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PROLONGED CHEMOTHERAPY IN CHRONIC PULMONARY TUBERCULOSIS
359 Her serum-globulin was high initially. sarcoidosis. With time the E.s.R. dropped to 27 and the serum-protein reverted to normal, when she was sent home. Her .s.R,. still remains no less than 20, she has been completely well in herself the whole time. William Budd Health Centre, Leinster Avenue, H. I.
but
HOWARD.
Bristol, 4.
A NORWICH SURGEON’S DIARY
great-grand-daughter of John Green Crosse extremely interested in your article last week
SiR,-As
a
I was about his diaries.
I have in my possession a letter from John Green Crosse one of his sons (my grandfather), a number of bound volumes of his hospital cases, a bound printed copy of the report of the " Fourteenth Anniversary Meeting of the Provincial Medical and Surgical Association " which was held in Norwich in 1846 under his presidency, newspaper cuttings with reference to his death and funeral, and various portraits. I also have a letter written by one of his grandsons (my father’s cousin) to my father, which gives some interesting sidelights on his life and cbaracter. It is not generally known that John Green Crosse founded the Eastern branch of the Provincial Medical and Surgical Association, which was afterwards combined with that previously founded at Worcester by Sir Charles Hastingsthe amalgamated societies ultimately becoming the British Medical Association. John Green Crosse was honoured by being buried in the Cloisters of Norwich Cathedral.
to
Sorrento
Maternity Hospital, Birmingham.
V. MARY CROSSE.
INTESTINAL OBSTRUCTION BY FOOD
SiR,-It is quite possible that intestinal obstruction
by undigested food is gastrectomy than the suggest.
much commoner after few published reports
partial would
Some two months ago I encountered a case precisely similar to that described by Mr. Thompson Rowling (Aug. 11). In this instance an edentulous woman had swallowed whole several segments of orange which became impacted about half-way down the small bowel. As the obstruction was complete, the bowel had to be opened and the food removed. Curiously enough, the patient- had little recollection of eating the offending citrus. ,
Department of Surgery, University of Liverpool.
SIR,-I
was
interested in Mr.
IAN W. MACPHEE.
Rowling’s
discussion of
his two
patients with obstruction due to oranges after partial gastrectomy. He refers to one of the cases which I reported previously with such an obstruction high in the jejunum. I have recently had a further example in an elderly edentulous man after a Polya partial gastrectomy with a wide stoma : here the bolus was impacted in the lower ileum and required enterotomy. It would be interesting to know of any patients with food obstructions after Billroth-i anastomoses. I have also operated lately on a patient with a complete obstruction due to apples in the lower ileum, but he had not had a partial gastrectomy. It was possible to break up the tightly impacted bolus and " milk " it into the caecum without ill effects. NEIL WARD-MCQUAID. Manpfield, N CJtts.
my worst and most distressing episode after using similar I have also seen patients with chronic sore throat who said that the soreness had disappeared while taking such lozenges, but had then returned eventually, obliging them to seek medical advice.
lozenges.)
These observations
suggest that :
1. The tonsillitis was aggravated by the action of benzocaine This action mav be comon infected and inflamed tissue. to the parable with that of guttae cocainae, which, if cornea continuously for the relief of pain, cause ulceration. p-Aminobenzoic acid, which is allied to benzocaine, is known to irritate the gastric mucosa.
applied
2. Trauma of the inflamed tissue may also be caused by the full range of use encouraged by the transient benzocaine ansesthesia and disappearance of pain. 3. The action of the antibiotic or antiseptic moiety of the lozenge is less likely to be effective if the benzocaine is simul.
taneously causing
trauma.
