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PRECAUTIONS AGAINST SHOCK DURING ELECTROTHERAPY.
1211 of bulbar treated easyin the group but here too the results
tropics. Taking a census is not likely to be an job when the population to be enumerated gets it into its head that " England has suddenly become unbearably hot, Queen Victoria desires virgins from each village in the territory to fan her day and night, and the census provides the means of selecting individuals for this purpose." Yet it is less than 200 years ago that the taking of a census in this country was opposed in the House of Commons on the grounds that Jehovah did not approve of the numbering of the people. A beginning must be made sometime even if it be on only a very small scale. In fact Major Edge goes so far as to propose that the best line of approach may lie in small-scale intensive inquiries, gradually widening in extent as means become available and as the inhabitants become inured to the cross-examinations by officials and the processes of registration.
cases
‘
was
considerably
remarkable in view of the very high normal mortality. From the experience gained in the treatment of these cases, Wilson emphasises three important principles to be followed when the respirator is employed. It must be used as early as possible after the onset of the paralysis, and before the onset of cyanosis and dyspnoea. Delay often results in a sudden increase in symptoms and severe collapse, when transport to the apparatus may not be sufficiently rapid to Treatment must be prolonged. Exhaustion save life. of the affected muscles is apt to take place suddenly after premature removal from the respirator, although for short periods the respiratory function may appear to have recovered. It is also necessary to keep in mind the possible danger of tetany, but this is very unlikely to develop if care is taken to avoid overventilation of the lungs. It is clear from Wilson’s results that the Drinker-Shaw respirator represents a real advance in the treatment of what is, happily, a comparatively rare type of case. Death from of the muscles is paralysis respiratory perhaps more it of slow than since consists other, any distressing suffocation whilst full consciousness is retained almost to the end. Undoubtedly the most striking feature of treatment with the respirator is the intense relief afforded to the patient-relief so marked that he will often fall into deep and prolonged sleep after the first few breaths within the apparatus.
higher,
were
RESPIRATORY FAILURE IN ACUTE ANTERIOR POLIOMYELITIS. A DESCRIPTION of the Drinker-Shaw respirator, an apparatus designed for the prolonged administration of artificial respiration, and extensively used in America for the treatment of carbon monoxide poisoning, was given by Mr. Philip Drinker in our columns last year (1931, i., 1186). Dr. J. L. Wilson1 has now reviewed 90 cases at the Children’s Hospital, Boston, in which it was used in the treatment of respiratory failure due to anterior poliomyelitis. In this disease respiratory failure may come on in PRECAUTIONS AGAINST SHOCK DURING three different ways, which it is important (though often difficult) to distinguish clinically. There may ELECTROTHERAPY. be direct paralysis of the intercostal muscles and THE risk of serious electric shock is acknowledged distribution of the to be diaphragm due to "spinal" from currents, which are " disease ; while a bulbar type of case may show now greater usedalternating for the main supplies throughout increasingly either pharyngeal paralysis, causing interference with the country, than from direct currents. On industrial respiration from accumulations of secretion around the premises 30 fatalities due to shock from alternating glottis, or paralysis of the respiratory nerve-centres currents at between 200 and 250 volts have occurred in the medulla. The treatment and prognosis will the past five years, as compared with one due during be somewhat different in the three types. The object to direct currents of similar voltages. In a memorof artificial respiration will in each case, however, andum (Memo. 161 Med.) to county and county be to rest as far as possible paralysed muscles (in councils the Ministry of Health outline accordance with the orthopaedic principles applied in borough shock from electromedical the early treatment of the disease), to avoid exhaustion, precautions against attention to careful which should go apparatus, and to abolish cyanosis-since, apart from the far to minimise the risk of accident. It is obvious distress that cyanosis indicates, anoxaemia may that old and improperly insulated apparatus is in actually contribute to the destruction of nerve itself a grave source of danger. A recent fatality tissue. Where there is pharyngeal paralysis, suction was due to loose fastenings in the metal holders of a must be used for the