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HEPARIN AND A RIVALWHEN CHARLES and BEST in Canada and JORPES

in Sweden purified heparin sufficiently to enable itto be given intravenously to patients, they opened upa wide field of possible therapeutics. Could we, byrendering the blood less coagulable in vivo, controlthose processes of embolism and thrombosis that areso difficult to treat ? - Would heparin help in operatingon blood-vessels ? Were patients liable to serious

haemorrhage when heparinised ? The progress made’in Sweden was described by various workers at asymposium on heparin held at Stockholm in Decem-ber last.! There was general agreement that heparinis most useful in the treatment of thrombosis of the

leg veins, in operations on blood-vessels such as

embolectomy, and in the prevention of postoperativethrombosis and embolism. It is now clear that

heparin cannot influence a thrombus once it hasformed, but if the onset of thrombosis can be detectedat a very early stage the process can be aborted byheparinisation of the blood, BAUER 2 finds theclassical clinical signs of early thrombosis very un-reliable and he uses " venography "-radiographicoutlining of the veins after injection of iodoxyl-todecide whether thrombosis is beginning or how farit has progressed. Good results cannot be expectedfrom heparin treatment if the thrombosis has spreadto the thigh veins and especially if the femoral vein isinvolved. If the case is suitable, he gives 100 mg.intravenously three times daily until the pulse andtemperature have returned almost to normal ; thistakes 4-7 days and he then allows the patient to getup. He reports 21 cases successfully treated in this

. way. LINDGREN and WILANDER 3 record the use ofheparin in 8 operations on blood-vessels ; 200-300 mg.divided into four intravenous injections was givendaily for 4-15 days and good results were obtained inall cases.The value of heparin as a prophylactic against

postoperative thrombosis is more difficult to assesssince these accidents are fortunately not common.CRAFOORD and JORPES 4 selected a group of 325 patientsall over 30 years of age who had to undergo operationsmore specially liable to thrombo-embolic complica-tions, such as those on the appendix, gall-bladder,stomach, or male genitalia. They were given regularheparin injections beginning 4 hours after the opera-tion and continuing for 5-10 days. Four intravenousdoses of 50, 50, 50 and 100 mg. were given every day,with an interval of 4 hours between each ; in somecases the dose was increased. At the end of heparini-sation the dose was diminished gradually, becauseafter sudden withdrawal pulmonary embolism some-times occurred 10-15 days later. No complicationswere recorded in these 325 patients. As a contrast,over the same period 302 similar cases were operatedon without heparinisation ; 33 (11%) had definitethrombo-embolic complications and 9 died ; in acontrol series of 809 similar cases from a previousperiod the incidence of thrombosis and embolism wasabout the same. Treatment after thrombosis hasoccurred is far less satisfactory ; in some patientsthere was considerable subjective relief and pulse andtemperature rapidly returned to normal, but in many1. Acta med. Scand. 1941, 107, 107. 2. Bauer, G. Ibid, p. 136.3. Lindgren, S. and Wilander, O. Ibid, p. 148.4. Crafoord, C., Jorpes, E. J. Amer. med. Ass. June 28,1941, p. 2831.

others -.there was no clear effect. According to

MURRAY,5 similar conclusions and results on all thesepoints have been obtained by Canadian workers, butthey prefer to give the heparin in a continuous intra-venous drip instead of in separated intravenous doses.

. Heparin is non-toxic and can be safely given 4-8hours after a surgioal operation or 24 hours afterdelivery in obstetrical cases ; should excess bleedingoccur it can be controlled by a small blood-transfusionor injection of protamine sulphate. But it is un-

fortunately difficult to make in quantity-the sourceis ox lung or liver and the yield is small-and it istherefore expensive. Patients with venous throm-bosis suitable for heparin treatment are not common,and embolectomy operations are distinctly rare, sothat hospitals might be able to bear the expense ofindividual cases of this sort, but the prophylactic useof heparin involves the treatment of hundreds ofpatients. At present rates the minimum prophy-lactic course costs about 6 (plus purchase tax) ifthe hospital makes its own sterile solution from thedry powder and much more if the heparin solutionmust be bought. This is obviously not practicablehowever desirable and MURRAY hopes that some

