- Email: [email protected]
ERYTHROMELALGIA
1164 that all disorders
17th anxsthetic administered), her liver function
M.A.O.
preoperatively (see accompanying table). There was no evidence of hepatitis at laparotomy, and the patient was discharged home, well, in the following month, but returned to hospital in November with further fistulous troubie. On Nov. I(after the 20th anaesthetic) liver-function tests were undertaken (see table). CASE 2.-A woman, aged 30, was admitted in December, 1962, with multiple injuries following a car accident; she had multiple blood-transfusions, operations, and bone-grafts. She had 27 anaesthetics in sixteen months. The length of the operations ranged from forty-five minutes to five hours. Her
responding to a certain treatment (in this case inhibitors) are varying manifestations of the same condition. That they must have something in common is evident, but no-one would consider schizophrenic excitement, endogenous depression, and delirium to be merely differing expressions of one illness, simply because they all respond to E.C.T., or that penicillin responsiveness blurs the distinction between pneumococcal pneumonia, staphylococcal boils, and general paralysis of the insane. In my experience, a smaller number of phobic-anxiety// depersonalisation cases are being referred than formerly. In Newcastle, over a two-year period from 1956, we managed to collect a series of 135 cases. The general practi-
tioners with whom I am associated have learned that M.A.O. inhibitors are effective. I know that some, and suspect that many, are now treating these patients themselves. St.
James’s Hospital, Leeds, 9.
J. CRAWFORD LITTLE.
LIVER DAMAGE AND FLUOTHANE
SIR,-Liver damage after fluothane (’ Halothane ’) anaesthesia has been put down to either a true halogenated hydrocarbon effect or an allergic reaction after repeated challenge.l The failure to produce liver damage experimentally seems to eliminate the hydrocarbon itself as a cause; but damage has been reported in patients who have had repeated fluothane anaesthetics or after cholecystectomy-an operation known to be associated with the socalled hepatorenal syndrome even before the advent of fluothane.2 Two patients, who each had over 20 fluothane anx-sthetics over a period of two years, sustained no liver
damage. CASE 1.-After an operation for intestinal obstruction, faecal nstulse developed for which major bowel resection was performed in 1957; in 1959 the iistulae were closed, and continuity of the gut was re-established. The patient returned to work, apparently well, but with malabsorption due to the small amount of bowel remaining. In September, 1961, a Bartholin’s cyst developed, and, after the failure of an incised abscess to heal and other complications, the patient underwent 22 general anaesthetics between January, 1961, and December, 1963. The time for each operation ranged between thirty minutes and four hours. The patient had a somewhat natural aversion to needles and hangovers; hence general anxsthesia, induced with fluothane after atropine gr. 1/100, was the rule for procedures ranging from minor sigmoidoscopy and dressing to laparotomy and cholecystectomy. On many occasions the patient was severely ill, with vomiting, diarrhoea, electrolyte and acid-base imbalance, emaciation, and infection. In May, 1963 (when the patient was admitted with obstructive jaundice and had her 1. Brit. med. J. 1963, i, 1494. 2. Wilersky, A. O. Arch. Surg.
1939, 38,
659.
was
tested
liver function was tested at the time of her 25th fluothane anxsthetic on Dec. 8, 1963 (see table).
These are only two cases, but both patients had over 20 anxsthetics. We have had no fluothane hepatitis in over 5000 cases in the past two years. Many had 2 or 3 fluothane anxsthetics. We wish to thank Mr. Brandon Stephens and Mr. David Lane for permission to publish clinical details of these cases; and Prof. W. T. Tesson for heln with the biochemical tests and for advice. Anaesthetics Department, Meath
Hospital,
H.
Dublin.
J. GALVIN.
ERYTHROMELALGIA SIR,-I was very interested to read Mr. Catchpole’s article (April 25) on erythromelalgia, with physiological details. In 1940, as a surgeon in the guerilla army areas of North China, I treated two cases. The first was a young soldier who had walked barefoot through the snow for eighty miles to reach us, and found in the snow some relief for the pain in his bright red feet and ankles. He had a clear demarcation line just above his ankles and at first, under a local anaesthetic, I did a periarterial sympathectomy of the anterior tibial and posterior tibial artery on one leg, but he found no relief. I next tried, under spinal anxsthesia a dissection of the pre-sacral autonomic pelvic plexus, still without relief. It was at this time that I saw the article by Telford and Simmons,l and so it was decided to look for and remove the third and fourth lumbar sympathetic ganglia on either side, again under spinal anxsthetic. The result was dramatic: as we removed the third ganglion side the corresponding foot immediately blanched; so completed the operation and the patient was relieved of his
on one we
symptoms and was able to return to his unit. A few weeks later a second soldier in his thirties arrived and we were able to do this same operation without delay. The first patient had had his condition for many months, but the latter was of a more recent onset. These are the only two cases that I saw in four years’ work in this area and in the only medical unit for a population of over ten million people. St. Ann’s Hospital, Canford Cliffs, Poole, Dorset. 1. Telford, E.
R. K. MCALL. D.,
Simmons, H. T. Lancet,
LIVER-FUNCTION TESTS AFTER MULTIPLE FLUOTHANE ANESTHETICS
1940, ii,
782.
