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NEW DEVICES AT THE LONDON
803 In America a similar dissatisfaction with traditional has led to the search for new amcebicides. Lately Anderson and others1 have described the action of two trivalent thioarsenite derivatives of carbarsonethe dithiocarboxyl methyl derivative and the dithiocarboxyl phenyl one. They claim that if the trivalent arsenic atom is masked by one of these thioarsenite groups its toxicity is diminished while its therapeutic activity (as judged on infected rats and monkeys) remains unchanged. Chemical opinion in this country, however, considers that these thioarsenite linkages are hydrolysed in solution and therefore will be loosened still more easily in the body ; fundamentally the use of these compounds is only a convenient way of giving trivalent carbarsone oxide, the active form to which the inactive pentavalent carbarsone is converted in the body. The Americans treated 82 patients with total doses of 3.0-4-2 g. by mouth in seven to ten days or 6.0-7-2 g. in ten to twenty-four days (either-compound). Four months later, 74 of the patients were found to be clear of the amoebic infection, and the smaller dosage seemed to be as effective as the larger. Twelve of the patients vomited after the first one to three days’ treatment ; there were no other toxic reactions except increased bowel movement after the third to sixth day. The two compounds were also found to be effective against infections with Balantidium coli (2 patients) but not against the other infections in which they were tried. On the face of it, these results seem promising. But since, from the chemical side, the new compounds do not differ greatly from carbarsone inside the body, and since carbarsone is generally recognised as being inadequate as the main element of treatment, we should perhaps not draw any definite conclusions until several further clinical reports have either confirmed or refuted this one. A more interesting development concerns the new antibiotic, aureomycin. McVay and others2 have given this by mouth to 3 patients with amoebic dysentery in divided doses of about 2 g. per day to a total of 19-22 g. The treatment caused the disappearance of E. histolytica from the stools and relieved symptoms, and the patients remained free from amoebae and cysts for three weeks afterwards. No toxic effects were observed, apart from nausea for 48 hours in one patient. Here again it is too soon to assess the value of the remedy, but the apparent response of this stubbornly resistant disease to an antibiotic alone is a hopeful sign.
therapy
-
PARENTERAL PROTEIN IN INFANCY SINCE their introduction ten years ago protein digests have entered increasingly into the treatment of infants. Williams and others3 have lately published for the Medical Research Council’s committee on the protein requirements-of infants a report on ’Casydrol,’ a British enzymic digest of casein. At the Children’s Hospital, Birmingham, they found that the intravenous infusion of casydrol is without danger, provided it is not given in greater concentration than 2-5%. They followed the standard practice of always relieving any dehydration with glucose and salt solutions and establishing a free flow of urine before starting the maintenance infusion containing casydrol. They point out that since the sodium in a continuous infusion of casydrol for a 10 lb. infant may be equivalent to as much as 2 g. of sodium chloride per day, one must watch for signs of salt retention such as oedema ; and they suggest that other preparations, such as the AmericanAmigen,’ which contain about half as much salt as casydrol, are preferable 1. Anderson, H. H., A. P., Packer, H.
Johnstone, H. G., Bostick, W., Chevarria, J. Amer. med. Ass. 1949, 140, 1251. 2. McVay, L. V., Laird, R. L., Sprunt, D. H. Science, 1949, 109, 530. 3. Williams, Y. J., Bishop, E. A., Young, W. F. Arch. Dis. Childh. 1949, 24, 159.
