- Email: [email protected]
NORTH WING
328
quantity; or, alternatively, the amnion has been of poor quality, thin and friable, or unduly thick with adherent corium or meconium. All these types of membranes unsuitable. King George Hospital, Ilford, Essex.
are
E. TROENSEGAARD-HANSEN.
FAMILY PATTERNING AND CHILDHOOD
(3) There should be separate compartments for notes on (a) patients being seen, (b) those awaiting examination, and (c) those already seen. (4) All requirements should be recessed within the desk (examining instruments, stationery forms, X-ray viewing box, dictating machine, &c.). (5) A ’Formica ’-topped slide should be available for injections, inspection of wounds of hand, forearm, &c.
DISORDERS This desk has now been in use for over a year. It was admirable article SIR,-Dr. Apley’s (Jan. 12) clearly made to look like a desk, and by putting fitted boards shows that psychiatry and pxdiatrics have evolved along over the recesses on top it is indistinguishable from a similar pathways. From interest centred upon the child normal desk. When new hospitals are being designed to came interest in the parent, leading on now to interest in meet special needs, the design of a functional consultingthe family background. I was glad that Dr. Apley referred room desk may reasonably be included. to the pioneering work of the clinic in family paediatrics at I am grateful to Mr. P. Fiske for the photograph and to Mr. F. McKenna of Messrs. F. McKenna, 10, Gatehouse, Ditton Road. Harvard, directed by Dr. Haggerty. A further step is possible. From an awareness that the Surbiton, Surrey, who made two of these desks for Heatherwood family background influences the child’s growth and Hospital. Heatherwood Hospital, ROY H. MAUDSLEY. symptoms, it is possible to proceed to the point where the Ascot. itself is as the unit in functional family regarded general CONVULSANT EFFECT OF PENICILLIN medicine or in psychiatry. Within general psychiatry, the of on treats emotional ills a family psychiatry practice SIR,-Further to Dr. Humphries’ letter (Jan. 12), may family basis. Intake clinics, for adults, children, and I point out that the convulsant action of penicillin applied adolescents, provide referral pathways for each member directly to brain tissue or injected intrathecally or into the of the family, but, thereafter, the whole family is regarded cisterna magna or lateral ventricles is quite well known, as the unit for investigation and treatment. and is described by, among others, L. S. Goodman and As child psychiatry and adult psychiatry have been A. Gilman in The Pharmacological Basis of Therapeutics combined in family psychiatry, so paediatrics and adult (second edition, 1955, p. 1349). medicine could combine to establish family medicine. A. E. WILDER SMITH, This would mean the disappearance of paediatrics, it is true. But by combining in this way, we can establish NORTH WING specialists (the family physicians, the family surgeons, and Dr. Lewis (Jan. 19) are to be SIR,-Dr. Dunkley and the family psychiatrists) to support the family doctor, their lucid and enlivening account of who has overall care of the natural functional unit-the congratulated upon North Wing. Experience in a small unit of twelve female family. beds in this hospital mirrors many of their findings. Department of Child and Family Psychiatry, Ipswich and East Suffolk Hospital, Ipswich.
JOHN G. HOWELLS.
A FUNCTIONAL OUTPATIENT DESK
SiR,—The special needs of the clinician have been taken into account in the design of the desk illustrated here. The following requirements were considered: (1) The writing
surface should be in front of the doctor but the whole desk. (2) The X-ray viewing box should be in front of doctor so that he does not have to turn awkwardly to look at a box on the wall, or on another table.
need
not cover
of the most striking and clinically invigorathas been the almost automatic development ing phenomena of a group life. This has had a strong supportive effect on new admissions, who, in states of depression particularly, evoke a feeling of protection and care from patients already getting better. This group identity has also shown, to use an oxymoron, positive-negative complications. Imperceptive, asocial, and over-demanding individuals quickly evoke a painful rejection, often poorly concealed. In a small unit, the In this unit,
one
floridly psychotic patient causes undue alarm unless group support and understanding are consciously sought in advance. Initially, it was found that a relatively high proportion of patients relapsed" in a most discouraging way shortly after discharge, producing many telephone calls from anxious relatives, and so on. This was found to be due to insufficient preparation for a return home from a warm and understanding group atmosphere. In general, all patients are now prepared, initially by indirect suggestion, and in many instances by a day visit and then a weekend at home before discharge. An early follow-up appointment is given, and all patients come, with very little encouragement, to visit the ward staff and their fellow patients. It is possible that some who are about to develop generalhospital units may be intimidated by the presence of 3n inflexible hierarchical system, by the paucity of accommoda"
tion, and by the lack of space for exercise and recreation. All these features (and more) are present here, so for the first an attempt has been made to avoid putting forward sped claims-in fact, to run the unit as any other ward in this hos’ pital of 594 beds. Within its limitations this seems to have been satisfactory, and one is driven to consider whether more time in bed and limited social activity does not intensity the therapeutic process. Boredom certainly has not been a striking problem, but the fact that frequent visiting is possible and encouraged may have a good deal to do with this.
