- Email: [email protected]
DRINKING-WATER PLUMBI-SOLVENCY
1131 with tetracycline or lincomycin to infected subfertile patients, and we also use one of these drugs as antibiotic cover for tubal insufflation, dilatation and It should be remembered, curettage, or laparoscopy. however, that T-strains are not sensitive to lincomycin.
According
ment
A fuller account of these findings is being prepared, and in a future study we hope to screen for both M. hominis and T-
mycoplasmas. Elizabeth Garrett Anderson Hospital, London NW1. Central Public
Health Laboratory,
Colindale, London NW9.
WENDY LOVE MARGARET JONES. BASIL ANDREWS MAIR THOMAS.
ASPIRIN IN RADIATION-INDUCED DIARRHŒA
SIR,—Those who have administered prostaglandin E2 or F2iX for the induction of labour or abortion have often observed the side-effects of nausea and diarrhoea. 1,2 It is also known that the oral administration of prostaglandin El to volunteers elicits similar reactions. 3,4 Because of these reports and since aspirin at low concentration blocks
prostaglandin biosynthesis,5-7 Collierin that aspirin-like drugs " might be expected
1971
predicted
relieve some 9 types of nausea or diarrhoea ". At that time also, Bennett suggested that aspirin-like drugs should be tested in cholera, because prostaglandins might be involved in the profuse diarrhoea of that disease. This suggestion was given support when aspirin was reported to inhibit the exudation of fluid into the lumen of the gut induced by cholera enterotoxin in the rat 10 and cat." These considerations led us to test aspirin against the diarrhoea induced by the radiation therapy of cancer of the uterine cervix. Cervical cancer may be treated by a combination of external radiation and radium. With external radiation, the treatment usually lasts about four weeks, at a dose of about 1000 rads per week. Such treatment often produces diarrhoea, probably because loops of bowel in the path of X rays are damaged. The diarrhoea usually begins within two days of initiating radiation, but there is great variation in its time of onset from patient to patient. It may persist throughout the course of treatment, but may clear up spontaneously after four or five days. In this diarrhoea, which may be accompanied by colicky pain, profuse watery stools are passed, sometimes as many as twenty in twentyfour hours. Conventionally, radiation-induced diarrhoea is treated with kaolin-and-morphine mixture, codeine phosphate, or diphenoxylate, but it sometimes does not respond at all or adequately to such treatment. If this treatment fails, not only may irradiation therapy have to be interrupted, but the patient suffers great distress. 15 women aged between 47 and 65, who had been irradiated for cancer of the cervix and who had developed diarrhoea that did not respond to conventional therapy, took part in a preliminary trial. When conventional therapy failed, it was abandoned and each patient was given 900 mg. of soluble aspirin B.P. (’Solfrin’) by mouth, four times daily. 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
to
Filshie, G. Ann. N.Y. Acad. Sci. 1971, 180, 553. Barr, W., Naismith, W. C. M. K. Br. med. J. 1972, ii, 188. Horton, E. W., Main, I. H. M., Thompson, C. J., Wright, P. M. Gut, 1968, 9, 655. Misiewicz, J. J., Walter, S. L., Kiley, N., Horton, E. W. Lancet, 1969, ii, 648. Vane, J. R. Nature New Biol. 1971, 231, 232. Smith, J. B., Willis, A. L. ibid. p. 235. Ferreira, S. H., Moncada, S., Vane, J. R. ibid. p. 237. Collier, H. O. J. Nature, 1971, 232, 17. Bennett, A. ibid. 1971, 231, 536. Jacoby, H. I., Marshall, C. H. ibid. 1972, 235, 163. Finck, A. D., Katz, R. L. ibid. 1972, 238, 273.
to
hours of starting
the results obtained within twenty-four were divided into four
aspirin, the patients
groups: No. in whom diarrhcea
Total
no.
