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PAIN AFTER HEAD INJURY
46 EFFECT
OF
MEMBRANE
CONCENTRATION
C1
POTENTIAL
ON
AND CALCULATED
POTASSIUM CONCENTRATION
INTRACELLULAR
E.C.F.,
CHLORIDE
AND INTRACELLULAR
[K]i
Studies referred to in this letter have been supported by grants from the Royal Society, the Dowager Countess Eleanor Peel Fund, the Endowment Fund of the Birmingham United Hospitals, and the Scientific Research Committee of the Royal Victoria Infirmary.
University, of Clinical Biochemistry, Royal Victoria Infirmary, Newcastle upon Tyne.
Department
Nutrition and Intestinal Unit, General Hospital, Birmingham.
C. T. G. FLEAR. IRENÉ FLORENCE
J. ALEXANDER WILLIAMS.
Calculated for: total
*
content of chloride in biopsy specimen 90 meq. per kg. dry weight and total water 3200 ml. per kg. dry weight values of Dr. Graham and his colleagues. Extracellular chloride concentration 109 meq./kg. water (serum-level corrected for Donnan equilibrium and amount of solids in serum which, for anions, summate rather than cancel). Total potassium content of biopsy taken as 310 meq. per kg. dry weight, and extracellular potassium concentration as 4 meq./kg. water. (Values for [C1]i and E.c.F. for membrane potentials -75 and z95 were transposed in table 1 of Dr. Graham and his colleagues.) Tissue with a membrane potential of -33 mV would contain more than 90 meq. chloride per kg. dry weight of tissue.
to the extent found for the biopsy specipatient (case 2), they apparently excluded potassium depletion by their failure to detect a lowered concentration of potassium in cellular fluids in the three samples of skeletal muscle analysed, which collectively cannot have con-
tissues were depleted men. In their second
tained much more than a millionth of the total mass of cells in her body. The validity of these assumptions must be tested in a wide range of clinical situations before inferences drawn from biopsies can be relied on with confidence. There is evidence in patients that skeletal muscle reflects change in body-potassium. But we need to know whether a low potassium-content in biopsy samples of muscle necessarily denotes depletion in tissues like the heart, the total potassium-content of which may be only a small part of total body-potassium, and whether depletion in other tissues (e.g., smooth muscle of the gut in a patient with paralytic ileus) can be excluded by failure to find lowering of potassium in samples from one skeletal muscle. From our experience we have come to the following conclusions : 1. For all tissues we have investigated (skeletal, smooth, and cardiac muscle, intestinal mucosa, brain, connective tissue) a sample does afford an index of the tissue sampled in control subjects and patients with severe cardiac or alimentary disease. (Some of this work was presented at the meeting of the Surgical Research Society held at Aberdeen on July 14 and 15, 1967.) 2. At any rate in patients with chronic heart-disease, with or without congestive heart-failure, a sample of one skeletal muscle (deltoid) affords an index of changes in another (gastrocnemius).88 3. A sample of skeletal muscle does not necessarily afford an index of all tissues. In patients in congestive heart-failure it affords an index of changes in myocardium, but not in brain tissue. Similarly, in the presence of severe intestinal obstruction, changes were noted in intestinal smooth muscle that were not present in samples of skeletal muscle.11
Even with full and error-free data for potassium concentration in cells in a biopsy specimen, estimates of body deficit would still be approximate in view of the need to assume: (a) that cells throughout the body have precisely the same composition as in the sample; (b) values for the patient’s total body-water and total E.C.F. (in order to derive the total volume of his cell fluid), or alternatively a value for his expected total body-potassium. We believe that we can obtain a no-less-approximate estimate of the state of body-potassium from the potassium-content of samples in the light of their sodium content,8 without attempting to obtain E.c.F. values. Comparison is made with suitable standards, which for definitive appraisal should be constructed from the same muscle.(We have elaborated standards for deltoid, gastrocnemius, and rectus abdominis.8) Appraisal is not simple, but we believe that it is possible to decide whether a sample is poor in potassium from depletion or from its having a relatively high proportion of extracellular chase. 8. Flear, C. T. G., Florence, I., Williams, J. A. Unpublished. 9. Flear, C. T. G., Carpenter, R. G., Florence, I. J. clin. Path. 18, 74.
