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LITHIUM AND THYROTOXICOSIS
1409 with very high R.B.C. lithium index which may be genetically determined. In our sample of 60 patients with manic-depressive psychosis the highest values (0-74 or more) we found exclusively in women, and we suggested a possible role for X-linked transmission in its determination.9 Further investigations are required to find out if patients with high R.B.C. lithium indices are distinctive on clinical, genetic, or biochemical ITt’onnds,
Department of Psychiatry, Academy of Medicine, 60-572 Poznan, Poland
JANUSZ RYBAKOWSKI WODZIMIERZ STRZYZEWSKI
LITHIUM AND THYROTOXICOSIS
S!R,—Thyrotoxicosis developing in patients on lithium carbonate has been reported by Dr Cubitt (June 5, p. 1247) and by Rosser.We should like to report a further case. The patient, a 50-year-old man, had a manic-depressive illness which began in his thirties. He drank heavily: when depressed because he felt ill and then when hypomanic because he felt so well. He had been treated since 1971 with lithium carbonate in a daily dose of between 0.5 and 1.0g. This kept his serum-lithium for most of the time at about 0.6 mmot/1. In April, 1974, it was 0-7 mmol/1. At that time he was tremulous, restless, fearful, sweating, and longing for a glass of whisky. He had a sinus tachycardia of 144, complained of "flashes of colour" and saw the "wallpaper squirming". It was thought that he was developing delirium tremens, especially since he had been drinking half a bottle of whisky a day for 3 months. 2 weeks later, it suddenly dawned that he was thyrotoxic. This was confirmed: T4 210 nmol/1 (normal 55-150), free-thyroxine index 238 units (normal 46-163). He scored 27 on the Wayne scale (score > 19 suggests thyrotoxicosis). No antibodies to thyroglobulin or to thyroid microsomes were found. An aunt had had thyrotoxicosis, his mother diabetes mellitus, and, oddly enough, his wife had thyrotoxic Graves disease. Both hyperthyroidism2 and alcohol withdrawal may cause a toxic confusional state; in this man they were presumably acting together to do so. Hyperthyroidism is sometimes difficult to diagnose because it poisons so many systems but none in a distinctive way. Diagnosis in this man was undoubtedly delayed because for several weeks his agitation and sweating were confidently ascribed to affective psychosis and his tremor to lithium. Perhaps the knowledge that lithium depresses the thyroid also delayed the diagnosis. We thank Dr. J. Becker and the Shrewsbury Hospital biochemistry for thyroid-function tests and Dr M. Horn for advice on
department treatment.
Shrewsbury Hospital, Salop
H. H. BAFAQEEH D. H. MYERS
THORACIC-DUCT CANNULATION FOR BLEEDING CESOPHAGEAL VARICES
S:R,—Iread with interest your editorial on bleeding oesophageal varices (April 17, p. 846). Since "the quickest and simplest operation should be chosen because these patients tolerate major surgery poorly", I would like to remind readers of a very simple and effective procedure carried out under local anaesthesia and based on a physiological approach. The liver sinusoids are freely permeable to water and protein. As a result, a minor increase in hepatic-vein pressure (as in early liver cirrhosis) increases significantly the amount of lymph produced by the liver.3 This compensatory mechanism expand* the outflow capacity of hepatic veins and tends to maintain normal pressure in the portal system. In advanced cirrhosis, 1. Rosser, R. Br. J. Psychiat. 1976, 128, 61. 2. Burston, B. Arch gen. Psychiat. 1961, 4, 267. 3. Dumont, A. E., Witte, M. H. Surg. Gynec. Obstet.
1966, 122,
524.
