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RADCLIFFE TRACHEOSTOMY TUBE
599 All the points showingthe presence of detectable triiodothyronine activity were obtained by enzymic hydrolysis, while 60% of the points showing no detectable triiodothyronine activity were obtained by alkaline hydrolysis. However, Braasch et al., " in their table 3, describe an experiment in which the column residual " fraction of an enzymic hydrolysis was rehydrolysed by alkali. This prolonged the minimum overall time to 116 hours and gave a triiodothyronine/thyroxine ratio of 0.14 . in the figure). These results are consistent with the existence of the error postulated at the beginning of this note. Inspection of the pertinent current literature reveals many papers to which the same criticism might be applicable but in which sufficient detail to determine whether or not this is so has not been
(shown as
supplied. Please let me make this point clear. A single possible source of error is pointed out in this note. As examples of where this source of error may play a part, I have cited papers which undeniably are worthwhile contributions in several respects. Furthermore, there are many thyroid experiments performed with radioactive iodide which could not be affected by this error because of the presence of carrier iodide, short duration, or the ruling out of this effect hv
nrnner
G. W. Carnrick
Newark,
New
rnntrnle
Company,
MARSHALL E. DEUTSCH.
Jersey.
RADCLIFFE TRACHEOSTOMY TUBE SIR,-It seems that, in one respect, Dr. Sandiford (Aug. 27) has misread our article of Aug. 20. Prototype A
tracheostomy tube caused irritation, but when this was replaced by a tube with identical measurements, overdipped in latex (prototype B), the skin condition healed. The Radcliffe tracheostomy tube has beeh available with for over arms of two different lengths since 1956,1 and eighteen months has been made in three. Nuffield Department of Anaesthetics, The Radcliffe Infirmary, Oxford.
R. H. SALT.
CEREBRAL MANIFESTATIONS OF ADDISONIAN PERNICIOUS ANÆMIA most ably describec common than is generally must be more which problem realised. In 14 years of general practice in this area 7 myself have come across three such cases.
SiR,-Dr. Fraser (Aug. 27) has
a
The first
hospital
was a man
of 54 who
was
admitted
to a
mental
typical case of endogenous depression of many months’ standing. The correct blood diagnosis was made in hospital and injections of ’Anahaemin’ alone raised the depression. He has kept well ever since and had regulai as a
injections
of vitamin B12’ The second was a case of depersonalisation in a woman of 43. She had in the first instance six months’ treatment in a mental hospital without any benefit. Later at home she developed extreme pallor with an icteric tinge, and she was diagnosed as a case of pernicious ansemia at the general hospital. Vitamin-BlI injections have given her a normal blood picture, but heI mental state has remained just the same. The third case was a woman of 53 who was a depressed diabetic. She had been in a state of depression for years. Pallor and parsesthesias developed and the local diabetic clinic diagnosed pernicious anasmia with subacute combined degeneration. She was given vitamin B12 and this cleared her ansmia, parsesthesise, and depression, and she has been remarkably well ever since. In all three cases the mental symptoms developed long before the blood picture became obvious. Under the circumstances it is fortunate that two out of the three made such a good recoverv. How Ions can pernicious anxmia lie latent ? 1.
Lancet, 1956, ii, 1247.
A friend of mine lost his father and his grandfather from pernicious anxmia. In middle age this man began to feel ill with intense lassitude and diarrhoea. With such a family history his physicians must have looked for pernicious anemia, but it was some four years before the blood-count revealed the true diagnosis. He has been perfectly well since the institution of vitamin-B12 treatment.
