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SURGICAL TREATMENT OF DUODENAL ULCERATION IN HÆMOPHILIACS
886
originally set up to popularise that method, which has now been abandoned in favour of the oral one. This committee has now been itself disbanded, and the " Elisha method " is everywhere taught in Denmark. In face of such strong evidence in support of mouth-tomouth artificial respiration, it is hard to understand why many first-aid workers fail to teach and practise it. Are they awaiting the findings of the M.R.C.’s working party, under Prof. Ian Donald, on emergency methods of resuscitation ? I for one am confident that their conclusions will confirm those of the countries I have mentioned.
was
Department of Public Health, Bristol.
ALEXANDER W. MACARA.
CLINICAL FEATURES OF PULMONARY EMBOLISM of SIR, The article April 8 by Dr. Barritt and Dr. Jordan prompts me to record certain observations I made on this condition over a period of some years in military
surgical practice, where patients were usually but not always younger. The first is that pulmonary embolism, either spontaneous or postoperative, appears with sufficient frequency in young people to emphasise the need to keep it in mind at all times. Another is that it is well worth paying strict attention to the complaints of the patient in the postoperative period, especially if there is some apparently unexplained pyrexia or tachycardia. Pulmonary infarction can affect fit young men for no apparent reason. The only common factor noted in a group of such cases was recent strenuous exercise. The following is an example: Overseas in 1952, a fit medical officer of 24, who was regularly playing good-class rugby, was admitted to medical wards because of right-sided basal pleurisy, followed by haemoptysis. My interest in anticoagulant therapy was the reason for my being asked to see him. Only after careful cross-questioning did the patient provide the
information that about a week before he had had some discomfort and aching in the right calf, of so little moment to his type as to be discounted and almost forgotten. Examination showed slight leg cedema, calf tenderness, and a positive Homan’s sign, indicating the diagnosis and treatment. Moreover, this patient offered two pieces of information found to be of value in pointing to a diagnosis of thromboembolism and pulmonary infarction. For some nights before the haemoptysis, he had difficulty with sleep and a feeling of being afraid-of what, he knew not.
I believe these two symptoms are important, so much so that in postoperative patients with some fever and tachycardia for no discoverable reason, who complain of sleeplessness and some bizarre fear, which they cannot describe or explain, I should suspect thromboembolism and its complications, and would not hesitate to give anticoagulants, even in the absence of more positive evidence, which in my experience will appear sooner or later. Anatomy Department, A. G. A. G. D. D. of Aberdeen. University University of Aberdeen
WHYTE.
SIR,-The article by Dr. Barritt and Dr. Jordan contains the traditional implication that pulmonary infarction is the almost invariable sequel of a pulmonary embolus. This prompts me to point out that while pulmonary emboli of varying sizes are only too frequently found during routine necropsies on patients who die in hospital, corresponding areas of pulmonary infarction are much less common. The abnormal signs found clinically and radiologically in some cases of pulmonary embolus must thus be due to a lesion other than infarction-one, indeed, which resolves more readily than an infarction would be expected to. When reviewing clinical and postmortem findings together, it is also apparent that some cases of pulmonary embolism may give rise to few or no abnormal physical signs in the lungs; the absence of such signs does not mean that a diagnosis of pul-
monary embolism can be discounted, when other such as Dr. Barritt and Dr. Jordan mention, like
evidec:: a
’I
sude::
of faintness, breathlessness, substernal pain, u:c’.. is suggestive. The point is an important one, view of the value-previously demonstrated by the same autf!c:: -of anticoagulant treatment after a first embolus. Department of Pathology, Royal Alexandra Hospital, J. T. ALBAN LLOYD. Rhyl, Flintshire.
episode
cardia, &c.,
WHO IS DELIVERED? SiR,-While agreeing with Mr. Russell (April 1) t:4: there are many inconsistencies and inaccuracies in ih:
of the word " deliver " in midwifery, I question IN_ statement that the verb is used intransitively. Surely to say that the mother is delivered is simply to use the passive of a transitive verb ?If someone delivers the mother 0Î her baby, or my bank manager reminds me of my overdraft, the object suffers the action of the verb in each case; and this applies no less when the mother is fortunate enough to deliver herself before any attendants arrive.
