926

Gans’ comments about skin preparation and the suggestion byFulenwider et al. that the findings ofendotoxaemia in cirrhosis byothers is due to "inadvertent contamination of specimens throughsampling and testing" seem unlikely since in all published seriesnegative results have been obtained from healthy controls.5-9Gloucestershire Royal Hospital,Gloucester GL1 3NN S. P. WILKINSON

LITHIUM CARBONATE IN HÆMATOLOGY

SIR,-Lithium carbonate appears to be a promising agent, as youpoint out in your editorial (Sept. 20, p. 626), for the attenuation ofchemotherapy induced neutropenias. We have used lithium duringthe induction therapy of adult acute lymphoblastic leukxmia(ALL), a disease whose treatment often induces severe neutropeniawith resulting increased risk of infection. 1,2 We were not worriedabout the hypothetical positive effect of lithium on the leukxniiccell population which has been suggested for acute non-lymphoidleukaemia.3’5Nine consecutive patients treated here after September, 1979, re-

ceived lithium; twelve patients treated consecutively before thatdate with the same induction regimen, were used as a control group.We did not randomise the patients to the two groups, because adultALL is a rare disease, the admission rate at our institute beingaround ten new patients per year. The two groups were comparablefor age, spleen size, haemoglobin level, blast cell count, poly-morphonuclear cell (PMN) count, and platelet count at diagnosis.Induction chemotherapy consisted of vincristine (VCR) 1’ 6 6 mg/m2 2weekly for 4-6 doses, daunomycin 60 mg/m2 given with the firstand second VCR, and 6-methylprednisolone 40 mg/m2 daily fromday 2 to day 28. Lithium carbonate was administered orally 300 mgthree times a day for 30 days.The duration of neutropenia was significantly shorter in the lith-

ium group (see table) but the duration of thrombocytopenia did notdiffer and complete remission rates were similar. We conclude that

7. Liehr H, Grun M, Brunswig D, Sautter TH. Endotoxinamie bei Leberzirrhose. ZGastroenterol 1976; 14: 14-26.

8. Prytz H, Holst-Chnstensen J, Korner B, Liehr H. Portal venous and systemicendotoxæmia in patients without liver disease and systemic endotoxæmia in patientswith cirrhosis. Scand J Gastroenterol 1976; 11: 857-63.

9. Tarao K, So K, Moroi T, Ikeuchi, T, Suyama T, Endo O, Fukushima K Detection ofendotoxinin plasma and ascitic fluid of patients with cirrhosis: its clinical signifi-cance. Gastroenterology 1977, 73: 539-42

1. Omura GA, Moffit S, Vogler WR, Salter HM, for the Southern Cancer Study Group.Combination chemotherapy of adult acute lymphoblastic leukæmia with random-ised central nervous system prophylaxis. Blood 1980; 55: 199-204.

2. Ruggero D, Baccarani M, Gobbi M, Tura S. Adult acute lymphoblastic leukæmia:Study of 32 patients and analysis of prognostic factors. Scand J Hœmat 1979, 22:154-64.

3. Hammond WP, Appelbaum F. Lithium and acute monocytic leukemia. N Engl J Med1980; 302: 808.

4. Orre LE, McKernan JF. Lithium reinduction of acute myeloblastic leukaemia. Lancet1979; i: 449.

5. Stein RS, Flexner JM, Grager SE. Lithium and granulocytopenia during inductiontherapy of acute myelogenous leukemia. Blood 1979; 54: 636-41

DURATION OF NEUTROPENIA AND THROMBOCYTOPENIA IN THE TWO

GROUPS OF ADULT ALL PATIENTS

Results as median and range. p values determined using Wilcoxon-Mann-Whitney analysis.

lithium is of value for limiting the severity and duration of neutro-penia during chemotherapy for remission induction of adult ALL.Institute of Hæmatology"Lorenzo e Ariosto Seragnoli",

