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ANÆSTHESIA FOR ELECTROCONVULSION THERAPY IN ACUTE PORPHYRIA
214
feature of the disorder, the enhanced faecal coproporphyrin It is appreciated that faecal and protoporphyrin excretion. uroporphyrin is also increased; but it is the level of the protoIn porphyrin and coproporphyrin that is important.
ASSAYABLE VITAMIN
B12 EXCRETED
PER DAY
(Mg."
seen in our Cape cutaneous porphyria as Coloured and Bantu communities (groups n D and possibly 11 E), faecal coproporphyrin and protoporphyrin are normal or only slightly increased. We would urge that in no case of porphyria is investiga-
symptomatic
tion
complete without full biochemical examination not only of the urine but also of the stool; this investigation should include
near
relatives.
Department of Medicine, University of Cape Town,
South Africa. Africa.
L. EALES G SWEENEY. G. S G.
ANÆSTHESIA FOR ELECTROCONVULSION THERAPY IN ACUTE PORPHYRIA
SIR,-Recent correspondence about
acute
porphyria,
particularly Dr. Cashman’s letter of June 17, prompts me to give the following information. Dr. M. J. Hurley asked me whether I would consider anxsthesia for electroconvulsion therapy in a known case of porphyria and I am indebted to her for the following history. A woman of 33 was admitted to St. Crispin Hospital on March 11, 1961, because of depression and over-anxiety after her second confinement nine weeks previously. Because of her history of porphyria and because her depression was mild it was decided not to give her E.c.T. unless it proved essential. She left hospital after ten days but had to be readmitted two weeks later considerably more depressed, so E.c.T. was given. Again there was no suggestion of an acute attack of porphyria. Before treatment her pseudocholinesterase level was 95 units per ml. She was given a preliminary dose of 0-64 mg. of atropine and I induced anaesthesia with nitrous oxide and 10-15 % oxygen. Immediately she lost consciousness an assistant injected 25 mg. of suxamethonium intravenously and the oxygen was turned up to 50%. When paralysis was complete the lungs were inflated with this 50/50 mixture once or twice and the shock administered. Immediately after the shock the facepiece was reapplied and the 50% mixture of nitrous oxide given once more until the respirations were of normal depth. She was then allowed to recover. Using this regime carefully the patient is not conscious of any effect of the suxamethonium and in fact she submitted to six treatments without demur. She left hospital fit and well a little later, but she has in fact since been readmitted. I am grateful to Dr. A. N. Graham, physician-superintendent of
and
St.
Crispin Hospital,
for
permission
Northampton General Hospital.
to use
this
The urinary loss of case 3 had an iron-deficiency anaemia. vitamin B 12 was greatly in excess of the maximum of 2% of the dose claimed by the manufacturers, and differed little from that expected after an injection of the same amount of a This conventional preparation (see accompanying table). might be due to possible inconsistencies in the preparation of the substance-we used three different batches from the hospital pharmacybut the manufacturers’ claims about this preparation, in its present form, do not seem justified. Western Infirmary, F ADAMS. ADAMS J. J F. Glasgow. J. F. ADAMS. Glasgow.
DANGEROUS CAVITY IN SYRINGES to install a central syringe service at the General Hospital, Birmingham, made it necessary to select suitable syringes that would give long service, be economical, and be easily obtainable through regular supply channels. We wanted glass syringes with an easily read scale, and with metal nozzles for additional strength; interchangeable barrels and plungers were needed for easy cleaning, assembly, and sterilisation. Ten separate makes of syringe conforming to these
SiR.—The decision
specifications
patient’s notes. F. F. WADDY.
metal " liner" of the nozzle. The volume of this cavity ranged from approximately 0’2 to 0-5 ml. Two of the makes in which the cavity was discovered were in regular use in
URINARY EXCRETION OF VITAMIN B12 AFTER DEPOT-VITAMIN INJECTIONS SIR,-The amount of vitamin B12 excreted in the urine
after intramuscular injection varies with the dose, and may be very large. Over half the injected dose is excreted after injections of 1000 g. A method of reducing this loss would be of therapeutic and possibly of economic value. A preparation of vitamin B12 combined with zinc and tannic acid has recently been introduced and it has been claimed that with this preparation the urinary loss of vitamin B12 is greatly reduced. 2 The daily urinary loss of vitamin B12 after an injection of 1000 jjLg. vitamin B12 zinc-tannate complex was measured in three patients by microbiological assay. Cases 1 and 2 had Addisonian pernicious anaemia in haematological relapse, and Davis, R. L., O’Connor, J., Wong, V., Lawton, A. H., Chow, B. F. Proc. Soc. exp. Biol., N.Y. 1959, 101, 211. 2. Thomson, R. E., Hecht, R. A. Amer. J. clin. Nutr. 1959, 7, 311. 1.
were
obtained. The glass in one was found to be inferior and it was rejected. The metal nozzles of the others were cut vertically and an unexpected and disturbing feature was revealed (see figure). Eight of the nine makes examined had a cavity of variable size between the glass mount and the
hospital in wards where they were sterilised by boiling alone; 10 of these syringes were withdrawn at random from regular ward use. Cross-sectional cutting of the metal nozzle
this
revealed that all had similar cavities and that most of these contained foreign matter, including blood and protein. Repeated washing, boiling, and dry sterilisation of the syringes failed to remove it, but some could be removed by washing after the syringes had been in an ultrasonic cleaner which caused the material to flake. Clearly if blood can be left inside the
cavity after ordinary washing, boiling syringe completely.
will
not
sterilise the
feature of the disorder, the enhanced faecal coproporphyrin It is appreciated that faecal and protoporphyrin excretion. uroporphyrin is also increased; but it is the level of the protoIn porphyrin and coproporphyrin that is important.
