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THE PROBLEM OF HOME ACCIDENTS
620 Tovell
Many
1948).
make
a
practice
of
giving
an
intravenous procaine drip throughout thoracic operations when the heart is to be handled and
anticipated. Allergic
writers et al.
arhythmias
(State
and
are
Wangen-
1946, Dressler and Dwork
dramatic
retrogression of symptoms and procaine in serum sickness and penicillin-sensitivity reactions, though the mode of action in these conditions was by no means clear until recently, when the close relationship between procaine and the anti-histamine drugs was established (see Burn 1947) describe
signs
a
after intravenous
1948). Procaine has also been advocated for asthma (Durieu et al. 1946). We have experience of one case of status asthmaticus of some 24 hours’ duration in which adrenaline and atropine were of no avail and the patient was exhausted and appeared in extremis, but the slow intravenous injection of 10 ml. of 1% procaine dramatically ended the attack. FATE IN
THE
BODY, TOXICITY,
AND
DOSAGE
Procaine
is broken down in the liver into p-aminobenzoic acid and diethylamino-ethanol (Fosdick and Hansen 1931). This breakdown also occurs, in part, in the blood-stream by the action of an enzyme (Goldberg et al. 1943). So far no significant biochemical upset in the body as a result of procaine therapy has been observed. Liver function is unimpaired (Jacoby et al.
1948).
3. As treatment for various allergic and allied conditionse.g., serum sickness, penicillin-sensitivity reactions, asthma, and urticaria. 4. As a treatment for vascular disease, where it may take the place of a sympathetic block.
Intravenous procaine is easily administered, but vigilant supervision is necessary if overdose is to be
avoided. REFERENCES
Ameuille, M. P. (1948) Medical Research in France during the War 1939-45. Paris ; p. 263. Allen, F. M. (1945) Amer. J. Surg. 70, 283. — Crossman, L. W., Lyons, L. V. (1946) Anesth. & Analges. 25, 1. Appelbaum, E., Abraham, A., Sinton, W. (1946) J. Amer. med. Ass. 131, 1274.
Barbour, C. M., Tovell, R. M. (1948) Anesthesiology, 9, 514. Beck, C. S., Mautz, F. R. (1937) Ann. Surg. 106, 525. Benda, R., Benda, P. (1946) Sem. Hôp. Paris, 22, 1577. Bier, A. (1909) Münch. med. Wschr. 1, 589. Bittrich, N. M., Powers, W. F. (1948) Anesth. & Analges. 27, 181. Burn, H. J. (1948) The Background of Therapeutics. London; p. 89.
Burstein, C. L. (1946) Anesthesiology, 7, 113. Marangoni, B. A., Degraff, A. C., Rovenstine, E. A. (1940) Ibid, 1, 167. Dawes, G. S. (1946a) Brit. med. J. i, 43. (1946b) Brit. J. Pharmacol. 1, 90. Dressier, S., Dwork, R. E. (1947) J. Amer. med. Ass. 133, 849. Durieu, H., de Clerq, F., Duprez, A. (1946) Acta clin. belg. 1, 150. Fosdick, L. S., Hansen, H. L. (1931) Dent. Cosmos, 73, 1082. Goldberg, A., Koster, H., Warshaw, R. (1943) Arch. Surg. 46, 49. Gordon, R. A. (1943) Canad. med. Ass. J. 49, 478. Graubard, D. J., Kovacs, J., Ritter, H. H. (1948a) Ann. intern. Med. 28, 1106. Ritter, H. H. (1947) Amer. J. Surg. 74, 765. Robertazzi, R. W., Peterson, M. C. (1947) Anesthesiology, 8, —
—
—
—
236.
