COLONIC BLEEDING

456 T.R.H.

Snt,—We

were

IN PSYCHOSES

interested

to note

Dr

Drayson’s letter

(Feb. 23, p. 312) on the ineffectiveness of thyrotrophinreleasing hormone (T.R.H.) in cyclical psychoses. We hope you might allow us to add further negative findings. Our results, like his,

are

by themselves necessarily of limited

significance. We too were stimulated by Prange et al.,l who reported prompt improvement in the symptoms of depression after a single intravenous injection of T.R.H. They suggested that the antidepressant effect of T.R.H. need not be thyroid-mediated and that T.R.H. has a direct central effect. Kastin et awl. and Van Der Vis-Melsen et awl. report similar findings. Such an approach to the treatment and xtiology of the depression could obviously be of theoretical importance. Hence we designed a double-blind experiment to investigate this possibility. We decided to study the effect of T.R.H. on patients presenting with so-called endogenous depressive illness. a

The patients were assessed by a " Newcastle rating ".4 Two male patients were selected on this basis. The first patient, aged 41, had no previous history of psychiatric illness. He was admitted to the hospital having had depression for 5 months. The second patient, aged 34, had a history of 12 years of several recurrent depressive episodes, each successfully treated with electroconvulsive treatment. He had had only one spontaneous manic phase. The third patient was a 62-year-old woman who had had in the past 3 years 3 episodes of endogenous depression. On admission she was almost stuporous and therefore the application of the rating scale was impossible. None of the patients had received any medication for at least 7 days. The

patients

euthyroid. The Hamilton rating scale 11 was used for assessment of the degree of depression at 8 A.M. and 4 P.M. The 100 mm. line test was selected as a self-rating scale.6 The patient was asked to mark the line from 9 A.M. to 4 P.M. inclusive, at hourly intervals. On the experimental days breakfast was withheld, the Hamilton and self-rating scales were applied, then a slow intravenous saline infusion was begun. At 9 A.M., 2 ml. (0-6 mg.) of T.R.H. or 2 ml. of saline was injected into the infusion tubing. At an interval of 3 days each patient received both the active material and the placebo. were

A psychiatrist, always the same one, interviewed the patient at hourly intervals. The patient was continuously attended by an experienced nurse, who also made an assessment of his mental state as part of the normal routine of the clinic. Though for 5 hours after the injection there was a fluctuation of mood in patients 1 and 2, with maximum improvement shown on the 100 mm. line test at about 2 P.M., the same changes occurred with the placebo These effects presumably reflect the diurnal (P>0-1). changes of mood in these patients. On the third patient we were not able to observe any change in her mental state. None of our patients reported any side-effects. Thyroidstimulating-hormone responses to T.R.H. studied in the second and third patients were normal.

From the study of these 3 patients we have not been able to confirm any antidepressant properties of T.R.H. reported by the other authors.

SUBNORMALITY AT THE CROSSROADS SiR,—Your editorial (Feb. 2, p. 156) decrying the lack of a unified approach to treating the mentally handicapped is interesting and noteworthy for its basic omission. You might as well whistle in the wind as suggest that the young student and doctor can be attracted to caring for the mentally handicapped by working in an " exciting clinical area ", well-funded and with challenging research and teaching potential, which will be highly respected in the medical profession. Who will inspire them ? And on what basis ? Exactly how will you recruit " workers who are strongly motivated to help this underprivileged

community group " ? Contemporary medicine exudes the objective philosophy that immediate results are imperative and rewarded. Yet you ask intelligent workers to put aside what they have been informally taught and enter a field in which meaningful results can be a long time in coming. There is another approach to this problem, and the discussion would involve words like love, responsibility, devotion, obligation, and charity. Not once in your editorial did you imply such a relationship. Obviously, in caring for inarticulate and generally helpless patients, more than scientific objectivism or normal medical interest is necessary. If you really want to get this message across, you may as well " bite the bullet " and point out that human beings should, and do, care for others for a higher reason than medicine alone. 675 Brown Road, Hazelwood, Missouri 63042, U.S.A.

DANIEL R. SHIPLEY.

