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TUBERCULOUS ABSCESS FOLLOWING INTRAMUSCULAR PENICILLIN
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arthritis, and if Dr. Jennings then set out his proof from that evidence that Dr. Harrison’s hypothesis about rats was wrong and Professor Selye’s hypothesis was correct, then the statistical experts should be able to pass impartial judgment supporting (or discrediting) his proof. I heartily endorse Dr. Jennings’s plea that medicine should keep in touch with statistics and vice versa: although since the statistician should also cover biology, astronomy, agriculture, psychology, economics, and the other social sciences, he must confine himself to their statistical aspects. Institute of Statistics, D. G. CHAMPERNOWNE. University of Oxford. -
TUBERCULOUS ABSCESS FOLLOWING INTRAMUSCULAR PENICILLIN
SiB,—In their article of Sept. 14 (p. 379) Mr. Ebrill and Dr. Elek say they were unable to find the source of the infection, though it was probably exogenous. In most penicillin drip set-ups there is a weak point that I have often tried to get rectified, but I have always met with the objection that the drip will stop flowing if my advice is followed. The weak point is the airintake, which should be guarded with a cotton-wool filter to exclude organisms ; without the filter a pint of solution is gradually replaced by a pint of bacteria-laden air from the ward. I do not suggest that a filter was omitted on this occasion ; what often happens is that cotton-wool from the filter for someone removes the "
practical "
reasons.
Tubercle bacilli are not uncommon in-the dust of hospital wards. It is not surprising that abscesses form at the site of injection ; the surprising thing-a testimonial to the vis medicatrix naturae—is that there are so few of them. FRANK MARSH. Epping, Essex. DEATH AFTER CURARE
SIR,-In your annotation of Sept. 21 you report- that the pathologist considered that the death of a patient after an operation was due to toxaemia and had been accelerated by respiratory failure due to curare. The effect of curare wears off rapidly and I do not believe that it causes respiratory depression 43 minutes after administration. The patient was 70 years of age and the anaesthetic used wasPentothal.’ It is my experience that a high proportion of elderly patients tolerate intravenous barbiturates extremely badly and that delayed recovery after intravenous anaesthesia is common among patients of any age. I know of two elderly men who never recovered consciousness after being given this anaesthetic . for the performance of emergency suprapubic cystotomy. We have all seen the young healthy adult who took a very long time to wake up. Pentothal is a drug which should be used with the greatest caution, and it is unfortunate that so many practitioners have been encouraged to administer an intravenous anaesthetic when some inhalation technique could be used’- In this country we are too ready to publish our successes and too reluctant to report our fatalities. If one studies the American journals one can obtain a more accurate appreciation of the dangers of " modern anaesthesia," which I do not find to be as safe or satisfactory as ether. As Flagg rightly says, " Far too many anaesthetists have tried too often to avoid the use of ether anaesthesia, and the skill with which it might be used is not so much in evidence today as it might be." If our medical students and newly qualified practitioners were taught to understand the value and wide range of usefulness of ether we should read of far fewer deaths under anaesthesia being inquired into by the coroners’ courts. All that is modern and new is not progressive, and we might well ponder on the fact that when ether and chloroform were used almost exclusively in England the number of deaths associated with anaesthesia reported to the coroner in one year was 347, whereas in 1941 it was 835. This in spite of the fact that far greater surgical risks were accepted in those days, and that restorative measures were not very satisfactory. We also no longer see the neglected abdominal emergency, once a common cause of operating-room deaths.
I cannot help feeling that in the case you mention the of death was the pentothal rather than the curare. Curare may be a highly dangerous drug-we do not yet know-but do not let us blame it for the offences of another drug. JOHN ELAM. New Barnet, Herts. SiR,-Your annotation of Sept. 21 on the death of a patient following an operation during which curare had been administered was marred for me by the fact that it did not contain the information, which cannot be too widely spread, that in physostigmine (eserine) orProstigmin’ we have an antidote for curare.Coramine’ or ’Veritol’ are of no value for counteracting this substance. No anaesthetist should administer curare unless he has readily available an injection of eserine cause
(1mg.)
or
prostigmin (2-5 mg.).
JAS. D. P. GRAHAM. Dept. of Materia Medica, Glasgow University.
