- Email: [email protected]
WAITING FOR THE DOCTOR
1251
in detection when smelled one after the other, showing that similar smells from different chemical entities
Annotations
WAITING FOR THE DOCTOR clearly share a part of the olfactory apparatus. He also found that self-adaptation was always more THE esteem in which the public holds its hospital powerful than heterogenous adaptation, sometimes services is easily influenced by other things than the skill even when the heterologous pair were as similar as and care shown in the treatment of patients. The patient n- and sec-butanol. Self-adaptation with n-butanol who has to wait an hour to see the doctor, especially raised the threshold some 200 times, but adaptation when he has been told that he has an appointment for with sec-butanol raised the threshold to n-butanol only a specified time, is likely to be more impressed by this than by the success of the consultation. Doubtless the Some similar smelling pairs behaved to 12 times. present arrangements are a big improvement on the : each other rather oddly adaptation with A might old days" when all outpatients had to attend ’’ good have a much greater action on the threshold concenat 8 A.M., and might not be seen till late in the afternoon ; tration of B than adaptation with B had on A. but letters to the newspapers and complaints to hospital Allowing that the primary stimulus consists of the administrators show that long waits in outpatient departadsorption of the odorous molecules on the olfactory ments have certainly not been eliminated. They cause membrane, this apparent anomaly can be explained the patient irritation and the community loss of working by a spatial pattern of adsorption and by differing time. A working party of the Hospital Discussion Group numbers of receptor sites for A and B, only some of has recently examined the ground for these complaints, and its report1 suggests general remedies. Two which are held in common. Occasionally a fair degree can be discerned : to disarm criticism ; (1) approaches of adaptation can be exerted for one substance by to improve the efficiency of clinic arrangements and (2) another with a dissimilar smell, which suggests that really reduce waiting-time. there may be a small proportion of the olfactory The working party objects to the term " appointments apparatus which is used by all smells. Adaptation system " because it gives a false idea of precision, and seems to be central rather than peripheral ; for suggests " clinic booking system " as a substitute. By instance, unilateral stimulation can cause bilateral this means and also by putting the hospital point of view fatigue. According to ADRIAN,2 the olfactory bulb is in the press and in notices on the attendance cards, it is hoped to make the public more tolerant of inevitable in a constant state of electrical activity, which is delays-some of which are in fact caused by patients temporarily disorganised by the receipt of sensory who arrive early or late. But few patients will be thus impulses. With a persisting smell he found no sign convinced that a long wait is really necessary, and they of receptor fatigue, but central activity built up again will go away feeling that some better system could be and swamped the transmitted olfactory signals. devised. And most of the report does in fact deal with Theoretically, then, self-adaptation should be severe, suggested changes in the arrangements. An important as MONCRIEFF found it to be. Experiments involving cause of delay is inconvenient timing of public transport ablation or stimulation of central areas showed clearly (especially in the country) and the need for economy in that there are two distinct olfactory systems—one the ambulance service. The transport authorities might be able to change their services, or bookings might be cortical and the other subcortical.1 The cortical better arranged to fit the existing time-tables. Ambulis concerned with and fine disjudgment system ances, it is suggested, should be allocated to large general crimination and the subcortical one with simpler with a transport officer for each hospital, who hospitals, discrimination and more automatic activities. could be in touch with those arranging clinics ; for The significance of a sense of smell is easier to define. example, some booking-times could be reserved for In the lower animals it helps them to find their food patients from a certain district. and their mates, and to avoid their enemies ; and it Many outpatient departments are in old and inadequate has presumably developed from the primitive chemical buildings, and the administrative services could be more if they had enough staff, space, and equipment. sensibility of unicellular organisms. By means of efficient Records offices and X-ray, physiotherapy, and other specially developed glandular secretions scent may act are often in inconvenient positions, special departments as a deterrent to aggressors, as it does in the skunk. and patients waste much time going to and fro between There is also some evidence that poisonous food may them and the outpatient department. Members of housebe recognised by smell. In man the significance of committees should regularly visit the clinics and confer smells is largely acquired and becomes built into the with the doctors and nurses about ways in which these unconscious or automatic part of the nervous system. impediments could be overcome. To man smells are useful in stimulating a good The most intractable delays are probably due to events preparatory flow of gastric juice and in giving æsthetic within the outpatient clinics. Obviously, it will never be possible to predict which consultations will take longer and remembered pleasure. Those who have by accithan others ; the consultant may have to see an unbooked dent lost the sense of smell know how much it adds urgent case in the clinic or he may be called away to one ; to the savour of food. What the anosmic loses on or other doctors may interrupt the clinic to confer with him. coffee he gains on castor-oil, but the price is too high. If the patient is sent for an investigation, when he returns Finally, in animals scent plays a large part in initial he makes, in effect, a second, unbooked, attendance. reproductive processes. FABRE 7 drew attention to To make the wheels turn as smoothly as possible, the the remarkable way in which some moths and butterlast, part of the clinic session should be set aside for flies can trace the scent of their mates over long patients booked late or’not at all. Ancillary services, distances. WRITTEN 8 has described how removal of the working party maintains, should be provided during the olfactory bulbs from mice significantly reduced the the whole period of the clinic. The report says that most clinicians are punctual in size of reproductive organs in the female, but not in the male, and how the females would not then mate starting their clinics. They can help further by taking an interest in an agreed policy and sticking to it, by even with vigorous males. -
