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MANIPULATIVE SURGERY.
1057 of air ; if
now aspiration be applied to the upper bubbles of air will escape from the lower chamber, and, when the aspiration ceases, a corresponding amount of fluid will be drawn into the lower cavity ; if this process be repeated sufficiently, the cavity will be completely filled. To apply this process to the sinuses, the patient lies on the back with the head extended so that the chin is vertically over the external auditory meatus, two cubic centimetres of the fluid are introduced into one nostril and the other firmly closed, while the patient breathes through the open mouth to raise the palate. Intermittent suction is then applied for three minutes by means of a rubber ball and a closely fitting nozzle, to which Dr. Le Mee has added a manometer; the negative pressure should be equal to 180 mm. of mercury. The skiagrams are taken immediately in an erect posture, and the method is of value in revealing thickening and abnormalities of the mucous membrane as well as anatomical aberrations. The sphenoidal and posterior ethmoidal sinuses are the more easily filled by this method but, in any sinus which is infected, occlusion of the ostium may prevent entrance of the fluid; in the opinion of Le Mee and Bouchet, the non-entry of lipiodol shows that the sinus is severely affected and must be treated surgically and, on the other hand, every sinus which admits the entrance of the fluid has a good prospect of recovery and should not be submitted to operation, even though the usual rules would appear to indicate it. They lay great stress on the value of this sign, which it would be interesting to see confirmed in other quarters. The time of evacuation of a sinus may also be studied by this method ; according to these authors, half the liquid has normally disappeared in 24 hours, two-thirds by the following day, and no trace remains after four days. For treatment from 1 claim results a they good per cent. solution of argyrol; the method is very applicable to children in whom the sinuses are small but their ostia large, and it is especially useful in the treatment of the posterior sinuses, which are the more easily reached, in contradistinction to other methods by which these cavities are particularly inaccessible.
PHYSICAL SIGNS OF BUNDLE-BRANCH BLOCK. IF there are physical signs of bundle-branch blockI which may be elicited by ordinary clinical methods and without the aid of the electrocardiograph, these will obviously be of value. Attempts have been made to establish a connexion between this condition and certain signs discoverable at or near the cardiac apex on inspection palpation and auscultation, but the relation can hardly yet be considered proved. Dr. Maurice Campbell and Dr. S. S. Suzman in our last issue reported the case of a patient with
hypertension, paroxysmal dyspnoea, bundle-branch block, and gallop rhythm. At a later date both the block and the gallop rhythm had disappeared. However, both block of this type and gallop rhythm are common findings in a heart whose reserve is seriously impaired, and the two signs may occur independently of one another. They may arise from a common cause-namely, the functional insufficiency of the heart muscle. Moreover, the commoner form of gallop rhythm is produced by the addition in early diastole of a third heart sound, while if bundle block be a cause of gallop rhythm would
expect the third sound to be located in early systole. In Campbell and Suzman’s case the electrocardiogram, taken after the disappearance one
of the characteristic bundle-block curve, presents
which have been repeatedly observed to and in the event of its disappearance, to succeed bundle-branch block. These consist of a well developed ventricular predominance, with a tall R wave and inverted T wave in lead I. This picture has usually been taken as indicating a severe degree of ventricular predominance, but from its frequent appearance as a stage in the development or recession of bundle-branch block, is considered by some to represent a mild grade of this form of block. J. T. King and D. MeEachernare of opinion that bundlebranch block can usually be recognised from physical signs. They find, in a series of 50 cases, a visible and palpable reduplication of the apex-beat in about 80 per cent. and a reduplication of the first sound in about 50 per cent. They have demonstrated a bifid apex-beat by photographing the movements of a straw attached to the apex directly on to a plate -a method which we owe to Parkinson-an electrocardiogram being taken at the same time. These tracings carry conviction, and it may be that with the cultivation of clinical technique a new sign of some value may be elicited by inspection and palpation of the cardiac apex.
changes precede,
-
MANIPULATIVE SURGERY.
