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THE FUNCTIONS OF A HOSPITAL
1235
Knowledge of the natural history of this syndrome is still meagre. The patient described by Schmid and Mahlerhad deteriorated over the years without having received any extra carbohydrate, while McArdle’s patient had always eaten vast amounts of carbohydrate food2 and for the last 3 years has been given fructose before exertion without any clinical evidence of weakness or wasting.3 In the latter patient, glucose had proved less effective than fructose and actually interfered with his activities by causing him to put on fat at an alarming rate. Patients with the McArdle syndrome or similar glycogenstorage diseases are unlikely to suffer from any lack of supervision, either clinical or biochemical. The wisdom, or folly, of any particular scheme of treatment will then become apparent before serious damage has been done. At the present time we shall continue to let our patients take fructose, but only within an hour or so before they intend to undertake some exertion which otherwise they would be unable to do. Guy’s Hospital, London. S.E. 1.
ROBERT MAHLER.
National Hospital for Nervous Diseases, London, W.9. The National Hospital, London, W.C.1.
R. S. MELLICK. B. P. HUGHES.
THE FUNCTIONS OF A HOSPITAL
Binks is
be congratulated on his concise SIR,-Dr. and thoughtful survey of the functions of a hospital (May 26). It is precisely because general clinicians have been unwilling to adopt the perspective which Dr. Binks so well describes that the specialty of geriatrics has arisen. Most geriatric units are now based on a triple system of " " assessment ", rehabilitation ", and " long stay " beds, fulfilling the criteria laid down by Dr. Binks. The failure of welfare authorities to meet the responsibilities to
he describes is well known. For this reason the hospital service must make what arrangements it can to lessen the " blocking " effect of large numbers of patients who remain in hospital for social reasons. Holiday-admission schemes and day hospitals are, partly at least, attempts to circumvent this problem. The geriatric day hospital has yet to prove itself. It seems extremely likely, however, that such a day hospital will allow earlier discharge of inpatients and, by continued surveillance of the more disabled, will diminish the need for periodic readmission. It is, after all, in the nature of much long-term disabling disease to require physical and environmental therapy intermittently for an indefinite period. To say, as Dr. Binks does, that most long-stay patients require hospital care because of severe mental changes is, I am sure, an exaggeration. Certainly a large number of long-stay patients are so confused that they would be unsafe in normal domestic life-and many have little physical disability. But a very large proportion of long-stay patients remain disabled because of residual deformities and paralyses-and their mental state, if it is abnormal at all, is due to the environmental apathy and despair of so many long-stay wards. A long-stay ward is a patient’s home for the remainder of his life. In it he is entitled to expect a great deal more personal liberty (physical and mental) than is possible in the more disciplined acute or rehabilitation ward. Any comparison between life in an average long-stay hospital ward and that in a Cheshire Home, for example, makes abundantly clear the deficiencies of the former. Yet (excluding the demented and severely confused) each is catering for patients of similar status. I am certain that as the triple division of hospital beds described by Dr. Binks becomes more widely used, a great
deal
more
thought
must
be
given
to
the
siting,
construc-
1. Schmid, R., Mahler, R. J. clin. Invest. 1959, 38, 2044. 2. McArdle, B. Clin. Sci. 1951, 10, 13. 3. Mahler, R., McArdle, B. Quart. J. Med. 1960, 29, 638.
tion, staffing, and daily life of long-stay wards. Dr. Russell Barton in his book Institutional Neurosis has already shown the terrible hazards inherent in long-stay hospital care. If a fraction of the thought and research which is put into the great technological advances in medicine and surgery were to be applied to this problem, it is hardly too much to say that the gain in terms of human happiness would be as considerable as that accruing from any of these great advances. Department of Geriatrics, The Lennard
Hospitals, Bromley, Kent.
JOHN C. BROCKLEHURST.
