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HEART-BLOCK AND THE STOKES-ADAMS SYNDROME.
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H17AR’I’-13LOCK AND THE STOKES-ADAMS SYNDROME.
or perforated. As an important addition toIexhibits the features characteristic either of a branch these mechanical methods lie employs the faradic and bundle lesion or of arborisation block. In cases of the galvanic current with his forceps as tho active complete A-V dissociation the idio-ventricular rhythm electrode, and maintains that by this means the current appears to be controlled by a centre situated between is more exactly limited to the ear than by other means, the A-V node and the bifurcation of the bundle of though he recognises the disadvantage that the con- His, and during the periods of ventricular asystole, sequent inflammation and desquamation of the drum which cliaracterise the Stokes-Adams syndrome, there may prevent a repetition of the treatment for a fort- is a temporary functional discontinuity between thenight. Further, he has used electrolysis to produce a idio-ventricular centre and the mass of the ventricular perforation of the membrana tympani, and lie suggests, muscle. though he has not tried, the same method to divide THE WORKS DOCTOR IN FRANCE. adhesions and destroy thickenings in the region of the DURING the war the necessity of protecting the fenestra ovalis. He also advises ionisation with the aid of these forceps in cases with perforation of the supply of labour was the principal occupation of the drum, but has not yet employed it ; it is difficult to French Ministry of Munitions. If the sacrifice of the see what advantages this can have over the ordinary workers’ health had gone on as at the outset, production simple method of ionisation, which is a well-established would have come to a standstill ; accordingly pretreatment for aural suppuration and of which Dr. cautions were taken to select the right type of worker Molinié does not appear to have heard. for particular jobs and to provide medical superFrom the description of these ingenious but elabo- vision in the workshops. During this time of stress, rate forms of treatment the reader will turn eagerly industrial physicians were installed in most of the to the final chapter on results, to find there little munition factories, and the workers themselves Prof. Etienne Martin, who encouragement to justify a method which must always recognised their value. cause inflammation of the drum with a risk of more tells the story in a recent issue of the Journal de serious damage. The hearing has not been found to Medecine de Lyon, assures us that the workers are undergo any appreciable alteration, though the now anxious to retain these medical services in author believes that the progress of deafness has been factories. In France the workers’ laws form a delayed ; tinnitus of catarrhal or post-suppurative labour code, which treats successively the work origin has usually been benefited, and even a few contract, wages, placing of workers, duration of work, cases of otosclerotic tinnitus have been improved, by night work, weekly rest, hygiene and security of the the mechanical treatment, while the claim is made that workers, and the inspection of the work. Special tinnitus of nervous origin without objective signs is regulations were miposed later on certain dangerous often satisfactorily relieved by the electrical method. industries. Where, for instance, a candidate for No figures are given of the numbers of cases treated employment will be exposed to the risk of lead or of the percentage of those improved, and the poisoning a visit to the employment office is enforced, impression is gained that, while Dr. Molinie has made and a medical certificate must be produced to the a courageous attempt to relieve where treatment has effect that he has not, at that time, any symptoms of lead poisoning, nor any disease likely to be aggrapreviously failed, the problem is not yet solved. vated by lead; this certificate must be renewed one month after engagement, and thereafter once a HEART-BLOCK AND THE STOKES-ADAMS quarter. Analogous precautions are imposed upon SYNDROME. industries concerned with mercury, glass-making, THE advance in our knowledge of the mechanism animal hair, and compressed air. Here we have of heart-block, which resulted from the introduction of something analogous in our own factory inspection, the polygraphic and electro-cardiographic methods, but in France all the large industries consider an was at first confined to those forms in which the con- industrial physician a necessity, although they are not ductivity between auricle and ventricle was impaired. obliged to employ a doctor by the labour code. Prof. More recently a considerable number of observations, Martin sets out as follows the various directions in " both clinical and experimental, have been published which the " medecin d’usine can be of service. 1. For putting into force the protective hygienic measures, concerning another variety of block which involves the Purkinje system below the A-V node. In a well- present or future, which constitute the labour code. 2. For obtaining a rational recruitment of the labour illustrated paper in the Lyon Medical Journal of and for the elimination of the sick and carriers supply a Dr. L. Gallavardin records series of 51 Sept. 20th, of disease who might infect their comrades. cases of heart-block which have come under his own 3. For exercising the indispensable control of the employer personal observation, and discusses various points of in all accidents, industrial diseases, and invalidity insurance. interest as exemplified by this group. The cases he 4. For minimising the effects of working accidents by divides into two main classes : (a) those exhibiting rendering immediate first-aid.
