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ANTIMONY POISONING
941
pictures a strange community in our midst which by some freakish providence is so constituted that noise and squalor are natural to its members. The adaptation of the evacuated people to their
and strange conditions will only be brought about without friction and ill-will if their new neighbours understand their state of mind and help them to readjust it. new
ANNOTATIONS FRACTURES OF THE JAWS
THE need for cooperation is particularly obvious in the treatment of fractures of the jaws, whether in peace or war. The first-aider and the general, dental or plastic surgeon must each know enough of the other’s subject to appreciate its special problems and its relation to his own work. An opportunity of studying the dental surgeon’s point of view was provided by a symposium at a meeting of the British Dental Association.l Mr. F. St. J. Steadman showed how in the less severe fractures of the mandible displacement depends on muscular action and the resulting deformity is determined by the site and direction of the fracture. For instance, in a fracture running from the ascending ramus downwards and forwards to below the last molar tooth there may be no displacement, for the temporal and masseter muscles pull the posterior fragment upwards and the mylohyoid pulls the anterior fragment downwards: the two fragments are in this way locked together. In some cases, therefore, no artificial fixation is necessary and Mr. Steadman claims good results by following this principle. He admits, however, that his policy of non-intervention cannot be adopted in severe injuries and gun-shot wounds. In severely shocked cases and in those where there is much swelling or sepsis Mr. Harold Round advises that immobilisation should be postponed for a few days, during which time fomentations may be applied and oral irrigation given. The irrigation should be done with saline, an alkaline wash or a weak solution of tincture of iodine: hydrogen peroxide should be avoided, for it is likely to spread infection. The method of choice for immobilising most fractured mandibles is, he says, interdental wiring, which was first used by Hippocrates. A general anaesthetic (preferably intratracheal) is usually necessary and a suitable tooth in the upper jaw is fixed to a corresponding tooth in the displaced mandibular fragment by means of stainless steel wire. The " eyelet " method of wiring has certain minor advantages. In edentulous patients the dentures may be used as splints combined with some form of jaw bandage, but sometimes splints have to be fixed by means of circumferential wiring. Mr. Kelsey Fry urged the advantages of splints over interdental wiring in many cases. He prefers metal cap splints, which are particularly useful in severe injuries when the remaining teeth are few and awkwardly placed for wiring. Mr. Fry believes that every fracture should be immobilised immediately: when the patient is badly shocked a temporary eyelet wire should be fixed at once and splints can be applied later. Mr. A. H. Parrott dealt with both the prevention and treatment of fractures of the maxilla. Most bilateral fractures of the maxilla are due to motor and especially aeroplane accidents, and in the last war Mr. Parrott introduced a padding device for the coaming round the cockpit which was adopted by the Air Ministry. The immobilisation of a fractured maxilla may often be effected by splinting it with the mandible, but in severe injuries this is inadequate and in any case prolonged fixation of the undamaged lower jaw is undesirable. Mr. Parrott 1. Brit. dent. J. Sept. 15, 1939, p. 273.
