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WATERHOUSE-FRIDERICHSEN SYNDROME TREATED WITH CORTISONE
1305
family, do not achieve a tolerable developing artificially imperturbable
vacancies. Consideration of school reports and essays has reduced this number by about a third, the remaining two-
thirds being
interviewed and
given
a
test devised
modus vivendi by exteriors. Groen4 has also noted the effects of emotion on the course of multiple sclerosis, and has a paper on the subject in the press. J. W. PAULLEY. Ipswich.
by the
headmaster of the school. Of the 85
girls engaged
since the commencement of the
scheme, 14 (16-5%) have left before completion of the course. Of these, 5 found the pay insufficient and took up more remunerativejobs, 3 left because of family difficulties, 2 became too homesick to continue (residential accommodation is found for a maximum of 12 cadets whose homes are too distant for daily travel), 2 found the daily travelling too tiring, and 2 were unstable and unsatisfactory. Of the 71 girls who entered the hospitals as student nurses, there has so far been a wastage of 5 (7%). Of these, 2 were homesick and the other 3 either changed their minds about nursing or entered hospitals for general training. It will be seen that these wastage figures Are low, especially for those cadets who have become student nurses.
It is surely a little late for people to be throwing up their hands in horror at the idea of these schemes. In face of the chronic shortage of nurses many hospital authorities will tap this vast potential of middle-teenagers who are keen on becoming nurses and want some means of bridging the gap." It is therefore a matter not of turning one’s back upon the idea but of seeing that any scheme adopted is properly controlled. It was with this in mind that the Ministry of Health in May, 1950, issued their circular on Employment of Young Persons in Hospitals [H.M.C.(50)36]. In the previous February the Manchester Regional Hospital Board had issued a report from its nursing committee on the same subject and for the same reason. It was a matter of satisfaction to my committee that neither of these documents conflicted with our own scheme, which had started some months earlier. "
Manchester Babies’ and Children’s Hospital Management Committee.
H. TAYLOR Secretary.
HALLUX VALGUS connection with the article by Dr. Hardy SIR,-In and Mr. Clapham (June 14) it might be of interest to mention a very interesting case which I described in 1950.’newborn boy, the first child of a father in whose hallux valgus formed a hereditary trait and of a mother who had rubella during the first months of pregnancy. This newborn baby had bilateral hallux valgus, and in addition pes adductus, brachydactyly of the great toes, severe hypospadias, and cleft scrotum with a testis in each half.
I
saw a
family
Hilversum, Holland.
D. P. R. KEIZER.
DISSEMINATED SCLEROSIS 14 makes some guarded references to the effect of emotion on disseminated sclerosis. In 1947 I was interviewing controls for a study of ulcerative colitis ; and from the few cases of multiple sclerosis then seen I suspected that there was a direct relationship between the onset of the disease and its relapses on the one hand and nervous tension on the other. In 1948 various papers appeared dealing with 3 nervous influences in disseminated sclerosis.2 There may or may not be a characteristic personality for this disease, but a feature that has struck me as particularly common is emotional detachment from stresses and disasters. This mood, often, amounting to euphoria, is usually attributed to the disease. Possibly the brain lesions magnify it ; but my information, gathered from parents and siblings, is that these patients have always had this emotional detachment, which often has distinguished them from their brothers and sisters early in childhood. Rigid family backgrounds and high parental standards are common, with emotional display often frowned on. One wonders whether these patients, often the most sensitive members of their
SIR,-Your leading article of June
.
