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SEDIMENTATION IN TUBERCULOSIS
174 CASE 2 occurred a week after case 1. A spinster, aged 64, from bruising, superficial abrasions and a simple fracture of the lower end of the left ulna was admitted as an air-raid casualty. She was very shocked, but had had no loss of blood. Her general condition was treated, and during the first 24 hours she received 2 pints of glucose saline and 2 pints of plasma by the intravenous drip method. Ten days later, when her condition was satisfactory, it was proposed to mani. pulate the fracture. Her previous medical history was negative. She had a moderate degree of arteriosclerosis, but no abnormal signs in heart or lungs. The urine was normal. No preoperative injection was given. After the injection of 2 c.cm. of 5% solution of pentothal sodium, at a count of 8, breathing suddenly stopped and the patient was unconscious. The pulse was 120 per minute, regular and of fair volume. The pupils were contracted and the face was pale, but there was no cyanosis. After a minute of artificial respiration the breathing re-started, the pulse dropped to 90 per minute, and a good colour soon returned to the face. She was unconscious and sufficiently relaxed for the fracture to be reduced and put into plaster. She regained consciousness an hour later and her further progress was uneventful. In neither case were there any of the recognised
suffering
contra-indications to barbiturate anaesthesia, and thinkin retrospect I see no way in which a repetition of these incidents might be avoided. W. H. HARRIS. Cardiff.
ing of them
SEDIMENTATION IN
TUBERCULOSIS
SIB,—I do not wish to belittle the value of any serial observations on patients suffering from chronic tuberculosis, but Dr. Day’s article of July 24 may do more harm than good if he convinces your readers that he has found a simple guide to progress intuberculosis. Alas, there are no short cuts to knowledge as to how the complex human organism reacts to a chronic disease process. As I wrote in the current number of the Practitioner:: "... an increased rate of sedimentation in pulmonary tuberculosis can be considered of clinical significance only when it is correlated with all the clinical and radiological data, and with simultaneous determinations of plasma-protein
content (by an accurate chemical method), plasma viscosity, refractive index of the plasma (permitting a rough estimate of the albumin-globulin ratio) and a complete blood-count, including a Schilling or Arneth differentiation of the polymorphonuclear cells. As facilities for such a complete investigation are rarely available in sanatorium-or dispensary practice, the test is of doubtful utility in this condition." Much more accurate hæmatological and biochemical work should be carried out, as a routine, on all sanatorium patients. The value of such findings, in close correlation with the clinical and radiological findings, would be inestimable. In the absence of facilities for such work, the educated senses of a good clinician provide a better guide to progress than laboratory findings ; isolated laboratory findings expressed with the authority of mathematical accuracy may even interfere with clinical judgment.
Finsbury. CETAVLON AND
E. OBERMER. SKIN INFECTIONS
SIR,—The detergent and antiseptic properties of ‘ Cetavlon ’described by Barnes,2 suggested a trial of an EMS hospital in two skin wards occupied by soldiers, many of whom had streptococcal or staphylococcal skin lesions.
this chemical at
The two wash-basins and two baths in each ward formerly cleaned with an abrasive soap ’Bon Ami ’ 1 in 20 carbolic acid swabbed over after cleaning with soap. After cleaning in this manner it was usually
were or with
possible to grow coliforms, proteus, streptococci or staphylococci in cultures from the basins. This was not surprising, for they were likely to be greasy with the
ointments used on patients, and their surfaces were worn and had cracks in the glaze. A 2% cetavlon solution removed dirt and grease rapidly, and was approved by the nursing staff. Subsequent cultures showed the surfaces to be sterile, and the method appears effective for preventing cross-infection. Cetavlon was also found useful for cleansing the skin 1.
Cetyl trimethyl ammonium bromide, Imperial Chemical Industries Ltd. Formerly called ’CTAB.’ 2. Barnes, J. M. Lancet, 1942, i, 531.
