- Email: [email protected]
SCIENTIFIC MEDICINE
907
the lack of equally therapeutically effective non-toxic substitutes as justifying the clinical use of phenylbutazone
long as the patient is firmly told to report rash, bleeding, &c., when " a blood-count at this early stage will soon reveal any important change ... ". This is sound advice, but is there evidence for your last sentence concerning phenylbutazone that " then treatment can be stopped while there is still time to avert irrevocable aplasia of the marrow " ? Do we just hope that this is an " early stage so
with
more
chance of reversibility
?
Auckland Public Hospital, Auckland 3, New Zealand.
** *
Marrow
T. P. CASEY.
aplasia with phenylbutazone
is
commonly
slow in onset. Early detection probably does increase the chances of recovery, 1,though admittedly the evidence is impressionistic.-ED. L.
SKIN WRINKLING IN CYSTIC FIBROSIS SIR,—Professor Elliott (July 13, p. 108) is correct in attributing the rapid wrinkling of the skin in cystic fibrosis, which follows immersion in tap water, to the increased salt flux from the sweat glands, although it is not an osmotic phenomenon, as a consideration of the physical chemistry of proteins and the chemical physics of aqueous solutions will reveal. All proteins bind water, thanks to their many charged (polar groups) which exert electrostatic attraction on the appropriate poles of water molecules. Water is itself an electric dipole, in which the charges are so distributed (because of the lone electron pair of the oxygen atom) as to yield a very high dielectric constant, which makes water such a versatile solvent and gives it its marked tendency to form hydrated ions in aqueous solutions, especially sodium salts all of which are freely soluble in water. Each ion (Na+) or (CI-) is surrounded by a hydration shell formed by the adjacent water molecules. The water-binding capacity of a protein is minimal at its isoelectric point (pH 3-5-5 for the keratins making up the horny layers) and increases with increasing divergence from the isoelectric point. It is for this reason that normal palmar skin wrinkles after moderate immersion in warm water, especially if it is soapy (pH 8 or more). However, in patients with cystic fibrosis it is the increased salt content of the sweat rather than the pH difference which increases the water-binding capacity of the keratin (because of the hydration shells of the ions mentioned above), and is responsible for the wrinkling in these patients. This phenomenon plays an important role in the pathogenesis of prickly heat, in which the salt-impregnated keratin ring round the sweat pore swells so as to occlude it, in dyshidrotic eczema (cheiropompholyx) and the soi-disant symmetrical lividity of the soles so familiar to Service medical officers. In these conditions, treatment with a weak acid such as acetic acid seems logical, in an effort to reduce the pH . of the skin and the consequent swelling of the affected horn, and trials with this are preceding at the Hospital for Sick Children. The increased water-binding capacity of proteins produced by salt can be exploited therapeutically and for the past 15 years we have been using salt ointments (5-20% sodium chloride in ung. emulsificans or appropriate base), the strength being determined by the thickness and hardness of the keratin to be treated, in the management of all conditions in which there is excess of keratin-e.g., the keratodermias, palmo-plantaris, the severe ichthyoses, severe pityriasis rubra pilaris, unsightly epithelial naevi, acanthosis nigricans, and the like-with satisfactory results, 1. de
Gruchy, G. C. Clinical Hæmatology in Medical Practice; chap.
Oxford, 1970. Drug and Therapeutics Bulletin, 1974, 12, VII.
2.
no.
18.
so
that other
keratolytics have been virtually entirely
replaced. Finally,
from the broader biological standpoint, it will be remembered that the pH and salt content of sweat increases with time and temperature and, as we have seen, both of these factors increase the amount of water bound to the horny layer and this must have been of evolutionary significance when man ceased to be an ape and became naked. The salt would help to retain water which might otherwise be lost and at the same time help to preserve a supple horny layer as he emerged in the environment of the warm tropical savannah, without which over-desiccation of his skin would have prejudiced his survival. Hospital for Sick Children, Great Ormond Street, London WC1N 3JH.
E. J. MOYNAHAN.
SKIN WRINKLING AND NERVE FUNCTION SIR,—We were interested in Professor Elliott’s description (July 13, p. 108) of early skin wrinkling in children with cystic fibrosis. Although this phenomenon may well be related to osmotic differences between skin and water, it has been observed that skin wrinkling (as seen on the finger pulp) is fully dependent on an intact peripheral nerve-supply. 1, This is a useful sign in peripheral nerve lesions and helpful in following recovery when the wrinkling returns.
