830 borubber

pads over vein prominences. Crepe may be used but will require repeated readjustment to maintain reasonable pressure which should be maintained for 4-6 weeks. ’Elastoplast’ over the tubegrip is probably more practical since more satisfactory pressure can be maintained without readadjustment. If a vein injected while collapsed can be maintained in this state, the walls will adhere, and complete disappearance of the varicose condition may result from one injection. Occasional difficulty may be met in passing the catheter up the collapsed vein. Should this happen thevein can be redistended with the manometer, and this will usually allow satisfactory passage. When starting to practise this technique, the catheter can be passed up the distended vein but with experience the collapsed vein can be used in almost all cases. With support the patient is ambulant immediately after the injection and attends weekly for six weeks for inspection of the support bandaging. Three months should elapse before a second leg is injected. High venous ligation may with advantage, be combined in certain cases. Department of Surgery, Liverpool Royal Infirmary, Liverpool L3 5PU

A. C. BREWER

SEASONALITY IN SCHIZOPHRENIA

SiR,—Your editorial of March 4 suggested various mechanisms by which summer conception or spring birth might convey increased risk of schizophrenia across an interval of 20-30 years. Subsequent correspondents have made other suggestions. May I add mine. There is evidence of circadian abnormalities in schizophrenia. There is phase- shifting of the sleep rhythm and of the body-temperature rhythm,2and the body clock is fast. 3,4 Abnormal setting of body clock speed in infancy may be the factor linking spring birth with schizophrenia. In the northern hemisphere day-length increases throughout the first half of the year. A child born in January-April will therefore be exposed to increasing day-length for the first 2-6 months of its independent life. This early exposure for at least 2 months may be an important environmental factor interacting with hereditary factors to determine within limits the abnormally fast setting of the body clock. Plants and. lower animals monitor day length and have aspects of their "behaviour" controlled by it. The effect of spring days on day-active lower animals is to speed up their body clock which serves to prepare them for progressively earlier dawns. An effect which occurs transiently in mature lower animals may perhaps occur more permanently in the newborn human infant. The necessary monitoring apparatus could be located in the pineal. The excess of spring births occurs not only in schizophrenia but also in manic-depressive psychosis. Circadian abnormalities occur in both conditions too. Body-clock speed is known to vary quite widely between individuals (Bunning6 gives a range of 24.7-26.0h in health, while Wever7 cites a mean of 25 h±s.D. 0.56), but I know of no work on the variables associated with or determining different speeds. This explanation is compatible with Torrey’s finding that in the U.S.A. seasonal amplitude of schizophrenic births is less in the South than in the higher latitudes of New England or the Morgan, R., Drew, C. D. A. Soc Psychiat. 1970, 5, 99. Morgan, R., Cheadle, J. Br J. Psychiat. 1976, 129, 350. Morgan, R. ibid. 1977, 131, 504. Mills, J. N., Morgan, R., Minors, D. S., Waterhouse, J. M. Chronobiologia (in the press). 5. Cloudsley-Thompson, J. L. in The Voices of Time (edited by J. T. Fraser). London, 1968. 6. Bunning, E. The Physiological Clock. London, 1973. 7. Wever, R. Int. J. Chronobiol. 1975, 3, 19. 8. Torrey, E. F., Torrey, B. B., Petersen, M. R. Archs gen. Psychiat. 1977, 34,

1. 2. 3. 4.

1065.

Mid-West. It does

not

fit with the finding of seasonality in the varies little throughout the

Philippines9 (where day-length year). St Wulstans

Hospital,

ROGER MORGAN

Malvern, Worcs WR14 4JS

FOOD OR FREEDOM?

SIR,-Ihave read Food First by F. M. Lappé and J. Collins, whose book you discussed in an editorial.’ Their conclusions are depressing and sobering; they say the maldistribution of food is a political and economic problem, not a biological or technical one. They are most impressed with the manner in which the Chinese seem to have resolved certain aspects of agricultural production and distribution. A disturbing thought is prompted by this admiration of China. Would Lappe and Collins wish to submerge their own individual desires and aspirations, as is necessary under the Chinese system so that agricultural reform could follow? Also it seems that Cambodia is attempting to rearrange the priorities of its population, changing from "colonial" type cash crops to primary food production. The terrible price being paid by the Cambodian population for agrarian reform is frequently portrayed in news articles. Discussion of such a significant subject is most relevant to the readers of The Lancet. We doctors are often accused of being indifferent to, and ignorant of, nutrition. Institute for Health Care Studies of the United Hospital Fund of New York, New York, N.Y. 10222, U.S.A.

JUDITH M.

