TRIGEMINAL NEURALGIA
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1249 haemolysis.. Verotoxin production could not be detected. E coli showing the same characteristics colonised the patient’s alimentary tract too. Blood cultures were negative but antibiotics had been started before sampling. Anti-haemolytic and anti-lung-toxic antibodies4,5 were found in high titres in the patient’s sera 4 days after admission, and titres tended to increase. We conclude that the a-haemolytic E coli strain initiated the patient’s infection and that a-haemolysin might have contributed to the HUS that developed. Departments of Microbiology, Urology, and Clinical Chemistry, University Medical School, H-7643 Pécs, Hungary LEVENTE EMODY MONIKA KERÉNYI ISTVÁN BÁTAI, JR SÁNDOR PÁCSA JÓZSEF SZÉKELY, JR MIKLÓS KELLERMAYER TRIGEMINAL NEURALGIA SIR,—Mr Small (May 5, p 1021) has an ingenious explanation for the origin of this mysterious condition. He writes: "There is only once condition found elsewhere in the body that appears similar in nature to trigeminal neuralgia, and that is the tiny glomus tumour, particularly if beneath the finger nail and not detectable". There are, however, also the "lightning pains" of tabes dorsalis, rarely encountered nowadays, which have the same intense and 3. Karmali MA, Steele BT, Petric M, Lim C Sporadic cases of haemolytic-uraemic syndrome associated with faecal cytotoxin and cytotoxin-producing Escherichia coli in stools. Lancet 1983, ii. 619-20 4. Emody L, Bátai I Jr, Kerényi M, Székely J Jr, Polyák L Anti-Escherichia coli alpha- haemolysin in control and patient sera. Lancet 1982; ii: 986. 5. Emody L, Kétyi I, Kuch B, Pácsa S. Antitoxic immunity against the so called lung toxin produced by Escherichia coli Acta Microbiol Acad Sci Hung 1979, 26: 233-39. paroxysmal nature. In this condition, the lesion is in the posterior root-entry zone, and it is in the analogous position in the brainstem that one may encounter a plaque of multiple sclerosis when the same sort of pain is experienced by patients with that disease. It is for this reason that I have believed that the trigeminal root-entry zone is the site of whatever is the local disorder that gives rise to the pain of tic douloureux. The poor old chap from Wells Cathedral is, I think, merely pointing to a tooth, which is where most patients believe the pain is originating. Department of Neurological Surgery, Radcliffe Infirmary, Oxford OX2 6HE JOHN POTTER REVERSAL OF DIABETIC NEPHROPATHY IN A TRANSPLANTED KIDNEY SIR,—Professor Abouna and colleagues, in their Dec 13, 1983, paper, state that they do not know of any other reports of regression of histologically established diabetic nephropathy. An article in Medical World News (Sept 27, 1974) contained the following statement: "two kidneys from a regional organ-sharing program were implanted before it was learned the dead donors were juvenile diabetics. Biopsies at the time of surgery showed vascular changes in their glomeruli. Follow-up biopsies of the kidney showed the glomerular lesions completely disappeared within six months". The physician interviewed was Dr Leslie E. Rudolf of the University of Virginia Medical Center in Charlottesville. Diabetes Program, Division of Endocrinology, Cedars-Sinai Medical Center, LosAngeles, California 90048, USA MAYER B. DAVIDSON Medicine and the Law Claim for Negligent Induction of Anaesthesia Dismissed, but no Costs for Defendant Health Authority THE plaintiff, then 28, was admitted to hospital for a hysterectomy, performed on July 12, 1976. She alleged she was insufficiently anaesthetised, and, though paralysed and unable to communicate, she remained "aware" until the moment of the incision. She suffered "conversion hysteria" subsequently. She did not complain of the experience until she was discharged. When she was readmitted because of symptoms arising from her experience, two weeks after the operation, she gave an account of her experience to a hospital doctor, who took the matter up with the hospital’s senior anaesthetist. The basis of the plaintiffs case was: she was not rendered unconscious to the stage intended by the anaesthetist and remained aware until the operation began; this failure was caused by incorrect administration of anaesthetic and a failure to check that it had worked; this failure was negligence by the anaesthetist and caused the plaintiff to suffer recurrent anxiety attacks. Following the respopse of the senior anaesthetist to the hospital doctor, the doctor wrote to the plaintiffs GP to say that the plaintiff had been given a relaxant with an inadequate dose of general anaesthetic in the first stage of intravenous injection. There was also suggestion of a cover-up. The letter said: "I brought this to the attention of our senior anaesthetist. He went back to the anaesthetic notes (the anaesthetic having been given by a competent junior anaesthetist). He was in entire agreement and pointed out that the drug-namely, ’Althesin’-in the dose used did leave the patient open to this liability ... The