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1. Babiak, W. Canad. med. Ass. J. 1961, 85, 377.2. Bateman, C. R. ibid. p. 959.3. Robertson, D. S. ibid. p. 711.

hence reduce greatly the cerebral blood-flow, but it willnot raise the arterial pO2 adequately. One of our patientsbecame unconscious on the ventilator as soon as 100%oxygen was no longer used to ventilate him, even thoughhis arterial pCO9 was quite normal.

R. D. BRADLEYD. S. C. CADMANS. J. G. SEMPLE.

Department of Medicine,St. Thomas’s Hospital

Medical School,London, S.E.1

CONVULSIVE EFFECTS OFTRANYLCYPROMINE AND IMIPRAMINE

IN COMBINATION

G. M. LINGM. NAGAIS. HANSEN.

Department of Pharmacology,Faculty of Medicine,

University of British Columbia,Vancouver, Canada.

SIR,-Recent clinical reports by Babiak and Bate-man 2 prompt us to draw attention to the convulsive

electroencephalographic effects we have observed inlaboratory animals treated with imipramine and

tranylcypromine.Tranylcypromine (’Parnate’) has been shown to produce

immediate E.E.G. desynchronisation, similar in characteristicsand intensity to that observed after giving amphetamine. In

contrast, imipramine (’ Tofranil ’) tends to synchronise ratherthan desynchronise the E.E.G., and its E.E.G. effects are similarto those observed with the phenothiazines (chlorpromazine andtrifluoperazine).When these two compounds (imipramine 10 mg. per kg. and

tranylcypromine 5 mg. per kg.) are given in combination, theE.E.G.-activating effects of tranylcypromine dominate the

recording. If the animal is pretreated with imipramine (10 mg.per kg. per day) for 5 days or more, and is then given tranylcy-promine (5 mg. per kg.), bursts of high-voltage activity are seenin the E.E.G. These soon give way to alternating periods ofconvulsive activity followed by periods of postictal depressionand eventual death. Such abnormal E.E.G. effects are not

observed if no imipramine has been given for at least 7 daysbefore first giving tranylcypromine.These observations are of particular interest in view of recent

fatalities 1 3 following accidental and intentional use of thesetwo drugs. It is clearly hazardous to give these compoundswithout allowing sufficient time for one drug to be completelyeliminated from the body. The possible mechanisms of theseconvulsions remain to be clarified.Our investigations were carried out under a Federal Mental

Health Grant. ,... r

A NEW IRON LUNG

Dr. W. H. Kelleher writes:"

Although implied, it was not made clear in my article ofNov. 18 that the manufacturers of my new respirator were theCape Engineering Company Limited, whose works are in

Warwick, England."

DISTAVAL

Mr. D. J. Hayman, managing director of the DistillersCompany (Biochemicals) Ltd., writes:We have just received reports from two overseas sources

possibly associating thalidomide (’Distaval ’) with harmfuleffects on the foetus in early pregnancy. Although the evidenceon which these reports is based is circumstantial, and therehave been no reports from Great Britain, either clinical or

pharmacological, we feel that we have no alternative but towithdraw the drug from the market immediately pendingfurther investigation. We are also withdrawing ’ Valgis ’,’Valgraine’, ’Asmaval’, and ’ Tensival’, all of which containthalidomide. We will continue to carry out pharmacologicaland other studies of our own, and the medical profession willbe kept fully informed of developments.

1. Ministry of Health: circular 26 61. See Lancet, Sept. 16, 1961, p. 653.2. See Lancet, Nov. 4, 1961, p. 1021.3. Memorandum on Immunological Procedures. W.O. Code 13161.

H.M. Stationery Office, 1961. Pp. 79. 4s. 6d.

Public Health

Routine Immunisation

THE evidence that immunisation against diphtheria withalum-precipitated toxoid (A.P.T.) slightly but definitelyincreased the risk of paralytic poliomyelitis led the

