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LIVER EXTRACTS
369
resistance, but I would only call a case resistant after repeated courses of intravenous urea stibamine and lack of response to stilbamidine ; and I have seen no case that would not respond to one or other of these lines of therapy. Nelson, New Zealand.
R. L. HAVILAND MINCHIN.
LIVER EXTRACTS
SiR,-I have followed with great interest the discussion in your columns initiated by Dr. McSorley with his letter of Jan. 22. In Norway our experience is similar, though here the difference between single batches is not so great, as we still are fortunate enough to have access to fresh frozen calf-liver as a starting-material. As I have pointed out,the sort of liver from which the extracts are prepared is important-a fact underlined in experiments by Laland and myself (unpublished) with extracts made from pigs’ livers by a method based on that of Laland and Klem.2 For three years in succession we have observed that hog-liver gave active extracts only during the summer and autumn months, while liver from pigs given " winter food " was inactive or pretty nearly so. Whether the same is true also of liver derived from other animals I do not know ; at least the phenomenon has never been observed with calf-liverour usual raw material. Experience in this country (Thjotta and Jonson, personal communication) with Lactobacilhcs lactis Dorner as a means of assaying anti-pemicious-ansemia potency is akin to that reported by Dr. Shaw (Feb. 5). JENS DEDICHEN. University of Oslo. GUM-SALINE
Sin,—During the use of 6 % for intravenous
the 1914-18 war Bayliss introduced gum-acacia in normal saline as a fluid use
in the treatment of shock and hoemor-
rhage ; and by the end of that war the clinical efficacy, the safety, and the convenience of the fluid were proved. Thereafter gum-saline was widely administered, and, in with many other clinicians who have used it extensively, I have no doubt about its efficacy in restoring blood-volume or about its freedom from serious drawbacks. Early in the late war plasma was introduced as a fluid to restore blood-volume ; and for a number of reasons gum-saline was soon forgotten, though never found unsatisfactory. I have always regretted the popular change from gum-saline to plasma : firstly because I have never seen any clinical evidence that gum-saline is less effective than plasma in rapidly restoring and maintaining blood-volume ; secondly because from experience I have come to regard gum-saline as safe ; and thirdly because on theoretical grounds the potentialities of undesirable (though as yet unknown) results from the use of protein intravenously are vastly greater than those from the use of simpler chemical substances such as gum-acacia. Recently bottles of plasma have been supplied with a warning notice attached. The warning must be familiar to all, but the first paragraph is short enough for quotation. It runs : common
To the Doctor in Charge. Dried plasma is thought to transmit hepatitis in up tb 10% of those transfused. The disease may not manifest itself until three or more months after transfusion, and, while usually mild, may be fatal."
" Important.
or dried
serum
I am at a loss to understand how anyone can offer for human consumption a fluid with such potentialities. It is not a good enough answer to say " you have been warned." Anyone who has worked with modern intravenous-minded doctors must know that a plentiful of an intravenous fluid conveniently packed is sufficient invitation to ensure its use. If it is as poisonous as the label on the bottle suggests (and indeed it may be worse), it ought never to be distributed for
supply
general use. My own remedy for the situation seemed at first sight very simple-to forbid the use of plasma in all patients 1. C.R. 20e Congrès de Médicine Interne des Pays du Nord, Réuni à Gottenbourg du 27 au 29 Juin, 1946. Helsingfors, 1948; P. 313. 2. Laland, P., Klem, A. Acta med. scand. 1936, 88, 620.
for whom I had clinical responsibility, and to insist that gum-saline should be used, since I knew the latter to be both effective and safe. But I had not reckoned with one other essential-that the gum-saline should be readily available. I am now astonished to find the greatest difficulty in obtaining supplies. Well-known manufacturers of the highest repute and enterprise who used to supply gum-saline, no longer make it and One such manuappear to be unwilling to start again. facturer expressed the greatest surprise that anyone still had a use for it. Possibly trials with new substances such as dextran may produce a fluid which is superior even to - gumsaline ; but in the meantime let us at least be allowed to buy what has for thirty years proved a safe, effective, and sometimes life-saving fluid. If my letter to you, Sir, stimulates enough others to ask for gum-saline, manufacturers may be persuaded to
suppiy it again. London, W.1.
