POLIOMYELITIS AND TONSILLECTOMY

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 "

"

825 occasion. The clinical result has been excellent; the very frequent acute attacks with fever ceased at once and the architectural result is most pleasing. For many years I have respected a theory of Torsten Skoogof Stockholm that the lymphadenoid tissue of the pharynx has a sensitising effect on the reticulo-endothelial system of the body. Dr. Melvin now postulates that these tissues may act " as a filter and buffer protecting over the 9th and 10th cranial-nerve offshoots in the area," presumably against the ascent to the central nervous system .of the virus of what used to be called more often " infantile paralysis." H. V. FORSTER. Liverpool, 1. THE

UNCONQUERED STAPHYLOCOCCUS

SiR,—Tour leading article last week gives many admirable suggestions for attacking this most tenacious of microbes. One point, however, seems to me to need

qualification. You suggest

that the use of typing methods will tell which strains " are actually dangerous." I do not think this is necessarily the case. Although there is some evidence to suggest that certain phage-types of staphylococci are associated with certain types of infection, coagulase-positive staphylococci of all phage-types can cause suppurative lesions and strains belonging to each of the three phage-groups have been isolated from fatal cases of septicoemia. It seems probable that all strains of coagulase-positive staphylococci become increasingly virulent by passage through infective processes, and recent studies suggest that virulence decreases when a strain is harboured in the anterior nares in a community devoid of sepsis. If this be true it is more important to know the source of a strain than its phage-type. It is, of course, true that a single strain of Staph. aureus may be responsible for most cases of infection occurring in a given ward or institution, in which case phage-typing studies may help to show how the infection is being spread. It would, however, be to assume that certain dangerous phage-types are invariably less virulent than others. us

Department of Bacteriology, Hospital Medical School, London, S.E.1.

St. Thomas’s

SIR,-Dr. Brenda Morrison

must be congratulated the effective oxygen concentrations that she has produced in the high-tension oxygen box described in her article last week. The graph in which performances of the experimental box and the standard oxygen tent are compared does nothing to upset the fallacy that to introduce a flow of 5 litres of oxygen per minute into a standard tent constitutes effective oxygen therapy. The reverse is usually the case. The patient who, outside a tent, might have received a reasonable oxygen supply by mask or catheter, is placed in an atmosphere of air when presumably his oxygen deprivation is at its highest, and the oxygen concentration is raised slowly at the rate of approximately 1% per minute. To flush fill a standard oxygen tent by increasing the main supply usually results in the blowing off of the rubber connections because the flow is limited at the Venturi jet. In my experience a double oxygen supply is the most effective method of achieving a satisfactory clinical result. In the case of patients requiring the maintenance of a previous high concentration such as is found during anaesthesia, the secondary supply is delivered to the patient inside the tent by means of an oxygen mask or catheter, and this is not removed until the tent oxygen concentration is deemed satisfactory. Alternatively, Acta

-

Plastic Surgery Centre, St. Lawrence Hospital, Chepstow, Mon.

Otolaryng., Stockh. 1936, 23, fasc. 1.

HARRY MIDDLETON.

ADRENALINE OVERDOSAGE

SIR,-I should like

to comment on two of the recommendations made by Dr. Freeman (Sept. 17). He very reasonably suggests that piperoxan or phentolamine should be kept at hand for the treatment of adrenaline overdosage. He might also have mentioned that when it is used systemically, adrenaline should be injected into one of the limbs, so that a tourniquet can be applied above the site of injection if necessary. Even if no adrenaline antagonist is available, the intermittent release of the tourniquet for a few seconds, at 5-10 minute intervals, would probably enable the patient to inactivate an otherwise lethal dose of adrenaline. I must disagree with Dr. Freeman when he wants to restrict the use of adrenaline for inhalations to solutions containing 0.4% or less. Many patients derive no benefit from such solutions, and more powerful inhalants are often needed. There is, however, a good case for substituting isoprenaline for adrenaline in all inhalants ; it is at least as effective, and is much less likely to be

injected. Department of Therapeutics, St. Thomas’s Hospital Medical School, London, S.E.1.

ANDREW HERXHEIMER.

VESICO-CŒLOMIC DRAINAGE

SIR,-Mr. Desmond Mulvany’s vesico-coeloniic operation for relief of ascites would appear to be an ingenious procedure of undoubted value when a diagnostic laparotomy is being performed. However, where surgical proof is not

required, it may be questioned operation is justifiable when the span so

on

Skoog, T.

’

whether a major of life is usually

short.

large cost, having so short a lease thy fading mansion spend. Experience of a recent case prompts me to suggest Why

MARY BARBER.

ANOXIA IN RESPIRATORY INFECTIONS OF CHILDHOOD

1.

the secondary supply is flushed into the tent by a tube inserted through one of the service flaps or through one of the cooling ports. It needs to be impressed upon the nurses that this routine must be repeated each time that the tent is opened widely for nursing attention.

so

Dost thou upon

simple procedure which is likely to be of more general application and which should make repeated paracenteses unnecessary. a

very

of 50, in whom a diagnosis of carcinomatosis made on clinical grounds, the presumptive evidence was sufficient to obviate a diagnostic laparotomy. She had been tapped three times at increasingly frequent intervals until 8 pints of fluid (containing 2-5 g. per 100 ml. of protein) had to be removed after an interval of five days. I then introduced a size-onePolythene’ tube through the paracentesis cannula into the abdominal cavity, and removed the cannula, leaving the tube in position, with a small glass olive-shape-ended rod as a spigot. Inexperience in the first instance led me to pierce the tube with a holding safetypin, but this was a mistake and ascitic fluid leaked round the pinholes. After re-introducing another length of tubing, no further snags were encountered ; the tube never became blocked (a little manipulation was sometimes necessary), there was no sepsis, hardly any skin reaction, no pain or discomfort, and positively no leakage round the wound. The patient remained completely comfortable with a daily drainage of one to two pints of fluid until her death seven weeks later. Her gratitude at not being subjected to the frequent ordeals of paracentesis-followed as they were by a day of complete exhaustion and then a crescendo of distension, discomfort, and anticipation until the next tappingwas a consoling factor in the conduct of her illness. Nor, with the simple daily manipulation of removing a spigot, was it difficult to disguise deterioration from her, so that she died in some comfort and contentment. In

a woman

peritonei

was

London, W.1.

S. CHARLES LEWSEN.