- Email: [email protected]
PAIN
198 PREVENTION OF PNEUMOCONIOSIS
SiR,-After perusing recent articles on pneumoconiosis one is again lost in wonder that no mention is made of the simple and sure means of prevention and protection-the use of a small light pad over the nose and mouth, as worn by nurses in the operating-theatre and children’s wards. The pads are, of course, merely some six folds of butter-muslin or gauze, with tapes to tie behind the head, and could be provided in unlimited quantities, to be discarded after use. By all means let us diminish or eliminate, as far as possible, the creation of dust and grit in trade processes and mining ; but surely real prevention of anthracosis, silicosis, or any form of pneumoconiosis can only be obtained by providing exposed workers with a shield which will prevent any dust particles from gaining access to the respiratory system. The director of the Pneumokoniosis Research Unit states that pneumoconiosis is a preventable disease, and calls for imperative administrative action. Is it too much to hope that such action might be directed towards preventing the condition, by the simple expedient suggested, rather than towards setting up a costly organisation to deal with the crippling and often fatal after-effects ?
LEONARD HEARN Senior Tuberculosis Officer Notts C.C.
Nottingham.
to the skin of the lower abdominal wall, the formation of a stitch abscess resulted in infection of the entire scrotal
cavity. I am indebted illustrations.
to
Miss Barbara NORMAN
Some of your readers may be interested in a simple bandaging procedure which I have used, with invariable success, during the past five or six years in all cases involving extensive separation of the cord and testicle from the scrotal wall. At the close of the operation the incision is dressed, and the dependent part of the scrotum is picked up by an assistant A strip of elastic adhesive between finger and thumb.
1%.
Fig.I
Fig. 2
bandage about 11/2 in. wide and about 12 in. long is wound spiral fashion around the scrotum from apex to base, obliterating the scrotal cavity by light and even compression (fig. 1),and so rendering the formation of a haematoma The testes are thereby displaced virtually impossible. towards the external inguinal rings. The spiral bandage must be retained in position by a strip of elastic adhesive bandage of similar dimensions extending from the perineum over the scrotum to the anterior abdominal wall (fig. 2). After three or four days the strapping may be released and a simple support substituted. The testicles soon regain
in
their normal
position.
For Other methods have not proved satisfactory. example, in one case in which the scrotum was stitched
for
the
GIBBON
Registrar to the surgical professorial unit. Department of Surgery, University of Liverpool.
SIR,-The admirable article (July 10) by Moloney and his colleagues on the nylon darn for hernia revives an old method in a new look. Thirty years ago Sampson Handleydescribed his darn and stay-lace method for the radical cure of inguinal hernia. As one of his surgical dressers I saw many of his cases, and the results were excellent. The material used was silk, and whilst there was occasional trouble from infection it was found that this could be avoided by soaking the silk in flavine, 1 in 1000, before use. The principles of the operation were the same as those now advocated-the avoidance ,of tension and of the displacement of normal structures. The darn was used to strengthen the external oblique which Handley contended was often stretched and split, and for which no provision is made in the present operation. The deeper layer of the darn in Moloney’s operation was the stay-lace in Handley’s and the latter seems a more appropriate name for it ; perhaps staylaces are no longer in fashion in the new look. E. W. RICHES. London, W.1.
OPERATIONS FOR HERNIA
Sin,-In reading the interesting article of Moloney, Gill, and Barclay in your issue of July 10, I am reminded by their report of scrotal hsematoma in 2 of the 230 cases discussed that this serious complication, with the almost inevitable sequel of infection, has not yet been eliminated from even the best of surgical practice.
