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DIPHTHERIA DIAGNOSIS BY POST
367 standards may be authorised by the senior police officers. It is well known that work which involves discrimination of detail, such as fine engraving, type-setting, proof reading, and sewing on dark material, should only be done under a high standard of lighting. The committee have not been able to lay down definite standards for various classes of fine work, but they reprint as an appendix the code 34 recommended by the Illuminating Engineering Society. This table of lighting standards ranges from 2 to 4 foot-candles in places where casual observation but not specific work is done, to over 50 foot-candles for precise work and tasks requiring rapid discrimination. For fine machine work, proof-reading, and type-setting, a standard of 15 to 25 foot-candles is recommended. The committee recommend light coloured walls and ceilings to ensure adequate reflection. They discuss the prevention of glare, pointing out that it is not much use tinkering with an out-of-date installation and that the best course is to replace it with modern equipment. If their recommendattons are given statutory force, however, there will be probably some difficulty in obtaining the necessary equipment to alter the present lighting arrangements in many factories. It would be better, they think, if compliance with the proposed regulations were not pressed in factories which are not engaged on work of primary importance, provided that the existing conditions are reasonably satisfactory. They add that in order to obtain the best results in lighting, alterations or new installations should be supervised by qualified illuminating engineers and that such experts over an appropriate age might well be included in the lists of persons in reserved occupations.
Annotations DIPHTHERIA DIAGNOSIS BY POST
A CHILD died of diphtheria the other day largely because the result of a throat swab could not be reported earlier than three days after it was taken. The swab was taken and posted on Saturday, was received at the
laboratory on Monday and a positive report was telephoned on Tuesday, by which time the child was so ill that it died later that day. Such happenings are not very rare, and every year the annual
reports reveal that deaths from diphtheria occur mostly among patients in whom treatment with antitoxin has been too long delayed. The responsibility for these tragedies must be shared partly by the parent who does not call in the doctor when a child complains of sore throat, partly by the practitioner who does not notify or give antitoxin to the doubtful case, and partly by the local authority which does not-usually cannot afford to-supply its own bacteriological laboratory to which swabs can be sent by messenger. Parental care is an individual matter which we cannot greatly influence. In the absence of compulsory immunisation, what can the practitioner and the :1LO.H. do to prevent deaths from diphtheria? The sage advice to the family doctor to give antitoxin to every case where the history or clinical condition indicates the need for a throat-swab carries more weight than ever in these daysof delayed posts. It cannot be too often emphasised that the diagnosis of diphtheria is primarily clinical and " when in doubt, give antitoxin." At the best a bacteriological report cannot be obtained in less than 24 hours 3. Transactions of Illuminating Engineering Society November, 1938. 4. Modern Factory Lighting, London, 1940, p. 17.
(London),
- 48 hours if the swab has been sent by post-and with the Loeffler slope in some disrepute the may require 48 hours to report a result from the particular blood-tellurite method he uses. The laboratory facilities for public-health bacteriology vary enormously in different parts of the country, and the whole system is in urgent need of revision and regionalisation. The emergency public-health laboratory service initiated by the Medical Research Council may, we hope, be the precursor of a regionalised service. London presents a special problem; some boroughs utilise the laboratories of voluntary hospitals, others the laboratory service of the London County Council, others again the Lister Institute, and still others private laboratories. Very few run their own laboratories for the simple reason that it would be uneconomical. Regionalisation is urgently needed, and the most rational scheme in metropolitan London would seem to be one in which the boroughs as public-health authorities joined hands with the L.C.C. as hospital authority. The L.C.C. has already an excellent system of group laboratories which would be readily accessible to the metropolitan boroughs for diagnostic work. The linking up of the two authorities by a joint laboratory service would doubtless lead to improvements in epidemiological and preventive medicine.
bacteriologist
COMPETENCE OF VENOUS VALVES
THE original Trendelenburg test for the competence of the valves in the great saphenous vein has been so elaborated that its interpretation and its bearing on treatment have become obscured. McCallig and Heyerdalehave simplified the whole subject by pointing out that all the surgeon wants to know is whether the valves in the three systems of veins-superficial, deep and intercommunicating-are competent or not. They sweep away as confusing labels such terms as positive, negative, and double positive Trendelenburg, and rely on three very simple To demonstrate tests, one for each venous system. incompetency of the great saphenous vein they examine the patient standing. The fingers of one hand are placed at the saphenous opening; the fingers of the other hand percuss a dilated segment of the vein below. If an impulse can be detected by the upper fingers incompetent valves and a dilated main saphenous trunk can be strongly suspected. Proof is provided by reversing the procedure; a wave passing down the vein can only mean incompetent valves. Not all cases of dilated varices are associated with this incompetence in the main saphenous trunk, but the importance of the test is that with competent valves local injection of the varices stands a good chance of success. Tying the main vein is needed as a preliminary to injection when the valves in the saphenous trunk are incompetent. Without this preliminary ligature recanalisation is to be anticipated. The test for incompetency of the intercommunicating veins is equally simple. The patient lies down and his leg is elevated to allow the blood to drain away from the varicose veins. A tourniquet is placed high on the thigh, and the patient then stands up. If the varicosities fill rapidly within thirty seconds, it is assumed that there has been an overIn flow from the deep to the superficial circulation. other words, the valves of the communicating veins are incompetent. This test has not much significance, because incompetence in the communicating veins is probably always associated with incompetence in the great saphenous veins, and efficient sclerosis in the main vein will in most cases counteract the effect of the back-flow through the communicating veins. In a few cases failure to occlude a localised segment may be explained by this back-flow, and carefully localised injection should be tried, and will probably be successful. The main contraindication to sclerosing therapy is occlusion of the deep 1.
