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CORTISONE IN RHEUMATOID ARTHRITIS
1102 theatres has made the use of ’Nembutal’ inadvisable For these in children about to have tonsillectomy. children I have found the following method of induction most
satisfactory.
possible, the child is visited in the ward, the night before operation, and the anaesthetist then " makes friends " with him. In an outpatient, this may have to be done in the few minutes preceding the induction. I tell the child that he is going to be told a story. The great majority of children If
between the ages of 4 and 9 welcome this news. Without saying anything about the anaesthetic, I then tell them a suitable fairy story or Rupert story. After the first few sentences, the anaesthetic mask is placed about eight inches from the patient’s head, and nitrous oxide allowed to flow at 10 litres per min. As the story progresses, so the mask is gradually brought a little closer to the face. After about 5 minutes the child has usually lost consciousness, and it is possible to apply the mask to the face, and to add trichlor-
ethylene, ether, or any Using this method,
other desired agent. I found it possible to soothe most nervous children, and the great majority go to sleep without The only complaint has been that they any sign of fear. did not hear" the end of the story ! Needless to say, this is non-toxic, and does not method of premedication depress the reflexes. It takes a little longer than other methods of induction, but I feel that the extra time spent is worth while. "
Alternatively, for children with visible veins, the technique of inducing with thiopentone, as described by Dr. Bullough,l could hardly be improved. With the use of a sharp needle, the child hardly feels the prick and goes to sleep quickly and safely. London, W.C.I.
ANDREW F. FORBAT.
SiR,-Following my letter in your issue of Nov. 7 concerning the use of morphine in the postoperative treatment of children, I have had a request from a correspondent for further information concerning the formula I quoted-namely, age over age + 12. I would like to make it clear that this formula represents the fraction, according to the age of the child, of the official adult dose. It does not represent the actual dose in grains. Black Notley Hospital, M. C. WILKINSON. Braintree, Essex.
CORTISONE IN RHEUMATOID ARTHRITIS SiR,—May I support strongly the sentiments expressed by Dr. Copeman and Dr. Savage (Oct. 17)1 After an experience of twenty-five years in endocrinology, I
looked upon the original claims for the therapeutic effects of cortisone and A.C.T.H. with guarded optimism. The present swing of the pendulum towards gloomy pessimism appears unwarranted, although not unusual. The following case, of a patient known to Dr. Savage and myself, illustrates the beneficial effect of small doses of cortisone in carefully selected patients even with a long history of rheumatoid arthritis, when other methods have failed
completely. A woman, aged 51 (periods still regular), had a ten years’ history of rheumatoid arthritis with moderate deformities of In June, 1952, a the fingers, wrists, knees, and ankles. recurrence began with swelling and pain, especially in ankles, knees, and shoulders. By August she could not leave her flat on the 2nd floor, because she could not manage the stairs. When seen by me in December, 1952, she was bedridden, Her erythrocyteimmobilised and in continuous pain. sedimentation rate was between 68 and 80 mm. (Westergren) after an hour. Salicylates up to 12 g. a day were without any effect ; gold had caused untoward reactions in the past. By the end of February, 1953, she was receiving 25 mg. of cortisone acetate daily with 3 g. of (buffered) salicylates. She has remained on that dosage to this day. There was no dramatic change but a slow and steady improvement. The pain has completely disappeared ; the deformities are the same as before the attack, but the swelling has gone. Her
1.
Bullough, J.
Lancet, 1952, ii, 999.
has become almost excessive, and she has put on one she now can manage 60 stairs without help and walk about I mile on the flat, slowly but fairly com. fortably, and can do allthe lighter housework and most of her cooking. There have been no side-effects towards the Cushmg range and she appears mentally and physically normal. The story is the more remarkable, because this patientfor entirely porsonal reasons-could not be admitted to hospital, and biochemical examinations had to be restricted to a bare minimum. Physiotherapy was given at home in a similarly restricted manner. The E.S.R. took over six months to decrease gradually to normal.
