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Annotations

INTRAVENOUS HAZARDS

SIMPLE intravenous infusion is often undertaken in alighthearted spirit. " Shoving-in " some blood, " jam-ming-in " a few c.cm. of intravenous Pentothal,’ thegay " exhibition of a syringe " and a pad of spirit-spakedwool, and some " plugging around " with a needle fora vein are commonplace enough. The difficulties anddangers of intravenous therapy were discussed by theMedical Society of London on March 13, with Prof.Grey Turner in the chair. What Mr. R. H. Franklincalled " a shady piece of work under a towel " is all toolikely to engender risks which could be avoided, and itis time the venesector was given more elbow room asa skilled mechanic in the surgical or medical team.A,B,O,M,N, rhesus, pyrogenic and anaphylactogenicsubstances all lie in wait to trip the incautious or faultytechniciaw, and Dr. C. J. C. Britton advocated the test-tube rather than slide methods of grouping. Knott 1,has recommended routine tube cell-tests with standard

sera, serum tests with standard cells and cross-matchingat 370 C.; subgroup agglutinins, especially sub A and Bin group O’s and rhesus-positives acquired throughprevious transfusions, will not be missed if these pre-cautions are adopted. When caution in administrationis added the " perfect tissue graft " of Whitby 2 shouldbe- attained. It is fortunate that the non-specific re-

actions from pyrogenic bacterial and other proteins-often due only to lack of cleanliness,with apparatus--are so rarely a danger to life. The same is not true of heathaemolysis or cold agglutination, and stored blood mustclearly be used with oare. Truly a bottle of blood canbe a nest of hornets. Adequate warning of these risksis not lacking in the everyday medical literature. In deedso much emphasis has been laid on them that there issome danger of overlooking the more immediatemechanical perils of venous infusion-blood, saline,anaesthetic drug, contrast medium, germicide, proteinhydrolysate or whatever it may be. Local infectionis still too common, especially in the leg veins, and therisk of leaving needles thinly if at all protected fromthe blanket can be reduced by bipp or sulphanilamidelocal dressings. Lawrence Abel’s suggestion of ambu-latory leg infusion, reservoir in hand, might be riskyfrom the point of view of infection. The dangers ofair-embolism, once as scorned as fat-embolism, wereagain brought out at the meeting by Dr. Keith Simpson.The use of closed pressure-fed reservoirs like the

McCartney bottle (when gravity feed and a good sizedneedle will suffice), of faulty rubber (especially war-timerubber) and leaky bevel unions, and the dangers of

fumbling with open venesection are at last becomingrecognised. Venesectors are liable at law for accidentswith apparatus, for as Kitchin 3 has said, " When aninanimate thing... is safe and proper if used with care "it is reasonable to argue that " an accident ... arisesfrom want of care." The public has a right to expectdue care and a degree of skill reasonable for the statusand experience of the operator and will assuredly obtainjudgment in the absence of either. It is a sign of thehealthy conscience of medicine that distinguishedexponents of intravenous anaesthesia have reported theirmisfortunes with aberrant arteries 4 Dr. Ronald Jarman

urged that if 28% of a group of Canadian soldiers areshown to possess such vessels due caution becomes amatter of " reasonable care and skill." We cannotafford to be ignorant of the possibility, and must ensurethat the vessel into which the needle is run is neither

1. Knott, F. A. Guy’s Hosp. Gaz. 1943, 56, 253.2. Wbitby, L. E. H. Lancet, 1942, i, 581.3. Kitchin, D. H. Legal Problems in Medical Practice, London.4. Macintosh, R. R. and Heyworth, P. S. A. Lancet, 1943, ii,

571.

pulsating nor contains bright red arterial blood. Whenan experienced anaesthetist gives warning of the dangerof handling phials whose labels have become detachedby storage, of unnecessarily concentrated solutions orbadly sterilised apparatus, it is time to tighten thestandards in infusion technique.

OPINION BY POSTMosT of our readers will now have had from the

British Medical Association a copy of the full white-paper on the National Health Service (provided by theMinistry of Health), an analysis setting out the BMAcouncil’s preliminary views, and a questionary preparedby.the British Institute of Public Opinion. The scientificstaff of the institute are to be congratulated on havingdrafted a document which is as lucid and objective ascould well be expected. The white-paper proposalsare certainly not easy to translate into questions capable

