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'THE TUBERCLE OF THE FIFTH METATARSAL.
MEDICINE AND THE LAW.
1318
throughout a vegetarian diet and on others having a high sugar diet. These figures will be published in
Dr. Peters notes that there were four nephritis in my alkaline series, one ending in death, but he does not mention that in three of these cases the alkali had been omitted 48 hours before the nephritis occurred, or that in the fatal case the kidneys at autopsy showed microscopical evidence of an antecedent chronic nephritis. Finally, I would like to take the opportunity of pointing out that I have only suggested the use of . alkalies in scarlet fever for the prevention of nephritis and not as treatment for the primary disease.
MEDICINE AND THE LAW.
due
course. cases of
T
ann
1T*
"<7on...."
f".;t.hfn 11..,
A. A. OSMAN.
London, Dec. llth, 1927.
’THE TUBERCLE OF THE FIFTH METATARSAL. To the Editor of THE LANCET. S]iP.,-l should like to congratulate Mr. A. G. R. Foulerton and Dr. G. F. Stebbing on their very interesting paper on Fractures of Metatarsal Bones by Indirect Violence, with special reference to Avulsion Fracture of the Tubercle of the Fifth Metatarsal (THE LANCET, Dec. 10th, p. 1225). May I at the same time point out that while they quote Testut and Gruber as having met only three cases in which the tubercle of the fifth metatarsal was a separate bone, in reality a separate ossific centre .for the styloid of the fifth metatarsal occurs quite commonly. In radiograms of 50 subjects between the ages of 10 and 17 I found a styloid epiphysis present in 14 (28 per cent.), and in a paper on the : subject, recently sent to the Journal of Bone and Joint Surgery, while speculating on the occurrence .of this epiphysis I suggested that it may represent a traction epiphysis produced by the tendon of the peroneus brevis or possibly the abductor of the fifth metatarsal man
—I
am
(Wood’s muscle) frequently present Sir faithfully
in
vours
LAMBERT ROGERS,
Surgical Unit, Welsh National School of Medicine, Dec. 12th, 1927. Royal Infirmary, Cardiff.
STATUS OF MENTAL NURSES. To the Editor
of THE LANCET. commented last week on the meeting SIR,-You ,of the Royal Medico-Psychological Association at which this subject was considered. My own view ;may be stated thus. In any attempt to assess the
comparative merits of the examinations of the Royal Medico-Psychological Association and the General - Nursing Council for Mental Nurses, the following points deserve consideration : 1. Registration should give every nurse a national qualification and status. 2. The preliminary examination should be the same ;for all branches of nursing, so that a nurse can qualify
in more than one branch without undergoing a test ,in practical elementary nursing more than once. :3. The devising and management of examinations for nurses should be in the hands of the nursing profession. The certificate of the Royal MedicoPsychological Association provides none of these ; .things.—I am, Sir, yours faithfully, H. WOLSELEY LEWIS, Medical Superintendent, Kent County Mental Dec. 12th, 1927. Hospital, Maidstone.
SURGEON. AFTER conflicting evidence, a verdict was given for the plaintiff in the case of Tyndall v. Alcock at Briotol Assizes in an action for damages for negligence brought against a surgeon. A girl of 8 years of age fell from a donkey in July, 1926, and fractured her left arm. She was then taken 10 miles in a motor-car to Gloucester where she was treated by Dr. Arnold Alcock, at first in a nursing-home and later in the The case for the Gloucester Royal Infirmary. plaintiff was that the arm became fixed at the elbow and, as the result of the development of Volkmann’s contracture, movement was permanently impaired. Dr. H. Chitty, giving evidence for the plaintiff, said that he examined the patient in October, 1926, and found no voluntary movement of the wrist, fingers, and thumb ; there was fixation and contracture such as usually arose from tight bandaging or splint pressure. Dr. Alcock, the defendant, gave evidence that at his first examination he found a fracture at the lower end of the humerus ; the fragments were in a bad position, the elbow slightly swollen, and the ends of the bone injuring the tissues. He manipulated the bones into position and a screen examination showed the fragments in alignment ; he was satisfied that the fracture had been properly reduced. The arm was then suspended from the shoulder and an X ray. photograph obtained. He stated-though this was one of the facts in dispute-that he had from the first taken a serious view of the injury and had so informed the girl’s mother. The upper bony fragment was almost through the skin and threatened severe damage