- Email: [email protected]
HYDROXYDIONE IN DEHYDRATED PSYCHOTIC PATIENTS
695 F. Forman for his continued interest and encouragement. The Naffziger operations were performed by Mr. de Villiers Hamman and Mr. A. Gonsky. The expenses incurred in connection with this report are defrayed by a grant from the Council for Scientific and Industrial Research. Endocrine Clinic, R. HOFFENBERG Department of Medicine, Groote Schuur Hospital and P. U. JACKSON. W. University of Cape Town.
fluid was infused. No ill effects were seen; the blood-pressure fell in four cases, but not dangerously. Four patients recovered and were able to eat. Two later died, one (who had had a hasmatemesis before treatment) of bronchopneumonia, and the other with a recurrence of status epilepticus.
All these patients were seriously ill, dehydrated, and difficult to nurse. During sedation with hydroxydione for varying periods, very necessary fluid was given with
ORDER AND DISORDER IN THE CEREBRAL CIRCULATION
comparative
SIR,-Sir Russell Brain1 quotes the investigations of Lawrence and Rewell2 into the cerebral circulation of the giraffe. These workers suggested that in the giraffe blood might be shunted from the carotid artery into the vertebral artery, with which the carotid communicates freely, and that this shunt would protect the brain of the giraffe from excessive hydrostatic blood-pressures. We have recently published our findings 3 in this species, and have shown that the rete mirabile is supplied by the vertebral artery. The connection was demonstrated by dissection and by angiography. If these findings are accepted, then Lawrence and Rewell’s hypothesis falls away. It was in any case difficult to understand why blood should shunt from one large artery into another, in which the blood-pressure would presumably be similar. There is no proof of any shunt mechanism in this animal. To make their suggestion’more plausible, Lawrence and Rewell had postulated that the giraffe would be found to have a high blood-viscosity. This has also not been verified in previous observations from this laboratory.44 We have suggested3 an alternative means by which the cerebral circulation of the giraffe may be adapted to the gravitational effects caused by changes of posture in this animal. R. H. GOETZ E. N. KEEN. University of Cape Town. HYDROXYDIONE IN DEHYDRATED PSYCHOTIC PATIENTS
SiR,—Since hydroxydione (’ Viadril ’) seemed a very drug (its L.D’50 is three times that of thiopentone), one of us (D. E. M.) suggested its use as a general sedative in disturbed patients; since it must be given intravenously in dilute solution, disturbed dehydrated psychotic patients seemed particularly suitable. safe
2-5 g. of hydroxydione was dissolved in 500 ml. of sterile 5% glucose saline solution. Two drip sets were used. A glucose saline drip was started, and the needle of a hydroxydione
drip was inserted into
the lumen of the lower part of the rubber
tubing of the first drip and secured by adhesive. Each drip was controlled independently by a screw clip. This ensured that (1) the transfusion channel was functioning properly before the hydroxydione was used, thus diminishing the risk of tissue necrosis; (2) the solutions could be used independently or together; and (3) the transfusion channel would not become blocked on change-over from one solution to the other. The hydroxydione solution was given at 150 drops a minute until the patient fell asleep; it was then turned off and the glucose saline drip turned on. The hydroxydione was restarted at the same rate when the patient began to show signs of restlessness, until he again fell asleep. Six patients were treated-three with senile psychoses, one with paraphrenia, one with status epilepticus, and one with delirium tremens. All were successfully kept asleep for periods ranging from 2 hours to 3 days, during which 1-7 litres of 1. 2. 3. 4.
Brain, R. Lancet, 1957, ii, 859. Lawrence, W. E., Rewell, R. E. Proc. Zool. Soc., Lond. 1948, 118, 202. Goetz, R. H., Keen, E. N. Angiology, 1957, 8, 542. Goetz, R. H., Budtz-Olsen, O. S. Afr. med. J. 1955, 29, 773.
ease.
r
,-.
"
___
D. E. MUNRO D. A. KNOX.
Stanley Royd Hospital, Wakefield.
