- Email: [email protected]
VIRAL HÆMORRHAGIC FEVERS
1144
In
Letters to the Editor
England Now
I was working late in the medical school the other evening; papers and files covered my desk, and the results I was trying to put together wouldn’t make sense. I pushed back my chair and looked out of the window. It was a still autumn evening, the sky was almost dark and the streetlamps were on. I have a limited but greatly treasured view of a tree through the window, and the lamps showed that some of its leaves were turning brown. On the other side of the room the corridor beyond the door was quiet, but occasionally there came the "chunk" of a bucket as it was pushed along and the swish of a mop being swung from side to side. Then, at first softly, but with growing volume and well-measured cadence, came the unmistakable strains of a fado. The slightly melancholy tune, the drawn-out syllables, and soft sch ... and chao... sounds were all there, and, yes, it was being sung in Portuguese. The voice was a little thin, but there was great beauty in it. Memories grew with the song, and I went back in my mind to a little restaurant near the Tagus in Lisbon where there are-or were-whitewashed walls with Russell Flint arches and alcoves, a stone floor, and black-painted ironwork. Candles provided the only light, and were stuck into bottles encrusted with the drippings of several years. Here there was a girl whose almost perfect Latin features could be matched only by her singing. She appeared nightly, a
black lace shawl over her head, with the candlelight on her face throwing soft shadows around her eyes and in the dimples of her cheeks. Golden flashes reflected from her earrings. Her eyelashes were very long, and now and again the light caught them, too. The memory, sunk for 13 years beneath innumerable others, much more mundane, became very clear as the song echoed along the corridor. When it ended I felt that I must meet the singer, so I went with a book to a nearby room. " Boas-noires ", I said, and a smile lit up features that were mellowing into late middle-age. She had, she told me, sung in the restaurants in Lisbon, but that was many years ago, and now the mop and bucket, not the guitar and piano, accompanied her singing. Would that hospitals and medical schools offered a bonus ła very special one-to their cleaners from Portugal who have been fado-singers. But perhaps it is better that they should not; maybe the memories they can evoke should be
conjured up only once every
13 years
s
or so. *
Old Mrs. D. suddenly became confused and semiconscious for no reason that I could discover, although she had been very irregular with her Largactil. There had been a previous gas leak and daughter was disturbed about the smell in the house. We both had catarrh and were unsure, and as meter was next door to open fire I phoned the Gas Board and also arranged a domiciliary visit. Consultant, Gas Board, and I arrived simultaneously. Much sniffing of the air as consultant examined patient and could find no obvious cause for her condition-at the same time Gas Board fitted elaborate apparatus and reported no leak to be found. Coming, still sniffing, downstairs, association of smell suddenly struck both of us, and we rushed up with again to confirm that the old lady’s breath was loaded " acetone-daughter meanwhile saying, for first time, she’s been drinking buckets of water for last few weeks-is it diabetes ? " The Gas Board was left to continue its investigations next door-none of us having the face to admit the true cause of the smell. Despite blood-glucose of 1430 mg. per 100 ml., Mrs. D. came under control very quickly and is home again now.
VIRAL HÆMORRHAGIC FEVERS SIR,-On account of your editorial of Oct. 16 (p. 858) we should like to submit the following information. As we have hinted,l-3 some promising attempts have been made to isolate an infectious agent from patients in Sweden, although the experiments were not reliably reproducible. Recently, however, an agent has been isolated from the urine from 3 out of 5 patients and from cultured renalbiopsy specimens from 2 patients. The presence of the agent was indicated by the appearance of a discrete cytopathic effect in inoculated cell-cultures of bovine kidneys. It was found possible to pass the agent indefinitely at titres of 107 per ml. Preliminary studies indicate that the agent is ether-sensitive and will pass a membrane filter with 200 nm. pore size. Department of Clinical Virology, Umeå
University. Department of Clinical Bacteriology, Linköping University. Department of Medicine, Umeå University. Department of Pædiatrics, Sundsvall Hospital, Sweden.
BERTIL HOORN.
SVEN BERGMAN. KURT NYSTRÖM. LARS
SÖDERHJELM.
