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Amorphous, nanoquasicrystalline and nanocrystalline alloys in Al-based systems
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villi of hydatidiform mole may be regarded as a primary defect in the formation of the villi in this disease and not
disappearance of the vascular anlagen, caused by the early death of the foetus ". According to this view hydatidiform-mole villi could be regarded as persistent secondary villi (whereas in chorio-epithelioma the process of formation of the villi is probably arrested in the as a "
nrimarv stage). University Department of Obstetrics and Gynæcology, St. Radboudziekenhuis, Nijmegen, Netherlands.
L. A. M. STOLTE H. I. A M. v. KESSEL J. C. SEELEN G. A. J. TIJDINK.
ARTIFICIAL INSEMINATION
SIR,-Concerning the astonishing suggestion that A.I.D. constitutes adultery even if performed with the full consent of the husband, and its defence that it is not sinful since concupiscence is lacking, I should propose to make intent the crucial test for marital deception. Having a child through A.I.D. is analogous with adopting a baby, and not with bearing a child conceived in adultery. A.I.D., like adoption, is dependent upon the consent of both husband and wife; it is an open act performed for a socially accepted purpose, and it lacks the intent to deceive. Making a concession to huriian nature, it appears good practice to mix the semen of the donor with that of the husband before performing A.I.D. The uncertainty introduced seems to help avoid an emotional stress on the husband; it is not the element of adultery, but the closer physical ties between child and mother that carry the seeds of conflict. In this way pater semper incertus
est
remains
true.
STEVEN E. ROSS.
SIR,-Dr. Audrey Roberts (Oct. 29) need not take so gloomy a view of moral theology. It can, and does, move with the times. No longer, for example, do its interpreters think it seemly to burn heretics at the stake: a distinct advance. L. N.
JACKSON.
RESPIRATORY OBSTRUCTION DUE TO FAULTY ENDOTRACHEAL TUBE
Sirshould like to suggest that this phenomenon is more often due to the use of too small an endotracheal tube than to a fault in the tube. reported a no. 6 or 7 tube was used for an adult obtain an airtight seal in an adult trachea with a tube of this size inevitably leads to an overdistension of the balloon with consequent bulging of any weak part in the balloon. In order to provide the patient with the best possible airway it is important to select the largest bore endotracheal tube that can be passed through the glottis without trauma; in my experience there is rarely a need to use anything smaller than a no. 10 in an adult and I very frequently use a no. 11 or 12. With tubes of these sizes an airtight seal within the trachea can be obtained with a minimum of distension of the balloon and consequently a minimum risk of causing the balloon to herniate or burst, with the possibility of obstruction in the one case and damage to the trachea in the other. Two points in the care of endotracheal tubes are of importance : always place the balloon end of the tube in a test-tube when testing the tube by inflation (this prevents overdistension of the balloon and a weakening of its wall during the test); and avoid the use of tube lubricants which have a fatty base (such lubricants have a very deleterious effect on the thin rubber of the balloon and weaken the wall, thus predisposing to bulging under inflation). In
one case
patient;
to
S. F. DURRANS.
DRIVING AND CORONARY THROMBOSIS
the past fourteen months I have seen 10 of coronary thrombosis, in 8 of which the patients had been driving their car in London just before the 3 of the patients drove themselves to my attack. consulting-room and their attacks occurred during the journey. The other 5 had attacks on arriving home after driving in London (1 patient collapsed after garaging his
SIR,-During
cases
car). The traffic in London becomes more and more congested every day and the stress of driving is proportionately increased. I am sure this stress and accompanying exhaustion, especially during the peak hours in London, is a cause of many coronary thromboses. But exhaust fumes may contain vasoconstrictor substances that act as a substantial contributory factor. In view of I do not the present-day conditions, support suggestion that driving can be a form of relaxation. MAX ODENS. POMP AND CIRCUMSTANCE
SIR,-What!i Abolish teaching ward rounds ? No, Never. It’s the one bright spot in the patient’s week, to hear the students and doctors cross-questioned. At least, so
I have been told bv
manv
ex-ward-natients. G. E. BEAUMONT.
