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FRACTURED FEMUR IN CONVULSION THERAPY
666
(b) Will retention in the service after operation to be of shorter duration and greater intensity than jeopardise his chance of complete recovery, or is it likely ’the former. Great variations exist in the character
to lead to a claim that his condition has been aggravated by service conditions ? If discomfort does persist, it is hard to deny the man’s right to such a claim. (c) Is posting to a unit where the patient can " live
a home of his own, regulating his own diet) possible ? Compassionate posting in war-time may be difficult, but may also be the deciding factor. (d) Does the man genuinely want to remain in the
out " (in
service ?
I have already met men who will gladly use the service facilities to obtain their operative treatment and convalescence on full pay, but whose persistent doubtful symptoms lead to the " invaliding " they have desired. Malingering still exists and half a stomach makes a good start. Many of the ulcer cases we are seeing now are men who failed to disclose the condition of which they were fully aware when, before war overtook them, they enlisted in the reserves. They believed their stomachs could answer a call that might never come. They belong to the middle-age group of which Professor Pannett speaks. Very few would be good investment for the state if they submitted to gastrectomy. It is fairer to all concerned to release them from service. They can still receive operative treatment as civilians. The formation of a "gastric " company, command or crew for dyspeptic officers and men, might solve the question of diet, but the nervous element in the excitation of peptic ulceration is difficult to control under conditions of active service.
and intensity of grand-mal attacks, not only of different epileptics but also of the same epileptic. This is also true of convulsions induced by drugs and the aim of course is to induce the mildest complete convulsion. The infrequent occurrence of fractures in epileptics is probably due to the fact that in most cases their bones have been habituated to the strain of fits from youth.
We are,
Sir,
Crichton Royal, Dumfries.
yours
faithfully,
ANDREW M. WYLLIE, W. MAYER-GROSS.
THE E.M.S. TODAY AND TOMORROW
SiR,—Many must have read with great interest the article by Sir James Walton in your issue of March 16. Sir James has learnt something from the war and is frank enough to admit it. Like a good many other members of the E.M.S. he has for the first time made personal contact with the municipal hospital service that provides accommodation for three out of every four of the citizens of London, when they need hospital treatment. He has found that in personnel, in elasticity and in capacity for getting things done this service is a very different thing from what he had imagined and he is honest enough to say so. So far I am in entire agreement. I agree also in what may be assumed from this article, although it is not perhaps definitely stated, namely, that it is wasteful and absurd to have two hospital systems doing the I am, Sir, yours faithfully, same sort of work and yet more or less in competition D. F. ELLISON NASH. with each other. There is one minor inaccuracy in Cranwell. the article. It is not strictly true to say "In the permanent state hospitals the great drawback to the FRACTURED FEMUR IN CONVULSION medical man is that as he advances in his profession THERAPY he ceases to be a doctor and becomes a pure adminisSIR,-The subject of Dr. Good’s letter in your issue trator," for the London County Council has a few of March 23 is one of topical interest in practical clinical appointments with salaries of E1500 a year psychiatry of to-day and deserves a fuller discussion and the Middlesex county council several. Moreover, in so far as the statement is correct at all, it is merely in which not only psychiatrists but also surgeons and should take All raised by an indication that the evolution of these hospitals, part. points radiologists Dr. Good are controversial. With regard to his statetaking origin as they have done but a few years since from poor-law institutions, is not yet complete. ment that " age or prolonged inactivity bear no Sir James goes on to say " It is now that a definite relation to the incidence of fractures " we would point out that in a series of 144 cases treated at the Crichton plan should be formulated so that if there be a union Royal, of whom 25 were over fifty years of age, between the state and voluntary systems the good that fracture of a long bone occurred in 3 patients. All is in each system may be retained and the bad eliminated." He proposes the formation of a committee to were females in the 6th decade of life who had been formulate such a scheme. When, however, he suggests thinks the Dr. Good for several hospitalised years. that such a committeeshould indeed be a British incidence of fractures in his series, 2 in 160 cases treated-i.e., 1.25 per cent.-exceptionally low. One of medical association of all consultants participating in us (A. M. W., J. ment. Sci. March, 1940, p. 248) has hospital work," I think he is wanting to restrict the made a study of the literature and found that in the membership too much. Surely those who are actually series where the fractures were actually reported, engaged in the work of the municipal hospitals will there were 28 fractures in 2342 cases-i.e., 1’20 per have something to contribute. Moreover, could not cent. If therefore the incidence of fractures in Dr. something be learned from laymen who have ’had Good’s series is not less than in the general experience experience in hospital administration and are also able to speak from the consumer’s point of view his argument that restraint is the principal cause of these fractures loses most of its ground. As a matter Sir James then sets out three essential provisos for of fact no worker advocates forcible restraint of the the new service. " (1) The surgeon or physician in patient during the tonic phase of the fit-i.e., at the charge would have to remain a doctor with complete control of his unit and would be freed of all administime when in our experience fractures occur. During the initial phase of clonic jerkings our nurses are trative work. (2) He would have to be provided with instructed gently to support the arms and to keep private rooms and consulting-rooms where he could the elbows close to the sides, preventing abduction at treat better-off patients at moderate fees, so that he the shoulders in order to minimise the risk of disloca- could mix with all grades and could obtain some added tion. It is improbable that this procedure can have reward for his labour and reputation. (3) He would the effect of causing fractures. be given full facilities for undergraduate and post Weagree with Dr. Good that there is no essential graduate teaching." With the first and third of these difference between the fits of idiopathic epilepsy and I am in entire agreement; with the second’prothose induced by Cardiazol, although the latter seem foundly disagree.
