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CONTROL OF ANTICOAGULANT THERAPY
785
peripheral nerve of the forearm or leg, with a current of 50 volts for 1/100 sec., failed to produce a contraction in a muscle three months after the onset of paralysis, and yet some useful degree of recovery developed later? If it can, we should know that hope must not be abandoned. If, on the other hand, we must assume permanent loss of function of a muscle, then rehabilitation can be planned accordingly, whether this means supervised muscle training or the more dramatic surgical interference such as muscle transplanting. Muscle regeneration and development While electrical stimulation is of value in the early stages of returning " life," as soon as the muscle is strong enough to cause joint movement the only important means of increasing strength is controlled active movement. I should like to make a plea here for the wider use of hydrotherapy. Many muscle movements are possible in a warm water bath that cannot otherwise be made. With careful supervision, true " movements are accomplished where in air, with gravity affecting the issue, only " trick " movements result. Also, in my experience, power returns surprisingly quickly with regular underwater exercises. In fact the start of this form of treatment marked a new phase in my recovery. For the poliomyelitis patient it is very, very valuable. A little psychological point. I have been undressed, carried up the steps, and lowered into the water ; but once there I am free. I can float on my back and kick myself along. I can sit down, and stand up, and walk about, and even climb up a step. All on my own. For a few minutes I am no longer so dependent on the strength and good will of others, and I gain emotional as well as physical power. This emotional strength is involved in another point. It is of almost incalculable value-to get a patient on his feet as early as possible. Use callipers, braces, and physiotherapy as much as necessary to prevent any strain or deformity, but try to retain some postural sense. After one has been paralysed and supine (except when prone) for two or three months, to be held upright even for thirty seconds is more inspiring than can easily be realised. I believe in getting about as quickly as possible, with any and every appliance that may be needed at the time, shedding the appliances as improvement makes them unnecessary. The resting of a recovering muscle because another muscle is still weaker is only rarely necessary. It is vitally important that the therapist in charge of a slowly improving poliomyelitic shall remember that he is dealing with a human being, and-perhaps especially in the case of the young adult whom the disease has attacked so frequently in recent years-a human being who has had a pretty big shock and who has a hard fight ahead. It is possible to be so careful in developing a symmetrical back that the personality can no longer cope with the difficulties of disability. Muscle adaptation Physiotherapists as a race worship the orthodox movement. This attitude is of course estimable and correct, but there comes a time when the permission of trick movement must be considered. It is here that definite knowledge of the possibility of nerve regeneration would be so valuable. But, even without this, I feel that the use of extra muscles to supplement or assist another, still paralysed or very weak after several months, should not be considered wicked. The trick movement is looked upon as something the patient will do instinctively and that he should be restrained from doing. This is only partially true, and I suggest that eventually, in almost all cases, trick movements should be encouraged and if necessary developed. Under skilled supervision, more independence will be possible for many crippled patients if the physiotherapist is trained to accept the possibility and advisability of All purposive movement abnormal muscle action. a
"
-
-
-
-
use of many muscles, and it may be possible to work out the end-the purpose of the movement-
involves the
the team-work of physiotherapist and patient, when the patient alone could not do it. The trick movement can be used without neglecting other muscle
through
development. adaptation
Personal
and rehabilitation When I see other infantile paralysis victims, apparently less disabled than I, trying to make their place in the, community, I realise how fortunate I am. In spite of a severe disability, with the help of a very brave wife and a
long-suffering hard-working partner, I manage to continue in general practice. But for others, and I think particularly of young adults and adolescents, the path may be hard. When the period in hospital is over, the young patient may be sent to a training centre for disabled persons, to learn a trade. There is a difficulty here that perhaps has The accidentnot been realised by the authorities. disabled person usually has normal muscles in the rest of his body, and through them can attain a considerable amount of compensation. If he has lost both legs, for example, his arms will soon be very strong and capable of pulling him about. But too often the poliomyelitis patient has a residual weakness in a large part of his body apart from actual paralysis. If his legs are useless, it may well be that his arms are at best only capable _of being developed into something approaching normality. This means that vocational training must often be like the trick movement-a complicated assessment and development of the actual and potential muscle power and of how it
can
be used.
Thus
even
in
a
residential
training centre the " disease paralysed," who has a very hard job to be independent at all, may find life difficult in competition with the " accident crippled." I should like above all things to see a specialised training centre for poliomyelitis patients, with accommodation for those who are not completely independent as well as those who are. This disease seems to develop in its victims a real sense of fellowship with each other, and the mutual encouragement would be of great help. Combined with vocational training, physiotherapy should and could be Such a centre would greatly increase the. continued. working capacity of these partially disabled people and would, I believe, help all who passed through it to attain fuller and
a
more
useful life. E. H. JOHNSON.
