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THE FATE OF THE AMPUTEE
633
describing it in any common set of terms. Physicists find that light behaves in some respect like waves and in some respects like particles, and they have to put up with this peculiarity of light and adapt their language accordingly. Neurologists and psychologists who are unable to find a common language can at least behave like good citizens of the world and acquire each other’s. Some have already done so, learning, in the process, something of each other’s methods and achievements, and finding approaches to their joint study in which they can collaborate. From such combined endeavour may be expected to grow new terms, new analogies, new hypotheses and experiments, and, finally, a common language ; and the two disciplines would be in harmony for the from
Communication naive belief that in science we use terms, Prof. J. Z. YourTr this week reminds us
EXPLODING any
precise
the contrary, our language is largely that of analogy. The difficulty of the scientist in describing his material is, in fact, exactly the difficulty of the poet and the mystic-the, necessity of finding which that,
on
words, and in what. order, will best convey
to another
remotely accurate idea of what he person is talking about. The poet, being born with some facility-which he can improve by practice-for arranging these counters, has perhaps the least exacting problem of the three. He proceeds, as the scientist does, by the method of analogy and compari. son, using verbal images to rouse in other minds some even
echoes of the emotion he feels in his own. The mystic, with no vocabulary whatever to express his experiences, encounters the greatest difficulty of the three. If he attempts exact description he is driven either to the spineless " ineffable " or to such humdrum mineral images as gold, jasper, and sardonyx. For him, too, the only profitable means of communication is the language of analogy and symbol. The scientist, though he can mint new counters as he needs them, has his own peculiar problem : once he has described his objects he has to measure them; and the terms and analogies he uses, as Professor YourrG points out, will decide what objects he measures. If he is not inventive enough, not rich enough in rewarding analogies, he may hinder the development of his study and cut it off from allied lines of research. Professor YourrG is particularly concerned with the lack of a common language between neuro-anatomy and psychology. For though he favours an abundance of new analogies, from which new hypotheses might spring, he nevertheless thinks the current analogies used in speaking about the nervous system are too The neurologist has equipped numerous and varied. himself well with words to describe the functions of nerve-fibres and nerve-cells, but cannot find words to say all he would about the activities of the brain. Meanwhile psychologists have a totally different set of terms to describe events in human consciousness, and find they have little need to use or refer to neurological terms. Some psychologists talk of the more elaborate aspects of human behaviour in terms of entities such as the " id " and the " super-ego " ; and these, Professor YouNG admits, at least provide more complete descriptions than anything the neurologist can offer at present. What we need, he feels, is a common language in which both neurologists and psychologists can express their concepts-some set of terms which compares the brain with something more complicated than any simple machine, and which offers means of describing the memory system. This general language, he suggests, might put all the descriptions of the nervous system-structural, chemical, electrical, psychological—into their place as part of a system for talking about the whole human being. He believes it could be done, and that unless we do it our age may come to be regarded as concerned
only with trivia. That such
-
synthesis is needed, and ultimately no-one will doubt ; yet it may be that at inevitable, present it is we are
a
beyond
examining
The nature of the material may prevent us, for the moment, us.
theme to which Professor YourrG invites us all-the study of the balance by which human life is maintained, and all the factors that influence it.
Annotations THE FATE OF THE AMPUTEE 1950 the director-general of medical services, Ministry of Pensions, set up, under the chairmanship1 of Sir Ernest Rock Carling, an advisory committee to consider whether limb amputation and the subsequent wearing of a prosthesis could initiate or aggravate cardiovascular disorder, and whether mortality-rates were higher in amputees than in equivalent nonamputated persons. A somewhat inconclusive interim report, based on a. statistical study of amputee pensioners from the first world war, was published in 1951, and revealed in those still living no abnormal incidence of cardiovascular disease but a slight elevation of mean blood-pressure. Amputation, in itself, did not appear to influence mortality-rates during the period 1930-50, but the rate was higher in pensioners who
IN
had suffered
amputation
severe
wounding,
not.