’ of simple answers, and the attempt has involved the useof questions of a length unusual in opinion surveys ;but we hope that even doctors who normally standaloof from " medical politics " will give the time and takethe pains necessary to send answers-if necessary fallingback on the philosophical formula " don’t know." Ifmany questionaries find their way into drawers or waste-paper baskets the survey will lose an important part ofits srignificance.Taylor has lately pointed out how misleading the

results of postal inquiries may be. NormaJly they aresent only to a representative sample of the people con-cerned, and since the returns are usually of the order of30% the sociologist may have no means of knowingwhat part of his sample has made the decision to returnthe questionary, and acted on it. But in this case thesituation is somewhat different. The questionary is beingaddressed hot to a sample but to the whole of the medicalprofession. It is thus in fact an attempt at a census.Errors in the drawing of the initial sample are thus beingavoided. To overcome the difficulty of the partialreturn, a detailed personal record is asked for in the lastpart of the questionary. The Central Medical WarCommittee already have all these details in hand for theentire profession, and by comparing the data it .wouldbe possible to weight the results of the returns-to makethem valid for sex, age, nature of work, place of practice,and so on. If some members of the profession do nptanswer the questions, such weighted results will be moreuseful than the simple gross totals expressed as percent-ages. It might still be argued that the inquiry revealedthe views of the more intelligent, informed and articulatedoctors inside each of the groups studied. The onlyway to have overcome this difficulty would have’ beento have interviewed a random sample of doctors drawnfrom the Medical Directory. A skilled interviewer has arefusal-rate with the general public of under 0-5%. Withdoctors this refusal-rate might perhaps have been higher,but it would nevertheless have been a small factor whencontrasted with the large field of error possibly arisingfrom non-return of questionaries. Unfortunately, thedistribution of the medical profession in space-fromBurma to Spitzbergen-makes the interviewing of arandom sample quite impossible ; so the British Institutehas been driven to apply the postal method as the onlyone available.The study of group opinion among experts is not quite

new. Professor Burt,2 in cooperation with the homeintelligence division of the Ministry of Information, hasinvestigated the opinions of teachers and educationistson educational reform. His questionary was even moreformidable than that of the BMA, but he used a verysmall sample. As we said last week, we welcome theBMA and BIPO experiment ; for it represents a new

1. Taylor, S. Public Administration, 1943, 21, 109.2. Burt, C. Occupational Psychology, 1943, 17, 157.

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attempt to make democracy work in a society which isyearly becoming more complex. ’ B

INFECTIONS WITH NON-SPORING ANAEROBESTHE frequency of gas gangrene and tetanus in the

wounded of the 1914-18 war led to much useful researchon the spore-bearing anaerobes, resulting in new methodsfor their cultivation and identification. The presentwar has given a further stimulus to the study of theseanaerobic bacteria, but so far little attention has beenpaid to the non-sporing anaerobes. MacLennan hasdescribed a gangrenous myositis, to be distinguishedfrom clostridial gas gangrene, due apparently to a

symbiotic action between the anaerobic streptococcus andone or other of the aerobic pyogenic cocci, while onanother page Forbes and Goligher report a case of genera-lised infection with a pleomorphic anaerobic gram-negative bacillus, Bacterium necrophorum. In peace-time these two organisms, the anaerobic streptococcusand the necrophorus bacillus, are not infrequentlyassociated with severe and characteristic-though, tothe uninitiated puzzlin-infections, and they are likelyto be responsible for similar infections in war casualties.

In civilian practice generalised infection with thesenon-sporing anaerobes is seen most often after difficultlabour or septic abortion where there are retainedproducts acting as a culture medium. Pelvic peritonitis,or more typically, septic thrombophlebitis, follows, andfrom the thrombophlebitis emboli are thrown off intothe circulation to be riddled out in the lungs particularly.Empyema is a common sequel to these multiple lungabscesses. Clinically this type of infection is charac-

terised by a remittent temperature to 103°-105° F. asso-ciated with daily rigors, signs of lung involvement, anincreasing anaemia and a downhill course. Spontaneousrecovery sometimes occurs for no obvious reason ; theinfection resists sulphonamide therapy. Anaerobic blood-culture reveals a non-haemolytic streptococcus or a finegram-negative bacillus, alone or associated with each otheror with other bacteria such as diphtheroids, enterococci,or coliform bacilli. An essentially similar syndrome hasbeen described by French writers 2 as a sequel to periton-sillar abscess ; the anaerobic gram-negative bacillus inthese infections is called Bacillus funduliformis but is

probably identical with Bact. necrophorum. Theseorganisms, incidentally, are poorly pathogenic for

laboratory animals, and in this respect differ from theBact. necrohoum of calf diphtheria, foot-rot in sheep,and labial necrosis of rabbits. Harris and Brownwho recovered the organism from infected caesarean ’

wounds, therefore suggested the name " pseudo-necro-phorus " for the human variant. Both the necrophorusbacillus and the anaerobic streptococcus, of which thereare also several variants,4 are to be found in the healthybody cavities (mouth, intestine and female genital canal)*and infection with one or other of them usually followssome necrosis or devitalisation of local tissue. The

range of these infections had lately been reviewed byMeleney and his co-workers.5 Wounds elsewhere in the

body, especially if there is necrotic tissue, may also actas a primary focus, and this is a possible explanation ofForbes and Goligher’s case where the infection began atthe site of a compound fracture of the thigh.

