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DEOXYCORTONE ACETATE AND LYMPHADENOPATHIES
329
sample of the same batch subjected to the process. The remaining two samples-those chloroformed four and five times—showed an appreciable loss of potency compared with the control. While the purification of vaccine lymph by phenol is certainly very simple and satisfactory, that by the passage of chloroform vapour has the advantage of being much quicker while being equally efficacious and harmless. This process seems to have been first described by Green,3 who has presented convincing experimental evidence of its suitability; and in India at least three institutes manufacturing vaccine lymph have adopted this method for routine purification. months,
as
that of the control
INFANTILE PYLORIC STENOSIS
which had not been
Vaccine Institute, Belgaum, Bombay.
SIR,—Mr. Ward-McQuaid and Dr. Porritt, in their article of Feb. 4, describe a method of medical treatment which shows a failure-rate of about 40%. (The the numbers treated exact figure cannot be stated as be not could accurately estimated medically ... With medical treatment such results usually end in the abandonment of the method altogether and operation on all cases from the beginning. In my opinion better results can be obtained with medical treatment by : (1) selecting suitable cases, (2) four-hourly feeding, (3) gross reduction of feed-volume (1-11/2 oz. per feed in the first 24 hours, and increasing slowly up to full feeds), and (4) large doses of atropine methylnitrate from the beginning. The authors give before each feed, whereas I give gr. gr. before three feeds in 24 hours, reducing this to two doses at about the 5th day. This large dose can be given conveniently in lamels made by Savory & Moore, in which gr. 1/100 is contained in 1/4 sq. cm. As these lamels are cut from sheets marked in squares of 1 sq. cm., care must be taken that only 1/4 of a marked square is used at each dose. In the past five years I have treated 61 selected cases by this method. There were 2 failures (33%) and no deaths. With regard to surgical treatment, Mr. Ward-McQuaid and Dr. Porritt, and also Professor Smellie in his letter of Feb. 11, emphasise the importance of complete preoperative hydration as a means of reducing mortality. There is another side to this argument, and Professor Smellie hints at it when he warns against the danger of overadministration of sodium chloride. Personally I prefer Mr. David Levi’s technique for Rammstedt’s operation, in which there is no need for preoperative hydration, and which incidentally shortens the period in hospital by about 24 hours. In five years I have thus treated 58 cases with 1 death (1-7%). Combining medical and surgical treatment, there are 119 cases with a mortality-rate of 0-8%. I would say that nowadays a number of people achieve very low mortality-rates using very different techniques. What seems common to all of them is a full understanding of the disease in general and their own method of "
’
R. SANJIVA RAO.
" IMPROVERS " OF FLOUR
SiR,-The decision of the authorities to discontinue the use of nitrogen trichloride (’ Agene’) in flour,4after the Medical Research Council had recognised its serious and often fatal effects on animals, is to be welcomed. It is difficult to understand, however, why it should have been necessary to replace this "improver" by another chlorine compound-chlorine dioxide-which is in my opinion unnecessary, and will, furthermore, cost vital dollars since it will have to be obtained from the U.S.A. Improvers are not necessary to safeguard baking qualities. They are merely artificial means to speed up the natural maturing of flour, at the same time bleaching it and giving a whiter-looking loaf. It is regrettable that in the popular belief whiteness in bread should be synonymous with purity. In fact, the very opposite is the case. To my mind, bread should contain nothing but pure unadulterated wheat flour. In the case of other foodstuffs, such as milk and butter, the addition of chemicals is already forbidden by law. Why not in the case of the " staff of life "-bread ? "
West
"
C. P. ALLINSON.
Wickham, Cambridgeshire.
DEOXYCORTONE ACETATE AND LYMPHADENOPATHIES
SIR,—In connection with the
numerous
recent articles
treatment in particular.
surprising effects on rheumatoid arthritis of ’Cortisone,’ adrenocorticotropic hormone (A.C.T.H.), and deoxycortone acetate together with ascorbic acid, I wish to call attention to one application
in your
journal
on
the
of the adrenal-cortex steroid hormones in the field of the lymphopathies. I found that the administration of large doses (20-50 mg. per day) of deoxycortone acetate (’ Cortivis ’ Vister) has a moderate, transient, and inconstant effect on Hodgkin’s disease and on lymphatic and myeloid leukæmia.5This action is not augmented by the simultaneous administration of ascorbic acid. Similar results have now been reported by Pearson, Eliel, and Talbot using A.C.T.H.6 On the other hand, I have observed sensational and permanent relief in a rare disorder-giant follicular ’lymphadenopathy (Brill-Symmers disease). In hyperplastic lymphopathies of other histological types I have also observed very good results, with complete and permanent disappearance of enlargement of lymph-nodes and spleen. These observations, recorded briefly last ,vear,5 have lately been described more fully.7 G. FRADÁ. Medical Clinic, University
3.
of
Palermo, Sicily.