TAYLOR

DIAGNOSTIC PERITONEAL LAVAGE

SIR,-I write to comment

on your editorial about diagnostic in blunt abdominal trauma (March 11, p.

peritoneal lavage 541). Blood in the peritoneal cavity is not an absolute indication for exploration-indeed often it may be better not to know about it. A peritoneal lavage producing blood does not necessarily mean that a lesion requiring surgery is present-nor even that there is free interperitoneal blood. In one of my cases frank blood was produced after insertion of the cannula; at urgent laparotomy this bleeding proved to be due to cannulation of

a

vein in the small-bowel mesentery. There

was no

in-

terperitoneal lesion. The patient had a mildly contused left kidney which had been diagnosed preoperatively. I have been involved in four other cases where either no lesion was found or where there was some self-limiting process such as a minor liver tear not requiring treatment. In another case abdominal physical examination was made nearly useless because the lavaging fluid went into the rectus abdominus sheath. This patient was managed without laparotomy and recovered. The five cases I describe above had equivocal physical signs, and without lavage might not have been taken to the operating-room. I would accept criticism for these decisions, but it is a brave surgeon who decides against exploration when faced with a positive peritoneal lavage. My current practice in teaching is that when a resident feels that a peritoneal lavage is needed, then the investigation of choice is a consultant opinion. In North American hospitals all the preliminary investigations are usually done by residents of varying experience before the surgeon arrives on the scene. The consultant may thus be faced with a bloody tap before he has had the opportunity to make his own examination, a situation understandably pre-empting any clinical decision he might make. 9. Parker, G., Balza, B. Acta psychiat. 1. Lancet, 1977, ii, 1334.

scand. 1977, 56, 143.

831 I suggest that caution be advised in the use of peritoneal lavage, for it is not some magical talisman but simply another variably valuable investigative tool. Like most other investigations its value is directly related to sound clinical indications for its use. Department of Surgery, University of British Columbia, Vancouver General Hospital,

JULIUS L. STOLLER

Vancouver, British Columbia, Canada

FATAL MULTISYSTEM TOXICITY AFTER CO-TRIMOXAZOLE

SiR,—Co-trimoxazole has been associated with severe damage to internal organsl-5 and neurological symptoms and signs.l,6 Of 655 adverse reactions to co-trimoxazole reported by Danish doctors from May 1, 1968, to March 31, 1977, 16 related to the central and peripheral nervous system and 5 to the special senses.7 We report here a case of cerebromedullospinal disconnection associated with lesions of the kidney, lung, and pancreas and cardiac arrhythmia after treatment with co-trimoxazole. The patient, a 62-year old man with no tendency to allergic reactions and in good health after an uncomplicated prostatectomy had bacteriuria diagnosed 3 weeks after the operation. Co-trimoxazole treatment was started (160 mg trimethoprim and 800 mg sulphamethoxazole twice daily) but after 8 days the patient had arthralgia and back pain. 2 days later he was admitted with a widespread pustulous eruption a temperature of 40-3° C cyanosis, tachycardia, and 90/60 mm Hg bloodpressure. X-rays showed diffuse lung infiltrations, and he was anuric within 24 h. On admission he

was treated with digoxin, frusemide and methylprednisolone intravenously, plasma, blood, dopamine and noradrenaline, artificial respiration, and peritoneal dialysis. Cultures from pustules, blood cerebrospinal fluid, urine, peritoneum, and the trachea were negative and he was treated with gentamicin, methicillin, and cephalothin sodium. After 3 days he had cardiac arrhythmia, and 2 days later he had a cardiac arrest, successfully treated by external cardiac massage and intravenous atropine. There was increasing evidence of damage to pancreas and liver (blood-sugar up to 750 mg/dl; lactic dehydrogenase 2200 units/I normal 150—450; bilirubin increasing to 4-7 mg/dl, normal 0.3-1.0) and at laparotomy 7 days after admission a severe hxmorrhagic pancreatitis was diagnosed. From the first day of admission he was thought unconscious, only reacting to pain. After a week he could open his eyes on

request and follow the examiner with theeyes, but he was otherwise global apractic, with rigid, reflexless extremities. After 2 months he had spontaneous respiration and, lateral gaze and would make small movements of tongue and lips. Except for these movements, he was mute, akinetic, and paralytic ; light and corneal reflexes, doll’s head reflex, and dilatation of the pupils when pinched in the face were normal, but he was without peripheral reactivity. This locked-in state ended by cardiac arrest after ten weeks. The necropsy showed acute tubulointerstitial nephropathy, acute pancreatitis, hepatic steatosis, and pulmonary fibrosis, several petechial hsemorrhages in the white substance of the hemispheres, and a 5 mm large haemorrhage caudally in the 1. Frisch, J. M. J. infect. Dis. 1973, 128, 607. 2. Kalowski, S., Mathew, T. H., Naura, R. S.,