University of Bologna,S.Orsola Hospital40138 Bologna, Italy

GIUSEPPE BANDINIPAOLO RICCIGIUSEPPE VISANISANTE TURA

CLONIDINE IN TOURETTE SYNDROME

SIR,-Tourette syndrome is a childhood-onset neurologicaldisorder characterised by multiple tics, involuntary vocalisations,and, occasionally, coprolalia. In one open study small doses ofcloni-dine (0 - 05-0 - 6 mg), an a-adrenergic agonist presumed to act byinhibiting central noradrenergic activity, resulted in improvementin some children who had not responded to haloperidol. We havedone a double-blind, placebo-controlled, dose-ranging clonidinestudy in which a blind rater determined total tic frequencies in onepatient 3-4 times a week for 8 months.The patient is a 38-year-old teacher with a 30-year history of

Tourette syndrome characterised by intermittent jerking of theright shoulder, facial grimacing, and periodic vocalisations. Therater is a student who counted the total number of shoulder tics,facial tics, and vocalisations during a 40-50 min classroom lectureheld at the same hour of the day. A total tic frequency was calculatedby adding shoulder, facial, and vocalisation frequencies. Tic countswere obtained during a 3-month, drug-free baseline period (n = 32).Thereafter, counts were determined during one week of placebo fol-lowed by one week each of 0’ 05, 0 - 10, 0 15, 0 - 20, and 0 - 25 mgclonidine daily. One month later a second double-blind, placebo-controlled study was carried out in which clonidine was increasedby increments ofO-1 1 mg each week from 0 - 1 mg per day to 0 - 6 mgper day. The dose was then tapered off over several weeks and wasfollowed by terminal one week placebo and one baseline periods.Sitting ’blood pressures were recorded weekly and gradually fellfrom a baseline level of 130/75 mm Hg to a minimum of 99/50 mmHg during the 0’ 6 mg dosage.There was no significant reduction in total tic frequency for any

dose of clonidine (see figure). Regression analyses of total tic

frequency versus dose showed that, compared with baseline data,total tic frequency increased significantly with dose (study 1, n=48,R=0-48, p<0-0005; study 2, n = 24, R=0-40, p<0-05) but that

compared with placebo, total tic frequency did not change signifi-cantly (study 1, n= 19, R=0-19; study 2, n =19, R-0-13) whichsuggests a negative placebo effect. Thus we have failed to confirmthe efficacy of clonidine in an adult patient with a long history of

1. Svensson TH, Bunney BS, Aghajanian GK. Inhibition of both noradrenergic andserotenergic neurons in brain by the &agr;-adrenergic agonist clonidine. Brain Res 1975;92: 291-306.

2. Cohen DJ, Young JG, Nathanson JA, Shaywitz BA. Clonidine in Tourette’s syndrome.Lancet 1979; ii: 551-53.

Total tic frequency in one patient with Tourette syndrome duringtreatment with clonidine.

927

Tourette syndrome. Although the observations come from only onecase they were measurements carefully obtained under controlledconditions. Because reports of subjective change may not corres-pondto changes in tic frequency, tic counts are necessary in describ-ing the natural variability that is an important aspect of this neuro-logical disorder.

Illinois State Psychiatric Institute,Chicago, Illinois 60612, USA

Andrews University,Berrien Springs, Michigan

Illinois State Psychiatric Institute

MAURICE W. DYSKEN

JOHN M. BERECZALANE SAMARZA

JOHN M. DAVIS

Commentary from Westminster

Labour’s Health Action Week

THIS week has seen a major propaganda effort by Labourpoliticians, aimed at uniting public feeling in opposition toGovernment health-service policies. On Monday the Com-mons resumes its work, starting with a full-scale debate on theN.H.S. and the Government’s restructuring plans.The Labour Party is certainly taking the situation