THE medical profession on the whole is broadminded and does not shrink from acquiring information from any source provided that source can produce scientific evidence for its contentions. The practices of bone-setters have aroused the enthusiasm of certain sections of the public, who are unwearied in twitting medical men for refusing to learn from them. But what the public does not wholly realise is that there exist within the ranks of the profession orthopaedic surgeons who make a special and profound study of bone and joint diseases, who are well versed in the presumed mysteries of manipulative treatment and who, on account of their better training, more varied experience, wider outlook, and greater facilities do, in fact, practise bone-setting better and more safely than bone-setters themselves. The reason why, in spite of the existence of ortho-
paedic speciKalists, unqualified practitioners continue thrive, is because orthopaedic surgery has only comparatively recently become recognised as an important specialty ; so that a large proportion of general practitioners have not had the advantage of serving their apprenticeship in the orthopaedic department of their teaching hospital during their student days. These practitioners are apt not to recognise cases that would benefit by manipulation, and the patients are obliged to take the treatment in their own hands, when they seek the advice of bonesetters, whose services can be advertised in the lay press in a way that is not open to registered doctors. The remedy for this state of affairs will come only when every student is obliged to serve as dresser in an orthopaedic department before being allowed to sit for any qualifying examination. Practitioners who have missed this valuable experience need not, however, remain without expert guidance in this branch of orthopaedics. Some seven years ago we had occasion to notice favourably a book on Manipulative Surgery, by Mr. Timbrell Fishes,2 and on another page of this issue will be found an appreciation of a recent work by Mr. Blundell Bankart on the same subject. Such books are useful, for it is necessary to emphasise more strongly than has hitherto been done that orthopaedics as a specialtyis concerned not only with the prevention and to
1 Amer. Jour. Med. Sci., April, 1932, p. 445. 2 THE LANCET, 1925, ii., 1286.
1058 the L.C.C., for which she had a great admiration. The resentment expressed in a letter from the nursing staff of the hospital in question to the chairman of the central public health committee of the L.C.C. is a good example of the attitude of nurses already acclimatised to the aspirations of newcomers, which may sometimes stand in the way of desirable reforms. Some of them, so they say, preferred curtained cubicles to private rooms, were loth to leave them, and so forth. All this, and the fact that the probationer did not remain in the hospital long enough to appreciate the many advantages offered, are irrelevant. The A ROOM OF ONE’S OWN. was not that promised, and accommodation THE London County Council are developing a the chief lesson supplied to be learnt from the episode is the nursing service which already includes between 9000 danger of premature propaganda. and 10,000 women, and is likely to grow even larger in the future. Among the advantages offered to an THE VEGETATIVE NERVOUS CENTRES. entrant to this service are that, within its boundsthat is, without loss of pension rights-experience THE possible situation of the centres controlling may be gained in practically any branch of nursing, vegetative activities-to which we referred on except perhaps private nursing, and that it is aI April 16th-is considered in greater detail by E. A. definite policy of the Council to encourage interchange SpiegeF and by J. Beattie.2 Spiegel indicates the and promotion between various hospitals and depart- difficulties encountered in attempting experimentally ments. Moreover, a uniform scale of salaries has to demonstrate a functional rapport between a given been devised ; the hours of work have been reduced organ and any definite area in the brain. The chief to 56 a week day duty, including a period for difficulty lies in the fact that visceral, as opposed to lectures, and the aim is to reduce them to 54 a week somatic, activity is largely independent of central as soon as practicable ; and one weekly rest day in nervous control and is normally a matter of more seven is assured. In some of the L.C.C. hospitals local reflexes. Consequently, experimental lesions the trained staff nurse who prefers to live out has an of the afferent or efferent nervous connexions of opportunity of doing so, her initial salary of E65 a the viscera rarely produce dramatic changes in year, including board while on duty, being supple- function. Even when changes do take place it is not mented by a living-out allowance of 90; sisters easy to be sure that they are not indirect consequences receive an initial salary of 90, including board of altered activity of the endocrine glands. Spiegel while on duty, with non-resident allowance of 130. also points out that the various nuclei vegetative THE LANCET Commission on Nursing recorded are no means sharply distinct from one another. by evidence that the innovation was regarded as most He concedes, however, that the hypothalamics successful by the authorities, and we learn that 500 may be divided into two parts, the one controlling of the trained nursing staff now live out. It is the pituitary gland, the other supplying the viscera patently the aim of the Council to provide a via the spinal cord. Beattie, on the other hand, of teaching, accommodation, personal freedom, and is more explicit. He recognised three anatomical amenities which compares favourably with