1. Keizer, D.P.R. Paris méd. Oct. 28, 1950. 2. Langworthy, O. R. Arch. Neurol. Psychiat. 1948, 59, 13. 3. Inman, W. S. Brit. J. Psychol. 1948, 21, 1135,
-
WATERHOUSE-FRIDERICHSEN SYNDROME TREATED WITH CORTISONE SiR,-Dr. Breen and his colleagues (June 7) report a case of the Waterhouse-Friderichsen syndrome in a baby of 10 months, who recovered with treatment by cortisone. As they have not been able to find a previous instance of recovery at such an age, the diagnosis of the syndrome in this and any subsequent cases reported is of paramount importance. The Waterhouse-Friderichsen syndrome, in their own words, is " the name commonly applied to fulminating meningococcal infection, characterised in life by collapse and hxmorrhages into the skin andpost mortem, in most cases, by haemorrhage into the adrenal glands." Obviously in recovered cases the adrenal damage cannot be verified so clearly as in fatal cases ; and in all claims of recovery under a new treatment the clinical evidence for the diagnosis should, if possible, be irrefutable. It should, for example, always include the results of attempts at a blood-pressure reading in both arms, preferably by two observers. In infants suffering from the established syndrome no sounds will usually be heard at all. In the case reported the evidence for circulatory collapse appears to have been based on cyanosis, an uncountable pulse-rate, respirations of 58 a minute, and a heavy purpuric rash over the legs and lower trunk with a few large ecchymoses. No sphygmomanometer reading is given. This may indeed have been a case of the Waterhouse-Friderichsen syndrome ; but it may almost equally have been a severe case of the ordinary form," especially since there was also purulent cerebrospinal fluid containing 100,000 polymorphs per c.mm. present within 12 hours of onset. The heavy blood and meningococcal infection, possibly accompanied by encephalitic involvement, may possibly have been responsible for the clinical symptoms mentioned. In well-established cases of the Waterhouse-Friderichsen syndrome meningitis of this degree. rarely supervenes so early as 12 hours after onset. I am well aware of the difficulties of securing that all steps shall be taken to confirm the diagnosis in such a medical emergency as this. I do, however, suggest that before cortisone is used for suspected cases of this syndrome, an attempt at least should be made to obtain "
a
blood-pressure reading.
H. STANLEY BANKS. Hospital, London, S.E.13. SIR,-I was interested to read the article by Dr. Breen and his colleagues, and I should like to describe a case I saw last year. A girl, aged 4 months, was admitted about midday on Park
Sept. 8, 1951, with a history of vomiting and restlessness from early morning. On admission her temperature was 100.6°F. She was pale and cyanosed. Her respirations were 60 per minute. There was a suspicion of neck rigidity. Examination of cerebrospinal fluid (O.S.F.) obtained by lumbar puncture on admission gave the following results : white blood-cells 100 per c.mIll.; red blood-cells 800 per c.mm.; 65 mg. per 100 ml. ; Pandy test weakly positive ; chlorides 700 mg. per 100 ml. ; sugar present. Sediment contained polymorphs and lymphocytes in equal numbers ; no organisms found. About three hours after admission large purple blotches appeared on the patient’s thighs and legs. She was treated with sulphamerazine 1-5 g. followed by 0-5 g. six-hourly, penicillin 200,000 units three-hourly, andEucortone ’ 1 ml.
protein
four-hourly. 4. Groen, J.
:
J. Mt. Sinai Hosp. 1951, 18, 71.
j
1306 On Sept. 10 a blood film showed intracellular diplococci which morphologically resembled meningococci. On Sept. 12 a specimen of C.S.F. showed : white blood-cells 200 per c.mm. ; protein 130 mg. per 100 ml. ; Pandy test positive ; chlorides 680 mg. per 100 ml. ; sugar present. Sediment : one polymorph cell containing 8 gram-negative
diplococci morphologically resembling meningococci
seen on
direct examination. This child was acutely ill on admission but made satisfactory progress. The temperature fell to normal after six days, when the sulphamerazine and the penicillin were discontinued. The eucortone was continued in reduced dosage for another
week. Convalescence
was
haemorrhagic spots
on
retarded the
ulceration of some of the These were slow to heal.
by
legs.
