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A NEW METHOD OF ARTIFICIAL RESPIRATION

IN this industrial age it is essential that all who

may have to render first aid should be fully awareof the vital importance of immediately giving arti-ficial respiration when life is endangered by accidentalsuffocation, shock, or poisoning. In a pertinentcriticism of the methods usually employed Prof.Stefan Jellinek, of Vienna, advocates in their placeanother simple manoeuvre. The subject lies supinewith a rolled up coat or other improvised bolsterbehind the shoulder blades. Then the operator,kneeling at the back of the head, presses the shouldersdown till they touch the ground for two seconds.Thus inspiration is brought about by enlarging thethoracic cage, expiration following when the pressureis released. To keep a clear airway the patient’sindex and middle finger of one hand are put into hismouth on the tongue and pushed back, the wristbeing attached to the neck by a handkerchief or otherimprovised cord. In this way the tongue is pre-vented from falling back and obstructing the larynx,an obstacle to success that is often insufficientlyanticipated by the inexperienced. Jellinek assertsthat on anatomical and physiological grounds thethorax should never be subjected to compression ;the only proper way to bring about respiration is toincrease its expansion. There seem, however,to be certain limitations to this doctrine in practice.When suspended respiration is due to the inhaledcontents of the lungs, as in drowning or duringansesthesia, the first efforts should surely be to expelthese. It seems to be the logical method in theseinstances to start with compression, however damagingtheoretically it may be in ordinary circumstances.

BLOOD VOLUME AFTER OPERATIONS

THE effect of surgical operations on the bloodvolume has been studied by Gibson and Branch,2who have used a dye method to measure the plasmavolume and have calculated the cell and totalvolumes from this and the haematocrit reading.They found that during anaesthesia there was an

early rise in plasma volume, but subsequent reduc-tion or increase depended on a rise or fall of bloodpressure respectively. Abdominal operations werealso accompanied by variations in the plasma volumedependent on changes in blood pressure. At the endof the operation the total volume was diminished,but the diminution was to some extent counteractedby an " influx of red cells into the circulation."Thus in one instance an increase of 330 c.cm. of redcells was registered. Two patients who had eachreceived a litre of normal saline solution intra-

venously showed an increase in plasma volume but adecrease in cell and total blood volume. None of the

patients were noted to have developed surgicalshock.The findings are open to the criticism that their

accuracy depends on the constant behaviour of thedye in the circulation under all conditions. It ishard to believe that in one case cited an increase ofcells of no less than 330 c.cm. should more thancover a decrease of plasma volume of 290 c.cm.

Whence could such a large volume of cells come insuch a short time ? It seems more likely that theplasma loss was much greater, but was masked bythe simultaneous disappearance of the dye from thecirculation, possibly into the tissue spaces along with

1 Pr. méd. Jan. 5th, 1938, p. 32.2 Gibson, J. G., and Branch, C. D., Surg. Gynec. Obstet.

December, 1937, p. 741.

the plasma, and that the increase in cell volume waspurely relative, the total blood volume beingdecreased. There seems no doubt that for theaccurate investigation of blood-volume changes inconditions where shock may occur, it is necessary touse direct methods for the simultaneous and separateestimation of the cell and plasma volume.

RICKETS AND OSTEOMALACIA IN CATTLE

PREVIOUS experiments in South Africa on themetabolism of calcium and phosphorus in cattle haveled workers there to attach little importance to

explanations of rickets and osteomalacia based onthe ratio of calcium to phosphorus in the diet (or themodified Erdalkali-alkalizität of the German investi-gators). The question of the Ca : P ratio has nowreceived close attention, and metabolism experimentson young cattle have shown 1 the influence of dietscontaining a sufficiency or deficiency of phosphorus,together with varying amounts of calcium. Ricketsor osteomalacia was produced only where the phos-phorus intake fell below normal, and was never

