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STAFFING THE TRANSFUSION SERVICE
197 adult life, except occasionally from some site which may be diseased, the treatment of which may stop the bleeding-e.g., epistaxis. In this case the repeated haematemeses were associated with gross atrophic gastritis. Haemophilia in this case was established only after the thromboplastin-generation and prothrombin-consumption tests. The need for these elaborate tests is especially important when absence of family history may weigh against a diagnosis of haemophilia. Despite its risks, a major operation in a haemophiliac may have to be done when his life is endangered or disorganised by repeated bleeding. Generous transfusions with fresh blood before and during the operation is the only measure now available but it is our hope that the antihaemophilic globulin being prepared at the Radcliffe Infirmary, Oxford, may be made available to general hospitals and prove the best safeguard against post-
approach particular
operative bleeding. M. G. ELDIN E. T. BASSADONE.
St. Alfege’s Hospital, London, S.E.10.
STAFFING THE TRANSFUSION SERVICE
SiR,-Your annotation last week gives some idea of the difficulties of the transfusion service with regard to technical staffing, but these difficulties are only part of a greater problem of technical staffing of hospital and transfusion laboratories. There has been a considerable drain from these to industry over the past five years. The general salary-scale and prospects of technicians are unsatisfactory. It would appear that a recent offer by the management side does not offer for technicians any great advance on present scales or any advancement of prospects. My own opinion is that younger technicians have only stayed in the hospital and transfusion laboratory service in the hope that the forthcoming negotiations would give them pay and prospects materially better than those they have at the moment. Unless the management side undergoes a change of heart and makes a more realistic offer, I think that hospital and transfusion laboratories throughout the country are going to suffer a further disastrous loss of trained and partly trained technicians which will make the present level of service impossible. Group Pathological Laboratory, Lakin Road, Warwick.
A. P. PRIOR.
ACUTE INFECTIVE POLYNEURITIS
SIR,-Dr. Allison and Dr. Gordon (July 16), in their review of acute infective polyneuritis, attribute its first description to Guillain, Barre, and Strohl in 1916. It should be noted that, although we may now regard their two cases as falling into this group, these authors were under the impression that they were describing something quite different, which they called polyradiculoneuritis." Guillain maintained this distinction at least until the symposium of 1938. He and his colleagues were the first to draw attention to the rise in cerebrospinal-fluid protein without increase in cells, which was later found in other forms of polyneuritis, such as that of diphtheria. An earlier account of the clinical features was that of Laurens.1 I question whether many now believe that a virus is responsible for this syndrome. In spite of much experimental work, no acceptable evidence of transmission of an infective agent has ever been obtained. In recent years the biochemical approach has appeared much more hopeful. There have also been reports of successful treatment based on the hypothesis that an altered tissue sensitivity causes the manifestations. The aetiology is not only unknown, as your contributors observe, but may be various. Their demonstration of a mechanical " cause in their report is of much interest, but to apply this interpretation to the generality of such
introductory
"
patients, as your readers might be tempted to do, would be to ignore the post-mortem studies of many neuropathologists published during the last forty years. C. P. PETCH.
London, W.l.
LEUKÆMIA IN ANKYLOSING SPONDYLITIS TREATED WITH X RAYS
SiR,—I have read with great interest the article by Dr. Court Brown and Dr. Abbatt (June 25) concerning the incidence of leukaemia in ankylosing spondylitis treated with X rays. Their findings are obviously of extreme importance, but it would seem that a much more detailed investigation should be carried out before the role of irradiation in producing leukaemia in these cases can be assessed. For instance, the authors state that the incidence of leukaemia is appreciably raised in patients given more than one course of X-ray treatment. There is, however, a wide variation between different radiotherapy centres both in the dosage given and in the volume irradiated in the treatment of this disease. Some centres give. as much as 2500r in two weeks to the whole spine and sacro-iliac joints, while others give as little as 100r-150r a week for six to ten weeks, often limited to the part of the spine giving symptoms. It would be interesting to know : (1) whether the incidence of leukaemia varies directly with the X-ray dosage given and/or the volume irradiated, and, if so, what are the safe levels ; (2) the incidence of leukaemia in untreated cases. Radiotherapy Department, St. Thomas’s Hospital, London, S.E.1.
