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DRUG SAMPLES
740 of catecholamine, in particular the hypothalamus and caudate nucleus. The widespread use of other groups of drugs, especially reserpine, phenothiazines, and monoamine-oxidase (M.A.O.) inhibitors, which interfere with catecholamine synthesis, storage, release, or metabolism, may also yield information on neuromelanin. The occulocutaneous and visceral pigmentation resulting from prolonged phenothiazine therapy3 suggests alteration in the synthesis of melanin from i-tyrosine as a result of disturbance of catecholamine formation from that aminoacid, and may be accompanied by similar pigmentation in the brain. Postmortem material necessary to substantiate the hypothesis is difficult to obtain. I should therefore be grateful for whole brains (or portions of the hypothalamus, caudate nucleus, and substantia nigra), fresh or fixed in formaldehyde, from necropsies of patients who had previously been treated for long periods with cc-methyldopa, reserpine, phenothiazines, or M.A.o. inhibitors, together with details of duration of treatment, and dosage of the drugs given. Department of Medicine, St. Thomas’s Hospital, DAVID MARSDEN. London, S.E.1.
DRUG SAMPLES have often wondered what happened to the numerous Sir and often expensive free drug samples given by pharmaceutical manufacturers’ representatives to general practitioners. After brief inquiry, it seems that the majority are either soon thrown away or else are stored in a cupboard until they become out of date and are eventually thrown away. It is usually easier to write a prescription than to search for a sample to give to a patient. Elsewhere-e.g., in Scandinavia-there is a scheme which enables general practitioners to send’unwanted samples to underdeveloped countries where they are used and much appreciated. Could not a similar scheme operate in this
country ? R. M. A. WEINSTEIN.
London, N.W.8.
THE CARPAL-TUNNEL SYNDROME
SIR,-Section of the flexor retinaculum of the wrist for the carpal-tunnel syndrome, as described in your leading article (July 17), is a procedure that is as logical and as effective as cutting the wires to a fire alarm. A shoe or a wedding ring will pinch if the foot or the finger becomes swollen. The carpal tunnel is no exception. The commonest cause for an increase in tissue volume is sodium retention. Sodium retention occurs particularly in the female sex in association with disturbances of the steroid pattern before the menses, during the third trimester of pregnancy, and at the menopause-and often in the same women. At such times subliminal tendencies may become overt through the excessive consumption of salt or from a deficient intake of fluid. Sodium retention is uncomfortable, disfiguring, and not always benign. It is responsible for middle-aged spread with its associated contours, for the bags under the eyes, the chimney-pot ankles, the painful panniculitis of Dercum, attacks of paroxysmal vertigo, aggravation of varicose conditions, and hypertension, and it may be a significant factor in the production of congestive heart-failure. A crude index of sodium retention at the menopause is weight gain. A much nicer one is the syndrome produced by anoxxmia of the median nerve at the wrist from embarrassment of its venous return. (With the subject sleeping on her side, it is the upper arm which first becomes parxsthetic and painful.) The medical treatment of the carpal-tunnel syndrome is more logical and just as dramatic as the surgical. Because it treats the cause and not one single effect, it has to be continued longer. Patients, however, are glad to continue their treatment because the comfort it gives is not limited to their hands. Occasionally it is sufficient to restrict salt and push fluids to four pints a day. Sometimes this regimen is successful if com3.
Lancet, 1965, ii, 331.
bined with administration of chlorothiazide in the morning. My routine treatment for the average case, however, is 100 mg. of chlorthalidone with prednisone 5 mg. (’Betnesol’ 0-5 mg.) given after breakfast. After a variable interval it is often sufficient to give this treatment on alternate days for three days a week. In the majority of cases treatment can be discontinued within six months to four years. Involutional sodium retention is a common disorder with many diverse and often distressing manifestations. The carpaltunnel syndrome serves as a valuable index of the efficacy of medical treatment. Christchurch, C.1, New Zealand.
H R. ti. H. R DONALD. D
BILIARY PERITONITIS AND T-TUBES SIR,-One of the disadvantages of post-choledochotomy drainage is the loss of bile, which is usually about a pint daily. But it may be more than a litre a day, and some even patients may develop the post-choledochostomy acidotic syndrome first described by Cass et al.l Undoubtedly the majority
of surgeons drain the common bile-duct routinely after exploration, and even those who, like Mr. Collins and Dr. Lubbers (Sept. 18), advise non-drainage still make exceptions for certain cases; so that a lot of valuable bile goes on being lost daily. A saving of about three-quarters of the bile can be effected by raising the collecting bag (or the tube leading to the bag) to about 12 inches above the level of the bed (see accompanying figure), with considerable advantages to the and postoperative bowel activity. London, W.I.
electrolyte balance GEORGE
QVIST.
PULMONARY ŒDEMA AFTER DEFIBRILLATION
SiR,—You have published 6 cases of pulmonary oedema after direct-current-shock termination of atrial fibrillation.2 Recent studies in this laboratory may be relevant to the
problem. Ventricular function of the dog’s heart was measured after direct application of different electric shocks of sufficient energy to produce ventricular defibrillation in dogs. The averages (from 4-6 experiments) of total stroke-work, at a left atrial pressure of 16 cm. water, at various times after the electric injury, expressed as percentages of the preshock value, were as follows:
A considerable reduction of stroke-work is apparent after both alternative-current (A.C.) and direct-current (D.c.) shocks The maximal depression occurred at 20-40 minutes in most dogs. Return of function was usually seen after l/z-2 hours. It is tempting to correlate these experimental observa1. Cass, M. H., Robson, B., Rundle, F. F. Med. J. Aust. 1955, i, 165. 2. Resnekov, L., McDonald, L. Lancet, 1965, i, 506; Honey, M., Nicholls, T. T., Towers, M. K. ibid. p. 765; Paloheimo, J. A. ibid. 1965, ii, 439.