The use of surface anaesthesia to alleviate pain from infected and inflamed tissue does not appear to be scientifically sound in principle. No doubt benzocaine has its uses as a local anaesthetic in surgical and diagnostic procedures, but there seems to be good ground for questioning the wisdom of its use in vulnerable infected and inflamed tissues. S. M. FREEDMAN. Salford, 7. PROLONGED CHEMOTHERAPY IN CHRONIC PULMONARY TUBERCULOSIS
SiR,—Dr. Sickenga has raised some important points in his letter last week about our article of July 28. The number of
was of course small, but the selected at random as described in our earlier paper.l The number of patients in group IP who showed streptomycin resistance at the end of treatment (see table vn) is certainly worthy of comment. In fact the organisms of these patients were tested for streptomycin sensitivity before treatment and only 2 out of 15 were found to be resistant. As Dr. Sickenga points out, this number had increased to 6 after the course ofisoniazid and p-aminosalicylic acid (P.A.S.) although no streptomycin had been given. This difference is most apparent in the slope results. Tube results showed that only the 2 patients who were originally resistant to streptomycin remained highly resistant to this drug. Work in the department of bacteriology at Guy’shas shown the difficulties in interpreting drugsensitivity tests and has emphasised that streptomycin slope tests are especially troublesome. The discrepancy may be due to the fact that the inoculum was smaller towards the end of therapy, as shown in table I in our paper. This that the cultures grow more slowly and therefore means the problem of drug inactivation assumes increasing our
two groups R and IP
patients were
importance. We agree that table v, as cited by Dr Sickenga, in another of our previous papers3 may be misleading In fact 12 (not 3) of the 15 patients showed sensitivity to all three drugs after twenty-four weeks’ therapy. 3 were resistant to streptomycin, and 2 of these were resistant to P.A.s. and isoniazid as well.
From our experience in the treatment of at least a hundred patients with chronic tuberculosis, we do not agree that P.A.s. resistance is likely to be any less permanent than that due to streptomycin, and we feel that the most effective chemotherapeutic regimen must include both isoniazid and streptomycin.
BENZOCAINE IN LOZENGES
SiR,—Acute tonsillitis is a limited illness which usually responds rapidly to therapy. I have seen a number of cases, however, which showed unusual soreness, toxicity, and constitutional disturbance, with temperatures from 104 to 105°F, and slow response to treatment. In each of these cases an attempt had been made to abort the attack by the use of lozenges containing benzocaine. (As a victim of attacks of tonsillitis, I myself experienced
Guy’s Hospital, London, S.E.1.
K. K. R. J.
S. MACLEAN MARSH KNOX D. CARROLL.
1. Joiner, C. L., Maclean, K. S., Pritchard, E. K., Anderson, K., Collard, P., King. M. B., Knox. R. Lancet, 1952, ii, 843. 2. Worssam, A. R. H., Collard, P., Carroll, J. D., Knox, R. Tubercle, Lond. 1956, 37, 73. 3. Joiner, C. L., Maclean, K. S., Carroll, J. D., Marsh, K., Collard,
P., Knox, R. Lancet, 1954, ii, 663.
but
HOWARD.
Bristol, 4.
A NORWICH SURGEON’S DIARY
great-grand-daughter of John Green Crosse extremely interested in your article last week
SiR,-As
a
I was about his diaries.
I have in my possession a letter from John Green Crosse one of his sons (my grandfather), a number of bound volumes of his hospital cases, a bound printed copy of the report of the " Fourteenth Anniversary Meeting of the Provincial Medical and Surgical Association " which was held in Norwich in 1846 under his presidency, newspaper cuttings with reference to his death and funeral, and various portraits. I also have a letter written by one of his grandsons (my father’s cousin) to my father, which gives some interesting sidelights on his life and cbaracter. It is not generally known that John Green Crosse founded the Eastern branch of the Provincial Medical and Surgical Association, which was afterwards combined with that previously founded at Worcester by Sir Charles Hastingsthe amalgamated societies ultimately becoming the British Medical Association. John Green Crosse was honoured by being buried in the Cloisters of Norwich Cathedral.
to
Sorrento
Maternity Hospital, Birmingham.
V. MARY CROSSE.
INTESTINAL OBSTRUCTION BY FOOD
SiR,-It is quite possible that intestinal obstruction
by undigested food is gastrectomy than the suggest.
much commoner after few published reports
partial would
Some two months ago I encountered a case precisely similar to that described by Mr. Thompson Rowling (Aug. 11). In this instance an edentulous woman had swallowed whole several segments of orange which became impacted about half-way down the small bowel. As the obstruction was complete, the bowel had to be opened and the food removed. Curiously enough, the patient- had little recollection of eating the offending citrus. ,
Department of Surgery, University of Liverpool.
SIR,-I
was
interested in Mr.
IAN W. MACPHEE.
