- Email: [email protected]
OPINION BY POST
408
Annotations INTRAVENOUS
HAZARDS SIMPLE intravenous infusion is often undertaken in
a
lighthearted spirit. " Shoving-in " some blood, " jamming-in " a few c.cm. of intravenousPentothal,’ the gay " exhibition of a syringe " and a pad of spirit-spaked wool, and some " plugging around " with a needle for a vein are commonplace enough. The difficulties and dangers of intravenous therapy were discussed by the Medical Society of London on March 13, with Prof. Grey Turner in the chair. What Mr. R. H. Franklin called " a shady piece of work under a towel " is all too likely to engender risks which could be avoided, and it is time the venesector was given more elbow room as a skilled mechanic in the surgical or medical team. A,B,O,M,N, rhesus, pyrogenic and anaphylactogenic substances all lie in wait to trip the incautious or faulty techniciaw, and Dr. C. J. C. Britton advocated the tube rather than slide methods of
grouping.
test-
Knott 1,
has recommended routine tube cell-tests with standard sera, serum tests with standard cells and cross-matching at 370 C.; subgroup agglutinins, especially sub A and B in group O’s and rhesus-positives acquired through previous transfusions, will not be missed if these precautions are adopted. When caution in administration is added the " perfect tissue graft " of Whitby2 should be- attained. It is fortunate that the non-specific reactions from pyrogenic bacterial and other proteinsoften due only to lack of cleanliness,with apparatus-are so rarely a danger to life. The same is not true of heat haemolysis or cold agglutination, and stored blood must clearly be used with oare. Truly a bottle of blood can be a nest of hornets. Adequate warning of these risks is not lacking in the everyday medical literature.In deed so much emphasis has been laid on them that there is some danger of overlooking the more immediate mechanical perils of venous infusion-blood, saline, anaesthetic drug, contrast medium, germicide, protein hydrolysate or whatever it may be. Local infection is still too common, especially in the leg veins, and the risk of leaving needles thinly if at all protected from the blanket can be reduced by bipp or sulphanilamide local dressings. Lawrence Abel’s suggestion of ambulatory leg infusion, reservoir in hand, might be risky from the point of view of infection. The dangers of air-embolism, once as scorned as fat-embolism, were again brought out at the meeting by Dr. Keith Simpson. The use of closed pressure-fed reservoirs like the McCartney bottle (when gravity feed and a good sized needle will suffice), of faulty rubber (especially war-time rubber) and leaky bevel unions, and the dangers of fumbling with open venesection are at last becoming recognised. Venesectors are liable at law for accidents with apparatus, for as Kitchin3 has said, " When an inanimate thing... is safe and proper if used with care " it is reasonable to argue that " an accident ... arises from want of care." The public has a right to expect due care and a degree of skill reasonable for the status and experience of the operator and will assuredly obtain judgment in the absence of either. It is a sign of the healthyconscience of medicine that distinguished exponents of intravenous anaesthesia have reported their misfortunes with aberrant arteries 4 Dr. Ronald Jarman urged that if 28% of a group of Canadian soldiers are shown to possess such vessels due caution becomes a matter of " reasonable care and skill." We cannot afford to be ignorant of the possibility, and must ensure that the vessel into which the needle is run is neither 1. Knott, F. A. Guy’s Hosp. Gaz. 1943, 56, 253. 2. Wbitby, L. E. H. Lancet, 1942, i, 581. 3. Kitchin, D. H. Legal Problems in Medical Practice, London. 4. Macintosh, R. R. and Heyworth, P. S. A. Lancet, 1943, ii, 571.