(1948b) Anesth. & Analges. 27, 222. Hermann, H., Jourdan, F. (1931) C.R. Soc. Biol. Paris, 106, 1153. Ing, H. R., Dawes, G. S., Wajda, I. (1945) J. Pharmacol. 85, 85. Jacoby, J. J., Coon, J. M., Woolf, M. P., Salerno, P. R., Livingstone, H. M. (1948) Anesthesiology, 9, 481. Johnson, K., Gilbert, C. R. A. (1946) Anesth. & Analges. 25, 133. Kochmann, M., Daeles, F. (1908) Arch. int. Pharmacodyn. 18, 41. Leriche, R., Fontaine, R. (1935) J. Chir., Brux. 34, 537. Lewy, R. B. (1937) Arch. Otolaryngol. 25, 178. Lundy, J. S. (1942) Clinical Anesthesia. Philadelphia. Mautz. F. R. (1936) J. thorac. Surg. 5, 612. McLachlin, J. A. (1945) Canad. med. Ass. J. 52, 383. Richards, R. K. (1947) Anesth. & Analges, 26, 22. Shen, T. C. R., Simon, M. A. (1938) Arch. int. Pharmacodyn. 59, 68. State, D., Wangensteen, O. H. (1946) J. Amer. med. Ass. 130, 990. —
An optimal intravenous dose of procaine gives the patient a feeling of warmth and relaxation. If this optimal dose is exceeded or administered too quickly signs of overdose appear-" pins and needles " in the hands and feet, dizziness, twitching, convulsions, and ultimately loss of consciousness. Vita1ÍlÏn-C deficiency increases the liability to these side-effects (Richards
1947) ; in fact, some advocate the addition of ascorbic acid to the procaine solution before use (Graubard et al. 1948b). Another precaution to reduce the possibility of convulsions is the previous administration of a barbiturate. The elimination of a therapeutic dose of procaine from the blood-stream occurs within 20 minutes (Graubard et al. 1947) Therefore, if a prolonged effect is desired, the injection of procaine must be repeated frequently, or the procaine must be administered as a continuous infusion of a dilute solution. Except in emergencies, the continuous drip is most satisfactory and a dilution of 0-1%—1 g. of procaine in 1000 ml. of normal salinewill be found convenient. For an optimal effect from a single dose, 25 mg. per stone (4 mg. per kg.) of body-weight, given as an infusion of a 0-1% solution in twenty minutes, is recommended (Graubard et al. 1947). Where a longer and less intense effect is desired the same dosage given at a slower rate suffices. In emergencies, such as ventricular fibrillation, status asthmaticus,
a,ngina, 1% procaine
severe
or
pulmonary embolism,
solution (100 mg.) may be A careful watch as a intravenous injection. given single should be maintained for the onset of convulsions and a up to 10 ml. of
syringe containing thiopentone kept handy
as
an
—
—
THE PROBLEM OF HOME ACCIDENTS
(FROM
THE LONDON SCHOOL OF HYGIENE AND TROPICAL
MEDICINE, PUBLIC
"
*
Procaine injected intravenously possesses well-marked analgesic, quinidine-like, anti-histamine, and anti-acetylcholine properties. Its versatility as a therapeutic agent is indicated by the following uses to which it has been put : .
of
generalised analgesic
for
*
m
year 15,000 people in England and Wales die the result of an accident : road accidents account for 6000 and industrial accidents for 2000. The greater pro- portion of the remainder can be classified as accidents in the home. For each person killed many more receive less serious and non-fata,l injuries. To obtain a little information on this latter group of non-fatal home accidents a survey was carried out by postgraduate students of this school. The survey covered a period of four months. During that time six hospitals
Every
SUMMARY
a
DEPARTMENT)
HOME accidents-what a mixed bag of domestic misfortunes the phrase suggests ! Yet when they are picked up and examined, there are features enough in common to make a study of their general or group causes worth while. With our knowledge of the means of preventing these accidents still woefully insufficient, even a limited exploratory survey research deserves attention. At the request of a panel " of the Scientific Advisory Committee of the Ministry of Works, a group of a dozen students at the London School of Hygiene was formed into a seminar to plan and execute a small home-accidents survey. The results of the investigation were interesting on their own account, but statistical information was inevitably slight. A number of special difficulties in method of inquiry and assessment of findings were brought to light. The following report deals with these. J. M. M.
antidote.
1. As
HEALTH
pains
due to
a
variety
causes.
2. As an emergency treatment for, or prophylactic against, cardiac arhythmias. It is a valuable addition to the armamenta.rium of the anaesthetist during thoracic operations.
as
(all except
one
being situated in Central London) notified
621 505 outpatients, of whom 150 were visited in their homes. For each case visited a four-page schedule was completed, covering all aspects of the case-medical details, the family, overcrowding, structure of the house, psychological features including accident-proneness, and precautions taken, in order that the fullest information should be available for deciding the cause of each accident, and the means by which it could have been prevented. The immediate purpose of the survey was to study The results were demonstrated methods of inquiry. by means of an exhibition, and a dramatic act based More leisurely analysis and conon our experience.’ sideration of the data have prompted this contribution to the problem of home accidents. We have naturally compared our results with those obtained by other investigators and by other methods, and we want to stress certain features of the data which are not always borne clearly in mind. BIAS IN OUR SOURCES OF INFORMATION source of information, taken alone, is bound to be biased and unrepresentative. The Registrar-General analyses and presents all the deaths from accidents, but he can tell us nothing about the patients who recover. The injuries which are rarely fatal are overlooked, while those which obey the " all or nothing " law, such as electrocution, suffocation, and poisoning, receive undue attention. In addition, changes in incidencerate and fatality-rate cannot be observed. Even for deaths, sufficient information to decide whether it is a home accident is not always forthcoming ; the cause is not always apparent, and the means which would have prevented the accident are rarely discernible. Attempts may be made to gain this additional information from coroners’ inquests, but here again the possibility of bias (in the statistical sense) enters. Certain types of accident are more likely to come to inquest, because they are surrounded by some mystery. In addition, the limelight focused on these tragedies by the very fact of there being an official inquiry may be prejudicial to eliciting the finer psychological points which may be so important. A similar type of bias is involved in the collection and statistical analysis of press cuttings, as is done for Government departments interested in these accidents. The cases most likely to be reported are those which will excite the emotions of the newspaper readers-sex interest (women in burning nightgowns), politics (explosives found in coal), the heartstrings of mother love (suffocated babies). Further distortion and misplacement of emphasis can readily occur during the editing and cutting. Above all, in any fatal accident, we are up against the difficulty that dead men tell no tales.
