- Email: [email protected]
HAIR-SPRAYS
709
hxmochromatosis. The
use
of desferrioxamine is thus
likely to be limited to those patients who cannot have repeated venesections. In patients with secondary haemochromatosis, Sephton Smithpointed out that desferrioxamine caused excretion of iron only when the iron-binding capacity of the plasma was almost totally saturated and iron stores were increased; and this was so in only some of the thalassaemia patients he treated. Moeschlin and Schnidertreated 5 patients with iron overload after repeated transfusions or hxmolytic anaemia, and they achieved daily excretions of 17-54 mg. of iron. In this group of patients desferrioxamine treatment is important, because they cannot be relieved by venesection. The use of desferrioxamine in iron poisoning has only recently been recorded. Moeschlin and Schniderfound that the drug would protect guineapigs given an L.n.o dose of ferrous sulphate. They suggested that desferrioxamine should be given into the stomach to neutralise iron not yet absorbed, and intravenously to combine with excess iron in the plasma: for the first purpose, they recommended 8-12 g. dissolved in distilled water and given by stomach tube; and for the second 2 g. dissolved in lxvulose solution and given by intravenous infusion. Henderson et al.in St. Louis have now successfully given desferrioxamine to a child with acute poisoning by ferrous gluconate. The child, aged 141,/2 months, was known to have taken more than thirty 300 mg. tablets of ferrous gluconate. She vomited 11/2 hours later and about twenty partly dissolved tablets were recovered; half an hour later more tablets were recovered from loose bloody motions. Gastric lavage was performed some 3 hours after the tablets were taken, and the patient was transferred to the children’s hospital, where she was seen about 41/2 hours after taking the tablets. Here she rapidly became collapsed and cyanotic; 5%glucose saline was given into a scalp vein, and then desferrioxamine (800 mg. in 20 ml. of water) was infused into a saphenous vein; at the same time 5 g. of desferrioxamine suspended in isotonic saline was given through a nasogastric tube. In blood taken at this time the serum-iron level was 2550 {ig. per 100 ml. and the ironbinding capacity was totally saturated. 5 hours later the serum-iron was down to 139 )J.g. per 100 ml. Further doses of 800 mg. of desferrioxamine were given intravenously 12 and 24 hours later; the total iron excreted in the urine was 25’37 mg. 44 hours after the first dose the serum-iron was 113 ag, per 100 ml. and the unsaturated iron-binding capacity of the plasma had reached 270 {ig. per 100 ml. The child had a stormy course, beset by convulsions, but recovered by the third day and did not relapse. Ferrous sulphate is the commonest iron preparation involved in poisoning incidents. Henderson et al.6 dipstinguish four phases of iron poisoning. The first phase begins B-1hour after taking the tablets; vomiting and bloody diarrhoea may be followed by acidosis and cardiovascular collapse;, coma and death follow in 4-6 hours in 20 Bof cases. In 80% the second phase of abatement of symptoms ensues, but this is followed after 8-16 hours by the dangerous third phase when progressive collapse, coma, and convulsions recur, and this phase accounts for the majority of deaths that occur. It was in this third phase that desferrioxamine rescued Henderson et al.’s patient. If the patient survives the third phase, the fourth phase of recovery
follows; but the child may later need operation to correct obstruction due to scarring. Sephton Smith, R. Brit. med. J. 1962, ii, 6 Henderson, F., Vietti, T. J., Brown, E. 186,1139.
