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ROAD ACCIDENTS IN DENMARK.
ANNOTATIONS BIOLOGICAL EFFECTS OF X RAYS. IN a noteworthy contribution Prof. Sidney Russ; and his co-workers record the results of experiments, carried out at the Middlesex Hospitalover a period of three years upon the cat and the rabbit. X rays of two different groups of wave-length were used corresponding to voltages of 150,000 and 230,000 respectively. The minimum dose of radiation necessary to produce the death of the animal was determined for each type of radiation, the whole ,
animal being exposed. It was found that the minimum lethal dose of the morepenetrating radiation was less than that of the other type in the ratio of 1 to 2-8. The tissue changes produced were most marked in
It was found that the effects of histamine did not bear any great similarity to X ray injections cachexia. An interesting feature of the research from the clinical point of view was the investigation of the effects of liver feeding on the development of the X ray anaeemia. Little or no influence upon the anaemia was detected, but in the animals to which liver had been administered there was an apparent increase in the sensitivity of the liver itself to the radiations. In all these animals more extensive destructive changes were observed in the liver as a result of the irradiation than in non-liver-fed animals with similar doses. This observation should lead to caution in the administration of liver extract in the hope of benefiting the anaemia produced by clinical irradiation. The authors point out that inferences drawn from the results of-experiments on lower animals may or may not be applicable to the human subject, and it is to be noted that the doses of radiation which they employed were relatively much greater than those applied in clinical work. Certain of the results however, have their clinical implications. Most important, perhaps, is the occurrence of septicaemia after irradiation of the abdomen, more particularly in view of the fact that mild intestinal lesions are not infrequently produced clinically in the treatment of malignant disease in the abdomen with heavy doses of radiation. Moreover, the fibrosis of the lungs which they describe agrees with the well-known clinical observations of Finzi and of Wintz ; if, as the authors believe, this condition is due to infection attempts might be made to combat it on appropriate lines. Another observation which may prove to be of possible clinical importance is the fact that recovery may appear in the leucocyte count after almost complete disappearance of leucocytes from the blood.
condition.
,small intestine, stomach, liver, spleen, respiratory tract, and white blood cells, although destructive changes could be produced in any tissue by the .administration of sufficiently large doses of radiation. In the small intestine there was widespread destruction ,of epithelium with petechial and even larger hoemorrhages ; infection occurring at a later stage appeared to be secondary to the destructive effects. Similar .changes were found in the stomach. The large intestine was more resistant. In the liver, congestion .and fatty infiltration were produced, with patches of necrosis. In the lungs changes were found in the - epithelium of the trachea and larger bronchi, with patchy areas of haemorrhagic and oedematous infiltration of the alveoli ; at later stages endothelial proliferation was observed in the alveolar walls and areas of fibrosis. When, however, the lungs alone were irradiated they were found to be resistant to radiation, the changes described being due in the In authors’ view to the occurrence of infection. the blood the effects were marked diminution in the 1ymphocyte content, followed later by diminution Nothing is known at present clinically as to the point of the polymorphonuclear cells; indeed, in some of the at which an X ray leucopenia becomes dangerous. .experiments the leucocytes almost disappeared from Finally, the authors suggest that further study might the blood for a time. Little or no effect was observed be undertaken of the effects of different diets during .on the platelets. X ray treatment in relation to the occurrence of X ray In some of the experiments localised regions only sickness. Certain differences in the general effects were exposed, and it was found that the typical changes between the cat and the rabbit might be due to the in the abdominal organs were only produced when diets of these animals. widely differing -these were directly irradiated. Bacteria were frequently found in the blood at a late stage. In the .authors’ opinion infection plays an important role ROAD ACCIDENTS IN DENMARK. in the production of tissue changes, entering the ONE of the measures which is assuredly calculated ! blood stream, it is believed, through the damaged in the long run to check the rising incidence of road intestinal wall. They refer to work of Cramer, accidents is an international pooling of experienceDrew, and Mottram, in which the entrance of a comparison of the various means adopted in the bacteria into the circulation was ascribed to thrombo- different countries to reduce this evil to a minimum. penia produced by the rays-an effect not observed It was, therefore, a most opportune study which in the present experiments. But Cramer and Dr. F. Svendsen, of the Danish Red Cross Society, his later inclined to the view colleagues presented in October to the fourteenth International that the thrombopenia was secondary, and that Red Cross Conference held in Brussels. After infection arose from the damaging effect upon the reviewing the statistics for the United States tissues. After large doses of radiation a state of briefly and showing that the deaths from road accidents cachexia was produced in the animals somewhat in 1929 in this country were nine times more numerous resembling the clinical condition known as "X ray than those in 1911, Dr. Svendsen gave the following sickness." In view of the fact that histamine or a statistics for Denmark for the first six months of similar substance is known to be liberated by tissues 1930. damaged by X rays, experiments were undertaken to determine if the absorption of such a substance might be responsible for the production of this __
1 The Physiological and Cytological Effects of Penetrating Rays upon the Cat and the Rabbit. By S. Russ, Samson Wright, H. A. Bulman, and L. H. Clark. Reprint from Proceedings of the Royal Society of Medicine, Section of ElectroTherapeutics, Oct., 1930, pp. 43-60.
