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PREVENTION OF BURNS AND SCALDS
488
Letters to the Editor CLINICAL PATHOLOGY
SIR,-A recent leading article,1 discussing the hsemato-
logical diseases of infancy, called for more cooperation between the physician who specialises in haematology and the paediatrician. At the time it occurred to me that the phrase " " physician who specialises in haematology was either a needless circumlocution for clinical pathologist, or an attempt to provoke a reaction from the increasing number of pathologists who favour the development of a concept of clinical pathology as an approach to medicine distinct from that of the clinician on the one hand and the academic pathologist on the other. This article resulted in only one cheer-from Dr. A. Piney,2 who applauded the inference that haematology was the province of the specialist physician. Clearly you were not merely indulging in circumlocution, for-you repeated your contention in unmistakable terms in a further leading article on Aug. 6 (p. 243) : The haematologist, on whom these surgeons rely, is not a clinical pathologist : he is a physician, a clinician who is capable of making his own assessment and if necessary a personal interpretation of the haematological data and material... in the light of the clinical picture as a whole." This challenge was taken up by one of our foremost clinical pathologists, Dr. S. C. Dyke (Aug. 13, p. 303). Unfortunately Dr. Dyke took these words from the article-" a clinician who is capable of making his own assessment and if necessary a personal interpretation of the hsematological data and material "-and suggested that this was a perfect definition of a clinical pathologist. No clinical pathologist will mistake Dr. Dyke’s meaning, but as it stands does it not concede the argument ? Is a definition of clinical pathologist to begin " a clinician For this is who ..." or " a pathologist who ..." the whole substance of the debate. So far no attempt has been made to formulate a succinct definition of clinical pathology. Those specialists who make a point of calling themselves clinical pathologists have a fairly clear idea of its content, its method, and its value. " Bringing the laboratory to the bedside " is a picturesque description, , but not very enlightening or convincing to the sceptic or uninitiated. The war and post-war years have seen great expansion in pathological services, exceeding that in any other branch of medicine. This expansion took place even though the number of trained pathologists was quite inadequate. It was impossible to provide each new laboratory centre with expert morbid anatomist, bacteriologist, haematologist, and biochemist, who formed the principal staff of the pathology departments in the teaching and larger municipal-hospital laboratories. At the same time, the demands on laboratory workers "
called the
emphasis : chemotherapy, antibiotics, and epidemiological investigations laboratory-worker more often away from the
laboratory
bench to the ward.
developed
a new
blood-transfusion,
Perhaps without being aware of it, the majority of pathologists in the Emergency Medical Service and the associated Emergency Public Health Laboratory Service found themselves practising clinical pathology, acting as consultants in those diseases where diagnosis and therapy depend largely on laboratory findings, and developing a new technique of cooperation between clinician and laboratory-worker. One manifestation of this new emphasis was the rapid increase in the membership of the Association of Clinical Pathologists. 1. 2.
Lancet, 1949, i, 919. Piney, A. Ibid, p. 1023.
