Showing papers in "BMJ in 1942"
TL;DR: In 1863, during the fiercest days of the American Civil War, Dr. A. W. Hammond, Surgeon-General to the Federal Armies, ordered the establishment of a unit for the observation and treatment of injuiries of the nervous system, and a signal result was the appearance in 1864 of a little book by Weir Mitchell, Morehouse, and Keen, Gunshot Wounds and Other Injuries of Nerves.
Abstract: In 1863, during the fiercest days of the American Civil War, Dr. W. A. Hammond, Surgeon-General to the Federal Armies, ordered the establishment of a unit for the observation and treatment of injuiries of the nervous system. A signal result of this instruction was the appearance in 1864 of a little book by Weir Mitchell, Morehouse, and Keen, Gunshot Wounds and Other Injuries of Nerves. This gave an account of the first organized study of nerve injuries, and in it we find not only the most perfect description of causalgia, a condition that will always remain associated with the name of Weir Mitchell, but descriptions of nerve injuries as we see them to-day. These enthusiastic workers laid a good foundation for all that has followed during the succeeding 80 years. But the means of investigation at their disposal were very limited, open operations were rare, and the syndromes described are not quite sufficiently clear-cut to serve as a guide in diagnosis and prognosis.
402 citations
TL;DR: Two more cases of periodic somnolence and morbid hunger typical of the syndrome described by Kleine and by Levin are reported, with special reference to blood-sugar estimations and, in one case, to the electro-encephalographic findings.
Abstract: In W. Kleine's report (1925) upon a series of five cases of periodic somnolence there were two patients in whom bouts of hypersomnia were associated with excessive appetite. Four years later M. Levin (1929) included in a paper entitled \"Narcolepsy and Other Varieties of Morbid Somnolence\" another case in which symptoms of polyphagia and pathological sleep periodically occurred in combination. In 1936 the same author, having collected seven such cases from the literature and from his own observation, published them as examples of a new syndrome of \"periodic somnolence and morbid hunger.\" This syndrome was considered to occur exclusively in males, starting in the second decade, and to be characterized by attacks of sleepiness lasting several days or weeks, associated with excessive hunger, motor unrest, and various psychological features, notably irritability, mild confusion, incoherent speech, and, at times, hallucinations. Three of the patients developed their initial symptoms soon after an acute illness (\" grippe,\" tonsillitis, influenza). Levin's paper did not attract much notice, as judged by the lack of fresh case records by other physicians. Another of his publications upon this subject (Levin, 1938) did not contain any new clinical material. We here report two more cases of periodic somnolence and morbid hunger typical of the syndrome described by Kleine and by Levin, with special reference to blood-sugar estimations and, in one case, to the electro-encephalographic findings. Case I The patient, an air mechanic aged 20, was admitted to a naval hospital on April 21, 1941. Apart from measles no illness had occurred. The family history revealed no nervous or mental disease. History of the Illness.-In 1937, after re-vaccination, the patient developed generalized vaccinia, but showed no symptoms suggesting encephalitis. Six months later there started attacks of drowsiness lasting about three days at a time. These recurred every six to nine months, though the interval between the last two attacks was bne year. His first attack began just before his midday meal, at a time when he was working at a rather uncongenial job on radio research. He attributed his attacks to overwork, either physical or mental. In his bouts of somnolence he would spend most of his time asleep, though he could be roused quite easily. By dint of physical activity he could manage to keep himself awake. He did not yawn or feel \" sleepy,\" but felt that he must shut his eyes, and then he would drop off to sleep at once. He has slept at work but never at meal-times, and in trains, but has never passed the proper station. He has never fallen asleep standing up. He thought that possibly his attacks were worse in the mornings. So far as he knew his diurnal sleep resembled his ordinary sleep, and he did not dream. During these bouts of sleepiness and while he was actually awake his mind was confused: in his own words: \"My mind feels funny; my thoughts are not connected; I know what is happening, but the events do not seem to connect; I am somewhat muddled.\" Apparently he looks and behaves sensibly in these attacks. He does not complain of physical discomfort and is not troubled with unpleasant thoughts. At night his sleep is normal; there is no delay in getting off to sleep, and there are no hypnagogic hallucinations; nor is there anything to suggest \" sleep paralysis \" either in the night or on waking. During the whole of his bout of sleepiness his appetite is excessive, but there is no undue thirst. Gradually the attack of sleepiness wears off and he comes round feeling none the worse. In other respects his health is exceptionally good. He is athletic in habits and his weight has remained stationary. There is nothing whatever in his history to suggest attacks of cataplexy, occurring either spontaneously or as a result of emotion or sudden noise. Those who had the opportunity of seeing him during one of }lis attacks reported that he became progressively more drowsy over the course of two days. His instructor found him so sleepy in classes that he referred him to the medical officer. While under medical observation he remained asleep almost the whole of the time, waking, however, for meals. He showed no obvious abnormal behaviour, and no delusions or hallucinations. When roused and questioned he appeared well orientated, but slow in cerebration, having difficulty in translating his thoughts into speech. He sometimes walked round the ward half asleep. There was no motor restlessness or agitation. On the day of admission he could give a satisfactory and detailed account of himself, but could not describe the actual thoughts that occurred during his bouts. His temperature remained normal throughout five days in hospital. His last period of hypersomnia lasted altogether about a week.
