- Email: [email protected]
GENERAL PRACTITIONERS IN HOSPITAL APPOINTMENTS
610
envisaged in the Kilbrandon report.2 The medical profession, so rightly proud of its tradition of community service, has some obligation-perhaps a growing one-to see juvenile delinquency as a social problem relevant to its emerging interest in behavioural science, and to act accordingly. Let us therefore hope that when courts are replaced by juvenile panels, doctors, especially family doctors, will respond to the real challenges of delinquency which are, first, its need for more refined research and, second, its need for attention from, and action by, those with good practical knowledge of sound family life. on
causes,
University General Practice Teaching and Research Unit, University Medical Buildings, Foresterhill, Aberdeen.
I. M. RICHARDSON.
HYPERSENSITIVITY TO TETRACYCLINE
SIR,-Dr. Ilyas’ report of hypersensitivity to ampicillin and tetracycline (Aug. 19, p. 417) brings to mind two cases of tetracycline hypersensitivity with hypothermia seen in this hospital. The first, a 25-year-old West Indian engineering student, was admitted here a few days after a car accident (in which he was not himself injured) complaining of left-sided chest and groin pain with cough. He was found to have left-lower-lobe consolidation, and treatment was commenced with ’ Hostacycline’ (tetracycline, Hoechst), 250 mg.,’Disprin’ gr. 10, and mist. expect. 6-hourly. He felt warm and perspired freely during the day, but 24 hours after the initial dose his temperature and blood-pressure began to fall and reached the low levels of 94-6°F and 70/50 mm. Hg respectively. The foot of the bed was raised with some improvement in his pressure readings, but it was not until he received hydrocortisone acetate (’ Efcortelan’) 100 mg. 6-hourly that his temperature began to rise and his general condition improve. Meanwhile, the tetracycline, which had been increased to 500 mg. per dose, was continued for a further 48 hours until sputum culture and sensitivity suggested changing the drug to ampicillin. The steroid had been stopped after 24 hours so that he received a further 24 hours of tetracycline therapy with no steroid cover, without any untoward reaction. The second patient, a 60-year-old Irish woman, was admitted with a recent history of vomiting and dizziness due to Meniere’s disease. She was treated with phenobarbitone 30 mg. 8-hourly and bendrofluazide 5 mg. daily. 4 days after admission she developed evening pyrexia. She was perspiring and had tinnitus. She also complained of a sore throat and dysphagia, though no abnormality could be found clinically. Repeated clinical examination failed to reveal a cause for the pyrexia, and she was given procaine penicillin 600,000 units daily. This failed to control the pyrexia, and after 4 days’ therapy she was given hostacycline 250 mg. 6-hourly. Within 24 hours she became drowsy and confused in her speech at intervals. Her temperature began to fall, and 36 hours after the initial dose it was 94-4°F. Hydrocortisone acetate 100 mg. 6-hourly was given parenterally, and all other drugs were stopped. Her temperature continued to fall to 93-4°F for a few hours but then rose, and her general condition improved greatly. Her throat, which she had consistently said was sore, now felt normal; her pulse, which had been irregular during the hypothermic phase, was now regular again; and her blood-pressure, which had fallen to 95 mm. Hg systolic, now rose gradually to 125 mm. Hg. The dose of steroid was reduced after 60 hours, and it was then stopped; she continued on promethazine theoclate (’Avomine’) for her dizziness, with good results. Both these cases differ from those referred to by Ilyas in that the symptoms did not begin for 24 hours. In case 1 the
continued after the steroids were stopped as it was not realised that this was the cause of the hypothermia, but no further reaction occurred. The reason for this is not clear. In neither case did any rash appear on the body, and, so far as can be ascertained, neither patient had received steroids previously. It is not known whether they had been treated with tetracycline previously, but it is quite reasonable to think that they had, as both had been in hospital before for other complaints. It may be, therefore, that they had been sensitised on a former occasion, and thus reacted when given the drug again. Reactions to tetracycline usually take the form of giant
tetracycline
2.
was
Report of the Committee on Children and Young Persons, Scotland. Cmd 2306. H.M. Stationery Office. 1964.
urticaria, asthma, dyspncea, itching of the hands and feet, oedema of the eyelids, lips, and hands, and hypotension.
