INSULIN LOSS DURING INJECTION

1038 that would be appropriate at each of the other levels. Much of the work of committees should be clarifying the basic assumptions and principles as well as ensuring that all administrative schemes are in agreement with them. If this policy is carried out much of the committee time now spent on details of administration could be saved and responsibility properly placed on individuals. Many of the current complaints are due to the fact that this has not been done. I venture to make some tentative suggestions at hospital level, as the one with which I am personally most concerned. I should like to see a similar statement for each of the other levels. The aims should include the

following : 1. To meet the general-hospital needs of the people of an area, modified by any arrangements which may exist in the region for special departments in certain hospitals ; to make some contribution to the hospital services of the region and the country outside the normal catchment area ; to give the best possible care to the patients who come under the supervision of the hospital staff as outpatients or inpatients, and to restore them to health, if this is possible, in the shortest time that may be ; to ensure that before discharge all curable obstacles to the full exercise of their mental and physical functions have been removed, or that they are placed under the conditions required for further treatment outside hospital. 2. To contribute to the general health service of the country in cooperation with those carrying on domiciliary and preventive medicine as well as those engaged in medical education. 3. To advance the cause of scientific medicine in every way that may be appropriate for a hospital. 4. To educate the medical and lay staff in all grades so as to develop an efficient machine for the work which the hospital has to do.

If we can agree on basic aims a simple test can be applied to all proposals ; but if there is a wide difference of opinion the service becomes a house divided against itself, and to prevent it from tottering or falling effective constructive criticism must be applied. Walton Hospital, Liverpool.

HENRY H. MACWILLIAM.

SPASTIC PARAPLEGIA IN LATE ADULT LIFE

oiR,—ihe interesting paper by Dr. spuiane and Dr. Lloyd in your issue of Oct. 13, on spastic paraplegia associated with degeneration and protrusion of cervical intervertebral discs, recalls to my mind the record of what must surely have been the first-if not indeed one of the latest-successful operations for the relief and It was performed at the cure of a paraplegia so caused. National Hospital, Queen Square, in 1892 by Sir Victor

Horsley. in Braira (1901, 24, 532) by Dr. and Dr. James Collier amongst a series of cases of lesion of the cervical cord associated with " optic neuritis." The James

case

is

reported

Taylor

The patient was a man who, while drunk, had fallen to the ground from a van, striking his right shoulder. There were no immediate neurological sequels, but next day his right arm was very painful, within a fortnight both arms were powerless, and within four months both legs were weak and bladder control impaired. On admission to hospital four months after the accident, he showed marked weakness of both hands and arms with wasting of small hand-muscles. The legs were intensely spastic and the seat of painful flexor spasms. The kneejerks were exaggerated, and there was bilateral ankle clonus. Cutaneous pain sense was lost below the 8th cervical segmental level, and over the same area sensibility to heat is said to have been slightly affected. He could not start the acts of micturition or defsecation. The 6th and 7th cervical spines were painful to pressure. Sir Victor Horsley removed the 6th cervical lamina and found the pia-arachnoid adherent to the theca, and the cord pushed backwards and compressed by a transverse ridge of bone projecting back from the body of the vertebra. ’Four months later the man was able to walk, and in eleven months after operation he is reported as completely recovered.

We should perhaps be unduly sanguine if we concluded that this remarkable success of one of the primitives of neurosurgery, achieved without skiagram or myelogram, or even lumbar puncture, will be invariably "

"

repeated. The interesting

association of " optic neuritiswith lesions of the cervical cord is another problem, for a discussion of which the reader may be referred to the original paper. Indeed, it is astonishing how much new knowledge may be gleaned from the pages of old

journals.

London,

F. M. R. WALSHE.

W.I.

INSULIN LOSS DURING INJECTION

SIR,-Dr. Luntz (Nov. 3) has pointed out the economic implications of the 25% wastage of insulin that appar.