the carrying capacity of the hymphatics is pressure increases, and finally its clinical
exceeded,3the porexpression may be
oesophageal bleeding. If the lymphatic compensatory mechanism is artificially helped, by cannulation of the thoracic duct, to carry the excess of lymphatic fluid the liver size decreases, the ascites may disappear, and the portal-vein pressure falls.4 The cannulation site is at the point where the thoracic duct joins the junction of the left subclavian vein with the left internal jugular vein. Since ten out of fifteen patients who bled massively from oesophageal varices stopped bleeding after cannulation of the thoracic duct by a supraclavicular approach, Dumont et al. concluded that this procedure was as effective as a portocaval shunt in decreasing the portal-vein pressure and controlling the oesophageal bleeding.34 This simple technique deserves further evaluation. Department of Internal Medicine, Naharyia Government Hospital, Naharyia, Israel
DAN ADERKA
OUTPATIENT FOLLOW-UP
SiR,—The stimulating contribution of Dr Loudon (April 3, has produced some valuable suggestions and a useful exchange of ideas. In so far as many of us indulge in periodic bouts of discharging patients when our registrars are on holiday we are guilty of mismanagement. On such occasions the thought occurs that if we are to employ registrars then they ought to see our new patients, leaving to the consultant the more difficult task of reviewing old patients. There are two important aspects of the problem not dealt with by your correspondents. Old patients who are being reviewed often assume that attendance at hospital implies disability. They are, therefore, reluctant to return to work. So long as they are attending hospital they will go back to their G.P. for certification. This applies particularly to compensation cases and results in much prolongation of "disability" and loss of work. On the other hand, if a patient is discharged too soon before he is fit for work he is in danger of drifting into chronic disability due to disuse and he too will remain off work for too p.
736)
long. The solution to this dilemma lies in early discharge combined with adequate communication between hospital and general practitioner. The G.P. requires from the hospital a firm opinion on the expected date of return to work together with an invitation to return the patient for reassessment in the event of any difficulty in getting back to work. This brings me to the second point-namely, the need for flexibility in appointment systems for review cases. A patient has the right to make an appointment with his G.P. whenever the need arises. In hospital practice it is different. The patient is given appointments at arbitrary intervals often regardless of need, and once he is discharged the door is shut to fresh appointments. Therefore, it is not surprising that the patient who is uncertain of his recovery continues to accept fresh appointments. This gives him security because he knows that when he is finally discharged it may take a very long time for another appointment to be obtained. Why should G.P. and hospital appointment systems be so different ? If the patient is discharged as soon as hospital treatment is no longer necessary and if he or his doctor is told that he can make another outpatient appointment as soon as he develops problems requiring hospital treatment then this will allay his fears and greatly reduce the burden of repeated and unnecessary outpatient attendances. I suppose that much of the unnecessary reviewing in hospital is due to a fear of missing somethine and is an example of
4.
Dumont, A. E., Mulholland, J. H. Ann. Surg. 1962, 156, 688.
Department of Psychiatry, Academy of Medicine, 60-572 Poznan, Poland
JANUSZ RYBAKOWSKI WODZIMIERZ STRZYZEWSKI
LITHIUM AND THYROTOXICOSIS
S!R,—Thyrotoxicosis developing in patients on lithium carbonate has been reported by Dr Cubitt (June 5, p. 1247) and by Rosser.We should like to report a further case. The patient, a 50-year-old man, had a manic-depressive illness which began in his thirties. He drank heavily: when depressed because he felt ill and then when hypomanic because he felt so well. He had been treated since 1971 with lithium carbonate in a daily dose of between 0.5 and 1.0g. This kept his serum-lithium for most of the time at about 0.6 mmot/1. In April, 1974, it was 0-7 mmol/1. At that time he was tremulous, restless, fearful, sweating, and longing for a glass of whisky. He had a sinus tachycardia of 144, complained of "flashes of colour" and saw the "wallpaper squirming". It was thought that he was developing delirium tremens, especially since he had been drinking half a bottle of whisky a day for 3 months. 2 weeks later, it suddenly dawned that he was thyrotoxic. This was confirmed: T4 210 nmol/1 (normal 55-150), free-thyroxine index 238 units (normal 46-163). He scored 27 on the Wayne scale (score > 19 suggests thyrotoxicosis). No antibodies to thyroglobulin or to thyroid microsomes were found. An aunt had had thyrotoxicosis, his mother diabetes mellitus, and, oddly enough, his wife had thyrotoxic Graves disease. Both hyperthyroidism2 and alcohol withdrawal may cause a toxic confusional state; in this man they were presumably acting together to do so. Hyperthyroidism is sometimes difficult to diagnose because it poisons so many systems but none in a distinctive way. Diagnosis in this man was undoubtedly delayed because for several weeks his agitation and sweating were confidently ascribed to affective psychosis and his tremor to lithium. Perhaps the knowledge that lithium depresses the thyroid also delayed the diagnosis. We thank Dr. J. Becker and the Shrewsbury Hospital biochemistry for thyroid-function tests and Dr M. Horn for advice on
department treatment.
