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NEW METHOD OF PHENOBARBITONE ADMINISTRATION
913 the use of potent " drugs "); (2) efficiency of action; (3) simplicity of use; (4) low cost; (5) that the rationale should be capable of convincing translation into a simple story which the patient can appreciate-this I consider most necessary in gaining the patient’s full cooperation. Certain of the hydrophilic colloid group fulfil these criteria admirably and are capable of preparation at low cost in hospital pharmacies. However weight reduction methods are " modish " creatures. treatments " 4 all In 1912 there were at least 24 proprietory of which have fallen by the wayside. Today a dozen or so methods come to mind including 3 or 4 potent drugs, and in the out
"
future
we
shall
no
doubt
meet new
variations of method.
with breast cancer registered between 1930 and 1939 inclusive. Also shown is the percentage of cases placed in clinical stages I and 11 each year. The graph of survival-rate is closely paralleled by that of the clinical staging, and this figure is analogous to that shown in Mr. Bond and Dr. Waterhouse’s letter. The age-distribution of the patients is also relevant in the comparison of different series, yet you make no mention of this point. Even in the absence of this information about the Mayo Clinic series, it would seem that the figures do no more than support the maxim that the apparently good results are mainly, if not wholly, the results of selection.
REGINALD S. MURLEY.
J. N. BADHAM. USE AND TOXICITY OF SULPHONAMIDES SIR,-It is good that Dr. Arneil (April 19) has sounded what I hope will be the death knell of that dangerous
drug, sulphamerazine. It is good, too, that in your annotation you emphasise the value and safety of sulphadimidine. Alas though, too many doctors only know of this drug as ’ Sulphamezathine’ which, to the ear, sounds little different from sulphamerazine. I have often found it necessary, when recommending the use of sulphadimidine, to add the proprietary name by way of explanation. Cannot the manufacturers suggest a way of avoiding this confusion ? Greater prominence of the official B.P. name on their labels would help. BERNARD M. LAURANCE. TREATMENT OF
BREAST
CANCER
SIR,-Mr. Bond and Dr. Waterhouse (Feb. 22) and Dr. George Crile, Jr. (April 5) are correct in implying that " the strong challenge from the Mayo Clinic " is indeed no challenge at all, except perhaps to those folk who seem unable to assess the proper significance of published figures. Your editorial certainly presents the Mayo Clinic figures in somewhat tendentious fashion, and though you find it difficult to compare " figures from the Mayo Clinic and those from Edinburgh " one is glad to see that your correspondents do not experience the same difficulty. The close correlation between survival-rate and the stage of the disease is well brought out in the accompanying figure from a series of 1044 cases seen at St. Bartholomew’s Hospital.5 The figure shows the crude five-year survival-rate for patients 4. More Secret Remedies. British Medical Association, London, 1912. 5. Williams, I. G., Murley, R. S., Curwen, M. P. Brit. med. J. 1953, ii, 787.
1044 cases of breast cancer. Continuous line-5-year-survival rate in all cases registered. Broken line-percentage of cases in clinical stagesI and II.
NEW METHOD OF PHENOBARBITONE ADMINISTRATION SIR,-Although my experience here is limited to "
one
"
hystero-epileptic patient, and a period of four weeks, Dr. Pearson’s (April 19, p. 853) critical comments on Dr. O’Connor’s innovation (March 22, p. 609) prompt me to say that this patient (who over the last two years proved impervious to any form of therapy) has changed beyond recognition since being put on phenobarbitone’Spansules.’ Wyke House Hospital, Isleworth, Middlesex.
H. PULLAR-STRECKER.
FLEXION SPASMS AND CONTRACTURES IN SPINAL-CORD DISEASE SIR,-My interest in the paper by Mr. Platt, Dr. Ritchie
Russell, and Dr. Willison (April 12) prompts me to make the following comments on some of their statements. It is indeed gratifying that clinicians are becoming more and more aware pf the various intrinsic and extrinsic factors that influence spasticity in patients suffering from spinal-cord afflictions, and, in this connection, the beneficial effect of utilising postural reflexes in the counteraction of flexor spasms, as postulated by previous workers, is confirmed by the authors. On the other hand, their sweeping statement that, in cases of spinal-cord disease causing severe paraplegia, a day or two in bed may lead to permanent loss of all capacity to be other than chair-ridden or even bed-fast is, to say the least, exaggerated, if not altogether misleading. Furthermore, I was to read the authors’ criticism of anterior rhizotomy of lumbar and sacral roots for relieving spasticity by claiming that it produces such wasting of gluteal muscles that sitting becomes uncomfortable. This view will hardly be acceptable to neurosurgeons who have had experience with this method, nor is it in accordance with the vast experience gained on patients with conus/cauda-equina lesions or residual paralysis following poliomyelitis. If anterior rhizotomy is contemplated in patients where severe and intractable spasms and contractures of the hip flexors and adductors are predominant, complete atrophy of the gluteal muscles can be avoided by sparing L4 or L5 roots. Judging from the immediate postoperative condition of their third case, following their technique of combined bilateral obturator resection and iliopsoas resection in one session, it is obvious that their procedure is no less formidable and hazardous to the patient than anterior rhizotomy, and anyone contemplating this type of operation would be well advised to carry it out in stages.
