367

FIG. 7-19,000 colonies of bacteria FIG. 9-One colony only, on aon a culture plate exposed to culture plate exposed to athe sneeze shown in fig. 1. sneeze as in fig. 8.

over 15 min. before falling on the culture plates.Such particles come within the category defined byWells 3 as " droplet nuclei," and are certainly capable

. of conveying infection under suitable conditions.

HYGIENIC MEASURES -

To prevent the spread of infectionwhen sneezing indoors one or more

of the following measures is usuallyadopted. We have placed them inorder of estimated efficiency.

Sneezing directly into a coal or gas fire(from a short distance) does. in our

opinion, ensure sterilisation of nearly-all the droplets, since, owing to the

chimney draught, few droplets willescape being carried into the fire or upthe chimney.

The careful use of a large handker-chief.—Figs. 8 and 9 show that thismethod can be very efficient. In fig. 8the subject is sneezing vigorously atthe moment of exposure, but no droplets can be seenescaping. Fig. 9 shows a culture plate similar to thatshown in fig. 7 but exposed in front of a sneeze trappedby a handkerchief as shown in fig. 8. This platecontained one colony only.A transparent mask.—Fig. 10 shows a vigorous sneeze

covered by a cheap mask of cellulose acetate 5! in. X 5in., such as has been provided in reserve for Londonshelter populations. The droplets from the sneeze canbe seen collected inside the mask except for three whichare seen below the mask in line with its surface. Thehigh apparent efficiency of this type of mask is rathersurprising, and it is possible that some very fine dropletsare escaping sideways without being visible in thephotograph.A gauze mask of good quality can be fairly efficient for a

single sneeze, but becomes messy and unpleasant aftermultiple sneezes, since, unlike a transparent plastic,gauze cannot be wiped clean and dry.

The hand.—Figs. 11 and 12 show how very inefficientthe hand is as a sneeze guard. With the closed hand infig. 11 inefficiency would be expected, but with the openhand placed in position well before the sneeze occurred,as in fig. 12, more protection might be expected. Itsfailure is due to the upward deflection of the air stream,which can be seen in this photograph, and has beenconfirmed in another instance.

TECHNIQUEFew people can sneeze regularly in front of a camera, owing

to the ease with which the sneezing reflex is inhibited. Wefound a number of subjects who ’could do it occasionally aftertaking snuff, and two who could sneeze regularly, one after

. taking snuff, and one after inhaling minute quantities of(J)- bromaceto -6 - methoxyquinoline hydrobromide.A stroboscope lamp was used with mercury kathode and a

special igniting electrode, supplied by British Thomson-Houston Ltd. The flash was made by discharging throughthis a battery of 100 X 1 ,uf dry condensers charged to 2100volts from a series of dry batteries and accumulators. A

3. Wells, W. F. Amer. J. Hyg. 1934, 20, 611.

cylindrical parabolic reflector of duralumin was placed behindthe lamp with small electric heaters at the sides to keep thelamp gently warmed. The flash was timed with a hand-controlled switch by an observer who watched the onset ofeach sneeze. The camera C, lamp L, and subject S wereplaced at the corners of a triangle of dimensions approxi-mately as follows : LC 55 in., LS 36 in., CS 41 in. The subjectsneezed on a line passing close to the lamp, but between it andthe camera. The lamp reflector was just to the left of the.portions of the photographs reproduced here. This systemgives maximum illumination as the droplets approach thelamp-i.e., at the farthest distance included in the photograph.It is in contrast to the system used by most American workers,who place the lamp very close to the subject’s head. Owingto the very brief duration of the flash the subject is not

dazzled, even if his eyes are open.

SUMMARY

The droplets from a sneeze contain many fine bacteria-laden particles which remain suspended in the air formore than ten minutes. A large handkerchief carefullyused prevents the scattering of these droplets, and asimple impermeable mask collects the vast majority of

FIG. I 1-The closed hand is very. inefficient.

FIG. 12-The open hand may only stop a fractionof the particles, and deflect the rest upwards.

them. The use of the hand for checking such scatteringis very inefficient.

We wish to thank the research staff of British Thomson-Houston Ltd. for advice on the use of this lamp, and thevarious subjects who have patiently sneezed for this study.We are also indebted to Mr. S. F. Wilkinson for suggesting thetaking of some of these photographs.

