1303
showing a striking susceptibility to immunisation either by autologous or heterologous antigenic stimulation. Detailed investigations of the at-risk groups 6,9-e.g., near (female) relatives of M.S. patients-must be regarded as necessary to give an answer about the inheritance of the metabolic component of
M.S.
Medical Section, University of Rostock, Immunological Research Division, Departments of Physiological Chemistry and Neurology, Lenin-Allee 70, 25 Rostock, German Democratic Republic.
E. MIX H. L. JENSSEN H. MEYER-RIENECKER J. TÖWE.
FACTOR-VIII CONCENTRATE IN HÆMOPHILIA
SIR,-Our reference laboratory lately investigated a sample of blood from a haemophiliac patient from a local hospital who had received 561 bottles of commercial factor-vm concentrate in one month. He also received 17 units of group-specific blood during this time. The patient was group A, Rho(D) positive. His red cells had a positive direct antiglobulin test and anti-A was eluted. His treatment included A.H.F. from two manufacturers and six different lots were used. One of the manufacturers provided their titre results for three lots of A.H.F. Their results ranged from 16 to 64 by anti-human-globulin techniques. One of these lots was available to us, and we found the antiglobulin titre with group-A cells to be 256.l One lot of the other manufacturers’ A.H.F. concentrate had an antiglobulin titre of 512. When large amounts of factor vill are needed in a short time, the ABO group of the patient should be considered (Rosati et al.2). In these instances perhaps group-compatible cryoprecipitate (human) may be used for treatment rather than commercial A.H.F. concentrates that contain anti-A and anti-B. Missouri-Illinois Regional Red Cross Blood Program, 4050 Lindell Boulevard, St. Louis, Missouri 63108, U.S.A.
CECILIA A. CRONIN, Director of Technical Services.
THE COST OF BOOKS: FROM MANUSCRIPT TO MICROFICHE
SiR,—The example of Topley and Wilson’s Principles of -Bacteriology, Virology, and Immunity increasing in price from S3 in 1946 to E65 with the present edition (Feb. 1, p. 272) should make us realise that we must adapt the way we write, read, and publish to rising prices, or scholarship will suffer. Costs can be reduced at most of the steps between the writer and his readers, and we must make the best use of all of them. The most radical solution, and one which is particularly suitable for Topley and Wilson, is to publish only in one of the more advanced miniature versions, such as microfiche, and to produce it directly from the author’s manuscript without setting up type. If we wanted particular pages in paper form, we could always get a photocopy. The resulting savings in composing, printing, storing, paper, postage, and capital might even bring Topley and Wilson back to its 1946 price. By reducing publishing delays it might also be available a year earlier. However, if we are to read such a miniature version at home we shall have to own our own viewers, but it is surely time we did. We should have an additional incentive if we could use one in an armchair, or prop it up on a pillow while reading in bed. The same shortcut from manuscript to miniature version could also reduce the cost of specialist journals. A less radical economy is for the author to save all composing costs by sending his manuscript to his publisher 1. A.A.B.B. Technical Methods and 2. Transfusion, 1974, 10, 139.
Procedures;
p. 121. 1974.
"
camera
ready ", so that it can be used directly for printing
books lithographically. Both these solutions demand that we accept what a good typewriter can produce for us and are prepared to forgo proportionate spacing, and a straight right-hand margin. They also demand that the author and his secretary produce exactly what they intend their readers to see without any further attention from the publisher. This has fortunately been made easier by such recent developments as the self-erasing typewriter, white correcting fluid, and the dry transfer (’ Letraset’). It is also a great opportunity for the specialist secretary working at home. Further solutions are for the author to forgo his royalties, as Morley1 has done, to obtain a subsidy to cover composing costs, or to cut out the retail bookseller by publishing through a non-profit mail-order service, such as TALC.* We must also be more prepared to publish in the form of slides and tapes. All this is to deny the author some of the most delicious moments 6f his life-opening the first copy of his new book with its glossy paper, superb typography, handsome binding, elegant jacket, and the intoxicating aroma of new print, but alas so expensive that none of his intended readers can buy it. Would Topley and Wilson have obtained the same satisfaction from a little packet of microfiches ? More seriously, can we standardise the miniature system we are going to use, and make viewers which are really suitable for domestic use ? Is there a publisher prepared to move with the times and produce miniature versions, or to print a new series of cheap textbooks straight from his author’s manuscripts ? Lembaga Kesehatan Nasional, Jalan Indrapura, MAURICE KING. Surabaya, Indonesia.