CONTINUOUS POSITIVE AIRWAYS PRESSURE IN RESPIRATORY-DISTRESS SYNDROME SiR,—The paper of Gregory et al. stimulated us, as it did Dr. Dunn and his colleagues (Oct. 30, p. 971), to use this method of treatment. For reasons we shall give later, we chose intubation as the method of applying continuous
positive airways On
pressure
(C.P.A.P.).
weighing 2090 g. was born by elective elderly primigravida at 34 weeks’ gestation. Pregnancy was complicated by moderately severe pre-eclampsia. Placental function as estimated by oestriols had always been extremely poor, and latterly showed a sudden deterioration. The Apgar score at 1 minute was 5. Oxygen by face-mask was necessary. Respiratory distress was first evident at 2 hours. Chest X-rays confirmed the diagnosis of respiratory-distress syndrome (R.D.S.). Serial blood-gas estimations showed a persistently falling Pao2 despite increases in the inspired-oxygen concentration. At 24 hours of life, when the baby was breathing 90% oxygen, the Pa02 was 30 mm. Hg and C.P.A.P. was commenced at 6 cm. H20. After 15 minutes the Pa02 had risen by 100%. A rise of 2 cm. H2O produced a further 30% increase in Pa02- With C.P.A.P. maintained at 8 cm. H20, we were able to reduce the amount of inspired oxygen over the following 96 hours to that of air. The infant’s respiratory efforts, however, were insufficient to maintain Pac02 at normal levels, and we found it necessary to " hand ventilate " for approximately 2 minutes in every hour over the first 72 hours. This reduced PaC02 by 30-40% on each occasion. When the baby was breathing air, C.P.A.P. was reduced by steps of 2 cm. H20. The final step from 2 cm. H2O to zero could only be safely performed by increasing the percentage of inspired oxygen to 30%. The endotracheal tube was Sept. 17,
cassarean
a
male
section to an
removed 2 hours after C.P.A.P. was discontinued. Treatment with C.P.A.P. was continued for 105 hours. We had no difficulty in maintaining the position of the endotracheal tube. Patency was ensured by hourly suction after the instillation of 0-5 ml. of 1. Nyström, K., Bergman, S., Hoorn, B. Report at XXVII Medicinska Riksstämman, Stockholm; Sammanfattningar av Symposier och Föredrag, 1970, p. 309. 2. Söderhjelm, L. J. inf. Dis. 1971, 124, 107. 3. Bergman, S., Hoorn, B., Nyström, K., Söderhjelm, L. Second International Symposium on Circumpolar Health, Oulu, Finland, June 21-24, 1971. 4. Gregory, G. A., Kitterman, J. A., Phibbs, R. H., Tooley, W. H., Hamilton, W. K. New Engl. J. Med. 1971, 284, 1333.
In
Letters to the Editor
England Now
I was working late in the medical school the other evening; papers and files covered my desk, and the results I was trying to put together wouldn’t make sense. I pushed back my chair and looked out of the window. It was a still autumn evening, the sky was almost dark and the streetlamps were on. I have a limited but greatly treasured view of a tree through the window, and the lamps showed that some of its leaves were turning brown. On the other side of the room the corridor beyond the door was quiet, but occasionally there came the "chunk" of a bucket as it was pushed along and the swish of a mop being swung from side to side. Then, at first softly, but with growing volume and well-measured cadence, came the unmistakable strains of a fado. The slightly melancholy tune, the drawn-out syllables, and soft sch ... and chao... sounds were all there, and, yes, it was being sung in Portuguese. The voice was a little thin, but there was great beauty in it. Memories grew with the song, and I went back in my mind to a little restaurant near the Tagus in Lisbon where there are-or were-whitewashed walls with Russell Flint arches and alcoves, a stone floor, and black-painted ironwork. Candles provided the only light, and were stuck into bottles encrusted with the drippings of several years. Here there was a girl whose almost perfect Latin features could be matched only by her singing. She appeared nightly, a
black lace shawl over her head, with the candlelight on her face throwing soft shadows around her eyes and in the dimples of her cheeks. Golden flashes reflected from her earrings. Her eyelashes were very long, and now and again the light caught them, too. The memory, sunk for 13 years beneath innumerable others, much more mundane, became very clear as the song echoed along the corridor. When it ended I felt that I must meet the singer, so I went with a book to a nearby room. " Boas-noires ", I said, and a smile lit up features that were mellowing into late middle-age. She had, she told me, sung in the restaurants in Lisbon, but that was many years ago, and now the mop and bucket, not the guitar and piano, accompanied her singing. Would that hospitals and medical schools offered a bonus ła very special one-to their cleaners from Portugal who have been fado-singers. But perhaps it is better that they should not; maybe the memories they can evoke should be
conjured up only once every
13 years
s
or so. *
Old Mrs. D. suddenly became confused and semiconscious for no reason that I could discover, although she had been very irregular with her Largactil. There had been a previous gas leak and daughter was disturbed about the smell in the house. We both had catarrh and were unsure, and as meter was next door to open fire I phoned the Gas Board and also arranged a domiciliary visit. Consultant, Gas Board, and I arrived simultaneously. Much sniffing of the air as consultant examined patient and could find no obvious cause for her condition-at the same time Gas Board fitted elaborate apparatus and reported no leak to be found. Coming, still sniffing, downstairs, association of smell suddenly struck both of us, and we rushed up with again to confirm that the old lady’s breath was loaded " acetone-daughter meanwhile saying, for first time, she’s been drinking buckets of water for last few weeks-is it diabetes ? " The Gas Board was left to continue its investigations next door-none of us having the face to admit the true cause of the smell. Despite blood-glucose of 1430 mg. per 100 ml., Mrs. D. came under control very quickly and is home again now.
