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MEPHENESIN IN RHEUMATISM
1105
giving
full indications of the difficulties likely to be of the precautions needed, and of the type of apparatus (e.g., pipettes) to be used. In discussing these problems a statistical approach essential. Replicate determinations and comparisons , different laboratories yield answers whose random variation is commonly greater than many are willing to admit. B pathologists The suggestion, in your leading article, of a review of these problems is timely and valuable. It is to be hoped that the Association of Clinical Pathologists, in collaboration with the other bodies you mention, will undertake
encountered,
between
the task.
ARTHUR JORDAN. JOltDAN.
Sheffield.
my series it was not necessary to use any other drug to relieve pain, for the response to mephenesin was rapid. When this drug is used in the treatment of patients with neuroses, a suitable barbiturate can be given at the same time. But 2 patients with anxiety neurosis and definite hypertension became decidedly worse when mephenesin was substituted for barbiturates in the treatment of their neuroses. In general, acute cases respond more rapidly than chronic conditions ; but mephenesin appears to be very effective in a variety of fibrositic disorders, and its virtual freedom from toxicity by the oral route makes it suitable for routine use. J. R. B. B.. PECKOVER. Worthing, Sussex.
MEPHENESIN IN RHEUMATISM
CIRCUMCISION OF THE NEWBORN
SIR,—The considerable number of reports recently the toxicity of phenylbutazone the very wide use of this drug in various skeletal complaints unconnected with rheumatoid arthritis, prompt the following comments on the results aohieved with another agent, mephenesin. I used this in between 20 and 30 cases of rheumatic " complaints, which included periarthritis and various forms of "fibrositis" with and without neuritic involvement. The drug was supplied in 0.5 g. tablets as ’Tolserol ’ by E. R. Squibb & Sons.
published regarding (’Butazolidin’), and
"
A woman of 70, suffering from chronic fibrositis, refused continue to take the tablets because they were too big," and was excluded from this group. "
to
All the remaining patients improved considerably within a short period, and the following examples illustrate typical results : A man, aged 46, suffering from acute spasm at the sacroiliac junction, reported much benefit within three to four days and complete relief after one week. A man, aged 50, with acute lumbago and sciatica-like pain in the right leg, was free from symptoms after one week’s treatment. A housewife, aged 32, who had suffered from chronic low backache for six or seven years, with exacerbation following the birth of a child two years ago, had complete remission within two days. A woman, aged about 50, with chronic fibrositis, mainly of the trapezius, and some low back pain of five years’ standing, was able to look over both shoulders after four days’ treatment, although she had been unable to do this for about
five years.
A woman, aged 40, with anxiety neurosis and chronic fibrositis of the shoulder, was much relieved within four days.
Greater improvement resulted when treatment with methylphenobarbitone was combined with mephenesin, though the
barbiturate caused
some feeling of lassitude. A woman, aged 40, with a history of sciatica following a divorce five years ago, had a second attack thought to be due to a domestic disturbance in August, 1952. She had been admitted to hospital where a prolapsed intervertebral disc was diagnosed, although not shown by X-ray examination. She had sciatica of the right leg and severe sacro-iliac spasm but no clinical evidence of prolapsed disc. After four days’ mephenesin, she was able to walk naturally, but full therapeutic response necessitated the administration of 6 g. daily for sixteen days. .
The
optimum daily
dose
was
usually
4-6 g.,
Most
patients responded satisfactorily within days, and in severe chronic cases, where there may be a tendency for the symptoms to recur, it would probably be advisable to give periodic short courses as necessary, rather than to prolong treatment in the hope of permanently eradicating the disease. 2 patients had very slight vertigo, but no
from
two to.