year
329 The North Wing findings that some patients will not accept psychiatric treatment except in the general-hospital unit has been fully confirmed, and the extension of these units is almost certain to provide treatment for individuals now vainly seeking relief by other means, or living in psychological discomfort. This aspect of psychiatry is clinically rewarding, and the nursing staff have a sense of involvement which is clearly and enjoyably apparent. Mayday Hospital, ARTHUR GRAHAM. Warlingham Park Hospital.
UMBILICAL ARTERY FOR TRANSFUSION
SIR,-Professor Wilkinson (Jan. 12) rightly draws attention to the use of the umbilical vein when transfusing infants undergoing neonatal surgery. With a little practice the umbilical arteries are equally easy to cannulate with a 6D Portex catheter and may be a safer route for prolonged fluid replacement. There is evidence that exchange transfusion has on occasions caused portal-vein thrombosis with subsequent cirrhosis.1-3 This is more likely to occur in the presence of infection or if the fluid is perfused through the liver than if the catheter is advanced via the ductus venosus into the right atrium. On the other hand this has the disadvantage of delivering a high concentration of ions directly into the heart.4 Both these problems are avoided by using the umbilical artery and advancing the catheter until it lies in the arch of the aorta. Neonatal blood-pressure is rarely over 80 mms Hg, so the drip-stand does not have to be unduly tall. The blood-flow is towards the periphery, so there is less likelihood of infection being carried from the umbilicus into the circulation.
The drawback of intra-arterial cannulation is the need tie off the vessel when the catheter is removed, and it is wise to dissect out a small length of artery when inserting the catheter. We believe that the umbilical artery is a safe means of obtaining repeated blood samples; that it is essential for determination of O2 saturation in respiratory distressand may be preferable to the umbilical vein for fluid replacement. It has been used on some sixty occasions without, as yet, any untoward sequelx. St. Thomas’ Hospital, DENNIS COTTOM. London, S.E.1.
salaried joint appointment here (as distinct from an honorary consultancy). This should not be unacceptable to the regents, since the university would not be paying for that part of the professor’s time devoted to purely clinical responsibilities. The exceptional opportunities demand that the new professor should be a man of outstanding ability. It would be a very dedicated man indeed who, possessing such ability, would take up this professorship at a stipend below that of a reader elsewhere. M. J. ALLWOOD.
:11::11::11: Our note may have given the misleading impression that the post of junior assistant pathologist to Adenbrooke’s Hospital, which was advertised at the same time as the new professorship, was also to be remunerated at a rate below that prevailing elsewhere. In fact the post of junior assistant pathologist is equivalent to that of senior houseofficer or registrar, and the remuneration offered conforms to the N.H.S. scales for these grades.-ED. L. ROLE OF CHLORIDE IN CORRECTION OF ALKALOSIS ASSOCIATED WITH POTASSIUM DEPLETION
SIR,-In view of the correspondence following the paper by Aber et al.,! we record observations made during the past three years on 4 patients with potassium depletion and raised plasma-bicarbonate levels. In 3 patients arterial-blood pH was also raised and in 1 patient DATA ON
4 CASES OF POTASSIUM DEPLETION AND RAISED PLASMA-
to
BICARBONATE LEVELS
MEDICAL SALARIES AT CAMBRIDGE SiRj—In your note of Jan. 26 you comment on the
exceptional opportunities offered by the new professorship of medicine at Cambridge, while reminding readers that the decision of the regents at Cambridge to discontinue differential payments to medical teachers means that the salary is below the level recommended by the University Grants Committee (and by the B.M.A.). I believe that a solution to the problem of medical salaries at Cambridge may be found in another advertisement appearing on the same page of The Lancet as that for the new professorship. The University of Belfast, advertising for a lecturer in physiology, state that this is a joint appointment with the Hospitals Authority, and that if the lecturer is graded as consultant a higher salary is payable. I have previously advocatedthe adoption of joint university and hospital-authority appointments for medically qualified teachers. As the advertisement for the new Cambridge professorship stipulates that the holder shall take a full share in the clinical work of Addenbrooke’s Hospital there would appear to be a firm basis for a 1. Habif, D. V. Surgery, 1959, 46, 212. 2. Shaldon, S., Sherlock, S. Lancet, 1962, i, 63. 3. Tizard, J. P. M. Proc. R. Soc. Med. 1962, 55, 772. 4. Cochran, W., Love, S. M. S. Lancet, Jan. 26, 1963, p. 220. 5. Warley, M. A., Gairdner, D. Arch. Dis. Childh. 1962, 37, 455. 6. Brit. med. J. 1960, ii, 1881.
