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X-RAY THERAPY FOR TOXIC GOITRE
296 wagon. Liquid paraffin is to be preferred where an oily instillation is indicated. In conclusion I would deprecate the advocacy by your distinguished correspondents of the tongueclip. This barbarous weapon should long have been abolished from the armamentarium of the anaesthetist. I am,
Sir, yours faithfully,
Harley Street, W.1, Jan. 28.
L. H. LERMAN.
X-RAY THERAPY FOR TOXIC GOITRE
SIR,-I note with much interest the remarks, in your last issue (p. 235), of Drs. Poulton and Watt as I have had experience of such cases over the past twenty years. I agree that our present results are" extremely good and at least 75 per cent. cures should be obtained with the accurate and standardised treatment that was not possible in the earlier days. In my opinion so-called " deep X rays " are not required ; I use 150 kV with 2 mm. Al. filtration and a dosage of 700 r. I have not found iodine medication necessary during treatment. I am, Sir, yours faithfully, "
WARNER COLLINS. Putney, London, S.W.15, Jan. 27. CLINICAL USE OF STILBŒSTROL on
SiR,—I have read with great interest the report the cestrogenic properties of stilboestrol contributed
to your issue of Jan. 7
by Drs. Bishop, Boycott, and Zuckerman. Recently I have studied the effects of this synthetic oestrogen on menopausal symptoms in 18 castrated women. The cestrogenic properties of stilbcestrol are beyond any doubt though I think that, when orally administered, it is three or four times less active than oestradiol benzoate subcutaneously injected at the same dosage. But I do not agree with Dr. Bishop and his associates about the toxicity of this drug. Among 46 patients they observed only 3 cases of transitory intolerance. I am somewhat less enthusiastic. All my patients have received stilbcestrol by mouth. In four cases the immediate reactions were very severe. After the absorption of doses so small as 0’3, 1, 2 and 3 mg. during two or three days, the patients experienced and continuous vomiting, rapidly severe nausea followed by a complete gastric intolerance, as long In these as stilbcestrol ingestion was continued. In cases the treatment was accordingly stopped. four other cases similar symptoms appeared later, after a continuous absorption of six weeks’ duration, involving total doses of 43, 53, 95 and 165 mg. Three other patients experienced slight and transitory nausea and epigastric pains after the ingestion of 46 mg. (in one month), 88 mg. (in one month) and 102 mg. (in two months). The remaining patients have tolerated stilboestrol quite well; but only two of them have had the treatment for more then six weeks.
Considering that this treatment of menopausal symptoms is one of substitution and must be continued over a very long period, I personally hesitate to employ it further ; for its innocuousness does not seem to me sufficiently demonstrated. I have never observed such an intolerance after or during the use of oestradiol benzoate or testosterone propionate for the relief of menopausal symptoms and I see no reason in replacing these drugs by stilbcestrol, which is less efficient and certainly toxic. I am, Sir, yours faithfully, Paris, Jan. 28.
J. VARANGOT.
SURGERY IN ULCERATIVE COLITIS
SiR,-Mr. Lockhart-Mummery has rightly stressed the need for differentiating between the degrees of severity of ulcerative colitis. The milder cases often respond well to medical treatment or appendicostomy. The bigger problem is the treatment of the bad cases, and particularly of those of the progressively fulminating type which rapidly go downhill and terminate fatally. It is in this last type that surgery is especially indicated. Appendicostomy has proved profoundly unsatisfactory in the severe case. Rest to an inflamed part is one of the primary maxims of surgery. and to secure this such operations as colostomy and caecostomy came into vogue. The objection to caecostomy is that it does not secure complete rest to the bowel, which is essential. If the object is to relieve distension and procure irrigation, this can be more satisfactorily accomplished by appendicostomy. Colostomy, whilst admirable in procuring rest to the bowel, has a limited applicability, for only rarely in the more severe cases is the distal segment of the colon only affected. Dr. Gaha’s treatment of ileosigmoidostomy and colostomy can only be applicable to the mild types. Anyone familiar, either at operation or post mortem, with the severe types knows that the friable, indurated and congested bowel precludes any form of anastomosis, the sigmoid colon and upper rectum often being involved. To procure the desired rest of the inflamed bowel a transverse ileostomy must be performed, and this treatment has been advocated by Mr. W. H. Ogilvie (Brit. med. J. 1938, 1, 1197). The following case is of interest with this in mind. A girl aged 22 was admitted to the Royal Victoria and West Hants Hospital under Dr. Watson Smith Five weeks before admission with ulcerative colitis. she experienced colicky pains chiefly in the left side of the abdomen. The pains were aggravated by food and somewhat relieved by defsecation. A week later she was suddenly seized with diarrhoea and began to pass 8-12 motions a day. The stools were normal in colour, they contained streaks of blood but
no mucus
and
were
very offensive.
