- Email: [email protected]
Accidents on the Road
990
The Cornell University team have now published some of their findings, based on a painstaking analysis of are this would seem orchidopexy accepted-and many thousand accidents.23 Over 2000 accidents were to the testes reasonable-possible damage by surgery investigated with the specific object of determining make the and the paediatrician may physician disinclined those features of car design that are most commonly to suggest orchidopexy at an early age. Many workers responsible for injury. The list is headed by the favour orchidopexy at a later age ; some would advise steering wheel and column, which were incriminated it at the age of eight to ten years,133 others when in 29% of all injuries. Ejection took second place ; but it was second to none in the severe-to-fatal puberty is established.44 As a prelude to surgery, most workers advise injury group. Other important items included the hormonal treatment.1-3 i4 18 In some cases this therapy instrument panel, the windshield, the backrest of alone leads to descent of the testes, and operation is the front seat (especially its top portion), and the door thereby avoided. With such treatment the testes are frames. It is gratifying to learn that several manuexposed to a stimulus comparable to that which they facturers have already modified designs to reduce the injury potential of these structures. This has would normally have received later at puberty, and it seems reasonable to conclude that the testes which provided the Cornell University team with an oppordescend would have descended at puberty. Hormonal’ tunity to test their findings by controlled statistical treatment, like orchidopexy, is not universally methods. The relevant data of 2750 car accidents, approved. WILKINS4 believes that such therapy may sustained over the past fifteen years, were carefully itself damage the testes,19 and states that he has seen analysed : in 200 the cars involved were of the latest a " number of young men " who had been treated for (1956) model and incorporated safety-locks, seatand other modifications designed to reduce the with chorionic belts, gonadotrophin cryptorchidism by risk of found to have who were later success but ejection. It was found that there was a 10-15% apparent Klinefelter’s syndrome of hyalinisation of the seminifodrop in the incidence of doors opening in both rollthat the incidence of over and other accidents ; rous tubules. It may be possible to avoid this danger was decreased by 6% (actually halving the by short, intensive courses of chorionic gonadotrophin. ejection ROBINSON and ENGLE 15 administer 4000 units daily number of people ejected) ; and that dangerous-tofatal injuries were reduced by 3%. Added weight to a total dosage of 12,000 units. HAND3 recommends is given to these figures by earlier studies of MOORE 4000 units thrice weekly to a total dosage of 40,000 units. SPENCE and SCOWEN 18 recommend doses of et al., 24 who found no difference when cars manufactured in 1944-49 and 1950-54 were similarly 500 units-a recommendation supported by BISHOP,1 who, in 139 cases, administered an average total dosage compared. To test further the effectiveness of safetyof 10,000 units. In cases where the testes can be belts the data of rural accidents, in which 300 cars palpated, hormonal therapy before puberty is likely with and 4000 cars without belts had been involved, were subjected to rigorous examination. 81 cars to succeed. in each group were suitable for comparative analysis. Thus no absolute rules can be laid down for the treatIn the control group (no safety-belts) some degree of ment of bilateral undescended testes. Those who prefer to postpone operation until the age of eight to ten injury had been sustained by 75% of the occupants, this with a short intensive course of against 30% in the experimental group (cars with years, preceding can be gonadotrophin therapy, reasonably certain, belts). Severe-to-fatal injuries were suffered by 4% of occupants in the control group, by only 1% in with expert surgery, of not doing their patients harm. But those who choose to postpone surgical treatment the experimental group. The findings at Cornell University leave no doubt till puberty cannot be accused of neglecting their patients’ interests. Whenever surgical treatment is that epidemiological and statistical methods can undertaken, a biopsy examination of both testes usefully be applied to the study of road casualties; that prophylaxis can help greatly to reduce their should be made. If all cases, however treated, are careboth the followed examination of semen number ; and that collaboration between engineers, by fully up, after puberty and by seeking evidence of fertility after manufacturers, and doctors can make prophylaxis marriage, we shall not only gain valuable guidance on especially effective. Whether such a concerted effort can offset the growing density, speed, and power treatment but also learn what proportion of undescended testes are the seat of irreversible genetic or of motorised traffic remains to be seen ; it seems likely environmental change, and how many are damaged by that for many years to come road accidents will continue to increase in