(b) Will retention in the service after operation to be of shorter duration and greater intensity than jeopardise his chance of complete recovery, or is it likely ’the former. Great variations exist in the character
to lead to a claim that his condition has been aggravated by service conditions ? If discomfort does persist, it is hard to deny the man’s right to such a claim. (c) Is posting to a unit where the patient can " live
a home of his own, regulating his own diet) possible ? Compassionate posting in war-time may be difficult, but may also be the deciding factor. (d) Does the man genuinely want to remain in the
out " (in
service ?
I have already met men who will gladly use the service facilities to obtain their operative treatment and convalescence on full pay, but whose persistent doubtful symptoms lead to the " invaliding " they have desired. Malingering still exists and half a stomach makes a good start. Many of the ulcer cases we are seeing now are men who failed to disclose the condition of which they were fully aware when, before war overtook them, they enlisted in the reserves. They believed their stomachs could answer a call that might never come. They belong to the middle-age group of which Professor Pannett speaks. Very few would be good investment for the state if they submitted to gastrectomy. It is fairer to all concerned to release them from service. They can still receive operative treatment as civilians. The formation of a "gastric " company, command or crew for dyspeptic officers and men, might solve the question of diet, but the nervous element in the excitation of peptic ulceration is difficult to control under conditions of active service.
and intensity of grand-mal attacks, not only of different epileptics but also of the same epileptic. This is also true of convulsions induced by drugs and the aim of course is to induce the mildest complete convulsion. The infrequent occurrence of fractures in epileptics is probably due to the fact that in most cases their bones have been habituated to the strain of fits from youth.
We are,
Sir,
Crichton Royal, Dumfries.
yours
faithfully,
ANDREW M. WYLLIE, W. MAYER-GROSS.
THE E.M.S. TODAY AND TOMORROW
SiR,—Many must have read with great interest the article by Sir James Walton in your issue of March 16. Sir James has learnt something from the war and is frank enough to admit it. Like a good many other members of the E.M.S. he has for the first time made personal contact with the municipal hospital service that provides accommodation for three out of every four of the citizens of London, when they need hospital treatment. He has found that in personnel, in elasticity and in capacity for getting things done this service is a very different thing from what he had imagined and he is honest enough to say so. So far I am in entire agreement. I agree also in what may be assumed from this article, although it is not perhaps definitely stated, namely, that it is wasteful and absurd to have two hospital systems doing the I am, Sir, yours faithfully, same sort of work and yet more or less in competition D. F. ELLISON NASH. with each other. There is one minor inaccuracy in Cranwell. the article. It is not strictly true to say "In the permanent state hospitals the great drawback to the FRACTURED FEMUR IN CONVULSION medical man is that as he advances in his profession THERAPY he ceases to be a doctor and becomes a pure adminisSIR,-The subject of Dr. Good’s letter in your issue trator," for the London County Council has a few of March 23 is one of topical interest in practical clinical appointments with salaries of E1500 a year psychiatry of to-day and deserves a fuller discussion and the Middlesex county council several. Moreover, in so far as the statement is correct at all, it is merely in which not only psychiatrists but also surgeons and should take All raised by an indication that the evolution of these hospitals, part. points radiologists Dr. Good are controversial. With regard to his statetaking origin as they have done but a few years since from poor-law institutions, is not yet complete. ment that " age or prolonged inactivity bear no Sir James goes on to say " It is now that a definite relation to the incidence of fractures " we would point out that in a series of 144 cases treated at the Crichton plan should be formulated so that if there be a union Royal, of whom 25 were over fifty years of age, between the state and voluntary systems the good that fracture of a long bone occurred in 3 patients. All is in each system may be retained and the bad eliminated." He proposes the formation of a committee to were females in the 6th decade of life who had been formulate such a scheme. When, however, he suggests thinks the Dr. Good for several hospitalised years. that such a committeeshould indeed be a British incidence of fractures in his series, 2 in 160 cases treated-i.e., 1.25 per cent.-exceptionally low. One of medical association of all consultants participating in us (A. M. W., J. ment. Sci. March, 1940, p. 248) has hospital work," I think he is wanting to restrict the made a study of the literature and found that in the membership too much. Surely those who are actually series where the fractures were actually reported, engaged in the work of the municipal hospitals will there were 28 fractures in 2342 cases-i.e., 1’20 per have something to contribute. Moreover, could not cent. If therefore the incidence of fractures in Dr. something be learned from laymen who have ’had Good’s series is not less than in the general experience experience in hospital administration and are also able to speak from the consumer’s point of view his argument that restraint is the principal cause of these fractures loses most of its ground. As a matter Sir James then sets out three essential provisos for of fact no worker advocates forcible restraint of the the new service. " (1) The surgeon or physician in patient during the tonic phase of the fit-i.e., at the charge would have to remain a doctor with complete control of his unit and would be freed of all administime when in our experience fractures occur. During the initial phase of clonic jerkings our nurses are trative work. (2) He would have to be provided with instructed gently to support the arms and to keep private rooms and consulting-rooms where he could the elbows close to the sides, preventing abduction at treat better-off patients at moderate fees, so that he the shoulders in order to minimise the risk of disloca- could mix with all grades and could obtain some added tion. It is improbable that this procedure can have reward for his labour and reputation. (3) He would the effect of causing fractures. be given full facilities for undergraduate and post Weagree with Dr. Good that there is no essential graduate teaching." With the first and third of these difference between the fits of idiopathic epilepsy and I am in entire agreement; with the second’prothose induced by Cardiazol, although the latter seem foundly disagree.