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EFFECT OF BENADRYL ON GASTRIC ACIDITY

SiB,—It is generally agreed that the acid gastric juiceplays an important part in the production of simplepeptic ulcers. The most reliable methods of producing" peptic ulcers " experimentally-e.g., the diversion ofthe alkaline duodenal contents into the ileum or theimplantation of histamine in beeswax-are all based onthe assumption that the acid gastric juice is the mainfactor concerned in ulcer formation, and this assumptionunderlies both the experimental quest for the best typeof surgical procedure, and the work of Schiffrin andIvy 1 on enterogastrone, the latest of the inhibitorsof gastric secretion.

Secretion of gastric juice is initiated by three wavesof stimuli: (1) those of psychic origin acting throughthe vagi ; (2) those of gastric origin, which are of twomain types, including the direct action of the products

ot digestion,and the mech-anical andchemical Istimulation ofthe pyloricmucosa withits hormonallink to theparietal cells ;and (3) thoseof intestinalorigin , causedby the produc-tion of secreta-gogues in theduodenumand jejunumfrom foodsubstances,the details ofwhose actionare unknown.All thesestimuli annar-

rluuko

Fig. I-Graph showing free acid secreted by eightpatients in each 1/4 hour of a fractional gastricanalysis, with and without benadryl.

ently act ultimately through the agency of histamine,which is the strongest pharmacological stimulant to acidsecretion that is known, and which has a selective anddirect action on the parietal cells.

’ Benadryl ’ being an antagonist of histamine, I decidedto test its power to diminish the acidity of the gastricsecretion. It was therefore given by mouth to a fewpatients with diseases in no way connected with the

stomach andduodenum. Toeight women

with surgicallesions of thebreast bena-dryl was givenby mouth,evenly spacedover the 45min. beforethe beginningof the gastricanalysis. Inthe first twocases 150 mg.was given;but, since thisproduced a

definite in-crease in both

the free andtotal acidity inboth patients,

Fig. 2-Free acid secreted by a patient with anactive duodenal ulcer, with and withoutbenadryl (300 mg. by mouth).

the amount given was increased to 300 mg. in the latertrials, but with exactly the same results (fig. 1). Twoother patients were tested also ; in one of them, who hada duodenal ulcer, there was a huge increase in theacidity of the fasting contents, in spite of the fact that300 mg. of benadryl had been given (fig. 2). Theinvestigation was stopped because the findings confirm1. Schifirin, M. J., Ivy, A. C. Arch. Surg., Chicago, 1942, 44, 399.

those of McElin and Horton 2 and Moersch andRivers,3 and because Crane et a1.4 have shownexperimentally that benadryl does not protect guineapigsagainst the development of ulcers after the implantationof histamine in beeswax.My experiments seem to show that benadryl is unlikely

. to prove effective in the treatment of gastric andduodenal ulcers, and they throw some doubt on thehypothesis that the ultimate stimulus to the parietalcells is normally histamine. The sharp rise in gastricacidity which follows administration of benadryl shouldbe remembered when this drug is given to relievebronchial spasm or anaphylactic shock in patients withpeptic ulcer.

I wish to thank Mr. R. L. Newell for his help in thepresentation of this work.Manchester Royal Infirmary. F. S. A. DORAN.

GASTRO-ENTERITIS AND MASTOIDITIS

SiB,—I would like to endorse the observations(Sept. 13) of my friend Mr. McGibbon. His point is thatthe middle-ear infection is caused by the passage ofinfected vomitus from the nasopharynx up the eustachiantube, and not by a blood-borne infection. This assertionis supported and amplified by a case of my own in whicha well-developed infant of 14 days developed otitis mediawhich proved to be tuberculous. The organism wasconsidered to be of the bovine type ; and this led to thediscovery that the milk supplied to the child was tuber-culous. Furthermore it had been the mother’s customto feed the infant lying flat on its back ; and, if theflow through the teat was free, milk was often noticedin the child’s nose. In other words, there was recurringregurgitation of tuberculous milk into the nasopharynx,with ultimate infection of the middle ear. Anothersuggestive point is the frequency of otitis media or itsresidua in children with cleft palate, in which conditionnasopharyngeal regurgitation can readily take place.The following prophylactic measures therefore com-

mend themselves :1. Babies should be fed in the sitting position. --2. Weakly infants with gastro-enteritis should be

nursed in the lateral position, so that there is less riskof vomitus reaching the nose and nasopharynx. This,of course, demands unremitting nursing attention.

JOHN ROBERTS.