an
1577. B. J. Amer. med. Ass. 1963,
Desferrioxamine is clearly
a
valuable addition
to
the
poisoning. But, like other treatment, it must be given without delay, so the drug and information about doses must be readily available. Henderson et al.’s paper is a very valuable guide. treatment
of iron
HAIR-SPRAYS
fixing agent in modern hair-sprays, lacquers, is either polyvinyl pyrrolidine (P.v.p.) or shellac, compounded with alcohol, lanolin, alginates, silicates, gums, and perfumes to make a solution in water which can be applied to the hair as a fine spray. Whether the spray is formed by a hand-operated pump or by an aerosol preparation, and whether it is applied by the hairdresser or by the hair-owner, there is bound to be dispersal THE main
and
wave-sets
of spray and some of it will be inhaled. There have been a number of reports, radiological and postmortem, of lung changes believed to be due to the inhalation and subsequent storage of hair-spray constituents in the respiratory system and its regional lymph-nodes, the first by Bergman et al.,! who included hair-spray lung disease in the general condition of " thesaurosis " (accumulation of substances in the tissues). Edelston2 reported in our columns a case of bilateral pulmonary mottling which he attributed to inhalation of hair-spray. Doubts began to fall on the reality of hair-spray lung disease when some, at least, of the reported examples were suggested to be cases of sarcoidosis; and in one instance Histoplasma capsulatum was found in the lungs. The issue was then recognised as by no means clear-cut or proven. Neither P.v.p. nor shellac are directly toxic, but in fine particles either could act as a foreign body in the respiratory system. Most of the particles from hand-pumped or aerosol hair-sprays are less than 1 [L in diameter; so they can certainly be inhaled into the lowest reaches of the lungs. Once settled in the alveoli and terminal bronchioles, the particles would be expected to evoke a foreign-body reaction which could progress to fibrosis. Radiological surveys of hairdressers exposed to the risk of spray inhalation were reported by John3 and by a group4 supported by the Medical Research Council. John dealt with 136 people from 14 salons who had been exposed for mean periods of 3-4 years (women) and 5-4 years (men): no lung abnormalities were detected. This was, however, a limited survey of relatively young people (average age less than 40), and a new reportfrom the Society of Cosmetic Chemists of Great Britain regards this inquiry as inconclusive. In the wider M.R.C. survey4 505 hairdressers were examined. During six years of exposure, 24-4% had been exposed to shellac-based sprays only, 21 % to P.v.p. sprays only, and 37% to both. Nothing to suggest hair-spray lung disease was found. Two cases of pulmonary disease apparently due to the inhalation of hair-spray are quoted,5 both outside the two surveys. The two women were exposed to shellac sprays, one for 13 years and the other for 11 years. In the latter case, lung biopsy excluded sarcoid and idiopathic interstitial pulmonary fibrosis; the biopsy showed fibrosis with many giant-cells and P.A.s.-positive granules. Though this sort of reaction is non-specific, these cases make it impossible to say with certainty that hair-spray disease 1. Bergman, M., Flance, I. J., Blumenthal, H.T.New. Engl.J.Med. 1958, 258, 471. 2. Edelston, B. G. Lancet, 1959, ii, 112. 3. John, H. H. Med. Offr, 1963, 109, 399. 4. McLaughlin, A. I. G., Bidstrup, P. L., Konstam, M. Fd Cosmet. Toxicol. 1963, 1, 171. 5. J. Soc.Cosmetic Chemists, 1964, 15, 45.
710
exist. At the most, its incidence is very low and be related to the duration of exposure. Yet there is clearly a need for investigation into the biological properties of shellac (and P.v.P.) and sensitivity to them before the matter can be regarded as settled. does
not
seems to
"AMERICA’S GREATEST CONTRIBUTION TO MEDICINE"
AFTER the death of J. S. Billings in 1913, William H. Welch spoke at two memorial meetings. At the one he described the development of the Surgeon-General’s library as " probably the most original and distinctive contribution of America to the medicine of the world" 1; and at the other he said: "
I question whether America has made any larger contribution to Medicine than that made by Billings in building up and developing the Surgeon-General’s library and in the publication of the’Index Catalogue ’ and the’Index Medicus’. That, in my judgement, is America’s greatest contribution to medicine and we owe it to this extraordinary man."2 That assessment of the library of the Surgeon-General’s Office of the U.S. Army was soon afterwards echoed by J. G. Adami. He was one of many who were disturbed an Army Appropriation Bill which would have ended the library’s independent existence; and he wrote: " I would go so far as to say that the outstanding service to medicine by the United States has been this library with its publication ..."3 A few months before his death, Welch, in conversation with Major E. E. Hume (then librarian of the Army Medical Library), made a pronouncement which so impressed Hume that, as he tells us, he " reduced