164 ROYAL SOCIETY OF )IEDICINE: SECTION OF SURGERY

TECHNIQUEThe method of cultivation can be readily understood

from the accompanying figure. The oxygen from acylinder is first passed through a wash bottle containinga 10% solution of potassium hydroxide and is thenled through a glass tube containing a sand and pulpfilter, such as is used in the filtration of virus-containingmaterial, into a test-tube of 50 c.cm. capacity. Thesame sand and pulp filter may be used for at least sixweeks. The test-tube is closed with a rubber corkcovered with tinfoil to ensure a tight fit. The inletglass tube is continued to within 2-3 mm. of the bottomof the test-tube, and at its outlet should have an internaldiameter of 5 mm. The exit tube from the test-tubeis closed with a plug of absorbent cotton. The test-tube,with inlet and outlet tubes in place, is first sterilised andis then filled with 30 c.cm. of the serum Tyrode culturemedium and about 0.5 c.cm. of finely minced chick-embryo. The minced chick-embryo sinks to the bottomof the test-tube, and it appears to be important that theinlet tube should reach into the mass of embryonictissue. The outlet screw of the oxygen cylinder isadjusted so that eight to ten drops of oxygen passthrough the medium per minute. If desired, two ormore test-tubes may be employed at the same time.Passages are made every four days. The whole of theapparatus is kept in the hot room at 37° C. If a hotroom is not available, arrangements can be made forthe test-tubes containing the culture media to stand inan incubator while the oxygen cylinder and the otherapparatus, connected to the tubes by a long rubbertube, remains outside at room temperature.

RESULTS

Twenty-four subcultures of the tissue-culture virus17 D have now been made in the oxygenated culturemedium in vitro. No change has been noted in thepathogenicity of the virus for mice, and titration of thevirus has shown that it is pathogenic, on intracerebralinjection of mice, in dilutions of 10-3 or 10-4, an end-pointwhich is equal, and in some cases superior, to that obtainedby culture in flasks.

Since the method has now been applied successfullyto three viruses as dissimilar as vaccinia, lymphogranu-loma inguinale, and yellow fever, it is probable thatmany other viruses and possibly rickettsiae may also begrown under the same conditions.

Medical Societies

R.S.M.: SECTION OF SURGERY

AT a meeting of this section of the Royal Society ofMedicine on July 30, with Mr. ZACHARY COPE presiding,an address on

Hysterical Contractures following War Injurieswas given by Sir ARTHUR HURST. He said that althoughin civilian life contractures after injuries were infrequentin war they were common. There was a danger that thelessons of the last war might be overlooked. Onlytowards the end was it recognised that these con-

tractures were usually hysterical and could be curedquickly. They commonly arise after injury to the softparts and sometimes follow a twist or sprain where thereis no actual wound. They may follow slight operationssuch as amputation of a hammer-toe or removal of semi-lunar cartilage ; the limb is found after the removal ofthe splint or bandage to be completely stiff. The com-monest are those which develop in the hand, of whichthere are two main varieties-those with the fingersstiffened in extension and those with the hand tightlyflexed and the fingers bent into the palm. The wrist maybe fixed, though uncommonly ; the elbow, shoulder,knee, hip or toes may be affected. Immediately after theinjury the patient adopts the position most comfortableto him and by maintaining it develops a contracture ;or the limb is immobilised by splints or plaster, and whenit is released remains fixed in the same position. Thepatient has lost the idea of movement, and nurses arenow generally instructed that when dressings are re-moved the patient must be put through the complete

range of movement of the affected part. Contracturesare very likely to arise if the patient is sent to thephysiotherapy department, and many cases would nothave developed in the last war but for the mistakentreatment they received. Babinski came to the con-clusion that the contractures were reflex and thereforeorganic in origin ; the trophic changes which take placein patients with deficient circulation following disuse of apart led to this mistake. The skin becomes wrinkled,blue, thin and shiny, the finger nails develop badly,being grey and lustreless, grooved and brittle, and thebones become abnormally translucent.

In the early days, Sir Arthur Hurst continued, thesecases were treated by suggestion and occasionallyhypnotism, but simpler methods of psychotherapy werefound to be more valuable. The patients had never beenshell-shocked. Persuasion, manipulation and re-educa-tion were found to be effective and in the ideal case curewas obtained without the patient being touched-he wasmerely told what to do. At Seale Hayne military hospitalin the last war there were ten medical officers, only oneof whom had had any experience of psychotherapy orneurology ; yet any one of them would have beenannoyed if he had not cured each case at a single sittingwhich might last a few minutes or extend into a few hours.No massage or electricity was used or needed. Themedical officer began by explaining how the contracturehad developed. The patient was taught to relax, to letthe limb go as limp as possible ; the doctor moved theaffected part a little and allowed it to relax again. Aftera while the patient was encouraged to move it for himself,and gradually, by a combination of passive and activemovements after complete relaxation, normal mobilitywas restored. Some of the cases had been regarded assurgical, and operated on, but the contracture persisted ;even sympathectomy had been done with no result.

