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NUMBERING OF FINGERS
824 line after the
bleeding had stopped and the blood-volume approximately restored (at the time of the " failed " intra-arterial drip) he would have had a different response.
was
The relative merits of noradrenaline and intra-arterial transfusion deserve close investigation, and the indications for using one or the other are by no means clear. Dr. Murray and Dr. Bruce were confronted by so alarming a collapse in their patient that they chose noradrenaline as the most readily available means of restoring the blood-pressure. Their choice was vindicated by the response, although Dr. Danziger obtained a similar result with intra-arterial transfusion in equally desperate
circumstances.
--
in resuscitation seems to stand out prominently. As long as serious haemorrhage persists, the treatment is adequate blood replacement, with two drips if necessary. If, when bleeding is controlled and the bloodvolume adequately restored, the blood-pressure cannot be raised, the choice of intra-arterial transfusion or noradrenaline remains. More information on this subject is required.
One
point
against shock and the non-specific responses to aggression. There are, however, many points needing clarification. I would suggest for a start that hypothermia be omitted until we can assess the value of the drug itself under normal working conditions. Furthermore, there is a case against using ether, and possibly the more toxic general anaesthetic agents, in conjunction with chlorpromazine. ,
,
Lambeth Hospital, London, S.E.11.
SIR,-After reading the article by Dr. Murray and Dr. recounting their management of a case of postpartum haemorrhage, I wondered whether the possibility Bruce
of fibrinogenopenia had been considered. It seems a distinct possibility in a 5-gravida, who early in the resuscitation received 0-67 litre of dextran, and in whom lap-arotomy revealed a firmly retracted uterus. Burntisland,
Hospital, Edinburgh.
I. E. W. GILMOUR.
SiR,-There are several points in the article by Dr. Murray and Dr. Bruce which merit comment and discussion, but for the sake of brevity I would like to draw attention to two especially. The profound hypotension during the packing of the uterus and vagina under ether and oxygen anaesthesia does not appear to be due, as the authors suggest, to the shock engendered by this procedure, but rather to the cardiovascular depressant properties of ether in the presence of adrenergic blockade, in this instance brought about by intramuscular chlorpromazine and pethidine half
an
hour before the anaesthetic.
*
The experiments of Brewster and others1 have shown that a critical myocardial depression with resultant hypotension or cardiac arrest may result from the direct depressant effect of diethyl ether upon the myocardium of a patient in whom the reflex increase of epinephrine and nor-epinephrine from the adrenal medullae and sympathetic nerve endings is reduced or abolished. This danger is present under the following conditions : (a) pathological or surgical ablation of the adrenal medullae, or pathological hypofunction of the adrenal medullae as in bilateral adrenalectomy, Addison’s disease, Cushing’s syndrome, adrenogenital syndrome, etc., (b) surgical sym-
pathectomy
or
pharmacological sympathetic ganglionic
blockade, (c) otherwise subnormal or’exhaused’ sympatho-
(d) in the hypothyroid individual (e) during deep Pentothal anaesthesia." This is no reason why chlorpromazine should be an exception to this statement. adrenal response to stimuli, and
Dr. Murray and Dr. Bruce preface their discussion by indicating that I and several others advocate " this type of potentiated anaesthesia" (presumably hypothermia and intravenous chlorpromazine, promethazine, and pethidine) " as a means of allowing surgery on patients formerly considered unfit for operation." For my part, I would like to make it quite clear that I do not consider that hypothermia is either necessary or useful when these drugs are used. On the other hand, there is a danger of hyperthermia if these patients are
overheated, and for this reason it is advisable to work in cool theatres, and avoid artificial heating when the patient returns to the ward. I do not wish my remarks to be taken as adverse criticism of a bold and courageous attempt to deal with an admittedly desperate situation. The means at our disposal of preventing and treating severe shock are at present meagre, and the etiology of the condition becoming more and more confused, as Dr. Danziger’s discussion (Oct. 1) indicates. There is a growing amount of clinical and experimental evidence that chlorpromazine without hypothermia has valuable preventive properties W. R., jun., Isaacs, J. P., Wainø-Andersen, T. Amer. J. Physiol. 1953, 175 399.
1. Brewster,
T-
D D. E. B. POWELL.
Fife.
