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SALARY SCALES

SIR,—May I support your correspondent " Chairman "

in last week’s issue ? Now that hospitals are no longerrun on a charitable basis they must be run on the basisof a business. If in business an employee is requiredthe employer decides what salary will attract the manor woman he wants. If he gets no satisfactoryresponse to his advertisement he reconsiders the matter,particularly with a view to upgrading the salary ; andthe salary eventually offered is that which will attractthe person he wants.

Hospitals are being cramped by the new principleof salary scales. For example, in my city I have littledifficulty in getting domestic staff on the basis of thesalary scales, but my colleague, the medical superin-tendent of the mental hospital, which is some 4 milesout and off a bus route, has great difficulty. It isobvious that if he was in private business he wouldimmediately offer more to attract people ; he would

possibly even organise a bus service ; but with salaryscales laid down he cannot do that.As a concrete example, we are having great trouble

over cooks. Our nurses’ home caters for about 500,and as the living conditions of nursing staff are by nomeans good it is most important, to my mind, that atany rate their feeding should be up to the best standard.But a chef at a hotel can get several pounds a weekmore than we are allowed to offer. When we advertisedat the salary scale, we got two totally unsatisfactoryreplies. Our present cook, whose salary was decidedbefore the Act came into force, is leaving because thesalary is too low.No business could be successfully run on this basis.

A business would immediately get a cook and pay thesalary required, and it seems to me. that if hospitals arenot to be inhibited they must be given full licence toengage people at the remuneration required to obtainthe person needed at the particular hospital for the

particular job. Salary scales are very good things,provided they are regarded as a minimum ; but when

they are absolutely fixed and rigid they become a

menace.iuuiiuuu.

SUPERINTENDENT.

** * This subject is discussed in a leading article.-ED. L.

FOOLPROOF BLOOD-TRANSFUSIONS

SIR,—In his erudite letter of June 18 Dr. Wienerwrites of mishaps due to occasional errors by a highlytrained technical staff. The chief dangers of blood-transfusion, however, lie in its wide use by doctors whohave had no adequate apprenticeship in grouping, col-

lecting, storing, transporting, and administering blood,and do not fully recognise the risks these operationsinvolve.

Clinicians would be less confident in the safety ofblood, and therefore more eclectic in its use, if they keptin mind the many possibly weak links in the chain ofits production. I have seen errors, for example, occurwhere the donor’s blood-group was inaccurately recordedbecause infected serum was used for grouping. (Alltest sera should, I think, be labelled with the details oftheir agglutinins and not only of their respective group-agglutinogens.) Or defects in the blood-arising eitherfrom old age or infection-may have been masked byshaking. (Once put in store, a bottle of blood shouldnot be shaken until a competent observer has carefullyexamined it for evidence of abnormality.)Assuming the blood itself to be beyond reproach,

there are still risks in transfusion which are insufficientlyappreciated. The idea that large quantities can betransfused rapidly without danger is based on war

’experience with previously healthy young men, and is

inapplicable to the aged or chronic sick, for whom the

choice of fluids, and the amount and rate of their adminis-tration, need careful consideration. A single pint ofblood, especially if fresh, will often improve a patient’scondition sufficiently to allow the vis mzedicatrix naturœto complete the cure ; but in such cases the likelihood ofbenefit must be balanced against the risks .inherent intransfusion. For the less expert, there is much truth inthe saying that blood should not be given at all unlessfive pints are needed. It has to be remembered that allreactions-and they are not as uncommon as theyshould be-increase the burden borne by the patient.- Even a mild reaction may provoke further h2emorrhagein a patient who has recently bled, and every knownprecaution must therefore be taken where a person hasbeen previously transfused or may require transfusionlater.

Blood-transfusion has in recent years developed into amass-produced remedy which daily presents fresh prob-lems. In the hands of experts it is virtually safe, andvery valuable ; but there is little doubt that today, inthis country as elsewhere, many deaths supposed to haveoccurred " in spite of transfusion " have really beencaused by it.

Administration of fluids is not a duty that should be" relegated " to inexperienced juniors. It is not just aproblem of minor surgery. In fact, there are few risksin transfusion when the doctor fails to insert a needleor cannula into a vein ; they begin to mount once hesucceeds.

London, N.4. I. H. MILNER.

