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` niou l. 0
`ORIGINAL ARTICLES
`
`
`Prognosis After Head Injury Based on Early Clinical Exam - ‘i'
`'
`I 631
`J m Overgaard, M.D., Steen Christensen, M.D., Jens Haase, M.D., Ole Hein, M.D.,
`le Hvid-Hansen, M.D., Anne-Marie Land, M.D., K. K. Pedersen, M.D.,
`W. A. Tweed, M.D.
`
`Kctotic 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
`
`635
`
`A Testosterone-secreting Tumour of the Adrenal Producing Virilisation
`in a Female Infant
`*
`I. M. Burr, M.R.A.C.P., J. Sullivan, a.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, mum,
`W. J. Irvine, r.n.c.r.a.
`
`643
`
`644
`
`REVIEWS
`Notices of Books
`
`OCCASIONAI. 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, 3.11.
`
`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
`
`646
`
`652
`
`654
`
`659
`
`661
`
`664
`
`665
`
`684
`685
`
`Epidemiology of Hodgkin’s
`Disease
`Treatment of Hemophilia
`Alcoholism
`Beta—blockade for Withdrawal
`Symptoms P
`Nephroblastoma: an Index
`
`Reference Cancer
`
`"
`
`669
`
`670
`
`670
`671
`671
`672
`
`673
`
`l|l|l|||jl_|_ll[|llll|lIllllllll
`
` _ L
`
`L41”
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`675
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`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 Salicylates
`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.r.c.r.
`Epidemiological Treatment of
`Gonorrhea
`678
`Dr A. Z. Meheus
`
`676
`
`679
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`679
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`680
`680
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`682
`
`682
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`683
`
`683
`683
`
`mentcmic Nephri a
`Partial Lipodystropigr and Hypocomple-
`Dr R. A. Thompson, Dr R. H. R. White
`Glomerulitis in Dermatitis
`LETTERS TO THE EDITOR
`Her etiformis
`Dr
`. E. DeCoteau and others
`The Conference of Royal Colleges and
`666
`Faculties in Scotland
`Withdrawal Symptoms in Neonates
`Dr I. Halliday Croom, and others
`Associated with Maternal Imipramine
`666
`Dialysis and Lead Absorption
`Thera y
`Miss Jeanette Blomfield, M.sc.
`Dr E.
`ggermont
`Electra-acupuncture and Pain Threshold 667
`Hereditary Angioneurotic (Edema
`Mr Jim Mumford, r.o.s., Dr David Bowsher
`Dr D. Brackertz, Dr F. Kueppels
`Bell’s Palsy in Pregnancy
`667
`Treatment of Respiratory-distress
`Dr I. D. O’Donovan
`680
`Syndrome
`The New N.I-I.S. Consultant Contract
`667
`Dr T. H. Macdonald
`Dr G. R. Feomley; Mr A. F. Rushforth, F.R.C.S.
`681
`Overdose of Salbutamol
`Dr G. W. Morrison, Dr M. J. B. Farebrother
`IgA Deficiency and Infantile Atopy
`668
`Dr Antti Koivikko; Dr R. Augustin
`Distribution of Clioquinol in Rats with
`Com aratlve Eflicac of Sulphonamide
`Hepatic Dysfunction
`681
`an Co-trimoxazo e
`669
`Dr Shosuke Wannabe and others
`Dr S. Senewiratne
`Bacteroides Infections
`682
`Cooperation in Child Health
`Dr A. A. B. Mitehell,Mr R. G. Simpson, P.R.c.s.
`Dr H. P. Burrowes
`A Possible In-vitro Blood Test for
`Government Wanting on Cigarette
`Cancer
`Packages
`Dr R. G. Fish
`Prof. P. R. J. Burch, PH.D.
`Mineralocorticoids and Rectal Potential
`Pretending to be Unconscious
`Diii'erenee
`Dr William Sargent
`Dr D. G. Beevers
`Geriatric Nursing Standards
`Miss Mollie Clark, Dr Peter Hot-rocks
`“ Delayed Menstruation " Induced by
`HL-A 27 and Reiter’s Syndrome
`Prostaglandin in Pregnant Patient!
`Dr J. C. Woodrow
`Dr P. Mocsary, Prof. A. I. Csapo, M.D.
`Depression after Hysterectomy
`Lymphocyte Response after Radio-
`Mr W. G. Mills, r.n.c.s.; Dr '1‘. I. Fahy
`therapy
`Skin Biopsy and Successful Fibroblast
`Dr Iudxth Braeman
`Culture
`Cephalosporins
`Dr I.
`'1‘. Cocoa, Dr Samuel Goldxtein;
`Dr Enrique Macias
`NOTES AND NEWS
`Dr R. A. Doherty and others
`Hon
`on's Chorea, Lithium, and
`685
`674
`Europhoria
`684
`ChA.
