161 We agree that lithium preparations may be toxic if blood levels are not monitored, but estimations of serum-lithium concentration are readily available in most hospitals. The side-effects experienced by our patients were mild and occurred only at the beginning of treatment. It seems unlikely that these complications would present serious problems in short-term management, although they should be viewed with concern in the long term. Lithium, unlike the thiocarbamide group of drugs, has not been reported to cause hair loss or blood dyscrasias. The introduction of existing drugs for new therapeutic purposes demands careful evaluation. We feel it would be prudent to delay final judgment on the indications for lithium in thyrotoxicosis until further experience becomes available. J. H. LAZARUS A. R. RICHARDS Department of Medicine, University Hospital of Wales, Cardiff CF4 4XW.
G. M. ADDISON G. M. OWEN.
NEONATAL JAUNDICE AFTER INDUCTION OF LABOUR
SIR,-Following the suggestion by Ghosh and Hudson1 that an increase in the incidence of neonatal jaundice coincided with a more liberal use of oxytocin we did a prospective study2 of this possible hazard of oxytocin and prostaglandins (P.G.s). Clinically normal mothers having a ripe cervix and carrying a healthy fetus were electively induced at term by combining low amniotomy with administration of an oxytocic compound (either intravenous oxytocin, intravenous p.G.F2a, or oral P.G.E2). Intraamniotic pressure and fetal heart-rate
were
monitored
throughout. Vaginal delivery was spontaneous in all cases. At birth, fetuses were in good clinical (Apgar scores) and biochemical condition (acid-base status and blood gases). No other drugs than the oxytocic (anaesthetics, analgesics, &c.) were given. At birth (umbilical vein blood) and on the third day peripheral-vein blood-samples were obtained from the neonate and assayed for unconjugated and total bilirubin levels. These values were compared with those from controls (see accompanying table). MEAN SERUM-BILIRUBIN LEVELS
(mg.
per 100
ml.)
PRIMARY MEDICAL CARE OF MENTAL ILLNESS SIR,-Iwas very interested in your editorial (Dec. 7, p. 1362) and your opening sentence of the third paragraph about Who should be the members of the primary-care team ?" In our group practice certainly the general practitioners, health visitors, and our own nurses and nurse midwives have all played a part in this very large problem, but I should like to draw your attention to a very interesting recent addition to this team which is probably going to be of great value. A few months ago we were approached by the principal clinical psychologist of our local mental hospital and asked if we would be interested in providing a consulting-room and time so that he could see any cases which we thought suitable for psychotherapy at our own surgery, using the usual appointment system. Naturally we were very interested in these proposals and immediately made available a room and time, and patients are seen on an hourly basis either weekly or less often as is thought fit. I know that it is rather early to get any definite idea of how the scheme is working, but so far the idea seems to have a promising future in helping to deal with the multitude of psychiatric disorders which come our way; mainly the psychoneuroses. The Surgery, Sutton Valence, near
Maidstone,
INTRALESIONAL P.P.D. IN MALIGNANT MELANOMA SIR,-We read with great interest the results of giving B.c.G. to patients with melanoma, reported by Grant et aLl They point out that B.C.G. immunotherapy is useful in the treatment of malignant melanoma, but it is also fraught with many dangers-granulomatous hepatitis, secondary to dissemination in the bloodstream of live B.C.G. and secondary pulmonary infection by B.C.G. These complications generally occurred when B.c.G. was administered intralesionally, apparently the most effective route. We have treated a patient with disseminated malignant melanoma involving multiple subcutaneous areas. The patient had received B.C.G. intradermally weekly for two months and later intralesional B.C.G. There was a good response, with conversion of P.P.D. test to positive, and all
differences were found between the mean serum-bilirubin levels (at birth and on day 3) of the 74 controls and those of the children born after induction with either oxytocin (n=27) or a P.G. (n=30). Therefore, we concluded that intravenous oxytocin, intravenous p.G.FzII} and oral P.G.E2 used for elective induction of labour did not induce neonatal hyperbilirubinaemia up to the third day of neonatal life. M. THIERY Departments of Obstetrics and D. DE HEMPTINNE Pædiatrics, L. SCHUDDINCK of University Ghent, G. MARTENS. 9000 Ghent, Belgium. 1. Ghosh, A., Hudson, F. F. Lancet, 2. de Hemptinne, D., Schuddinck, 3.
1972, ii, 823. L., Thiery, M., Martens, G. International Research Communications System (73-12) 10-14-3. Calder, A. A., Moar, V. A., Ounsted, M. K., Turnbull, A. C. Lancet, 1974, ii, 1339.
lesions
essentially disappeared. Because of disease, the patient received more intralesional injections and subsequently developed B.C.G. peritonitis. The patient was treated with isoniazid and ethambutol, the symptoms of peritonitis resolved within four days, and the patient continued on this therapy for The subcutaneous malignant-melanoma three weeks. which not injected, continued to grow and were lesions,
injected multiple
The results of this study are at variance with those reported by Calder et al.3. Indeed, no statistically significant
R. H. G. PERKS.
Kent.
new
recurrent
crops of lesions
were
observed.
Because of jhe fear
causing another dissemination of s.c.G., the new lesions were injected with second-strength P.P.D. (Connaught, Pan-Ray Division, New Jersey). Two lesions were injected and they had identical local reactions with complete disappearance of tumour, and, in addition, one uninjected of
lesion disappeared. Grant et al. suggest that one should look for new nonspecific immunostimulants which preferably are nonvirulent. Purified protein derivative (P.P.D.) is such a material. We are reporting for the first time, to our knowledge, the successful use of intralesional P.P.D. in a patient who has been primed immunologically with viable B.C.G. as an approach to a more conservative and perhaps safer treatment of disseminated malignant melanoma. Perhaps another 1. Grant, R. M., Mackie, R., Cochran, A. Ross, C. Lancet, 1974, ii, 1096.