SiR,-While supporting strongly your aim (Feb. 2, p. 156) in bringing this area of work to the attention of academic institutions with the proposal of encouraging university research-based units, this, I feel, may well receive a disproportionate priority. Those working in the area will know only too well that effective methods of therapy and training already exist and have been proved in high staff/patient ratio settings. It is not always the lack of information concerning the behaviourdl sciences that hampers the service-it is the lack of ward-based personnel to perform the therapeutic work already within their area of expertise. The current priority must surely be to provide a setting in which educational expertise can be practised by skilled nurses and teachers in developing self-help and social behaviours in the patients in their direct care. The respectability offered by an academic unit must not supersede this direct action based upon practical and The emphasis on clinical not intellectual sophistication. medicine in mental handicap may only serve to cloud further the day-to-day problems faced by a ward staff of two nurses caring for thirty handicapped individuals in poorly designed living units. Lea Hospital, Stourbridge Road,

C. WILLIAMS,

Bromsgrove, Worcs. B61 OAX.

Senior Clinical

Psychologist.

Unit for Metabolic Studies in

Psychiatry, University Department of Psychiatry, Middlewood Hospital, Sheffield S6 1TP.

1. 2.

3. 4. 5. 6.

M. DIMITRIKOUDI E. HANSON-NORTY F. A. JENNER.

Prange, A. J., Jr., Wilson, I. C., Lara, P. P., Alltop, L. B., Breese, G. R. Lancet, 1972, ii, 999. Kastin, A. J., Ehrensing, R. H., Schalch, D. S., Anderson, M. S. ibid. p. 740. Van Der Vis-Melsen, M. J. E., Wiener, J. D. ibid. p. 1415. Gurney, C., Roth, M., Garside, R. F. Proc. R. Soc. Med. 1970, 63, 232. Hamilton, M. J. Neurol. Neurosurg. Psychiat. 1960, 23, 56. Zealley, A. K., Aitken, R. C. B. Proc. R. Soc. Med. 1969, 62, 993.

COLONIC BLEEDING

SIR,—Your editorial (Jan. 19, p. 85) stated that, once colonic bleeding has stopped, a double-contrast barium enema should form an essential part of the thorough investigation into the cause. However, many of the patients involved are elderly, and it has been our experience that in such patients bowel preparation for a barium enema may be badly tolerated and of limited success. The barium-enema examination itself is strenuous for the patient and often diagnostically

457 The anal sphincter is often incompetent catheters may have to be used, with the associated dangers of mucosal tearing and entry of barium into the rectal wall. In our opinion mesenteric angiography is the method of choice not only in the acute situation where bleeding continues, but also in the elderly patient in whom the source of bleeding is investigated after it has ceased. Compared with a barium enema in the elderly, the mesenteric angiogram is safer, better tolerated, and diagnostically

Water temp.

unrewarding. and

self-retaining

more

rewarding.

Departments of Geriatric Medicine Leeds

and Diagnostic Radiology, (St. James’s) University Hospital,

H. DROLLER H. HERLINGER.

Leeds LS9 7TF.

VAGINAL ADENOCARCINOMAS AND MATERNAL ŒSTROGEN INGESTION

SIR,-Your editorial (Feb. 16, p. 250) raises the question of of

screening women

for vaginal adenocarcinomas in the daughters receiving stilboestrol during pregnancy. A

B.B.C. television programme last October, called Take Two a Day, discussed the side-effects of drugs and highlighted this association. This programme was watched by a family friend, who had herself been given stilboestrol during pregnancy and has a young daughter of eleven. Not unnaturally alarmed, she has since been investigating screening facilities but has received only bland reassurance. The B.B.C. presumably had medical advice about their programme and were aware that a demand for screening might be created. Your editorial suggests that this demand is not unjustified: the Department of Health and Social Security should therefore take steps to meet it by locating those mothers who took stilboestrol during pregnancy and screening their female offspring. This may be both difficult and time-consuming, but the cohort involved is fortunately limited. 82 St. Keverne Square, Newcastle upon Tyne NE5 3YL.