114 citations
TL;DR: Most methods of estimating haemoglobin are standardized by reference to determinations of the oxygencarrying power of blood, but they may provide a false picture of the pigment metabolism, since they take no account of inactive haemochemistry which may be capable of regeneration to the active form.
Abstract: Haemoglobinometry has at present two chief functionsfirst, the detection of diseases characterized by deficiency or excess of haemoglobin; secondly, the study of changes in haemoglobin concentration caused by loss or gain of plasma. For both purposes it is desirable that the method employed should estimate the concentration of all the forms of haem-pigment circulating in the blood. Ammundsen (1939, 1941) has shown that under modern conditions a normal adult may have from 2 to 12% of his total haemoglobin circulating in an inactive form. The inactive fraction is chiefly composed of carboxyhaemoglobin, methaemoglobin, and sulphaemoglobin. Drugs of the sulphonamide class often increase the proportion of inactive haemoglobin in patients receiving this form of treatment. Most methods of estimating haemoglobin are standardized by reference to determinations of the oxygencarrying power of blood. These yield valuable information concerning one important function of the blood, but they may provide a false picture of the pigment metabolism, since they take no account of inactive haemoglobin which may be capable of regeneration to the active form. They may imply the presence of anaemia where none exists. Several methods of estimation are in general use, and it is pertinent to inquire not only into the accuracy of each but also if total pigment or merely active haemoglobin is being measured.
108 citations
TL;DR: If an investigation is made on representative samples of the population in wartime the results can be compared with similar figures obtained in peacetime, and in this way the effect of war conditions on national health can be demonstrated.
Abstract: a population can be assessed in various ways, the estimation of iron deficiency being one method. The advantage of this method is that iron deficiency can be accurately determined by estimation of haemoglobin concentrations. If such an investigation is made on representative samples of the population in wartime the results can then be compared with similar figures obtained in peacetime, and in this way the effect of war conditions on national health can be demonstrated.
62 citations
61 citations
TL;DR: Although there was no significant correlation between the weight of the individual placenta and the concentration of vitamin B, in it, in both cases, as with the urinary excretion of the vitamin, the average readings for the group of eclamptic patients are very significantly below those for the normal group.
Abstract: B, excreted and the data subsequently recorded for the placenta these data are here summarized independently. The placentae were collected as soon as possible after labour and weighed without cord and membranes. The fresh tissue was then fed direct to rats, usually 6 for each placenta, at a dose level of 71 g. a rat. The concentrations of vitamin B, in the placenta were then estimated as described above. The resulting figures are plotted, again on a logarithmic scale, in Fig. 2, and summarized together with the weights in Table 11. Although there was no significant correlation between the weight of the individual placenta and the concentration of vitamin B, in it, in both cases, as with the urinary excretion of the vitamin, the average readings for the group of eclamptic patients are very significantly below those for the normal group. The t-test shows that the odds against the chance occurrence of differences as large as those observed are many thousands to one in the case of the placenta weights, and millions to one in the case of the vitamin B, concentrations. None of the other clinical groups differs very significantly from the normal in its vitamin B, concentration; a difference as large as that recorded between the average placenta weights in the pre-eclamptic and normal groups would occur by chance on rather less than 1 in 40 occasions, but since the scatter of the mean weights in the first 4 clinical groups is not nearly so exceptional we prefer not to stress this particular contrast. A similar remark applies to the difference between the average vitamin B, concentrations in the oedema and normal groups.
50 citations
TL;DR: Not only has an explanation now been found for many of the hitherto unexplained haemolytic reactions following certain homologous-group blood transfusions, but also a dramatic advance has been made in the understanding of the ha Hemolytic anaemias of the newborn.
Abstract: The discovery of the Rh factort (Landsteiner and Wiener, 1940) and the demonstration of its importance in various fields of medicine (Wiener and Peters, 1940; Levine, Katzin, and Burnham, 1941) have recently aroused the greatest interest. Not only has an explanation now been found for many of the hitherto unexplained haemolytic reactions following certain homologous-group blood transfusions, but also a dramatic advance has been made in the understanding of the haemolytic anaemias of the newborn.
46 citations
TL;DR: The work of the rescue parties, ambulance services, first-aid posts, and resuscitation teams must all be organized in such a way as to enable surgical treatment to be given with the minimum of delay, and the amount of anaesthetic given should be the minimum required to enable the surgeon to carry out his task.