pulsating nor contains bright red arterial blood. When an experienced anaesthetist gives warning of the danger of handling phials whose labels have become detached by storage, of unnecessarily concentrated solutions or badly sterilised apparatus, it is time to tighten the standards in infusion technique. OPINION
BY
POST
MosT of our readers will now have had from the British Medical Association a copy of the full whitepaper on the National Health Service (provided by the Ministry of Health), an analysis setting out the BMA council’s preliminary views, and a questionary prepared by.the British Institute of Public Opinion. The scientific staff of the institute are to be congratulated on having drafted a document which is as lucid and objective as could well be expected. The white-paper proposals are certainly not easy to translate into questions capable ’ of simple answers, and the attempt has involved the use of questions of a length unusual in opinion surveys ; but we hope that even doctors who normally stand aloof from " medical politics " will give the time and take the pains necessary to send answers-if necessary falling back on the philosophical formula " don’t know." If many questionaries find their way into drawers or wastepaper baskets the survey will lose an important part of its srignificance. Taylor has lately pointed out how misleading the results of postal inquiries may be. NormaJly they are sent only to a representative sample of the people concerned, and since the returns are usually of the order of 30% the sociologist may have no means of knowing what part of his sample has made the decision to return the questionary, and acted on it. But in this case the situation is somewhat different. The questionary is being addressed hot to a sample but to the whole of the medical profession. It is thus in fact an attempt at a census. Errors in the drawing of the initial sample are thus being avoided. To overcome the difficulty of the partial return, a detailed personal record is asked for in the last part of the questionary. The Central Medical War Committee already have all these details in hand for the entire profession, and by comparing the data it .would be possible to weight the results of the returns-to make them valid for sex, age, nature of work, place of practice, and so on. If some members of the profession do npt answer the questions, such weighted results will be more useful than the simple gross totals expressed as percentages. It might still be argued that the inquiry revealed the views of the more intelligent, informed and articulate doctors inside each of the groups studied. The only way to have overcome this difficulty would have’ been to have interviewed a random sample of doctors drawn from the Medical Directory. A skilled interviewer has a refusal-rate with the general public of under 0-5%. With doctors this refusal-rate might perhaps have been higher, but it would nevertheless have been a small factor when contrasted with the large field of error possibly arising from non-return of questionaries. Unfortunately, the distribution of the medical profession in space-from Burma to Spitzbergen-makes the interviewing of a random sample quite impossible ; so the British Institute has been driven to apply the postal method as the only one available. The study of group opinion among experts is not quite Professor Burt,2 in cooperation with the home new. intelligence division of the Ministry of Information, has investigated the opinions of teachers and educationists His questionary was even more on educational reform. formidable than that of the BMA, but he used a very small sample. As we said last week, we welcome the BMA and BIPO experiment ; for it represents a new 1. Taylor, S. Public Administration, 1943, 21, 109. 2. Burt, C. Occupational Psychology, 1943, 17, 157.
409
attempt to make democracy work yearly becoming more complex.
in
a
society which
is
TOO MUCH SUN Air Commodore Morton told the Royal Society of Tropical Medicine and Hygiene on March 16 something of INFECTIONS WITH NON-SPORING ANAEROBES his experiences in the prevention and treatment of heat THE frequency of gas gangrene and tetanus in the effects during five hot seasons in Iraq. Superstitions wounded of the 1914-18 war led to much useful research about sunstroke have been .discarded with spinal pads, on the spore-bearing anaerobes, resulting in new methods but the topee is still useful in really hot parts of the for their cultivation and identification. The present Ill effects from the sun are due simply to overtropics. of a stimulus to the these further war has given study of the tissues and body fluids ; they are essentianaerobic bacteria, but so far little attention has been heating similar to those seen in furnace workers in ally paid to the non-sporing anaerobes. MacLennanhas climates. The least serious result is fainting, temperate caused by a to be described gangrenous myositis, distinguished cardiovascular disturbance but without temporary from clostridial gas gangrene, due apparently to a of the chloride balance. serious. derangement More action between the anaerobic streptococcus and symbiotic exposure leads to heat exhaustion. Collapse, profuse one or other of the aerobic pyogenic cocci, while on another page Forbes and Goligher report a case of genera- perspiration, fall in blood-pressure, nausea, vomiting and severe muscular cramps are associated with a fall in blood lised infection with a pleomorphic anaerobic gramand urinary chlorides. Mouth temperature may be Bacterium In negative bacillus, peacenecrophorum. normal but rectal temperature is often raised to 100° or time these two organisms, the anaerobic streptococcus 101° F. The victims are usually of the lean, anxious and and the necrophorus bacillus, are not infrequently spare type ; many are affected soon after their first associated with severe