Any one
NON -F ATAL ACCIDENTS
Our
.
of information for non-fatal accidents are just as precarious. Some investigations have been made into special types of injuries, such as burns and scalds, in hospital inpatients, and in a limited number the circumstances of the home have also been investigated. These cannot be considered representative of all types of accidents, since all social classes do not use the hospitals to the same extent, and all kinds of accidents do not need, in the same degree, admission to hospital. Another approach has been to investigate accidents met with in the houses visited by health visitors. They naturally found a high proportion of accidents in young children and housewives, and one can understand the tendency shown to exonerate the patient, and to lay the blame on the inanimate environment. The police have also made a survey : they were not so chary of moral censure. Being on the spot immediately after the accident and being by training on the look-out for sources
1. See
Lancet, 1948, i, 758.
a relaof accidents due to drunkenness. The survey based on outpatients notified by the hospitals in Central London clearly revealed the numerous It was sources of bias in our method of approach. known from other sources2 that only a fraction of the incapacitated seek advice at hospitals, and it was speedily realised that it is not necessarily the severity of the lesion that leads to hospital attendance. A cut which bleeds calls for spectacular treatment : a humdrum crushed finger or twisted ankle is disregarded. An anxious mother will hurry to hospital with her child : her own injury is neglected until brought to light by a routine attendance at an infant-welfare clinic. Comparison of the hospitals revealed differences in their notifications. On the whole females predominated except at the extremes of age, yet one hospital notified more males than females. Some hospitals served an area lying within only a few miles of the hospital : - the patients of others were spread well beyond the bounds of Greater London. Curious offshoots were found, determined either by the attraction of easy transport routes, or connexions with local practitioners, or by faith in central hospitals. Notification does not mean the same thing to all hospitals. One will notify everything that might conceivably be a home accident, so that a large proportion need to be rejected after investigation ; another hospital, whose almoners carefully sift the records, does the preliminary screening so thoroughly that nearly all A hospital with a unsuitable material is discarded. centralised records department could easily report on any patient in or attending the hospital ; while, another with separate registers for outpatients, for casualty, and for fracture clinic, and its inpatient records distributed on every floor of the hospital would find considerable difficulties. The attempt to visit the homes of the patients caused further selection. Some addresses were never found, and inexperience and lack of local knowledge may have contributed in some degree to these failures ; other addresses were located, but the alleged patient wasnot known there, and it seems that a small proportion of patients gave misleading addresses. Patients living far afield were not visited, and others seemed to be always at work or not at home to callers. For those finally run to earth the scope of the investigation varied considerably. We found, as have others, that women are most successful at these front-door interviews, better able to break down any " snooper resistance " and to obtain entry to the house, and confidences about any family skeletons. In assessing the cause of the accident there is ample scope for individual judgment : two assessors may weight the human and the inanimate causes very differently in the same case, or the same assessor may find the accent misplaced when reviewing a case-history at a later date.
drunkenness, it is natural that they should fin.d
tively large proportion
.
FURTHER RESEARCH
The approach to home accidents differs from that towards accidents in industry or in the Services. In the latter, the main object is to weed out the unsuitable or accident-prone person. We cannot take this attitude towards the housewife : we have to accept people living in the home. There may be an analogy between the new entrant to industry, and the young infant facing the unknown dangers of the hearth and stairs, but the results of inquiry into industrial accidents are not immediately applicable to home accidents. An accident is the result of human action, and accident research is a subject for psychological study. It has been noted that after an accident the patient tends to adopt one of two extreme attitudes, either blaming himself 2.
Slater, P.
Survey of Sickness, Social Survey.
1946.