G. F. GIBBERD.
MESENTERIC ADENITIS
SiR,—In connexion with Mr. ]Elickinbotharn’s letter of Feb. 5, I should like to report a case seen by me last year. A male infant, aged 22 months, had a 3-day history typical of intussusception-the passage of blood per rectum, and quiescent periods interspersed with bouts of crying out in pain. On examination there was an indefinite, sausage-shaped tumour on the left of the abdomen, and per rectum there was blood and mucus. A paramedian exploration revealed some thin bloodstained fluid in the peritoneal cavity, the entire mesentery studded with enlarged glands typical of nonspecific mesenteric adenitis, the whole length of the small bowel remarkably spastic and collapsed, and two easily reducible entero-enteric intussusceptions-one about 2 ft. from the ileocaecal valve and the other 2 ft. from the duodenojejunal flexure.
It seemed possible that these numerous glands were irritating the autonomic nerves in the mesentery, thus producing a spastic condition of the bowel and painful self-reducing intussusceptions. It would be interesting to note the state of the mesenteric glands in cases of ileocolic intussusception. T"T
City General Hospital,
.
T-. -
F. V. A. Bosc. --
Stoke-on-Trent.
DENTAL
CONDITIONS IN PULMONARY TUBERCULOSIS SiR,-Correlation of dental conditions with systemic disease is a field which has often been neglected. We would like to stress the possibilities of closer cooperation between the chest physician and dental surgeon in the assessment and treatment of pulmonary tuberculosis. In 1937 the Borough of Southwark opened a dental clinic in the tuberculosis dispensary, and as a result the chest physician and the dental surgeon, each of whom was interested in the other’s work, were able to make parallel observations on the oral condition and the progress of the lung disease. It soon became apparent that dental caries was frequently seen in association with active tuberculosis even during the immune period (25-40). After further observations it was found possible to divide our findings into six main groups : 1. Active caries in newly diagnosed cases with active lung disease. 2. Active caries in treated cases which have become quiescent, coinciding with reactivation of the lung disease. 3. Active caries with evidence of old paradental disease in new cases with evidence of widespread lung damage and
relatively
recent symptoms. 4. Paradental disease in a new case coinciding with widespread pulmonary disease with very few symptoms. 5. Paradental disease in treated cases of long standing showing a marked tendency to chronicity or arrest. 6. The gradual onset of paradental symptoms with quiescence of the dental caries as the active lung lesion becomes controlled. This is particularly noticeable in cases treated by
collapse therapy. Thus it will be seen that we have in a well-informed opinion on the oral condition a useful pointer to the
resistance, but I would only call a case resistant after repeated courses of intravenous urea stibamine and lack of response to stilbamidine ; and I have seen no case that would not respond to one or other of these lines of therapy. Nelson, New Zealand.
R. L. HAVILAND MINCHIN.
LIVER EXTRACTS
SiR,-I have followed with great interest the discussion in your columns initiated by Dr. McSorley with his letter of Jan. 22. In Norway our experience is similar, though here the difference between single batches is not so great, as we still are fortunate enough to have access to fresh frozen calf-liver as a starting-material. As I have pointed out,the sort of liver from which the extracts are prepared is important-a fact underlined in experiments by Laland and myself (unpublished) with extracts made from pigs’ livers by a method based on that of Laland and Klem.2 For three years in succession we have observed that hog-liver gave active extracts only during the summer and autumn months, while liver from pigs given " winter food " was inactive or pretty nearly so. Whether the same is true also of liver derived from other animals I do not know ; at least the phenomenon has never been observed with calf-liverour usual raw material. Experience in this country (Thjotta and Jonson, personal communication) with Lactobacilhcs lactis Dorner as a means of assaying anti-pemicious-ansemia potency is akin to that reported by Dr. Shaw (Feb. 5). JENS DEDICHEN. University of Oslo. GUM-SALINE
Sin,—During the use of 6 % for intravenous
the 1914-18 war Bayliss introduced gum-acacia in normal saline as a fluid use
in the treatment of shock and hoemor-
rhage ; and by the end of that war the clinical efficacy, the safety, and the convenience of the fluid were proved. Thereafter gum-saline was widely administered, and, in with many other clinicians who have used it extensively, I have no doubt about its efficacy in restoring blood-volume or about its freedom from serious drawbacks. Early in the late war plasma was introduced as a fluid to restore blood-volume ; and for a number of reasons gum-saline was soon forgotten, though never found unsatisfactory. I have always regretted the popular change from gum-saline to plasma : firstly because I have never seen any clinical evidence that gum-saline is less effective than plasma in rapidly restoring and maintaining blood-volume ; secondly because from experience I have come to regard gum-saline as safe ; and thirdly because on theoretical grounds the potentialities of undesirable (though as yet unknown) results from the use of protein intravenously are vastly greater than those from the use of simpler chemical substances such as gum-acacia. Recently bottles of plasma have been supplied with a warning notice attached. The warning must be familiar to all, but the first paragraph is short enough for quotation. It runs : common
To the Doctor in Charge. Dried plasma is thought to transmit hepatitis in up tb 10% of those transfused. The disease may not manifest itself until three or more months after transfusion, and, while usually mild, may be fatal."
