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AGRANULOCYTOSIS FOLLOWING TREATMENT WITH PHENYLINDANEDIONE
708 which I trust will not be forgotten like its predecessor. The points I have mentioned, however, merit consideration if the shortage of tutors is to be overcome. J. CHRISTIE. Perth.
increase in size of the miscible pool of uric acid in previously reported by Benedict et awl.4
gout,
Instituto de Investigaciones Médicas, MédicRs, ROCHE. ROCFIE. MARCEL MARC Venezuela. EL OCHE. Caracas, Venezuola.
SiR,-Dr. Dixon is mistaken when he says that AGRANULOCYTOSIS FOLLOWING TREATMENT WITH PHENYLINDANEDIONE SiR,ŇI am most interested by Dr. Knut Kirkeby’s article (Sept. 18). I had a case recently with similar
features. The patient, a man aged 60, was under treatment for confirmed coronary thrombosis. On July 26 he developed several thromboses of the right leg. He was given heparin 12,500 units intramuscularly, followed by phenylindanedione (’Dindevan’) 25 mg. b.i.d. The thromboses gradually improved, but on Aug. 19 he developed a sore throat. I stopped the phenylindanedione and gave ascorbic acid 100 mg. q.i.d. and oral penicillin 400,000 units q.i.d. On the following day he had a diffuse and extremely itchy red rash over his back. I ascribed this to penicillin allergy and at once switched The rash to erythromycin (’Erythrocin’) 200 mg. q.i.d. faded ; but the throat did not improve, and he developed several painful ulcers of the mouth. His temperature, which had been 101°F before treatment, dropped during these two days to subnormal. I suspected a possible early aplastic anaemia, but was reassured by his haemoglobin reading of
78% (Tallqvist). The ulcers gradually improved, the throat cleared up, and the rash faded ; but he developed an adenitis behind the right ear and angle of the jaw. This discharged on Sept. 19, and appears to have recovered. I have no details of blood examination, but I feel that this reaction, which I thought was possibly due to a lack of vitamin C, may have been due to incipient
he
now
agranulocytosis, Tarbert, Argyll.
averted
by stopping phenylindanedione. A. C. MAYER MAYER. ’
TERMINOLOGY IN LACTATIONAL PHYSIOLOGY SiR,-The right use of " suckle " and " suckling " can be easily learnt from Johnson’s Dictionary. To suckle is to nurse at the breast : "Two thriving calves she suckles twice a day " (Dryden). Whereas a suckling is a young creature yet fed by the pap ; " Young animals participate of the nature of their aliment, as sucklings of milk " (Arbuthnot). In short, mothers suckle : sucklings suck. If there has been an attempt to prescribe a misuse of the verb suckle in scientific literature by transferring it from the mother to the offspring, a mistake has been made. It would be handsome in those responsible if they made acknowledgment and amended their usage, instead of trying to justify themselves by some rare or wayward example from 1688. What was this example ?’1 H. H. ST. ST. H. VERTUE. Orpington, Kent. RHEUMATISM: THE AMERICAN SCENE
SiR,-Referring to the article by Dr. Dixon in your issue of Aug. 7, I wish to point out that the work of Benedict et all performed in Stetten’s laboratory, was not intended to explode " the old idea that exogenous uric acid is derived solely from nucleoproteins present in food." That idea had been " exploded " before by Sonne and collaborators in the pigeon2 and by Shemin and Rittenberg in man.3 The work of these investigators established that dietary glycine furnished the nitrogen atom in position 7 of the purine ring of uric acid. Our work did show, in a preliminary way, that in one gouty subject there was a more rapid incorporation of dietary glycine into uric acid, and that " overproduction of uric acid may be largely responsible for the pathological "
1. Benedict, J. D., Roche, M., Yu, T. F., Bien, E. J., Gutman, A. B. Stetten, H. DeW. jun. Metabolism, 1952, 1, 3. 2. Sonne, J. C., Buchanan, J. M., Delluva, A. M. J. biol. Chem.
1948, 173, 81. 3. Shemin, D., Rittenberg, D.
Ibid, 1947, 172, 67.
"
Ex-Servicemen and their families
care
can get free inpatient hospitals." In fact, families of exget no care from the Veterans’ Adminis-
at Veterans’
Servicemen tration.
can
New York.
ABRAHAM S. HAFT.
