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CLINICAL GERIATRICS
469
We still tend to think of the helicopter finishing its job when the patient has been delivered to the waiting ambulance on the shore or at the airfield. Surely we should think much faster, and see that a helicopter land-
ing-site is arranged alongside every major hospital. Various Cornish hospitals were reported to be doing this,3 and no doubt there are others in the country besides those mentioned by Dr. Edwards. The time cannot be " far off for a landing-ground to be a must " for the selfrespect of every management committee. Rescue by helicopter calls for knowledgeable cooperation by the rescued; people need to know something about the drill if they are to be prevented from chopping their heads off on tail rotors, falling out of strops, burning themselves on exhausts, capsizing their sailing-boat under the down-draught, and entangling the rescue cable in their backstays. Such avoidable misadventures not add to the difficulties of rescue but further imperil only the lives of the aircrew. There are notes for sailors4 in areas where helicopters operate, but it seems that more Recent television widespread guidance might help. programmes have included helicopter mock rescues as an entertainment feature, and there may be scope in this medium for a more educational approach. We never know when we may be thankful for help from the skies. The Armed Services are the main source of helicopter help in Britain, but many other countries have developed aerial aid by civilian enterprise. La Garde Aerienne Suisse de Sauvetage (G.A.S.S.), set up in Zurich in 1952, is supported by voluntary effort.5 G.A.S.S. offers to help in air accidents, avalanches, landslides, and floods, as well as sailing and road accidents. It is essentially an auxiliary service to be called out by the normal rescue It can provide planes, helicopters, and authorities. parachute teams who are all trained volunteers. Bloodtransfusion can be brought direct to the patient, and even search dogs can be flown in. G.A.S.S. already has a fine record of achievement, ranging from the simple airlift of a seriously injured woodcutter between a remote hillside and hospital, within six minutes, to the evacuation of the victims from the tragic avalanches at Vorarlberg in Austria. The United States called on help from G.A.S.S. when two airliners collided in 1956 over the Grand Canyon, falling in a most inaccessible place. Aerial rescue is assuming an increasingly important role in many other countries. Soon it will be almost world-wide. CLINICAL GERIATRICS
probably no diseases peculiar to old age, but elderly people is associated with special some of which have been reviewed by Anderproblems, Son.6 For instance, in the aged, history-taking is liable to be more difficult, and symptoms and signs less obvious, than in younger patients. A fractured femur may cause only slight weakness in the affected limb after a fall; cardiac infarction may result in only a little breathlessness or faintness; and acute appendicitis may lurk behind mild abdominal pain. Mental confusion is an alarming symptom which usually precipitates a domestic crisis. Where the onset is sudden it is often symptomatic of some acute physical disturbance such as pneumonia, urinary infection, THERE
the
3.
care
are
of
Times, Aug. 25,
1956.
4. Notes for Yachtsmen: Sea Rescues by Helicopter. Ministry of Transport and Civil Aviation. February, 1957. 5. Rev. int. Croix-Rouge, 1957, 10, 593 6. The Care of The Elderly Sick in General Practice. By W. F. ANDERSON. Publication no. 9 of the Royal College of Physicians, 9, Queen Street, Edinburgh, 2. 1957.
