TREATMENT OF STATUS ASTHMATICUS

1327 FLUORIDATION AND THE COUNCILLORS SIR,-In her letter (May 14) the honorary secretary of the National Pure Water Association refers to " the general practice ... to limit the permitted amount of food additives or pesticides to 1 % of the maximum no-effects level as ascertained by animal experiments ". I hope she will not adhere too strongly to this formula; it may embarrass us all. There is a particular well-characterised substance which, when administered by mouth to rabbits in daily doses of 300-333 ml. per kg. body-weight, causes listlessness, ataxia, diuresis, stupor, convulsions, and death within two to three weeks. This clearly is beyond the no-effect level. Even so, if we apply to it the 1 % factor as suggested by your correspondent, the permitted level so deduced should be substantially less than 3-0-3-3 ml. per kg. daily, or, in practical terms, somewhat over 200 ml. daily for a man. That substance

is-pure

water.

National Poisons Information Service, Guy’s Hospital, London S.E.1.

ROY GOULDING.

FLUORIDES AND THE LOCOMOTOR SYSTEM SiR,—The knowledge of the possible relations of fluoride ingestion to various rheumatic disorders has been extensively described in your leading article (May 28). A more direct cause and effect relation to bone changes has been reported, and is a European condition as distinct from the pronounced osteosclerosis with bony exostoses that you describe as of Eastern origin. The condition described as " periostitis deformans " by Professor Soriano of Barcelona is no doubt the same as the " ankylosing hyperostosis " first referred to by Jacques Forestier in 1964. Soriano states categorically that the vehicle causing the hyperfluoridosis is the common wine of the district, to which great amounts of sodium fluoride are added for preservation. The article makes no mention of any associated malnutrition, but the author leaves little doubt as to the fluoride intake being directly related to the osteophytic outgrowths in this condition. Charterhouse Rheumatism Clinic, 54—60 Weymouth Street, London W.1.

HARRY COKE.

THE DISPLACEMENT SYNDROME SIR,-Dr. Goodall’s intercepted letter (May 14) should help many to beware of unnecessary displacement. I used to be a believer in unlimited powers of adaptation. Now, after

PROJECT 70

SiR,—Thank you for your notice last week of Project 70; we should like to point out that this plan aims at solving the problem of financing better accommodation for the aged, rather than the quite distinct one of staffing, which has to be solved in any event. It should, however, be easier to attract good staff for the small, modern units provided by our scheme than for the huge, antiquated communities resulting from the isolation of mental hospitals. In a symposium held this year at Severalls Hospital, Dr. Stephen Horsley expressed the opinion that the main cause of staff shortage is the atmosphere of hopelessness. Letters received by AEGIS (Aid for the Elderly in Government Institutions) from staff who have left this branch of nursing endorse his opinion. May we ask in what way the proposed new towns would be " artincial " communities ? Is it seriously suggested that the inclusion of a proportion of the elderly in new towns is more artificial than their segregation in mental hospitals ? Your note speaks of old people being " moved around " as if they were to be shunted about like goods trucks in a marshalling yard. Those affected would, however, change hospital sites but once. Surely much depends on the way that they are prepared for such moves, the spirit in which the journey is undertaken, and the reception given on arrival. We do not of course profess to offer a total panacea for a complex problem. We have, however, made a serious attempt at resolving a part of the Government’s hospital rebuilding difficulties. Might we not have hoped for a more cordial welcome in an issue of The Lancet containing a lament for the inadequacy of the Government’s new white-paper ? 10

Hampstead Grove, London N.W.3.

z*

does not condemn Project 70, but mentions it raises. It has been repeatedly shown that human relations are more important than physical environment. An atmosphere of hopelessness can be found in small new geriatric hospitals as well as in old institutions. The artificiality of a new town and its effect on the elderly is a moot point, but evidence of the ill effect of moving old people is enough to warrant consideration. Old people are rotting in miserable overcrowded institutional wards. A plan like Project 70 which may improve their lot should be seriously investigated, but to ignore its disadvantages will benefit no-one.-ED. L. some

Our

BARBARA ROBB P. G. M. THOMSON.

