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TREATMENT OF PARKINSONIAN TREMOR
1086 would represent first-line management with responsibility for putting policy into practice. She would be respcnsible to nurses in middle management (grades 7 and 8), controlling units of three to six such sections and responsible for the practical implications of policy decisions. Top management (grades 9 and 10) would control the work of divisions. These would be of three kinds -nursing, teaching, and midwifery-and, where more than one is represented in the hospital, the chief nursing officer would coordinate their functioning and present nursing policy to the governing body. Given systematic seniority, systematic training, and selection for nursing administration would become practicable. The committee emphasises that the senior nurse administrator would not need basic qualifications in every specialty within her sphere. She would need training in management techniques, and preparatory courses should be instituted at each level.
ment
The committee recognises that such reorganisation would take time. It suggests that it be started experimentally in selected areas. Hospital management groups should begin by assessing the nature of their senior nursing posts and equating them with the new grades. New Whitley scales to correspond would have to be agreed. Regional and national nursing committees should be set up to arrange the necessary training courses. Meanwhile, through regional and national conferences, the proposed new structure of the profession should be explained to its members. The committee reckons that to complete reform throughout the country would take about five years. But if, thereafter, the profession could attract and retain recruits and speak with greater authority, the upheaval would be well justified.
" WATCH WHAT YOU EAT"
fats, and cut down on starch and sugar. Avoid anything irritating, especially aspirin, and take less salt." " .. ,
no
often asked to control their diet in some way; and, usually, the instructions they are given are not exactly precise. To see just how the doctor’s words might be interpreted was the object of a survey among 162 volunteers in Liverpool.’ They were asked which of several named foods they would avoid, if given certain non-specific instructions. Although no account was taken of quantities, it does seem that there is a wide area of nonagreement about what constitutes fatty, starchy, or sugary food even though the main " offenders "-butter, margarine, and pork products, and white bread, shortcake, condensed milk, and potatoes-would be avoided by most people who were asked to cut down on fats or sugar/starch. Notable exceptions were cheddar cheese and sirloin of beef which have a high fat content but which would have been avoided by only 32 "oand 27 °o, respectively, of those for whom a low-fat diet was advised. As for irritating foods, only pickles, nuts, and fried bacon would have been eschewed by more than half those questioned, and, since these items are not everyone’s staple diet, the position here is clearly unsatisfactory. Understandably, there was also confusion when it came to deciding which over-the-counter preparations contained aspirin, but this could be corrected by more positive advice-for example, by naming a mild analgesic not containing aspirin. On the other hand, when
Patients
are
1.
Riley,
C. S. Med. Care,
1966, 4,
34.
told to avoid solid foods, 85% of the group would do so; but only 19% took " doing without salt " to include not using it in cooking. That instructions like this are only partly effective will be news. Most doctors would agree with the conclusion of the Liverpool survey-that specific instructions are desirable, but they take up a lot of the doctor’s time. A wider use of diet sheets, including specimen meals, would help. Certainly, if a diet is to be effective and remain palatable, it is as important to state what can be eaten as it is to declare what must be shunned. not
TREATMENT OF PARKINSONIAN TREMOR
THE investigation and treatment of parkinsonian tremor have been hampered by lack of suitable objective methods for its measurenJ ent. An apparatus for this purpose must disturb as little as possible the part to which it is attached. Transducers which restrict the movement of a limb are, therefore, unsuitable, but two methods have now been introduced which deserve further attention. By means of an electromyographic needle, Herring recorded photographically the electrical activity of a muscle in the hand or forearm which showed regular spontaneous contractions, and counted the number of electrical spikes to be seen over given periods of time before and after intravenous pronethalol and water. Taking the mean values of 10 patients, the electrical activity after water settled to 66% of the baseline values, while after pronethalol it fell to 31 %, a difference significant at the 5% level. In contrast to this method, Vas and his colleagues 23 devised a transducer which responds to displacement in any direction in a single plane. Over the relevant tremor frequency range of 4-2-8-6 cycles per second,4 its output is proportional to the rate of change of acceleration of the transducer produced by the movement of the hand to which it is strapped. In a double-blind comparison of intravenous saline with propranolol (which has superseded pronethalol as a p-adrenergic blocking drug), Vaswas unable to show any statistical difference in effect on tremor. But methixine, a thiaxanthen derivative which is claimed to suppress extrapyramidal tremor,5 was very effectivein controlling tremor in 12 of 13 patients, and in 6 the tremor disappeared completely. The difference in amplitudes of tremor after saline and methixine in the 13 patients was highly significant. The difference between pronethalol and propranolol in these experiments is unlikely to be due to differences in
their pharmacological activity, since both block &bgr;-adrenergic receptors, propranolol having a therapeutic ratio ten or twenty times that of pronethalol. The difference is more likely to result from methodological variations, which Clarke et al. particularly emphasised. The amplitude of tremor increases greatly in response to external and
experimental stimuli, especially the injections of placebo drug, and Herring’s technique1 would probably provoke a greater response than the simpler and less traumatic method of Vas and his colleagues. With the trauma of injection the tremor decreases significantly after placebo and
as well as drug, which necessitates the use of controlled 1. 2. 3. 4. 5.
