428 district general book" has been which is carried at all times

grafting the system on to an existing unit in hospital. Our other difference is that "the

a

scaled down to an ordinary diary, in the consultant’s pocket. The system works well on the whole. The patients like it because they are given their admission date as soon as the decision is made to operate, and not placed on a long impersonal waiting-list. Telephone numbers of those willing to come at very short notice are invaluable in filling sudden list vacancies. The team work-load can be planned well ahead. And most of all, as Mr Cox points out, the system is doctor controlled-in fact consultant controlled. I agree with Mr Cox that loss of the book could be disastrous. The "team" has been seen wandering the hospital corridors, not knowing where they should be next! But happily it is a well-known book, and is usually returned to the consultant’s pocket within minutes of being mislaid. However, we have the added safeguard that all the operating-list information is entered on the hospital computer and the consultant receives an updated print-out twice a week. But this system has one disadvantage which is especially evident in the district general hospital. The demand for outpatient referrals from G.p.s far outstrips the operating capacity of the hospital. Therefore to make this system work, without an appreciable inpatient waiting-list, the load is transferred to the outpatient appointment waiting-list, which may reach many weeks. Thus an added responsibility is placed on the general practitioner to indicate clearly to the consultant the degree of urgency of the patient upon referral-which is perhaps not a bad thing because normally the general practitioner in his health centre should be the "sorting station", not the consultant in his hospital clinics. This system of running a surgical unit is not new. Mr Cox is the first surgeon I know to have written about it, but I first learnt it from Mr Andrew Desmond at St. James Hospital, Balham in 1959. Southend

Hospital,

Westcliff-on-Sea,

BRIAN STERRY ASHBY

Essex SS0 0RY

SIR,-I found Mr Cox’s article

most interesting. In a unique he has resorted to a simple method of admission control. I wonder if, when he plans the list, he has found out if nurses are likely to be available to care for the patients. His excellent plans could be further frustrated and the patient inconvenienced if nurses are not there.

hospital

Manor

House,

Headington,

Oxford OX3 9DZ

J. FLINDALL

And so what? Is it beyond the wit of man to devise a system that is comparatively cheap? I ask, accepting the implied contention that the first requirement of a Health Service is that it should be cheap, albeit nasty. And what alternative do you offer? The mixture as before, make do and mend, make do and mend, until the whole structure sinks into oblivion, for all you care, as long as the precious free-at-the-time principle is not abandoned. And you ask this of doctors, while strengthening the impression given by previous Lancet editorials that you think they are nothing but money-grubbing parasites. No wonder morale is low. Whether they are so or not, they are the only doctors we have. So you are abusing resources too. One would wish you would contribute positively to discussion of the problems, if indeed you accept that there are any, instead of hastily concurring with the Minister in prejudging the issues being considered by the Royal Commission. Can you not discuss the possibilities inherent in the B.M.A.’s (and others’) suggestion, accepting the possibility that they are presented in good faith, and encourage a friendly and rational discussion of the issues? It may indeed emerge that the suggestion will not work, in which case we could all accept that. 22

Lugano Road, Bramhall, Stockport, Cheshire SK7 3HX

J. R. SAMPSON

SIR,-Some of the recommendations of the B.M.A. Council in its draft evidence to the Royal Commission on the N.H.S. would appear to ignore the needs of those with chronic conditions and, indeed, to increase the burdens which these patients may have to bear in the future. Many of these patients, such as those with severe psoriasis, are not exempted from the existing although there is a strong case for this, and yet they require daily treatment, frequent prescriptions, and in some cases hospital admission for periods of three weeks or more at least once a year. Implementation of the B.M.A.’s suggestions would mean that these people would be required to pay a substantial contribution to the hotel costs of hospital admission and possibly increased prescription charges, while some retired patients would additionally lose their present exemptions from payment. These recommendations are retrogressive, and it is therefore to be hoped that, in the forthcoming debate, greater sympathy and understanding will be shown for the needs and interests of the chronically sick.

