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TRACHEOTOMY IN AN INFANT.
594
fof
is. 2. The consanguinity of the parents, the day. In these 14 cases we were able to watch been a feature of a large proportion ofJfclosely the results of an aggregate of 169 days of alcaptonuric families. 3. The excess of males over treatment and to examine 212 stools, and the following females, which is a noteworthy feature in this and is a summary of our observations:allied inborn errors of metabolism. Leakage.-1Vo leakage in 11 cases-Nos. 2, 3, and Debenedetti records a family with an even higher 6 to 14. proportion of alcaptonuric members .2
certainly
which has
In the collaboration of this report I have had the great advantage of the advice and assistance of Sir Archibald Garrod, and it is at his instigation that I wrote out these notes of this family. Gloucester.
I
I
PARAFFINUM LIQUIDUM. A REPORT ON THE ACTION OF LIQUID PARAFFINS OF WIDELY VARYING VISCOSITIES.
BY H. B.
RUSSELL, M.D.,
M.R.C.P.
LOND.,
AND
P. C.
BRETT, M.B., B.S. LOND.
THE lubricant action of liquid paraffin is now and its use as a mechanical laxative has grown to an enormous extent of late years. Because, we were aware of these facts and knew that the preparations universally obtainable, although probably answering the tests of the British Pharmacopoeia, nevertheless differed widely in viscosity, we thought it worth while to make extensive clinical trials with paraffins of widely varying viscosities. In THE LANCET of August 12th, 1916, it was emphasised that all liquid paraffins sold should be of British Pharmacopoeia standard, and earlier in the same journal (1915, ii., 761) it was pointed out that many samples of liquid paraffin sold to the public, although answering the British Pharmacopceia tests, varied widely as regards viscosity-the extremes being 296 and 71and that it was very improbable that paraffins of such extremes of viscosity would give precisely similar therapeutic effects. Referring to the great importance of viscosity, the conclusion was arrived at in THE LANCET (1915, ii., 884) that " a good working physiological viscosity would probably be in the neighbourhood of the figure of 105." Because we, too, appreciate the fact that viscosity is such an important factor (since lubrication is by no means ideal unless the lubricant is intimately mixed with the faeces), and because from casual observations we were under the impression that a viscosity of 105 was far too low for a really satisfactory liquid paraffin, that we made the following investigations, in which were used : (a) Liquid paraffin low viscosity (130),
generally recognised,
The paraffin of high viscosity had a slightly more laxative action than that of low viscosity, and the result of the investigations shows that there is decidedly more tendency to leakage with the low viscosity than with the high, for although definite leakage was detected in 5 instances only out of 85 with the low viscosity as against 3 out of 84 with the high, yet the fact remains that in 25 instances out of 85 with the low viscosity the paraffin was so imperfectly mixed with the stool as to be evident, whereas with the high viscosity this state of affairs was noticed in only 4 out of 84 instances. From the foregoing series of investigations it is clear that a paraffin of viscosity 230 gave more satisfactory results than one with a viscosity of 130, and in our opinion it is preferable always to use a paraffin of high viscosity. The mean of the viscosities of the two paraffins used in our trials is 180, and we strongly recommend that a viscosity standard of certainly not less than 180 should be adopted. The viscosity figure is the time in seconds taken by 50 c.cm. of oil maintained at 100’F. to flow out from a Redwood viscometer.
