- Email: [email protected]
BRAIN DAMAGE AFTER DENTAL ANÆSTHESIA
1029 The lack of direct plasmavotume measurements in the patients reported in the article by Dr. Mouridsen and Professor Faber makes their conclusions somewhat speculative. Department of Surgery,
plasma-volume by interstitial fluid.
Harvard Medical School, Beth Israel Hospital,
Boston,
JOHN J. SKILLMAN.
Massachusetts 02215.
ILEAL BYPASS IN HYPERCHOLESTEROLÆMIA SIR,-The report by Dr. Davis and his colleagues last week (p. 971) on the use of ileal bypass in an attempt to lower serum-cholesterol levels makes me ask whether the results of
other lipid investigations, including serum-triglyceride levels and electrophoretic analysis, were available. Knowledge of serum-cholesterol levels alone does not permit recognition of the type of hyperlipidaemia present. In assessing whether surgery or other treatments are effective in decreasing raised lipid levels, it is desirable that the different hyperlipoproteinxmias be distinguished. Royal Infirmary, Glasgow C.4.
B. M. RIFKIND.
PROLONGED COMA AFTER HEAD INJURY SIR,-The observations of Dr. Crompton and his colleagues last week (p. 938) support mine on acute head injuries. It seems possible that minor damage of the white matter may occur in all patients with head injuries, but the frequency is difficult to estimate, since too few acute head injuries have been investigated microscopically. I have described the neuropathological changes in the white matter in 40 acute head injuries.’ Evidence of demyelination was present in several cases within 24 hours, and conspicuous in every patient surviving longer than 14 days, as shown by the following results:
These findings, with others,23 confirm that an injury to the skull may result in a diffuse lesion of the white matter throughout the brain without the naked-eye lesions familiar in severe head injury. Indeed, such anatomical lesions may play a possible role in the sudden loss of consciousness in cerebral concussion and in the numerous manifestations of the post-
breathing easily. The delay in recovery was the first pointer that something was amiss. That a period of hypotension occurred during the operation must be accepted. Postoperatively there was certainly no hypotension, and during the recovery period the dental chair was tipped back to a position 20° from the horizontal. For over 2 hours the patient was in this position, with an adequate blood-pressure (B.P.). Do Dr. Brierley and Dr. Miller feel that cerebral oligaemia was increased during this time ? I am only too conscious of the fact that it is essential to have a finger on the pulse when administering anaesthesia. Sometimes this proves easier said than done. It can prove difficult to hold the angles of the jaw, to hold the dental gag in position, and to maintain a finger on the pulse, all at the one time. I agree that an electrical pulse-monitor would be of benefit to give early warning of an impending fall in B.P. Department of Anæsthesia, Royal Infirmary, MERTON SEIGLEMAN. Blackburn. This letter has been shown to Dr. Brierley and Dr. Miller, who write as follows: " Dr. Seigleman is correct in stating that the case we described was not discussed with him directly. Our information was derived from a consultant pathologist at the hospital concerned, to whom we addressed all subsequent inquiries. He gave us the answers to specific points (including the length of the period for which the seated posture was maintained) after discussion and consultation with Dr. Seigleman. This information was faithfully reproduced by us, and is the reason for our acknowledgments to the pathologist and to Dr. Seigleman himself ".-ED. L.
LEGALISING ABORTION SIR,-Mr. Hall says in his letter last week (p. 974) that many members of the medical profession feel it is ethically wrong ever to procure an abortion. Many other members of the medical profession, however, feel it is ethically right to procure abortions in cases not provided for under present legislation. The public discussion that has taken place on this subject during the past year has made this abundantly clear. Surely then the only reasonable conclusion one can come to is that the law on abortion needs to be amended in such a way as will enable medical men of both ethical persuasions to practise according to their lights. Mr. Hall tells us, further, of his persistent refusal to procure an abortion throughout the forty years of his career. He says he cannot recall a single case " of a woman who has suffered as a result. Is this confident conclusion based on long-term "
psychiatric follow-up studies,
or on
pious hopes ? M. B. SIMMS.
head-injury syndrome. of Pathology, Institute of Pathology,
Department
Queen’s University,
N. C. NEVIN.
Belfast 12.
