484 ARSENIC IN OPIUM

SiR,—Ihave seen the typical clinical picture of arsenical neuropathy in patients consuming opium. They denied the intake of arsenic through any other source and lived in areas where the water was not contaminated by arsenic. 1These patients had been consuming 10-20 g of opium per day for the previous twenty years. To understand the significance of opium in the production of this clinical picture the arsenic conARSENIC CONTENT OF OPIUM

Report form giving quantitative data on drugs plus pathological information.

mmol/1). Thus the hyperuricaemia could be attributed

to

mefruside, and inappropriate treatment was avoided. These two cases show how drugs may result in misinterpretation of laboratory investigations by causing true changes in the blood concentration of the substances being studied. Drugs can also cause a spurious change in concentration by interfering with the chemical analysis. For example, paracetamol (acetaminophen) causes a spurious increase in serum-urate as measured by the Technicon SMA 12/60 method.-’ This is important because many patients with joint pains are likely to be taking paracetamol when investigated for gout. To assess the significance of drug interference with one common laboratory investigation (serum-urate, for which Young et awl.2 list nearly 300 entries), I drew up a short-list of the more important examples given in Hansten’s book .6 Serum-urate was measured with a Technicon ’AutoAnalyzer’ method N-13b (reduction of a phosphotungstate complex in the presence of sodium cyanide and urea). All clinicians who use our laboratory were shown specimens of four styles of report form and asked to comment on their suitability with special reference to avoiding misinterpretation of the serum-urate result. Clinicians were asked to vote for the style preferred, and both general practitioners (51%) and hospital doctors (40%) preferred the report form which showed both pathological and drug information and was the most complex (see figure). The least popular of the four styles was the simple, normal-range type in common use. A version of this form without the pathological information has now been introduced as routine. The new report form reminds clinicians of the drugs influencing interpretation of the laboratory investigation each time they see a serum-urate result, and an additional advantage is in the education of medical students and the training of junior laboratory staff. Clearly it would be difficult, though not impossible, to present such detailed information with a report form for a multichannel analysis. The extent of this problem is difficult to assess, but before informative reporting was introduced, I found that of a batch of 15 serum-urate analyses, 10 were for patients receiving drugs which influence interpretation (paracetamol, frusemide, bendrofluazide, methyldopa). Bold has suggestedthat the problem could be solved by computerised recording of all drugs administered to each patient so that the laboratory and clinician would be automatically alerted to a misleading result. Since computer facilities are scarce, the simple expedient of informative reporting using rubber stamps or some similar device might be more applicable. I thank Dr R. B. Payne for his initial scepticism and for his structive criticism, and Dr V. Standing for his advice. Department of Chemical Pathology, St. James’s University Hospital, Leeds LS9 7TF

con-

J. G. SALWAY

5. Wilding, P., Heath, D. A. Ann. clin. Biochem. 1975, 12, 142. 6. Hansten, P. D. Drug Interactions; p. 379. Philadelphia, 1973. 7. Bold, A. M. Lancet, 1976, i, 951.

tent

of

opium consumed by these patients was estimated.3 obtained from patients and from an illegal source had

Opium a very high arsenic content (table). One patient consuming opium containing 70 ug of arsenic/100 g had neuropathy and high concentrations of arsenic in urine (149 v. normal 40 p.g!day), nails (500 v. 50 (ig/100 g), and hair (107 v. 50 g/100 g). The precise source of arsenic in opium could not be traced. It is, however, quite commonly used in India as an aphrodisiac and for treatment of illnesses of diverse nature. Postgraduate Institute of Medical Education and Research,

