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EMERGENCY RESUSCITATION IN RUPTURED ECTOPIC GESTATION
287 RED-CELL DIAMETER IN INDONESIA
SIR,-Our investigations of red-cell diameter in our country show higher normal values of 7-39 ,u (male: 7-38 fl, female: 7-40 fJ.). subjects for these measurements were 30 males and 10 females, all members of the staff of preclinical departments. They showed no signs of anaemia and hxmoglobin level, redcell count, colour-index, packed-cell volume, and standard The
"
within normal limits. The technique used was the microprojection method described by Price Jones, but a groundglass screen was used. With this modification, magnification of 5000 times is still clear enough to distinguish the erythrocyte’s outlines sharply. 500 red cells were measured in each subject. Although we obtained higher values for mean corpuscular volume (80-3-116-7 c.,u) which is not surprising, we also obtained lower values for mean corpuscular haemoglobin (24-6-34-8 uyg.) and mean corpuscular haemoglobin concentration (285-376°,0). Clearly increase in diameter parallels increase in mean corpuscular volume but not necessarily mean
deviation
were
corpuscular hxmoglobin
or
mean
corpuscular haemoglobin
concentration. This suggests that Burker’s rule, which states that the haemoglobin content of the red cells is proportional to the surface area, is not valid for normal or for pathological cells. Department of Physiology, Airlangga University,
L. M.
Surabaja, Indonesia.
TJAN HOEN LAY.
EMERGENCY RESUSCITATION IN RUPTURED ECTOPIC GESTATION interested was in Dr. Azie’s letter of Dec. 12. SiR,—I As these cases are always extremely urgent I consider that looking for a compatible donor is a waste of time. I think that a slight improvement on Dr. Azie’s tech-
nique, where the facilities
are
available, is
as
follows:
When the patient is ready for operation an intravenous plasma dextrose saline drip is started. When this is working properly it is stopped, because, as Dr. Azie says, it is only diluting the blood and washing red cells into the peritoneum. The abdomen is then opened and the bleeding stopped in the usual way. A sterile transfusion bottle containing sodium citrate has in the meantime been attached to a sucker. The sucker is turned on and when the bottle is full it is exchanged for the plasma or saline bottle and blood-transfusion is started. Another transfusion bottle is then attached to the sucker. In this way several pints of blood may be collected rapidly for subsequent transfusion when the patient has returned to the ward. A bowl of sterile normal saline is kept handy in case the sucker becomes blocked. This method has the advantage that less blood is wasted and there is no guddling about with soup ladles, &c. Cameroons Development Corporation Medical Head Office, R. F. ANTONIO or
Bota/Victoria,
Southern Cameroons.
Chief Medical Officer.
HIGH PLASMA-IRON IN PORPHYRIA
SIR,-During the course of a survey of Africans with porphyria, we measured the plasma-iron levels in 23 consecutive patients, with the following results: In 15 cases, the plasma-iron was over 200 ug. per 100 ml., the highest being 345 //g. per 100 ml. (The mean plasma-iron level for normal African subjects in Durban is about 100 g. per 100 ml.) 2 of the remaining 8 patients had amoebic dysentery, and a 3rd had pulmonary tuberculosis; infections are known to lower plasma-iron values, and this may account for the relatively normal values found in these 3 patients.
Large increases in plasma-iron have, to our knowledge, been reported only in patients with haemochromatosis and transfusion siderosis,l in a proportion of African patients 1.
Rath, C. E., Finch, C. A. J. clin. Invest. 1949, 28, 79.
