- Email: [email protected]
DANGERS OF GLOVE POWDER
430 are often adopted widely for the CtTSHiNG always insisted, however, good. that the freshness of these young branches must not obscure the primary function of general medicine and surgery, with its role of support and linkage, both in training and in treatment. The necessary balance in outlook is one that can be achieved only through inspired clinical leadership, not by administration, and CuSHiNG’s own life is an example of that inspiration. He showed that the specialist can and should have an influence far beyond his own sphere, and should add to the strength of the parent stock, instead of taking it away. And incidentally his qualities of mind and heart made him what he always wanted to be-a good doctor to his patients.
which in return common
Annotations CARE OF THE CHILD AFTER POLIOMYELITIS
WHEN children leave hospital after a bout of poliomyelitis, nicely booted and callipered, is there any more to be done1 The parents can be told that there is a chance of further recovery of muscle power up to 18 months after the onset of paralysis ; and that, later on, an arthrodesis, transplantation of tendons, or sympathectomy may diminish the patient’s disability. It is also worth discussing how they themselves propose to treat the child in his daily life, for much depends on this. It is sensible to guide a crippled child towards intellectual and artistic activities, but the over-ambitious parent should be reminded that, though her offspring may become a Roosevelt, he can easily be strained beyond his capacity and be additionally disabled by anxiety ; or, particularly at a boarding-school, he may develop a disproportionate envy of his athletic colleagues which may haunt him beyond his schooldays. Physical recreation should be discussed with the parents; for it is common to meet crippled children, or adults crippled in early life, whose incapacity has never been questioned because of their outward appearance, so they finally do not know what they cannot do, what they are afraid to do, and what they have never acquired the habit of doing. Exercise also has important social and symbolic values, apart from its physical benefits, and there are dangers in a purely intellectual life. Many normal children feel insecure, and a lower-limb palsy may turn a phantasy of insecurity into reality. Confidence can be restored by games in which balance is controlled mainly by other muscles than those of the legs. Diving involves poise in the air by means of trunk and neck muscles. - The legs -are of minor importance, particularly in diving off a spring-board, and any child or jump a few inches can enjoy this sport. fairly flat country can be performed by a child with one or even half an active leg, provided that a light machine, with a three-speed gear and a fixed wheel, is used. Horse-riding, for those who can afford it, is more a matter of balance than of leg-grip and is within the capacity of many apparently disabled older children. The physical exercise of power is also missed unnecessarily by some of these children. If shoulder muscles are weak, a golf shot of fair length can still be made with wrists and forearms. Municipal golf-courses and artisans’ clubs are scattered over Britain, though more thickly in the north. Six or seven years is probably the best age for a child to learn to swim, but four-yearolds can be taught, even iitheir legs are paralysed. Leg action is essential in the breast-stroke but of minor importance in the crawl, and swimmers such as Arne Borg obtained nine-tenths of their propulsive power from
who
can
Bicycling
hop in
the arms. An exercise suitable for those with one weak upper or lower limb is jujitsu. One of the principles of
this art is that the opponent, though rendered incapable of doing injury, should not himself be injured. Its moral value is considerable, and instructors can be found in clubs in most large towns. The overt aim in all these activities should be that of achievement rather than competition, for failure in competition is more likely to dishearten the partially paralysed than the fit. Esthetics must not be neglected. A case of poliomyelitis should be reviewed at intervals, when perhaps a walking-iron which was helpful and unobjectionable on rough fields may be discarded while going to school through town streets under the eye of other children. A night splint alone may be sufficient to prevent a dropfoot from contracting after the first year of the disease. An early promotion to long trousers can make a small boy the envy of his friends and hide a withered limb of which he is more conscious than he seems. A padded stocking or padded shoulders for a fourteen-year-old girl are more justifiable artifices than lipstick. One cannot dogmatise about individuals of different character who resemble one another only in having weakness of one or more muscle groups. But it may be said that the mental effects of poliomyelitis often outweigh the physical and are no less amenable to prevention and treatment. DANGERS OF GLOVE POWDER
