102 the the
corresponding conceptions seem to coincide with those of highest birth-rate. Therefore peaks in the conception curve may be expected to be levelled out, and the troughs are difficult
to
explain by excessive pregnancy wastage.
Thirdly, spontaneous intrauterine mortality after pill use is said not necessarily to imply a harmful after-effect. We do not agree with this statement because intrauterine loss seems to be only a small part of the "continuum of reproductive menstrual cycles after disconcasualty"." In fact in the first tinuing oral contraceptives18 19 a protraction of the pre-ovulatory phase has been noted.111-20 Therefore in these situations, an increased risk of pre-ovulatory overripeness and ensuing ovopathy can, theoretically, be expected." These aspects, we suggest, might be included in the clinical and laboratory studies we and Janerich et al. plead for. Huize "Marie Roepaan", Centre of Observation and Treatment of Mental Retardates, Ottersum (L.), Netherlands Institute of Human Free University,
P.
H. JONGBLOET
Genetics,
These data confirm the association of colitis with S. enteritidis infection; small-bowel changes appear less prominent. The possible role of an enterotoxin similar to those excreted by Vibrio cholerce and enteropathogenic Escherichia coli strainsz3 requires elucidation. Departments of Microbiology, Pædiatrics and Pathology, Faculty of Medicine, University of Natal, South Africa
P. C. APPELBAUM
J. SCRAGG M. M. SCHONLAND
SIR,-We are grateful to Dr Thomas and Mrs Tillett23 for drawing our attention to their interesting work,24 showing the frequency of dysenteric features in Salmonella infections, because it provides good indirect evidence in support of our view that colonic involvement occurs commonly in human salmonellosis.2 We have not, however, noted any special propensity for S. typhimurium to cause colonic involvement; approximately half of our colitic cases (9 out of 21) had S. typhimurium infection, "other salmonellas" accounting for the rest.
J. H. J. ZWETS
Amsterdam
Regional Department
of Infectious Diseases,
Monsall Hospital, Manchester 10
B. K. MANDAL V. MANI
COLONIC INVOLVEMENT IN SALMONELLOSIS
ANÆSTHESIA FOR SHORT-STAY SURGERY
SIR,-We read with interest the article by Mandal and Mani,21 and wish to confirm their findings. We have reviewed case-histories of 68 children from whom Salmonella enteritidis serotypes had been isolated from stools during life and who subsequently died and were examined post mortem. Most patients (87%) were in the first year of life. At death, nutritional status varied: 18 children were well nourished, 16 had suboptimal nutritional status, 24 were marasmic, and 10 had kwashiorkor. Various disease processes were evident at necropsy and macroscopic gut lesions were present in 46 cases:
SIR,-Prescott et al.26 conclude that atropine/droperidol premedication is preferable to atropine alone or atropine/diazepam in anaesthesia for major day surgery because it causes less nausea, headache, and pain postoperatively. In my study comparing different types of general anaesthesia in short-stay surgery27 patients were premedicated with atropine 0.1 mg/10kg and pethidine 1 mg/kg. The anaathetic technique in my halothane group (47 patients) seems to be similar to that used by Prescott et al. except that induction was done with propanidid (’Epontol’) instead of thiopentone. All patients were women being operated on for varicose veins with stripping and Trendelenburg. The patients stayed in hospital overnight. On the morning after surgery 7% complained of nausea, 2% of vomiting, and 8% of headache, frequencies which are less than those in the atropine/droperidol group reported on by Prescott et al. who recorded nausea in 19% and headache in 17%. In my study 15% of patients complained of dizziness and 2% of drowsiness. These different results may be due to the different premedications or on the differences between Finnish and Scottish populations. Furthermore the same anaesthetic techniques in different hands can give different results. When the effect of premedications is studied in short-stay surgery the patient groups should be as homogeneous as possible with regard to sex, age, and operation performed. The evaluation of recovery should be based not only on the occurrence of nausea, headache, and pain but also on other indices such as motor coordination and ability to concentrate. Few drug combinations for premedication have been compared so far. Droperidol is long-acting, and it affects motor coordination for at .least 10 h.28 Several other drug combinations should be studied before firm recommendations on premedication for short-stay surgery are made. A study of this kind is under way in the department of anuesthesiology, University of Helsinki.
No. 10 9
Necropsy findings Enterocolitis (E.C.) only E.c. E.C.
with marantic thrombosis with marantic thrombosis and
2 17 4
bronchopneumonia with bronchopneumonia E.c. with systemic candidiasis E.c.
with meningtis/pyelonepktritis/hepatic necrosis
E.c.