note

problems

developing displacement syndrome, complicated by replacement, I wish I had been more cautious. After ten years of postgraduate training and post-training work in foreign countries (some more advanced than mine, some more rewarding), and on both sides of the Atlantic, and exposure to many different cultures and five major languages, I was finally about to re-enter my homeland with the intention’of definitely settling down there. I was full of misgivings and uncertainties about both country and work, undecided among conflicting philosophies. Five miles from the frontier I was seized by an acute attack of replacement fear. For three days and many hundred miles I drove back and forth, undecided. Being aware of my state of alienation but unable to overcome it, I remembered Dr. Jean Lamour, a kind soul with a providential name, an old mate in Boston and now living not too far from the scene. Jean, who had once been around the world, readily diagnosed what Dr. Goodall would perhaps call chronic displacement, plus overdose and fear of weaning. Jean and his wife relieved my anguish by the orthodox method of merely revealing the diagnosis (and the less orthodox one of telling their own troubles). Next day I crossed the border and became a displaced person in his own place: a displacedreplaced person. Eighteen months later new symptoms of displacement are appearing-perhaps a matter of disreplacement ? F. CARDENAL. 1.

Rowntree, L. G. Archs

intern.

Med. 1923, 32, 157.

TREATMENT OF STATUS ASTHMATICUS to the therapeutic measures advocated by Mr. Marchand and Dr. Hasselt (Jan. 29) and Dr. Thompson (Feb. 26) for treatment of status asthmaticus I would suggest diuretics of the thiazide group-given together with an antibiotic (chloramphenicol or tetracycline). I have found them extremely valuable in easing the breathing in this distressful condition, especially in children who respond particularly well. Fever if any drops to normal, the patient micturates freely, dyspnoea recedes, and relief is obtained in a few hours. " Large quantities of urine may be passed as an attack subsides according to Savill.1

SIR,-In addition

T. M. SUSAI.

SiR,—We consider the statements made by Dr. Grant (Feb. 12) on the use of massive doses of steroids both timely and appropriate. In our experience, in pursuance of which we have to treat a patient with status asthmaticus at least once every day of the year, there have, never been any complications associated with large doses of steroids on the short-term basis required to bring this ailment under rapid control. Perhaps it 1. Savill’s 1950.

System of Clinical Medicine (edited by

E. C.

Warner). London,

1328

speaks for itself that by using such doses we have had to perform only one tracheostomy and no bronchoscopies in five years. Children’s Asthma Research Institute and Hospital, Denver, Colorado 80204.

N. GORDON H. CHAI.

CARBON-DIOXIDE TITRATION CURVE SIR,-The debate about the practical and theoretical importance of the difference between the in-vivo and the in-vitro carbon-dioxide titration curve of blood, which was initiated by the article of Schwartz and Relman,l has caused much confusion in the opinions of various authors and investigators on the fundamental understanding of acid-base problems and of the interpretation of analytical values found. The Special Article of Dr. Armstrong and his colleagues (April 2) gives a notional and, in principle, correct evaluation of the bicarbonate shift between intravascular and extracellular space when a change of PC02 occurs. It is obviously initiated by the presumed existence of two controversial approaches to the evaluation of acid-base problems-the whole-body approach and the whole-blood approach-of which only one can be valid. This conception, however, is incorrect, since the approaches are not at all controversial. The whole-blood approach (the in-vitro carbon-dioxide titration line) refers to the mathematical treatment of results measured on drawn blood. It should be stressed that in reality any procedure for measuring acid-base values of blood follows the laws for the in-vitro carbon-dioxide titration curve. This is true not only for the equilibration methods, but also for all kinds of gasometric methods where the Peo2 of the blood is decreased to zero by absorbing the liberated carbon-dioxide. From this aspect it is unimportant that the liberation of carbon dioxide is accelerated by adding acid and/or by evacuation, and thus has no significance for the results if they are found by using analytical systems where the PC02 is brought to 0 mm. Hg, to 40 mm. Hg, or to any other value. Therefore it is not surprising that the same values for total carbon dioxide of plasma (blood) are found when using the equilibration and gasometric methods. The whole-body approach (the in-vivo carbon-dioxide titration curve), however, should be used when evaluating the physiological processes involved in creating the acid-base state measured-for example, to explain the shifts of bicarbonate ions from blood to extracellular space when Peo2 is varied. Here, when a blood-sample is drawn from a normal person at an arterial Peo2 of 40 mm. Hg and then equilibrated in vitro at 80 mm. Hg (sample A), and another sample is drawn from the same person at an arterial Peo" of 80 mm. Hg (sample B), the Pco2-dependent shift in-vivo of bicarbonate ions from blood to extracellular space will give a lower total carbon dioxide of plasma (blood) in sample B than in sample A. This will be true whether the determinations are done by gasometric or equilibration methods. The shift in bicarbonate ions can be expressed as the difference between the values obtained for total carbon dioxide; and the total shift in acid (base) in mEq. can be expressed by using the difference between the buffer base values or between the base-excess values found in samples A and B. The shifts, however, are under most circumstances small, as correctly pointed out by Dr. Armstrong and his colleagues. That the two approaches are non-controversial and that both of them are necessary for treating acid-base problems properly, has always been advocated by Danish investigators. The one-sided view that one approach is incorrect and the other one false is not advocated by Dr. Armstrong and his colleagues, but has been advocated by so many other participants in the debate that we feel that this misunderstanding is the real origin of the debate. Therefore a continuation of the debate-which indeed does not deserve the name " Great Transatlantic Acid-base Debate " (Bunker 2)on the correctness of the two approaches will not serve any sound scientific purpose. 1. Schwartz, W. B., Relman, A. New Engl. J. Med. 1963, 268, 1382. 2.