ently occurs when injections are given with a 2 ml, syringe and a size 20 " needle. He has demonstrated the large part played in this wastage by the dead-space of the syringe and needle, and as a result of careful investigations recommends the substitution of a tuber. culin-type 1 ml. syringe and a smaller-gauge needle. Any attempt to save expense of drugs deserves support (and, as Dr. Luntz points out, not only insulin is involved), "

but there would appear to be several limitations to his recommendations. While in his obviously expert hands the relatively delicate tuberculin-type syringe would have a long life, the casualty. rate of such syringes in the hands of the ordinary diabetic patient (and even of ordinary doctors and nurses) would probably be much higher than that of the stout insulin syringe. I understand that the cost to a hospital of a 2 ml. insulin syringe is about 6s. and that of a tuberculin-type syringe about 12s. 6d. It is obviously impossible to calculate what additional expense would be involved if the latter were in common use, but it would considerably reduce the saving estimated by Dr. Luntz. The substitution of a needle of very small calbre might also be an economy of doubtful value. Dr. Luntz recommends " the smallest needle compatible with safety and the use of comfort for the patient." (It is not clear what system he is using for describing the calibre of the needles, since size intradermal " needle and corre26 B.W.G. is known as an sponds to size 20 on the hypodermic " scale. It is difficult to imagine a needle smaller than this being used for hypo. dermic injections, and so presumably the numbers to which " he refers are the B.w.G. scale. If this is the case the " size 20 the Hammersmith needles supplied to diabetic patients at Hospital are certainly safe but cannot be very comfortable!)!) But the smaller the calibre of the needle the more difficult it is to maintain in good order and the shorter its life, at least in the hands of the technically untrained, as pointed out by Dr. Wauchope (Nov. 17). I understand that there is very little difference in the cost of the two needles discussed by Dr. Luntz. In addition, the smaller the calibre of the needle the greater the risk of fluid being forced backwards between the piston and the barrel of the syringe or escaping at the junction of needle and syringe-a situation analogous to that pointed out by Dr. Luntz in an earlier communication. The use of a needle of very fine bore might thus necessitate discarding a syringe relatively early in its life. "

"

Dr. Luntz does not mention a method for saving the fluid lost in the dead-space of the needle and syringe that would appear to be simple and safe-the injection ofa bubble of air (0-25 to 0.5 ml.) at the end of the manceuvre. This is of value especially when giving intramuscular injections of drugs (such as bismuth) that are irritant if allowed to escape into the subcutaneous tissues or skin. The introduction of a small quantity of air at the end of the injection expels the drug from the dead-space (including the lumen of the needle), so that when the needle is withdrawn there is the minimum of risk that any drug is left in the track of the needle. A saving in the volume of the drug used would only be achieved, of course, if allowance for the dead-space were 1.

Luntz, G. R. W. N.

Guy’s Hosp. Rep. 1943, 92, 94.

1039

syringe was being charged ; but as this is constant for any syringe and needle combination it would be easy to do. After the syringe has been charged (to, say, 0-25 ml. less than the prescribed amount, or whatever allowance is to be made for the dead-space) the plunger is withdrawn and a bubble of air allowed to enter. When the injection is being given care must be taken to ensure that the air goes in last. This may be difficult, for example, when giving a patient in the erect position an injection into the deltoid region, but easy for the diabetic injecting himself in the thigh. Dr. Luntz might be able to calculate what saving could be effected by this simple measure, which has, so far as I am aware, no contra-indications.