622 for his own " carelessness," or exculpating himself completely, and laying all the blame on the material environment. It was interesting to observe the incredulity of some patients that we should think an accident should have any cause-" Why, it’was a pure accident, doctor ! The possibility of explaining accidents on the basis of Freud’s theory of everyday mistakes and slips has been suggested. Here is an example within our recent experience : an elderly woman, who was known to be jealous of her husband’s popularity with the ladies, was presiding at the tea-table. The conversation turned to her husband, who was away being photographed with the matron and nurses of the hospital with which he was connected. The flippant conversation was interrupted by the wife knocking over the hot-water jug, and being scalded on the leg and foot, accidentally. Yes, a genuine accident, but what an effective way of changing the subject, and attracting attention and sympathy. Unless one is present during the occurrence of the accident, and on the look-out for such psychological causes, it is difficult to disinter them later, and particularly difficult at a street-door interview with a slightly suspicious housewife. There is a tendency to reject such motivated egplanations 3 ; to determine how important they are needs intensive or introspective research, and is a field where the general practitioner’s personal knowledge of the patient would be an asset. In the past attention has been focused on major accidents, and minor injuries have tended to be ignored. In our first list (of 15 notifications) there were 5 attendances as hospital outpatients for " fish-bone in throat." These we brushed superciliously aside, but regretted having done so later when we found that this type of injury appeared to come in epidemic waves-as if some particular consignment of fish, or some vagary of the weather or the meat situation had a bearing on its incidence. Foreign bodies in the eye, again, hardly seemed worthy of attention, but when we reflect how commonly it happens to every one of us, in a minor form, and how frequently treatment is sought outside of hospitals, it assumes an added importance. Accidents are fortunately fairly rare in the experience of any one individual-sufficiently uncommon to make experimental procedures and the testing of preventive methods a matter of difficulty. This is an argument in favour of the study of minor injuries which are relatively It has been suggested, in the case of more frequent. traffic accidents, to use some manifestation which occurs more often than accidents-say to observe the number of people who step carelessly into the road. In pilots once a correlation between accidents and a certain type of reaction has been established, the reaction may be used as an indicator in experimental studies.3 The need is to find some attribute closely connected with domestic accidents-possibly lack of attention, use of makeshifts, slovenly movements, minor injuries, and abrasions -so that without waiting for an accident to happen, one may judge of the likelihood of an accident happening. Further knowledge is required about the " exposure to risk " in various accidents. For example, a third of all falls in the home were found to occur on the stairs ; and since the time spent on the stairs is very much less than a third of our waking hours, one may safely conclude that stairs present an increased hazard. It was also found that only one fall in the series occurred on carpeted stairs, but it is impossible to draw any conclusions about the safety or otherwise of carpeted stairs unless we know the proportion in the general population of houses. Background knowledge such as this-the proportion of houses with steep stairs, with winders, with structural defects-is essential before the statistics from accidents
-mercilessly
"
3. Pilot
Error, A.P. 3139A, Air Ministry, 1948.
be fully interpreted. The guidance of expert social investigators, with adequate secretarial and statistical can
facilities is desirable to make the best
use
of the medical
personnel. The general practitioner,
with his facilities for easy and other diseases, both for accidents houses, is in a singularly fortunate position for accumulating data of this kind. The survey of sickness carried out by the Social Survey has shown that sick persons seek treatment not only from their own doctors and from hospitals, but also from chemists and factory nurses ; or they may not go to any outside agency. Any investigation limited to one angle of approach can give only a partial and biased picture, but by combining together different approaches - especially through the hospitals and through general practitioners-a truer picture of accident incidence and composition will be obtained. It will not necessarily be complete, but it will be less incomplete than any existing survey.
access
to
NEW ZEALAND HOSPITAL
SALARIES
FROM A CORRESPONDENT
UNDER a new award,l the salaries of whole-time hosmedical officers are to be increased throughout New Zealand.
pital
The medical superintendent-in-chief at Auckland is to receive 1:2000 rising to 1:2250, while at Wellington the figures The salaries of the are to be E1900 and C2150 respectively. superintendents of smaller hospitals are to range from a minimum of E1250 to a maximum of .S1500 ; and at Christchurch and Dunedin the minimum is to be S1650 and the maximum 1900. Three scales are provided for specialists, with minima ranging from f:1050 to E1750 and maxima from £ 130 to .S2000. Whole-time medical officers not otherwise provided for are covered in six scales ranging up to a maximum of f:l550.
Even with these increases the salaries of wholetime hospital doctors will compare unfavourably with the earnings of general practitioners. In a recent lawsuit the head of a medical combine in Dunedin sued a colleague for possession of a consulting-room ; and the defendant stated in his evidence that his gross takings for eighteen months amounted to 8600, or nearly 1:5750 a year. Small wonder that with such figures as these before them, many parents see in medicine an unusually lucrative future for their children, and that in consequence the medical school is filled to overflowing. Steps have had to be taken to limit the number of entrants by making the first medical examination competitive. Those already qualified are no doubt rejoicing that this method did not exist in their time. Overcrowding is no new phenomenon. Prof. L. S. P. Davidson, now on a visit to the Dominion, lately told the press that with 120 medical graduates a year the doctor’s economic position would deteriorate, so there would be no need for further provision for medical education by opening a new medical school in Auckland ;and the present dearth of research-workers would be righted because the promising graduates would not be diverted into the golden path of general practice. The relation of cause and effect is doubtless as difficult to estimate in the realm of economics as in medicine, but there is every reason to suppose that the publicity given to medical earnings can have done no-one any good. The doctor who sees his neighbour, the mechanic, setting out with his family for the beach on a Saturday morning will say that if a 40-hour week is good enough for one it is good enough for another, and will refuse to answer a weekend call. The mechanic, who cannot get a doctor to visit him, and who may be dissatisfied with the care he receives when he does, will 1. See
Lancet, March 26, p. 537.
