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NOISE IN HOSPITAL
93 POLIOMYELITIS AND REMOTE TONSILLECTOMY
SIR,-The Medical Research Council committee (July 2) conclude that persons whose tonsils have been removed are more likely to have the bulbar form of poliomyelitis than those who have not had the operation, even if years have elapsed between the removal of the tonsils and the onset of poliomyelitis. They are not in favour of a theory that there may be some local condition of the pharynx which, on the one hand, is an indication for tonsillectomy and, on the other, makes the child more liable to bulbar poliomyelitis even after the operation. Though I am not an ardent tonsillectomist I think we should pause and consider this point in more detail. Lacey1 say : "In man the incidence of paralysis has been ... possibly slightly greater in heavier children and in persons with a particular recessive gene, fair hair, or of mongoloid or subendocrinopathic type characterised by a tendency to growth without corresponding development, hypogonadism, and various stigmata." Now the incidence of tonsillectomy itself varies in different types. It is, for instance, much more common in asthmatic children. I have shown2 that children and university students who have postnormal occlusion of the teeth are more likely to have suffered this operation. The postnormals may well belong to the subendocrinopathic type mentioned by Lacey. I think that there may be a common cause for both the tonsillectomy and the attack of poliomyelitis, and this could be a local one connected with the development and shape of the mouth andjaws. HUGH R. E. WALLIS. Bath. SIR,-I doubt whether it is fair to contrast a group of tonsillectomised children with a control group of average children. The former presumably have a poor resistance to upper respiratory infections, and it would therefore be reasonable to expect a more severe attack of poliomyelitis in this group than in a group of average children. G. A. FRASER. Hove. BAYTENAL IN PSYCHIATRY
is a recently introduced thioconsisting of the sodium salt of 5.5 allyl-(2methylpropyl)-thiobarbituric acid. It is a yellowish powder easily soluble in water producing a solution having an alkaline reaction. The drug is dispensed in vials containing 1 gramme and it is used intravenously as a 10% solution. Good results have been reported in over 350 cases where baytenal was used as a short-acting anaesthetic.3 Preliminary investigation in psychiatric cases indicates that it is useful in securing a rapid safe coma prior to electroconvulsive therapy (E.C.T.), either with relaxants or alone.
SIR,-’ Baytenal’
barbiturate
-
Following its use in E.c.T., I have used a new technique conveniently referred to as narco-relaxation in cases where tension is a prominent feature. I explain to the patient that the treatment will not necessarily cure his condition, but he will secure rapid relief from his tension and anxiety and this will enable him to cope with his difficulties more satisfactorily by the breaking of the vicious circle that is usually operating
in neurotic conditions. The patient lies in bed with the head propped up and the arm to be used for the injection is placed in a comfortable position. 1-11/2 m!: of 10% baytenal solution is injected into a suitable elbow vein over a period of 50-70 seconds. The patient is asked to state when he feels the effects of the drug and this is usually 1-11/2 min. after the injection begins ; there is much relief from tension and a feeling of well-being. The baytenal is thereafter injected at the rate of 1 ml. during each 5 min. or alternatively 0-2 ml. may be injected at minute intervals. 1. Lacey, B. W. Lancet, 1949, i, 849. 2. Dent. Rec. 1953, 73, 519. 3. Dtsch. med. Wschr. 1954, 79, 601.
This procedure maintains the patient in a state of contented relaxation without impairment of consciousness. At any time during the injection sopor or sleep may be produced by increasing the rapidity of the injection, and withholding the drug for a minute or two will bring the patient back to consciousness. At the end of 25 min. the needle is withdrawn. He may dress 5 min. later and he is usually able to leave the hospital 10 min. or so after cessation of treatment. It is desirable that he be accompanied. He should have been advised not to have a meal for about 3 hours prior to having the treatment. For elderly patients gr. 1/100atropine should be given before the treatment. The treatment may be at weekly intervals. No side-reactions, vomiting, or and excitement does not occur.
repeated
drug rashes have been noted
I have found baytenal narco-relaxation a great help in the treatment of cases of neurosis where tension is prominent, and also in tension states accompanying
paranoid schizophrenia. Barnsley Hall Hospital, Bromsgrove, Worcestershire.