BRAIN DAMAGE AFTER DENTAL ANÆSTHESIA SiR,-At no time did Dr. Brierley and Dr. Miller discuss with me the anaesthetic details of the case described in their article (Oct. 22, p. 869). It was strange therefore to receive their gratitude in their acknowledgments. Perhaps there is an
explanation. In view of the comment,
"
Delay in placing the patient in the have contributed materially to the subsequent brain damage," may I point out that at the end of the operation there was little to indicate that a period of hypotension had occurred ? At this time both peripheral and carotid pulses were strong, and the patient was well oxygenated and horizontal position
must
Nevin, N. C. J. Neuropath, exp. Neurol, (in the press). Strich, S. J. Lancet, 1961, ii, 443. 3 Girard, P. F., Tommasi, M., Trillet, M. Acta neuropath. 1963, 2, 313.
1 2
CANDIDA ALBICANS AND ORAL CONTRACEPTIVES SIR,-May I inject a note of caution into the idea that candidiasis follows hard upon the long-term taking of the contraceptive pill ? In this department, of the last 6 patients taking oral contraceptives and attending with lower genitourinary symptoms, 2 did and 4 did not have candidiasis. This incidence corresponds to that for candidiasis among all women attending. Of the last 20 women attending with genital candidiasis (as a disorder related to coitus) most were not on oral contraceptives. Candidiasis is apparently on the increase, and practitioners with experience of the genital and alimentary tracts will have noted that this has occurred mainly over the past fiveyears. The increase is too large and widespread to propose on slender evidence that oral contraception is responsible. Although one well knows that candidiasis in pregnancy is difficult to clean up, this is not true for candidiasis in patients who are on the " pill ". Department of Venereology, Guy’s Hospital, London S.E.1.
A. GRIMBLE.
plasma-volume by interstitial fluid.
Harvard Medical School, Beth Israel Hospital,
Boston,
JOHN J. SKILLMAN.
Massachusetts 02215.
ILEAL BYPASS IN HYPERCHOLESTEROLÆMIA SIR,-The report by Dr. Davis and his colleagues last week (p. 971) on the use of ileal bypass in an attempt to lower serum-cholesterol levels makes me ask whether the results of
other lipid investigations, including serum-triglyceride levels and electrophoretic analysis, were available. Knowledge of serum-cholesterol levels alone does not permit recognition of the type of hyperlipidaemia present. In assessing whether surgery or other treatments are effective in decreasing raised lipid levels, it is desirable that the different hyperlipoproteinxmias be distinguished. Royal Infirmary, Glasgow C.4.
