emotion. And beyond this, it is meant to show how all of us as physiciansjudge ourselves too harshly, and too quickly condemn ourselves. Indeed, would the old doctor’s fiancee, with her juvenile-onset diabetes, have lived a long life in those days, even if she had been treated with Prontosil? MICHAEL A. LA~OMBE,.M.D. Oxford Hills Internal Medrcine Group Norway, Maine 04268-1191 1. Cecil RL: A textbook of medicine. Philadelphia: WE Saunders, 1941. 2. Long PH. Bliss A: The clinical and experimental use of sulfonamide, sulfapyridine. and allied compounds. New York: Macmillan, 1939. 3. Galdstone I: Behind the sulfa drugs: a short history of chemotherapy. New York: Appleton-Centurycrofts, 1943. 4. Carithers HA: The first use of an antibiotic in America. Am J Dis Child 1974: 128: 207-211.
CORRECTION In the article “Pathophysiology of Gastroesophageal Reflux” by AItorki and Skinner (June 1989, pages 685 to 6891, line 27 in the right column on page 685 should read “ ...1955. Belsey [7] and Nissen [8] introduced....”
The American
Journal
of Medicine
Volume
87
365
The Reply: As emphasized in Langevitz and Buskila’s letter, the major role for colchicine is in the prevention of recurrent episodes and the amyloidosis of FMF [l-3]. Our report (Am J Med 1989; 86: 356-357) described a patient who developed severe toxicity after receiving intravenous colchicine for an apparent exacerbation of FMF. I was asked to examine and manage this patient at the time of the clinical deterioration of her condition, several days after colchicine therapy was initiated. The purpose of our report was to highlight the clinicopathologic features of colchicine toxicity. It is not our intent to imply that intravenous colchicine is part of the usual treatment of acute episodes of FMF. To the best of my knowledge, this patient had no pre-existing hepatic or renal disease. RICHARDJ. SIMONS,M.D. The Milton S. Hershey Medical Center Hershey, Pennsylvania 17033 1. Goldfinger SE: Colchicine for familial Mediterranean fever. N Engl J Med 1972; 287: 1302. 2. Zemer D. Revach M, Pras M: A controlled trial of colchicine in preventing attacks of familial Mediterranean fever. N Engl J Med 1974; 291: 932-934. 3. Zemer D. Pras M. Sohar E, Modan M. Cabili S. Gafnr J: Colchicine in the prevention and treatment of the amyloidosis of familial Mediterranean fever. N Engl J Med 1986: 314: 1001-1005.
ONE PARTICULAR
LEVIATHAN
To the Editor: I thought the article “One Particular Leviathan” by LaCombe (Am J Med 1989; 86: 319-321) was touching and interesting. I would like to comment on his discussion of the
drug Prontosil. This was an early sulfonamide and wasgiven intravenously. I remember very well that one of the effects of Prontosil was a diffuse reddening of the entire body. But by the 194Os,when Dr. LaCombe was in Great Britain, in the United States Army during the Second World War, Prontosil was certainly not the only sulfonamide available. Several others were obtainable by that time and each was far more effective than Prontosil, such as sulfanilamide, sulfapyridine, and sulfathiazine. I am sure that these drugs were available for his fiancee, who had diabetes and sepsis. SELVAN DAVISON, M.D.,F.A.C.P. Manhattan Medical G~OUD New York, New York 10021 Submitted
April 7. 1989,
and accepted
June 6. 1989
The Reply: I guessthat I had better state at the outset that I only write fiction. That said, I must also add that where history of medicine comes into my stories, I make every attempt to be as factual as possible. For “One Particular Leviathan,” I used Cecil’s 1941 edition of A Textbook of Medicine, to research use of sulfonamides and the treatment of diabetes mellitus in the late 1930s. Dr. Davison is entirely correct that many of the sulfonamides were available in the 1940s. However, the old doctor in the story joined the British Medical Corps in 1939 to serve as physician for British soldiers. In the story, his fiancee died in 1939. From what I can gather from Cecil’s text [l] and from other references as well [2-41,
September
1989
Prontosil and the other sulfonamideswere not widely available or widely used in America until after 1939. More than this I cannot say, and would certainly defer to Dr. Davison. He was there, and I was not. Historical fact aside, “One Particular Leviathan” is a love story, a story of missed opportunity, and a story of conflict between reason and emotion. And beyond this, it is meant to show how all of us as physiciansjudge ourselves too harshly, and too quickly condemn ourselves. Indeed, would the old doctor’s fiancee, with her juvenile-onset diabetes, have lived a long life in those days, even if she had been treated with Prontosil? MICHAEL A. LA~OMBE,.M.D. Oxford Hills Internal Medrcine Group Norway, Maine 04268-1191 1. Cecil RL: A textbook of medicine. Philadelphia: WE Saunders, 1941. 2. Long PH. Bliss A: The clinical and experimental use of sulfonamide, sulfapyridine. and allied compounds. New York: Macmillan, 1939. 3. Galdstone I: Behind the sulfa drugs: a short history of chemotherapy. New York: Appleton-Centurycrofts, 1943. 4. Carithers HA: The first use of an antibiotic in America. Am J Dis Child 1974: 128: 207-211.
CORRECTION In the article “Pathophysiology of Gastroesophageal Reflux” by AItorki and Skinner (June 1989, pages 685 to 6891, line 27 in the right column on page 685 should read “ ...1955. Belsey [7] and Nissen [8] introduced....”
The American
Journal
of Medicine
Volume
87
365