- Email: [email protected]
PERSONAL HYGIENE
641 It
was
unfortunate that was obtainable.
only
such
a
small amount
of cafes!;ol
We wish to thank Messrs. British Schering Ltd., for ing the cafestol and the British substitute.
Regional Medical Research Centre, Royal Bath Hospital, Harrogate.
supply-
G. NORMAN MYERS D. N. Ross.
SULPHONAMIDES AND PENICILLIN IN THE PATHOGENESIS OF SYSTEMIC LUPUS ERYTHEMATOSUS SiR,-Since publication of my article (Feb. 3), my attention has been drawn to the earlier papers of Barber on the administration of sulphonamides for chronic lupus erythematosus. He was treating patients as early as 1938and made a report in 19402 summarizing his experiences. It is quite evident that he was well He aware of the hazards of this form of treatment. stated : ’
" Apart from the serious and sometimes fatal effects that even in may follow the administration of moderate dosage, the severity of the reactions that often result from their use in lupus erythematosus makes it imperative that they should be given with the greatest discretion.... It cannot be too strongly emphasised that the indiscriminate use of the sulphonamides is fraught with
sulphonamides
"
danger." Further confirmation of the responsibility of the 3
sulphonamides
has
come
from
the
U.S.A.
Wile
has stated : " The incidence of this group has increased amazingly the past fifteen or twenty years. I believe this increase is real rather than apparent. At the University Hospital (Ann Arbor, Mich.) there has been an increase of 450% over this period.... Coincident in time with this increase there came in to the picture the more or less general use of the sulphonamide drugs, first used for serious infections such as pneumonia. It soon became a general habit for many people to use sulphonamides for common colds and for all types of infections. Many of these patients are photosensitive... and these drugs have shown themselves to be
during
photo-sensitizing agents." I have also had many letters from other observers this thesis. STEPHEN GOLD. London, W.l.
supporting
INTRAVENOUS IRON
SiR,-Dr. Klopper, commenting (March 3) on the (Feb. 17), shares
recent work of Dr. Scott and Dr. Govan
with them a difficulty in interpreting the percentage utilisation of iron administered intravenously during I would like to draw attention to a pregnancy. mathematical observation which occurred to me when I was engaged in similar work three years ago. Inthe absence of iron deficiency, as pregnancy advances there is a slight increase in the total amount of circulating haemoglobin, but for the purpose of this note let it be assumed that it remains constant. In a perfectly normal pregnancy, where no iron deficiency can be shown to exist, at about the 30th week of gestation quite a usual finding would be a haemoglobin level of 75%. Now this fall in percentage is due to fluid retention and consequent haemodilution, and a finding of 75% Hb is produced by the same total circulating haemoglobin that gave a reading of 100% before pregnancy began. Treatment of such a case on the non-pregnant basis that 100 mg. elemental iron will result in a 4% increase in the haemoglobin level, will obviously result in a finding that the utilisation of iron is nil. Further, assume a similar case, but one with demonstrable iron-deficiency anaemia, and’in which the haemoglobin level is 70%. If the haemodilution is the same in 1. 2. 3.
Barber, H. W. Lancet, 1938, ii, 668. Ibid, 1940, i, 583. Wile, J. U. Arch. Derm. Syph., Chicago, 1951, 63, 49.
this
case,
this
haemoglobin
pregnant level of
170tdeficient x
level represents
a
non-
93%. Such a case is in haemoglobin, but 7% ; corrected by the injection of
70
=
therefore not 30% and the anaemia should be 200 mg. iron, and not 750 mg. as would appear at first sight. If 750 mg. iron were injected, it is evident that some large quantity, in the region of 500 mg., would be diverted to storage depots and the calculated percentage utilisation would be very low. It will be seen. therefore, that the treatment by present methods of iron-deficiency anaemia in pregnancy results in gross overdosage. In practice this is a good thing, for the reason that the very presence of an irondeficiency anaemia in pregnancy is an indication that depot stores of iron are very low and that they would benefit from the excess dosage. The problem of iron-deficiency anaemia in pregnancy is obscured by a lack of clear understanding of the total circulating blood-volume during pregnancy. D. G. FRENCH. Kidsgrove, Staffs. PERSONAL HYGIENE
SiR,—Dr. Bourne (Jan. 27), stressing the importance of cleansing the hands from any faecal contamination, suggests the fitting of foot controls for flushing the cistern, opening the door of the w.c., and turning the tap over the basin. A far more practicable suggestion is that all elementary-school teachers should instruct their children that what might be called the toilet-paper hand should never be used for these operations until cleaned. It is extraordinary how quickly this habit can be learned so that it is repulsive to the child for that hand to be used for these purposes until it has gone under the tap. A. H. SPICER. Petworth, Sussex. CORTISONE AND FAT METABOLISM
