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The Consumers Association is gathering informationon safety bindings and will presumably report in Which? ?For the expert, there is a report in the British Ski Yearbookfor 1962; and from this it seems that there are as yet noall-purpose release bindings which are easy to adjust andmaintain, which open only at the right moment, whichprotect against forward falls and rotational strains, andwhich, by a simple action, can be converted to touringbindings with free-heel movement. But perhaps this is

asking too much. It might be better to design a ski

binding suitable only for downhill skiing, in which therelease mechanism is not a spring but a shear-pin,designed to give way before the tibia and fibula or theligaments of the ankle. After scientifically bench-testinga number of release bindings, Stockbridge and Large 34concluded that there was much room for improvement indesign, and the " shear-pin " is their idea.

ACCIDENTS IN HOSPITAL

ACCIDENTS will happen, in hospital, it seems, as well asoutside. Griffiths 35 examined the 1958-62 records ofaccidents in a group of three general acute hospitals, achildren’s acute hospital, a long-stay children’s hospital,a geriatric hospital, and three maternity units in this

country. Like the figures of Snell,36 which were taken in1956 from a group of hospitals with 1450 beds, they showthat the proportion of serious accidents was small. Morethan half were bedside accidents. Patients (morecommonly men, and more often medical patients, ratherthan surgical) fell out of bed, or reached for the lockerand fell, or fell in the ward. The higher rate in medicalwards is perhaps accounted for by the reluctance of

surgical patients to move too soon, whereas in medicalwards patients forget they are not in their own beds athome until it is too late. High beds seem to play a part;and Griffiths believes there is a strong case for the wideruse of adjustable beds. Some accidents, however, wereserious. Among injuries to the staff there were reports of" sister kicked in ribs ", " nurse kicked on ankle andbitten ", and " matron violently assaulted ". There wasno evidence from the figures that older patients weremore liable to accidents.

GASTROINTESTINAL RADIOGRAPHY

BARIUM-SULPHATE suspension with various modifica-tions has been the standard contrast medium in the radio-

graphic investigation of the gastrointestinal tract for overfifty years-a long time indeed in the history of radiology.Moreover, there is no present indication of any othermedium being so widely applicable. With barium

sulphate one disadvantage is a tendency for a foreign-body reaction to develop when it is deposited in body-tissues-for example, when there is a perforation from, or afistulous communication with, some part of the alimentarycanal. Another disadvantage is the inspissation that canoccur in the colon as the suspending water is absorbed-a process through which a partial obstruction may beconverted into a complete one. When the colon distalto a colostomy must be examined, especial care has to betaken if barium suspension is employed; for, otherwise,hard lumps of barium may be retained in the rectum formanv months. The surgeon should remember that a

34. Quoted by Young, N. J. E. British Ski Year Book, 1962.35. Griffiths, L. L. Mon. Bull. Minist. Hlth Lab. Serv. 1963, 22, 220.36. Snell, W. E. Lancet, 1956, ii, 1202.

patient who has lately had a barium meal or enema mayhave his colon loaded with barium for a week or moreafterwards. In these circumstances a resection or

anastomosis of the stomach or bowel carried out at

laparotomy may be imperilled by the patient’s difficultyin passing flatus postoperatively, and the patient’s first

attempts at a bowel action may be agonising and evendangerous.

In the past ten years water-soluble contrast media havebeen used in cases where barium sulphate is likely to causetrouble. Any water-soluble contrast medium must benon-toxic and of good radiographic density whenadministered in reasonable quantity; its absorption, if

any, from the alimentary tract should be slow so that itsradiographic density is well maintained throughout theexamination; and it should not be affected by contact withdigestive juices. Fortunately most of the urographiccontrast media, such as sodium acetrizoate, sodiumdiatrizoate, and ’ Urografin ’ (a mixture of sodium andmethyl glucamine salts of tri-iodo-benzoic acid), are

suitable. Nesbitt and Lapides 1 described the rectal

injection of 300-500 ml. of 15% sodium acetrizoate todemonstrate reflux into ureters which had been trans-planted into the sigmoid colon, and they administereda somewhat smaller quantity orally or through a stomachtube in the investigation of some patients with suspectedobstruction. Canada 2 used 30% sodium acetrizoate ina small series of 13 cases (including 4 enema examinations)and in 4 noted contrast medium in the renal tract, indicatingthat some had been absorbed. Moore 3 described the useof oral Diodrast’ in the diagnosis of gastrointestinalperforation: the presence of contrast in the peritonealcavity after oral administration of 60 ml. of dilutedmedium made the diagnosis clear. Davis et al.,4Epstein,5 6 and Lowman and Davis 7 focused attention onthe use of water-soluble media in the diagnosis of intestinalobstruction. Robinson and Levene 8 and Berman andAvnet noted progressive dilution of the contrast mediumas it passed down the small intestine, owing to its osmotichygroscopic effect there. Shehadi 10 remarked thatdefinition was better in the colon than in the distal smallbowel, and he also described the occasional instancewhere some of the medium (sodium diatrizoate 76% orGastrografin ’ 76%) crystallised in the stomach and morerarely in the colon. Samuel11 used gastrografin (uro-grafin 76% with a wetting and a flavouring agent) ina dose of 100 ml. for the radiographic investigationof hasmatemesis, postoperative leaks, perforation, andobstruction and in the diagnosis of acute pancreatitis.Matheson and Dudley12 found that 30 ml. of gastro-grafin given by mouth after abdominal operations pro-vided useful information on intestinal motility. These

