Document a1qw9zD15qxr7Q9ybee1JQv4N

/ '1 v V 1Z 1963 .CORRESPONDENCE BlUTUM MidiCal Jou*haa 123 PLAINTIFF'S ti EXHIBIT - ' Congenital Defects Due to Thalidomide condition, basal asbestosis, and stress its association not Sir,--We were interested to read Dr. M. A. L6cutier's case report (December I, p. 1447) of a baby with j.'tipie congenital deformities which were attributed to only with malignant mesothelioma of the pleura but also of the peritoneum.1 Briefly, the following poiots were made: Jdomide: Similar features were observed at a (1) There is a condition, limited or basal asbestosis, aecropsy recently performed on a baby born in this where the lesion is more or less confined to the lung hospital. Io tfus case, however, the date of prescription bases, presumably due to the downward movement of of ihaiidomide has been checked from the original ' the sharp asbestos fibres, before they become asbestos * prescription. bodies. This produces no pulmonary signs or symptoms, ` is not evident clinicaily, and is usually overlooked at Case History.--A woman aged 29 was delivered normally of j lb. {2.9 kg.) female infant at 41 weeks' gestation. She has one other live normal child aged 8. The mother necropsy. It will be missed even microscopically, unless sections arc examined from the lung bases. was prescribed triptizoi" (amitriptyline) 25 ms. t.dj. oa (2) While this basal asbestosis is unlike classical September 14, 1961. for depression, and thalidomide asbestosis in most particulars, it appears to attain locally ("distavai ") was added on October 10. 1961, 25 mg. daily. a carcinogenic concentration, and as this lesion does not One hundred tablets were prescribed. She returned to beu shorten the patient's life the carcinogenic action of general practitioner on January 11, 1962. and reported that the was pregnant (LM.P. November 26, 1961). Pregnancy was normal throughout. At birth the baby was noted to have gross upper limb deformities and an abnormal, flattened face. On the tenth day of life a systolic murmur was heard for the first time. Her general condition was otherwise good and she was discharged. She returned to asbestos can presumably act for a longer period. Indeed, this basal asbestosis may be found later to produce more malignant tumours than classical asbestosis. (3) In three years in the necropsy service of a teaching hospital six cases of malignant mesothelioma were encountered, three pleural and three peritoneal, and in the routine foiiow-up clinic aged 6 weeks in cardiac failure five of these the basal asbestosis was demonstrated. The and was admitted to the Royal Hospital for Sick Children, where she died on November 19. Necropsy.--There was gross shortening of both forearms with absence of uinar bones and flexural deformities of both wrists. There were only four fusiform digits on both hands and a vestigial thumb had been amputated from the left hand on September 19. The heart was enlarged and showed truneus arteriosus and a high interventricular septal defect. lung bases are only a few millimetres distant from the peritoneum over the diaphragm, and the occurrence of peritoneal mesothelioma io basal asbestosis is aot unexpected. (4) In 1961 in four centres in the United States I fouad nine examples of basal asbestosis out of 15 cases of pieural and peritoneal mesotheliomas in which adequate The lungs showed terminal congestion but were otherwise lung was available for study. In all but two of them rmai. There was a deficiency of the left diaphragm. The the basal asbestosis had been overlooked. ' was normal apart from the absence of the appendix, left kidney was absent and the right kidney 1+ times normal si2e- The uterus was unicomuate, the one horn oo the right side. All other organs were examined but found normal. It appears that this woman became pregnant whilst taking thalidomide and continued to take it for four to five weeks after conception. In a recent article in this journal (October 13. p. 944) Drs. C. Lutwak-Mann and M. F. Hay, working on rats, suggest that thalidomide affects the preimplantation embryo, in addition to the toxic effect on limb buds. The generalized abnormali ties in this baby are in keeping with this suggestion, and this case re-emphasizes the potential dangers of prescribing any drugs to females of child-bearing age whether pregnaat or not. I am grateful to Dr. J. W. Farquhar for permission to report this case. (5) In very few of these cases was an industrial or occupational exposure to asbestos mentioned, but this is of no significance unless direct questions are put to patients or their relatives. What is more important is chat the world's annual consumption of asbestos has increased from 500.000 tons in 1942 to 2.400.000 tons in 1961, and that asbestos is to-day used in such a wide variety of manufactured products that, theoretically at least, the number of peopie who may be exposed to asbestos is enormous, and few of those thus exposed work in factories which are designated asbestos factories. In January, 1963, will appear an article* in which 1 draw attention to asbestos as a modern urban hazard. Asbestos is virtually indestructibie, and while strontium90 has a half-life of 23 years asbestos has a half-life of an infinity of years. The article demonstrates on evidence from necropsies that a large and increasing --I am, etc., Anne Stewart. percentage of the population are inhaling asbestos fibres. Elsie Ingiis Memorial Maternity Hospital. Edinburgh 3. ' As these tend to gravitate to the lung bases there will be a cumulative effect, and one wonders if in 20 years' Exposure to Asbestos Dust and Diffuse Pleural Mesotheliomas time asbestos-induced mesothelioma may not be as common as cancer of the lung is to-day.