specific gravity 0-8718 ; (b) liquid paraffin high viscosity (230), specific gravity 0-8902. -Ilethod of Investigation. The method of investigation was as follows : 44 cases were
_______________
Clinical and
treated for about three weeks each with
paraffins of the two viscosities mentioned-130 and 230. The low and high viscosities were given in each case for alternate weeks ; in about half the cases the low viscosity was given first, in the other half the and the doses varied from 1 to 3 oz. in the 24 hours. Careful attention was paid to the results, the following points being especially noted : (1) the laxative action ; (2) the amount of leakage, if any ; (3) the tendency to leakage, which latter was shown by marked evidence of paraffin imperfectly mixed with the stools. Thirty of these cases were normal pregnant or lactating women, and here it was impossible to watch the results of treatment, so that we had to rely on verbal information ; the other 14, however, were hospital medical cases suffering from a variety of complaints. Some of these patients were entirely confined to bed, others were up and about for the greater part
TRACHEOTOMY IN AN INFANT. BY EUSTACE THORP, O.B.E., L.R.C.P. EDIN., L.R.F.P.S. GLASG., D.P.H.,
high,
2
Il
Policlinico, 1920, xxvii., p. 1379.
Laboratory Notes.
ASSISTANT HEALTH
OFFICER, SUNDERLAND.
THE of the
following case is interesting chiefly by reason difficulty in breathing experienced after the tracheotomy tube was removed the second time. although no obstruction was present. A male child,
aged 9 months, was admitted to hospital July 13th, 1922, suffering from laryngeal diphtheria of two days’ duration,’no antitoxin had been administered. Tracheotomy was necessary and was performed (very high and practically a laryngo-tracheotomy) by a practitioner e in the neighbourhood before my arrival ; on arrival I gave 18,000 units of antitoxin in three doses. Two days later the on
I
595 1 child was doing well except for a profuse mucous symptoms, crediting them to the child’s nervousness. and the coughing of pieces of membrane. This discharge has In a day or two he began to settle down, and breathing continued to date, varying in consistence only. Repeated became normal. He is now doing well. attempts to remove the tube failed, plugging of the tube The child was discharged in November. The wound brought on urgent symptoms immediately. There was no healed and he has been frequently seen since ; the mother laryngeal paralysis and apparently no stenosis or granula- states that he is very well, though at times he can produce tions, but there was slight ulceration of the trachea, nervous- a dyspnoea at will, but having been warned of this peculiarity she was never alarmed at it. Swabs after the first tracheoness was present, and the child always objected to the removal of the tube, and would endeavour to remove plugs tomy gave the following results : July 25th, positive ;
dischargeurgent
August
8th, negative ; 22nd, positive ; 28th, negative ; coverings put on with a view to re-establishing breathing by the nose. About the middle of September such breathing Sept. 2nd, negative ; llth, negative. was observed, and the child frequently coughed up mucus The case is interesting, not only from the rather through the mouth. unusual length of time during which the tube waq
or
On Oct. 2nd I determined to clear the matter up ; diffi-
retained and because of the
of
difficulty breathing, culty was being met with in replacing the tube, and I opened also because of the nervousness of the child. up the wound, and performed a lower tracheotomy, incising but the trachea for about an inch, making a thorough examina- A certain amount of nervousness is to be expected tion, removing any small granulations found. I passed a when the tube is first removed, but in this case the Belloc’s sound through the larynx to the mouth, making observed was remarkable. I see the child sure that these passages were normal ; I then put in the now, and he appears to be entirely free frequently tracheotomy tube, and commenced treatment as a new from any dyspnoea. The latter recurred at times, tracheotomy. On the third day I removed the tube alto- during the four months following the patient’s gether and the child became very nervous, endeavouring to remove the coverings from the wound and to establish discharge from hospital, when he was excited or breathing by the trachea. Difficult breathing with retraction crying. There is now no abnormality of any kind of ribs came on, and he slept little; but knowing that the present. trachea and the larynx were clear I ignored the apparently Sunderland.
degree .
A CASE OF
CRANIO-CLEIDO DYSOSTOSIS. BY ALBERT B.
COCKER, M.R.C.S., L.D.S.
R.C.S. ENG.,
AND
H. SEWELL
SIMS, M.B., B.CH., B.A.O. R.U.I.
Tins case of cranio-cleido dysostosis has several points of interest. The patient is a healthy-looking girl, aged 16 years, height 4 ft. 10 in., weight 7 st. Her normal appearance is shown in Fig. 1.