M. G. MCCOLL.
NOISE IN HOSPITAL
SiR,-For about
I was a patient in where I was treated with large provincial hospital great efficiency and kindness, but the incessant noise from early morning until late at night was wearing to the stoutest nerves. The most trying thing was the slamming of doors a
week
recently
a
- cars,
lorries, ambulances,
room
doors, cupboard doors,
and above all the entrance door to the ward. Wooden floors are not quiet, and the tramping of feet went on all day. Furniture and utensils, crates, tins, and pails were pushed and dragged, dropped, flung, and bumped about, and laden trollies clattered and rattled on their way. So it was not surprising that repairs were necessary and there seemed to be plenty of energetic workmen with hammers. Then there was the loudspeaker calling Dr. So-and-So, and the telephone, both in constant use. These were just some of the noises which, it seems to me, tend to undermine the good the hospital is doing for the patient. Much of this noise is quite unnecessary and could be prevented, and I know there are hospitals where much has been done in this direction. It is to be hoped that all hospitals will soon tackle this matter seriously and see to it that all unnecessary noise is eliminated. IDA SEYMOUR. London, N.W.3. ADENOSINE TRIPHOSPHATE IN PAROXYSMAL TACHYCARDIA
SiR,-We would like to add some observations to Dr. Somlo’s letter and your annotation of May 28. So far we have given over 300 intravenous injections of adenosine triphosphate (A.T.P.) (’Atriphos’) to 52 patients suffering from supraventricular paroxysmal tachycardia. Single doses of 10-70 mg. have been used without harmful side-effects. Only exceptionally is it necessary to exceed 40 mg. If so, we give the dose in two parts, the second 20-30 minutes after the first. Only when the attack is over, during the shift to normal rate, have we observed a few seconds’ asystole accompanied by severe malaise, but no permanent effect. One patient who had very frequent attacks received 53 injections at this hospital and 130 at other institutions-a total of 183 in less than four years. This patient had hypertension and signs of myocardial damage. We tried to relieve the first attack with various drugs, but three days’ treatment did not stop it. The heart began to fail on the fourth day, so we decided on intravenous A.T.P. The response was prompt. Since then the patient has had many attacks and has been given A.T.p. each time, yet the cardiac condition is compensated, and the electrocardiogram has shown no change during the whole period.
Neither in this case nor in others where and sedatives have been ineffective
measures
physical can
we
SIR,-The Medical Research Council committee (July 2) conclude that persons whose tonsils have been removed are more likely to have the bulbar form of poliomyelitis than those who have not had the operation, even if years have elapsed between the removal of the tonsils and the onset of poliomyelitis. They are not in favour of a theory that there may be some local condition of the pharynx which, on the one hand, is an indication for tonsillectomy and, on the other, makes the child more liable to bulbar poliomyelitis even after the operation. Though I am not an ardent tonsillectomist I think we should pause and consider this point in more detail. Lacey1 say : "In man the incidence of paralysis has been ... possibly slightly greater in heavier children and in persons with a particular recessive gene, fair hair, or of mongoloid or subendocrinopathic type characterised by a tendency to growth without corresponding development, hypogonadism, and various stigmata." Now the incidence of tonsillectomy itself varies in different types. It is, for instance, much more common in asthmatic children. I have shown2 that children and university students who have postnormal occlusion of the teeth are more likely to have suffered this operation. The postnormals may well belong to the subendocrinopathic type mentioned by Lacey. I think that there may be a common cause for both the tonsillectomy and the attack of poliomyelitis, and this could be a local one connected with the development and shape of the mouth andjaws. HUGH R. E. WALLIS. Bath. SIR,-I doubt whether it is fair to contrast a group of tonsillectomised children with a control group of average children. The former presumably have a poor resistance to upper respiratory infections, and it would therefore be reasonable to expect a more severe attack of poliomyelitis in this group than in a group of average children. G. A. FRASER. Hove. BAYTENAL IN PSYCHIATRY
is a recently introduced thioconsisting of the sodium salt of 5.5 allyl-(2methylpropyl)-thiobarbituric acid. It is a yellowish powder easily soluble in water producing a solution having an alkaline reaction. The drug is dispensed in vials containing 1 gramme and it is used intravenously as a 10% solution. Good results have been reported in over 350 cases where baytenal was used as a short-acting anaesthetic.3 Preliminary investigation in psychiatric cases indicates that it is useful in securing a rapid safe coma prior to electroconvulsive therapy (E.C.T.), either with relaxants or alone.
