1321

keeping out of each other’s way. Consultation over

individual patients is the easiest and most natural way todraw priest and doctor together, but both Commissionssuggest that this could be extended by meetings betweensmall groups of clergy and doctors to exchange views andexperiences. They also propose that medical and theo-logical students should be given an opportunity of learningsomething of the work and responsibilities of each other’sprofession. The Scottish Commission was able to reportthat in at least one of their theological colleges a courseof lectures is given to final-year students by the medicalsuperintendent of a mental hospital and that the studentsvisit the wards of the hospital. Another opportunityfor cooperation which the Scottish Commission urge is inhospitals with chaplains. They would like to see the

chaplain treated as a recognised member of the staff anddrawn more often into consultation with his medicalcolleagues.

In their training and approach the doctor and thepriest inevitably differ. But they share a common

concern for the patient, and when a patient seeks helpfrom both it will be most effectively given by colleagueswho respect and trust each other.

1. Churchill-Davidson, H. C., Richardson, A. T. Lancet, 1957, i, 1221.2. Grob, D., Johns, R. J. Amer. J. Med. 1958, 24, 497, 512.3. Namba, T., Hiraki, K. J. Amer. med. Ass. 1958, 166, 1834.

ANTICHOLINESTERASE INHIBITORS

THE anticholinesterases commonly used in the diagnosisand treatment of myasthenia gravis are neostigmine,pyridostigmine, and edrophonium. Less commonly usedare organophosphorous compounds with powerful anti-cholinesterase activity-di-isopropyl fluorophosphate andtetraethyl pyrophosphate. Overdosage of an anti-cholinesterase may lead to a

" cholinergic crisis " due toaccumulation of acetylcholine in the tissues. This stage isoften difficult to recognise. Clinical deterioration after anintravenous dose of edrophonium is evidence of the

cholinergic state; and, because of the drug’s transient

action, this test is fairly safe. Until recently there was nospecific therapy for anticholinesterase poisoning. Themain weapons were withdrawal of neostigmine andadministration of atropine, which neutralises the gastro-intestinal, bronchial, and cardiac effects. A free airwaymust be maintained, and sometimes mechanical aids torespiration are necessary. d-Tubocurarine has beenrecommended 1; but the dose needed for " competitiveblocking " of anticholinesterase is uncomfortably close tothat producing muscular paralysis. The action in man oftwo specific anticholinesterase inhibitors has now beenthoroughly studied by Grob and Johns.2These substances are pyridine-2-aldoxine (2-P.A.M.) and

diacetyl monoxine (D.A.M.). They were found to reversecholinesterase inhibition and neuromuscular block due to

organophosphorous or quaternary ammonium anticholin-esterases. 2-P.A.M. proved the better of the two when admin-istered before or after other anticholinesterases. A verylarge dose of 2-P.A.M. can produce a neuromuscular blockin animals, but in man the recommended dose-1-2 g.intravenously-is unlikely to have this effect. Clearly2-P.A.M. should now be held ready for emergency therapyin cholinergic crises. Unfortunately at this serious stagemany myasthenics are in a precarious balance between theprogressive disease and high neostigmine dosage; thus,whatever treatment is applied, many may fail to recover.Namba and Hiraki 3 found that these two substances alsocounteracted Parathion ’, an organophosphorous insecti-cide which sometimes gives rise to accidental poisoning.

A NEW HOSPITAL REGION

THE South West Metropolitan Regional HospitalBoard, responsible for a vast straggling area and a popula-tion of nearly 5 million, has deliberately fostered partialautonomy in its most distant sector-that of Wessex

(Hampshire, Dorset, Wiltshire, and the Isle of Wight).The Minister of Health has now announced that theautonomy is to be complete from April 1 next year, whena Wessex Regional Hospital Board will come into opera-tion. The new region, which is compact, contains about13/4 million people; and in it every specialty except neuro-surgery is already covered. If Southampton were

eventually to have a medical school, this might end theregion’s reliance on London; but meanwhile it is

likely to continue its association with the University ofLondon-notably the British Postgraduate MedicalFederation and the three undergraduate teaching hos-pitals (St. George’s, St. Thomas’s, and Westminster)that are linked with the South West Metropolitan region.Ten years ago a Wessex hospital region would have had

to rely on London for many specialties. Today that is nolonger so. The fact that the new region will from thestart be so largely self-reliant testifies to the remarkableimprovement, during the past decade, in hospital servicesoutside the capital.

1. Harris, S., Harris, T. N., Farber, M. B. J. Immunol. 1954, 72, 148.2. Fagreus, A. ibid. 1948, 58, 1.3. Keunig, F. J., van der Slekke, L. B. J. Lab. clin. Med. 1950, 36, 167.4. Nossal, G. J. V., Lederberg, J. Nature, Lond. 1958, 181, 1419.

ANTIBODY FORMATION IN VITRO

THE mechanism by which antibodies are formed is notcompletely understood, but it has been found that lymph-nodes transplanted from an immunised animal to a normalanimal continue to produce antibody in the new host.Washed cells from the lymph-nodes of an immunisedrabbit give rise to antibodies when injected intravenouslyinto a normal rabbit.1 Antibody formation also occurs invitro in cultures of various tissues removed from immu-nised animals.2 3 Some interesting experiments whichcarry the matter a stage further are now reported 4 byDr. Nossal and Professor Lederberg, well known for hiswork on bacterial genetics in the University of Wisconsin,who has been the Fulbright visiting professor inMelbourne.

Rats were each immunised with two different strains ofsalmonella and the popliteal lymph-nodes were excised.Cell suspensions were prepared from these lymph-nodes,and by micromanipulation methods single cells were

isolated. Some of these single cells when incubated in aserum-saline medium produced antiflagellar antibodiescapable of immobilising one or other of the bacterialstrains with which the rats had been immunised.

Quite apart from the interesting possibility of demon-strating antibody formation in vitro by single cells, thisachievement makes it possible to investigate various

problems of antibody formation. The two salmonellastrains used had different specific flagellar antigens, andthe rats produced two distinct antibodies each capable ofimmobilising the specific strain. The question arisestherefore whether the two kinds of antibody are producedby a single cell or whether a separate cell is necessary toproduce each kind of antibody. In the experimentsreported, 456 single cells were tested for antibodyproduction, and of these 33 were active against Salmonellaadelaide and 29 against Salmonella typhi, but none of these62 immobilised both strains. Possibly some cells may have