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POTASSIUM-SECRETING TUMOURS OF THE LARGE INTESTINE
514
The case described is relatively uncomplicated by these additional factors and the diagnosis seems to me to rest between (1) dual blockade, or (2) a low pseudocholinesterase level.
thetical nuclear lesions may influence those cellular and tissue mechanisms which normally maintain a regular numerical, spatial, contactual, and functional relationship between the cells of an organ or tissue, all of us interested in the behaviour of the cancer cell will indeed be
grateful. Department of Experimental Pathology, and Cancer Research, School of Medicine, Leeds.
JOHN O. LAWS.
AIDS TO ARTIFICIAL SPEECH
SIR,-In your issue of July 11, there were descriptions of appliances for the production of artificial voice (p. 38) and an annotation on this subject (p. 31). I have recently used the apparatus described by Mr. R. V. Tait (who kindly made it available to me) to help a patient with ascending paralysis who required treatment with positive-pressure respiration. As often happens in these cases, the patient was unable to move upper or lower limbs, but fortunately maintained good movement of the bulbar and facial muscles. Since he could not write, he found communication very difficult after tracheostomy had been performed, but was able to make himself understood quite well after only 24 hours’ practice with the oral vibrator. He has now recovered to the extent that his tracheostomy can be closed, and he speaks very highly of the contribution which this device made to his peace of mind during the period when he was on positive-pressure
The use of atropine followed by 5-10 mg. of edrophonium (‘ Tensilon ’) will give a quick response if the cause of the prolonged apnoea is dual blockade. This can then be followed by atropine and up to 2-5 mg. of neostigmine. This was done successfully in 2 personal cases, one in which the apnoea after a single dose of 40 mg. of suxamethonium chloride had lasted two hours. If it is due to a low pseudocholinesterase level, infusion of fresh frozen plasma will restart respiration.6 The management of a case of prolonged apncea under the conditions described is passage of an endotracheal tube and inflation with nitrous oxide (to maintain hypnosis) and oxygen, with carbon-dioxide absorption. While artificial ventilation is being carried out there is no deterioration in the patient’s condition and no urgency. A careful review of the drugs given will indicate the most fruitful line of treatment. St. George’s Hospital, D. M. DAVIES. London, S.W.1.
POTASSIUM-SECRETING TUMOURS OF THE LARGE INTESTINE SIR,—The following case should prove the existence of
potassium-secreting tumours of the large intestine and give the data required by Dr. Abbott and his colleagues in their letter of Sept. 5.
respiration. J. B. STANTON.
Edinburgh
DEATH AFTER FIRST TREATMENT WITH
ELECTROPLEXY, THIOPENTONE, AND SUXETHONIUM BROMIDE
of death in the case of prolonged apnoea due to suxethonium bromide, described by Dr. Campbell (Sept. 19), seems to be circulatory failure due to asphyxia (anoxia and carbon-dioxide accumulation) due to the prolonged effect of a depolarising-type muscle relaxant. Many cases of prolonged apnoea due to suxamethonium chloride (succinylcholine) have been described by Harper,l Hewer,2 Love,3 and Evans.4 Although the hydrolysis rate of suxethonium bromide is 50% faster than suxamethonium chloride, its action on the muscle end-plate is the same-i.e., preliminary stimulation followed by more prolonged depolarisation. When prolonged apnœa is present at the end of a surgical operation many factors have to be taken into account in reaching a diagnosis:
SIR,—The
cause
(1) Respiratory
centre
depression by narcotics, barbiturates,
and anxsthetic gases. (2) An alteration in carbon-dioxide tension, either an increase leading to carbon-dioxide narcosis and respiratory depres"
"
decrease resulting in acapnia. Factors which tend to maintain high concentrations of relaxant at the endplate-e.g., dehydration, oligæmic shock, hypotension, hypothermia, overdosage, poor renal function, or low pseudocholinesterase level. (4) Factors which tend to potentiate the effect of the relaxant at the endplate-e.g., electrolyte imbalance (especially low potassium concentration) (Keating 5) or the presence of other anaesthetic agents, such as ether. (5) Special features of the relaxant-e.g., the occurrence of dual blockade, mixed blockade, or high concentration of
sion,
or a
(3)
succinylmonocholine. 1. 2. 3. 4. 5.
