METHOD OF ADMINISTERING DICOUMAROL

395

Wheatley’s suggestion that penicillin and streptomycin should be applied locally. Topical streptomycin is particularly liable to produce skin reactions, and topical penicillin is not free from the same disadvantage. I have not yet seen a skin reaction with chloramphenicol. 5% chloramphenicol in propylene glycol is not expensive ; 100-150 applications cost 8s., if the solution is made up in one’s own dispensary. The total cost in antibiotics of treating a case of paronychia was 3s. 7d.; Dr.

it is now less. Mr. Jones’s investigation of seasonal variations (Jan. 31) interested me greatly. I agree there are so many factors that it is difficult to prove anything. I have, however, taken from last year’s records on septic hands (976 cases) a few figures which may be relevant. In the months January, February, March, October, November, and December, 58 cases of common septic hand conditions took over a fortnight to heal, 21 over three weeks, and 10 over a month. In the months April-September the corresponding figures were 26, 10, and 4. The figures for paronychia were : over a fortnight, in the winter 18 and in the summer 4 ; over three weeks, in the winter 4 and in the summer nil; over a month, in the winter 2 and in the summer nil. It is the clinically resistant cases that we hope to abolish. Some, as I have shown, are due to bacteriological resistance, and chloramphenicol will help. Many are due to faulty surgery in the first place, and bacteriological resistance is acquired secondarily. Paronychia is the first septic condition of the hand in which penicillinresistant organisms have been noted in significant numbers on first attendance at the clinic. This casualty appointment, like many others, has been unfilled for some time ; and in the past year no less than seventeen housemen have been detailed, at one time or another, to operate on the cases. Under such conditions it is impossible to maintain a consistently high standard. Nevertheless the 230 cases of paronychia treated since the principles I adopted have been emphasised, have had an average duration of treatment of 7-11 days. This is nearly a 40% improvement on anything we have had before, and exactly half the average disability in 1950. Royal Infirmary, Sunderland.

T. G. LOWDEN.

A SURGICAL POLICY FOR PEPTIC ULCER

SIR,-May I congratulate Mr. Orr and Mr. Daintree Johnson on their excellent article in your issue of Feb. 7 ? They have recognised the surgeon’s dilemma : excellent as ulcer surgery is, a fairly high resection is necessary for sure relief, and the higher one goes the more likely one is to encounter untoward effects (of which we have seen examples from all over the country). The authors’ plan of operation is designed to secure the benefits of gastric surgery without its disadvantages. In my own clinic we treated a small series of patients by limited gastrectomy with vagotomy, and we were well pleased with the results, but we are waiting a little longer before going on. Meanwhile, we are giving an extended trial to another promising procedure, the results of which have not yet been assessed for publication. These latest figures from Mr. Orr and Mr. Johnson are a strong encouragement to us to begin a second series of limited gastrectomy with vagotomy in suitable cases. It is only from the most careful personal analysis of an adequate series of cases such as this, that any, deductions can be The authors mention ’ drawn. important that they have also had access to a second series, operated upon by a colleague. I should like to emphasise the value of this method in which the same observer takes stock of both series and can therefore safelv draw comparisons. We also have made a start in this direction, and we hope soon to extend similar inquiries much more

widely.

Finally, may I voice one criticism ? I believe they are wrong in supposing that even the most cunning questionnaire is as good as an interview : for example, the signs of riboflavine deficiency have to be looked for if they are not to be missed. Moreover, patients who have, through surgery, been relieved of their life-long ulcer pains are often reluctant, unless pressed, to admit to even so gross a feature as bilious vomiting, and, moreover, they often mistake bile for food. In this article, the incidence of bilious vomiting is about " right," but that of the vomiting of food seems to me too high. Department of Surgery, University of Liverpool.

CHARLES WELLS.

METHOD OF ADMINISTERING DICOUMAROL

SiR,-The paper by Dr. Bjerkelund (Feb. 7) was very interesting to us here as, for some years, the determination of prothrombin levels and the task of working out further dosages of dicoumarol or of ethyl biscoumacetate (’ Tromexan ’) has been entrusted to the biochemist. This arose because the requests were often inscribed" please advise dosage of anticoagulant," and also because we found commonly that inexperienced housemen either were reluctant to order enough dicoumarol or ordered excessive amounts. Furthermore, daily prothrombin estimations were becoming a burden to both staff and patients. Consequently the following scheme was devised : The

initial any determined by

including

request form contains full clinical details,

dosage already given.