applications of water-soluble media, now well triedand established, have been reviewed by Levy,13 whocomments favourably on their relatively rapid transit-time and low viscosity. Levy advocates their use in allcontrast studies on very young infants, in oesophagea!1. Nesbitt, R. M., Lapides, J. Univ. Mich. med. Bull. 1950, 16, 37.2. Canada, W. J. Radiology, 1955, 54, 867.3. Moore, H. D. Lancet, 1955, i, 163.4. Davis, L. A., Huang, K. C., Pirkey, E. C. J. Amer. med. Ass. 1956,

160, 373.5. Epstein, B. S. ibid. 1957, 165, 44.6. Epstein, B. S. Radiology, 1960, 74, 581.7. Lowman, R. M., Davis, L. Surg. Gynec. Obstet. 1958, 106, 567.8. Robinson, D., Levene, J. M. Amer. J. Roentgenol. 1958, 80, 79.9. Berman, C. Z., Avnet, N. L. Brit. J. Radiol. 1960, 33, 92.

10. Shehadi, W. H. Amer. J. Roentgenol. 1960, 83, 933.11. Samuel, E. Brit. J. Radiol. 1960, 33, 82.12. Matheson, N. A., Dudley, H. A. F. Lancet, 1963, i, 914.13. Levy, J. I. S. Afr. med. J. 1963, 37, 996.

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obstruction or fistult, and in all early postoperativeexaminations.

Lilienfeld 14 and Lilienfeld and Ross 15 have shed lighton the absorption of water-soluble contrast media fromthe alimentary tract which is responsible for the occasionalcoincident pyelogram. The normal subject excretes

about 20% of the ingested contrast medium through hiskidneys, but the proportion can be reduced by increasingthe concentration in which it is administered and bygiving an alkali such as 4 g. of sodium bicarbonate.

Absorption is rapid when there is any sinus track or otherdirect contact between the medium and body-tissues:in 3 patients with bowel fistulas the urinary excretion wasnearly doubled. There was a similar increase in patientswith obstructive jaundice, the absence of bile in the gutincreasing the absorption-rate. The concentration in thebile of dogs which had a biliary fistula after ligationof the common duct was very low-of the order of 1 %.Used with discretion, water-soluble media have an

undoubted though limited place in preference to bariumsulphate. For general use barium sulphate is still much

preferable, on account of its uniformity of behaviour,adherence to the mucosa, and low cost.

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LUNG TRANSPLANTATION

TRANSPLANTATION of the lung in man has not beenreported. In the laboratory the preliminary stagestowards some assurance of eventual success have been

passed. The first question that had to be answered waswhether the lung could continue to function if it was takenout and put back again. In dogs the operation itself

(described elsewhere in this issue by Mr. MacPhee andMr. Wright) has been shown to be feasible.16-21 As tofunction, Reemtsma et al.,22 in common with other workers,found that ventilation remained almost normal in dogssubjected to left pneumonectomy and immediate replace-ment of the lung, but that oxygen uptake was impaired,though this subsequently returned to normal. The removedlung can function after being kept at 4°C for two hours,and occasionally even for twenty-four hours, but re-

implantation of the lung should’preferably not be delayedfor more than a few hours.23 Although dogs can survivereimplantation of a lung for as long as three years, theyusually die within a few days if the normal lung on theother side is completely removed soon after. But Nigroet al,24 had some success when they delayed interventionfor a few months. They then removed the upper lobe onthe normal side, and a month later cauterised the lower-lobe bronchus with silver nitrate. The effect was to putthe whole lung on that side out of action, leaving only thereimplanted lung to function. 3 out of 8 dogs so treatedsurvived two to two and a half years after the originaloperation; 1 gave birth to a litter of 6 normal puppieswhile living on the reimplanted lung alone.So much for autotransplantation. Homologous trans-

plantation-the implantation of a lung from one dog into14. Lilienfeld, R. M. Act. radiol., Stockh. 1959, 51, 251.15. Lilienfeld, R. M., Ross, C. A. Amer. J. Roentgenol. 1960, 83, 931.16. Neptune, W. B., Redondo, J., Bailey, C. P. Surg. Forum, 1953, 3, 379.17. Hardin, C. A., Kettle, F. C. Science, 1954, 119, 97.18. Hughes, F. A., Kehne, J. H., Fox, J. R. Surgery, 1954, 36, 1101.19. Lmberg, E. J., Demetriades, A., Armstrong, B. W., Konsuwan, N.

