INFECTIONS OF THE HAND

885 24 hours after anaesthesia. In the same year Davison2 two cases with scarlatiniform rash and pyrexia. In 1946 Grant Peterkin3 described a case of purpuric rash after thiopentone which began 2 days afterangesthesia and lasted a week. In the correspondence 4 which followed, four different writers gave details of five cases, including one where treatment with small subcutaneous doses of adrenaline was successful. In the ten cases thus reviewed the rash varied consider.ably both in type and distribution, and with the exception of one case (described above), all subsided spontaneously within 2-7 days after operation. In four of the reported
reported

cases.

MARK SWERDLOW.

Manchester.

SENSITISATION OF PENICILLIN-RESISTANT BACTERIA SIR,—The work of Voureka (Lancet, Jan. 10, p. 62) must have stimulated investigation into the sensitivity of staphylococci in many laboratories. The following is an account of failure to repeat her results. Early in the year six strains of penicillin-resistant Staph. pyogenes and one micrococcus (284) were collected from routine cultures in this laboratory. The sensitivity to penicillin and the production of penicillinase, hyaluronidase, and ot toxin were tested. Two of Voureka’s techniques were repeated. In one technique the sensitive strain (Strep. Heatley) and the resistant organisms were grown separately in broth. Equal volumes of resistant and sensitive cultures were fused and left in the ice chest. Subcultures from the mixture were made at varying times-from 4 hours to 70 days. Staphylococcal colonies were picked off and tested for change of penicillin-sensitivity and penicillinaseproduction. In the other technique, Strep. Heatley and the resistant staphylococci were inoculated into one tube of nutrient broth, or Staph. Mayo and the resistant organism were inoculated together. These cultures were incubated at 37°C. The Staph. Mayo did not produce a toxin, while the Staph. pyogenes chosen for testing did. Blood-agar plates incorporating a strip of filter-paper soaked in a antitoxin enabled the test Staph. pyogenes to be isolated. To test the

penicillin-sensitivity, dilutions of penicillin one drop of a 1 in 100 dilution of an overnight growth of the test culture. For quantitative penicillinase estimation a plate was poured with assay agar containing

were

inoculated with

2. Davison, T. C. Anesth. & Analges. 1943, 22, 52. 3. Peterkin, G. A. G. Brit. med. J. 1946, ii, 52. 4. Ibid, pp. 138, 172, 209, 340. TABLE I-CHARACTERISTICS

OF

STRAINS BEFORE

TREATMENT

AND

AFTER

Staph. Mayo. Equal volumes of varying dilutions of penicillin and constant dilution of supernatant fluid from the broth culture were placed together in cups of an assay plate. From table I it will be noted that micrococcus 284 is the only strain whose resistance lessened with treatment TABLE II-CHANGING MINIMAL BACTERICIDAL

PENICILLIN TO MICROCOCCUs TEMPERATURE FOR 80 DAYS

OF

Day of test

.....

Min. bact. cone. (units cillin per ml.)

peni-

....

284

1

3

10

6

6

2

CONCENTRATION HELD

15

0.01

26

ROOM

AT

80 0.015

0.015

From Barber’s observations (Lancet, May 8, p. 730) it has been established that in working with single colonies there is the chance of picking a more sensitivevariant. However, this strain was further investigated. The nutrient broth culture 284 was left on the bench for 80 days. During this time its sensitivity was repeatedly tested. The result, depicted in table II, shows that a strain kept at room temperature in nutrient broth may become more sensitive to penicillin without any treatment whatsoever. The reverse process of raising the resistance of this strain was obtained by subculturing, from a growth in a tube containing a minimal penicillin dilution to the next tube with a higher concentration of penicillin. After 5 weeks, during which time the inoculations had been transferred twice weekly, the resistance was raised from 0.015 unit of penicillin per ml. to 3,0 units per ml. We foresaw the possibility that the metabolites of strains sensitive to penicillin might be used thera peutically, incorporated in a cream, for nasal or skin carriers of resistant strains. For this reason the toxin and hyaluronidase production of sensitising and resistant strains was originally tested. Itis obvious from our findings that at present there is not sufficient evidence that the sensitive variants may enable resistant strains to become penicillin-sensitive. W. H. BENNISON HERTA SCHWABACHER. Ministry of Health Laboratory, Sector IV, Peace Memorial Hospital, Watford.

