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BRONCHODILATOR AEROSOLS
677
objective commentary on what medicine still has to learn. There is a feeling among many physicians, including pathologists, that newer diagnostic techniques such as ultrasonics, electromicroscopy, isotope scanning, and arteriography have lessened the importance of the necropsy. This resistance apathy threatens to retard medical progress. 21 East 90th Street, JOHN PRUTTING
or
New York, New York 10028.
President, The Foundation for the Advancement of Medical Knowledge.
TECHNIQUE OF RENAL BIOPSY SIR,-In their interesting letter (Sept. 2, p. 511) Dr. Manitz and Dr. Matthes say that " intravenous pyelography may present a serious risk of deterioration of kidney function in patients with severe renal parenchymal damage ". Reports I have readdo not confirm this statement, and I should be grateful to learn on what evidence it is based. Milton Hospital, DAVID M. JACKSON. Milton, Massachusetts 02186.
PRESERVATION OF CANINE KIDNEYS SIR,-The highly successful method of preserving canine kidneys reported by Dr. Belzer and his colleagues (Sept. 9, p. 536) is a real advance in organ preservation. Too many workers have used more complex systems and even more complex methods of assessment, which have made logical evaluation difficult. My attempt2 to devise a synthetic substitute for whole blood, with its well-substantiated unsuitabilities,3 was limited by intrinsic complexities. The use of homologous canine plasma with additives and after microfiltration is another approach to the same problem which Dr. Belzer and his colleagues have shown to be acceptable as far as short-term function of the replanted kidney is concerned. Dr. Belzer and his colleagues are probably correct in asserting that 24-72 hours is an adequate period of preservation during which the preparation of a human recipient for a transplant can be completed, but much longer storage is necessary before recent advances in tissue typing 4 can be used for selecting the most compatible transplant from a bank of several organs. Royal Infirmary,
J. MAXWELL ANDERSON.
Glasgow C.4.
FORCED DIURESIS AFTER BARBITURATES SIR,-We read with interest the letter from Dr. Matthew and Dr. Lawson (Sept. 9, p. 559) commenting on our paper (Aug. 19, p. 377). We regret that we did not make it clear that all the patients included in the series of 110 patients had blood-barbiturate levels in excess of 3-5 mg. per 100 ml. (intermediate acting) or 10 mg. per 100 ml. (long acting). In table III we included 2 extra patients who had begun forced diuresis before it was known that the blood-barbiturate level was below that required for inclusion in the series; we quoted the amount of drug removed in these patients in order to show that only small amounts of intermediate-acting drugs are removed when the blood-level is low. Neither patient was included in the series for the purposes of calculation of mortality, and we feel that our series should be compared with the group of 83 patients of Matthew and Lawson who had comparable blood-levels, and in whom there were 4 deaths.5 1.
Schwarz, W. B., Hurwitz, A., Ettinger, A. New Engl. J. Med. 1963, 269, 277. Schenker, B. Radiology, 1966, 87, 304. Bloomfield, J. A. Australas. Radiol. 1966, 10, 49. 2. Anderson, J. M. Br. J. Surg. 1966, 53, 802. 3. Rapport, M. M., Green, A. A., Page, I. H. J. biol. Chem. 1948, 176, 1243. Reid, G. Med. J. Aust. 1943, ii, 244. Richards, A. N., Plant, O. H. Am. J. Physiol. 1922, 59, 144. Starling, E. H., Verney, E. B. Proc. R. Soc. B., 1925, 97, 321. Zucker, M. B. Am. J. Physiol. 1944, 142, 12. 4. Ceppellini, R. 1st International Congress of the Transplantation Society, 1967. 5.
Matthew, H., Lawson,
A. A. H.
Q. Jl Med. 1966, 35, 539.
We stated in our paper, in agreement with the view of Matthew and Lawson, that the amounts of intermediate-acting drugs removed by forced diuresis are small when their bloodlevel is less than 4 mg. per 100 ml. At higher blood-levels, amounts of drug equivalent to 3 or 4 capsules were being removed in 8 hours-a fourfold or fivefold increase over unassisted renal excretion. Since the technique of forced diuresis seems safe, we contend that this probably represents a significant contribution to shortening of duration of coma. We presume that there is general agreement on the value of forced diuresis in poisoning with long-acting drugs, where the amounts removed are large. In addition to increasing rate of removal of drug, forced diuresis also ensures a high urine-flow rate and correction of hypovolasmia, this may explain why renal failure complicated barbiturate poisoning 4 times in the series of Matthew and Lawsonf but never in ours. Finally, we do not agree that forced diuresis should be restricted to specialised units; care in its control is, of course, necessary, but it is certainly no more difficult than basic intensive supportive therapy involving assessment of respiratory state and decisions about endotracheal intubation and the use of a ventilator. We do not feel that the safe use of forced diuresis is beyond the competence of a well-trained
registrar. Western
Infirmary, Glasgow W.1.