London, S.E.4.
CONTROL OF ANTICOAGULANT THERAPY differences 01 opinion among anricoagiiiaevinced in the letters from Dr. Brafield andDr. Walther (Oct. 20) and from Dr. Bedford (Oct. 6), is another example of right and wrong coinciding. Only one thing seems to be agreed upon by everybody-the necessity for careful laboratory supervision of patients. being treated with dicoumarol or’Tromexan’ or any drug of that group. Each anticoagulationist sticks up for his own method,. which he finds reliable, and runs down all other methods, with few exceptions. As Dr. Brafield and Dr. Walther write : " Since our own experience has not been so, unfavourable we wonder whether some difference in technique may not account for the discrepancy between Dr. Bedford’s results and our own." This, of course, is. the crux of the problem ; every exponent is best at the method he likes best and reports bad results with methods. he does not like. It seems certain that those who are interested in the various methods do get good results with the method they prefer. I prefer the plasma and viper venom method in spite of general agreement against it at the present time. I like this method because in my hands it gives reliable and accurate results, as I have stated before.!
SIR,—the
tionists,
as
-
1. Brit. med. J. 1946, ii, 963 ;
Ibid, 1948, i, 319; Ibid,
p.
Ibid, 1947, ii, 748 ; Ibid, p. 1009; 1207; Ibid, 1950, i, 305.
786 After all, technique is a very personal thing and cannot always be imparted to others by written communications. A long series of difficult cases treated by dicoumarol or tromexan without any haemorrhagic episodes or untoward results is surely the best evidence that any particular method is reliable in the hands of its protagonist. Such evidence is supplied by Dr. Brafield and Dr. Walther and is lacking in the letters and articles of many other writers. Because a thing is a mystery it need not be discredited. St. Margaret’s Hospital, Epping, Essex.
FRANK MARSH.
A RAPID GUIDE TO INTRAVENOUS DRIP RATE AND FLUID INTAKE ACHIEVED IN INFANTS
SIR,—Recent articles on intravenous drip therapy in childhood have laid stress on the dangers both of infection
and of overloading the circulation. Assuming a constant rate of intravenous infusion, the number of fluid ounces delivered in 24 hours by this route divided by three exactly equals the number of minims delivered per minute. The volume of a single drop flowing from the dripper depends on several factors, including the terminal bore of the dripper, the rate of the drip, and the type of fluid in use, but it is usually slightly less than 1 minim in volume. This being so, it might be helpful to paediatric housephysicians, especially in dealing with infants under 6 months of age, to remember that if the intravenous drip rate is so adjusted that the number of drops per minute equals the weight of the infant in pounds, a fluid intake of approximately two and a half fluid ounces per pound body-weight in 24 hours will be achieved. Hillingdon Hospital, Uxbridge, Middlesex.
HARRY V. L. FINLAY.
TALC PNEUMOCONIOSIS
SiR,-I have observed
apparently of
a
rubber
caused
11cases of
by inhaling talc, factory in Japan.
pneumoconiosis, employees
among the
The first patient, seen in 1944, was a man of 39 who had handled talc in the factory for nearly 30 years. He had been healthy until the symptoms developed-mainly cough and tiredness-which led him to consult me. He was diagnosed as a common cold, but an X-ray film of his chest revealed numerous nodules throughout the lung fields, resembling the picture of miliary tuberculosis. However, there was nothing to confirm that the nodules were tuberculous, and no tubercle bacilli have been found in his sputum at any time. Despite the X-ray findings the patient felt perfectly well in a few days, and he has been working ever since in fairly good condition.