thinned,
--
5. For managing the surgery, works of assistance, or auriculo-ventricular block characterised by impairment of conductivity from auricle to ventricle ; and beneficences which have been created by the management. " The cooperation here suggested between doctor (b) those with " nodo-ventricular block in which the lesion is presumably situated distal to the A-V node. and employer is very close, and Prof. Martin meets Both lesions are frequently associated with one another some of the familiar objections which have been in the same case, and the importance of differentiating raised to it. The most serious from the workers’ between them lies in the functional manifestations to standpoint is the interference with the so-called But it is, as Prof. Martin points which they give rise. In the former group, even when liberty of labour. auriculo-ventricular dissociation is complete, the func- out, in the workers’ own interest that only such as are tional activity of the heart may still be maintained by fit for employment shall be taken on. The disease the appearance of an idio-ventricular rhythm, and, carrier is a risk to his comrades. The medical visit once the idio-ventricular rhythm is established, Stokes- before engagement is not for the purpose of rejecting Adams attacks will occur only if the case is complicated the mutilated or the infirm, but to protect them from by the addition of nodo-ventricular block. But it is aggravation of their infirmity and to place them not only the more prolonged periods of ventricular according to their working ability. To avoid the asystole which, according to Dr. Gallavardin, are works doctor coming into unfair competition with attributable to nodo-ventricular block, for he points the general practitioner the author suggests that he out that simple intermissions of the pulse due to heart- shall be paid by the employer, and thinks that a block are not infrequently met with in cases in which part-timer should be restrained from treating a there is no evidence of impaired conductivity between worker outside the factory, except by special request. auricle and ventricle. Such incidents suggest thatBut he points out that full-time doctors would more the lapse of the ventricle is due to involvement of the, readily secure the cooperation of general practitioners Partial nodo-ventricularin the neighbourhood. Prof. Martin lays great stress nodo-ventricular region. block may be recognised graphically by alterations inL on the collaboration with the employer, which puts the the ventricular complex of the electrocardiogram,whichworks doctor in a position quite apart from that of a
H17AR’I’-13LOCK AND THE STOKES-ADAMS SYNDROME.
or perforated. As an important addition toIexhibits the features characteristic either of a branch these mechanical methods lie employs the faradic and bundle lesion or of arborisation block. In cases of the galvanic current with his forceps as tho active complete A-V dissociation the idio-ventricular rhythm electrode, and maintains that by this means the current appears to be controlled by a centre situated between is more exactly limited to the ear than by other means, the A-V node and the bifurcation of the bundle of though he recognises the disadvantage that the con- His, and during the periods of ventricular asystole, sequent inflammation and desquamation of the drum which cliaracterise the Stokes-Adams syndrome, there may prevent a repetition of the treatment for a fort- is a temporary functional discontinuity between thenight. Further, he has used electrolysis to produce a idio-ventricular centre and the mass of the ventricular perforation of the membrana tympani, and lie suggests, muscle. though he has not tried, the same method to divide THE WORKS DOCTOR IN FRANCE. adhesions and destroy thickenings in the region of the DURING the war the necessity of protecting the fenestra ovalis. He also advises ionisation with the aid of these forceps in cases with perforation of the supply of labour was the principal occupation of the drum, but has not yet employed it ; it is difficult to French Ministry of Munitions. If the sacrifice of the see what advantages this can have over the ordinary workers’ health had gone on as at the outset, production simple method of ionisation, which is a well-established would have come to a standstill ; accordingly pretreatment for aural suppuration and of which Dr. cautions were taken to select the right type of worker Molinié does not appear to have heard. for particular jobs and to provide medical superFrom the description of these ingenious but elabo- vision in the workshops. During this time of stress, rate forms of treatment the reader will turn eagerly industrial physicians were installed in most of the to the final chapter on results, to find there little munition factories, and the workers themselves Prof. Etienne Martin, who encouragement to justify a method which must always recognised their value. cause inflammation of the drum with a risk of more tells the story in a recent issue of the Journal de serious damage. The hearing has not been found to Medecine de Lyon, assures us that the workers are undergo any appreciable alteration, though the now anxious to retain these medical services in author believes that the progress of deafness has been factories. In France the workers’ laws form a delayed ; tinnitus of catarrhal or post-suppurative labour code, which treats successively the work origin has usually been benefited, and