Herring, A. B. Lancet, 1964, ii, 892. Clarke, S., Hay, G. A., Vas, C. J. Br. J. Pharmacol. 1966, 26, 345. Vas, C. J. Lancet, Jan. 22, 1966, p. 182. Wachs, H., Boshes, B. Archs Neurol. Psychiat., Chicago, 1961, 4, 66. Gozzano, M., Millefiorini, M. Lavoro neuropsichiat. 1962, 31, fasc. 2.
1087 trials comparing drug with placebo in the same subjects, ideally under double-blind conditions. In addition there is a striking spontaneous variation in tremor within and between subjects, which means that a substantial number of subjects are needed before a significant effect can be detected. Although the effect of adrenergic receptor blockade is uncertain, the results with methixine are encouraging, and the introduction of these methods may herald a more rational approach to the treatment of this distressing condition. crossover
STRANGULATION OF THE TESTIS IN CHILDREN
STRANGULATION of the testis or one of its appendages is In fifteen years only 61 cases were admitted to the Alder Hey Hospital, Liverpool.’ It is remarkable that 15 of these arose in the first year of life and 6 in the first month, but nearly half between 11 and 16 years. Torsion of the cord was found in 36 children and torsion of a vestigial appendage in 19. In 4 strangulation was associated with an incarcerated hernia, and in 2 there was a localised testicular infarction of unknown origin. Torsion affected only 4 undescended testes, 3 of them in the first year of life. Pain in the early morning and vomiting were both more common in testicular torsion than in torsion of the appendices. Pain was usually felt in the scrotum on the affected side, but sometimes it was in the centre of the abdomen or began in the iliac fossa or groin. The main physical sign was a tender, red, and hardened swelling in the scrotum; in 5 cases of appendicular torsion the swelling was limited to the upper pole of the testis, and in the others it was diffuse and firm and individual structures could not be recognised by palpation. rare.
Of the 36 instances of torsion of the spermatic cord, in 18 the testis was infarcted; in 9 its viability was doubtful and in 9 it survived. Of the other 3 examples of infarction, 2 were associated with incarcerated hernia and in the other the cause was not evident. At operation 31 out of 61 testes were viable and 21 were infarcted. In 40 patients the testis was preserved; in 18 of these, after torsion of the spermatic cord with a testis of doubtful viability, 4 subsequently recovered, 2 became hypotrophic, and in 3 the remains of a testis were removed because of suppuration. Of the 9 testes judged viable at operation after torsion of the spermatic cord, 7 made a good recovery, 1 was hypotrophic after a year, and 1 was not followed up. In the remaining 22 cases there was good recovery of the testis.
history of injury is likely to suggest an incorrect diagnosis of hxmatocele, which was made in 3 of McFarland’s patients.1 Even aspiration of the fluid may mislead, A
since blood may be found in association with a tumour as well as with injury or a strangulated testis. Strangulation of the testis may be thought to be a strangulated hernia, but at least such a mistake would lead to operation without delay and to relief of the torsion. In adults recurrent torsion of the testis is not uncommon and may be reduced by self-manipulation. One of the difficult decisions is whether to preserve or remove a testis of doubtful viability. Sonda and Lapides2 showed that in dogs the damage to the testis depended on the degree and duration of torsion. Four complete turns of the spermatic 1. 2.