HAZARDS OF SURGICAL INDUCTION OF LABOUR
SIR,-Mr. Evans, in his otherwise excellent paper of Sept. 18, spoils the force of his arguments against the indiscriminate use of surgical induction by basing them on premises which hardly bear detailed analysis. Of the three maternal deaths attributed to the method, the first was due to haemorrhage from separation of the placenta by the catheter-a complication due to operative clumsiness. The second resulted from infection following rupture of the forewaters-not the generally accepted method of choice. The third followed induction with the stomach tube-a surgically dirty method, the dangers of which I exposed during a discussion at the Royal Society of Medicine in 1937. If we take it that surgical induction of labour nowadays means careful catheter rupture of the hindwaters, the overwhelming mass of statistics prove that it is safe for mother and child ; the cases cited by Mr. Evans provide no true contradiction. Indeed, his red herring may have harmful results in exaggerating the dangers of the operation, so depriving patients of its many proven benefits. The dangers to mother and child inherent in that most barbaric of operations-the " difficult" forceps (which can so often be avoided by a well-timed induction)-are surely considerably greater than those involved in catheter rupture of the hindwaters ; and the foetal salvage obtained by surgical induction in pre-eclamptic toxaemia is also established. It is to be hoped that Mr. Evans’s statistics will not dissuade the timorous obstetrician from giving his patients the benefits of carefully performed catheter induction ; it would be tragic if this well-proven and foetal-life-saving method were to be discarded on such
grounds. London, Zi‘.1.
ALBERT DAVIS.
SiR,-It is evident from the tone of his article that Mr. Evans has a strong bias against the induction of labour. This is a matter of opinion with which some obstetricians may perhaps agree, but it impairs the value of his paper. The recording of an unfavourable issue after an induction is used as evidence against inductions in general, regardless of the method used and the training of the operator. Numerous references are given to reports noting the hazards of -the procedure in question, but the pioneer work and enthusiasm of Drew-Smythe escape mention. The bald assertion : the maternal-mortality rate associated with surgical induction is therefore 3.6 per 1000 is made on the strength of 3 unfortunate cases in twenty-five years ; they include a haemorrhagic death that could probably have been avoided, an error of judgment in attempting to induce labour at the 32nd week, and a case of paralytic ileus following decompression of hydramnios at term. No mention is made of maternal deaths that might have been prevented by timely tapping of the waters. Three such cases have recently come to my notice. In two, death was due to amniotic embolism following extremely powerful uterine contractions with intact forewaters ; while in the third there was associated with the conservative pulmonary collapse treatment of a vast hydramnios. "
4. Benedict, J. D., 181, 183.
Forsham, P. H., Stetten, H. DeW.
Ibid, 1949
increase in size of the miscible pool of uric acid in previously reported by Benedict et awl.4
gout,
Instituto de Investigaciones Médicas, MédicRs, ROCHE. ROCFIE. MARCEL MARC Venezuela. EL OCHE. Caracas, Venezuola.
SiR,-Dr. Dixon is mistaken when he says that AGRANULOCYTOSIS FOLLOWING TREATMENT WITH PHENYLINDANEDIONE SiR,ŇI am most interested by Dr. Knut Kirkeby’s article (Sept. 18). I had a case recently with similar
features. The patient, a man aged 60, was under treatment for confirmed coronary thrombosis. On July 26 he developed several thromboses of the right leg. He was given heparin 12,500 units intramuscularly, followed by phenylindanedione (’Dindevan’) 25 mg. b.i.d. The thromboses gradually improved, but on Aug. 19 he developed a sore throat. I stopped the phenylindanedione and gave ascorbic acid 100 mg. q.i.d. and oral penicillin 400,000 units q.i.d. On the following day he had a diffuse and extremely itchy red rash over his back. I ascribed this to penicillin allergy and at once switched The rash to erythromycin (’Erythrocin’) 200 mg. q.i.d. faded ; but the throat did not improve, and he developed several painful ulcers of the mouth. His temperature, which had been 101°F before treatment, dropped during these two days to subnormal. I suspected a possible early aplastic anaemia, but was reassured by his haemoglobin reading of
78% (Tallqvist). The ulcers gradually improved, the throat cleared up, and the rash faded ; but he developed an adenitis behind the right ear and angle of the jaw. This discharged on Sept. 19, and appears to have recovered. I have no details of blood examination, but I feel that this reaction, which I thought was possibly due to a lack of vitamin C, may have been due to incipient
he
now
agranulocytosis, Tarbert, Argyll.