and characteristic-though, to arrival in hot climates. Treatment is best carried out in the uninitiated puzzlin-infections, and they are likely a temperature of about 75° F. Abundant fluid, with to be responsible for similar infections in war casualties. glucose and sodium chloride, should be given by mouth. In civilian practice generalised infection with these 0.9% sodium chloride must be given intranon-sporing anaerobes is seen most often after difficult If necessary, it is important to keep careful watch on but venously, labour or septic abortion where there are retained the balance between input and output of fluids ; otheras a culture Pelvic medium. products acting peritonitis, wise there is a serious risk of pulmonary oedema. Diuresis or more typically, septic thrombophlebitis, follows, and a rise in urinary chlorides are reliable signs of and from the thrombophlebitis emboli are thrown off into the circulation to be riddled out in the lungs particularly. recovery. Attempts to correct acidosis or alkalosis should not be made in the absence of strict biochemical control. Empyema is a common sequel to these multiple lung The most serious condition is that of heat hyperpyrexia. abscesses. Clinically this type of infection is characThick-necked chronic alcoholics with high blood-pressure a F. remittent to 103°-105° assotemperature terised by are most often affected, usually after they have been ciated with daily rigors, signs of lung involvement, an in the tropics. Besides a fall in urinary several increasing anaemia and a downhill course. Spontaneous chloridesyears there is a failure of heat regulation. The sometimes occurs for no obvious the reason ; recovery coma are infection resists sulphonamide therapy. Anaerobic blood- flushed face, dry burning skin, delirium or 108°-112° F. associated with rectal to temperatures up culture reveals a non-haemolytic streptococcus or a fine If life is to be saved the temperature must be brought or with other alone associated each gram-negative bacillus, down quickly to 102-103° F. by whatever means ’ are or with other bacteria such as diphtheroids, enterococci, at hand. In active service conditions, an iced enema An essentially similar syndrome has or coliform bacilli. been described by French writers2 as a sequel to periton- is indicated, but this interferes with the recording of sillar abscess ; the anaerobic gram-negative bacillus in rectal temperatures. In hospitals, sponging with cold or iced water and the use of fans should be continued these infections is called Bacillus funduliformis but is until the temperature falls. A useful wind-tunnel was These identical with Bact. probably necrophorum. with a shock cradle covered by d blanket. organisms, incidentally, are poorly pathogenic for improvised were hung from the roof, and fans blew a stream Ice-bags laboratory animals, and in this respect differ from the of cold air over the body. Air-conditioning of wards is Bact. necrohoum of calf diphtheria, foot-rot in sheep, a great help to nu-rsing ; 60° F. is the temperature recomand labial necrosis of rabbits. Harris and Brown who recovered the organism from infected caesarean ’ mended for the initial stages, but as soon as the danger from is past the patient should be nursed wounds, therefore suggested the name " pseudo-necro- at 75°hyperpyrexia F. and glucose should be given Fluid with phorus for the human variant. Both the necrophorus by mouth ; intravenoussalt salines are seldom needed unless bacillus and the anaerobic streptococcus, of which there vomiting is persistent-they may do harm by overloadare also several variants,4 are to be found in the healthy a circulation. It is important to be sure that body cavities (mouth, intestine and female genital canal) ing failingare not due to malignant tertian malaria, and symptoms *and infection with one or other of them usually follows be given if any doubt arises. intravenous should quinine some necrosis or devitalisation of local tissue. The Much can be done to prevent casualties from heat effects range of these infections had lately been reviewed by ensuring that newcomers are introduced gradually Meleney and his co-workers.5 Wounds elsewhere in the by to the sun, and by arrangement of working hours so- as body, especially if there is necrotic tissue, may also act to allow as many as possible to spend some of their as a primary focus, and this is a possible explanation of Forbes and Goligher’s case where the infection began at off-duty time in air-conditioned rooms. Men should be encouraged to drink more water " and " eat more salt." the site of a compound fracture of the thigh. Routine anaerobic culture needs to be practised more When the thermometer is really high, extra salt should in bacteriological laboratories so that infections of this be put in the food. To ensure that this is done the medical officer may have to take his courage in one hand and a type shall not be missed. Useful advice is given in the bag of salt in. the other and have it out with the cook. second edition of the Medical Research Council’s memorandum no. 2 on gas gangrene. Brigadier F. A. E. CREW, FRs, has been appointed to the Bruce and John Usher chair of public health in the 1. MacLennan, J. D. Lancet, 1943, i, 584. 2. Lemierre, A. Ibid, 1936, i, 701. University of Edinburgh in succession to Prof. P. S. ’ B
"
"
,
3. Harris, J. W. and Brown, J. D. Bull. Johns Hopk. Hosp. 1927,
40, 203. 4.
Prévot,
A. R. Manuel de Classification et de Détermination des Bactéries Anaérobies, Paris, 1940, p. 27. 5. Sandusky, W. R., Pulaski, E. J., Johnson, B. A., Meleney, F. L. Surg. Gynec. Obstet. 1942, 75, 145.
Lelean who has retired. Dr. Crew has held the Buchanan chair of animal genetics in the university since 1928, but for nearly two years has been working in the medical department at the War Office, where he is director of biological research.
