9
BRITISH MEDICAL JOURNAL
JULY
123
1977
cost of £2 per smear might be reasonable at the present time. Thus a sum of £6000 has been spent, the cytological services have examined 3000 normal smears from an age group where the chances of positive findings are notably low, and little has been achieved. The difficulty is that publicity in women's magazines together with the policy of the Family Planning Association and the Brook Clinics make those who do not do routine smears in young people appear negligent, and it is as quick to take a smear as to explain one's reasons for not doing so. There is a need now for publicity to be given in non-medical magazines to Drs Spriggs and Husain's paper.
screened for a substantial part of the precursor phase before one could expect the mortality rate of the subsequent cancer to decline. The authors of the Walton Report' have shown this to be so in British Columbia, where about 80 '% of the population has now been screened, which probably relates to about 60°` of the total group at risk as these seem to accumulate in the unscreened population. Looking at the age-specific mortality rates of cervical cancer quoted by J G Thomson in his article in Health Trends in 19712 one could see that there was a considerable drop in mortality in women in the 35-44-year age group but in no other. In my lecture to the Marie Curie Foundation in 1975 (in press as a triennial report) I had suggested that this could have been due in part to the screening programme. The more recent figures provided by kind permission of Dr A M Adelstein of the Office of Population Censuses and Surveys (table I) demonstrate this effect even more clearly, with the drop in mortality extending into the 45-54-year age group. The other explanation was, of course, that a lower-risk cohort had emerged over the past few years or that the disease was losing its aggressiveness. Table II does indicate that this drop could be due to cohort differences, but may not explain the whole effect (data kindly supplied by Dr Adelstein). Indeed, there appears to be a younger cohort following up behind in which the rate is rising again, and it is for this reason that, in our recent article, we suggest in our model proposition for a screening schedule that we should take note of any mortality and morbidity trends, especially in view of the changing life style of the young women of today. 0 A N HUSAIN
Anaesthetic waste gas scavenging systems
SIR,-I was very interested to see the letter from Professor L Rendell-Baker and Dr R A Milliken (21 May, p 1348) on the above subject. They came to the same conclusion as we did (19 February, p 507), that an effective scavenging system used without adequate ventilation will not correct pollution problems in operating theatres. We have suggested two additional measures which are necessary to achieve effective control of ambient pollution -that is, regular equipment maintenance with careful anaesthetic techniques to prevent gas leaks and institution of an air monitoring programme to indicate the effectiveness of D G H SYLVESTER these preventive measures. Regular equipment Students' Health Service, University of Bristol maintenance involves frequent testing of pipe lines, anaesthetic machines, ventilators, and scavenging systems for gas-tightness. However, I am surprised by their statement communication the to further SIR,-I write that passive systems are difficult to use since from Dr A I Spriggs and myself (1 1 June, the driving power, the positive force of p 1516) relating to the age and frequency of expiration, and circuit overflow also tend to screening for cervical cancer in order to bring the pollutants into the theatres. This propel of some significance. further out a point has not been our experience. In our study,' we The National Screening Programme, now were able, with the help of a passive scavenging in its 13th year with an annual load of around system and operating room ventilation with an 3 million smears, was originally designed to air exchange rate of 10 times per hour, to five years. 35 once every over women aged test halothane levels to the order of 0-2 ppm. reduce As a result of the open-door policy, the This was achieved irrespective of the type of enthusiasm of the young, and the use of anaesthetic circuit used and gas flows and maternity and family planning clinics in which vapour concentration employed. In our recent to collect the smears 50 , of the tests entering on passive disposal of expired study2 our laboratories are from women under the anaesthetic gases the results showed that the age of 35. This has resulted in the application resistance offered by the conduction channels of about 1-5 million tests to about 6 500 000 and the terminal gas exhaust valve of the passive young women, whereas the other 15 million disposal system was extremely low. It was tests have been spread over nearly 13 000 000 to be 25 Pa at a gas flow rate of 30 1/min. found women with a diminishing frequency as they Provided the various components and joints Cytology Centre, get older. (Figures taken from Registrar Regional St Stephen's Hospital, of the passive scavenging system are gas-tight General's Statistical Review of England and London SWlO there is no reason why it should be less Wales, 1973, Part II.) Walton Medical Association Canadian Report, _Journal, effective than any active system in keeping It would be expected that a substantial 1976, 114, 1003. operating rooms pollution-free. number of women at risk would need to be 2 Thompson, J G, Health Trends, 1971, 3, 24. S MEHTA Department of Anaesthetics, General Hospital, Burnley, Lancs
