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reign for combating shock, inducing sweating, or

artificially raising the temperature of the body.The earliest device was a radiant heat shock cradle,containing twelve carbon filament bulbs. This had

given fairly good results but improvements had beenmade by using elements which generated far less lightand more heat. He had lately made experiments tocompare the heat generated by the various types ofapparatus and the pyrexia produced. The apparatusinvestigated had been the old type radiant heatcradle, the London County Council model shockcradle, the infra-red tunnel of the British Red CrossSociety, and an electric blanket and short-wave

apparatus of two types, the inductotherm and Wilde’spyretic bath. The British Red Cross Society used aheating element consisting of a self-insulated wirein a quartz tube. The infra-red rays were greaterand the light less than in the old cradle and theclinical results were better ; in particular this cradlerelieved periarticular muscular spasm.The effects of heat treatment differed widely accord-

ing to the mixture of the rays, the site of entry, theintensity of the beam, and its duration. Tests showedthat once the heat-regulating mechanism of the bodywas altered, either by a kind of breakdown or areadjustment on a new plane, very little energywas required to maintain the general bodytemperature above normal. Treatment with a radiantheat bath should not be started until at least twohours after a light fluid meal, or nausea and otherdistressing symptoms might occur. The patient’stoleration and comfort were enhanced if he drank

large quantities of glucose and saline fluid flavouredwith lemon. The concentration of saline must be0-2 per cent., which was not a pleasant drink butwhich was absolutely essential to replace the saltlost in excessive sweating.The conditions of the experiments had been made

as standard as possible. When the L.C.C. cradle hadfirst been tested at the Royal Free Hospital with adummy on the bed the temperature had risen rapidlyto a very high level and large differences of tempera-ture were observable on the surface. On the otherhand, when a patient was in the bath the temperatureon the top of the blanket became stable at 152° F.and the skin temperature under the blanket becamestable at 116° F. This illustrated the powerfulthermostatic effect of the patient. A radiant heatbath of this type could rapidly produce sweatingand rise of temperature with full power, but so

intensive a treatment could not De good for shockor safe for prolonged pyrexia. When six lamps wereused instead of twelve the temperature, pulse-rate,and blood pressure were not affected while the skintemperature was slightly raised. The electricalblanket provided an efficient and not uncomfortablemethod of transferring heat energy to the patient.

Dr. Heald referred to the lecture delivered byDr. C. A. Neymann before the Royal Society ofMedicine in the present year, in which the Americanworker pointed out the advantages of securinghyperpyrexia by high-frequency current: ordinarydiathermy, short-wave diathermy, and inductothermy.Dr. Heald showed a chart of a typical response todiathermy from both hands to both feet ; temperature,pulse-rate, and respiration-rate were all raised and

sweating was profuse. He had included in his

experiments a test of short-wave apparatus and

inductothermy and had, like Dr. Neymann, concludedthat inductothermy was probably the best of thesemethods. It differed in that the current was notpassed directly through the patient but through a

coil of insulated wire laid upon the pack in which hewas wrapped : usually an airtight bag with a zipfastener. The generator was said to have an outputof 950 watts, and the very rapid expansion andcontraction of the electric field in the wire caused

eddy currents within the conducting parts of thebody-the fluids, muscles, and nerves. A featureof inductothermy treatment was that the feeling ofwarmth it produced remained for several hours aftertreatment was discontinued. On the whole, theelectrical methods were more comfortable than theapplication of rays.

Dr. Heald commented on the difference betweenthe American and the English reports on the whitecell counts during treatment. While the white cellswere generally reported by English workers to fall,the Americans showed a great increase. It was

possible that the Americans had not allowed, as hehad, for dehydration. The count was an invaluablecontrol, for a rapid fall was a signal to stop treatment.At the close of his address, Dr. Heald gave a

demonstration in support of his belief that infra-redrays actually penetrated the patient’s body andexerted an effect upon its constituents. A’photo-electric cell was connected to a Cossor Robertsonelectrocardiograph of the latest type, and thesensitive bridge of the cell was completely coveredwith a substantial piece of meat; but when infra.red rays were directed at the meat the oscillographshowed a vigorous response. It showed a similar

response when Dr. Heald irradiated the meat with a

Kromayer lamp fitted with a filter which cut out allvisible rays. He took this result to indicate that,besides the ultra-violet rays which it is constructed toemit, the Kromayer lamp also emits an isolated bandof infra-red rays and that its therapeutic effects maybe due in considerable measure to this band-a

sharply defined and comparatively narrow band

being known to have a greater effect than the sameband grading off into higher and lower wave-lengths.