produced when the calcium intake was below normalunless the phosphorus was also low. It is evidenttherefore that the Ca : P ratio plays no essential partin causing rickets in cattle under the conditions of thisparticular experiment ; but it certainly influences thesubsequent course of the disease. Phosphorusdeficiency in cattle is well known to depress theappetite, which makes for poor growth. The presentexperiments demonstrate that the loss of appetite isgreatest when there is excess of calcium and leastwhen the ration is deficient in calcium as well asphosphorus. It follows therefore that rickets willadvance rapidly with a diet deficient in both phos-phorus and calcium, because there is little disturbanceof appetite and growth in consequence proceeds atalmost the normal rate, though there is not enoughmineral to build up the bones. If, on the other hand,the diet contains a deficiency of phosphorus and anexcess of calcium, the appetite is poor, growth ismuch retarded, and the rickets consequently makesslow progress.

CURE OF GONORRHŒA IN THE FEMALE

THE diagnosis of gonorrhoea in the female is besetwith difficulties, and it is often impossible to findgonococci in women who are believed to have trans-mitted the infection. The corollary is that it is veryhard to say that a patient has been definitely cured,and some go so far as to believe that gonorrhoea inthe female is an ineradicable disease. A statementby the surgeon-general of the United States publichealth service, that " we have no sure means of

rendering such cases non-infectious," has impelledDr. Wharton,2 of the Johns Hopkins Hospital, toreview his own results and suggest criteria of cure.He describes his experiences with 76 cases (21 childrenand 55 adults) treated in private practice during thepast ten years. Of the 21 children with vulvo-vaginitis18 completed the course and were passed as curedafter periods averaging 22 months from the cessationof treatment. One of them married twelve yearslater without transmitting infection and has borne ahealthy child. Wharton’s standards of cure in thesecases include observation with negative clinicalfindings over at least a year, with a minimum ofsix negative smears taken at monthly intervals andconfirmed where possible by cultures. The 55 adults

1 Theiler, A., Du Toit, P. J., and Malan, A. I., Onderstepoort J.1937, 8, 375.

2 Wharton, L. R., Amer. J. Syph. Gon. ven. Dis. 1937, 21, 593.

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were divided into 33 who were treated by localapplications alone and 22 in whom these were supple-mented by various operations, such as removal ofinfected Fallopian tubes, excision of Bartholin’s

glands, and cautery or excision of urethral or cervicalglands. In the former group only 1 certain cure

is claimed, in the case of a patient who was followedfor a year with repeatedly negative findings, andlater married and became pregnant without trans-ferring infection to her husband. Wharton statesthat " the results of incomplete treatment are evidentin this group. Marital infections, arthritis andinvalidism are common." The number of thesepatients discharged as cured and the tests appliedare not stated, but either the patients failed in

cooperation or the tests were inadequate. Of the 22in whom foci of infection were treated radically,17 were traced and submitted to further examinationand tests. In all but 2 the clinical examination andtests were negative ; 1 patient has become pregnantsince she was discharged as non-infectious, and herhusband has remained uninfected.From this experience Wharton recommends that

criteria of cure should be based on careful observationthrough the stages of the disease with radical excisionof infected foci after localisation ; on repeatedfollow-up examination and testing for a year ; andon the absence of recurrence or marital transferenceof infection. This last test of course can only beused by the clinician in retrospect-as a measure ofthe accuracy of past decisions-and as such it wouldcertainly provide convincing evidence. Informationof this kind is, however, difficult to obtain and theexamples recorded in Wharton’s paper are insufficientto justify his conclusion that " gonorrhoea in womencan be cured and that we have reliable criteria ofcure." In fact this retrospective. assessment showsonly too well the pitfalls that even the most carefulclinician may not avoid in deciding that gonorrhoeain the female is cured.

