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·THE HOUSE PHYSICIAN'S HANDBOOK

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·THE HOUSE PHYSICIAN'S
HANDBOOK
BY
CALLAN BIRCH
MD. FRCP
Physician
Chase Farm Hospital Enfield
E & S LIVINGSTONE LTD
EDINBURGH AND LONDON
1955

·Printed in Great Britain

·PREFACE
THIS
HIS small book has been compiled to provide
information about many of the procedures which
the house physician will have to use or know about day
by day in his work Some teaching hospitals have issued
valuable books of this type It is hoped that doctors
working in Regional Hospitals will find this one equally
useful
The doses of all newer drugs are given in the Metric
System but the Imperial System is used for drugs at
present commonly prescribed in it The approximate
Metric equivalent is added in the hope that the house
physician will learn it as a step towards the day when
Metric doses alone will be used
As the list of subjects which could have been included
is endless criticism of the present selection and sug
gestions for its improvement are expected and will be
welcomed
CALLAN BIRCH
CHASE FARM HOSPITAL
ENFIELD MIDDLESEX
1955

·CONTENTS
PAGE
CHAPTER
INTRODUCTION
V11
I GENERAL DUTIES AND INFORMATION
1
11 CLINICAL PROCEDURLS
44
11 CLINICAL PATHOLOGY
63
IV TREATMENT
107
V XRAY DEPARTMENT
154
INDEX
158
V1

·INTRODUCTION on YOUR resident post, in hospital provides a great opporturuty for you to learn about the continuing care of the patients under your charge Make the most of this Watch carefully day by day the course of illness and the effect of treatment Learn all you can of the art of prognosis and of dealing with relatives Much of this book is about the technical procedures used in diagnosis and treatment but you should not regard your patients merely as interesting cases whom to use these techniques They are human beings many of them anxious worried and full of doubts and fears The picture each presents will be coloured by his emotional make up Always remember that you are treating patients and not diseases for as Trousseau said long ago il ny a pas de maladies il ny a que des malades For all patients the best doctor is the one who can best inspire hope In all your work therefore do not forget the human touch "Tis the human touch in this world that counts The touch of your hand on mine Which means far more to the fainting heart Than shelter and bread and wine For shelter is gone when the night is o er And bread lasts only a day But the touch of the hand and the sound of the voice Sing on in the soul alway Spencer Michael Free 1856 1938 MD Johns Hopkins 1880 VII

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·CHAPTER I
General Duties and Information
ON ARRIVAL
1 Try to meet your predecessor before he leaves and
learn from him the peculiarities of the job
- 2 Fairly soon after arrival make yourself familiar with
the administrative arrangements of the Laboratory
the X ray Department the Dispensary the Records
Department and the Almoners Office
3 Make sure that you are a member of a Medical
Defence Society and that your subscription is not in
arrears Many Hospital Management Committees
make this a condition of employment
ON DEPARTURE
1 Complete and return all outstanding case notes
2 Return all library books and keys
3 Ask your chief for a testimonial
4 Leave a forwarding address
ETIQUETTE AND ADVICE
1 Don t put a practitioner through a viva voce when he
requests a bed for his patient He probably knows
more about the common causes of acute illness
than you do
2 If you are only a locum preserve the status quo
Leave any improvements to the permanent staff
3 Don t write letters to committees without consulting
your chief first Your requests are then more likely
to receive favourable consideration
1
1

·2 THE HOUSE PHYSICIANS HANDBOOK 4 When another member of the staff has seen your patient previously be careful not to leave him un informed or not consulted without reason He and the patient may be pleased to meet again 5 Never let the patient see that you are in a hurry 6 Don t pooh pooh the patients suggestions but give them courteous consideration 7 Remember that if a patient is not satisfied his treat ment is incomplete Curb any aptitude for debate or taste for recrimination as far as he is concerned 8 Dont think it infra dignitatem to ask Sisters opinion She has had much experience 9 Always be reassuring to the patient even when you have to tell his relatives the sad truth Kipling said The most powerful drug in medicine is the spoken word 10 Whatever you tell the patient let it be in words that he can understand Except ye utter by the tongue words easy to be understood how shall it be known what is spoken For ye shall speak into the air I Corinthians XIV 9 11 Use your unaided senses first Eyes without the microscope ears without the stethoscope wits without the help of chemistry and radiology not that we should deny ourselves the proper use of these can often carry us a long way John Ryle So order investigations with discrimination and use the least unpleasant ones first 12 Read Sir William Osler s address Aequanimitas CASUALTY DUTIES You may be called on to do a period of casualty duty in the evenings Do not change this without notifying the ·GENERAL DUTIES AND INFORMATION 3 Receiving Room and the telephonist If you are likely to be elsewhere than in your wards or room let the Receiving Room and the telephonist know where you can be found When admitting a child it is very helpful to record - whether he has had measles etc It is necessary to remind all housemen that in the case of a possible fracture no matter how trivial the injury you should always 1 Have the patient X rayed and see the wet film 2 Give the patient appropriate treatment and refer him to the next fracture clinic 3 See the radiologist s report later NOTE TAKING This art is by far the most important part of the clinical examination and great care should be spent on it The patient s story should be elicited and written down legibly under the headings-History of the present condition Past Illnesses and Family History though not necessarily in this order It is often best to let the patient tell his story to the doctor in his own way and in some cases alone in a quiet room He may have to be coaxed to find words to express what he feels Do not hinder this by using what may be an unsuitable mode of address but try to size up the patient and sense which approach is best to make In the case of a child find out from the parents before they leave whether he has had the various fevers and when and also what immunising injections have been given The various systems should be examined and the findings recorded A brief summary of the positive and important negative findings is useful as are also a final few words showing how the patient was disposed of It ·4 THE HOUSE PHYSICIANS HANDBOOK is well to initial or sign the notes If you have to write letters about the patient make it clear that you do so on behalf of your chief Try to avoid abbreviations especially private ones and also facetious comments and exclamation marks You do not know who may read your notes later and you may meet them again in a court of law If your hospital uses a unit system for records put the patients unit number as well as his name on all his papers You should also try to complete any items on the Details Sheet which were omitted by the Admissions Officer eg the National Health Service Number A more elaborate examination should be made of the system or part which seems to be mainly involved On almost every patient it is advisable to record the blood! pressure the result of urine testing and to have the chest X rayed and the haemoglobin estimation made When certain diagnoses seem probable the house physician may order the various investigations and per form the necessary manipulations on his own initiative eg in septicaemia (blood culture) in possibly syphilitic conditions (Wassermann reaction) and so on But he should beware of ordering without due forethought a large number of tests or tests involving much labour in the laboratory (see page 65) He should always explain to the patient what it is proposed to do Acquiescence in the examination implies consent but for anything of an operative nature a form of consent should be signed PATIENTS WHO DO NOT SPEAK ENGLISH The following words and phrases may help the house physician faced with a patient who speaks no English ·Engl F h Ital What is your name? Comment vous appelez 1 ie heissen Sie? vous? Come vi chimate? Are you married? Etes vous marié(e)? Sind Sie verheiratet? Siete sposato (sposata)? How old are you? Quel áse avez vous? Wre alt sind Sie Quanti anni avete? Where do you live? Ou habitez vous? Wo wohnen Sie Dove abitate? What is the matter? Qu avez vous? Was fehlt Ihnen? Quali disturbi? Where the pain? Ou avez vous mal? Wo tut es weh? Dove e che vi fa male? Have you had an opera Avez vous été opéré(e)? Sind Sie operiert worden? Avete subito un inter lion vento operatorio? Have you had a similar Avez vous dé)4, eu une Haben Sie schon mal Avete avuto prima un attack before? maladie semblable? eigen ähnlichen Anfall simile attacco? gehabt? Take off your shirt Enlevez votre chemise Ziehen Sie Ihr Hemd aus Volete togliervi la cami cia e la maglia Lie on the couch Couchez vous sur le Legen Sie sich auf das Sdraiatevi sul lettino per divan Sofa favore Open your mouth Ouvrez la bouche Öffnen Sie Ihren Mund Aprite la bocca per placere GENERAL DUTIES AND INFORMATION ·6 E gl h F G D Ital n Say Ah! Dites Ahi Say 991 (or phrase used |Dites 33! (trente trois) for same purpose) Swallow Avalez Sagen Sie Ah! Dite Ah! Sagen Sie 99' (neun Dite 33 (trentatre) undneunzig) Schlucken Sie loghiottite Toussez Husten Sie rossite Stehen Sie stult Ed ora-state fermo Cough Keep still Breathe deeply Draw up your knees Restez tranquille Respirez profondement Atmen Sie tief Respicate profondamente Soulevez les genoux Ziehen Sie Ihre Kniee Piegate le ginocchia e hoch tiratele su THE HOUSE PHYSICIANS HANDBOOK This will not hurt you Ceci ne vous fera pas mal Das tut nicht weh Questo non fara male Dont be afraid Nayez pas peur Haben Sie ke ne Angst Non abbiate paura I shall not be long now Je ne serai pas long Exren Augenblick temp maintenant Ho quası finito You are very good Vous etes très brave Sie sind sehr tapfer Bravo cosi va bene All over C est fini Das is alles Ho finito grazie Medicine Médecine Vedızın Medicine ·F C gl hi h It lan Gm For external use Pour usage externe Fur ausserlichen Geb Per uso esterno rauch Do not drink itt Ne buvez pas cela Nicht trinken Non bevetelo! Three times a day Trois fois par jour Dreimal taglich Tre volte al giorno Accident? Accident? Unfall? Accidente? All right? C est bien? Gut? Va bene? Good? Bon? Gut? Bene? Bad Mauvais Schlecht GENERAL DUTIES AND INFORMATION Cattivo Better Mieur Besser Meglio Black Noir Schwarz Nero Blood Bowels open today? Sang Blut Sangne Avez vous le ventre Haben Sie heute Stuhl Sie audato di corpo oggi? libre aujourd hur? gang gehabt? Toussez! Husten' Tossz! Cough! Cough? Toussez vous? Husten Sie? Tosse? Fever Fièvre Fieber Febbre 7 ·8 Engl Geras Italan Headache Mal de téle hopfwch Malc di capo Krankenhaus Hospital Ospedale Hospital Hopital How many days? Combien d heures? Quante ore? Wie viele Tage? Haben Sie Hunger? Hungry? Avez vous fatti Avete fame? Injection Injechon Iouezione Eldspritzung Achtung! Lock out Prer z garde! Badater NO han Nest) No THE HOUSE PHYSICIANS HANDBOOK Not Pas ne pas Nicht Non Parn Douleur Schmeszen Dolore Pregnant En einte Schwanger Gravida Rigars Frissons Suhüttelfrost Accesso febbraio Auswurf Spiedo Shuium Expectorations Temperature and pulse Température et pouls Temperatur und Puls Temperatura e poſso Thyssty? Avez vods 30:17 Durstis? Avcte Setc ·It 1 Germs F E glish h Today Aujourdhur Heute Oggi Demain Tomorrow Morgen Domani Tonight Stanotte Ce soir Heute Abend Uryat Urine Urina Urin GENERAL DUTIES AND INFORMATION Vomited? Avez vous vomi? Haben Sie erbrochen? Avete voi vomitato? When Quand Wann Quando Where Ou Ho Dove Yes Oui Ja Si Yesterday Hier Cestern leri 9 ·10 THE HOUSE PHYSICIANS HANDBOOK Further help in other languages may be obtained from the British Red Cross Society s language cards (14 Grosvenor Crescent London SW 1 SLOane 519)) When pronunciation is a difficulty progress may be made by pointing to the appropriate word Often a colleague or nurse can be found who speaks the language in question SIGNS OF DEATH In cases of long illness it is not difficult to decide when death has occurred Cooling rigor mortis and post mortem changes are the infallible signs and in some cases eg drowning they should be awaited before re suscitative measures are given up In other cases of probable sudden death eg coronary occlusion cessation of circulation as shown by auscultation is the best sign Death cannot be considered as certain until the heart has stopped beating for at least five minutes Fragmentation of the column of blood in reunal vessels | cattle trucking is a useful sign coming on within a few minutes of death and soon passing off If requested to perform a special test of death expose the radial artery at the wrist and cut it across Having demonstrated the absence of bleeding apply a strip of plaster HOW LONG DEAD? You may occasionally be asked your opinion as to when death occurred In the case of a recently dead person it is well to collect the evidence (rectal tem peraturel on which this opinion can be based Since the rate of fall of body temperature after death is approx ·GENERAL DUTIES AND INFORMATION 11 mately 15 F per hour in room temperature between 50 F and 70 F the number of hours since death is given by the formula 98 4 minus rectal temperature IS The result should be interpreted with caution The state of rigor mortis may be helpful It starts on the face six hours after death and reaches the hands and feet at twelve hours it stays for twelve hours and takes twelve hours to pass off PERMISSION FOR POST MORTEM EXAMINATIONS After death the patients body is the property of the relatives and while not a strict legal requirement their permission should be sought before a post mortem examination is made in some hospitals a special person in the records or almoner s department interviews the relatives but in others it is the doctor s job You may already have some idea of the mental attstude of the relatives and this will help you in the kind of approach to be made If possible see the responsible relative in a quiet room and let him be seated Allow him to discuss the illness and ask questions One of these will often give the opportunity to say that a true answer can only be given after a post mortem examina lion has been made Failing this you should make a direct request for permission to make the examination Stress the fact that it is in the interest of the relatives and their descendants to know the exact cause of death In most cases permission is readily given ·13 THE HOUSE PHYSICIANS HANDBOOK 011 When objections are raised don't make a begging approach or the relatives may feel they would be doing you a favour in giving permission Point out that post mortem examinations are quite usval that the body is not disfigured and that the face is not touched Dispel iny misconceptions that the body will be experimented or used for teaching anatomy If you have some real doubt as to the cause of death you may say that you would find it difficult to sign a certificate and that one giving an uncertain cause would be refused by the registrar and referred to the coroner It is unfair however to use the possible alter native of an inquest as a definite threat (Once a case has been reported to the coroner a post mortem examina tion can only be made with his consent) Sometimes a partial examination is allowed Always then be careful to tell the pathologist lest he do too much If the relatives ask to be told the nndings send them a letter written in simple non technical language Try to reassurc them if possible that the cause of death was such that in the present state of medical knowledge no treatment could have prevented it DEATH CERTIFICATES There is considerable confusion in the minds of many doctors on the subject of death certificates and notifica tion of the coroner It is hoped that the following notes will make the present position clear It is usually the houseman s job to certify the cause of death on the prescribed form to the best of his knowledge and belief and without fee Before signing ·GENERAL DUTIES AND INFORMATION 13 your first death certificate you would be wise to make an opportunity to study the Notes and Suggestions to Certifying Medical Practitioners in the front of the certificate book and the List of Indefinite ar Undesir able Terms By the Deaths Registration Act 1953 all deaths must be certified if a doctor has attended the patient during his last illness irrespective of whether the doctor or someone else has reported the case to the coroner The doctor who certifies must be the registered (or provisionally registered) medical practitioner who has been in attendance during the deceased s last illness He must also have seen the deceased within fourteen days before death or his body after death (but not necessarily both) Unless it is for cremation there is no legal obligation on the doctor to see the body after death but he must be satisfied es from the ward sister s report that the patient is dead seen The section after death by me on the not seen certificate is included to help the registrar to decide whether to report the death to the coroner The procedure should therefore be as follows-Carefully observe the rules of your hospital about the time and place for signing death certificates Sign the certificate (for placing in the envelope addressed to the registrar) the Notice to Informant (for handing to the informant) and the counterfoil (for retention) The certificate must be sent to the registrar forthwith Dont keep the relatives waiting or delay signing until after an autopsy since this would mean two visits for ·14 THE HOUSE PHYSICIAN S HANDBOOK them-one to give permission and another to get the certificate Give the certificate at once so that funeral arrangements can proceed In the case of a cremation certificate however it is generally best to complete this after autopsy since the cause has to be certified definitely and not just to the best of your knowledge and belief If you do not know the cause put down Not known or uncertain In such a case and also if the death was one of those which the registrar is bound by law to report to the coroner (see page 15) it will save time if you report the case yourself You should then initial the back of the certificate at A If there is an autopsy initial space B on the back of the certificate and correct the diagnosis later if need be when asked If you see a patient for the first time who is moribund and who dies in the receiving room you are not qualified to give a death certificate since it has been held that one attendance is not sufficient to justify your stating that you attended during the last illness You should ring up the home doctor and if he cannot or will not give a certificate then you should inform the coroner Scottish death certificates differ in several ways from those in use in England and Wales The causes of death are stated in the reverse order from that used in England and the doctor is not required to say whether they were confirmed by post mortem or whether he has seen the body after death There are no provisions for initialling the back of the certificate there is no Notice to Informant certain particulars about pregnancy are required and the certificate must be delivered to the registrar within seven days ·GENERAL DUTIES AND INFORMATION 15 NOTIFICATION OF THE CORONER The Registrar of Deaths is the chief person whose statutory duty it is to report to the coroner (or in Scotland the Procurator Fiscal) deaths which seem to him to come within the coroner s jurisdiction There is no similar statutory duty laid on a doctor as such though this duty may apply to him in his capacity as head of an institution such as a mental hospital It may be that the coroner has a social or moral claim on the doctor as on anyone else to report an unnatural death to him but as such a claim would have no statutory basis and as in any case the test of enforcement could not be applied no claim of this sort is exercised The doctor and indeed anyone else should be careful that he could not by any intended act or omission be held to be obstructing the coroner in his duties A system of cordial cooperation has grown up whereby coroners cases are reported direct to the coroner by the doctor and this is very convenient to all concerned if you are in doubt as to whether the coroner should be informed consult your chief or the records officer or have a word with the coroner s officer himself Deaths which it is the registrars statutory duty to report to the coroner are -- 1 those where a registered medical practitioner was not in attendance 2 those where no certificate can be given 3 those where the deceased was seen neither after death nor within fourteen days before death 4 those where the cause of death is unknown (ie where there is an uncertain certificate)

·16 THE HOUSE PHYSICIANS HANDBOOK
5 those where death was unnatural due to accident
violence or neglect or where it occurred under sus
picious circumstances
6 those where death occurred after an operation
7 those where death was due to abortion industrial
disease or poisoning
The list of industrial diseases is modified from time to
time and includes -anthrax chrome ulceration com
pressed air sickness epitheliomatous viceration toxic
anaemia toric jaundice and poisoning by anılıe arsenic
benzene beryllium carbon di sulphide lead manganese
mercury and phosphorus It would be wise to include
also deaths from alcoholism and drug addiction and any
unusual diseases like glanders or those of possible
accidental origin like Weil s disease
Some coroners ask that all deaths within twenty four
hours of admission to hospital should be notified to them
but this is a purely private local arrangement
In a case of great clinical interest which from some
accident comes under the coroner s jurisdiction the house
physician should make a special request to be present at
the autopsy (see page 17) Otherwise valuable material
although of no medico legal importance may remain
unexamined
ATTENDANCE AT A CORONER S Post MORTEM
EXAMINATION
Although it is within the power and discretion of the
coroner to say who may be present and who may be
excluded from a post mortem examination there is usually