Hypothermia
has
Mercer’s Hospital, Dublin 2.
not
previously
been described.
ISAAC
J. COPPERMAN.
PAYING FOR THE N.H.S. you for your support of the poor, creaking N.H.S. The ideal that our countrymen should be able to get medical attention when they are sick, not just when they have money in their pockets, is not one of which we need be ashamed. Last autumn I visited the U.S.A. There I met many of my son-in-law’s friends, professional people, like himself, with young families. They did not seem very keen on American doctors and envied us our N.H.S. Although retired from general practice on a very modest pension, I am glad I did not practise in the U.S.A. I have only two comments to add to your annotation (Sept. 2, p. 504). If the gross national expenditure on medical treatment is fixed, it makes no difference to the national economy how much is paid for in taxes and how much by private individuals. In other words, it is just as uneconomic for a private patient to send for a doctor unnecessarily (or drink an unnecessary bottle of medicine) as it is for a State patient. Secondly, most people seem to imagine that the more medical attention they have the better off they will be. This is not true, since it is quite possible to be overdoctored. Our own middle class who were, perhaps naturally, greedy at the start of the N.H.S. are now learning that it is no bad thing to wait in a queue sometimes. I agree, of course, that the N.H.S. needs more money and greater efficiency. An extra 1-5% of the national income would provide the money. Surely the doctors might provide the
SIR,-Thank
efficiency. Girton, Cambridge.
CLEMENT W. WALKER.
GENERAL PRACTITIONERS IN HOSPITAL APPOINTMENTS
SIR,-On July 26 I wrote a personal letter to the Minister of Health in which I stressed the need for general practitioners with the necessary abilities to be employed in far greater numbers on a part-time sessional basis in district hospitals. My firm belief is that such a step would not only slow down the " brain drain " overseas, where one of the principal incentives is the opportunity for hospital practice, but it would have the tremendous advantage of making greater use of the younger members of the profession who have acquired skills which the National Health Service just cannot afford to lose. An appointment of an ex-registrar G.P. at the age of 30 on a parttime sessional basis would guarantee up to 35 years of invaluable service at a time when hospitals are short of medical staff. I received a reply from a member of the secretariat of the Minister, who was at that time absent abroad, in which he wrote:
"As for opportunities for general practitioners to parttime in the hospital service, this in practice is perhaps more widespread than you believe. Our records show that on 30th September last, 5,120 general practitioners were working part-time in hospitals (other than in general practitioner units) and they gave the equivalent service of 993 whole-time staff. In the Minister’s view the greater employment of general practitioners can only be for the good of both hospital and general practice. The Department has been discussing the terms on which this should be encouraged with representatives of general practitioners for some time, but unfortunately it has not been found possible to reach agreement on certain matters. Nevertheless, the practice is likely to become more widespread as its value is becoming increasingly appreciated. The relatively new Medical Assistant grade will provide increasing opportunities for part-time permanent posts of responsibility in the
work
hospital service."
611 There was, quite justifiably, no comment on my suggestion that a part or the whole of the sum allocated for G.P. merit awards should be utilised for meeting the additional cost, for only those with proved merit would obtain these appointments. The information I have obtained is most valuable, for it means that the Minister is prepared to offer medical-assistant grading; but I have, from many inquiries which I have made, been unable to ascertain why the professional representatives, whoever they may be, have so far not been able to reach agreement on this potentially tremendous step forward, which would bring new hope to a very large number of able general practitioners who feel frustrated by their divorce from hospital nractice. CHARLES W. BROOK. London S.E.9.
