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FRUSEMIDE IN ACUTE PULMONARY ŒDEMA
1004 EFFECT OF OXYGEN ON SPLIT-SKIN GRAFTS SiR,-The suggestion by Mr. Perrins (April 22, p. 868) that the beneficial effect of hyperbaric oxygen on the survival of skin-grafts might depend, at any rate in part, on increased diffusion through the epithelial surface stimulates me to recall that the late Mr. Sampson Handley tried to make use of the same principle. His technique was to introduce a catheter connected with an oxygen cylinder into the dressings covering the skin-grafts. DAVID PATEY. London W.1.
that will be useful in their own organisational, administrative, and educational background rather than with a more detailed knowledge of pmdiatric entities. It might be even more valuable to send more experts on 6-12-month visits to African paediatric centres where their long and special experience could reinforce local cultural and developmental attitudes and allow the centres to run their own postgraduate courses and ultimately confer their own postgraduate
diplomas. Already some hospital leading the way towards " newer paediatric departments paediatrics in the tropics and knitting together many fragmental "
are
activities into national child-health schemes suitable to the resources of each country. African countries know very well that in the end the health (rather than numbers) of their children will be their greatest national asset. Royal Hospital for Sick Children, A. VICTOR NEALE. Bristol 2.
political, economic, and medical MANAGEMENT OF PHÆOCHROMOCYTOMA SIR,-Your annotation (April 1, p. 717) states that halothane has been successfully used in the surgical management of phxochromocytoma. In fact, this agent has been used in at least 43 cases, 12with varying success. In a recent series of 14 consecutive patientshalothane was judged to be a valuable adjunct in the anaesthetic management of phaeochromocytoma because of its property of sympatho-adrenal depression. Serious arrhythmias were encountered but proved to be controllable with propranolol. In only 1 of these patients, all of whom had been treated preoperatively with K-methyl-tyrosine, did vasopressor support of blood-pressure become transiently necessary. Anesthesiology Department, Clinical Center, National Institutes of Health, Bethesda, Maryland.
PHILIP E. G. MANN.
A CHILDREN’S WARD IN THE TROPICS SiR,-The medical schools of the developing countries are showing a rapidly growing awareness of the need to give priority to paediatrics in their educational programmes, not only for medical students, but also for nurses, nutritionists, medical assistants, and teachers. When these and other child-health workers come to this country for postgraduate training they should be recognised as people with considerable knowledge of their own country’s needs, customs, socioeconomic conditions, educational standards, home-grown foods, and transport. Those concerned with postgraduate courses in this country should be alert towards the individuality of each guest, and such courses should leave each student in no doubt that his instructors know what they are doing, and why. Pxdiatrics has only emerged as a subject in this century, and it has progressed here along pathways suitable for our own country. Its emergence in tropical countries calls for progress in different pathways, and those responsible for instructing overseas visitors in advanced paediatrics should beware that common principles are not overshadowed by sophisticated attitudes which might distract from the proper applications of paediatrics in the tropics. There family care, welfare, and personal guidance must be the nuclear concern of the peediatrician and teacher of paediatrics. As Dr. Khan has shown (April 15, p. 850) a children’s ward may be a centre of health education for parents as well as medical undergraduates and graduates. Efficient " consultative-diagnostic centres "-incidentally a better name for such focal points of communication than the conventional outpatients "-can be part of the paediatric service of the hospital. Postgraduates should return from overseas with experience "
1. Cooperman, L. H., Mann, P. E. G. Anesthesiology (in the press). 2. Nanson, E. M. et al. Can. med. Ass. J. 1961, 85, 1032. Riddell, D. H., Schull, L. G., Frist, T. F., Baker, T. D. Ann. Surg. 1963, 157, 980. Etsten, B. E., Shimosato, S. Anesthesiology, 1965, 26, 688. Schnelle, N., Carney, F. M. T., Didier, E. P., Faulconer, A. Surg. Clins. N. Am. 1965, 45, 991. Murphy, M., Prior, F. N., Joseph, S. Br. J. Anœsth. 1964, 36, 813. Kirkendall, W. M., Liechty, R. D., Culp, D. A. Archs intern. Med. 1965, 115, 529. Goldfien, A. Anesthesiology, 1963, 24, 462. Robertson, A. I. G., Proc. R. Soc. Med. 1962, 55, 432. Rollason, W. N. Br. J. Anœsth. 1964, 36, 251. Kilduff, C. J. Can. Anœsth. Soc. J. 1962, 9, 74. Tressider, G. C. Br. J. Urol. 1963, 35, 367. Luna, R., Katz, I., Ernst, R. W. Archs Surg., Chicago, 1963, 87, 369. Seward, E. H. Lancet, 1961, ii, 903.