·GENERAL DUTIES AND INFORMATION 17 no objection to your attending if you do so purely out of medical interest if you had assisted at an operation or had given an anaesthetic to the deceased person and might be deemed to have been negligent then you should not attend without the coroner s consent Under the Coroners (Amendment) Act 1926 you could send a representative ROUGH WEIGHTS IN OUNCES OF CERTAIN ORGANS (For ranges sex differences and weights of other organs see the table in the post mortem room) Thyroid 1 oz (30 G) Pancreas 3 OZ (90 G) Kidneys 41 oz each (135 G) Spleen 6 oz (180 G) Heart 10 Oz (300 G) Liver 50 to 60 oz (3 lb +) (1 5 to 18 kg) DEATH BED WILLS The house physician or anybody else (eg a nurse even if under twenty-one) may witness the signature to a will If asked the house physician may help a patient to make his will if a solicitor is not available and if he is satisfied that the patient is of sound disposing mind' If a special form is not used simply write in ink on plain paper as follows This is the last Will and Testament of Mr AB of in the county of I revoke all former Wills by me made I appoint to be the Executor(s) of this my Will (Here follou all bequests and instructions) ·18 THE HOUSE PHYSICIANS HANDBOOK In witness thereof I have hereunto set my hand this day of one thousand nine hundred and Signed and acknowledged by the said AB the testator as and for his (her) last Will in the presence of us both present at the same time who at his (her) request in his (her) presence and in the presence of each other have hereunto subscribed our names as witnesses Testator s signature Witness s signature address and occupation Witness s signature address and occupation (If itnesses must not be executors or persons who benefit under the 17 all) DYING DEPOSITIONS AND DECLARATIOVS The house physician may be asked to take down the statement of a dying patient He would generally be wise to do so although there is no legal obligation When the patient is in settled hopeless expectation of death the statement he makes is a dying declaration It is limited to cases of homicide but is only admissible as evidence in reference to the person who makes it What he says should be written down in full together with any questions used to elicit full information and their answers The phrase Having the fear of death before me and being without hope of recovery must be included The presence of a magistrate is unnecessary The declaration should be signed by the dying patient if possible and by the person who writes it down Witnesses are not necessary but are desirable When it is the doctor who thinks the patient is unlikely to recover but the patient is unaware of the imminence of death the statement taken is a deposition A magistrate ·GENERAL DUTIES AND INFORMATION 19 should be summoned and he will see that the legal requirements are complied with EMBALMING The probability of having to embalm a body is remote but when it has arisen it has usually been bungled by the young doctor It is always best to call in the expert but these instructions are given to help the house physician who may have to comply unarded with a request to preserve a body 1 If no embalming materials are available ice or solid CO should be packed around the body which should be kept in the coolest available place 2 In the absence of ice or instruments other than a syringe any available antiseptic (preferably formalın) should be poured into the mouth and injected into the chest and abdomen The coffin should then be packed with a mixture of ashes or sand with chloride of lime (bleaching powder) This will delay decom position but should not be used if the relatives wish to view the body later 3 For embalming various solutions containing formalın are used A good one is — Formalın (40 per cent) 4 pints (2 25 litres) Carbolic acid (crystalline) 1 lb (500 G) Water 2 gallons (9 litres approx) le roughly 20 per cent formalin and 4 per cent carbolic acid in water Very much weaker solutions are adequate for newly-dead tissues There are many excellent proprietary solutions ( Arandee Carswan and 20th Century) For obvious medico legal reasons arsenic should ·20 THE HOUSE PHYSICIAN S HANDBOOK never be used in most cases two gallons of solution will be needed for an adult Technique --To avoid fixation in awkward positions the body should be horizontal and the eyes and mouth closed If necessary a thread may be inserted round the lower jaw and through the nasal septum and tied A small pad of vaselined wool under the eyelids improves the facial appearance Rigor mortis should be broken down by moving all joints Any necessary shaving should be done before injecting The lips should be smeared with petroleum jelly to protect them against preserving fluid regurgitated from the lungs The axıllary artery and vein are exposed and the vein divided Using a Higginsons syringe or a cannula connected to a cistern three to six feet high the artery is first injected both ways with warm water containing four teaspoonfuls of salt to a bucketful This washes out all the blood and avoids trouble from possible coagulation by formalin The washings can be collected by a special cannula in the vein to avoid undue soiling of the bed The embalming solution is then injected and its penetr? tion aided by gentle massage Complete distribution can be aided by cutting off the venous drainage at intervals Enough has been used when it begins to return from the vein and the tissues assume a definite firmness Any parts which do not firm up should be separately injected The body cavities and bladder should be aspirated and injected separately using a 12 inch trocar through a small incision just above the umbilicus If a post mortem examination has been performed then the Six point method must be used This consists of injecting in both directions each carotid axıllary and femoral artery In addition the wall of the abdomen and ·GENERAL DUTIES AND INFORMATION 21 chest must be infiltrated by needle and syringe The soft Viscera are best destroyed otherwise they should be soaked for twenty four hours in the solution and then returned If autopsy is performed after embalming it should be delayed twenty four hours The cosmetic aspect should not be ignored The body should be smeared with petroleum jelly (preferably con taining 10 per cent of thymol to prevent the growth of moulds) ON CERTAIN RELIGIOUS MATTERS These brief notes are included to guide the house physician on religious matters concerning his patients He should be on friendly terms with all visiting clergymen and religious workers and help them in every way possible in their work Only urgent and essential treatment should delay their access to patients Church of England patients - The clergyman is usually informed by the relatives that the patient is in hospital or by the ward sister at the patient s request When Holy Communion is administered a table or locker with a white cloth and a medicine glass of water are provided at the bedside behind screens When anointing is requested a little cotton wool should be put out also Roman Catholic patients --The priest is usually sum moned by the nursing staff but it is well that the house physician should know how and when this is done The priest should be informed as soon as a Roman Catholic patient is placed on the Seriously Ill List It is helpful if he can be told if the patient is unconscious If a Roman Catholic patient is brought in dead or quickly dies the priest should be informed nevertheless Extreme Unction or Last Rites are administered to seriously ill ·22 THE HOUSE PHYSICIAN S HANDBOOK pQuents and for this it is usual for the ward sister to provide the same materials as for Church of England patients A small vase of flowers may be included Similar preparations arç made for Holy Communion The patient must be fasting though a cup of tea an hour previously is allowable Medicines need not be omitted Patients of other denominations ---The Minister con cerned will make his requirements known to the ward sister Jewish patients - When a Jewish patient dies the body should not be removed to another room but should be kept in the ward at least until dawn and preferably not taken to the mortuary until a watcher arrives In the case of a moribund Jewish infant no special measures are called for and after death the procedure is as for an adult Post mortem examinations are usually only per formed on Jewish patients on the coroner s order BAPTISM The house physician should know what to do if faced with a request for baptism of a very ill child The clergy man should be summoned if possible and baptism by a lay person such as 3 doctor or a nurse should be per formed only in a case of necessity The reality of the necessity however is for the person performing the baptism to decide Baptism may be administered by any sane person male or female whether he or she has been baptised or not and irrespective of religious belief provided it is intended to do what the Church does Two things are necessary (1) Invocation of the Holy Trinity and (2) the use of water If these are used baptism is valid Godparents are unnecessary in an emergency ·GENERAL DUTIES AND INFORMATION 23 The doctor s fingers moistened with water should touch the child s forehead while he says 1 baptise thee (A) in the name of the Father and of the Son and of the Holy Ghost (Roman Catholics require the water to be poured) A name is not necessary for emergency baptism If there is any doubt particularly in the mother s mind as to whether baptism has already been performed or whether the child is alive the baptism should be made conditional by prefacing the above words with can be baptised The clergyman of the parents denomination should be informed afterwards If you MEDICO LEGAL NOTES Many doctors are very vague about certain medico legal points and so a few selected subjects of general interest are briefly mentioned here When any circum stances may even remotely involve the doctor in medico legal difficulties the best advice he can be given is that he should inform his medical defence society at once of all the circumstances in detail He must not have neglected of course to pay his annual subscription and every newly qualified doctor is strongly advised to do this by a Banker s Order (A pre registration house physician can join a medical defence society on taking up his appointment and is entitled to full benefits and privileges) OWNERSHIP OF CLINICAL RECORDS Clinical records are the property of the Hospital Management Committee It is perfectly proper for the Committee to call for them when confronted with a Situation ég legal proceedings necessitating their eramination It is not permissible for committee members to peruse them for personal reasons ·224 THE HOUSE PHYSICIANS HANDBOOK Occasionally a patient prefers that certain facts should not be recorded in black and white in the notes Then and also when you feel it would be prudent to omit them either nothing should be written down in the notes or the papers should be kept in your private file A tactful records officer before handing over a patients records to the Committee s representative will first seek the formal permission of the doctor concerned On some occasions it would be wise to obtain the patient's written consent first RESPONSIBILITY OF HOUSE PHYSICIANS There are certain duties which you can properly perform without reference to your chief eg lumbar puncture in possible meningitis There are other duties about which your chief should first be consulted When you engage in a procedure which is well within your competence and skill and which is within the general delegation which you enjoy then you can be held responsible for all that flows from that procedure So long as you restrict your activities to the orbit within which it is usual for a house physician to act then your chief can repudiate responsibility for any mishap As he cannot do all the work himself you are there to help him but he has a responsibility for the supervision of your work and so might be involved also in any action against yourself Under the provisions of the Medical Act 1950 sub section 3 a pre registration houseman is entitled only to carry out duties assigned to his appointment ie he can only practise in hospital ·GENERAL DUTIES AND INFORMATION 25 HOUSE PHYSICIANS WHO ARE MARRIED WOMEN As confusion may arise eg on certain certificates if a registered medical practitioner does not use the name by which he or she is registered with the General Medical Council a married woman practitioner should continue to use her maiden or other name in which she was originally registered She can change her name in the Medical Register by sending her written request with her marriage certificate and a fee of five shillings to the General Medical Council 44 Hallam Street London W1 STUDENTS IN THE WARDS Many students now work not only in teaching hospitals but also during vacations in regional hospitals Their position in the wards has never been defined by legal decision You should therefore only give them duties which they could reasonably be expected to perform In any legal action the circumstances of the case would be all important and also whether the student exercised what was regarded as a reasonable degree of skill and care Only a registered medical practitioner (or a pre registration houseman in hospital) may legally prescribe a dangerous drug but a student or nurse may legally administer it MEASURES UNDERTAKEN BY THE NURSING STAFF The house physician should remember that if he asks a nurse to carry out some procedure eg taking of blood or giving an intravenous injection which is outside the scope of her normal duties he takes the responsibility He should only do this if he has satisfied himself by personal observation of the nurses competence If he is doubtful ·26 THE HOUSE PHYSICIANS HANDBOOK about this he should use the needle himself Nurses who hold the ophthalmic certificate are qualified to remove corneal foreign bodies PATIENTS WHO RFruSE TREATMENT If after clear explanation the parent refuses to stay hospital or to have treatment as advised the fact should be recorded in the notes The patient should be asked to sign a statement ACCIDENTS TO PATIENTS Should an accident befall any patient go promptly when summoned Enquire into the circumstances examine the patient fully and order any necessary X ray eramına tron Make a written record (on a special form if required) and include a note of the place where the accident occurred It is often helpful to note the condition of the patients shoes Take all steps necessary to reverse the consequences of any accident If it seems that you may be involved as a cause inform your Medical Defence Society DISCLOSURE or INFORMATION Normal enquiries by relatives and friends about health and progress should always be answered courteously with patience and in general terms Confidential informa tion is in a quite different category No employer or member of a patients family or solicitor or other person acting on their behalf should be given any confidential information without the patients written consent To act otherwise particularly in cases of pregnancy and venereal disease would be to place vourself in a position of perit ·GENERAL DUTIES AND INFORMATION 27 with regard to breach of professional secrecy Only by meticulous observance of this rule can you avoid the risk of serious trouble If detailed information is wanted for some specific purpose either during the illness or after wards the patients written consent to give it should always be obtained When it is the police who ask and particularly if they ask over the telephone the house physician should refuse to be stampeded by the official atmosphere into saying something which he might later regret It is always best to consult the patient and obtain his consent to give information If this is not possible and the doctor feels it would be ethically wrong to speak he should not do so His knowledge is confidential but he should be careful that his refusal would not be against the public interest or such as to make him liable to be charged as an accessory PROFESSIONAL SECRECY WHEN IN COURT Professional secrecy is not legally recognised and so you have an obligation to answer questions put to you in the witness box It is quite proper however if you find yourself asked for information when you do not hold the patient s consent to disclose it to appeal to the judge nevertheless to take the professional rule of secrecy into consideration You should do it when the question is asked and say to the judge My lord it would involve a breach of professional secrecy if I were to answer this question am I compelled to answer? You would then be wise to follow the judge s ruling though you could accept imprisonment for contempt of court instead if you still felt you could not answer ·28 THE HOUSE PHYSICIANS HANDBOOK WHAT TO DO IN A CASE or ALLEGED RAPE If faced with this problem the house physician would be wise to seek the help of a senior colleague Alleged rape is an emergency situation since conclusive evidence of it soon disappears Examination should be made at once but never without the person s consent In the case of a girl under sixteen the consent of the parent or guardian is essential It is best to exclude all relatives and friends and then a detailed history of all the circum stances should be taken A general examination for scratches and bruises should follow The woman should then be thoroughly examined in the lithotomy position in a good light Take charge of underclothing for sub sequent examination for seminal stains Note and take a specimen of any matted pubic hair Look for bleeding and for bruising of the vulva and tearing of the hymen Note the condition of the vagina Using a swab stick moistened with physiological salıne make thin smears from the vagina on several glass slides If requested to examine a male accused of rape only do it with his full consent (preferably written and witnessed) Tell him of his right to refuse look for scratches and bruises and examine the penis for recent turgescence and tears of the frenum Mahe smears from any meatal moisture INSANITY When a patient s mental state becomes such that he cannot remain in a general ward the house physicians main concern is how to remove him rather than to make an actual diagnosis He should telephone the Mental Welfare Officer (duly authorised) of the Local Health Authority and explain the circumstances It is well to ·GENERAL DUTIES AND INFORMATION 29 say in a simple written statement Mr X Y of is suffering from a mental disturbance sufficiently grave for him to need care at once The Mental Welfare Officer will provide the ambulance The patient is taken to a mental observation ward on a three day order There is usually no difficulty but if this procedure is unacceptable to the relatives the psychiatrist should be called in to arrange admission to a mental hospital in one of the various ways If the patient is certifiable this will involve calling in a magistrate This can be done whether the relatives agree or not They cannot refuse to have the patient certified if the magistrate is satisfied on the medical evidence that this is necessary DRUNK? It sometimes happens that the house physician has to decide whether a patient in the receiving room is drunk or ull Consent to any reasonable examination may be presumed if the patient is too drunk or ill to give it The doctor may consult with the police surgeon but he would be wise not to discuss the case with police officers and if asked to write a statement he should make a non-committal one such as I have examined AB On Make an ordinary physical examination when under the influence of alcohol the temperature is subnormal the pulse rapid and bounding the pupils dilated and sluggish and the tongue dry Speech is slurred and the breath smells of alcohol The patient may gesticula wildly and break down emotionally Hiccup and saliva tion are additional features Then apply some special test such as walking along a chalked line smoking a cigarette ·30 THE HOUSE PRYSICIANS HANDBOOK reading Writing and using a telephone directory if the patient protests that he has taken little or no alcohol let him provide a specimen of urine for testing heep it in the refrigerator USTRUL ADDRESSES British Broadcasting Corporation Broadcasting House London Vi Tel LANgham 4468 British Medical Association BMA House Tavistock Square London WCI Tel EUSton 4499 Central Laboratory of N Ireland Hospitals Authority 51 Lisborn Road Belfast "Tel 29241 Central Public Health Laboratory Colindale Avenue London NW 4 Tel COLindale 7041 Department of Health for Scotland St Andrews House Edinburgh Ye! CENtrat 2500 1 ewiss Medical Lending Library 136 Gower Street London WCI Tel EUSton 4282 Medical Defence Union Lid Tavistock House South Tavistock Square London WC1 Tel EUSton 4244 Medical and Datal Defence Varon of Scotland Lid 205 Saint Vincen Stre! Glasgow C2 Tel Ceatral 8381 Medical Protection Society (London and Counties) Victory House Leicester Square London WC2 Tel GERrard 4814 Medical Research Counci) 38 Old Queen Street London SWI Tel WHhehall 4834 Mental Welfare Officer duly authorised Ministry of Health 23 Saville Row Loudon Wirel REGent 8471 Oxygenaire Lid 8 Duke Street Wigmore Street London WS Tel WET beck 4477 Birmingham Victoria 2484 Bristol Abson 281 Cards 31161 Leeter Topsham 3070 Leeds 59}N? Man-hester Sale 56 0 Glasgow Bearsden 4313 Relfast 09766 BROADCASTING SOS MESSAGES The BBC (LANgham 4468) will broadcast a message asking relatives to go to a sick person only if you certify that the patient is dangeroush ill and that other means of communication have failed and that the full name of the person wanted is known Messages will not be accepted after the patient has died

·GENERAL DUTIES AND INFORMATION
31
THERMOMETER READINGS
The normal Fahrenheit reading of 98 4 corresponds
to 369 Centigrade To convert F to C subtract 32
and multiply by 5/9 To convert C to F multiply by
9/5 and add 32
Modern clinical thermometers are not marked with the
time they should be kept in the mouth but simply as
quick and slow acting In all cases adequate time should
be allowed-usually at least two minutes Try to spare
the nursing staff by not expecting routine temperature
readings on every patient Those with apyrexial illnesses
may be omitted from the
temperature round unless
their condition suggests otherwise