DOCTORS IN INDUSTRY admirable annotation1 on the report of the SIR,-Your of College Physicians unfortunately drew little comment. Royal There is one disturbing aspect which the report ignored. What are the health needs of young people in industry ? Should the care of young people be separated from general factory supervision? Can the school health service select those who may need help during the next three years ? How will they attempt selection and are they equipped or staffed to achieve more than selection of gross defect ? Why is a tutorial and student health service developing rapidly for the more able, and on what grounds are the less able and less socially privileged " to be largely abandoned ? Is a red card " system for the " unfit"asign of progress or regression ? Is not a unique set of duties affording opportunity for cooperation and integration of services being abandoned without due investigation or experiment? What is the connection between education and health, and how can the various services work together to phase out from school to work ? Farnham Royal, Bucks.
M. E. M. HERFORD.
GLUCOSE AND PANCREATIC SECRETION SIR,-The finding of Dr. Sum and Dr. Preshaw (Aug. 12, p. 340) that infusion of glucose into the small intestine in man is not accompanied by demonstrable effects on the exocrine pancreas leads to the conclusion that neither secretin nor pancreozymin is involved in the potentiation of insulin secretion associated with this particular stimulus. There is accumulating evidence in favour of the suggestion that a humoral agent secreted by the intestine and detectable in the immunoassay for glucagon mediates this effect. However, it seems that the endocrine response to absorption of glucose from the small intestine can be further modified by stimuli that cause secretion of other intestinal hormones. We have shown that exogenous secretin, gastrin, and pancreozymin are capable of increasing the rise in bloodinsulin concentration that occurs in man in response to intravenous infusion of glucose.3 Pancreozymin is also capable of enhancing the rise in blood-insulin concentration associated with intravenous infusion of arginine, and this effect is accompanied by enhancement of the concomitant rise in peripheral plasma-glucagon-like-immunoreactivity. Qualitatively similar effects have been observed in the dog.4 A potent stimulus to the release of secretin is acidfication of the duodenal mucosa. We have shown that the infusion of hydrochloric acid in physiological doses into the small intestine in man enhances the rise in insulin concentration associated with intravenous infusion of glucose.3 The absence of this effect in the experiments of Bovns et al. mav be attributed to the lower dose of 1. 2. 3. 4.
Lancet, 1967, i, 1370. Unger, R. H. Sixth Congr. int. Diabetes Fed. (in the press). Dupré, J., Curtis, J. D., Beck, J. C. ibid. Unger, R. H., Ketterer, M., Dupré, J., Eisentraut, A. M. J. clin. Invest. 1967, 46, 630.
acid administered in this study.5 The effect of gastrin may thus be, at least in part, a result of stimulation of secretion of gastric acid. A potent stimulus to the secretion of pancreozymin is the presence of protein hydrolysate in the small intestine. It has been found that the addition of protein to ingested carbohydrate leads to enhancement of glucose tolerance, accompanied by an increased rise in blood-insulin concentration. Dissociation of the effect of ingested protein from that of a rising blood-aminoacid concentration is seen in maturity-onset diabetics, who show little response to intravenous aminoacids,’ but whose blood-insulin level increases strikingly after ingestion of protein.88 Thus it seems that intestinal hormones known to regulate digestive secretions also have effects on the endocrine functions of the pancreas that are of physiological importance. The relative magnitudes of these effects, their interactions, and their importance in the pathophysiology of diabetes remain to be seen. J. DUPRÉ R. W. WADDELL Fraser Laboratory for Research in Diabetes, J. D. CURTIS Royal Victoria Hospital, Montreal 2, Canada. J. C. BECK.
