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VASOPRESSIN AND BLEEDING ŒSOPHAGEAL VARICES
372
polyarthritis who regularly take somi or intermittently take tab codeine co. B.P. or some similar mixture containing phenacetin The opening medicine varies, but is usually Epsom salt Glauber salt, or some proprietary mixture containing these in my last case, a week or so ago, it was ’Fynnon Salt ’. We know that in patients with favism the glucose-6-phosphatedehydrogenase (G.6P.D.) and the reduced glutathione (G.S.H.: are normal shortly after recovery from a haemolytic episode, but fall to much lower values after 40-60 days.3 We also know that in patients with polyarthritis the life of the red cell is sometimes reduced by 20-30%. If the G.s.H. content of normal cells diminishes during their life span, though more slowly and less completely than does that of the abnormal red cell of G.6P.D. deficiency (favism), then one would expect patients with polyarthritis to show a distribution curve for red cell G.S.H. skewed somewhat to the right. women
with chronic
opening medicine, and constantly
Since none of the figures Dr. McCutcheon gives are outside the range of normal established by Beutler,4 it may be that his observed association between high G.S.H. levels and sulphaemoglobinaemia is due to chance; but I submit that the hypothesis outlined here is no less likely than that which he puts forward and, moreover, it is somewhat more amenable to experimental verification or contradiction. Central Middlesex Hospital, London, N.W.10.
GEORGE DISCOMBE.
PREVENTION AND TREATMENT OF BEDSORES SIR,-Having used on my geriatric wards since November, 1959, a silicone aerosol spray of the composition
described so clearly by Dr. Kelly (May 14) I now feel I can confirm his observations. One case stands out. A 69-year-old woman with paraplegia in flexion, admitted in
have banned physiotherapy. Of the 33 consecutive adult tibial shaft fractures so treated 32 united straightforwardly. Only 1
required a bone-graft. It must be remembered, however, that the paradox concerns only the forces of internal origin. The effect of such a plaster against external forces is one of lowered efficiency. Therefore only a very uneasy compromise can ever be reached with external splintage in any form. It can be the treatment of choice only for the very mildest of tibial fractures-those that are highly likely to do well whatever the treatment. Something more efficient is required for the severe fractures such as are occurring in increasing numbers today. Birmingham Accident Hospital.
J. H. HICKS.
VASOPRESSIN AND BLEEDING ŒSOPHAGEAL VARICES SIR,-During the past year we have been using intra-
vasopressin (’ Pitressin ’) as an adjunct to the control of haemorrhage from oesophageal varices, and our experience agrees with that of Professor Sherlock and her colleagues (July 30). venous
Using our method of recording portal pressure1 we have found that vasopressin will regularly lower portal venous pressure in man. The accompanying table illustrates the degree and duration of this action. The intestinal colic which also occurs, whilst distressing to the patient, has the advantage of emptying the bowel of blood and therefore helps to prevent the development of hepatic coma which is so often the sequel of a large gastro-oesophageal haemorrhage in patients with cirrhosis of the liver. Although by virtue of its constricting action on the arterioles and capillaries of the splanchnic bed and also on the intraQUANTITATIVE
EFFECT OF VASOPRESSIN ON PORTAL PRESSURE
April, 1959, with a discharging sinus after various operations on a fractured femur, had multiple bedsores and urinary incontinence. Months of arduous nursing succeeded in maintaining life, but after twelve days’ use of a trial supply of the spray a dramatic improvement of the bedsores was noted. Severe relapse followed exhaustion of the trial supply eight weeks later, but improvement was steady after a new supply was obtained. In particular the spray keeps the skin immune to irritation from urine. Since May she has been quite perky in a pleasant " convalescent ward. Many factors, of course, are involved; several expensive preparations have played their part, but the only two now in use are the spray and nursing care, which is, as Dr. Pathy (March 12) truly remarks, of paramount importance. "
Summerfield Hospital,
Birmingham.
ROBERT J. HETHERINGTON.