granuloma is now a recognised late complication operation wounds, though few surgeons would be prepared to diagnose it clinically. A more serious result of contamination of the peritoneum with glove powder has been described by Roberts 1-granuloma of the fallopian tubes, producing sterility. This disastrous result of an otherwise uncomplicated operation had not previously been recognised because the symptoms are TALC
of
not very severe and may take several years to appear ; and when the tubes are examined histologically the similarity to tuberculous granuloma is close enough to confuse the diagnosis. Several of the tubal lesions described by Roberts had previously been diagnosed as tuberculous, and only the detection of doubly -refractive material in the sections revealed their true nature. Roberts has raised the question whether some cases diagnosed histologically as tuberculous endometritis may not also be silicious granuloma, since the talc may pass via the fimbriated ends of the fallopian tubes to the
endometrium. The long latent period between the original operation and the detection of the granulomata is well illustrated by the history of the seven cases reported by Roberts. Each patient had had a previous appendicectomy. Two patients came under observation on account of swelling of the scar, one 12 and the other 11years after operation. The scars excised resembled keloids, and were nodular on section. Histologically the mass in each case was composed of multiple follicles containing giant and endotheloid cells. Numerous small anisotropic particles were demonstrated with the polarising microscope. These were intimately related to the giant cells, which were in the main grouped around them, and their silicious nature was established by microchemical methods. The five other cases in Roberts’s series all had granulomatous changes in the fallopian tubes, and histological examination revealed the same intimate
relationship of anisotropic particles to-giant cells, the particles sometimes being actually inside the cells. Appendicectomy had been performed in these cases 2, 17, 10, 8, and 11 years before the pelvic operations. Only one of the patients had become pregnant after the appendix operation, and this single pregnancy had
ended in abortion. All the women were married and apparently sterile. Their symptoms suggested a low-grade pelvic inflammation. were
1. Roberts, G. B. S.
Brit. J.
Surg. 1947, 34, 417.
431
the group given. caudal analgesia. Only 2-5% of the Further evidence of the irritating effect of glove infants in the caudal-analgesia group required respiratory on the peritoneum appears in the experimental work on dogs done by Lee and Lehman2 in the United stimulants, compared with 8-7% among the controls, whose mothers had usually received inhalational anmsStates. Small quantities of powder from the surface of thetics such as nitrous oxide and ether. rubber gloves introduced into the peritoneal cavity with reaction dense The most striking finding was the reduction in stilla violent peritoneal produced birth and neonatal (’up to one week) death-rates : in the adhesions between the coils of gut. These writers think it dangerous to use talc on surgical gloves, so they have ’caudal-analgesia group the stillbirth-rate was 9-1per 1000 live births, compared with 24-8 per 1000 in the been looking for an efficient substitute. They have control group, while the neonatal death-rates were 11.5 chosen a commercially prepared dusting powder derived and 20-8 per 1000 live births. These differences could from corn starch, which is treated by physical and not be explained by any differing incidence of premachemical means so that it no longer tends to agglutinate in the autoclave and thus lose its lubricating power, as turity-incidentally, caudal analgesia seemed less harmful to the premature infant-and they were unlikely to have do many other physiologically safe powders. The flow and fineness of the powder are unimpaired by autooccurred by chance. The authors of the report calculate claving, and its complete absorption from the peritoneum that the employment of this method in all deliveries in has been proved experimentally. A brief clinical trial the United States with the same results would halve the has demonstrated its practical efficiency, and autoclaved present annual loss of 125,000 viable infants ! It would, samples have proved completely sterile. An alternative of course, be impracticable to use caudal analgesia for powder has been prepared by Correll and Wise3 from domiciliary- confinements, but this careful and compregelatin flour. They have rendered the gelatin relatively hensive American account should be seen by all concerned insoluble in water and at the same time amenable to with lessening the pain and hazard of labour conducted proteolytic digestion in vitro by subjecting the finely in hospital or maternity home. ground flour to a temperature of 145°C in an electric CONVALESCENT HOMES oven for 25 hours. The