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GASTRIC ULCER AND THE ULCER EQUATION
1205 oxygen therapy for swallowing of the
respiratory distress. In known or suspected poison, the stomach contents should be washed out as soon as possible. All cases should be kept imperatively at rest, for excitement and exertion may seriously aggravate symptoms. Since P.A.M. actually reverses the cholinesterase inhibition caused by most organophosphorus insecticides, there is a the atropine dosage previously given may then excessive, and cause toxic effects (e.g., mental confusion). This may lead the physician to wrongly believe that
possibility that become
P.A.M. therapy has been ineffective. P.A.M. is only likely to be ineffective in
the
poisoning
due
to
Dr. Sales also criticises the use of albamycin-T on the ground that antibiotic-resistant strains of staphylococci develop. Here he is on firmer ground. As he says, the use of antibiotic combinations as a panacea is to be condemned. But this should not be taken to mean that their use in general practice, in selected cases, and in adequate dosage, is wrong. In my experience this antibiotic combination is safe and reduces hospital admissions of patients with exacerbations of chronic bronchitis, thereby helping the patient and saving monev. O. DE S. PINTO. London, N.6.
certain organophosphorus insecticides (i.e., schradan, dimefox, is no evidence that it is contraindicated in such cases. The chemical nature or name of the particular compound concerned can almost always be found on the label of the container. Information of considerable future value in research could be obtained from cholinesterase determinations on successive blood-samples from patients before and during oxime therapy. Medical Department, Chesterford Park Research Station, Fisons Pest Control Ltd., E. F. EDSON.
’Rogor ’), but there
Saffron Walden, Essex.
GASTRIC ULCER AND THE ULCER EQUATION SiR,łYour discursive leading article last week, which covers 31/2 columns of your valuable space, concludes: " We cannot say, in fact, what defeats the aggressiveness of acid in most people for most of their lives-or, indeed, whether it needs defeating at all." Is it conceivable that the gastric glands produce a substance-hydrochloric acid-which finally succeeds in destroying the glands which secrete it ? Would it not be more logical to abandon the meaningless idea of a locus minoris resistentiae as the associated cause of gastroduodenal ulcer, which is only a way of shifting the difficulty in order to hide a confused state of affairs, rather than to look for some outside factor which in the presence of hydrochloric acid liberates destructive elements which injure the gastric mucous membrane and results in ulcer formation in the strictlv acid-bearins area ? J.-JACQUES SPIRA. London, W.1. ANTIBIOTIC COMBINATIONS
read Dr. Sales’ letter of May 30 in which he continues to criticise the use ofAlbamycin-T ’. I have used this combination of novobiocin and tetracycline in 109 patients suffering from exacerbations of chronic bronchitis.
SiR;,łIwas interested
The
to
2 tablets twelve-hourly for twenty-four hours and then 1 tablet twice a day for a further four days (a tablet contains 125 mg. of each antibiotic). In this small series no patients developed any skin rash and no jaundice
dosage
was
patients complained of slight nausea but stopping treatment and usually disappeared after instructing them to take the tablets with a milky drink. The clinical response was more satisfactory than when tetracycline was used alone and this seems to indicate that adequate amounts were given. In my experifew
was
observed;
this
was never so severe as to warrant
a
ence this combination of antibiotics causes more diarrhoea than tetracycline but this has always responded to a simple kaolin preparation. I have only once seen a skin sensitivity reaction that was probably due to albamycin-T and this was in a child. Dr. Sales quotes Sir Stanley Davidson’s Principles and Practice of Medicine in support of his suggestions that sensitivity reactions to albamycin-T are common. I note that he did not mention the doses recommended by this author. I would add that if standard textbooks were to keep their notes on treatment up to date, new editions would have to be published with uneconomic frequency.
AN OSCILLATING CIRCUIT
Sir,- was interested to see this heading to your leader of May 16 referring to the functions of the basal ganglia. I wrote an article, The C.N.S. is a Living Electrical System -Acceptor Circuits, whose object was to present the problems of the C.N.s. as they would appear to an electronic engineer, viewing the function of the C.N.S. as a matter of electronic
circuits.
