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CORTISONE AND RHEUMATOID ARTHRITIS
1319
community
to benefit from his abilities.
is a vocation, stammerer the
and if treated so will priority he deserves.
Speech therapy secure
for the
H. ST. JOHN RUMSEY Consulting speech therapist to Guy’s Hospital.
London, N.W.I.
THE INSULIN MYTH
SrR,-Dr. Hunter’s contribution (Nov. 28)
to the the respective merits of E.C.T. and deep insulin in the treatment of schizophrenia is in fact an attack upon all physical methods of treatment. While not being representative of the views generally held in the department of psychological medicine at Guy’s Hospital on this subject-for which all honour to the individuality of the author-it contains a certain amount of special pleading. The clinical improvement displayed by patients who respond to deep insulin therapy is not a mere induced anosognosia ; nor is such treatment simply an irrational therapy. Apart from the work of Quastel, Himwich, and Gellhorn, mentioned by Professor Mayer-Gross in his letter in the same issue, there is a recent paper by Lovett Doust1 which describes the effects of insulin-coma therapy upon blood-oxygen saturation, emphasising the correlation between a significant increase in such level following treatment, and clinical improvement in the patients so treated. The author points out that this investigation confirms essentially similar findings by other workers, of the effects of insulin therapy upon arterial pressure and cerebral metabolism. Deep insulin treatment remains in fact a standardprocedure for selected cases of schizophrenia treated in the York Clinic of this hospital, where it seems to most of us to continue to be justified by results. Guy’s Hospital, DAVID STAFFORD-CLARK.
controversy
over
London, S.E.1.
CORTISONE AND RHEUMATOID ARTHRITIS SiR,-It was a pleasure to read the article by Dr. West and Dr. Newns in your issue of Nov. 28. The statement that cortisone acetate (50-75 mg. daily) administered to 27 patients with rheumatoid arthritis over an average period of nineteen months was not to be recommended, and does not favourably influence the course of rheumatoid disease, is of considerable importance, especially coming from rheumatologists. The conclusions were
reached in a controlled series, with a very fair assessment, based on accepted criteria. As they point out, the profound effect of cortisone, in a daily dose of 100 mg. or more, on the symptoms and signs of the disease in the early weeks of treatment is an acknowledged fact : but doses of 75 mg. or more can rarely be maintained for many months without serious
complications. .
Since its introduction into this country from the U.S.A., the supplies of cortisone have depended on dollar exchange or generous gifts, and the restricted amounts,
precious than gold, have been delegated to various hospitals and centres for treatment of rheumatic diseases, where fundamental or essential research was supposed to be carried out, although much of this had already been adequately completed on a vastly larger scale in America. more
Although it is accepted that cortisone, in addition, may be of considerable benefit in some of the collagen diseases, certain skin diseases, eye conditions, and acute rheumatic fever, the more rationally and logically treated diseases such as Sheehan’s syndrome, Addison’s disease, and adrenocortical hyperplasia with excessive androgen production, have had to manage with second best or merely glean the crumbs which dropped from the rich 1.
Doust, J. W. L.
Canad. med. Ass. J. 1953, 69, 108.
man’s table. Other indications are already apparent from the literature, such as cortisone maintenance following hypophysectomy or bilateral adrenalectomy for advanced carcinoma of breast or prostate, or for
gross
hypertension.