made when the

cherished

by

our

best

general practitioners with regard

it. That the science of medicine can be advanced in general practice was clearly shown by Sir James Mackenzie not so very long ago ; and in our own time Dr. W. N. Pickles, to mention only one name, has shown that the inspired and scientifically educated general practitioner can contribute as a fieldworker to human biology in its widest sense. Evidence of original research work will no doubt be one of the qualifications for founder-membership of such a college as we are considering if one is established, but not all of those of us who are members of the established and Royal colleges necessarily need show this particular attribute. No doubt a higher diploma of one of the established General Infirmary, colleges, or training to a high standard in a medical or G. O. HORNE. Leeds. surgical specialty, would qualify a general practitioner POTENTIATION OF SULPHATHIAZOLE BY for membership of a College of General Practice. Further, GLUTAMINE it is not difficult to contemplate an examination which, Ware’s article (Nov. 10) prompts me to in breadth rather than in depth, would test a general SiR,-Mr. out that and Nelson’ have O’Meara, McNally, practitioner’s high professional competence. No doubt point shown that the sulphonamides are lethal only for micro- the general practitioners concerned in the movement for organisms in the logarithmic phase of growth. In watery the establishment of a college of their own have contemsolution they have no action on suspended bacteria plated other equally valuable criteria, and the possibility because the bacteria do not grow. also of election. In an incomplete synthetic medium such as Mr. Ware’s The practitioners most active in this movement will no doubt come to their own decision, with the advice basic medium, the organisms grow imperfectly, and correspondingly the sulphonamides added to such a2 of their colleagues, whether a college, a corporation, a medium have a feeble effect. Fildes and Gladstone faculty, or a society would be the most suitable title for their proposed organisation, and whether that organisahave shown that such imperfect media may be rendered tion should take advantage of some previously established more complete, and better growth may be obtained, by the addition of glutamine. Correspondingly Mr. Ware corporation whose hospitality it might use. But if has found that with the addition of glutamine the action physical educators, speech therapists, nurses, and midwives have the opportunity of membership of a college, of sulphathiazole is better. Fildes and Gladstone also showed that still better results may be obtainable by surely it can be conceded that general practitioners of adding glutamic acid and, perhaps, traces of iron to the the highest standing should have this opportunity too. For my part I should like to pay tribute to those who are medium in addition to glutamine. Thus the organisms bent on cherishing a high standard of professional may be brought more fully into the logarithmic phase of growth and rendered more susceptible to sulphonamide efficiency and ethics and the possibility of real medical and biological research in general practice in this country. action by these and further similar additions to the medium. Department of Surgery, Postgraduate Medical School In order to prove that a substance potentiates sulphonIAN AIRD. of London, NY.12. amides against growing bacteria, Mr. Ware will have to NORMAL CLOTTING-TIME AFTER TRANSFUSION show that it causes enhancement of sulphonamide action IN HÆMOPHILIA on bacteria growing in the logarithmic phase, and that this enhancement is independent of any acceleration of SiR,-It is known that whole blood or plasma adminisgrowth which it may provide. Otherwise he is merely tered intravenously, even in small amounts, commonly restores to normal the clotting-time in liemo-phili.acs.1 showing what is already known. But the transfusion of blood or plasma in amounts just Mercer’s Hospital, Dublin. P. A. MCNALLY. sufficient to produce this result does not necessarily A COLLEGE OF GENERAL PRACTICE restore all coagulation factors to normal. SiR,-Only one specialist has, I think, written in your Preliminary observations have been made by Quick,2 columns to support the proposal for the establishment using the so-called prothrombin-consumption test3 of a College of General Practice. I hope I will not be (prothrombin-time in serum). Using the same techconsidered impertinent in making one or two observations. nique, we observed in a number of haemophiliacs that No-one who has observed the best English general the values thus obtained remained abnormal or unchanged practitioners in the conduct of their practices can fail even shortly after transfusions of 2-3 ml. per kg. bodyto recognise them asthe finest family doctors in the weight. This applied also to hæmophiliacs who had not world ; and the loss to the community of the breadth received any previous transfusion, notwithstanding the of knowledge, human understanding, and high personal prompt and complete return to normal of the clottingethic required in the conduct of general practice in its time. (See also observations in hæmophilic dogs4 and highest form demands support for any measure which man,5in relation to those by Merskey6 and van Creveld will ensure its continued influence and stimulate its and Paulssen.1) extension in our community. Haemophiliacs transfused with submaximal amounts It is natural that fellows of the older colleges should of blood have, therefore, a condition which can be compause to consider whether a College of General Practice paredwith the thromboeytopenias : in this disease would merit recognition among the colleges which are the clotting defect is not apparent, and only the test already established in relation to the whole profession 1. Alexander, B., Landwehr, G. J. Amer. med. Ass. 1948, 138, 174. of medicine. 2. Quick, A. J. Amer. J. med. Sci. 1947, 214, 272. 3. Baserga, A., de Nicola, P. Schweiz. med. Wschr. 1949, 79, 801 ; In broad terms, I suppose that the aim of the older Le malattie emorragiche. Milan, 1950. J. B., Buckwalter, J. A., Hartley, L. J., Brinkhous, colleges is the advancement of the science and art of 4. Graham, K. M. J. exp. Med. 1949, 90, 97. medicine, surgery, and obstetrics and gynaecology. A 5. Croizat, P., Favre-Gilly, J., Borel-Milhet. J. Sang, 1951, 22, 353. little reflection shows that at least as high an aim is 6. Merskey, C. J. clin. Path. 1950, 3, 130. to medicine

as

they practise

.

7.

1. O’Meara, R. A. Q., McNally, P. A., Nelson, H. G. Lancet, 1947, ii, 747. 2. Fildes, P., Gladstone, G. P. Brit. J. exp. Path. 1939, 20, 334.

8.

Creveld, S., Paulssen, M. M. P. Ned. Tijdschr. Geneesk. 1950, 97, 441. Stefanini, M., Crosby, W. H. Proc. Soc. exp. Biol., N.Y. 1950, van

73, 301.