insisting
J. H. Social Life in the Insect World. 1912. 8. Whitten, W. K. J. Endocrin. 1956, 14, 160.
on
seeing patients
7. Fabre,
1. The
in the order in which
Hospital, 1956, 52,
575.
they
1252 have been booked, and by confining other activities during the clinic hours to the minimum needed to deal with urgent cases. The best possible scheme can succeed only if everyone concerned (doctors, nurses, administrators, and patients) do their bestto make it work. The working party hopes that, by adopting the proposals, all hospitals could do as well as those in which good systems are in force " and where " the average wait before a patient sees a consultant is not more than 30 minutes." Perhaps this is the best that can be hoped for, but some people will not think it good enough. "
PATENT DUCTUS ARTERIOSUS CLOSURE of the patent ductus arteriosus, the first form of surgical attack on congenital heart-disease to become a routine operation, is now one of the commonest tasks of the cardiac surgeon. Few physicians hesitate to advise it once the diagnosis is certain, because it is curative and safe. Hay and Ward1 have lately reviewed in detail their experiences with patent ductus during the four years 1949-53. They choose to discuss patients over the age of one year and they deal with the diagnostic and surgical problems involved. So much doubt has been cast on cardiologists’ obiter dicta by the findings of the surgeons that it is agreeable to see a large well-documented series in which the preoperative diagnosis was so often right. The incidence of patent ductus varies in the different series that have been reported, because they refer to different age-groups. Any series with a high proportion of infants will have fewer instances of isolated patent ductus arteriosus, since it will include many infants with multiple anomalies and rapidly fatal conditions. Accurate diagnosis is most difficult in infants not only because of the many other malformations to be considered but also because auscultation, electrocardiography, and radiology give less definite help than in older children. In a large, representative group of patients, which included many infants, Gasul2found that patent ductus accounted for almost 10% of congenital heart-disease-a similar figure to that in Maude Abbott’s celebrated collection of post-mortem observations. In the typical case diagnosis is easy. The clinical of with a a continuous murmur over the girl picture pulmonary area, accentuated in systole, a thrill, and probably a collapsing pulse is unlikely to be missed even by those not on the lookout for the disorder. But there Bonham Carter are traps in the path to diagnosis. and Lovel3have recorded examples of patent ductus in which atypical murmurs were heard and the usual machinery murmur was absent ; and in a contrasting series4 there was a continuous tnurmur in the pulmonary area without a patent ductus or any of the usual causes The premature infant with of such a murmur. an enlarging but failing heart may well have this remediable condition, but a commoner finding is simply a systolic murmur which will not become continuous until later in life. In such circumstances retrograde aortography may be necessary to prove the diagnosis. Between 20 and 25% of children with patent ductus die in infancy and Zeigler5 has emphasised the importance of recognising it early in life. To persist in medical measures may be a fatal mistake. Pulmonary hypertension may also be an indication for urgent surgery and it is vital to recognise this complication. Again the murmur is often systolic only, and the electrocardiogram shows right-ventricular preponderance ,only in advanced cases. Where there is real doubt cardiac catheterisation is needed. Pulmonary hypertension increases the risk of operation, but it is probably justifiable to intervene when the pressures are evenly balanced on the systemic and pulmonary sides. Pressures 1. Hay, J. D., Ward, O. C. Arch. Dis. Childh. 1956, 31, 279. 2. Gasnl, B. M., Fell, E. H. J. Amer. med. Ass. 1956, 161, 39. 3. Bonham Carter, R. E., Lovel, K. Gt. Ormond St. J. 1953, 6, 93. 4. Bonham Carter, R. E., Walker, C. H. M. Lancet, 1955, i, 272. 5. Zeigler, R. F. Amer. Heart J. 1952, 43, 553.
