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TRANSPORTING PATIENTS WITH POLIOMYELITIS AND BULBAR OR RESPIRATORY PARALYSIS
515
coagulating, at
or
to relieve the
work, there is
a
trolley
pain.
with
When the needle is not doses to be taken by
more
mouth. One of the results of this continual attention is immense tiredness. The very sight of a nurse with a glass or syringe is exhausting. It is bad enough having to be in a ward with perhaps 30-50 other patients (although this has its advantages in taking one’s mind off oneself), but any brief nap is inter-
rupted ruthlessly,
so
that this is not certain procedures are of circumstance. aware
that the
patient gradually becomes hospital at all, but a factory in which performed every few minutes, regardless a
CERVICAL VERTIGO have read with great interest the article by SIR,—I Dr. Ryan and Dr. Cope (Dec. 31). I fully agree that vertigo is often unconnected with disorder of the inner ear.
In 1940 I described1 a disorder of the neck musclesis often associated with giddiness, notably on movement of the head, and sometimes with occipital headache. I have since again drawn attention to the frequency of this form of giddiness,2 which can be rapidly cured by treatment of the muscular lesion. This remarkable fact is explained by the experimental finding3 that the neck muscles, largely concerned with equilibrium and maintaining the posture of the head, have a nervous connection with the It is obvious that the position of the head, labyrinth. relative to that of the body determined by the tonus of the neck muscles, serves as do the eyes the function of
especially trapezii-which
I have heard it said, proudly, that " the days walked on tiptoe if someone was ill " are gone forever, it is not the nurses who are at fault. They do not invent these new methods. They obey orders, and many of them do so with all the gentleness and grace they can summon to aid them in their lives of devotion and service. But I do suggest that a new callousness is creeping into our hospitals, and I think that certain practices should be frequently reviewed in the hope of eliminating the distress and discomfort they cause. In particular, since it is mainly the old who have to submit to them, I would like very senior doctors to be consulted. And most of all, I would like the human being, rather than the human being’s ailment, to have top priorityhowever unscientific that may sound. A PATIENT’S FRIEND.
Though
when
omissions I apologise to Sir William. I am indebted to him for pointing out my misinterpretation of certain historical facts."-ED. L.
one
equilibrium. M. G. GOOD. TRANSPORTING PATIENTS WITH POLIOMYELITIS AND BULBAR OR RESPIRATORY PARALYSIS summer we supervised the transport of with severe acute poliomyelitis to the regional patients poliomyelitis unit at Rush Green Hospital, Romford, Essex. These patients had either : bulbar paralysis ; or
SIR,—Last
12
MALARIA AND THE THAMES
SIR,-Almost the whole of the initial historical section of this paper (Lancet, April 14) has been borrowed from a paper of mine,l sometimes word-for-word, sometimes with so little care that mistakes have been introduced that cannot be passed uncorrected. In his Ecclesiastical History the Venerable Bede never mentions the lencten ádl (" spring ill," i.e., malaria), nor does he " draw attention " to any " prevalent " fever. He refers only to a single case of fever where the sufferer went and sat by St. Oswald’s tomb, so that the attack did not return either on the second or third day ; or subsequently. All that interested Bede was the miracle. The point of my story was, that the translator of Bede’s Latin, presumably King Alfred, in turning this passage into Anglo-Saxon did not render Bede’s vague "febris " by an A.-S. equivalent, but replaced it by the specific lencten tidl "; thus naming the disease malaria, which probably it was. Shakespeare did not use " ague " in Macbeth " mistakenly "; this old name for typhus still lingered on in his day, and survived still longer in Ireland. Samuel Butler, Charles II’s favourite poet, is called " the essayist "-here perhaps he is confused with Samuel (Erewhon) Butler. Horace Walpole was not the first person to employ the word malaria ; he was merely the first, so far as is known, to introduce this existing Italian term into English. He was not writing to Thomas Gray, and Gray was not in London-he was with Walpole in Italy. The letter in question was not dated " 1840," but July 5, 1740, and was addressed to the Hon. H. S. Conway. In it Walpole explains that he has left Rome because of the horrid thing called the mal’aria ; and adds, " I do not care for being killed so far from Christian burial ! " And, finally, the author of the Elegy did not spell his surname " Grev." "
The British Council, London, W.1.
