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The Widdicombe File

IV (2).-ALL IN THE DAY’S WORK y

MY DEAR BREWER,I am glad to know that you intend to do some of your

own clinical pathology. We all have a weakness for thatmythical beast, the old horse-and-buggy doctor, who,between daily tracheotomies and nightly csesarean

sections, cured every hysteric for miles around by forceof personality alone. You will be his lineal successor. Donot be afraid of poaching my preserves. The properprovince of the general practitioner is everything whichhe can do without interfering with all his other duties.If your venture does no more than spare me and mycolleagues some wasted hours looking at normal fluidsand excretions we shall be in your debt.

May I make some brief comments on your plansThe M.R.C. haemoglobinometer is a lovely yoke. I justwonder if for your job it is not rather like using a Purdygun for scaring blackbirds. The main fault with almost

every method of measuring haemoglobin is that you mustdo so with a pipette. Now cleaning pipettes is a nicehealthy job, but it must be done while the blood is wet.If you are called away as you are about to do it youwill either have to put in a lot of work with causticfluids or buy a new pipette. (And you would be surprisedhow many blocked-up pipettes there are in the backs ofthe cupboards of the most conscientious doctors.) Thereused to be a hsemoglobinometer—there may be still-which did not require a pipette but measured the bloodby allowing a thin film to run by capillary action betweentwo glass plates a fixed distance apart. When you hadfinished you merely wiped the two glass plates cleanwith some dry gauze or your handkerchief. There istoo another trick which I learned from one of the elderbrethren while sitting on a medical board. Apparatusrequired : needle, 1 ; corner of white blotting-paper,1 piece. Prick the patient and take a small drop ofblood on the paper. Prick yourself and put your dropbeside it. Compare. If your blood contains 14-5 g. of

hemoglobin per 100 ml. (or more or less) you will beable to detect a comparative pallor in his or her specimenif it contains 10 g. or less. Probatwln est as the old bookson magic say.Why use Leishman’s stain ? Jenner’s is easier to make

and to use and leaves you in no doubt whether a cellis a lymphocyte or a large mononuclear. IncidentallyI used to prefer it on aesthetic grounds. I am sure youare right to eschew the counting of blood cells. But ifyou own a haemocytometer keep it handy. Rarely, veryvery rarely, there are times in the middle of the nightwhen a knowledge of the total white-cell count is wortha lot. Any fool can do sedimentation-rates : to interpretthem demands mental powers of a very high order.Before you stain your vaginal swabs look at them wet-i.e., in saline. First you will see that some of them,despite the volume of the discharge, contain almost nopus at all but masses of desquamated epithelium. Passthem by. I do not know the cause or cure of this con-dition but I never find any infective agent in thesesmears. Trichomonas is plain to see but I would take noheed of monilia (candida in the best circles nowadays)unless accompanied by pus. Lastly I am all in favour ofyour syringe service. It will cost a lot but it seems tocome nearer to perfection than most of the tricks usedby your colleagues. When the practice can run to it,buy a small electric dry steriliser. I have known womenso ignorant that they thought meringues more importantin the domestic oven than glassware.

*Dr. Hawke is here answering Dr. William Brewer’s letterpublished on Nov. 14.

A sprinkling of clinical pathology can bring mucheclat and quite a lot of new patients to a practice. I haveseen it happen. When your practice has expanded to thepoint when the laboratory bench is used to house recordcardsŇŇŇI will not go on. May I add two words more I

Fascinating though all the gadgets are when they firstarrive I believe that the mere performance of thesetests will pall in time. Set yourself a plan which willkeep your mind as well as your fingers busy. How manymen and women are doing their daily job with less than12 g. of haemoglobin per 100 ml. ? We know a lot abouthospital admissions and expectant mothers but not muchabout the ambulant population. How many young menshow positive tests for occult blood who have neitherulcers nor piles ’? My other precept is a graver one.

Never believe your results if they contradict your otherobservations or common sense. " I beseech you, in thebowels of Christ, think it possible that you may bemistaken " : Noll had the right idea. An unshakeablecertainty of the correctness of his own findings is thesurest hallmark of an inferior clinical pathologist

Yours sincerely,HARRY HAWKE.

N.B.-Always prick the lobe of the ear and not thefinger ; they can’t wriggle so much.

HARRY HAWKE.

1. Western Daily Press, Nov. 11, 1953; South Wales Echo, NOV. 9.

Medicine and the Law

Hospital Charged with Inadequate SupervisionSnORTAGE of staff in a small hospital proved to

be no defence in a recent action at Monmouthshireat;::;Îzes.1A patient who was admitted to hospital at 2 P.1!,

was suffering from pneumonia. The sister on dutystated that he had shown no sign of being irrational whenshe handed over charge to another sister at 8 P.M..Accord.ing to the counsel appearing for the patient’s widow,the delirium stage of pneumonia had been reached,There were signs by 8.20 that the patient was slightlyirrational and by 11.30 that he was definitely in thatcondition. Some time between 1.30 A.M. and 3.15 heleft the ward in his pyjamas with a blanket round hisshoulders. He tried to enter the cab of a lorry whichhad stopped temporarily at traffic lights. The driver,being forbidden to give lifts to passengers, refused himentry. Eventually the body was recovered from theriver Wye, some strips of the blanket being found oneach side of a bridge. At 3.25 of the night on which hedisappeared he was reported to the police as missingas from 3.15. It appeared that an entry " patient walkedout between hours of 2 A.M. and 3 A.M." had been

pasted over the original entry " fairly comfortable

night."It was contended for the defence that the patient

might have got up and walked out if he had remainedat home. The judge did not regard this argument asexcusing the hospital. He held that the night sisterand the orderly on duty with her were negligent in

leaving the man unwatched. There was also negligencein the staffing of the hospital. The defendants knewthat the patient was suffering from a dangerous diseaseand that delirium at some stage was likely. A medicalwitness, called by the plaintiff, had expressed the viewthat one trained nurse and a ward orderly with nonight porter were insufficient night staff in relation tothe case. The hospital matron said the system of lockingthe outside doors of the hospital and leaving the k-ey’on the inside was the best possible.Damages of 3049 were awarded by the judge to the

widow and infant daughter.