- Email: [email protected]
MENINGITIS FOLLOWING SPINAL ANÆSTHESIA
352 RETURN OF THE BLOOD TO THE HEART SIR,-The answer to Dr. Penman’s question is very simple. When a tourniquet is applied for the purpose of an intravenous injection the dilated veins become more
prominent on clenching the fist because they are pushed against the skin by the swollen and hardened musclebellies. If the fist is kept clenched this prominence may in the next few seconds become yet more pronounced as more blood enters the arm, but it is no greater if the fist is alternately opened and elenehed. Before Dr. Penman’s letter appeared three of my colleagues came to me with the same question. By a
demonstration on the arm of one of them I convinced them that this observation was correct. The idea that alternate contraction and relaxation of the muscles increases the distension of the veins by a pumping action is an excellent, example of the facility with which the senses can be deceived and practice influenced by belief in a preconceived theory which has no basis in fact. In this case the whole of the profession seems to have been taken in. FF. ROBERTS. Cambridge. MENINGITIS FOLLOWING SPINAL ANÆSTHESIA R SIR,—Your correspondents have properly emphasised two major factors which may give rise to infection during the administration of a spinal aneasthetic-namely, the (ab)use of spirit and of " sterile distilled water." But insufficient attention is paid to the certain-contamination of the needle if it is held in the bare fingers, whether or not the hands have been thoroughly washed, for the skin If the hands are wet, can never be rendered sterile. however carefully one handles the needle, it is certain to get moistened and contamination has then occurred. Gloves are the obvious precaution, but there is a simple alternative as suggested by Dr. Mills. The needle is held through a small sterile towel, the hands being absolutely dry. To ensure their dryness it is better not to wash up ; the hands are then consciously " recognised as dirty " and a perfect no-touch technique will be practised. Slight practice is necessary to acquire the knack, but once obtained there is a great saving of time. Many thousands of lumbar punctures must have been performed in this neurosurgical unit, by this method of holding the needle through a towel, with never a case of resultant meningitis. It is absolutely reliable, and I believe practised by the entire neurosurgical ,
fraternity. Neurosurgical Unit, Chase Farm Hospital and London Hospital.
D. W. C. NORTHFIELD.
PREGNANCY AND PULMONARY LOBECTOMY SiR,-In your issue of Dec. 16 last Mr. Graham Bryce and Miss Mills remark that there are few recorded cases of pregnancy following pulmonary lobectomy or pneumonectomy. The following somewhat unusual case may therefore be worth recording. A single girl of 22 was referred on Jan. 4, 1943, to the
from the tuberculosis clinic for " ? non-tuberculous unilateral bronchiectasis of the left lung" ; surgical resection of the lung was suggested. She was admitted under the care of Dr. S. B. Benton, and investigations in hospital led to the diagnosis of congenital cystic bronchiectasis of the left lung. The right lung was found to be free from disease by clinical and bronchographic examinations. Her physique was moderate, stature below average, and weight 6 st. 8 lb. A definite midthoracic scoliosis to the right was present, which had been treated at an orthopaedic clinic’when she was 12 years old. Mr. G. A. Mason did a left pneumonectomy on Feb. 20, and she made a good immediate recovery. On March 8 it was noticed that she was 16-18 weeks’ pregnant. Her chest condition was not such as to warrant interruption of the pregnancy, but after arrangements had been made to discharge her from hospital, she had a spontaneous abortion on March 27. The foetus and placenta were macerated and the foetus had evidently died some considerable time before. The abortion did not distress her cardiorespiratory system to any extent and she made a steady recovery from this unexpected intervening condition. She was discharged on April 6— 6t weeks after operation. Bronchoscopy and
Nottingham City Hospital
bronchography on May 22 showed her chest condition to be wholly satisfactory, Her weight was 6 st. 7 lb. Some two months later she became a hospital cleaner and she was able to do the work without any respiratory embarrassment. I saw her again at the hospital antenatal clinic on April 28, 1944, when she was 20-22 weeks’ pregnant. Her physical condition had improved beyond the standard before pneumonectomy, and- her weight was 7 st. 4 lb. Her chest wall was well healed and the right lung seemed normal. She pursued her employment as a cleaner, though advised not to do so, until August 1, when she was 34+ weeks’ pregnant. At this time her vital capacity was 1500 c.cm. An intermediate degree of pelvic contraction was present, but she was spontaneously delivered of a living female infant after a labour of 21 hours on August 28. The second stage occupied 2 hours and normal progress of the labour and her freedom from any cardiorespiratory embarrassment made assistance unnecessary. A careful watch was keptfor any undue dyspncea with each pain in the second stage, but none was observed. Nitrous oxide was given for the delivery only, and was tolerated well. Her puerperium was uneventful and she was discharged with her infant on Sept. 15. Since then her chest condition has remained satisfactory. This girl seems to have had an unusual tolerance to physical strain, despite her impaired physique. For many years she had to all intents only one normally functioning lung, and this had sufficient reserve to withstand the repeated obstetric demands made upon it. I must thank Dr. Benton for access to the case-records and Dr. C. L. C. Crowe, medical superintendent of the hospital, for permission to publish this case. J. B. COCHRANE. Nottins’ha.m. i
ACCOMMODATION FOR WOMEN STUDENTS SiB,—We, the undersigned, all received our medical education in different medical schools of London volun-
tary hospitals, which at that time were providing coeducation-namely, St. Mary’s, St. George’s, University College, and the London Hospital. In each hospital special accommodation for women students was limited to the provision of a cloakroom and lavatories, and in the common-room
officers
no
also.