denatured powder has proved a UNDER the National Health Service Act the definition satisfactory lubricant. When injected into the peritoneal cavity of rats it produced no granulomata, and it of a hospital includes " any institution for the reception was completely absorbed by the end of 4-5 weeks. and treatment of persons during convalescence or persons should be aware the of of Surgeons potential dangers requiring medical rehabilitation." This is a very wide talc powder and be willing to give a trial to substitutes. definition and there has been much speculation on how In the meantime surplus powder should be washed off it would be construed, especially in relation to conthe outside of gloves before operations begin ; nurses valescent homes. should be careful not to load the finger tips with excess It is now announced that the homes owned and powder which may escape if the glove is punctured;managed by the Birmingham Hospitals Saturday Fund and if a puncture is suspected the gloves should certainly have, with one exception, been excluded from the be changed before the hand is used to manipulate the operation of the Act. The criterion has been the amount contents of the peritoneal cavity. of treatment given, and apparently the Minister has decided that these homes do not give enough to warrant CAUDAL ANALGESIA IN CHILDBIRTH their inclusion in the National Health Service. All of To the obstetric anaesthetist asked to assess the value them have a matron and an assistant matron who are of a new technique the fundamental question is-does State-registered nurses, and some of them have a few the new method effectively relieve pain without increasing assistant nurses as well; but the Birmingham Hospital the risk to mother or child1 This can be answered only Saturday Fund argued that these are really administraby the statistical analysis of a large series of cases,, and tive staff. Their nursing qualifications are required this has now been done for caudal analgesia4 with only in an occasional emergency such as an accident ’Metycaine,’ .as introduced early in 1942 by Edwards or an unexpected relapse, and in either of these events and Hingson.5 Analgesia by this method can be started the patient is much in the same position as an ordinary early in labour and maintained throughout delivery, and member of the public, being nursed in the home if the where necessary continued for postpartum repair. illness is trivial or sent to hospital if it is serious : the In 2516 deliveries conducted at the Philadelphia staff of the homes do not undertake any serious treatment. Lying-in Unit of the Pennsylvania Hospital caudal Again, though the homes have an honorary medical analgesia produced complete relief from pain in 90-4% officer, who is available if required, he is more comparable of the mothers ; in only 5-3% was no alleviation obtained. to the family doctor than to the resident physician in On the other hand, there was a drop in systolic blood. a hospital. pressure of more than 25 mm. Hg in a third of the This decision will be of great interest to all those mothers. Whether this implies any added risk to mother for the management of convalescent homes. responsible or child can be determined only from a controlled comCLINICAL CYANOSIS parison. Ideally, the control group should be drawn from a concurrent series of deliveries differing only in THE clinical assessment of the degree of cyanosis is the method of analgesia employed. Since this was notoriously difficult, even to -the observer with an artistic impracticable comparisons were made with a series of eye, and the clinical detection of slight cyanosis is no 1024 cases delivered in the previous spring and summer. easier. According to Lundsgaard and Van Slyke, The two groups were very similar in all the main factors will not be detectable until 5 g. of reduced cyanosis likely to influence maternal and child mortality-age, haemoglobin is present in 100 ml. of capillary blood, parity, previous health, and so on-and it was thought which corresponds to an arterial oxygen saturation of unlikely that time trends, such as seasonal swings in 80%. Stadie,2 however, found that the correlation epidemic disease or new therapeutic advances, invali- between arterial oxygen saturation and clinical assessdated the comparisons. The outlet forceps rate was ments of cyanosis varied considerably. For instance, in rather higher among the caudal group (68%) than 12 patients with " moderate cyanosis " the saturation among the controls (56%), but less blood was lost and from 65% to 91%, while in 12 patients with ranged the incidence of pyrexia and subinvolution was lower in from 56% "tomarked cyanosis " the saturation ranged 2. Lee, C. M., Lehman, E. P. Surg. Gynec. Obstet. 1947, 84, 689. 86%. Comroe and Botelho3 have now measured the
powder
’
3. Correll, J. T., Wise, E. C. Science, 1947, 105, 529. 4. Collins, S. D., Phillips, F. R., Oliver, D. S. Publ. Hlth
Wash. 1946, 61, 1713. 5. Edwards, W. B., Hingson, R. A.
Amer. J.
Rep.,
Surg. 1942, 57, 459.
