345 left to conclude that reduced placental blood-flow due to myometrial tension is linked with renal states, biochemically detectable, in which diminished glomerular filtration and renal blood-flow occur—suggestion of the Trueta mechanism. According to Bradley, this pattern characterises both acute glomerular nephritis and pre-eclamptic toxæmia. Perhaps a more reasonable integration of Browno and Veale’s valuable data in the setiological thesis of preeclampsia is held by you or by others. My communication invites it. JOHN SOPHIAN. Salisbury, Southern Rhodesia. JOHN
THE WRONG BLOOD
SIR,—Your leader of Aug.
1 and Dr. James’s review in blood-transfusion (p. 243) of the legal responsibility are indeed timeous and very necessary ; for, in general, there appears to be a peculiar unawareness of the risks of blood-transfusion and an equal absence of precautionary measures, as judged by most of the fatal incompatible transfusions reported in the national and
local press. In the North-East Metropolitan Region the subject of blood-transfusion in hospitals of all kinds was considered jointly by the Senior Administrative Medical Officer and all the pathologists about two years ago ; and the Regional Advisory Committee in Pathology prepared memoranda on the administrative, clinical, and serological aspects. Thus, in accordance with R.H.B.
(51)82/3(1), hospital management
mittees were advised that blood-banks should be under the care of the hospital pathologist and that they should ensure that satisfactory arrangements were made for the care of the bank and for and crossmatching at night and at weekends by supervised resident Likewise pathologists or experienced technicians. medical advisory committees were asked to have regard to the need for transfusion as evidenced by blood-loss, and they were acquainted of the risk of errors in grouping and matching being proportionate to the urgency of the demand, and also of the time of two hours now deemed necessary for the adequate serological tests to determine blood-groups and compatibility. Cooperation of clinicians was invited for the greater use of plasma and plasma-substitutes for immediate fluid replacement pending blood-grouping and matching.
followed in determining the ABO and Rh group of the recipient and in
always to verify the patient’s group was stressed, and methods The to be adopted in cases of urgency were approved. memorandum on methods was later expanded and revised by the Ministry’s Adviser on Blood-transfusion and circulated in other regions. As regards the prevention of errors from the confusion of names, an inadequate history of previous transfusions, the labelling of specimens, and the checking of the bottle of blood to be given to a particular patient, two main A special form was printed for measures were introduced. use throughout the region to facilitate complete grouping and of compatible blood for transfusion. This form provides for a note of previous transfusions and any reactions, and of stillbirths and jaundiced babies, as well as an indication of how much blood is required and when. The reverse of the form is used to record the .patient’s group and the blood matched, with a note of the tests in saline and in albumin, the time allowed for the tests, the gram-stained film of the donor blood, and the signatures of the technician and the doctor checking the tests. Group-coloured tie-on labelsare attached to each bottle of blood when matched so that a final check may be made at the bedside.
ments in this
equal importance are the administrative arrangehospital to provide matched blood
Mth the minimum of handling and absolute safety. It may be helpful to
delay and with give the arrange-
6. Sophian, J. Symposium on Circulation. Ciba Foundation, 1952. 7. Bradley, S. E., Bradley, G. P., Tyson, C. J., Curry, J., Blake, W. D. Amer. J. Med. 1950, 9, 772.
