- Email: [email protected]
DETERGENTS AT LARGE
1233
for providing services for the mentally ill : " It does little to foster a positive approach to mental health." The psychiatric hospital can be either the best or the worst possible thing for a patient-a therapeutic community or an instrument of desocialisation. Good treatment depends on a humane and well-trained staff, and in all countries the first necessity for which the law should provide is the recruitment and training of such staff. The number of hospital beds should depend on the number of people to staff them : " Good psychiatrists without specialised hospital establishments would render greater service to patients and to the community than psychiatric hospitals without adequate professional staff." Naturally the law must provide for the treatment, without their consent, of patients who are dangerous ; but it should also guarantee them guardianship and medical supervision. The type of guardianship proposed by the committee would be flexible, providing advice for patients capable of giving valid consent on the management of their private affairs, assisting those who are capable only of giving an opinion on such matters, and acting on behalf of those who are wholly incapable in this respect. A patient should bave-ready means of appeal at any time after involuntary admission; and, whatever the composition of the body which hears the appeal and, if necessary, authorises compulsory detention, its purpose should be to pronounce on the legality of the detention : it need not and should not be required to certify that a patient is insane or mentally subnormal. " The distinction between the authorisation of detention and the certification of an individual’s state of mind is an important one." The committee also favour much more flexible arrangements for the discharge of patients, believing that the more widely, within reason, such powers are distributed the better. The next-ofkin should have, as here, power to discharge a patient, subject only to a veto from the medical superintendent on the grounds that the patient is dangerous to himself or others ; and the next-of-kin should also have the right of appeal against such a veto. The medical superintendent, the medical inspectors of the health authority, the hospital management committee, and the local or central health authority should all, the committee hold, have the right to discharge patients : for nothing deters people from seeking early treatment more effectively than the fear that once one goes into a mental hospital it is difficult to get out. The committee find in almost every country conflicting attitudes to the mentally ill: in some of them the laws are advanced while public opinion remains primitive ; in others psychiatric care is well developed and legislation backward. They suggest that while new legislation is going forward, the old laws should be retained and allowed imperceptibly to fall into abeyance, or else that legislation should provide for a permanent body to be responsible for revising, at stated intervals, the laws affecting mental patients. Though this second proposal would hardly be consistent with British constitutional practice, we have other means of reaching the same end ; and our laws relating to certification and detention of the mentally ill are at present being reviewed by the Royal Commission presided over by Lord PERCY of NEWCASTLE.2o 20.
Lancet, 1954, i, 353.
Annotations DETERGENTS AT LARGE THE regulations which assess the quality and cleanliness of milk by statutory tests have without doubt been of benefit to the consumer, but when these qualities are measured by the simple yardstick of pass " or " fail " it is easy to forget the complexity of the biological mochanisms involved. Milk of an unusually high quality may be as proper a subject of inquiry as that which is judged unfit to be drunk. Until a recent change in the regulations, the pasteurised milk supplied to the hospitals of Paris should not have contained more than 100,000 organisms per ml. (i.e., the same standard which applied formerly in England and Wales). Routine testing showed that, in fact, a surprisingly large number of samples yielded bacterial counts so far below this figure that the presence of some disinfectant substance was suspected.l The most probable was a detergent used in cleaning the milk plant, especially one of the quaternary ammonium compounds which are powerful bactericidal agents and enjoy considerable popularity. Like all detergents these are not easy to remove from surfaces of glass or metal without very thorough rinsing. Using a simple but not entirely specific test, the investigators showed that 12% of milk cans contained traces of substances which might have been of this nature. We know of no similar observations in this country. The chemical detection of detergents is not easy and the quaternary ammonium compounds are usually reckoned too costly for use in the dairy. Evidence for and against their toxicity in small doses is scanty. Chemical technology is in fact bounding forward at such a pace that new compounds whose properties are but half known are on the market within a short time of their discovery. Seldom has the buyer or the seller the scientific knowledge to form any estimate of the possible risk from some secondary action. While the expert is in the position to forecast that a compound might cause dermatitis or cancer, the public must rely upon the protection of the common law and the good conscience of the manufacturer--and to dismiss the second as valueless is both foolish and unjust. The greatest danger from compounds new to our experience arise not when they are used for their designed purpose but when by accident or oversight they penetrate where they are unexpected and unwanted-to this milk, for example. Penicillin used for treating bovine mastitis has given the cheese-maker many headaches by killing his starter cultures. It is to be hoped that overzealous sanitation in the milk factories will not make unwanted (and illegal 2) additions to our morning cup of tea. "
ASPIRINS FOR EMPHYSEMA?
SOME emphysematous patients puff and blow for many years without much deterioration ; others decline into respiratory acidosis and anoxic heart-failure with scarcely a sigh. Measurement of the respiratory response of such patients to induced changes in arterial gas tensions and pH confirms the clinical inference that the sensitivity of central respiratory control is reduced.3 One aspect of decreased sensitivity to carbon dioxide, which attracted attention some years ago, is the tendency for oxygen therapy to aggravate hypercapnia and respiratory acidosis, with consequent drowsiness or even coma. Many physicians became unduly timid about giving oxygen to anoxic patients, but recent work4 suggests that, in acute respiratory insufficiency, the acute anoxia 1. Charonnat, R. Bull. Acad. Med. Paris, 1955, 139, 450. 2. Milk and Dairies Regulations, 1949, IX, 26, 6 c. H.M. Stationery Office. 3. Prime, F. J., Westlake, E. K. Clin. Sci. 1954. 13, 321. 4. Westlake, E. K., Simpson, T., Kaye, M. Quart. J. Med. 1955, 24, 155.