·32 THE HOUSE PHYSICIANS HANDBOOK AVERAGE WEIGHT FOR Hright or A HEALTHY ADULT AGED 30 (IN CLOTHES AND SHOES) INIPEPIAL WEIGHT HEIONIT MAN WOMAN ft 15 stib 48 49 4 10 st 16 74 77 10 5D 8 3 8 7 8 10 90 94 9 8 9 11 10 1 10 S 108 10 12 112 11 5 119 11 13 12 2 8 8 8 11 90 93 96 99 1360oWoWCOCOU want Bi Anibawomourosonar VS 9 sto Sil 62 For ages between 30 and 55 add 0 2 lb (009 kg) for men and 05 lb (023 Kg) for women for cach year above 30 LEMSLLY W F F (1952) Body weight at different ages and heights Ann Eugen Lond 16 316 334 ·GENERAL DUTIES AND INFORMATION 33 HEIGHT AND WEIGHT CONVERSION FACTORS To contert Inches to centimetres Inches to metres Feet to metres Pounds to kilogrammes Kilogrammes to pounds Multiply by 2539 0 0254 0 3048 04535 22 CONVALESCENCE It is usually easy to decide when the patient is ready to go to a convalescent home The almoner will make the arrangements In some diseases however the decision is difficult and the house physician should not act without advice In two such conditions the following criteria are suggested to help to decide when to allow the patient to get up Acute nephritis - The temperature and sedimentation rates should be normal and there should be less than ten million red cells in a twelve hour specimen of urine (In patients going on to the chronic hydraemic phase these criteria may have to be relaxed Albuminuria is not a reliable index of activity) Acute rheumatism and carditis - It is usual to allow the patient up two weeks after signs of activity (symptoms pyrexia tachycardia and raised ESR) are gone Sodium salicylate (1 to 2 grains per lb body weight or 120 to 240 mg per Kg appror maximum 100 grains or 6 G per day) should continue to be taken until two weeks after activity has ceased Salicylates should be stopped if cardiac failure supervenes 3 ·34 THE HOUSE PHYSICIANS HANDBOOK Post OPERATIVE ILLNESS The house physician may be approached by his surgical colleague about a patient in whom something has gone wrong after operation It often means a consultation between the physician and surgeon concerned but the house physician should be aware of the possibilities so as to be able to give his chief a true picture However reassuring the house surgeon is about what his chief did always consider whether something has gone wrong surgically If it is not surgical the following scheme may help 1 Is it pulmonary? A small pulmonary embolus Atelectasis Pneumonia - including the results of inhaling foreign matter 2 Is it cardio-vascular? Coronary thrombosis Large pulmonary embolus Circulatory overloading Shock (peripheral circulatory failure) Thrombosis of leg veins 3 Is it related to find intake and output? Salt depletion and extra renal uraemia Potassium depletion Transfusion reaction 4 Is it the result of the anaesthetic or operation? Toxaemia Fat embolism Inhaled vomit Pneumothorax ·GENERAL DUTIES AND INFORMATION 35 5 Is it the result of some underlying disease? Diabetes Addisons Disease Thyrotoxicosis Chronic nephritis INFECTIOUS DISEASES IN GENERAL WARDS What should the house physician do when an infectious fever occurs in a general ward? There is no rule of thumb plan about isolation and quarantine Our aim should be to prevent spread of the disease to susceptible patients and at the same time not to interrupt the work of the ward unnecessarily Surveillance often achieves this object better than quarantine but the nursing staff should be told what to look for eg slight coryza and rise of temperature Measles rubella chicken pox and mumps can be regarded as almost inevitable and it is a good thing if healthy children can get over them before they grow up Elaborate measures to escape them are not to be encouraged except in special cases Any members of the staff who have not had the disease in question should be carefully watched It is best to let them leave the children s or maternity ward for an adult ward Erysipelas meningitis and poliomyelitis are of low infectivity and patients can be nursed in general wards if otherwise convenient by barrier methods In order to obtain special treatment and for adminstrative reasons it may be wiser to transfer them In the case of certain diseases the Medical Officer of Health must be notified In some areas he wishes to know about rubella also and other diseases may be made notifiable in special circumstances eg chicken pox during an epidemic of small por ·36 THE HOUSE PHYSICIAN S HANDBOOL The following is a list of notifiable infectious diseases in England Wales Scotiand and Northern Ireland Cholera Pneumonia Acute Influcazat Diphther11 Poliomyelitis Acute Dysenter; Psittacosis (N Ireland only) Encephalitis (Acute) (Scotland Pucsperal Pyrexja forective N Ireland Leth Relapsing Fever artica) Rheumatic Fever (N Ireland Fnteric (Typhoid and Para only) typhoid) Fever Scarlatina or Scarlet Fever Trysipelas Small Pok Gastro enteritis in children under Trachoma (N Ireland only two year's (W Ireland only) Tuberculosis (N Ireland to Malaria Tuberculosis authority) Measles (not in Scotland) Typhus Membranous croup Undulant Fever (Ireland Meningowocal Infection (Scot only! land and N Ireland Cere Vincents Aogoa ( NBreasd brospinal Fever) only) Ophthalmia Neonatorum Whooping Cough Yellow Fever ( Ireland only) Food poisoning (or suspected Pemphigus (N Ireland only) food poisoning) (not o Scot Plague land N Treland Bactersal Pneumonia Acute Primary only) Measles -A child who contracts measles should be sent home or to the isolation hospital If this is įm practicable isolate him in a separate room and use barrier nursing technigues Find out which of the other children have had measles (This should be stated on the admis sion sheet but it is as well to verify the evidence) Nothing further need be done about these children Gre the parents of children who are well enough and who have not had measles the option of taking them home possibly to develop this inevitable disease Gamma globulin (obtainable from The Central Public Health Laboratory Colindale Avenue London NW9 Telephone COLindale 7041) may be used to prevent or modify an attack It is difficult and experisive to prepare and its use hould be confined to children who have some other serious disease or who are weakly If the supply ·GENERAL DUTIES AND INFORMATION 37 is short restrict its use to children in beds next to the measles case rather than give a smaller dose all round As the attack rate in infant contacts under six months is low they need not be given gamma globulin one can be quite sure that the mother has had measles Gamma globulin is issued in ampoules containing 250 mg of protein which should be dissolved in 3 ml of sterile distilled water It is given subcutaneously or intra muscularly within two or three days of the rash in the infecting case in doses according to the following table Immunity conferred by gamma globulin lasts from three to four weeks td 1 y ar Ove y 15 3 yrs Prevention 3 ml (-50 mg) 6 ml (500 mg) 9 ml (750 mg) Modification 3 mi (.50 mg) . 3 ml (50 mg) 3 mi (250 mg) If gamma globulin is unobtainable convalescent serum (preferably from a single donor) may be used It should be given from the first to fifth day after exposure in doses of 03 ml per pound (06 ml per Kg approx ) body weight (for prevention) or 01 ml per pound (02 ml per Kg appror ) body weight (for modification) The use of pooled adult serum should be abandoned because of the risk of serum hepatitis If preventive doses are given admissions and discharges can go on as before Mumps -The primary case should be sent home or to the isolation hospital Nothing need be done for fourteen days and then if there are susceptible children left the ·38 THE HOUSE PHYSICIANS HANDBOOK ward should be closed for a week The children should be watched for early symptoms The likelihood of cases developing after the twenty first day is very slight Only children who are definitely known to have had mumps should be admitted during the period of surveillance Rubella --This is not highly infectious and secondary cases are not inevitable Hence when the primary case has been disposed of surveillance only should be practised A child should not be sent home if his mother is in the early stages of pregnancy (re up to the end of the fourth month) Diphtheria - The patient should be isolated-usually in the infectious diseases hospital All contacts (patients and staff) should be questioned about immunisation and their throats and noses should be swabbed Those who are positive should be isolated and the others should be carefully watched Un immunised children and staff with negative swabs may be given passive immunity (which lasts fourteen to twenty-one days) by antitoxin (2 000 to 4 000 units intramuscularly) Active immunisation should also be started Scarlet fever -The case should be sent home or to the isolation hospital or to a separate room and treated with penicillin Scarlet fever is usually mild and uncompli cated but it should not be regarded lightly in a surgical or maternity Ward Throat swabs should be taken from the remaining patients and staff and those who show haemolytic streptococci or who have symptoms should be isolated and given penicillin This eliminates the strepto cocci in four or five days and drug resistance does not develop The ward need not be closed for admissions because of a single case but closure may be necessary for a few days if further cases occur ·GENERAL DUTIES AND INFORMATION 39 Chicken por —The chud should be sent home or to an isolation hospital Chicken Por is very infectious and as cases are not usually dragnosed in the early stages secondary cases can be expected A history of chicken por should be regarded as doubtful if careful search does not show any pock marks If susceptible children are left in the ward only patients who give a definite past history of chicken pox should be admitted for twenty-one days ---the quarantine period An adult with herpes zoster may give rise to chicken pox in child contacts Smallpox – If this is suspected ring up the Medical Officer of Health and act on his instructions Whooping cough ---The case (suspected because a spasmodic cough and a lymphocytosis or proved by a per nasal swab (see page 50) should be sent home or to the isolation hospital Further cases will not occur until the end of the incubation period—say in seventeen days Hence admission of children with a definite past history of whooping cough can go on for the first ten days Children in the ward who have not had whooping cough may be given gamma globulin as a prophylactic in doses double those recommended for measles Admissions should cease from the tenth to twenty first day after the case has been received and the remaining children should be carefully watched Sonne dysentery –The patient should be sent to the isolation hospital or isolated under strict barrier nursing precautions until several consecutive stool cultures are negative Rectal swabs or preferably stools of all con tacts should be examined Members of the staff must report any diarrhoea Admissions need not be restricted ·THE HOUSE PHYSICIANS HANDBOOK TABLE SHOWING INCUBATION INFECTIVITY AND QUARANTINE INCUTATION in day INFECTIVITY QUARATIVE indys 1 Chicken pox Extremes 10 to 16 Until all scabs are Commonest 14 off Diphtheria 2 to 10 7 Until two con secutive pose and throat swabs are negative Measles 71 7 to 14 14 days from the Normally koplik s) appearance of the spots on the 9th rash or in mild day and rash on attacks until the the I th day i end of clinical symptoms 1 Rubella 15 to 31 21 17 days from the appearance of the rash Mumps 78 Extremes 10 to 281 week afier Commodest 17 glands subside 14 to 16 14 Whooping cough 121 days or until all calarth has gone ·GENERAL DUTIES AND INFORMATION 41 MILESTONES IN INFANT DEVELOPMENT A baby doubles his birth weight (7 lb) in 6 months (14 Ib ) and trebles it (21 lb) by the end of his first year For the next three years he gains about 5 lb a year Rate of increase of weight is 6 oz a week in the first 6 months and 3 oz a week in the second 6 months Teeth --Lower central incisors appear at 6 to 9 months All milk teeth (20) are present at 2'), years Permanent teeth (32) begin to appear at 6 years--(molars first) and all are erupted (except wisdoms) at 12 years Anterior fontanelle should be closed at_18 months Circumference of head-13'/ inches at birth 18 inches at 1 year For intermediate ages see table Progress-An infant Holds up his head at 3 months at 6 months Crawls at 9 months Stands at 12 months Walks at 12 to 15 months Says words at 1 year Says sentences at 2 years Sits up CENTRES OF OSSIFICATION IN THE WRIST At birth entirely cartilaginous 6 months 1 centre 1 year 2 centres 3 years 3 centres 4 years 4 centres 5 years 5 centres 6 years 6 centres 7 years 7 centres 12 years 8 centres The lower radial epiphysis begins to ossify at 21 months and the lower ulnar epiphysis at 7 years ·42 THE HOUSE PHISICIANS HANDBOOK WEIGHT AND CIRCUMFERENCE OF HEAD or INFANTS 1 eight in 16 Head Circumference in inches AGE BOYS CIRLS BOYS GIRLS Birth 7 55 716 13.9 13 S 6 months 160 155 170 166 12 months 205 198 180 176 18 months 228 220 18 5 180 2 years 26 5 255 189 18 6 3 years 31 2 30-0 193 190 4 years 350 340 197 195 5 years 41 2 39 8 205 202 6 years 451 438 7 years 49 5 480 8 years 545 $29 9 years 600 573 10 years 666 64 1 210 07 11 years 724 703 13 years 798 814 For conversion factors to Metric System see page 33 ·GENERAL DUTIES AND INFORMATION 43 INFANT FEEDING The fluid requirements of an infant are 2'/, fl oz per lb body weight in each twenty four hours The calorie requirements are 45 to 50 per lb in each twenty four hours The feeds should be based on the expected body weight for the age but the amount can only be reached gradually if the infant is much under weight The calorie value of both breast milk and cows milk (raw or dried and reconstituted) is 20 calories per fl oz From these simple facts the sufficiency of an infants diet can be easily calculated The calorie value of 1 fl oz of some milk foods is as follows They are all reconstituted 1 in 8 (ie 1 measure of powder to 8 measures (=1 fl oz) of water) except when otherwise stated National Dried Milk --Full cream 18 Half cream 14 Con and Gate Products Full cream and Full cream Lacıdac 184 Half cream and Half creum Laçıdac 14 3 Separated milk food and Lacıdac separated (both 1 in 10) 104 Humanised 18 Frailac (1 in 10) 18 Allergılac 17 Prolac (1 in 12) 11 2 Sprulac 15 Trufood products -Full cream 18 5 Half cream 15 75 Humanised 18 Lactogen 184 Ideal Milk --60 calories per fl oz (re 1 in 3 dilution yields 20 calories per fi oz) Nestles Milk –100 calories per fi oz (te 1 in 5 dilution yields 20 calories per fi oz) Bone and vegetable soup --13 calories per fl oz ·CHAPTER 11 Clinical Procedures CATHETERISATION Alen It is best to put a rubber sheet under the patient first Having scrubbed the hands thoroughly retract the prepuce if necessary and clean the glans whi in 1000 cetrimide Then wash the hands again Lubricate the catheter with sterile lubricant and pass it into the meatus and gently on into the bladder Collect the urine in a dish or bottle If need be a sedative such as amylobarbicone 60 mg Il gr) by mouth or even morphine 15 mg (gr ) by injection may be given beforehand When catheterisation is painful Smal of 1 per cent amethocaine may be injected into the urethra and kept there for ten minutes by a penile clip A special glass syringe which fits the meatus tightly and a rubber bulb must be used the solution should be massaged into the posterior urethra before the clip is removed It is best not to use a local anaesthetic after bleeding has occurred Catheterisation in men is done to relieve retention If uncontaminated urine is all that is wanted then a mud stream specimen is satisfactory The glans and meatus are cleaned Some urine is passed and discarded and then the rest passed straight into a sterile bottle Women ---In 1 good light clean the labia majora by swabbing from before backwards with 1 in 1000 cetri mide Then separate the labia minora with the left thumb ·CLINICAL PROCEDURES 45 and index finger and clean with a swab With a third swab clean the region of the meatus and leave this swab in place Wash the hands and then holding the lubricated catheter near its tip introduce it into the urethra Urine flows immediately and should be collected in a sterile bottle Unless the meatus is clearly seen it is easy to make the mistake of passing the catheter into the vagina REMOVAL OF ASCITIC FLUID Give a sedative if the patient is anxious (eg amylo barbitone 100 mg (gr 1'/) Make sure that the bladder is emptied Put a many tail bandage or binder under the patient The puncture site may be in the mid line between the umbilicus and the symphysis pubis or just above McBurney s point (midway between the anterior superior iliac spine and the umbilicus) Cleanse the skin and put sterile towels over the abdomen Infiltrate the puncture site with 2 per cent procaine Make a tiny nick with a scalpel and push in the trocar and cannula It is more comfortable if the cannula is removed after threading fine plastic tubing through it When Southey s cannula is used dont forget the little silver guard The fine tubing is attached to the cannula and the sharp trocar pushed through the rubber into it Remove the fluid siowly into a Winchester bottle and tighten the bandage as it drains Inject 500 000 units of penicillin dissolved in 2 ml of physiological saline down the cannula before removal Seal the puncture with collodion and a dressing Send two samples of fluid to the laboratory (or all of it if requested) One sample should have citrate added to it If there is doubt as to whether the fluid removed is ascitic fluid or urine have its urea content estimated Urine contains ·CHAPTER II Clinical Procedures CATHETERISATION Men It is best to put a rubber sheet under the patient first Having scrubbed the hands thoroughly retract the prepuce if necessary and clean the glans with 1 in 1000 cetrimide Then wash the hands again Lubricate the catheter with sterile lubricant and pass it into the mesfus and gently on into the bladder Collect the unine in a dish or bottle If need be a sedative such as amylobarbitone 60 mg (1 gri by mouth or even morphine 15 mg (gr) by injection may be given beforehand When catheterisation is painful 5 ml of 1 per cent amethocaine may be injected into the urethra and kept there for ten minutes by a penile clip A special glass syringe which fits the meatus tightly and a rubber bulb must be used The solution should be massaged into the posterior urethra before the clip is removed It is best not to use a local anaesthetic after bleeding has occurred Catheterisation in men is done to relieve retention if uncontaminated urine is all that is wanted then a mid stream specimen is satisfactory The glans and meatus are cleaned Some urine is passed and discarded and then the rest passed straight into a sterile bottle Women ---In a good light clean the labia majora by swabbing from before backwards with 1 in 1000 cetri mide Then separate the Jabia minora with the left thumb ·CLINICAL PROCEDURES 47 ray examination will often help greatly but the best evidence of fluid is to obtain it by needling Put a pillow on a bed table and let the patient sit up and rest his arms on it He may need support also Most patients do not need premedication The usual site for puncture is in the eighth or ninth space between the scapular and posterior axıllary lines Try to choose a place where dullness is marked and where there is a characteristic feel in the intercostal space Raise a wheal with 2 per cent procaine and then infiltrate down to the pleura - Try to avoid the lower edge of the upper rib where the intercostal vessels are Use a large needle attached to a 20 ml syringe to penetrate the pleura and always make sure it is not blocked before use Withdraw fluid and put some in a plain tube (for culture) and some in a citrate tube (for cytological examination) Seal the puncture site with collodion or similar preparation If a broncho pleural fistula is suspected inject 5 to 10 ml of methylene blue into the pus Blue sputum sub sequently indicates a fistula Pleural aspiration - This is done in the same way as pleural exploration but a 50 ml syringe and two way tap are used Be prepared to spend considerable time in taking off the fluid but desist when coughing is trouble some or faintness comes on (If the latter seems serious treat as for air embolism-see page 152) When a massive effusion causing dyspnoea and gross mediastinal displacement calls for removal of much fluid then it is sometimes an advantage to remove the first 400 ml or so quickly by a Potain s aspirator A bottle which can be evacuated by a hand pump is connected to the needle in the chest Practise with it first so as to be sure that it is not wrongly connected or else you may ·46 THE HOUSE PHYSICIANS HANDBOOK about 2,000 mg of urca per 100 ml whereas ascitic fluid contains only about 30 mg per 100 ml REMOVAL Or OEDEMA FLUID This is occasionally necessary when mersalyl and Diamox are not sufficiently effective The patient should be nursed for several days in a cardiac bed with the legs low This ensures that as much oedema fluid as possible is dramed into the legs A plastic sheet is arranged so as to divert fluid into a large bowl The skin is cleaned with 1 in 1000 cetrimide and then smeared with Lassat s paste or penicillin cream Infiltrate about ten or a dozen places on the dorsum of the foot and inner aspect of the leg below the knee with 2 per cent procaine and insert wide bore serum needles into each for an inch or so Fiud should be allowed to emerge for several days Then the paste as cleaned off and the punctures sealed with collodion The legs should be raised for twenty four hours or so ifter wards Alternatively five or six Southey s tubes may be inserted in a similar way and connected by fine rubber tubing to a bottle NEFDLING THE PLEURA The house physician will often have to introduce a needle into the pleura (1) to search for pus of fluid and (2) to remove fluid known to be present Pleural exploration Stony dullness silence on auscul tation and cardiac displacement are the best physical signs of fluid but solid lung with blocked bronchi may produce signs resembling fluid and fluid under pressure which compresses normal lung may mimic consolidarion ·CLINICAL PROCEDURES 49 the blood may be put into a bijou bottle so as to fill it and then centrifuged for an hour The plasma is then drawn off and placed in the refrigerator if not used at once BLOOD CULTURE Try to take blood at a time when the temperature is rising or at the onset of a rigor Cleanse the forearm Thoroughly with soap and water 70 per cent alcohol and ether Using a dry sterile syringe tale 20 ml of blood from a vein Unscrew the cap from a bottle of glucose broth (preferably kept until use at incubator temperature) add the blood and quickly replace the cap Label the bottle and put it in an incubator without delay When certain infections suspect special media are used eg heart brain broth for anaerobes and bile salt broth for intestinal organisms The pathologist should be consulted about these CIRCULATION TIME Arm to tongue — The patient should be lying down with his arm on a pillow_so that it is at the same level as his heart Into an elbow vein inject a solution of 24 G saccharine in 4 ml of Water for Injection The nurse should start the watch as soon as you begin the injection and stop it as soon as the patient indicates that he tastes the saccharine The normal time.sten to seventeen seconds It is increased in left ventricular failure ( cardiac asthma ) whereas it is normal in true or bronchial asthma Arm to lung - This is performed in the same way using 0 3 ml (5 minims) of ether in 0 3 ml (5 minims) of physiological saline The patient shows the end point ·48 THE HOUSE PHYSICIANS HANDBOOK introduce air under pressure into the chest As you may wish to continue with a syringe and two way tap arrange your needle adaptors carefully first Replacement of fluid by air will often allow aspiration to go on longer than would be possible otherwise because the lung is prevented from expanding too quickly A few syringefuls of air (but fewer in number than the syringe fuls of fluid removed) are injected with the aspirating syringe If a large amount of au is replaced it is well to put a second needle into the air pocket and connect to a pneumothorax apparatus The amount of air should be adjusted so as to leave the pressure slightly negative If there is any question of a broncho-pleural fistula always X ray the chest before needling You can then be certain that any gas in the pleura was not artificially introduced ARTERIAL PUNCTURE With the elbow extended determine the course of the brachial artery by palpation as it lies on the inner side of the lower end of the humerus Raise a wheal over it with 2 per cent procaine and infiltrate the tissues down to the artery Using a serum needle and an all glass syringe introduce the needle at an angle of 45 degrees and approach the artery Keep the left index finger over the artery just above where it is to be punctured when the needle touches the artery wall pulsations are transmitted to it and when the lumen is entered blood rises easily into the syringe without the need to pull on the piston Remove 8 to 10 ml of blood The nurse or the patient himself should press on the artery for five minutes Remove the needle from the syringe and expel any air bubbles Draw up a little mercury to act as a seal and then plug the nozzle with a match stick Alternatively ·CLINICAL PROCEDURES 51 120 near the end The swab is moistened with sterile water and passed carefully over the back of the tongue without touching anything until it is at the glottis The patient then coughs violently and the swab is withdrawn and placed in its tube It is wise to wear a mask yourself while doing this PREPARATION FOR GASTROSCOPY The patient must not take any food or drink after supper Next morning about 1'/, hours before the ex amination he is given morphine 15 mg (gr) and hyoscine 05 mg (approx gry) subcutaneously (Women should have morphine 10 mg (gr .) and hyoscine 04 mg (gr.) Five minutes before the examination he gargles with 2 ml of 2 per cent Butacaine Sulphate BPC (Butyn Abbott) and swallows it The house physician should send a list of patients for gastroscopy to the theatre Patients should be reassured that gastroscopy is not an operation and that the ex amination only lasts five or ten minutes When there is gastric retention preliminary gastric lavage is useful A Senorans evacuator should be ready in case fluid has to be removed in the theatre No special measures are needed after examination beyond avoidance of hot drinks for some hours If there is undue dysphagia an oeso phageal tear may be suspected (about 1 in 1000 cases and usually in elderly women) The neck should be palpated for subcutaneous emphysema LIVER BIOPSY Have the patients prothrombin actuity estimated and give vitamin K, (konakion Roche) 10 mg in fruit juice by mouth if it is low Defer the operation until it is ·50 THE HOUSE PHYSICIANS HANDBOOK by signalling or coughing The normal time is four 10 eight seconds It is increased in congestive cardiac failure and decreased if the cardiac output is high as in anaemia emphysema and thyrotoxicosis VAGINAL TRICHOMONIASIS Vaginal swabs are not very satisfactory it is better to put the patient in the lithotomy position and insert a speculum 2 or 3 ml of physiological salıne are then washed in and out of the vagina with a teat pipette a few times and the fluid put in a test tube THREADWORMS When the question of threadworm infestation arises the diagnosis is most conveniently made by a search for eggs on adhesive cellophane tape Preferably before a morning bath or bowel action apply a narrow strip of the tape along the anal margin and press it against the skin with the end of a test tube Then place it firmly on a clean glass slide and send it to the laboratory It can be examined for clumps of eggs without further preparation PER NASAL SWABS (for whooping cough) These are of cotton wool on long straight pieces of wire The swab is pushed horizontally backwards through one or other nostril until it impinges on the posterior pharyngeal wall and then withdrawn and placed in its tube This method is more likely to give a positive result than is the use of a cough plate LARYNGEAL SWABS (for tuberculosis) The swab is a 9 in piece of wite with cotton wool firmly wrapped round the end It is bent to an angle of ·CLINICAL PROCEDURES 53 eight hours or 400 mg of a gelatin dextrose preparation (Heparin Retard) intramuscularly every twenty four to forty-eight hours Estimate the coagulation time before the next injection and aim at a dose which doubles or trebles it Overdosage can be quickly reversed by pro tamine sulphate 5 mg per kg body weight intravenously Phenindione (Dindevan) —This acts in twenty four to thirty six hours after a loading dose 150 to 200 mg by mouth Usually prothrombin activity between 20 to 30 per cent of normal can be maintained on doses of 50 mg twice a day Overdosage can be corrected by transfusion of fresh blood or vitamin K (Konakion Roche) 10 mg by mouth PROTHROMBIN ACTIVITY When a patient is having anti-coagulant therapy the house physician may have to take the blood for estima tion of its prothrombin activity The blood must be treated with a known amount of oxalate A special tube is issued by the laboratory containing exactly 0 25 M ml of sodium oxalate (1 34 Gin 100 ml) Blood 10 is then added up to the level of 25 ml The blood and oralate are thoroughly mixed and the tubes sent to the laboratory OXYGEN THERAPY Normal capacity of cylinders is 24 48 120 and 180 cubic feet to work out how long a cylinder will last remember that there are 28 3 litres to a cubic foot If F equals the number of cubic feet in the cylinder and M ·52 THE HOUSE PHYSICIANS HANDBOOK normal (Vitamin K analogues such as Synkavit Roche 10 mg intramuscularly are less effective) Have the patients blood group determined in case of need If ascites is present this should be tapped first Premedication is advisable with morphine 15 mg (gr.) an hour before the biopsy The operator will use a special syringe and needle The patient will have to hold his breath at the end of expiration if the puncture is done through an intercostal space If he breathes the liver may be torn So it is well to get him to practise first according to the instructions Breathe in breathe out hold your breath If the liver is enlarged the puncture may be made through the abdominal wall The breath should then be held at the height of inspiration ELECTROENCEPHALOGRAPHY Make an appointment in the department or at the hospital concerned and see that the patient presents himself at the appointed time having had no food or drink for the previous four hours Phenytoin (Epanutın) should be discontinued for forty-eight hours beforehand but phenobarbitone need not be omitted ELECTROCARDIOGRAPHY Ask the electrocardiographer to show you how to make a record in case of need When sending a patient always provide information on the following points --Heart rate and rhythm blood pressure whether having digitalis or not and for how long ANTI COAGULANT THERAPY Heparin -For immediate action use heparin-adult dose 100 mg (10 000 units) intravenously every six to ·CLINICAL PROCEDURES 55 to the skin through the lymph about thirty times There should be no movement of the needle in its long axis No bleeding should occur No dressing is necessary until a vesicle forms but it should certainly be applied then in children lest they scratch the site and then inoculate their eyes by rubbing them with contaminated fingers For the same reason it is wise in children to wipe off excess lymph To eject lymph dont blow down the capillary tube itself Push the tube through a needle puncture in the end of a pipette bulb or the hole in the teat of a baby s bottle Until it projects from the open end Break off this end and pull the tube back by the intact end until only a little of the tube remains in the bulb Break off this intact end and connect the bulb to a length of glass tubing with a cotton wool plug in it You may blow down this tube with safety The lymph can be ejected drop by drop and there is no back suction Alternatively the lymph can be ejected by connecting the capillary tube to a teat pipette by an inch or so of fine rubber tubing For certification purposes the description of the result Inust be precise The international certificate simply requires the doctor to say whether vaccination was primary or a re vaccination and if primary whether it was successful Other certificates (eg for local auth orities) ask for the type of result This may be --- 1 Typical primary vaccinia The reaction begins on the third or fourth day and by the seventh to tenth day there is a vesicle with surrounding red induration 2 Accelerated or vaccinoid reaction This appears on the fifth to seventh day and is like primary vaccinia but smaller It indicates that the patient has partial immunity ·54 THE HOUSE PHYSICIAN S HANDBOOK equals the number of litres per minute of flow then the F cylinder will last hours Since oxygen does not liquefy 2M at the pressure in cylinders (1 800 lb per sq inch or 120 atmospheres) the volume of gas in the cylinder is proportional to the pressure and the pressure gauge is used to tell gas content (This is not the case with gases like nitrous oxide which easily liquefy) Warning Oil and grease must not be used on oxygen taps and valves Electrical apparatus of all kinds and any thing liable to spark must be kept well away from the oxygen tent Smoking and the use of matches and lighters must be absolutely forbidden near an oxygen tent or mask when in use The house physician should satisfy himself that these points are clearly understood by all who use oxygen VACCINATION Order vaccine lymph in advance from the dispensary or from one of the laboratories of the Public Health Laboratory Service It will remain potent for at least six months if kept below freezing point and for fourteen days at 0 C to 10 C (re in a domestic refrigerator) it loses potency in two or three days at room temperature Technique --The multiple pressure method is best using a single site but in an epidemic two areas separated by about an inch should be vaccinated Cleanse (but do not irritate) the skin with ether and place on it a drop of lymph Grip the patient s upper arm with the left hand to render the skin taut Smear the lymph over an area the size of sixpence with a darning needle and through this area perform a shallow tangential pricking with the needle held parallel to the skin and crosswise to the arm The side of the needle point must be pressed firmly on ·CLINICAL PROCEDURES S5 to the skin through the lymph about thirty times There should be no movement of the needle in its long aus No bleeding should occur No dressing is necessary until a vesicle forms but it should certainly be applied then in children lest they scratch the site and then inoculate their eyes by rubbing them with contaminated fingers For the same reason it is wise in children to wipe off excess lymph To eject lymph dont blow down the capillary tube itself Push the tube through a needle puncture in the end of a pipette bulb or the hole in the teat of a baby s bottle until it projects from the open end Break off this end and pull the tube back by the intact end until only a Iittle of the tube remains in the bulb Break off this intact end and connect the bulb to a length of glass tubing with a cotton wool plug in it You may blow down this tube with safety The lymph can be ejected drop by drop and there is no back suction Alternatively the lymph can be ejected by connecting the capillary tube to a teat pipette by an inch or so of fine rubber tubing For certification purposes the description of the result must be precise The international certificate simply requires the doctor to say whether vaccination was primary or a re vaccination and if primary whether it was successful Other certificates (eg for local auth orities) ask for the type of result This may be — 1 Typical primary vaccinia The reaction begins on the third or fourth day and by the seventh to tenth day there is a vesicle with surrounding red induration 2 Accelerated or vaccinoid reaction This appears on the fifth to seventh day and is like primary vaccinia but smaller It indicates that the patient has parttal immunity ·56 THE HOUSE PHYSICIANS HANDBOOK 3 Maximum local reaction This occurs in persons with a high degree of immunity Redness appears on the second or third day but there is no resicle or induration 4 No local reaction 3 and 4 indicate immunity of the lymph was potent but it will save misunderstanding if 3 and 4 are both recorded as Reaction of Immunity For the same reason in recording the date Arabic numerais should be used for the day and year and Roman numerals for the month Thus 10 Aug 1954 would be 10 VIII 1954 Successful vaccination in the first six days of the incuba tion period will probably prevent smallpor in the next three days it will modify the attack but after the ninth day it will be ineffective Should a person flatly refuse urgent vaccination during an epidemic he might be given immune globulin active against the variola virus if any should be available at the Central Public Health Laboratory Colindale Avenue London NW9 Tel Colindale 7041 BLOOD TRANSFUSIONS The house physician should read carefully the Notes on Transfusion provided for him by the Ministry of Health Accidents are more often due to clerical than to technical errors So be very careful in filling up the forms Except in an emergency it is better for all blood grouping and cross matching to be done unhurriedly by a pathologist or technician experienced in the method and familiar with the many difficulties which may arise Only the techniques of rapid grouping of Os and As and of cross matching are therefore described here since they ·CLINICAL PROCEDURES 57 are really all that the house physician should undertake and then only exceptionally Rapid grouping of O's and A's -As group 0 ( uni versal donor ) Rh negative blood is in short supply and may be harmful to some patients the practice of giving it in all emergencies is not desirable A simple rapid method of deciding whether a patient can be given A Rh negative or O Rh negative blood has been described by Dr R A Zeitlin Slides are provided coated with potent anti A serum and protected by polythene adhesive They remain active at refrigerator temperature for three months One drop of the recipient s blood and one drop of water are mixed on the slide if the patients group is A or AB macroscopic agglutination can be seen within a minute Such a patient can be given A Rh negative blood If there is no agglutination the patient belongs to group O or B and may be given O Rh negative blood Cross matching -The recipients serum is matched against the donor s cells suspended both in saline at room temperature and in 20 per cent albumin at 37 C (to detect immune antı bodies) The donors serum similarly tested against the recipient s cells The following tubes must be prepared and all care fully labelled with a grease pencil 1 Recipient's serum - This is obtained by taking 5 ml of blood from the recipient and allowing it to clot The serum should be centrifuged to clear it of red cells The serum is removed by a teat pipette 2 Recipient s cells in salıne -Two or three drops of the recipients blood are put into a tube of saline 1$ ·58 THE HOUSE PHYSICIANS HANDBOOK 3 Recipient's cells washed and resuspended in saline A tube prepared as in 2 is centrifuged and the fluid poured of and more salıne added 4 Donor's plasma -- This is obtained by centrifuging some blood from the bouille 5 Donor's cells in salıne - This is prepared as in 2 using blood from the donors finger or from the bottle 6 Donor's cells washed and resuspended in saline --This is prepared as in 3 For each cross matching four aggluunation tubes must be set up in wooden rachs as shown So that the volumes of all shall be about the same a drop of sahne is put in the saline tubes to take the place of the drop of albumin in the albumin tubes Each tube therefore contains three drops as follows --- Tue 1 These saline tubes covered and kept at room terspera ture for 2 hours TUBE 2 1 drop earh oi Washed donor s cells in saline Recipients serum Saline Washed recipients cells in saline Donors serum Saline (Washed donot s cells in saline Recipients s run (20 per cent albumin (Washed recipients cells in saline Donors serum 20 per cent albumin Tag 3 These albumin tubes in in ubator at 37 C for hours TUBE 4 After two hours a drop from each tube is removed with d teat pipette and spread on a slide and examined under a low power for agglutination In an urgent case the reading can be made after fifteen minutes incubation and ·CLINICAL PROCEDURES 59 centrifuging at 1000 revolutions for one minute If rouleaux formation is suspected a drop of salıne added to the tube may help to facilitate reading Special precautions to be observed in using blood for transfusion 1 Checking of blood bottles Before connecting each bottle to the patient check carefully the following points — (a) That the full name age and ward on the cross match label are those of the patient (b) That the numbers on the bottle and cross match label are the same (c) That the expiry date has not been reached (d) That the blood group on the cross match label is the same as that recorded in the patient s notes 2 If a pilot bottle is provided use this to obtain blood for testing rather than open the blood bottle itself 3 Do not warm blood before use 4 Return the used blood bottle unwashed to the laboratory BLOOD TRANSFUSION IN BABIES How much?-An infant s blood volume is 40 ml per pound Hence if an 8 lb baby (blood volume 320 ml) has Hb 60 per cent a rise of 40 per cent will call for 1/1.0 320 = 128 ml of blood (Note Bottled blood is about one fifth citrate) How fast?—30 to 40 ml per hour is safe ie 1 drop every five seconds Since 1 drop='/20 ml at 1 drop per second (60 drops or 3 ml per minute) he will get 180 ml per hour One fifth of this rate is 36 ml per hour ·60 THE HOUSE PHYSICIANS HANDBOOK A useful rule for infants is that the normal require ment of 2'/ fl oz per pound per twenty four hours will be achieved if the number of drops per minute equals the weight in pounds Blood TRANSFUSION REACTIONS These are mostly non specific chills and rigors and result from haemolysed blood foreign matter from new tubing or too rapid transfusion Intense bachache so characteristic of incompatible transfusion does not occur If slowing down the transfusion does not bring improve ment the blood bottle should be changed should the house physician witness the now very rare true trans fusion reaction from incompatible blood characterised by shock back pain and tightness in the chest the ans fusion should be stopped at once All measures to keep up the blood pressure and prevent renal failure should be adopted A transfusion of compatible blood is valuable Measure the urinary output carefully If this is low put the patient on an electrolyte free gastric drip (400 G glucose and 100 G peanut oil) in 1 litre of water (with sufficient acacia to emulsify the oil) every twenty four hours Always send the discarded blood to the laboratory Circulatory overloading from too rapid transfusion of too much blood in a patient with a failing heart causes cough frothy sputum dyspnoea and basal rales Stop the transfusion Remove blood or apply tourniquets to the legs and give morphine and oxygen LUMBAR PUNCTURE The house physician will have ample opportunity to become skilled in this operation ·CLINICAL PROCEDURES 61 Put the patient on his left side with his left buttock and shoulder on the hard edge of the bed Fracture boards may be needed The long axis of the spine must be horizontal and the plane of the iliac crests vertical The spine must be fully flexed These details about the patients position are most important Raise a wheal with 2 per cent procaine at the point of entry This is where the plane of the highest points of the iliac crests crosses the mid line (It is between the spines of the 3rd and 4th lumbar vertebrae) Use dry hands and needle Direct the needle so that while in the horizontal plane it is inclined about 5 degrees towards the head—so that it is parallel to the slope of the vertebral spines The ligamentum flavum should be pierced with the bevel in the spinal axis so as to separate rather than cut across the fibres Withdraw the stilette and fluid should flow The first few drops may be discarded as they often contain red blood cells Take the specimen into a plain bottle but if it is cloudy a little should be taken into a citrate bottle also Avoid lumbar puncture if there is papilloedema and also if the skin of the back is infected If it has to be done when raised intracranial pressure is suspected use a fine needle and take very little fluid Difficulties 1 No fluid flows Advance the needle a little and rotate it 2 Bone is encountered Withdraw the needle and correct the patients position generally by increasing flexion 3 Blood appears If only a drop and then nothing more the needle is only in the subdural space Advance ·62 THE HOUSE PHYSICIAN S HANDBOOK it a little If the fluid is bloodstained it means trauma (bloody tap') or subarachnoid haemorrhage Traumatic bleeding clears as fluid drains If in doubt take it into three numbered tubes A diminish ing blood count in each indicates traumatic blood This frequently clots and leaves clear fluid In sut arachnoid haemorrhage clotting does not occur and the fluid is yellow (a simpler word than xanthochromic) CSF pressure --Using one of the types of manomater note the resting pressure and the response to coughing Compress the R and L jugular veins separately and then together and note the effect The patient should be breathing easily and not holding his breath as CO: retention raises CSF pressure

·CHAPTER III
Clinical Pathology
Amongst the following are some simple laboratory
investigations which the house physician could reasonably
be expected to perform if occasion arose In all of them
he should be fully aware of the principles concerned
HOW TO SEND SPECIMENS FOR LABORATORY TESTS
Although in most hospitals many specimens are
collected by technicians and sometimes by nurses (see
page 25) the house physician should know what kind of
specimen is needed for which test and why If you are
not sure what to send always ask the laboratory first
Blood should be taken with dry sterilised syringes The
needle should be detached and the bottle cap removed
before injecting the blood into the bottle If a syringe
has been boiled it should be rinsed with sterile physio
logical saline
Use plain bottles, in which blood can clot for
All agglutination tests
The Paul Bunnell test for glandular fever
Cold agglutinins
Wassermann and Kahn tests
Gonococcal complement fixation test
Cross matching (also send 1 ml of blood in a
heparin bottle)
Sodium
Potassium
63