Ministry of Health in 1957 to replace the issue of A.P.T. bythat of formol toxoid (F.T.). For the same reason itfrowned-but without severity-on the use of combinedprophylactics for children. This September it issued tolocal authorities some suggestions on immunising pro-cedure which amount to a right-a bout-face. 1There is some evidence that F.T. is not a satisfactory agent for

primary immunisation; and poliomyelitis is at the moment arare disease. Moreover, vaccination against poliomyelitis makesinfection after other immunising procedures unlikely. Manylocal authorities are already using combinations of prophy-lactics against diphtheria, whooping-cough, and tetanus withoutobviously disastrous consequences. There may be theoreticaladvantages in single inoculations; but mothers do not care tohave their infants treated as pin-cushions, and there is evidencethat some combinations give no worse, and perhaps give better,immunity. For these reasons the Ministry recommended inSeptember the use of a combined diphtheria-pertussis-tetanusprophylactic (three doses), Salk vaccine (three doses), andvaccination against smallpox-all in the first two years of life.Immunity against diphtheria, tetanus, and smallpox can bereinforced at school and’B.c.G. given after the age of 12. Twoalternative schedules are suggested. In schedule P whooping-cough vaccine (in combination with diphtheria and tetanusprophylactics) is given early in life, since fatalities from thisdisease are commonest in the first six months. The disadvantageof this schedule is the risk of paralytic poliomyelitis induced bytwo toxoids and a bacterial vaccine. Schedule Q begins withvaccination against poliomyelitis and defers immunisationagainst the other-diseases until the age of six months or more, bywhich time antibody production nears its maximum. The

responsibility for the choice and provision of prophylactics willin future lie with the local authorities.

These proposals were no doubt welcomed both by those whohold the needle and by the mothers of those who receive it. Wehope that further attention will be given to the problem ofmarking permanently those who have been immunised againsttetanus. A serum reaction is a cheap price to pay for avoidingthat disease, but active immunisation is designed to preventboth these misfortunes. The Ministry made it clear that itscircular was liable to modification; and already it has authorisedroutine use of attenuated-virus vaccine, administered by mouth,for immunisation against poliomyelitis. 2

Among the questions most often asked of a medical officer ofhealth are those concerning immunisation, and some of theseare not easy to answer pat. As a comprehensive source ofaccurate information we know nothing better than theMemorandum on Immunological Procedures, now issued by theWar Office in a new edition.3 It is, of course, primarily con-cerned with the health of the soldier, but the needs of camp-followers of all ages receive attention. It lists those parts of theworld where the traveller must be inoculated against yellowfever. It describes in detail the intradermal administration of

T.A.B., which will be new to many and which must have saveda lot of discomfort. There are excellent descriptions of thevarious kinds of reaction which may follow immunisation andadequate directions for prevention and treatment. There areadmirable suggestions for picking up the thread of an inter-rupted course of prophylaxis. There is a useful table of the

expected life of immunising substances stored in the cold and atroom temperature. It is, indeed, difficult to find a questionwhich cannot be answered with the help of this very cheap book.

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1. See Lancet, Nov 11, 1961, p. 1099.

The medical officer of health or, for that matter, any familydoctor who wants a reliable and up-to-date guide to practicalimmunology will do well to keep it on his desk.

Fish Out of Water

Unrewarded efforts to persuade a firm to improve thehygienic conditions of a fish shop are described by Dr.J. D. Kershaw, medical officer of Colchester, in his reportfor 1960.

In 1956 the public-health department had the strongestpossible evidence that staphylococcal contamination of

exposed fish, almost certainly by dust, had occurred and hadcaused at least one case of poisoning. The firm was approached;and next year Dr. Kershaw was assured that the shop wasscheduled for conversion. In 1958 he learned that the firmwas seeking an alternative site. In 1959 an interview with thefirm’s area manager produced no satisfactory response-thefirm could not agree that fitting a glass window would effectany improvement, and it was not ready to go to the expenseof installing refrigerated display cabinets in the existing pre-mises. It did say that the matter might be solved in itsmodernisation programme, to be completed by the end of 1962.

This, says Dr. Kershaw, is an example of the way in whicha large and wealthy national concern may sometimes viewmatters of food hygiene: smaller and less wealthy undertakingshave had modern food display apparatus in use for years. The" little shop at the corner " is no more likely to be dangerousthan the big store. Dr. Kershaw hopes that, before he retiresfrom the authority’s service in 1970, either the firm will havedone something of its own accord or the Food HygieneRegulations will have been strengthened so that his departmentcan take stronger action.