Dr. J. B. MENNEH, agreed that physiotherapy wascalculated to make the patient worse. It was futile totreat either hysterical contractures or hysterical paralysisby physical methods.Colonel HENRY YELLOWLEES complained that Sir

Arthur Hurst had made only one remark about thepsychopathology of these cases-namely, that the patienthad lost the idea of movement. That might be satisfyingto the surgeon, to the expert in physical medicine, andeven to the neurologist, but it was not satisfying to thosewho knew anything about hysteria. It was interesting tohear that only one of his team of ten had had anyexperience of psychological medicine or even of neurology ;if that was so there must be precious little in psycho-therapy. Otherwise how was it possible for nine of theteam who knew nothing of the subject to become equallyexpert in a few months ? It was not clear whether theyhad relied on suggestion or persuasion ; probably SirArthur was not clear either.-Sir Arthur Hurst remindedColonel Yellowlees that in the last war psychotherapy hadnot developed to its present extent ; it was impossible atthat time to get any large group of trained psycho-therapists. If the ten members of his team, thoughignorant of modern psychotherapy, were able to cure allthe hysterical cases and they remained well, as it wasknown they did, that was all that was required.

Sir ALFRED WEBB-JoHsox said that most of thepatients at Seale Hayne had an hysterical contracturegrafted on the top of an injury and the tragedy was thatthe condition was not recognised for many monthsafter it came into being, yet it was susceptible of rapidcure.

Dr. E. B. STRAUSS emphasised the great differencebetween cases of hysterical contracture and conversionhysteria. The average case of conversion hysteriawould not clear up in a single sitting, whereas an hystericalcontracture would. The majority of cases of contracturein civilian life were due to over-splinting and physio-therapy ; the hand had gone to sleep and " forgotten howto wake up."

Colonel YELLOWLEES asked whether cases of deafmutism and conversion hysteria were cured in France atone sitting.-Sir Arthur Hurst replied that they wereconstantly cured. The cases he had spoken of were in adifferent category ; they did not come in within twenty-four hours, but were seen after perhaps eighteen monthsin different hospitals where they had got worse and at lastbecome completely demoralised ; and although it was

165THE RECRUIT’S HEART

possible to eliminate their symptoms they were fit onlyto be returned to civilian life.

Mr. ZACHARY COPE suggested that, under deepanaesthesia, a joint which was not absolutely ankylosedwould be movable.-Sir Arthur Hurst remembered a

patient with knees rigidly extended who had had manykinds of treatment and was given a general anaesthetic butcould not relax. Psychotherapy was tried and graduallyrelaxation was obtained. It was extremely difficult toexplain these cases.

Dr. J. F. VENABLES mentioned a case of a stiff knee inwhich there were no signs of disease and no changes wereseen on radiographic examination. Dr. R. L. WoRRALLasked whether any disturbance of sensation in theaffected areas was noticed and whether there was anycontraction of the muscles of the face or of respiration.-Sir Arthur Hurst replied that he had never looked forsensory changes, being quite sure he would find them if hedid so. He remembered only one case of facial spasmand that did not follow an injury but was associated withdreams and night terrors. The spasm disappeared withthe dreams.

Colonel H. C. GARLAND emphasised the importance ofdiagnosis of all hysterical disorders ; and Mr. LIONELNoRBUBT said he had had several cases of functionalhysterical contraction in women after breast operations.

THE RECRUIT’S HEART

IIETHODS of detecting effort syndrome and diseasesof the heart and arteries are the subject of the latestrecommendations to the Minister of Labour by LordHorder’s advisory committee on the examination ofrecruits.

EFFORT SYNDROME

Effort syndrome has been known under variousnames, including soldier’s heart, irritable heart, andD.A.H. The condition was first mentioned in theAmerican Civil War, and has probably cropped up amongsoldiers ever since the idea of collecting warriors intobands and leading them into battle occurred to theearliest war-lords, though we owe its present name toSir Thomas Lewis. Lord Horder’s committee haveamended and amplified the instructions already issuedfor the guidance of medical boards, using the term effortsyndrome to denote " a condition in which the characteris-tic symptoms are nervousness, a feeling of exhaustion,left mammary discomfort, palpitation, giddiness anddyspnoea on exertion." They point out that of themany men who break down during training or activeservice with these symptoms, the majority are neuro-paths ; in a few the symptoms can be ascribed to chronicor temporary toxaemia ; there is rarely any lesion of theheart. A medical board may be able to foretell that agiven recruit is likely to break down in this way from hisappearance and demeanour or by evidence of nervousinstability in his history or on examination. The com-mittee suggest that habitual avoidance of exertion inrecreation is suggestive. An exercise-tolerance test willnot help the board to detect potential cases but it maymake it easier to gauge the degree of emotional distur-bance in patients who have already developed thesyndrome. The committee prescribe the followingrevised exercise-tolerance test.

