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PREMEDICATION WITH ATROPINE BY MOUTH
111 Bourne’s work was published. Yet this fear should long since have largely been allayed by Goldman et al.whose findings were a sustained rise in blood-pressure in every one of 100 cases under N20, Indeed this is the normal response to hypoxia, no doubt accentuated by anxiety or fear. Fainting is not in my experience the response of the frightened, save in the reactionary period, whether one considers the dentist’s chair or the emotional stresses of everyday life. Goldman et al. confirm this reactionary fall in all their cases. Fainting during anaesthesia must be a very rare
hazard indeed.
Though I do not believe that halothane is the ideal for general anaesthesia, I claim it is invaluable in dental outpatients and will come to be more widely used. Given with full oxygenation, as it must always be, it seems as suitable for the preschool child as the traditional " brewer’s drayman ", and could on present evidence supplant the generally satisfactory but far from ideal " straight N20 ". Meanwhile, if trichlorethylene must be used as an adjuvant in a difficult case, the 02 percentage must be increased immediately to 20% within a few breaths, and N20 regarded mainly as a vehicle.
dose is of the order of only about 3 mg. by mouth daily, and in this sense it is more potent than any of the available
tenance
phenothiazines. Haloperidol is
now being used extensively on the Continent for the treatment of various schizophrenic conditions. The drug is also used as an anti-emetic and as a pre-anoesthetic agent. Haloperidol is undergoing extensive clinical trials in Britain and the United States. It was discussed on June 22, 1960, at the Royal Society of Medicine in London, when eight papers on the subject were presented by English investigators.
Research Laboratorium Dr. C.
Beerse, Belgium.
all
P. BUTLER.
Exeter.
Janssen,
PAUL A.
J. JANSSEN.
PREMEDICATION WITH ATROPINE BY MOUTH
SIR,-We apologise to Dr. Gusterson for missing his paper The Management of Children Undergoing Tonsillectomy,l in which he refers to premedication with atropine by mouth. We appreciate the point in Dr. Murphy’s letter of Dec. 10, but should like to say that we planned our controlled study in order to eliminate, as far as we could, the coincidence that Dr. Murphy mentions, and we found that, whether the atropine was given by mouth or by injection, similar effects
produced. object of our trial was to determine whether absorption of atropine from the intestinal tract is unpredictable as Dr. Murphy says, and the results proved otherwise. Dr. R. J. Hamer Hodges, of Portsmouth, has kindly written to us to say that he has not used atropine by injection for any were
A SIGN OF SURGICAL EMPHYSEMA
SIR,-Dr. Raison (Dec. 24) has modestly avoided a claim for originality in his observation of a curious nasal intonation in patients with surgical emphysema. Sampson,8 in fact, has described a nasal twang to the voice " in patients with spontaneous rupture of the oesophagus. With some diffidence I quoted Sampson’s observation in a recent work of mine since, like Dr. Raison, I felt that the sign might be of negligible value. Now I believe it may have some clinical importance because a few weeks ago I had admitted under my care a patient with the signs and symptoms of a perforated peptic ulcer. "
This patient had a most unusual nasal twang to his voice, and for this reason I had the chest radiographed as well as the abdomen. Air was seen in the neck,in the mediastinum, and under the diaphragm. A few hours later emphysema was detected clinically in the neck. Operation was impossible because a cardiac condition made the patient quite unfit for general anaesthesia. At necropsy there was found the unusual combination of a perforated duodenal ulcer and a supradiaphragmatic rupture of the lower end of the oesophagus.
Cheshire.
A. SHEPHERD. JOHN A. JOHN
TRANQUILLISERS IN PSYCHIATRY
SIR,-Your leading article of Oct. 15 on this subject authoritative and accurate. I should, however, like to point out an important omission. There is a third class of drugs, besides the phenothiazines and the reserpine-like was
alkaloids, which should be classified among the neuroleptics. The prototype of these compounds, haloperidol, has been adequately described in at least 62 clinical and pharmacological papers, the first one being published in England.99 Haloperidol is 4-fluoro-4- 1- [4-hydroxy-4-
(4’-chloro)-phenyl-piperidino]} butyrophenon. This compound is effective in various schizophrenic conditions ; it is liable to produce extrapyramidal symptoms and is similar, pharmacologically, to the more potent piperazinopropylphenothiazines. In animals, haloperidol is up to 200 times more active than chlorpromazine; it is better absorbed orally and has a longer duration of action. Clinically its usual main6. Bourne, J. G. Lancet, 1957, ii, 499. 7. Goldman, V., Cornwell, W. B., Lethbridge, V R. E. ibid. 1958, i, 1367. 8. Sampson, P. C. Surg. Gynec. Obstet. 1951, 93, 221. 9. Janssen, P. A. J., van de Westeringh, C., Jageneau, A. H. M., Demoen, P. A. J., Hermans, B. K. F., Van Daele, G. H. P., Schellekens, K. H. L., Van der Eycken, C. A. M., Niemegeers, C. J. E. J. med. pharm. Chem. 1959, 1, 281.
