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CURARE AND PRECIPITATE LABOUR
963
reticulocytes rose to 172%, with a subsequent increase erythrocytes from an initial 2,400,000 per c.mm. to
HEAT CRAMPS
of
SiR,,-I was much interested in the article of Nov. 5 by Dr. Ladell, having myself made some relatively insignificant observations on the same subject1 when enjoying for that study-so far as environment goes(to quote Sir Charles Martin) unrivalled opportunities.
A second case c.mm. within two weeks. similar way. Department of Internal Medicine, KURT HAUSMANN.
3,200,000 per reacted in
a
St. Georg General
Hospital,
Hamburg.
Dr. Ladell remarks that heat cramps may occur when water is not drunk to excess or even when it is not drunk at all; this is true. It is also true that almost imperceptible changes in blood-chloride enable the balance in the affected muscle-fibres to be restored, after the administration of salt and water. Another fact is that the miners in Pendleton colliery put small amounts of cream of tartar (potassium bitartrate) in their drinking-water as a cramp preventive.2 A further curious experience is that of Morton,3 who administered 1-F/2 pints of 2% sodium bicarbonate to his cases, with rapid improvement. I do not think that cramps are a simple osmotic effect, as Dr. Ladell seems to imply ; nor do I consider that muscular exertion is an essential preliminary. A cold environment, I have observed, makes the pain of heat cramps temporarily worse, and cold is a potent cause of muscular cramps even in temperate climes. One of my patients was very worried in case the heat cramps, which occurred in muscle-fibres situated in parts of the body remote from each other, should spread to his heart. I tried to reassure him by saying that the heartmuscle had never been affected, so far as I knew. The " patient remarked : " I might be the first case !
ANTIBIOTICS AND COAGULATION
SiR,-I should like to correct the impression, which your annotation of Oct. 22 (p. 756) may have given, that
we
have done any work
on
the influence of anti-
biotics in thrombo-embolism. The presentation which I made before the International Surgical Society was based
analysis of 7 years’ experience at the Charity Hospital in New Orleans. We have been interested in thromboembolism for more than a decade and have felt that we were able to prevent most cases of venous thrombosis, and to prevent fatality in those cases in which it did occur by recognition of the phlebothrombosis and ligation of the vein proximal to the site of the thrombus. We were astounded, however, in our analysis to find that there has been a tremendous increase in the incidence of venous thrombosis and fatal pulmonary embolism in the Charity Hospital in spite of all the measures which we have undertaken to prevent them. The study showed that there was an increase in the average yearly incidence of thrombo-embolism from 66 to 124 during a period when the admissions increased only 20%. The number of fatal cases of pulmonary embolism in the last two years is approximately the same as in the previous five years, which represents an increase in the average yearly incidence from 20 to 52. This study demonstrates that thrombo-embolism has definitely increased. Though we have not yet been able to prove it, the suggestion was made that the increase in thrombo-embolism might be due to the almost routine administration of antibiotics to hospitalised patients ; at least, there is a parallelism between the two. Whether this is a factor or the sole factor cannot be said at the present time. on
School of Medicine, Tulane University of Louisiana, New Orleans.
CURARE AND PRECIPITATE LABOUR
SIR,-As anaesthetists
is somewhat similar to that described
<
by him.
Medical
School, Dundee.
curare
for upperthe
25, was admitted to hospital with Sept. 22, 1949. She was 38 weeks temperature was 100-8°F and pulse-rate
Her The abdomen was very tender, with 130 per min. localised guarding in the right iliac fossa. The chest was clear and the urine normal, and she had had no symptoms during her pregnancy. At 6.20 P.M. she was givenOmnopon ’ gr. l/s and scopolamine gr. 1/160 intravenously. At 6.25 P.M. anaesthesia, was induced with a mixture of 10 ml. of thiopentone (5%) and 15 mg. of d-tubocurarine chloride (Duncan & Flockhart). Since the patient had had a little food and a drink a short time before, a cuffed tube was inserted. Anaesthesia was maintained with 45% nitrous oxide, 10% cyclopropane, and 45% oxygen. The operation started at 6.35 P.M. An acutely inflamed appendix was removed. Before closing the peritoneum the surgeon was requested to feel the uterus, which he said was as hard as a bullet. The operation was completed at 7.5 r.M. On leaving the theatre the patient was almost conscious ; no neostigmine and atropine were necessary, and the fatal heart was easily audible and beating at 120 per min. The patient was quite comfortable in the ward until 9.30 r.M. when she requested a bedpan, which she did not use. At 9.45 P.M. she complained of sudden backache, and shortly afterwards labour pains became strong and frequent. At 10.20 P.M. a dead baby girl, weighing approximately 6 lb., was suddenly delivered. No postoperative drugs were given until 11.40 P.M., when the patient received heroin gr. 1/12.
pregnant.
