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FATALITY FROM SURGICAL CONDITIONS IN TEACHING AND NON-TEACHING HOSPITALS
893
pelvic wall near the site
of the previous resection, but the liver and all other intra-abdominal organs were normal. A further wedge-resection of the involved mesentery, large lymph-node, and loop of ileum was performed and continuity restored. The tiny adjacent peritoneal deposits made permanent cure
unlikely. During operation
the anaesthetist remarked that it was a good colour despite intubation and high percentage delivery of oxygen. Following operation the man’s facial colour became less blue, and there have been no further flushes. His urinary excretion of 5-hydroxyindole acetic acid fell to normal and has remained so. He feels well and is gaining weight. The histological picture was similar to that of the original tumour removed eighteen months
impossible
to maintain
previously. This patient did not have all the features of the fully developed argentaffinoma syndrome, probably because of its early discovery, but had severe face-flushing, pronounced borborygmi, and a raised excretion of 5-hydroxyindole acetic acid. The case is recorded because some features of this syndrome were present, despite the absence of widespread hepatic secondary argentaffin deposits. The features of this syndrome are due to a raised blood-level of 5-hydroxytryptamine, which in this case was produced by a large lymphatic-node deposit in the mesentery. There were no argentaffin deposits in the liver or
lungs.
We feel it worth while, at follow-up examinations in cases of malignant argentaffinoma, to examine the urine routinely for increased excretion of 5-hydroxyindole acetic acid and to inquire about flushing and borborygmi, for these may be present before deposits are widespread and may justify a second-look " laparotomy. "
I would like to thank Mr. J. C. F.
allowing me to present this
Lloyd Williamson,
for
case.
I. S. M. JONES. TREATMENT OF TUBERCULOUS MENINGITIS
very interested to read the Scottish Joint Committee’s report on the treatment of tuberculous meningitis and to note that when isoniazid was used in high doses the reduction of the duration of intrathecal treatment by streptomycin to one week did not lead to any greater mortality. I note, however, that all the 111 patients did receive intrathecal therapy, and that of the 43 who were planned to have only seven injections an additional 7 required further intrathecal streptomycin treatment. It is, therefore, unjustifiable to conclude the paper with the sentence " The results of the trial indicate that, when isoniazid is included in the chemotherapy, intrathecal streptomycin is not an essential part of the treatment schedule". None of the patients in this series in fact were treated without intrathecal streptomycin. The Children’s Hospital J. LORBER. Sheffield.
SIR,—I
was
STERILISATION OF SYRINGES BY INFRA-RED RADIATION
SIR,—In your report of Oct. 12 of the proceedings of the Association of Clinical Pathologists, we are quoted as saying that " in a third group (of syringes) when temperatures of 180°C were reached all the tests were sterile." This unfortunately is not correct. For out of 87 tests, even when the temperature exceeded 180°C six positive cultures were obtained, one at a 1-minute exposure, two at 3 minutes, two at 6 minutes, and one at 7 minutes. Syringes heated for more than 7 minutes on 54 occasions were found to be sterile by both anaerobic and aerobic culture. It was for these reasons that we recommended that if the total heat treatment was 22½ minutes, 11or more minutes should be at a temperature of more than 180°C. Central Laboratory, Portsmouth and Isle of Wight Area Pathological Service, Portsmouth.