J., Murray, E. L., Hoyle, D.,
G. M. ADDISON G. M. OWEN.
NEONATAL JAUNDICE AFTER INDUCTION OF LABOUR
SIR,-Following the suggestion by Ghosh and Hudson1 that an increase in the incidence of neonatal jaundice coincided with a more liberal use of oxytocin we did a prospective study2 of this possible hazard of oxytocin and prostaglandins (P.G.s). Clinically normal mothers having a ripe cervix and carrying a healthy fetus were electively induced at term by combining low amniotomy with administration of an oxytocic compound (either intravenous oxytocin, intravenous p.G.F2a, or oral P.G.E2). Intraamniotic pressure and fetal heart-rate
were
monitored
throughout. Vaginal delivery was spontaneous in all cases. At birth, fetuses were in good clinical (Apgar scores) and biochemical condition (acid-base status and blood gases). No other drugs than the oxytocic (anaesthetics, analgesics, &c.) were given. At birth (umbilical vein blood) and on the third day peripheral-vein blood-samples were obtained from the neonate and assayed for unconjugated and total bilirubin levels. These values were compared with those from controls (see accompanying table). MEAN SERUM-BILIRUBIN LEVELS
(mg.
per 100
ml.)
PRIMARY MEDICAL CARE OF MENTAL ILLNESS SIR,-Iwas very interested in your editorial (Dec. 7, p. 1362) and your opening sentence of the third paragraph about Who should be the members of the primary-care team ?" In our group practice certainly the general practitioners, health visitors, and our own nurses and nurse midwives have all played a part in this very large problem, but I should like to draw your attention to a very interesting recent addition to this team which is probably going to be of great value. A few months ago we were approached by the principal clinical psychologist of our local mental hospital and asked if we would be interested in providing a consulting-room and time so that he could see any cases which we thought suitable for psychotherapy at our own surgery, using the usual appointment system. Naturally we were very interested in these proposals and immediately made available a room and time, and patients are seen on an hourly basis either weekly or less often as is thought fit. I know that it is rather early to get any definite idea of how the scheme is working, but so far the idea seems to have a promising future in helping to deal with the multitude of psychiatric disorders which come our way; mainly the psychoneuroses. The Surgery, Sutton Valence, near
Maidstone,
INTRALESIONAL P.P.D. IN MALIGNANT MELANOMA SIR,-We read with great interest the results of giving B.c.G. to patients with melanoma, reported by Grant et aLl They point out that B.C.G. immunotherapy is useful in the treatment of malignant melanoma, but it is also fraught with many dangers-granulomatous hepatitis, secondary to dissemination in the bloodstream of live B.C.G. and secondary pulmonary infection by B.C.G. These complications generally occurred when B.c.G. was administered intralesionally, apparently the most effective route. We have treated a patient with disseminated malignant melanoma involving multiple subcutaneous areas. The patient had received B.C.G. intradermally weekly for two months and later intralesional B.C.G. There was a good response, with conversion of P.P.D. test to positive, and all
differences were found between the mean serum-bilirubin levels (at birth and on day 3) of the 74 controls and those of the children born after induction with either oxytocin (n=27) or a P.G. (n=30). Therefore, we concluded that intravenous oxytocin, intravenous p.G.FzII} and oral P.G.E2 used for elective induction of labour did not induce neonatal hyperbilirubinaemia up to the third day of neonatal life. M. THIERY Departments of Obstetrics and D. DE HEMPTINNE Pædiatrics, L. SCHUDDINCK of University Ghent, G. MARTENS. 9000 Ghent, Belgium. 1. Ghosh, A., Hudson, F. F. Lancet, 2. de Hemptinne, D., Schuddinck, 3.
1972, ii, 823. L., Thiery, M., Martens, G. International Research Communications System (73-12) 10-14-3. Calder, A. A., Moar, V. A., Ounsted, M. K., Turnbull, A. C. Lancet, 1974, ii, 1339.
lesions
essentially disappeared. Because of disease, the patient received more intralesional injections and subsequently developed B.C.G. peritonitis. The patient was treated with isoniazid and ethambutol, the symptoms of peritonitis resolved within four days, and the patient continued on this therapy for The subcutaneous malignant-melanoma three weeks. which not injected, continued to grow and were lesions,
injected multiple
The results of this study are at variance with those reported by Calder et al.3. Indeed, no statistically significant
R. H. G. PERKS.
Kent.
new
recurrent
crops of lesions
were
observed.
Because of jhe fear
causing another dissemination of s.c.G., the new lesions were injected with second-strength P.P.D. (Connaught, Pan-Ray Division, New Jersey). Two lesions were injected and they had identical local reactions with complete disappearance of tumour, and, in addition, one uninjected of
lesion disappeared. Grant et al. suggest that one should look for new nonspecific immunostimulants which preferably are nonvirulent. Purified protein derivative (P.P.D.) is such a material. We are reporting for the first time, to our knowledge, the successful use of intralesional P.P.D. in a patient who has been primed immunologically with viable B.C.G. as an approach to a more conservative and perhaps safer treatment of disseminated malignant melanoma. Perhaps another 1. Grant, R. M., Mackie, R., Cochran, A. Ross, C. Lancet, 1974, ii, 1096.
J., Murray, E. L., Hoyle, D.,
