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Splenic hemangioma
660
The Journal of P E D I A T R I C S
The Journal of Pediatrics April 1969
Letters to the Editor Splenic b e m a n g i o m a To the Editor: The findings of anemia, reticulocytosis, and absent haptoglobin suggest that hemolysis was present in the patient described in the interesting report, "Splenic hemangioma with thrombocytopenia and afibrinogenemia," by Thatcher, CIatanoff, and Stiehm in the September, 1968, issue of the JOURNAL, page 345. It would be important to know whether helmet cells or other morphologic manifestations of traumatized red cells were present. The latter were seen in a case of Kasabach-Merritt syndrome we described (Blood 28: 623, 1966), and we postulated that one obscure mechanism (? microangiopathy) might, in certain cases, have dual sequelae, shortened survival of platelets, and red blood cells. The decrease in platelets and fibrinogen are offered by Thatcher and associates as evidence for a consumptive coagulopathy, although Factors V and V I I I are not strikingly reduced. An alternate possibility is that fibrinogen may be catabolized normally by capillary endothelium, and that the rate here was above normal because of the vast endothelial network in the hemangioma. This is consistent with current theories of serum protein degradation as outlined by Freeman (H. Peeters, editor: Protides of the biological fluids, New York, 1968, Elsevier Publishing Company. RIGHA!qD ~P. PROPP~ M.D. WILLIAI~I B. SCHARFMAN, M.D. DIVISION OF H E M A T O L O G Y DEPARTMENT OF ~viEDICINE ALBANY UNION ALBANY~
MEDICAL
COLLEGE
OF
UNIVERSITY NEW
YORK
Reply To the Editor: The comments of Drs. Propp and Scharfman on our paper are appreciated and point up a plausible explanation for the hemolytic anemia present in the patient we studied. However, we did not observe helmet cells or other traumatic red ceils that they describe in their patient. The presence of split products of fibrinogen in the serum, the histologic evidence of fibrin
Vol. 74, No. 4, p. 660
in the removed spleen, and the rapid rise of Factors V and V I I I after splenectomy suggest that intravascular coagulation was occurring rather than rapid fibrinogen catabolism. E. RICHARD STIEI-IM~ M.D. ASSOCIATE PROFESSOR DEPARTMENT OF PEDIATRICS UNIVERSITY OF
WISCONSIN
MEDICAL CENTER MADISON, WIS.
D i g i t a l intratracloeal intubation: A student's
support a n d
tribute
To the Editor: The article on direct digital intratracheal intubation by Drs. Woody (J. PEDIAT 73: 903, 1968) will evoke interest and opposition. For the interested, practice on fresh morgue specimens is suggested. After rigor morris sets in the "feel" for pulmonary resistance and muscle tone is lost, as Drs. Woody clearly state, but the morgue lends itself to participation by more students and the anatomic relationships are preserved. As a former student of Dr. Norman Woody, I recall his taking groups to the morgue for instruction on resuscitative procedures: (1) direct digital intubation, ( 2 ) l o c a t i n g the distal portion of the internal saphenous vein as it crosses the ankle for cut down, (3) cardiac massage, etc. I remember vividly a day when the esophagus was entered no less than a dozen times as Dr. Woody painstakingly stood on until the trachea was intubated. The instruction paid off. Recently I digitally intubated a neonate when the Iaryngoscope light failed, a tribute partly to Dr. Woody's patience that day, and also to continued practice over the years. (Intubation is a difficult procedure by any method for the inexperienced.) For members of the opposition, the "laryngoscope only" group, I offer only hope that you are not faced with a similar situation. True, there is no excuse for failure of resuscitative equipment, but nonetheless it does occur. ROBERT A. MC CORMICK, JR., M.D.
CAPTAIN, USAF (MC) MOODY AIR FORCE ttASE~ GEORGIA
The Journal of P E D I A T R I C S
The Journal of Pediatrics April 1969
Letters to the Editor Splenic b e m a n g i o m a To the Editor: The findings of anemia, reticulocytosis, and absent haptoglobin suggest that hemolysis was present in the patient described in the interesting report, "Splenic hemangioma with thrombocytopenia and afibrinogenemia," by Thatcher, CIatanoff, and Stiehm in the September, 1968, issue of the JOURNAL, page 345. It would be important to know whether helmet cells or other morphologic manifestations of traumatized red cells were present. The latter were seen in a case of Kasabach-Merritt syndrome we described (Blood 28: 623, 1966), and we postulated that one obscure mechanism (? microangiopathy) might, in certain cases, have dual sequelae, shortened survival of platelets, and red blood cells. The decrease in platelets and fibrinogen are offered by Thatcher and associates as evidence for a consumptive coagulopathy, although Factors V and V I I I are not strikingly reduced. An alternate possibility is that fibrinogen may be catabolized normally by capillary endothelium, and that the rate here was above normal because of the vast endothelial network in the hemangioma. This is consistent with current theories of serum protein degradation as outlined by Freeman (H. Peeters, editor: Protides of the biological fluids, New York, 1968, Elsevier Publishing Company. RIGHA!qD ~P. PROPP~ M.D. WILLIAI~I B. SCHARFMAN, M.D. DIVISION OF H E M A T O L O G Y DEPARTMENT OF ~viEDICINE ALBANY UNION ALBANY~
MEDICAL
COLLEGE
OF
UNIVERSITY NEW
YORK
Reply To the Editor: The comments of Drs. Propp and Scharfman on our paper are appreciated and point up a plausible explanation for the hemolytic anemia present in the patient we studied. However, we did not observe helmet cells or other traumatic red ceils that they describe in their patient. The presence of split products of fibrinogen in the serum, the histologic evidence of fibrin
Vol. 74, No. 4, p. 660
in the removed spleen, and the rapid rise of Factors V and V I I I after splenectomy suggest that intravascular coagulation was occurring rather than rapid fibrinogen catabolism. E. RICHARD STIEI-IM~ M.D. ASSOCIATE PROFESSOR DEPARTMENT OF PEDIATRICS UNIVERSITY OF
WISCONSIN
MEDICAL CENTER MADISON, WIS.
D i g i t a l intratracloeal intubation: A student's
support a n d
tribute
To the Editor: The article on direct digital intratracheal intubation by Drs. Woody (J. PEDIAT 73: 903, 1968) will evoke interest and opposition. For the interested, practice on fresh morgue specimens is suggested. After rigor morris sets in the "feel" for pulmonary resistance and muscle tone is lost, as Drs. Woody clearly state, but the morgue lends itself to participation by more students and the anatomic relationships are preserved. As a former student of Dr. Norman Woody, I recall his taking groups to the morgue for instruction on resuscitative procedures: (1) direct digital intubation, ( 2 ) l o c a t i n g the distal portion of the internal saphenous vein as it crosses the ankle for cut down, (3) cardiac massage, etc. I remember vividly a day when the esophagus was entered no less than a dozen times as Dr. Woody painstakingly stood on until the trachea was intubated. The instruction paid off. Recently I digitally intubated a neonate when the Iaryngoscope light failed, a tribute partly to Dr. Woody's patience that day, and also to continued practice over the years. (Intubation is a difficult procedure by any method for the inexperienced.) For members of the opposition, the "laryngoscope only" group, I offer only hope that you are not faced with a similar situation. True, there is no excuse for failure of resuscitative equipment, but nonetheless it does occur. ROBERT A. MC CORMICK, JR., M.D.
CAPTAIN, USAF (MC) MOODY AIR FORCE ttASE~ GEORGIA