FATAL REACTION ASSOCIATED WITH TRANYLCYPROMINE AND METHYLAMPHETAMINE
Mason’s report (May 19) of a fatal be the first, the effect of giving methylamphetamine intravenously to a patient taking any of the monoamine-oxidase inhibitors (M.A.o.I.) (iproniazid,
SIR,-Although Dr.
reaction appears
to
phenelzine, isocarboxazid, phenoxypropazine, pheniprazine, nialamide, tranylcypromine), whether or not they are hydrazines, is always, in my experience, alarming. Within seconds of the injection the patient develops an occipital headache, so severe that he may scream with pain. He has a terrifying sense of constriction in his chest, and this, together with tachycardia and palpitations, convinces him that he is about to die. He is pale, cold, and sweaty; he breathes rapidly and may vomit. The severe symptoms may last up to six hours, and the patient may not feel himself for several days. This reaction may occur if methylamphetamine is given within two weeks of stopping the M.A.O.i., due to the slow rate of excretion of these drugs. A man of 38, who had been on phenelzine until eight days before, was given intravenous methylamphetamine. His blood-pressure rose immediately from 120/80 to 280/150, and remained at this level for the next hour. Two hours later it was 210/100, and after four hours had fallen to 180/90. His headache was then still severe, but was now bearable. Twenty-four hours later the pressure was 150/80, and had returned to its normal level by the next day. Treatment with aspirin and intravenous sodium amylobarbitone gave little relief; but intravenous ergotamine, given to a similar case on another occasion, did seem to lessen and shorten these effects. Exactly the same may occur if adrenaline is given to a patient, for example, an asthmatic who is taking M.A.O.I. This reaction is similar to the shorter-lived but equally alarming side-effect that may occur with the M.A.O.I. alone. This comes on only after the drug has been taken for some weeks (although if dextroamphetamine is combined with the M.A.O.I. it may occur within a fortnight), and it is usually preceded by transitory spells of tachycardia or palpitation, or by an unpleasant tingling sensation down the back of the neck. Unless the drug is stopped or reduced at once, the characteristic headache will develop. The blood-pressure will suddenly rise, the pulse-rate will increase, and the patient will become acutely anxious and disturbed. If he lies down, these symptoms will usually lessen after 30-60 minutes, but milder effects may last much longer. At least 2 patients known to me developed these symptoms and were admitted for a suspected subarachnoid hxmorrhage and subjected to lumbar puncture. Because of the widespread use of the M.A.O.I. by physicians and general practitioners, as well as psychiatrists, it seems important that this complication should be well known, and that particular care should be taken to inquire about these drugs before giving methylamphetamine or adrenaline by injection.
These side-effects are very similar to the hypertensive paroxysms associated with a phxochromocytoma, and suggest the interesting possibility that the adrenal medulla
Knowledge of the natural history of this syndrome is still meagre. The patient described by Schmid and Mahlerhad deteriorated over the years without having received any extra carbohydrate, while McArdle’s patient had always eaten vast amounts of carbohydrate food2 and for the last 3 years has been given fructose before exertion without any clinical evidence of weakness or wasting.3 In the latter patient, glucose had proved less effective than fructose and actually interfered with his activities by causing him to put on fat at an alarming rate. Patients with the McArdle syndrome or similar glycogenstorage diseases are unlikely to suffer from any lack of supervision, either clinical or biochemical. The wisdom, or folly, of any particular scheme of treatment will then become apparent before serious damage has been done. At the present time we shall continue to let our patients take fructose, but only within an hour or so before they intend to undertake some exertion which otherwise they would be unable to do. Guy’s Hospital, London. S.E. 1.
ROBERT MAHLER.
National Hospital for Nervous Diseases, London, W.9. The National Hospital, London, W.C.1.
R. S. MELLICK. B. P. HUGHES.
THE FUNCTIONS OF A HOSPITAL
Binks is
be congratulated on his concise SIR,-Dr. and thoughtful survey of the functions of a hospital (May 26). It is precisely because general clinicians have been unwilling to adopt the perspective which Dr. Binks so well describes that the specialty of geriatrics has arisen. Most geriatric units are now based on a triple system of " " assessment ", rehabilitation ", and " long stay " beds, fulfilling the criteria laid down by Dr. Binks. The failure of welfare authorities to meet the responsibilities to
he describes is well known. For this reason the hospital service must make what arrangements it can to lessen the " blocking " effect of large numbers of patients who remain in hospital for social reasons. Holiday-admission schemes and day hospitals are, partly at least, attempts to circumvent this problem. The geriatric day hospital has yet to prove itself. It seems extremely likely, however, that such a day hospital will allow earlier discharge of inpatients and, by continued surveillance of the more disabled, will diminish the need for periodic readmission. It is, after all, in the nature of much long-term disabling disease to require physical and environmental therapy intermittently for an indefinite period. To say, as Dr. Binks does, that most long-stay patients require hospital care because of severe mental changes is, I am sure, an exaggeration. Certainly a large number of long-stay patients are so confused that they would be unsafe in normal domestic life-and many have little physical disability. But a very large proportion of long-stay patients remain disabled because of residual deformities and paralyses-and their mental state, if it is abnormal at all, is due to the environmental apathy and despair of so many long-stay wards. A long-stay ward is a patient’s home for the remainder of his life. In it he is entitled to expect a great deal more personal liberty (physical and mental) than is possible in the more disciplined acute or rehabilitation ward. Any comparison between life in an average long-stay hospital ward and that in a Cheshire Home, for example, makes abundantly clear the deficiencies of the former. Yet (excluding the demented and severely confused) each is catering for patients of similar status. I am certain that as the triple division of hospital beds described by Dr. Binks becomes more widely used, a great
deal
more
thought
must
be
given
to
the
siting,
construc-
1. Schmid, R., Mahler, R. J. clin. Invest. 1959, 38, 2044. 2. McArdle, B. Clin. Sci. 1951, 10, 13. 3. Mahler, R., McArdle, B. Quart. J. Med. 1960, 29, 638.
