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Physical disease and psychiatric emergencies
Physical Disease and Psychiatric Emergencies By M. D. EILENBEHG, M.B.,
M.R.C.P.,
D.P.M. AND P. B. WHATMOHE, M.B., LL.B.
H E lMPLlCAnONS of the Mental Health Act 1959 (England) have yet to be fuJly realised, but re-organisation of existing psychiatric services and establishment of new psychiatric units are inevitable. The intelligent planning of such units requires a basis of factual data, and this paper contributes to one aspect of the problem by assessing the frequency and causal "ignificance of physical diseases in patients admitted as psychiatric emergencies to an observation unit. Although previous papers have studied the significance of this relationship, the populations studied have usually been a highly selected group, small in number and admitted to units organised specifically for treatment (Marshall 1949, Herridge W60). The present unit of 82 beds (41 male, 41 female) situated in southeast London, but admitting patients throughout the city, is so staffed by psychiatric registrars and Consultants from the associated postgraduate teaching hospital that a 24-hour 7 days a week service is provided. Nearly 1400 admissions occur annually and as refusal is exceptional, the sample admitted is representative of acute psychotic illness.
T
METHOD
All case records of patients admitted to the Observation Unit between
Ist April 1959 and 31st March 1960, inclusive, were examined by one author (P. B. W.) and the case notes of three random samples of one hundred cases each, admitted during the same period were scrutinised by another author (M. D. E.) as a check. Patients having a physical disease were further S1lbdivided into two groups, these in whom this was considered to be only an associated disease and those in whom it was causative in producing the psychiatric illness (referred to below as "related"). Of the total number of patients admitted. 18.4 per cent had some physical disease, although in only 7.2 pel' cent was the psychiatric disorder secondary to a physical disease, i.e., the "related" group. As only 7.8 pel' cent of total admissions for the year were 65 years or over, the incidence of physical illness is not explained by the age distribution alone. The 15 miscellaneous cases included chronic nephritis, cirrhosis of the liver, erythema multiforme, Crohn's disease, cataract (5), peptic ulcer (2), glaucoma, pediculosis corporis and capitis and uraemia (2). The total figures do not coincide with the number of 232 patients who have physical disease as some patients had multiple diseases. The approximate percentage of 7.5 per cent for neurolcgical diseases (including "related" epilepsy and alcoholism, and neurosyphilis is ccmparable to the 5 per cent quoted by Goody, Gautier-Smith and Dunkley (1960), epilepsy in both studies contributing the largest proportion. Of 59 patients (28 males, 31 females) whose "related" physical diseases were known at the time of admission, 44 (74.6 per cent) had previous contact with a medical practitioner a short time before admission, whereas of the 31
358
359
PHYSICAL DISEASE AND PSYCHiATRIC EMERGENCIES
Table I.-Incidence of "Related" and "Unrelated" Phl/rical D;,e/lllf' (Percentage in parentheses) Physical disease
Mal..
Fem.le,
Total
46 (8,2)
44 (6.2)
90 (7.2)
39(7.0)
103(14.7)
142(11.2)
85 ( 15.2)
147 (20.9)
232 ( 18.4)
uoo:
1259 ( ioo)
--------------"Related"
"Unrelated"
.., - - - - - _....
Total
--------,--------------No physical disease 473 (84.8) 554 (79.1) 1027 (1l1.6) ---------------_._-_.,----- - - - - ,558
Total
uoo:
701
Table 2.-Typc. of PIIl/lical Diaea.e
-------._-------C.V.S. Epilepsy
C.N.S. Acutc infcctions )Ii curnsyphills Endocrine Locomotive system Postopera tivc Childbearing ,Alcoholism "Trailina Miscellaneous
No.
Per cent
99 40 36 18 13 13 9
37.1 15.0 13.4 6.7 4.9 4.9
I}
3.0 2.22') 1.5 5.7
3,-[
6 6 4 15
-----
Table 3.-Patient.
---------
100
267 w~th
"Related" Phl/sic,ll Disease» Cla"i/ied as Diagn08ed or Undiagnosed Before Admialion Di... nosed
Diagnosis
Epilepsy C.N.S.
C.V.S. Alcoholism Post-operative Neurosyphilis Endocrine Acute infections Trauma All diagnoses
Before admission
After admission
Tota! No.