·64 THE HOUSE PHYSICIANS HANDBOOK Use Oralate bottle for Blood urea (shake gently) Prothrombin Use heparin bottle (shale gently) for Sodium and Potassium by ſlame photometer Bro mides Calcium Chlorides Cholesterol Diastase Lipase Liver function tests (also send at least 1 ml of blood in a plain bottle) Acid and alkaline phosphatase Phosphorus (send to laboratory at once) Proteins Salicylates Sedimentation rate Uric acid Van den Bergh reaction (send to laboratory at once) Use fluoride oxalate bottle for Sugar (shake gently) (state the time of the last meal) Use Citrate bottle for Pleural fluid Ascitic fluid All fluids for cytological examination and culture Blood gases --When blood is taken for oxygen or CO, content contact between the specimen and the air must be carefully avoided A small amount of heparin solution is used to moisten the syringe before taking up the blood The needle is detached and any air bubbles are expelled A little mercury is drawn up from a watch glass to help in mixing the blood and to seal the nozzle This is closed by a match stick and the syringe is sent to the laboratory where it is kept in the refrigerator Stools for amoebac — The specimen must be fresh Any portion containing mucus should be sent It must be kept warm ·CLINICAL PATHOLOGY 65 Stools for steatorrhoea-(see page 77) Reticulocytes-use a special slide covered with dye Urine for lead-Send a twenty four hour specimen in a chemically clean bottle obtained specially from the laboratory (see page 69) SPARE THE PATHOLOGIST Request forms—Be specific in your requests For example don t ask for a Full blood count when all you really need is a haemoglobin estimation Give the path ologist the clinical details he wants He will then be able to interpret his findings for you Dont request elaborate investigations without consulting the pathologist first Haematological investigations —A Hb estimation and an expert examination of a blood film are the basic inves tigations and will often yield all the information needed Dont ask for platelet counts until a film has been examined for them Unless the platelets are reduced there is little point in estimating the bleeding time The clothing time is rarely prolonged except in haemophilia so dont ask for it in elderly women who are much more likely to have senile purpura Bacteriological investigations - Don t let swabs dry but send them to the laboratory (or refrigerator) promptly The laboratory should be warned beforehand if swabs for gonococci are contemplated Try to be sure that a specimen of sputum will not be saliva and will not be mixed with antiseptic Leaking specimen pots are dangerous and will probably be destroyed unexamined Specimens for histology - If you assist at an operation and are asked whether a specimen should be kept always 6 ·66 THE HOUSE PHYSICIANS HANDBOOK say Yes Leave it to the pathologist to refuse it and also to cut it up PATHOLOGICAL SPECIMENS BY POST The house physician may sometimes have to send a specimen by post to another hospital It must be sent by letter post and on no account by parcel post it should be surrounded by sufficient wool or sawdust to absorb any spilled fluid and must be marked 'Fragile With Care and Pathological Specimen Otherwise the parcel may be stopped and destroyed Bottles containing preservative should be used for any blood specimens sent by post Fluoride-oxalate bottles may be used for blood for sugar estimations Bottles containing streptomycin (1 mg in a solution and dried for a bottle taking 10 mi of blood) are used when haemoglobin estimation and (with oxalate also) when urea estimation is wanted OBTAINING BLOOD FROM A SMALL CHILD From the heel Warm the foot by immersing it in warm water for two minutes Rub the heel with alcohol and quickly dry it Then apply a thin layer of petroleum jelly (this facilitates the formation of discrete drops of blood) Grasp the foot firmly so that the heel projects between the thumb and index finger Puncture the heel deeply with a triangular needle Collect the blood with a Pasteur teat pipette and eject it into a tube Between each drawing up of blood the grip should be completely relaxed Rinse the pipette with physiological saline from time to time to clear any small clots Alternatively the blood may be simply allowed to drip into a small tube ·CLINICAL PATHOLOGY 67 From the external jugular vein - The nurse holds the chuld wrapped firmly in a blanket on her lap so that he faces her with his head on her knees She compresses the vein just above the clavicle and turns the head to the opposite side Then insert the needle towards the thorar where the vein crosses the sterno mastoid inuscle ERYTHROCYTE SEDIMENTATION RATE (ESR) The methods of Wintrobe (using undiluted heparinised blood) and Westergren (using blood diluted with citrate solution) do not always agree If one test does not seem to fit in with the clinical findings both should be per formed Wintrobe's method -Take a few ml of venous blood with a dry syringe and put in a heparin bottle Using a new Pasteur pipette fill a Wintrobe tube from the bottom upwards to the 10 mark (Tubes are numbered in case several tests are being done) Avoid bubbles Set the tube in a special stand and adjust the screw feet until the spirit level shows the tube to be vertical This is very important Set the clock to ring in one hour and then read the length of the column of plasma ie from the 10 mark to the top of the column of red cells (disregarding the greyish layer of leucocytes) The tube should then be put in the centrifuge at 3 000 revolutions per minute for half an hour and the height of the red cells read (Packed Cell Volume) The observed ESR is then corrected for the observed PCV Since the difference between the normal ESR in men and women depends on the difference in PCV all rates can be corrected to a PCV of 47 per cent A chart is provided which plots ESR horizontally against PCV vertically The intersection of the observed ESR and PCV lines is found The nearest curved line ·68 THE HOUSE PHYSICIANS HANDBOOK Is then followed down until it intersects the PCV 47 vertical line and the ESR corresponding to this inter section is the corrected ESR Normal reading for men 0 to 9 for women 0 to 20 Westergren's method. It is more convenient to pre pare a slight excess (25 ml) of the citrate blood mixture than the exact amount needed (2 ml) Tale blood into a heparin bottle as in the Wintrobe method The Westergren tube is graduated in 200 divisions begin ning from the top Draw up 38 per cent sodium citrate solution to the 150 mark and blow it out into a bottle Then draw up heparinised blood to the zero mark at the top of the tube and eject it into the citrate Mit thoroughly Draw up some of the mixture (of which one fifth is citrate) to the zero mark Set up the tube vertically in the stand with its lower end on a rubber bung After one hour measure the distance from the lower end of the meniscus to the upper surface of the column of red cells This is the ESR As the PCV cannot be measured on the citrated specimen no correction can be applied in this method Normal reading for men 3 to 5 mm for women 4 to 7 mm Bodian's method --This is a micro method using only 03 ml of blood The blood is citrated and so no correc tion can be applied Normal reading 3 to 10 graduations in one hour LABORATORY AID IN CARBON MONOXIDE POISONING With normal haemoglobin levels unconsciousness does not result until 60 per cent of the total Hb is combined with co but it will do so at lower levels in anaemic patients Gross poisoning with CO can be confirmed by ·CLINICAL PATHOLOGY 69 diluting blood 1 in 300 with dilute ammonia (04 ml of Ammonia SG 088 in 100 ml of water) and noting its pink colour compared with normal blood similarly diluted The reversion spectroscope is necessary to detect small amounts of HbCO in the presence of oryhaemoglobin The bands of the two spectra of oxyhaemoglobin are adjusted to overlap exactly Then the patient s diluted blood is substituted If HbCO is present the alpha bands move slightly to the violet end of the spectrum-complete saturation with CO causing a shift of 60 Angstrom units This method will detect 50 per cent or more of CO in the blood Percentages as low as 20 per cent can be found by refinements in the method Send heparinised blood covered with liquid paraffin but don t take it too long after admission as breathing fresh air soon gets rid of CO SUSPECTED LEAD POISOVING 1 Ask for an examination of a blood film for punctate basophilia & punctate red cells per 1000 indicates lead toxaemia (though not necessarily clinical poisoning) 2 Estimation of lead in blood may be made in doubtful cases Blood must be taken with a special Pyrex syringe and either put into a Pyrex tube containing oxalate for transference to the laboratory or direct into the laboratory crucible 005 mg of lead or more per 100 ml of blood indicates lead poisoning 3 If urine is sent it should be a 24 hour specimen passed directly into a chemically clean bottle prepared by the laboratory Up to 0 08 mg per litre is normally found in healthy people ·70 THE KOUSL PHYSICIANS HANDBOOK THICK FILMS FOR MALARIA If malaria is suspected thick as well as ordinary films should be made during a rise of temperature and also at its peak Using a match stick or needle spread out a drop of blood to cover an area of a shilling keep the slide horizontal and allow the blood to dry thoroughly Protect it from dust and do not blot i The slide should be sent to the laboratory for staining It is put face downwards yn running tap water until completely dehaemoglobinised It is then fixed for fifteen minutes in absolute alcohol and stained with Leishmans stain This method enables us to find parasites when few are present Glucose TOLERANCE TEST Special techniqucs using capillary blood may be used if the test is done by the laboratory worker If the house physician obtains the specimen himself the following technique is suitable The patient should preferably be in bed and should have had a normal diet for the previous few days No food at all should be eaten for twelve hours before the test but the patient may take a cup of tea without sugar or mull four hours before the test Ask the patient to empty his bladder and straight away take 5 ml of venous blood into a fluoride bottle The patient then drinks 50 G glucose in 250 ml of water flavoured with lemon juice (For children give 1 G glucose per 3 lb body weight) Take specimens of blood half ope one and a half and two hours afterwards Unide should be collected at one and two hours Label all speciniens correctly A normal patient shows a fasting blood sugar of 80 to 100 mg per 100 ml and a maximum rise within an hour ·CLINICAL PATHOLOGY 71 to 140 to 180 mg per 100 ml The fasting level should be regained in two hours Sugar should be absent from both specimens of urine INSULIN SENSITIVITY TEST A diet containing at least 300 G of carbohydrate should be taken on three days prior to the test Only a little water to drink but no food is taken after the evening before the test on the morning of the test blood is taken for fasting blood sugar determination and then 0 1 units of soluble insulin per kg body weight is injected intravenously In Addison s disease and panhypopituitar ism it is wise not to give more than 25 units Blood is taken at half hourly intervals for two hours The drop in blood sugar level is generally expressed as a percentage of the fasting level It usually falls to 50 per cent of the fasting level and returns to its previous level in one and a half to two hours In pituitary adrenal and thyroid disease in which the natural antagonism to insulin is deficient the sensitivity to insulin is increased and the fall of blood sugar is greater than normal and lasts longer The duration of hypoglycaemia is more significant than its degree Some sterile 25 per cent dextrose solution should be ready for prompt intravenous injection in case excessive sensitivity to insulin causes alarming hypo glycaemic symptoms In cases of Addison s disease 20 mi of Iojection of Suprarenal Cortex BPC should be given intravenously with the dextrose URINE CONCENTRATION-DILUTION TESTS These tests should be avoided in oedematous patients Concentration test (This test is unnecessary if the specific gravity of the urine is over 1025 and it is free ·70 THE HOUSE PHYSICIANS HANDBOOK THICK FILMS FOR MALARIA If malaria is suspected thick as well as ordinary films should be made during a rise of temperature and also at its peak Using a match stick or needle spread out a drop of blood to cover an area of a shilling Keep the slide horizontal and allow the blood to dry thoroughly Protect it from dust and do not blot it The slide should be sent to the laboratory for staining It is put face downwards in running tap water until completely dehaemoglobinised It is then fixed for fifteen minutes in absolute alcohol and stained with Leishmans stain This method enables us to find parasites when few are present GLUCOSE TOLERANCE TEST Special techniques using capillary blood may be used of the test is done by the laboratory worker If the house physician obtains the specimen himself the following technique is suitable The patient should preferably be in bed and should have had a normal diet for the previous few days No food at all should be eaten for twelve hours before the test but the patient may take a cup of tea without sugar or milk four hours before the test Ask the patient to empty his bladder and straight away take 5 ml of venous blood into a fluoride bottle The patient then drinks 50 G glucose in 250 ml of water flavoured with lemon juice (For children give 1 G glucose per 3 lb body weight) Tale specimens of blood balf one one and a half and two hours afterwards Urine should be collected at one and two hours Label all specimens correctly A normal patient shows a fasting blood sugar of 80 to 100 mg per 100 ml and a maximum rise within an hour ·CLINICAL PATHOLOGY 73 first hour or 100 ml in subsequent hours then a urea concentration below 25 per cent may not mean renal damage and the test should be repeated UREA CLEARANCE TEST The data required for this test are the volume and urea content of the urine excreted in a given time and the urea content of blood taken during this time As the secretion time is an essential part of the test a stop watch should be used 7 am Light breakfast Weak tea but no coffee 9 am Empty bladder (discard) Set the stop watch at 9 am and start it as soon as the bladder is empty (As the bladder must be emptied completely the test is valueless in cases of urinary obstruction) 945 a m Take blood for blood urea 10 am Empty bladder Stop the watch as soon as bladder is empty Send all of this specimen to the laboratory and put on the label the number of minutes during which it was secreted as shown by the stop watch It may not be exactly 60 minutes Some pathologists like to have a further timed specimen at 11 am for a duplicate test Interpretation - The urea clearance is a theoretical expression of the volume of blood which must lose the whole of the urea in it in order to yield the amount of urea excreted in one minute Suppose the secretion rate is 120 ml per hour (2 ml per minute) and the urea content of the urine 15 G per 100 ml (1 500 mg per 100 ml ) Then 2 ml of urine contain 30 mg of urea If the blood urea is 40 mg per 100 ml then 30 mg urea will be contained in 75 ml of blood This figure 75 is ·72 THE HOUSE PHYSICIANS HANDBOOK from sugar and albumın} Nothing to drink after mid-day on the day before test Dry tea supper and breakfascm Preferably containing protein Empty bladder before Tetiring on night before test and discard this specimen Empty bladder on waking and one and two hours later Save these three specimens Measure the volume of each 11 a glass cylinder and take the specific gravity of each Use a special hydrometer which reads only butween 1010 and 1030 One or more specimens should show a specific Sravity over 1020 Dilution test -The patient empties his bladder and discards the specimen He empties his bladder again one hour later This specimen is kept He then drinks 600 ml of water and the urine is collected each hour afterwards for four hours The volume and specific gravity of each of the five specimens is measured The total water excreted less the amount which on the basis of the first hour would have been secreted if the 600 ml of water had not been drunk is the extra water excreted This should be at least 450 ml The specific gravity of at least one of the hourly specimens should be as low as 3006 UREA CONCENTRATION TEST Nothing to drink after 10 pm 8 am empty the bladder and drink urea (15 G dissolved in 100 ml of water and flavoured with tincture of Orange) (Dont mention the word ured to the patient lest he thinks he is drinking urine and vomits) The patient may then have a dry breakfast if he wishes Specimens of urine are collected at 9 10 and 1} am and their urea content determined This should reach 25 per cent It may be lower in the first specimen because of the diuretic effect of urea If the volume of urine exceeds 120 ml in the ·CLINICAL PATHOLOGY 75 NB-It 18 well to do a preliminary test with distilled water to make sure there is no contamination of the chromate solution with chloride Chlorides should be regarded as absent of the end point is reached with the first drop This may occur in normal persoas if urine is very dilute If it occurs in concentrated unge (specific gravity 1020 or more) less than 3G per litre suggests salt depletion A patient is not suffering from salt depletion of the urine contains SG or more of salt per litre (except in Addison s disease and during the administration of intravenous saline) OCCULT BLOOD N FAECES This is most suitably tested for on the ward by the house physician or nurse using a modified Gregersens test As this is not extremely sensitive a restricted diet is unnecessary though liver and black pudding should be avoided At least 3 ml of blood must have been ingested to give positive result The test on the con version of benzidine to a blue-coloured product by peroxide in the presence of a catalyst such as iron A waxed paper packet contains a powder consisting of 25 mg of benzidine hydrochloride and 200 mg of barium peroxide This is shaken up with 5 ml of glacial acetic acid and makes a 05 per cent solution of benzi dine A smear of faeces on a white filter paper is made from the gloved finger or a swab stick from the rectum or bed pan A little of the solution is poured over it A deep blue colour within 15 seconds indicates the presence of occult blood If no colour change occurs in 30 seconds the test is negative A weakly positive result is one showing a greenish colour within 30 seconds When sending faeces to the laboratory for a more delicate test the patient should have avoided meat herrings green vegetables purgatives of the senna type and iron medicines for three or four days These tests are of little value in telling us the site of the haemorrhage When this is high enough to allow ·74 THE HOUSE PHYSICIANS HANDBOOK the normal clearance and is obtained from the formula Unne Urea Clearances x Secretion Rate Blood Urea As the kidneys do not clear the blood completely of urea during one passage the figure is a theoretical one When the secretion rate is less than 2 ml per minute the clearance is proportional to the square root of the Secretion rate It is convenient in practice to express clearance as a percentage of normal function over 70 per cent of normal function is within the normal range between 40 and 20 per cent of function indicates moderate renal impairment and under 10 per cent serious impairment In the case of children and very tall or short adults the height and weight should be given so that the labora tory can apply corrections for body size FANTUS TEST FOR CHLORIDES IN URINE Reagents and apparatus- 20 per cent potassium chromate solution 29 per cent silver nitrate solution Distilled water Test tube Small pipette ( fountain pen filler ") NB-The same pipette must be used throughout the tests so that the drops shall be of the same size Technique Tilter the urine if not already clear and if albumin is present Temove by bouling and filtering Take 10 drops of urine in the test tube Riose pipette Add 1 drop of potassium chromate solution (the indicator) Rinse pipette Add silver nitrate solulion drop by drop and shake the test tube after each drop End point is a sharp change of colour from yellow to brown The number of drops needed to produce ibe colour change indicates the number of grammes of sodium chloride per litre ·CLINICAL PATHOLOGY 77 is empty by aspirating when sitting up lying on the back face and night and left side The patient should spit out rather than swallow his saliva or sputum Inject sub cutaneously 05 mg of histamine and withdraw the stomach contents half one and one and a half hours later The specimens are then put in labelled tubes and sent to the laboratory If no free acid is present in the first specimen (as shown by a red colour when a little juice is mixed with Topfer s reagent on a white tile) a further 05 mg of histamine may be given but this should be avoided in patients whose blood pressure is grossly abnormal If we only want to know about the presence or absence of hydrochloric acid (as in ' pernicious anaemia) the simplified meal is sufficient Obtain fasting juice and examine it for free HCI by Topfer s reagent If negative give a cup of water to drink and inject 05 mg histamine subcutaneously Take a further sample half an hour later and if there is still no HCI then a diagnosis of achlorhydria can be made FAT BALANCE TEST Don t ask for this test unless you are sure that the nursing and laboratory staff can cope with it Unless carefully performed it is useless The patient eats a diet provided by the dietitian containing a fixed amount (50 G or 75 G) of fat Any uneaten food must be returned to the dietitian so that the figure for the amount of fat eaten can be adjusted The stools for the first three days are discarded and on the morning of the third day the patient has a simple tap-water enema (no soap) The result is discarded Then for a period of at least seven days all stools (and toilet paper) are collected into a previously Heighed and labelled jar On the morning of the last ·76 THE HOUSE PHYSICIANS HANDBOOK time for bacterial action to split off the iron fraction porphyrin is formed and can be detected spectroscopi cally The presence of red cells indicates bleeding low down The degree of bleeding and rate of passage must be taken into consideration 2 pm ASCORBIC ACID SATURATION TEST 8 am Empty bladder and take 700 mg ascorbic acid 12 noon Empty bladder and discard specimen Empty the bladder and keep the specimen Within an hour estimate the ascorbic acid content of the whole of it Repeat the test daily until the patient excretes more than 30 mg ascorbic acid in the two hour specimen Patients with ascorbic acid deficier may take more than seven days to reach saturation while normally saturation is reached in three days FRACTIONAL TEST MEAL The main information nowadays desired from a test meal 15 about the nature of the resting juice and whether acid is present or not A charcoal biscurt may be eaten at supper time since charcoal particles in the resting juice next morning are good evidence of stasis Antacids and routine medicines should be stopped from the evening before a test meal The teeth should not be brushed before the test lest the gums bleed A Ryles tube is lubricated with fiquid paraffin and then passed by the nose or mouth and swallowed down into the stomach Occasionally spraying the throat with 2 per cent Buta caine Sulphate (Butyn Abbott) is necessary The tube is marked at 40 cm (=the cardia) and 57 cm (=the pylorus) By suction with a syringe the resting juice is obtained and put in a bottle Make sure that the stomach ·CLINICAL PATHOLOGY 79 Jaundice -A strongly positive flocculation reaction and an alkaline phosphatase level under 15 units suggests that jaundice is non obstructive A negative flocculation reaction and an alkaline phosphatase level over 35 units suggests that jaundice is obstructive THE KEPLER TESTS FOR ADRENAL CORTICAL INSUFFICIENCY (ADDISON S DISEASE) These tests must not be used in patients who have renal disease or oedema of any kind Procedure 1 A test of the ability to have druresis — This test is based on the fact that patients with adrenal cortical insufficiency fail to show the normal degree of diuresis following a rapid intake of water The volume of night urine is measured then water is drunk (9 ml per pound body weight) and hourly urine volume measured If the volume of the largest hourly specimen is less than the volume of night urine the test is positive and Addison s disease is not excluded On the day before the test the patient eats three ordinary meals but omits extra salt He must not eat or drink anything after 6 o clock in the evening Until this tune he may drink water as desired At 10 30 pm he empties his bladder and discards the urine All urine which is voided from then on until and including that passed at 730 am is collected The volume of this urine is measured and saved for chemical analysis of this should be necessary later Breakfast is omitted The patient empties his bladder again at 830 am and immediately thereafter he is given 20 ml of water per kg of body weight (9 ml per pound) He is asked to drink this within the next forty five minutes At 9 30 10 30 11 30 ·78 THE HOUSE PHYSICIANS HANDBOOK day a tap water enema is given and the result added to the stools already collected The whole specimen is sent to the laboratory for fat estimation No laxatives must be given during the test Absorption of less than 90 per cent of the fat intake indicates deficient absorption If it is wished to avoid enemas as in children an alternative technique is to give two capsules of carmine (about 200 mg in each) with breakfast and save the stool in which it first appears and subsequent ones On the day before the test is to end give two or three charcoal biscuits with breakfast Save all stools until the one in which charcoal appears and discard this one Send the collected specimens to the laboratory The following simplified method involves less work for nurses and technicians Ask the pathologist for details Briefly the procedure is to collect the faeces for three or four twenty four hour periods separately These are homogenised and their fat contents estimated On the usual daily intake of up to 100 G of fat normal people excrete not more than 5 G of fat per day LIVER FUNCTION TESTS NORMAL VALUES Bromsulphalein test Blood is taken five and forty five min utes after injecting 5 mg of dye per ke body weight intravenously A normal liver clears the blood of dye in forty five minutes Serum bilirubin Less than 1 mg per 100 ml Icteric index. 