ORIGINAL ARTICLES
`
`Prognosis After Head Iniury Based on Early Clinical Exam - ‘ i'
`J m Overgaard, M.D., Steen Christensen, M.D., Jens Haase, M.D., Ole Hein, M.D.,
`1e Hvid-Hansen, M.D., Anne-Marie Land, M.D., K. K. Pedersen, M.D.,
`W. A. Tweed, M.D.
`
`Ketotic Hyperosmolar Coma
`Prof. Milford Fulop, M.D., Hyman Tannenbaum, M.D., Neil Dreyer, M.D.
`
`Relative Importance of Specific Dynamic Action in Weight-reduction
`Diets
`Prof. R. B. Bradfield, M.D., M. H. Jourdan
`
`A Testosterone-secreting Tumour of the Adrenal Producing Virilisation
`in a Female Infant
`I. M. Burr, M.R.A.C.P., J. Sullivan, n.sc., T. Graham, M.D., W. H. Hartman, M.D.,
`J. O’Neill, M.D.
`Raised Plasma-T.S.H. Levels in Thyrotoxic Patients Treated with
`Iodine-131
`A. D. Toft, M.R.c.p., E. W. Barnes, M.R.C.P., W. H. Hunter, PH.D., J. Seth, PH.D.,
`W. J. Irvine, r.n.c.r.r.
`
`644
`
`675
`
`676
`
`679
`
`679
`
`680
`680
`
`632
`
`682
`
`683
`
`
`
`Lymphocyte Sensitisation in Myasthenia
`Gravis: Function of the Adult Thymus
`Gland
`Prof. E. J. Field, P.R.C.P., and others
`Suppression of Lymphocyte Transfor-
`mation by Salicylatea
`C. Loveday, V. Eisen; Prof. W. Schneider,
`M.D., and others
`677
`Diagnosis of Bacterial Meningitis
`Dr N. Buchanan
`677
`Vitamin C and Fertility
`Dr M. H. Briggs
`678
`Detection of Gluten in Flour
`Dr J. W. Keyser, Prof. R. F. Mahler, r.n.c.r.
`Epidemiological Treatment of
`Gonorrhea
`678
`Dr A. Z. Meheus
`Partial Lipodystroph
`and Hypocomple-
`mentmmic Nephri a
`Dr R. A. Thompson, Dr R. H. R. White
`Glomerulitis in Dermatitis
`Her etiformis
`Dr
`. E. DeCoteau and others
`Withdrawal Symptoms in Neonates
`Associated with Maternal Imipramine
`Thera y
`Dr E.
`ggermont
`Hereditary Angioneurotic (Edema
`Dr D. Brackertz, Dr F. Kueppets
`Treatment of Respiratory-distress
`680
`Syndrome
`Dr T. H. Macdonald
`681
`Overdose of Salbutamol
`Dr G. W. Morrison, Dr M. J. B. Farebrother
`Distribution of Clioquinol in Rats with
`Hepatic Dysfunction
`681
`Dr Shosuke Wannabe and others
`Bacteroides Infections
`682
`Dr A. A. B. Mitchell,Mr R. G. Simpson, r.R.c.s.
`Government Wanting on Cigarette
`Packages
`Prof. P. R. J. Burch, PH.D.
`Mineralocorticoids and Rectal Potential
`Difi'erence
`Dr D. G. Beevers
`“ Delayed Menstruation " Induced by
`Prostaglandin in Pregnant Patients
`Dr P. Mocsary, Prof. A. I. Csapo, M.D.
`Lymphocyte Response after Radio-
`therapy
`Dr Iudxth Braeman
`Cephalosporins ‘
`Dr Enrique Macros
`Hun
`on's Chorea, Lithium, and
`684
`G.A.
`.A.
`Dr Bengt Mattsson, Dr Sven-Ake Persson
`Antidiuretic Action of Chlorpropamide 684
`Dr Vecihi Batumsn
`
`REVIEWS
`Notices of Books
`
`OCCASIONAL SURVEY
`Epile sy After Head Injury
`Prof.
