- Email: [email protected]
AGEING AND DEATH
270
practitioners and in non-psychiatric clinics.’ Observations in a homogeneous group might be less valuable than in a heterogeneous one. After all, patients with all kinds of disease may be depressed and tense. Double-blind trials do not always give the information they seek, and sometimes clinical observations may be just as valid. The numerous writers on tranylcypromine the same conclusion-that it is an effective Can anti-depressant. they all be wrong ? It is almost certain that the troublesome side-effects of tranylcypromine are due to its monoamine-oxidase inhibitory activity. Anyone interested can consult Spencer et al. Horwitz and Sjoerdsma,2and Gertner3 for the effect on autonomic ganglia, and Lee et al.,4 Pletscher and Pellmont,5 Kako et al.,6 Crout et al.,and Ahlquist8 for direct cardiac effects. It is by no means as certain that the anti-depressant activity of tranylcypromine is due to monoamine-oxidase inhibition. It 9-11 may be due to an amphetamine-like action on the brain.7 Dr. Blackwell is to be thanked for more references to the side-effects of the drug.
have all
placebos. ,
__
_
F. LEES C. W. BURKE.
St. Bartholomew’s Hospital, London, E.C.1.
SIR,-With reference to the article by Dr. Lees and Dr. Burke (Jan. 5) and the letters from Dr. McCormick and Dr. Blackwell (Jan. 19), I wish to report a case of addiction to tranylcypromine. The patient, a man born in 1939, had a severe personality disorder. Since an early age he had been shy and solitary. At acne vulgaris, which led to the overvalued idea that it was disfiguring and the source of attention from all around him. His work record had been poor; he spent long periods confined in the house, afraid to go out because of the acne. In 1961, after the death of his grandmother and the family had moved into a less congenial house, his symptoms became worse and depression became prominent. He was treated with phenelzine (’ Nardil ’) early in 1962 with not much effect. In April, 1962, he was given etryptamine acetate (’ Monase ’). This had a dramatic effect, and he was able to get out and about and put in regular attendance at his work (then as a bus conductor). This drug was withdrawn from the market, however, and he was put on nialamide (’Niamid’). This had no effect and he deteriorated again. In May, 1962, he was given tranylcypromine (’Parnate’), which he took in increasing doses up to twenty 10 mg. tablets a day. He started to get out and about, took an interest in the opposite sex, spent money excessively, and went to see his father, whom he had not seen since the age of 7, in order to borrow money. He changed his general practitioner six times in the course of nine months in order to get the drug. Only when he had had a dose of ten to twenty tablets was he able to get out of the house to look for employment. Supplies have since become more difficult to obtain, and he is now returning to his previous habit of virtual social isolation. is notable that the structure of tranylcypro-
puberty he developed
It
Amphetamine itself is
a
monoamine-oxidase inhibitor.
Jordanburn Hospital, Edinburgh.
JOHN LE GASSICKE.
come to
The ideal drug would be an " improved " tranylcypromine with the anti-depressant action but without the systemic effects of monoamine-oxidase inhibition. We look forward to the separation of these two effects. Until then, we have to make the best of things. The dangers have to be weighed against the benefits in therapeutics when one is dealing with effective drugs and not mere
chemical
Spencer, J. N., Porter, N. Z., Froehlich, H. L., Wendel, H. Fed. Proc. 1960, 19, 277. 2. Horwitz, D., Sjoerdsma, A. Proc. Soc. exp. Biol., N.Y. 1961, 106, 118. 3. Gertner, S. B. J. Pharmacol. exp. Ther. 1961, 131, 223. 4. Lee, W. C., Shin, W. H., Shideman, F. E. ibid. 1961, 133, 180. 5. Pletscher, A., Pellmont, B. P. J. clin. Psychopath. 1958, 19, 163. 6. Kako, K., Chrysohou, A., Bing, R. J. Amer. J. Cardiol. 1960, 6, 1109. 7. Crout, J. R., Creveling, C. R., Udenfriend, S. J. Pharmacol. exp. Ther. 1961, 132, 162. 8. Ahlquist, R. P. in Pharmacology in Medicine; p. 378. New York, 1958. 9. Tedeschi, R. E., Tedeschi, D. H., Ames, P. L., Cook, L., Mattis, P. A., Fellows, E. J. Proc. Soc. exp. Biol., N.Y. 1959, 102, 380. 10. Horita, A., McGrath, W. R. Biochemical Pharmacology; vol. 3, 206. London, 1960. 11. Green, H., Erickson, R. W. J. Pharmacol. exp. Ther. 1960, 129, 237. 1.
