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THE TEACHING HOSPITAL
1125
Letters
to
the Editor
(myxoedema), and " My colour-blindness).
water
has turned
green " (hxmaturia
with
Cambridge.
ROBERT PLATT.
THE TEACHING HOSPITAL
SIR,-In your leading article (Nov. 13) you refer to the small special hospitals in London, and recommend the implementation of the plan to group many of them together. But you go on to say: " This will not be done unless the people who matter-the staffs of the hospitals-force the issue: which they are unlikely to do, since few of them have experienced a university medical centre." This comment displays an ignorance of the facts. We can assure you that the medical staffs of the small hospitals concerned have given their full support to the implementation of the plan to group several of them together on a site in Chelsea, as announced in Parliament by the then Minister of Health in June, 1961. Since that date, many of us have spent long hours on various planning committees and subcommittees, in the belief and hope that the plan would be implemented as soon as possible, and we have done all in our power to further that end. It now seems likely, however, that the plan will shortly be abandoned or, perhaps even worse, deferred for ten years; and this at a time when the architects have imaginatively solved most of the difficult problems involved in putting three formerly separate hospitals on one site. If you would advise us what further steps the medical staffs can take to ensure that the plan is implemented without delay-that is, to " force the issue "-and use your own influence to that end, we should all be grateful: as, we are sure, would many future generations of postgraduate students wishing to come to London to further their medical education and gain experience in a modern postgraduate hospital. D. M. WALLACE D. INNES WILLIAMS. St. Peter’s Hospital. J. J. STEVENSON R. B. C. PUGH. St. Paul’s Hospital. P. GREENING. Royal Marsden Hospital. St. Mark’s
Hospital.
H. E. LOCKHART-MUMMERY BASIL C. MORSON.
THE DIGITAL COMPUTER issue of last week contains an interesting special SIR,-Your article by a professor of chemical pathology and a research registrar which prompts me to call attention to some of the limitations of computer diagnosis. There is little doubt that the computer may help in some problems of diagnosis and prognosis: for instance, it might call attention to the importance of proteinuria in the prognosis of hypertension. But the diagnostic problems that it can help to solve are not usually the real difficulties which confront the doctor, and in any case the computer is only as good as the information fed into it. Anyone who has achieved eminence in the profession, whether his skill is real or imagined, soon becomes familiar with the syndrome of Pasbaltod, to use the modem craze for initialsin other words, " patients already seen by at least three other doctors "-and will soon know that the real problem is not that the other doctors have failed to realise that anxmia may be caused by hiatus hernia, or that renal-artery stenosis is said to be a cause of hypertension, but that no-one has yet taken an adequate history. Ask the hypertensive woman whose symptoms do not quite fit with her blood-pressure whether she is happy, and she may burst into tears. Of course there is no reason why this response should not be fed into a computer for the benefit of future diagnosticians, but it can only be fed in by those who recognise its significance. Nevertheless I am sympathetic to the ethical computer out to do its best, and I have been collecting a number of diagnostic symptoms worthy of memory-storage. The gems of the collection so far are " I can no longer do The Times crossword "
TETANUS PROPHYLAXIS
SIR,-I write in full support of your plea for universal active immunisation with tetanus toxoid (Nov. 13). But I cannot agree with your view that, until supplies of human antitetanus globulin (human A.T.G.) are adequate, or until the efficacy of careful wound cleansing and antibiotic prophylaxis is established beyond doubt, we shall have to depend largely on equine or bovine antisera for tetanus prophylaxis in the non-immune injured patient. Other workers, besides those you cite,2have discontinued using prophylactic tetanus antitoxin in all tetanus-prone patients, including those who have never been given tetanus toxoid, and recommend that the management of such patients should comprise adequate excision of wounds, antibiotics for five to seven days, and active immunisation with adsorbed tetanus toxoid. It has further been stated that thorough wound toilet makes the use of either tetanus antitoxin or prophylactic antibiotics unnecessary.33 You refer to the " danger of serum shock, which is occasionally fatal ", after a prophylactic injection of equine antitetanus serum, but