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THE EXPERT WITNESS
42
Although a certain amount of continued practice by the consultant in the more menial tasks is good for him, he is of most value to the general practitioner if he has, and continues to gain, wide experience of the unusual ; and lack of junior staff must of necessity curtail this experience. Also the cutting out of domiciliary consultations to make more time for hospital work would, I consider, be bad for the service, since such consultations strengthen the bond between general practitioner and hospital service and enable both to gain more understanding of each other’s problems. Children’s Annexe, Luton and Dunstable Hospital, Luton, Bedfordshire.
GRAHAME FAGG. SIR,-At the risk of taking their attention off their floats I suggest that the three unsuccessful anglers on Wigan piet’ (May 23) will do well to change their baits and their quarry. Not long ago there were fewer anglers and the fish tumbled over each other to be caught, and I have reason to think that these veteran anglers are no less succesful now. Those with empty creels will do well to consider their methods and copy their more seductive lures. They are hoping to catch, not stokers and kitchenmaids, but ambitious members of a learned profession. I do not pretend that this is the whole answer to their troubles. A change of bait will earn them better fish but not enough to fill their establishments. There are too many fishermen and too few fish. To overstock the pond is a desperate remedy. Those who now angle in vain might do worse than try for other fish. The post of " assistant medical officer," so common before the war, has ceased to exist; there may be a place for a general-duty registrar." The bait to take these will not be that which attracts a younger man, but greater experience will make them more profitable game. As any angler knows there is always room for experiment. Now, gentlemen, tisht lines. FILIUS TERRAE. N.B.-I hope that they put back the young doctors who do not reach the limit of industry or ability.
readers claiming they experienced the phenomenon " came from people suffering from a form of real nightmare. Ernest Jones wrote a comprehensive book1 on this subject, about which I also have written.2 In these publications will be found an account of the literature. These phenomena are important, too, because they throw light on the sleep mechanism in general. ARTHUR STERN. Jerusalem. MYSOLINE IN THE TREATMENT OF EPILEPSY SiB,,-—We were interested to read Dr. Butter’s article in your issue of May 23. During the past nine months, in general practice, we have treated 6 patients with Mysoline,’ and our observations may be of interest. Of 10 patients with idiopathic epilepsy, 6 were selected
being inadequately controlled by other anticonvulsant drugs ; all were cases of grand mal. The results are shown in the accompanying table. Of the 6 patients 5
as
EFFECT OF MYSOLINE COMPARED WITH THAT OF OTHER TREATMENT IN 6 CASES OF GRAND MAL
"
THE EXPERT WITNESS
to
Sm,—It is important that injustice should not be done a single case, let alone a " minimal number, and "
equally that justice should be done to all. Dr. Armstrong Davison introduces a new aspect
when insane person can be protected legally by what he calls a defence in depth. This does not constitute an issue as far as I am concerned, but I am afraid lest the complacent tone of his letter should beguile you into believing that he has answered my point, and that all is well, because lie appears to have failed entirely to see it. Otherwise he could not have fair decision for a jury of laymen " written that it is a to make-i.e., the assessment of insanity under the McNaughten rules.
he says (June 20) that
an
"
Department of Pathology, Queen’s University of Belfast.
A. L. WELLS.
SLEEP PARALYSIS
have read with interest your annotation this subject. There have been many reports on sleep paralysis from the pathological point of view. The attacks appear
SIR,-I (Feb. 14)
not
on
uncommonly as a sequel to encephalitis lethargica, especially in the morning as " waking attacks " or delayed psychomotor awakening," and are the expression of sleep dissociation " between sleep of the brain and sleep of the body, as in other sleep disturbances. The striking feature is complete inability to move or speak although consciousness is quite clear. These waking attacks are very similar and are related to the well-known symptom of real nightmare, and it seems to me very probable that the " more than 600 letters" received by Mr. Chapman Pincher (March 7) " from "
"
showed marked improvement, although in 3 better results obtained when mysoline was reinforced with
were
phenobarbitone. Mysoline was introduced gradually, as recommended by Handley and Stewart,3 over a period of three to four weeks. 2 patients showed an increase in frequency of fits during this period, and it is possible that the change 3 patients showed was too rapid for these patients. drowsiness, and 1 giddiness ; and in 1 patient drowsiness No other toxic was associated with slurring of speech. In 1 patient (case 4) effects were encountered. treatment was established in hospital. No statistical conclusions can be drawn from this small number of cases, but we can say that we have not It is not encountered any difficulties in treatment. possible to predict whether a patient with major fits will be benefited by mysoline. The drug seems to be worth a trial in patients not well controlled by other anticonvulsant drugs, or in those in whom an unduly high dosage has to be given. 1. 2. 3.
Jones, E. Nightmare, Witches, Devils. New York, 1931. Stern, A. Schweiz. Arch. Neurol. Psychiat. 1951, 57, 405. Handley, R., Stewart, A. S. R. Lancet, 1952, i, 742.