TABLE I-Deaths from cancer of the cervix uteri Age group (years) Year
1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
2
0-24
25-34
35-44
45-54
55-64
65 and over
All ages
1 3 3 2
31 32 33 27 32 32 32 34 41 46 39 50 68
316 337 330 280 241 226 205 170 184 164 137 122 136
561 627 596 535 628 630 564 566 580 510 542 443 412
570 561 604 599 574 618 607 625 594 604 605 524 597
986
2465 2577 2453 2464 2449 2434 2417 2343 2315 2218 2249
3 3 6 5 2 4 7 5 9
1017 887 1021 971 925 1003 1003 914 890 919
2068 2143
924 921
TABLE II-Cohort mortalitv from carcinoma of the cervix in England and Wales Central date of birth 1881 1886 1891 1896 1901 1906 1911 1916 1921 1926 1931 1936
1941
1946
Death rate (per million) in women aged 25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69 304
285
10 9 5 7 10
30 37 18 15 22
58 74 67 44 38
93 119 134 106 67
136 154 180 176 130
203 181 187 204 190
254 197
178 201 199
246 222
193 199
.284
32.T '217 ~
193
70-74 315 313 2741 24
26'
Mehta, S, et al, Canadian Anaesthetists' Society J'ournal, 1975, 22, 271. Mehta, S, et al, British Journal of Anaesthesia, 1977, 49, 589.
Effect of antihypertensive drugs on growth hormone secretion SIR,-The report by Drs I Lancranjan and P Marbach (4 June, p 1472) on the failure of BS 100-141, a new oc-adrenoceptor agonist, to raise plasma growth hormone (GH) levels in hypertensive patients after both acute and chronic treatment prompts us to report our experience with clonidine, another central c-adrenoceptor agonist which was found to increase GH secretion in young normal male volunteers.' Seven patients aged 40-60 years with moderate hypertension volunteered for the study. There were five men and two women. All patients had discontinued their antihypertensive treatment for at 41aotjwiek,and took no medicatiowilther than clonidine during the study. On the first day clonidine (015 mg diluted in normal saline) was infused intravenously over a 10-min period and blood was drawn for GH radioimmunoassay at 15-min intervals for 90 min. On the following day 0-15 mg of clonidine was administered orally and blood was taken at hourly intervals for 3 h. This test was followed by treatment with clonidine
9
BRITISH MEDICAL JOURNAL
124
0Q15 rug twvice or thrice daily for seven davs blod w as collected every day beforc the morning dosc of the drug and on the fourth and seventh davs blood samples wcre also taken at hourly intervals for 3 h aftcr the first daily dosc of clonidine. No significant increase in serum GH wvas detectcd during the acute studies, though minor elevations occurred in three male subjects after intravenous clonidine (net increase ranging bctwecn 2'3 and 4 3 jig 1) and in tvwo of them aftcr oral administration of the drug (net inicrease 2-4-4-6 [tg 1). During the seven days of treatinent only one man and one woman patient exhibited isolated increases in serum GH concentration of minor magnitude less than 5 tg 1). T hough we have no personal data on the
have analysed a consecutive series of 1 31 patients undergoing elective truncal vagotomv and pvloroplastv for peptic ulcer. All other gastric operations were excluded. Sixty-one patients had vagotomy and pvloroplastv and 70 incidental appendicectomv as well. The primary wound sepsis rates were 3 34 (8 8 respectively in patients and 2 30 (6-71 protected by cephaloridine and 6 27 (22 2",) and 10 40 (250",) in the others. There are no significant differences between the rates with and without appendicectomV. A V POLLOCK MARY EVANS
JULY 197,
its ow-n had failcd utterly to prevent relapses. whiich, wvhen they occurred, always prcscntcd clinicallv with excitemcnt, ideas of refcrence, thouglht disorder, dclusions, and hallucinations. Hcr last attack was uishered in by an acceleration of psychomotor activity accompanicd by a severe insomnia state. After abotut 10 days she then began to express delusions of a religious and paranoid nature, showed ideas of reference, and had auditory hallucinations. In this state she too was quite unresponsive to phcnothiazines. Howevcr, response to lithium carbonate syas both rapid and sustained, and her progress in the nine months since then has been surprisingly- good. She is rapidly discarding hcr "chronic patient" image and, as her parents report, "is rcturning to her old self."
