1378

on the skin can reduce contamination to practicallynil .41 1% iodine in 70% alcohol is still beloved byolder surgeons, but the iodine should be removedafterwards with spirit. In a survey among medicalmen having immunisations all preferred an unhurriedapproach in private with skin sterilisation by iodine.The arm was preferred as the injection site. Therewas a surprisingly high incidence of minor syncope.

Millions of injections are given every year withoutmishap, but most control-of-infection officers can tellof unfortunate accidents, many caused by undue haste.Complications due to injections have been analysed bya French medical defence society. 48 Among some majordisasters were a broken tibia, broken teeth, and a brokennose caused by falls during a faint-most patientsand their friends are rather frightened by the wholeprocedure and it is unwise to allow a patient to stand.The operator will also feel more secure if he is seated.

Injections in the leg are out of sight, and manypatients tolerate quite severe pain, believing this to beinevitable. In one incident the patient had a sedativeinjection in the leg after a minor operation. The painof a streptococcal cellulitis was not reported and thecondition progressed to fatal septicaemia.

ORAL ANALGESIC DRUGS

THE relief of pain is one of the clinician’s mostimportant responsibilities. Yet the ideal oral analgesicdrug has still to be found, and doctors must choosebetween narcotic analgesics with their unwantedeffects on the central nervous system and addictionliability on the one hand, and the less effective " simple "antipyretic analgesics on the other. Aspirin andparacetamol remain the most popular simple analgesics,but several new drugs have been introduced. Mucheffort has been devoted to the search for effective

synthetic narcotic analgesics without significant addic-tion potential, and considerable progress has beenmade. Propoxyphene and ethoheptazine have beenavailable for many years, but are not widely used.Pentazocine is a relative newcomer, but, although it isvirtually no less effective as an analgesic than morphine,it can cause gastrointestinal side-effects, respiratorydepression, and alarming psychotomimetic reactions.It is obviously important to establish the relativeclinical efficacy and toxicity of oral analgesics, butthere have been few adequately controlled comparativetrials in patients with different types of pain. Un-

fortunately, such trials are difficult to carry out, andparadoxical results are not uncommon.

Moertel et al.49have compared the analgesic efficacyof aspirin (650 mg.), paracetamol (650 mg.), phen-acetin (650 mg.), mefenamic acid (250 mg.), codeine(65 mg.), pentazocine (50 mg.), propoxyphene (65 mg.),and ethoheptazine (75 mg.) in 57 patients with chronicpain due to cancer. Single doses of each drug weregiven orally in random sequence under double-blindconditions, and changes in the intensity of pain wererecorded by the patients. Aspirin proved superior tothe other drugs tested; and aspirin, phenacetin, para-47. Drewett, S. E., Payne, D. J. H., Tuke, W., Verdon, P. E. Lancet,

May 27, 1972, p. 1172.48. See Can. med. Ass. J. 1972, 106, 957.49. Moertel, C. G., Ahmann, D. L., Taylor, W. F., Schwartau, N.

New Engl. J. Med. 1972, 286, 815.

cetamol, mefenamic acid, codeine, and pentazocineall produced significantly greater relief of pain thanplacebo. However, there was no evidence that pro-poxyphene and ethoheptazine had any significant thera-peutic activity-a conclusion reached previously byother investigators. The usefulness of pentazocinewas limited by gastrointestinal and central-nervous-system toxicity, and 21 % of the patients obtained morethan 50% relief of pain with placebo. Interestingly,both the therapeutic response to the active drugs andthe incidence of side-effects was greater in the placeboreactors. The results of this study can of course only beinterpreted in the context of administration of singledoses of these drugs to patients with pain due to cancer.A major criticism of this (and many another) com-

parative trial is that none of the drugs were given asstandard commercially available preparations. Instead,they were all made up in blue gelatin capsules, and noevidence is provided concerning their absorptioncharacteristics or bioavailability. Changes in drugformulation, such as the packing of crushed tabletsinto capsules, can play havoc with drug absorption. Insuch circumstances the results of clinical trials maybe quite misleading,50,51 and it is conceivable that thelack of analgesic effect of propoxyphene and etho-heptazine in this study was due to slow or incompleteabsorption. Nevertheless, similar negative findingshave been reported by other investigators; and, as

Moertel et a!. 49 point out, the therapeutic credentialsof propoxyphene and ethoheptazine are doubtful, tosay the least. Both drugs are available in this country,but are often prescribed in combination with effectiveanalgesics such as aspirin or paracetamol.

FUTURE OF THE MENTAL-HEALTH SERVICES

ON p. 1390 this week, Dr. Richards asks an awkwardbut apt question. Is the National Health Service aboutto go too far in its plans for reorganising residentialservices for the mentally handicapped ? In short,by how much should hospital resources be cut in theexpectation that many of these patients can be caredfor elsewhere ? Comparable doubts are raised in areport 52 from a committee under the chairmanshipof Dr. Francis Pilkington. Looking at the mental-health service as a whole, the committee had misgivingsabout the closure or contraction of mental hospitals at atime when community services might not yet be strongenough to carry the extra burden. The forecastclosure of hospitals could hamper the work of theirstaff by blunting morale, in many places none tookeen already. The report urges that more resources begiven to existing hospitals for the subnormal " whichare gravely short of money and seriously understaffed ".More psychogeriatric units able to take emergencyadmissions were urgently needed; and another of thereport’s criticisms was directed at the long wait whichmany disturbed children had to undergo before theycould see a child-psychiatrist.50. Prescott, L. F., Nimmo, J. Acta pharmac. tox. 1971, 29, suppl. 3,

p. 288.51. Freestone, D. S. Lancet, 1969, ii, 98.52. The Mental Health Service after Unification: Report of the

Tripartite Committee (the Royal College of Psychiatrists,the Society of Medical Officers of Health, and the British MedicalAssociation). Obtainable from the Journal Department, B.M.A.House, Tavistock Square, London WC1H 9JR. 50p.