19 14 7 .5 5 4 3 2
2
21 2\) 14
- - _ .._--------------.--------
59 (65.5)
6 7 1
Ij
s 5 2 7 1 31 (34.5)
9 5 9 1 90 (100)
patients (17 males, 14 females) whose physical diseases were nut known until after admission, only 16 (51.6 per cent) bad medical contact. The term "diagnosed before admission" does not necessarily imply direct medical contact as the Duly Authorised Officer, or relative, may be aware of thephysical basis of the disease, e.g., epilepsy or alcohol. Awareness of ·the existence of physical abnormalities by the referring agency was considered sufficient to warrant the patient's inclusion in the category "diagnosed before admission." The 90 cases with physical diseases "related" to their, psychiatric state were next tabulated into two groups, classified according to the presence of organic
360
E lLENBERG AND WHATMORE
mental symptoms (table 4 below) . The lalter was based on the finding of disturbed consciousness, disorientation, amnesia or confabulation. In just under two thirds of the "related" group organic mental features were present. In the diagnostic groups, diseases of the central nervous sy. tem and alcoholism produced the greatest proportio of patients with organic mental symptoms. From table 5 above it can be seen that 40 out of 90 pa tients with "related" physical diseases were either sent home or sent to a general hospital , i.e., 44 per cent of these patients required short term psychiatric supervision. The averag e lengt h of stay at the Observation Unit of these pati ents who were discharged home or to a general hospital , was 10.9 days. During the survey period there were 6 deaths in the Unit, 2 in the "related" group, a mortality rat e of 2.2 per cent, compar ed with 0.42 per cent for the total number of admissions. D ISCUSSION
Th e datu shows that 18.4 per cent had physical diseases and 7.2 per cent had psychiatric disturbances as a secondary conditi on; that this latt er group reTable 4.-Patients with Phy.,ical Disease "Related" to Psychiatric D isorders
Classified by Diagnosis ami Differentiated for the Presence of Organic Mental Symptoms ( Percentage in par entheses ) Orga nic svmp toms
Diagnosis
Present
Absent
Pl'obJ
Epilep sy C.N.S. C.V.S. Acut e ini ecti on Neurosyp hilis Alcoholism En docrine Postop erative
11 18 10 6
10 2 4 3 3 1
21 20
4 5
5 5
6
5
14 9 9 6
1
Trauma 32 (35.6)
58 ( 64.4)
All diagnoses
90 (100 )
Table 5.- Disposal of Putientt: with l' hysical Diseases "Relater!." to
Psychiatric Disorders Diagnosis
---
-
Epilepsy C.N .S. C.V.S. Acute infections Neurosyphilis Alcoholi sm Endocrine Postoperative Trauma All diagnoses
- --
Home
Mental hospital
General hospital
14 4 5 1 1
7 15 8 1 8
1 1 7
2 2
2 31
Died
'X'oW
21 20 140 9 9
3
6
3 3
5 5
48
9
1
1
2
90
PHYSICAL DISEASE A:-iU PSYCHIATRIC EMERGENCIES
361
quired skilled general medical care and their psychiatric illness resolved within 11 days. The intervention of a doctor prior to the patient's admission resulted in a lower incidence of misdiagnosis and to illustrate some of the diagnostic problems experienced in the Unit, five brief case summaries are appended below. The present study reveals that in acute psychiatric disorder the referring practitioner must constantly be aware of the possible physical basis of such a disturbance. A physical examination is as imperative a procedure as a simple psychiatric assessment with particular reference to the presence of or~ani<: mental symptoms allowing an earlier and more appropriate disposal. Mapother (1934) ill his paper on "Sudden Insanity" pointed out that acute psychotic disturbance comparable in their acuteness to physical illness is an unusual phenomenon. In persons of stable personality with no preceding psychiatric history the possible physical basis for an acute breakdown should be uppermost in the examining clinician's mind Stokes, Nabarro, Rosenheim and Dunkley (1954) analyzed physical illness in an observation ward over a 5year period. In 54 patients death was due to physical diseases, unrecognised before admission, and 30 of the 54 patients were admitted from general hospitals. They made a special plea for the wider recognition of mental symptoms in physical illness. Crawford (1954) briefly lists physical diseases seen in a six month period during 1949 at the Observation Unit here studied. He found 29 per cent of 248 patients had physical disease and the overall mortality rate was 9.2 per cent. Steel (1960) and Bockner and Coltart (1960) presented two clinical studies of 27 patients with a diagnosis of neurosyphilis admitted to two Observation Wards during 1957, 1958 ancl 1959 and cautioned aghinst the tendency to assume that neurosyphilis was a rare disorder nowadays, a view point subscribed to by the present authors' experience. Although it is appreciated that patients with psychiatric illness, secondary to physical disease, may require admission to a psychiatric unit the possibility of nursing such patients in a side room on general medical wards with psychiatric supervision is suggested by the fact that 40 out of 90 patients were psychiatrically normal within 11 days. Observation wards, or other units for the reception of patients with acute psychiatric illness should be conceived of in a medical setting with psychiatric staff experienced in general medicine, sited in or associated with general hospitals where laboratory facilities and specialist advice are available. These points were underlined by Dunkley (1959) and Asher (19.54, 19.57) in their memoranda to the Royal Commission on Mental Illness 19.57 and receive statistical support from the present paper.