Annotations INTRAVENOUS
HAZARDS SIMPLE intravenous infusion is often undertaken in
a
lighthearted spirit. " Shoving-in " some blood, " jamming-in " a few c.cm. of intravenousPentothal,’ the gay " exhibition of a syringe " and a pad of spirit-spaked wool, and some " plugging around " with a needle for a vein are commonplace enough. The difficulties and dangers of intravenous therapy were discussed by the Medical Society of London on March 13, with Prof. Grey Turner in the chair. What Mr. R. H. Franklin called " a shady piece of work under a towel " is all too likely to engender risks which could be avoided, and it is time the venesector was given more elbow room as a skilled mechanic in the surgical or medical team. A,B,O,M,N, rhesus, pyrogenic and anaphylactogenic substances all lie in wait to trip the incautious or faulty techniciaw, and Dr. C. J. C. Britton advocated the tube rather than slide methods of
grouping.
test-
Knott 1,
has recommended routine tube cell-tests with standard sera, serum tests with standard cells and cross-matching at 370 C.; subgroup agglutinins, especially sub A and B in group O’s and rhesus-positives acquired through previous transfusions, will not be missed if these precautions are adopted. When caution in administration is added the " perfect tissue graft " of Whitby2 should be- attained. It is fortunate that the non-specific reactions from pyrogenic bacterial and other proteinsoften due only to lack of cleanliness,with apparatus-are so rarely a danger to life. The same is not true of heat haemolysis or cold agglutination, and stored blood must clearly be used with oare. Truly a bottle of blood can be a nest of hornets. Adequate warning of these risks is not lacking in the everyday medical literature.In deed so much emphasis has been laid on them that there is some danger of overlooking the more immediate mechanical perils of venous infusion-blood, saline, anaesthetic drug, contrast medium, germicide, protein hydrolysate or whatever it may be. Local infection is still too common, especially in the leg veins, and the risk of leaving needles thinly if at all protected from the blanket can be reduced by bipp or sulphanilamide local dressings. Lawrence Abel’s suggestion of ambulatory leg infusion, reservoir in hand, might be risky from the point of view of infection. The dangers of air-embolism, once as scorned as fat-embolism, were again brought out at the meeting by Dr. Keith Simpson. The use of closed pressure-fed reservoirs like the McCartney bottle (when gravity feed and a good sized needle will suffice), of faulty rubber (especially war-time rubber) and leaky bevel unions, and the dangers of fumbling with open venesection are at last becoming recognised. Venesectors are liable at law for accidents with apparatus, for as Kitchin3 has said, " When an inanimate thing... is safe and proper if used with care " it is reasonable to argue that " an accident ... arises from want of care." The public has a right to expect due care and a degree of skill reasonable for the status and experience of the operator and will assuredly obtain judgment in the absence of either. It is a sign of the healthyconscience of medicine that distinguished exponents of intravenous anaesthesia have reported their misfortunes with aberrant arteries 4 Dr. Ronald Jarman urged that if 28% of a group of Canadian soldiers are shown to possess such vessels due caution becomes a matter of " reasonable care and skill." We cannot afford to be ignorant of the possibility, and must ensure that the vessel into which the needle is run is neither 1. Knott, F. A. Guy’s Hosp. Gaz. 1943, 56, 253. 2. Wbitby, L. E. H. Lancet, 1942, i, 581. 3. Kitchin, D. H. Legal Problems in Medical Practice, London. 4. Macintosh, R. R. and Heyworth, P. S. A. Lancet, 1943, ii, 571.
