312
both the volumes. None accurately assessed only one of the two volumes. There was no correlation between the degree of accuracy and the education status or age of the mother. We conclude that mothers grossly overestimate emesis volumes by visual inspection. One should therefore not base fluid replacements on mothers’ estimates, especially in the small infant. FRANCY PILLO-BLOCKA KRISTA JURIMAE VIKRAM KHOSHOO STANLEY ZLOTKIN
Division of Clinical Nutrition, Department of Paediatrics, Hospital for Sick Children, Toronto, Canada M5G 1 X8
should be taken to avoid damage to the amniotic membrane. The placental site is very dependent on the uterine position, which can be easily altered by the degree of bladder filling. This, in addition to the choice of the appropriate angle of needle insertion, should allow direct placental sampling irrespective of position. As far as we are aware no other centre practises penetration of the amniotic sac to sample "posterior" placentas, and in view of the excessive fetal loss we suggest that this technique is not used at any gestation. We still believe that transabdominal CVScan be done safely, with a low fetal loss rate, between 10 and 12 weeks’ gestation for all maternal ages.3 Birmingham Maternity Hospital,
Jejunal secretion
in short bowel
syndrome
SIR,-Dr Gerson (Dec 1, p 1379) suggests that parenteral fluids may contribute to the high intestinal output of patients with a short bowel ending in a jejunostomy. However, jejunostomy output does not decrease if a patient is dehydrated or given aldosteronel and it is unlikely that jejunostomy output would increase if excess parenteral fluid is given. Our patients (Sept 29, p 765) received only enough parenteral fluid and electrolyte supplement to compensate for their obligatory intestinal losses, so maintaining normal hydration and urine output. The normal physiology of a high jejunostomy was shown in 6 healthy people in whom a test meal was diluted three to five fold in the duodenum by exocrine secretions, which persisted to a distance of 130 cm from the nose, which corresponded to the upper jejunum.2 When a steak meal of homogenised volume 645 ml was fed to 5 normal subjects the volume increased to about 1500 ml in the mid-duodenum and 750 ml in the upper jejunum.3 We have confirmed this observation in healthy subjects who took a liquid test meal .4
1.
Jackson L, Wapner R Risk of chorionic villus sampling. Clinics Obstet Gynaecol 1987,
1: 513-31 2. Mackenzie WE, Holmes DS, Newton JR A study comparing transcervical with transabdominal chorionic villus sampling Br J Obstet Gynaecol 1988; 95: 75-78 3 McCormack MJ, Mackenzie WE. Chorionic villus sampling Lancet 1990, 336: 637.
A
unique Fothergillian medal
SiR,—The bicentennial of the award of the first (John)
Fothergillian gold medal to Robert Willan (1757-1812)’ led us to re-examine the two Fothergillian medals in the Brettauer collection in Vienna.2 Of the original six (John) Fothergillian gold medals awarded between 1787 and 18033 (a seventh was presented to Kmg George III and is in the British Museum) only the one awarded to Willan has survived, and it is held by the Medical Society of London. Willan was given the medal for his dermatological treatise in 1790 on March 8, John Fothergill’s birthday.
J. M. D. NIGHTINGALE J. E. LENNARD-JONES
St Mark’s Hospital, London EC1V 2PS, UK 1.
M. J. MCCORMACK W. E. MACKENZIE
Queen Elizabeth Medical Centre, Birmingham B15 2TG, UK
Ladefoged K, Olgaard K. Sodium homeostasis after small-bowel resection. ScandJ Gastroenterol 1985; 20: 361-69
Borgstrom B, Dahlqvist A, Lundh G, Sjovall J Studies of intestinal digestion and absorption in the human. J Clin Invest 1957; 36: 1521-36 3. Fordtran JS, Locklear TW. Ionic constituents and osmolality of gastric and small intestinal fluids after eating. Am J Dig Dis 1966; 11: 503-21. 4. Rodrigues CA, Walker ER, Thompson DG, Farthing MJG, Lennard-Jones JE. Can net fluid loss in short bowel patients after a meal be explained by normal endogenous secretion? Gut 1989; 30: A719.
