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DANGERS OF OXYTETRACYCLINE
1017
Letters
to
the Editor
THE UNLOCKED DOOR
SIR,—" I . remember that
saw sixty-five years ago. called a cabinetmaker’s jimmy then" says Sir Patrick Cullen in The Doctor’s Dilemma of Mr. Walpole’s invention. The unlocking of the doors of mental hospitals is not new. Seventy and eighty years -ago it was done in several Scottish mental hospitals. In 1881 Dr. Batty Tuke1 was able to boast that the doors of the Fife and Kinross Asylum had been open for ten years ; and that the same system of open doors was working in the Midlothian Asylum, "the Lenzie Asylum, and the Saughton Hall It is now possible," said Dr. Cameron of the asylum. Midlothian asylum in the same year, " to traverse the entire building without requiring to use a key." " Liberty of action is no more controlled than in the wards of a general hospital," said Dr. Tuke of his acute patients. The merits and risks of this new system were discussed in medical and general journals on very much the same lines as in your articles ; but the system, hailed by Dr. Tuke2 as marking " an era in the history of the treatment of the insane," seems later to have been abandoned. When and why ? J. GIBSON. Gloucester.
It
was
DIPHTHERIA IMMUNISATION Sir.,-The chief medical officer of the Ministry of Health is very properly concerned that more than twothirds of babies aged one year have not been immunised against diphtheria.3 In addressing a message about this to medical officers of health, it seems that he is turning again to a method which has failed in the past. A different approach might be more profitable. The problem can be solved if family doctors accept as their responsibility the medical care of infants on their lists, both in health and sickness. In the partnership in which I work this is done ; our records show that of babies born in one year (1952-53) to mothers on our lists, 100% had completed a course of injections of diphtheria-pertussis prophylactic at the age of one year, and 82% had been vaccinated against smallpox. An account of the way we work is to be published in the December issue of Medical World. The white-paper of 1944 expected a new type of general practice to evolve in the National Health Service. It was to have been based on health centres where groups of doctors were to work in cooperation and be paid by salary, like their colleagues in hospital. Then one could have expected that, in the words of the white-paper, "the family practitioner should begin to undertake many of the duties at present performed by his colleagues in the public health service." The need for such health centres remains urgent ; but even without them the proportion of infants vaccinated and immunised could be greatly increased if the family doctor could be used as ’
propagandist. L. M. FRANKLIN.
St. Paul’s Cray. Cray, Kent.
DANGERS OF OXYTETRACYCLINE SIR,—Oxytetracycline (terramycin) has now been decontrolled. The prospect of its free prescription on
E.C.10
prompts
with this
given by
us
to
report
some
A woman,
aged 81,
experiences warning already
recent
drug and to reinforce the other writers.
admitted for symptoms due to and urinary infection by coli. She was treated for eight days with Oxytetracycline (2 g. daily), and at the end of the course she was
hypertensive encephalopathy Escherichia
1. J. ment. Sci. 1881, 27, 408. 2. Ibid, 1876, 22, 306. 3. See Lancet, Nov. 6, 1954, p.
complained of some abdominal pain and headaches. A week later diarrhoea developed, and, as the connection with the antibiotic was not immediately recognised, she was given more oxytetracycline for six days. Her condition deteriorated alarmingly, with generalised abdominal pain and tenderness, diarrhoea, proctitis, and pyrexia. Her tongue profuse became fiery red and very sore, in spite of parenteral administration of vitamin-B complex. She became confused and later semicomatose. The prognosis appeared very serious. At this stage coagulase-positive Staphylococcus aureus was recovered in culture from her fasces. She was therefore put on a sevenday course of erythromycin, and her recovery was prompt. A woman, aged 51, was admitted with a thrombophlebitis of the left leg. She was treated with anticoagulants and penicillin, which was later changed to oxytetracycline (2 g. daily for six days). On the sixth day of oxytetracycline she complained of abdominal pain, headache, nausea, and vomiting. The symptoms increased in severity during the following week and a low-grade fever developed. Her stools were relaxed and frequent. The sudden deterioration in her condition and widespread guarding suggested the possibility of an abdominal emergency. Mr. D. P. B. Turner carried out a laparotomy, but no surgical cause for her condition was found. Pea-soup diarrhoea developed, and a staphylococcal No infection became established in the laparotomy wound. her After were recovered from stools. pathogenic organisms our recent experiences with erythromycin we decided to treat her on the same lines : she had 1-6 g. daily for a week. The response was dramatic and in a few days she was free of
green
symptoms.