has devised a splint to solve this problem: a silver cap splint is fitted to all the teeth in the upper jaw; a moulded vulcanite appliance is then prepared to fit accurately on the lower part of the forehead, on the bridge of the nose and into the upper part of the orbits; these two units are then connected by metal tubes passing down the sides of the nose and through the angles of the mouth; and finally the whole splint is secured by straps round the head from the frontal component. He claims that this appliance has several advantages over the older Kingsley splint: it not only immobilises the fracture but allows mastication because the upward pressure of the mandible is transmitted from the cap splint to the upper border of the orbits, so that the maxilla is left undisturbed; moreover, the absence of projections from the side of the face allows the patient a freer and more comfortable contact with his pillow. ANTIMONY POISONING
FROM time to time antimony poisoning follows the use of enamelled hollow ware in which antimony oxide has been employed to render the enamel opaque. As a rule the victims have drunk acid beverages, such as lemonade and limade, which have been standing in enamel vessels long enough to dissolve the antimony oxide in the enamel and to form compounds for example tartar emetic. Excluding such examples of
misguided catering, however, poisoning with this metal appears to be rare. In industry the use of antimony compounds is limited, and even in the smelting of antimony ores few constitutional disturbances have been described. Local irritation of the skin in the form of antimony " lumps " or " pocks " is known to occur ; but some writers ascribe these and all other observed effects to the constant presence of arsenic as an impurity in the antimony ores. The skin troubles encountered certainly do resemble those caused by arsenic, and the constitutional symptoms, such as vomiting, colic and diarrhoea in acute cases, and indigestion, anorexia and loss of weight in the chronic form, do simulate arsenical poisoning. Recently Feilhas described the findings in his examinations of 15 men who were working in a foundry where antimony ore was being smelted. On analysis the ore consisted of quartz, antimony sulphide (1550 per cent.), and traces of gold and arsenic. In the richest specimens the amount of arsenic did not exceed 10 mg. per kg., and Foil therefore maintains that any clinical effects that he found in the workmen could not possibly be ascribed to arsenic. The men were exposed to the fumes of antimony oxide at various times during the process of smelting, as for instance when the furnaces were opened to be charged with coke and ore, and when the molten antimony was being run off. Of the 15 studied, 7 had an " antimony rash " at the time of examination, while 7 others gave a history of previous skin trouble and some of them showed scars it had left. The rash in its acute form is very itchy and its component parts resemble chickenpox and smallpox. The lesion begins as a red papule raised about 2 mm. above the skin level and sooner or later a vesicle appears in the centre, 1.
Feil, A.,
Pr. méd.
July 19, 1939, p. 1134.
942
developing finally into a pustule. In the course of a drys up and a crust forms over it. The eruption spreads in successive crops and it is common to find in one case rashes of different stages of development-either papules, vesicles, pustules and crusts or even ulcers and eczematous lesions if the patient has scratched his skin. The affection is commonly seen on the neck, the forearms and the lower limbs,
week it
acquires the property methaemoglobin.
of
oxidising haemoglobin
to
While these observations make suggestive contributions to the pharmacology of sulphonamide compounds, one is again struck by the anomaly that p-aminobenzenesulphonamide apparently gives rise to methsemoglobinagmia in the United States but not in this country. It would therefore be useful if in Britain a series of cases as large as that of Harris but any part of the skin area may be involved ; it and Michel could be examined with equal care. We lasts about three weeks, and disappears spontaneously, especially if the man gives up his work for the also need further light on the capacity of different time being. It is usually worse in the summer, and members of the sulphonamide series of drugs to cause is aggravated by scratching, heat and excessive alteration in blood pigments. Dubort and Durel5 not one of 15 workmen had find that p-acetylaminophenylsulphonamide often prothe Only sweating. duces cyanosis, p-aminophenylsulphonamide less often suffered from an antimony rash, but he had shown some constitutional symptoms of poisoning by the and p-aminophenylsulphonamidopyridine, sulphamido. furnace fumes. The symptoms troubling these men chrysoidine and benzyl p-aminobenzenesulphonamide were slight, the list includes conjunctivitis, tracheitis, only very rarely. The in-vitro method described by pharyngitis, anaemia, headache, vomiting and Harrismay provide a ready means of confirming anorexia, and Feil rightly points out that some of these conclusions, which must, at the moment, be based these could have been caused solely by the heat of chiefly on impressions. the furnaces. But he does not make out a convincing case for the view that the signs and symptoms are ADRENALINE IN MALARIA due to antimony, nor has he established that arsenic AscoLi’s method of treating malaria consists in was not partly responsible for the clinical features intravenous injections of a progressively described. A low percentage of arsenic in the ore does daily solution of adrenaline in conjunction with stronger not necessarily mean that a higher concentration the customary quinine therapy. It is usual to begin would not have been found in the furnace fumes if with 1 c.cm. of a 1 in 100,000 solution, followed the they had been chemically analysed. 