- Email: [email protected]
OPERATING-THEATRE STERILISERS
1158 School of Dental Science until 1861.
was
not associated with
a
dental
hospital
Finally, Sir, the oldest dental hospital in this country, and possibly (dare I say t) in the world, is the Birmingham Dental Hospital, which celebrates its centenary in January, 1958 ; and although I agree with my friend Mr. Bowdler Henry that it was at first a small dispensary, it was properly organised, with the mayor of the town as president, a committee, and the usual officers. R. A. COHEN. Warwick. OPERATING-THEATRE STERILISERS
SIR,-Where central sterile supply departments have yet been instituted, the following sterilisers are essential in all surgical suites : (1) dressing sterilisers for porous or packaged equipment ; (2) hot-air ovens for cleaving or lubricated instruments,Vaseline’ gauze, (3) bulk water/saline autoclaves for powders, oils, &c.; basin nuids ; (4) instrument-washer sterilisers or, where instruments are to be hand-scrubbed, rapid high-pressure Where comprehensive instrument/bowl autoclaves. not
central theatre
supply has
effectively instituted, the only steriliser required is an instrument-washer steriliser or alternatively a dressing steriliser with a special rapid high-pressure additional steam circuit for bowls been
and instruments. In certain theatres a hot-air oven is also essential-e.g., eyes. Mr. Barrington Brock (Oct. 13 and Nov. 24) is therefore justified in his contention that operating-theatre sterilisers include hot-air ovens. I would like to congratulate you on your leading article of Nov. 10 which emphasises the need for providing our theatres with either central supply or the essential range of sterilisers each so designed as to be capable of effecting sterilisation. Department of Bacteriology, Royal Infirmary, Edinburgh.
J. H. BOWIE.
ENCEPHALITIS, MENINGITIS, OR POLIOMYELITIS SIR,—
by any other Name would Smell as Sweet." inevitable, I suppose, that the absence of
"A Rose
It
was
of
a
from the series I
encephalitis single recognisable described as encephalitic (Nov. 17) should cause some comment in your annotation last week. My aim was to announce the existence of an unusual epidemic disease in a community, but not to describe it in all its manifestations. Incomplete reports tend to mislead, but at this point some evidence of encephalitis seems to be called case
for. The rash, the lymphadenopathy, the faucial and conjunctival injection, the presence in the blood of numbers of abnormal lymphocytes, the occasional albuminuria, the hepatitis (jaundice rare but abnormal liver-function tests not uncommon), the muscle pain and tenderness indicate that the Newton epidemic is of a general disease, and the subjective and objective sensory disturbances, reflex changes, and That this weakness that the nervous system is involved. neurological injury is sometimes encephalitic cannot be denied, for by McAlpine’s1 criteria (nystagmus, photophobia, and neck stiffness after fever and headache) there have been five such cases, and the appearance of various patterns of pyramidal-tract, ocular, and psychological disturbance suggests the diagnosis in several more. One cannot yet produce a definitive, or even useful, account of this disease because there is still a good deal of material to be collected and sorted out ; but an analysis of the first 125 cases of all ages shows that, among other signs and symptoms, 102 had headache, 24 had marked neck stiffness, 19 had photophobia, 6 adults had violent vomiting unaccompanied by nausea, 18 other adults and 32 children vomited more than twice, 32 were drowsy, 21 described various " queer feelings " in the head, 16 had attacks of dizziness (usually without sensations of rotation), 9 had nystagmus, 9 had blurring of 1.
McAlpine,
D.
Proc. R. Soc. Med. 1947, 40, 929.
vision or difficulty in focussing, 5 had Babinski responses, 8 had very brisk tendon jerks (sometimes unilateral), and 22 became very irritable and 9 depressed in convalescence. In a few the electro-encephalogram was abnormal, but the signifiAcute muscle pain and cance of the changes is doubtful. tenderness were found in 48, of whom 34 were adults, and usually dominated the clinical picture. Gross papilloedema was not seen, but some blurring of the disc margin was by no means rare.
that the people with clinical evidence the central nervous system are in a of dysfunction but it is this minority which causes the minority ; physician most anxiety, which is likely to lead to admission to hospital and which, I think, justifies the use of the word encephalitis in the title of the disease. Happily, there have been no deaths and no parkinsonian sequelae. The classical types of acute illness described by von Economo2 have not once been observed here, and the fleeting neurological signs which have so often been seen make the diagnosis of poliomyelitis an unlikely one.3 Apropos poliomyelitis, one case has been diagnosed here this year and type-1 virus was isolated from the stool. It will be
seen
of
Newton-le-Willows,
Lancashire.