Chandigarh-160011, India

D. V. DATTA

CATARACTS IN AVIATION ENVIRONMENTS

SIR,-Fifty years ago Duke-Elder demonstrated that cumulative radiant energy exposure, including long-term irradiation by sunlight, was the primary or sensitising aetiological factor for most cataracts ordinarily acquired during life.4 He presented data indicating that rays originating anywhere throughout the spectrum, from the longest rays generated by electrical oscillations to the shortest wavelengths of ionising radiation, could initiate cataract formation. Here our attention will be limited to the wavelengths occupying the middle region of the non-ionising spectrum (i.e., hertzian radiation) including microwaves and radiowaves. High levels of stray non-ionising radiation ("electronic smog") are now recognised as important air pollutants. 5 Millions of people in the general population are exposed daily (e.g., from telecommunication networks) to intensities far exceeding background levels.6 Cataracts apart, repeated microwave radiation exposure has been incriminated7 as an xtiological or contributory factor in neurophysiological, hormonal, haematopoietic, immunological and cardiovascular dysfunction, teratogenesis, and mutagenesis. However, doctors are not yet aware of these findings and their significance. Perhaps some insight may be gained by discussing a special population group at risk (operational aviation workers) and an objective sign (capsular cataract) which we believe to be correlative. Capsular cataract, originating in the membrane surrounding the lens, is unusual; cataract is usually found within the lens substance. That hertzian radiation may produce capsular cataract was first reported in 1964 in three young microwave workersB and confirmed in a young radar technician,9 and it 1 Datta, D. V. Luncet, 1976, i, 433. 2. Datta, D. V., Kaul, M. K J. Ass. Physns. India. 1976, 24, 599. 3. Kingsley, G. R., Schaffert, R. R. Anal. Chem. 1951, 23, 914. 4. Duke-Elder, S. Lancet, 1926, i, 1188. 5. Bowers, R., Frey, J. Sci. Am. 1972, 226, 13. 6. Tunney, J. V. Radiation Control for Health and Safety: Hearings before the Committee on Commerce, U.S. Senate. 1973. Serial no. 93-24. 7. Czerski, P. (editor). Biologic Effects and Health Hazards of Microwave Radiation. Warsaw, 1974. 8. Zaret, M M. U.S. Air Force Technical Documentary Report no. RADC-TDR-64-273, 1964. Griffiss Air Force base, New York. 9. Bouchat, J., Marsol, C. Arch. Ophthal. (Paris). 1967, 27, 593.

485 has been reported in a middle-aged housewife using a household microwave oven.’0 One of us (M.M.Z.) was consulted over a period of years by nine individuals who worked in operational aviation where hertzian radiation has widespread communication, navigation, and radar applications and in whom hertzian radiation cataract was suspected. Three had been radar technicians aboard EC-121 (electronic intelligence) type aircraft,’ five were airtraffic controllers, and one was an airline pilot. All exhibited

capsular cataract. W.Z.S. has examined one of these cataracts histologically, confirming the presence of a capsular lesion, vacuolisation, and degeneration of the subcapsular epithelium and capsular adhesions, all similar to that described in cataract after exposure to non-ionising radiant energy.’ These findings are consistent with the clinical diagnosis of chronic hertzian radiation cataract, a capsular cataract which develops slowly over the years after repeated irradiations at non-thermal intensities without any evidence of burn, the lesion instead resembling a delayed purely radiation effect. The earliest symptom of radiant-energy cataract is often transient visual problems, such as looking through a misty fog or wet glass, symptoms which can antedate objective signs by years. For example, one of the air-traffic controllers, during a five-year period between 1967 and 1972, experienced many episodes of wrongly identifying aircraft or losing others on his radar plot. Several times mid-air collisions were prevented only by the intervention of colleagues. Throughout this period numerous ophthalmological examinations and an extensive physical and neurological evaluation failed to reveal the diagnosis. The earliest sign of lens opacification appeared in his left eye in 1970; but it was not until 1972, when visual acuity was still correctable to 20/20 in the right eye and reduced only to 20/30 in the left, that he was diagnosed as having an incipient cataract and finally disqualified as an air-traffic controller. Ophthalmological tests for certifying the visual status of operational aviation personnel are inadequate. Careful slitlamp inspection of the lens capsule and evaluation of entopic glare function should be added. In addition to improving air safety, this will permit early diagnosis and removal from further exposure. New York University School of Medicine, New York, N.Y., U.S.A.