1 c.cm. of a 1 in 90,000, the next by 1 in 80,000, and so on by daily reductions of the dilution until a strength of 1 in 20,000 or 1 in
next
SULPHONAMIDES AND BLOOD PIGMENTS
WHILE the
use of the sulphonamide group of drugs is still largely empirical, more and more is becoming known about their toxic actions; and these may provide the clue to the therapeutic value. One of the least serious, but not the least interesting, toxic effect is the development of methaemoglobinaemia and sulphaemoglobinaemia. All accept these complications as common-varying between 20 and 50 per cent.but they are certainly commonest in the clinics where spectroscopy is most carefully carried out. The truth is that the detection and differentiation of abnormal blood pigments, especially in minimal amounts, requires considerable and specialised skill, and it is therefore important that reports concerned with these phenomena should state what methods of examination have been employed. Harris and Michel/ using a sensitive method of detection, have been able to demonstrate methaemoglobin in the blood of 277 out of 476 patients receiving sulphanilamide (p-aminobenzonesulphonamide) and find that the average methaemoglobin content was proportional to the sulphonamide concentration. These figures agree with those of ZVendleand Campbell and Morgan.3 In addition, Harris and Michel find that within certain limits the methaemoglobinsemia tends to diminish with the duration of therapy. This, together with the
observation that methasmoglobinsemia rapidly disappears when sulphonamide treatment is withdrawn, leads them to conclude that the pigment is produced by oxidation of the haemoglobin by a derivative of sulphonamide and is reduced to haemoglobin by the tissues, so that its accumulation in the blood will depend on a balance of these factors. That a menthaemoglobin-forming substance is formed from sulphonamide in the tissues is demonstrated by the experiments of Harris,’ who shows that when a solution of sulphonamide is incubated with rat liver it Harris, J. S., Michel, H. O., J. clin. Invest. September, 1939, p. 507. 2. Wendle, W. B., J. Lab. clin. Med. 1938, 24, 96. 3. Campbell, D., and Morgan, T. N., Lancet, July 15, 1939, p. 123. 4. Harris, J. S., J. clin. Invest. September, 1939, p. 521. 1.
day by
1 c.cm. of
a
10,000 is reached, the final concentration being used for three or four weeks more. By this method the body becomes accustomed to tolerate massive doses of adrenaline. This cannot be done by subcutaneous injection, because of local reactions. Care must be taken that the adrenaline is of the best quality and the solution freshly prepared. It is claimed that the first injection is followed quickly by a diminution of fever, a normal blood-picture, a feeling of better health, and a decrease in the size of the spleen ; and that the full course of injections will prevent relapse for about a year. The idea is that adrenaline causes the spleen to contract and thus compels the parasites, harboured in the splenic parenchyma, to emerge into the blood-stream, where they can be attacked with quinine. The adrenaline is also thought to have an action, not yet understood, which counters the development of anaemia. Boccia and Matteo,6 of Buenos Aires, report the successful use of Ascoli’s method in the case of a general paralytic in whom quartan malaria had been induced therapeutically, the fever becoming uncontrollable by the usual measures and the patient apparently moribund. The effect of the first intravenous injection was instantaneous ; there was no more fever, and during the course of treatment the patient quickly regained not only his general health but also a less clouded mind. The rapid cure of neurological complications of malaria is reported by Pizzillo,7 of Palermo, who gives details of one case with symptoms of cerebellar disorder and of two cases of sciatica and cites Longo’s case of malarial polyneuritis cured by only eight injections of adrenaline. Conflicting results are reported from Sardinia. Mastio 8 claims success in 46 out of 48 cases in which adrenaline was given by mouth instead of by intraDubort, P., and Durel, P., Ann Méd. 1939, 46, 56. Boccia, D., and Di Matteo, T. B., Rev. Sud-Amer. Endocrinol. Feb. 15, 1939, p. 80. 7. Pizzillo, G., Riv. Malariol. 1939, p. 211. 8. Mastio, C., Rassegna clin. Terap. Sci. affini, JanuaryFebruary, 1939, p. 23. 5. 6.