At
present the inadequacy in the supply of trained pathologists is being made good. The pattern of establishments now being designed for pathology departments in the health service is once again a consultant in each of the special departments. This is undoubtedly to the good. But it would be a great loss if these specialists were to abandon entirely the new approach to applied pathology which has received such impetus in recent years. There is perhaps a real danger that once again cerebrospinal fluid, for example, may be investigated in three separate departments, each unaware of the other’s findings and all sublimely unaware of the patient. It is for this reason that a clear definition of clinical pathology is needed-to crystallise an outlook and practice which has done as much as, and perhaps more than, any other to raise the general level of medical practice in this country in recent years. I put forward as a tentative definition : " Clinical pathology is the laboratory analysis of symptoms and signs," and for the sake of completeness would add " and the laboratory control of therapy." Such a definition brings the clinical pathologist straight into the wards and faces him with the needs of the patient. It makes clear that his method is laboratory method, and leaves no room for misconception of him as an amateur physician. Yet his work demands considerable clinical training. An important point is the emphasis on laboratory method. It is difficult for the untrained to appreciate fully that the interpretation of laboratory results is intimately associated with the techniques used to obtain them. And it is the acquisition of these techniques as his primary tools which distinguishes the pathologist from the physician. Herein lies the fallacy of the remarks in your leading articles. If a specialist chooses to practise clinical pathology and yet call himself a physician, he of course may ; but there is no more ground for calling haematology the province of the physician than there is for calling morbid histology the province of the surgeon or bacteriology the province of the medical officer of health. The question is one of orientation. The patient can only gain when the clinical pathologist thinks of oedema in terms of plasma-proteins ; he can only lose if the physician fails to think in terms of malnutrition. Yet both think of cedema. Does this ban laboratory methods to the physician ?‘? By no means. The physician must have some training in clinical pathology. But the physician who habitually looks down the microscope is in grave danger of losing sight of his patient. J. FIELDING. Paddington Hospital, London, W.9. PREVENTION OF BURNS AND SCALDS SiR,-May I let you know how the problems raised by Dr. and Mrs. Colebrook in.their article of July 30 appear to the textile chemist’? It is appalling to read of the loss of life and injuries suffered by young children as a result of their clothes catching fire. That little or nothing has been done to prevent accidents of this type is dismaying, and may be very largely due to widespread ignorance of their frequency. In this respect the article will do good. There is no easy solution to the problem of making’ cotton, wool-cotton mixtures, or viscose rayon fabrics non-inflammable ; if there had been, it would doubtless have been adopted. The application of the relatively large quantities of metallic salts necessary to make
cellulose fabrics non-inflammable is always accompanied by serious disadvantages ; the most obvious of these is that the " handle " of the fabric is badly affected ; it is and no of the most textile materials.
roughened is
one
longer has the kindly ’"feel" which widely appreciated characteristics of
489
Secondly, the fire-proofing of textiles usually depends the application to the fabric of some chemical which, the fabric when heated, will chemically " destroy below its ignition temperature. Phosphates are among the best fire-proofing agents, but when ammonium phosphate is heated ammonia is evolved and phosphoric .
on
"
acid liberated ; this is a very strong acid and chars the fabric well below its ignition temperature. A hot iron that will only slightly scorch an untreated fabric will often blacken the same fabric if it has been fireproofed. Thirdly, and perhaps most important of all, I believe that no known fire-proofing process is fast to washing. After application the fire-proofing agent ’gradually leaches out, and the dangers attending the use of a " fire-proofed material which after repeated washing has lost its proof, are evident. The false sense of security may well make matters worse. There are some fire-retardants on the market ; one of the best, popular in America, is a mixture essentially of 85 parts ammonium sulphamate and 15 parts ammonium phosphate. But I believe that no known agent will keep cotton or winceyette fabric fire-proof after repeated washing ; and all adversely affect the desirable attributes of a textile material. Usually the textile manufacturer is not reluctant to adopt a " functional finish " which serves a useful purpose ; the almost universal application of the crease-resistant finish to spun rayon is an example of this. Manufacturers and finishers have not adopted a fire-proof finish for cotton and winceyette fabrics for the sole reason that no satisfactory process is known. There is, however, another line along which the problem of providing children with flame-proof clothing may be attacked, and that is by the manufacture of fabrics from fibres other than cotton or viscose rayon. Cellulose acetate has for many years been used for