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INCREASED ADRENOCORTICAL ACTIVITY AND MALIGNANT DISEASE
434 DISPOSABLE UNDERPADS FOR INCONTINENT PATIENTS NURSED AT HOME
SIR,-Dr. Roberts and Miss Mann (July 23) discuss disposable underpads for incontinent patients nursed at home, and suggest the use of those obtained from Johnson & Johnson. May I describe my own experience with them ? My invalided mother was the patient. First there is no adequate material to take care of faecal incontinence, provided the stool is not diarrhoeic. Fasces cling to anus, buttocks, and pad. As for urinary incontinence, Johnson & Johnson underpads will take care of dribbling, but cannot sop up the massive gush. urine on to the bed sheets.
The result is
an
overflow of
Trial and error produced what proved to be a satisfactory device. Several layers of ’Cellucotton ’, totalling about 3 in. in thickness, are enclosed in a continuous sheet of paper towelling. The latter holds the absorbent material together when wet by urine. The pad, thus enclosed, rests on many thicknesses of newspaper beneath which is a plastic sheet of somewhat larger dimensions to keep the bed sheet dry. When the wet pad is to be removed, the patient is turned as when changing the bed linen. The plastic sheet is wiped clean and dried, and a new pad placed in position. Almost 2 years of use Droved the efficacv of the method. S. M. RABSON. Los Angeles. INCREASED ADRENOCORTICAL ACTIVITY AND MALIGNANT DISEASE
SIR,-We were interested to read the papers in your issue of Aug. 6 by Dr. Allott and Dr. Skelton and by Dr. Bagshawe concerning increased adrenocortical activity in association with malignant disease. It appears that in only one patient so far has increased aldosterone excretion been demonstrated. We should like to add a further case recently seen in which a raised aldosterone excretion was associated with neoplasm of pancreatic islet tissue. A 47-year-old male presented with oedema of the feet and mild generalised pigmentation. He subsequently developed diabetes mellitus but none of the other classical features of Cushing’s syndrome. After the finding of hypochloraemic alkalosis and a serum-potassium of 1 -5 mEq. per litre the aldosterone output was measured and found to be 16 g. per 24 hours (upper limit of normal, 6 jjLg. per 24 hours; estimation by Dr. B. Singer, method of Neher and Wettstein 1956). His 17-ketosteroid excretion was 59 mg. per 24 hours and 17hydroxycorticosteroid excretion was 134 mg. per 24 hours. Death occurred within three months of the onset of the illness and was accelerated by the development of multiple abscesses, later found to contain a fungus. The primary growth was an islet-cell carcinoma of the pancreas. The adrenal glands were both enlarged but contained no secondary deposits. Royal Hospital, Sheffield. Children’s Hospital, Birmingham.
P. C. FARRANT.
J. INSLEY.
ARTIFICIAL INSEMINATION SiR,ňIn your leading article of July 30 you state " donor insemination and adultery are poles apart; but... as in adultery, the wife receives the seed of a man other
than her husband ". This surely is the theological argument against A.I.D. in a nutshell. The techniques may be new, but the theological attitude can hardly change with the times, as you hope, without cutting at the roots of Christian morality. The physical or emotional reactions of the woman concerned are beside the point, whether she commits adultery in the normal way, or whether she stifles her repugnance at receiving the spermatozoa of a total stranger by means of A.I.D. To make my point clear, may I put it in another way ?
Like G. K. Chesterton, I find quite incomprehensible Those who do not have the Faith, and will not have the fun ". It comes to the same thing in the end. "
Hale,
AUDREY F. ROBERTS.
Cheshire.
PAY INCREASE TO MEDICAL SUPERINTENDENTS
SIR,-The offer of more money for the medical superintendent is a retrograde move if it is designed to coax the best bedside (or couchside) psychiatric clinicians into the administrative office chair. Administration is not all that difficult and esoteric. The way of it-to satisfy the needs of the led--can be learned. If medical administration there must be, then this should take the form of a shared consultative duty taken in rotation by senior medical colleagues for a few years at a time without additional payment as a social obligation. The offer of more money for the administrator at this time is paradoxical, as under the new Mental Health Act the medical superintendent will have less responsibility. The Royal Commission contained business experts accustomed to be generous in the recognition of administrative service. Whether as an assessment of the value of the medical " superintendents’ added responsibility or as a golden handshake " the extra E250 awarded can only be regarded as a
derisory
comment.