frequency and severity. surgical or hormonal treatment. If manufacturers, designers, and the car-buying public are now beginning to heed medical advice Accidents on the Road on how to prevent accidents, doctors must turn IN many little ways, as Mme. DU DEFFAND observed, with renewed interest to their actual management. men differ from sheep ; but the urge to exist and There are, broadly speaking, three ways in which migrate in crowds is not one of them. Hence one of progress can be made. The first is by teaching the most acute social, economic, engineering, and and propaganda. The fundamental principles of medical problems of our age-road traffic. We with the severely injured cannot be too widely dealing have lately referred 20 to attempts in the United States disseminated ; in first-aid treatment of road accidents to study traffic accidents by epidemiological methods. 2122 every passer-by becomes a member of the " greater
puberty,
5
were
Even if these
married, and, of these, 4 had children. sanguine reports of the success of
more
18. Spence, A. W., Soowen, E. F. Lancet, 1938, ii, 983. 19. See Maddock, W. W., Nelson, W. O. J. clin. Endocrin. 985. 20. Lancet, Sept. 28, 1957, p. 627. 21. McFarland, R. A., Moore, R. C. New Engl. J. Med. 1957, 22. Braunstein, P. W. J. Amer. med. Ass. 1957, 163, 249.
1952, 12, 256, 792.
23.
Braunstein, P. W., Moore, J. O., Wade, P. A. Surg. Gynec. Obstet. 1957, 105, 257. 24. Moore, J. O., Tourin, B., Garrett, J. W. A. Study of Crash Injuries Patterns as Related to Two Periods of Vehicular Design. Department of Public Health and Preventive Medicine, Cornell University Medical College, 1955.
991
profession." organisation: as Mr. medical
The second task is LOWDEN wrote last
one
of
year,25 country-
efficient accident service, organised on a wide basis, is essential if the public is to receive the full benefit of new theoretical knowledge and practical skill. If much, or at least some, progress has been made along these two fronts, all is singularly quiet on the third. Many victims of road accidents still die between the time of the accident and their arrival in hospital ; some arrive moribund ; a few, to the despair of the surgeon, arrive desperately in need of, but unfit for, operative treatment. This is no criticism of the ambulance service, which on the whole works admirably. The fact is that war experience sometimes befogs our vision. Under front-line conditions rapid staged evacuation of the wounded is the secret of success ; so essential is it that the question of whether it is medically desirable hardly arises In peace-time there are cases-for example, of suspected intracranial haemorrhage—where immediate transportation, however great the risks, offers the best chance of survival. Yet there is no doubt that lives could be saved if removal to hospital was sometimes delayed long enough" an
25.
Lowden, T. G. Lancet, 1956, i, 955, 1006, 1060.
Annotations MUSCLE FUNCTION AND POTASSIUM A RELATIONSHIP between the function of cardiac muscle and the potassium content of its perfusing fluid was demonstrated experimentally by Ringer 1; and the clinical relevance of a similar relationship in skeletal muscle was shown by Aitken et at. 2in a patient with familial periodic paralysis. Later work has brought out some of the complexities in the relation of muscle function to potassium metabolism : not only may low levels of plasma-potassium be accompanied by no muscle weakness, but also paralysis, as well as the more usual paraesthesiae, may be associated with hyperkalaemia.455 The potassium levels accompanying hyperkalaemic paralysis have usually been very high-upwards of 8 mEq. per litre-and it has been suggestedlargely because of the association with paraesthesise, that this type of paralysis may represent a neuropathy rather than a primary affection of muscle. It is therefore uncertain how far sporadic hyperkalemic paralysis is condition of " adynamia analogous to the interesting " episodica hereditaria reported in two Swedish families."6 In this syndrome, spontaneous paralysis is associated with a relatively small increase in the plasma-potassium ; attacks may follow exertion, and in one such attack there was striking muscle weakness at a serum-potassium level of only 6-8 mEq. per litre. Attacks have also been precipitated by quite small amounts (4 g. or less) of potassium chloride ; electromyography showed a change in pattern " suggesting loss of active muscle fibres." The urinary potassium usually increased ; so there was evidence of loss of potassium from cells, though not necessarily from the muscle-cells involved. The attack could be controlled by giving calcium intravenously. The common discrepancies between plasma-potassium level and muscle-power have naturally focused attention on the intracellular potassium and also on change in the 1. Ringer, S. J. Physiol. 1883, 4, 29. 2. Aitken, R. S., Allott, E. N., Castleden, L. I. M., Walker, M. Clin. Sci. 1937, 3, 47. 3. Allott, E. N., McArdle, B. ibid, 1938, 3, 229. 4. Finch, C. A., Sawyer, C. G., Flynn, J. M. Amer. J. Med. 1946, 1, 337. 5. Bull, G. M., Carter, A. B., Lowe, K. G. Lancet, 1953, ii, 60. 6. Gamstorp, I., Hauge, M., Helweg-Larsen, H. F., Mjones, H., Sagild, U. Amer. J. Med. 1957, 23, 385.