Scarborough Hospital. effects of x-adrenoceptor agonists on GH Scarboroug2h secretion in normal subjects, Lal et a1,' using Pollock, A V, and 1.Evans, .\1. 1Brzitsh MedlLca! 7journal. clonidine, and Drs L ancranjan and M\tarbach, 1977, 1, 20. using BS 100-141, found that they caused an increase in serum GH levels in healthv male volunteers. Clonidine was also found to stimulate GH secretion in adult male rhesus Use of ritodrine ir. pregnant diabetics monkeys2 and rats.' Though aging has been associated with reduced spontaneous and SIR,-F01l0lwing several reports of the successstimulateu GH release,' i Drs Lancranjan and ful use of ritodrine in pregnant women the Marbach found no increase in plasma GH data sheet for ritodrine has been altered as levels in young hypertensive patients under Dr C J Chandler suggests ('30 April, p 1159). chroiic treatment with BS 100-141. Thereforc It will now read as follows: the possibility cannot be excluded that the failure of x-adrenoceptor agonists to stimulate P1 rcalcti(ws GH secretion in hypertensive subjects might 'Paragraph 2, Although glucose and insulin be due to some alteration in Y-adrenoceptors profiles in normal pregnant women have been associated with the hypertensive state. shown in controlled clinical trials not to alter under Yutopar therapy, it is recommended CARLO FERRARI that in the diabetic patient monitoring of GIAMI'AOLo T1STORI glucose levels be undertaken.
ROBERTO CALDARA CRISTIANo BARBIERI
)uphlar I.ahoratries Ltd. Southampton
2nd Dcpartment of Medicine.
Fatebentfratelli Hospital. Milan, Italy
The above cases are interesting for two reasons. One is the diagnostic one: schizoaffectiv-e illness is a definite clinical entity containing as it does features common to both schizophrenic and affective states. However, it is important to make the diagnosis accurately as otherwise the patient will usually be classified as schizophrenic and will therefore receiVe inadequate medication. In this regard there is a lot to be said for Ollerenshaw's1 recommendation that acute schizophrenia should be regarded as simply a variant of the manic phase of manic-depressiv-e illness. Secondly, and more intriguingly, what exactly is the role of sleep deprivation in these states ? Could, for instance, severe sleep loss, as in the above twro cases, be the missing ingredient which converts a manic state into an acute schizophrenic one? The role of sleep deprivation in producing psychiatric sy'mptoms is not fully clear,2 but the kind of sleep loss in a manic state must surelv be very considerable and perhaps T C G SMITH nearer to being a total sleep loss state than that Medical dircctor produced experimentally. A
J MCGINNIS
St John's Day Centre,
I al, S, er al, 7our7iat of (linicatl E,idocrzi7tioo! and Aletaboism,i, 1975, 41, 827. Chbambers, J W, and Brown, G; M, Emldsrioltogy, 1976, 98, 420. Rueb, W, et ua, Expertewina, 1976. 32, 529. We'eitzman, A D. Ann7mual R'ei'e-,c o(f Afedicinie, 1976, 27, 225. Bazzarre, T I., et al, in lPryeedinies of the Illrd Inter-
iiatzollal .S'vmp(solm ont (rozo nth Hormone rid Rtlatetd Peptil'o. Mi/an. 1975, ed A IPecile and E F' Muller. Amstcrdam, 1l.xcepta MNdicla, 1976.