Routine anaerobic culture needs to be practised morein bacteriological laboratories so that infections of thistype shall not be missed. Useful advice is given in thesecond edition of the Medical Research Council’s memo-randum no. 2 on gas gangrene. ,

1. MacLennan, J. D. Lancet, 1943, i, 584.2. Lemierre, A. Ibid, 1936, i, 701.3. Harris, J. W. and Brown, J. D. Bull. Johns Hopk. Hosp. 1927,

40, 203.4. Prévot, A. R. Manuel de Classification et de Détermination des

Bactéries Anaérobies, Paris, 1940, p. 27.5. Sandusky, W. R., Pulaski, E. J., Johnson, B. A., Meleney, F. L.

Surg. Gynec. Obstet. 1942, 75, 145.

TOO MUCH SUNAir Commodore Morton told the Royal Society of

Tropical Medicine and Hygiene on March 16 something ofhis experiences in the prevention and treatment of heateffects during five hot seasons in Iraq. Superstitionsabout sunstroke have been .discarded with spinal pads,but the topee is still useful in really hot parts of thetropics. Ill effects from the sun are due simply to over-heating of the tissues and body fluids ; they are essenti-ally similar to those seen in furnace workers in temperateclimates. The least serious result is fainting, caused bytemporary cardiovascular disturbance but without

derangement of the chloride balance. More serious.exposure leads to heat exhaustion. Collapse, profuseperspiration, fall in blood-pressure, nausea, vomiting andsevere muscular cramps are associated with a fall in bloodand urinary chlorides. Mouth temperature may benormal but rectal temperature is often raised to 100° or101° F. The victims are usually of the lean, anxious andspare type ; many are affected soon after their firstarrival in hot climates. Treatment is best carried out ina temperature of about 75° F. Abundant fluid, withglucose and sodium chloride, should be given by mouth.If necessary, 0.9% sodium chloride must be given intra-venously, but it is important to keep careful watch onthe balance between input and output of fluids ; other-wise there is a serious risk of pulmonary oedema. Diuresisand a rise in urinary chlorides are reliable signs of

recovery. Attempts to correct acidosis or alkalosis shouldnot be made in the absence of strict biochemical control.The most serious condition is that of heat hyperpyrexia.

Thick-necked chronic alcoholics with high blood-pressureare most often affected, usually after they have beenseveral years in the tropics. Besides a fall in urinarychlorides there is a failure of heat regulation. Theflushed face, dry burning skin, delirium or coma areassociated with rectal temperatures up to 108°-112° F.If life is to be saved the temperature must be broughtdown quickly to 102-103° F. by whatever means ’ areat hand. In active service conditions, an iced enemais indicated, but this interferes with the recording ofrectal temperatures. In hospitals, sponging with coldor iced water and the use of fans should be continueduntil the temperature falls. A useful wind-tunnel wasimprovised with a shock cradle covered by d blanket.Ice-bags were hung from the roof, and fans blew a streamof cold air over the body. Air-conditioning of wards isa great help to nu-rsing ; 60° F. is the temperature recom-mended for the initial stages, but as soon as the dangerfrom hyperpyrexia is past the patient should be nursedat 75° F. Fluid with salt and glucose should be givenby mouth ; intravenous salines are seldom needed unlessvomiting is persistent-they may do harm by overload-ing a failing circulation. It is important to be sure thatsymptoms are not due to malignant tertian malaria, andintravenous quinine should be given if any doubt arises.Much can be done to prevent casualties from heat effects

by ensuring that newcomers are introduced graduallyto the sun, and by arrangement of working hours so- asto allow as many as possible to spend some of theiroff-duty time in air-conditioned rooms. Men should be

encouraged to " drink more water " and " eat more salt."

When the thermometer is really high, extra salt shouldbe put in the food. To ensure that this is done the medicalofficer may have to take his courage in one hand and a

bag of salt in. the other and have it out with the cook.

Brigadier F. A. E. CREW, FRs, has been appointed tothe Bruce and John Usher chair of public health in theUniversity of Edinburgh in succession to Prof. P. S.Lelean who has retired. Dr. Crew has held the Buchananchair of animal genetics in the university since 1928,but for nearly two years has been working in the medicaldepartment at the War Office, where he is director ofbiological research.