...
I
Family History.-Youngest of 11, one died at 11 months of meningitis, the other nine all healthy and no deformities. Mother alive and healthy, father died eight years ago of cardio-vascular disease, aged 54. No history of deformities I on either side of family. Personal History.-Full-term child, but very small, noI serious illnesses. Pulsations over the head could be seen and felt until she was about 14 years old ; up till this time she often complained of headaches, which have disappeared. Pulsations cannot now be felt. Intellect above the average, can play piano, do typewriting and shorthand. Does not complain of any weakness about the shoulders and did not know I the clavicles were missing until told about 12 months ago. Present Condition.-Forehead high, square, and slightly projecting, frontal and parietal eminences prominent, and depression between frontal eminences well marked. There is a large flattening corresponding to the anterior fontanelle and a smaller one corresponding to the posterior fontanelle,
Normal appearance of the
subject.
Showing mobility
of
shoulders.
plastic and since the extractions two months ago the enlarged glands cannot now be felt. Clavicles.-Both clavicles are represented by about
X ray photograph of shoulder-girdle, showing olavioies, represented at the sternal end only by bones one-third of their normal length.
and
flattening along the sagittal suture. Only a few teeth’, erupted. In the upper jaw both permanent laterals, ’ the four premolars, and left second molar are erupted. In z, the lower jaw two temporary incisors, left temporary canine, and second temporary molar are erupted. Where the teeth are not erupted the alveolus is thick and firm, and most of the unerupted teeth can be felt. The four permanent molars were extracted on account of being septic with enlarged glands in the neck ; these teeth were are
I
first
hypo-
one-third of their sternal end ; these can be felt, and the free ends moved about among the soft parts of the supra- clavicular triangle (Fig. 3). The remarkable mobility of the shoulders, which can be made to touch each other anteriorly, is shown in Fig. 2.
We are much indebted to Dr. Robert Dr. David Morrow for the illustrations. Palmer’s Green, N.
Simpson
and
fof
is. 2. The consanguinity of the parents, the day. In these 14 cases we were able to watch been a feature of a large proportion ofJfclosely the results of an aggregate of 169 days of alcaptonuric families. 3. The excess of males over treatment and to examine 212 stools, and the following females, which is a noteworthy feature in this and is a summary of our observations:allied inborn errors of metabolism. Leakage.-1Vo leakage in 11 cases-Nos. 2, 3, and Debenedetti records a family with an even higher 6 to 14. proportion of alcaptonuric members .2
certainly
which has
In the collaboration of this report I have had the great advantage of the advice and assistance of Sir Archibald Garrod, and it is at his instigation that I wrote out these notes of this family. Gloucester.
I
I
PARAFFINUM LIQUIDUM. A REPORT ON THE ACTION OF LIQUID PARAFFINS OF WIDELY VARYING VISCOSITIES.
BY H. B.
RUSSELL, M.D.,
M.R.C.P.
LOND.,
AND
P. C.
BRETT, M.B., B.S. LOND.
