1163

WARMING EMERGENCY BLOOD-TRANS FUSIONS

JOSEPH B. VANDERVEER, JR.Toppenish, Washington,

U.S.A.

SIR,-It was encouraging to read (April 8, p. 782) the letterfrom Dr. Tacchi emphasising the value of warming emergencyblood-transfusions. The point is one which needs reiteration.The effect of rapidly infusing cold blood is not only " shiver-

ing and much apprehension "--often it is cardiac arrest or

ventricular fibrillation. That such effects are not due to factorsbesides temperature (e.g., citrate intoxication, or pH or

electrolyte changes) was shown by Boyan and Howland 1 in astudy of matched groups of patients who received largevolumes of rapidly transfused blood. Whereas over half of 36patients receiving cold blood developed cardiac arrest, only 1out of 40 patients who received warmed blood did so. My ownobservations have borne this out. When the infusion-rate islow (less than 10 ml. per minute), there is no problem, sincethe body can warm the blood before it reaches the heart. Butwith rapid flow-rates (50-100 ml. per minute), cold blood canupset a delicate balance and cause irreversible shock or cardiacarrest.

Such rapid infusion-rates are common in postpartum andgastrointestinal haemorrhage or after large blood-losses duringmajor surgery. In such cases the simple device illustrated byDr. Tacchi is quite effective. (Often, if several units are to begiven, one may be warmed via the submerged tubing while asecond bottle is set in another warm water-bath.) I have useda convenient modification of the technique in the form of anelectric blood-bank water-bath with an adjustable thermostat.With the thermostat set at about 40 C and six ft. of coiled

tubing (two extension-sets tightly coupled and taped together)in the water, rapidly infused blood can be warmed to bodytemperature.

"THE SAFETY OF ORAL CONTRACEPTIVES"

SIR,-Professor Morrison last week (p. 1097) uses the historyof the oral-contraceptive-safety question as an example ofmedical administration. Unfortunately, by accepting the Dollreport’s account he has omitted the first three years: " In

January 1966, at the request of the Committee on Safety ofDrugs, the Ministry of Health asked the Medical ResearchCouncil for their views. The Council accordingly set up asubcommittee ..." 2

In 1961 was reported the first British case of thromboembol-ism associated with oral-contraceptive medication.3 On June 6,1962, in the House of Lords, Lord Brain, president of theFamily Planning Association, said: " I would urge the govern-ment to hold a watching brief on the clinical tests of oral

contraceptives or, better still, to sponsor such tests them-selves." 4 Lord Brain was also chairman of the Medical

Advisory Council of the F.P.A., which on July 26, 1962, issueda press statement that:

" the Council considers that the MedicalResearch Council should also accept the responsibility for in-vestigating their possible ill-effects." 5 6On Aug. 4, 1962, the British Medical Journal in a strongly

worded annotation on this statement singled out thrombo-embolism as the main risk,6 and attracted wide attention.7 InNovember, 1962, the Medical Research Council appointed acommittee on steroid sex hormones to study " the possiblelong-term effects of administration of steroid sex hormones ". 8aLord Brain accepted this as a fulfilment of his June 6 speech. 9In December, 1962, in the House of Lords, Lord Newton,1. Boyan, C. P., Howland, W. S. J. Am. med. Ass. 1963, 183, 58.2. Medical Research Council Subcommittee Report. Br. med. J. May 6,

1967, p. 355.3. Jordan, W. M. Lancet, 1961, ii, 1146.4. ibid. 1962, i, 1295.5. ibid. 1962, ii, 236.6. Br. med. J. 1962, ii, 315.7. ibid. p. 426.8. ibid. p. 1268.9. Brain, Lord, Parkes, A. S., Bishop, P. M. F. Lancet, 1964, ii, 1329.

agreeing with Lady Summerskill that the committee’s terms ofreference, though " wider ", included thrombosis, added:" I should think that that investigation may well take quite along time."loOn Sept. 1, 1966, the steroid sex hormones committee still

existed but, according to a personal communication, had pub-lished no report. The January, 1966, body is clearly continuinga part of that committee’s function.

ROBERT J. HETHERINGTON.Summerfield Hospital,

Birmingham 18.

EFFECTS OF ORAL CONTRACEPTIVES

GUILLERMO DI PAOLAF. PUCHULUM. ROBINR. NICHOLSONM. MARTIN.

1st Chair of Gynæcology,2149 Córdoba,

Buenos Aires, Argentina.

SIR,-Wynn and Doar’s report 11 of the incidence of abnormalglucose-tolerance tests in women taking oral contraceptivesprompts us to give here the results of a similar investigationwhich confirms their findings.Our study was carried out in 161 women who had been

submitted to various treatments: mestranol, ethinyloestradiol,norethisterone acetate combined with mestranol and norethis-terone combined with ethinyloestradiol. Prednisone/glucose-tolerance tests (P.G.T.T.) showed abnormal responses in 53% ofthe women who had received contraceptives containingmestranol, whereas previously the incidence of pathologicalresponses was 9-4%-a difference of statistical significance.On the other hand the results in patients treated with ethi-nylcestradiol, norethisterone, or both combined, did not

reveal any significant variations of P.G.T.T. The proportion ofabnormal P.G.T.T.S in women who had received mestranol hadno special relation to age, personal history linked with diabetes,obesity index, or obstetric history, but an increased proportionof diabetic curves was observed in women with a familyhistory of diabetes or with incidence of early menarche.A paper on our findings is about to be published.

ORAL CONTRACEPTION AFTER DELIVERY

SIR,-It is thought important to draw attention to certainfacts concerning the use of oral contraceptives in the post-partum period.The main point concerns the physiology of ovulation after

delivery. I have discussed this 12 with particular reference tohow long a mother should wait after having a baby beforestarting oral contraception. From extensive studies,13 I haveemphasised that the earliest day for which there is presumptiveevidence of ovulation is the 42nd day post partum. I have alsoevidence that ovulation occurred premenstrually in some

women-two women in a large series investigated had notmenstruated until 10 weeks after ovulation. Moreover, I havedescribed a post-partum follow-up in a large number of cases inwhich three non-lactating mothers became pregnant 6 weeksafter delivery, but none became pregnant earlier; in these threemothers menstruation had not been re-established. There istherefore considerable doubt whether taking " the pill " as acontraceptive measure should be postponed until after the firstmenstrual period, as is widely suggested-e.g., Kistner,14 whostated that it is generally recommended that oral contraceptionshould be started on day 5 after the first spontaneous period.There is little unanimity of advice given by the various manu-facturers : one advertises: " For convenience of timing, it may10. ibid. 1962, ii, 1231.11. Wynn, V., Doar, J. W. H. ibid. 1966, ii, 715.12. Sharman, A. 5th World Congress of the International Fertility Asso-

tion, Stockholm, June, 1966 (in the press); International Symposium onOral Gestogens, Folkestone, October, 1966 (in the press).

13. Sharman, A. Reproductive Physiology of the Post-Partum Period.Edinburgh, 1966.

14. Kistner, R. W. Postgrad. Med. 1966, 39, 207.