It seemed highly probable that this was an example of talc pneumoconiosis, though I could find no published records of the condition at that time. In view of the findings I investigated a number of other workmen who had handled talc for a long time, and 10 similar cases were discovered. Talc pneumoconiosis would be likely to aggravate pulmonary tuberculosis if the two occurred together. This seems worthy of serious consideration by those responsible for industrial hygiene in factories where talc is used. The condition has lately been legally recognised in Japan on the same footing as silicosis. YOSIRO KAWASE. Kobe Hospital, Japan. to talc pneumoconiosis since 1896 *The references were .reviewed by A. 1. G. McLaughlin, Enid Rogers, and K. C. Dunham in the British Journal of Industrial Medicine (1949, 6, 184). These authors also described the clinical, pathological, and radiographic features of a man of 50 who had worked for 36 years on a tyre-extruding machine in a rubber factory. The presence of talc pneumoconiosis which resembles asbestosis was proved by petrological and X-ray diffraction examination of the dust in the lungs. Though talc is a mineral composed of flakes with a small percentage of fibres, only the latter were present in the lungs. Further reference to
this case was made by McLaughlin at a conference of the Belgian Society of Industrial Medicine on Dec. 17, 1949 (Lancet, 1950, i, 225 and Arch. belges Med. soc. 1950, 7, 451).-ED. L. BOVINE TUBERCULOSIS PREVENTS HUMAN TUBERCULOSIS ? SIR,—Ever
since
the
initiation
OJ
me
Inuauermal
tuberculin test for cattle it has been assumed that the eradication of tuberculosis from cattle would lead to a reduction of tuberculosis in man. But the opposite has
happened. The Attested Cattle Scheme commenced in 1936, and the milk from Scotland is now 80% from attested tuberculosis-free cattle. But whereas the notifications of non-pulmonary tuberculosis have fallen by about half, the number of new cases of pulmonary tuberculosis notified rose from 4736 in 1936 to 8427 in 1949. In England and Wales, on the other hand, only about 20% of cows are in attested herds and there has been a fall in pulmonary notifications from 57,503 in 1924 to 43,971 in 1948. Non-pulmonary notifications have been reduced by about half in England as in Scotland, and the reduction is similar in all Scottish areas whether the percentage of attested cattle is high or low. Glasgow is a black spot for tuberculosis. In 1936 1647 new cases of pulmonary tuberculosis were notified, and in 1948 this figure had risen to 2775. Non-pulmonary infection has been slightly more than halved. The county figures for Scotland follow a pattern, in that a high proportion of attested cattle is linked to a sharply rising number of notifications of pulmonary tuberculosis. The converse is also true, in that a minority of attested cattle is related to a reduction in human pulmonary tuberculosis. In the following summary it can be taken that in the early years mentioned there were few attested cattle, or none. The final figure of number of attested cattle is given in each case (col. 5). SCOTTISH COUNTIES WITH A HIGH PERCENTAGE OF ATTESTED CATTLE
peripheral nerve of the forearm or leg, with a current of 50 volts for 1/100 sec., failed to produce a contraction in a muscle three months after the onset of paralysis, and yet some useful degree of recovery developed later? If it can, we should know that hope must not be abandoned. If, on the other hand, we must assume permanent loss of function of a muscle, then rehabilitation can be planned accordingly, whether this means supervised muscle training or the more dramatic surgical interference such as muscle transplanting. Muscle regeneration and development While electrical stimulation is of value in the early stages of returning " life," as soon as the muscle is strong enough to cause joint movement the only important means of increasing strength is controlled active movement. I should like to make a plea here for the wider use of hydrotherapy. Many muscle movements are possible in a warm water bath that cannot otherwise be made. With careful supervision, true " movements are accomplished where in air, with gravity affecting the issue, only " trick " movements result. Also, in my experience, power returns surprisingly quickly with regular underwater exercises. In fact the start of this form of treatment marked a new phase in my recovery. For the poliomyelitis patient it is very, very valuable. A little psychological point. I have been undressed, carried up the steps, and lowered into the water ; but once there I am free. I can float on my back and kick myself along. I can sit down, and stand up, and walk about, and even climb up a step. All on my own. For a few minutes I am no longer so dependent on the strength and good will of others, and I gain emotional as well as physical power. This emotional strength is involved in another point. It is of almost incalculable value-to get a patient on his feet as early as possible. Use callipers, braces, and physiotherapy as much as necessary to prevent any strain or deformity, but try to retain some postural sense. After one has been paralysed and supine (except when prone) for two or three months, to be held upright even for thirty seconds is more inspiring than can easily be realised. I believe in getting about as quickly as possible, with any and every appliance that may be needed at the time, shedding the appliances as improvement makes them unnecessary. The resting of a recovering muscle because another muscle is still weaker is only rarely necessary. It is vitally important that the therapist in charge of a slowly improving poliomyelitic shall remember that he is