Correspondence
73
The Bangalore MD We refer to the account by Dr Bradshaw (Anaesthesia, 1976, 31, 1341) of her visit to Bangalore and other centres in India. If I read correctly, D r Bradshaw understood that the M D degree at Bangalore comprised of ‘merely the collecting of twenty cases’. We were rather surprised at this interpretation. The MD degree is awarded after a 3 year course comprising both clinical and theoretical work. The students must administer anaesthesia under the guidance of qualified staff members. They attend the emergencies round the clock on rotation. The students also participate in seminars and symposia in anaesthesia and allied subjects and are also expected to participate in the undergraduate teaching programmes. A thesis or dissertation comprising of twenty cases anaesthetised by them is submitted at the end of the course to their supervisor and to the university. The dissertations are reviewed by a panel of Professors from different institutions unknown to the candidate. There is also a university examination at the end of this course comprising basic sciences, physics, clinical medicine
and anaesthesiology. The candidate has also to write an essay on some topic in Anaesthesiology, in a written examination lasting 3 h. The clinical examination consists of examination of one major and two minor clinical cases, usually a surgical case with medical or other problems. This is followed by a really searching viva-voce conducted by professors from various medical colleges who are experienced postgraduate examiners. The DA examination differs only slightly from this and a thesis is not required. 48 K . H . Road, Bungalore,
560027, India.
K.R.C. NAIDU, S. MALATHI AND B.S.JAGADISH
A reply
I am grateful for the opportunity to reply to Dr Naidu’s informative letter. I apologise if the information l received about past requirements for the M D qualifications was incomplete. Wythenshuwe Hospital, Munchester M 2 3 9LT.
ELIZABETH G . BRADSHAW
A hazard of naso-tracheal intubation
The intracranial introduction of a naso-gastric catheter has been reported in some cases of craniofacial injuryl.z.3.4 but so far as we know a similar
Fig. I .
accident has not been reported following attempted naso-trachael intubation. The case which we report concerns a 4 4 year old man who suffered severe head trauma and was admitted to the Limoges’ hospital in a deep coma. A nasal tube had been introduced before admission, in the hospital where he received first aid. Intubation had been performed before X-ray examination. The fact that the tube was in the wrong position was obvious since the patient had not breathed through it. Roengtenographic examination of the skull revealed the abnormal way in which the tube had travelled through the brain up to the posterior fossa (Figs I and 2). The tube was removed and artificial ventilation was applied after orotrachael intubation. Nevertheless, the neurological status of the patient worsened and he died a few hours after admission. Postmortem examination confirmed the complex fracture of the skull and the presence of a right temporal subdural haematoma. The inadvertent introduction of the tube was facilitated by a fracture involving the upper part of the nasal fossae. The cerebral lesions in relation with intubation were located in the white matter of the right hemosphere. Centre Huspirulier et Universitaire, 8703 1 Liniuges, France.
M.F. HORELLOU, D. MATHEAND P. FEISS
14
Correspondence
Fig. 2.
3.
Heferetices MARTIFIELLt, F., MONTANT, J., HAZEAUX, c. & R EN A R DM . (1974) Penetration intra-crlnienne d’une
sonde gastrique A travers une dehiscence traumatique de la lame criblee. Cahiivs cl’anesrhksiologie 22, 345. ROCHET,D. ( 1976) Sonde gastrique intra-crlnienne Cahiers tl’cinc~sthdsiologic~,24, 833.
J . , NOZIK,D. & M A I H I E L IA, . (I975 Inadvertent introduction o f a nasogastric tube, a complication of severe maxillo-facial trauma. SttBACHtR,
Anesthesiology, 42, 100.