because they can be more safely given in larger amounts than the conventional 1 g. per lb. body-weight per day which is the bare maintenance requirement of protein in infancy. They urge that casein hydrolysates should be given slowly, as by a drip, because of the risk of serious systemic reactions when they are given more rapidly, as by injection. Williams and her colleagues also indicate the desirability of improving nutrition by increasing the glucose content of parenteral solutions to 10%-a practice which is usually shunned because of the allegedly increased risk of venous thrombosis but which has been successfully adopted in America.4 5 Better results have been achieved with parenteral maintenance therapy in the last few years not only because of the introduction of protein digests but also because of the more accurate estimation of water and electrolyte requirements, the giving of optimal amounts of vitamins, and the routine prophylactic use of penicillin and sulphonamides. The Birmingham report concludes that the nutrition of very sick infants is benefited by the introduction of casydrol into their electrolyte-glucose intravenous solution, and that with such an addition infants will survive long periods of
parenteral feeding. NEW DEVICES AT THE LONDON
antique practices in the handling of soiled linen in many of our hospitals. It is customary for persist nurses, before sending linen down to the laundry, to count and sort it in the ward, and to sluice," or rinse out, badly soiled articles in the sluice-room-or even in the ward bathroom. The laundry-maids count the linen again, both before and after washing it, and the nurses count it once more when it gets back to the ward. The whole elaborate process is not only time-consuming but unhygienic and even at times dangerous. The London Hospital, a pioneer in the neglected art of leaving nurses free to nurse, has solved this No linencounting is done anywhere in the hospital. Each ward has its linen-trolleys—large tubular canvas sacks suspended open-mouthed on circular iron frames which. run on castors. These frames are light, and can be easily wheeled to the bedside, where soiled bed-linen can be tucked uncounted into the sack. Filled sacks are taken from the frames, tied up, and dropped down a chute to the basement, where an electric trolley carries them to the laundry. They are sorted, washed, and returned uncounted to a central store ; and from this store the ward sister indents daily for what she wants. Badly soiled linen is tied up separately and washed separately in the laundry. Thus linen sorting and counting, and the sluicing of soiled linen in the wards, as well as all the vexations of stocktaking day are avoided ; and all the hospital linen is in constant circulation : no large stocks have to be kept in the wards, waiting to be used. A method of checking stock is necessary, of course. Every article is embroidered with the year of issue and a serial number ; and when the sheets issued in a given year are to be checked, the sister at the central linen-store notes the numbers down as they pass through ; over a period of three months an accurate report on the number circulating can always be made. Various new measures have lately been taken at the London Hospital for the comfort of patients. Curtains on all-but-silent runners can now be drawn to form a cubicle round every bed ; and while the nurses are glad to be spared screen-carrying, the patients rejoice in the screens left are used to isolate added privacy. The infections : they run who develop respiratory patients are covered in on castors like the linen-trolleys and SOME
"
problem.
,
only
4.
Butler, 621.
A. M.,
Talbot, N. B. New Engl. J. Med. 1944, 231, 585,
5. Dodd, K., Rapoport, S.
J. Pediat. 1946, 29, 758.
804
glass-clear plastic which allows the patient to see everything going on around him and merely intercepts his droplets. Bedside commodes are now in regular use ; the light chromium pan, with a fitting lid, is set beneath an ordinary lavatory seat in a wheel-chair. The pan, and the rack which carries it, can be removed, and the seat will then fit over the pan of the ward water-closet. The nurses find that patients generally prefer being taken to the lavatory to using the commode at the bedside ; and if they are well enough to get into the chair they are usually fit to be wheeled to the closet. Each patient has his own thermometer in a test-tube hung in a clip at the head of his bed. His wireless headphones plug into a switch by means of which he can select his programme. For those who are not up to using headphones,’Pillotones’ are provided. These are about as big as a Yorkshire parkin, and lie comfortably under the pillow delivering music, vaudeville, or Women’s Hour softly into the sufferer’s ear. The wards are newly painted in a gentle oyster shade known locally as " putty B " or " Matron’s grey" ; and the green curtains of the cubicles look well against it. The empty-bed puzzle has also been very largely solved. The difficulty has always been that, as every chief has his own beds, a gynaecological case can never be put into an E.N.T. bed, or a patient with asthma into the bed of a neurologist. And as every houseman guards his chief’s beds like Cerberus, there are apt to be empty beds in inconvenient parts of the hospital. At the Londonevery ward has a side-room with a single bed in it which nobody can fill but the matron or the housegovernor. If a patient needs to be admitted to a ward which is already full, one of these officers does a little juggling. A patient due to go out is moved into the side ward for a day or two, and the newcomer gets his place. These side wards mean that there are always 10 unallotted beds in the hospital which cannot be claimed by housemen on behalf of their chiefs ; and by the judicious use of these the empty-bed rate has been reduced from 21%, before the war, to 5%. Patients’ relatives make their telephone inquiries direct to the ward, and receive a much fuller account than is possible when inquiries are answered from the gate. The task of dealing with these calls is among the duties allotted to the newly appointed ward clerks. MOTH-BALL ANÆMIA
