A comfortable nasal catheter for oxygen therapy

1084 distress

or

remorse,

though

11 later

came to

express regret and

yearning. 9 of the men came from broken homes with an absent father, and most lived with a possessive mother. None had mature sexual feelings and only 3 had heterosexual feelings at all. The majority had experienced homosexual contact or fantasy, and about half showed close interest in their mother’s sexual conduct. On the whole the patients were passive, dependent, unambitious, and hypochondriacal with strong feelings of social and sexual inferiority. Beneath superficial conformity they were resentful and hostile.

The

Aggressive Psychopath

Dr. E. L. UDWIN described the Broadmoor method of treating the most aggressive of psychopaths. These men could only be handled under the highest security, and the hierarchy of the institution was somewhat rigid. The nurses readily distinguished between the " mad " and the " bad "; and allowed the impulsive schizophrenic considerably more latitude than the acting-out psychopath. The age of these patients ranged from the mid-teens to the fifties, and mixed states were so usual that a straightforward diagnosis was seldom possible. Common to all was violence and anti-authority behaviour (sexual psychopaths were a group apart), but they fell into two broad groups-those with psychotic episodes and those without. The prognosis was best for the young and worst in the old. Only serious offenders reached Broadmoor; though psychopaths seldom committed murder, and then only as part of some other nefarious exploit. Nurses used to be forbidden to speak to patients, but nowadays administration was less rigid, though security precautions still interfered with what was otherwise a fairly normal

hospital regime. The nurses were often the second or third generation of a family to work at Broadmoor; and they tended to be suspicious of outside doctors and newfangled ideas. The Broadmoor system was based on the idea that, if the psychopath was offered rewards, he would work for them. Anything good or constructive in the personality was fostered; immediate toughness was shown if a patient stepped out of line. The nurses were constantly on guard against the formation of anti-authority groups. Considering the record of most of the men, there was little violence and it mostly arose during quarrels between patients. Attacks on staff were rare; when they occurred the doctor was expected to seclude the patient or put him to bed. Failure to carry this out produced anxiety among both nurses and patients. Among the doctors there was

a

permissive regime with

of

tendency towards a more occupational therapy and discussion groups. This was not always welcomed by the psychopaths, who tended to be rigid, conservative, and punitive. One had said that he would rather do nine months’ solitary than spend his time arguing about why he had hit someone. Group sessions tended to produce jealousy and disruption, perhaps because of the large proportion of homosexuals. On the whole, however, the men were not highly sexed and were little upset by prolonged deprivation. Under the traditional reward-and-punishment regime the patient probably left hospital unchanged, unless he happened to mature during his stay. Dr. Udwin was sure that a hospital was the right place to treat aggressive psychopaths, and he would like to see a permissive group regime within Broadmoor’s perimeter walls, followed by further care as an inpatient or outpatient at mental hospitals or at special forensic outpatient more use

centres-for which there seemed

to be

great need.

New Inventions A COMFORTABLE NASAL CATHETER FOR OXYGEN THERAPY THERE are many devices for administering oxygen. Paradoxically the crudest and least efficient of these-the Tudor Edwards spectacles-is still popular in clinical practice. This can only be because the final decision whether any piece of apparatus is acceptable lies literally in the hands of the user-the hypoxic patient. No difficulty arises with the unconscious patient, and most conscious patients will tolerate any device for a time; but when a patient is drowsy and confused constant supervision is needed to make sure that the appliance is worn continuously. This is particularly important in patients with chronic bronchitis and emphysema in exacerbation. A simple double nasal catheter has been designed to provide more continuous and comfortable oxygen therapy for these patients. The catheter is made of soft translucent polyethylene tubing. It consists of a long tube about 1/3 in. (7 mm.) in diameter,

Fig. 2-Catheter in

use.

