the CHFT equation predicted a mean of 32.0 (±4.7) ml/kg.min. One-way analysis of variance revealed no significant difference at the 0.01 level between the measured and CHFT-predicted Vo2 max. However, the mean difference between the predicted Vo2 max from the Astrand-Ryhming procedure and the measured Vo, max was significant at the 0.01 level. In this limited number of subjects the CHFT equation provided a more accurate prediction of Vo2 max than the AstrandRyhming procedure. MAURICE JETTE, PH D Department of kinanthropology School of human kinetics and leisure studies University of Ottawa Ottawa, ON

Adverse interaction of lithium carbonate and methyldopa To the editor: The following adverse interaction occurred between two drugs that are being used with increasing frequency - lithium carbonate and methyldopa. A 42-year-old woman complained on May 3 of shakiness, swelling of the feet and soreness of the mouth. She was ataxic and her speech was slurred. These symptoms had been developing for about 2 or 3 weeks but had not begun until after methyldopa therapy for hypertension had been begun by her family physician. She had had five admissions to a psychiatric ward since 1960 in both the manic and the depressed phase of a manicdepressive psychosis and had come under my care in April 1974. Therapy with lithium carbonate had been started in August 1973. I had been seeing her every 3 months and her serum lithium values had remained within the therapeutic range for the most part; she had had a low value of 0.4 mmol/l once and a high value of 1.1 mmol/l in October 1975. I discontinued all her drugs. The serum lithium value was 1.5 mmol/I on May 5, 0.4 mmol/l on May 10 and 0.1 mmol/l on May 14, when she felt much better and there was no ataxia or tremor, though her speech was still slurred. On May 21 there were no signs of any remaining toxic effects. It is possible that the methyldopa produced a slowing of the rate of renal excretion of lithium carbonate, thus giving rise to high serum concentrations of lithium and the toxic symptoms. These symptoms continued when the lithium serum value was quite low, as was true in a previously reported case.1 Since internists and family practitioners are likely to be the physicians prescribing methyldopa when a patient is already taking lithium carbonate, they should be aware of this dangerous and possibly lethal interaction. It may be wise not to prescribe methyldopa for a patient who is taking lithium

The otitis drop designed to penetrate wax.

oolvmvoin otlo The only otic with thonzonium bromide to help the active ingredients get right to the site of infection - even through cerumen and debris. DESTROYS COMMON PATH 0GENS - Provides the broad-spectrum bactericidal actions of colistin sulphate and neomycin sulphate. REDUCES SWELLING, RELIEVES ITCHING -Also contains the proven benefits of hydrocortisone acetate. Composition: Each ml. contains - colistin base activity 3.0 mg. (as the sulphate); neomycin base activity 3.3 mg. (as the sulphate); hydrocortisone acetate 10.0 mg.; thonzonium bromide 0.5 mg. Dosage: Instil 4 drops b.i.d. Precautions: If sensitivity or irritation occurs, medication should be discontinued promptly. Overgrowth of resistant organisms is possible. Use with care in cases

with perforated eardrum or in long standing otitis media because of the possibility of ototoxicity caused by neomycin. Contraindications: COLY-MYCIN OTIC' is contraindicated if there is a history of sensitivity to any of its components, or in tubercular, fungal, and most viral lesions, especially herpes simplex, vaccinia and varicella. Supplied: 5 ml. bottles. Full information is avaliable on request.