McFarland, J. B. Br. J. Surg. 1966, 53, 110. Sonda, L. P., Lapides, J. Surg. Forum, 1961, 12,
502.
cord for a period of two hours were necessary to produce irreversible damage, whereas one turn for up to twelve hours or a quarter-turn for seven days produced no evidence of necrosis. Smithdemonstrated that spermatogenic cells in dogs were slightly damaged by two hours’ ischaemia of the testis, severely damaged by four hours’, and destroyed by six hours’ ischsemia. The Leydig cells were severely damaged after eight hours and destroyed after ten hours of ischaemia. After untwisting, a small incision in the tunica albuginea is usually advisable to see whether the blood-supply is intact. Fixation of the opposite testis has often been recommended, and it undoubtedly helps to prevent torsion of the sole remaining testis. Not everyone agrees, however, with the routine fixation of the second testis in the absence of signs on that side, since any operation in the scrotum involves some risk to a testis and its attachments. But fixation does give much comfort to parents and children, and this is an important point in its favour.
TIMOR MORTIS CONTURBAT ME
DOCTORS have a duty to their patients who are dying or threatened by death. What precisely that duty is and how it should be discharged has been a matter of long debate within and without the profession, but dogmatic statements are commoner than agreement. A basic assumption seems to be that fear-great fear-of death is general, almost universal, a fact of Nature, like desiring to live. Granted that most adults in this and many other countries do fear death, is that fear inborn or implanted ? Does either our community or our profession try to discourage it or to substitute a courageous or positive attitude ? Children meet and recognise death very early: it cannot be hid or glossed over; but does it, of itself, arouse fear? May it not be that we inculcate this fear of death which often mars the doctor’s dealings with those dying or doomed to die and their relatives ? Soon the child must learn that death, dying, and dead are obscene words, to be uttered only in periphrases or euphemisms. What cannot be spoken must be unspeakably dreadful. Even so, fear of " the necessary end of all " may be less common than convention assumes. At a symposium held by the American Group for the Advancement of Psychiatry4 it was reported that, whereas 69-90% of doctors questioned in various studies favoured " not telling the patient ", 77-89% of the patients wished to be told they were dying. They gave good reasons, including " I don’t want to be denied the experience of realising that I am dying "-reminiscent of the expectant mother determined not to be " put under " in the second stage of labour. One contributor to the discussion remarked, " We do not even permit the dying person to say goodbye to
us."
A positive, courageous, and realistic approach to death and dying has been common, at least as an ideal, through much of history, but we seem to have lost it. Over the past few years people have begun to take a new look, perhaps at age, certainly at childbearing. Could we not now usefully persuade ourselves to take a new look at death and dying? 3. Smith, G. I. J. Urol. 1955, 73, 355. 4. Death and Dying: Attitudes of Patient and Doctor. G.A.P. Symposium no. 11. 1965. Pp. 667. $1.50. (Obtainable from G.A.P.. 104 East 25th Street, New York, N.Y.)
ment
The committee recognises that such reorganisation would take time. It suggests that it be started experimentally in selected areas. Hospital management groups should begin by assessing the nature of their senior nursing posts and equating them with the new grades. New Whitley scales to correspond would have to be agreed. Regional and national nursing committees should be set up to arrange the necessary training courses. Meanwhile, through regional and national conferences, the proposed new structure of the profession should be explained to its members. The committee reckons that to complete reform throughout the country would take about five years. But if, thereafter, the profession could attract and retain recruits and speak with greater authority, the upheaval would be well justified.
" WATCH WHAT YOU EAT"
fats, and cut down on starch and sugar. Avoid anything irritating, especially aspirin, and take less salt." " .. ,
no
often asked to control their diet in some way; and, usually, the instructions they are given are not exactly precise. To see just how the doctor’s words might be interpreted was the object of a survey among 162 volunteers in Liverpool.’ They were asked which of several named foods they would avoid, if given certain non-specific instructions. Although no account was taken of quantities, it does seem that there is a wide area of nonagreement about what constitutes fatty, starchy, or sugary food even though the main " offenders "-butter, margarine, and pork products, and white bread, shortcake, condensed milk, and potatoes-would be avoided by most people who were asked to cut down on fats or sugar/starch. Notable exceptions were cheddar cheese and sirloin of beef which have a high fat content but which would have been avoided by only 32 "oand 27 °o, respectively, of those for whom a low-fat diet was advised. As for irritating foods, only pickles, nuts, and fried bacon would have been eschewed by more than half those questioned, and, since these items are not everyone’s staple diet, the position here is clearly unsatisfactory. Understandably, there was also confusion when it came to deciding which over-the-counter preparations contained aspirin, but this could be corrected by more positive advice-for example, by naming a mild analgesic not containing aspirin. On the other hand, when
Patients
are
1.
