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BETTER OPERATING CONDITIONS
1164
preparation of clear metaphase figures from various organs of Every American physician, whether specialist or family the chick-embryo.7 Male (ZZ) and female (ZW) avian cells doctor, is a diagnostician: he, and not the machine, makes can be readily distinguished from each other in good preparathe diagnosis, but a modicum of diagnostic equipment is a tions, since the Z chromosome is the only large mediocentric must for all except the " witch doctor ". The passing element present. This chromosome-marker technique in a of the general practitioner is mourned by few, since study on blood-cell chimxrism in twin embryos9 afforded the the internist and the paediatrician, singly or in combinaopportunity of investigating possible germ-cell chimxrism. are fully capable of taking over. There never was a Unfortunately a very high mortality is found in embryos tion, derived from double-yolked eggs, and only two pairs of embryos practitioner who was really general any way, except as a of 11 and 12 days’ incubation were obtained. In the pair pipedream of wishful thinking. The infirm, old, and poor sampled at 11 days’ incubation, 20% (4 mitotic figures out of a are no less well taken care of by a family internist who total of 20) of the dividing cells in the male gonads were of does not do surgery or obstetrics, but who is well trained female sex; no metaphase figures were obtained from the in treating their disorders. female partner. In the pair sampled at 12 days’ incubation 14% GEORGE VASH. (5 mitoses in a total 35) of dividing cells were female in the male gonads, but no cells of male sex were found in a total of 18 metaphases from the female gonad. PHYTOHÆMAGGLUTININ IN THE TREATMENT OF "
"
The
of the dividing cells sampled is unknown; the chimserism although may be in cell types other than these observations germ cells, provide some supporting evidence that germ-cell chimxrism may exist and may be important in the genital abnormalities noted. M. A. S. MOORE Anthropology Laboratory, Department of Human Anatomy, J. J. T. OWEN. South Parks Road, Oxford.
SIR,-Humble1 presented evidence which suggested that phytohaemagglutinin (P.H.A.) might be efficacious in aplastic anaemia, and Baker and Oliver2 believed that P.H.A. might have been responsible for a remission in a case induced by phenylbutazone. Gruenwald et awl. reported a patient with severe marrow hypoplasia (possibly due to
BETTER OPERATING CONDITIONS SIR,-In your leading article (May 15) the establishment of theatre sterile supply units (T.s.s.u.) is suggested, and you say that " this system ... is in use in the
with phenacetin) who recovered after three of P.H.A., the third following splenectomy; and another in whom there was evidence of bone-marrow stimulation when P.H.A. was given for hypoplastic anaemia induced by busulphan therapy. In a third patient, in
nature
APLASTIC ANÆMIA
treatment
This statement is incorrect-the system used here is the Edinburgh pre-set tray system and the unit providing the service is a theatre service centre (T.S.C.).IO Your leading article is misleading in that a T.s.c., unlike a T.S.S.U., supplies packed sanitised equipment (e.g., for anxsthesia) as well as sterile packs. Further, all surgical instruments and soft goods required for an operation are packed together in order of use in special trays before sterilisation and are thus ready for immediate use in the operating-room. A T.s.s.u. entails the provision of gravity-displacement instrument sterilisers and sterile trolley-setting-rooms, neither of which are required with
Edinburgh Royal Infirmary ...".
a T.S.C.
Bacteriological Department, Royal Infirmary of Edinburgh.
J. H. BOWIE.
THE AMERICAN PHYSICIAN
SIR, Your quotation from The Economist (April 17) brief but devastating with bias, slant, and error.
was
As an internist, who used to be a G.P., I am familiar both with family doctors and specialists in several American states. After twenty-five years of working with colleagues in Oregon, Massachusetts, Louisiana, West Virginia, and Maryland, I have yet to find justification for the third sentence, "Diagnosis is done with a battery of machines and gadgets by a diagnostician... ". On the contrary, both American family physicians and specialists are at home at the hospital. Both make far fewer house calls now than twenty years ago, since the hospital outpatient department takes care of most picayune " emergencies " which, I understand, bedevil our colleagues in England. A slight amount of "gadgetry" is, of course, necessary here, as it is everywhere in the world, for, without X-rays and blood examination, diseases of the gastrointestinal tract and bloodforming organs, to mention only two areas, are impossible to diagnose: guessing, of course, can be done without any instruments. 7. Owen, J. J. T. Chromosoma (in the press). 8. Owen, J. J. T., Moore, M. A. S., Harrison, G. A. Nature, Lond. (in the press). 9. Moore, M. A. S., Owen, J. J. T. Unpublished. 10. Bowie, J. H., Gillingham, F. J., Campbell, I. O., Gordon, A. R. Br. med. J. 1963, ii, 1322.