1. The pulse-rate is taken for 15 seconds with the manstanding.

2. He places one foot on a chair at least 15 in. in height,keeping the other foot on the floor ; he then raises himselfuntil both feet are on the chair and his body is upright, andthen lowers himself until one foot is on the floor. This is

repeated twenty times in 60 seconds. He may use the backof the chair to steady himself when getting on and off thechair.

3. The pulse-rate is then taken for 15 seconds.4. The man stands still, and 45 seconds later-that is, one

minute after completing the exercise-the pulse is taken

again for 15 seconds. By that time the rate should be thesame as the original rate or lower. Any persisting dyspnoeaor distress is noted.

If the original pulse-rate is regained in 60 seconds andthere is no dyspnoea or distress the man is said to have

good exercise tolerance. An unsatisfactory result maybe due to nervous instability or some cardiovasculardefect, and must be investigated appropriately. Thetest alone is not conclusive evidence of these conditionsor of a man’s unfitness for grade 1. The response maybe affected by temporary factors such as a common coldor lack of fitness following prolonged sedentary work.

DISEASE OF HEART AXD ARTERIES

Examination for disease of the heart and arteries isto be carried out while the man is standing and alsowhen he is lying on his left side, a position which makesit easier to detect some types of murmur. The com-mittee consider that any man should be classed as grade4 whose heart shows signs of enlargement, aortic ormitral disease, or congenital malformation, even thoughthe lesion is well compensated and the man gives a fairresponse to the exercise-tolerance test. A systolicmurmur heard at the apex is not to be accepted alone asevidence of structural disease, but when it is present ahigh exercise tolerance should be required, and mitraland aortic disease must be carefully excluded. Thecommittee point out that a systolic murmur heard at thebase is common in health, and may be disregarded whenloudest in the pulmonary area, unless associated withother signs of congenital heart disease. If it is loudestin the aortic area, transmitted upwards, and accom-panied by a thrill it is to be taken to indicate aorticstenosis.They point out that if the cardiac impulse is felt

beyond the mid-clavicular line the heart is enlarged, unlessthe displacement is due to scoliosis, however slight, or topulmonary disease. The commonest causes of enlarge-ment are mitral and aortic disease. Hypertension andcongenital heart disease are less common causes.

Abnormal rhythm is not necessarily evidence of organicdisease. Before grading a man his previous history mustbe reviewed-his occupation and athletic habit-as wellas his response to the exercise-tolerance test. Tachy-cardia is most commonly due to nervousness, especiallyin younger men, but hyperthyroidism should be excluded.Paroxysmal tachycardia is rare, but if diagnosed wouldcall for low grading. The possibility that the man hastaken drugs must be borne in mind. Cases of cardiacarrhy-thmia and tachycardia of doubtful nature are to bereferred to a consultant. The blood-pressure is to betaken in all men over forty, and in any case of unex-plained cardiac enlargement or suspected arteriosclerosis.A man with a diastolic reading between 90 and 100mm. Hg (as estimated when the pulse sound disappears)should not be placed higher than grade 3. If the dias-tolic reading is over 100 mm. Hg the man must be placedin grade 4.

WE are not the only country affected by the loss ofEurope’s herb gardens, or the disorganisation of thedrug market. Surgeon General Parran, addressing thehealth officers and public health nurses of America lastmonth, pointed out that as Holland was no longer ableto import, prepare and distribute quinine, the onlysource of the drug was now the Dutch East Indies.The Dutch cartel had made it impossible to store asufficient war chest with quinine and yet all central andsouth America looked to the United States to supplytheir need. Military operations in the tropics could notbe carried out unless quinine-or the equally potentsynthetic drug, Atebrin-was available in large quan-tities. The position in regard to morphia was morepromising. The vaults once used to store gold atWashington now held enough morphine to last threeyears, and opium poppies could be grown in many partsof the United States ; but it was important to plan theplanting now. The Surgeon General added that intropical America yellow fever was still a problem. Hementioned that the present reserve of vaccine would beinsufficient to immunise one regiment, and that fundswere needed to build up an effective reserve.

"ADDRESS UNCOMMUNICATED."-The editor of theMedical Directory asks us to remind certain of our readersthat these words will appear in the 1941 directory aftertheir names if they do not provide an alternative withoutdelay. The offices of the directory are at 104, GloucesterPlace, London, W.I.