Case No.1 G, C., a single man, aged 30 years, was admitted under a Statutory Order having "gone berserk in a cafe." He was taken to a Teaching Hospital where nothing was Found on physical examination, other than a cut scalp. On (l(ll11i88ioll he was. lying in a curled up position talking incoherently mid showing hyperactive repetitive movements, e.g., brushing his hair wlth his hand. He was persplring freely and his temperature was 100 F. Immediate contact with his landlady revealed
,1(i2
EILENBEHG AND WIIATMOHE
t hat the patient w"s a known diabetic of 12 yean standing. Intravenous glucose brought a rapid unprovcnx-nt and 111(~ following day the patient was bewildered and resentful of his ad.ll1issifln, staling that he had similar disturbances with previous hypoglycemic episodcs.
Case No.2 iJ. C., a :311 year old married man, by profession, a scientific officer. He was admitted [rom houu- by his pructitioncr sufl'ering from an "acute psychosis." Family liision: was th"l his father I",d asthma .mrl his mother was described as a "cheerful hypochondriac." The pul icnt was h.ippily married and had a 2 year old daughter. History of his present ill111'.1'.1' was of 2 wceks headache, irritability and prior to admission "fits in which he became still." his r'y"s rolled up and he did not appear to recognize his wife. On admission he was IInab'" to gil'c an ndcqnatc account of himself, complained of headache and appeared drowsy. A mild Kcrnig sign was queried. His pulse was 70 and temperature normal. Lumbar puncture showed 600 cells composed of lymphocytes and monocytcs, Protein 2,00 mgm. pCI' cent, sng,lr 62mglll. pCI' cent and chlorides 667mgm. per cent. C.S.F.\V,R. negalive. E.E.C. nothing abnormal. He Was transferred to a Ccnerul Hospital with a provisional diagnosis or lymphocytic meningitis and was shortly discharged home well, apart Iroru
Case »: H. .II., :\ widow aged 43 years, machinist by trade. She was admitted from a Teaching Ilospil:d Casualty Department with a diagnosis of "hysterical vomiting and blindness" following lu-r son's dl'alh a week previous, On admissioil she complained of severe headache, vomiting and appcarctl drowsy. Plujsica! exuminatinn revealed a leIt hemiplegia, bilaterally incre::sed rcHexes, L >R; astcroognosis, apraxia and sensory inattention on the Idt. The Idt plantar reflex was equivocal, She was immediately transferred to the ncuroxurgicul unit with a diagnosis of right parietal lesion. This Was confirmed, following burrhole and brain biopsy, as a "secondary carcinomatosis deposit, primary unknown."
Case No.4 H. 1'., a GO-year old married man admitted from horne under Statutory Order. The :) clay history was of "wrenching his neck at work" which was followed by dizziness, vomiting and syncope. He was sent home but still complained of frontal and occipital headache radiating down his spine, At night he was confused, aggressive if restrai ned and inappropriately attempted to go to work. He misidentified people and was also disorlcntated durim; the day. On admission he was drowsy but cooperative, complaining of headache and slill' neck; pulxc rate was 40 /minute, blood pressure 170/100. He appeared slow during mental testing but did not show any other abnormal features, A lumbar puncture showed blood in his C.SY. and he was transferred that day to a neurosurgical unit for further diagnosis and manngcmcnt with a diagnosis of subarachnoid hemorrhage.