appetite stone in
weight ;
V. C. MEDVEI.
London, S.W.3. GOUT
Sm,-Dr. Jennings’s following questions :
letter last week
prompts the
(1) Is interval therapy with gr. 80 of sodium salicylate daily for 4 days per week sufficient to maintain the serum uric acid of gouty patients at a normal level, as has been shown to occur when gr. 60-140 (usually gr. 90) ofsodiumsalicylatedailyis given continuously?1 (2) Does interval therapy induce a favourable therapeutic response in chronic gout, and if so, how does it compare with that obtained by continuous therapy ? (3) Does interval therapy induce less salicylism than continued therapy ? (4) Should a high fluid intake be recommended ? -
I
suggest
the
following
answers :
(1) Dr. Jennings’s paperstated : " Our
cases
have
far remained well as long as they have taken the drug (sodium salicylate) in 80 gr. doses daily for three or four days a week. Taken in this way it maintains normal levels of blood uric acid." I take this to mean that after stopping salicylate therapy the serum uric acid does not return to abnormal levels within at least three to four days. Dr. Jennings takes me to task for disproving this fact on a single patient, but I would suggest that further perusal of the article will illustrate this point in figs. 4 and 6 which refer to 2 further patients. In my experience the serum uric acid almost invariably rises to abnormal levels within one to two days of stopping salicylate administration, even if this has been continued for many months. It is unfortunate that Dr. Jennings’s paper did not give sufficient serum uric acid figures to illustrate his conclusions. Bauer and Klemperer3 were unable to confirm them, and it appears that no such confirmation has ever been published. (2) Dr. Jennings has presumably had experience of interval therapy for at least sixteen of the many years during which it has been advocated. Subjective improvement is often difficult to assess and it is not surprising that, in the absence of really conclusive results with such therapy, there is divided opinion upon its occurrence and degree. It would appear that the subjective improvement following continuous therapy, and detailed in the article under question, compares favourably with any published report with interval therapy. I would suggest that in those patients with definite radiological changes, repeated radiographs may provide objective evidence of response to therapy. It is surely significant that despite such considerable experience of interval therapy there has not been a single report of radiological improvement, and yet within a few months of continuous therapy it was possible to show such improvement in 3 patients.4 (3) I find it difficult to believe that initial administration of sodium salicylate, in a dosage sufficient to lower the serum uric acid appreciably, does not usually induce symptoms of salicylism. Graham5 reported that these symptoms were such as to make cinchopen a more so
1. Marson, F. G. W. Quart. J. Med. 1953, 22, 331. 2. Rep. chron. rheum. Dis. 1937, 3, 106. 3. Bauer, W., Klemperer, F. New Engl. J. Med. 1944, 231, 681. 4. Marson, F. G. W. Brit. J. Radiol. 1952, 25, 539. 5. Proc. Roy. Soc. Med. 1926, 20, 257.
satisfactory.
possible, the child is visited in the ward, the night before operation, and the anaesthetist then " makes friends " with him. In an outpatient, this may have to be done in the few minutes preceding the induction. I tell the child that he is going to be told a story. The great majority of children If
between the ages of 4 and 9 welcome this news. Without saying anything about the anaesthetic, I then tell them a suitable fairy story or Rupert story. After the first few sentences, the anaesthetic mask is placed about eight inches from the patient’s head, and nitrous oxide allowed to flow at 10 litres per min. As the story progresses, so the mask is gradually brought a little closer to the face. After about 5 minutes the child has usually lost consciousness, and it is possible to apply the mask to the face, and to add trichlor-
ethylene, ether, or any Using this method,
other desired agent. I found it possible to soothe most nervous children, and the great majority go to sleep without The only complaint has been that they any sign of fear. did not hear" the end of the story ! Needless to say, this is non-toxic, and does not method of premedication depress the reflexes. It takes a little longer than other methods of induction, but I feel that the extra time spent is worth while. "
Alternatively, for children with visible veins, the technique of inducing with thiopentone, as described by Dr. Bullough,l could hardly be improved. With the use of a sharp needle, the child hardly feels the prick and goes to sleep quickly and safely. London, W.C.I.
ANDREW F. FORBAT.
SiR,-Following my letter in your issue of Nov. 7 concerning the use of morphine in the postoperative treatment of children, I have had a request from a correspondent for further information concerning the formula I quoted-namely, age over age + 12. I would like to make it clear that this formula represents the fraction, according to the age of the child, of the official adult dose. It does not represent the actual dose in grains. Black Notley Hospital, M. C. WILKINSON. Braintree, Essex.