Large numbers of patients have been treated with oxytetracycline for long periods and without major untoward effects.3- But the recent paper by Hay and McKenzie,2 and our own experience, suggest that a good deal of caution is necessary in the
patient receiving oxytetracycline broad-spectrum antibiotics. Newsham General LIVERPOOL Liverpool.
A. G. MEZEY H. FULD.
MEGALOBLASTIC ANÆMIA DUE TO PHENYTOIN SODIUM article SIR,—The by Dr. Hawkins and Dr. Meynell in your issue of Oct. 9 and the subsequent correspondence prompts me to record a somewhat similar case in this hospital in October, 1951. A mentally defective epileptic girl, aged 23, who had been treated with phenytoin sodium (gr. P/2 b.d.) regularly since August, 1947, was admitted to hospital with severe anaemia, There was a previous purpura, and ulcerative stomatitis.
history of excessive bleeding following a biopsy of hyper-, trophied gum which showed only inflammatory changes in August, 1951. Clinically she was an underdeveloped girl with some brownish pigmentation of the skin as well as petechiae. There was slight enlargement of the liver but otherwise nothing of note, and the central nervous system was normal. Her haemoglobin on admission was 3-6 g. per 100 ml. (24%) ; white cells 1800 per c.mm. (25% neutrophil polymorphs, 75% lymphocytes) ; and platelets approximately 1000 per Her red cells showed anisocytosis, poikilocytosis, c.mm. and an occasional late normoblast. Examination of sternal marrow revealed a megaloblastic hyperplasia with associated large myelocytes and metamyelocytes and hypersegmented adult neutrophils. Megakaryocytes appeared diminished. A fractional test-meal showed free hydrochloric acid after injection of histamine. Analysis of fsecal fat gave a figure of 23% total fat, of which 82% was split. Barium meal showed disordered motor function of the bowel but was otherwise inconclusive. On admission she was given a blood-transfusion of 1¼ pints, 100 ml. of which was introduced into the sternum. On discovery of the megaloblastie marrow she was given a trial of ’ Cytamen ’ (50 µ.g.) to which she gave a slight but definite reticulocyte response. On the strength of this she was given 50 µg. of cytamen on alternate days for a month,
injection
Helm, W. H., May, J. R., Livingstone, J. L. 1954, p. 630. 2. Hay, P., McKlenzie, P. Ibid, 1954, i, 945. 1.
968.
Hospital,
of any any of the other
management or
Lancet, Sept. 25,
Letters
to
the Editor
THE UNLOCKED DOOR
SIR,—" I . remember that
saw sixty-five years ago. called a cabinetmaker’s jimmy then" says Sir Patrick Cullen in The Doctor’s Dilemma of Mr. Walpole’s invention. The unlocking of the doors of mental hospitals is not new. Seventy and eighty years -ago it was done in several Scottish mental hospitals. In 1881 Dr. Batty Tuke1 was able to boast that the doors of the Fife and Kinross Asylum had been open for ten years ; and that the same system of open doors was working in the Midlothian Asylum, "the Lenzie Asylum, and the Saughton Hall It is now possible," said Dr. Cameron of the asylum. Midlothian asylum in the same year, " to traverse the entire building without requiring to use a key." " Liberty of action is no more controlled than in the wards of a general hospital," said Dr. Tuke of his acute patients. The merits and risks of this new system were discussed in medical and general journals on very much the same lines as in your articles ; but the system, hailed by Dr. Tuke2 as marking " an era in the history of the treatment of the insane," seems later to have been abandoned. When and why ? J. GIBSON. Gloucester.
It
was
DIPHTHERIA IMMUNISATION Sir.,-The chief medical officer of the Ministry of Health is very properly concerned that more than twothirds of babies aged one year have not been immunised against diphtheria.3 In addressing a message about this to medical officers of health, it seems that he is turning again to a method which has failed in the past. A different approach might be more profitable. The problem can be solved if family doctors accept as their responsibility the medical care of infants on their lists, both in health and sickness. In the partnership in which I work this is done ; our records show that of babies born in one year (1952-53) to mothers on our lists, 100% had completed a course of injections of diphtheria-pertussis prophylactic at the age of one year, and 82% had been vaccinated against smallpox. An account of the way we work is to be published in the December issue of Medical World. The white-paper of 1944 expected a new type of general practice to evolve in the National Health Service. It was to have been based on health centres where groups of doctors were to work in cooperation and be paid by salary, like their colleagues in hospital. Then one could have expected that, in the words of the white-paper, "the family practitioner should begin to undertake many of the duties at present performed by his colleagues in the public health service." The need for such health centres remains urgent ; but even without them the proportion of infants vaccinated and immunised could be greatly increased if the family doctor could be used as ’
propagandist. L. M. FRANKLIN.
