- Email: [email protected]
" REGISTRAR PROBLEM "
100 of current of varying voltage for a period of 30 to 60 seconds. A control knob allows the therapist to alter the voltage so that clonic movements can be reduced to a slight twitching which indicates the course of the convulsion. Ectonus is a refined method which is both safer and more effective therapeutically than the traditional (" straight " or one-shot ") E.C.T. In 1953 Dr. Russell and his colleagues1 described " itensified E.C.T." to which method later the term
application
"
"
"
fused-dosage or " interrupted fused-dosage " (LF.D.) was applied. Many of us who used it regarded this method as itself an improvement on the traditional method, but the same therapists would probably now regard LF.D. as having been for the most part replaced by ectonus; but in acute mania, and some emergencies such as threatened suicide or refusal of food, one might prefer i.F.D. to ectonus for its greater potency and quicker results. No-one, I believe, with good experience of the two newer techniques and who had used them in the recommended way, would ever want to return to the cruder older method. But more than most, psychiatrists are slow to
change. Just over a year ago a series of articles was published giving a full account of the combination of ectonus E.C.T. with promazine drugs, the name ectonus-promazine therapy or E.P.T. being given"to this planned combination.2 It is strongly recommended that, whether ectonus or other technique is used, the electrical part of the combined treatment should be given intensively-i.e., on successive days. With ectonus the course on average would be one dose a day for seven successive days. This corresponds closely to what Jacoby3 calls " regressive shock therapy,"amethod whereby E.c.T. is given by intensive daily dosage to the extent of producing a transient but severe confusional state. Dr. Jacoby’s technique, however, involved the use of the older method of E.C.T. With E.P.T. good and lasting recoveries are achieved,5 and the period of confusion lasts only four or five days and is much less severe than that described by Dr.Jacoby. It is important to note too that recovery of memory is rapid and comolete. Lennox Castle
Hospital, Lennoxtown,
Stirlingshire.
ALLAN A. MACDOUGALL.
STAPHYLOCOCCAL INFECTION IN HOSPITALS recent editorials on problems of infection have been most praiseworthy. They have hospitals been perhaps just a little above the head of one who is so little advanced that he is still at the stage of having to battle with problems of ordinary domestic cleanliness;
SIR,-Your
in
but nevertheless your remarks not only are appreciated but also act as a stimulus to further efforts. In an effort to get the walls of a hospital cleaned, I have been reduced to the somewhat dubious pastime of writing on the walls of the main corridors. Being a progressive individual, I felt that I could combine in one action both a cleansing and an educational effect upon our administrators by writing in water on a background of dirt the words shown in the accompanying photograph. 1. 2.
Russell, R. J., Page, L. G. M., Jillett, R. L. Lancet, 1953, ii, 1177. MacDougall, A. A., Campbell, D. Nursing Mirror, 1957, 106, Nov. 29,
3. 4. 5.
Jacoby, M. G. Brit. med. J. 1958. i, 282. Jacoby, M. G., Babikian, H. M. N.Y. St. J. Med. 1958, 58, 2965. MacDougall, A. A. Brit. med. J. 1958, i, 1180.
Dec. 6, 13.
To illustrate further my difficulties I may add that my initial efforts were not successful. The words were merely smeared out, and the smears remained for ten days. It was only when I was observed by a member of the hos. pital administration actually having photographs taken that something was done about it. You can easily imagine that at one stage in my cam. paign I felt that I might have to emulate that eccentric character of the time of the Great Plague, Solomon Eccles, and face the management committee dressed in a loin-cloth and wearing on my head a brazier of live coals shouting the words " After the Pestilence cometh the Fire. Prepare to meet thy Doom ". I would be quite prepared to do this if I thought it would do any goodwhich I doubt-but I feel sure that the support of your editorials and valuable space will prove far more effective. Meanwhile, just in case, my wife and daughter have started to knit me a loin-cloth. Gateshead,
STANLEY WAY.