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It should be noted that these figures deal only with accidents brought to the attention of the police, and
.
1357 do not include any of which the police took no cogni- nervous patients who cannot be relied upon to keep More than half of all the accidents-i.e. 2727, sance. during the operation, but when operating with occurred in Copenhagen, with a population of 708,600. avertin it is necessary to fix the eyeball firmly with The total population of Denmark is 3,518,000. As forceps during the incision, and this fixture is not so great a proportion of the accidents as 83-9 per cent. convenient as voluntary depression by the patient concerned motor-cars. In 55 per cent. of the traffic himself in obedience to the surgeon’s directions. accidents, the blame was laid exclusively on the Nevertheless any method of relieving apprehension drivers of motor-cars; in 13-7 per cent. bicyclists either before or during an operation on the eye is The main contra-indications were held responsible, in 8-5 per cent. pedestrians and worth a great deal. passengers; only in 2 per cent. were physical conditions, to the use of avertin are a serious degree of nephritis such as the state of the roads or visibility, held or severe disturbances of the liver. Old age is not responsible, and in 1-2 per cent. the state of the motor itself of importance, and though the authors of this vehicle. In the remainder. the responsibility was paper have not used the drug on children under 16, shared by a combination of two or more of the above there seems to be no reason why they should not do factors. Travellers familiar with the swarms of so. Avertin is a narcotic rather than an anaesthetic, bicyclists in the streets of Copenhagen will not be and one of its main advantages is that it can be used surprised to learn that they and pedestrians play to remove the patient’s anxiety for an hour or so a much more important part in the genesis of motor before operation. accidents than is the case in other countries. Among the improvements effected of late, the filling in of THE I.M.S. ditches beside the roads in order to provide bicycling IN an ample quarto volume Lieut.-Colonel D. G. paths deserves special mention. This reform has Crawford, whose " History of the I.M.S." did very been made possible by the arrangement which allots nearly as much for the service as Boswell did for part of the revenue from motor-car taxation to the ’, Dr. Johnson, has continued his labours in a volume local authorities. There are over 2500 doctors in ’, entitled " The Roll of the Indian Medical Service."l Denmark-i.e., one for every 1360 inhabitants, and The title is, perhaps, unfortunate, since it suggests if Copenhagen and its 629 doctors are discounted, a book on the lines of the Army List or Bradshaw. the proportion of doctors to inhabitants is as one to In fact Colonel Crawford takes the opportunity, in 1500. Thanks to the comparative density of the the introduction, of bringing his history up to date, population even in the country, the radius of action and apart from the brief individual records of service of a general hospital (of which there were 170 in 1929) many notes testify to the enterprise of the author in is seldom more than 15 kilometres. Copenhagen discovering interesting material in the most unexpected is served with 16 and the rest of the country with sources. The term I.M.S. has been used in a very 139 ambulances, the radius of whose action is about broad sense to cover the name of every man who 15 kilometres. For the purpose of comparison it served, even for the shortest period, in the East should be noted that the corresponding radius of India Company’s land medical services, including the action in England is about 25 kilometres. The part surgeons’ mates (assistant surgeons), who were not played by the Danish Red Cross with regard to commissioned officers, but served under warrants ambulances consists largely of financing them at issued by the colonels commanding their regiments. the outset ; later, they are often taken over and run Some remarkable histories may be deduced from the by the local authorities. laconic entries in this Roll. In the Madras list occurs the name of Mungo Park, the son of the famous African explorer, who had himself been surgeon’s AVERTIN IN OPHTHALMOLOGY. mate of an Indiaman. Readers of Lockhart’s " Life IN the British Journal of Ophthalmology for Scott " may remember how the father, having November Mr. 0. Gayer Morgan and Mr. J. M. obtained by influence the promise of a post in the Lees record their experience of rectal narcosis with company’s service, provided he could qualify as a avertin, based on more than 50 cases, including surgeon, rushed