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ISCHÆMIA OF FOREARM AFTER INTRAVENOUS INJECTION
551 there has been
no
difficulty
in
using the reduced-volume
technique. Our results with the reduced-volume and with the original technique were compared in 200 duplicate analyses before we adopted the reduced-volume technique as our routine method, and the results are to be published in Nordisk Medicin in Danish.
With this simple device we have solved the economy side of the transition from our former method (Larsen and Plum’s method) to the thrombotest method. In our experience the thrombotest is far superior in the control of anticoagulant therapy. Central Laboratory, Svendborg County Hospital,
TORBEN K. WITH
Denmark.
able tension bulged through the incisions and oedema fluid oozed out. Subsequently the hand and upper arm became swollen but it was possible to suture the incisions in stages, seven to fourteen days later. Two superficial areas of skin necrosed but have now healed, and the muscle function has almost completely returned and is still improving. The ulnar artery in the right arm was abnormal, arising high and running superficially in the forearm, and it seemed that the common interosseous artery in the left arm must have been in spasm. It was unlikely from the degree of recovery that the collateral circulation could have been entirely responsible. I do not know whether arterial spasm of such duration is possible without permanent arterial occlusion. The relief of tension
produced very striking improvement. A photograph taken on Oct. 27 illustrates the
extent
and
boundaries of the lesion.
ISCHÆMIA OF FOREARM AFTER INTRAVENOUS
INJECTION
Sm,-I feel that the following case should be recorded. On Sept. 13, 1959, a fit 30-year-old man was given antiAbout three-quarters of an hour later he reaction and was given adrenaline intramuscularly in the buttock and promethazine 50 mg. intravenously in the left antecubital fossa. At the end of the intravenous injection he experienced a transient shooting pain at the tip of the left elbow. The pain ceased at once, and as after half an hour he appeared to be all right, he was sent home. He was completely comfortable for three hours and then had acute pain in the left forearm with " pins and needles " and severe cramps. Four hours after the onset of this pain he came back to hospital at 1.15 A.M. on Sept. 14. The left forearm was dusky, mottled, cold, swollen, tense, and acutely painful from elbow to wrist. The hand appeared to be unaffected and warm and the radial pulse was normal. At 3.15 A.M. left brachial-plexus and stellate-ganglion block relieved the pain, improved the colour somewhat, reduced the tension, and the arm became warm. He was also given pethidine and phenoxybenzamine (’ Dibenyline ’). Pain started to return at about 8.30 A.M. A second plexus and ganglion block at 10.20 relieved the pain and slightly improved the colour but had no appreciable effect on the tension. As soon as possible Mr. E. W. Bintcliffe incised the deep fascia of both anterior and posterior muscle compartments to relieve the tension. Healthy-looking muscle under consider-
tetanus serum.
returned with
a severe
Kent and Sussex Hospital, Tunbridge Wells.
ERIC FOWLER.
CATHETER DRAINAGE AND INFECTION IN ACUTE RETENTION OF URINE SIR,-I have read with interest the letters from Mr. Ashton Miller and Dr. Harrison (Feb. 20 and 27) about
the use of the ’Portex ’ Gibbon catheter. A modification of this catheter, designed by Mr. A. Walsh, of Dublin, has now been developed for use after prostatectomy. This is of larger bore than the standard Gibbon catheter, with facilities for bladder irrigation, and effectively overcomes the disadvantages mentioned by Mr. Miller (Feb. 27). D. E. STEELE Hythe,
Kent.
Medical
Adviser, Portland Plastics
Ltd.
REJECTION OF RENAL HOMOGRAFTS SIR,-In his interesting report of Feb. 20 Mr. Calne observed that 6-mercaptopurine abolished the immature plasma-cell reaction in homotransplanted kidneys. This was surely to be expected since the drug will act on the reticuloendothelial system of both the host and the transplant. The same applies to cortisone which also can abolish the immature plasma cells without, however, prolonging survival. Local X-irradiation of the kidney prior to transplantation can also abolish the development of the immature plasma cells.2 These cells have failed to appear in a kidney transferred from a donor of bonemarrow to a
total-body-irradiated dog.3
That the immature plasma cells evolve from reticulum cells in the homotransplanted kidney has convinced few people 4 The evidence now is that these cells can be prevented from appearing in kidneys transplanted to dogs treated with cortisone and 6-mercaptopurine, and also by local X-irradiation of the kidney prior to transplantation. The conclusion drawn from the results obtained from the first and last agency was that the immature plasma cells were not responsible for the disintegration of homotransplanted kidneys.’ There is a hint in the report of primary anuria, and this I take to be type-1 anuria which has already been fully described.5 It is gratifying to find that Mr. Calne has given up bilateral nephrectomy at the time of the transplant operation. The advantages of unilateral nephrectomy in kidney transplantation experiments have already been stressed.6 If one wishes to apply severe measures, such as total-body irradiation and 6-mercaptopurine, to dogs special postoperative In addition to antibiotics, a special care must be ensured. room, well heated and sterilised by ultraviolet light, is essential if the dogs are not to die of intercurrent infections. This precaution might allow 6-mercaptopurine treated dogs to survive
4.
Dempster, W. J. Arch. int. Pharmacodyn. 1953, 95, 253. Dempster, W. J. Brit. J. Surg. 1953, 40, 447. Mannick, J. A., Lochte, H. L., Ashley, C. A., Donnall Thomas, E., Ferrebee, J. W. Surgery, 1959, 46, 821. Darmady, E. M., Dempster, W. J., Stranack, F. J. Path. Bact. 1955,
5. 6.
Dempster, Dempster,
1. 2. 3.
70, 225.
Appearance
of forearms
on
Oct. 27.