J. Amer. med. Ass. 1961, 178, 486.20. Nigro, S. L., Reimann, A. F., Fry, W. A., Mock, L. F., Adams, W. E.

Surg. Forum, 1961, 12, 56.21. Yeh, T. J., Ellison, I. T., Ellison, R. G. Amer. Rev. resp. Dis. 1962,

86, 791.22. Reemtsma, K., Rogers, R. E., Lucas, J. F., Schmidt, F. E., Davis, F. H.

J. thorac. cardiovasc. Surg. 1963, 46, 589.23. Hardy, J. D., Eraslan, S., Dalton, M. L., Jr. ibid. p. 606.24. Nigro, S. L., Evans, R. H., Benfield, J. R., Gago, O., Fry, W. A.,

Adams, W. E. ibid. p. 598.

another-is a different matter. The obstacle here is

immunological rejection of the transplanted organ.

Hardy et al.23 attempted to suppress the immune responseby means of radiomimetic drugs. Control dogs thatsurvived homotransplantation rejected the lung on anaverage in a week, but, when methotrexate was given, thesurvival-time in 20 dogs was almost twice as long. Whenazathioprine (’ Imuran’) or azathioprine and hydro-cortisone were used as immunosuppressants, 30 dogs sur-vived for almost a month-four times the length of survivalof the controls. But here again, removal of the contra-lateral normal lung soon after the transplantation causeddeath of the dogs, though all respiratory activity could besupported for a few days in some. Apparently, then,respiratory capacity can be augmented for a time before alung homograft is rejected. As with kidney transplants,lung transplants between monozygotic or isogenouspersons could conceivably be accepted; but, in the absenceof better means of suppressing the immune response, lungtransplantation seems to have grave limitations. Theimmune barrier, as MacPhee and Wright observe, remainsin the way.

MUSCLE AND ITS DISEASES

INCREASING interest in the anatomy and physiology ofskeletal muscle and in the diseases which affect it has been

acknowledged by the American Journal of Medicine in asymposium issue published last November; and theseven papers encompass a good deal of present knowledgeabout structure, function, and diseases of muscle.

Price 1 describes the ultramicroscopic structure ofhuman skeletal muscle. He shows conclusively that viewspreviously expressed about the structure of the myofibril(based largely on studies of material from the rabbit andother animals 2) also apply to man. Mommaerts 3 drawsparticular attention to the importance of the sarcotubularsystem in transmission of the electrical impulse from thefibre membrane into the interior of the cell, and confirmsthe existence of a relaxing factor.4 Apparently the actinand myosin filaments can be induced to contract throughthe action of adenosine triphosphate, which is in turn

produced in the mitochondria by oxidative phosphoryla-tion and in the sarcoplasm by glycolysis; but suchcontraction can be inhibited by a relaxing factor.

Valuable information from neurophysiological studiesis described by Johns. The normal membrane potentialrecorded by inserting a microelectrode into a muscle cell isabout 80 mV. This membrane potential can be recordedboth in vivo and in vitro. Although this potential dependson the concentration of ions on either side of the fibre

membrane, it remains normal in hypokalaemic periodicparalysis during an attack 6; apparently when paralysisoccurs, while potassium moves into the cell, there is also amassive influx of water. In the hyperkalsemic type,7 bycontrast, there is a slight but significant reduction in

potential.Genetic aspects of muscle diseases are covered by Boyer

and Fainer,8 who give reasons for believing in the geneticheterogeneity of the different forms of muscle disease.Whereas a single gene may be involved in all forms of

1. Price, H. M. Amer. J. Med. 1963, 35, 589.2. Huxley, H. E. J. Biophys. Biochem. Cytol. 1957, 3, 631.3. Mommaerts, W. F. H. M. Amer. J. Med. 1963, 35, 606.4. Gergely, J. Ann. N.Y. Acad. Sci. 1959, 81, 490.5. Johns, R. J. Amer. J. Med. 1963, 35, 611.6. Shy, G. M., Wanko, T., Rowley, P. T., Engel, A. G. Exp. Neurol.

1961, 3, 53.7. Creutzfeldt, O. D., Abbott, B. C., Fowler, W. M. Pearson, C. M.

Electroenceph. clin. Neurophysiol. 1963, 15, 508.8. Boyer, S. H., Famer, D. C. Amer. J. Med. 1963, 35, 622.