to allow
an
intravenous infusion to be set up
on
the
spot. This would require the supply to ambulances of infusion apparatus and fluids and the attendance at serious and remote accidents of a doctor capable of judging when to wait for resuscitation and when to But move the injured at once-a skilled decision. there is no real reason why such provisions should not be part of an adequately staffed accident service ; and the case is particularly strong in areas where casualties may have to be taken many miles to hospital. Resuscitation can be given on wheels, in the front-garden of a suburban house or in the backyard of a farm, as effectively as in hospital. It would clearly be unsound, however, to divert a large number of hospital staff to such "roadside " resuscitation duties, for many of the accidents could be dealt with perfectly well under existing arrangements. But when first reports suggest serious injuries and when there is a long way to go, a resuscitation team might be dispatched with the ambulance. Often enough its services would not be vital; but it would from time to time undoubtedly save life, and it would do away with the unhappy picture of an ambulance car trundling over bumpy country lanes, with a shocked patient hopelessly enclosed in it. distribution of other ions, particularly sodium.7 Many of the factors influencing the intracellular potassium content have been defined by observations on animal muscle, often in vitro 8; but it is difficult to combine such observations with assessment of muscle function. Although the human forearm, by comparison with the excised frog gastrocnemius, is,less patient of quantitative study of potassium shifts, it is also less remote from the clinical situation; and the studies of Grob et al.,9 comparing arteriovenous potassium differences and musclefunction, form an important contribution to this vexing problem. Most of their findings, not surprisingly, were predictable from the experience with isolated muscle. For example, muscle contraction and the intra-arterial injection of acetylcholine were associated with release of potassium from the forearm ; while oral administration of potassium chloride and arterial administration of adrenaline were followed by uptake of potassium, and in the resting state there was a small uptake of potassium by the forearm. While oral glucose by itself was associated with uptake of potassium, when oral glucose was followed by arterial injection of insulin there was discharge of potassium from the forearm on that side. Grob et al. suggest that when insulin is added to glucose the further lowering of plasma-potassium, by increaseduptake in the liver, increases the efflux of potassium from musclecells by increasmg the concentration gradient between intracellular and extracellular fluid. The uptake of potassium into the forearm after oral glucose could also be prevented by giving cortisone orally, or hydrocortisone Muscle function was hemisuccinate intra-arterially. studied in the same experiments by recording actionpotentials and isometric tension during percutaneous ulnar-nerve stimulation ; and the effect of acetylcholine and neostigmine given intra-arterially was observed, with It was found that in intermittent nerve stimulation. those situations where the ratio of intracellular to extracellular potassium had probably decreased, there was increased muscle contractility and readier depolarisation by acetylcholine ; these changes are ascribed to a fall in resting membrane-potential. Conversely, in situations where the ratio of intracellular to extracellular potassium 7. See Lancet, 1957, i, 824. 8. Fenn, W. O. Physiol. Rev. 1940, 20, 377. 9. Grob, D., Liljestrand, A., Johns, R. J. 23, 340.
Amer.