Furthermore, it was our impression that in normal individuals wrinkling was more apparent on the left hand than on the right in right-handed individuals. However, in a preliminary study using fingerprint densities measured by photometry, no significant differences were found between the sides. Jewish Hospital and Medical MARTIN WEINSTEIN Center of Brooklyn, JOHN RYAN 555 Prospect Place, PAUL ROGERS. N.Y. U.S.A. Brooklyn, 11238, SCIENTIFIC MEDICINE
SIR,—Like Dr Steinberg (Sept. 21, p. 725) I regret that in his otherwise excellent essay Dr Bennet (Aug. 24, p. 453) should have included the so-called " medical model " among the list of potential pitfalls for the doctor. The fashionable attacks on the medical model often seem to equate medical with an exclusively organic, physical model, and disease exclusively with physical illness. But a great many medical men-older as well as younger
family doctors, hospital physicians, community physicians, social psychiatrists, and others-have always been concerned with the whole " person and his interaction with society, and with the psychosomatic and psychosocial aspects of illness.3.4 Dr Bennet rightly stresses the need to be aware of the living human being, of social forces, the mening of illness, and the importance of human relationships; he is right, too, to stress the fact that the doctor is a member of an interdisciplinary team who should always be ready to listen to the voice of the patient and of the ancillary staff. But surely many doctors have practised all this for years. To give only one example: under the inspiring guidance of Dr T. P. Rees, the Warlingham Park Hospital of the 1940s and 1950s functioned as a permissive therapeutic community, the emphasis being on team work and human relationships, with extensive group therapy and group "
Buncke, J. Surg. Clins N. Am. 1972, 52, 1267. O’Riain, S. Br. med. J. 1973, iii, 615. Glatt, M. M. A Guide to Addiction and its Treatment—Drugs, Society and Man; p. 313. Lancaster, 1974. 4. Glatt, M. M. in Alcoholism: A Medical Profile. Proceedings of the First International Conference on Alcoholism; p. 122. London, 1. 2. 3.
1974.
908 and growth in living cells even though of the nutrient is wasted. Penicillin may have to be given in huge doses, so wasting most of it, in order to achieve optimum therapeutic levels. The question then is not whether it is wasted but whether it is effective. When there is a general consensus that a substance is therapeutic, there is little discussion of waste. But with ascorbic acid there is no such consensus. Many physicians equate consensus with efficacy. This often delays for many years the proper examination of a new therapeutic idea because consensus may require up to 40
increasing vigour
social clubs within the hospital, outpatient clubs, and so on.5 All this was going on for years before the advent of the modern tranquillisers, which are so often claimed to have revolutionised life in psychiatric hospitals. Quite clearly, in such circumstances all members of the interacting triad, man and society, as well as drugs,3 were regarded as the doctor’s concern, and the hospital was regarded not only as a place for treatment by an interdisciplinary therapeutic team, but also as initiating a reconstruction of personality and a resocialisation.5 Attacks on an unduly narrowly defined medical model and disease concept are frequently made in relation to the treatment of alcoholism and drug dependence. It has been claimed by the critics 6 that the commonest response by those committed to maintaining that alcoholism is a disease has been simply to ignore the attacks as not worth dignifying with a reply. In the event, however, nearly all of the medical specialists attending the First International Medical Conference on Alcoholism (held in London in September, 1973, under the auspices ’of the Medical Council on Alcoholism) came out in clear support of the medical model and the disease concept-understood not only in terms of the " agent ", but of the dynamic interaction between host, environment, and agent.3,4 Prof. W. K. van Dijk concluded by saying that " the medical model is a multidimensional construct which takes into account the psychological and social as well as the physical aspects of the afflicted person. For this reason, the medical model should not be replaced by other constructs but it should reckon with them and incorporate them wherever this is possible and useful 11.7
activities,
some
years. 1201 CN Towers, First Avenue South,
Saskatoon, Saskatchewan S7K 1J5.
TUBERCULIN IN RHEUMATOID ARTHRITIS
SIR,—Dr Rewald (Sept. 28, p. 785) discusses the possibility of the use of B.C.G. in the treatment of rheumatoid arthritis, and refers to the work of Kåss et al./ although they did not, in fact, mention B.C.G. by name and seem to have used transfer factor prepared from normal blood. I write simply to make the point that the late Dr Geoffrey Loxton, working in this hospital, began using tuberculin in rheumatoid arthritis at least twenty years ago. He never published his results, but I myself saw a number of patients in whom the disease was permanently arrested. Brook General Hospital, London SE18.