EXTERNAL SPLINTAGE OF FRACTURES
SIR,-Dr. Robinson (Aug. 6) will be pleased to know logical solution has been tried out. Since external splintage plus muscle contractions tend to cause movement at the fracture site, one remedy is, as he says, deliberately to make the plaster case loose from the joint below downwards, and another remedy is to avoid that his
exercises. This " loose-below " plaster would also guard against another hazard of conventional treatment that I had not mentioned. The usual plaster case after a few weeks tends to become loose around the upper part of the limb, whilst remaining comparatively tight around the foot. This must result in much of the weight of the case being supported by the part of the limb distal to the fracture. The combined weights of distal part of limb and of the attached splintage seems to be a most undesirable load for the fracture to have to support. I have put these conclusions into practice and for several " years have used a tight-above-loose-below " plaster and 3. Szeinberg, A., Sheba, Ch., Hirschorn, N., Bodonizi, E. Bull. Res. Coun, Israel, 1957, 6E, 115.
4. Beutler, E. J. Lab. clin. Med. 1957, 49, 84.
hepatic communications between the portal vein and hepatic artery, vasopressin reduces the flow of blood into the liver, the drug may also, by raising the systemic arterial pressure, increase the flow through the hepatic artery itself, and hence to some extent compensate for the decreased flow through the other channels. We have been able to show this experimentally in the dog and cat, using a heated thermocouple needle as our measurement of changes in liver blood-flow, and we have also similar evidence for this occurrence in man. Vasopressin is also useful during operations on the portal system when venous oozing obscures the operative field. For example we recently found that intravenous administration of the drug produced a relatively bloodless field for the surgeon during a difficult portacaval anastomosis. In a similar way we use the drug during the performance of portacaval anastomosis on normal animals in whom clamping the portal vein for half an hour results in congestion of the mesentery. Vasopressin prevents this. In exactly the same way the drug should be of value were one to resect the portal vein during operation for carcinoma of the head of the pancreas, and it might also be of use in reducing the flow of blood into the liver in severe liver -
injuries. Department of Surgery,
University
CYRIL SHALDON.
of Bristol. 1.
Shaldon,
C. Lancet,
July 30, 1960, p. 244.
polyarthritis who regularly take somi or intermittently take tab codeine co. B.P. or some similar mixture containing phenacetin The opening medicine varies, but is usually Epsom salt Glauber salt, or some proprietary mixture containing these in my last case, a week or so ago, it was ’Fynnon Salt ’. We know that in patients with favism the glucose-6-phosphatedehydrogenase (G.6P.D.) and the reduced glutathione (G.S.H.: are normal shortly after recovery from a haemolytic episode, but fall to much lower values after 40-60 days.3 We also know that in patients with polyarthritis the life of the red cell is sometimes reduced by 20-30%. If the G.s.H. content of normal cells diminishes during their life span, though more slowly and less completely than does that of the abnormal red cell of G.6P.D. deficiency (favism), then one would expect patients with polyarthritis to show a distribution curve for red cell G.S.H. skewed somewhat to the right. women
with chronic
opening medicine, and constantly
Since none of the figures Dr. McCutcheon gives are outside the range of normal established by Beutler,4 it may be that his observed association between high G.S.H. levels and sulphaemoglobinaemia is due to chance; but I submit that the hypothesis outlined here is no less likely than that which he puts forward and, moreover, it is somewhat more amenable to experimental verification or contradiction. Central Middlesex Hospital, London, N.W.10.
GEORGE DISCOMBE.
PREVENTION AND TREATMENT OF BEDSORES SIR,-Having used on my geriatric wards since November, 1959, a silicone aerosol spray of the composition
described so clearly by Dr. Kelly (May 14) I now feel I can confirm his observations. One case stands out. A 69-year-old woman with paraplegia in flexion, admitted in
have banned physiotherapy. Of the 33 consecutive adult tibial shaft fractures so treated 32 united straightforwardly. Only 1
required a bone-graft. It must be remembered, however, that the paradox concerns only the forces of internal origin. The effect of such a plaster against external forces is one of lowered efficiency. Therefore only a very uneasy compromise can ever be reached with external splintage in any form. It can be the treatment of choice only for the very mildest of tibial fractures-those that are highly likely to do well whatever the treatment. Something more efficient is required for the severe fractures such as are occurring in increasing numbers today. Birmingham Accident Hospital.