pictures a strange community in our midst which by some freakish providence is so constituted that noise and squalor are natural to its members. The adaptation of the evacuated people to their
and strange conditions will only be brought about without friction and ill-will if their new neighbours understand their state of mind and help them to readjust it. new
ANNOTATIONS FRACTURES OF THE JAWS
THE need for cooperation is particularly obvious in the treatment of fractures of the jaws, whether in peace or war. The first-aider and the general, dental or plastic surgeon must each know enough of the other’s subject to appreciate its special problems and its relation to his own work. An opportunity of studying the dental surgeon’s point of view was provided by a symposium at a meeting of the British Dental Association.l Mr. F. St. J. Steadman showed how in the less severe fractures of the mandible displacement depends on muscular action and the resulting deformity is determined by the site and direction of the fracture. For instance, in a fracture running from the ascending ramus downwards and forwards to below the last molar tooth there may be no displacement, for the temporal and masseter muscles pull the posterior fragment upwards and the mylohyoid pulls the anterior fragment downwards: the two fragments are in this way locked together. In some cases, therefore, no artificial fixation is necessary and Mr. Steadman claims good results by following this principle. He admits, however, that his policy of non-intervention cannot be adopted in severe injuries and gun-shot wounds. In severely shocked cases and in those where there is much swelling or sepsis Mr. Harold Round advises that immobilisation should be postponed for a few days, during which time fomentations may be applied and oral irrigation given. The irrigation should be done with saline, an alkaline wash or a weak solution of tincture of iodine: hydrogen peroxide should be avoided, for it is likely to spread infection. The method of choice for immobilising most fractured mandibles is, he says, interdental wiring, which was first used by Hippocrates. A general anaesthetic (preferably intratracheal) is usually necessary and a suitable tooth in the upper jaw is fixed to a corresponding tooth in the displaced mandibular fragment by means of stainless steel wire. The " eyelet " method of wiring has certain minor advantages. In edentulous patients the dentures may be used as splints combined with some form of jaw bandage, but sometimes splints have to be fixed by means of circumferential wiring. Mr. Kelsey Fry urged the advantages of splints over interdental wiring in many cases. He prefers metal cap splints, which are particularly useful in severe injuries when the remaining teeth are few and awkwardly placed for wiring. Mr. Fry believes that every fracture should be immobilised immediately: when the patient is badly shocked a temporary eyelet wire should be fixed at once and splints can be applied later. Mr. A. H. Parrott dealt with both the prevention and treatment of fractures of the maxilla. Most bilateral fractures of the maxilla are due to motor and especially aeroplane accidents, and in the last war Mr. Parrott introduced a padding device for the coaming round the cockpit which was adopted by the Air Ministry. The immobilisation of a fractured maxilla may often be effected by splinting it with the mandible, but in severe injuries this is inadequate and in any case prolonged fixation of the undamaged lower jaw is undesirable. Mr. Parrott 1. Brit. dent. J. Sept. 15, 1939, p. 273.
