- Email: [email protected]
DEATH AFTER DOG-BITE
650 another case that developed a definite toxic dermatitis after very small dosage. 4. Because, in my opinion, its use impairs reason, it is of no value in the treatment of alcoholism ; and I have not seen or heard any case-reports where a chronic alcoholic has derived more than temporary benefit. 5. It is agreed that the drug produces an evanescent euphoria ; but in my experience the law of diminishing returns applies to amphetamine more surely perhaps than to any other drug in the pharmacopoeia. 6. Its use may become a social danger, for it increases the average individual’s capacity for swallowing alcohol without untoward symptoms ; but the alcohol is then ingested in larger doses and the final pitiable picture is a mixture of alcoholic stupor and amphetamine excitement. This condition, apparent to an experienced eye, is dangerous to the victim, often producing disastrous consequences. 7. Is there a reputable psychiatrist who places the slightest reliance on the drug in the treatment of any psychotic or neurotic disease ?P CHRISTOPHER HOWARD. London, W.l. .
DEATH AFTER DOG-BITE
SiR,-Your annotation last week states that
a
boy
died from anaphylaxis after the injection of 2 c.cm. of gasgangrene antiserum. Some years ago Lamsonreviewed 42 such cases in most of which death took place within ten minutes of an injection of an.tidiphtheritic serum ; and many others have been reported. Sensitisation to horse-serum is very common,- and it is estimated that this fatality is likely to occur in 1-70,000 cases. But it can easily be avoided by a skin test. If a control puncture is made, say on the front of the forearm, with an empty hypodermic needle, and another one is made two inches away through a drop of the fluid to be injected, redness, irritation, and a weal will be seen for certain within a quarter of an hour, at the site of the second puncture, in any patient who is grossly sensitive. If in such a case it is essential to give the injection this can be done by commencing with a dose of 0.1 c.cm. and continuing at half-hourly intervals, doubling the dose each time and giving three minims of adrenaline with each to anchor the dose and slow down its absorption. FRANK COKE. London, W.I. --
HÆMOLYTIC DISEASE OF THE NEWBORN
SiB,—Ihave read with great interest your editorial of April 5, discussing substitution transfusion in the treatment of erythroblastosis foetalis and the possible effect of that treatment on prognosis.. You are quite correct in stating that the value of this method is limited in that it can be applied only after the infant is born. It is also true that complete reliance upon antibody studies as indications for treatment will occasionally lead us astray. We have recently observed an instance in which there was an antibody titre of 1 : 4000 in the mother’s serum and 1 : 512 in the foetalcord serum, with anaemia but no jaundice in the infant. Recovery took place after a single intratibial transfusion given at two weeks. We have also seen an instance where no antibody, either complete or incomplete, was demonstrable in either the mother’s serum or the fcetal-cord blood in a second pregnancy. We expected no serious illness and were greatly chagrined when after twenty-four hours the infant developed a severe and fulminating jaundice, dying within a few hours despite the substitution transfusion instituted at that time. Autopsy indicated that the procedure performed one day earlier might have been life-saving ; but we were lulled into a false sense of security by the apparent absence of antibodies. Such experiences, fortunately, are the exception rather than the rule. I agree that many of the infants will be so damaged in utero as to make the substitution technique useless. I do feel, however, that in the large group which appear normal at birth and yet develop severe icterus gravis within the next twenty-four hours the method is not only life-saving but also preventative of the unfortunate sequelae of brain and liver damage. In the comparatively small series studied to date we find a mortality-rate of less than 10%, compared to our former figures of 5Ci%. 1.
J. Amer. med. Ass. 1924, 82, 1091.
There is
doubt in my mind that it is necessary to still larger series before the method can be properly evaluated. In the long run, a procedure to prevent the formation of the maternal antibody will make all other methods of therapy obsolete. Until such a treatment is available the substitution transfusion appears to offer the best hope of a living and healthy baby to some families previously unable to anticipate that joy. I wish to thank you for the favourable comment in your editorial, and to assure you and your readers that while we feel that some progress has been made in the treatment of the disease, there is still much to be done. HARRY WALLERSTEIN Director. Erythroblastosis Fetalis Clinic, Jewish
study
no
a
Memorial Hospital, New York.
