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BRITISH MEDICAL JOURNAL 11 SEPTEMBE 1971 615 symptoms. She is a woman of 50 who a year before had a hysterectomy and has not felt well since. She has backaches, headaches, dizziness, insomnia, and a persistent sense of depression. She sometimes gets up in the night to turn off the gas or to see that the door is locked. She has no serious financial difficulties, but her husband and children take no notice of her and she feels that life in the future stretches out like a desert. She has been seeing her doctor regularly and receiving tranquillizers, but she has not been to him for three months because she feels she is wasting his time.In many others there are no symptoms but the same life situation. In others there is an acute stress (the woman who shoplifted the day before taking her son, who had a sarcoma of the elbow, to see a surgeon). Rather younger women may have had a recent miscarriage, fear sterility, or mourn the death of children. Current menopausal symptoms are not more common than is to be expected for the age group.Most women shoplifters of this kind, who represent not less than 10%1 and perhaps more than 20%' of those arrested, are convicted only once. Those of similarly good character who persist in shoplifting, the rare "compulsive" shoplifters, are often very different. They are of exemplary character, with an attitude of robust mental health, and unwilling to admit the existence of obvious stresses. From our figures, however, it is tempting to suppose that in a fair proportion of cases shoplifting is the first symptom of a frank depressive illness. It is also possible that the conviction has quite a traumatic effect. A number of middle-aged recidivists seem to feel that the first conviction muined their reputation for honesty and that nothing will efface this memory.

Persistent profound visual loss following contusion of the globe or ocular adnexae has been well documented, the visual loss being attributed to haemorrhage into, or contusion of, the optic nerve, or to interference with the blood supply of the eye. The patient described below presented after a contusion of the eye and orbit, with the clinical picture of ischaemic optic neuropathy presumably resulting from injury to the posterior ciliary arteries. Case reportOnJune 30, 197I, a housewife aged 47 years was kicked around the left orbit by a young man wearing leather shoes; 3 days later, as the eyelid haematoma abated, she was able to open her left eye and noticed that she could not distinguish between light and darkness. She immediately attended the emergency eye clinic where it was confirmed that she had no perception of light in this eye. ExaminationThere was bruising of the eyelids with a total bulbar subconjunctival haematoma. There was some proptosis, and depression and elevation in abduction of the globe were deficient. The pupil was dilated, not reacting to light, but reacting briskly consensually. Red blood cells and flare were noted in the anterior chamber. Fundus examination revealed oedema around the disc extending about one disc diameter from its margin. The disc itself was pale with circumferential blurring of the margin. Apart from this, the posterior pole did not show oedema, and there was no cherryred spot at the macula. The retinal vessels appeared normal and there was no cilio-retinal artery. No haemorrhages were seen either on the disc or in the rest of the fundus. X-ray of the facial bones, including tomograms, revealed no fracture at this time, but the left antrum was opaque, probably because of local haemorrhage.The patient was observed in hospital, no specific treatment being given, and 4 days later the left disc was still swollen and pale, the peridisc oedema was regressing, and the eye movements were full. Intraocular tension was 14 mm. Hg in the right eye and 12 mm. Hg in the left. Stereoscopic colour photographs ofeach disc confirmed the swelling and blurring of the optic disc and its margin.Fluorescein angiography showed increase of fluorescence over the whole area of the affected disc as compared to the normal right disc. The left disc also showed leakage of dye from 2 to at least 40 minutes after thedye transit. CourseAfter 4 weeks there was still no perception of light in the left eye, which gave amaurotic pupil responses, and in which optic atrophy was developing. Eye movements were full, but there was still

4-Hydroxybutyrate (Gamma-OH, Egic) was introduced into anaesthetic practice by Laborit, Buchard, Laborit, Kind, and Weber (i960) in France. It has been used extensively in America and Europe as a hypnotic. Its use in anaesthesia in Great Britain was discussed at a symposium at the Royal Society of Medicine (Gamma Hydroxybutyric Acid, I968), and further information in the British literature is provided by Robertson (I967) and Tunstall (i968a). It seemed to us that 4-hydroxybutyrate could be used to produce a light level of unconsciousness for patients undergoing ocular surgery with local anaesthesia. Preliminary studies were carried out on patients undergoing extraocular operations to assess its suitability for intraocular procedures. The technique was found to be satisfactory and this paper describes its use to maintain unconsciousness in a series of patients undergoing ophthalmic surgery. The results are compared with those from another series who were given a conventional general anaesthetic similar to that described by Kaufman (i 967). The changes in intraocular pressure are described elsewhere (Wyllie, Beveridge, and Smith, I972). Pharmacology 4-Hydroxybutyrate is the sodium salt of gamma-hydroxybutyric acid. It is a basal hypnotic which acts on the cerebral cortex directly with no subcortical action, and therefore has no analgesic properties. An analgesic supplement, however, depresses reflex activity and allows the dose of 4-hydroxybutyrate to be reduced from 70 to 40 mg./kg., as recommended by Tunstall (I 968b). There is bradycardia and a slight fall in cardiac output which can be reversed by atropine (Virtue, Lund, Beckwitt, and Vogel, I966). Surgical stimuli may cause hypertension, tachycardia, and a rise in cardiac output. These reactions can be prevented by a phenothiazine, e.g. perphenazine, which depresses the reticular activating system (Vickers, I968). A short-acting barbiturate, e.g. methohexitone, hastens induction and also eliminates the clonic movements which are an occasional accompaniment of 4-hydroxybutyrate narcosis.Methods 339 patients were studied in this series, of which 64 per cent. were women. i68 patients received 4-hydroxybutyrate and I7I had conventional general anaesthesia. The groups were comparable for age and sex. The ages ranged from 27 to 92 years (mean 68: S.D. I I 5). All patients were assessed preoperatively as fit for anaesthesia. 27 patients had diabetes mellitus and three suffered from myotonic dystrophy. There was the usual high incidence of cardiovascular and respiratory disease associated with elderly ophthalmic patients.