Abstract: The special features of modern warfare, and particularly the wide use of the aerial bomb, have introduced a great diversity in the type of war wounds, while the new strategy of air attack on the civil population has necessitated fresh arrangements for the reception and treatment of casualties. The organization of the surgical services must be adapted to the requirements of the varying conditions, but the actual treatment of any war wound-whatever the nature or scene of the battle in which it was received-should always be based on certain fundamental biological principles. A Five-point Programme The biological treatment of wounds (if we may so call it) rests on five basic principles. To ensure the greatest possible success in treating a recently inflicted wound, each and all of these five principles or \" points,\" as we shall term them, should be applied. They are: (1) prompt surgical treatment; (2) cleansing of the wound; (3) excision of the wound; (4) provision of drainage; (5) immobilization in a plaster-of-Paris cast. Point 1: Prompt Surgical Treatment.-The successful healing of a wound depends largely on the promptitude with which appropriate treatment is given. The risk of serious post-traumatic infection is directly proportional to the time interval between the receipt of the wound and the surgical operation. The work of the rescue parties, ambulance services, first-aid posts, and resuscitation teams must all be organized in such a way as to enable surgical treatment to be given with the minimum of delay. The shorter the period during which the casualty is left untended, and the shorter the time taken in transport to hospital, the earlier can resuscitation begin and the patient be ready for operation. At this stage let me say that the choice of anaesthetic is important if the operation is not to cause undue risk. Spinal anaesthesia should never be used in shocked patients. Gas-and-oxygen should be given only by an experienced anaesthetist, and if the latter is not available ether should be used. It is important to remember that a patient suffering from shock requires much less anaesthesia than a fit subject. The amount of anaesthetic given should be the minimum required to enable the surgeon to carry out his task. In cases of .evere shock a local anaesthetic should be employed. Point 2: Cleansing of the Wound. No antiseptic known to-day is equal to soap and water as a means of dealing with contamination in a wound. Even the best antiseptic is unable to remove \" dirt \" from the wound, and the majority in fact actually fix the dirt in the tissues. Others increase the risk of infection by further destruction of the cells. Both sodium coco-nut soap and sodium ricinoleate are more effective in getting rid of bacteria from a wound than are most of the non-caustic antiseptics. The staphylococcus is the only organism that has a certain degree of resistance against these soaps. For the skin a solution of iodine or a similar skin antiseptic should be used. At the end of the operation the wound may be dusted with sulphanilamide. I never used this in my country, where I treated over a thousand cases with this technique, and with only a very few exceptions had uniformly good results; but there now appears to be enough experimental evidence to justify the local application of one of the sulphonamide compounds as a prophylactic measure. Point 3: Excision of the Wound.-This is the keystone of the whole technique and the factor which permits the final procedurenamely, the application of a closed plaster. Without proper excision no recent wound should be enclosed in plaster. This is a rule to which there can be no exception, and it is generally a lack of appreciation of the vital importance of proper excision that is responsible for the failures that may occur with this technique. To ensure proper excision the wound must first be enlarged (the debridement of the French). In wounds caused by high-explosives the extent of damage in deeper tissues, particularly the muscles, is often enormously greater than that in the skin and superficial layers, and consequently, unless the traumatic opening in the skin is considerably enlarged by incision, excision of the deeper tissues is very difficult and must generally be incomplete. After the initial incision of the skin and fascia, and the excision of the dead portions of these tissues, the operation proceeds layer by layer into the deeper tissues in successive stages of incision and excision, until the bottom of the wound is reached. The periosteum, however, must never be incised. Only a narrow strip of skin should be excised; excision of the fascia should be radical, and that of the muscles still more radical, but in the case of the bone we must be as conservative as possible and limit resectioh to fragments which have lost their periosteal connexions or their muscular attachments.
45 citations
TL;DR: The similarity between the shock-azotaemic state following the trauma of difficult labour and the crush syndrome is drawn attention and further evidence suggests that this state is by no means a rare sequel of difficult obstetrics.
Abstract: There are two\"conditions in obstetrics in which massive damage affecting the placenta, uterine muscle, or other pelvic tissues may be followed by renal insufficiency and azotaemia-accidental (retroplacental) haemorrhage (Young, 1942) and the trauma of labour (Young and McMichael, 1941). They show the same clinical sequence. (1) There is the initial tissue damage. (2) In severe cases there is \"shock,\" which may be immediately fatal. In milder cases there may be an absence, of shock. In cases which survive the shock there are (3) anuria or oliguria, with a urine containing hyaline and granular casts and leucocytes, and (4) a rising blood urea which reaches its maximum usually between the 5th and 9th days and which is followed by death or by an increasing diuresis and eventual recovery. These two clinical states resemble the \"crush syndrome \" (Bywaters and Beall, 1941). In the latter condition the chief histological changes are found in the kidney; these have recently been fully described by Bywaters and Dible (1942). They consist of a degenerative and necrotic lesion specially affecting the ascending limt of Henle and the second convoluted tubule, usually with the presence of pigmented (myohaemoglobin) casts. We have recently drawn attention to the similarity between the shock-azotaemic state following the trauma of difficult labour and the crush syndrome (Young and McMichael, 1941). Further evidence, to be published later, suggests that this state is by no means a rare sequel of difficult obstetrics.
42 citations
TL;DR: In many places the use of group 0 blood for recipients of all groups has become established, but whether this practice is always advisable is still a matter for speculation.
