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MYOCARDIAL INFARCTION AND CHRONIC ACNE
685
staff should be able to supervise after bringing the child back to the ward.
treatment, without
at St. James’ Hospital, Balham, where outpatient department is provided, it is used only by paediatricians, the other consultants continuing to see their psdiatric patients in the adult clinics. This, surely, is a question of planning. We now approach the problem of the sick child as a whole, duly recognising the fact that it is not good medicine to straighten a toe or repair a hernia if, in the process, what ’the report refers to as social and psychological conditions operating in mixed wards or outpatients " may be such as to mar the future personality of the child. It may well be thought that the consultants might be prepared to step from
The report states that
such
an
"
wards to the children’s ward to care for their child Is it over-imaginative to suppose that at the end of patients. their adult session they might also step over to the children’s outpatients department in order to see the two or three children coming to consult them ? Your annotation did not mention that the report also summarily dismisses the claims of children having tonsil-andadenoid operations, suggesting that the paediatricians do not want to be responsible for their supervision, and presenting them as a happy little social group, all awaiting operation, and recovering, together. Quite a different picture of this operation has been presented to me by parents, and by the writers of a series of letters to the B.B.C., following their broadcasts on Children in Hospital in 1957. The commonest complaints contained in letters to the B.B.C. were from the parents of children subjected to tonsil-and-adenoid operations, admitted " to fever hospitals where the rules of no visiting " operated, and children submitted to minor operations in casualty departments not specially geared to children. These letters, and letters I have received myself recently, suggest that such are still not granted the care and consideration offered to them in a properly equipped children’s unit. One correspondent wrote to me of a department in which children, awaiting tonsil-andadenoid operations, watched their predecessors on the list coming round, before they themselves had been premedicated; in another (where two auxiliary nurses were regarded as adequate staff to look after a long list of children who had undergone tonsillectomy) a mother, who happened to be visiting another patient, stated how glad she and other visitors were that during visiting hours they were available to comfort and assist the children coming round after tonsillectomy. It is interesting to note that the need for children’s beds has not diminished, and that the decline in admissions which happened during the time the Platt Committee was sitting has not continued; the need for children’s beds remaining in 1961 about the same as it was in 1951. The Nuffield report made no mention of the regional children’s hospital, such as is suggested in your annotation. Presumably this idea is to be regarded as a concept of the their
own
long-term planners, aimed at making adequate provision for the training of paediatric nurses and doctors; otherwise the necessity for it (in a region with a large number of up-to-date district hospitals containing adequate bed space for children) escapes me-since undoubtedly, as the more highly specialised operations become more widespread, a large district hospital will have the facilities to deal with the child who needs a lung or heart operation, and the child with a head iniurv. ELIZABETH TYLDEN. London, W.2. PREVALENCE OF COMMON MENSTRUAL SYMPTOMS was interested in Dr. McAllister’s comments SIR,łI on the treatment of dysmenorrhoea. Like him, (Aug. 17) I have been using diazepam (’ Valium ’) in this condition, and the good results in the majority of patients for whom I have prescribed it are encouraging. The dosage prescribed is three tablets (2 mg.), to be taken as soon as the
or flow commences, followed by one tablet every four hours thereafter as required. Whether the results so far are predominantly due to this drug’s anti-anxiety effect, acting centrally, or its direct effect on uterine musculature, it is hard to say; but I believe the results so far warrant further trial.
pain
Steventon,
A. M. SEMMENCE.
Berks.
MYOCARDIAL INFARCTION AND CHRONIC ACNE SIR,-Imay be able to help answer Mr. Howell’s
question (Sept. 14). In 35 women with ischaemic heart-disease (20 with acute infarction, 15 with angina), I have not found any with acne. Only 2 patients (1acute infarction,1 angina) had any previous history of acne. This was in their teens and was said to be mild. There was no evidence of scarring in either case. Pontefract,
A. NUGENT.
Yorkshire.
TRANSPLACENTAL FŒTAL BLOOD-LOSS SIR,-Recent studies, as indicated in your leading article of Sept. 7, have shown that the phenomenon of transplacental haemorrhage (T.P.H.) is not uncommon, and that the widely held concept of the total separation of the cellular elements of the maternal and foetal circulation can no
longer be supported.
