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BARBITURATE POISONING
308
Although I have tried most of the agents recommended for the treatment of impetigo, none has proved as effective as graneodin ointment. J. MCMASTER. McMASTER. Walton, Liverpool. PERFORATED PEPTIC ULCERS SiR,-ņIn your issue of Jan. 22 Mr. Moore
gives
an
excellent account of his successful results in the treatacutely perforated peptic ulcers. One wonders, however, whether he is justified on his own findings in reaching some of the conclusions he did. For example, he attributes the satisfactory results in three very seriously ill patients with perforations to operation, despite the fact that it is likely that the energetic resuscitative measures employed played at least as much a part as the operation, and he uses this as an argument in favour of operative treatment for seriously ill cases. It is possible that his three patients who died on the conservative management were also treated by energetic resuscitative measures, but there is no mention of this in his paper. If they were not so treated then surely it is rather unfair to blame their deaths on conservative ment of
management. The conclusions he draws from his table iv are much too general for the type of data he has assembled there. Each section of the table shows a very variable mortality. In the first part this ranges from no deaths to a 20% mortality ; in the second, it ranges from 1.8 to 17--% ; while in the third, it ranges from 0 to 17%. The various series included under each of the three headings certainly do not appear to be identical, nor are their ages mentioned. In view of this great variability, it would be unwise to conclude, as Mr. Moore does, that whichever method of treatment is used the results are apparently much the same. Department of Surgery, Medical School, JOHN GRIEVE. Dundee. METHYLPENTYNOL AND HABIT FORMATION SiR,-Two recent articles in your columns have again dealt with methylpentyno1,12 and its use--not only as
doctor but also "
unofficially "-seems widespread. It has frequently popular press as " not habitwhilst our own earlier experiences with and forming," 3 this drug did not show any evidence to the contrary,4 5 this happy state of affairs has unfortunately not continued for long.
prescribed by
a
to have become more been described in the
Recent experience with psychopathic and neurotic alcoholics has, not unexpectedly, shown habit formation and addiction with the use of methylpentynol to be a definite possibility in the case of unstable personalities. We now know of at least six alcoholics who took large quantities of this drug. Two of these developed a confusional and highly emotional state, with slurring of speech and ataxic gait, after taking up to 20 capsules for two or three days, while others (not personally observed) seem to have taken equally large numbers for a somewhat longer period. All these alcoholics had, as far as we know, also been in the habit of taking other hypnotic
drugs
to excess.
In this connection it may perhaps be mentioned that a number of outpatients stated that methylpentynol seemed to increase considerably the effect of alcohol when taken together, an effect6 resembling the synergistic action of alcohol and barbiturates. The possible synergism between barbiturates and methylpentynol,7-9 and the fact that a death after taking 18 to 24 capsules of the drug has been reported in America,lo should also be kept in mind when considering the danger of unrestricted self-medication by the public. 1. Bourne, G. Lancet, 1954, ii, 522. 2. Trotter, P. A. Ibid, p. 1302. 3. Evening News, July 14, 1954. 4. Brit. med. J. 1954, i, 760. 5. Lancet, 1954, ii, 143. 6. Brit. med. J. 1953, i, 1269. 7. Gialdroni, C. Grassi, C.. Atti Soc. Lombarda Sci. med. biol. 1952, 7, 90. 8. Zoboli, P. Boll. Soc. ital. Biol. sper. 1953, 29, 111. 9. Lancet, 1954, ii, 1332. 10. Cares, R. M., Newman, B., Manceri, J. C. Amer. J. clin. Path. 1953, 23, 129.
these drawbacks, in our experience i has proved a satisfactory drug, in normal amounts non-toxic both on clinical and laboratory investigations. As far as alcoholics are concerned, most of whom appear to be unable " to handle any kind of
Apart from methylpentynol
drug in moderation," 11 methylpentynol, on balance, still appears to be preferable to the older hypnotics, where a hypnotic is necessary. Its use, however, should be discontinued (and this can be done fairly easily) as soon as possible after the first few days. It is regrettable that members of the public should apparently still be able to purchase large quantities of this drug so easily without a prescription, in spite of the advice of the Council of the Pharmaceutical Society that it should be supplied only on a prescription,i’as this may possibly bring a valuable drug into disrepute through excessive and indiscriminate use. Warlingham Park Hospital, M. M. GLATT. Surrey. BARBITURATE POISONING SiR,-The treatment of acute barbiturate
poisoning
remains highly controversial, with the advocates of the use of analeptics on the one hand,13 and of a more con. servative approach on the other.14 15S Having had some experience of both approaches I have become converted to the latter. Dr. Lurie,16 who has found corticotrophin of value in this disorder, writes : " The action of corticotrophin in suppressing pathological reactions is still largely unexplained, and we are certainly not in a position to offer any explanation of its role in barbiturate poisoning." Einhauser 17 showed in rats that barbiturates acted initially on the vasomotor centre causing early vascular collapse, and later acted directly on the peripheral vessels causing increased vascular permeability and collapse. Experimentally Menkin 18 and Benditt et al.1’ found that vascular permeability is decreased by the In patients with administration of corticotrophin. et Faloon al.10 found a thrombocytopenic purpura increase in resistance but consistent capillary temporary during treatment with corticotrophin. Presumably this temporary reduction of vascular permeability by corticotrophin might account for the striking results obtained by Dr. Lurie in barbiturate coma.