Case No. S G. P., a ,53-year old man, was admitted under a Statutory Order because he had "lost his will power to cat or drink." On admission his wife stated he had a gastrectomy 10 years previously. A recent history of depression, loss of weight and inability to talk, eat, read newspapers or get out of hcd was obtained. On examination the patient was emaciated, ahrasions on pressure areas wus noted; his lips were blue, his skin grey and pallid. He had vomited bile fluid and a right husnl pneumonia was found. The patient was too weak and ill for au adequate mental exmnination. Contact with the hospital where the patient was opcrutcd upon revealed that the patient had post-gastrectomy steatorrhea and recurrent hypokalemic episodes due to potassium loss. The patient was immediately transferred to a general hospital.
PHYSICAL DISEASE AND PSYCHIATIUC E.1\1ERGENCIES
36.3
SUMMARY
The incidence, type and causal significance of physical disease in patients admitted to a mental observation ward during a 12-month period is presented. Clinical and administrative points arising from the data are briefly discussed and illustrated by case-summaries. REFERENCES
1. Asher, R.: Physical basis of mental illness. Tr. ivf, Soc. London 70:93-114, 1954. 2. - : Memorandum Submitted to Royal Commission on the Law relating to Mental Illness and Deficiency. Page 1317, 1957, H.M.S.O., London. 3. Bockner, S" Coltart, N.: New cases of GPr. Brit. M. .I. 1: 18-20, 1961. 4. Dunkley, F. W.: Memorandum submitted to Royal Commission on the Law relating to Mental Illness and Deficiency. Page 1203, 1957, H.M.S. 0., London. 5. Goody, W., Gautier-Smith, P. C., Dunkley, F. W.: Neurological practice ill a mental observation unit. Lancet 2:
1290-1292, 1960. 6. Herridge, C. F.: Physical disorders in psychiatric illness. Lancet, 2: 949951, 1960. 7. Mapother, E. M.: Sudden insanity. The Medi~al press and circular suppl., 18S, 10-14, 1934. 8, Marshall, H. E. S.: Incidence of physical disorders among psychiatric inpatients. Brit. M. J. 2:468-470, 1949. 9. Steel, R.: G. P. I. in an observation unit. Lancet 1: 121-123, 1960. 10. Stokes, .I. R., Nabarro, .I. D. N., Rosenheim, M. 1., Dunkley, E. W.: Physical disease in a mental observation unit. Lancet 2:862-863, 1954.
M. D. Ei/enberg, M.B., M.R.C.P., D.P.M., Senior Registrar, Maudsley Hospital, London, England; Present address, Mayo Clinic, Rochester, Minnesota. P. B. Whatmore, M.B., LL.B., Senior Registrar, Maudsley Hospital, London, England.
M.R.C.P.,
D.P.M. AND P. B. WHATMOHE, M.B., LL.B.
H E lMPLlCAnONS of the Mental Health Act 1959 (England) have yet to be fuJly realised, but re-organisation of existing psychiatric services and establishment of new psychiatric units are inevitable. The intelligent planning of such units requires a basis of factual data, and this paper contributes to one aspect of the problem by assessing the frequency and causal "ignificance of physical diseases in patients admitted as psychiatric emergencies to an observation unit. Although previous papers have studied the significance of this relationship, the populations studied have usually been a highly selected group, small in number and admitted to units organised specifically for treatment (Marshall 1949, Herridge W60). The present unit of 82 beds (41 male, 41 female) situated in southeast London, but admitting patients throughout the city, is so staffed by psychiatric registrars and Consultants from the associated postgraduate teaching hospital that a 24-hour 7 days a week service is provided. Nearly 1400 admissions occur annually and as refusal is exceptional, the sample admitted is representative of acute psychotic illness.