CORROSIVE STRICTURE OF THE STOMACHWITHOUT INVOLVEMENT OF THE ŒSOPHAGUS

C. A. R. SCHULENBURG, M.B. Cape Town, F.R.C.S.LATELY SURGEON IN AN E.M.S. HOSPITAL

CrcATR,icmr. stricture of the oesophagus followingingestion of corrosive acids or alkalis is well known, andlesions of the stomach in association with an oesophagealstricture have been reported (Sager and Jenkins 1935,Vinson and Hartmann 1928), but stricture of thestomach with an unharmed oesophagus seems to be veryrare, at any rate in England, though the condition isfully dealt with in a number of foreign papers.The only recorded case in the English language is

described by Vinson and Harrington (1929). A man of59 accidentally swallowed formaldehyde, subsequentlydeveloping signs of obstruction in the stomach ; bariummeal 4 weeks after the episode showed a double strictureof the stomach, which was confirmed at operation ;there had been no permanent damage to the oesophagus.There is also a case in the autopsy records at Guy’sHospital (Bishop, P. M. F., personal communication) of awoman of 61 who swallowed hydrochloric acid anddeveloped signs of pyloric obstruction ; she died 4 weeksafter admission from bronchopneumonia. At autopsy theoesophagus was found to be free from any lesion, whilethe stomach showed a tight, fibrous, annular stricture for3 cm. above the pylorus. Prof. Grey Turner, who has hadextensive experience of strictures of the oesophagus andother lesions following the ingestion of corrosives, tells methat he knovis of only one case where pyloric stenosis

368

occurred after the swallowing of lysol. Similar cases havebeen reported by Pop and Galdau (1928a and b), Bock andHin (1931), Popp (1931) and Faynberg (1935). Orator(1929) reviews the clinical findings on the basis of 34collected cases, and Petrov (1935) reports 41 operationsfor burns of the stomach by strong acids and alkalis.Their conclusions are similar :

1. Acid burns are much more liable to cause gastric stenosisthan alkalis, which affect mainly the oesophagus.

2. The site of stricture formation is almost invariably thepyloric and prepyloric regions.

3. The surgical procedures for relief are determined by thestage at which the patient is seen. In the earliest stages,with gross damage to the stomach, jejunostomy is the

operation of choice. At a later stage, when stenosis withobstruction is established, gastrojejunostomy is the onlyrational procedure.An interesting experimental study is provided by

Testa (1938). A small amount of caustic soda, with’

added barium, was introduced into the oesophagus ofdogs, and its passage observed by X rays. In thestomach, the alkali flowed along the lesser curvature

and a severe

pre-antralspasm was pro-duced whichlasted for r a

variable time eand was s

followed byperistalsisand relaxationof the spasmand of thepylorus. Sub-

sequent exam-ination showedthe severesttrauma andchanges to be

in the parts where the nuid hadbeen held up by the spasm.These traumatic strictures of thestomach are indistinguishable clini-cally and radiologically fromthose due to ulcers. The historv

- :-- . alone can decide the question.Tracing of radiogram The prepyloric strictures oftenafter barium simulate carcinoma, b u t t h e

defect in the radiogram has a smoother outline thanin cancer.

CASE-HISTORY

A railway-station attendant of 52 was admitted to St.

Alfege’s Hospital on Nov. 26, 1940, with a history of havingswallowed 1 oz. of concentrated hydrochloric acid about twohours before. Until this time he had always been well. Hehad vomited twice before admission, and had some epigastricpain. His voice was thick and slurred, and his tongue,cheeks and fauces were badly burned. Routine immediatetreatment was applied. Four days after admission he

complained of difficulty in swallowing and epigastric dis-comfort. A barium swallow was given 16 days after admis-sion, but showed no oesophageal delay or stricture. On Dec.19 (23 days after admission) a barium meal X-ray examinationwas made by Dr. K. J. Yeo, and a stricture of the stomachproximal to the pylorus was demonstrated, the distal pocketbeing collapsed and empty (see figure). On Dec. 30 (34 daysafter admission) the patient began to vomit daily. He wasthen transferred to the Southern Hospital, Dartford, wherethe vomiting was controlled for some time by small, frequentfeeds. Improvement was.not sustained, however, and whenI saw him first, on Jan. 29, he presented a classical picture ofpyloric obstruction, with dilated stomach, succussion splashand visible peristalsis. The stomach was aspirated continu-ously through an indwelling Ryle’s tube, and continuousintravenous saline with glucose was administered.

