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VINCA ALKALOIDS AND SALIVARY-GLAND PAIN
336
Neglect of allergy as a specialty in this country is undoubtedly due
lack of interest because of poor treatment results, but recent advances in immunology could stimulate young physicians to enter this field with as much enthusiasm as colleagues in the United States. Allergists observe the chronic asthmatic through all the seven ages, because for them there is no demarcation between childhood and adolescence, with transfer to another consultant at a crucial period in the patient’s life. Dr. Jacoby’s approach to the problem of the asthmatic child is enlightened, but in ignoring allergic factors there is the potential danger that some children will become unnecessarily steroid-dependent. One is thankful for the means to give relief, but magic formulas for quick, easy cures remain as elusive as
tion of dietary sugar and total calories. Apart from the diet it is quite possible, and even likely, that the treated group are more highly motivated than the control group to reduce weight, take more exercise, and alter their smoking habits. The construction and running of one of these large trials cannot, of course, be beyond criticism, but at the same time caution must be exercised in the evaluation of the results. A. J. SALTER Basle, Switzerland.
to
ever.
H. MORROW BROWN.
VINCA ALKALOIDS AND SALIVARY-GLAND PAIN SiR,—The combination of salivary-gland pain and severe constipation was not uncommon in patients treated with
pempidine hydrogen
tartrate
(’Tenormal’, ’Perolysen’)
at a
time when the absence of other effective hypotensive drugs required its use in high dosage. Distension of the salivary glands was not found in these patients-indeed, salivary secretion was reduced. The similar and unusual combination of symptoms described by Dr. Rose (Jan. 28, p. 213) in patients treated with vinca alkaloids makes a ganglion-blockade effect
tempting explanation. The constipation of pempidine-induced ganglion blockade resembles that resulting from other similar agents. It is at least partly due to decreased intestinal motility, as described by Goldstone1 in a patient receiving pentamethonium, whose condition of abdominal pain, vomiting, distension, and constipation mimicked acute intestinal obstruction so closely that laparotomy was undertaken. The small gut was principally a
affected. The outcome was fatal. If a ganglion-blockade effect is the correct explanation in the case of vinca alkaloids too, then, while laxatives clearly have a place, the use of neostigmine might be considered if distension has developed. I wonder whether guanethidine relieved the symptoms, as it sometimes did when they were due to
pempidine. Royal Free Hospital, Gray’s Inn Road, London W.C.1.
ANTHONY G. WHITE.
PROPRANOLOL IN MYOCARDIAL INFARCTION SIR,-Dr. Smith (Jan. 21, p. 165) has misread our letter.2 We do not use propranolol routinely in acute myocardial infarction. Our reason for writing was to indicate that the complication of recurrent ventricular fibrillation may be amenable to treatment with propranolol, in a dosage onetenth of that recommended by Sloman et awl.3 H. IKRAM Charing Cross Hospital, P. G. F. NIXON. London W.C.2.
THE ANTI-CORONARY CLUB SiR,—Ishould like to comment on your annotation (Jan. 21,
p. 148). It is certainly very important that a group such as the Anticoronary Club has produced a significant reduction in mortality from coronary heart-disease, but it should not be assumed, however, that this reduction in mortality is necessarily the result of a change in the polyunsaturated saturated fat ratio in the diet. The findings of the Club do not help to make the question of aetiology any less controversial than before, for if their diet is carefully studied it will be seen that there is a reduc1. Goldstone, B. S. Afr. med. J. 1952, 26, 552. 2. Ikram, H., Nixon, P. G. F. Lancet, 1966, ii, 1134. 3. Sloman, G. J., Robinson, J. S., Mclean, K. H. Br. med. J. 1965, i, 895.
UTERINE CANCER in your annotation,’ We have three remark SIR,-The Women and Oriental in of Occidental Jewish groups (i.e., with similar very low Israel, as well as New York City] incidence-rates for cervical cancer, yet showing very wide differences in the only factors that have seemed to be positively associated with cervical cancer", calls for a number of reservations. The comprehensive report by Stewart et al.,2 the basis for your statement, has one major drawback: its classification of all Israeli Jews coming from Asia and Africa, together with the "
...