T
METHOD
All case records of patients admitted to the Observation Unit between
Ist April 1959 and 31st March 1960, inclusive, were examined by one author (P. B. W.) and the case notes of three random samples of one hundred cases each, admitted during the same period were scrutinised by another author (M. D. E.) as a check. Patients having a physical disease were further S1lbdivided into two groups, these in whom this was considered to be only an associated disease and those in whom it was causative in producing the psychiatric illness (referred to below as "related"). Of the total number of patients admitted. 18.4 per cent had some physical disease, although in only 7.2 pel' cent was the psychiatric disorder secondary to a physical disease, i.e., the "related" group. As only 7.8 pel' cent of total admissions for the year were 65 years or over, the incidence of physical illness is not explained by the age distribution alone. The 15 miscellaneous cases included chronic nephritis, cirrhosis of the liver, erythema multiforme, Crohn's disease, cataract (5), peptic ulcer (2), glaucoma, pediculosis corporis and capitis and uraemia (2). The total figures do not coincide with the number of 232 patients who have physical disease as some patients had multiple diseases. The approximate percentage of 7.5 per cent for neurolcgical diseases (including "related" epilepsy and alcoholism, and neurosyphilis is ccmparable to the 5 per cent quoted by Goody, Gautier-Smith and Dunkley (1960), epilepsy in both studies contributing the largest proportion. Of 59 patients (28 males, 31 females) whose "related" physical diseases were known at the time of admission, 44 (74.6 per cent) had previous contact with a medical practitioner a short time before admission, whereas of the 31
358
359
PHYSICAL DISEASE AND PSYCHiATRIC EMERGENCIES
Table I.-Incidence of "Related" and "Unrelated" Phl/rical D;,e/lllf' (Percentage in parentheses) Physical disease
Mal..
Fem.le,
Total
46 (8,2)
44 (6.2)
90 (7.2)
39(7.0)
103(14.7)
142(11.2)
85 ( 15.2)
147 (20.9)
232 ( 18.4)
uoo:
1259 ( ioo)
--------------"Related"
"Unrelated"
.., - - - - - _....
Total
--------,--------------No physical disease 473 (84.8) 554 (79.1) 1027 (1l1.6) ---------------_._-_.,----- - - - - ,558
Total
uoo:
701
Table 2.-Typc. of PIIl/lical Diaea.e
-------._-------C.V.S. Epilepsy
C.N.S. Acutc infcctions )Ii curnsyphills Endocrine Locomotive system Postopera tivc Childbearing ,Alcoholism "Trailina Miscellaneous
No.
Per cent
99 40 36 18 13 13 9
37.1 15.0 13.4 6.7 4.9 4.9
I}
3.0 2.22') 1.5 5.7
3,-[
6 6 4 15
-----
Table 3.-Patient.
---------
100
267 w~th
"Related" Phl/sic,ll Disease» Cla"i/ied as Diagn08ed or Undiagnosed Before Admialion Di... nosed
Diagnosis
Epilepsy C.N.S.
C.V.S. Alcoholism Post-operative Neurosyphilis Endocrine Acute infections Trauma All diagnoses
Before admission
After admission
Tota! No.
19 14 7 .5 5 4 3 2
2
21 2\) 14
- - _ .._--------------.--------
59 (65.5)
6 7 1
Ij
s 5 2 7 1 31 (34.5)
9 5 9 1 90 (100)
patients (17 males, 14 females) whose physical diseases were nut known until after admission, only 16 (51.6 per cent) bad medical contact. The term "diagnosed before admission" does not necessarily imply direct medical contact as the Duly Authorised Officer, or relative, may be aware of thephysical basis of the disease, e.g., epilepsy or alcohol. Awareness of ·the existence of physical abnormalities by the referring agency was considered sufficient to warrant the patient's inclusion in the category "diagnosed before admission." The 90 cases with physical diseases "related" to their, psychiatric state were next tabulated into two groups, classified according to the presence of organic
360
E lLENBERG AND WHATMORE
mental symptoms (table 4 below) . The lalter was based on the finding of disturbed consciousness, disorientation, amnesia or confabulation. In just under two thirds of the "related" group organic mental features were present. In the diagnostic groups, diseases of the central nervous sy. tem and alcoholism produced the greatest proportio of patients with organic mental symptoms. From table 5 above it can be seen that 40 out of 90 pa tients with "related" physical diseases were either sent home or sent to a general hospital , i.e., 44 per cent of these patients required short term psychiatric supervision. The averag e lengt h of stay at the Observation Unit of these pati ents who were discharged home or to a general hospital , was 10.9 days. During the survey period there were 6 deaths in the Unit, 2 in the "related" group, a mortality rat e of 2.2 per cent, compar ed with 0.42 per cent for the total number of admissions. D ISCUSSION