The most immediate practical application of these studies lies in the diagnosis and management of " massive 2.r.H. ". It is not widely appreciated that this condition may present in two ways.12 If the haemorrhage occurs during pregnancy, haemodynamic equilibrium is nearly always regained and the presentation is that of an unexplained neonatal anaemia; the diagnosis can usually be made by examination of the maternal blood, using the acid-elution technique, and recovery is usually uneventful without specific therapy, although oral hasmatinics can be used. If the massive T.P.H. occurs during delivery the clinical picture is that of cardiovascular collapse. Thus, there is pallor, loss of muscle tone, and tachycardia, with failure to revive with oxygen but a dramatic response to transfusion. Diagnostic confusion may arise in severe cerebral anoxia and cerebral trauma, which also result in pallor and loss of muscle tone (asphyxia pallida). The importance of recognising this condition is that rapid diagnosis followed by transfusion can be
lifesaving. The second application lies in the management of the nonsensitised Rh-negative mother. It is now generally accepted that primary sensitisation usually occurs in the pregnancy (the sensitising pregnancy) preceding that in which antibodies are first detected, and there is a growing body of evidence to suggest that the T.P.H. responsible for sensitisation usually occurs during the process of delivery.3 Recent studies,3 4 now confirmed by Zipursky et al.,6 suggest that the incidence and magnitude of T.P.H. is increased by any process likely to lead to trauma to the uteroplacental junction. We would therefore go further than your leader and suggest that there should be a reorientation of obstetric thought with regard to haemolytic disease; and that the main obstetric endeavour should be concentrated on the non-sensitised Rh-negative mother, and research should be directed towards determining whether it is possible to reduce the incidence of T.P.H. associated with delivery. By this means the risk of subsequent rhesus sensitisation might be significantly reduced.
In contrast to your leader we feel, however, that the major advance produced by these studies on T.P.H. has been the recognition of a high-risk group of non"
"
Goodall, H. B., Graham, F. S., Miller, M. C., Cameron, C. J. clin. Path. 1958, 11, 251. 2. Durking, C. M., Finn, R. Lancet, 1961, ii, 100. 3. Finn, R., Harper, D. T., Stallings, S. A., Krevans, J. R. Transfusion, 1963, 3, 114. 4. Wimhofer, H., Schneider, J., Leidenberger, F. Geburtsh. u. Frauenheilk. 1962, 22, 589. 5. Zipursky, A., Pollock, J., Neelands, P., Chown, B., Israels, L. G., Lancet, Sept. 7, 1963, p. 489. 1.
staff should be able to supervise after bringing the child back to the ward.
treatment, without
at St. James’ Hospital, Balham, where outpatient department is provided, it is used only by paediatricians, the other consultants continuing to see their psdiatric patients in the adult clinics. This, surely, is a question of planning. We now approach the problem of the sick child as a whole, duly recognising the fact that it is not good medicine to straighten a toe or repair a hernia if, in the process, what ’the report refers to as social and psychological conditions operating in mixed wards or outpatients " may be such as to mar the future personality of the child. It may well be thought that the consultants might be prepared to step from
The report states that
such
an
"
wards to the children’s ward to care for their child Is it over-imaginative to suppose that at the end of patients. their adult session they might also step over to the children’s outpatients department in order to see the two or three children coming to consult them ? Your annotation did not mention that the report also summarily dismisses the claims of children having tonsil-andadenoid operations, suggesting that the paediatricians do not want to be responsible for their supervision, and presenting them as a happy little social group, all awaiting operation, and recovering, together. Quite a different picture of this operation has been presented to me by parents, and by the writers of a series of letters to the B.B.C., following their broadcasts on Children in Hospital in 1957. The commonest complaints contained in letters to the B.B.C. were from the parents of children subjected to tonsil-and-adenoid operations, admitted " to fever hospitals where the rules of no visiting " operated, and children submitted to minor operations in casualty departments not specially geared to children. These letters, and letters I have received myself recently, suggest that such are still not granted the care and consideration offered to them in a properly equipped children’s unit. One correspondent wrote to me of a department in which children, awaiting tonsil-andadenoid operations, watched their predecessors on the list coming round, before they themselves had been premedicated; in another (where two auxiliary nurses were regarded as adequate staff to look after a long list of children who had undergone tonsillectomy) a mother, who happened to be visiting another patient, stated how glad she and other visitors were that during visiting hours they were available to comfort and assist the children coming round after tonsillectomy. It is interesting to note that the need for children’s beds has not diminished, and that the decline in admissions which happened during the time the Platt Committee was sitting has not continued; the need for children’s beds remaining in 1961 about the same as it was in 1951. The Nuffield report made no mention of the regional children’s hospital, such as is suggested in your annotation. Presumably this idea is to be regarded as a concept of the their
own
long-term planners, aimed at making adequate provision for the training of paediatric nurses and doctors; otherwise the necessity for it (in a region with a large number of up-to-date district hospitals containing adequate bed space for children) escapes me-since undoubtedly, as the more highly specialised operations become more widespread, a large district hospital will have the facilities to deal with the child who needs a lung or heart operation, and the child with a head iniurv. ELIZABETH TYLDEN. London, W.2. PREVALENCE OF COMMON MENSTRUAL SYMPTOMS was interested in Dr. McAllister’s comments SIR,łI on the treatment of dysmenorrhoea. Like him, (Aug. 17) I have been using diazepam (’ Valium ’) in this condition, and the good results in the majority of patients for whom I have prescribed it are encouraging. The dosage prescribed is three tablets (2 mg.), to be taken as soon as the
or flow commences, followed by one tablet every four hours thereafter as required. Whether the results so far are predominantly due to this drug’s anti-anxiety effect, acting centrally, or its direct effect on uterine musculature, it is hard to say; but I believe the results so far warrant further trial.
