194

lax and over-gapping joint-can result in severe exacerba-tion.

Osteopathy has now had a long history of practicalexperience in assessing and handling joint derangements,and can perhaps rightly claim to have evolved a demonstrableskill in dealing successfully with many of the clinical mani-festations in this field. It is, of course, to be stressed thatproper training in diagnosis, and the application of treat-ment, is an essential prerequisite for practice-a conditionwhich does appertain, we affirm, among members of theGeneral Council and Register of Osteopaths (M.R.O.s).

R. F. MILLERChairman,

General Council and Register of Osteopaths.London S.W.I.

AMPICILLIN RASHES

SIR,-In an annotation in your issue of Nov. 8 (p. 993),you suggest that the frequency of rashes may increase withincreased doses of ampicillin. We have analysed the datafor our article, which appeared in the same issue (p. 969), and

s.E. =Standard error of the difference between the means.N.S. =Not significant.

find no evidence of an association between the mean dailydose of ampicillin and the frequency of drug rash. Nor isthere any evidence of an association with duration of treat-ment (see accompanying table). In our view, the absence ofevidence, in our data, of dose-dependence, favours anallergic aetioloev.

S. SHAPIROD. SLONEV. SISKINDG. P. LEWISH. JICK.

Clinical Pharmacology Unit,Tufts University School of Medicine,

Waltham, Massachusetts 02154.

HOSPITAL MILK KITCHEN

SIR,-Dr. Pugh (Nov. 29, p. 1190) asks why Dr. Gamsuand his colleagues (Nov. 15, p. 1049) favour the use of amilk kitchen rather than ready-to-feed units. Comparingthe costs of the various methods, he states that the costof the traditional milk-kitchen feed should be less than 6d.

Hurst,’ however, has shown that the labour costs aloneare between 3.8d. and 10-3d. per feed.

But it is not only financial considerations which favourthe use of plastic disposable sterile bottles: they are asadaptable in use as glass non-disposable bottles; they donot limit the choice of branded milk; and they can providefeeds of different sizes without undue wastage. With theuse of ready-to-feed units, some form of milk-room would

1. Hurst, A. Br. Hosp. J. 1968, 78, 337.

still be necessary for preparation of special feeds and extrassuch as boiled water and sterile bottles.

Finally, plastic bottles are so much lighter than glassbottles, and are quieter when handled. There is also less

danger from shattered glass, and they are easily incineratedwhen they are finally disposed of.

G. A. B. STANILANDMarketing Executive.

Smith & Nephew—Southalls Ltd.,Welwyn Garden City,

Herts.

AUSTRALIA ANTIGEN IN RUMANIA

SIR,-Considerable interest in Australia antigen hasbeen shown in your columns during the past few months.We should like to report our own experience, since, eventhough the antigen is probably strongly related to hepatitisB (and A) virus, its incidence varies between differentcountries.

In Bucharest we found Australia antigen in 129 out of161 patients with acute viral hepatitis. Of 126 patientswith probable hepatitis A, 75% had Australia antigen; andof 35 patients with hepatitis B, 97% had Australia antigen.No Australia antigen was found in 48 anicteric controls;but the antigen was present in 2 out of 13 icteric controls.A detailed report will be published elsewhere.

M. BALSC. BOCÎRNEAL. HAGIESCU.

2nd Clinic of Infectious Diseases,Institute of Medicine and Pharmacy,

Colentina Hospital,Bucharest,Rumania.

LEUKÆMIA AND IMMUNE RESPONSE

SIR,-The report by Dr. Meadow and his colleagues,!of fatal measles in a patient receiving cyclophosphamidefor nephrosis, raises an important point about immuneresponse and the use of immune stimulants together withconventional chemotherapy in leukxmia. Measles is a

potentially fatal hazard in patients receiving treatment forleukxmia; yet, a considerable number of such patientstolerate measles infections easily, and some derive tempo-rary benefit. As an example, we recently observed a

5-year-old child with a leukaemic process no longer respon-sive to therapy. Her relapse was marked by massive

hepatosplenomegaly, disfiguring lymphadenopathy, and awhite-cell count of 400 per c.mm. (20 polymorphs, 320lymphocytes, 60 blasts). 2 weeks later she developedmeasles. Immunoglobulin assays throughout the disease

always gave results within the normal range. At the onsetof measles the IgG level was 7-6 mg. per ml. (normal 5-6-15-6 mg. per ml.). Within 12 days she had a completeclinical and haematological remission, and at that time theIgG level had risen to 12-5 mg. per ml. 3 weeks later she

again relapsed, her IgG level fell to 2-5 mg. per ml., andshe died 5 days later after a Clostridium septicum septicaemia.During the septicaemia the IgG levels remained below2-0 mg. per ml. The assays in our patient were strikinglysimilar to those described by Dr. Meadows and his

colleagues, whose patient also had normal immunoglobulinsthroughout therapy, an abnormally low IgG level (2-1 mg.per ml.) at the onset of measles, and no immune responseto the infection.

In a report on IgG levels in leukaemic children, weindicated that IgG levels below 2-5-3-0 mg. per ml. wereinvariably followed by an immunologically unresponsivesepticaemic disorder, whatever the number of small

lymphocytes or the type and duration of therapy.’Apparently, therefore, a very major concern in suchdisorders is that state of immune responsiveness. There

1. Meadow, S. R., Weller, R. O., Archibald, R. W. R. Lancet, 1969,ii, 876.

2. Kiran, O., Gross, S. Blood, 1969, 33, 198.