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NO CHAIR
229
they are taking with her assertion that " intensive psychotherapy helps the patient to acquire insight... and finally to avoid the temptation to augment his income by selling drugs ". How can they have any drug to spare if they minimise their requirements ? Lady Frankau has conceded that some of her former patients do not return for treatment after relapse. May I inquire how she can be satisfied that those others who do not return are still free of dependence on drugs ? ELLIS STUNGO. NO CHAIR
SIR,-Iwas interested in Dr. Spencer’s letter (Jan. 7) on the absence of a chair in psychiatry in Birmingham. unfortunate state of affairs exists in clinical infectious diseases. Except for Glasgow, there is no chair in the whole of the British Isles! It is true that some holders of general medical chairs-notably Prof. C. H. Stuart-Harris-have both taken an interest and made fundamental contributions to knowledge in this field. Apart from them, however, little or nothing has been done, possibly because of apathy, indifference, professional jealousies, and the competing claims of general medicine The
same
and pxdiatrics. There is no doubt that
active chair stimulates the growth, development, prestige of a specialty, just as the presence of a queen bee is essential to the well-being of a hive!It is all the more surprising that some charitable foundations have not come forth with offers of financial help. Competing claims of other equally pressing and just causes may well be put forward. Perhaps, if an approach could be made by influential lay or medical people, something might vet be achieved for both our specialties. an
and
I. M. LIBRACH. DEATHS UNDER DENTAL ANÆSTHESIA SlR,_Dr. Butler’s letter (Jan. 14) raises three vital issues in outpatient anaesthesia-viz., the safety of trichloroethylene, adequate oxygenation, and fainting in the
dental chair. The use of any potent adjuvant in the presence of inadequate oxygenation has long been recognised as dangerous. McConnellexpressed this in relation to trichloroethylene, and I would go further and suggest that this agent cannot be " regarded as unquestionably safe " under whatever conditions it is used. In an account of 1000 deaths associated with anaesthesia, Edwards2 reports 12 with trichloroethylene. 3 were attributable to overdosage, and the remaining 9 were thought to have resulted from " primary cardiac failure ". Having reported one of these latter cases myself I am convinced that this is a real hazard, which can be minimised only by the preoperative use of atropine and adequate oxygenation. Being actively concerned with the teaching of dental anesthesia I am distressed to read that dental outpatients are "regularly subjected to oxygen concentrations as low as 5% ". While it is perfectly correct to emphasise the increased hazards introduced by the addition of adjuvants to anoxic mixtures, surely nowadays the use of such anoxic mixtures in themselves should be universally recognised as physiologically unsound. That nitrous oxide can be effective even when used with an adequate oxygen supply has been recognised by Tom3 and Mostert f and can readily be demonstrated provided the signs of third-stage surgical anaesthesia are not expected. Where this light level of anaesthesia will not suffice, I agree with Dr. Butler that halothane, especially if administered from a Goldman vaporiser, is preferable to the use of any other adjuvant. That fainting can occur in the dental chair is well recognised 1. McConnell, W. S. Proc. R. Soc. Med. 1959, 52, 323. 2. Edwards, G., Morton, H. J. V., Pask, E. A., Wylie, W. D. Anœsthesia, 1956, 11, 194. 3. Tom, A. Brit. med. J. 1956, i, 1085. 4. Mostert, W. J. ibid. 1958, i, 502.
by those who only employ local anaesthesia. I have observed fainting on more than one occasion, in susceptible people, during the recovery period after general anxsthesia when the danger is that it may be unrecognised and the patient left sitting upright. Fainting during a general anaesthetic in the dental chair is another matter. I believe that, by definition, the existence of the condition cannot be proved. If, however, the accompanying physical signs appear, for safety’s sake the condition should be regarded as a circulatory collapse in response to the anaesthetic technique and appropriate treatment commenced forthwith. Finally may I point out that, as there are more general anaesthetics given in this country for dental surgery than for all other types of surgery, there is a widespread need for postgraduate courses of instruction in dental anxsthesia, which at present are available only in London. These must be comprehensive and available to all who are concerned in the administration of dental anxstheticsi.e., to doctors and dentists alike. In this way our two professions can cooperate to improve the service to the natient. Dental Hospital, Manchester.
