NEW TREATMENT FOR PRIAPISM

220 cumulative doses of mitoxantrone become available, caution is clearly required, particularly when doxorubicin has previously been used. We are unable to suggest strict criteria for withdrawal of mitoxantrone in patients with significant falls in ejection fraction estimations on serial radionuclide cardiac scans, or to recommend confidently a maximum cumulative dose for mitoxantrone. Nevertheless, we would urge caution with mitoxantrone in cumulative doses of more than 140 mg/m2, and possibly at even lower doses in patients heavily pretreated with doxorubicin. R. STUART-HARRIS* M. PEARSON I. E. SMITH

Royal Marsden Hospital, London SW 3 6JJ National Heart London W1

Hospital,

*Present address:

E. G. J. OLSEN Ludwig

Institute of Cancer Research,

Um versify of Sydney, Australia

R, Smith IE. Mitoxantrone. A phase II study in the treatment of patients with advanced breast cancer and other solid tumours. Cancer Chemother Pharmacol 1982; 8: 179-82. 2. Stuart-Harris RC, Bozek T, Pavlidis NA, Smith IE. Mitoxantrone. An active new agent in the treatment of advanced breast cancer. Cancer Chemother Pharmacol 1984 ; 12: 1-4 3. Henderson BM, Dougherty WJ, James VC, Tilley LP, Noble JF. Safety assessment ofaa new anti-cancer compound, mitoxantrone, m beagle dogs compared with h doxorubicin 1: Clinical observations. Cancer Treat Rep 1982; 66: 1145-58. 4. Schell SC, Yap HY, Blumenschein G, Valdivieso M, Bodey G. Potential cardiotoxicity with mitoxantrone. Cancer Treat Rep 1982; 66: 1641-43. 5. Pratt CB, Crom DB, Wallenberg J, Sanyal SE, Miliauskos J, Sohlberg K. Fatal congestive heart failure following mitoxantrone treatment in two children previously treated with doxorubicin and cisplatin. Cancer Treat Rep 1983; 67: 85-86. 6. Unverferth DV, Unverferth BJ, Balcerzak SP, Bashore TA, Neidhart JA. Cardiac evaluation ofmitoxantrone. Cancer Treat Rep 1983, 67 : 343-50. 1. Sluart-Harns

LEFT

LATERAL, PLEASE

S’R,—I have long marvelled at the widespread use of the supine position for gynaecological examination. As a student at University College Hospital in 1950 I was taught by the late and beloved "Tim" Flew always to use the left lateral (modified Sims’) position both for bimanual and speculum examination. Since then, as the advertisements say, "I have used no other" and I have tried to pass on this message to successive generations of medical students, evidently to little avail. Over many years of examining for finals and the MRCOG I have rarely met a candidate who chooses the left lateral position in preference to the supine or a fellow examiner who shares my views. It is unedifying and sometimes excruciating to observe examination candidates struggling to expose the cervix with a bivalve (Cusco) speculum, its corrugated handle (with screw and

ratchet) being pressed ever more firmly against the highly sensitive urethra, clitoris, and mons pubis

as the blades are widened. Contrast this with the gentleness and comparative delicacy of the left lateral position. The patient can lie comfortably on her side. She does not need to abduct her thighs and can remain minimally exposed. The speculum can be passed with ease and elegancehandle rearwards so that the pressure of the widening blades is exerted against the less sensitive posterior vaginal wall and perineum. Besides routine inspection and the taking of smears, this position allows excellent access for minor procedures such as cryocautery and insertion of contraceptive devices. For such manoeuvres the necessary screwing open of the speculum is far less traumatic than if the handle is anterior when it is all too easy to entangle pubic hair in the mechanism. Medical students are usually initiated into the skills of bimanual examination in the operating room whilst their patient is undergoing a dilatation and curettage. It is undoubtedly easier to grasp the basics with the patient in this dorsal position, but there is no good reason why digital pelvic examination in the conscious patient should not be done with the patient lying on her left side, and the effort required to translate supine into lateral thinking will be amply repaid. When learned, palpation of the pelvic organ is just as efficient and, more importantly, a rectal examination-too often omitted by gynaecologists-may be done as well. It is rare indeed to meet a patient who would not prefer to be examined lying on her left side rather than flat on her back with her "heels together and knees

apart".