`.A.
`After 75 years
`Dr A. J. Duggan
`686
`Down to Earth
`Dr Bengt Mattsson, Dr Sven-Ake Persson
`Anti-lymphocyte Globulin and Factor-VIII-
`686
`Antidiuretic Action of Chlorpropamide 684
`Following Shaw
`'
`related Antigen
`674
`Dr Vecihi Batumsn
`Dr I. R. Peakc and others
`686
`Child-proof Containers
`
`
`Editorial Olfice: 7 Adam Street, London WC2N 6AD, England.
`II “3
`TS
`W D ROB
`In U.S.and
`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,
`321.43 BR! DLE. PATH.
`© The Lancet Ltd.,
`Mass, and at a ditional mailing ofliccs.
`.
`.
`22 September 1973. Notificstion on Form 3579 IS to be married
`The Lancet, 34 Beacon Street, Boston, Mass. 02106.
`
`
`THE WHOLE OF THE LITERARY MATTER IN THE LANCET IS COPYRIGHT
`
`Page 1 of 2
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`CSL EXHIBIT 1074
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`Page 1 of 2
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`CSL EXHIBIT 1074
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`

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`680
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`THE LANCET, SEPTEMBER 22, 1973
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`Since no other cause for the glomerulitis was found, it
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`is possible that the patient’s renal lesion developed on the
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`basis of immune-complex formation. On the other hand,
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`it is well known that the alternate complement pathway is
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`activated in the skin of dermatitis herpetiformis patients."‘-’
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`Perhaps a similar phenomenon also occurs in the kidney.
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`One certainly cannot conclude from our case that glomeru-
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`litis is an integral part of dermatitis herpetiformis, but
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`other patients with dermatitis herpetiformis might be
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`studied for
`the presence of glomerulonephritis, and
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`appropriate immunological studies might be performed.
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`W. E. DECOTEAU
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`University Hospital,
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`J. W. GERRARD
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`Saskatoon, Saskatchewan,
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`Canada S7N 0978.
`T. A. CUNNINGHAM.
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`WITHDRAWAL SYMPTOMS IN NEONATES
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`ASSOCIATED WITH MATERNAL
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`IMIPRAMINE THERAPY
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`SIR,—-I was interested in Dr Webster’s letter (Aug. 11,
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`p. 318) and I should like to mention that I also observed
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`three newborn infants with respiratory, circulatory, and
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`neurological signs causing much concern during the first
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`week of life and whose mothers had taken imipramine
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`during pregnancy.a
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`Department of Paediatrics,
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`University of Leuven,
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`Leuven, Belgium.
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`E. EGGERMONT.
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`TREATMENT OF RESPIRATORY-DISTRESS
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`SYNDROME
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`SIR,—I read with interest your leading article (Aug. 4,
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`p. 244) on the treatment of the idiopathic respiratory-
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`distress syndrome (I.R.D.S.).
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`Since reporting the first case in this department treated
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`with continuous positive airway pressure (C.P.A.P.) 1 both
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`this and constant positive—pressure breathing (C.P.P.B.) have
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`been in regular use.
`I have been impressed by the potency
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`of this technique and it seems probable that an excessive
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`transpulmonary pressure may be produced particularly
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`during recovery from I.R.D.S. This has been noted by
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`Davies et al.’2 also, and the cardiovascular disturbances
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`recorded by Gregory et al.3 in their original series seem
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`particularly significant.
`In infants in this unit dying
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`unexpectedly during the 3rd—7th day of life the foramen
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`ovale and ductus arteriosus were widely patent.
`It seemed
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`probable that increased intracardiac shunting had occurred.
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`An objective method of assessing the optimum level of
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`C.P.A.P. at any given stage of the illness was sought and, in
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`view of the above, the central venous pressure (C.V.P.) as
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`well as arterial pressure have both been continuously
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`monitored (by Elema Schonander transducers E.M.T. 33
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`and E.M.T. 34 with indwelling argyle SFG umbilical
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`catheters).
`c.v.P. measurements have proven valuable in
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`estimating the level of C.P.A.I’. and of positive end—expiratory
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`pressure (P.E.E.P.) to be used, the C.V.P. rising when the
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`appropriate transpulmonary pressure is exceeded.
`Such
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`measurements have prompted reductions in C.P.A.P. during
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`the recovery phase of I.R.D.S. resulting in a rise in Pa02—
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`that is, a reduction in right-to-left shunt.
`It seems likely
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`therefore that an excessive transpulmonary pressure will
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`increase right—to-left shunt, causing deterioration in the
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`infant’s condition. For these reasons I believe that C.P.A.P.
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`and constant negative pressure (C.N.P.) do not have identical
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`effects on the cardiovascular system, but I would suggest
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`that unless the above monitoring facilities are available, it
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`may well be “ safer ” to use C.N.P. in preference to C.P.A.P.
