1147LEADING ARTICLES

A Modern Plague

THE LANCETLONDON 25 MAY 1963

ACCIDENTS are now so common in Great Britain-

fatal accidents alone average nearly 20,000 a year-thatthey ought to be regarded as a social disease, comparablewith plague, which calls for environmental control, thestrictest therapeutic measures, legislation, and education.This was the theme of the Convention on AccidentPrevention and Life Saving, sponsored by the RoyalCollege of Surgeons, and held last week with Mr.NORMAN CAPENER as chairman.

Perhaps because of its very constancy, this source ofdeath, disfigurement, physical and mental suffering, andeconomic loss is dismissed almost without comment or

accepted apathetically. In his summing-up of the

convention, Mr. CAPENER said:" If the country were informed that next week and every

week during the coming summer 150 people would die ofpoliomyelitis and that ten times that number would be seriouslyparalysed, or that 50 young children each week would die ofsmallpox, would not this cause alarm and galvanise the countryinto action ? Why is it that so little notice is taken if we trans-late these figures to deaths and serious injuries arising fromroad accidents and to deaths occurring amongst children injuredin the home ?"

Why indeed ? In 1961 it was suggested that the medicalprofession should give guidance about accident pre-vention, and as a result a medical working party was setup. Diagnosis must precede remedy; and the workingparty began by studying accidents as an epidemic, andlooking for the multiple causal factors. Evidence andadvice was sought from Government departments,youth organisations, voluntary societies, the ArmedForces and police, road-user organisations, industry, thevarious societies which have special concern with

accident prevention (especially the Royal Society forthe Prevention of Accidents, which has the widest

scope), and from many other people both in this countryand abroad.The very considerable efforts of the working party

culminated in last week’s convention of medical and laymen and women, at which there were eighty-fourspeakers. Sessions were devoted to defining the extentof the problem; to analysing the causes of accidents; tomeans of prevention; and to the principles of remedialaction, including first-aid and life-saving techniques, andgood citizenship. The various types of accident wereconsidered in relation to the home, industry, roads, andadventure and sport. It is perhaps not generally realisedthat accidents at home are responsible for even moredeaths (8000 a year or more) than are road accidents.The two groups particularly at risk are children undeIfive and the elderly. The number of non-fatal homeaccidents is difficult to estimate, but not less than2 million people a year are treated at hospitals because

of home accidents; and this must obviously cause

untold tragedy and suffering.The burden of accidents on hospitals and doctors is

great, and their annual cost to the country is estimatedat E500 million. 300,000 patients are admitted to hospitaleach year because of accidents, and far more receivetreatment as outpatients or from general practitioners.But much of the work so created, and much of thesuffering to the patients themselves, is unnecessary.Accidents due to unpredictable forces of Nature are rare;all other accidents are potentially preventable, and verymany of them could be avoided if it were not for humanerrors. There is need for improvement in the design ofour homes and domestic equipment, roads and vehicles,factories and machines; but most important of all are theoutlook of mind, the thoughtfulness, and the sense ofresponsibility of the individual. The way a personbehaves reflects his character, which has been influencedby training, experience, and tradition. This is also trueof the behaviour of the country as a whole; and accidentfigures sadly suggest that in this respect our society isseriously sick.The convention took the view that any scheme for

accident prevention should aim at influencing the

younger generation. Training should begin in infancy,with positive instruction in how to avoid hazards, andinculcation of physical and mental control. Childrenshould be encouraged to exercise their judgment and tocare for other people’s welfare; they should learn

courtesy and road safety; and as soon as is reasonable

they should begin training in first-aid and life-savingtechniques. Adolescents should not be discouragedfrom adventure, which provides a necessary outlet andvaluable experience; but they must be encouraged firstto undergo sufficient training. Risks are justifiable insport and recreation only if they are calculated risks andnot foolhardiness masquerading as toughness. Public

propaganda about accident prevention should be educa-tional ; and here the press, wireless, and television couldwield great influence for good.Nobody can deny the magnitude or importance of the

accident plague; but what can we of the medical pro-fession do about it ? It was suggested that first-aid andlife-saving should be part of the curriculum in allmedical schools, so that doctors can set an examplewhenever the need arises, and also play a greater part intraining lay people in these techniques. The generalpractitioner should devote as much time as possible towarning his patients of obvious dangers in their homes,and to instructing them about simple safety precautions.And, finally, the profession as a body is in a position toadvise the Government on accident prevention; for thisis a social issue which should affect the national policy.With the information gained from the convention, the

working party will now prepare its final report, which is- to be published. Meanwhile, supported by the DUKE OF

EDINBURGH, who was the convention’s guest of honour,’ and Mr. ERNEST MARPLES, the Minister of Transport,- the working party made the recommendation:l that there should be a permanent commission of: medical men who would promote research and provide a

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source of information on all aspects of accident preventionincluding techniques of first aid and life saving. Such a com-mission should co-operate with the accident preventionsocieties and provide a link where they overlap. It should

co-operate with other research bodies such as the MedicalResearch Council and the appropriate branches of the Depart-ment of Scientific and Industrial Research ".