SiR,-In his article of Oct. 8, Mr. Crowe observes that of a peptic ulcer shortly after gastroenterostomy appears to be uncommon. The following The patient, a man aged 32, was operated on by Mr. F. R. Brown on June 16, 1949, when a wedge resection of a lessercurvature uJcer was carried out. He made an uneventful recovery, and pathological examination of the ulcer confirmed that it was simple in nature. He was readmitted to hospital on July 31 with shortness of breath and the story of having had sudden severe upper abdominal pain that day. The pain had not eased, and when he was examined typical signs of perforated ulcer were found. His abdomen was rigid and there was a substantial amount of free fluid. At operation on the same day the presence of free fluid was confirmed, and a small acute perforated ulcer was found just to the pyloric side of the anastomosis where the wedge had been removed. The perforation was closed by a series of three stitches of catgut, and the abdomen was closed in layers. His wound healed satisfactorily and he was fit to leave hospital on Aug. 12. His general condition at that time was fairly poor ; although he was about 6 ft. tall, his weight was only 9 st. 7 lb. However, when seen again recently, his weight had increased to 12 st., and he looked the very picture of health. He has not been dieted apart from being told to omit all heavy greasy food and spiced dishes, and he has had no complaint of abdominal discomfort. Department of Surgery, JOHN GRIEVE.
use
A primipara, aged acute appendicitis on
PERFORATED PEPTIC ULCER AFTER GASTRO-ENTEROSTOMY
case
now
segment csesarean section and for forceps deliveries, following case-report may be of interest.
ALTON OCHSNER.
perforation
FRANK MARSH.
Epping, Essex.
Even without curare, operation for appendicitis on pregnant women is said to be followed by abortion or premature labour in 40-80% of cases ; and in view of the great increase in uterine tone produced by curare it would seem inadvisable to use it in operations of this type. Scunthorpe, Mnos.
W. N. ROLLASON.
Trans. R. Soc. trop. Med. Hyg. 1930, 24, 277 ; 1. Marsh, F. 1933, 27, 259 ; Ibid, 1935, 29, 309. 2. Moss, K. M. Gases, Dust, and Heat in Mines. London, p. 190. 3. Morton, T. C. S. Proc. R. Soc. Med. 1932, 25, 1263.
Ibid, 1917;
reticulocytes rose to 172%, with a subsequent increase erythrocytes from an initial 2,400,000 per c.mm. to
HEAT CRAMPS
of
SiR,,-I was much interested in the article of Nov. 5 by Dr. Ladell, having myself made some relatively insignificant observations on the same subject1 when enjoying for that study-so far as environment goes(to quote Sir Charles Martin) unrivalled opportunities.
A second case c.mm. within two weeks. similar way. Department of Internal Medicine, KURT HAUSMANN.
3,200,000 per reacted in
a
St. Georg General
Hospital,
Hamburg.
Dr. Ladell remarks that heat cramps may occur when water is not drunk to excess or even when it is not drunk at all; this is true. It is also true that almost imperceptible changes in blood-chloride enable the balance in the affected muscle-fibres to be restored, after the administration of salt and water. Another fact is that the miners in Pendleton colliery put small amounts of cream of tartar (potassium bitartrate) in their drinking-water as a cramp preventive.2 A further curious experience is that of Morton,3 who administered 1-F/2 pints of 2% sodium bicarbonate to his cases, with rapid improvement. I do not think that cramps are a simple osmotic effect, as Dr. Ladell seems to imply ; nor do I consider that muscular exertion is an essential preliminary. A cold environment, I have observed, makes the pain of heat cramps temporarily worse, and cold is a potent cause of muscular cramps even in temperate climes. One of my patients was very worried in case the heat cramps, which occurred in muscle-fibres situated in parts of the body remote from each other, should spread to his heart. I tried to reassure him by saying that the heartmuscle had never been affected, so far as I knew. The " patient remarked : " I might be the first case !
