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the sinus wall or of the ophthalmic veins may causechemosis and exophthalmos. The diagnosis is diffi-cult and cases-may pass- unrecognised. Rarerformsof thrombosis follow spread along the pterygoid venousplexus or from the sphenoidal or other nasal accessorysinuses, or from direct contact with acute suppuratingpetrositis, and each may give rise to the acute orchronic syndrome.

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Whatever its underlying cause/venous thrombosismust be regarded as a protective mechanism followingon phlebitis. The thrombus may be aseptic-that is,the body defence may have overcome and destroyedthe infecting organisms before or while the clot is

forming=or septic, when this attempt has beenunsuccessful. It is in this way that to the local effectsof venous occlusion may be added the general onesof. toxaemia together with septicaemia or pyaemia.Treatment must be directed against the general effectsof the infection, and may also be needed to relieve thelocal effects of venous obstruction, since these can bedisastrously incapacitating. - But it is essential toremember that the thrombosis is a part of the naturalmechanism of repair tending to a spontaneous cure.These principles’ have long been appreciated andattempts have been made to apply them in cavernoussinus thrombosis by direct surgical attack on -thesinus itself and its tributaries and by more conserva-tive methods such as serotherapy, blood-transfusions,and chemotherapy. In reviewing the cases success-fully treated up to 1936 CAVENAGH 5 found that out ofa total of something less than 50 cases (the number isuncertain owing to overlapping references and doubt-ful diagnosis) probably not more than 7 were of theacute infective type. Treatment by radical operationwas adopted in 3 of them. Of the remainder, only 2had been treated by operation on the sinus itself;the others, cleared up with surgical eradication of theprimary source of infection and of any localised areasof suppuration. Conservatism is a good rule in

treating acute pyogenic infection of the sinus, opera-tion being reserved for cases where pus has formedor there. is necrosis of bone. Other methods of meet-ing the original onslaught of the infecting organismsare essential, preferably those acting in harmony withthe normal body processes. EAGLETON (pp. 156-7)prophetically wrote :

" The nature of the pathologicalanatomy of thrombophlebitis ... would appear tobe favourable for treatment by sterilisation of theblood-stream by ... bactericides.... In the nearfuture there will be discovered specific chemicalcompounds which will influence the different pyogenicinfections of the blood-stream ... and will be speci-fic for (each type)." The sulphonamides and peni-cillin have fulfilled the greater part of this prediction.The sulphonamides are now part of the routine treat-ment of the early stages of an acute pyogenic infectionof any severity, and their success in sterilising theblood-stream and the forming thrombus in the cavern-ous sinus has been recorded by SEYDELL,6 MoRRisoNand SCHINDLER,7 WOLFE and WOLFE,8 and others.Since many of these sinus infections arise from super-ficial staphylococcal lesions it was to be expected thateven greater success would be achieved with penicillin,and the hope looked like being fulfilled when, in their

5. Cavenagh, J. B. Brit. med. J. 1936, i. 1195.6. Seydell, E. M. Arch. Otolaryng., Chicago, 1939, 30, 429.7. Morrison, L. F., Schindler, M. Ibid. 1940, 32, 948.8. Wolfe, C. T., Wolfe, W. C. Ibid, 1941, 33, 81.

first series of infections treated with penicillin,FLOREY and his colleagues 9 restored a boy withcavernous sinus thrombosis from a’ moribund state toconvalescence. This boy later died of a rupturedmycotic aneurysm, but subsequent cases have beenmore fortunate. Thus JOHNSTONE reported in thesecolumns on Jan. 6 a case in which complete recoverywas attained although penicillin treatment was un-avoidably delayed for 10 -days. Full doses of a

sulphonamide and penicillin would seem the mostpromising coinbination, since some strains of strepto-cocei and staphylococci, as well as B. proteus and Ps.pyocyanea, are resistant to one or other of these drugs.Chemotherapy is likely to cure just that type of casewhere the outcome was formerly almost hopeless-spread of infection from anterior veins draining aseptic lesion of the face-because a lesion here isplainly visible, and any divergence from routine heal-ing, or signs-of more deep-seated mischief, becomerapidly obvious, so treatment can be begun in time.The osteoplastic flap of Kroenlein, evisceration of theorbit, and other dramatic operative procedures arelikely to be relegated to history except for cases

where thrombosis and infection reach - the sinusfrom more obscure lesions, and even here chemo-therapy may succeed in sterilising the clot before itliquefies to pus. ,