Riley,
C. S. Med. Care,
1966, 4,
34.
told to avoid solid foods, 85% of the group would do so; but only 19% took " doing without salt " to include not using it in cooking. That instructions like this are only partly effective will be news. Most doctors would agree with the conclusion of the Liverpool survey-that specific instructions are desirable, but they take up a lot of the doctor’s time. A wider use of diet sheets, including specimen meals, would help. Certainly, if a diet is to be effective and remain palatable, it is as important to state what can be eaten as it is to declare what must be shunned. not
TREATMENT OF PARKINSONIAN TREMOR
THE investigation and treatment of parkinsonian tremor have been hampered by lack of suitable objective methods for its measurenJ ent. An apparatus for this purpose must disturb as little as possible the part to which it is attached. Transducers which restrict the movement of a limb are, therefore, unsuitable, but two methods have now been introduced which deserve further attention. By means of an electromyographic needle, Herring recorded photographically the electrical activity of a muscle in the hand or forearm which showed regular spontaneous contractions, and counted the number of electrical spikes to be seen over given periods of time before and after intravenous pronethalol and water. Taking the mean values of 10 patients, the electrical activity after water settled to 66% of the baseline values, while after pronethalol it fell to 31 %, a difference significant at the 5% level. In contrast to this method, Vas and his colleagues 23 devised a transducer which responds to displacement in any direction in a single plane. Over the relevant tremor frequency range of 4-2-8-6 cycles per second,4 its output is proportional to the rate of change of acceleration of the transducer produced by the movement of the hand to which it is strapped. In a double-blind comparison of intravenous saline with propranolol (which has superseded pronethalol as a p-adrenergic blocking drug), Vaswas unable to show any statistical difference in effect on tremor. But methixine, a thiaxanthen derivative which is claimed to suppress extrapyramidal tremor,5 was very effectivein controlling tremor in 12 of 13 patients, and in 6 the tremor disappeared completely. The difference in amplitudes of tremor after saline and methixine in the 13 patients was highly significant. The difference between pronethalol and propranolol in these experiments is unlikely to be due to differences in
their pharmacological activity, since both block &bgr;-adrenergic receptors, propranolol having a therapeutic ratio ten or twenty times that of pronethalol. The difference is more likely to result from methodological variations, which Clarke et al. particularly emphasised. The amplitude of tremor increases greatly in response to external and
experimental stimuli, especially the injections of placebo drug, and Herring’s technique1 would probably provoke a greater response than the simpler and less traumatic method of Vas and his colleagues. With the trauma of injection the tremor decreases significantly after placebo and
as well as drug, which necessitates the use of controlled 1. 2. 3. 4. 5.
Herring, A. B. Lancet, 1964, ii, 892. Clarke, S., Hay, G. A., Vas, C. J. Br. J. Pharmacol. 1966, 26, 345. Vas, C. J. Lancet, Jan. 22, 1966, p. 182. Wachs, H., Boshes, B. Archs Neurol. Psychiat., Chicago, 1961, 4, 66. Gozzano, M., Millefiorini, M. Lavoro neuropsichiat. 1962, 31, fasc. 2.
1087 trials comparing drug with placebo in the same subjects, ideally under double-blind conditions. In addition there is a striking spontaneous variation in tremor within and between subjects, which means that a substantial number of subjects are needed before a significant effect can be detected. Although the effect of adrenergic receptor blockade is uncertain, the results with methixine are encouraging, and the introduction of these methods may herald a more rational approach to the treatment of this distressing condition. crossover
STRANGULATION OF THE TESTIS IN CHILDREN
STRANGULATION of the testis or one of its appendages is In fifteen years only 61 cases were admitted to the Alder Hey Hospital, Liverpool.’ It is remarkable that 15 of these arose in the first year of life and 6 in the first month, but nearly half between 11 and 16 years. Torsion of the cord was found in 36 children and torsion of a vestigial appendage in 19. In 4 strangulation was associated with an incarcerated hernia, and in 2 there was a localised testicular infarction of unknown origin. Torsion affected only 4 undescended testes, 3 of them in the first year of life. Pain in the early morning and vomiting were both more common in testicular torsion than in torsion of the appendices. Pain was usually felt in the scrotum on the affected side, but sometimes it was in the centre of the abdomen or began in the iliac fossa or groin. The main physical sign was a tender, red, and hardened swelling in the scrotum; in 5 cases of appendicular torsion the swelling was limited to the upper pole of the testis, and in the others it was diffuse and firm and individual structures could not be recognised by palpation. rare.
