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Sir: Thank you for the opportunity to reply to Drs. Ligtenberg, Zijlstra, and Girbes. We acknowledge that adrenal insufficiency may be clinically indistinguishable from septic shock, and that this condition must always be considered in patients who are critically ill and catecholamine dependent. We certainly considered this possibility in the management of our patient, and he was given 100 mg hydrocortisone intravenously on his admission to the intensive care unit and then 100 mg q.d.s. for 4 days thereafter, and we omitted to mention this in the case report. His adreno-cortical function was not formally measured because of the severity and changing requirements of his illness, but he required only single inotrope therapy in the form of dopamine at 20 mg/ kg per minute when the hydrocortisone was discontinued after 4 days. We would never advocate seeking the highest possible noradrenaline dose in the management of septic shock. We report this particular case as an instance in which noradrenaline was used in doses far in excess of the recommended conventional dose limits, and which was associated (against our expectations) with a favourable outcome.