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`The potency of C.P.A.P. may partly be explained by the
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`tracheal pressures noted in some of these cases. These
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`measurements were made by a 5 FG micro-tip transducer
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`placed in the trachea outside the endotracheal tube. As
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`expected, during expiration,
`the infant has to produce
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`considerable effort, and pressures in excess of 30 cm. H20
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`were commonly found. During inspiration, however,
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`tracheal pressures rarely fell significantly below the C.P.A.P.
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`being applied, except with gasping inspirations. This con—
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`trasts with the large negative deflections during inspiration
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`noted in the C.V.P. which to some extent must reflect intra—
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`pleural pressures. The mean tracheal pressure is con-
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`sequently maintained at a surprisingly high level and high
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`transpulmonary pressures are produced during both in-
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`spiration and expiration.
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`In those infants who require assisted ventilation C.P.P.B.
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`has been shown to improve oxygenation.‘ Some infants
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`require high peak inspiratory pressures with high P.E.E.P.
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`and such a wave form especially if inspiration is also
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`prolonged, is not without its dangers.4 Considerable rises
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`in C.V.P. can occur with high levels of P.E.E.P. and this eifect
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`is increased when the infant breathes out of phase with the
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`ventilator. Both tracheallpressures and C.V.P. may rise
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`dramatically.
`In some infants, high pressures are required
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`to inflate the lungs “ and it may be that such pressures
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`significantly impair pulmonary perfusion with increase in
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`intracardiac shunting. The use of a device to initiate
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`l. Macdonald, T. 1-1., Speirs, A. L. Lancet, 1971, ii, 1144.
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`2. Davies, P. A., Robinson, R. J., Scopes, J. W., Tizzard, J. P. Mo
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`Wigglesworth, J. S. in Medical Care of New Born Babies. London,
`1972.
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`3. Gregory, G. A., Kitterrnan, J. A., Phibbs, R. H., Tooley, W. H-)
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`Hamilton, W. .K. New Engl. J. Med. 1971, 284, 1333.
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`4. Herman, S., Reynolds, E. O. R. Arch: Dis. Childh. 1973, 48, 612.
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`HEREDITARY ANGIONEUROTIC (EDEMA
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`SIR,—-Your editorial 4 and Professor Pickering’s letter 5
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`prompt us to record our experience with replacement
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`therapy in this condition.
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`We have used a partially purified preparation of C1
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`inhibitor, approximately the amount present in 2 litres of
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`human plasma in 2 patients during an acute attack.“7
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`This preparation was kindly given to us by Dr Schwick
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`(Behringwerke) and was active as an inhibitor of Cl
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`esterase (1200 inactivator units).8 A 28-year-old woman
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`was given this preparation 4 hours after the onset of
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`facial oedema. Despite this substitution and symptomatic
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`therapy of 100 mg. of prednisolone per day the (edema
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`subsided only on the third day.
`In contrast, a male of
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`55 responded within 4 hours to the same quantity of the
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`partially purified preparation.
`Previous attacks usually
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`lasted 48 hours.
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`The use of purified inhibitors may have several advan-
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`tages: diminished risk of transfusion hepatitis and avoid-
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`ance of further supplying the patient with C4 and C2, the
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`natural substrates of C1 esterase. Furthermore, it is an
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`obvious advantage that this preparation can be given in
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`10—20 ml. of saline.
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`We cannot yet say whether replacement therapy will be
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`successful in every case, but with increasing experience we
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`hope to be able to make a more definite statement.
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`Rheumatologische Univ.-Klinik,
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`Basle, Switzerland.
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`Mayo Clinic,
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`Rochester,
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`F. KUEPI’ERS.
`Minnesota 55901, U.S.A.
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`. Provost, T. '1‘., Tomasi, T. B., Jr. 7. Immxm. 1973, 111, 290.
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`. Seah, P. P., Fry, L., Mazaherri, M. R., Mowbray, J. F., Hofl'brand,
`NH
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`A. V., Holborow, E. J. Lancet, July 28, 1973, p. 175.
`5”
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`Eggermont, E., Raveschot, J., Deneve, V., Casteels-van Daele, M.
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`Acta medial. belg. 1972, 26, 197.
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`Lancet, 1973, i, 1044.
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`Pickering, R. J.
`ibid. July 7, 1973, p. 41.
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`Brackettz, D., Kueppers, F. Klin. Wichr. 1973, 51, 620.
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`Brackertz, D., Kueppers, F. Allerg. Immunopath. (in the press).
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`Haupt, H., Heirnburger, N., Kranz, T., Schwick, H. G. Eur. 3'.
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`Biochem. 1970, 17, 254.
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`D. BRACKERTZ.
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`$19.49.“?
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`Page 2 of 2
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