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SUBARACHNOID INJECTION OF CARBOLIC ACID
1179
SUBARACHNOID INJECTION OF CARBOLIC ACID SIR,-Iam most grateful to you for drawing attention in the reference to Dr. R. M. Maher’s work in of Nov. 8. The use of the carbolic-acid solution my paper in reported my article is a direct result of the paperby Dr. Maher published in 1957. By a mishap my article referred only to Dr. Maher’s 1955 work. This approach to the problem has undoubtedly provided a relatively simple means of managing intractable pain in carcinoma. to an error
The Royal Infirmary,
Edinburgh.
ALLAN S. BROWN.
OF CARBOLIC ACID IN INCURABLE CANCER
INJECTION
SiR,—In his first report on the relief of pain in incurable
technique for intrathecal injection of 1/20 phenol in glycerin or’Myodil’. In subsequent reports 3he mentioned the use of epidural injection of 1/15-1/10 phenol in glycerin or myodil to supplement the intrathecal injection. Dr. Brown, in his cancer, Maher2 described his
paper of Nov. 8, concentrates on the subarachnoid technique and mentions that epidural injection has never succeeded where subarachnoid injection has failed. With the change in climate of opinion away from intrathecal and towards epidural anaesthesia in recent years 5, it was decided to investigate the use of epidural phenol in glycerin without simultaneous use of intrathecal phenol in glycerin. Four patients are reported here, treated with 1/10 phenol in glycerin epidurally, using a slight modification of Maher’s technique.4 The patients tilt, and the lay on their sides, with a 300 foot-down " epidural space was identified by the loss of resistance " test using a Tuohy needle. At L4-5 interspace 3 ml. of 1/10 phenol in glycerin was injected, the dural sac being simultaneously collapsed by intrathecal puncture at Ll-2 interspace. The patients were then slowly turned on to their backs and kept still for an hour. In two of these patients pain disappeared completely, while in the third and fourth there has been some improvement. CASE l.-Woman of 59. Cancer of the cervix, treated with
radium, spreading in the pelvis and producing severe leg pain making it impossible to sleep without morphine. Two epidural injections were given on Feb. 13 and Feb. 20, 1958, resulting in complete relief of pain up till the patient’s death on March 2. CASE 2.-Man of 82. Inoperable cancer of the sigmoid colon invading the pelvis. Severe pain in the sacrum and coccyx entirely resistant to morphine. Epidural injection on Oct. 20, 1958, abolished pain completely. CASE 3.-Man of 60. Cancer of the prostate, treated by prostatectomy and later orchidectomy, with severe pelvic pain. Epidural injection on June 3, 1958, partly relieved further pain until his death on Aug. 10. CASE 4.-Man of 65. Cancer of the rectum, treated by abdominoperineal excision and later local excision for perineal metastases. Severe residual pain in the perineum. Epidural injection on June 2, 1958, produced no noteworthy improvement, though the patient’s doctor reports some improvement after the patient’s discharge from hospital. 1. 2. 3. 4. 5.
STAPHYLOCOCCAL INFECTION IN MATERNITY HOSPITALS SiR,—In view of the communications you have recently published on this subject, I think it is relevant to report a limited outbreak of phage-type-80 staphylococcal infection
in Perivale
the form in which it reached us Dr. Brown’s paper referred in the text to Dr. Maher’s 1957 article, but in the list of references the date was 1955. An attempt to correct this discrepancy led to the unfortunate consequence which both he and we regret.-ED. L.
*** In
EPIDURAL
It is suggested that the epidural approach may be of value when injecting phenol in glycerin for the relief of pain in incurable ’cancer. BASIL FINER.
Lancet, 1957, i, 16. Maher, R. M. ibid. 1955, i, 18. Maher, R. M. ibid. 1957, i, 16. Maher, R. M. Personal communication, 1957. Hewer, C. L., Lee, J. A. Recent Advances in Anaesthesia and Analgesia; p. 136. London, 1957.