--I am, etc.. Department of Pathology. THOMSON. Sir.--The letters of Dr. W. J. Smithers and his colleagues (November 3, p. 1194) and of Dr. W. T. E. University of Capetown Medical School, Observatory, C.P., South Africa. McCaughey and his colleagues (November 24, p. 1397) Referswcis -'-aw attention to the association between malignant "i*heiioma of the pleura and exposure to asbestos In the first letter it is mentioned that the degree of . .monary asbestosis in these cases of pieural meso 1 Thomson, J G.. S. A.fr. med. J.. 1962. 36. 759. ' -- Kdschuia, R_ O. C.. and 'MacOonaid. R. R.. ibid., hi press. Risks of Primary Vaccinarion thelioma may be variable, and in the second that the StR.--Professor G. W. A. Dick (November 17. p. 1275) duration of the exposure to asbestos dust may be reprinrs a table (1) on "Mortality per Million Primary intermittent. It wouid appear that they have not noticed Vaccinations which seems to me to mislead. There is a recent article in which I describe a new pulmonary no mention of the number at risk in each separate age S' 9, W>(3 CORRESPONDENCE 3MTI1II MtOICAk JOl'HHAt 401 o abdominal .pain. Obviously patients who sulFcr i chrome headaches, from whatever cause, must be !ercd on their merits. In this respect it is worth 'niog that Mr. Hanna's second case of appendi- * which he could discover no urinary cause. I a severe headache 12 hours after the onset ae abdominal pain (personal communication). With e provisos, however. I reaffirm that I have never 3untercd a true headache that coincided with the :t of the abdominal pain in a case of uncomplicated :e appendicitis.--I am. etc.. . Austell. Cornwall. D. G. WiLSON G.YNE. ir.--In the correspondence arising from Dr. H. E. ding's article (October 20. p. 102S) little has been about his suggestion that psychological factors at be important. An explanation put forward by George Qvist (November 3, p. 1189) for the surfeit normal appendices removed is that the symptoms produced'by psychologically determined appendiceal c. However, Professor J. Chassar Moir (December 1467) has pointed out that such pain would be rred to the midline and not the right iliac fossa, re is certainly no evidence that appendicitis, histocaily proved, is a psychosomatic disease.1 lowever, I believe that in some cases surgeons are iced to operate for quite complicated reasons. 1 ember a 16-year-old girl who was under treatment me with psychotherapy, and who developed aodomipain. This localized in the right iliac fossa when she ceived that this area caused her G.P. most anxiety '-he examined her. Twice she was referred to colleagues whom I persuaded not to operate, bird occasion she saw a surgeon who did not sio. that psychological factors were relevant. A mai appendix was removed and the patient enjoyed hospital admission enormously. General hospitals are used very much more than some :tors. beiieve as sources of care, as refuges from ironmentai difficulties, and places where conflicts be resolved. The trouble begins when a patient 3 prefers his pseudo-organic complaint to solving resses at a psychological level meets a doctor-who siders " the search for the biochemical and structural on . . . the exclusive object of clinical inquiry.'*5 :at contemporary favourites are pseudo-disk lesions i pseudo-cervical spondyloses. }r. J. C. Barker (November 24. p. 1405) has again 'ught to our attention those who inflict on themselves iberate disabilities. Such patients suggest that less iignant forms of self-destruction occur and how ststem earnest surgery-seekers can be. The huge nbers of attempted suicides point towards the fact t patients are willing to take considerable risks with ir lives and bodies in order to obtain some emotional a which another person might think trivial. \ study of the ways bodily complaints are used in the otional economy of the person might be of consider:e interest. A start could be made with the owners those bulging case notes containing a record of a it to every specialist in the hospital.--I am. etc.. v.,i. Ian J. MacDonald. References 1 8agge. L.. J. psyehosom. Res.. 6. ii. 1 Hill. 0.. 3rit. mrd. J.. i960. I. 917. Sir.