It is very laudable that we should gain experience with this new hormone and confirm or confute the American experimental work, but it was estimated last year1 that home production of cortisone would exceed the then consumption by July of this year. I understand that much of the material hitherto in use in this country was made by the French laboratories of Roussel ; whether or not the dollar exchange operates here, I do not know. Further, I am informed that in the not too distant future, more manufacturing chemists will be making cortisone in Britain. May I make a plea that cortisone should be more readily available to the medical profession and not only to the privileged few. I feel that there are already the in N.H.S., both in hospital and adequate safeguards general practice, to deal with unjustified use of expensive drugs ; and, as regards the dangers of overdosage, it is reasonable to assume that if a doctor is sufficiently intelligent to prescribe the correct dose of morphia, insulin, nitrogen-mustard, or a host of other more potentially harmful substances, then he is fit to treat his patient with cortisone, provided there are acknowledged indications. Most new therapeutic discoveries suffer at first from over-enthusiastic use and wild claims, but in the end a reasonable and balanced judgment prevails, and Dr. West and Dr. Newns must be congratulated on helping to swing the pendulum. GEORGE L. FOSS. Bristol. FLORENCE NIGHTINGALE HOUSE
SiR,-Advanced work for nurses was an important aspect of Florence Nightingale’s nursing policy. She wanted nurses of all nations to be what she called missionaries of health " by training others and raising the standard of health wherever they went. Next year will see the centenary of Florence Nightingale’s mission to the Crimea. The National Florence Nightingale Memorial Committee in the United Kingdom is seeking funds to establish permanently a fitting memorial to her noble work and inspiration. It is "
proposed : To endow a residence for 44 nurses of all nations while advanced courses in London. (2) To further the advance of nursing education by the award of scholarships.
(1)
undergoing
Throughout the world, similar national committees are raising funds for the award of scholarships to nurses. They are all part of the Florence Nightingale International Foundation which is concerned with nursing education internationally. The successful candidates at Florence
come
to Britain and reside
Nightingale House, 173-175, Cromwell Road,
S.W.5, during their postgraduate training, adding
an
the committee in this country ; but this is the land of Miss Nightingale’s birth and we must not fail in our duty to her memory. We therefore appeal to everyone who appreciates her magnificent work for the nursing profession, and to everyone who has experienced the kindness of a nurse, and to everyone who wishes to express in tangible form their gratitude. Please either send a donation, or write for a copy of an informative illustrated booklet, to the Florence Nightingale Memorial Committee of Great Britain and Northern Ireland, 12, Whitehall, London, S.W.I. LUKE
additional
responsibility
to
Chairman. 1. See
Lancet, 1952,
ii, 992.
community
to benefit from his abilities.
is a vocation, stammerer the
and if treated so will priority he deserves.
Speech therapy secure
for the
H. ST. JOHN RUMSEY Consulting speech therapist to Guy’s Hospital.
London, N.W.I.
THE INSULIN MYTH
SrR,-Dr. Hunter’s contribution (Nov. 28)
to the the respective merits of E.C.T. and deep insulin in the treatment of schizophrenia is in fact an attack upon all physical methods of treatment. While not being representative of the views generally held in the department of psychological medicine at Guy’s Hospital on this subject-for which all honour to the individuality of the author-it contains a certain amount of special pleading. The clinical improvement displayed by patients who respond to deep insulin therapy is not a mere induced anosognosia ; nor is such treatment simply an irrational therapy. Apart from the work of Quastel, Himwich, and Gellhorn, mentioned by Professor Mayer-Gross in his letter in the same issue, there is a recent paper by Lovett Doust1 which describes the effects of insulin-coma therapy upon blood-oxygen saturation, emphasising the correlation between a significant increase in such level following treatment, and clinical improvement in the patients so treated. The author points out that this investigation confirms essentially similar findings by other workers, of the effects of insulin therapy upon arterial pressure and cerebral metabolism. Deep insulin treatment remains in fact a standardprocedure for selected cases of schizophrenia treated in the York Clinic of this hospital, where it seems to most of us to continue to be justified by results. Guy’s Hospital, DAVID STAFFORD-CLARK.
controversy
over
London, S.E.1.
CORTISONE AND RHEUMATOID ARTHRITIS SiR,-It was a pleasure to read the article by Dr. West and Dr. Newns in your issue of Nov. 28. The statement that cortisone acetate (50-75 mg. daily) administered to 27 patients with rheumatoid arthritis over an average period of nineteen months was not to be recommended, and does not favourably influence the course of rheumatoid disease, is of considerable importance, especially coming from rheumatologists. The conclusions were
reached in a controlled series, with a very fair assessment, based on accepted criteria. As they point out, the profound effect of cortisone, in a daily dose of 100 mg. or more, on the symptoms and signs of the disease in the early weeks of treatment is an acknowledged fact : but doses of 75 mg. or more can rarely be maintained for many months without serious
complications. .
