LITHIUM TOXICITY

415 tion. This programme should be flexible and could include both new buildings and conversion of suitable old houses. (3) Hospitals that are severely overcrowded should be given a prefabricated type of villa with a life-expectancy of ten to twenty years. These would cope with the present overcrowding which will slowly abate when the above two procedures are put into ooeration. Whixley Hospital, York.

J. NEWCOMBE.

PSYCHIATRIC UNIT IN THE DISTRICT GENERAL HOSPITAL SIR,-Whilst it is encouraging that psychiatry is becoming more integrated with general medicine, it does seem premature to claim, as does the Bonham-Carter Report,l that all psychiatric care can take place in the district general hospital. The two most recent papers, by Baker2 and Oldham,3 described the functioning of units in a general hospital serving metropolitan urban areas. It is important to recognise that these areas are ones in which there is an above-average amount of social drift and a below-average concentration of elderly people. Both factors are likely to result in an under recording of morbidity in the two major psychoses, schizophrenic and senile-conditions in which a major share of hospital beds is necessary and more floor area essential for effective therapy. The comprehensive hospital plan of the Manchester region, laudable though it is, has not resulted in.a dissolution of the vast psychiatric hospitals. It is as yet unproven that schizophrenia can be cared for as

effectively in a general-hospital setting as in the traditional psychiatric hospital milieu. The danger of the studies cited above is that this will be assumed. No mention has been made of the increasing numbers of patients dealt with under sections 60, 65, and 72 of the Mental Health Act. Are we really saying that we can manage these people on the district general hospital campus, and is it believed that the elderly brain-damaged patient with parietal-lobe symptoms will be best cared for in a restricted space on, say, the tenth floor ? It has been said that, if the district general hospital and area hospital operate concomitantly, the one must " cream off " from the other. What is important is that the patient’s needs should be adequately met, for otherwise both patient and community suffer, as Grad and Sainsbury’s studies show.44 The problem detailed above is not confined to psychiatry and the following principles of growth of the hospital service are worth consideration.

(1) That the patient is selected for the district general hospital existing area hospital according to his needs. It shall be seen that together they provide a comprehensive service. (2) That some medical and nursing staff of the district general hospital and area hospital shall be interchangeable and work in both types of hospital (rotational schemes or sessional redistribution). (3) That urgent consideration shall be given to the implementation of combined and reciprocal training schemes of nursing staff of the area and district hospitals, so that the services can be seen to be integrated, and the vast amount of specialised knowledge amongst nursing personnel of the area hospitals can be made available to the developing service. or

If these measures are adopted we shall do much to avoid two-tier level of hospital care, and, at the same time, ensure that morale is maintained in the existing peripheral

a

hospitals. Hellingly Hospital, Hailsham. Sussex.

R. MAGGS.

1. The Functions of the District General Hospital. H.M. Office, 1969. 2. Baker, A. A. Lancet, 1969, i, 1090. 3. Oldham, A. J. Br. J. Psychiat. 1969, 115, 465. 4. Grad, J., Sainsbury, P. ibid. 1968, 114, 265.

Stationery

RESUSCITATION AMBULANCES SiR,-The Brighton resuscitation ambulance was evolved almost entirely from the experience and help of Dr. Pantridge and his department. Quite obviously, we too realise that speedy resuscitation must be carried out wherever the patient may be; transport comes later. Our case-load has a different spectrum from that in Belfast. We have a disproportionate number of bathing, skindiving, and boating accidents, and of suicides. In these circumstances, I would use the ambulance, halted at the site of the incident, as a one-bed ward. We are at a disadvantage compared with Belfast, firstly because we have fewer experienced hospital staff available for clinical help and secondly because I am not sure that I have convinced all the local consultants of the value of

taking

treatment to

Health Department, Brighton, Sussex.

the

patient. W. S. PARKER.

