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INTRAGLOSSAL INJECTIONS : A COMPLICATION
324 to 6’5 mEq, and it remained lower than the pre-transfusion level for three days (see figure). Profuse diuresis began on the eleventh day of anuria, and after energetic electrolyte replacement the patient made an excellent recovery.
fallen
Why exchange transfusion should be successful when simple transfusion is not, I am unable to suggest, but I regard as significant this fall of 0-9 mEq. per litre in the serum-potassium, and the long-continued effect of the transfusion in the presence of absolute anuria. Such encouraging results are definitely worthy of further investigation. The cells should be thoroughly packed by slow centrifugation. The ideal material to use would be washed cells, where the plasma with its high potassium content has been completely removed. Edgware General Hospital, Edgware,
P. D. HUGHES.
Middlesex.
INTRAGLOSSAL
INJECTIONS :
A COMPLICATION
SIR,-Dr. Bullough’s short paper (Jan. 11) suggested what appeared to be a useful route for injections when all the usual veins are inaccessible. that he has used it for five Encouraged I ventured to inject, as he suggests, without mishap, years 100 mg. of suxamethonium into the tongue of a patient undergoing myomectomy. The desired effect appeared in one to two minutes, and provided good relaxation during abdominal closure. Three days later, the patient complained of pain and swelling of the tongue. This lasted for several days, and was accompanied by swollen, tender glands round the angle of the jaw on the left side and by some earache. There was no pyrexia, but the pain and swelling subsided gradually under treatment with penicillin and Deguadin ’ lozenges. At its worst, there was considerable oedema of the left side of the tongue, and the patient could not " put it out " between the teeth. She was able to take only a liquid diet, and said she suffered more discomfort from the tongue than from her operation.
by his
statement
It is difficult to be certain as to the cause of the swelling in this case. Suxamethonium has been used intramuscularly on too many cases for a local reaction to seem likely. The tongue is so vascular that a localised infection seemed at first unlikely, and the syringe and needle were from the usual sterile tray and the injected solution came from a freshly opened ampoule. Whatever the cause or the rarity of such a reaction following intraglossal injection, there is no doubt that it causes far more discomfort and distress to the patient than the painful sequelae of, say, intramuscular injections. The use of an irritant solution, even in an emergency, by intraglossal injection would seem dangerous, since the resulting oedema might well obstruct respiration in the pharynx. I personally feel disinclined to repeat the procedure with any solution. Altrincham, Cheshire.
FRANK L. ROBERTSHAW.
COAGULABILITY OF THE BLOOD IN ISCHÆMIC HEART-DISEASE
interested to read of the experiments of Dr. McDonald and Dr. Edgillbecause of our somewhat similar work.
SiR,—We
were
We observed acceleration of coagulation in thrombophlebitis, hypertension, arteriosclerosis, and old myocardial infarction. In these cases shortening of coagulation-time, Rosenthal’s heparin clotting-time, and antithrombin-time, and acceleration
of retraction
were
observed.2-4 In the
thromboplastin-genera-
1. McDonald, L., Edgill, M. Lancet, 1957, ii, 457. 2. Ulutin, O. N. Yeni Klinik Ilmi, 1955, 1, 322. 3. Ulutin, O. N. A Study of the Formation of Thromboplastin in Hæmorrhagic Disorders; p. 92. Istanbul, 1957. 4. Ulutin, O. N., Sestakof, D. Bull. Soc. turq. Méd. 1957, 23, 689.
EFFECT OF HEPARIN ON FORMATION OF THROMBOPLASTIN
*
Both with ischemic heart-disease.
tion test higher thromboplastin curves than the normal were obtained. In such cases we examined closely the result of the " heparin loading test". 100 mg. heparin was given intravenously; 15, 30, 60, 90, 120, 180, and 240 minutes later venous blood was obtained for the thromboplastin-generation test of Biggs and Douglas. We found that the maximal antithromboplastic effect of heparin in normal persons continued for 120-180 minutes, and then a subnormal curve was obtained. Using this method, different results were seen in Buerger’s disease, thrombophlebitis, ischoemic heart-disease, and essential hypertension. In some cases the antithromboplastic effect of heparin continued only 15-30 mins., and at 60 mins. 100-
130% thromboplastin
was
produced.