can also be measured directly at operation, and the final If there is a reversal of the test is a trial occlusion. shunt the operation should be abandoned since in these cases the mor.tality is 50%, even in the hands of the Mayo Clinic team.6 Severe pulmonary hypertension is thus the principal contra-indication to operation. At the other end of the scale is the apparently healthy child whose lesion is identified at a routine examination. and otherwise normal Why operate on an asymptomatic " the heart from patientBlalock’s answer is to protect an eventually disabling burden."7 Though there are exceptions, the expectation of life is much shorter than normal even if we exclude the constant threat of subacute
bacterial endocarditis (of which there is a 10% risk). time bomb with a very long fuse." Patent ductus is a Between three and seven years of age is a convenient time for the elective operation. In Hay and Ward’s series there was no death due to ligation of the uncomplicated ductus, and Potts operated on 250 consecutive cases without a death. The commonest cause of disaster seems to be misdiagnosis. As for the type of operation, most American surgeons favour division of the vessel, while their British and Continental colleagues are content to ligate in continuity. Gross,8the first man to close a patent ductus successfully, gave up ligation after some recurrences and Pottshas also abandoned the simpler method. Ekstrom 10 found that recurrence could follow both ligation and division, but that it was less likely with division. Infection was an important cause of recurrence. The proportion of recurrences after ligation varies greatly from one series to another, depending to a considerable extent on the nature, calibre, and tensile strength of the ligature material. A single thread is less likely to be effective and more likely to cut through than two pieces of large Chinese-silk twist. Blalock, of Baltimore, and Mustard, of Toronto, choose suture ligation reinforced by umbilical tape. The question of ligature or division ’will take another decade to settle : at the moment it seems that most forms of patent ductus can be safely and effectively tied, but there are others which should be divided; the surgeon must be prepared to do either. As a rule, the short wide ductus is difficult to occlude and should be divided. "
SERUM
HEPATITIS AFTER DENTAL
INJECTIONS
parenteral administration of human blood, plasma, or plasma derivatives is occasionally succeeded, after a long incubation period, by the appearance of a condition very like infective hepatitis. Work depending entirely on the use of volunteers as test animals has definitely established that this serum-transmitted disease is due to a virus of remarkable infectivity and resistance THE
to adverse environmental conditions. Moreover, it can survive in the human host for many years 11 without giving any sign of its presence until it is inoculated into another susceptible host. Since homologous-serum jaundice has been experimentally transmitted by as little as 0.0001 ml. of serum, it is not surprising that many small epidemics have been caused by faulty sterilisation in places where many patients are given thera-
prophylactic injections. Indeed, the infectivity great that those handling blood or blood products run a distinct risk of contracting the disease.12 Serum-transmittedjaundice can result from almost every kind of skin penetration, therapeutic or otherwise ; and it is remarkable that injections of local anaesthetics for dental operations seem so far to have escaped blame. But the results of an investigation by Foley and Giitheim,13 peutic
or
may be
so
6. Ellis, F. H., Kirklin, J. W., Callahan, J. A., Ward, E. H. J. thorac. Surg. 1956, 31, 268. 7. Blalock, A. Bull. N.Y. Acad. Med. 1946, 22, 57. 8. Gross, R. E. Surg. Gynec. Obstet. 1944, 78, 36. 9. Potts, W. J. Arch. Surg. 1953, 66, 468. 10. Ekstrom, G. Acta. chir. scand. 1952, suppl. no. 169. 11. Stokes, J. jun., et al. J. Amer. med. Ass. 1954, 154, 1059. M. 12. Trumbull, L., Geiner, D. J. Ibid, 1951, 145, 965. 13. Foley, F. E., Gutheim, R. N. Ann. intern. Med. 1956, 45, 369.
