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SALICYLATES AND ADRENOCORTICAL STEROIDS
1348 is
so much greater than the anti-inflammatory action that if the latter exists its role in man and therapeutic significance is likely to be slight. Dr. Coutu is confused by the term " antiphlogistic " ; he provides a list of 22 references to support his contention that cortisone exerts an anti-inflammatory action. Of these, 9 are devoted to the anti-allergic action of cortisone and 7 to the effects not of cortisone but of cortiootrophin. It is easy to select references to show that cortisone exerts remarkable effects which do not occur in my laboratory, but a mass of reports will not fill the role of a single convincing paper. Dr. Coutu provides an excellent example of the difflculties in obtaining first-rate evidence. He worked on the effect of corticotrophin on the inflammatory response to mustard powder, and, in spite of the logical and practical objection that corticotrophin and cortisone are not the same thing, questions my work with cortisone. I spent some years working on the influence of corticotrophin on inflammatory responses. I found they were decreased, but only by certain batches of corticotrophin. Such responses bore no relation to the unitage and could not be duplicated with cortisone or with other available adrenal steroids. Moreover, the effects of corticotrophin in the guineapig were so transient that I could not distinguish hetween real and compensating effects. I could not therefore interpret my own results ; neither can I interpret his.
National Institute for Medical Research, Mill Hill, London, N.W.7.
D. A. LONG.
SALICYLATES AND ADRENOCORTICAL STEROIDS SIR,-In your issue of May 15, Dr. Smith and his colleagues and Dr. Bayliss and Dr. Steinbeck discuss the action of salicylates on the 17-hydroxycorticosteroids in man. As regards the first of these papers, similar work with similar results was described by Hungarian authors in 1952,1 and by Coste et al.in France 1953, using the biological method of Cope.3 The daily excretion of
in
urinary cortisone-activematerial salicylate therapy.
was
unaltered
during
On the other hand massive doses of salicylate commonly increased plasma 17-hydroxycorticosteroid levels in the patients of Ely et al.4 we have repeatedly suggested that the therapeutic effect of salicylate can
Finally,
’h.g.rtil-v be explained in thie way 15
University Medical School, Szeged, Hungary.
E. KELEMEN.
and about the same distance behind the coronal suture. There little comminution of bone,-and haemorrhage was mainly from the noso. He could see and hear normally. I took him several milos over imperfect roads by ambulance truck to hospital, whore a careful wound toilet was carried out. The patient made an uninterrupted recovery, and several months later he was well enough to appear before a court-martial. There was no mental defect and no history of post-traumatic epilepsy. All the cranial nerves were functioning normally. It was remarkable that the left optic nerve escaped injury. was
As
a
further illustration of the resistance of the brain
hemispheres to trauma applied at right-angles to the skull, I might mention the ancient Chinese practice of passing metal needles through the head to provide an outlet for evil spirits. R. T. S. LOUTTIT.
Iiirkuk, Iraq.
CERTIFICATION FOR MENTAL DISORDERS SIR.-Many of your readers are, like myself, deeply
concerned with improving mental hospitals and the of mental illness ; and they chiefly want to know how they can do this with the means at their disposal. Yet, not only do many otherwise well-informed people still seem to regard certification as an essential and inevitable part of psychiatric care, but the great majority of psychiatrists seem to be unaware that certification has been virtually abolished in both Eire and Northern Ireland. To these I commend that masterpiece of humamitarianism, the Mental Health Act (Northern care
Ireland),
1948. As a medical journal is hardly the best place for a lay writer to offer medical statistics, I will confine myself to the statement that in the British Isles-excluding Northern Ireland-we have today some 200,000 mental patients certified under an Act which is archaic and should be amended. That the Act is obsolete is evident from the establishment of the Royal Commission, to which it was recently my privilege to submit evidence on this score. Surely, we-who were first in the field with anæsthetics, antiseptics, antibiotics, and other great advances - must advance also in the field of psychological medicine. For certain, the time has come for us to separate the " insauity" of the law from the " mental illness " of medicine. Let us, therefore, follow the lead given by Northern Ireland and Eire. H. G. WOODLEY. Edzell, Angus.
**This subject is discussed in a leading article-Ed. L. FŒTAL HEPATITIS
TRAVERSING WOUND OF THE HEAD
SIR,-Mr. B. H. Dawson’s article of May 22, describing a
traversing injury
reminds
me
of
a
of the head with
complete
somewhat similar remarkable
recovery, case.