INTESTINAL KNOTS

THE curious fact about knotting of the intestineis that some three-quarters of the reported cases comefrom Finland, where writings on the subject dateback to 1906. Faltin 1 has critically examined thematerial collected by previous authors and hasclassified the types of knot. Those involving a singleloop of intestine, though theoretically possible, are

probably excessively rare : the solitary case reportfound by Faltin failed to convince him. Much the com-monest is the knot between a loop of small intestineand a loop of the pelvic colon ; 133 were reportedby Kallio 2 in this situation, as against 26 elsewhere.The caecum- and small intestine were involved onlytwice, and Faltin shows by description and illustra-tion that this is likely to be a complication of thelong bag-like cecum. Only once did the knotinvolve two parts of the large bowel, but in 21 itwas between two coils of small intestine, and ofthese 21 not more than 6 were described outsideFinland. The knots between the small intestineand the pelvic colon are alone of much practicalimportance, and Faltin shows that they must of neces-sity fall into two main groups, and that recognitionof this fact is the first step to their successful resolu-tion at operation. In twisting itself round the pelvicflexure the coil of small intestine passes either above(cephalad) or below (caudad) the root of the pelvicmesentery, and the twist is to the right in the former

1 Faltin, R., Acta chir. scand. 1937, 80, 1.2 Kallio, K. E., Acta chir. scand. 1932, 70, Suppl. 21.

and to the left in the latter. Faltin recommends holdingthe loop of pelvic colon out of the wound verticallyin the sagittal plane. The direction in which the.two loops of bowel cross one another is then deter-mined before an attempt is made to untie them.The operator can untwist the coils by supinating-the right hand, if it is a twist to the right, and bypronating, when the twist is to the left. Sometimes,particularly near the ileocsecal junction, one coil ofintestine may pass through behind the mesenteryof the small intestine, tying the knot even tighter.Obstruction of one or other coil may be complete.The condition of intestinal knotting is now so wellrecognised in Finland that five cases are on recordin which a pre-operative diagnosis was made of a.

knot between the pelvic colon and the small intes-tine. Faltin thinks that tenesmus associated withabdominal pain may prove to be a useful diagnosticsign. Blood in the fluid return from an enema, orthe passage of blood-stained mucus have also beennoted. The meteorism and the severity of onset,characteristic of volvulus of the sigmoid, should serve-to eliminate that diagnosis.

LIESEGANG RINGS IN THE BLOOD

Dr. Rudolf Bucher, director of the laboratory ofthe surgical clinic at Basle University, has long beenstudying the formation of Liesegang rings in the

plasma-gel obtained by addition of a calcium salt tocitrated blood plasma, and has now devised a newsystem of blood investigation based on this reaction.1.Briefly, the method consists in the addition of potas-sium dichromate to the plasma, and after clotting-has occurred, pouring on to the surface a solutionof silver nitrate. The precipitation of silver chromate,in the presence of a colloid (plasma-gel), occurs indefinite zones or bands, separated from each otherby regions free from any precipitate ; the discovererof these rings, Prof. Liesegang, contributes a prefaceto this book. Dr. Bucher has conducted very elab-orate measurements of the time of appearance anddistance apart of these rings in blood of many species.of animals and in human blood from subjects ofvarious ages. The results do not permit of brief-summary, but as would be expected there is a rela-tionship between this diffusion phenomenon and theprotein content of the plasma. Some chapters ofthe book are devoted to the post-operative bloodand the changes in narcosis, and a figure illustrates..the reaction in carcinoma, but the changes seen arenot specific for cancer. Dr. Bucher intends now to-proceed with an investigation of the Liesegang ringsin the blood of a variety of pathological conditions.

INSTITUTIONAL TREATMENT OF RHEUMATISM

IN SWEDEN

So much doubt is expressed about the aetiologyand treatment of the rheumatic diseases that it needscourage and vision to plan a system of institutionaltreatment likely to give satisfaction several yearshence. It has been calculated that the presentprovision of about 500 hospital beds for chronicrheumatism in Sweden is so far inadequate thatanother 1300 will have to be provided ; and even so,a supplementary scheme of polyclinics will benecessary. With regard to hospital beds it has beena moot point whether they should form independentunits or be incorporated in already existing hospitalunits under the medical control of physicians notspecialising exclusively in the rheumatic diseases.

1 Bucher, R., Helv. med. Acta, 1937, 4, suppl. II.