87

THE LANCET.

LONDON: SATURDAY, JANUARY 13, 1923.

THE SURGERY OF INFANCY.—HOSPITAL REPORTS.

THE SURGERY OF INFANCY.THERE is a widely held belief that the physiological

economy of the child, and especially that of the infant,resents the affront offered by a surgical operation moreacutely than does that of the adult. It is particularlyregarded as a serious adventure to perform a laparo-tomy in an infant, where much intra-abdominal workis likely to be called for. To obtain a right perspective in this matter is not easy, for intestinal resections,anastomoses, and excisions of such viscera as the gall-bladder are rarely required in children under the sameconditions as in adults. At first sight, the increasedseverity of these operations in the young would seemto be proved by the mortality following, for example,the resection of irreducible intussusception, or thedivision of the pyloric sphincter for hypertrophicstenosis. Dr. L. G. PARSONS and Mr. S. G. BARLING,elsewhere in this issue, relate their experiences of thislatter operation and report a mortality of 48 per cent.for this seemingly simple procedure. These results,which are actually under, not over, the average mortalityin skilled hands, would seem to justify us in taking agrave view of operations upon the very young. Buta consideration of a wider operative field will not lendequal support to this view. Indeed, many surgeons f

would not subscribe to it : on the contrary, thevwould be ready to affirm that the young withstandoperative insult to their physiology better than thefully grown, provided that certain precautions arescrupulously observed.The conditions prevailing in operations upon small

children are less favourable than in adults for severalreasons which depend wholly upon their diminutiveproportions compared with the operator and hisinstruments. The incision for a laparotomy has to berelatively longer than in the adult. This entails a

larger exposure of the abdominal wall and the conse-quent larger heat-loss, whilst the severance of a greaternumber of sensory nerves is more conducive to shock.But of more concern than this is the fact that a largerarea of peritoneal-covered surface is subjected to thenocuous influence of the manipulations necessary tocarry out the intended procedure. Again, a loss ofblood which is insignificant in an adult may easilybe a measurably great fraction of the total bloodvolume of a child. Yet, despite these drawbacks,children recuperate after severe operations muchbetter than adults because of the more than counter-

balaneing favourable factors. The child has a greatermargin of reserve than the adult, his tissues are morecapable of adaptation of function and more vigorousin repair, his hæmopoietic system exhibits greateractivity, and his comparatively undifferentiatednervous system is less mobile and less unstable. Thetruth of this contention is the more evident if the courseof events after operations for abdominal injuries inchildren be remembered. The recovery is often sur-

prising in its occurrence and amazing in its rapidity.Why, then, should Rammstedt’s operation possess

such a high mortality rate There are several reasons,but the greatest of all is that the infant with hyper-trophic stenosis is a starved animal with a resistance

to trauma, to shock, to infection of the intestinalmucosa at a low ebb. The operation is usually per-formed under the worst possible circumstances, medicalmeasures having been tried and found wanting. If therecommendation of Dr. PARSONS and Mr. BARLINGto consider this disease a surgical one from the

beginning were accepted generally, undoubtedly themortality would fall considerably. These two observersin seven consecutive private patients carried out theoperation without a death, an indication of the goodresults to be anticipated in the hands of practitionerswho have ceased to regard the disease as a primarilymedical one. Division of the pyloric muscle ring is-the ideal procedure for congenital hypertrophicstenosis. It causes a relaxation of the sphincter whichlasts just long enough for a cure to be effected ; thetwo cut ends after some months are usually found tohave united by a simple linear scar whenever an

opportunity has occurred to make such observation.This temporary relief is all that is desirable, for,invariably, with the passage of time, in children whosurvive early infancv, the normal relation betweenthe strength and size of the sphincteric and generalgastric musculature is established. The factors ofsuccess in operating upon young children are aboveall gentleness in the manipulation of their delicatetissues ; speed, if this does not entail roughness ; theavoidance of the loss of one drop of blood more thanis necessary; and an inflexible determination todiminish the intra-abdominal trauma and the exposureof the viscera to a minimum, whilst every possibleheat unit in the child’s body is conserved.

