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BLACK HAIRY TONGUE
179 teeth projecting from its inner surface. When this is tightly ligatured around the aorta the teeth elevate the body of the fixation ring from the outer surface of the aorta sufficiently to avoid necrosis of its wall, while coapting it to the prosthesis closely enough to prevent leakage. The third problem was the best site The descending aorta beyond for the plastic valve. the left subclavian artery was chosen, because aortic occlusion is well tolerated at this level; a valve at this site controls about 75% of the total regurgitant flow, thus giving the greatest benefit with least risk. Fortified by experience of plastic valves placed in the thoracic aorta of 300 dogs, some of which are still living five years later, Hufnagel and his co-workers selected a series of patients with severe aortic insufficiency for a clinical trial of the method. They now report 23 operations with 6 deaths. All the 17 surviving patients are greatly improved by subjective and objective criteria. (The opening and closing of the valve in the prosthesis is readily audible without a stethoscope in the first few days. After some weeks the sound gradually diminishes, presumably owing to covering of the valve with fibrous
multiple
tissue.) From direct observation at operation and from the assessment of postoperative results, a new " pathology of the living " is growing up to supplement, modify, and sometimes supplant the older pathology based on clinical signs and necropsy appearances. Thus Hayward points out that the view that regurgitation was an unimportant feature in mitral disease has had to be modified since a large number of mitral valves have been palpated during life and the regurgitant stream felt, leaving no doubt of its importance in many cases. Similarly, Hufnagel et al. noted that in their series the vast majority of cases of relatively pure aortic insufficiency were of rheumatic origin. This contrasts sharply with the common concept that rheumatic valvular involvement is predominantly that of aortic stenosis with little or no aortic insufficiency. GASTRIC WATER-ABSORPTION
considerable variation in the curves for different normal and irregularities were found in venous-plasma but not in arterial-plasma levels. A few people swallowed heavy water mixed with barium suspension, which was still in the stomach after the peak level of deuterium in the plasma had been passed. In proposing their technique as a measure of gastric water-absorption, Code et al. do not mention the possibilities that water may have passed through the pylorus even though no barium had yet done so, and that the entry of deuterium into the body may have been by exchange rather than by net absorption ; but these points may be clarified in the further work they are doing.
people ;
ARMY TUMOUR REGISTRY
ALTHOUGH an Army medical museum was begun in the York Hospital, Chelsea, as long ago as 1816 by Sir James McGrigor, it was not until 1905 that a histological reference laboratory was instituted. It served a useful purpose, but in the course of time it became clear that its principal value lay in the diagnosis of malignant disease. In April, 1948, an Army tumour registry was officially launched at the instance of Colonel J. Manifold, then assistant director of pathology, and Major (now Lieut.-Colonel) D. W. Bell was appointed the first officer in charge. The objects of this registry are to ensure of accuracy diagnosis and ease of histological consultation, to assist in the following up of cases, to provide material for statistical analysis, and to have available sets of slides both for teaching and for
private study. As the scheme has only been running a short time statistical conclusions cannot yet be drawn, but the doctors concerned in managing this registry are to be congratulated on its progress. The 3732 specimens examined have included 841 instances of malignant disease. Approximately a fifth of all specimens received are gynaecological. An admirable report1 on the first five years’ work, prepared by Lieut.-Colonel J. B. Neal with a foreword by Major-General A. Saehs, analyses the material received and refers briefly to certain rare cases. As this registry becomes better known more people will avail themselves of it, and of course its value will increase
THE diuresis which follows water-drinking has been turned to good account both in medical practice, as in every year. Volhard’s Wasserstoss, and also in the conduct of daily BLACK HAIRY TONGUE alarm in the " Sioux clock " described as life, by Wolf 1 ; THE condition known as black hairy tongue has been a Sioux brave could regulate his hour of waking by the quantity of water which he drank before going to sleep. recognised for at least a hundred and fifty years,2 but until the introduction of antibiotics it was very rare. Medical interest has been centred on the excretory aspect of this process, and the water-diuresis test has The lesion consists in elongation and cornification of the filiform papillae. It has been variously attributed to an been used not only in renal