Hospital inpatient provision for patients with dementia
SIR,-Dr David Jolley (21 Miav, p 1335) doubts the DHSS plan of 2 5-3-0 beds for elderly demented for every 1000 people over 65 because this estimate is based only on the number of demented patients in mental hospitals in 1971. He also wants to include those in geriatric beds and Part III accommodation, making 5 beds per 1000. But has Dr Jolley included elderly demented patients in the wards of general hospitals ? There are usually two or three in my wards waiting almost indefinitely for transfer.
J H BARON St Charles Hospital,
London %10
Wound sepsis: effect of incidental
appendicectomy SIR,-In a series of 224 patients we found' that removal of a normal appendix together with the gall bladder caused a higher rate of wound sepsis than cholecystectomy alone in patients not protected by cephaloridine. We
I)uLblin Lithium carbonate in schizoaffective states
SIR,-I was interested to read about Dr W W Sargant's use of lithium carbonate in schizoaffective states (4 Junc, p 1470). At this unit there are two outpatients currently attending who suffer from recurring bouts of schizoaffective illncss and for whom the use of lithium carbonate has been found to be of great help. Case 1-An 18-ycar-old male patient who had his first attack at the age of 13. The clinical picture then wvas of very florid and bizarre delusions, with auditory- hallucinations, thought disordcr, and accompanicd by great psychomotor activitv. A diagnosis of schizoplhrenia was made and phenothiazine medication instituted. A further similar florid psvlchotic breakdown occurred tsvo years later. Last car while attcnding this unit and wvhile still on a high level of long-acting phenothiazine mcdication he developed a third attack. It was very interesting to observe how tthe attack developed. H1 became more active, more restless, showed pressure of spccch, and for the nlext 14 days he showved gross irnsomnia. All of thcse features were quite resistant to even high doses of phenothiazines. At the end of this period he showed a typical acute schizophrenic picture sith gross thought disorder, delusions, and hallucinations. Howvever, when put on lithium carboinate he rapidly stabilised, and over thc past eight months continuatitn of lithium carbonate along wvith a small dose of phenothiazines has stabilised him so well that he is now in open emplovment for the first time in his life. Case 2-A 28-vear-old female paticnt who had five rccurring schizoaffective attacks for 11 years resulting in 18 months of hospitalisatioin over this period of time. She toolhad been on a high levcl of long-acting phenothiazine medication, which on
Ollerenshaw, I) PI, Bri'tishJ ural of PsYchiatrr, 1973. 122, 517. Oswald, I. Sleep, 3rd edni. London, Pclican, 1974.
Microsomal enzymes in malnutrition
SIR,-We apologise for commenting so late on the interesting article by Dr K Krishnaswamy and Dr A N Naidu entitled "IMicrosomal enzymes in malnutr-ition as deternilned bv plasma half life of antipvrine," (26 February, p 538), but our personal half life for absorption of the B1A1_ is currently prolonged. We believe that this article, quoted in your recent leading article (21 May, p 1304), is somewhat nisleading. In the summary we read that "the half lifc of antipyrine was modified in undernourished subjects and those with nutritional oedema." In the article, however, it is clearly shown that there is no difference in antipyrine half life between the group of undernourished subjects who were smokers (and exposed to pesticides) and the appropriate control group of smokers. It is not possible to judge whether the half life of antipyrine was modified in those with nutritional oedema as we appear not to be told if this group (group 4) were smokers; the mean half life for group 4 was apparently longer, although no P value was given, than that for the smoking controls (group 2) but no different from that for the non-smoking controls (group 1). Even if the half life of antipyrine were prolonged in patients with nutritional oedema when compared with the appropriate control subjects, this could at least partly result from a
BRITISH MEDICAL JOURNAL
JULY
123
1977
cost of £2 per smear might be reasonable at the present time. Thus a sum of £6000 has been spent, the cytological services have examined 3000 normal smears from an age group where the chances of positive findings are notably low, and little has been achieved. The difficulty is that publicity in women's magazines together with the policy of the Family Planning Association and the Brook Clinics make those who do not do routine smears in young people appear negligent, and it is as quick to take a smear as to explain one's reasons for not doing so. There is a need now for publicity to be given in non-medical magazines to Drs Spriggs and Husain's paper.