INFECTIONS OF THE HAND SIR,—Some months ago I was depressed by-reading articles which advocated the archaic practice of early incision in the treatment of septic infections of the hand. Lack of adequate case records deterred me from written comment, and I waited in vain for any opposing view. THE LANCET for May 22 contains the answer, I should like to congratulate the authors on an excellent piece of work, which should be brought to the notice -of every hospital resident. The principles laid down by the writers are those which I have preached to my housesurgeons for many years. I was driven to adopt them by observing the results of orthodox treatment. It has given me great pleasure to note the results obtained in pulp infections. In the 1907 edition of Keen’s Surgery one reads, under whitlow : " early incision is strongly indicated " to prevent bone necrosis. Who originated the doctrine I know not, but it makes scant allowance for the vis medicatrix naturæ. : I have-reached a stage in my surgical career when I see few infected fingers other than those bad enough to require admission to hospital. In nearly every case the patient has been the victim of well-meant but ill-timed -

.

operation.

-

summary of some experimental work which demonstrated the dire effect on the defence mechanism of early incision of inflamed tissues. Perhaps some reader can supply the reference. C. C. HOLMAN. Northampton. A few years ago I read

a

SIR,—The conservativetreatment of the infected hand set out by Professor Pilcher and -his colleagues is a most interesting departure from conventional treatment, as

which hitherto has seemed to be increasingly surgical. A similar change took place in the therapy of carbuncle. which was treated by cruciate incisions until the second decade of this century when Morison, - a surgeon, int-roduced his hygroscopic paste and with it a new era of

886 conservative treatment, for which patients with carbuncles should be duly grateful. So diverse and even opposing are present methods of treating septic hands that one is forced to the conclusion that human tissues usually react successfully to these predominantly staphylococcal lesions under the most varied of therapeutic environments. Some incise early ; others late. Some advocate hygroscopic paste : others loathe it. Some praise wet heat ; others shun it, while not a few avoid heat of all kinds. The literature on the infected hand still treats these important lesions as if they were isolated surgical events. The implications of much bacteriological work on staphylococcal skin carriage is ignored. Sutherland and 1/ in a recent study of 111 septic hands, found that 17 of the patients had a boil and 12 another septic hand during the course of 9 months, suggesting that the persistent carrier state should not be overlooked in the study of these cases. Again, staphylococcal lesions are contagious. Wright, working on nurses in the Emergency Medical Service, and Branson, on nurses at St. Bartholomew’s Hospital, both found that the chief cause of sick absence was staphylococcal skin lesions and infected hands. This contrasts with industrial sick absence for which the main single cause is respiratory illness. Sutherland and I showed that in an industrial community boils and infected hands varied from time to time not only in frequency but probably also in severity, and that both diseases had a parallel course and a sea,sonal peak in the autumn. These fluctuations, if confirmed, might show it to be fallacious for one surgeon to compare his results with another’s. We also found that these staphylococcal lesions have greatly increased over the last few years. As these lesions and the associated carrier state are the chief reservoir from which many surgical tragedies,- such as osteomyelitis, are derived, the significance is obvious. It is curious that we do not see the things which are always before us. We notice with alarm some hundreds of cases of poliomyelitis or 3 oases of smallpox, but the great staphylococcal pandemic with its many ramifications in every branch of medicine and surgery catches us on the blind spot. We only recognise the individual lesions it produces. G. P. B. WHITWELL. Oxford.

practice. Probably a number of the non-European graduates will have to be employed in the Government’s health centres as medical officers, -with a probable diminution in the number of posts available to European practitioners. It would be as well to consider the fact that South Africa has a population of roughly 21/2 million Europeans, 1 million Coloured and Asiatic persons, and 8½ million natives. Of these the natives pay taxes which, together with considerable sums from general revenue, are devoted to native administration and welfare. The Coloured and Asiatic persons are also to some extent a charge on the State so far as taxation is concerned, and at the most about 1½ to 2 million Europeans are affected by direct taxation and in a position to pay their own doctors. Of these the majority is found in the urban areas.