Th e datu shows that 18.4 per cent had physical diseases and 7.2 per cent had psychiatric disturbances as a secondary conditi on; that this latt er group reTable 4.-Patients with Phy.,ical Disease "Related" to Psychiatric D isorders
Classified by Diagnosis ami Differentiated for the Presence of Organic Mental Symptoms ( Percentage in par entheses ) Orga nic svmp toms
Diagnosis
Present
Absent
Pl'obJ
Epilep sy C.N.S. C.V.S. Acut e ini ecti on Neurosyp hilis Alcoholism En docrine Postop erative
11 18 10 6
10 2 4 3 3 1
21 20
4 5
5 5
6
5
14 9 9 6
1
Trauma 32 (35.6)
58 ( 64.4)
All diagnoses
90 (100 )
Table 5.- Disposal of Putientt: with l' hysical Diseases "Relater!." to
Psychiatric Disorders Diagnosis
---
-
Epilepsy C.N .S. C.V.S. Acute infections Neurosyphilis Alcoholi sm Endocrine Postoperative Trauma All diagnoses
- --
Home
Mental hospital
General hospital
14 4 5 1 1
7 15 8 1 8
1 1 7
2 2
2 31
Died
'X'oW
21 20 140 9 9
3
6
3 3
5 5
48
9
1
1
2
90
PHYSICAL DISEASE A:-iU PSYCHIATRIC EMERGENCIES
361
quired skilled general medical care and their psychiatric illness resolved within 11 days. The intervention of a doctor prior to the patient's admission resulted in a lower incidence of misdiagnosis and to illustrate some of the diagnostic problems experienced in the Unit, five brief case summaries are appended below. The present study reveals that in acute psychiatric disorder the referring practitioner must constantly be aware of the possible physical basis of such a disturbance. A physical examination is as imperative a procedure as a simple psychiatric assessment with particular reference to the presence of or~ani<: mental symptoms allowing an earlier and more appropriate disposal. Mapother (1934) ill his paper on "Sudden Insanity" pointed out that acute psychotic disturbance comparable in their acuteness to physical illness is an unusual phenomenon. In persons of stable personality with no preceding psychiatric history the possible physical basis for an acute breakdown should be uppermost in the examining clinician's mind Stokes, Nabarro, Rosenheim and Dunkley (1954) analyzed physical illness in an observation ward over a 5year period. In 54 patients death was due to physical diseases, unrecognised before admission, and 30 of the 54 patients were admitted from general hospitals. They made a special plea for the wider recognition of mental symptoms in physical illness. Crawford (1954) briefly lists physical diseases seen in a six month period during 1949 at the Observation Unit here studied. He found 29 per cent of 248 patients had physical disease and the overall mortality rate was 9.2 per cent. Steel (1960) and Bockner and Coltart (1960) presented two clinical studies of 27 patients with a diagnosis of neurosyphilis admitted to two Observation Wards during 1957, 1958 ancl 1959 and cautioned aghinst the tendency to assume that neurosyphilis was a rare disorder nowadays, a view point subscribed to by the present authors' experience. Although it is appreciated that patients with psychiatric illness, secondary to physical disease, may require admission to a psychiatric unit the possibility of nursing such patients in a side room on general medical wards with psychiatric supervision is suggested by the fact that 40 out of 90 patients were psychiatrically normal within 11 days. Observation wards, or other units for the reception of patients with acute psychiatric illness should be conceived of in a medical setting with psychiatric staff experienced in general medicine, sited in or associated with general hospitals where laboratory facilities and specialist advice are available. These points were underlined by Dunkley (1959) and Asher (19.54, 19.57) in their memoranda to the Royal Commission on Mental Illness 19.57 and receive statistical support from the present paper.
Case No.1 G, C., a single man, aged 30 years, was admitted under a Statutory Order having "gone berserk in a cafe." He was taken to a Teaching Hospital where nothing was Found on physical examination, other than a cut scalp. On (l(ll11i88ioll he was. lying in a curled up position talking incoherently mid showing hyperactive repetitive movements, e.g., brushing his hair wlth his hand. He was persplring freely and his temperature was 100 F. Immediate contact with his landlady revealed
,1(i2
EILENBEHG AND WIIATMOHE
t hat the patient w"s a known diabetic of 12 yean standing. Intravenous glucose brought a rapid unprovcnx-nt and 111(~ following day the patient was bewildered and resentful of his ad.ll1issifln, staling that he had similar disturbances with previous hypoglycemic episodcs.