B. M. RIFKIND.
PROLONGED COMA AFTER HEAD INJURY SIR,-The observations of Dr. Crompton and his colleagues last week (p. 938) support mine on acute head injuries. It seems possible that minor damage of the white matter may occur in all patients with head injuries, but the frequency is difficult to estimate, since too few acute head injuries have been investigated microscopically. I have described the neuropathological changes in the white matter in 40 acute head injuries.’ Evidence of demyelination was present in several cases within 24 hours, and conspicuous in every patient surviving longer than 14 days, as shown by the following results:
These findings, with others,23 confirm that an injury to the skull may result in a diffuse lesion of the white matter throughout the brain without the naked-eye lesions familiar in severe head injury. Indeed, such anatomical lesions may play a possible role in the sudden loss of consciousness in cerebral concussion and in the numerous manifestations of the post-
breathing easily. The delay in recovery was the first pointer that something was amiss. That a period of hypotension occurred during the operation must be accepted. Postoperatively there was certainly no hypotension, and during the recovery period the dental chair was tipped back to a position 20° from the horizontal. For over 2 hours the patient was in this position, with an adequate blood-pressure (B.P.). Do Dr. Brierley and Dr. Miller feel that cerebral oligaemia was increased during this time ? I am only too conscious of the fact that it is essential to have a finger on the pulse when administering anaesthesia. Sometimes this proves easier said than done. It can prove difficult to hold the angles of the jaw, to hold the dental gag in position, and to maintain a finger on the pulse, all at the one time. I agree that an electrical pulse-monitor would be of benefit to give early warning of an impending fall in B.P. Department of Anæsthesia, Royal Infirmary, MERTON SEIGLEMAN. Blackburn. This letter has been shown to Dr. Brierley and Dr. Miller, who write as follows: " Dr. Seigleman is correct in stating that the case we described was not discussed with him directly. Our information was derived from a consultant pathologist at the hospital concerned, to whom we addressed all subsequent inquiries. He gave us the answers to specific points (including the length of the period for which the seated posture was maintained) after discussion and consultation with Dr. Seigleman. This information was faithfully reproduced by us, and is the reason for our acknowledgments to the pathologist and to Dr. Seigleman himself ".-ED. L.
LEGALISING ABORTION SIR,-Mr. Hall says in his letter last week (p. 974) that many members of the medical profession feel it is ethically wrong ever to procure an abortion. Many other members of the medical profession, however, feel it is ethically right to procure abortions in cases not provided for under present legislation. The public discussion that has taken place on this subject during the past year has made this abundantly clear. Surely then the only reasonable conclusion one can come to is that the law on abortion needs to be amended in such a way as will enable medical men of both ethical persuasions to practise according to their lights. Mr. Hall tells us, further, of his persistent refusal to procure an abortion throughout the forty years of his career. He says he cannot recall a single case " of a woman who has suffered as a result. Is this confident conclusion based on long-term "
psychiatric follow-up studies,
or on
pious hopes ? M. B. SIMMS.
head-injury syndrome. of Pathology, Institute of Pathology,
Department
Queen’s University,
N. C. NEVIN.
Belfast 12.
BRAIN DAMAGE AFTER DENTAL ANÆSTHESIA SiR,-At no time did Dr. Brierley and Dr. Miller discuss with me the anaesthetic details of the case described in their article (Oct. 22, p. 869). It was strange therefore to receive their gratitude in their acknowledgments. Perhaps there is an
explanation. In view of the comment,
"
Delay in placing the patient in the have contributed materially to the subsequent brain damage," may I point out that at the end of the operation there was little to indicate that a period of hypotension had occurred ? At this time both peripheral and carotid pulses were strong, and the patient was well oxygenated and horizontal position
must
Nevin, N. C. J. Neuropath, exp. Neurol, (in the press). Strich, S. J. Lancet, 1961, ii, 443. 3 Girard, P. F., Tommasi, M., Trillet, M. Acta neuropath. 1963, 2, 313.
1 2
CANDIDA ALBICANS AND ORAL CONTRACEPTIVES SIR,-May I inject a note of caution into the idea that candidiasis follows hard upon the long-term taking of the contraceptive pill ? In this department, of the last 6 patients taking oral contraceptives and attending with lower genitourinary symptoms, 2 did and 4 did not have candidiasis. This incidence corresponds to that for candidiasis among all women attending. Of the last 20 women attending with genital candidiasis (as a disorder related to coitus) most were not on oral contraceptives. Candidiasis is apparently on the increase, and practitioners with experience of the genital and alimentary tracts will have noted that this has occurred mainly over the past fiveyears. The increase is too large and widespread to propose on slender evidence that oral contraception is responsible. Although one well knows that candidiasis in pregnancy is difficult to clean up, this is not true for candidiasis in patients who are on the " pill ". Department of Venereology, Guy’s Hospital, London S.E.1.
A. GRIMBLE.