in detection when smelled one after the other, showing that similar smells from different chemical entities
Annotations
WAITING FOR THE DOCTOR clearly share a part of the olfactory apparatus. He also found that self-adaptation was always more THE esteem in which the public holds its hospital powerful than heterogenous adaptation, sometimes services is easily influenced by other things than the skill even when the heterologous pair were as similar as and care shown in the treatment of patients. The patient n- and sec-butanol. Self-adaptation with n-butanol who has to wait an hour to see the doctor, especially raised the threshold some 200 times, but adaptation when he has been told that he has an appointment for with sec-butanol raised the threshold to n-butanol only a specified time, is likely to be more impressed by this than by the success of the consultation. Doubtless the Some similar smelling pairs behaved to 12 times. present arrangements are a big improvement on the : each other rather oddly adaptation with A might old days" when all outpatients had to attend ’’ good have a much greater action on the threshold concenat 8 A.M., and might not be seen till late in the afternoon ; tration of B than adaptation with B had on A. but letters to the newspapers and complaints to hospital Allowing that the primary stimulus consists of the administrators show that long waits in outpatient departadsorption of the odorous molecules on the olfactory ments have certainly not been eliminated. They cause membrane, this apparent anomaly can be explained the patient irritation and the community loss of working by a spatial pattern of adsorption and by differing time. A working party of the Hospital Discussion Group numbers of receptor sites for A and B, only some of has recently examined the ground for these complaints, and its report1 suggests general remedies. Two which are held in common. Occasionally a fair degree can be discerned : to disarm criticism ; (1) approaches of adaptation can be exerted for one substance by to improve the efficiency of clinic arrangements and (2) another with a dissimilar smell, which suggests that really reduce waiting-time. there may be a small proportion of the olfactory The working party objects to the term " appointments apparatus which is used by all smells. Adaptation system " because it gives a false idea of precision, and seems to be central rather than peripheral ; for suggests " clinic booking system " as a substitute. By instance, unilateral stimulation can cause bilateral this means and also by putting the hospital point of view fatigue. According to ADRIAN,2 the olfactory bulb is in the press and in notices on the attendance cards, it is hoped to make the public more tolerant of inevitable in a constant state of electrical activity, which is delays-some of which are in fact caused by patients temporarily disorganised by the receipt of sensory who arrive early or late. But few patients will be thus impulses. With a persisting smell he found no sign convinced that a long wait is really necessary, and they of receptor fatigue, but central activity built up again will go away feeling that some better system could be and swamped the transmitted olfactory signals. devised. And most of the report does in fact deal with Theoretically, then, self-adaptation should be severe, suggested changes in the arrangements. An important as MONCRIEFF found it to be. Experiments involving cause of delay is inconvenient timing of public transport ablation or stimulation of central areas showed clearly (especially in the country) and the need for economy in that there are two distinct olfactory systems—one the ambulance service. The transport authorities might be able to change their services, or bookings might be cortical and the other subcortical.1 The cortical better arranged to fit the existing time-tables. Ambulis concerned with and fine disjudgment system ances, it is suggested, should be allocated to large general crimination and the subcortical one with simpler with a transport officer for each hospital, who hospitals, discrimination and more automatic activities. could be in touch with those arranging clinics ; for The significance of a sense of smell is easier to define. example, some booking-times could be reserved for In the lower animals it helps them to find their food patients from a certain district. and their mates, and to avoid their enemies ; and it Many outpatient departments are in old and inadequate has presumably developed from the primitive chemical buildings, and the administrative services could be more if they had enough staff, space, and equipment. sensibility of unicellular organisms. By means of efficient Records offices and X-ray, physiotherapy, and other specially developed glandular secretions scent may act are often in inconvenient positions, special departments as a deterrent to aggressors, as it does in the skunk. and patients waste much time going to and fro between There is also some evidence that poisonous food may them and the outpatient department. Members of housebe recognised by smell. In man the significance of committees should regularly visit the clinics and confer smells is largely acquired and becomes built into the with the doctors and nurses about ways in which these unconscious or automatic part of the nervous system. impediments could be overcome. To man smells are useful in stimulating a good The most intractable delays are probably due to events preparatory flow of gastric juice and in giving æsthetic within the outpatient clinics. Obviously, it will never be possible to predict which consultations will take longer and remembered pleasure. Those who have by accithan others ; the consultant may have to see an unbooked dent lost the sense of smell know how much it adds urgent case in the clinic or he may be called away to one ; to the savour of food. What the anosmic loses on or other doctors may interrupt the clinic to confer with him. coffee he gains on castor-oil, but the price is too high. If the patient is sent for an investigation, when he returns Finally, in animals scent plays a large part in initial he makes, in effect, a second, unbooked, attendance. reproductive processes. FABRE 7 drew attention to To make the wheels turn as smoothly as possible, the the remarkable way in which some moths and butterlast, part of the clinic session should be set aside for flies can trace the scent of their mates over long patients booked late or’not at all. Ancillary services, distances. WRITTEN 8 has described how removal of the working party maintains, should be provided during the olfactory bulbs from mice significantly reduced the the whole period of the clinic. The report says that most clinicians are punctual in size of reproductive organs in the female, but not in the male, and how the females would not then mate starting their clinics. They can help further by taking an interest in an agreed policy and sticking to it, by even with vigorous males. -