equally non-toxic substance with similar propertieswill be found that is less expensive. BUTT, ALLEN,and BOLLMAN 6 suggest that a substance with thedesired properties has been found in 3,3’-methylene-bis-(4-hydroxycoumarin). This compound is chemic-ally quite different from heparin. It was originallyfound in hay or silage made from the common sweetclovers which had been improperly cured; this isknown to cause a haemorrhagic disease in cattle.K. P. LINK of the University of Wisconsin and hisassociates isolated the hsemorrhagic agent of spoiledsweet clover and have succeeded in synthesising it.Preliminary work has shown it to be non-toxic inhuman patients. It greatly prolongs the coagulationand prothrombin times of the blood but takes about48 hours to develop its effect ; but when the effectis fully developed, it is lasting. It seems best to giveit in a series of divided doses and it has the enormousadvantage of being active when given by mouth ingelatin capsules. Its effect can be rapidly checkedby a, small transfusion of normal blood. This sub-stance should be relatively cheap, and may makegeneral preoperative prophylaxis a practical possi-bility. Let us hope its discoverers will think of ashorter name for it, preferably one that will recallits pastoral origin.

NURSING RECONSIDEREDENGLISH nursing is falling off for lack of

candidates for training-not merely of suitablecandidates, but of sufficient candidates of any kind.The high standards set by the nineteenth centurypioneers can only be maintained if the best type ofwoman in the country is willing to take up nursing.That the cream of our public and secondary school’ .girls-young women of character and promise-atpresent choose other callings in preference to nursingcannot be said to reflect on the girls. They haveplenty of interest in public welfare, applying in largenumbers to train as social workers, though appoint-ments for those who qualify are scanty; ; moreover,

5. Murray, G. D. W. Brit. J. Surg. 1940, 27, 567.6. Butt, H. R., Allen, E. V. and Bollman, J. L. Proc. Mayo Clin.

June 18, 1941. p. 388.

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most women have an instinctive bias which makessuch nursing as comes their way congenial. Whenan attractive occupation is neglected the fault mustlie in the terms of service.The establishment of a nursing division at the

Ministry of Health is evidence that remedies are

being sought, and organisations up and down thecountry are making suggestions. One proposed statescheme of training for nurses has lately been drawnup, as a basis for discussion, by the Manchester public-health department, in which a plan is set out wherebythe nurse might obtain basic general training, and alsospecialised training, within a period of four years.A wise proposal is that schools of nursing should beattached to the universities so that student nurseswould have the same standing as students taking adiploma in social science. This would go far towardsbringing a nursing qualification into line with otheracademic and technical diplomas. At present onlytwo English universities, Leeds and London, givediplomas in nursing, in painful contrast with the

copious references in the index of the UniversitiesYearbook to nursing diplomas in Canada and South’Africa. Special training for assistant nurses is alsosuggested in the Manchester scheme, either in the

. form of a modified course in hospital, with examina-tions in practical nursing, or as a special course atapproved institutions. If a second grade of wardhelper is essential-and in the present straits she

certainly is-it is wholly desirable that she should havea defined training and clearly specified duties ; she maythen prove to be a reliable and even indispensablemember of her profession. But it seems at least

equally important that she should be designated bysome title other than that of nurse. A construc-tive scheme based on wide inquiry has lately beenoutlined by four members of the nursing professionwho may justly speak with authority-Miss E. C.PEARCE, Mrs. B. A. BENNETT, Miss L. SNOWDENand Miss G. B. CARTER. They accept the principlethat two grades of nurse have become necessaryand suggest that students training for grade Istandard should hold the school-leaving certificateor a higher qualification and should be in trainingfor 4t years. Grade II students would be drawnfrom secondary or elementary schools and need holdno certificates ; their training would last 2t years,terminating in an examination largely practical andoral. They suggest the descriptive term " sister "for the first, and " nurse " for the second grade.Thus to diminish the title of nurse seems unfortunate :

surely it should be kept for the state-registered woman,and the term " student nurse " for the woman

intending to qualify. For a helper of the secondgrade some other description must be found (e.g." ancilla ") ; to call her a nurse-even- an assistantnurse-is to debase the currency of nursing and toinvite confusion in the minds of the public.The Manchester suggestions are timely, but they

look at nursing from within. If recruitment is tobe improved it is essential to look at the professionthrough the eyes of the recruit and it is inept to sayto her. " The welfare of the patient must be the firstconsideration. The nurse must be prepared to sacri-fice herself to that." An appreciation of the patient’sclaims can only develop fully in a woman who has

