7 September 1968 Correspondence MEDICAL JOURNAL 617 ion of moderate severity and a-haemolytic plement fixation test. When the investiga- money. The user must decide whether to streptococci were cultured from the blood. tions were repeated 30 days after stopping analyse the cylinders himself or to accept the Br Med J: first published as 10.1136/bmj.3.5618.617-b on 7 September 1968. Downloaded from Six hundred mg. (1 mega unit) of benzylpenicillin penicillin therapy no agglutination could be manufacturer's certificate. If one assumes was given six-hourly by intramuscular injection. demonstrated by either technique. that our analyses gave the " right " values, This was increased to 1,200 mg. six-hourly when on the B.O.C. the temperature did not settle quite to normal. As in the previously reported cases, com- acceptance of the values Even so, low-grade fever persisted, and during paratively high doses of penicillin had been certificates would rarely have caused esti- the seventh week of treatment he developed a administered. The most striking feature of mates of blood-gas tensions to be more than sore throat and generalized muscular pains. our patient was the occurrence of agranulo- 1.0 mm. Hg "wrong." Whether the user There was pronounced neutropenia (total white cytosis on two occasions following penicillin analyses a cylinder or accepts the certificate cells 2,300/c.mm. with 2% neutrophil poly- and the demonstration of leucocyte antibodies it is wise to use the electrodes to compare a morphs), slight anaemia (haemoglobin 11.0 g./ during the second attack. As far as we are fresh cylinder with the old one before the old 100 ml.), and moderate thrombocytopenia (plate- been pre- is completely empty. lets 65,000/c.mm.). Penicillin was stopped, after aware thrombocytopenia has not one which the temperature became normal, symp- viously observed.-We are, etc., These gas mixtures are now available from toms disappeared, and the haematological values M. A. RosSITER. British Oxygen (Special Gases Department, the rapidly returned to normal. I. R. GRAY. British Oxygen Company, Deer Park Road, A second attack of infective endocarditis London S.W.19). We are grateful to Mr. R. C. occurred in December 1966, and a-haemolytic N. K. SHINTON. Warwickshire Postgraduate Heape, Mr. J. Pennington, and Mr. J. H. Scawin streptococci were again cultured from the blood. Medical Centre, for their enthusiastic collaboration. Intramuscular benzylpenicillin was given for Coventry, Warwicks. four days while waiting for sensitivity studies. -We are, etc., His treatment was then changed to phenethicillin REFERENCE E. J. M. CAMPBELL. with probenecid 1 g. l Gray, I. R., Tai, A. R., Wallace, J. G., and I g. six-hourly together Calder, J. H., Lancet, 1964, 2, 110. HELEN M. POPE. six-hourly, because it has previously been shown Department of Medicine, by one of us' that oral therapy is effective and Royal Postgraduate kinder to patients when the organism causing Medical School, infective endocarditis is fully sensitive to peni- Gas Mixtures for Calibration London W.12. cillin. The temperature, which had quickly fallen to normal, rose again during the second SIR,-The accuracy of blood P02 and Pco2 REFERENCE week of treatment. Although serum levels of measurements by the electrode techniques Lloyd, B. B., 7. Physiol. (Lond.), 1958, 143, SP. phenethicillin were high compared with the depends, among other factors, on the accu- sensitivity of the infecting organism it was racy of the gas mixtures used to calibrate the thought wise to* return to parenteral treatment electrodes. As the preparation and analysis with benzylpenicillin. The leucocyte count fell of these calibrating gas mixtures requires slightly during the first three weeks of treatment. the operation of the elec- During the fourth week the patient became quite more skill than with generalized muscular pains, sweat- trodes, most users now purchase their cali- Hereditary Quivering of the Chin unwell, brating gas mixtures. The demand for ing, and sore throat. The pharynx was red, but read your there was no ulceration and no significant numerous individual cylinders of " special" SIR,-I have been interested to bacterial growth from a throat-swab. Haemo- mixtures is now very great; their prepara- leading article (20 July, p. 138) and the globin was 11.1 g./100 ml.; leucocytes 800/ tion, analysis, and delivery are expensive. In ensuing correspondence about hereditary c.mm. with 4% neutrophil polymorphs, platelets our experience three