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EMPYEMA THORACIS
267 Six goats
PROSPECTS IN PSYCHIATRY
SiR,—In your annotation of July 21 you say : " Inpatient clinics for maladjusted -children are beginning to be established, and the first Scottish clinic of the kind was opened at Crichton Royal a few months ago." This is not strictly accurate as a residential clinic of this kind was established in September, 1940, at Nerston, East Kilbride, in connection with the child-guidance service of the Glasgow Corporation educational and publichealth departments. Although this clinic was started under pressure of the social problem of coping with unbifletable children," it has been a functioning residential clinic for maladjusted children from its inception, and mentally defective and frankly psychotic children were excluded to facilitate this object. There are, of course, distinctive features in the department of child psychiatry at Crichton Royal to which you refer, and it may possibly be the first Scottish inpatient clinic to be opened in association with a mental hospital. This is a valued addition to the mental health services, especially when one considers the excellent and wide facilities available there, but the fact remains that the staff of educational psychologists and the consulting psychiatrist at Nerston have been doing good work for many years. Gartloch Hospital, Gartcosh, Glasgow.
WILLIAM W. GORDON.
PREPARATION OF ANTI-COBRA SERUM
SiR,-I have previously describedthe preparation of a crystalline toxin from the cobra (Naja tripudians). This was a secondary proteose which caused : (1) liberation of histamine, arterial hypotension, and venous hypertension in the dog ; (2) vasoconstriction in the ear, dilatation of the coronary arteries, extrasystoles, and bradycardia in the rabbit ; (3) tachycardia in the cat ; and (4) augmentation of the heart-beat, ventricular block, and respiratory paralysis in the frog. These symptoms
antagonised by atropine (’ Bellafoline,’ Sandoz) together with ergotoxine (’ Gynergen,’ Sandoz), strychnine, vitamin Bi, and histidine hydrochloride. In preparing anti-cobra serum, toxin may be used from the beginning if the toxic effects are combated by also giving these drugs in combination.
are
Twenty-four dogs were immunised in the course of six months by subcutaneous injections of toxin at weekly intervals. With the early injections symptoms were prevented by giving 0-04 mg. per kg. body-weight, ergotamine tartrate 0-05 mg. per kg. body-weight, strychnine hydrochloride 0-mg. per kg. body-weight, vitamin Bl 25 mg., and histidine hydrochloride 0’04 mg. By the time the animals had become actively immune to 6 minimum lethal doses (M.L.D.) of the toxin it was no longer necessary to use the antagonist drugs to protect them. After some loss of weight in the early stages, the animals returned to their previous weight and remained in good condition throughout. One dog became immune to 165 M.L.D., and another to 74 M.L.D., after this course of immunisation. In these dogs the antitoxic titre of the serum was tested by the method of Shousha,2 various quantities of serum being added to 2 M.L.D. of toxin, incubated for an hour, and injected subcutaneously into albino rats weighing 100 g. The M.L.D. of toxin for rats of this weight is 0’03 mg. Using this procedure it has been found that 1 ml. of serum neutralises at least 0 rat 1VI.L.D. Twelve rabbits were immunised by subcutaneous injections of toxin in the same way. They were also given atropine 0’5 mg. per kg. body-weight, ergotamine tartrate 0-5 mg. per kg. body-weight, vitamin Bl 25 mg., and strychnine hydrochloride 0-mg. per kg. body-weight and histidine 0-1mg. per kg. body-weight subcutaneously at the same time as the toxin for the first 10 injections. The injections were given weekly. By injecting rats with mixtures of 2 M.L.D. of toxin incubated for one hour with various quantities of the serum taken from one of these immunised rabbits, it has been shown that 1 ml. <’.f the serum neutralises 65 rat M.L.D.
atropine
’
1. Mohammed, A. H. Lancet, 1949, ii, 716. 2. Shousa, A. T. Congr. int. Méd. trop. 1928, 3, 95.
were
immunised in the
same
way, and for the first
15
injections only they were protected with the antagonist drugs. The first dose of toxin was 12 mg., but three months later they were receiving 160 mg. of toxin. The serum was highly potent, 1 ml. neutralising up to 140 M.L.D. for 100 g. rats.
’
It may be concluded that blocking all the actions of cobra toxin by giving the five drugs that are,antagonistic to it enables lethal doses of the toxin to be injected safely. Furthermore, the antagonists do not interfere with the antigenic power of the active toxin ; and dogs, rabbits, and goats injected in -this way acquire a high degree of immunity. Horses could also be used for the mass production of the serum. Physiology Department, AHMED HASSAN MOHAMMED. Abbassia Medical Faculty, Ibrahim I University, Cairo.