removal of secretion from the radiant heat bath, the patient under treatment being glottis, and Wilson advocates the parenteral and electrocuted when he grasped the bedstead, which rectal administration of saline and carbohydrate It is essential was in contact with a hot-water pipe. until the paralysed muscles show some degree of when patients are receiving electrical treatment in recovery. In this way the stomach is kept empty, bed that the iron bedstead should not be in contact and the danger of vomiting and inhalation of fluidor water pipes, with any earthed metal-e.g., heating a frequent sequela of tube-feeding in these cases-is or even an earthed " wireless receiver. radiators, avoided. A tracheotomy may be necessary. Among Where apparatus not insulated from mains is in use, 23 cases of the " spinal " type treated in the respirator, is undesirable that patients undergoing treatment there were two deaths from pneumonia and one in the same room or ward should be (in an adult) secondary to infected bed-sores. While simultaneously reach of each other. The source of supply within no claim is made that the condition in all the remaining for heat treatment by electrothermal compresses 20 would, in the absence of artificial respiration, have should be at low voltage. Patients wearing proved fatal, the low mortality is very striking. wirelessalways headphones while undergoing electrical treatAlso, since the date of two of the fatalities, technical or handling electrical apparatus, should be ment, improvements have been made in the apparatus which protected by the insulation of the output circuit permit of frequent changes of position-an important to which the headphones are connected. Internal factor in preventing both bed-sores and pneumonia be fitted to the lamps and holders mesh should guards -and all necessary nursing procedures to be carried in radiant heat baths, and to projectors for light out without removal of the patient from the apparatus. In general the use of sets for generating As would be expected, the percentage mortality treatment. electricity (as galvanic, faradic, and sinusoidal currents) which are not isolated electrically from the source 1 New Eng. Jour. Med., April 28th, p. 887. "
"
it
1212 of main supply, is deprecated. In the safer method of construction known as " earth free," electric shock at mains pressure would be possible only if a breakdown of insulation between the two systems occurred, and in good-class apparatus there seems to be no great risk of this occurring. For medical diathermy treatment the apparatus favoured is that which makes provision for the patient’s circuit to be isolated electrically from the intermediate (or spark gap) circuit ; the spark gap to be mounted inside the cabinet or enclosure containing the apparatus; the door of the cabinet or enclosure to be interlocked with the source of main supply so that the latter is disconnected when the door is opened. Regular and systematic inspection by competent experts should be made of all electromedical apparatus to ensure the maintenance of efficient insulation.
THE
BRITISH
LEGION VILLAGE.
IN April, 1925, when the British Legion took over the activities at Preston Hall, there were some 27 settlers -tuberculous ex-Service men-left by its predecessors, the Industrial Settlements Incorporated. At the end of September, 1931, there were 230 patients in the sanatorium, 555 in the Settlement, and a staff of 44. The institution, therefore, well deserves the title of " village." When a patient has been discharged from the sanatorium he lives in the hostel, if single, and in a house in the village with his wife and family if married. He is given the medical attention, sheltered employment, hygienic conditions, and social environment that he needs. He is on the panel of the medical director, and therefore eligible for all benefits under the National Health Insurance Acts, and his children attend the child welfare centre in the village. His dependents have the benefit of routine medical examination and are, on the whole, extraordinarily healthy. Not a single child has developed pulmonary tuberculosis, and among the 58 births which have taken place there has not been a single case of tuberculous meningitis. Dr. J. B. McDougall, the medical director, ascribes these happy results to the social environment ; the freedom from worry and the relatively high standard of living. There is urgent need for more room for settlers, and the council feels that the local authorities, which have hitherto contributed nothing, should take. their share in further expansion. The industries include the manufacture of portable buildings and travelling
goods, a wood-graining department, a printing department, a live-stock department, and a village store. In the year ending Sept. 30th, 1931, the industries spent 30,368 ; paid 18,084 in salaries,
NARROW SPECIALISATION.