"
Sephardi Jews, as being " Sephardi-Oriental Jews as opposed to Ashkenazi Jews-those of European origin-is rather mechanical. The Jewish communities in the different Islamic countries, of which the largest were in Yemen, Iraq, and North Africa, were isolated from each other for many centuries, and differ strikingly both genetically and culturally. For example, glucose-6-phosphate-dehydrogenase deficiency is highly prevalent in Iraq, but less so in Yemenite Jews (5:1), and much less in Jews from North Africa (20:1).3 The frequency of various forms of cancer, such as of stomachand cesophagus,l differs between these groups as well. Thus, even the grouping by continent of origin such as Asia and Africa is unsatisfactory, and distinction should be made by country of exile-i.e., Yemen, Babylon (Iraq, Iran, and Kurdistan), North Africa, and Eastern and Central Europe (Ashkenazis). Evidence collected so far points to the fact that this is probably true for cancer of the cervix as well. Preliminary "
"
evaluation of the rates6 for the past 5 years indicates that agecancer of Israeli women born in North Africa is about twice as high as in women born in Rumania and more than three times as high as in those born in Russia, Poland, and Germany. These figures confirm former clinical impressions in our hospital that cancer of the cervix is more prevalent among women coming from North Africa than in the European group and in other, though non-Ashkenazi, groups like the Yemenites. Consequently by grouping the Yemenites with a low incidence and the Iraqui Jews with a medium one into one " Sephardi-Oriental " conglomerate, as is done by Stewart et al., these differences would obviously cancel each other out. A more detailed evaluation of this problem is now in progress. Thus, your query whether " Jewish women are partly protected from cervical cancer " and your conclusion that " all the obvious leads seem to have petered out " are not supported. On the contrary, we have at hand several groups of Jewish women who differ widely in both incidence of cervical cancer and marital history and habits. These observations, as well as the recent data of Martin and Lilienfeld7 on coital factors in cervical cancer among Jewish women, may provide an excellent opportunity for the evaluation of associated attributes. BARUCH MODAN MICHAELA MODAN Tel Hashomer Government Hospital, CHAIM SHEBA. Israel.
adjusted incidence of cervical
1. 2. 3. 4. 5. 6. 7.
Lancet, 1966, ii, 1453. Stewart, H. L., Dunham, L. J., Casper, J., Dorn, H. F., Thomas, L. B., Edgcom, J. H., Symeonidis, A. J. Natn. Cancer Inst. 1966, 37, 1. Sheba, Ch., Szeinberg, A., Ramot, B., Adam, A., Ashkenazi, I. Am. J. publ. Hlth, 1962, 52, 1101. Tulchinsky, D., Modan, B. Cancer, N. Y. (in the press). Fishel, B. Unpublished. Steinitz, R. Harefuah, 1966, 71, 347. Martin, C. Paper presented at the American Public Health Association meeting, San Francisco, November, 1966.
Neglect of allergy as a specialty in this country is undoubtedly due
lack of interest because of poor treatment results, but recent advances in immunology could stimulate young physicians to enter this field with as much enthusiasm as colleagues in the United States. Allergists observe the chronic asthmatic through all the seven ages, because for them there is no demarcation between childhood and adolescence, with transfer to another consultant at a crucial period in the patient’s life. Dr. Jacoby’s approach to the problem of the asthmatic child is enlightened, but in ignoring allergic factors there is the potential danger that some children will become unnecessarily steroid-dependent. One is thankful for the means to give relief, but magic formulas for quick, easy cures remain as elusive as
tion of dietary sugar and total calories. Apart from the diet it is quite possible, and even likely, that the treated group are more highly motivated than the control group to reduce weight, take more exercise, and alter their smoking habits. The construction and running of one of these large trials cannot, of course, be beyond criticism, but at the same time caution must be exercised in the evaluation of the results. A. J. SALTER Basle, Switzerland.
to
ever.
H. MORROW BROWN.
VINCA ALKALOIDS AND SALIVARY-GLAND PAIN SiR,—The combination of salivary-gland pain and severe constipation was not uncommon in patients treated with
pempidine hydrogen
tartrate
(’Tenormal’, ’Perolysen’)
at a
time when the absence of other effective hypotensive drugs required its use in high dosage. Distension of the salivary glands was not found in these patients-indeed, salivary secretion was reduced. The similar and unusual combination of symptoms described by Dr. Rose (Jan. 28, p. 213) in patients treated with vinca alkaloids makes a ganglion-blockade effect
tempting explanation. The constipation of pempidine-induced ganglion blockade resembles that resulting from other similar agents. It is at least partly due to decreased intestinal motility, as described by Goldstone1 in a patient receiving pentamethonium, whose condition of abdominal pain, vomiting, distension, and constipation mimicked acute intestinal obstruction so closely that laparotomy was undertaken. The small gut was principally a
affected. The outcome was fatal. If a ganglion-blockade effect is the correct explanation in the case of vinca alkaloids too, then, while laxatives clearly have a place, the use of neostigmine might be considered if distension has developed. I wonder whether guanethidine relieved the symptoms, as it sometimes did when they were due to
pempidine. Royal Free Hospital, Gray’s Inn Road, London W.C.1.