DANGERS OF ORAL DIURETICS IN A HOT CLIMATE
SiR,ŁThe use of diuretics such as chlorothiazide and hydrochlorothiazide , as hypotensive drugs for nonoedematous patients has lately increased considerably. The following case illustrates how these drugs may produce severe hypotension if not adequately controlled. of 69, who had never shown signs of cardiac treated in the U.S.A. with hydrochlorothiazide for more than 2 years. Her blood-pressure before treatment was about 220/100 mm. Hg and was controlled by 25 mg. of hydrochlorothiozide twice daily at around 160 systolic and 80-90 diastolic. She kept to this regimen when she arrived in Israel for a visit. After her arrival she had diarrhcea for several days. Subsequently, on a very hot day, when the dry eastern winds (khamseen) prevailed she took a trip by bus (10-11hours from Haifa) to Elath on the shore of the Red Sea. The temperature there was 42°C (107-6°F) with relative humidity below 10%. As she had not felt well on the previous days she had increased her dose to 75 mg. daily without consultinga doctor. At Elath she felt, as she said, extremely weak and could hardly Next morning she went back by plane and arrived move. with great difficulty at her temporary residence near here. She rested and called me, for the first time, on the fourth day after her return. Her blood-pressure was 95/45. As she had stopped taking the drug 3 days previously it can be presumed that her blood-pressure was lower still at Elath and that she had been in a state of near collapse. An electrocardiogram next day showed no myocardial damage and no signs of potassium depletion, but evidence of left heart strain. As she refused further examinations, no estimation of electrolytes or plasma-volume was made. Recovery was quick and uneventful. Without any medication her blood-pressure returned to 150/80 within 16 days and remained so till her departure from Haifa. This case showed a combination of several factors: dehydration after diarrhoea and exposure to a hot dry climate without sufficient intake of fluid, aggravated by an increased dose of hydrochlorothiazide, combining to induce dangerous hypotension. Similar reactions, though not as dramatic, were seen lately in two other patients, also new arrivals from abroad and not yet A
woman
failure,
was
villi of hydatidiform mole may be regarded as a primary defect in the formation of the villi in this disease and not
disappearance of the vascular anlagen, caused by the early death of the foetus ". According to this view hydatidiform-mole villi could be regarded as persistent secondary villi (whereas in chorio-epithelioma the process of formation of the villi is probably arrested in the as a "
nrimarv stage). University Department of Obstetrics and Gynæcology, St. Radboudziekenhuis, Nijmegen, Netherlands.
L. A. M. STOLTE H. I. A M. v. KESSEL J. C. SEELEN G. A. J. TIJDINK.
ARTIFICIAL INSEMINATION
SIR,-Concerning the astonishing suggestion that A.I.D. constitutes adultery even if performed with the full consent of the husband, and its defence that it is not sinful since concupiscence is lacking, I should propose to make intent the crucial test for marital deception. Having a child through A.I.D. is analogous with adopting a baby, and not with bearing a child conceived in adultery. A.I.D., like adoption, is dependent upon the consent of both husband and wife; it is an open act performed for a socially accepted purpose, and it lacks the intent to deceive. Making a concession to huriian nature, it appears good practice to mix the semen of the donor with that of the husband before performing A.I.D. The uncertainty introduced seems to help avoid an emotional stress on the husband; it is not the element of adultery, but the closer physical ties between child and mother that carry the seeds of conflict. In this way pater semper incertus
est
remains
true.
STEVEN E. ROSS.
SIR,-Dr. Audrey Roberts (Oct. 29) need not take so gloomy a view of moral theology. It can, and does, move with the times. No longer, for example, do its interpreters think it seemly to burn heretics at the stake: a distinct advance. L. N.
JACKSON.