cardiac infarction, a cerebrovascular accident, or dehydration. Sometimes it is due to a change of environment, and occasionally to drugs-especially bromides, hyoscine, and barbiturates. Nocturnal restlessness and wandering are commonly due to reversal of sleep rhythm, and the more active an old person can be kept in the day time the better is his chance of a quiet night. Urinary and fxcal incontinence is a distressing problem in the home and a common cause of admission to hospital. Incontinence of urine is sometimes due to a remediable local cause such as cystitis, prolapse, or prostatism, and sometimes to a central cause such as cerebral thrombosis or an emotional upset. The polyuria of diabetes and chronic nephritis may also cause incontinence. The trouble is always worse in patients confined to bed, and is sometimes cured by getting the patient up. Fxcal incontinence is less common and more distressing, but fortunately more remediable. It is often due to fxcal impaction, aggravated by apathy and bedfastness. Impaction of faeces in the rectum is potentially fatal, and it is often unrecognised. It may present as rectal discomfort, as abdominal pain with vomiting, as faecal incontinence, or as diarrhoea: constipation is seldom absolute. The diagnosis is readily made by rectal examination; and repeated enemas, sometimes after initial manual removal, relieve the condition. Hemiplegia due to cerebral thrombosis is one of the commonest geriatric problems; but the extent to which most hemiplegics can be reabled needs to be more widely known. Early passive movement followed by bed-end exercises and walking between parallel bars or with a walking machine are the foundation of treatment. A toe-spring or calliper with a heel-stop is a useful aid to All this contributes to the mainprevent foot-drop. tenance of activity, which is a fundamental principle of geriatric care. " The successful doctor and nurse of the elderly are those who help their patients to die with their boots on."7 DIAGNOSIS OF BRONCHIECTASIS
THE anatomical extent of bronchiectasis
can
be
accur-
ately assessed in life only by bronchography, and the usefulness of this investigation has increased with the introduction in the past few years of new contrast media that are rapidly cleared from the lungs. Opinion is less unanimous about the diagnostic value of a plain chest film. In 112 patients in whom the diagnosis was established bronchographically Gudbjerg8 found that only 7% had completely normal plain films. 31 % showed lobar collapse, unquestionably the most suggestive sign; 43% showed honeycombing; and no less than 85% showed increased lung markings. This last figure must be treated with reserve because in the assessment of increased lung markings the subjective factor is immensely strong, particularly when the observer knows beforehand that the patient has proven bronchiectasis; but few will dispute Gudbjerg’s conclusion that a normal plain film is on occasion compatible with severe bronchiectasis. 7. 8.
Rudd, T. N. The Nursing of the Elderly Sick; p. 15. London, Gudbjerg, C. E. Acta radiol., Stockh. 1957, suppl. 143.
1953.
THE INDEX and title-page to Vol. II, 1957, which was THE LANCET of Dec. 28, is published with our present issue. A copy will be sent gratis to subscribers on receipt of a postcard addressed to the Manager of THE LANCET, 7, Adam Street, Adelphi, W.C.2. Subscribers who have not already indicated their desire to receive indexes regularly as published should do so now.
completed with
We still tend to think of the helicopter finishing its job when the patient has been delivered to the waiting ambulance on the shore or at the airfield. Surely we should think much faster, and see that a helicopter land-
ing-site is arranged alongside every major hospital. Various Cornish hospitals were reported to be doing this,3 and no doubt there are others in the country besides those mentioned by Dr. Edwards. The time cannot be " far off for a landing-ground to be a must " for the selfrespect of every management committee. Rescue by helicopter calls for knowledgeable cooperation by the rescued; people need to know something about the drill if they are to be prevented from chopping their heads off on tail rotors, falling out of strops, burning themselves on exhausts, capsizing their sailing-boat under the down-draught, and entangling the rescue cable in their backstays. Such avoidable misadventures not add to the difficulties of rescue but further imperil only the lives of the aircrew. There are notes for sailors4 in areas where helicopters operate, but it seems that more Recent television widespread guidance might help. programmes have included helicopter mock rescues as an entertainment feature, and there may be scope in this medium for a more educational approach. We never know when we may be thankful for help from the skies. The Armed Services are the main source of helicopter help in Britain, but many other countries have developed aerial aid by civilian enterprise. La Garde Aerienne Suisse de Sauvetage (G.A.S.S.), set up in Zurich in 1952, is supported by voluntary effort.5 G.A.S.S. offers to help in air accidents, avalanches, landslides, and floods, as well as sailing and road accidents. It is essentially an auxiliary service to be called out by the normal rescue It can provide planes, helicopters, and authorities. parachute teams who are all trained volunteers. Bloodtransfusion can be brought direct to the patient, and even search dogs can be flown in. G.A.S.S. already has a fine record of achievement, ranging from the simple airlift of a seriously injured woodcutter between a remote hillside and hospital, within six minutes, to the evacuation of the victims from the tragic avalanches at Vorarlberg in Austria. The United States called on help from G.A.S.S. when two airliners collided in 1956 over the Grand Canyon, falling in a most inaccessible place. Aerial rescue is assuming an increasingly important role in many other countries. Soon it will be almost world-wide. CLINICAL GERIATRICS
probably no diseases peculiar to old age, but elderly people is associated with special some of which have been reviewed by Anderproblems, Son.6 For instance, in the aged, history-taking is liable to be more difficult, and symptoms and signs less obvious, than in younger patients. A fractured femur may cause only slight weakness in the affected limb after a fall; cardiac infarction may result in only a little breathlessness or faintness; and acute appendicitis may lurk behind mild abdominal pain. Mental confusion is an alarming symptom which usually precipitates a domestic crisis. Where the onset is sudden it is often symptomatic of some acute physical disturbance such as pneumonia, urinary infection, THERE
the
3.