Royal Infirmary,
IAN A. KELLOCK.
Manchester.
ISOBEL CRIPPS CENTRE
Mr. Charles Neil
writes ::. to Dr. Barlow I must point out that the omb of suspecting," or " not suspecting " the presence of illiiesq1not on me, since the only cases that are taken without medical care are those who come to improve some skill, such as the violinist, the dancer, or the golfer. I maintain that we take every safeguard that can be taken, like the physiotherapist, with whom ive enjoy a friendly and cooperative relationship. When our methods and our institute have become more securely established, there will then be no need to advertise. as is now so in the medical profession, but was not always so. In
"
answer
"
In the mean time, our present intensive advertising MMpaign" consists of one advertisement a fortnight in the lectures and specialised training column of the le-c Statesman, and great care is taken to see that this does nOl mislead, or claim too much. Dr. Barlow had to go back to 1950 to find one which contained a doubtful phrase, and which I had stopped as soon as my attention was drawn to it. "
"
11. Sedatives and the Alcoholic. New York, 1952 : p. 8. 12. Pharm. J. July 31, 1954, p. 80. 13. Koppanyi, T., Fazekas, J. F. Amer. J. med. Sci. 1950, 220, 559. 14. Nilsson, E. Acta med. scand. 1951, suppl. 253. 15. Locket, S., Angus, J. Lancet, 1952, i, 580. 16. Lurie, I. Ibid, 1954, ii, 601. 17. Einhauser, M. Klin. Wschr. 1939, 18, 423. 18. Menkin, V. Proc. Soc. exp. Biol., N.Y. 1951, 77, 592. 19. Benditt, E. P., Schiller, S., Wong, H., Dorfman, A. Ibid, 1950 20.
75, 782. Faloon, W. W., Greene, R. W., Lozner, E. L. Amer. J. Med. 1952, 13, 12.
Although I have tried most of the agents recommended for the treatment of impetigo, none has proved as effective as graneodin ointment. J. MCMASTER. McMASTER. Walton, Liverpool. PERFORATED PEPTIC ULCERS SiR,-ņIn your issue of Jan. 22 Mr. Moore
gives
an
excellent account of his successful results in the treatacutely perforated peptic ulcers. One wonders, however, whether he is justified on his own findings in reaching some of the conclusions he did. For example, he attributes the satisfactory results in three very seriously ill patients with perforations to operation, despite the fact that it is likely that the energetic resuscitative measures employed played at least as much a part as the operation, and he uses this as an argument in favour of operative treatment for seriously ill cases. It is possible that his three patients who died on the conservative management were also treated by energetic resuscitative measures, but there is no mention of this in his paper. If they were not so treated then surely it is rather unfair to blame their deaths on conservative ment of
management. The conclusions he draws from his table iv are much too general for the type of data he has assembled there. Each section of the table shows a very variable mortality. In the first part this ranges from no deaths to a 20% mortality ; in the second, it ranges from 1.8 to 17--% ; while in the third, it ranges from 0 to 17%. The various series included under each of the three headings certainly do not appear to be identical, nor are their ages mentioned. In view of this great variability, it would be unwise to conclude, as Mr. Moore does, that whichever method of treatment is used the results are apparently much the same. Department of Surgery, Medical School, JOHN GRIEVE. Dundee. METHYLPENTYNOL AND HABIT FORMATION SiR,-Two recent articles in your columns have again dealt with methylpentyno1,12 and its use--not only as
doctor but also "
unofficially "-seems widespread. It has frequently popular press as " not habitwhilst our own earlier experiences with and forming," 3 this drug did not show any evidence to the contrary,4 5 this happy state of affairs has unfortunately not continued for long.
prescribed by
a
to have become more been described in the
Recent experience with psychopathic and neurotic alcoholics has, not unexpectedly, shown habit formation and addiction with the use of methylpentynol to be a definite possibility in the case of unstable personalities. We now know of at least six alcoholics who took large quantities of this drug. Two of these developed a confusional and highly emotional state, with slurring of speech and ataxic gait, after taking up to 20 capsules for two or three days, while others (not personally observed) seem to have taken equally large numbers for a somewhat longer period. All these alcoholics had, as far as we know, also been in the habit of taking other hypnotic
drugs
to excess.