insisting
J. H. Social Life in the Insect World. 1912. 8. Whitten, W. K. J. Endocrin. 1956, 14, 160.
on
seeing patients
7. Fabre,
1. The
in the order in which
Hospital, 1956, 52,
575.
they
1252 have been booked, and by confining other activities during the clinic hours to the minimum needed to deal with urgent cases. The best possible scheme can succeed only if everyone concerned (doctors, nurses, administrators, and patients) do their bestto make it work. The working party hopes that, by adopting the proposals, all hospitals could do as well as those in which good systems are in force " and where " the average wait before a patient sees a consultant is not more than 30 minutes." Perhaps this is the best that can be hoped for, but some people will not think it good enough. "
PATENT DUCTUS ARTERIOSUS CLOSURE of the patent ductus arteriosus, the first form of surgical attack on congenital heart-disease to become a routine operation, is now one of the commonest tasks of the cardiac surgeon. Few physicians hesitate to advise it once the diagnosis is certain, because it is curative and safe. Hay and Ward1 have lately reviewed in detail their experiences with patent ductus during the four years 1949-53. They choose to discuss patients over the age of one year and they deal with the diagnostic and surgical problems involved. So much doubt has been cast on cardiologists’ obiter dicta by the findings of the surgeons that it is agreeable to see a large well-documented series in which the preoperative diagnosis was so often right. The incidence of patent ductus varies in the different series that have been reported, because they refer to different age-groups. Any series with a high proportion of infants will have fewer instances of isolated patent ductus arteriosus, since it will include many infants with multiple anomalies and rapidly fatal conditions. Accurate diagnosis is most difficult in infants not only because of the many other malformations to be considered but also because auscultation, electrocardiography, and radiology give less definite help than in older children. In a large, representative group of patients, which included many infants, Gasul2found that patent ductus accounted for almost 10% of congenital heart-disease-a similar figure to that in Maude Abbott’s celebrated collection of post-mortem observations. In the typical case diagnosis is easy. The clinical of with a a continuous murmur over the girl picture pulmonary area, accentuated in systole, a thrill, and probably a collapsing pulse is unlikely to be missed even by those not on the lookout for the disorder. But there Bonham Carter are traps in the path to diagnosis. and Lovel3have recorded examples of patent ductus in which atypical murmurs were heard and the usual machinery murmur was absent ; and in a contrasting series4 there was a continuous tnurmur in the pulmonary area without a patent ductus or any of the usual causes The premature infant with of such a murmur. an enlarging but failing heart may well have this remediable condition, but a commoner finding is simply a systolic murmur which will not become continuous until later in life. In such circumstances retrograde aortography may be necessary to prove the diagnosis. Between 20 and 25% of children with patent ductus die in infancy and Zeigler5 has emphasised the importance of recognising it early in life. To persist in medical measures may be a fatal mistake. Pulmonary hypertension may also be an indication for urgent surgery and it is vital to recognise this complication. Again the murmur is often systolic only, and the electrocardiogram shows right-ventricular preponderance ,only in advanced cases. Where there is real doubt cardiac catheterisation is needed. Pulmonary hypertension increases the risk of operation, but it is probably justifiable to intervene when the pressures are evenly balanced on the systemic and pulmonary sides. Pressures 1. Hay, J. D., Ward, O. C. Arch. Dis. Childh. 1956, 31, 279. 2. Gasnl, B. M., Fell, E. H. J. Amer. med. Ass. 1956, 161, 39. 3. Bonham Carter, R. E., Lovel, K. Gt. Ormond St. J. 1953, 6, 93. 4. Bonham Carter, R. E., Walker, C. H. M. Lancet, 1955, i, 272. 5. Zeigler, R. F. Amer. Heart J. 1952, 43, 553.
