- Email: [email protected]
THE FORGOTTEN PATIENT
1139 nitrous oxide, and suxamethonium bromide which I use as a routine for cæsarean section. When followed by nitrousoxide/oxygen anaesthesia to supplement its effects, recovery is not delayed, and there are all the advantages of an intravenous induction with the rapid recovery of nitrous oxide. It does not appear to have any advantage over the established barbiturates for induction for major surgery. With the help of Dr. Gordon Chorley, Dr. A. E. Nesling, and Staff-nurse J. A. Littlejohn of this hospital, bloodpressure readings and pulse-rates were recorded every minute during induction and maintenance of these cases. The records show that there is a slight transient fall in systolic-pressure, little change in diastolic, and a slight slowing of the pulse during induction. The blood-pressure returned to normal 4-5 minutes after the start of the injection, and the pulse-rate within 2 minutes. The fall in blood-pressure is slight and has Once the bloodnever called for measures to combat it. pressure starts to rise it appears that the patient is ready for
operation.
A slight transient slowing of respirations and reduction in depth has also been noted; but there were no signs calling for the administration of oxygen in over 100 patients, whose ages
varied from 17 to over 70. There is considerable individual variation in the reaction to the drug, and it seems that the amount of the initial injection related to-the patient’s physique and habits is the important factor in judging this. These remarks apply to the unpremedicated patient or the patient who has had nothing but atropine. In patients who have been
premedicated withOmnopon ’ and scopolamine, atropine and morphine, hypotension and bradycardia may be more striking and long-lasting; and, although recovery of consciousness may not be delayed, a period of lethargy and mild hypotension may ensue for 12 hours or more. There has been no vomiting in patients who have not been prepared and have had a meal that day, and patients who have retched during induction have not been sick, although 2 patients who were " prepared " vomited slightly on coming round (they had had an opiate). or
The important things to remember are : (i) the initial dose must be given quickly ; (ii) it should be adjusted to the patient’s condition and habits ; (iii) the remainder should be given slowly; pause being made to allow any coughing, sneezing, or retching to settle, and the injection continued more slowly ; (iv) no operations should begin until the whole dose has been given and the patient is sleeping quietly. If these precautions are disregarded there is a danger of a useful drug getting into disrepute before it has had a proper trial. Messrs.
May
&
Baker
supplied
Gloucester Royal Hospital.
the ’Transithal.’
J. SHEGOG RUDDELL.
ENURESIS
SIR,-Dr. Mark Bonnin, in his letter of Nov. 12, seems to have failed to appreciate that in your leader1 it was " correctly stated that the " conditioning approach to the2 treatment of nocturnal enuresis originated by Mowrer is used widely in the U.S.A. Since
our
paper3 appeared
there have been very many
requests and inquiries for the apparatus made and sold by the
occupational-therapy department of the Colony for Epileptics, where it is produced at a tenth of the price mentioned by Dr. Bonnin. It is difficult to devise a suitable, durable, and comfortable pad on which the patient may sleep. Even using nickel wire there is fairly rapid corrosion, and we are now experimenting with conducting rubber. In Crosby’s4 original apparatus the arousal stimulus was a faradic shock, and rather complicated electrodes were fitted to the patient. We have found the bell perfectly satisfactory, and it obviates the use of genital electrodes and the " shock," both of which I feel are psychologically bad. Some time ago a follow-up of 70 cases treated by this method showed that 75% were cured ; and in many 1. Lancet, 1955, i, 391. 2. Mowrer, O. H., Mowrer, W. M. Amer. J. Orthopsychiat. 8, 436. 3. Davidson, J. R., Douglass, E. Brit. med. J. 1950, i, 1345. 4. Crosby, N. D. Med. J. Aust. 1950, ii, 533.
