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RELIEF OF MENTAL HOSPITALS
255 Dr. IticeOxley prophesies, once more under the mgi8 of the physician. Meanwhile, when the changes in the colon are deemed irreversible or the patient’s life in in danger, the best chance of restoring health is by ntdieal surgery, undertaken as soon as possible. The thonhtfulness of surgeons in special centres, who have perfected surgical technique and improved the appliances for the and excision of thecolon patient, has made ileostomy an operation which offers the patient a safe, comfortable, and unrestricted life. D. LANG D. LANG STEVENSON. Aford.
and a successful issue may well
bring colitis,
as
RELIEF OF MENTAL HOSPITALS
SiR,-Dr. Atkin (July 4) seems to overlook the fact a mental hospital is, to all intents and purposes, an institute for detention ; and no separate units within its walls would alter that feature. Moreover, the time that
when every mental hospital will have such units is in the remote future. The need for relief is very acute in all parts of the country; and we have to rely on buildings already standing and staffed. At several general hospitals I have found rooms unused. These rooms could be converted into units of the sort I have proposed ; and, like very many mental hospitals, they could work without having the full staffing described by Dr. Atkin as indispensable. Surely, too, the overcrowding of mental hospitals is to a great extent due to admission of patients who should be in a general hospital. I should have understood Dr. Atkin’s reluctance better if he had been writing from a general hospital rather than a mental hospital. We are, however, in full agreement on one point : like him, I believe that my proposal to set aside general-hospital beds for mental patients is unlikely to get much immediate support from other specialists. But I also believe that the time has come when it should be recognised that psychiatry is no less than medicine plus .the art of understanding the mind. Medicine has reached a point where it can get little further without the aid of its crude but powerful and rapidlygrowing younger brother. Dingleton Mental Hospital,
Mental
J. "t"t’" J W. ". MULLNER. Melrose. Melrose.
ANESTHESIA AND CLINICAL INVESTIGATIONS Sn:,—With the principle stated in your leading article last week few would disagree. You say " that the only factor limiting the use of anaesthesia for this [pneumoencephalography] and many other investigations that entail distress should be the number of trained anaes-
thetists.""
However, it is one thing to define a limiting factor, and quite another to remedy it. Over a decade ago, I found that the duties of anaesthetist in a large teaching hospital could be accomplished by a mixture of guesswork and common sense. Since that time it has become obvious that sheer practice and experience, however extensive, is not adequate without proper training. To my mind, the most serious question posed by the consideration of anaesthetics and clinical investigation is that of training. Trained anoesthetists are not unduly numerous; and senior anaesthetists, who alone can pass on their special skill, are even less numerous. One has seen the stiffening of the standards for anaesthetic diplomas-and rightly, for the responsibility carried by the anaesthetist has increased very greatly. Experience has shown that even after the potential anaesthetist has been allowed time to become a reasonably experienced clinician, at least two years of uninterrupted training and supervised work, solely in anaesthetics, is necessary before anaesthetics for clinical investigations should be tackled. Whereas at an operation, an experienced surgeon is present (at least as counsel and companion in crisis),
clinical investigation may be entrusted to technicians. As a rule these technicians are well trained and qualified in their special task, but lack the broader background of clinical experience. The anmathetic may be prolonged long after the removal, for example, of a lumoar-puncture needle. The anaesthetist may often find himself virtually alone to deal with dangers and difficnlties, arising, not from the anaesthetic, but from the essential nature of the investigation. The better the anpR!-)thetint, the more likely these are to occur ; for goocl anaesthesia encourages thorough and methodical investigation, which takes a long time. Investigation like this is greatly to the advantage of precise diagnosis, and anaesthesia, is of real value, for the conscious patient simply cannot tolerate the ordeal of lengthy posturing. In addition, the anaesthetist may adjust the hlood-pressure to assist the insertion of the needle in carotid or vertebral arteriography. I, for one, would reject absolutely the idea that patients should go home after a long anaesthetic, whatever the agent. To persist in such a practice would, in my opinion, guarantee a collision with untoward circumstance The first twenty-four hours after an - sooner or later. anesthetic belongs to the anaesthetist to follow up his As there are case, and it should be claimed as a right. considerations after such rarely surgical investigations, these cases offer particular scope for observation and clinical examination in the postanaesthetic phase.
large parts
Watford
of
a
Maternity Hospital, Watford.
