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PREVENTION OF THROMBOSIS IN THE CALF
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Stengel wondered whether this was due to these drugs being more readily procured since the inauguration of the National Health Service. If this were so, many who had attempted suicide owed their lives to the N.H.S., for sedatives were a relatively inefficient method of suicide. In his experience, the genuine suicide usually succeeded at the first attempt. Of the 138 patients in his series, only 1 subsequently committed suicide. Most (100) were sent to mental hospitals ; 27 were discharged to their homes ; and the remaining 11 either died or were transferred to general hospitals. In the four years since their admission to the observation unit, 24 men and 10 women had died from natural causes ; 6 men and 4 women had remained in mental hospitals ; and 1 man and 6 women were still in mental hospitals after readmission there. The most striking feature about these patients was their relative isolation in the com. munity ; 22% of them were living alone, compared with 6% in the general population. Only 9% were motivated by awareness of physical illness. About half of them were vaguely aware that to commit suicide was against the law, but these said that at the time this factor carried no weight with them. Only 43 of them were brought to the notice of the police, who brought 12 to the observation unit ; none was charged. The importance of the patient’s isolation was confirmed by Dr. P. Sainsbury from his study of 400 successful suicides. Dr. T. C. N. Gibbens said that the tendency for the police to take proceedings fluctuated somewhat with the number of attempted suicides. Nowadays only about 0-5% were sent to prison, and the maximum sentence was six months. Since the late war, about halfof the cases brought to court were dealt with by probation. He cited with approval an opinion voiced at a meeting of the Howard League by Prof. Glanville Williams, that these cases should be brought before the court as adults in need of care and protection, just as-children could be brought before a juvenile court for that purpose. As Dr. Clifford Scott pointed out, suicide, attempted suicide, and violence towards others are all different manifestations of hate and aggression. The patient’s attempt at suicide is often aimed at dominating, alarming, or spiting his family or society at large ; but the element of guilt and self-reproach about this may well account for some of the successful attempts. Dr. Stengel described attempted suicide as Janus-like, in that it faces towards death and destruction on the one side, and towards life and renewal of human contacts on the other. Possibly this is another way of saying that these patients are in a highly ambivalent position between their impulses of hate and of love. o
PREVENTION OF THROMBOSIS IN THE CALF " SILFNT " clotting in the deep veins of the legs, the recognised precursor of pulmonary embolism in immobilised patients, is often difficult to detect, and its prevention is therefore doubly important. Of the many factors predisposing to insidious phlebothrombosis stasis of- blood in the veins seems the most significant. In active exercise, both the squeezing effect of muscular contraction and the suction resulting from deep breathing aid the return of venous blood to the chest ; and it may derive a further impetus from the vigorous arterial pulse and the pull of the contracting right auricle. When the venous valves are incompetent or there are varicose dilatations of the deep calf veins, which are fairly common in older people, an efficient blood-flow from the legs is even more dependent on exercise, and sudden confinement to bed may be disastrous. Fractures and other severe injuries in the legs are a recognised cause of deep venous thrombosis and pulmonary embolism. But Crane"has lately drawn attention 1. Crane, C. New Engl. J. Med. 1952, 246, 529.