LITHIUM TOXICITY to draw attention to some of the dangers wish SIR,-We which may be encountered with lithium even when the drug is used within the accepted range of dosage. Since the opening of our department 18 months ago, four patients have been given lithium (300 mg. twice or thrice daily) for manicdepressive psychosis (depressive phase) and for reactive depression. Subjective assessment suggests that three patients responded favourably and tolerated lithium without side-effects for a period of 6 months. The range of serum-lithium levels, on repeated determinations, was 0.50-1.50 meq. per litre. The fourth patient was a woman of 68, admitted with the primary diagnosis of involutional melancholia. She had had repeated depressive episodes during the past 15 years, for which she had been treated with antidepressants, tranquillisers, and electroconvulsive therapy (E.C.T.). As time progressed, the symptom-free periods became shorter. In addition to her mental illness, she had primary hypothyroidism (treated with maintenance L-thyroxine), maturity-onset diabetes mellitus (treated with oral hypoglycaemic agents), and essential hypertension. On admission the following features were noted: severely depressed affect, great anxiety, severe hypochrondriasis, irritability, loss of interest, insomnia with early awakening, and fully developed paranoid delusions. Lithium carbonate was started in a dose of 300 mg. thrice daily. The serum-lithium slowly increased from 0-11 meq. per litre but never exceeded 1-62 meq. During the 24 days of drug administration per litre. there was no change in the patient’s emotional illness, but, rather suddenly, her speech became slurred, her gait became unsteady and ataxic, and her level of consciousness deteriorated progressively until she was stuporose. The skin was flushed and there was evidence of dehydration. Deep tendon reflexes were hyperactive, but no focal or lateralising abnormalities of the motor and sensory systems were found. The cranial nerves appeared to be intact and the optic discs were normal. Serum-lithium was 0-88 meq. per litre. Serum sodium, potassium, and chloride were 137.0, 3-2, and 94.0 meq. per litre respectively. Blood-ureawas normal; fasting blood-sugar was raised at 154 mg. per 100 ml. Since there were no detectable neurological or metabolic abnormalities -of decisive nature her clinical state was attributed to lithium toxicity. This diagnosis received further support when lithium was withdrawn and the patient was rehvdrated she quickly regained her alertness, and the extrapyramidal signs disappeared. Thus, in one out of four patients randomly selected for lithium treatment the drug produced a serious toxic state necessitating intensive supportive care. It might be argued

nitrogen

416 that the patient was hvpothyroid and had inadequately controlled diabetes. But we know of no evidence that these conditions alter the metabolic handling of lithium. Our patient had severe toxic effects when her serum-lithium was 0-88 meq. per litre, although lithium usually produces toxic effects when the serum level exceeds 2-5 meq. per litre.! We conclude that, when lithium is given to patients with endocrine or metabolic disorders, extra caution may be

infant is easier to restrain, and insertion is not done blindly, fumbling for the orifice and for the direction for insertion. Perhaps the infant reported was in the proper position; I would place my wager to the contrary. Department of Pediatrics University of California School of Medicine San Francisco, California 94122.

EDWARD B. SHAW.

necessary.

Departments of Psychiatry and .Medicine, Reddy Memorial Hospital, and Clinical Investigation Unit, Queen Mary Veterans Hospital, Montreal, Canada.

SKIN-GRAFTING LEG ULCERS P. G. EDGELL G. PETERFY E. J. PINTER.

SIR,-It is essential to establish whether Dr. Rivlin (Jan. 31, p. 247) thinks he is able to diagnose deep-vein thrombosis with any degree of accuracy. Does he think that and varicose veins are two unrelated diseases ? The two, in our experience, coincide in a very considerable number of cases. We do not think the differentiation is of any importance, since patients with varices and good leg pumps are symptomless, while those with no varicosities and inadequate pumps have symptoms (the group in which ulcers develop). Maintaining nutrition of the skin and the healing of an ulcer are the same problem; both are dependent upon catabolite clearance, which, in turn, is dependent on improved venous hypotension brought about by walking or by elevation of the limb. The method of achieving this satisfactory state of tissuefluid clearance-whether it be by competent bandaging,