screened for a substantial part of the precursor phase before one could expect the mortality rate of the subsequent cancer to decline. The authors of the Walton Report' have shown this to be so in British Columbia, where about 80 '% of the population has now been screened, which probably relates to about 60°` of the total group at risk as these seem to accumulate in the unscreened population. Looking at the age-specific mortality rates of cervical cancer quoted by J G Thomson in his article in Health Trends in 19712 one could see that there was a considerable drop in mortality in women in the 35-44-year age group but in no other. In my lecture to the Marie Curie Foundation in 1975 (in press as a triennial report) I had suggested that this could have been due in part to the screening programme. The more recent figures provided by kind permission of Dr A M Adelstein of the Office of Population Censuses and Surveys (table I) demonstrate this effect even more clearly, with the drop in mortality extending into the 45-54-year age group. The other explanation was, of course, that a lower-risk cohort had emerged over the past few years or that the disease was losing its aggressiveness. Table II does indicate that this drop could be due to cohort differences, but may not explain the whole effect (data kindly supplied by Dr Adelstein). Indeed, there appears to be a younger cohort following up behind in which the rate is rising again, and it is for this reason that, in our recent article, we suggest in our model proposition for a screening schedule that we should take note of any mortality and morbidity trends, especially in view of the changing life style of the young women of today. 0 A N HUSAIN
Anaesthetic waste gas scavenging systems
SIR,-I was very interested to see the letter from Professor L Rendell-Baker and Dr R A Milliken (21 May, p 1348) on the above subject. They came to the same conclusion as we did (19 February, p 507), that an effective scavenging system used without adequate ventilation will not correct pollution problems in operating theatres. We have suggested two additional measures which are necessary to achieve effective control of ambient pollution -that is, regular equipment maintenance with careful anaesthetic techniques to prevent gas leaks and institution of an air monitoring programme to indicate the effectiveness of D G H SYLVESTER these preventive measures. Regular equipment Students' Health Service, University of Bristol maintenance involves frequent testing of pipe lines, anaesthetic machines, ventilators, and scavenging systems for gas-tightness. However, I am surprised by their statement communication the to further SIR,-I write that passive systems are difficult to use since from Dr A I Spriggs and myself (1 1 June, the driving power, the positive force of p 1516) relating to the age and frequency of expiration, and circuit overflow also tend to screening for cervical cancer in order to bring the pollutants into the theatres. This propel of some significance. further out a point has not been our experience. In our study,' we The National Screening Programme, now were able, with the help of a passive scavenging in its 13th year with an annual load of around system and operating room ventilation with an 3 million smears, was originally designed to air exchange rate of 10 times per hour, to five years. 35 once every over women aged test halothane levels to the order of 0-2 ppm. reduce As a result of the open-door policy, the This was achieved irrespective of the type of enthusiasm of the young, and the use of anaesthetic circuit used and gas flows and maternity and family planning clinics in which vapour concentration employed. In our recent to collect the smears 50 , of the tests entering on passive disposal of expired study2 our laboratories are from women under the anaesthetic gases the results showed that the age of 35. This has resulted in the application resistance offered by the conduction channels of about 1-5 million tests to about 6 500 000 and the terminal gas exhaust valve of the passive young women, whereas the other 15 million disposal system was extremely low. It was tests have been spread over nearly 13 000 000 to be 25 Pa at a gas flow rate of 30 1/min. found women with a diminishing frequency as they Provided the various components and joints Cytology Centre, get older. (Figures taken from Registrar Regional St Stephen's Hospital, of the passive scavenging system are gas-tight General's Statistical Review of England and London SWlO there is no reason why it should be less Wales, 1973, Part II.) Walton Medical Association Canadian Report, _Journal, effective than any active system in keeping It would be expected that a substantial 1976, 114, 1003. operating rooms pollution-free. number of women at risk would need to be 2 Thompson, J G, Health Trends, 1971, 3, 24. S MEHTA Department of Anaesthetics, General Hospital, Burnley, Lancs