it was at the upper limit of normal. The details the accompanying table.
are
in
pH, oxygen, and COz content were measured and calculated. In the remaining 3 cases pC02 p02 pC02 and p02 were measured directly by bubble equilibration and pH was measured with a glass electrode. In
1
case
and
These findings accord with the observation by Aber al. of normal or low pC02 in the presence of extracellular alkalosis. Dr. Polakwondered whether potassium depletion altered " the buffer properties of whole blood in some manner which invalidates the Astrup method of measuring its pC02 ". In our patients pC02 was measured by other methods. A surprising finding is the low p02 in all 4 patients. In case 1 this may have been due to error in estimating p02 from the oxygen-dissociation curves at high saturation and pH. In the other 3 patients, however, p02 was measured directly. Patients 2 and 3 had neoplasms or the bronchus, but in patients 1 and 4 there was no clinical or radiological evidence of lung disease. We have no satisfactory explanation to offer- for this finding. The normal et
1. 2.
Aber, G. M., Sampson, P., Whitehead, T. P., Brooke, 1962, ii, 1028. Polak, A. ibid. p. 1275.
B. N.
Lancet,
quantity; or, alternatively, the amnion has been of poor quality, thin and friable, or unduly thick with adherent corium or meconium. All these types of membranes unsuitable. King George Hospital, Ilford, Essex.
are
E. TROENSEGAARD-HANSEN.
FAMILY PATTERNING AND CHILDHOOD
(3) There should be separate compartments for notes on (a) patients being seen, (b) those awaiting examination, and (c) those already seen. (4) All requirements should be recessed within the desk (examining instruments, stationery forms, X-ray viewing box, dictating machine, &c.). (5) A ’Formica ’-topped slide should be available for injections, inspection of wounds of hand, forearm, &c.
DISORDERS This desk has now been in use for over a year. It was admirable article SIR,-Dr. Apley’s (Jan. 12) clearly made to look like a desk, and by putting fitted boards shows that psychiatry and pxdiatrics have evolved along over the recesses on top it is indistinguishable from a similar pathways. From interest centred upon the child normal desk. When new hospitals are being designed to came interest in the parent, leading on now to interest in meet special needs, the design of a functional consultingthe family background. I was glad that Dr. Apley referred room desk may reasonably be included. to the pioneering work of the clinic in family paediatrics at I am grateful to Mr. P. Fiske for the photograph and to Mr. F. McKenna of Messrs. F. McKenna, 10, Gatehouse, Ditton Road. Harvard, directed by Dr. Haggerty. A further step is possible. From an awareness that the Surbiton, Surrey, who made two of these desks for Heatherwood family background influences the child’s growth and Hospital. Heatherwood Hospital, ROY H. MAUDSLEY. symptoms, it is possible to proceed to the point where the Ascot. itself is as the unit in functional family regarded general CONVULSANT EFFECT OF PENICILLIN medicine or in psychiatry. Within general psychiatry, the of on treats emotional ills a family psychiatry practice SIR,-Further to Dr. Humphries’ letter (Jan. 12), may family basis. Intake clinics, for adults, children, and I point out that the convulsant action of penicillin applied adolescents, provide referral pathways for each member directly to brain tissue or injected intrathecally or into the of the family, but, thereafter, the whole family is regarded cisterna magna or lateral ventricles is quite well known, as the unit for investigation and treatment. and is described by, among others, L. S. Goodman and As child psychiatry and adult psychiatry have been A. Gilman in The Pharmacological Basis of Therapeutics combined in family psychiatry, so paediatrics and adult (second edition, 1955, p. 1349). medicine could combine to establish family medicine. A. E. WILDER SMITH, This would mean the disappearance of paediatrics, it is true. But by combining in this way, we can establish NORTH WING specialists (the family physicians, the family surgeons, and Dr. Lewis (Jan. 19) are to be SIR,-Dr. Dunkley and the family psychiatrists) to support the family doctor, their lucid and enlivening account of who has overall care of the natural functional unit-the congratulated upon North Wing. Experience in a small unit of twelve female family. beds in this hospital mirrors many of their findings. Department of Child and Family Psychiatry, Ipswich and East Suffolk Hospital, Ipswich.