IN England the moth-ball is gradually disappearing, its place being taken by D.D.T. in various forms. But in the United States the traditional moth-balls are still in current use, at least among the negro population. Now moth-balls are shiny glittering objects, just the kind of thing that any child of 2 years or so would want to put into its mouth, and the piccaninnies of Detroit seem to like sucking them as well. For Zuelzer and Apt1 report four cases of acute haemolytic anaemia in negro children of this age, all due to sucking moth-balls ; and surely the surprising part of their paper is that they could not find any previous reports of such cases. The explanation may be that those who treated the patients never thought of asking about moth-balls ; Zuelzer and Apt had always to probe for the history-for instance, in one of their cases a neighbour had seen the child sucking a moth-ball. Moth-balls are composed of pure naphthalene, and this chemical is presumably responsible for the syndrome that comes on I to 4 days after ingestion. The child looks listless and ill, may vomit and have diarrhoea, and goes pale but not icteric. Quite soon the urine turns a port-wine " colour and tests reveal haemoglobin in it ; no porphyrins are found. The free haemoglobin in the plasma is considerably increased. The blood smear "
1.
Zuelzer, W. W., Apt, L.
J. Amer. med. Ass. 1949,
141, 183.
fragmented red cells, and in one patient inclusion (Heinz) bodies were found inside the red cells. There is severe anaemia, with haemoglobin levels reduced to 5-5 g. per 100 ml. or less ; there is a well-marked leucocytosis shows
The red cells and many nucleated red cells appear. show spherocytosis and increased fragility in saline All tests for abnormal agglutinins and solutions. hsemolysins are negative. Reticulocytes appear eventually and their increase heralds the recovery phase. All this is typical of the picture of an acute haemolytic anaemia due to any cause. Zuelzer and Apt could find no other cause than naphthalene poisoning in their young patients. But they decided to put the matter to the test by feeding known amounts of flake naphthalene to dogs. The clinical picture seen in the children was accurately reproduced in the dogs ; the fragmentation of erythrocytes and the Heinz bodies were also seen ; when reticulocytosis occurred the number of Heinz bodies declined and recovery set in. All four children were treated with blood-transfusion and recovered without incident. It is clear that if the history of sucking moth-balls had not been obtained the diagnosis might have been Lederer’s anaemia ; the presence of acute anaemia and spherocytosis might have tempted some clinician to diagnose an acute phase of hereditary spherocytosis and to recommend splenectomy. Splenectomy has no place in the treatment of such cases ; they will recover if tided over the acute phase by blood-transfusion. Not much moth-ball anaemia is likely to be seen in this country, but the report will remind us how well worth while it is to take a
thorough history. ESTIMATING THE DEPTH OF BURNS IN fresh burns it is often impossible to tell by eye whether the skin has been totally or only partially destroyed. Yet the information may be important because excision and grafting of a burn will save much time if the skin is totally destroyed ; whereas it is meddlesome, if not positively harmful, to excise and graft a burn which still contains living epithelium and will heal rapidly by itself. A few days must usually elapse before the depth of burning can be, estimated clinically, and meanwhile infection may have occurred to jeopardise delayed surgical enterprises. Various attempts have been made to devise immediate tests for the degree of skin destruction. Dingwall has suggested intravenous fluorescein and examination of the burn under ultraviolet light for fluorescence. Patey and Scarff2 used Van Geison’s stain (picrofuchsin) on fresh burns and found that areas of partial skin loss stained pink whereas total skin destruction resulted in yellow coloration. The latest of such tests has been devised by Bull and Lennard-Jones,3 at the Birmingham Accident Hospital. Following the knowledge that burned surfaces became partly or completely anesthetic, they investigated the sensitivity of experimental burns produced on themselves. Pain was found to be the most reliable of the skin sensations and was evoked by using weighted needles. Partial-thickness burns showed diminished pain sensibility, whereas full-thickness burns were completely or almost completely anaesthetic with a surrounding zone of hyperaesthesia. Using needles weighted to 3 or 6 grammes with blobs of solder, they investigated actual burns in six patients and confirmed the experimental results. Biopsies and clinical progress, both in the experiments and in the cases, confirmed the depth of burning. Without disparaging the careful and valuable observations of the Birmingham workers, one may wonder how a test of this kind, which depends 1. Dingwall, J. A. Ann. Surg. 1943, 118, 427. 2. Patey, D. H., Scarff, R. W. Brit. J. Surg. 1944, 32, 32. Clin. Sci. 1949, 8, 155. 3. Bull, J. P., Lennard-Jones, J. E.