The

prothrombin

is

Quick’s one-stage method using rabbit-brain

thromboplastin, and the result is reported as the index and corresponding percentage normal. This is written direct on to the request form together with dosage details for the evening of the day of test, the following day or days, and the morning of the next test day. The form then goes back to the ward ; or in the case of outside hospitals in the group the report is telephoned. Usually tests are done every other day-chiefly Mondays, Wednesdays, and Fridays. The

advantages

are

briefly :

1. The report gets to the ward quickly and treatment can be started with little delay. 2. There is no laboratory office work except to note incoming requests in the day-book ; there is no typing (to save technical time, the report is written within a rubber-stamp framework), and we keep our own record of the dosages in the laboratory prothrombin-time book. 3. Tests are necessary only every other day. 4. In the case of ethyl biscoumacetate, the dosages are divided into morning and evening tablets, and usually one 300 mg. tablet is given at 6 A.M. on the day of test to maintain a satisfactory level until the result of the test is known. 5. Whilst it might be argued that it is unwise to leave the dosage to the laboratory, in practice this works very well ; for the biochemist, unlike the houseman who has many such drug dosages to work out, can bring a fresh mind to the problem. Furthermore, it is obviously an asset to have someone who has been concentrating on this dosage problem for several years and who has the patient’s previous figures at his finger-tips. Indeed, provided full clinical details are given, it is possible for the laboratory to point out the inadvisability of starting a course of ethyl biscoumacetate in, for example, pregnancy, if this has been overlooked by the clinicians. 6. General practitioners are more ready to treat their own patients instead of admitting them to hospital. In the case of ambulant patients the blood is taken by the laboratory, the result and dosage telephoned to the doctor, and the dosage alone telephoned to the patient. The doctor then has merely to check the clinical side every other day. He knows what dosage the patient has been instructed to take, and can alter it if he considers this necessary. This is surely a good example of a general practitioner receiving immediate and full cooperation from a hospital department and yet maintaining full control of the patient. 7. Only two cases of major h2emorrhage in the past four One was in the early days, through years can be recollected. too infrequent testing, and was controlled by transfusion.

396 in an old lady who had had a ureteric transplanhysterectomy ; she had only one kidney, which was subsequently found to be riddled with chronic nephritis, so the fatal haemorrhage which ensued was not surprising. The other

was

tation and

EXAMINATION OF RIB BONE-MARROW FOR

a

This emphasises the need to include full clinical details on the request form. Dr. Bjerkelund pleads for " long-continued treatment

of ambulant outpatients." Surely the danger of recurring thrombo-embolic incidents could be substantially reduced if the patient were maintained on ethyl biscoumacetate for longer than is now customary. We cheerfully subject people to lifelong liver and insulin injections with accompanying laboratory control, and yet we are reluctant to do the same in the case of dicoumarol or its derivatives. If a dosage advisory service could be arranged on the lines indicated above, most of the principal objections to the use of this drug would be overruled. Is it not worth it ?’? Royal Infirmary,

E. B. LOVE.

Preston.

TURERCLE

BACILLI

Sin,-The discrepancy between our findings and those of Dr. Marsh and Mr. Barton,l who found no tubercle bacilli in the rib bone-marrow of their patients, may be explained by the following facts : (1) The haematogenous (disseminated) form of tuberculosis is

in children. The sternum is relatively richer in

commoner

(2)

marrow

than the

ribs.

In our work on this subject we have made comparative studies of blood, bone-marrow, and gastric-juice cultures from tuberculous children, and these have confirmed our previous results. This study encouraged us to make a more detailed review of the literature, and we have found that the bone-marrow of tuberculous patients has repeatedly siven positive results in the past.2-5 K. CHOREMIS. University of Athens.