use
I agree that to speak of delivering the baby does not have the same biblical or historical precedent; but have we any verb to describe what is done to the baby ? This may be the reason for the midwifery slang of my young days: " 1 homed a baby ". If there is no verb for this purpose, should we invent one ? The infant-mortality rate of invented words is very high. Should we therefore agree to extend the use ofdeliver", so that, just as we deliver the mother of an increasing load, so we deliver the baby from its very constricted quarters. Even " so, to say she delivered a breech is, as Mr. Russell suggests; absurd-I personally always made it my practice to deliver the whole baby-but this is only an extension of the unfortunate custom of calling one of our fellow creatures an appendix,a coronary, or a hallux valgus. "
MIDWIFE. SURGICAL TREATMENT OF DUODENAL ULCERATION IN HÆMOPHILIACS
SIR,-Dr. Handley and his colleagues (March 4) are to be congratulated upon successfully conducting major surgery on 2 patients with the help of antihsmophitic globulin of animal origin; but I wish to make it clear that my patient, to whom they refer, also underwent parts gastrectomy quite without incident or anxiety. The con. siderable amount of blood and blood products to which they refer was given entirely as a prophylactic measure immediately before operation and during convalescence until we felt that his wounds had completely healed. My experience of this and a number of other patients who have
undergone lesser surgical interference has led me to value
human-blood products highly. We believe in daily
or
almot
daily administration with, of course, the usual precaution against circulatory overloading. We have found it easier to control patients with simple ckx wounds and our greatest difficulties have arisen when patient: as a result of trauma, have developed deep-seated haematOl1’2S with extensive diffusion of blood into muscles and soft 6sso We have regarded evacuation of hsematomas by aspiration0’ surgical drainage as contributing to improvement; and subsequent lavage with hypochlorite solution has seemed to he:.."
considerably. There are obvious advantages in not sensitise= patients by repeated injections of serum of animal ori and I am writing to encourage preliminary intensive of fresh human-blood products, at least as a first step.= dealing with hasmophiliacs requiring any form of sure-
interference. Royal Victoria Infirmary, Newcastle upon Tyne.
T. H. BOON.
originally set up to popularise that method, which has now been abandoned in favour of the oral one. This committee has now been itself disbanded, and the " Elisha method " is everywhere taught in Denmark. In face of such strong evidence in support of mouth-tomouth artificial respiration, it is hard to understand why many first-aid workers fail to teach and practise it. Are they awaiting the findings of the M.R.C.’s working party, under Prof. Ian Donald, on emergency methods of resuscitation ? I for one am confident that their conclusions will confirm those of the countries I have mentioned.
was
Department of Public Health, Bristol.
ALEXANDER W. MACARA.
CLINICAL FEATURES OF PULMONARY EMBOLISM of SIR, The article April 8 by Dr. Barritt and Dr. Jordan prompts me to record certain observations I made on this condition over a period of some years in military
surgical practice, where patients were usually but not always younger. The first is that pulmonary embolism, either spontaneous or postoperative, appears with sufficient frequency in young people to emphasise the need to keep it in mind at all times. Another is that it is well worth paying strict attention to the complaints of the patient in the postoperative period, especially if there is some apparently unexplained pyrexia or tachycardia. Pulmonary infarction can affect fit young men for no apparent reason. The only common factor noted in a group of such cases was recent strenuous exercise. The following is an example: Overseas in 1952, a fit medical officer of 24, who was regularly playing good-class rugby, was admitted to medical wards because of right-sided basal pleurisy, followed by haemoptysis. My interest in anticoagulant therapy was the reason for my being asked to see him. Only after careful cross-questioning did the patient provide the
information that about a week before he had had some discomfort and aching in the right calf, of so little moment to his type as to be discounted and almost forgotten. Examination showed slight leg cedema, calf tenderness, and a positive Homan’s sign, indicating the diagnosis and treatment. Moreover, this patient offered two pieces of information found to be of value in pointing to a diagnosis of thromboembolism and pulmonary infarction. For some nights before the haemoptysis, he had difficulty with sleep and a feeling of being afraid-of what, he knew not.
