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EXUDATIVE TONSILLITIS
192 any interest in ophthalmo-political matters until the ABO passed a motion at its annual general meeting in 1943 to initiate a movement to found a’ College or Faculty or
similar Institute of Ophthalmology. It would seem that the CBO was then suddenly stimulated into active interest. The council of the ABO welcomed this interest in the hope that its origin was disinterested, but it transpires that the CBO’s intention was, and is, to take control of the movement and direct its future course. The constitution proposed by the CBO included a non-elected senior directorate or " upper house." It was also suggested that the constitution was not to be subject to alteration" by any future majority vote ‘of the constituent members. The ABO gave way on various matters, but insisted that the constitution of the proposed Faculty must be entirely democratic ; that election to the Faculty council must be by vote ; that a majority postal vote of members must be binding on all matters ; and that the proposed constitution must be subject to alteration annually in the same democratic fashion. It refused to give way on this point : hence the final failure of negotiations. Under the constitution now proposed by the CBO only a small - proportion of ophthalmologists will be eligible for election as members of the Faculty : generally* speaking, they must have charge of beds in hospitals approved by the CBO, and " provisionally, these will be general hospitals of more than 200 beds and special ophthalmic hospitals of more than 20 beds." Other ophthalmic surgeons of consultant rank " approved by the CBO " will also be eligible. Of the 21 members of the future Council of British Ophthalmologists, which will be executive of the new Faculty, 15 will be elected by this small and select constituency. The Faculty has been registered by the CBO already, and this step was taken during an interval between negotiations without the knowledge or approval of the ABO, at a time when the ABO had been requested not to take any official steps which might in any way upset the mutually desired successful conclusion of the negotiation. London, Wl.
LIONEL M. GREEN.
PNEUMOCOCCAL LOBAR PNEUMONIA
SIR,—The paper by Ramsay et al. in your issue of
Jan. 20 .confirms the efficacy
of sulphamezathine
in the
treatment. of pneumococcal lobar pneumonia. The results, however, hardly justify it as the drug of choice.
In 1941-42 I treated irf Glasgow 441 cases of’typed pneumococcus lobar pneumonia with sulphapyridine. There were 38 deaths ; excluding 8 patients who died within 24 hours of admission to hospital the fatalityrate was 7-0%. Although the newer chemotherapeutic agents such as sulphadiazine and sulphamezathine are admittedly less toxic, they are no more effective than sulphapyridine.. Sulphadiazine is probably the one of choice ; I have seen severe leucopenia develop soon after administration of sulphamezathine. In spite of chemotherapy, failures in the treatment of
pneumococcal lobar pneumonia are inevitable. The results of chemotherapy combined with serum or vaccine therapy are no better than those of chemotherapy alone.l I wondered whether the results could be improved by giving a more intensive course of chemotherapy ; but the observations I recorded in your last issue show that the clinical response cannot be correlated with the concentration of the drug in the blood. Hence I do not believe that the fatality-rate could be lowered by giving larger doses. In their analysis of fatal cases Ramsay et al. mention 5 patients who died and who had low blood-levels of sulphamezathine. Unfortunately only one case is analysed in detail-that of a man aged 57, with a type V infection, admitted on the 10th day of illness. They later refer to 9 patients-all with adequate, and 3 with high blood-levels-in whom death was attributed to toxaemia ; 3 of these were treated before the 7th day of illness. It is obvious that deaths can occur in the presence of a high blood-level; are Ramsay et al. justified in assuming that the deaths of the first 5 patients were due to the low blood-level of sulphamezathine ? It is clearly established that in the aged the sulphon1. Dick, A. Lancet, 1944, i, 564; Plummer, N., Solomon, S. Kammerer, W. H., Kulkstein, H. K. J. Amer. med. Ass. 1941, 116, 2366.
Liebmann, J., M., Ensworth,
are not nearly so effective as earlier in life; in the aged pneumonia is likely to be a severe disease. Moreover many patients are admitted to hospital when the
amides
disease is already well established. If we are to reduce the fatality-rate the diagnosis must be made earlier in the illness. More reliance might be placed on the history and early physical signs, and treatment should begin before the classical signs of dullness on percussion and tubular breathing are well established. Royal Northern Infirmary, ARCHIBALD DICK. Inverness.