3 to 8 units Urobilinogen in urine Normally absent Scrum alkalice phosphatase 3 10 13 King Armstrong units per 100 ml Thymol turbidity reaction o to 4 units Thymol flocculation reaction Negative in absence of parenchyma tous liver disease Plasma proteins (diet must be adequate and albuminuria absent) Total 6 3 to 8 29 G per 100 ml. Albumin 35 to 576 per 100 ml Globulin 15 to 300 per 100 ml ·CLINICAL PATHOLOGY 81 From these four determinations and from the results obtained from Procedure 1 the following factor is cal culated Urea in urine (mg per cent) Chloride in plasma (mg per cent) х Urea in plasma (mg per cent) Chloride in urine (mg per cent) Volume of day unde (ml) Х Volume of night urine (ml) The term day urine applies to thu largest of the hourly specimens voided during the day night urine' to the entire amount which was voided from 10 30 pm to 730 am If the value of the factor is greater than 30 the patient probably does not have Addison s disease If the factor is less than 25 the patient probably has Addisons disease pro that nephritis has been excluded The result is an all or nothing one and does not indicate degrees of adrenal cortical insufficiency SPECIFIC GRAVITY OF PLASMA This may be quickly and easily measured by the falling drop method It is useful in deciding how much fluid (but not salt) is needed to correct severe dehydration The laboratory has a row of bottles of copper sulphate solution of different specific gravities The patients plaşma is obtained by centrifuging heparinised blood and a drop of it is released into the bottle from a pipette whose point is 1 cm above the surface of the solution The rise or fall of the drop during the ten seconds after it has lost its initial momentum indicates whether it is lighter or heavier than the test solution It is well to do a control test on normal plasma at the same time A bottle of 100 ml of the solution may be used 100 times before its specific gravity is affected The normal specific gravity is 1027 and for every 0 001 rise above this 200 ml of 6 ·80 THE HOUSE PHYSICIAN S HANDBOOK am and 1230 pm he is requested to empty his bladder In order to eliminate the effects of exercise and posture on urinary excretion he is kept at rest in bed except when up to yoid Each specimen is kept in a separate container The volume of the largest one of these four specimens is measured ( day urine ) Under these conditions some patients having Addisons disease will excrete so little urine that thev are unable to void more than once or twice during the entire morning In such instances the amount of urine excreted per hour may be calculated frequently however such calculations are unnecessary because of the very low urinary output throughout the entire morning Inferences that may be drawn from Procedure 1 (1) If the volume of any single hourly specimen voided during the morning is greater than the volume of urine during the night the response to the test is negative that is such a response indicates the absence of Addisons disease (2) If the volume of the largest hourly specimen voided during the morning is less than the volume of urine voided during the night the response to the test is positive that is Addison s disease may or may not be present To establish the diagnosis Procedure 2 should be instituted Procedure 2 A test of the ability to elimunate urea and conserve chloride - This test depends on the fact that in Addison s disease the kidneys retain urea but excrete an excessive amount of salt Details - Take blood before giving the ter in Procedure I and estimate the chloride and urea in its plasma Also measure the volume of the mized night urine and estimate its chloride and urea content ·CLINICAL PATHOLOGY 81 From these four determinations and from the results obtained from Procedure 1 the following factor is cal culated Urea in urine (mg per cent) Chloride in plasma (mg per cent) X Urea in plasma (mg per cent) Chloride in urine (mg per cent) Volume of day urine (ml) х Volume of night urine (ml) The term day urine applies to the largest of the hourly specimens voided during the day night urine to the entire amount which was voided from 10 30 pm to 730 am It the value of the factor is greater than 30 the patient probably does not have Addison s disease If the factor is less than 25 the patient probably has Addison s disease provided that nephritis has been excluded The result is an all or nothing does not indicate degrees of adrenal cortical insufficiency one and SPECIFIC GRAVITY OF PLASMA This may be quickly and easily measured by the falling drop method It is useful in deciding how much fluid (but not salt) is needed to correct severe dehydration The laboratory has a row of bottles of copper sulphate solution of different specific gravities The patients plasma is obtained by centrifuging heparinised blood and a drop of it is released into the bottle from a pipette whose point is 1 cm above the surface of the solution The rise or fall of the drop during the ten seconds after it has lost its initial momentum indicates whether it is lighter or heavier than the test solution It is well to do a control test on normal plasma at the same time A bottle of 100 ml of the solution may be used 100 times before its specific gravity is affected The normal specific gravity is 1027 and for every 0001 rise above this 200 ml of 6 ·82 THE HOUSL PHYSICIAN S HANDBOOK water is lacking in the vascular compartment of body fluid (providing the plasma proteins were originally normal) BLOOD COUNTS Red cells -First get a tube with ground glass stopper containing 4 ml of red cell fluid (1 per cent formalın in 3 per cent sodium citrate) Prick the lobe of the ear or the finger (don t squeeze) and draw up blood to the 002 ml mark in a ' haemoglobin pipette and add this amount to the tube This gives a dilution of 1 in 200 (strictly 1 in 201) Shake for about a minute Using a needle lower the special cover glass on to the counting slide The centre of the glass should overlie the ruled area It is correctly flat when Newtons concentric refraction rings appear Take up some fluid from the tube with a Pasteur pipette and allow a drop to run under the cover glass by capillary action If fluid enters the moat' begin again After allowing to settle for a minute or two count the red cells in eighty small squares (five sets of sixteen large squares) When cells lie on lines only count those on the upper and left hand lines so that no cell is counted twice The area counted is 5 x 16 x 1/400 square millimetre The chamber depth is 0 1 mm Hence at dilution 1 in 200 the volume of fluid counted is 5x16 10 x 400 x 200 10 000 Although the thousandth part of a litre 15 now called a millilitre it is nevertheless correct to speak of the volume used in blood counting as a cubic millimetre rather than a millimil This 13 because a cubic millimetre is a volume based strictly on a liptar measurement the millimetre-whereas the mtor thousandth part of a litre is a measure of volume not so based 1 cu mm * ·CLINICAL PATHOLOGY 83 The red cell count is therefore the number of cells in five sets of sixteen squares multiplied by 10 000 White cells - Proceed as in the red cell count but put the 002 ml of blood into a stoppered bottle containing 0 380 ml of white cell fluid (2 per cent acetic acid coloured with gentian violet) This gives a dilution of 1 in 20 Count four sets of sixteen large squares ie a total area of 4 sq mm At dilution 1 in 20 and chamber depth 01 mm the volume of blood counted is 4 10 x 20 Hence the number of cells in sixteen large squares multiplied by fifty equals white cell count in cells per 50 cu mm cu mm Leave the pipettes clean Draw water alcohol and ether through them in this order and then dry in air If absolute values are wanted blood should be taken into a heparin bottle so that it can be used for the haematocrit reading This blood can be used for the blood count by the usual technique but it is not quite so satisfactory for the white count as the cells tend to stick together Haemoglobin estimation — The house physician should make himself familiar with the particular form of haemoglobinometer in the laboratory whether it be a photo electric colorimeter using alkaline haematın and an artificial standard or the Medical Research Council circular grey wedge photometer For the MRC photo Note If the house physician does not do the red cell count himself he should not ask the laboratory to do it without due con sideration It is at best very inaccurate and in most cases the cliaician can get all the information he needs from estimation of HD PCV (to give the MCHC) and a blood film ·84 THE HOUSE PHYSICIANS HANDBOOK meter 0 02 ml of blood in the pipette is placed in a tube containing 004 per cent solution of ammonia The volume is made up to 4 ml (= 1 in 200) and the fluid is put in the photometer Haemoglobin is estimated as oxyhaemoglobin by its power of absorbing green bght compared with that of the calibrated grey wedge For rapid bedside examination the Tallqvist method using blotting paper and a scale of red colours is more accurate than is generally supposed Blood films-Use a new slide cleaned with a handker chief and one with its corner broken off as a spreader Excessive cleaning prevents the formation of a smooth film Touch the pricked ear with the slide so that a drop of blood is left near one end Hold the spreader at an angle of 40 degrees to the slide and move it back to touch the drop Then move the spreader quickly forwards to make a film 3 cm long Let the film dry in the air Write the patients name on it in pencil Flood the slide with Leishman s stain for half a minute or so Then add twice the amount of distilled water whose pH has been adjusted to 68 and leave for ten minutes before washing and drying Lymphocytes tend to stay in the middle of the film and polymorphs to move to the tail especially in slowly spread films If a film is satisfactory polymorphs should be present in the centre Cells in longitudinal strips of the film should be counted NORVAL VALUES IN HAEMATOLOGY Total blood volume This is 75 mi per Kg in a man 65 ml per Kg in a woman and 100 ml per kg (or 40 mi per Ib ) in an infant A man weighing 11 stone (154 lb or 70 Kg) therefore has 5 200 ml of blood or roughly 8. pints ·CLINICAL PATHOLOGY 85 Red Cells --The average mean normal for an adult is 5 million per cu mm In more detail Men 4 5 to 6 8 millions per cu mm Women 39 to 56 Children at one year 45 Children at ten years 47 Packed cell volume (PCV or haematocrit reading) This is the volume of pached cells per 100 ml of blood It is 47 per cent in men and 42 per cent in women Low readings are found when the number or size of red cells is diminished and indicate anaemia High readings are found when there is haemoconcentration Whute count - Total 4000 to 10 000 per cu mm Pete I tal P r cu mm of blood 40 75 500 7500 6 200 400 Granulocytes Neutrophil Eosinophil Basophil Lymphocytes Monocytes 0 1 15 100 20 45 1 500 3,500 2 10 200 800 For each type of cell the absolute count is of much more value than its percentage of the total which can be misleading in counts outside the normal range Mean haemoglobin content -14 8 G per 100 ml of blood This represents 100 per cent in the Haldane scale ·86 THE HOUSE PHYSICIANS HANDBOOK Reticulocytes 01 to 1 5 per cent Platelets ---250 000 to 400 000 per cu mm Red cell fragility --Normally haemolysis begins in saline of strength 045 G per 100 ml and 18 completed in saline of strength 0 35 G per 100 ml Bleeding turne (Ivy) -1 to 4 minutes (Duke) 2 to 5 minutes Coagulation time (Lee and White using venous blood at 37 C) -4 to 10 minutes ABSOLUTE VALUES The old index system eg colour inder was based on fixed arbitrary figures taken as normal Absolute Values are calculated from observed figures and so the range of normality is taken into account Mean corpuscular volume (MCV--This is the average volume in cubic microns (ch) of a single red cell and is calculated from Volume of packed cells expressed as a percentage x 10 Red cells in millions per cu mm For example if the PCV is 45 per cent then 1 cu mm of blood (= 5 000 000 cells) contains (45 cu mm of cells and the volume of one cell ( MCV) is 0 45 cu mm 5 000 000 The pormal reading is 86 cp Increase means macro cytosis for spherocytosis) and decrease means microcytosis Mean corpuscular haemoglobin ( MCH)-This is the average amount of Hb in micro microgrammes per red 290 CP ·CLINICAL PATHOLOGY 87 cell For example if 100 ml of blood contains 15 G Hb then 1 cu mm of blood contains 15 100 x 1 000 As 1 cu mm of blood contains 5 000 000 red cells each cell contains 15 G Hb 100 x 1000 x 5 x 10 or 30 micro microgrammes The normal range is 27 to 30 micro microgrammes Mean corpuscular haemoglobin concentration ( MCHC)While the colour index or percentage of haemoglobin number of red cells expressed as a percentage of 5 x 10° (normally 1) expresses the saturation of red cells with haemoglobin the MCHC does this more accurately without reference to an arbitrary figure for normal It 15 really the amount of Hb in 100 ml of red cells (not whole blood) The red cells in 100 ml of whole blood occupy 45 ml (packed cell volume or PCV or haema tocrit reading) and the amount of Hb in 100 ml of blood 1s 15 G Then 100 ml of red cells contain 15 45* 100=33 3G of Hb The MCHC is calculated from Hb in G per 100 ml of blood PCV in mi per 100 ml of blood * 100 The normal range is 32 to 38 Low values mean that red cells are not tully saturated with Hb Should the anaemia be macrocytic (MCV over 86C) and the MCHC low (less than 32) it means that iron as well as liver is indicated ·88 THE HOUSE PHYSICIAN S HANDBOOK Packed cell volume (PCV)-This is the percentage of the volume of blood occupied by red cells A Wintrobe tube is filled to mark 10 as for the Erythrocyte Sedimenta tion Rate and put in the centrifuge at 3 000 revolutions per minute for half an hour The height of the packed red cell column is then read THE ACCURACY OF SOME HAEMATOLOGICAL ESTIMATIONS It is important for the clinician to know whether a numerical difference in two reported readings represents a real change or an inaccuracy in the method The degree of error is computed mathematically and it is sufficient here merely to give a table showing the significant differences expressed as a percentage of the normal readings The significant differences for readings above and below normal levels approximate to these figures It should be remembered that red cell counts are always very inaccurate and especially so when only 500 cells are counted whereas the Hb estimation and the PCV have only a small error On the other hand errors in the white cell count are not so important A 20 per cent error for example would only raise or lower a 5 000 cell count by 1 000 which would be within the limits of physiological variation ·CLINICAL PATHOLOGY 89 ACCURACY OF HAEMATOLOGICAL INVESTIGATIONS I est gatto Normal r ading in I d figures Sgn fi ant differenc Pess d R perc 1.8 1th normal cading 100 148 Haemoglobin (Haldane) Haemoglobin ( MRC photometer) 148 G 84 per 100 ml Red cell count Smillon per cu mm 266 1e 1 3 millions Reticulocytes 01 to 1 5 per cent 1133 Platelets 642 250 000 per cu mm Haematocrit 45 24 S minutes Coagulation time (Lee & White) 133 (1 e 0 66 minute) ·90 THE HOUSE PHYSICIANS HANDBOOK OTHER NORMAL VALUES FOR BLOOD (S=Serum) (P= Plasma) (B=Whole blood) Sugar --B-80 to 120 mg per 100 ml (fasting) Urea -B-20 to 40 mg per 100 ml (15 to 50 in children and old folks 15 to 30 during pregnancy) Uric acid-S-20 to 60 mg per 100 ml Alkalı reserve-P-53 to 77 vols of CO, per 100 ml (23 34 mEq/litre) Alkaline phosphatase-S or P-3 to 13 King Arm strong units Acid phosphatases or P-0 to 4 King Armstrong units CholesterolS or P-115 to 260 mg per 100 ml Serum proteins-S-6 10 8 G per 100 ml (Albumın 4 to 5 Globulin 1 2 to 29) Chloride-P-560 to 620 mg per 100 ml (as NaCl) 340 to 380 mg per 100 ml (96 to 108 mEq/litre) (as chloride) Calcium-S-9 to 11 mg per 100 ml Phosphorus-S or P-2 to 4 mg per 100 ml Potassium-5--14 to 21 mg per 100 ml (36 to 54 mEq/litre) Sodium-S-300 to 350 mg per 100 ml (130 to 152 mEq/litre) Bilirubin-S01 to 10 mg per 100 ml Diastase —P or S-Wohlgemuth-less than 10 units per mi Somogyı—70 to 200 units per 100 ·CLINICAL PATHOLOGY 91 Agglutination tests Paul Bunnell test for glandular fever - The minimum diagnostic titre of unabsorbed serum which agglutinates sheep s red cells is I in 128 but this test may be confused by the antibody of serum sickness and by the natural antibody It is usual therefore to perform it also (1) on serum treated with a suspension of guinea pig kidney and (2) on serum treated with ox cells Glandular fever can be differentiated because agglutination occurs with (1) but not with (2) For details consult the pathologist Cold agglutination salmonella dysentery and brucella organisms --The pathologist will give an opinion as to the significance of the result The test alone should not be interpreted without the other evidence Erythrocyte sedimenta tion rate (E.SR Wintrobe Men 0 to 9 Women 0 to 20 Westergren Men 3 to 5 Women 4 to 7 Bodian 3 to 10 ·92 THE HOUSE PHYSICIAN S HANDBOOK NORMAL CEREBRO-SPINAL FLUID Clear and colourless Pressure 125 mm Cells - Up to 4 lymphocytes Protein 20 to 40 mg per 100 ml and globulin not in excess (i e trace only) Chlorides (as NaCl) --Adults 720 to 750 mg per 100 mi children 700 to 760 mg per 100 ml Since Na and Ci ions may vary independently it is better to give the concentration of chloride ions normally 425 to 460 mg per 100 ml or 120 to 130 mEq/litre Glucose 50 to 70 mg per 100 ml Urea 15 to 30 mg per 100 ml Lange's colloidal gold curvenormal 0000000000 meningitic 0000123433 luetic 0024321000 paretic 5554433100 CEREBRO-SPINAL FLUID CEIL COUNT It is sufficient to add one drop of 0 2 per cent toluidine blue to about 05 ml of CSF The fluid should be allowed to stand for not more than ten minutes It is then put in a Fuchs Rosenthal counting chamber and the white cells which are stained blue counted under the y.th inch objective The amount of dilution by the stain may be neglected The number of cells in 85 small squares is the cell count in cubic millimetres ·CLINICAL PATHOLOGY 93 CSF IN POLIOMYELITIS BE paraly Aft par ty Appearance Clear and colour less Clear and colour less Cells Up to 2000 per cu mm 25 per ceat polymorphs 5 to 10 lymphocytes Protein About 100 mg Normal or slightly raised per 100 ml Globulin Negative + Chlorides and Gluose Normal Normal Lange No change 0011210000 ·92 THE HOUSE PHYSICIAN S HANDBOOK NORMAL CEREBRO-SPINAL FLUID Clear and colourless Pressure 125 mm Cells-Up to 4 lymphocytes Protein -20 to 40 mg per 100 ml and globulin not in excess (i e trace only) Chlorides (as Naci)-Adults 720 to 750 mg per 100 ml children 700 to 760 mg per 100 ml Since Na and C ions may vary independently it is better to give the concentration of chloride ions normally 425 to 460 mg per 100 ml or 120 to 130 mEq/hitre Glucose 50 to 70 mg per 100 ml Urea 15 to 30 mg per 100 ml Lange s colloidal gold curvenormal 0000000000 meningitic 0000123433 luetic 0024321000 paretic 5554433100 CEREBRO SPINAL FLUID CELL COUNT It is sufficient to add one drop of O2 per cent toluidine blue to about 05 ml of CSF The fluid should be allowed to stand for not more than ten minutes It is then put in a Fuchs Rosenthal counting chamber and the white cells which are stained blue counted under the 'ath inch objective The amount of dilution by the stain may be neglected The number of cells in 85 small squares is the cell count in cubic millimetres ·CLINICAL PATHOLOGY 95 Com * 100 ARTERIAL BLOOD ANALYSIS Orygen saturation (breathing air) O, content ie 95 per cent O, capacity CO, content of arterial blood -45 to 55 volumes per 100 ml CO, content of plasma --55 to 65 volumes per 100 ml CO tension (PCO) (calculated from plasma Co, and pH) -35 to 45 mm of mercury pH at 38 C-738 to 7 41 Alkalı reserve (CO, combining power) of venous blood -53 to 77 volumes per 100 ml (23 to 34 mEq/litre) MILLI EQUIVALENTS Chemical substances in body fluid react together not by their absolute weights but by their equivalent weights (The equivalent weight of an element is that weight which will combine with or take the place of 8 parts by weight of oxygen For univalent elements the equivalent weight is the same as the atomic weight for divalent elements It is half the atomic weight and so on) It is convenient to express in terms of milli equivalents substances such as acids and bases which react together Acid radicles are chloride bicarbonate (expressed in terms of CO,) phosphate sulphate organic acids and proteins Basic radıcles are sodium potassium calcium and magnesium A milli-equivalent of any substance is the amount con tained in 1 ml of its normal solution (A normal solution contains the equivalent weight of a substance in grammes per litre The term normal saline however is physiological or isotonic saline and is only about one sixth the strength of chemically normal saline) 1 milliequivalent of sodium is 23 mg and so on ·94 THE HOUSE PHYSICIANS HANDBOOK CSF IN MENINGITIS Pyogen T berculous Virus Pressure + + + + + Appearance Turbid Opalescent Clear Cells Hundreds or thousands Polymorphs Tens or hundreds Mainly lymphocytes Up to 200 Lymphocytes Protein Increased 100 mg or more Increased 100 mg or more Around 100 mg Globulin + + + Chlorides Only a slight decrease Decreased down to 650 mg per 100 ml 600 to 650 mg per 100 ml Below $50 13 practically diagnostic say 680 Glucosc Absent Normal Decreased 20 to 40 mg per 100 ml Falls earlier than chlorides do Noge Srcar Organisms visible Tubercle bacilli may be visibic Steri + Culture ·CLINICAL PATHOLOGY 97 Blood plasma has normally about 7 G protein per 100 ml and thus has the power of binding about 16 mEq/litre of base Equivalent weights of common substances are sodium 23 potassium 40 calcium 20 chlorine 355 sodium chloride 58 5 bicarbonate 224 (The latter is not strictly the equivalent weight but as explained above is used in the same way) NORMAL VALUES (BLOOD) mg per 100 ml mEq/Ltr litr ghts 355 3 550 35 S 100 Chloride (as chlorine) (as sodium chloride) 585 5850 58 5 100 Sodium 330 3300 23 14_ Potassium 20 200 40 5 Calcium 10 100 20 5 Bicarbonate 60 ml 600 m 224 27 URINE TESTING The house physician should on occasion take pride in performing certain simple urine tests properly and should not expect these always to be performed by the laboratory or nursing staff The urine is best inspected in a conical glass of the old fashioned type Sometimes ingenuity is needed to obtain or test a specimen eg wringing out a napkin or performing the nitroprusside test on the bed sheets of an incontinent patient Albumin —Tests for albumin are often carelessly per formed The urine should be filtered if cloudy and the ·le a 96 THE HOUSE PHYSICIAN S HANDBOOK The term milli-equivalent per litre (mEq/litre) means the thousandth part of the equivalent weight of the substance in grammes per litre The simplest way of con verting mg per 100 ml into mEq/litre is to express the substance as mg per litre and divide by its equivalent weight (-atomic weight - valency) mg per 100 ml x 10 mEq/lıtre equivalent weight Conversely mEq/litre can be converted into mg per 100 ml by multiplying mEq/litre by the equivalent weight and dividing by 10 mEq/litre x equivalent weight te mg per 100 ml = 10 The cases of bicarbonate and proteins require special explanation Bicarbonate-We measure the plasma bicarbonate by the amount of CO which it will yield-normally about 60 ml per 100 ml of plasma or 600 ml per litre Now the molecular weight in grammes of any gas occupies 224 ltres at normal temperature and pressure In the case of Co, the molecular weight is also the equivalent weight If 600 is divided by 22 4 we get 27 which is the figure for the mEq/litre of CO derived from bicarbonate Proteins - Proteins act as weak acids and are expressed in terms of the amount of base they neutralise The average equivalent weight of proteins is that part of their molecular weight which will neutralise 1 equivalent of NaOH When the concentration of protein in mg per litre is divided by this we obtain a figure for the milli equivalents of protein It is more simple to use the formula Protein in G per 100 ml x 243 = mEq/litre ·CLINICAL PATHOLOGY 99 The results compare as follows - G per litre (Esba b) G per ent per 100 1 Ht test 10 1 volume 5 05 1 volume I to 2 01 to 0. 1 01 Granular deposit Heavy cloud Slight cloud or trace <01 Sugar -- Take 25 ml (about inch in a test tube) of Benedict s solution add four drops of urine and boil for two minutes A green orange or brick red turbidity indicates sugar A trace of sugar may show only as a yellowish precipitate like grains of sand There are few fallacies If there is doubt ask the pathologist to identify the reducing substance He will use the osazone test or the more reliable method of paper chromatography A translucent green appearance but without a yellowish deposit does not indicate sugar (Patients taking thio uracil may show a black deposit) CLINITEST METHOD -Place five drops of urine in a short test tube Rinse the dropper and place ten drops of water in the tube Put one clinitest tablet into the tube and wait fifteen seconds before shaking and reading the result A colour change to shades of green brown and orange indicates the presence of sugar Ketone bodies — These are often referred to as acetone but this substance though it may occur in the breath is only present in traces in fresh urine 70 per cent ·98 THE HOUSE PHYSICIAN S HANDBOOK lest tube nearly filled Make it faintly acid to litarus paper by adding 10 per cent acetic acid drop by drop Boil the upper inch and compare it with the clear urine below Whether cloudy or not add a few drops more of acetic acıd if the cloud disappears it was phosphates only If the urine remains clear albumin is not present Cloudiness which persists after boiling even if it clears a bit after adding acid indicates albumin If cloudiness appears after adding acıd to a urine which was clear on boiling it also indicates albumin SALICYL SULPHONIC ACID TEST --Add drop by drop a 20 per cent aqueous solution of salicyl sulphonic acid Albumin and globulin give a precipitate (and also Bence Jones protein but this clears on heating) Patients who have taken pheniodol (but not Telepaque) the previous day for cholecystography may give a false positive test High concentrations of penicillin may give similar false positive tests THF AMOUNT OF ALBUMIN This can be expressed in several ways Heat coagulation --The acidified urine should be boiled and the result described as slight cloud heavy cloud etc or if there is much albumin it should be allowed to settle for twenty four hours and the volume it occupies expressed as a proportion of the total ſud in the tube Esbach s method --Pour the acidified urine into an Esbach tube up to the mark U Add Lsbach s reagent up to the mark R Close the tube with a cork and mix its contents Allow to stand twenty four hours and then read the height of the protein precipitate from the bottom in grams per litre ·CLINICAL PATHOLOGY 101 Blood - Red blood cells and haemoglobin can be detected by the guaiacum test Put one inch of urine in a test tube and add two or three drops of fresh tincture of guaiacum A white precipitate forms Holding the tube at an angle pour on one inch of ozonic ether Do not shake but allow a separate layer to form A blue ring indicates blood (Iodides and pus give false positive results) To differentiate between blood and haemoglobin microscopy is necessary Bile pigments — Bile stained urine shows a yellow froth on shaking FOUCHETS TEST - Make the urine acıd with acetic acid To a test tube half full of urine add half its volume of 10 per cent barium chloride Shake and filter Re move the filter paper and allow it to dry Put one drop of Fouchets reagent on its edge A green colour indicates the presence of bile pigment TABLET TEST –Moisten the special asbestos test mat with five drops of urine and put the tablet of dye on it Place one drop of water on the tablet and a few seconds later another drop which washes fluid on to the mat if bilirubin is present the mat around the tablet turns purple Any colour developing after thirty seconds is ignored Urobilin does not give a false positive test Microscopic examination of urine --The urine should be centrifuged and the deposit examined for blood cells pus casts crystals and organisms In some laboratories it is the practice to do the cell count on undiluted urine using a CSF counting chamber The normal cell count is very similar to that of CSF-up to 10 cells per cu mm being regarded as normal ·100 THE HOUST PHYSICIANS HANDBOOK of the hetone bodies in the urine consists of Bhydroxy butyric acid for which we cannot test The remaining 30 per cent is nearly all diacetic acid This is detected by the nitroprusside test in dilutions of 1 in 400 000 Acetone (which is formed when diacetic acid decomposes) glves a positiv nitroprusside reaction in dilutions of only 1 in 20 000 The fertic chloride test is positive for diacetic acid in dilutions of 1 in 2 000 and is negative for acetone NITROPRUSSIDE TEST-Put about half an inch of the mixture of ammonium sulphate and nitroprusside crystals in the test tube and add one inch of urine Shake and add more crystals if necessary so that some remain un dissolved Add , inch of strong ammonia and shake If positive a purple colour develops FERRIC CHLORIDE TEST --Add 10 per cent ferric chloride solution drop by drop to some urine Diacetic acid is shown by a reddish brown colour Phosphates give a precipitate but this dissolves when excess of fertic chloride is added Do a control on normal urine if the result is doubtful Aspirin and similar substances give a purple colour Prior boiling does not abolish the reaction of due to aspırın but it will drive off the volatile diacetic acid and render subsequent tests negative ACETEST TABLETS - Place a tablet on a clean surface Put one drop of urine on it Take a reading in thirty seconds When the test is positive the colour varies from lavender to deep purple When negative the tablet simply becomes creamy from wetting This test is inter mediate in sensitivity between the nitroprusside and ferric chloride tests ·CLINICAL PATHOLOGY 103 an orange colour and the froth is yellow Large amounts make the urine reddish brown and in long standing jaundice when the pigment is mainly biliverdin the urine is dark green Riboflavin (vitamin B ) is commonly given in multi Vitamin pills and makes the urine very yellow Santonin and chrysophanic acid (from rhubarb and senna) make an acid urine yellow When flavine and picric acid are applied to raw surfaces sufficient may be absorbed to colour the urine more yellow than normal The new antı coagulant phenındrone is said to turn the urine a pinkish orange colour Red and pink urines – Uroerythrin usually shows as a pink or brick dust rather than red deposit of urates in cases of congestive cardiac failure Its only importance is that patients may think it is blood Really red urine is generally caused by blood or haemoglobin Both give the chemical and spectroscopic tests for blood but haema turia is distinguished from haemoglobinuria by the presence of red cells and by the fact that filtration largely clears at The experienced eye can detect small quantities of blood in the urine because in addition to the character istic smokiness the meniscus is dark and the urine in the upper part of the vessel is rather pink compared with the rest After standing for some time blood in the urine becomes brownish from the formation of methaemoglobin Numerous extraneous pigments will colour the urine red A meal of beetroot will do it Eosin in sweets causes the urine to be very pink with a greenish fluorescence Mercurochrome if injected causes red urine Santonin and chrysophanic acid already mentioned will make the urine Pink if it is alkaline ·102 THE HOUSE PHYSICIANS HANDBOOK SENDING URINE TO THE LABORATORY For laboratory investigations a generous specimen say 200 ml should always be sent For urea clearance tests and estimations of total output of various constituents the quantity of urine passed must be accurately measured So ask the nurse to send the whole specimen to the laboratory and not just enough to fill the bottle No preservative is needed as a rule but if urine has to be kept add 5 ml of chloroform to 100 ml of urine As it reduces copper solution boil it off before testing for sugar ABNORMAL COLOUR OF THE URINE Normal urine is coloured by urochrome and varies from pale straw to deep amber The depth of colour depends on the concentration and so the urine is always pale in polyuria Quite colourless usine suggests diabetes insipidus Broadly speaking urines from the point of view of colour fall into four groups 1 Yellow 2 Red 3 Brownish black 4 Greenish blue In considering the unusual colour of any specimen we should ask ourselves the questions - 1 Is there an excess of normal pigment? 