it to Welch’s words as writing immediately afterwards". " been Hume were: I have asked on more reported by than one occasion what have been the really great contributions of this country (i.e., U.S.A.) to medical knowledge. I have given the subject some thought and think that four should be named: (1) The discovery of aneesthesia. (2) The discovery of insect transmission of disease. (3) The development of the modern public-health laboratory, in all that the term implies. (4) The Army Medical and its Index Catalogue, and " (he added slowly) Library " this library and its catalogue are the most important of the four."4 In 1936, Sir Humphry Rolleston, speaking at the Army Medical Library, then celebrating its centenary, reminded his hearers of the judgments of Welch and Adami, and said that the Index Catalogue and the Index Medicus had made the whole medical world " hopelessly insolvent debtors".5 When Sir Humphry spoke, the Army Medical Library was to some extent " coasting " on the impetus of past activities: it no longer published the Index Medicus, and the Index Catalogue (with a huge backlog of publication) was becoming less and less appropriate in the face of the greater volume of contemporary publications. That it has since developed into the Armed Forces Medical Library (1952-56) and ultimately into the National Library of Medicine is largely due to the labours of Frank B. Rogers, who became its director in 1949. At a time when adequate physical housing of the library and its activities lay more than a decade ahead, the vision, energy, and leadership of Rogers brought new spirit and new vigour to the enter-
by
1. Welch, W. H. Collected Papers; vol. 3, p. 2. ibid. p. 400. 3. Bull. med. Lib. Ass. 1914, 3, 56. 4. Hume, E. E. Mil. Surg. 1936, 78, 241. 5. Rolleston, H. D. Med. Life, 1936, 43, 543.
397. Baltimore,
1920.
prise. Each task undertaken was but the preliminary of something further-each a response to the needs of medicine and each showing remarkable prevision. The growth and scope of the library again began to reflect the great duties which it was reassuming. Generous support from well-wishers, such as Dr. Atherton Seidell, allowed the publication of what was, at first, a guide to material obtainable through the library’s loan services-the Current List into
of Medical Literature.
Within
a
few years this grew
monthly index to much of the world’s medical periodical publication, and that in turn became the present, new series, Index Medicus. New methods were introduced to lessen delays between publication and indexing; and even while mechanical methods in the preparation of this conventional index were being improved, plans were being made to use the much greater potential capacities for depth and scope of indexing which might be found in the computer. This project, the MEDLARS scheme, has now moved out of the first stages of experiment and trial, and this year the Index Medicus appears as one only of a number of products to come from it. The words of Oliver Wendell Holmes, spoken in 1889, have lost none of their force:"The greatIndex Medicus ’... is the master key to the storehouses of knowledge, which, without it, few would ever have even tried to open."6 At the entrance to the new building of the National Library of Medicine, at Bethesda, the figures of Billings, Fletcher, and Garrison are incised on the wall. Could Welch visit that new building, as he so often did the old one, he might well reiterate his words of fifty years ago. He would, beyond all doubt, add another name to those three, the name of the man who has set the library anew on its course, and who, having retired from its directorship, is now professor of medical bibliography at the University of Colorado Medical Center-Frank Bradway Rogers. a
RESIGNATION OF DR. DAVIES
WHEN the Special Conference of Local Medical Committees met on March 12 to discuss the memorandur of evidence to be submitted to the Review Body, it decide, that certain additions should be made to the documeni some of which the General Medical Services Committe had previously considered and deemed inappropriatt The conference also expressed dissatisfaction with th G.M.S. Committee’s choice of general practitioners t, represent them on the evidence committee, which i meeting the Review Body, and insisted on the inclusio of another general practitioner, Dr. I. M. Jones, in thi
deputation. Dr. A. B. Davies regards these decisions as a vote of no confidence in the G.M.S. Committee and in its chairman and has resigned from the chairmanship and from the committee. His resignation will be regretted by all who appreciate his skill in negotiation, his ability to explaii complex and confusing issues, his tact in handling intra. professional problems, and his unsparing efforts on behal of the profession. He has been a member of the G.M.S Committee since 1948 and its chairman since 1957. On March 19 the G.M.S. Committee chose as its new chairman Dr. J. C. Cameron, who is in practice at Wallington in Surrey. He is the chairman of the Surrey local medical committee and has represented his county on the G.M.S. Committee since 1956. 6.
Holmes, O. W. Boston med.
surg.
