1004

This list does not even touch upon other considera-tions such as stability, cost, and freedom from adverseeffects. But as everyone knows, if you ask FatherChristmas for too much you may not get anything at all.

BELIEF AND RELIEF OF PHANTOM-LIMB PAIN

PHANTOM limb is a common sequel to complete orpartial amputation. Occasionally the phantom is verypainful, and then the patient not only has to cope withthe pain; he must also convince others of his distress-that, in effect, he has an extracorporeal pain. That thephantom pain is a real condition, in a manner of speak-ing, is attested by certain constant features. For exam-ple, a painful phantom usually occurs when chronic painwas a feature before the limb was amputated. Moreover,the phantom pain will usually arise in the part that waspreviously painful, and will be precipitated by the samesort of stimulus.

Phantom-limb pain must be distinguished from stumppain, which it may or may not accompany. Stump paintends to be associated with a neuroma or some kind oflocalised neuritis whereas phantom pain seems to in-volve the central nervous system quite widely. For in-stance, phantom-limb pain can be precipitated by injec-tion of hypertonic saline or pinching of the skin on thesame or the opposite side of the body at the segmentallevel of the affected limb. Sometimes it is produced con-sistently by stimulation of areas with a different segmen-tal supply. Feinstein, Luce, and Langton2 reported 25years ago that counterirritation with strategic injectionsof hypertonic saline first exacerbated phantom-limb painbut could then give lasting, even permanent, relief.Later, Nashold and Friedman3 used dorsal-columnstimulation successfully in the relief of phantom-limbpain. Now Miles and Lipton4 report similar success withthis technique and with the simpler methods of implant-ing stimulating electrodes on to the regional peripheralnerves, or just the application of surface electrodes fortranscutaneous stimulation. Patients need less stimula-tion as time progresses, which is contrary to what mightbe expected if phantom-limb pain were just a figment of

,

the imagination in a disturbed individual. Clearly, coun-terirritation merits a prime place in the clinical work-upof patients with phantom-limb pain. Whilst implant-ation of stimulating electrodes requires special skills,the initiation of investigation, and possibly successfultreatment with transcutaneous nerve stimulation,should be within the capabilities of all doctors.

DANGEROUS PATHOGENS—MORE THOUGHTSFROM THE HSE

THE Health and Safety Executive has published draftregulations and draft guidance notes concerning thecompulsory notification of work with dangerous patho-

1. Melzack R. The puzzle of pain. Harmondsworth: Penguin, 1973.2. Feinstein B, Luce JC, Langton JNK. The influence of phantom limbs. In:

Klopsteg P, Wilson P, eds Human limbs and their substitutes. New York:1954.

3. Nashold BS, Friedman H. Dorsal column stimulation for control of pain.J Neurosurg 1972, 36, 590-97.

4. Miles J, Lipton S. Phantom limb pain treated by electrical stimulation. Pain1978; 5: 373-82.

gens.l Comments are requested by Jan. 18, 1980. Willthe HSE staff have time to sift through all the replies?The intention is to identify all places and persons in-

volved in work with or transportation of listed patho-gens, including diagnostic microbiology laboratories

(which one would suppose to be already known and areobviously liable to encounter whatever pathogenic mi-crobe turns up). Schedule 3, regulation 4, requests a listof details of who does the work, who supervises it, andwho is directly in charge; where the work will be done;and what pathogens are to be worked with-informationwhich could not reasonably be provided and kept up todate in the flexible circumstances of a diagnostic labora-tory with staff rotation and training. The pathogensconcerned are listed in two schedules. Schedule 1 corre-

sponds to category A pathogens, which are already fullycontrolled by the Dangerous Pathogens Advisory Groupon which HSE is represented and who already have topass judgment on any proposed work with or transpor-tation of these pathogens. Schedule 2 is a curious rag-bag of germs, not corresponding to the "Howie"

group-B list and including some, fairly harmless

organisms. The prize, perhaps, goes to contagious pustu-lar dermatitis virus, a common endemic infection of

sheep which many farmers, veterinary students, andbutchers acquire at some time, characterised by an indo-lent skin lesion and discomfort of little more than nuis-ance value: it would be more logical (though still ludi-crous) to list Staphylococcus aureus or Streptococcuspyogenes. Then again, "serum hepatitis virus" is inade-quately specific. Does "yellow fever virus" include thevaccine, and if so do all yellow-fever vaccinating stationsand holding premises have to comply? Clostridium botu-linum is listed: is this just the types producing toxinsdangerous for man, or all are all soil organisms in-cluded ? "Other species of pathogenic myobacteria" is

similarly unclear. A curious selection from the sal-monellæ is listed-why pick on sendai and cholerœsuis?"Other pathogenic rickettsiae" is ill-defined. Of chla-

mydi2e, "other species" presumably embraces not onlythe common oculogenital agents of low pathogenicitybut also numerous non-human infections. Incidentally,the term pathogen is used to include "any exotoxin pro-duced by the pathogen ..." (except licensed medicinalproducts)-how can this be legally or scientificallydefended? .

Those with a sense of priorities can ponder on the jus-tification of such a bureaucratic juggernaut as that pro-posed. What evidence is there of serious damage to healthfrom laboratory-acquired infections today? Data onhepatitis suggest a fall from the already low incidence afew years ago, before expensive protective arrangementshad been introduced and presumably as a consequenceof increased awareness.2 It would be useful to have simi-lar up-to-date information about tuberculosis and otherinfections: anecdotal evidence is insufficient. A clinical

laboratory worker, one suspects, is more likely to

acquire infection by eating canteen meals or travellingabroad on holiday than from exposure at work.

1. Dangerous pathogens: draft regulations and draft guidance notes. Healthand Safety Executive, Baynards House, 1 Chepstow Place, London W24TF. 50p.

2. Grist NR. Hepatitis in clinical laboratories 1975-76. J Clin Path 1978, 31,415-17.