disease but also in Addison’s irritant action of the antibiotics or their vehicles ; to disease and hypopituitarism.2 Usually when waterinterference with the enzymes concerned in cornification ; diuresis is delayed or diminished the diuretic response to vitamin deficiency, particularly of the B group, to intravenous isotonic glucose is also less than usual ; induced by disturbance of the normal flora of the gut ; and little attention has been paid to delayed absorption as a cause of faulty water-diuresis. Wollaeger and and to overgrowth of monilia and chromogenic bacteria in the absence of normal organisms suppressed by the Scribner3noted that water diuresis was delayed in patients with steatorrhoea ; and Taylor4 has confirmed. antibiotic. The intense, colour has been attributed to this and has likewise observed that water-diuresis is pigment-producing bacteria or to extraneous substances, impaired only when the intestine contains food, and such as coloured medicaments (including iron), to not when water is swallowed after a night’s fast. The tobacco, and to mercury amalgam. On the skin thick is is normal, keratin is usually brown or black, as in warts and implication that, though water-absorption " On mucosal surfaces, however, hypersome " in the be held during digestion may alimentary ichthyosis. tract by the slow absorption of food. keratotic lesions are characteristically white : hence Code et a1.5 have now attempted to define water leukoplakia and the milk spots of oral lichen more In means of deuterium. absorption precisely by planus. Nevertheless, several workers are satisfied normal persons a peak level of deuterium was found in that the colour is due- to the hyperkeratosis of the plasma taken 18-56 minutes after ingestion of heavy papillae. Giunchi and Sorice2 summarise 26 recent accounts of water ; thereafter there was an exponential decline in the deuterium concentration. 13 of these describe it following oral this condition. There was, however, administration of penicillin, 4 following penicillin aerosol, 1. Wolf, A. V. The Urinary Function of the Kidney. New York, 4 following parenteral penicillin, 7 following oral aureo1950. 2. Oleesky, S. Lancet, 1953, i, 769. 3. Wollaeger, E. E., Scribner, B. H. Gastroenterology, 1951, 19, 224. 4. Taylor, W. H. Clin. Sci. 1954, 13, 239. 5. Code, C. F., Scholer, J. F., Hightower, N. C. jun., Dietzler, F. K., Baldes, E, J. Proc. Mayo Clin. 1954, 29, 235.
1. The
Royal Army Medical College, Department of Pathology : Report on the First Five Years’ Work of the Army Tumour Registry, 1948-52. The War Office (A.M.D.8), London, S.W.1. 2. Giunchi, G., Sorice, F. Policlinico, 1954, 61, 477.
180
mycin, 2 following oral chloramphenicol, 2 following streptomycin by mouth, 1 following streptomycin aerosol, and 1 following oral oxytetracycline’ (terramycin). Giunchi and Sorice observed 15 cases-6 after oral penicillin in the form of tablets or lozenges, 5 after penicillin aerosol, 3 after parenteral penicillin, and 1 after oral capsules of aureomycin. In 3 cases the soft palate and uvula were intensely red, and in 3 others there was erythema of the margins of the tongue accompanied by a burning sensation. The Italian workers reproduced the lesions by applying locally a solution of penicillin 1 million units per ml. of physiological saline. A drop of this solution was applied to the tongue of each of 12 normal people twice daily for ten consecutive days. 1 had to drop out of the experiment on the second day, because of painful aphthous stomatitis ; but in 10 of the remaining 11the lesion developed. Of 5 persons in whom aureomycin was applied in the same way, 2 developed the lesion ; and of 5 exposed to chloramphenicol, 1 developed the lesion. The disorder disappeared two to twelve days after the applications were discontinued. Inactivated penicillin or aureomycin did not produce the lesion, and the simultaneous administration of massive doses of B vitamins along with the active antibiotics did not prevent it. Giunchi and Sorice conclude that the antibacterial action of the antibiotics was an important factor in the development of the tongue lesion. They cultured Candida abbicans from 12 of the 15 clinical cases and from 9 of the 10 which developed after experimental application of penicillin. Escherichia coli was also isolated in several cases in both groups. They suggest that the overgrowth of C. albicans does not account alone for the lesion, since this is rare in moiiiliasis of the mouth. They believe that an additional factor-namely, the irritant or toxic effect of the antibiotic on the mucosa-must operate. Another possible explanation is the development of contact stomatitis due to hypersensitivity to the antibiotic ; and this might account for the irregular incidence of the condition. BrowWdescribed a case of penicillin contact glossitis in which exfoliation of the papille was preceded by a stage resembling black hairy tongue. _