pulsating nor contains bright red arterial blood. When an experienced anaesthetist gives warning of the danger of handling phials whose labels have become detached by storage, of unnecessarily concentrated solutions or badly sterilised apparatus, it is time to tighten the standards in infusion technique. OPINION
BY
POST
MosT of our readers will now have had from the British Medical Association a copy of the full whitepaper on the National Health Service (provided by the Ministry of Health), an analysis setting out the BMA council’s preliminary views, and a questionary prepared by.the British Institute of Public Opinion. The scientific staff of the institute are to be congratulated on having drafted a document which is as lucid and objective as could well be expected. The white-paper proposals are certainly not easy to translate into questions capable ’ of simple answers, and the attempt has involved the use of questions of a length unusual in opinion surveys ; but we hope that even doctors who normally stand aloof from " medical politics " will give the time and take the pains necessary to send answers-if necessary falling back on the philosophical formula " don’t know." If many questionaries find their way into drawers or wastepaper baskets the survey will lose an important part of its srignificance. Taylor has lately pointed out how misleading the results of postal inquiries may be. NormaJly they are sent only to a representative sample of the people concerned, and since the returns are usually of the order of 30% the sociologist may have no means of knowing what part of his sample has made the decision to return the questionary, and acted on it. But in this case the situation is somewhat different. The questionary is being addressed hot to a sample but to the whole of the medical profession. It is thus in fact an attempt at a census. Errors in the drawing of the initial sample are thus being avoided. To overcome the difficulty of the partial return, a detailed personal record is asked for in the last part of the questionary. The Central Medical War Committee already have all these details in hand for the entire profession, and by comparing the data it .would be possible to weight the results of the returns-to make them valid for sex, age, nature of work, place of practice, and so on. If some members of the profession do npt answer the questions, such weighted results will be more useful than the simple gross totals expressed as percentages. It might still be argued that the inquiry revealed the views of the more intelligent, informed and articulate doctors inside each of the groups studied. The only way to have overcome this difficulty would have’ been to have interviewed a random sample of doctors drawn from the Medical Directory. A skilled interviewer has a refusal-rate with the general public of under 0-5%. With doctors this refusal-rate might perhaps have been higher, but it would nevertheless have been a small factor when contrasted with the large field of error possibly arising from non-return of questionaries. Unfortunately, the distribution of the medical profession in space-from Burma to Spitzbergen-makes the interviewing of a random sample quite impossible ; so the British Institute has been driven to apply the postal method as the only one available. The study of group opinion among experts is not quite Professor Burt,2 in cooperation with the home new. intelligence division of the Ministry of Information, has investigated the opinions of teachers and educationists His questionary was even more on educational reform. formidable than that of the BMA, but he used a very small sample. As we said last week, we welcome the BMA and BIPO experiment ; for it represents a new 1. Taylor, S. Public Administration, 1943, 21, 109. 2. Burt, C. Occupational Psychology, 1943, 17, 157.
409
attempt to make democracy work yearly becoming more complex.
in
a
society which
is
TOO MUCH SUN Air Commodore Morton told the Royal Society of Tropical Medicine and Hygiene on March 16 something of INFECTIONS WITH NON-SPORING ANAEROBES his experiences in the prevention and treatment of heat THE frequency of gas gangrene and tetanus in the effects during five hot seasons in Iraq. Superstitions wounded of the 1914-18 war led to much useful research about sunstroke have been .discarded with spinal pads, on the spore-bearing anaerobes, resulting in new methods but the topee is still useful in really hot parts of the for their cultivation and identification. The present Ill effects from the sun are due simply to overtropics. of a stimulus to the these further war has given study of the tissues and body fluids ; they are essentianaerobic bacteria, but so far little attention has been heating similar to those seen in furnace workers in ally paid to the non-sporing anaerobes. MacLennanhas climates. The least serious result is fainting, temperate caused by a to be described gangrenous myositis, distinguished cardiovascular disturbance but without temporary from clostridial gas gangrene, due apparently to a of the chloride balance. serious. derangement More action between the anaerobic streptococcus and symbiotic exposure leads to heat exhaustion. Collapse, profuse one or other of the aerobic pyogenic cocci, while on another page Forbes and Goligher report a case of genera- perspiration, fall in blood-pressure, nausea, vomiting and severe muscular cramps are associated with a fall in blood lised infection with a pleomorphic anaerobic gramand urinary chlorides. Mouth temperature may be Bacterium In negative bacillus, peacenecrophorum. normal but rectal temperature is often raised to 100° or time these two organisms, the anaerobic streptococcus 101° F. The victims are usually of the lean, anxious and and the necrophorus bacillus, are not infrequently spare type ; many are affected soon after their first associated with severe