As in Dr. Breen’s case,
we also had a mild case of on the same day, admitted meningococcal meningitis which ran a straightforward course so that the patient was discharged in three weeks. This coincidence has on other one occasion in this hospital in the happened last three years, when 2 cases of meningococcal meningitis were admitted on the same day.
Cork Fever Hospital and House of Recovery.
M. J. LYNCH.
CALCIFEROL IN PULMONARY TUBERCULOSIS SiR,-In his letter of June 7 Dr. Jackson, surveying his series of cases in which calciferol was used with streptomycin and P.A.S., reports that " calciferol does not notably enhance the action of streptomycin and P.A.S. in any of the common forms of tuberculous
disease." Since this does not accord with Fielding’s1 observations, we should like to direct attention to the fact that Dr. Jackson’s cases were treated for six weeks only. Surely this is a much shorter period than most workers have advocated for comparable trials ? Calciferol has been investigated chiefly in lupus ; and Dowling,2 for one, observed that the earliest response to treatment did not appear in less than two or three months. In pulmonary tuberculosis, streptomycin and P.A.s. are the antibacterial agents, and calciferol acts at most as a tissue-repair stimulant. The views of the Medical Research Council on streptomycin and P.A.S. are relevant. Substantial response to treatment may not appear until two or three months have elapsed. In Fielding’s series treatment lasted for nine weeks to six months. But even if calciferol should not enhance the action of streptomycin and P.A.S., the question still remains as to whySterogyl-15 ’ should have no effect on the connective tissue of the lung when, as has been established, it has such a distinct effect on the connective tissue of the skin. Perhaps, in the cases treated by Dr. Jackson, the inflammatory process was in the initial stage of congestion and had not yet reached the stage of deposition of fibres, during which period alone the
pulmonary
gradual repair
process may Roussel Laboratories Ltd., London, N.W.10. GRIND YOUR
SIR,-In
begin. RANDOLPH WHITE.
OWN
BREAKFAST
her letter of
May 31, the vice-chairman of Housewives’ League when referring to wheat the adulteration, deprivation, and gassing of
the British mentions " The way to avoid the effects of these evil our food." processes is to grind your own breakfast.
coarse-grind an eggcupful of English compost-grown wheatgrain with some thirty turns of a small hand coffee-mill clamped to the table, damp it with six teaspoons of water I
and work it with
a
fork in
an
enamel bowl into
a
2-inch
ball, roll it out thin to about 5 inches square, cross-cut into This gives four, and leave them to dry on a wire grid. me freshly ground sweet-tasting wheatcakes, like Scottish oatcakes, of the whole of the wheat berry-its germ, its husk, its bran, and all-without any heating. I know that nothing 1. 2.
Fielding, J., Maloney, J. J. Lancet, 1951, ii, 614. Dowling, G. B., Gauvain, S., Macrae, D. E. Brit. med. J. 1948, i, 430.
has been added or taken away or gassed because I see the These self-ground actual grain before I grind it myself. wheatcakes cost much less than bread.
Those who
prefer
the
germless, branlcss, tasteless,
food-worthless agenised starch miscalled bread " may have it and any diseases it causes. GEOFFREY BOWLES. London, S.W.1.