SURGICAL TREATMENT OF HYPERPIESIA
SIR,-In connection with your annotation of May 3, I suggest that the most dangerous complications are
vascular accidents. They may often overlooked and not described, is usually accompanied by spasm of the arterioles and capillaries, including those of the venous system. This spasm causes different degrees of hypertension in various parts of the vascular tree; a patient may have hypertension in the body, but hypotension in the brain. These cases are usually subject to myocardial failure or coronary thrombosis; and, if operated upon, they are liable to have cerebral heemorrhage or thrombosis. The same applies to the retina. A preliminary examination by Pachon’s oscillometer and an estimation of retinal blood-pressure by Baillart’s method would probably clarify the issue. N. PINES. London, E.l. cerebral
and
retinal
depend upon the fact, that the hyperpiesia
ASCORBIC-ACID METABOLISM
SiR,-In their article (March 29) on the ascorbic-acid metabolism of Bantu soldiers, Professor Kekwick, Dr. Wright, and Dr. Raper express disagreement with several of the conclusions reached by us in a somewhat similar study published in 1940.1 It is unnecessary to discuss these divergences in detail, for some at least might be expected with groups whose circumstances and general levels of health are probably different. But we would like to stress that we have never supposed that the ascorbic-acid require,
ments of the Bantu differ from those of other races, or that the use of low daily intakes is to be condoned. Our main interest was to study the well-known fact that an extremely low daily intake of this vitamin may be found amongst persons doing hard work and apparently maintaining a high level of general health. Obviously this type of experiment is open to many objections. The only reliable way by which extraneous factors can be excluded and the true functions and daily requirements of the vitamin established is by the study of healthy subjects consuming a diet believed to be adequate in all other respects. Such studies have now been made, and they have thrown much light on the subject ; incidentally, they have fully confirmed the findings reported by us. The first of these was the classical experiment of Crandon2 on himself, but several others may be mentioned-for example-, the studies of Ancel Keys. Particularly relevant are two papers by Pijoan and Lozner3 and Najjar, Holt, and Royston.4 The following conclusions may now be regarded as
well established :
1. Ascorbic acid
.
known purposes-the. prevention of scurvy and the treatment of scurvy. 2. A healthy subject initially saturated with ascorbic acid, when placed on a diet devoid of this substance but otherwise adequate, will be protected against scurvy for as. long as serves
only two
five or six months. The appearance of scorbutic symptoms -e.g., gum lesions and delayed healing of wounds-is sudden. (Until then the individual may be compared to someone approaching a precipice :: though his danger is increasing 1. Fox, F. W., Dangerfield, L. F., Gottlich, S. F., Jokl, E. Brit. med. J. 1940, ii, 143; with Suzman, H. Proc. Transv. Mine med. Offrs Ass. 1940, 19, 249. 2. Crandon, J. H., Lund, C. C., Dill, D. B. New Engl. J. Med. 1940, 223, 353. Bull. Johns Hopk. Hosp. 1944, 3. Pijoan, M., Lozner, E. L.
75, 303. 4. Najjar, V. A., Holt, L. E., Royston, H. M.
Ibid, 315.
DEATH AFTER DOG-BITE
SiR,-Your annotation last week states that
a
boy
died from anaphylaxis after the injection of 2 c.cm. of gasgangrene antiserum. Some years ago Lamsonreviewed 42 such cases in most of which death took place within ten minutes of an injection of an.tidiphtheritic serum ; and many others have been reported. Sensitisation to horse-serum is very common,- and it is estimated that this fatality is likely to occur in 1-70,000 cases. But it can easily be avoided by a skin test. If a control puncture is made, say on the front of the forearm, with an empty hypodermic needle, and another one is made two inches away through a drop of the fluid to be injected, redness, irritation, and a weal will be seen for certain within a quarter of an hour, at the site of the second puncture, in any patient who is grossly sensitive. If in such a case it is essential to give the injection this can be done by commencing with a dose of 0.1 c.cm. and continuing at half-hourly intervals, doubling the dose each time and giving three minims of adrenaline with each to anchor the dose and slow down its absorption. FRANK COKE. London, W.I. --
HÆMOLYTIC DISEASE OF THE NEWBORN
SiB,—Ihave read with great interest your editorial of April 5, discussing substitution transfusion in the treatment of erythroblastosis foetalis and the possible effect of that treatment on prognosis.. You are quite correct in stating that the value of this method is limited in that it can be applied only after the infant is born. It is also true that complete reliance upon antibody studies as indications for treatment will occasionally lead us astray. We have recently observed an instance in which there was an antibody titre of 1 : 4000 in the mother’s serum and 1 : 512 in the foetalcord serum, with anaemia but no jaundice in the infant. Recovery took place after a single intratibial transfusion given at two weeks. We have also seen an instance where no antibody, either complete or incomplete, was demonstrable in either the mother’s serum or the fcetal-cord blood in a second pregnancy. We expected no serious illness and were greatly chagrined when after twenty-four hours the infant developed a severe and fulminating jaundice, dying within a few hours despite the substitution transfusion instituted at that time. Autopsy indicated that the procedure performed one day earlier might have been life-saving ; but we were lulled into a false sense of security by the apparent absence of antibodies. Such experiences, fortunately, are the exception rather than the rule. I agree that many of the infants will be so damaged in utero as to make the substitution technique useless. I do feel, however, that in the large group which appear normal at birth and yet develop severe icterus gravis within the next twenty-four hours the method is not only life-saving but also preventative of the unfortunate sequelae of brain and liver damage. In the comparatively small series studied to date we find a mortality-rate of less than 10%, compared to our former figures of 5Ci%. 1.