2 Is there present an abnormal pigment originating in the body? 3 Is there present extraneous pigment? Yellow urines Excess of urobilin from haemolysis in pernicious anaemia and acholuric jaundice and in liver disease makes the urine very yellow It froths easily but the froth is not yellow Bile in the urine often gics it ·CLINICAL PATHOLOGY 103 an orange colour and the froth is yellow Large amounts make the urine reddish brown and in long standing jaundice when the pigment is mainly bılıverdin the urine is dark green Riboflavin (vitamin B ) is commonly given in multi vitamin pills and makes the urine very yellow Santonın and chrysophanıc acid (from rhubarb and senna) make an acid urine yellow When flavine and picric acid are applied to raw surfaces sufficient may be absorbed to colour the urine more yellow than normal The new antı coagulant phenindione is said to turn the urine a pinkish orange colour Red and pink urines - Uroerythrin usually shows as a pink or brick dust rather than red deposit of urates in cases of congestive cardiac failure Its only importance is that patients may think it is blood Really red urine is generally caused by blood or haemoglobin Both give the chemical and spectroscopic tests for blood but haema turia is distinguished from haemoglobinuria by the presence of red cells and by the fact that filtration largely clears it The experienced eye can detect small quantities of blood in the urine because in addition to the character istic smokiness the meniscus is dark and the urine in the upper part of the vessel is rather pink compared with the rest After standing for some time blood in the urine becomes brownish from the formation of methaemoglobin Numerous extraneous pigments will colour the urine red A meal of beetroot will do it Eosin in sweets causes the urine to be very pink with a greenish fluorescence Mercurochrome if injected causes red wine Santonin and chrysophanic acid already mentioned will make the urine pink if it is alkaline ·104 THE HOUSE PHYSICIAN'S HANDBOOK A urine of red colour resembling port wine Occurs in porphyria either idiopathic or in liver disease and poisoning by barbiturates The urine may be of normal colour when passed but if allowed to stand in the light and especially if acidified a colourless precursor porpho bilinogen is converted into deep reddish brown porphyrın pigments Tests for blood are negative and the abnormal pigment may be identified spectroscopically Pospbo bilinogen is identified as follows To one volume of urine add one volume of Erhlich s aldehyde reagent and allow it to stand for five minutes then add two or three volumes of a saturated solution of sodium acetate Extract with 5 ml of chloroform If the pink colouration semains in the upper aqueous layer it is due to porpho bilinogen whild if it is extracted into the lower chloroform Jayer urobilinogen is present It is essential to neutralise all the hydrochloric acid in the Erhlich s reagent as other wise false positive reactions may be obtained as when indole acetic acid is present and is converted into the pink-coloured urorosein by acid In cases of obscure abdominal colic the possibility of acute porphyria should be kept in mind The vomiting pain and absence of diarrhoea and tigidity suggest in testinal obstruction Presumably the abnormal pigment stimulates smooth muscle and causes the pain Brown and blach unnes It is convenient to consider these in two groups according to whether the urine is black when passed or blackens on standing 1 URINES WHICH ARE BROWN OR BLACK WHEY PASSED These are usually examples of great excess of pigments of other kinds such as bile and haemoglobin Smali amounts of blood in the urine may be converted into acid haematin and give it a brown colour ·CLINICAL PATHOLOGY 105 2 URINES WHICH BLACKEN ON STANDING --Indican which appears in the urine in intestinal stasis and results from bacterial decomposition of protein causes the urine on standing to go dark from the surface downwards A similar appearance occurs in carbolic acid poisoning Really black urine is found in cases of melanotic sarcoma with liver metastases In alkaptonuria a rare inborn error of metabolism homogentisic acıd appears in the urine This causes the specimen to darken slowly on standing but it becomes black at once if alkali is added The alkalinised specimen is luminous in the dark Alkapton uria is symptomless for many years but later in life pigmentation of cartilages (ochronosis) and osteoarthritis may appear Green and blue urine – These do not usually cause much trouble The urine in long standing jaundice is often more greenish than yellow and simple tests prove the presence of bile Really blue urine is nearly always due to methylene blue given in pills or sweets When only a little is present the appearance is green and the pigment exists as fine particles and can be filtered off Methylene blue or some similar pigment has occasionally found its way into the urine of children who have sucked some coloured object Quinine in the urine gives it a blue green fluorescence Lastly it must be remembered that substances other than pigments may alter the appearance of the urine Chyle in the urine from filariasis gives it a milky appear ance as also does an excess of phosphate crystals Occasionally a patient seeks to give his urine an abnormal appearance by adding such things as ink Dettol and condensed milk to it Similar substances can also find their way into the urine from dirty bottles ·104 THE HOUSE PHYSICIANS HANDBOOK A urine of red colour resembling port wine occurs in porphyria uither idiopathic or in liver disease and poisoning by barbiturates The urine may be of normal colour when passed but if allowed to stand in the light and especially if acidified a colourless precursor porpho bilinogen is converted into deep reddish brown porphyrın pigments Tests for blood are negative and the abnormal pigment may be identified spectroscopically Porpho bilinogen is identified as follows To one volume of urine add one volume of Frhlich s aldehyde reagent and allow it to stand for five minutes then add two or three volumes of a saturated solution of sodium acetate Extract with 5 ml of chloroform If the pink colouration remains in the upper aqueous layer it is due to porphobilinogen whưe if it is extracted into the lower chloroform layer urobilinogen is present It is essential to neutralise all the hydrochloric acid in the Lrhlich s reagent as other wise false positive reactions may be obtained as when indole acetic acıd is present and is converted into the pink-coloured urorosein by acid In cases of obscure abdominal colic the possibility of acute porphyria should be kept in mind The vomiting pain and absence of diarrhoea and rigidity suggest in testipal obstruction Presumably the abnormal pigment stunulates smooth muscle and causes the pain Brown and blach urines It is convenient to consider these in two groups according to whether the urine is black when passed or blachens on standing 1 URINES WHICH ARE BROWN OR BLACK WHEN PASSED These are usually eximples of great excess of pigments of <ther kinds such as bile and haemoglobin Small amounts of blood in the urine may be converted into acid haematin and give it a brown colour ·CHAPTER IV Treatment DOSAGES OF DRUGS The doses of most of the commonly used drugs will be found in the accompanying tables (modified from Macgregor and Kinnear 1953) Those of a few as yet proprietary drugs follow and space is allowed for the house physician to add other new ones Some drug firms still issue their products in Imperial rather than Metric doses but apart from this there is really no justification for retamıng Imperial doses As a step towards the universal adoption of the Metric or International system this one alone is used in the dosage table The term Metric system is now strictly a misnomer because the litre and kilogram are measures of volume and mass no longer based on the metre but on artificial standards (albeit almost exactly the same as the original litre and kilogram as planned) Medicines are frequently prescribed in teaspoon and tablespoon doses Although there is a British Standard Specification for a medicinal teaspoon (60m or 36 ml (approx 4)) the domestic teaspoon varies from 24 to 70 ml and so wherever possible it is best to avoid domestic measures and to use a measuring glass CONVERSION TABLE FOR WEIGHTS AND MEASURES 1 milligram (mg) Igrain (gr) 15 mg 60 mg 100 mg (= 01 G) 1 gr 11 gr 107 ·106 THE HOUSE PHYSICIAN S HANDBOOK TUBERCULIN TESTS Mantoux - Special all glass syringes are used and preferably a separate one for each strength of tuberculin As it is very difficult to rid them of tuberculin it is most important that they should not be used for any other purpose Inject intra-dermally into the forearm 01 ml of tuberculin If active tuberculosis is a possibility start with 1 in 10 000 dilution A patient is not Mantour negative unless he fails to react to 1 in 100 tubercuhn Read the result not earlier than forty-eight hours and preferably seventy two hours after injection A positive result shows an area of oedema 5 mm or more in diameter an area of redness without oedema is not significant Note --Saline dilutions of old tuberculin are only stable for a few days It is best to make them up freshly Dilutions with a borate buffer do not deteriorate for three months Patch test --Cleanse the skin between the scapulae with ether and apply the patch Avoid washing the back Remove the patch after forty eight hours and read the result twenty four hours later The centre square is the control The skin under it remains normal The lateral squares show redness induration and vesicles if the test is positive ·CHAPTER IV Treatment DOSAGES OF DRUGS The doses of most of the commonly used drugs will be found in the accompanying tables (modified from Macgregor and Kinnear 1953) Those of a few as yet proprietary drugs follow and space is allowed for the house physician to add other new ones Some drug firms still issue their products in Imperial rather than Metric doses but apart from this there is really no justification for retaining Imperial doses As a step towards the universal adoption of the Metric or International system this one alone is used in the dosage table The term Metric system is now strictly a misnomer because the litre and kilogram are measures of volume and mass no longer based on the metre but on artificial standards (albeit almost exactly the same as the original litre and kilogram as planned) Medicines are frequently prescribed in teaspoon and tablespoon doses Although there is a British Standard Specification for a medicinal teaspoon (60m or 36 ml (approx 4)) the domestic teaspoon varies from 24 to 70 ml and so wherever possible it is best to avoid domestic measures and to use a measuring glass CONVERSION TABLE FOR WEIGHTS AND MEASURES 1 milligram (mg) l.. grain (gr) 15 mg 60 mg 100 mg (= 01 G) 1 gr 11 g 107 ·108 THE 110USE PHYSICIANS HANDBOOK 01 milltitre (ml) 03 G and 03 m 05 G and OS ml IG and 1 ml 30 G and 30 ml 600 ml (approx) 1 Kg 1 minims (m) 5 gr and 5 m 8 gr and 8 m 15 gr and 15 m 1 oz and I ft oz I pint 22 lb ABBRFVIATIONS SC = Subcutaneous injection IM - Intramuscular injection IV = Intravenous ifjection PR = Prophylactic dose TK = Therapeutic dose IN = Initial dose SUB = Subsequent doses S - Single dose S(R) Single dose-usually repeated two or three times in the day D * Daily dose DI = Daily total in divided doses W = Weekly dose The route of administration is by mouth unless another route is indicated The doses in the table are for an adult and in general are taken from the British Pharmacopæia 1953 A few non official drugs are included and are distinguished by the square brackets [ ] enclosing the name of the drug Although proprietary nimes should be avoided a few popular ones are added in brackets They are intended to assist the house physician to note and learn the approved names ·TREATMENT 109 NAM OF D LG ROUTE O An IINI IRA TION Do e REMARK S(R) A tylsali yt cd (Asp ) Adr al Act 1 (1 1 000 sol tion) Am ophyth 03t is 0 to 0 m) SC S(R) S(R) S I or IM 01 to 05G per ft molt 05G (ppost ry) 03 to 4G 5t 10 mg out 03G Ama chi nde Amph tamine s Ipht [Amyl barbote (BPC)] (S4) (Amyt !) 4 ene hyd och! ride S(R) S(R) S As orbi acid t 5 mg St 50 mg 50 mg 200 500 Owt 1 mg 1 to G Atrop Ipht Aeomy 11 DPR DTH DPR DTH S D/ BP (193) dos Hgh d & It 9 d S S(R) S f Barbt (S4) Bellado a t tur [Bt barbt (BPC NF)] (S4) (S Calciferci 03 06G 06 to 2 m 100 to 00 mg 01 DPR mg 4 000 t 002 (1 000 ts) 01w t (5000 1. mg DTH 50 000 t nte D) tio tv IM Calcun got Calm si Cal o lact te Carbah [Ca bimaz 1 ] (NO it 40 it G it is S(R) S SIR) SC oto mg t $mg t 10 mg 1 D17 troll & dos t dos Carbo ti biond Casca $ grad 1d trct of Cas fa sagt da, dn d xtr t of t 4 ml S 01 t 05 G S Cast til Cul 1 bydrt Chloramp! Cy of balam n( tm un S s D/ 14 IN B1 ) IM 4t 16 ml 031 G 15+ 4G 100 i crogramm 50 t 100 mcrogrammes three * ks SUB ·110 THE HOUSE PHYSICIANS HANDBOOK NAME OF DRUG ROUTE OF ADMINISTRA TION Dose REMARKS 200 400 mg S (Cyclobarb top (BPC)) (S4) (Phanodorm) Deo ycortone cet te Implt IBC 01 to 0 4G to 5 mg to 10 mg D D xampbet mine Slphate (BPC) (D xedrine) Dienoest ol Dgtal prepared 0 to 10 mg 30 to 100 mg D S{R) 100 mg powde edafo ma approx mately Ditul digital sed D ma t nance dose S DI D8 IV IM 1 to 1 mg o to mg 0 1 1 mg 100 mg 50 to 100 mg S(R) D gox n ) et on Dm cap ol (BAL) (D phe hyd am 3 (S4) (B nadeyl) Emetine and bm th d de Emet ne hy lo hlonde Eph dna hydrochtonde E betri male te Ergotam de rt at (F m IM SC 60 t 00 mg 30 to 60 mg 1 to 60 mg 0.1 mg it D D S(R) S S SC PM Eth nylo trad 1 S D m To 0 mg 10 100 grammes to 100 mg Oct 1 G Eth terone Ethyl bsc mett D D (Tt em IN Fol c ad Glyceryl tro trat Heparin [He ameth mb tartrat ) Hyos 9 hs dr bom d Ju) in SBI sa IY SC IM SC SC IV IV 01 09 D SUB (das X d pods PO thmbnat ty ! mg D 05 1 mg S(R) 6 ono t 100 nit S(R) o to 7 mg 031 06 mg Dostb dt mnd by the phys w th th (Cont 20 40 or 80 t per tol (C at 40 80nts (C ata 40 er en typ ml) (Co tn 400 80 0 I pe mi 1 Soluble 10s 1 Prot mn ne IC Globa sal I D C suspense Iro - Feric amo ni mctat Iterto 3 Rlcn] 1+ 3G 031 06G SIR) S(R) ·TREATMENT 111 MAVE OF DRUG ROUTE OF ADMV STRA TON DOSE RENARES Irod F NO$ wipht (S barat d S(R) siccated de CO 00 mg 0 100 mg o 1V 100 to al mg S $ Iphat (h mg S(R) d xtr mplex) | IN (Imfer) Isopr dal Si gual Epo) Mgnes m sulphate Men si mtn lc te Malina lod M phth IM Мер и hyd hind tratt + 16 G 03 G jt 611 m& S S(R) S D DPR D TIL S(R) D 616 DOG 6 G D3t 08G и ругата (S4) (Mephes (BPC) malet (Anths) Mall at [Meth (BPC)] (Mech lyl) IM d 0 to 100 t m? 100 mg S с hyd hl nd 10 t w mg t 20 mg $ S (S4) 0 mg D MtId (DDA) B thylp! ba bt (Phmt) Methylth 5 phú Iph te (DDA) Teo pl ru Leostig m thyl Ipht D D S + 111 SC IV S(R) not 600 mg 0° 0 mg mg 01 06G 1 + 69 mg ot mg 1 t 30 mg Otomg 03t ml 01 t - mg SCIB "K! SIR) md f (DDA) Opm Obai 10 ytet ry! ] DPR D TIS S $ D ti (Tert my Oxytoc Pm qua SC IV 10+ n1 mg S SR) D/ dum Pra-mo-sal It (BPC) P raffin la a Paraid hyd Р IBI At 90 m] t 8 mal + 8 ml р t rd SIR) S IS dt om d by th phys with th d f the pat cul b t ·112 THF HOUSE PHYSICIANS KANDBOOK MAN OF DRUG ROUTE OF ADMINISTRA TION Dose REMARKS Pen aliin-contd Crystalho bn ylpen in Proca de be lyp nich with benzylped citin n) ct oa Patob rb tone sod 4m (5 41 (Vemb tal) Petkedin hydrochlord (DDA) (Conta ng 300 000 ts P pro beazy! Dclln pls 100 000 unts be plne cQ Det ml) 010 G $ w to 100 mg 5 IBV Po cetin Phen nở e (D ndey) to 100 mp 03 to 06 130 00 mg 50 + 100 mg Pth more Phen bot ng (S 41 Phenyt 10$ d m Pcrot in At 190 mp 20 100 mg 06t 6 mg S S(R) IN SUB (dos depends 01 act v ty) S(R) SIRI ht be gavged by respo fotect 5(R) S(R) D Tyra > COAS Other duti D Des & Pota s m chloride Pot s um ctat P tas 101 odid (Primon) Mysol ne) Pgut Promethaz ne (S47 Propylt. Ta ) (541 1 to G 1 to G 30 to mg 3 to 6 07 t IG 01 046 mg 00t €00 mg to 400 mg Ot 100 mg 50t po me D Corte Il ng dos ce dose D 1V s (Protar s Ipht) Qu Dalbatbt $ xdium (S4) (Scopal) Quin dipe sulph te de hydr blonde Rube ne t 300 mg 031 06G Saat in $ 13a. 29 dextr !! Sadama th on 1 to t ID mg 600 mg 061 mnl 10 t 100 mg SR) S(R) DPR DTH S S (told 6 por ced s1C) S RY S(R) D D 131 Soduits 8 arbor le Sod mi alcolae Sttooestrol S rept my in Suce byl ulpbathiacol (S4) Sus had an ac (54) 0-6 t oft 5 mg JC 3! 66 IM SIR) IN SLB his) tout ·TREATMENT 113 NAXE DAG ROJTE OP ADMIN STILA TION EM SẼ Slphadımıdup (S4) 3 G it 1 G I SUB ( S ry six ) dim IV Sulph dim de ject (S4) Test st Test tero e Imp! t IM 011 06G Pop opate D IV S D S(R) IMC IV The Pin di mn (S4) Thyrd ET 11 hydro bi nd (BPC)] (Pns 1) (S4) (Trdi e) Vas pess an) to Vt min A Halib tl v Oul 91t 05 30 t 40 mg 51 50 mg 10 t 0 mg it G Ot 07 ml Tudo D/ S SC IM D ) Co 0 06 03 m (1 500 t 7.00 0 06 t 06 ml (500 t 5000 tat deltn . Drugs which are subject to the regulations of the Dangerous Drugs Acts and those which are classified as Schedule 4 Poisons are indicated by the abbreviations (DDA) and (S 4) respectively NEWER DRUGS Diamor (Lederle) (Acetazoleamide) (Non mercurial oral diuretic) -250 mg (1 tablet) each morning Largactil (May and Baker) (Chlorpromazine) —25 to 50 mg (1 or 2 tablets) three times a day Eumydrin (Bayer) (Atropine methonitrate B PC)-06 per cent alcoholic solution 2 drops before each feed for pyloric spasm in babies Piperazine (Entacyl British Drug Houses) for thread worms 300 mg tablets Dose Children up to 6 years 1 tablet per day per year of life over 6 years -2 tablets 8 ·NOTES ·TREATMENT 115 three times a day Seven days treatment Repeat after one week s rest if necessary Vitamin K (Konakion Roche) 10 mg in gelatin capsule The dose is squeezed out into some orange juice and swallowed Also supplied in 50 mg ampoules (Mephyton Merck) for intravenous use ANALGESIC DRUGS Mild ones like aspirin and Compound Tablets of Codeine BP ( Veganın ) should be tried first Morphine (DDA) in doses of 10 to 30 mg (gr/ to '/) by subcutaneous injection is the drug of choice for severe pain if it causes vomiting Dılaudid may be used instead Dılaudid (dihydromorphinone) (D DA) The dose is about '/, that of morphine ie 2 mg (gr /) is equivalent to 10 mg (gr %) morphine it causes fewer side effects than morphine Omnopon (Roche) (Papaveretum BPC) (DDA) 20 mg (gr/s) = Morphine 10 mg (gr .) Nepenthe (DDA)-a liquid preparation of opium Dose 03 to 25 ml (m 5 to 40 approx) 15 ml (m 25) has the same effect as morphine 15 mg (gr /> Physeptone (Amidone) (DDA) Dose 5 to 10 mg 30 mg is the upper limit An analgesic without the sedative effect of morphine 12 mg has the same effect as morphine 15 mg (gr/) Dromoran ( Methorphinan) (DDA) Dose 15 to 4 mg by mouth by injection A powerful analgesic with less hypnotic effect than morphine (Note-It precipi tates if mixed with thiopentone) ·116 THE HOUSE PHYSICIANS HANDBOOK Pethidinte (DDA) Dose 50 to 150 mg 250 mg is the usual upper limit It has an action midway between aspirin and morphine and also spasm relieving properties in the colon uterus and ureter 125 mg has the same effect as morphine 15 mg (gr %. SEDATIVES AND HYPNOTICS During his term as house physician the young doctor has an excellent opportunity of learning at first hand the way to use sedative drugs He will be wise to become really familiar with a small number and to avoid pro prietary combinations of sedatives and analgesics The following are suggested (oral doses for adults and dura tion of effect is shown)-- Phenobarbitone (Luminal) (S4) and Phenobarbitone sodium (S4) (soluble) 30 to 120 mg (4 to 2 grains) 8 to 16 hours Barbitone Sodium (Medinal) (S 4) 03 to 06 G (5 to 10 grains) 8 to 16 hours Ainylobarbitone (Amytal) (S4) 45 mg (l. grain) as sedative 90 to 300 mg (1'/, to ? grainsas hypnotic 4 to 8 hours Butobarbitone (Soneryl) (S 4) 60 to 120 mg (1 to 2 grains) 4 to 8 hours Pentobarbitone (Nembutal) (S 4) 90 to 180 mg (1'/ to 3 grains) 4 10 8 hours Chloral hidrate 03 to 18 G 15 to 30 gtains) / to 4 hours Chloral draught BPC -Chioral Hydrate 12 G (gr 20) Liquid Extract of Liquorice 2 mi (m 30) Water to 45 mi (Y/, ft oz) ·TREATMENT 117 Paraldehyde 2 to 8 ml (30 to 120 m) A very safe hypnotic Effect comes on in twenty minutes and lasts several hours Paraldehyde draught BPC-Paraldehyde 4 ml (m 60) Syrup 8 ml (m 120) Liquid Extract of Liquorice 3 ml (m 45) Water to 45 ml (1/2 fl oz) By intramuscular injection 5 to 10 ml for adults By rectum 03 ml per Kg (m 30 per stone) as a 1 in 10 solution in physiological saline Note-Barbiturates chloral and paraldehyde have no analgesic effect SEDATIVES FOR CHILDREN Chloral hydrate - This is most useful for the newborn and for tiny infants Give 60 mg (1 grain) as a single dose for a small baby and 60 mg (1 grain) before each feed (maximum 03 G (5 grains) in twenty four hours) for larger babies NoteDon t use neat Syrup of Chloral BPC for children as 4 ml (60 minims) of it contains 0 6 G (10 9 grains) of chloral Chloral is often combined with bromide eg Chloral and Potassium Bromide Mixture for Infants B PC-Syrup of Chloral 06 ml (m 10) Potassium Bromide 150 mg (gr 2/2) Liquid Extract of Liquorice 0 2 ml (m 24/2) Glycerine 06 ml (10) Water to 4 ml ( m60) (this dose contains about 1'/s grains (approx 100 mg) of chloral hydrate) Paraldehyde —2 to 4 ml intramuscularly for con vulsions By rectum m 30 per stone in physiological salıne (Solubility 1 in 10ie m 60 in 1 fl oz or 4 ml in 30 ml) ·118 THE HOUSE PHYSICIANS HANDBOOK Aspirin-02 G (gr 24/2) acts as a sedative in small children Pentobarbitone (Nembutal) (S 4) 6 mg per Kg (ST s/ per stone) Maximun dose 180 mg (3 grains) Quinalbarbitone --(Seconal) (S 4) 8 mg per kg (gr 7. per stone) Maximum dose 180 mg (3 grains) Sup positories contain 120 mg (2 grains) Injection of Papaveretum BPC (Omnopon) (DDA) 006 ml (one minim) per year of age RECTAL THIOPENTOVE FOR CHILDREN The dose is 20 mg per pound body weight The maximum dose is 1 G irrespective of body weight A small enema should be given if the child is constipated and then no food for three hours Give atropine 04 to 06 mg (gr 10 to 1200) subcutaneously half an hour before the thiopentone to prevent salivation Dissolve 0 5 or 10 G of thiopentone in 20 to 40 ml of tap water and take up the appropriate amount into the syringe Tell the chud that he is just having another enema or that he is having his temperature taken and inject the dose slowly into the rectum through a small catheter Strap the buttocks together Should some of the solution be returned give half the original dose half an hour later The chud will be very drowsy within half an hour Have oxygen and a sucker and nikethamide ready in case of excessive sed tion This method is very useful for such procedures as lumbar puncture chest aspiration and ophthalmoscopy It is not contraindicated by the fact that the child is seriously all ·TREATMENT 119 PRESCRIPTIONS Only prescribe by title preparations of the current BP and the current National Formulary Prescriptions not in these publications should be avoided if possible Other prescriptions should be written legibly in full and pre ferably in English Roman numerals and the signs 3 and 3 should be avoided Use m 60 for 3) and 1 fl oz for 3 when prescribing in the Imperial system In the Metric system conform to BP practice and prescribe milli grammes for any amount less than 01 G Always put the child s age on his prescription so as to emphasise to the pharmacist that the medicine is intended for a child POISONS AND DANGEROUS DRUGS Prescriptions for Dangerous Drugs (opium etc cocaine cannabis indica pethidine physeptone heroin) and Schedule IV poisons (sulphonamides barbiturates etc) must show the name and address of the patient the total quantity of drug or preparation to be supplied the date and the doctor s signature and address For patients in hospital addresses are unnecessary and the doctor s initials instead of his signature are acceptable Only private prescriptions can carry instructions to repeat and then only twice (re three dispensings in all) the pre scription being retained by the pharmacist DANGEROUS COVIBINATIONS OF DRUGS Avoid blunderbuss therapy and remember that drugs innocuous in themselves may prove dangerous in com bination Examples are calcium and digitalis (intravenous calcium in a digitalised patient may cause death from ventricular fibrillation) adrenaline and chloroform or trilene anaesthesia morphine and barbiturates ·120 THE HOUSE PHYSICIANS HANDBOOK ANTIBIOTIC DOSAGE Prescribing rules for antibiotics are the same as for Schedule IV poisons All antibiotics except penicillin are prescribed by weight It is undesirable however to try to alter the established practice of prescribing penicillin in units and there is the additional difficulty that 1 mg of different preparations does not contain the same number of units (procaine penicillin 1000 units and crystalline sodium penıcıllın 1 600 units per mg) Penıcıllın by injection - Crystalline penrcıllın (Benzyl penicillin or Penicillin G sodium salt) Usual adult dose 500 000 units twice a day Procaine penicillin (Distuquaine Seclopen) Daily dose is 300 000 units fortified with 100 000 units benzyl peni cillin Intramuscular only Penethamate hydriodide (Estopen) 1 mega unit daily Dibenzylethylenediamine dipenicillin G (DBED) 300 000 units every three days Penidural all purpose penicillin ~ When reconsti tuted with 15 ml water one dose yields 600 000 units of DBED dipenicillin G 300 000 units of Procaine penicillin G 300 000 units of Potassium penicillin G with sodium Citrate buffcr This single dose is said to be enough for most infections (except bacterial endocardit15) Pentcıllın by mouth.DBED dipenıcıllın G (Peni dural) 300 000 units in 5 ml every six hours Oral tablets contain 200 000 and 400 000 units of crystalline penicillin Five times the intramuscular dose every three hours is advised ·TREATMENT 121 Penıcıllın by inhalation-Use 1 to 2 ml of a solution containing 100 000 units per mi in fifteen minutes Streptomycin - Total daily dose of streptomycin and dihydrostreptomycin is 1 to 2 Gintramuscularly Intra thecal dose 25 to 100 mg Oral dose 2 to 4 G daily (bowel infections only not absorbed) Chloramphenicol --50 mg per Kg daily in divided dosage by mouth 250 mg capsules for deep intra muscular injection use a solution of 250 mg per ml in dimethylacetamide If used intravenously it must be diluted first by injecting 2 ml slowly into 100 ml of physiological saline with the needle point below the surface Dilution in the ordinary way may cause pre cipitation Chlortetracycline (Aureomycin)—12 5 to 20 mg per Kg daily in divided dosage (up to 15 G a day for an adult) For intravenous injection use 10 ml of physio logical salıne to dissolve 100 mg of buffered powder and then dilute so that there is 1 ml of salıne for each mg of aureomycin Stronger solutions are very apt to cause thrombosis Intramuscular injection is painful and should be avoided Oxytetracycline (Terramycin) —By mouth 1 to 2 G a day for adults and 20 to 40 mg per Kg for children Intramuscularly about 05 G a day for adults Erythromycin ---By mouth up to 2 G a day for adults and 30 mg per kg per day for children Tetracycline-By mouth or intravenous drip for adults 1 to 2 G a day and for children 10 to 20 mg per pound per day ·122 THE HOUSE PHYSICIAN S HANDBOOK Sulphonamide dosage The maximum safe daily dose for an adult is 10 G and for the smallest infant 2 G provided urinary output is adequate (1 500 ml a day for an adult) Gantrısın (sulphafurazole) is effective in doses as small as 6 G daily With Urolucosii (svlphamethizole) 1 G1 day is sufficient (01 G tablets) The poorly absorbed sulphonamides (phthalyl sulphathiazole) may be given in doses of 20 G a day or more COST OF ANTIBIOTICS The house physician should be aware of the cost of the antibiotics he prescribes In many hospitals thev account for up to halt of the drug bill and there is reason to believe that they are often prescribed excessively or unnecessarily The price of those under Ministry control is confidential but it can be stated that whereas three days treatment with penicillin one mega unit a day costs 4/6d treatment by daily dosage of 15 G for three days with aureomycin or terramycin costs hospitals six times as much and with erythromycin nearly ten times as much Sulphonamide dosage costs less than antibiotic dosage 100 tablets of sulphathiazole (05 G each) for example costs 5/3d ANTIBIOTIC ANTAGOVISM Penicillin and streptomycin art primarily bactericidal and their effects synergistic (particularly against Strepto coccus faecalis) Aureomycin chloramphenicol and oxy tetracycline are primarily bacteriostatic and the effect of combining them simply additive Combinations of bactericidal and bacteriostatic antibiotics are usually antagonistic when the organism 15 very sensitite to the bactericidal drug because the growing forms on which ·TREATMENT 123 the bactericidal drug would act are suppressed If an organism is not very sensitive to penicillin and strepto mycin then the effect of adding aureomycin chior amphenicol and oxytetracycline is synergistic Although sulphonamides are bacteriostatic they enhance the effect of penicillin and streptomycin because their activity is very dependent on the number of organisms present Penıcıllın and streptomycin reduce the numbers of organisms to a level at which sulphonamides are most effective Antagonism does not present a problem with the broad spectrum antibiotics but it is best to use one of them and await sensitivity tests CERTAIN URGENT CONDITIONS The following notes are provided in the hope that they may help to avoid the feeling of helplessness which may Overcome the young house physician when faced with certain situations requiring immediate action SUDDEN DYSPNOEA Common causes are — (1) Left ventricular failure as in hypertension and coronary disease Lungs full of moist sounds May be pink frothy sputum Sit the patient up give morphine 10 to 30 mg (gr / to '1 ) subcutaneously perform vene section and administer oxygen Other remedies are aminophylline 05 G diluted intravenously mersalyl 2 ml intramuscularly and digoxin 1 mg diluted in 10 ml of physiological saline intravenously (2) Pneumothorax -The side of the chest is resonant silent and immobile Give a barbiturate and orygen If distress persists put a needle into the sixth space in the ·124 THE HOUSE PHYSICIANS HANDBOOK mid axillary line to release the tension Remove the air by a reversed pneumothorax apparatus Leave the needle in place and connect it to rubber tubing which dips under tvater (3) In a comatose patient think of diabetic ketosis (sco page 141) and aspirin poisoning (see pane 145) (4) Hystencal hyperpnoea THE ACUTE ABDOMEN The house physician may expect to be suddenly faced with the acute abdomen in the casualty department but may take the view that nothing like that can happen in his own domain These comments are provided to help him refute the gibe that the worst place to perforate is in the medical ward The main pitfall to avoid is to call the surgeon too late Many abdominal pains are medical in origin but when they last longer than six hours they are generally caused by a surgical condition A medical and a surgical cause may coincide Pneumonia can occur with appendicitis and coronary occlusion with cholecystitis So do not be lulled by the origina} diagnostic label but examine the patient afresh flat in bed and bare from breast to thigh If he cannot raise himself without using his arms an acute abdomen is likely Palpate the abdomen with the flar of the warm hind examining the place com plained of last of all Note any tenderness or ngidity and watch the mobility of the chest wall if it is fixed or tecedes on inspiration peritoneal vritation is suggested Examine the chest (for pneumonia) the gums for blue line (lead colic) and the knee jerks and pupils (for tabes) Dont forget the hernial orifices and rarely omit a rectal examination