Bunker, J. P. Anesthesiology, 1965, 26, 591.

The greatest value of the debate on the in-vivo and the in-vitro lines is in the accurate and important studies on the in-vivo carbon-dioxide titration curves carried out by some investigators (Brackett et al.,3 Brown and Clancy,4 and others). If these studies were actually initiated by the debate, they would be a good excuse for its existence. Department of Clinical Chemistry, POUL ASTRUP Rigshospitalet, Copenhagen, Denmark.

KJELD JØRGENSEN.

TIMOR MORTIS CONTURBAT ME SIR,-Your annotation (May 14) and the moving letter from Miss Pearce last week rightly focus attention on the duty of doctor and nurse to dying patients. If a patient in his right mind asks a straight question he is entitled to a straight answer, and it is clearly wrong to lie; indeed to do so indicates a lack of moral courage on the part of the attendant. But relatives may not always be prepared to accept a situation which entails prolonged day-to-day contact with one who knows his time is short, and the doctor or nurse may be subjected to much pressure to withhold the truth. The temperaments of patients also differ, however, and we must all have had the experience of people who know very well that they are going to die, but cannot face a sentence of death; so doctor and patient as it were play a game with each other. The fact is that in dying as in living no two patients are alike, and the percipient doctor must treat each according to his needs and in the light of his experience. Only experience can teach, and it is in this respect that the young doctor is most in need of guidance.

GERALD F. KEATINGE.

DEFIBRINATION SYNDROME SIR,-The case of postpartum hxmorrhage described by Mr. Topiwala (May 28) is most interesting, but no explanation has been offered as to the possible mechanism responsible for this syndrome occurring four weeks after delivery. I have demonstrated that living normal tissues are free of fully active thromboplastin,5 and that the formation of tissue thromboplastin is a time-consuming process.6 In addition, intrauterine foetal death is followed by an increase in the thromboplastic activity of amniotic fluid."6 It thus appears that the presence of placental remnants in Mr. Topiwala’s patient was the source of trouble, with tissue thromboplastic activity increasing gradually in the dead placental tissue, and producing the coagulation defect on reaching the circulating blood. This is supported by: (a) the activation of fibrinolysis being secondary in Mr. Topiwala’s patient; and (b) the principle that four weeks is usually the maximal time recommended for termination of pregnancy in cases of intrauterine death in order to avoid bleeding complications. Department of Pathology, Shenley Hospital, Hertfordshire.

F. NOUR-ELDIN.

IDIOPATHIC TROPICAL SPLENOMEGALY SIR,-We were interested to see the haemodynamic findings in " big spleen disease " (B.S.D.) reported from Mulago Hospital by Dr. Williams and his colleagues (Feb. 12). In a smaller and less sophisticated studywe obtained similar findings, although we did not measure splenic blood-flow. Significant anaemia was not a finding in our group of patients, who all had hxmoglobin values greater than 11 per 100 ml., so this appears not to be a factor causing the elevated portal pressure. We adopted a hypothesis that vasoconstriction could be a factor causing the elevated portal pressure. This hypo3.

Brackett, N. C., Cohen, J. J., Schwartz, W. B. New Engl. J. Med. 1965, 272, 6. 4. Brown, E. B., Clancy, R. L. J. appl. Physiol. 1965. 20, 885. 5. Nour-Eldin, F. Ann. N.Y. Acad. Sci. 1964, 105, 983. 6. Nour-Eldin, F. ibid. (in the press). 7. Harries, J. R., Forrester, A. T. T., Bhardwaj, V. B., Bagshawe, A. F. E. Afr. med. J. 1965, 42, 575.