- Email: [email protected]
THE WALTER FLETCHER MEMORIAL
178
AIAGiNESIU31 SULPHATE IN ACUTE INTESTINAL STRANGULATION
THE WALTER FLETCHER MEMORIAL
To the Editor
of THE LANCET of issue June SiR,-In your 16th, 1934, you printed a letter from Mr. Stanley Baldwin and others, including the undersigned trustees, proposing a tribute to the memory of the late Sir Walter Morley Fletcher, first secretary of the Medical Research Council. Subscriptions were invited to a fund to be used in the first place for a personal memorial at the National Institute for Medical Research at Hampstead, and in the second place towards the cost of building a Walter Fletcher Laboratory at Mill Hill for nutritional investigations. We are now glad to record that the response has been no less than was confidently expected, and that the means for giving effect to the projects are assured. The total brought by the appeal already exceeds E2000, and it is believed that there are still many who intend to contribute before the fund is closed. It is an appropriate result that a great part of this sum is made up of small subscriptions from a large number of research workers and others, although donations of substantial amount have also been received. We are. Sir,
yours
faithfully,
DAWSON
OF
PENN,
H. H. DALE, T. R. ELLIOTT, E. MELLANBY.
Jan. 14th.
MONOCYTIC LEUKÆMIA
To the Editor of THE LANCET Sm,-In the paper by Drs. Whitby and Christie appearing in your last issue I am credited with having made haematological statements, and with holding certain haematological beliefs, which I disclaim completely; never having made or held them. " Naegeli maintained that the monocytes described were unusual forms of myeloblasts, a view which Here the even to this day is supported by Piney." authors mention page 178 of the third edition of my " Recent Advances in Haematology " as authority for this statement, but the only relevant remark that occurs on this page is " Naegeli’s view that it (monocyte) belongs to the myeloid series of leucocytes seems, on the whole, more satisfactory than the conception of an origin from a third hsematopoietic system...." The sentence, following the first one quoted above, reads: " It must, however, be borne in mind that both Naegeli and Piney regard the monocyte as a cell derived directly from the myeloblast." But on page 26 of the book the authors do me the honour to quote I say that the term " pro" monocyte " is preferable to monoblast," because the latter implies that the monocytes have a separate genealogical history. Surely it is clear that my contention is that the monocyte is not derived directly from the myeloblast, but that I believe that an intermediate cell-form, the pro-monocyte, can be distinguished. So far as I know the only writer who has ever contended that monocytes were altered myeloblasts was Ziegler, but the view never found
acceptance.
"
After this defence of my position, may I attack another statement that appears in the paper by Whitby and Christie ? " The appearance of myeloblasts in the terminal phases has been recorded by other observers and does not, in our opinion, justify a diagnosis of myeloblastic leukaemia, but merely suggests that the myeloblast andmonoblast ’ have a common precursor cell." Now, in many cases of chronic myeloid leukaemia in which myelocytes dominate the blood picture
for months or years, there may be great myeloblastosis in the terminal acute stage. The number of myeloblasts in the blood may be so great as to make it impossible, except on clinical grounds, to distinguish the condition from a primarily acute myeloblastic Ieukaemia. It has been, and still is, usual to adduce this fact as evidence in favour of the view that myelocytes are derived from myeloblasts, but Whitby and Christie would presumably contend that it merely suggests that the myeloblast and the myelocyte have a common precursor cell ! If, however, they would agree to the commonly accepted interpretation of the fact, their argument in favour of the fundamental distinction between myeloblast and " monoblast " fails to carry conviction. And when they say, " The case, as judged by histological sections, appeared to present a partial myeloid termination ..." my view that the monocyte is a myeloid cell is strengthened rather than weakened by their observations. The very fact that a leukaemia which starts with a monocytic blood picture runs a less acute course than does a primarily myeloblastic leukaemia supports my view, because it is a commonplace that the more differentiated the predominant cell-type the less acute the course. This is clearly shown in Whitby and Christie’s case ; and I have observed it in two cases (unpublished): one of a lady aged 72, and the other a man of 67. The former died six months after the onset of symptoms, and the latter lived for 18 months. Incidentally, in both of these cases there was enlargement of the liver, but not of the spleen. It is unfortunate that there is so little information concerning the number of thrombocytes in monocytic leukaemia. In the case of the woman mentioned above, these elements were normal in number and structure throughout the illness, whereas in the man there was thrombocytopenia (down to 40,000 per c.mm.) during the last three months of life ; and there were many poikilothrombocytes. Both cases were treated with Campolon and calcium gluconate, with only transient improvement. ’
T
a,m.
Sir.
vnnrs
fa.ithfl1]lv.
A. PINEY, M.D.,
M.R.C.P.
