SPINAL INJURIES

362 At lower speeds they will more readily follow the tortuous paths of the neighbouring fluid particles. Bearing this in mind, we suggest that the flow at both the velocities illustrated was turbulent. This raises a second question : are we now to suppose that the flow in the coronary arteries is always turbulent ? For reasons explained below, we consider this to be highly unlikely. The existence of laminar or turbulent flow depends largely on the value of Reynolds number: if this is less than about 2000, flow is invariably laminar. There may be a slight local disturbance at an obstruction or branching, but this will be rapidly and completely damped out. Even at the maximum flow likely to occur in a coronary artery (about 500 ml. per minute) the Reynolds number is only 500-well below the critical value for turbulence. The disparity between this prediction and the observations Dr. Osborn on the coronary model requires explanation. nor nature of the dimensions of model the neither the specifies the fluid and the flow-rates used. We have no knowledge also of the method used to diminish the flow-rate. Without these data we would clearly be unwise to offer an explanation of his unexpected results. We are, however, of the opinion that the experiment should be re-examined to verify the existence of dynamical similarity between the model and living conditions before conclusions are drawn from it. Departments of Fluid Mechanics JEAN M. DRABBLE and Surgery, LESLIE J. TEMPLE. University of Liverpool.

CLINICAL RESEARCH thoroughly endorse Dr. Purdon Martin’s statement (July 27) concerning the lack of interest shown on the question of small grants by the big battalions. The Trust which I represent has been able to do a very little to help by grants-in-aid of up to E400 per annum for some of these projects. But many others have had to be passed over (a) because of the Trust’s lack of capital reserves, and (b) because in some cases they do not fulfil all the requirements of the Trust. If some central contact agency such as Dr. Purdon Martin mentions could be established, we should be only too happy to cooperate with them by passing on for their consideration applications received by us which we are unable to assist. There are very many such applications, and I feel that such an agency would be performing a real service.

SIR,-Ican

Lawson Tait Memorial Trust, c/o Midland Bank Ltd., 22, Victoria Street, London, S.W.1.

WILFRED RISDON Secretary.

TRAINING FOR FAMILY PRACTICE

SIR,-The organisation of in-service training for the general practitioner requires much thought on his future relation to the local hospital. The problem is not the same in all parts of the country : in rural areas or in the smaller towns with only one or two hospitals the needs are different from those in large towns and particularly in the conurbations. It is doubtful, for example, whether there is any place for the general-practitioner cottage hospital in the centre of a large town. The expense of laboratory and radiological equipment and the scarcity of nursing and other ancilliary staff (if for no other reasons) make district hospitals essential. In more sparsely populated areas, distance warrants the retention of the small hospital in which the general practitioner may have charge of beds. On the other hand, the hospital is the obvious choice as the focal point of all medical matters in the district. Therefore, the general practitioner has to be found a place in the hospital. At present he goes to the hospital for refresher courses, for occasional rounds, and to act as a clinical assistant in the outpatient department. Is this enough ? You, Sir, have indicated (Aug. 3) that it is not, and I agree with you.

I can see only a very limited need (if any) for generalpractitioner beds in urban hospitals. We have enough to do for our patients outside the hospital-and our lists are increasing. Also I am not convinced that there is any place for the established general practitioner as a clinical (or " medical ") assistant.in the general medical or surgical outpatient departments. As training posts these appointments fulfil a need. But it has always seemed illogical-and uneconomical-that one general practitioner should see another general practitioner’s patients and offer advice. The special departments, such as venereology, dermatology, and ear, nose, and throat, are exceptions; but as a general rule patients should see a specialist for advice and then be referred back to their own practitioner as speedily as possible. What, then, is the place of the general practitioner in the

district hospital of the future ?Isuggest that he should become a full member of the hospital medical staff, which would entitle him to at least three things:

Open access to the radiology and pathology departments. Open access to his own patients in the wards.-He would be expected to make notes about his patients in the hospital records. Time does not always permit the general practitioner and consultant to meet on ward rounds; consultation by note is the next best thing. The general practitioner should, however, attend some ward rounds and clinicopathological conferences. 3. Open access to the common-room.-Here the general practitioner and consultant can discuss difficult cases. A large proportion of G.P. referrals to outpatients are routine, and a 1. 2.