that subdivisions of the vegetative centre : an anterior provided at most voluntary hospitals. The immense or supra-optic nucleus, situated directly above the task of coordinating the practice at ’seventy-odd optic chiasma and bounded in front by the anterior hospitals, some of which fell under the administration commissure and behind by the pituitary stalk; of the central public health committee of the intermediate tuber cinereum surrounding like Council only two years ago, has been tackled with the and a posterior a collar the infundibular recess ; great vigour, and it was inevitable that inequalities nucleus spread out over the lateral wall of the third should continue to exist for a time. Accommodation ventricle behind the middle commissure and extending has been one of the most difficult problems, since in downwards to the Of these nuclei mamillary body. the interests of the patients and of the nurses them- he believes that the posterior controls sympathetic selves it was decided to enlist the services of 500 and the anterior activities. In parasympathetic An illustrated addition to the connexions mentioned extra nurses and probationers. above, the pamphlet, issued early last year in order to stimulate nuclei receive afferent fibres from the olfactory recruitment, contained the statement that " the areas and the optic thalamus, and send efferent L.C.C. nurse has, from her first day as probationer, fibres to the intermediate and posterior lobes of the It was a comfortably furnished room of her own." The close functional relationship pituitary gland. evidently the intention of the Council that this between the latter gland and the hypothalamus should be true before the pamphlet was issued, but (the " neuro-hypophyseal mechanism " of Cushing) though 3664 probationers (81 per cent.) do have is also illustrated by the observation of Popa and single rooms, 215 still occupy wooden cubicles, 92 Fielding3 that a part of the blood draining the curtain cubicles, and 529 share a bedroom. Following pituitary is diverted, as a portal " network, to a complaint by a probationer, who left a hospital the adjacent hypothalamus. irrigate after only four days, Miss Esther Rickards, F.R.C.S., The charting of the hypothalamus and the asses&drew the attention of the Council to the inaccuracy ment of its role in metabolic and visceral activity of the pamphlet in this respect, and it has now been form a of considerable importance. Its problem from nurses which her The protests withdrawn. solution should entail a cooperation between the action has aroused have been unmerited. At a neurologist and the "internist (to borrow a useful meeting of the London and National Society for American term) which should be to the advantage -Women’s Service held on May 5th to discuss the of both. Final Report of THE LANCET Commission on Nursing, 1 Bull. Johns Hopkins Hosp., April, 1932, p. 237. Miss Rickards took an opportunity of disclaiming 2 Canad. Med. Assoc. Jour., April, 1932, p. 400. intention of to do harm to the service 3 Jour. Anat., 1930, lxv., 88. any nursing correction of deformities, but also with the art and practice of moving joints for therapeutic purposes. Orthopaedic surgeons have acquired, in addition to manipulative skill, a training in differential diagnosis founded on a knowledge of general as well as regional pathology, and a patient who seeks help from a qualified man has all the resources of surgery at his disposal should manipulation be deemed unsuitable, or be unsuccessful in effecting a cure.
standard
I
I
"
"
now aspiration be applied to the upper bubbles of air will escape from the lower chamber, and, when the aspiration ceases, a corresponding amount of fluid will be drawn into the lower cavity ; if this process be repeated sufficiently, the cavity will be completely filled. To apply this process to the sinuses, the patient lies on the back with the head extended so that the chin is vertically over the external auditory meatus, two cubic centimetres of the fluid are introduced into one nostril and the other firmly closed, while the patient breathes through the open mouth to raise the palate. Intermittent suction is then applied for three minutes by means of a rubber ball and a closely fitting nozzle, to which Dr. Le Mee has added a manometer; the negative pressure should be equal to 180 mm. of mercury. The skiagrams are taken immediately in an erect posture, and the method is of value in revealing thickening and abnormalities of the mucous membrane as well as anatomical aberrations. The sphenoidal and posterior ethmoidal sinuses are the more easily filled by this method but, in any sinus which is infected, occlusion of the ostium may prevent entrance of the fluid; in the opinion of Le Mee and Bouchet, the non-entry of lipiodol shows that the sinus is severely affected and must be treated surgically and, on the other hand, every sinus which admits the entrance of the fluid has a good prospect of recovery and should not be submitted to operation, even though the usual rules would appear to indicate it. They lay great stress on the value of this sign, which it would be interesting to see confirmed in other quarters. The time of evacuation of a sinus may also be studied by this method ; according to these authors, half the liquid has normally disappeared in 24 hours, two-thirds by the following day, and no trace remains after four days. For treatment from 1 claim results a they good per cent. solution of argyrol; the method is very applicable to children in whom the sinuses are small but their ostia large, and it is especially useful in the treatment of the posterior sinuses, which are the more easily reached, in contradistinction to other methods by which these cavities are particularly inaccessible.
