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ANTITOXINS AND ANTIBIOTICS
642 decreased considerably ; interscapular brown fat was reduced in amount and had taken the appearance of white adipose
tissue.
From our results it appears that cortisone increases fat content of liver, probably through an increase of fat mobilisation. Fatty liver produced by A.C.T.H. may be regarded as a consequence of adrenal stimulation.
the
G. A. M. C.
Anatomo-Pathological Institute, University of Milan, and Farmitalia Research Laboratories.
SALA AMIRA
BOKASI CAVALLERO.
METHONIUM COMPOUNDS IN HYPERTENSION Sm,-In their letter last week, Dr. Hirson and Dr. Kelsall describe a fatality due to excessive low bloodpressure after administration of hexamethonium. An attempt was made to raise the blood-pressure by an intravenous drip containing adrenaline ; and the report notes that the " pressure always dropped precipitately during the brief periods when the drip was discontinued." It does not appear to be generally known that this result is to be expected, since it has been shown that adrenaline itself has a blocking action on sympathetic ganglia. If an intravenous infusion of adrenaline is given, the adrenaline by direct action on the vessel walls causes vasoconstriction ; but, by its action on sympathetic ganglia, it prevents the stream of impulses emitted by the vasomotor centres from reaching the vessels. When the adrenaline infusion is stopped, the direct action on the vessels disappears ; and, because tonic impulses from the centre cannot pass the ganglia, the blood-pressure falls precipitately. In this respect noradrenaline has the same action as adrenaline. Fortunately, however, posterior-lobe extract of the pituitary gland has no such effect ; and, so far as animal experiments afford a guide, the right treatment of a patient in whom the blood-pressure has fallen low because of the action of hexamethonium would seem to be to give an intravenous drip containing 10 units pituitary (posterior-lobe) extract in each 50 ml. saline. We have some evidence, which is too little to be conclusive, that posterior-lobe extract may increase ganglionic transmission, and therefore it may prove to be a positive antidote to ganglionic block. However this may be, the interruption of a drip containing posterior-lobe extract would certainly not be followed by the precipitate fall of blood-pressure which occurs at the end of an adrenaline drip. In using an intravenous drip containing posteriorlobe extract, the effect on the coronary vessels will be constrictor, and therefore the drip should be given slowly. The evidence for the action of adrenaline on ganglionic transmission will be found in the ,70urnal of Physiology
(1942, 101, 289). Department of Pharmacology, J. H. BURN. Oxford University. ANTITOXINS AND ANTIBIOTICS
Snt,—Some of the most potent poisons known at the present time are bacterial toxins;so-called" bacterio-
logical warfare " substances. Antibiotics deal
is
based
on
knowledge
of
these
faithfully with bacteria but offer no their products. Antitoxic treatment is a routine for cases of diphtheria, tetanus, and botulism ; and with less effect for gas-gangrene due to Olostridium, welchii with its multiplicity of toxins, occupying half the letters of the Greek alphabet. It is not generally realised that Streptococcus pyogenes can produce a powerful multi-type toxin ; and also the common pyogenes, in certain instances, can produce Staphylococcus " an enterotoxin" and, more often, cell-destroying and blood-clotting toxins. Before antibiotics came into use, streptococcal antiserum and staphylococcal antitoxin were often used, with uneven results.
protection against
The brilliant effects of treatment with antibiotics seem to have discouraged the serologists who formerly worked enthusiastically on the improvement of antisera. One or two recent tragedies have underlined our lack of effective sera, and also the fact that the present generation seems to have forgotten that such things exist or can be used with success. One such case was a young woman with a (staphylococcal) infected wisdom root. This was operated on, and the woman died two days later of a pulmonary embolism, despite active antibiotic therapy. I think she might have been saved by simultaneous antibiotic and staphylococcal-antitoxin treatment. Another young woman developed localised osteomyelitis in a metatarsal bone, and died of general peripheral circulatory failure, despite the exhibition of astronomical doses of antibiotics.
I think that a streptococcal toxin was to blame for the unfortunate outcome in the second case, but it never occurred to anybody to try antistreptococcal serum. Nobody was really to blame for the fatal termination in either case ; but I would like to suggest that the serologists be encouraged to get busy again, and develop their art to the utmost ; and perhaps advertise their
products.