EMPYEMA THORACIS
Six,-The article by Dr. Asher and Dr. Davies1 reminded ago.
me
of
a case
which I looked after
a
few months
A little Arab boy, 6 years of age, was admitted in a severely toxic condition, with empyema thoracis filling about threequarters of the right interpleural space. The child had been ill for about two months. On -admission he had remittent pyrexia. From pus withdrawn from the thorax a pure growth of pneumococci was obtained. Parenteral penicillin was started immediately, and the empyema was aspirated daily for ten days, 200,000 units penicillin being instilled each time ; altogether 4500 ml. pus was withdrawn. After ten days of this treatment the child’s general condition had improved considerably, and the
temperature
was
settling.
weeks after admission radiographic examination showed almost complete disappearance of the fluid except in the right costophrenic angle ; but a round shadow was seen in the right lower lobe close to the back, and this was diagnosed as a lung abscess. An attempt was made to aspirate this abscess, and about 30 ml. of pus was withdrawn ; culture proved sterile. A further 200,000 units of penicillin was instilled into the abscess cavity. After a further week the abscess had practically disappeared, and the lung had expanded completely, except that the right costophrenic angle was obliterated and the movements of the right diaphragm were still diminished. The child was discharged home in excellent general health. About a month later, when re-examined, he was still well. Unfortunately he has not returned for further examination. Three
In this case conservative treatment was successful not only for empyema but for a lung abscess close to the thoracic wall. Department of Hadassah Medical
Medicine, Organisation, Beer-Sheba, Israel.
E. E. LEHMANN.
BIOCHEMISTRY AND HEPATOLENTICULAR DEGENERATION
SiR,—Your annotation on this subject2 failed to mention the observation in one case of reduced arteriovenous oxygen difference reversible by cytochrome c.3 Chronic tissue hypoxia, perhaps due to a toxic effect of copper or manganese on tissue respiratory enzymes, may be responsible for lenticular degeneration and hepatic cirrhosis. In familial cases a hereditary metabolic defect may be the cause. Bilateral lenticular degeneration occurs in nearly every case of carbon monoxide asphyxia in which coma has lasted more than twenty-four hours.4 Persistent depression of oxidation has been implicated as a determining factor in the production of hepatic fibrosis.5 Winter Veterans Administration Hospital, Topeka, Kansas, U.S.A. 1. 2. 3. 4. 5.
SAMUEL ZELMAN.
Asher, R., Davies, D. Lancet, 1950, i, 924 Lancet, 1951, i, 1404. Zelman, S., Gilbert, T. Arch. intern. Med. 1948, 81, 485. Helpern, M. J. Amer. med. Ass. 1939, 113, 493. Gillman, J., Gillman, T. Perspectives in Human Malnutrition. New York, 1951; p. 266.
PROSPECTS IN PSYCHIATRY
SiR,—In your annotation of July 21 you say : " Inpatient clinics for maladjusted -children are beginning to be established, and the first Scottish clinic of the kind was opened at Crichton Royal a few months ago." This is not strictly accurate as a residential clinic of this kind was established in September, 1940, at Nerston, East Kilbride, in connection with the child-guidance service of the Glasgow Corporation educational and publichealth departments. Although this clinic was started under pressure of the social problem of coping with unbifletable children," it has been a functioning residential clinic for maladjusted children from its inception, and mentally defective and frankly psychotic children were excluded to facilitate this object. There are, of course, distinctive features in the department of child psychiatry at Crichton Royal to which you refer, and it may possibly be the first Scottish inpatient clinic to be opened in association with a mental hospital. This is a valued addition to the mental health services, especially when one considers the excellent and wide facilities available there, but the fact remains that the staff of educational psychologists and the consulting psychiatrist at Nerston have been doing good work for many years. Gartloch Hospital, Gartcosh, Glasgow.
WILLIAM W. GORDON.
PREPARATION OF ANTI-COBRA SERUM
SiR,-I have previously describedthe preparation of a crystalline toxin from the cobra (Naja tripudians). This was a secondary proteose which caused : (1) liberation of histamine, arterial hypotension, and venous hypertension in the dog ; (2) vasoconstriction in the ear, dilatation of the coronary arteries, extrasystoles, and bradycardia in the rabbit ; (3) tachycardia in the cat ; and (4) augmentation of the heart-beat, ventricular block, and respiratory paralysis in the frog. These symptoms
antagonised by atropine (’ Bellafoline,’ Sandoz) together with ergotoxine (’ Gynergen,’ Sandoz), strychnine, vitamin Bi, and histidine hydrochloride. In preparing anti-cobra serum, toxin may be used from the beginning if the toxic effects are combated by also giving these drugs in combination.