fibres, and enormous quantities of cellulose-acetate rayon are made. The raw material is cellulose, usually from cotton linters or wood-pulp ; but the substance has been acetylated during manufacture. The acetylation is a true chemical combination, so there is no possibility of the acetyl content being reduced during washing or dry-cleaning. The chance of a cellulose-acetate fabric being considerably consumed by accidental contact with an electric fire is extremely small ; fabrics made from mixtures of wool and cellulose acetate would be even less dangerous. Cellulose acetate is made in the form of continuous-filament artificial silk," and also in the form of cut staple-i.e., filaments cut into lengths of one or two inches and then spun into a yarn in the same way as cotton. Garments made from cellulose-acetate rayon, or from mixtures of it with wool, have the normal attributes of a good textile material, but are legsinflammable than most. If such fabrics are thrown into a hot fire, they will burn away ; but if ignited only locally the flame will sometimes extinguish itself. It appears, in fact, that the use of celluloseacetate staple-fibre rayon, instead of cotton, would reduce the danger of injury through clothes catching fire. Other possibilities present themselves, but are hardly suitable for immediate adoption. Thus, many of the new fibres, particularly those made from chlorinated vinyl compounds, are fireproof.Pe Ce,’ a heavily chlorinated vinyl-chloride polymer, was used by the Germans for fire-resistant clothing for their flying personnel.Saran ’ and ’Velon,’ which are essentially polyvinylidene chloride, are fire-proof ; but these fibres are moisture-resistant, they will not absorb perspiration, and they cannot be ironed normally ; they are usually considered unsuitable for indoor wear, and particularly for underwear ; at present they are quite unsuitable for children’s wear ; and it is doubtful if they are obtainable, at least in the United Kingdom, in large quantities. In "
"
future it may well be that wool will be diluted (for cheapness) not with cotton but with regenerated protein fibres, which will be much less inflammable than cotton. AlreadyVicara ’ (made from maize protein) is obtainable in America, andArdil’ (made from ground-nuts) is being made on a pilot-plant scale in Scotland. But these are for the future-they offer no immediate solution to the problem of providing large quantities of
non-inflammable material. ’Nylon,’ as your contributors note, is useful ;
and,
when large quantities become available in staple form at a low price, will undoubtedly be used for wool mixtures. For the present, the substitution of cellulose acetate for cotton and viscose rayon appears to offer a reduction of the fire risk. R. W. MONCRIEFF. Harrogate. NATIONAL COAL BOARD
SIR,-I read with interest the article
on the Mines Medical Service in your Students’ Number (Aug. 27). The last paragraph, which purports to describe the responsibilities and achievements of the National Coal Board in the field of health, does less than justice to the considerable developments which the board has made since Jan. 1, 1947. As the article says, the board has a statutory duty " to secure the health " of the people it employs. To this end the Board decided, in 1947, to establish a medical service for the industry along the lines of the best practice in other industries. It was to provide pre-entry and other medical examinations first, and on occasion further treatment of accidents, the first treatment of illness arising at work, consultation in certain cases, advice on environmental conditions, supervision of hygiene and working conditions generally on
the surface and underground, and so on. The first seeds of a service had been sown by the Ministry of Fuel and Power in their medical treatment centre scheme, but when the National Coal Board took over the industry no medical treatment centres had yet been completed, and the industry employed only three full-time doctors, a number of part-time doctors, and 22 State-registered nurses. The National Coal Board by now employs 25 full-time medical officers, 66 State-registered nurses, and a considerable number of part-time doctors. Fifteen medical centres have been completed, and at fifty-one collieries existing buildings have been adapted to provide accommodation for this service. But for the request of the Prime Minister in June, 1949, when he set up the Dale Committee, that industries should withhold any major developments of their medical services, much greater developments would by now have taken place. The scientific department of the National Coal Board is contributing to research on medical and other human problems in the industry. The rehabilitation centres and other health activities of the Miners’ Welfare Commission are now coordinated with the National
Coal Board. Whilst acknowledging the very valuable work the Mines Medical Service of the Ministry of Fuel and Power has carried out in the past and continues to carry out, your article hardly makes clear the fundamental difference in responsibility between this service and that of the National Coal Board. The Ministry of Fuel and Power medical officers are primarily concerned with the supervision of the industry with respect to the various statutory requirements on health and advising the Minister on various professional matters. The responsibility for executive action in securing the health of persons employed is that of the National Coal Board, and this responsibility the Board ’
has
fully accepted.
National Coal Board, London, S.W.1.