However,
or
whether
more 1945—49 did a
accompanied by
detailed study of
certificates of deaths in suggest-though point of statistical significance-that patients with leg amputations died earlier, and more commonly from cardiovascular disease, than comparable pensioners with leg wounds not requiring amputation. The final report now being laid before Parliament describes further investigations, which have shown that thigh amputees and double leg amputees have a reduced expectation of life compared with normals or men with single below-knee amputations ; and also that, within the average figures for amputees as a whole, expectation of life was particularly lessened for those who had suffered serious prolonged sepsis after wounding. In this class of case also there was a greater than normal probability that certain cardiovascular disorders would be certified as the underlying cause of death ; and, unexpectedly, when cases of fractured femur and other leg wounds which had not led to amputation were analysed on the basis of whether major sepsis had occurred or not, it was found that this complication was again associated with a higher late incidence of cardiovascular disease and an earlier average age of death. The factors involved are complex and difficult to separate. Possibly the overweight and sedentary living consequent on limb amputation predispose to cardiovascular disorder ; and the committee, recognising that the strain of carrying an artificial leg may become an increasing physiological burden with advancing years, not to the
,
1.
Since the interim report appeared in April, 1951, the members of the committee have been:Sir ERNEST ROCK CARLING, F.B.C.S., Dr. A. GREIG ANDERSON, P.R.C.P., Prof. G. R. CAMERON, F.R.C.P., F.R.S., Dr. T. F. COTTON, Prof. J. L. D’SILVA, M.K.C.P., Prof. K. J. FRANKLIN, F.R.C.P., Dr. A. HOPE GOSSE, Dr. W. B. LLOYD, Dr. W. P. D. LOGAN, the late Mr. P. H. MITCHINER, F.R.C.S., and Dr. E. LIVINOSTONE (secretary).
634
cautiously suggest the possible need for reassessing some of these pensioners in later life : An important effect of our further studies is to suggest "
that
amongst amputees and other classes of wounded
there individuals who with the lapse of time reach a stage deserving of reconsideration. In any such reconsideration careful discrimination would be needed, as our conclusions are based on average tendencies and do not necessarily apply to any particular individual." are some
Of immediate relevance are some studies, by Dr. Verne T. Inman and his colleagues2 in San Francisco, of the energy expended in displacing the centre of gravity of the body through space. While the belowknee amputee is relatively normal from this point of view, the thigh amputee has to expend some 27% more energy for the same physical performance. Such a man, in effect, walks 5 yards to a normal man’s 4. An interesting point that emerges from the analysis ,is that major sepsis was also associated with a reduced liability to subsequent death from cancer, even allowing for the effect of an earlier average age of death on the incidence of malignant disease. This obviously calls for .
.
further study. Dr. A. Hope Gosse, in a minority report supported by Dr. W. E. Lloyd, denies that the evidence shows that the strain of wearing an artificial limb for thirty years increases the risk either of cardiovascular disease or of earlier death, and doubts whether one and the same statistical survey can show any true relation between previous sepsis on the one hand and cardiovascular or malignant disease on the other. And he takes the robust commonsense view-on a matter in which his opinion carries great weight-that there is no reason why life assurance should not be offered to these patients and to amputees in general at normal or near-normal rates. For the present, therefore, the matter cannot be regarded as entirely decided. Further investigation is called for by the committee, whose work is one more instance of the interesting and sometimes unexpected findings that may emerge from the statistical analysis of large numbers of detailed case-records.
INCREASES IN MATERNITY BENEFITS THE changes in maternity benefits set out in the National Insurance Bill, presented to Parliament on March 17, give effect to the recommendations made a year ago by an advisory committee.3 One of the most important principles which the committee urged was that the woman who wished to have her baby at home should not lose by this decision, and the Bill introduces a new home confinement grant of 13 which will do something to meet the extra expenses which a domiciliary birth always entails. The grant will be paid to mothers who are confined at their own expense and who do not occupy an N.H.S. hospital bed. The Bill continues to offer different benefits to meet the differing needs of the housewife and the employed woman. The first is the larger group, for six out of every, seven who claim maternity benefits are housewives. At present they receive a grant of f:4 and a weekly attendance allowance of Ela week for four weeks after the birth. In future they will receive a lump grant of E9 (plus the E3 home confinement grant when appropriate), and this sum will be paid before or after the birth as the mother chooses. For the employed woman the changes are even more advantageous. The advisory committee thought that maternity benefits, like sickness or employment benefits, should be payable only to women who chose to pay their own contributions ; and that an employed married woman should no longer be eligible by right of her husband’s The committee hoped that the money contribution. saved in this way would go to enlarge the grant made to contributors. The Bill gives effect to this restriction of 2. See Lancet, 1952, 3. Ibid, i, 201.