W. P. MACARTHUR.
*** This letter has been shown to Dr. W. D. L. Smith, who writes : " At one point in my article I gave a reference to Sir William MacArthur’s article ; but I quoted from this work several times and should have acknowledged the source on each occasion. For these 1. Brit. med. Bull. 1951, 8, 76.
of diaphragm and/or intercostal combined bulbar and paralysis.
paralysis
respiratory
or
in service in in a complete " iron lung." The equipment carried included all the instruments, drugs, and endotracheal tubes necessary for tracheotomy under general or local anoesthesia; positivepressure apparatus, consisting of an Oxford inflating bellows and a Beaver Mark I or 11 machine, portable suction apparatus, oxygen cylinders, bronchoscope, laryngoscope, torches, and spatulæ. This equipment is fairly compact and takes up little space in an ambulance or police car. The distances covered varied from 12 to 30 miles.
The ambulances used
were
of the usual
muscles ;
Essex, except when transporting
Bulbcar
a
type
patient
Paralysis
cases were either " dry " or " wet ’’-that is, with partial or complete pharyngeal paralysis, this factor determining the degree of pooling " of saliva and mucus in the pharynx and larynx. Dry " bulbar cases were not difficult or worrying to transport. The patients were conveyed prone with the head turned to one side, a few pillows placed under the abdomen facilitating posturaldrainage on the ambulance stretcher-bed ; secretions ran out of the mouth easily since the head was inclined downwards. This is the position adopted for patients immediately after tonsillectomy, except that in poliomyelitis The patients were cases the tilt often needs to be steeper. given swabs and encouraged to spit out their saliva, and suction was usually not necessary to maintain a clear airway. Wet " bulbar cases with complete pharyngeal paralysis
These
’‘
"
"
often very irritable and, because of severe headache, reluctant to remain in the safe prone position with head inclined downwards. Vomiting was common, partly because the frequent suction necessary irritated the pharyngeal wall. Torch, spatula, and suction apparatus were the essential instruments during the journey with these cases. A stethoscope was invaluable for listening over the trachea to check that the airway was clear. were
were
Respiratory Involvement When the respiratory paralysis was slight (e.g., some intercostal weakness) there was no difficulty in transporting the patient in an ordinary ambulance. Respiration was 1. Good, M. G. Lancet, 1940, ii, 326. 2. Proc. R. Soc. Med. 1950, 43, 290. 3. Mies, H. Klin. Wschr. 1937, 16, 593.
516 aided, if necessary, by an Oxford inflating bellows, using a face-mask. In cases with moderately severe respiratory paralysis, a por+able cuirass respirator, such as the tried but was ineffective. Some patients with very extensive respiratory paralysis, already in a tank respirator, were transferred to the unit. A large coach-type ambulance with seats removed was supplied, and the patients were transported in an iron lung, the pump unit being operated manually. Before the journey a Ryle’s tube was passed and the stomach emptied in case acute dilatation occurred in the ambulance.
Monaghanwas
Combiiied .J3MJ’&
and
Respiratory Paralysis
We should like to thank Dr. E. James, under whose care patients were admitted, for his helpful criticism and a,dvice, and for the opportunity of supervising their transfer. ANTHONY F. C. SCOTT these
BEULAII R. KNOX. HAMMER-TOES IN THREE GENERATIONS
SIR,-The accompanying pedigree shows hammer-toe in three generations of a family, involving the second toe of both feet in the four females affected and of the left foot alone in the one male affected. A fifth female in
be divided into two categories : (a) established respiratory paralysis with definite bulbar signs ; and (b) established bulbar paralysis with slight respiratory involvement. These
cases
can
Patients in the first of these two groups not difficult to manage during transport
usually they had already had a tracheotomy done. They were placed on their back on the ambulance stretcher, and pulmonary the second filial generation is said to have shown this ventilation was maintained by manual operation of an intermittent-positive-pressure apparatus (e.g., Oxford condition as a baby but was cured by the application of inflating bellows), with or without added oxygen run little splints to stretch the toe ; little malformation can be through the inflation circuit. These cases appeared to observed now. be the safest to transport, since there was an established The flexor digitorum brevis muscle arises from the calcanairway well below the pooled secretions in the pharynx eum, passes forwards across the arch of the foot, and divides Since the endotracheal