- Email: [email protected]
CARE OF THE UNCONSCIOUS PATIENT
357 Another point raised by Dr. Parry is the rather doubtful value of the visitor to an overseas medical school who stays for up to three months. In Uganda, over the years, we have had several selected visitors from the department of medicine of the Postgraduate Medical School of London, each of whom has stayed for one to two months. Each came at the invitation of the Department of Medicine of Makerere University College, and there is no doubt that the benefits to be derived from such visits are directly related to the amount of preparation for the visitor made by the inviting department. It is our experience that essential research techniques can be introduced successfully in that short time. Lastly there is one vital topic not mentioned by Dr. Parrythe need for trained technicians. Only in a few tropical countries (e.g., Jamaica) are these obtainable locally, and many medical schools in the tropics must still rely on expatriate technicians. Without their backing, research projects may be impossible, have to be limited in scope, or progress very slowly. Secondment of trained technicians, or their provision in some other way, may for a time be as important as the secondment of lecturer staff. Department of Medicine, Makerere
University College, Kampala, Uganda.
J. A. TULLOCH.
GIANT-CELL MYOCARDITIS SIR,-Prof. S. M. Rab and his colleagues are incorrect in stating (July 27) that we were able to find only 25 reported cases of myocardial sarcoidosis since 1941. In an excellent paper on the subject, to which we made reference in our article, Porter1 collected 51 proven cases and several more " probables ". Our 25 only represent histologically proven cases, in which the myocardial sarcoid was considered by us to have been the lesion primarilv and directlv responsible for death. GILBERT FORBES Department of Forensic Medicine, ALAN USHER. The University, Sheffield 10.
SiR,—The interesting case described by Professor Rab colleagues prompts me to call attention to a paper by Kirchheiner 2 in which he collected 40 reported and his
of sarcoidosis cordis. Of 23 patients in whom electrocardiographic findings were recorded, 3 had ventricular paroxysmal tachycardia, 3 had atrial fibrillation, cases
’
and 1 had ventricular fibrillation. I agree that the diagnosis of sarcoidosis cordis is very difficult in vivo. It can only be suspected in patients with cardiac symptoms and sarcoid manifestations elsewhere. Frederiksborg Amts Centralsygehus, Hillerød, Denmark.
A. W.
J. HOUGHTON.
BARBITURATE POISONING
SIR,-There are hospitals designated to treat patients suffering from barbiturate poisoning. The appropriate authority should consider the advisability of equipping and maintaining mobile squads to deal with all cases of poisoning-possibly along the lines of obstetric flyingsauads. C. H. BATEMAN. PLASTIC COATING FOR PLASTER-OF-PARIS
SIR,-A plastic coating specially developed for applying to the
surface of plaster-of-paris
general
casts
is
now
available for
use.
The material is a non-toxic water-based plastic which can be applied by brush, like a paint, to the hardened cast. It not only forms a skin over the surface but soaks into the outer layers of the plaster, giving added strength which prevents cracking and crumbling. This is achieved without any increase in the weight of the plaster, and does not complicate its removal. The coating dries in about 10 minutes and is fully hardened after 24 hours. It can be applied at any time after the plaster cast is dry. Treated with the coating, the plaster takes on a highly glazed, tough, and completely waterproof surface, which can be kept clean with soap and water. This aids nursing care where contamination with excreta is troublesome. The cost of the coating (trade name ’Plastalac ’) applied to a forearm plaster is approximately 2d. Further information and supplies can be obtained from the Plastic Coating Research Co. Ltd., 52. Hish Street. Kinsston
unon
Thames. Surrev.
I. MACDOUGALL.
tn
inirDTiQnDnQ n!lt1pntQ
B. R. SIMPSON. 1. 2.
Royal Salop Infirmary, Shrewsbury.
TORBEN ANDERSEN.