for providing services for the mentally ill : " It does little to foster a positive approach to mental health." The psychiatric hospital can be either the best or the worst possible thing for a patient-a therapeutic community or an instrument of desocialisation. Good treatment depends on a humane and well-trained staff, and in all countries the first necessity for which the law should provide is the recruitment and training of such staff. The number of hospital beds should depend on the number of people to staff them : " Good psychiatrists without specialised hospital establishments would render greater service to patients and to the community than psychiatric hospitals without adequate professional staff." Naturally the law must provide for the treatment, without their consent, of patients who are dangerous ; but it should also guarantee them guardianship and medical supervision. The type of guardianship proposed by the committee would be flexible, providing advice for patients capable of giving valid consent on the management of their private affairs, assisting those who are capable only of giving an opinion on such matters, and acting on behalf of those who are wholly incapable in this respect. A patient should bave-ready means of appeal at any time after involuntary admission; and, whatever the composition of the body which hears the appeal and, if necessary, authorises compulsory detention, its purpose should be to pronounce on the legality of the detention : it need not and should not be required to certify that a patient is insane or mentally subnormal. " The distinction between the authorisation of detention and the certification of an individual’s state of mind is an important one." The committee also favour much more flexible arrangements for the discharge of patients, believing that the more widely, within reason, such powers are distributed the better. The next-ofkin should have, as here, power to discharge a patient, subject only to a veto from the medical superintendent on the grounds that the patient is dangerous to himself or others ; and the next-of-kin should also have the right of appeal against such a veto. The medical superintendent, the medical inspectors of the health authority, the hospital management committee, and the local or central health authority should all, the committee hold, have the right to discharge patients : for nothing deters people from seeking early treatment more effectively than the fear that once one goes into a mental hospital it is difficult to get out. The committee find in almost every country conflicting attitudes to the mentally ill: in some of them the laws are advanced while public opinion remains primitive ; in others psychiatric care is well developed and legislation backward. They suggest that while new legislation is going forward, the old laws should be retained and allowed imperceptibly to fall into abeyance, or else that legislation should provide for a permanent body to be responsible for revising, at stated intervals, the laws affecting mental patients. Though this second proposal would hardly be consistent with British constitutional practice, we have other means of reaching the same end ; and our laws relating to certification and detention of the mentally ill are at present being reviewed by the Royal Commission presided over by Lord PERCY of NEWCASTLE.2o 20.
Lancet, 1954, i, 353.
Annotations DETERGENTS AT LARGE THE regulations which assess the quality and cleanliness of milk by statutory tests have without doubt been of benefit to the consumer, but when these qualities are measured by the simple yardstick of pass " or " fail " it is easy to forget the complexity of the biological mochanisms involved. Milk of an unusually high quality may be as proper a subject of inquiry as that which is judged unfit to be drunk. Until a recent change in the regulations, the pasteurised milk supplied to the hospitals of Paris should not have contained more than 100,000 organisms per ml. (i.e., the same standard which applied formerly in England and Wales). Routine testing showed that, in fact, a surprisingly large number of samples yielded bacterial counts so far below this figure that the presence of some disinfectant substance was suspected.l The most probable was a detergent used in cleaning the milk plant, especially one of the quaternary ammonium compounds which are powerful bactericidal agents and enjoy considerable popularity. Like all detergents these are not easy to remove from surfaces of glass or metal without very thorough rinsing. Using a simple but not entirely specific test, the investigators showed that 12% of milk cans contained traces of substances which might have been of this nature. We know of no similar observations in this country. The chemical detection of detergents is not easy and the quaternary ammonium compounds are usually reckoned too costly for use in the dairy. Evidence for and against their toxicity in small doses is scanty. Chemical technology is in fact bounding forward at such a pace that new compounds whose properties are but half known are on the market within a short time of their discovery. Seldom has the buyer or the seller the scientific knowledge to form any estimate of the possible risk from some secondary action. While the expert is in the position to forecast that a compound might cause dermatitis or cancer, the public must rely upon the protection of the common law and the good conscience of the manufacturer--and to dismiss the second as valueless is both foolish and unjust. The greatest danger from compounds new to our experience arise not when they are used for their designed purpose but when by accident or oversight they penetrate where they are unexpected and unwanted-to this milk, for example. Penicillin used for treating bovine mastitis has given the cheese-maker many headaches by killing his starter cultures. It is to be hoped that overzealous sanitation in the milk factories will not make unwanted (and illegal 2) additions to our morning cup of tea. "
ASPIRINS FOR EMPHYSEMA?
SOME emphysematous patients puff and blow for many years without much deterioration ; others decline into respiratory acidosis and anoxic heart-failure with scarcely a sigh. Measurement of the respiratory response of such patients to induced changes in arterial gas tensions and pH confirms the clinical inference that the sensitivity of central respiratory control is reduced.3 One aspect of decreased sensitivity to carbon dioxide, which attracted attention some years ago, is the tendency for oxygen therapy to aggravate hypercapnia and respiratory acidosis, with consequent drowsiness or even coma. Many physicians became unduly timid about giving oxygen to anoxic patients, but recent work4 suggests that, in acute respiratory insufficiency, the acute anoxia 1. Charonnat, R. Bull. Acad. Med. Paris, 1955, 139, 450. 2. Milk and Dairies Regulations, 1949, IX, 26, 6 c. H.M. Stationery Office. 3. Prime, F. J., Westlake, E. K. Clin. Sci. 1954. 13, 321. 4. Westlake, E. K., Simpson, T., Kaye, M. Quart. J. Med. 1955, 24, 155.