tube was cuffed, into four tendons, one of which is inserted into the middle and larynx. these secretions could not leak into the trachea and phalanx of each of the four minor toes. Their action is to flex the middle phalanges on the proximal ones. In the main bronchi. Tracheal phlegm was easily aspirated by cases the tendon supplying the second toe only is suction through the endotracheal tube. Pharyngeal present short, resulting in a hammer-toe. The parents congenitally pooling was prevented by frequent suction through the and two siblings of the progenitor of this condition, together patient’s mouth. with their fairly closely inbred descendants, show no sign of it. The patients that caused most anxiety during the It has been suggested that this is an example of sex ambulance journey were those with fully established limitation. bulbar paralysis with slight respiratory involvement PATRICK JAMES. (e.g., with paresis of the lower intercostal muscles). The problem was to assess how well this type of patient could TREATMENT OF BEDSORES tolerate a journey of up to thirty miles. If a tracheotomy Dr. L. GUTTMANN, director of the National Spinal Injuries is not considered necessary the patient must be transCentre, Stoke Mandeville Hospital, Aylesbury, Bucks, writes: ported in a prone and tilted position, because of the It has been brought to my notice that in 1954 you reported bulbar paralysis. But there are certain disadvantages me as recommending, in the course of a lecture, the application in this position, especially in a moving vehicle. The to bedsores of a pack moistened with Dettol ’ solution.l In diaphragm has extra work to do, because of the weak fact I did not mention dettol, and I consider that the use of this substance is absolutely contra-indicated in the treatment lower intercostal muscles, the added weight of the of such lesions. My views on their treatment have been set abdominal viscera, and compression of the chest against out elsewhere.2 the stretcher ; and the paralysis may not yet be at its maximum. Some of these patients who had not had a AMATEUR BOXING tracheotomy (respiratory aid not seeming necessary) Dr. J. L. BLONSTEIN, hon. medical officer of the London caused considerable anxiety during the journey. Their Amateur Boxing Association, writes : Under its medical general condition deteriorated, with vomiting, copious welfare scheme the association has made it compulsory for all secretion of saliva and mucus, and laboured breathing ; boxers to have an initial medical examination. Will those this happened despite continuous suction from the mouth doctors who are interested in amateur boxing and are not and pharynx to maintain a clear airway-a life-saving already on the panel of boxing medical officers please communicate with me at the London A.B.A., 69, Victoria Street, for the measure. On but, patient, extremely exhausting London, S.W.I, if they would like to participate in this scheme ? arrival at the unit some of these patients were very exhausted, with an apparent increase of the respiratory paralysis ; in 1 patient an immediate tracheotomy was In view of our experiences, we necessary on arrival. Appointments feel that a tracheotomy should always be seriously considered in this type of case before the journey, especially CHURCH, R. E., M.D. Camb., M.R.o.P. : part-time consultant dermatologist, duties at Grimsby, Scunthorpe, Louth, and Lincoln. if it is a long one. It is always safer to transport such HiND, A. W., M.B. Lond., 117.F.A. R.C.S., D.A.: consultant anaesthetist, a patient with a cuffed tracheotomy tube in position. Royal Masonic Hospital, London. It may then not even be necessary to aid the patient’s SiMrsoN, J. H., M.D. Camb., M.R.o.p. : asst. physician in geriatrics, Norfolk and Norwich area. breathing by intermittent-positive-pressure apparatus, SMITH, P. A. J., M.B. Lond., M.R.c.P. : consultant dermatologist, and the patient can lie in comfort on his back during Queen Mary’s Hospital, Roehampton, London. the journey. Pharyngeal secretions are prevented from STHYR, L. V., M.D. Lond., M.R.C.P.: asst. physician (geriatrics), Buckinghamshire area. entering the trachea by the cuffed tube, and by adequate THORNTON, D. J., M.R.o.a. : registrar in ophthalmology, Norfolk and were
as
suction.
We should like to emphasise the importance of seeking early assistance for patients with the types of poliomyelitis described here. Where this was done we found that, as a rule, the transport of the patient caused less anxiety and the prognosis was correspondingly better.
Norwich Hospital.
TROBRIDGE, G. F.,
M.B. Birm., M.R.c.P. : asst. chest physician, Hawkmoor Chest Hospital, Bovey Tracey, Devon. WETHERELL, G. A., M.B., M.CH.ORTH. Lpool, r.R.C.S. : whole-time asst. orthopaedic surgeon, Clatterhridge Hospital.