Abstract: The use of group 0 (universal donor) blood for recipients of other groups was first suggested by Ottenberg (1911). He argued that its anti-A and anti-B iso-agglutininstheoretically incompatible for recipients whose cells possess the corresponding agglutinogens-would be so diluted by the recipient's plasma as to be rendered innocuous. In many places the use of group 0 blood for recipients of all groups has become established, but whether this practice is always advisable is still a matter for speculation.
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TL;DR: The increased incidence of scabies in this country, particularly among the armed Forces, has once again centred attention on the treatment of this troublesome and timewasting disease, with the result that numerous remedies have been advocated to supplant the traditional sulphur therapy.
Abstract: The old saying that \"a disease with many remedies has no cure\" is sometimes rather unjustly applied to scabies, for sulphur has for many centuries been regarded, with good reason, as a specific in its treatment. Nevertheless, the search for a better remedy has continued, and to-day the increased incidence of scabies in this country, particularly among the armed Forces, has once again centred attention on the treatment of this troublesome and timewasting disease, with the result that numerous remedies have been advocated to supplant thetraditional sulphur therapy. This search for a better remedy seems to be due partly to the liability of sulphur to provoke dermatitis, and partly to the fact that it is commonly prescribed in the inelegant form of an ointment, which is uncomfortable for the patient and damaging to his clothes.
TL;DR: The muscular thickening and the concentration of ganglion cells must indicate increased muscular action where the common bile duct penetrates the circular coat of the bowel from without.
Abstract: collected in that area in much greater numbers than in the duodenal wall elsewhere. The muscular thickening and the concentration of ganglion cells must indicate increased muscular action where the common bile duct penetrates the circular coat of the bowel from without. No sign of any intrinsic circular muscle ring round an ampulla has been discernible. It is hoped that in the future further comparative histological investigation
TL;DR: It is found that 2 or 3 bandages are required to cover completely the lower limb, and 1 or 2 for the upper limb; in order to avoid oedema below the lower limit of the bandage, the foot and hand should be included.
Abstract: be assessed by noting some convenient longitudinal line on the bandage. Only a light force with the forearm is required to stretch the bandage to the correct degree, and it should be possible with a little practice for even the inexperienced in bandaging to apply it correctly. In order to avoid oedema below the lower limit of the bandage, the foot and hand should be included. We have found that 2 or 3 bandages are required to cover completely the lower limb, and 1 or 2 for the upper limb.
TL;DR: The object of the present investigation was to analyse more precisely the characteristic features of these vasomotor attacks of blood donors, and signs such as colour changes, sweating, convulsions, vomiting, and incontinence, and blood pressure and pulse rate before and after bleeding were observed.
Abstract: * The removal of two-thirds of a pint of blood for the Transfusion Service has little effect. on the majority of blood donors. A small group-about 5%-show certain vasomotor phenomena, which are commonly called \" faints,\" although loss of consciousness is uncommon. The object of the present investigation was to analyse more precisely the characteristic features of these vasomotor attacks. Records were obtained of 48 donors who fainted. Initial observations were often made on donors before bleeding and not followed up when fainting did not occur. Factors which may influence the incidence of these faints, such as age, sex, time since last meal, type of work, atmosphere and temperature of the room, are being studied in a larger series and will'be reported upon later. A regular routine is adopted' for bleeding donors. Donors from factories and institutions are usually fetched by car from their place of work in parties of three or four. On arrival at the clinic they are given their cards, and every effort is made to set their minds at rest if they show any signs of nervousness. As a rule they are bled as soon as they arrive, but at rush periods there is often an unavoidable queue of them, usually good-humoured and cheerful. Having removed their coats, donors are taken by a nurse to the room for bleeding. Here they lie on a couch with their head and shoulders raised to an angle of about 40 degrees; in cold weather they are covered with a blanket. The arm is supported on a pillow, and the skin of the front of the forearm is cleaned by a nurse. A sphygmomanometer cuff is put on the upper arm and a pressure of 80 mm. Hg applied: for routine bleeding the cuff is kept at this pressure, which has been found to be the optimum to obtain a satisfactory flow in most donors. It is occasionally found, however, that the blood flows better if the pressure is lowered to 40 mm. Hg. Approximately 0.2 c.cm. of local anaesthetic-novutox-is injected at the site of venepuncture; this produces a sharp sting, due to its antiseptic content. The venepuncture needle is then inserted. Each step is explained to the donor. The bleeding takes from three to ten minutes, depending on whether the needle is well in place and on the size of the vein. The nurses talk to the donors throughout the proceedings. The donors remain on the couch for two to three, minutes after the removal of the needle while the arm is being bandaged. They then get up and walk to the recovery room, where they lie flat for ten to fifteen minutes: they then sit up in a chair, have a cup of tea and a biscuit, and leave shortly afterwards. It has been found that donors prefer to move d A report to the Medical Research Council from the North-West London Blood Supply Depot. away from the slightly medical surroundings of the bleeding-couch, even though they have to walk to another room for the rest period, Most donors show no after-effects, and are able to return at once to their work. In addition to recording symptoms in donors about to faint, signs such as colour changes, sweating, convulsions, vomiting, and incontinence, and blood pressure and pulse rate before and at intervals after bleeding were observed. Since the majority of donors are factory workers, anxious to return to work, we are not able to keep them lying down for a long period before bleeding in order to obtain a baseline for'pulse and blood-pressure levels in the recumbent position. It should be noted that blood pressure and pulse readings taken before the attack are with the donor's head and shoulders propped up, those during it with the donor lying flat, and some of the later ones with the donor sitting. Treatment.-VWhen donors faint the head of the bleedingcouch is immediately lowered and the nurse does her best to assure them that nothing serious has occurred. They remain on the couch until well enough to walk to the recovery room. Adrenaline has been given in some cases, and is thought to have hastened recovery. Controlled observations on this point are now being made. In some cases smelling-salts are used; the effect of these on pulse and blood pressure is unknown.