4. VALETTA, J. (1975) Sonde gastrique fourvoyee Cahicrs d’ani~sthh.sio/cJgie,23, 209.
Snakes, snake bites and trouble at Grantchester
I would like to make a comment on Drs Burgess and Shuttleworth’s letter on snakes and snake bites (Atiaesthesia, 1977,32,664). When I was in India in the RAMC between 1916 and 1919 I had an excellent book on snakes (written by Major Wall, I think) in which it was stated that each kind of snake had its own individual arrangement of scales (scale pattern); all types were clearly illustrated i n the book. Thus, as with finger prints, no type had the scale pattern of another type and, as each type always kept its own scale pattern, the identification of type was easy. I had t o treat only one bad snake bite (cobra o r Russel’s viper, not Krait as that was invariably fatal) and the patient was very ill for some I2 h or so and then recovered.
I feel that I must also draw attention to the error in the Editors comment ‘Editorial nostalgia for real time’. Rupert Brooke’s last line in ‘The Old Vicarage, Grantchester’ (the ‘1’ was omitted) is ‘And is there honey still for tea’. The addition of ‘shire’ to Cambridge also breaks the scansion in the other line quoted-a pity.
I Marbeck Close, Witiclwr, Berkshire SL4 5 R E .
STEPHkN COl k I N
Air Editorial apology
The Editor apologises-surely there can be no greater sin than omitting the ‘tea’ in Grantchester.
Unrecognised tracheo-oesophageal fistula
I would like to comment on the case of unrecognised tracheo-oesophageal fistula reported hy Dr Ng and his colleagues (Anaesthesia, 1977, 32, 31) and to make the following points. First, no premedication was used, even though this would have greatly reduced the ‘constant puddle of secretions in the pharynx and perilaryngeal areas’ described in the case report, and I would also have decreased the reported reduction in heart rate. I f a suitable sedative had been used as well it would have considerably decreased the patient’s agitation. Secondly,
if the patient’s acceptance of a local anaesthetic technique was in doubt (as would seem likely with Korsakow’s psychosis) it should not have been embarked upon. Thirdly, I would have thought that a respiratory depressant like Thalamonal was contraindicated in a chronic bronchitic. Fourthly, if anaesthesia is being induced, or as in this case the mode of induction changed, it is advisable to give a n adequate dosage at one time and not three separate small doses, otherwise the patient is unlikely to be sufficiently ‘deep’ to promote good
73
The Bangalore MD We refer to the account by Dr Bradshaw (Anaesthesia, 1976, 31, 1341) of her visit to Bangalore and other centres in India. If I read correctly, D r Bradshaw understood that the M D degree at Bangalore comprised of ‘merely the collecting of twenty cases’. We were rather surprised at this interpretation. The MD degree is awarded after a 3 year course comprising both clinical and theoretical work. The students must administer anaesthesia under the guidance of qualified staff members. They attend the emergencies round the clock on rotation. The students also participate in seminars and symposia in anaesthesia and allied subjects and are also expected to participate in the undergraduate teaching programmes. A thesis or dissertation comprising of twenty cases anaesthetised by them is submitted at the end of the course to their supervisor and to the university. The dissertations are reviewed by a panel of Professors from different institutions unknown to the candidate. There is also a university examination at the end of this course comprising basic sciences, physics, clinical medicine
and anaesthesiology. The candidate has also to write an essay on some topic in Anaesthesiology, in a written examination lasting 3 h. The clinical examination consists of examination of one major and two minor clinical cases, usually a surgical case with medical or other problems. This is followed by a really searching viva-voce conducted by professors from various medical colleges who are experienced postgraduate examiners. The DA examination differs only slightly from this and a thesis is not required. 48 K . H . Road, Bungalore,
560027, India.
K.R.C. NAIDU, S. MALATHI AND B.S.JAGADISH
A reply
I am grateful for the opportunity to reply to Dr Naidu’s informative letter. I apologise if the information l received about past requirements for the M D qualifications was incomplete. Wythenshuwe Hospital, Munchester M 2 3 9LT.
