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DANGER OF PHENOL WITH PENICILLIN
97 of representation of whole-time conthe staff side was also discussed at some length. pointed out by our deputation that there was not a
5. The.
sultants It
was
question
on
single whole-time consultant employed by
a
regional hospital
board on the staff side, and that therefore there had never been available to the staff side of Whitley Committee B the advice of anyone competent to speak for the whole-time regional board consultants.
We would like to
state
that we received an extremely the staff side of Whitley from sympathetic hearing Committee B, and it is realised that one of the greatest bars to progress has been the predominating influence of the Ministry of Health and the absence of an arbitration agreement either within or without Whitley Council.2 Association of Whole-time Salaried Specialists, 45, Lincoln’s Inn Fields,
found on this station, which was a recruit centre ; but obvious correlation was found between this and the incidence of splenomegaly. was
no
In general children with
RUFUS C. THOMAS President.
London, W.C.2.
DANGER OF PHENOL WITH PENICILLIN
Sir,-The hazard demonstrated by Dr.
Aronson,
Dr. Leys, and Dr. Swift (Dec. 20) can be avoided by careful supervision of all injectable solutions. It is, or should be, normal practice for the pharmacist who prepares the solution to indicate on the label the nature and concentration of any added bacteriostatic. Injections should not be prepared by a nurse, for this and other reasons. The British Pharmaeop6eia directs that solutions of medicaments intended for intrathecal, intracisternal, or peridural injection shall not be sterilised by heating with a bactericide, nor issued in multi-dose containers, which may be taken to mean any containers closed with a puncturable rubber cap. The force of the latter provision is that solutions in multi-dose containers are invariably _required to contain bacteriostatic substances. The golden rule for safety is that intrathecal solutions, whatever their nature, shall be drawn from sealed glass ampoules, and from no other type of container. Normally the pharmacist will prepare such solutions with rigid asepsis, transfer them to sterilised ampoules, and seal them by fusion of the glass. When stored, preferably for periods not exceeding 48 hours, they are refrigerated. Ampoules, warmed to blood heat, should be scratched with an efficient file or diamond point before opening, to avoid contamination with glass spicules. There is one serious objection to intrathecal injections prepared directly in a rubber-capped vial of antibiotic. We have satisfied ourselves in this hospital that fine particulate matter is by no means rare in solutions so ,prepared. Furthermore, rubber fragments may be present, or may be introduced by the needle used for withdrawal ; they constitute a serious hazard. Ampouled solutions, examined in a powerful indirect light before being passed for issue, have given no such trouble. Pharmaceutical Department, Southmead Hospital, Bristol.
cases of tonsillitis and upper respiratory infections during the same period. In none of these was splenomegaly recorded. Throat-swabs from all the cases of scarlet fever and a large number of the cases of tonsillitis were cultured ; and almost invariably these yielded haemolytic streptococci, which were, however, not typed. As might be expected perhaps, a rather high incidence of rheumatic iever
Some 300
were seen
PETER COOPER.
SPLENOMEGALY IN SCARLET FEVER
SiR,-Dr. O’Reilly’s letter in your issue of Dec. 20 very interesting. A few years ago while stationed at an R.A.F. hospital I saw about 80 cases of scarlet fever, all in young men aged 18-20 years. Of these, 7 were found to have was
palpable spleens.
practice
tonsillitis
I have since seen two or three who have had palpable spleens. D. P. FITZGERALD.
HEPATITIS encouragement of clinical and
SiR,-Your
epidemio-
observations of hepatitisprompts me to comment on the American studies 23 to which you referred in the light of work done in England.44 The American observations of anicteric cases in young children and of symptomless infections revealed by liverfunction tests are an extension of Pollock’s 5 demonstration of a positive Hunter’s test for bilirubin in the urine of apparently healthy young children during an outbreak in a residential nursery. The lack of effect of isolation of suspected children on the spread of infection in the American epidemic may have been due to the occurrence of infectivity during the early part of the incubation period (25-35 days4 6). Infectivity at this time was thought to account for an explosive outbreak 4 in some wards of an institution for mental defectives. Infectivity is usually greatest and before after shortly symptoms appear, as is shown by the few cases where transmission by a short and single exposure has allowed the identification of the time at which a case was infectious, and by the general experience that successive cases in close contacts in the family7 or in Army units8 commonly occur at intervals of approximately one month. The disease in young children is rarely as severe as in the cases reported by Wylie and Edmunds.9 In England in several outbreaks in day and residential nurseries there were no severe cases, and in epidemics in villages deaths from acute yellow atrophy were very few and occurred in children of school age and in adults. In families where a case occurred, young children were usually not ill at all, though parents and grandparents quite frequently became jaundiced. The suggestion3 that infective hepatitis virus may be a cause of infantile diarrhoea’’ is not in agreement with my experience in England, where (1) in a hospital with hepatitis endemic in nurses there was no undue incidence of diarrhoea in infants in maternity and children’s wards, and (2) in several outbreaks of " infantile diarrhcea " there were no cases of hepatitis in nurses in the hospital at the relevant time. From the data available, it is more likely that the diarrhoea in the American cluldren was due to some other virus and a precursor of the hepatitis cases in the same way that epidemics of typhoid,10 intestinal infections,l1 and upper respiratory infections,12 have preceded some epidemics of poliomyelitis. A. M. MCFARLAN.