Many
1948).
make
a
practice
of
giving
an
intravenous procaine drip throughout thoracic operations when the heart is to be handled and
anticipated. Allergic
writers et al.
arhythmias
(State
and
are
Wangen-
1946, Dressler and Dwork
dramatic
retrogression of symptoms and procaine in serum sickness and penicillin-sensitivity reactions, though the mode of action in these conditions was by no means clear until recently, when the close relationship between procaine and the anti-histamine drugs was established (see Burn 1947) describe
signs
a
after intravenous
1948). Procaine has also been advocated for asthma (Durieu et al. 1946). We have experience of one case of status asthmaticus of some 24 hours’ duration in which adrenaline and atropine were of no avail and the patient was exhausted and appeared in extremis, but the slow intravenous injection of 10 ml. of 1% procaine dramatically ended the attack. FATE IN
THE
BODY, TOXICITY,
AND
DOSAGE
Procaine
is broken down in the liver into p-aminobenzoic acid and diethylamino-ethanol (Fosdick and Hansen 1931). This breakdown also occurs, in part, in the blood-stream by the action of an enzyme (Goldberg et al. 1943). So far no significant biochemical upset in the body as a result of procaine therapy has been observed. Liver function is unimpaired (Jacoby et al.
1948).
3. As treatment for various allergic and allied conditionse.g., serum sickness, penicillin-sensitivity reactions, asthma, and urticaria. 4. As a treatment for vascular disease, where it may take the place of a sympathetic block.
Intravenous procaine is easily administered, but vigilant supervision is necessary if overdose is to be
avoided. REFERENCES
Ameuille, M. P. (1948) Medical Research in France during the War 1939-45. Paris ; p. 263. Allen, F. M. (1945) Amer. J. Surg. 70, 283. — Crossman, L. W., Lyons, L. V. (1946) Anesth. & Analges. 25, 1. Appelbaum, E., Abraham, A., Sinton, W. (1946) J. Amer. med. Ass. 131, 1274.
Barbour, C. M., Tovell, R. M. (1948) Anesthesiology, 9, 514. Beck, C. S., Mautz, F. R. (1937) Ann. Surg. 106, 525. Benda, R., Benda, P. (1946) Sem. Hôp. Paris, 22, 1577. Bier, A. (1909) Münch. med. Wschr. 1, 589. Bittrich, N. M., Powers, W. F. (1948) Anesth. & Analges. 27, 181. Burn, H. J. (1948) The Background of Therapeutics. London; p. 89.
Burstein, C. L. (1946) Anesthesiology, 7, 113. Marangoni, B. A., Degraff, A. C., Rovenstine, E. A. (1940) Ibid, 1, 167. Dawes, G. S. (1946a) Brit. med. J. i, 43. (1946b) Brit. J. Pharmacol. 1, 90. Dressier, S., Dwork, R. E. (1947) J. Amer. med. Ass. 133, 849. Durieu, H., de Clerq, F., Duprez, A. (1946) Acta clin. belg. 1, 150. Fosdick, L. S., Hansen, H. L. (1931) Dent. Cosmos, 73, 1082. Goldberg, A., Koster, H., Warshaw, R. (1943) Arch. Surg. 46, 49. Gordon, R. A. (1943) Canad. med. Ass. J. 49, 478. Graubard, D. J., Kovacs, J., Ritter, H. H. (1948a) Ann. intern. Med. 28, 1106. Ritter, H. H. (1947) Amer. J. Surg. 74, 765. Robertazzi, R. W., Peterson, M. C. (1947) Anesthesiology, 8, —
—
—
—
236.
