373

region need vaccination. The board suggests that

hospital management committees should appoint some-one to " persuade the staff to be vaccinated " ; and

there can be little doubt that suitable propagandawithin the hospitals would increase very considerablythe number of those protected. It was also suggestedthat, the practice in many hospitals before 1948 of makingvaccination a condition of employment might bereintroduced.The matter is closely linked with infant vaccination :

the rate in this country is now only 34%. Primary vacci-nation in adults carries a greater risk of complicationsthan in infants, and there is some doubt about thewisdom of vaccinating large numbers of adults, unlessthere is immediate danger. But nurses, and particularlynurses in infectious-diseases hospitals, run special risks,and we share the misgiving of the Sheffield board attheir vulnerability. The annual reports of the Ministryof Health have repeatedly drawn attention to thisserious position ; and the Ministry has just produceda revised version of the memorandum 12 on smallpoxvaccination. Yet apparently not enough has been said,for clearly not enough has been done. Air journeys fromsmallpox-endemic areas take less time than the incubationperiod of the disease. There have been 23 importationsof variola major in the past ten years, and there willundoubtedly be more; it is very probable, also, thatunrecognised cases will once again enter hospital. All thestaff must be protected.

12. Ministry of Health : Memorandum on Vaccination AgainstSmallpox. H.M. Stationery Office. Pp. 8. 6d.

13. Cent. Afr. J. Med. 1955, 1, 269.

AMŒBÆ PRESENT?

EVERY morning a long file of black soldiers in whitepyjamas used to approach the laboratory down theavenue of palm-trees. Each bore before him a bedpandecently shrouded in a

" cloth, distinctive." They werethe inmates of the dysentery ward bearing their dailyofferings. After a few weeks it was easy to demonstratewithout hesitation the amoebae of all sorts, both ambulant-and encysted. But the mind goes dim as quickly as theeye, and most pathologists who thought that they" knew the amoebae " would admit that when they see asuspicious object under the microscope today their handreaches for the textbook and its pictures. Though thesewill refresh the memory, for the student of tropicalmedicine no book can replace the teaching of the masterat the bench-and weeks, months, and years of experi-ence. The tricks of the trade are many and hard to

put on paper. Some rely for detection upon the flashof the refractile amoeba as the microscope is brought intofocus : others on a background of weak eosin to distin-guish protozoon from trash. Arguments on the properstrength of the iodine solution to display nuclei havenever stopped. Some put great faith in concentratingthe cysts by changing the specific gravity of the sub-strate : others say that the examination of up to tennatural specimens yields more profitable results. Whenthe masters disagree the pupil may do worse than tofollow undeviatingly the methods of one of them until heknows enough to disagree. Into a few pages of the newlyfounded Central Africait Journal of ltledici7ae 13 Sir PhilipManson-Bahr has distilled a life-time’s knowledge ofamoebiasis. Here are the wisdom of experience andmethods proved by time. Many a solitary doctor inthe further parts of the world will, having read thisarticle, turn back to the bench with renewed enthusiasm ;but the author still would be the first to admit thatwithout a microscope and ample material the studentwill learn little by reading alone. It is probable that thisdifference between experience and booklearning explainsthe wide range of estimates of the occurrence of cysts ofEntamaeba histolytica in this country. The practised eye

in the hospital for tropical diseases sees things over-looked in most laboratories. It is time for a clear answerto the question, " How many normal’ people in thiscountry are passing cysts ? " and, as a corollary, " Whydo we see so few patients with the classical disease ? "

1. Whitley Councils for the Health Services (Great Britain)Professional and Technical Council " B." P.T.B. circular 53.

PROSPECTS FOR LABORATORY TECHNICIANS

DURING the past twenty years laboratory technicianshave become more numerous and more necessary, moreskilled and more responsible, and they are now essentialmembers of the team headed by the pathologist. Similarchanges have taken place elsewhere, in pharmaceuticalmanufacturing houses and in Government departments,and many of the young men who would once have takenan apprenticeship now stay at school a year or two

longer and then enter some laboratory. If the NationalHealth Service is to get its proper share of the best menfor its laboratories, the financial prospects it offersshould broadly resemble those in industry and in

comparable grades of the Scientific Civil Service. It maybe useful to compare the salaries offered to men of

comparable education and skill for jobs of similar respons-ibility, in the National Health Service (under the newgrading and salary structure recently announced 1), in alarge pharmaceutical manufacturing firm, and in a largeinstitution of the Scientific Civil Service.