The
child older than three years since 1955, and has drawn attention to two further references.23
our
M. C. JOSEPH R. J. VALE.
Guy’s Hospital, London, S.E.1.
PROTEIN IN HYALINE MEMBRANE
in your excellent leading article4 that " no effective remedy is in sight prompted me to send you the following preliminary data.
SIR,-The
statement
"
When studying the effect of administering pure O2 on the respiration of premature infants, using a body-plethysmograph, I found that initially the volume of the lungs increased (raised functional residual air), and then the depth and frequency of respiration.
There were indications that the raised functional residual air when breathing O2 is a consequence of hyperxmia of the lung vessels producing " lung-erection "; and that the increased depth and frequency of respiration are an adaptation to this. Since in experimental animals exposure to O2 can produce hyaline membranes in the lungs, I thought that the symptoms of the respiratory-distress syndrome in children might also be attributable to hyperxmia of the lung vessels, possibly brought about by changes in the circulation after birth. To reduce hyperxmia I have treated this syndrome by withdrawing 20-30 ml. of blood by catheter from the umbilical vein. As Usher5 has reported that in premature infants with this syndrome a toxic degree of reversible hyperkaltmia develops, I administered 10-15 ml. of 5% glucose intravenously after withdrawing blood to avoid this possibility. I treated five babies with weights ranging from 1100 to 3100 g. All showed signs of the respiratory-distress syndrome The serum-potassium of one infant was and needed O2. determined: it was 7 mEq. per litre. The serum of the others was ha:molytic. After treatment O2 had to be given but they improved within 2 hours. After 12-24 hours supplementary O2 was no longer necessary. All the children survived. Snouck
van
Loosenziekenhuis,
Enkhuizen,
E. JJ. E Netherlands. ’ J..b.
KALE B KALE. B.
1. Gusterson, F. R. Lancet, 1955, i, 940. 2. Hamer Hodges, R. J. ibid. 1960, i, 82. 3. Hamer Hodges, R. J. Film presented at the Annual General Meeting of the Association of Anæsthetists, Great Britain and Ireland. Stratford, October, 1959. 4. Lancet, 1960, ii, 1014. 5. Usher, R. Pediatrics, 1959, 24, 562.
hazard indeed.
Though I do not believe that halothane is the ideal for general anaesthesia, I claim it is invaluable in dental outpatients and will come to be more widely used. Given with full oxygenation, as it must always be, it seems as suitable for the preschool child as the traditional " brewer’s drayman ", and could on present evidence supplant the generally satisfactory but far from ideal " straight N20 ". Meanwhile, if trichlorethylene must be used as an adjuvant in a difficult case, the 02 percentage must be increased immediately to 20% within a few breaths, and N20 regarded mainly as a vehicle.
dose is of the order of only about 3 mg. by mouth daily, and in this sense it is more potent than any of the available
tenance
phenothiazines. Haloperidol is
now being used extensively on the Continent for the treatment of various schizophrenic conditions. The drug is also used as an anti-emetic and as a pre-anoesthetic agent. Haloperidol is undergoing extensive clinical trials in Britain and the United States. It was discussed on June 22, 1960, at the Royal Society of Medicine in London, when eight papers on the subject were presented by English investigators.
Research Laboratorium Dr. C.
Beerse, Belgium.
all
P. BUTLER.
Exeter.
Janssen,
PAUL A.