Maternity Hospital,
a
52-bedded unit in
Greenford, Middlesex. In November, 1957, four patients developed bad breast abscesses which failed to respond to treatment with penicillin instituted immediately. The onset was acute and all the patients were very ill. The abscesses spread from segment to segment of the breast, and in every case drainage of -the abscesses had to be repeated on several occasions. In addition, one baby had a severe suppurative infection of the lacrimal duct, which required incision and drainage. The organism isolated from all these cases was a coagulase-positive Staphylococcus aureus, sensitive only to chloramphenicol and erythromycin. The organisms were later identified as phage-type 80. These cases occurred within ten days of each other. A common source of the pathogens was not found. At the onset of infection mothers and babies were isolated in cubicles and barrier-nursed. The whole of the hospital staff (about 50 persons) was swabbed on three separate occasions, and as a result 6 pupil midwives were found to be nasal carriers of type-80 staphylococci. The carriers were sent away from the hospital with topical treatment, and they were not allowed to return to work until two consecutive nasal swabs had been negative. The cubicles and one six-bedded ward, which had housed the infected patients, were fumigated with a 10% formalin spray. But following this the virulent organisms were still to be found in the rooms, and especially on the light switches and in the dust on the bed wheels. The affected rooms and their furniture were therefore washed down thoroughly with domiphen bromide (’ Bradosol ’) 1 in 500, and subsequent bacteriological investigations failed to isolate type-80 staphylococci. All linen and blankets were soaked for 24 hours in 1 in 1000 domiphen before being sent to the laundry.
This small-scale epidemic confirmsthe observations of Dr. Timbury and her colleagues (Nov. 22) regarding the virulence of type-80 staphylococcal infections. And it also confirms the relatively low incidence of carriers amongst the staff. I believe that the small number of patients who became infected in this hospital was attributable to prompt isolation of infected cases (mother and baby being treated as a unit) with adequate barrier nursing, and also to the fact that the affected wards were not used again until the responsible organism had been eradicated. But the difficulties encountered in disinfecting rooms and furniture are especially noteworthy. Eleven beds were closed for 14 days and since then no further cases of infection with this organism have occurred. I think that it is possible by taking prompt and stern measures at the first sign of an outbreak of virulent staphylococcal infection to limit its spread and perhaps avoid closing the whole of a unit. St. Thomas’s
Hospital, London, S.E.1.
PETER
J. HUNTINGFORD.
SIR,-Dr. Gillespie and his colleagues (Nov. 22) recommend disinfection of infants’ blankets and garments, the use of a disinfectant hand-cream by nurses, and the application of ’Ster-Zac’ powder to the newborn’s umbilicus. Dr. Timbury and her co-authors record a victory for type-80 staphylococci in a maternity hospital. Your leader rebukes the careless user of antibiotics in
SUBARACHNOID INJECTION OF CARBOLIC ACID SIR,-Iam most grateful to you for drawing attention in the reference to Dr. R. M. Maher’s work in of Nov. 8. The use of the carbolic-acid solution my paper in reported my article is a direct result of the paperby Dr. Maher published in 1957. By a mishap my article referred only to Dr. Maher’s 1955 work. This approach to the problem has undoubtedly provided a relatively simple means of managing intractable pain in carcinoma. to an error
The Royal Infirmary,
Edinburgh.
ALLAN S. BROWN.
OF CARBOLIC ACID IN INCURABLE CANCER
INJECTION
SiR,—In his first report on the relief of pain in incurable
technique for intrathecal injection of 1/20 phenol in glycerin or’Myodil’. In subsequent reports 3he mentioned the use of epidural injection of 1/15-1/10 phenol in glycerin or myodil to supplement the intrathecal injection. Dr. Brown, in his cancer, Maher2 described his
paper of Nov. 8, concentrates on the subarachnoid technique and mentions that epidural injection has never succeeded where subarachnoid injection has failed. With the change in climate of opinion away from intrathecal and towards epidural anaesthesia in recent years 5, it was decided to investigate the use of epidural phenol in glycerin without simultaneous use of intrathecal phenol in glycerin. Four patients are reported here, treated with 1/10 phenol in glycerin epidurally, using a slight modification of Maher’s technique.4 The patients tilt, and the lay on their sides, with a 300 foot-down " epidural space was identified by the loss of resistance " test using a Tuohy needle. At L4-5 interspace 3 ml. of 1/10 phenol in glycerin was injected, the dural sac being simultaneously collapsed by intrathecal puncture at Ll-2 interspace. The patients were then slowly turned on to their backs and kept still for an hour. In two of these patients pain disappeared completely, while in the third and fourth there has been some improvement. CASE l.-Woman of 59. Cancer of the cervix, treated with
radium, spreading in the pelvis and producing severe leg pain making it impossible to sleep without morphine. Two epidural injections were given on Feb. 13 and Feb. 20, 1958, resulting in complete relief of pain up till the patient’s death on March 2. CASE 2.-Man of 82. Inoperable cancer of the sigmoid colon invading the pelvis. Severe pain in the sacrum and coccyx entirely resistant to morphine. Epidural injection on Oct. 20, 1958, abolished pain completely. CASE 3.-Man of 60. Cancer of the prostate, treated by prostatectomy and later orchidectomy, with severe pelvic pain. Epidural injection on June 3, 1958, partly relieved further pain until his death on Aug. 10. CASE 4.-Man of 65. Cancer of the rectum, treated by abdominoperineal excision and later local excision for perineal metastases. Severe residual pain in the perineum. Epidural injection on June 2, 1958, produced no noteworthy improvement, though the patient’s doctor reports some improvement after the patient’s discharge from hospital. 1. 2. 3. 4. 5.