THE alternative educational
of
our
system,
characteristic
public schools, which involves choice at
an
early age between the humanities and science, marks The distinction between the a transitional period. classical and modern side of a school is already less rigid than it was, and there is much overlapping. Most educational authorities are in fact agreed that anyhow up to the age of 16 specialisation should be discouraged. Unfortunately, however, as Sir Walter Fletcher pointed out in the course of an address to the Royal Institution last Friday, narrow specialisation after that age, and indeed throughout the undergraduate’s career, has been pushed to excess. It is possible, and even usual, for students of physics and chemistry to proceed through school life and to a university degree without ever being made aware of the relevance of their work to matter endowed The system under which university -with life. scholarships are allocated naturally influences the teaching in the higher forms of schools, and encourages concentration on physics and chemistry to the exclusion of biology. In a leading article in Nature last week W. H. G. deplores the spoon-feeding of ordinary students to enable them to gain honours degrees, since this policy favours " the present highly specialised school science teaching with its shocking neglect of biological science." Sir Walter Fletcher has peculiar opportunities for watching the subsequent development of the raw material from which students of science are made, and his comments merit close attention. It is wholly wrong, he contends, that the acquisition of manipulative and analytical skill should be associated chiefly with inanimate matter, when it is so urgently neecled for the service of biochemistry and biophysics. It is to this absence of a broad basis of training that Sir Walter attributes the fact that organic chemists have been less active in promoting the growth of biochemistry than have physiologists. His plea for the encouragement of the more general study of living matter was the more effective since it followed a masterly survey of recent history in medical He showed how the varied fields now research. being explored call at every point for the intensive application of physics and chemistry, and illustrated by apt examples the absurdity of allowing artificial boundaries to separate the different sciences on which progress in medicine must depend. WE regret to announce the death on May 30th of Dr. Remington Hobbs, medical superintendent of St. Mary Abbot’s Hospital, and consulting gynoecologist to the borough of Kensington.
wages, and commissions; and received from sales 54,571. The prosperity of the industries in the face of world-wide depression has been remarkable, and most of the departments are self-supporting. The appliance department has carried out work THE executive committee of the British Social for a number of county, urban and rural district councils, and the high standard of the printing Hygiene Council announce that, after further condepartment, which sells 9000 worth of print per sultation with representatives of the British Medical annum, is manifest in the format of the annual report. Association, they have decided to abandon their During the year, 351 patients were admitted to and proposal to approve the opening by their secretary297 were discharged from the sanatorium section. general of an economically self-supporting personal Besides the necessary clinical work, in which problems bureau, under the auspices of the Council, artificial pneumothorax plays a large part, some as to do this might be held to render it impossible research on the cellular content of tuberculous for the British Medical Association to continue to blood has been undertaken. At the request The work includes a be represented on the Council. valuable after-care department, which sees that of the committee Mrs. Neville Rolfe has agreed ex-patients get a fair chance in their struggle in the circumstances not to proceed with this with life. project.
tropics. Taking a census is not likely to be an job when the population to be enumerated gets it into its head that " England has suddenly become unbearably hot, Queen Victoria desires virgins from each village in the territory to fan her day and night, and the census provides the means of selecting individuals for this purpose." Yet it is less than 200 years ago that the taking of a census in this country was opposed in the House of Commons on the grounds that Jehovah did not approve of the numbering of the people. A beginning must be made sometime even if it be on only a very small scale. In fact Major Edge goes so far as to propose that the best line of approach may lie in small-scale intensive inquiries, gradually widening in extent as means become available and as the inhabitants become inured to the cross-examinations by officials and the processes of registration.
cases
‘
was
considerably
remarkable in view of the very high normal mortality. From the experience gained in the treatment of these cases, Wilson emphasises three important principles to be followed when the respirator is employed. It must be used as early as possible after the onset of the paralysis, and before the onset of cyanosis and dyspnoea. Delay often results in a sudden increase in symptoms and severe collapse, when transport to the apparatus may not be sufficiently rapid to Treatment must be prolonged. Exhaustion save life. of the affected muscles is apt to take place suddenly after premature removal from the respirator, although for short periods the respiratory function may appear to have recovered. It is also necessary to keep in mind the possible danger of tetany, but this is very unlikely to develop if care is taken to avoid overventilation of the lungs. It is clear from Wilson’s results that the Drinker-Shaw respirator represents a real advance in the treatment of what is, happily, a comparatively rare type of case. Death from of the muscles is paralysis respiratory perhaps more it of slow than since consists other, any distressing suffocation whilst full consciousness is retained almost to the end. Undoubtedly the most striking feature of treatment with the respirator is the intense relief afforded to the patient-relief so marked that he will often fall into deep and prolonged sleep after the first few breaths within the apparatus.