junior anaesthetist concerned was being notified of what had happened, he having in fact now left this hospital". At the trial Judge Forbes formed the opinion that the misleading suggestion that the anaesthetic was given by a junior anaesthetist who had left the hospital seemed to be an attempt to cover up a mistake. The senior anaesthetist must have known who had given the anaesthetic. The judge said that, had he been able tc find for the plaintiff, he would have awarded £3000, but he concluded there had been no negligence and that procedures had been routine. The plaintiff had not proved negligence and he was satisfied that, though the plaintifl’s recollection was honest, it was not accurate. Appeal All three judges found the case disquieting, but they ultimately concluded that the plaintiff, as she recovered from the anaesthetic, had transposed events at the end of the operation and events before it. The evidence of the anaesthetist persuaded the Court of Appeal that he could not have failed to inject althesin into a vein, and that the dose in a patient of 71/2 stones was sufficient to ensure an adequate level of unconsciousness. He had carried out all the usual checks to assess depth of anaesthesia. It was, however, just possible that the plaintiff was one of those rare patients who reacted in an abnormal way to anaesthesia and, though paralysed, remained aware to a greater or lesser degree. The plaintiff was legally aided, but the health authority’s costs against the Legal Aid Fund were refused on the grounds that the hospital had brought the litigation on itself. When the patient related her experiences to the hospital doctor and when that doctor had inquired what had- occurred, he had "received a wholly untruthful and unsatisfactory answer which he repeated to the plaintiff and her husband". Com ment One of the commonest criticisms of the NHS and of hospitals is a lack of direct response a’nd information after a complaint or even a query. In this case, the inquiry to the senior anaesthetist was unforn" ’tely translated into a piece of misleading information, and not into a request to the anaesthetist who gave the anaesthetic to see the patient and to explain matters to her. The plaintiff was thus encouraged to believe the hospital was engaged in a cover-up and the idea was planted in her mind that she had not been given the proper amount of althesin or that’ it had not entered the vein. It also produced an ordeal for the anaesthetist, many days in court for all parties, and a hefty bill for the taxpayer. Jacobs ’l’ Great Yarmouth and Waveney Health Authority. Court of Appeal, March 27, 1984 Stephenson, O’Connor, and Griffiths LJJ. Appeal from Forbes J, Dec 9, 1982, QBD DIANA BRAHAMS, Barrister-at-Law
Transcript of TRIGEMINAL NEURALGIA
1249
haemolysis.. Verotoxin production could not be detected. E colishowing the same characteristics colonised the patient’s alimentarytract too. Blood cultures were negative but antibiotics had beenstarted before sampling.Anti-haemolytic and anti-lung-toxic antibodies4,5 were found in
high titres in the patient’s sera 4 days after admission, and titrestended to increase. We conclude that the a-haemolytic E coli straininitiated the patient’s infection and that a-haemolysin might havecontributed to the HUS that developed.
Departments of Microbiology,Urology, and Clinical Chemistry,
University Medical School,H-7643 Pécs, Hungary
LEVENTE EMODYMONIKA KERÉNYIISTVÁN BÁTAI, JRSÁNDOR PÁCSA
JÓZSEF SZÉKELY, JRMIKLÓS KELLERMAYER
TRIGEMINAL NEURALGIA
SIR,—Mr Small (May 5, p 1021) has an ingenious explanation forthe origin of this mysterious condition. He writes: "There is onlyonce condition found elsewhere in the body that appears similar innature to trigeminal neuralgia, and that is the tiny glomus tumour,particularly if beneath the finger nail and not detectable". Thereare, however, also the "lightning pains" of tabes dorsalis, rarelyencountered nowadays, which have the same intense and
3. Karmali MA, Steele BT, Petric M, Lim C Sporadic cases of haemolytic-uraemicsyndrome associated with faecal cytotoxin and cytotoxin-producing Escherichia coliin stools. Lancet 1983, ii. 619-20
4. Emody L, Bátai I Jr, Kerényi M, Székely J Jr, Polyák L Anti-Escherichia coli alpha-haemolysin in control and patient sera. Lancet 1982; ii: 986.
5. Emody L, Kétyi I, Kuch B, Pácsa S. Antitoxic immunity against the so called lung toxinproduced by Escherichia coli Acta Microbiol Acad Sci Hung 1979, 26: 233-39.
paroxysmal nature. In this condition, the lesion is in the posteriorroot-entry zone, and it is in the analogous position in the brainstemthat one may encounter a plaque of multiple sclerosis when the samesort of pain is experienced by patients with that disease. It is for thisreason that I have believed that the trigeminal root-entry zone is thesite of whatever is the local disorder that gives rise to the pain of ticdouloureux. The poor old chap from Wells Cathedral is, I think,merely pointing to a tooth, which is where most patients believe thepain is originating.
