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ACHILLES TENDON RUPTURE
554
(A.N.L.L.) are different in that they have long periods of profound granulocytopenia quite unlike most other tumour or transplant patients. Under these conditions, standard methods of infection therapy are often invalid. Until such time as a controlled prospective trial is completed, must
we
not
maintain
our
present belief that incision of in patients with A.N.L.L. is
perirectal abscesses generally efficacious.
perianal
or
We agree that fluctuance is a late sign; indeed the patient A.N.L.L. may be moribund if the physician waits for The initial this evidence before diagnosing infection. lesion often begins as a small area of erythema and mucosal tearing at the base of a haemorrhoids but may progress to cellulitis, abscess, or septicaemia in less than 24 hours. The low-residue diet of Winitz to which we referred is composed of simple sugars, fatty acids, aminoacids, vitamins, and minerals. It is almost totally absorbed in the small intestine, such that the patient has bowel move-
with
only weekly, thereby resting the lower colon, rectum, and anus. The high mortality of these lesions emphasises the need for prevention. The use of laminar-air-flow rooms with oral, non-absorbable antibiotics appears to be reducing the frequency of these lesions. Once developed, all therapy is aimed at maintaining life until a complete hsematological remission can be induced with return of normal host defences. ments
National Institute of Allergy and Infectious Diseases, Clinical Mycology Section, National Institutes of Health, Bethesda, Maryland 20014, U.S.A.
STEPHEN C. SCHIMPFF PETER H. WIERNIK JEROME B. BLOCK.
ACHILLES TENDON RUPTURE
SIR,-Having played squash regularly for
20 years, it nevertheless came as a shock when my Achilles tendon ruptured in classic fashion during a match on the evening after I had read your editorial (Jan. 27, p. 189) on the subject. However, having opted for the conservative treatment suggested, and accepted the role of a middle-aged man, dire warnings were to follow (Mr Sadow and Mr Hafner, Feb. 10, p. 313) of delayed healing due to hxmatoma formation and, more surprisingly, of delayed diagnosis. with Dr Clarke’s (Feb. 17, My own experience coupled " squash ankle " leads me to wonp. 369) observations on der whether we are not describing together two fairly clear-
entities:
cut
Squash ankle.-The classical complete rupture of the lower part of the Achilles tendon accompanied by pronounced instability of the heel when the foot is not in equinus. Pain is not a feature after the initial shock as there is little contusion or hxmatoma formation. Diagnosis is unlikely to be delayed and healing is by first intention in suitable equinus. 2. Partial or complete rupture at the upper musculotendinous end of the Achilles tendon mechanism. This, dare I suggest, is more likely in the middle-aged man; it is painful and accompanied by swelling and hsemaA measure of toma formation in the lower calf. stability is achieved by this, diagnosis may be less clear, and treatment delayed. The need for suture would depend on the function at the time of diagnosis; in partial rupture, healing by first intention, while not satisfactory, may be acceptable and may occur frequently in undiagnosed cases. This last classification could be stretched to include a resting-place where the mythical rupture of the tendon to plantaris may be decently laid1.
Burnham Health Centre,
Burnham, Bucks.
T. M. MITCHELL-FOX.
SURVEY OF ANALGESIC CONSUMPTION
SiR,—The survey of analgesic consumption by Dr Waters and his colleagues (Feb. 17, p. 341) rests on one indefensible assumption-that subjects filling in a questionary will accurately report their analgesic intake. Unfortunately, as has often been noted,1-5 analgesic abusers are extremely secretive about their habits. Indeed, in a recent study I found that, of 51 patients with analgesic nephropathy, 19 initially denied they took analgesics, while the majority of the remainder grossly underestimated their actual consumption.5 Thus, the very subjects that Dr Waters and others wished to identify are likely to have been missed. That this has occurred is suggested by their finding that 1 of their 50 analgesic takers took the drugs for only " mainly psychological reasons ". By contrast, most reports of patients with analgesic nephropathy stress that the analgesics are almost always taken for psychological reasons.1,2,4,6Ihave argued elsewhere that such patients show many of the characteristics of drug dependence,5 and one cannot expect drug-dependent subjects to answer a questionary about their drug history accurately. The failure of Dr Waters and his colleagues to check self-reports of analgesic ingestion by testing for analgesic metabolites in the urine invalidates their conclusions. Maudsley Hospital, Denmark Hill, London SE5.
ROBIN M. MURRAY.
