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EXUDATIVE TONSILLITIS
287 seen such a case,’and I have heard of more deaths and It will cases of cellulitis of the arm than I care to recall. when we in the for the British be a the use of succeed in medical
happy day profession
public discontinuing sterile water (except out of ampoules) and of spirit for sterilisation. Spirit is a good preservative of germs ; yet both the medical and nursing professions hold on to it faithfully for storage of instruments-a costly ’
fidelity.
The essentials for spinal anaesthesia are to boil everything-needles, syringes, and ampoules-and- lay up dry. The area must be towelled adequately with a sterile towel. The lumbar area must be properly prepared. And finally, the administrator must wash up to the elbows for 4-5 minutes and touch as little
possible. London,
-
as
-
HAROLD DODD.
Wl.
Sm,-Any help in preventing the tragedy of the infected spinal injection must be welcome to surgeons and anæthetists, but I fear that the advice given by Dr. Frankis Evans (Jan. 27 ) by attempting too much will in fact accomplish little ; not only do his five para" " graphs of well-defined rules obscure the essentials, but many may even be altogether deterred from using this-admirable form of analgesia. In brief, the operation consists in the transference of fluid from an ampoule, via the sterile interior of syringe and needle, into the patient’s meninges, and the fewer extraneous solutions (such as reputedly sterile saline, and fluid of any sort from a rubber-capped bottle) that touchthese vital channels, the better. In my opinion there are four essential rules : To boil syringe and needle immediately before use. To waslr out the syringe with a little of the anaesthetic solution which is to be injected. The interior of the needle will be
irrigated by emerging cerebrospinal
fluid when the
puncture is made. To hold the spinal needle in a gauze swab. To make a preliminary skin puncture with any large serum needle, thus preventing a lump of epidermis becoming impaled upon the spinal stilette. -
useful accessories, but if these observed there need be no hesitation in using spinal analgesia under any conditions which are fit for surgery at all. W. G. MILLS. BLA. Other
precautions
are
four cardinal points
are
FRACTURES OF THE FIRST RIB SIR,—May I briefly answer the criticism of my paper made by Dr. Blair Hartley in your issue of Jan. 27? Firstly, my study was based on radiography and personal interrogation of the subjects : Arbuthnot Lane had the advantage of me, as of course none of my cases has as yet come to post-mortem ! Secondly, although only 35 cases in a series of 55,451 consecutivefluorograms were recorded, I stated that " not infrequently first ribs were noted to be broadened or to show some departure from the normal architecture near the scalene tubercle " -the site of the undoubted lesion. These cases, had they been recognised.and recorded earlier, would surely have increased the incidence of-fracture of the first rib to a considerable extent, assuming that such appearances are accepted as the healed lesion. Thirdly, the excerpt from Arbuthnot Lane’s paper is hardly relevant, as I recorded that in only 2 of my 35 cases was any history of direct injury obtained, and of these one was so vague as to be of little value. main objection is to my use of the word " stress." I feel certain he does not deny the presence of fracture. Further research into the antecedent history of another 29 cases in my next 26,231 consecutive fiuorograms, not one of which even under pressure admitted direct injury, satisfies me that the use of the word stress " is likely in the majority of cases to be justified. In applying the criteria formulated by Hartley, taking both series of cases, 64 in all, (1) the affected ribs were apparently normal in all other respects, with one possible exception, and no obvious associated congenital abnormality was recorded in the thoracic cage ; (2) only 2 cases can be ruled out on the score of direct injury ; (3) " sub-threshold stress " is difficult of definition and is very personal, especially when applied to an anatomical STRESS
Hartley’s
mechanism not constantly weight-bearing, or at least not so constantly as the pelvis and lower extremities. But surely the first rib with its intimate muscular association with the shoulder girdle frequently comes under this heading and is therefore equally exposed from time to time to sub-threshold stress, in particular heavy weightlifting. In this connexion, no less than 6 of the later series of 29 cases give a definite history of lifting and carrying weights of 1 cwt. and over, while one of them was employed for several years in a flour mill carrying 2 ewt. bags of wheat, but whether this can be regarded as a sub-threshold stress is a moot point! In conclusion, if stress or fatigue fractures can occur in the lower extremities, for no other apparent reason than frequently applied sub-threshold stress, and this is not in doubt, there would appear to be no reason to suppose that a similar condition, especially in the almost monotonous absence of history of injury, is unlikely in the first rib when it is subjected to heavy weight-lifting or for that matter, to any other unaccustomed physical exertion over varying periods of time affecting the shoulder girdle and thereby the first rib. B. ROXBY ALDERSON. Chatham.