17th anxsthetic administered), her liver function
M.A.O.
preoperatively (see accompanying table). There was no evidence of hepatitis at laparotomy, and the patient was discharged home, well, in the following month, but returned to hospital in November with further fistulous troubie. On Nov. I(after the 20th anaesthetic) liver-function tests were undertaken (see table). CASE 2.-A woman, aged 30, was admitted in December, 1962, with multiple injuries following a car accident; she had multiple blood-transfusions, operations, and bone-grafts. She had 27 anaesthetics in sixteen months. The length of the operations ranged from forty-five minutes to five hours. Her
responding to a certain treatment (in this case inhibitors) are varying manifestations of the same condition. That they must have something in common is evident, but no-one would consider schizophrenic excitement, endogenous depression, and delirium to be merely differing expressions of one illness, simply because they all respond to E.C.T., or that penicillin responsiveness blurs the distinction between pneumococcal pneumonia, staphylococcal boils, and general paralysis of the insane. In my experience, a smaller number of phobic-anxiety// depersonalisation cases are being referred than formerly. In Newcastle, over a two-year period from 1956, we managed to collect a series of 135 cases. The general practi-
tioners with whom I am associated have learned that M.A.O. inhibitors are effective. I know that some, and suspect that many, are now treating these patients themselves. St.
James’s Hospital, Leeds, 9.
J. CRAWFORD LITTLE.
LIVER DAMAGE AND FLUOTHANE
SIR,-Liver damage after fluothane (’ Halothane ’) anaesthesia has been put down to either a true halogenated hydrocarbon effect or an allergic reaction after repeated challenge.l The failure to produce liver damage experimentally seems to eliminate the hydrocarbon itself as a cause; but damage has been reported in patients who have had repeated fluothane anaesthetics or after cholecystectomy-an operation known to be associated with the socalled hepatorenal syndrome even before the advent of fluothane.2 Two patients, who each had over 20 fluothane anx-sthetics over a period of two years, sustained no liver
damage. CASE 1.-After an operation for intestinal obstruction, faecal nstulse developed for which major bowel resection was performed in 1957; in 1959 the iistulae were closed, and continuity of the gut was re-established. The patient returned to work, apparently well, but with malabsorption due to the small amount of bowel remaining. In September, 1961, a Bartholin’s cyst developed, and, after the failure of an incised abscess to heal and other complications, the patient underwent 22 general anaesthetics between January, 1961, and December, 1963. The time for each operation ranged between thirty minutes and four hours. The patient had a somewhat natural aversion to needles and hangovers; hence general anxsthesia, induced with fluothane after atropine gr. 1/100, was the rule for procedures ranging from minor sigmoidoscopy and dressing to laparotomy and cholecystectomy. On many occasions the patient was severely ill, with vomiting, diarrhoea, electrolyte and acid-base imbalance, emaciation, and infection. In May, 1963 (when the patient was admitted with obstructive jaundice and had her 1. Brit. med. J. 1963, i, 1494. 2. Wilersky, A. O. Arch. Surg.
1939, 38,
659.
was
tested
liver function was tested at the time of her 25th fluothane anxsthetic on Dec. 8, 1963 (see table).
These are only two cases, but both patients had over 20 anxsthetics. We have had no fluothane hepatitis in over 5000 cases in the past two years. Many had 2 or 3 fluothane anxsthetics. We wish to thank Mr. Brandon Stephens and Mr. David Lane for permission to publish clinical details of these cases; and Prof. W. T. Tesson for heln with the biochemical tests and for advice. Anaesthetics Department, Meath
Hospital,
H.
Dublin.
J. GALVIN.
ERYTHROMELALGIA SIR,-I was very interested to read Mr. Catchpole’s article (April 25) on erythromelalgia, with physiological details. In 1940, as a surgeon in the guerilla army areas of North China, I treated two cases. The first was a young soldier who had walked barefoot through the snow for eighty miles to reach us, and found in the snow some relief for the pain in his bright red feet and ankles. He had a clear demarcation line just above his ankles and at first, under a local anaesthetic, I did a periarterial sympathectomy of the anterior tibial and posterior tibial artery on one leg, but he found no relief. I next tried, under spinal anxsthesia a dissection of the pre-sacral autonomic pelvic plexus, still without relief. It was at this time that I saw the article by Telford and Simmons,l and so it was decided to look for and remove the third and fourth lumbar sympathetic ganglia on either side, again under spinal anxsthetic. The result was dramatic: as we removed the third ganglion side the corresponding foot immediately blanched; so completed the operation and the patient was relieved of his
on one we
symptoms and was able to return to his unit. A few weeks later a second soldier in his thirties arrived and we were able to do this same operation without delay. The first patient had had his condition for many months, but the latter was of a more recent onset. These are the only two cases that I saw in four years’ work in this area and in the only medical unit for a population of over ten million people. St. Ann’s Hospital, Canford Cliffs, Poole, Dorset. 1. Telford, E.
R. K. MCALL. D.,
Simmons, H. T. Lancet,
LIVER-FUNCTION TESTS AFTER MULTIPLE FLUOTHANE ANESTHETICS
1940, ii,
782.