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CHEMOTHERAPY OF MYELOMA AND MULTIPLE MYELOMA
926
adequately
served by public transport; special hospital transwould add very considerably to the expense. port Whilst it is true that we have little definite information on the cost per patient-illness of day patients as against inpatients, there can be no doubt that as far as capital cost is concerned, there is an immense advantage in day hospitals. They can readily be converted out of existing buildings or can be accommodated in relatively cheap temporary structures. In the present state of uncertainty as to the future arrangement of psychiatric services, they can therefore provide a great deal of treatment, without much capital commitment. If experience from the first few years working of the Mental Health Act should prove that, in fact, other kinds of hospital provision were more suitable, these buildings could then be scrapped with very little loss. Inpatient units must inevitably require capital expenditure on a much greater scale, causing rigidity in planning, in the same way that 19th-century mental hospitals do today. This aspect of the question is discussed in the report by Farndale which is shortly to be published, and which is likely to supply much ammnution for these controversies. Littlemore Hospital, Oxford
comparison, however, of the results of treating 485 patients with multiple myeloma with a group of patients described by 30 other investigators as having myeloma reveals some interesting differences in response to chemotherapy.8 A
Some of these differences
9
are as
follows:
and others have
pointed out the difficulty of recognising clinically solitary plasmocytoma, and undoubtedly a number of the cases of myeloma described in the literature are disseminated plasma-cell myelomas or multiple myelomas. Diamond
There is need for more controlled studies on the response of these malignant diseases to chemotherapeutic agents before it can be declared that a difference does exist. Furman University, Greenville, South Carolina.
JOHN R. SAMPEY.
H. L. FREEMAN. HYPERCALCIURIA IN WILSON’S DISEASE
REINFORCEMENT OF IMMUNITY TO DIPHTHERIA SIR,-In a symposium1 on immunisation in childhood two speakers advocated the use of toxoid-antitoxin
floccules (T.A.F.)
to
reinforce immunity against diphtheria.
I was somewhat surprised to see no mention of another floccule antigen, alkali-dissolved floccules (D.F.), which has been used with satisfaction in South Africa for 10 years. It is employed as the secondary stimulus in those people who have received AlP04-adsorbed floccules (A.D.F.) as a primary stimulus, and as a booster in older children, adolescents, and adults. D.F. and T.A.F. are tolerated by the body to the same extent, but D.F. has certain advantages. It is more easily prepared, is more antigenic, is water clear, its toxoid content can be found by the flocculation test, and it contains much less protein of equine
origin. Either the publications 2-4 referring to A.D.F. and D.F. have escaped the notice of the British authorities or, as concerns the use of D.F. as a reinforcing injection, they have found disadvantages of which we in South Africa are unaware. It would he intereqtincr
Germiston, Transvaal.
tf)
],j1VP their views
P. B. PEACOCK.
CHEMOTHERAPY OF MYELOMA AND MULTIPLE MYELOMA
SIR,-Do myeloma and multiple myeloma respond differently to chemotherapy ? Descriptions of the chemo-
therapeutic control of both diseases indicate little differin the responses. Nabarronoted no response in a patient with multiple myeloma who was given the nitrogen mustard, HN2, and no benefit was observed in another patient with myeloma given the aromatic mustard, R48. Marchal et al. reported clinical remissions in 3 out of 4 patients with myeloma, following treatment with corticotrophin (A.C.T.H.) and cortisone, and a slight response in 1 patient with multiple myeloma on the same therapy. Fadda et al.7 described remissions of 6 to 24 months in a case of myeloma and several cases of multiple myeloma given urethane, corticotrophin, cortisone, and radiotherapy. ence
1. 2. 3. 4. 5. 6. 7.
Proceedings of a Symposium on Immunisation in Childhood; pp. 75, 77. Edinburgh and London, 1959. Mason, J. H. J. Hyg. Camb. 1950, 48, 418. Mason, J. H. Lancet, 1951, 1, 504. Mason, J. H., Robinson, M., Brown, M. S. S. Afr. med. J. 1953, 27, 293. Nabarro, J. D. N. Brit. J. Radiol. 1951, 24, 507. Marchal, G., Duhamel, G., Gervais, P., Toulouse, J. Sem. Hôp., Paris, 1954, 30, 898. Fadda, C. F., Lucchini, M. A., Vera, G. A. Rev. méd. Valparaiso, 1953, 6, 370.