J. NOEL JACKSON.
IDIOPATHIC HYPERCALCÆMIA IN INFANTS
Sir,--" Marasmus," so named by our predecessors but mystery to them, is no longer considered to be a single disease, and (as you noted some months ago 1) many of
a
the different conditions included under this general term have now been separated off. As we turn the fine adjustment of the diagnostic microscope, it is most important to avoid confusion in our new and, we hope, more accurate terminology. Confusion at any stage, especially at the beginning, can easily hinder progress ; meticulous care must therefore be taken over nomenclature. Ideally each new disease name should indicate the aetiology ; when this is not yet possible it should be accurately descriptive, preferably in terms of function and structure ; failing this it must be simply clinical. Attention is now being directed to a group of disturbances affecting infants in which chronic hypercalcsemia is present, not associated with overt poisoning by vitamin D or with hyperparathyroidism. The nomenclature used in the description of these cases of hypercalcaemia will not be easy until more is known about them and especially about their aetiology ; for the moment we can only label these syndromes descriptively. One type of syndrome manifesting hypercalcaemia has been labelled by observers in England and in Switzerland, as follows : Generalised retardation, with renal impairment, hypercalcaemia, and osteosclerosis of skull. (One patient, described by Butler.2) Chronic hypercalcsemia with osteosclerosis, craniostenosis, and cortical
nephrocalcinosis.
(One patient,
described
by
Fanconi.3)
Subsequently, these English and Swiss patients were fully reported under the title " Chronische Hypercalcamie, kombiniert mit Osteosklerose, Hyperazotamie, Minderwuchs und kongenitalen Missbildungen by 4 more
"
Fanconi et awl. Another syndrome occurs, more common than the first, which is more benign and shows a less distinctive 1. 2. 3. 4.
Lancet, 1953, i, 78. Butler, N. R. Proc. R. Soc. Med. 1951, 44, 296. Fanconi, G. Schweiz. med. Wschr. 1951, 81, 908. Fanconi, G., Girardet, P., Schlesinger, B., Butler, N., Black, J. Helv. pœdiat. Acta, 1952, 7, 314.
and a successful issue may well
bring colitis,
as
RELIEF OF MENTAL HOSPITALS
SiR,-Dr. Atkin (July 4) seems to overlook the fact a mental hospital is, to all intents and purposes, an institute for detention ; and no separate units within its walls would alter that feature. Moreover, the time that
when every mental hospital will have such units is in the remote future. The need for relief is very acute in all parts of the country; and we have to rely on buildings already standing and staffed. At several general hospitals I have found rooms unused. These rooms could be converted into units of the sort I have proposed ; and, like very many mental hospitals, they could work without having the full staffing described by Dr. Atkin as indispensable. Surely, too, the overcrowding of mental hospitals is to a great extent due to admission of patients who should be in a general hospital. I should have understood Dr. Atkin’s reluctance better if he had been writing from a general hospital rather than a mental hospital. We are, however, in full agreement on one point : like him, I believe that my proposal to set aside general-hospital beds for mental patients is unlikely to get much immediate support from other specialists. But I also believe that the time has come when it should be recognised that psychiatry is no less than medicine plus .the art of understanding the mind. Medicine has reached a point where it can get little further without the aid of its crude but powerful and rapidlygrowing younger brother. Dingleton Mental Hospital,
Mental
J. "t"t’" J W. ". MULLNER. Melrose. Melrose.
ANESTHESIA AND CLINICAL INVESTIGATIONS Sn:,—With the principle stated in your leading article last week few would disagree. You say " that the only factor limiting the use of anaesthesia for this [pneumoencephalography] and many other investigations that entail distress should be the number of trained anaes-
thetists.""