a paradoxical thrombosis after minor injuries or simple He describes four cases of calf muscular strain. thrombosis in students aged 19-24 after an exercise. tolerance test in which they stepped up on a platform 18 inches high and down again every 4 seconds for 5 minutes. The clinical picture was almost identical in each casea dull aching in one calf beginning a day or two after the test, local tenderness and swelling, cedema of the ankle, and pain on dorsiflexion of the foot. With rest and elevation of the leg the condition cleared up in about a week. In nine further patients aged 27-70, one of them a woman, the symptoms began during or after playing some game, running for a train, jumping, or kneeling down. Most of these had an acute onset-"something seemed to give way " in their calf muscles. Only one patient, a woman of 70, developed a pulmonary infarct, and Crane emphasises the rarity of pulmonary embolism after this kind of thrombosis. He advises rest in bed, with elevation and compression bandaging of the leg until symptoms and signs have subsided. In tall men, Naide2 has lately reported 6 cases of spontaneous venous thrombosis of the calf developing after unac. customed strain ; these thromboses seem to be of a particularly dangerous type, their first symptom being pulmonary infarction. Thrombosis on effort in the legs may arise in the same way as the more common clotting in the axillary and subclavian veins, and both may be associated with congenital venous abnormalities. A pressure of 10-15 mm. Hg applied to the outside of the leg will accelerate the deep venous blood-flow in the limb, presumably by reducing the calibre of the veins, since the velocity of flow in a vein is inversely proportional to its cross-sectional area. The effect is greatest in people with dilated deep veins, demonstrable radiologically.3 This observation is the basis of a method now under trial to reduce the incidence of pulmonary embolism in hospital patients resting in bed. In 5426 general 4medical and surgical patients Wilkins and colleagues have fitted every other case with knee-length elastic stockings, maintaining a pressure of IO-15 mm. Hg, and the controls with loose stockinet, only patients with cardiac oedema or obliterative vascular disease of the legs being excluded. There have been fewer pulmonary emboli among the patients wearing stockings, but the figures are not statistically impressive, chiefly because of the rarity of thrombo-embolism in general hospital patients unless they have congestive heart. failure. In further trials patients in congestive failure are to be included. If the results are convincing, elastic become the routine wear for hospital stockings may inpatients, especially those in whom the chance of thrombosis is highest-the elderly, the cases of congestive failure, and the patients recovering from major abdominal operations, particularly for neoplastic disease. Another possible factor is suggested by Crane’s’1 discussion of the predisposing causes of "effort" thromboses. The high intra-abdominal pressures pro. duced by straining or lifting are conveyed down the veins of the leg if their valves are ineffective; and a vein may burst and thrombose at some weak spot, or where it is compressed by muscle or tendon or bent at a sharp angle, as may easily happen in the popliteal space. But if increased intra-abdominal pressure is a possible cause of thrombosis in the calf, may not postoperative clotting be favoured by the tight many-tailed bandages that many surgeons apply in the irroutine after-treatment!
to
Sir RUSSELL BRAIN, P.R.C.P., has been appointed additional member of the Royal Commission oa Marriage and Divorce. an
2. Naide, M. J. Amer. med. Ass. 1952, 148, 1202. 3. Stanton, J. R., Freis, E. D., Wilkins, R. W. J. clin. Invest. 1949, 28, 553. 4. Wilkins, R. W., Mixter, G., Stanton, J. R., Litter, J. New Engl. J. Med. 1952, 246, 360.
Stengel wondered whether this was due to these drugs being more readily procured since the inauguration of the National Health Service. If this were so, many who had attempted suicide owed their lives to the N.H.S., for sedatives were a relatively inefficient method of suicide. In his experience, the genuine suicide usually succeeded at the first attempt. Of the 138 patients in his series, only 1 subsequently committed suicide. Most (100) were sent to mental hospitals ; 27 were discharged to their homes ; and the remaining 11 either died or were transferred to general hospitals. In the four years since their admission to the observation unit, 24 men and 10 women had died from natural causes ; 6 men and 4 women had remained in mental hospitals ; and 1 man and 6 women were still in mental hospitals after readmission there. The most striking feature about these patients was their relative isolation in the com. munity ; 22% of them were living alone, compared with 6% in the general population. Only 9% were motivated by awareness of physical illness. About half of them were vaguely aware that to commit suicide was against the law, but these said that at the time this factor carried no weight with them. Only 43 of them were brought to the notice of the police, who brought 12 to the observation unit ; none was charged. The importance of the patient’s isolation was confirmed by Dr. P. Sainsbury from his study of 400 successful suicides. Dr. T. C. N. Gibbens said that the tendency for the police to take proceedings fluctuated somewhat with the number of attempted suicides. Nowadays only about 0-5% were sent to prison, and the maximum sentence was six months. Since the late war, about halfof the cases brought to court were dealt with by probation. He cited with approval an opinion voiced at a meeting of the Howard League by Prof. Glanville Williams, that these cases should be brought before the court as adults in need of care and protection, just as-children could be brought before a juvenile court for that purpose. As Dr. Clifford Scott pointed out, suicide, attempted suicide, and violence towards others are all different manifestations of hate and aggression. The patient’s attempt at suicide is often aimed at dominating, alarming, or spiting his family or society at large ; but the element of guilt and self-reproach about this may well account for some of the successful attempts. Dr. Stengel described attempted suicide as Janus-like, in that it faces towards death and destruction on the one side, and towards life and renewal of human contacts on the other. Possibly this is another way of saying that these patients are in a highly ambivalent position between their impulses of hate and of love. o
PREVENTION OF THROMBOSIS IN THE CALF " SILFNT " clotting in the deep veins of the legs, the recognised precursor of pulmonary embolism in immobilised patients, is often difficult to detect, and its prevention is therefore doubly important. Of the many factors predisposing to insidious phlebothrombosis stasis of- blood in the veins seems the most significant. In active exercise, both the squeezing effect of muscular contraction and the suction resulting from deep breathing aid the return of venous blood to the chest ; and it may derive a further impetus from the vigorous arterial pulse and the pull of the contracting right auricle. When the venous valves are incompetent or there are varicose dilatations of the deep calf veins, which are fairly common in older people, an efficient blood-flow from the legs is even more dependent on exercise, and sudden confinement to bed may be disastrous. Fractures and other severe injuries in the legs are a recognised cause of deep venous thrombosis and pulmonary embolism. But Crane"has lately drawn attention 1. Crane, C. New Engl. J. Med. 1952, 246, 529.