JOHN G. HOWELLS.
A FUNCTIONAL OUTPATIENT DESK
SiR,—The special needs of the clinician have been taken into account in the design of the desk illustrated here. The following requirements were considered: (1) The writing
surface should be in front of the doctor but the whole desk. (2) The X-ray viewing box should be in front of doctor so that he does not have to turn awkwardly to look at a box on the wall, or on another table.
need
not cover
of the most striking and clinically invigorathas been the almost automatic development ing phenomena of a group life. This has had a strong supportive effect on new admissions, who, in states of depression particularly, evoke a feeling of protection and care from patients already getting better. This group identity has also shown, to use an oxymoron, positive-negative complications. Imperceptive, asocial, and over-demanding individuals quickly evoke a painful rejection, often poorly concealed. In a small unit, the In this unit,
one
floridly psychotic patient causes undue alarm unless group support and understanding are consciously sought in advance. Initially, it was found that a relatively high proportion of patients relapsed" in a most discouraging way shortly after discharge, producing many telephone calls from anxious relatives, and so on. This was found to be due to insufficient preparation for a return home from a warm and understanding group atmosphere. In general, all patients are now prepared, initially by indirect suggestion, and in many instances by a day visit and then a weekend at home before discharge. An early follow-up appointment is given, and all patients come, with very little encouragement, to visit the ward staff and their fellow patients. It is possible that some who are about to develop generalhospital units may be intimidated by the presence of 3n inflexible hierarchical system, by the paucity of accommoda"
tion, and by the lack of space for exercise and recreation. All these features (and more) are present here, so for the first an attempt has been made to avoid putting forward sped claims-in fact, to run the unit as any other ward in this hos’ pital of 594 beds. Within its limitations this seems to have been satisfactory, and one is driven to consider whether more time in bed and limited social activity does not intensity the therapeutic process. Boredom certainly has not been a striking problem, but the fact that frequent visiting is possible and encouraged may have a good deal to do with this.
year
329 The North Wing findings that some patients will not accept psychiatric treatment except in the general-hospital unit has been fully confirmed, and the extension of these units is almost certain to provide treatment for individuals now vainly seeking relief by other means, or living in psychological discomfort. This aspect of psychiatry is clinically rewarding, and the nursing staff have a sense of involvement which is clearly and enjoyably apparent. Mayday Hospital, ARTHUR GRAHAM. Warlingham Park Hospital.
UMBILICAL ARTERY FOR TRANSFUSION
SIR,-Professor Wilkinson (Jan. 12) rightly draws attention to the use of the umbilical vein when transfusing infants undergoing neonatal surgery. With a little practice the umbilical arteries are equally easy to cannulate with a 6D Portex catheter and may be a safer route for prolonged fluid replacement. There is evidence that exchange transfusion has on occasions caused portal-vein thrombosis with subsequent cirrhosis.1-3 This is more likely to occur in the presence of infection or if the fluid is perfused through the liver than if the catheter is advanced via the ductus venosus into the right atrium. On the other hand this has the disadvantage of delivering a high concentration of ions directly into the heart.4 Both these problems are avoided by using the umbilical artery and advancing the catheter until it lies in the arch of the aorta. Neonatal blood-pressure is rarely over 80 mms Hg, so the drip-stand does not have to be unduly tall. The blood-flow is towards the periphery, so there is less likelihood of infection being carried from the umbilicus into the circulation.
