RELAPSING BENIGN TERTIAN MALARIA

45

psychogenic.

One

knows, of

course,

that individual

idiosyncrasies to drugs are continually observed, but in my opinion this applies to amphetamine far more than to others. London, W.1.

.

CHRISTOPHER HOWARD.

RELAPSING BENIGN TERTIAN MALARIA SIR,—Dr. Johnstone (Dec. 7) in his interesting report on the treatment of relapsing benign tertian (B.T.) - malaria, showed that relapses are less frequent with quinine-pamaquin (15’6 %) than with ’Paludrine ’ (43 %). It is especially noteworthy that with paludrine the relapse-rate was the same whether 0-05 g. or the tenfold dose, 0,5 g., was given each day. Your annotation of Dec. 14 says : "Against this achievement must be set the facts that quinine in the dosage advocated has unpleasant side-effects...." You are right: gr. 30 (2 g.) of quinine-corresponding to 1460 mg. (sulphate) or 1640 mg. (hydrochloride) of quinine baseoften causes unpleasant side-effects. However, I believe the dosage of quinine advocated by Dr. Johnstone is unnecessarily high. I know that many British malariologists, especially in the tropical countries of your Empire, prescribe 2 g. daily. But with B.T. malaria (not with subtertian) a smaller dose suffices. Not only in Holland but also in Java B.T. malaria responds as quickly to gr. 12-15 of quinine sulphate as to gr. 20 or even gr. 30. Our malaria patients, including those from the endemic districts of Holland and the many thousands of repatriated military and civil internees from Java and Sumatra, are at present successfully treated as a routine with 0’75—1 g. (gr. 12-15) of quinine sulphate, combined with pamaquin naphthoate 50 mg. daily, without admission to hospital. C. W. F. WINCKEL. Amsterdam. AIDS TO THE DIAGNOSIS AND TREATMENT OF VENEREAL DISEASES am most SIR,—I grateful to your reviewer (Dec. 14) :for the kind things he says about my little book, but Jhe is in error when he says I omitted to mention postarsphenamine jaundice resulting from faulty sterilisation of syringes ; if he will refer to page 115 he will see that I did not omit it. Of course it was not possible in the space at my disposal to go into details, but in view of the fact that I was the person most concerned about the high incidence of post-arsenical jaundice in the Army it was very unlikely that I should forget to mention it. T. E. OSMOND. Ashford, Middlesex. SOLUBLE SULPHONAMIDE SIR,—The soluble sodium salts

COMPOUNDS

of sulphapyridine, introduced first in sulphathiazole, sulphadiazine, &c., 1939, have been exceedingly useful preparations for intravenous injection, especially in the unconscious patient. Their great disadvantage, as is now well known, is their high alkalinity and consequent liability to cause irritation and even necrosis in the tissues unless they are highly diluted. This property is occasionally dangerous, as when, by some inadvertence, these preparations are injected undiluted into the theca, the brachial artery

(in mistake for a vein), or the subcutaneous tissues (in mistake for a muscle). From these respective causes I have seen -permanent -sciatic palsy, loss of an arm, and deep sloughing ulcers of subcutaneous tissue and skin. It would seem therefore that these preparations would by general agreement be superseded as soon as a neutral preparation, proved to be harmless and equally efficient, could be obtained. This I consider has been done. and I have injected the preparation known as’ Soluthiazole ’ (May & Baker) intravenously

My colleagues

whenever a sulphonamide injection indicated in this hospital for over two years. We quite satisfied that this preparation is harmless intravenously, intramuscularly, and even when injected, as sometimes happens, deeply into the subcutaneous tissue. The pH value is around 7. The solution is not, or

intramuscularly

was are

however, isotonic ; it is hypertonic. Accordingly, we have not used it, nor indeed have had occasion to use it, in contact with mucous or serous membranes. The first preparation which we tried had a tendency to crystallise out in some of the ampoules, but I understand that the preparation now in use has been slightly modified to

obviate this defect, and wehave seen no trace of crystallisation in any of our ainpoules for more than a year. The ampoules of 5 c.cm., each containing 1 g. ofsulphathiazole, should be kept at room temperature, not in the cold. In

teaching students and postgraduates I have been struck by the almost universal ignorance of the existence of a soluble neutral sulphonamide preparation in concentrated form and completely satisfactory for intravenous and intramuscular injection. Hence this letter. H. STANLEY BANKS. Park Hospital, London, S.E.13. CORONARY DISEASE

SIR,—I too have considered the alternative and view, which Dr. M. Symons " generally accepted (Dec. 28) puts forward, that the leucocytosis and increased erythrocyte-sedimentation rate (E.S.R.) in coronary occlusion are due to the myocardial infarction and resulting destruction of tissue, and not to a septic process. It would be interesting to know if Dr. Symons has "

records of cases in which it has been proved that the infarct in any site was simple and aseptic, and in which leucocytosis and an increased F,.S.R. also occurred. G. E. BEAUMONT. London, W.1.

Obituary RICHARD ROBERT CRUISE G.C.V.O., F.R.C.S. Sir Richard Cruise, surgeon oculist to Queen Mary and surgeon to the Royal Westminster Ophthalmic Hospital, died in St. Mary’s Hospital on Christmas Eve, after a short illness. Born at Purneah, in India, the son of the late Francis Cruise, he was educated at Harrow and at St. Mary’s Hospital, whence he qualified in 1900. After holding a house-appointment’ at Bristol Eye Hospital he took his F.R.C.S. in 1903 and returned to London to obtain further experience in the specialty on which he was now decided. During the next five years he held clinical assistantships at the Royal Eye Hospital, Southwark, the Royal London Ophthalmic Hospital, and the Westminster Ophthalmic Hospital, where in 1909 he was appointed to the staff. During the 1914-18 war Cruise served with the R.A.M.C. in France and with the 3rd London General Hospital. He invented a visor of light chain mail to protect the eyes against injury, recommended by the Ophthalmological Society for universal use among the troops and adopted by the authorities in 1918. At the meeting of the society in 1919 he also described his plastic operation to prepare contracted sockets for the of artificial eyes. fitting " Cruise," writes A. S. P., " will be remembered by generations of house-surgeons, by whom he was greatly loved, as the man who gave them their first cataract to do, and then stood by and gave them the confidence with which to do it. He never tired of teaching them, and they could have had no -better master, for his confidence was unbounded and he inspired a like feeling in pupils and patients. His beautiful cataract results-were achieved by cultivating the relationship between surgeon and " patient, making the patient into his assistant," and doing without most of the modern sutures and safeguards. Cruise taught simplicity and gentleness in operating, and when he did a cataract extraction things never looked like going wrong-’I do a simple extraction,* my boy, and don’t forget the word simple,’ lie would say. And again of cataract surgery-’ There are no sticky lenses,

only sticky surgeons.’ "A courageous and lovable man, he was daunted by nothing, and made himself master of everything to which he set his hand. Never ruffled, he showed the same coolness at steeplechasing and golf, at both of which he excelled, as he did in his surgical work. He set himself a standard of achievement and never allowed himself to fall below it. To the last he maintained this fine standard of work and it was best that he should die in harness. He would not have liked to grow old."

Sir Richard, who was

appointed

1922 and

was

surgeon

c.v.o. in 1917 G.c.v.o. in 1936. *

i.e.,

a

oculist to KingGeorge v, promoted K.c.v.o. in

and

cataract extraction with iridectomy.