a paradoxical thrombosis after minor injuries or simple He describes four cases of calf muscular strain. thrombosis in students aged 19-24 after an exercise. tolerance test in which they stepped up on a platform 18 inches high and down again every 4 seconds for 5 minutes. The clinical picture was almost identical in each casea dull aching in one calf beginning a day or two after the test, local tenderness and swelling, cedema of the ankle, and pain on dorsiflexion of the foot. With rest and elevation of the leg the condition cleared up in about a week. In nine further patients aged 27-70, one of them a woman, the symptoms began during or after playing some game, running for a train, jumping, or kneeling down. Most of these had an acute onset-"something seemed to give way " in their calf muscles. Only one patient, a woman of 70, developed a pulmonary infarct, and Crane emphasises the rarity of pulmonary embolism after this kind of thrombosis. He advises rest in bed, with elevation and compression bandaging of the leg until symptoms and signs have subsided. In tall men, Naide2 has lately reported 6 cases of spontaneous venous thrombosis of the calf developing after unac. customed strain ; these thromboses seem to be of a particularly dangerous type, their first symptom being pulmonary infarction. Thrombosis on effort in the legs may arise in the same way as the more common clotting in the axillary and subclavian veins, and both may be associated with congenital venous abnormalities. A pressure of 10-15 mm. Hg applied to the outside of the leg will accelerate the deep venous blood-flow in the limb, presumably by reducing the calibre of the veins, since the velocity of flow in a vein is inversely proportional to its cross-sectional area. The effect is greatest in people with dilated deep veins, demonstrable radiologically.3 This observation is the basis of a method now under trial to reduce the incidence of pulmonary embolism in hospital patients resting in bed. In 5426 general 4medical and surgical patients Wilkins and colleagues have fitted every other case with knee-length elastic stockings, maintaining a pressure of IO-15 mm. Hg, and the controls with loose stockinet, only patients with cardiac oedema or obliterative vascular disease of the legs being excluded. There have been fewer pulmonary emboli among the patients wearing stockings, but the figures are not statistically impressive, chiefly because of the rarity of thrombo-embolism in general hospital patients unless they have congestive heart. failure. In further trials patients in congestive failure are to be included. If the results are convincing, elastic become the routine wear for hospital stockings may inpatients, especially those in whom the chance of thrombosis is highest-the elderly, the cases of congestive failure, and the patients recovering from major abdominal operations, particularly for neoplastic disease. Another possible factor is suggested by Crane’s’1 discussion of the predisposing causes of "effort" thromboses. The high intra-abdominal pressures pro. duced by straining or lifting are conveyed down the veins of the leg if their valves are ineffective; and a vein may burst and thrombose at some weak spot, or where it is compressed by muscle or tendon or bent at a sharp angle, as may easily happen in the popliteal space. But if increased intra-abdominal pressure is a possible cause of thrombosis in the calf, may not postoperative clotting be favoured by the tight many-tailed bandages that many surgeons apply in the irroutine after-treatment!
to
Sir RUSSELL BRAIN, P.R.C.P., has been appointed additional member of the Royal Commission oa Marriage and Divorce. an
2. Naide, M. J. Amer. med. Ass. 1952, 148, 1202. 3. Stanton, J. R., Freis, E. D., Wilkins, R. W. J. clin. Invest. 1949, 28, 553. 4. Wilkins, R. W., Mixter, G., Stanton, J. R., Litter, J. New Engl. J. Med. 1952, 246, 360.