All this makes one wonder how many more chronic in general practice are suffering from latent pernicious anxmia. We are rightly advised not to give B12 until a precise diagnosis has been made, but the temptation to give some of these patients " a shot in the arm " is very real. How accurate are the methods of early diagnosis advocated by Dr. Fraser, and how soon will they be available to our patients ? C. A. H. WATTS. cases
DOUBTFUL PROGRESS IN PSYCHIATRY
SiR,łThe balanced and judicious comments by Dr. Oliver (July 30) are indeed timely and deserve very careful consideration. Those of us who have been privileged to gain our early experience in the most progressive mental hospitals, and have also acquired an eclectic psychiatric orientation-comprising individual and social psychological, as well as organic and physiological, concepts-" and whose outlook is consequently far from " reactionary or overcautious, have nevertheless all too often been faced, for various reasons, with the dilemma of steering a treacherous course between the Scylla of institutionalisation and the Charybdis of discharging prematurely our
psychotic patients. The social and legal problems which confront apparent in the following statement l:
us are
"
It is necessary to balance the possible benefits of treatof other training, the protection of the patient and persons, on the one hand, against the patient’s loss of liberty on the other "-although in practice this is sometimes easier said than done, depending as it does on clinical judgment and experience, and too often also on administrative expediency. It is no doubt true, as Professor Hargreaves2 says, that those requiring compulsory detention are "a minority of about 20% of the patients who enter mental hospitals ", but it remains primarily the onerous responsibility of psychiatrists to ensure that these 20% are cared for in hospital as long as may be necessary, and that the community is also reasonably protected so far as some of these patients are concerned. Taking the for for and Wales 1955, alone, 20% of England figures admissions to mental hospitals still represent some 19,500 patients, and 20% of the mental hospital population, some 30,700 patients; and, in addition, it should be noted that, in 1954, second or subsequent admissions to mental hospitals were equivalent to approximately two-thirds of new admissions during the same year (63% for males, and 69% for females).l It is of interest that the main points raised by Dr. Oliver are emphasised in almost identical terms in a recent article by a French psychiatrist,3 in which he draws attention to a large series of serious crimes of violence committed in France in the past few years by prematurely discharged mental patients (without, as the author observes, taking into account the numerous suicides and other tragedies attributable to this same cause). Many patients thus " sacrificed to administrative expediency " and the policy of rapid turnover are subsequently readmitted to hospital on a number of occasions, each time a little more deteriorated. Leconte concludes that the present situation, in France, " appears to be serious not only for public order and personal safety, but for the mental patients themselves who, when ment or
...
Report of the Royal Commission on the Law relating to Mental Illness; pp. 110, 310-311. Cmd. 169. H.M. Stationery Office, 1957. 2. Hargreaves, G. R. Psychiatry and the Public Health; pp. 113, 68-71. London, 1958. 3. Leconte, M. Ann. Méd. lég. 1960, 40, 246. 1.
(shown as
supplied. Please let me make this point clear. A single possible source of error is pointed out in this note. As examples of where this source of error may play a part, I have cited papers which undeniably are worthwhile contributions in several respects. Furthermore, there are many thyroid experiments performed with radioactive iodide which could not be affected by this error because of the presence of carrier iodide, short duration, or the ruling out of this effect hv
nrnner
G. W. Carnrick
Newark,
New
rnntrnle
Company,
MARSHALL E. DEUTSCH.
Jersey.
RADCLIFFE TRACHEOSTOMY TUBE SIR,-It seems that, in one respect, Dr. Sandiford (Aug. 27) has misread our article of Aug. 20. Prototype A
tracheostomy tube caused irritation, but when this was replaced by a tube with identical measurements, overdipped in latex (prototype B), the skin condition healed. The Radcliffe tracheostomy tube has beeh available with for over arms of two different lengths since 1956,1 and eighteen months has been made in three. Nuffield Department of Anaesthetics, The Radcliffe Infirmary, Oxford.
R. H. SALT.
CEREBRAL MANIFESTATIONS OF ADDISONIAN PERNICIOUS ANÆMIA most ably describec common than is generally must be more which problem realised. In 14 years of general practice in this area 7 myself have come across three such cases.