1965,
PAIN AFTER HEAD INJURY SiR,-One of the tragedies entailed in increased specialisation
is the lack of communication between the various medical disciplines. To those in manipulative practice it seems fantastic that .LB1.r. Wilson, in his article last week (p. 1391), should assume that injuries to the head sufficient to cause skull fracture are not associated with cervical-joint injury. Every skull fracture must involve strain of the neck joints in juxtaposition to the emerging cervical nerve-roots. The basis of the assumption is the negative X-ray findings (which one would not expect to be positive much before the development of spondylosis in, say, five years’ time) coupled with a normal range of neck movement on gross testing. The latter can be discounted, since the range at the individual joint-complexes at each level were not tested. Pain, parxsthesia, and hyperalgesia were probably referred from the joints of the vertebral arch. In all probability the pain could have been relieved within a few weeks by the use of local hydrocortisone injections and cervical manipulation. London W.1. JOHN EBBETTS
TREATMENT OF FRACTURED CLAVICLE SIR,-Sir Selwyn Selwyn-Clarke’s clavicular ring splint (Dec. 23, p. 1364) is more comfortable, but why must we be reminded of a principle of treatment which was so effectively condemned in your journal only nine months ago?1 Le Vay later suggested that no form of treatment was of any value whatever.2 A corollary is that fractures of the clavicle will do well with any treatment which does no harm. This no doubt explains Walker’s " excellent results " with carefully applied figure-of-
eight bandages.3 I should like to renew my plea 4 for the abandonment of all types of figure-of-eight bandages and rings, because they are irrational, cause unnecessary discomfort, and can be dangerous. They are irrational because, contrary to oft-repeated statements,3 the outer fragment is usually displaced behind the inner fragment and the figure of eight aggravates this deformity. Moreover, the idea that a figure-of-eight helps by pulling out over-riding fragments should be discarded for two reasons. Firstly, over-riding should be left alone, because it encourages early union. Secondly, a pad sufficiently large to pull out the clavicle causes insufferable pressure in the axilla.5
Although well-applied figure-of-eight bandages
or
rings
can
make the patient feel more comfortable initially, it is not long before chafing and pressure cause more discomfort than the fracture. Moreover, frequent attendances of patients to have bandages or rings tightened and adjusted are inconvenient and waste time. Finally, the figure-of-eight bandages may be dangerous, because over-zealous application can cause severe swelling of the arm and harmful pressure on the neurovascular bundle.56** Three-quarters of patients with fractures of the clavicle are under twenty, and it has been suggested that treatment may be undertaken more for the satisfaction of the parent than for 1. Mullick, S. Lancet, 1967, i, 499. 2. Le Vay, D. ibid. p. 723. 3. Walker, D. ibid. p. 623. 4. Fowler, A. W. J. Bone Jt Surg. 1962, 44B, 440. 5. Nichol, E. A. ibid. 1954, 36B, 171. 6. Merryweather, R. Personal communication.
OF
MEMBRANE
CONCENTRATION
C1
POTENTIAL
ON
AND CALCULATED
POTASSIUM CONCENTRATION
INTRACELLULAR
E.C.F.,
CHLORIDE
AND INTRACELLULAR
[K]i
Studies referred to in this letter have been supported by grants from the Royal Society, the Dowager Countess Eleanor Peel Fund, the Endowment Fund of the Birmingham United Hospitals, and the Scientific Research Committee of the Royal Victoria Infirmary.
University, of Clinical Biochemistry, Royal Victoria Infirmary, Newcastle upon Tyne.
Department
Nutrition and Intestinal Unit, General Hospital, Birmingham.
C. T. G. FLEAR. IRENÉ FLORENCE
J. ALEXANDER WILLIAMS.
Calculated for: total
*
content of chloride in biopsy specimen 90 meq. per kg. dry weight and total water 3200 ml. per kg. dry weight values of Dr. Graham and his colleagues. Extracellular chloride concentration 109 meq./kg. water (serum-level corrected for Donnan equilibrium and amount of solids in serum which, for anions, summate rather than cancel). Total potassium content of biopsy taken as 310 meq. per kg. dry weight, and extracellular potassium concentration as 4 meq./kg. water. (Values for [C1]i and E.c.F. for membrane potentials -75 and z95 were transposed in table 1 of Dr. Graham and his colleagues.) Tissue with a membrane potential of -33 mV would contain more than 90 meq. chloride per kg. dry weight of tissue.