TL;DR: Analysis of 84 necropsies reveals that rupture into the peritoneal cavity has occurred on 27 occasions, and 6 of these were in the later months of pregnancy.
Abstract: Aneurysm of the spienic artery is said to occur once in every 1,500 necropsies. A summary of 58 recorded cases was made by Anderson and Gray (1929), who reported a case, and subsequently Machemer and Fuge (1939) collected a further 24 cases and added one of their own. Analysis of these 84 cases reveals that rupture into the peritoneal cavity has occurred on 27 occasions, and 6 of these were in the later months of pregnancy. Operation was undertaken on 9 of the ruptured cases, splenectomy with removal of the aneurysm being performed in 3 of them; of these three,
TL;DR: The quantities of arsenic found in thehair and bones in Case I and in the hair and adipocere in Case II indicate that more than the accepted fatal dose must have been taken before death; and the symptoms described in the two cases respectively point to chronic and acute arsenical poisoning, thus conforming with the conditions necessary for proof of death from arsenic poisoning as emphasized by Taylor (1928).
Abstract: lishes a figure of 1 to 3 mg. as usual in acute and chronic poisoning. In the Armstrong case it was only 0.45 mg. probably eight days after the first dose. Two of five cases recorded by Schwartz and Deckert (1936) showed concentration for scalp hair at 0.1 and 0.5 mg. in chronic arsenical poisoning from wine. It is of great importance to consider the presence or absence of arsenic in normal hair. Althausen and Gunther (1929) record two analyses-0.08 and 0.16 mg. of arsenic per 100 grammes of hair of known history. The locality and previous treatment are of paramount importance in this consideration. Wuhrer (1937) carried out thirty analyses in Berlin on both male and female hair, mainly from barbers' shops: the great majority were at concentrations between 0.015 and 0.038 mg. of arsenic per 100 grammes of hair. Bagchi and Ganguly (1937) found between 0.056 and 0.094 mg. in four normal cases in India. The results of Myers and Cornwall (1925) are much more variable and less convincing. No method of analysis is given. Twenty-one specimens of normal hair were examined, and nine were reported as negative. The twelve recorded as positive varied from 0.05 mg. up to 10.6 mg. There is a doubt whether some of these individuals were receiving or had received arsenical therapy. The question of \"normal\" arsenic in hair is therefore^ one for further investigation, but the general conclusion to be drawn tentatively is that the value is usually below 0.1 mg. of arsenic per 100 grammes of hair. 4. The presence of a trace of arsenic in bone, presumably in the form of the highly insoluble calcium arsenate, is to be expected, especially in chronic or subacute poisoning. In 1889 Brouardel, according to Webster (1930), stated: \"Arsenic accumulates very sensibly in the spongy tisstie of bones and becomes fixed in such manner that its presence can be detected, in the bones of the skull or vertebrae particularly, some time after every trace has disappeared from organs such as the liver, in which it is localized in greater amount.\" Webster says: \" It would appear that this localization in the bones is less marked and the elimination is more rapid when arsenic is absorbed in quantities sufficient to cause rapid onset of symptoms of poisoning=a point which has been brought out by Chittenden (1884-5) in connexion with differentiation between acute and chronic arsenic poisoning, the bones tending to retain arsenic in the chronic cases while, in the acute cases, arsenic may not be found in them.\" Even in the acute condition the presence of traces had been established in the Seddon and Armstrong cases (Willcox, 1922). Its presence in bone after such a long period in the earth is of significance in the present cases. 5. The quantities of arsenic found in the hair and bones in Case I and in the hair and adipocere in Case II, though small, indicate that more than the accepted fatal dose must have been taken before death; and the symptoms described in the two cases respectively point to chronic and acute arsenical poisoning, thus conforming with the conditions necessary for proof of death from arsenic poisoning as emphasized by Taylor (1928).
TL;DR: It has been recognized since 1842 that a severe anaemia of the pernicious type may complicate pregnancy and Osier (1919) discussed this latter condition and pointed out that it differed from Addisonian anaemia in that recovery, when it takes place, is permanent.