Regional Alcoholism and Drug
SIR,—Iwould be grateful for the opportunity to report fascinating case we have seen at this hospital and to inquire whether anyone can help us with the diagnosis.
M. M. GLATT.
a
THE MEGAVITAMIN SCENE
SIR,—Dr Martin and Dr Lines (July 13, p. 103) suggested that doses of ascorbic acid larger than those recommended to prevent scurvy are wasteful and ineffective. To illustrate this view they reported a patient who took 1 g. of ascorbic acid per day and excreted 158 mg. per 100 ml. of urine-an
extremely high excretion-rate. It is important to examine the commonly held belief that urinary excretion of any substance means waste. This idea ignores the relationship between the concentration of a metabolite in the blood and the amount absorbed by tissues. Usually there is a curvilinear relationship, and, as the amount in solution increases, more is retained in the body until it is saturated. In other words, a certain amount of nutrient may be wasted in order to provide optimum concentrations. This may be a measure of the state of saturation of the body. Assume a dose of 100 mg. divides into 50 mg. excreted and 50 mg. retained, while a dose of 1000 mg. results in 800 mg. excreted and 200 mg. retained. So even if 800 mg. is wasted the body has use of 200 mg. Certain processes may require these larger doses. It has been suggested, for example, that to saturate the leukaemic cells in a patient with this condition may require 7000 mg. per day. If less is given the avidity of these cells for vitamin C causes the scorbutic symptoms in the rest of the body
(petechiæ, capillary fragility, bleeding gums).
Pauling
8
has outlined the scientific evidence for his view that increasing doses of an important nutrient can produce Rees, T. P., Glatt, M. M. in The Fields of Group Psychotherapy (edited by S. R. Slavson); p. 17. New York, 1956. 6. Room, R. Q. Jl Stud. Alcohol. 1972, 33, 1049.
5.
Dijk, W. K. in Alcoholism: A Medical Profile. Proceedings of the First International Conference on Alcoholism; p. 133. London, 1974. 8. Pauling, L. Science, 1968, 160, 265.
7.
van
DAVID LE VAY.
UNEXPLAINED TETANIC SPASMS
Dependence Unit, St. Bernard’s Hospital, Southall, Middlesex.
A. HOFFER.
A 12-year-old boy who had been perfectly well except for slight neck stiffness was suddenly taken ill with severe intermittent spasm of the right side of his neck. He was in great pain during the spasms, which rapidly became worse and started to involve his back. He was immediately taken to the local casualty department and there it was reported that he was having a tonic spasm of his whole back muscles. He kept having spasms of
different muscle groups about every four or five minutes. The muscles relaxed between these spasms and during each spasm he He was lucid during this time and was screaming with pain. complained to being unable to breathe and a feeling of suffocation, although his mouth and face were not involved in the spasms. He was immediately transferred to our care with the diagnosis of severe tetanus. In the ambulance he became apnceic for a few seconds during a severe spasm. On arrival he was in another severe spasm, lying in opisthotonos, with his abdominal muscles taut, his arms hyperextended, the thumbs across the palms, and the fingers extended. The legs were extended with adductor spasm. His eyes were open and staring with dilated pupils. There was no risus sardonicus. He was unable to breathe and cyanosed. He was immediately given intravenous suxamethonium chloride (’ Scoline ’) and thiopentone, and intubated and put on a ventilator. There were no other physical signs, except that at the slightest stimulation he developed tetanic spasm of all muscle groups. Initial investigations showed a normal serum calcium and electrolytes and arterial pH. The creatinine phosphokinase, aldolase, and transaminases were raised. He was given penicillin and 500 µg. of human tetanus antitoxin to cover the remote possibility of tetanus. After six hours his condition had greatly improved, the muscular excitability had resolved, and thiopentone and ventila. tion were stopped. Within eighteen hours he had completely recovered. X-ray of his spine showed no crush fractures. Al specimens were analysed for strychnine and other drugs by the forensic laboratory in Lancashire, but no trace of any poisonou substance could be found. 1.