Since its introduction into this country from the U.S.A., the supplies of cortisone have depended on dollar exchange or generous gifts, and the restricted amounts,
precious than gold, have been delegated to various hospitals and centres for treatment of rheumatic diseases, where fundamental or essential research was supposed to be carried out, although much of this had already been adequately completed on a vastly larger scale in America. more
Although it is accepted that cortisone, in addition, may be of considerable benefit in some of the collagen diseases, certain skin diseases, eye conditions, and acute rheumatic fever, the more rationally and logically treated diseases such as Sheehan’s syndrome, Addison’s disease, and adrenocortical hyperplasia with excessive androgen production, have had to manage with second best or merely glean the crumbs which dropped from the rich 1.
Doust, J. W. L.
Canad. med. Ass. J. 1953, 69, 108.
man’s table. Other indications are already apparent from the literature, such as cortisone maintenance following hypophysectomy or bilateral adrenalectomy for advanced carcinoma of breast or prostate, or for
gross
hypertension.
It is very laudable that we should gain experience with this new hormone and confirm or confute the American experimental work, but it was estimated last year1 that home production of cortisone would exceed the then consumption by July of this year. I understand that much of the material hitherto in use in this country was made by the French laboratories of Roussel ; whether or not the dollar exchange operates here, I do not know. Further, I am informed that in the not too distant future, more manufacturing chemists will be making cortisone in Britain. May I make a plea that cortisone should be more readily available to the medical profession and not only to the privileged few. I feel that there are already the in N.H.S., both in hospital and adequate safeguards general practice, to deal with unjustified use of expensive drugs ; and, as regards the dangers of overdosage, it is reasonable to assume that if a doctor is sufficiently intelligent to prescribe the correct dose of morphia, insulin, nitrogen-mustard, or a host of other more potentially harmful substances, then he is fit to treat his patient with cortisone, provided there are acknowledged indications. Most new therapeutic discoveries suffer at first from over-enthusiastic use and wild claims, but in the end a reasonable and balanced judgment prevails, and Dr. West and Dr. Newns must be congratulated on helping to swing the pendulum. GEORGE L. FOSS. Bristol. FLORENCE NIGHTINGALE HOUSE
SiR,-Advanced work for nurses was an important aspect of Florence Nightingale’s nursing policy. She wanted nurses of all nations to be what she called missionaries of health " by training others and raising the standard of health wherever they went. Next year will see the centenary of Florence Nightingale’s mission to the Crimea. The National Florence Nightingale Memorial Committee in the United Kingdom is seeking funds to establish permanently a fitting memorial to her noble work and inspiration. It is "
proposed : To endow a residence for 44 nurses of all nations while advanced courses in London. (2) To further the advance of nursing education by the award of scholarships.
(1)
undergoing
Throughout the world, similar national committees are raising funds for the award of scholarships to nurses. They are all part of the Florence Nightingale International Foundation which is concerned with nursing education internationally. The successful candidates at Florence
come
to Britain and reside
Nightingale House, 173-175, Cromwell Road,
S.W.5, during their postgraduate training, adding
an
the committee in this country ; but this is the land of Miss Nightingale’s birth and we must not fail in our duty to her memory. We therefore appeal to everyone who appreciates her magnificent work for the nursing profession, and to everyone who has experienced the kindness of a nurse, and to everyone who wishes to express in tangible form their gratitude. Please either send a donation, or write for a copy of an informative illustrated booklet, to the Florence Nightingale Memorial Committee of Great Britain and Northern Ireland, 12, Whitehall, London, S.W.I. LUKE
additional
responsibility
to
Chairman. 1. See
Lancet, 1952,
ii, 992.