make no mention of the serious neurological complications which may also occur. An extensive review of the published reports by Bardenwerper4 has revealed 130 cases of serum neuritis. There is a predilection for involvement of the brachial plexus, particularly c5 and c6, though the lumbar plexus may also be affected. Ocular, facial, intercostal, and diaphragmatic palsies have been reported, and death may occur as a result of encephalomyelitis and respiratory paralysis. In support of a previous plea for universal active immunisation with tetanus toxoidIpresented full clinical details of 2 further cases of serum neuritis which occurred after a prophylactic injection of tetanus antitoxin made with horseserum;6in 1 of these patients, in whom this complication appeared nine days after a test dose of only 175 units, considerable muscle weakness and wasting, and sensory loss, were still present some two years later, and permanent neurological sequelx were reported in 20% of published cases. Trinca’s recommendation,’ which you cite, that bovine antisera should be used " for patients showing sensitivity to horse-serum after a subcutaneous test injection " can therefore no longer be considered valid. But, because a prophylactic injection of tetanus antitoxin made with horse-serum is still being advocated and practised, I make no excuse for reiterating my view that adequate supplies of human A.T.G. must be made available for general use in of equine-derived tetanus antitoxin.6 Human A.T.G., which is non-antigenic in man, does not produce hyper" sensitivity reactions; and though, as you stress, it is scarce, since it must be obtained from volunteers ", surely in these days when so many people, including members of the Armed Forces, are being actively immunised, there should be no shortage of persons willing to donate blood,8 as has been demonstrated in Leeds, where human A.T.G. has been in use for some years.9 I thus cannot accept the recommendation of the Advisory Group on Protection against Tetanus 10 that " in those cases in which tetanus antitoxin is indicated a horse-serum preparation will almost always be appropriate ", and I therefore feel that the case against the use of equine-derived tetanus antitoxin requires restating." On the evidence submitted, and in the knowledge that even a test dose of tetanus antitoxin made with
place
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Hadgraft, J. W., Qvist, G., Ramsay, A. M., Thomas, P. K., Br. med. J. 1964, i, 768. Cox, C. A., Knowelden, J., Sharrard, W. J. W. ibid. 1963, ii, 1360. Bourns, H. K. ibid. 1964, ii, 571. Bardenwerper, H. W. J. Am. med. Ass. 1962, 179, 763. Br. med. J. 1963, i, 902. Freeman, A. G. ibid. p. 1738; ibid. 1964, ii, 247. Trinca, J. C. Med. J. Aust. July 17, 1965, p. 113. Bousfield, G. Br. med. J. 1964, ii, 446. Ellis, M. ibid. 1963, i, 1123. See Lancet, 1964, ii, 196. Freeman, A. G. Br. med. J. Oct. 23, 1965, p. 986.
Letters
to
the Editor
(myxoedema), and " My colour-blindness).
water
has turned
green " (hxmaturia
with
Cambridge.
ROBERT PLATT.
THE TEACHING HOSPITAL
SIR,-In your leading article (Nov. 13) you refer to the small special hospitals in London, and recommend the implementation of the plan to group many of them together. But you go on to say: " This will not be done unless the people who matter-the staffs of the hospitals-force the issue: which they are unlikely to do, since few of them have experienced a university medical centre." This comment displays an ignorance of the facts. We can assure you that the medical staffs of the small hospitals concerned have given their full support to the implementation of the plan to group several of them together on a site in Chelsea, as announced in Parliament by the then Minister of Health in June, 1961. Since that date, many of us have spent long hours on various planning committees and subcommittees, in the belief and hope that the plan would be implemented as soon as possible, and we have done all in our power to further that end. It now seems likely, however, that the plan will shortly be abandoned or, perhaps even worse, deferred for ten years; and this at a time when the architects have imaginatively solved most of the difficult problems involved in putting three formerly separate hospitals on one site. If you would advise us what further steps the medical staffs can take to ensure that the plan is implemented without delay-that is, to " force the issue "-and use your own influence to that end, we should all be grateful: as, we are sure, would many future generations of postgraduate students wishing to come to London to further their medical education and gain experience in a modern postgraduate hospital. D. M. WALLACE D. INNES WILLIAMS. St. Peter’s Hospital. J. J. STEVENSON R. B. C. PUGH. St. Paul’s Hospital. P. GREENING. Royal Marsden Hospital. St. Mark’s
Hospital.