·TREATMENT
125
If you are still in doubt obtain a surgical opinion via
your opposite number He may find what you have
missed but it is better to be humiliated at the bedside
early than when it is too late for the patient s life to be
saved
STATUS ASTHMATICUS
Remember that All is not asthma that wheezes
Useful remedies
1 Injection of Adrenaline B P 006 ml (1 minim) every
thirty seconds subcutaneously 8 ml (120 minıms)
may be needed so strap the needle to the skin
2 Aminophylline 0 25 to 05 G intravenously slowly
3 Paraldehyde up to 5 ml for an adult intramusc
4 ACTH 25 mg every four hours intramuscularly
Beware of morphine in asthma
HAEMATEMESIS AND MELAENA
Reassure the patient and give him morphine 10 mg
(gT '.) If shocked raise the foot of the bed and give
oxygen by mask at 6 litres per minute
Order an hourly pulse chart
Take blood (oxalated) for Hb estimation and in a
plain tube) for grouping
Allow dilute salinę by mouth and soon go on to semi
solid food
Drip blood transfusion if Hb below 50 per cent or the
patient is severely shocked Call a surgeon if shocked
aged over 50 or if bleeding is recurrent but don t delay
calling him until the patient is at his last gasp

·PAROXYSMAL TACHYCARDIA AURICULAR TÁCIE CARDIA AL RICULAR FLUTTER IZYTRICULAR TACHYCARDIA REMARKS Age at onset Before 40 After 40 After 50 Ventricular rate Over 160 Under 160 Over 180 Higher rates are against futter ind in favour of auricular and ven tricular tachycardia Ventscular shythm Regular Regular with occasional Very slight ar Measure rate and rhythm interruption rythm13 by auscultation and not palpation because of pulse defict Duration 12 hours or 2 31 A day or two Several days days at most Previous alla ks Frequent Common Exceptional Carotid Sous Vay abolish attack Induces stimulanon or be without temporary No effect irregular ventricular effect rhythm Tachycardia rclurns after transient slowing Heart muscic lealthy Slightly damaged Usually grossly damaged Associaled condi Mitral stenosis tions Induces auricular fibril1 Myocardial in ation farction 2 Over digitalisa Paroxysmal tron Digitalis May abruplly abotish Coronary scleros Aggravates and Tachycar la common contraind cated 126 THE HOUSE PHYSICIANS HANDBOOK a ·TREATMENT 127 PAROXYSMAL TACHYCARDIA The table on page 126 (from Emergencies in Medical Practice) will help the house physician to decide the type and treatment An ECG should be arranged CEREBRAL MALARIA Always suspect this in a seaport town if a seaman is brought with headache drowsiness and delirium Take thick and thin blood films (see page 70) Give Quinine bihydrochloride 05 G intravenously slowly and prefer ably in 300 mi (10 fl oz) of dextrose saline Repeat six hourly until able to swallow ARTERIAL OCCLUSION Arterial embolism is shown by sudden pain pallor and paralysis of a limb in a patient with mitral stenosis or other source of an embolus Arterial thrombosis being slower is less likely to cause pain Don t delay Give pethidine 100 to 150 mg sub cutaneously (not into the affected limb) for pain if necessary Give papaverine 30 to 60 mg ("/ to 1 grain) intravenously and tolazoline (Priscol) 25 mg intra venously Give whisky or brandy in liberal doses All these measures aim at causing dilatation of col laterals Forbid smoking which might have the opposite effect Dont elevate the limb This would hinder its blood supply Don t warm the limb but leave it exposed at toom temperature This reduces its oxygen requirements Put a glove on the opposite hand and a bedsock on the opposite foot and let the patient wear his bed jacket These measures may release vasoconstriction reflexly Start anticoagulant therapy with heparin 15 000 units ·PAROXYSMAL TACHYCARDIA AURICULAR TacIES CARDIA AURICULAR FLUTTER VENTRICULAR TACHYCARDIA REMARKS 126 Age at onset Before 40 After 40 After 50 Ventricular rate Over 160 Under 160 Over 180 Higher rates are against flutter and in favour of auricular and ven tricular tachycardia Ventricular rhythm Regular Regular with occasional Very slight ar Measure rate and rhythm interruption rythmia by auscultation and not palpation because of pulse deficit Duration 1 2 hours or 2 3A day or two Several days days at most Previous attacks Frequent Common Fxceptional Carotid sinus May abolish attack Induces temporary No cffect stimulation or bc without irregular Ventricular effect rhythm Tachycardia returns after transient slowing Heart muscle Healthy Slightly damaged Usually grossly damaged Associated condi Mitral stenosis Induces auricular fibrit 1 Myocardial in tions ation farction Over digitalisa Paroxysmal tion Digitalis May abolish Coronary sclerosis Aggravates and is Tachycardia abruptly Common contraindicated THE HOUSE PHYSICIANS HANDBOOK a ·TREATMENT 129 obvious septicaemia penicillin and cortisone should be used also Pneumococcal meningitis - Give one intra thecal in jection of crystalline penicillin G 25 000 units in 5 ml of water and 2 to 4 mega units four hourly intramuscularly with sulphadiazine as in meningococcal meningitis Streptococcal and staphylococcal meningitis --Treat as for pneumococcal meningitis but if the organism is peni cillin resistant then use chloramphenicol (as in H Influen ae meningitis) and sulphadiazine (as in meningococcal meningitis) Haemophilus influenzae meningitis-Chloramphenicol 50 mg per Kg in twenty four hours by mouth is the drug of choice for children the tasteless chloramphenicol palmitate (250 mg in 8 ml ) is best Streptomycin should be avoided as it may quickly cause deafness in sensitive patients but one or two doses (25 to 50 mg in 3 to 5 ml of saline every twenty four hours) may be given intra thecally if there is vomiting Tuberculous meningitis --The CSF will clearly indicate a meningitis but it will be sterile and the problem is to distinguish between tuberculous meningitis non paralytic poliomyelitis meningitis following an infectious fever and lymphocytic chorio meningitis (see pages 93 and 94) If there is doubt it is best to play for safety and start treatment as for tuberculous meningitis with streptomycin 20 mg per pound daily by intramuscular injection (none intrathecally) and INAH 5 mg per pound daily by mouth EPISTAXIS Bleeding from the nose only becomes a job for the doctor when it won t stop Sometimes this is because of in 9 ·128 THE HOUSE PHYSICIAN S HANDBOOK intravenously and pheniodione 200 mg by mouth Notify your senior so that a surgeon may be consulted STATUS EPILEPTICUS Give paraldehyde 5 ml (from an ampoule but if need be straight from the bottle) intramuscularly and repeat if necessary in half an hour The fits must be stopped and should paraldehyde fail thiopentone intravenously or chloroform by inhalation may be used MENINGITIS-WHICH DRUG TO USE? Once the question of meningitis has seriously crossed your mind you must do a lumbar puncture Which drug to use will depend on the CSF findings Avoid intra thecal treatment if possible and never inject any sul phonamide intra thecally Sulphadiazine and chlor amphenicol are the two substances which penetrate best into the CSF Practically no Tertumycin (oxy tetra cycline) when given by mouth will reach the CSF The following notes are provided to help you to decide which drug to use Until an organism is revealed you will have to rely on clinical judgment and the other CSF findings if the CSF is normal treat the con dition_usually pneumonia--which is causing meningitic symptoms (meningism) Meningococcal meningitis --Give sulphadiazine in full dosage (2 G a day for the smallest child and 10 G 1 day for an adult) If vomiting precludes oral administra tion the first doses of sulphadiazine sodium may be given well diluted by intravenous injection An adult must take 6 pints of fluid in twenty four hours and a child 1 pint for each gramme of sulphadiazine given When there is ·TREATMENT 131 has had a tooth extracted during the previous twenty four hours and is still bleeding Reassure the patient and if necessary give him a sedative Clear the mouth of loose clots using cotton wool and physiological salıne Verify the site of bleeding Make a roll of gauze like a cigar and put it across the socket Tell the patient to bite on this A bandage may be used to keep the jaws together After twenty minutes remove the gauze gently This is usually all that is necessary as the bleeding was capillary in origin If bleeding continues there is probably some periosteal separation Anaesthetise the gum on either side with 2 per cent procaine and put in a horizontal suture of nylon or silk to draw the gum margins together Should this fail you should seek help from your senior colleague THE FIXED WEDDING RING The house physician may have to do evening casualty duty and he may be faced with a woman who cannot remove her ring from her swollen finger It is a pity (and difficult) to cut the ring and the following little known simple manoeuvre is often successful Beginning near the distal inter phalangeal joint wind a fine string carefully round the finger until it comes up to the ring push the end under the ring with a match stick then pull gently towards the finger tip As the string unwinds the ring comes with it Rings with stones require patience and manipulation when unwinding A little lubricant may help A very swollen finger may be first reduced in size by injecting into it 1000 units of hyaluronidase in 1 ml of 1 per cent procaine and massaging it ·130 THE HOUSE PHYSICIANS HANDBOOK expert handling at home It is best to ty simple measures first Prop the patient well up with a comfortable inclination to one side arrange a large pad of wool for him to dribble into put a dental prop between his teeth forbid him to breathe through the nose or swallow and give a substantial dose of morphia Only by mouth breathing and a complete cessation of swallowing can the bleeding area be given the necessary and almost in fallibly haemostatic rest' (Wilfred Trotter) As in most cases the bleeding point is at the front of the septum the next step if bleeding continues should be to put in a little wool smeared with petroleum jelly The patient should press the side of his nose against it for fifteen minutes This is more comfortable than packing In the few cases when bleeding suill goes on cauterisa tion of the bleeding point on the septum should be tried Using a dental syringe anaesthetise the skin of the nostri! and the mucous membrane of the septum with 2 per cent procaine Touch the bleeding point with an electric cautery at cherry red heat If too hot it will cut the vessel and if too cold it will stick to it and tear at Cauterisation by a suab stick moistened with deliquescent crystals of trichloracetic acid is less frightening than the cautery for children The rare serious haemorrhage from vessels on the lateral wall and posterior part of the nose and in haemophilia and hypertension should be referred to an ear nose and throat surgeon THE BLEEDING TOOTH SOCKET The problem usually presents to the house physician as a call to the Casualty Department to see a patient who ·TREATMENT 133 cult to get a clear picture of the patient s progress from these charts In cases of dehydration the house physician is therefore advised to write a short statement each morning of the position up to 8 am and to renew the instructions for the day WATER DEPLETION (results from inadequate water in take with no excessive loss of salt as in coma and high fever) —Thurst Scanty urine containing salt No circu latory failure Plasma sodium normal or high Blood urea normal or slowly rising SALT DEPLETION (results from excessive loss of salt with adequate water intake as in protracted vomiting diarrhoea and Addison s disease) -No thurst Urine not scanty but free from salt (except in Addison s disease) Peripheral circulatory failure and low B P Plasma sodium low Blood urea high (eg 100 mg per 100 ml) Patient confused listless and later comatose MIXED WATER AND SALT DEPLETION (results from ex cessive loss of salt and inadequate water intake as in acute vomiting) -Dehydrated and thirsty Urine scanty but salt present Blood urea high How Much FLUID? How Much SALT? These questions are best considered under two headings 1 Prevention-how to deal with the patient in normal fluid and electrolyte balance when first seen 2 Treatment-how to deal with the patient who is already depleted of water and electrolytes when first seen Prevention Complicated electrolyte replacement is not needed at once In each period of twenty four hours a 70 Kg man needs 2 to 3 litres of water These can be ·132 THE HOUSE PHYSICIANS HANDBOOK NOTES ON FLUID AND ELECTROLYTES Normal plasma levels Sodium-143 mEq/litre (range 133 to 152) or 330 mg per 100 ml (range 306 to 350) Potassium --5 mEq/htre (range 36 to 56) or 20 mg per 100 ml (range 14 to 22) Chloride -- 100 mEq/litre (range 99 to 107) or 355 mg per 100 mi (range 350 to 380) (Sodium chloride -100 mEq/lıtre (range 97 to 108) or 585 mg per 100 ml (range 570 to 630) In some laboratories only the chloride is estimated and the result expressed as sodium chloride) Bicarbonate --27 mEq/litre (range 25 to 33) or 60 volumes CO, per 100 ml (range 56 to 74) Proteins -- 15 to 20 mEq/litre or 6 to 8 G per 100 ml Body fluid --The total body fluid is 60 per cent of the body weight (plasma 5 per cent extra-cellular fluid 15 per cent intra-cellular Nuid 40 per cent) Normal inevitable losses of fluid by an adult every twenty four hours are about 1 500 ml (perspiration 600 ml expired air 400 ml fluid to get rid of waste products in urine 500 ml) The iud in food and produced by its oridation roughly balance the skin and lung losses and so the urinary output usually equals the fluid drunk Sweating rapid breathing youth and age increase these requirements For safety and comfort it is best to aim at giving 3 litres of fluid every twenty four hours The adult daily requirements of sodium chloride are 4 5 6 (say 80 mEq or 500 ml of physiological saline) and of potassium chloride 6G (80 mEq) Fluid charts --Charts of varying kinds (usually for twenty four hour periods beginning at 8 am) are used in different hospitals After several days it may be diffi ·100 TREATMENT 135 litre) can be regarded as the same as that of physiological salice (160 mEq of Na per litre) A rough idea of the amount of sodium needed can be obtained by calculation as follows — Deficit of Na = (normal level - patient s level) ~ volume of body fluid = (142 - Patients Na level in mEq) x 60 per cent of body weight For a 70 kg man with a plasma sodium of 118 mEq/lıtre deficit (142 118) x 60 x 70 = 24 x 42 = 1000 mEq Na (approx) 1 litre of physiological saline = 160 mEq Na (approx) the required replacement Deficit litres of physiological salıne 160 = about 6'/ litres A simple formula 1slitres of physiological salıne needed 142 patient s serum sodium level in mEq 3 Such a calculation is only a rough guide for it is fallacious to suppose that knowing the body weight and the plasma electrolyte levels it is possible to calculate exactly how much salt is needed to bring the plasma level back to normal Calculations cannot allow for the state of the intra-cellular fluid or the efficiency of the kidneys and they ignore the adjustments which are continually taking place We should judge the patients state by considering all the evidence the history of fluid loss by vomiting diarrhoea or through a gastric suction tube or fistula = ·134 THF HOUSE PHYSICIAN S XANDBOOK given by mouth or as a rectal drip of tap water or hypo tonic saline or as an intravenous drip of 5 per cent dextrose The daily salt requirement of 45 G can be supplied as half a litre (one bottle) of physiological saline intravenously or if diluted by mouth or as a rectal drip These considerations do not apply for the first few days after a major operation because various factors including the endocrine response (increased secretion of adrenal cortical and pituitary anti-diuretic hormones) result in a fall in the output of water and salt (and an increased loss of potassium) Water retention lasts twenty four to forty-eight hours and salt retention three to four days in these cases urine chloride estimations might suggest that the patient needed salt while the plasma sodium level would show that he was full of it for the first two days after operation the fluid intake should be under 2 litres in twenty four hours (say two bottles of 5 per cent dextrose and one bottle of physiological saline) A urine specific gravity under 1010 is a signal to increase the salıne intake If the patient can soon the food and fluid by mouth we need not worry further but if intra venous fluid is needed for several days it may be necessary to give potassium also A deficit should however bu demonstrated first Treatment -A guide to the already dehydrated patients need for salt (except after operation) is given by the chloride content of the urine as shown by Fantus test (see page 74) If urinary chlorides are low less than 4 G per litre) or when fluid is lost by vomiting then physiological salınt should be given intravenously When much saline has to be given it is well to replace one bottle in three or four by M/6 sodium lactate solution to prevent acidosis Its electrolyte content (154 mEq of Na per ·TREATMENT 137 potassium Alternatively capsules containing 1 G of potassium chloride (13 mEq potassium) can be used When a patient can take food and fluid by mouth we need not worry about his potassium intake but if intra Venous fluid is needed for several days it is generally necessary to give potassium In all cases a deficit should be demonstrated first It is best not to give potassium until water and sodium deficits are corrected and the urinary output is good When intravenous replacement is needed a useful solution is Naci 225 G (= 40 mEq) KC 30 G (= 40 mEq) 5 per cent dextrose 1 000 ml Two litres of this in twenty four hours will give the patient his 45 G NaCl (80 mEq) and 6 G KCI (80 mEq) Any extra furd needed should be given as 5 per cent dextrose Darrow s solution (27 G KCI and 4 G NaCl per litre) IS similar Another plan is to inject potassium chloride into the bottle Not more than 15 G of potassium chloride should be put into one bottle since this strength (40 mEq per litre) is the maximum safe strength for intravenous administration The rate should not exceed 12 mEq per POTASSIUM INTOXICATION This results from excessive intravenous medication particularly if there is also renal failure It causes weak ness flaccid paralysis and paraesthesiae Sudden death may occur from cardiac arrest even when the patient does not appear very ill The lethal level is 10 mEq/litre (40 mg per 100 ml) Treatment is to promote diuresis by intramuscular mersalyi injections and to reduce the extra cellular potassium by causing increased cellular uptake This is done by giving insulin and dextrose (0 25 unit of insulin for each gramme of dextrose) hour ·136 THE HOUSE PHYSICIANS HANDBOOK the presence or absence of thirst the clinical signs of dehydration (slack skin dry tongue soft eyeballs and collapsed veins) the urinary volume specific gravity and chloride content and the serum sodium and potassium levels It must be remembered too that in addition to replacement of deficits the patient must recere also his basic needs of 1'/, litres of fluid (best given as 5 per cent dextrose) and '/, litre of physiological salide (= 45 G NaCl) In general it can be stated that a patient with thirst and oliguria is short of about 4 litres of fluid and if his BP is below 90 and chlorides are absent from his urine he needs 0 75 G Naci per kg body weight (re about 4/ litres of physiological salıne for a 60 Kg man) POTASSIUM DEPLETION In sodium depletion the extra cellular fluid is hypotonic and as cell membranes are relatively impermeable to electrolytes the body cannot easily correct this completely Some potassium does pass into the plasma however but the kidneys cannot conserve it. The plasma becomes depleted and symptoms result This possibility is in creased if potassium free fluid is infused for several days Suggestive symptoms are muscular weakness abdominal distension and mental confusion Potassium depletion can be confirmed by estimating the serum potassium by flame photometry Treatment --Potassium depletion is best corrected by giving potassium by mouth The potassium citrate mixture of the onal Formulary is suitable Pot Citrate 3 G (gr 45) Citric Acid 06 G (gr 9) Syrup of Ginger 4 ml (m 60) Chloroform water to 15 ml (1, fi oz) and 15 ml ('/, fi oz) of it contains 25 mEq of ·TREATMENT 139 hour since the size of the average drop is ^/ ml One drop every three seconds (60 ml per hour) is fast enough to start with The rate should be cut down after an hour or SO A useful rule is that the normal requirement of 2 la i oz per pound per twenty four hours will be met if the number of drops per minute equals the weight in pounds ELECTROLYTE CONTENT IN MEQ OF A 500 ML BOTTLE OF VARIOUS SOLUTIONS Sodum Potassium Chloride Physiological Saline (09 per cent ) 80 80 Darrow s Solution 117 33 84 143 5 55 Hartmanns Solution M/6 Sodium Lactate 77 Plasma 76 3. 76 DEHYDRATION IN ADDISON S DISEASE (ADDISONIAN CRISIS) Since symptoms are probably the result of both dehydration and hypoglycaemia both salt and dextrose should be given (2 litres in the first twelve hours of 5 per cent dextrose in 15 per cent saline by intravenous drip) In addition give cortisone 100 mg intramuscularly at once and then 50 mg every six hours by mouth and 10 mg of Deoxycortone Acetate BP in oil intra muscularly every six hours ·138 THE HOUSE PHYSICIANS HANDBOOK DEHYDRATION IN CHILDREN Infants have a water turnover five times greater than adults because their greater metabolism means more waste products have to pass through their relatively in efficient kidneys A chloride output of 2 to 3 G per litre Is normal for a child Type of fluid —Never use full strength physiological saline for an infant Use half strength physiological saime in 4 per cent dextrose or half strength Hartmanns solution (Compound Injection of Sodium Lactate BP 1953) How much flud"--The daily fluid requirements of normal children are During 1st year-21 fl oz (70 ml) per pound of expected body weight At 3 years-32 to 50 fl oz (1 000 to 1 500 ml) At 8 years--50 to 65 fl oz (1 500 to 1 900 ml) At 12 years—70 fl oz (2 000 ml) A dehydrated child needs extra fluid the amount being Difference between actual and expected weight Expected weight * Expected requirements Example --Expected weight 15 lb Actual weight 12 1b Difference = 3 Expected requirements = 21 x 15 = 3711 ft Oz Extra fluid needed is / of 37'/2 = 7'/, 1 oz Route ---By mouth if possible Otherwise intravenously or subcutaneously with Hyalase (Benger) 100 units or Rondase (Evans) 3 mg injected into the tubing Rate of drip-The average drip bulb kept at one drop per second should deliver 3 ml per minute or 180 ml per ·TREATMENT 141 10 red portions contain the average amount of protein and fat normally eaten by adults and yield about 1 G protein per kg body weight 10 black portions is the minimum amount of carbohydrate advised since 100 G carbohydrate are necessary to prevent ketosis Insulin - In using a mixture of soluble insulin and protamıne zinc insulin adjust the proportions so that the urine is sugar free or nearly so (1) before breakfast—to make sure the PZI is enough (2) before the mid-day meal-to make sure the soluble insulin is enough The bladder should always be emptied half an hour before a further specimen is passed for testing Make any increment or reduction at least one fifth of the previous dose The effect of smaller changes is inappreciable RULE FOR CHANGING FROM SOLUBLE TO PZI + SOLUBLE--Giver of the previous total daily dose of soluble insulin as PZI and add it to half the previous morning dose of soluble insulin A daily dose of 12 units or less can be replaced entirely by PZI Always take the soluble insulin into the syringe first for it does not matter if a little contaminates the PZI bottle DIABETIC KETOSIS (PRE COMA AND COMA) Diabetic ketosis should not be treated by rule of thumb but a basic outline of the method will give the house physician confidence He should always seek the advice of his senior colleague Pre coma (Patient conscious and able to swallow) This comes on gradually (in contra-distinction to insulin coma) The patient goes off his food and is drowsy The urine contains diacetic acid (ferric chloride test) Put the patient on a four hourly regime Give a dose of in ulin ·140 THE HOUSE PHYSICIAN S HANDBOOK COMA When coma is the presenting symptom you will gener ally see the patient in the receiving room Use a common sense approach The police or relatives may provide the diagnosis at once Answers to the following three questions will usually point to the cause 1 Is there a previous history of disease which might cause coma? eg diabetes (test urine for ketone bodies) insulin coma (if suspected give dextrose 10 G intravenously) nephritis (test urine for albumin) pernicious malaria (examine thick and thin blood films) 2 Does the immediate past history point to the cause? eg injury (do not too readıly assume that is the whole cause) poisoning (including alcohol) epil epsy (fits may be symptomatic of other disease hypertension nephritis meningitis) 3 Are there any physical signs of disease in the central nervous system? eg of cerebral vascular accidents and meningitis Always make a full examination and record the findings These must include the urine pupils fundı heart rate blood pressure and temperature Beware of saying a patient is only drunk and handing him over to the police when he might have a head injury also It 18 wiser to admit him dead drunk than for him to be found dead at home from some other cause next morning NOTES ON DIABLTES Lawrence s line diet --1 line 155 calories 1 black portion = 10 G carbohydrate = 41 calories 1 red portion = 7'/, G Protein + 9 G fat = 114 calories ·TREATMENT 143 One and a half hours later (ie two hours from onset) estimate blood sugar again If rising give double the previous dose of insulin If the same give the same dose of insulin If falling give no more insulin When the blood sugar is falling and provided the urinary output is good change the drip to potassium glucose solution which contains 5 per cent dextrose (Sodium lactate 22 G Potassium chloride 100 Sodium chloride 06 G Potassium hydrogen phosphate 05 G Dextrose 50 G per litre) One and a half hours later (re three and a half hours from onset) estimate blood sugar At four hours from onset give more insulin if blood sugar is not falling Give nothing by mouth until the blood sugar starts to fall When consciousness returns and fluids are retained change over to the four hourly regime as for pre-coma Control by urine tests however is of little value until the blood sugar approaches the renal threshold and certainly not if it is over 300 When swallowing is adequate potassium should be given by mouth every four hours until food can be taken The Potassium Citrate mixture of the National Formulary is satisfactory (see page 136) Additional measures are gastric lavage if there is much vomiting blood transfusion if the BP is low antibiotics for infection and vitamin B complex (Becosym Roche 2 ml in twin ampoules) Comatose diabetics should be nursed with the greatest care Do not sit them up in bed until fully conscious and rehydrated lest sudden cardiac failure closes the scene ·142 THL HOUSE PHYSICIANS HANDBOOK up to 100 units and 50 G carbohydrate (10 G carbohydrate are contained in 2 lumps of sugar 4 fl oz orange juice 7 f oz milk 2 teaspoonfuls of Bengers food Horlicks milk or Ovaltine The proprietary drinks Lucozade and Glydexıl contain roughly 20 per cent W/V of glucose re 20 G in 100 ml (3'/, fl oz) A little weak tea or Marmite may be given at any time After three hours empty the bladder and before the fourth hour empty it again and test the urine by Benedicts test The result will decide the next dose of insulin If red give 40 units yellow give 30 units green give 20 units blue give no insulin 50 G carbohydrate is given every four hours and this goes on until ketosis has cleared-usually in 24 hours The patient should then get back to his usual diet Look carefully for any infection which might have caused ketosis Diabenc coma --(Patient unconscious and unable to swallow) Give 100 units insulin (*/, ie 80 units intra muscularly and '/ le 20 units intravenously) Take blood for blood sugar (blood sugar control is necessary in the early stages) Set up an intravenous drip of physiological saline or M saline lactate (300 ml 7 sodium lactate with 700 ml physiological saline) to give 3 litres in three hours (ie drip bulb at drops per second) Blood sugar level is known in say thirty minutes If over 600 mg per 100 ml give another 100 units insulin (20 units of it intravenously) ·TREATMENT 145 POISONING Suspect poisoning or overdosage in any comatose or curiously ill patient The general principles of treatment are to remove or neutralise the poison and to keep the patient alive by dealing with whatever state is most threatening life These measures are more important than the use of antidotes except in those cases where there is a very specific antidote and the poison is known While getting ready to wash out the stomach a dessertspoonful of Universal Antidote may be given if available and if the patient can swallow Powdered activated charcoal 2 parts Magnesium oxide (or milk of magnesia) 1 part Tannic Acid (or very strong tea) 1 part Make it into a paste before swallowing Don t let this procedure delay gastric lavage which is more important Carbon monoxide poisoning-Clear the airway by pulling forward the tongue Give 7 per cent Co in oxygen by an oro nasal mask Use artificial respiration if the breathing is shallow Aspirin poisoning --Wash out the stomach with the head low so as to avoid inhalation of gastric contents Give sufficient bicarbonate of soda to keep the urine alkaline—if necessary by intravenous injection (Bicar bonate in solution decomposes on boiling so simply boil the water first and then add bicarbonate powder under sterile conditions) Warmth orygen and other measures for shock may be needed 10 ·DIAGNOSIS OF THE CAUSE OF COMA IN A DIABETIC Cause of Coma Colour Breathing Eyes Tongue Benedict heto818 Babinshi 8 Sign Ketosis Flushed Dry + + + + + + + + Air hunger Soft Acetone in breath 144 THE HOUSE PHYSICIAN S HANDBOOK Hypogly caemia Palc Normal Normal Moist Probably Nil Ni1 Stroke May be + Nil Flushed or Stertorous or Pupillary Normal pale Cheyne changes Stokes Drugs Varies Not Nul Slow and May be Normal shallow small pupils May be 1 ·TREATMENT 147 for the patient and if a prosecution would not be in the patient s interest avoid saying anything which might make it take place Steps to avoid a further attempt--such as moving the patient away from an upstairs windowwould be wise FOOD POISONING Bacterial food poisons Symptoms within two to four hours after eating Usually cream cake or trifle con taining staphylococcal toxın Bacterial food infections - Symptoms more than twelve hours after eating Often manipulated meats (salmonella organisms) Note the foods eaten take charge of any remains save vomit and faeces and notify the Medical Officer of Health Don t ask for agglutination tests until the stools have been cultured or in any case during the first week Treatment --If vomiting is troublesome wash out the stomach Give castor oil 30 ml (1 fl oz) for an adult Start fluids by mouth when possible otherwise give intra venously Give bismuth and opium or similar mixture Avoid giving a certificate of Food poisoning until proved It may be wanted simply to blackmail a restaurant POISONOUS FOODS Treatment should be on general lines unless there are special remedies Belladonna poisoning –Usually a child who has eaten berries and is found confused flushed and dry Empty the stomach by tube or emetic (2 tablespoonsful of salt to half a tumbler of water is preferable to apomorphine in these cases) and give neostigmine (Prostigmın) 05 to 10 mg intramuscularly ·146 THE HOUSE PHYSICIANS HANDBOOK Barbiturate poisoning Wash out the stomach Only use an emetic (apomorphine 75 mg (gr .) subcutane ously) if a stomach tube is not available Decide whether poisoning is mild (patient conscious) moderate (patient stuporose) or severe (patient comatose) In severe cases give an analeptic Methylamphetamını hvdrochloride (Methedrine) 15 to 30 mg intravenously and repeated half hourlı if necessary is safe The more powerful picro toxin is not approved of by all so consult your chief before using it It is given in doses of from 2 to 40 mg intravenously every fifteen minutes according to the depth of coma Overdosage will cause convulsions and the dose to aim at is one which just causes facial twitchings and return of corneal reflexes The effects of picrotoxin do not come on at once so don t give it more often than every fifteen minutes lest cumulation cause convulsions Lumbar puncture artificial respiration and intravenous flud may all be needed Mild and moderate cases may be simply nursed and watched for progress in all cases penicillin should bt started A new barbiturate antagonist Megimide 50 mg intravenously may be used instead of an analeptic Consult your chief before trying it Antidotes ---For morphine poisoning use nalorphine (Lethidrone Burroughs Wellcome) 5 to 10 mg It also antagonises pethidine and methadone (Physeptone) but not barbiturates For cyanide poisoning use amylmtite by inhalation For mercury poisoning use BAL (Dimercaprol) 300 mg intramuscularly and then 150 mg four hourly SHOULD YOU TELL THE TOLICE?. No attempted suicide is a misdemeanour only and you are under no legal obligation to report it Always do what you think best ·TREATMENT 149 THE RED EYE Conjunc truttus heratitis Iratis Glaucoma Discharge + Waterin, only Watering only Watering only Pain ++ + Discomfort only + + + and vomiting Vision Normal Depends on how Reduced much opacity covers the pupil Greatly re duced Congestion Conjunc Ciliary Ciliary Clary tival Localısed opacity General haze Corneal Normal transparency General clouding Normal Normal Shallow Anterior Normal chamber Iris pupu and Normal reactions Small and reacts Small and bound No reaction to light down Reflexes to Irght may be absent Tension Nonnal Normal Perhaps a little Greatly increased increased The other Often affec Old scars of May be old untis May be cup eye ted also previous ulcers with bound down ped disc pupil ·148 THE HOUSE PHYSICIANS HANDBOOK Mushroom' poisoning Treat on general Ines unless poisoning by Death Cap (Amanıa phalloides) is suspected Confirm this by 1 Examining uncaten fung: The Death Cap has white gills 2 Noting the twelve hour interval before symptoms begin 3 Sending vomit and faeces for examination for spores Treat by antı phallınıc serum (Central Public Health Jaboratory Colindale Avenue NW9 COLindale 7041) and possibly the rabbit stomach brain treatment (see Emergencies in Medical Practice 4th Edition page 67) THE RED EYE The patient with a red eye presents the house physician with a worrying problem If in serious doubt he should seek expert advice The following table will help hun to decide it is good practice to use a drop of 1 per cent amethocaine hydrochloride to facilitate examination of a painful eye TRACHEOTOMY Nearly always the patient needing tracheotomy can be moved to the theatre and a planned operation performed Should urgency preclude this then quickly obtain 3 scalpel un artery forceps and a catheter or piece of stout rubber tubing With the patient s neck fully extended hold the farynx firmly between the left thumb and middle finger and place the forefinger on the cricoid Incise downwards exacus in the middle line and through the first two tracheal rings Even though you have never donc it before you won t find it difficult Dont bother about