In this connection it may perhaps be mentioned that a number of outpatients stated that methylpentynol seemed to increase considerably the effect of alcohol when taken together, an effect6 resembling the synergistic action of alcohol and barbiturates. The possible synergism between barbiturates and methylpentynol,7-9 and the fact that a death after taking 18 to 24 capsules of the drug has been reported in America,lo should also be kept in mind when considering the danger of unrestricted self-medication by the public. 1. Bourne, G. Lancet, 1954, ii, 522. 2. Trotter, P. A. Ibid, p. 1302. 3. Evening News, July 14, 1954. 4. Brit. med. J. 1954, i, 760. 5. Lancet, 1954, ii, 143. 6. Brit. med. J. 1953, i, 1269. 7. Gialdroni, C. Grassi, C.. Atti Soc. Lombarda Sci. med. biol. 1952, 7, 90. 8. Zoboli, P. Boll. Soc. ital. Biol. sper. 1953, 29, 111. 9. Lancet, 1954, ii, 1332. 10. Cares, R. M., Newman, B., Manceri, J. C. Amer. J. clin. Path. 1953, 23, 129.
these drawbacks, in our experience i has proved a satisfactory drug, in normal amounts non-toxic both on clinical and laboratory investigations. As far as alcoholics are concerned, most of whom appear to be unable " to handle any kind of
Apart from methylpentynol
drug in moderation," 11 methylpentynol, on balance, still appears to be preferable to the older hypnotics, where a hypnotic is necessary. Its use, however, should be discontinued (and this can be done fairly easily) as soon as possible after the first few days. It is regrettable that members of the public should apparently still be able to purchase large quantities of this drug so easily without a prescription, in spite of the advice of the Council of the Pharmaceutical Society that it should be supplied only on a prescription,i’as this may possibly bring a valuable drug into disrepute through excessive and indiscriminate use. Warlingham Park Hospital, M. M. GLATT. Surrey. BARBITURATE POISONING SiR,-The treatment of acute barbiturate
poisoning
remains highly controversial, with the advocates of the use of analeptics on the one hand,13 and of a more con. servative approach on the other.14 15S Having had some experience of both approaches I have become converted to the latter. Dr. Lurie,16 who has found corticotrophin of value in this disorder, writes : " The action of corticotrophin in suppressing pathological reactions is still largely unexplained, and we are certainly not in a position to offer any explanation of its role in barbiturate poisoning." Einhauser 17 showed in rats that barbiturates acted initially on the vasomotor centre causing early vascular collapse, and later acted directly on the peripheral vessels causing increased vascular permeability and collapse. Experimentally Menkin 18 and Benditt et al.1’ found that vascular permeability is decreased by the In patients with administration of corticotrophin. et Faloon al.10 found a thrombocytopenic purpura increase in resistance but consistent capillary temporary during treatment with corticotrophin. Presumably this temporary reduction of vascular permeability by corticotrophin might account for the striking results obtained by Dr. Lurie in barbiturate coma.
Royal Infirmary,
IAN A. KELLOCK.
Manchester.
ISOBEL CRIPPS CENTRE
Mr. Charles Neil
writes ::. to Dr. Barlow I must point out that the omb of suspecting," or " not suspecting " the presence of illiiesq1not on me, since the only cases that are taken without medical care are those who come to improve some skill, such as the violinist, the dancer, or the golfer. I maintain that we take every safeguard that can be taken, like the physiotherapist, with whom ive enjoy a friendly and cooperative relationship. When our methods and our institute have become more securely established, there will then be no need to advertise. as is now so in the medical profession, but was not always so. In
"
answer
"
In the mean time, our present intensive advertising MMpaign" consists of one advertisement a fortnight in the lectures and specialised training column of the le-c Statesman, and great care is taken to see that this does nOl mislead, or claim too much. Dr. Barlow had to go back to 1950 to find one which contained a doubtful phrase, and which I had stopped as soon as my attention was drawn to it. "
"
11. Sedatives and the Alcoholic. New York, 1952 : p. 8. 12. Pharm. J. July 31, 1954, p. 80. 13. Koppanyi, T., Fazekas, J. F. Amer. J. med. Sci. 1950, 220, 559. 14. Nilsson, E. Acta med. scand. 1951, suppl. 253. 15. Locket, S., Angus, J. Lancet, 1952, i, 580. 16. Lurie, I. Ibid, 1954, ii, 601. 17. Einhauser, M. Klin. Wschr. 1939, 18, 423. 18. Menkin, V. Proc. Soc. exp. Biol., N.Y. 1951, 77, 592. 19. Benditt, E. P., Schiller, S., Wong, H., Dorfman, A. Ibid, 1950 20.
75, 782. Faloon, W. W., Greene, R. W., Lozner, E. L. Amer. J. Med. 1952, 13, 12.