1938,
of these it proved effective when all other forms of treatment had failed. The Orphan Homes of Scotland, J. ROMANES DAVIDSON Medical Superintendent. Bridge of Weir, Renfrewshire. THE FORGOTTEN PATIENT
to an article written by a medical about his own specialty I may show lack of discretion. But as one of thousands of laymen who give much of their time to helping to care for the mentally afflicted, I view this kind of article with alarm and resentment, because I know the damage they can do. I am sure that they are usually written with the best of intentions, but that does not make them any the less mischievous and misleading to the would-be nurse, to the relatives of patients, and to the general public, when they consist of half-truths or paint a picture in lurid colours. I am not qualified to rebut Dr. Bickford’s statement that " psychiatrists have failed to cure and discharge their patients," which seems to presume that they could cure but do not. But I do know the concern and distress it could cause in the mind of a person having a relative in a mental hospital, and the kind of reaction that might arise. Further, if we are to accept this contention, then we public representatives ought to be asking ourselves why public money is being spent on public servants who are not doing their job to the best of their ability. Whatever may be Dr. Bickford’s experiences in his own hospital, or elsewhere, he is grossly overstating some of the facts so far as the South West Metropolitan Region is concerned-a region that has far more mental-health beds than any other hospital region. Take, for instance, his claim that " in many hospitals droves of patients labour in the fields and cow-houses." A recent return in our region showed that, in the 24 mental hospitals and mental-deficiency hospitals that had farms attached or adjacent to them, 418 patients were engaged on farm work of one kind or another, and 265 patients were engaged in hospital gardens-a total of 683. The number of patients in those 24 hospitals at the time of the return was 31,173. A ratio of 1 : 119.4 engaged on farm work as such. Droves " hardly seems the right word. The Old Folk.-I am in full sympathy with Dr. Bickford’s desire to serve the interest of old people who could be removed from a mental hospital if there were some other accommodation they could go to, and we have given the problem a great deal of attention and made it a point in our evidence to the Royal Commission But in his on the Law relating to Mental Health. he to make a case is convincing anxiety creating the impression that many old people who are not mentally ill are forced into mental hospitals, merely because there is nowhere else for them to go. During our examination of the problem in our region we found that the 17 mental hospitals concerned had a total of 9887 patients over 65 years of age. Of these 971 were fit for other hospital accommodation, and 2348 were suitable for local-authority welfare accommodation But of the 3303 admissions of patients over 65 years of age in 1953, only 455 were suitable for other hospital accommodation and 105 for welfare institutions, and even some of those were borderline cases. In other words the great majority were rightly adotitted to a mental hospital because they needed that form of treatment, but have so far recovered after treatment that they could leave now if there were other accommodation for them. I know this is not a matter to be complacent about, but it is mischievous and wrong to suggest that most elderly people are forced into mental hospitals wrongly. Moreover Dr. Bickford did not mention that there are a number of old people in other accommodation who should be receiving psychiatric treatment and
SIR,- In replying
man
"
nursing.
1140
of Incentive to Discharge Patients.-As to the general charge that " doctors have little incentive to discharge their patients "-to which the obvious retort could be that the care and cure of their patients is their primary responsibility-it requires but little imagination to see the effect of this on patients or relatives who are being advised by their doctor to seek mental-hospital treatment. There is enough ignorance, prejudice, and misunderstanding already about the care and treatment of the mentally afflicted without statements of this kind being made to lend further colour to them-particularly at a time when great strides are being made in the direction of creating confidence in, and acceptance of, earlier diagnosis and treatment of mental instability. Again I must talk about what we are doing in the South West Metropolitan Region, even at the risk of being thought boastful. Since April, 1953, we have reserved parts of several of our mental hospitals for the admission of non-statutory patients-i.e., patients without even the requirement of signing a voluntary order, who can walk out of the hospital at a moment’s notice if they desire. Up to Sept. 30-two and a half years-3680 patients had been admitted to these beds, and a large proportion of these had been discharged as sufficiently recovered as not to require further hospital treatment. The average length of stay of these patients has been approximately six to eight weeks. The original number of such beds provided was 330, but since Oct. 1 it has been increased to 688, and it will steadily rise as Absence
"
"
accommodation becomes available. The more such facts are known and emphasised, the greater the confidence in psychiatric diagnosis and treatment ; and, if this leads to greater cooperation between hospital, patient, and relative, the greater will be our service to suffering humanity. The Committee.-My only comment about the kind of committee members described by Dr. Bickford is that either he must be grossly exaggerating or else he has an .extraordinary preponderance of stupid and gullible people serving on the committees of which he has experience. Whatever other faults they may have, failure to visit every part of their hospital regularly and frequently, and to become very vocal about matters they think need remedying, cannot be laid at the door of the majority of members of hospital management committees that my mental-health committee control. R. SARGOOD more
Chairman, Mental Health Committee, South West Metropolitan Regional Hospital Board. MUSCLE IMBALANCE IN SCOLIOSIS
SIR,-In the article by Mr. Riddle and Mr. Roaf (June 18) there are certain features which should not go unchallenged. First, there is the conclusion that,
apparently because " the spinal muscles were significantly stronger on the convex side at the apex of the curve," the cause of the curve was this over-activity. The authors’do not mention the possibility that the overactivity is a result rather than a cause. There seems to be confusion, too, in differentiating between inherent " strength " and the amount of activity at rest or during specific movements. These are not synonymous, though under certain controlled conditions they can be correlated. The suggested treatment-i.e., " to excise alternate laminae and transverse processes at the apex of the curve on the convex side "-must
therefore be
highly questionable.