No-one, except for
a
few enthusiasts overseas, took the
slightest interest in this aspect of the C.N.S. so it has come as a pleasant surprise to me to find your journal using " oscillating circuit " in one of its leading articles. In 1950 the concept of the C.N.S. as a living electrical system evidently was a little " off beat "; but today I would think that only the museum-minded cling to any alternative outlook. I hope your readers will give further thought to your comment since such a concept opens up a means of understanding the C.N.s. not possible by a mere anatomical or physiological approach. Manor Hospital, Walsall.
KENNETH HAZELL. MITRAL VALVOTOMY
SIR, The remarks by Dr. Lannigan (May 16) concerning my letter of Feb. 14 deserve additional comment. The key questions continue to be (1) what is the clinical significance of the Aschoff body in rheumatic carditis, (2) is the auricular appendage biopsy representative of the process in other areas of the heart, and (3) by what histological criteria shall we define the term active "
rheumatic carditis " ? Dr. Lannigan states that up to 75 % of auricular appendage biopsies " contain inflammatory lesions similar to those of rheumatic carditis". Most pathologists agree that in the absence of the pathognomonic Aschoff body the microscopic diagnosis of rheumatic carditis remains uncertain. Detailed studies of the heart in fatal acute attacks of rheumatic fever have shown that the lesions in the appendage are identical with lesions in the atria, valves, and ventricles. Postmortem examinations of hearts from patients who have expired in the immediate postoperative period has revealed a high correlation between the demonstration of typical Aschoff bodies in the ventricular myocardial stroma and the auricular appendage. The reverse has rarely been true. If the microscopic appendage changes are classified as similar, probable, possible, or Aschofflike, the dilemma becomes compounded and we become locked in an endless battle of semantics. It would appear that the tissue demonstration of the Aschoff body in association with other evidence of active inflammation constitutes for the pathologist the diagnostic constellation of active rheumatic carditis. Whether this means the same thing to the clinician now is open to question because of the appendage biopsy findings in a small proportion of cases. Dr. Lannigan agrees that active or early lesions occur in biopsy specimens but does not accept the standard histological criteria used to define these alterations. Until evidence is presented that other parameters are equally valid and of proven clinicalpathological significance, the classic studies remain valid. All 1. Med. Pr. May 3, 1950.
respiratory distress. In known or suspected poison, the stomach contents should be washed out as soon as possible. All cases should be kept imperatively at rest, for excitement and exertion may seriously aggravate symptoms. Since P.A.M. actually reverses the cholinesterase inhibition caused by most organophosphorus insecticides, there is a the atropine dosage previously given may then excessive, and cause toxic effects (e.g., mental confusion). This may lead the physician to wrongly believe that
possibility that become
P.A.M. therapy has been ineffective. P.A.M. is only likely to be ineffective in
the
poisoning
due
to
Dr. Sales also criticises the use of albamycin-T on the ground that antibiotic-resistant strains of staphylococci develop. Here he is on firmer ground. As he says, the use of antibiotic combinations as a panacea is to be condemned. But this should not be taken to mean that their use in general practice, in selected cases, and in adequate dosage, is wrong. In my experience this antibiotic combination is safe and reduces hospital admissions of patients with exacerbations of chronic bronchitis, thereby helping the patient and saving monev. O. DE S. PINTO. London, N.6.
certain organophosphorus insecticides (i.e., schradan, dimefox, is no evidence that it is contraindicated in such cases. The chemical nature or name of the particular compound concerned can almost always be found on the label of the container. Information of considerable future value in research could be obtained from cholinesterase determinations on successive blood-samples from patients before and during oxime therapy. Medical Department, Chesterford Park Research Station, Fisons Pest Control Ltd., E. F. EDSON.
’Rogor ’), but there
Saffron Walden, Essex.
GASTRIC ULCER AND THE ULCER EQUATION SiR,łYour discursive leading article last week, which covers 31/2 columns of your valuable space, concludes: " We cannot say, in fact, what defeats the aggressiveness of acid in most people for most of their lives-or, indeed, whether it needs defeating at all." Is it conceivable that the gastric glands produce a substance-hydrochloric acid-which finally succeeds in destroying the glands which secrete it ? Would it not be more logical to abandon the meaningless idea of a locus minoris resistentiae as the associated cause of gastroduodenal ulcer, which is only a way of shifting the difficulty in order to hide a confused state of affairs, rather than to look for some outside factor which in the presence of hydrochloric acid liberates destructive elements which injure the gastric mucous membrane and results in ulcer formation in the strictlv acid-bearins area ? J.-JACQUES SPIRA. London, W.1. ANTIBIOTIC COMBINATIONS
read Dr. Sales’ letter of May 30 in which he continues to criticise the use ofAlbamycin-T ’. I have used this combination of novobiocin and tetracycline in 109 patients suffering from exacerbations of chronic bronchitis.