and characteristic-though, to arrival in hot climates. Treatment is best carried out in the uninitiated puzzlin-infections, and they are likely a temperature of about 75° F. Abundant fluid, with to be responsible for similar infections in war casualties. glucose and sodium chloride, should be given by mouth. In civilian practice generalised infection with these 0.9% sodium chloride must be given intranon-sporing anaerobes is seen most often after difficult If necessary, it is important to keep careful watch on but venously, labour or septic abortion where there are retained the balance between input and output of fluids ; otheras a culture Pelvic medium. products acting peritonitis, wise there is a serious risk of pulmonary oedema. Diuresis or more typically, septic thrombophlebitis, follows, and a rise in urinary chlorides are reliable signs of and from the thrombophlebitis emboli are thrown off into the circulation to be riddled out in the lungs particularly. recovery. Attempts to correct acidosis or alkalosis should not be made in the absence of strict biochemical control. Empyema is a common sequel to these multiple lung The most serious condition is that of heat hyperpyrexia. abscesses. Clinically this type of infection is characThick-necked chronic alcoholics with high blood-pressure a F. remittent to 103°-105° assotemperature terised by are most often affected, usually after they have been ciated with daily rigors, signs of lung involvement, an in the tropics. Besides a fall in urinary several increasing anaemia and a downhill course. Spontaneous chloridesyears there is a failure of heat regulation. The sometimes occurs for no obvious the reason ; recovery coma are infection resists sulphonamide therapy. Anaerobic blood- flushed face, dry burning skin, delirium or 108°-112° F. associated with rectal to temperatures up culture reveals a non-haemolytic streptococcus or a fine If life is to be saved the temperature must be brought or with other alone associated each gram-negative bacillus, down quickly to 102-103° F. by whatever means ’ are or with other bacteria such as diphtheroids, enterococci, at hand. In active service conditions, an iced enema An essentially similar syndrome has or coliform bacilli. been described by French writers2 as a sequel to periton- is indicated, but this interferes with the recording of sillar abscess ; the anaerobic gram-negative bacillus in rectal temperatures. In hospitals, sponging with cold or iced water and the use of fans should be continued these infections is called Bacillus funduliformis but is until the temperature falls. A useful wind-tunnel was These identical with Bact. probably necrophorum. with a shock cradle covered by d blanket. organisms, incidentally, are poorly pathogenic for improvised were hung from the roof, and fans blew a stream Ice-bags laboratory animals, and in this respect differ from the of cold air over the body. Air-conditioning of wards is Bact. necrohoum of calf diphtheria, foot-rot in sheep, a great help to nu-rsing ; 60° F. is the temperature recomand labial necrosis of rabbits. Harris and Brown who recovered the organism from infected caesarean ’ mended for the initial stages, but as soon as the danger from is past the patient should be nursed wounds, therefore suggested the name " pseudo-necro- at 75°hyperpyrexia F. and glucose should be given Fluid with phorus for the human variant. Both the necrophorus by mouth ; intravenoussalt salines are seldom needed unless bacillus and the anaerobic streptococcus, of which there vomiting is persistent-they may do harm by overloadare also several variants,4 are to be found in the healthy a circulation. It is important to be sure that body cavities (mouth, intestine and female genital canal) ing failingare not due to malignant tertian malaria, and symptoms *and infection with one or other of them usually follows be given if any doubt arises. intravenous should quinine some necrosis or devitalisation of local tissue. The Much can be done to prevent casualties from heat effects range of these infections had lately been reviewed by ensuring that newcomers are introduced gradually Meleney and his co-workers.5 Wounds elsewhere in the by to the sun, and by arrangement of working hours so- as body, especially if there is necrotic tissue, may also act to allow as many as possible to spend some of their as a primary focus, and this is a possible explanation of Forbes and Goligher’s case where the infection began at off-duty time in air-conditioned rooms. Men should be encouraged to drink more water " and " eat more salt." the site of a compound fracture of the thigh. Routine anaerobic culture needs to be practised more When the thermometer is really high, extra salt should in bacteriological laboratories so that infections of this be put in the food. To ensure that this is done the medical officer may have to take his courage in one hand and a type shall not be missed. Useful advice is given in the bag of salt in. the other and have it out with the cook. second edition of the Medical Research Council’s memorandum no. 2 on gas gangrene. Brigadier F. A. E. CREW, FRs, has been appointed to the Bruce and John Usher chair of public health in the 1. MacLennan, J. D. Lancet, 1943, i, 584. 2. Lemierre, A. Ibid, 1936, i, 701. University of Edinburgh in succession to Prof. P. S. ’ B
"
"
,
3. Harris, J. W. and Brown, J. D. Bull. Johns Hopk. Hosp. 1927,
40, 203. 4.
Prévot,
A. R. Manuel de Classification et de Détermination des Bactéries Anaérobies, Paris, 1940, p. 27. 5. Sandusky, W. R., Pulaski, E. J., Johnson, B. A., Meleney, F. L. Surg. Gynec. Obstet. 1942, 75, 145.
Lelean who has retired. Dr. Crew has held the Buchanan chair of animal genetics in the university since 1928, but for nearly two years has been working in the medical department at the War Office, where he is director of biological research.