EXUDATIVE TONSILLITIS SIR,—Judging by his letter of Dec. 30, Dr. Alcock cannot have read Neubauer’s paper (Lancet-, 1943, ii, 192). In my experience diphtheria in an immunised person is a very definite entity. The condition simulates tonsillitis closely, but may include any of the classical signs—fœtor, adenitis, oedema, myocarditis, and neuritis —and a new one, circumoral pallor. Naturally after immunisation these are not as obvious as in ordinary diphtheria. In the immunised patient the membrane is very like that seen in tonsillitis ; it is easily stripped without bleeding, but recurs and is resistant to sulphonamides. To say that membrane alone is the essential and diagnostic lesion is a very big statement. RONNIE CLARKE. 3fachynlleth, Montgomeryshire. Rh ANTIBODY IN BREAST MILK
SIR,—In your leader of Nov. 4,1944, A Year’s Work on the Rh Factor; the statement is made that breast-feeding
is contra-indicated in babies affected with hsemolytic disease of the newborn because of the risk of continued haemolysis of the baby’s red cells from Rh antibodies ingested with the breast milk ; you recommend that the breast milk should be drawn off and boiled before use. To deny the baby the breast without good reason is such a major catastrophe that one is tempted to ask what evidence there is that Rh antibodies from the mother’s milk can reach the baby’s blood-stream, in sufficient titre to damage the red cells. And, in view of your statement, I describe below the findings in a case which I have recently investigated which indicate that the hæmolytic process continues quite apart from breast-
feeding. Clinical jaundice developed in a baby (blood-group A, Rhpositive) on the third day after birth. Investigation revealed that its mother was group A, Rh-negative, and that an Rh antibody, active to a titre of 4-8 against the baby’s cells, The jaundice was demonstrable in the mother’s serum. rapidly cleared, but the baby became increasingly anaemic, and when 12 days old its haemoglobin was 58% (Haldane). Despite the transfusion of 100 c.cm. of Rh-negative blood compatible with the mother’s serum, the hsemolytic progress continued, and after a further Idays the baby’s haemoglobin had dropped to 50% and its red cells totalled 2,400,000 per c.mm. A differential-agglutination count showed that approximately 1,300,000 of these cells were transfused cells, so that had no transfusion been given the baby’s: haemoglobin level would have been in the region of 22%. After a further transfusion of Rh-negative blood, the baby made an uneventfulrecovery. This case was thus a typical example of the progressive type of anaemia associated with haemolytic disease of the newborn, but the most significant finding was that the baby had not been put to the breast after the second day as the mother had developed a serosanguinous discharge from both nipples. During the time when the hsemolytic process was proceeding steadily it was being
fed
on was no
a
boiled
possibility
Rh antibodies
was
cow’s-milk mixture. Hence, there in this instance that the ingestion of responsible for the continuance of the
haemolytic
process. Army Blood Transfusion Service.
GEOFFREY H. TOVEY.
** * Rh antibodies were first demonstrated in breastby E. Witebsky, G. W. Anderson, and A. Heide (Proc. Soc. exp. Biol., NY, 1942, 49, 179. 1943, 52, 280). The titre is usually low, and there is no direct evidence that breast-feeding in these cases causes continued hoemolysis of the baby’s cells, but E. Nickerson and R. T. Moulton (New Engl. J. Nled. 1943, 229, 863) noticed that even apparently unaffected infants nursed by sensitised mothers did not do so well as expected.-ED. L. milk
similar Institute of Ophthalmology. It would seem that the CBO was then suddenly stimulated into active interest. The council of the ABO welcomed this interest in the hope that its origin was disinterested, but it transpires that the CBO’s intention was, and is, to take control of the movement and direct its future course. The constitution proposed by the CBO included a non-elected senior directorate or " upper house." It was also suggested that the constitution was not to be subject to alteration" by any future majority vote ‘of the constituent members. The ABO gave way on various matters, but insisted that the constitution of the proposed Faculty must be entirely democratic ; that election to the Faculty council must be by vote ; that a majority postal vote of members must be binding on all matters ; and that the proposed constitution must be subject to alteration annually in the same democratic fashion. It refused to give way on this point : hence the final failure of negotiations. Under the constitution now proposed by the CBO only a small - proportion of ophthalmologists will be eligible for election as members of the Faculty : generally* speaking, they must have charge of beds in hospitals approved by the CBO, and " provisionally, these will be general hospitals of more than 200 beds and special ophthalmic hospitals of more than 20 beds." Other ophthalmic surgeons of consultant rank " approved by the CBO " will also be eligible. Of the 21 members of the future Council of British Ophthalmologists, which will be executive of the new Faculty, 15 will be elected by this small and select constituency. The Faculty has been registered by the CBO already, and this step was taken during an interval between negotiations without the knowledge or approval of the ABO, at a time when the ABO had been requested not to take any official steps which might in any way upset the mutually desired successful conclusion of the negotiation. London, Wl.
LIONEL M. GREEN.
PNEUMOCOCCAL LOBAR PNEUMONIA
SIR,—The paper by Ramsay et al. in your issue of
Jan. 20 .confirms the efficacy
of sulphamezathine
in the
treatment. of pneumococcal lobar pneumonia. The results, however, hardly justify it as the drug of choice.