Kåss, E., Frøland, S. S., Natvig, J. B., Blichfeldt, P., Høyeraal H. M. Lancet, 1974, i, 627.
the lack of equally therapeutically effective non-toxic substitutes as justifying the clinical use of phenylbutazone
long as the patient is firmly told to report rash, bleeding, &c., when " a blood-count at this early stage will soon reveal any important change ... ". This is sound advice, but is there evidence for your last sentence concerning phenylbutazone that " then treatment can be stopped while there is still time to avert irrevocable aplasia of the marrow " ? Do we just hope that this is an " early stage so
with
more
chance of reversibility
?
Auckland Public Hospital, Auckland 3, New Zealand.
** *
Marrow
T. P. CASEY.
aplasia with phenylbutazone
is
commonly
slow in onset. Early detection probably does increase the chances of recovery, 1,though admittedly the evidence is impressionistic.-ED. L.
SKIN WRINKLING IN CYSTIC FIBROSIS SIR,—Professor Elliott (July 13, p. 108) is correct in attributing the rapid wrinkling of the skin in cystic fibrosis, which follows immersion in tap water, to the increased salt flux from the sweat glands, although it is not an osmotic phenomenon, as a consideration of the physical chemistry of proteins and the chemical physics of aqueous solutions will reveal. All proteins bind water, thanks to their many charged (polar groups) which exert electrostatic attraction on the appropriate poles of water molecules. Water is itself an electric dipole, in which the charges are so distributed (because of the lone electron pair of the oxygen atom) as to yield a very high dielectric constant, which makes water such a versatile solvent and gives it its marked tendency to form hydrated ions in aqueous solutions, especially sodium salts all of which are freely soluble in water. Each ion (Na+) or (CI-) is surrounded by a hydration shell formed by the adjacent water molecules. The water-binding capacity of a protein is minimal at its isoelectric point (pH 3-5-5 for the keratins making up the horny layers) and increases with increasing divergence from the isoelectric point. It is for this reason that normal palmar skin wrinkles after moderate immersion in warm water, especially if it is soapy (pH 8 or more). However, in patients with cystic fibrosis it is the increased salt content of the sweat rather than the pH difference which increases the water-binding capacity of the keratin (because of the hydration shells of the ions mentioned above), and is responsible for the wrinkling in these patients. This phenomenon plays an important role in the pathogenesis of prickly heat, in which the salt-impregnated keratin ring round the sweat pore swells so as to occlude it, in dyshidrotic eczema (cheiropompholyx) and the soi-disant symmetrical lividity of the soles so familiar to Service medical officers. In these conditions, treatment with a weak acid such as acetic acid seems logical, in an effort to reduce the pH . of the skin and the consequent swelling of the affected horn, and trials with this are preceding at the Hospital for Sick Children. The increased water-binding capacity of proteins produced by salt can be exploited therapeutically and for the past 15 years we have been using salt ointments (5-20% sodium chloride in ung. emulsificans or appropriate base), the strength being determined by the thickness and hardness of the keratin to be treated, in the management of all conditions in which there is excess of keratin-e.g., the keratodermias, palmo-plantaris, the severe ichthyoses, severe pityriasis rubra pilaris, unsightly epithelial naevi, acanthosis nigricans, and the like-with satisfactory results, 1. de
Gruchy, G. C. Clinical Hæmatology in Medical Practice; chap.
Oxford, 1970. Drug and Therapeutics Bulletin, 1974, 12, VII.
2.
no.
18.
so
that other
keratolytics have been virtually entirely
replaced. Finally,
from the broader biological standpoint, it will be remembered that the pH and salt content of sweat increases with time and temperature and, as we have seen, both of these factors increase the amount of water bound to the horny layer and this must have been of evolutionary significance when man ceased to be an ape and became naked. The salt would help to retain water which might otherwise be lost and at the same time help to preserve a supple horny layer as he emerged in the environment of the warm tropical savannah, without which over-desiccation of his skin would have prejudiced his survival. Hospital for Sick Children, Great Ormond Street, London WC1N 3JH.
E. J. MOYNAHAN.
SKIN WRINKLING AND NERVE FUNCTION SIR,—We were interested in Professor Elliott’s description (July 13, p. 108) of early skin wrinkling in children with cystic fibrosis. Although this phenomenon may well be related to osmotic differences between skin and water, it has been observed that skin wrinkling (as seen on the finger pulp) is fully dependent on an intact peripheral nerve-supply. 1, This is a useful sign in peripheral nerve lesions and helpful in following recovery when the wrinkling returns.