deep-vein thrombosis SALT SUPPLEMENTS WITH LITHIUM extra sodium chloride may prevent many of the side-effects of lithium carbonate. During the past 1’/2 years, we have treated nine patients with lithium carbonate. All but one of them had manicdepressive psychoses, manic stage. The sole exception was a patient who had been in and out of hospitals for 14 years, with schizophrenia, schizo-affective type. All nine patients improved substantially, were discharged from the hospital, and returned to regular jobs in the community. Treatment initially consisted of 600 mg. lithium carbonate thrice daily, and the dose was gradually increased to up to 2-7 g. daily, together with sodium chloride, O’5-l-O g. thrice daily. Peak plasma-lithium levels as high as 2-05 meq. per litre were achieved and maintenance levels ranged from 0-55 to 1-03 meq. per litre. Side-effects have commonly been reported with peaks lower than these, but in our series the only side-effect noted was fine hand tremor in one patient receiving relatively high doses four days after the initiation of treatment. It later disappeared. This particular patient was very anxious about the treatment, and this may have been responsible for the tremor. Unintentionally, two experiments were performed. One woman, who had been doing very well on the above combination, discontinued the salt supplement while remaining on the maintenance dose of lithium carbonate. 4 weeks later she became nauseated and dizzy and complained of strange ill-defined feelings and generalised weakness shortly after taking each dose. A second patient was started on lithium carbonate without salt supplements and had similar symptoms 1’/z weeks after treatment was started. These side-effects disappeared when sodium chloride supplements were started. We conclude that sodium chloride supplements may diminish the side-effects frequently reported with lithium carbonate treatment. Further investigations are indicated.

SiR,-We believe that administration of

Central

Falkirk Hospital, Valley, New York, N.Y.

HERMAN BLEIWEISS.*

RECTAL PERFORATION BY THERMOMETER SIR,-The dismal accident recorded by Mr. Smiddy and Mr. Bensonmust have occurred with the infant lying recumbent-which position, for some reason or other, seems to be preferred by nurses and mothers. If the welllubricated thermometer is inserted with the infant lying prone, this accident is completely prevenlable; if only the very slight force necessary and permissible is employed, the thermometer practically drops in. In this position the *

injection-compression sclerotherapy, or a surgical operation no importance because the method does not significantly influence the healing of the ulcer. The important considerations, therefore, are the patient’s comfort, the morbidity, and the economics. In some cases a reduction in the amount of standing, and more walking exercise, can effect and enhance healing without any other treatment. In a review of 129 patients with varicose ulcers treated by surgery over a 10-year period Lofgren et al. established a 30% recurrence-rate. In our own clinic, where 33,000 patients have been treated to date, and where the ulcerratio is higher than anywhere else in the world, we report approximately a 30% recurrence over a 5-10 year period in the general intake of those with ulcers treated by compression sclerotherapy. Therefore I feel that there is no room for dogmatism, but I think it is clear from Dr. Rivlin’s -is of

letter that he does

Malitz, S., Wharton, R.

in

American Handbook of

vol. III, p. 509. Toronto, 1966. 2. Smiddy, F. G., Benson, E. A. Lancet,

1969, ii,

805.

psychiatry;

understand the fundamentals of the

is about 30 "o after 5 years. This does not reflect on operator or technique, but reflects gross damage in the deep-vein valves, without satisfactory compensation by the muscle pumps. We are satisfied that the most important single cause of chronic leg ulcers is damage to valves in the perforating veins of the foot and leg, with or without associated damage to the valves in the deep veins. The incompetent-perforating-vein theory, which in fact was postulated in 1938 by Lintonis far from " blown ". In the minds of many people there are two entities-deepvein thrombosis and superficial vein thrombosis-both followed by recanalisation and primary valvular damage. " Experience has taught us that this " black and white approach does not help, and that all degrees of deep-vein thrombosis are possible and can be followed by partial or complete recanalisation. Department of Clinical Surgery, recurrence-rate

Sir Patrick Dun’s Hospital, Dublin 2, Eire.

Present address: Instituto de Genetica Medica, Sarmiento 2569, Buenos Aires, Argentina. 1.

not

problem with which he has been dealing for so long. As an analogue, recurrence in the treatment of hernias is more dependent on raised intra-abdominal pressure than on the operator or technique used. Most people can cure 100"o of ulcers but, despite the operator or technique, the

GEORGE FEGAN.

Lofgren, K. A., Lauvstad, W. A., Bonnemaison, M.F. Proc. Staff Mut. Mayo Clin. 1965, 40, 560. 2. Linton, R. R. Ann. Surg. 1938, 107, 582. 1.