Case No.2 iJ. C., a :311 year old married man, by profession, a scientific officer. He was admitted [rom houu- by his pructitioncr sufl'ering from an "acute psychosis." Family liision: was th"l his father I",d asthma .mrl his mother was described as a "cheerful hypochondriac." The pul icnt was h.ippily married and had a 2 year old daughter. History of his present ill111'.1'.1' was of 2 wceks headache, irritability and prior to admission "fits in which he became still." his r'y"s rolled up and he did not appear to recognize his wife. On admission he was IInab'" to gil'c an ndcqnatc account of himself, complained of headache and appeared drowsy. A mild Kcrnig sign was queried. His pulse was 70 and temperature normal. Lumbar puncture showed 600 cells composed of lymphocytes and monocytcs, Protein 2,00 mgm. pCI' cent, sng,lr 62mglll. pCI' cent and chlorides 667mgm. per cent. C.S.F.\V,R. negalive. E.E.C. nothing abnormal. He Was transferred to a Ccnerul Hospital with a provisional diagnosis or lymphocytic meningitis and was shortly discharged home well, apart Iroru
Case »: H. .II., :\ widow aged 43 years, machinist by trade. She was admitted from a Teaching Ilospil:d Casualty Department with a diagnosis of "hysterical vomiting and blindness" following lu-r son's dl'alh a week previous, On admissioil she complained of severe headache, vomiting and appcarctl drowsy. Plujsica! exuminatinn revealed a leIt hemiplegia, bilaterally incre::sed rcHexes, L >R; astcroognosis, apraxia and sensory inattention on the Idt. The Idt plantar reflex was equivocal, She was immediately transferred to the ncuroxurgicul unit with a diagnosis of right parietal lesion. This Was confirmed, following burrhole and brain biopsy, as a "secondary carcinomatosis deposit, primary unknown."
Case No.4 H. 1'., a GO-year old married man admitted from horne under Statutory Order. The :) clay history was of "wrenching his neck at work" which was followed by dizziness, vomiting and syncope. He was sent home but still complained of frontal and occipital headache radiating down his spine, At night he was confused, aggressive if restrai ned and inappropriately attempted to go to work. He misidentified people and was also disorlcntated durim; the day. On admission he was drowsy but cooperative, complaining of headache and slill' neck; pulxc rate was 40 /minute, blood pressure 170/100. He appeared slow during mental testing but did not show any other abnormal features, A lumbar puncture showed blood in his C.SY. and he was transferred that day to a neurosurgical unit for further diagnosis and manngcmcnt with a diagnosis of subarachnoid hemorrhage.
Case No. S G. P., a ,53-year old man, was admitted under a Statutory Order because he had "lost his will power to cat or drink." On admission his wife stated he had a gastrectomy 10 years previously. A recent history of depression, loss of weight and inability to talk, eat, read newspapers or get out of hcd was obtained. On examination the patient was emaciated, ahrasions on pressure areas wus noted; his lips were blue, his skin grey and pallid. He had vomited bile fluid and a right husnl pneumonia was found. The patient was too weak and ill for au adequate mental exmnination. Contact with the hospital where the patient was opcrutcd upon revealed that the patient had post-gastrectomy steatorrhea and recurrent hypokalemic episodes due to potassium loss. The patient was immediately transferred to a general hospital.
PHYSICAL DISEASE AND PSYCHIATIUC E.1\1ERGENCIES
36.3
SUMMARY
The incidence, type and causal significance of physical disease in patients admitted to a mental observation ward during a 12-month period is presented. Clinical and administrative points arising from the data are briefly discussed and illustrated by case-summaries. REFERENCES
1. Asher, R.: Physical basis of mental illness. Tr. ivf, Soc. London 70:93-114, 1954. 2. - : Memorandum Submitted to Royal Commission on the Law relating to Mental Illness and Deficiency. Page 1317, 1957, H.M.S.O., London. 3. Bockner, S" Coltart, N.: New cases of GPr. Brit. M. .I. 1: 18-20, 1961. 4. Dunkley, F. W.: Memorandum submitted to Royal Commission on the Law relating to Mental Illness and Deficiency. Page 1203, 1957, H.M.S. 0., London. 5. Goody, W., Gautier-Smith, P. C., Dunkley, F. W.: Neurological practice ill a mental observation unit. Lancet 2:
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M. D. Ei/enberg, M.B., M.R.C.P., D.P.M., Senior Registrar, Maudsley Hospital, London, England; Present address, Mayo Clinic, Rochester, Minnesota. P. B. Whatmore, M.B., LL.B., Senior Registrar, Maudsley Hospital, London, England.