special
case of one or two of them a For women resident medical accommodation was provided;
bedrooms, sitting-rooms, common-rooms, bathrooms, and lavatories were used, as they would be in an hotel or boarding-house, without any sex discrimination. It would therefore appear that there is no legitimate the score of lack of accommodation for delaying the entry of women medical students into the medical schools and hospitals which are at present reserved for men only. It should not be an insuperable difficulty, even in war-time, to provide a common-room (if it is thought necessary), a cloakroom, and lavatory accommodation for women medical students. DORIS G. LITHERLAND. DOROTHY M. HOWSE. MARY G. MITCHELL. PHŒBE WOODWARD. reason on
Bournemouth.
COUPONS FOR BELTS have SiR,-We just had a very good instance of the hardship which you mention in your annotation of March 10. We manufactured a surgical belt for a soldier in hospital with an incisional hernia. Our representative called,at the hospital with the completed belt, but as the patient had no clothing coupons the belt was brought back. Soldiers, we believe, get ten coupons a year, and the next issue is probably in June. As we understood the case was very urgent, we broke the law, which incidentally made us liable to fines or imprisonment, and supplied the patient with the belt. At the same time we notified the Board of Trade that we had done this. ALLEN & HANBURYS LTD. Wigmore Street, BV1. IN MEMORY OF SIR THOMAS BARLOW.-Of his hundred years Sir Thomas Barlow spent seventy on the staff of Great Ormond Street Hospital, and the hospital felt him so peculiarly their own that they held a small " family " service in his honour at their chapel on March 7. Sir Robert Hutchison, who was Sir Thomas’s house-physician at the hospital nearly fifty years ago, spoke at the service and said that Barlow would be remembered both for what he did and for what he was.
i
j
’,
prominent on clenching the fist because they are pushed against the skin by the swollen and hardened musclebellies. If the fist is kept clenched this prominence may in the next few seconds become yet more pronounced as more blood enters the arm, but it is no greater if the fist is alternately opened and elenehed. Before Dr. Penman’s letter appeared three of my colleagues came to me with the same question. By a
demonstration on the arm of one of them I convinced them that this observation was correct. The idea that alternate contraction and relaxation of the muscles increases the distension of the veins by a pumping action is an excellent, example of the facility with which the senses can be deceived and practice influenced by belief in a preconceived theory which has no basis in fact. In this case the whole of the profession seems to have been taken in. FF. ROBERTS. Cambridge. MENINGITIS FOLLOWING SPINAL ANÆSTHESIA R SIR,—Your correspondents have properly emphasised two major factors which may give rise to infection during the administration of a spinal aneasthetic-namely, the (ab)use of spirit and of " sterile distilled water." But insufficient attention is paid to the certain-contamination of the needle if it is held in the bare fingers, whether or not the hands have been thoroughly washed, for the skin If the hands are wet, can never be rendered sterile. however carefully one handles the needle, it is certain to get moistened and contamination has then occurred. Gloves are the obvious precaution, but there is a simple alternative as suggested by Dr. Mills. The needle is held through a small sterile towel, the hands being absolutely dry. To ensure their dryness it is better not to wash up ; the hands are then consciously " recognised as dirty " and a perfect no-touch technique will be practised. Slight practice is necessary to acquire the knack, but once obtained there is a great saving of time. Many thousands of lumbar punctures must have been performed in this neurosurgical unit, by this method of holding the needle through a towel, with never a case of resultant meningitis. It is absolutely reliable, and I believe practised by the entire neurosurgical ,
fraternity. Neurosurgical Unit, Chase Farm Hospital and London Hospital.
