- Email: [email protected]
ADDICTION TO PLASTER?
795
administrations
recurs
so
frequently
in these
cases
of the
postoperative hepatic necrosis that it suggests to us inadvisability of a second administration of the drug to anyone patient, unless this is specifically indicated, at least, until the pathogenesis of the condition is established.
Where its use on a second occasion is considered necessary, preoperative liver-function tests should be carried out. The discovery of any abnormality should be an absolute contraindication to further exposure.
Summary A patient who died of postoperative massive hepatic necrosis had had three anaesthetics in which halothane was used in the three weeks before the onset of jaundice. We wish to thank Mr. N. G. Godfrey for permission to publish chnical details of this case; and Mr. J. F. Hibbert, coroner for Central Cheshire, for the necropsy findings. REFERENCES British Medical Journal (1963) i, 1494. Chamberlain, G. C. (1963) ibid. p. 1524. Drummond Hart, D. (1963) ibid. p. 1674. Florey, M. E. (1960) The Clinical Application of Antibiotics;
Oxford.
vol. 4, p. 153.
Gordon, J. (1963) Anœsthesia, 18, 299. Heidenberg, W. J., Torio, I. S., Cebula, J. (1963) Lancet, i, 1185. Lancet (1963a), i, 1195. — (1963b) ii, 818. Lmdenbaum, J., Leifer, E. (1963) New Engl. J. Med. 268, 525. New England Journal of Medicine (1963) 268, 558. Schultz, J. C., Adamson, J. S., Jr., Workman, W. W., Norman, T. D. (1963) New Engl. J. Med. 269, 999. Temple, R. L., Cote, R.A., Gorens, S. W. (1962) Curr. Res. Anesth. 41, 586. Wilims, W. (1963) Personal communication. Witts, L. J. (1963) Lancet, ii, 1004.
ADDICTION TO PLASTER? ALAN W. F. LETTIN M.B., B.Sc. Lond., F.R.C.S. MOST people are extremely anxious to be rid of a plaster cast; it comes as somewhat of a surprise, therefore, to find a patient who has willingly tolerated a plaster-ofparis spinal jacket unchanged for 12 years. In 1934 a lady’s maid, aged 26, sought advice for backache which had been troubling her since a fall 2 years earlier. Investigation revealed no cause for the pain, and she was admitted to hospital and made to rest in a plaster bed. The patient gained some relief from her symptoms, and wore a plaster jacket intermittently until she came under the care of Mr. David Trevor in 1938. Further investigation failed to elucidate the cause of the backache, but without the plaster jacket the pain was unbearable and work impossible. Throughout the war years, the jacket was changed in the outpatient department as necessary-usually once or twice a year. Attempts were made to substitute a spinal support for the cast, but always the pain returned. A further admission to hospital was brought about in 1950 by pain radiating down the right leg. A definite diagnosis was no nearer, and it was thought that there must be psychiatric reasons for this complete dependence on plaster of paris. The patient refused to see a psychiatrist, and was discharged wearing the plaster jacket once more. The following year another attempt was made to persuade her to do without the plaster, but after arriving home she found the lack of support unbearable. Imploring letters arrived at hospital and on Nov. 30, 1951, Mr. Trevor personally put a new jacket on. A month later in the outpatient department commented in the notes: ’ For hygienic purposes should now have a surgical corset :T.2de exactly like the plaster-of-paris jacket, either moulded ,:2ther or plastic." The thought of losing the plaster may have ::tn responsible for the fact that the patient did not return to hospital for 12 years. For 9 years she had worked as
Spinal jacket unchanged
for 12 years: lumbar lordosis and
rigidity
of back after removal.
in a solicitor’s office and had remained quite comfortable. She returned because of abdominal pain. On admission in November, 1963, she was still wearing the cast applied in 1951. It had been split a year before to enable the abdomen to be examined, but it was replaced immediately and encircled by a plaster bandage. The jacket extended from the manubrium sterni to the symphysis pubis (see figure) and showed few signs of wear. It had been kept clean by means of a tubular silk garment, frequently changed, which was pulled over the head and the jacket and then tucked in at the top and bottom. From time to time it was drawn through the gap between plaster and skin, dislodging the desquamating epidermis. A liberal amount of talcum powder somehow found its way into this same space, but the skin received no other care. After the jacket was removed, the skin was found to be dry and scaly, but clean. The pressure areas were slightly pigmented, looking like the skin under a truss. The waist was narrow, and the lumbar lordosis extended upward as a smooth curve into the lower thoracic region (see figure). The sacrospinalis muscles were scarcely palpable, and the back was completely rigid. The trunk leaned forward at the hips, when the patient stood, and any attempt at movement was resisted by pain, or perhaps fear. X-ray showed moderate
receptionist
osteoporosis. To wear a plaster jacket unchanged for 12 years must surely be a record, but of more interest is this patient’s increasing dependence on the plaster. In some ways it is similar to the addiction to drugs. Initially the patient was anxious to be free of the plaster, but later she resisted the change to a spinal corset in the same way a patient taking regular doses of morphine might resist a change to aspirin. The complete incapacity and the imploring letters which followed the sudden removal of the plaster could even be compared to the withdrawal symptoms of the drug addict. From 1951, the patient has been rather like a registered addict, for her dependence on plaster is now complete, and we expect to be applying new jackets from time to time for the rest of her life, but probably at less than
12-year intervals! I should like to thank Mr. David Trevor for allowing me to report this account; and Prof. Nicholas Martin for his advice in its
preparation.
administrations
recurs
so
frequently
in these
cases
of the
postoperative hepatic necrosis that it suggests to us inadvisability of a second administration of the drug to anyone patient, unless this is specifically indicated, at least, until the pathogenesis of the condition is established.
