P.S. London

The somatomedin activity in plasma from patients with multiple mechanical injuries: with observations on plasma cortisol

The somatomedin activity (SMA) was assayed in 247 plasma samples from 30 patients with moderate or severe injuries. The injury severity score (ISS) was assessed for each patient and ranged from 9 to 50. The plasma SMA was reduced or eliminated within 4 days of injury. The activity then increased in the patients who recovered, normal levels being attained within 1 or 2 weeks of the injury. Five patients had at least one further fall in plasma SMA during treatment. Seven patients died and 4 of these had little or no SMA before death. The magnitude and duration of the depression of SMA after injury correlated both with the ISS and with the probability of mortality. The plasma cortisol concentration was elevated in all but 4 patients within 48 hours of injury. There was no relationship between the plasma SMA and the cortisol concentration. When plasma samples from 10 patients taken soon after injury were mixed with normal human serum, samples from only 1 patient were found to contain an inhibitor(s) of SMA. The reduced plasma SMAs in the remaining patients may have resulted from the impaired production of somatomedins (SM), the degradation of SM, the dilution of circulating SM with transfusion fluids or the binding of SM to damaged tissues.

Fracture-dislocations of the spine that may spare the cord: an explanation

The combination of severe fracture-dislocation of the spine with little or no damage to the spinal cord and its roots is rare. There is a characteristic pattern of bony injury that seems most likely to result from a combination of extension and longitudinal compression and may not endanger the neural tissue. The usual clinical features of severe injury of the spine may be lacking and the radiological interpretation is difficult. Although the reports suggest that these injuries are stable in deformity this may not always be so and the spine should be afforded the usual protection.

Injury and pregnancy

Abstract This subject receives very little attention in textbooks and most of the articles in journals report small numbers of injuries of one kind or another. One general review suggests that between 5 and 10 per cent of pregnant women suffer injury, usually with no risk to the pregnancy: for example, the incidence of abortion ascribed to accidental injury is less than 1 in 10,000. Personal and reported experience can be summarized as follows. The baby may be injured during pregnancy or during birth, or may be harmed by the effects or complications of injury to the mother, e.g. Gram-negative septicaemia or hypoxic states. Injuries inflicted on the baby during pregnancy are most often fractures, which affect the skull almost as often as any other bone, and frequently accompany fractures of the mothers pelvis. Gunshot and other penetrating injuries of the child are rare and are not always fatal. Fractures of the maternal pelvis are the most frequent of the major injuries and are serious to viscera and other parts of the body. In some patients deformation of the pelvis can be corrected or prevented by operation, but it is usually best accepted. Rigid internal fixation of fractures of the lower limbs sustained in the later months of pregnancy can make labour much easier for the patient and her attendants. If the effect of injury on pregnancy is usually obvious, the effect of pregnancy on recovery from injury is usually not.

Observations on medical investigation of ambulance services

Abstract Nearly 1500 emergency ambulance journeys made in 2 1 2 years have been investigated from the medical point of view. Written records made by ambulance crews were studied and commented on. Copies were then sent to the authorities concerned. If detailed and accurate information is required, it is unlikely to be obtained unless the crews are interviewed by a suitably interested and experienced doctor who then fills in the form. This is best done while the patient is still available for any demonstrations that may be instructive. Forms to be completed without medical supervision should be as simple and short as possible, and they should be looked upon as no more than a means of passing on information that cannot be conveyed directly and by word of mouth. Accepting the limitations of this study, it appeared that although there were some respects in which performance and equipment in ambulance services could be improved there was no evidence that lives had been lost unnecessarily.