NOMENCLATURE OF BARBITURATES SIR,-The interesting and practical paper by Dr. Linton and his colleagues (Aug. 19, p. 377) illustrates once more how illogical is the current classification of barbiturates when regarded from the viewpoint of the toxicologist. Thus, the better prognosis with long-acting " barbiturates, such as phenobarbitone, in toxic doses and the shorter duration of coma when compared with cases involving " short-acting " or " intermediate-acting drugs, such as amylobarbitone, pentobarbitone and butobarbitone is an anomaly puzzling to students and the occasional resuscitator and discomforting to the professional toxicologist. The anomaly, it seems to me, could be resolved by basing nomenclature not on duration of activity (which may be quite different in the toxic compared with the therapeutic dose range), but on the rapidity of onset of the effects.Thus phenobarbitone would be classified as a "
"
"
"
slow-acting " barbiturate, pentobarbitone as quick-acting ", and thiopentone as ultra-quick-acting ". Whether it would be worth sustaining an intermediate classification is debatable. The rapidity of onset of the effects of these drugs is unrelated "
to
the dose. Department of Pharmacology and Pharmacy, University of Otago Medical School, Dunedin, New Zealand.
E. G.
MCQUEEN
Director, National Poisons Information Centre.
FORCED DIURESIS IN BARBITURATE INTOXICATION reference to the paper by Dr. Linton and his SIR,-With colleagues (Aug. 19, p. 377) I should like to draw attention to the fact that diuretics have also been used with success in the treatment of salicylate intoxication.1O In this instance, acetazolamide was the drug chosen because the aim of therapy was not so much forced diuresis as alkalinisation of the urine. Since Linton et al. have pointed out the value of alkalinising the urine in the elimination of barbiturate, it would be of interest to assess the effect of acetazolamide, which they apparently did not use, in this form of poisoning. Department of Pediatrics, Montefiore Hospital, New York.
L. S. TAITZ.
5. Boyns, D. R., Jarrett, R. J., Keen, H. Br. med. J. 1967, ii, 676. 6. Rabinowitz, D., Merimee, T. J., Maffezzoli, R. Burgess, J. A. Lancet, 1966, ii, 454. 7. Merimee, T. J., Burgess, J. A., Rabinowitz, D. ibid. 1966, i, 1300. 8. Berger, S., Vargaraya, S. Diabetes, 1966, 15, 303. 9. McQueen, E. G. N.Z. med. J. 1967, 66, 137. 10. Feuerstein, R. C., Finberg, L., Fleishman, E. Pediatrics, Springfield, 1960, 25, 215.
envisaged in the Kilbrandon report.2 The medical profession, so rightly proud of its tradition of community service, has some obligation-perhaps a growing one-to see juvenile delinquency as a social problem relevant to its emerging interest in behavioural science, and to act accordingly. Let us therefore hope that when courts are replaced by juvenile panels, doctors, especially family doctors, will respond to the real challenges of delinquency which are, first, its need for more refined research and, second, its need for attention from, and action by, those with good practical knowledge of sound family life. on
causes,
University General Practice Teaching and Research Unit, University Medical Buildings, Foresterhill, Aberdeen.
I. M. RICHARDSON.
HYPERSENSITIVITY TO TETRACYCLINE
SIR,-Dr. Ilyas’ report of hypersensitivity to ampicillin and tetracycline (Aug. 19, p. 417) brings to mind two cases of tetracycline hypersensitivity with hypothermia seen in this hospital. The first, a 25-year-old West Indian engineering student, was admitted here a few days after a car accident (in which he was not himself injured) complaining of left-sided chest and groin pain with cough. He was found to have left-lower-lobe consolidation, and treatment was commenced with ’ Hostacycline’ (tetracycline, Hoechst), 250 mg.,’Disprin’ gr. 10, and mist. expect. 6-hourly. He felt warm and perspired freely during the day, but 24 hours after the initial dose his temperature and blood-pressure began to fall and reached the low levels of 94-6°F and 70/50 mm. Hg respectively. The foot of the bed was raised with some improvement in his pressure readings, but it was not until he received hydrocortisone acetate (’ Efcortelan’) 100 mg. 6-hourly that his temperature began to rise and his general condition improve. Meanwhile, the tetracycline, which had been increased to 500 mg. per dose, was continued for a further 48 hours until sputum culture and sensitivity suggested changing the drug to ampicillin. The steroid had been stopped after 24 hours so that he received a further 24 hours of tetracycline therapy with no steroid cover, without any untoward reaction. The second patient, a 60-year-old Irish woman, was admitted with a recent history of vomiting and dizziness due to Meniere’s disease. She was treated with phenobarbitone 30 mg. 8-hourly and bendrofluazide 5 mg. daily. 