Luckily, the appointment of future medical superintendents is to become discretionary. Abolition of the post will bring back from the office into the wards and clinics at least a hundred badly needed full-time senior clinicians -a third of the total consultant psychiatric strength in the mental hospitals. Deva
Hospital,
Chester.
I. FROST.
EXTENSIVE VENOUS THROMBOSIS AFTER USE OF HYPERTONIC UREA
SIR,-In his letter of June 4, Mr. Small described local tissue necrosis following the use of hypertonic urea. Recently hypertonic urea was given to a patient undergoing a craniotomy for a cerebral tumour. Before operation, the patient was comatose and had a right hemiplegia. There were few veins available but an intravenous infusion was started in the right foot where there was a reasonably good vein. After the dura had been reflected, an infusion of hypertonic urea was started. When 150 ml. had been run in, it was noticed that two veins proximal to the infusion site had become reddened. Soon the surrounding local area of skin became purplish and blotchy. The infusion of hypertonic urea was stopped and saline was injected through the needle. Within half an hour the whole leg and foot had become bluish. The dorsalis pedis artery was palpable and remained so. It was obvious that an extensive spasm or thrombosis of the leg veins had occurred. The condition was treated with intraarterial tolazoline and two lumbar sympathetic blocks with some improvement. The circulation slowly improved but on the following day the patient had a small pulmonary embolus. As the swelling did not extend beyond the ankle, the right superficial femoral vein was explored. It contained a fresh clot. After opening it and removing the thrombus, satisfactory back flow was not obtained until an area probably as far proximal as the inferior vena cava had been cleared. The femoral vein was ligated. The patient’s condition continued to improve during the next few days.
In this
there was no extravenous leakage of and there was a satisfactory reduction of hypertonic urea, intracranial pressure. There have been reports of local venous thrombosis but it does seem worth reporting this case in view of the case
SIR,-Dr. Roberts and Miss Mann (July 23) discuss disposable underpads for incontinent patients nursed at home, and suggest the use of those obtained from Johnson & Johnson. May I describe my own experience with them ? My invalided mother was the patient. First there is no adequate material to take care of faecal incontinence, provided the stool is not diarrhoeic. Fasces cling to anus, buttocks, and pad. As for urinary incontinence, Johnson & Johnson underpads will take care of dribbling, but cannot sop up the massive gush. urine on to the bed sheets.
The result is
an
overflow of
Trial and error produced what proved to be a satisfactory device. Several layers of ’Cellucotton ’, totalling about 3 in. in thickness, are enclosed in a continuous sheet of paper towelling. The latter holds the absorbent material together when wet by urine. The pad, thus enclosed, rests on many thicknesses of newspaper beneath which is a plastic sheet of somewhat larger dimensions to keep the bed sheet dry. When the wet pad is to be removed, the patient is turned as when changing the bed linen. The plastic sheet is wiped clean and dried, and a new pad placed in position. Almost 2 years of use Droved the efficacv of the method. S. M. RABSON. Los Angeles. INCREASED ADRENOCORTICAL ACTIVITY AND MALIGNANT DISEASE
SIR,-We were interested to read the papers in your issue of Aug. 6 by Dr. Allott and Dr. Skelton and by Dr. Bagshawe concerning increased adrenocortical activity in association with malignant disease. It appears that in only one patient so far has increased aldosterone excretion been demonstrated. We should like to add a further case recently seen in which a raised aldosterone excretion was associated with neoplasm of pancreatic islet tissue. A 47-year-old male presented with oedema of the feet and mild generalised pigmentation. He subsequently developed diabetes mellitus but none of the other classical features of Cushing’s syndrome. After the finding of hypochloraemic alkalosis and a serum-potassium of 1 -5 mEq. per litre the aldosterone output was measured and found to be 16 g. per 24 hours (upper limit of normal, 6 jjLg. per 24 hours; estimation by Dr. B. Singer, method of Neher and Wettstein 1956). His 17-ketosteroid excretion was 59 mg. per 24 hours and 17hydroxycorticosteroid excretion was 134 mg. per 24 hours. Death occurred within three months of the onset of the illness and was accelerated by the development of multiple abscesses, later found to contain a fungus. The primary growth was an islet-cell carcinoma of the pancreas. The adrenal glands were both enlarged but contained no secondary deposits. Royal Hospital, Sheffield. Children’s Hospital, Birmingham.
