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PÆDIATRIC GASTROSCOPY
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give an honest assessment of the scope of examination of the duodenum in an unselected series of patients with this instrument, since we believe that this is what a clinician wishes to know before he purchases an expensive instrument. Although our and Dr. Salmon’s hospital are fortunate in possessing both the Olympus and ACMI instruments this may not be possible in every unit and some might hesitate to subject the patient to two examinations of this to
type. We certainly agree that cannulation of the ampulla of Vater is an important advantage of the Olympus JF-B duodenoscope, particularly in cases of jaundice where the stiology is not already clear, although in our experience it is not an easy procedure, and may not be free of risk. Finally, may we deplore the use of unattractive terms like " bulboscopy " ? Are we to have " second-partoscopy " " or ampulla-oscopy " ?
Royal Infirmary of Edinburgh.
DAVID J. C. SHEARMAN R. R. G. WARWICK I. B. MACLEOD A. C. B. DEAN.
PÆDIATRIC GASTROSCOPY
SIR,-The use of the fibre-optic gastroscope has become well established in clinical practice. There is, however, no instrument available which is suitable for use in infants or children. For the past five years attempts were made to obtain a suitable fibrescope, since it was felt that there was a definite need for such an instrument, but manufacturers were reluctant to develop it because they were unable to cope with the current demand for adult gastroscopes. In January, 1971, we obtained the Olympus bronchoscope (Model BF-5B) with the following specifications:
Range of observation 5’45 mm.; angle of view field 83° (forward field view), outer diameter 5 mm. (4 mm. and 3 mm. diameter models are also available, BF-4B and BF-3A); working length of fibrescope 557 mm.; bending angle up to 130° down to 300; radius of bending 7 mm. Also available-brush cytology and photographic facilities with the Olympus Medical Camera Model FIT, used with Ektachrome EHB.135-20 (ASA 125). The instrument has been successfully used in a variety of clinical situations-pyloric stenosis, acute gastric erosions, and investigation of dyspepsia. The age of the children ranged from 6 weeks to 15 years. As the instrument has a forward field view it has been particularly useful as an oesophagoscope, especially in the postoperative assessment of colon transplants, where it is impossible to use a
rigid oesophagoscope.
Alder Hey Children’s Hospital, West Derby, Liverpool.
Until contrary evidence is produced it would seem that dental clearance offers the patient an advantage which outweighs the disadvantages of having a denture. That the dentures must be well fitting and the oral hygiene good goes without saying. Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford.
B. E.
JUEL-JENSEN.
SERUM INHIBITORS OF LYMPHOCYTE RESPONSES
SIR,-Evidence to support an association between cancer and immunity is now abundant. However, the problem of separating cause from effect in this relationship still exists and lends importance to studies such as those of Mr. Whittaker and his co-workers,l who report reduced transformation to phytohaemagglutinin (P.H.A.) in breast-cancer patients and the presence of an inhibitor of normal lymphocyte in-vitro responses to P.H.A. in the serum of six of these patients. We 2,3 and others 4 have similarly observed depressed P.H.A. responses in patients with non-lymphoid forms of cancer. More than two-thirds of 104 patients studied in our laboratory, including 13 patients with breast cancer, had strikingly depressed P.H.A. responses.3 Each patient was paired with an age-matched control, since Pisciotta et al. have shown that P.H.A. responses diminish with age. It seems a natural second question to ask, in these patients, By what mechanisms are the lymphocyte responses to P.H.A. depressed ? Those who have asked this question have discovered, and rediscovered, inhibitory factors in the plasmas of such patients.1.3.7.8 Similar plasma inhibitors of lymphocyte responses have also been described in tuberculosis,9 multiple sclerosis" hepatitis,’1 chronic mucocutaneous candidiasis,12 ataxia telangiectasia,13 and, as mentioned by Mr. Whittaker and his colleagues, in syphilis.14They have been described in lymphoid forms of cancer, such as Hodgkin’s disease,8 and in an alpha2globulin fraction derived from normal human serum. 15 In several of the above conditions, the plasma inhibitory effect appears and disappears with time and clinical status in the same patient, so that, while the existence of such inhibitors is beyond doubt, their clinical significance is difficult to interpret. In our studies, we found inhibitors of allogeneic lymphocyte responses to P.H.A. in the plasmas of 16 of 21 patients with various forms of non-lymphoid malignant disease, including 2 of 5 with breast cancer. None of these patients had received chemotherapy or steroids for at least
lymphocyte
N. V. FREEMAN. 1.
Whittaker, M. G., Rees, K., Clark, C. G. Lancet, May 1, 1971, i, 892.