dealing with a human being, and-perhaps especially in the case of the young adult whom the disease has attacked so frequently in recent years-a human being who has had a pretty big shock and who has a hard fight ahead. It is possible to be so careful in developing a symmetrical back that the personality can no longer cope with the difficulties of disability. Muscle adaptation Physiotherapists as a race worship the orthodox movement. This attitude is of course estimable and correct, but there comes a time when the permission of trick movement must be considered. It is here that definite knowledge of the possibility of nerve regeneration would be so valuable. But, even without this, I feel that the use of extra muscles to supplement or assist another, still paralysed or very weak after several months, should not be considered wicked. The trick movement is looked upon as something the patient will do instinctively and that he should be restrained from doing. This is only partially true, and I suggest that eventually, in almost all cases, trick movements should be encouraged and if necessary developed. Under skilled supervision, more independence will be possible for many crippled patients if the physiotherapist is trained to accept the possibility and advisability of All purposive movement abnormal muscle action. a
"
-
-
-
-
use of many muscles, and it may be possible to work out the end-the purpose of the movement-
involves the
the team-work of physiotherapist and patient, when the patient alone could not do it. The trick movement can be used without neglecting other muscle
through
development. adaptation
Personal
and rehabilitation When I see other infantile paralysis victims, apparently less disabled than I, trying to make their place in the, community, I realise how fortunate I am. In spite of a severe disability, with the help of a very brave wife and a
long-suffering hard-working partner, I manage to continue in general practice. But for others, and I think particularly of young adults and adolescents, the path may be hard. When the period in hospital is over, the young patient may be sent to a training centre for disabled persons, to learn a trade. There is a difficulty here that perhaps has The accidentnot been realised by the authorities. disabled person usually has normal muscles in the rest of his body, and through them can attain a considerable amount of compensation. If he has lost both legs, for example, his arms will soon be very strong and capable of pulling him about. But too often the poliomyelitis patient has a residual weakness in a large part of his body apart from actual paralysis. If his legs are useless, it may well be that his arms are at best only capable _of being developed into something approaching normality. This means that vocational training must often be like the trick movement-a complicated assessment and development of the actual and potential muscle power and of how it
can
be used.
Thus
even
in
a
residential
training centre the " disease paralysed," who has a very hard job to be independent at all, may find life difficult in competition with the " accident crippled." I should like above all things to see a specialised training centre for poliomyelitis patients, with accommodation for those who are not completely independent as well as those who are. This disease seems to develop in its victims a real sense of fellowship with each other, and the mutual encouragement would be of great help. Combined with vocational training, physiotherapy should and could be Such a centre would greatly increase the. continued. working capacity of these partially disabled people and would, I believe, help all who passed through it to attain fuller and
a
more
useful life. E. H. JOHNSON.
London, S.E.4.
CONTROL OF ANTICOAGULANT THERAPY differences 01 opinion among anricoagiiiaevinced in the letters from Dr. Brafield andDr. Walther (Oct. 20) and from Dr. Bedford (Oct. 6), is another example of right and wrong coinciding. Only one thing seems to be agreed upon by everybody-the necessity for careful laboratory supervision of patients. being treated with dicoumarol or’Tromexan’ or any drug of that group. Each anticoagulationist sticks up for his own method,. which he finds reliable, and runs down all other methods, with few exceptions. As Dr. Brafield and Dr. Walther write : " Since our own experience has not been so, unfavourable we wonder whether some difference in technique may not account for the discrepancy between Dr. Bedford’s results and our own." This, of course, is. the crux of the problem ; every exponent is best at the method he likes best and reports bad results with methods. he does not like. It seems certain that those who are interested in the various methods do get good results with the method they prefer. I prefer the plasma and viper venom method in spite of general agreement against it at the present time. I like this method because in my hands it gives reliable and accurate results, as I have stated before.!
SIR,—the
tionists,
as
-
1. Brit. med. J. 1946, ii, 963 ;
Ibid, 1948, i, 319; Ibid,
p.
Ibid, 1947, ii, 748 ; Ibid, p. 1009; 1207; Ibid, 1950, i, 305.
786 After all, technique is a very personal thing and cannot always be imparted to others by written communications. A long series of difficult cases treated by dicoumarol or tromexan without any haemorrhagic episodes or untoward results is surely the best evidence that any particular method is reliable in the hands of its protagonist. Such evidence is supplied by Dr. Brafield and Dr. Walther and is lacking in the letters and articles of many other writers. Because a thing is a mystery it need not be discredited. St. Margaret’s Hospital, Epping, Essex.
FRANK MARSH.