CORTISONE IN RHEUMATOID ARTHRITIS SiR,—May I support strongly the sentiments expressed by Dr. Copeman and Dr. Savage (Oct. 17)1 After an experience of twenty-five years in endocrinology, I
looked upon the original claims for the therapeutic effects of cortisone and A.C.T.H. with guarded optimism. The present swing of the pendulum towards gloomy pessimism appears unwarranted, although not unusual. The following case, of a patient known to Dr. Savage and myself, illustrates the beneficial effect of small doses of cortisone in carefully selected patients even with a long history of rheumatoid arthritis, when other methods have failed
completely. A woman, aged 51 (periods still regular), had a ten years’ history of rheumatoid arthritis with moderate deformities of In June, 1952, a the fingers, wrists, knees, and ankles. recurrence began with swelling and pain, especially in ankles, knees, and shoulders. By August she could not leave her flat on the 2nd floor, because she could not manage the stairs. When seen by me in December, 1952, she was bedridden, Her erythrocyteimmobilised and in continuous pain. sedimentation rate was between 68 and 80 mm. (Westergren) after an hour. Salicylates up to 12 g. a day were without any effect ; gold had caused untoward reactions in the past. By the end of February, 1953, she was receiving 25 mg. of cortisone acetate daily with 3 g. of (buffered) salicylates. She has remained on that dosage to this day. There was no dramatic change but a slow and steady improvement. The pain has completely disappeared ; the deformities are the same as before the attack, but the swelling has gone. Her
1.
Bullough, J.
Lancet, 1952, ii, 999.
has become almost excessive, and she has put on one she now can manage 60 stairs without help and walk about I mile on the flat, slowly but fairly com. fortably, and can do allthe lighter housework and most of her cooking. There have been no side-effects towards the Cushmg range and she appears mentally and physically normal. The story is the more remarkable, because this patientfor entirely porsonal reasons-could not be admitted to hospital, and biochemical examinations had to be restricted to a bare minimum. Physiotherapy was given at home in a similarly restricted manner. The E.S.R. took over six months to decrease gradually to normal.
appetite stone in
weight ;
V. C. MEDVEI.
London, S.W.3. GOUT
Sm,-Dr. Jennings’s following questions :
letter last week
prompts the
(1) Is interval therapy with gr. 80 of sodium salicylate daily for 4 days per week sufficient to maintain the serum uric acid of gouty patients at a normal level, as has been shown to occur when gr. 60-140 (usually gr. 90) ofsodiumsalicylatedailyis given continuously?1 (2) Does interval therapy induce a favourable therapeutic response in chronic gout, and if so, how does it compare with that obtained by continuous therapy ? (3) Does interval therapy induce less salicylism than continued therapy ? (4) Should a high fluid intake be recommended ? -
I
suggest
the
following
answers :
(1) Dr. Jennings’s paperstated : " Our
cases
have
far remained well as long as they have taken the drug (sodium salicylate) in 80 gr. doses daily for three or four days a week. Taken in this way it maintains normal levels of blood uric acid." I take this to mean that after stopping salicylate therapy the serum uric acid does not return to abnormal levels within at least three to four days. Dr. Jennings takes me to task for disproving this fact on a single patient, but I would suggest that further perusal of the article will illustrate this point in figs. 4 and 6 which refer to 2 further patients. In my experience the serum uric acid almost invariably rises to abnormal levels within one to two days of stopping salicylate administration, even if this has been continued for many months. It is unfortunate that Dr. Jennings’s paper did not give sufficient serum uric acid figures to illustrate his conclusions. Bauer and Klemperer3 were unable to confirm them, and it appears that no such confirmation has ever been published. (2) Dr. Jennings has presumably had experience of interval therapy for at least sixteen of the many years during which it has been advocated. Subjective improvement is often difficult to assess and it is not surprising that, in the absence of really conclusive results with such therapy, there is divided opinion upon its occurrence and degree. It would appear that the subjective improvement following continuous therapy, and detailed in the article under question, compares favourably with any published report with interval therapy. I would suggest that in those patients with definite radiological changes, repeated radiographs may provide objective evidence of response to therapy. It is surely significant that despite such considerable experience of interval therapy there has not been a single report of radiological improvement, and yet within a few months of continuous therapy it was possible to show such improvement in 3 patients.4 (3) I find it difficult to believe that initial administration of sodium salicylate, in a dosage sufficient to lower the serum uric acid appreciably, does not usually induce symptoms of salicylism. Graham5 reported that these symptoms were such as to make cinchopen a more so
1. Marson, F. G. W. Quart. J. Med. 1953, 22, 331. 2. Rep. chron. rheum. Dis. 1937, 3, 106. 3. Bauer, W., Klemperer, F. New Engl. J. Med. 1944, 231, 681. 4. Marson, F. G. W. Brit. J. Radiol. 1952, 25, 539. 5. Proc. Roy. Soc. Med. 1926, 20, 257.