D. W. C. NORTHFIELD.
PREGNANCY AND PULMONARY LOBECTOMY SiR,-In your issue of Dec. 16 last Mr. Graham Bryce and Miss Mills remark that there are few recorded cases of pregnancy following pulmonary lobectomy or pneumonectomy. The following somewhat unusual case may therefore be worth recording. A single girl of 22 was referred on Jan. 4, 1943, to the
from the tuberculosis clinic for " ? non-tuberculous unilateral bronchiectasis of the left lung" ; surgical resection of the lung was suggested. She was admitted under the care of Dr. S. B. Benton, and investigations in hospital led to the diagnosis of congenital cystic bronchiectasis of the left lung. The right lung was found to be free from disease by clinical and bronchographic examinations. Her physique was moderate, stature below average, and weight 6 st. 8 lb. A definite midthoracic scoliosis to the right was present, which had been treated at an orthopaedic clinic’when she was 12 years old. Mr. G. A. Mason did a left pneumonectomy on Feb. 20, and she made a good immediate recovery. On March 8 it was noticed that she was 16-18 weeks’ pregnant. Her chest condition was not such as to warrant interruption of the pregnancy, but after arrangements had been made to discharge her from hospital, she had a spontaneous abortion on March 27. The foetus and placenta were macerated and the foetus had evidently died some considerable time before. The abortion did not distress her cardiorespiratory system to any extent and she made a steady recovery from this unexpected intervening condition. She was discharged on April 6— 6t weeks after operation. Bronchoscopy and
Nottingham City Hospital
bronchography on May 22 showed her chest condition to be wholly satisfactory, Her weight was 6 st. 7 lb. Some two months later she became a hospital cleaner and she was able to do the work without any respiratory embarrassment. I saw her again at the hospital antenatal clinic on April 28, 1944, when she was 20-22 weeks’ pregnant. Her physical condition had improved beyond the standard before pneumonectomy, and- her weight was 7 st. 4 lb. Her chest wall was well healed and the right lung seemed normal. She pursued her employment as a cleaner, though advised not to do so, until August 1, when she was 34+ weeks’ pregnant. At this time her vital capacity was 1500 c.cm. An intermediate degree of pelvic contraction was present, but she was spontaneously delivered of a living female infant after a labour of 21 hours on August 28. The second stage occupied 2 hours and normal progress of the labour and her freedom from any cardiorespiratory embarrassment made assistance unnecessary. A careful watch was keptfor any undue dyspncea with each pain in the second stage, but none was observed. Nitrous oxide was given for the delivery only, and was tolerated well. Her puerperium was uneventful and she was discharged with her infant on Sept. 15. Since then her chest condition has remained satisfactory. This girl seems to have had an unusual tolerance to physical strain, despite her impaired physique. For many years she had to all intents only one normally functioning lung, and this had sufficient reserve to withstand the repeated obstetric demands made upon it. I must thank Dr. Benton for access to the case-records and Dr. C. L. C. Crowe, medical superintendent of the hospital, for permission to publish this case. J. B. COCHRANE. Nottins’ha.m. i
ACCOMMODATION FOR WOMEN STUDENTS SiB,—We, the undersigned, all received our medical education in different medical schools of London volun-
tary hospitals, which at that time were providing coeducation-namely, St. Mary’s, St. George’s, University College, and the London Hospital. In each hospital special accommodation for women students was limited to the provision of a cloakroom and lavatories, and in the common-room
officers
no
also.
special
case of one or two of them a For women resident medical accommodation was provided;
bedrooms, sitting-rooms, common-rooms, bathrooms, and lavatories were used, as they would be in an hotel or boarding-house, without any sex discrimination. It would therefore appear that there is no legitimate the score of lack of accommodation for delaying the entry of women medical students into the medical schools and hospitals which are at present reserved for men only. It should not be an insuperable difficulty, even in war-time, to provide a common-room (if it is thought necessary), a cloakroom, and lavatory accommodation for women medical students. DORIS G. LITHERLAND. DOROTHY M. HOWSE. MARY G. MITCHELL. PHŒBE WOODWARD. reason on
Bournemouth.
COUPONS FOR BELTS have SiR,-We just had a very good instance of the hardship which you mention in your annotation of March 10. We manufactured a surgical belt for a soldier in hospital with an incisional hernia. Our representative called,at the hospital with the completed belt, but as the patient had no clothing coupons the belt was brought back. Soldiers, we believe, get ten coupons a year, and the next issue is probably in June. As we understood the case was very urgent, we broke the law, which incidentally made us liable to fines or imprisonment, and supplied the patient with the belt. At the same time we notified the Board of Trade that we had done this. ALLEN & HANBURYS LTD. Wigmore Street, BV1. IN MEMORY OF SIR THOMAS BARLOW.-Of his hundred years Sir Thomas Barlow spent seventy on the staff of Great Ormond Street Hospital, and the hospital felt him so peculiarly their own that they held a small " family " service in his honour at their chapel on March 7. Sir Robert Hutchison, who was Sir Thomas’s house-physician at the hospital nearly fifty years ago, spoke at the service and said that Barlow would be remembered both for what he did and for what he was.
i
j
’,