IMMUNODEFICIENCY AND STEELY HAIR
SIR,—Your editorial, " Copper and Steely Hair " (April 19, p. 902), underlines the many metabolic consequences of copper
deficiency. In a patient with steely-hair syndrome (S.H.S.) we have lately found evidence of impaired T-cell function; others have reported increased susceptibility to infection in S.H.S.2-5 Our patient was first seen at the age of 10 months; the history and clinical picture were characteristic of the S.H.S.3 Serum-copper ranged between 37 and 44 tg. per 100 ml. (normal 65-165 g.) and caeruloplasmin between 6 and 10 mg. per 100 ml. (normal 20-60 mg.). During the hospital stay the child had repeated episodes of bronchopneumonia, pyelonephritis, and enteritis, and a single Serum episode of Staphylococcus aureus septicaemia. immunoglobulin and complement (C3, C4) levels, isohasmagglutinin and antistreptolysin-0 titres, antibody response to the H and 0 antigens of Salmonella typhi, and the number of circulating B lymphocytes (700-1200 per c.mm.) were all in the normal range for our laboratory values. Candidin, P.P.D., and S.K.-S.D. (’Varidase’, Lederle) skin tests were negative; furthermore, dinitrochlorobenzene failed to sensitise the child on repeated challenges. The number of circulating T lymphocytes (E rosettes) was in the low normal range on repeated testing (1700-3100 per c.mm.), and the lymphocyte response to stimulation with mitogens (phytohasmagglutinin, concanavalin A, and pokeweed mitogen) and allogeneic cells (mixed culture) * Teaching Aids at Low Cost, Institute of Child Health, 30 Guilford Street, London WC1N 1EH. 1. Morley, D. C. Pædiatric Priorities in the Developing World. London, 1973. 2. Danks, D. M., Cartwright, E., Campbell, P. E., Mayne, V. Lancet, 1971, ii, 1089. 3. Danks, D. M., Campbell, P. E., Stevens, B. J., Mayne, V., Cartwright, E. Pediatrics, Springfield, 1972, 50, 188. 4. Singh, S., Bresman, M. J. Am. J. Dis. Child. 1973, 125, 572. 5. Walker-Smith, J. A., Turner, B., Blomfield, J., Wise, G. Archs Dis. Childh. 1973, 48, 958.
1304
consistently low or even absent both in autologous and pool serum (3-10% as compared to age-matched controls).. Nitroblue-tetrazolium-reduction test was positive. Whether the T-cell defect found in this patient is an
concurrently ? (3) Was the the patients’ clinical status aware of the type of treatment the patient had had ? Department of Pharmacology and Therapeutics, London Hospital Medical College, ARTHUR O. K. OBEL. Turner Street, London E1 2AD.
was
ways of treatment carried out
in AB
physician who
occasional association or a characteristic feature of S.H.S. remains to be established. To our knowledge no immunological study of this syndrome has been reported; the present findings suggest that such studies are worth while, not only in s.H.s. but also in the mottled-mouse model of copper deficiency.6 Our patient is now being given a therapeutic trial with copperand the results might shed some light on the problem. Pædiatric Clinic, University of Pavia, Italy.
ELISA PEDRONI ELENA BIANCHI ALBERTO G. UGAZIO G. R. BURGIO.
