- Email: [email protected]
HOSPITAL COSTS
1226 Another difficulty is that increasing specialisation has changed the attitude of residents, so that they are less to fill gaps. Gone are the days when a houseman crammed into his days all possible medical experience. Now he hesitates to take responsibility outside his own particular field. In big hospitals this may matter little ; but in the not so big hospital the loss is great. Possibly the introduction next year of the compulsory preregistration twelve months in hospital posts may bring some relief. But can outlying hospitals, even if given an allocation of interns, be sure of obtaining them‘ Will not the demand continue to exceed the supply‘d
willing
Sideup, Kent.
URSULA HAMILTON PATERSON.
DANGER OF PHENOL WITH PENICILLIN SIR,-We wish to call attention to a risk attached to the common practice of using 0.5% phenol as a preservaThis amount of phenol tive in penicillin solutions. or into into even veins, appears to be muscles, injected innocuous ; but the intrathecal injection of even very small quantities of such a solution may be highly dangerous. We have recently had reason to suspect that the accidental employment of a penicillin solution containing phenol may have been the direct cause of convulsions in an infant with meningitis, and we have learned of at least one other case in which an even more minute quantity of phenol injected into the theca was the probable cause of severe damage to the nervous
system.
HOSPITAL COSTS
The necessary
SiR,-The proposals described in your leading article of Nov. 29 would lead to great improvement in the system of hospital accounting, but might work out to the apparent disadvantage of hospitals with a quick " turnover " of patients. The more quickly investigations and treatment are carried out, the higher will be the cost per patient per day ; yet it is obviously in the interests of both patients in hospital and those awaiting admission that the stay should be as brief as is compatible with good treatment. For this reason it would perhaps be better to relate the cost both of inpatient and of outpatient treatment to the total number of patients of each type treated per year. K. W. LOVEL. Paris. -
DIAGNOSIS OF MIXED PAROTID TUMOURS
SIR,-In their very interesting article of Aug. 16, Mr. Patey and Mr. Hand refer to the difficulties which surround the clinical diagnosis of mixed parotid tumours. Certainly these difficulties are especially important now that ideas on the treatment of these tumours are changing. I am, however, only concerned with their statement that " Redon (1952) now incises as a routine all parotid tumours as a first stage of the operation and to excise a small piece for microscopy." The histological classification of parotid tumours is uncertain ; and it would, I believe, be a retrograde step if biopsy came to be accepted as an accurate guide to treatment. Few workers can have had such extensive experience of the histology and prognosis of salivary tumours as McFarland. From an analysis1 of 421 cases of salivary gland mixed tumours he concluded : " From the present study it appears that something more than a simple microscopic examination of a section of tissue will be required before an accurate prognosis of a mixed tumour of the salivary glands becomes possible. At present our methods are no more accurate or scientific than the flipping of a coin."
Ahlbom,2 too, who also studied a large series, found that the histological approach alone was unsatisfactory and believed that accurate classification must be based on macroscopic, microscopic, and clinical characteristics. On thisbasis he divided tumours into benign, semimalignant, and malignant. Redon’s views were expressed in a personal communication ; and his reasons for favouring immediate biopsy are not given. Unless his evidence is very weighty, it would surely be unwise to attach too great importance to biopsy findings and to base therapy on histological criteria which are open to such fallacies. In any case there may be other risks associated with biopsy of salivary tumours, There may be, however, as Mr. Patey and Mr. Hand point out, a place for immediate microscopy after preliminary enucleation of a parotid tumour. REGINALD T. PAYNE. London, W.I. McFarland, J. Amer. J. med. Sci. 1942, 203, 502. 2. Ahlbom, H. E. Acta radiol., Stockh. 1935, suppl. 23.
simple, but need to be bottle of penicillin solution rigidly applied. Firstly, every issued by a dispenser, and containing phenol, must be distinctively labelled as such, and as suitable only for intramuscular injection. Secondly, all hospital medical officers should be reminded that when it is necessary to give penicillin intrathecally the solution should be made by themselves, at the time qf injection, from unopened containers of crystalline penicillin. R. P. ARONSON D. G. LEYS Children’s Department, P. N. SWIFT. Kent. Farnborough Hospital, precautions
are
--
PORPHYRIA TREATED WITH DIMERCAPROL
SiR,-Clinically there are two types of porphyria -acute and congenital. The following case seems to belong to the congenital group, for no suggestion of a toxic cause could be found by careful interrogation and examination of the patient. History A married woman, aged 28, had been very fit until the last three months of her first pregnancy two years ago. She then had some albuminuria, followed by two eclamptic attacks immediately before delivery, which was completed by forceps. She was neverjaundiced, and the albuminuria stopped two weeks after delivery. In March, 1952, a month before the delivery of her second child, she noticed that her urine was a peculiar bright-red colour. At this time three bullous eruptions developed on The bullae contained a clear liquid, and the one finger. surrounding skin was normal. Gradually new eruptions of the same kind appeared on the face and the exposed parts of both arms. There were no symptoms related to the gastro-intestinal tract or nervous system. She had taken no drugs which could account for the condition. By the end of June the bullae involved a much wider area, including the neck and the medial aspect of the knees. In some areas the appearances were those of epidermolysis bullosa. New eruptions were constantly breaking out, and the skin on the dorsal surface of both hands finally broke down, leaving large ulcers, 6 to 8 em. in diameter.
Laboratory Investigations Urine.-Dark red in colour. Concentrated HCI gave a distinct green colour, changing to yellow after some drops of 3% R2O2 were added. Acidified urine gave the characteristic absorption spectrum of porphyrin. ’’’ Blood.-Erythrocyte-sedimentation rate (three successive occasions) 67, 60, and 25 mm.; Hb 98% ; red cells 4,420,000 perc.mm.; colour-index 1 ; retioulocytes 0-1% ; fragility of red URINARY
ANALYSES
BEFORE
AND
AFTER
DIMERCAPROL
1.