1. Lundsgaard, C., Van Slyke, D. D. Medicine, Baltimore, 1923, 2. Stadie, W. C. J. exp. Med. 1919, 30, 215. 3. Comroe, J. H., Botelho, S. Amer. J. med. Sci. 1947, 214, 1.
M3
2, 1.
which in return common
Annotations CARE OF THE CHILD AFTER POLIOMYELITIS
WHEN children leave hospital after a bout of poliomyelitis, nicely booted and callipered, is there any more to be done1 The parents can be told that there is a chance of further recovery of muscle power up to 18 months after the onset of paralysis ; and that, later on, an arthrodesis, transplantation of tendons, or sympathectomy may diminish the patient’s disability. It is also worth discussing how they themselves propose to treat the child in his daily life, for much depends on this. It is sensible to guide a crippled child towards intellectual and artistic activities, but the over-ambitious parent should be reminded that, though her offspring may become a Roosevelt, he can easily be strained beyond his capacity and be additionally disabled by anxiety ; or, particularly at a boarding-school, he may develop a disproportionate envy of his athletic colleagues which may haunt him beyond his schooldays. Physical recreation should be discussed with the parents; for it is common to meet crippled children, or adults crippled in early life, whose incapacity has never been questioned because of their outward appearance, so they finally do not know what they cannot do, what they are afraid to do, and what they have never acquired the habit of doing. Exercise also has important social and symbolic values, apart from its physical benefits, and there are dangers in a purely intellectual life. Many normal children feel insecure, and a lower-limb palsy may turn a phantasy of insecurity into reality. Confidence can be restored by games in which balance is controlled mainly by other muscles than those of the legs. Diving involves poise in the air by means of trunk and neck muscles. - The legs -are of minor importance, particularly in diving off a spring-board, and any child or jump a few inches can enjoy this sport. fairly flat country can be performed by a child with one or even half an active leg, provided that a light machine, with a three-speed gear and a fixed wheel, is used. Horse-riding, for those who can afford it, is more a matter of balance than of leg-grip and is within the capacity of many apparently disabled older children. The physical exercise of power is also missed unnecessarily by some of these children. If shoulder muscles are weak, a golf shot of fair length can still be made with wrists and forearms. Municipal golf-courses and artisans’ clubs are scattered over Britain, though more thickly in the north. Six or seven years is probably the best age for a child to learn to swim, but four-yearolds can be taught, even iitheir legs are paralysed. Leg action is essential in the breast-stroke but of minor importance in the crawl, and swimmers such as Arne Borg obtained nine-tenths of their propulsive power from
who
can
Bicycling
hop in
the arms. An exercise suitable for those with one weak upper or lower limb is jujitsu. One of the principles of
this art is that the opponent, though rendered incapable of doing injury, should not himself be injured. Its moral value is considerable, and instructors can be found in clubs in most large towns. The overt aim in all these activities should be that of achievement rather than competition, for failure in competition is more likely to dishearten the partially paralysed than the fit. Esthetics must not be neglected. A case of poliomyelitis should be reviewed at intervals, when perhaps a walking-iron which was helpful and unobjectionable on rough fields may be discarded while going to school through town streets under the eye of other children. A night splint alone may be sufficient to prevent a dropfoot from contracting after the first year of the disease. An early promotion to long trousers can make a small boy the envy of his friends and hide a withered limb of which he is more conscious than he seems. A padded stocking or padded shoulders for a fourteen-year-old girl are more justifiable artifices than lipstick. One cannot dogmatise about individuals of different character who resemble one another only in having weakness of one or more muscle groups. But it may be said that the mental effects of poliomyelitis often outweigh the physical and are no less amenable to prevention and treatment. DANGERS OF GLOVE POWDER
granuloma is now a recognised late complication operation wounds, though few surgeons would be prepared to diagnose it clinically. A more serious result of contamination of the peritoneum with glove powder has been described by Roberts 1-granuloma of the fallopian tubes, producing sterility. This disastrous result of an otherwise uncomplicated operation had not previously been recognised because the symptoms are TALC
of