In 1946, while serving with the Forces overseas, I was called out one afternoon to see a young soldier who had just shot himself through the head. I expected to find him dead, but instead he was lying on his bed with blood streaming from nostrils and mouth and able to talk coherently. He had been suffering from mental depression for several days and had resolved to commit suicide. He had fired one shot through the open mouth from a Smith-Wesson revolver while lying After doing this, on his back with his head on a low pillow. he was distressed to find that he could get up and walk around the room. He was pale. The pulse-rate was about 90, with poor volume. There was a small circular entry wound in the midline of the hard palate and a larger irregular exit wound in the left parietal region two inches from the midline J. clin. Endocrin. 1952, 12, 1249. Kelemen, E., Majoros, M., Soltész, R., Tanos, B. Dtsch. med. Wschr. 1952, 77, 1317. Kelemen, E., Tanos, B., Soltész, R., Kovács, K. Acta endocr., Copenhagen, 1953, 13, 231. Coste, F., Bourel, M., Delbarre, F., Weissenbach, R. Pr. méd. 1953, 61, 979. Cope, C. L. Brit. med. J. 1951, i, 271. Ely, R. S., Done, A. K., Kelley, V. C. Amer. J. Dis. Child. 1953, 86, 656. Kelemen, E., Majoros, M. Lancet, 1951, i, 962.
1. Kelemen, E.
2. 3. 4. 5.
‘
may be of interest in view of your annotation of June 5.
SIR,-The following
case
A 3-week-old infant was brought to this hospital with deep jaundice of 2-3 days’ duration. All the evidence pointed to the jaundice being obstructive in origin. The plasma-bilirubin was of the order of 30 mg. per 100 ml. and a 24-hour specimen of faeces was entirely free from stercobilin. The alkaline phosphatase, however, was 8-5 King-Armstrong units. The blood picture was entirely normal, and the Coombs test negative. Thus bile-duct, atresia was diagnosed, and the child was submitted to laparotomy. At operation, however, absolutely nothing abnormal was found. At this stage it was decided to regard the case as one of hepatitis due to umbilical sepsis and umbilical-vein pyaemia,l although there was no obvious evidence of either umbilical infection or umbilical pylephlebitis. Aureomycin was accordingly given, and the jaundice regressed rapidly after 3-4 days. A complicating feature was the development of severe anaemia of aplastic type which reached its height when the recovery from the jaundice was almost complete. At this stage there was still no evidence of haemolysis or the presence
of antibodies, and the anaemia was not considered to be due to the medication, which had been started after the ansemia The child received a blood-transfusion, was first detected. 1.
Morison, J. E.
J. Path. Bact. 1944, 56, 531.
so much greater than the anti-inflammatory action that if the latter exists its role in man and therapeutic significance is likely to be slight. Dr. Coutu is confused by the term " antiphlogistic " ; he provides a list of 22 references to support his contention that cortisone exerts an anti-inflammatory action. Of these, 9 are devoted to the anti-allergic action of cortisone and 7 to the effects not of cortisone but of cortiootrophin. It is easy to select references to show that cortisone exerts remarkable effects which do not occur in my laboratory, but a mass of reports will not fill the role of a single convincing paper. Dr. Coutu provides an excellent example of the difflculties in obtaining first-rate evidence. He worked on the effect of corticotrophin on the inflammatory response to mustard powder, and, in spite of the logical and practical objection that corticotrophin and cortisone are not the same thing, questions my work with cortisone. I spent some years working on the influence of corticotrophin on inflammatory responses. I found they were decreased, but only by certain batches of corticotrophin. Such responses bore no relation to the unitage and could not be duplicated with cortisone or with other available adrenal steroids. Moreover, the effects of corticotrophin in the guineapig were so transient that I could not distinguish hetween real and compensating effects. I could not therefore interpret my own results ; neither can I interpret his.
National Institute for Medical Research, Mill Hill, London, N.W.7.
D. A. LONG.
SALICYLATES AND ADRENOCORTICAL STEROIDS SIR,-In your issue of May 15, Dr. Smith and his colleagues and Dr. Bayliss and Dr. Steinbeck discuss the action of salicylates on the 17-hydroxycorticosteroids in man. As regards the first of these papers, similar work with similar results was described by Hungarian authors in 1952,1 and by Coste et al.in France 1953, using the biological method of Cope.3 The daily excretion of
in
urinary cortisone-activematerial salicylate therapy.
was
unaltered
during
On the other hand massive doses of salicylate commonly increased plasma 17-hydroxycorticosteroid levels in the patients of Ely et al.4 we have repeatedly suggested that the therapeutic effect of salicylate can
Finally,
’h.g.rtil-v be explained in thie way 15
University Medical School, Szeged, Hungary.