colourless, "
NIGHT ACIDITY AND DUODENAL ULCER
SiR,-The daily fluctuation in secretion and acidity of gastric juice depends upon the times of meals and on the kind of food, as Pavlov 1 demonstrated. After a meal containing fat, oil, or butter, secretion and acidity diminish, while they are increased by a meal of bread, potatoes, meat, or cheese. Boric, in a report to the the
Serbian Academy of Sciences in 1951, stated that here in Yugoslavia, where maize bread forms a large part of the diet, the rise in gastric acidity is very high. He found that the carbohydrates in maize stimulated the production of a highly acid secretion. Kahlson2 showed that gastric secretion is increased by vagal dominance, the so-called vagotonia. Vagotonia is a result of pituitary action, particularly at night or in conditions of stress-e.g., in labour or during an asthmatic attack. In duodenal ulcer vagotonia is pronounced ; and during the night it leads to hypersecretion and hyperacidity of the gastric juice, which is at its most abundant and most acid shortly after midnight.3-5 I 4ave investigated the night secretion of gastric juice in 51 patients with radiologically verified duodenal ulcers. The patients were all on a bland ulcer diet for several At 6 P.M. they had a meal of before the experiment. rice with milk, white bread (100 g.), and butter (20 g.). At 1 A.M.-i.e., after 7 hours without food-samples of gastric juice were withdrawn. The fasting volume and acidity were roughly double the daytime figures. In several patients,
days
Gastric acidity in duodenal ulceration by day and by night, showing effect of caffeine.
moreover, the relation between free HC1 and total acidity was not the same during the night as it was during the day. In most cases the two curves were roughly parallel throughout the twenty-four hours, the highest rates being between
1 and 3 A.M. But in some patients the difference between free hydrochloric acid and total acidity rose sharply during the night-e.g., from 20 ml. of 0-1 NHCI (free acid 60, total acidity 80) during the day to 50 ml. (free acid 80, total acidity
130)
at
night.
I also investigated the effect of caffeine. A dose of 0-2 g. in 300 ml. of water produced a sharp fall in acidity, particularly during the night, in about a third of the patients. The accompanying graph shows this effect, and also the acidity curves in a typical case. Hypersecretion and hyperacidity were found in 42 patients (82%), with a peak between 1 and 2 A.M. The 1. Pavlov, I. The Work of the Digestive Glands. London, 1910. 2. Kahlson, G. Brit. med. J. 1948, ii, 1091. 3. Chalfen, S. S. Arch. VerdauKr. 1930, 47, 106. 4. Katsch, G. Diseases of the Digestive Organs. Berlin, 1938. 5. Bockus, H. L. Gastroenterology. Philadelphia, 1947 ; vol. 1.
family, do not achieve a tolerable developing artificially imperturbable
vacancies. Consideration of school reports and essays has reduced this number by about a third, the remaining two-
thirds being
interviewed and
given
a
test devised
modus vivendi by exteriors. Groen4 has also noted the effects of emotion on the course of multiple sclerosis, and has a paper on the subject in the press. J. W. PAULLEY. Ipswich.
by the
headmaster of the school. Of the 85
girls engaged
since the commencement of the
scheme, 14 (16-5%) have left before completion of the course. Of these, 5 found the pay insufficient and took up more remunerativejobs, 3 left because of family difficulties, 2 became too homesick to continue (residential accommodation is found for a maximum of 12 cadets whose homes are too distant for daily travel), 2 found the daily travelling too tiring, and 2 were unstable and unsatisfactory. Of the 71 girls who entered the hospitals as student nurses, there has so far been a wastage of 5 (7%). Of these, 2 were homesick and the other 3 either changed their minds about nursing or entered hospitals for general training. It will be seen that these wastage figures Are low, especially for those cadets who have become student nurses.
It is surely a little late for people to be throwing up their hands in horror at the idea of these schemes. In face of the chronic shortage of nurses many hospital authorities will tap this vast potential of middle-teenagers who are keen on becoming nurses and want some means of bridging the gap." It is therefore a matter not of turning one’s back upon the idea but of seeing that any scheme adopted is properly controlled. It was with this in mind that the Ministry of Health in May, 1950, issued their circular on Employment of Young Persons in Hospitals [H.M.C.(50)36]. In the previous February the Manchester Regional Hospital Board had issued a report from its nursing committee on the same subject and for the same reason. It was a matter of satisfaction to my committee that neither of these documents conflicted with our own scheme, which had started some months earlier. "
Manchester Babies’ and Children’s Hospital Management Committee.