MEDICAL SOCIETY OF LONDON

AT a meeting of this society on Oct. 28th, withProf. G. E. GASK, the president, in the chair, adiscussion on

Electrical Injurieswas opened by Dr. MACDONALD CRITCHLEY. Ineach year, he said, the number of fatalities fromelectrocution in England and Wales was 50 or 60,but there must also be a very large number of minorand major injuries both in industry and in the home.In Germany the number of deaths was higher-probably about 400 annually-and in the UnitedStates it was 700 to 800. In this country the con-sumption of electricity was four times what it wasin 1912, but the mortality in 1934 was lower. Severalfactors determined the type and severity of theaccident, and the first was voltage. In generalterms, the higher the voltage the greater the danger ;but 45 volts had been known to kill a person, and60 certainly would do so. Deaths from contact withthe ordinary electric lighting main were very common;on the other hand, cases were on record in whichpeople had touched a main and received 132,000volts and still survived. The next factor was

amperage : it was the amount of current passingthrough the person which was important ratherthan the pressure ; 20 to 30 amperes was an unpleasantstrength, 80 to 90 was dangerous. The type of

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current was also important ; volt for volt, the alternat-ing current was much more dangerous than the direct,and that fact was borne out by the Home Office

figures, particularly up to a voltage of 250. Thenext important factor was the resistance of thetissues. Skin, especially when dry, was highlyresistant to the electric current ; sweating reducedits resistance 12 times and immersion in water

25 times. The best conductor of electricity in thehuman economy was the cerebro-spinal fluid, and itwas closely followed by the blood, the muscles, andthe liver. The nervous system was resistant; ithad been found that the sciatic nerve had eight timesthe resistance of Atlantic cable. A further importantfactor was the duration of the current’s passage ;momentary contact with a heavy charge might beinnocuous, but the longer the duration the morethe tissue resistance dropped.A person receiving a strong electric shock almost

always experienced highly unpleasant pain ; survivorsof such shock described an agonising pain throughoutthe body. Many complained of deafness and tinnitusif the shock continued ; often they were completelyblind, and some described actual hallucinations-balls of fire, a brilliant setting sun, balls or flashes oflight, and moons. Some spoke of a feeling of a

shrinkage of the body, and a loss of time-sense, sothat a contact of five seconds seemed like tenminutes. In some cases there seemed to have beena notable absence of pain, though other sensationswere felt. Unconsciousness did not necessarilyfollow, but might do so. It might result immedi-ately from pain, or the person might fall to the

ground soon after receiving the shock and remainunconscious for minutes, hours, or a day or so ;

during this period there might be motor agitation,convulsion, twitching, tremor, and a sense of increasedintracranial pressure. The tension of the cerebro-

spinal fluid might be raised, and it might containblood; some stated that its temperature was raised.As in concussion injuries, there might be retrogradeamnesia-e.g., in the case of a boy who climbed upa pylon, made contact, fell to the ground, and,when he reached home, asked for his midday meal,although he had already had both dinner and tea.Another type of unconsciousness was that whichcame on after an interval of, perhaps, some hours ;

=this was due to increasing cerebral cedema.Electric burns were abnormally deep ; secondly,

they tended to spread in the first few days after theshock, and this might be dangerous because of theliability to reactionary haemorrhage, especially as

one effect of the shock was to make the blood-vesselsof the locality unusually friable. In Vienna this

danger was so well recognised that means of dealingwith sudden haemorrhages from this cause were alwayskept ready in the hospitals. In comparison with aburn from an ordinary fire, the surrounding erythemawas much more limited. One authority stated thatelectric burns were painless, but Dr. Critchley didnot agree, though the explanation that the painmight be due to the burning of the clothing was apossible one. Another statement which he did notaccept was that electric burns were sterile. Theyhealed rapidly, and the resultant scar was a goodone, mostly free of contractures, it was said ; buthe had seen bad deformities follow. The points atwhich the current entered and left the body wereusually indicated by rounded greyish areas, whichwere painless. The patients showed a peculiarmetalisation of the skin, an appearance much

resembling morning frost on a pane of glass, due to

minute depositions of copper in the dermis. Insevere cases the burns might amount to gigantictissue necrosis ; indeed, a whole limb might bealmost amputated by the electric current.Bony injuries caused by electricity were important

