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COTTON LIGATURES
53 TREATMENT OF THE "CRUSH SYNDROME" SiR,-In June of last year we brought forward evidence to suggest that the approach to the problem of the " crush syndrome " had previously been from a wrong basis, and that the condition including its renal manifestations was the result, primarily, not of toxaemia, but simply of the loss of blood constituents into the injured limb, the capillaries of which had temporarily lost their function. Applying this conception therapeutically, we argued that the primary principle of treatment should be to stop the limb swelling, or if it was swollen to reduce the cedema. This we achieved by applying positive pressure of 60 mm. Hg to the limb. We published details of two cases successfully treated on these lines (Lancet, 1941, i, 780). Strong experimental support for our theory has recently been furnished by Duncan and Blalock (Ann. Surg. 1942, 115, 684). By compressing the limbs of dogs in a special clamp, they have produced a syndrome similar to the crush syndrome of man, including shock and renal failure. Untreated, 18 out of 19 dogs died. But when the damaged limbs immediately after release from compression were enclosed in a pneumatic tube with a pressure of 40 mm. Hg 15 out of 21 dogs survived. Further experimental work is clearly required, particularly to elucidate the mechanism of production of the renal symptoms. We suggest, however, that there is now sufficient evidence to justify routine prophylactic treatment being standardised on the lines advocated in our article. If this view is accepted, first-aid workers should be instructed to bandage firmly the limb as soon as it has been released. Immediate treatment on the same lines should be carried out in hospital either with the apparatus we suggested or some modification which fulfils the same principles. The present lull in aerial bombardment in many districts offers a suitable opportunity for working out the requisite measures of
organisation. The Middlesex Hospital, W.1.
REACTIONS
DAVID H. PATEY, J. DOUGLAS ROBERTSON.
TO
THE REPORT
erstwhile
special commissioner, SIR,-May your personal capacity, congratulate the BMA Medical Planning Commission on their draft interim report ?P The striking reforms which it proposes, and with which
in his
I think most younger doctors will agree, are : 1. A complete medical service for 90%of the population. 2. A substantial measure of free choice of home doctor. 3. A substantial improvement in the conditions of work (and therefore in the standard of possible service) of the home doctor, including a period of apprenticeship in a health centre, the abolition of sale of practices, appointment .on merit,
.
same time, new problems in the prevention of exploitation will arise, as a result of deliberate absenteeism and refusal to work, and feigned or hysterical illness. The solution is not to be found in more and better medical boards, but rather in transferring the responsibility for these decisions to committees of the worker’s equals. Such committees should hear medical evidence, and are inherently likely to give reasonable decisions which will have the sanction of the workers’ own societv. This has in fact been the war-time answer to the problem of absenteeism ; judgment on the offender is passed by the works production committee, often with a worker in the chair. The proposed links between the National Medical Service and the public which it serves are not of a very direct and personal nature. The war has brought home to many of us that the British public will always cooperate if approached cooperatively. If one is prepared to listen patiently to all complaints and explain difficulties, the feeling of partnership in enterprise is built up. There is room for local health committees in areas served by each small group of health centres. Such committees can act’as valuable channels for receiving information from the public and also imparting it in a personal and direct way. A working war-time example of such a service is the local information committees of the Ministry of Information. The r6le of the medical officer of health is not defined. He is to be shorn of his clinical duties. What is he to become ? His special function should be that of the " social doctor," with the rank of a specialist on the staff of the local or group hospital, available for consultation with the home doctor whenever environment appears to be implicated. He should keep the statistical picture of the health of the area, and provide a health intelligence service, while retaining his functions in connexion with advice on environmental matters to local authorities. There is a long and hard road to be travelled between the draft interim report and the Statute Book. One hopes that the report may be strengthened-or at least not watered down-in its passage through the commission and the association. Beyond that lies a stiff job of lay education-first among the ordinary.public, secondly among the legislature and the central government officials, and last, but by no means least, among the local
authorities.