P. C. FARRANT.
J. INSLEY.
ARTIFICIAL INSEMINATION SiR,ňIn your leading article of July 30 you state " donor insemination and adultery are poles apart; but... as in adultery, the wife receives the seed of a man other
than her husband ". This surely is the theological argument against A.I.D. in a nutshell. The techniques may be new, but the theological attitude can hardly change with the times, as you hope, without cutting at the roots of Christian morality. The physical or emotional reactions of the woman concerned are beside the point, whether she commits adultery in the normal way, or whether she stifles her repugnance at receiving the spermatozoa of a total stranger by means of A.I.D. To make my point clear, may I put it in another way ?
Like G. K. Chesterton, I find quite incomprehensible Those who do not have the Faith, and will not have the fun ". It comes to the same thing in the end. "
Hale,
AUDREY F. ROBERTS.
Cheshire.
PAY INCREASE TO MEDICAL SUPERINTENDENTS
SIR,-The offer of more money for the medical superintendent is a retrograde move if it is designed to coax the best bedside (or couchside) psychiatric clinicians into the administrative office chair. Administration is not all that difficult and esoteric. The way of it-to satisfy the needs of the led--can be learned. If medical administration there must be, then this should take the form of a shared consultative duty taken in rotation by senior medical colleagues for a few years at a time without additional payment as a social obligation. The offer of more money for the administrator at this time is paradoxical, as under the new Mental Health Act the medical superintendent will have less responsibility. The Royal Commission contained business experts accustomed to be generous in the recognition of administrative service. Whether as an assessment of the value of the medical " superintendents’ added responsibility or as a golden handshake " the extra E250 awarded can only be regarded as a
derisory
comment.
Luckily, the appointment of future medical superintendents is to become discretionary. Abolition of the post will bring back from the office into the wards and clinics at least a hundred badly needed full-time senior clinicians -a third of the total consultant psychiatric strength in the mental hospitals. Deva
Hospital,
Chester.
I. FROST.
EXTENSIVE VENOUS THROMBOSIS AFTER USE OF HYPERTONIC UREA
SIR,-In his letter of June 4, Mr. Small described local tissue necrosis following the use of hypertonic urea. Recently hypertonic urea was given to a patient undergoing a craniotomy for a cerebral tumour. Before operation, the patient was comatose and had a right hemiplegia. There were few veins available but an intravenous infusion was started in the right foot where there was a reasonably good vein. After the dura had been reflected, an infusion of hypertonic urea was started. When 150 ml. had been run in, it was noticed that two veins proximal to the infusion site had become reddened. Soon the surrounding local area of skin became purplish and blotchy. The infusion of hypertonic urea was stopped and saline was injected through the needle. Within half an hour the whole leg and foot had become bluish. The dorsalis pedis artery was palpable and remained so. It was obvious that an extensive spasm or thrombosis of the leg veins had occurred. The condition was treated with intraarterial tolazoline and two lumbar sympathetic blocks with some improvement. The circulation slowly improved but on the following day the patient had a small pulmonary embolus. As the swelling did not extend beyond the ankle, the right superficial femoral vein was explored. It contained a fresh clot. After opening it and removing the thrombus, satisfactory back flow was not obtained until an area probably as far proximal as the inferior vena cava had been cleared. The femoral vein was ligated. The patient’s condition continued to improve during the next few days.
In this
there was no extravenous leakage of and there was a satisfactory reduction of hypertonic urea, intracranial pressure. There have been reports of local venous thrombosis but it does seem worth reporting this case in view of the case