A RAPID GUIDE TO INTRAVENOUS DRIP RATE AND FLUID INTAKE ACHIEVED IN INFANTS
SIR,—Recent articles on intravenous drip therapy in childhood have laid stress on the dangers both of infection
and of overloading the circulation. Assuming a constant rate of intravenous infusion, the number of fluid ounces delivered in 24 hours by this route divided by three exactly equals the number of minims delivered per minute. The volume of a single drop flowing from the dripper depends on several factors, including the terminal bore of the dripper, the rate of the drip, and the type of fluid in use, but it is usually slightly less than 1 minim in volume. This being so, it might be helpful to paediatric housephysicians, especially in dealing with infants under 6 months of age, to remember that if the intravenous drip rate is so adjusted that the number of drops per minute equals the weight of the infant in pounds, a fluid intake of approximately two and a half fluid ounces per pound body-weight in 24 hours will be achieved. Hillingdon Hospital, Uxbridge, Middlesex.
HARRY V. L. FINLAY.
TALC PNEUMOCONIOSIS
SiR,-I have observed
apparently of
a
rubber
caused
11cases of
by inhaling talc, factory in Japan.
pneumoconiosis, employees
among the
The first patient, seen in 1944, was a man of 39 who had handled talc in the factory for nearly 30 years. He had been healthy until the symptoms developed-mainly cough and tiredness-which led him to consult me. He was diagnosed as a common cold, but an X-ray film of his chest revealed numerous nodules throughout the lung fields, resembling the picture of miliary tuberculosis. However, there was nothing to confirm that the nodules were tuberculous, and no tubercle bacilli have been found in his sputum at any time. Despite the X-ray findings the patient felt perfectly well in a few days, and he has been working ever since in fairly good condition.
It seemed highly probable that this was an example of talc pneumoconiosis, though I could find no published records of the condition at that time. In view of the findings I investigated a number of other workmen who had handled talc for a long time, and 10 similar cases were discovered. Talc pneumoconiosis would be likely to aggravate pulmonary tuberculosis if the two occurred together. This seems worthy of serious consideration by those responsible for industrial hygiene in factories where talc is used. The condition has lately been legally recognised in Japan on the same footing as silicosis. YOSIRO KAWASE. Kobe Hospital, Japan. to talc pneumoconiosis since 1896 *The references were .reviewed by A. 1. G. McLaughlin, Enid Rogers, and K. C. Dunham in the British Journal of Industrial Medicine (1949, 6, 184). These authors also described the clinical, pathological, and radiographic features of a man of 50 who had worked for 36 years on a tyre-extruding machine in a rubber factory. The presence of talc pneumoconiosis which resembles asbestosis was proved by petrological and X-ray diffraction examination of the dust in the lungs. Though talc is a mineral composed of flakes with a small percentage of fibres, only the latter were present in the lungs. Further reference to
this case was made by McLaughlin at a conference of the Belgian Society of Industrial Medicine on Dec. 17, 1949 (Lancet, 1950, i, 225 and Arch. belges Med. soc. 1950, 7, 451).-ED. L. BOVINE TUBERCULOSIS PREVENTS HUMAN TUBERCULOSIS ? SIR,—Ever
since
the
initiation
OJ
me
Inuauermal
tuberculin test for cattle it has been assumed that the eradication of tuberculosis from cattle would lead to a reduction of tuberculosis in man. But the opposite has
happened. The Attested Cattle Scheme commenced in 1936, and the milk from Scotland is now 80% from attested tuberculosis-free cattle. But whereas the notifications of non-pulmonary tuberculosis have fallen by about half, the number of new cases of pulmonary tuberculosis notified rose from 4736 in 1936 to 8427 in 1949. In England and Wales, on the other hand, only about 20% of cows are in attested herds and there has been a fall in pulmonary notifications from 57,503 in 1924 to 43,971 in 1948. Non-pulmonary notifications have been reduced by about half in England as in Scotland, and the reduction is similar in all Scottish areas whether the percentage of attested cattle is high or low. Glasgow is a black spot for tuberculosis. In 1936 1647 new cases of pulmonary tuberculosis were notified, and in 1948 this figure had risen to 2775. Non-pulmonary infection has been slightly more than halved. The county figures for Scotland follow a pattern, in that a high proportion of attested cattle is linked to a sharply rising number of notifications of pulmonary tuberculosis. The converse is also true, in that a minority of attested cattle is related to a reduction in human pulmonary tuberculosis. In the following summary it can be taken that in the early years mentioned there were few attested cattle, or none. The final figure of number of attested cattle is given in each case (col. 5). SCOTTISH COUNTIES WITH A HIGH PERCENTAGE OF ATTESTED CATTLE