`ryan Jennett, F.R.C.S.,
`Derek Teather, M.sc.,
`Susan Bennie, B.sc.
`Caveat to Protein Replacement
`Therapy for Genetic Disease
`Prof. S. H. Boyer, M.D.,
`D. C. Siggers, M.R.C.P.,
`L. J. Krueger, an.
`
`PUBLIC HEALTH
`Duration of Immunity after
`Tetanus Vaccination
`Prof. A. R. Meira, M.D.
`Echovirus-17 Infections in
`Britain 1969—71
`R. J. C. Hart, M.R.C.PA'1'H.,
`D. L. Miller, F.F.C.M.
`
`IN ENGLAND NOW
`A Running Commentary by
`Peripatetic Correspondents
`
`TALKING POLITICS
`Single-parent Families
`
`OBITUARY
`John Maurice Hardman Campbell
`Charles Sydney Douglas Don
`
`NOTES AND NEWS
`After 75 years
`Down to Earth
`Following Shaw
`Child-proof Containers
`
`665
`
`684
`685
`
`685
`686
`686
`686
`
`Epidemiology of Hodgkin’s
`Disease
`Treatment of Hemophilia
`Alcoholism
`Beta—blockade for Withdrawal
`Symptoms P
`Nephroblastoma: an Index
`Reference Cancer
`
`LETTERS TO THE EDITOR
`The Conference of Royal Colleges and
`666
`Faculties in Scotland
`Dr I. Halliday Croom, and others
`666
`Dialysis and Lead Absorption
`Miss Jeanette Blomfield, M.sc.
`Electra-acupuncture and Pain Threshold 667
`Mr Jim Mumford, r.o.s., Dr David Bowsher
`Bell’s Palsy in Pregnancy
`667
`Dr I. D. O’Donovan
`The New N.I-I.S. Consultant Contract
`667
`Dr G. R. Fearnley; Mr A. F. Rushi'orth, r.n.c.s.
`IgA Deficiency and Infantile Atopy
`668
`Dr Antti Koivikko; Dr R. Augustin
`Com aratlve Eflicac of Sulphonamide
`an Co-trimoxazo e
`669
`Dr S. Senewiratne
`Cooperation in Child Health
`Dr H. P. Burrowes
`A Possible In-vitro Blood Test {or
`Cancer
`Dr R. G. Fish
`Pretendin: to be Unconscious
`Dr William Sargant
`Geriatric Nursing Standards
`Miss Mollie Clark, Dr Peter Hot-rocks
`HL-A 27 and Reiter’s Syndrome
`Dr J. C. Woodrow
`Depression after Hysterectomy
`Mr W. G. Mills, r.n.c.s.; Dr '1‘. I. Fahy
`Skin Biopsy and Successful Fibroblast
`Culture
`Dr I.
`'1‘. Cocoa, Dr Samuel Goldxtein;
`Dr R. A. Doherty and others
`674
`Europhorin
`Dr A. J. Duggan
`Anti-lymphocyte Globulin and Factor-VIII-
`related Antigen
`'
`674
`Dr I. R. Peakc and others
`
`669
`
`670
`
`670
`671
`671
`672
`
`673
`
`"
`
`Editorial Olfice: 7 Adam Street, London WC2N 6AD, England.
`North American Edition published weekly by Little, Brown and
`Company, 34 Beacon St., Boston, Mass. 02106.
`Canada, annual subscription $18.50; resident and intern rate
`$11.50; single co y $2.00. Second class postage paid at Boston,
`Mass, and at a ditional mailing oflices. © The Lancet Ltd.,
`22 September 1973. Notification on Form 3579 is to be mailed
`The Lancet, 34 Beacon Street, Boston, Mass. 02106.
`THE WHOLE OF THE LITERARY MATTER [N THE LANCET IS COPYRIGHT
`
`In U.S.snd
`
`w D ROB
`
`TS
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`3214-; BR! DLE. PATH.