seven
encountered, in the
treated
other toxic effects were aith tolserol. mephenesin is a muscle relaxant and its blocking action breaks the spasm-pain cycle, but the drug does not appear to have any direct analgesic effect ; but in cases
concerning bleeding from haemorrhagic disease of the newborn following immediate circumcision—and indeed haemorrhage due to other causes after this operation-is answered by the work of Miller and Snyder.l They advocate operation only upon normal, healthy, full-term infants. In their series no babies with icterus, erythroblastosis, or purpura were circumcised : the rhesus state of the mother had previously been determined ; and they were able to show, from a study of 700 bleeding and coagulation times taken after delivery, that there was no inherent defect of the clotting mechanism at birth. Postoperative bleeding was of import in 0.3% of the children and was due to faulty technique. Dr. Morris’s suggestion that circumcision was delayed until the eighth day of life because of the dangers of bleeding finds confirmation in the writings of Maimonides2 and also in the Talmud.3 But haemorrhage itself would have been no deterrent to the ritual, rather the reverse, for the shedding of blood was of significance4 and was often all that was demanded. The age at which circumcision is done varies so much throughout the world and is so connected with the origins of the act that (even excluding savage races and manhood-initiation ages) no one reason can be given. Among the Jews the eighth day was chosen, for in the first week of life neither animal nor man could be offered to God.5 6 In people of other sects or cultures, circumcision might be at the end of the seventh day of life, as in the Falashas, in the first month among the Southwestern Arabs, in the second month among the Mazequas, in the third year among the Persian Mohammedans, or in the seventh year among the Christian Copts.7 The Arabs circumcised when the child was 13, for at that age Ishmael was thus operated upon. Some Islamite tribes performed the rite when the child was old enough to be able to quote religious tracts or profess his faith, and others when the boy was at an age (variously and curiously defined) of reason. THOMAS MARMION. Benenden, Kent.
Public Health Smallpox
given
iu divided doses every four hours, except during the
llight.
SIR,—The question raised by Dr. Morris (May 2)
No further cases have been reported from Lancashire and the West Riding where the outbreak of smallpox has so far involved 30 people, 8 of whom have died. A fortnight has now gone by without a new case. At the Chesterfield Royal Hospital, Derbyshire, precautions have been taken pending the result of investigations into the death of a 19-year-old youth on May 24.8 1. 2. 3. 4. 5. 6. 7.
Miller, R. L., Snyder, D. C. Amer. J. Obstet. Gynec. 1953, 65, 1. Moussa Ben Maimon. On Circumcision. I. Talmud. Jebamoth. 646. Leviticus, XVII, 11. Genesis, XVII, x-xii. Leviticus, XXII, xxvii. Edited by I. Singer. Jewish Encyclopedia. vol. IV, p. 97.
8. Manchester Guardian,
May 26, 1953.
London, 1904;
giving
full indications of the difficulties likely to be of the precautions needed, and of the type of apparatus (e.g., pipettes) to be used. In discussing these problems a statistical approach essential. Replicate determinations and comparisons , different laboratories yield answers whose random variation is commonly greater than many are willing to admit. B pathologists The suggestion, in your leading article, of a review of these problems is timely and valuable. It is to be hoped that the Association of Clinical Pathologists, in collaboration with the other bodies you mention, will undertake
encountered,
between
the task.
ARTHUR JORDAN. JOltDAN.
Sheffield.
my series it was not necessary to use any other drug to relieve pain, for the response to mephenesin was rapid. When this drug is used in the treatment of patients with neuroses, a suitable barbiturate can be given at the same time. But 2 patients with anxiety neurosis and definite hypertension became decidedly worse when mephenesin was substituted for barbiturates in the treatment of their neuroses. In general, acute cases respond more rapidly than chronic conditions ; but mephenesin appears to be very effective in a variety of fibrositic disorders, and its virtual freedom from toxicity by the oral route makes it suitable for routine use. J. R. B. B.. PECKOVER. Worthing, Sussex.
MEPHENESIN IN RHEUMATISM
CIRCUMCISION OF THE NEWBORN
SIR,—The considerable number of reports recently the toxicity of phenylbutazone the very wide use of this drug in various skeletal complaints unconnected with rheumatoid arthritis, prompt the following comments on the results aohieved with another agent, mephenesin. I used this in between 20 and 30 cases of rheumatic " complaints, which included periarthritis and various forms of "fibrositis" with and without neuritic involvement. The drug was supplied in 0.5 g. tablets as ’Tolserol ’ by E. R. Squibb & Sons.
published regarding (’Butazolidin’), and
"
A woman of 70, suffering from chronic fibrositis, refused continue to take the tablets because they were too big," and was excluded from this group. "
to
All the remaining patients improved considerably within a short period, and the following examples illustrate typical results : A man, aged 46, suffering from acute spasm at the sacroiliac junction, reported much benefit within three to four days and complete relief after one week. A man, aged 50, with acute lumbago and sciatica-like pain in the right leg, was free from symptoms after one week’s treatment. A housewife, aged 32, who had suffered from chronic low backache for six or seven years, with exacerbation following the birth of a child two years ago, had complete remission within two days. A woman, aged about 50, with chronic fibrositis, mainly of the trapezius, and some low back pain of five years’ standing, was able to look over both shoulders after four days’ treatment, although she had been unable to do this for about
five years.
