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INJURY FROM ELECTRIC WASHING-MACHINES
77 50 mm. Hg, and he was no longer with his heart. But to my annoyance he spoilt this satisfactory picture of recovery by complaining of a Twice while new symptom-sudden collapse while walking. shopping in the town he suddenly felt giddy and had to sit down. His legs gave way beneath him ; objects tended to rotate ; and he had a rather severe occipital headache, but Examination showed no nystagmus ; no nausea or tinnitus. with his phobia about tabes he has always had some rombergism, and to elicit the knee-jerks some reinforcement has been needed. Once again I attributed the " attacks " to psychogenic I argued that this man, with his fear of angina, causes. was collapsing out of doors as a defence against exercise that might strain a heart he believed to be vulnerable. I reiterated my assurances about the state of his myocardium, and reduced the dose of sodium amytal to gr. 2 a day. CASE 3.-The next day I visited a woman, aged 50, the headmistress of a school. She is of manic-depressive temperament, and some years ago was operated on for exophthalmic goitre. She was sleeping badly, feeling " end-oftermish," and bothered by a possessive attachment formed by a member of her staff. I prescribed sodium amytal gr. 3 at night. Some weeks later she reported that she felt extremely weak in the legs ; that it took her ten minutes to walk 200 yards to the post-box ; and that she feared to cross the road and would not go out alone lest she collapsed.
blood-pressure dropped by
precoccupied
Electromyographic studies have shown that sodium amytal lowers toni-is.1- In cats the lethal dose varies widely, and some which partly recovered had a persistent syndrome of altered reflexes and abnormal posture and gait ; pathological changes were confined to the Purkinje cell layer in the cerebellum.2 With these findings in mind, I reviewed the 3 cases. Re-examination of the lst patient showed that she had very flabby calf muscles ; and the ankle-jerk on the left side could not be elicited. There was no nystagmus and no incoordination in the upper limbs. Sodium amytal was replaced by a bromide and soluble-barbitone mixture. A week later she was free of vertigo and had not collapsed again. The 2nd patient was also found to have very poor muscle tone in the calves ; both ankle-jerks were, however, present. There was no nystagmus and no incoordination in the upper limbs. Sodium amytal was gradually replaced by phenobarbitone and the patient has not collapsed again. The 3rd patient had no evidence of altered tendon-reflexes and no incoordination or ataxia ; but muscle tone was poor. Sodium amytal was stopped and phenobarbitone prescribed. In less than three days she was walking alone with confidence, and had lost the vertigo.
The idiosyncrasy in these cases may have been associated with hepatic dysfunction, which is said to increase toxicity.3 Sodium amytal belongs to the group of barbiturates which are chiefly broken down in the liver (though not to the same extent as thiopentone and hexobarbitone) ; only 3-5% is excreted in the urine, compared with 25% of phenobarbitone and 30% of allobarbitone. Of the 3 cases described here, the 1st had no history or evidence of hepatic disorder ; the 2nd was known to have gall-stones and had had several attacks of biliary colic ; and the 3rd may be presumed to have had is usually hepatic dysfunction since hyperthyroidism associated with defective liver function.44 This series illustrates some of the difficulties of assessing the origin of symptoms in patients with psychiatric or psychosomatic disorders. It is easy to accept as functional, symptoms which actually have an organic cause ; and but for the coincidence of 3 cases arising within a fortnight, this syndrome of cerebellar dysfunction following administration of amytal might easily have been overlooked. FRANK BODMAN. Bristol. 1. Jacobson, E. Ann. intern. Med. 1944, 21, 455. 2. Skrop, K., Gold, H. J. Pharmacol. 1945, 88, 260. 3. Cushny’s Pharmacology and Therapeutics. Edited by A. Grollman, D. Slaughter. London, 1947 ; p. 316. 4. Langdon-Brown, W., Simpson, S. L. Medical Annual. Bristol,
1944; p. 319.