Duckworth
PAIN
SIR,—In his interesting paper published on July 3. Dr. Keele rightly emphasised the value of pain as an aid to diagnosis, and in particular, he drew attention to the help which may be gained from consideration of It is agreed that in such the time-intensity curve. conditions as angina pectoris, duodenal ulcer, thromboangiitis obliterans, and some forms of sinusitis the information thus obtained is often enough to enable a positive diagnosis to be made. Dr. Keele’s views on what he terms " psychogenic pain " may not, however, gain the same ready acceptance. The term " psychogenic pain " is a bad one, loosely applied, as it often is, to a multiplicity of conditions in which the diagnosis may be obscure. Further, every pain is ina sense at least partly psychogenic, in that it is a psychosomatic experience, the reaction to which is determined not merely by the nature and severity of the pain but by all the related circumstances and in particular by the general2 make-up of the individual concerned. As Leriche has remarked, " Physical pain is not a simple fact of nervous impulses travelling over a nerve at a predetermined gait. It is the resultant of the conflict between the stimulus and the individual." Generally speaking, pain is not a prominent feature of purely neurotic states. The hysterical individual, free from organic disease, who proclaims the agony of his pains in extravagant terms can hardly be regarded as suffering from pain in the generally accepted sense of the term when one views the happy mien of his coun" tenance, or considers " la belle indifference with which he accepts his misfortunes. In the anxiety states, a local cause for pains can generally be discovered : headaches may be due to subconsciously maintained, persistent scalp contraction ; the low backache of many neurotic women is only what one might expect from the drooping posture they maintain ; local muscular pains can result from prolonged tenseness ; intestinal disorders are often the result of emotionally determined derangement of function and so on. Pain, though appreciated centrally, usually arises peripherally. The extent of the reaction to all pain is determined by the factor of attention and by the emotional state. So it is that suggestible, neurotic patients may respond badly to the experience of pain and benefit temporarily from purely psychological influences. Similarly, the sight of a dentist’s chair may abolish the toothache of a, normally stable individual, even although the pain originates in an obviously carious tooth. For these reasons one should not attach too much diagnostic ,
1.
Handley,
W. S.
2. Leriche, R.
Practitioner, 1918, 100, 466. Surgery of Pain. London, 1940.
199
importance to the behaviour of pain in response to suggestion or an injection of distilled water masquerading as an analgesic. Nor can a positive diagnosis of a psychoneurosis exclude the possibility that a pain is organically determined, even though clinical examination reveals Neurotes are plentiful, and they no obvious cause. are not immune to obscure and puzzling algetic diseases. Further, it must be recognised that even in- the most stable individual, prolonged severe pain is capable of inducing a clinical state closely resembling the commoner it is not unknown for the to be found in the psychowithout his complaint having
psychological illnesses ; and sufferer from, say, causalgia logical-medicine department
been diagnosed. Pain is a vivid subjective experience,
often with
comparatively slight objective manifestations, and so there is no easy way in which we can assess its severity or reality. That is known only to the sufferer. For these reasons the evaluation of pain of obscure origin necessitates not only careful investigation and the most meticulous history taking but also, as Dr. Barton Hall (July 17) has emphasised, a consideration of the previous psychiatric record of both the patient and his immediate relatives. London, W.2.
remembered that the life-assurance rates are those obtainable at present, and the pension quoted is the one that most leading life-assurance offices will be prepared to guarantee now. The comparison is based on equal contributions to the National Health Service scheme In the case of life assurance I and to life assurance. have assumed that a practitioner will take the obvious advantages of a " with profits " contract, and I have estimated the bonus conservatively. The table illustrates the case of a doctor aged 35, with a wife of the same age, and an income (after deduction of expenses) of £1200 per annum. Under either scheme the total contribution is £168, of which he pays £72 and the Minister pays the remainder. Under the N.H.S. scheme he receives full tax relief on his share, but under the life-assurance scheme twofifths’ tax relief. The life-assurance policy is for £4500 with profits.