__
_
AND MALIGNANT DISEASE suggestion of Dr. Alice Stewart and’her
RADIATION, LEUKÆMIA,
SIR, The colleagues1 that antenatal X-ray examinations may cause malignant disease and leukxmia in the child has been ably refuted by your correspondents,2-s but the growing publicity that this hypothesis has obtained and the widely expressed fear of diagnostic irradiation that it has encouraged demand further action. This should be your duty because of the uncritical enthusiasm with which you endorsed the preliminary communication in a leading editorial.11 Your editorials are so influential that no in your correspondence columns can outargument them with most readers, and although you are not weigh to act as a referee in all such arguments, in this expected of because case, your original attitude, you are morally bound to express a further opinion. When you do so may I suggest that you emphasise the following points ? Stewart et al. have agreed that " Dr. Reid is justified in stressing that, on the evidence of our figures, over 90% of cases of malignant disease in children under 10 years of age (which are in any case rare) must be due to causes other than diagnostic irradiation ". In the less than 10% of cases in which the children were irradiated antenatally these other causes could not be excluded, and the probability is that the same incidence of " other causes " would have been operative in this group. The absurdity of postulating diagnostic irradiation as a possible cause becomes manifest when this argument is applied to the
remaining less-than-1 %. The controls used in this work were inadequate.2-5 8 Stewart et al. did not deny their inadequacy; instead they stated 7"as previously reported, a higher incidence of antenatal irradiation is still found among our cases when comparison is restricted to controls of corresponding parity ". Unfortunately, reference to the letter they 9 does not appear to substantiate this statement, quote for therein appears: " they were deliberately not matched for birth rank ", and " I am not at the moment in a position to quote parity figures for the mothers included in the preliminary report"; and the controls remain nebulous and inadequate. The figures given by Stewart et al. do not show, as they claim, " that the child population dying of leukxmia and cancer
nowadays includes
a
disproportionately large
number of first-born and twins " ; nor is there evidence that matching for birth rank would have obscured this information if it were present. Indeed, such matching would have provided a sounder basis for attempting to 1. 2. 3. 4. 5. 6. 7. 8. 9.
Stewart, A., Webb, J., Giles, D., Hewitt, D. Lancet, 1956, ii, 447. Rabinowitch, J. ibid. p. 1261. Rabinowitch, J. ibid. 1957, i, 219. Reid, F. ibid. p. 428. Sonnenblick, B. P. ibid. p. 1197. ibid. 1956, ii, 449. Stewart, A., Webb, J., Giles, D., Hewitt, D. ibid. 1957, i, 528. Ellis, F., Lewis, C. L. ibid. 1956, ii, 573. Stewart, A. ibid. p. 573.
fluid was infused. No ill effects were seen; the blood-pressure fell in four cases, but not dangerously. Four patients recovered and were able to eat. Two later died, one (who had had a hasmatemesis before treatment) of bronchopneumonia, and the other with a recurrence of status epilepticus.
All these patients were seriously ill, dehydrated, and difficult to nurse. During sedation with hydroxydione for varying periods, very necessary fluid was given with
ORDER AND DISORDER IN THE CEREBRAL CIRCULATION
comparative
SIR,-Sir Russell Brain1 quotes the investigations of Lawrence and Rewell2 into the cerebral circulation of the giraffe. These workers suggested that in the giraffe blood might be shunted from the carotid artery into the vertebral artery, with which the carotid communicates freely, and that this shunt would protect the brain of the giraffe from excessive hydrostatic blood-pressures. We have recently published our findings 3 in this species, and have shown that the rete mirabile is supplied by the vertebral artery. The connection was demonstrated by dissection and by angiography. If these findings are accepted, then Lawrence and Rewell’s hypothesis falls away. It was in any case difficult to understand why blood should shunt from one large artery into another, in which the blood-pressure would presumably be similar. There is no proof of any shunt mechanism in this animal. To make their suggestion’more plausible, Lawrence and Rewell had postulated that the giraffe would be found to have a high blood-viscosity. This has also not been verified in previous observations from this laboratory.44 We have suggested3 an alternative means by which the cerebral circulation of the giraffe may be adapted to the gravitational effects caused by changes of posture in this animal. R. H. GOETZ E. N. KEEN. University of Cape Town. HYDROXYDIONE IN DEHYDRATED PSYCHOTIC PATIENTS
SiR,—Since hydroxydione (’ Viadril ’) seemed a very drug (its L.D’50 is three times that of thiopentone), one of us (D. E. M.) suggested its use as a general sedative in disturbed patients; since it must be given intravenously in dilute solution, disturbed dehydrated psychotic patients seemed particularly suitable. safe
2-5 g. of hydroxydione was dissolved in 500 ml. of sterile 5% glucose saline solution. Two drip sets were used. A glucose saline drip was started, and the needle of a hydroxydione
drip was inserted into
the lumen of the lower part of the rubber
tubing of the first drip and secured by adhesive. Each drip was controlled independently by a screw clip. This ensured that (1) the transfusion channel was functioning properly before the hydroxydione was used, thus diminishing the risk of tissue necrosis; (2) the solutions could be used independently or together; and (3) the transfusion channel would not become blocked on change-over from one solution to the other. The hydroxydione solution was given at 150 drops a minute until the patient fell asleep; it was then turned off and the glucose saline drip turned on. The hydroxydione was restarted at the same rate when the patient began to show signs of restlessness, until he again fell asleep. Six patients were treated-three with senile psychoses, one with paraphrenia, one with status epilepticus, and one with delirium tremens. All were successfully kept asleep for periods ranging from 2 hours to 3 days, during which 1-7 litres of 1. 2. 3. 4.