to amphetamine. It appears that it is the amphetamine-like effect which is partly responsible for the symptomatic improvement in depressive illnesses,
mine is similar
SPONTANEOUS PNEUMOTHORAX SIR,-Your interesting annotation of Jan. 12 states: " The first episode is probably best managed conservatively, although if there is respiratory.distress, and especially if there is positive pressure, the air is commonly aspirated." Many doctors with experience of this condition will recall at least one, and probably several, cases of sudden death, and usually in young patients in whom the first episode was treated in this manner. Presumably
death resulted from the pneumothorax suddenly taking on The treatment, therefore, should be a tension factor. catheter drainage in the second intercostal space anteriorly if the lung has not re-expanded by the first or second day. It is quite misleading to write about surgical morbidity (which must be quite unusual) and omit to mention medical mortality. If there is a positive intrapleural " pressure the statement the air is commonly aspirated is much too weak. The air must be aspirated by catheter drainage attached to Monaldi suction if the occurrence of further disasters resulting from tension pneumothorax is to be avoided. "
Western
Infirmary, Glasgow.
KENNETH FRASER.
AGEING AND DEATH SIR,-Sir Robert Platt is to be congratulated on his excellent paper of Jan. 5, and particularly on his remarks upon death and his own response to its nearness in his patients. He, like Dr. Duddington (Jan. 19), believes that patients may gain succour by being allowed to face their position realistically with their physician and speak about their fears if they want to. This is, of course, the basis of psychotherapy and Sir Robert’s concept of the " conspiracy of silence " applies far more widely than to death alone. Dr. Duddington raises the question of how doctors are to be helped that they may become proficient in this skill. -
Unfortunately they cannot be made proficient. Essentially, proficiency will depend on their becoming more at ease with dis-ease" with their own feelings, since it is their own themselves which makes them ill at ease with the feelings of their patients. During their training all medical students are said to suffer from at least three incurable and fatal illnesses. Surely, this epitomises the human being’s fear of disease and death. As far as I am aware, nobody ever encourages the medical student to discuss these fears. If they did, perhaps they would have a better appreciation, in due course, of their patients’ fears. Instead the reaction of their mentors is negative and the fears are hidden in the " conspiracy of silence ". It is hardly surprising therefore that when faced with their patients’ anxieties they in turn react negatively ". If medical students were encouraged to discuss their feelings and to listen to their patients’ experiences and then to discuss their findings in a group with someone more experienced and understanding than themselves, they might show greater ability to react positively " and to succour. This is one of the functions that the psychiatric departments of medical schools should be performing. I myself know of only one where anything like this is being done. "
"
"
"
"
Opposition to these ideas seems, in my experience, to" be based on the belief that if a student starts " meddling in a patient’s emotions (mind) the patient will get hurt
271
and therefore it is better that students do not " meddle ". The same could be said of surgical and medical treatment, but they are taught still. The student is encouraged to " meddle" surgically, but under supervision, and to share in operations by watching, and he learns to cope at matters. So it should least with simple everyday be with everyday emotional problems. To me the very " " regard for the danger of meddling seems adequate justification of the importance and potential value of this part of a doctor’s work and therefore reason enough that there should be wide opportunities for its learning.
surgical
Psychiatric Department, The London Hospital, London, E.1.
GERALD A. HEASMAN.