TEETH AND STREPTOCOCCUS VIRIDANS ENDOCARDITIS
SIR,-The two interesting papers by Dr. Croxson and others (June 12, p. 1205) and by Dr. Simon and Professor Goodwin (June 12, p. 1207) point out that subacute bacterial endocarditis due to Streptococcus viridans (S.V.E.) may occur in edentulous patients. However, the article by Beeley1 is the only one that has direct evidence bearing on the point at issue: whether removal of teeth lessens the chance of a recurrence of s.v.E. Beeley traced 13 of the 17 survivors of our series of 25 patieats with S.V.E.2 5 had had complete dental clearance, in 12 unhealthy teeth only had been removed. All 5 edentulous patients were traced, none had had a recurrence. Of the remaining 8 patients with teeth, 5 had had a recurrence of S.V.E. and 3 died. 1. Beeley, L. Br. dent. J. 1969, 127, 424. 2. Hobson, F. G., Juel-Jensen, B. E. Br. med. J. 1956, ii. 1501.
Garrioch, D. B., Good, R. A., Gatti, R. A. ibid. 1970, i, 618. Gatti, R. A., Garrioch, D. B., Good, R. A. in Proceedings of Fifth Leukocyte Culture Conference (edited by J. Harris); p. 339. New York, 1970. 4. Ricci, M., Passaleva, A., Ricca, M. Lancet, 1966, ii, 503. 5. Sutherland, R. M., Inch, W. R., McCredie, J. A. in Proceedings of Tenth International Cancer Congress, Houston, 1970 (in the press). 6. Pisciotta, A. V., Westring, D. W., De Prey, C., Walsh, B. Nature, 1967, 215, 193. 7. Silk, M. Cancer, 1967, 20, 2088. 8. Trubowittz, S., Masek, B., Del Rosario, A. ibid. 1966, 19, 2019. 9. Heilman, D. H., Macfarland, W. Int. Archs Allergy, 1966, 30, 58. 10. Knowles, M., Hughes, D., Caspary, E. A., Field, E. J. Lancet, 1968, ii, 1207. 11. Paronetto, F., Popper, H. New Engl. J. Med. 1970, 283, 277. 12. Canales, L., Middlemas, R. O., Louro, J. M., South, M. A. Lancet, 2. 3.
1969, ii, 567. 13. McFarlin, D. E., Oppenheim, J. J. J. Immun. 1969, 103, 1212. 14. Levene, G. M., Turk, J. L., Wright, D. J. M., Grimble, A. G. S. Lancet, 1969, ii, 246. 15. Cooperband, S. R., Bondevik, H., Schmid, K., Mannick, J. A. Science, 1968, 159, 1243.
give an honest assessment of the scope of examination of the duodenum in an unselected series of patients with this instrument, since we believe that this is what a clinician wishes to know before he purchases an expensive instrument. Although our and Dr. Salmon’s hospital are fortunate in possessing both the Olympus and ACMI instruments this may not be possible in every unit and some might hesitate to subject the patient to two examinations of this to
type. We certainly agree that cannulation of the ampulla of Vater is an important advantage of the Olympus JF-B duodenoscope, particularly in cases of jaundice where the stiology is not already clear, although in our experience it is not an easy procedure, and may not be free of risk. Finally, may we deplore the use of unattractive terms like " bulboscopy " ? Are we to have " second-partoscopy " " or ampulla-oscopy " ?
Royal Infirmary of Edinburgh.
DAVID J. C. SHEARMAN R. R. G. WARWICK I. B. MACLEOD A. C. B. DEAN.
PÆDIATRIC GASTROSCOPY
SIR,-The use of the fibre-optic gastroscope has become well established in clinical practice. There is, however, no instrument available which is suitable for use in infants or children. For the past five years attempts were made to obtain a suitable fibrescope, since it was felt that there was a definite need for such an instrument, but manufacturers were reluctant to develop it because they were unable to cope with the current demand for adult gastroscopes. In January, 1971, we obtained the Olympus bronchoscope (Model BF-5B) with the following specifications:
Range of observation 5’45 mm.; angle of view field 83° (forward field view), outer diameter 5 mm. (4 mm. and 3 mm. diameter models are also available, BF-4B and BF-3A); working length of fibrescope 557 mm.; bending angle up to 130° down to 300; radius of bending 7 mm. Also available-brush cytology and photographic facilities with the Olympus Medical Camera Model FIT, used with Ektachrome EHB.135-20 (ASA 125). The instrument has been successfully used in a variety of clinical situations-pyloric stenosis, acute gastric erosions, and investigation of dyspepsia. The age of the children ranged from 6 weeks to 15 years. As the instrument has a forward field view it has been particularly useful as an oesophagoscope, especially in the postoperative assessment of colon transplants, where it is impossible to use a
rigid oesophagoscope.
Alder Hey Children’s Hospital, West Derby, Liverpool.
Until contrary evidence is produced it would seem that dental clearance offers the patient an advantage which outweighs the disadvantages of having a denture. That the dentures must be well fitting and the oral hygiene good goes without saying. Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford.