HOSPITAL MEDICAL RECORDS WELL-WRITTEN case-notes play an essential part in establishing an accurate diagnosis, and progress notes are an important record of the response to treatment. Detailed notes are invaluable when a patient is readmitted or is treated at another hospital, and for medicolegal They also have a role in clinical research purposes. -though forward-planned research is more satisfactory. The storage of medical records is a serious problem in many hospitals, and a Ministry memorandum4 sets out various recommendations and clarifies the legal situation. All medical records are now subject to the provisions of the Public Records Office Acts, which means that a schedule of minimum times for retention of all hospital documents must be prepared. This will shortly be laid before Parliament. Meanwhile, strictly speaking, no medical records may be destroyed. Subject to parliamentary approval, the Ministry suggests that all records should be preserved for at least six years. There will be no obligation to destroy them then or subsequently, and the period of their retention should depend on advice given by unit medical advisory committees, bearing in mind the clinical and research requirements and storage facilities. Technically, the term"medical records " includes not only the case-sheets but also such diverse records as day and night nursing report books, outpatient appointment sheets, and radiographs. The retention of case-notes is of value only if they are fully cross-indexed by unit number, name, and
diagnosis,
3. Brown, R. L. 4. H.M.(54)47.
and the memorandum recommends
Arch. Otolaryng., Chicago, 1947, 45, 355.
that the unit
system of numbering should be generally
adopted. The memorandum includes suggestions for minimising the space required for storing records. Initial editing enable some forms with may purely administradealing tive arrangements to be discarded, but such editing must be done carefully-if necessary by the doctor in charge of the case. Another method for reducing the bulk would be to prepare a summary at the conclusion of inpatient treatment, if possible on the reverse of the front sheet of the’ patient’s.notes, on which would appear After a period his name and address, unit number, &c. exceeding the statutory minimum for retaining documents it should be possible to discard the original notes, retaining only the summary. At the end of inpatient treatment the case-papers may be marked so as to indicate whether they may be disposed of after the statutory minimum period ; if not, for how long they should be retained or whether (and if so how long after the expiration of the statutory minimum period) the main notes may be disposed of and only the summary kept. Whether the records are in fact destroyed after the time indicated will, of course, depend on developments in the interim period-for example, whether the patient has received further treatment-but continuous " weeding out " on these lines will clearly help to ease storage difficulties. There would be no objection to microfilming of records if the records were retained in the original for the first two years and then preserved on micro-film for at least the remainder of the statutory period. Micro-filming makes possible a 99% reduction in the amount of material to be stored, and may be invaluable when storage difficulties are great. The memorandum suggests that general responsibility for these arrangements should remain with the medical staff committee of the hospital. HYALURONIDASE AND PARAPHIMOSIS PARAPHiMOSis is a common and distressing condition, and its reduction, even with an anaesthetic, may not be easy. Reduction may be made easier by a dorsal slit, but this often results in disfigurement and chronic oedema so that circumcision is ultimately necessary. Immediate circumcision is sometimes the best treatment, but it may be most inconvenient for the patient to have an unexpected operation. Ratliff,1 at Ann Arbor, Michigan, has devised a method of reducing paraphimosis which seems to be painless, quick, and easy and leaves no wound. He injects into each side of the swollen ring of prepuce 1 ml. of normal saline containing 150 turbidity units of hyaluronidase. In two minutes the swelling can be pitted, and in twelve it has disappeared completely and the prepuce can be drawn forwards easily and without pain. This treatment has been applied in only four cases, but in each it was successful. Such a simple and promising method deserves thorough trial. RESEARCH IN GERONTOLOGY AT the colloquium on Ageing held by the Ciba Foundation last week, Dr. E. D. Adrian, o.M., P.R.S., announced the trustees’ plans to stimulate research in gerontology. Over the next five years the representatives of th& founder are to provide an extra sum of money for thi& purpose. The foundation intends to hold further colloquia on this subject and the proceedings of these meetings are to be published in a series of volumes similar to the foundation’s Colloquia on Endocrinology. An annual lectureship, awards for experimental work, and travelling fellowships will also be offered to encourage the investigations of problems in which age is a factor. Further particulars may be had from Dr. G. E. W. Wolstenhoime, the director of the foundation, 41, Portland Place, London, At.1. 1.