ERNEST H. CAPEL Chief Medical Officer.
Letters to the Editor CLINICAL PATHOLOGY
SIR,-A recent leading article,1 discussing the hsemato-
logical diseases of infancy, called for more cooperation between the physician who specialises in haematology and the paediatrician. At the time it occurred to me that the phrase " " physician who specialises in haematology was either a needless circumlocution for clinical pathologist, or an attempt to provoke a reaction from the increasing number of pathologists who favour the development of a concept of clinical pathology as an approach to medicine distinct from that of the clinician on the one hand and the academic pathologist on the other. This article resulted in only one cheer-from Dr. A. Piney,2 who applauded the inference that haematology was the province of the specialist physician. Clearly you were not merely indulging in circumlocution, for-you repeated your contention in unmistakable terms in a further leading article on Aug. 6 (p. 243) : The haematologist, on whom these surgeons rely, is not a clinical pathologist : he is a physician, a clinician who is capable of making his own assessment and if necessary a personal interpretation of the haematological data and material... in the light of the clinical picture as a whole." This challenge was taken up by one of our foremost clinical pathologists, Dr. S. C. Dyke (Aug. 13, p. 303). Unfortunately Dr. Dyke took these words from the article-" a clinician who is capable of making his own assessment and if necessary a personal interpretation of the hsematological data and material "-and suggested that this was a perfect definition of a clinical pathologist. No clinical pathologist will mistake Dr. Dyke’s meaning, but as it stands does it not concede the argument ? Is a definition of clinical pathologist to begin " a clinician For this is who ..." or " a pathologist who ..." the whole substance of the debate. So far no attempt has been made to formulate a succinct definition of clinical pathology. Those specialists who make a point of calling themselves clinical pathologists have a fairly clear idea of its content, its method, and its value. " Bringing the laboratory to the bedside " is a picturesque description, , but not very enlightening or convincing to the sceptic or uninitiated. The war and post-war years have seen great expansion in pathological services, exceeding that in any other branch of medicine. This expansion took place even though the number of trained pathologists was quite inadequate. It was impossible to provide each new laboratory centre with expert morbid anatomist, bacteriologist, haematologist, and biochemist, who formed the principal staff of the pathology departments in the teaching and larger municipal-hospital laboratories. At the same time, the demands on laboratory workers "
called the
emphasis : chemotherapy, antibiotics, and epidemiological investigations laboratory-worker more often away from the
laboratory
bench to the ward.
developed
a new
blood-transfusion,
Perhaps without being aware of it, the majority of pathologists in the Emergency Medical Service and the associated Emergency Public Health Laboratory Service found themselves practising clinical pathology, acting as consultants in those diseases where diagnosis and therapy depend largely on laboratory findings, and developing a new technique of cooperation between clinician and laboratory-worker. One manifestation of this new emphasis was the rapid increase in the membership of the Association of Clinical Pathologists. 1. 2.
Lancet, 1949, i, 919. Piney, A. Ibid, p. 1023.