1. Lancet, 1954, 2. e.g., Brit. J.
ii, 98. plast. Surg. 1955, 7, 196.
coagulating, at
or
to relieve the
work, there is
a
trolley
pain.
with
When the needle is not doses to be taken by
more
mouth. One of the results of this continual attention is immense tiredness. The very sight of a nurse with a glass or syringe is exhausting. It is bad enough having to be in a ward with perhaps 30-50 other patients (although this has its advantages in taking one’s mind off oneself), but any brief nap is inter-
rupted ruthlessly,
so
that this is not certain procedures are of circumstance. aware
that the
patient gradually becomes hospital at all, but a factory in which performed every few minutes, regardless a
CERVICAL VERTIGO have read with great interest the article by SIR,—I Dr. Ryan and Dr. Cope (Dec. 31). I fully agree that vertigo is often unconnected with disorder of the inner ear.
In 1940 I described1 a disorder of the neck musclesis often associated with giddiness, notably on movement of the head, and sometimes with occipital headache. I have since again drawn attention to the frequency of this form of giddiness,2 which can be rapidly cured by treatment of the muscular lesion. This remarkable fact is explained by the experimental finding3 that the neck muscles, largely concerned with equilibrium and maintaining the posture of the head, have a nervous connection with the It is obvious that the position of the head, labyrinth. relative to that of the body determined by the tonus of the neck muscles, serves as do the eyes the function of
especially trapezii-which
I have heard it said, proudly, that " the days walked on tiptoe if someone was ill " are gone forever, it is not the nurses who are at fault. They do not invent these new methods. They obey orders, and many of them do so with all the gentleness and grace they can summon to aid them in their lives of devotion and service. But I do suggest that a new callousness is creeping into our hospitals, and I think that certain practices should be frequently reviewed in the hope of eliminating the distress and discomfort they cause. In particular, since it is mainly the old who have to submit to them, I would like very senior doctors to be consulted. And most of all, I would like the human being, rather than the human being’s ailment, to have top priorityhowever unscientific that may sound. A PATIENT’S FRIEND.
Though
when
omissions I apologise to Sir William. I am indebted to him for pointing out my misinterpretation of certain historical facts."-ED. L.
one
equilibrium. M. G. GOOD. TRANSPORTING PATIENTS WITH POLIOMYELITIS AND BULBAR OR RESPIRATORY PARALYSIS summer we supervised the transport of with severe acute poliomyelitis to the regional patients poliomyelitis unit at Rush Green Hospital, Romford, Essex. These patients had either : bulbar paralysis ; or
SIR,—Last
12
MALARIA AND THE THAMES
SIR,-Almost the whole of the initial historical section of this paper (Lancet, April 14) has been borrowed from a paper of mine,l sometimes word-for-word, sometimes with so little care that mistakes have been introduced that cannot be passed uncorrected. In his Ecclesiastical History the Venerable Bede never mentions the lencten ádl (" spring ill," i.e., malaria), nor does he " draw attention " to any " prevalent " fever. He refers only to a single case of fever where the sufferer went and sat by St. Oswald’s tomb, so that the attack did not return either on the second or third day ; or subsequently. All that interested Bede was the miracle. The point of my story was, that the translator of Bede’s Latin, presumably King Alfred, in turning this passage into Anglo-Saxon did not render Bede’s vague "febris " by an A.-S. equivalent, but replaced it by the specific lencten tidl "; thus naming the disease malaria, which probably it was. Shakespeare did not use " ague " in Macbeth " mistakenly "; this old name for typhus still lingered on in his day, and survived still longer in Ireland. Samuel Butler, Charles II’s favourite poet, is called " the essayist "-here perhaps he is confused with Samuel (Erewhon) Butler. Horace Walpole was not the first person to employ the word malaria ; he was merely the first, so far as is known, to introduce this existing Italian term into English. He was not writing to Thomas Gray, and Gray was not in London-he was with Walpole in Italy. The letter in question was not dated " 1840," but July 5, 1740, and was addressed to the Hon. H. S. Conway. In it Walpole explains that he has left Rome because of the horrid thing called the mal’aria ; and adds, " I do not care for being killed so far from Christian burial ! " And, finally, the author of the Elegy did not spell his surname " Grev." "
The British Council, London, W.1.