TABLE I-Deaths from cancer of the cervix uteri Age group (years) Year
1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
2
0-24
25-34
35-44
45-54
55-64
65 and over
All ages
1 3 3 2
31 32 33 27 32 32 32 34 41 46 39 50 68
316 337 330 280 241 226 205 170 184 164 137 122 136
561 627 596 535 628 630 564 566 580 510 542 443 412
570 561 604 599 574 618 607 625 594 604 605 524 597
986
2465 2577 2453 2464 2449 2434 2417 2343 2315 2218 2249
3 3 6 5 2 4 7 5 9
1017 887 1021 971 925 1003 1003 914 890 919
2068 2143
924 921
TABLE II-Cohort mortalitv from carcinoma of the cervix in England and Wales Central date of birth 1881 1886 1891 1896 1901 1906 1911 1916 1921 1926 1931 1936
1941
1946
Death rate (per million) in women aged 25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69 304
285
10 9 5 7 10
30 37 18 15 22
58 74 67 44 38
93 119 134 106 67
136 154 180 176 130
203 181 187 204 190
254 197
178 201 199
246 222
193 199
.284
32.T '217 ~
193
70-74 315 313 2741 24
26'
Mehta, S, et al, Canadian Anaesthetists' Society J'ournal, 1975, 22, 271. Mehta, S, et al, British Journal of Anaesthesia, 1977, 49, 589.
Effect of antihypertensive drugs on growth hormone secretion SIR,-The report by Drs I Lancranjan and P Marbach (4 June, p 1472) on the failure of BS 100-141, a new oc-adrenoceptor agonist, to raise plasma growth hormone (GH) levels in hypertensive patients after both acute and chronic treatment prompts us to report our experience with clonidine, another central c-adrenoceptor agonist which was found to increase GH secretion in young normal male volunteers.' Seven patients aged 40-60 years with moderate hypertension volunteered for the study. There were five men and two women. All patients had discontinued their antihypertensive treatment for at 41aotjwiek,and took no medicatiowilther than clonidine during the study. On the first day clonidine (015 mg diluted in normal saline) was infused intravenously over a 10-min period and blood was drawn for GH radioimmunoassay at 15-min intervals for 90 min. On the following day 0-15 mg of clonidine was administered orally and blood was taken at hourly intervals for 3 h. This test was followed by treatment with clonidine
9
BRITISH MEDICAL JOURNAL
124
0Q15 rug twvice or thrice daily for seven davs blod w as collected every day beforc the morning dosc of the drug and on the fourth and seventh davs blood samples wcre also taken at hourly intervals for 3 h aftcr the first daily dosc of clonidine. No significant increase in serum GH wvas detectcd during the acute studies, though minor elevations occurred in three male subjects after intravenous clonidine (net increase ranging bctwecn 2'3 and 4 3 jig 1) and in tvwo of them aftcr oral administration of the drug (net inicrease 2-4-4-6 [tg 1). During the seven days of treatinent only one man and one woman patient exhibited isolated increases in serum GH concentration of minor magnitude less than 5 tg 1). T hough we have no personal data on the
have analysed a consecutive series of 1 31 patients undergoing elective truncal vagotomv and pvloroplastv for peptic ulcer. All other gastric operations were excluded. Sixty-one patients had vagotomy and pvloroplastv and 70 incidental appendicectomv as well. The primary wound sepsis rates were 3 34 (8 8 respectively in patients and 2 30 (6-71 protected by cephaloridine and 6 27 (22 2",) and 10 40 (250",) in the others. There are no significant differences between the rates with and without appendicectomV. A V POLLOCK MARY EVANS
JULY 197,
its ow-n had failcd utterly to prevent relapses. whiich, wvhen they occurred, always prcscntcd clinicallv with excitemcnt, ideas of refcrence, thouglht disorder, dclusions, and hallucinations. Hcr last attack was uishered in by an acceleration of psychomotor activity accompanicd by a severe insomnia state. After abotut 10 days she then began to express delusions of a religious and paranoid nature, showed ideas of reference, and had auditory hallucinations. In this state she too was quite unresponsive to phcnothiazines. Howevcr, response to lithium carbonate syas both rapid and sustained, and her progress in the nine months since then has been surprisingly- good. She is rapidly discarding hcr "chronic patient" image and, as her parents report, "is rcturning to her old self."