clothing

takes the pull of

supply

which is worn over the ears like spectacle frames and looped under the nose. It is held loosely in place by elastic behind the head. One end is closed off, and oxygen fed into the other end flows out through two smaller side tubes placed about 1/2 in. (12-5 mm.) inside the nares (figs. 1 and 2). The catheter can be constructed easily in about five minutes without any special tools. One end of a 2 ft. length of 0.28 in. (7 mm.) tubing (Portex no. 11) is heated above a bunsen flame until the plastic adheres when pinched together to close off the lumen. Two holes are made about 7 in. from this end in the side of the tube by melting the plastic with a heated nail slightly less in diameter than the nasal tubes which are to be inserted. Too much heat will char the plastic and hinder proper joining. The smaller tubes

Fig. I-The complete catheter.

Patient’s

tube.

are 3/4 in. (2-5 mm.) lengths of 0-19 in. (5 mm.) tubing (Portex no. 7). One end of each of these is wetted with cyclohexanone, and is inserted in one of the holes prepared in the large tube. When dry, the tubes are fused together and cannot be parted without tearing the plastic. Tubing from disposable plastic drip-sets may be used but this

1085 is harder and less comfortable. Soft elastic is tied firmly to the closed end of the catheter and less tightly to the long limb so that the tension may be adjusted to the individual head. The cost of the catheter is less than a shilling. Before treatment 29 mm. Hg

30 min.

1 hr.

3 hr.

64 mm. Hg 150 mm. Hg Hg The efficiency of the device is illustrated by the above arterial oxygen tensions obtained without other treatment in a mouthbreathing emphysematous patient at rest who was receiving oxygen through the catheter at 4 litres per minute: The main advantages, however, are the absence of the suffocating sensation with most masks, and the lack of interference with speaking, eating, drinking, or the wearing of ordinary spectacles. Restless and befuddled patients resent it less, and often seem unaware of its presence. The nasal tubes are not long enough to cause mucosal irritation, and their bore is wide enough to avoid the disadvantages of a high-velocity gas jet inside the nose. G. J. ADDIS Southern General Hospital, M.B. M.R.C.P. S.W.1 Edin.,, M.R.C.P. Glasg. Glasgow, 53

mm.

Reviews of Books Our Adult World and Other MELANIE KLEIN. Pp. 121. 15s.

Essays

London: Heinemann Medical Books.

1963.

Melanie Klein and her work have been the centre of the greatest controversy about the human mind since Freud. Many criticisms of her observations, and the theories she derived from them, have been almost identical with those used against Freud’s findings and conclusions. Both psychoanalysts might have replied: " It is no use blaming me because I happen to have found out something distasteful, disturbing, or difficult to comprehend." Freud is reputed to have said " Ich bin nicht Freudian", but Melanie Klein certainly was, and acknowledged her great debt to Freud. She also owed much to two of Freud’s pupils and colleagues, Ferenczi and Abraham. Without their personal help and their scientific work to build on, she might never have undertaken the painstaking and detailed examination of the minds of children which was such an important part of her contribution to human psychology and psychiatry. Of the four essays in this book only one, On The Sense of Loneliness, can be described as a scientific paper which shows Melanie Klein at work in all her breadth and comprehensiveness. Anyone who holds the view that she overemphasised destructiveness should read this paper. The essay from which this volume takes its title, Our Adult World and its Roots in Infancy, is wrongly described on the cover as a study in social anthropology. It is in fact a straightforward statement, simplified for a non-psychoanalytic audience, of some of Mrs. Klein’s conclusions about the relationship between the infant’s and the adult’s mind and personality. Since it is not possible to go into details about the vast amount of work which preceded these conclusions, they must be taken for granted, as so often happens in these days of specialisation. The essay on the Oresteia was incomplete at the time of Mrs. Klein’s death, but it was decided to publish it. Although in the direct Freudian tradition of analysing ancient works of art, it is unpleasingly dull. The use of English was not her strong point, which is understandable since it was not her native language. Sometimes it has seemed that she was so afraid of glib and facile verbal expression that she erred on the side of

incomprehensibility. On Identification, however, redeems Mrs. Klein’s reputation for doing work of special interest to creative artists.