seriously. At an opening press conference for the HealthAction Week, the shadow Social Services Secretary, Mr StanOrme, along with the general secretary of the National Unionof Public Employees, Mr Alan Fisher, introduced a newLabour plan for the future of the N.H.S. Health policy, MrOrme said, could not, for a start, ignore provisions which lieoutside the health service itself, such as housing, milk, schoolmeals, child benefits, and the level of unemployment. Preven-tion had to be the watchword of any serious health policy forthe future. Many important preventive measures would in-volve little or no increase in public spending. "What they dorequire is the political will to act in areas which are controver-sial," he declared. Cigarette smoking was the prime example.Perhaps the time had come for the banning of all sales promo-tion, including the funding of sports events by tobacco firms.Compulsory wearing of car seat-belts was another obviousarea where the Government should step in. Water authoritiesshould "have the duty to add fluoride to water on the requestof health authorities". There should also be bolder action toattack alcohol and drug abuse, to combat obesity and un-balanced nutrition, and to promote exercise. In addition to asubstantial increase in child benefit and the restoration of thefull free school meals service, Mr Orme wanted to considergiving women financial incentives to attend antenatal clinics.Salaried posts for doctors were one possible way of improvingprimary care in the inner cities. "We must find ways of get-ting committed, young G.P.s into the inner city areas (includ-ing those which are arithmetically over-doctored) to work inteams with health visitors, nurses, and others, from purpose-built or adapted premises."Mr Orme said it was time to advance from the "come and

get it" health service to one which took on more responsi-bility for "searching out those who particularly need its

help-whether it is women who book late for antenatal care oryoung children who are not given the type of thorough andregular health assessment recommended by the Court reporton child health services." An incoming Labour Governmentwould find itself in charge of a health service more under-financed than ever before, as part of a nation that would bepoorer rather than richer after the period of Conservative ad-

ministration. "We have to establish clear priorities and tar-gets now, which we can achieve during the period of the nextLabour Government." The N.H.S. had to be democratised,and the most practical approach, Mr Orme thought, would bea continuation of the existing system with stronger partici-pation by staff interests, pending wider reform of the struc-ture of local government. Community health councils shouldbe strengthened, and there should be new forms of participa-tion in the provision of primary care. The "blueprint onwhich we must build" was the motion passed by an over-whelming majority at Labour’s conference, demanding aboli-tion of all N.H.S. charges and all private medicine and thenationalisation of the pharmaceutical industry.Mr Fisher addressed himself largely to the future of the

N.H.S. as it affects NUPE members. He called for the estab-lishment of a new pay comparability body, to follow theClegg Commission. It could be for the N.H.S. only, or forpublic services as a whole, but without such a body therewould be little chance of a fair wage for all who worked in theN.H.S. He warned that members of his union would not hesi-tate to take political action in the N.H.S. (though he did notspecify what forms he thought acceptable) to protect it as faras they could against Conservative attacks.This theme has been taken up by Labour’s shadow Health

Minister, Mr Roland Moyle. He has spoken of "a mood ofquiet sullen resistance to the Government’s attempts to sub-contract their essential services to private firms" which isgrowing in the N.H.S. This, he said, was because of "thepractical knowledge of health professionals from one end ofthe country to the other that, by and large, laundry, catering,medical, nursing, and many other services can only be under-taken by private firms less efficiently or less cheaply, or both,than by the N.H.S." A health service financed by the Govern-ment was not only the just way, but also the best and mosteffective way.The next major event in the health week, a one-day confer-

ence in London, produced fierce criticism from the SocialistMedical Association, of the "24-hour retirement" system.The Association’s president, Dr Cyril Taylor, promised toraise the issue with the D.H.S.S. He complained of doctorsgoing through the formalities of retirement at 60 or 65, col-lecting lump-sum payments of f20 000, plus their pensions,and then returning to work. The result is, according to DrTaylor, that younger doctor’s find it hard to get work. Fur-thermore, since these "retired" doctors often reduced theirlists of patients in order to comply with rules on limitation oftheir earnings, another result was often to throw extra workon neighbouring G.P.s. Dr Taylor said, that so far 18 doctorsin the Liverpool area had taken advantage of 24-hour retire-ment. But a D.H.S.S. spokesman maintains this is not aGovernment responsibility. "We don’t see this as a majorproblem. It is something that has grown up by tradition fromthe time when doctors were few and far between, and weneeded every doctor we could get. Doctors certainly can dothis, but it’s up to the family practitioner committee which

has to approve it". It was up to the committee to decidewhether or not the doctor was needed. The matter had beendiscussed with administrators of family practitioner commit-tees, but no D.H.S.S. action was likely.Mr Orme has managed to muster large audiences for the

public meetings in the Health Action Week, and reasonablePress coverage. But when the points made in the campaignare deployed in Monday’s debate there is no likelihood of theGovernment being diverted from the path it has chosen.

RODNEY DEITCH