CHLORAMPHENICOL OVER THE COUNTER SiR,—The tragic description (Jan. 20, p. 150) of the death in Britain of a young woman who had taken chloramphenicol bought in Spain over-the-counter brings up the necessary question of blame. What could she know of the danger of her purchase ? The pharmacist should have known, but could be forgiven for believing what he read printed on the package. Who was responsible for that printing ? Most of the chloramphenicol in Spain and Mexico (at the very least) is produced by the same manufacturers who sell it in the United Kingdom and North America. In the U.S.A. and U.K., to my certain knowledge, we find the drug advocated for only salmonella among " tracheo-
bronchitis, catarrh, grippe, pneumonia, pneumonitis, sinusitis, otitis, salmonella infections, measles, whoopingcough, and other eruptive infections of infancy, chronic bronchitis, smoker’s cough, asthmatic bronchitis, bronchiectasis, &c.". Why is chloramphenicol advocated in other countries for any of these infections ? Primarily because more gets sold. Try as I have to discover an alternative reason, I have failed. In the U.S.A. now, any dissatisfaction with the Food and
Drug Administration is fomented by
numerous
pressure
the pharmaceutical and food industries. I read in Newsweek (January, 1973) the argument by Milton Friedman, the Chicago economist, that people may be dying because of delays in propagation of new drugs. I could, in fact, put up an equally tenuous argument that some newer antibiotics damage more than they cure. What this tragic example should do is remind us of the continuing necessity for the regulatory functions of such bodies as the Medicines Commission and Food and Drug
groups,
1.
obviously-and
most
noisily-from
Gault, M. H., Rudwal, T. C., Engles, W. D., Dossetor, J. D.
Ann. intern. Med. 1968, 68, 906. Fellner, S. K., Tuttle, E. P. Archs intern. Med. 1969, 124, 379. Kincaid-Smith, P. Ann. intern. Med. 1968, 68, 949. Clarkson, A. J. R., Lawrence, J. R. in Renal Infection and Renal Scarring (edited by P. Kincaid-Smith and K. F. Fairley); p. 375. Melbourne, 1970. 5. Murray, R. M. Br. J. Psychiat. (in the press). 6. Kielholz, P. Bull. Narcot. 1970, 22, 2, 1.
2. 3. 4.
(A.N.L.L.) are different in that they have long periods of profound granulocytopenia quite unlike most other tumour or transplant patients. Under these conditions, standard methods of infection therapy are often invalid. Until such time as a controlled prospective trial is completed, must
we
not
maintain
our
present belief that incision of in patients with A.N.L.L. is
perirectal abscesses generally efficacious.
perianal
or
We agree that fluctuance is a late sign; indeed the patient A.N.L.L. may be moribund if the physician waits for The initial this evidence before diagnosing infection. lesion often begins as a small area of erythema and mucosal tearing at the base of a haemorrhoids but may progress to cellulitis, abscess, or septicaemia in less than 24 hours. The low-residue diet of Winitz to which we referred is composed of simple sugars, fatty acids, aminoacids, vitamins, and minerals. It is almost totally absorbed in the small intestine, such that the patient has bowel move-
with
only weekly, thereby resting the lower colon, rectum, and anus. The high mortality of these lesions emphasises the need for prevention. The use of laminar-air-flow rooms with oral, non-absorbable antibiotics appears to be reducing the frequency of these lesions. Once developed, all therapy is aimed at maintaining life until a complete hsematological remission can be induced with return of normal host defences. ments
National Institute of Allergy and Infectious Diseases, Clinical Mycology Section, National Institutes of Health, Bethesda, Maryland 20014, U.S.A.
STEPHEN C. SCHIMPFF PETER H. WIERNIK JEROME B. BLOCK.