Anticoagulant Treatment forCoronary Thrombosis

SINCE we reviewed this subject last September thesupporters of short-term or long-term treatment andthose who favour no treatment at all have been relativelyquiet. An immense amount of data has now been

gathered about the possible benefits of anticoagulanttreatment after an incident of myocardial infarction, andto collect a comparable amount of new information toanswer more questions will take time. Meanwhile somenewly published work will be a help in choosing betweenthe alternatives.

GRIFFITH et awl. based their analysis on the age of thepatient, the severity of the infarction, and the adequacyof anticoagulant treatment. Severely ill patients werethose who gave a history of increasing dyspnoea, thosewho presented with cardiac failure or clinical shock, andthose in whom arrhythmia developed within 48 hours ofadmission. "

Adequate "

treatment meant that a valueof 10-30% of normal level was maintained using a

modification of OwREN’s " prothrombin-proconvertin(P. & P.) technique. They took the age of 70 as a dividingline. They had data about 191 patients and they foundthat no statistically significant benefit was obtained, fromadequate anticoagulant treatment, by mild cases of allages or by severely ill patients over 70 years old. Theyhad 55 patients who were under 70 years old and wereseverely ill; 19 of them had treatment regarded as ade-quate and 2 died; 18 had inadequate treatment and 10died; in the remaining group of 18 who did not haveanticoagulants at all there were 11 deaths. Reviewingthese and other recorded data, including their own, LEAKand GILCHRIST conclude that " the dilemma of anti-

coagulant therapy of acute myocardial infarction is notwhether or not to give anticoagulants, but to whom anti-coagulants should be given." They would give it to allpatients under 70 years old provided there are no contra-indications and that therapy can be properly controlled;they remind us too that ineffective treatment is poten-tially dangerous as well as useless.No recent papers have given further support to the

idea of long-term anticoagulant treatment. On the

contrary, BJERKELUND 4 has produced results which

suggest that the recurrence of myocardial infarction isunrelated to the effectiveness of long-term anticoagulantcontrol, and that the same is true of the occurrence ofsudden death in patients with previous myocardialinfarction. BJERKELUND studied 119 patients who hadbeen treated with dicoumarol for periods of forty-two toninety-seven months after a myocardial infarction; the1. Lancet, 1962, ii, 648.2. Griffith, G. C., Leak, D., Hegde, B. Ann. intern. Med. 1962, 57, 254.3. Leak, D., Gilchrist, A. R. Scot. med. J. 1962, 7, 512.4. Bjerkelund, C. J. Amer. J. Cardiol. 1963, 11, 158.

method used for control was the P. & P. method ofOWREN. BJERKELUND comments that all laboratorieshave to deal with some patients whose anticoagulantcontrol cannot be kept stable for various reasons; suchirregular control is thought to involve risk to the patientwhen the prothrombin level rises. In the series of 119

patients, 29 had recurrent infarctions during the obser-vation period and 90 did not; the estimated level of pro-thrombin was known throughout the period of treatmentand the results showed no significant difference in thedistribution of the pp levels between the two groups.In 7 patients with recurrent infarcts, detailed recordswere available for the previous five years and at the timeof admission to hospital: 6 had stable values throughout;1 had been difficult to control and had Pp values of over40% on occasion, but when the infarct occurred the ppvalue was satisfactory and had been so for eight weeks.In another investigation the PP levels of 10 patients whodied suddenly were studied for twenty-six weeks beforedeath; in 9 patients control was stable and satisfactorythroughout and there was no rise before the fatalincidents. One patient had shown variable control

throughout, with values up to 60% a week before death,though 20% was recorded just before; the postmortemexamination showed no sign of recent thrombosis oracute myocardial infarction, though there were severalold infarcts and extensive myocardial fibrosis.From his results BJERKELUND concludes that: (1)

treatment in general was no less satisfactory in patientswho had recurrent infarctions than in those who did not;(2) rises in the prothrombin-preconvertin (factor vil)levels above therapeutic range were not responsible forthe recurrences; and (3) " these findings question theprophylactic anti-thrombin effect of this therapy in

coronary (arterial) thrombosis’. He points out, however,that in assessing the value of anticoagulant treatment it isbetter to take account of recurrent infarctions rather thansudden deaths, because sudden deaths have been shownby various investigators to coincide with new coronarythrombosis in only 10- 20/O of cases. This supportsIRVING WRIGHT’S contention that it is the incidence ofthromboembolic episodes rather than death-rates whichshould be used to judge the effectiveness of anticoagulanttherapy. Thus the opinion of most physicians seems stillto be that anticoagulant treatment should be given tosuitable patients for one year as a rule, since the evidencesuggests that treatment is progressively less effectiveafter that period, and the dangers of stopping treatmentare more likely to be serious. It is interesting to notethat OwREN,’ in his latest article on anticoagulanttherapy, is particularly concerned with the prophylacticrather than the curative value of the treatment, and withthe use of prophylactic long-term anticoagulant therapyin angina pectoris and rheumatic heart-disease.A suggested alternative to the dicoumarol and heparin

types of anticoagulants is the use of a fibrinolysin, whichcould, perhaps, actually dissolve the clot in the blood-vessel and not aim solely at preventing recurrent -throm-boses. Progress reports on the use of fibrinolysin in

5. Wright, I. S. Lancet, 1962, ii, 654.6. Owren, P. A. Arch. intern. Med. 1963, 111, 240.