- Email: [email protected]
NEUROPSYCHOLOGISTS IN MEDICAL SCHOOLS
48
schizophrenics
are not
likely
to
ask for
treatment nor
EFFICIENCY OF CARDIAC MASSAGE
refuse it, I submit {that at least the final paragraph in Dr. Sargant’s article is speculative, and dangerous-to
SIR,-The paper of May 12 by Mr. Weale and Mr. Rothwell-Jackson invites a reply, since its condemnation
chronic
of external cardiac massage is based on a review of inappropriate mortality figures collected from the literature and on the authors’ experimental data, the interpretation of which is subject to dispute. The authors’ advocacy of open-chest massage in preference to external massage seems to be founded primarily on four points, which we shall attempt to answer:
schizophrenics.
Severalls Hospital,
Colchester,
RUSSELL BARTON.
Essex.
INFORMATION ON TOXICITY SIR,-As some of your readers already know, the medical department of this Company has provided for some years now, a poisons information centre. The need for this service arose, in the first place, as a result of the frequent appeals for information that were received from our 1300 retail pharmacies. Such queries refer to a wide variety of potentially toxic substances used for medical, domestic, veterinary, or horticultural purposes. It is always possible to give accurate information regarding the toxicity of our own products, and we have also received the full cooperation of other manufacturers so that our records contain information on the composition and known toxic hazards of many preparations, together with reports of actual cases of accidental or intentional poisoning. We find these records invaluable when answering queries, whether from the retail pharmacies or, as we now frequently receive them, from
(1) They correctly observe that the survival-rate in our reported series1 is low, whereas the survival-rate in several reported series of cardiac arrest treated by open-chest massage is much higher. They overlook the fact, however, that the selection of cases in the different series reported is in no way comparable. Because of its simplicity, external massage has frequently been applied in cases which were hopeless because of underlying disease. On the other hand, in the review by Briggs et al.from our own institution, only cases of circulatory arrest occurring in the operating-room are considered. In this particular group a low mortality would be expected, since circulatory arrest occurs in many of these patients because of the vicissitudes of anaesthesia without a background of underlying
serious metabolic or cardiac disease. When the operating-room practising hospital departments. group is considered separately in our report, or in that of We are already cooperating with newly established poison Kouwenhoven et awl. or of Jude et al. a similar high survivalcentres and we should like to put it on record that our service rate is produced by external massage. The cases at issue, is available to any new centres with whom we have not yet therefore, must be those in which arrest takes place outside the been in contact. operating-room, and in this group we feel that open-chest Medical Department, massage offers very little. Boots Pure Drug Co. Ltd., E. HALL. J. (2) The authors claim that the higher arterial pressure Nottingham. produced in their dogs by internal massage favours this method NEUROPSYCHOLOGISTS IN MEDICAL SCHOOLS over external massage. We agree that this finding demonstrates " I forward a for a SiR,—May put " strong plea medically the superiority of internal massage in the dog, but our own experience teaches us that this is not the case in man. The our with anatomists qualified psychologist (comparable and physiologists) as opposed to the clinical psychologist dog has a small heart, which is easily compressed within the hand of an adult man. The human does not. In addition, the or the psychiatrist at present teaching psychology in some diameter of the dog’s chest makes him a of our medical schools. Since psychology is probably as long anteroposterior poor candidate for external massage. His flimsy mediastinum necessary a foundation to the later study of clinical and relatively mobile heart likewise poorly fit him for external neurology as of psychiatry, perhaps " medically qualified massage, whereas the relatively thick mediastinum of man " neuropsychologist would be a better term. immobilises his heart between the sternum and the vertebral column. Since our paper appeared we have had the opportuThe direct influence of such a person need not necessarily be entirely preclinical 12 since he would also be strategically nity to study arterial pressures in a number of patients during closed-chest massage and subsequent open-chest massage. In to facilitate of and to interchange knowledge promote placed all cases the arterial pressure, both systolic and mean, produced what Fleminger and Mallett3 refer to as " awareness of external massage was higher than that produced by openfactors " The accent by his amongst colleagues. psychological might then be placed on such fruitful correlations4 as probably chest massage. The chest was opened in these patients because exist, for example, between hypochondriasis and non-gaseous it had proven impossible to defibrillate the heart by external means. In only one case have we been able