charges,

-

Psoriasis Association, 7 Milton Street, Northampton NN2 7JG

R. G.

JOBLING,

National Chairman

PLASMA EXCHANGE IN MYASTHENIA GRAVIS TEN MINUTES FOR EVERYONE

SiR,—Your comments on my paper on work-load in general practice (Feb. 12, p. 344) are generous but not quite accurate. I did not conclude that demand could not be reduced, but that reduction (or, more important, a shift in content) must depend

relatively slow process of mutual re-education of patients and doctors rather than on primitive measures such as consultation charges. A shift to fewer but less superficial consultations is both possible and necessary.

on a

Glyncorring Health Centre, near

Port

Talbot,

Glamorgan

SA13 3BL

JULIAN TUDOR HART

B.M.A. EVIDENCE TO THE ROYAL COMMISSION

SIR,-You emphatically dismiss the British Medical Association’s proposals about financing the N.H.S. (Feb. 5, p. 293) on the feeble ground that these will lead to item-of-service payment which has proved expensive in some countries. Will they?

SiR,—Dr Finn and Dr Coates (Jan. 22. p., 190) ask whether the response we observed’ following plasma exchange in acquired myasthenia gravis might be attributed to a placebo effect, which they apparently concluded was responsible for their own patient’s improvement. Were this to have been the case in our patients, improvement should have begun at the onset of treatment and have declined thereafter. In the event, there was a latent period of several days before signs of decreased fatiguability and increased strength were evident, and improvement continued for some days after the last exchange. We have now treated four further patients with plasma exchange, all of whom have shown clear signs of improvement, and the latent period in one of them was ten days. The complete absence of response in the only patient with congenital myasthenia gravis, who knew of the beneficial results in the first two cases, further argues against the suggestion that theirs was a placebo response. 1.

Pinching, A. J., Peters, D. K., Davis, J.

N. Lancet, 1976, ii, 1373.

429 Steroid-dose reduction in both cases of acquired myasthenia had always been associated with prompt relapse (as stated); thus the suggestion that steroid reduction after exchange contributed to the remission is improbable. Immunosuppression did not underlie the improvement either for, as we pointed out, the improvement preceded its introduction (now confirmed in two other patients). Immunosuppressive treatment was used to try to maintain the remission since there were no good reasons for supposing that improvement following plasma exchange would be other than short-lived. It should not cause surprise that the response to exchange varies between individuals since, as pointed out by Dr Finn and Dr Coates, the degree of postsynaptic damage will certainly be one factor influencing the short-term reversibility of the transmission defect. As we were careful to stress, the place of plasma exchange in the management of myasthenia gravis has yet to be defined.

gravis

Hospital and Royal Postgraduate Medical School,

Hammersmith London W12

Batten Unit, National Hospital for Nervous Diseases, London WC1

A. J. PINCHING D. K. PETERS

might be a "sparing agent" for other immunosuppressive drugs such as systemic corticosteroids, azathioprine, and cyclophosphamide with greater long-term sideeffects. Clinical, trials of dapsone in a variety of immunological diseases normally treated with these agents seem justifiable, as do further studies by immunologists on its precise mode of agent and

action. Wellcome Laboratories for Research into Skin Disease, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP

HYPERCALCÆMIA IN IDIOPATHIC RHABDOMYOLYSIS

SIR,-As you state in your editorial’ the hypercalcaemia developing in acute renal failure caused by idiopathic rhabdomyolysis has been attributed 23 to transient secondary hyperparathyroidism. Plasma levels of parathyroid hormone (r.T..) measured during the hypercalcaemic period were high in two cases 23 but subnormal in another one.4 Sequential measurements

J.