Kincaid-Smith, P. Lancet, 1973,

i, 394. 3. Tamtamy, S. E. ibid. 1974, i, 929. 4. Knudsen, L., Weismann, K. Ugeskr. Lœg. 1977, 139, 1007. 5. Ramaiah, R. S., Gallagher, M. A., Biagi, R. W. Lancet, 1977, i, 604. 6 Grossman, A. B., Braimbridge, M. V., Ross Russell, R. W., Smith, S. E. ibid.

ii, 616. 7. Sundhedsstyrelsens

Bivirkningsnævn (Danish

Reactions). Unpublished.

State

Register for Adverse

corpus callosum. There were no macroscopic abnormalities in the brainstem. Our case was more severe than those reported by Kalowski et al .2 (acute tubular necrosis), Ramaiah et al.5 (anuria), and Knudsen and Weismann(liver and kidney damage). Our patient had toxic and/or allergic reactions affecting skin, lungs, kidneys, liver, pancreas, and central nervous system with probable loss of central neural control of the heart.8 Cerebromedullospinal disconnection may have been established before the first cardiac arrest but neurological examination and E.E.G. were not done until after the cardiac arrest, so the disconnection may have followed the cardiac arrest.9 There can be little doubt, however, that this case illustrates a fatal reaction to co-trimoxazole, since the patient was in fine health except for dysuria before treatment and from the eighth day of treatment he showed most of the reactions hitherto as-

sociated with co-trimoxazole. Department of Neurology and Intensive Care, Copenhagen Municipal Hospital, Copenhagen, Denmark

JØRGEN BRØCKNER ERIK BOISEN

PERHEXILENE MIMICKING BRONCHIAL CARCINOMA

SIR,-Perhexilene maleate is a useful anti-anginal drug, and side-effects, though common, are usually minor and reversible. We describe here a patient assumed to have carcinoma of the bronchus, but whose symptoms were subsequently attributed to perhexilene. A 63-year-old labourer was transferred to this hospital for He had been well until 3 months before admission when he began to have difficulty with balance, and he was said by his wife to be "walking like a drunk". He also complained of dizziness with no rotational element. Progressive dysaesthesiae in the feet started 2 months later. He had also lost 10 kg in weight over a 3 month period. Direct questioning revealed longstanding effort dyspnoea, mild orthopncea, and cough with mucopurulent sputum. 9 years earlier he had had a myocardial infarction after which hypertension was diagnosed. He was put on oxprenolol 80 mg and perhexilene 100 mg, both three times a day, 12 months before admission. He drank modest amounts of alcohol and he had stopped smoking 20 years previously. On examination he was emaciated and

investigation.

pyrexial (38 °C), blood-pressure 110/60 mm Hg, pulse 68/min, sinus rhythm. His chest was hyperinflated and he had consolidation in the right upper lobe. His voice was slightly hoarse and he was dysarthric. He had generalised wasting and the lower limbs were hypotonic. There was symmetrical loss of power and moderate ataxia in all four limbs, most severe in the legs. He was areflexic and the plantars were flexor. A rest tremor of the arms and titubation of the head were noted. On sensory examination he was found to have a panmodal loss in a

glove-and-stocking distribution. Hb was 13.5g/dl, white cells 13 500/1 (neutrophilia), erythrocyte-sedimentation-rate 90 mm/h, s.G.o.T. 739 iu/1, creatine phosphokinase 141 iu/1. Remainder of blood tests normal. A chest X-ray showed bilateral apical pleural thickening, calcification in both apices, and upper-lobe fibrosis. He also had consolidation of the right upper lobe and slight widening of the superior mediastinum. Bronchoscopy revealed no neoplasm. Nerve-conduction studies were compatible with a sensorimotor neuropathy affecting all four limbs. 3 days after admission he died of an overwhelming chest infection. Necropsy revealed no evidence of a bronchial carcinoma. The presumptive diagnosis had been bronchial carcinoma with non-metastatic neurological complications. However, investigations and necropsy findings failed to reveal a neoplasm. Perhexilene has been associated with proximal myopathy,l per8. 9. 1.

Korner, P. I. Physiol. Rev. 1971, 51, 312. Boisen, E., Siemkowicz, E. Lancet, 1976, i, 1381. Tomlinson, I. W., Rosenthal, F. D. Br. med. J. 1977, i, 1319.

Diagnostic peritoneal lavage.

830 borubber pads over vein prominences. Crepe may be used but will require repeated readjustment to maintain reasonable pressure which should be mai...
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