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A PLASTIC SURGICAL MARKING-INK
519 THE FINAL EXAMINATION
SIR.—I have read with great interest Professor Bull’s paper (Aug. 25), in which he casts doubt on the value of final examinations in medicine. Ile views with some favour what he terms multiplechoice questions. May I quote the example he gives ? Ynu are called at midnight to a previously well-balanced diabetic patient who has been receiving 20 units of insulin The patient is unconscious. There are no twice daily. abnormal neurological signs except for extensor plantar responses. Urine passed 3 hours previously contains glucose and gives a faintly positive Rothera’s test. The correct proeedllre is : 1. Inject 40 units of insulin. 2. Inject 50 g. glucose intravenously. 3. Do a lumbar puncture to see if the cerebrospinal fluid contains blood. 4. Take a sample of blood for glucose estimation before -
-
deciding
on
J. J. CONYBEARE. J.
A PLASTIC SURGICAL MARKING-INK
SIR,—The need for a surgical marking-ink that is proof against preoperative preparation of the skin has long been felt, particularly in varicose-vein surgery. Numerous formulae have been mooted, but in my hands all have supplanted their initial success by failing me on the very occasion when skin marking has been most vital and crucial. With the introduction of ’Nobecutane ’ plastic dressing,1 so easily applied by brush or rod, it occurred to me that at last we had in our grasp the ideal vehicle for a coloured surgical marking-ink, and in concert with Dr. R. Powell of the medical division of Evans Medical Supplies some clinical experiments were made to deternuue the best dye to incorporate in this liquid plastic medium. Cellaquer-blue appeared to suit our purpose best, and when mixed with nobecutane it forms a plastic ink which withstands rigorous skin preparation and stands ilut boldly in colour relief. It is simple to apply, dries mpidly, and is proof almost against shaving ! It can be used with confidence at any time under twenty-four hours before operation, whilst after operation it will peel off ni a few days.
becoming
a
junior " pro " again.
SIR,—In your last issue Professor Choremis and his
colleagues suggest that tuberculous meningitis and repeated lumbar punctures may give rise to the rare epidermoid tumour which sometimes occurs within the spinal theca. Their five cases in children between the
ages of 7 and 12, all of whom had from three to seven years previously been treated successfully for tuberculous meningitis and had had repeated lumbar punctures, led to their conclusion that the spinal tumours may have arisen from implanted epithelial cells. Epithelial cells implanted in this way some years before the appearance of these tumours may be the origin of some of them, but that this is not always the explanation may be concluded from a case which we have had here recently.
A little boy aged 6, except for attacks of measles and chickenpox, had been a perfectly healthy child until five months before his admission when he began to drag his feet when walking. He was referred by Dr. G. Petty to the care of my colleague, Dr. J. D. Spillane, who found sensory changes accompanying a spastic paraparesis. Myelography showed a lesion at the level of the first thoracic vertebra, and at laminectomy an opaque, white, epidermoid intrathecal and extramedullary tumour, weighing 3-5 g. was removed with the subsequent recovery of the child.
A point of interest in these cases in children is the normal cerebrospinal fluid, or one in which there is only a slightly raised protein content, obtained on lumbar puncture. This was so in our case and in three of the five Greek cases. I should like to congratulate Dr. Choremis and his colleagues in the paediatric clinic and polyclinic at Athens on their remarkable series of these rare tumours. Surgical Unit,
The Royal Infirmary, Cardiff.
LAMBERT ROGERS.
THYROIDECTOMY AND THE RECURRENT LARYNGEAL NERVES
SHORTAGE OF MIDWIVES
1. Ellerker, A. G. Lancet, 1955, i, 200.
TERENCE G. ROBINSON.
INTRASPINAL EPIDERMOID TUMOURS
STANLEY RIVLIN.