with nutritional siderosis,2 in infectious hepatitis,3 in some types of ansemia, and after iron administration. ..It would be of interest to know whether other workers have measured plasma-iron in cases with other types of porphyria. If similar high levels have been found, it might throw light on possible relationships between porphyrin biosynthesis and iron metabolism. M. HATHORN University of Natal, and King Edward VIII Hospital, N. MCE. LAMONT. Durban. THE COST OF DRUG TREATMENT
Sir,-Dr. Harman’s report of his impressions derived from " economy committees " are entertaining and no doubt are not meant to be taken seriously. As however his letter has prime place in your columns on Jan. 23 and refers to a serious problem in the economy of the N.H.S., comment from one to whom its conclusions are antipathetic may be justified. His first generalisation that waste is inevitable is followed by a defeatist recommendation that it had better It will be generally admitted that any be accepted. organisation which aims at efficiency takes steps to limit waste to the minimum, whether it be in the home, big business, or a Government department. In attempting to control extravagant expenditure in drugs the administrator can do little more than issue recommendations unless he interferes unduly with the doctor-patient relationship, and the drug houses cannot be prevented from advertising. On the other hand, the medical practitioner surely can by act and advice exert considerable influence. The cooperation of doctors is the key to the problem, and we should not divest ourselves of the social responsibility though it may not be a matter of direct self-interest. Savings on drug expenditure leave more for hospital building, more doctors, and more money for them. pay Whether a high drug bill should be a source of national pride is a matter of opinion. Certainly those who doubt the contribution of much drug-taking to what is called the positive health of the nation would not agree to the
proposition. In the last paragraph of Dr. Harman’s letter I do not know what is meant by its own law of growth ". Does it derive from Parkinson or Dr. Pangloss ? Anyhow I do not think the profession should adopt an attitude of laissez-faire in its approach to the problem at issue. MAX PAGE. Selling, Faversham, Kent. "
SIR,-In their paper of Jan. 2 Dr. Miller and Dr. Smith suggest that distributive costs may account for one-third of the total national drug bill. This is not unlikely. It should be realised that the cost of most consumer goods increases by at least 50% between leaving farm or factory and their purchase by the consumer (discounting the distorting effects of subsidies, purchase-tax, and similar taxes). Often the increase is far greater. The cost of distributing drugs in the National Health Service would thus not appear to be excessive in comnarison with the cost of distributing other consumer soods. West Middlesex Hospital, Isleworth, Middlesex.
J.
R. SEALE.
SIR,-Of the letters dealing with our paper, I think only that of Dr. Springett calls for a reply. P.A.S. is marketed in
manv
forms, and its basic
cost
varies bv
Gillman, T., Lamont, N. McE., Hathorn, M., Canham, P. A. S. Lancet, 1957, ii, 173. 3. Peterson, R. E. J. Lab. clin. Med. 1952, 39, 225. 2.
SIR,-Our investigations of red-cell diameter in our country show higher normal values of 7-39 ,u (male: 7-38 fl, female: 7-40 fJ.). subjects for these measurements were 30 males and 10 females, all members of the staff of preclinical departments. They showed no signs of anaemia and hxmoglobin level, redcell count, colour-index, packed-cell volume, and standard The
"
within normal limits. The technique used was the microprojection method described by Price Jones, but a groundglass screen was used. With this modification, magnification of 5000 times is still clear enough to distinguish the erythrocyte’s outlines sharply. 500 red cells were measured in each subject. Although we obtained higher values for mean corpuscular volume (80-3-116-7 c.,u) which is not surprising, we also obtained lower values for mean corpuscular haemoglobin (24-6-34-8 uyg.) and mean corpuscular haemoglobin concentration (285-376°,0). Clearly increase in diameter parallels increase in mean corpuscular volume but not necessarily mean
deviation
were
corpuscular hxmoglobin
or
mean
corpuscular haemoglobin
concentration. This suggests that Burker’s rule, which states that the haemoglobin content of the red cells is proportional to the surface area, is not valid for normal or for pathological cells. Department of Physiology, Airlangga University,
L. M.
Surabaja, Indonesia.
TJAN HOEN LAY.
EMERGENCY RESUSCITATION IN RUPTURED ECTOPIC GESTATION interested was in Dr. Azie’s letter of Dec. 12. SiR,—I As these cases are always extremely urgent I consider that looking for a compatible donor is a waste of time. I think that a slight improvement on Dr. Azie’s tech-
nique, where the facilities
are
available, is
as
follows:
When the patient is ready for operation an intravenous plasma dextrose saline drip is started. When this is working properly it is stopped, because, as Dr. Azie says, it is only diluting the blood and washing red cells into the peritoneum. The abdomen is then opened and the bleeding stopped in the usual way. A sterile transfusion bottle containing sodium citrate has in the meantime been attached to a sucker. The sucker is turned on and when the bottle is full it is exchanged for the plasma or saline bottle and blood-transfusion is started. Another transfusion bottle is then attached to the sucker. In this way several pints of blood may be collected rapidly for subsequent transfusion when the patient has returned to the ward. A bowl of sterile normal saline is kept handy in case the sucker becomes blocked. This method has the advantage that less blood is wasted and there is no guddling about with soup ladles, &c. Cameroons Development Corporation Medical Head Office, R. F. ANTONIO or
Bota/Victoria,
Southern Cameroons.