J. H. HICKS.
VASOPRESSIN AND BLEEDING ŒSOPHAGEAL VARICES SIR,-During the past year we have been using intra-
vasopressin (’ Pitressin ’) as an adjunct to the control of haemorrhage from oesophageal varices, and our experience agrees with that of Professor Sherlock and her colleagues (July 30). venous
Using our method of recording portal pressure1 we have found that vasopressin will regularly lower portal venous pressure in man. The accompanying table illustrates the degree and duration of this action. The intestinal colic which also occurs, whilst distressing to the patient, has the advantage of emptying the bowel of blood and therefore helps to prevent the development of hepatic coma which is so often the sequel of a large gastro-oesophageal haemorrhage in patients with cirrhosis of the liver. Although by virtue of its constricting action on the arterioles and capillaries of the splanchnic bed and also on the intraQUANTITATIVE
EFFECT OF VASOPRESSIN ON PORTAL PRESSURE
April, 1959, with a discharging sinus after various operations on a fractured femur, had multiple bedsores and urinary incontinence. Months of arduous nursing succeeded in maintaining life, but after twelve days’ use of a trial supply of the spray a dramatic improvement of the bedsores was noted. Severe relapse followed exhaustion of the trial supply eight weeks later, but improvement was steady after a new supply was obtained. In particular the spray keeps the skin immune to irritation from urine. Since May she has been quite perky in a pleasant " convalescent ward. Many factors, of course, are involved; several expensive preparations have played their part, but the only two now in use are the spray and nursing care, which is, as Dr. Pathy (March 12) truly remarks, of paramount importance. "
Summerfield Hospital,
Birmingham.
ROBERT J. HETHERINGTON.
EXTERNAL SPLINTAGE OF FRACTURES
SIR,-Dr. Robinson (Aug. 6) will be pleased to know logical solution has been tried out. Since external splintage plus muscle contractions tend to cause movement at the fracture site, one remedy is, as he says, deliberately to make the plaster case loose from the joint below downwards, and another remedy is to avoid that his
exercises. This " loose-below " plaster would also guard against another hazard of conventional treatment that I had not mentioned. The usual plaster case after a few weeks tends to become loose around the upper part of the limb, whilst remaining comparatively tight around the foot. This must result in much of the weight of the case being supported by the part of the limb distal to the fracture. The combined weights of distal part of limb and of the attached splintage seems to be a most undesirable load for the fracture to have to support. I have put these conclusions into practice and for several " years have used a tight-above-loose-below " plaster and 3. Szeinberg, A., Sheba, Ch., Hirschorn, N., Bodonizi, E. Bull. Res. Coun, Israel, 1957, 6E, 115.
4. Beutler, E. J. Lab. clin. Med. 1957, 49, 84.
hepatic communications between the portal vein and hepatic artery, vasopressin reduces the flow of blood into the liver, the drug may also, by raising the systemic arterial pressure, increase the flow through the hepatic artery itself, and hence to some extent compensate for the decreased flow through the other channels. We have been able to show this experimentally in the dog and cat, using a heated thermocouple needle as our measurement of changes in liver blood-flow, and we have also similar evidence for this occurrence in man. Vasopressin is also useful during operations on the portal system when venous oozing obscures the operative field. For example we recently found that intravenous administration of the drug produced a relatively bloodless field for the surgeon during a difficult portacaval anastomosis. In a similar way we use the drug during the performance of portacaval anastomosis on normal animals in whom clamping the portal vein for half an hour results in congestion of the mesentery. Vasopressin prevents this. In exactly the same way the drug should be of value were one to resect the portal vein during operation for carcinoma of the head of the pancreas, and it might also be of use in reducing the flow of blood into the liver in severe liver -
injuries. Department of Surgery,
University
CYRIL SHALDON.
of Bristol. 1.
Shaldon,
C. Lancet,
July 30, 1960, p. 244.