Abstract: Apart from the apparent anaemia caused by physiological dilution of the corpuscles resulting from increased plasma volume in pregnancy (Dieckmann and Wegner, 1934) and the hypochromic anaemia due to nutritional iron deficiency which has been shown by Davidson, Fullerton, and Camp bell (1935) to be of frequent occurrence in pregnant women of the poorer classes, it has been recognized since 1842 (Channing, 1842) that a severe anaemia of the pernicious type may complicate pregnancy. Very occasionally it is of the classical Addisonian type, having antedated the onset of pregnancy, but more often it is an anaemia closely resembling Addisonian pernicious anaemia which develops during the course of pregnancy. Osier (1919) discussed this latter condition and pointed out that it differed from Addisonian anaemia in that recovery, when it takes place, is permanent. It should be noted, however, that the num ber of cases upon which this observation was based was small and that the haematological data submitted were inadequate and unsatisfactory?for instance, two of the cases had a colour index of 0.6.
TL;DR: The unfortunate woman in this case had 3 abdominal operations and a vaginal examination with a total operating time of just over an hour and a half, although, or because, the original hysterectomy was performed in 10 minutes.
Abstract: haemostasis was inadequate because of a slip in technique. As every operator in the pelvis is well aware, bleeding from a cervical stump can at times be very troublesome, but a few minutes spent, if necessary, in securing primary control of bleeding is time well spent. The unfortunate woman in this case had 3 abdominal operations and a vaginal examination with a total operating time of just over an hour and a half, although, or because, the original hysterectomy was performed in 10 minutes. An operator with sufficient manual dexterity to accomplish this manceuvre would require very little longer to transfix the pedicles and securely suture the cervical stump, so that ligatures could not slip off the uterine artery or -oozing \" endanger the patient's life. Festina lenite is not a bad motto even in an emergency.-I am, etc..
TL;DR: The right cornea remained healthy until investigations into the problems of tear secretion were carried out, then a keratitis developed which necessitated closure of the lids by tarsorrhaphy and the patient began to complain of pains elsewhere in the body.
Abstract: The right cornea remained healthy until investigations into the problems of tear secretion were carried out. After this a keratitis developed which necessitated closure of the lids by tarsorrhaphy. For many months this woman was completely relieved of the pain in the right side of the head, but later began to complain of pains elsewhere in the body and, according to her doctor, was beginning to show distinct mental changes. On Jan. 24, 1942, 'Prof. Jefferson wrote to me to say that he had seen the patient again. He told me that my operation had completely relieved the pain on the right side of the head but that obvious migrainous pains were starting on the left side. Moreover, she complained of pains elsewhere in the body.
TL;DR: It is affirmed that an excellent surface operation is within the powers of any surgeon with training, and that attention should be focused on the more superficial parts, deep excursions into the brain being avoided.
Abstract: The Operation Once the scalp or the patient has been anaesthetized the wound should be opened up fully with retractors and its interior inspected in a good light. Portions of hair, masonry, dust, and other foreign matter are wiped out with wet swabs and the wound freely irrigated with sterile normal saline. As the wound is usually grossly contaminated with pulverized brick, cement, and dust driven in by the blast, actual application of soap and scrubbing-brush will be necessary. Saline alone will not get rid of dirt. The wound should be thoroughly irrigated with normal saline until it is " white." The floor of the wound is now examined for a crack or depressed fracture or hole of entry. Scalp wounds are apt to be more complicated than they look, and it is not always possible, unless really good radiographs have been taken beforehand, to know with absolute certainty that a fracture will not be found tucked away under a flap of skin. Even when the wound is first held open a fracture may not be seen. If there is a depression the operator may run into trouble. The withdrawal of a bone fragment may cause an ugly situation in which every technical aid may be required. The easiest cases are those in which the bone has been fragmented and lies loose in the wound-e.g., in a gutter wound. The most dangerous are those in which a piece of bone is tilted edge-on against the sagittal or lateral sinuses. It is not our purpose to speak of the details of treatment in such emergency situations. But it must be affirmed that an excellent surface operation is within the powers of any surgeon with training, and that attention should be focused on the more superficial parts, deep excursions into the brain being avoided. If no fracture is found after the wound has been thoroughly gone over, floor and sides, all bruised and damaged soft tissue must be removed from the floor, and the contused edges or even clean-cut edges should be excised. This must be done sparingly because the removal of wide ellipses of scalp leaves concave margins that cannot be approximated, so inelastic is the scalp proper. A slice 2 to 3 mm. in thickness is quite adequate. The hindrances to neat excision are two: first, the vascularity of scalp may cause free bleeding that impedes the view; secondly, irregularities and cross-fissures in the wound may pass beyond the line of the intended cut. The first difficulty is got over by the finger-pressure of an assistant exsanguinating the scalp margins until artery clips can be placed on the galea and turned over. A quick worker can do this single-handed. The weight and pull of the forceps on the galea quickly stops the bleeding while the other side is dealt with. As for the cross-fissures, they do not matter if they are well cleaned and thoroughly irrigated with normal saline so that all dirt is removed mechanically, but if a fissure is large it calls for separate deliberate excision. At this stage sulphanilamide, sulphadiazine, or sulphathiazole, or all three, should be freely dusted into the wound. Closure is effected by one row of sutures if the laceration is not excessively large or bleeding too profuse, and in those rarer wounds which do not divide the galea. Fine silk, " fine dermal," and nylon are all satisfactory suture material, though most neurosurgeons have come to prefer silk. Silkworm-gut, unless it is the finest procurable, is bad for the scalp. Closure of a scalp wound with one row of sutures requires that the skin and galea should be included in the stitch and just enough tension used in tying, so that good apposition is obtained and the margins of the wound lie flat. These stitches are put in at intervals of about 1 cm. When necessary more superficial sutures may be placed between them. A soft rubber (Penrose) drain should be brought out of one end of the incision or through a separate stab wound. When two rows of sutures are used the deeper layer of stitches takes only the galea they are inserted about 1 cm. apart; after tying, the ends are cut very short-indeed, practically on the knot. Fine silk or fine nylon is the only type of material suitable for this deep layer of sutures. Buried catgut is thoroughly bad, for it leads to trouble. Linen thread and cotton are little better. The general surgeon would do best to use the one-layer closure. Again, it is best to drain such wounds just as if only one row of sutures had been put in. Following closure with one layer of sutures, and even if two rows have been used, a well-padded and firmly applied headdressing is required. This, if it produces firm pressure on the scalp wound, will minimize bleeding. Dressings should be changed at the end of 12 to 18 hours-observing the most meticulous technique against droplet and cross-infection-the drain removed, and somewhat less firm dressings applied. Skin stitches may be removed after 3 to 4 days.