Furthermore, it was our impression that in normal individuals wrinkling was more apparent on the left hand than on the right in right-handed individuals. However, in a preliminary study using fingerprint densities measured by photometry, no significant differences were found between the sides. Jewish Hospital and Medical MARTIN WEINSTEIN Center of Brooklyn, JOHN RYAN 555 Prospect Place, PAUL ROGERS. N.Y. U.S.A. Brooklyn, 11238, SCIENTIFIC MEDICINE
SIR,—Like Dr Steinberg (Sept. 21, p. 725) I regret that in his otherwise excellent essay Dr Bennet (Aug. 24, p. 453) should have included the so-called " medical model " among the list of potential pitfalls for the doctor. The fashionable attacks on the medical model often seem to equate medical with an exclusively organic, physical model, and disease exclusively with physical illness. But a great many medical men-older as well as younger
family doctors, hospital physicians, community physicians, social psychiatrists, and others-have always been concerned with the whole " person and his interaction with society, and with the psychosomatic and psychosocial aspects of illness.3.4 Dr Bennet rightly stresses the need to be aware of the living human being, of social forces, the mening of illness, and the importance of human relationships; he is right, too, to stress the fact that the doctor is a member of an interdisciplinary team who should always be ready to listen to the voice of the patient and of the ancillary staff. But surely many doctors have practised all this for years. To give only one example: under the inspiring guidance of Dr T. P. Rees, the Warlingham Park Hospital of the 1940s and 1950s functioned as a permissive therapeutic community, the emphasis being on team work and human relationships, with extensive group therapy and group "
Buncke, J. Surg. Clins N. Am. 1972, 52, 1267. O’Riain, S. Br. med. J. 1973, iii, 615. Glatt, M. M. A Guide to Addiction and its Treatment—Drugs, Society and Man; p. 313. Lancaster, 1974. 4. Glatt, M. M. in Alcoholism: A Medical Profile. Proceedings of the First International Conference on Alcoholism; p. 122. London, 1. 2. 3.
1974.
908 and growth in living cells even though of the nutrient is wasted. Penicillin may have to be given in huge doses, so wasting most of it, in order to achieve optimum therapeutic levels. The question then is not whether it is wasted but whether it is effective. When there is a general consensus that a substance is therapeutic, there is little discussion of waste. But with ascorbic acid there is no such consensus. Many physicians equate consensus with efficacy. This often delays for many years the proper examination of a new therapeutic idea because consensus may require up to 40
increasing vigour
social clubs within the hospital, outpatient clubs, and so on.5 All this was going on for years before the advent of the modern tranquillisers, which are so often claimed to have revolutionised life in psychiatric hospitals. Quite clearly, in such circumstances all members of the interacting triad, man and society, as well as drugs,3 were regarded as the doctor’s concern, and the hospital was regarded not only as a place for treatment by an interdisciplinary therapeutic team, but also as initiating a reconstruction of personality and a resocialisation.5 Attacks on an unduly narrowly defined medical model and disease concept are frequently made in relation to the treatment of alcoholism and drug dependence. It has been claimed by the critics 6 that the commonest response by those committed to maintaining that alcoholism is a disease has been simply to ignore the attacks as not worth dignifying with a reply. In the event, however, nearly all of the medical specialists attending the First International Medical Conference on Alcoholism (held in London in September, 1973, under the auspices ’of the Medical Council on Alcoholism) came out in clear support of the medical model and the disease concept-understood not only in terms of the " agent ", but of the dynamic interaction between host, environment, and agent.3,4 Prof. W. K. van Dijk concluded by saying that " the medical model is a multidimensional construct which takes into account the psychological and social as well as the physical aspects of the afflicted person. For this reason, the medical model should not be replaced by other constructs but it should reckon with them and incorporate them wherever this is possible and useful 11.7
activities,
some
years. 1201 CN Towers, First Avenue South,
Saskatoon, Saskatchewan S7K 1J5.
TUBERCULIN IN RHEUMATOID ARTHRITIS
SIR,—Dr Rewald (Sept. 28, p. 785) discusses the possibility of the use of B.C.G. in the treatment of rheumatoid arthritis, and refers to the work of Kåss et al./ although they did not, in fact, mention B.C.G. by name and seem to have used transfer factor prepared from normal blood. I write simply to make the point that the late Dr Geoffrey Loxton, working in this hospital, began using tuberculin in rheumatoid arthritis at least twenty years ago. He never published his results, but I myself saw a number of patients in whom the disease was permanently arrested. Brook General Hospital, London SE18.
