1154

which finger was testedand the actual range of

temperatures used.All the intrinsic

muscles of the handcould be made to con-tract voluntarily, andmuscle wasting was re-markably slight. The

range of passive move-ment of the fingers wasnormal; but active flexionwas slightly limited, andactive extension was sig-nificantly limited. Mostfingers could be flexed towithin 2 cm. of the palmand a satisfactory fistcould be made.

Wrist movements were limited both actively and passively,only 20° of active extension of the wrist being possible. Thiswas partly due to joint changes resulting from the proximity ofthe traumatic amputation and partly because the extensor

tendons had united with lengthening. The patient could

pronate through 60° and supinate through 80°. The shoulderand elbow were normal.The extent to which the hand had again become part of the

patient was quite remarkable.He used the hand normallyand naturally in gesticulating.He could knit at a fair speed,and he used the reattached

right hand in preference to

the left one for writing. Beforehis injury he had been re-garded by his workmates as

a very promising ping-pongplayer. Now he had resumedplaying ping-pong and hishand was strong enough toenable him to use a hammerand to lift moderately heavydumbbells. His good tactilesensibility, normal sweatingand skin texture, and amplerange of thumb movementsenabled him to hold a glass ofwater with complete assur-

ance (figs. 4 and 5). There isno doubt that function will

continue to improve, but already it is as good as one wouldexpect to follow a total repair of nerves and tendons in frontof the wrist.

DISCUSSION

The operation was performed unhurriedly, with carefultechnique. The cut was clean, and very little tissue hadbeen devitalised, and there was relatively little delaybetween the injury and the restoration of circulation."The use of plastic cuffs in anastomosing the radial and

ulnar arteries simplified the procedure and probablyhelped to maintain patency of the vessels in the all-

important early postoperative period. At a later phase,they may have resulted in slight stenosis of the vessels but,if so, this produced no clinical ill effects.The decision to use internal fixation on the radius was

undoubtedly correct. If rigidity had not been restored,the anastomosed vessels would have been subjected totwisting, bending, and traction strains which might havehad disastrous results.The advisability of primary nerve suture will be ques-

tioned by many, but in this case it paid handsome divi-

Fig. 4-Hand grip eight months afteroperation.

Fig. 5-Reattached hand usedin play.

11. Hardy, E. G., Tibb, D. J. Brit. med. J. 1960, i, 1001.

dends; for recovery of function both in the ulnar andmedian nerves was unusually complete. In my opinionthe decision was correct because (a) the extent of theintraneural scarring was, from the nature of the injury,not likely to be great; (b) shortening of the bones permitteda radical excision and accurate approximation of the nerveends; (c) the lesion was low and the earliest signs ofrecovery could be expected within a few weeks. If signs ofrecovery had not appeared then, it would not have beentoo late to re-explore and resuture with expectation of agood result.

Since this case Dr. Chen has successfully reattachedtwo more completely amputated limbs. In dealing withthese, he paid particular attention to anastomosing mostof the venous channels, and as a consequence the limb didnot become oedematous.

MUST MACKINTOSH SHEETS BE USED TOCOVER PATIENTS AT OPERATIONS?

J. A. C. WEATHERALLM.B., B.Sc. Edin.

H. K. ASHWORTHM.B. Manc., F.F.A. R.C.S.

H. J. CRAWFORDM.B., B.Sc. Lond., M.R.C.P.

B. MURPHYM.B. Lond., D.Obst.

H. I. WINNERM.A., M.D. Cantab., F.C.Path.

From the Departments of Bacteriology and Anœsthetics,Charing Cross and Fulham Hospitals, London.

IN many operating-theatres it is still customary to coverthe patients with mackintosh sheets under sterile towelsduring operations. The reason usually given is thatmackintoshes can prevent bacteria from the patient’s skinreaching the operation site. Anarsthetists find that the useof mackintoshes, especially during long operations, makesit extremely difficult to control the patient’s body tempera-ture, and in some cases leads to hyperthermia. Conse-

quently we undertook some experiments to determinewhether in the absence of mackintoshes contamination ofthe operation site was an appreciable risk, and whetherthe risk was reduced by the use of mackintoshes.

METHODS

The experiments were conducted in the main theatres at

Charing Cross and Fulham Hospitals. In the first series,alternate operations were performed either with sterile mackin-toshes or with nothing between the skin of the patient and theoperation towel. The surface of the towel was sampled forbacteria by placing a standard sterile beaker, underside upper-most, under the towel, and inverting a sterile petri dish contain-ing blood-agar over the beaker so that it made contact with thetowel. The petri dish rested in position for about 15 seconds.One sample was taken from each operation and samples weretaken either 1 hour, 45 minutes, or 30 minutes after the start ofthe operation. The site sampled was usually over the pubiswhere instruments had been laid during the operation. Each

agar plate was incubated for 24 hours and the numbersof colonies on the surface were counted. The results are

summarised in the accompanying table.In a second series of experiments the surface of towels was

also sampled by direct contact with an agar surface, but themethod described by Lawrie and Jones (1952) was used. 8 in.of a sterile 2 in. bandage was embedded in a molten blood-agarplate. When cold, a disc of blood-agar gel could be lifted bythe bandage ends from the petri dish. The under surface ofthe disc was laid on the surface of the operation towel. Contactbetween the disc and the towel was maintained for 30 seconds.Where contact had been made the pattern of the towel couldbe seen on the surface of the disc. The disc was then turnedover, returned to the petri dish, and incubated for 24 hours.The number of colonies in four separate 1 sq. cm. areas wascounted. If no towel pattern was seen on a sampled area, no

1155

NO. OF BACTERIAL COLONIES ON OPERATION TOWELS (MEAN)

No. of observations in parentheses. Copies of tables showing results infull may be obtained from: Dr. H. 1. Winner, Bacteriology Department,Charing Cross Hospital Medical School, London, W.C.2.

count was made of that area. For each plate the mean numberof colonies in 1 sq. cm. was calculated.At each operation some operation towels were laid directly

over the skin of the patient, and some were laid over a sterilisedmackintosh. Samples were taken at the end of each operationafter the skin had been closed but before any towels were dis-turbed. Half the samples were taken from towels overlyingskin only, and the other half from similar sites overlyingmackintoshes. Each pair of samples, over mackintosh and overskin, were matched as closely as possible for distance from theoperation site, and for wetness, contamination, and blood-staining. Fifty samples in all were taken at fifteen operations(see table).