T. DINSDALE.
PSYCHIATRIC ASPECTS OF ACUTE PORPHYRIA
SIR,-Dr. Cashman’s letter (Jan. 14), describing two of acute porphyria, raises again the question of the
cases
incidence of the condition in this country. It also reiterates the need for constant awareness, particularly amongst psychiatrists, of the presenting features, which may fall into a well-defined pattern as is illustrated by the following case-record. true
The patient, a single woman of 44, was first admitted to a mental hospital in April, 1959, complaining of weakness, pain in the abdomen, shoulders, and arms, and depression. The results of physical examination were entirely normal except for a haemoglobin level of 74%. Hysteria was diagnosed. She received sulphonamide therapy for a heavy urinary infection, which cleared up quickly, but was given no other medication. She rapidly ceased to complain and was discharged symptomfree. Her previous medical history included nine admissions to general hospitals since 1938. On each admission she had complained of abdominal pain, sometimes generalised, on two occasions starting in the loin. Investigations had included barium-meal examination, intravenous pyelography, and cystoscopy. The diagnosis arrived at had varied with each admission and had included duodenal ulcer, neurasthenia, dysmenorrhcea, urinary infection, pyrexia of unknown origin, osteoarthritis of the spine, renal colic, and chronic hysteria. Her mother had died in 1938 of a wasting disease. The cause of death was given as chronic bulbar palsy. It was noticed at home during the last illness that the mother’s urine was dark and stained the sheets, and urine-testing during the two days she spent in hospital showed the presence of urobilinogen. One brother had died in 1957 of pneumonia and was found post mortem to have complete situs inversus. There are four other siblings, none of whom has any similar illness. Two weeks after discharge the patient was readmitted to this hospital complaining of weakness and depression. Once again no abnormality was found, but her urine was port-winecoloured and contained porphyrins. Acute porphyria was diagnosed, and the urine of all known relatives was tested for porphyrins. Traces of porphobilinogen were found in the urine of two nephews, neither of whom had ever had symptoms of the disease. This case illustrates well three aspects to be borne in mind in making the diagnosis: 1. The triad of presenting features described by Cross 1abdominal pain, paralysis, and psychic changes. On each of 1.
Cross, T. N. Amer. J. Psychiat. 1956, 112, 1010.
they are taking with her assertion that " intensive psychotherapy helps the patient to acquire insight... and finally to avoid the temptation to augment his income by selling drugs ". How can they have any drug to spare if they minimise their requirements ? Lady Frankau has conceded that some of her former patients do not return for treatment after relapse. May I inquire how she can be satisfied that those others who do not return are still free of dependence on drugs ? ELLIS STUNGO. NO CHAIR
SIR,-Iwas interested in Dr. Spencer’s letter (Jan. 7) on the absence of a chair in psychiatry in Birmingham. unfortunate state of affairs exists in clinical infectious diseases. Except for Glasgow, there is no chair in the whole of the British Isles! It is true that some holders of general medical chairs-notably Prof. C. H. Stuart-Harris-have both taken an interest and made fundamental contributions to knowledge in this field. Apart from them, however, little or nothing has been done, possibly because of apathy, indifference, professional jealousies, and the competing claims of general medicine The
same
and pxdiatrics. There is no doubt that
active chair stimulates the growth, development, prestige of a specialty, just as the presence of a queen bee is essential to the well-being of a hive!It is all the more surprising that some charitable foundations have not come forth with offers of financial help. Competing claims of other equally pressing and just causes may well be put forward. Perhaps, if an approach could be made by influential lay or medical people, something might vet be achieved for both our specialties. an
and
I. M. LIBRACH. DEATHS UNDER DENTAL ANÆSTHESIA SlR,_Dr. Butler’s letter (Jan. 14) raises three vital issues in outpatient anaesthesia-viz., the safety of trichloroethylene, adequate oxygenation, and fainting in the
dental chair. The use of any potent adjuvant in the presence of inadequate oxygenation has long been recognised as dangerous. McConnellexpressed this in relation to trichloroethylene, and I would go further and suggest that this agent cannot be " regarded as unquestionably safe " under whatever conditions it is used. In an account of 1000 deaths associated with anaesthesia, Edwards2 reports 12 with trichloroethylene. 3 were attributable to overdosage, and the remaining 9 were thought to have resulted from " primary cardiac failure ". Having reported one of these latter cases myself I am convinced that this is a real hazard, which can be minimised only by the preoperative use of atropine and adequate oxygenation. Being actively concerned with the teaching of dental anesthesia I am distressed to read that dental outpatients are "regularly subjected to oxygen concentrations as low as 5% ". While it is perfectly correct to emphasise the increased hazards introduced by the addition of adjuvants to anoxic mixtures, surely nowadays the use of such anoxic mixtures in themselves should be universally recognised as physiologically unsound. That nitrous oxide can be effective even when used with an adequate oxygen supply has been recognised by Tom3 and Mostert f and can readily be demonstrated provided the signs of third-stage surgical anaesthesia are not expected. Where this light level of anaesthesia will not suffice, I agree with Dr. Butler that halothane, especially if administered from a Goldman vaporiser, is preferable to the use of any other adjuvant. That fainting can occur in the dental chair is well recognised 1. McConnell, W. S. Proc. R. Soc. Med. 1959, 52, 323. 2. Edwards, G., Morton, H. J. V., Pask, E. A., Wylie, W. D. Anœsthesia, 1956, 11, 194. 3. Tom, A. Brit. med. J. 1956, i, 1085. 4. Mostert, W. J. ibid. 1958, i, 502.