It has been suggested that thrombus formation canbe prevented by the’ administration of the anti.

coagulants heparin and dicoumarol. In addition to3 recoveries with heparin recorded by LYONS 10 andSCRALL,11 another was reported by MUNTARBHORN inour issue of Jan. 6. In -all these cases full dose of asulpha drug were also given. LOCKWOOD, WHITE, andMURPHY,12 too, employed heparin and dicoumarol asan adjunct’to penicillin in a successful case. But withthe available evidence of recoveries with chemo-

therapy alone, and in the absence of controls, theaddition of anticoagulants cannot yet claim to haveestablished its practical value. They may have a partto play in the cases of chronic obliterative thrombosiswhich arise from the lateral sinus and spread to thecavernous sinus, for if the diagnosis is made very earlyheparin or dicoumarol could possibly limit the exten-sion of the clotting process. In other cases it doesnot seem justifiable to oppose a natural defencemechanism.

A Regional PlanTHOSE who put their faith in regional planning will

be pleased with an interim report just issued by themedical services committee of the Yorkshire RegionalHospitals Council.13 If this is a fair specimen of aregional plan, it is certainly encouraging-alwaysprovided the plans can be translated from paper topractice. The committee is nicely balanced betweenthe voluntary hospitals, the medical officers of health,the university faculty of medicine, and the generalpractitioners of the region ; which, it should be ex-plained, covers the East and all save the southern tipof the’ West Riding, but not the North Riding, whichrelates naturally to Tees-side.9. Abraham, E. P., Chain, E., Fletcher, C. M., Gardner, A. D.,

Heatley, N, G., Jennings, M. A., Florey, H. W. Lancet, 1941,ii, 177.

10. Lyons, C. Ann. Surg. 1941, 133, 113.11. Schall, L. A. J. Amer. med. Ass. 1941, 117, 581.12. Lockwood, J. S., White, W. L., Murphy, F. D. Ann. Surg. 1944,

120, 311.13. Nuffield Provincial Hospitals Trust. Yorkshire Regional

Hospitals Council. 1944. 6. Butt’s Court, Leeds, 1.

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The, proposals follow closely those made in theinterim report of Medical Planning Research,14 and itis interesting to see how these theoretical conceptionsprove applicable to an actual area. An intermediate

type of hospital, between the key hospital and theperipheral hospital, is introduced under the name ofdistrict hospital. It is proposed that the 3 major ordivisional hospital centres should be at Leeds, Brad-’ford, and Hull ; Leeds, as the university centre, would -be the main one. There would be 9 district hospitalcentres, all staffed by whole-time specialists. Specialdepartments would be situated within, and be part of,a hospital centre—an arrangement beneficial alike topatients and staff. There would be no sharp lines ofdemarcation to prevent a patient going to a hospitaloutside his own area, or evenhis own region, if he wishedto do so ; and this would remove one of the biggest dis-advantages of the present municipal hospital service.Throughout the plan, municipal and voluntaryhospitals are treated on a par, with common visitingspecialist staffs, and common central admissionbureaux. In estimating staff and bed requirements,the pre-war figures are omitted since those availableare thought to be unreliable. However, it stated thata 15-20 per cent. increase in general surgical beds isneeded, while the increase in beds for dermatology andthoracic surgery must be several hundred per cent.Again, there will be need of twice as many general phy-sicians as before the war, while paediatricians should beincreased seven-fold. Such figures make one wonderhow the people of Yorkshire have survived so long.

Detailed reports are made on each of the specialties.Whereas the subcommittee on general practiceadvocates surgery by general practitioners in peri-pheral hospitals, the main committee expects it todie out. Again, the GPs want a resident house-officer in each of their hospitals, while the main com-mittee apparently does not. A house-officer would

certainly be needed if the visiting surgeons were to doany large volume of work peripherally ; but inasmuchas his presence might be an extra inducement to thepractitioner to

" do a spot of surgery on the side," hemight not be an unmixed blessing. It is at the peri-phery that the plan seems to have been least clearlythought out ; and it is here that things are most likelyto go wrong, from the patient’s point of view. Byand large, however, the proposals appear sound ; andprovided the Minister of Health injects the necessarycash, the wheels of the Yorkshire regional hospitalservice should turn smoothly.