Operation was performed on Jan. 30 under local analgesia.The stomach was exposed through a high midline incision ; itshowed a tight, fibrous stricture about 2 in. proximal to thepylorus, the greater curvature being drawn up to the lessercurvature by the scarring. The proximal pouch of thestomach was much hypertrophied and dilated, while thedistal pocket was collapsed and empty. There was no

evidence of malignant disease, and there were no enlargedglands along the curvatures. The gall-bladder was smalland contained one stone. An anterior, antecolic gastro-jejunostomy was performed, and the abdominal wall wassutured with interrupted buried floss-silk sutures. Intra-venous fluids and aspiration of the stomach were continuedfor a further 36 hours, and the patient made a good recovery.A barium meal on March 13 showed the oesophagus normaland the stoma functioning well. The distal part of thestomach was faintly. outlined and showed the stricture, whichallowed the passage of only a small amount of barium.Œsophagoscopy on April 16 showed no signs of stricture orulceration, and the cardia was normal. By May the patienthad gained a stone and a half in weight, was eating well, andhad no abdominal discomfort.

COMMENT

A constant feature of the recorded cases is the rapidityof onset of the stenosis. One of the cases reported byPop and Galdau had a complete stricture 19 days afterswallowing caustic soda, while the cases mentioned inthis paper had developed tight strictures within 4 weeks.This can be explained by rapid healing with fibrosis,following intense localised destruction of mucous mem-brane and stomach coats by the corrosive while held upby the pyloric and pre-antral spasm. This holding upof the corrosive by spasm was well demonstrated inTesta’s experiments. The intensity of this destructionis shown by the fact that acute perforation of the stomachwall can occur if the acid remains localised to one area.The radiographic appearances may be indistinguishablefrom those produced by carcinoma or sclerosing ulcers.This is important, because malignant disease must beexcluded or appropriately treated at operation. Thepreponderance of stomach lesions where acid has beenswallowed and of oesophageal stenosis where alkali hasbeen taken is noted by all observers, but no rational’explanation has been given. Complete absence of injuryto the cesophagus was demonstrated in the case recordedhere by X-ray examination and oesophagoscopy. ,

I wish to thank Dr. W. Allen Daley, medical officer ofhealth to the London County Council, for permission to

publish this case, and Dr. P. M. F. Bishop for a note of thecase at Guy’s Hospital.

REFERENCESBock, H. and Hin, G. (1931) Röntgenpraxis, 3, 740.Faynberg, B. (1938) Sovetsk. Vrach. Gaz. No. 4, p. 320.Galdau, D. and Pop, A. (1928) Fortschr. Röntgenstr. 37, 705.Orator, V. (1939) Zbl. Chir. 56, 514.Petrov, B. (1935) Sovetsk. No. 6, p. 106.Pop, A. and Galdau, D. (1928) Rev. Stiint. med. 17, 717.Popp. L. (1931) Clujul. med. 12, 546.Sager, W. W. and Jenkins, W. H. (1935) Ann. Surg. 101, 969.Testa, G. F. (1938) Radiol. med., Torino, 25, 17.Vinson, P. P. and Harrington, S. W. (1929) J. Amer. med. Ass. 93, 917.

— and Hartmann, H. R. (1928) Med. Clin. N. Amer. 8, 1037.

Medical Societies

OPHTHALMOLOGICAL SOCIETY OF THE

UNITED KINGDOM

THE annual congress of this society took place at Trinity College, Cambridge, on Sept. 4 and 5 under thepresidency of Mr. R. AFFLECK GREEvES (London) whoread a paper on cedema of the macula. He thought thiscondition was always accompanied by deterioration ofcentral vision, varying in degree according to the severityof the oedema. The distortion of straight lines was acommon symptom and a valuable diagnostic point. Asense of diminution in the size of objects was also common.The clinical signs were loss of retinal transparency,though in the slightest degrees of oedema a minuteophthalmoscopic examination and a careful comparisonwith the appearance of the macula of the other eye mightbe necessary for its detection. After oedema centralvision might be restored, improve up to a point, remainpermanently reduced (possibly with some visual dis-tortion), or be permanently destroyed, as in most casesof central venous thrombosis. The ophthalmoscopicappearance of the macula might return to normal, butsome permanent pigmentary disturbance could oftenbe seen. A complete restoration of the normal appear-ance of the fundus did not always connote full recovery