CARING

313 confusional state. Doctors prefer a pathological definition of disease to one that is descriptive or syndromal. You seem to favour a behavioural definition. In one patient cited a mild disorder of function becomes a severe disorder with pneumonia and a mild disorder again after treatment. What is the pathology of such a process? Certainly the component that improved is not related to irreversible death of neurones and should not warrant a diagnosis of dementia in pathological terms. Delirium superimposed on dementia would be logically acceptable, but not "treatable dementia". These considerations lead me to suggest the following terminology and classification. Brain failure would be described clinically as "organic mental state" or "brain syndrome" and the pathology would be varied, reversible and/or irreversible processes being at work, and it would be acute or chronic:

CARING

SIR,-In his Point of View (Jan. 1, p. 36) Mr Rippe of Harvard Medical School class of 1979 preaches to the organisers of medical education, sketching ideals for them to follow. Will the organisers of medical education understand how to comply with his call ? nature of caring is unclear in his account. It covers the caring for the individual patient, it covers the planner arranging health care for a community, and it seems to cover the medical student being considerate to his fellows. Now these activities are mutually exclusive-at least in the sense that one cannot carry them all out simultaneously, nor plan to devote one’s career to all of them together. Is medical education to teach caring in the void, or caring for individual patients, or just the avoidance of non-caring activities (golf?). Further, is caring a skill, an attitude, an instinct (Mr Rippe’s word), or even perhaps a cardinal virtue? The answer matters. Whether education has any bearing on caring depends on caring’s nature; if caring is an instinct, the educational organisers will legitimately complain of unreasonable demands upon them, and suggest an endocrinological approach. If caring is an attitude, is it right to manipulate other medical students into the attitude Mr Rippe approves? They are people too, and some of them may prefer certain medical roles where there is very little personal caring to do, yet perhaps enormous ultimate useful-

’I’he doctor

ness.

If caring needs skill and information, medical education is firmer ground; it has always aimed to instil the necessary items. But Mr Rippe detects an omission; can we surmise what its nature is? Tact is evidently a gap, and perhaps insight into individual human thoughts, in which perhaps the surgeon he mentions was lacking. Are books and seminars to be the instructional methods to prevent such mishaps? Example and ex- perience are better and more personal teachers. Could more admirable examples be set by teaching staff? Perhaps; how are the organisers to provide for an improvement? Another omission is apparently information about the nature and medical needs of society. This information is available. Should more of it be taught (and examined) at Harvard? on

^

In clinical practice cases may present as pure acute (short history), pure chronic (long history without sudden recent change in rate of deterioration), or acute on chronic (long history with sudden recent change in rate of deterioration). Clinical observation points to "acute on chronic" as the commonest presentation in practice, and I would suggest that this is the correct

categorisation of the cases cited in your editorial. The acute brain syndrome is treated, but not the dementia. Nevertheless, the total functional capacity of the patient is much improved by reason of improvement in the acute element. Clinical differentiation of the groups can be achieved with reasonable certainty even though the pathological basis can only be implied. One final word of caution. Deterioration of behaviour is used above in the sense of any change into forgetfulness, loss of cognitive function, and change in personality whether the change is socially obtrusive or not. The social obtruders (i.e. the incontinent, wandering, nocturnally disturbed, noisy, aggressive, or sexually disinhibited) are a subgroup of "organic" patients on quite another social dimension. I believe that there is a strong clinical correlation between social obtrusiveness and acute brain syndrome whether or not chronic brain syndrome is present as well. The clinical approach is therefore even more important in these cases even though it is the social dimension that brings them to notice. There used to be a definition of a psychiatrist as a consulwho moves patients from A to B, It should those who care for the elderly mentally ill patient. tant

Exe Vale Hospital, Exminster, Exeter EX6 6AB

not

apply

to

G. E. LANGLEY

It would be presumptuous to hazard an opinion from another country, and Mr Rippe does not clearly tell us his. Students primarily attracted towards individual care may not be very interested. Caring isn’t a "soft abstraction" (Mr Rippe’s phrase); it may mean missing one’s lunch, or infinite listening with patience, or much worse. The lack of it for poorer patients isn’t a newly recognised problem, as Mr Rippe seems to think: "The slave doctors

run

about and

cure

the slaves,

or watt

for them

dispensaries-practitioners of this sort never talk to their own patients individually, or let them talk about their own individual complamts. The slave-doctor prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a tyrant, he rushes off with equal assurance to some other servant who is ill... But the other doctor, who is a freeman, attends and practises upon freemen ; and he carries the enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and in

with his friends, and is at once getting information from the sick man, and also instructing him so far as he is able, and he will not prescribe for him until he has at first convinced him; at last, when he has brought the patient more or less under his persuasive influences and set him on the road to health, he attempts to effect a cure".’I

The classic expression of medical caring wasn’t written in 1927 (except perhaps for Harvard men); one of many written by Hippocrates around 450 B.C. runs: "Where there is love of mankind, there is love of the [medical] art." The real deficiencies Mr Rippe sees may not be in knowledge but in the love of mankind, and formal education-medical or other-is, thank God, a poor tool for instilling that. Could we then select 1 Plato. Laws 2 Hippocrates

(translated by Precepts 6

B

Jowett); 5, 103. Oxford, 1871.