off to commence his medical studies, cataract extraction, acute glaucoma, excision, eviscera- and in six months time returned with the required tion, acute dacryocystitis, removal of the lacrymal diploma. Other even more striking examples of sac in chronic dacryocystitis, and minor and major adaptability are not difficult to find. A sergeant in plastic operations on the eyelids. They conclude the St. Helena garrison was given dispensary duties, that it is not a dangerous drug when given with care, and served in that capacity for 15 years and that it well merits a trial in ophthalmic surgery. was having assistant surgeon. Later he went to appointed The amount injected should never exceed 1.0g. per obtained the M.R.C.S., and returned England, kg. of body-weight, and the temperature should not eventually to become full surgeon at St. Helena. be more than 40° C., for otherwise the avertin may As time went on, and medicine rose in the social decompose and set up colitis; to ensure against this scale, I.M.S. men not only cured the wives and families two drops of Congo red solution can be added to of potentates, and shook pagoda trees, but distinguished 5 c.cm. of avertin, and decomposition will be shown themselves in many other ways, rendering eminent by appearance of a blue colour. If any of the solution, services in several branches of science, furnishing as injected, be returned by the patient it is unsafe administrators and diplomats, and to attempt to make up the amount by an extra distinguished commercial houses the names of which are founding injection, since absorption is so rapid that it is still household words in India. The firm of Jardine impossible to estimate how much of the drug has been and Mathieson was started by one of the company’s rejected. In most cases no other anaesthetic, general surgeons, and the well-known publishing house of or local, was used, but Morgan and Lees employed a Thacker and Co., which produces Colonel Crawford’s preliminary injection of morphia gr. with atropine work, is also said to have had a medical origin. gr. 1/100, though this is not considered necessary. The Roll contains several interesting appendices, If the claims of its advocates are confirmed the drug tables of honours and rewards, and analyses of has obvious advantages where a general anaesthetic notably 1 Roll of the Indian Medical Service, 1615-1930. Compiled is contra-indicated or a local anaesthetic is insufficient. Lieut-Col. D. G. Crawford, Bengal Medical Service, ret. In cataract extraction it is chiefly applicable to very by London : W. Thacker and Co. 1930. Pp. 711. 28s.
still
I
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animal being exposed. It was found that the minimum lethal dose of the morepenetrating radiation was less than that of the other type in the ratio of 1 to 2-8. The tissue changes produced were most marked in
It was found that the effects of histamine did not bear any great similarity to X ray injections cachexia. An interesting feature of the research from the clinical point of view was the investigation of the effects of liver feeding on the development of the X ray anaeemia. Little or no influence upon the anaemia was detected, but in the animals to which liver had been administered there was an apparent increase in the sensitivity of the liver itself to the radiations. In all these animals more extensive destructive changes were observed in the liver as a result of the irradiation than in non-liver-fed animals with similar doses. This observation should lead to caution in the administration of liver extract in the hope of benefiting the anaemia produced by clinical irradiation. The authors point out that inferences drawn from the results of-experiments on lower animals may or may not be applicable to the human subject, and it is to be noted that the doses of radiation which they employed were relatively much greater than those applied in clinical work. Certain of the results however, have their clinical implications. Most important, perhaps, is the occurrence of septicaemia after irradiation of the abdomen, more particularly in view of the fact that mild intestinal lesions are not infrequently produced clinically in the treatment of malignant disease in the abdomen with heavy doses of radiation. Moreover, the fibrosis of the lungs which they describe agrees with the well-known clinical observations of Finzi and of Wintz ; if, as the authors believe, this condition is due to infection attempts might be made to combat it on appropriate lines. Another observation which may prove to be of possible clinical importance is the fact that recovery may appear in the leucocyte count after almost complete disappearance of leucocytes from the blood.
condition.