SALMONELLA IN THE BACK-YARD

SIR,-Your annotation of Aug. 23, does not emphasisethe recognised importance of different animal speciesas possible reservoirs of human salmonella infections inthis country. Reference is made to the danger ofS. typhi-murium food-poisoning from the consumptionof inadequately cooked duck eggs, and to that sectionof the Medical Research Council report dealing withthe isolation of salmonellas from the mesenteric lymph-glands of healthy pigs at slaughter. The annotationthen continues : " Other domestic animals may alsohave been invaded but there is no information on thispoint." In a survey of avian salmonellosis in Great Britain,Gordon and Buxton 6 have recorded the isolation frompoultry of S. pullorum, S. gallinar2czn, S. typhi-murium,S. thompson, S. enteritidis, S. eal-i,fornia, S. bareilly,S. montevideo, S. anatum, and S. london. Later, thesame workers reported S. oranienburg and S. bovismorbificans as causing serious disease in chicks ; andduring May of this year S. cubana and S. brancasterwere isolated from two separate hatches of turkeypoults. During the first eight months of this year overninety outbreaks of avian salmonellosis, excludingS. pullorum and S. gallinarum, have been recorded atthis laboratory ; and the organism most frequentlyencountered has been S. thompson.The importance of poultry as a possible reservoir of

salmonella infections from both the agricultural andpublic-health points of view is fully realised by theveterinary profession. Investigations into the methods

2. McElin, T. W., Horton, T. B. Proc. Mayo Clin. 1945, 20, 417.3. Moersch, R. U., Rivers, A. B. Gastroenterology, 1946, 7, 91.4. Crane, J. T., Lindsay, S., Dailey, M. E. Amer. J. digest. Dis.

1947. 14, 56. 5. Spec. Rep. Ser. med. Res. Coun., Lond. no. 260, 1947.6. Vet. J. 1946, 102, 187.7. Brit. med. J. 1947, i, 898.

491

of controlling salmonellosis of animal origin are beingcarried out. After S. pullorum (bacillary white diarrhoeaof chicks) and S. gallinarum (fowl typhoid), S. thompsonand S. typhi-murium are the commonest salmonella

types found in poultry in this country ; and much recentresearch has been directed against these types.8 8 Thecommon methods of egg contamination in the case ofS. thompson infection of fowls and S. typhi-muriuminfection of ducks have been demonstrated, and workis now in progress on practical methods of egg disin-fection.

Similar investigations into the incidence and controlof salmonellosis in other domestic animals, especiallyS. dublin infection of cattle,9 have also been in progressduring the last two years. It is hoped that from theseresults a clearer understanding of the relationshipbetween salmonella infections in man and animals willbe obtained.

Ministry of Agriculture,Veterinary Laboratory, Weybridge.

R. F. GORDONA. BUXTON.

STREPTOMYCIN TRIALS

SIR,-With regard to your report (Sept. 13, p. 398) ofmy paper to the International Conference of Physicians,may I make it clear that the cases I discussed were onlythose treated at the Hospital for Sick Children, GreatOrmond Street ? This hospital is but one of the manycentres where the Medical Research Council clinicaltrials with streptomycin have been taking place.Hospital for Sick Children,Great Ormond Street.

1. A. B. CATHIE.

POLIOMYELITIS IN SEMI-ISOLATEDCOMMUNITIES

SiR,-One of the fundamental problems of theepidemiology of poliomyelitis is how the virus getsits teeth, and it is suggested that a study of outbreakswhich have occurred or may occur in semi-isolatedcommunities such as residential schools and children’shomes at different stages of the general high prevalencemight throw some light on this problem. The essentialobject of the inquiry would be to find out how the diseasebehaves in such communities at different seasons of theyear. These communities have been chosen because itshould be easier to determine the number of subclinicalcases 10 occurring in them than in the general population.

I should be most grateful for information from doctorswho have had or may have to deal with outbreaks ipsemi-isolated communities. In the first instance a shortstatement as to the approximate date of the outbreak,population at risk, and the number of definite anddoubtful cases would make it possible to decide whethera more detailed investigation would be likely to con-tribute to the solution of the problem stated in thefirst sentence of this letter. Subsequently it will benecessary to collect information in a more or less standardform for ease of analysis. I should also like to hearimmediately when a first case appears in a previouslyunaffected communitv.Ministry of Health. W. H. BRADLEY.