Chief Medical Officer.
HIGH PLASMA-IRON IN PORPHYRIA
SIR,-During the course of a survey of Africans with porphyria, we measured the plasma-iron levels in 23 consecutive patients, with the following results: In 15 cases, the plasma-iron was over 200 ug. per 100 ml., the highest being 345 //g. per 100 ml. (The mean plasma-iron level for normal African subjects in Durban is about 100 g. per 100 ml.) 2 of the remaining 8 patients had amoebic dysentery, and a 3rd had pulmonary tuberculosis; infections are known to lower plasma-iron values, and this may account for the relatively normal values found in these 3 patients.
Large increases in plasma-iron have, to our knowledge, been reported only in patients with haemochromatosis and transfusion siderosis,l in a proportion of African patients 1.
Rath, C. E., Finch, C. A. J. clin. Invest. 1949, 28, 79.
with nutritional siderosis,2 in infectious hepatitis,3 in some types of ansemia, and after iron administration. ..It would be of interest to know whether other workers have measured plasma-iron in cases with other types of porphyria. If similar high levels have been found, it might throw light on possible relationships between porphyrin biosynthesis and iron metabolism. M. HATHORN University of Natal, and King Edward VIII Hospital, N. MCE. LAMONT. Durban. THE COST OF DRUG TREATMENT
Sir,-Dr. Harman’s report of his impressions derived from " economy committees " are entertaining and no doubt are not meant to be taken seriously. As however his letter has prime place in your columns on Jan. 23 and refers to a serious problem in the economy of the N.H.S., comment from one to whom its conclusions are antipathetic may be justified. His first generalisation that waste is inevitable is followed by a defeatist recommendation that it had better It will be generally admitted that any be accepted. organisation which aims at efficiency takes steps to limit waste to the minimum, whether it be in the home, big business, or a Government department. In attempting to control extravagant expenditure in drugs the administrator can do little more than issue recommendations unless he interferes unduly with the doctor-patient relationship, and the drug houses cannot be prevented from advertising. On the other hand, the medical practitioner surely can by act and advice exert considerable influence. The cooperation of doctors is the key to the problem, and we should not divest ourselves of the social responsibility though it may not be a matter of direct self-interest. Savings on drug expenditure leave more for hospital building, more doctors, and more money for them. pay Whether a high drug bill should be a source of national pride is a matter of opinion. Certainly those who doubt the contribution of much drug-taking to what is called the positive health of the nation would not agree to the
proposition. In the last paragraph of Dr. Harman’s letter I do not know what is meant by its own law of growth ". Does it derive from Parkinson or Dr. Pangloss ? Anyhow I do not think the profession should adopt an attitude of laissez-faire in its approach to the problem at issue. MAX PAGE. Selling, Faversham, Kent. "
SIR,-In their paper of Jan. 2 Dr. Miller and Dr. Smith suggest that distributive costs may account for one-third of the total national drug bill. This is not unlikely. It should be realised that the cost of most consumer goods increases by at least 50% between leaving farm or factory and their purchase by the consumer (discounting the distorting effects of subsidies, purchase-tax, and similar taxes). Often the increase is far greater. The cost of distributing drugs in the National Health Service would thus not appear to be excessive in comnarison with the cost of distributing other consumer soods. West Middlesex Hospital, Isleworth, Middlesex.
J.
R. SEALE.
SIR,-Of the letters dealing with our paper, I think only that of Dr. Springett calls for a reply. P.A.S. is marketed in
manv
forms, and its basic
cost
varies bv
Gillman, T., Lamont, N. McE., Hathorn, M., Canham, P. A. S. Lancet, 1957, ii, 173. 3. Peterson, R. E. J. Lab. clin. Med. 1952, 39, 225. 2.