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HYPERTENSIVE RESPONSE TO INJURY
1247 I am grateful to Dr. G. C. Paine, in whose laboratory at the Jessop Hospital for Women, Sheffield, these numerous endocrine assays were made by Mr. L. F. Mitchell, PH.D., and
early transfusion, which is not contra-indicated by a raised blood-pressure. There remains the problem of the nature of the hypertensive response itself. I have the impression that it is not necessarily either " compensatory or clinically desirable. I am not certain that " over-compensation explains anything at all. There is a considerable body of evidence that the over-all nature of the circulatory response to injury cannot be explained solely in terms of blood-volume changes. The nature of the injury and its treatment are relevant. Further elucidation of the mechanisms involved requires consideration of various
Mr. i4I. J. Level, B.SC., for permission to publish them. Dr. J. F. Scott, after the manner of good house-physicians, drew my attention to the gynecomastia.
XERORADIOGRAPHY SiR,-Both you and Dr. Allchin (Dec. 3) appear to be very unfortunate in the radiographs you see. In charge of a busy department, I see many radiographs, and the adequate visualisation of bone and soft-tissue structures The seems to me commonplace and essential practice. that we procedures pursue interesting special suggestion " while failing in the efficient performance of everyday radiography needs to be refuted. The significance of the illumination and viewing conditions in relation to the subjective contrast and definition of the image does not appear to be fully appreciated by those outside X-ray departments. Often in clinics and wards one sees a good-quality film showing to poor advantage against an illuminator in which 20% of the bulbs are not functioning, while the remaining 80% are in combat with direct sunlight. Or, worse still, the image is sketchily surveyed with the help of the nearest window; Dr. Allchin’s reference to the necessity for correct exposures and processing needs to be extended to include the optimum viewing conditions.
MURIEL O. CHESNEY.
HYPERTENSIVE RESPONSE TO INJURY
SiR,--In your annotation of Nov.
12 you draw attention clinical feature of many patients with moderate and even severe injuries. Under civilian conditions, and particularly when patients are seen early and transfusion is started promptly, a hypertensive response to trauma is less uncommon than is suggested by the experience of Grant and Reeved During the past few years we have been studying clinical patterns of response to injury in association with determinations of blood-volume. A phase of hypertension has occurred in nearly 50% of 80 patients investigated. In some of these the increase in blood-pressure is transient and the pressure falls to normal with anesthesia. These patients are similar in many respects to those described by Prentice et a1.2 from Korea. They have relatively minor injuries and small blood-loss, and clinical evidence suggests that the high blood-pressure may be determined by painful stimuli or psychogenic influences. In many of our patients with hypertension, however, blood-loss has been greater than 30% ; and in these hypertension has not always responded to anaesthesia, nor has it necessarily indicated a good prognosis. Increasingly we have become convinced that within the first two hours after injury there is little correlation between the blood-pressure and the degree of oligaemia. Transfusion needs can be assessed more adequately from the extent of injury than from the pattern of response, except when this consists in an extreme fall in blood-pressure associated with pallor, cold extremities, and a rapid pulse. Commonly such patients have already lost half their blood-volume. I agree with your statement that " hypertensive response should be viewed against the background of the severity of the injury and should give rise to a cautious attitude and repeated observation." It is not, however, just a question of watching such patients for a later fall in blood-pressure. Such collapse can often be anticipated and prevented by adequate and
to
an
"
DOUGLAS HUBBLE.
Derby.
Birmingham, 32.
"
important
1. Grant, R. T., Reeve, E. B. Spec. Rep. Ser. med. Res. Coun., Lond. 1951, no. 277. 2. Prentice, T. C., Olney, J. M. jun., Artz, C. P., Howard, J. M. Surg. Gynec. Obstet, 1954, 99, 542.
neurogenic components affecting circulatory patterns. These can be evaluated only against a background of quantitative knowledge of blood-loss and the adequacy of its replacement.3
RUSCOE CLARKE.
Birmingham Accident Hospital.
MODIFIED ELECTROCONVULSION THERAPY .
SIR,-We cannot agree with Dr. Kelleher and Dr.
Whiteley (Dec. 3) that any the ’Ectonus ’ technique of
undue
cyanosis
occurs
with
E.C.T.