Shrewsbury Hospital, Salop
H. H. BAFAQEEH D. H. MYERS
THORACIC-DUCT CANNULATION FOR BLEEDING CESOPHAGEAL VARICES
S:R,—Iread with interest your editorial on bleeding oesophageal varices (April 17, p. 846). Since "the quickest and simplest operation should be chosen because these patients tolerate major surgery poorly", I would like to remind readers of a very simple and effective procedure carried out under local anaesthesia and based on a physiological approach. The liver sinusoids are freely permeable to water and protein. As a result, a minor increase in hepatic-vein pressure (as in early liver cirrhosis) increases significantly the amount of lymph produced by the liver.3 This compensatory mechanism expand* the outflow capacity of hepatic veins and tends to maintain normal pressure in the portal system. In advanced cirrhosis, 1. Rosser, R. Br. J. Psychiat. 1976, 128, 61. 2. Burston, B. Arch gen. Psychiat. 1961, 4, 267. 3. Dumont, A. E., Witte, M. H. Surg. Gynec. Obstet.
1966, 122,
524.
the carrying capacity of the hymphatics is pressure increases, and finally its clinical
exceeded,3the porexpression may be
oesophageal bleeding. If the lymphatic compensatory mechanism is artificially helped, by cannulation of the thoracic duct, to carry the excess of lymphatic fluid the liver size decreases, the ascites may disappear, and the portal-vein pressure falls.4 The cannulation site is at the point where the thoracic duct joins the junction of the left subclavian vein with the left internal jugular vein. Since ten out of fifteen patients who bled massively from oesophageal varices stopped bleeding after cannulation of the thoracic duct by a supraclavicular approach, Dumont et al. concluded that this procedure was as effective as a portocaval shunt in decreasing the portal-vein pressure and controlling the oesophageal bleeding.34 This simple technique deserves further evaluation. Department of Internal Medicine, Naharyia Government Hospital, Naharyia, Israel
DAN ADERKA
OUTPATIENT FOLLOW-UP
SiR,—The stimulating contribution of Dr Loudon (April 3, has produced some valuable suggestions and a useful exchange of ideas. In so far as many of us indulge in periodic bouts of discharging patients when our registrars are on holiday we are guilty of mismanagement. On such occasions the thought occurs that if we are to employ registrars then they ought to see our new patients, leaving to the consultant the more difficult task of reviewing old patients. There are two important aspects of the problem not dealt with by your correspondents. Old patients who are being reviewed often assume that attendance at hospital implies disability. They are, therefore, reluctant to return to work. So long as they are attending hospital they will go back to their G.P. for certification. This applies particularly to compensation cases and results in much prolongation of "disability" and loss of work. On the other hand, if a patient is discharged too soon before he is fit for work he is in danger of drifting into chronic disability due to disuse and he too will remain off work for too p.
736)
long. The solution to this dilemma lies in early discharge combined with adequate communication between hospital and general practitioner. The G.P. requires from the hospital a firm opinion on the expected date of return to work together with an invitation to return the patient for reassessment in the event of any difficulty in getting back to work. This brings me to the second point-namely, the need for flexibility in appointment systems for review cases. A patient has the right to make an appointment with his G.P. whenever the need arises. In hospital practice it is different. The patient is given appointments at arbitrary intervals often regardless of need, and once he is discharged the door is shut to fresh appointments. Therefore, it is not surprising that the patient who is uncertain of his recovery continues to accept fresh appointments. This gives him security because he knows that when he is finally discharged it may take a very long time for another appointment to be obtained. Why should G.P. and hospital appointment systems be so different ? If the patient is discharged as soon as hospital treatment is no longer necessary and if he or his doctor is told that he can make another outpatient appointment as soon as he develops problems requiring hospital treatment then this will allay his fears and greatly reduce the burden of repeated and unnecessary outpatient attendances. I suppose that much of the unnecessary reviewing in hospital is due to a fear of missing somethine and is an example of
4.
Dumont, A. E., Mulholland, J. H. Ann. Surg. 1962, 156, 688.