gas mixtures greatly quivering of the chin. I have this condition 275,000/c.mm. Bone marrow showed normo- facilitate blood P02 and Pco2 measurement myself and so has my sister. My father, blastic erythropoiesis but absence of granulo- grandfather, and at least two of his sibs and myelocyte stage of develop- by spanning the most important range for cytes beyond the both gases; they are 4% C02, 13% 02; his mother also suffered with this. We have ment. Megakaryocytosis was normal. Penicillin by rapid move- was stopped, after which the temperature re- 6% C02, 11% 02; and 10% COa, 7% 02. all found it to be precipitated turned to normal within 24 hours. The leuco- We therefore approached the British Oxygen ments of the eyes such as playing table tennis cyte count rose to 5,500/c.mm. (62% neutrophil Company with the suggestion that they pro- or any ball game or watching birds flying, etc. polymorphs) after three days and remained vide these gas mixtures on loan stock. They It quite frequently occurs during sleep, and I http://www.bmj.com/ normal. After 30 days haemoglobin had risen agreed and undertook to prepare the mixtures have many times been woken up by an attack. to 12.5 g./l00 ml., and apart from,symptoms and, as an It has been most troublesome in childhood well. with a tolerance of ± 0.5% of the heart condition he has remained optional extra service, to supply a certificate and puberty, attacks tending to become in- Serological investigations: Erythrocytes- of analysis stating the composition to frequent and shorter in duration with age, Group 0 rhesus positive, phenotype ccDE. ±0.05%. This note is to draw attention to although different members of the family Direct Coombs test positive. Eluate showed this service and report the agreement between have been affected more badly than others. weak direct agglutination with pooled Group the manufacturers and our own analyses. I am at present trying to compile our com- and would appreciate O red cells suspended in both AB serum and Ten, cylinders of each gas mixture were re- plete family incidence, saline containing 40 mg./ml. benzylpeni- ceived between November 1966 and January being informed by any other affected persons on 25 September 2021 by guest. Protected copyright. cillin at 0' C., 22' C., and 370 C. High titre 1968, and analysed with the Lloyd-Haldane or by their doctors if they have any patients agglutination was found using an indirect apparatus. Each cylinder was analysed in dupli- with this complaint.-I am, etc., Coombs test with broad spectrum antihuman cate. Room air was analysed at each session globulin, antilgG, and antiIgM, again at all and the results were as follows: CO. 0.04%, ROSEMARY J. SIMPSON. three temperatures. Similar results were S.D. 0.022; 0, 20.92%, S.D. 0.028 (n=23). the serum with B.O.C. analysed the cylinders either by gas 14 St. Aubin's Park, obtained by testing patient's chromatography or by the Bone and Wheeler West Hayling, Group 0 cells treated with penicillin. Both absorption technique. All the cylinders supplied Hayling Island, serum and eluate reactions against penicillin- contaned gas mixtures within the specified toler- Hants. treated red cells were inhibited by previous ance of ±0.5%. The comparison between the exposure for 30 minutes to penicillin, IgM certificates supplied by B.O.C. and our analyses or IgG. There was no evidence of blood were as follows: Cerebral Malaria group specificity of the antibody present in the eluate or the serum. Thirty days after SIR,-It was with great interest that the the penicillin was stopped the direct Coombs C02 02 preliminary communication entitled "Use of in Cerebral Malaria," by test was negative and no penicillin red cell Mean difference +0.048 (B.O.C. Dexamethasone antibodies could be demonstrated. Leuco- an iR.P.M.S.) -0.003 Professor A. W. Woodruff and Dr. C. J. S.D. of difference 0.063 0.078 Dickinson (6 July, p. 31), was read at the cytes: There was direct agglutination of two S.E.M. of difference 0.01 is 0.014 out of four leucocyte suspensions. All four Maximum difference 0.22 -0.18 93rd Evacuation Hospital, Long Binh, Viet com- P <0.001