STAPHYLOCOCCAL INFECTION IN MATERNITY HOSPITALS SiR,—In view of the communications you have recently published on this subject, I think it is relevant to report a limited outbreak of phage-type-80 staphylococcal infection
in Perivale
the form in which it reached us Dr. Brown’s paper referred in the text to Dr. Maher’s 1957 article, but in the list of references the date was 1955. An attempt to correct this discrepancy led to the unfortunate consequence which both he and we regret.-ED. L.
*** In
EPIDURAL
It is suggested that the epidural approach may be of value when injecting phenol in glycerin for the relief of pain in incurable ’cancer. BASIL FINER.
Lancet, 1957, i, 16. Maher, R. M. ibid. 1955, i, 18. Maher, R. M. ibid. 1957, i, 16. Maher, R. M. Personal communication, 1957. Hewer, C. L., Lee, J. A. Recent Advances in Anaesthesia and Analgesia; p. 136. London, 1957.
Maternity Hospital,
a
52-bedded unit in
Greenford, Middlesex. In November, 1957, four patients developed bad breast abscesses which failed to respond to treatment with penicillin instituted immediately. The onset was acute and all the patients were very ill. The abscesses spread from segment to segment of the breast, and in every case drainage of -the abscesses had to be repeated on several occasions. In addition, one baby had a severe suppurative infection of the lacrimal duct, which required incision and drainage. The organism isolated from all these cases was a coagulase-positive Staphylococcus aureus, sensitive only to chloramphenicol and erythromycin. The organisms were later identified as phage-type 80. These cases occurred within ten days of each other. A common source of the pathogens was not found. At the onset of infection mothers and babies were isolated in cubicles and barrier-nursed. The whole of the hospital staff (about 50 persons) was swabbed on three separate occasions, and as a result 6 pupil midwives were found to be nasal carriers of type-80 staphylococci. The carriers were sent away from the hospital with topical treatment, and they were not allowed to return to work until two consecutive nasal swabs had been negative. The cubicles and one six-bedded ward, which had housed the infected patients, were fumigated with a 10% formalin spray. But following this the virulent organisms were still to be found in the rooms, and especially on the light switches and in the dust on the bed wheels. The affected rooms and their furniture were therefore washed down thoroughly with domiphen bromide (’ Bradosol ’) 1 in 500, and subsequent bacteriological investigations failed to isolate type-80 staphylococci. All linen and blankets were soaked for 24 hours in 1 in 1000 domiphen before being sent to the laundry.
This small-scale epidemic confirmsthe observations of Dr. Timbury and her colleagues (Nov. 22) regarding the virulence of type-80 staphylococcal infections. And it also confirms the relatively low incidence of carriers amongst the staff. I believe that the small number of patients who became infected in this hospital was attributable to prompt isolation of infected cases (mother and baby being treated as a unit) with adequate barrier nursing, and also to the fact that the affected wards were not used again until the responsible organism had been eradicated. But the difficulties encountered in disinfecting rooms and furniture are especially noteworthy. Eleven beds were closed for 14 days and since then no further cases of infection with this organism have occurred. I think that it is possible by taking prompt and stern measures at the first sign of an outbreak of virulent staphylococcal infection to limit its spread and perhaps avoid closing the whole of a unit. St. Thomas’s
Hospital, London, S.E.1.
PETER
J. HUNTINGFORD.
SIR,-Dr. Gillespie and his colleagues (Nov. 22) recommend disinfection of infants’ blankets and garments, the use of a disinfectant hand-cream by nurses, and the application of ’Ster-Zac’ powder to the newborn’s umbilicus. Dr. Timbury and her co-authors record a victory for type-80 staphylococci in a maternity hospital. Your leader rebukes the careless user of antibiotics in