,small intestine, stomach, liver, spleen, respiratory tract, and white blood cells, although destructive changes could be produced in any tissue by the .administration of sufficiently large doses of radiation. In the small intestine there was widespread destruction ,of epithelium with petechial and even larger hoemorrhages ; infection occurring at a later stage appeared to be secondary to the destructive effects. Similar .changes were found in the stomach. The large intestine was more resistant. In the liver, congestion .and fatty infiltration were produced, with patches of necrosis. In the lungs changes were found in the - epithelium of the trachea and larger bronchi, with patchy areas of haemorrhagic and oedematous infiltration of the alveoli ; at later stages endothelial proliferation was observed in the alveolar walls and areas of fibrosis. When, however, the lungs alone were irradiated they were found to be resistant to radiation, the changes described being due in the In authors’ view to the occurrence of infection. the blood the effects were marked diminution in the 1ymphocyte content, followed later by diminution Nothing is known at present clinically as to the point of the polymorphonuclear cells; indeed, in some of the at which an X ray leucopenia becomes dangerous. .experiments the leucocytes almost disappeared from Finally, the authors suggest that further study might the blood for a time. Little or no effect was observed be undertaken of the effects of different diets during .on the platelets. X ray treatment in relation to the occurrence of X ray In some of the experiments localised regions only sickness. Certain differences in the general effects were exposed, and it was found that the typical changes between the cat and the rabbit might be due to the in the abdominal organs were only produced when diets of these animals. widely differing -these were directly irradiated. Bacteria were frequently found in the blood at a late stage. In the .authors’ opinion infection plays an important role ROAD ACCIDENTS IN DENMARK. in the production of tissue changes, entering the ONE of the measures which is assuredly calculated ! blood stream, it is believed, through the damaged in the long run to check the rising incidence of road intestinal wall. They refer to work of Cramer, accidents is an international pooling of experienceDrew, and Mottram, in which the entrance of a comparison of the various means adopted in the bacteria into the circulation was ascribed to thrombo- different countries to reduce this evil to a minimum. penia produced by the rays-an effect not observed It was, therefore, a most opportune study which in the present experiments. But Cramer and Dr. F. Svendsen, of the Danish Red Cross Society, his later inclined to the view colleagues presented in October to the fourteenth International that the thrombopenia was secondary, and that Red Cross Conference held in Brussels. After infection arose from the damaging effect upon the reviewing the statistics for the United States tissues. After large doses of radiation a state of briefly and showing that the deaths from road accidents cachexia was produced in the animals somewhat in 1929 in this country were nine times more numerous resembling the clinical condition known as "X ray than those in 1911, Dr. Svendsen gave the following sickness." In view of the fact that histamine or a statistics for Denmark for the first six months of similar substance is known to be liberated by tissues 1930. damaged by X rays, experiments were undertaken to determine if the absorption of such a substance might be responsible for the production of this __
1 The Physiological and Cytological Effects of Penetrating Rays upon the Cat and the Rabbit. By S. Russ, Samson Wright, H. A. Bulman, and L. H. Clark. Reprint from Proceedings of the Royal Society of Medicine, Section of ElectroTherapeutics, Oct., 1930, pp. 43-60.
.
_._
_
I
X
It should be noted that these figures deal only with accidents brought to the attention of the police, and
.
1357 do not include any of which the police took no cogni- nervous patients who cannot be relied upon to keep More than half of all the accidents-i.e. 2727, sance. during the operation, but when operating with occurred in Copenhagen, with a population of 708,600. avertin it is necessary to fix the eyeball firmly with The total population of Denmark is 3,518,000. As forceps during the incision, and this fixture is not so great a proportion of the accidents as 83-9 per cent. convenient as voluntary depression by the patient concerned motor-cars. In 55 per cent. of the traffic himself in obedience to the surgeon’s directions. accidents, the blame was laid exclusively on the Nevertheless any method of relieving apprehension drivers of motor-cars; in 13-7 per cent. bicyclists either before or during an operation on the eye is The main contra-indications were held responsible, in 8-5 per cent. pedestrians and worth a great deal. passengers; only in 2 per cent. were physical conditions, to the use of avertin are a serious degree of nephritis such as the state of the roads or visibility, held or severe disturbances of the liver. Old age is not responsible, and in 1-2 per cent. the state of the motor itself of importance, and though the authors of this vehicle. In the remainder. the responsibility was paper have not used the drug on children under 16, shared by a combination of two or more of the above there seems to be no reason why they should not do factors. Travellers familiar with the swarms of so. Avertin is a narcotic rather than an anaesthetic, bicyclists in the streets of Copenhagen will not be and one of its main advantages is that it can be used surprised to learn that they and pedestrians play to remove the patient’s anxiety for an hour or so a much more important part in the genesis of motor before operation. accidents than is the case in other countries. Among the improvements effected of late, the filling in of THE I.M.S. ditches beside the roads in order to provide bicycling IN an ample quarto volume Lieut.