ELIZABETH G . BRADSHAW
A hazard of naso-tracheal intubation
The intracranial introduction of a naso-gastric catheter has been reported in some cases of craniofacial injuryl.z.3.4 but so far as we know a similar
Fig. I .
accident has not been reported following attempted naso-trachael intubation. The case which we report concerns a 4 4 year old man who suffered severe head trauma and was admitted to the Limoges’ hospital in a deep coma. A nasal tube had been introduced before admission, in the hospital where he received first aid. Intubation had been performed before X-ray examination. The fact that the tube was in the wrong position was obvious since the patient had not breathed through it. Roengtenographic examination of the skull revealed the abnormal way in which the tube had travelled through the brain up to the posterior fossa (Figs I and 2). The tube was removed and artificial ventilation was applied after orotrachael intubation. Nevertheless, the neurological status of the patient worsened and he died a few hours after admission. Postmortem examination confirmed the complex fracture of the skull and the presence of a right temporal subdural haematoma. The inadvertent introduction of the tube was facilitated by a fracture involving the upper part of the nasal fossae. The cerebral lesions in relation with intubation were located in the white matter of the right hemosphere. Centre Huspirulier et Universitaire, 8703 1 Liniuges, France.
M.F. HORELLOU, D. MATHEAND P. FEISS
14
Correspondence
Fig. 2.
3.
Heferetices MARTIFIELLt, F., MONTANT, J., HAZEAUX, c. & R EN A R DM . (1974) Penetration intra-crlnienne d’une
sonde gastrique A travers une dehiscence traumatique de la lame criblee. Cahiivs cl’anesrhksiologie 22, 345. ROCHET,D. ( 1976) Sonde gastrique intra-crlnienne Cahiers tl’cinc~sthdsiologic~,24, 833.
J . , NOZIK,D. & M A I H I E L IA, . (I975 Inadvertent introduction o f a nasogastric tube, a complication of severe maxillo-facial trauma. SttBACHtR,
Anesthesiology, 42, 100.
4. VALETTA, J. (1975) Sonde gastrique fourvoyee Cahicrs d’ani~sthh.sio/cJgie,23, 209.
Snakes, snake bites and trouble at Grantchester
I would like to make a comment on Drs Burgess and Shuttleworth’s letter on snakes and snake bites (Atiaesthesia, 1977,32,664). When I was in India in the RAMC between 1916 and 1919 I had an excellent book on snakes (written by Major Wall, I think) in which it was stated that each kind of snake had its own individual arrangement of scales (scale pattern); all types were clearly illustrated i n the book. Thus, as with finger prints, no type had the scale pattern of another type and, as each type always kept its own scale pattern, the identification of type was easy. I had t o treat only one bad snake bite (cobra o r Russel’s viper, not Krait as that was invariably fatal) and the patient was very ill for some I2 h or so and then recovered.
I feel that I must also draw attention to the error in the Editors comment ‘Editorial nostalgia for real time’. Rupert Brooke’s last line in ‘The Old Vicarage, Grantchester’ (the ‘1’ was omitted) is ‘And is there honey still for tea’. The addition of ‘shire’ to Cambridge also breaks the scansion in the other line quoted-a pity.
I Marbeck Close, Witiclwr, Berkshire SL4 5 R E .
STEPHkN COl k I N
Air Editorial apology
The Editor apologises-surely there can be no greater sin than omitting the ‘tea’ in Grantchester.
Unrecognised tracheo-oesophageal fistula
I would like to comment on the case of unrecognised tracheo-oesophageal fistula reported hy Dr Ng and his colleagues (Anaesthesia, 1977, 32, 31) and to make the following points. First, no premedication was used, even though this would have greatly reduced the ‘constant puddle of secretions in the pharynx and perilaryngeal areas’ described in the case report, and I would also have decreased the reported reduction in heart rate. I f a suitable sedative had been used as well it would have considerably decreased the patient’s agitation. Secondly,
if the patient’s acceptance of a local anaesthetic technique was in doubt (as would seem likely with Korsakow’s psychosis) it should not have been embarked upon. Thirdly, I would have thought that a respiratory depressant like Thalamonal was contraindicated in a chronic bronchitic. Fourthly, if anaesthesia is being induced, or as in this case the mode of induction changed, it is advisable to give a n adequate dosage at one time and not three separate small doses, otherwise the patient is unlikely to be sufficiently ‘deep’ to promote good