4 days after admission she developed evening pyrexia. She was perspiring and had tinnitus. She also complained of a sore throat and dysphagia, though no abnormality could be found clinically. Repeated clinical examination failed to reveal a cause for the pyrexia, and she was given procaine penicillin 600,000 units daily. This failed to control the pyrexia, and after 4 days’ therapy she was given hostacycline 250 mg. 6-hourly. Within 24 hours she became drowsy and confused in her speech at intervals. Her temperature began to fall, and 36 hours after the initial dose it was 94-4°F. Hydrocortisone acetate 100 mg. 6-hourly was given parenterally, and all other drugs were stopped. Her temperature continued to fall to 93-4°F for a few hours but then rose, and her general condition improved greatly. Her throat, which she had consistently said was sore, now felt normal; her pulse, which had been irregular during the hypothermic phase, was now regular again; and her blood-pressure, which had fallen to 95 mm. Hg systolic, now rose gradually to 125 mm. Hg. The dose of steroid was reduced after 60 hours, and it was then stopped; she continued on promethazine theoclate (’Avomine’) for her dizziness, with good results. Both these cases differ from those referred to by Ilyas in that the symptoms did not begin for 24 hours. In case 1 the
continued after the steroids were stopped as it was not realised that this was the cause of the hypothermia, but no further reaction occurred. The reason for this is not clear. In neither case did any rash appear on the body, and, so far as can be ascertained, neither patient had received steroids previously. It is not known whether they had been treated with tetracycline previously, but it is quite reasonable to think that they had, as both had been in hospital before for other complaints. It may be, therefore, that they had been sensitised on a former occasion, and thus reacted when given the drug again. Reactions to tetracycline usually take the form of giant
tetracycline
2.
was
Report of the Committee on Children and Young Persons, Scotland. Cmd 2306. H.M. Stationery Office. 1964.
urticaria, asthma, dyspncea, itching of the hands and feet, oedema of the eyelids, lips, and hands, and hypotension.
Hypothermia
has
Mercer’s Hospital, Dublin 2.
not
previously
been described.
ISAAC
J. COPPERMAN.
PAYING FOR THE N.H.S. you for your support of the poor, creaking N.H.S. The ideal that our countrymen should be able to get medical attention when they are sick, not just when they have money in their pockets, is not one of which we need be ashamed. Last autumn I visited the U.S.A. There I met many of my son-in-law’s friends, professional people, like himself, with young families. They did not seem very keen on American doctors and envied us our N.H.S. Although retired from general practice on a very modest pension, I am glad I did not practise in the U.S.A. I have only two comments to add to your annotation (Sept. 2, p. 504). If the gross national expenditure on medical treatment is fixed, it makes no difference to the national economy how much is paid for in taxes and how much by private individuals. In other words, it is just as uneconomic for a private patient to send for a doctor unnecessarily (or drink an unnecessary bottle of medicine) as it is for a State patient. Secondly, most people seem to imagine that the more medical attention they have the better off they will be. This is not true, since it is quite possible to be overdoctored. Our own middle class who were, perhaps naturally, greedy at the start of the N.H.S. are now learning that it is no bad thing to wait in a queue sometimes. I agree, of course, that the N.H.S. needs more money and greater efficiency. An extra 1-5% of the national income would provide the money. Surely the doctors might provide the
SIR,-Thank
efficiency. Girton, Cambridge.
CLEMENT W. WALKER.