J. DONALDSON CRAIG. SUPERANNUATION
SIR,—By now most doctors will havehad a chance to study the Ministry of Health’s leaflet s.D.D., containing the provisions by which practitioners holding lifeassurance policies can " opt out " of the National Health Service superannuation scheme. Many will have read also the excellent article by Mr. A. N. Dixon, manager of the Medical Insurance Agency, published in the British Medical Journal supplement of July 3, 1948. To those who are still considering whether to enter the superannuation scheme or rely on life-assurance policies, I would point out that delay is inadvisable, since the option will lapse on Oct. 4. In order to use this option a practitioner must have had in force on July 5, 1948, an endowment assurance policy, maturing not earlier than age 60, on which a premium of at least .S50 per annum is being paid. If the premium is less than .E150 he must take out a further policy which will increase it to that figure or a higher one. His total premiums should be equivalent to approximately 14 % of his anticipated net remuneration, for he is required to contribute 6 % per annum to which the Minister of Health will add 8 %. A qualifying policy will not be acceptable, however, if it is assigned to a third party. Many practitioners, I know, possess substantial life-assurance policies, on which they are paying substantial premiums, but which have been assigned to banks and others as collateral security for loans obtained for purchasing their practices. Such policies cannot be used to provide for their superannuation-which is perhaps unfortunate, particularly as so many of these policies contain a provision whereby they could later be modified to endowment assurance which would meet the requirements of the National Health Service (Superannuation) Regulations. They can be used only if the practitioner is able to secure reassignment of the policy to himself before Oct. 4. This should be clearly understood, for I feel sure that a large number of practitioners who are intending to rely on their life assurance will not qualify to do so because of this restriction.
That many will wish to opt out there is no doubt ; for, excellent though the superannuation scheme is, it
has deficiencies at this stage which will be obvious, particularly to a young practitioner with family responsibilities. Briefly, these deficiencies are : (a) inadequate provision for the widow throughout, and during the first five years’ service no provision whatever ; (b) on retirement compulsory acceptance of a pension, though the payment of capital would be far more acceptable in many cases-e.g., for a, retiring practitioner in a poor state of health, or for one who wants to live outside the United Kingdom income-tax area. A practitioner relying on life assurance is able to counteract these deficiencies in the scheme. and the accompanying table may
help
those who are still undecided as to what they In considering this table, it should be
should do.
Under the N.H.S. scheme, if a practitioner dies after retirement, his widow will receive for the rest of her life one-third of his retirement pension ; but this of course Under life assurance, ceases immediately on her death. on the other hand, pensions can be guaranteed for a fixed period, and a retiring practitioner could elect to accept a pension which would be guaranteed for 15 years, regardless of survivals. Unlike those we have previously considered, such a pension during the guaranteed period would not be subject to tax, and if accepted on this basis it would amount to £392 per annum. If the practitioner survived more than 15 years after retirement, this pension would continue to be payable during his life-time, but would attract incometax after the guaranteed period had expired. If incometax is assumed at the modest rate of 7s. in the £, a pension of ;S540 per annum will give the possessor £351 per annum. For the first 15 years, therefore, the practitioner would be financially better placed if he accepted the pension for the guaranteed period. If he died soon after retirement his widow would receive the full pension till the end of the 15 years, and in this way his capital would return to his estate. I do not intend these observations to be construed as a recommendation to opt out of the N.H.S. superannuation scheme, but rather as a guide to practitioners who can fulfil the qualifying conditions and want to decide what is best suited to their circumstances. Many who do not at present qualify to opt out may find that it is not too late to modify their policies-e.g., by altering the endowment period or by reassigning the policywhich will enable them to exercise free choice of method. A. SHAW Liverpool.
Medical Agent and Medical Insurance Consultant.
THE editor of the Medical Directory writes: " To maintain the accuracy of our annual volume we rely upon the return of our schedule, which has been posted to each member of the medical profession. Should the schedule have been lost or mislaid we will gladly forward a duplicate upon request. The full names of the doctor should be sent for identification." The directory is published by Messrs. J. & A. Churchill,
Ltd., 104, Gloucester Place, London, W.I.