VIRAL HÆMORRHAGIC FEVERS SIR,-On account of your editorial of Oct. 16 (p. 858) we should like to submit the following information. As we have hinted,l-3 some promising attempts have been made to isolate an infectious agent from patients in Sweden, although the experiments were not reliably reproducible. Recently, however, an agent has been isolated from the urine from 3 out of 5 patients and from cultured renalbiopsy specimens from 2 patients. The presence of the agent was indicated by the appearance of a discrete cytopathic effect in inoculated cell-cultures of bovine kidneys. It was found possible to pass the agent indefinitely at titres of 107 per ml. Preliminary studies indicate that the agent is ether-sensitive and will pass a membrane filter with 200 nm. pore size. Department of Clinical Virology, Umeå
University. Department of Clinical Bacteriology, Linköping University. Department of Medicine, Umeå University. Department of Pædiatrics, Sundsvall Hospital, Sweden.
BERTIL HOORN.
SVEN BERGMAN. KURT NYSTRÖM. LARS
SÖDERHJELM.
CONTINUOUS POSITIVE AIRWAYS PRESSURE IN RESPIRATORY-DISTRESS SYNDROME SiR,—The paper of Gregory et al. stimulated us, as it did Dr. Dunn and his colleagues (Oct. 30, p. 971), to use this method of treatment. For reasons we shall give later, we chose intubation as the method of applying continuous
positive airways On
pressure
(C.P.A.P.).
weighing 2090 g. was born by elective elderly primigravida at 34 weeks’ gestation. Pregnancy was complicated by moderately severe pre-eclampsia. Placental function as estimated by oestriols had always been extremely poor, and latterly showed a sudden deterioration. The Apgar score at 1 minute was 5. Oxygen by face-mask was necessary. Respiratory distress was first evident at 2 hours. Chest X-rays confirmed the diagnosis of respiratory-distress syndrome (R.D.S.). Serial blood-gas estimations showed a persistently falling Pao2 despite increases in the inspired-oxygen concentration. At 24 hours of life, when the baby was breathing 90% oxygen, the Pa02 was 30 mm. Hg and C.P.A.P. was commenced at 6 cm. H20. After 15 minutes the Pa02 had risen by 100%. A rise of 2 cm. H2O produced a further 30% increase in Pa02- With C.P.A.P. maintained at 8 cm. H20, we were able to reduce the amount of inspired oxygen over the following 96 hours to that of air. The infant’s respiratory efforts, however, were insufficient to maintain Pac02 at normal levels, and we found it necessary to " hand ventilate " for approximately 2 minutes in every hour over the first 72 hours. This reduced PaC02 by 30-40% on each occasion. When the baby was breathing air, C.P.A.P. was reduced by steps of 2 cm. H20. The final step from 2 cm. H2O to zero could only be safely performed by increasing the percentage of inspired oxygen to 30%. The endotracheal tube was Sept. 17,
cassarean
a
male
section to an
removed 2 hours after C.P.A.P. was discontinued. Treatment with C.P.A.P. was continued for 105 hours. We had no difficulty in maintaining the position of the endotracheal tube. Patency was ensured by hourly suction after the instillation of 0-5 ml. of 1. Nyström, K., Bergman, S., Hoorn, B. Report at XXVII Medicinska Riksstämman, Stockholm; Sammanfattningar av Symposier och Föredrag, 1970, p. 309. 2. Söderhjelm, L. J. inf. Dis. 1971, 124, 107. 3. Bergman, S., Hoorn, B., Nyström, K., Söderhjelm, L. Second International Symposium on Circumpolar Health, Oulu, Finland, June 21-24, 1971. 4. Gregory, G. A., Kitterman, J. A., Phibbs, R. H., Tooley, W. H., Hamilton, W. K. New Engl. J. Med. 1971, 284, 1333.