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DOUBLE-EXPOSURE RADIOGRAMS OF THE CHEST
628
negative pregnanediol results during early
H.T.
phases
confirms the results of Hamblen and others.4In a study of 58 women correlated with endometrial biopsies it was found that 43% of patients bleeding from progestational endometria excreted no pregnanediol, and 62 % of patients bleeding from opstrogenio endometria excreted pregnanediol in amounts equal to those found with progestational bleeding. That progestogen definitely raises the body temperature was first observed by
Fig. 3-Vaginal temperature in a hyperaestrogenic subject with amenorrhcea. Lutocyclin 60 mg. sublingually was given on days 20-25.
serum is approximately equivalent to 70 c.cm. of triple strength plasma in its protein concentration. It is therefore unreasonable to suppose that 20 c.cm. of triple strength plasma given half-hourly to a patient who has already presented . evidence of over-permeability of capillaries by developing pulmonary oedema, and who
is also suboxygenated and liable to further abnormal loss, will produce any very definite effect. In my own experience 400 c.cm. of triple strength plasma given over a period of 45-60 minutes was the minimum and usual dosage necessary in successful cases. The difficulty of deciding what method of treatment to apply in pulmonary oedema due to chest injuries (and other forms of trauma) is only equalled by the difficulty of assessing the value of the treatment adopted. In one case, venesection alone may produce a successful, outcome. In the next, the administration of concentrated plasma alone may be successful. In a third case, every means of clearing the airway (suction, coughing, posture, &c.), combined with oxygen administration, preliminary venesection, and subsequent administration of concentrated plasma may be required. In a fourth, all means will fail. And who is to say that the fourth case was not in reality a case of irrecoverable peripheral circulatory failure due to trauma in which the pulmonary oedema was merely a terminal event, rather than the cause of a terminal event ? I suggest that your readers should withhold their judgment on the value of concentrated plasma in pulmonary oedema until they have read the experiences of others and preferably until they have tried it themselves in suitable cases. GAVIN CLELAND. Glasgow. .
Martin,5 and
confirmed by my investi 9 ation3 of body-temperature changes when progestogen was given by the intramuscular or oral route (figs. 2 and 3). No more than two phases were observed in any of the 150 cycles, and the common postmenstrual temperature rise and -mid-luteal decrease seems to represent the normal variations during both phases, since the follicular curve never rises as high as the curve in the luteal phase. Cyclic changes in body temperature appear to be largely under hormonal control, and yield valuable diagnostic data not only in regard to ovulation but also in relation to various menstrual disorders. H. E. NIEBURGS. London, N.W.6. was
PULMONARY ŒDEMA IN CHEST WOUNDS SiR,-The results from the treatment of pulmonary oedema recounted by Harper and Tait in their article of April 13 are depressing indeed. I am stimulated to comment on their article because my own experience with the use of concentrated plasma in pulmonary oedema
(to be published)
was
far
more
encouraging.
In the case-record presented, Harper and Tait state that the patient admitted to their operating centre already showed evidence of pulmonary cedema. In Italy, it was observed occasionally that over-ambitious transfusion of chest cases at the field ambulance level resulted in a pulmonary cedema being present when the case reached the operating centre. No mention is made in the case-record of any transfusion before the patient reached their hands. This is most important, for it was well recognised that venesection aided the over-transfusion type of case in just the dramatic manner described in their patient. In their opening paragraph Harper and Tait point out that the ultimate effect of the pulmonary cedema is obstruction to the flow of air into the alveoli. In spite of this, no mention is made of a preliminary clearance of the trachea and larger bronchi by suction, a method which produces an immediate response though not a sustained one, and which is of immediate priority in treating pulmonary cedema due to trauma. Unless the mechanical obstruction to air-flow is relieved before oxygen administration is begun, it is unreasonable to suppose that concentrated plasma can have any valuable effect, for it cannot be expected to remove fluid from the smaller bronchi by its osmotic action. Turner6 indicated that 40 c.cm. of five-times concentrated serum produces a 5 % dilution of the blood (by osmosis) in 70 minutes when administered in 2-3 minutes. He was using the concentrated serum in cases of head injury where, presumably, capillary suboxygenation was not present to increase fluid loss into the interstitial tissues. This quantity of five-times concentrated 4. 5. 6.