logical
"
"
In each
case the spleen was firm and not tender ; and it was enlarged beyond three finger-breadths below the left costal margin. In most cases the enlargement was noticed on admission to the wards and subsided slowly during the following fortnight, although in 1 case the spleen was palpable as long as four weeks after the onset.
never
1. 2. 3. 4.
All the cases of scarlet fever were mild, and there was no difference between the symptoms of those with palpable spleens and those without. Total and differential white blood-cell counts and Paul-Bunnell reactions were performed on all the cases of splenomegaly, and in none was there any haematological evidence of infectious mononucleosis.
5. 6. 7. 8. 9. 10.
2. Ibid, p. 233.
12.
11.
Lancet, 1952, ii, 1212. Capps, R. B., Bennett, A. M., Stokes, J. Arch. intern. Med. 1952, 89, 6. Bennett, A. M., Capps, R. B., Drake, M. E., Ettinger, R. A., Mills, E. H., Stokes, J. Ibid, 90, 37. Infective Hepatitis. Spec. Rep. Ser. med. Res. Coun., Lond. no. 273. H.M. Stationery Office, 1951. Pollock, M. R. Brit. med. J. 1945, ii, 598. Pickles, W. N. Epidemiology in Country Practice. Bristol, 1939. McFarlan, A. M. Lancet, 1945, i, 592. McFarlan, A. M. Quart. J. Med. 1945, 55, 125. Wylie, W. G., Edmunds, M. E. Lancet, 1949, ii, 553. Seddon, H. J., Agius, T., Bernstein, H. G. G., Tunbridge, R. E. Quart. J. Med. 1945, 14, 1. McFarlan, A. M., Dick, G. W. A., Seddon, H. J. Ibid, 1946, 15, 183. McFarlan, A. M. J. R. Army med. Cps, 1946, 87, 37.
5. The.
sultants It
was
question
on
single whole-time consultant employed by
a
regional hospital
board on the staff side, and that therefore there had never been available to the staff side of Whitley Committee B the advice of anyone competent to speak for the whole-time regional board consultants.
We would like to
state
that we received an extremely the staff side of Whitley from sympathetic hearing Committee B, and it is realised that one of the greatest bars to progress has been the predominating influence of the Ministry of Health and the absence of an arbitration agreement either within or without Whitley Council.2 Association of Whole-time Salaried Specialists, 45, Lincoln’s Inn Fields,
found on this station, which was a recruit centre ; but obvious correlation was found between this and the incidence of splenomegaly. was
no
In general children with
RUFUS C. THOMAS President.
London, W.C.2.
DANGER OF PHENOL WITH PENICILLIN
Sir,-The hazard demonstrated by Dr.
Aronson,
Dr. Leys, and Dr. Swift (Dec. 20) can be avoided by careful supervision of all injectable solutions. It is, or should be, normal practice for the pharmacist who prepares the solution to indicate on the label the nature and concentration of any added bacteriostatic. Injections should not be prepared by a nurse, for this and other reasons. The British Pharmaeop6eia directs that solutions of medicaments intended for intrathecal, intracisternal, or peridural injection shall not be sterilised by heating with a bactericide, nor issued in multi-dose containers, which may be taken to mean any containers closed with a puncturable rubber cap. The force of the latter provision is that solutions in multi-dose containers are invariably _required to contain bacteriostatic substances. The golden rule for safety is that intrathecal solutions, whatever their nature, shall be drawn from sealed glass ampoules, and from no other type of container. Normally the pharmacist will prepare such solutions with rigid asepsis, transfer them to sterilised ampoules, and seal them by fusion of the glass. When stored, preferably for periods not exceeding 48 hours, they are refrigerated. Ampoules, warmed to blood heat, should be scratched with an efficient file or diamond point before opening, to avoid contamination with glass spicules. There is one serious objection to intrathecal injections prepared directly in a rubber-capped vial of antibiotic. We have satisfied ourselves in this hospital that fine particulate matter is by no means rare in solutions so ,prepared. Furthermore, rubber fragments may be present, or may be introduced by the needle used for withdrawal ; they constitute a serious hazard. Ampouled solutions, examined in a powerful indirect light before being passed for issue, have given no such trouble. Pharmaceutical Department, Southmead Hospital, Bristol.
cases of tonsillitis and upper respiratory infections during the same period. In none of these was splenomegaly recorded. Throat-swabs from all the cases of scarlet fever and a large number of the cases of tonsillitis were cultured ; and almost invariably these yielded haemolytic streptococci, which were, however, not typed. As might be expected perhaps, a rather high incidence of rheumatic iever
Some 300
were seen
PETER COOPER.
