963

vide general health care as well as contraception.22 On p. 946 this week a report from this centre records experience with the injectable contraceptive, depot medroxyprogesterone. Loss to follow-up was almost nil and continuation-rates were higher than one might expect in view of the formidable side-effects. This contrasts with reports3,4from Thailand which recorded fewer side-effects with this agent but considerable loss to follow-up. Presumably, many of the women who disappeared were unwilling to return after experiencing unpleasant side-effects. Until contraceptives improve, women will need constant access to advice and support. The Bangladesh workers argue fiercely against the

speed-and-numbers approach. Barefoot-doctor programmes depend on large numbers of workers with little education and a short practical training. They must be enthusiastic and conscientious. In addition, they must accept the limits of their knowledge and skill. When a scheme expands too quickly, well-motivated candidates become scarce, teaching and supervision are delegated, and standards are diluted. In the training of paramedical workers, the emphasis is on particular procedures which must be followed to the letter. Decisions on what can be jettisoned and what must be preserved cannot be reached in haste. Unless primary-care workers are carefully trained and perform their work skilfully and conscientiously, the whole concept is at risk. The population statistics are indeed horrifying, but the solution does not lie in crash programmes promising quick results; the need is for a humane approach, and a measure of patience.

screened with 1211-fibrinogen) the satisfactory results that are claimed should be treated with caution. Nevertheless, the technique of ambulant anticoagulation certainly deserves further investigation. Heparin, 20 000 u, was given subcutaneously into the abdominal fat-pad and the bleeding-time was apparently prolonged beyond 20 minutes for the next 24 hours, although the frequency of administration is not stated. (10 000 u heparin subcutaneously has been shown in the past to give heparin levels within the therapeutic range for 12 hours, and self-administration for up to 10 weeks has proved satisfactory in women with placental insuffi-, ciency.7) In the New York study some patients continued to give themselves heparin for many years, but whether this is necessary or has any advantages over conventional oral anticoagulation is impossible to say. Prolonging oral anticoagulation beyond six weeks is probably necessary only in patients with recurrent thrombosis,

pulmonary embolism, or a persistent predisposing cause 8 Only 9 patients had any abnormal bleeding while on subcutaneous heparin and the bleeding always stopped when heparin was withdrawn. As regards haemorrhagic complications, therefore, this type of anticoagulation compares favourably with long-term oral

anticoagulation.9 The exercise programme included daily walking and with a hot bath. Probably this aspect of the treatment is more.important than the anticoagulation, since muscular exercise and heat both stimulate fibrinolysis 10,11and exercise increases blood-flow. Certainly small untreated calf thrombi lyse more rapidly if the patient is taking exercise.12Few of the patients in the New York study were lost to follow-up and there were only seven confirmed episodes of pulmonary embolism, none fatal. On this evidence, exercise does not seem to dislodge thrombi. These ideas ought to be further investigated. Many patients would be saved a lot of misery, and health services a lot of money, if they were shown to be

swimming,

correct.

EXERCISE FOR DEEP-VENOUS THROMBOSIS How should a deep venous thrombosis be treated? In the current enthusiasm for prevention the matter has been almost lost to view. The standard treatment is bed rest and anticoagulation, but the duration of rest and the type and duration of anticoagulation are still controversial. Now some work from New York raises the question of whether rest is necessary at all and employs a novel method of Stillman et al 5 treated all their D.v.T. patients, except those with accompanyingfever or leucocytosis, at home with self-administered subcutaneous heparin, elastic stockings, and a programme of exercise. (Those patients who had a systemic disturbance as well as local signs were admitted to hospital for anticoagulation and later transferred to the home regimen.) Venography was performed in only 119 of the 407 patients, and since this investigation is essential for accurate diagnosis6 (except in patients being

anticoagulation.

2

Lancet, 1976, i, 26. 3 McDaniel, E B. Paper read at International Planned Parenthood Federation meeting, April 26, 1976. 4 IPPF. med.Bull. 1975, 9, no. 1. 5 Stillman, R. M., Chapa, L., Stark, M. L., Malik, L. N., Keates, J. R. W., Sawyer, P N. Surgery Gynec. Obstet. 1977, 145, 193. 6 Tibbutt, D. A. D M. thesis, University of Oxford, 1976.

JOINING UP THE LOWER GUT

SURGEONS fuss about technique, and rightly so because the best of bedside manners and the finest of postoperative care is as naught by comparison with getting the cutting and sewing right. (A live patient is an essential preliminary to exercising the finer points of social interaction.) There are aspects of surgical technique which defy the analysis which would enable us to distinguish the adequate from the inadequate surgeon. Even the best technique can fail when the operator lacks touch or judgment. That individual surgical flair and the fruits of long experience remain paramount is no excuse for not seeking better surgical methods. An essential preliminary is demonstration that current practice is inadequate. Goligher and his colleagues’ did a great service by pointing out that colo-rectal anastomosis is 7. Bonnar, J., Denson, K. W. E., Biggs, R. Lancet, 1972, ii, 539. 8. Sullivan, E. F. Med. J. Aust. 1972, ii, 1104. 9. Pastor, B. H., Resnick, M. E., Rodman, T. J. Am. med. Ass. 1962, 180, 747. 10. Cash, J. D., Woodfield, D. G. Br. med. J. 1968, ii, 658. 11. Britton, B. J., Hawkey, C. Peele, M., Kaye, J., Irving, M. H. ibid. 1974, ii, 139. 12. Flanc, C., Kakkar, V. V., Clarke, M. B. Lancet, 1969, i, 477. 1. Goligher, J. C., Graham, W. G., De Dombal, F. T. Br. J. Surg. 1970, 57, 109.

Exercise for deep-venous thrombosis.

963 vide general health care as well as contraception.22 On p. 946 this week a report from this centre records experience with the injectable contrac...
150KB Sizes 0 Downloads 0 Views