870 additional social remission were good ".1 The patients we are reporting had a mean age of 31 years, average duration of illness of 13 years, and mean hospital stay of 8 years. All were men and were diagnosed as chronic undifferentiated schizophrenia. Off medication they were bizarre, autistic, and hallucinated. On medication they were under considerably better social control but showed the usual hallmarks of having severe chronic process schizophrenic illness. Our patients must be regarded as significantly more ill than those in the other report. Our clinical results do not give any encouragement for further study of a similar population of chronic schizophrenics, but it does remain possible that there might be some individuals carrying this diagnosis who would be particularly responsive to exogenous T.R.H. In this vein it has been shown in a number of studies that T.R.H. is ineffective in depressed patients as a group.6-8 The positive and reproducible result found by van der VisMelsonin a case of depression with possible organic features as well as the case-report of tranquillisation in a 15-year-old boy with cerebral gigantism and explosive behaviour 10 should stimulate further work on a possible role of T.R.H. in maintaining behavioural homceostasis.
There are many letters from those who anticipate the worst when SI units are introduced, but a dearth of letters from those with first-hand experience of the change. As consultants in a laboratory which adopted SI units over seven months ago, we feel that the problems have been exaggerated. Admittedly the unfamiliar figures have involved more work, and it will take many more months before we are totally conversant with the system, especially for the less common tests; but the costs have been negligible, there have been no serious problems or complaints, and the clinical staff have been most cooperative. It would be unrealistic to claim many benefits of the change, though eventually these should come with greater uniformity, Here and now there are some advantages. For example, acidbase disorders are easier to comprehend in term of hydrogenion concentration than in the inverse logarithmic pH system; in hyperosmolar coma moles are much easier to comprehend than mass. Many laboratories like our own have been stimulated into trying to make reports more informative-for instance, by including preprinted reference values. Hopefully the inconvenience of unfamiliar values might lead to greater discrimination in requesting laboratory work, and more thought about the meaning of the results.
Addendum. Davis et al. (Davis, K. E., Hollister, L. E., Berger, P. A. Am. y. Psychiat. 1975, 132, 951), have just reported that seven of nine male chronic schizophrenic patients deteriorated while receiving oral T.R.H. The other two patients improved somewhat, but these changes were not ascribed to the medication.
A. M. BOLD P. WILDING
Laboratory of Clinical LLEWELLYN B. BIGELOW Psychopharmacology, National Institute of Mental Health? J. CHRISTIAN GILLIN Saint Elizabeth’s Hospital, CHARLES SEMAL Wm. A. White Building, Washington, D.C. 20032, U.S.A RICHARD J. WYATT SI UNITS
Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Edgbaston, Birmingham B15 2TH.
RELIEF OF MYOCLONUS BY L-TRYPTOPHAN
SIR,-Last year Van Woert and Sethyand Chadwick
reported relief of post-anoxic myoclonus3 by L-5-hydroxytryptophan (L-5-H.T.P.), the immediate preWe observed in 2 cases a cursor of serotonin (5-H.T.).
et
al.
similar beneficial effect with L-5-H.T.P. In addition both patients were improved by L-tryptophan, the parent compound in the biosynthesis of 5-H.T. man was examined 9 months after a his chest which restricted his respiratory movements for 10 minutes. He emerged from the initial state of coma and convulsions with persistent completely disabling action myoclonus and mild cerebellar signs. There were involuntary jerks of trunk and limbs activated by willed movements. Case 2.-A 72-year-old woman had had a respiratory arrest following intoxication with barbiturates. Her neurological condition 27 months after the anoxic incident resembled that in case 1.