A woman, aged 40, with anxiety neurosis and chronic fibrositis of the shoulder, was much relieved within four days.
Greater improvement resulted when treatment with methylphenobarbitone was combined with mephenesin, though the
barbiturate caused
some feeling of lassitude. A woman, aged 40, with a history of sciatica following a divorce five years ago, had a second attack thought to be due to a domestic disturbance in August, 1952. She had been admitted to hospital where a prolapsed intervertebral disc was diagnosed, although not shown by X-ray examination. She had sciatica of the right leg and severe sacro-iliac spasm but no clinical evidence of prolapsed disc. After four days’ mephenesin, she was able to walk naturally, but full therapeutic response necessitated the administration of 6 g. daily for sixteen days. .
The
optimum daily
dose
was
usually
4-6 g.,
Most
patients responded satisfactorily within days, and in severe chronic cases, where there may be a tendency for the symptoms to recur, it would probably be advisable to give periodic short courses as necessary, rather than to prolong treatment in the hope of permanently eradicating the disease. 2 patients had very slight vertigo, but no
from
two to.
seven
encountered, in the
treated
other toxic effects were aith tolserol. mephenesin is a muscle relaxant and its blocking action breaks the spasm-pain cycle, but the drug does not appear to have any direct analgesic effect ; but in cases
concerning bleeding from haemorrhagic disease of the newborn following immediate circumcision—and indeed haemorrhage due to other causes after this operation-is answered by the work of Miller and Snyder.l They advocate operation only upon normal, healthy, full-term infants. In their series no babies with icterus, erythroblastosis, or purpura were circumcised : the rhesus state of the mother had previously been determined ; and they were able to show, from a study of 700 bleeding and coagulation times taken after delivery, that there was no inherent defect of the clotting mechanism at birth. Postoperative bleeding was of import in 0.3% of the children and was due to faulty technique. Dr. Morris’s suggestion that circumcision was delayed until the eighth day of life because of the dangers of bleeding finds confirmation in the writings of Maimonides2 and also in the Talmud.3 But haemorrhage itself would have been no deterrent to the ritual, rather the reverse, for the shedding of blood was of significance4 and was often all that was demanded. The age at which circumcision is done varies so much throughout the world and is so connected with the origins of the act that (even excluding savage races and manhood-initiation ages) no one reason can be given. Among the Jews the eighth day was chosen, for in the first week of life neither animal nor man could be offered to God.5 6 In people of other sects or cultures, circumcision might be at the end of the seventh day of life, as in the Falashas, in the first month among the Southwestern Arabs, in the second month among the Mazequas, in the third year among the Persian Mohammedans, or in the seventh year among the Christian Copts.7 The Arabs circumcised when the child was 13, for at that age Ishmael was thus operated upon. Some Islamite tribes performed the rite when the child was old enough to be able to quote religious tracts or profess his faith, and others when the boy was at an age (variously and curiously defined) of reason. THOMAS MARMION. Benenden, Kent.
Public Health Smallpox
given
iu divided doses every four hours, except during the
llight.
SIR,—The question raised by Dr. Morris (May 2)
No further cases have been reported from Lancashire and the West Riding where the outbreak of smallpox has so far involved 30 people, 8 of whom have died. A fortnight has now gone by without a new case. At the Chesterfield Royal Hospital, Derbyshire, precautions have been taken pending the result of investigations into the death of a 19-year-old youth on May 24.8 1. 2. 3. 4. 5. 6. 7.
Miller, R. L., Snyder, D. C. Amer. J. Obstet. Gynec. 1953, 65, 1. Moussa Ben Maimon. On Circumcision. I. Talmud. Jebamoth. 646. Leviticus, XVII, 11. Genesis, XVII, x-xii. Leviticus, XXII, xxvii. Edited by I. Singer. Jewish Encyclopedia. vol. IV, p. 97.
8. Manchester Guardian,
May 26, 1953.
London, 1904;