effect resembled a short-lived drucken state—dizziness, unreality, somewhat "clouded mind", slight excitement (but without aggressive feelings "unless you had been previously in an aggressive mood"), "hearing" noises which might be frightening (one man claimed to have been "seeing things"), a feeling of "pins and needles all over", "everything seemed to stick out and become exaggerated". Most felt "quiet" when sniffing on their own but giggled and laughed when doing so in a group. Those who kept on sniffing or inhaling or tried to hold their breath occasionally "passed out". Seven men reported a fairly mild "buzz" or "high", lasting perhaps 5 min; and the "come down" was either completely absent or very mild (e.g., a mild, temporary depression). Six men who had in the past taken a number of other drugs, were asked to rank them according to their personal preference. All put thinners at the bottom, directly behind alcohol; oral amphetamines or intravenous methylamphetamine usually came first, followed by cannabis, and then by opiates. All these men stated that they would not bother with thinners outside prison as the "buzz" was not strong and long enough: "it was just better than nothing". In all cases, the underlying personality was unstable, inadequate, and immature; intelligence was about average in eight and slightly above average in two; employment record had usually been poor; eight of the ten were single; and almost all had a fairly long-standing history of antisocial behaviour. Investigations arranged by the industrial manager at the prison (Mr A. Kelsal) showed that the solvent responsible was probably methylethylketone. The use of this solvent was subsequently discontinued in the shop concerned, and no cases were seen after 1969. Methylethylketone is a commonly used solvent.’ Smaller quantities of this substance were contained in a liquid shoe-cleaning preparation sniffed by adolescent schoolchildren.5 "Thinner addiction" among- children and adolescents has been described in the U.S.A.’ and in Sweden.5 The symptoms-initial excitement followed, when higher concentrations were reached, by somnolence or unconsciousness closely resembled those in the prisoners. St. Bernard’s Hospital, Southall, Middlesex

BACTERIAL THRUSH-LIKE LESIONS OF THE MOUTH IN RENAL TRANSPLANT PATIENTS

MILTON M. ZARET WENDY Z. SNYDER

SIR,-Candidal infections of the oral ABUSE OF SOLVENTS "FOR KICKS"

SIR,-As Dr Oliver and Dr Watson (Jan. 8, p. 84) state, the abuse of solvents "for kicks" is not a new problem. It has been reported among children and adolescents in North America since the early 1960s;’-’ in Britain Merry reported a case of glue-sniffing in 1967.4 I saw a few glue sniffers in the late 1960s, and more (aged 16 or 17) lately. Social workers report that glue sniffing among youngsters is not uncommon, at least m the London area. I saw a slightly different form of sniffing or inhaling of a solvent (i.e., paint thinner) in 1968 in a London prison. Over a period of a few months I saw ten men (aged 18-22) who had come across this substance whilst working in one of the shops. Two had sniffed paint thinner before coming to prison; the others heard about it whilst in prison. They sniffed the thinner either in small groups or when on their own. Effects started rapidly, usually within a few minutes, and lasted 15-30 min, unless sniffing was sustained or resumed after an interval. The 10 Zaret, M.M.N.Y. State J. Med. 1974, 74, 2032. 11 Zaret, M. M., Snyder, W. Z., Birenbaum, L. B.J. Ophthal. 1976, 60, 632. 1 Krug, D. C., Sokol, J., Nylander, I. in Drug Addiction in Youth (edited by E Harms); p.36. Oxford, 1965. 2 Sokol, J in Drugs and Youth (edited by E. Harms), p.73. Oxford, 1973. 3. Malcolm, A I. Addictions, 1973, 15, 12. 4 Merry, J.Br. med.J. 1967, n, 360.

M. M. GLATT

mucosa

develop

in

heavily immunosuppressed patients, and many of these seem resistant to antifungal antibiotics. We have seen six such patients with lesions clinically resembling acute pseudomembranous candidiasis (thrush), in which the organisms involved were bacteria not fungi. These lesions fulfilled the usual clinical criteria accepted for oral thrush-the appearance of white superficial plaques, removable by scraping, leaving a bleeding surface behind. The organisms were coagulase-negative staphylococci (two cases), streptococci together with coagulasenegative staphylococci (one case), lactobacilli (one case), Neisseria (one case), and coliforms (one case). Candida were not demonstrated on culture, whilst direct smear preparations from the lesions demonstrated only bacteria, effete epithelial cells, and mucoid substances, no hyphal structures being present.

These bacterial thrush-like lesions developed during episodes of acute rejection following renal transplantation -and after treatment with high doses of methylprednisolone together with azathioprine. Treatment depended on the identification of the organism and the application of appropriate antibiotics, together with measures designed to break down the mucoid matrix of the plaques, such as ascorbic-acid mouthwashes, trypsinisation, and mechanical debridement.

5.

Hepple,

N. V. ibid.

1968, ii, 387.

Cataracts in aviation environments.

484 ARSENIC IN OPIUM SiR,—Ihave seen the typical clinical picture of arsenical neuropathy in patients consuming opium. They denied the intake o...
321KB Sizes 0 Downloads 0 Views