1. Nursing Mirror, Aug. 23.

begun to study nursing and to love her calling. Ademand at the outset for sacrifices only alarms thehesitant ; and in any case no more sacrifices shouldbe required from a student nurse than from any otheryoung person studying for a profession. Few careersin medicine fail to include a sense of vocation buthow many deans of medical schools find themselvesextolling sacrifice to prospective students ? It isnot at the outset a question of money : students in

professions other than nursing expect to pay, not tobe paid. At the beginning of this year the Ministerof Health tried to overcome the shortage of applicantsby raising rates of pay and by appealing for morenurses. The rates of pay in the Civil Nursing Reserve .

were set at E40 a year for student nurses, 105 fortrained nurses, f55 for nursing auxiliaries and f70 forassistant nurses, in all cases with board, lodging andlaundry allowed. There are objections to this

arrangement ; at present most auxiliaries and assistantnurses are only partly trained women who for onereason or another are not attempting to becomestate-registered nurses. They are living in closeassociation with student nurses, and-though havinga somewhat lower status-are receiving highersalaries. The establishment of two grades, trained fordifferent purposes, would help to overcome this

difficulty. It might then become possible to treatstudent nurses as true students and pay them nothing ;but in that case the hospital should cease to dependon their labour for the care of patients. Theyshould be, like medical students, an accessory not anintegral part of the staff. To run hospital nursinglargely on student labour, as is done at present, is

unjust both to the trained nurse and the nurse intraining. It limits the number of posts open totrained women and subordinates the interests of thestudent to hospital convenience. If she is being paidfor service, at however inadequate a rate, the nurse isin a weak position to argue her cause as a student.The salaries to trained staff are moderate when all

emoluments are reckoned in ; but part of theseemoluments take the form of board and lodging, andthe trained nurse is thus compelled to live in hospital-a plan which makes for hospital convenience andeconomy, but has serious side-effects for the nurse.Few people, male or female, benefit by living in acircumscribed world composed largely of theirown sex ; maturity of the mind and emotions isdifficult to achieve and maintain in such surroundings.Intelligent girls contemplating the profession feelthat nurses should have at least as much privateliberty as women doing, say, secretarial work ; andthat they would be the better for it. Nor are the

prospects for the older nurse outside hospital suchas to inspire confidence in parents seeking a safe liveli-hood for their daughters, or in the daughters them-selves. In private nursing the young nurse is oftenprized above her seniors. District and school nursing,though giving a measure of freedom, are hard exact-ing jobs and not particularly well paid. Mental

nursing is interesting work and pensionable, but theisolation of many mental hospitals and the need tolive in (as well as that uninformed dread of mentalpatients which is almost universal) deters many ;while the higher rates of pay offered attract thosewho are driven rather by their financial needs orresponsibilities than by an interest in mental work.

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The logical way out of the recruiting dilemma isto ask the girls themselves what they want and topay some attention to the answers. These are

reasonable enough : they want equal freedom andleisure with other girls in training ; prospects of asafe. and adequate livelihood ; and an opportunity,when training is complete, to live a normal homelife outside working hours. And if they cannot getthese things they will not flock to become nurses :it is as simple as that. The national committee on

nursing which the Minister of Health contemplatessetting up is to have panels representing employersand employed. It might be as well to add a thirdpanel composed of parents, headmistresses and

possibly of girls leaving school-or at least to hearevidence from these interested and interesting parties.A real appreciation of fundamental issues appearsin the scheme drafted by Miss PEARCE and her

colleagues, and also in a bill on nursing lately drawn upby the Women’s Parliament, at their first session onJuly 13 last. This bill asks for reorganisation of the

training system so that students should not be

required to perform full hospital duties simultaneouslywith their studies ; for a forty-eight hour week, withfour weeks holiday annually for student nurses andfive weeks for trained nurses ; that trained nursesshall be allowed to live outside hospital and to con-tinue their employment after marriage ; and thatnurses’ homes for those in training shall be runas hostels, controlled by an elected committee ofthe residents. There are other suggestions, aboutrates of pay, pensions, uniform and the training ofnursing auxiliaries ; but those set out above strikeat the heart of the difficulty. They are preciselythose which the hospitals find it hardest to face,because they alter fundamentally their disciplinaryand economic relations with the nursing staff. Ifthe best types of woman in the country, however, areunwilling to submit themselves to the traditional

conditions, the conditions must give way. We not

only want the best nurses : we can have them-buton contemporary terms.

