358

crystalloid inclusions) which are known to develop in non-tumorous livers of women on contraceptive steroids.5 Ii

Although these fine structural changes are non-specificand may occur also in various other conditions, theywere thought to represent the fine-structural manifesta-tions of the protracted action of contraceptive steroids inour case. Our findings do not clarify whether or notcontraceptive steroids are involved in the causation ofbenign hepatomas. Further critical studies are needed.

Department of Pathology,St. Michael’s Hospital,University of Toronto,

Toronto, Ontario, Canada.

E. HORVATHK. KOVACSR. C. Ross.

1. Baum, J. K., Holtz, F., Bookstein, J. J., Klein, E. W. Lancet, 1973,ii, 926.

2. Contostavlos, D. L. ibid. p. 1200.3. ibid. p. 1481.4. Horvath, E., Kovacs, K., Ross, R. C. Digestion, 1972, 7, 74.5. Perez, V., Gorosdisch, S., De Martire, J., Nicholson, R., Di Paola,

G. Science, 1969, 165, 805.

PRETENDING TO BE UNCONSCIOUS

SIR,-Dr Hopkins’ article 1 prompts me to present thefollowing case-history.A young hospital worker was admitted overnight

after complaining of headache following involvement in aroad traffic accident in whjtch she was neither injured norrendered unconscious. She returned to duty next day butwas readmitted as an emergency after senior nursing staffhad seen her " staggering and bumping into things ". Afteradmission she had a " fit " and became inaccessible. The

duty house-physician, thinking her heart had stopped,resuscitated her with a blow on the chest and she wasthen monitored until next morning. Next morning theduty physician noted that there was a very emotionalatmosphere in her side-ward, where it was felt among thenursing staff that neurosurgical aid should have beensummoned long before. Others considered she might havetetanus, because of her posture which resembled

opisthotonos.The patient resisted attempts at examination, and her

attacks of hyperventilation alternated with breath-holdingto the point of cyanosis. The physician made a diagnosis ofhysteria but decided to cover himself by getting an anses-thetist to attend while she was sedated. A neurosurgeonfelt that there was no neurological damage, and the physi-cian then approached a psychiatrist, who agreed thatfurther exclusion of organic disease was called for. Electro-encephalography and lumbar puncture and some furtherblood-tests were done. No underlying disease was found.These tests occupied two days, during which time sheremained " unconscious ", her hydration being assuredby a drip. Then she suddenly became accessible andrational, but denied recollection of events since the accidentand seemed quite unconcerned. Subsequently it becameclear that she had escaped from an intolerable situationcaused by the stress of simultaneously coping with hercareer and supporting her family financially and emotionallywhile her parents planned divorce. She soon returned toduty.The case illustrates the reluctance to rely on a purely

clinical diagnosis, the efforts felt appropriate to excludeorganic disease, and the emotional involvement of otherstaff when a colleague is the patient. Consequently the" emergency " occupies a considerable part of a busygeneral hospital’s emergency resources. Moreover, theintensive care thus given probably reinforces attention-seeking behaviour and this prolongs the " coma ".

382 Clifton Drive North,St. Annes-on-Sea FY8 2PN. M. W. P. CARNEY.

1. Hopkins, A. Lancet, 1973, ii, 312.

NEURAL-TUBE DEFECTS ANDTWINNING

SIR,-Dr Ian Leck’s comment (Feb. 2, p. 178) on

Knox’s fetus/fetus interaction hypothesis is certainlysupported by some clinical findings in spina-bifida babies.One swallow doesn’t make a summer, but one of the most

striking cases that I have seen was a baby boy with amyelocele and an aborted twin attached at the site of themyelocele. The teratoid twin had well-formed digitswhich responded to stimulation of the legs of the hostbaby. A notable feature of most myeloceles is their grossexcess of neural tissue and skin. Although this has beenexplained by some as merely representing a failure tocheck normal growth at the posterior neuropore, thisfinding supports the aborted-twin theory. Another featurethat is not well recognised is that scalp-type hair growsaround the myelocele and not normal body hair. Thisaccords with the suggestion that the area represents thehead of a second fetus.

Clearly a detailed analysis of all twinning found inchildren with spina bifida and anencephaly is called for.

10 Kingswood Drive,Dulwich,

London SE19 1UT. D. F. ELLISON NASH.

DIGOXIN IN BENIGN INTRACRANIALHYPERTENSION

SIR,-Digoxin in normal doses substantially reduced thevolume of cerebrospinal fluid (c.s.F.) obtained from thelateral ventricles of three patients with various centralnervous system disorders.1 We have therefore attemptedto use digoxin to control a persistent increase in C.S.F.

pressure, refractory to more usual therapy, in a patientsuffering from benign intracranial hypertension (B.l.H.).Moreover, as a result of repeated therapeutic lumbar

puncture, we have been able to compare simultaneousplasma and c.s.F. digoxin levels, of interest to us especiallysince the report of moderate passage of digoxin fromplasma to c.s.F. in four infants on maintenance digoxintherapy. 2

A 37-year-old man under the care of Prof. John Marshallhad been evaluated 18 months earlier for symptoms of a fewdays’ intermittent, bilateral obscuration of vision, his previoushealth having been excellent. Examination revealed chronicbilateral papillredema (confirmed by fluorescein angiography)and an arcuate field defect in the region of the left blind spot,visual acuity remaining unimpaired. The presenting visualsymptoms resolved shortly after his initial admission and havenot subsequently recurred. Apart from a raised lumbar c.s.F.pressure of between 210 and 310 mm. c.s.F., determined on fouroccasions during the first admission, neurological investigation,including lumbar pneumoencephalography, demonstrated no

abnormality, and a diagnosis was made of B.l.H. unassociatedwith any known precipitating factor. He was treated byrepeated lumbar puncture and removal of sufficient c.s.F. to

lower the pressure to 90-100 mm. c.s.F., and also with acetazol-amide (’Diamox’) and steroids, acetazolamide later beingwithdrawn when the patient had renal colic from a calculus. Thesteroids were gradually withdrawn after about three months.After follow-up for a year, during which time the c.s.F. pressurehad ranged from 250 to 350 mm. c.s.F., another attempt to reducethis pressure was made by the reintroduction of steroids (oraldexamethasone 6 mg. daily). There had been little effect on thepressure, however, after a month’s treatment, and it was decidedthat oral digoxin should be introduced in addition.

After digitilisation, the patient was maintained on digoxin(’ Lanoxin ’) 0-25 mg. 8-hourly, continued for sixweeks. Lumbarpuncture was performed on seven occasions during this period,and digoxin was assayed on a sample of the c.s.F. obtained, aconcurrent heparinised venous-blood sample also being assayedfor digoxin. Plasma-digoxin was estimated by radioimmunoassayusing the method of Smith et al.3 with minor modifications.The same method was used for the detection of digoxin in C.S.F,j