One of the desirable features of this technique is that respiration is stimulated and the period of apncea is shortened.In practice we find that cyanosis is rare and is always much less than in straight E.c.T. The extended tonus stage produced with ectonus is no longer than the clonic phase with straight E.C.T. The Valsalva phenomenon may possibly occur, but in our experience it has.
produced any ill effects. Regarding the fatality and fracture rates with ectonus, wefind a great improvement compared with other methods. We have given over 5000 ectonus treatments (over 1000 cases} in the past eighteen months. There has been 1 death and 1 fracture. The fatality was an exceptional case in that thepatient had had a lobectomy twelve days before E.c.T. and at this treatment spontaneous pneumothorax developed on the unaffected side,. The fracture was an impacted neck of humerus in a woman aged 69. Radiography showed marked rarifaction
not
of the bones. Many of our cases have been " poor risks," including 2 with recent coronary thrombosis, but we have felt confident to treat them because we believe that ectonus offers a higher degree of safety than other methods. ,
We feel that the use of muscle relaxants, with or without anaesthesia, should be reserved for the few cases where these are definitely indicated.- Thus the majority of patients are relieved of the undeniable anxietyassociated with premedication and injections. R. J. RUSSELL L. G. M. PAGE T. M. MOYLETT R. L. JILLETT Three Counties Hospital, A. BUCKLEY. Beds. Arlesey, ’
STAFFING LABORATORIES
SiR,—Wewish to express our consternation at the proposed grading and salary-scales for medical laboratory technologists which have just been published in draft form.4 Far from raising the status of the technologist, we fear that the proposed arrangement will have the opposite effect. Meagre salary increases are proposed, and the career value of the profession is threatened by the ridiculous insistence on relating grading either to the number of technical staff employed or to a very vague definition of what constitutes a division of a laboratory. This unfair method of grading really takes no account of work done or of responsibility, nor of the fact that the senior technologist does most of the work of training
juniors. If the
management
attitude, they will in
a
side persists in its unrealistic few years have very few tech-
R., Flear, C. T. G., Topley, E. Lancet, 1955, i, 629. of the Institute of Medical Laboratory Technology November, 1955.
3. Clarke, 4. Gazette
early transfusion, which is not contra-indicated by a raised blood-pressure. There remains the problem of the nature of the hypertensive response itself. I have the impression that it is not necessarily either " compensatory or clinically desirable. I am not certain that " over-compensation explains anything at all. There is a considerable body of evidence that the over-all nature of the circulatory response to injury cannot be explained solely in terms of blood-volume changes. The nature of the injury and its treatment are relevant. Further elucidation of the mechanisms involved requires consideration of various
Mr. i4I. J. Level, B.SC., for permission to publish them. Dr. J. F. Scott, after the manner of good house-physicians, drew my attention to the gynecomastia.
XERORADIOGRAPHY SiR,-Both you and Dr. Allchin (Dec. 3) appear to be very unfortunate in the radiographs you see. In charge of a busy department, I see many radiographs, and the adequate visualisation of bone and soft-tissue structures The seems to me commonplace and essential practice. that we procedures pursue interesting special suggestion " while failing in the efficient performance of everyday radiography needs to be refuted. The significance of the illumination and viewing conditions in relation to the subjective contrast and definition of the image does not appear to be fully appreciated by those outside X-ray departments. Often in clinics and wards one sees a good-quality film showing to poor advantage against an illuminator in which 20% of the bulbs are not functioning, while the remaining 80% are in combat with direct sunlight. Or, worse still, the image is sketchily surveyed with the help of the nearest window; Dr. Allchin’s reference to the necessity for correct exposures and processing needs to be extended to include the optimum viewing conditions.
MURIEL O. CHESNEY.
HYPERTENSIVE RESPONSE TO INJURY
SiR,--In your annotation of Nov.