15
Abolished
Improved
4
was
Worsened 21
Unchanged
8
In 4 patients the diarrhoea cleared up completely within twenty-four hours of giving aspirin. In another 8 patients the diarrhoea was improved, although in 2 it relapsed forty-eight hours after improvement was first noticed, despite continued treatment with aspirin. Colicky pain which accompanied diarrhoea in 3 patients disappeared during aspirin therapy, and 1 patient who had severe nausea experienced dramatic relief. Our findings indicate that aspirin may be of value in the treatment of diarrhoea induced by radiation. Recent animal experiments support this possibility. The giving of prostaglandins to dogs induces diarrhoea, 1-2and the administration of Escherichia coli endotoxin, which releases prostaglandins in dogs,I3,14 also induces diarrhoea 15; this is inhibited by the intravenous administration of sodium acetylsalicylate. 16 Further, since prostaglandin synthesis can be provoked by many different forms of stimulation,5 and because aspirin at low concentrations inhibits this synthesis,5 we suggest that prostaglandins are involved in
radiation-induced diarrhoea. This suggestion accords with the predictions 8,9 mentioned and indicates the need for a carefully controlled trial of aspirin in the treatment of radiation-induced diarrhoea. This
we are now
Royal Marsden Hospital, Fulham Road, London SW3 6JJ.
doing. A. T. MENNIE VERA DALLEY.
DRINKING-WATER PLUMBI-SOLVENCY
SIR,—Work in this laboratory on samples of drinkingwater, taken after running the taps for ten minutes, from 23 cities in the United Kingdom has shown that all the specimens contained less than the World Health Organisation’s maximum allowable concentration of 0-10 mg. per 1. of lead. However, after only one minute’s contact with new lead pipe all the samples dissolved from 0-7 to 12 times the W.H.O. 16-hour contact limit of 0-30 mg. per 1. Further, using one of the sources of water and simulating a domestic installation to investigate the rapid protective coating property which is supposed to build up inside the pipe, it was found that after 36 days’ continuous use, the 16hour samples still contained three times the permitted level. Also disturbing was the uptake of lead from copper pipes with sweated joints. Here, it was found that 24-hour samples initially produced 27 times the 0-3 level, falling to 5 times this standard after 19 days, and that the 16-hour W.H.O. limit was always reached after only 15 minutes’ contact.
The substitution of stock brass fittings instead of the sweated joints still presented a hazard in that drinkingwater after 1 hour’s contact dissolved 0-1 mg. per 1. of lead. There is, undoubtedly, a continuous health hazard from drinking-water’s solvent property towards lead piping and alloys containing lead. This risk is at its greatest whenever newly constructed property is occupied 12. 13.
14. 15. 16.
Robert, A., Nezamis, J. E., Phillips, J. P. Am. J. dig. Dis. 1967, 12, 1073. Anderson, F. L., Jubiz, W., Kralios, A. C., Tsagaris, T. J., Kuida, H. Circulation, 1972, 45 and 46, 11-124. Collier, J. G., Herman, J. G., Vane, J. R. J. Physiol. Lond. (in the press). Pierce, N. F., Wallace, C. K. Gastroenterology, 1972, 63, 439. Kellett, D. N., Birtley, R. D. N., Davies, J., Collier, H. O. J. Personal communication.
1132 when plumbing repairs have been carried action further aggravates the situation. or
out.
Galvanic
Municipal Laboratory, Department of Civil Engineering Annexe, Mount Pleasant, P.O. Box 147, Liverpool L69 3BX.
C. D. REED J. A. TOLLEY.
PRESCRIBING OF ORAL CONTRACEPTIVES SIR,-In a survey of the prescribing of chloramphenicol, amphetamines, and bronchodilator aerosols in Northern Ireland, Wade and Hood1 concluded that the prescribing habits of most doctors are firmly fixed and that changes in their patterns of prescribing in response to reports of adverse reactions to drugs occur slowly and only after a long time. PERCENTAGES OF DIFFERENT OESTROGEN
MANAGEMENT OF CHILDHOOD PYREXIA USING CENTRAL AND PERIPHERAL TEMPERATURE RECORDINGS
CEPTIVES
DISPENSED
ON
NOVEMBER, 1969, JANUARY,
1970,
DOSE/TYPE
IN
N.H.S.
AND
ORAL CONTRAIRELAND IN
NORTHERN
OCTOBER, 1972
SiR,—The technique of simultaneous measurement of central and peripheral temperature is valuable in the management of shock and postoperative hypovolsemic hyperpyrexia.1 Such measurements have shown that conventional treatment of pyrexia in adults, when associated with hypovolaEmia, by tepid sponging and exposure to a cold current of air from a fan causes further vasoconstriction and heat retention.1,2 We describe the application of this simple technique to the management of two pyrexial children. The children, aged 10 and 4, had lobar pneumonia. The first was well hydrated, the second had been vomiting
*
Control and peripheral temperatures in lobar pneumonia.
two
children with
was mildly dehydrated. Both were given intramuscular penicillin, exposed to a current of air, and sponged with tepid water. A rectal probe and skin applicator attached
and
1 unit is that
quantity required
to
be taken for
a
28-day cycle.