At
present the inadequacy in the supply of trained pathologists is being made good. The pattern of establishments now being designed for pathology departments in the health service is once again a consultant in each of the special departments. This is undoubtedly to the good. But it would be a great loss if these specialists were to abandon entirely the new approach to applied pathology which has received such impetus in recent years. There is perhaps a real danger that once again cerebrospinal fluid, for example, may be investigated in three separate departments, each unaware of the other’s findings and all sublimely unaware of the patient. It is for this reason that a clear definition of clinical pathology is needed-to crystallise an outlook and practice which has done as much as, and perhaps more than, any other to raise the general level of medical practice in this country in recent years. I put forward as a tentative definition : " Clinical pathology is the laboratory analysis of symptoms and signs," and for the sake of completeness would add " and the laboratory control of therapy." Such a definition brings the clinical pathologist straight into the wards and faces him with the needs of the patient. It makes clear that his method is laboratory method, and leaves no room for misconception of him as an amateur physician. Yet his work demands considerable clinical training. An important point is the emphasis on laboratory method. It is difficult for the untrained to appreciate fully that the interpretation of laboratory results is intimately associated with the techniques used to obtain them. And it is the acquisition of these techniques as his primary tools which distinguishes the pathologist from the physician. Herein lies the fallacy of the remarks in your leading articles. If a specialist chooses to practise clinical pathology and yet call himself a physician, he of course may ; but there is no more ground for calling haematology the province of the physician than there is for calling morbid histology the province of the surgeon or bacteriology the province of the medical officer of health. The question is one of orientation. The patient can only gain when the clinical pathologist thinks of oedema in terms of plasma-proteins ; he can only lose if the physician fails to think in terms of malnutrition. Yet both think of cedema. Does this ban laboratory methods to the physician ?‘? By no means. The physician must have some training in clinical pathology. But the physician who habitually looks down the microscope is in grave danger of losing sight of his patient. J. FIELDING. Paddington Hospital, London, W.9. PREVENTION OF BURNS AND SCALDS SiR,-May I let you know how the problems raised by Dr. and Mrs. Colebrook in.their article of July 30 appear to the textile chemist’? It is appalling to read of the loss of life and injuries suffered by young children as a result of their clothes catching fire. That little or nothing has been done to prevent accidents of this type is dismaying, and may be very largely due to widespread ignorance of their frequency. In this respect the article will do good. There is no easy solution to the problem of making’ cotton, wool-cotton mixtures, or viscose rayon fabrics non-inflammable ; if there had been, it would doubtless have been adopted. The application of the relatively large quantities of metallic salts necessary to make
cellulose fabrics non-inflammable is always accompanied by serious disadvantages ; the most obvious of these is that the " handle " of the fabric is badly affected ; it is and no of the most textile materials.
roughened is
one
longer has the kindly ’"feel" which widely appreciated characteristics of
489
Secondly, the fire-proofing of textiles usually depends the application to the fabric of some chemical which, the fabric when heated, will chemically " destroy below its ignition temperature. Phosphates are among the best fire-proofing agents, but when ammonium phosphate is heated ammonia is evolved and phosphoric .
on
"
acid liberated ; this is a very strong acid and chars the fabric well below its ignition temperature. A hot iron that will only slightly scorch an untreated fabric will often blacken the same fabric if it has been fireproofed. Thirdly, and perhaps most important of all, I believe that no known fire-proofing process is fast to washing. After application the fire-proofing agent ’gradually leaches out, and the dangers attending the use of a " fire-proofed material which after repeated washing has lost its proof, are evident. The false sense of security may well make matters worse. There are some fire-retardants on the market ; one of the best, popular in America, is a mixture essentially of 85 parts ammonium sulphamate and 15 parts ammonium phosphate. But I believe that no known agent will keep cotton or winceyette fabric fire-proof after repeated washing ; and all adversely affect the desirable attributes of a textile material. Usually the textile manufacturer is not reluctant to adopt a " functional finish " which serves a useful purpose ; the almost universal application of the crease-resistant finish to spun rayon is an example of this. Manufacturers and finishers have not adopted a fire-proof finish for cotton and winceyette fabrics for the sole reason that no satisfactory process is known. There is, however, another line along which the problem of providing children with flame-proof clothing may be attacked, and that is by the manufacture of fabrics from fibres other than cotton or viscose rayon. Cellulose acetate has for many years been used for fibres, and enormous