NUMBERING OF FINGERS
-
Leith
D. A. BUXTON HOPKIN.
SiR,—Will you please tell Dr. Forbes (Oct. 1) that while
(like many others) I have only eight fingers, I have ten digits on my hands. If we always used the correct term in describing these organs mistakes would be fewer. " " After all, even if the ordinary man says gasteritis, lumbar punch, penicillian, and flat feet, there is need for doctors to imitate them. It was not Alice but the Mad Hatter who said, " You might as well say I say what I mean ’ is the same thing as ’Imean what I say.’ " It is nearly everyone who says, My hair wants cutting " when they mean " My hair needs cutting." Nearly everyone says, "Can I have a piece of cake when they mean " May I have a piece of cake ? " It is not pedantic to be exact-it is scientific-and much simpler-and shorter-and certain.
casuality, no ’
"
W. SAYLE-CREER.
Manchester, 3.
POLIOMYELITIS AND TONSILLECTOMY
SIR,-Laryngologists will be very interested to read Dr. James Melvin’s letter last week, and members of the British Association of Otolaryngologists know that our council keep this problem under review and from time to time call our attention especially to relevant passages in official memoranda. My senior colleagues will remember that the oldfashioned operation of tonsillotomy with removal of adenoids brought relief to many children suffering from " lymphadenoid-tissue stenosis and also reduced the incidence of recurrent acute infections more readily attacking the enlarged palatine tonsil, though they could not approve of so uncertain a technique. I believe that this objection was one of the reasons why principal school medical officers were advised to call upon some of us in the early days after the first world war to assist them in our capacity as specialists, though at the same time providing us with the opportunity to persuade education authorities to establish rational E.N.T. clinics rather than departments for T. and A. operations. The problem of the physiology and clinical pathology of the lymphadenoid tissue of the pharynx continues to be of great importance to our specialty, and Dr. Melvin’s experience is most stimulating. For some time I have nursed a secret heresy that one day part removal of the enlarged and pedunculated palatine tonsil may return to favour, but in the form of deliberate selective tonsillotomy. I have very occasionally dared to perform such an operation, and I remember the loud cries of disapproval from a full house of the section of laryngology of the Royal Society of Medicine when, speaking from the rostrum, I confessed that for one of my own children I had done a deliberate selective tonsillotomy for which I had unearthed a discarded reversed Heath’s guillotine and sharpened it for the "
"
bleeding had stopped and the blood-volume approximately restored (at the time of the " failed " intra-arterial drip) he would have had a different response.
was
The relative merits of noradrenaline and intra-arterial transfusion deserve close investigation, and the indications for using one or the other are by no means clear. Dr. Murray and Dr. Bruce were confronted by so alarming a collapse in their patient that they chose noradrenaline as the most readily available means of restoring the blood-pressure. Their choice was vindicated by the response, although Dr. Danziger obtained a similar result with intra-arterial transfusion in equally desperate
circumstances.
--
in resuscitation seems to stand out prominently. As long as serious haemorrhage persists, the treatment is adequate blood replacement, with two drips if necessary. If, when bleeding is controlled and the bloodvolume adequately restored, the blood-pressure cannot be raised, the choice of intra-arterial transfusion or noradrenaline remains. More information on this subject is required.
One
point
against shock and the non-specific responses to aggression. There are, however, many points needing clarification. I would suggest for a start that hypothermia be omitted until we can assess the value of the drug itself under normal working conditions. Furthermore, there is a case against using ether, and possibly the more toxic general anaesthetic agents, in conjunction with chlorpromazine. ,
,
Lambeth Hospital, London, S.E.11.
SIR,-After reading the article by Dr. Murray and Dr. recounting their management of a case of postpartum haemorrhage, I wondered whether the possibility Bruce
of fibrinogenopenia had been considered. It seems a distinct possibility in a 5-gravida, who early in the resuscitation received 0-67 litre of dextran, and in whom lap-arotomy revealed a firmly retracted uterus. Burntisland,
Hospital, Edinburgh.
I. E. W. GILMOUR.
SiR,-There are several points in the article by Dr. Murray and Dr. Bruce which merit comment and discussion, but for the sake of brevity I would like to draw attention to two especially. The profound hypotension during the packing of the uterus and vagina under ether and oxygen anaesthesia does not appear to be due, as the authors suggest, to the shock engendered by this procedure, but rather to the cardiovascular depressant properties of ether in the presence of adrenergic blockade, in this instance brought about by intramuscular chlorpromazine and pethidine half
an
hour before the anaesthetic.
