282 unrelated to effort or emotion. For three years before operation she was treated for moderate hypertension. Case 4.6-A 40-year-old woman admitted to hospital with ten " years’ history of migraine ". B.P. noted to be high only once; at several other observations B.P. was normal. On the day of hospital admission she complained of substernal pressure and nausea. Shock, B.P. 75; 60, and pulmonary redema developed. E.c.G. showed anteroseptal myocardial infarction. At necropsy, the coronary arteries were patent, no atherosclerotic changes. She also had right adrenal phaeochromocytoma. Case —A 22-year-old man was seen because of excessive sweating episodes. He had spent four years in the U.S. Army. B.P. was normal on admission to the Army. Two years earlier he was admitted to hospital with " headache ", and B.P. then was 180/150. On Feb. 24, 1948, he was operated on and a right adrenal phaeochromocytoma was removed. Two hours postoperatively he had an acute posterior myocardial infarction. Case 6.8-A 22-year-old man had a fatal acute myocardial infarction. He was known to have had headaches for the previous two years. B.p. then was 160-240/120-160 and cardiomegaly was also found. Necropsy showed a recent posterior myocardial infarction and a left adrenal phxochromocytoma.
The early results of our survey point in the same direction as these case-reports. The fact that the frequency of acute myocardial infarction is sizeable in patients with phseochromocytoma who do not have persistent hypertension seems to support the hypothesis that excessive sudden stimulation of p-receptors in the heart could lead to myocardial infarction in man. The results of trials on larger numbers of patients and longer follow-up along lines similar to those of Wilhelmsson et al., if confirmatory of their findings, may really prove to be the turning-point in our thinking about the possible preventive use of drugs in patients who have had a myocardial infarction, and, maybe later, in those patients thought to be prone to it-e.g., those with hypertension, diabetes, or a strong family history. University Department of Medicine, Martin Wing, General Infirmary, Leeds LS1 3EX.
K. K. GUPTA.
A TIME TO BE BORN
SiR,—Ihave been prompted by your leader on induction of labour (Nov. 16, p. 1183) to relate my own experience of two very different births. My first child was born naturally in 1967 while I was suffering from toxaemia. The first stage of labour lasted 15 hours, the second stage 1 hour, and the third stage 10 minutes. During the actual birth I required no anaesthetics and my husband was present; it was a very rewarding experience. My second child was born in October last year. I again had the same symptoms during pregnancy, and was admitted to hospital to be induced. I approached the birth in a state of happy expectancy and confidence, since the procedure had been explained to me. However, I received a severe shock. The membranes were ruptured, causing extreme pain and great mental distress. Then the oxytocin drip was set up, and about 10 minutes later contractions started, roughly 40 minutes apart at first. Later they were coming every 2 minutes and were very painful; at no time ride it ". Injections had could I control the pain and no effect, and I was thankful to be given gas-and-air, but the pain was so great and so regular that I could not use it without assistance. Finally, I was roused and told to push. After the third push I was told to stop, and the baby was delivered by forceps. My immediate reaction was relief that it was over, instead of a feeling of achievement. "
6. 7.
8.
Pelkonen, R., Pitkanen, E. Acta med. scand. 1963, 173, 41. Wilkins, R. W., Greer, W. E. R., Culbertson, J. W., Halperin, M. H., Litter, J., Burnett, C. H., Smithwick, R. H. Archs intern. Med. 1952, 86. 51. Priest, W. M. Br. med. J. 1952, ii 860.
a great deal of pain, and required 3 weeks to recover, compared with 11 days on the previous occasion. The whole birth was a very distressing experience and one I will not repeat. I realise that, in my case, the life of my baby and myself could not be risked by allowing the pregnancy to continue, but if I, understanding this and having confidence in my doctors, could experience such distress and pain, what must the effect be on women who are being induced to suit the convenience of the hospital authorities ? I appeal to all hospital staff to remember that women in labour. are human beings, and to allow them to have their babies with pleasure and dignity.
Afterwards, I had
6 Parc Hen
Bias, Llanfairfechan, Gwynedd LL33 0RW, North Wales.