Rowling’s
discussion of
his two
patients with obstruction due to oranges after partial gastrectomy. He refers to one of the cases which I reported previously with such an obstruction high in the jejunum. I have recently had a further example in an elderly edentulous man after a Polya partial gastrectomy with a wide stoma : here the bolus was impacted in the lower ileum and required enterotomy. It would be interesting to know of any patients with food obstructions after Billroth-i anastomoses. I have also operated lately on a patient with a complete obstruction due to apples in the lower ileum, but he had not had a partial gastrectomy. It was possible to break up the tightly impacted bolus and " milk " it into the caecum without ill effects. NEIL WARD-MCQUAID. Manpfield, N CJtts.
my worst and most distressing episode after using similar I have also seen patients with chronic sore throat who said that the soreness had disappeared while taking such lozenges, but had then returned eventually, obliging them to seek medical advice.
lozenges.)
These observations
suggest that :
1. The tonsillitis was aggravated by the action of benzocaine This action mav be comon infected and inflamed tissue. to the parable with that of guttae cocainae, which, if cornea continuously for the relief of pain, cause ulceration. p-Aminobenzoic acid, which is allied to benzocaine, is known to irritate the gastric mucosa.
applied
2. Trauma of the inflamed tissue may also be caused by the full range of use encouraged by the transient benzocaine ansesthesia and disappearance of pain. 3. The action of the antibiotic or antiseptic moiety of the lozenge is less likely to be effective if the benzocaine is simul.
taneously causing
trauma.
The use of surface anaesthesia to alleviate pain from infected and inflamed tissue does not appear to be scientifically sound in principle. No doubt benzocaine has its uses as a local anaesthetic in surgical and diagnostic procedures, but there seems to be good ground for questioning the wisdom of its use in vulnerable infected and inflamed tissues. S. M. FREEDMAN. Salford, 7. PROLONGED CHEMOTHERAPY IN CHRONIC PULMONARY TUBERCULOSIS
SiR,—Dr. Sickenga has raised some important points in his letter last week about our article of July 28. The number of
was of course small, but the selected at random as described in our earlier paper.l The number of patients in group IP who showed streptomycin resistance at the end of treatment (see table vn) is certainly worthy of comment. In fact the organisms of these patients were tested for streptomycin sensitivity before treatment and only 2 out of 15 were found to be resistant. As Dr. Sickenga points out, this number had increased to 6 after the course ofisoniazid and p-aminosalicylic acid (P.A.S.) although no streptomycin had been given. This difference is most apparent in the slope results. Tube results showed that only the 2 patients who were originally resistant to streptomycin remained highly resistant to this drug. Work in the department of bacteriology at Guy’shas shown the difficulties in interpreting drugsensitivity tests and has emphasised that streptomycin slope tests are especially troublesome. The discrepancy may be due to the fact that the inoculum was smaller towards the end of therapy, as shown in table I in our paper. This that the cultures grow more slowly and therefore means the problem of drug inactivation assumes increasing our
two groups R and IP
patients were
importance. We agree that table v, as cited by Dr Sickenga, in another of our previous papers3 may be misleading In fact 12 (not 3) of the 15 patients showed sensitivity to all three drugs after twenty-four weeks’ therapy. 3 were resistant to streptomycin, and 2 of these were resistant to P.A.s. and isoniazid as well.
From our experience in the treatment of at least a hundred patients with chronic tuberculosis, we do not agree that P.A.s. resistance is likely to be any less permanent than that due to streptomycin, and we feel that the most effective chemotherapeutic regimen must include both isoniazid and streptomycin.
BENZOCAINE IN LOZENGES
SiR,—Acute tonsillitis is a limited illness which usually responds rapidly to therapy. I have seen a number of cases, however, which showed unusual soreness, toxicity, and constitutional disturbance, with temperatures from 104 to 105°F, and slow response to treatment. In each of these cases an attempt had been made to abort the attack by the use of lozenges containing benzocaine. (As a victim of attacks of tonsillitis, I myself experienced
Guy’s Hospital, London, S.E.1.
K. K. R. J.
S. MACLEAN MARSH KNOX D. CARROLL.
1. Joiner, C. L., Maclean, K. S., Pritchard, E. K., Anderson, K., Collard, P., King. M. B., Knox. R. Lancet, 1952, ii, 843. 2. Worssam, A. R. H., Collard, P., Carroll, J. D., Knox, R. Tubercle, Lond. 1956, 37, 73. 3. Joiner, C. L., Maclean, K. S., Carroll, J. D., Marsh, K., Collard,
P., Knox, R. Lancet, 1954, ii, 663.