BRACHIAL NEURITIS OR HERNIATED DISC SIR,—In your issue of Jan. 6 Majors Elliott and Kremer lucidly describe a type of brachial neuritis involving C7 root, and bring forward fairly convincing evidence that it is due to compression of the root by a laterallyplaced protrusion of the intervertebral disc between C6 and C7. In the past eighteen months I have seen 20 patients suffering from this condition, and it appears to be a common type of brachial neuritis among Service personnel in this country. All the patients were men except one who was a nursing sister. The outcome in these 20 cases may be of interest. The acute pain radiating down the arm stopped within five weeks in 16 cases, and within six weeks in 1. In 2 e cases there was still pain of decreasing severity after five weeks when they had to be transferred to other hospitals,. and 1 patient had fairly severe pain after nine weeks when he was invalided from the Service. When the severe pain has stopped there may still be a minor degree of disability ; occasional dull aches in the arm may occur, some weakness of the triceps may persist for some weeks, and dysæsthesia in the index finger may continue for several months. - The triceps-jerk can certainly remain absent for many months, and it seems possible that it may remain absent permanently—-a finding comparable to the loss of the ankle-jerk in radicular sciatica due to a prolapsed disc or other cause, which may be absent many years after the sciatic pain has stopped. No case of a second attack of severe pain has yet been seen. These results, without., special treatment other than mild analgesics and in the more severe cases rest on the lines described by Elliott and Kremer, suggest that the prognosis of the condition is good and that operative removal of the disc protrusion should very rarely be necessary. The last line of your annotation on the subject (p. 24) is very true. J. W. ALDREN TURNER. EXUDATIVE TONSILLITIS SIR,—The diagnosis of diphtheria in the inoculated cannot be made on clinical grounds alone, nor is a positive e throat-swab conclusive for such a diagnosis. As I pointed out ’in my paper, the state of immunity of the patient has to be ascertained, by’a Schick test or by an estimation of the antitoxin content in the blood. In the series of 50 cases which I published, the throat lesion varied between minute spots and large deposits covering the whole tonsil, but virulent diphtheria bacillus and no other organism was found in the throat, and the Schick test was positive in all. The diagnosis of diphtheria cannot be doubted. It is obviously wrong to accept the diagnosis only in those cases which exhibited a severe throat lesion and to repudiate it in those with a small deposit. If the criteria mentioned above be observed it will be found that diphtheria in the inoculated is very rare indeed, and it was found to be less than 1/1000 inoculated in this hospital.
Newcastle-upon-Tyne.
C. NEUBAUER.
happy day profession
public discontinuing sterile water (except out of ampoules) and of spirit for sterilisation. Spirit is a good preservative of germs ; yet both the medical and nursing professions hold on to it faithfully for storage of instruments-a costly ’
fidelity.
The essentials for spinal anaesthesia are to boil everything-needles, syringes, and ampoules-and- lay up dry. The area must be towelled adequately with a sterile towel. The lumbar area must be properly prepared. And finally, the administrator must wash up to the elbows for 4-5 minutes and touch as little
possible. London,
-
as
-
HAROLD DODD.
Wl.
Sm,-Any help in preventing the tragedy of the infected spinal injection must be welcome to surgeons and anæthetists, but I fear that the advice given by Dr. Frankis Evans (Jan. 27 ) by attempting too much will in fact accomplish little ; not only do his five para" " graphs of well-defined rules obscure the essentials, but many may even be altogether deterred from using this-admirable form of analgesia. In brief, the operation consists in the transference of fluid from an ampoule, via the sterile interior of syringe and needle, into the patient’s meninges, and the fewer extraneous solutions (such as reputedly sterile saline, and fluid of any sort from a rubber-capped bottle) that touchthese vital channels, the better. In my opinion there are four essential rules : To boil syringe and needle immediately before use. To waslr out the syringe with a little of the anaesthetic solution which is to be injected. The interior of the needle will be
irrigated by emerging cerebrospinal
fluid when the
puncture is made. To hold the spinal needle in a gauze swab. To make a preliminary skin puncture with any large serum needle, thus preventing a lump of epidermis becoming impaled upon the spinal stilette. -
useful accessories, but if these observed there need be no hesitation in using spinal analgesia under any conditions which are fit for surgery at all. W. G. MILLS. BLA. Other
precautions
are
four cardinal points
are