to other structures. He gave instructions that the circulation should be carefully watched. Next day the hand was slightly swollen and the bandages were loosened. Four or five days later there was more discoloration. He realised that circulation was obstructed ; the bandages were loosened and the strapping removed. Three or four days after the accident he suspected the possibility of Volkmann’s contracture ; by the third week of treatment he was sure of it. He knew the fracture was slightly over-reduced, but he thought this advisable since it involved less interference with the blood-vessels. Prof. Hey Groves, of Bristol, gave evidence for Dr. Alcock, as also did Dr. C. V. Knight (senior surgeon at the infirmary), the matron of the nursing-home, and a masseuse. Prof. Groves observed that the skiagram showed severe fracture of the lower end of the humerus with satisfactory reduction or over-reduction ; if symptoms of Volkmann’s contracture occurred, it was much more important to restore circulation than to restore alignment. He thought Dr. Alcock had adopted the proper course’ of treatment. Counsel for defendant submitted that Dr. Alcock had not omitted any necessary step ; he had made radiological examinations in consultation with a skilled radiologist. The jury, after an absence of one and a half hours, returned a verdict that the defendant had not properly set the bone and had failed to treat the case properly afterwards. Mr. Justice Shearman refused to accept this, and, after a fresh retirement, the jury found a verdict for the plaintiff with JE2000 damages and £150 for the mother. A stay of execution was granted on terms. DAMAGES
AGAINST A
I
MERCUROCHROME INTRAVENOUSLY. To the Editor of THE LANCET. REDHILL HOSPITAL, EDGWARE. - Mr. Neville SIR,-Mr. Martindale’s warning, under this head- Chamberlain, the Minister of Health, last week opened the ing in THE LANCET last week, is warranted. In new Redhill Hospital, Edgware, which has been built by the ’’ New and Non-Official Remedies," a volume in which Hendon Board of Guardians at a cost of 123,000. There are entered products approved by the Council on are at present 175 beds, but the accommodation can be in the future to provide for 500. In his speech Pharmacy and Chemistry of the American Medical extended Mr. Chamberlain pointed out that in the county of Middlesex Association (and accepted by them for inclusion) the voluntary hospital accommodation, in proportion to the there will often be found precepts of practical value population, is considerably below the average for the whole
.to British
practitioners.
I am,
Sir,
yours
faithfully, M.D.
of London,
or even
for the country. The new institution is of acute medical and surgical
essentially for the treatment cases.
1318
throughout a vegetarian diet and on others having a high sugar diet. These figures will be published in
Dr. Peters notes that there were four nephritis in my alkaline series, one ending in death, but he does not mention that in three of these cases the alkali had been omitted 48 hours before the nephritis occurred, or that in the fatal case the kidneys at autopsy showed microscopical evidence of an antecedent chronic nephritis. Finally, I would like to take the opportunity of pointing out that I have only suggested the use of . alkalies in scarlet fever for the prevention of nephritis and not as treatment for the primary disease.
MEDICINE AND THE LAW.
due
course. cases of
T
ann
1T*
"<7on...."
f".;t.hfn 11..,
A. A. OSMAN.
London, Dec. llth, 1927.
’THE TUBERCLE OF THE FIFTH METATARSAL. To the Editor of THE LANCET. S]iP.,-l should like to congratulate Mr. A. G. R. Foulerton and Dr. G. F. Stebbing on their very interesting paper on Fractures of Metatarsal Bones by Indirect Violence, with special reference to Avulsion Fracture of the Tubercle of the Fifth Metatarsal (THE LANCET, Dec. 10th, p. 1225). May I at the same time point out that while they quote Testut and Gruber as having met only three cases in which the tubercle of the fifth metatarsal was a separate bone, in reality a separate ossific centre .for the styloid of the fifth metatarsal occurs quite commonly. In radiograms of 50 subjects between the ages of 10 and 17 I found a styloid epiphysis present in 14 (28 per cent.), and in a paper on the : subject, recently sent to the Journal of Bone and Joint Surgery, while speculating on the occurrence .of this epiphysis I suggested that it may represent a traction epiphysis produced by the tendon of the peroneus brevis or possibly the abductor of the fifth metatarsal man
—I
am
(Wood’s muscle) frequently present Sir faithfully
in
vours
LAMBERT ROGERS,
Surgical Unit, Welsh National School of Medicine, Dec. 12th, 1927. Royal Infirmary, Cardiff.