ii, 80.
a transitional period the rights of women who have not yet had time to qualify. The basic grant which an employed woman receives is increased from E4 to E9 (E12 if the confinement is at home). It also provides that her maternity allowance, now 36s. a week, will in future be paid at the standard benefit rate, which at present stands at 32s. 6d. a week. She will receive this allowance for eighteen weeks (instead of thirteen) and it will start eleven weeks before the expected date of her confinement (instead of six weeks). This allowance may be increased when the The effect of these changes mother has dependents. will be that a woman who is doing paid work will receive £38 5s. (or jE41 5s. if her confinement takes place at home) instead of E27 8s. as at present. Minor changes in the number of qualifying contributions ’are also designed to bring maternity benefit into line with sickness and unemployment benefits. But here, too, the woman who wishes to give up work earlier is offered help, for she may complete her qualifying con. tributions by paying the last thirteen at the non-employed reduced rates.
claims, but safeguards for
A LONG-ACTING LOCAL ANESTHETIC
IN the treatment of pain, analgesics only stop a gap until the cause is disposed of ; and the so-called " local anaesthetics " may perhaps be regarded in the same way. With a duration of activity normally measured in hours, they allow ample time for various surgical manoeuvres, and their effect may be prolonged, if need be, by giving with them vasoconstrictor drugs which delay dispersion from the site of injection. A new preparation,Efocaine,’ has now been devised, however, in which the span of local anaesthetic action has been considerably extended. First developed in the United States,12 it isa solution of 1% procaine base, 0.25% procaine hydrochloride, and 5% butyl-p-aminobenzoate at a critical level of saturation in propylene glycol, polyethylene glycol, and water. It will remain stable at room-temperatures for more than three months. Even after repeated intramuscular injections, the solvents used have produced no apparent local damage or systemic toxic effects. Dilution of this preparation with body-fluids at once brings about deposition of the aqueous insoluble aneesthetic base. When this occurs after intramuscular injection an in-vivo microcrystalline depot is formed. Absorption then takes place slowly and anaesthesia may be prolonged for days or even weeks. In fact, the solution has the advantages of an insoluble suspension without the disadvantages in manipulating a suspension with syringe and needle. It is claimed, but not completely confirmed, that injection of efocaine produces no local pain. In the dosage recommended, only the medium and small nerve-fibres, with comparatively thin myelin sheaths, are blocked ; thus pain and tactile sensibility are lost without interference with motor innervation. Permanent nerve damage has never been detected. its efficacy and relative safety, what is the place in clinical practice for this remarkably longacting local anæsthetic? It is perhaps most useful for the relief of postoperative pain. When the anaesthetic was given to 54 patients after a variety of operations, the results were " unsatisfactory " in only 3 cases.’ No examples of systemic toxicity or local tissue reaction were encountered. The doses given did not exceed 15 ml. Roualle3 reported good results after operation in 8 out of 14 patients, and in another 3 the results were fair. He considered that an accurate nerve block was more effective than local infiltration, because it was important to achieve adequate concentration in close proximity to the nerves supplying the area. He suggested that the
!