TEMPERATURE-TAKING other SIR,-The day the front page of a leading newsa carried charming photograph of a nurse taking a paper child’s temperature-during a power cut. Had this picture appeared 50 years ago, it would have been claimed as praiseworthy (as then there was little else that one could do for the patient). But now that so much more is possible, is it not time that the thermometer round (with obvious exceptions) be consigned to a museum as a relic of medical tradition ? Eleven years ago, on my first call to a patient as a brand new general practitioner, with a brand new thermometer, I accidentally left that instrument in the patient. Not having the necessary courage to return and retrieve it, I have carried on without one from that day to this. During that time I have taken part in over 100,000 consultations and no-one has yet questioned me about not taking their temperature. Assuming there are about 250,000 patients in hospitals having their temperatures taken twice a day, and allowing 30 seconds for the performance with each patient, this means some 4000 nurse-hours are spent daily in this way. The amount of nursing time involved annually in taking temperatures is beyond my arithmetical capabilities. L. I. NORMAN. ,
RUBELLA BEFORE CONCEPTION AS A CAUSE OF FœTAL ABNORMALITY SiR,—Mr. Whitehouse (Jan. 19) draws attention
once
from various countries 12 more information is needed about the type of deformity after preconception rubella, in particular whether these deformities correspond to the classical triad. Furthermore, it would be of interest to know how soon after rubella, impregnation would appear to be safe. In my series,3 preconception rubella starting 24 days before conception produced a congenital abnormality, whilst three women who contracted rubella 16, 19, and 20 weeks before conception gave birth to normal babies. In the absence of definite information about any safe period for conception after an attack of rubella, it is perhaps useful to remember that occipital and postauricular lymphadenitis usually persists long enough to make a retrospective diagnosis of rubella if supported by a characteristic differential white blood-cell count. This is true also of subclinical rubella, which is probably the most likely condition to be overlooked and which can be similarly responsible for foetal damage, as is rubella with rash.3
F. K. M. HILLENBRAND. by Töndury, Étudesneo-nat., Zurich, 1953, ii, 2.
Bamatter, F. Cited Lundström, R. Acta pœdiat., Stockh. 1952, 41, 583. Hillenbrand, F. K. M. Lancet, 1956, i, 64.
the country. For the detection of platelet antibodies
we were using platelet agglutination and indirect antiglobulin-consumption techniques. In no case were we able to demonstrate unequivocally the presence of either complete or incomplete platelet
antibodies. As Dr. Wallace reports difficulty in getting platelet-antibody tests performed, may I say that several blood-transfusion centres of the National Blood Transfusion Service perform these tests; and if these arrangements are not available in a particular regional centre, we are always pleased to do them at the Blood Group Reference Laboratory. Medical Research Council Blood Group Reference Laboratory, The Lister
Institute, London, S.W.1.
K. L. G. GOLDSMITH.
COLD INJURY IN THE ELDERLY
SIR,-We have been hearing a good deal lately about cold injury to newborn and small babies, but I believe that we should also be on the lookout for a similar condition in elderly and frail patients. Many of these patients are being looked after in icy bedrooms, or are living alone in cottages without modem conveniences, where the effort to carry coal and do the chores has been too much for them during the cold spell. They become apathetic and drowsy, take to bed, and may die for no apparent reason. They do not feel particularly cold to the touch and look fairly pink, but the temperature may be well below 95 and cannot be measured on the ordinary clinical thermometer. Removal to warmer conditions may be lifesaving. J. C. GRAVES. DIRECT BLOOD-TRANSFUSION IN SEVERE HÆMORRHAGE AFTER HEART SURGERY
SIR,-With regard to tests for residual heparin, fibrinodepletion, and fibrinolysis advocated by Dr. Sharp and Mr. Gunning (Jan. 19), our findings over a series of nearly 200 cases of open-heart surgery are as follows: gen
again to the lamentable fact that an infection with rubella before conception may cause foetal damage. Although there are a number of reports on this possibility
1. 2. 3.
THROMBOCYTOPENIC PURPURA AFTER RUBELLA SIR,-We were very interested to read Dr. Wallace’s article of Jan. 19. We ourselves have examined the sera of seven cases of rubella for platelet antibodies. The samples were sent to us by colleagues in various parts of
The heparin level has been estimated in all cases where there appeared to be excessive blood-loss. Any residual heparin effect is treated by the administration of an appropriate dose of protamine sulphate. We have estimated the fibrinogen level on many occasions but have never found significant fibrinogen depletion. We attribute this to the fact that heparin is administered in repeated doses throughout the operation so as to maintain a constant therapeutic level at all times. We feel that the common practice of using a single large dose of heparin does not provide adequate protection against defibrination in long operations. Significant fibrinolysis has been an extremely rare condition in our experiences of open-heart surgery. We again say that, in our experience of severe non-surgical bleeding, specific assays of coagulation factors have been of no real help in practical management. Severity of bleeding in cases of thromobcytopenia cannot be exactly correlated with the platelet-count. Over a period of 20 years, it has been found by one of us (J. McL.) that direct blood-transfusion is the most effective haemostatic treatment in cases of severe haemorrhage associated with thrombocytopenia. Although we believe that the beneficial effect of this method is due to transfusion of viable platelets, we cannot exclude other factors, as mentioned by Dr. Nour-Eldin (Jan. 19).