H. LYLE. W. W. R.
HYPOTENSIVE EPISODES FOLLOWING TREATMENT WITH MEPROBAMATE
SIR,-Meprobamate (’Equanil,’ ’Miltown’)’is in tranquilliser in states of anxiety and tension. We wish to report hypotensive episodes in three patients receiving the drug. common use as a
CASE 1.ŁA woman,
aged 63,
had been admitted with
severe
depression probably induced by reserpine given for the treatment of hypertension. The reserpine had been withdrawn fourteen days before meprobamate was given. Her bloodpressure (B.P.) was 190/110 mrn. Hg. After two days of meprobamate 800 mg. b.d., she complained of drowsiness. Her B.P. was found to be 120/80. Physical examination
showed no changes which might have accounted for the fall in B.P. The B.p. rose to the previous level after meprobamate was withdrawn. CASE 2.-The second patient was a woman, aged 57, with an obsessional tension state and B.P. 180/100. With bed rest and sedation her B.P. fell to 160/90. The barbiturate was replaced by meprobamate 800 mg. t.d.s., and two days later she said she felt very dizzy and weak and looked pale and iU; her B.P. was 90/50. There were no other abnormal physical signs. The dose of meprobamate was reduced to 400 mg. b.d., and her B.P. rose to 135/90 within twenty-four hours. CASE 3.-The third patient, a man aged 60, had a severe involutional depression ; his B.r. was 145/85. He was given meprobamate 400 mg. q.i.d. for twenty-four hours and then 800 mg. t.d.s. for a further twenty-four hours. Subsequently he was found lying motionless in bed, pale and cold to the touch ; his B.P. was 90/50, and physical examination revealed no other abnormality. Meprobamate was stopped ; but, even after 15 mg. of methylamphetamine hydrochloride intramuscularly, the B.P. did not rise to a level of 140/80 for nearly twenty-four hours. A week later the patient was (with his consent) given meprobamate 800 mg. and his B.r. was recorded hourly. After four hours it had fallen from 135/85 to 115/80. A further 800 mg. of meprobamate was given, and within two hours his B.P. fell to 90/50 ; again he became pale, cold, inert, and less responsive, but his condition improved gradually over the next twenty-four hours. Three days later his mean B.P.
was
115/85.
None of these
pulse-rate
or
patients
showed
temperature.
significant changes Respiration was normal
in in
rate but shallow. Sweating was not increased. It is not clear what these three patients had in common that they should react so alarmingly to a drug given to many other patients with no ill effects. All were elderly, two had psychotic depression, and two had raised bloodpressure. Bergerstates that meprobamate acts on the 2. von Economo. Encephalitis Lethargica : its Sequelæ and Treatment. London, 1931. 3. Toomey, J. A. J. Amer. med. Ass. 1941, 117, 269. 4. Berger, F. M. Int. Rec. Med. 1956, 169, 184.
was
not associated with
a
dental
hospital
Finally, Sir, the oldest dental hospital in this country, and possibly (dare I say t) in the world, is the Birmingham Dental Hospital, which celebrates its centenary in January, 1958 ; and although I agree with my friend Mr. Bowdler Henry that it was at first a small dispensary, it was properly organised, with the mayor of the town as president, a committee, and the usual officers. R. A. COHEN. Warwick. OPERATING-THEATRE STERILISERS
SIR,-Where central sterile supply departments have yet been instituted, the following sterilisers are essential in all surgical suites : (1) dressing sterilisers for porous or packaged equipment ; (2) hot-air ovens for cleaving or lubricated instruments,Vaseline’ gauze, (3) bulk water/saline autoclaves for powders, oils, &c.; basin nuids ; (4) instrument-washer sterilisers or, where instruments are to be hand-scrubbed, rapid high-pressure Where comprehensive instrument/bowl autoclaves. not
central theatre
supply has
effectively instituted, the only steriliser required is an instrument-washer steriliser or alternatively a dressing steriliser with a special rapid high-pressure additional steam circuit for bowls been
and instruments. In certain theatres a hot-air oven is also essential-e.g., eyes. Mr. Barrington Brock (Oct. 13 and Nov. 24) is therefore justified in his contention that operating-theatre sterilisers include hot-air ovens. I would like to congratulate you on your leading article of Nov. 10 which emphasises the need for providing our theatres with either central supply or the essential range of sterilisers each so designed as to be capable of effecting sterilisation. Department of Bacteriology, Royal Infirmary, Edinburgh.