In advance of a more formal poll of my gynaecological colleagues up and down the country I am firing this missive as a preliminary shot in a campaign for a return to laterality-and, incidentally, issuing an invitation for a supine reply. St

George’s Hospital, London SW 170QT

A. G. AMIAS

NEW TREATMENT FOR PRIAPISM

SIR,-During experiments that led to the treatment of erectile impotence by cavernosal alpha blockade, 1,2 I tried on myself the intracavernosal injection of the alpha-adrenoceptor-stimulating drug metaraminol. The smallest dose tried (0-44 mg) caused conspicuous shrinkage of the penis lasting its hours. During this time it was difficult, but not impossible, to obtain a psychogenic or reflex erection. 0 - 6, 1-0, and 1 - 5 mg had similar but not obviously greater effects. The largest dose was followed by palpitation and slight tremor of the hands lasting about 5 min. No side-effects were noticed after the smaller doses. These observations made it seem likely that intracavernosal injection of metaraminol might be useful in treating priapism. The condition treated was iatrogenic priapism, lasting at least 15 h. It occurred in four impotent men after they had been treated by intracavernosal injection of drugs that relax smooth muscle, 1-3 and in the author after an experiment. The four impotent patients (A, C, D, and E) are aged 64, 43, 59 and 45, respectively. All of them when first seen complained of difficulty in achieving erection and incompleteness of erection when achieved. All said they sometimes woke with an erection, though far less often in the past few years than in youth. Patients A, C and D have no known organic disease likely to cause impotence. The author (B) is aged 58, is healthy, and can achieve full erection easily. Patient E is an insulin-dependent diabetic who has partial sensory loss in his feet. The sensory loss and impotence began 14 years ago and have been stationary for 13 years. Patient A had three episodes of priapism after intracavernosal injections of phenoxybenzamine. Five other injections in the same range of dosage had been followed by painless full erections lasting 2-6 h. The author (B) had one episode of priapism after intracavernosal injection of phenoxybenzamine. Eleven earlier and two subsequent injections of 3-6 mg of phenoxybenzamine have been followed by painless full erections lasting 2-5 h. Patient C had one episode of priapism after a self-administered intracavernosal injection of an unknown and probably large dose of phenoxybenzamine. Three earlier and eight subsequent injections of 3, 4, or 5 mg phenoxybenzamine have been followed by painless full erections lasting 2-5 h. Patients D and E each had one episode of priapism after intracavernosal injection of papaverine. Treatment consisted of withdrawing 20-70 ml of blood from a corpus cavernosum, injecting 0-8-3 mg metaraminol (0-08-0-33 ml of aramine injection), and massaging the penis for about 30 s in an attempt to distribute the drug throughout both corpora cavernosa. The withdrawal of blood always eased the pain; the

massaging was always painful. The results are shown in the table. The first episode of priapism in patient A and its treatment have been briefly mentioned in an earlier publications"Definite improvement" means a decrease in rigidity of the penis obviously greater than that caused immediately by the withdrawal of blood. In the second and third episodes of priapism suffered by patient A, three treatments were given, an hour or more apart. Patients A to D now have erections approximately as good as they had before the episodes of priapism. Patient C continues to treat his erectile impotence by cavernosal alpha-blockade, successfully. Patients A and D have abandoned this treatment. In patient A on March 4, 1983, it seems likely that the recovery at 23 hours owed nothing to the treatment given 3 hours earlier. If this was a spontaneous recovery, the other recoveries could conceivably have been spontaneous, but it would be a surprising coincidence if in subjects B, C, and D the erection, having lasted unchanged for 15, 23 and 31 h, showed spontaneous definite decrease within 10, 35 and 30 min of treatment. For patient E the matter is even clearer. Priapism that had lasted for 40 h was

221 EFFECTS OF METARAMINOL ON IATROGENIC PRIAPISM

*Bo definite improvement.