But the purpose of stimulate a discussion
our on
communication the depletion of
was
not to
coagulation
practitioners and in non-psychiatric clinics.’ Observations in a homogeneous group might be less valuable than in a heterogeneous one. After all, patients with all kinds of disease may be depressed and tense. Double-blind trials do not always give the information they seek, and sometimes clinical observations may be just as valid. The numerous writers on tranylcypromine the same conclusion-that it is an effective Can anti-depressant. they all be wrong ? It is almost certain that the troublesome side-effects of tranylcypromine are due to its monoamine-oxidase inhibitory activity. Anyone interested can consult Spencer et al. Horwitz and Sjoerdsma,2and Gertner3 for the effect on autonomic ganglia, and Lee et al.,4 Pletscher and Pellmont,5 Kako et al.,6 Crout et al.,and Ahlquist8 for direct cardiac effects. It is by no means as certain that the anti-depressant activity of tranylcypromine is due to monoamine-oxidase inhibition. It 9-11 may be due to an amphetamine-like action on the brain.7 Dr. Blackwell is to be thanked for more references to the side-effects of the drug.
have all
placebos. ,
__
_
F. LEES C. W. BURKE.
St. Bartholomew’s Hospital, London, E.C.1.
SIR,-With reference to the article by Dr. Lees and Dr. Burke (Jan. 5) and the letters from Dr. McCormick and Dr. Blackwell (Jan. 19), I wish to report a case of addiction to tranylcypromine. The patient, a man born in 1939, had a severe personality disorder. Since an early age he had been shy and solitary. At acne vulgaris, which led to the overvalued idea that it was disfiguring and the source of attention from all around him. His work record had been poor; he spent long periods confined in the house, afraid to go out because of the acne. In 1961, after the death of his grandmother and the family had moved into a less congenial house, his symptoms became worse and depression became prominent. He was treated with phenelzine (’ Nardil ’) early in 1962 with not much effect. In April, 1962, he was given etryptamine acetate (’ Monase ’). This had a dramatic effect, and he was able to get out and about and put in regular attendance at his work (then as a bus conductor). This drug was withdrawn from the market, however, and he was put on nialamide (’Niamid’). This had no effect and he deteriorated again. In May, 1962, he was given tranylcypromine (’Parnate’), which he took in increasing doses up to twenty 10 mg. tablets a day. He started to get out and about, took an interest in the opposite sex, spent money excessively, and went to see his father, whom he had not seen since the age of 7, in order to borrow money. He changed his general practitioner six times in the course of nine months in order to get the drug. Only when he had had a dose of ten to twenty tablets was he able to get out of the house to look for employment. Supplies have since become more difficult to obtain, and he is now returning to his previous habit of virtual social isolation. is notable that the structure of tranylcypro-
puberty he developed
It
Amphetamine itself is
a
monoamine-oxidase inhibitor.
Jordanburn Hospital, Edinburgh.
JOHN LE GASSICKE.
come to
The ideal drug would be an " improved " tranylcypromine with the anti-depressant action but without the systemic effects of monoamine-oxidase inhibition. We look forward to the separation of these two effects. Until then, we have to make the best of things. The dangers have to be weighed against the benefits in therapeutics when one is dealing with effective drugs and not mere
chemical
Spencer, J. N., Porter, N. Z., Froehlich, H. L., Wendel, H. Fed. Proc. 1960, 19, 277. 2. Horwitz, D., Sjoerdsma, A. Proc. Soc. exp. Biol., N.Y. 1961, 106, 118. 3. Gertner, S. B. J. Pharmacol. exp. Ther. 1961, 131, 223. 4. Lee, W. C., Shin, W. H., Shideman, F. E. ibid. 1961, 133, 180. 5. Pletscher, A., Pellmont, B. P. J. clin. Psychopath. 1958, 19, 163. 6. Kako, K., Chrysohou, A., Bing, R. J. Amer. J. Cardiol. 1960, 6, 1109. 7. Crout, J. R., Creveling, C. R., Udenfriend, S. J. Pharmacol. exp. Ther. 1961, 132, 162. 8. Ahlquist, R. P. in Pharmacology in Medicine; p. 378. New York, 1958. 9. Tedeschi, R. E., Tedeschi, D. H., Ames, P. L., Cook, L., Mattis, P. A., Fellows, E. J. Proc. Soc. exp. Biol., N.Y. 1959, 102, 380. 10. Horita, A., McGrath, W. R. Biochemical Pharmacology; vol. 3, 206. London, 1960. 11. Green, H., Erickson, R. W. J. Pharmacol. exp. Ther. 1960, 129, 237. 1.