Acknowledging
le
Ansbro, F. P., Iason, A. H., Shaftel, H. E., Halpern, A., Latteri. F. S., Bodell, B. Anesthesiology, 1952, 13, 306. 2. ’Efocaine’ is now manufactured in this country by Messrs, Crookes Laboratories Ltd. 3. Roualle, H. L. M. Brit. med. J. 1952, ii, 1293. 1.
describing it in any common set of terms. Physicists find that light behaves in some respect like waves and in some respects like particles, and they have to put up with this peculiarity of light and adapt their language accordingly. Neurologists and psychologists who are unable to find a common language can at least behave like good citizens of the world and acquire each other’s. Some have already done so, learning, in the process, something of each other’s methods and achievements, and finding approaches to their joint study in which they can collaborate. From such combined endeavour may be expected to grow new terms, new analogies, new hypotheses and experiments, and, finally, a common language ; and the two disciplines would be in harmony for the from
Communication naive belief that in science we use terms, Prof. J. Z. YourTr this week reminds us
EXPLODING any
precise
the contrary, our language is largely that of analogy. The difficulty of the scientist in describing his material is, in fact, exactly the difficulty of the poet and the mystic-the, necessity of finding which that,
on
words, and in what. order, will best convey
to another
remotely accurate idea of what he person is talking about. The poet, being born with some facility-which he can improve by practice-for arranging these counters, has perhaps the least exacting problem of the three. He proceeds, as the scientist does, by the method of analogy and compari. son, using verbal images to rouse in other minds some even
echoes of the emotion he feels in his own. The mystic, with no vocabulary whatever to express his experiences, encounters the greatest difficulty of the three. If he attempts exact description he is driven either to the spineless " ineffable " or to such humdrum mineral images as gold, jasper, and sardonyx. For him, too, the only profitable means of communication is the language of analogy and symbol. The scientist, though he can mint new counters as he needs them, has his own peculiar problem : once he has described his objects he has to measure them; and the terms and analogies he uses, as Professor YourrG points out, will decide what objects he measures. If he is not inventive enough, not rich enough in rewarding analogies, he may hinder the development of his study and cut it off from allied lines of research. Professor YourrG is particularly concerned with the lack of a common language between neuro-anatomy and psychology. For though he favours an abundance of new analogies, from which new hypotheses might spring, he nevertheless thinks the current analogies used in speaking about the nervous system are too The neurologist has equipped numerous and varied. himself well with words to describe the functions of nerve-fibres and nerve-cells, but cannot find words to say all he would about the activities of the brain. Meanwhile psychologists have a totally different set of terms to describe events in human consciousness, and find they have little need to use or refer to neurological terms. Some psychologists talk of the more elaborate aspects of human behaviour in terms of entities such as the " id " and the " super-ego " ; and these, Professor YouNG admits, at least provide more complete descriptions than anything the neurologist can offer at present. What we need, he feels, is a common language in which both neurologists and psychologists can express their concepts-some set of terms which compares the brain with something more complicated than any simple machine, and which offers means of describing the memory system. This general language, he suggests, might put all the descriptions of the nervous system-structural, chemical, electrical, psychological—into their place as part of a system for talking about the whole human being. He believes it could be done, and that unless we do it our age may come to be regarded as concerned
only with trivia. That such
-
synthesis is needed, and ultimately no-one will doubt ; yet it may be that at inevitable, present it is we are
a
beyond
examining
The nature of the material may prevent us, for the moment, us.
theme to which Professor YourrG invites us all-the study of the balance by which human life is maintained, and all the factors that influence it.
Annotations THE FATE OF THE AMPUTEE 1950 the director-general of medical services, Ministry of Pensions, set up, under the chairmanship1 of Sir Ernest Rock Carling, an advisory committee to consider whether limb amputation and the subsequent wearing of a prosthesis could initiate or aggravate cardiovascular disorder, and whether mortality-rates were higher in amputees than in equivalent nonamputated persons. A somewhat inconclusive interim report, based on a. statistical study of amputee pensioners from the first world war, was published in 1951, and revealed in those still living no abnormal incidence of cardiovascular disease but a slight elevation of mean blood-pressure. Amputation, in itself, did not appear to influence mortality-rates during the period 1930-50, but the rate was higher in pensioners who
IN
had suffered
amputation
severe
wounding,
not.