Where its use on a second occasion is considered necessary, preoperative liver-function tests should be carried out. The discovery of any abnormality should be an absolute contraindication to further exposure.
Summary A patient who died of postoperative massive hepatic necrosis had had three anaesthetics in which halothane was used in the three weeks before the onset of jaundice. We wish to thank Mr. N. G. Godfrey for permission to publish chnical details of this case; and Mr. J. F. Hibbert, coroner for Central Cheshire, for the necropsy findings. REFERENCES British Medical Journal (1963) i, 1494. Chamberlain, G. C. (1963) ibid. p. 1524. Drummond Hart, D. (1963) ibid. p. 1674. Florey, M. E. (1960) The Clinical Application of Antibiotics;
Oxford.
vol. 4, p. 153.
Gordon, J. (1963) Anœsthesia, 18, 299. Heidenberg, W. J., Torio, I. S., Cebula, J. (1963) Lancet, i, 1185. Lancet (1963a), i, 1195. — (1963b) ii, 818. Lmdenbaum, J., Leifer, E. (1963) New Engl. J. Med. 268, 525. New England Journal of Medicine (1963) 268, 558. Schultz, J. C., Adamson, J. S., Jr., Workman, W. W., Norman, T. D. (1963) New Engl. J. Med. 269, 999. Temple, R. L., Cote, R.A., Gorens, S. W. (1962) Curr. Res. Anesth. 41, 586. Wilims, W. (1963) Personal communication. Witts, L. J. (1963) Lancet, ii, 1004.
ADDICTION TO PLASTER? ALAN W. F. LETTIN M.B., B.Sc. Lond., F.R.C.S. MOST people are extremely anxious to be rid of a plaster cast; it comes as somewhat of a surprise, therefore, to find a patient who has willingly tolerated a plaster-ofparis spinal jacket unchanged for 12 years. In 1934 a lady’s maid, aged 26, sought advice for backache which had been troubling her since a fall 2 years earlier. Investigation revealed no cause for the pain, and she was admitted to hospital and made to rest in a plaster bed. The patient gained some relief from her symptoms, and wore a plaster jacket intermittently until she came under the care of Mr. David Trevor in 1938. Further investigation failed to elucidate the cause of the backache, but without the plaster jacket the pain was unbearable and work impossible. Throughout the war years, the jacket was changed in the outpatient department as necessary-usually once or twice a year. Attempts were made to substitute a spinal support for the cast, but always the pain returned. A further admission to hospital was brought about in 1950 by pain radiating down the right leg. A definite diagnosis was no nearer, and it was thought that there must be psychiatric reasons for this complete dependence on plaster of paris. The patient refused to see a psychiatrist, and was discharged wearing the plaster jacket once more. The following year another attempt was made to persuade her to do without the plaster, but after arriving home she found the lack of support unbearable. Imploring letters arrived at hospital and on Nov. 30, 1951, Mr. Trevor personally put a new jacket on. A month later in the outpatient department commented in the notes: ’ For hygienic purposes should now have a surgical corset :T.2de exactly like the plaster-of-paris jacket, either moulded ,:2ther or plastic." The thought of losing the plaster may have ::tn responsible for the fact that the patient did not return to hospital for 12 years. For 9 years she had worked as
Spinal jacket unchanged
for 12 years: lumbar lordosis and
rigidity
of back after removal.
in a solicitor’s office and had remained quite comfortable. She returned because of abdominal pain. On admission in November, 1963, she was still wearing the cast applied in 1951. It had been split a year before to enable the abdomen to be examined, but it was replaced immediately and encircled by a plaster bandage. The jacket extended from the manubrium sterni to the symphysis pubis (see figure) and showed few signs of wear. It had been kept clean by means of a tubular silk garment, frequently changed, which was pulled over the head and the jacket and then tucked in at the top and bottom. From time to time it was drawn through the gap between plaster and skin, dislodging the desquamating epidermis. A liberal amount of talcum powder somehow found its way into this same space, but the skin received no other care. After the jacket was removed, the skin was found to be dry and scaly, but clean. The pressure areas were slightly pigmented, looking like the skin under a truss. The waist was narrow, and the lumbar lordosis extended upward as a smooth curve into the lower thoracic region (see figure). The sacrospinalis muscles were scarcely palpable, and the back was completely rigid. The trunk leaned forward at the hips, when the patient stood, and any attempt at movement was resisted by pain, or perhaps fear. X-ray showed moderate
receptionist
osteoporosis. To wear a plaster jacket unchanged for 12 years must surely be a record, but of more interest is this patient’s increasing dependence on the plaster. In some ways it is similar to the addiction to drugs. Initially the patient was anxious to be free of the plaster, but later she resisted the change to a spinal corset in the same way a patient taking regular doses of morphine might resist a change to aspirin. The complete incapacity and the imploring letters which followed the sudden removal of the plaster could even be compared to the withdrawal symptoms of the drug addict. From 1951, the patient has been rather like a registered addict, for her dependence on plaster is now complete, and we expect to be applying new jackets from time to time for the rest of her life, but probably at less than
12-year intervals! I should like to thank Mr. David Trevor for allowing me to report this account; and Prof. Nicholas Martin for his advice in its
preparation.