care
are
of
Times, Aug. 25,
1956.
4. Notes for Yachtsmen: Sea Rescues by Helicopter. Ministry of Transport and Civil Aviation. February, 1957. 5. Rev. int. Croix-Rouge, 1957, 10, 593 6. The Care of The Elderly Sick in General Practice. By W. F. ANDERSON. Publication no. 9 of the Royal College of Physicians, 9, Queen Street, Edinburgh, 2. 1957.
cardiac infarction, a cerebrovascular accident, or dehydration. Sometimes it is due to a change of environment, and occasionally to drugs-especially bromides, hyoscine, and barbiturates. Nocturnal restlessness and wandering are commonly due to reversal of sleep rhythm, and the more active an old person can be kept in the day time the better is his chance of a quiet night. Urinary and fxcal incontinence is a distressing problem in the home and a common cause of admission to hospital. Incontinence of urine is sometimes due to a remediable local cause such as cystitis, prolapse, or prostatism, and sometimes to a central cause such as cerebral thrombosis or an emotional upset. The polyuria of diabetes and chronic nephritis may also cause incontinence. The trouble is always worse in patients confined to bed, and is sometimes cured by getting the patient up. Fxcal incontinence is less common and more distressing, but fortunately more remediable. It is often due to fxcal impaction, aggravated by apathy and bedfastness. Impaction of faeces in the rectum is potentially fatal, and it is often unrecognised. It may present as rectal discomfort, as abdominal pain with vomiting, as faecal incontinence, or as diarrhoea: constipation is seldom absolute. The diagnosis is readily made by rectal examination; and repeated enemas, sometimes after initial manual removal, relieve the condition. Hemiplegia due to cerebral thrombosis is one of the commonest geriatric problems; but the extent to which most hemiplegics can be reabled needs to be more widely known. Early passive movement followed by bed-end exercises and walking between parallel bars or with a walking machine are the foundation of treatment. A toe-spring or calliper with a heel-stop is a useful aid to All this contributes to the mainprevent foot-drop. tenance of activity, which is a fundamental principle of geriatric care. " The successful doctor and nurse of the elderly are those who help their patients to die with their boots on."7 DIAGNOSIS OF BRONCHIECTASIS
THE anatomical extent of bronchiectasis
can
be
accur-
ately assessed in life only by bronchography, and the usefulness of this investigation has increased with the introduction in the past few years of new contrast media that are rapidly cleared from the lungs. Opinion is less unanimous about the diagnostic value of a plain chest film. In 112 patients in whom the diagnosis was established bronchographically Gudbjerg8 found that only 7% had completely normal plain films. 31 % showed lobar collapse, unquestionably the most suggestive sign; 43% showed honeycombing; and no less than 85% showed increased lung markings. This last figure must be treated with reserve because in the assessment of increased lung markings the subjective factor is immensely strong, particularly when the observer knows beforehand that the patient has proven bronchiectasis; but few will dispute Gudbjerg’s conclusion that a normal plain film is on occasion compatible with severe bronchiectasis. 7. 8.
Rudd, T. N. The Nursing of the Elderly Sick; p. 15. London, Gudbjerg, C. E. Acta radiol., Stockh. 1957, suppl. 143.
1953.
THE INDEX and title-page to Vol. II, 1957, which was THE LANCET of Dec. 28, is published with our present issue. A copy will be sent gratis to subscribers on receipt of a postcard addressed to the Manager of THE LANCET, 7, Adam Street, Adelphi, W.C.2. Subscribers who have not already indicated their desire to receive indexes regularly as published should do so now.
completed with