It would be very
to know if the surgeons who referred patients have taken the advice of the authors in this regard. Another serious omission appears to be the absence of
interesting
fibrillation potentials of denervation on the so-called weaker side. Surely it is pertinent to note the presence or the absence of this one sure electromyographic sign of denervation.
Finally, we must conclude from the significant conflict of data with needle and surface electrodes that this study requires greater expansion before any of the conclusions can be considered valid. Of course it has been long held that an imbalance of muscle activity, especially of rotators, is the probable underlying cause of scoliosis. However, the evidence presented in the article could be manipulated by the skilful antagonist of this theory, if such there be, to refute this belief rather than support it. Department of Anatomy, University of Toronto.
J. V. BASMAJIAN.
THE RING AND THE SWOLLEN FINGER
SiR, Many methods have been used to remove rmgs from swollen fingers. For lesser degrees of swelling a little soap may suffice, or a thread wound round the With gross swelling such distal part of the finger. methods may fail and the patient may plead that the ring be cut off. At times a painful struggle may follow, ending with some damage to the finger if suitable instruments are not available. A description of a simpler technique for the removal of rings from grossly swollen fingers and its application in two cases may be of interest. CASE 1.-A housewife, aged 28, had fractures of the left forearm. The displacement was corrected, plaster-of-paris applied, and her wedding ring removed. She was seen on the following evening when she was wearing the ring on the 4th finger of the right hand. She stated that even under normal conditions there was difficulty in putting the ring on this finger, which was now grossly swollen, congested, and painful. The usual methods having been tried without success, a solution of 2000 units of hyaluronidase in 1 ml. of water was injected subcutaneously into the proximal portion of the swollen area and under the ring, on the dorsum and sides of the finger, which was massaged gently to spread the injected solution. A thin rubber tube was then wrapped round the finger, commencing at the tip and continuing proximally up the finger, up to and including the ring. This was left in situ for 5 minutes. When it was removed the swelling had been dispersed sufficiently to permit the withdrawal of the
ring
without
difficulty.
CASE 2.-A van driver, aged 51, had been struck on the dorsum of the left hand with a starting-handle. There was bruising over the 3rd and 4th metacarpophalangeal joints and 4th proximal interphalangeal joint. The 4th finger bore a heavy signet ring and was grossly swollen distal to this. A procedure similar to that used in the first case was carried out and the ring removed with ease. -
An important contra-indication to this method would be evidence of sepsis in the affected digit, when there would be a danger of spreading the infection. I have not seen this method recorded elsewhere, so I should like to draw attention to it because it may avoid injury to the patient and the ring. I should like to thank Mr. H. W. C. to publish these cases.
Bailie,
F.R.C.S., for
permission
Coleraine Hospital,
Northern Ireland.
R. J. W. RYDER.
TUBERCULOSIS OF THE PUBIS
SIR,-Bevan1 has lately pointed out that the pubic bone is an uncommon site for tuberculosis and that coldabscess formation from such a lesion seems peculiarly rare. In view of this apparent rarity I would like briefly to describe a further 4 cases which have occurred in this hospital since 1948. A woman of 50, with a tuberculous left hip and dorsal
spine, had a sinus in the left labia. Subsequent X-ray examination showed destruction and irregularity of the symphysis pubis. She was sent to a sanatorium where rest and chemotherapy resulted in healing of the sinus. A woman of 31 presented with a painless spherical mass about 11/2 in. in diameter attached to the posterior aspect of the left upper border of the symphysis pubis. X-ray examination showed widening and partial destruction with some new bone formation of the symphysis pubis. There was 1. Bevan, P. G. Brit. med. J. Oct. 1, 1955, p. 832.