The results of a study of N.H.S. prescriptions for oral contraceptives written by general practitioners in Northern Ireland during the months November, 1969, January, 1970,and October, 1972, are shown in the accompanying table and figure. It seems that doctors responded rapidly to, and have continued to heed, the warning issued in December, 1969, by the then Committee on Safety of Drugs against the use of oral contraceptives containing the higher doses of oestrogen. I suggest that the reasons for the rapid change in pre-
1.
Wade, 0. L., Hood, H. Br. y. prev.
soc.
Med. 1972, 26, 205.
the lateral side of the great toe were used to measure central and peripheral temperatures. The hydrated child had an initial central-peripheral temperature difference of4°C, and conventional treatment caused a steady fall in both temperatures without causing distress (fig. a). In contrast, the mildly dehydrated child had an initial temperature difference of 10-5 °C, the same treatment then causing a further increase to 15-5°C as a result of a fall in skin temperature alone. At this point the child was distressed and shivering. The antithesis of conventional treatment was commenced. He was covered, the room was heated, and he was given 500 ml. of fluid over the next seven hours. As a result, the central temperature fell sharply, with subsequent approximation of the skin/rectal temperature difference (fig. b). We suggest that the simultaneous measurement of central and peripheral temperature may be a useful guide to both the volaemic state and the management of pyrexial children.
to
Department of Pædiatrics, Radcliffe Infirmary, Oxford OX2 6HE. 1. 2.
A. AYNSLEY-GREEN D. PICKERING.
Ross, B. A., Brock, R., Aynsley-Green, A. Br. J. Surg. 1969, 56, 877. Spitzer, A. G., Brock, R. Guy’s Hosp. Rep. 1968, 117, 131.
Percentages of oral contraceptives dispensed Northern Ireland.
D N
Containing 50 v.g. oestrogen. Containing more than 50 g. cestrogen.
on
N.H.S. in
According
ment
A fuller account of these findings is being prepared, and in a future study we hope to screen for both M. hominis and T-
mycoplasmas. Elizabeth Garrett Anderson Hospital, London NW1. Central Public
Health Laboratory,
Colindale, London NW9.
WENDY LOVE MARGARET JONES. BASIL ANDREWS MAIR THOMAS.
ASPIRIN IN RADIATION-INDUCED DIARRHŒA
SIR,—Those who have administered prostaglandin E2 or F2iX for the induction of labour or abortion have often observed the side-effects of nausea and diarrhoea. 1,2 It is also known that the oral administration of prostaglandin El to volunteers elicits similar reactions. 3,4 Because of these reports and since aspirin at low concentration blocks
prostaglandin biosynthesis,5-7 Collierin that aspirin-like drugs " might be expected
1971
predicted
relieve some 9 types of nausea or diarrhoea ". At that time also, Bennett suggested that aspirin-like drugs should be tested in cholera, because prostaglandins might be involved in the profuse diarrhoea of that disease. This suggestion was given support when aspirin was reported to inhibit the exudation of fluid into the lumen of the gut induced by cholera enterotoxin in the rat 10 and cat." These considerations led us to test aspirin against the diarrhoea induced by the radiation therapy of cancer of the uterine cervix. Cervical cancer may be treated by a combination of external radiation and radium. With external radiation, the treatment usually lasts about four weeks, at a dose of about 1000 rads per week. Such treatment often produces diarrhoea, probably because loops of bowel in the path of X rays are damaged. The diarrhoea usually begins within two days of initiating radiation, but there is great variation in its time of onset from patient to patient. It may persist throughout the course of treatment, but may clear up spontaneously after four or five days. In this diarrhoea, which may be accompanied by colicky pain, profuse watery stools are passed, sometimes as many as twenty in twentyfour hours. Conventionally, radiation-induced diarrhoea is treated with kaolin-and-morphine mixture, codeine phosphate, or diphenoxylate, but it sometimes does not respond at all or adequately to such treatment. If this treatment fails, not only may irradiation therapy have to be interrupted, but the patient suffers great distress. 15 women aged between 47 and 65, who had been irradiated for cancer of the cervix and who had developed diarrhoea that did not respond to conventional therapy, took part in a preliminary trial. When conventional therapy failed, it was abandoned and each patient was given 900 mg. of soluble aspirin B.P. (’Solfrin’) by mouth, four times daily. 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
