SERUM-AMYLASE

375 THE FORGOTTEN SWAB SiR,-In connection with your excellent leading article last week, I am writing to ask if you know of any hospitals in this country that are fortunate enough to be able to obtain a type of swab, manufactured in the U.S.A., that has a fine metal thread incorporated in the material. We managed to obtain samples of these swabs from Illinois and New Jersey, and have tried them in the pathological department, where they have been found to be satisfactorily visible with X rays. I have made many inquiries among manufacturers in this country, and am told that the supplies of gauze do not warrant the production of these swabs in this country. We have approached the Ministry of Health and have been told that they anticipate difficulty in getting any firm to adopt the manufacture, as it would not be an economical proposition for the weavers. If these swabs could be obtained they would be an additional protection for the patient, but they would not of course exonerate the theatre team from taking the usual careful precautions enumerated in your article. It seems a very great pity that the manufacturers in this country cannot divert some of the existing gauze already made into theatre swabs to make the particular type described above. It is quite obvious that by making these, the number of swabs and the amount of cotton gauze would in no way be increased. This problem is of such vital importance to the patient and also to the surgeons and the theatre staffs that I would be most grateful for any help you could give us. CLARE ALEXANDER The London Hospital, E.1.

Matron.

disadvantage of the quadriceps action on the knee is less in the extended than in the flexed position, irrespective of whether or not the tibia is fixed or movable ; and the reason is that the patella in the extended knee is riding on the anterior surface of the femur and is holding the patellar tendon further from the axis of rotation. As regards the cases to which Fowler and Mitchell refer, it does not appear justifiable to go further than to say that the whole extensor apparatus was subject to a sudden strain and rupture took place at the weakest point in each case. Rationalisation is a good thing in so far as it clarifies and aids understanding, but it must be accurate and should not be taken too far. H. A. HAXTON. Manchester. SERUM-AMYLASE

SiR,-The annotation on the significance of raised serum-amylase readings in your issue of Feb. 11, conveys the impression that Musgrove,! of the Mayo Clinic, is the first to describe its occurrence in free perforations of gastroduodenal lesions. I should like to point out that Hughes2 read a paper on this interesting side-effect to the Royal Society of Medicine in 1942, the only differenc in his approach being in the use of the urine as the medium of study. My own paper on the serumamylase and serum-lipase changes in a series of 30 cases of perforated peptic ulcer was published in this journal last year.3 To Musgrove, however, must go the credit for the supposition that the alterations in the blood-levels are due to absorption of the pancreaticoduodenal juices lying free in the peritoneal cavity. In