(HEPATICOLENTICULAR DEGENERATION) SIR,-In 1959 we reported hypercalciuria in 4 of 5
patients with Wilson’s disease.10 Of the 4 patients,I had bilateral nephrocalcinosis and another had a calculus in the left kidney. We have since had the opportunity to study another patient with Wilson’s disease who had hypercalciuria, thus confirming our original observation. A 27-year-old white man with cedema and jaundice was first seen at the Mayo Clinic in July, 1959. In 1956 he had noted some enlargement of his breasts. He felt well otherwise until the middle of 1958 when he began to tire easily and to gain weight. In May, 1959, he became jaundiced and was found to have cedema of his legs and ascites. About that time, he first noted a tremor of his hands. That same month he was admitted to the hospital and found to have impending hepatic coma. His condition improved and he was dismissed from the hospital the next month. After he returned home, however, his condition worsened and in July he registered at the clinic. Physical examination revealed a slight static tremor of the hands and some slurring of speech. Typical Kayser-Fleischer rings were present as well as left pleural effusion, ascites, and oedema of the legs. The lower edge of the liver was palpable at the level of the umbilicus. The lower edge of the spleen was 4 fingerbreadths below the left costal margin.
Laboratory investigations.-Prothrombin-time, 37 sec.; concentration of bilirubin per 100 ml. serum, 0 direct and 2-74 mg. indirect; cholesterol-cephalin flocculation test, 4+; thymol turbidity 7 units; alkaline-phosphatase 15-6 King-Armstrong units, uric acid 1-7 mg., calcium 8-4 and 8-0 mg., and inorganic phosphate 3’3 mg. per 100 mL serum; cholesterol 153 mg. per 100 ml. plasma; copper-oxidase activity present in the serum; total proteins, 4-94 g. per 100 ml. serum with electrophoretic fractions of 1-57 g. albumin, 0.26 g. alpha-1-globulin, 0-34 g. alpha-2-globulin, and 2-77 g. beta and gamma globulin combined.
X-rays of the thorax showed a large pleural effusion on the left side. The renal areas did not show evidence of nephrocalcinosis or renal calculus. The daily urinary excretion of calcium and other materials was measured for three days during which time the patient was given a diet containing an average of 213 mg. of calcium, 2-93 mg. of copper, 62 g. of protein, 111 g. of fat, and 244 g. of carbohydrate per twenty-four hours and distilled water as desired. During this period, the urinary excretions of calcium were 317, 331, and 258 mg. (average 302 mg.) per twenty-four hours. Over the same three-day period the average urinary excretion of phosphorus was 829 mg., copper 0-23 mg., and alpha-amino-nitrogen 414 mg., all per twenty-four hours. 8. Sampey, J. R. J. S. C. med. Ass. 1959, 55. 183. 9. Diamond, H. D. Medical Management of Cancer. New York, 1958. 10. Litin, R. B., Randall, R. V., Goldstein, N. P., Power, M. H., Diessner, G. R. Amer. J. med. Sci. 1959, 238, 614.
adequately
served by public transport; special hospital transwould add very considerably to the expense. port Whilst it is true that we have little definite information on the cost per patient-illness of day patients as against inpatients, there can be no doubt that as far as capital cost is concerned, there is an immense advantage in day hospitals. They can readily be converted out of existing buildings or can be accommodated in relatively cheap temporary structures. In the present state of uncertainty as to the future arrangement of psychiatric services, they can therefore provide a great deal of treatment, without much capital commitment. If experience from the first few years working of the Mental Health Act should prove that, in fact, other kinds of hospital provision were more suitable, these buildings could then be scrapped with very little loss. Inpatient units must inevitably require capital expenditure on a much greater scale, causing rigidity in planning, in the same way that 19th-century mental hospitals do today. This aspect of the question is discussed in the report by Farndale which is shortly to be published, and which is likely to supply much ammnution for these controversies. Littlemore Hospital, Oxford
comparison, however, of the results of treating 485 patients with multiple myeloma with a group of patients described by 30 other investigators as having myeloma reveals some interesting differences in response to chemotherapy.8 A
Some of these differences
9
are as
follows:
and others have
pointed out the difficulty of recognising clinically solitary plasmocytoma, and undoubtedly a number of the cases of myeloma described in the literature are disseminated plasma-cell myelomas or multiple myelomas. Diamond
There is need for more controlled studies on the response of these malignant diseases to chemotherapeutic agents before it can be declared that a difference does exist. Furman University, Greenville, South Carolina.
JOHN R. SAMPEY.
H. L. FREEMAN. HYPERCALCIURIA IN WILSON’S DISEASE
REINFORCEMENT OF IMMUNITY TO DIPHTHERIA SIR,-In a symposium1 on immunisation in childhood two speakers advocated the use of toxoid-antitoxin
floccules (T.A.F.)
to
reinforce immunity against diphtheria.