HORMONE TREATMENT OF THE SEXUAL

OFFENDER

SIR,—The article of June 11 by Dr. Golla and Dr.Sessions Hodge is of interest to me since it confirms myinitial observations on the value of oestrogenic prepara-tions in the treatment of sexual offenders.

Since 1940 I have used stilbcestrol in the treatment ofsexual offenders and for inhibiting libido in sexuallyaggressive psychiatric males committed to mental

hospitals. I prefer stilbcestrol because by oral adminis-tration I can better control and regulate dosage to meetindividual requirements. In my original article I

reported that the degree of the gynæcomastic reactioninvariably produced in males receiving stilboestrol closelyparallels the extent to which the anterior-pituitarygonadotropins and the 17-ketosteroids are depressedthe extent of the degeneration in the cells of theseminiferous tubules, the inhibition of spermatogenesis orazoospermia, and the degree of suppression of libido andthe patient’s ability to mechanically stimulate penilereaction. As the breast reaction resolves, libidoreappears, degenerative changes in the tubules cease,and the gonadotropins and 17-ketosteroids increase.However, when stilbcestrol is administered in largedosage-5 mg. over an extended period-atrophy of thetestes results and the changes in the size of the testes arepermanent.The need for an objective therapeutic reaction to

indicate the adequacy of therapy is particularly apparentin psychiatric male patients. In this group of patients1 mg. of stilbeestrol is usually sufficient to depress libidoand maintain gynsecomastic response. Here the advan-

tage of stilboestrol-induced testicular atrophy over

castration is that the climacteric symptom is avoided ;furthermore, any degree of testicular atrophy may beproduced.The target point of stilbcestrol action in suppressing libido

and penile reaction appears to be, as Dr. Spence (June 25)presumes, the inhibition of anterior-pituitary gonado-tropin production. This could be tested by administeringstilbcestrol to the eunuchoidal patient with infantile

atrophic testes, normal or high gonadotropins and

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androgens in the urine, and normal libido. We studiedthe comparative effects of ethinyl oestradiol and methyltestosterone in a recent surgical castrate with normallibido. In this patient both hormones were of equalvalue for the flushes and sweats, but ethinyl cestradiolfailed to produce the sense of

" well being " and metabolicbalance which is maintained with methyl testosterone.The libido of the patient practically ceased while ethinyloestradiol was administered. In view of the patient’sprogressive weakness and weight loss during the periodof oestrogen therapy we attributed diminished libido tohis constitutional state; we have found that in patientswith severe male hormone deficiency the general con-stitutional effect of methyl testosterone must beestablished before libido is stimulated.The report by Dr. Golla and Dr. Sessions Hodge

clearly establishes that castration for the treatment ofsexual offenders should be abandoned.

Philadelphia. CHARLES W. DUNN.

PREGNANEDIOL IN URINE

SIR,—Your editorial last week on hormone assaysgives an unfavourable impression of the value ofpregnanediol estimation, which was discussed at thetwelfth British Congress of Obstetrics and Gynaecology.My remarks in the discussion were not .reported by you(p. 164), and I would like briefly to restate them.

Firstly, in answer to Dr. P. M. F. Bishop, the estimationcan be, and is carried out in my laboratory as a routinetest by the technical staff. No special arrangementsneed be made, and any specimen delivered here beforelunch is reported on the same day. Secondly, in answer toDr. G. 1. M. Swyer and Dr. A. C. Crooke, the results areinaccurate if the amount of pregnanediol is calculated asper unit volume of urine. The output per hour, however,is apparently constant over a short period, and if thepregnanediol is calculated as per unit of time the resultsare much more consistent. My clinical colleagues findthem of value. It is possible to arrive at the dailyoutput on this constant hourly excretion without thenecessity of obtaining 24-hourly specimens.My series is as yet too small to justify publishing

figures, but I hope later to present a full analysis of myresults.

St. Woolos Hospital, Newport, Mon.DAVID STERN

Pathologist.PAIN

SIR,—In his interesting observations on the role ofthe cortex in the perception of pain, a matter of greatimportance to us, Mr. Theobald (July 16) brings to noticehow in the excitement of battle a man may be unawarethat he has been wounded. The most striking accountof this phenomenon is to be found in the pages ofLucretius, who describes it with the eloquence of a poetand the relish of a schoolboy.