Entrants, who are expected to have the GeneralCertificate of Education with passes at ordinary level infour subjects, including English, mathematics, and ascience, have salaries nearly £ 100 per annum less in theNational Health Service than in industry or in the CivilService ; the difference falls to :!:75 a year by the ageof 21, but it is not until at least five years after entry,when the associate examination of the Institute ofMedical Laboratory Technology has been passed, thatthe scales coincide. In the National Health Servicethere are two marks of efficiency, the intermediate andfinal examinations of the Institute of Medical LaboratoryTechnology, which do not exist in the Civil Service gradeof scientific assistant, though in industry the supervisor’sassessment of merit, on which salary increases depend,probably plays an equivalent part.The selection of supervisory technicians varies greatly.

In the National Health Service they are selected fromthose who have passed the final examination of theI.M.L.T. in a second branch, some six years or more afterentering the laboratory ; and to gain this advancement(and a further promotion to chief technician five or tenyears later) the technician may have to move his home.In industry promotion is by selection, and if a move isnecessary the employers often give financial help. Inboth cases, the senior or supervisory technician can expecta maximum salary of between :!:800 and Y,1000. TheScientific Civil Service selects its supervisory technicians,who are called experimental officers, by open competitionat ages between 18 and 31, from those who passed eitherthe G.C.E. at advanced level in two mathematical orscientific subjects, the intermediate B.sc., or the HigherNational Certificate, or who hold a pass degree-or whohave attained equivalent standards, according to age atentry. Scientific assistants, the junior grade, are con-sidered only when they are recommended by their presentdepartment or have attained the requisite educationalstandards. Successful candidates can rely on attaininga gross salary of £935 in thirteen years, and some mayenjoy accelerated promotion. A very few may be

promoted to higher grades whose duties have no equivalentin the hospital service.The range of salaries offered to technicians in the

National Health Service under the new agreement is thusroughly comparable with those elsewhere ; but there is

374

no financial recognition of the added responsibility of theN.H.S. technician’s work as part of a team concernedwith the well-being of patients. The low salary atentrance is a reflection of the low educational standardswhich were accepted by the I.M.L.T., but now thatthese standards have been raised there are good reasonsfor making the scales of junior technicians the same asthose of the " scientific assistant " grade of the Civil

Service, which would require a further increase of80-100 a year up to the technician grade (holder of theA.I.M.L.T.).The most disappointing change in the new arrangements

is the limitation of senior technicians in small laboratoriesto a maximum of E725. Their responsibility for otherstaff may be less, but their responsibility to the patholo-gist and to the patient is greater. This limitation willincrease the drift of energetic and ambitious young mento the large laboratories in the towns, leaving the equallyimportant laboratories in country hospitals inadequatelystaffed, both in quantity and in quality. On the otherhand, there is provision for promoting technicians whoare regularly engaged on individual work of specialdifficulty, responsibility, or skill as senior technician II

(up to 800) or chief technician i (up to £900), independ-ently of the general staffing of the laboratory. If this

provision can be used to upgrade technicians in sole

charge of a laboratory or in charge of blood-groupingand compatibility testing-who certainly undertake workof special responsibility-it may counteract to someextent the centripetal effect of the new grading.On the whole the new salary scales are reasonable ;

but they are not yet likely to attract many school-leavers,nor do the senior scales offer a good career in a countryhospital. It might be an advantage to unite the threegrades, senior technician i and II and chief technician i,into a single grade of supervisory technician, which wouldtake nineteen years to climb, but which could be enteredwith six or thirteen years’ seniority by those appointedto the grades now called senior technician II or chieftechnician i.

1. Lancet, 1954, ii, 374.2. Brewis, E. G. Brit. med. J. 1954, i, 1298.3. Miller, H. G., Gibbons. J. L. Ann. intern. Med. 1954, 40, 755.4. Harvey, C. C., Haworth, J. C.. Lorher, J. Arch. Dis. Childh.

1955, 30, 338.