TL;DR: Bagasse is the term applied to broken sugar-cane after the sugar has been extracted, which is now employed in the manufacture of board which has the 'property of insulating any cavity lined with it against sound and temperature changes'.
Abstract: Bagasse is the term applied to broken sugar-cane after the sugar has been extracted. This formerly waste product of the sugar-cane industry is now employed in the manufacture of board which, besides being an easily worked and durable material, has the 'property of insulating any cavity lined with it against sound and temperature changes. The many possible applications of these properties in building are obvious. At the present time the material is in demand for war purposes. The bagasse arrives at the board-making factory in open bales, which are then \"broken \"-i.e., the raw material is further crushed into small fragments. When manufacture was first started in England the bale-breaking was carried out under water. The process was slow, however, and about two years ago machinery was devised for breaking the bales in a dry state that proved to be much more rapid but gave rise to a great deal of dust, some very finely divided, in the air near the machinery.
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TL;DR: In 1921 Tietze described 4 patients aged from 28 to 50, 3 females and 1 male, who all showed the same clinical picture-viz.
Abstract: In 1921 Tietze described 4 patients aged from 28 to 50, 3 females and 1 male, who all showed the same clinical picture-viz., swellings of costal cartilages of insidious onset associated with little or no constitutional disturbance, spontaneously painful, and with a prolonged course characterized by fluctuations in the size and tenderness of the swellings. Though one case was followed for over a year, no signs of suppuration developed. The lesions were firm and were confined to the cartilages, which appeared to be expanded locally. The skin over them was normal and freely movable. In one case the intercostal space was filled by the mass. In two patients, aged 42 and 50, radiographs showed calcification of the cartilage, but this may have been coincidental.
TL;DR: This step is essential to ensure stability for radiography, and the gaping of the incision may have distorted the lateral position of the calibrated guide, hence the importance of noting the angle to the horizontal.
Abstract: is desirable. Cyclopropane or gas-and-oxygen is the anaesthetic of choice. Technique.-The fracture is reduced by the Whitman manceuvre, and the feet are attached to the foot-pieces of an orthopaedic table by plaster-of-Paris. This step is essential to ensure stability for radiography. To depend on the human factor in holding the limb is giving a hostage to fortune, and one should not rely on fortune in a surgical operation. A Michel clip is placed over the head of the femur and another over the lowest limit of the fracture. These are verified by radiography, and a point two inches below the lower clip is chosen. A calibrated guide (the Hey Groves measure may be used instead of the calibrated guide if preferred) is passed anterior to the shaft and neck of the femur over this point. It will therefore enter the skin an inch distal to this. It is passed in the direction of the femoral head, and its angle to the horizontal is noted, the latter being a constant. A 4-inch incision is made and the lateral surface of the femur exposed. With a one-third-inch gouge a longitudinal furrow is made in the long axis of the femur, starting at the trochanteric end. This is done to prevent splintering, and, as the gouge is directed away from the fracture, splintering up into it cannot occur. The furrow should be one and a half inches long and just wide enough to admit the flanges of the nail but not the head. A Watson-Jones guide is now inserted into the bone and its position checked by antero-posterior and lateral radiographs. The gaping of the incision may have distorted the lateral position of the calibrated guide, hence the importance of noting the angle to the horizontal. If the radiographs show a satisfactory position the nail is inserted in the usual way, a 12 to 15 cm. one. being used. A fter-treatment.-The patient does active quadriceps exercises and knee movements from the second day. The sutures are removed on the tenth day and the patient is allowed up on crutches after three to four weeks. If the position of the nail is satisfactory, weight-bearing may be permitted after six weeks. The weight-bearing calliper which protects the entire limb below the fracture and throws a torsion strain on the fracture is vetoed. Possible Criticisms
TL;DR: It is felt that only when due consideration is given to such evolutionary factors as have here been instanced shall the authors get a true picture of the origin of many foot troubles or be able-to explain their distribution among the population-well shod, badlyShod, or even completely unshod.