Scarborough Hospital. effects of x-adrenoceptor agonists on GH Scarboroug2h secretion in normal subjects, Lal et a1,' using Pollock, A V, and 1.Evans, .\1. 1Brzitsh MedlLca! 7journal. clonidine, and Drs L ancranjan and M\tarbach, 1977, 1, 20. using BS 100-141, found that they caused an increase in serum GH levels in healthv male volunteers. Clonidine was also found to stimulate GH secretion in adult male rhesus Use of ritodrine ir. pregnant diabetics monkeys2 and rats.' Though aging has been associated with reduced spontaneous and SIR,-F01l0lwing several reports of the successstimulateu GH release,' i Drs Lancranjan and ful use of ritodrine in pregnant women the Marbach found no increase in plasma GH data sheet for ritodrine has been altered as levels in young hypertensive patients under Dr C J Chandler suggests ('30 April, p 1159). chroiic treatment with BS 100-141. Thereforc It will now read as follows: the possibility cannot be excluded that the failure of x-adrenoceptor agonists to stimulate P1 rcalcti(ws GH secretion in hypertensive subjects might 'Paragraph 2, Although glucose and insulin be due to some alteration in Y-adrenoceptors profiles in normal pregnant women have been associated with the hypertensive state. shown in controlled clinical trials not to alter under Yutopar therapy, it is recommended CARLO FERRARI that in the diabetic patient monitoring of GIAMI'AOLo T1STORI glucose levels be undertaken.
ROBERTO CALDARA CRISTIANo BARBIERI
)uphlar I.ahoratries Ltd. Southampton
2nd Dcpartment of Medicine.
Fatebentfratelli Hospital. Milan, Italy
The above cases are interesting for two reasons. One is the diagnostic one: schizoaffectiv-e illness is a definite clinical entity containing as it does features common to both schizophrenic and affective states. However, it is important to make the diagnosis accurately as otherwise the patient will usually be classified as schizophrenic and will therefore receiVe inadequate medication. In this regard there is a lot to be said for Ollerenshaw's1 recommendation that acute schizophrenia should be regarded as simply a variant of the manic phase of manic-depressiv-e illness. Secondly, and more intriguingly, what exactly is the role of sleep deprivation in these states ? Could, for instance, severe sleep loss, as in the above twro cases, be the missing ingredient which converts a manic state into an acute schizophrenic one? The role of sleep deprivation in producing psychiatric sy'mptoms is not fully clear,2 but the kind of sleep loss in a manic state must surelv be very considerable and perhaps T C G SMITH nearer to being a total sleep loss state than that Medical dircctor produced experimentally. A
J MCGINNIS
St John's Day Centre,
I al, S, er al, 7our7iat of (linicatl E,idocrzi7tioo! and Aletaboism,i, 1975, 41, 827. Chbambers, J W, and Brown, G; M, Emldsrioltogy, 1976, 98, 420. Rueb, W, et ua, Expertewina, 1976. 32, 529. We'eitzman, A D. Ann7mual R'ei'e-,c o(f Afedicinie, 1976, 27, 225. Bazzarre, T I., et al, in lPryeedinies of the Illrd Inter-
iiatzollal .S'vmp(solm ont (rozo nth Hormone rid Rtlatetd Peptil'o. Mi/an. 1975, ed A IPecile and E F' Muller. Amstcrdam, 1l.xcepta MNdicla, 1976.