However, it is one thing to define a limiting factor, and quite another to remedy it. Over a decade ago, I found that the duties of anaesthetist in a large teaching hospital could be accomplished by a mixture of guesswork and common sense. Since that time it has become obvious that sheer practice and experience, however extensive, is not adequate without proper training. To my mind, the most serious question posed by the consideration of anaesthetics and clinical investigation is that of training. Trained anoesthetists are not unduly numerous; and senior anaesthetists, who alone can pass on their special skill, are even less numerous. One has seen the stiffening of the standards for anaesthetic diplomas-and rightly, for the responsibility carried by the anaesthetist has increased very greatly. Experience has shown that even after the potential anaesthetist has been allowed time to become a reasonably experienced clinician, at least two years of uninterrupted training and supervised work, solely in anaesthetics, is necessary before anaesthetics for clinical investigations should be tackled. Whereas at an operation, an experienced surgeon is present (at least as counsel and companion in crisis),
clinical investigation may be entrusted to technicians. As a rule these technicians are well trained and qualified in their special task, but lack the broader background of clinical experience. The anmathetic may be prolonged long after the removal, for example, of a lumoar-puncture needle. The anaesthetist may often find himself virtually alone to deal with dangers and difficnlties, arising, not from the anaesthetic, but from the essential nature of the investigation. The better the anpR!-)thetint, the more likely these are to occur ; for goocl anaesthesia encourages thorough and methodical investigation, which takes a long time. Investigation like this is greatly to the advantage of precise diagnosis, and anaesthesia, is of real value, for the conscious patient simply cannot tolerate the ordeal of lengthy posturing. In addition, the anaesthetist may adjust the hlood-pressure to assist the insertion of the needle in carotid or vertebral arteriography. I, for one, would reject absolutely the idea that patients should go home after a long anaesthetic, whatever the agent. To persist in such a practice would, in my opinion, guarantee a collision with untoward circumstance The first twenty-four hours after an - sooner or later. anesthetic belongs to the anaesthetist to follow up his As there are case, and it should be claimed as a right. considerations after such rarely surgical investigations, these cases offer particular scope for observation and clinical examination in the postanaesthetic phase.
large parts
Watford
of
a
Maternity Hospital, Watford.
J. NOEL JACKSON.
IDIOPATHIC HYPERCALCÆMIA IN INFANTS
Sir,--" Marasmus," so named by our predecessors but mystery to them, is no longer considered to be a single disease, and (as you noted some months ago 1) many of
a
the different conditions included under this general term have now been separated off. As we turn the fine adjustment of the diagnostic microscope, it is most important to avoid confusion in our new and, we hope, more accurate terminology. Confusion at any stage, especially at the beginning, can easily hinder progress ; meticulous care must therefore be taken over nomenclature. Ideally each new disease name should indicate the aetiology ; when this is not yet possible it should be accurately descriptive, preferably in terms of function and structure ; failing this it must be simply clinical. Attention is now being directed to a group of disturbances affecting infants in which chronic hypercalcsemia is present, not associated with overt poisoning by vitamin D or with hyperparathyroidism. The nomenclature used in the description of these cases of hypercalcaemia will not be easy until more is known about them and especially about their aetiology ; for the moment we can only label these syndromes descriptively. One type of syndrome manifesting hypercalcaemia has been labelled by observers in England and in Switzerland, as follows : Generalised retardation, with renal impairment, hypercalcaemia, and osteosclerosis of skull. (One patient, described by Butler.2) Chronic hypercalcsemia with osteosclerosis, craniostenosis, and cortical
nephrocalcinosis.
(One patient,
described
by
Fanconi.3)
Subsequently, these English and Swiss patients were fully reported under the title " Chronische Hypercalcamie, kombiniert mit Osteosklerose, Hyperazotamie, Minderwuchs und kongenitalen Missbildungen by 4 more
"
Fanconi et awl. Another syndrome occurs, more common than the first, which is more benign and shows a less distinctive 1. 2. 3. 4.
Lancet, 1953, i, 78. Butler, N. R. Proc. R. Soc. Med. 1951, 44, 296. Fanconi, G. Schweiz. med. Wschr. 1951, 81, 908. Fanconi, G., Girardet, P., Schlesinger, B., Butler, N., Black, J. Helv. pœdiat. Acta, 1952, 7, 314.