are
Twenty-four dogs were immunised in the course of six months by subcutaneous injections of toxin at weekly intervals. With the early injections symptoms were prevented by giving 0-04 mg. per kg. body-weight, ergotamine tartrate 0-05 mg. per kg. body-weight, strychnine hydrochloride 0-mg. per kg. body-weight, vitamin Bl 25 mg., and histidine hydrochloride 0’04 mg. By the time the animals had become actively immune to 6 minimum lethal doses (M.L.D.) of the toxin it was no longer necessary to use the antagonist drugs to protect them. After some loss of weight in the early stages, the animals returned to their previous weight and remained in good condition throughout. One dog became immune to 165 M.L.D., and another to 74 M.L.D., after this course of immunisation. In these dogs the antitoxic titre of the serum was tested by the method of Shousha,2 various quantities of serum being added to 2 M.L.D. of toxin, incubated for an hour, and injected subcutaneously into albino rats weighing 100 g. The M.L.D. of toxin for rats of this weight is 0’03 mg. Using this procedure it has been found that 1 ml. of serum neutralises at least 0 rat 1VI.L.D. Twelve rabbits were immunised by subcutaneous injections of toxin in the same way. They were also given atropine 0’5 mg. per kg. body-weight, ergotamine tartrate 0-5 mg. per kg. body-weight, vitamin Bl 25 mg., and strychnine hydrochloride 0-mg. per kg. body-weight and histidine 0-1mg. per kg. body-weight subcutaneously at the same time as the toxin for the first 10 injections. The injections were given weekly. By injecting rats with mixtures of 2 M.L.D. of toxin incubated for one hour with various quantities of the serum taken from one of these immunised rabbits, it has been shown that 1 ml. <’.f the serum neutralises 65 rat M.L.D.
atropine
’
1. Mohammed, A. H. Lancet, 1949, ii, 716. 2. Shousa, A. T. Congr. int. Méd. trop. 1928, 3, 95.
were
immunised in the
same
way, and for the first
15
injections only they were protected with the antagonist drugs. The first dose of toxin was 12 mg., but three months later they were receiving 160 mg. of toxin. The serum was highly potent, 1 ml. neutralising up to 140 M.L.D. for 100 g. rats.
’
It may be concluded that blocking all the actions of cobra toxin by giving the five drugs that are,antagonistic to it enables lethal doses of the toxin to be injected safely. Furthermore, the antagonists do not interfere with the antigenic power of the active toxin ; and dogs, rabbits, and goats injected in -this way acquire a high degree of immunity. Horses could also be used for the mass production of the serum. Physiology Department, AHMED HASSAN MOHAMMED. Abbassia Medical Faculty, Ibrahim I University, Cairo.
EMPYEMA THORACIS
Six,-The article by Dr. Asher and Dr. Davies1 reminded ago.
me
of
a case
which I looked after
a
few months
A little Arab boy, 6 years of age, was admitted in a severely toxic condition, with empyema thoracis filling about threequarters of the right interpleural space. The child had been ill for about two months. On -admission he had remittent pyrexia. From pus withdrawn from the thorax a pure growth of pneumococci was obtained. Parenteral penicillin was started immediately, and the empyema was aspirated daily for ten days, 200,000 units penicillin being instilled each time ; altogether 4500 ml. pus was withdrawn. After ten days of this treatment the child’s general condition had improved considerably, and the
temperature
was
settling.
weeks after admission radiographic examination showed almost complete disappearance of the fluid except in the right costophrenic angle ; but a round shadow was seen in the right lower lobe close to the back, and this was diagnosed as a lung abscess. An attempt was made to aspirate this abscess, and about 30 ml. of pus was withdrawn ; culture proved sterile. A further 200,000 units of penicillin was instilled into the abscess cavity. After a further week the abscess had practically disappeared, and the lung had expanded completely, except that the right costophrenic angle was obliterated and the movements of the right diaphragm were still diminished. The child was discharged home in excellent general health. About a month later, when re-examined, he was still well. Unfortunately he has not returned for further examination. Three
In this case conservative treatment was successful not only for empyema but for a lung abscess close to the thoracic wall. Department of Hadassah Medical
Medicine, Organisation, Beer-Sheba, Israel.
E. E. LEHMANN.
BIOCHEMISTRY AND HEPATOLENTICULAR DEGENERATION
SiR,—Your annotation on this subject2 failed to mention the observation in one case of reduced arteriovenous oxygen difference reversible by cytochrome c.3 Chronic tissue hypoxia, perhaps due to a toxic effect of copper or manganese on tissue respiratory enzymes, may be responsible for lenticular degeneration and hepatic cirrhosis. In familial cases a hereditary metabolic defect may be the cause. Bilateral lenticular degeneration occurs in nearly every case of carbon monoxide asphyxia in which coma has lasted more than twenty-four hours.4 Persistent depression of oxidation has been implicated as a determining factor in the production of hepatic fibrosis.5 Winter Veterans Administration Hospital, Topeka, Kansas, U.S.A. 1. 2. 3. 4. 5.
SAMUEL ZELMAN.
Asher, R., Davies, D. Lancet, 1950, i, 924 Lancet, 1951, i, 1404. Zelman, S., Gilbert, T. Arch. intern. Med. 1948, 81, 485. Helpern, M. J. Amer. med. Ass. 1939, 113, 493. Gillman, J., Gillman, T. Perspectives in Human Malnutrition. New York, 1951; p. 266.