CARE OF THE UNCONSCIOUS PATIENT SIR,-Many of our national newspapers recently gave prominence to a picture of an unconscious patient, suffering from barbiturate intoxication, being carried with a significant degree of " head-up " tilt, on a litter borne by two members of an ambulance service. He was thus exposed to the hazard of a hypotensive episode. The patient was also lying supine, and therefore in the position most likely to lead to asphyxiation and/or aspiration of vomit. Similarly, many unconscious victims of accidents are placed in the supine position pending the arrival of skilled help. The prognosis of such cases would be greatly improved as the result of an energetic campaign designed to make the general public aware of the dangers of tile snninf nncitinn
IPECACUANHA IN BARBITURATE TABLETS SIR,-Consultant physicians must be increasingly concerned at the number of " overdoses " that are admitted as emergencies to their wards. All these case$must be regarded as serious; all take up time, beds, and public money which could be used to better advantage. Fortunately, there is a simple and effective answer. At least one drug manufacturer incorporates a little ipecacuanha with each barbiturate tablet. In therapeutic doses this has no effect, but in larger doses severe nausea is induced, while in dangerous amounts immediate vomiting occurs. The larger the overdose the greater the amount of vomiting. To my mind, this idea is near a stroke of genius. The expense entailed is negligible, life is not imperilled, and hospital beds are not wasted.
Porter, G. H. New Engl. J. Med. 1960, 263, 1350. Kirchheiner, B. Acta med. scand. 1960, 168, 223.
A GENETIC THEORY OF INFLAMMATORY POLYARTHRITIS
SiR,-Dr. Burch1 suggests a somatic mutational theory of inflammatory polyarthritis, based on the observations of Lawrence2 on the prevalence of the disease at various ages in men and women. Its essential features are: 1. Inflammatory polyarthritis is an autoimmune disease, the in its causation being somatic mutations in competent cells. 2. A somatic mutation in a single cell gives rise to a " forbidden " clone of cells. Burch supposes that in individuals with clinical grade 1, one mutation has occurred, and that two, three, or more mutations, occurring in separate cell lines and giving rise to two or more forbidden clones, are required to produce clinical grades 2, 3, and so on. 3. The somatic mutations are dominant and occur at a sex-linked locus. 4. Half of the population only is at risk. Burch suggests that two alleles with the same frequency are segregating at an autosomal locus, such that only homozygotes are at risk. 1. Burch, P. R. J. Lancet, 1963, i, 1253. unit
events
immunologically
2.
Lawrence, J. S. Ann. rheum. Dis. 1961, 20, 11.
University College, Kampala, Uganda.
J. A. TULLOCH.
GIANT-CELL MYOCARDITIS SIR,-Prof. S. M. Rab and his colleagues are incorrect in stating (July 27) that we were able to find only 25 reported cases of myocardial sarcoidosis since 1941. In an excellent paper on the subject, to which we made reference in our article, Porter1 collected 51 proven cases and several more " probables ". Our 25 only represent histologically proven cases, in which the myocardial sarcoid was considered by us to have been the lesion primarilv and directlv responsible for death. GILBERT FORBES Department of Forensic Medicine, ALAN USHER. The University, Sheffield 10.
SiR,—The interesting case described by Professor Rab colleagues prompts me to call attention to a paper by Kirchheiner 2 in which he collected 40 reported and his
of sarcoidosis cordis. Of 23 patients in whom electrocardiographic findings were recorded, 3 had ventricular paroxysmal tachycardia, 3 had atrial fibrillation, cases
’
and 1 had ventricular fibrillation. I agree that the diagnosis of sarcoidosis cordis is very difficult in vivo. It can only be suspected in patients with cardiac symptoms and sarcoid manifestations elsewhere. Frederiksborg Amts Centralsygehus, Hillerød, Denmark.