courses
whom
a totally aplastic marrow developed for no known during pregnancy, P.H.A. was without demonstrable effect. Astaldi et al. report some improvement in a patient with primary aplastic anaemia treated by the removal of peripheral-blood leucocytes, cultivation of these in vitro in a medium containing P.H.A., and injection of the tissueculture after forty-eight hours into the patient’s bonemarrow cavity. Others 5 6 have had a more disappointing experience of the drug, and in the following case of aplastic ansemia no improvement followed treatment with P.H.A. A 56-year-old housewife was admitted to this hospital on Dec. 22, 1964. Throughout her life she had bruised easily, but, 2 months before admission, after completing an 8-week course of ’ Delta-butazolidine ’ two tablets twice daily (each tablet contains phenylbutazone 50 mg. and prednisone 1-25 mg.) prescribed elsewhere, this bruising tendency had become more pronounced; she was pale and had developed purpura. There were no abnormal physical signs except those of anxmia and widespread purpura and bruising. A blood-count showed: hxmoglobin 45% (6-6 g. per 100 ml.); white blood-cells 2000 per c.mm. (neutrophils 180, lymphocytes 1760, monocytes 60); platelets less than 10,000 per c.rrim.; reticulocytes 0-3%. Sternal marrow puncture revealed a severely hypoplastic
reason
marrow.
Repeated transfusions with whole blood and platelets, comlarge doses of prednisone, produced only transient improvement; and the addition of testosterone later in the illness had no better result. From Jan. 14 to 20, 1965, seven injections of P.H.A. were given as described by Humbler treatment with prednisone being continued. There was no bined with
noticeable effect
on
the clinical condition
or on
the blood-
picture ; and the atypical mononuclear cells, described by Humble, were not observed in the peripheral blood. Sideeffects were mild and consisted in a diffuse sensation of heat after each injection.and a rise of temperature to 99°F (35-4°C) after the first injection. Three more injections of P.H.A. were given from Jan. 26 to 28, again without benefit. The patient’s 1. Humble, J. G. Lancet, 1964, i, 1345. Baker, G. P., Oliver, R. A. M. ibid. Feb. 20, 1965, p. 438. Gruenwald, H., Taub, R. N., Wong, F. M., Kiossoglou, K. A., Dameshek, W. ibid. May 1, 1965, p. 962. 4. Astaldi, G., Airò, R., Sauli, S., Costa, G. ibid. May 15, 1965, p. 1070. 5. Fleming, A. F. ibid. 1964, ii, 648. 6. Retief, F. P., Wasserman, H. P., Hofmeyer, N. G. ibid. p. 1343. 2. 3.
preparation of clear metaphase figures from various organs of Every American physician, whether specialist or family the chick-embryo.7 Male (ZZ) and female (ZW) avian cells doctor, is a diagnostician: he, and not the machine, makes can be readily distinguished from each other in good preparathe diagnosis, but a modicum of diagnostic equipment is a tions, since the Z chromosome is the only large mediocentric must for all except the " witch doctor ". The passing element present. This chromosome-marker technique in a of the general practitioner is mourned by few, since study on blood-cell chimxrism in twin embryos9 afforded the the internist and the paediatrician, singly or in combinaopportunity of investigating possible germ-cell chimxrism. are fully capable of taking over. There never was a Unfortunately a very high mortality is found in embryos tion, derived from double-yolked eggs, and only two pairs of embryos practitioner who was really general any way, except as a of 11 and 12 days’ incubation were obtained. In the pair pipedream of wishful thinking. The infirm, old, and poor sampled at 11 days’ incubation, 20% (4 mitotic figures out of a are no less well taken care of by a family internist who total of 20) of the dividing cells in the male gonads were of does not do surgery or obstetrics, but who is well trained female sex; no metaphase figures were obtained from the in treating their disorders. female partner. In the pair sampled at 12 days’ incubation 14% GEORGE VASH. (5 mitoses in a total 35) of dividing cells were female in the male gonads, but no cells of male sex were found in a total of 18 metaphases from the female gonad. PHYTOHÆMAGGLUTININ IN THE TREATMENT OF "
"
The
of the dividing cells sampled is unknown; the chimserism although may be in cell types other than these observations germ cells, provide some supporting evidence that germ-cell chimxrism may exist and may be important in the genital abnormalities noted. M. A. S. MOORE Anthropology Laboratory, Department of Human Anatomy, J. J. T. OWEN. South Parks Road, Oxford.