THE lubricant action of liquid paraffin is now and its use as a mechanical laxative has grown to an enormous extent of late years. Because, we were aware of these facts and knew that the preparations universally obtainable, although probably answering the tests of the British Pharmacopoeia, nevertheless differed widely in viscosity, we thought it worth while to make extensive clinical trials with paraffins of widely varying viscosities. In THE LANCET of August 12th, 1916, it was emphasised that all liquid paraffins sold should be of British Pharmacopoeia standard, and earlier in the same journal (1915, ii., 761) it was pointed out that many samples of liquid paraffin sold to the public, although answering the British Pharmacopceia tests, varied widely as regards viscosity-the extremes being 296 and 71and that it was very improbable that paraffins of such extremes of viscosity would give precisely similar therapeutic effects. Referring to the great importance of viscosity, the conclusion was arrived at in THE LANCET (1915, ii., 884) that " a good working physiological viscosity would probably be in the neighbourhood of the figure of 105." Because we, too, appreciate the fact that viscosity is such an important factor (since lubrication is by no means ideal unless the lubricant is intimately mixed with the faeces), and because from casual observations we were under the impression that a viscosity of 105 was far too low for a really satisfactory liquid paraffin, that we made the following investigations, in which were used : (a) Liquid paraffin low viscosity (130),
generally recognised,
The paraffin of high viscosity had a slightly more laxative action than that of low viscosity, and the result of the investigations shows that there is decidedly more tendency to leakage with the low viscosity than with the high, for although definite leakage was detected in 5 instances only out of 85 with the low viscosity as against 3 out of 84 with the high, yet the fact remains that in 25 instances out of 85 with the low viscosity the paraffin was so imperfectly mixed with the stool as to be evident, whereas with the high viscosity this state of affairs was noticed in only 4 out of 84 instances. From the foregoing series of investigations it is clear that a paraffin of viscosity 230 gave more satisfactory results than one with a viscosity of 130, and in our opinion it is preferable always to use a paraffin of high viscosity. The mean of the viscosities of the two paraffins used in our trials is 180, and we strongly recommend that a viscosity standard of certainly not less than 180 should be adopted. The viscosity figure is the time in seconds taken by 50 c.cm. of oil maintained at 100’F. to flow out from a Redwood viscometer.
specific gravity 0-8718 ; (b) liquid paraffin high viscosity (230), specific gravity 0-8902. -Ilethod of Investigation. The method of investigation was as follows : 44 cases were
_______________
Clinical and
treated for about three weeks each with
paraffins of the two viscosities mentioned-130 and 230. The low and high viscosities were given in each case for alternate weeks ; in about half the cases the low viscosity was given first, in the other half the and the doses varied from 1 to 3 oz. in the 24 hours. Careful attention was paid to the results, the following points being especially noted : (1) the laxative action ; (2) the amount of leakage, if any ; (3) the tendency to leakage, which latter was shown by marked evidence of paraffin imperfectly mixed with the stools. Thirty of these cases were normal pregnant or lactating women, and here it was impossible to watch the results of treatment, so that we had to rely on verbal information ; the other 14, however, were hospital medical cases suffering from a variety of complaints. Some of these patients were entirely confined to bed, others were up and about for the greater part
TRACHEOTOMY IN AN INFANT. BY EUSTACE THORP, O.B.E., L.R.C.P. EDIN., L.R.F.P.S. GLASG., D.P.H.,
high,
2
Il
Policlinico, 1920, xxvii., p. 1379.
Laboratory Notes.
ASSISTANT HEALTH
OFFICER, SUNDERLAND.
THE of the
following case is interesting chiefly by reason difficulty in breathing experienced after the tracheotomy tube was removed the second time. although no obstruction was present. A male child,
aged 9 months, was admitted to hospital July 13th, 1922, suffering from laryngeal diphtheria of two days’ duration,’no antitoxin had been administered. Tracheotomy was necessary and was performed (very high and practically a laryngo-tracheotomy) by a practitioner e in the neighbourhood before my arrival ; on arrival I gave 18,000 units of antitoxin in three doses. Two days later the on
I