SIR,—That the future maternity services depend on adeqnate numbers of trained midwives is obvious. T thcie is growing apprehension among obstetricians and down the country concerning the recruitment of pupil midwives. One hears of the closure of wards and of understaffing of beds. The latter is perhaps the greater evil, leading sooner or later to outbreaks of tion among both patients and staff. The majority of pupil midwives are recruited from the erently qualified " State-registered nurses, and it is from this source that an improvement in recruiting should sought.I feel that the time has come for those conemed with the present arrangements for the training of
look at the whole
interest in obstetrics and arouse an ambition to become a pupil midwife after she has taken her final State examination. Undoubtedly the ease with which a newly fledged State-registered nurse can obtain a staff nurse’s appointment (and pay) is an attraction to many who feel that to become a pupil midwife is synonymous with
I understand that it is now available from Evans Medical Supplies Ltcl. under the name of ’Nobecutane Marking Ink.’ London Varicose Clinic, London, S.W.11.
a new
problem. I suggest that the State-registered nurse should have had some practical acquaintance with midwifery before entering for her final State examination. At present her syllabus requires her to have had eight lectures on obstetrics and gynaecology, but her training-school is unable to provide her with practical experience in midwifery. Would not a short time spent in a maternity hospital make her a more complete nurse than at present ?’ This introduction to midwifery might stimulate her
treatment.
S.E.I.
and midwives to take
The Genera] Hospital, South Shields.
Although the brief details available suggest hypoglycæmia as the most likely cause of the loss of consciousness, surely a careful doctor-or indeed medical student—would insist on a thorough clinical examination before reaching a vital decision regarding treatment. As set, the question seems to cater for only three possible diagnoses out of the many which might produce unconsciousness in a patient, whose age, sex, and previous history are undisclosed. London,
nurses
SIR,—It takes some weeks for yourjournal to reach these shores and there is further delay before it i reviewed here. Hence the tardiness of this comment on the paper by Roy, Gardiner, and Niblock.l The high percentage of recovery, or effective compensation, following damage to the recurrent laryngeal nerves found in their series of thyroidectomies is of considerable interest. However, the number of patients in whom the nerve was damaged might have been substantially decreased by the practice of routine exposure of the Their technique of thyroidectomy nerves at operation. is evidentlv exactlv that used bv Joll 2 :-. and. however Roy, A. D., Gardiner, R. H., Niblock, W. M. Lancet, 1956 i, 988. Diseases of the Thyroid Gland. London, 1932. 2. Joll, C. A. 1.
SIR.—I have read with great interest Professor Bull’s paper (Aug. 25), in which he casts doubt on the value of final examinations in medicine. Ile views with some favour what he terms multiplechoice questions. May I quote the example he gives ? Ynu are called at midnight to a previously well-balanced diabetic patient who has been receiving 20 units of insulin The patient is unconscious. There are no twice daily. abnormal neurological signs except for extensor plantar responses. Urine passed 3 hours previously contains glucose and gives a faintly positive Rothera’s test. The correct proeedllre is : 1. Inject 40 units of insulin. 2. Inject 50 g. glucose intravenously. 3. Do a lumbar puncture to see if the cerebrospinal fluid contains blood. 4. Take a sample of blood for glucose estimation before -
-
deciding
on
J. J. CONYBEARE. J.
A PLASTIC SURGICAL MARKING-INK
SIR,—The need for a surgical marking-ink that is proof against preoperative preparation of the skin has long been felt, particularly in varicose-vein surgery. Numerous formulae have been mooted, but in my hands all have supplanted their initial success by failing me on the very occasion when skin marking has been most vital and crucial. With the introduction of ’Nobecutane ’ plastic dressing,1 so easily applied by brush or rod, it occurred to me that at last we had in our grasp the ideal vehicle for a coloured surgical marking-ink, and in concert with Dr. R. Powell of the medical division of Evans Medical Supplies some clinical experiments were made to deternuue the best dye to incorporate in this liquid plastic medium. Cellaquer-blue appeared to suit our purpose best, and when mixed with nobecutane it forms a plastic ink which withstands rigorous skin preparation and stands ilut boldly in colour relief. It is simple to apply, dries mpidly, and is proof almost against shaving ! It can be used with confidence at any time under twenty-four hours before operation, whilst after operation it will peel off ni a few days.
becoming
a
junior " pro " again.