HOSPITAL REPORTS.WE reviewed recently the latest volume of the

St. Bartholomew’s Hospital Reports, which have

appeared yearly, except for a short intermission duringthe war, since 1865. Similar reports have been pub-lished regularly by Guy’s Hospital since 1836, and byother hospitals for longer or shorter periods, thoughin some cases they have consisted only of statisticaltables. It may be doubted whether the publicationof tables by individual hospitals serves any usefulpurpose, and we notice that they do not find a place inthe volume now issued by St. Bartholomew’s Hospital,but the whole question of the value of hospital reportsis worth a little consideration. Their appearance hasbeen taken for granted, while their contents seem to befortuitous. Many important contributions to medicineand surgery, under names that have now becomehistoric, have first made their appearance in suchreports, if only because, at the times when the publica-tions were instituted, medical and surgical periodicalswere largely non-existent, and the younger men,whether attached to the great hospitals or enjoyinggood opportunities for acquiring experience, had farfewer opportunities to put their work before their

colleagues. At the present time work of merit canfind publication in one of the general or special medicaljournals, so that at first sight the necessity seems no

longer to exist for the multiplication of volumes fromthe separate hospitals. But we do not feel at all clearupon this point. Even if the records of a great hospitaltend to be read only by past students of the schoolresponsible for their issue, they have an excellentraison-d’être, while in hospital reports there is a flexi-bility which may be absent at any particular time fromthe overcrowded pages of a medical journal. We have

noted frequently that when some main statement ofprinciple is being enunciated in our own columns, areference, for the sake of the details, is given to a volume

88 CARBON MONOXIDE IN COAL-GAS.

of hospital reports. This being so, no one need hesitateto give of his best to be " buried

" in a volume of

hospital reports, because resurrection is a certaintywhen the article calls for it.

But if hospital reports are to maintain a highstandard, the traditional pride in their publication mustbe fostered. This difficulty has been met at the MayoClinic, for example, by the yearly publication of avolume containing a collection of papers which havealready appeared in many different journals, but whichhad their inspiration from the Clinic. There would,how-ever, be no need for any British medical school, givingsigns of active life, to look outside its own organisationfor the production of a yearly volume of new andvaluable matter, which would be an index of theactivities yearly, nay hourly, being carried on withinits hospital. There will always be subjects for literarytreatment, whether historical, statistical, biographical,clinical, or purely scientific, worthy to be printed inthe archives of the institution, though some of themwould be unsuitable for publication elsewhere fornumerous reasons, some of which will immediatelyoccur to the mind. A valuable article may, moreover,be offered to the hospital reports purely owing to thewriter’s loyalty to his own school, though he knows thatit would be eagerly accepted elsewhere ; in such acase references in literature of a wider appeal willcall attention to it, and incidentally to the volume inwhich it appears. What has to be recognised is thatonly loyalty on the part of past members of a schoolwill enable hospital reports to maintain a worthyexistence. The matter must be supplied for the mostpart by those actively engaged on the staff of the

hospital ; the subscriptions must be furnished largelyby old students who have gone out into the world, butwho wish to maintain some link of communicationwith the school that bred them. We are glad to seethat St. Bartholomew’s is still able to maintain a highstandard in its reports in spite of present difficultiesintroduced by the costs of production. The currentissue, as we said in our review, is the first for which themedical school is responsible, former issues havingbeen edited and published by a committee made up ofmembers of the staff. We learn that previousto the appearance of this present volume there wasa question as to whether reports should be publishedat all, but publication was finally decided upon.The question is not so much whether hospital reportsshould be published, but as to what material they shouldcontain. The bulk of the volume will consist ofsummaries of the work done in the hospital along somedefinite lines, the articles recording with circumstanceand detail the experiences which have been met with inthe institution, and the general lessons to be drawnfrom them. For over eighty years the Guy’s HospitalReports have provided an admirable example of thisform of report, and under the editorship of Dr.A. F. HuRST the standard is steadily maintained.Statistical tables must, of course, form a proportionof these records, but we doubt their scientific value.It is not the bare figures that are wanted, but thereasons for their significance, and these should be putforward with every measure of proof that can be taken.There is a side to the records of a hospital which it

seems to us might be developed. Most people knowof the existence of, and some have even read, the oldmonastic chronicles of abbeys and priories, those, for Iinstance, of St. Albans, Jocelin of Brakelond’s work

dealing with the Abbacy of Samson, the Chronicles ofGlastonbury and Lanercost. In such chronicles wehave recorded brilliant pictures of the working of agreat society, of social customs, estate matters,agriculture, Poor-law and so on, which bring the lives

of our forefather vividly before us. Would it not bepossible for a hospital to keep a modern chronicle,and issue portions of such chronicle as a hospitalreport ? Most large hospitals have an interesting socialstory. Medical and surgical matters, also, need notalways be considered from the purely professionalpoint of view, but as matters affecting our fellowcreatures and from the patient’s point of view as wellas that of the staff. Papers on the economics of thehospital written by the steward or bursar should findregular acceptance—the hard-worked and resistingofficial should be goaded to supply them. All whoknew him can imagine what interesting matterthe late steward of St. Bartholomew’s Hospitalcould have put upon paper, and the contents of abook recently published by the chairman of theLondon Hospital would have brightened up therecords of that great institution in a wonderful way.Hospital reports in their present form are read by butfew-perhaps by none of those who subscribe to

hospital funds. Far more persons would take an interestin hospitals if the reports were more direct and simplein their appeal, and judicious excerpts from the minutesof governors’ meetings, revealing the nursing anddomestic side of hospital life might lead to valuablepecuniary response. The working of a great hospitalis of abiding interest, and we believe that, if somecourse such as we suggest were adopted. volumes of

hospital reports, if not ranking among "best sellers,"would appeal to many persons who do not now buythem and that thereby hospital incomes might beincreased.