E. M. DARMADY K. E. A. HUGHES W. TUKE.
FATALITY FROM SURGICAL CONDITIONS IN TEACHING AND NON-TEACHING HOSPITALS
SIR,—The article by Dr. Lee and his colleagues (Oct. 14) to overlook a possibly important difference between the patients-namely, their social class. In large towns where teaching and non-teaching hospitals are fairly close to each other it often seems that the clientele of the former is, on the average, of a higher social class than that of the latter. If so, the patients attending the teaching hospital might have many advantages-for instance better nutrition, higher intelligence leading to insistence on early and efficient medical aid, &c. It would be interesting to know if the authors have any data on the social class by occupation (or husband’s occupation) of the patients they were considering. ROBERT PLATT. seems
SIR,—As chairman of the records committee of one of the non-teaching hospitals that contributed to the collection of statistics for the national morbidity inquiry in 1949, I must draw attention to the following facts. Owing to the reorganisation of the records department which took place that year, with the introduction of a unit system, the returns for the six months of January to June were incomplete. The total of discharges during this period in hospitals of comparable size were : Beds Total discharges 704 4389 Edgware General Hospital ...... Leicester Royal Infirmary ...... 654 1238 Chase Farm Hospital ....... 518 3698 Leicester General Hospital ...... 441 3495 St. Woolos Hospital ....... 400 2172 The actual figure of the discharges from Leicester Royal Infirmary from January to June, 1949, was 6668 (the average figure for 1952-54 was 6646). I feel that these missing cases must invalidate some of the conclusions drawn in the article by Dr. Lee and his
colleagues. As
matter of interest, the figures for cases of acute and acute appendicitis with peritonitis for both sexes in 1951 from the Leicester Royal Infirmary a
appendicitis were :
Total cases
Acute appendicitis Acute appendicitis with peritonitis ......
384
Total Alive 383
132 128
Dead 1
mortality ( %)
4
3-03
0-26
The paper by Dr. Lee and his associates is obviously of the greatest importance and must be gone into more fully by the hospitals concerned. I would like to take this opportunity of making a plea for the fuller development of records departments in non-teaching hospitals, where the production of statistics means many long hours of work for the consultants concerned, in contrast to the better facilities that exist in teaching hospitals. J. C. BARRETT Leicester Royal Infirmary. STRAPPING FOR PLEURAL PAIN 26 on the value of strapping for the relief of pleural pain prompts me to ask whether this method is still widely used by doctors in this country. For several years past, I have given up strapping the chest in favour of the simple application to the affected side of warm cotton-wool loosely held in place by a bandage. This I have found to be just as effective as strapping in relieving pleural pain, and senior doctors and nurses who have used both methods confirm my
SIR,—Your annotation of Oct.
experience. The objections
to strapping are many. It is less comfortable for the patient, local physical signs are obscured, and difficulties may arise if further investigations, such as a chest aspiration, are needed. The removal of the strapping, even by a sympathetic and gentle hand, may cause such agonies (especially to the hairy man) that the pain of the original pleurisy would will-
pelvic wall near the site
of the previous resection, but the liver and all other intra-abdominal organs were normal. A further wedge-resection of the involved mesentery, large lymph-node, and loop of ileum was performed and continuity restored. The tiny adjacent peritoneal deposits made permanent cure
unlikely. During operation
the anaesthetist remarked that it was a good colour despite intubation and high percentage delivery of oxygen. Following operation the man’s facial colour became less blue, and there have been no further flushes. His urinary excretion of 5-hydroxyindole acetic acid fell to normal and has remained so. He feels well and is gaining weight. The histological picture was similar to that of the original tumour removed eighteen months
impossible
to maintain
previously. This patient did not have all the features of the fully developed argentaffinoma syndrome, probably because of its early discovery, but had severe face-flushing, pronounced borborygmi, and a raised excretion of 5-hydroxyindole acetic acid. The case is recorded because some features of this syndrome were present, despite the absence of widespread hepatic secondary argentaffin deposits. The features of this syndrome are due to a raised blood-level of 5-hydroxytryptamine, which in this case was produced by a large lymphatic-node deposit in the mesentery. There were no argentaffin deposits in the liver or
lungs.
We feel it worth while, at follow-up examinations in cases of malignant argentaffinoma, to examine the urine routinely for increased excretion of 5-hydroxyindole acetic acid and to inquire about flushing and borborygmi, for these may be present before deposits are widespread and may justify a second-look " laparotomy. "
I would like to thank Mr. J. C. F.
allowing me to present this
Lloyd Williamson,
for
case.
I. S. M. JONES. TREATMENT OF TUBERCULOUS MENINGITIS
very interested to read the Scottish Joint Committee’s report on the treatment of tuberculous meningitis and to note that when isoniazid was used in high doses the reduction of the duration of intrathecal treatment by streptomycin to one week did not lead to any greater mortality. I note, however, that all the 111 patients did receive intrathecal therapy, and that of the 43 who were planned to have only seven injections an additional 7 required further intrathecal streptomycin treatment. It is, therefore, unjustifiable to conclude the paper with the sentence " The results of the trial indicate that, when isoniazid is included in the chemotherapy, intrathecal streptomycin is not an essential part of the treatment schedule". None of the patients in this series in fact were treated without intrathecal streptomycin. The Children’s Hospital J. LORBER. Sheffield.
