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BED-OCCUPANCY AND WAITING-LIST FIGURES
1087 This lack of deference to human dignity in my view lowers the esteem of the medical profession and reduces these operations to the level of a new kind of nationalist rat-race. Is this the image of themselves the team wish to preserve for
posterity ? I hope
not.
"
BERNARD SANDLER.
Manchester 3
BED-OCCUPANCY AND WAITING-LIST FIGURES
SIR,-Mr. Bryan Williams’ comments (last week, p. 1029) on waiting-list figures are interesting, but I would suggest that in future a waiting-list should be compounded not in numbers of patients, but in the estimated number of months which patients may expect to wait before they can be admitted for non-urgent operations such as tonsillectomy, hernia repair, varicose veins, and certain orthopxdic and gynaecological procedures. After all, it is the waiting time only which concerns the patient. In my view, if this period is definitely below 6 months, the situation is just about under control; but when it reaches a year, very many cases are never admitted at all, for they are repeatedly kept back by more urgent demands and are delayed by such things as building work, staff shortages, and "
"
stoppages due
to outbreaks of infection. I do not agree that many surgeons take pleasure in adding such cases to a long waiting-list. Indeed, it is a frustrating waste of time and effort making careful decisions about applications one knows one will have small chance of being able to undertake; yet if patients are sent for opinion as to how their disability may be relieved, what choice has one ? It can hardly be denied that lack of staff and facilities is entirely a Ministerial
responsibility.
NAIL-FOLD CAPILLARIES IN CONNECTIVE-TISSUE DISORDERS was to read that the striking clinical signs interested Sirs of posterior nail-fold telangiectasia and haemorrhage, which have been of such value over the years in the diagnosis of so-called connective-tissue disorders, have been quantitated by Dr. Buchanan and Dr. Humpston (April 20, p. 845). I wonder, however, if it is necessary to speculate on an antigenantibody reaction in the capillaries to explain these signs ? I do not think that the vessel changes are specific for connective-tissue disorders: for example, Ryan and I1 saw similar changes in a young man with extreme (cold sensitive) acrocyanosis. In fact, perhaps a closer relationship between systemic lupus erythematosus, scleroderma, and dermatomyositis, the " connective-tissue diseases " of Dr. Buchanan and Dr. Humpston’s series, is sensitivity to cold and not an allergic " reaction as they imply. The extreme vasospastic response of Raynaud’s phenomenon is also commonly seen in this disease group. Furthermore, I doubt whether it is valid to compare these vessels with normal ones, because it may be that they represent the dilated survivors of a " second row " that may be seen more easily because those originally overlying them have long since disappeared with their supporting tissue, following thrombosis. Much has been written on the microcirculation by dermatologists and others, and the subject received fresh impetus from the work of Lewis.2 If we are going to speculate on the cause of thrombosis and haemorrhage in these vessels and on the development of posterior nail-fold telangiectasia, I would consider, from among other factors, the following: "
blood-flow (particularly if the patient has Nowhere else in the body are bloodvessels so near to the external environment as in the skin. The effect of the reduction of blood-flow may be exaggerated when superon
Raynaud’s phenomenon). 1. 2.
Copeman, P. W. M., Ryan, T. J. Bibl. Anat. (in the press). Lewis, T. The Blood Vessels of the Human Skin and their Responses. London, 1927.
may lead to
a
permanent block with infarction.
(3) Platelet stickiness measured by
screen filtration pressure methods is increased in the cold.5 In a group of patients with ischsemie necrosis of the skin capillaries with connective-tissue disorders and acrocyanosis, we have found increased platelet stickiness with a normal platelet-count, fibrinogen levels, and euglobulin lysis-time.1 (4) Increased viscosity of the blood slows the flow, and this can be observed directly by capillary microscopy. The consequent diversion of blood from just those areas where it is needed most allows thrombosis of the superficial capillaries. This may result 6 in dilatation of the deeper blood-vessels so that there is a direct communication between the capillaries that fill directly from dermal arterioles with those that drain straight into the subpapillary venous
plexus. The flow through these dilated vessels is uncertain. Even times when it seems to be greater, it may be " metabolically " less effective. This will tend to perpetuate the sclerotic process and obliterate any superficial capillaries that remain. Section of Dermatology, Mayo Clinic, P. W. MONCKTON COPEMAN. Rochester, Minnesota, U.S.A. at
PSYCHIATRIC CARE OF THE ADOLESCENT
SIR,-We read NORMAN A. PUNT.
London S.W.3.
