comprehensive primary care; however, it is unlikely that such decreases in use and expenditures could have been due solely to changes in the approach to caring for these problems.

We would agree with Dr Paul that and competency in treating emotional problems is fundamental to both improving the quality of care and controlling expenditures for care. Physicians will vary in their interest and competency in dealing with specific problems. Physicians interested in improving their effectiveness in meeting patients' needs require a feedback loop that assesses total performance. With¬ out this assessment, as Dr Paul points out, they can be ignoring very major areas of patient needs. This can influence, both directly and indirectly, increased use of services. In our esti¬ mation, the problem-oriented system— because it demands definition of goals, preservation of logic, structured rules for data and audit—is a very effective tool for providing this assessment and correction of performance. awareness

Henry M. Tufo, MD

University

of Vermont

Given Health Care Center

Burlington

in Blood Pressure Between Arms To the Editor.\p=m-\Whilethe consultants

Disparity

in QUESTIONS

1977)

(237:1871, stating that the

AND ANSWERS

are correct in common cause of

dissimilar blood arms of a 77\x=req-\ year-old man is arteriosclerotic occlusion of the subclavian artery, they make no mention of alternative explanations that may be responsible or most pressure

readings in the

contributory. Asymmetrical sphygmomanometric recordings can occur with the scalenus anticus syndrome, a cervi-

cal rib, or other forms of the thoracic outlet syndrome. Adson's test is usually positive in these cases.1

myself Anesthesiologists sionally give anesthesia to these as

occa-

pa-

tients for unrelated surgery, and often positioning them on the operating table can incur a spurious hypotension in the affected arm. Contralateral normalrange Korotkoff sounds delineate the discrepancy, and repositioning amends it. Unilaterally diminished arterial pulsations may also be seen status after open heart surgery or cardiac catheterization. Checking the blood pressure in both arms is worthwhile not only in detecting a relative pseudohypotension, as in these patients, but also in recognizing a potential pseudohypertension in pa¬ tients with pneumatically incompres-

sible calcified brachial arteries.2 This

phenomenon occurred recently in an elderly patient at our hospital (blood

pressure in right arm, 230/90 mm Hg; left arm, 150/90 mm Hg), and its recognition averted unnecessary anti-

hypertensive therapy.

Caution should be used in evaluating divergent blood pressures in the upper limbs, and intra-arterial measure¬ ments may be indicated in

some cases.

Walter P. Zmyslowski, MD Boston University School of Medicine Boston Boston

City Hospital

1. Schwartz SI (ed): Principles of Surgery. New York, McGraw-Hill Book Co Inc, 1969, pp 760-764. 2. Taguchi JT, Suwangool P: "Pipe stem" brachial arteries: A cause of pseudohypertension. JAMA 228:733,

1974.

Pop Bottle Explosions To the Editor.\p=m-\Bergeson et al (238: 1048-1049, 1977) have done well in

drawing our attention to the dangers of pop bottle explosions. My wife has

twice been a victim. The first incident occurred in a small store. There were several tall bottles of carbonated drinks standing on the concrete floor, and when she brushed against one of them, it tipped over and exploded. She suffered a 2- to 3-cm laceration just above one ankle. One day this summer a large bottle of one of the soft drinks was brought into our home. Noticing that it felt hot, my wife thought it should be cooled before being opened. She placed it in a deep pan and began to run water from the cold faucet into the pan, not directly onto the bottle. Almost immediately the bottle exploded, scattering tiny glass splinters throughout the entire kitchen. At the same instant she felt a shower of splinters against her glasses. She was holding the bottle by her right hand when it exploded, and she sustained several small lacerations on the fingers of that hand. Glass is indeed a dangerous environ¬ mental hazard. Frederic Speer, MD

Shawnee Mission, Kan

Catatonia To the Editor.\p=m-\Regestein et al have made an excellent presentation of two cases of catatonic stupor that ended tragically (238:618, 1977). Lethal catatonia can develop on the basis of many underlying pathologic states, some of which have been mentioned in the report by Regestein et al. Unfortunately, one of the important causes of lethal catatonia that was first described by Delaye and Dineker1 (malignant neuroleptic syndrome) is

chlorpromazine hydrochloride itself. This drug was used in rather large doses in both cases. Knowledge about the anticholinergic and cardiotoxic2,3 and hypotensive effects of chlorpromazine would also indicate that the use of this drug should be avoided in patients with fever of catatonic origin and tachycardia. Whatever the origin of the catatonic state, electroconvulsive therapy (ECT) is the safest and most effective treatment in the majority of catatonic states. In the first case where vigorous medical intervention was used, Regestein et al do not mention why they did not include ECT in their thera¬ peutic regimen. In the second case where ECT was employed, the authors do not mention the indications for the use of excessive doses of chlorproma¬ zine, in spite of the fact that the patient had a cardiac rate of 138 beats per minute. It is likely that the chances for survival would have greatly in¬ creased in the first patient if ECT had been instituted early in the course of hospitalization. In the second patient the likelihood of recovery would have been greater if the use of chlorproma¬ zine had been avoided and ECT insti¬ tuted soon after the onset of the cata¬ tonic state. The purpose of this letter is not to criticize the therapeutic approaches taken by the authors but to stress the primacy of the usefulness of ECT in these lethal catatonic states character¬ ized by fevers and intercurrent infec¬ tions. Also, if a neuroleptic has to be used in the treatment of the psychiat¬ ric condition underlying the catatonía, then cautious doses of drugs such as haloperidol (Haldol) and trifluoperazine hydrochloride (Stelazine) should be used since these have fewer anti¬ cholinergic and hypotensive properties; however, these drugs also may worsen the catatonic state.

Rafiq Waziri, MD

The University of Iowa

Iowa City Delaye J, Dineker P: Drug induced extrapyramidal syndromes, in Vinker PJ, Bruyn GW (eds): Handbook of Clinical Neurology. New York, John Wiley and Sons Inc, 1.

1968, sec 6. 2. Ban TA, St Jean A: The effect of phenothiazines on the electrocardiogram. Can Med Assoc J 91:537-540, 1964. 3. Wendkes MH: Cardiac changes related to phenothiazine therapy, with special reference to thioridazine. J Am Geriatr Soc 15:20-28, 1967.

In Reply.\p=m-\Iagree with Dr Waziri that ECT was probably indicated in the first patient. She had been admitted some years ago and was not under my psychiatric care. Her direful physical condition probably dissuaded her psychiatrist from treatments with ECT. In the second case we decided that the probability of losing the patient

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