Hamblen,
E. C., Cuyler, W. K., Baptist, M. Gynec. 1942, 44, 442. P. L. Ibid, 1943, 46, 453. Martin, Turner, J. W. A. Lancet, 1941, ii, 557.
Amer. J. Obstet.
DOUBLE-EXPOSURE RADIOGRAMS OF THE CHEST SiR,-Double-exposure X-ray films, the use of which in cases of asthma, emphysema, &c., was described by Dr. Maxwell in your issue of April 6, can also be used with advantage in pulmonary tuberculosis. I have found them of special value in the management of cases of artificial pneumothorax and also of artificial pneumoperitoneum and phrenic operations. The double-exposure film gives, so to speak, a permanent record of screening and so enables one to study and discuss it more thoroughly at one’s leisure. It is also of great value for demonstration purposes. It is a common experience for anyone treating pulmonary tuberculosis to wish to screen a patient who may be too ill to be moved to the X-ray department ; a doubleexposure film, which can be taken with the portable apparatus, is then of great assistance. I feel sure that when enough material is available for fuller study and analysis we shall be able to understand much more about the " behaviour " of the lung, and have a better insight into the management of the artificial pneumothorax, &c., through the introduction of doubleexposure raalOgrapny. H. C. MUKERJI, Senior Resident Medical Officer. Preston Hall, Maidstone.
EXPERIENCE IN THE FORCES SIR.-I wish to support Dr. L, Rich’s objections (April 13) to the present accepted axiom that all Service medical officers are professionally inferior creatures and are in urgent need of rehabilitation. " Rehabilitation " has long since passed from the medical to the political sphere, and now that docile Thomas Atkins is no longer available in sufficient numbers, we must needs seek material elsewhere. Since my own " rehabilitation," I have had contact with many ex-Service doctors, some of whom have been prisoners-of-war, while most have served in field units for five or six years. (I have helped to rehabilitate a colonel !) Some of the 1939 vintage went straight from their final examination into the Services. Others had six or twelve months of hospital experience before joining up, while others had been in practice or in one of the civil services for varying periods. I have talked to them in " refresher " courses and socially, and a few have been my house-surgeons. So subtle are the influences of repeated propaganda that they all believe that they are inferior beings. They are not. While it is true that they have missed the blotting-paper advertise-
negative pregnanediol results during early
H.T.
phases
confirms the results of Hamblen and others.4In a study of 58 women correlated with endometrial biopsies it was found that 43% of patients bleeding from progestational endometria excreted no pregnanediol, and 62 % of patients bleeding from opstrogenio endometria excreted pregnanediol in amounts equal to those found with progestational bleeding. That progestogen definitely raises the body temperature was first observed by
Fig. 3-Vaginal temperature in a hyperaestrogenic subject with amenorrhcea. Lutocyclin 60 mg. sublingually was given on days 20-25.
serum is approximately equivalent to 70 c.cm. of triple strength plasma in its protein concentration. It is therefore unreasonable to suppose that 20 c.cm. of triple strength plasma given half-hourly to a patient who has already presented . evidence of over-permeability of capillaries by developing pulmonary oedema, and who
is also suboxygenated and liable to further abnormal loss, will produce any very definite effect. In my own experience 400 c.cm. of triple strength plasma given over a period of 45-60 minutes was the minimum and usual dosage necessary in successful cases. The difficulty of deciding what method of treatment to apply in pulmonary oedema due to chest injuries (and other forms of trauma) is only equalled by the difficulty of assessing the value of the treatment adopted. In one case, venesection alone may produce a successful, outcome. In the next, the administration of concentrated plasma alone may be successful. In a third case, every means of clearing the airway (suction, coughing, posture, &c.), combined with oxygen administration, preliminary venesection, and subsequent administration of concentrated plasma may be required. In a fourth, all means will fail. And who is to say that the fourth case was not in reality a case of irrecoverable peripheral circulatory failure due to trauma in which the pulmonary oedema was merely a terminal event, rather than the cause of a terminal event ? I suggest that your readers should withhold their judgment on the value of concentrated plasma in pulmonary oedema until they have read the experiences of others and preferably until they have tried it themselves in suitable cases. GAVIN CLELAND. Glasgow. .