·КІ НТ
ANET
FIG 1
Holger Nelsen method Showing the position of the operators hands
(shown as gloves) his left foot shown as a shoe) his right knee and
also the correct position of the patients arms and head
FIG
Holger Nelsen method Inspiration Duration 1 secs
&DIJ)

·150 THE HOUSE PHYSICIANS HANDBOOK bleeding it is usually a good sign and brings relief Push the rubber tube through the tracheal opening Having thus saved the patient s life call your surgical colleague and let him put in a proper tracheotomy tube ARTIFICIAL RESPIRATION Holger Nelsen s technique (a push and pull method) is the best and is now officially recommended by the British Red Cross Society The chest is compressed against the ground for ex piration and raised by the arms for inspiration 1 Turn the patient face downwards with arms upwards and elbows flered so that his head is turned to the side and rests on his hands 2 Kneel on one knee at the patients head and facing his feet The opposite foot is near the patient s elbow (Fig 1) 3 Inspiration Grasp the arms above the elbows and rock backwards (Fig 2) raising the arms until tension is felt Count 1 2 3 while doing this (= 2'/, seconds) 4 Expiration Drop the arms (Fig 3) and put your hands on the patients back just below the scapulae with your thumbs touching (Fig 4) counting 4 as you do it Rock forwards with your elbows straight and erert steady pressure on the chest (Fig 5) count 5 6 7 while doing this (= 2 / seconds) 5 Slide your hands off the chest and on to the patients arms as you count 8 This cycle should be repeated ten to twelve times a minute

·FIC 4
Position of operators hands and arms at bezinning of expiration
Expirali
Frus
Op rai ricks forward with his arms straight Duration
1 SCCS

·pi
Y
Www
FIG 3
Holger Nelsen method Patient s arms dropped at end of inspiration

·LY
FIG 4
Position of operators hand and arms at beginning of expiration
*
FIGS
Expiration Operator ricks forward with his arms straight
- /sess
Duration

·No text on this page.

·TREATMENT 151 SOME URGENT MEDICAL ACCIDENTS on Almost any of the common medical procedures used by the house physician may occasion prove hazardous He should be aware of what might go wrong and know what he would do if it did Here are a few reminders Wrong injections - Always read the label on the bottle before using its contents Broken needles —Test the strength before use If a needle breaks and a little projects remove it with forceps Otherwise immobilise the part and leave it alone until X ray examination and a planned operation can be made Tell the patient but don t admit liability Keep the parts and report to your Medical Defence Society Accidental intra arterial injection-Avoid this by palpation (for pulsation) and drawing back blood before injecting (to note bright red arterial blood) If it happens as shown by pain in the hand leave the needle in situ and slowly inject into it 5 ml of 2 per cent procaine followed by 30 mg ("/ grain) of papaverine in 20 ml of physiological saline Accidental injection of a toxic dose - If in a limb apply a tourniquet and release momentarily at intervals Elsewhere consider incision and apply ice Use an antı dote eg nalorphine (Lethidrone ) for morphine over dosage Potain's aspirator --Make sure that the pump is evacuating the bottle and not filling it with air under pressure ·152 THE HOUSE PHYSICIANS HANDBOOK Gastric lavage - In a comatose patient (ie with no coughi reflex) always have the head lower than the stomach so that should the larynx be entered drowning wont result ANAPHYLAYUS Always ask about asthma and urticaria before giving in injection of serum or any foreign material Before giving serum always test for sensitiveness Puncture the forearm with a hypodermic needle (= control) and do it again nearby through a drop of serum Redness and wheal formation within fifteen minutes mean sensitivity In such a case the first dose of serum should be 0 1 mi und this should be doubled at half hourly intervals for six doses and then the rest can be given Each dose should be combined with 03 ml of Injection of Adrena line BP Should anaphylaxis occur give Injection of Adrenaline 05 ml and Injection of Nikethamide 2 m) intra muscularly at once AIR EMBOLISM If collapse follows needling of the chest or in pneumothorax refills air mav have entered the left heart and reached the coronary arteries or brain Withdraw the needle lower the head and turn the patient on to his left side The portion of the aortic orifice uppermost will then be the part which does not have a coronary orifice in it A similar accident following injection into a peri pheral vein will fill the night heart with froth (or cross to the left side by a patent foramen ovale- paradoxical embolism ) Treat in the same way The risk of frothy blood rising into the outflow tract of the right ventricte is lessened by lying on the left side

·TREATMENT
153
DRUG ADDICTION
This may present itself to the house physician in two
Ways -
1 As a puzzling case of mysterious illness whose cause
(drug deprivation) the patient does not disclose
Suspicion can often be confirmed by finding
numerous marks of needle punctures-often infected
Admit the patient and seek further advice
2 As a self-confessed addict who asks for his drug
because he can t buy it Regard him as a sick person
and don t turn him away Give him one dose of
drug and refer him to his own doctor if he has one
If the patient has no medical source of supply give
him enough drug for a few days persuade him to
see a psychiatrist with a view to treatment and
(preferably with the patients permission) notify the
Home Office It is best to give any supply of drug
as a solution so that it is less easy for it to be sold

·CHAPTER V X-ray Department If you have a patient X rayed on your own responsi bility eg from the Casualty Department always see the film and then see the radiologist s report also in case you have missed for example a fracture When examining a film the first thing to do is to make sure that it refers to the patient in question Grave consequences have followed the wrong labelling of films Be particularly watchful if there are two patients of the same name or if the X ray and clinical findings are inexplicably at variance When filling in the request forms always be careful to give the patients names (and unit number) correctly and indicate how the patient will reach the department ie stretcher chair walking or carry Do not ask for portable X rays unless the patient cannot go to the X ray department If a portable film is wanted other than of the chest or a limb discuss the case with the radiologist first PREPARATIONS FOR VARIOUS X RAY EXAMINATIONS Banum meal and follow through --Give an aperient (vegetable laxative pills or cascara but not castor oil) two nights before the examination Give a light diet on the day before but rothing at all liquid or solid must be given after midnight preceding the examination The stomach must be empty when the examination begins Bismuth medicines should be discontinued five days 154 ·Y RAY DEPARTMENT 155 before the examination Follow through cases attend again in the afternoon and next morning No enemas or aperients must be given until the examination is complete Barium enema --An aperient should be given two nights before the examination A few hours before it a thorough high bowel wash out should be done The aperient should be omitted in cases of ulcerative colitis but if the examination is unsatisfactory it should be pre ceded next time by a wash out with warm physiological saline Plain X ray of the abdomen --The patient should be encouraged to have his bowels opened before attending for this Cholecystography - The stomach should be empty and the bowel as free of gas and faces as possible No laxative should be taken however but an enema may be given on the morning of the examination Nothing should be eaten after the evening meal which should consist of non fatty foods All fats including milk cream butter eggs mayonnaise and fried foods should be avoided A little water may be drunk up to bed time The patient should swallow 6 Telepaque (lopanoic acid BPC) tablets one at a time after supper and report next morning without having had any breakfast Films of the gall bladder are made ten to twelve hours after taking the tablets A fatty meal (2 egg yolks in a glass of creamy milk) is taken and films made ten and forty minutes later These films may show the cystic and common bile ducts The hepatic duct is not normally seen Intravenous cholangiography (to show the biliary ducts) — The general preparation to rid the bowel of gas should be as for oral cholecystography but it is not ·156 THE HOUSE PHYSICIANS HANDBOOK absolutely necessary Biligrafin is injected intravenously taking five minutes (This is a preparation containing 64 per cent iodine prepared by Schering A G Berlin A 20 per cent solution is isotonic and only slightly usitant) It is wise to make a 30 second pause after 2 ml have been injected Films of the gall bladder area are taken twenty minutes after the beginning of the injection and at forty and sixty minutes and at two hours Finally a film is made fifteen minutes after a fatty meal Concentration of Biligrafin in the gall bladder is not necessary for visualisation and so the method is valuable in cases of non functioning gall bladder Excretion vrography (often erroneously termed Intra venous Pyelography or I VP) The patient should be on a light diet and should take an aperient on each of the two preceding nights No food or drink should be taken for eight hours before the examination The bowel should be as empty of gas as possible This is facilitated if the patient is up and about Pıtressin 0 5 ml may be given half an hour before the examination at the discretion of the doctor (It may make the patient ghastly pale) Diodone 20 m} is injected into an elbow vein and films are taken ten twenty and thirty minutes later Avoid excretion urography in asthmatic and allergic patients and in those suffering from cardiac failure and Intensive sulphonamide therapy should be avoided just before excretion urography SUBCUTANEOUS METHOD FOR CHILDREN -For children up to five years 1000 Benger units (= 500 turbidity reducing units) of hyaluronidase are added to 5 ml of 35 per cent Diodone and made up to 15 ml with distilled water This amount should be injected subcutancously uraemia ·Y RAY DEPARTMENT 157 over each scapula (i e 30 ml in all) and massaged This method will give satisfactory pyelograms Bronchography --This is best carried out in the case of a child in conjunction with the anaesthetist The method used will depend on which one the operator knows best Tipping several times a day before the examination will render the bronchial tree as free of secretions as possible Bronchi of the right lung are best seen on the lateral film and those of the left lung in the oblique film The right side is filled first avoid over lapping Dionosil is a good preparation to use because it is soon absorbed 8 ml for each lung is sufficient for children up to eleven years Four syringes should be prepared-one for each lung and two in reserve in case of need Shake the Dionosil well and pour it into the Oiled dry syringe Afterwards disconnect and wash at once-otherwise the syringe is easily gummed up No special preparation is needed for X ray examination of the pharynx and oesophagus or the heart ·INDEX ABSOLUTE VALUES 86 Cholecystography 155 Accidents medical 151 Circulatory overloading 60 to patients 26 Circulation time 49 Accuracy of haematological es Cliccat records ownership 23 timations 88 89 Clioitest method 99 Acetazoleamide 113 CO porsoning 68 Acetest tablets 100 Colour of urine abnormal 107 Acute abdomen 124 Coma 140 Addiction drug 153 diabetic 142 Addison s disease tests for 79 - differential diagnosis in Addresses 30 diabetes 144 Acquanimifas 2 Contempt of Court 27 Ajf embolism 152 Convalescence 33 Analgesic drugs 115 Conversion table for weights Anaphylaxis 152 and measures 107 Antibiotics antagonism 122 Coroner notification of 15 cost of 122 CSF fluid count 92 Anticoagulant therapy 52 in meningitis 94 Antidotes 146 normal y Arterial occlusion 127 in poliomyelitis 93 Arterial puncture 48 Artificial respiration 150 Ascitic fluid removal of 45 DANGEROLS DRUCS 119 Ascorbic acid saturation test 76 Dead how long! 10 Aureomycin 121 Death cap 148 Death certificates 12 BAPTISM 22 Scottish 14 Barbiturates 116 Death signs of 10 Barium cnema 155 Dehydration 133 Barium meal 154 19 Addison s disease 139 Buigrafin 156 in children 138 Blood from small child 66 Details sheet 4 Blood counts 82 Diabetes 140 Blood culture 49 Diamox 113 Blood gases 95 Dilaudid IS Blood transfusions 56 Dindevan 53 - in babies 59 Dionosil 157 reactions 60 Disclosure of information 76 Bodian 68 Diphtheria 38 Bronchography 157 Dosage of drugs 107 Butyn 76 Dromoran 115 Drug addiction 153 CASUALTY DUTIES 2 Drunk 9 Catheterisation 44 Dying declaration 18 Chicken por 39 Chloramphenicol 121 Dying depositions 18 Chlorpromazine 113 Dysentery Sonne 39 Chloretracycline 11 Dyspnoca 193 158 ·INDEY 159 | JEWISH PATIENTS 22 KEPLER TESTS 79 ketosis diabetic 141 honakion 155 ELECTROCARDIOGRAPHY 5. Electroencephalography 5. Electrolytes 139 Embalming 19 Embolism air 15. - arterial 127 Eptacyl 111 Eprstaxis 129 Erythromyera 121 Esbach s method 98 ESR 67 Estopen 120 Eumydrın 113 Extreme unction 21 Eye red 148 149 LANGUAGES other than Eng Lash 4 Largactul 113 Laryngeal swabs 50 Last rites 21 Left ventricular failure 123 Lethidrone 146 149 Liver biopsy 51 Liver function tests normal values 78 Lumbar puncture 60 FANTUS TEST 74 Fat balance test 77 Fluid and electrolytes 13.. Fluid ascitic 45 - oedema 45 pleural 46 replacement by air 48 Foods poisonous 147 Fouchets test 101 Fractional test meal 76 Fractures 3 MALARIA cerebral 1.7 thick films 70 Measles 36 Medical Defence Society 151 Medico legal notes 23 Megim de 146 Melaena 125 Muestoges 41 Milli equivalents 95 Meningitis which drug? 178 Mental welfare officer 8 Mephyton 115 Morphine 115 Mumps 37 Mushroom Poisoning 148 GAMMA GLOBULIN 37 Gastroscopy 1 Glucose tolerance test 70 Gregersen s test 75 HAEMIATEMESIS 1.5 Haemoglobin estimation 83 Head circumference of 42 Heparin 5. Holy Communion -- Hypnotics 116 NALORPAINE 146 149 Namne marden 25 Neilsens method of artificial respiration 150 Nepenthe 115 Nephritis convalescence 33 Normal values for blood 90 ja baematology 8+ Note taking 3 INDUSTRIAL DISEASES 16 Infast feediøg 43 Infectious diseases in gegeral wards 35 Insanity - 8 Ipsula sensitivity test 71 Intra arterial injection acci dedtal 151 TYP 156 OCCLL SION arterta! 127 Occult blood in faeces 75 Dedema fluid, removal of 45 Omnopoa 113 Ossification centres of 41 ·160 THE HOUSE PHYSICIAN S HANDBOOK Oxygen therapy S3 Oxytetracycline 121 PAPILLOEDFYA and lumbar puncture 61 Paraldehyde 117 Paroxysmal tachycardia 127 Penicillin 120 Penidural 120 Per nasal swabs so Pethidine 116 Phenindione 53 Physeptone 115 Piperizine 113 Plasma specific gravity of 81 Pleural fluid removal of 46 Pneumothorax 123 Poisoning 145 - aspitin 145 barbiturate 146 belladonda 147 CO 68 145 - food 147 Jead 69 - mushroom 147 Police ? tell 146 Post mortem examinations per mission for 11 Post operative illness 34 Potain s aspirator 47 Potassium depletion 136 intotication 137 Prescriptions 119 Pressure of CSE 62 Priscol 127 Prothrombin activity 53 SALICYL SULPHONIC ACID TEST 98 Scarlet fever 38 Secrecy professional 27 Sedatives 116 Smallpor 39 SOS messages 30 Specimens how to send 63 by post 66 Status asthmaticus 12$ Status cpilepticus 128 Streptomycin 121 Students Sulphonamides 122 TELEPAQUE 155 Terramycin 121 Testimonial 1 Tetracycline 121 Thermometer readings 31 Thiopentone recta for child Ten 118 Threadworms 50 Three day order 29 Tolazoline 127 Tooth socket bleeding 130 Trachectomy 148 Trichomoniasis vaginal 50 Tuberculin tests 106 UREA CLEARANCF TEST 73 Urea concentration test 72 Urine concentration - dilution tests 71 Uripe colour of 102 testing 97 Urography excretion 156 QVARANTINE 40 VACCINATION 54 -- certificates 55 Vitamin K 115 RAPE 28 Refusal of treatment 26 Religious matters 1 Responsibility of house physi clans 24 of nursing staff 25 Rheumatis77 acute convales cense 33 Rigor mortis 11 20 Rubella 38 WEDDING RING fixed 131 Weight for height table 32 Weights of organs 17 Hestergren 68 Whooping cough 39 Wolls death bed 17 Wintrobe 67

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