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chronic cases, but many mental hospitals have alreadysucceeded in achieving this segregation by buildinga separate unit. If this is run on general hospitallines-no locked doors, no blocked windows, abolitionof asylum taps and lavatory half-doors, no restrictionson personal belongings-and if it is limited for voluntarywell-behaved patients, one will find no difficulty in obtain-ing admissions. In fact one will develop a waiting-list.

I. ATKINPhysician-Superintendent.

Park Prewett Hospital,Basingstoke.

1. Rutter, A. G. Brit. med. J. 1952, ii, 1418.2. Rappaport, F. Acta med. orient. 1946, 5, 115.3. Royalle, H. L. M. Brit. med. J. 1952, ii, 1293.4. J. Amer. med. Ass. 1911, 57, 878.

PREVENTION OF POSTOPERATIVE CHESTCOMPLICATIONS

ALLENSON G. RUTTER.

SiR,-Dr. Davidson’s article (June 20) on the pre-vention of postoperative pulmonary complications bythe use of a long-acting local anaesthetic to relieve post-operative pain is another instance of the increased interestbeing taken in this subject. The method used, however-the separate injection of two solutions, one of them anoily one-seems unnecessarily complicated and lesscertain in effect than the use of a single watery solution.

It seems worth while to call attention again to a verysimple, easily prepared, and inexpensive combination ofthe same two drugs which I reported on briefly last year.’-This is a solution of 2% benzocaine and 40% urethanein distilled water. Its use was first described as longago as 1946 by Rappaport.2 It is perfectly stable, non-viscid, and very easy to inject-much more so indeedthan the proprietary preparation Efocaine,’ which hasalso been used for this purpose.3

Since my earlier report I have been using this solutionfor bilateral intercostal block after all upper abdominaloperations. Apart from one or two partial failures due toinaccurate placing of the solution under one or two ribs,satisfactory analgesia has been obtained in all cases andno undesirable side-effects have been observed. Anaes-thesia to pinprick has been present at the removal ofstitches ten days later. The dosage of morphine requiredafter operation has been approximately half that givento patients without the interoostal block.

I have little doubt that surgeons and anaesthetistswill make increasing use of this method of postoperativepain relief as its benefits become apparent to them, andthe simpler the method the more effective it is likely toprove.

Sidcup, Kent. ALLENSON G. RUTTER.

INJURY OF THE SPINAL CORD

LAMBERT ROGERS.Surgical Unit,

The Royal Infirmary,Cardiff.

SIR,-In your annotation of June 20 on experimentalinjuries of the spinal cord the question is raised of

laminectomy, incision of the pia mater, and posteriormyelotomy as an urgent measure in cases of injury ofthe spinal cord in man. Probably the belief of mostsurgeons in this country today is that the majorityof cases of spinal injury, like the majority of cases ofacute head injury, are best treated conservatively ;but the results of the experimental work of Freeman andWright, to which you refer, suggest that early operationon the contused human cord may offer a better chanceof preserving its function.

This is no new conception but one which was madeover forty years ago following similar experiments madeby A. R. Allen of Philadelphia,4 who wrote :

" My tentative conclusion is that in cases of fracturedislocation of the spinal column in the human subject, inwhich there exists the symptom picture of transverse lesionof the spinal cord, it were well to perform laminectomyat the earliest possible moment, and if the cord be notcompletely severed to make a median longitudinal incisionthrough the area of impact by means of a fine canaliculusknife in order to drain the injured tissue of the productsof cedema and hoemorrhage."

We should not forget this work of A. R. Allen, whoseearly death probably curtailed much of what lie had inmind.

Early operation has been practised in a few clinics,notably that of Prof. Rene Leriche when he was at

Strasbourg ; but as far as I know, no report of resultshas been issued, and there would appear to be little or noenthusiasm among surgeons’ generally for the practice.There are difficulties associated with it which may notat first be apparent. Spinal shock may mask the earlyclinical picture, and what may at the time appear to bea complete transverse lesion may recover completely,function having been merely temporarily suppressedby concussion of the cord. Because of its destructiveeffect, an incision into the cord in such cases is liableto do more harm than good, especially at the hands ofan inexperienced surgeon, while the operation to exposethe cord in the shocked patient is itself not without risk.

Early exploration may well be advisable in somecases of injury of the spinal cord, but it should be doneby a surgeon experienced in the surgery of the cordand in surroundings where full facilities exist for copingwith shock and haemorrhage. Reports on some casesso treated are urgently wanted.

Surgical Unit,The Royal Infirmary, -r _ -r.,-..-.The

Cardie. LAMBERT ROGERS.

PHENYLBUTAZONE

SiR,—The increasing number of fatalities due to

phenylbutazone poisoning compels us to examine onceagain our ideas on the origin of rheumatism. Followingthe introduction of each new " cure " of rheumatoidarthritis the sequence of events assumes a pattern whoseconstant repetition makes it easy to recognise. Firstly,there is the dramatic response in the individual case,followed by a test in a group of cases. Then come reportsof " side-effects " or " toxic effects." Finally there arethe fatal results and the belated recognition that we aredealing with a poisonous or debilitating agent. In our

preoccupation with the fatal case we are apt to lose

sight of the connection between toxic effect and cure.This connection, to which I first alluded in 1942, has

been maintained in all the effective therapeutic agentsintroduced since then. Cortisone appeared at first to bedifferent, but now it is pretty certain that hyper-adrenalinism is the active agent. Insulin was effectivebecause it induced a state of abnormal metabolism innon-diabetic subjects. The profound metabolic disturb-ances induced by phenylbutazone need no emphasis. Thereaction which is rheumatism is not initiated or sustainedby the tissues in conditions of abnormal metabolism or indebilitated states.

I am particularly disappointed with phenylbutazone,since I had hoped by a special technique to reap thera-peutic benefits while the toxic effects were still reversible.Among 20 cases treated so far, 3 showed toxic effects-nausea, headache, and oedema. At the same time, inspite of the absence of controls, there was no doubt ofthe efficacy of the drug when given in high dosage. Asthe toxic manifestations disappeared when the drug waswithdrawn I have been giving it in full doses of 600-800mg. daily for three days and withholding it for two days.This regime has been satisfactory, but the case describedby Dr. Dilling (June 20) shows that it is not safe. In

your leading article you advocate close attention to thesigns of toxicity and careful selection of cases. You goon to say, " it is questionable whether these conditionscan be fulfilled without hospital supervision."How can one foretell whether a patient will develop

agranulocytosis or not ? In Dr. Dilling’s case it was

preceded by other toxic manifestations which cleared upon withdrawal of the drug. The agranulocytosis developedsubsequently after three days on a reduced dosage.