I believe these two symptoms are important, so much so that in postoperative patients with some fever and tachycardia for no discoverable reason, who complain of sleeplessness and some bizarre fear, which they cannot describe or explain, I should suspect thromboembolism and its complications, and would not hesitate to give anticoagulants, even in the absence of more positive evidence, which in my experience will appear sooner or later. Anatomy Department, A. G. A. G. D. D. of Aberdeen. University University of Aberdeen
WHYTE.
SIR,-The article by Dr. Barritt and Dr. Jordan contains the traditional implication that pulmonary infarction is the almost invariable sequel of a pulmonary embolus. This prompts me to point out that while pulmonary emboli of varying sizes are only too frequently found during routine necropsies on patients who die in hospital, corresponding areas of pulmonary infarction are much less common. The abnormal signs found clinically and radiologically in some cases of pulmonary embolus must thus be due to a lesion other than infarction-one, indeed, which resolves more readily than an infarction would be expected to. When reviewing clinical and postmortem findings together, it is also apparent that some cases of pulmonary embolism may give rise to few or no abnormal physical signs in the lungs; the absence of such signs does not mean that a diagnosis of pul-
monary embolism can be discounted, when other such as Dr. Barritt and Dr. Jordan mention, like
evidec:: a
’I
sude::
of faintness, breathlessness, substernal pain, u:c’.. is suggestive. The point is an important one, view of the value-previously demonstrated by the same autf!c:: -of anticoagulant treatment after a first embolus. Department of Pathology, Royal Alexandra Hospital, J. T. ALBAN LLOYD. Rhyl, Flintshire.
episode
cardia, &c.,
WHO IS DELIVERED? SiR,-While agreeing with Mr. Russell (April 1) t:4: there are many inconsistencies and inaccuracies in ih:
of the word " deliver " in midwifery, I question IN_ statement that the verb is used intransitively. Surely to say that the mother is delivered is simply to use the passive of a transitive verb ?If someone delivers the mother 0Î her baby, or my bank manager reminds me of my overdraft, the object suffers the action of the verb in each case; and this applies no less when the mother is fortunate enough to deliver herself before any attendants arrive.
use
I agree that to speak of delivering the baby does not have the same biblical or historical precedent; but have we any verb to describe what is done to the baby ? This may be the reason for the midwifery slang of my young days: " 1 homed a baby ". If there is no verb for this purpose, should we invent one ? The infant-mortality rate of invented words is very high. Should we therefore agree to extend the use ofdeliver", so that, just as we deliver the mother of an increasing load, so we deliver the baby from its very constricted quarters. Even " so, to say she delivered a breech is, as Mr. Russell suggests; absurd-I personally always made it my practice to deliver the whole baby-but this is only an extension of the unfortunate custom of calling one of our fellow creatures an appendix,a coronary, or a hallux valgus. "
MIDWIFE. SURGICAL TREATMENT OF DUODENAL ULCERATION IN HÆMOPHILIACS
SIR,-Dr. Handley and his colleagues (March 4) are to be congratulated upon successfully conducting major surgery on 2 patients with the help of antihsmophitic globulin of animal origin; but I wish to make it clear that my patient, to whom they refer, also underwent parts gastrectomy quite without incident or anxiety. The con. siderable amount of blood and blood products to which they refer was given entirely as a prophylactic measure immediately before operation and during convalescence until we felt that his wounds had completely healed. My experience of this and a number of other patients who have
undergone lesser surgical interference has led me to value
human-blood products highly. We believe in daily
or
almot
daily administration with, of course, the usual precaution against circulatory overloading. We have found it easier to control patients with simple ckx wounds and our greatest difficulties have arisen when patient: as a result of trauma, have developed deep-seated haematOl1’2S with extensive diffusion of blood into muscles and soft 6sso We have regarded evacuation of hsematomas by aspiration0’ surgical drainage as contributing to improvement; and subsequent lavage with hypochlorite solution has seemed to he:.."
considerably. There are obvious advantages in not sensitise= patients by repeated injections of serum of animal ori and I am writing to encourage preliminary intensive of fresh human-blood products, at least as a first step.= dealing with hasmophiliacs requiring any form of sure-
interference. Royal Victoria Infirmary, Newcastle upon Tyne.
T. H. BOON.