TRAVELLING EXHIBITIONS ON CLEANLINESS SiR,-May I assure Dr. Forster, who wrote last week, that the Central Council for Health Education is dealing
with the problem of its present stands being rather cumbersome. By September, 250 light frames, on which exhibition pieces can be displayed, will be available to local health authorities, making treble the number of stands in circulation. These stands have been designed so that they can, if necessary, be carried in a private car, and assembled and dismantled in a few minutes. Reports from medical officers of health indicate that where stands have been shown in factories, they have proved very popular, and the Council hopes that more approaches to this tvDe of audience will be arranged. Central Council for Health
ROBERT SUTHERLAND
Education, Tavistock House, London, W.C.1.
Medical Adviser and
Secretary.
INJURY FROM ELECTRIC WASHING-MACHINES
SiR,-In the U.S.A. housewives and children
are not automatic washing-machines. uncommonly injured by In this city a woman had her arm pummelled for half an hour before she freed it by the slow process of dragging the machine to the switch, which she turned off. The injury may be severe, and may be followed by extensive loss of skin through damage to the cutaneous blood-supply. Injury to the muscles of the arm and forearm may seriously limit the activity of the fingers and hands. The condition calls for prompt treatment in hospital. Immediate application of an efficient pressure bandage prevents collection of subcutaneous exudate. Fine judgment is needed in the use of the pressure bandage and of rest ; the time for starting active treatment must be chosen with care because cedema may recur. Though at first the damage may appear very slight, ultimately destruction may be great. In the late stages the victim presents with an enormous subcutaneous hoematoma, extending over the whole length of the forearm. There may be areas of skin necrosis and associated infection ; and severe oedema and puffiness develops in the hand, probably owing to obstruction of the lymphatic channels draining this region. There is an area of relatively normal appearance around the wrist where the skin seems to be least affected, and the whole appearance is somewhat akin to that of an inverted champagne bottle. Fortunately, in the British Isles domestic washingmachines with electrically operated rollers are rare, so the condition is unlikely to be seen ; but a safety device should be installed on any machines that have
Boston, Mass.
J. D. WADE.
ANOXIA IN THE FŒTUS AND NEWBORN an
SIR,—In your leading article last week you perpetuate argument concerning periodic breathing which
does not seem to have any justification. You say : " The alternating hyperpnoea and apncea commonly seen in premature infants is a characteristic of ’mountain sickness’ and gives place to regular respirations in an Premature infants with oxygen-enriched atmosphere.
periodic respiration should therefore be given oxygen...." This suggests that the periodic breathing of the premature infant has the same physiological basis as the anoxic periodic breathing of mountain sickness, and neglects facts of fundamental importance. These are : (1) that periodic breathing is almost as common in the full-term as in the premature infant ; (2) that while this periodic breathing is occurring in the newborn, generally there is no cyanosis, which sharply distinguishes
blood-pressure dropped by
precoccupied
Electromyographic studies have shown that sodium amytal lowers toni-is.1- In cats the lethal dose varies widely, and some which partly recovered had a persistent syndrome of altered reflexes and abnormal posture and gait ; pathological changes were confined to the Purkinje cell layer in the cerebellum.2 With these findings in mind, I reviewed the 3 cases. Re-examination of the lst patient showed that she had very flabby calf muscles ; and the ankle-jerk on the left side could not be elicited. There was no nystagmus and no incoordination in the upper limbs. Sodium amytal was replaced by a bromide and soluble-barbitone mixture. A week later she was free of vertigo and had not collapsed again. The 2nd patient was also found to have very poor muscle tone in the calves ; both ankle-jerks were, however, present. There was no nystagmus and no incoordination in the upper limbs. Sodium amytal was gradually replaced by phenobarbitone and the patient has not collapsed again. The 3rd patient had no evidence of altered tendon-reflexes and no incoordination or ataxia ; but muscle tone was poor. Sodium amytal was stopped and phenobarbitone prescribed. In less than three days she was walking alone with confidence, and had lost the vertigo.