not very severe and may take several years to appear ; and when the tubes are examined histologically the similarity to tuberculous granuloma is close enough to confuse the diagnosis. Several of the tubal lesions described by Roberts had previously been diagnosed as tuberculous, and only the detection of doubly -refractive material in the sections revealed their true nature. Roberts has raised the question whether some cases diagnosed histologically as tuberculous endometritis may not also be silicious granuloma, since the talc may pass via the fimbriated ends of the fallopian tubes to the
endometrium. The long latent period between the original operation and the detection of the granulomata is well illustrated by the history of the seven cases reported by Roberts. Each patient had had a previous appendicectomy. Two patients came under observation on account of swelling of the scar, one 12 and the other 11years after operation. The scars excised resembled keloids, and were nodular on section. Histologically the mass in each case was composed of multiple follicles containing giant and endotheloid cells. Numerous small anisotropic particles were demonstrated with the polarising microscope. These were intimately related to the giant cells, which were in the main grouped around them, and their silicious nature was established by microchemical methods. The five other cases in Roberts’s series all had granulomatous changes in the fallopian tubes, and histological examination revealed the same intimate
relationship of anisotropic particles to-giant cells, the particles sometimes being actually inside the cells. Appendicectomy had been performed in these cases 2, 17, 10, 8, and 11 years before the pelvic operations. Only one of the patients had become pregnant after the appendix operation, and this single pregnancy had
ended in abortion. All the women were married and apparently sterile. Their symptoms suggested a low-grade pelvic inflammation. were
1. Roberts, G. B. S.
Brit. J.
Surg. 1947, 34, 417.
431
the group given. caudal analgesia. Only 2-5% of the Further evidence of the irritating effect of glove infants in the caudal-analgesia group required respiratory on the peritoneum appears in the experimental work on dogs done by Lee and Lehman2 in the United stimulants, compared with 8-7% among the controls, whose mothers had usually received inhalational anmsStates. Small quantities of powder from the surface of thetics such as nitrous oxide and ether. rubber gloves introduced into the peritoneal cavity with reaction dense The most striking finding was the reduction in stilla violent peritoneal produced birth and neonatal (’up to one week) death-rates : in the adhesions between the coils of gut. These writers think it dangerous to use talc on surgical gloves, so they have ’caudal-analgesia group the stillbirth-rate was 9-1per 1000 live births, compared with 24-8 per 1000 in the been looking for an efficient substitute. They have control group, while the neonatal death-rates were 11.5 chosen a commercially prepared dusting powder derived and 20-8 per 1000 live births. These differences could from corn starch, which is treated by physical and not be explained by any differing incidence of premachemical means so that it no longer tends to agglutinate in the autoclave and thus lose its lubricating power, as turity-incidentally, caudal analgesia seemed less harmful to the premature infant-and they were unlikely to have do many other physiologically safe powders. The flow and fineness of the powder are unimpaired by autooccurred by chance. The authors of the report calculate claving, and its complete absorption from the peritoneum that the employment of this method in all deliveries in has been proved experimentally. A brief clinical trial the United States with the same results would halve the has demonstrated its practical efficiency, and autoclaved present annual loss of 125,000 viable infants ! It would, samples have proved completely sterile. An alternative of course, be impracticable to use caudal analgesia for powder has been prepared by Correll and Wise3 from domiciliary- confinements, but this careful and compregelatin flour. They have rendered the gelatin relatively hensive American account should be seen by all concerned insoluble in water and at the same time amenable to with lessening the pain and hazard of labour conducted proteolytic digestion in vitro by subjecting the finely in hospital or maternity home. ground flour to a temperature of 145°C in an electric CONVALESCENT HOMES oven for 25 hours. The denatured powder has proved a UNDER the National Health Service Act the definition satisfactory lubricant. When injected into the peritoneal cavity of rats it produced no granulomata, and it of a hospital includes " any institution for the reception was completely absorbed by the end of 4-5 weeks. and treatment of persons