CHEST PHYSICIANS

1297

LETTERS TO THE EDITOR

and had total doses of 1-58 g. and 1-7 g. respectively. 3rd had only 1-0 g. before dilatation and curettage.

This

drug

is much

superior

The

to either of the thio-

barbiturates, thiopentone and thialbarbitone (’ Kemias regards rapid recovery of consciousness. it is less potent than either, and a for weight, Weight dose of at least 0.5 g. is necessary to maintain adequate ansesthesia in outpatients, even during operations lasting only 10 minutes. Delayed recovery, however, is a drawback and therefore the drug cannot, I think, be unreservedly recommended for routine use, even in carefully prepared outpatients. On the,other hand, if thialbutone sodium is used purely for induction in such cases and if full use is made of supplementary nitrous-oxide/oxygen maintenance, then a smooth and rapid recovery can be predicted far more confidently than with other intravenous agents used in the same way. Turning to some of the points in Dr. Ruddell’s letter, I never noted wretching in any patient during induction, but a few patients vomited during the recovery phase ; all but one had had opiate premedication. In the unpremedicated adult, if the maximum dose is confined to 1-0 g., then 41/2-5 minutes is perhaps an unnecessarily long time for giving the dose.

thal’),

such as exist I believe in no other country in the world, and I am not aware that we are the better doctors for them : a man is known by the quality of his work, not by the diploma he holds. ’ NON HABET.

SIR,-I

trying

A REPORT FROM HOSPITAL note from Mr. Gruber’s letter (Dec.

to achieve

brevity

I have fallen into

3) that in

obscurity.

I should perhaps have made it clear that when I wrote to the surgeon asking for information about one of his patients he replied giving me precisely the information I wanted but asked me to write to the administrative chief of the hospital for an official report. The report I eventually had from the house-surgeon via the administrator was equally courteous but in no way more informative than the letter I had already had from the senior surgeon.

I entirely agree with Mr. Gruber that consultants are almost always glad to inform and advise about their patients, and the present consultant was no exception. The administrative merry-go-round in this case was, however, new to me. R. E. W. FISHER. London, N.1. PROTOPHRENIA

SIR,-Dr. Bourne’s article of Dec. 3 brings to the notice My thanks are due to Dr. P. W. S. Gray and Dr. D. Zuch for their help and encouragement. Messrs. Bayer of Leverof all who work in the psychiatric field with children a kusen kindly supplied their drug (’Baytenal’) used in the very important problem which I think many of us have first series, and I am grateful to May & Baker. Ltd. for the been aware of for years. This statistical study, coming thialbutone sodium (’Transithal’) used in the second series. from an institution dealing with young grossly mentally PETER NOBES. deficient children, pinpoints the importance of nurture London, N.10. in achieving full potential development. Nevertheless I HYDROCORTISONE IN PAINFUL SHOULDER think Dr. Bourne does less than justice to the problem SIR,-I have read with interest the correspondence of vulnerability. He points the analogy with the tubercle whose pathogenicity none would question arising from the article by Mr. Murnaghan and Mr. bacillus, " Mclntosh (Oct. 15). though the vast majority infected with it are not ill." This does not in any way answer the question why some I had been using procaine 1% in these cases for some time ; but when hydrocortisone appeared on the market are and others are not ; and in making a similar study of family case-histories, some of them pursued over years, I changed to this. For a long time now I have been it has seemed to me that the very striking absence of of the opinion that the results were not significantly affected siblings does suggest that the piling up of different. I have found that if the patient has not difficulties, plus some unknown source of vulnerability benefited from the injection of local anaesthetic he is to such difficulties, may be sufficient to turn what could to relief from the of derive introduction hydrounlikely cortisone at the same site. The most important point have been a normal development into a severely distorted one. seems to be to deposit the solution at the " correct site." It has been my custom to regard most of these children The addition of hyaluronidase to the solution of local as psychotic, prefacing any remarks I may make about anaesthetic does not seem to lessen the importance them with a clear statement that in this context we of this. know what psychotic means. Dr. Bourne regards hardly Morse, Saskatchewan, M. GLASSMAN. it as a condition which may be treatable if taken in the Canada. early stages, and quotes the therapeutic work of Rank CHEST PHYSICIANS in Boston. Even with intensive psychotherapy, howSIR,-In their letter of Nov. 5 Dr. Hendry and Dr. ever, many such children do not come back to a wholly Tattersall spoke of the grading committees’ harsh treatnormal course of development, and some have to be ment of some former members of the tuberculosis service. regarded as permanently " atypical," and ultimately are There is no doubt that gross injustices were done to often lost sight of as members of the mentally defective senior physicians in charge of chest clinics (of whom I population. Perhaps the most important point that he am one) at the time of the inception of the National makes is the real need, in building up ego function, that Health Service and since, in that few of them were raised adjustments and associations should be made at the stage to consultant status although their long experience in of development to which they normally belong. Howthis special branch of clinical medicine entitled them to ever successful therapy is in retracing the steps and in be so elevated ; and there is equally no doubt that the re-forming sounder relationships, a good deal of evidence regional hospital boards, the selection committees, and is accumulating that it is only rarely possible for these the Ministry of Health remain quite unconcerned at the children to make a full return to normal. plight of so many skilled and experienced physicians. Reverting to Dr. Bourne’s rejection of the term The Royal Colleges of Physicians and Surgeons have " psychotic," surely a child makes some kind of ego established such a stranglehold upon the profession that organisation at however primitive a level from the time virtually nobody can hope to be appointed to a con- that he begins his separate existence ? Disintegration sultant post unless he holds the membership or fellowoccurring at a very early age prevents many further in and I that cases out of a believe ninety-nine ship ; integrations from taking place, and I would have thought hundred the colleges direct the policy of the regions and the concept of ego disintegration was valid, provided we the selection committees. are able to establish at least some very early normal function. It is characteristic of some of these histories The medical profession in this country is bedevilled that they include abnormal maternal attitudes which are with a variety of registrable and unregistrable diplomas

.