J. 1889, 120,129.
hxmochromatosis. The
use
of desferrioxamine is thus
likely to be limited to those patients who cannot have repeated venesections. In patients with secondary haemochromatosis, Sephton Smithpointed out that desferrioxamine caused excretion of iron only when the iron-binding capacity of the plasma was almost totally saturated and iron stores were increased; and this was so in only some of the thalassaemia patients he treated. Moeschlin and Schnidertreated 5 patients with iron overload after repeated transfusions or hxmolytic anaemia, and they achieved daily excretions of 17-54 mg. of iron. In this group of patients desferrioxamine treatment is important, because they cannot be relieved by venesection. The use of desferrioxamine in iron poisoning has only recently been recorded. Moeschlin and Schniderfound that the drug would protect guineapigs given an L.n.o dose of ferrous sulphate. They suggested that desferrioxamine should be given into the stomach to neutralise iron not yet absorbed, and intravenously to combine with excess iron in the plasma: for the first purpose, they recommended 8-12 g. dissolved in distilled water and given by stomach tube; and for the second 2 g. dissolved in lxvulose solution and given by intravenous infusion. Henderson et al.in St. Louis have now successfully given desferrioxamine to a child with acute poisoning by ferrous gluconate. The child, aged 141,/2 months, was known to have taken more than thirty 300 mg. tablets of ferrous gluconate. She vomited 11/2 hours later and about twenty partly dissolved tablets were recovered; half an hour later more tablets were recovered from loose bloody motions. Gastric lavage was performed some 3 hours after the tablets were taken, and the patient was transferred to the children’s hospital, where she was seen about 41/2 hours after taking the tablets. Here she rapidly became collapsed and cyanotic; 5%glucose saline was given into a scalp vein, and then desferrioxamine (800 mg. in 20 ml. of water) was infused into a saphenous vein; at the same time 5 g. of desferrioxamine suspended in isotonic saline was given through a nasogastric tube. In blood taken at this time the serum-iron level was 2550 {ig. per 100 ml. and the ironbinding capacity was totally saturated. 5 hours later the serum-iron was down to 139 )J.g. per 100 ml. Further doses of 800 mg. of desferrioxamine were given intravenously 12 and 24 hours later; the total iron excreted in the urine was 25’37 mg. 44 hours after the first dose the serum-iron was 113 ag, per 100 ml. and the unsaturated iron-binding capacity of the plasma had reached 270 {ig. per 100 ml. The child had a stormy course, beset by convulsions, but recovered by the third day and did not relapse. Ferrous sulphate is the commonest iron preparation involved in poisoning incidents. Henderson et al.6 dipstinguish four phases of iron poisoning. The first phase begins B-1hour after taking the tablets; vomiting and bloody diarrhoea may be followed by acidosis and cardiovascular collapse;, coma and death follow in 4-6 hours in 20 Bof cases. In 80% the second phase of abatement of symptoms ensues, but this is followed after 8-16 hours by the dangerous third phase when progressive collapse, coma, and convulsions recur, and this phase accounts for the majority of deaths that occur. It was in this third phase that desferrioxamine rescued Henderson et al.’s patient. If the patient survives the third phase, the fourth phase of recovery
follows; but the child may later need operation to correct obstruction due to scarring. Sephton Smith, R. Brit. med. J. 1962, ii, 6 Henderson, F., Vietti, T. J., Brown, E. 186,1139.