CARBON MONOXIDE IN COAL-GAS.THE fatal results of leakage from a main supply

pipe in Bethnal Green have recalled public attentionto the lethal properties of coal-gas. It is perfectlywell known that carbon monoxide is the poisonousconstituent. The Gas Regulation Act of 1920 gavethe supplying companies no greater latitude than wasenjoyed previously in regard to the percentage ofcarbon monoxide in the gas supplied. A departmentalcommittee, appointed in 1898 by the Home Office,had recommended that the percentage should belimited to 12, but no legislative action was ever takento give effect to this recommendation. The LocalGovernment Board, however, made it a practice inapproving loans to local authorities to require thatthe gas supplied should not contain more than 15 percent., although no steps were taken to ensure thatthis limit was adhered to. What the Gas RegulationAct did was to give the Board of Trade authority todepart from previous practice and to prescribe alimit, if, after due inquiry, it thought wise to do so.A committee, of which Sir WILLIAM PEARCE waschairman, and Dr. T. CARNWATH the medical member,came to the conclusion, after careful consideration,that-on the evidence at present available and havingregard to what is likely to be the trend of developmentin the gas industry during the immediate future--it was inadvisable to impose any limit. The depart-ments concerned, however, were put on their guardcarefully to watch the situation so that, if the freedomfrom limitation were accompanied by unexpectedlyunfavourable results, the attention of Parliamentshould again be directed to the matter.

There is an impression abroad that gas companieshave availed themselves liberally of their right to admixwater-gas. What are the facts ? The gas supplied bythe South Metropolitan Gas Company contains noadmixture of water-gas, and, speaking for the largergas companies generally, there has been no materialchange of practice as regards the proportionof carbon monoxide supplied during recent years.The proportion of carbon monoxide in the gassupplied by the Gas, Light and Coke Company

89COMPENSATED LAMENESS.

has averaged about 15 per cent. for the last twentyyears. That supplied in 1919 gave an averagepercentage of 15-17 for the year; the Bethnal Greenaccident occurred on the night of Dec. 28th/29th-on the 28th the percentage was 14-8. and on the29th it was 15-0. There can be little doubt thatfor several hours before the discovery was made,the concentration of gas in the air of the roomin which the deaths occurred was so great thatthe issue would have been fatal even had the gasbeen " straight

"

coal-gas containing only 8 per cent.of carbon monoxide.

The suggestion that the gas now supplied has notsuch a characteristic smell as formerlv seems to bedevoid of foundation, although it may have been trueto some extent of those supplies from which tolueneand benzene were extracted during the war. Thecharacteristic smell of coal-gas is due in the main toheavy hydrocarbons and to certain little knownsulphur and nitrogen compounds ; the smell ofcarburetted water-gas is even more penetrating thanthat of ordinary coal-gas. By the Gas Companies(Removal of Sulphur Restrictions) Act, 1906, therestrictions with regard to the presence in gas ofsulphur compounds, other than sulphuretted hydrogen,were abolished. In practice, however, gas companiesare careful to remove sulphur as completely as possibleowing to its injurious effect on pipes and fittings.The great bulk of the sulphur in crude gas is presentin the form of sulphuretted hydrogen ; of theremainder, which averages about 40 gr. per 100 cub. ft.,some 34 gr. are in the form of carbon bisulphide and6 gr. in the form of obscure compounds which cannotbe removed by any known method. Opinion in thiscountry is opposed to the addition of any extra-neous substance to give to coal-gas a tell-tale smell.Its peculiar odour is now so well known as a

danger signal that the substitution of another odourwould be unwise. Such a substance would anvhowbe hard to find, for it must be easily perceptible inlow dilution and the smell should vary with its con-centration in the atmosphere and disappear as soon asthe leak was remedied and the escaped gas dissipated.Further, it should be insoluble in water and shouldnot be readily removed by earth or other adsorbent Isubstance. As the outcome of experiments carried onin America by KATZ and ALLISON, under the auspicesot the Bureau of Mines, certain mercaptans andpyridine were suggested as stenches, but it is impossiblewithout extensive trial to say whether they wouldbe found of practical value.However much we may regret the occasional cases