(1948b) Anesth. & Analges. 27, 222. Hermann, H., Jourdan, F. (1931) C.R. Soc. Biol. Paris, 106, 1153. Ing, H. R., Dawes, G. S., Wajda, I. (1945) J. Pharmacol. 85, 85. Jacoby, J. J., Coon, J. M., Woolf, M. P., Salerno, P. R., Livingstone, H. M. (1948) Anesthesiology, 9, 481. Johnson, K., Gilbert, C. R. A. (1946) Anesth. & Analges. 25, 133. Kochmann, M., Daeles, F. (1908) Arch. int. Pharmacodyn. 18, 41. Leriche, R., Fontaine, R. (1935) J. Chir., Brux. 34, 537. Lewy, R. B. (1937) Arch. Otolaryngol. 25, 178. Lundy, J. S. (1942) Clinical Anesthesia. Philadelphia. Mautz. F. R. (1936) J. thorac. Surg. 5, 612. McLachlin, J. A. (1945) Canad. med. Ass. J. 52, 383. Richards, R. K. (1947) Anesth. & Analges, 26, 22. Shen, T. C. R., Simon, M. A. (1938) Arch. int. Pharmacodyn. 59, 68. State, D., Wangensteen, O. H. (1946) J. Amer. med. Ass. 130, 990. —
An optimal intravenous dose of procaine gives the patient a feeling of warmth and relaxation. If this optimal dose is exceeded or administered too quickly signs of overdose appear-" pins and needles " in the hands and feet, dizziness, twitching, convulsions, and ultimately loss of consciousness. Vita1ÍlÏn-C deficiency increases the liability to these side-effects (Richards
1947) ; in fact, some advocate the addition of ascorbic acid to the procaine solution before use (Graubard et al. 1948b). Another precaution to reduce the possibility of convulsions is the previous administration of a barbiturate. The elimination of a therapeutic dose of procaine from the blood-stream occurs within 20 minutes (Graubard et al. 1947) Therefore, if a prolonged effect is desired, the injection of procaine must be repeated frequently, or the procaine must be administered as a continuous infusion of a dilute solution. Except in emergencies, the continuous drip is most satisfactory and a dilution of 0-1%—1 g. of procaine in 1000 ml. of normal salinewill be found convenient. For an optimal effect from a single dose, 25 mg. per stone (4 mg. per kg.) of body-weight, given as an infusion of a 0-1% solution in twenty minutes, is recommended (Graubard et al. 1947). Where a longer and less intense effect is desired the same dosage given at a slower rate suffices. In emergencies, such as ventricular fibrillation, status asthmaticus,
a,ngina, 1% procaine
severe
or
pulmonary embolism,
solution (100 mg.) may be A careful watch as a intravenous injection. given single should be maintained for the onset of convulsions and a up to 10 ml. of
syringe containing thiopentone kept handy
as
an
—
—
THE PROBLEM OF HOME ACCIDENTS
(FROM
THE LONDON SCHOOL OF HYGIENE AND TROPICAL
MEDICINE, PUBLIC
"
*
Procaine injected intravenously possesses well-marked analgesic, quinidine-like, anti-histamine, and anti-acetylcholine properties. Its versatility as a therapeutic agent is indicated by the following uses to which it has been put : .
of
generalised analgesic
for
*
m
year 15,000 people in England and Wales die the result of an accident : road accidents account for 6000 and industrial accidents for 2000. The greater pro- portion of the remainder can be classified as accidents in the home. For each person killed many more receive less serious and non-fata,l injuries. To obtain a little information on this latter group of non-fatal home accidents a survey was carried out by postgraduate students of this school. The survey covered a period of four months. During that time six hospitals
Every
SUMMARY
a
DEPARTMENT)
HOME accidents-what a mixed bag of domestic misfortunes the phrase suggests ! Yet when they are picked up and examined, there are features enough in common to make a study of their general or group causes worth while. With our knowledge of the means of preventing these accidents still woefully insufficient, even a limited exploratory survey research deserves attention. At the request of a panel " of the Scientific Advisory Committee of the Ministry of Works, a group of a dozen students at the London School of Hygiene was formed into a seminar to plan and execute a small home-accidents survey. The results of the investigation were interesting on their own account, but statistical information was inevitably slight. A number of special difficulties in method of inquiry and assessment of findings were brought to light. The following report deals with these. J. M. M.
antidote.
1. As
HEALTH
pains
due to
a
variety
causes.
2. As an emergency treatment for, or prophylactic against, cardiac arhythmias. It is a valuable addition to the armamenta.rium of the anaesthetist during thoracic operations.
as
(all except
one
being situated in Central London) notified
621 505 outpatients, of whom 150 were visited in their homes. For each case visited a four-page schedule was completed, covering all aspects of the case-medical details, the family, overcrowding, structure of the house, psychological features including accident-proneness, and precautions taken, in order that the fullest information should be available for deciding the cause of each accident, and the means by which it could have been prevented. The immediate purpose of the survey was to study The results were demonstrated methods of inquiry. by means of an exhibition, and a dramatic act based More leisurely analysis and conon our experience.’ sideration of the data have prompted this contribution to the problem of home accidents. We have naturally compared our results with those obtained by other investigators and by other methods, and we want to stress certain features of the data which are not always borne clearly in mind. BIAS IN OUR SOURCES OF INFORMATION source of information, taken alone, is bound to be biased and unrepresentative. The Registrar-General analyses and presents all the deaths from accidents, but he can tell us nothing about the patients who recover. The injuries which are rarely fatal are overlooked, while those which obey the " all or nothing " law, such as electrocution, suffocation, and poisoning, receive undue attention. In addition, changes in incidencerate and fatality-rate cannot be observed. Even for deaths, sufficient information to decide whether it is a home accident is not always forthcoming ; the cause is not always apparent, and the means which would have prevented the accident are rarely discernible. Attempts may be made to gain this additional information from coroners’ inquests, but here again the possibility of bias (in the statistical sense) enters. Certain types of accident are more likely to come to inquest, because they are surrounded by some mystery. In addition, the limelight focused on these tragedies by the very fact of there being an official inquiry may be prejudicial to eliciting the finer psychological points which may be so important. A similar type of bias is involved in the collection and statistical analysis of press cuttings, as is done for Government departments interested in these accidents. The cases most likely to be reported are those which will excite the emotions of the newspaper readers-sex interest (women in burning nightgowns), politics (explosives found in coal), the heartstrings of mother love (suffocated babies). Further distortion and misplacement of emphasis can readily occur during the editing and cutting. Above all, in any fatal accident, we are up against the difficulty that dead men tell no tales.