averted
by stopping phenylindanedione. A. C. MAYER MAYER. ’
TERMINOLOGY IN LACTATIONAL PHYSIOLOGY SiR,-The right use of " suckle " and " suckling " can be easily learnt from Johnson’s Dictionary. To suckle is to nurse at the breast : "Two thriving calves she suckles twice a day " (Dryden). Whereas a suckling is a young creature yet fed by the pap ; " Young animals participate of the nature of their aliment, as sucklings of milk " (Arbuthnot). In short, mothers suckle : sucklings suck. If there has been an attempt to prescribe a misuse of the verb suckle in scientific literature by transferring it from the mother to the offspring, a mistake has been made. It would be handsome in those responsible if they made acknowledgment and amended their usage, instead of trying to justify themselves by some rare or wayward example from 1688. What was this example ?’1 H. H. ST. ST. H. VERTUE. Orpington, Kent. RHEUMATISM: THE AMERICAN SCENE
SiR,-Referring to the article by Dr. Dixon in your issue of Aug. 7, I wish to point out that the work of Benedict et all performed in Stetten’s laboratory, was not intended to explode " the old idea that exogenous uric acid is derived solely from nucleoproteins present in food." That idea had been " exploded " before by Sonne and collaborators in the pigeon2 and by Shemin and Rittenberg in man.3 The work of these investigators established that dietary glycine furnished the nitrogen atom in position 7 of the purine ring of uric acid. Our work did show, in a preliminary way, that in one gouty subject there was a more rapid incorporation of dietary glycine into uric acid, and that " overproduction of uric acid may be largely responsible for the pathological "
1. Benedict, J. D., Roche, M., Yu, T. F., Bien, E. J., Gutman, A. B. Stetten, H. DeW. jun. Metabolism, 1952, 1, 3. 2. Sonne, J. C., Buchanan, J. M., Delluva, A. M. J. biol. Chem.
1948, 173, 81. 3. Shemin, D., Rittenberg, D.
Ibid, 1947, 172, 67.
"
Ex-Servicemen and their families
care
can get free inpatient hospitals." In fact, families of exget no care from the Veterans’ Adminis-
at Veterans’
Servicemen tration.
can
New York.
ABRAHAM S. HAFT.
HAZARDS OF SURGICAL INDUCTION OF LABOUR
SIR,-Mr. Evans, in his otherwise excellent paper of Sept. 18, spoils the force of his arguments against the indiscriminate use of surgical induction by basing them on premises which hardly bear detailed analysis. Of the three maternal deaths attributed to the method, the first was due to haemorrhage from separation of the placenta by the catheter-a complication due to operative clumsiness. The second resulted from infection following rupture of the forewaters-not the generally accepted method of choice. The third followed induction with the stomach tube-a surgically dirty method, the dangers of which I exposed during a discussion at the Royal Society of Medicine in 1937. If we take it that surgical induction of labour nowadays means careful catheter rupture of the hindwaters, the overwhelming mass of statistics prove that it is safe for mother and child ; the cases cited by Mr. Evans provide no true contradiction. Indeed, his red herring may have harmful results in exaggerating the dangers of the operation, so depriving patients of its many proven benefits. The dangers to mother and child inherent in that most barbaric of operations-the " difficult" forceps (which can so often be avoided by a well-timed induction)-are surely considerably greater than those involved in catheter rupture of the hindwaters ; and the foetal salvage obtained by surgical induction in pre-eclamptic toxaemia is also established. It is to be hoped that Mr. Evans’s statistics will not dissuade the timorous obstetrician from giving his patients the benefits of carefully performed catheter induction ; it would be tragic if this well-proven and foetal-life-saving method were to be discarded on such
grounds. London, Zi‘.1.
ALBERT DAVIS.
SiR,-It is evident from the tone of his article that Mr. Evans has a strong bias against the induction of labour. This is a matter of opinion with which some obstetricians may perhaps agree, but it impairs the value of his paper. The recording of an unfavourable issue after an induction is used as evidence against inductions in general, regardless of the method used and the training of the operator. Numerous references are given to reports noting the hazards of -the procedure in question, but the pioneer work and enthusiasm of Drew-Smythe escape mention. The bald assertion : the maternal-mortality rate associated with surgical induction is therefore 3.6 per 1000 is made on the strength of 3 unfortunate cases in twenty-five years ; they include a haemorrhagic death that could probably have been avoided, an error of judgment in attempting to induce labour at the 32nd week, and a case of paralytic ileus following decompression of hydramnios at term. No mention is made of maternal deaths that might have been prevented by timely tapping of the waters. Three such cases have recently come to my notice. In two, death was due to amniotic embolism following extremely powerful uterine contractions with intact forewaters ; while in the third there was associated with the conservative pulmonary collapse treatment of a vast hydramnios. "
4. Benedict, J. D., 181, 183.
Forsham, P. H., Stetten, H. DeW.
Ibid, 1949