- Email: [email protected]
" THESE DYING DISEASES "
1177 the card should fall (a) on welfare clinics where the triple vaccine is used, (b) school medical officers, and (c) medical officers in the Forces. United Leeds
MAURICE ELLIS.
Hospitals.
SIR,-As a casualty officer seeing many I was interested in Dr. Scott’s letter.
cases
of
injury
It is our experience here that a large number of patients who attend are able to tell us that they have been treated elsewhere for injuries and have been given irijections, but they have no idea what they were given or why, and in many cases they are extremely vague about the time of the injury. It has been our custom for some time past to issue all patients in need of toxoid with a record card, on which is entered the amount of the toxoid given, the date on which it was given, and a reminder date for the reinforcing dose. This card, which is of pocket size, is given to the patient with instructions that it should always be carried with him and produced whenever he has to be given any injection. The amount of clerical work in filling in these cards has been found to be negligible. The card, which is obtainable from Messrs. Burroughs Wellcome, contains space for the recording of any type of protective inoculation, with a small space for the blood-group. In our experience the patients are pleased to receive these cards and do appreciate that it is in their interests that they carry them with them, and we have no difficulty in getting them to report on the appropriate date for their booster doses of toxoid.
H. WYNFORD JONES. YOUNG
GIRL,
OLD GIRL?
review in your issue of May 17 you speak young girl of nineteen, making use of what is now accepted terminology. According to this system of classification, a girl is unequivocally juvenile, but a young girl is someone considerably older who might almost be described as a young woman, were that permissible. It seems, however, that agreement is still lacking on the gradations that may correctly be used to bridge the gap between this phase and that later period when the young sirl has finallv acauired the status of an old sirl.
SIR,-In
of
a
a
Bushey Heath, Hertfordshire.
F. CAMPBELL ROSE.
ORAL TREATMENT OF PERNICIOUS ANÆMIA
SIR,-We are grateful for the comments on our article pernicious anaemia by Dr. Latner (May 17, p. 1077), who has worked for so long in this field with such distinction. We feel, however, that to criticise the dose given in the first week and yet ignore the lengthy maintenance period on low dosage is somewhat eccentric. We were quite aware that daily oral doses of 100 .g. of vitamin B12, no matter in what form it was given, would produce a on
response of some kind. We were less interested in this initial response than in ascertaining whether the vitamin]312-peptide could maintain patients in full health over long periods on small doses. We believe that the literature is already overcrowded with reports of short-term responses to various preparations and we had no desire to confuse the picture still further. Although it is true that responses can be obtained with 5 tg. of vitamin B12, the massive doses of " intrinsic factor " required to facilitate its absorption (one thousand to two hundred thousand times the amount of vitamin) indicate that such preparations are not really very effective on a weight basis. We have not attempted, as yet, to determine the minimal effective daily dose of our preparation in terms of vitamin B12, but no matter what this is
finally discovered to be, as it is complexed with less than seven times its weight of peptide, it remains quite easily the most effective preparation for the oral therapy of pernicious ansemia yet described. Lastly we do not deny that there is some factor within the normal stomach which brings about the relevant proteolysis-indeed, that is precisely what we have already said in our article. That, however, is totally different from believing in the existence of the " intrinsic factor ", as currently understood, which is supposed to combine with pure vitamin B12 to facilitate its absorption. J. G. HEATHCOTE St. Helens
Hospital.
F. S. MOONEY.
" THESE DYING DISEASES "
SIR,-Dr. Vickers states in his letter of April 19 that non-specific urethritis are now the major problem, and these are in need of general medical investigation and care ". If the v.D. service is disbanded, as he suggests, who will diagnose these cases from gonorrhoea and study the relation of promiscuous exposure to certain cases of urethritis ? Who will investigate the various types of non-specific urethritis and study the relationship of urethritis and prostatic infection to rheumatoid arthritis "cases of
and other rheumatic conditions. I believe that the great majority of physicians, surgeons, and general practitioners are glad of the specialised help that venereologists can give in trying to solve these problems. In many of the large cities gonorrhoea itself is a major and the ultimate success of modern methods of treatment is by no means assured. Contact tracing and follow-up of defaulters, therefore, remain essential to control the disease, and this would become impossible if the cases were scattered
problem
practitioners. V.D. departments have an important part to play in investigation of doubtful blood reactions in pregnancy. In the genuine cases of syphilis, treatment and follow-up of mother and baby can best be done through an organised v.D. service. The immigration from countries with a high rate of syphilitic among
The
infection makes this a formidable task in some areas. If, as Dr. Vickers states, the majority of cases of late syphilis are treated by the physician specialising in the organ mainly affected, and not by a venereologist, then the incidence of late syphilis in this country must indeed be high and cause for grave national concern.