SiR,-After perusing recent articles on pneumoconiosis one is again lost in wonder that no mention is made of the simple and sure means of prevention and protection-the use of a small light pad over the nose and mouth, as worn by nurses in the operating-theatre and children’s wards. The pads are, of course, merely some six folds of butter-muslin or gauze, with tapes to tie behind the head, and could be provided in unlimited quantities, to be discarded after use. By all means let us diminish or eliminate, as far as possible, the creation of dust and grit in trade processes and mining ; but surely real prevention of anthracosis, silicosis, or any form of pneumoconiosis can only be obtained by providing exposed workers with a shield which will prevent any dust particles from gaining access to the respiratory system. The director of the Pneumokoniosis Research Unit states that pneumoconiosis is a preventable disease, and calls for imperative administrative action. Is it too much to hope that such action might be directed towards preventing the condition, by the simple expedient suggested, rather than towards setting up a costly organisation to deal with the crippling and often fatal after-effects ?
LEONARD HEARN Senior Tuberculosis Officer Notts C.C.
Nottingham.
to the skin of the lower abdominal wall, the formation of a stitch abscess resulted in infection of the entire scrotal
cavity. I am indebted illustrations.
to
Miss Barbara NORMAN
Some of your readers may be interested in a simple bandaging procedure which I have used, with invariable success, during the past five or six years in all cases involving extensive separation of the cord and testicle from the scrotal wall. At the close of the operation the incision is dressed, and the dependent part of the scrotum is picked up by an assistant A strip of elastic adhesive between finger and thumb.
1%.
Fig.I
Fig. 2
bandage about 11/2 in. wide and about 12 in. long is wound spiral fashion around the scrotum from apex to base, obliterating the scrotal cavity by light and even compression (fig. 1),and so rendering the formation of a haematoma The testes are thereby displaced virtually impossible. towards the external inguinal rings. The spiral bandage must be retained in position by a strip of elastic adhesive bandage of similar dimensions extending from the perineum over the scrotum to the anterior abdominal wall (fig. 2). After three or four days the strapping may be released and a simple support substituted. The testicles soon regain
in
their normal
position.
For Other methods have not proved satisfactory. example, in one case in which the scrotum was stitched
for
the
GIBBON
Registrar to the surgical professorial unit. Department of Surgery, University of Liverpool.
SIR,-The admirable article (July 10) by Moloney and his colleagues on the nylon darn for hernia revives an old method in a new look. Thirty years ago Sampson Handleydescribed his darn and stay-lace method for the radical cure of inguinal hernia. As one of his surgical dressers I saw many of his cases, and the results were excellent. The material used was silk, and whilst there was occasional trouble from infection it was found that this could be avoided by soaking the silk in flavine, 1 in 1000, before use. The principles of the operation were the same as those now advocated-the avoidance ,of tension and of the displacement of normal structures. The darn was used to strengthen the external oblique which Handley contended was often stretched and split, and for which no provision is made in the present operation. The deeper layer of the darn in Moloney’s operation was the stay-lace in Handley’s and the latter seems a more appropriate name for it ; perhaps staylaces are no longer in fashion in the new look. E. W. RICHES. London, W.1.
OPERATIONS FOR HERNIA
Sin,-In reading the interesting article of Moloney, Gill, and Barclay in your issue of July 10, I am reminded by their report of scrotal hsematoma in 2 of the 230 cases discussed that this serious complication, with the almost inevitable sequel of infection, has not yet been eliminated from even the best of surgical practice.