SiR,-It is generally assumed that adrenocorticotropic hormone and other anterior pituitary hormones influence fat mobilisation and increase the fat content of the liver ; but the influence of ’Cortisone’ on fat metabolism has not yet been ascertained. In clinical research Sprague et al.,’ Adlersberg et al.,2 and Sala et al.3 have found that cortisone increases plasma phospholipids and cholesterol. According to Winter et al.,4 Kobernick and More,5 and Rich et al.,6 it produces hyperlipsemia, in rats and rabbits. Payne,7 on the other hand, minimises the role of adrenal cortex in fat metabolism, and Levin and Farber8 deny that cortisone may provoke fatty liver. We have determined the fat content of the liver in two groups of adult male rats, respectively treated daily with 1 and 5 mg. of cortisone for 70 and 20 days. ’
The rats were fed a diet consisting of 56% carbohydrate, 30% protein, 10% fat, with adequate supplement of salts, vitamins, and lipotropic factors. The experimental, groups consumed the same quantity of food daily. Dried and powdered liver was extracted with ether by reflux distillation. The fat content of the livers was significantly higher in cortisone-treated animals than in controls (p values of 0,99 determined by the use of Student’s t). Post-mortem examination showed varying degrees of hepatic perilobular steatosis, without necrotic foci or fibrous proliferation ; body fat was 1. Sprague, R. G., Power, M. H. P., Mason, H. L., Albert, A., Mathieson, D. R., Hench, P. S., Kendall, E. C., Slocumb, C. H., Polley, H. F. Arch. intern. Med. 1950, 85, 199. 2. Adlersberg, D., Schaefer, L. E., Dritch, R. Proc. Soc. exp. Biol. Med. 1950, 74, 877. 3. Sala, G., Fasoli, A., Bonelli, M., Bonomo, E., Ratti, G., Migliavacca, A., Ballabio, C. B. Reumatismo, 1950, suppl. 3, p. 33. 4. Winter, C. A., Silber, R. H., Stoerk, H. C. Endocrinology, 1950, 5.
47, 60. Kobernick, S. D., More, R.
H.
Proc. Soc. exp. Biol. Med.
74, 602. 6. Rich, A. R., Coehran, T. H., McGoon, D. C.
1950,
Bull. Johns Hopk. Hosp. 1951, 88, 101. 7. Payne, R. W. Endocrinology, 1949, 45, 305. 8. Levin, L., Farber, R. K. Proc. Soc. exp. Biol. Med. 1950
74, 758.
was
unfortunate that was obtainable.
only
such
a
small amount
of cafes!;ol
We wish to thank Messrs. British Schering Ltd., for ing the cafestol and the British substitute.
Regional Medical Research Centre, Royal Bath Hospital, Harrogate.
supply-
G. NORMAN MYERS D. N. Ross.
SULPHONAMIDES AND PENICILLIN IN THE PATHOGENESIS OF SYSTEMIC LUPUS ERYTHEMATOSUS SiR,-Since publication of my article (Feb. 3), my attention has been drawn to the earlier papers of Barber on the administration of sulphonamides for chronic lupus erythematosus. He was treating patients as early as 1938and made a report in 19402 summarizing his experiences. It is quite evident that he was well He aware of the hazards of this form of treatment. stated : ’
" Apart from the serious and sometimes fatal effects that even in may follow the administration of moderate dosage, the severity of the reactions that often result from their use in lupus erythematosus makes it imperative that they should be given with the greatest discretion.... It cannot be too strongly emphasised that the indiscriminate use of the sulphonamides is fraught with
sulphonamides
"
danger." Further confirmation of the responsibility of the 3
sulphonamides
has
come
from
the
U.S.A.
Wile
has stated : " The incidence of this group has increased amazingly the past fifteen or twenty years. I believe this increase is real rather than apparent. At the University Hospital (Ann Arbor, Mich.) there has been an increase of 450% over this period.... Coincident in time with this increase there came in to the picture the more or less general use of the sulphonamide drugs, first used for serious infections such as pneumonia. It soon became a general habit for many people to use sulphonamides for common colds and for all types of infections. Many of these patients are photosensitive... and these drugs have shown themselves to be
during
photo-sensitizing agents." I have also had many letters from other observers this thesis. STEPHEN GOLD. London, W.l.
supporting
INTRAVENOUS IRON
SiR,-Dr. Klopper, commenting (March 3) on the (Feb. 17), shares
recent work of Dr. Scott and Dr. Govan
with them a difficulty in interpreting the percentage utilisation of iron administered intravenously during I would like to draw attention to a pregnancy. mathematical observation which occurred to me when I was engaged in similar work three years ago. Inthe absence of iron deficiency, as pregnancy advances there is a slight increase in the total amount of circulating haemoglobin, but for the purpose of this note let it be assumed that it remains constant. In a perfectly normal pregnancy, where no iron deficiency can be shown to exist, at about the 30th week of gestation quite a usual finding would be a haemoglobin level of 75%. Now this fall in percentage is due to fluid retention and consequent haemodilution, and a finding of 75% Hb is produced by the same total circulating haemoglobin that gave a reading of 100% before pregnancy began. Treatment of such a case on the non-pregnant basis that 100 mg. elemental iron will result in a 4% increase in the haemoglobin level, will obviously result in a finding that the utilisation of iron is nil. Further, assume a similar case, but one with demonstrable iron-deficiency anaemia, and’in which the haemoglobin level is 70%. If the haemodilution is the same in 1. 2. 3.