to
Filshie, G. Ann. N.Y. Acad. Sci. 1971, 180, 553. Barr, W., Naismith, W. C. M. K. Br. med. J. 1972, ii, 188. Horton, E. W., Main, I. H. M., Thompson, C. J., Wright, P. M. Gut, 1968, 9, 655. Misiewicz, J. J., Walter, S. L., Kiley, N., Horton, E. W. Lancet, 1969, ii, 648. Vane, J. R. Nature New Biol. 1971, 231, 232. Smith, J. B., Willis, A. L. ibid. p. 235. Ferreira, S. H., Moncada, S., Vane, J. R. ibid. p. 237. Collier, H. O. J. Nature, 1971, 232, 17. Bennett, A. ibid. 1971, 231, 536. Jacoby, H. I., Marshall, C. H. ibid. 1972, 235, 163. Finck, A. D., Katz, R. L. ibid. 1972, 238, 273.
to
hours of starting
the results obtained within twenty-four were divided into four
aspirin, the patients
groups: No. in whom diarrhcea
Total
no.
15
Abolished
Improved
4
was
Worsened 21
Unchanged
8
In 4 patients the diarrhoea cleared up completely within twenty-four hours of giving aspirin. In another 8 patients the diarrhoea was improved, although in 2 it relapsed forty-eight hours after improvement was first noticed, despite continued treatment with aspirin. Colicky pain which accompanied diarrhoea in 3 patients disappeared during aspirin therapy, and 1 patient who had severe nausea experienced dramatic relief. Our findings indicate that aspirin may be of value in the treatment of diarrhoea induced by radiation. Recent animal experiments support this possibility. The giving of prostaglandins to dogs induces diarrhoea, 1-2and the administration of Escherichia coli endotoxin, which releases prostaglandins in dogs,I3,14 also induces diarrhoea 15; this is inhibited by the intravenous administration of sodium acetylsalicylate. 16 Further, since prostaglandin synthesis can be provoked by many different forms of stimulation,5 and because aspirin at low concentrations inhibits this synthesis,5 we suggest that prostaglandins are involved in
radiation-induced diarrhoea. This suggestion accords with the predictions 8,9 mentioned and indicates the need for a carefully controlled trial of aspirin in the treatment of radiation-induced diarrhoea. This
we are now
Royal Marsden Hospital, Fulham Road, London SW3 6JJ.
doing. A. T. MENNIE VERA DALLEY.
DRINKING-WATER PLUMBI-SOLVENCY
SIR,—Work in this laboratory on samples of drinkingwater, taken after running the taps for ten minutes, from 23 cities in the United Kingdom has shown that all the specimens contained less than the World Health Organisation’s maximum allowable concentration of 0-10 mg. per 1. of lead. However, after only one minute’s contact with new lead pipe all the samples dissolved from 0-7 to 12 times the W.H.O. 16-hour contact limit of 0-30 mg. per 1. Further, using one of the sources of water and simulating a domestic installation to investigate the rapid protective coating property which is supposed to build up inside the pipe, it was found that after 36 days’ continuous use, the 16hour samples still contained three times the permitted level. Also disturbing was the uptake of lead from copper pipes with sweated joints. Here, it was found that 24-hour samples initially produced 27 times the 0-3 level, falling to 5 times this standard after 19 days, and that the 16-hour W.H.O. limit was always reached after only 15 minutes’ contact.
The substitution of stock brass fittings instead of the sweated joints still presented a hazard in that drinkingwater after 1 hour’s contact dissolved 0-1 mg. per 1. of lead. There is, undoubtedly, a continuous health hazard from drinking-water’s solvent property towards lead piping and alloys containing lead. This risk is at its greatest whenever newly constructed property is occupied 12. 13.
14. 15. 16.