J. Med.
1957,
The Cornell University team have now published some of their findings, based on a painstaking analysis of are this would seem orchidopexy accepted-and many thousand accidents.23 Over 2000 accidents were to the testes reasonable-possible damage by surgery investigated with the specific object of determining make the and the paediatrician may physician disinclined those features of car design that are most commonly to suggest orchidopexy at an early age. Many workers responsible for injury. The list is headed by the favour orchidopexy at a later age ; some would advise steering wheel and column, which were incriminated it at the age of eight to ten years,133 others when in 29% of all injuries. Ejection took second place ; but it was second to none in the severe-to-fatal puberty is established.44 As a prelude to surgery, most workers advise injury group. Other important items included the hormonal treatment.1-3 i4 18 In some cases this therapy instrument panel, the windshield, the backrest of alone leads to descent of the testes, and operation is the front seat (especially its top portion), and the door thereby avoided. With such treatment the testes are frames. It is gratifying to learn that several manuexposed to a stimulus comparable to that which they facturers have already modified designs to reduce the injury potential of these structures. This has would normally have received later at puberty, and it seems reasonable to conclude that the testes which provided the Cornell University team with an oppordescend would have descended at puberty. Hormonal’ tunity to test their findings by controlled statistical treatment, like orchidopexy, is not universally methods. The relevant data of 2750 car accidents, approved. WILKINS4 believes that such therapy may sustained over the past fifteen years, were carefully itself damage the testes,19 and states that he has seen analysed : in 200 the cars involved were of the latest a " number of young men " who had been treated for (1956) model and incorporated safety-locks, seatand other modifications designed to reduce the with chorionic belts, gonadotrophin cryptorchidism by risk of found to have who were later success but ejection. It was found that there was a 10-15% apparent Klinefelter’s syndrome of hyalinisation of the seminifodrop in the incidence of doors opening in both rollthat the incidence of over and other accidents ; rous tubules. It may be possible to avoid this danger was decreased by 6% (actually halving the by short, intensive courses of chorionic gonadotrophin. ejection ROBINSON and ENGLE 15 administer 4000 units daily number of people ejected) ; and that dangerous-tofatal injuries were reduced by 3%. Added weight to a total dosage of 12,000 units. HAND3 recommends is given to these figures by earlier studies of MOORE 4000 units thrice weekly to a total dosage of 40,000 units. SPENCE and SCOWEN 18 recommend doses of et al., 24 who found no difference when cars manufactured in 1944-49 and 1950-54 were similarly 500 units-a recommendation supported by BISHOP,1 who, in 139 cases, administered an average total dosage compared. To test further the effectiveness of safetyof 10,000 units. In cases where the testes can be belts the data of rural accidents, in which 300 cars palpated, hormonal therapy before puberty is likely with and 4000 cars without belts had been involved, were subjected to rigorous examination. 81 cars to succeed. in each group were suitable for comparative analysis. Thus no absolute rules can be laid down for the treatIn the control group (no safety-belts) some degree of ment of bilateral undescended testes. Those who prefer to postpone operation until the age of eight to ten injury had been sustained by 75% of the occupants, this with a short intensive course of against 30% in the experimental group (cars with years, preceding can be gonadotrophin therapy, reasonably certain, belts). Severe-to-fatal injuries were suffered by 4% of occupants in the control group, by only 1% in with expert surgery, of not doing their patients harm. But those who choose to postpone surgical treatment the experimental group. The findings at Cornell University leave no doubt till puberty cannot be accused of neglecting their patients’ interests. Whenever surgical treatment is that epidemiological and statistical methods can undertaken, a biopsy examination of both testes usefully be applied to the study of road casualties; that prophylaxis can help greatly to reduce their should be made. If all cases, however treated, are careboth the followed examination of semen number ; and that collaboration between engineers, by fully up, after puberty and by seeking evidence of fertility after manufacturers, and doctors can make prophylaxis marriage, we shall not only gain valuable guidance on especially effective. Whether such a concerted effort can offset the growing density, speed, and power treatment but also learn what proportion of undescended testes are the seat of irreversible genetic or of motorised traffic remains to be seen ; it seems likely environmental change, and how many are damaged by that for many years to come road accidents will continue to increase in frequency and severity. surgical