STEPHEN TAYLOR.
London.
COTTON
LIGATURES
SiR,-In support of Professor Pannett’s plea for the extended use of cotton as ligation and suture material, I should like to record that during the past few months I have performed nearly 150 general surgical operations contributory pensions, full professional cooperation, and an using Coats’s No. 24 black cotton for every purpose increasing part in preventive medical services (ante- and post- except for uniting mucous surfaces. For suturing the natal work, school medicine and immunisation services). peritoneum a strand of cotton has been used doubled 4. In return, the home doctor will relinquish his consultant and inserted as a continuous stitch, but in all other and specialist activities to those who are specially qualified situations intermittent single-thickness sutures were and continuously practising the specialties.. employed. The cotton, which costs 6121 d. a reel, is wound 5. A regional hospital service, with full-time and partin a single layer (I think this is important) around a time clinical posts, and a domiciliary consultant service. piece of - rubber drainage-tube and is boiled for 20 , 6. In both general and special practice, the clinician is to minutes. It is convenient to clip the loaded rubber be equal with and not subordinate to the administrator, both tube to the towels near the wound so that a continuous in status and remuneration; and community is to be assured.
a
democratic medical
Are there good and sufficient reasons for excluding the " upper 10% " ? Among this group there are many people who prefer private contract, but there are also many who would welcome the opportunity of joining the National Medical Service. The burdens of sickness are often proportionally heavier on those earning 2420 a year and upwards than on the lower income groups. Surely, the common-sense answer is to open the National Medical Service voluntarily to the " over 2420s." The question of social medicine as a factor in positive health is not considered. By social medicine one does not mean anything mysterious or " high falutin," but rather the prevention of poverty, whether due to sickness, disablement, large families, old age, or unemployment. If we can abolish poverty, we shall have largely overcome the problems of suboptimal nutrition; apart altogether from the mental results of financial insecurity. At the
of ligature material is at hand. The assistant must be instructed to cut the ligature much closer than when catgut is employed. In all cases I have dusted ’the parts concerned in the cotton with sulphanilamideallantoin powder (Genatosan). No case of wound infection has yet occurred. A small proportion of the operations were for infected conditions-e.g., appendicectomy for perforated appendix with peritonitis, Thorek’s cholecystectomy for empyema of the gall-bladder. HAMILTON BAILEY. Harley Street, W.1.
supply
*:j;*Messrs. Allen and Hanburys Ltd. suggest that Professor Pannett’s article may give the impression that sterilised surgical catgut is difficult to obtain. They assure us that the eight firms licensed by the Ministry of Health to manufacture sterilised catgut in this country will be able to meet future demands in both home and export markets, though difficulty may be encountered in obtaining supplies of some brands.ED. L.
organisation. The Middlesex Hospital, W.1.
REACTIONS
DAVID H. PATEY, J. DOUGLAS ROBERTSON.
TO
THE REPORT
erstwhile
special commissioner, SIR,-May your personal capacity, congratulate the BMA Medical Planning Commission on their draft interim report ?P The striking reforms which it proposes, and with which
in his
I think most younger doctors will agree, are : 1. A complete medical service for 90%of the population. 2. A substantial measure of free choice of home doctor. 3. A substantial improvement in the conditions of work (and therefore in the standard of possible service) of the home doctor, including a period of apprenticeship in a health centre, the abolition of sale of practices, appointment .on merit,
.