though less common than other forms. When acurrent passed through a long bone it produced alongitudinal fracture, without fragmentation, but theapposition was so good and the fissure so narrow, thatit was not recognised, even by radiography. As

pain persisted, another radiogram was taken, and bythis time the parts fractured were not in such closeapposition, and osteomyelitis, and perhaps sequestra-tion, followed. A second type was a fracture or

fracture-dislocation due to direct muscle violence.A third was injury of the skull; this was speciallyapt to occur when the skull formed one of the pointsof contact. In one such case a man was picked upunconscious and all that was seen on his head wasa slight pimply swelling, with a mark on the sole ofthe foot where the current had apparently left thebody. The "pimple" subsequently developed andformed an extensive ulcer, which was sharply punchedout, with much thinning of the underlying skull.The remote effects of electric shock were rarities

but often missed. They were either ocular or neuro-logical. The ocular were two only: optic atrophyand cataract. The neurological were much morecomplex, and might consist of organic disease of thespinal cord or brain. It must also be realised that

organic neurological diseases could be precipitatedby electric shock—e.g., disseminated sclerosis, parkin-sonism, cerebral tumour, myasthenia gravis. Cerebral

complications were not very common ; they took theform of focal lesions-i.e., haemorrhages, softenings, orabscesses. There were records of cases in which theonset of epilepsy was ascribed to an electric shock.The post-concussional syndrome was also seen inthese cases, especially those in which the head formedthe point of electrical contact. Such a patientmight draw compensation for years because of

giddiness, headache, and the like. Much more

characteristic were the complications in the spinalcord. Here the picture was like that of amyotrophiclateral sclerosis ; there was a wasting of the musclesof the hand, which spread up the arm, and thendeveloped in the other hand; later the legs becameaffected, and there was pyramidal involvement, withdouble extensor plantar responses. There seemed tobe a close association between the electric shock andthe onset of spinal atrophy, and the term " spinalatrophic palsy " was used in this connexion. Peri-

pheral nerve lesions were uncommon after shock, butthey did occur ; there might be palsy of either medianor ulnar nerve.

Psychological disorders often started after severeelectrocution ; or they might be modified-and evencured-by the shock. Psychoses had been relieved,and in some cases cured, by electric shock, just asby lightning stroke ; a boy in an asylum sufferingfrom dementia praecox climbed up a pylon and afterrecovering from the immediate shock was mentallymuch better. Hysteria was very common afterelectric shock, as after lightning. A striking case

was that of a man in Berlin who fell on to an electricline so that his arm came into contact with thelive rail. His arm was paralysed and apparentlyinsensible to touch, and it remained inert at his sidefor a long time. But later it was clearly proved thatthere was no current in the rail at the time of the fall.The actual cause of death remained a problem.

One theory was that it resulted from ventricular

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fibrillation ; another that it was due to medullaryinhibition of respiration. Dr. Critchley thought it

probable that both were correct. Books on ambulancework still insisted that if necessary artificial respira-tion should be continued for hours, though it wasestablished that the brain cells could not revive if

deprived of circulation for 20 to 30 minutes. Butas respiration and circulation, though very feeble andnot detectable, might still be carried on, it was wellnot to alter the ambulance instructions. As regardsprevention, Dr. Critchley paid a tribute to the

adequacy and thoroughness of the Home Office

Regulations, and the energy with which failure tocontrol industrial apparatus was punished. Thiscontrol, however, did not extend to home accidents,and there the need seemed to be proper education,especially about the risks of worn flex for ironingor lighting.

Mr. ERIC PEARCE GouLD said that for judicialelectrocution at Sing Sing Prison a current of 22,000volts was used, and it was kept on until the fleshbegan to burn, a matter of some 17 seconds. Ifthe stethoscope showed that the heart had notceased to beat, the doctor signalled for a second

discharge, but this was very rarely necessary. He

gathered that there was a good deal of pulping of thebrain immediately subjacent to the head injury.He had seen some cases of electrically caused injuryon the Southern Railway in the old days. It wasa different story now with the third conductor rail,because the voltage there was only 650 of directcurrent. Of 2274 accidents on that railway in 1934,the total number of electrical injuries was 38, andonly two of these were fatal, both the victims beingchildren (aged 6 and 12) who had strayed on to theline. The average period of incapacity following theinjuries was 7 weeks 2 days. That surprised him,because among those who had sustained electricalaccidents he had noted a definite distaste to resumethe work, from fear of a recurrence of the experience.His impression was that burns caused by electricitywere not as painful as those caused in other ways.Some healed with scars which would be recognisedas those following burns, but in some cases, despite theextent of the burn, there was surprisingly little