,- So they record how the scythed chariots, reeking withindiscriminate slaughter, suddenly chop off the limbs, andthe severed part that falls is seen to quiver on the ground ;but such is the quickness of the injury and the eagernessof the man’s mind that he cannot feel the pain ; andbecause his mind is given over to the zest of battle, maimed

though he be, he plunges afresh into the fray and theslaughter. And here among the horses is one unawarethat his left arm, shield and all, has been torn off by thewheels and devouring scythes and lost ; and from anotherthe right falls, and yet he mounts and presses on ; and thereis one who has lost his leg, but struggles to rise, while hardby upon the ground the dying foot twitches its toes ;and when a head is chopped off from a warm and livingtrunk, it keeps for a moment the look of life and the eyesremain open, until the last traces of the soul are given up."III, 642-656. (I follow Munro’s punctuation in I. 646 andtake vis and mens in 1. 645 to be a hendiadys.)The Romans illustrate Mr. Theobald’s contention

that susceptibility to pain varies with environment and

heredity. With their fortitude, stoicism, ferociouspunishments, and bloodthirsty amusements they musthave been much less sensitive than we are, even those ofus who have eschewed the blighting influences of " thecinema, the lurid press, and aspirin," but not, I suppose,of " the other factors." If only Mr. Theobald could tellus what these are, we should be wiser men still!

Orpington, Kent. H. St. H. VERTUE.

EPIDEMIOLOGY OF POLIOMYELITIS

SIR,—With regard to Dr. Lambert’s letter in your issueof July 23, we have had some cases of poliomyelitishere this year, the first two being notified in one house-hold on June 18 although the dates of onset were June 10and June 11. Local inquiries indicated that there hadbeen some transient obscure illnesses in the family andin the neighbourhood, but there had been no recognisedcase of poliomyelitis in the borough since the previousOctober. These other cases could not definitely beregarded as poliomyelitis, but it seems likely that thepoliomyelitis virus was present in the borough fromthe end of May or the beginning of June. On June 20(a Monday) I had a letter saying that two dead hedgehogshad been seen three days previously lying in a road,which road happened to be within the affected area buta little over half a mile from the two recognised cases ofpoliomyelitis. The road where they were found is neara public park. I asked the refuse collection departmentwhether dead hedgehogs were at all commonly found inroads or refuse bins, but I was told the occurrence wasexceedingly rare. I then telephoned the Virus ReferenceLaboratory to see if they were interested in view of thecoincident poliomyelitis cases, but they told me theywere not. Nothing further was therefore done.

I would add that two years ago when we had nearly80 recognised cases of poliomyelitis in the borough (anincidence of 35 per 100,000 population) there were noreports of dead hedgehogs being found prior to or duringthe outbreak.

Catford, London, S.E.6.E. H. R. SMITHARD

Medical Officer of Health.

MALE TOADS IN PREGNANCY TESTS

SIR,—We were very interested in the article of July 2by Dr. Klopper and Mr. Frank. While welcomingthe results of their experiments, we note that theydid not refer to our account of 610 tests 1—one of thefirst publications on this subject in Europe.As we there observed, we found Bufo vulgaris equally

satisfactory, but we soon changed to Rana esculentafor the following reasons : (1) B. vulgaris is notavailable in every season of the year ; (2) R. esc’ulentahas proved more sensitive, giving a positive resultwith only 10-12 units of gonadotrophic hormone (or5-6 units when hepatectomised) ; (3) 2?. esculenta ismore resistant to the toxic effects of some urines. Thesefindings may explain the high incidence of false negativesfrom B. vulgaris as compared with our results (lessthan 1%).We have now made over 1100 tests in all seasons.

Frogs caught in winter are less sensitive, requiringabout 40 units of gonadotrophic hormone for a positiveresult. We have been able, however, to restore tonormal the sensitivity of hibernating frogs by givingthem 1 µg. of thyroxine 24 hours before injection ofthe urine. After administration of thyroxine positiveresults have sometimes been obtained with as little as5-6 units ; but thyroxine does not increase the sensitivityof frogs caught in any other season.

OTI Hospital, Budapest.

1. BACHI. SZMUK.

1. Bach, I., Szmuk, I., Robert, L., Klinger, B. Lancet, 1949, i, 124.