H. TAYLOR Secretary.
HALLUX VALGUS connection with the article by Dr. Hardy SIR,-In and Mr. Clapham (June 14) it might be of interest to mention a very interesting case which I described in 1950.’newborn boy, the first child of a father in whose hallux valgus formed a hereditary trait and of a mother who had rubella during the first months of pregnancy. This newborn baby had bilateral hallux valgus, and in addition pes adductus, brachydactyly of the great toes, severe hypospadias, and cleft scrotum with a testis in each half.
I
saw a
family
Hilversum, Holland.
D. P. R. KEIZER.
DISSEMINATED SCLEROSIS 14 makes some guarded references to the effect of emotion on disseminated sclerosis. In 1947 I was interviewing controls for a study of ulcerative colitis ; and from the few cases of multiple sclerosis then seen I suspected that there was a direct relationship between the onset of the disease and its relapses on the one hand and nervous tension on the other. In 1948 various papers appeared dealing with 3 nervous influences in disseminated sclerosis.2 There may or may not be a characteristic personality for this disease, but a feature that has struck me as particularly common is emotional detachment from stresses and disasters. This mood, often, amounting to euphoria, is usually attributed to the disease. Possibly the brain lesions magnify it ; but my information, gathered from parents and siblings, is that these patients have always had this emotional detachment, which often has distinguished them from their brothers and sisters early in childhood. Rigid family backgrounds and high parental standards are common, with emotional display often frowned on. One wonders whether these patients, often the most sensitive members of their
SIR,-Your leading article of June
.
1. Keizer, D.P.R. Paris méd. Oct. 28, 1950. 2. Langworthy, O. R. Arch. Neurol. Psychiat. 1948, 59, 13. 3. Inman, W. S. Brit. J. Psychol. 1948, 21, 1135,
-
WATERHOUSE-FRIDERICHSEN SYNDROME TREATED WITH CORTISONE SiR,-Dr. Breen and his colleagues (June 7) report a case of the Waterhouse-Friderichsen syndrome in a baby of 10 months, who recovered with treatment by cortisone. As they have not been able to find a previous instance of recovery at such an age, the diagnosis of the syndrome in this and any subsequent cases reported is of paramount importance. The Waterhouse-Friderichsen syndrome, in their own words, is " the name commonly applied to fulminating meningococcal infection, characterised in life by collapse and hxmorrhages into the skin andpost mortem, in most cases, by haemorrhage into the adrenal glands." Obviously in recovered cases the adrenal damage cannot be verified so clearly as in fatal cases ; and in all claims of recovery under a new treatment the clinical evidence for the diagnosis should, if possible, be irrefutable. It should, for example, always include the results of attempts at a blood-pressure reading in both arms, preferably by two observers. In infants suffering from the established syndrome no sounds will usually be heard at all. In the case reported the evidence for circulatory collapse appears to have been based on cyanosis, an uncountable pulse-rate, respirations of 58 a minute, and a heavy purpuric rash over the legs and lower trunk with a few large ecchymoses. No sphygmomanometer reading is given. This may indeed have been a case of the Waterhouse-Friderichsen syndrome ; but it may almost equally have been a severe case of the ordinary form," especially since there was also purulent cerebrospinal fluid containing 100,000 polymorphs per c.mm. present within 12 hours of onset. The heavy blood and meningococcal infection, possibly accompanied by encephalitic involvement, may possibly have been responsible for the clinical symptoms mentioned. In well-established cases of the Waterhouse-Friderichsen syndrome meningitis of this degree. rarely supervenes so early as 12 hours after onset. I am well aware of the difficulties of securing that all steps shall be taken to confirm the diagnosis in such a medical emergency as this. I do, however, suggest that before cortisone is used for suspected cases of this syndrome, an attempt at least should be made to obtain "
a
blood-pressure reading.