Of the 36 instances of torsion of the spermatic cord, in 18 the testis was infarcted; in 9 its viability was doubtful and in 9 it survived. Of the other 3 examples of infarction, 2 were associated with incarcerated hernia and in the other the cause was not evident. At operation 31 out of 61 testes were viable and 21 were infarcted. In 40 patients the testis was preserved; in 18 of these, after torsion of the spermatic cord with a testis of doubtful viability, 4 subsequently recovered, 2 became hypotrophic, and in 3 the remains of a testis were removed because of suppuration. Of the 9 testes judged viable at operation after torsion of the spermatic cord, 7 made a good recovery, 1 was hypotrophic after a year, and 1 was not followed up. In the remaining 22 cases there was good recovery of the testis.
history of injury is likely to suggest an incorrect diagnosis of hxmatocele, which was made in 3 of McFarland’s patients.1 Even aspiration of the fluid may mislead, A
since blood may be found in association with a tumour as well as with injury or a strangulated testis. Strangulation of the testis may be thought to be a strangulated hernia, but at least such a mistake would lead to operation without delay and to relief of the torsion. In adults recurrent torsion of the testis is not uncommon and may be reduced by self-manipulation. One of the difficult decisions is whether to preserve or remove a testis of doubtful viability. Sonda and Lapides2 showed that in dogs the damage to the testis depended on the degree and duration of torsion. Four complete turns of the spermatic 1. 2.
McFarland, J. B. Br. J. Surg. 1966, 53, 110. Sonda, L. P., Lapides, J. Surg. Forum, 1961, 12,
502.
cord for a period of two hours were necessary to produce irreversible damage, whereas one turn for up to twelve hours or a quarter-turn for seven days produced no evidence of necrosis. Smithdemonstrated that spermatogenic cells in dogs were slightly damaged by two hours’ ischaemia of the testis, severely damaged by four hours’, and destroyed by six hours’ ischsemia. The Leydig cells were severely damaged after eight hours and destroyed after ten hours of ischaemia. After untwisting, a small incision in the tunica albuginea is usually advisable to see whether the blood-supply is intact. Fixation of the opposite testis has often been recommended, and it undoubtedly helps to prevent torsion of the sole remaining testis. Not everyone agrees, however, with the routine fixation of the second testis in the absence of signs on that side, since any operation in the scrotum involves some risk to a testis and its attachments. But fixation does give much comfort to parents and children, and this is an important point in its favour.
TIMOR MORTIS CONTURBAT ME
DOCTORS have a duty to their patients who are dying or threatened by death. What precisely that duty is and how it should be discharged has been a matter of long debate within and without the profession, but dogmatic statements are commoner than agreement. A basic assumption seems to be that fear-great fear-of death is general, almost universal, a fact of Nature, like desiring to live. Granted that most adults in this and many other countries do fear death, is that fear inborn or implanted ? Does either our community or our profession try to discourage it or to substitute a courageous or positive attitude ? Children meet and recognise death very early: it cannot be hid or glossed over; but does it, of itself, arouse fear? May it not be that we inculcate this fear of death which often mars the doctor’s dealings with those dying or doomed to die and their relatives ? Soon the child must learn that death, dying, and dead are obscene words, to be uttered only in periphrases or euphemisms. What cannot be spoken must be unspeakably dreadful. Even so, fear of " the necessary end of all " may be less common than convention assumes. At a symposium held by the American Group for the Advancement of Psychiatry4 it was reported that, whereas 69-90% of doctors questioned in various studies favoured " not telling the patient ", 77-89% of the patients wished to be told they were dying. They gave good reasons, including " I don’t want to be denied the experience of realising that I am dying "-reminiscent of the expectant mother determined not to be " put under " in the second stage of labour. One contributor to the discussion remarked, " We do not even permit the dying person to say goodbye to
us."
A positive, courageous, and realistic approach to death and dying has been common, at least as an ideal, through much of history, but we seem to have lost it. Over the past few years people have begun to take a new look, perhaps at age, certainly at childbearing. Could we not now usefully persuade ourselves to take a new look at death and dying? 3. Smith, G. I. J. Urol. 1955, 73, 355. 4. Death and Dying: Attitudes of Patient and Doctor. G.A.P. Symposium no. 11. 1965. Pp. 667. $1.50. (Obtainable from G.A.P.. 104 East 25th Street, New York, N.Y.)