As there at Dec. 31,

°

MEDICAL PRACTICE IN SOUTH AFRICA

SIR,—-At the meeting of the federal council of the

Medical Association of South Africa held in Johannesburg at the end of February, 1948, grave misgivings were expressed regarding the prospects of the many doctor settlers who are continuing to enter the Union from ’

overseas.

It is recognised that many who have already arrived have settled down and are building up practices ; but it would seem that the number of medical men entering the country is out of proportion to the number of other settlers. Most of them are naturally unilingual, and, until they are able to become conversationally bilingual at least, the country districts present difficulties. The coastal areas and the larger cities are thus in danger of becoming overcrowded and the newcomer is having a, more difficult time in establishing himself. In addition the three medical schools of the Union are estimated as producing between 250 and 300 new graduates each year and this number annually will be seeking practices and appointments. Inevitably the majority of these younger men enter general practice and the number of appointments available to them is limited. Even the extension of the health-centre system will not make a great deal of difference, as the gradual development of these centres-reaching a maximum of, say, 400 in the course of time-will only absorb a certain number of the annual output of local graduates. It is a matter of time before the new medical school for non-Europeans at Durban will be sending its graduates out into the world, and although there is vast scope amongst the native population for medical practice it is not of the kind that will produce a reasonably lucrative 1.

Whitwell, G. P. B., Sutherland, I. 5, 88.

were

5013 medical

practitioners registered

as

1947, it would seem that the ratio is reasonably

satisfactory from the economic point of view at present. During 1947 443 medical practitioners were registered or re-registered, and of these 282 had received their qualifying degrees in South Africa. If the normal increase in the number of medical practitioners is to remain in the neighbourhood of 400 per annum it would appear that,it will not be -long before doctors in South Africa will be forced to emigrate if they are to continue the practice of medicine. There is a tendency at present towards some form of national health service, although progress is slow. In any case the number of underprivileged persons requiring help makes such a service imperative sooner or later. Medical practice is divided generally into the two classes-general practitioners and specialists-the latter being about one-eighth of the total number of practitioners on the medical register. The specialists’ register was instituted about ten years ago at the request of the Medical Association of South Africa ; but with the rapid strides recently made in the theory and practice of medicine it has been found necessary to tighten up the rules for the registration of specialists to such an extent that it is now very much more difficult to acquire legal recognition as a specialist. (Inquiries regarding ordinary medical registration, and registration as a specialist in particular, should be addressed to the registrar, S.A. Medical and Dental Council, P.O. Box 205, Pretoria.) Normally an overseas medical man wishing to settle in the Union is welcomed (and he still is), but it is felt to be right and proper to issue a note of warning to men who may be considering leaving an assured income and living in the country of their origin for the chance of establishing themselves in the Union, where the possibilities of reasonable private practice are diminishing. No man would be wise who would give up what he has. to settle here, until at least he had visited the Union—on holiday perhaps-to see things for himself and to make up his mind as to his chances. A. H. TONKIN Secretary, Medical Association of 35, Wale Street, Cape Town.

South Africa.

LEUKÆMIA AND WAR SERVICE

SIR,—On reading your article (May 22), on Kinkaid v. Minister of Pensions, I cannot help feeling that you have misinterpreted some of the learned judge’s remarks. In these pension cases there can never be any question of " finally establishing "- that a certain type of disease is never to be accepted as attributable to, or aggravated by, war service. In a recent batch of cases, Docherty & others. f. Minister of Pensions, heard in the Court of Session, the question of putting diseases into classes which could or could not be attributable to war service was fully dealt with. The following quotationfrom the opinion of the Lord Justice Clerk, Lord Thompson, given in these cases, shows that the Scottish Bench does not support the argument that it is possible to schedule various diseases for pension purposes : "

In our view there is no overhead method of solving the possible problems that may arise. The use of formulas and categories may cause injustice. The task of the Tribunal is to decide each case on the material before it."

Brit. J. indust. Med. 1948, 1.

Chapman’s Reports, vol. 2,

p. 637.