She
improved slightly with bismuth and opium mixtures and dieting. Shortly before admission she began to get attacks of vomiting and nausea, and her stools now contained chiefly blood and mucus. She had lost 1 ly st. in five weeks. On admission her temperature was 102°F., pulse-rate 112 and she was pale and looked ill. The abdomen was slightly distended and tender all over, especially over her splenic and descending colon. Rectal examination with a speculum showed ulceration, and caused the passage of blood and
mucus.
Agglutination tests were negative for the typhoid and paratyphoid groups, the food-poisoning bacilli, Br. abortus and melitensis, B. dysenteriae, Flexner V. W. Y. Z. and Sonne ; positive for Shiga’s bacillus 1 in 25 and B. Newcastle 1 in 50. This was suggestive of a Shiga infection. Culture of stools gave a profuse growth of Streptococcus fcecalis, some haemolytic streptococci and a fair growth of B. pyocyaneus. Blood-count : 3,600,000 red cells, haemoglobin 46 per cent., leucocytes 12,000, polymorphs 78 per cent. The patient was treated medically for a further three weeks. Large doses of antidysenteric sera given daily ; Albargin washouts, Yatren injections. During this time she was going rapidly downhill.
When I was asked to see her she was very toxic and ill. Her temperature was swinging between 100°-103° F., pulse-rate 120. Under local aneesthetic I did an ileostomy with a spur. The whole of the colon from caecum to rectum appeared to be involved. The patient’s condition was critical but Within was improved with a blood transfusion.
Sir, yours faithfully,
Harley Street, W.1, Jan. 28.
L. H. LERMAN.
X-RAY THERAPY FOR TOXIC GOITRE
SIR,-I note with much interest the remarks, in your last issue (p. 235), of Drs. Poulton and Watt as I have had experience of such cases over the past twenty years. I agree that our present results are" extremely good and at least 75 per cent. cures should be obtained with the accurate and standardised treatment that was not possible in the earlier days. In my opinion so-called " deep X rays " are not required ; I use 150 kV with 2 mm. Al. filtration and a dosage of 700 r. I have not found iodine medication necessary during treatment. I am, Sir, yours faithfully, "
WARNER COLLINS. Putney, London, S.W.15, Jan. 27. CLINICAL USE OF STILBŒSTROL on
SiR,—I have read with great interest the report the cestrogenic properties of stilboestrol contributed
to your issue of Jan. 7
by Drs. Bishop, Boycott, and Zuckerman. Recently I have studied the effects of this synthetic oestrogen on menopausal symptoms in 18 castrated women. The cestrogenic properties of stilbcestrol are beyond any doubt though I think that, when orally administered, it is three or four times less active than oestradiol benzoate subcutaneously injected at the same dosage. But I do not agree with Dr. Bishop and his associates about the toxicity of this drug. Among 46 patients they observed only 3 cases of transitory intolerance. I am somewhat less enthusiastic. All my patients have received stilbcestrol by mouth. In four cases the immediate reactions were very severe. After the absorption of doses so small as 0’3, 1, 2 and 3 mg. during two or three days, the patients experienced and continuous vomiting, rapidly severe nausea followed by a complete gastric intolerance, as long In these as stilbcestrol ingestion was continued. In cases the treatment was accordingly stopped. four other cases similar symptoms appeared later, after a continuous absorption of six weeks’ duration, involving total doses of 43, 53, 95 and 165 mg. Three other patients experienced slight and transitory nausea and epigastric pains after the ingestion of 46 mg. (in one month), 88 mg. (in one month) and 102 mg. (in two months). The remaining patients have tolerated stilboestrol quite well; but only two of them have had the treatment for more then six weeks.