`
`CSL EXHIBIT 1074
`CSL v. Shire
`
`Page 1 of 2
`
`

`

`680
`
`Since no other cause for the glomerulitis was found, it
`is possible that the patient's renal lesion developed on the
`basis of immune-complex formation. On the other hand,
`it is well known that the alternate complement pathway is
`activated in the skin of dermatitis herpetiformis patients. 1
`2
`,
`Perhaps a similar phenomenon also occurs in the kidney.
`One certainly cannot conclude from our case that glomeru(cid:173)
`litis is an integral part of dermatitis herpetiformis, but
`other patients with dermatitis herpetiformis might be
`studied for
`the presence of glomerulonephritis, and
`appropriate immunological studies might be performed.
`w. E. DECOTEAU
`J. W. GERRARD
`T. A. CUNNINGHAM.
`
`University Hospital,
`Saskatoon, Saskatchewan,
`Canada S7N OW8.
`
`WITHDRAW AL SYMPTOMS IN NEONATES
`ASSOCIATED WITH MATERNAL
`IMIPRAMINE THERAPY
`SrR,-I was interested in Dr Webster's letter (Aug. 11,
`p. 318) and I should like to mention that I also observed
`three newborn infants with respiratory, circulatory, and
`neurological signs causing much concern during the first
`week of life and whose mothers had taken imiprarnine
`during pregnancy. a
`Depanment of Prediatrics,
`University of Leuven,
`Leuven, Belgium.
`
`E. EGGERMONT.
`
`HEREDITARY ANGIONEUROTIC <EDEMA
`SIR,-Your editorial 4 and Professor Pickering's letter 5
`prompt us to record our experience with replacement
`therapy in this condition.
`We have used a partially purified preparation of Cl
`inhibitor, approximately the amount present in 2 litres of
`human plasma in 2 patients during an acute attack. 6 ,'
`This preparation was kindly given to us by Dr Schwick
`(Behringwerke) and was active as an inhibitor of Cl
`esterase (1200 inactivator units). 8 A 28-year-old woman
`was given this preparation 4 hours after the onset of
`facial cedema. Despite this substitution and symptomatic
`therapy of 100 mg. of prednisolone per day the cedema
`In contrast, a male of
`subsided only on the third day.
`55 responded within 4 hours to the same quantity of the
`partially purified preparation. Previous attacks usually
`lasted 48 hours.
`The use of purified inhibitors may have several advan(cid:173)
`tages: diminished risk of transfusion hepatitis and avoid(cid:173)
`ance of further supplying the patient with C4 and C2, the
`natural substrates of Cl esterase. Furthermore, it is an
`obvious advantage that this preparation can be given in
`10-20 ml. of saline.
`We cannot yet say whether replacement therapy will be
`successful in every case, but with increasing experience we
`hope to be able to make a more definite statement.
`Rheumatologische Univ.-Klinik,
`Basie, Switzerland.
`Mayo Clinic,
`Rochester,
`Minnesota 55901, U.S.A.
`
`D. BRACKERTZ.
`
`F. KUEPPERS.
`
`1. Provost, T. T., Tomasi, T. B., Jr. J. Imm11n. 1973, 111, 290.
`2. Seah, P . P., Fry, L., Mazaherri, M. R., Mowbray, J. F., Hoffbrand,
`A. V., Holborow, E. J . Lancet, July 28, 1973, p. 175.
`3 . Eggermont, E., Raveschot, J., Deneve, V., Casteels-van Daele, M.
`Acta ptediat. belg. 1972, 26, 197.
`4. Lancet, 1973, i, 1044.
`5. Pickering, R. J. ibid. July 7, 1973, p. 41.
`6. Brackertz, D., Kueppers, F. Klin. Wschr. 1973, 51, 620.
`7. Brackenz, D., Kueppers, F. Al/erg. lmmunopath. (in the press).
`8. Haupt, H., Heimburger, N., Kranz, T., Schwick, H. G. Eur. J.
`Biochem. 1970, 17, 254.
`
`THE LANCET, SEPTEMBER 22, 1973
`
`TREATMENT OF RESPIRATORY-DISTRESS
`SYNDROME
`SIR,-I read with interest your leading article (Aug. 4,
`p. 244) on the treatment of the idiopathic respiratory(cid:173)
`distress syndrome (r.R.D.S.).