from the aide-memoire
to all members of the medical staff
and which is suitably displayed : joiiiiiig " Matched blood is placed in the refrigerator in the main corridor where it is reserved for two days and from which place it is to be taken : (i) by a member of the medical staff only ; (ii) immediately before use, 1 pint only at a time (except at night when 2 pints allowed) ; and (iii) date, time, and signature entered against each bottle removod, on the appropriate line and sheet. (All bottles in the
account is blood to be taken and kept in a ward refrigerator. Blood matched for a patient is for that patient and none other. Matched blood must not be taken for emergency cases ; unmatched blood is available for emergencies. " It is a doctor’s responsibility to check, with the help of the’luggage ’ label tied to each bottle, that each recipient is transfused with the blood specially matched for him or her. The names of the recipient and blooddonor must be checked with those on theluggage ’ label, first when the blood is taken from the refrigerator, and finally when double-checked (preferably witnessede.g., by a nurse) before the blood is given. Neither the dutv of collection of the blood from the refrigerator nor the responsibility of the actual transfusion, including changing from saline or other fluid to blood, is to be delegated to a nursing sister or other nursing member. Blood required as soon as matched will be issued to the orderly or nurse sent to collect it only on receipt of a note of the patient’s (recipient’s) full name, age, and ward, at the laboratorv. Packed cells deteriorate rapidly and are to be given immediately after they have been packed. All blood should be matched before transfusion. When in extreme emergency this is not feasible and group-0 blood is used. it is essential that a sample of the patient’s blood (as for Wassermann reaction) be secured before transfusion is begun in order that the patient’s own group can be determined in the laboratory later and the patient’s serum used for further matching. The demand for blood is undiminished. All doctors are asked to obtain replacement volunteers from relatives On
The disquieting number of reports of incompatible blood-transfusions has also engaged the attention of the Consulting Pathologists Group Committee of the British Medical Association and a note of their views will appear
shortly. Finally, should a " human error " result in incompatible transfusion, appropriate treatment, having regard to the water balance and carbohydrate and fat diet in the oliguric and/or anuric phase and in the later diuretic phases, should be instituted in cases with resulting renal damage. It is a matter of regret and disquiet that even now these patients may not have the benefit of the valuable studies of Bull, Joekes, and Lowe, published three years ago. North Middlesex Hospital, London, N.18.
ments made in each
J. F. HEGGIE,
Chairman, Pathology Advisory Committee, North-East Metropolitan Region. ENDOCRINE FACTORS IN AFFECTIVE DISORDERS
SIR,—If the practitioners in Warwickshire have been into using ’Menopax ’ for climacteric women,. Professor McLaren is obviously going to have his clinic burdened with cases of oestrogen withdrawal bleeding. One menopax tablet, containing 0.01 mg. ethinyl oestradiol, has 40 times the oestrogenic activity of 0- 1 mg. oestrone, the unit I advised. A dose of such magnitude could have no place in the treatment of a " negativestate balance " in an elderly woman, which was the point under discussion. (I base my figure on the com-
Bull, G. M., Joekes, A. M., Lowe, Clin. Sci. 1950, 9, 379.
Lancet, 1949, ii, 229;
346 of cestrogens given by Bishop1 who says that cestrone is 1/20th the strength of stilboestrol, which is itself 1/20th the strength of ethinyl œstradiol.) Until the profession rids itself of portmanteau prescriptions and changes its ideas on medicaments and dosage, menopausal women will suffer either because their
practitioners prescribe oestrogen, or because, quite properly, they fear to do so. Professor McLaren has no need to dread the arrival of œstrogen-bleeders treated along the lines I have suggested : all he need fear is that his colleagues fail to read my comments with "
’ JOAN JOAN MALLESON.
SIR,—’ Preceptin Vaginal Gel ’ is being widely adver-
pressed upon the medical profession and the ’’a major advance in conception control " and as being " dependable without a diaphragm." This kind of advertising is going to lead to disasters and it tised and
than normal sleep, but if the precautions well known to anaesthetists are taken, then E.c.T. can be given by this technique without added risk. It is not suggested that there is a best method of giving modified E.C.T. and that any other is unsatisfactory, but surely Dr. Tewfik is making unnecessary difficulties for himself in using a two-syringe technique and rolling over The finding an unconscious and paralysed patient ? that the blood-pressure varies only within 10-15 mm. Hg is unusual. Two independent investigations 12 indicate that the usual rise in blood-pressure following an injection of succinylcholine is round about 40 mm. It follows that patients with hypertension should be given special consideration when this drug is used. Department of Psychiatry, DAVID J. ADDERLEY University of Leeds School of MAX HAMILTON. Medicine THE TREATMENT OF ECZEMA
behoves all of us who come across cases where failure to make them known and to state once more in no uncertain terms that we have not yet advanced from the position where, for maximum safety, it is necessary to advise the use of a mechanical barrier with a good spermicidal preparation of one sort or another. The advent of preceptin does not, unfortunately, alter this situation in. spite of the superficially convincing figures published by various workers in America. In time, preceptin will find its own level of usefulness, but it should not be handed out to highly fertile parous women, particularly when their lives depend upon it, in the mistaken belief that it will protect them as fully as one of the combined methods (cap or sheath plus spermicide). I have met a number of preceptin failures, most of which mattered little, but my most recent experience cannot be treated so lightheartedly. occurs
The patient, a severe asthmatic, had had 2 babies in two years ; within five months she was pregnant for a third time and her condition was such that the pregnancy had to be terminated by hysterotomy at the fourth month. Having recovered from that, she was fitted with a Dutch cap and given Two months later she was a spermicidal paste to use with it. told by a doctor that preceptin was " just as good, or better " ; six weeks later she was again pregnant.