LESLEY J. STRAIN.
EMERGENCY DOMICILIARY TREATMENT FOR HÆMOPHILIA SIR,-Le Quesne et al.1 reported a home treatment programme for haemophiliacs in which close relatives of patients learnt to prepare and administer plasma fractions. We would like to report the findings of a small pilot study in which a State-registered nurse, trained specifically in giving plasma fractions to haemophiliacs, provided a limited domiciliary service. There are several advantages of this modification to the usual home-treatment programmes; documentation is easier to control, samples for assays and screening for HBAg can be carried out more easily, and venepuncture tends to be of,a higher standard. It is also possible in such a scheme to include patients whose relatives would not be suitable for a routine home-treatment programme of the type described by Le Quesne et al. A disadvantage is that a doctor is not involved, unless the nurse feels that the nature or extent of the bleeding episode warrants further medical opinion; the director of the haemophilia centre has, of course, to agree to be responsible for the nurse. The pilot study ran for six months (July, 1974, to December, 1974). 6 severe haemophiliacs were selected for the study,
ranging from 10 to 33 years. All had a factor vm of less than 1%. 4 took part in the study, and a total of 27 emergency calls were made. At first, patients were diffident about using the service but towards the end of the study more confidence was gained by patients and their relatives; eventually up to 4 ’
calls a week were carried out. The system involved the use of an’Air-Call’ radio system switchboard. Patients would call this number, the nurse would be located, and the visit made within an hour. We felt that the services of a routine hospital switchboard might just as easily have been used; it so happened that one of the patient’s parents had a radio-telephone system at his disposal.’The nurse was on call from 12 noon-11.00 P.M. on Saturdays, 9.00 A.M.-l1.00 P.M. on Sundays and 6.00 p.M.-ll.OO P.M. on weekdays, and was paid the routine rates for on-call services. Only spontaneous and minor bleeding episodes were treated, with either 6 packs of cryoprecipitate cr 500 units of freeze-dried factor vin concentrate (’Hemofil’) as a standard treatment regime. Possible bleeding episodes into chest, abdomen, or skull, and all traumatic bleeding episodes were excluded from the domiciliary service, and treated at the hospital centre.
The
of
"
"
nurse-practitioners in the treatment of haemophilia may be an improvement on some of the existing schemes. Professor Ingram (St. Thomas’s Hospital Haemophilia Centre) has employed a sister for treating haemophilia during working hours. We would be interested use
hear of any other centres using similar schemes for the " after emergency treatment of haemophilia, particularly
to
hours ". Quesne, B., Britten, M. I., Maragaki, C., Dormandy, K. M. Lancet, 1974, ii, 507.
1. Le
The early results of our survey point in the same direction as these case-reports. The fact that the frequency of acute myocardial infarction is sizeable in patients with phseochromocytoma who do not have persistent hypertension seems to support the hypothesis that excessive sudden stimulation of p-receptors in the heart could lead to myocardial infarction in man. The results of trials on larger numbers of patients and longer follow-up along lines similar to those of Wilhelmsson et al., if confirmatory of their findings, may really prove to be the turning-point in our thinking about the possible preventive use of drugs in patients who have had a myocardial infarction, and, maybe later, in those patients thought to be prone to it-e.g., those with hypertension, diabetes, or a strong family history. University Department of Medicine, Martin Wing, General Infirmary, Leeds LS1 3EX.
K. K. GUPTA.
A TIME TO BE BORN
SiR,—Ihave been prompted by your leader on induction of labour (Nov. 16, p. 1183) to relate my own experience of two very different births. My first child was born naturally in 1967 while I was suffering from toxaemia. The first stage of labour lasted 15 hours, the second stage 1 hour, and the third stage 10 minutes. During the actual birth I required no anaesthetics and my husband was present; it was a very rewarding experience. My second child was born in October last year. I again had the same symptoms during pregnancy, and was admitted to hospital to be induced. I approached the birth in a state of happy expectancy and confidence, since the procedure had been explained to me. However, I received a severe shock. The membranes were ruptured, causing extreme pain and great mental distress. Then the oxytocin drip was set up, and about 10 minutes later contractions started, roughly 40 minutes apart at first. Later they were coming every 2 minutes and were very painful; at no time ride it ". Injections had could I control the pain and no effect, and I was thankful to be given gas-and-air, but the pain was so great and so regular that I could not use it without assistance. Finally, I was roused and told to push. After the third push I was told to stop, and the baby was delivered by forceps. My immediate reaction was relief that it was over, instead of a feeling of achievement. "
6. 7.