Harper, J. Brit. med. J. 1952, i, 666. Hewer, C. L. ibid. p. 971. Love, S. Anæsthesia, 1952, 7, 113. Evans, F., Gray, P. W. S., Lehmann, H., Silk, E. Lancet, 1952, i, Keating, V., Tang, K. Anesth. Analg. 1957, 36, 32.
1229.
Our patient had a colostomy performed 9 months ago for subacute intestinal obstruction due to a tumour of the rectum. The colostomy has worked perfectly, producing one wellformed motion per day, but he is losing about 8 oz. of a thin, clear, mucous fluid per rectum every day. His serum-potassium is 3-75 mEq. per litre and the mucous fluid contains 137’5 mEq. of potassium per litre. He has been on a normal diet and has not shown any signs of hypokalaemia, except some general myasthenia, but since the appearance of this correspondence in your columns, he has been put on potassium supplements, Central Pathological Laboratory, G. BEHR. Burnley, Lancs. BEDS FOR CONFINEMENT
SIR.—In what purported to be a factual survey of the Emergency Bed Service, Dr. Abercrombie (Sept. 19) wrote that " nothing is done until the patient goes into labour " when the conditions of her home make it unsuitable for a confinement. This statement has been seized upon by the popular Press to justify a serious misrepresentation of the local health authorities in the London area. Of this area the County of Middlesex forms a not inconsiderable part, and some facts about the working of its antenatal services may help to put the
problem in
its
setting.
In 1958 the total number of births in the county was 27,282. During the six months ending in March, 1959, there were 73 E.B.s. cases, making an average of about 146 a year, or 1 in 187. If the 9317 hospital confinements are taken separately the E.B.s. cases are 1 in 64. When a patient’s home conditions are unsatisfactory every effort is made to arrange for the confinement to be in hospital, but two difficulties arise. (a) Patients with poor home conditions very often do not bother to make their pregnancy known until it is well advanced and hospital beds that might have been available have already been booked. (b) Some obstetricians book at an early date such a high percentage of the beds in the units they control that no beds are available when application is made later by the local health authority for the accommodation of cases of social need. Time and again the doctor ina local health authority clinic will spend half the morning on the telephone attempting to find a bed for a patient who cannO! have her baby at home. It is simply not true to suggest th3t 6.
Levin, J. Personal communication, 1958.
The case described is relatively uncomplicated by these additional factors and the diagnosis seems to me to rest between (1) dual blockade, or (2) a low pseudocholinesterase level.
thetical nuclear lesions may influence those cellular and tissue mechanisms which normally maintain a regular numerical, spatial, contactual, and functional relationship between the cells of an organ or tissue, all of us interested in the behaviour of the cancer cell will indeed be
grateful. Department of Experimental Pathology, and Cancer Research, School of Medicine, Leeds.
JOHN O. LAWS.
AIDS TO ARTIFICIAL SPEECH
SIR,-In your issue of July 11, there were descriptions of appliances for the production of artificial voice (p. 38) and an annotation on this subject (p. 31). I have recently used the apparatus described by Mr. R. V. Tait (who kindly made it available to me) to help a patient with ascending paralysis who required treatment with positive-pressure respiration. As often happens in these cases, the patient was unable to move upper or lower limbs, but fortunately maintained good movement of the bulbar and facial muscles. Since he could not write, he found communication very difficult after tracheostomy had been performed, but was able to make himself understood quite well after only 24 hours’ practice with the oral vibrator. He has now recovered to the extent that his tracheostomy can be closed, and he speaks very highly of the contribution which this device made to his peace of mind during the period when he was on positive-pressure
The use of atropine followed by 5-10 mg. of edrophonium (‘ Tensilon ’) will give a quick response if the cause of the prolonged apnoea is dual blockade. This can then be followed by atropine and up to 2-5 mg. of neostigmine. This was done successfully in 2 personal cases, one in which the apnoea after a single dose of 40 mg. of suxamethonium chloride had lasted two hours. If it is due to a low pseudocholinesterase level, infusion of fresh frozen plasma will restart respiration.6 The management of a case of prolonged apncea under the conditions described is passage of an endotracheal tube and inflation with nitrous oxide (to maintain hypnosis) and oxygen, with carbon-dioxide absorption. While artificial ventilation is being carried out there is no deterioration in the patient’s condition and no urgency. A careful review of the drugs given will indicate the most fruitful line of treatment. St. George’s Hospital, D. M. DAVIES. London, S.W.1.