W. J. Acta med. scand. 1954, W. J. ibid. 1953, 144, 360.
148,
91.
no
difficulty
in
using the reduced-volume
technique. Our results with the reduced-volume and with the original technique were compared in 200 duplicate analyses before we adopted the reduced-volume technique as our routine method, and the results are to be published in Nordisk Medicin in Danish.
With this simple device we have solved the economy side of the transition from our former method (Larsen and Plum’s method) to the thrombotest method. In our experience the thrombotest is far superior in the control of anticoagulant therapy. Central Laboratory, Svendborg County Hospital,
TORBEN K. WITH
Denmark.
able tension bulged through the incisions and oedema fluid oozed out. Subsequently the hand and upper arm became swollen but it was possible to suture the incisions in stages, seven to fourteen days later. Two superficial areas of skin necrosed but have now healed, and the muscle function has almost completely returned and is still improving. The ulnar artery in the right arm was abnormal, arising high and running superficially in the forearm, and it seemed that the common interosseous artery in the left arm must have been in spasm. It was unlikely from the degree of recovery that the collateral circulation could have been entirely responsible. I do not know whether arterial spasm of such duration is possible without permanent arterial occlusion. The relief of tension
produced very striking improvement. A photograph taken on Oct. 27 illustrates the
extent
and
boundaries of the lesion.
ISCHÆMIA OF FOREARM AFTER INTRAVENOUS
INJECTION
Sm,-I feel that the following case should be recorded. On Sept. 13, 1959, a fit 30-year-old man was given antiAbout three-quarters of an hour later he reaction and was given adrenaline intramuscularly in the buttock and promethazine 50 mg. intravenously in the left antecubital fossa. At the end of the intravenous injection he experienced a transient shooting pain at the tip of the left elbow. The pain ceased at once, and as after half an hour he appeared to be all right, he was sent home. He was completely comfortable for three hours and then had acute pain in the left forearm with " pins and needles " and severe cramps. Four hours after the onset of this pain he came back to hospital at 1.15 A.M. on Sept. 14. The left forearm was dusky, mottled, cold, swollen, tense, and acutely painful from elbow to wrist. The hand appeared to be unaffected and warm and the radial pulse was normal. At 3.15 A.M. left brachial-plexus and stellate-ganglion block relieved the pain, improved the colour somewhat, reduced the tension, and the arm became warm. He was also given pethidine and phenoxybenzamine (’ Dibenyline ’). Pain started to return at about 8.30 A.M. A second plexus and ganglion block at 10.20 relieved the pain and slightly improved the colour but had no appreciable effect on the tension. As soon as possible Mr. E. W. Bintcliffe incised the deep fascia of both anterior and posterior muscle compartments to relieve the tension. Healthy-looking muscle under consider-
tetanus serum.
returned with
a severe
Kent and Sussex Hospital, Tunbridge Wells.
ERIC FOWLER.
CATHETER DRAINAGE AND INFECTION IN ACUTE RETENTION OF URINE SIR,-I have read with interest the letters from Mr. Ashton Miller and Dr. Harrison (Feb. 20 and 27) about
the use of the ’Portex ’ Gibbon catheter. A modification of this catheter, designed by Mr. A. Walsh, of Dublin, has now been developed for use after prostatectomy. This is of larger bore than the standard Gibbon catheter, with facilities for bladder irrigation, and effectively overcomes the disadvantages mentioned by Mr. Miller (Feb. 27). D. E. STEELE Hythe,
Kent.
Medical
Adviser, Portland Plastics
Ltd.
REJECTION OF RENAL HOMOGRAFTS SIR,-In his interesting report of Feb. 20 Mr. Calne observed that 6-mercaptopurine abolished the immature plasma-cell reaction in homotransplanted kidneys. This was surely to be expected since the drug will act on the reticuloendothelial system of both the host and the transplant. The same applies to cortisone which also can abolish the immature plasma cells without, however, prolonging survival. Local X-irradiation of the kidney prior to transplantation can also abolish the development of the immature plasma cells.2 These cells have failed to appear in a kidney transferred from a donor of bonemarrow to a
total-body-irradiated dog.3
That the immature plasma cells evolve from reticulum cells in the homotransplanted kidney has convinced few people 4 The evidence now is that these cells can be prevented from appearing in kidneys transplanted to dogs treated with cortisone and 6-mercaptopurine, and also by local X-irradiation of the kidney prior to transplantation. The conclusion drawn from the results obtained from the first and last agency was that the immature plasma cells were not responsible for the disintegration of homotransplanted kidneys.’ There is a hint in the report of primary anuria, and this I take to be type-1 anuria which has already been fully described.5 It is gratifying to find that Mr. Calne has given up bilateral nephrectomy at the time of the transplant operation. The advantages of unilateral nephrectomy in kidney transplantation experiments have already been stressed.6 If one wishes to apply severe measures, such as total-body irradiation and 6-mercaptopurine, to dogs special postoperative In addition to antibiotics, a special care must be ensured. room, well heated and sterilised by ultraviolet light, is essential if the dogs are not to die of intercurrent infections. This precaution might allow 6-mercaptopurine treated dogs to survive
4.
Dempster, W. J. Arch. int. Pharmacodyn. 1953, 95, 253. Dempster, W. J. Brit. J. Surg. 1953, 40, 447. Mannick, J. A., Lochte, H. L., Ashley, C. A., Donnall Thomas, E., Ferrebee, J. W. Surgery, 1959, 46, 821. Darmady, E. M., Dempster, W. J., Stranack, F. J. Path. Bact. 1955,
5. 6.
Dempster, Dempster,
1. 2. 3.
70, 225.
Appearance
of forearms
on
Oct. 27.
W. J. Acta med. scand. 1954, W. J. ibid. 1953, 144, 360.
148,
91.