the other reference in your annotation, Pemberton, TREATMENT OF WOUNDED IN MALAYA and Bollman,4’also of the Mayo Clinic, are SiR,—Dr. Binning, in his letter which appeared in Grindlay, as having confirmed the absorptive theory by quoted your issue of Dec. 31, expressed concern lest the lessons experiments carried out on dogs. of medical tactics learnt in the war of 1939-45 might I subscribed to the view that peritonitis leading to be in danger of being forgotten. In particular he feared some derangement of pancreatic function might be the that early surgical treatment -was not being afforded explanation ; and it is to be noted that the three cases to those who were wounded in the operations against with abnormal amylase values cited by Musgrove had the bandits in Malaya. generalised peritonitis. It so happens, however, that I I should like to reassure Dr. Binning that the valuable too gave serious consideration to, and carried out some medical lessons of the last war are not forgotten, and the to substantiate, the absorptive theory. experience gained in the campaigns in Burma forms the experiments Whether or not it was due to the existence of incalculable basis on which our present medical tactical doctrine variables one cannot say, but the results turned out to in Malaya is founded. be meaningless and were therefore discarded. Moreover, N. CANTLIE I considered that the inclusion of doubtful data would Director-General Army The War Office, London, S.W.1. Medical Services. only detract from the point of my article, which was in the nature of a warning to surgeons who are apt to RUPTURE OF EXTENSOR TENDONS OF THE KNEE place too much reliance on a biochemical diagnosis. Now that this problem is beginning to arouse some SIR,-It is interesting to observe how frequently the this work may be worth publishing even if principles of mechanics are ill understood or wrongly attention, to show how difficult is the clinical approach to it. only in medical literature. One recent example is applied This I hope to do in the near future. in the explanation proffered by Mr. Fowler and Mr. HENRY WAPSHAW. Western Infirmary, Glasgow. Mitchell (Feb. 4) of the forces underlying rupture of the extensor tendon of the knee-joint. SiR,—We were most interested in your annotation They reproduce the old story that the factor which of Feb. 11, and felt that the following case was of alters the mechanical disadvantage of the extensor tendon interest in this connection : is a shifting fulcrum on the patella. But by far the most A man, 32, was admitted to this hospital, under the important factor, as I have shown,1 is the distance of care of Mr.aged J. H. Conyers, on Feb. 12, 1949, with violent the patellar tendon from the axis of rotation of the epigastric pain of 11/2 hours’ duration. The pain was constant, knee-joint. In addition, they make the curious claim went through to the back, and made him sit up and lean that the distribution of the forces is reversed according forward to obtain partial relief. One hour after the onset as the tibia or the femur is free to move. They deduce of the pain he began to vomit repeatedly ; the vomitus consisted of clear fluid and a little sediment. For a few weeks that when the foot is off the ground the force of the before admission he had had a constant ache in the right quadriceps acts to much better advantage in the extended iliac fossa. than in the flexed position of the knee, but that if the On examination he was in obvious pain and slightly shocked. tibia is fixed the reverse is the case. This is the sort of He vomited every few minutes and sat upright with the hands argument that has been advanced in many reports on 1. Musgrove, J. E. Proc. Mayo Clin. 1950, 25, 8. the action of muscles, and it is at variance with the 2. Hughes, E. B. Proc. R. Soc. Med. 1942, 35, 339. principles of mechanics. In actual fact the mechanical 3. Pemberton, A. H., Grindlay, J. H., Bollman, J. L. Proc. Mayo -

1. Surg.

Gynec. Obstet. 1945, 80, 389.

4.

Clin. 1950, 25, 5. Wapshaw, H. Lancet, 1949, ii, 414.

376

clasped across the abdomen. Movement appeared to cause pain and there was no sign of jaundice. The blood-pressure was 134/64 mm. Hg, the pulse-rate 60 per min., and the temperature 97°F. The abdomen moved well but there

THE CHEST PHYSICIAN

no

tenderness over the whole of the upper abdomen; peristaltic sounds were absent. X-ray examination of the abdomen showed no evidence of free gas in the peritoneal was

cavity. A diagnosis of acute pancreatitis was made, and this was strengthened by the finding, eight hours after the onset of the pain, of a urinary diastatic index of over 200 units. This test was carried out with fresh solution and adequate controls. Conservative treatment was instituted and carried on until Feb. 17, when recurrence of vomiting with a rising pulse-rate and abdominal distension led to the decision to perform laparotomy. Free fluid was present in the abdominal cavity, and 2 ft. of the terminal ileum were found to be the site of regional ileitis. Resection of the affected gut was carried out and the patient made a good recovery. Histological examination of the excised intestine confirmed the diagnosis of Crohn’s disease.

It is

to speculate on the cause of the high diastatic index in this case. It is known that urinary after total removal of the pancreas, the blood and urine amylase levels soon return to normal and that most of the dietary carbohydrate can be digested in such circumstanees.1 We feel that it is possible that the cells of the ileum may contain amylase, which is liberated as a result of the hypersemia due to inflammatory lesions, and thus cause elevation of blood and urine diastase levels in cases such as the one we have described. We should be interested to know if any of your readers have had a similar experience with inflammatory conditions of the small intestine.

interesting

We wish to thank Mr. J. H. report this case.

for

Conyers

permission

to

P. R. R. CLARKE Surgical Registrar.

J. H. BLACKBURN County Hospital, York.

Biochemist.

oiB,—in the letter ot ±eb. 11irom JL)r. Liddos Santos, which records death following instillation of a solution of cocaine into the urethra, no mention is made of possible methods of treatment. In an accident of this sort it would, I think, be worth trying the intravenous exhibition of a soluble barbiturate to control convulsions caused by the local anaesthetic. --

-

HUGH DUNLOP.