RESPIRATORY OBSTRUCTION DUE TO FAULTY ENDOTRACHEAL TUBE
Sirshould like to suggest that this phenomenon is more often due to the use of too small an endotracheal tube than to a fault in the tube. reported a no. 6 or 7 tube was used for an adult obtain an airtight seal in an adult trachea with a tube of this size inevitably leads to an overdistension of the balloon with consequent bulging of any weak part in the balloon. In order to provide the patient with the best possible airway it is important to select the largest bore endotracheal tube that can be passed through the glottis without trauma; in my experience there is rarely a need to use anything smaller than a no. 10 in an adult and I very frequently use a no. 11 or 12. With tubes of these sizes an airtight seal within the trachea can be obtained with a minimum of distension of the balloon and consequently a minimum risk of causing the balloon to herniate or burst, with the possibility of obstruction in the one case and damage to the trachea in the other. Two points in the care of endotracheal tubes are of importance : always place the balloon end of the tube in a test-tube when testing the tube by inflation (this prevents overdistension of the balloon and a weakening of its wall during the test); and avoid the use of tube lubricants which have a fatty base (such lubricants have a very deleterious effect on the thin rubber of the balloon and weaken the wall, thus predisposing to bulging under inflation). In
one case
patient;
to
S. F. DURRANS.
DRIVING AND CORONARY THROMBOSIS
the past fourteen months I have seen 10 of coronary thrombosis, in 8 of which the patients had been driving their car in London just before the 3 of the patients drove themselves to my attack. consulting-room and their attacks occurred during the journey. The other 5 had attacks on arriving home after driving in London (1 patient collapsed after garaging his
SIR,-During
cases
car). The traffic in London becomes more and more congested every day and the stress of driving is proportionately increased. I am sure this stress and accompanying exhaustion, especially during the peak hours in London, is a cause of many coronary thromboses. But exhaust fumes may contain vasoconstrictor substances that act as a substantial contributory factor. In view of I do not the present-day conditions, support suggestion that driving can be a form of relaxation. MAX ODENS. POMP AND CIRCUMSTANCE
SIR,-What!i Abolish teaching ward rounds ? No, Never. It’s the one bright spot in the patient’s week, to hear the students and doctors cross-questioned. At least, so
I have been told bv
manv
ex-ward-natients. G. E. BEAUMONT.
DANGERS OF ORAL DIURETICS IN A HOT CLIMATE
SiR,ŁThe use of diuretics such as chlorothiazide and hydrochlorothiazide , as hypotensive drugs for nonoedematous patients has lately increased considerably. The following case illustrates how these drugs may produce severe hypotension if not adequately controlled. of 69, who had never shown signs of cardiac treated in the U.S.A. with hydrochlorothiazide for more than 2 years. Her blood-pressure before treatment was about 220/100 mm. Hg and was controlled by 25 mg. of hydrochlorothiozide twice daily at around 160 systolic and 80-90 diastolic. She kept to this regimen when she arrived in Israel for a visit. After her arrival she had diarrhcea for several days. Subsequently, on a very hot day, when the dry eastern winds (khamseen) prevailed she took a trip by bus (10-11hours from Haifa) to Elath on the shore of the Red Sea. The temperature there was 42°C (107-6°F) with relative humidity below 10%. As she had not felt well on the previous days she had increased her dose to 75 mg. daily without consultinga doctor. At Elath she felt, as she said, extremely weak and could hardly Next morning she went back by plane and arrived move. with great difficulty at her temporary residence near here. She rested and called me, for the first time, on the fourth day after her return. Her blood-pressure was 95/45. As she had stopped taking the drug 3 days previously it can be presumed that her blood-pressure was lower still at Elath and that she had been in a state of near collapse. An electrocardiogram next day showed no myocardial damage and no signs of potassium depletion, but evidence of left heart strain. As she refused further examinations, no estimation of electrolytes or plasma-volume was made. Recovery was quick and uneventful. Without any medication her blood-pressure returned to 150/80 within 16 days and remained so till her departure from Haifa. This case showed a combination of several factors: dehydration after diarrhoea and exposure to a hot dry climate without sufficient intake of fluid, aggravated by an increased dose of hydrochlorothiazide, combining to induce dangerous hypotension. Similar reactions, though not as dramatic, were seen lately in two other patients, also new arrivals from abroad and not yet A
woman
failure,
was