or hormonal treatment. If manufacturers, designers, and the car-buying public are now beginning to heed medical advice Accidents on the Road on how to prevent accidents, doctors must turn IN many little ways, as Mme. DU DEFFAND observed, with renewed interest to their actual management. men differ from sheep ; but the urge to exist and There are, broadly speaking, three ways in which migrate in crowds is not one of them. Hence one of progress can be made. The first is by teaching the most acute social, economic, engineering, and and propaganda. The fundamental principles of medical problems of our age-road traffic. We with the severely injured cannot be too widely dealing have lately referred 20 to attempts in the United States disseminated ; in first-aid treatment of road accidents to study traffic accidents by epidemiological methods. 2122 every passer-by becomes a member of the " greater
puberty,
5
were
Even if these
married, and, of these, 4 had children. sanguine reports of the success of
more
18. Spence, A. W., Soowen, E. F. Lancet, 1938, ii, 983. 19. See Maddock, W. W., Nelson, W. O. J. clin. Endocrin. 985. 20. Lancet, Sept. 28, 1957, p. 627. 21. McFarland, R. A., Moore, R. C. New Engl. J. Med. 1957, 22. Braunstein, P. W. J. Amer. med. Ass. 1957, 163, 249.
1952, 12, 256, 792.
23.
Braunstein, P. W., Moore, J. O., Wade, P. A. Surg. Gynec. Obstet. 1957, 105, 257. 24. Moore, J. O., Tourin, B., Garrett, J. W. A. Study of Crash Injuries Patterns as Related to Two Periods of Vehicular Design. Department of Public Health and Preventive Medicine, Cornell University Medical College, 1955.
991
profession." organisation: as Mr. medical
The second task is LOWDEN wrote last
one
of
year,25 country-
efficient accident service, organised on a wide basis, is essential if the public is to receive the full benefit of new theoretical knowledge and practical skill. If much, or at least some, progress has been made along these two fronts, all is singularly quiet on the third. Many victims of road accidents still die between the time of the accident and their arrival in hospital ; some arrive moribund ; a few, to the despair of the surgeon, arrive desperately in need of, but unfit for, operative treatment. This is no criticism of the ambulance service, which on the whole works admirably. The fact is that war experience sometimes befogs our vision. Under front-line conditions rapid staged evacuation of the wounded is the secret of success ; so essential is it that the question of whether it is medically desirable hardly arises In peace-time there are cases-for example, of suspected intracranial haemorrhage—where immediate transportation, however great the risks, offers the best chance of survival. Yet there is no doubt that lives could be saved if removal to hospital was sometimes delayed long enough" an
25.
Lowden, T. G. Lancet, 1956, i, 955, 1006, 1060.
Annotations MUSCLE FUNCTION AND POTASSIUM A RELATIONSHIP between the function of cardiac muscle and the potassium content of its perfusing fluid was demonstrated experimentally by Ringer 1; and the clinical relevance of a similar relationship in skeletal muscle was shown by Aitken et at. 2in a patient with familial periodic paralysis. Later work has brought out some of the complexities in the relation of muscle function to potassium metabolism : not only may low levels of plasma-potassium be accompanied by no muscle weakness, but also paralysis, as well as the more usual paraesthesiae, may be associated with hyperkalaemia.455 The potassium levels accompanying hyperkalaemic paralysis have usually been very high-upwards of 8 mEq. per litre-and it has been suggestedlargely because of the association with paraesthesise, that this type of paralysis may represent a neuropathy rather than a primary affection of muscle. It is therefore uncertain how far sporadic hyperkalemic paralysis is condition of " adynamia analogous to the interesting " episodica hereditaria reported in two Swedish families."6 In this syndrome, spontaneous paralysis is associated with a relatively small increase in the plasma-potassium ; attacks may follow exertion, and in one such attack there was striking muscle weakness at a serum-potassium level of only 6-8 mEq. per litre. Attacks have also been precipitated by quite small amounts (4 g. or less) of potassium chloride ; electromyography showed a change in pattern " suggesting loss of active muscle fibres." The urinary potassium usually increased ; so there was evidence of loss of potassium from cells, though not necessarily from the muscle-cells involved. The attack could be controlled by giving calcium intravenously. The common discrepancies between plasma-potassium level and muscle-power have naturally focused attention on the intracellular potassium and also on change in the 1. Ringer, S. J. Physiol. 1883, 4, 29. 2. Aitken, R. S., Allott, E. N., Castleden, L. I. M., Walker, M. Clin. Sci. 1937, 3, 47. 3. Allott, E. N., McArdle, B. ibid, 1938, 3, 229. 4. Finch, C. A., Sawyer, C. G., Flynn, J. M. Amer. J. Med. 1946, 1, 337. 5. Bull, G. M., Carter, A. B., Lowe, K. G. Lancet, 1953, ii, 60. 6. Gamstorp, I., Hauge, M., Helweg-Larsen, H. F., Mjones, H., Sagild, U. Amer. J. Med. 1957, 23, 385.