Any one
NON -F ATAL ACCIDENTS
Our
.
of information for non-fatal accidents are just as precarious. Some investigations have been made into special types of injuries, such as burns and scalds, in hospital inpatients, and in a limited number the circumstances of the home have also been investigated. These cannot be considered representative of all types of accidents, since all social classes do not use the hospitals to the same extent, and all kinds of accidents do not need, in the same degree, admission to hospital. Another approach has been to investigate accidents met with in the houses visited by health visitors. They naturally found a high proportion of accidents in young children and housewives, and one can understand the tendency shown to exonerate the patient, and to lay the blame on the inanimate environment. The police have also made a survey : they were not so chary of moral censure. Being on the spot immediately after the accident and being by training on the look-out for sources
1. See
Lancet, 1948, i, 758.
a relaof accidents due to drunkenness. The survey based on outpatients notified by the hospitals in Central London clearly revealed the numerous It was sources of bias in our method of approach. known from other sources2 that only a fraction of the incapacitated seek advice at hospitals, and it was speedily realised that it is not necessarily the severity of the lesion that leads to hospital attendance. A cut which bleeds calls for spectacular treatment : a humdrum crushed finger or twisted ankle is disregarded. An anxious mother will hurry to hospital with her child : her own injury is neglected until brought to light by a routine attendance at an infant-welfare clinic. Comparison of the hospitals revealed differences in their notifications. On the whole females predominated except at the extremes of age, yet one hospital notified more males than females. Some hospitals served an area lying within only a few miles of the hospital : - the patients of others were spread well beyond the bounds of Greater London. Curious offshoots were found, determined either by the attraction of easy transport routes, or connexions with local practitioners, or by faith in central hospitals. Notification does not mean the same thing to all hospitals. One will notify everything that might conceivably be a home accident, so that a large proportion need to be rejected after investigation ; another hospital, whose almoners carefully sift the records, does the preliminary screening so thoroughly that nearly all A hospital with a unsuitable material is discarded. centralised records department could easily report on any patient in or attending the hospital ; while, another with separate registers for outpatients, for casualty, and for fracture clinic, and its inpatient records distributed on every floor of the hospital would find considerable difficulties. The attempt to visit the homes of the patients caused further selection. Some addresses were never found, and inexperience and lack of local knowledge may have contributed in some degree to these failures ; other addresses were located, but the alleged patient wasnot known there, and it seems that a small proportion of patients gave misleading addresses. Patients living far afield were not visited, and others seemed to be always at work or not at home to callers. For those finally run to earth the scope of the investigation varied considerably. We found, as have others, that women are most successful at these front-door interviews, better able to break down any " snooper resistance " and to obtain entry to the house, and confidences about any family skeletons. In assessing the cause of the accident there is ample scope for individual judgment : two assessors may weight the human and the inanimate causes very differently in the same case, or the same assessor may find the accent misplaced when reviewing a case-history at a later date.
drunkenness, it is natural that they should fin.d
tively large proportion
.
FURTHER RESEARCH
The approach to home accidents differs from that towards accidents in industry or in the Services. In the latter, the main object is to weed out the unsuitable or accident-prone person. We cannot take this attitude towards the housewife : we have to accept people living in the home. There may be an analogy between the new entrant to industry, and the young infant facing the unknown dangers of the hearth and stairs, but the results of inquiry into industrial accidents are not immediately applicable to home accidents. An accident is the result of human action, and accident research is a subject for psychological study. It has been noted that after an accident the patient tends to adopt one of two extreme attitudes, either blaming himself 2.
Slater, P.
Survey of Sickness, Social Survey.
1946.