2
Belching SIR,-Your Jan
5 editorial misses
one
important point-most
Chaimberlaine’s
Fothergillian Medal.
reads. "Soc Med London Gulielmo Inscription (reverse) Chaimberlaine Octo Anms E Secretis" Obverse shows bust of John Fothergill. (Courtesy of the Brettauer Collection of Coins and Medals, Faculty of Medicine, University of Vienna )
belches in a patient complaining of "wind" are not of gastric origin. If one asks such a patient to belch during a fluoroscopic examination he or she will swallow a bolus of air into the oesophagus, then regurgitate it with satisfaction. It may be that a small amount of oesophageal air is the initial irritant and is relieved by adding to it to allow a belch. Gastric belches can be identified by their taste: oesophageal belches are tasteless. 23 Anson Road, Manchester M14 5BZ, UK
J. G. B. RUSSELL
Transabdominal chorionic villus
sampling
SIR,-Dr Saura and colleagues (Dec 1, p 1385) emphasise that the fetal loss rate was greater with posterior placentas than with other positions (18% vs 1-6%) because penetration of the amniotic membrane was necessary with their technique. These results might be expected, since membrane damage or rupture during chorionic villus sampling could be responsible for subsequent spontaneous abortion.1 We have now done transabdominal chorionic villus sampling (CVS) in a total of 942 women between 10 and 12 weeks’ gestation without the need to penetrate the amniotic membrane during any of the procedures. We used the transabdominal method in 652 patients2 and had no technical difficulty with any placental position. Our spontaneous abortion rate is 1.4%. In our experience of transabdominal CVS the placental position should have no effect on the sampling technique, and great care
The Brettauer collection of about 7000 coins and medals relating medicine, healing, and physicians contains two Fothergilhan medals. One is an (Anthony) Fothergilhan medal awarded to the surgeon Walter Cooper Dendy (1794-1871) in 1845, and erroneously referred to in Holzmair’s catalogue as "William Cooper". The other is a silver, gilded (John) Fothergillian medal, dedicated to a London surgeon William Chaimberlaine (1747to
1822). The list of recipients between 1787 and 1803 does not mention Chaimberlaine but the minutes book of the Medical Society of London shows that in 1794 he was awarded a silver medal, cast from the original mould, for his services to the Society as its honorary secretary for eight years. How this found its way into the Brettauer collection is not known. No comparable silver medal was awarded by the Medical Society of London. This seems to be a unique piece, awarded for administrative rather than scientific merit. Institute for the History of Medicine, A-1090 Vienna, Austria
KARL HOLUBAR
Faculty of History of Medicine, Society of Apothecaries, London, UK
ALEX SAKULA
1. Holubar K The award of the Fothergillian gold medal to Robert Willan in 1790 a bicentennial not to be forgotten. J Invest Dermatol 1991, 96: 292-93 2 Holubar K, Sakula A. William Chaimberlaine (1747-1822) and his Fothergilian
medal Wien Klin Wochenschr (in press) 3. Booth CC. The Fothergillian medals of the Medical 1981, 15: 254-58
Society of London J R Coll Phys
both the volumes. None accurately assessed only one of the two volumes. There was no correlation between the degree of accuracy and the education status or age of the mother. We conclude that mothers grossly overestimate emesis volumes by visual inspection. One should therefore not base fluid replacements on mothers’ estimates, especially in the small infant. FRANCY PILLO-BLOCKA KRISTA JURIMAE VIKRAM KHOSHOO STANLEY ZLOTKIN
Division of Clinical Nutrition, Department of Paediatrics, Hospital for Sick Children, Toronto, Canada M5G 1 X8
should be taken to avoid damage to the amniotic membrane. The placental site is very dependent on the uterine position, which can be easily altered by the degree of bladder filling. This, in addition to the choice of the appropriate angle of needle insertion, should allow direct placental sampling irrespective of position. As far as we are aware no other centre practises penetration of the amniotic sac to sample "posterior" placentas, and in view of the excessive fetal loss we suggest that this technique is not used at any gestation. We still believe that transabdominal CVScan be done safely, with a low fetal loss rate, between 10 and 12 weeks’ gestation for all maternal ages.3 Birmingham Maternity Hospital,
Jejunal secretion
in short bowel
syndrome
SIR,-Dr Gerson (Dec 1, p 1379) suggests that parenteral fluids may contribute to the high intestinal output of patients with a short bowel ending in a jejunostomy. However, jejunostomy output does not decrease if a patient is dehydrated or given aldosteronel and it is unlikely that jejunostomy output would increase if excess parenteral fluid is given. Our patients (Sept 29, p 765) received only enough parenteral fluid and electrolyte supplement to compensate for their obligatory intestinal losses, so maintaining normal hydration and urine output. The normal physiology of a high jejunostomy was shown in 6 healthy people in whom a test meal was diluted three to five fold in the duodenum by exocrine secretions, which persisted to a distance of 130 cm from the nose, which corresponded to the upper jejunum.2 When a steak meal of homogenised volume 645 ml was fed to 5 normal subjects the volume increased to about 1500 ml in the mid-duodenum and 750 ml in the upper jejunum.3 We have confirmed this observation in healthy subjects who took a liquid test meal .4
1.
Jackson L, Wapner R Risk of chorionic villus sampling. Clinics Obstet Gynaecol 1987,
1: 513-31 2. Mackenzie WE, Holmes DS, Newton JR A study comparing transcervical with transabdominal chorionic villus sampling Br J Obstet Gynaecol 1988; 95: 75-78 3 McCormack MJ, Mackenzie WE. Chorionic villus sampling Lancet 1990, 336: 637.