FRUSEMIDE IN ACUTE PULMONARY ŒDEMA SIR,-Dr. Biagi and Dr. Bapat (April 15, p. 849) report the beneficial effect of frusemide in a patient with severe respiratory failure (PC02 95 mm. Hg), which they attribute to pulmonary oedema. I feel an alternative explanation for their patient’s disorder and subsequent recovery should be considered. Their initial investigation suggests that their patient had severe obstructive airways disease with greatly diminished maximum voluntary ventilation and forced expiratory volume in one second. Before bronchoscopy he received ’Omnopon’ 22 mg. (an opium derivative), which is a respiratory depressant, and in such a patient can produce further hypoventilation and acute respiratory acidosis with all its consequences. This can be further compounded by administration of oxygen. Pulmonary oedema is less likely to be accompanied by a severe degree of hypercapncea; in fact, there is often no retention of carbon dioxide,’ because of its rapid diffusion through oedematous tissue, as contrasted with slower diffusion of oxygen leading to striking hypoxia. The harsh breath-sounds described may have been due to retained tracheal and bronchial secretions rather than alveolar oedema fluid. Since the patient did not receive an opium antidote such as nalorphine (’Nalline’), this hypothesis will remain unproven. If, however, this was the mechanism, the recovery following frusemide could have been fortuitous, and due to spontaneous metabolism and removal of the drug. Elliott P. Joslin Research Laboratory, Harvard Medical School, Boston, Massachusetts 02215.
G. L. A. FROM.
GUILLAIN-BARRE
SYNDROME COMPLICATING MUMPS SIR,-The letters of Dr. Ehrlich and others (Jan. 14, p. 115) and Dr. Ghosh (April 22, p. 895) are of considerable interest and have prompted me to report the following case. A man of 22 had complained of feverishness, malaise, anorexia, and headache for 2 days. He then started having pain in the back and limbs associated with a feeling of stiffness in the neck. He was referred as a case of meningitis. On admission, his temperature was 101°F (38-4°C) and pulse-rate 110 per minute, and he had an inflamed throat and enlarged tonsils. He complained of weakness and increasing pain in both lower limbs, accompanied by a severe headache on the next day. Clinical reassessment showed flaccid paresis of both lower limbs (the proximal segments were as affected as the distal ones) with absent superficial reflexes and diminished deep reflexes. Lumbar puncture showed clear cerebrospinal fluid under a pressure of 180 mm. of water, and protein content of 280 mg. per 100 ml.; sugar and chloride were normal; test for 1. Valentine, P. A., Fluck, C. D., Mounsey, J. P. D., Reid, D., J. P., Steiner, R. E. Lancet, 1966, ii, 837.
Shillingford,
that will be useful in their own organisational, administrative, and educational background rather than with a more detailed knowledge of pmdiatric entities. It might be even more valuable to send more experts on 6-12-month visits to African paediatric centres where their long and special experience could reinforce local cultural and developmental attitudes and allow the centres to run their own postgraduate courses and ultimately confer their own postgraduate
diplomas. Already some hospital leading the way towards " newer paediatric departments paediatrics in the tropics and knitting together many fragmental "
are
activities into national child-health schemes suitable to the resources of each country. African countries know very well that in the end the health (rather than numbers) of their children will be their greatest national asset. Royal Hospital for Sick Children, A. VICTOR NEALE. Bristol 2.
political, economic, and medical MANAGEMENT OF PHÆOCHROMOCYTOMA SIR,-Your annotation (April 1, p. 717) states that halothane has been successfully used in the surgical management of phxochromocytoma. In fact, this agent has been used in at least 43 cases, 12with varying success. In a recent series of 14 consecutive patientshalothane was judged to be a valuable adjunct in the anaesthetic management of phaeochromocytoma because of its property of sympatho-adrenal depression. Serious arrhythmias were encountered but proved to be controllable with propranolol. In only 1 of these patients, all of whom had been treated preoperatively with K-methyl-tyrosine, did vasopressor support of blood-pressure become transiently necessary. Anesthesiology Department, Clinical Center, National Institutes of Health, Bethesda, Maryland.
PHILIP E. G. MANN.