an
1577. B. J. Amer. med. Ass. 1963,
Desferrioxamine is clearly
a
valuable addition
to
the
poisoning. But, like other treatment, it must be given without delay, so the drug and information about doses must be readily available. Henderson et al.’s paper is a very valuable guide. treatment
of iron
HAIR-SPRAYS
fixing agent in modern hair-sprays, lacquers, is either polyvinyl pyrrolidine (P.v.p.) or shellac, compounded with alcohol, lanolin, alginates, silicates, gums, and perfumes to make a solution in water which can be applied to the hair as a fine spray. Whether the spray is formed by a hand-operated pump or by an aerosol preparation, and whether it is applied by the hairdresser or by the hair-owner, there is bound to be dispersal THE main
and
wave-sets
of spray and some of it will be inhaled. There have been a number of reports, radiological and postmortem, of lung changes believed to be due to the inhalation and subsequent storage of hair-spray constituents in the respiratory system and its regional lymph-nodes, the first by Bergman et al.,! who included hair-spray lung disease in the general condition of " thesaurosis " (accumulation of substances in the tissues). Edelston2 reported in our columns a case of bilateral pulmonary mottling which he attributed to inhalation of hair-spray. Doubts began to fall on the reality of hair-spray lung disease when some, at least, of the reported examples were suggested to be cases of sarcoidosis; and in one instance Histoplasma capsulatum was found in the lungs. The issue was then recognised as by no means clear-cut or proven. Neither P.v.p. nor shellac are directly toxic, but in fine particles either could act as a foreign body in the respiratory system. Most of the particles from hand-pumped or aerosol hair-sprays are less than 1 [L in diameter; so they can certainly be inhaled into the lowest reaches of the lungs. Once settled in the alveoli and terminal bronchioles, the particles would be expected to evoke a foreign-body reaction which could progress to fibrosis. Radiological surveys of hairdressers exposed to the risk of spray inhalation were reported by John3 and by a group4 supported by the Medical Research Council. John dealt with 136 people from 14 salons who had been exposed for mean periods of 3-4 years (women) and 5-4 years (men): no lung abnormalities were detected. This was, however, a limited survey of relatively young people (average age less than 40), and a new reportfrom the Society of Cosmetic Chemists of Great Britain regards this inquiry as inconclusive. In the wider M.R.C. survey4 505 hairdressers were examined. During six years of exposure, 24-4% had been exposed to shellac-based sprays only, 21 % to P.v.p. sprays only, and 37% to both. Nothing to suggest hair-spray lung disease was found. Two cases of pulmonary disease apparently due to the inhalation of hair-spray are quoted,5 both outside the two surveys. The two women were exposed to shellac sprays, one for 13 years and the other for 11 years. In the latter case, lung biopsy excluded sarcoid and idiopathic interstitial pulmonary fibrosis; the biopsy showed fibrosis with many giant-cells and P.A.s.-positive granules. Though this sort of reaction is non-specific, these cases make it impossible to say with certainty that hair-spray disease 1. Bergman, M., Flance, I. J., Blumenthal, H.T.New. Engl.J.Med. 1958, 258, 471. 2. Edelston, B. G. Lancet, 1959, ii, 112. 3. John, H. H. Med. Offr, 1963, 109, 399. 4. McLaughlin, A. I. G., Bidstrup, P. L., Konstam, M. Fd Cosmet. Toxicol. 1963, 1, 171. 5. J. Soc.Cosmetic Chemists, 1964, 15, 45.
710
exist. At the most, its incidence is very low and be related to the duration of exposure. Yet there is clearly a need for investigation into the biological properties of shellac (and P.v.P.) and sensitivity to them before the matter can be regarded as settled. does
not
seems to
"AMERICA’S GREATEST CONTRIBUTION TO MEDICINE"
AFTER the death of J. S. Billings in 1913, William H. Welch spoke at two memorial meetings. At the one he described the development of the Surgeon-General’s library as " probably the most original and distinctive contribution of America to the medicine of the world" 1; and at the other he said: "
I question whether America has made any larger contribution to Medicine than that made by Billings in building up and developing the Surgeon-General’s library and in the publication of the’Index Catalogue ’ and the’Index Medicus’. That, in my judgement, is America’s greatest contribution to medicine and we owe it to this extraordinary man."2 That assessment of the library of the Surgeon-General’s Office of the U.S. Army was soon afterwards echoed by J. G. Adami. He was one of many who were disturbed an Army Appropriation Bill which would have ended the library’s independent existence; and he wrote: " I would go so far as to say that the outstanding service to medicine by the United States has been this library with its publication ..."3 A few months before his death, Welch, in conversation with Major E. E. Hume (then librarian of the Army Medical Library), made a pronouncement which so impressed Hume that, as he tells us, he " reduced it to