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INTEGRATION OF PSYCHIATRIC SERVICES TO AN URBAN COMMUNITY
221
repeated doses of suxamethonium to infants. What we question, as have others,14-16 is the indiscriminate use of atropine. Dr. Buxton Hopkin may be right in deciding to continue to use atropine routinely for premedication, but he will need stronger arguments than those he has produced to justify it. Research Department of Anæsthetics, Royal College of Surgeons of England.
Department of Anæsthetics, Postgraduate Medical School, London, W.12.
J. P. PAYNE. C. M. CONWAY
P. J. TOMLIN.
RENAL AND RESPIRATORY FAILURE AFTER TRAUMA
SIR,-The importance of vigorous anti-shock measures, including transfusion, in the early stages after injury is rightly stressed by Dr. L. J. Wolfson and Mr. J. H. Hicks (Jan. 11), and we would agree that such a policy substantially reduces the subsequent incidence of acute renal failure; but cases of renal failure after injury, and after other causes of acute blood-loss and shock, still occur either because the patient is not seen at an early enough stage, as in our case, or sometimes even despite the prompt institution of such measures. This is clear from reports from many artificial-kidney centres, in this country and
elsewhere, and the purpose of our paper was to emphasise the type of problems encountered when the renal failure is extremely severe and when it is associated with respiratnrv
failure_
The
Royal Infirmary,
Glasgow.
A. C. KENNEDY D. CAMPBELL R. G. LUKE.
INTEGRATION OF PSYCHIATRIC SERVICES TO AN URBAN COMMUNITY SIR,-Dr. Little’s plan 1’ introduces a new concept into psychiatry and perhaps into medicine in general-doctors should look after only those they can cure. In psychiatry this leaves a group of formidable size which is apparently to be unworthy of the psychiatrist’s attention, except perhaps for occasional visits to the medium-stay unit which he suggests. It is, of course, embarrassing to have to continue to see patients one has failed to cure, and very comforting to have somewhere to send them where one may see them infrequently, if at all. The phrase " Out of mind, out of sight " applied, one thought, to the past era of psychiatry. Dr. Little has elevated it to the status of a watchword for the future. In the description of the work done in the psychiatric unit at St. James’s Hospital, Leeds, the impression is given that this unit is responsible for the bulk of, if not all, the psychiatric work done in the city. In fact, the effect of the operation of this unit in its first year was that the number of patients admitted to psychiatric hospitals serving the city was more than doubled. I have just obtained the figures for 1963 of those patients admitted to the various hospitals and units serving Leeds, in whose admission the mental-welfare officers were concerned. It will, I think, be agreed that these must constitute the most acute and most serious of the cases of mental illness: ’
informal admissions) It will be seen, therefore, that almost two-thirds of this type of case were admitted not to the psychiatric unit at St. Tames’s, 14. 15.
Vandam, L. D. Surv. Anesth. 1960, 4, 143. Eger, E. I. Anesthesiology, 1962, 21, 363. 16. Ruben, H. Surv. Anesth. 1961, 5, 473. 17. Little, J. C. Lancet, 1963, ii, 1159.
but to the psychiatric hospitals serving the city. This does not take into account the many cases admitted directly to these hospitals without the intervention of the mental-welfare officers.
Since Dr. Little bases his service for the future on experience in Leeds-experience which seems to ignore almost two-thirds of the problem-it is difficult to escape the conclusion that this plan is unrealistic. Before any estimate of the efficiency of psychiatric units in general hospitals can be made, it seems to me essential that at least one, for experimental purposes, should be given a catchment area related to its size and made to assume complete and continuing responsibility for every type of mental disorder occurring in that area. Only in this way can it be shown whether the psychiatric services of the future can be effectively centred on such units. High Royds Hospital, Menston, Ilkley, Yorkshire.