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CMA JOURNAL/SEPTEMBER 4, 1976/VOL. 115 385

carbonate until more is known about this interaction. J.B. O'REGAN, MD, FRcP[c] 803 CN Towers Saskatoon, SK

Reference 1. Bmn GJ: Methyldopa and lithium carbonate: suspected interaction. JAMA 233: 320, 1975

Locked wards in Canadian mental hospitals To the editor: I was dismayed on several counts at your publication of the misleading polemic "Locked wards in Canadian mental hospitals: the return to custodialism" by Dr. G. Voineskos (Can Med Assoc J 114: 689, 1976). The data Dr. Voineskos has gathered are interesting. The reasons given for locked wards and the advantages and disadvantages cited by medical directors seem reasonable. However, instead of examining critically the uses of locked wards, Dr. Voineskos concludes that all wards should be opened and that progress has been slow in achieving that end. The only possible justification for such a conclusion that I can find in the report is the extremely doubtful (indeed, probably incorrect) assertion that the mentally ill who are in our public mental hospitals do not exhibit more violent behaviour than the general population. Whether violent behaviour is more common in the mentally ill is irrelevant. What counts is how best to identify the violent ones and how best to design our hospital care so that only the patients for whom the advantages outweigh the disadvantages are confined. Dr. Voineskos may believe there are no such patients, but there are no data in the report that bear on the question. Another disturbing feature of the article is the surreptitious introduction of the author's bias by the use of such tricks as always pairing "custodial" and "antitherapeutic" in the text, describing a minister's opinion that agrees with his own as "courageous", and substituting "custodial" and "harsh restrictions" for closed, and "enlightened therapeutic freedom" for open. This game was even indulged in by your cover artist, who showed a girl made lonely and subdued (my wife's interpretation) by the awful set of keys. Such imprecise use of words and introduction of pejorative terms have no place in the scientific section of the Journal. They serve only to arouse passions and obscure the real issues in the locked ward debates. They also give rise to false impressions of psychiatrists like me who believe that locked doors are therapeutic for some patients and that the protection of society from violent patients is a legitimate function of my

HALOG CREAM

profession. I assure you I am gentle, 0.1% not harsh; enlightened, not unenlight- Helcinonlde Cream (halcinonide, 0.1%) is intended for use ened; and I use every tool I can find Halog as an anti-inflammatory a9ent for topical application. Halog Cream, 0.1%, provides 0.1% halcinonide, in a to help my patients. form ulated water-washable base consisting of Finally, I take issue with the con- specially .Iycerylmonostearate, cetyl alcohol, myristyl stearate, isopropyl palmitate, polysorbate 60, and propylene clusion implicit in the title "the return to custodialism". According to Dr. glycol. ACTION: Halog Cream, 0.1%,produces significant or Voineskos' data, the percentage of complete therapeutic responses in patients with acute locked wards has decreased from 46% or chronic corticosteroid-responsive dermatoses. INDICATIONS: Halog Cream, 0.1%, is indicated for in 1961 to 35% in 1975. Taking into topical application for relief of the many acute or account the drastic reduction in mental chronic corticosteroid-responsive dermatoses. hospital population over that period, CONTRNNDICATIONS: Turberculous, fungal and viral lesions of the skin (including herpes simplex, the percentage of the population con- most vaccinia and varicella). fined in our hospitals in 1975 must be Haiog Cream is not intended for use in the eye nor in external auditory canal of patients with perforated less than one fourth of the percentage the in 1961. Is that a return to custodial- eardrums. WARNINGS: Systemic side effects may occur and ism? What are needed now are not must be kept in mind particularly during use over large or for an extended period of time. Occasionally, more well meant, fuzzy generalizations, areas symptoms of steroid withdrawal may deveiop when the there but careful assessments of whether medication is stopped after proionged use. is a beneficial use of locked doors for Pregnancy: Safety has not been established. Potential should be weighed against possible hazard. specific patient groups at specific benefit PRECAUTIONS: If local infection (other than those stages of their illnesses. Perhaps it will cited in CONTRAINDICATIONS) exists, suitable conbe found that practitioners advocating comitant antimicrobial therapy should be administered. If a favourable does not occur promptiy, apa total open-door policy are handling plication of the response corticosteroid should be discontinued some of their patients badly. Are some until the infection is adequately controlled by appropatients not even referred to such hos- Irlocal irritation or sensitization deveiops, haicinonide pitals because the hospitals are not cream should be discontinued. Occlusive Dressing Technique: The use of occlusive prepared to treat them? P.D. GATFIELD, MD St. Thomas Psychiatric Hospital St. Thomas, ON