Department of Neurological Surgery,Radcliffe Infirmary,Oxford OX2 6HE JOHN POTTER
REVERSAL OF DIABETIC NEPHROPATHY IN ATRANSPLANTED KIDNEY
SIR,—Professor Abouna and colleagues, in their Dec 13, 1983,paper, state that they do not know of any other reports of regressionof histologically established diabetic nephropathy. An article inMedical World News (Sept 27, 1974) contained the followingstatement: "two kidneys from a regional organ-sharing programwere implanted before it was learned the dead donors were juvenilediabetics. Biopsies at the time of surgery showed vascular changes intheir glomeruli. Follow-up biopsies of the kidney showed theglomerular lesions completely disappeared within six months".The physician interviewed was Dr Leslie E. Rudolf of the
University of Virginia Medical Center in Charlottesville.
Diabetes Program,Division of Endocrinology,Cedars-Sinai Medical Center,LosAngeles, California 90048, USA MAYER B. DAVIDSON
Medicine and the Law
Claim for Negligent Induction of AnaesthesiaDismissed, but no Costs for Defendant Health
AuthorityTHE plaintiff, then 28, was admitted to hospital for a
hysterectomy, performed on July 12, 1976. She alleged she wasinsufficiently anaesthetised, and, though paralysed and unable tocommunicate, she remained "aware" until the moment of theincision. She suffered "conversion hysteria" subsequently. She didnot complain of the experience until she was discharged. When shewas readmitted because of symptoms arising from her experience,two weeks after the operation, she gave an account of her experienceto a hospital doctor, who took the matter up with the hospital’ssenior anaesthetist.The basis of the plaintiffs case was: she was not rendered
unconscious to the stage intended by the anaesthetist and remainedaware until the operation began; this failure was caused by incorrectadministration of anaesthetic and a failure to check that it had
worked; this failure was negligence by the anaesthetist and causedthe plaintiff to suffer recurrent anxiety attacks.Following the respopse of the senior anaesthetist to the hospital
doctor, the doctor wrote to the plaintiffs GP to say that the plaintiffhad been given a relaxant with an inadequate dose of generalanaesthetic in the first stage of intravenous injection. There was alsosuggestion of a cover-up. The letter said: "I brought this to theattention of our senior anaesthetist. He went back to the anaestheticnotes (the anaesthetic having been given by a competent junioranaesthetist). He was in entire agreement and pointed out that thedrug-namely, ’Althesin’-in the dose used did leave the patientopen to this liability ... The junior anaesthetist concerned wasbeing notified of what had happened, he having in fact now left thishospital".At the trial Judge Forbes formed the opinion that the misleading
suggestion that the anaesthetic was given by a junior anaesthetistwho had left the hospital seemed to be an attempt to cover up amistake. The senior anaesthetist must have known who had giventhe anaesthetic.The judge said that, had he been able tc find for the plaintiff, he
would have awarded £3000, but he concluded there had been no
negligence and that procedures had been routine. The plaintiff hadnot proved negligence and he was satisfied that, though theplaintifl’s recollection was honest, it was not accurate.
AppealAll three judges found the case disquieting, but they ultimately
concluded that the plaintiff, as she recovered from the anaesthetic,had transposed events at the end of the operation and events beforeit. The evidence of the anaesthetist persuaded the Court of Appealthat he could not have failed to inject althesin into a vein, and thatthe dose in a patient of 71/2 stones was sufficient to ensure anadequate level of unconsciousness. He had carried out all the usualchecks to assess depth of anaesthesia. It was, however, just possiblethat the plaintiff was one of those rare patients who reacted in anabnormal way to anaesthesia and, though paralysed, remainedaware to a greater or lesser degree.The plaintiff was legally aided, but the health authority’s costs
against the Legal Aid Fund were refused on the grounds that thehospital had brought the litigation on itself. When the patientrelated her experiences to the hospital doctor and when that doctorhad inquired what had- occurred, he had "received a whollyuntruthful and unsatisfactory answer which he repeated to theplaintiff and her husband".
Com ment
One of the commonest criticisms of the NHS and of hospitals is alack of direct response a’nd information after a complaint or even aquery. In this case, the inquiry to the senior anaesthetist wasunforn" ’tely translated into a piece of misleading information, andnot into a request to the anaesthetist who gave the anaesthetic to seethe patient and to explain matters to her. The plaintiff was thusencouraged to believe the hospital was engaged in a cover-up and theidea was planted in her mind that she had not been given the properamount of althesin or that’ it had not entered the vein. It also
produced an ordeal for the anaesthetist, many days in court for allparties, and a hefty bill for the taxpayer.Jacobs ’l’ Great Yarmouth and Waveney Health Authority. Court of Appeal, March 27,1984 Stephenson, O’Connor, and Griffiths LJJ. Appeal from Forbes J, Dec 9, 1982,QBD
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DIANA BRAHAMS,Barrister-at-Law