to allow
an
intravenous infusion to be set up
on
the
spot. This would require the supply to ambulances of infusion apparatus and fluids and the attendance at serious and remote accidents of a doctor capable of judging when to wait for resuscitation and when to But move the injured at once-a skilled decision. there is no real reason why such provisions should not be part of an adequately staffed accident service ; and the case is particularly strong in areas where casualties may have to be taken many miles to hospital. Resuscitation can be given on wheels, in the front-garden of a suburban house or in the backyard of a farm, as effectively as in hospital. It would clearly be unsound, however, to divert a large number of hospital staff to such "roadside " resuscitation duties, for many of the accidents could be dealt with perfectly well under existing arrangements. But when first reports suggest serious injuries and when there is a long way to go, a resuscitation team might be dispatched with the ambulance. Often enough its services would not be vital; but it would from time to time undoubtedly save life, and it would do away with the unhappy picture of an ambulance car trundling over bumpy country lanes, with a shocked patient hopelessly enclosed in it. distribution of other ions, particularly sodium.7 Many of the factors influencing the intracellular potassium content have been defined by observations on animal muscle, often in vitro 8; but it is difficult to combine such observations with assessment of muscle function. Although the human forearm, by comparison with the excised frog gastrocnemius, is,less patient of quantitative study of potassium shifts, it is also less remote from the clinical situation; and the studies of Grob et al.,9 comparing arteriovenous potassium differences and musclefunction, form an important contribution to this vexing problem. Most of their findings, not surprisingly, were predictable from the experience with isolated muscle. For example, muscle contraction and the intra-arterial injection of acetylcholine were associated with release of potassium from the forearm ; while oral administration of potassium chloride and arterial administration of adrenaline were followed by uptake of potassium, and in the resting state there was a small uptake of potassium by the forearm. While oral glucose by itself was associated with uptake of potassium, when oral glucose was followed by arterial injection of insulin there was discharge of potassium from the forearm on that side. Grob et al. suggest that when insulin is added to glucose the further lowering of plasma-potassium, by increaseduptake in the liver, increases the efflux of potassium from musclecells by increasmg the concentration gradient between intracellular and extracellular fluid. The uptake of potassium into the forearm after oral glucose could also be prevented by giving cortisone orally, or hydrocortisone Muscle function was hemisuccinate intra-arterially. studied in the same experiments by recording actionpotentials and isometric tension during percutaneous ulnar-nerve stimulation ; and the effect of acetylcholine and neostigmine given intra-arterially was observed, with It was found that in intermittent nerve stimulation. those situations where the ratio of intracellular to extracellular potassium had probably decreased, there was increased muscle contractility and readier depolarisation by acetylcholine ; these changes are ascribed to a fall in resting membrane-potential. Conversely, in situations where the ratio of intracellular to extracellular potassium 7. See Lancet, 1957, i, 824. 8. Fenn, W. O. Physiol. Rev. 1940, 20, 377. 9. Grob, D., Liljestrand, A., Johns, R. J. 23, 340.
Amer.
J. Med.
1957,