Abstract: The layman's ideas of aetiology certainly are practically always of this kind, the classical example being the mentally defective child whose parents attribute its defect to a fall out of a pram. No doubt from the point of view of human self-respect such an attitude is very admirable, but when searching for the truth we must recognize it for what it is -namely, a form of self-conceit. In the case of the feet it has become customary to place. the blame for almost all disabilities and deformities (other than those patently congenital) upon footwear. That the form of the foot can be profoundly altered by restricting forces is not denied-the Chinese ladies' feet of a previous generation are sufficient evidence-nor is it proposed to exonerate the shoemaker entirely; but I feel that only when due consideration is given to such evolutionary factors as have here been instanced shall we get a true picture of the origin of many foot troubles or be able-to explain their distribution among the population-well shod, badly shod, or even completely unshod. A well-developed foot, judged by evolutionary criteria, may stand up to considerable abuse, failing only when the maltreatment becomes excessiVe; but a badly adjusted foot may fail under the normal stresses of ordinary locomotion without any misuse whatsoever.
TL;DR: It was suggested that oestrogenic hormones might be used for the inhibition of lactation in puerperal women, and numerous reports of this use of the naturally occurring oestrogens have appeared.
Abstract: The hormone control of lactation was reviewed by Nelson (1936). He concluided that the ovarian hormones, which are present in enormously increased amounts in pregnancy, are necessary for the development of the breasts, but inhibit the secretion of milk. The initiation and maintenance of lactation depend on the anterior lobe of the pituitary. After parturition the oestrogenic hormone ceases to be produced in large amounts, and with this release of control lactation begins. A further factor in the maintenance of lactation is the stimulus of suckling, the mechanism of which is obscure; nor is it known how the oestrogenic hormones inhibit lactation, though it is assumed that they do so by inhibiting the action of the anterior lobe. Folley (1936) showed that when the oestrogenic hormone was administered to the lactating cow, lactation was inhibited and the milk yield was reduced. This effect was temporary and depended on obtaining a high level of oestrogen in the blood. Folley and Kon (1936) studied the effect of sex hormones on lactation in the rat. They found that oestradiol caused a marked inhibition in intact rats, and a definite though less well marked effect in rats ovariectomized on the day after parturition. Testosterone propionate also caused pronounced inhibition, but progesterone and androsterone had no effect. On the basis of these and similar findings it was suggested that oestrogenic hormones might be used for the inhibition of lactation in puerperal women, and numerous reports of this use of the naturally occurring oestrogens have appeared. Foss and Phillips (1938) obtained satisfactory results in 62 cases with oestradiol (progynon B, Schering), giving a total dose of 10,000 I.U. They found that oestrogenic hormone was also useful for flushed and engorged breasts, relieving the symptoms without interfering with lactation. Lehmann (1938) used progynon B oleosum. He found that 100,000 units given by injection in the first 24 hours post partum inhibited lactation in 91% of cases. Inhibition of established lactation was pbtained in 89% of cases with 200,000 units, but in only 50% with 150,000 units. Jeffcoate (1939) gave oestrone by mouth in doses of 2 to 6 mg., gradually decreasing the dose over 3 to 6 days. He found that,it was usually necessary to supplement this by 1 to 2 mg. of oestradiol benzoate by injection.
TL;DR: The belief that chlorinated naphthalenes were the responsible toxic agents has been substantiated by the production of liver necrosis in laboratory animals by administration of these compounds subcutaneously, by inhalation, and by mouth.
Abstract: Chlorinate,d naphthalenes in the form of waxes are now used extensively in industry for insulating wire and in the manufacture of electrical apparatus. Among workers exposed to these compounds an acneform skin eruption (chloracne) characterized by pustules, papules, and comedones is common. The comedones are often accompanied by a severe pruritus, and paronychia of the fingers sometimes occurs. The eruption is characteristically present on the extensor surfaces of the arms, especially round the elbows (Mayers and Silverberg, 1938). Jones (1941) has reported a high percentage of chloracne in this country, and gives methods of effectively reducing its incidence. In addition a number of cases of toxic jaundice due to liver necrosis have been recorded in America among workers exposed to chloronaphthalenes: in one survey the incidence was as high as 9 cases out of 250 workers exposed in three different shops (Flinn and Jarvik, 1938). The belief that chlorinated naphthalenes were the responsible toxic agents has been substantiated by the production of liver necrosis in laboratory animals by administration of these compounds subcutaneously (Flinn and Jarvik, 1936), by inhalation, and by mouth (Drinker, Warren, and Bennett, 1937). The naphthalenes are used either melted by heat or dissolved in volatile solvents. Drinker et al. (1937) consider that the inhalation of the fumes from these processes is the mode of absorption in the cases with hepatic damage. Jones (1941) is of the opinion that the skin lesions are produced by direct contamination.