4
The 22 cases without macroscopic evidence of gut lesions died of a miscellany of diseases including bronchopneumonia, meningitis, non-specific liver necrosis, cirrhosis, tuberculosis, and cerebral abscess. Macroscopic examination of the bowel at necropsy revealed lesions in small and large intestine in 30 (44%), colonic lesions only in 9 (13%), and small-intestinal lesions in 7 (10%) cases. A variety of macroscopic lesions was found, including mucosal hyperaemia and oedema, superficial haemorrhage and ulceration, and lymphoid hyperplasia. The small bowel was occasionally dilated, and 2 cases showed pneumatosis coli. Histological examination of the bowel was undertaken in 23 cases. Large-bowel sections were reviewed in 16, small bowel in 5, and in the remainder both were available. Superficial ulceration with a predominantly mononuclear-cell infiltration was a feature in 9 colonic sections. In 3 of these the ulceration extended deep into the muscularis mucosae, and in 1 signs of peritonitis were present. More commonly, changes were less specific, especially in the small bowel; these included hypersemia and oedema (7) and lymphoid hyperplasia (4); in 5 cases the histological picture was normal. 18. Larsson-Cohn, U. ibid. 1969, 48, 416. 19. Homesley, H. D., Goss, D. A. Obstet. Gynœc. 1970, 35, 734. 20. Girotti, M. Ovulationshemmer und Reproduktive Funktion. Bern, 1975. 21 Mandal, B. K., Mani, V. Lancet, 1976, i, 887. 22. Kantor, H. S. J. infect. Dis. 1975, 131, suppl.
S22.
Department of Anæsthesiology, Meilahti University Central Hospital, 00290 Helsinki 29, Finland
ULLA AROMAA
Thomas, M., Tillett, H. Lancet, 1976, i, 1129. Thomas, M., Mogford, H. E. J. Hyg, Camb. 1970, 68, 663. Mandal, B. K., Mani, V. Lancet, 1976, i, 887. Prescott, R. J., Espley, A. J., Davie, I. T., Slawson, K. B., Ruckley, C Lancet, 1976, i, 1148. 27. Aromaa, U. Ann. Chir. Gynœc. fenn. 1974, suppl. 187, p. 63. 28. Korttila, K., Linnoila, M. Br. J. Anœsth. 1974, 46, 961.
23. 24. 25. 26.
corresponding conceptions seem to coincide with those of highest birth-rate. Therefore peaks in the conception curve may be expected to be levelled out, and the troughs are difficult
to
explain by excessive pregnancy wastage.
Thirdly, spontaneous intrauterine mortality after pill use is said not necessarily to imply a harmful after-effect. We do not agree with this statement because intrauterine loss seems to be only a small part of the "continuum of reproductive menstrual cycles after disconcasualty"." In fact in the first tinuing oral contraceptives18 19 a protraction of the pre-ovulatory phase has been noted.111-20 Therefore in these situations, an increased risk of pre-ovulatory overripeness and ensuing ovopathy can, theoretically, be expected." These aspects, we suggest, might be included in the clinical and laboratory studies we and Janerich et al. plead for. Huize "Marie Roepaan", Centre of Observation and Treatment of Mental Retardates, Ottersum (L.), Netherlands Institute of Human Free University,
P.
H. JONGBLOET
Genetics,
These data confirm the association of colitis with S. enteritidis infection; small-bowel changes appear less prominent. The possible role of an enterotoxin similar to those excreted by Vibrio cholerce and enteropathogenic Escherichia coli strainsz3 requires elucidation. Departments of Microbiology, Pædiatrics and Pathology, Faculty of Medicine, University of Natal, South Africa
P. C. APPELBAUM
J. SCRAGG M. M. SCHONLAND
SIR,-We are grateful to Dr Thomas and Mrs Tillett23 for drawing our attention to their interesting work,24 showing the frequency of dysenteric features in Salmonella infections, because it provides good indirect evidence in support of our view that colonic involvement occurs commonly in human salmonellosis.2 We have not, however, noted any special propensity for S. typhimurium to cause colonic involvement; approximately half of our colitic cases (9 out of 21) had S. typhimurium infection, "other salmonellas" accounting for the rest.