H. E. LOCKHART-MUMMERY BASIL C. MORSON.
THE DIGITAL COMPUTER issue of last week contains an interesting special SIR,-Your article by a professor of chemical pathology and a research registrar which prompts me to call attention to some of the limitations of computer diagnosis. There is little doubt that the computer may help in some problems of diagnosis and prognosis: for instance, it might call attention to the importance of proteinuria in the prognosis of hypertension. But the diagnostic problems that it can help to solve are not usually the real difficulties which confront the doctor, and in any case the computer is only as good as the information fed into it. Anyone who has achieved eminence in the profession, whether his skill is real or imagined, soon becomes familiar with the syndrome of Pasbaltod, to use the modem craze for initialsin other words, " patients already seen by at least three other doctors "-and will soon know that the real problem is not that the other doctors have failed to realise that anxmia may be caused by hiatus hernia, or that renal-artery stenosis is said to be a cause of hypertension, but that no-one has yet taken an adequate history. Ask the hypertensive woman whose symptoms do not quite fit with her blood-pressure whether she is happy, and she may burst into tears. Of course there is no reason why this response should not be fed into a computer for the benefit of future diagnosticians, but it can only be fed in by those who recognise its significance. Nevertheless I am sympathetic to the ethical computer out to do its best, and I have been collecting a number of diagnostic symptoms worthy of memory-storage. The gems of the collection so far are " I can no longer do The Times crossword "
TETANUS PROPHYLAXIS
SIR,-I write in full support of your plea for universal active immunisation with tetanus toxoid (Nov. 13). But I cannot agree with your view that, until supplies of human antitetanus globulin (human A.T.G.) are adequate, or until the efficacy of careful wound cleansing and antibiotic prophylaxis is established beyond doubt, we shall have to depend largely on equine or bovine antisera for tetanus prophylaxis in the non-immune injured patient. Other workers, besides those you cite,2have discontinued using prophylactic tetanus antitoxin in all tetanus-prone patients, including those who have never been given tetanus toxoid, and recommend that the management of such patients should comprise adequate excision of wounds, antibiotics for five to seven days, and active immunisation with adsorbed tetanus toxoid. It has further been stated that thorough wound toilet makes the use of either tetanus antitoxin or prophylactic antibiotics unnecessary.33 You refer to the " danger of serum shock, which is occasionally fatal ", after a prophylactic injection of equine antitetanus serum, but make no mention of the serious neurological complications which may also occur. An extensive review of the published reports by Bardenwerper4 has revealed 130 cases of serum neuritis. There is a predilection for involvement of the brachial plexus, particularly c5 and c6, though the lumbar plexus may also be affected. Ocular, facial, intercostal, and diaphragmatic palsies have been reported, and death may occur as a result of encephalomyelitis and respiratory paralysis. In support of a previous plea for universal active immunisation with tetanus toxoidIpresented full clinical details of 2 further cases of serum neuritis which occurred after a prophylactic injection of tetanus antitoxin made with horseserum;6in 1 of these patients, in whom this complication appeared nine days after a test dose of only 175 units, considerable muscle weakness and wasting, and sensory loss, were still present some two years later, and permanent neurological sequelx were reported in 20% of published cases. Trinca’s recommendation,’ which you cite, that bovine antisera should be used " for patients showing sensitivity to horse-serum after a subcutaneous test injection " can therefore no longer be considered valid. But, because a prophylactic injection of tetanus antitoxin made with horse-serum is still being advocated and practised, I make no excuse for reiterating my view that adequate supplies of human A.T.G. must be made available for general use in of equine-derived tetanus antitoxin.6 Human A.T.G., which is non-antigenic in man, does not produce hyper" sensitivity reactions; and though, as you stress, it is scarce, since it must be obtained from volunteers ", surely in these days when so many people, including members of the Armed Forces, are being actively immunised, there should be no shortage of persons willing to donate blood,8 as has been demonstrated in Leeds, where human A.T.G. has been in use for some years.9 I thus cannot accept the recommendation of the Advisory Group on Protection against Tetanus 10 that " in those cases in which tetanus antitoxin is indicated a horse-serum preparation will almost always be appropriate ", and I therefore feel that the case against the use of equine-derived tetanus antitoxin requires restating." On the evidence submitted, and in the knowledge that even a test dose of tetanus antitoxin made with
place
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Hadgraft, J. W., Qvist, G., Ramsay, A. M., Thomas, P. K., Br. med. J. 1964, i, 768. Cox, C. A., Knowelden, J., Sharrard, W. J. W. ibid. 1963, ii, 1360. Bourns, H. K. ibid. 1964, ii, 571. Bardenwerper, H. W. J. Am. med. Ass. 1962, 179, 763. Br. med. J. 1963, i, 902. Freeman, A. G. ibid. p. 1738; ibid. 1964, ii, 247. Trinca, J. C. Med. J. Aust. July 17, 1965, p. 113. Bousfield, G. Br. med. J. 1964, ii, 446. Ellis, M. ibid. 1963, i, 1123. See Lancet, 1964, ii, 196. Freeman, A. G. Br. med. J. Oct. 23, 1965, p. 986.