SiR,-Dr. Fraser (Aug. 27) has
a
The first
hospital
was a man
of 54 who
was
admitted
to a
mental
typical case of endogenous depression of many months’ standing. The correct blood diagnosis was made in hospital and injections of ’Anahaemin’ alone raised the depression. He has kept well ever since and had regulai as a
injections
of vitamin B12’ The second was a case of depersonalisation in a woman of 43. She had in the first instance six months’ treatment in a mental hospital without any benefit. Later at home she developed extreme pallor with an icteric tinge, and she was diagnosed as a case of pernicious ansemia at the general hospital. Vitamin-BlI injections have given her a normal blood picture, but heI mental state has remained just the same. The third case was a woman of 53 who was a depressed diabetic. She had been in a state of depression for years. Pallor and parsesthesias developed and the local diabetic clinic diagnosed pernicious anasmia with subacute combined degeneration. She was given vitamin B12 and this cleared her ansmia, parsesthesise, and depression, and she has been remarkably well ever since. In all three cases the mental symptoms developed long before the blood picture became obvious. Under the circumstances it is fortunate that two out of the three made such a good recoverv. How Ions can pernicious anxmia lie latent ? 1.
Lancet, 1956, ii, 1247.
A friend of mine lost his father and his grandfather from pernicious anxmia. In middle age this man began to feel ill with intense lassitude and diarrhoea. With such a family history his physicians must have looked for pernicious anemia, but it was some four years before the blood-count revealed the true diagnosis. He has been perfectly well since the institution of vitamin-B12 treatment.
All this makes one wonder how many more chronic in general practice are suffering from latent pernicious anxmia. We are rightly advised not to give B12 until a precise diagnosis has been made, but the temptation to give some of these patients " a shot in the arm " is very real. How accurate are the methods of early diagnosis advocated by Dr. Fraser, and how soon will they be available to our patients ? C. A. H. WATTS. cases
DOUBTFUL PROGRESS IN PSYCHIATRY
SiR,łThe balanced and judicious comments by Dr. Oliver (July 30) are indeed timely and deserve very careful consideration. Those of us who have been privileged to gain our early experience in the most progressive mental hospitals, and have also acquired an eclectic psychiatric orientation-comprising individual and social psychological, as well as organic and physiological, concepts-" and whose outlook is consequently far from " reactionary or overcautious, have nevertheless all too often been faced, for various reasons, with the dilemma of steering a treacherous course between the Scylla of institutionalisation and the Charybdis of discharging prematurely our
psychotic patients. The social and legal problems which confront apparent in the following statement l:
us are
"
It is necessary to balance the possible benefits of treatof other training, the protection of the patient and persons, on the one hand, against the patient’s loss of liberty on the other "-although in practice this is sometimes easier said than done, depending as it does on clinical judgment and experience, and too often also on administrative expediency. It is no doubt true, as Professor Hargreaves2 says, that those requiring compulsory detention are "a minority of about 20% of the patients who enter mental hospitals ", but it remains primarily the onerous responsibility of psychiatrists to ensure that these 20% are cared for in hospital as long as may be necessary, and that the community is also reasonably protected so far as some of these patients are concerned. Taking the for for and Wales 1955, alone, 20% of England figures admissions to mental hospitals still represent some 19,500 patients, and 20% of the mental hospital population, some 30,700 patients; and, in addition, it should be noted that, in 1954, second or subsequent admissions to mental hospitals were equivalent to approximately two-thirds of new admissions during the same year (63% for males, and 69% for females).l It is of interest that the main points raised by Dr. Oliver are emphasised in almost identical terms in a recent article by a French psychiatrist,3 in which he draws attention to a large series of serious crimes of violence committed in France in the past few years by prematurely discharged mental patients (without, as the author observes, taking into account the numerous suicides and other tragedies attributable to this same cause). Many patients thus " sacrificed to administrative expediency " and the policy of rapid turnover are subsequently readmitted to hospital on a number of occasions, each time a little more deteriorated. Leconte concludes that the present situation, in France, " appears to be serious not only for public order and personal safety, but for the mental patients themselves who, when ment or
...
Report of the Royal Commission on the Law relating to Mental Illness; pp. 110, 310-311. Cmd. 169. H.M. Stationery Office, 1957. 2. Hargreaves, G. R. Psychiatry and the Public Health; pp. 113, 68-71. London, 1958. 3. Leconte, M. Ann. Méd. lég. 1960, 40, 246. 1.