EFFECT OF DEOXYCORTONE ACETATE AND ASCORBIC ACID ON CIRCULATING EOSINOPHILS AND LYMPHOCYTES

SiR,—In view of the recent correspondence on the use of the above drugs in rheumatoid arthritis, we investigated the changes in peripheral eosinophils and lymphocytes in four patients in the fasting state over periods of 51/2 hours ; two patients were suffering from rheumatoid arthritis, and two had a peripheral eosinophilia. Peripheral-blood examinations were made following the injection of deoxycortone acetate and ascorbic acid in the dosage recommended by Lewin and vVassén 2 ; and as a control, these were repeated a few days later under fasting conditions over a similar 51! 2-hour period not preceded by any injection. In no case did the drugs have a significant effect on the peripheral eosinophil or lymphocyte level. These findings would seem to be consistent with Le Vay and Loxton’s3 view that these drugs act, not through the production of ’Cortisone,’ but by a peripheral mechanism. E. K. BLACKBURN J. B. BURKE. Sheffield. Everett, M. H. Medical Biochemistry. New York, 2. Lewin, E., Wassén, E. Lancet, 1949, ii. 993. 3. Le Vay, D., Loxton, G. E. Ibid, Feb. 4, p. 209.

1.

"

course to adopt was for the Tb. Officers to part-time contracts : (a) with the Regional Hospital* Board, and (b) with the Local Authority. For this purpose, where the two part-time contracts together were intended to amount to full-time employment it was necessary for the Regional Hospital Board and the Local Authority to agree as to the proportion of the services of the Officer which each employing body required. As Regional Hospital Boards had no power to employ staff to carry out L.H.A. duties, it was not a proper arrangement for the Regional Hospital

the proper have separate

Board to enter into a full-time contract with the Officer under which he would be paid by the Regional Hospital Board the full-time salary at the rate specified in document enclosed with R.H.B. (49) 85 and for the Local Authority to pay to the Regional Hospital Board an amount for the time given by the Officer to the Local Authority service calculated at the lower rate of salary at present payable by the Local A uthorities to such Oljicer8. If the combi4ed duties of the Tuberculosis Officer add up to full-time employment, the Officer was not entitled to the weighting factor applicable to part-time employment. The weighting factor would only apply where the combined duties amounted to part-time

employment only." The following resolutions have been accepted by the tuberculosis group committee of the British Medical Association and by the Central Consultants’ and

Specialists’ Committee :

1. That a practitioner engaged predominantly in work for regional hospital board and also giving part of his time to work for a local authority should be employed under one’ contract by the authority in whose duties he is predominantly engaged. The authority for which the smaller proportion of work is done should reimburse the employing authority and

a

°

not the individual officer.

THE WRONG DRUG

London, W.I.

SIR,-Chest physicians throughout the country share the concern expressed by Dr. Toussaint in your issue of Feb. 11. The Ministrv’s attitude was made clear at a meeting of treasurers of regional hospital boards held at the Ministry of Health on Nov. 2, 1949. Boards were advised that

1946;

p. 162.

Where the rate of repayment is

higher than that received by the officer under his employing authority, a corresponding addition should be made to his salary. 2. That work carried out by a chest physician on behalf of a local authority is consultant and advisory in character and is indivisible from his clinical work. The physician is able to do this work only by virtue of his skill and experience. Such work should be remunerated at a rate not less than the physician’s appropriate rate according to the terms and conditions of service of hospital medical staff. 3. That practitioners in the specialty of chest disease should have the same freedom of choice between full-time and part-time employment as practitioners in other specialties and that all superannuation rights should be safeguarded where a practitioner excercises the choice to transfer from full-time to part-time duties. 4. That it is contrary to the terms of service for a regional board to offer a whole-time contract for part-time duties, and that the terms of service do not give the regional board power to stipulate or determine the manner in which a parttime officer shall spend that part of his time not governed by his contract with the board.

It is clear that the employment of chest physicians is governed by the terms and conditions for hospital medical and dental staff and that the Ministry cannot legally depart from those terms and conditions except, by prior mutual agreement or’through the operation of Whitley machinery. Whether " Tb. Officers " still exist, or what are their conditions of service I do not know. Regional hospital boards must obey the Ministry’s orders and will offer dual contracts. I suggest that chest physicians should regard the above resolutions as the only basis for negotiation. Two points in Dr. Toussaint’s letter call for further comment. My legal adviser tells me that the interim contracts now being offered, though unstamped, unwit-