even a few contract, wages, placing of workers, duration of work, cases of otosclerotic tinnitus have been improved, by night work, weekly rest, hygiene and security of the the mechanical treatment, while the claim is made that workers, and the inspection of the work. Special tinnitus of nervous origin without objective signs is regulations were miposed later on certain dangerous often satisfactorily relieved by the electrical method. industries. Where, for instance, a candidate for No figures are given of the numbers of cases treated employment will be exposed to the risk of lead or of the percentage of those improved, and the poisoning a visit to the employment office is enforced, impression is gained that, while Dr. Molinie has made and a medical certificate must be produced to the a courageous attempt to relieve where treatment has effect that he has not, at that time, any symptoms of lead poisoning, nor any disease likely to be aggrapreviously failed, the problem is not yet solved. vated by lead; this certificate must be renewed one month after engagement, and thereafter once a HEART-BLOCK AND THE STOKES-ADAMS quarter. Analogous precautions are imposed upon SYNDROME. industries concerned with mercury, glass-making, THE advance in our knowledge of the mechanism animal hair, and compressed air. Here we have of heart-block, which resulted from the introduction of something analogous in our own factory inspection, the polygraphic and electro-cardiographic methods, but in France all the large industries consider an was at first confined to those forms in which the con- industrial physician a necessity, although they are not ductivity between auricle and ventricle was impaired. obliged to employ a doctor by the labour code. Prof. More recently a considerable number of observations, Martin sets out as follows the various directions in " both clinical and experimental, have been published which the " medecin d’usine can be of service. 1. For putting into force the protective hygienic measures, concerning another variety of block which involves the Purkinje system below the A-V node. In a well- present or future, which constitute the labour code. 2. For obtaining a rational recruitment of the labour illustrated paper in the Lyon Medical Journal of and for the elimination of the sick and carriers supply a Dr. L. Gallavardin records series of 51 Sept. 20th, of disease who might infect their comrades. cases of heart-block which have come under his own 3. For exercising the indispensable control of the employer personal observation, and discusses various points of in all accidents, industrial diseases, and invalidity insurance. interest as exemplified by this group. The cases he 4. For minimising the effects of working accidents by divides into two main classes : (a) those exhibiting rendering immediate first-aid.
thinned,
--
5. For managing the surgery, works of assistance, or auriculo-ventricular block characterised by impairment of conductivity from auricle to ventricle ; and beneficences which have been created by the management. " The cooperation here suggested between doctor (b) those with " nodo-ventricular block in which the lesion is presumably situated distal to the A-V node. and employer is very close, and Prof. Martin meets Both lesions are frequently associated with one another some of the familiar objections which have been in the same case, and the importance of differentiating raised to it. The most serious from the workers’ between them lies in the functional manifestations to standpoint is the interference with the so-called But it is, as Prof. Martin points which they give rise. In the former group, even when liberty of labour. auriculo-ventricular dissociation is complete, the func- out, in the workers’ own interest that only such as are tional activity of the heart may still be maintained by fit for employment shall be taken on. The disease the appearance of an idio-ventricular rhythm, and, carrier is a risk to his comrades. The medical visit once the idio-ventricular rhythm is established, Stokes- before engagement is not for the purpose of rejecting Adams attacks will occur only if the case is complicated the mutilated or the infirm, but to protect them from by the addition of nodo-ventricular block. But it is aggravation of their infirmity and to place them not only the more prolonged periods of ventricular according to their working ability. To avoid the asystole which, according to Dr. Gallavardin, are works doctor coming into unfair competition with attributable to nodo-ventricular block, for he points the general practitioner the author suggests that he out that simple intermissions of the pulse due to heart- shall be paid by the employer, and thinks that a block are not infrequently met with in cases in which part-timer should be restrained from treating a there is no evidence of impaired conductivity between worker outside the factory, except by special request. auricle and ventricle. Such incidents suggest thatBut he points out that full-time doctors would more the lapse of the ventricle is due to involvement of the, readily secure the cooperation of general practitioners Partial nodo-ventricularin the neighbourhood. Prof. Martin lays great stress nodo-ventricular region. block may be recognised graphically by alterations inL on the collaboration with the employer, which puts the the ventricular complex of the electrocardiogram,whichworks doctor in a position quite apart from that of a