ACHILLES TENDON RUPTURE
SIR,-Having played squash regularly for
20 years, it nevertheless came as a shock when my Achilles tendon ruptured in classic fashion during a match on the evening after I had read your editorial (Jan. 27, p. 189) on the subject. However, having opted for the conservative treatment suggested, and accepted the role of a middle-aged man, dire warnings were to follow (Mr Sadow and Mr Hafner, Feb. 10, p. 313) of delayed healing due to hxmatoma formation and, more surprisingly, of delayed diagnosis. with Dr Clarke’s (Feb. 17, My own experience coupled " squash ankle " leads me to wonp. 369) observations on der whether we are not describing together two fairly clear-
entities:
cut
Squash ankle.-The classical complete rupture of the lower part of the Achilles tendon accompanied by pronounced instability of the heel when the foot is not in equinus. Pain is not a feature after the initial shock as there is little contusion or hxmatoma formation. Diagnosis is unlikely to be delayed and healing is by first intention in suitable equinus. 2. Partial or complete rupture at the upper musculotendinous end of the Achilles tendon mechanism. This, dare I suggest, is more likely in the middle-aged man; it is painful and accompanied by swelling and hsemaA measure of toma formation in the lower calf. stability is achieved by this, diagnosis may be less clear, and treatment delayed. The need for suture would depend on the function at the time of diagnosis; in partial rupture, healing by first intention, while not satisfactory, may be acceptable and may occur frequently in undiagnosed cases. This last classification could be stretched to include a resting-place where the mythical rupture of the tendon to plantaris may be decently laid1.
Burnham Health Centre,
Burnham, Bucks.
T. M. MITCHELL-FOX.
SURVEY OF ANALGESIC CONSUMPTION
SiR,—The survey of analgesic consumption by Dr Waters and his colleagues (Feb. 17, p. 341) rests on one indefensible assumption-that subjects filling in a questionary will accurately report their analgesic intake. Unfortunately, as has often been noted,1-5 analgesic abusers are extremely secretive about their habits. Indeed, in a recent study I found that, of 51 patients with analgesic nephropathy, 19 initially denied they took analgesics, while the majority of the remainder grossly underestimated their actual consumption.5 Thus, the very subjects that Dr Waters and others wished to identify are likely to have been missed. That this has occurred is suggested by their finding that 1 of their 50 analgesic takers took the drugs for only " mainly psychological reasons ". By contrast, most reports of patients with analgesic nephropathy stress that the analgesics are almost always taken for psychological reasons.1,2,4,6Ihave argued elsewhere that such patients show many of the characteristics of drug dependence,5 and one cannot expect drug-dependent subjects to answer a questionary about their drug history accurately. The failure of Dr Waters and his colleagues to check self-reports of analgesic ingestion by testing for analgesic metabolites in the urine invalidates their conclusions. Maudsley Hospital, Denmark Hill, London SE5.
ROBIN M. MURRAY.
CHLORAMPHENICOL OVER THE COUNTER SiR,—The tragic description (Jan. 20, p. 150) of the death in Britain of a young woman who had taken chloramphenicol bought in Spain over-the-counter brings up the necessary question of blame. What could she know of the danger of her purchase ? The pharmacist should have known, but could be forgiven for believing what he read printed on the package. Who was responsible for that printing ? Most of the chloramphenicol in Spain and Mexico (at the very least) is produced by the same manufacturers who sell it in the United Kingdom and North America. In the U.S.A. and U.K., to my certain knowledge, we find the drug advocated for only salmonella among " tracheo-
bronchitis, catarrh, grippe, pneumonia, pneumonitis, sinusitis, otitis, salmonella infections, measles, whoopingcough, and other eruptive infections of infancy, chronic bronchitis, smoker’s cough, asthmatic bronchitis, bronchiectasis, &c.". Why is chloramphenicol advocated in other countries for any of these infections ? Primarily because more gets sold. Try as I have to discover an alternative reason, I have failed. In the U.S.A. now, any dissatisfaction with the Food and
Drug Administration is fomented by
numerous
pressure
the pharmaceutical and food industries. I read in Newsweek (January, 1973) the argument by Milton Friedman, the Chicago economist, that people may be dying because of delays in propagation of new drugs. I could, in fact, put up an equally tenuous argument that some newer antibiotics damage more than they cure. What this tragic example should do is remind us of the continuing necessity for the regulatory functions of such bodies as the Medicines Commission and Food and Drug
groups,
1.
obviously-and
most
noisily-from
Gault, M. H., Rudwal, T. C., Engles, W. D., Dossetor, J. D.
Ann. intern. Med. 1968, 68, 906. Fellner, S. K., Tuttle, E. P. Archs intern. Med. 1969, 124, 379. Kincaid-Smith, P. Ann. intern. Med. 1968, 68, 949. Clarkson, A. J. R., Lawrence, J. R. in Renal Infection and Renal Scarring (edited by P. Kincaid-Smith and K. F. Fairley); p. 375. Melbourne, 1970. 5. Murray, R. M. Br. J. Psychiat. (in the press). 6. Kielholz, P. Bull. Narcot. 1970, 22, 2, 1.
2. 3. 4.