Brain, R. Lancet, 1957, ii, 859. Lawrence, W. E., Rewell, R. E. Proc. Zool. Soc., Lond. 1948, 118, 202. Goetz, R. H., Keen, E. N. Angiology, 1957, 8, 542. Goetz, R. H., Budtz-Olsen, O. S. Afr. med. J. 1955, 29, 773.
ease.
r
,-.
"
___
D. E. MUNRO D. A. KNOX.
Stanley Royd Hospital, Wakefield.
__
_
AND MALIGNANT DISEASE suggestion of Dr. Alice Stewart and’her
RADIATION, LEUKÆMIA,
SIR, The colleagues1 that antenatal X-ray examinations may cause malignant disease and leukxmia in the child has been ably refuted by your correspondents,2-s but the growing publicity that this hypothesis has obtained and the widely expressed fear of diagnostic irradiation that it has encouraged demand further action. This should be your duty because of the uncritical enthusiasm with which you endorsed the preliminary communication in a leading editorial.11 Your editorials are so influential that no in your correspondence columns can outargument them with most readers, and although you are not weigh to act as a referee in all such arguments, in this expected of because case, your original attitude, you are morally bound to express a further opinion. When you do so may I suggest that you emphasise the following points ? Stewart et al. have agreed that " Dr. Reid is justified in stressing that, on the evidence of our figures, over 90% of cases of malignant disease in children under 10 years of age (which are in any case rare) must be due to causes other than diagnostic irradiation ". In the less than 10% of cases in which the children were irradiated antenatally these other causes could not be excluded, and the probability is that the same incidence of " other causes " would have been operative in this group. The absurdity of postulating diagnostic irradiation as a possible cause becomes manifest when this argument is applied to the
remaining less-than-1 %. The controls used in this work were inadequate.2-5 8 Stewart et al. did not deny their inadequacy; instead they stated 7"as previously reported, a higher incidence of antenatal irradiation is still found among our cases when comparison is restricted to controls of corresponding parity ". Unfortunately, reference to the letter they 9 does not appear to substantiate this statement, quote for therein appears: " they were deliberately not matched for birth rank ", and " I am not at the moment in a position to quote parity figures for the mothers included in the preliminary report"; and the controls remain nebulous and inadequate. The figures given by Stewart et al. do not show, as they claim, " that the child population dying of leukxmia and cancer
nowadays includes
a
disproportionately large
number of first-born and twins " ; nor is there evidence that matching for birth rank would have obscured this information if it were present. Indeed, such matching would have provided a sounder basis for attempting to 1. 2. 3. 4. 5. 6. 7. 8. 9.
Stewart, A., Webb, J., Giles, D., Hewitt, D. Lancet, 1956, ii, 447. Rabinowitch, J. ibid. p. 1261. Rabinowitch, J. ibid. 1957, i, 219. Reid, F. ibid. p. 428. Sonnenblick, B. P. ibid. p. 1197. ibid. 1956, ii, 449. Stewart, A., Webb, J., Giles, D., Hewitt, D. ibid. 1957, i, 528. Ellis, F., Lewis, C. L. ibid. 1956, ii, 573. Stewart, A. ibid. p. 573.