CORRECTION OF RETROVERSION SIR,-Chronic low backache and dyspareunia have been treated by regimens varying from reassurance to surgical correction of associated retroversion of the uterus. Some authorities take the view that surgery for dyspareunia is rarely indicated,l even if there is a mobile retroversion. A few general practitioners delay referral until coitus is so painful that it causes marital disharmony. Once referred, the patient with pure mobile uterine retroversion is either given a plastic pessary for a short trial period followed by a ventrosuspension procedure such as Gilliam’s or BaldyWebster’s, or in a small number of cases is treated by ventrofixation of the uterine fundus. These procedures involve laparotomy and a long inpatient stay, and may
provide only short-term relief since intervening pregnancies result in retroversion of the uterus and further symptoms. With the laparoscope the gynxcologist can now diagnose many of the causes of pelvic pain and dyspareunia previously identified only at laparotomy. Steptoe2 has described a technique of ventrosuspension after diagnostic laparoscopy whereby the round ligaments are stitched to the rectus fascia after being pulled through the abdominal wall, the mid-portion being excised. The patient is in hospital for three days at the most, being discharged on the first postoperative day if recovery is satisfactory. We have dealt with several cases in whom dyspareunia and low backache have been cured. We follow Steptoe’s technique except that we employ polyglycolic-acid sutures, not non-absorbable sutures, to anchor the round ligaments to the rectus-sheath fascia. We submit that in units where laparoscopy is performed routinely this should be the standard treatment, replacing the plastic pessary and operations involving long inpatient stay. Department of Obstetrics and Gynæcology, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE.
P. I. SILVERSTONE A. S. McINTOSH.
GLYCEROL v. DEXAMETHASONE IN ACUTE CEREBRAL INFARCTION
SiR,—Although Professor Gilsanz and his colleagues (May 10, p. 1049) said they " followed Mathew’s criteria for the selection of patients, design of trial and evaluation of the results with a neurological scoring system", a number of points require clarification on how they modified these criteria to suit their local environment. (1) How were the patients allocated to each treatment ? (2) Were the two 6. 7. 1. 2.
Hunt, D. M. Nature, 1974, 249, 852. Grover, W. D., Scrutton, M. C. J. Pediat. 1975, 86, 216. Fullerton, W. T. Br. med. J. 1971, ii, 32.
Steptoe, P. C. Laparoscopy in Gynaecology. Edinburgh, 1957.
was
assessing
*** We showed this reply follows.-ED. L.
letter
to
Professor Gilsanz, whose
Sm,-Patients were alternately allocated to one or other of both forms of treatment, following strictly their order of admission. A double-blind method was not used, as can be deduced from the different routes of administration for dexamethasone (intramuscular injection) and glycerol (intravenous infusion). Department of Internal Medicine, University Medical School, Madrid 3, Spain.
V. GILSANZ.
Obituary WILLIAM ERNEST LLOYD
M.D.Lond., F.R.C.P. Dr W. E.
Lloyd, consulting physician to the Westminster Hospital for Diseases of the Chest, died on May 26. He qualified from St. Bartholomew’s Hospital in 1921, graduating M.B. in 1923 and M.D. (with gold medal) in
1925; he became
F.R.C.P.
in 1934. He
was
senior house-
physician in the medical unit at Bart’s and medical registrar at the Westminster Hospital and the Brompton Hospital before being appointed to the consultant staff of these two hospitals. He was also consultant physician to Bolingbroke Hospital. He was an examiner in medicine for the Conjoint Board. In 1951 he gave the Mitchell lecture of the Royal College of Physicians of London. P. A. Z. writes: "
Doctors make their contribution to society in different Some do it by the service they render; others by their research contributions; others still by teaching. ’Ernie’ Lloyd was unique. An M.D. gold medallist who eventually became senior physician of the Brompton, Royal Masonic, and Westminster Hospitals, he made his own contribution by his remarkable qualities as a general ways.
a good friend, and an exceptional colleague. few papers, was little interested in research for himself, and was-except by precept-an unremarkable teacher. To see him at his best required a visit to his outpatients. There large numbers of patients would wait for long periods to receive his care and his reassurance. " As a hospital colleague, Ernie Lloyd oiled the works better than anyone can ever have done. He was very quick to sense any disagreement, and would then immediately seek out both sides and emphasise to each what good people were those of the opposite opinion. His elevation to censor of the Royal College of Physicians was an orthodox recognition of his value, but countless patients and doctors still recall with gratitude what they owe to this remarkable man who managed them, their families, and their medical problems with such skill. He seldom declared a diagnosis but was never in doubt about what to do next. Being so interested in chest diseases, he often consulted with his lifelong friend and Westminster colleague, Sir Clement Price-Thomas. " Ernie is survived by his wife Olive, who nursed him in his last illness, so emphasising her great contribution to his life, by two sons, and by countless sorrowing doctors, nurses, and patients."
physician, He
wrote
showing a striking susceptibility to immunisation either by autologous or heterologous antigenic stimulation. Detailed investigations of the at-risk groups 6,9-e.g., near (female) relatives of M.S. patients-must be regarded as necessary to give an answer about the inheritance of the metabolic component of
M.S.