Considering that this treatment of menopausal symptoms is one of substitution and must be continued over a very long period, I personally hesitate to employ it further ; for its innocuousness does not seem to me sufficiently demonstrated. I have never observed such an intolerance after or during the use of oestradiol benzoate or testosterone propionate for the relief of menopausal symptoms and I see no reason in replacing these drugs by stilbcestrol, which is less efficient and certainly toxic. I am, Sir, yours faithfully, Paris, Jan. 28.
J. VARANGOT.
SURGERY IN ULCERATIVE COLITIS
SiR,-Mr. Lockhart-Mummery has rightly stressed the need for differentiating between the degrees of severity of ulcerative colitis. The milder cases often respond well to medical treatment or appendicostomy. The bigger problem is the treatment of the bad cases, and particularly of those of the progressively fulminating type which rapidly go downhill and terminate fatally. It is in this last type that surgery is especially indicated. Appendicostomy has proved profoundly unsatisfactory in the severe case. Rest to an inflamed part is one of the primary maxims of surgery. and to secure this such operations as colostomy and caecostomy came into vogue. The objection to caecostomy is that it does not secure complete rest to the bowel, which is essential. If the object is to relieve distension and procure irrigation, this can be more satisfactorily accomplished by appendicostomy. Colostomy, whilst admirable in procuring rest to the bowel, has a limited applicability, for only rarely in the more severe cases is the distal segment of the colon only affected. Dr. Gaha’s treatment of ileosigmoidostomy and colostomy can only be applicable to the mild types. Anyone familiar, either at operation or post mortem, with the severe types knows that the friable, indurated and congested bowel precludes any form of anastomosis, the sigmoid colon and upper rectum often being involved. To procure the desired rest of the inflamed bowel a transverse ileostomy must be performed, and this treatment has been advocated by Mr. W. H. Ogilvie (Brit. med. J. 1938, 1, 1197). The following case is of interest with this in mind. A girl aged 22 was admitted to the Royal Victoria and West Hants Hospital under Dr. Watson Smith Five weeks before admission with ulcerative colitis. she experienced colicky pains chiefly in the left side of the abdomen. The pains were aggravated by food and somewhat relieved by defsecation. A week later she was suddenly seized with diarrhoea and began to pass 8-12 motions a day. The stools were normal in colour, they contained streaks of blood but
no mucus
and
were
very offensive.
She
improved slightly with bismuth and opium mixtures and dieting. Shortly before admission she began to get attacks of vomiting and nausea, and her stools now contained chiefly blood and mucus. She had lost 1 ly st. in five weeks. On admission her temperature was 102°F., pulse-rate 112 and she was pale and looked ill. The abdomen was slightly distended and tender all over, especially over her splenic and descending colon. Rectal examination with a speculum showed ulceration, and caused the passage of blood and
mucus.
Agglutination tests were negative for the typhoid and paratyphoid groups, the food-poisoning bacilli, Br. abortus and melitensis, B. dysenteriae, Flexner V. W. Y. Z. and Sonne ; positive for Shiga’s bacillus 1 in 25 and B. Newcastle 1 in 50. This was suggestive of a Shiga infection. Culture of stools gave a profuse growth of Streptococcus fcecalis, some haemolytic streptococci and a fair growth of B. pyocyaneus. Blood-count : 3,600,000 red cells, haemoglobin 46 per cent., leucocytes 12,000, polymorphs 78 per cent. The patient was treated medically for a further three weeks. Large doses of antidysenteric sera given daily ; Albargin washouts, Yatren injections. During this time she was going rapidly downhill.
When I was asked to see her she was very toxic and ill. Her temperature was swinging between 100°-103° F., pulse-rate 120. Under local aneesthetic I did an ileostomy with a spur. The whole of the colon from caecum to rectum appeared to be involved. The patient’s condition was critical but Within was improved with a blood transfusion.