One
important problem is not dealt with either in Mr. King’s original article (March 29) or in subsequent letters. This is the small-town clinic where in many instances the number of patients attending does not justify the expenditure on staff, buildings, and equipment. Many of the patients in these areas travel to the nearest large centre where there is less chance of casual recognition. There is no easy solution to this problem, and I think each individual clinic needs careful consideration to decide whether (a) better facilities would improve the attendance or (b) the clinic should close. The General
Hospital, Birmingham.
G. H. KNIGHT.
SIR,—The letter by Dr. Willcox (May 24) about the increasing incidence of gonorrhoea in spite of antibiotic recalls a conversation which I had with Sir Alexander Fleming a few weeks before his death. He told me that he thought the antibiotic era, especially in relation to venereal infections, would be over in about five years. I replied that although he was more able to judge than anyone else, surely he underrated the value of treatment
penicillin.
1178 The
alarming statistics of the increase of these " dying
diseases " suggest that
Fleming’s
statement was
justified.
T. ANWYL-DAVIES. A LOW-RESISTANCE RESPIRATORY VALVE
SiR,—We are grateful
to Dr. Cunningham (April 5) for that our brief pointing report (Feb. 22) on a lowresistance valve gives the false impression that the valve of Bannister and Cormack is not of similar low resistance. This was not intended. Of the many valves examined, a few were included in our report, and two only were discussed-the valve of McKerrow and Otis, which has a large deadspace, and that of Bannister and Cormack. The latter has hinged valve flaps operated by gravity, and although we regret that we have not had one of their valves to test, it seems unlikely that it could operate effectively during tests of maximum breathing capacity where respiratory rate may exceed 200 per minute. Pneumoconiosis Research Laboratory, S. ZWI. Braamfontein, Johannesburg. out
CHANGES IN THE LIVER IN GLOMERULONEPHRITIS WITH ŒDEMA SIR, There is no doubt that the combination of renal and hepatic disease is not a coincidence, since both organs have excretory functions and may be damaged by the same toxic and infective agents, as in yellow fever and Weil’s disease. Practically all the studies published deal with the effect of liver disease on the kidneys. Boydcould find no changes in liver-function tests in cases of nephritis. We studied 51 patients with oedema-caused acute glomerulonephri-
by
tis in
13, sub-
acute
nephritis
in 9, subchronic nephritis in 23, cardiac failure in 3, and malnutrition in 3. They were in-
vestigated means
by
of liver-
several function tests, and repeated liver biopsies stained and examined for
Fig. 2-The middle half shows a massive focus, made of several disintegrating liver cells infiltrated b neutrophils and lymphocytes. (x450.) small foci (fig. 1 ), made up of
one or two liver cells in early cases, (fig. 2 of one or two columns of liver cells in oedema of longer standing. These foci were early infiltrated with neutrophils, then lymphocytes, and’in the massive necrosis cases) later fibroblasts and regenerating liver cells around them (fig. 3) according to the duration of the (’edema; the small foci healed completely. The patchy appearance of the liver cells cuboidal cells alternating with clear globular vaculated cells) denoting possible phases of functional activities, could be confirmed in the specimens
to massive
necrosis
studied.
The factor
responsible for these changes in the liver
may be metabolic, the result of disturbed renal function; it may be related to the hypoalbuminarmia or vascular capillaries, or to bacterial emboli not dealt with by the liver because of loss of complement in the urinary protein; or it may be allergic, in view of the response of oedema in some cases to antihistaminic drugs2 and the fall in the histamine-binding power of the blood in the cases
studied. 2.
Dorry Loutfy,
Kh.
V. 1-,’g,pi. md.
Ass.
1951, 34, 755.
structure,
protein, glycogen,
and
fat
content.
Fig. 1-In the centre is a minute focus made of one or two disintegrating liver cells infiltrated by neutrophils. ( x 450.)
To summarise the results in the 45 cases of ne-
phritis :
1. Clinical.The liver was in proportion to the duration
found to be progressively enlarging of the oedema in 40% of the cases of glomerulonephritis. 2. Liver-function Tests.-The galactose-tolerance test was disturbed in 62% and the galactose index in 80% of the glomerulonephritis cases. Bromsulphalein retention was increased in 33% and thymol turbidity was increased in 25%. Both the icterus index and Van den Bergh test were normal, while the alkaline-phosphatase figures were in the high normal range. 3. Liver Biopsy.-Examination of many serial sections revealed the presence of foci of disintegrated liver cells, varying in size from 1. Boyd, R. I.
Arch. intern. Med. 1949, 83, 298.
Fig. 3-On the left
is a focus infiltrated mainly by lymphocytes and few fibroblasts. On the right is a more chronic focus, made up mainly of fibroblasts. (connecting the two foci is a beginning band of fibrous tissue ( x 200.)