conspicuously improved in 7 min and entirely relieved in 16 min. Priapism due to drugs acting at or distal to the alphaadrenoceptors may be actually less favourable for treatment by metaraminol than priapism of other kinds. The aim of treatment is to activate trabecular and arteriolar smooth muscle,2 and if every intracavernosal alpha-adrenoceptor site were blocked by phenoxybenzamine, or if every intracavernosal smooth muscle cell were wholly poisoned by papaverine, the metaraminol could presumably do nothing. This may be the reason for the failure of the first two treatments of patient A on Oct 6 and Nov 2, 1983; one must wait for some alpha-adrenoceptor sites to regenerate before the drug can act. This treatment seems worth trial in other forms of priapism. A dose of 2 mg may be effective. If not, it can safely be repeated an

diarrhoea. There were 232 family members, 155 of whom were free of diarrhoea and were negative for cryptosporidial oocysts during the diarrhoea episodes of their counterparts with diarrhoea. All 7 oocyst-positive family contacts were associated with 2 oocystpositive animal attendants. The study shows that animal attendants on this Bangladesh farm were at high risk of diarrhoea and suggests that cryptosporidiosis was transmitted from calves to human contacts. The clustering of cryptosporidiosis in two families of oocyst-positive animal attendants suggests human-to-human transmission. Other publications support these possibilities. 4-6

hour later. Department of Physiology, Institute of Psychiatry,

G. S. BRINDLEY

London SE58AF

International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka-2, Bangladesh 1.

GS Cavernosal alpha-blockade a new technique for investigating and treating erectile impotence. Br J Psychiatry 1983; 143: 332-37 Brindley GS. Cavernosal alpha-blockade and human penile erection. J Physiol 1983; 342: 24P. Virag R, Frydman D, Legman M, Virag H Intracavernous injection ofpapaverine as a diagnostic and therapeutic method in erectile failure Angiology 1984, 35: 79-87.

1 Brindley 2 3

CRYPTOSPORIDIOSIS IN CALVES AND THEIR HANDLERS IN BANGLADESH

A. S. M. H. RAHAMAN S. C. SANYAL K. A. AL-MAHMUD A. SOBHAN K. S. HOSSAIN B. C. ANDERSON

Højlyng N, Molbak K, Jepsen S. Cryptosporidiosis in Liberian children. Lancet 1984;

i 734. 2. Anderson BC, Hall RF Cryptosporidial infection in Idaho dairy calves. J Am Vet Med Assoc 1982, 181: 484 3. Schultz MG. Emerging zoonoses. N Engl J Med 1983; 308: 1285-86. 4. Current WL, Reese NC, Ernst JV, et al. Human cryptosporidiosis in immunocompetent and immunodeficient persons. N Engl J Med 1983; 308; 1252-57. 5. Anderson BC. Cryptosporidiosis in a veterinary student. J Am Vet Med Assoc 1982; 180: 408-09 6. Baxby D, Hart CA, Taylor C. Human cryptosporidiosis: a possible case of hospital cross infection. Br Med J 1983; 287: 1760-61.

SIR,-Hdjlyng and colleagues’ have suggested that cryptosporidiosis is a more significant problem in developing than in developed countries. We assume that the suggestion did not encompass animals; in the US dairy State of Idaho up to 67% of dairies have calves with cryptosporidiosis, and it is difficult to find dairies without cryptosporidial infections (in calves) in some of the well-developed parts of the south-eastern United States. Our study of cryptosporidial infection, both human and animal, in Bangladesh supports the contention that cryptosporidiosis is an emerging

zoonosis.3,4 The study was done between December, 1982, and November, 1983, at a dairy farm at Savar. Calves, their attendants, and family members of attendants

were

examined. Faecal

smears were

stained

by a standard Giemsa method. 14% of 208 1-28-day-old calves with diarrhoea were positive while only 1% of 202 age-matched calves without diarrhoea were positive. Most positive calves were 7-21 days old and most cases of cryptosporidiosis were detected in the warm, wet season (August and September) (figure). Animal handlers and their families were studied from August to December, the highest proportion of cryptosporidial cases being detected in August and September. All 88 animal attendants had diarrhoea during this period and 7 of them had cryptosporidial oocysts in their stool smears. An additional 7 Cryptosporidiumpositive smears were found amongst 77 family members with

Frequency (by mouth)

of

specimens of dairy calves.

Cryptosporidium oocysts in faecal