of accidental gas poisoning, it is difficult to see howthey can be avoided by prescribing its composition.Careful inquiry into 114 fatal cases of gas poisoningduring the past year has shown that in only 22 casesdid the percentage of carbon monoxide exceed 16.In no case did it exceed 20 per cent. It would be idleto deny that an increase in the proportion of water-gas must almost necessarily be accompanied bysomewhat greater risk to the consumer. From themedical point of view the question for considerationis whether this increased risk is more than counter-balanced by the advantage of a clearer atmosphere.Much of the risk can be obviated by more carefulattention to mains and fittings and by greaterpromptitude in the notification of escapes. In BethnalGreen the smell of gas was clearly perceptible onDec. 28th, and an occupant of one of the houseswrote to the gas company complaining of thesmell. If this information had been telephoned, ornotified to the police, the tragedy might have beenaverted.

INDEX TO " THE LAXCET," VOL. II.. 1922.THE Index and Title-page to Vol. II., 1922, which

was completed with the issue of Dec. 30th. willshortly be published. A copy will be sent gratis tosubscribers on receipt of a post-card addressed to theManager of THE LAXCET. 1, Bedford-street, Strand,W.C. 2.

Annotations."Ne quid minis." "

COMPENSATED LAMENESS.

THE 15-mile flat race recently organised by theproprietors of the Star for men with one or moreartificial lower limbs was a remarkable object-lessonof compensated disability. We understand that Mr.F. G. Ernst, the orthopaedic mechanician, originatedthe idea of such a walking race. Out of 300 or moreentries 264 actually started and of these 196 finishedthe course. We have been favoured with a completelist of those who finished, with the time occupied, and anindication of the type of limb worn. The winner com-pleted in just under three hours-that is, an averagespeed of over five miles an hour--the second being lessthan five minutes behind. Both of these men werebelow-knee amputations, the stump being aboutten inches long, and both were wearing " Rowley "wooden limbs with ball-bearing joints and sponge-rubber feet. Ten of the leading group of walkersexceeded a speed of six miles an hour for some partof the course, and the winner covered the first mileand a half in 14 minutes 5 seconds. There were aboutan equal number of above-knee and below-kneeamputations among the walkers, and naturally mostof the early places were taken by men who stillpossessed a natural knee-joint, but the forty-eighthplace, with the excellent time of 3 hours 33 minutes,was taken by a man with an amputation above theknee, wearing a

,. Desoutter" metal limb. Thedifference was not, however, very great, for taking acomparable group of 25 men wearing limbs of thesame make, the average time of 15 below-knee amputa-tions was 3 hours 42 minutes, and of 10 above-kneeamputations 4 hours 14 j minutes. A man withdouble amputation below the knee came in eighty-eighth in the astonishing time of 3 hours 49 minutes ;he was wearing two " Grossmith

" wooden legs. Weare informed that another double amputation wasmaking even better time until chafed by a strap nearthe finish. Among the last six to arrive were two menwith disarticulation at the hip-joint, and a third witha stump so short as to require the misnamed " tilting-table," who, in spite of this major disability, hadcovered the 15 miles in live hours. Of these one waswearing a " Grossmith " wooden, one an " Ernst "wooden, and the third a Hanger " light metal limb.A lad of 15 excited enthusiasm by coming in at4 hours 29 minutes on a wooden peg leg. In regardto the apparatus responsible for these remarkableresults, even a casual glance at the records suggeststhat different makes and types of limb are veryevenly distributed over the race, and the opinionis confirmed that any prejudice against woodenlimbs is not justified in fact. Metal limbs have onlybeen issued in any quantity during the last yearor so. The claim is made for the heavier woodenlimb that advantage is gained from the " pendulum "action, owing to which the foot swings forward by itsown weight with less of conscious exertion-and therewas nothing in the race to refute this claim. It is,however, a little difficult from the records to ascertainexactly the proportion of wooden and metal limbsworn, since some of the makers supply both. In18 cases the nature of the limb is not stated at all, andof the remaining 188, as far as we have been able toascertain, not more than 30 were of metal. A fewwere wearing the new Desoutter limb, which hasa wooden socket for the reception of the stump, theremainder being of the standard metal pattern. Towalk 15 miles is an achievement in itself ; to do so infive hours with a disarticulated hip-joint on a coursewith a long up-hill rie at the finish is an exhibi-tion of endurance and pluck which must commandrespect for both the human and the physical element,.It was generallv admitted that the majority of themen suffered little or no bad effects from their