PHYSICAL SIGNS OF BUNDLE-BRANCH BLOCK. IF there are physical signs of bundle-branch blockI which may be elicited by ordinary clinical methods and without the aid of the electrocardiograph, these will obviously be of value. Attempts have been made to establish a connexion between this condition and certain signs discoverable at or near the cardiac apex on inspection palpation and auscultation, but the relation can hardly yet be considered proved. Dr. Maurice Campbell and Dr. S. S. Suzman in our last issue reported the case of a patient with
hypertension, paroxysmal dyspnoea, bundle-branch block, and gallop rhythm. At a later date both the block and the gallop rhythm had disappeared. However, both block of this type and gallop rhythm are common findings in a heart whose reserve is seriously impaired, and the two signs may occur independently of one another. They may arise from a common cause-namely, the functional insufficiency of the heart muscle. Moreover, the commoner form of gallop rhythm is produced by the addition in early diastole of a third heart sound, while if bundle block be a cause of gallop rhythm would
expect the third sound to be located in early systole. In Campbell and Suzman’s case the electrocardiogram, taken after the disappearance one
of the characteristic bundle-block curve, presents
which have been repeatedly observed to and in the event of its disappearance, to succeed bundle-branch block. These consist of a well developed ventricular predominance, with a tall R wave and inverted T wave in lead I. This picture has usually been taken as indicating a severe degree of ventricular predominance, but from its frequent appearance as a stage in the development or recession of bundle-branch block, is considered by some to represent a mild grade of this form of block. J. T. King and D. MeEachernare of opinion that bundlebranch block can usually be recognised from physical signs. They find, in a series of 50 cases, a visible and palpable reduplication of the apex-beat in about 80 per cent. and a reduplication of the first sound in about 50 per cent. They have demonstrated a bifid apex-beat by photographing the movements of a straw attached to the apex directly on to a plate -a method which we owe to Parkinson-an electrocardiogram being taken at the same time. These tracings carry conviction, and it may be that with the cultivation of clinical technique a new sign of some value may be elicited by inspection and palpation of the cardiac apex.
changes precede,
-
MANIPULATIVE SURGERY.
THE medical profession on the whole is broadminded and does not shrink from acquiring information from any source provided that source can produce scientific evidence for its contentions. The practices of bone-setters have aroused the enthusiasm of certain sections of the public, who are unwearied in twitting medical men for refusing to learn from them. But what the public does not wholly realise is that there exist within the ranks of the profession orthopaedic surgeons who make a special and profound study of bone and joint diseases, who are well versed in the presumed mysteries of manipulative treatment and who, on account of their better training, more varied experience, wider outlook, and greater facilities do, in fact, practise bone-setting better and more safely than bone-setters themselves. The reason why, in spite of the existence of ortho-
paedic speciKalists, unqualified practitioners continue thrive, is because orthopaedic surgery has only comparatively recently become recognised as an important specialty ; so that a large proportion of general practitioners have not had the advantage of serving their apprenticeship in the orthopaedic department of their teaching hospital during their student days. These practitioners are apt not to recognise cases that would benefit by manipulation, and the patients are obliged to take the treatment in their own hands, when they seek the advice of bonesetters, whose services can be advertised in the lay press in a way that is not open to registered doctors. The remedy for this state of affairs will come only when every student is obliged to serve as dresser in an orthopaedic department before being allowed to sit for any qualifying examination. Practitioners who have missed this valuable experience need not, however, remain without expert guidance in this branch of orthopaedics. Some seven years ago we had occasion to notice favourably a book on Manipulative Surgery, by Mr. Timbrell Fishes,2 and on another page of this issue will be found an appreciation of a recent work by Mr. Blundell Bankart on the same subject. Such books are useful, for it is necessary to emphasise more strongly than has hitherto been done that orthopaedics as a specialtyis concerned not only with the prevention and to