(1) Effects of cold
imposed upon such changes as occur in any capillaries supplying a metabolically active tissue. This includes alteration in haematocrit, in plasma protein and fibrinogen concentration due to fluid loss, which give an increase in blood viscosity, and in red-cell flexibility due to blood-gas and pH changes. (2) Often the connective-tissue disorders " may have associated blood-protein abnormalities which may tend to cause aggregation of red blood-cells even in the absence of cold precipitable proteins. This in itself may not be harmful 3 4 but if disaggregation is slow this
your editorial
(March 30,
p.
676) with great
interest. Our institution, an open psychiatric hospital of 125 beds, has an adolescent department of 50 beds, which has been functioning since 1963. This unit admits patients of both sexes, aged 12-18 years from the whole country. The admissionrate is between 100 and 120 cases per year. In our experience, the 20-25 beds per million (which the U.K. Ministry of Health recommended) is inadequate. Diagnostic evaluation of the adolescent is a long process, mainly, as you mention, because of our lack of understanding of adolescent psychopathology and doubts as to when the behaviour disorder conceals a psychotic process (not necessarily schizophrenic). Secondly, the treatment and particularly reablement, which must be part of the whole treatment programme in the unit, lasts longer than with adults. The total number of patients in this age-group in active psychiatric units in this country is far higher than the figure suggested. We can handle the severest psychosis in the adolescent in an open ward, but the management of severe behaviour disorders or addiction in this framework presents the greatest difficulties and has proved virtually impossible. The diagnostic difficulties are legion; adult nosology, as you stress, does not fit the patients " in a large percentage of our patients in this "
age-group. The problem of defective or inadequate functioning outside hospital and the effect of admission on the adolescent in this situation is highly unpredictable. There is a tendency in many cases to disintegration of personality functions in the psychotic, after a short period in the ward, in spite of active and compre-
hensive treatment. Adolescents with very slight brain damage admitted with severe behaviour problems or psychotic disturbances, make up a large percentage of cases. We have learnt to regard severe neurotic and hypochondriac symptomatology with the utmost suspicion. We have integrated day-patient treatment into the framework of the unit. Unfortunately, financial problems have Kinsley, M. H., Black, E. H., Eliot, T. S., Warner, L. Science, N.Y. 1967, 106, 43. 4. Davis, M. J., Demis, D. J., Lawler, J. C. J. invest. Derm. 1960, 34, 31. 5. Dhall, D. H., Engeset, J., Matheson, N. A. Biothelology (in the press). 6. Ryan, T. J. in In vivo Techniques in Histology (edited by G. H. Bourne). Baltimore, 1967. 3.
posterity ? I hope
not.
"
BERNARD SANDLER.
Manchester 3
BED-OCCUPANCY AND WAITING-LIST FIGURES
SIR,-Mr. Bryan Williams’ comments (last week, p. 1029) on waiting-list figures are interesting, but I would suggest that in future a waiting-list should be compounded not in numbers of patients, but in the estimated number of months which patients may expect to wait before they can be admitted for non-urgent operations such as tonsillectomy, hernia repair, varicose veins, and certain orthopxdic and gynaecological procedures. After all, it is the waiting time only which concerns the patient. In my view, if this period is definitely below 6 months, the situation is just about under control; but when it reaches a year, very many cases are never admitted at all, for they are repeatedly kept back by more urgent demands and are delayed by such things as building work, staff shortages, and "
"
stoppages due
to outbreaks of infection. I do not agree that many surgeons take pleasure in adding such cases to a long waiting-list. Indeed, it is a frustrating waste of time and effort making careful decisions about applications one knows one will have small chance of being able to undertake; yet if patients are sent for opinion as to how their disability may be relieved, what choice has one ? It can hardly be denied that lack of staff and facilities is entirely a Ministerial
responsibility.
NAIL-FOLD CAPILLARIES IN CONNECTIVE-TISSUE DISORDERS was to read that the striking clinical signs interested Sirs of posterior nail-fold telangiectasia and haemorrhage, which have been of such value over the years in the diagnosis of so-called connective-tissue disorders, have been quantitated by Dr. Buchanan and Dr. Humpston (April 20, p. 845). I wonder, however, if it is necessary to speculate on an antigenantibody reaction in the capillaries to explain these signs ? I do not think that the vessel changes are specific for connective-tissue disorders: for example, Ryan and I1 saw similar changes in a young man with extreme (cold sensitive) acrocyanosis. In fact, perhaps a closer relationship between systemic lupus erythematosus, scleroderma, and dermatomyositis, the " connective-tissue diseases " of Dr. Buchanan and Dr. Humpston’s series, is sensitivity to cold and not an allergic " reaction as they imply. The extreme vasospastic response of Raynaud’s phenomenon is also commonly seen in this disease group. Furthermore, I doubt whether it is valid to compare these vessels with normal ones, because it may be that they represent the dilated survivors of a " second row " that may be seen more easily because those originally overlying them have long since disappeared with their supporting tissue, following thrombosis. Much has been written on the microcirculation by dermatologists and others, and the subject received fresh impetus from the work of Lewis.2 If we are going to speculate on the cause of thrombosis and haemorrhage in these vessels and on the development of posterior nail-fold telangiectasia, I would consider, from among other factors, the following: "
blood-flow (particularly if the patient has Nowhere else in the body are bloodvessels so near to the external environment as in the skin. The effect of the reduction of blood-flow may be exaggerated when superon
Raynaud’s phenomenon). 1. 2.