St. Paul’s Cray. Cray, Kent.
DANGERS OF OXYTETRACYCLINE SIR,—Oxytetracycline (terramycin) has now been decontrolled. The prospect of its free prescription on
E.C.10
prompts
with this
given by
us
to
report
some
A woman,
aged 81,
experiences warning already
recent
drug and to reinforce the other writers.
admitted for symptoms due to and urinary infection by coli. She was treated for eight days with Oxytetracycline (2 g. daily), and at the end of the course she was
hypertensive encephalopathy Escherichia
1. J. ment. Sci. 1881, 27, 408. 2. Ibid, 1876, 22, 306. 3. See Lancet, Nov. 6, 1954, p.
complained of some abdominal pain and headaches. A week later diarrhoea developed, and, as the connection with the antibiotic was not immediately recognised, she was given more oxytetracycline for six days. Her condition deteriorated alarmingly, with generalised abdominal pain and tenderness, diarrhoea, proctitis, and pyrexia. Her tongue profuse became fiery red and very sore, in spite of parenteral administration of vitamin-B complex. She became confused and later semicomatose. The prognosis appeared very serious. At this stage coagulase-positive Staphylococcus aureus was recovered in culture from her fasces. She was therefore put on a sevenday course of erythromycin, and her recovery was prompt. A woman, aged 51, was admitted with a thrombophlebitis of the left leg. She was treated with anticoagulants and penicillin, which was later changed to oxytetracycline (2 g. daily for six days). On the sixth day of oxytetracycline she complained of abdominal pain, headache, nausea, and vomiting. The symptoms increased in severity during the following week and a low-grade fever developed. Her stools were relaxed and frequent. The sudden deterioration in her condition and widespread guarding suggested the possibility of an abdominal emergency. Mr. D. P. B. Turner carried out a laparotomy, but no surgical cause for her condition was found. Pea-soup diarrhoea developed, and a staphylococcal No infection became established in the laparotomy wound. her After were recovered from stools. pathogenic organisms our recent experiences with erythromycin we decided to treat her on the same lines : she had 1-6 g. daily for a week. The response was dramatic and in a few days she was free of
green
symptoms.
Large numbers of patients have been treated with oxytetracycline for long periods and without major untoward effects.3- But the recent paper by Hay and McKenzie,2 and our own experience, suggest that a good deal of caution is necessary in the
patient receiving oxytetracycline broad-spectrum antibiotics. Newsham General LIVERPOOL Liverpool.
A. G. MEZEY H. FULD.
MEGALOBLASTIC ANÆMIA DUE TO PHENYTOIN SODIUM article SIR,—The by Dr. Hawkins and Dr. Meynell in your issue of Oct. 9 and the subsequent correspondence prompts me to record a somewhat similar case in this hospital in October, 1951. A mentally defective epileptic girl, aged 23, who had been treated with phenytoin sodium (gr. P/2 b.d.) regularly since August, 1947, was admitted to hospital with severe anaemia, There was a previous purpura, and ulcerative stomatitis.
history of excessive bleeding following a biopsy of hyper-, trophied gum which showed only inflammatory changes in August, 1951. Clinically she was an underdeveloped girl with some brownish pigmentation of the skin as well as petechiae. There was slight enlargement of the liver but otherwise nothing of note, and the central nervous system was normal. Her haemoglobin on admission was 3-6 g. per 100 ml. (24%) ; white cells 1800 per c.mm. (25% neutrophil polymorphs, 75% lymphocytes) ; and platelets approximately 1000 per Her red cells showed anisocytosis, poikilocytosis, c.mm. and an occasional late normoblast. Examination of sternal marrow revealed a megaloblastic hyperplasia with associated large myelocytes and metamyelocytes and hypersegmented adult neutrophils. Megakaryocytes appeared diminished. A fractional test-meal showed free hydrochloric acid after injection of histamine. Analysis of fsecal fat gave a figure of 23% total fat, of which 82% was split. Barium meal showed disordered motor function of the bowel but was otherwise inconclusive. On admission she was given a blood-transfusion of 1¼ pints, 100 ml. of which was introduced into the sternum. On discovery of the megaloblastie marrow she was given a trial of ’ Cytamen ’ (50 µ.g.) to which she gave a slight but definite reticulocyte response. On the strength of this she was given 50 µg. of cytamen on alternate days for a month,
injection
Helm, W. H., May, J. R., Livingstone, J. L. 1954, p. 630. 2. Hay, P., McKlenzie, P. Ibid, 1954, i, 945. 1.
968.
Hospital,
of any any of the other
management or
Lancet, Sept. 25,