scarring.Mr. ZACHARY COPE related cases of severe lightning

burns and electric shock which he had seen.-Com-mander T. N. D’ARCY described a case in which anelectric shock from a main was carried along a streamof urine.—Mr. A. SIMPSON-SMITH gave a short descrip-tion of legal electrocution carried out in Massachusetts,and Dr. CRITCHLEY briefly replied.

LIVERPOOL MEDICAL INSTITUTION

A MEETING of this institution held on Oct. 17th,with Dr. C. 0. STALLYBRASS, the president, in thechair, was devoted to a discussion on

Coronary ThrombosisDr. E. WYN Jos described the coronary circula-

tion as demonstrated by radiography. He laidemphasis on the age changes in the vessels andespecially on the development of anastomotic channelswith increasing age.

Dr. H. WALLACE JONES outlined the clinical aspectsof coronary thrombosis. Only during the last fewyears, he said, had it been realised that most patientsrecover from the attack. The illness fell into two

stages : (1) the initial anginal attack, and (2) the

evidence of myocardial infarction and damage.During the attack important features were pain,vomiting, air-swallowing, fall in blood pressure, anddistant heart sounds. The subsequent signs includedpericardial friction, congestive failure, pyrexia, leuco-cytosis, emboli, and abnormal rhythms. Atypicalforms of the condition included the painless, ingra-vescent, and abdominal types.

Dr. E. NOBLE CHAMBERLAIN, speaking of the

electrocardiographic changes, said that one of theirmost important features was frequent variation withina comparatively short period. Lack of knowledgemeant that the treatment was not yet on a fullysatisfactory basis. Morphia should be used in dosessufficient to relieve the pain, which often meant givingas much as 1 grain within two hours of the onset.The usual treatment of shock was indicated in caseswhere collapse was conspicuous, and if the fall ofblood pressure was extreme adrenaline or ephedrinemight be helpful. Digitalis should be reserved forcases in which definite signs of congestive heart failuredevelop a few days after the attack of coronarythrombosis, and those complicated by auricularfibrillation. Oxygen-preferably given in an oxygentent-was useful in cases where cyanosis and dyspnceawere prominent. In the subsequent treatment themost important point was the restriction of unduemental or physical exertion, the treatment of the

angina of effort which usually followed, and theenforcement of rest in cases where recurrent cardiac

pain occurred without effort.Prof. J. H. DIBLE described coronary thrombosisas the last act in the long drawn out drama of coronaryatheroma-a disease which in some people affectedthe coronary arteries much more than others. Bythe time the disease had advanced to the stage ofthrombosis the chronic isch2emia had usually led toa good deal of focal destruction of the myocardiumwhich had a high oxygen-consumption and whenactively contracting demanded 1-12 litres of bloodper minute. The thrombosis was followed by a

cardiac infarct and a new set of conditions arose.

The process of organisation began immediately,whilst pericarditis developed on the surface and muralthrombosis frequently in the interior of the ventricles.Both systemic and pulmonary emboli were possibleconsequences of the latter whilst autolytic softeningof the infarct might occasionally result in cardiacrupture. When the organisation of the infarctwas complete, it left a fibrous scar in the ventricularwall which might become the site of a cardiac

aneurysm.The PRESIDENT said he would add a word on how

not to diagnose coronary thrombosis. Sudden deathin a person not known to have suffered from coronarydisease did not justify this diagnosis.

Prof. JOHN HAY spoke of the importance of theatypical manifestations. Correct diagnosis was

necessary because prolonged treatment was advisableafter even a minimal thrombosis. The usual symptomsof pain and collapse might be present but mild, orthe pain might be absent or negligible, with some otherfeature dominating the picture-e.g., apprehension,much dyspnoea, congestive cardiac failure, a patho-logical rhythm, or symptoms suggesting an acute andserious abdominal lesion. The proportion of cases

in which pain was absent was far higher than wasgenerally appreciated.

Dr. 1. HARRIS said it was risky to rely on electro-cardiographic evidence alone, because often electro-cardiograms suggested coronary thrombosis when noclinical evidence of it could be found. The condition