ANTHONY G. WHITE.
PROPRANOLOL IN MYOCARDIAL INFARCTION SIR,-Dr. Smith (Jan. 21, p. 165) has misread our letter.2 We do not use propranolol routinely in acute myocardial infarction. Our reason for writing was to indicate that the complication of recurrent ventricular fibrillation may be amenable to treatment with propranolol, in a dosage onetenth of that recommended by Sloman et awl.3 H. IKRAM Charing Cross Hospital, P. G. F. NIXON. London W.C.2.
THE ANTI-CORONARY CLUB SiR,—Ishould like to comment on your annotation (Jan. 21,
p. 148). It is certainly very important that a group such as the Anticoronary Club has produced a significant reduction in mortality from coronary heart-disease, but it should not be assumed, however, that this reduction in mortality is necessarily the result of a change in the polyunsaturated saturated fat ratio in the diet. The findings of the Club do not help to make the question of aetiology any less controversial than before, for if their diet is carefully studied it will be seen that there is a reduc1. Goldstone, B. S. Afr. med. J. 1952, 26, 552. 2. Ikram, H., Nixon, P. G. F. Lancet, 1966, ii, 1134. 3. Sloman, G. J., Robinson, J. S., Mclean, K. H. Br. med. J. 1965, i, 895.
UTERINE CANCER in your annotation,’ We have three remark SIR,-The Women and Oriental in of Occidental Jewish groups (i.e., with similar very low Israel, as well as New York City] incidence-rates for cervical cancer, yet showing very wide differences in the only factors that have seemed to be positively associated with cervical cancer", calls for a number of reservations. The comprehensive report by Stewart et al.,2 the basis for your statement, has one major drawback: its classification of all Israeli Jews coming from Asia and Africa, together with the "
...
"
Sephardi Jews, as being " Sephardi-Oriental Jews as opposed to Ashkenazi Jews-those of European origin-is rather mechanical. The Jewish communities in the different Islamic countries, of which the largest were in Yemen, Iraq, and North Africa, were isolated from each other for many centuries, and differ strikingly both genetically and culturally. For example, glucose-6-phosphate-dehydrogenase deficiency is highly prevalent in Iraq, but less so in Yemenite Jews (5:1), and much less in Jews from North Africa (20:1).3 The frequency of various forms of cancer, such as of stomachand cesophagus,l differs between these groups as well. Thus, even the grouping by continent of origin such as Asia and Africa is unsatisfactory, and distinction should be made by country of exile-i.e., Yemen, Babylon (Iraq, Iran, and Kurdistan), North Africa, and Eastern and Central Europe (Ashkenazis). Evidence collected so far points to the fact that this is probably true for cancer of the cervix as well. Preliminary "
"
evaluation of the rates6 for the past 5 years indicates that agecancer of Israeli women born in North Africa is about twice as high as in women born in Rumania and more than three times as high as in those born in Russia, Poland, and Germany. These figures confirm former clinical impressions in our hospital that cancer of the cervix is more prevalent among women coming from North Africa than in the European group and in other, though non-Ashkenazi, groups like the Yemenites. Consequently by grouping the Yemenites with a low incidence and the Iraqui Jews with a medium one into one " Sephardi-Oriental " conglomerate, as is done by Stewart et al., these differences would obviously cancel each other out. A more detailed evaluation of this problem is now in progress. Thus, your query whether " Jewish women are partly protected from cervical cancer " and your conclusion that " all the obvious leads seem to have petered out " are not supported. On the contrary, we have at hand several groups of Jewish women who differ widely in both incidence of cervical cancer and marital history and habits. These observations, as well as the recent data of Martin and Lilienfeld7 on coital factors in cervical cancer among Jewish women, may provide an excellent opportunity for the evaluation of associated attributes. BARUCH MODAN MICHAELA MODAN Tel Hashomer Government Hospital, CHAIM SHEBA. Israel.
adjusted incidence of cervical
1. 2. 3. 4. 5. 6. 7.
Lancet, 1966, ii, 1453. Stewart, H. L., Dunham, L. J., Casper, J., Dorn, H. F., Thomas, L. B., Edgcom, J. H., Symeonidis, A. J. Natn. Cancer Inst. 1966, 37, 1. Sheba, Ch., Szeinberg, A., Ramot, B., Adam, A., Ashkenazi, I. Am. J. publ. Hlth, 1962, 52, 1101. Tulchinsky, D., Modan, B. Cancer, N. Y. (in the press). Fishel, B. Unpublished. Steinitz, R. Harefuah, 1966, 71, 347. Martin, C. Paper presented at the American Public Health Association meeting, San Francisco, November, 1966.