by those who only employ local anaesthesia. I have observed fainting on more than one occasion, in susceptible people, during the recovery period after general anxsthesia when the danger is that it may be unrecognised and the patient left sitting upright. Fainting during a general anaesthetic in the dental chair is another matter. I believe that, by definition, the existence of the condition cannot be proved. If, however, the accompanying physical signs appear, for safety’s sake the condition should be regarded as a circulatory collapse in response to the anaesthetic technique and appropriate treatment commenced forthwith. Finally may I point out that, as there are more general anaesthetics given in this country for dental surgery than for all other types of surgery, there is a widespread need for postgraduate courses of instruction in dental anxsthesia, which at present are available only in London. These must be comprehensive and available to all who are concerned in the administration of dental anxstheticsi.e., to doctors and dentists alike. In this way our two professions can cooperate to improve the service to the natient. Dental Hospital, Manchester.
T. DINSDALE.
PSYCHIATRIC ASPECTS OF ACUTE PORPHYRIA
SIR,-Dr. Cashman’s letter (Jan. 14), describing two of acute porphyria, raises again the question of the
cases
incidence of the condition in this country. It also reiterates the need for constant awareness, particularly amongst psychiatrists, of the presenting features, which may fall into a well-defined pattern as is illustrated by the following case-record. true
The patient, a single woman of 44, was first admitted to a mental hospital in April, 1959, complaining of weakness, pain in the abdomen, shoulders, and arms, and depression. The results of physical examination were entirely normal except for a haemoglobin level of 74%. Hysteria was diagnosed. She received sulphonamide therapy for a heavy urinary infection, which cleared up quickly, but was given no other medication. She rapidly ceased to complain and was discharged symptomfree. Her previous medical history included nine admissions to general hospitals since 1938. On each admission she had complained of abdominal pain, sometimes generalised, on two occasions starting in the loin. Investigations had included barium-meal examination, intravenous pyelography, and cystoscopy. The diagnosis arrived at had varied with each admission and had included duodenal ulcer, neurasthenia, dysmenorrhcea, urinary infection, pyrexia of unknown origin, osteoarthritis of the spine, renal colic, and chronic hysteria. Her mother had died in 1938 of a wasting disease. The cause of death was given as chronic bulbar palsy. It was noticed at home during the last illness that the mother’s urine was dark and stained the sheets, and urine-testing during the two days she spent in hospital showed the presence of urobilinogen. One brother had died in 1957 of pneumonia and was found post mortem to have complete situs inversus. There are four other siblings, none of whom has any similar illness. Two weeks after discharge the patient was readmitted to this hospital complaining of weakness and depression. Once again no abnormality was found, but her urine was port-winecoloured and contained porphyrins. Acute porphyria was diagnosed, and the urine of all known relatives was tested for porphyrins. Traces of porphobilinogen were found in the urine of two nephews, neither of whom had ever had symptoms of the disease. This case illustrates well three aspects to be borne in mind in making the diagnosis: 1. The triad of presenting features described by Cross 1abdominal pain, paralysis, and psychic changes. On each of 1.
Cross, T. N. Amer. J. Psychiat. 1956, 112, 1010.