Ratliff, R. K. J. Amer. med. Ass. 1954, 155, 746.
multiple
tissue.) From direct observation at operation and from the assessment of postoperative results, a new " pathology of the living " is growing up to supplement, modify, and sometimes supplant the older pathology based on clinical signs and necropsy appearances. Thus Hayward points out that the view that regurgitation was an unimportant feature in mitral disease has had to be modified since a large number of mitral valves have been palpated during life and the regurgitant stream felt, leaving no doubt of its importance in many cases. Similarly, Hufnagel et al. noted that in their series the vast majority of cases of relatively pure aortic insufficiency were of rheumatic origin. This contrasts sharply with the common concept that rheumatic valvular involvement is predominantly that of aortic stenosis with little or no aortic insufficiency. GASTRIC WATER-ABSORPTION
considerable variation in the curves for different normal and irregularities were found in venous-plasma but not in arterial-plasma levels. A few people swallowed heavy water mixed with barium suspension, which was still in the stomach after the peak level of deuterium in the plasma had been passed. In proposing their technique as a measure of gastric water-absorption, Code et al. do not mention the possibilities that water may have passed through the pylorus even though no barium had yet done so, and that the entry of deuterium into the body may have been by exchange rather than by net absorption ; but these points may be clarified in the further work they are doing.
people ;
ARMY TUMOUR REGISTRY
ALTHOUGH an Army medical museum was begun in the York Hospital, Chelsea, as long ago as 1816 by Sir James McGrigor, it was not until 1905 that a histological reference laboratory was instituted. It served a useful purpose, but in the course of time it became clear that its principal value lay in the diagnosis of malignant disease. In April, 1948, an Army tumour registry was officially launched at the instance of Colonel J. Manifold, then assistant director of pathology, and Major (now Lieut.-Colonel) D. W. Bell was appointed the first officer in charge. The objects of this registry are to ensure of accuracy diagnosis and ease of histological consultation, to assist in the following up of cases, to provide material for statistical analysis, and to have available sets of slides both for teaching and for
private study. As the scheme has only been running a short time statistical conclusions cannot yet be drawn, but the doctors concerned in managing this registry are to be congratulated on its progress. The 3732 specimens examined have included 841 instances of malignant disease. Approximately a fifth of all specimens received are gynaecological. An admirable report1 on the first five years’ work, prepared by Lieut.-Colonel J. B. Neal with a foreword by Major-General A. Saehs, analyses the material received and refers briefly to certain rare cases. As this registry becomes better known more people will avail themselves of it, and of course its value will increase
THE diuresis which follows water-drinking has been turned to good account both in medical practice, as in every year. Volhard’s Wasserstoss, and also in the conduct of daily BLACK HAIRY TONGUE alarm in the " Sioux clock " described as life, by Wolf 1 ; THE condition known as black hairy tongue has been a Sioux brave could regulate his hour of waking by the quantity of water which he drank before going to sleep. recognised for at least a hundred and fifty years,2 but until the introduction of antibiotics it was very rare. Medical interest has been centred on the excretory aspect of this process, and the water-diuresis test has The lesion consists in elongation and cornification of the filiform papillae. It has been variously attributed to an been used not only in renal disease but also in Addison’s irritant action of the antibiotics or their vehicles ; to disease and hypopituitarism.2 Usually when waterinterference with the enzymes concerned in cornification ; diuresis is delayed or diminished the diuretic response to vitamin deficiency, particularly of the B group, to intravenous isotonic glucose is also less than usual ; induced by disturbance of the normal flora of the gut ; and little attention has been paid to delayed absorption as a cause of faulty water-diuresis. Wollaeger and and to overgrowth of monilia and chromogenic bacteria in the absence of normal organisms suppressed by the Scribner3noted that water diuresis was delayed in patients with steatorrhoea ; and Taylor4 has confirmed. antibiotic. The intense, colour has been attributed to this and has likewise observed that water-diuresis is pigment-producing bacteria or to extraneous substances, impaired only when the intestine contains food, and such as coloured medicaments (including iron), to not when water is swallowed after a night’s fast. The tobacco, and to mercury amalgam. On the skin thick is is normal, keratin is usually brown or black, as in warts and implication that, though water-absorption " On mucosal surfaces, however, hypersome " in the be held during digestion may alimentary ichthyosis. tract by the slow absorption of food. keratotic lesions are characteristically white : hence Code et a1.5 have now attempted to define water leukoplakia and the milk spots of oral lichen more In means of deuterium. absorption precisely by planus. Nevertheless, several workers are satisfied normal persons a peak level of deuterium was found in that the colour is due- to the hyperkeratosis of the plasma taken 18-56 minutes after ingestion of heavy papillae. Giunchi and Sorice2 summarise 26 recent accounts of water ; thereafter there was an exponential decline in the deuterium concentration. 