However,
or
whether
more 1945—49 did a
accompanied by
detailed study of
certificates of deaths in suggest-though point of statistical significance-that patients with leg amputations died earlier, and more commonly from cardiovascular disease, than comparable pensioners with leg wounds not requiring amputation. The final report now being laid before Parliament describes further investigations, which have shown that thigh amputees and double leg amputees have a reduced expectation of life compared with normals or men with single below-knee amputations ; and also that, within the average figures for amputees as a whole, expectation of life was particularly lessened for those who had suffered serious prolonged sepsis after wounding. In this class of case also there was a greater than normal probability that certain cardiovascular disorders would be certified as the underlying cause of death ; and, unexpectedly, when cases of fractured femur and other leg wounds which had not led to amputation were analysed on the basis of whether major sepsis had occurred or not, it was found that this complication was again associated with a higher late incidence of cardiovascular disease and an earlier average age of death. The factors involved are complex and difficult to separate. Possibly the overweight and sedentary living consequent on limb amputation predispose to cardiovascular disorder ; and the committee, recognising that the strain of carrying an artificial leg may become an increasing physiological burden with advancing years, not to the
,
1.
Since the interim report appeared in April, 1951, the members of the committee have been:Sir ERNEST ROCK CARLING, F.B.C.S., Dr. A. GREIG ANDERSON, P.R.C.P., Prof. G. R. CAMERON, F.R.C.P., F.R.S., Dr. T. F. COTTON, Prof. J. L. D’SILVA, M.K.C.P., Prof. K. J. FRANKLIN, F.R.C.P., Dr. A. HOPE GOSSE, Dr. W. B. LLOYD, Dr. W. P. D. LOGAN, the late Mr. P. H. MITCHINER, F.R.C.S., and Dr. E. LIVINOSTONE (secretary).
634
cautiously suggest the possible need for reassessing some of these pensioners in later life : An important effect of our further studies is to suggest "
that
amongst amputees and other classes of wounded
there individuals who with the lapse of time reach a stage deserving of reconsideration. In any such reconsideration careful discrimination would be needed, as our conclusions are based on average tendencies and do not necessarily apply to any particular individual." are some
Of immediate relevance are some studies, by Dr. Verne T. Inman and his colleagues2 in San Francisco, of the energy expended in displacing the centre of gravity of the body through space. While the belowknee amputee is relatively normal from this point of view, the thigh amputee has to expend some 27% more energy for the same physical performance. Such a man, in effect, walks 5 yards to a normal man’s 4. An interesting point that emerges from the analysis ,is that major sepsis was also associated with a reduced liability to subsequent death from cancer, even allowing for the effect of an earlier average age of death on the incidence of malignant disease. This obviously calls for .
.
further study. Dr. A. Hope Gosse, in a minority report supported by Dr. W. E. Lloyd, denies that the evidence shows that the strain of wearing an artificial limb for thirty years increases the risk either of cardiovascular disease or of earlier death, and doubts whether one and the same statistical survey can show any true relation between previous sepsis on the one hand and cardiovascular or malignant disease on the other. And he takes the robust commonsense view-on a matter in which his opinion carries great weight-that there is no reason why life assurance should not be offered to these patients and to amputees in general at normal or near-normal rates. For the present, therefore, the matter cannot be regarded as entirely decided. Further investigation is called for by the committee, whose work is one more instance of the interesting and sometimes unexpected findings that may emerge from the statistical analysis of large numbers of detailed case-records.
INCREASES IN MATERNITY BENEFITS THE changes in maternity benefits set out in the National Insurance Bill, presented to Parliament on March 17, give effect to the recommendations made a year ago by an advisory committee.3 One of the most important principles which the committee urged was that the woman who wished to have her baby at home should not lose by this decision, and the Bill introduces a new home confinement grant of 13 which will do something to meet the extra expenses which a domiciliary birth always entails. The grant will be paid to mothers who are confined at their own expense and who do not occupy an N.H.S. hospital bed. The Bill continues to offer different benefits to meet the differing needs of the housewife and the employed woman. The first is the larger group, for six out of every, seven who claim maternity benefits are housewives. At present they receive a grant of f:4 and a weekly attendance allowance of Ela week for four weeks after the birth. In future they will receive a lump grant of E9 (plus the E3 home confinement grant when appropriate), and this sum will be paid before or after the birth as the mother chooses. For the employed woman the changes are even more advantageous. The advisory committee thought that maternity benefits, like sickness or employment benefits, should be payable only to women who chose to pay their own contributions ; and that an employed married woman should no longer be eligible by right of her husband’s The committee hoped that the money contribution. saved in this way would go to enlarge the grant made to contributors. The Bill gives effect to this restriction of 2. See Lancet, 1952, 3. Ibid, i, 201.