Case l.-A
crush
SIR,-Professor Alberti (Oct. 25, p. 820) writes of "the joy that SI has brought to the clinical biochemist". Perhaps such a serious topic needs the injection of a little humour and irony. Unfortunately some of the published letters on SI units are
downright misleading. Whether the introduction of SI units in their present form into clinical medicine is on balance a good idea is a matter of opinion. The amount of consultation that took place before a decision to introduce these was made is a matter of fact. Clark and Sheldon (Oct. 11, p. 700), in a statement typical of many, assert that the recommendations on SI units were drawn up "without consultation, discussion, approval, or consent" (i.e., by clinicians). We were not members of the working-party on SI units, but we are led to believe this is not true and that after the working-party representing scientific bodies had drafted their recommendations, the D.H.S.S. consulted user organisations, including the clinical Royal Colleges. Only after approval had been given and comments noted was it decided to recommend the introduction of SI units. Detailed proposals were published over a year ago in the Journal of Clinical Pathology and articles on SI units have since appeared in many other journals. Initial apathy about SI units, presumably in the hope that they would go away, is followed by a late waking up to the implications. It is fashionable to blame the D.H.S.S. for everything we don’t like; in this instance it would be more appropriate for any dissatisfied clinicians to direct their fire at their representatives. 5. Mountjoy, C. Q., Price, J. S., Weller, M., Hunter, P., Hall, R., Dewar, J. H. ibid. 1974, i, 958. 6. Coppen, A., Peet, M., Montgomery, S., Bailey, J., Marks, V., Woods, P. ibid. 1974, ii, 433. 7. Hollister, L. E., Berger, P., Floradell, L. O., Arnold, R. C., Johnson, A. Archs gen. Psychiat. 1974, 31, 468. 8. Benkert, O., Martschke, D., Gordon, A. Lancet, 1974, ii, 1146. 9. van der Vis-Melson, M. J. E., Wiener, J. D. ibid. 1972, ii, 1415. 10. Tiwary, C. M., Frias, J. L., Rosenbloom, A. L. ibid. p. 1086.
injury
In each
suspension of methylcellulose and water L-tryptophan per 15 ml. was prepared administered orally at the level of 10 g. daily in five
containing and
64-year-old
to
case a
1 g. of
divided doses. The beneficial effect was moderate and was reversed by substitution of placebo. In contrast to L-5-H.T.P., administration of L-tryptophan represents a more specific means of increasing brainserotonin levels selectively in the serotonergic neurons. This is so because the enzyme which transforms L-tryptophan to serotonin, the rate-limiting L-tryptophan hydroxylase, is localised specifically in serotonin neurons in the brain. Thus, it has been demonstrated that, following parenteral administration of L-tryptophan in laboratory animals, (a) there is a several-fold increase in brain-serotonin levels,4 (b) the pattern of the increased serotonin levels parallels the normal pattern of serotonin distribution,’ and (c) the concentrations of brain tyrosine, dopamine, and homovanillic acid are not significantly different from normal values.6 In the light of these data, the beneficial effect of oral L-tryptophan 10 g. daily, as observed in our 2 cases, can be 1. Van Woert, M. H., Sethy, V. H. Lancet 1974, i, 1285. 2. Chadwick, D., Reynolds, E. H., Marsden, C. D. ibid. 1974, ii, 111, 3. Lance, J. W., Adams, R. D. Brain 1963, 86, III. 4. Moir, A. T. B., Eccleston, D. J. Neurochemistry, 1968, 15, 1093. 5. Moir, A. T. B. Br. J. Pharmac. 1971, 43, 715. 6. Moir, A. T. B. ibid. p. 724.
There are many letters from those who anticipate the worst when SI units are introduced, but a dearth of letters from those with first-hand experience of the change. As consultants in a laboratory which adopted SI units over seven months ago, we feel that the problems have been exaggerated. Admittedly the unfamiliar figures have involved more work, and it will take many more months before we are totally conversant with the system, especially for the less common tests; but the costs have been negligible, there have been no serious problems or complaints, and the clinical staff have been most cooperative. It would be unrealistic to claim many benefits of the change, though eventually these should come with greater uniformity, Here and now there are some advantages. For example, acidbase disorders are easier to comprehend in term of hydrogenion concentration than in the inverse logarithmic pH system; in hyperosmolar coma moles are much easier to comprehend than mass. Many laboratories like our own have been stimulated into trying to make reports more informative-for instance, by including preprinted reference values. Hopefully the inconvenience of unfamiliar values might lead to greater discrimination in requesting laboratory work, and more thought about the meaning of the results.
Addendum. Davis et al. (Davis, K. E., Hollister, L. E., Berger, P. A. Am. y. Psychiat. 1975, 132, 951), have just reported that seven of nine male chronic schizophrenic patients deteriorated while receiving oral T.R.H. The other two patients improved somewhat, but these changes were not ascribed to the medication.
A. M. BOLD P. WILDING
Laboratory of Clinical LLEWELLYN B. BIGELOW Psychopharmacology, National Institute of Mental Health? J. CHRISTIAN GILLIN Saint Elizabeth’s Hospital, CHARLES SEMAL Wm. A. White Building, Washington, D.C. 20032, U.S.A RICHARD J. WYATT SI UNITS
Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Edgbaston, Birmingham B15 2TH.