Although a certain amount of continued practice by the consultant in the more menial tasks is good for him, he is of most value to the general practitioner if he has, and continues to gain, wide experience of the unusual ; and lack of junior staff must of necessity curtail this experience. Also the cutting out of domiciliary consultations to make more time for hospital work would, I consider, be bad for the service, since such consultations strengthen the bond between general practitioner and hospital service and enable both to gain more understanding of each other’s problems. Children’s Annexe, Luton and Dunstable Hospital, Luton, Bedfordshire.
GRAHAME FAGG. SIR,-At the risk of taking their attention off their floats I suggest that the three unsuccessful anglers on Wigan piet’ (May 23) will do well to change their baits and their quarry. Not long ago there were fewer anglers and the fish tumbled over each other to be caught, and I have reason to think that these veteran anglers are no less succesful now. Those with empty creels will do well to consider their methods and copy their more seductive lures. They are hoping to catch, not stokers and kitchenmaids, but ambitious members of a learned profession. I do not pretend that this is the whole answer to their troubles. A change of bait will earn them better fish but not enough to fill their establishments. There are too many fishermen and too few fish. To overstock the pond is a desperate remedy. Those who now angle in vain might do worse than try for other fish. The post of " assistant medical officer," so common before the war, has ceased to exist; there may be a place for a general-duty registrar." The bait to take these will not be that which attracts a younger man, but greater experience will make them more profitable game. As any angler knows there is always room for experiment. Now, gentlemen, tisht lines. FILIUS TERRAE. N.B.-I hope that they put back the young doctors who do not reach the limit of industry or ability.
readers claiming they experienced the phenomenon " came from people suffering from a form of real nightmare. Ernest Jones wrote a comprehensive book1 on this subject, about which I also have written.2 In these publications will be found an account of the literature. These phenomena are important, too, because they throw light on the sleep mechanism in general. ARTHUR STERN. Jerusalem. MYSOLINE IN THE TREATMENT OF EPILEPSY SiB,,-—We were interested to read Dr. Butter’s article in your issue of May 23. During the past nine months, in general practice, we have treated 6 patients with Mysoline,’ and our observations may be of interest. Of 10 patients with idiopathic epilepsy, 6 were selected
being inadequately controlled by other anticonvulsant drugs ; all were cases of grand mal. The results are shown in the accompanying table. Of the 6 patients 5
as
EFFECT OF MYSOLINE COMPARED WITH THAT OF OTHER TREATMENT IN 6 CASES OF GRAND MAL
"
THE EXPERT WITNESS
to
Sm,—It is important that injustice should not be done a single case, let alone a " minimal number, and "
equally that justice should be done to all. Dr. Armstrong Davison introduces a new aspect
when insane person can be protected legally by what he calls a defence in depth. This does not constitute an issue as far as I am concerned, but I am afraid lest the complacent tone of his letter should beguile you into believing that he has answered my point, and that all is well, because lie appears to have failed entirely to see it. Otherwise he could not have fair decision for a jury of laymen " written that it is a to make-i.e., the assessment of insanity under the McNaughten rules.
he says (June 20) that
an
"
Department of Pathology, Queen’s University of Belfast.
A. L. WELLS.
SLEEP PARALYSIS
have read with interest your annotation this subject. There have been many reports on sleep paralysis from the pathological point of view. The attacks appear
SIR,-I (Feb. 14)
not
on
uncommonly as a sequel to encephalitis lethargica, especially in the morning as " waking attacks " or delayed psychomotor awakening," and are the expression of sleep dissociation " between sleep of the brain and sleep of the body, as in other sleep disturbances. The striking feature is complete inability to move or speak although consciousness is quite clear. These waking attacks are very similar and are related to the well-known symptom of real nightmare, and it seems to me very probable that the " more than 600 letters" received by Mr. Chapman Pincher (March 7) " from "
"
showed marked improvement, although in 3 better results obtained when mysoline was reinforced with
were
phenobarbitone. Mysoline was introduced gradually, as recommended by Handley and Stewart,3 over a period of three to four weeks. 2 patients showed an increase in frequency of fits during this period, and it is possible that the change 3 patients showed was too rapid for these patients. drowsiness, and 1 giddiness ; and in 1 patient drowsiness No other toxic was associated with slurring of speech. In 1 patient (case 4) effects were encountered. treatment was established in hospital. No statistical conclusions can be drawn from this small number of cases, but we can say that we have not It is not encountered any difficulties in treatment. possible to predict whether a patient with major fits will be benefited by mysoline. The drug seems to be worth a trial in patients not well controlled by other anticonvulsant drugs, or in those in whom an unduly high dosage has to be given. 1. 2. 3.
Jones, E. Nightmare, Witches, Devils. New York, 1931. Stern, A. Schweiz. Arch. Neurol. Psychiat. 1951, 57, 405. Handley, R., Stewart, A. S. R. Lancet, 1952, i, 742.