Duckworth
PAIN
SIR,—In his interesting paper published on July 3. Dr. Keele rightly emphasised the value of pain as an aid to diagnosis, and in particular, he drew attention to the help which may be gained from consideration of It is agreed that in such the time-intensity curve. conditions as angina pectoris, duodenal ulcer, thromboangiitis obliterans, and some forms of sinusitis the information thus obtained is often enough to enable a positive diagnosis to be made. Dr. Keele’s views on what he terms " psychogenic pain " may not, however, gain the same ready acceptance. The term " psychogenic pain " is a bad one, loosely applied, as it often is, to a multiplicity of conditions in which the diagnosis may be obscure. Further, every pain is ina sense at least partly psychogenic, in that it is a psychosomatic experience, the reaction to which is determined not merely by the nature and severity of the pain but by all the related circumstances and in particular by the general2 make-up of the individual concerned. As Leriche has remarked, " Physical pain is not a simple fact of nervous impulses travelling over a nerve at a predetermined gait. It is the resultant of the conflict between the stimulus and the individual." Generally speaking, pain is not a prominent feature of purely neurotic states. The hysterical individual, free from organic disease, who proclaims the agony of his pains in extravagant terms can hardly be regarded as suffering from pain in the generally accepted sense of the term when one views the happy mien of his coun" tenance, or considers " la belle indifference with which he accepts his misfortunes. In the anxiety states, a local cause for pains can generally be discovered : headaches may be due to subconsciously maintained, persistent scalp contraction ; the low backache of many neurotic women is only what one might expect from the drooping posture they maintain ; local muscular pains can result from prolonged tenseness ; intestinal disorders are often the result of emotionally determined derangement of function and so on. Pain, though appreciated centrally, usually arises peripherally. The extent of the reaction to all pain is determined by the factor of attention and by the emotional state. So it is that suggestible, neurotic patients may respond badly to the experience of pain and benefit temporarily from purely psychological influences. Similarly, the sight of a dentist’s chair may abolish the toothache of a, normally stable individual, even although the pain originates in an obviously carious tooth. For these reasons one should not attach too much diagnostic ,
1.
Handley,
W. S.
2. Leriche, R.
Practitioner, 1918, 100, 466. Surgery of Pain. London, 1940.
199
importance to the behaviour of pain in response to suggestion or an injection of distilled water masquerading as an analgesic. Nor can a positive diagnosis of a psychoneurosis exclude the possibility that a pain is organically determined, even though clinical examination reveals Neurotes are plentiful, and they no obvious cause. are not immune to obscure and puzzling algetic diseases. Further, it must be recognised that even in- the most stable individual, prolonged severe pain is capable of inducing a clinical state closely resembling the commoner it is not unknown for the to be found in the psychowithout his complaint having
psychological illnesses ; and sufferer from, say, causalgia logical-medicine department
been diagnosed. Pain is a vivid subjective experience,
often with
comparatively slight objective manifestations, and so there is no easy way in which we can assess its severity or reality. That is known only to the sufferer. For these reasons the evaluation of pain of obscure origin necessitates not only careful investigation and the most meticulous history taking but also, as Dr. Barton Hall (July 17) has emphasised, a consideration of the previous psychiatric record of both the patient and his immediate relatives. London, W.2.
remembered that the life-assurance rates are those obtainable at present, and the pension quoted is the one that most leading life-assurance offices will be prepared to guarantee now. The comparison is based on equal contributions to the National Health Service scheme In the case of life assurance I and to life assurance. have assumed that a practitioner will take the obvious advantages of a " with profits " contract, and I have estimated the bonus conservatively. The table illustrates the case of a doctor aged 35, with a wife of the same age, and an income (after deduction of expenses) of £1200 per annum. Under either scheme the total contribution is £168, of which he pays £72 and the Minister pays the remainder. Under the N.H.S. scheme he receives full tax relief on his share, but under the life-assurance scheme twofifths’ tax relief. The life-assurance policy is for £4500 with profits.