A. W.
J. HOUGHTON.
BARBITURATE POISONING
SIR,-There are hospitals designated to treat patients suffering from barbiturate poisoning. The appropriate authority should consider the advisability of equipping and maintaining mobile squads to deal with all cases of poisoning-possibly along the lines of obstetric flyingsauads. C. H. BATEMAN. PLASTIC COATING FOR PLASTER-OF-PARIS
SIR,-A plastic coating specially developed for applying to the
surface of plaster-of-paris
general
casts
is
now
available for
use.
The material is a non-toxic water-based plastic which can be applied by brush, like a paint, to the hardened cast. It not only forms a skin over the surface but soaks into the outer layers of the plaster, giving added strength which prevents cracking and crumbling. This is achieved without any increase in the weight of the plaster, and does not complicate its removal. The coating dries in about 10 minutes and is fully hardened after 24 hours. It can be applied at any time after the plaster cast is dry. Treated with the coating, the plaster takes on a highly glazed, tough, and completely waterproof surface, which can be kept clean with soap and water. This aids nursing care where contamination with excreta is troublesome. The cost of the coating (trade name ’Plastalac ’) applied to a forearm plaster is approximately 2d. Further information and supplies can be obtained from the Plastic Coating Research Co. Ltd., 52. Hish Street. Kinsston
unon
Thames. Surrev.
I. MACDOUGALL.
tn
inirDTiQnDnQ n!lt1pntQ
B. R. SIMPSON. 1. 2.
Royal Salop Infirmary, Shrewsbury.
TORBEN ANDERSEN.
CARE OF THE UNCONSCIOUS PATIENT SIR,-Many of our national newspapers recently gave prominence to a picture of an unconscious patient, suffering from barbiturate intoxication, being carried with a significant degree of " head-up " tilt, on a litter borne by two members of an ambulance service. He was thus exposed to the hazard of a hypotensive episode. The patient was also lying supine, and therefore in the position most likely to lead to asphyxiation and/or aspiration of vomit. Similarly, many unconscious victims of accidents are placed in the supine position pending the arrival of skilled help. The prognosis of such cases would be greatly improved as the result of an energetic campaign designed to make the general public aware of the dangers of tile snninf nncitinn
IPECACUANHA IN BARBITURATE TABLETS SIR,-Consultant physicians must be increasingly concerned at the number of " overdoses " that are admitted as emergencies to their wards. All these case$must be regarded as serious; all take up time, beds, and public money which could be used to better advantage. Fortunately, there is a simple and effective answer. At least one drug manufacturer incorporates a little ipecacuanha with each barbiturate tablet. In therapeutic doses this has no effect, but in larger doses severe nausea is induced, while in dangerous amounts immediate vomiting occurs. The larger the overdose the greater the amount of vomiting. To my mind, this idea is near a stroke of genius. The expense entailed is negligible, life is not imperilled, and hospital beds are not wasted.
Porter, G. H. New Engl. J. Med. 1960, 263, 1350. Kirchheiner, B. Acta med. scand. 1960, 168, 223.
A GENETIC THEORY OF INFLAMMATORY POLYARTHRITIS
SiR,-Dr. Burch1 suggests a somatic mutational theory of inflammatory polyarthritis, based on the observations of Lawrence2 on the prevalence of the disease at various ages in men and women. Its essential features are: 1. Inflammatory polyarthritis is an autoimmune disease, the in its causation being somatic mutations in competent cells. 2. A somatic mutation in a single cell gives rise to a " forbidden " clone of cells. Burch supposes that in individuals with clinical grade 1, one mutation has occurred, and that two, three, or more mutations, occurring in separate cell lines and giving rise to two or more forbidden clones, are required to produce clinical grades 2, 3, and so on. 3. The somatic mutations are dominant and occur at a sex-linked locus. 4. Half of the population only is at risk. Burch suggests that two alleles with the same frequency are segregating at an autosomal locus, such that only homozygotes are at risk. 1. Burch, P. R. J. Lancet, 1963, i, 1253. unit
events
immunologically
2.
Lawrence, J. S. Ann. rheum. Dis. 1961, 20, 11.