quantities of cellulose-acetate rayon are made. The raw material is cellulose, usually from cotton linters or wood-pulp ; but the substance has been acetylated during manufacture. The acetylation is a true chemical combination, so there is no possibility of the acetyl content being reduced during washing or dry-cleaning. The chance of a cellulose-acetate fabric being considerably consumed by accidental contact with an electric fire is extremely small ; fabrics made from mixtures of wool and cellulose acetate would be even less dangerous. Cellulose acetate is made in the form of continuous-filament artificial silk," and also in the form of cut staple-i.e., filaments cut into lengths of one or two inches and then spun into a yarn in the same way as cotton. Garments made from cellulose-acetate rayon, or from mixtures of it with wool, have the normal attributes of a good textile material, but are legsinflammable than most. If such fabrics are thrown into a hot fire, they will burn away ; but if ignited only locally the flame will sometimes extinguish itself. It appears, in fact, that the use of celluloseacetate staple-fibre rayon, instead of cotton, would reduce the danger of injury through clothes catching fire. Other possibilities present themselves, but are hardly suitable for immediate adoption. Thus, many of the new fibres, particularly those made from chlorinated vinyl compounds, are fireproof.Pe Ce,’ a heavily chlorinated vinyl-chloride polymer, was used by the Germans for fire-resistant clothing for their flying personnel.Saran ’ and ’Velon,’ which are essentially polyvinylidene chloride, are fire-proof ; but these fibres are moisture-resistant, they will not absorb perspiration, and they cannot be ironed normally ; they are usually considered unsuitable for indoor wear, and particularly for underwear ; at present they are quite unsuitable for children’s wear ; and it is doubtful if they are obtainable, at least in the United Kingdom, in large quantities. In "
"
future it may well be that wool will be diluted (for cheapness) not with cotton but with regenerated protein fibres, which will be much less inflammable than cotton. AlreadyVicara ’ (made from maize protein) is obtainable in America, andArdil’ (made from ground-nuts) is being made on a pilot-plant scale in Scotland. But these are for the future-they offer no immediate solution to the problem of providing large quantities of
non-inflammable material. ’Nylon,’ as your contributors note, is useful ;
and,
when large quantities become available in staple form at a low price, will undoubtedly be used for wool mixtures. For the present, the substitution of cellulose acetate for cotton and viscose rayon appears to offer a reduction of the fire risk. R. W. MONCRIEFF. Harrogate. NATIONAL COAL BOARD
SIR,-I read with interest the article
on the Mines Medical Service in your Students’ Number (Aug. 27). The last paragraph, which purports to describe the responsibilities and achievements of the National Coal Board in the field of health, does less than justice to the considerable developments which the board has made since Jan. 1, 1947. As the article says, the board has a statutory duty " to secure the health " of the people it employs. To this end the Board decided, in 1947, to establish a medical service for the industry along the lines of the best practice in other industries. It was to provide pre-entry and other medical examinations first, and on occasion further treatment of accidents, the first treatment of illness arising at work, consultation in certain cases, advice on environmental conditions, supervision of hygiene and working conditions generally on
the surface and underground, and so on. The first seeds of a service had been sown by the Ministry of Fuel and Power in their medical treatment centre scheme, but when the National Coal Board took over the industry no medical treatment centres had yet been completed, and the industry employed only three full-time doctors, a number of part-time doctors, and 22 State-registered nurses. The National Coal Board by now employs 25 full-time medical officers, 66 State-registered nurses, and a considerable number of part-time doctors. Fifteen medical centres have been completed, and at fifty-one collieries existing buildings have been adapted to provide accommodation for this service. But for the request of the Prime Minister in June, 1949, when he set up the Dale Committee, that industries should withhold any major developments of their medical services, much greater developments would by now have taken place. The scientific department of the National Coal Board is contributing to research on medical and other human problems in the industry. The rehabilitation centres and other health activities of the Miners’ Welfare Commission are now coordinated with the National
Coal Board. Whilst acknowledging the very valuable work the Mines Medical Service of the Ministry of Fuel and Power has carried out in the past and continues to carry out, your article hardly makes clear the fundamental difference in responsibility between this service and that of the National Coal Board. The Ministry of Fuel and Power medical officers are primarily concerned with the supervision of the industry with respect to the various statutory requirements on health and advising the Minister on various professional matters. The responsibility for executive action in securing the health of persons employed is that of the National Coal Board, and this responsibility the Board ’
has
fully accepted.
National Coal Board, London, S.W.1.
ERNEST H. CAPEL Chief Medical Officer.