Medical Section, University of Rostock, Immunological Research Division, Departments of Physiological Chemistry and Neurology, Lenin-Allee 70, 25 Rostock, German Democratic Republic.
E. MIX H. L. JENSSEN H. MEYER-RIENECKER J. TÖWE.
FACTOR-VIII CONCENTRATE IN HÆMOPHILIA
SIR,-Our reference laboratory lately investigated a sample of blood from a haemophiliac patient from a local hospital who had received 561 bottles of commercial factor-vm concentrate in one month. He also received 17 units of group-specific blood during this time. The patient was group A, Rho(D) positive. His red cells had a positive direct antiglobulin test and anti-A was eluted. His treatment included A.H.F. from two manufacturers and six different lots were used. One of the manufacturers provided their titre results for three lots of A.H.F. Their results ranged from 16 to 64 by anti-human-globulin techniques. One of these lots was available to us, and we found the antiglobulin titre with group-A cells to be 256.l One lot of the other manufacturers’ A.H.F. concentrate had an antiglobulin titre of 512. When large amounts of factor vill are needed in a short time, the ABO group of the patient should be considered (Rosati et al.2). In these instances perhaps group-compatible cryoprecipitate (human) may be used for treatment rather than commercial A.H.F. concentrates that contain anti-A and anti-B. Missouri-Illinois Regional Red Cross Blood Program, 4050 Lindell Boulevard, St. Louis, Missouri 63108, U.S.A.
CECILIA A. CRONIN, Director of Technical Services.
THE COST OF BOOKS: FROM MANUSCRIPT TO MICROFICHE
SiR,—The example of Topley and Wilson’s Principles of -Bacteriology, Virology, and Immunity increasing in price from S3 in 1946 to E65 with the present edition (Feb. 1, p. 272) should make us realise that we must adapt the way we write, read, and publish to rising prices, or scholarship will suffer. Costs can be reduced at most of the steps between the writer and his readers, and we must make the best use of all of them. The most radical solution, and one which is particularly suitable for Topley and Wilson, is to publish only in one of the more advanced miniature versions, such as microfiche, and to produce it directly from the author’s manuscript without setting up type. If we wanted particular pages in paper form, we could always get a photocopy. The resulting savings in composing, printing, storing, paper, postage, and capital might even bring Topley and Wilson back to its 1946 price. By reducing publishing delays it might also be available a year earlier. However, if we are to read such a miniature version at home we shall have to own our own viewers, but it is surely time we did. We should have an additional incentive if we could use one in an armchair, or prop it up on a pillow while reading in bed. The same shortcut from manuscript to miniature version could also reduce the cost of specialist journals. A less radical economy is for the author to save all composing costs by sending his manuscript to his publisher 1. A.A.B.B. Technical Methods and 2. Transfusion, 1974, 10, 139.
Procedures;
p. 121. 1974.
"
camera
ready ", so that it can be used directly for printing
books lithographically. Both these solutions demand that we accept what a good typewriter can produce for us and are prepared to forgo proportionate spacing, and a straight right-hand margin. They also demand that the author and his secretary produce exactly what they intend their readers to see without any further attention from the publisher. This has fortunately been made easier by such recent developments as the self-erasing typewriter, white correcting fluid, and the dry transfer (’ Letraset’). It is also a great opportunity for the specialist secretary working at home. Further solutions are for the author to forgo his royalties, as Morley1 has done, to obtain a subsidy to cover composing costs, or to cut out the retail bookseller by publishing through a non-profit mail-order service, such as TALC.* We must also be more prepared to publish in the form of slides and tapes. All this is to deny the author some of the most delicious moments 6f his life-opening the first copy of his new book with its glossy paper, superb typography, handsome binding, elegant jacket, and the intoxicating aroma of new print, but alas so expensive that none of his intended readers can buy it. Would Topley and Wilson have obtained the same satisfaction from a little packet of microfiches ? More seriously, can we standardise the miniature system we are going to use, and make viewers which are really suitable for domestic use ? Is there a publisher prepared to move with the times and produce miniature versions, or to print a new series of cheap textbooks straight from his author’s manuscripts ? Lembaga Kesehatan Nasional, Jalan Indrapura, MAURICE KING. Surabaya, Indonesia.