Regional Alcoholism and Drug
SIR,—Iwould be grateful for the opportunity to report fascinating case we have seen at this hospital and to inquire whether anyone can help us with the diagnosis.
M. M. GLATT.
a
THE MEGAVITAMIN SCENE
SIR,—Dr Martin and Dr Lines (July 13, p. 103) suggested that doses of ascorbic acid larger than those recommended to prevent scurvy are wasteful and ineffective. To illustrate this view they reported a patient who took 1 g. of ascorbic acid per day and excreted 158 mg. per 100 ml. of urine-an
extremely high excretion-rate. It is important to examine the commonly held belief that urinary excretion of any substance means waste. This idea ignores the relationship between the concentration of a metabolite in the blood and the amount absorbed by tissues. Usually there is a curvilinear relationship, and, as the amount in solution increases, more is retained in the body until it is saturated. In other words, a certain amount of nutrient may be wasted in order to provide optimum concentrations. This may be a measure of the state of saturation of the body. Assume a dose of 100 mg. divides into 50 mg. excreted and 50 mg. retained, while a dose of 1000 mg. results in 800 mg. excreted and 200 mg. retained. So even if 800 mg. is wasted the body has use of 200 mg. Certain processes may require these larger doses. It has been suggested, for example, that to saturate the leukaemic cells in a patient with this condition may require 7000 mg. per day. If less is given the avidity of these cells for vitamin C causes the scorbutic symptoms in the rest of the body
(petechiæ, capillary fragility, bleeding gums).
Pauling
8
has outlined the scientific evidence for his view that increasing doses of an important nutrient can produce Rees, T. P., Glatt, M. M. in The Fields of Group Psychotherapy (edited by S. R. Slavson); p. 17. New York, 1956. 6. Room, R. Q. Jl Stud. Alcohol. 1972, 33, 1049.
5.
Dijk, W. K. in Alcoholism: A Medical Profile. Proceedings of the First International Conference on Alcoholism; p. 133. London, 1974. 8. Pauling, L. Science, 1968, 160, 265.
7.
van
DAVID LE VAY.
UNEXPLAINED TETANIC SPASMS
Dependence Unit, St. Bernard’s Hospital, Southall, Middlesex.
A. HOFFER.
A 12-year-old boy who had been perfectly well except for slight neck stiffness was suddenly taken ill with severe intermittent spasm of the right side of his neck. He was in great pain during the spasms, which rapidly became worse and started to involve his back. He was immediately taken to the local casualty department and there it was reported that he was having a tonic spasm of his whole back muscles. He kept having spasms of
different muscle groups about every four or five minutes. The muscles relaxed between these spasms and during each spasm he He was lucid during this time and was screaming with pain. complained to being unable to breathe and a feeling of suffocation, although his mouth and face were not involved in the spasms. He was immediately transferred to our care with the diagnosis of severe tetanus. In the ambulance he became apnceic for a few seconds during a severe spasm. On arrival he was in another severe spasm, lying in opisthotonos, with his abdominal muscles taut, his arms hyperextended, the thumbs across the palms, and the fingers extended. The legs were extended with adductor spasm. His eyes were open and staring with dilated pupils. There was no risus sardonicus. He was unable to breathe and cyanosed. He was immediately given intravenous suxamethonium chloride (’ Scoline ’) and thiopentone, and intubated and put on a ventilator. There were no other physical signs, except that at the slightest stimulation he developed tetanic spasm of all muscle groups. Initial investigations showed a normal serum calcium and electrolytes and arterial pH. The creatinine phosphokinase, aldolase, and transaminases were raised. He was given penicillin and 500 µg. of human tetanus antitoxin to cover the remote possibility of tetanus. After six hours his condition had greatly improved, the muscular excitability had resolved, and thiopentone and ventila. tion were stopped. Within eighteen hours he had completely recovered. X-ray of his spine showed no crush fractures. Al specimens were analysed for strychnine and other drugs by the forensic laboratory in Lancashire, but no trace of any poisonou substance could be found. 1.
Kåss, E., Frøland, S. S., Natvig, J. B., Blichfeldt, P., Høyeraal H. M. Lancet, 1974, i, 627.