STATUS OF MENTAL NURSES. To the Editor
of THE LANCET. commented last week on the meeting SIR,-You ,of the Royal Medico-Psychological Association at which this subject was considered. My own view ;may be stated thus. In any attempt to assess the
comparative merits of the examinations of the Royal Medico-Psychological Association and the General - Nursing Council for Mental Nurses, the following points deserve consideration : 1. Registration should give every nurse a national qualification and status. 2. The preliminary examination should be the same ;for all branches of nursing, so that a nurse can qualify
in more than one branch without undergoing a test ,in practical elementary nursing more than once. :3. The devising and management of examinations for nurses should be in the hands of the nursing profession. The certificate of the Royal MedicoPsychological Association provides none of these ; .things.—I am, Sir, yours faithfully, H. WOLSELEY LEWIS, Medical Superintendent, Kent County Mental Dec. 12th, 1927. Hospital, Maidstone.
SURGEON. AFTER conflicting evidence, a verdict was given for the plaintiff in the case of Tyndall v. Alcock at Briotol Assizes in an action for damages for negligence brought against a surgeon. A girl of 8 years of age fell from a donkey in July, 1926, and fractured her left arm. She was then taken 10 miles in a motor-car to Gloucester where she was treated by Dr. Arnold Alcock, at first in a nursing-home and later in the The case for the Gloucester Royal Infirmary. plaintiff was that the arm became fixed at the elbow and, as the result of the development of Volkmann’s contracture, movement was permanently impaired. Dr. H. Chitty, giving evidence for the plaintiff, said that he examined the patient in October, 1926, and found no voluntary movement of the wrist, fingers, and thumb ; there was fixation and contracture such as usually arose from tight bandaging or splint pressure. Dr. Alcock, the defendant, gave evidence that at his first examination he found a fracture at the lower end of the humerus ; the fragments were in a bad position, the elbow slightly swollen, and the ends of the bone injuring the tissues. He manipulated the bones into position and a screen examination showed the fragments in alignment ; he was satisfied that the fracture had been properly reduced. The arm was then suspended from the shoulder and an X ray. photograph obtained. He stated-though this was one of the facts in dispute-that he had from the first taken a serious view of the injury and had so informed the girl’s mother. The upper bony fragment was almost through the skin and threatened severe damage to other structures. He gave instructions that the circulation should be carefully watched. Next day the hand was slightly swollen and the bandages were loosened. Four or five days later there was more discoloration. He realised that circulation was obstructed ; the bandages were loosened and the strapping removed. Three or four days after the accident he suspected the possibility of Volkmann’s contracture ; by the third week of treatment he was sure of it. He knew the fracture was slightly over-reduced, but he thought this advisable since it involved less interference with the blood-vessels. Prof. Hey Groves, of Bristol, gave evidence for Dr. Alcock, as also did Dr. C. V. Knight (senior surgeon at the infirmary), the matron of the nursing-home, and a masseuse. Prof. Groves observed that the skiagram showed severe fracture of the lower end of the humerus with satisfactory reduction or over-reduction ; if symptoms of Volkmann’s contracture occurred, it was much more important to restore circulation than to restore alignment. He thought Dr. Alcock had adopted the proper course’ of treatment. Counsel for defendant submitted that Dr. Alcock had not omitted any necessary step ; he had made radiological examinations in consultation with a skilled radiologist. The jury, after an absence of one and a half hours, returned a verdict that the defendant had not properly set the bone and had failed to treat the case properly afterwards. Mr. Justice Shearman refused to accept this, and, after a fresh retirement, the jury found a verdict for the plaintiff with JE2000 damages and £150 for the mother. A stay of execution was granted on terms. DAMAGES
AGAINST A
I
MERCUROCHROME INTRAVENOUSLY. To the Editor of THE LANCET. REDHILL HOSPITAL, EDGWARE. - Mr. Neville SIR,-Mr. Martindale’s warning, under this head- Chamberlain, the Minister of Health, last week opened the ing in THE LANCET last week, is warranted. In new Redhill Hospital, Edgware, which has been built by the ’’ New and Non-Official Remedies," a volume in which Hendon Board of Guardians at a cost of 123,000. There are entered products approved by the Council on are at present 175 beds, but the accommodation can be in the future to provide for 500. In his speech Pharmacy and Chemistry of the American Medical extended Mr. Chamberlain pointed out that in the county of Middlesex Association (and accepted by them for inclusion) the voluntary hospital accommodation, in proportion to the there will often be found precepts of practical value population, is considerably below the average for the whole
.to British
practitioners.
I am,
Sir,
yours
faithfully, M.D.
of London,
or even
for the country. The new institution is of acute medical and surgical
essentially for the treatment cases.