In other cases, even 15 mins. later the effect of heparin was not seen (see table).
The experiments show that heparin consumed or quickly neutralised. Second Internal Clinic of Istanbul University, Guraba Hospital, Istanbul, Turkey.
antithromboplastic was
either
rapidly
ORHAN N. ULUTIN D. SESTAKOF.
TREATMENT OF BREAST CANCER
SiR,—Your leading article last week deals once more with the radical-mastectomy v. local-mastectomy-andirradiation controversy in terms of alternatives and fiveyear survival-rates. It had seemed to me that we had progressed beyond this point. McWhirter performed a considerable service in challenging an oversimplified reliance on radical mastectomy as the one hope of cure for patients with carcinoma of the breast but offered in return at least as rigid a treatment scheme. It is almost certain that he supplied better radiotherapy together with less dissemination due to restriction of the surgery attempted in the more advanced cases, showing a gain on balance but a loss whenever radical mastectomy remained the best treatment. There has been a concerted attempt to throw doubt on McWhirter’s results, which are far better presented than those of most of his critics-notably than those of the " strong challenge " you quote from the Mayo Clinic. His recording and reporting are models which most would do well to follow; it is his conclusions and the practice they have led to which we I hold that no-one who has are all entitled to debate. made a careful and unbiased study of the course of breast cancer should any longer believe that one simple treatment plan, applied rigidly by clinical stage of advancement alone, represents the best that can be done today for their breast-tumour patients. You refer to the improvement in five-year survival-rates with time. In 19521 you published a lecture of mine showing that this had been occurring all over the world for many years irrespective of combination of treatment method employed. I listed several factors other than treatment which might be responsible for this and added a plea for individual selection of treatment to suit individual people and circumstances, based on our considerable knowledge of the chances of success. Much has appeared to support this view since then and to help us to better individual choice. The over-riding importance to prognosis of tumour grade2 has been even more securely 1. 2.
Smithers, D. W. Lancet, 1952, ii, 495. Bloom, H. J. G., Richardson, W. L. Brit. J. Cancer, 1957, 11,
359.
fallen
Why exchange transfusion should be successful when simple transfusion is not, I am unable to suggest, but I regard as significant this fall of 0-9 mEq. per litre in the serum-potassium, and the long-continued effect of the transfusion in the presence of absolute anuria. Such encouraging results are definitely worthy of further investigation. The cells should be thoroughly packed by slow centrifugation. The ideal material to use would be washed cells, where the plasma with its high potassium content has been completely removed. Edgware General Hospital, Edgware,
P. D. HUGHES.
Middlesex.
INTRAGLOSSAL
INJECTIONS :
A COMPLICATION
SIR,-Dr. Bullough’s short paper (Jan. 11) suggested what appeared to be a useful route for injections when all the usual veins are inaccessible. that he has used it for five Encouraged I ventured to inject, as he suggests, without mishap, years 100 mg. of suxamethonium into the tongue of a patient undergoing myomectomy. The desired effect appeared in one to two minutes, and provided good relaxation during abdominal closure. Three days later, the patient complained of pain and swelling of the tongue. This lasted for several days, and was accompanied by swollen, tender glands round the angle of the jaw on the left side and by some earache. There was no pyrexia, but the pain and swelling subsided gradually under treatment with penicillin and Deguadin ’ lozenges. At its worst, there was considerable oedema of the left side of the tongue, and the patient could not " put it out " between the teeth. She was able to take only a liquid diet, and said she suffered more discomfort from the tongue than from her operation.
by his
statement
It is difficult to be certain as to the cause of the swelling in this case. Suxamethonium has been used intramuscularly on too many cases for a local reaction to seem likely. The tongue is so vascular that a localised infection seemed at first unlikely, and the syringe and needle were from the usual sterile tray and the injected solution came from a freshly opened ampoule. Whatever the cause or the rarity of such a reaction following intraglossal injection, there is no doubt that it causes far more discomfort and distress to the patient than the painful sequelae of, say, intramuscular injections. The use of an irritant solution, even in an emergency, by intraglossal injection would seem dangerous, since the resulting oedema might well obstruct respiration in the pharynx. I personally feel disinclined to repeat the procedure with any solution. Altrincham, Cheshire.