has devised a splint to solve this problem: a silver cap splint is fitted to all the teeth in the upper jaw; a moulded vulcanite appliance is then prepared to fit accurately on the lower part of the forehead, on the bridge of the nose and into the upper part of the orbits; these two units are then connected by metal tubes passing down the sides of the nose and through the angles of the mouth; and finally the whole splint is secured by straps round the head from the frontal component. He claims that this appliance has several advantages over the older Kingsley splint: it not only immobilises the fracture but allows mastication because the upward pressure of the mandible is transmitted from the cap splint to the upper border of the orbits, so that the maxilla is left undisturbed; moreover, the absence of projections from the side of the face allows the patient a freer and more comfortable contact with his pillow. ANTIMONY POISONING
FROM time to time antimony poisoning follows the use of enamelled hollow ware in which antimony oxide has been employed to render the enamel opaque. As a rule the victims have drunk acid beverages, such as lemonade and limade, which have been standing in enamel vessels long enough to dissolve the antimony oxide in the enamel and to form compounds for example tartar emetic. Excluding such examples of
misguided catering, however, poisoning with this metal appears to be rare. In industry the use of antimony compounds is limited, and even in the smelting of antimony ores few constitutional disturbances have been described. Local irritation of the skin in the form of antimony " lumps " or " pocks " is known to occur ; but some writers ascribe these and all other observed effects to the constant presence of arsenic as an impurity in the antimony ores. The skin troubles encountered certainly do resemble those caused by arsenic, and the constitutional symptoms, such as vomiting, colic and diarrhoea in acute cases, and indigestion, anorexia and loss of weight in the chronic form, do simulate arsenical poisoning. Recently Feilhas described the findings in his examinations of 15 men who were working in a foundry where antimony ore was being smelted. On analysis the ore consisted of quartz, antimony sulphide (1550 per cent.), and traces of gold and arsenic. In the richest specimens the amount of arsenic did not exceed 10 mg. per kg., and Foil therefore maintains that any clinical effects that he found in the workmen could not possibly be ascribed to arsenic. The men were exposed to the fumes of antimony oxide at various times during the process of smelting, as for instance when the furnaces were opened to be charged with coke and ore, and when the molten antimony was being run off. Of the 15 studied, 7 had an " antimony rash " at the time of examination, while 7 others gave a history of previous skin trouble and some of them showed scars it had left. The rash in its acute form is very itchy and its component parts resemble chickenpox and smallpox. The lesion begins as a red papule raised about 2 mm. above the skin level and sooner or later a vesicle appears in the centre, 1.
Feil, A.,
Pr. méd.
July 19, 1939, p. 1134.
942
developing finally into a pustule. In the course of a drys up and a crust forms over it. The eruption spreads in successive crops and it is common to find in one case rashes of different stages of development-either papules, vesicles, pustules and crusts or even ulcers and eczematous lesions if the patient has scratched his skin. The affection is commonly seen on the neck, the forearms and the lower limbs,
week it
acquires the property methaemoglobin.
of
oxidising haemoglobin
to
While these observations make suggestive contributions to the pharmacology of sulphonamide compounds, one is again struck by the anomaly that p-aminobenzenesulphonamide apparently gives rise to methsemoglobinagmia in the United States but not in this country. It would therefore be useful if in Britain a series of cases as large as that of Harris but any part of the skin area may be involved ; it and Michel could be examined with equal care. We lasts about three weeks, and disappears spontaneously, especially if the man gives up his work for the also need further light on the capacity of different time being. It is usually worse in the summer, and members of the sulphonamide series of drugs to cause is aggravated by scratching, heat and excessive alteration in blood pigments. Dubort and Durel5 not one of 15 workmen had find that p-acetylaminophenylsulphonamide often prothe Only sweating. duces cyanosis, p-aminophenylsulphonamide less often suffered from an antimony rash, but he had shown some constitutional symptoms of poisoning by the and p-aminophenylsulphonamidopyridine, sulphamido. furnace fumes. The symptoms troubling these men chrysoidine and benzyl p-aminobenzenesulphonamide were slight, the list includes conjunctivitis, tracheitis, only very rarely. The in-vitro method described by pharyngitis, anaemia, headache, vomiting and Harrismay provide a ready means of confirming anorexia, and Feil rightly points out that some of these conclusions, which must, at the moment, be based these could have been caused solely by the heat of chiefly on impressions. the furnaces. But he does not make out a convincing case for the view that the signs and symptoms are ADRENALINE IN MALARIA due to antimony, nor has he established that arsenic AscoLi’s method of treating malaria consists in was not partly responsible for the clinical features intravenous injections of a progressively described. A low percentage of arsenic in the ore does daily solution of adrenaline in conjunction with stronger not necessarily mean that a higher concentration the customary quinine therapy. It is usual to begin would not have been found in the furnace fumes if with 1 c.cm. of a 1 in 100,000 solution, followed the they had been chemically analysed. 