SIR,-’ Baytenal’
barbiturate
-
Following its use in E.c.T., I have used a new technique conveniently referred to as narco-relaxation in cases where tension is a prominent feature. I explain to the patient that the treatment will not necessarily cure his condition, but he will secure rapid relief from his tension and anxiety and this will enable him to cope with his difficulties more satisfactorily by the breaking of the vicious circle that is usually operating
in neurotic conditions. The patient lies in bed with the head propped up and the arm to be used for the injection is placed in a comfortable position. 1-11/2 m!: of 10% baytenal solution is injected into a suitable elbow vein over a period of 50-70 seconds. The patient is asked to state when he feels the effects of the drug and this is usually 1-11/2 min. after the injection begins ; there is much relief from tension and a feeling of well-being. The baytenal is thereafter injected at the rate of 1 ml. during each 5 min. or alternatively 0-2 ml. may be injected at minute intervals. 1. Lacey, B. W. Lancet, 1949, i, 849. 2. Dent. Rec. 1953, 73, 519. 3. Dtsch. med. Wschr. 1954, 79, 601.
This procedure maintains the patient in a state of contented relaxation without impairment of consciousness. At any time during the injection sopor or sleep may be produced by increasing the rapidity of the injection, and withholding the drug for a minute or two will bring the patient back to consciousness. At the end of 25 min. the needle is withdrawn. He may dress 5 min. later and he is usually able to leave the hospital 10 min. or so after cessation of treatment. It is desirable that he be accompanied. He should have been advised not to have a meal for about 3 hours prior to having the treatment. For elderly patients gr. 1/100atropine should be given before the treatment. The treatment may be at weekly intervals. No side-reactions, vomiting, or and excitement does not occur.
repeated
drug rashes have been noted
I have found baytenal narco-relaxation a great help in the treatment of cases of neurosis where tension is prominent, and also in tension states accompanying
paranoid schizophrenia. Barnsley Hall Hospital, Bromsgrove, Worcestershire.
M. G. MCCOLL.
NOISE IN HOSPITAL
SiR,-For about
I was a patient in where I was treated with large provincial hospital great efficiency and kindness, but the incessant noise from early morning until late at night was wearing to the stoutest nerves. The most trying thing was the slamming of doors a
week
recently
a
- cars,
lorries, ambulances,
room
doors, cupboard doors,
and above all the entrance door to the ward. Wooden floors are not quiet, and the tramping of feet went on all day. Furniture and utensils, crates, tins, and pails were pushed and dragged, dropped, flung, and bumped about, and laden trollies clattered and rattled on their way. So it was not surprising that repairs were necessary and there seemed to be plenty of energetic workmen with hammers. Then there was the loudspeaker calling Dr. So-and-So, and the telephone, both in constant use. These were just some of the noises which, it seems to me, tend to undermine the good the hospital is doing for the patient. Much of this noise is quite unnecessary and could be prevented, and I know there are hospitals where much has been done in this direction. It is to be hoped that all hospitals will soon tackle this matter seriously and see to it that all unnecessary noise is eliminated. IDA SEYMOUR. London, N.W.3. ADENOSINE TRIPHOSPHATE IN PAROXYSMAL TACHYCARDIA
SiR,-We would like to add some observations to Dr. Somlo’s letter and your annotation of May 28. So far we have given over 300 intravenous injections of adenosine triphosphate (A.T.P.) (’Atriphos’) to 52 patients suffering from supraventricular paroxysmal tachycardia. Single doses of 10-70 mg. have been used without harmful side-effects. Only exceptionally is it necessary to exceed 40 mg. If so, we give the dose in two parts, the second 20-30 minutes after the first. Only when the attack is over, during the shift to normal rate, have we observed a few seconds’ asystole accompanied by severe malaise, but no permanent effect. One patient who had very frequent attacks received 53 injections at this hospital and 130 at other institutions-a total of 183 in less than four years. This patient had hypertension and signs of myocardial damage. We tried to relieve the first attack with various drugs, but three days’ treatment did not stop it. The heart began to fail on the fourth day, so we decided on intravenous A.T.P. The response was prompt. Since then the patient has had many attacks and has been given A.T.p. each time, yet the cardiac condition is compensated, and the electrocardiogram has shown no change during the whole period.
Neither in this case nor in others where and sedatives have been ineffective
measures
physical can
we