FRANK L. ROBERTSHAW.
COAGULABILITY OF THE BLOOD IN ISCHÆMIC HEART-DISEASE
interested to read of the experiments of Dr. McDonald and Dr. Edgillbecause of our somewhat similar work.
SiR,—We
were
We observed acceleration of coagulation in thrombophlebitis, hypertension, arteriosclerosis, and old myocardial infarction. In these cases shortening of coagulation-time, Rosenthal’s heparin clotting-time, and antithrombin-time, and acceleration
of retraction
were
observed.2-4 In the
thromboplastin-genera-
1. McDonald, L., Edgill, M. Lancet, 1957, ii, 457. 2. Ulutin, O. N. Yeni Klinik Ilmi, 1955, 1, 322. 3. Ulutin, O. N. A Study of the Formation of Thromboplastin in Hæmorrhagic Disorders; p. 92. Istanbul, 1957. 4. Ulutin, O. N., Sestakof, D. Bull. Soc. turq. Méd. 1957, 23, 689.
EFFECT OF HEPARIN ON FORMATION OF THROMBOPLASTIN
*
Both with ischemic heart-disease.
tion test higher thromboplastin curves than the normal were obtained. In such cases we examined closely the result of the " heparin loading test". 100 mg. heparin was given intravenously; 15, 30, 60, 90, 120, 180, and 240 minutes later venous blood was obtained for the thromboplastin-generation test of Biggs and Douglas. We found that the maximal antithromboplastic effect of heparin in normal persons continued for 120-180 minutes, and then a subnormal curve was obtained. Using this method, different results were seen in Buerger’s disease, thrombophlebitis, ischoemic heart-disease, and essential hypertension. In some cases the antithromboplastic effect of heparin continued only 15-30 mins., and at 60 mins. 100-
130% thromboplastin
was
produced.
In other cases, even 15 mins. later the effect of heparin was not seen (see table).
The experiments show that heparin consumed or quickly neutralised. Second Internal Clinic of Istanbul University, Guraba Hospital, Istanbul, Turkey.
antithromboplastic was
either
rapidly
ORHAN N. ULUTIN D. SESTAKOF.
TREATMENT OF BREAST CANCER
SiR,—Your leading article last week deals once more with the radical-mastectomy v. local-mastectomy-andirradiation controversy in terms of alternatives and fiveyear survival-rates. It had seemed to me that we had progressed beyond this point. McWhirter performed a considerable service in challenging an oversimplified reliance on radical mastectomy as the one hope of cure for patients with carcinoma of the breast but offered in return at least as rigid a treatment scheme. It is almost certain that he supplied better radiotherapy together with less dissemination due to restriction of the surgery attempted in the more advanced cases, showing a gain on balance but a loss whenever radical mastectomy remained the best treatment. There has been a concerted attempt to throw doubt on McWhirter’s results, which are far better presented than those of most of his critics-notably than those of the " strong challenge " you quote from the Mayo Clinic. His recording and reporting are models which most would do well to follow; it is his conclusions and the practice they have led to which we I hold that no-one who has are all entitled to debate. made a careful and unbiased study of the course of breast cancer should any longer believe that one simple treatment plan, applied rigidly by clinical stage of advancement alone, represents the best that can be done today for their breast-tumour patients. You refer to the improvement in five-year survival-rates with time. In 19521 you published a lecture of mine showing that this had been occurring all over the world for many years irrespective of combination of treatment method employed. I listed several factors other than treatment which might be responsible for this and added a plea for individual selection of treatment to suit individual people and circumstances, based on our considerable knowledge of the chances of success. Much has appeared to support this view since then and to help us to better individual choice. The over-riding importance to prognosis of tumour grade2 has been even more securely 1. 2.
Smithers, D. W. Lancet, 1952, ii, 495. Bloom, H. J. G., Richardson, W. L. Brit. J. Cancer, 1957, 11,
359.