W. P. MACARTHUR.
*** This letter has been shown to Dr. W. D. L. Smith, who writes : " At one point in my article I gave a reference to Sir William MacArthur’s article ; but I quoted from this work several times and should have acknowledged the source on each occasion. For these 1. Brit. med. Bull. 1951, 8, 76.
of diaphragm and/or intercostal combined bulbar and paralysis.
paralysis
respiratory
or
in service in in a complete " iron lung." The equipment carried included all the instruments, drugs, and endotracheal tubes necessary for tracheotomy under general or local anoesthesia; positivepressure apparatus, consisting of an Oxford inflating bellows and a Beaver Mark I or 11 machine, portable suction apparatus, oxygen cylinders, bronchoscope, laryngoscope, torches, and spatulæ. This equipment is fairly compact and takes up little space in an ambulance or police car. The distances covered varied from 12 to 30 miles.
The ambulances used
were
of the usual
muscles ;
Essex, except when transporting
Bulbcar
a
type
patient
Paralysis
cases were either " dry " or " wet ’’-that is, with partial or complete pharyngeal paralysis, this factor determining the degree of pooling " of saliva and mucus in the pharynx and larynx. Dry " bulbar cases were not difficult or worrying to transport. The patients were conveyed prone with the head turned to one side, a few pillows placed under the abdomen facilitating posturaldrainage on the ambulance stretcher-bed ; secretions ran out of the mouth easily since the head was inclined downwards. This is the position adopted for patients immediately after tonsillectomy, except that in poliomyelitis The patients were cases the tilt often needs to be steeper. given swabs and encouraged to spit out their saliva, and suction was usually not necessary to maintain a clear airway. Wet " bulbar cases with complete pharyngeal paralysis
These
’‘
"
"
often very irritable and, because of severe headache, reluctant to remain in the safe prone position with head inclined downwards. Vomiting was common, partly because the frequent suction necessary irritated the pharyngeal wall. Torch, spatula, and suction apparatus were the essential instruments during the journey with these cases. A stethoscope was invaluable for listening over the trachea to check that the airway was clear. were
were
Respiratory Involvement When the respiratory paralysis was slight (e.g., some intercostal weakness) there was no difficulty in transporting the patient in an ordinary ambulance. Respiration was 1. Good, M. G. Lancet, 1940, ii, 326. 2. Proc. R. Soc. Med. 1950, 43, 290. 3. Mies, H. Klin. Wschr. 1937, 16, 593.
516 aided, if necessary, by an Oxford inflating bellows, using a face-mask. In cases with moderately severe respiratory paralysis, a por+able cuirass respirator, such as the tried but was ineffective. Some patients with very extensive respiratory paralysis, already in a tank respirator, were transferred to the unit. A large coach-type ambulance with seats removed was supplied, and the patients were transported in an iron lung, the pump unit being operated manually. Before the journey a Ryle’s tube was passed and the stomach emptied in case acute dilatation occurred in the ambulance.
Monaghanwas
Combiiied .J3MJ’&
and
Respiratory Paralysis
We should like to thank Dr. E. James, under whose care patients were admitted, for his helpful criticism and a,dvice, and for the opportunity of supervising their transfer. ANTHONY F. C. SCOTT these
BEULAII R. KNOX. HAMMER-TOES IN THREE GENERATIONS
SIR,-The accompanying pedigree shows hammer-toe in three generations of a family, involving the second toe of both feet in the four females affected and of the left foot alone in the one male affected. A fifth female in
be divided into two categories : (a) established respiratory paralysis with definite bulbar signs ; and (b) established bulbar paralysis with slight respiratory involvement. These
cases
can
Patients in the first of these two groups not difficult to manage during transport
usually they had already had a tracheotomy done. They were placed on their back on the ambulance stretcher, and pulmonary the second filial generation is said to have shown this ventilation was maintained by manual operation of an intermittent-positive-pressure apparatus (e.g., Oxford condition as a baby but was cured by the application of inflating bellows), with or without added oxygen run little splints to stretch the toe ; little malformation can be through the inflation circuit. These cases appeared to observed now. be the safest to transport, since there was an established The flexor digitorum brevis muscle arises from the calcanairway well below the pooled secretions in the pharynx eum, passes forwards across the arch of the foot, and divides Since the endotracheal tube was cuffed, into four tendons, one