HALLUX VALGUS

SiR,-Your leader last week stimulates me to make certain observations on this important subject. Apart from terminal-phalanx hallux valgus, which is congenital, hallux valgus is, I understand, found among peoples who have always been barefoot only in adults ; and the disorder appears to be due to injury of the first metatarsus or proximal phalanx. Developmental hallux valgus is, I believe, virtually unknown among children who have always been barefoot. Since in this country some 50-75% of adolescents have a developmental hallux valgus (as any school medical officer will testify) only some all-embracing factor, such as tight shoes, can be involved. Again, since our Ealing shoe scheme showed quite clearly among growing children that the supply of well-fitting shoes leads to the disappearance of hallux valgus, it is difficult to accept your assumption that " there is commonly no apparent cause whatever for hallux valgus." The child with a broad foot needs no wide metatarsal angle to have difficulty in finding suitable fittings in footwear ; and children’s shoes at a price within the reach of the ordinary parent are made in only one fitting. At least half the children could not therefore possibly obtain satisfactory shoe fittings even if there were enough trained shoe-fitters in the shops and every parent were aware of the importance of securing correct fittings. Every child needs a new fitting approximately every three months, but with shoes at their present cost it is almost impossible for parents to follow this practice. How sad it is that this preventable condition is not prevented ! W. G. BOOTH Medical Officer of Health.

CONGENITAL DEFECTS FROM MATERNAL RUBELLA

SrR,-Mr. Ian Robinrecommended that, in order to

danger of infection with rubella during pregnancy, should be taken to infect girls with the opportunity every disease before leaving school. I am in absolute agreement, and there seems every advantage in following such a course in a school where all the girls are boarders. But, as medical officer to a girls’ public school in which only 153 of the 521 girls are boarders, I find the decision by Some of the girls may be returning no means so simple. daily to a mother who may herself be pregnant, or they may share public transport and entertainment with pregnant women ; the risk would therefore be spread I should welcome over a large section of the community. avoid

the views of others who may be faced with the

same

problem. DUDLEY M. BAKER. 1.

Robin, I. G.

Lancet, 1952, ii,

1034.

THE LATE Dr. H. W. DIAMOND Dr. J. B. Wrathall Rowe writes : " Dr. Hugh Welch Diamond, who died at Twickenham in 1886, was a pioneer in the field of medical photography and photomicrography. I should be grateful if anyone with knowledge or early examples of Dr. Diamond’s work would write to me c/o the Medical Department, Kodak Ltd., Harrow, Middlesex. I should also welcome information about Dr. Diamond’s descendants: Dr. Warren Hastings Diamond may have been his son, and he is thought to have had a grandson R. Hugh Clarke."

named

Medicine and the Law Nationalised Hospitals and Negligence THE degree (if any) to which the nationalised hospitals and their staffs are protected from claims for negligence is still being worked out at the expense of plaintiffs and defendants. In Bullard v. Croydon Hospital Group Management Committee and Latta6 it was alleged that a patient suffering from acute appendicitis was not operated upon till five days after admission to hospital; by that time, it was said, peritonitis had developed and death occurred on the day of the operation. A claim for damages was brought against the hospital managers and the surgeon concerned. The hospital managers replied that, in so far as they were responsible for the treatment of the deceased, they undertook it as their duty under the National Health Service Act ; the surgeon, they contended, was acting on their behalf or as an officer under their direction in the discharge of their responsibility, and they claimed protection from liability by virtue of section 72 of the Act. Section 72 provides that section 265 of the Public Health Act, 1875, shall have effect as if the public authorities referred to therein (local authorities, joint boards, and port sanitary authorities) included a hospital Section 265 provides that management committee. nothing done by such authorities or any of their officers or other persons acting under their directions, "if the thing were done ... bona fide for the purpose of executing " [the Act of 1875], shall " subject them ... personally to any action, liability, claim or demand* whatsoever." Mr. Justice Parker decided in favour of the plaintiff, the administrator of the deceased patient’s estate. He referred to section 13 of the 1946 Act which states that hospital management committees, notwithstanding that ...

1. Marsh, K., Barton, G. E. Lancet, 1952, ii, 1059. 2. Debré, R., Lamy, M., See, G., Mallarmé, J. Pr. méd. 1936, 44, 1853. 3. Even, R., Lecoeur, J., Sors, C. Bull. Soc. Soc. méd. Hôp. Paris,

1947, 63, 113. 4. Bernard, E., Kreis, B., Lotte, A. 5. Katz, S., Lifschutz, S. 6. Times, Feb. 13, 1953.

Ibid, 1949, 65, 360.

Med. Clin. N. Amer. 1950

34, 1817.