Barber, H. W. Lancet, 1938, ii, 668. Ibid, 1940, i, 583. Wile, J. U. Arch. Derm. Syph., Chicago, 1951, 63, 49.
this
case,
this
haemoglobin
pregnant level of
170tdeficient x
level represents
a
non-
93%. Such a case is in haemoglobin, but 7% ; corrected by the injection of
70
=
therefore not 30% and the anaemia should be 200 mg. iron, and not 750 mg. as would appear at first sight. If 750 mg. iron were injected, it is evident that some large quantity, in the region of 500 mg., would be diverted to storage depots and the calculated percentage utilisation would be very low. It will be seen. therefore, that the treatment by present methods of iron-deficiency anaemia in pregnancy results in gross overdosage. In practice this is a good thing, for the reason that the very presence of an irondeficiency anaemia in pregnancy is an indication that depot stores of iron are very low and that they would benefit from the excess dosage. The problem of iron-deficiency anaemia in pregnancy is obscured by a lack of clear understanding of the total circulating blood-volume during pregnancy. D. G. FRENCH. Kidsgrove, Staffs. PERSONAL HYGIENE
SiR,—Dr. Bourne (Jan. 27), stressing the importance of cleansing the hands from any faecal contamination, suggests the fitting of foot controls for flushing the cistern, opening the door of the w.c., and turning the tap over the basin. A far more practicable suggestion is that all elementary-school teachers should instruct their children that what might be called the toilet-paper hand should never be used for these operations until cleaned. It is extraordinary how quickly this habit can be learned so that it is repulsive to the child for that hand to be used for these purposes until it has gone under the tap. A. H. SPICER. Petworth, Sussex. CORTISONE AND FAT METABOLISM
SiR,-It is generally assumed that adrenocorticotropic hormone and other anterior pituitary hormones influence fat mobilisation and increase the fat content of the liver ; but the influence of ’Cortisone’ on fat metabolism has not yet been ascertained. In clinical research Sprague et al.,’ Adlersberg et al.,2 and Sala et al.3 have found that cortisone increases plasma phospholipids and cholesterol. According to Winter et al.,4 Kobernick and More,5 and Rich et al.,6 it produces hyperlipsemia, in rats and rabbits. Payne,7 on the other hand, minimises the role of adrenal cortex in fat metabolism, and Levin and Farber8 deny that cortisone may provoke fatty liver. We have determined the fat content of the liver in two groups of adult male rats, respectively treated daily with 1 and 5 mg. of cortisone for 70 and 20 days. ’
The rats were fed a diet consisting of 56% carbohydrate, 30% protein, 10% fat, with adequate supplement of salts, vitamins, and lipotropic factors. The experimental, groups consumed the same quantity of food daily. Dried and powdered liver was extracted with ether by reflux distillation. The fat content of the livers was significantly higher in cortisone-treated animals than in controls (p values of 0,99 determined by the use of Student’s t). Post-mortem examination showed varying degrees of hepatic perilobular steatosis, without necrotic foci or fibrous proliferation ; body fat was 1. Sprague, R. G., Power, M. H. P., Mason, H. L., Albert, A., Mathieson, D. R., Hench, P. S., Kendall, E. C., Slocumb, C. H., Polley, H. F. Arch. intern. Med. 1950, 85, 199. 2. Adlersberg, D., Schaefer, L. E., Dritch, R. Proc. Soc. exp. Biol. Med. 1950, 74, 877. 3. Sala, G., Fasoli, A., Bonelli, M., Bonomo, E., Ratti, G., Migliavacca, A., Ballabio, C. B. Reumatismo, 1950, suppl. 3, p. 33. 4. Winter, C. A., Silber, R. H., Stoerk, H. C. Endocrinology, 1950, 5.
47, 60. Kobernick, S. D., More, R.
H.
Proc. Soc. exp. Biol. Med.
74, 602. 6. Rich, A. R., Coehran, T. H., McGoon, D. C.
1950,
Bull. Johns Hopk. Hosp. 1951, 88, 101. 7. Payne, R. W. Endocrinology, 1949, 45, 305. 8. Levin, L., Farber, R. K. Proc. Soc. exp. Biol. Med. 1950
74, 758.