A
unique Fothergillian medal
SiR,—The bicentennial of the award of the first (John)
Fothergillian gold medal to Robert Willan (1757-1812)’ led us to re-examine the two Fothergillian medals in the Brettauer collection in Vienna.2 Of the original six (John) Fothergillian gold medals awarded between 1787 and 18033 (a seventh was presented to Kmg George III and is in the British Museum) only the one awarded to Willan has survived, and it is held by the Medical Society of London. Willan was given the medal for his dermatological treatise in 1790 on March 8, John Fothergill’s birthday.
J. M. D. NIGHTINGALE J. E. LENNARD-JONES
St Mark’s Hospital, London EC1V 2PS, UK 1.
M. J. MCCORMACK W. E. MACKENZIE
Queen Elizabeth Medical Centre, Birmingham B15 2TG, UK
Ladefoged K, Olgaard K. Sodium homeostasis after small-bowel resection. ScandJ Gastroenterol 1985; 20: 361-69
Borgstrom B, Dahlqvist A, Lundh G, Sjovall J Studies of intestinal digestion and absorption in the human. J Clin Invest 1957; 36: 1521-36 3. Fordtran JS, Locklear TW. Ionic constituents and osmolality of gastric and small intestinal fluids after eating. Am J Dig Dis 1966; 11: 503-21. 4. Rodrigues CA, Walker ER, Thompson DG, Farthing MJG, Lennard-Jones JE. Can net fluid loss in short bowel patients after a meal be explained by normal endogenous secretion? Gut 1989; 30: A719.
2
Belching SIR,-Your Jan
5 editorial misses
one
important point-most
Chaimberlaine’s
Fothergillian Medal.
reads. "Soc Med London Gulielmo Inscription (reverse) Chaimberlaine Octo Anms E Secretis" Obverse shows bust of John Fothergill. (Courtesy of the Brettauer Collection of Coins and Medals, Faculty of Medicine, University of Vienna )
belches in a patient complaining of "wind" are not of gastric origin. If one asks such a patient to belch during a fluoroscopic examination he or she will swallow a bolus of air into the oesophagus, then regurgitate it with satisfaction. It may be that a small amount of oesophageal air is the initial irritant and is relieved by adding to it to allow a belch. Gastric belches can be identified by their taste: oesophageal belches are tasteless. 23 Anson Road, Manchester M14 5BZ, UK
J. G. B. RUSSELL
Transabdominal chorionic villus
sampling
SIR,-Dr Saura and colleagues (Dec 1, p 1385) emphasise that the fetal loss rate was greater with posterior placentas than with other positions (18% vs 1-6%) because penetration of the amniotic membrane was necessary with their technique. These results might be expected, since membrane damage or rupture during chorionic villus sampling could be responsible for subsequent spontaneous abortion.1 We have now done transabdominal chorionic villus sampling (CVS) in a total of 942 women between 10 and 12 weeks’ gestation without the need to penetrate the amniotic membrane during any of the procedures. We used the transabdominal method in 652 patients2 and had no technical difficulty with any placental position. Our spontaneous abortion rate is 1.4%. In our experience of transabdominal CVS the placental position should have no effect on the sampling technique, and great care
The Brettauer collection of about 7000 coins and medals relating medicine, healing, and physicians contains two Fothergilhan medals. One is an (Anthony) Fothergilhan medal awarded to the surgeon Walter Cooper Dendy (1794-1871) in 1845, and erroneously referred to in Holzmair’s catalogue as "William Cooper". The other is a silver, gilded (John) Fothergillian medal, dedicated to a London surgeon William Chaimberlaine (1747to
1822). The list of recipients between 1787 and 1803 does not mention Chaimberlaine but the minutes book of the Medical Society of London shows that in 1794 he was awarded a silver medal, cast from the original mould, for his services to the Society as its honorary secretary for eight years. How this found its way into the Brettauer collection is not known. No comparable silver medal was awarded by the Medical Society of London. This seems to be a unique piece, awarded for administrative rather than scientific merit. Institute for the History of Medicine, A-1090 Vienna, Austria
KARL HOLUBAR
Faculty of History of Medicine, Society of Apothecaries, London, UK
ALEX SAKULA
1. Holubar K The award of the Fothergillian gold medal to Robert Willan in 1790 a bicentennial not to be forgotten. J Invest Dermatol 1991, 96: 292-93 2 Holubar K, Sakula A. William Chaimberlaine (1747-1822) and his Fothergilian
medal Wien Klin Wochenschr (in press) 3. Booth CC. The Fothergillian medals of the Medical 1981, 15: 254-58
Society of London J R Coll Phys