H. STANLEY BANKS. Hospital, London, S.E.13. SIR,-I was interested to read the article by Dr. Breen and his colleagues, and I should like to describe a case I saw last year. A girl, aged 4 months, was admitted about midday on Park
Sept. 8, 1951, with a history of vomiting and restlessness from early morning. On admission her temperature was 100.6°F. She was pale and cyanosed. Her respirations were 60 per minute. There was a suspicion of neck rigidity. Examination of cerebrospinal fluid (O.S.F.) obtained by lumbar puncture on admission gave the following results : white blood-cells 100 per c.mIll.; red blood-cells 800 per c.mm.; 65 mg. per 100 ml. ; Pandy test weakly positive ; chlorides 700 mg. per 100 ml. ; sugar present. Sediment contained polymorphs and lymphocytes in equal numbers ; no organisms found. About three hours after admission large purple blotches appeared on the patient’s thighs and legs. She was treated with sulphamerazine 1-5 g. followed by 0-5 g. six-hourly, penicillin 200,000 units three-hourly, andEucortone ’ 1 ml.
protein
four-hourly. 4. Groen, J.
:
J. Mt. Sinai Hosp. 1951, 18, 71.
j
1306 On Sept. 10 a blood film showed intracellular diplococci which morphologically resembled meningococci. On Sept. 12 a specimen of C.S.F. showed : white blood-cells 200 per c.mm. ; protein 130 mg. per 100 ml. ; Pandy test positive ; chlorides 680 mg. per 100 ml. ; sugar present. Sediment : one polymorph cell containing 8 gram-negative
diplococci morphologically resembling meningococci
seen on
direct examination. This child was acutely ill on admission but made satisfactory progress. The temperature fell to normal after six days, when the sulphamerazine and the penicillin were discontinued. The eucortone was continued in reduced dosage for another
week. Convalescence
was
haemorrhagic spots
on
retarded the
ulceration of some of the These were slow to heal.
by
legs.
As in Dr. Breen’s case,
we also had a mild case of on the same day, admitted meningococcal meningitis which ran a straightforward course so that the patient was discharged in three weeks. This coincidence has on other one occasion in this hospital in the happened last three years, when 2 cases of meningococcal meningitis were admitted on the same day.
Cork Fever Hospital and House of Recovery.
M. J. LYNCH.
CALCIFEROL IN PULMONARY TUBERCULOSIS SiR,-In his letter of June 7 Dr. Jackson, surveying his series of cases in which calciferol was used with streptomycin and P.A.S., reports that " calciferol does not notably enhance the action of streptomycin and P.A.S. in any of the common forms of tuberculous
disease." Since this does not accord with Fielding’s1 observations, we should like to direct attention to the fact that Dr. Jackson’s cases were treated for six weeks only. Surely this is a much shorter period than most workers have advocated for comparable trials ? Calciferol has been investigated chiefly in lupus ; and Dowling,2 for one, observed that the earliest response to treatment did not appear in less than two or three months. In pulmonary tuberculosis, streptomycin and P.A.s. are the antibacterial agents, and calciferol acts at most as a tissue-repair stimulant. The views of the Medical Research Council on streptomycin and P.A.S. are relevant. Substantial response to treatment may not appear until two or three months have elapsed. In Fielding’s series treatment lasted for nine weeks to six months. But even if calciferol should not enhance the action of streptomycin and P.A.S., the question still remains as to whySterogyl-15 ’ should have no effect on the connective tissue of the lung when, as has been established, it has such a distinct effect on the connective tissue of the skin. Perhaps, in the cases treated by Dr. Jackson, the inflammatory process was in the initial stage of congestion and had not yet reached the stage of deposition of fibres, during which period alone the
pulmonary
gradual repair
process may Roussel Laboratories Ltd., London, N.W.10. GRIND YOUR
SIR,-In
begin. RANDOLPH WHITE.