-
--
FRANK MARSH. Epping, Essex. WILL WE NEVER LEARN? SIR,-After an interval of five weeks the first comment on a report by Surgeon Commander Latta Jan. 27) on casualties in the Korean campaign. He stressed two important points : (1) that primary suture of war wounds is usually disastrous ; (2) that rapid evacuation of casualties from a war zone can be a mixed blessing. That he has to stress these points bears out Sir Heneage Ogilvie’s text " Will we never learn" I think Commander Latta has done a considerable service in making his clear and unbiased report. AsSir Heneage indicates (March 3), there is something wrong with the training of the military surgeon. As a reservist in one Service before the late war I used to do periods of training. In my youthful enthusiasm I expected to be taught something about war surgery. But no-one seemed very interested, and the Service journals in periods of peace bear witness to this extraordinary lack of attention to a subject which should be very much in the minds of Service doctors-particularly surgical specialists. The non-medical branches of the Services in peace-time prepare for war, but for some There should be intensive reason the doctors do not. training in the surgery of trauma for both regulars and reservists. Suitable courses could easily be arranged and interested tutors would not be lacking. The individual is not usually prepared to educate himself in these matters, and so he must be subjected to some discipline as Sir Heneage suggests. It would at least be possible to drum into everyone concerned the principles of treatment of soft-tissue wounds. No-one would expect to train abdominal surgeons, thoracic surgeons, or neurosurgeons in a night, but it ought to be feasible to teach most Service medical officers how to diminish mortality and morbidity in the major group of war wounds. I have long believed that the conscientious perusal of Professor Trueta’s small monograph on war surgery published in 1939 would have saved a lot of needless suffering. I still think that most of the answers are in this book. (For one thing it scarcely mentions chemotherapy or antibiotic therapy-an unwarranted faith in these has often lead to the neglect of surgical principles.) Jolly’s Field Surgery in Total War was another book of great value in those early years. The point is that remarkably few bothered to read these books in 1939 and 1940, and it does look as if appropriate study must be directed. If there is another war and if, as is all too likely, there is intensive bombin-atomic or otherwise-casualties
appears
(Lancet,
tissue.
From our results it appears that cortisone increases fat content of liver, probably through an increase of fat mobilisation. Fatty liver produced by A.C.T.H. may be regarded as a consequence of adrenal stimulation.
the
G. A. M. C.
Anatomo-Pathological Institute, University of Milan, and Farmitalia Research Laboratories.
SALA AMIRA
BOKASI CAVALLERO.
METHONIUM COMPOUNDS IN HYPERTENSION Sm,-In their letter last week, Dr. Hirson and Dr. Kelsall describe a fatality due to excessive low bloodpressure after administration of hexamethonium. An attempt was made to raise the blood-pressure by an intravenous drip containing adrenaline ; and the report notes that the " pressure always dropped precipitately during the brief periods when the drip was discontinued." It does not appear to be generally known that this result is to be expected, since it has been shown that adrenaline itself has a blocking action on sympathetic ganglia. If an intravenous infusion of adrenaline is given, the adrenaline by direct action on the vessel walls causes vasoconstriction ; but, by its action on sympathetic ganglia, it prevents the stream of impulses emitted by the vasomotor centres from reaching the vessels. When the adrenaline infusion is stopped, the direct action on the vessels disappears ; and, because tonic impulses from the centre cannot pass the ganglia, the blood-pressure falls precipitately. In this respect noradrenaline has the same action as adrenaline. Fortunately, however, posterior-lobe extract of the pituitary gland has no such effect ; and, so far as animal experiments afford a guide, the right treatment of a patient in whom the blood-pressure has fallen low because of the action of hexamethonium would seem to be to give an intravenous drip containing 10 units pituitary (posterior-lobe) extract in each 50 ml. saline. We have some evidence, which is too little to be conclusive, that posterior-lobe extract may increase ganglionic transmission, and therefore it may prove to be a positive antidote to ganglionic block. However this may be, the interruption of a drip containing posterior-lobe extract would certainly not be followed by the precipitate fall of blood-pressure which occurs at the end of an adrenaline drip. In using an intravenous drip containing posteriorlobe extract, the effect on the coronary vessels will be constrictor, and therefore the drip should be given slowly. The evidence for the action of adrenaline on ganglionic transmission will be found in the ,70urnal of Physiology
(1942, 101, 289). Department of Pharmacology, J. H. BURN. Oxford University. ANTITOXINS AND ANTIBIOTICS
Snt,—Some of the most potent poisons known at the present time are bacterial toxins;so-called" bacterio-
logical warfare " substances. Antibiotics deal
is
based
on
knowledge
of
these
faithfully with bacteria but offer no their products. Antitoxic treatment is a routine for cases of diphtheria, tetanus, and botulism ; and with less effect for gas-gangrene due to Olostridium, welchii with its multiplicity of toxins, occupying half the letters of the Greek alphabet. It is not generally realised that Streptococcus pyogenes can produce a powerful multi-type toxin ; and also the common pyogenes, in certain instances, can produce Staphylococcus " an enterotoxin" and, more often, cell-destroying and blood-clotting toxins. Before antibiotics came into use, streptococcal antiserum and staphylococcal antitoxin were often used, with uneven results.