Copeman, P. W. M., Ryan, T. J. Bibl. Anat. (in the press). Lewis, T. The Blood Vessels of the Human Skin and their Responses. London, 1927.
may lead to
a
permanent block with infarction.
(3) Platelet stickiness measured by
screen filtration pressure methods is increased in the cold.5 In a group of patients with ischsemie necrosis of the skin capillaries with connective-tissue disorders and acrocyanosis, we have found increased platelet stickiness with a normal platelet-count, fibrinogen levels, and euglobulin lysis-time.1 (4) Increased viscosity of the blood slows the flow, and this can be observed directly by capillary microscopy. The consequent diversion of blood from just those areas where it is needed most allows thrombosis of the superficial capillaries. This may result 6 in dilatation of the deeper blood-vessels so that there is a direct communication between the capillaries that fill directly from dermal arterioles with those that drain straight into the subpapillary venous
plexus. The flow through these dilated vessels is uncertain. Even times when it seems to be greater, it may be " metabolically " less effective. This will tend to perpetuate the sclerotic process and obliterate any superficial capillaries that remain. Section of Dermatology, Mayo Clinic, P. W. MONCKTON COPEMAN. Rochester, Minnesota, U.S.A. at
PSYCHIATRIC CARE OF THE ADOLESCENT
SIR,-We read NORMAN A. PUNT.
London S.W.3.
(1) Effects of cold
imposed upon such changes as occur in any capillaries supplying a metabolically active tissue. This includes alteration in haematocrit, in plasma protein and fibrinogen concentration due to fluid loss, which give an increase in blood viscosity, and in red-cell flexibility due to blood-gas and pH changes. (2) Often the connective-tissue disorders " may have associated blood-protein abnormalities which may tend to cause aggregation of red blood-cells even in the absence of cold precipitable proteins. This in itself may not be harmful 3 4 but if disaggregation is slow this
your editorial
(March 30,
p.
676) with great
interest. Our institution, an open psychiatric hospital of 125 beds, has an adolescent department of 50 beds, which has been functioning since 1963. This unit admits patients of both sexes, aged 12-18 years from the whole country. The admissionrate is between 100 and 120 cases per year. In our experience, the 20-25 beds per million (which the U.K. Ministry of Health recommended) is inadequate. Diagnostic evaluation of the adolescent is a long process, mainly, as you mention, because of our lack of understanding of adolescent psychopathology and doubts as to when the behaviour disorder conceals a psychotic process (not necessarily schizophrenic). Secondly, the treatment and particularly reablement, which must be part of the whole treatment programme in the unit, lasts longer than with adults. The total number of patients in this age-group in active psychiatric units in this country is far higher than the figure suggested. We can handle the severest psychosis in the adolescent in an open ward, but the management of severe behaviour disorders or addiction in this framework presents the greatest difficulties and has proved virtually impossible. The diagnostic difficulties are legion; adult nosology, as you stress, does not fit the patients " in a large percentage of our patients in this "
age-group. The problem of defective or inadequate functioning outside hospital and the effect of admission on the adolescent in this situation is highly unpredictable. There is a tendency in many cases to disintegration of personality functions in the psychotic, after a short period in the ward, in spite of active and compre-
hensive treatment. Adolescents with very slight brain damage admitted with severe behaviour problems or psychotic disturbances, make up a large percentage of cases. We have learnt to regard severe neurotic and hypochondriac symptomatology with the utmost suspicion. We have integrated day-patient treatment into the framework of the unit. Unfortunately, financial problems have Kinsley, M. H., Black, E. H., Eliot, T. S., Warner, L. Science, N.Y. 1967, 106, 43. 4. Davis, M. J., Demis, D. J., Lawler, J. C. J. invest. Derm. 1960, 34, 31. 5. Dhall, D. H., Engeset, J., Matheson, N. A. Biothelology (in the press). 6. Ryan, T. J. in In vivo Techniques in Histology (edited by G. H. Bourne). Baltimore, 1967. 3.