`Since reporting the first case in this department treated
`with continuous positive airway pressure (C.P.A.P.) 1 both
`this and constant positive-pressure breathing (c.P.P.B.) have
`been in regular use. I have been impressed by the potency
`of this technique and it seems probable that an excessive
`transpulmonary pressure may be produced particularly
`during recovery from I.R.D.S. This has been noted by
`Davies et al. 2 also, and the cardiovascular disturbances
`recorded by Gregory et al. 3 in their original series seem
`In infants in this unit dying
`particularly significant.
`unexpectedly during the 3rd-7th day of life the foramen
`ovale and ductus arteriosus were widely patent. It seemed
`probable that increased intracardiac shunting had occurred.
`An objective method of assessing the optimum level of
`C.P.A.P. at any given stage of the illness was sought and, in
`view of the above, the central venous pressure (c.v.P.) as
`well as arterial pressure have both been continuously
`monitored (by Elema Schonander transducers E.M.T. 33
`and E.M.T. 34 with indwelling argyle 5FG umbilical
`catheters). C.V.P. measurements have proven valuable in
`estimating the level of C.P .A.P. and of positive end-expiratory
`pressure (P.E.E.P.) to be used, the c.v.P. rising when the
`appropriate transpulmonary pressure is exceeded. Such
`measurements have prompted reductions in c.P.A.P. during
`the recovery phase of I.R.D.S. resulting in a rise in Pao,(cid:173)
`that is, a reduction in right-to-left shunt. It seems lik~ly
`therefore that an excessive transpulmonary pressure will
`increase right-to-left shunt, causing deterioration in the
`infant's condition. For these reasons I believe that C.P.A.P.
`and constant negative pressure (c.N.P.) do not have identical
`effects on the cardiovascular system, but I would suggest
`that unless the above monitoring faci lities are available, it
`may well be " safer" to use C.N.P. in preference to C.P.A.P.
`The potency of C.P.A.P. may partly be explained by the
`tracheal pressures noted in some of these cases. These
`measurements were made by a 5 FG micro-tip transducer
`placed in the trachea outside the endotracheal tube. As
`expected, during expiration, the infant has to produce
`considerable effort, and pressures in excess of 30 cm. H 20
`were commonly found. During inspiration, however,
`tracheal pressures rarely fell significantly below the c.P.A.P.
`being applied, except with gasping inspirations. This con(cid:173)
`trasts with the large negative deflections during inspiration
`noted in the C.V.P. which to some extent must reflect intra(cid:173)
`pleural pressures. The mean tracheal pressure is con(cid:173)
`sequently maintained at a surprisingly high level and high
`transpulmonary pressures are produced during both in(cid:173)
`spiration and expiration.
`In those infants who require assisted ventilation c.P.P.B.
`has been shown to improve oxygenation. 4 Some infants
`require high peak inspiratory pressures with high P.E.E.P.
`and such a wave form especially if inspiration is also
`prolonged, is not without its dangers.• Considerable rises
`in c.v.P. can occur with high levels of P.E.E.P. and this effect
`is increased when the infant breathes out of phase with the
`ventilator. Both tracheal . pressures and c.v.P. may rise
`dramatically. In some infants, high pressures are required
`to inflate the lungs 4 and it may be that such pressures
`significantly impair pulmonary perfusion with increase in
`intracardiac shunting. The use of a device to initiate
`
`1. Macdonald, T. H., Speirs, A. L. Lancet, 1971, ii, 1144.
`2. Davies, P. A., Robinson, R. J., Scopes, J. W., Tizzard, J. P. M.,
`Wigg!eswonh, J. S. in Medical Care of New Born Babies. London,
`1972.
`3. Gregory, G. A., Kitterman, J. A., Phibbs, R. H., Tooley, W. H.,
`Hamilton, W. K. New Engl. J. Med. 1971, 284, 1333.
`4. Herman, S., Reynolds, E. 0 . R. Archs Dis. Chi/dh. 1973, 48, 612.
`
`Page 2 of 2
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