tion, staffing, and daily life of long-stay wards. Dr. Russell Barton in his book Institutional Neurosis has already shown the terrible hazards inherent in long-stay hospital care. If a fraction of the thought and research which is put into the great technological advances in medicine and surgery were to be applied to this problem, it is hardly too much to say that the gain in terms of human happiness would be as considerable as that accruing from any of these great advances. Department of Geriatrics, The Lennard
Hospitals, Bromley, Kent.
JOHN C. BROCKLEHURST.
FATAL REACTION ASSOCIATED WITH TRANYLCYPROMINE AND METHYLAMPHETAMINE
Mason’s report (May 19) of a fatal be the first, the effect of giving methylamphetamine intravenously to a patient taking any of the monoamine-oxidase inhibitors (M.A.o.I.) (iproniazid,
SIR,-Although Dr.
reaction appears
to
phenelzine, isocarboxazid, phenoxypropazine, pheniprazine, nialamide, tranylcypromine), whether or not they are hydrazines, is always, in my experience, alarming. Within seconds of the injection the patient develops an occipital headache, so severe that he may scream with pain. He has a terrifying sense of constriction in his chest, and this, together with tachycardia and palpitations, convinces him that he is about to die. He is pale, cold, and sweaty; he breathes rapidly and may vomit. The severe symptoms may last up to six hours, and the patient may not feel himself for several days. This reaction may occur if methylamphetamine is given within two weeks of stopping the M.A.O.i., due to the slow rate of excretion of these drugs. A man of 38, who had been on phenelzine until eight days before, was given intravenous methylamphetamine. His blood-pressure rose immediately from 120/80 to 280/150, and remained at this level for the next hour. Two hours later it was 210/100, and after four hours had fallen to 180/90. His headache was then still severe, but was now bearable. Twenty-four hours later the pressure was 150/80, and had returned to its normal level by the next day. Treatment with aspirin and intravenous sodium amylobarbitone gave little relief; but intravenous ergotamine, given to a similar case on another occasion, did seem to lessen and shorten these effects. Exactly the same may occur if adrenaline is given to a patient, for example, an asthmatic who is taking M.A.O.I. This reaction is similar to the shorter-lived but equally alarming side-effect that may occur with the M.A.O.I. alone. This comes on only after the drug has been taken for some weeks (although if dextroamphetamine is combined with the M.A.O.I. it may occur within a fortnight), and it is usually preceded by transitory spells of tachycardia or palpitation, or by an unpleasant tingling sensation down the back of the neck. Unless the drug is stopped or reduced at once, the characteristic headache will develop. The blood-pressure will suddenly rise, the pulse-rate will increase, and the patient will become acutely anxious and disturbed. If he lies down, these symptoms will usually lessen after 30-60 minutes, but milder effects may last much longer. At least 2 patients known to me developed these symptoms and were admitted for a suspected subarachnoid hxmorrhage and subjected to lumbar puncture. Because of the widespread use of the M.A.O.I. by physicians and general practitioners, as well as psychiatrists, it seems important that this complication should be well known, and that particular care should be taken to inquire about these drugs before giving methylamphetamine or adrenaline by injection.
These side-effects are very similar to the hypertensive paroxysms associated with a phxochromocytoma, and suggest the interesting possibility that the adrenal medulla