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synovitis, lymphadenopathy, nodules, a sensory neuropathy, scleritis, and extensive nailfold vasculitis.Ophthalmological examination including rose bengal staining confirmed sicca syndrome, and bilateral active scleritis with scleral thinning was also noted. Also the right retina showed a background pigmentary disturbance and several large fresh soft white exudates randomly distributed over the posterior pole. No retinal changes were seen in the left eye. Her right visual acuity was 6/18. At an ophthalmic examination six months earlier both retinae were normal and the right visual acuity 6/9.Investigations showed haemoglobin concentration 14 5 g/dl, viscosity 223 mPa s (223 cP), rheumatoid factor titre 1/2560, and antinuclear factor titre 1/40. C3 and C4 values were normal, though there was evidence of high concentrations of circulating immune complexes: anticomplementary activity 1/32 (normal 1/2). Clq binding was 65% (normal 20%0), platelet aggregation 1/512 (normal 1/16), and cryoglobulins positive. Chest radiography showed extensive old tuberculosis but results of sputum culture and microscopy were negative. The patient was treated with bed rest, non-steroidal anti-inflammatory drugs, local hypromellose and cortisone eye drops. After two months there was a noticeable improvement, and by six months the retinal changes had disappeared and visual acuity had improved. Her systemic rheumatoid disease also became less active, she gained weight, and tests for circulating immune complexes became negative. DiscussionRetinal vasculitis may complicate many systemic diseases,' including tuberculosis, sarcoidosis, Behcet's syndrome, and systemic lupus erythematosus. In a recent review2 of 17 patients with retinal vasculitis, immune complexes were found in the sera of 13 and rheumatoid factor was present in four.Vasculitis complicating rheumatoid arthritis3 4 usually occurs in nodular disease, with high titres of classical IgM rheumatoid factor and raised concentrations of circulating immune complexes. Infarcts in nailfold capillaries are often seen and weight loss and general malaise are common. Our patient had all these features, including circulating immune complexes detected by four different assays. The timing of the retinal disease and the observed rapid clinical improvement that accompanied the fall in concentrations of circulating immune complexes suggest that the retinal changes were a direct consequence of her active rheumatoid disease.We suggest that the retina should be examined for evidence of vasculitis in rheumatoid disease, and that vasculitis should be added to the list of ocular complications of rheumatoid arthritis. Haloperidol secreted in breast milk L J WHALLEY, P G BLAIN, J K PRIME Abstract A nursing mother was given haloperidol 5 mg twice daily for puerperal psychosis and continued to breast feed under hospital supervision. Despite considerable amounts of haloperidol being secreted in the breast milk (up to 23 5 tg/l), the infant was apparently not sedated, fed well, and continued to thrive. The fin...

SYNOPSISThe concentrations of total and free plasma tryptophan were measured in 12 unipolar depressed patients before and after a course of electroconvulsive therapy (ECT) and before and after single ECTs during the course of treatment. Eleven patients undergoing diagnostic cystoscopy served as controls to examine the acute effect of anaesthesia. Total and free plasma tryptophan concentrations in the depressed patients were not significantly different from control values and were not changed by the course of ECT. Free plasma tryptophan varied considerably within individual patients. Total plasma tryptophan was reduced acutely by ECT/anaesthesia in the depressed patients (P < 0·05) and by anaesthesia in the cystoscopy controls (P < 0·01). Free plasma tryptophan was not significantly altered. This reduction in total plasma tryptophan could be secondary to an effect of thiopentone on albumin binding of tryptophan.

Erythrocyte membrane adenosine triphosphatase activities were examined in twelve unipolar depressed patients receiving ECT. Eleven patients undergoing diagnostic cystoscopy served as controls for the acute effects of anaesthesia, and sixteen healthy subjects served as non-depressed controls. The unipolar depressed patients had a slight reduction in their (Na+ + K+)-ATPase activity but effective ECT treatment was not associated with any increase in this activity. This approach is unlikely to cast further light on the membrane phenomenology of depressive illness.

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