-Colonel D. G. paths deserves special mention. This reform has Crawford, whose " History of the I.M.S." did very been made possible by the arrangement which allots nearly as much for the service as Boswell did for part of the revenue from motor-car taxation to the ’, Dr. Johnson, has continued his labours in a volume local authorities. There are over 2500 doctors in ’, entitled " The Roll of the Indian Medical Service."l Denmark-i.e., one for every 1360 inhabitants, and The title is, perhaps, unfortunate, since it suggests if Copenhagen and its 629 doctors are discounted, a book on the lines of the Army List or Bradshaw. the proportion of doctors to inhabitants is as one to In fact Colonel Crawford takes the opportunity, in 1500. Thanks to the comparative density of the the introduction, of bringing his history up to date, population even in the country, the radius of action and apart from the brief individual records of service of a general hospital (of which there were 170 in 1929) many notes testify to the enterprise of the author in is seldom more than 15 kilometres. Copenhagen discovering interesting material in the most unexpected is served with 16 and the rest of the country with sources. The term I.M.S. has been used in a very 139 ambulances, the radius of whose action is about broad sense to cover the name of every man who 15 kilometres. For the purpose of comparison it served, even for the shortest period, in the East should be noted that the corresponding radius of India Company’s land medical services, including the action in England is about 25 kilometres. The part surgeons’ mates (assistant surgeons), who were not played by the Danish Red Cross with regard to commissioned officers, but served under warrants ambulances consists largely of financing them at issued by the colonels commanding their regiments. the outset ; later, they are often taken over and run Some remarkable histories may be deduced from the by the local authorities. laconic entries in this Roll. In the Madras list occurs the name of Mungo Park, the son of the famous African explorer, who had himself been surgeon’s AVERTIN IN OPHTHALMOLOGY. mate of an Indiaman. Readers of Lockhart’s " Life IN the British Journal of Ophthalmology for Scott " may remember how the father, having November Mr. 0. Gayer Morgan and Mr. J. M. obtained by influence the promise of a post in the Lees record their experience of rectal narcosis with company’s service, provided he could qualify as a avertin, based on more than 50 cases, including surgeon, rushed off to commence his medical studies, cataract extraction, acute glaucoma, excision, eviscera- and in six months time returned with the required tion, acute dacryocystitis, removal of the lacrymal diploma. Other even more striking examples of sac in chronic dacryocystitis, and minor and major adaptability are not difficult to find. A sergeant in plastic operations on the eyelids. They conclude the St. Helena garrison was given dispensary duties, that it is not a dangerous drug when given with care, and served in that capacity for 15 years and that it well merits a trial in ophthalmic surgery. was having assistant surgeon. Later he went to appointed The amount injected should never exceed 1.0g. per obtained the M.R.C.S., and returned England, kg. of body-weight, and the temperature should not eventually to become full surgeon at St. Helena. be more than 40° C., for otherwise the avertin may As time went on, and medicine rose in the social decompose and set up colitis; to ensure against this scale, I.M.S. men not only cured the wives and families two drops of Congo red solution can be added to of potentates, and shook pagoda trees, but distinguished 5 c.cm. of avertin, and decomposition will be shown themselves in many other ways, rendering eminent by appearance of a blue colour. If any of the solution, services in several branches of science, furnishing as injected, be returned by the patient it is unsafe administrators and diplomats, and to attempt to make up the amount by an extra distinguished commercial houses the names of which are founding injection, since absorption is so rapid that it is still household words in India. The firm of Jardine impossible to estimate how much of the drug has been and Mathieson was started by one of the company’s rejected. In most cases no other anaesthetic, general surgeons, and the well-known publishing house of or local, was used, but Morgan and Lees employed a Thacker and Co., which produces Colonel Crawford’s preliminary injection of morphia gr. with atropine work, is also said to have had a medical origin. gr. 1/100, though this is not considered necessary. The Roll contains several interesting appendices, If the claims of its advocates are confirmed the drug tables of honours and rewards, and analyses of has obvious advantages where a general anaesthetic notably 1 Roll of the Indian Medical Service, 1615-1930. Compiled is contra-indicated or a local anaesthetic is insufficient. Lieut-Col. D. G. Crawford, Bengal Medical Service, ret. In cataract extraction it is chiefly applicable to very by London : W. Thacker and Co. 1930. Pp. 711. 28s.
still
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of