8.
Pelkonen, R., Pitkanen, E. Acta med. scand. 1963, 173, 41. Wilkins, R. W., Greer, W. E. R., Culbertson, J. W., Halperin, M. H., Litter, J., Burnett, C. H., Smithwick, R. H. Archs intern. Med. 1952, 86. 51. Priest, W. M. Br. med. J. 1952, ii 860.
a great deal of pain, and required 3 weeks to recover, compared with 11 days on the previous occasion. The whole birth was a very distressing experience and one I will not repeat. I realise that, in my case, the life of my baby and myself could not be risked by allowing the pregnancy to continue, but if I, understanding this and having confidence in my doctors, could experience such distress and pain, what must the effect be on women who are being induced to suit the convenience of the hospital authorities ? I appeal to all hospital staff to remember that women in labour. are human beings, and to allow them to have their babies with pleasure and dignity.
Afterwards, I had
6 Parc Hen
Bias, Llanfairfechan, Gwynedd LL33 0RW, North Wales.
LESLEY J. STRAIN.
EMERGENCY DOMICILIARY TREATMENT FOR HÆMOPHILIA SIR,-Le Quesne et al.1 reported a home treatment programme for haemophiliacs in which close relatives of patients learnt to prepare and administer plasma fractions. We would like to report the findings of a small pilot study in which a State-registered nurse, trained specifically in giving plasma fractions to haemophiliacs, provided a limited domiciliary service. There are several advantages of this modification to the usual home-treatment programmes; documentation is easier to control, samples for assays and screening for HBAg can be carried out more easily, and venepuncture tends to be of,a higher standard. It is also possible in such a scheme to include patients whose relatives would not be suitable for a routine home-treatment programme of the type described by Le Quesne et al. A disadvantage is that a doctor is not involved, unless the nurse feels that the nature or extent of the bleeding episode warrants further medical opinion; the director of the haemophilia centre has, of course, to agree to be responsible for the nurse. The pilot study ran for six months (July, 1974, to December, 1974). 6 severe haemophiliacs were selected for the study,
ranging from 10 to 33 years. All had a factor vm of less than 1%. 4 took part in the study, and a total of 27 emergency calls were made. At first, patients were diffident about using the service but towards the end of the study more confidence was gained by patients and their relatives; eventually up to 4 ’
calls a week were carried out. The system involved the use of an’Air-Call’ radio system switchboard. Patients would call this number, the nurse would be located, and the visit made within an hour. We felt that the services of a routine hospital switchboard might just as easily have been used; it so happened that one of the patient’s parents had a radio-telephone system at his disposal.’The nurse was on call from 12 noon-11.00 P.M. on Saturdays, 9.00 A.M.-l1.00 P.M. on Sundays and 6.00 p.M.-ll.OO P.M. on weekdays, and was paid the routine rates for on-call services. Only spontaneous and minor bleeding episodes were treated, with either 6 packs of cryoprecipitate cr 500 units of freeze-dried factor vin concentrate (’Hemofil’) as a standard treatment regime. Possible bleeding episodes into chest, abdomen, or skull, and all traumatic bleeding episodes were excluded from the domiciliary service, and treated at the hospital centre.
The
of
"
"
nurse-practitioners in the treatment of haemophilia may be an improvement on some of the existing schemes. Professor Ingram (St. Thomas’s Hospital Haemophilia Centre) has employed a sister for treating haemophilia during working hours. We would be interested use
hear of any other centres using similar schemes for the " after emergency treatment of haemophilia, particularly
to
hours ". Quesne, B., Britten, M. I., Maragaki, C., Dormandy, K. M. Lancet, 1974, ii, 507.
1. Le