MAURICE ELLIS.
Hospitals.
SIR,-As a casualty officer seeing many I was interested in Dr. Scott’s letter.
cases
of
injury
It is our experience here that a large number of patients who attend are able to tell us that they have been treated elsewhere for injuries and have been given irijections, but they have no idea what they were given or why, and in many cases they are extremely vague about the time of the injury. It has been our custom for some time past to issue all patients in need of toxoid with a record card, on which is entered the amount of the toxoid given, the date on which it was given, and a reminder date for the reinforcing dose. This card, which is of pocket size, is given to the patient with instructions that it should always be carried with him and produced whenever he has to be given any injection. The amount of clerical work in filling in these cards has been found to be negligible. The card, which is obtainable from Messrs. Burroughs Wellcome, contains space for the recording of any type of protective inoculation, with a small space for the blood-group. In our experience the patients are pleased to receive these cards and do appreciate that it is in their interests that they carry them with them, and we have no difficulty in getting them to report on the appropriate date for their booster doses of toxoid.
H. WYNFORD JONES. YOUNG
GIRL,
OLD GIRL?
review in your issue of May 17 you speak young girl of nineteen, making use of what is now accepted terminology. According to this system of classification, a girl is unequivocally juvenile, but a young girl is someone considerably older who might almost be described as a young woman, were that permissible. It seems, however, that agreement is still lacking on the gradations that may correctly be used to bridge the gap between this phase and that later period when the young sirl has finallv acauired the status of an old sirl.
SIR,-In
of
a
a
Bushey Heath, Hertfordshire.
F. CAMPBELL ROSE.
ORAL TREATMENT OF PERNICIOUS ANÆMIA
SIR,-We are grateful for the comments on our article pernicious anaemia by Dr. Latner (May 17, p. 1077), who has worked for so long in this field with such distinction. We feel, however, that to criticise the dose given in the first week and yet ignore the lengthy maintenance period on low dosage is somewhat eccentric. We were quite aware that daily oral doses of 100 .g. of vitamin B12, no matter in what form it was given, would produce a on
response of some kind. We were less interested in this initial response than in ascertaining whether the vitamin]312-peptide could maintain patients in full health over long periods on small doses. We believe that the literature is already overcrowded with reports of short-term responses to various preparations and we had no desire to confuse the picture still further. Although it is true that responses can be obtained with 5 tg. of vitamin B12, the massive doses of " intrinsic factor " required to facilitate its absorption (one thousand to two hundred thousand times the amount of vitamin) indicate that such preparations are not really very effective on a weight basis. We have not attempted, as yet, to determine the minimal effective daily dose of our preparation in terms of vitamin B12, but no matter what this is
finally discovered to be, as it is complexed with less than seven times its weight of peptide, it remains quite easily the most effective preparation for the oral therapy of pernicious ansemia yet described. Lastly we do not deny that there is some factor within the normal stomach which brings about the relevant proteolysis-indeed, that is precisely what we have already said in our article. That, however, is totally different from believing in the existence of the " intrinsic factor ", as currently understood, which is supposed to combine with pure vitamin B12 to facilitate its absorption. J. G. HEATHCOTE St. Helens
Hospital.
F. S. MOONEY.
" THESE DYING DISEASES "
SIR,-Dr. Vickers states in his letter of April 19 that non-specific urethritis are now the major problem, and these are in need of general medical investigation and care ". If the v.D. service is disbanded, as he suggests, who will diagnose these cases from gonorrhoea and study the relation of promiscuous exposure to certain cases of urethritis ? Who will investigate the various types of non-specific urethritis and study the relationship of urethritis and prostatic infection to rheumatoid arthritis "cases of
and other rheumatic conditions. I believe that the great majority of physicians, surgeons, and general practitioners are glad of the specialised help that venereologists can give in trying to solve these problems. In many of the large cities gonorrhoea itself is a major and the ultimate success of modern methods of treatment is by no means assured. Contact tracing and follow-up of defaulters, therefore, remain essential to control the disease, and this would become impossible if the cases were scattered
problem
practitioners. V.D. departments have an important part to play in investigation of doubtful blood reactions in pregnancy. In the genuine cases of syphilis, treatment and follow-up of mother and baby can best be done through an organised v.D. service. The immigration from countries with a high rate of syphilitic among
The
infection makes this a formidable task in some areas. If, as Dr. Vickers states, the majority of cases of late syphilis are treated by the physician specialising in the organ mainly affected, and not by a venereologist, then the incidence of late syphilis in this country must indeed be high and cause for grave national concern.