,
operation.
A slight transient slowing of respirations and reduction in depth has also been noted; but there were no signs calling for the administration of oxygen in over 100 patients, whose ages
varied from 17 to over 70. There is considerable individual variation in the reaction to the drug, and it seems that the amount of the initial injection related to-the patient’s physique and habits is the important factor in judging this. These remarks apply to the unpremedicated patient or the patient who has had nothing but atropine. In patients who have been
premedicated withOmnopon ’ and scopolamine, atropine and morphine, hypotension and bradycardia may be more striking and long-lasting; and, although recovery of consciousness may not be delayed, a period of lethargy and mild hypotension may ensue for 12 hours or more. There has been no vomiting in patients who have not been prepared and have had a meal that day, and patients who have retched during induction have not been sick, although 2 patients who were " prepared " vomited slightly on coming round (they had had an opiate). or
The important things to remember are : (i) the initial dose must be given quickly ; (ii) it should be adjusted to the patient’s condition and habits ; (iii) the remainder should be given slowly; pause being made to allow any coughing, sneezing, or retching to settle, and the injection continued more slowly ; (iv) no operations should begin until the whole dose has been given and the patient is sleeping quietly. If these precautions are disregarded there is a danger of a useful drug getting into disrepute before it has had a proper trial. Messrs.
May
&
Baker
supplied
Gloucester Royal Hospital.
the ’Transithal.’
J. SHEGOG RUDDELL.
ENURESIS
SIR,-Dr. Mark Bonnin, in his letter of Nov. 12, seems to have failed to appreciate that in your leader1 it was " correctly stated that the " conditioning approach to the2 treatment of nocturnal enuresis originated by Mowrer is used widely in the U.S.A. Since
our
paper3 appeared
there have been very many
requests and inquiries for the apparatus made and sold by the
occupational-therapy department of the Colony for Epileptics, where it is produced at a tenth of the price mentioned by Dr. Bonnin. It is difficult to devise a suitable, durable, and comfortable pad on which the patient may sleep. Even using nickel wire there is fairly rapid corrosion, and we are now experimenting with conducting rubber. In Crosby’s4 original apparatus the arousal stimulus was a faradic shock, and rather complicated electrodes were fitted to the patient. We have found the bell perfectly satisfactory, and it obviates the use of genital electrodes and the " shock," both of which I feel are psychologically bad. Some time ago a follow-up of 70 cases treated by this method showed that 75% were cured ; and in many 1. Lancet, 1955, i, 391. 2. Mowrer, O. H., Mowrer, W. M. Amer. J. Orthopsychiat. 8, 436. 3. Davidson, J. R., Douglass, E. Brit. med. J. 1950, i, 1345. 4. Crosby, N. D. Med. J. Aust. 1950, ii, 533.