to amphetamine. It appears that it is the amphetamine-like effect which is partly responsible for the symptomatic improvement in depressive illnesses,
mine is similar
SPONTANEOUS PNEUMOTHORAX SIR,-Your interesting annotation of Jan. 12 states: " The first episode is probably best managed conservatively, although if there is respiratory.distress, and especially if there is positive pressure, the air is commonly aspirated." Many doctors with experience of this condition will recall at least one, and probably several, cases of sudden death, and usually in young patients in whom the first episode was treated in this manner. Presumably
death resulted from the pneumothorax suddenly taking on The treatment, therefore, should be a tension factor. catheter drainage in the second intercostal space anteriorly if the lung has not re-expanded by the first or second day. It is quite misleading to write about surgical morbidity (which must be quite unusual) and omit to mention medical mortality. If there is a positive intrapleural " pressure the statement the air is commonly aspirated is much too weak. The air must be aspirated by catheter drainage attached to Monaldi suction if the occurrence of further disasters resulting from tension pneumothorax is to be avoided. "
Western
Infirmary, Glasgow.
KENNETH FRASER.
AGEING AND DEATH SIR,-Sir Robert Platt is to be congratulated on his excellent paper of Jan. 5, and particularly on his remarks upon death and his own response to its nearness in his patients. He, like Dr. Duddington (Jan. 19), believes that patients may gain succour by being allowed to face their position realistically with their physician and speak about their fears if they want to. This is, of course, the basis of psychotherapy and Sir Robert’s concept of the " conspiracy of silence " applies far more widely than to death alone. Dr. Duddington raises the question of how doctors are to be helped that they may become proficient in this skill. -
Unfortunately they cannot be made proficient. Essentially, proficiency will depend on their becoming more at ease with dis-ease" with their own feelings, since it is their own themselves which makes them ill at ease with the feelings of their patients. During their training all medical students are said to suffer from at least three incurable and fatal illnesses. Surely, this epitomises the human being’s fear of disease and death. As far as I am aware, nobody ever encourages the medical student to discuss these fears. If they did, perhaps they would have a better appreciation, in due course, of their patients’ fears. Instead the reaction of their mentors is negative and the fears are hidden in the " conspiracy of silence ". It is hardly surprising therefore that when faced with their patients’ anxieties they in turn react negatively ". If medical students were encouraged to discuss their feelings and to listen to their patients’ experiences and then to discuss their findings in a group with someone more experienced and understanding than themselves, they might show greater ability to react positively " and to succour. This is one of the functions that the psychiatric departments of medical schools should be performing. I myself know of only one where anything like this is being done. "
"
"
"
"
Opposition to these ideas seems, in my experience, to" be based on the belief that if a student starts " meddling in a patient’s emotions (mind) the patient will get hurt
271
and therefore it is better that students do not " meddle ". The same could be said of surgical and medical treatment, but they are taught still. The student is encouraged to " meddle" surgically, but under supervision, and to share in operations by watching, and he learns to cope at matters. So it should least with simple everyday be with everyday emotional problems. To me the very " " regard for the danger of meddling seems adequate justification of the importance and potential value of this part of a doctor’s work and therefore reason enough that there should be wide opportunities for its learning.
surgical
Psychiatric Department, The London Hospital, London, E.1.
GERALD A. HEASMAN.