IMMUNODEFICIENCY AND STEELY HAIR
SIR,—Your editorial, " Copper and Steely Hair " (April 19, p. 902), underlines the many metabolic consequences of copper
deficiency. In a patient with steely-hair syndrome (S.H.S.) we have lately found evidence of impaired T-cell function; others have reported increased susceptibility to infection in S.H.S.2-5 Our patient was first seen at the age of 10 months; the history and clinical picture were characteristic of the S.H.S.3 Serum-copper ranged between 37 and 44 tg. per 100 ml. (normal 65-165 g.) and caeruloplasmin between 6 and 10 mg. per 100 ml. (normal 20-60 mg.). During the hospital stay the child had repeated episodes of bronchopneumonia, pyelonephritis, and enteritis, and a single Serum episode of Staphylococcus aureus septicaemia. immunoglobulin and complement (C3, C4) levels, isohasmagglutinin and antistreptolysin-0 titres, antibody response to the H and 0 antigens of Salmonella typhi, and the number of circulating B lymphocytes (700-1200 per c.mm.) were all in the normal range for our laboratory values. Candidin, P.P.D., and S.K.-S.D. (’Varidase’, Lederle) skin tests were negative; furthermore, dinitrochlorobenzene failed to sensitise the child on repeated challenges. The number of circulating T lymphocytes (E rosettes) was in the low normal range on repeated testing (1700-3100 per c.mm.), and the lymphocyte response to stimulation with mitogens (phytohasmagglutinin, concanavalin A, and pokeweed mitogen) and allogeneic cells (mixed culture) * Teaching Aids at Low Cost, Institute of Child Health, 30 Guilford Street, London WC1N 1EH. 1. Morley, D. C. Pædiatric Priorities in the Developing World. London, 1973. 2. Danks, D. M., Cartwright, E., Campbell, P. E., Mayne, V. Lancet, 1971, ii, 1089. 3. Danks, D. M., Campbell, P. E., Stevens, B. J., Mayne, V., Cartwright, E. Pediatrics, Springfield, 1972, 50, 188. 4. Singh, S., Bresman, M. J. Am. J. Dis. Child. 1973, 125, 572. 5. Walker-Smith, J. A., Turner, B., Blomfield, J., Wise, G. Archs Dis. Childh. 1973, 48, 958.
1304
consistently low or even absent both in autologous and pool serum (3-10% as compared to age-matched controls).. Nitroblue-tetrazolium-reduction test was positive. Whether the T-cell defect found in this patient is an
concurrently ? (3) Was the the patients’ clinical status aware of the type of treatment the patient had had ? Department of Pharmacology and Therapeutics, London Hospital Medical College, ARTHUR O. K. OBEL. Turner Street, London E1 2AD.
was
ways of treatment carried out
in AB
physician who
occasional association or a characteristic feature of S.H.S. remains to be established. To our knowledge no immunological study of this syndrome has been reported; the present findings suggest that such studies are worth while, not only in s.H.s. but also in the mottled-mouse model of copper deficiency.6 Our patient is now being given a therapeutic trial with copperand the results might shed some light on the problem. Pædiatric Clinic, University of Pavia, Italy.
ELISA PEDRONI ELENA BIANCHI ALBERTO G. UGAZIO G. R. BURGIO.