SIR,—I
was
STERILISATION OF SYRINGES BY INFRA-RED RADIATION
SIR,—In your report of Oct. 12 of the proceedings of the Association of Clinical Pathologists, we are quoted as saying that " in a third group (of syringes) when temperatures of 180°C were reached all the tests were sterile." This unfortunately is not correct. For out of 87 tests, even when the temperature exceeded 180°C six positive cultures were obtained, one at a 1-minute exposure, two at 3 minutes, two at 6 minutes, and one at 7 minutes. Syringes heated for more than 7 minutes on 54 occasions were found to be sterile by both anaerobic and aerobic culture. It was for these reasons that we recommended that if the total heat treatment was 22½ minutes, 11or more minutes should be at a temperature of more than 180°C. Central Laboratory, Portsmouth and Isle of Wight Area Pathological Service, Portsmouth.
E. M. DARMADY K. E. A. HUGHES W. TUKE.
FATALITY FROM SURGICAL CONDITIONS IN TEACHING AND NON-TEACHING HOSPITALS
SIR,—The article by Dr. Lee and his colleagues (Oct. 14) to overlook a possibly important difference between the patients-namely, their social class. In large towns where teaching and non-teaching hospitals are fairly close to each other it often seems that the clientele of the former is, on the average, of a higher social class than that of the latter. If so, the patients attending the teaching hospital might have many advantages-for instance better nutrition, higher intelligence leading to insistence on early and efficient medical aid, &c. It would be interesting to know if the authors have any data on the social class by occupation (or husband’s occupation) of the patients they were considering. ROBERT PLATT. seems
SIR,—As chairman of the records committee of one of the non-teaching hospitals that contributed to the collection of statistics for the national morbidity inquiry in 1949, I must draw attention to the following facts. Owing to the reorganisation of the records department which took place that year, with the introduction of a unit system, the returns for the six months of January to June were incomplete. The total of discharges during this period in hospitals of comparable size were : Beds Total discharges 704 4389 Edgware General Hospital ...... Leicester Royal Infirmary ...... 654 1238 Chase Farm Hospital ....... 518 3698 Leicester General Hospital ...... 441 3495 St. Woolos Hospital ....... 400 2172 The actual figure of the discharges from Leicester Royal Infirmary from January to June, 1949, was 6668 (the average figure for 1952-54 was 6646). I feel that these missing cases must invalidate some of the conclusions drawn in the article by Dr. Lee and his
colleagues. As
matter of interest, the figures for cases of acute and acute appendicitis with peritonitis for both sexes in 1951 from the Leicester Royal Infirmary a
appendicitis were :
Total cases
Acute appendicitis Acute appendicitis with peritonitis ......
384
Total Alive 383
132 128
Dead 1
mortality ( %)
4
3-03
0-26
The paper by Dr. Lee and his associates is obviously of the greatest importance and must be gone into more fully by the hospitals concerned. I would like to take this opportunity of making a plea for the fuller development of records departments in non-teaching hospitals, where the production of statistics means many long hours of work for the consultants concerned, in contrast to the better facilities that exist in teaching hospitals. J. C. BARRETT Leicester Royal Infirmary. STRAPPING FOR PLEURAL PAIN 26 on the value of strapping for the relief of pleural pain prompts me to ask whether this method is still widely used by doctors in this country. For several years past, I have given up strapping the chest in favour of the simple application to the affected side of warm cotton-wool loosely held in place by a bandage. This I have found to be just as effective as strapping in relieving pleural pain, and senior doctors and nurses who have used both methods confirm my
SIR,—Your annotation of Oct.
experience. The objections
to strapping are many. It is less comfortable for the patient, local physical signs are obscured, and difficulties may arise if further investigations, such as a chest aspiration, are needed. The removal of the strapping, even by a sympathetic and gentle hand, may cause such agonies (especially to the hairy man) that the pain of the original pleurisy would will-