to the extent found for the biopsy specipatient (case 2), they apparently excluded potassium depletion by their failure to detect a lowered concentration of potassium in cellular fluids in the three samples of skeletal muscle analysed, which collectively cannot have con-
tissues were depleted men. In their second
tained much more than a millionth of the total mass of cells in her body. The validity of these assumptions must be tested in a wide range of clinical situations before inferences drawn from biopsies can be relied on with confidence. There is evidence in patients that skeletal muscle reflects change in body-potassium. But we need to know whether a low potassium-content in biopsy samples of muscle necessarily denotes depletion in tissues like the heart, the total potassium-content of which may be only a small part of total body-potassium, and whether depletion in other tissues (e.g., smooth muscle of the gut in a patient with paralytic ileus) can be excluded by failure to find lowering of potassium in samples from one skeletal muscle. From our experience we have come to the following conclusions : 1. For all tissues we have investigated (skeletal, smooth, and cardiac muscle, intestinal mucosa, brain, connective tissue) a sample does afford an index of the tissue sampled in control subjects and patients with severe cardiac or alimentary disease. (Some of this work was presented at the meeting of the Surgical Research Society held at Aberdeen on July 14 and 15, 1967.) 2. At any rate in patients with chronic heart-disease, with or without congestive heart-failure, a sample of one skeletal muscle (deltoid) affords an index of changes in another (gastrocnemius).88 3. A sample of skeletal muscle does not necessarily afford an index of all tissues. In patients in congestive heart-failure it affords an index of changes in myocardium, but not in brain tissue. Similarly, in the presence of severe intestinal obstruction, changes were noted in intestinal smooth muscle that were not present in samples of skeletal muscle.11
Even with full and error-free data for potassium concentration in cells in a biopsy specimen, estimates of body deficit would still be approximate in view of the need to assume: (a) that cells throughout the body have precisely the same composition as in the sample; (b) values for the patient’s total body-water and total E.C.F. (in order to derive the total volume of his cell fluid), or alternatively a value for his expected total body-potassium. We believe that we can obtain a no-less-approximate estimate of the state of body-potassium from the potassium-content of samples in the light of their sodium content,8 without attempting to obtain E.c.F. values. Comparison is made with suitable standards, which for definitive appraisal should be constructed from the same muscle.(We have elaborated standards for deltoid, gastrocnemius, and rectus abdominis.8) Appraisal is not simple, but we believe that it is possible to decide whether a sample is poor in potassium from depletion or from its having a relatively high proportion of extracellular chase. 8. Flear, C. T. G., Florence, I., Williams, J. A. Unpublished. 9. Flear, C. T. G., Carpenter, R. G., Florence, I. J. clin. Path. 18, 74.
1965,
PAIN AFTER HEAD INJURY SiR,-One of the tragedies entailed in increased specialisation
is the lack of communication between the various medical disciplines. To those in manipulative practice it seems fantastic that .LB1.r. Wilson, in his article last week (p. 1391), should assume that injuries to the head sufficient to cause skull fracture are not associated with cervical-joint injury. Every skull fracture must involve strain of the neck joints in juxtaposition to the emerging cervical nerve-roots. The basis of the assumption is the negative X-ray findings (which one would not expect to be positive much before the development of spondylosis in, say, five years’ time) coupled with a normal range of neck movement on gross testing. The latter can be discounted, since the range at the individual joint-complexes at each level were not tested. Pain, parxsthesia, and hyperalgesia were probably referred from the joints of the vertebral arch. In all probability the pain could have been relieved within a few weeks by the use of local hydrocortisone injections and cervical manipulation. London W.1. JOHN EBBETTS
TREATMENT OF FRACTURED CLAVICLE SIR,-Sir Selwyn Selwyn-Clarke’s clavicular ring splint (Dec. 23, p. 1364) is more comfortable, but why must we be reminded of a principle of treatment which was so effectively condemned in your journal only nine months ago?1 Le Vay later suggested that no form of treatment was of any value whatever.2 A corollary is that fractures of the clavicle will do well with any treatment which does no harm. This no doubt explains Walker’s " excellent results " with carefully applied figure-of-
eight bandages.3 I should like to renew my plea 4 for the abandonment of all types of figure-of-eight bandages and rings, because they are irrational, cause unnecessary discomfort, and can be dangerous. They are irrational because, contrary to oft-repeated statements,3 the outer fragment is usually displaced behind the inner fragment and the figure of eight aggravates this deformity. Moreover, the idea that a figure-of-eight helps by pulling out over-riding fragments should be discarded for two reasons. Firstly, over-riding should be left alone, because it encourages early union. Secondly, a pad sufficiently large to pull out the clavicle causes insufferable pressure in the axilla.5
Although well-applied figure-of-eight bandages
or
rings
can
make the patient feel more comfortable initially, it is not long before chafing and pressure cause more discomfort than the fracture. Moreover, frequent attendances of patients to have bandages or rings tightened and adjusted are inconvenient and waste time. Finally, the figure-of-eight bandages may be dangerous, because over-zealous application can cause severe swelling of the arm and harmful pressure on the neurovascular bundle.56** Three-quarters of patients with fractures of the clavicle are under twenty, and it has been suggested that treatment may be undertaken more for the satisfaction of the parent than for 1. Mullick, S. Lancet, 1967, i, 499. 2. Le Vay, D. ibid. p. 723. 3. Walker, D. ibid. p. 623. 4. Fowler, A. W. J. Bone Jt Surg. 1962, 44B, 440. 5. Nichol, E. A. ibid. 1954, 36B, 171. 6. Merryweather, R. Personal communication.