SPLENOMEGALY IN SCARLET FEVER
SiR,-Dr. O’Reilly’s letter in your issue of Dec. 20 very interesting. A few years ago while stationed at an R.A.F. hospital I saw about 80 cases of scarlet fever, all in young men aged 18-20 years. Of these, 7 were found to have was
palpable spleens.
practice
tonsillitis
I have since seen two or three who have had palpable spleens. D. P. FITZGERALD.
HEPATITIS encouragement of clinical and
SiR,-Your
epidemio-
observations of hepatitisprompts me to comment on the American studies 23 to which you referred in the light of work done in England.44 The American observations of anicteric cases in young children and of symptomless infections revealed by liverfunction tests are an extension of Pollock’s 5 demonstration of a positive Hunter’s test for bilirubin in the urine of apparently healthy young children during an outbreak in a residential nursery. The lack of effect of isolation of suspected children on the spread of infection in the American epidemic may have been due to the occurrence of infectivity during the early part of the incubation period (25-35 days4 6). Infectivity at this time was thought to account for an explosive outbreak 4 in some wards of an institution for mental defectives. Infectivity is usually greatest and before after shortly symptoms appear, as is shown by the few cases where transmission by a short and single exposure has allowed the identification of the time at which a case was infectious, and by the general experience that successive cases in close contacts in the family7 or in Army units8 commonly occur at intervals of approximately one month. The disease in young children is rarely as severe as in the cases reported by Wylie and Edmunds.9 In England in several outbreaks in day and residential nurseries there were no severe cases, and in epidemics in villages deaths from acute yellow atrophy were very few and occurred in children of school age and in adults. In families where a case occurred, young children were usually not ill at all, though parents and grandparents quite frequently became jaundiced. The suggestion3 that infective hepatitis virus may be a cause of infantile diarrhoea’’ is not in agreement with my experience in England, where (1) in a hospital with hepatitis endemic in nurses there was no undue incidence of diarrhoea in infants in maternity and children’s wards, and (2) in several outbreaks of " infantile diarrhcea " there were no cases of hepatitis in nurses in the hospital at the relevant time. From the data available, it is more likely that the diarrhoea in the American cluldren was due to some other virus and a precursor of the hepatitis cases in the same way that epidemics of typhoid,10 intestinal infections,l1 and upper respiratory infections,12 have preceded some epidemics of poliomyelitis. A. M. MCFARLAN.
logical
"
"
In each
case the spleen was firm and not tender ; and it was enlarged beyond three finger-breadths below the left costal margin. In most cases the enlargement was noticed on admission to the wards and subsided slowly during the following fortnight, although in 1 case the spleen was palpable as long as four weeks after the onset.
never
1. 2. 3. 4.
All the cases of scarlet fever were mild, and there was no difference between the symptoms of those with palpable spleens and those without. Total and differential white blood-cell counts and Paul-Bunnell reactions were performed on all the cases of splenomegaly, and in none was there any haematological evidence of infectious mononucleosis.
5. 6. 7. 8. 9. 10.
2. Ibid, p. 233.
12.
11.
Lancet, 1952, ii, 1212. Capps, R. B., Bennett, A. M., Stokes, J. Arch. intern. Med. 1952, 89, 6. Bennett, A. M., Capps, R. B., Drake, M. E., Ettinger, R. A., Mills, E. H., Stokes, J. Ibid, 90, 37. Infective Hepatitis. Spec. Rep. Ser. med. Res. Coun., Lond. no. 273. H.M. Stationery Office, 1951. Pollock, M. R. Brit. med. J. 1945, ii, 598. Pickles, W. N. Epidemiology in Country Practice. Bristol, 1939. McFarlan, A. M. Lancet, 1945, i, 592. McFarlan, A. M. Quart. J. Med. 1945, 55, 125. Wylie, W. G., Edmunds, M. E. Lancet, 1949, ii, 553. Seddon, H. J., Agius, T., Bernstein, H. G. G., Tunbridge, R. E. Quart. J. Med. 1945, 14, 1. McFarlan, A. M., Dick, G. W. A., Seddon, H. J. Ibid, 1946, 15, 183. McFarlan, A. M. J. R. Army med. Cps, 1946, 87, 37.