Although it has been published before, this fascinating and deeply illuminating paper is a pleasure to reread, particularly in a book which in parts might justifiably be used in the service of unscientific criticism of a great psychoanalyst’s work.

Peripheral Vascular

Diseases

3rd ed. EDGAR V. ALLEN, M.D., M.S., section of medicine, Mayo Clinic; NELSON W. BARKER, M.D., M.S., F.A.C.P., EDGAR A. HINES, Jr, M.D., M.S., professors of medicine, Mayo Foundation Graduate School, University of Minnesota. Philadelphia and London: W. B. Saunders. 1962. Pp. 1044. 126s.

SINCE the first edition of "Allen, Barker, and Hines" in 1946 its subject has enlarged far beyond the scope of the general physician or cardiologist with an interest in the peripheral circulation. The book has grown in keeping with the advances of the past fifteen years, and its authorship now includes 26 of the editors’ associates at the Mayo Clinic, though the surgeons are still in the minority with a team of 9. Its presentation bears evidence of a certain strain between the needs of today and the loyalties and protocol necessary where so many close colleagues of different generations are involved. For example, aneurysms are clinically described (by one of the editors presumably) in the traditional manner, though very well, and with a balance that a vascular surgeon might find more difficult to convey; but, for their treatment, the reader must turn to a later part of the book. He is thus denied those invaluable asides on management-the steps of diagnosis along with treatment-and other aphoristic material that a surgeon in everyday contact with patients might have offered had he been given full charge of the subject. The same division of interest is more evident in the material on obliterative arterial disease: long sections on the minutiae of ischaemic degeneration, though good in themselves, are quite out of relation to the stages corresponding to them in modern treatment. Indeed, several pages are occupied by difficult medical regimens which are admitted to be often of little avail. Direct measures to increase the arterial inflow to the part are applicable " in a limited number of cases", and their description indeed is confined to a few pages in quite another part of the book. But, as the editors say in a preface, their aim was to aid the physician and to inform the student, so any surgical bias in this now preeminently surgical subject was hardly to be expected.

Nevertheless, this book was the first comprehensive survey of vascular disease, and, in the descriptive and classifying sense, it can still meet all its newer rivals on more than equal terms. The clinical appraisal of sudden arterial occlusion, for example, is as good as can be found anywhere, and so is the chapter on thromboangiitis obliterans. The reader cannot open the book without finding some wise and experienced observation on vascular disease. This still great work is a treasury of clinical wisdom, a record of the evidence and of the pattern of a growing group of diseases. It will remain the standard text on the natural history of vascular illness, for, by itself and by its references, most of today’s knowledge is encompassed with literary grace and professional excellence. The

Disposal of the Dead

C. J. POLSON, M.D., F.R.C.P., professor of forensic medicine, University of Leeds; R. P. BRITTAIN, M.A., B.SC., M.B., B.L., LL.B., senior registrar, Broadmoor Hospital, Berks; T. K. MARSHALL, M.D., lecturer in pathology (forensic medicine), Queen’s University, Belfast. London: English Universities Press. 1962. Pp.356. 45s. 2nd ed.

SKILFUL pruning of some of the material in the first edition has prevented all but a slight increase in the size of this invaluable reference book, despite the introduction of chapters dealing more fully with disposal by burial, as well as the various revisions necessitated by recent Acts. After ten years it was only to be expected that the price would rise. The rewritten first chapter, on historical matters, will interest the archxologically minded, for this is a brief but admirable survey of worldwide methods of disposal of the dead from the Mousterian to the Modern Ages: the references in this chapter reflect the very wide reading that such a study required and are useful sources for fuller information. The value of the book to those concerned with the problems and