The idiosyncrasy in these cases may have been associated with hepatic dysfunction, which is said to increase toxicity.3 Sodium amytal belongs to the group of barbiturates which are chiefly broken down in the liver (though not to the same extent as thiopentone and hexobarbitone) ; only 3-5% is excreted in the urine, compared with 25% of phenobarbitone and 30% of allobarbitone. Of the 3 cases described here, the 1st had no history or evidence of hepatic disorder ; the 2nd was known to have gall-stones and had had several attacks of biliary colic ; and the 3rd may be presumed to have had is usually hepatic dysfunction since hyperthyroidism associated with defective liver function.44 This series illustrates some of the difficulties of assessing the origin of symptoms in patients with psychiatric or psychosomatic disorders. It is easy to accept as functional, symptoms which actually have an organic cause ; and but for the coincidence of 3 cases arising within a fortnight, this syndrome of cerebellar dysfunction following administration of amytal might easily have been overlooked. FRANK BODMAN. Bristol. 1. Jacobson, E. Ann. intern. Med. 1944, 21, 455. 2. Skrop, K., Gold, H. J. Pharmacol. 1945, 88, 260. 3. Cushny’s Pharmacology and Therapeutics. Edited by A. Grollman, D. Slaughter. London, 1947 ; p. 316. 4. Langdon-Brown, W., Simpson, S. L. Medical Annual. Bristol,
1944; p. 319.
TRAVELLING EXHIBITIONS ON CLEANLINESS SiR,-May I assure Dr. Forster, who wrote last week, that the Central Council for Health Education is dealing
with the problem of its present stands being rather cumbersome. By September, 250 light frames, on which exhibition pieces can be displayed, will be available to local health authorities, making treble the number of stands in circulation. These stands have been designed so that they can, if necessary, be carried in a private car, and assembled and dismantled in a few minutes. Reports from medical officers of health indicate that where stands have been shown in factories, they have proved very popular, and the Council hopes that more approaches to this tvDe of audience will be arranged. Central Council for Health
ROBERT SUTHERLAND
Education, Tavistock House, London, W.C.1.
Medical Adviser and
Secretary.
INJURY FROM ELECTRIC WASHING-MACHINES
SiR,-In the U.S.A. housewives and children
are not automatic washing-machines. uncommonly injured by In this city a woman had her arm pummelled for half an hour before she freed it by the slow process of dragging the machine to the switch, which she turned off. The injury may be severe, and may be followed by extensive loss of skin through damage to the cutaneous blood-supply. Injury to the muscles of the arm and forearm may seriously limit the activity of the fingers and hands. The condition calls for prompt treatment in hospital. Immediate application of an efficient pressure bandage prevents collection of subcutaneous exudate. Fine judgment is needed in the use of the pressure bandage and of rest ; the time for starting active treatment must be chosen with care because cedema may recur. Though at first the damage may appear very slight, ultimately destruction may be great. In the late stages the victim presents with an enormous subcutaneous hoematoma, extending over the whole length of the forearm. There may be areas of skin necrosis and associated infection ; and severe oedema and puffiness develops in the hand, probably owing to obstruction of the lymphatic channels draining this region. There is an area of relatively normal appearance around the wrist where the skin seems to be least affected, and the whole appearance is somewhat akin to that of an inverted champagne bottle. Fortunately, in the British Isles domestic washingmachines with electrically operated rollers are rare, so the condition is unlikely to be seen ; but a safety device should be installed on any machines that have
Boston, Mass.
J. D. WADE.
ANOXIA IN THE FŒTUS AND NEWBORN an
SIR,—In your leading article last week you perpetuate argument concerning periodic breathing which
does not seem to have any justification. You say : " The alternating hyperpnoea and apncea commonly seen in premature infants is a characteristic of ’mountain sickness’ and gives place to regular respirations in an Premature infants with oxygen-enriched atmosphere.
periodic respiration should therefore be given oxygen...." This suggests that the periodic breathing of the premature infant has the same physiological basis as the anoxic periodic breathing of mountain sickness, and neglects facts of fundamental importance. These are : (1) that periodic breathing is almost as common in the full-term as in the premature infant ; (2) that while this periodic breathing is occurring in the newborn, generally there is no cyanosis, which sharply distinguishes