ASSAYABLE VITAMIN
B12 EXCRETED
PER DAY
(Mg."
seen in our Cape cutaneous porphyria as Coloured and Bantu communities (groups n D and possibly 11 E), faecal coproporphyrin and protoporphyrin are normal or only slightly increased. We would urge that in no case of porphyria is investiga-
symptomatic
tion
complete without full biochemical examination not only of the urine but also of the stool; this investigation should include
near
relatives.
Department of Medicine, University of Cape Town,
South Africa. Africa.
L. EALES G SWEENEY. G. S G.
ANÆSTHESIA FOR ELECTROCONVULSION THERAPY IN ACUTE PORPHYRIA
SIR,-Recent correspondence about
acute
porphyria,
particularly Dr. Cashman’s letter of June 17, prompts me to give the following information. Dr. M. J. Hurley asked me whether I would consider anxsthesia for electroconvulsion therapy in a known case of porphyria and I am indebted to her for the following history. A woman of 33 was admitted to St. Crispin Hospital on March 11, 1961, because of depression and over-anxiety after her second confinement nine weeks previously. Because of her history of porphyria and because her depression was mild it was decided not to give her E.c.T. unless it proved essential. She left hospital after ten days but had to be readmitted two weeks later considerably more depressed, so E.c.T. was given. Again there was no suggestion of an acute attack of porphyria. Before treatment her pseudocholinesterase level was 95 units per ml. She was given a preliminary dose of 0-64 mg. of atropine and I induced anaesthesia with nitrous oxide and 10-15 % oxygen. Immediately she lost consciousness an assistant injected 25 mg. of suxamethonium intravenously and the oxygen was turned up to 50%. When paralysis was complete the lungs were inflated with this 50/50 mixture once or twice and the shock administered. Immediately after the shock the facepiece was reapplied and the 50% mixture of nitrous oxide given once more until the respirations were of normal depth. She was then allowed to recover. Using this regime carefully the patient is not conscious of any effect of the suxamethonium and in fact she submitted to six treatments without demur. She left hospital fit and well a little later, but she has in fact since been readmitted. I am grateful to Dr. A. N. Graham, physician-superintendent of
and
St.
Crispin Hospital,
for
permission
Northampton General Hospital.
to use
this
The urinary loss of case 3 had an iron-deficiency anaemia. vitamin B 12 was greatly in excess of the maximum of 2% of the dose claimed by the manufacturers, and differed little from that expected after an injection of the same amount of a This conventional preparation (see accompanying table). might be due to possible inconsistencies in the preparation of the substance-we used three different batches from the hospital pharmacybut the manufacturers’ claims about this preparation, in its present form, do not seem justified. Western Infirmary, F ADAMS. ADAMS J. J F. Glasgow. J. F. ADAMS. Glasgow.
DANGEROUS CAVITY IN SYRINGES to install a central syringe service at the General Hospital, Birmingham, made it necessary to select suitable syringes that would give long service, be economical, and be easily obtainable through regular supply channels. We wanted glass syringes with an easily read scale, and with metal nozzles for additional strength; interchangeable barrels and plungers were needed for easy cleaning, assembly, and sterilisation. Ten separate makes of syringe conforming to these
SiR.—The decision
specifications
patient’s notes. F. F. WADDY.
metal " liner" of the nozzle. The volume of this cavity ranged from approximately 0’2 to 0-5 ml. Two of the makes in which the cavity was discovered were in regular use in
URINARY EXCRETION OF VITAMIN B12 AFTER DEPOT-VITAMIN INJECTIONS SIR,-The amount of vitamin B12 excreted in the urine
after intramuscular injection varies with the dose, and may be very large. Over half the injected dose is excreted after injections of 1000 g. A method of reducing this loss would be of therapeutic and possibly of economic value. A preparation of vitamin B12 combined with zinc and tannic acid has recently been introduced and it has been claimed that with this preparation the urinary loss of vitamin B12 is greatly reduced. 2 The daily urinary loss of vitamin B12 after an injection of 1000 jjLg. vitamin B12 zinc-tannate complex was measured in three patients by microbiological assay. Cases 1 and 2 had Addisonian pernicious anaemia in haematological relapse, and Davis, R. L., O’Connor, J., Wong, V., Lawton, A. H., Chow, B. F. Proc. Soc. exp. Biol., N.Y. 1959, 101, 211. 2. Thomson, R. E., Hecht, R. A. Amer. J. clin. Nutr. 1959, 7, 311. 1.
were
obtained. The glass in one was found to be inferior and it was rejected. The metal nozzles of the others were cut vertically and an unexpected and disturbing feature was revealed (see figure). Eight of the nine makes examined had a cavity of variable size between the glass mount and the
hospital in wards where they were sterilised by boiling alone; 10 of these syringes were withdrawn at random from regular ward use. Cross-sectional cutting of the metal nozzle
this
revealed that all had similar cavities and that most of these contained foreign matter, including blood and protein. Repeated washing, boiling, and dry sterilisation of the syringes failed to remove it, but some could be removed by washing after the syringes had been in an ultrasonic cleaner which caused the material to flake. Clearly if blood can be left inside the
cavity after ordinary washing, boiling syringe completely.
will
not
sterilise the