677

lysis ; the reduction of available histaminase at birth

may explain the onset immediately afterwards of icterus

gravis.In the light of this working hypothesis I administer

anti-histamine substances in tox2emia of pregnancy andRh incompatibility.Amsterdam. R. SCHUURMANS.R. SCHUURMANS.

1. Proceedings of the 1st European Congress on Clinical Chemistry,Amsterdam, 1954.

2. Bassir, O. Ass. clin. Biochem. Newsletter, 1954, 2, 10.3. Bassir, O. Unpublished.

INACCURACY IN THE LABORATORY

O. BASSIR.Area Pathology Laboratory,

Westwood Hospital,Beverley, Yorks.

SIR,-It is gratifying to note, from your annotationlast week, that freeze-dried samples of blood-serum willsoon be available for use as standards in hospitallaboratories. But one wonders to what extent this willbe effective in localising the sources of error in clinicalbiochemistry, and in remedying them.The international survey to which you referred was

conducted with similar material, and this was availableto all laboratories in this country. Yet only a fewparticipated. Besides, detailed analysis of the problem 2,has shown the matter to be complicated by a numberof factors, not the least being the degree of skill andthe psychological condition of the analyst. Furtherwork 3 has shown that the standardisation of proprietarybrands of laboratory reagents may leave much to bedesired; while some of the techniques employed do notstand up to critical scientific appraisal.What does seem desirable is a thorough overhaul,

possibly at the national level, to involve analyticalmethods, standardisation of reagents, laboratory equip-ment, and personnel. Would the clinical value of thelaboratory results warrant such an effort ? IN-hat is theposition with regard to the other branches of clinical

pathology ?

MASKED EPILEPSY

R. S. ILLINGWORTH.Department of Child Health,University of Sheffield.

O. N. ULUTIN.Gureba Hospital,Istanbul, Turkey.

SiR,łI am glad that Dr. Kempton (Jan. 22) com-mented on Dr. Wallis’s paper on masked epilepsy (Jan. 8).It is, of course, well known that there are various unusualmanifestations of epilepsy, such as sudden attacks ofabdominal pain, sudden vomiting, and psychomotorequivalents. I agree with Dr. Kempton, however, thatit is going altogether too far to suggest that epilepsy isan important cause of cyclical vomiting, headaches,night terrors, unexplained fever, personality disorders,pains in various parts of the body, and even the so-calledthree-month colic. I can see not the slightest connectionor resemblance between, for instance, three-month colicand epilepsy.

I found Dr. Wallis’s case-records unconvincing. The twocases of so-called cyclical vomiting were certainly not typicalof that condition ; and the association with unconsciousnesssuggests that the diagnosis was something else, perhapsepilepsy. Dr. Wallis does not mention the mode of onset inhis case-histories. For instance, headache of gradual onsetwould not make one suspect epilepsy ; headache or other painof very sudden onset might.

It is well known that acute infection with fever mayprecipitate fits in an epileptic (apart from the so-called febrileconvulsions), and that elevation of temperature may resultfrom a severe major convulsion. That is another thing,however, from saying that attacks of fever may bemanifestations of epilepsy.

I am similarly unconvinced by the finding of an " abnormal"

electro-encephalogram. In the first place, very few of usclinicians are competent to interpret electro-encephalograms.We have to rely on someone who knows how to interpretthem. " Abnormal " electro-encephalograms can be found inotherwise normal persons, such as relatives of epileptics, and inchildren with fever as a result of an acute infectious disease.

The finding of an "abnormal" electro-encephalogram in

patients with vomiting surely does not prove that the vomitingis due to epilepsy. After all, epilepsy is common. So arecyclical vomiting, headaches, three-month colic, abdominalpain, and personality disorders ; and it would be surprisingif some epileptics did not have some of these conditions.

It would be a tragedy if all children with cyclicalvomiting and the other conditions mentioned were deemedto be epileptics. If general practitioners accepted Dr.Wallis’s thesis, the hospitals would be inundated withrequests to investigate these cases for epilepsy.Department of Child Health, R. S. ILLINGWORTH.

University of Sheffield.

SiR,-Having read Dr. Wallis’s article and hisreply (Feb. 26) to Dr. Millichap’s letter (Feb. 19),I want to add that we saw in our clinic about four monthsago a patient with cyclical vomiting and a patientwith periodic symptoms who had received several formsof treatment without benefit. We concluded that these

might be instances of masked epilepsy ; and we begantreatment with phenobarbitone, which has provedsuccessful. We hope soon to publish these cases alongwith the electro-encephalographic findings.

TREATMENT OF CHRONIC AMŒBICDYSENTERY

C. B. ANDRADE.

SIR,-In his article on the Treatment of ChronicAmoebic Dysentery with Antibiotics in Combination withother Drugs (March 12), Lieut.-Colonel Inder Singh says :" Usually gr. 4 of emetine will quickly control an acuteattack of amcebic dysentery but the amoebic cysts arenot affected." Again, later in the article, he States :" Since then aureomycin and oxytetracycline have beenfound to combat the secondary infection and to destroyboth the trophozoites and the cysts."

One gets the impression that the destruction of cystsis an important aim in treatment. This misapprehensionis prevalent even among physicians with a wide experienceof tropical diseases. In reality it is pointless to considertreatment to destroy harmless cysts whose presence inthe fseces is merely indicative of the existence of aninfection of the bowel wall with amcebae. Destroy theamoebae and cyst production ceases. Despite assertionsto the contrary it is by no means certain that any druggiven by mouth destroys cysts within the lumen of thebowel; it is much more probable that such a drug woulddestroy trophozoites, thus preventing further formationof cysts with consequent disappearance of the latterfrom the fseces.

Calcutta. C. B. ANDRADE.

HOSPITAL REPORTS FOR INDUSTRIAL MEDICALOFFICERS

SiR,-In common with many other industrial medicalservices it is the practice in this department to examineall employees who have had accidents or serious illnessesor operations, before they resume duty. Most ofthem have attended hospital either as an outpatient orinpatient.

Obviously it is vitally important for us to have aclear history of what has happened, what diagnosis hasbeen made, and what treatment given before we canassist in the patient’s full rehabilitation by giving hima suitable job. The patient is seldom able to supply thisinformation, and never with accuracy. Therefore weobtain his consent and write for details to his generalpractitioner, who almost without exception is extremelycourteous and cooperative. Although this help is willinglygiven, it must be an infernal nuisance for the doctor(possibly at the end of a long day) to dig out. hospitalreports, and often write further details and send themto us.