"

consultation " in the true sense is unnecessary, but there are few cases where personal contact between G.P. and specialist would undoubtedly benefit the patient. The presence of the G.P. in a busy outpatient clinic (I have tried it) is impracticable. Furthermore, by meeting his consultant colleagues in the common-room the G.P. would lose his feeling of isolation. a

Lastly, departments of general practice, staffed by general practitioners, should be created in the teaching hospitals. STUART CARNE.

SIR,-May

I

SPINAL

INJURIES

comment

belatedly

on

your

leading

article1 on the management of acute spinal injuries ? It is disturbing that confusion still exists on this subject, and that, despite the fundamental work of Guttmann and Munro, it is still not generally appreciated that the correct management of a fracture-dislocation of the spine with injury to the spinal cord may be entirely different when the skeletal injury is not complicated by injury to the cord. Munro2 has demonstrated very clearly the confusion which arises when attempts are made to draw general conclusions from mixed series of skeletal injuries-some with and some without cord injuries-and that, in patients with spinal cord injuries, early operation is usually unnecessary and is dangerous. It is in the light of these observations that the work of Holdsworth’g and Beatson 4 on the classification and treatment of skeletal injuries should be judged. In a patient with a spinal-cord lesion, the skeletal injury can only be treated in the context of the predominating cord lesion.. For this reason I disagree, as Guttmann5 has done, with your proposal that early spinal surgery, even if performed under the guise of stabilisatior., should precede the patient’s transfer to a spinal injuries centre. Experience in this centre, which serves an area about the size of the United Kingdom, is that most patients who sustain spinal-cord injuries have no major associated injuries, and are best transported as soon as possible after the accident. In the past four years 269 new patients have been admitted to this centre. Of these, about 40% were admitted within the first twelve hours, and 70% within the 1. 2. 3. 4. 5.

Lancet, 1963, i, 1088. Munro, D. New Engl. J. Med. 1961, 264, 573. Holdsworth, F W. J. Bone Jt Surg. 1963, 45B, 6. Beatson, T. R. ibid. p. 21. Guttman, L. Lancet, 1963, i, 1216.

363 first twenty-four hours. Very few of these patients had other injuries severe enough to justify anything other than resuscitative treatment elsewhere. A comprehensive spinal-injuries centre is ideally part of an active general hospital, and any associated injuries can receive specialised treatment.at the same time as the patient is receiving the treatment for his spinal injury.

showing sarcoid microscopic features may give a false sense of security, and does not rule out the possibility of malignant disease in the lung. On the other hand, the finding of malignancy only in a scalene-node biopsy specimen does not exclude

Finally, I am convinced that the risks to life of a wellplanned journey by air or road ambulance are less than the risks to an incompletely damaged spinal cord from examination and treatment in a hospital where the staff are

THE ADVANCE OF THE VENEREAL DISEASES

unfamiliar with the complexities of the necessary medical and nnrsinc care. Spinal Injuries Centre, Austin Hospital, Heidelberg, Victoria, Australia.

D.

J. E. CHESHIRE.

FOAMING CURE

SIR,-Not uncommonly during perfusion with the Melrose stainless-steel oxygenator the blood foams and spills out. Masses of minute air-bubbles generated in this way can overwhelm the arterial filter, generally with lethal results. This happened in 3 of my cases in a series of 32 perfusions; detection of the causes was difficult. Eventually it was found that spill-out, as distinct from foaming, was due to positioning the first (drive) section of the oxygenator incorrectly. This must be fitted with the plate groove advanced rotationally by one bolt hole in relation to the next section when this contains

large area plates. Foaming is due to insufficient silicone/antifoam barriers; it can be completely abolished by thinly coating all parts of the trombone before assembly. It is all too easy to rub this off accidentally during transport and handling in containers that permit anything to come into contact with this film. Details on the subject of foaming and how the cause was found will be reported fully elsewhere. This letter, it is hoped, will be of immediate value

to

difficulty. I have had no further foaming or in spill-out the last 40 perfusions, which averaged 4-51/2 litres per minute. R. N. G. ATHERSTONE. London Chest Hospital, E.2. those in