" Important.
or dried
serum
I am at a loss to understand how anyone can offer for human consumption a fluid with such potentialities. It is not a good enough answer to say " you have been warned." Anyone who has worked with modern intravenous-minded doctors must know that a plentiful of an intravenous fluid conveniently packed is sufficient invitation to ensure its use. If it is as poisonous as the label on the bottle suggests (and indeed it may be worse), it ought never to be distributed for
supply
general use. My own remedy for the situation seemed at first sight very simple-to forbid the use of plasma in all patients 1. C.R. 20e Congrès de Médicine Interne des Pays du Nord, Réuni à Gottenbourg du 27 au 29 Juin, 1946. Helsingfors, 1948; P. 313. 2. Laland, P., Klem, A. Acta med. scand. 1936, 88, 620.
for whom I had clinical responsibility, and to insist that gum-saline should be used, since I knew the latter to be both effective and safe. But I had not reckoned with one other essential-that the gum-saline should be readily available. I am now astonished to find the greatest difficulty in obtaining supplies. Well-known manufacturers of the highest repute and enterprise who used to supply gum-saline, no longer make it and One such manuappear to be unwilling to start again. facturer expressed the greatest surprise that anyone still had a use for it. Possibly trials with new substances such as dextran may produce a fluid which is superior even to - gumsaline ; but in the meantime let us at least be allowed to buy what has for thirty years proved a safe, effective, and sometimes life-saving fluid. If my letter to you, Sir, stimulates enough others to ask for gum-saline, manufacturers may be persuaded to
suppiy it again. London, W.1.
G. F. GIBBERD.
MESENTERIC ADENITIS
SiR,—In connexion with Mr. ]Elickinbotharn’s letter of Feb. 5, I should like to report a case seen by me last year. A male infant, aged 22 months, had a 3-day history typical of intussusception-the passage of blood per rectum, and quiescent periods interspersed with bouts of crying out in pain. On examination there was an indefinite, sausage-shaped tumour on the left of the abdomen, and per rectum there was blood and mucus. A paramedian exploration revealed some thin bloodstained fluid in the peritoneal cavity, the entire mesentery studded with enlarged glands typical of nonspecific mesenteric adenitis, the whole length of the small bowel remarkably spastic and collapsed, and two easily reducible entero-enteric intussusceptions-one about 2 ft. from the ileocaecal valve and the other 2 ft. from the duodenojejunal flexure.
It seemed possible that these numerous glands were irritating the autonomic nerves in the mesentery, thus producing a spastic condition of the bowel and painful self-reducing intussusceptions. It would be interesting to note the state of the mesenteric glands in cases of ileocolic intussusception. T"T
City General Hospital,
.
T-. -
F. V. A. Bosc. --
Stoke-on-Trent.
DENTAL
CONDITIONS IN PULMONARY TUBERCULOSIS SiR,-Correlation of dental conditions with systemic disease is a field which has often been neglected. We would like to stress the possibilities of closer cooperation between the chest physician and dental surgeon in the assessment and treatment of pulmonary tuberculosis. In 1937 the Borough of Southwark opened a dental clinic in the tuberculosis dispensary, and as a result the chest physician and the dental surgeon, each of whom was interested in the other’s work, were able to make parallel observations on the oral condition and the progress of the lung disease. It soon became apparent that dental caries was frequently seen in association with active tuberculosis even during the immune period (25-40). After further observations it was found possible to divide our findings into six main groups : 1. Active caries in newly diagnosed cases with active lung disease. 2. Active caries in treated cases which have become quiescent, coinciding with reactivation of the lung disease. 3. Active caries with evidence of old paradental disease in new cases with evidence of widespread lung damage and
relatively
recent symptoms. 4. Paradental disease in a new case coinciding with widespread pulmonary disease with very few symptoms. 5. Paradental disease in treated cases of long standing showing a marked tendency to chronicity or arrest. 6. The gradual onset of paradental symptoms with quiescence of the dental caries as the active lung lesion becomes controlled. This is particularly noticeable in cases treated by
collapse therapy. Thus it will be seen that we have in a well-informed opinion on the oral condition a useful pointer to the