corded. Post-cerebral malaria (? oedema) complete recovery even after five days' deep base in medicine and social work (i.e., health residua have been non-existent (by psycholo- coma, and fully justifies persisting with visitors). Br Med J: first published as 10.1136/bmj.3.5618.617-b on 7 September 1968. Downloaded from gical and intelligence testing). We have used strenuous efforts to support the patient until Secondly, if workers dealing with the the drug as a life-saving measure in spite of consciousness returns. social factors of illness are entirely separated its reported ability to exacerbate dormant Falciparum malaria in the non-immune from the medical services a profoundly dis- amoebiasis and tuberculosis. Its effect on justly deserves the prefix " malignant," and turbing situation could arise. Patients re- melioidosis is unknown. in view of its increasing occurrence in Britain ferred for social difficulties with a medical We are taking our study one step further. must be recognized promptly and treated causation-e.g., physical and mental long- It is a clinical impression that if an absolute efficiently if we are to avoid fatal or near term handicap-could be " treated " by contraindication to a short course of steroids fatal results.-We are, etc., social workers with little or no medical in- (three days) does not exist, dexamethasone in sight. This, I feel, is extremely likely to doses of 4-6 mg. intravenously every 4-6 DAVID H. SMITH. occur if those workers (e.g., psychiatric social School of Tropical Medicine, hours decreases the morbidity of the disease. Liverpool 3. workers) connected with the disabled are in- Severe haemolysis (except in G.6-P.D. defi- PETER S. HARPER. corporated in the social work department. To ciency), cerebral malaria, renal and pulmonary David Lewis Northern Hospital, some extent this already happens. Anyone complications may be prevented or rapidly Liverpool 3. in the profession must surely regard the reversed. We have been disseminating this development of a second-rate medical con- information verbally. A protocol is being sultative service for the poor and socially followed, and when significant case numbers vulnerable as highly undesirable. are accumulated a report with positive results Intraperitoneal Blood Transfusion Thirdly, the social factors concerned with undoubtedly will be recorded. This brief SIR,- The paper by Dr. J. M. Fowler and the epidemiology would be much more diffi- letter may initially make physicians aware of others (27 July, p. 220) certainly demonstra- cult to elicit. This is because very few what may be a significant advance in a ted the effectiveness of intraperitoneal blood existing departments keep centralized records disease that is still a world-wide problem.- transfusion in the adult, but as an aid to the and are unlikely to develop them in the near I am, etc., treatment of 'severe anaemia there is a much future. RALPH G. ORISCELLO. simpler method. However, it is absolutely certain that social 93rd Evacuation Hospital, work should be organized in a single social A.P.O. S.F. 96491. If a short-acting diuretic is given during intravenous transfusion there follows a brisk work department. Indeed, the possibility of diuresis which prevents circulatory overload. social workers being stationed in the field in Fisher et al.,' using frusemide, have shown the health centre working alongside general this method to be successful, while Ledingham2 practitioners is an exciting one. Moreover, SIR,-Recently a Spanish sailor of 50 was some may argue that the Seebohm Report's admitted to a Liverpool hospital. He was has transfused patients initially in congestive heart failure by adding ethacrynic acid to the recommendations are based on the jealousy of transferred from his ship, which had just a very new profession for the skill, power, returned from the west coast of Africa via transfused blood. Blood transfusions under- taken in this hospital on children with thalas- and position of a very old profession. This, the Canaries, having been found unconscious I feel, is not true. However, initially, before in his cabin. Six days previously- he had saemia are always aided by a diuresis from frusemide, and over the past two years there responsibilities are delineated, it is important been seen on arrival in Bristol and given a to ascertain the true sociological role of the course of tetracycline for a pyrexia which have been no complications. The is itself. new social work department and to realize had started six days earlier, accompanied by technique simplicity The that a wrong analysis of the situation result- headache and chest signs. intravenous transfusion is started and 20 mg. of frusemide given intramuscularly. This ing in ill-trained staff in charge of the large On admission he was deeply unconscious with dose is repeated if the urine output falls resources