In 1941-42 I treated irf Glasgow 441 cases of’typed pneumococcus lobar pneumonia with sulphapyridine. There were 38 deaths ; excluding 8 patients who died within 24 hours of admission to hospital the fatalityrate was 7-0%. Although the newer chemotherapeutic agents such as sulphadiazine and sulphamezathine are admittedly less toxic, they are no more effective than sulphapyridine.. Sulphadiazine is probably the one of choice ; I have seen severe leucopenia develop soon after administration of sulphamezathine. In spite of chemotherapy, failures in the treatment of
pneumococcal lobar pneumonia are inevitable. The results of chemotherapy combined with serum or vaccine therapy are no better than those of chemotherapy alone.l I wondered whether the results could be improved by giving a more intensive course of chemotherapy ; but the observations I recorded in your last issue show that the clinical response cannot be correlated with the concentration of the drug in the blood. Hence I do not believe that the fatality-rate could be lowered by giving larger doses. In their analysis of fatal cases Ramsay et al. mention 5 patients who died and who had low blood-levels of sulphamezathine. Unfortunately only one case is analysed in detail-that of a man aged 57, with a type V infection, admitted on the 10th day of illness. They later refer to 9 patients-all with adequate, and 3 with high blood-levels-in whom death was attributed to toxaemia ; 3 of these were treated before the 7th day of illness. It is obvious that deaths can occur in the presence of a high blood-level; are Ramsay et al. justified in assuming that the deaths of the first 5 patients were due to the low blood-level of sulphamezathine ? It is clearly established that in the aged the sulphon1. Dick, A. Lancet, 1944, i, 564; Plummer, N., Solomon, S. Kammerer, W. H., Kulkstein, H. K. J. Amer. med. Ass. 1941, 116, 2366.
Liebmann, J., M., Ensworth,
are not nearly so effective as earlier in life; in the aged pneumonia is likely to be a severe disease. Moreover many patients are admitted to hospital when the
amides
disease is already well established. If we are to reduce the fatality-rate the diagnosis must be made earlier in the illness. More reliance might be placed on the history and early physical signs, and treatment should begin before the classical signs of dullness on percussion and tubular breathing are well established. Royal Northern Infirmary, ARCHIBALD DICK. Inverness.
EXUDATIVE TONSILLITIS SIR,—Judging by his letter of Dec. 30, Dr. Alcock cannot have read Neubauer’s paper (Lancet-, 1943, ii, 192). In my experience diphtheria in an immunised person is a very definite entity. The condition simulates tonsillitis closely, but may include any of the classical signs—fœtor, adenitis, oedema, myocarditis, and neuritis —and a new one, circumoral pallor. Naturally after immunisation these are not as obvious as in ordinary diphtheria. In the immunised patient the membrane is very like that seen in tonsillitis ; it is easily stripped without bleeding, but recurs and is resistant to sulphonamides. To say that membrane alone is the essential and diagnostic lesion is a very big statement. RONNIE CLARKE. 3fachynlleth, Montgomeryshire. Rh ANTIBODY IN BREAST MILK
SIR,—In your leader of Nov. 4,1944, A Year’s Work on the Rh Factor; the statement is made that breast-feeding
is contra-indicated in babies affected with hsemolytic disease of the newborn because of the risk of continued haemolysis of the baby’s red cells from Rh antibodies ingested with the breast milk ; you recommend that the breast milk should be drawn off and boiled before use. To deny the baby the breast without good reason is such a major catastrophe that one is tempted to ask what evidence there is that Rh antibodies from the mother’s milk can reach the baby’s blood-stream, in sufficient titre to damage the red cells. And, in view of your statement, I describe below the findings in a case which I have recently investigated which indicate that the hæmolytic process continues quite apart from breast-
feeding. Clinical jaundice developed in a baby (blood-group A, Rhpositive) on the third day after birth. Investigation revealed that its mother was group A, Rh-negative, and that an Rh antibody, active to a titre of 4-8 against the baby’s cells, The jaundice was demonstrable in the mother’s serum. rapidly cleared, but the baby became increasingly anaemic, and when 12 days old its haemoglobin was 58% (Haldane). Despite the transfusion of 100 c.cm. of Rh-negative blood compatible with the mother’s serum, the hsemolytic progress continued, and after a further Idays the baby’s haemoglobin had dropped to 50% and its red cells totalled 2,400,000 per c.mm. A differential-agglutination count showed that approximately 1,300,000 of these cells were transfused cells, so that had no transfusion been given the baby’s: haemoglobin level would have been in the region of 22%. After a further transfusion of Rh-negative blood, the baby made an uneventfulrecovery. This case was thus a typical example of the progressive type of anaemia associated with haemolytic disease of the newborn, but the most significant finding was that the baby had not been put to the breast after the second day as the mother had developed a serosanguinous discharge from both nipples. During the time when the hsemolytic process was proceeding steadily it was being
fed
on was no
a
boiled
possibility
Rh antibodies
was
cow’s-milk mixture. Hence, there in this instance that the ingestion of responsible for the continuance of the
haemolytic
process. Army Blood Transfusion Service.
GEOFFREY H. TOVEY.
** * Rh antibodies were first demonstrated in breastby E. Witebsky, G. W. Anderson, and A. Heide (Proc. Soc. exp. Biol., NY, 1942, 49, 179. 1943, 52, 280). The titre is usually low, and there is no direct evidence that breast-feeding in these cases causes continued hoemolysis of the baby’s cells, but E. Nickerson and R. T. Moulton (New Engl. J. Nled. 1943, 229, 863) noticed that even apparently unaffected infants nursed by sensitised mothers did not do so well as expected.-ED. L. milk