pain
Steventon,
A. M. SEMMENCE.
Berks.
MYOCARDIAL INFARCTION AND CHRONIC ACNE SIR,-Imay be able to help answer Mr. Howell’s
question (Sept. 14). In 35 women with ischaemic heart-disease (20 with acute infarction, 15 with angina), I have not found any with acne. Only 2 patients (1acute infarction,1 angina) had any previous history of acne. This was in their teens and was said to be mild. There was no evidence of scarring in either case. Pontefract,
A. NUGENT.
Yorkshire.
TRANSPLACENTAL FŒTAL BLOOD-LOSS SIR,-Recent studies, as indicated in your leading article of Sept. 7, have shown that the phenomenon of transplacental haemorrhage (T.P.H.) is not uncommon, and that the widely held concept of the total separation of the cellular elements of the maternal and foetal circulation can no
longer be supported.
The most immediate practical application of these studies lies in the diagnosis and management of " massive 2.r.H. ". It is not widely appreciated that this condition may present in two ways.12 If the haemorrhage occurs during pregnancy, haemodynamic equilibrium is nearly always regained and the presentation is that of an unexplained neonatal anaemia; the diagnosis can usually be made by examination of the maternal blood, using the acid-elution technique, and recovery is usually uneventful without specific therapy, although oral hasmatinics can be used. If the massive T.P.H. occurs during delivery the clinical picture is that of cardiovascular collapse. Thus, there is pallor, loss of muscle tone, and tachycardia, with failure to revive with oxygen but a dramatic response to transfusion. Diagnostic confusion may arise in severe cerebral anoxia and cerebral trauma, which also result in pallor and loss of muscle tone (asphyxia pallida). The importance of recognising this condition is that rapid diagnosis followed by transfusion can be
lifesaving. The second application lies in the management of the nonsensitised Rh-negative mother. It is now generally accepted that primary sensitisation usually occurs in the pregnancy (the sensitising pregnancy) preceding that in which antibodies are first detected, and there is a growing body of evidence to suggest that the T.P.H. responsible for sensitisation usually occurs during the process of delivery.3 Recent studies,3 4 now confirmed by Zipursky et al.,6 suggest that the incidence and magnitude of T.P.H. is increased by any process likely to lead to trauma to the uteroplacental junction. We would therefore go further than your leader and suggest that there should be a reorientation of obstetric thought with regard to haemolytic disease; and that the main obstetric endeavour should be concentrated on the non-sensitised Rh-negative mother, and research should be directed towards determining whether it is possible to reduce the incidence of T.P.H. associated with delivery. By this means the risk of subsequent rhesus sensitisation might be significantly reduced.
In contrast to your leader we feel, however, that the major advance produced by these studies on T.P.H. has been the recognition of a high-risk group of non"
"
Goodall, H. B., Graham, F. S., Miller, M. C., Cameron, C. J. clin. Path. 1958, 11, 251. 2. Durking, C. M., Finn, R. Lancet, 1961, ii, 100. 3. Finn, R., Harper, D. T., Stallings, S. A., Krevans, J. R. Transfusion, 1963, 3, 114. 4. Wimhofer, H., Schneider, J., Leidenberger, F. Geburtsh. u. Frauenheilk. 1962, 22, 589. 5. Zipursky, A., Pollock, J., Neelands, P., Chown, B., Israels, L. G., Lancet, Sept. 7, 1963, p. 489. 1.