The drawback of intra-arterial cannulation is the need tie off the vessel when the catheter is removed, and it is wise to dissect out a small length of artery when inserting the catheter. We believe that the umbilical artery is a safe means of obtaining repeated blood samples; that it is essential for determination of O2 saturation in respiratory distressand may be preferable to the umbilical vein for fluid replacement. It has been used on some sixty occasions without, as yet, any untoward sequelx. St. Thomas’ Hospital, DENNIS COTTOM. London, S.E.1.
salaried joint appointment here (as distinct from an honorary consultancy). This should not be unacceptable to the regents, since the university would not be paying for that part of the professor’s time devoted to purely clinical responsibilities. The exceptional opportunities demand that the new professor should be a man of outstanding ability. It would be a very dedicated man indeed who, possessing such ability, would take up this professorship at a stipend below that of a reader elsewhere. M. J. ALLWOOD.
:11::11::11: Our note may have given the misleading impression that the post of junior assistant pathologist to Adenbrooke’s Hospital, which was advertised at the same time as the new professorship, was also to be remunerated at a rate below that prevailing elsewhere. In fact the post of junior assistant pathologist is equivalent to that of senior houseofficer or registrar, and the remuneration offered conforms to the N.H.S. scales for these grades.-ED. L. ROLE OF CHLORIDE IN CORRECTION OF ALKALOSIS ASSOCIATED WITH POTASSIUM DEPLETION
SIR,-In view of the correspondence following the paper by Aber et al.,! we record observations made during the past three years on 4 patients with potassium depletion and raised plasma-bicarbonate levels. In 3 patients arterial-blood pH was also raised and in 1 patient DATA ON
4 CASES OF POTASSIUM DEPLETION AND RAISED PLASMA-
to
BICARBONATE LEVELS
MEDICAL SALARIES AT CAMBRIDGE SiRj—In your note of Jan. 26 you comment on the
exceptional opportunities offered by the new professorship of medicine at Cambridge, while reminding readers that the decision of the regents at Cambridge to discontinue differential payments to medical teachers means that the salary is below the level recommended by the University Grants Committee (and by the B.M.A.). I believe that a solution to the problem of medical salaries at Cambridge may be found in another advertisement appearing on the same page of The Lancet as that for the new professorship. The University of Belfast, advertising for a lecturer in physiology, state that this is a joint appointment with the Hospitals Authority, and that if the lecturer is graded as consultant a higher salary is payable. I have previously advocatedthe adoption of joint university and hospital-authority appointments for medically qualified teachers. As the advertisement for the new Cambridge professorship stipulates that the holder shall take a full share in the clinical work of Addenbrooke’s Hospital there would appear to be a firm basis for a 1. Habif, D. V. Surgery, 1959, 46, 212. 2. Shaldon, S., Sherlock, S. Lancet, 1962, i, 63. 3. Tizard, J. P. M. Proc. R. Soc. Med. 1962, 55, 772. 4. Cochran, W., Love, S. M. S. Lancet, Jan. 26, 1963, p. 220. 5. Warley, M. A., Gairdner, D. Arch. Dis. Childh. 1962, 37, 455. 6. Brit. med. J. 1960, ii, 1881.
it was at the upper limit of normal. The details the accompanying table.
are
in
pH, oxygen, and COz content were measured and calculated. In the remaining 3 cases pC02 p02 pC02 and p02 were measured directly by bubble equilibration and pH was measured with a glass electrode. In
1
case
and
These findings accord with the observation by Aber al. of normal or low pC02 in the presence of extracellular alkalosis. Dr. Polakwondered whether potassium depletion altered " the buffer properties of whole blood in some manner which invalidates the Astrup method of measuring its pC02 ". In our patients pC02 was measured by other methods. A surprising finding is the low p02 in all 4 patients. In case 1 this may have been due to error in estimating p02 from the oxygen-dissociation curves at high saturation and pH. In the other 3 patients, however, p02 was measured directly. Patients 2 and 3 had neoplasms or the bronchus, but in patients 1 and 4 there was no clinical or radiological evidence of lung disease. We have no satisfactory explanation to offer- for this finding. The normal et
1. 2.
Aber, G. M., Sampson, P., Whitehead, T. P., Brooke, 1962, ii, 1028. Polak, A. ibid. p. 1275.
B. N.
Lancet,