J. DONALDSON CRAIG. SUPERANNUATION
SIR,—By now most doctors will havehad a chance to study the Ministry of Health’s leaflet s.D.D., containing the provisions by which practitioners holding lifeassurance policies can " opt out " of the National Health Service superannuation scheme. Many will have read also the excellent article by Mr. A. N. Dixon, manager of the Medical Insurance Agency, published in the British Medical Journal supplement of July 3, 1948. To those who are still considering whether to enter the superannuation scheme or rely on life-assurance policies, I would point out that delay is inadvisable, since the option will lapse on Oct. 4. In order to use this option a practitioner must have had in force on July 5, 1948, an endowment assurance policy, maturing not earlier than age 60, on which a premium of at least .S50 per annum is being paid. If the premium is less than .E150 he must take out a further policy which will increase it to that figure or a higher one. His total premiums should be equivalent to approximately 14 % of his anticipated net remuneration, for he is required to contribute 6 % per annum to which the Minister of Health will add 8 %. A qualifying policy will not be acceptable, however, if it is assigned to a third party. Many practitioners, I know, possess substantial life-assurance policies, on which they are paying substantial premiums, but which have been assigned to banks and others as collateral security for loans obtained for purchasing their practices. Such policies cannot be used to provide for their superannuation-which is perhaps unfortunate, particularly as so many of these policies contain a provision whereby they could later be modified to endowment assurance which would meet the requirements of the National Health Service (Superannuation) Regulations. They can be used only if the practitioner is able to secure reassignment of the policy to himself before Oct. 4. This should be clearly understood, for I feel sure that a large number of practitioners who are intending to rely on their life assurance will not qualify to do so because of this restriction.
That many will wish to opt out there is no doubt ; for, excellent though the superannuation scheme is, it
has deficiencies at this stage which will be obvious, particularly to a young practitioner with family responsibilities. Briefly, these deficiencies are : (a) inadequate provision for the widow throughout, and during the first five years’ service no provision whatever ; (b) on retirement compulsory acceptance of a pension, though the payment of capital would be far more acceptable in many cases-e.g., for a, retiring practitioner in a poor state of health, or for one who wants to live outside the United Kingdom income-tax area. A practitioner relying on life assurance is able to counteract these deficiencies in the scheme. and the accompanying table may
help
those who are still undecided as to what they In considering this table, it should be
should do.
Under the N.H.S. scheme, if a practitioner dies after retirement, his widow will receive for the rest of her life one-third of his retirement pension ; but this of course Under life assurance, ceases immediately on her death. on the other hand, pensions can be guaranteed for a fixed period, and a retiring practitioner could elect to accept a pension which would be guaranteed for 15 years, regardless of survivals. Unlike those we have previously considered, such a pension during the guaranteed period would not be subject to tax, and if accepted on this basis it would amount to £392 per annum. If the practitioner survived more than 15 years after retirement, this pension would continue to be payable during his life-time, but would attract incometax after the guaranteed period had expired. If incometax is assumed at the modest rate of 7s. in the £, a pension of ;S540 per annum will give the possessor £351 per annum. For the first 15 years, therefore, the practitioner would be financially better placed if he accepted the pension for the guaranteed period. If he died soon after retirement his widow would receive the full pension till the end of the 15 years, and in this way his capital would return to his estate. I do not intend these observations to be construed as a recommendation to opt out of the N.H.S. superannuation scheme, but rather as a guide to practitioners who can fulfil the qualifying conditions and want to decide what is best suited to their circumstances. Many who do not at present qualify to opt out may find that it is not too late to modify their policies-e.g., by altering the endowment period or by reassigning the policywhich will enable them to exercise free choice of method. A. SHAW Liverpool.
Medical Agent and Medical Insurance Consultant.
THE editor of the Medical Directory writes: " To maintain the accuracy of our annual volume we rely upon the return of our schedule, which has been posted to each member of the medical profession. Should the schedule have been lost or mislaid we will gladly forward a duplicate upon request. The full names of the doctor should be sent for identification." The directory is published by Messrs. J. & A. Churchill,
Ltd., 104, Gloucester Place, London, W.I.