767 how such a mechanism would explain reduction of fibrin deposition on dialyser membranes after a single dose.’ The effects on platelet turnover occur also in rabbits8 which have no uric acid in the serum, making it unlikely that sulto see
McDonald have shown that the drug inhibits platelet prosta-
glandin synthesis. Gastric prostaglandin synthesis may be spared, however, since unlike, aspirin oral sulphinpyrazone no sulphinpyrazone increase in farcal blood-loss.10 This has advantage over aspirin in prevention of shunt thrombosis and dialyser fibrin deposition in uraemic patients who are already usually anaemic. The reduction of sudden deaths after myocardial infarction in patients treated with sulphinpyrazone" is further proof of the value of this interesting antithrombotic agent, by whatever mechanism it may act. Dulwich Hospital, MICHAEL J. WESTON London SE22 8PT. causes
MENTAL HEALTH CARE IN SOUTH AFRICA
S!R,—Ifeel that Dr Jablensky (Feb. 4, p. 270) has created the impression that there is a wilful bias against Black South Africans in respect of mental health and psychiatric care. He unfairly uses blanket statements which give a slanted view, such as "race being the determinant of the type, extent and quality of service provided", and he has still not got some of his facts right. One has the impression that in his distaste for the politics of the country, he is discrediting all the positive and praise-worthy features that exist or are being developed in mental health. Moreover, he diminishes the efforts of many dedicated psychiatrists. There are extensive and advanced psychiatric services for Blacks in South Africa, and there are ambitious schemes for the future. The World Health Organisation, of which Jablensky is a senior official, was invited to South Africa to see for itself but has never done so, and incorrect conceptions
However, I do take his major point-namely, that there
still differences in certain facilities for Blacks and Whites. These are mainly in respect of the type of accommodation rather than the standard of medical treatment, and some are the result of cultural and socioeconomic factors in a developing country which have nothing to do with politics. The W.H.O. itself has stressed the fallacy of applying the norms of highly developed Western cultures to traditional African rural societies. However, there is room for improvement. There has been underfinancing of our mental health services over many years, and many of our hospitals need modernising. There are also considerable staff shortages. All this cannot be made right in a day, but Jablensky should acknowledge that great efforts are being made both for Blacks and Whites. Jablensky asks whether frankly political factors can be ignored in causing psychosocial stresses. Obviously not, for they are urgent and vital, and there are some social practices that arise out of them which are not conducive to mental health (for instance, the splitting of families because of the migrant labour system). He gives the impression, however, that political pressures are the only ones in mental health. South Africa is in the, throes of massive and rapid socioeconomic change with industrialisation, unemployment, mass migration from rural areas, social mobility, and changing value systems, and these also contribute to personal and psychological stress. The above comments are not intended as an apology or justifi7. Dawson, A., Lavinski, C., Weston, M. J., Parsons, V. in Technical Aspects of Renal Dialysis (edited by T. H. Frost) London (in the press). 8. Mustard, J. F., Rowsell, H. C., Smythe, H. A., Sengi, A., Murphy, E. A.
Blood, 1967, 29, 859. 9. Ali, M., McDonald, J. W. D. 10. Dawson, A., Lavinski, C.,
J. Lab. clin. Med. 1977, 89, 868. Parsons, V., Weston, M. J. Thrombosis Res. (in
cation of decisions, but merely to explain the complex web of pressures that bear upon the mental health of all South’ Mricans, White and Black. The other point at issue is whether psychiatrists or their professional organisation, the Society of Psychiatrists, are doing enough. Our primary role is to give practical psychiatric help and to develop facilities wherever they are needed, and we have done this for many years. The Society has made representations to the authorities and has been responsible for some of the many improvements in practice and changes in mentalhealth legislation that have taken place. Moreover, many South African psychiatrists, notwithstanding shortages and stresses, have chosen to remain where the real problems are and to remedy them individually and collectively-training staff, improving conditions in psychiatric hospitals, setting up community services. It is so easy to sit outside the laundry and comment on the dirty washing, but those who work there every day must decide how to do the job in a humane and ethical way. It is Jablensky’s right to quarrel with us as to how we remedy the situation, but we must insist that we are doctors and not politicians. Department of Psychiatry, L. S. GILLIS, University of Cape Town Chairman, Executive Committee and Groote Schuur Hospital, Society of Psychiatrists Cape Town 7925, South Africa of South Africa (M.A.S.A.)
RAPID DETERIORATION IN SUBACUTE SCLEROSING PANENCEPHALITIS AFTER MEASLES IMMUNISATION
patient with subacute sclerosing who deteriorated after being impanencephalitis (S.S.P.E.) munised against measles. The rubeola immunisation may have led to an acceleration of a slowly evolving S.S.P.E. The patient was evaluated in December, 1977, at the age of 8 years. At age 13 months he had had a 5-day illness thought to be rubeola. Neurological symptoms appeared in the summer of 1976, 18 months before his death, when his grandmother noted transient weakness of the right leg. The following school year he performed at grade level or better on standardised tests of academic achievement. In the summer of 1977 he occasionally dragged his left foot. In September, his teachers noted deterioration in his academic performance, forgetfulness, incontinence, and tremulousness. A previously gregarious, likeable child, he was shunned by his classmates. In mid-October he received an attenuated rubeola vaccine. Examination 3 weeks later indicated ataxia, hyperreflexia, and extensor plantar reflexes. Motor and intellectual deterioration continued and by Dec. 6 he was no longer able to walk and had generalised spasticity. His speech was progressively limited. By Dec. 10 he had a spastic tetraplegia with persistent extension of the lower extremities and left upper extremity, flexion of the right upper extremity and spontaneous clonus. By Dec. 17 he would not withdraw from pain and gave no evidence of visual fixation or recognition of his parents’ voices. On Dec. 21 myoclonic twitches began and became generalised and multifocal. The patient was no longer able to swallow and required feeding by nasogastric tube. 1 week later he died. Necropsy was not done. S.S.P.E. was diagnosed by the high titres of antibodies against measles in serum and cerebrospinal fluid (c.s.F.), 1/512 and 1/32, respectively; oligoclonal bands by ’Agarose’ electrophoresis in c.s.F.; a raised IgG/albumin in c.s.F. of 0-64 (normal less than 0.27); and ratio of c.s.F. IgG/albumin divided by the ratio in serum of 2-56(normal less than 0 - 66). This patient’s course suggests that S.S.P.E. may be accelerated by immunisation with attenuated rubeola virus. Although S.S.P.E. usually progresses predictably, considerable variability does occur’ and the course of the disease in this patient needs seen
11. Anturane Reinfarction Trial Research Group New Engl. J. Med. 1978, 298, 289.
Jabbour, J. T., Duenas, D. A., Modlin, J. Archs Neurol. 1975, 32, 493.