--I have been watching the correspondence about rors iq diagnosing appendicitis with considerable interest: for after nearly 40 years, during which I have been diagnosing it, I find f still make mistakes. The extra difficulty in young women is of course particularly well known to those of us who perforce have to be both surgeon and gynaecologist (and physician)--at least in acute cases. Nevertheless. I have waited in vain so far for some one to point out that it is precisely in young women that there is the most to lose if one fails to diagnose a truly present acute appendicitis. I have come across so many young women complaining of sterility and in whom there is a history of appendicitis with pelvic peritonitis. Personally, in girls and young women I feel it is less harmful for me to do* the occasional unnecessary laparotomy in the doubtful case than to risk future unhappiness to the patient from sterility due to adhesions from peritonitis.--I am, etc., Wairoa. New Zealand. L. A. RlDOELL. Exposure to Asbestos Dust Sir,--I was interested to read Dr. J. G. Thomson's letter (January 12, p. 123) in which he describes the condition basal asbestosis and notes its association with mesothelioma of both the pleura and peritoneum. In the Department of Radiology of the Royal Victoria Infirmary. Newcastle, a study has been made of calcified pieurai piaques occurring in the chest radiographs of asbestos workers. During the last 12 months calcified piaques overlying the diaphragm have been noted in the chest and subphrenic radiographs of two patients attend ing the casualty department with acute abdominal dis comfort. Questioning of the patients confirmed that they both worked with asbestos and in each case there bad been prolonged exposure. lo neither case was there any history of dyspnoea, which is in keeping with Dr. Thomson's first point. Further investigations did not reveal any cause for the abdominal pain, and it is interesting to postulate that it might be due to peritoneal involvement by asbestos fibres and that abdominal discomfort may be another presentation of asbestosis.-- I am, etc.. Deoartment of Radiolo^r, The Royal Victoria Infirmary. Newcastle upon Tyne !. ^ ^-ASVSON- Drugs for Depression Sir.--At St. Thomas's Hospital we have for several years now been investigating the value of the newer drugs in the treatment of various types of depression under general hospital conditions. Cases seen are much more akin to those seen in general practice compared with patients in psychiatric hospitals, which generally have to treat only the severer types of depression. And l am sure your Current Practice article on the use of these drugs (January 19. p. 173) is going to mislead many general practitioners about them, and calls for comment and criticism. . For instance, when it is suggested that combinations such as dexamphetamine and amyiobarbiione have been shown to be "about as beneficial as a dummy medica tion.'* this is certainiy not true in the case of the more psychopathic types of depression. In fact, as most general practitioners know, we are facing a virtual epidemic of " drinamyi '* (dexamphetamine and amylo- barbitone) addiction, simply because it can be so " -ikpr ' -i, ' > ' : )- vi .. &j i'Ufiiis. : Mfcjs !t"<r '.f i S3 i J3,i !fr Tii -tijf ^1$ & ;B5& nvs ** *\ I r;` t?.- j8.& 1I c- T*. lF ^ ; t' i& i&s: !:& I IF't' **>*1, m .1 ^ -ri iJ:*- *' jfg - Vft ' : !,;3fd } };gg j ; | y?n :1 tT lfc St M ^ Exposure to Asbestos Dust 5R.~^incc my communication of February 9 (p. 401) Pbave learnt that one of the patients referred to in the letter Was died. The post-mortem findings are interest ing and, I think, relevant to the previous correspondence in exposure to asbestos. The patient, a man aged 64. who had been exposed to asbestos for 34 years, attended the casualty department of the Royal Victoria Infirmary, Newcastle, with pain in the upper abdomen and left shoulder. This was his most severe attack of pain, although similar but less intense attacks had occurred over the previous 15 weeks. The pain gradually subsided and he was discharged following a barium meal examination, which did not show any abnormality in the upper gastrointestinal tract. He died several months later and a post-mortem examination, performed in another hospital, confirmed the diagnosis of asbestosis and in addition demonstrated diffuse involvement of the peritoneum by tumour tissue.. The gastrointestinal and other systems snowed no abnormality. Histologically this was thought to be either a secondary carcinoma, due to an unknown primary, or a mesothelioma. --1 am. etc.. Department of Neuro-Radiology, Newcastle General Hospital, Newcastle upoa Tyoe, 4. J- P- Lawson. New Methods of. Resuscitation Sir.--I was disappointed to read the two letters published under the beading " New Methods of Resuscitation " (January 12, p. 124). Oral resuscitation was of course known, practised, and taught in the eighteenth century. C. Kite, in his paper on drowning to the Humane Society in 1788. stated: " Direct an assistant to blow into the mouth through a oarse cloth, or use bellows.'