Welch’s words as writing immediately afterwards". " been Hume were: I have asked on more reported by than one occasion what have been the really great contributions of this country (i.e., U.S.A.) to medical knowledge. I have given the subject some thought and think that four should be named: (1) The discovery of aneesthesia. (2) The discovery of insect transmission of disease. (3) The development of the modern public-health laboratory, in all that the term implies. (4) The Army Medical and its Index Catalogue, and " (he added slowly) Library " this library and its catalogue are the most important of the four."4 In 1936, Sir Humphry Rolleston, speaking at the Army Medical Library, then celebrating its centenary, reminded his hearers of the judgments of Welch and Adami, and said that the Index Catalogue and the Index Medicus had made the whole medical world " hopelessly insolvent debtors".5 When Sir Humphry spoke, the Army Medical Library was to some extent " coasting " on the impetus of past activities: it no longer published the Index Medicus, and the Index Catalogue (with a huge backlog of publication) was becoming less and less appropriate in the face of the greater volume of contemporary publications. That it has since developed into the Armed Forces Medical Library (1952-56) and ultimately into the National Library of Medicine is largely due to the labours of Frank B. Rogers, who became its director in 1949. At a time when adequate physical housing of the library and its activities lay more than a decade ahead, the vision, energy, and leadership of Rogers brought new spirit and new vigour to the enter-
by
1. Welch, W. H. Collected Papers; vol. 3, p. 2. ibid. p. 400. 3. Bull. med. Lib. Ass. 1914, 3, 56. 4. Hume, E. E. Mil. Surg. 1936, 78, 241. 5. Rolleston, H. D. Med. Life, 1936, 43, 543.
397. Baltimore,
1920.
prise. Each task undertaken was but the preliminary of something further-each a response to the needs of medicine and each showing remarkable prevision. The growth and scope of the library again began to reflect the great duties which it was reassuming. Generous support from well-wishers, such as Dr. Atherton Seidell, allowed the publication of what was, at first, a guide to material obtainable through the library’s loan services-the Current List into
of Medical Literature.
Within
a
few years this grew
monthly index to much of the world’s medical periodical publication, and that in turn became the present, new series, Index Medicus. New methods were introduced to lessen delays between publication and indexing; and even while mechanical methods in the preparation of this conventional index were being improved, plans were being made to use the much greater potential capacities for depth and scope of indexing which might be found in the computer. This project, the MEDLARS scheme, has now moved out of the first stages of experiment and trial, and this year the Index Medicus appears as one only of a number of products to come from it. The words of Oliver Wendell Holmes, spoken in 1889, have lost none of their force:"The greatIndex Medicus ’... is the master key to the storehouses of knowledge, which, without it, few would ever have even tried to open."6 At the entrance to the new building of the National Library of Medicine, at Bethesda, the figures of Billings, Fletcher, and Garrison are incised on the wall. Could Welch visit that new building, as he so often did the old one, he might well reiterate his words of fifty years ago. He would, beyond all doubt, add another name to those three, the name of the man who has set the library anew on its course, and who, having retired from its directorship, is now professor of medical bibliography at the University of Colorado Medical Center-Frank Bradway Rogers. a
RESIGNATION OF DR. DAVIES
WHEN the Special Conference of Local Medical Committees met on March 12 to discuss the memorandur of evidence to be submitted to the Review Body, it decide, that certain additions should be made to the documeni some of which the General Medical Services Committe had previously considered and deemed inappropriatt The conference also expressed dissatisfaction with th G.M.S. Committee’s choice of general practitioners t, represent them on the evidence committee, which i meeting the Review Body, and insisted on the inclusio of another general practitioner, Dr. I. M. Jones, in thi
deputation. Dr. A. B. Davies regards these decisions as a vote of no confidence in the G.M.S. Committee and in its chairman and has resigned from the chairmanship and from the committee. His resignation will be regretted by all who appreciate his skill in negotiation, his ability to explaii complex and confusing issues, his tact in handling intra. professional problems, and his unsparing efforts on behal of the profession. He has been a member of the G.M.S Committee since 1948 and its chairman since 1957. On March 19 the G.M.S. Committee chose as its new chairman Dr. J. C. Cameron, who is in practice at Wallington in Surrey. He is the chairman of the Surrey local medical committee and has represented his county on the G.M.S. Committee since 1956. 6.
Holmes, O. W. Boston med.
surg.
J. 1889, 120,129.