622 for his own " carelessness," or exculpating himself completely, and laying all the blame on the material environment. It was interesting to observe the incredulity of some patients that we should think an accident should have any cause-" Why, it’was a pure accident, doctor ! The possibility of explaining accidents on the basis of Freud’s theory of everyday mistakes and slips has been suggested. Here is an example within our recent experience : an elderly woman, who was known to be jealous of her husband’s popularity with the ladies, was presiding at the tea-table. The conversation turned to her husband, who was away being photographed with the matron and nurses of the hospital with which he was connected. The flippant conversation was interrupted by the wife knocking over the hot-water jug, and being scalded on the leg and foot, accidentally. Yes, a genuine accident, but what an effective way of changing the subject, and attracting attention and sympathy. Unless one is present during the occurrence of the accident, and on the look-out for such psychological causes, it is difficult to disinter them later, and particularly difficult at a street-door interview with a slightly suspicious housewife. There is a tendency to reject such motivated egplanations 3 ; to determine how important they are needs intensive or introspective research, and is a field where the general practitioner’s personal knowledge of the patient would be an asset. In the past attention has been focused on major accidents, and minor injuries have tended to be ignored. In our first list (of 15 notifications) there were 5 attendances as hospital outpatients for " fish-bone in throat." These we brushed superciliously aside, but regretted having done so later when we found that this type of injury appeared to come in epidemic waves-as if some particular consignment of fish, or some vagary of the weather or the meat situation had a bearing on its incidence. Foreign bodies in the eye, again, hardly seemed worthy of attention, but when we reflect how commonly it happens to every one of us, in a minor form, and how frequently treatment is sought outside of hospitals, it assumes an added importance. Accidents are fortunately fairly rare in the experience of any one individual-sufficiently uncommon to make experimental procedures and the testing of preventive methods a matter of difficulty. This is an argument in favour of the study of minor injuries which are relatively It has been suggested, in the case of more frequent. traffic accidents, to use some manifestation which occurs more often than accidents-say to observe the number of people who step carelessly into the road. In pilots once a correlation between accidents and a certain type of reaction has been established, the reaction may be used as an indicator in experimental studies.3 The need is to find some attribute closely connected with domestic accidents-possibly lack of attention, use of makeshifts, slovenly movements, minor injuries, and abrasions -so that without waiting for an accident to happen, one may judge of the likelihood of an accident happening. Further knowledge is required about the " exposure to risk " in various accidents. For example, a third of all falls in the home were found to occur on the stairs ; and since the time spent on the stairs is very much less than a third of our waking hours, one may safely conclude that stairs present an increased hazard. It was also found that only one fall in the series occurred on carpeted stairs, but it is impossible to draw any conclusions about the safety or otherwise of carpeted stairs unless we know the proportion in the general population of houses. Background knowledge such as this-the proportion of houses with steep stairs, with winders, with structural defects-is essential before the statistics from accidents
-mercilessly
"
3. Pilot
Error, A.P. 3139A, Air Ministry, 1948.
be fully interpreted. The guidance of expert social investigators, with adequate secretarial and statistical can
facilities is desirable to make the best
use
of the medical
personnel. The general practitioner,
with his facilities for easy and other diseases, both for accidents houses, is in a singularly fortunate position for accumulating data of this kind. The survey of sickness carried out by the Social Survey has shown that sick persons seek treatment not only from their own doctors and from hospitals, but also from chemists and factory nurses ; or they may not go to any outside agency. Any investigation limited to one angle of approach can give only a partial and biased picture, but by combining together different approaches - especially through the hospitals and through general practitioners-a truer picture of accident incidence and composition will be obtained. It will not necessarily be complete, but it will be less incomplete than any existing survey.
access
to
NEW ZEALAND HOSPITAL
SALARIES
FROM A CORRESPONDENT
UNDER a new award,l the salaries of whole-time hosmedical officers are to be increased throughout New Zealand.
pital
The medical superintendent-in-chief at Auckland is to receive 1:2000 rising to 1:2250, while at Wellington the figures The salaries of the are to be E1900 and C2150 respectively. superintendents of smaller hospitals are to range from a minimum of E1250 to a maximum of .S1500 ; and at Christchurch and Dunedin the minimum is to be S1650 and the maximum 1900. Three scales are provided for specialists, with minima ranging from f:1050 to E1750 and maxima from £ 130 to .S2000. Whole-time medical officers not otherwise provided for are covered in six scales ranging up to a maximum of f:l550.
Even with these increases the salaries of wholetime hospital doctors will compare unfavourably with the earnings of general practitioners. In a recent lawsuit the head of a medical combine in Dunedin sued a colleague for possession of a consulting-room ; and the defendant stated in his evidence that his gross takings for eighteen months amounted to 8600, or nearly 1:5750 a year. Small wonder that with such figures as these before them, many parents see in medicine an unusually lucrative future for their children, and that in consequence the medical school is filled to overflowing. Steps have had to be taken to limit the number of entrants by making the first medical examination competitive. Those already qualified are no doubt rejoicing that this method did not exist in their time. Overcrowding is no new phenomenon. Prof. L. S. P. Davidson, now on a visit to the Dominion, lately told the press that with 120 medical graduates a year the doctor’s economic position would deteriorate, so there would be no need for further provision for medical education by opening a new medical school in Auckland ;and the present dearth of research-workers would be righted because the promising graduates would not be diverted into the golden path of general practice. The relation of cause and effect is doubtless as difficult to estimate in the realm of economics as in medicine, but there is every reason to suppose that the publicity given to medical earnings can have done no-one any good. The doctor who sees his neighbour, the mechanic, setting out with his family for the beach on a Saturday morning will say that if a 40-hour week is good enough for one it is good enough for another, and will refuse to answer a weekend call. The mechanic, who cannot get a doctor to visit him, and who may be dissatisfied with the care he receives when he does, will 1. See
Lancet, March 26, p. 537.