595 1 child was doing well except for a profuse mucous symptoms, crediting them to the child’s nervousness. and the coughing of pieces of membrane. This discharge has In a day or two he began to settle down, and breathing continued to date, varying in consistence only. Repeated became normal. He is now doing well. attempts to remove the tube failed, plugging of the tube The child was discharged in November. The wound brought on urgent symptoms immediately. There was no healed and he has been frequently seen since ; the mother laryngeal paralysis and apparently no stenosis or granula- states that he is very well, though at times he can produce tions, but there was slight ulceration of the trachea, nervous- a dyspnoea at will, but having been warned of this peculiarity she was never alarmed at it. Swabs after the first tracheoness was present, and the child always objected to the removal of the tube, and would endeavour to remove plugs tomy gave the following results : July 25th, positive ;
dischargeurgent
August
8th, negative ; 22nd, positive ; 28th, negative ; coverings put on with a view to re-establishing breathing by the nose. About the middle of September such breathing Sept. 2nd, negative ; llth, negative. was observed, and the child frequently coughed up mucus The case is interesting, not only from the rather through the mouth. unusual length of time during which the tube waq
or
On Oct. 2nd I determined to clear the matter up ; diffi-
retained and because of the
of
difficulty breathing, culty was being met with in replacing the tube, and I opened also because of the nervousness of the child. up the wound, and performed a lower tracheotomy, incising but the trachea for about an inch, making a thorough examina- A certain amount of nervousness is to be expected tion, removing any small granulations found. I passed a when the tube is first removed, but in this case the Belloc’s sound through the larynx to the mouth, making observed was remarkable. I see the child sure that these passages were normal ; I then put in the now, and he appears to be entirely free frequently tracheotomy tube, and commenced treatment as a new from any dyspnoea. The latter recurred at times, tracheotomy. On the third day I removed the tube alto- during the four months following the patient’s gether and the child became very nervous, endeavouring to remove the coverings from the wound and to establish discharge from hospital, when he was excited or breathing by the trachea. Difficult breathing with retraction crying. There is now no abnormality of any kind of ribs came on, and he slept little; but knowing that the present. trachea and the larynx were clear I ignored the apparently Sunderland.
degree .
A CASE OF
CRANIO-CLEIDO DYSOSTOSIS. BY ALBERT B.
COCKER, M.R.C.S., L.D.S.
R.C.S. ENG.,
AND
H. SEWELL
SIMS, M.B., B.CH., B.A.O. R.U.I.
Tins case of cranio-cleido dysostosis has several points of interest. The patient is a healthy-looking girl, aged 16 years, height 4 ft. 10 in., weight 7 st. Her normal appearance is shown in Fig. 1.
...
I
Family History.-Youngest of 11, one died at 11 months of meningitis, the other nine all healthy and no deformities. Mother alive and healthy, father died eight years ago of cardio-vascular disease, aged 54. No history of deformities I on either side of family. Personal History.-Full-term child, but very small, noI serious illnesses. Pulsations over the head could be seen and felt until she was about 14 years old ; up till this time she often complained of headaches, which have disappeared. Pulsations cannot now be felt. Intellect above the average, can play piano, do typewriting and shorthand. Does not complain of any weakness about the shoulders and did not know I the clavicles were missing until told about 12 months ago. Present Condition.-Forehead high, square, and slightly projecting, frontal and parietal eminences prominent, and depression between frontal eminences well marked. There is a large flattening corresponding to the anterior fontanelle and a smaller one corresponding to the posterior fontanelle,
Normal appearance of the
subject.
Showing mobility
of
shoulders.
plastic and since the extractions two months ago the enlarged glands cannot now be felt. Clavicles.-Both clavicles are represented by about
X ray photograph of shoulder-girdle, showing olavioies, represented at the sternal end only by bones one-third of their normal length.
and
flattening along the sagittal suture. Only a few teeth’, erupted. In the upper jaw both permanent laterals, ’ the four premolars, and left second molar are erupted. In z, the lower jaw two temporary incisors, left temporary canine, and second temporary molar are erupted. Where the teeth are not erupted the alveolus is thick and firm, and most of the unerupted teeth can be felt. The four permanent molars were extracted on account of being septic with enlarged glands in the neck ; these teeth were are
I
first
hypo-
one-third of their sternal end ; these can be felt, and the free ends moved about among the soft parts of the supra- clavicular triangle (Fig. 3). The remarkable mobility of the shoulders, which can be made to touch each other anteriorly, is shown in Fig. 2.
We are much indebted to Dr. Robert Dr. David Morrow for the illustrations. Palmer’s Green, N.
Simpson
and