Hospital inpatient provision for patients with dementia
SIR,-Dr David Jolley (21 Miav, p 1335) doubts the DHSS plan of 2 5-3-0 beds for elderly demented for every 1000 people over 65 because this estimate is based only on the number of demented patients in mental hospitals in 1971. He also wants to include those in geriatric beds and Part III accommodation, making 5 beds per 1000. But has Dr Jolley included elderly demented patients in the wards of general hospitals ? There are usually two or three in my wards waiting almost indefinitely for transfer.
J H BARON St Charles Hospital,
London %10
Wound sepsis: effect of incidental
appendicectomy SIR,-In a series of 224 patients we found' that removal of a normal appendix together with the gall bladder caused a higher rate of wound sepsis than cholecystectomy alone in patients not protected by cephaloridine. We
I)uLblin Lithium carbonate in schizoaffective states
SIR,-I was interested to read about Dr W W Sargant's use of lithium carbonate in schizoaffective states (4 Junc, p 1470). At this unit there are two outpatients currently attending who suffer from recurring bouts of schizoaffective illncss and for whom the use of lithium carbonate has been found to be of great help. Case 1-An 18-ycar-old male patient who had his first attack at the age of 13. The clinical picture then wvas of very florid and bizarre delusions, with auditory- hallucinations, thought disordcr, and accompanicd by great psychomotor activitv. A diagnosis of schizoplhrenia was made and phenothiazine medication instituted. A further similar florid psvlchotic breakdown occurred tsvo years later. Last car while attcnding this unit and wvhile still on a high level of long-acting phenothiazine mcdication he developed a third attack. It was very interesting to observe how tthe attack developed. H1 became more active, more restless, showed pressure of spccch, and for the nlext 14 days he showved gross irnsomnia. All of thcse features were quite resistant to even high doses of phenothiazines. At the end of this period he showed a typical acute schizophrenic picture sith gross thought disorder, delusions, and hallucinations. Howvever, when put on lithium carboinate he rapidly stabilised, and over thc past eight months continuatitn of lithium carbonate along wvith a small dose of phenothiazines has stabilised him so well that he is now in open emplovment for the first time in his life. Case 2-A 28-vear-old female paticnt who had five rccurring schizoaffective attacks for 11 years resulting in 18 months of hospitalisatioin over this period of time. She toolhad been on a high levcl of long-acting phenothiazine medication, which on
Ollerenshaw, I) PI, Bri'tishJ ural of PsYchiatrr, 1973. 122, 517. Oswald, I. Sleep, 3rd edni. London, Pclican, 1974.
Microsomal enzymes in malnutrition
SIR,-We apologise for commenting so late on the interesting article by Dr K Krishnaswamy and Dr A N Naidu entitled "IMicrosomal enzymes in malnutr-ition as deternilned bv plasma half life of antipvrine," (26 February, p 538), but our personal half life for absorption of the B1A1_ is currently prolonged. We believe that this article, quoted in your recent leading article (21 May, p 1304), is somewhat nisleading. In the summary we read that "the half lifc of antipyrine was modified in undernourished subjects and those with nutritional oedema." In the article, however, it is clearly shown that there is no difference in antipyrine half life between the group of undernourished subjects who were smokers (and exposed to pesticides) and the appropriate control group of smokers. It is not possible to judge whether the half life of antipyrine was modified in those with nutritional oedema as we appear not to be told if this group (group 4) were smokers; the mean half life for group 4 was apparently longer, although no P value was given, than that for the smoking controls (group 2) but no different from that for the non-smoking controls (group 1). Even if the half life of antipyrine were prolonged in patients with nutritional oedema when compared with the appropriate control subjects, this could at least partly result from a