SIR,—In your last issue Professor Choremis and his
colleagues suggest that tuberculous meningitis and repeated lumbar punctures may give rise to the rare epidermoid tumour which sometimes occurs within the spinal theca. Their five cases in children between the
ages of 7 and 12, all of whom had from three to seven years previously been treated successfully for tuberculous meningitis and had had repeated lumbar punctures, led to their conclusion that the spinal tumours may have arisen from implanted epithelial cells. Epithelial cells implanted in this way some years before the appearance of these tumours may be the origin of some of them, but that this is not always the explanation may be concluded from a case which we have had here recently.
A little boy aged 6, except for attacks of measles and chickenpox, had been a perfectly healthy child until five months before his admission when he began to drag his feet when walking. He was referred by Dr. G. Petty to the care of my colleague, Dr. J. D. Spillane, who found sensory changes accompanying a spastic paraparesis. Myelography showed a lesion at the level of the first thoracic vertebra, and at laminectomy an opaque, white, epidermoid intrathecal and extramedullary tumour, weighing 3-5 g. was removed with the subsequent recovery of the child.
A point of interest in these cases in children is the normal cerebrospinal fluid, or one in which there is only a slightly raised protein content, obtained on lumbar puncture. This was so in our case and in three of the five Greek cases. I should like to congratulate Dr. Choremis and his colleagues in the paediatric clinic and polyclinic at Athens on their remarkable series of these rare tumours. Surgical Unit,
The Royal Infirmary, Cardiff.
LAMBERT ROGERS.
THYROIDECTOMY AND THE RECURRENT LARYNGEAL NERVES
SHORTAGE OF MIDWIVES
1. Ellerker, A. G. Lancet, 1955, i, 200.
TERENCE G. ROBINSON.
INTRASPINAL EPIDERMOID TUMOURS
STANLEY RIVLIN.
SIR,—That the future maternity services depend on adeqnate numbers of trained midwives is obvious. T thcie is growing apprehension among obstetricians and down the country concerning the recruitment of pupil midwives. One hears of the closure of wards and of understaffing of beds. The latter is perhaps the greater evil, leading sooner or later to outbreaks of tion among both patients and staff. The majority of pupil midwives are recruited from the erently qualified " State-registered nurses, and it is from this source that an improvement in recruiting should sought.I feel that the time has come for those conemed with the present arrangements for the training of
look at the whole
interest in obstetrics and arouse an ambition to become a pupil midwife after she has taken her final State examination. Undoubtedly the ease with which a newly fledged State-registered nurse can obtain a staff nurse’s appointment (and pay) is an attraction to many who feel that to become a pupil midwife is synonymous with
I understand that it is now available from Evans Medical Supplies Ltcl. under the name of ’Nobecutane Marking Ink.’ London Varicose Clinic, London, S.W.11.
a new
problem. I suggest that the State-registered nurse should have had some practical acquaintance with midwifery before entering for her final State examination. At present her syllabus requires her to have had eight lectures on obstetrics and gynaecology, but her training-school is unable to provide her with practical experience in midwifery. Would not a short time spent in a maternity hospital make her a more complete nurse than at present ?’ This introduction to midwifery might stimulate her
treatment.
S.E.I.
and midwives to take
The Genera] Hospital, South Shields.
Although the brief details available suggest hypoglycæmia as the most likely cause of the loss of consciousness, surely a careful doctor-or indeed medical student—would insist on a thorough clinical examination before reaching a vital decision regarding treatment. As set, the question seems to cater for only three possible diagnoses out of the many which might produce unconsciousness in a patient, whose age, sex, and previous history are undisclosed. London,
nurses
SIR,—It takes some weeks for yourjournal to reach these shores and there is further delay before it i reviewed here. Hence the tardiness of this comment on the paper by Roy, Gardiner, and Niblock.l The high percentage of recovery, or effective compensation, following damage to the recurrent laryngeal nerves found in their series of thyroidectomies is of considerable interest. However, the number of patients in whom the nerve was damaged might have been substantially decreased by the practice of routine exposure of the Their technique of thyroidectomy nerves at operation. is evidentlv exactlv that used bv Joll 2 :-. and. however Roy, A. D., Gardiner, R. H., Niblock, W. M. Lancet, 1956 i, 988. Diseases of the Thyroid Gland. London, 1932. 2. Joll, C. A. 1.