I. CHURCHILL-DAVIDSON.
TREATMENT OF STATUS EPILEPTICUS
SiR,—The recent admission to this hospital of a patient in status epilepticus who had failed to respond to the usual forms of treatment, and the admission of other cases of the same condition during the past nine years, prompts me to draw attention to a method of treatment which deserves to be more widely known. The only reference of I which am aware 1 deals with its published use in status epilepticus occurring as a complication of insulin-coma therapy. It is through the kindness of one of the authors of this article, Dr. S. W. Gillman, that I am recording the method anew. The patient, four years, the
of 28, has been a known epileptic for confirmed by an electroencephalogram in 1952. She has been in status epilepticus once before-in March, 1954. Her present attack began on May 8 and was initially controlled for a short time by intramuscular paraldehyde, but there was a recurrence on May 10 when she was admitted to this hospital as a temporary patient. On the morning of admission she had 16 grand-mal attacks. She was then given 5 ml. of a 10% solution of hexobarbitone This controlled her fits for sodium into each buttock. three hours, when a further two convulsions necessitated the injection of an additional 10 ml. This proved sufficient to establish control and she was then placed upon routine a woman
diagnosis having been
treatment with
phenobarbitone
and
primidone.
Intramuscular hexobarbitone sodium in doses between 0.5 g. and 1 g. has been used successfully at this hospital in the treatment of every case of status epilepticus for at least nine years. It has proved more reliable than the intramuscular injection of paraldehyde or phenobarbitone. Furthermore, it is technically easier to give than intravenous barbiturates in a patient with clonic movements, and the need for an anaesthetic machine to give positivepressure respiration does not arise. Although a 10% solution of hexobarbitone sodium is alkaline (pH 10-5), no local reactions have been found to occur if it is given deeply into the muscle. I am grateful to Dr. E. S. Stern for details of this case-
permission
to
publish
"
1. Paris thesis
no.
210; 1908.
The Central Hospital, near Warwick. 1.
PETER J. WILLIAMSON.
Gillman, S. W., Parfitt, D. N. J. ment. Sci. 1938, 84, 718.
approach particular
operative bleeding. M. G. ELDIN E. T. BASSADONE.
St. Alfege’s Hospital, London, S.E.10.
STAFFING THE TRANSFUSION SERVICE
SiR,-Your annotation last week gives some idea of the difficulties of the transfusion service with regard to technical staffing, but these difficulties are only part of a greater problem of technical staffing of hospital and transfusion laboratories. There has been a considerable drain from these to industry over the past five years. The general salary-scale and prospects of technicians are unsatisfactory. It would appear that a recent offer by the management side does not offer for technicians any great advance on present scales or any advancement of prospects. My own opinion is that younger technicians have only stayed in the hospital and transfusion laboratory service in the hope that the forthcoming negotiations would give them pay and prospects materially better than those they have at the moment. Unless the management side undergoes a change of heart and makes a more realistic offer, I think that hospital and transfusion laboratories throughout the country are going to suffer a further disastrous loss of trained and partly trained technicians which will make the present level of service impossible. Group Pathological Laboratory, Lakin Road, Warwick.