NEWSOM DAVIS

DAPSONE IN DERMATITIS HERPETIFORMIS AND OTHER IMMUNOLOGICAL DISEASES

SIR,-Iwas very interested in the report by Dr Constable McConkey (Jan. 1, p. 44) on the effects of dapsone on immune-complex formation in vitro and experimental serum sickness in vivo. Despite the fact that immune-complex formaand Dr

tion was not affected they report a significant reduction of the duration of proteinuria in rabbits with experimental serum sickness and conclude that the drug may act at the site of immune-complex deposition. They also refer to the effect of this drug in dermatitis herpetiformis (D.H.). D.H. is characterised by aggregated IgA in dermal papillae throughout the skin, a feature which is of great diagnostic specificity.’ I have repeatedly observed that these deposits persist after successful treatment with dapsone even, in one patient, after as long as 34 years. Circulating immune complexes have also been observed in D.H.2 but unfortunately the effect of dapsone was not investigated. However, aggregated IgA has been shown in vitro to activate complement by the alternate pathway, and there is evidence that this pathway is important in the skin in D.H.3 4 Preliminary, though as yet unconfirmed data,5 suggest that dapsone may inhibit alternatepathway activation of complement, and its efficacy in D.H. has been attributed to this effect. Various other dermatoses have occasionally been reported to be dapsone responsive. These include various types of vasculitis,6-8 pemphigus’ and generalised pustular psoriasis.lO Abnormal immune mechanisms are well recognised or suspected in these diseases. Moreover suppression of experimental Arthus reactions has been demonstrated in guineapigs.11I Dr Constable and Dr McConkey cite observations that in rheumatoid arthritis the beneficial effects of dapsone were approximately equivalent to those of gold. It seems that dapsone may prove to have a more general value as an immunosuppressive

M. G. C. DAHL

of P.T.H.

were not

done.

30-year-old man who had transient while recovering from acute renal failure. hypercalcaemia Clinical findings (fever, severe myalgias, similar attack 15 years before) and laboratory data (increased muscular enzymes, positive o-tolidine reaction in urine) suggested the We have studied

a

Lancet, 1976, ii, 1343. Leonard, C. D., Eichner, E. R. J. Am. med. Ass. 1970, 211, 1539. 3. Wu, B. C., and others. S. Afr. med. J. 1972, 46, 1631. 4. Turkington, R. W., Delcher, H. K., Neelon, F. A. J. clin. Endocr. Metab. 1968, 28, 1224. 1. 2.

1. Fry, L., Seah, P. P. Br. J. Derm. 1974, 90, 137. 2. Mowbray, J. F., Hoffbrand, A. V., Holborow, E.

J., Seah, P. P., Fry, L. Lancet, 1973, i, 400. 3. Fry, L., Seah, P. P. in Immunological Aspects of Skin Diseases (edited by L. Fry and P. P. Seah); p. 45. Lancaster, 1974. 4. Provost, T. T., Tomasi, T. B. Clin. Immun. Immunopath. 1974, 3, 178. 5. Millikan, L. E., Conway, F. R. Cited by J. O’D. Alexander,. Dermatitis Herpetiformis; p. 214. London, 1975. 6. Wells, G. C. Proc. R. Soc. Med. 1969, 62, 665. 7. Cream, J. J., Levene, G. M., Calnan, C. D. Br. J. Derm. 1971, 84, 393. 8. Thomson, D. M., Main, R. A., Swanson Beck, J., Albert-Recht, F. ibid. 1973, 117. 9. Piamphongsant, T. ibid. 1976, 94, 681. 10. Macmillan, A. L., Champion, R. H. ibid. 1973, 88 183. 11. Thompson, D. M., Souhami, R. Proc. R. Soc. Med. 1975, 68, 273.

Plasma P.T.H. and serum creatinine, calcium, and phosphate levels before haemodialysis, and after fifth dialysis in 30-yearold patient with acute renal failure from idiopathic rhabdo-

myolysis.

Plasma exchange in myasthenia gravis.

428 district general book" has been which is carried at all times grafting the system on to an existing unit in hospital. Our other difference is tha...
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