CEREBRAL
R. MCDONALD.
INJURY FOLLOWING CARDIAC OPERATIONS
SzR3 Your leader of Jan. 11suggests that cerebral damage after cardiac surgery " might possibly " be caused by cerebral vasospasm of the smaller arteries, thus accounting for the " geographical lesions described by Dr. J. B. Brierley. There is good evidence that cerebral vasospasm is a marked feature when cold blood is perfused into the brain, unless special steps are taken to prevent this. 12 Local hypothermia by intracarotid cooling in both dog and man allows the increase in resistance to be studied, and it is found that the resistance falls again as "
the brain becomes cold.
The rise in resistance may be prevented by adding CO2 the anxsthetic gases, and also by the use of ganglion-blocking agents such as trimetaphan1 or halothane. The cause of the spasm is unclear, but Drew and Kristiansen (personal communication) have to
COMPARATIVE FLOW-RATES AS RECORDED BY THE REVOLUTION COUNTER
expressed the belief that rapidity of cooling is dangera fall in partial pressure of or to cold may be responsible. a direct C023 response
both
ous, and this suggests that
I have not been able to find any evidence of 5-H.T. release in perfused blood, which has been suggested as a cause.4 " Sludging of blood elements, which has been directly observed during profound hypothermia,5 is most probably a contributory cause of poor flow, and I have found that low-molecular-weight dextran (’ Rheomacrodex ’), when used to prime the extracorporeal circuit, is more effective than antispasmodics in maintaining a high flow-rate during cerebral hypothermia in dogs. The table shows the mean flow-rates produced through the commoncarotid artery by perfusion at constant pressures, using cold blood in 66 dogs. The pressure used was determined "
1. 2. 3. 4. 5.
Lund, I., Johansen, K., Krog, J., Birkeland, S. Acta anœsth. scand. 1958, 2, 149. Williams, B. N. Acta neurochir. (in the press). Marshall, R., Gunning, A. J. J. surg. Res. 1962, 3, 54. Hollenberg, M. D. J. thorac. cardiovasc. Surg. 1963, 45, 403. Nielsen, K. C. Acta med. scand. 1961, 170, 775.
repeated doses of suxamethonium to infants. What we question, as have others,14-16 is the indiscriminate use of atropine. Dr. Buxton Hopkin may be right in deciding to continue to use atropine routinely for premedication, but he will need stronger arguments than those he has produced to justify it. Research Department of Anæsthetics, Royal College of Surgeons of England.
Department of Anæsthetics, Postgraduate Medical School, London, W.12.
J. P. PAYNE. C. M. CONWAY
P. J. TOMLIN.
RENAL AND RESPIRATORY FAILURE AFTER TRAUMA
SIR,-The importance of vigorous anti-shock measures, including transfusion, in the early stages after injury is rightly stressed by Dr. L. J. Wolfson and Mr. J. H. Hicks (Jan. 11), and we would agree that such a policy substantially reduces the subsequent incidence of acute renal failure; but cases of renal failure after injury, and after other causes of acute blood-loss and shock, still occur either because the patient is not seen at an early enough stage, as in our case, or sometimes even despite the prompt institution of such measures. This is clear from reports from many artificial-kidney centres, in this country and
elsewhere, and the purpose of our paper was to emphasise the type of problems encountered when the renal failure is extremely severe and when it is associated with respiratnrv
failure_
The
Royal Infirmary,
Glasgow.