GENERAL PRACTITIONERS IN HOSPITAL APPOINTMENTS
SIR,-On July 26 I wrote a personal letter to the Minister of Health in which I stressed the need for general practitioners with the necessary abilities to be employed in far greater numbers on a part-time sessional basis in district hospitals. My firm belief is that such a step would not only slow down the " brain drain " overseas, where one of the principal incentives is the opportunity for hospital practice, but it would have the tremendous advantage of making greater use of the younger members of the profession who have acquired skills which the National Health Service just cannot afford to lose. An appointment of an ex-registrar G.P. at the age of 30 on a parttime sessional basis would guarantee up to 35 years of invaluable service at a time when hospitals are short of medical staff. I received a reply from a member of the secretariat of the Minister, who was at that time absent abroad, in which he wrote:
"As for opportunities for general practitioners to parttime in the hospital service, this in practice is perhaps more widespread than you believe. Our records show that on 30th September last, 5,120 general practitioners were working part-time in hospitals (other than in general practitioner units) and they gave the equivalent service of 993 whole-time staff. In the Minister’s view the greater employment of general practitioners can only be for the good of both hospital and general practice. The Department has been discussing the terms on which this should be encouraged with representatives of general practitioners for some time, but unfortunately it has not been found possible to reach agreement on certain matters. Nevertheless, the practice is likely to become more widespread as its value is becoming increasingly appreciated. The relatively new Medical Assistant grade will provide increasing opportunities for part-time permanent posts of responsibility in the
work
hospital service."
611 There was, quite justifiably, no comment on my suggestion that a part or the whole of the sum allocated for G.P. merit awards should be utilised for meeting the additional cost, for only those with proved merit would obtain these appointments. The information I have obtained is most valuable, for it means that the Minister is prepared to offer medical-assistant grading; but I have, from many inquiries which I have made, been unable to ascertain why the professional representatives, whoever they may be, have so far not been able to reach agreement on this potentially tremendous step forward, which would bring new hope to a very large number of able general practitioners who feel frustrated by their divorce from hospital nractice. CHARLES W. BROOK. London S.E.9.
DOCTORS IN INDUSTRY admirable annotation1 on the report of the SIR,-Your of College Physicians unfortunately drew little comment. Royal There is one disturbing aspect which the report ignored. What are the health needs of young people in industry ? Should the care of young people be separated from general factory supervision? Can the school health service select those who may need help during the next three years ? How will they attempt selection and are they equipped or staffed to achieve more than selection of gross defect ? Why is a tutorial and student health service developing rapidly for the more able, and on what grounds are the less able and less socially privileged " to be largely abandoned ? Is a red card " system for the " unfit"asign of progress or regression ? Is not a unique set of duties affording opportunity for cooperation and integration of services being abandoned without due investigation or experiment? What is the connection between education and health, and how can the various services work together to phase out from school to work ? Farnham Royal, Bucks.
M. E. M. HERFORD.
GLUCOSE AND PANCREATIC SECRETION SIR,-The finding of Dr. Sum and Dr. Preshaw (Aug. 12, p. 340) that infusion of glucose into the small intestine in man is not accompanied by demonstrable effects on the exocrine pancreas leads to the conclusion that neither secretin nor pancreozymin is involved in the potentiation of insulin secretion associated with this particular stimulus. There is accumulating evidence in favour of the suggestion that a humoral agent secreted by the intestine and detectable in the immunoassay for glucagon mediates this effect. However, it seems that the endocrine response to absorption of glucose from the small intestine can be further modified by stimuli that cause secretion of other intestinal hormones. We have shown that exogenous secretin, gastrin, and pancreozymin are capable of increasing the rise in bloodinsulin concentration that occurs in man in response to intravenous infusion of glucose.3 Pancreozymin is also capable of enhancing the rise in blood-insulin concentration associated with intravenous infusion of arginine, and this effect is accompanied by enhancement of the concomitant rise in peripheral plasma-glucagon-like-immunoreactivity. Qualitatively similar effects have been observed in the dog.4 A potent stimulus to the release of secretin is acidfication of the duodenal mucosa. We have shown that the infusion of hydrochloric acid in physiological doses into the small intestine in man enhances the rise in insulin concentration associated with intravenous infusion of glucose.3 The absence of this effect in the experiments of Bovns et al. mav be attributed to the lower dose of 1. 2. 3. 4.