ANTIBIOTICS AND COAGULATION
SiR,-I should like to correct the impression, which your annotation of Oct. 22 (p. 756) may have given, that
we
have done any work
on
the influence of anti-
biotics in thrombo-embolism. The presentation which I made before the International Surgical Society was based
analysis of 7 years’ experience at the Charity Hospital in New Orleans. We have been interested in thromboembolism for more than a decade and have felt that we were able to prevent most cases of venous thrombosis, and to prevent fatality in those cases in which it did occur by recognition of the phlebothrombosis and ligation of the vein proximal to the site of the thrombus. We were astounded, however, in our analysis to find that there has been a tremendous increase in the incidence of venous thrombosis and fatal pulmonary embolism in the Charity Hospital in spite of all the measures which we have undertaken to prevent them. The study showed that there was an increase in the average yearly incidence of thrombo-embolism from 66 to 124 during a period when the admissions increased only 20%. The number of fatal cases of pulmonary embolism in the last two years is approximately the same as in the previous five years, which represents an increase in the average yearly incidence from 20 to 52. This study demonstrates that thrombo-embolism has definitely increased. Though we have not yet been able to prove it, the suggestion was made that the increase in thrombo-embolism might be due to the almost routine administration of antibiotics to hospitalised patients ; at least, there is a parallelism between the two. Whether this is a factor or the sole factor cannot be said at the present time. on
School of Medicine, Tulane University of Louisiana, New Orleans.
CURARE AND PRECIPITATE LABOUR
SIR,-As anaesthetists
is somewhat similar to that described
<
by him.
Medical
School, Dundee.
curare
for upperthe
25, was admitted to hospital with Sept. 22, 1949. She was 38 weeks temperature was 100-8°F and pulse-rate
Her The abdomen was very tender, with 130 per min. localised guarding in the right iliac fossa. The chest was clear and the urine normal, and she had had no symptoms during her pregnancy. At 6.20 P.M. she was givenOmnopon ’ gr. l/s and scopolamine gr. 1/160 intravenously. At 6.25 P.M. anaesthesia, was induced with a mixture of 10 ml. of thiopentone (5%) and 15 mg. of d-tubocurarine chloride (Duncan & Flockhart). Since the patient had had a little food and a drink a short time before, a cuffed tube was inserted. Anaesthesia was maintained with 45% nitrous oxide, 10% cyclopropane, and 45% oxygen. The operation started at 6.35 P.M. An acutely inflamed appendix was removed. Before closing the peritoneum the surgeon was requested to feel the uterus, which he said was as hard as a bullet. The operation was completed at 7.5 r.M. On leaving the theatre the patient was almost conscious ; no neostigmine and atropine were necessary, and the fatal heart was easily audible and beating at 120 per min. The patient was quite comfortable in the ward until 9.30 r.M. when she requested a bedpan, which she did not use. At 9.45 P.M. she complained of sudden backache, and shortly afterwards labour pains became strong and frequent. At 10.20 P.M. a dead baby girl, weighing approximately 6 lb., was suddenly delivered. No postoperative drugs were given until 11.40 P.M., when the patient received heroin gr. 1/12.
pregnant.
SiR,-In his article of Oct. 8, Mr. Crowe observes that of a peptic ulcer shortly after gastroenterostomy appears to be uncommon. The following The patient, a man aged 32, was operated on by Mr. F. R. Brown on June 16, 1949, when a wedge resection of a lessercurvature uJcer was carried out. He made an uneventful recovery, and pathological examination of the ulcer confirmed that it was simple in nature. He was readmitted to hospital on July 31 with shortness of breath and the story of having had sudden severe upper abdominal pain that day. The pain had not eased, and when he was examined typical signs of perforated ulcer were found. His abdomen was rigid and there was a substantial amount of free fluid. At operation on the same day the presence of free fluid was confirmed, and a small acute perforated ulcer was found just to the pyloric side of the anastomosis where the wedge had been removed. The perforation was closed by a series of three stitches of catgut, and the abdomen was closed in layers. His wound healed satisfactorily and he was fit to leave hospital on Aug. 12. His general condition at that time was fairly poor ; although he was about 6 ft. tall, his weight was only 9 st. 7 lb. However, when seen again recently, his weight had increased to 12 st., and he looked the very picture of health. He has not been dieted apart from being told to omit all heavy greasy food and spiced dishes, and he has had no complaint of abdominal discomfort. Department of Surgery, JOHN GRIEVE.
use
A primipara, aged acute appendicitis on
PERFORATED PEPTIC ULCER AFTER GASTRO-ENTEROSTOMY
case
now
segment csesarean section and for forceps deliveries, following case-report may be of interest.
ALTON OCHSNER.
perforation
FRANK MARSH.
Epping, Essex.
Even without curare, operation for appendicitis on pregnant women is said to be followed by abortion or premature labour in 40-80% of cases ; and in view of the great increase in uterine tone produced by curare it would seem inadvisable to use it in operations of this type. Scunthorpe, Mnos.
W. N. ROLLASON.
Trans. R. Soc. trop. Med. Hyg. 1930, 24, 277 ; 1. Marsh, F. 1933, 27, 259 ; Ibid, 1935, 29, 309. 2. Moss, K. M. Gases, Dust, and Heat in Mines. London, p. 190. 3. Morton, T. C. S. Proc. R. Soc. Med. 1932, 25, 1263.
Ibid, 1917;