Co. Durham. "
REGISTRAR PROBLEM
"
SIR,-Have those who could act on the registrar problem never read Twenty Years A-growing by Maurice O’Sullivan? In which the following truth is written: Did you never hear how the life of man is divided?1 Twenty years a-growing, twenty years in blossom, twenty years a-stooping and twenty years declining." " NEARLY OUT OF BLOOM." "
TREATMENT OF LEPTOSPIROSIS WITH OXYTETRACYCLINE SIR,-We were interested to read the article on leptospirosis by Dr. Russell (Nov. 29). Factors governing the fall in the mortality of lepto-
spirosis include (a) better diagnosis identifying mild cases previously unrecognised, and (b) early diagnosis facilitating skilled medical and nursing care. Also of much significance in the improved prognosis of severe leptospirosis is the skilled application of modern knowledge in the early recognition of water and salt depletion and its remedy, and the maintenance of correct hydration and electrolyte balance. No longer is it true to say, as one writer did less than a decade ago, that more lives are lost by intravenous fluid administration than are saved by it.
Our decision not to have actual controls in our workwas deliberately taken. Much of the work on the diagnosis, clinical manifestations, and methods of treatment reported from postwar Malaya was done on security forces in British military hospitals.2-6 The annual reports of the successive consultant physicians FARELF were a mine of information. Furthermore, we believed that there was sufficient evidence that penicillin was effective in man, provided it was given early enough, often enough, and in adequate dosage. 7-9 Accordingly, as so much work had been done in the previous five years on security forces in Malaya, from the same leptospiral environments that we were to draw our cases, we felt that the patients studied by our predecessors could act as phantom controls. Indeed, in the
original script on our work, reference was made to these controls; but inadvertently it was not included in the work as
published. F. J. R. Army med. Cps, 1957, 103, 186. Hobson, A. C. M.D. Thesis, University of London, 1952. Hughes, W. D. Annual Report of Consultant Physician, FARELF, 1954. Fairburn, A. C., Semple, S. J. G. Lancet, 1956, i, 13. 5. Trimble, A. P. Annual Report of Consultant Physician, FARELF, 1955; Proc. R. Soc. Med. 1957, 50, 125. 6. McCrumb, F. R. Amer. J. trop. Med. Hyg. 1957, 6, 238. 7. Smith, J. Brit. J. industr. Med. 1949, 6, 213. 8. Varfolomeeva, A. A. Soviet Med., Moscow 1951, 11, 29. 9. Doherty R. L. Aust. Ann. Med. 1955, 4, 53. 1. 2. 3. 4.
Mackay-Dick, J., Robinson, J.
’;
application
"
"
"
fused-dosage or " interrupted fused-dosage " (LF.D.) was applied. Many of us who used it regarded this method as itself an improvement on the traditional method, but the same therapists would probably now regard LF.D. as having been for the most part replaced by ectonus; but in acute mania, and some emergencies such as threatened suicide or refusal of food, one might prefer i.F.D. to ectonus for its greater potency and quicker results. No-one, I believe, with good experience of the two newer techniques and who had used them in the recommended way, would ever want to return to the cruder older method. But more than most, psychiatrists are slow to
change. Just over a year ago a series of articles was published giving a full account of the combination of ectonus E.C.T. with promazine drugs, the name ectonus-promazine therapy or E.P.T. being given"to this planned combination.2 It is strongly recommended that, whether ectonus or other technique is used, the electrical part of the combined treatment should be given intensively-i.e., on successive days. With ectonus the course on average would be one dose a day for seven successive days. This corresponds closely to what Jacoby3 calls " regressive shock therapy,"amethod whereby E.c.T. is given by intensive daily dosage to the extent of producing a transient but severe confusional state. Dr. Jacoby’s technique, however, involved the use of the older method of E.C.T. With E.P.T. good and lasting recoveries are achieved,5 and the period of confusion lasts only four or five days and is much less severe than that described by Dr.Jacoby. It is important to note too that recovery of memory is rapid and comolete. Lennox Castle
Hospital, Lennoxtown,
Stirlingshire.
ALLAN A. MACDOUGALL.
STAPHYLOCOCCAL INFECTION IN HOSPITALS recent editorials on problems of infection have been most praiseworthy. They have hospitals been perhaps just a little above the head of one who is so little advanced that he is still at the stage of having to battle with problems of ordinary domestic cleanliness;
SIR,-Your
in
but nevertheless your remarks not only are appreciated but also act as a stimulus to further efforts. In an effort to get the walls of a hospital cleaned, I have been reduced to the somewhat dubious pastime of writing on the walls of the main corridors. Being a progressive individual, I felt that I could combine in one action both a cleansing and an educational effect upon our administrators by writing in water on a background of dirt the words shown in the accompanying photograph. 1. 2.