higher,
were
RESPIRATORY FAILURE IN ACUTE ANTERIOR POLIOMYELITIS. A DESCRIPTION of the Drinker-Shaw respirator, an apparatus designed for the prolonged administration of artificial respiration, and extensively used in America for the treatment of carbon monoxide poisoning, was given by Mr. Philip Drinker in our columns last year (1931, i., 1186). Dr. J. L. Wilson1 has now reviewed 90 cases at the Children’s Hospital, Boston, in which it was used in the treatment of respiratory failure due to anterior poliomyelitis. In this disease respiratory failure may come on in PRECAUTIONS AGAINST SHOCK DURING three different ways, which it is important (though often difficult) to distinguish clinically. There may ELECTROTHERAPY. be direct paralysis of the intercostal muscles and THE risk of serious electric shock is acknowledged distribution of the to be diaphragm due to "spinal" from currents, which are " disease ; while a bulbar type of case may show now greater usedalternating for the main supplies throughout increasingly either pharyngeal paralysis, causing interference with the country, than from direct currents. On industrial respiration from accumulations of secretion around the premises 30 fatalities due to shock from alternating glottis, or paralysis of the respiratory nerve-centres currents at between 200 and 250 volts have occurred in the medulla. The treatment and prognosis will the past five years, as compared with one due during be somewhat different in the three types. The object to direct currents of similar voltages. In a memorof artificial respiration will in each case, however, andum (Memo. 161 Med.) to county and county be to rest as far as possible paralysed muscles (in councils the Ministry of Health outline accordance with the orthopaedic principles applied in borough shock from electromedical the early treatment of the disease), to avoid exhaustion, precautions against attention to careful which should go apparatus, and to abolish cyanosis-since, apart from the far to minimise the risk of accident. It is obvious distress that cyanosis indicates, anoxaemia may that old and improperly insulated apparatus is in actually contribute to the destruction of nerve itself a grave source of danger. A recent fatality tissue. Where there is pharyngeal paralysis, suction was due to loose fastenings in the metal holders of a must be used for the removal of secretion from the radiant heat bath, the patient under treatment being glottis, and Wilson advocates the parenteral and electrocuted when he grasped the bedstead, which rectal administration of saline and carbohydrate It is essential was in contact with a hot-water pipe. until the paralysed muscles show some degree of when patients are receiving electrical treatment in recovery. In this way the stomach is kept empty, bed that the iron bedstead should not be in contact and the danger of vomiting and inhalation of fluidor water pipes, with any earthed metal-e.g., heating a frequent sequela of tube-feeding in these cases-is or even an earthed " wireless receiver. radiators, avoided. A tracheotomy may be necessary. Among Where apparatus not insulated from mains is in use, 23 cases of the " spinal " type treated in the respirator, is undesirable that patients undergoing treatment there were two deaths from pneumonia and one in the same room or ward should be (in an adult) secondary to infected bed-sores. While simultaneously reach of each other. The source of supply within no claim is made that the condition in all the remaining for heat treatment by electrothermal compresses 20 would, in the absence of artificial respiration, have should be at low voltage. Patients wearing proved fatal, the low mortality is very striking. wirelessalways headphones while undergoing electrical treatAlso, since the date of two of the fatalities, technical or handling electrical apparatus, should be ment, improvements have been made in the apparatus which protected by the insulation of the output circuit permit of frequent changes of position-an important to which the headphones are connected. Internal factor in preventing both bed-sores and pneumonia be fitted to the lamps and holders mesh should guards -and all necessary nursing procedures to be carried in radiant heat baths, and to projectors for light out without removal of the patient from the apparatus. In general the use of sets for generating As would be expected, the percentage mortality treatment. electricity (as galvanic, faradic, and sinusoidal currents) which are not isolated electrically from the source 1 New Eng. Jour. Med., April 28th, p. 887. "
"
it
1212 of main supply, is deprecated. In the safer method of construction known as " earth free," electric shock at mains pressure would be possible only if a breakdown of insulation between the two systems occurred, and in good-class apparatus there seems to be no great risk of this occurring. For medical diathermy treatment the apparatus favoured is that which makes provision for the patient’s circuit to be isolated electrically from the intermediate (or spark gap) circuit ; the spark gap to be mounted inside the cabinet or enclosure containing the apparatus; the door of the cabinet or enclosure to be interlocked with the source of main supply so that the latter is disconnected when the door is opened. Regular and systematic inspection by competent experts should be made of all electromedical apparatus to ensure the maintenance of efficient insulation.
THE
BRITISH
LEGION VILLAGE.