TEMPERATURE-TAKING other SIR,-The day the front page of a leading newsa carried charming photograph of a nurse taking a paper child’s temperature-during a power cut. Had this picture appeared 50 years ago, it would have been claimed as praiseworthy (as then there was little else that one could do for the patient). But now that so much more is possible, is it not time that the thermometer round (with obvious exceptions) be consigned to a museum as a relic of medical tradition ? Eleven years ago, on my first call to a patient as a brand new general practitioner, with a brand new thermometer, I accidentally left that instrument in the patient. Not having the necessary courage to return and retrieve it, I have carried on without one from that day to this. During that time I have taken part in over 100,000 consultations and no-one has yet questioned me about not taking their temperature. Assuming there are about 250,000 patients in hospitals having their temperatures taken twice a day, and allowing 30 seconds for the performance with each patient, this means some 4000 nurse-hours are spent daily in this way. The amount of nursing time involved annually in taking temperatures is beyond my arithmetical capabilities. L. I. NORMAN. ,
RUBELLA BEFORE CONCEPTION AS A CAUSE OF FœTAL ABNORMALITY SiR,—Mr. Whitehouse (Jan. 19) draws attention
once
from various countries 12 more information is needed about the type of deformity after preconception rubella, in particular whether these deformities correspond to the classical triad. Furthermore, it would be of interest to know how soon after rubella, impregnation would appear to be safe. In my series,3 preconception rubella starting 24 days before conception produced a congenital abnormality, whilst three women who contracted rubella 16, 19, and 20 weeks before conception gave birth to normal babies. In the absence of definite information about any safe period for conception after an attack of rubella, it is perhaps useful to remember that occipital and postauricular lymphadenitis usually persists long enough to make a retrospective diagnosis of rubella if supported by a characteristic differential white blood-cell count. This is true also of subclinical rubella, which is probably the most likely condition to be overlooked and which can be similarly responsible for foetal damage, as is rubella with rash.3
F. K. M. HILLENBRAND. by Töndury, Étudesneo-nat., Zurich, 1953, ii, 2.
Bamatter, F. Cited Lundström, R. Acta pœdiat., Stockh. 1952, 41, 583. Hillenbrand, F. K. M. Lancet, 1956, i, 64.
the country. For the detection of platelet antibodies
we were using platelet agglutination and indirect antiglobulin-consumption techniques. In no case were we able to demonstrate unequivocally the presence of either complete or incomplete platelet
antibodies. As Dr. Wallace reports difficulty in getting platelet-antibody tests performed, may I say that several blood-transfusion centres of the National Blood Transfusion Service perform these tests; and if these arrangements are not available in a particular regional centre, we are always pleased to do them at the Blood Group Reference Laboratory. Medical Research Council Blood Group Reference Laboratory, The Lister
Institute, London, S.W.1.
K. L. G. GOLDSMITH.
COLD INJURY IN THE ELDERLY
SIR,-We have been hearing a good deal lately about cold injury to newborn and small babies, but I believe that we should also be on the lookout for a similar condition in elderly and frail patients. Many of these patients are being looked after in icy bedrooms, or are living alone in cottages without modem conveniences, where the effort to carry coal and do the chores has been too much for them during the cold spell. They become apathetic and drowsy, take to bed, and may die for no apparent reason. They do not feel particularly cold to the touch and look fairly pink, but the temperature may be well below 95 and cannot be measured on the ordinary clinical thermometer. Removal to warmer conditions may be lifesaving. J. C. GRAVES. DIRECT BLOOD-TRANSFUSION IN SEVERE HÆMORRHAGE AFTER HEART SURGERY
SIR,-With regard to tests for residual heparin, fibrinodepletion, and fibrinolysis advocated by Dr. Sharp and Mr. Gunning (Jan. 19), our findings over a series of nearly 200 cases of open-heart surgery are as follows: gen
again to the lamentable fact that an infection with rubella before conception may cause foetal damage. Although there are a number of reports on this possibility
1. 2. 3.
THROMBOCYTOPENIC PURPURA AFTER RUBELLA SIR,-We were very interested to read Dr. Wallace’s article of Jan. 19. We ourselves have examined the sera of seven cases of rubella for platelet antibodies. The samples were sent to us by colleagues in various parts of
The heparin level has been estimated in all cases where there appeared to be excessive blood-loss. Any residual heparin effect is treated by the administration of an appropriate dose of protamine sulphate. We have estimated the fibrinogen level on many occasions but have never found significant fibrinogen depletion. We attribute this to the fact that heparin is administered in repeated doses throughout the operation so as to maintain a constant therapeutic level at all times. We feel that the common practice of using a single large dose of heparin does not provide adequate protection against defibrination in long operations. Significant fibrinolysis has been an extremely rare condition in our experiences of open-heart surgery. We again say that, in our experience of severe non-surgical bleeding, specific assays of coagulation factors have been of no real help in practical management. Severity of bleeding in cases of thromobcytopenia cannot be exactly correlated with the platelet-count. Over a period of 20 years, it has been found by one of us (J. McL.) that direct blood-transfusion is the most effective haemostatic treatment in cases of severe haemorrhage associated with thrombocytopenia. Although we believe that the beneficial effect of this method is due to transfusion of viable platelets, we cannot exclude other factors, as mentioned by Dr. Nour-Eldin (Jan. 19).
But the purpose of stimulate a discussion
our on
communication the depletion of
was
not to
coagulation