The analysis
gives
a
tigure correct to the nearest 51Lg.
willing
Sideup, Kent.
URSULA HAMILTON PATERSON.
DANGER OF PHENOL WITH PENICILLIN SIR,-We wish to call attention to a risk attached to the common practice of using 0.5% phenol as a preservaThis amount of phenol tive in penicillin solutions. or into into even veins, appears to be muscles, injected innocuous ; but the intrathecal injection of even very small quantities of such a solution may be highly dangerous. We have recently had reason to suspect that the accidental employment of a penicillin solution containing phenol may have been the direct cause of convulsions in an infant with meningitis, and we have learned of at least one other case in which an even more minute quantity of phenol injected into the theca was the probable cause of severe damage to the nervous
system.
HOSPITAL COSTS
The necessary
SiR,-The proposals described in your leading article of Nov. 29 would lead to great improvement in the system of hospital accounting, but might work out to the apparent disadvantage of hospitals with a quick " turnover " of patients. The more quickly investigations and treatment are carried out, the higher will be the cost per patient per day ; yet it is obviously in the interests of both patients in hospital and those awaiting admission that the stay should be as brief as is compatible with good treatment. For this reason it would perhaps be better to relate the cost both of inpatient and of outpatient treatment to the total number of patients of each type treated per year. K. W. LOVEL. Paris. -
DIAGNOSIS OF MIXED PAROTID TUMOURS
SIR,-In their very interesting article of Aug. 16, Mr. Patey and Mr. Hand refer to the difficulties which surround the clinical diagnosis of mixed parotid tumours. Certainly these difficulties are especially important now that ideas on the treatment of these tumours are changing. I am, however, only concerned with their statement that " Redon (1952) now incises as a routine all parotid tumours as a first stage of the operation and to excise a small piece for microscopy." The histological classification of parotid tumours is uncertain ; and it would, I believe, be a retrograde step if biopsy came to be accepted as an accurate guide to treatment. Few workers can have had such extensive experience of the histology and prognosis of salivary tumours as McFarland. From an analysis1 of 421 cases of salivary gland mixed tumours he concluded : " From the present study it appears that something more than a simple microscopic examination of a section of tissue will be required before an accurate prognosis of a mixed tumour of the salivary glands becomes possible. At present our methods are no more accurate or scientific than the flipping of a coin."
Ahlbom,2 too, who also studied a large series, found that the histological approach alone was unsatisfactory and believed that accurate classification must be based on macroscopic, microscopic, and clinical characteristics. On thisbasis he divided tumours into benign, semimalignant, and malignant. Redon’s views were expressed in a personal communication ; and his reasons for favouring immediate biopsy are not given. Unless his evidence is very weighty, it would surely be unwise to attach too great importance to biopsy findings and to base therapy on histological criteria which are open to such fallacies. In any case there may be other risks associated with biopsy of salivary tumours, There may be, however, as Mr. Patey and Mr. Hand point out, a place for immediate microscopy after preliminary enucleation of a parotid tumour. REGINALD T. PAYNE. London, W.I. McFarland, J. Amer. J. med. Sci. 1942, 203, 502. 2. Ahlbom, H. E. Acta radiol., Stockh. 1935, suppl. 23.
simple, but need to be bottle of penicillin solution rigidly applied. Firstly, every issued by a dispenser, and containing phenol, must be distinctively labelled as such, and as suitable only for intramuscular injection. Secondly, all hospital medical officers should be reminded that when it is necessary to give penicillin intrathecally the solution should be made by themselves, at the time qf injection, from unopened containers of crystalline penicillin. R. P. ARONSON D. G. LEYS Children’s Department, P. N. SWIFT. Kent. Farnborough Hospital, precautions
are
--
PORPHYRIA TREATED WITH DIMERCAPROL
SiR,-Clinically there are two types of porphyria -acute and congenital. The following case seems to belong to the congenital group, for no suggestion of a toxic cause could be found by careful interrogation and examination of the patient. History A married woman, aged 28, had been very fit until the last three months of her first pregnancy two years ago. She then had some albuminuria, followed by two eclamptic attacks immediately before delivery, which was completed by forceps. She was neverjaundiced, and the albuminuria stopped two weeks after delivery. In March, 1952, a month before the delivery of her second child, she noticed that her urine was a peculiar bright-red colour. At this time three bullous eruptions developed on The bullae contained a clear liquid, and the one finger. surrounding skin was normal. Gradually new eruptions of the same kind appeared on the face and the exposed parts of both arms. There were no symptoms related to the gastro-intestinal tract or nervous system. She had taken no drugs which could account for the condition. By the end of June the bullae involved a much wider area, including the neck and the medial aspect of the knees. In some areas the appearances were those of epidermolysis bullosa. New eruptions were constantly breaking out, and the skin on the dorsal surface of both hands finally broke down, leaving large ulcers, 6 to 8 em. in diameter.
Laboratory Investigations Urine.-Dark red in colour. Concentrated HCI gave a distinct green colour, changing to yellow after some drops of 3% R2O2 were added. Acidified urine gave the characteristic absorption spectrum of porphyrin. ’’’ Blood.-Erythrocyte-sedimentation rate (three successive occasions) 67, 60, and 25 mm.; Hb 98% ; red cells 4,420,000 perc.mm.; colour-index 1 ; retioulocytes 0-1% ; fragility of red URINARY
ANALYSES
BEFORE
AND
AFTER
DIMERCAPROL
1.
The analysis
gives
a
tigure correct to the nearest 51Lg.