12 you draw attention clinical feature of many patients with moderate and even severe injuries. Under civilian conditions, and particularly when patients are seen early and transfusion is started promptly, a hypertensive response to trauma is less uncommon than is suggested by the experience of Grant and Reeved During the past few years we have been studying clinical patterns of response to injury in association with determinations of blood-volume. A phase of hypertension has occurred in nearly 50% of 80 patients investigated. In some of these the increase in blood-pressure is transient and the pressure falls to normal with anesthesia. These patients are similar in many respects to those described by Prentice et a1.2 from Korea. They have relatively minor injuries and small blood-loss, and clinical evidence suggests that the high blood-pressure may be determined by painful stimuli or psychogenic influences. In many of our patients with hypertension, however, blood-loss has been greater than 30% ; and in these hypertension has not always responded to anaesthesia, nor has it necessarily indicated a good prognosis. Increasingly we have become convinced that within the first two hours after injury there is little correlation between the blood-pressure and the degree of oligaemia. Transfusion needs can be assessed more adequately from the extent of injury than from the pattern of response, except when this consists in an extreme fall in blood-pressure associated with pallor, cold extremities, and a rapid pulse. Commonly such patients have already lost half their blood-volume. I agree with your statement that " hypertensive response should be viewed against the background of the severity of the injury and should give rise to a cautious attitude and repeated observation." It is not, however, just a question of watching such patients for a later fall in blood-pressure. Such collapse can often be anticipated and prevented by adequate and
to
an
"
DOUGLAS HUBBLE.
Derby.
Birmingham, 32.
"
important
1. Grant, R. T., Reeve, E. B. Spec. Rep. Ser. med. Res. Coun., Lond. 1951, no. 277. 2. Prentice, T. C., Olney, J. M. jun., Artz, C. P., Howard, J. M. Surg. Gynec. Obstet, 1954, 99, 542.
neurogenic components affecting circulatory patterns. These can be evaluated only against a background of quantitative knowledge of blood-loss and the adequacy of its replacement.3
RUSCOE CLARKE.
Birmingham Accident Hospital.
MODIFIED ELECTROCONVULSION THERAPY .
SIR,-We cannot agree with Dr. Kelleher and Dr.
Whiteley (Dec. 3) that any the ’Ectonus ’ technique of
undue
cyanosis
occurs
with
E.C.T.
One of the desirable features of this technique is that respiration is stimulated and the period of apncea is shortened.In practice we find that cyanosis is rare and is always much less than in straight E.c.T. The extended tonus stage produced with ectonus is no longer than the clonic phase with straight E.C.T. The Valsalva phenomenon may possibly occur, but in our experience it has.
produced any ill effects. Regarding the fatality and fracture rates with ectonus, wefind a great improvement compared with other methods. We have given over 5000 ectonus treatments (over 1000 cases} in the past eighteen months. There has been 1 death and 1 fracture. The fatality was an exceptional case in that thepatient had had a lobectomy twelve days before E.c.T. and at this treatment spontaneous pneumothorax developed on the unaffected side,. The fracture was an impacted neck of humerus in a woman aged 69. Radiography showed marked rarifaction
not
of the bones. Many of our cases have been " poor risks," including 2 with recent coronary thrombosis, but we have felt confident to treat them because we believe that ectonus offers a higher degree of safety than other methods. ,
We feel that the use of muscle relaxants, with or without anaesthesia, should be reserved for the few cases where these are definitely indicated.- Thus the majority of patients are relieved of the undeniable anxietyassociated with premedication and injections. R. J. RUSSELL L. G. M. PAGE T. M. MOYLETT R. L. JILLETT Three Counties Hospital, A. BUCKLEY. Beds. Arlesey, ’
STAFFING LABORATORIES
SiR,—Wewish to express our consternation at the proposed grading and salary-scales for medical laboratory technologists which have just been published in draft form.4 Far from raising the status of the technologist, we fear that the proposed arrangement will have the opposite effect. Meagre salary increases are proposed, and the career value of the profession is threatened by the ridiculous insistence on relating grading either to the number of technical staff employed or to a very vague definition of what constitutes a division of a laboratory. This unfair method of grading really takes no account of work done or of responsibility, nor of the fact that the senior technologist does most of the work of training
juniors. If the
management
attitude, they will in
a
side persists in its unrealistic few years have very few tech-
R., Flear, C. T. G., Topley, E. Lancet, 1955, i, 629. of the Institute of Medical Laboratory Technology November, 1955.
3. Clarke, 4. Gazette