Green, A. B. Report of the Medical Officer, Local Government Board, 1900-01, p. 639 ; Ibid, 1901-02, p. 575 ; Ibid, 1902-03,
p. 659. 4. See Lancet, Feb. 4, pp. 219, 227. 5. Sicilia Med. 1949, 6, 267. 6. Cited in leading article, Lancet, Jan. 7. Fradà, G. Pr. méd. 1950, 58, 78.
28, p. 169.
N. M. JACOBY.
Tunbridge Wells.
SIR,—No child has died who has been operated upon
pyloric stenosis at the Westminster Children’s Hospital (formerly the Infants’ Hospital, Vincent Square) since 1947, when this hospital was reopened. My personal figures have lately been published.! I should like to emphasise the importance of ensuring that these infants are treated by a trained pædiatric team and that they are not operated on by the duty surgeon of the day unless he has had specialised paediatric for
’
experience. DAVID LEVI.
London, W.I.
SIR,—A series of
more than 100 cases of congenital stenosis has been treated by Rammstedt’s operapyloric tion in the Leeds General Infirmary since February, 1947, with a mortality of less than 1% : 96 cases were operated on consecutively without a death. The paediatrician makes the diagnosis within a few hours of seeing the infant, and unless there is some associated disease or dehydration he asks for early operation. The ansesthestist is an artist with open ether, shuns ethyl chloride, and is careful that the trickle of oxygen inside the mask does not become a blast to blow up the stomach. The surgeon is merely the craftsman in the team. No special instruments of any kind are used ; a rectus-split incision is made high so that the
1.
Post-grad.
med. J.
1950, 26, 24.
sample of the same batch subjected to the process. The remaining two samples-those chloroformed four and five times—showed an appreciable loss of potency compared with the control. While the purification of vaccine lymph by phenol is certainly very simple and satisfactory, that by the passage of chloroform vapour has the advantage of being much quicker while being equally efficacious and harmless. This process seems to have been first described by Green,3 who has presented convincing experimental evidence of its suitability; and in India at least three institutes manufacturing vaccine lymph have adopted this method for routine purification. months,
as
that of the control
INFANTILE PYLORIC STENOSIS
which had not been
Vaccine Institute, Belgaum, Bombay.
SIR,—Mr. Ward-McQuaid and Dr. Porritt, in their article of Feb. 4, describe a method of medical treatment which shows a failure-rate of about 40%. (The the numbers treated exact figure cannot be stated as be not could accurately estimated medically ... With medical treatment such results usually end in the abandonment of the method altogether and operation on all cases from the beginning. In my opinion better results can be obtained with medical treatment by : (1) selecting suitable cases, (2) four-hourly feeding, (3) gross reduction of feed-volume (1-11/2 oz. per feed in the first 24 hours, and increasing slowly up to full feeds), and (4) large doses of atropine methylnitrate from the beginning. The authors give before each feed, whereas I give gr. gr. before three feeds in 24 hours, reducing this to two doses at about the 5th day. This large dose can be given conveniently in lamels made by Savory & Moore, in which gr. 1/100 is contained in 1/4 sq. cm. As these lamels are cut from sheets marked in squares of 1 sq. cm., care must be taken that only 1/4 of a marked square is used at each dose. In the past five years I have treated 61 selected cases by this method. There were 2 failures (33%) and no deaths. With regard to surgical treatment, Mr. Ward-McQuaid and Dr. Porritt, and also Professor Smellie in his letter of Feb. 11, emphasise the importance of complete preoperative hydration as a means of reducing mortality. There is another side to this argument, and Professor Smellie hints at it when he warns against the danger of overadministration of sodium chloride. Personally I prefer Mr. David Levi’s technique for Rammstedt’s operation, in which there is no need for preoperative hydration, and which incidentally shortens the period in hospital by about 24 hours. In five years I have thus treated 58 cases with 1 death (1-7%). Combining medical and surgical treatment, there are 119 cases with a mortality-rate of 0-8%. I would say that nowadays a number of people achieve very low mortality-rates using very different techniques. What seems common to all of them is a full understanding of the disease in general and their own method of "
’