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14. Lancet (Suppl.), Nov. 21, 1942.

RECRUITMENT OF Bl OFFICERS.—To meet the needs of theServices in forthcoming campaigns the Central Medical WarCommittee will shortly be issuing preliminary recruitmentnotices to all resident medical officers, resident surgical officers,and others who have held a Bl post or posts for two years ormore (Ministry of Health circular 180/44). The Minister ofHealth is not unmindful of the needs of the civilian populationand he appreciates that many of these doctors have been re-tained to deal with Service patients treated under the Emer-gency Hospital Scheme, but he is advised that it is now necessaryto consider their recruitment and he urges hospitals, whereverpossible, to release them. Substitutes may be found amongholders of A and B 2 posts, and he suggests that it will beto the advantage of hospitals after the war if these youngmen, who would otherwise have been recruited to the Forces,can now be given further experience. Replacements may alsobe found among medical officers invalided from the Forcesor- released on the applicat.ion of the Central Medical WarCommittee. ,

Annotations

UNIVERSITY STUDENTS AS CRITICS OFFACTORY LIFE

TWENTY students from the Universities of Oxford,London, Cambridge, St. Andrews, and Liverpool spentsix weeks of their vacation working in a large factory.They were acting as " guineapigs " in a field experimentaimed at discovering whether a certain chemical producedill effects on the people who had to handle it. Duringtheir stay at the factory they were encouraged to recordtheir impressions of the social and technical side of thework. Dr. Alice Stewart and Miss Mary Lamb summariseand discuss the students’ impressions of their factorylife.1 At first they thought that the welfare conditionswere good, but they later realised that there were snags,and that production was hampered by a number of smallirritations which, taken together, induced a cynical orindifferent attitude on the part of the workers. Thestudents soon learnt that nothing is more certain toundermine a fundamental willingness to work thanconstant petty irritations and mismanagements, andthey felt also that too little was done to ensure that theworker really knew what he was doing and felt it to beimportant. This, they thought, was the chief cause ofabsenteeism, slackness, indifference, and careless work.Another cause of absenteeism, particularly amongst themarried women, was the delay caused by irregularity ofsupplies of goods essential to production. The marriedwomen, with homes to run, inevitably felt that they hadsomething better to do than to hang around wastingtime at the factory. In this factory little was done tofamiliarise the workers with the possible consequences ofcarelessness at work. The products of the factory weredangerous to the workers themselves and to those whohad to handle them after they left the factory. Thestudents approached the management and were given aspecial lecture on the nature and uses of the products onwhich they were engaged ; they were also taken on a tourof the whole factory so that they might see how the variousprocesses were related. It was not customary to givethese privileges to the other workers in the factory.The students commented unfavourably on the general

factory hygiene. They found the sanitary accommoda-tion most unpleasant because it was only cleaned once aweek; most of the time the place was very dirty andfoul-smelling and there were no locks on the lavatorydoors. The workers appeared to have little confidence inthe factory doctors. Medical examinations were said tobe perfunctory in the extreme. No-one who has experience of industry will quarrel

with the conclusions reached by Dr. Stewart and MissLamb, but it is perhaps a mistake to say, as they do,that theirs is a new approach to the problem. Again, nogeneralisations about factory conditions should be madefrom those observed at this particular factory, which wasobviously large-too large-new, and unwieldy. - Therehad been apparently -little time for personalities andprocesses to settle down. In old-established factoriesthings’ are better. Sanitary accommodation is clean andwholesome in many of them. Workers have, and use,the power to express themselves either direct to themanagement or through works councils and joint produc-tion committees. Many of them make suggestions,which are accepted, for improvement in working con-ditions and in technical processes. In many instancesthe better " channels of communication " for which theauthors plead are already laid down. But it nearly alldepends on the people in charge and on their personalities.When the factory is small enough for each worker to bepersonally known to the manager, there is little or notrouble. There are of course unhappy factories, but alsomany happy ones, and these are usually places employing

1. Industrial Welfare, Nov.-Dec., 1944, p. 175.