can also be measured directly at operation, and the final If there is a reversal of the test is a trial occlusion. shunt the operation should be abandoned since in these cases the mor.tality is 50%, even in the hands of the Mayo Clinic team.6 Severe pulmonary hypertension is thus the principal contra-indication to operation. At the other end of the scale is the apparently healthy child whose lesion is identified at a routine examination. and otherwise normal Why operate on an asymptomatic " the heart from patientBlalock’s answer is to protect an eventually disabling burden."7 Though there are exceptions, the expectation of life is much shorter than normal even if we exclude the constant threat of subacute
bacterial endocarditis (of which there is a 10% risk). time bomb with a very long fuse." Patent ductus is a Between three and seven years of age is a convenient time for the elective operation. In Hay and Ward’s series there was no death due to ligation of the uncomplicated ductus, and Potts operated on 250 consecutive cases without a death. The commonest cause of disaster seems to be misdiagnosis. As for the type of operation, most American surgeons favour division of the vessel, while their British and Continental colleagues are content to ligate in continuity. Gross,8the first man to close a patent ductus successfully, gave up ligation after some recurrences and Pottshas also abandoned the simpler method. Ekstrom 10 found that recurrence could follow both ligation and division, but that it was less likely with division. Infection was an important cause of recurrence. The proportion of recurrences after ligation varies greatly from one series to another, depending to a considerable extent on the nature, calibre, and tensile strength of the ligature material. A single thread is less likely to be effective and more likely to cut through than two pieces of large Chinese-silk twist. Blalock, of Baltimore, and Mustard, of Toronto, choose suture ligation reinforced by umbilical tape. The question of ligature or division ’will take another decade to settle : at the moment it seems that most forms of patent ductus can be safely and effectively tied, but there are others which should be divided; the surgeon must be prepared to do either. As a rule, the short wide ductus is difficult to occlude and should be divided. "
SERUM
HEPATITIS AFTER DENTAL
INJECTIONS
parenteral administration of human blood, plasma, or plasma derivatives is occasionally succeeded, after a long incubation period, by the appearance of a condition very like infective hepatitis. Work depending entirely on the use of volunteers as test animals has definitely established that this serum-transmitted disease is due to a virus of remarkable infectivity and resistance THE
to adverse environmental conditions. Moreover, it can survive in the human host for many years 11 without giving any sign of its presence until it is inoculated into another susceptible host. Since homologous-serum jaundice has been experimentally transmitted by as little as 0.0001 ml. of serum, it is not surprising that many small epidemics have been caused by faulty sterilisation in places where many patients are given thera-
prophylactic injections. Indeed, the infectivity great that those handling blood or blood products run a distinct risk of contracting the disease.12 Serum-transmittedjaundice can result from almost every kind of skin penetration, therapeutic or otherwise ; and it is remarkable that injections of local anaesthetics for dental operations seem so far to have escaped blame. But the results of an investigation by Foley and Giitheim,13 peutic
or
may be
so
6. Ellis, F. H., Kirklin, J. W., Callahan, J. A., Ward, E. H. J. thorac. Surg. 1956, 31, 268. 7. Blalock, A. Bull. N.Y. Acad. Med. 1946, 22, 57. 8. Gross, R. E. Surg. Gynec. Obstet. 1944, 78, 36. 9. Potts, W. J. Arch. Surg. 1953, 66, 468. 10. Ekstrom, G. Acta. chir. scand. 1952, suppl. no. 169. 11. Stokes, J. jun., et al. J. Amer. med. Ass. 1954, 154, 1059. M. 12. Trumbull, L., Geiner, D. J. Ibid, 1951, 145, 965. 13. Foley, F. E., Gutheim, R. N. Ann. intern. Med. 1956, 45, 369.