EARLY POSTOPERATIVE GASTROINTESTINAL ACTIVITY

SIR,-In their excellent and important article (July 13) Mr. Rothnie and his colleagues have inadvertently overlooked our communication on the same subject. Happily, the two sets of observations and conclusions accord almost

completely. CHARLES WELLS

J. K. M. RAWLINSON HOWEL JONES. SCALENE-NODE BIOPSIES

SIR,-Dr. Lal and Dr. Poole (July 20) rightly emphasise the value of scalene-node biopsy as an aid to diagnosis in patients with puzzling pulmonary lesions. The interpretation of scalene-node biopsies, however, requires care, and must

be considered in relation to all other features of the

case.

This is

particularly important when the coexistence

of two disorders is suspected. A scalene-node biopsy may show sarcoid microscopic features in: (1) pulmonary sarcoidosis; (2) sarcoidosis complicated by malignant disease in the lung, without metastasis to the scalene node; or (3) merely a local sarcoid reaction to malignant disease. In other words, a scalene-node biopsy specimen 1. Wells, 2.

C., Rawlinson, K., Tinckler, L., Jones, H., Saunders, J. Lancet, 1961, ii, 136. Sakula, A. Brit. J. Cancer, 1963, 17, 206.

coexistent sarcoidosis. Redhill General Hospital,

A. SAKULA.

Redhill, Surrey.

SIR,-We should like to comment on one among many important observations made by Dr. Catterall (July 20)the frequency with which trichomonal vaginitis and

gonorrhoea

coexist.

In this laboratory all genital swabs sent in Stuart’s transport medium (and even ordinary swabs when received without undue delay) for the diagnosis of gonorrhoea are also examined microscopically-and, if negative, culturally-for Trichomonas vaginalis. We find that cultural methods enable us to establish trichomoniasis in about 16% more cases than would have been diagnosed by microscopy alone. Over a four-year period the number of positive gonococcal swabs in which trichomonads were also found was as follows:

Over the whole period 30% of our patients with gonorrhoea also had trichomoniasis-which, while barely half the proportion cited by Dr. Catterall, still amply corroborates his assertion. It is impossible to say, from the information supplied to us, in how many of these the trichomonal infection would in any case have been apparent to the patient’s doctor. How strong the clinical suspicion of gonorrhcea may have been is even less clear, but there can be no doubt that in at least a few the finding of N. gonorrhaeae came as a surprising revelation. If this were the whole story there would be no cause for anxiety, but one suspects that far too often trichomoniasis is diagnosed solely by visual examination-the textbook shibboleth about " the characteristic frothy discharge " dies hard-and we therefore welcome Dr. Catterall’s warning that " it cannot be stated too often that trichomonal vaginitis and gonorrhoea very often occur together in the same patient, and that the symptoms may be produced entirely by Trich. vaginalis. If such a patient is given empirical treatment with metronidazole the symptoms will disappear, but the gonoccocal infection will remain undiscovered until complications, such as salpingitis, develop or until the sexual partner is reinfected with the gonococcus ".

The

safeguard lies in full laboratory investigation of patient with a genital discharge, specimens of which should be carefully taken before any form of treatment is begun. T. F. ELIAS-JONES City Laboratory, 23, Montrose Street, L. YOUNG. JEAN C.1. Glasgow, every

AIR-EMBOLISM SIR,-Dr. Hunter1 states that inhalation of oxygen for air-embolism can be dangerous because pockets of air in tissues may enlarge considerably as a result of breathing

high concentrations

of

" highly soluble "

gases.

If this

loops of intestine distended with gas should expand during the inhalation of 95% oxygen or of the ansesthetic gases. The usual experience in patients does not support this hypothesis. Nor is this the case in the laboratory animal. When a loop of collapsed gut in the animal is deliberately distended with air, and oxygen is breathed by the animal thereafter, the total volume of were true

of oxygen,

2

gas in the loop will be considerably reduced. 1. Hunter, A. R. Lancet, 1963, i, 1055. 2. Fine, J., Sears, J. B., Banks, B. Amer. J. dig. Dis. 1935, 11,

361.