1 c.cm. of a 1 in 90,000, the next by 1 in 80,000, and so on by daily reductions of the dilution until a strength of 1 in 20,000 or 1 in
next
SULPHONAMIDES AND BLOOD PIGMENTS
WHILE the
use of the sulphonamide group of drugs is still largely empirical, more and more is becoming known about their toxic actions; and these may provide the clue to the therapeutic value. One of the least serious, but not the least interesting, toxic effect is the development of methaemoglobinaemia and sulphaemoglobinaemia. All accept these complications as common-varying between 20 and 50 per cent.but they are certainly commonest in the clinics where spectroscopy is most carefully carried out. The truth is that the detection and differentiation of abnormal blood pigments, especially in minimal amounts, requires considerable and specialised skill, and it is therefore important that reports concerned with these phenomena should state what methods of examination have been employed. Harris and Michel/ using a sensitive method of detection, have been able to demonstrate methaemoglobin in the blood of 277 out of 476 patients receiving sulphanilamide (p-aminobenzonesulphonamide) and find that the average methaemoglobin content was proportional to the sulphonamide concentration. These figures agree with those of ZVendleand Campbell and Morgan.3 In addition, Harris and Michel find that within certain limits the methaemoglobinsemia tends to diminish with the duration of therapy. This, together with the
observation that methasmoglobinsemia rapidly disappears when sulphonamide treatment is withdrawn, leads them to conclude that the pigment is produced by oxidation of the haemoglobin by a derivative of sulphonamide and is reduced to haemoglobin by the tissues, so that its accumulation in the blood will depend on a balance of these factors. That a menthaemoglobin-forming substance is formed from sulphonamide in the tissues is demonstrated by the experiments of Harris,’ who shows that when a solution of sulphonamide is incubated with rat liver it Harris, J. S., Michel, H. O., J. clin. Invest. September, 1939, p. 507. 2. Wendle, W. B., J. Lab. clin. Med. 1938, 24, 96. 3. Campbell, D., and Morgan, T. N., Lancet, July 15, 1939, p. 123. 4. Harris, J. S., J. clin. Invest. September, 1939, p. 521. 1.
day by
1 c.cm. of
a
10,000 is reached, the final concentration being used for three or four weeks more. By this method the body becomes accustomed to tolerate massive doses of adrenaline. This cannot be done by subcutaneous injection, because of local reactions. Care must be taken that the adrenaline is of the best quality and the solution freshly prepared. It is claimed that the first injection is followed quickly by a diminution of fever, a normal blood-picture, a feeling of better health, and a decrease in the size of the spleen ; and that the full course of injections will prevent relapse for about a year. The idea is that adrenaline causes the spleen to contract and thus compels the parasites, harboured in the splenic parenchyma, to emerge into the blood-stream, where they can be attacked with quinine. The adrenaline is also thought to have an action, not yet understood, which counters the development of anaemia. Boccia and Matteo,6 of Buenos Aires, report the successful use of Ascoli’s method in the case of a general paralytic in whom quartan malaria had been induced therapeutically, the fever becoming uncontrollable by the usual measures and the patient apparently moribund. The effect of the first intravenous injection was instantaneous ; there was no more fever, and during the course of treatment the patient quickly regained not only his general health but also a less clouded mind. The rapid cure of neurological complications of malaria is reported by Pizzillo,7 of Palermo, who gives details of one case with symptoms of cerebellar disorder and of two cases of sciatica and cites Longo’s case of malarial polyneuritis cured by only eight injections of adrenaline. Conflicting results are reported from Sardinia. Mastio 8 claims success in 46 out of 48 cases in which adrenaline was given by mouth instead of by intraDubort, P., and Durel, P., Ann Méd. 1939, 46, 56. Boccia, D., and Di Matteo, T. B., Rev. Sud-Amer. Endocrinol. Feb. 15, 1939, p. 80. 7. Pizzillo, G., Riv. Malariol. 1939, p. 211. 8. Mastio, C., Rassegna clin. Terap. Sci. affini, JanuaryFebruary, 1939, p. 23. 5. 6.