Robert, A., Nezamis, J. E., Phillips, J. P. Am. J. dig. Dis. 1967, 12, 1073. Anderson, F. L., Jubiz, W., Kralios, A. C., Tsagaris, T. J., Kuida, H. Circulation, 1972, 45 and 46, 11-124. Collier, J. G., Herman, J. G., Vane, J. R. J. Physiol. Lond. (in the press). Pierce, N. F., Wallace, C. K. Gastroenterology, 1972, 63, 439. Kellett, D. N., Birtley, R. D. N., Davies, J., Collier, H. O. J. Personal communication.
1132 when plumbing repairs have been carried action further aggravates the situation. or
out.
Galvanic
Municipal Laboratory, Department of Civil Engineering Annexe, Mount Pleasant, P.O. Box 147, Liverpool L69 3BX.
C. D. REED J. A. TOLLEY.
PRESCRIBING OF ORAL CONTRACEPTIVES SIR,-In a survey of the prescribing of chloramphenicol, amphetamines, and bronchodilator aerosols in Northern Ireland, Wade and Hood1 concluded that the prescribing habits of most doctors are firmly fixed and that changes in their patterns of prescribing in response to reports of adverse reactions to drugs occur slowly and only after a long time. PERCENTAGES OF DIFFERENT OESTROGEN
MANAGEMENT OF CHILDHOOD PYREXIA USING CENTRAL AND PERIPHERAL TEMPERATURE RECORDINGS
CEPTIVES
DISPENSED
ON
NOVEMBER, 1969, JANUARY,
1970,
DOSE/TYPE
IN
N.H.S.
AND
ORAL CONTRAIRELAND IN
NORTHERN
OCTOBER, 1972
SiR,—The technique of simultaneous measurement of central and peripheral temperature is valuable in the management of shock and postoperative hypovolsemic hyperpyrexia.1 Such measurements have shown that conventional treatment of pyrexia in adults, when associated with hypovolaEmia, by tepid sponging and exposure to a cold current of air from a fan causes further vasoconstriction and heat retention.1,2 We describe the application of this simple technique to the management of two pyrexial children. The children, aged 10 and 4, had lobar pneumonia. The first was well hydrated, the second had been vomiting
*
Control and peripheral temperatures in lobar pneumonia.
two
children with
was mildly dehydrated. Both were given intramuscular penicillin, exposed to a current of air, and sponged with tepid water. A rectal probe and skin applicator attached
and
1 unit is that
quantity required
to
be taken for
a
28-day cycle.
The results of a study of N.H.S. prescriptions for oral contraceptives written by general practitioners in Northern Ireland during the months November, 1969, January, 1970,and October, 1972, are shown in the accompanying table and figure. It seems that doctors responded rapidly to, and have continued to heed, the warning issued in December, 1969, by the then Committee on Safety of Drugs against the use of oral contraceptives containing the higher doses of oestrogen. I suggest that the reasons for the rapid change in pre-
1.
Wade, 0. L., Hood, H. Br. y. prev.
soc.
Med. 1972, 26, 205.
the lateral side of the great toe were used to measure central and peripheral temperatures. The hydrated child had an initial central-peripheral temperature difference of4°C, and conventional treatment caused a steady fall in both temperatures without causing distress (fig. a). In contrast, the mildly dehydrated child had an initial temperature difference of 10-5 °C, the same treatment then causing a further increase to 15-5°C as a result of a fall in skin temperature alone. At this point the child was distressed and shivering. The antithesis of conventional treatment was commenced. He was covered, the room was heated, and he was given 500 ml. of fluid over the next seven hours. As a result, the central temperature fell sharply, with subsequent approximation of the skin/rectal temperature difference (fig. b). We suggest that the simultaneous measurement of central and peripheral temperature may be a useful guide to both the volaemic state and the management of pyrexial children.
to
Department of Pædiatrics, Radcliffe Infirmary, Oxford OX2 6HE. 1. 2.
A. AYNSLEY-GREEN D. PICKERING.
Ross, B. A., Brock, R., Aynsley-Green, A. Br. J. Surg. 1969, 56, 877. Spitzer, A. G., Brock, R. Guy’s Hosp. Rep. 1968, 117, 131.
Percentages of oral contraceptives dispensed Northern Ireland.
D N
Containing 50 v.g. oestrogen. Containing more than 50 g. cestrogen.
on
N.H.S. in