J. H. J. ZWETS
Amsterdam
Regional Department
of Infectious Diseases,
Monsall Hospital, Manchester 10
B. K. MANDAL V. MANI
COLONIC INVOLVEMENT IN SALMONELLOSIS
ANÆSTHESIA FOR SHORT-STAY SURGERY
SIR,-We read with interest the article by Mandal and Mani,21 and wish to confirm their findings. We have reviewed case-histories of 68 children from whom Salmonella enteritidis serotypes had been isolated from stools during life and who subsequently died and were examined post mortem. Most patients (87%) were in the first year of life. At death, nutritional status varied: 18 children were well nourished, 16 had suboptimal nutritional status, 24 were marasmic, and 10 had kwashiorkor. Various disease processes were evident at necropsy and macroscopic gut lesions were present in 46 cases:
SIR,-Prescott et al.26 conclude that atropine/droperidol premedication is preferable to atropine alone or atropine/diazepam in anaesthesia for major day surgery because it causes less nausea, headache, and pain postoperatively. In my study comparing different types of general anaesthesia in short-stay surgery27 patients were premedicated with atropine 0.1 mg/10kg and pethidine 1 mg/kg. The anaathetic technique in my halothane group (47 patients) seems to be similar to that used by Prescott et al. except that induction was done with propanidid (’Epontol’) instead of thiopentone. All patients were women being operated on for varicose veins with stripping and Trendelenburg. The patients stayed in hospital overnight. On the morning after surgery 7% complained of nausea, 2% of vomiting, and 8% of headache, frequencies which are less than those in the atropine/droperidol group reported on by Prescott et al. who recorded nausea in 19% and headache in 17%. In my study 15% of patients complained of dizziness and 2% of drowsiness. These different results may be due to the different premedications or on the differences between Finnish and Scottish populations. Furthermore the same anaesthetic techniques in different hands can give different results. When the effect of premedications is studied in short-stay surgery the patient groups should be as homogeneous as possible with regard to sex, age, and operation performed. The evaluation of recovery should be based not only on the occurrence of nausea, headache, and pain but also on other indices such as motor coordination and ability to concentrate. Few drug combinations for premedication have been compared so far. Droperidol is long-acting, and it affects motor coordination for at .least 10 h.28 Several other drug combinations should be studied before firm recommendations on premedication for short-stay surgery are made. A study of this kind is under way in the department of anuesthesiology, University of Helsinki.
No. 10 9
Necropsy findings Enterocolitis (E.C.) only E.c. E.C.
with marantic thrombosis with marantic thrombosis and
2 17 4
bronchopneumonia with bronchopneumonia E.c. with systemic candidiasis E.c.
with meningtis/pyelonepktritis/hepatic necrosis
E.c.
4
The 22 cases without macroscopic evidence of gut lesions died of a miscellany of diseases including bronchopneumonia, meningitis, non-specific liver necrosis, cirrhosis, tuberculosis, and cerebral abscess. Macroscopic examination of the bowel at necropsy revealed lesions in small and large intestine in 30 (44%), colonic lesions only in 9 (13%), and small-intestinal lesions in 7 (10%) cases. A variety of macroscopic lesions was found, including mucosal hyperaemia and oedema, superficial haemorrhage and ulceration, and lymphoid hyperplasia. The small bowel was occasionally dilated, and 2 cases showed pneumatosis coli. Histological examination of the bowel was undertaken in 23 cases. Large-bowel sections were reviewed in 16, small bowel in 5, and in the remainder both were available. Superficial ulceration with a predominantly mononuclear-cell infiltration was a feature in 9 colonic sections. In 3 of these the ulceration extended deep into the muscularis mucosae, and in 1 signs of peritonitis were present. More commonly, changes were less specific, especially in the small bowel; these included hypersemia and oedema (7) and lymphoid hyperplasia (4); in 5 cases the histological picture was normal. 18. Larsson-Cohn, U. ibid. 1969, 48, 416. 19. Homesley, H. D., Goss, D. A. Obstet. Gynœc. 1970, 35, 734. 20. Girotti, M. Ovulationshemmer und Reproduktive Funktion. Bern, 1975. 21 Mandal, B. K., Mani, V. Lancet, 1976, i, 887. 22. Kantor, H. S. J. infect. Dis. 1975, 131, suppl.
S22.
Department of Anæsthesiology, Meilahti University Central Hospital, 00290 Helsinki 29, Finland
ULLA AROMAA
Thomas, M., Tillett, H. Lancet, 1976, i, 1129. Thomas, M., Mogford, H. E. J. Hyg, Camb. 1970, 68, 663. Mandal, B. K., Mani, V. Lancet, 1976, i, 887. Prescott, R. J., Espley, A. J., Davie, I. T., Slawson, K. B., Ruckley, C Lancet, 1976, i, 1148. 27. Aromaa, U. Ann. Chir. Gynœc. fenn. 1974, suppl. 187, p. 63. 28. Korttila, K., Linnoila, M. Br. J. Anœsth. 1974, 46, 961.
23. 24. 25. 26.