R. SANJIVA RAO.
" IMPROVERS " OF FLOUR
SiR,-The decision of the authorities to discontinue the use of nitrogen trichloride (’ Agene’) in flour,4after the Medical Research Council had recognised its serious and often fatal effects on animals, is to be welcomed. It is difficult to understand, however, why it should have been necessary to replace this "improver" by another chlorine compound-chlorine dioxide-which is in my opinion unnecessary, and will, furthermore, cost vital dollars since it will have to be obtained from the U.S.A. Improvers are not necessary to safeguard baking qualities. They are merely artificial means to speed up the natural maturing of flour, at the same time bleaching it and giving a whiter-looking loaf. It is regrettable that in the popular belief whiteness in bread should be synonymous with purity. In fact, the very opposite is the case. To my mind, bread should contain nothing but pure unadulterated wheat flour. In the case of other foodstuffs, such as milk and butter, the addition of chemicals is already forbidden by law. Why not in the case of the " staff of life "-bread ? "
West
"
C. P. ALLINSON.
Wickham, Cambridgeshire.
DEOXYCORTONE ACETATE AND LYMPHADENOPATHIES
SIR,—In connection with the
numerous
recent articles
treatment in particular.
surprising effects on rheumatoid arthritis of ’Cortisone,’ adrenocorticotropic hormone (A.C.T.H.), and deoxycortone acetate together with ascorbic acid, I wish to call attention to one application
in your
journal
on
the
of the adrenal-cortex steroid hormones in the field of the lymphopathies. I found that the administration of large doses (20-50 mg. per day) of deoxycortone acetate (’ Cortivis ’ Vister) has a moderate, transient, and inconstant effect on Hodgkin’s disease and on lymphatic and myeloid leukæmia.5This action is not augmented by the simultaneous administration of ascorbic acid. Similar results have now been reported by Pearson, Eliel, and Talbot using A.C.T.H.6 On the other hand, I have observed sensational and permanent relief in a rare disorder-giant follicular ’lymphadenopathy (Brill-Symmers disease). In hyperplastic lymphopathies of other histological types I have also observed very good results, with complete and permanent disappearance of enlargement of lymph-nodes and spleen. These observations, recorded briefly last ,vear,5 have lately been described more fully.7 G. FRADÁ. Medical Clinic, University
3.
of
Palermo, Sicily.
Green, A. B. Report of the Medical Officer, Local Government Board, 1900-01, p. 639 ; Ibid, 1901-02, p. 575 ; Ibid, 1902-03,
p. 659. 4. See Lancet, Feb. 4, pp. 219, 227. 5. Sicilia Med. 1949, 6, 267. 6. Cited in leading article, Lancet, Jan. 7. Fradà, G. Pr. méd. 1950, 58, 78.
28, p. 169.
N. M. JACOBY.
Tunbridge Wells.
SIR,—No child has died who has been operated upon
pyloric stenosis at the Westminster Children’s Hospital (formerly the Infants’ Hospital, Vincent Square) since 1947, when this hospital was reopened. My personal figures have lately been published.! I should like to emphasise the importance of ensuring that these infants are treated by a trained pædiatric team and that they are not operated on by the duty surgeon of the day unless he has had specialised paediatric for
’
experience. DAVID LEVI.
London, W.I.
SIR,—A series of
more than 100 cases of congenital stenosis has been treated by Rammstedt’s operapyloric tion in the Leeds General Infirmary since February, 1947, with a mortality of less than 1% : 96 cases were operated on consecutively without a death. The paediatrician makes the diagnosis within a few hours of seeing the infant, and unless there is some associated disease or dehydration he asks for early operation. The ansesthestist is an artist with open ether, shuns ethyl chloride, and is careful that the trickle of oxygen inside the mask does not become a blast to blow up the stomach. The surgeon is merely the craftsman in the team. No special instruments of any kind are used ; a rectus-split incision is made high so that the
1.
Post-grad.
med. J.
1950, 26, 24.