C. K. DRINKWATER.

BATH ORDERS

SiR,—Iwas most interested to read your note on ambient temperatures and comfort (Jan. 12, p. 55), especially as there seems to be a need for similar research on the temperature of hot water used for washing and bathing patients. For example, the building note for psychiatric day-hospitals states " the hot water temperature should be controlled at a maximum of 40°C "1 and operational policy notes for 2 and " harness " geriatric units3 geriatric day-hospitals " the command, temperature should be limited to 38°C ". Simple research confirms the impression that these hot-water temperatures are too low for two reasons. Firstly, the cooling of the water does not seem to have been considered. At an ambient temperature of 240C the water temperature in a wash-basin or bath is always some 2°C cooler than the temperature of the water in the hot-water tap, since heat is required to warm the porcelain or iron container. In addition, the fall in bath or basin water temperature for a bath-time-say, 5 minutes-is about O.5OC per minute. Thus, within 2 minutes of a bath being filled by hot water at 38-40 °C the water will have cooled by 30C to uncomfortably cool levels-well below the water temperature recommended by nursing textbooks.4 Secondly, temperatures preferred by patients have not been taken into account. A small survey of 12 subjects aged 17-60 and 8 patients aged 50-75 was carried out to assess the favoured water temperature for handwashing, foot-washing, and bathing. The results, necessarily subjective, showed that age had no effect on temperature preference or tolerance:

(°C) 37-40 42 44 46 49

Too cool

Lukewarm

Justwarm Warm Hot Max. tolerable * 20 tested.

Whilst these some

Foot-washingt

Hand-washing

thought

Bathr Cool

...

Comfortable

Comfortable

Too hot

Too hot

....

t

10 tested.

t 5 tested.

preferences were identical to within 1°C, that they preferred a temperature hotter or

colder than others. Probably the scalding temperature is at least 49 °C, and more research is needed before arbitrary figures are stated for in-pipe hot-water temperature. Royal Southern Hospital, Liverpool L8 5SH.

R. OSBORNE HUGHES.

Department of Health and Social Security. Hospital Building Note: Psychiatric Day Hospital; p. 13. 2. Department of Health and Social Security. Operational Policy Geriatric Day Hospital. 1970. 3. Department of Health and Social Security. Operational Policy Harness Design. 4. Hector, W. Modern Nursing Theory and Practice. London, 1965. 1.

PROPRANOLOL AND DIGITALIS

SIR,-We read with interest the speculations of Dr O’Reilly and his colleagues (Jan. 26, p. 138) on the alleged impropriety of combining digitalis and propranolol in the treatment of angina pectoris in patients without heartfailure. We have reported clinical data in 15 such patients and in 10 normal subjects, and we must disagree with some of the theoretical objections to combined digitalis and propranolol therapy.1-3 Dr O’Reilly and his associates say that propranolol benefited angina pectoris primarily by decreasing myocardial contractility, and that by augmenting contractility the addition of digitalis might reduce the effectiveness of propranolol in preventing angina pectoris. We found no such antagonistic effects of the two drugs. As expected, oral propranolol alone in doses of 160 mg. per day or greater was sufficient to reduce the resting heart-rate by at least 10 beats per minute. This rate was accompanied by a fall in the frequency of angina in our 15 patients from an average of 17 to 6 attacks per week (p < 0-03). The addition of digoxin in doses sufficient to produce therapeutic bloodlevels did not adversely affect the symptomatic improvement with propranolol. However, digoxin alone in the same dosage increased the frequency of angina pectoris in 7 of the 15 patients. These data indicate that changes in contractility may not be the only explanation for the beneficial effects of propranolol. In our normal subjects and in the patients with angina pectoris, propranolol consistently lowered the resting heart-rate and the heart-rate/blood-pressure product during exercise. The addition of digoxin did not alter this effect of propranolol, yet digoxin alone produced no significant change in resting heart-rate. Heart-rate is a major determinant of myocardial oxygen consumption, since it not only influences the oxygen demand per beat 4 but also affects the myocardial oxygen demand.55 Thus, our results suggest that a major beneficial effect of propranolol in angina pectoris is to prevent the usual augmentation of heart-rate produced by exercise. Dr O’Reilly and his colleagues also suggested that digitalis could benefit patients with angina pectoris if it decreased ventricular size, thereby reducing myocardialwall tension, but that such a reduction " could only occur in the setting of congestive heart-failure ". 5 of our 15 patients had abnormal left-ventricular function without overt congestive cardiac failure. However, no patient developed X-ray evidence of increased pulmonary venous