E. KELEMEN.
and about the same distance behind the coronal suture. There little comminution of bone,-and haemorrhage was mainly from the noso. He could see and hear normally. I took him several milos over imperfect roads by ambulance truck to hospital, whore a careful wound toilet was carried out. The patient made an uninterrupted recovery, and several months later he was well enough to appear before a court-martial. There was no mental defect and no history of post-traumatic epilepsy. All the cranial nerves were functioning normally. It was remarkable that the left optic nerve escaped injury. was
As
a
further illustration of the resistance of the brain
hemispheres to trauma applied at right-angles to the skull, I might mention the ancient Chinese practice of passing metal needles through the head to provide an outlet for evil spirits. R. T. S. LOUTTIT.
Iiirkuk, Iraq.
CERTIFICATION FOR MENTAL DISORDERS SIR.-Many of your readers are, like myself, deeply
concerned with improving mental hospitals and the of mental illness ; and they chiefly want to know how they can do this with the means at their disposal. Yet, not only do many otherwise well-informed people still seem to regard certification as an essential and inevitable part of psychiatric care, but the great majority of psychiatrists seem to be unaware that certification has been virtually abolished in both Eire and Northern Ireland. To these I commend that masterpiece of humamitarianism, the Mental Health Act (Northern care
Ireland),
1948. As a medical journal is hardly the best place for a lay writer to offer medical statistics, I will confine myself to the statement that in the British Isles-excluding Northern Ireland-we have today some 200,000 mental patients certified under an Act which is archaic and should be amended. That the Act is obsolete is evident from the establishment of the Royal Commission, to which it was recently my privilege to submit evidence on this score. Surely, we-who were first in the field with anæsthetics, antiseptics, antibiotics, and other great advances - must advance also in the field of psychological medicine. For certain, the time has come for us to separate the " insauity" of the law from the " mental illness " of medicine. Let us, therefore, follow the lead given by Northern Ireland and Eire. H. G. WOODLEY. Edzell, Angus.
**This subject is discussed in a leading article-Ed. L. FŒTAL HEPATITIS
TRAVERSING WOUND OF THE HEAD
SIR,-Mr. B. H. Dawson’s article of May 22, describing a
traversing injury
reminds
me
of
a
of the head with
complete
somewhat similar remarkable
recovery, case.
In 1946, while serving with the Forces overseas, I was called out one afternoon to see a young soldier who had just shot himself through the head. I expected to find him dead, but instead he was lying on his bed with blood streaming from nostrils and mouth and able to talk coherently. He had been suffering from mental depression for several days and had resolved to commit suicide. He had fired one shot through the open mouth from a Smith-Wesson revolver while lying After doing this, on his back with his head on a low pillow. he was distressed to find that he could get up and walk around the room. He was pale. The pulse-rate was about 90, with poor volume. There was a small circular entry wound in the midline of the hard palate and a larger irregular exit wound in the left parietal region two inches from the midline J. clin. Endocrin. 1952, 12, 1249. Kelemen, E., Majoros, M., Soltész, R., Tanos, B. Dtsch. med. Wschr. 1952, 77, 1317. Kelemen, E., Tanos, B., Soltész, R., Kovács, K. Acta endocr., Copenhagen, 1953, 13, 231. Coste, F., Bourel, M., Delbarre, F., Weissenbach, R. Pr. méd. 1953, 61, 979. Cope, C. L. Brit. med. J. 1951, i, 271. Ely, R. S., Done, A. K., Kelley, V. C. Amer. J. Dis. Child. 1953, 86, 656. Kelemen, E., Majoros, M. Lancet, 1951, i, 962.
1. Kelemen, E.
2. 3. 4. 5.
‘
may be of interest in view of your annotation of June 5.
SIR,-The following
case
A 3-week-old infant was brought to this hospital with deep jaundice of 2-3 days’ duration. All the evidence pointed to the jaundice being obstructive in origin. The plasma-bilirubin was of the order of 30 mg. per 100 ml. and a 24-hour specimen of faeces was entirely free from stercobilin. The alkaline phosphatase, however, was 8-5 King-Armstrong units. The blood picture was entirely normal, and the Coombs test negative. Thus bile-duct, atresia was diagnosed, and the child was submitted to laparotomy. At operation, however, absolutely nothing abnormal was found. At this stage it was decided to regard the case as one of hepatitis due to umbilical sepsis and umbilical-vein pyaemia,l although there was no obvious evidence of either umbilical infection or umbilical pylephlebitis. Aureomycin was accordingly given, and the jaundice regressed rapidly after 3-4 days. A complicating feature was the development of severe anaemia of aplastic type which reached its height when the recovery from the jaundice was almost complete. At this stage there was still no evidence of haemolysis or the presence
of antibodies, and the anaemia was not considered to be due to the medication, which had been started after the ansemia The child received a blood-transfusion, was first detected. 1.
Morison, J. E.
J. Path. Bact. 1944, 56, 531.