of which is inserted into the middle and larynx. these secretions could not leak into the trachea and phalanx of each of the four minor toes. Their action is to flex the middle phalanges on the proximal ones. In the main bronchi. Tracheal phlegm was easily aspirated by cases the tendon supplying the second toe only is suction through the endotracheal tube. Pharyngeal present short, resulting in a hammer-toe. The parents congenitally pooling was prevented by frequent suction through the and two siblings of the progenitor of this condition, together patient’s mouth. with their fairly closely inbred descendants, show no sign of it. The patients that caused most anxiety during the It has been suggested that this is an example of sex ambulance journey were those with fully established limitation. bulbar paralysis with slight respiratory involvement PATRICK JAMES. (e.g., with paresis of the lower intercostal muscles). The problem was to assess how well this type of patient could TREATMENT OF BEDSORES tolerate a journey of up to thirty miles. If a tracheotomy Dr. L. GUTTMANN, director of the National Spinal Injuries is not considered necessary the patient must be transCentre, Stoke Mandeville Hospital, Aylesbury, Bucks, writes: ported in a prone and tilted position, because of the It has been brought to my notice that in 1954 you reported bulbar paralysis. But there are certain disadvantages me as recommending, in the course of a lecture, the application in this position, especially in a moving vehicle. The to bedsores of a pack moistened with Dettol ’ solution.l In diaphragm has extra work to do, because of the weak fact I did not mention dettol, and I consider that the use of this substance is absolutely contra-indicated in the treatment lower intercostal muscles, the added weight of the of such lesions. My views on their treatment have been set abdominal viscera, and compression of the chest against out elsewhere.2 the stretcher ; and the paralysis may not yet be at its maximum. Some of these patients who had not had a AMATEUR BOXING tracheotomy (respiratory aid not seeming necessary) Dr. J. L. BLONSTEIN, hon. medical officer of the London caused considerable anxiety during the journey. Their Amateur Boxing Association, writes : Under its medical general condition deteriorated, with vomiting, copious welfare scheme the association has made it compulsory for all secretion of saliva and mucus, and laboured breathing ; boxers to have an initial medical examination. Will those this happened despite continuous suction from the mouth doctors who are interested in amateur boxing and are not and pharynx to maintain a clear airway-a life-saving already on the panel of boxing medical officers please communicate with me at the London A.B.A., 69, Victoria Street, for the measure. On but, patient, extremely exhausting London, S.W.I, if they would like to participate in this scheme ? arrival at the unit some of these patients were very exhausted, with an apparent increase of the respiratory paralysis ; in 1 patient an immediate tracheotomy was In view of our experiences, we necessary on arrival. Appointments feel that a tracheotomy should always be seriously considered in this type of case before the journey, especially CHURCH, R. E., M.D. Camb., M.R.o.P. : part-time consultant dermatologist, duties at Grimsby, Scunthorpe, Louth, and Lincoln. if it is a long one. It is always safer to transport such HiND, A. W., M.B. Lond., 117.F.A. R.C.S., D.A.: consultant anaesthetist, a patient with a cuffed tracheotomy tube in position. Royal Masonic Hospital, London. It may then not even be necessary to aid the patient’s SiMrsoN, J. H., M.D. Camb., M.R.o.p. : asst. physician in geriatrics, Norfolk and Norwich area. breathing by intermittent-positive-pressure apparatus, SMITH, P. A. J., M.B. Lond., M.R.c.P. : consultant dermatologist, and the patient can lie in comfort on his back during Queen Mary’s Hospital, Roehampton, London. the journey. Pharyngeal secretions are prevented from STHYR, L. V., M.D. Lond., M.R.C.P.: asst. physician (geriatrics), Buckinghamshire area. entering the trachea by the cuffed tube, and by adequate THORNTON, D. J., M.R.o.a. : registrar in ophthalmology, Norfolk and were
as
suction.
We should like to emphasise the importance of seeking early assistance for patients with the types of poliomyelitis described here. Where this was done we found that, as a rule, the transport of the patient caused less anxiety and the prognosis was correspondingly better.
Norwich Hospital.
TROBRIDGE, G. F.,
M.B. Birm., M.R.c.P. : asst. chest physician, Hawkmoor Chest Hospital, Bovey Tracey, Devon. WETHERELL, G. A., M.B., M.CH.ORTH. Lpool, r.R.C.S. : whole-time asst. orthopaedic surgeon, Clatterhridge Hospital.
1. Lancet, 1954, 2. e.g., Brit. J.
ii, 98. plast. Surg. 1955, 7, 196.