CORRECTION OF RETROVERSION SIR,-Chronic low backache and dyspareunia have been treated by regimens varying from reassurance to surgical correction of associated retroversion of the uterus. Some authorities take the view that surgery for dyspareunia is rarely indicated,l even if there is a mobile retroversion. A few general practitioners delay referral until coitus is so painful that it causes marital disharmony. Once referred, the patient with pure mobile uterine retroversion is either given a plastic pessary for a short trial period followed by a ventrosuspension procedure such as Gilliam’s or BaldyWebster’s, or in a small number of cases is treated by ventrofixation of the uterine fundus. These procedures involve laparotomy and a long inpatient stay, and may
provide only short-term relief since intervening pregnancies result in retroversion of the uterus and further symptoms. With the laparoscope the gynxcologist can now diagnose many of the causes of pelvic pain and dyspareunia previously identified only at laparotomy. Steptoe2 has described a technique of ventrosuspension after diagnostic laparoscopy whereby the round ligaments are stitched to the rectus fascia after being pulled through the abdominal wall, the mid-portion being excised. The patient is in hospital for three days at the most, being discharged on the first postoperative day if recovery is satisfactory. We have dealt with several cases in whom dyspareunia and low backache have been cured. We follow Steptoe’s technique except that we employ polyglycolic-acid sutures, not non-absorbable sutures, to anchor the round ligaments to the rectus-sheath fascia. We submit that in units where laparoscopy is performed routinely this should be the standard treatment, replacing the plastic pessary and operations involving long inpatient stay. Department of Obstetrics and Gynæcology, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE.
P. I. SILVERSTONE A. S. McINTOSH.
GLYCEROL v. DEXAMETHASONE IN ACUTE CEREBRAL INFARCTION
SiR,—Although Professor Gilsanz and his colleagues (May 10, p. 1049) said they " followed Mathew’s criteria for the selection of patients, design of trial and evaluation of the results with a neurological scoring system", a number of points require clarification on how they modified these criteria to suit their local environment. (1) How were the patients allocated to each treatment ? (2) Were the two 6. 7. 1. 2.
Hunt, D. M. Nature, 1974, 249, 852. Grover, W. D., Scrutton, M. C. J. Pediat. 1975, 86, 216. Fullerton, W. T. Br. med. J. 1971, ii, 32.
Steptoe, P. C. Laparoscopy in Gynaecology. Edinburgh, 1957.
was
assessing
*** We showed this reply follows.-ED. L.
letter
to
Professor Gilsanz, whose
Sm,-Patients were alternately allocated to one or other of both forms of treatment, following strictly their order of admission. A double-blind method was not used, as can be deduced from the different routes of administration for dexamethasone (intramuscular injection) and glycerol (intravenous infusion). Department of Internal Medicine, University Medical School, Madrid 3, Spain.
V. GILSANZ.
Obituary WILLIAM ERNEST LLOYD
M.D.Lond., F.R.C.P. Dr W. E.
Lloyd, consulting physician to the Westminster Hospital for Diseases of the Chest, died on May 26. He qualified from St. Bartholomew’s Hospital in 1921, graduating M.B. in 1923 and M.D. (with gold medal) in
1925; he became
F.R.C.P.
in 1934. He
was
senior house-
physician in the medical unit at Bart’s and medical registrar at the Westminster Hospital and the Brompton Hospital before being appointed to the consultant staff of these two hospitals. He was also consultant physician to Bolingbroke Hospital. He was an examiner in medicine for the Conjoint Board. In 1951 he gave the Mitchell lecture of the Royal College of Physicians of London. P. A. Z. writes: "
Doctors make their contribution to society in different Some do it by the service they render; others by their research contributions; others still by teaching. ’Ernie’ Lloyd was unique. An M.D. gold medallist who eventually became senior physician of the Brompton, Royal Masonic, and Westminster Hospitals, he made his own contribution by his remarkable qualities as a general ways.
a good friend, and an exceptional colleague. few papers, was little interested in research for himself, and was-except by precept-an unremarkable teacher. To see him at his best required a visit to his outpatients. There large numbers of patients would wait for long periods to receive his care and his reassurance. " As a hospital colleague, Ernie Lloyd oiled the works better than anyone can ever have done. He was very quick to sense any disagreement, and would then immediately seek out both sides and emphasise to each what good people were those of the opposite opinion. His elevation to censor of the Royal College of Physicians was an orthodox recognition of his value, but countless patients and doctors still recall with gratitude what they owe to this remarkable man who managed them, their families, and their medical problems with such skill. He seldom declared a diagnosis but was never in doubt about what to do next. Being so interested in chest diseases, he often consulted with his lifelong friend and Westminster colleague, Sir Clement Price-Thomas. " Ernie is survived by his wife Olive, who nursed him in his last illness, so emphasising her great contribution to his life, by two sons, and by countless sorrowing doctors, nurses, and patients."
physician, He
wrote