protection against
The brilliant effects of treatment with antibiotics seem to have discouraged the serologists who formerly worked enthusiastically on the improvement of antisera. One or two recent tragedies have underlined our lack of effective sera, and also the fact that the present generation seems to have forgotten that such things exist or can be used with success. One such case was a young woman with a (staphylococcal) infected wisdom root. This was operated on, and the woman died two days later of a pulmonary embolism, despite active antibiotic therapy. I think she might have been saved by simultaneous antibiotic and staphylococcal-antitoxin treatment. Another young woman developed localised osteomyelitis in a metatarsal bone, and died of general peripheral circulatory failure, despite the exhibition of astronomical doses of antibiotics.
I think that a streptococcal toxin was to blame for the unfortunate outcome in the second case, but it never occurred to anybody to try antistreptococcal serum. Nobody was really to blame for the fatal termination in either case ; but I would like to suggest that the serologists be encouraged to get busy again, and develop their art to the utmost ; and perhaps advertise their
products.
-
--
FRANK MARSH. Epping, Essex. WILL WE NEVER LEARN? SIR,-After an interval of five weeks the first comment on a report by Surgeon Commander Latta Jan. 27) on casualties in the Korean campaign. He stressed two important points : (1) that primary suture of war wounds is usually disastrous ; (2) that rapid evacuation of casualties from a war zone can be a mixed blessing. That he has to stress these points bears out Sir Heneage Ogilvie’s text " Will we never learn" I think Commander Latta has done a considerable service in making his clear and unbiased report. AsSir Heneage indicates (March 3), there is something wrong with the training of the military surgeon. As a reservist in one Service before the late war I used to do periods of training. In my youthful enthusiasm I expected to be taught something about war surgery. But no-one seemed very interested, and the Service journals in periods of peace bear witness to this extraordinary lack of attention to a subject which should be very much in the minds of Service doctors-particularly surgical specialists. The non-medical branches of the Services in peace-time prepare for war, but for some There should be intensive reason the doctors do not. training in the surgery of trauma for both regulars and reservists. Suitable courses could easily be arranged and interested tutors would not be lacking. The individual is not usually prepared to educate himself in these matters, and so he must be subjected to some discipline as Sir Heneage suggests. It would at least be possible to drum into everyone concerned the principles of treatment of soft-tissue wounds. No-one would expect to train abdominal surgeons, thoracic surgeons, or neurosurgeons in a night, but it ought to be feasible to teach most Service medical officers how to diminish mortality and morbidity in the major group of war wounds. I have long believed that the conscientious perusal of Professor Trueta’s small monograph on war surgery published in 1939 would have saved a lot of needless suffering. I still think that most of the answers are in this book. (For one thing it scarcely mentions chemotherapy or antibiotic therapy-an unwarranted faith in these has often lead to the neglect of surgical principles.) Jolly’s Field Surgery in Total War was another book of great value in those early years. The point is that remarkably few bothered to read these books in 1939 and 1940, and it does look as if appropriate study must be directed. If there is another war and if, as is all too likely, there is intensive bombin-atomic or otherwise-casualties
appears
(Lancet,