* He realized then the difficulties which still deter the less venturesome. " The blowing into the mouth may upon an emergency answer , for a few times, but the difficulty of getting people to continue it will be- easily conceived on account of the operation being so extremely disagreeable and trouble some.'* Electrical stimulation of the heart was also advocated. The nineteenth century showed a steady swing away -from mechanical respirators and oral resuscitation to methods which moved the thoracic cage manually. 3oth letters refer to mechanical difficulties which the various first-aid organizations have been teaching their members to overcome Sor the past year. The fact that hundreds of non-medical personnel carry out mouth-tomouth resuscitation and external cardiac massage effi ciently suggests that these procedures are not difficult to teach anti understand. This has only been possible by the use of practice dummies mostly made in Norway, where even schoolchildren are taught and have saved lives by using one or both of these methods. As we in this country have entered this field rather late, the efforts which we must ail make in training must be quick, widespread and. more important, co-ordinated. Obviously all doctors must be given the opportunity to practise these methods, to ensure that they are not " put to shame** by first-aid personnel. Many of the latter will of course be only too glad to exhibit their skill to 'be embarrassment of the untrained doctor. Airways are unnecessary as an immediate first-aid measure, and should only be used by doctors. A simple anaesthetic airway is usually efficient and enables resuscitation and massage to be carried out from the side, which is usually more convenient than from the head, which is obligatory if the Brook airway is used. Without an airway the tongue, however toneless, can usually be kept clear provided tbat the bead is well extended and the jaw pulled up with the teeth closed. An airtight seal is not difficult to attain with practice, and exhaustion on the part of the resuscitator is usually due to incomplete clearing of tie casualty's airway, too forceful a '* blow,** or too frequent insufflations. Any feeling of " revulsion '* can be overcome by placing a handkerchief or thin cloth over the patient's face and blowing through this. If froth or vomit is troublesome, mouth-to-nose insufflation should be tried. Vomit is. of course, inhaled whether the patient is supine or prone, but in fact can -usually be cleared quicker with the patient on bis back, which gives a better view of the pharynx, etc., and so causes less interruption with the resuscitation. Vomiting, even following drowning, is not usually very troublesome. It may be that Schaefer's method, which requires pressure on the loins, may be more prone to cause vomiting by resultant abdominal pressure than oral resuscitation. May not most of the water that the advocates of Schaefer's method say is expressed so efficiently from the lungs in fact come from the stomach ? Even io the eighteenth century there was doubt as to how much water in fact reaches the lungs themselves. May I therefore suggest that doctors contact their local Red Cross and SL John Ambulance centres and ask to be shown the models now used in first-aid training, and not be too ashamed to request a demonstration and opportunity to try their '* hands and lungs ** in an art which unfortunately appears to be currently better demonstrated by " laymen " than medical personnel.-- I am. etc., Mansfield. Notts. 3- S. Baker. SfR.--Following the very useful article on " New Methods of Resuscitation '' (December 15. p. 1564), and the widespread publicity that " mouth-to-mouth '* artificial respiration has enjoyed recently, it is dis appointing to read the theoretical criticisms voiced bv Dr. T. H. Gillison (January 12, p. 124) and Dr. G. M. Hunter (January 26, p. 261). While in theory the aesthetic objections can loom large, it has been found that in the heat of an emergency neither medically trained nor lay persons have been deterred by these considerations from using the method to save life. Surely, too. the evidence already presented,1 both from controlled experimental studies and from a series of cases under emergency conditions in the field, is adequate proof of the superiority of this method. Of paramount importance in any method of artificial respiration must be the maintenance of a clear airway, otherwise no amount of manual pressure will result in air entering the lungs. In none of the manual methods, however, is this a primary consideration, and indeed only in mouth-to-mouth respiration are the hands free to maintain a patent airway. Because of his position, the rescuer in this technique immediately becomes aware of any obstruction of the* airway, can see if the chest expands during inflation, can readily carry out airway toilet, and can feei at once the return of spontaneous breathing. In contrast, the frequent failure of back pressure artificial respiration methods is due to upper airway obstruction which goes unnoticed. Only by mouth-to-mouth respiration can women, and even children, ventilate large adult men. and in addition > i 9