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PRIMUM NON NOCERE
275
commendable initiative. Manchester transferred its dental staff to reception areas within the first few weeks of war, Preston sent travelling clinics to the schools, and others gave ready assistance to reception authorities. On the other hand, so pro-
gressive an authority as Cambridge delayed making dental appointments pending elucidation of the Board’s financial proposals. Some difficulties still remain. Reception authorities have to decide whether to make new appointments now when the evacuated population is flowing homewards but may return overnight Another if the industrial areas are attacked. most that treatment is is being carried problem consent. It without is not always out parental a to avoid anaesthetic in these general possible it to and is too much that there will cases, hope
be no accidents. Local authorities can safeguard themselves and their staffs by arranging for evacuation authorities to obtain consent from the parents; this arrangement is already working satisfactorily in several areas. The factor which in the last five months has helped to get things done more than all the memoranda, circulars and minutes has been the child suffering pain for want of effective treatment. Were this sufficiently
realised we should soon see the machinery overhauled and central departments cooperating more readily with local authorities. The school dental service has been developing steadily, and if war had not come the increasing interest of the public would have led to the large extension in staff which was necessary. This development should not be held up by the war.
ANNOTATIONS PRIMUM NON NOCERE
Though spinal anaesthesia is not without its dangers, in the absence of an operation they are minimal. If Bennett’s findings are confirmed, the one really serious objection to convulsion therapy will have been Two other useful hints are given by removed. Bennett. For apprehensive patients, if gr. 1/1501/100 hyoscine an hour before the convulsion fails to relieve the fear, insulin coma may be induced, glucose being given immediately after the convulsion to terminate the coma. Large doses of cardiazol may be avoided by a preliminary intravenous injection of 0’5 c.cm. of liq. adrenaline. At the moment of facial half the usual dose of cardiazol is injected, blanching, and the result is said to be equal to that of the full dose.
THE value of convulsant therapy, whether Cardiazol, Triazol or electricity is used, is perhaps most striking to those who actually witness the rapid changes it produces in psychotic patients. Hard statistical facts setting out results of treatment alongside spontaneous recoveries are less impressive. But few now deny that at least it hastens a favourable outcome in schizophrenics in whom time would have ultimately produced a cure. The same appears to be true of severe depressive and manic illnesses. Bennett1 reports the results of cardiazol therapy in 61 cases of depression and 9 of mania. Most of the depressed patients were There was no electroover the age of forty-five. CARBOHYDRATES AND STAPHYLOCOCCAL cardiographic evidence that the convulsions produced cardiac damage, even in patients who already had INFECTIONS heart disease. Of the depressed patients, 28 obtained IN discussing the relationship between staphyloa full remission and 32 made a social recovery, while coccal skin infections and diabetes it must be remem7 relapsed, though of these 4 improved on a second bered that, since the infection comes from without, course of treatment. The results were extremely rapid. virulent cocci must always be present on the skin Nine-tenths of the severe depressive attacks were before a boil can develop, whether the patient is terminated after two to three weeks of treatment, diabetic or not. If therefore diabetics are averaging 6 to 7 shocks. Therapy was most effective prone to infection, this is presumably due toespecially the fact in the depressions of middle and late middle age. that their resistance is lowered so that in them the Two-thirds of the severe manic attacks were terminated lesion is more serious and the susceptibility to cocci likewise, the average length of treatment being sixteen of moderate virulence greater than in normal people. and a half days, with 4 shocks. Such remarkably lowers the sugar tolerance In addition the infection satisfactory results would call for universal adoption still further and a vicious circle is apt to be estabof the treatment in the affective psychoses were it not 1 for two facts. In the first place, spontaneous recovery lished. Jackson, Nicholson and Holman have the precise relationship is the rule in these psychoses. Nevertheless, a severe attempted to investigate metabolism and staphylococcus between carbohydrate depression may last as long as two years-it is infection in rabbits. By keeping the animals for some perhaps the most unpleasant illness that can fall to weeks on a diet containing 89 per cent. of carbohydrate the lot of man-and a treatment which will end it their tolerance for glucose was regularly (dry weight) in a fortnight must be a godsend to patient and lowered. These rabbits, together with controls, were psychiatrist alike. The second fact is the known inoculated ’with living staphylococci, intradermally danger of the treatment. Vertebral and long-bone and the local lesions and the effect on sugar tolerance fractures are not a light price to pay, and elsewhere were compared in the two series. The influence of in this issue Dr. Blair records a case of hemiplegia of toxin intradermal was also tested in a injections following therapeutic convulsions. It is here that Bennett offers the most valuable similar way. Unfortunately, however, there seem to advice. In his series, vertebral and lower limb frac- have been no preliminary tests for circulating antitoxin in the rabbits which were used. A pre-existing tures were completely eliminated by giving a spinal anaesthetic an hour before the cardiazol was injected. immunity, such as is often present in otherwise normal Either 10 mg. of Pontocaine hydrochloride or 100 mg. animals, would certainly, as Downiehas shown, of Novocain was used. The aneasthetic was dissolved account for the localised lesions which developed in in 4 c.cm. of cerebrospinal fluid obtained by puncture the majority of the dieted animals, whereas its absence between the first and second lumbar vertebras. 1. Jackson, S. H., Nicholson, T. F., and Holman, W. L., J. Path. 1. Bennett, A. E., Amer. J. med. Sci. 1939, 198, 695.