A. L. LINTON R. G. LUKE J. D. BRIGGS.
MARRIAGE AND THE G.M.C. SIR,-Iwas glad to see your annotation (Aug. 19, p. 408) on the failure of our profession to absorb doctors who had not had a British medical education. In 1933, when there were the first refugees from Nazi Germany, the inability of the G.M.C. to permit recognition, or to promote the necessary legislation, was a source of shame to many. Since then we seem to have bumbled along, taxing the understanding of many doctors who wished to come here and turning away help which we could ill afford to lose. Now the advent of E.E.C. may open a door which remains closed to humanity and common sense, but this is a problem of more countries than the half-dozen in Western Europe. In North America, Australia, and many other countries they find ways to deal with this question of registrable qualifications; there was mutual recognition of qualifications by Italy and Britain, with benefit to each, until political action in 1940 ended an old and fruitful association. Westmeston, Hassocks, Sussex.
DENIS PIRRIE.
BRONCHODILATOR AEROSOLS SiR,—The recent warning by the Committee on Safety of Drugs leaves it in doubt whether the deaths following the use of pressurised bronchodilators (aerosols) are due to the bronchodilator or to the pressurising agent or to both. No toxic symptoms are described. Manufacturers have stated that the pressurising agent, which is usually a fluorinated hydrocarbon, is non-toxic, and supporting evidence is cited. Close examination reveals, however, that the evidence may not be altogether valid; and much is made of the alleged fact that there has been little complaint from the public or doctors. The pressurising agent is also used in packs other than those for inhalants-such as shaving creams, hair lotions, and other cosmetic products, where any toxic effects of the fluorocarbon might be expected to be less important since little would be inhaled. Most of the claims of non-toxicity by the manufacturers of the chemical and of the pack seem to be based on topical tests on animals. Tests to detect any side-effects after inhalation are few and do not carrv much conviction. M. A. PHILLIPS. Upminster, Essex.
objective commentary on what medicine still has to learn. There is a feeling among many physicians, including pathologists, that newer diagnostic techniques such as ultrasonics, electromicroscopy, isotope scanning, and arteriography have lessened the importance of the necropsy. This resistance apathy threatens to retard medical progress. 21 East 90th Street, JOHN PRUTTING
or
New York, New York 10028.
President, The Foundation for the Advancement of Medical Knowledge.
TECHNIQUE OF RENAL BIOPSY SIR,-In their interesting letter (Sept. 2, p. 511) Dr. Manitz and Dr. Matthes say that " intravenous pyelography may present a serious risk of deterioration of kidney function in patients with severe renal parenchymal damage ". Reports I have readdo not confirm this statement, and I should be grateful to learn on what evidence it is based. Milton Hospital, DAVID M. JACKSON. Milton, Massachusetts 02186.
PRESERVATION OF CANINE KIDNEYS SIR,-The highly successful method of preserving canine kidneys reported by Dr. Belzer and his colleagues (Sept. 9, p. 536) is a real advance in organ preservation. Too many workers have used more complex systems and even more complex methods of assessment, which have made logical evaluation difficult. My attempt2 to devise a synthetic substitute for whole blood, with its well-substantiated unsuitabilities,3 was limited by intrinsic complexities. The use of homologous canine plasma with additives and after microfiltration is another approach to the same problem which Dr. Belzer and his colleagues have shown to be acceptable as far as short-term function of the replanted kidney is concerned. Dr. Belzer and his colleagues are probably correct in asserting that 24-72 hours is an adequate period of preservation during which the preparation of a human recipient for a transplant can be completed, but much longer storage is necessary before recent advances in tissue typing 4 can be used for selecting the most compatible transplant from a bank of several organs. Royal Infirmary,
J. MAXWELL ANDERSON.
Glasgow C.4.