AMŒBOMA AND
CARCINOMA
SiR,-Mr. M. J. Smyth’s article of Sept. 14 is of value in drawing attention to a subject which
particular
is not familiar to those who have been denied the opportunities of tropical practice. From time to time examples of amoeboma of the rectum will occur in this country, and only careful differential diagnosis will prevent surgical disasters. Amoeboma of the rectum is one of the rarer forms of intestinal amoebiasis, and even in tropical countries no one surgeon is likely to see many examples. It may present as an ulcer or as a papilliferous overgrowth, and in either form may appear indistinguishable from carcinoma. The diagnosis, however, will rarely present much difficulty to those who follow Mr. Smyth’s advice -that any tumour of the colon or rectum discovered in a patient who has served in the East should be regarded as amceboma rather than carcinoma until thorough pathological examination has proved otherwise. This should apply to all patients who have at any time been exposed to amoebic dysentery, whether they give a history of dysentery or not, and even if they have been discharged as cured of this disease, so noted for its tendency to -
relapse. Repeated
examination of the stools and of scrapings from the surface of an amceboma may fail to disclose On the other hand, as Mr. the Bntamaeba histolytica. Smyth reminds us, the presence of the E. histolytica does not exclude carcinoma. Fortunatelv in emetine Whether we have a valuable aid to diagnosis. E. histolytica has been found or not, before resorting to operation a course of this drug should be given, its effect being checked by repeated sigmoidoscopy. As a general rule the amoeboma very rapidly responds, but only a. complete resolution can be accepted as proof that the lesion is amoebic. If this is not obtained biopsy must be done. During four years’ military service in endemic -areas, I saw six examples of amoeboma of the rectum which simulated carcinoma. Five- of these resolved completely on medical treatment alone. The sixth patient was admitted as an advanced case of carcinomaof the rectum, and the clinical condition was consistent with this diagnosis. When repeated examination of the stools and of the discharge from the surface of the tumour proved negative, colostomy was proposed ; but a proctoscopic examination made on the operation table produced a specimen containing many typical E. histolytica and operation was therefore postponed. Emetine was given but the patient died within a few days. Post-mortem examination revealed how futile a colostomy would have proved, for the whole length of the colon was involved in a diffuse amoebic ulceration. These cases are reported in Surgery, Gynecology and Obstetrics (1945, 81, 387) and the Iiuerpeol .L11edico-chirurgical Journal (in the press). It would be unfortunate if Mr. Smyth’s statement "have no doubt that in amoeboma of the rectum colostomy is helpful rather than otherwise " were to encourage the
frequent performance
of this
operation.
Whereas in the vast majority of cases of rectal amoeboma. medical measures result in a rapid and complete disappearance -of the lesion, colostomy exposes the patient
-
arthritis, and if Dr. Jennings then set out his proof from that evidence that Dr. Harrison’s hypothesis about rats was wrong and Professor Selye’s hypothesis was correct, then the statistical experts should be able to pass impartial judgment supporting (or discrediting) his proof. I heartily endorse Dr. Jennings’s plea that medicine should keep in touch with statistics and vice versa: although since the statistician should also cover biology, astronomy, agriculture, psychology, economics, and the other social sciences, he must confine himself to their statistical aspects. Institute of Statistics, D. G. CHAMPERNOWNE. University of Oxford. -
TUBERCULOUS ABSCESS FOLLOWING INTRAMUSCULAR PENICILLIN
SiB,—In their article of Sept. 14 (p. 379) Mr. Ebrill and Dr. Elek say they were unable to find the source of the infection, though it was probably exogenous. In most penicillin drip set-ups there is a weak point that I have often tried to get rectified, but I have always met with the objection that the drip will stop flowing if my advice is followed. The weak point is the airintake, which should be guarded with a cotton-wool filter to exclude organisms ; without the filter a pint of solution is gradually replaced by a pint of bacteria-laden air from the ward. I do not suggest that a filter was omitted on this occasion ; what often happens is that cotton-wool from the filter for someone removes the "
practical "
reasons.