dressings increases the percutaneous absorption of corticosterolds and the possibility of systemic effects. For patients with extensive lesions it may be preferable to use a sequential approach. The patient should be kept under close observation during proionged occlusive therapy. Thermal homeostasis may be impaired if large areas of the body are occluded. Occasionally, a patient may deveiop a sensitivity reaction to a particular occlusive dressing material or adhesive. If infection deveiope, discontinue the use of the occlusive dressings and institute appropriate antimicrobial therapy. ADVERSE REACTIONS: Significant local irritation is uncommon; a transient burning sensation may occur in some patients. The use of corticosteroids under ccclusive dressings is known to produce miliaria, folliculitis, pyoderma, or localized cutaneous atrophy; striae occasionally deveiop. Erythema, dryness, itching and change in skin pigmentation have been reported with topical sterolds.

To the edit'or: Dr. Gatfield has attributed to me statements that are erroneous. For instance, he states that "according to Dr. Voineskos' data, the percentage of locked wards has decreased from 46% in 1961 to 35% in 1975". Nowhere in my paper is it stated that the percentage of locked wards in 1961 was 46%. What is stated is that Wake reported that 46% of the wards "were classified as 'open' ". Furthermore, Dr. Gatfield's deduction that, in view of SYMPTOMS AND TREATMENT OFOVERDOSAGE: the drastic reduction in mental hospital Mild, reversible suppression of adrenal function, of the skin, peptic ulceration, hypertenpopulation between 1961 .nd 1975, ecchymoses aggravation of infection, hirsutism, acne, edema there must be a proportionate reduction sion, and muscle weakness due to protein depletion are all in the percentage of patients in locked toxic symptoms of corticosteroids. Animal studies sugthat overdosage may result in swollen breasts or wards does not stand to reason. Per- gest Factation. Treatment is symptomatic; corticosterold haps what Dr. Gatfield meant was a administration should be discontinued. reduction in the absolute numbers of DOSAGE AND ADMINISTRATION: Usual adult dosage range: 2to 3 applications daly. patients in locked wards. The percent- Occlusive Dressing Technique: Gently rub a small ages remain unaffected by the overall amount of the Halog Cream, 0.1%, into the lesion until the cream disappears. Then re-apply the cream, leavreduction of the population. a thin coating on the lesion and cover with a pliable Dr. Gatfield seems to have missed ing non-porous film. Good results have been obtained by applying Haiog Cream, 0.1%, under occlusion in the implicit that the conclusion the point and reapplying Haiog Cream, 0.1%, without in the title "the return to custodialism" evening occlusion in the moming (i.e. - 12-hour occlusion). was not based simply on the figures for Reapplication of the preparation is essential at each dressing the existing locked wards. It was based DOSAGEchange. Haiog Cream is supplied as cream on our chief clinicians' predictions for formulationFORMS: contalning 0.1% halcinonide, in tubes of the next decade and primarily on the 15, 30 and 60 g. STORAGE: Store at room temperature. Avoid freezexpectations and pressures of society, ing. Avoid prolonged storage at temperatures exceedchannelled through the political and ing 300C. judicial systems, to lock up patients Product monograph available to physicians and pharmacists on request. and wards. 1. Data on file, Squibb Institute of Dr. Gatfield objects to what he calls References: Medical Research. 2. Sudilovsky A, Clewe TH: "pairing 'custodial' and antitherapeu- J CNn Pharmacol 15:779-784, 1975.3, Clark RF, tic'" and "substituting 'custodial' and Clement ER:Arch Dermatol 111:731-733, 1975. 'harsh restrictions' for closed", and so E R.SQUIBB& SONS LTD. on. On this point he would, of course, I2ED 2365 COTE DE LIESSE, MONTREAL, QUE. H4N 2M7 chief have to take issue firstly with our

386 CMA JOURNAL/SEPTEMBER 4, 1976/VOL. 115