J. JANSSEN.
PREMEDICATION WITH ATROPINE BY MOUTH
SIR,-We apologise to Dr. Gusterson for missing his paper The Management of Children Undergoing Tonsillectomy,l in which he refers to premedication with atropine by mouth. We appreciate the point in Dr. Murphy’s letter of Dec. 10, but should like to say that we planned our controlled study in order to eliminate, as far as we could, the coincidence that Dr. Murphy mentions, and we found that, whether the atropine was given by mouth or by injection, similar effects
produced. object of our trial was to determine whether absorption of atropine from the intestinal tract is unpredictable as Dr. Murphy says, and the results proved otherwise. Dr. R. J. Hamer Hodges, of Portsmouth, has kindly written to us to say that he has not used atropine by injection for any were
A SIGN OF SURGICAL EMPHYSEMA
SIR,-Dr. Raison (Dec. 24) has modestly avoided a claim for originality in his observation of a curious nasal intonation in patients with surgical emphysema. Sampson,8 in fact, has described a nasal twang to the voice " in patients with spontaneous rupture of the oesophagus. With some diffidence I quoted Sampson’s observation in a recent work of mine since, like Dr. Raison, I felt that the sign might be of negligible value. Now I believe it may have some clinical importance because a few weeks ago I had admitted under my care a patient with the signs and symptoms of a perforated peptic ulcer. "
This patient had a most unusual nasal twang to his voice, and for this reason I had the chest radiographed as well as the abdomen. Air was seen in the neck,in the mediastinum, and under the diaphragm. A few hours later emphysema was detected clinically in the neck. Operation was impossible because a cardiac condition made the patient quite unfit for general anaesthesia. At necropsy there was found the unusual combination of a perforated duodenal ulcer and a supradiaphragmatic rupture of the lower end of the oesophagus.
Cheshire.
A. SHEPHERD. JOHN A. JOHN
TRANQUILLISERS IN PSYCHIATRY
SIR,-Your leading article of Oct. 15 on this subject authoritative and accurate. I should, however, like to point out an important omission. There is a third class of drugs, besides the phenothiazines and the reserpine-like was
alkaloids, which should be classified among the neuroleptics. The prototype of these compounds, haloperidol, has been adequately described in at least 62 clinical and pharmacological papers, the first one being published in England.99 Haloperidol is 4-fluoro-4- 1- [4-hydroxy-4-
(4’-chloro)-phenyl-piperidino]} butyrophenon. This compound is effective in various schizophrenic conditions ; it is liable to produce extrapyramidal symptoms and is similar, pharmacologically, to the more potent piperazinopropylphenothiazines. In animals, haloperidol is up to 200 times more active than chlorpromazine; it is better absorbed orally and has a longer duration of action. Clinically its usual main6. Bourne, J. G. Lancet, 1957, ii, 499. 7. Goldman, V., Cornwell, W. B., Lethbridge, V R. E. ibid. 1958, i, 1367. 8. Sampson, P. C. Surg. Gynec. Obstet. 1951, 93, 221. 9. Janssen, P. A. J., van de Westeringh, C., Jageneau, A. H. M., Demoen, P. A. J., Hermans, B. K. F., Van Daele, G. H. P., Schellekens, K. H. L., Van der Eycken, C. A. M., Niemegeers, C. J. E. J. med. pharm. Chem. 1959, 1, 281.
The
child older than three years since 1955, and has drawn attention to two further references.23
our
M. C. JOSEPH R. J. VALE.
Guy’s Hospital, London, S.E.1.
PROTEIN IN HYALINE MEMBRANE
in your excellent leading article4 that " no effective remedy is in sight prompted me to send you the following preliminary data.
SIR,-The
statement
"
When studying the effect of administering pure O2 on the respiration of premature infants, using a body-plethysmograph, I found that initially the volume of the lungs increased (raised functional residual air), and then the depth and frequency of respiration.
There were indications that the raised functional residual air when breathing O2 is a consequence of hyperxmia of the lung vessels producing " lung-erection "; and that the increased depth and frequency of respiration are an adaptation to this. Since in experimental animals exposure to O2 can produce hyaline membranes in the lungs, I thought that the symptoms of the respiratory-distress syndrome in children might also be attributable to hyperxmia of the lung vessels, possibly brought about by changes in the circulation after birth. To reduce hyperxmia I have treated this syndrome by withdrawing 20-30 ml. of blood by catheter from the umbilical vein. As Usher5 has reported that in premature infants with this syndrome a toxic degree of reversible hyperkaltmia develops, I administered 10-15 ml. of 5% glucose intravenously after withdrawing blood to avoid this possibility. I treated five babies with weights ranging from 1100 to 3100 g. All showed signs of the respiratory-distress syndrome The serum-potassium of one infant was and needed O2. determined: it was 7 mEq. per litre. The serum of the others was ha:molytic. After treatment O2 had to be given but they improved within 2 hours. After 12-24 hours supplementary O2 was no longer necessary. All the children survived. Snouck
van
Loosenziekenhuis,
Enkhuizen,
E. JJ. E Netherlands. ’ J..b.
KALE B KALE. B.
1. Gusterson, F. R. Lancet, 1955, i, 940. 2. Hamer Hodges, R. J. ibid. 1960, i, 82. 3. Hamer Hodges, R. J. Film presented at the Annual General Meeting of the Association of Anæsthetists, Great Britain and Ireland. Stratford, October, 1959. 4. Lancet, 1960, ii, 1014. 5. Usher, R. Pediatrics, 1959, 24, 562.