Tubercle bacilli are not uncommon in-the dust of hospital wards. It is not surprising that abscesses form at the site of injection ; the surprising thing-a testimonial to the vis medicatrix naturae—is that there are so few of them. FRANK MARSH. Epping, Essex. DEATH AFTER CURARE
SIR,-In your annotation of Sept. 21 you report- that the pathologist considered that the death of a patient after an operation was due to toxaemia and had been accelerated by respiratory failure due to curare. The effect of curare wears off rapidly and I do not believe that it causes respiratory depression 43 minutes after administration. The patient was 70 years of age and the anaesthetic used wasPentothal.’ It is my experience that a high proportion of elderly patients tolerate intravenous barbiturates extremely badly and that delayed recovery after intravenous anaesthesia is common among patients of any age. I know of two elderly men who never recovered consciousness after being given this anaesthetic . for the performance of emergency suprapubic cystotomy. We have all seen the young healthy adult who took a very long time to wake up. Pentothal is a drug which should be used with the greatest caution, and it is unfortunate that so many practitioners have been encouraged to administer an intravenous anaesthetic when some inhalation technique could be used’- In this country we are too ready to publish our successes and too reluctant to report our fatalities. If one studies the American journals one can obtain a more accurate appreciation of the dangers of " modern anaesthesia," which I do not find to be as safe or satisfactory as ether. As Flagg rightly says, " Far too many anaesthetists have tried too often to avoid the use of ether anaesthesia, and the skill with which it might be used is not so much in evidence today as it might be." If our medical students and newly qualified practitioners were taught to understand the value and wide range of usefulness of ether we should read of far fewer deaths under anaesthesia being inquired into by the coroners’ courts. All that is modern and new is not progressive, and we might well ponder on the fact that when ether and chloroform were used almost exclusively in England the number of deaths associated with anaesthesia reported to the coroner in one year was 347, whereas in 1941 it was 835. This in spite of the fact that far greater surgical risks were accepted in those days, and that restorative measures were not very satisfactory. We also no longer see the neglected abdominal emergency, once a common cause of operating-room deaths.
I cannot help feeling that in the case you mention the of death was the pentothal rather than the curare. Curare may be a highly dangerous drug-we do not yet know-but do not let us blame it for the offences of another drug. JOHN ELAM. New Barnet, Herts. SiR,-Your annotation of Sept. 21 on the death of a patient following an operation during which curare had been administered was marred for me by the fact that it did not contain the information, which cannot be too widely spread, that in physostigmine (eserine) orProstigmin’ we have an antidote for curare.Coramine’ or ’Veritol’ are of no value for counteracting this substance. No anaesthetist should administer curare unless he has readily available an injection of eserine cause
(1mg.)
or
prostigmin (2-5 mg.).
JAS. D. P. GRAHAM. Dept. of Materia Medica, Glasgow University.
AMŒBOMA AND
CARCINOMA
SiR,-Mr. M. J. Smyth’s article of Sept. 14 is of value in drawing attention to a subject which
particular
is not familiar to those who have been denied the opportunities of tropical practice. From time to time examples of amoeboma of the rectum will occur in this country, and only careful differential diagnosis will prevent surgical disasters. Amoeboma of the rectum is one of the rarer forms of intestinal amoebiasis, and even in tropical countries no one surgeon is likely to see many examples. It may present as an ulcer or as a papilliferous overgrowth, and in either form may appear indistinguishable from carcinoma. The diagnosis, however, will rarely present much difficulty to those who follow Mr. Smyth’s advice -that any tumour of the colon or rectum discovered in a patient who has served in the East should be regarded as amceboma rather than carcinoma until thorough pathological examination has proved otherwise. This should apply to all patients who have at any time been exposed to amoebic dysentery, whether they give a history of dysentery or not, and even if they have been discharged as cured of this disease, so noted for its tendency to -
relapse. Repeated
examination of the stools and of scrapings from the surface of an amceboma may fail to disclose On the other hand, as Mr. the Bntamaeba histolytica. Smyth reminds us, the presence of the E. histolytica does not exclude carcinoma. Fortunatelv in emetine Whether we have a valuable aid to diagnosis. E. histolytica has been found or not, before resorting to operation a course of this drug should be given, its effect being checked by repeated sigmoidoscopy. As a general rule the amoeboma very rapidly responds, but only a. complete resolution can be accepted as proof that the lesion is amoebic. If this is not obtained biopsy must be done. During four years’ military service in endemic -areas, I saw six examples of amoeboma of the rectum which simulated carcinoma. Five- of these resolved completely on medical treatment alone. The sixth patient was admitted as an advanced case of carcinomaof the rectum, and the clinical condition was consistent with this diagnosis. When repeated examination of the stools and of the discharge from the surface of the tumour proved negative, colostomy was proposed ; but a proctoscopic examination made on the operation table produced a specimen containing many typical E. histolytica and operation was therefore postponed. Emetine was given but the patient died within a few days. Post-mortem examination revealed how futile a colostomy would have proved, for the whole length of the colon was involved in a diffuse amoebic ulceration. These cases are reported in Surgery, Gynecology and Obstetrics (1945, 81, 387) and the Iiuerpeol .L11edico-chirurgical Journal (in the press). It would be unfortunate if Mr. Smyth’s statement "have no doubt that in amoeboma of the rectum colostomy is helpful rather than otherwise " were to encourage the
frequent performance
of this
operation.
Whereas in the vast majority of cases of rectal amoeboma. medical measures result in a rapid and complete disappearance -of the lesion, colostomy exposes the patient
-