‘

Annotations

INTRACAPSULAR FRACTURES

NEARLY 40 years ago Royal Whitman of New Yorkbegan to teach that fractures of the neck of the femur-which for many generations had been regarded by sur-geons as a lost cause-could be reduced by manipulation,and, if fixed in a plaster spica with the hip abducted andextended, could be expected to unite soundly. In duecourse Whitman was able to demonstrate to unbelieversthat the abduction plaster could be used with safety inold and frail patients. This was a notable landmark inthe evolution of modern fracture treatment, and theWhitman procedure soon became- the accepted routine insurgical clinics throughout the world. As experienceincreased, it became evident that there were manydisappointments and failures still to be faced ; even

in experienced hands, and in recent years, the treatment.of this type of fracture carried with it a mortality of12-15%, and bony union was observed in not more than

’

50% of the cases. In 1907 Pierre Delbet of Paris haddevised an operation in which the fracture line wastransfixed in the long axis of the femoral 4ieck by a screwor nail, the whole procedure being carried out under X-raycontrol. The Delbet technique attracted few followers,and it was not until 1931, when Smith-Petersen 1 ofBoston reported the first series of cases in which he hadused his now famous triflanged nail, that interest wasreawakened in the problem of internal fixation of thefracture. Smith-Petersen’s mode of attack was to reducethe fracture after exposing the fragments through ananterior arthrotomy, and to insert the nail under directvisual control. The disadvantages and risks of a wideexposure of the hip-joint in the older patients led to arevival of the Delbet principle of nailing under X-raycontrol. Since 1934 this principle has gained almostuniversal approval, and the triflanged nail provided witha central canaliculus to allow its insertion over a guide,has been used in the majority of surgical clinics. In the

perfection of the technique of extra-articular nailing,Sven Johansson of Gothenberg and Thomas King ofMelbourne,3 amongst others, have played a notable part.

In the United States, multiple wires of the Kirschnertype have found favour as an alternative means ofinternal fixation, and more recently the advantages of a

1. Smith-Petersen, M. N., Cave, E. F. and Vangorder, G. W.Arch. Surg. Chicago, 1931, 23, 715.

2. Operative Treatment of Collum Femoris Fractures, Copenhagen,1934.

3. Med. J. Aust. 1935, 2, 521.

special screw so constructed as to exert a binding orimpaction force on the fragments, were stressed by thelate Vittorio Putti 4 in one of the last contributions madeby this great intellectual leader of orthopaedic surgery.Some of the-earlier reports of the results of extra-articularnailing, which were based on comparatively short periodsof observation, created the impression that the problemof the intracapsular fracture of the femoral neck was nowfinally solved. But evidence which is now becomingavailable shows that this optimistic view is unjustified.A valuable report of a commission set up by the AmericanAcademy of Orthopedic Surgeons has been recentlyissued, the commission has analysed the late results ofpinning in 247 sub capital and transcervical fractures,which-out of 923 documented cases-were accepted asfulfilling the following requirements : the fractures wererecent and showed definite displacement ; pre-reductionand post-reduction radiograms were available for

scrutiny ; and radiograms of the fracture taken one yearlater accompanied the clinical notes. In these 247 casesthe fracture was secured by a triflanged nail in 144;by multiple wires (pins or spikes) in 83 ; and by mis-cellaneous means (screws, grafts) in 14. The commissionfound that bony union was obtained in 169 cases (’70 1 %),with a slightly higher figure in fractures treated by thetriflanged nail as compared with those fixed by multiplewires. Arthritic changes of varying degree developed ina quarter of the cases in which bony union occurred ;the most severe types of arthritis, which were character-ised by aseptic necrosis and disintegration of the femoralhead, were seen in cases examined 18 months and 2 yearsfrom the time of the operation. In the non-union group(30%) there was a higher incidence of failures in fracturesimperfectly reduced. ’

The 923 cases (of which 682 were rejected in the surveyof late results) yielded valuable collateral information.The mortality was 11.6%-not very different from thefigures for the Whitman method. Failure to maintainfixation of the fragments, owing to breaking of the nail orshifting of the nail, was reported in 11 % of the triflangednail cases, in 21 % of the multiple wire cases, and in 20%of the cases fixed by miscellaneous means. It was notedthat a shifting nail tended to be extruded, whereasmultiple wires tended to enter the joint cavity. Despitethese drawbacks the commission were in no doubt thatin the hands of expert surgeons the modern method ofinternal fixation had improved the results of the treat-ment of intracapsular fractures of the femoral neck.

4. Cura Operatione delle Fratture del Colle del Femore, Bologna, 1940.5. J. Bone Jt Surg. 1941, 23.