Some thoughts on the strength of material in the human body

A GREAT deal of valuable work has been done to study and to measure the effects of different stresses on the human body. As a clinician with little knowledge of engineering and the necessary mathematics, I am at times more interested by the methods of testing and measurement than convinced of the clinical pertinenceof thefindings. One can both admire the courage of men like Colonel Stapp and recognize the practical value of his study of how the tolerance of the human body to high forces of acceleration can be dramatically increased by a suitable combination of posture and restraint. The practical value of correlating tolerance of the human skull to impact with the deformability and penetrability of windscreens, or of correlating the breaking strength of a steering-column or the area of its central boss with the ability of the chest wall to withstand impact is obvious. Another useful field of investigation is to correlate the degree of deformation of, for example, the dashboard of a crashed vehicle with the force required to produce it and with the damage to whatever part of the body caused it. Tests such as these are more realistic than those in which, for example, a bone or a bony structure, such as the foot, is subjected to static loading, because in life it is at least unlikely that the structure under test will behave in the same way as one that is inert, however well its consistency may have been preserved. For the clinician with experience of injuries, one criterion of the pertinence of such tests is likely to be whether

Wrinkle Corner: A special view for mid-tarsal fracture-subluxation

Summary The nature of mid-tarsal injuries can be elucidated by a film exposed with the central ray directed at the talonavicular joint, in the plane of the base of the metarsus and at right angles to the long axis of the foot.

Observations on the treatment of some fractures of the forearm by splintage that does not include the elbow.

Fractures in the forearms of children up to the age of about 15 years have hinges of bone, as with greenstick fractures, or of soft tissues. The hinge can lead to recurrence of deformity that has been corrected by manipulation. It is widely believed that this makes it necessary to ‘complete the fracture’, i.e., break the hinge, in order to remove its deforming influence. The assumptions on which this recommendation is based are refuted and the way in which the hinge can be used to facilitate reduction and maintain position of the fracture is described. It does not depend for its success on encasing the elbow in plaster but upon suitable padding and moulding of the splint. It is acknowledged that in many cases failure to achieve or to maintain a good position of a fracture in the forearm of a child is rendered unimportant because of the correction that is brought about by growth, but it is shown that deformity can be permanent and can permanently restrict the range of pronation and supination.

Unsuspected injury of the caecum accompanying fracture of the pelvis

FRACTURES of the pelvis are not infrequently complicated, most often by persistent bleeding, by injuries of the bladder and urethra and by impotence. Injuries of the bowel are rare. Patterson and Morton (1973) found five examples in 633 persons with fracture of the pelvis. Lunt (1970) reported four cases in which bowel was trapped in the fracture. Stein (1964) reported four cases of anorectal avulsion injuries in persons that had been run over, two of whom had fractures of the pelvis. Cotler et al. (1983) reported a mildly stove-in hip that trapped the ileum and caused gas to appear in the hip joint within 12 hours. They referred to six similar cases in which four fractures were near the acetabulum and one each in the pubis and the sacrum. An 88-year-old man was knocked down in the road and was admitted with an apparently mild fracture of the pelvis, which was recorded as being firm, but he was bleeding from the urethra (Figs. 1 and 2). A suprapubic catheter was inserted and let out bloody urine. Three days later a catheter was passed per urethram during the course of suprapubic exploration, without opening the peritoneum. After this he developed fever, diarrhoea, faecal incontinence and a suprapubic urinary fistula. Twelve days after his accident his belly was distended but there was no sign of free gas and bowel sounds were heard. It was thought that the haematoma had become infected as well as his bladder. He died the next day. Necropsy showed peritonitis with fibrinous matting of the guts resulting from a l-cm perforation on the anterior wall of the caecum. The pelvis was described as being flail, with fractures of the right pubic rami and the right sacroiliac region. There was haemorrhagic cystitis and much bleeding around but no obvious rupture of the urethra. The prostate was just over 3 in. in diameter.

Fracture of the shaft of the femur: a tale of woe

Abstract Repeated operations were performed on a fracture that could well have been managed by closed methods. Each attempt to achieve union reduced the blood supply of the bone ends and the prospects of success. A final surgical attempt to achieve union was complicated by infection and made amputation necessary.

Ambulance and other emergency services

Abstract Among the debatable subjects in accident services today is the organization of ambulance services and the part that doctors should be prepared and encouraged to play in emergency services outside hospital. Opinions vary a good deal from country to country and in different parts of the same country. These opinions owe something to local conditions and something to differences in political outlook.