sceptic will say that through carelessness she well have become pregnant again even if she had continued with the cap and paste and that the only solution to such a case should be sterilisation ; but that is merely confusing the issue and, moreover, this patient was not careless. MARGARET HADLEY JACKSON. Crediton, Devon. The
E.C.T. MODIFIED BY SUXAMETHONIUM SiR,,-Electroconvulsive therapy (E.C.T.) is not only an important method of treatment but it may sometimes be a life-saving measure, in the sense that it may abolish strong suicidal tendencies both in schizophrenic and depressive patients. Any advance in technique, such as using a relaxant, which diminishes the contraindications to treatment is, therefore, of great importance. It would be most unfortunate if the paper by Dr. Tewfik (July 18) were to give the impression, needlessly, that in certain circumstances E.C.T. is contra-indicated. The five conditions in which he prefers to avoid treatment are not in themselves, other things being equal, contra-indications. By the use of a suitable technique1 in which the convulsion is completely abolished, E.C.T. may be given to patients who have ununited fractures, have lately undergone- major operations, or who have had recent coronary thrombosis. Patients who have pulmonary infections or oral sepsis are endangered by any procedure which involves unconsciousness deeper 1. Bishop. P. M. F. 1951.
SIR,—I regret that in the discussion of the physical characters of soft paraffin necessary for producing Lassar’s paste of desirable consistence, the figures quoted in my article of July 25 were inaccurate. The range of melting-point temperatures allowed by the British Pharmaeopœia for soft paraffin, which I criticised, is 38° - 56°C, not 38° - 46°C. The melting-point at which the dispensary at this hospital standardises soft paraffin is 46°C in the winter. In the summer it is necessary to add between 25% and 5% of hard paraffin wax to this to achieve the desirable consistence. The particulate size of the powders may also be important. General Infirmary, Leeds.
JOHN T. INGRAM.
CARE OF THE AGED
SIR,—I envy your peripatetic correspondent (Aug. 8) his skill in presenting the case for keeping the old and possibly demented happy at home in their own natural surroundings, however defective these may be by other peoples’ standards. I was reminded of reading in an old book, which must have been published 70 years ago, a criticism of the compulsory segregation of the old High. land fools who at one time roamed the roads of Scotland and could be sure of a bed at any steading where they knocked. Certainly no doctor in these days, however, who wishes to preserve his own sanity, would attempt the disposal to a public institution of any old person, other than frankly lunatic, since it is quite impossible to find accommodation even for those old people-not a great many-who wish to spend their last years in the comfort of a Home. It is to be hoped that high Authorities will not treat your correspondent’s remarks as a comfortable soporific and an encouragement not to press forward every effort to provide adequate accommodation for the everincreasing numbers of old people who will be needing it, not only in Homes but also in hospital ; when one cannot obtain admission for an eighty-year-old woman with a broken thigh living alone, or a blind arthritic diabetic
lodger with total strangers, or a seventy-yearwith bronchopneumonia living alone in a cottage, one is hardly likely to ask for the admission of an old person who is merely a little queer and dirty. After all, we are all a little queer. I fear that today more and more emphasis is laid on the reablement of old folk. It is clear, however, that these old folk, if they are fortunate enough to obtain admission at all for reablement, will, in another five or ten years, be in the same difficulties as before, only in a more serious form. The tendency of Authority today is merely to tinker with this problem, trying to put it off till someone else has to face up to it before many years have passed. living old
1. Adderley, D. J., Hamilton, M. Brit. med. J. 1953, i, 195. 2. McDowell, D. H., Rahill, A., Tyndall, J. A. J. Irish Med. Ass. 240. 1952, 31,