I was somewhat surprised to see no mention of another floccule antigen, alkali-dissolved floccules (D.F.), which has been used with satisfaction in South Africa for 10 years. It is employed as the secondary stimulus in those people who have received AlP04-adsorbed floccules (A.D.F.) as a primary stimulus, and as a booster in older children, adolescents, and adults. D.F. and T.A.F. are tolerated by the body to the same extent, but D.F. has certain advantages. It is more easily prepared, is more antigenic, is water clear, its toxoid content can be found by the flocculation test, and it contains much less protein of equine
origin. Either the publications 2-4 referring to A.D.F. and D.F. have escaped the notice of the British authorities or, as concerns the use of D.F. as a reinforcing injection, they have found disadvantages of which we in South Africa are unaware. It would he intereqtincr
Germiston, Transvaal.
tf)
],j1VP their views
P. B. PEACOCK.
CHEMOTHERAPY OF MYELOMA AND MULTIPLE MYELOMA
SIR,-Do myeloma and multiple myeloma respond differently to chemotherapy ? Descriptions of the chemo-
therapeutic control of both diseases indicate little differin the responses. Nabarronoted no response in a patient with multiple myeloma who was given the nitrogen mustard, HN2, and no benefit was observed in another patient with myeloma given the aromatic mustard, R48. Marchal et al. reported clinical remissions in 3 out of 4 patients with myeloma, following treatment with corticotrophin (A.C.T.H.) and cortisone, and a slight response in 1 patient with multiple myeloma on the same therapy. Fadda et al.7 described remissions of 6 to 24 months in a case of myeloma and several cases of multiple myeloma given urethane, corticotrophin, cortisone, and radiotherapy. ence
1. 2. 3. 4. 5. 6. 7.
Proceedings of a Symposium on Immunisation in Childhood; pp. 75, 77. Edinburgh and London, 1959. Mason, J. H. J. Hyg. Camb. 1950, 48, 418. Mason, J. H. Lancet, 1951, 1, 504. Mason, J. H., Robinson, M., Brown, M. S. S. Afr. med. J. 1953, 27, 293. Nabarro, J. D. N. Brit. J. Radiol. 1951, 24, 507. Marchal, G., Duhamel, G., Gervais, P., Toulouse, J. Sem. Hôp., Paris, 1954, 30, 898. Fadda, C. F., Lucchini, M. A., Vera, G. A. Rev. méd. Valparaiso, 1953, 6, 370.
(HEPATICOLENTICULAR DEGENERATION) SIR,-In 1959 we reported hypercalciuria in 4 of 5
patients with Wilson’s disease.10 Of the 4 patients,I had bilateral nephrocalcinosis and another had a calculus in the left kidney. We have since had the opportunity to study another patient with Wilson’s disease who had hypercalciuria, thus confirming our original observation. A 27-year-old white man with cedema and jaundice was first seen at the Mayo Clinic in July, 1959. In 1956 he had noted some enlargement of his breasts. He felt well otherwise until the middle of 1958 when he began to tire easily and to gain weight. In May, 1959, he became jaundiced and was found to have cedema of his legs and ascites. About that time, he first noted a tremor of his hands. That same month he was admitted to the hospital and found to have impending hepatic coma. His condition improved and he was dismissed from the hospital the next month. After he returned home, however, his condition worsened and in July he registered at the clinic. Physical examination revealed a slight static tremor of the hands and some slurring of speech. Typical Kayser-Fleischer rings were present as well as left pleural effusion, ascites, and oedema of the legs. The lower edge of the liver was palpable at the level of the umbilicus. The lower edge of the spleen was 4 fingerbreadths below the left costal margin.
Laboratory investigations.-Prothrombin-time, 37 sec.; concentration of bilirubin per 100 ml. serum, 0 direct and 2-74 mg. indirect; cholesterol-cephalin flocculation test, 4+; thymol turbidity 7 units; alkaline-phosphatase 15-6 King-Armstrong units, uric acid 1-7 mg., calcium 8-4 and 8-0 mg., and inorganic phosphate 3’3 mg. per 100 mL serum; cholesterol 153 mg. per 100 ml. plasma; copper-oxidase activity present in the serum; total proteins, 4-94 g. per 100 ml. serum with electrophoretic fractions of 1-57 g. albumin, 0.26 g. alpha-1-globulin, 0-34 g. alpha-2-globulin, and 2-77 g. beta and gamma globulin combined.
X-rays of the thorax showed a large pleural effusion on the left side. The renal areas did not show evidence of nephrocalcinosis or renal calculus. The daily urinary excretion of calcium and other materials was measured for three days during which time the patient was given a diet containing an average of 213 mg. of calcium, 2-93 mg. of copper, 62 g. of protein, 111 g. of fat, and 244 g. of carbohydrate per twenty-four hours and distilled water as desired. During this period, the urinary excretions of calcium were 317, 331, and 258 mg. (average 302 mg.) per twenty-four hours. Over the same three-day period the average urinary excretion of phosphorus was 829 mg., copper 0-23 mg., and alpha-amino-nitrogen 414 mg., all per twenty-four hours. 8. Sampey, J. R. J. S. C. med. Ass. 1959, 55. 183. 9. Diamond, H. D. Medical Management of Cancer. New York, 1958. 10. Litin, R. B., Randall, R. V., Goldstein, N. P., Power, M. H., Diessner, G. R. Amer. J. med. Sci. 1959, 238, 614.