SIR,-Humble1 presented evidence which suggested that phytohaemagglutinin (P.H.A.) might be efficacious in aplastic anaemia, and Baker and Oliver2 believed that P.H.A. might have been responsible for a remission in a case induced by phenylbutazone. Gruenwald et awl. reported a patient with severe marrow hypoplasia (possibly due to
BETTER OPERATING CONDITIONS SIR,-In your leading article (May 15) the establishment of theatre sterile supply units (T.s.s.u.) is suggested, and you say that " this system ... is in use in the
with phenacetin) who recovered after three of P.H.A., the third following splenectomy; and another in whom there was evidence of bone-marrow stimulation when P.H.A. was given for hypoplastic anaemia induced by busulphan therapy. In a third patient, in
nature
APLASTIC ANÆMIA
treatment
This statement is incorrect-the system used here is the Edinburgh pre-set tray system and the unit providing the service is a theatre service centre (T.S.C.).IO Your leading article is misleading in that a T.s.c., unlike a T.S.S.U., supplies packed sanitised equipment (e.g., for anxsthesia) as well as sterile packs. Further, all surgical instruments and soft goods required for an operation are packed together in order of use in special trays before sterilisation and are thus ready for immediate use in the operating-room. A T.s.s.u. entails the provision of gravity-displacement instrument sterilisers and sterile trolley-setting-rooms, neither of which are required with
Edinburgh Royal Infirmary ...".
a T.S.C.
Bacteriological Department, Royal Infirmary of Edinburgh.
J. H. BOWIE.
THE AMERICAN PHYSICIAN
SIR, Your quotation from The Economist (April 17) brief but devastating with bias, slant, and error.
was
As an internist, who used to be a G.P., I am familiar both with family doctors and specialists in several American states. After twenty-five years of working with colleagues in Oregon, Massachusetts, Louisiana, West Virginia, and Maryland, I have yet to find justification for the third sentence, "Diagnosis is done with a battery of machines and gadgets by a diagnostician... ". On the contrary, both American family physicians and specialists are at home at the hospital. Both make far fewer house calls now than twenty years ago, since the hospital outpatient department takes care of most picayune " emergencies " which, I understand, bedevil our colleagues in England. A slight amount of "gadgetry" is, of course, necessary here, as it is everywhere in the world, for, without X-rays and blood examination, diseases of the gastrointestinal tract and bloodforming organs, to mention only two areas, are impossible to diagnose: guessing, of course, can be done without any instruments. 7. Owen, J. J. T. Chromosoma (in the press). 8. Owen, J. J. T., Moore, M. A. S., Harrison, G. A. Nature, Lond. (in the press). 9. Moore, M. A. S., Owen, J. J. T. Unpublished. 10. Bowie, J. H., Gillingham, F. J., Campbell, I. O., Gordon, A. R. Br. med. J. 1963, ii, 1322.
courses
whom
a totally aplastic marrow developed for no known during pregnancy, P.H.A. was without demonstrable effect. Astaldi et al. report some improvement in a patient with primary aplastic anaemia treated by the removal of peripheral-blood leucocytes, cultivation of these in vitro in a medium containing P.H.A., and injection of the tissueculture after forty-eight hours into the patient’s bonemarrow cavity. Others 5 6 have had a more disappointing experience of the drug, and in the following case of aplastic ansemia no improvement followed treatment with P.H.A. A 56-year-old housewife was admitted to this hospital on Dec. 22, 1964. Throughout her life she had bruised easily, but, 2 months before admission, after completing an 8-week course of ’ Delta-butazolidine ’ two tablets twice daily (each tablet contains phenylbutazone 50 mg. and prednisone 1-25 mg.) prescribed elsewhere, this bruising tendency had become more pronounced; she was pale and had developed purpura. There were no abnormal physical signs except those of anxmia and widespread purpura and bruising. A blood-count showed: hxmoglobin 45% (6-6 g. per 100 ml.); white blood-cells 2000 per c.mm. (neutrophils 180, lymphocytes 1760, monocytes 60); platelets less than 10,000 per c.rrim.; reticulocytes 0-3%. Sternal marrow puncture revealed a severely hypoplastic
reason
marrow.
Repeated transfusions with whole blood and platelets, comlarge doses of prednisone, produced only transient improvement; and the addition of testosterone later in the illness had no better result. From Jan. 14 to 20, 1965, seven injections of P.H.A. were given as described by Humbler treatment with prednisone being continued. There was no bined with
noticeable effect
on
the clinical condition
or on
the blood-
picture ; and the atypical mononuclear cells, described by Humble, were not observed in the peripheral blood. Sideeffects were mild and consisted in a diffuse sensation of heat after each injection.and a rise of temperature to 99°F (35-4°C) after the first injection. Three more injections of P.H.A. were given from Jan. 26 to 28, again without benefit. The patient’s 1. Humble, J. G. Lancet, 1964, i, 1345. Baker, G. P., Oliver, R. A. M. ibid. Feb. 20, 1965, p. 438. Gruenwald, H., Taub, R. N., Wong, F. M., Kiossoglou, K. A., Dameshek, W. ibid. May 1, 1965, p. 962. 4. Astaldi, G., Airò, R., Sauli, S., Costa, G. ibid. May 15, 1965, p. 1070. 5. Fleming, A. F. ibid. 1964, ii, 648. 6. Retief, F. P., Wasserman, H. P., Hofmeyer, N. G. ibid. p. 1343. 2. 3.