DEODORISING REFRIGERATORS

SIR,-Dr. Marsh, who describes the use of a chloraminespray to abolish the odour of large refrigerating rooms(April 26, p. 576), may be interested to know that whenI was studying the value of activated vegetable charcoalin the purification of water-supplies some years ago Itested this material as a deodorant for domestic refrigera-tors in which fruit, milk, and other dairy products werestored. About 3-4 oz. of activated powdered charcoal,or twice this quantity of granular charcoal, was kept inan enamel saucer, nicely spread out to the rim, andallowed to remain on the top shelf of the refrigerator.The organic smell of the fruit and other food materials,which was very noticeable on opening the door, and the8. Gordon, R. F., Buxton, A. J. Hyg., Camb. 1945, 44, 179 ; Mon.

Bull. Min. Hlth. P.H.L.S. 1945, 4, 46. Wilson, J. E. Vet. Rec.1945, 57, 411. Gordon, R. F., Garside, J. S. J. comp. Path.1944, 54, 61.

9. John, F. V. Vet. Rec. 1946, 58, 211. Bythell, D. W. P. Ibid,425.

10. See Casey, A. E., Fishbein, W.I., Abrams, A. Amer. J. Dis.Child. 1946, 72, 661. Annotation in Brit. med. J. Sept. 13,p. 423.

refrigerating odour which was always present were nolonger evident. The activated charcoal remained efficientand potent for from 7 to 12 days, depending on thequantity of stored materials and possibly also on theintensity of the odour of some of the fruits. Duringthis period the charcoal was turned and disturbed withthe fingers every 2 or 3 days to bring fresh surfaces to thetop.

T. N. S. RAGHAVACHARI.

PLASTIC ARCH-SUPPORTS

SiR,-The value of arch-supports for weakness of boththe longitudinal and the transverse arches has beendebated for many years. A great variety’of methods oftreatment has been suggested. These include wedgesplaced at various points of the sole and heel; theWhitman brace made to a corrected plaster cast of thefoot; manipulation and immobilisation in the over-

corrected position in plaster-of-paris ; and callipersdesigned to correct both the leg and the foot. The basicidea in all of them is to make the patient walk with thefoot in the straight or neutral position and to removestrain from painful areas.At least in a proportion of cases the mal-alignment of

the foot appears to call for some type of arch-support.Lightness of weight and ease of manufacture and adjust-ment are important desiderata. A substance whichappears to possess these attributes is a plastic developedat the beginning of the late war by the Du PontCorporation in America.The American plastic is transparent, is light in weight, is

impervious to any chemical reagent except some alcohols,and while rigid at body temperatures is sufficientlysoftened by a somewhat greater heat to allow of mouldingand manipulation. When softened in this way it willconform to any shape or pattern and has been usedinstead of the customary plaster-of-paris cast in thetreatment of spinal and limb deformities and fractures.It has also been used in the treatment of varicose ulcersof the leg to provide support, exclude air, and atthe same time allow of inspection of the ulcer andsurrounding skin.The method adopted is to take a plaster cast of the

part. After setting, the cast is removed and a paperpattern made. The pattern is used to cut out from sheet-plastic of suitable thickness a piece which can be softenedby heat and moulded to the plaster cast. When appliedto the patient any defects, such as pressure points, arevisible and can be remedied immediately by localsoftening and adjustment. Its advantages over plaster-of-paris are :

.

1. Its transparency allows examination of the part withoutremoval of the splint.

2. Pressure points are visible and can be remedied at once.3. The splint is only a fraction of the weight of plaster-of-

paris.4. Corrections of shape can be made without making a

new complete cast.5. Being made in various thicknesses it is easy to choose

whatever strength is required.For my experiments in making arch-supports I used

’Perspex,’ supplied by Imperial Chemical Industries Ltd.The technique adopted was similar to that described byMac&owan. 1

1. A slipper cast made with plaster-of-paris bandages istaken of the foot while at rest-i.e., non-weight-bearing, forit is when weight-bearing that deformity appears.

2. While the plaster is still deformable any necessarycorrection of shape is made by digital pressure.

3. After removing the plaster cast a positive is made, andon this the outline of the desired support is drawn with anindelible-ink pencil. A paper pattern is cut to conform to theoutline and from it the necessary shaped piece of perspex iscut.

4. The perspex is then heated until pliable, placed on theplaster positive, and pressed until it conforms to every contour.

5. The hardened support is finished by smoothing all edgesand by polishing.

According to the amount of support required a suit-able thickness of perspex is chosen. It must be borne

1. MacGowan, T. J. B. A. Lancet, 1943, i, 805.