Russell, R. J., Page, L. G. M., Jillett, R. L. Lancet, 1953, ii, 1177. MacDougall, A. A., Campbell, D. Nursing Mirror, 1957, 106, Nov. 29,
3. 4. 5.
Jacoby, M. G. Brit. med. J. 1958. i, 282. Jacoby, M. G., Babikian, H. M. N.Y. St. J. Med. 1958, 58, 2965. MacDougall, A. A. Brit. med. J. 1958, i, 1180.
Dec. 6, 13.
To illustrate further my difficulties I may add that my initial efforts were not successful. The words were merely smeared out, and the smears remained for ten days. It was only when I was observed by a member of the hos. pital administration actually having photographs taken that something was done about it. You can easily imagine that at one stage in my cam. paign I felt that I might have to emulate that eccentric character of the time of the Great Plague, Solomon Eccles, and face the management committee dressed in a loin-cloth and wearing on my head a brazier of live coals shouting the words " After the Pestilence cometh the Fire. Prepare to meet thy Doom ". I would be quite prepared to do this if I thought it would do any goodwhich I doubt-but I feel sure that the support of your editorials and valuable space will prove far more effective. Meanwhile, just in case, my wife and daughter have started to knit me a loin-cloth. Gateshead,
STANLEY WAY.
Co. Durham. "
REGISTRAR PROBLEM
"
SIR,-Have those who could act on the registrar problem never read Twenty Years A-growing by Maurice O’Sullivan? In which the following truth is written: Did you never hear how the life of man is divided?1 Twenty years a-growing, twenty years in blossom, twenty years a-stooping and twenty years declining." " NEARLY OUT OF BLOOM." "
TREATMENT OF LEPTOSPIROSIS WITH OXYTETRACYCLINE SIR,-We were interested to read the article on leptospirosis by Dr. Russell (Nov. 29). Factors governing the fall in the mortality of lepto-
spirosis include (a) better diagnosis identifying mild cases previously unrecognised, and (b) early diagnosis facilitating skilled medical and nursing care. Also of much significance in the improved prognosis of severe leptospirosis is the skilled application of modern knowledge in the early recognition of water and salt depletion and its remedy, and the maintenance of correct hydration and electrolyte balance. No longer is it true to say, as one writer did less than a decade ago, that more lives are lost by intravenous fluid administration than are saved by it.
Our decision not to have actual controls in our workwas deliberately taken. Much of the work on the diagnosis, clinical manifestations, and methods of treatment reported from postwar Malaya was done on security forces in British military hospitals.2-6 The annual reports of the successive consultant physicians FARELF were a mine of information. Furthermore, we believed that there was sufficient evidence that penicillin was effective in man, provided it was given early enough, often enough, and in adequate dosage. 7-9 Accordingly, as so much work had been done in the previous five years on security forces in Malaya, from the same leptospiral environments that we were to draw our cases, we felt that the patients studied by our predecessors could act as phantom controls. Indeed, in the
original script on our work, reference was made to these controls; but inadvertently it was not included in the work as
published. F. J. R. Army med. Cps, 1957, 103, 186. Hobson, A. C. M.D. Thesis, University of London, 1952. Hughes, W. D. Annual Report of Consultant Physician, FARELF, 1954. Fairburn, A. C., Semple, S. J. G. Lancet, 1956, i, 13. 5. Trimble, A. P. Annual Report of Consultant Physician, FARELF, 1955; Proc. R. Soc. Med. 1957, 50, 125. 6. McCrumb, F. R. Amer. J. trop. Med. Hyg. 1957, 6, 238. 7. Smith, J. Brit. J. industr. Med. 1949, 6, 213. 8. Varfolomeeva, A. A. Soviet Med., Moscow 1951, 11, 29. 9. Doherty R. L. Aust. Ann. Med. 1955, 4, 53. 1. 2. 3. 4.
Mackay-Dick, J., Robinson, J.
’;