RELIEF OF MYOCLONUS BY L-TRYPTOPHAN
SIR,-Last year Van Woert and Sethyand Chadwick
reported relief of post-anoxic myoclonus3 by L-5-hydroxytryptophan (L-5-H.T.P.), the immediate preWe observed in 2 cases a cursor of serotonin (5-H.T.).
et
al.
similar beneficial effect with L-5-H.T.P. In addition both patients were improved by L-tryptophan, the parent compound in the biosynthesis of 5-H.T. man was examined 9 months after a his chest which restricted his respiratory movements for 10 minutes. He emerged from the initial state of coma and convulsions with persistent completely disabling action myoclonus and mild cerebellar signs. There were involuntary jerks of trunk and limbs activated by willed movements. Case 2.-A 72-year-old woman had had a respiratory arrest following intoxication with barbiturates. Her neurological condition 27 months after the anoxic incident resembled that in case 1.
Case l.-A
crush
SIR,-Professor Alberti (Oct. 25, p. 820) writes of "the joy that SI has brought to the clinical biochemist". Perhaps such a serious topic needs the injection of a little humour and irony. Unfortunately some of the published letters on SI units are
downright misleading. Whether the introduction of SI units in their present form into clinical medicine is on balance a good idea is a matter of opinion. The amount of consultation that took place before a decision to introduce these was made is a matter of fact. Clark and Sheldon (Oct. 11, p. 700), in a statement typical of many, assert that the recommendations on SI units were drawn up "without consultation, discussion, approval, or consent" (i.e., by clinicians). We were not members of the working-party on SI units, but we are led to believe this is not true and that after the working-party representing scientific bodies had drafted their recommendations, the D.H.S.S. consulted user organisations, including the clinical Royal Colleges. Only after approval had been given and comments noted was it decided to recommend the introduction of SI units. Detailed proposals were published over a year ago in the Journal of Clinical Pathology and articles on SI units have since appeared in many other journals. Initial apathy about SI units, presumably in the hope that they would go away, is followed by a late waking up to the implications. It is fashionable to blame the D.H.S.S. for everything we don’t like; in this instance it would be more appropriate for any dissatisfied clinicians to direct their fire at their representatives. 5. Mountjoy, C. Q., Price, J. S., Weller, M., Hunter, P., Hall, R., Dewar, J. H. ibid. 1974, i, 958. 6. Coppen, A., Peet, M., Montgomery, S., Bailey, J., Marks, V., Woods, P. ibid. 1974, ii, 433. 7. Hollister, L. E., Berger, P., Floradell, L. O., Arnold, R. C., Johnson, A. Archs gen. Psychiat. 1974, 31, 468. 8. Benkert, O., Martschke, D., Gordon, A. Lancet, 1974, ii, 1146. 9. van der Vis-Melson, M. J. E., Wiener, J. D. ibid. 1972, ii, 1415. 10. Tiwary, C. M., Frias, J. L., Rosenbloom, A. L. ibid. p. 1086.
injury
In each
suspension of methylcellulose and water L-tryptophan per 15 ml. was prepared administered orally at the level of 10 g. daily in five
containing and
64-year-old
to
case a
1 g. of
divided doses. The beneficial effect was moderate and was reversed by substitution of placebo. In contrast to L-5-H.T.P., administration of L-tryptophan represents a more specific means of increasing brainserotonin levels selectively in the serotonergic neurons. This is so because the enzyme which transforms L-tryptophan to serotonin, the rate-limiting L-tryptophan hydroxylase, is localised specifically in serotonin neurons in the brain. Thus, it has been demonstrated that, following parenteral administration of L-tryptophan in laboratory animals, (a) there is a several-fold increase in brain-serotonin levels,4 (b) the pattern of the increased serotonin levels parallels the normal pattern of serotonin distribution,’ and (c) the concentrations of brain tyrosine, dopamine, and homovanillic acid are not significantly different from normal values.6 In the light of these data, the beneficial effect of oral L-tryptophan 10 g. daily, as observed in our 2 cases, can be 1. Van Woert, M. H., Sethy, V. H. Lancet 1974, i, 1285. 2. Chadwick, D., Reynolds, E. H., Marsden, C. D. ibid. 1974, ii, 111, 3. Lance, J. W., Adams, R. D. Brain 1963, 86, III. 4. Moir, A. T. B., Eccleston, D. J. Neurochemistry, 1968, 15, 1093. 5. Moir, A. T. B. Br. J. Pharmac. 1971, 43, 715. 6. Moir, A. T. B. ibid. p. 724.