SiR;,łIwas interested
The
to
2 tablets twelve-hourly for twenty-four hours and then 1 tablet twice a day for a further four days (a tablet contains 125 mg. of each antibiotic). In this small series no patients developed any skin rash and no jaundice
dosage
was
patients complained of slight nausea but stopping treatment and usually disappeared after instructing them to take the tablets with a milky drink. The clinical response was more satisfactory than when tetracycline was used alone and this seems to indicate that adequate amounts were given. In my experifew
was
observed;
this
was never so severe as to warrant
a
ence this combination of antibiotics causes more diarrhoea than tetracycline but this has always responded to a simple kaolin preparation. I have only once seen a skin sensitivity reaction that was probably due to albamycin-T and this was in a child. Dr. Sales quotes Sir Stanley Davidson’s Principles and Practice of Medicine in support of his suggestions that sensitivity reactions to albamycin-T are common. I note that he did not mention the doses recommended by this author. I would add that if standard textbooks were to keep their notes on treatment up to date, new editions would have to be published with uneconomic frequency.
AN OSCILLATING CIRCUIT
Sir,- was interested to see this heading to your leader of May 16 referring to the functions of the basal ganglia. I wrote an article, The C.N.S. is a Living Electrical System -Acceptor Circuits, whose object was to present the problems of the C.N.s. as they would appear to an electronic engineer, viewing the function of the C.N.S. as a matter of electronic
circuits.
No-one, except for
a
few enthusiasts overseas, took the
slightest interest in this aspect of the C.N.S. so it has come as a pleasant surprise to me to find your journal using " oscillating circuit " in one of its leading articles. In 1950 the concept of the C.N.S. as a living electrical system evidently was a little " off beat "; but today I would think that only the museum-minded cling to any alternative outlook. I hope your readers will give further thought to your comment since such a concept opens up a means of understanding the C.N.s. not possible by a mere anatomical or physiological approach. Manor Hospital, Walsall.
KENNETH HAZELL. MITRAL VALVOTOMY
SIR, The remarks by Dr. Lannigan (May 16) concerning my letter of Feb. 14 deserve additional comment. The key questions continue to be (1) what is the clinical significance of the Aschoff body in rheumatic carditis, (2) is the auricular appendage biopsy representative of the process in other areas of the heart, and (3) by what histological criteria shall we define the term active "
rheumatic carditis " ? Dr. Lannigan states that up to 75 % of auricular appendage biopsies " contain inflammatory lesions similar to those of rheumatic carditis". Most pathologists agree that in the absence of the pathognomonic Aschoff body the microscopic diagnosis of rheumatic carditis remains uncertain. Detailed studies of the heart in fatal acute attacks of rheumatic fever have shown that the lesions in the appendage are identical with lesions in the atria, valves, and ventricles. Postmortem examinations of hearts from patients who have expired in the immediate postoperative period has revealed a high correlation between the demonstration of typical Aschoff bodies in the ventricular myocardial stroma and the auricular appendage. The reverse has rarely been true. If the microscopic appendage changes are classified as similar, probable, possible, or Aschofflike, the dilemma becomes compounded and we become locked in an endless battle of semantics. It would appear that the tissue demonstration of the Aschoff body in association with other evidence of active inflammation constitutes for the pathologist the diagnostic constellation of active rheumatic carditis. Whether this means the same thing to the clinician now is open to question because of the appendage biopsy findings in a small proportion of cases. Dr. Lannigan agrees that active or early lesions occur in biopsy specimens but does not accept the standard histological criteria used to define these alterations. Until evidence is presented that other parameters are equally valid and of proven clinicalpathological significance, the classic studies remain valid. All 1. Med. Pr. May 3, 1950.