governing medical services could no focal neurological abnormalities and was below This cause inefficiency, lack of co-ordination, and apyrexial. As his cabin locker had contained the level of the fluid intake. the prevention of progressive developments. large quantities of proprietary medicines he was method has wide application for all severe -I am, etc., initially considered to have taken an overdose of anaemias, unless associated with renal MARY E. BRENNAN. http://www.bmj.com/ drugs. Examination of the blood and urine, disease; does not require the apparatus for Coventry. however, failed to confirm this, and later the same exchange techniques, and retains an intact day he developed a fever of 100' F. (38' C.). REFERENCE peritoneum.-I am, etc., Report of the Committee on the Local Authority A lumbar puncture was entirely normal, but D. E. BRADFORD. and Allied Personal Social Services, 1968, blood films revealed infection with P. falciparum British Military Hospital, Cmnd. 3703. H.M.S.O., London. (malignant tertian malaria). The parasitaemia Dhekelia. was 9%. Mature forms including schizonts were REFERENCES found in the peripheral blood. He was treated Fisher, J. A., Gibbon, J. E., Netscher, M., and Bradford, D. E., Lancet, 1966, 2, 545. with parenteral chloroquine, and within 72 hours 2 the blood was clear of parasites. Corticosteroids Ledingham, J. G. G., Lancet, 1964, 1, 952. in the form of hydrocortisone hemisuccinate Purgatives and the Colon on 25 September 2021 by guest. Protected copyright. were given in high dosage, initially 200 mg. four- SIR,-As the manufacturers of standard- hourly, without any observable effect on the we have been greatly course of the illness. He remained comatose for Doctor or Social Worker? ised senna (Senokot) five days after admission, and during this time interested in the studies of Dr. F. Avery showed evidence of a left hemiparesis and SIR,-I found your leading article (3 Jones' and Dr. Barbara Smnith2 on the suffered a generalized epileptic attack. However, August, p. 265) on the Seebohm Committee's " cathartic colon " and especially in your he then rapidly regained consciousness and made report' very pertinent and the remarks of Dr. assessment of their work (13 July, p. 74) a full recovery with no residual neurological J. D. Kershaw (24 August, p. 497) equally "Purgatives and the Colon." sequelae. apt. I believe a few other points are also The histopathology described by Dr. In this patient diagnosis was delayed worth consideration. Smith clearly provides valuable objective several hours because the temperature was Firstly, the expansion of community care evidence of the cellular damage caused by normal on admission. The importance of programmes under medically qualified person- prolonged purging, but whether the effects blood-film examination in any unconscious nel capable of evaluating the service and the described are specific to a particular drug or patient who has recently returned from a needs of the individual within the service drugs, or whether they are the non-specific malaria endemic area cannot be too strongly would inevitably be stopped. Indeed, it seems effects of excessive purging, is open to ques- emphasized. In fact the diagnosis might well certain that existing provisions would be tion. Dr. Smith favours the idea of a specific have been made when the patient first pre- curtailed. Many hospital consultants now causation, because, as she puts it, " it is sented six days earlier with fever and head- recognize the value of comprehensive analysis almost impossible to wear out a physiological ache. Blood-film examination at that time of intertwining social and medical factors reflex in the presence of normal neurones." would have averted a severe illness and what both within and without the hospital setting, An alternative and, we think, a more likely could have been a fatal outcome. With and appreciate that, for the individual, the possibility is to be found in the atrophy successful treatment of the infection pro- service should be fully co-ordinated. This is which results from disuse of all muscle longed coma is unusual in cerebral malaria, surely better done by administrators trained tissue. In the case of the colon, motility but this case not only confirms that it does in medicine and sociology (i.e., social medi- mechanisms are easily disrupted, and we occur but also demonstrates the possibility of cine consultants) and field workers with a suggest that atony leading to atrophy of its