ANOTHER FAMILIAL ENCEPHALITIS

WE remarked some time ago on the difficulty of

framing a rational classification of the different types ofencephalitis in childhood. Brewis 2 showed that less thana third of cases were sequels to recognised infections.Classification in terms of causal agents is usuallyimpossible, and Brewis suggested a useful symptomaticclassification ; but he found that nearly a quarter of hiscases were too bizarre to fit into any group.A familial encephalitis affecting 3 children of the same

parents was described by Miller and Gibbons 1 in 1954.Harvey, Haworth, and Lorber,4 of Sheffield, have nowadded a fresh syndrome to the familial group. A fatherand 5 of his children were affected. The father was

mentally retarded, and he had kyphoscoliosis, choreo-

athetosis, and pes cavus. His children fell ill in, as itwere, familial epidemics characterised by fever and oftenby loss of consciousness. After the acute illness, athetosis,hypotonia, and mental dullness remained as sequelae.The wave of acute illness recurred at least thrice. Aftereach attack deterioration was evident. Very careful

investigation by the Sheffield workers failed to reveal anysigns of the known degenerative diseases of childhood,nor, indeed, did their special investigations reveal any-thing more than some non-specific electro-encephalo-graphic changes.

Harvey et al. suggest that this syndrome may have adouble aetiology : the acute febrile episodes may havebeen attacks of viral encephalomyelitis striking down

brains which were genetically predisposed to fail in a.

particular way.

1. Van Beek, C., Haex, A. J. C. Acta med. scand. 1943, 113, 125.2. Mather, G., Dawson, J. Hoyle, C. Quart. J. Med. 1955, 24, 331.3. Consden. R., Glynn, L. E. Lancet. 1955, i, 943.

THE LIVER IN SARCOIDOSIS

SARCOIDOSIS is often suspected on clinical and radio-logical evidence. In the absence of a specific biochemicalor bacteriological test, however, the diagnosis is finallyreached by the exclusion of other diseases, especiallytuberculosis and other varieties of granulomatosis.Histological confirmation, although highly desirable, is

usually lacking since it entails a biopsy examination ofthe lung or an affected and accessible lymph-gland.Aspiration biopsy of the liver provides a much moreconvenient method of obtaining material suitable bothfor microscopy and bacteriology.The first account of liver biopsy in sarcoidosis appeared

in 1943.1 In the next ten years several small series werepublished dealing with 92 patients in 71 of whom sarcoidfollicles were demonstrated in the liver. Mather, Dawson,and Hoyle 2 have lately recorded the most extensive anddetailed study of this kind yet published. It is basedon 200 biopsies in 93 patients with the clinical and radio-logical diagnosis of sarcoidosis, in 32 with various formsof tuberculosis, and in 37 with miscellaneous diseases.The results fully confirm the great diagnostic value ofthis procedure. Typical lesions were found in 59 of the93 cases of sarcoidosis. The proportion with positivefindings appeared to be independent of the clinicalmanifestations, of the tissues clinically affected, or ofthe degree of tuberculin sensitivity. A comparison of thelesions with those in tuberculosis showed that in theabsence of caseation the two are indistinguishable.Attempts to demonstrate acid-fast bacilli microscopically,by culture, or by guineapig inoculation were also equallyunsuccessful. Repeat biopsies on several patients revealedthe remarkable persistence of the characteristic folliclesin many cases, although sometimes clinical recovery wasaccompanied by complete resolution or hyaline scarring.Repeat biopsies were also used to study the effect oftreatment. Only combined treatment with cortisoneand streptomycin produced significant results ; in 3 outof 9 patients the lesions disappeared completely, and inthe remaining 6 decrease in size or number was accom-panied bv fibrosis.The degree of hepatic involvement is noteworthy. Theestimated average number of lesions in the whole liverin the positive cases was 150,000. Despite this severeinvolvement there was little evidence of disturbed hepaticfunction. Hyperglobulinaemia, when present, was moreprobably the result of the generalised disturbance of thereticulo-endothelial system than an indication of hepaticdysfunction. Histologically, too, the liver parenchymawas normal apart from some fatty change in about 10%of cases. Diffuse fibrosis, which so often affects thesarcoid lung, was notably absent from the liver.A comparison of the prevalence of hepatic lesions in

sarcoidosis and tuberculosis is of interest. In miliarytuberculosis tuberculous lesions have been found in theliver in every one of the few cases investigated but inprimary tuberculosis in only 16 out of 25 cases. Thus theproportion of positive findings in sarcoidosis and primarytuberculosis is almost identical. If the two diseases are

entirely unrelated the similarity of these figures is remark-able. Failure to demonstrate tubercle bacilli in sarcoidlesions is the major objection to regarding sarcoidosis asa manifestation of tuberculosis. If, however, as Matherand his colleagues suggest,2 sarcoidosis represents anexaggerated and long-lasting reticulo-endothelial reactionfollowing primary tuberculosis, this criticism is largelymet. The chemical demonstration of specific bacterialresidues in the lesions 3 would give strong supportingevidence.