One
important problem is not dealt with either in Mr. King’s original article (March 29) or in subsequent letters. This is the small-town clinic where in many instances the number of patients attending does not justify the expenditure on staff, buildings, and equipment. Many of the patients in these areas travel to the nearest large centre where there is less chance of casual recognition. There is no easy solution to this problem, and I think each individual clinic needs careful consideration to decide whether (a) better facilities would improve the attendance or (b) the clinic should close. The General
Hospital, Birmingham.
G. H. KNIGHT.
SIR,—The letter by Dr. Willcox (May 24) about the increasing incidence of gonorrhoea in spite of antibiotic recalls a conversation which I had with Sir Alexander Fleming a few weeks before his death. He told me that he thought the antibiotic era, especially in relation to venereal infections, would be over in about five years. I replied that although he was more able to judge than anyone else, surely he underrated the value of treatment
penicillin.
1178 The
alarming statistics of the increase of these " dying
diseases " suggest that
Fleming’s
statement was
justified.
T. ANWYL-DAVIES. A LOW-RESISTANCE RESPIRATORY VALVE
SiR,—We are grateful
to Dr. Cunningham (April 5) for that our brief pointing report (Feb. 22) on a lowresistance valve gives the false impression that the valve of Bannister and Cormack is not of similar low resistance. This was not intended. Of the many valves examined, a few were included in our report, and two only were discussed-the valve of McKerrow and Otis, which has a large deadspace, and that of Bannister and Cormack. The latter has hinged valve flaps operated by gravity, and although we regret that we have not had one of their valves to test, it seems unlikely that it could operate effectively during tests of maximum breathing capacity where respiratory rate may exceed 200 per minute. Pneumoconiosis Research Laboratory, S. ZWI. Braamfontein, Johannesburg. out
CHANGES IN THE LIVER IN GLOMERULONEPHRITIS WITH ŒDEMA SIR, There is no doubt that the combination of renal and hepatic disease is not a coincidence, since both organs have excretory functions and may be damaged by the same toxic and infective agents, as in yellow fever and Weil’s disease. Practically all the studies published deal with the effect of liver disease on the kidneys. Boydcould find no changes in liver-function tests in cases of nephritis. We studied 51 patients with oedema-caused acute glomerulonephri-
by
tis in
13, sub-
acute
nephritis
in 9, subchronic nephritis in 23, cardiac failure in 3, and malnutrition in 3. They were in-
vestigated means
by
of liver-
several function tests, and repeated liver biopsies stained and examined for
Fig. 2-The middle half shows a massive focus, made of several disintegrating liver cells infiltrated b neutrophils and lymphocytes. (x450.) small foci (fig. 1 ), made up of
one or two liver cells in early cases, (fig. 2 of one or two columns of liver cells in oedema of longer standing. These foci were early infiltrated with neutrophils, then lymphocytes, and’in the massive necrosis cases) later fibroblasts and regenerating liver cells around them (fig. 3) according to the duration of the (’edema; the small foci healed completely. The patchy appearance of the liver cells cuboidal cells alternating with clear globular vaculated cells) denoting possible phases of functional activities, could be confirmed in the specimens
to massive
necrosis
studied.
The factor
responsible for these changes in the liver
may be metabolic, the result of disturbed renal function; it may be related to the hypoalbuminarmia or vascular capillaries, or to bacterial emboli not dealt with by the liver because of loss of complement in the urinary protein; or it may be allergic, in view of the response of oedema in some cases to antihistaminic drugs2 and the fall in the histamine-binding power of the blood in the cases
studied. 2.
Dorry Loutfy,
Kh.
V. 1-,’g,pi. md.
Ass.
1951, 34, 755.
structure,
protein, glycogen,
and
fat
content.
Fig. 1-In the centre is a minute focus made of one or two disintegrating liver cells infiltrated by neutrophils. ( x 450.)
To summarise the results in the 45 cases of ne-
phritis :
1. Clinical.The liver was in proportion to the duration
found to be progressively enlarging of the oedema in 40% of the cases of glomerulonephritis. 2. Liver-function Tests.-The galactose-tolerance test was disturbed in 62% and the galactose index in 80% of the glomerulonephritis cases. Bromsulphalein retention was increased in 33% and thymol turbidity was increased in 25%. Both the icterus index and Van den Bergh test were normal, while the alkaline-phosphatase figures were in the high normal range. 3. Liver Biopsy.-Examination of many serial sections revealed the presence of foci of disintegrated liver cells, varying in size from 1. Boyd, R. I.
Arch. intern. Med. 1949, 83, 298.
Fig. 3-On the left
is a focus infiltrated mainly by lymphocytes and few fibroblasts. On the right is a more chronic focus, made up mainly of fibroblasts. (connecting the two foci is a beginning band of fibrous tissue ( x 200.)