POTASSIUM-SECRETING TUMOURS OF THE LARGE INTESTINE SIR,—The following case should prove the existence of
potassium-secreting tumours of the large intestine and give the data required by Dr. Abbott and his colleagues in their letter of Sept. 5.
respiration. J. B. STANTON.
Edinburgh
DEATH AFTER FIRST TREATMENT WITH
ELECTROPLEXY, THIOPENTONE, AND SUXETHONIUM BROMIDE
of death in the case of prolonged apnoea due to suxethonium bromide, described by Dr. Campbell (Sept. 19), seems to be circulatory failure due to asphyxia (anoxia and carbon-dioxide accumulation) due to the prolonged effect of a depolarising-type muscle relaxant. Many cases of prolonged apnoea due to suxamethonium chloride (succinylcholine) have been described by Harper,l Hewer,2 Love,3 and Evans.4 Although the hydrolysis rate of suxethonium bromide is 50% faster than suxamethonium chloride, its action on the muscle end-plate is the same-i.e., preliminary stimulation followed by more prolonged depolarisation. When prolonged apnœa is present at the end of a surgical operation many factors have to be taken into account in reaching a diagnosis:
SIR,—The
cause
(1) Respiratory
centre
depression by narcotics, barbiturates,
and anxsthetic gases. (2) An alteration in carbon-dioxide tension, either an increase leading to carbon-dioxide narcosis and respiratory depres"
"
decrease resulting in acapnia. Factors which tend to maintain high concentrations of relaxant at the endplate-e.g., dehydration, oligæmic shock, hypotension, hypothermia, overdosage, poor renal function, or low pseudocholinesterase level. (4) Factors which tend to potentiate the effect of the relaxant at the endplate-e.g., electrolyte imbalance (especially low potassium concentration) (Keating 5) or the presence of other anaesthetic agents, such as ether. (5) Special features of the relaxant-e.g., the occurrence of dual blockade, mixed blockade, or high concentration of
sion,
or a
(3)
succinylmonocholine. 1. 2. 3. 4. 5.
Harper, J. Brit. med. J. 1952, i, 666. Hewer, C. L. ibid. p. 971. Love, S. Anæsthesia, 1952, 7, 113. Evans, F., Gray, P. W. S., Lehmann, H., Silk, E. Lancet, 1952, i, Keating, V., Tang, K. Anesth. Analg. 1957, 36, 32.
1229.
Our patient had a colostomy performed 9 months ago for subacute intestinal obstruction due to a tumour of the rectum. The colostomy has worked perfectly, producing one wellformed motion per day, but he is losing about 8 oz. of a thin, clear, mucous fluid per rectum every day. His serum-potassium is 3-75 mEq. per litre and the mucous fluid contains 137’5 mEq. of potassium per litre. He has been on a normal diet and has not shown any signs of hypokalaemia, except some general myasthenia, but since the appearance of this correspondence in your columns, he has been put on potassium supplements, Central Pathological Laboratory, G. BEHR. Burnley, Lancs. BEDS FOR CONFINEMENT
SIR.—In what purported to be a factual survey of the Emergency Bed Service, Dr. Abercrombie (Sept. 19) wrote that " nothing is done until the patient goes into labour " when the conditions of her home make it unsuitable for a confinement. This statement has been seized upon by the popular Press to justify a serious misrepresentation of the local health authorities in the London area. Of this area the County of Middlesex forms a not inconsiderable part, and some facts about the working of its antenatal services may help to put the
problem in
its
setting.
In 1958 the total number of births in the county was 27,282. During the six months ending in March, 1959, there were 73 E.B.s. cases, making an average of about 146 a year, or 1 in 187. If the 9317 hospital confinements are taken separately the E.B.s. cases are 1 in 64. When a patient’s home conditions are unsatisfactory every effort is made to arrange for the confinement to be in hospital, but two difficulties arise. (a) Patients with poor home conditions very often do not bother to make their pregnancy known until it is well advanced and hospital beds that might have been available have already been booked. (b) Some obstetricians book at an early date such a high percentage of the beds in the units they control that no beds are available when application is made later by the local health authority for the accommodation of cases of social need. Time and again the doctor ina local health authority clinic will spend half the morning on the telephone attempting to find a bed for a patient who cannO! have her baby at home. It is simply not true to suggest th3t 6.
Levin, J. Personal communication, 1958.