1004

This list does not even touch upon other considerations such as stability, cost, and freedom from adverse effects. But as everyone knows, if you ask Father Christmas for too much you may not get anything at all. BELIEF AND RELIEF OF PHANTOM-LIMB PAIN PHANTOM limb is

sequel to complete or partial amputation. Occasionally the phantom is very painful, and then the patient not only has to cope with the pain; he must also convince others of his distressthat, in effect, he has an extracorporeal pain. That the phantom pain is a real condition, in a manner of speaking, is attested by certain constant features. For example, a painful phantom usually occurs when chronic pain was a feature before the limb was amputated. Moreover, the phantom pain will usually arise in the part that was previously painful, and will be precipitated by the same a common

of stimulus. Phantom-limb pain must be distinguished from stump pain, which it may or may not accompany. Stump pain tends to be associated with a neuroma or some kind of localised neuritis whereas phantom pain seems to involve the central nervous system quite widely. For instance, phantom-limb pain can be precipitated by injection of hypertonic saline or pinching of the skin on the same or the opposite side of the body at the segmental level of the affected limb. Sometimes it is produced consistently by stimulation of areas with a different segmental supply. Feinstein, Luce, and Langton2 reported 25 years ago that counterirritation with strategic injections of hypertonic saline first exacerbated phantom-limb pain but could then give lasting, even permanent, relief. Later, Nashold and Friedman3 used dorsal-column stimulation successfully in the relief of phantom-limb pain. Now Miles and Lipton4 report similar success with this technique and with the simpler methods of implanting stimulating electrodes on to the regional peripheral nerves, or just the application of surface electrodes for transcutaneous stimulation. Patients need less stimulation as time progresses, which is contrary to what might be expected if phantom-limb pain were just a figment of the imagination in a disturbed individual. Clearly, counterirritation merits a prime place in the clinical work-up of patients with phantom-limb pain. Whilst implantation of stimulating electrodes requires special skills, the initiation of investigation, and possibly successful treatment with transcutaneous nerve stimulation, should be within the capabilities of all doctors.

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DANGEROUS PATHOGENS—MORE THOUGHTS FROM THE HSE THE Health and

regulations compulsory

Safety Executive has published draft and draft guidance notes concerning the notification of work with dangerous patho-

1. Melzack R. The puzzle of pain. Harmondsworth: Penguin, 1973. B, Luce JC, Langton JNK. The influence of phantom limbs. In: Klopsteg P, Wilson P, eds Human limbs and their substitutes. New York: 1954. 3. Nashold BS, Friedman H. Dorsal column stimulation for control of pain.

gens.l Comments are requested by Jan. 18, 1980. Will the HSE staff have time to sift through all the replies? The intention is to identify all places and persons involved in work with or transportation of listed pathogens, including diagnostic microbiology laboratories (which one would suppose to be already known and are obviously liable to encounter whatever pathogenic microbe turns up). Schedule 3, regulation 4, requests a list of details of who does the work, who supervises it, and who is directly in charge; where the work will be done; and what pathogens are to be worked with-information which could not reasonably be provided and kept up to date in the flexible circumstances of a diagnostic laboratory with staff rotation and training. The pathogens concerned are listed in two schedules. Schedule 1 corresponds to category A pathogens, which are already fully controlled by the Dangerous Pathogens Advisory Group on which HSE is represented and who already have to pass judgment on any proposed work with or transportation of these pathogens. Schedule 2 is a curious ragbag of germs, not corresponding to the "Howie" group-B list and including some, fairly harmless organisms. The prize, perhaps, goes to contagious pustular dermatitis virus, a common endemic infection of sheep which many farmers, veterinary students, and butchers acquire at some time, characterised by an indolent skin lesion and discomfort of little more than nuisance value: it would be more logical (though still ludicrous) to list Staphylococcus aureus or Streptococcus pyogenes. Then again, "serum hepatitis virus" is inadequately specific. Does "yellow fever virus" include the vaccine, and if so do all yellow-fever vaccinating stations and holding premises have to comply? Clostridium botulinum is listed: is this just the types producing toxins dangerous for man, or all are all soil organisms included ? "Other species of pathogenic myobacteria" is similarly unclear. A curious selection from the salmonellæ is listed-why pick on sendai and cholerœsuis? "Other pathogenic rickettsiae" is ill-defined. Of chlamydi2e, "other species" presumably embraces not only the common oculogenital agents of low pathogenicity but also numerous non-human infections. Incidentally, the term pathogen is used to include "any exotoxin produced by the pathogen ..." (except licensed medicinal products)-how can this be legally or scientifically defended?

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Those with a sense of priorities can ponder on the justification of such a bureaucratic juggernaut as that proposed. What evidence is there of serious damage to health from laboratory-acquired infections today? Data on hepatitis suggest a fall from the already low incidence a few years ago, before expensive protective arrangements had been introduced and presumably as a consequence of increased awareness.2 It would be useful to have similar up-to-date information about tuberculosis and other infections: anecdotal evidence is insufficient. A clinical laboratory worker, one suspects, is more likely to acquire infection by eating canteen meals or travelling abroad on holiday than from exposure at work.

2. Feinstein

J Neurosurg 1972, 36, 590-97. J, Lipton S. Phantom limb pain treated by electrical stimulation. Pain 1978; 5: 373-82.

4. Miles

Dangerous pathogens: draft regulations and draft guidance notes. Health and Safety Executive, Baynards House, 1 Chepstow Place, London W2 4TF. 50p. 2. Grist NR. Hepatitis in clinical laboratories 1975-76. J Clin Path 1978, 31, 1.

415-17.

Belief and relief of phantom-limb pain.

1004 This list does not even touch upon other considerations such as stability, cost, and freedom from adverse effects. But as everyone knows, if you...
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