to defibrillate the abdominal bloating5 on the one hand and, say, cortical localisaheart of man by placing electrodes directly upon it after tion and schizophrenic symptomatology on the other. Although neither the above authors nor Marshall 6 indicate external defibrillation failed. whether any of their " alimentary " group were hypochondriacal (3) The production of peripheral venous pulsations during in this sense, the method of vertical-column cross-reference external massage in the authors’ dogs is taken by them as an advocated by Symondshas been used in a way8 which makes indication that the atrioventricular valves are incompetent in it possible to suggest that his deluded patients with frontal-lobe the arrested heart. On reflection, however, it is clear that tumours 9 were left-handed or showed mixed laterality of some compression of the closed chest is bound to squeeze not only sort (e.g., of eyedness or earedness perhaps, or even footedness). the ventricles but also the atria and the great veins within the A medically qualified neuropsychologist would not wish to thorax. It must, therefore, produce a peripheral venous exclude the clinical psychologist from preclinical teaching, but pulsation regardless of the state of the atrioventricular valves. rather to enlist her aid, much as he might seek the help of the (4) As we mentioned, clinical experience does not support E.E.G. department in trying to demonstrate the cerebral electrical the superiority of direct massage of the heart over closed-chest changes accompanying alterations. in attention or level of massage. In an experience now numbering several hundred awareness-that is, if the neuriatrist in charge were willing!i cases, we have not found a single patient in whom internal Ide Hill, was successful in providing adequate peripheral massage P CRAWFORD. CRAWFORD. Kent. J P. J. circulation after external massage failed. At present, open1. Hill, J. D. N. Proc. R. Soc. Med. 1961, 54, 1082. chest cardiac massage is reserved for patients in whom circula2. Crawford, J. P. Brit. med. J. 1961, 1, 1040. 3. Fleminger, J. J., Mallett, B. L. J. ment. Sci. 1962, 108, 183. tory arrest develops during or immediately before a planned doctors
or
...
Ide Hill,
4. Crawford, J. P. Guy’s Hosp. Gaz. 1955, 69, 48. 5. Lancet, 1959, ii, 168. 6. Marshall, H. E. S. Brit. med. J. 1949, ii, 468. 7. Symonds, C. P. Arch. Neurol. Psychiat. 1954, 72, 631. 8. Crawford, J. P. Lancet, 1961, ii, 487. 9. Symonds, C. P. Brit. med. J. 1960, ii, 1.
1. Baringer, J. R., Salzman, E. W., Jones, W. Engl. J. Med. 1961, 265, 62. 2. J. Amer. med. Ass. 1956, 150, 1439. 3. ibid. 1960, 173, 1064. 4. Ann. Surg. 1961, 154, 311.
A., Friedlick, A. L. New
schizophrenics
are not
likely
to
ask for
treatment nor
EFFICIENCY OF CARDIAC MASSAGE
refuse it, I submit {that at least the final paragraph in Dr. Sargant’s article is speculative, and dangerous-to
SIR,-The paper of May 12 by Mr. Weale and Mr. Rothwell-Jackson invites a reply, since its condemnation
chronic
of external cardiac massage is based on a review of inappropriate mortality figures collected from the literature and on the authors’ experimental data, the interpretation of which is subject to dispute. The authors’ advocacy of open-chest massage in preference to external massage seems to be founded primarily on four points, which we shall attempt to answer:
schizophrenics.
Severalls Hospital,
Colchester,
RUSSELL BARTON.
Essex.
INFORMATION ON TOXICITY SIR,-As some of your readers already know, the medical department of this Company has provided for some years now, a poisons information centre. The need for this service arose, in the first place, as a result of the frequent appeals for information that were received from our 1300 retail pharmacies. Such queries refer to a wide variety of potentially toxic substances used for medical, domestic, veterinary, or horticultural purposes. It is always possible to give accurate information regarding the toxicity of our own products, and we have also received the full cooperation of other manufacturers so that our records contain information on the composition and known toxic hazards of many preparations, together with reports of actual cases of accidental or intentional poisoning. We find these records invaluable when answering queries, whether from the retail pharmacies or, as we now frequently receive them, from
(1) They correctly observe that the survival-rate in our reported series1 is low, whereas the survival-rate in several reported series of cardiac arrest treated by open-chest massage is much higher. They overlook the fact, however, that the selection of cases in the different series reported is in no way comparable. Because of its simplicity, external massage has frequently been applied in cases which were hopeless because of underlying disease. On the other hand, in the review by Briggs et al.from our own institution, only cases of circulatory arrest occurring in the operating-room are considered. In this particular group a low mortality would be expected, since circulatory arrest occurs in many of these patients because of the vicissitudes of anaesthesia without a background of underlying