J. H. BOWIE.
ENCEPHALITIS, MENINGITIS, OR POLIOMYELITIS SIR,—
by any other Name would Smell as Sweet." inevitable, I suppose, that the absence of
"A Rose
It
was
of
a
from the series I
encephalitis single recognisable described as encephalitic (Nov. 17) should cause some comment in your annotation last week. My aim was to announce the existence of an unusual epidemic disease in a community, but not to describe it in all its manifestations. Incomplete reports tend to mislead, but at this point some evidence of encephalitis seems to be called case
for. The rash, the lymphadenopathy, the faucial and conjunctival injection, the presence in the blood of numbers of abnormal lymphocytes, the occasional albuminuria, the hepatitis (jaundice rare but abnormal liver-function tests not uncommon), the muscle pain and tenderness indicate that the Newton epidemic is of a general disease, and the subjective and objective sensory disturbances, reflex changes, and That this weakness that the nervous system is involved. neurological injury is sometimes encephalitic cannot be denied, for by McAlpine’s1 criteria (nystagmus, photophobia, and neck stiffness after fever and headache) there have been five such cases, and the appearance of various patterns of pyramidal-tract, ocular, and psychological disturbance suggests the diagnosis in several more. One cannot yet produce a definitive, or even useful, account of this disease because there is still a good deal of material to be collected and sorted out ; but an analysis of the first 125 cases of all ages shows that, among other signs and symptoms, 102 had headache, 24 had marked neck stiffness, 19 had photophobia, 6 adults had violent vomiting unaccompanied by nausea, 18 other adults and 32 children vomited more than twice, 32 were drowsy, 21 described various " queer feelings " in the head, 16 had attacks of dizziness (usually without sensations of rotation), 9 had nystagmus, 9 had blurring of 1.
McAlpine,
D.
Proc. R. Soc. Med. 1947, 40, 929.
vision or difficulty in focussing, 5 had Babinski responses, 8 had very brisk tendon jerks (sometimes unilateral), and 22 became very irritable and 9 depressed in convalescence. In a few the electro-encephalogram was abnormal, but the signifiAcute muscle pain and cance of the changes is doubtful. tenderness were found in 48, of whom 34 were adults, and usually dominated the clinical picture. Gross papilloedema was not seen, but some blurring of the disc margin was by no means rare.
that the people with clinical evidence the central nervous system are in a of dysfunction but it is this minority which causes the minority ; physician most anxiety, which is likely to lead to admission to hospital and which, I think, justifies the use of the word encephalitis in the title of the disease. Happily, there have been no deaths and no parkinsonian sequelae. The classical types of acute illness described by von Economo2 have not once been observed here, and the fleeting neurological signs which have so often been seen make the diagnosis of poliomyelitis an unlikely one.3 Apropos poliomyelitis, one case has been diagnosed here this year and type-1 virus was isolated from the stool. It will be
seen
of
Newton-le-Willows,
Lancashire.
H. LYLE. W. W. R.
HYPOTENSIVE EPISODES FOLLOWING TREATMENT WITH MEPROBAMATE
SIR,-Meprobamate (’Equanil,’ ’Miltown’)’is in tranquilliser in states of anxiety and tension. We wish to report hypotensive episodes in three patients receiving the drug. common use as a
CASE 1.ŁA woman,
aged 63,
had been admitted with
severe
depression probably induced by reserpine given for the treatment of hypertension. The reserpine had been withdrawn fourteen days before meprobamate was given. Her bloodpressure (B.P.) was 190/110 mrn. Hg. After two days of meprobamate 800 mg. b.d., she complained of drowsiness. Her B.P. was found to be 120/80. Physical examination
showed no changes which might have accounted for the fall in B.P. The B.p. rose to the previous level after meprobamate was withdrawn. CASE 2.-The second patient was a woman, aged 57, with an obsessional tension state and B.P. 180/100. With bed rest and sedation her B.P. fell to 160/90. The barbiturate was replaced by meprobamate 800 mg. t.d.s., and two days later she said she felt very dizzy and weak and looked pale and iU; her B.P. was 90/50. There were no other abnormal physical signs. The dose of meprobamate was reduced to 400 mg. b.d., and her B.P. rose to 135/90 within twenty-four hours. CASE 3.-The third patient, a man aged 60, had a severe involutional depression ; his B.r. was 145/85. He was given meprobamate 400 mg. q.i.d. for twenty-four hours and then 800 mg. t.d.s. for a further twenty-four hours. Subsequently he was found lying motionless in bed, pale and cold to the touch ; his B.P. was 90/50, and physical examination revealed no other abnormality. Meprobamate was stopped ; but, even after 15 mg. of methylamphetamine hydrochloride intramuscularly, the B.P. did not rise to a level of 140/80 for nearly twenty-four hours. A week later the patient was (with his consent) given meprobamate 800 mg. and his B.r. was recorded hourly. After four hours it had fallen from 135/85 to 115/80. A further 800 mg. of meprobamate was given, and within two hours his B.P. fell to 90/50 ; again he became pale, cold, inert, and less responsive, but his condition improved gradually over the next twenty-four hours. Three days later his mean B.P.
was
115/85.
None of these
pulse-rate
or
patients
showed
temperature.
significant changes Respiration was normal
in in
rate but shallow. Sweating was not increased. It is not clear what these three patients had in common that they should react so alarmingly to a drug given to many other patients with no ill effects. All were elderly, two had psychotic depression, and two had raised bloodpressure. Bergerstates that meprobamate acts on the 2. von Economo. Encephalitis Lethargica : its Sequelæ and Treatment. London, 1931. 3. Toomey, J. A. J. Amer. med. Ass. 1941, 117, 269. 4. Berger, F. M. Int. Rec. Med. 1956, 169, 184.