of ointments, and for the removal of scabs and crusts from impetiginised areas or where there was widespread dermatitis or eczema. In the initial experiments two patients with generalised boils were washed down with 1% solution daily, and the skin rinsed and dried. One of them had also an area of dermatitis due to strapping. Both cleared in ten days. In such cases cetavlon readily removes dirt and grease and reduces the staphylococcal population of the skin ; the natural bactericidal powers of the skin should then suffice to deal with the infection. A case with severe nummular eczema which had had two relapses (sensitisation to flavine being suspected), a severe chronic infective dermatitis, and cases of impetigo of the face were cleaned once or twice daily with cetavlon and progress was satisfactory. Absence of the trauma involved when oil or soap and water are used must be of importance in the treatment of inflamed and infected skins. There is no doubt that some individuals show intolerance, but the work of Williams et al.3 indicates that the proportion is small. However one of our cases of impetigo of the face developed moderately severe dermatitis after the use of cetavlon twice daily for six days to remove crusts. Two other patients, with generalised impetigo, complained of dryness of the skin, but the application of cetavlon was continued and no dermatitis attributable to its use could be detected at the end of a week. My thanks are due to Sister G. M. Jones and the staff of the ward, to Dr. Bodoana of the LCC pathological department for carrying out the cultures, and to Imperial Chemical Industries Ltd. for supplies. Devonshire Place, W.l.
L. FORMAN.
OF RADIOLOGICAL PRACTICE of the probability that a comprehensive view SIR,—In medical service may be introduced by the Government it is generally felt that the time has come when further steps should be taken to safeguard the interests of medical radiologists in such a service. We therefore invite medical radiologists to a mass meeting to be held on Saturday, Aug. 7, at 11 AM, in the Reid-Knox Hall at 32, Welbeck Street, London. W.1, when all those interested in the future of radiology will have an opportunity of expressing their views. R. E ROBERTS, J. DUNCAN WHITE. FUTURE
COAGULASE-POSITIVE STAPHYLOCOCCI SIR,—Referring to the article on the slide-test by Cadness-Graves et al. (Lancet, June 12, p. 736) it is of interest to note that during a similar investigation in this laboratory the chief source of error was found to be false positive results, given by about 10% of nonpathogenic albits strains, which persisted with serum and seemed to be due to agglutinins. No false negative reactions with Staph. pyogenes were recorded. BirchHirschfeld has shown that this clumping phenomenon’ is due mainly to the prothrombin fraction of the plasma and that no clumping at all occurs with pure fibrinogen solutions. Unfortunately the preparation of a fibrinogen-free prothrombin solution is not a simple operation for a routine bacteriological laboratory, and rather robs the test of its simplicity. The substitution of plasma, however, by a prothrombin-fibrinogen solution greatly improves the specificity of the test and this simply prepared solution is, in many ways, more convenient than plasma. The reaction is remarkably sensitive, but varies with different strains, and its quantitative nature appears to be roughly parallel with the time taken to coagulate plasma. Birch-Hirschfeld has also shown that the agglutination and coagulation activity Thus a seem, to a certain degree, to be independent. high concentration of sodium chloride (above 15%) tends to inhibit agglutination but not coagulation, while coagulation does not occur with high dilutions of prothrombin-fibrinogen solution when agglutination is still obtainable. Fresh young cultures are the most reliable and those grown on blood agar appear to give stronger reactions than those of the same organism on plain agar. The reaction is not affected by the usual 3. Williams, R., Clayton-Cooper, B., Duncan, J. McK. and Miles, E. Ibid, 1943, i, 522.
suffering
contra-indications to barbiturate anaesthesia, and thinkin retrospect I see no way in which a repetition of these incidents might be avoided. W. H. HARRIS. Cardiff.
ing of them
SEDIMENTATION IN
TUBERCULOSIS
SIB,—I do not wish to belittle the value of any serial observations on patients suffering from chronic tuberculosis, but Dr. Day’s article of July 24 may do more harm than good if he convinces your readers that he has found a simple guide to progress intuberculosis. Alas, there are no short cuts to knowledge as to how the complex human organism reacts to a chronic disease process. As I wrote in the current number of the Practitioner:: "... an increased rate of sedimentation in pulmonary tuberculosis can be considered of clinical significance only when it is correlated with all the clinical and radiological data, and with simultaneous determinations of plasma-protein
content (by an accurate chemical method), plasma viscosity, refractive index of the plasma (permitting a rough estimate of the albumin-globulin ratio) and a complete blood-count, including a Schilling or Arneth differentiation of the polymorphonuclear cells. As facilities for such a complete investigation are rarely available in sanatorium-or dispensary practice, the test is of doubtful utility in this condition." Much more accurate hæmatological and biochemical work should be carried out, as a routine, on all sanatorium patients. The value of such findings, in close correlation with the clinical and radiological findings, would be inestimable. In the absence of facilities for such work, the educated senses of a good clinician provide a better guide to progress than laboratory findings ; isolated laboratory findings expressed with the authority of mathematical accuracy may even interfere with clinical judgment.