DRUG SAMPLES have often wondered what happened to the numerous Sir and often expensive free drug samples given by pharmaceutical manufacturers’ representatives to general practitioners. After brief inquiry, it seems that the majority are either soon thrown away or else are stored in a cupboard until they become out of date and are eventually thrown away. It is usually easier to write a prescription than to search for a sample to give to a patient. Elsewhere-e.g., in Scandinavia-there is a scheme which enables general practitioners to send’unwanted samples to underdeveloped countries where they are used and much appreciated. Could not a similar scheme operate in this
country ? R. M. A. WEINSTEIN.
London, N.W.8.
THE CARPAL-TUNNEL SYNDROME
SIR,-Section of the flexor retinaculum of the wrist for the carpal-tunnel syndrome, as described in your leading article (July 17), is a procedure that is as logical and as effective as cutting the wires to a fire alarm. A shoe or a wedding ring will pinch if the foot or the finger becomes swollen. The carpal tunnel is no exception. The commonest cause for an increase in tissue volume is sodium retention. Sodium retention occurs particularly in the female sex in association with disturbances of the steroid pattern before the menses, during the third trimester of pregnancy, and at the menopause-and often in the same women. At such times subliminal tendencies may become overt through the excessive consumption of salt or from a deficient intake of fluid. Sodium retention is uncomfortable, disfiguring, and not always benign. It is responsible for middle-aged spread with its associated contours, for the bags under the eyes, the chimney-pot ankles, the painful panniculitis of Dercum, attacks of paroxysmal vertigo, aggravation of varicose conditions, and hypertension, and it may be a significant factor in the production of congestive heart-failure. A crude index of sodium retention at the menopause is weight gain. A much nicer one is the syndrome produced by anoxxmia of the median nerve at the wrist from embarrassment of its venous return. (With the subject sleeping on her side, it is the upper arm which first becomes parxsthetic and painful.) The medical treatment of the carpal-tunnel syndrome is more logical and just as dramatic as the surgical. Because it treats the cause and not one single effect, it has to be continued longer. Patients, however, are glad to continue their treatment because the comfort it gives is not limited to their hands. Occasionally it is sufficient to restrict salt and push fluids to four pints a day. Sometimes this regimen is successful if com3.
Lancet, 1965, ii, 331.
bined with administration of chlorothiazide in the morning. My routine treatment for the average case, however, is 100 mg. of chlorthalidone with prednisone 5 mg. (’Betnesol’ 0-5 mg.) given after breakfast. After a variable interval it is often sufficient to give this treatment on alternate days for three days a week. In the majority of cases treatment can be discontinued within six months to four years. Involutional sodium retention is a common disorder with many diverse and often distressing manifestations. The carpaltunnel syndrome serves as a valuable index of the efficacy of medical treatment. Christchurch, C.1, New Zealand.
H R. ti. H. R DONALD. D
BILIARY PERITONITIS AND T-TUBES SIR,-One of the disadvantages of post-choledochotomy drainage is the loss of bile, which is usually about a pint daily. But it may be more than a litre a day, and some even patients may develop the post-choledochostomy acidotic syndrome first described by Cass et al.l Undoubtedly the majority
of surgeons drain the common bile-duct routinely after exploration, and even those who, like Mr. Collins and Dr. Lubbers (Sept. 18), advise non-drainage still make exceptions for certain cases; so that a lot of valuable bile goes on being lost daily. A saving of about three-quarters of the bile can be effected by raising the collecting bag (or the tube leading to the bag) to about 12 inches above the level of the bed (see accompanying figure), with considerable advantages to the and postoperative bowel activity. London, W.I.
electrolyte balance GEORGE
QVIST.
PULMONARY ŒDEMA AFTER DEFIBRILLATION
SiR,—You have published 6 cases of pulmonary oedema after direct-current-shock termination of atrial fibrillation.2 Recent studies in this laboratory may be relevant to the
problem. Ventricular function of the dog’s heart was measured after direct application of different electric shocks of sufficient energy to produce ventricular defibrillation in dogs. The averages (from 4-6 experiments) of total stroke-work, at a left atrial pressure of 16 cm. water, at various times after the electric injury, expressed as percentages of the preshock value, were as follows:
A considerable reduction of stroke-work is apparent after both alternative-current (A.C.) and direct-current (D.c.) shocks The maximal depression occurred at 20-40 minutes in most dogs. Return of function was usually seen after l/z-2 hours. It is tempting to correlate these experimental observa1. Cass, M. H., Robson, B., Rundle, F. F. Med. J. Aust. 1955, i, 165. 2. Resnekov, L., McDonald, L. Lancet, 1965, i, 506; Honey, M., Nicholls, T. T., Towers, M. K. ibid. p. 765; Paloheimo, J. A. ibid. 1965, ii, 439.