therapy
-
PARENTERAL PROTEIN IN INFANCY SINCE their introduction ten years ago protein digests have entered increasingly into the treatment of infants. Williams and others3 have lately published for the Medical Research Council’s committee on the protein requirements-of infants a report on ’Casydrol,’ a British enzymic digest of casein. At the Children’s Hospital, Birmingham, they found that the intravenous infusion of casydrol is without danger, provided it is not given in greater concentration than 2-5%. They followed the standard practice of always relieving any dehydration with glucose and salt solutions and establishing a free flow of urine before starting the maintenance infusion containing casydrol. They point out that since the sodium in a continuous infusion of casydrol for a 10 lb. infant may be equivalent to as much as 2 g. of sodium chloride per day, one must watch for signs of salt retention such as oedema ; and they suggest that other preparations, such as the AmericanAmigen,’ which contain about half as much salt as casydrol, are preferable 1. Anderson, H. H., A. P., Packer, H.
Johnstone, H. G., Bostick, W., Chevarria, J. Amer. med. Ass. 1949, 140, 1251. 2. McVay, L. V., Laird, R. L., Sprunt, D. H. Science, 1949, 109, 530. 3. Williams, Y. J., Bishop, E. A., Young, W. F. Arch. Dis. Childh. 1949, 24, 159.
because they can be more safely given in larger amounts than the conventional 1 g. per lb. body-weight per day which is the bare maintenance requirement of protein in infancy. They urge that casein hydrolysates should be given slowly, as by a drip, because of the risk of serious systemic reactions when they are given more rapidly, as by injection. Williams and her colleagues also indicate the desirability of improving nutrition by increasing the glucose content of parenteral solutions to 10%-a practice which is usually shunned because of the allegedly increased risk of venous thrombosis but which has been successfully adopted in America.4 5 Better results have been achieved with parenteral maintenance therapy in the last few years not only because of the introduction of protein digests but also because of the more accurate estimation of water and electrolyte requirements, the giving of optimal amounts of vitamins, and the routine prophylactic use of penicillin and sulphonamides. The Birmingham report concludes that the nutrition of very sick infants is benefited by the introduction of casydrol into their electrolyte-glucose intravenous solution, and that with such an addition infants will survive long periods of
parenteral feeding. NEW DEVICES AT THE LONDON
antique practices in the handling of soiled linen in many of our hospitals. It is customary for persist nurses, before sending linen down to the laundry, to count and sort it in the ward, and to sluice," or rinse out, badly soiled articles in the sluice-room-or even in the ward bathroom. The laundry-maids count the linen again, both before and after washing it, and the nurses count it once more when it gets back to the ward. The whole elaborate process is not only time-consuming but unhygienic and even at times dangerous. The London Hospital, a pioneer in the neglected art of leaving nurses free to nurse, has solved this No linencounting is done anywhere in the hospital. Each ward has its linen-trolleys—large tubular canvas sacks suspended open-mouthed on circular iron frames which. run on castors. These frames are light, and can be easily wheeled to the bedside, where soiled bed-linen can be tucked uncounted into the sack. Filled sacks are taken from the frames, tied up, and dropped down a chute to the basement, where an electric trolley carries them to the laundry. They are sorted, washed, and returned uncounted to a central store ; and from this store the ward sister indents daily for what she wants. Badly soiled linen is tied up separately and washed separately in the laundry. Thus linen sorting and counting, and the sluicing of soiled linen in the wards, as well as all the vexations of stocktaking day are avoided ; and all the hospital linen is in constant circulation : no large stocks have to be kept in the wards, waiting to be used. A method of checking stock is necessary, of course. Every article is embroidered with the year of issue and a serial number ; and when the sheets issued in a given year are to be checked, the sister at the central linen-store notes the numbers down as they pass through ; over a period of three months an accurate report on the number circulating can always be made. Various new measures have lately been taken at the London Hospital for the comfort of patients. Curtains on all-but-silent runners can now be drawn to form a cubicle round every bed ; and while the nurses are glad to be spared screen-carrying, the patients rejoice in the screens left are used to isolate added privacy. The infections : they run who develop respiratory patients are covered in on castors like the linen-trolleys and SOME