J. Amer. med. Ass. 1924, 82, 1091.
There is
doubt in my mind that it is necessary to still larger series before the method can be properly evaluated. In the long run, a procedure to prevent the formation of the maternal antibody will make all other methods of therapy obsolete. Until such a treatment is available the substitution transfusion appears to offer the best hope of a living and healthy baby to some families previously unable to anticipate that joy. I wish to thank you for the favourable comment in your editorial, and to assure you and your readers that while we feel that some progress has been made in the treatment of the disease, there is still much to be done. HARRY WALLERSTEIN Director. Erythroblastosis Fetalis Clinic, Jewish
study
no
a
Memorial Hospital, New York.
SURGICAL TREATMENT OF HYPERPIESIA
SIR,-In connection with your annotation of May 3, I suggest that the most dangerous complications are
vascular accidents. They may often overlooked and not described, is usually accompanied by spasm of the arterioles and capillaries, including those of the venous system. This spasm causes different degrees of hypertension in various parts of the vascular tree; a patient may have hypertension in the body, but hypotension in the brain. These cases are usually subject to myocardial failure or coronary thrombosis; and, if operated upon, they are liable to have cerebral heemorrhage or thrombosis. The same applies to the retina. A preliminary examination by Pachon’s oscillometer and an estimation of retinal blood-pressure by Baillart’s method would probably clarify the issue. N. PINES. London, E.l. cerebral
and
retinal
depend upon the fact, that the hyperpiesia
ASCORBIC-ACID METABOLISM
SiR,-In their article (March 29) on the ascorbic-acid metabolism of Bantu soldiers, Professor Kekwick, Dr. Wright, and Dr. Raper express disagreement with several of the conclusions reached by us in a somewhat similar study published in 1940.1 It is unnecessary to discuss these divergences in detail, for some at least might be expected with groups whose circumstances and general levels of health are probably different. But we would like to stress that we have never supposed that the ascorbic-acid require,
ments of the Bantu differ from those of other races, or that the use of low daily intakes is to be condoned. Our main interest was to study the well-known fact that an extremely low daily intake of this vitamin may be found amongst persons doing hard work and apparently maintaining a high level of general health. Obviously this type of experiment is open to many objections. The only reliable way by which extraneous factors can be excluded and the true functions and daily requirements of the vitamin established is by the study of healthy subjects consuming a diet believed to be adequate in all other respects. Such studies have now been made, and they have thrown much light on the subject ; incidentally, they have fully confirmed the findings reported by us. The first of these was the classical experiment of Crandon2 on himself, but several others may be mentioned-for example-, the studies of Ancel Keys. Particularly relevant are two papers by Pijoan and Lozner3 and Najjar, Holt, and Royston.4 The following conclusions may now be regarded as
well established :
1. Ascorbic acid
.
known purposes-the. prevention of scurvy and the treatment of scurvy. 2. A healthy subject initially saturated with ascorbic acid, when placed on a diet devoid of this substance but otherwise adequate, will be protected against scurvy for as. long as serves
only two
five or six months. The appearance of scorbutic symptoms -e.g., gum lesions and delayed healing of wounds-is sudden. (Until then the individual may be compared to someone approaching a precipice :: though his danger is increasing 1. Fox, F. W., Dangerfield, L. F., Gottlich, S. F., Jokl, E. Brit. med. J. 1940, ii, 143; with Suzman, H. Proc. Transv. Mine med. Offrs Ass. 1940, 19, 249. 2. Crandon, J. H., Lund, C. C., Dill, D. B. New Engl. J. Med. 1940, 223, 353. Bull. Johns Hopk. Hosp. 1944, 3. Pijoan, M., Lozner, E. L.
75, 303. 4. Najjar, V. A., Holt, L. E., Royston, H. M.
Ibid, 315.