FORCED DIURESIS AFTER BARBITURATES SIR,-We read with interest the letter from Dr. Matthew and Dr. Lawson (Sept. 9, p. 559) commenting on our paper (Aug. 19, p. 377). We regret that we did not make it clear that all the patients included in the series of 110 patients had blood-barbiturate levels in excess of 3-5 mg. per 100 ml. (intermediate acting) or 10 mg. per 100 ml. (long acting). In table III we included 2 extra patients who had begun forced diuresis before it was known that the blood-barbiturate level was below that required for inclusion in the series; we quoted the amount of drug removed in these patients in order to show that only small amounts of intermediate-acting drugs are removed when the blood-level is low. Neither patient was included in the series for the purposes of calculation of mortality, and we feel that our series should be compared with the group of 83 patients of Matthew and Lawson who had comparable blood-levels, and in whom there were 4 deaths.5 1.
Schwarz, W. B., Hurwitz, A., Ettinger, A. New Engl. J. Med. 1963, 269, 277. Schenker, B. Radiology, 1966, 87, 304. Bloomfield, J. A. Australas. Radiol. 1966, 10, 49. 2. Anderson, J. M. Br. J. Surg. 1966, 53, 802. 3. Rapport, M. M., Green, A. A., Page, I. H. J. biol. Chem. 1948, 176, 1243. Reid, G. Med. J. Aust. 1943, ii, 244. Richards, A. N., Plant, O. H. Am. J. Physiol. 1922, 59, 144. Starling, E. H., Verney, E. B. Proc. R. Soc. B., 1925, 97, 321. Zucker, M. B. Am. J. Physiol. 1944, 142, 12. 4. Ceppellini, R. 1st International Congress of the Transplantation Society, 1967. 5.
Matthew, H., Lawson,
A. A. H.
Q. Jl Med. 1966, 35, 539.
We stated in our paper, in agreement with the view of Matthew and Lawson, that the amounts of intermediate-acting drugs removed by forced diuresis are small when their bloodlevel is less than 4 mg. per 100 ml. At higher blood-levels, amounts of drug equivalent to 3 or 4 capsules were being removed in 8 hours-a fourfold or fivefold increase over unassisted renal excretion. Since the technique of forced diuresis seems safe, we contend that this probably represents a significant contribution to shortening of duration of coma. We presume that there is general agreement on the value of forced diuresis in poisoning with long-acting drugs, where the amounts removed are large. In addition to increasing rate of removal of drug, forced diuresis also ensures a high urine-flow rate and correction of hypovolasmia, this may explain why renal failure complicated barbiturate poisoning 4 times in the series of Matthew and Lawsonf but never in ours. Finally, we do not agree that forced diuresis should be restricted to specialised units; care in its control is, of course, necessary, but it is certainly no more difficult than basic intensive supportive therapy involving assessment of respiratory state and decisions about endotracheal intubation and the use of a ventilator. We do not feel that the safe use of forced diuresis is beyond the competence of a well-trained
registrar. Western
Infirmary, Glasgow W.1.
A. L. LINTON R. G. LUKE J. D. BRIGGS.
MARRIAGE AND THE G.M.C. SIR,-Iwas glad to see your annotation (Aug. 19, p. 408) on the failure of our profession to absorb doctors who had not had a British medical education. In 1933, when there were the first refugees from Nazi Germany, the inability of the G.M.C. to permit recognition, or to promote the necessary legislation, was a source of shame to many. Since then we seem to have bumbled along, taxing the understanding of many doctors who wished to come here and turning away help which we could ill afford to lose. Now the advent of E.E.C. may open a door which remains closed to humanity and common sense, but this is a problem of more countries than the half-dozen in Western Europe. In North America, Australia, and many other countries they find ways to deal with this question of registrable qualifications; there was mutual recognition of qualifications by Italy and Britain, with benefit to each, until political action in 1940 ended an old and fruitful association. Westmeston, Hassocks, Sussex.
DENIS PIRRIE.
BRONCHODILATOR AEROSOLS SiR,—The recent warning by the Committee on Safety of Drugs leaves it in doubt whether the deaths following the use of pressurised bronchodilators (aerosols) are due to the bronchodilator or to the pressurising agent or to both. No toxic symptoms are described. Manufacturers have stated that the pressurising agent, which is usually a fluorinated hydrocarbon, is non-toxic, and supporting evidence is cited. Close examination reveals, however, that the evidence may not be altogether valid; and much is made of the alleged fact that there has been little complaint from the public or doctors. The pressurising agent is also used in packs other than those for inhalants-such as shaving creams, hair lotions, and other cosmetic products, where any toxic effects of the fluorocarbon might be expected to be less important since little would be inhaled. Most of the claims of non-toxicity by the manufacturers of the chemical and of the pack seem to be based on topical tests on animals. Tests to detect any side-effects after inhalation are few and do not carrv much conviction. M. A. PHILLIPS. Upminster, Essex.