A CHILDREN’S WARD IN THE TROPICS SiR,-The medical schools of the developing countries are showing a rapidly growing awareness of the need to give priority to paediatrics in their educational programmes, not only for medical students, but also for nurses, nutritionists, medical assistants, and teachers. When these and other child-health workers come to this country for postgraduate training they should be recognised as people with considerable knowledge of their own country’s needs, customs, socioeconomic conditions, educational standards, home-grown foods, and transport. Those concerned with postgraduate courses in this country should be alert towards the individuality of each guest, and such courses should leave each student in no doubt that his instructors know what they are doing, and why. Pxdiatrics has only emerged as a subject in this century, and it has progressed here along pathways suitable for our own country. Its emergence in tropical countries calls for progress in different pathways, and those responsible for instructing overseas visitors in advanced paediatrics should beware that common principles are not overshadowed by sophisticated attitudes which might distract from the proper applications of paediatrics in the tropics. There family care, welfare, and personal guidance must be the nuclear concern of the peediatrician and teacher of paediatrics. As Dr. Khan has shown (April 15, p. 850) a children’s ward may be a centre of health education for parents as well as medical undergraduates and graduates. Efficient " consultative-diagnostic centres "-incidentally a better name for such focal points of communication than the conventional outpatients "-can be part of the paediatric service of the hospital. Postgraduates should return from overseas with experience "
1. Cooperman, L. H., Mann, P. E. G. Anesthesiology (in the press). 2. Nanson, E. M. et al. Can. med. Ass. J. 1961, 85, 1032. Riddell, D. H., Schull, L. G., Frist, T. F., Baker, T. D. Ann. Surg. 1963, 157, 980. Etsten, B. E., Shimosato, S. Anesthesiology, 1965, 26, 688. Schnelle, N., Carney, F. M. T., Didier, E. P., Faulconer, A. Surg. Clins. N. Am. 1965, 45, 991. Murphy, M., Prior, F. N., Joseph, S. Br. J. Anœsth. 1964, 36, 813. Kirkendall, W. M., Liechty, R. D., Culp, D. A. Archs intern. Med. 1965, 115, 529. Goldfien, A. Anesthesiology, 1963, 24, 462. Robertson, A. I. G., Proc. R. Soc. Med. 1962, 55, 432. Rollason, W. N. Br. J. Anœsth. 1964, 36, 251. Kilduff, C. J. Can. Anœsth. Soc. J. 1962, 9, 74. Tressider, G. C. Br. J. Urol. 1963, 35, 367. Luna, R., Katz, I., Ernst, R. W. Archs Surg., Chicago, 1963, 87, 369. Seward, E. H. Lancet, 1961, ii, 903.
FRUSEMIDE IN ACUTE PULMONARY ŒDEMA SIR,-Dr. Biagi and Dr. Bapat (April 15, p. 849) report the beneficial effect of frusemide in a patient with severe respiratory failure (PC02 95 mm. Hg), which they attribute to pulmonary oedema. I feel an alternative explanation for their patient’s disorder and subsequent recovery should be considered. Their initial investigation suggests that their patient had severe obstructive airways disease with greatly diminished maximum voluntary ventilation and forced expiratory volume in one second. Before bronchoscopy he received ’Omnopon’ 22 mg. (an opium derivative), which is a respiratory depressant, and in such a patient can produce further hypoventilation and acute respiratory acidosis with all its consequences. This can be further compounded by administration of oxygen. Pulmonary oedema is less likely to be accompanied by a severe degree of hypercapncea; in fact, there is often no retention of carbon dioxide,’ because of its rapid diffusion through oedematous tissue, as contrasted with slower diffusion of oxygen leading to striking hypoxia. The harsh breath-sounds described may have been due to retained tracheal and bronchial secretions rather than alveolar oedema fluid. Since the patient did not receive an opium antidote such as nalorphine (’Nalline’), this hypothesis will remain unproven. If, however, this was the mechanism, the recovery following frusemide could have been fortuitous, and due to spontaneous metabolism and removal of the drug. Elliott P. Joslin Research Laboratory, Harvard Medical School, Boston, Massachusetts 02215.
G. L. A. FROM.
GUILLAIN-BARRE
SYNDROME COMPLICATING MUMPS SIR,-The letters of Dr. Ehrlich and others (Jan. 14, p. 115) and Dr. Ghosh (April 22, p. 895) are of considerable interest and have prompted me to report the following case. A man of 22 had complained of feverishness, malaise, anorexia, and headache for 2 days. He then started having pain in the back and limbs associated with a feeling of stiffness in the neck. He was referred as a case of meningitis. On admission, his temperature was 101°F (38-4°C) and pulse-rate 110 per minute, and he had an inflamed throat and enlarged tonsils. He complained of weakness and increasing pain in both lower limbs, accompanied by a severe headache on the next day. Clinical reassessment showed flaccid paresis of both lower limbs (the proximal segments were as affected as the distal ones) with absent superficial reflexes and diminished deep reflexes. Lumbar puncture showed clear cerebrospinal fluid under a pressure of 180 mm. of water, and protein content of 280 mg. per 100 ml.; sugar and chloride were normal; test for 1. Valentine, P. A., Fluck, C. D., Mounsey, J. P. D., Reid, D., J. P., Steiner, R. E. Lancet, 1966, ii, 837.
Shillingford,