A. P. PRIOR.
ACUTE INFECTIVE POLYNEURITIS
SIR,-Dr. Allison and Dr. Gordon (July 16), in their review of acute infective polyneuritis, attribute its first description to Guillain, Barre, and Strohl in 1916. It should be noted that, although we may now regard their two cases as falling into this group, these authors were under the impression that they were describing something quite different, which they called polyradiculoneuritis." Guillain maintained this distinction at least until the symposium of 1938. He and his colleagues were the first to draw attention to the rise in cerebrospinal-fluid protein without increase in cells, which was later found in other forms of polyneuritis, such as that of diphtheria. An earlier account of the clinical features was that of Laurens.1 I question whether many now believe that a virus is responsible for this syndrome. In spite of much experimental work, no acceptable evidence of transmission of an infective agent has ever been obtained. In recent years the biochemical approach has appeared much more hopeful. There have also been reports of successful treatment based on the hypothesis that an altered tissue sensitivity causes the manifestations. The aetiology is not only unknown, as your contributors observe, but may be various. Their demonstration of a mechanical " cause in their report is of much interest, but to apply this interpretation to the generality of such
introductory
"
patients, as your readers might be tempted to do, would be to ignore the post-mortem studies of many neuropathologists published during the last forty years. C. P. PETCH.
London, W.l.
LEUKÆMIA IN ANKYLOSING SPONDYLITIS TREATED WITH X RAYS
SiR,—I have read with great interest the article by Dr. Court Brown and Dr. Abbatt (June 25) concerning the incidence of leukaemia in ankylosing spondylitis treated with X rays. Their findings are obviously of extreme importance, but it would seem that a much more detailed investigation should be carried out before the role of irradiation in producing leukaemia in these cases can be assessed. For instance, the authors state that the incidence of leukaemia is appreciably raised in patients given more than one course of X-ray treatment. There is, however, a wide variation between different radiotherapy centres both in the dosage given and in the volume irradiated in the treatment of this disease. Some centres give. as much as 2500r in two weeks to the whole spine and sacro-iliac joints, while others give as little as 100r-150r a week for six to ten weeks, often limited to the part of the spine giving symptoms. It would be interesting to know : (1) whether the incidence of leukaemia varies directly with the X-ray dosage given and/or the volume irradiated, and, if so, what are the safe levels ; (2) the incidence of leukaemia in untreated cases. Radiotherapy Department, St. Thomas’s Hospital, London, S.E.1.
I. CHURCHILL-DAVIDSON.
TREATMENT OF STATUS EPILEPTICUS
SiR,—The recent admission to this hospital of a patient in status epilepticus who had failed to respond to the usual forms of treatment, and the admission of other cases of the same condition during the past nine years, prompts me to draw attention to a method of treatment which deserves to be more widely known. The only reference of I which am aware 1 deals with its published use in status epilepticus occurring as a complication of insulin-coma therapy. It is through the kindness of one of the authors of this article, Dr. S. W. Gillman, that I am recording the method anew. The patient, four years, the
of 28, has been a known epileptic for confirmed by an electroencephalogram in 1952. She has been in status epilepticus once before-in March, 1954. Her present attack began on May 8 and was initially controlled for a short time by intramuscular paraldehyde, but there was a recurrence on May 10 when she was admitted to this hospital as a temporary patient. On the morning of admission she had 16 grand-mal attacks. She was then given 5 ml. of a 10% solution of hexobarbitone This controlled her fits for sodium into each buttock. three hours, when a further two convulsions necessitated the injection of an additional 10 ml. This proved sufficient to establish control and she was then placed upon routine a woman
diagnosis having been
treatment with
phenobarbitone
and
primidone.
Intramuscular hexobarbitone sodium in doses between 0.5 g. and 1 g. has been used successfully at this hospital in the treatment of every case of status epilepticus for at least nine years. It has proved more reliable than the intramuscular injection of paraldehyde or phenobarbitone. Furthermore, it is technically easier to give than intravenous barbiturates in a patient with clonic movements, and the need for an anaesthetic machine to give positivepressure respiration does not arise. Although a 10% solution of hexobarbitone sodium is alkaline (pH 10-5), no local reactions have been found to occur if it is given deeply into the muscle. I am grateful to Dr. E. S. Stern for details of this case-
permission
to
publish
"
1. Paris thesis
no.
210; 1908.
The Central Hospital, near Warwick. 1.
PETER J. WILLIAMSON.
Gillman, S. W., Parfitt, D. N. J. ment. Sci. 1938, 84, 718.