Lancet, 1967, i, 1370. Unger, R. H. Sixth Congr. int. Diabetes Fed. (in the press). Dupré, J., Curtis, J. D., Beck, J. C. ibid. Unger, R. H., Ketterer, M., Dupré, J., Eisentraut, A. M. J. clin. Invest. 1967, 46, 630.
acid administered in this study.5 The effect of gastrin may thus be, at least in part, a result of stimulation of secretion of gastric acid. A potent stimulus to the secretion of pancreozymin is the presence of protein hydrolysate in the small intestine. It has been found that the addition of protein to ingested carbohydrate leads to enhancement of glucose tolerance, accompanied by an increased rise in blood-insulin concentration. Dissociation of the effect of ingested protein from that of a rising blood-aminoacid concentration is seen in maturity-onset diabetics, who show little response to intravenous aminoacids,’ but whose blood-insulin level increases strikingly after ingestion of protein.88 Thus it seems that intestinal hormones known to regulate digestive secretions also have effects on the endocrine functions of the pancreas that are of physiological importance. The relative magnitudes of these effects, their interactions, and their importance in the pathophysiology of diabetes remain to be seen. J. DUPRÉ R. W. WADDELL Fraser Laboratory for Research in Diabetes, J. D. CURTIS Royal Victoria Hospital, Montreal 2, Canada. J. C. BECK.
NOMENCLATURE OF BARBITURATES SIR,-The interesting and practical paper by Dr. Linton and his colleagues (Aug. 19, p. 377) illustrates once more how illogical is the current classification of barbiturates when regarded from the viewpoint of the toxicologist. Thus, the better prognosis with long-acting " barbiturates, such as phenobarbitone, in toxic doses and the shorter duration of coma when compared with cases involving " short-acting " or " intermediate-acting drugs, such as amylobarbitone, pentobarbitone and butobarbitone is an anomaly puzzling to students and the occasional resuscitator and discomforting to the professional toxicologist. The anomaly, it seems to me, could be resolved by basing nomenclature not on duration of activity (which may be quite different in the toxic compared with the therapeutic dose range), but on the rapidity of onset of the effects.Thus phenobarbitone would be classified as a "
"
"
"
slow-acting " barbiturate, pentobarbitone as quick-acting ", and thiopentone as ultra-quick-acting ". Whether it would be worth sustaining an intermediate classification is debatable. The rapidity of onset of the effects of these drugs is unrelated "
to
the dose. Department of Pharmacology and Pharmacy, University of Otago Medical School, Dunedin, New Zealand.
E. G.
MCQUEEN
Director, National Poisons Information Centre.
FORCED DIURESIS IN BARBITURATE INTOXICATION reference to the paper by Dr. Linton and his SIR,-With colleagues (Aug. 19, p. 377) I should like to draw attention to the fact that diuretics have also been used with success in the treatment of salicylate intoxication.1O In this instance, acetazolamide was the drug chosen because the aim of therapy was not so much forced diuresis as alkalinisation of the urine. Since Linton et al. have pointed out the value of alkalinising the urine in the elimination of barbiturate, it would be of interest to assess the effect of acetazolamide, which they apparently did not use, in this form of poisoning. Department of Pediatrics, Montefiore Hospital, New York.
L. S. TAITZ.
5. Boyns, D. R., Jarrett, R. J., Keen, H. Br. med. J. 1967, ii, 676. 6. Rabinowitz, D., Merimee, T. J., Maffezzoli, R. Burgess, J. A. Lancet, 1966, ii, 454. 7. Merimee, T. J., Burgess, J. A., Rabinowitz, D. ibid. 1966, i, 1300. 8. Berger, S., Vargaraya, S. Diabetes, 1966, 15, 303. 9. McQueen, E. G. N.Z. med. J. 1967, 66, 137. 10. Feuerstein, R. C., Finberg, L., Fleishman, E. Pediatrics, Springfield, 1960, 25, 215.