MeCallig,
J. J. and
1940, p. 97.
Heyerdale, W. W. J. Amer. med. Ass. July 13,
Annotations DIPHTHERIA DIAGNOSIS BY POST
A CHILD died of diphtheria the other day largely because the result of a throat swab could not be reported earlier than three days after it was taken. The swab was taken and posted on Saturday, was received at the
laboratory on Monday and a positive report was telephoned on Tuesday, by which time the child was so ill that it died later that day. Such happenings are not very rare, and every year the annual
reports reveal that deaths from diphtheria occur mostly among patients in whom treatment with antitoxin has been too long delayed. The responsibility for these tragedies must be shared partly by the parent who does not call in the doctor when a child complains of sore throat, partly by the practitioner who does not notify or give antitoxin to the doubtful case, and partly by the local authority which does not-usually cannot afford to-supply its own bacteriological laboratory to which swabs can be sent by messenger. Parental care is an individual matter which we cannot greatly influence. In the absence of compulsory immunisation, what can the practitioner and the :1LO.H. do to prevent deaths from diphtheria? The sage advice to the family doctor to give antitoxin to every case where the history or clinical condition indicates the need for a throat-swab carries more weight than ever in these daysof delayed posts. It cannot be too often emphasised that the diagnosis of diphtheria is primarily clinical and " when in doubt, give antitoxin." At the best a bacteriological report cannot be obtained in less than 24 hours 3. Transactions of Illuminating Engineering Society November, 1938. 4. Modern Factory Lighting, London, 1940, p. 17.
(London),
- 48 hours if the swab has been sent by post-and with the Loeffler slope in some disrepute the may require 48 hours to report a result from the particular blood-tellurite method he uses. The laboratory facilities for public-health bacteriology vary enormously in different parts of the country, and the whole system is in urgent need of revision and regionalisation. The emergency public-health laboratory service initiated by the Medical Research Council may, we hope, be the precursor of a regionalised service. London presents a special problem; some boroughs utilise the laboratories of voluntary hospitals, others the laboratory service of the London County Council, others again the Lister Institute, and still others private laboratories. Very few run their own laboratories for the simple reason that it would be uneconomical. Regionalisation is urgently needed, and the most rational scheme in metropolitan London would seem to be one in which the boroughs as public-health authorities joined hands with the L.C.C. as hospital authority. The L.C.C. has already an excellent system of group laboratories which would be readily accessible to the metropolitan boroughs for diagnostic work. The linking up of the two authorities by a joint laboratory service would doubtless lead to improvements in epidemiological and preventive medicine.
bacteriologist
COMPETENCE OF VENOUS VALVES
THE original Trendelenburg test for the competence of the valves in the great saphenous vein has been so elaborated that its interpretation and its bearing on treatment have become obscured. McCallig and Heyerdalehave simplified the whole subject by pointing out that all the surgeon wants to know is whether the valves in the three systems of veins-superficial, deep and intercommunicating-are competent or not. They sweep away as confusing labels such terms as positive, negative, and double positive Trendelenburg, and rely on three very simple To demonstrate tests, one for each venous system. incompetency of the great saphenous vein they examine the patient standing. The fingers of one hand are placed at the saphenous opening; the fingers of the other hand percuss a dilated segment of the vein below. If an impulse can be detected by the upper fingers incompetent valves and a dilated main saphenous trunk can be strongly suspected. Proof is provided by reversing the procedure; a wave passing down the vein can only mean incompetent valves. Not all cases of dilated varices are associated with this incompetence in the main saphenous trunk, but the importance of the test is that with competent valves local injection of the varices stands a good chance of success. Tying the main vein is needed as a preliminary to injection when the valves in the saphenous trunk are incompetent. Without this preliminary ligature recanalisation is to be anticipated. The test for incompetency of the intercommunicating veins is equally simple. The patient lies down and his leg is elevated to allow the blood to drain away from the varicose veins. A tourniquet is placed high on the thigh, and the patient then stands up. If the varicosities fill rapidly within thirty seconds, it is assumed that there has been an overIn flow from the deep to the superficial circulation. other words, the valves of the communicating veins are incompetent. This test has not much significance, because incompetence in the communicating veins is probably always associated with incompetence in the great saphenous veins, and efficient sclerosis in the main vein will in most cases counteract the effect of the back-flow through the communicating veins. In a few cases failure to occlude a localised segment may be explained by this back-flow, and carefully localised injection should be tried, and will probably be successful. The main contraindication to sclerosing therapy is occlusion of the deep 1.
MeCallig,
J. J. and
1940, p. 97.
Heyerdale, W. W. J. Amer. med. Ass. July 13,