surprised
The authors, in the techniques of physical therapy described, have very closely followed the principles and details of treatment introduced and practised during the last 14 years in the National Spinal Injuries Centre, Stoke Mandeville, and have freely used its resources. In their description of their first case, whom I had the opportunity to see myself in consultation, I missed any reference to the remarkable beneficial effects of hydrotherapy in our swimming-pool-not only as an overall training effect but, indeed, in this particular case, as a most efficient method of relieving spasticity. Moreover, this patient is photo-
"
future
we
shall
no
doubt
meet new
variations of method.
with breast cancer registered between 1930 and 1939 inclusive. Also shown is the percentage of cases placed in clinical stages I and 11 each year. The graph of survival-rate is closely paralleled by that of the clinical staging, and this figure is analogous to that shown in Mr. Bond and Dr. Waterhouse’s letter. The age-distribution of the patients is also relevant in the comparison of different series, yet you make no mention of this point. Even in the absence of this information about the Mayo Clinic series, it would seem that the figures do no more than support the maxim that the apparently good results are mainly, if not wholly, the results of selection.
REGINALD S. MURLEY.
J. N. BADHAM. USE AND TOXICITY OF SULPHONAMIDES SIR,-It is good that Dr. Arneil (April 19) has sounded what I hope will be the death knell of that dangerous
drug, sulphamerazine. It is good, too, that in your annotation you emphasise the value and safety of sulphadimidine. Alas though, too many doctors only know of this drug as ’ Sulphamezathine’ which, to the ear, sounds little different from sulphamerazine. I have often found it necessary, when recommending the use of sulphadimidine, to add the proprietary name by way of explanation. Cannot the manufacturers suggest a way of avoiding this confusion ? Greater prominence of the official B.P. name on their labels would help. BERNARD M. LAURANCE. TREATMENT OF
BREAST
CANCER
SIR,-Mr. Bond and Dr. Waterhouse (Feb. 22) and Dr. George Crile, Jr. (April 5) are correct in implying that " the strong challenge from the Mayo Clinic " is indeed no challenge at all, except perhaps to those folk who seem unable to assess the proper significance of published figures. Your editorial certainly presents the Mayo Clinic figures in somewhat tendentious fashion, and though you find it difficult to compare " figures from the Mayo Clinic and those from Edinburgh " one is glad to see that your correspondents do not experience the same difficulty. The close correlation between survival-rate and the stage of the disease is well brought out in the accompanying figure from a series of 1044 cases seen at St. Bartholomew’s Hospital.5 The figure shows the crude five-year survival-rate for patients 4. More Secret Remedies. British Medical Association, London, 1912. 5. Williams, I. G., Murley, R. S., Curwen, M. P. Brit. med. J. 1953, ii, 787.
1044 cases of breast cancer. Continuous line-5-year-survival rate in all cases registered. Broken line-percentage of cases in clinical stagesI and II.
NEW METHOD OF PHENOBARBITONE ADMINISTRATION SIR,-Although my experience here is limited to "
one
"
hystero-epileptic patient, and a period of four weeks, Dr. Pearson’s (April 19, p. 853) critical comments on Dr. O’Connor’s innovation (March 22, p. 609) prompt me to say that this patient (who over the last two years proved impervious to any form of therapy) has changed beyond recognition since being put on phenobarbitone’Spansules.’ Wyke House Hospital, Isleworth, Middlesex.
H. PULLAR-STRECKER.
FLEXION SPASMS AND CONTRACTURES IN SPINAL-CORD DISEASE SIR,-My interest in the paper by Mr. Platt, Dr. Ritchie
Russell, and Dr. Willison (April 12) prompts me to make the following comments on some of their statements. It is indeed gratifying that clinicians are becoming more and more aware pf the various intrinsic and extrinsic factors that influence spasticity in patients suffering from spinal-cord afflictions, and, in this connection, the beneficial effect of utilising postural reflexes in the counteraction of flexor spasms, as postulated by previous workers, is confirmed by the authors. On the other hand, their sweeping statement that, in cases of spinal-cord disease causing severe paraplegia, a day or two in bed may lead to permanent loss of all capacity to be other than chair-ridden or even bed-fast is, to say the least, exaggerated, if not altogether misleading. Furthermore, I was to read the authors’ criticism of anterior rhizotomy of lumbar and sacral roots for relieving spasticity by claiming that it produces such wasting of gluteal muscles that sitting becomes uncomfortable. This view will hardly be acceptable to neurosurgeons who have had experience with this method, nor is it in accordance with the vast experience gained on patients with conus/cauda-equina lesions or residual paralysis following poliomyelitis. If anterior rhizotomy is contemplated in patients where severe and intractable spasms and contractures of the hip flexors and adductors are predominant, complete atrophy of the gluteal muscles can be avoided by sparing L4 or L5 roots. Judging from the immediate postoperative condition of their third case, following their technique of combined bilateral obturator resection and iliopsoas resection in one session, it is obvious that their procedure is no less formidable and hazardous to the patient than anterior rhizotomy, and anyone contemplating this type of operation would be well advised to carry it out in stages.
surprised
The authors, in the techniques of physical therapy described, have very closely followed the principles and details of treatment introduced and practised during the last 14 years in the National Spinal Injuries Centre, Stoke Mandeville, and have freely used its resources. In their description of their first case, whom I had the opportunity to see myself in consultation, I missed any reference to the remarkable beneficial effects of hydrotherapy in our swimming-pool-not only as an overall training effect but, indeed, in this particular case, as a most efficient method of relieving spasticity. Moreover, this patient is photo-