*
The experiments of Brewster and others1 have shown that a critical myocardial depression with resultant hypotension or cardiac arrest may result from the direct depressant effect of diethyl ether upon the myocardium of a patient in whom the reflex increase of epinephrine and nor-epinephrine from the adrenal medullae and sympathetic nerve endings is reduced or abolished. This danger is present under the following conditions : (a) pathological or surgical ablation of the adrenal medullae, or pathological hypofunction of the adrenal medullae as in bilateral adrenalectomy, Addison’s disease, Cushing’s syndrome, adrenogenital syndrome, etc., (b) surgical sym-
pathectomy
or
pharmacological sympathetic ganglionic
blockade, (c) otherwise subnormal or’exhaused’ sympatho-
(d) in the hypothyroid individual (e) during deep Pentothal anaesthesia." This is no reason why chlorpromazine should be an exception to this statement. adrenal response to stimuli, and
Dr. Murray and Dr. Bruce preface their discussion by indicating that I and several others advocate " this type of potentiated anaesthesia" (presumably hypothermia and intravenous chlorpromazine, promethazine, and pethidine) " as a means of allowing surgery on patients formerly considered unfit for operation." For my part, I would like to make it quite clear that I do not consider that hypothermia is either necessary or useful when these drugs are used. On the other hand, there is a danger of hyperthermia if these patients are
overheated, and for this reason it is advisable to work in cool theatres, and avoid artificial heating when the patient returns to the ward. I do not wish my remarks to be taken as adverse criticism of a bold and courageous attempt to deal with an admittedly desperate situation. The means at our disposal of preventing and treating severe shock are at present meagre, and the etiology of the condition becoming more and more confused, as Dr. Danziger’s discussion (Oct. 1) indicates. There is a growing amount of clinical and experimental evidence that chlorpromazine without hypothermia has valuable preventive properties W. R., jun., Isaacs, J. P., Wainø-Andersen, T. Amer. J. Physiol. 1953, 175 399.
1. Brewster,
T-
D D. E. B. POWELL.
Fife.
NUMBERING OF FINGERS
-
Leith
D. A. BUXTON HOPKIN.
SiR,—Will you please tell Dr. Forbes (Oct. 1) that while
(like many others) I have only eight fingers, I have ten digits on my hands. If we always used the correct term in describing these organs mistakes would be fewer. " " After all, even if the ordinary man says gasteritis, lumbar punch, penicillian, and flat feet, there is need for doctors to imitate them. It was not Alice but the Mad Hatter who said, " You might as well say I say what I mean ’ is the same thing as ’Imean what I say.’ " It is nearly everyone who says, My hair wants cutting " when they mean " My hair needs cutting." Nearly everyone says, "Can I have a piece of cake when they mean " May I have a piece of cake ? " It is not pedantic to be exact-it is scientific-and much simpler-and shorter-and certain.
casuality, no ’
"
W. SAYLE-CREER.
Manchester, 3.
POLIOMYELITIS AND TONSILLECTOMY
SIR,-Laryngologists will be very interested to read Dr. James Melvin’s letter last week, and members of the British Association of Otolaryngologists know that our council keep this problem under review and from time to time call our attention especially to relevant passages in official memoranda. My senior colleagues will remember that the oldfashioned operation of tonsillotomy with removal of adenoids brought relief to many children suffering from " lymphadenoid-tissue stenosis and also reduced the incidence of recurrent acute infections more readily attacking the enlarged palatine tonsil, though they could not approve of so uncertain a technique. I believe that this objection was one of the reasons why principal school medical officers were advised to call upon some of us in the early days after the first world war to assist them in our capacity as specialists, though at the same time providing us with the opportunity to persuade education authorities to establish rational E.N.T. clinics rather than departments for T. and A. operations. The problem of the physiology and clinical pathology of the lymphadenoid tissue of the pharynx continues to be of great importance to our specialty, and Dr. Melvin’s experience is most stimulating. For some time I have nursed a secret heresy that one day part removal of the enlarged and pedunculated palatine tonsil may return to favour, but in the form of deliberate selective tonsillotomy. I have very occasionally dared to perform such an operation, and I remember the loud cries of disapproval from a full house of the section of laryngology of the Royal Society of Medicine when, speaking from the rostrum, I confessed that for one of my own children I had done a deliberate selective tonsillotomy for which I had unearthed a discarded reversed Heath’s guillotine and sharpened it for the "
"