again in accordance with the major swings of the and

business cycle. In this manner the investor is able to

Clinical Notes, Suggestions
sidestep entirely the problem of what stock or bond New Instruments
to buy or sell. His only question is one of timing
his purchases and sales in the class of securities to meet A NEW METHOD FOR FINGER TIP AMPUTATION
his objective. In fact, it is possible for all or a
WILLIAM KUTLER, M.D.
substantial percentage of the doctor's investment port- Cleveland
folio to be adjusted in this manner with a minimum
of effort and worry on his part. A new technic for repair of finger amputation was first
published in February 1944. Since that time many additional
There are certain "detail" advantages also inherent cases have come to
my attention. As a result of this experience,
in the use of these funds. Because of the "pooling" several improvements have been effected.
action of his investment through this medium, it affords
INDICATIONS
a simplification of his tax and estate accounting with
Use of this technic is indicated:
respect to his security holdings that cannot be surpassed For fingers or toes in which the tips are destroyed but
by the average portfolio employing the usual methods the1. nail matrix is still intact or only slightly injured.
of stock and bond buying. Furthermore, it represents 2. In any extremity where further shortening by a ventral
an investing medium that is subject to close federal
flap technic is not desirable (a) because the function at that
and state regulation. Finally, there is no penalty on the joint may be further decreased or (b) because the stump is
small buyer such as is represented by the "premium" already short for an appliance.
paid on the purchase of an "odd lot" of
securities on the large exchanges, nor
is there discrimination in management
fees between the large and the small Points of 5kin is slightly
amputation undermined, but«
investor. lef t attached to f
Subcutaneous
Although tha primary objective of tissue. *
the mutual fund management is to do
better than most investors do for them- incision throu
skin on both
selves whether their objective is income sides of finder'
or appreciation, there is nothing mys-
terious about their methods. In order
to do this job the investment managers
of each fund rely on the rigid employ- V shaped defect closed
ment of the three fundamentals already w/th fine silk sutures
or dermal
referred to—selection, diversification Completed
operation
and continuous supervision, the same
factors the doctor must observe if he
hopes to achieve better than average
results in his own portfolio operations.
The life insurance industry has a
very precise way of describing the
finder pulled
result of a purchase of a life insurance Flaps and over end of
sutured
policy. "At the stroke of a pen, you 1 ^
have created an estate and hired the
people to manage your affairs." This Steps in new technic for repair of finger amputation.
*
Since this illustration was first
action has its counterpart in the secur- published experience has shown that undermining is not necessary.
ities field. When he buys the shares
of the mutual investment funds suggested by his invest- The technic which has given the best result is as follows :
ment adviser, the doctor creates what is in effect a The end of the crushed finger or thumb is scrubbed thoroughly
with soap and water and every particle of foreign matter is
personal investment account. By this simple action he removed. All devitalized tissue is excised and the tip of the
has hired a bank trustee or custodian who is responsible phalanx smoothed. Two triangular skin flaps are prepared,
to him for holding in safekeeping the securities pur- one on each side of the finger, by making a V-shaped incision

chased for his account. By the same token and without on each lateral aspect with the apex pointing proximally and
found that if the incision out-
additional expense, he has hired accountants to keep his the basethedistally. It has been is carried down through the sub-
lining triangular flap
books and lawyers to see that his investment affairs are cutaneous tissue the skin flap will became loose enough to be
in proper shape. When he bought those shares he pulled over the tip of the finger. Undermining of the skin
thereby employed experienced investment managers to flap is not only unnecessary but undesirable, because in some
instances the blood supply is impaired and the skin flap
handle his portfolio in exact accordance with his own
investment requirements. In other words, he has sloughed. The flaps are drawn across the end of the finger
and sutured together across the midline with fine interrupted
employed these people to do for him the things he would silk or dermal sutures. The triangular flaps are further secured
have to do if he had research facilities and training as by several sutures around the circumference of the finger.
well as the time and inclination to do it himself. Finally, Occasionally, it is necessary to place a suture at the dorsal
it should be remembered that he has hired these people aspect in order to hold the flap right up to the area where the
nail will eventually come through. A large dressing is applied
to do this work for him as long as he retains his shares which is not disturbed for seven to nine days. Healing usually
in these funds. He will continue to hold those shares— takes place without infection.
and thereby hire these people—only as long as the job ADVANTAGES OVER THE OLDER METHOD
they do is satisfactory to him. 1. The end result is a smooth, rounded finger tip which is
120 Broadway, New York 5. actually slightly lengthened without impairment of its function.

Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 06/13/2015

 With the ventral flap method, the finger is shortened from
3/4 to 1 inch (1.9 to 2.5 cm.), and there is considerable impair-
ment in function.
2. The finger tip is not painful or tender. If the area is
allowed to granulate, the result is frequently a deformed and
extremely tender finger tip.
3. The method is simple to carry out. Although good results
can be obtained with full thickness or pedicle grafts, the pro-
cedure is difficult and requires considerable time for complete
healing; frequently, due to the sloughing of the grafts, the
results with this older method are disappointing.
602 Rose Building.
Council
on Pharmacy and Chemistry
REPORT OF THE COUNCIL
The Therapeutic
Trials Committee, a standing committee of
the Council on Pharmacy and Chemistry, has adopted the follow-
ing report, and the Council has authorised publication of the
report so that it may be ividely disseminated to those who have
a serious interest in medical research.
Austin Smith, M.D.,
Secretary of the Council.
Walton Van Winkle Jr., M.D.,
Secretary of the Committee.
THE COST OF CLINICAL RESEARCH
The medical profession and the public have come to recog-
nize that the cost of research, particularly medical research, is
enormous. The opinion is often expressed that in the case of
medical research the principal cost arises from laboratory-
studies. It does not seem to be generally appreciated that
clinical research, if properly performed, is often as expensive as
laboratory investigations.
Unfortunately, clinical research has not, in many instances,
received the financial support to which it is entitled. This lack
of support has resulted in the performance of poorly controlled
and ill conceived investigations the data from which do not
advance the science of medicine, by reason of incompleteness
and unreliability. Admittedly, merely increasing the size of the
grants made for clinical investigations will not insure better
results. However, adequate financial support will enable the
competent investigator to do his best work.
In order to secure more adequate support of clinical research,
all participants must develop an appreciation of the factors
involved in the cost of such investigations. The group supply-
ing the funds, such as universities, foundations, commercial con-
cerns or private donors, must be prepared to make grants of
sufficient size to cover both the direct and the indirect costs of
the proposed investigation. The investigator must understand
and estimate with some precision the expenses which will be
incurred if he is to do an adequate investigation. Both the
grantor and the grantee must play fair ; neither side should com-
promise to the detriment of the research problem.
FACTORS TO BE CONSIDERED IN COST
(a) Professional Assistants.—It is not customary for investi-
gators who derive their personal income from salaries from
hospitals, clinics or universities or from private or industrial
practice to accept personal remuneration for performing research.
Research may be considered a privilege and a duty of those
members of the medical profession who are equipped by training
and experience, as well as by natural endowments, to conduct
original investigations.
Often, however, the investigator must employ one or more
assistants, such as residents
young instructors, to carry out
or
the details of the investigation. These assistants may devote
all or a substantial part of their time to the investigation. At
times they may be employed solely for the purpose of assisting
in research, and therefore their salaries are a proper charge
against the funds supplied for the investigation. The charge
should be based on an actual appraisal of the amount of time
Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 06/13/2015
they will devote to the investigation. Research funds should not
be used to get professional help cheaply for the hospital or clinic.
Evaluation of prophylactic and therapeutic measures has often
been seriously retarded by inadequate collection and analysis of
quantitative data. Too often sole reliance has been placed on
uncontrolled clinical impressions and experience. Consultation
with an expert statistician with regard to the planning and con-
duct of a clinical investigation will often be desirable. Statis-
tical analysis will often be necessary for reliable evaluation of
the data collected. Ideally there should be proper training in
the medical schools in the handling of quantitative data. As
things are at present, funds for statistical consultation will often
be necessary.
(ft) Technical Assistants.—Clinical research no longer is con-
fined merely to subjective observations. Objective measurements
of the function of various organs and systems, pathologic exami-
nation of tissues obtained by biopsy or at operation form an
essential part of most clinical investigations. These tests are
,
often time consuming and require skilled personnel especially
trained in these technics. Usually universities, hospitals and
large clinics have such technical assistants on their staff.
Unfortunately, their time is usually devoted entirely to the tests
necessary for the routine diagnosis and care of patients. The
superimposition of a research project on the ordinary duties of
this group often results in curtailment of many tests which might
be performed advantageously. In addition, it may seriously
affect the adequate performance of the regular duties of the staff.
It is often necessary, therefore, to employ additional technical
help whose sole duties are in connection with the research prob-
lem. The salaries of such personnel are a legitimate charge
against the funds supplied for the project.
Many of the observations made on patients are performed by
the nursing staff. Hospitals, particularly those receiving charity
or part pay patients, are almost universally understaffed with
nurses. Furthermore, the turnover in nurses is high because of
competitive bidding for their services. An important factor in
the successful prosecution of clinical research is a continuity in
nursing service. To insure adequate nursing care it may be
necessary to pay a premium for such special duty or hire addi-
tional nurses outright. The cost of such additional service
should be a legitimate charge against the research funds.
(c)' Clerical and Stenographic Assistants. Proper record
—
keeping is essential to the successful prosecution of any research.
Laboratory workers have long recognized the importance of
complete records of experiments written at the time the obser-
vations are made. Many clinical observers are more lax in the
matter of records, often depending on nurses, medical students,
assistants or others to record the pertinent observations. These
aides have many other duties to perform, and "paperwork" is
considered drudgery and is often postponed, resulting in depen-
dence on an imperfect memory. Adequate clerical and steno-
graphic assistance can obviate this difficulty and, in addition,
such personnel can prepare the charts, reports and so on that
should be made as the investigation progresses. Usually full
time clerical or stenographic help is not necessary except where
the clinical study is of great magnitude. In budgeting this item,
the time to be devoted to this task should be appraised and
charges made accordingly.
(d) Expense of Patients.—Clinical investigations require more
than ordinary observation of the patients under study. It is often
desirable to hospitalize patients who would otherwise be treated
as outpatients. In such instances the patient cannot be asked
to bear the cost of hospitalizado»} nor can these funds be legiti-
mately requested from the hospital, school or agency supplying
the facilities. The cost must be borne by the research grant.
Patients who would ordinarily be in the hospital for treatment
may be asked to remain longer than usually required in order
that adequate post-treatment observations may be made. The
extra expense entailed in keeping such patients hospitalized
beyond the usual time should be paid from the research funds.
(e) Equipment. It is rarely necessary to expend funds
intended for clinical research for large or expensive equipment.
—
Most institutions have such equipment, but occasionally the
nature of the problem will require the use of some instrument
or apparatus that is not part of the regular equipment of a
hospital or clinic. If this equipment is unexpendable, i. e. not