same time, new problems in the prevention of exploitation will arise, as a result of deliberate absenteeism and refusal to work, and feigned or hysterical illness. The solution is not to be found in more and better medical boards, but rather in transferring the responsibility for these decisions to committees of the worker’s equals. Such committees should hear medical evidence, and are inherently likely to give reasonable decisions which will have the sanction of the workers’ own societv. This has in fact been the war-time answer to the problem of absenteeism ; judgment on the offender is passed by the works production committee, often with a worker in the chair. The proposed links between the National Medical Service and the public which it serves are not of a very direct and personal nature. The war has brought home to many of us that the British public will always cooperate if approached cooperatively. If one is prepared to listen patiently to all complaints and explain difficulties, the feeling of partnership in enterprise is built up. There is room for local health committees in areas served by each small group of health centres. Such committees can act’as valuable channels for receiving information from the public and also imparting it in a personal and direct way. A working war-time example of such a service is the local information committees of the Ministry of Information. The r6le of the medical officer of health is not defined. He is to be shorn of his clinical duties. What is he to become ? His special function should be that of the " social doctor," with the rank of a specialist on the staff of the local or group hospital, available for consultation with the home doctor whenever environment appears to be implicated. He should keep the statistical picture of the health of the area, and provide a health intelligence service, while retaining his functions in connexion with advice on environmental matters to local authorities. There is a long and hard road to be travelled between the draft interim report and the Statute Book. One hopes that the report may be strengthened-or at least not watered down-in its passage through the commission and the association. Beyond that lies a stiff job of lay education-first among the ordinary.public, secondly among the legislature and the central government officials, and last, but by no means least, among the local
authorities.
STEPHEN TAYLOR.
London.
COTTON
LIGATURES
SiR,-In support of Professor Pannett’s plea for the extended use of cotton as ligation and suture material, I should like to record that during the past few months I have performed nearly 150 general surgical operations contributory pensions, full professional cooperation, and an using Coats’s No. 24 black cotton for every purpose increasing part in preventive medical services (ante- and post- except for uniting mucous surfaces. For suturing the natal work, school medicine and immunisation services). peritoneum a strand of cotton has been used doubled 4. In return, the home doctor will relinquish his consultant and inserted as a continuous stitch, but in all other and specialist activities to those who are specially qualified situations intermittent single-thickness sutures were and continuously practising the specialties.. employed. The cotton, which costs 6121 d. a reel, is wound 5. A regional hospital service, with full-time and partin a single layer (I think this is important) around a time clinical posts, and a domiciliary consultant service. piece of - rubber drainage-tube and is boiled for 20 , 6. In both general and special practice, the clinician is to minutes. It is convenient to clip the loaded rubber be equal with and not subordinate to the administrator, both tube to the towels near the wound so that a continuous in status and remuneration; and community is to be assured.
a
democratic medical
Are there good and sufficient reasons for excluding the " upper 10% " ? Among this group there are many people who prefer private contract, but there are also many who would welcome the opportunity of joining the National Medical Service. The burdens of sickness are often proportionally heavier on those earning 2420 a year and upwards than on the lower income groups. Surely, the common-sense answer is to open the National Medical Service voluntarily to the " over 2420s." The question of social medicine as a factor in positive health is not considered. By social medicine one does not mean anything mysterious or " high falutin," but rather the prevention of poverty, whether due to sickness, disablement, large families, old age, or unemployment. If we can abolish poverty, we shall have largely overcome the problems of suboptimal nutrition; apart altogether from the mental results of financial insecurity. At the
of ligature material is at hand. The assistant must be instructed to cut the ligature much closer than when catgut is employed. In all cases I have dusted ’the parts concerned in the cotton with sulphanilamideallantoin powder (Genatosan). No case of wound infection has yet occurred. A small proportion of the operations were for infected conditions-e.g., appendicectomy for perforated appendix with peritonitis, Thorek’s cholecystectomy for empyema of the gall-bladder. HAMILTON BAILEY. Harley Street, W.1.
supply
*:j;*Messrs. Allen and Hanburys Ltd. suggest that Professor Pannett’s article may give the impression that sterilised surgical catgut is difficult to obtain. They assure us that the eight firms licensed by the Ministry of Health to manufacture sterilised catgut in this country will be able to meet future demands in both home and export markets, though difficulty may be encountered in obtaining supplies of some brands.ED. L.