OWN
BREAKFAST
her letter of
May 31, the vice-chairman of Housewives’ League when referring to wheat the adulteration, deprivation, and gassing of
the British mentions " The way to avoid the effects of these evil our food." processes is to grind your own breakfast.
coarse-grind an eggcupful of English compost-grown wheatgrain with some thirty turns of a small hand coffee-mill clamped to the table, damp it with six teaspoons of water I
and work it with
a
fork in
an
enamel bowl into
a
2-inch
ball, roll it out thin to about 5 inches square, cross-cut into This gives four, and leave them to dry on a wire grid. me freshly ground sweet-tasting wheatcakes, like Scottish oatcakes, of the whole of the wheat berry-its germ, its husk, its bran, and all-without any heating. I know that nothing 1. 2.
Fielding, J., Maloney, J. J. Lancet, 1951, ii, 614. Dowling, G. B., Gauvain, S., Macrae, D. E. Brit. med. J. 1948, i, 430.
has been added or taken away or gassed because I see the These self-ground actual grain before I grind it myself. wheatcakes cost much less than bread.
Those who
prefer
the
germless, branlcss, tasteless,
food-worthless agenised starch miscalled bread " may have it and any diseases it causes. GEOFFREY BOWLES. London, S.W.1.
colourless, "
NIGHT ACIDITY AND DUODENAL ULCER
SiR,-The daily fluctuation in secretion and acidity of gastric juice depends upon the times of meals and on the kind of food, as Pavlov 1 demonstrated. After a meal containing fat, oil, or butter, secretion and acidity diminish, while they are increased by a meal of bread, potatoes, meat, or cheese. Boric, in a report to the the
Serbian Academy of Sciences in 1951, stated that here in Yugoslavia, where maize bread forms a large part of the diet, the rise in gastric acidity is very high. He found that the carbohydrates in maize stimulated the production of a highly acid secretion. Kahlson2 showed that gastric secretion is increased by vagal dominance, the so-called vagotonia. Vagotonia is a result of pituitary action, particularly at night or in conditions of stress-e.g., in labour or during an asthmatic attack. In duodenal ulcer vagotonia is pronounced ; and during the night it leads to hypersecretion and hyperacidity of the gastric juice, which is at its most abundant and most acid shortly after midnight.3-5 I 4ave investigated the night secretion of gastric juice in 51 patients with radiologically verified duodenal ulcers. The patients were all on a bland ulcer diet for several At 6 P.M. they had a meal of before the experiment. rice with milk, white bread (100 g.), and butter (20 g.). At 1 A.M.-i.e., after 7 hours without food-samples of gastric juice were withdrawn. The fasting volume and acidity were roughly double the daytime figures. In several patients,
days
Gastric acidity in duodenal ulceration by day and by night, showing effect of caffeine.
moreover, the relation between free HC1 and total acidity was not the same during the night as it was during the day. In most cases the two curves were roughly parallel throughout the twenty-four hours, the highest rates being between
1 and 3 A.M. But in some patients the difference between free hydrochloric acid and total acidity rose sharply during the night-e.g., from 20 ml. of 0-1 NHCI (free acid 60, total acidity 80) during the day to 50 ml. (free acid 80, total acidity
130)
at
night.
I also investigated the effect of caffeine. A dose of 0-2 g. in 300 ml. of water produced a sharp fall in acidity, particularly during the night, in about a third of the patients. The accompanying graph shows this effect, and also the acidity curves in a typical case. Hypersecretion and hyperacidity were found in 42 patients (82%), with a peak between 1 and 2 A.M. The 1. Pavlov, I. The Work of the Digestive Glands. London, 1910. 2. Kahlson, G. Brit. med. J. 1948, ii, 1091. 3. Chalfen, S. S. Arch. VerdauKr. 1930, 47, 106. 4. Katsch, G. Diseases of the Digestive Organs. Berlin, 1938. 5. Bockus, H. L. Gastroenterology. Philadelphia, 1947 ; vol. 1.