Parliament

Community WorkersIn moving the second reading of the Bill which is to set up

training councils for health visitors and social workers, MissEDITH PITT said that these two groups had much in common-both worked in people’s homes, both worked on their ownthough often in cooperation with others. It was therefore

proposed that their training councils should have some

members in common and the same chairman. Sir JohnWolfenden had accepted this key position. Training for thehealth visiting service was long established, and the councilwould be able to make use of the high standards set by theRoyal Society for the Promotion of Health and the RoyalSanitary Association of Scotland. On the other hand, trainingfor social work in the local authority health and welfare serviceswas new. It was hoped that workers with a university trainingwould enter the local authority service, but the bulk of thiswork would fall to people with the new general training. Atfirst the council would be concerned with social work in thehealth and welfare services, but the Bill did not limit its scope.It was hoped that local authorities would appoint some peopleto the council with experience of other services and thusfacilitate, for example, eventual extension of the council’sfunction to child care. The new councils would be financed

by the Exchequer, and it was estimated that they would needabout E50.000 annually.The success of the services for prevention and for com-

munity care would largely depend on the work of these twotraining councils. Without the stimulus to training, many ofthe aims of earlier legislation would remain unrealised-forexample, the Mental Health Acts with their reorientation ofcare for mental disorder towards care in the community.Though the Health Service Acts and the National AssistanceAct had been passed more than ten years ago, their aimscould not be fully achieved without this small measure.

Mr. KENNETH ROBINSON welcomed the Bill though hethought it belated. He wondered whether the functions ofthe social workers’ training council might in time extend tothe hospital service and include training for probation officers,prison welfare officers, or even officers of the NationalAssistance Board. The services for which training was beingorganised through the Bill were all seriously understaffed, yetthe councils apparently had no concern with the selection orrecruitment of students and no power to make central traininggrants. He thought it optimistic to rely on local authoritygrants. The financial provision made for the councils seemedto be grossly inadequate. The councils were given powers tocarry out and assist in research, but the explanatory memoran-dum said " the additional expenditure ... on research ...will be very small". This seemed to be little more than a

" perfunctory genuflexion " to an idea.Dame IRENE WARD regretted that there was to be no training

council for psychiatric workers and hospital almoners. She

thought that the local authorities had too many representativeson the councils and the professions concerned too few.Mr. KENNETH LEWIS thought it might have been better to

discuss where coordination could take place in the healthservices before settling the channels of training. For instance,only when the Minister had decided whether he would extendthe hospital maternity service or encourage women to havetheir babies at home, could we determine the kind of trainingto be given to the health visitor and the social worker. At themoment he believed that their training was too narrow. He,too, felt that more use should be made of part-time workers.It would be a good thing if we could change the WelfareState, in which the Government did everything, into theWelfare Community, in which people were prepared to helpeach other. He thought that we had not yet begun to explorethe use of people’s spare time in jobs to help their fellows.But Mrs. JUDITH HART argued that voluntary work couldonly supplement, and never take the place of, full-time pro-fessional work, and she reminded the House how few trainedworkers there still were, especially in the mental-health service.Mr. LEO ABSE considered that the Bill dodged the

clamorous need to fill the yawning gaps in the socialservices ". In some areas, like Wales, the social services wereso primitive and so chronically short of trained workers thatthe new councils would find it well nigh impossible to findtutors for those who wished to take their courses.Mr. ENOCH POWELL, the Minister of Health, said that the

link proposed in the Bill between the training of the healthvisitor and the social worker was a compromise, but he hopedthat it would ensure their present coordination and perhapslead to an even closer relationship. The professional andeducational representation, if taken together, commanded amajority in both councils. He made no apology that the localauthorities were strongly represented, for they were statutorilyresponsible for the provision of the services. The Bill left itopen for other aspects of social work to be brought under thecouncils, and it would be inconsistent for him at this point tosay exactly which should be included and which excluded,but any accessions must be willing. Only an Order in Council,and not legislation, would be needed to adjust the membershipof the Social Workers Training Council.

There was no provision in the Bill for direct Exchequergrants to those who would take the courses promoted by thecouncils. The making of grants for further education was afunction of the local authorities. It would be wrong, certainlyat this stage, for that function to be taken away from the localauthorities and replaced by direct grants from the Exchequer.We should see how the normal machinerv works before weconsidered whether it had to be displaced or reinforced.On research, there was a genuine misunderstanding about

the terms of the last paragraph of the explanatory memorandum.In the course of their work the local authorities and the centralGovernment departments come into possession of an immenseamount of material which could be made to yield valuableinformation. With comparatively little extra expenditure, if thepower were there, as it was not at the moment, this information