B. E.
JUEL-JENSEN.
SERUM INHIBITORS OF LYMPHOCYTE RESPONSES
SIR,-Evidence to support an association between cancer and immunity is now abundant. However, the problem of separating cause from effect in this relationship still exists and lends importance to studies such as those of Mr. Whittaker and his co-workers,l who report reduced transformation to phytohaemagglutinin (P.H.A.) in breast-cancer patients and the presence of an inhibitor of normal lymphocyte in-vitro responses to P.H.A. in the serum of six of these patients. We 2,3 and others 4 have similarly observed depressed P.H.A. responses in patients with non-lymphoid forms of cancer. More than two-thirds of 104 patients studied in our laboratory, including 13 patients with breast cancer, had strikingly depressed P.H.A. responses.3 Each patient was paired with an age-matched control, since Pisciotta et al. have shown that P.H.A. responses diminish with age. It seems a natural second question to ask, in these patients, By what mechanisms are the lymphocyte responses to P.H.A. depressed ? Those who have asked this question have discovered, and rediscovered, inhibitory factors in the plasmas of such patients.1.3.7.8 Similar plasma inhibitors of lymphocyte responses have also been described in tuberculosis,9 multiple sclerosis" hepatitis,’1 chronic mucocutaneous candidiasis,12 ataxia telangiectasia,13 and, as mentioned by Mr. Whittaker and his colleagues, in syphilis.14They have been described in lymphoid forms of cancer, such as Hodgkin’s disease,8 and in an alpha2globulin fraction derived from normal human serum. 15 In several of the above conditions, the plasma inhibitory effect appears and disappears with time and clinical status in the same patient, so that, while the existence of such inhibitors is beyond doubt, their clinical significance is difficult to interpret. In our studies, we found inhibitors of allogeneic lymphocyte responses to P.H.A. in the plasmas of 16 of 21 patients with various forms of non-lymphoid malignant disease, including 2 of 5 with breast cancer. None of these patients had received chemotherapy or steroids for at least
lymphocyte
N. V. FREEMAN. 1.
Whittaker, M. G., Rees, K., Clark, C. G. Lancet, May 1, 1971, i, 892.
TEETH AND STREPTOCOCCUS VIRIDANS ENDOCARDITIS
SIR,-The two interesting papers by Dr. Croxson and others (June 12, p. 1205) and by Dr. Simon and Professor Goodwin (June 12, p. 1207) point out that subacute bacterial endocarditis due to Streptococcus viridans (S.V.E.) may occur in edentulous patients. However, the article by Beeley1 is the only one that has direct evidence bearing on the point at issue: whether removal of teeth lessens the chance of a recurrence of s.v.E. Beeley traced 13 of the 17 survivors of our series of 25 patieats with S.V.E.2 5 had had complete dental clearance, in 12 unhealthy teeth only had been removed. All 5 edentulous patients were traced, none had had a recurrence. Of the remaining 8 patients with teeth, 5 had had a recurrence of S.V.E. and 3 died. 1. Beeley, L. Br. dent. J. 1969, 127, 424. 2. Hobson, F. G., Juel-Jensen, B. E. Br. med. J. 1956, ii. 1501.
Garrioch, D. B., Good, R. A., Gatti, R. A. ibid. 1970, i, 618. Gatti, R. A., Garrioch, D. B., Good, R. A. in Proceedings of Fifth Leukocyte Culture Conference (edited by J. Harris); p. 339. New York, 1970. 4. Ricci, M., Passaleva, A., Ricca, M. Lancet, 1966, ii, 503. 5. Sutherland, R. M., Inch, W. R., McCredie, J. A. in Proceedings of Tenth International Cancer Congress, Houston, 1970 (in the press). 6. Pisciotta, A. V., Westring, D. W., De Prey, C., Walsh, B. Nature, 1967, 215, 193. 7. Silk, M. Cancer, 1967, 20, 2088. 8. Trubowittz, S., Masek, B., Del Rosario, A. ibid. 1966, 19, 2019. 9. Heilman, D. H., Macfarland, W. Int. Archs Allergy, 1966, 30, 58. 10. Knowles, M., Hughes, D., Caspary, E. A., Field, E. J. Lancet, 1968, ii, 1207. 11. Paronetto, F., Popper, H. New Engl. J. Med. 1970, 283, 277. 12. Canales, L., Middlemas, R. O., Louro, J. M., South, M. A. Lancet, 2. 3.
1969, ii, 567. 13. McFarlin, D. E., Oppenheim, J. J. J. Immun. 1969, 103, 1212. 14. Levene, G. M., Turk, J. L., Wright, D. J. M., Grimble, A. G. S. Lancet, 1969, ii, 246. 15. Cooperband, S. R., Bondevik, H., Schmid, K., Mannick, J. A. Science, 1968, 159, 1243.