ii, 80.
a transitional period the rights of women who have not yet had time to qualify. The basic grant which an employed woman receives is increased from E4 to E9 (E12 if the confinement is at home). It also provides that her maternity allowance, now 36s. a week, will in future be paid at the standard benefit rate, which at present stands at 32s. 6d. a week. She will receive this allowance for eighteen weeks (instead of thirteen) and it will start eleven weeks before the expected date of her confinement (instead of six weeks). This allowance may be increased when the The effect of these changes mother has dependents. will be that a woman who is doing paid work will receive £38 5s. (or jE41 5s. if her confinement takes place at home) instead of E27 8s. as at present. Minor changes in the number of qualifying contributions ’are also designed to bring maternity benefit into line with sickness and unemployment benefits. But here, too, the woman who wishes to give up work earlier is offered help, for she may complete her qualifying con. tributions by paying the last thirteen at the non-employed reduced rates.
claims, but safeguards for
A LONG-ACTING LOCAL ANESTHETIC
IN the treatment of pain, analgesics only stop a gap until the cause is disposed of ; and the so-called " local anaesthetics " may perhaps be regarded in the same way. With a duration of activity normally measured in hours, they allow ample time for various surgical manoeuvres, and their effect may be prolonged, if need be, by giving with them vasoconstrictor drugs which delay dispersion from the site of injection. A new preparation,Efocaine,’ has now been devised, however, in which the span of local anaesthetic action has been considerably extended. First developed in the United States,12 it isa solution of 1% procaine base, 0.25% procaine hydrochloride, and 5% butyl-p-aminobenzoate at a critical level of saturation in propylene glycol, polyethylene glycol, and water. It will remain stable at room-temperatures for more than three months. Even after repeated intramuscular injections, the solvents used have produced no apparent local damage or systemic toxic effects. Dilution of this preparation with body-fluids at once brings about deposition of the aqueous insoluble aneesthetic base. When this occurs after intramuscular injection an in-vivo microcrystalline depot is formed. Absorption then takes place slowly and anaesthesia may be prolonged for days or even weeks. In fact, the solution has the advantages of an insoluble suspension without the disadvantages in manipulating a suspension with syringe and needle. It is claimed, but not completely confirmed, that injection of efocaine produces no local pain. In the dosage recommended, only the medium and small nerve-fibres, with comparatively thin myelin sheaths, are blocked ; thus pain and tactile sensibility are lost without interference with motor innervation. Permanent nerve damage has never been detected. its efficacy and relative safety, what is the place in clinical practice for this remarkably longacting local anæsthetic? It is perhaps most useful for the relief of postoperative pain. When the anaesthetic was given to 54 patients after a variety of operations, the results were " unsatisfactory " in only 3 cases.’ No examples of systemic toxicity or local tissue reaction were encountered. The doses given did not exceed 15 ml. Roualle3 reported good results after operation in 8 out of 14 patients, and in another 3 the results were fair. He considered that an accurate nerve block was more effective than local infiltration, because it was important to achieve adequate concentration in close proximity to the nerves supplying the area. He suggested that the
!
Acknowledging
le
Ansbro, F. P., Iason, A. H., Shaftel, H. E., Halpern, A., Latteri. F. S., Bodell, B. Anesthesiology, 1952, 13, 306. 2. ’Efocaine’ is now manufactured in this country by Messrs, Crookes Laboratories Ltd. 3. Roualle, H. L. M. Brit. med. J. 1952, ii, 1293. 1.