Park-square West, N.W., Jan. 13th. MAGNESIUM SULPHATE IN ACUTE INTESTINAL STRANGULATION
To the Editor
of
THE LANCET
SiR,-In his valuable article on Prognosis in Acute Intestinal Strangulation LANCET, (THE Jan. 12th, p. 103) Mr. Claude Frankau states that the only safe drug to give by mouth is magnesium sulphate, as it acts purely by osmosis and helps to sweep away toxic products. From my much more limited experience I would agree about its value, especially when given at the same time as an injection of pituitrin, but not with his explanation. Over 25 years ago Mr. Frank Cook and Mr. E. G. Slesinger, then students at Guy’s Hospital, carried out some experiments with me, reported to the Therapeutical Section of the Royal Society of Medicine (see THE LANCET, 1908, ii., 1444), which proved that, whatever may occur in animals, saline aperients in man act only after absorption into the blood stream and not by attracting water into the lumen of the bowel. A watery stool is passed before the salts have reached the caecum, but not before some has been absorbed and excreted in the urine. The watery stool generally contains none of the salt, some of which is rapidly excreted in the urine
AIAGiNESIU31 SULPHATE IN ACUTE INTESTINAL STRANGULATION
THE WALTER FLETCHER MEMORIAL
To the Editor
of THE LANCET of issue June SiR,-In your 16th, 1934, you printed a letter from Mr. Stanley Baldwin and others, including the undersigned trustees, proposing a tribute to the memory of the late Sir Walter Morley Fletcher, first secretary of the Medical Research Council. Subscriptions were invited to a fund to be used in the first place for a personal memorial at the National Institute for Medical Research at Hampstead, and in the second place towards the cost of building a Walter Fletcher Laboratory at Mill Hill for nutritional investigations. We are now glad to record that the response has been no less than was confidently expected, and that the means for giving effect to the projects are assured. The total brought by the appeal already exceeds E2000, and it is believed that there are still many who intend to contribute before the fund is closed. It is an appropriate result that a great part of this sum is made up of small subscriptions from a large number of research workers and others, although donations of substantial amount have also been received. We are. Sir,
yours
faithfully,
DAWSON
OF
PENN,
H. H. DALE, T. R. ELLIOTT, E. MELLANBY.
Jan. 14th.
MONOCYTIC LEUKÆMIA
To the Editor of THE LANCET Sm,-In the paper by Drs. Whitby and Christie appearing in your last issue I am credited with having made haematological statements, and with holding certain haematological beliefs, which I disclaim completely; never having made or held them. " Naegeli maintained that the monocytes described were unusual forms of myeloblasts, a view which Here the even to this day is supported by Piney." authors mention page 178 of the third edition of my " Recent Advances in Haematology " as authority for this statement, but the only relevant remark that occurs on this page is " Naegeli’s view that it (monocyte) belongs to the myeloid series of leucocytes seems, on the whole, more satisfactory than the conception of an origin from a third hsematopoietic system...." The sentence, following the first one quoted above, reads: " It must, however, be borne in mind that both Naegeli and Piney regard the monocyte as a cell derived directly from the myeloblast." But on page 26 of the book the authors do me the honour to quote I say that the term " pro" monocyte " is preferable to monoblast," because the latter implies that the monocytes have a separate genealogical history. Surely it is clear that my contention is that the monocyte is not derived directly from the myeloblast, but that I believe that an intermediate cell-form, the pro-monocyte, can be distinguished. So far as I know the only writer who has ever contended that monocytes were altered myeloblasts was Ziegler, but the view never found
acceptance.
"
After this defence of my position, may I attack another statement that appears in the paper by Whitby and Christie ? " The appearance of myeloblasts in the terminal phases has been recorded by other observers and does not, in our opinion, justify a diagnosis of myeloblastic leukaemia, but merely suggests that the myeloblast andmonoblast ’ have a common precursor cell." Now, in many cases of chronic myeloid leukaemia in which myelocytes dominate the blood picture
for months or years, there may be great myeloblastosis in the terminal acute stage. The number of myeloblasts in the blood may be so great as to make it impossible, except on clinical grounds, to distinguish the condition from a primarily acute myeloblastic Ieukaemia. It has been, and still is, usual to adduce this fact as evidence in favour of the view that myelocytes are derived from myeloblasts, but Whitby and Christie would presumably contend that it merely suggests that the myeloblast and the myelocyte have a common precursor cell ! If, however, they would agree to the commonly accepted interpretation of the fact, their argument in favour of the fundamental distinction between myeloblast and " monoblast " fails to carry conviction. And when they say, " The case, as judged by histological sections, appeared to present a partial myeloid termination ..." my view that the monocyte is a myeloid cell is strengthened rather than weakened by their observations. The very fact that a leukaemia which starts with a monocytic blood picture runs a less acute course than does a primarily myeloblastic leukaemia supports my view, because it is a commonplace that the more differentiated the predominant cell-type the less acute the course. This is clearly shown in Whitby and Christie’s case ; and I have observed it in two cases (unpublished): one of a lady aged 72, and the other a man of 67. The former died six months after the onset of symptoms, and the latter lived for 18 months. Incidentally, in both of these cases there was enlargement of the liver, but not of the spleen. It is unfortunate that there is so little information concerning the number of thrombocytes in monocytic leukaemia. In the case of the woman mentioned above, these elements were normal in number and structure throughout the illness, whereas in the man there was thrombocytopenia (down to 40,000 per c.mm.) during the last three months of life ; and there were many poikilothrombocytes. Both cases were treated with Campolon and calcium gluconate, with only transient improvement. ’
T
a,m.
Sir.
vnnrs
fa.ithfl1]lv.
A. PINEY, M.D.,
M.R.C.P.
Park-square West, N.W., Jan. 13th. MAGNESIUM SULPHATE IN ACUTE INTESTINAL STRANGULATION
To the Editor
of
THE LANCET
SiR,-In his valuable article on Prognosis in Acute Intestinal Strangulation LANCET, (THE Jan. 12th, p. 103) Mr. Claude Frankau states that the only safe drug to give by mouth is magnesium sulphate, as it acts purely by osmosis and helps to sweep away toxic products. From my much more limited experience I would agree about its value, especially when given at the same time as an injection of pituitrin, but not with his explanation. Over 25 years ago Mr. Frank Cook and Mr. E. G. Slesinger, then students at Guy’s Hospital, carried out some experiments with me, reported to the Therapeutical Section of the Royal Society of Medicine (see THE LANCET, 1908, ii., 1444), which proved that, whatever may occur in animals, saline aperients in man act only after absorption into the blood stream and not by attracting water into the lumen of the bowel. A watery stool is passed before the salts have reached the caecum, but not before some has been absorbed and excreted in the urine. The watery stool generally contains none of the salt, some of which is rapidly excreted in the urine