Bact. January, 1940, p. 1. 2. Downie, A. W., Ibid, 1937, 44, 573.
commendable initiative. Manchester transferred its dental staff to reception areas within the first few weeks of war, Preston sent travelling clinics to the schools, and others gave ready assistance to reception authorities. On the other hand, so pro-
gressive an authority as Cambridge delayed making dental appointments pending elucidation of the Board’s financial proposals. Some difficulties still remain. Reception authorities have to decide whether to make new appointments now when the evacuated population is flowing homewards but may return overnight Another if the industrial areas are attacked. most that treatment is is being carried problem consent. It without is not always out parental a to avoid anaesthetic in these general possible it to and is too much that there will cases, hope
be no accidents. Local authorities can safeguard themselves and their staffs by arranging for evacuation authorities to obtain consent from the parents; this arrangement is already working satisfactorily in several areas. The factor which in the last five months has helped to get things done more than all the memoranda, circulars and minutes has been the child suffering pain for want of effective treatment. Were this sufficiently
realised we should soon see the machinery overhauled and central departments cooperating more readily with local authorities. The school dental service has been developing steadily, and if war had not come the increasing interest of the public would have led to the large extension in staff which was necessary. This development should not be held up by the war.
ANNOTATIONS PRIMUM NON NOCERE
Though spinal anaesthesia is not without its dangers, in the absence of an operation they are minimal. If Bennett’s findings are confirmed, the one really serious objection to convulsion therapy will have been Two other useful hints are given by removed. Bennett. For apprehensive patients, if gr. 1/1501/100 hyoscine an hour before the convulsion fails to relieve the fear, insulin coma may be induced, glucose being given immediately after the convulsion to terminate the coma. Large doses of cardiazol may be avoided by a preliminary intravenous injection of 0’5 c.cm. of liq. adrenaline. At the moment of facial half the usual dose of cardiazol is injected, blanching, and the result is said to be equal to that of the full dose.
THE value of convulsant therapy, whether Cardiazol, Triazol or electricity is used, is perhaps most striking to those who actually witness the rapid changes it produces in psychotic patients. Hard statistical facts setting out results of treatment alongside spontaneous recoveries are less impressive. But few now deny that at least it hastens a favourable outcome in schizophrenics in whom time would have ultimately produced a cure. The same appears to be true of severe depressive and manic illnesses. Bennett1 reports the results of cardiazol therapy in 61 cases of depression and 9 of mania. Most of the depressed patients were There was no electroover the age of forty-five. CARBOHYDRATES AND STAPHYLOCOCCAL cardiographic evidence that the convulsions produced cardiac damage, even in patients who already had INFECTIONS heart disease. Of the depressed patients, 28 obtained IN discussing the relationship between staphyloa full remission and 32 made a social recovery, while coccal skin infections and diabetes it must be remem7 relapsed, though of these 4 improved on a second bered that, since the infection comes from without, course of treatment. The results were extremely rapid. virulent cocci must always be present on the skin Nine-tenths of the severe depressive attacks were before a boil can develop, whether the patient is terminated after two to three weeks of treatment, diabetic or not. If therefore diabetics are averaging 6 to 7 shocks. Therapy was most effective prone to infection, this is presumably due toespecially the fact in the depressions of middle and late middle age. that their resistance is lowered so that in them the Two-thirds of the severe manic attacks were terminated lesion is more serious and the susceptibility to cocci likewise, the average length of treatment being sixteen of moderate virulence greater than in normal people. and a half days, with 4 shocks. Such remarkably lowers the sugar tolerance In addition the infection satisfactory results would call for universal adoption still further and a vicious circle is apt to be estabof the treatment in the affective psychoses were it not 1 for two facts. In the first place, spontaneous recovery lished. Jackson, Nicholson and Holman have the precise relationship is the rule in these psychoses. Nevertheless, a severe attempted to investigate metabolism and staphylococcus between carbohydrate depression may last as long as two years-it is infection in rabbits. By keeping the animals for some perhaps the most unpleasant illness that can fall to weeks on a diet containing 89 per cent. of carbohydrate the lot of man-and a treatment which will end it their tolerance for glucose was regularly (dry weight) in a fortnight must be a godsend to patient and lowered. These rabbits, together with controls, were psychiatrist alike. The second fact is the known inoculated ’with living staphylococci, intradermally danger of the treatment. Vertebral and long-bone and the local lesions and the effect on sugar tolerance fractures are not a light price to pay, and elsewhere were compared in the two series. The influence of in this issue Dr. Blair records a case of hemiplegia of toxin intradermal was also tested in a injections following therapeutic convulsions. It is here that Bennett offers the most valuable similar way. Unfortunately, however, there seem to advice. In his series, vertebral and lower limb frac- have been no preliminary tests for circulating antitoxin in the rabbits which were used. A pre-existing tures were completely eliminated by giving a spinal anaesthetic an hour before the cardiazol was injected. immunity, such as is often present in otherwise normal Either 10 mg. of Pontocaine hydrochloride or 100 mg. animals, would certainly, as Downiehas shown, of Novocain was used. The aneasthetic was dissolved account for the localised lesions which developed in in 4 c.cm. of cerebrospinal fluid obtained by puncture the majority of the dieted animals, whereas its absence between the first and second lumbar vertebras. 1. Jackson, S. H., Nicholson, T. F., and Holman, W. L., J. Path. 1. Bennett, A. E., Amer. J. med. Sci. 1939, 198, 695.
Bact. January, 1940, p. 1. 2. Downie, A. W., Ibid, 1937, 44, 573.