alcohol, liquid paraffin, propyleneglycol, and water. With very painful wounds morphine or pentazocine can be given. Oral treatment, targeted at mustard gas and yellow rain, should consist of 40 g activated charcoal three times every four hours; administration of 25 g magnesium sulphate and 1 g potassium chloride in 100 ml of water; or administraton of 10% mannitol, with
liquid food and a milk diet. Intravenous therapy for mustard gas consists of 3 g vitamin C three times a day, 300 mg acetylcysteine four times a day (up to 150 mg/kg), 2 g thienamycin twice a day (after antibiotic sensitivity testing), 3 g L-carnitine daily, and 30 g sodium thiosulphate daily. Oral sprays of thiomersal in ethanol, 0.2% hexomedine,
discovered on plain X-ray filins. Empty sella is now diagnosed more easily with high resolution computerised tomography (CT) and magnetic resonance imaging.’ However, little is known about the evolution of this disorder. Between 1981 and 1983, 21 patients with primary empty sella were investigated with iopamidol CT cistemography at our institution.412 of these patients (all women) were followed up for at least 5 years. The evolution of empty sella was wholly independent of the sellar dimensions and of the grade of disease at diagnosis. The sella, re-evaluated with plain radiography in all patients and with CT in the 3 patients with visual damage, was unchanged. Symptoms and signs in our patients were:
sulphonamides may be helpful.
Eye treatment, which may be needed for photophobia (which can last for several weeks), should consist of a 0-2% solution in water of mercury oxycyanide with methylene-blue or 15% sulphacetamide inhydroxypropylmethylcellulose or chlortetracycline eye ointment
Obesity galactorrhoea Oligo-amenorrhoea Hypothyroidism
(5 or 10 mg/g). In Vienna the above general regimen was used except that the skin was treated with’Actisorb’ (activated charcoal) twice every day, this being left on. Actisorb was washed off twice daily with 1500 ml human breast milk for 3 weeks. 1500 ml breast milk was given by mouth every day.
Nerve gases For the nerve gases immediate treatment should be intravenous 7 x2 mg every 2 min repeated until the pupils dilate (which may take up to 1000 mg in a day). In serious cases we start with 50 mg by slow injection. Chloramide (’Contrathion’) 2 x 2 200 mg ampoules every 2 h should also be given, every ampoule being dissolved in 50 ml water and injected intravenously. This gives better results than obidoxime (’Toxogonin’).
Cyanides For cyanides ("nylon bombs") 2 ml ampoules of amyl nitrite or 13% sodium nitrite should be given intravenously, if available at the battlefield, followed by 25% sodium thiosulphate as 10 ml ampoules intravenously. Repeat if necessary after 10 min. Also give oxygen.
Tricresylphosphate For tricresylphosphate bombs we used 10% calcium gluconate and 10% diazepam intravenously, further treatment being as for cyanides. Mycotoxins Exposure to mycotoxins requires the general treatment discussed above. In serious cases we have found high concentrations of methaemoglobin, and haemoperfusion may be necessary. In all cases perfusion solutions (eg, glucose, mannitol, and electrolytes) should be available. Further guidance can be found in the proceedings of the First and Second World Congresses on New Compounds in Biological and Chemical Warfare (published by the University Press, Ghent, in 1984 and 1986).
Department of Toxicology, State University of Ghent, 9000 Ghent, Belgium
Hypogonadotropism Hyperprolactinaemia Hypertension Visual impairment
SIR,-In empty sella syndrome the suprasellar subarachnoid space extends into the sellar cavity, thus compressing the pituitary gland, stretching the stalk, and eventually causing hormonal disregulation. Empty sella is defined as primary if it arises in the absence of any previous known pituitary disease.’Investigators have noted the predominance of obese, middle aged, often multiparous women.1,2 Headaches and slight endocrine alterations are frequent but not characteristic; visual damage and cerebrospinal fluid rhinorrhoea are rare complications.1-3 These patients are generally investigated for suspected pituitary adenoma because of sellar enlargement
1989 8 7 8 8 5 2 2 2 2 1 3 1 2 1 5 1 3
Headaches had disappeared in only 1 patient, and obesity persisted in all patients. In 1 patient menstrual function became normal without therapy and in the other it became so with sporadic bromocriptine administration. In this latter patient prolactin
concentrations returned to normal. Galactorrhoea was absent in the 3 patients in whom it had been an inconsistent finding. Hypothyrodism was unchanged; gonadotropic insufficiency had developed in 1 patient. 1 patient had died after 6 years from unrelated disease. In the patient with visual impairment, supposedly due to chiasmal damage, this deficit remained stable. The other 2 patients who became visually impaired were also diabetic and hypertensive and this symptom was therefore attributed to these diseases rather than to empty sella. The 3 patients who became diabetic needed oral antidiabetic medication, and the 5 with moderate arterial hypertension required diuretics. In view of the age of our population (mean 43 years, range 31-58) at the time of follow-up, the findings of diabetes and hypertension are important. They seem to be the most frequent and clinically significant pathological events that are likely to be seen in the natural history of primary empty sellar syndrome. Division of Neurosurgery and Service of Endocrinology, Regina Elena Institute for Cancer Research and Therapy, 00161 Rome, Italy
ALFREDO POMPILI FRANCESCO CALVOSA MARIALUISA APPETECCHIA
1. Editorial. Pituitary tumours and the empty sella syndrome. Lancet 1986; ii: 1371-72. 2. Jordan RM, Kendall JW, Kerber CW. The primary empty sella syndrome. Am J Med 1977; 62: 569-80. 3. Spaziante R, De Divitiis E, Stella L, Cappabianca P, Genovese L. The empty sella. Surg Neural 1981; 16: 418-26. 4. Pompili A, Iachetti M, Riccio A, Squillaci S. Computed tomographic cisternography with iopamidol in the diagnosis of primary empty sella. Surg Neurol 1985; 24: 16-22.
A. HEYNDRICKX B. HEYNDRICKX
primary empty sella syndrome
Lack of inhibitor to monoclonal-antibody purified factor VIII concentrate SIR,-Dr Mondorf and Dr Scharrer (Sept 22, p 747) record their experience with ’Hemof1l M’ (Baxter/Travenol) in 22 adults aged 19-58, stating that no patient had an inhibitor to FVIII:C. This is not surprising since most patients with haemophilia who are destinedl to acquire an inhibitor antibody to FVIII do so in
childhood-ie, one cannot compare a group of adults with series of previously untreated infants and children. In several reported series least two-thirds of patients who acquired FVIII inhibitors did so before age 2(P’*’ and after a low number of exposure days to FVIII I am aware of only one published report of an adult who has acquired an FVIII inhibitor while receiving a monoclonal antibody purified FVIII concentrate.6 No doubt more such cases will arise since there is no age at which a patient with at