13 of these describe it following oral this condition. There was, however, administration of penicillin, 4 following penicillin aerosol, 1. Wolf, A. V. The Urinary Function of the Kidney. New York, 4 following parenteral penicillin, 7 following oral aureo1950. 2. Oleesky, S. Lancet, 1953, i, 769. 3. Wollaeger, E. E., Scribner, B. H. Gastroenterology, 1951, 19, 224. 4. Taylor, W. H. Clin. Sci. 1954, 13, 239. 5. Code, C. F., Scholer, J. F., Hightower, N. C. jun., Dietzler, F. K., Baldes, E, J. Proc. Mayo Clin. 1954, 29, 235.
1. The
Royal Army Medical College, Department of Pathology : Report on the First Five Years’ Work of the Army Tumour Registry, 1948-52. The War Office (A.M.D.8), London, S.W.1. 2. Giunchi, G., Sorice, F. Policlinico, 1954, 61, 477.
180
mycin, 2 following oral chloramphenicol, 2 following streptomycin by mouth, 1 following streptomycin aerosol, and 1 following oral oxytetracycline’ (terramycin). Giunchi and Sorice observed 15 cases-6 after oral penicillin in the form of tablets or lozenges, 5 after penicillin aerosol, 3 after parenteral penicillin, and 1 after oral capsules of aureomycin. In 3 cases the soft palate and uvula were intensely red, and in 3 others there was erythema of the margins of the tongue accompanied by a burning sensation. The Italian workers reproduced the lesions by applying locally a solution of penicillin 1 million units per ml. of physiological saline. A drop of this solution was applied to the tongue of each of 12 normal people twice daily for ten consecutive days. 1 had to drop out of the experiment on the second day, because of painful aphthous stomatitis ; but in 10 of the remaining 11the lesion developed. Of 5 persons in whom aureomycin was applied in the same way, 2 developed the lesion ; and of 5 exposed to chloramphenicol, 1 developed the lesion. The disorder disappeared two to twelve days after the applications were discontinued. Inactivated penicillin or aureomycin did not produce the lesion, and the simultaneous administration of massive doses of B vitamins along with the active antibiotics did not prevent it. Giunchi and Sorice conclude that the antibacterial action of the antibiotics was an important factor in the development of the tongue lesion. They cultured Candida abbicans from 12 of the 15 clinical cases and from 9 of the 10 which developed after experimental application of penicillin. Escherichia coli was also isolated in several cases in both groups. They suggest that the overgrowth of C. albicans does not account alone for the lesion, since this is rare in moiiiliasis of the mouth. They believe that an additional factor-namely, the irritant or toxic effect of the antibiotic on the mucosa-must operate. Another possible explanation is the development of contact stomatitis due to hypersensitivity to the antibiotic ; and this might account for the irregular incidence of the condition. BrowWdescribed a case of penicillin contact glossitis in which exfoliation of the papille was preceded by a stage resembling black hairy tongue. _
HOSPITAL MEDICAL RECORDS WELL-WRITTEN case-notes play an essential part in establishing an accurate diagnosis, and progress notes are an important record of the response to treatment. Detailed notes are invaluable when a patient is readmitted or is treated at another hospital, and for medicolegal They also have a role in clinical research purposes. -though forward-planned research is more satisfactory. The storage of medical records is a serious problem in many hospitals, and a Ministry memorandum4 sets out various recommendations and clarifies the legal situation. All medical records are now subject to the provisions of the Public Records Office Acts, which means that a schedule of minimum times for retention of all hospital documents must be prepared. This will shortly be laid before Parliament. Meanwhile, strictly speaking, no medical records may be destroyed. Subject to parliamentary approval, the Ministry suggests that all records should be preserved for at least six years. There will be no obligation to destroy them then or subsequently, and the period of their retention should depend on advice given by unit medical advisory committees, bearing in mind the clinical and research requirements and storage facilities. Technically, the term"medical records " includes not only the case-sheets but also such diverse records as day and night nursing report books, outpatient appointment sheets, and radiographs. The retention of case-notes is of value only if they are fully cross-indexed by unit number, name, and