DISCUSSION

In neither the first nor the second series of observationswas there any significant difference between the mean

number of colonies isolated from towels with or without

underlying mackintoshes. In the first series, operationswere not matched for site, and there is a suggestive trendtowards greater contamination of towels in lower abdo-minal and perineal operations, irrespective of whetherthese had mackintoshes underneath or not. In the secondseries of matched observations no such trend is obvious.The only high counts were obtained after a mouth opera-tion when both sets of towels were highly contaminated.The figures shown here suggest that the use of mackin-

tosh sheets to cover patients at operation does not materiallyaffect the number of bacteria reaching the surface of theoperation towels during operation and, therefore, does notprovide any appreciable protection to the operation sitefrom infection from the patient’s skin. It seems to us that

any possible bacteriological protection provided by mack-intosh sheets is more than counterbalanced by the dis-advantage of preventing free skin ventilation in patientsundergoing operation, particularly in hot operating-theatres.

We acknowledge with thanks the unstinting help given by thesurgeons and theatre staffs at Charing Cross and Fulham Hospitals.

REFERENCE

Lawrie, P., Jones, B. (1952) Pharm. J. 168, 288.

Points of View

MAST-CELLS AND ANAPHYLAXIS

JAMES F. RILEYM.D., Ph.D. St. And., F.R.C.S.E., D.M.R.T.

CONSULTANT RADIOTHERAPIST, ROYAL INFIRMARY, DUNDEE;READER IN EXPERIMENTAL MEDICINE. UNIVERSITY OF ST. ANDREWS

As is well known, patients who survive an infectionoften acquire immunity against a second attack. One ofthe great contributions of medicine in the 19th centurywas the exploitation of this phenomenon by deliberatelyinjecting the patient with dead or attenuated organismsor their toxins to stimulate a prophylaxis (protection)against subsequent infection. Such ability of.the body todevelop a resistance to infection seems not unexpected inthe general scheme of evolution: immunity, natural oracquired, obviously carries survival value. More unex-

pected, therefore, was the discovery by Portier and Richet(1902) that occasionally the very opposite occurs: the

patient or experimental animal reacts violently, even

fatally, against a second injection of a foreign substancewhich initially was barely toxic. Instead of prophylaxis,anaphylaxis has developed.Some functions of the tissue mast-cells have been des-

cribed previously (Riley 1954, 1962). My purpose here isto discuss the part played by the mast-cell in anaphylaxisňa small area of a very large field. A recent textbook byHumphrey and White (1963) and the delightful review onanaphylaxis by Sir Henry Dale (1954) give a more generalsurvey of the subject.*

HYPOTHESES ON ANAPHYLAXIS

The manifestations of anaphylaxis vary from one speciesto another. The dog reacts with spasm of the suprahepaticveins and engorgement of the liver and portal system; the* Schild (1956), Ungar and Hayashi (1958), Rocha e Silva (1959),

Wolstenholme and O’Connor (1960), Feldberg (1961), West(1961), and Keller (1962) provide detailed information on variousaspects of anaphylaxis. An important review by Mota (1963)has appeared more recently.

rabbit develops a spasm of the pulmonary arteries, whichcauses distension of the right heart and deprives the lungsof blood; the guineapig responds with a spasm of thesmaller bronchioles so intense that even when the thoraxis opened the lungs remain in a state of emphysema. Ineach case reaction is a spasm of plain muscle. The out-standing feature, as stated above, is that this violentreaction occurs only on the reintroduction of a high-molecular substance foreign to the organism. As Richet(1952), who received a Nobel prize for his work, remarks:" c’est une sensibilite plus grande, une sorte de r6voltecontre cette seconde injection parenterale qui seraitfuneste. A la premiere injection l’organisme surpris n’arien oppose. A la seconde injection, il s’est mis en etat dedefense, et repond par le choc anaphylactique." Just whatthis state of readiness is and how the subsequent shock isprecipitated have formed the subject of innumerableinvestigations over the past 50 years. The discovery ofhistamine in the mast-cell has at least helped to clarifysome aspects of the problem (Riley 1959).

Portier and Richet (1902) believed that anaphylaxis isdue to an altered state of the blood. This " humoral hypo-thesis " appeared to gather support when Friedberger(1909), Bordet (1913), and others showed that, when serumis incubated with antigen/antibody complexes or even

simpler high-molecular substances (agar, starch, insulin),it is so changed that on reinjection it produces a syndromeresembling anaphylaxis. The serum was believed to havegenerated an anaphylatoxin, in which process haemolyticcomplement is consumed.Meanwhile Ackermann (1910) and Kutscher (1910) had

isolated histamine, first synthesised by Windaus and Vogt(1907); and Dale had embarked upon his classic pharma-cological studies which showed that histamine embodiesmany of the properties of the anaphylactic poison requiredin the humoral hypothesis (Dale and Laidlaw 1910, 1911).Yet agar-treated serum neither contains nor generateshistamine. Dale therefore suggested that if histamine isinvolved in anaphylaxis it must be of cellular origin. Thiswas made abundantly clear by his demonstration that