"
problem.
,
only
4.
Butler, 621.
A. M.,
Talbot, N. B. New Engl. J. Med. 1944, 231, 585,
5. Dodd, K., Rapoport, S.
J. Pediat. 1946, 29, 758.
804
glass-clear plastic which allows the patient to see everything going on around him and merely intercepts his droplets. Bedside commodes are now in regular use ; the light chromium pan, with a fitting lid, is set beneath an ordinary lavatory seat in a wheel-chair. The pan, and the rack which carries it, can be removed, and the seat will then fit over the pan of the ward water-closet. The nurses find that patients generally prefer being taken to the lavatory to using the commode at the bedside ; and if they are well enough to get into the chair they are usually fit to be wheeled to the closet. Each patient has his own thermometer in a test-tube hung in a clip at the head of his bed. His wireless headphones plug into a switch by means of which he can select his programme. For those who are not up to using headphones,’Pillotones’ are provided. These are about as big as a Yorkshire parkin, and lie comfortably under the pillow delivering music, vaudeville, or Women’s Hour softly into the sufferer’s ear. The wards are newly painted in a gentle oyster shade known locally as " putty B " or " Matron’s grey" ; and the green curtains of the cubicles look well against it. The empty-bed puzzle has also been very largely solved. The difficulty has always been that, as every chief has his own beds, a gynaecological case can never be put into an E.N.T. bed, or a patient with asthma into the bed of a neurologist. And as every houseman guards his chief’s beds like Cerberus, there are apt to be empty beds in inconvenient parts of the hospital. At the Londonevery ward has a side-room with a single bed in it which nobody can fill but the matron or the housegovernor. If a patient needs to be admitted to a ward which is already full, one of these officers does a little juggling. A patient due to go out is moved into the side ward for a day or two, and the newcomer gets his place. These side wards mean that there are always 10 unallotted beds in the hospital which cannot be claimed by housemen on behalf of their chiefs ; and by the judicious use of these the empty-bed rate has been reduced from 21%, before the war, to 5%. Patients’ relatives make their telephone inquiries direct to the ward, and receive a much fuller account than is possible when inquiries are answered from the gate. The task of dealing with these calls is among the duties allotted to the newly appointed ward clerks. MOTH-BALL ANÆMIA
IN England the moth-ball is gradually disappearing, its place being taken by D.D.T. in various forms. But in the United States the traditional moth-balls are still in current use, at least among the negro population. Now moth-balls are shiny glittering objects, just the kind of thing that any child of 2 years or so would want to put into its mouth, and the piccaninnies of Detroit seem to like sucking them as well. For Zuelzer and Apt1 report four cases of acute haemolytic anaemia in negro children of this age, all due to sucking moth-balls ; and surely the surprising part of their paper is that they could not find any previous reports of such cases. The explanation may be that those who treated the patients never thought of asking about moth-balls ; Zuelzer and Apt had always to probe for the history-for instance, in one of their cases a neighbour had seen the child sucking a moth-ball. Moth-balls are composed of pure naphthalene, and this chemical is presumably responsible for the syndrome that comes on I to 4 days after ingestion. The child looks listless and ill, may vomit and have diarrhoea, and goes pale but not icteric. Quite soon the urine turns a port-wine " colour and tests reveal haemoglobin in it ; no porphyrins are found. The free haemoglobin in the plasma is considerably increased. The blood smear "
1.