1 Amer. Jour. Med. Sci., April, 1932, p. 445. 2 THE LANCET, 1925, ii., 1286.
1058 the L.C.C., for which she had a great admiration. The resentment expressed in a letter from the nursing staff of the hospital in question to the chairman of the central public health committee of the L.C.C. is a good example of the attitude of nurses already acclimatised to the aspirations of newcomers, which may sometimes stand in the way of desirable reforms. Some of them, so they say, preferred curtained cubicles to private rooms, were loth to leave them, and so forth. All this, and the fact that the probationer did not remain in the hospital long enough to appreciate the many advantages offered, are irrelevant. The A ROOM OF ONE’S OWN. was not that promised, and accommodation THE London County Council are developing a the chief lesson supplied to be learnt from the episode is the nursing service which already includes between 9000 danger of premature propaganda. and 10,000 women, and is likely to grow even larger in the future. Among the advantages offered to an THE VEGETATIVE NERVOUS CENTRES. entrant to this service are that, within its boundsthat is, without loss of pension rights-experience THE possible situation of the centres controlling may be gained in practically any branch of nursing, vegetative activities-to which we referred on except perhaps private nursing, and that it is aI April 16th-is considered in greater detail by E. A. definite policy of the Council to encourage interchange SpiegeF and by J. Beattie.2 Spiegel indicates the and promotion between various hospitals and depart- difficulties encountered in attempting experimentally ments. Moreover, a uniform scale of salaries has to demonstrate a functional rapport between a given been devised ; the hours of work have been reduced organ and any definite area in the brain. The chief to 56 a week day duty, including a period for difficulty lies in the fact that visceral, as opposed to lectures, and the aim is to reduce them to 54 a week somatic, activity is largely independent of central as soon as practicable ; and one weekly rest day in nervous control and is normally a matter of more seven is assured. In some of the L.C.C. hospitals local reflexes. Consequently, experimental lesions the trained staff nurse who prefers to live out has an of the afferent or efferent nervous connexions of opportunity of doing so, her initial salary of E65 a the viscera rarely produce dramatic changes in year, including board while on duty, being supple- function. Even when changes do take place it is not mented by a living-out allowance of 90; sisters easy to be sure that they are not indirect consequences receive an initial salary of 90, including board of altered activity of the endocrine glands. Spiegel while on duty, with non-resident allowance of 130. also points out that the various nuclei vegetative THE LANCET Commission on Nursing recorded are no means sharply distinct from one another. by evidence that the innovation was regarded as most He concedes, however, that the hypothalamics successful by the authorities, and we learn that 500 may be divided into two parts, the one controlling of the trained nursing staff now live out. It is the pituitary gland, the other supplying the viscera patently the aim of the Council to provide a via the spinal cord. Beattie, on the other hand, of teaching, accommodation, personal freedom, and is more explicit. He recognised three anatomical amenities which compares favourably with that subdivisions of the vegetative centre : an anterior provided at most voluntary hospitals. The immense or supra-optic nucleus, situated directly above the task of coordinating the practice at ’seventy-odd optic chiasma and bounded in front by the anterior hospitals, some of which fell under the administration commissure and behind by the pituitary stalk; of the central public health committee of the intermediate tuber cinereum surrounding like Council only two years ago, has been tackled with the and a posterior a collar the infundibular recess ; great vigour, and it was inevitable that inequalities nucleus spread out over the lateral wall of the third should continue to exist for a time. Accommodation ventricle behind the middle commissure and extending has been one of the most difficult problems, since in downwards to the Of these nuclei mamillary body. the interests of the patients and of the nurses them- he believes that the posterior controls sympathetic selves it was decided to enlist the services of 500 and the anterior activities. In parasympathetic An illustrated addition to the connexions mentioned extra nurses and probationers. above, the pamphlet, issued early last year in order to stimulate nuclei receive afferent fibres from the olfactory recruitment, contained the statement that " the areas and the optic thalamus, and send efferent L.C.C. nurse has, from her first day as probationer, fibres to the intermediate and posterior lobes of the It was a comfortably furnished room of her own." The close functional relationship pituitary gland. evidently the intention of the Council that this between the latter gland and the hypothalamus should be true before the pamphlet was issued, but (the " neuro-hypophyseal mechanism " of Cushing) though 3664 probationers (81 per cent.) do have is also illustrated by the observation of Popa and single rooms, 215 still occupy wooden cubicles, 92 Fielding3 that a part of the blood draining the curtain cubicles, and 529 share a bedroom. Following pituitary is diverted, as a portal " network, to a complaint by a probationer, who left a hospital the adjacent hypothalamus. irrigate after only four days, Miss Esther Rickards, F.R.C.S., The charting of the hypothalamus and the asses&drew the attention of the Council to the inaccuracy ment of its role in metabolic and visceral activity of the pamphlet in this respect, and it has now been form a of considerable importance. Its problem from nurses which her The protests withdrawn. solution should entail a cooperation between the action has aroused have been unmerited. At a neurologist and the "internist (to borrow a useful meeting of the London and National Society for American term) which should be to the advantage -Women’s Service held on May 5th to discuss the of both. Final Report of THE LANCET Commission on Nursing, 1 Bull. Johns Hopkins Hosp., April, 1932, p. 237. Miss Rickards took an opportunity of disclaiming 2 Canad. Med. Assoc. Jour., April, 1932, p. 400. intention of to do harm to the service 3 Jour. Anat., 1930, lxv., 88. any nursing correction of deformities, but also with the art and practice of moving joints for therapeutic purposes. Orthopaedic surgeons have acquired, in addition to manipulative skill, a training in differential diagnosis founded on a knowledge of general as well as regional pathology, and a patient who seeks help from a qualified man has all the resources of surgery at his disposal should manipulation be deemed unsuitable, or be unsuccessful in effecting a cure.
standard
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I
"
"