Finsbury. CETAVLON AND
E. OBERMER. SKIN INFECTIONS
SIR,—The detergent and antiseptic properties of ‘ Cetavlon ’described by Barnes,2 suggested a trial of an EMS hospital in two skin wards occupied by soldiers, many of whom had streptococcal or staphylococcal skin lesions.
this chemical at
The two wash-basins and two baths in each ward formerly cleaned with an abrasive soap ’Bon Ami ’ 1 in 20 carbolic acid swabbed over after cleaning with soap. After cleaning in this manner it was usually
were or with
possible to grow coliforms, proteus, streptococci or staphylococci in cultures from the basins. This was not surprising, for they were likely to be greasy with the
ointments used on patients, and their surfaces were worn and had cracks in the glaze. A 2% cetavlon solution removed dirt and grease rapidly, and was approved by the nursing staff. Subsequent cultures showed the surfaces to be sterile, and the method appears effective for preventing cross-infection. Cetavlon was also found useful for cleansing the skin 1.
Cetyl trimethyl ammonium bromide, Imperial Chemical Industries Ltd. Formerly called ’CTAB.’ 2. Barnes, J. M. Lancet, 1942, i, 531.
of ointments, and for the removal of scabs and crusts from impetiginised areas or where there was widespread dermatitis or eczema. In the initial experiments two patients with generalised boils were washed down with 1% solution daily, and the skin rinsed and dried. One of them had also an area of dermatitis due to strapping. Both cleared in ten days. In such cases cetavlon readily removes dirt and grease and reduces the staphylococcal population of the skin ; the natural bactericidal powers of the skin should then suffice to deal with the infection. A case with severe nummular eczema which had had two relapses (sensitisation to flavine being suspected), a severe chronic infective dermatitis, and cases of impetigo of the face were cleaned once or twice daily with cetavlon and progress was satisfactory. Absence of the trauma involved when oil or soap and water are used must be of importance in the treatment of inflamed and infected skins. There is no doubt that some individuals show intolerance, but the work of Williams et al.3 indicates that the proportion is small. However one of our cases of impetigo of the face developed moderately severe dermatitis after the use of cetavlon twice daily for six days to remove crusts. Two other patients, with generalised impetigo, complained of dryness of the skin, but the application of cetavlon was continued and no dermatitis attributable to its use could be detected at the end of a week. My thanks are due to Sister G. M. Jones and the staff of the ward, to Dr. Bodoana of the LCC pathological department for carrying out the cultures, and to Imperial Chemical Industries Ltd. for supplies. Devonshire Place, W.l.
L. FORMAN.
OF RADIOLOGICAL PRACTICE of the probability that a comprehensive view SIR,—In medical service may be introduced by the Government it is generally felt that the time has come when further steps should be taken to safeguard the interests of medical radiologists in such a service. We therefore invite medical radiologists to a mass meeting to be held on Saturday, Aug. 7, at 11 AM, in the Reid-Knox Hall at 32, Welbeck Street, London. W.1, when all those interested in the future of radiology will have an opportunity of expressing their views. R. E ROBERTS, J. DUNCAN WHITE. FUTURE
COAGULASE-POSITIVE STAPHYLOCOCCI SIR,—Referring to the article on the slide-test by Cadness-Graves et al. (Lancet, June 12, p. 736) it is of interest to note that during a similar investigation in this laboratory the chief source of error was found to be false positive results, given by about 10% of nonpathogenic albits strains, which persisted with serum and seemed to be due to agglutinins. No false negative reactions with Staph. pyogenes were recorded. BirchHirschfeld has shown that this clumping phenomenon’ is due mainly to the prothrombin fraction of the plasma and that no clumping at all occurs with pure fibrinogen solutions. Unfortunately the preparation of a fibrinogen-free prothrombin solution is not a simple operation for a routine bacteriological laboratory, and rather robs the test of its simplicity. The substitution of plasma, however, by a prothrombin-fibrinogen solution greatly improves the specificity of the test and this simply prepared solution is, in many ways, more convenient than plasma. The reaction is remarkably sensitive, but varies with different strains, and its quantitative nature appears to be roughly parallel with the time taken to coagulate plasma. Birch-Hirschfeld has also shown that the agglutination and coagulation activity Thus a seem, to a certain degree, to be independent. high concentration of sodium chloride (above 15%) tends to inhibit agglutination but not coagulation, while coagulation does not occur with high dilutions of prothrombin-fibrinogen solution when agglutination is still obtainable. Fresh young cultures are the most reliable and those grown on blood agar appear to give stronger reactions than those of the same organism on plain agar. The reaction is not affected by the usual 3. Williams, R., Clayton-Cooper, B., Duncan, J. McK. and Miles, E. Ibid, 1943, i, 522.