diagnosis,
3. Brown, R. L. 4. H.M.(54)47.
and the memorandum recommends
Arch. Otolaryng., Chicago, 1947, 45, 355.
that the unit
system of numbering should be generally
adopted. The memorandum includes suggestions for minimising the space required for storing records. Initial editing enable some forms with may purely administradealing tive arrangements to be discarded, but such editing must be done carefully-if necessary by the doctor in charge of the case. Another method for reducing the bulk would be to prepare a summary at the conclusion of inpatient treatment, if possible on the reverse of the front sheet of the’ patient’s.notes, on which would appear After a period his name and address, unit number, &c. exceeding the statutory minimum for retaining documents it should be possible to discard the original notes, retaining only the summary. At the end of inpatient treatment the case-papers may be marked so as to indicate whether they may be disposed of after the statutory minimum period ; if not, for how long they should be retained or whether (and if so how long after the expiration of the statutory minimum period) the main notes may be disposed of and only the summary kept. Whether the records are in fact destroyed after the time indicated will, of course, depend on developments in the interim period-for example, whether the patient has received further treatment-but continuous " weeding out " on these lines will clearly help to ease storage difficulties. There would be no objection to microfilming of records if the records were retained in the original for the first two years and then preserved on micro-film for at least the remainder of the statutory period. Micro-filming makes possible a 99% reduction in the amount of material to be stored, and may be invaluable when storage difficulties are great. The memorandum suggests that general responsibility for these arrangements should remain with the medical staff committee of the hospital. HYALURONIDASE AND PARAPHIMOSIS PARAPHiMOSis is a common and distressing condition, and its reduction, even with an anaesthetic, may not be easy. Reduction may be made easier by a dorsal slit, but this often results in disfigurement and chronic oedema so that circumcision is ultimately necessary. Immediate circumcision is sometimes the best treatment, but it may be most inconvenient for the patient to have an unexpected operation. Ratliff,1 at Ann Arbor, Michigan, has devised a method of reducing paraphimosis which seems to be painless, quick, and easy and leaves no wound. He injects into each side of the swollen ring of prepuce 1 ml. of normal saline containing 150 turbidity units of hyaluronidase. In two minutes the swelling can be pitted, and in twelve it has disappeared completely and the prepuce can be drawn forwards easily and without pain. This treatment has been applied in only four cases, but in each it was successful. Such a simple and promising method deserves thorough trial. RESEARCH IN GERONTOLOGY AT the colloquium on Ageing held by the Ciba Foundation last week, Dr. E. D. Adrian, o.M., P.R.S., announced the trustees’ plans to stimulate research in gerontology. Over the next five years the representatives of th& founder are to provide an extra sum of money for thi& purpose. The foundation intends to hold further colloquia on this subject and the proceedings of these meetings are to be published in a series of volumes similar to the foundation’s Colloquia on Endocrinology. An annual lectureship, awards for experimental work, and travelling fellowships will also be offered to encourage the investigations of problems in which age is a factor. Further particulars may be had from Dr. G. E. W. Wolstenhoime, the director of the foundation, 41, Portland Place, London, At.1. 1.
Ratliff, R. K. J. Amer. med. Ass. 1954, 155, 746.