Zuelzer, W. W., Apt, L.
J. Amer. med. Ass. 1949,
141, 183.
fragmented red cells, and in one patient inclusion (Heinz) bodies were found inside the red cells. There is severe anaemia, with haemoglobin levels reduced to 5-5 g. per 100 ml. or less ; there is a well-marked leucocytosis shows
The red cells and many nucleated red cells appear. show spherocytosis and increased fragility in saline All tests for abnormal agglutinins and solutions. hsemolysins are negative. Reticulocytes appear eventually and their increase heralds the recovery phase. All this is typical of the picture of an acute haemolytic anaemia due to any cause. Zuelzer and Apt could find no other cause than naphthalene poisoning in their young patients. But they decided to put the matter to the test by feeding known amounts of flake naphthalene to dogs. The clinical picture seen in the children was accurately reproduced in the dogs ; the fragmentation of erythrocytes and the Heinz bodies were also seen ; when reticulocytosis occurred the number of Heinz bodies declined and recovery set in. All four children were treated with blood-transfusion and recovered without incident. It is clear that if the history of sucking moth-balls had not been obtained the diagnosis might have been Lederer’s anaemia ; the presence of acute anaemia and spherocytosis might have tempted some clinician to diagnose an acute phase of hereditary spherocytosis and to recommend splenectomy. Splenectomy has no place in the treatment of such cases ; they will recover if tided over the acute phase by blood-transfusion. Not much moth-ball anaemia is likely to be seen in this country, but the report will remind us how well worth while it is to take a
thorough history. ESTIMATING THE DEPTH OF BURNS IN fresh burns it is often impossible to tell by eye whether the skin has been totally or only partially destroyed. Yet the information may be important because excision and grafting of a burn will save much time if the skin is totally destroyed ; whereas it is meddlesome, if not positively harmful, to excise and graft a burn which still contains living epithelium and will heal rapidly by itself. A few days must usually elapse before the depth of burning can be, estimated clinically, and meanwhile infection may have occurred to jeopardise delayed surgical enterprises. Various attempts have been made to devise immediate tests for the degree of skin destruction. Dingwall has suggested intravenous fluorescein and examination of the burn under ultraviolet light for fluorescence. Patey and Scarff2 used Van Geison’s stain (picrofuchsin) on fresh burns and found that areas of partial skin loss stained pink whereas total skin destruction resulted in yellow coloration. The latest of such tests has been devised by Bull and Lennard-Jones,3 at the Birmingham Accident Hospital. Following the knowledge that burned surfaces became partly or completely anesthetic, they investigated the sensitivity of experimental burns produced on themselves. Pain was found to be the most reliable of the skin sensations and was evoked by using weighted needles. Partial-thickness burns showed diminished pain sensibility, whereas full-thickness burns were completely or almost completely anaesthetic with a surrounding zone of hyperaesthesia. Using needles weighted to 3 or 6 grammes with blobs of solder, they investigated actual burns in six patients and confirmed the experimental results. Biopsies and clinical progress, both in the experiments and in the cases, confirmed the depth of burning. Without disparaging the careful and valuable observations of the Birmingham workers, one may wonder how a test of this kind, which depends 1. Dingwall, J. A. Ann. Surg. 1943, 118, 427. 2. Patey, D. H., Scarff, R. W. Brit. J. Surg. 1944, 32, 32. Clin. Sci. 1949, 8, 155. 3. Bull, J. P., Lennard-Jones, J. E.