Martin,5 and
confirmed by my investi 9 ation3 of body-temperature changes when progestogen was given by the intramuscular or oral route (figs. 2 and 3). No more than two phases were observed in any of the 150 cycles, and the common postmenstrual temperature rise and -mid-luteal decrease seems to represent the normal variations during both phases, since the follicular curve never rises as high as the curve in the luteal phase. Cyclic changes in body temperature appear to be largely under hormonal control, and yield valuable diagnostic data not only in regard to ovulation but also in relation to various menstrual disorders. H. E. NIEBURGS. London, N.W.6. was
PULMONARY ŒDEMA IN CHEST WOUNDS SiR,-The results from the treatment of pulmonary oedema recounted by Harper and Tait in their article of April 13 are depressing indeed. I am stimulated to comment on their article because my own experience with the use of concentrated plasma in pulmonary oedema
(to be published)
was
far
more
encouraging.
In the case-record presented, Harper and Tait state that the patient admitted to their operating centre already showed evidence of pulmonary cedema. In Italy, it was observed occasionally that over-ambitious transfusion of chest cases at the field ambulance level resulted in a pulmonary cedema being present when the case reached the operating centre. No mention is made in the case-record of any transfusion before the patient reached their hands. This is most important, for it was well recognised that venesection aided the over-transfusion type of case in just the dramatic manner described in their patient. In their opening paragraph Harper and Tait point out that the ultimate effect of the pulmonary cedema is obstruction to the flow of air into the alveoli. In spite of this, no mention is made of a preliminary clearance of the trachea and larger bronchi by suction, a method which produces an immediate response though not a sustained one, and which is of immediate priority in treating pulmonary cedema due to trauma. Unless the mechanical obstruction to air-flow is relieved before oxygen administration is begun, it is unreasonable to suppose that concentrated plasma can have any valuable effect, for it cannot be expected to remove fluid from the smaller bronchi by its osmotic action. Turner6 indicated that 40 c.cm. of five-times concentrated serum produces a 5 % dilution of the blood (by osmosis) in 70 minutes when administered in 2-3 minutes. He was using the concentrated serum in cases of head injury where, presumably, capillary suboxygenation was not present to increase fluid loss into the interstitial tissues. This quantity of five-times concentrated 4. 5. 6.
Hamblen,
E. C., Cuyler, W. K., Baptist, M. Gynec. 1942, 44, 442. P. L. Ibid, 1943, 46, 453. Martin, Turner, J. W. A. Lancet, 1941, ii, 557.
Amer. J. Obstet.
DOUBLE-EXPOSURE RADIOGRAMS OF THE CHEST SiR,-Double-exposure X-ray films, the use of which in cases of asthma, emphysema, &c., was described by Dr. Maxwell in your issue of April 6, can also be used with advantage in pulmonary tuberculosis. I have found them of special value in the management of cases of artificial pneumothorax and also of artificial pneumoperitoneum and phrenic operations. The double-exposure film gives, so to speak, a permanent record of screening and so enables one to study and discuss it more thoroughly at one’s leisure. It is also of great value for demonstration purposes. It is a common experience for anyone treating pulmonary tuberculosis to wish to screen a patient who may be too ill to be moved to the X-ray department ; a doubleexposure film, which can be taken with the portable apparatus, is then of great assistance. I feel sure that when enough material is available for fuller study and analysis we shall be able to understand much more about the " behaviour " of the lung, and have a better insight into the management of the artificial pneumothorax, &c., through the introduction of doubleexposure raalOgrapny. H. C. MUKERJI, Senior Resident Medical Officer. Preston Hall, Maidstone.
EXPERIENCE IN THE FORCES SIR.-I wish to support Dr. L, Rich’s objections (April 13) to the present accepted axiom that all Service medical officers are professionally inferior creatures and are in urgent need of rehabilitation. " Rehabilitation " has long since passed from the medical to the political sphere, and now that docile Thomas Atkins is no longer available in sufficient numbers, we must needs seek material elsewhere. Since my own " rehabilitation," I have had contact with many ex-Service doctors, some of whom have been prisoners-of-war, while most have served in field units for five or six years. (I have helped to rehabilitate a colonel !) Some of the 1939 vintage went straight from their final examination into the Services. Others had six or twelve months of hospital experience before joining up, while others had been in practice or in one of the civil services for varying periods. I have talked to them in " refresher " courses and socially, and a few have been my house-surgeons. So subtle are the influences of repeated propaganda that they all believe that they are inferior beings. They are not. While it is true that they have missed the blotting-paper advertise-