during convalescence or persons should be aware the of of Surgeons potential dangers requiring medical rehabilitation." This is a very wide talc powder and be willing to give a trial to substitutes. definition and there has been much speculation on how In the meantime surplus powder should be washed off it would be construed, especially in relation to conthe outside of gloves before operations begin ; nurses valescent homes. should be careful not to load the finger tips with excess It is now announced that the homes owned and powder which may escape if the glove is punctured;managed by the Birmingham Hospitals Saturday Fund and if a puncture is suspected the gloves should certainly have, with one exception, been excluded from the be changed before the hand is used to manipulate the operation of the Act. The criterion has been the amount contents of the peritoneal cavity. of treatment given, and apparently the Minister has decided that these homes do not give enough to warrant CAUDAL ANALGESIA IN CHILDBIRTH their inclusion in the National Health Service. All of To the obstetric anaesthetist asked to assess the value them have a matron and an assistant matron who are of a new technique the fundamental question is-does State-registered nurses, and some of them have a few the new method effectively relieve pain without increasing assistant nurses as well; but the Birmingham Hospital the risk to mother or child1 This can be answered only Saturday Fund argued that these are really administraby the statistical analysis of a large series of cases,, and tive staff. Their nursing qualifications are required this has now been done for caudal analgesia4 with only in an occasional emergency such as an accident ’Metycaine,’ .as introduced early in 1942 by Edwards or an unexpected relapse, and in either of these events and Hingson.5 Analgesia by this method can be started the patient is much in the same position as an ordinary early in labour and maintained throughout delivery, and member of the public, being nursed in the home if the where necessary continued for postpartum repair. illness is trivial or sent to hospital if it is serious : the In 2516 deliveries conducted at the Philadelphia staff of the homes do not undertake any serious treatment. Lying-in Unit of the Pennsylvania Hospital caudal Again, though the homes have an honorary medical analgesia produced complete relief from pain in 90-4% officer, who is available if required, he is more comparable of the mothers ; in only 5-3% was no alleviation obtained. to the family doctor than to the resident physician in On the other hand, there was a drop in systolic blood. a hospital. pressure of more than 25 mm. Hg in a third of the This decision will be of great interest to all those mothers. Whether this implies any added risk to mother for the management of convalescent homes. responsible or child can be determined only from a controlled comCLINICAL CYANOSIS parison. Ideally, the control group should be drawn from a concurrent series of deliveries differing only in THE clinical assessment of the degree of cyanosis is the method of analgesia employed. Since this was notoriously difficult, even to -the observer with an artistic impracticable comparisons were made with a series of eye, and the clinical detection of slight cyanosis is no 1024 cases delivered in the previous spring and summer. easier. According to Lundsgaard and Van Slyke, The two groups were very similar in all the main factors will not be detectable until 5 g. of reduced cyanosis likely to influence maternal and child mortality-age, haemoglobin is present in 100 ml. of capillary blood, parity, previous health, and so on-and it was thought which corresponds to an arterial oxygen saturation of unlikely that time trends, such as seasonal swings in 80%. Stadie,2 however, found that the correlation epidemic disease or new therapeutic advances, invali- between arterial oxygen saturation and clinical assessdated the comparisons. The outlet forceps rate was ments of cyanosis varied considerably. For instance, in rather higher among the caudal group (68%) than 12 patients with " moderate cyanosis " the saturation among the controls (56%), but less blood was lost and from 65% to 91%, while in 12 patients with ranged the incidence of pyrexia and subinvolution was lower in from 56% "tomarked cyanosis " the saturation ranged 2. Lee, C. M., Lehman, E. P. Surg. Gynec. Obstet. 1947, 84, 689. 86%. Comroe and Botelho3 have now measured the
powder
’
3. Correll, J. T., Wise, E. C. Science, 1947, 105, 529. 4. Collins, S. D., Phillips, F. R., Oliver, D. S. Publ. Hlth
Wash. 1946, 61, 1713. 5. Edwards, W. B., Hingson, R. A.
Amer. J.
Rep.,
Surg. 1942, 57, 459.
1. Lundsgaard, C., Van Slyke, D. D. Medicine, Baltimore, 1923, 2. Stadie, W. C. J. exp. Med. 1919, 30, 215. 3. Comroe, J. H., Botelho, S. Amer. J. med. Sci. 1947, 214, 1.
M3
2, 1.