FRACTURES OF THE FIRST RIB SIR,—May I briefly answer the criticism of my paper made by Dr. Blair Hartley in your issue of Jan. 27? Firstly, my study was based on radiography and personal interrogation of the subjects : Arbuthnot Lane had the advantage of me, as of course none of my cases has as yet come to post-mortem ! Secondly, although only 35 cases in a series of 55,451 consecutivefluorograms were recorded, I stated that " not infrequently first ribs were noted to be broadened or to show some departure from the normal architecture near the scalene tubercle " -the site of the undoubted lesion. These cases, had they been recognised.and recorded earlier, would surely have increased the incidence of-fracture of the first rib to a considerable extent, assuming that such appearances are accepted as the healed lesion. Thirdly, the excerpt from Arbuthnot Lane’s paper is hardly relevant, as I recorded that in only 2 of my 35 cases was any history of direct injury obtained, and of these one was so vague as to be of little value. main objection is to my use of the word " stress." I feel certain he does not deny the presence of fracture. Further research into the antecedent history of another 29 cases in my next 26,231 consecutive fiuorograms, not one of which even under pressure admitted direct injury, satisfies me that the use of the word stress " is likely in the majority of cases to be justified. In applying the criteria formulated by Hartley, taking both series of cases, 64 in all, (1) the affected ribs were apparently normal in all other respects, with one possible exception, and no obvious associated congenital abnormality was recorded in the thoracic cage ; (2) only 2 cases can be ruled out on the score of direct injury ; (3) " sub-threshold stress " is difficult of definition and is very personal, especially when applied to an anatomical STRESS
Hartley’s
mechanism not constantly weight-bearing, or at least not so constantly as the pelvis and lower extremities. But surely the first rib with its intimate muscular association with the shoulder girdle frequently comes under this heading and is therefore equally exposed from time to time to sub-threshold stress, in particular heavy weightlifting. In this connexion, no less than 6 of the later series of 29 cases give a definite history of lifting and carrying weights of 1 cwt. and over, while one of them was employed for several years in a flour mill carrying 2 ewt. bags of wheat, but whether this can be regarded as a sub-threshold stress is a moot point! In conclusion, if stress or fatigue fractures can occur in the lower extremities, for no other apparent reason than frequently applied sub-threshold stress, and this is not in doubt, there would appear to be no reason to suppose that a similar condition, especially in the almost monotonous absence of history of injury, is unlikely in the first rib when it is subjected to heavy weight-lifting or for that matter, to any other unaccustomed physical exertion over varying periods of time affecting the shoulder girdle and thereby the first rib. B. ROXBY ALDERSON. Chatham.
BRACHIAL NEURITIS OR HERNIATED DISC SIR,—In your issue of Jan. 6 Majors Elliott and Kremer lucidly describe a type of brachial neuritis involving C7 root, and bring forward fairly convincing evidence that it is due to compression of the root by a laterallyplaced protrusion of the intervertebral disc between C6 and C7. In the past eighteen months I have seen 20 patients suffering from this condition, and it appears to be a common type of brachial neuritis among Service personnel in this country. All the patients were men except one who was a nursing sister. The outcome in these 20 cases may be of interest. The acute pain radiating down the arm stopped within five weeks in 16 cases, and within six weeks in 1. In 2 e cases there was still pain of decreasing severity after five weeks when they had to be transferred to other hospitals,. and 1 patient had fairly severe pain after nine weeks when he was invalided from the Service. When the severe pain has stopped there may still be a minor degree of disability ; occasional dull aches in the arm may occur, some weakness of the triceps may persist for some weeks, and dysæsthesia in the index finger may continue for several months. - The triceps-jerk can certainly remain absent for many months, and it seems possible that it may remain absent permanently—-a finding comparable to the loss of the ankle-jerk in radicular sciatica due to a prolapsed disc or other cause, which may be absent many years after the sciatic pain has stopped. No case of a second attack of severe pain has yet been seen. These results, without., special treatment other than mild analgesics and in the more severe cases rest on the lines described by Elliott and Kremer, suggest that the prognosis of the condition is good and that operative removal of the disc protrusion should very rarely be necessary. The last line of your annotation on the subject (p. 24) is very true. J. W. ALDREN TURNER. EXUDATIVE TONSILLITIS SIR,—The diagnosis of diphtheria in the inoculated cannot be made on clinical grounds alone, nor is a positive e throat-swab conclusive for such a diagnosis. As I pointed out ’in my paper, the state of immunity of the patient has to be ascertained, by’a Schick test or by an estimation of the antitoxin content in the blood. In the series of 50 cases which I published, the throat lesion varied between minute spots and large deposits covering the whole tonsil, but virulent diphtheria bacillus and no other organism was found in the throat, and the Schick test was positive in all. The diagnosis of diphtheria cannot be doubted. It is obviously wrong to accept the diagnosis only in those cases which exhibited a severe throat lesion and to repudiate it in those with a small deposit. If the criteria mentioned above be observed it will be found that diphtheria in the inoculated is very rare indeed, and it was found to be less than 1/1000 inoculated in this hospital.
Newcastle-upon-Tyne.
C. NEUBAUER.