serious metabolic or cardiac disease. When the operating-room practising hospital departments. group is considered separately in our report, or in that of We are already cooperating with newly established poison Kouwenhoven et awl. or of Jude et al. a similar high survivalcentres and we should like to put it on record that our service rate is produced by external massage. The cases at issue, is available to any new centres with whom we have not yet therefore, must be those in which arrest takes place outside the been in contact. operating-room, and in this group we feel that open-chest Medical Department, massage offers very little. Boots Pure Drug Co. Ltd., E. HALL. J. (2) The authors claim that the higher arterial pressure Nottingham. produced in their dogs by internal massage favours this method NEUROPSYCHOLOGISTS IN MEDICAL SCHOOLS over external massage. We agree that this finding demonstrates " I forward a for a SiR,—May put " strong plea medically the superiority of internal massage in the dog, but our own experience teaches us that this is not the case in man. The our with anatomists qualified psychologist (comparable and physiologists) as opposed to the clinical psychologist dog has a small heart, which is easily compressed within the hand of an adult man. The human does not. In addition, the or the psychiatrist at present teaching psychology in some diameter of the dog’s chest makes him a of our medical schools. Since psychology is probably as long anteroposterior poor candidate for external massage. His flimsy mediastinum necessary a foundation to the later study of clinical and relatively mobile heart likewise poorly fit him for external neurology as of psychiatry, perhaps " medically qualified massage, whereas the relatively thick mediastinum of man " neuropsychologist would be a better term. immobilises his heart between the sternum and the vertebral column. Since our paper appeared we have had the opportuThe direct influence of such a person need not necessarily be entirely preclinical 12 since he would also be strategically nity to study arterial pressures in a number of patients during closed-chest massage and subsequent open-chest massage. In to facilitate of and to interchange knowledge promote placed all cases the arterial pressure, both systolic and mean, produced what Fleminger and Mallett3 refer to as " awareness of external massage was higher than that produced by openfactors " The accent by his amongst colleagues. psychological might then be placed on such fruitful correlations4 as probably chest massage. The chest was opened in these patients because exist, for example, between hypochondriasis and non-gaseous it had proven impossible to defibrillate the heart by external means. In only one case have we been able to defibrillate the abdominal bloating5 on the one hand and, say, cortical localisaheart of man by placing electrodes directly upon it after tion and schizophrenic symptomatology on the other. Although neither the above authors nor Marshall 6 indicate external defibrillation failed. whether any of their " alimentary " group were hypochondriacal (3) The production of peripheral venous pulsations during in this sense, the method of vertical-column cross-reference external massage in the authors’ dogs is taken by them as an advocated by Symondshas been used in a way8 which makes indication that the atrioventricular valves are incompetent in it possible to suggest that his deluded patients with frontal-lobe the arrested heart. On reflection, however, it is clear that tumours 9 were left-handed or showed mixed laterality of some compression of the closed chest is bound to squeeze not only sort (e.g., of eyedness or earedness perhaps, or even footedness). the ventricles but also the atria and the great veins within the A medically qualified neuropsychologist would not wish to thorax. It must, therefore, produce a peripheral venous exclude the clinical psychologist from preclinical teaching, but pulsation regardless of the state of the atrioventricular valves. rather to enlist her aid, much as he might seek the help of the (4) As we mentioned, clinical experience does not support E.E.G. department in trying to demonstrate the cerebral electrical the superiority of direct massage of the heart over closed-chest changes accompanying alterations. in attention or level of massage. In an experience now numbering several hundred awareness-that is, if the neuriatrist in charge were willing!i cases, we have not found a single patient in whom internal Ide Hill, was successful in providing adequate peripheral massage P CRAWFORD. CRAWFORD. Kent. J P. J. circulation after external massage failed. At present, open1. Hill, J. D. N. Proc. R. Soc. Med. 1961, 54, 1082. chest cardiac massage is reserved for patients in whom circula2. Crawford, J. P. Brit. med. J. 1961, 1, 1040. 3. Fleminger, J. J., Mallett, B. L. J. ment. Sci. 1962, 108, 183. tory arrest develops during or immediately before a planned doctors
or
...
Ide Hill,
4. Crawford, J. P. Guy’s Hosp. Gaz. 1955, 69, 48. 5. Lancet, 1959, ii, 168. 6. Marshall, H. E. S. Brit. med. J. 1949, ii, 468. 7. Symonds, C. P. Arch. Neurol. Psychiat. 1954, 72, 631. 8. Crawford, J. P. Lancet, 1961, ii, 487. 9. Symonds, C. P. Brit. med. J. 1960, ii, 1.
1. Baringer, J. R., Salzman, E. W., Jones, W. Engl. J. Med. 1961, 265, 62. 2. J. Amer. med. Ass. 1956, 150, 1439. 3. ibid. 1960, 173, 1064. 4. Ann. Surg. 1961, 154, 311.
A., Friedlick, A. L. New