IN April, 1925, when the British Legion took over the activities at Preston Hall, there were some 27 settlers -tuberculous ex-Service men-left by its predecessors, the Industrial Settlements Incorporated. At the end of September, 1931, there were 230 patients in the sanatorium, 555 in the Settlement, and a staff of 44. The institution, therefore, well deserves the title of " village." When a patient has been discharged from the sanatorium he lives in the hostel, if single, and in a house in the village with his wife and family if married. He is given the medical attention, sheltered employment, hygienic conditions, and social environment that he needs. He is on the panel of the medical director, and therefore eligible for all benefits under the National Health Insurance Acts, and his children attend the child welfare centre in the village. His dependents have the benefit of routine medical examination and are, on the whole, extraordinarily healthy. Not a single child has developed pulmonary tuberculosis, and among the 58 births which have taken place there has not been a single case of tuberculous meningitis. Dr. J. B. McDougall, the medical director, ascribes these happy results to the social environment ; the freedom from worry and the relatively high standard of living. There is urgent need for more room for settlers, and the council feels that the local authorities, which have hitherto contributed nothing, should take. their share in further expansion. The industries include the manufacture of portable buildings and travelling
goods, a wood-graining department, a printing department, a live-stock department, and a village store. In the year ending Sept. 30th, 1931, the industries spent 30,368 ; paid 18,084 in salaries,
NARROW SPECIALISATION.
THE alternative educational
of
our
system,
characteristic
public schools, which involves choice at
an
early age between the humanities and science, marks The distinction between the a transitional period. classical and modern side of a school is already less rigid than it was, and there is much overlapping. Most educational authorities are in fact agreed that anyhow up to the age of 16 specialisation should be discouraged. Unfortunately, however, as Sir Walter Fletcher pointed out in the course of an address to the Royal Institution last Friday, narrow specialisation after that age, and indeed throughout the undergraduate’s career, has been pushed to excess. It is possible, and even usual, for students of physics and chemistry to proceed through school life and to a university degree without ever being made aware of the relevance of their work to matter endowed The system under which university -with life. scholarships are allocated naturally influences the teaching in the higher forms of schools, and encourages concentration on physics and chemistry to the exclusion of biology. In a leading article in Nature last week W. H. G. deplores the spoon-feeding of ordinary students to enable them to gain honours degrees, since this policy favours " the present highly specialised school science teaching with its shocking neglect of biological science." Sir Walter Fletcher has peculiar opportunities for watching the subsequent development of the raw material from which students of science are made, and his comments merit close attention. It is wholly wrong, he contends, that the acquisition of manipulative and analytical skill should be associated chiefly with inanimate matter, when it is so urgently neecled for the service of biochemistry and biophysics. It is to this absence of a broad basis of training that Sir Walter attributes the fact that organic chemists have been less active in promoting the growth of biochemistry than have physiologists. His plea for the encouragement of the more general study of living matter was the more effective since it followed a masterly survey of recent history in medical He showed how the varied fields now research. being explored call at every point for the intensive application of physics and chemistry, and illustrated by apt examples the absurdity of allowing artificial boundaries to separate the different sciences on which progress in medicine must depend. WE regret to announce the death on May 30th of Dr. Remington Hobbs, medical superintendent of St. Mary Abbot’s Hospital, and consulting gynoecologist to the borough of Kensington.
wages, and commissions; and received from sales 54,571. The prosperity of the industries in the face of world-wide depression has been remarkable, and most of the departments are self-supporting. The appliance department has carried out work THE executive committee of the British Social for a number of county, urban and rural district councils, and the high standard of the printing Hygiene Council announce that, after further condepartment, which sells 9000 worth of print per sultation with representatives of the British Medical annum, is manifest in the format of the annual report. Association, they have decided to abandon their During the year, 351 patients were admitted to and proposal to approve the opening by their secretary297 were discharged from the sanatorium section. general of an economically self-supporting personal Besides the necessary clinical work, in which problems bureau, under the auspices of the Council, artificial pneumothorax plays a large part, some as to do this might be held to render it impossible research on the cellular content of tuberculous for the British Medical Association to continue to blood has been undertaken. At the request The work includes a be represented on the Council. valuable after-care department, which sees that of the committee Mrs. Neville Rolfe has agreed ex-patients get a fair chance in their struggle in the circumstances not to proceed with this with life. project.