314 students for it? Mr Rippe suggests that a ’’potential to provide and/or study patient care" could be assessed. And so it could. For one year, or even two. After that, the techniques used for assessing motivation would be known to every good school careers adviser, and the assessment would become an exercise in the detection of hypocrisy-which, like the detection of malingering, is a most difficult art. Alternatively, special weight might be given to promise in economics and statistics, for future study of health care-and dare anyone say that all medical students should excel in these? Eagerness to manipulate others by formal education into one’s own pattern of virtue is very understandable. But even supposing the techniques to do it effectively were available to medical educators, the product is puppets, not doctors. Some uneasy balance in the matter of caring is likely to persist between the good (who care, but may be too sensitive to learn) and the clever (who may be too busy learning to be sensitive), so perhaps there is room for both in medicine. 120

Mormngside Dnve,

1?dmburgh

JOHN FORRESTER

EH10 SNS.

SOCIAL INJUSTICE FOR A SOCIAL WORKER

SiR,—Ihave been involved in lengthy negotiations with London

borough about

tumour

spread

a

patient of mine who applied and was initially accepted for the post of social worker. This woman had had a mastectomy for breast cancer in March last year. Since then she has been very well, and there is no evidence of a

or recurrence

clinically, radiologically,

JOHN

BANCEWICZ

SAVING ON HOSPITAL CATERING

S!R,—The national Press has reported a scheme for saving the country millions of pounds by substituting a proportion of the meat in school lunches by vegetable protein. The discussion on hospital catering at a seminar I attended recently gave the impression that the primary objective was to provide the patient with meals that as nearly as possible resembled those he was used to. In an age when virtually all rights over mind and body are abrogated when a person turns into a hospital patient, it is odd that what he eats should be vigorously defended. Perhaps one day space sticks will provide precise nutrient requirements for patients in hospital: until then there is no justification for the hospital caterers not to follow this lead given by the schools. Department of Physiology, University Medical School, Edinburgh EH8 9AG

SIR,-You statel that an oxidase specific for reduced nicotinamide adenine dinucleotide (N.A.D.H) is the enzyme responsible for the respiratory burst in neutrophils. That statement is made with a degree of assurance which is not warranted by the facts. The identity of the burst enzyme is as controversial now as it has been for nearly 15 years. The controversy is about whether the burst enzyme is an N.A.D.H dependent or an N.A.D.p.H (reduced N.A.D. phosphate) dependent oxidase. Out of the vast literature generated by this controversy, only two papers were cited,23both supporting N.A.D.H. The non-specialist would mistakenly conclude that the issue had been settled in favour of the N.A.D.H-requiring system (if indeed he was even aware of the dispute, a matter which was not raised in your editorial). The opposing view was not cited even though three papers-one by Hohn and Lehrer (J. clin. Invest. 1975, 55, 707) and two from our laboratory (New Engl. J. Med. 197$, 293, 628, and J. clin. Invest. 1976, 58, 989)-provide at least as much experimental support for an N.A.D.P.H-requiring enzyme as the cited papers do for the N.A.D.H-requiring enzyme. The controversy is still simmering: you should have cited both points of view and let the readers judge for themselves, Hematology Service, Department of Medicine, Tufts University School of Medicine, New England Medical Center Hospital,

COMPENSATION FOR VACCINE-DAMAGED CHILDREN

SiR,—Iam daily acquainted with the loss, anguish and suffered by the parents of mentally handicapped children. But I am alarmed by the growing assumption that it is natural and proper to pay compensation for certain mentally handicapped children-namely, those whose plight might be attributed to the use of a vaccine. The idea is growing that it is only a matter of time before the Government will do the decent thing and pay up. I hope a great deal more consideration will be given before such a course is entered upon. I advise against it. Medicine tries to ensure that its practices do not cause harm in one area while benefiting another, but medical procedures cannot be entirely without risk. When the risks are sufficiently low they must be regarded as "natural hazard". My principal objection is that it is unfair to compensate some victims of natural hazard, those reacting unusually to a vaccine, but not others, the grim majority where the cause is unknown. I think it is divisive. Further, medical care is not obligatory, and in Britain patients are not offered treatment for profit. So a capitalist principle is being unfairly applied to a socialised service. The relationship between giving a vaccine and mental handicap is tenuous and cannot be proved for certain in a given case. Thus compensation will rest on opinion, and I find it difficult to see how a case can be fairly argued. It seems improper, yet unavoidable, to involve those of us who care for the patients and their families in such arguments. Despite the small number of instances where "vaccine damage" is re-

hardship

motely likely,

a

disproportionately large screening procedure

will need to be financed. The chances of overlooking victims and compensating non-victims are large. Already children who are known to be mentally handicapped for other reasons are likely to be excluded from compensation although there is no

why their problem vaccine reactions. reason

1. Lancet, 1976, ii, 1391. 2. Briggs, R. T., Drath, D.

D. S. MCLAREN

BERNARD M. BABIOR

Boston, Massachusetts 02111, U.S.A.

or on

bone scan. However, the offer of the job was withdrawn because she is ineligible, on medical grounds, for superannuation.-The medical advisers in London are unwilling to recommend this woman for employment until several years have elapsed after surgery. None of the clinicians I have spoken to here have had any similar experiences. I would be interested to hear whether others have encountered this problem. If this incident is not an isolated one there would seem to be a good case for changing the superannuation regulations, in particular the rule which requires all employees in some professions to be superannuable. My patient would be prepared to work without superannuation for the present. It seems ironic that this objection should be raised by an authority which employs social workers and which might be expected to be at the forefront of social progress. Department of Surgery, Western Infirmary, Glasgow G11 6NT

RESPIRATORY BURST IN NEUTROPHILS

3.

might

not

have been

aggravated by

B., Karnovsky, M. L., Karnovsky, Biol. 1975, 67, 566. Segal, A. W., Peters, T. J. Lancet, 1976, i, 1363.

M.

J. J. Cell