A. C. KENNEDY D. CAMPBELL R. G. LUKE.
INTEGRATION OF PSYCHIATRIC SERVICES TO AN URBAN COMMUNITY SIR,-Dr. Little’s plan 1’ introduces a new concept into psychiatry and perhaps into medicine in general-doctors should look after only those they can cure. In psychiatry this leaves a group of formidable size which is apparently to be unworthy of the psychiatrist’s attention, except perhaps for occasional visits to the medium-stay unit which he suggests. It is, of course, embarrassing to have to continue to see patients one has failed to cure, and very comforting to have somewhere to send them where one may see them infrequently, if at all. The phrase " Out of mind, out of sight " applied, one thought, to the past era of psychiatry. Dr. Little has elevated it to the status of a watchword for the future. In the description of the work done in the psychiatric unit at St. James’s Hospital, Leeds, the impression is given that this unit is responsible for the bulk of, if not all, the psychiatric work done in the city. In fact, the effect of the operation of this unit in its first year was that the number of patients admitted to psychiatric hospitals serving the city was more than doubled. I have just obtained the figures for 1963 of those patients admitted to the various hospitals and units serving Leeds, in whose admission the mental-welfare officers were concerned. It will, I think, be agreed that these must constitute the most acute and most serious of the cases of mental illness: ’
informal admissions) It will be seen, therefore, that almost two-thirds of this type of case were admitted not to the psychiatric unit at St. Tames’s, 14. 15.
Vandam, L. D. Surv. Anesth. 1960, 4, 143. Eger, E. I. Anesthesiology, 1962, 21, 363. 16. Ruben, H. Surv. Anesth. 1961, 5, 473. 17. Little, J. C. Lancet, 1963, ii, 1159.
but to the psychiatric hospitals serving the city. This does not take into account the many cases admitted directly to these hospitals without the intervention of the mental-welfare officers.
Since Dr. Little bases his service for the future on experience in Leeds-experience which seems to ignore almost two-thirds of the problem-it is difficult to escape the conclusion that this plan is unrealistic. Before any estimate of the efficiency of psychiatric units in general hospitals can be made, it seems to me essential that at least one, for experimental purposes, should be given a catchment area related to its size and made to assume complete and continuing responsibility for every type of mental disorder occurring in that area. Only in this way can it be shown whether the psychiatric services of the future can be effectively centred on such units. High Royds Hospital, Menston, Ilkley, Yorkshire.
CEREBRAL
R. MCDONALD.
INJURY FOLLOWING CARDIAC OPERATIONS
SzR3 Your leader of Jan. 11suggests that cerebral damage after cardiac surgery " might possibly " be caused by cerebral vasospasm of the smaller arteries, thus accounting for the " geographical lesions described by Dr. J. B. Brierley. There is good evidence that cerebral vasospasm is a marked feature when cold blood is perfused into the brain, unless special steps are taken to prevent this. 12 Local hypothermia by intracarotid cooling in both dog and man allows the increase in resistance to be studied, and it is found that the resistance falls again as "
the brain becomes cold.
The rise in resistance may be prevented by adding CO2 the anxsthetic gases, and also by the use of ganglion-blocking agents such as trimetaphan1 or halothane. The cause of the spasm is unclear, but Drew and Kristiansen (personal communication) have to
COMPARATIVE FLOW-RATES AS RECORDED BY THE REVOLUTION COUNTER
expressed the belief that rapidity of cooling is dangera fall in partial pressure of or to cold may be responsible. a direct C023 response
both
ous, and this suggests that
I have not been able to find any evidence of 5-H.T. release in perfused blood, which has been suggested as a cause.4 " Sludging of blood elements, which has been directly observed during profound hypothermia,5 is most probably a contributory cause of poor flow, and I have found that low-molecular-weight dextran (’ Rheomacrodex ’), when used to prime the extracorporeal circuit, is more effective than antispasmodics in maintaining a high flow-rate during cerebral hypothermia in dogs. The table shows the mean flow-rates produced through the commoncarotid artery by perfusion at constant pressures, using cold blood in 66 dogs. The pressure used was determined "
1. 2. 3. 4. 5.
Lund, I., Johansen, K., Krog, J., Birkeland, S. Acta anœsth. scand. 1958, 2, 149. Williams, B. N. Acta neurochir. (in the press). Marshall, R., Gunning, A. J. J. surg. Res. 1962, 3, 54. Hollenberg, M. D. J. thorac. cardiovasc. Surg. 1963, 45, 403. Nielsen, K. C. Acta med. scand. 1961, 170, 775.