599 the posterior urethra, and the ethacridine, if injected slowly, will dissolve the spermatozoa in the vas deferens and seminal vesicles.1 Women’s Clinic, Central Hospital,
S 531 ol Lidkoping, Sweden.
BO
VON
FRIESEN.
STEROIDS IN MOUNTAIN RESCUE SIR,-In our article2 we stated, correctly, that there are no published data on the effects of parenteral steroid administration in young people found in an exhausted state on the hills. However, I have personally used parenteral steroids in cases of " pure " hypothermia, cases of exposure shock following cold and exhaustion, and cases of severe injury (particularly severe head injury), often associated with lying out on the mountains in wet or cold conditions. I have also been in touch with other practitioners associated with mountain-rescuework who have used steroids as a last resort in apparently moribund patients. In all these cases there has been a good response, and so far there are no reports of adverse effects, short or long term. None of the patients mentioned in our article were given steroids since their condition was not critical. I have found it impractical to take blood samples under mountain-rescue conditions from critically ill patients, because of intense
peripheral vasospasm. In patients with severe head injury, steroids can be expected to decrease cerebral cedema and improve the blood-pressure and circulation, thus decreasing cerebral anoxia and improving the prognosis. Often our patients are hours away from hospital and have to be subjected to prolonged rescue procedures. I have been lucky enough, so far, not to lose any patient who was alive when reached by the rescue team (lowest recorded body-temperature 90 °F), but report of another case in a different area where the alive when found, was not given steroids, and patient died during rescue procedures, from " exposure ". I can see no contraindication to a trial of steroids under these desperate conditions. I also have personal knowledge of a case where a climber had been in a glacier crevasse for hours, and, when rescued, His friends had been was apparently lifeless and rigid. attempting resuscitation for approximately 1 t hrs, with no effect. At this point my husband (non-medical but with a vast experience of mountain rescue) chanced upon them and again, as a last resort, offered steroids, which they decided to accept. Much to their surprise he began to improve thereafter, and even walked back to his camp several hours later. Unfortunately, no temperature readings were made, but he was stated to feel " icy ". I have
a
was
Glencoe, by Ballachulish, Argyll.
C. MACINNES.
SiR,-There is nothing novel in the concept that the to produce enough cortisol in
adrenal cortices may fail response to the stress of
illness.
prolonged
exhaustion
or severe
Only lately, however, has formal justification for
the
therapeutic administration of intravenous hydrocortisone in such conditions been provided. The paper by MacInnes et al.,2 and previous studies by the same group of investigators,3 demonstrate that unexpectedly low plasma-11-hydroxycorticosteroid levels may be found in a minority of very ill people. We have studied adrenocortical function in acutely ill patients not expected to 1. 2. 3.
Boeminghaus, H., Baldus, U. Z. Urol. 1934, 28, 433. MacInnes, C., Rothwell, R. I., Jacobs, H. S., Nabarro, J. D. N. Lancet, Jan. 9, 1971, p. 49. Jacobs, H. S., Nabarro, J. D. N. Br. med.J. 1969, i, 595.
have an impaired cerebral-hypothalamic-pituitary-adrenal axis and found that 6 of 41 very ill patients had plasma11-hydroxycorticosteroid levels actually below the lowest limit of normal for healthy people at rest-that is, less than 6 ug. per 100 ml. We also found that this group failed to increase their plasma-11-hydrocorticosteroid levels significantly when given acute stimulation with 250 ug. tetracosactrin.4 We would therefore agree with MacInnes et al. that, when in doubt, intravenous hydrocortisone should be
given
to severely ill people with the usual precautions; but before the therapy is commenced, blood should be taken for estimation of the 11-hydroxycorticosteroid level. If, subsequently, this level is found to be high, which is usual, then due consideration can be given to modifying management in the light of all other factors.
University Department of Medicine, Royal Infirmary, Glasgow C.4.
W. R. GREIG J. D. MAXWELL J. A. BOYLE R. M. LINDSAY MARGARET C. K. BROWNING.
SCIENCE AND NON-SCIENCE IN PSYCHIATRY SiR,-I have found most stimulating the correspondence on this subject which was triggered off by your kind editorial5 on the Mapother Lecture of last November. Perhaps my critics will be so kind as to suspend final judgment until I can get my ideas on this subject published ; and then I hope that they will wade in. All the rest of us are
hoping one day to see psychoanalysts entering
the debating chamber, and laying on and receiving wallops with equal good humour. If they really want a science, this is the way by which out of psychoanalysis a new science might eventually grow. Surely the time is now past for the sensitiveness and defensiveness that can be detected in some of the letters. I cannot see why Dr. Wolff 6 should think, on the basis of what I said, that I had any wish " to blackball psychoanalysis in toto and to eliminate it as a’foreign body’ from the psychiatric field ". Psychiatry is only partly a science; and it is only in the scientific part that psychoanalysis, which is a non-science, finds itself misplaced. The British Journal of Psychiatry has found space for ten teaching lectures on psychoanalytic concepts in its last nine issues; as its editor, I could have hoped that Dr. Wolff would let me off the unbecoming accusation of " being motivated by personal prejudices ". Whether psychoanalysis is a science is an epistemological question, and it has been answered, I think decisively, by the epistemologists. Dr. Wolff should address himself, not to this unimportant personal opinion of mine, but to the epistemological arguments themselves. I think he will find they are a very hard nut to crack. But why should not psychoanalysts abandon their insubstantial and disruptive claim for scientific status ? What is in it for them, if psychoanalysis is classified epistemologically as a science or as a non-science ? We must remember that clinical work, though it may use a scientific technology, is essentially non-scientific in nature. There is plenty of non-science in all the medical arts; and it is in the non-science that we get most of the stimulation. If psychoanalysts could bring themselves to see their study not as a science but as the womb of a science, they could begin to use it really productively, as the matrix 4. 5. 6.
Greig, W. R., Maxwell, J. D., Boyle, J. A., Lindsay, R. M., Browning, M. C. K. Postgrad. med. J. 1969, 45, 307. Lancet, 1970, ii, 1174. Wolff, H. ibid. p. 1255.