1938,
of these it proved effective when all other forms of treatment had failed. The Orphan Homes of Scotland, J. ROMANES DAVIDSON Medical Superintendent. Bridge of Weir, Renfrewshire. THE FORGOTTEN PATIENT
to an article written by a medical about his own specialty I may show lack of discretion. But as one of thousands of laymen who give much of their time to helping to care for the mentally afflicted, I view this kind of article with alarm and resentment, because I know the damage they can do. I am sure that they are usually written with the best of intentions, but that does not make them any the less mischievous and misleading to the would-be nurse, to the relatives of patients, and to the general public, when they consist of half-truths or paint a picture in lurid colours. I am not qualified to rebut Dr. Bickford’s statement that " psychiatrists have failed to cure and discharge their patients," which seems to presume that they could cure but do not. But I do know the concern and distress it could cause in the mind of a person having a relative in a mental hospital, and the kind of reaction that might arise. Further, if we are to accept this contention, then we public representatives ought to be asking ourselves why public money is being spent on public servants who are not doing their job to the best of their ability. Whatever may be Dr. Bickford’s experiences in his own hospital, or elsewhere, he is grossly overstating some of the facts so far as the South West Metropolitan Region is concerned-a region that has far more mental-health beds than any other hospital region. Take, for instance, his claim that " in many hospitals droves of patients labour in the fields and cow-houses." A recent return in our region showed that, in the 24 mental hospitals and mental-deficiency hospitals that had farms attached or adjacent to them, 418 patients were engaged on farm work of one kind or another, and 265 patients were engaged in hospital gardens-a total of 683. The number of patients in those 24 hospitals at the time of the return was 31,173. A ratio of 1 : 119.4 engaged on farm work as such. Droves " hardly seems the right word. The Old Folk.-I am in full sympathy with Dr. Bickford’s desire to serve the interest of old people who could be removed from a mental hospital if there were some other accommodation they could go to, and we have given the problem a great deal of attention and made it a point in our evidence to the Royal Commission But in his on the Law relating to Mental Health. he to make a case is convincing anxiety creating the impression that many old people who are not mentally ill are forced into mental hospitals, merely because there is nowhere else for them to go. During our examination of the problem in our region we found that the 17 mental hospitals concerned had a total of 9887 patients over 65 years of age. Of these 971 were fit for other hospital accommodation, and 2348 were suitable for local-authority welfare accommodation But of the 3303 admissions of patients over 65 years of age in 1953, only 455 were suitable for other hospital accommodation and 105 for welfare institutions, and even some of those were borderline cases. In other words the great majority were rightly adotitted to a mental hospital because they needed that form of treatment, but have so far recovered after treatment that they could leave now if there were other accommodation for them. I know this is not a matter to be complacent about, but it is mischievous and wrong to suggest that most elderly people are forced into mental hospitals wrongly. Moreover Dr. Bickford did not mention that there are a number of old people in other accommodation who should be receiving psychiatric treatment and
SIR,- In replying
man
"
nursing.
1140
of Incentive to Discharge Patients.-As to the general charge that " doctors have little incentive to discharge their patients "-to which the obvious retort could be that the care and cure of their patients is their primary responsibility-it requires but little imagination to see the effect of this on patients or relatives who are being advised by their doctor to seek mental-hospital treatment. There is enough ignorance, prejudice, and misunderstanding already about the care and treatment of the mentally afflicted without statements of this kind being made to lend further colour to them-particularly at a time when great strides are being made in the direction of creating confidence in, and acceptance of, earlier diagnosis and treatment of mental instability. Again I must talk about what we are doing in the South West Metropolitan Region, even at the risk of being thought boastful. Since April, 1953, we have reserved parts of several of our mental hospitals for the admission of non-statutory patients-i.e., patients without even the requirement of signing a voluntary order, who can walk out of the hospital at a moment’s notice if they desire. Up to Sept. 30-two and a half years-3680 patients had been admitted to these beds, and a large proportion of these had been discharged as sufficiently recovered as not to require further hospital treatment. The average length of stay of these patients has been approximately six to eight weeks. The original number of such beds provided was 330, but since Oct. 1 it has been increased to 688, and it will steadily rise as Absence
"
"
accommodation becomes available. The more such facts are known and emphasised, the greater the confidence in psychiatric diagnosis and treatment ; and, if this leads to greater cooperation between hospital, patient, and relative, the greater will be our service to suffering humanity. The Committee.-My only comment about the kind of committee members described by Dr. Bickford is that either he must be grossly exaggerating or else he has an .extraordinary preponderance of stupid and gullible people serving on the committees of which he has experience. Whatever other faults they may have, failure to visit every part of their hospital regularly and frequently, and to become very vocal about matters they think need remedying, cannot be laid at the door of the majority of members of hospital management committees that my mental-health committee control. R. SARGOOD more
Chairman, Mental Health Committee, South West Metropolitan Regional Hospital Board. MUSCLE IMBALANCE IN SCOLIOSIS
SIR,-In the article by Mr. Riddle and Mr. Roaf (June 18) there are certain features which should not go unchallenged. First, there is the conclusion that,
apparently because " the spinal muscles were significantly stronger on the convex side at the apex of the curve," the cause of the curve was this over-activity. The authors’do not mention the possibility that the overactivity is a result rather than a cause. There seems to be confusion, too, in differentiating between inherent " strength " and the amount of activity at rest or during specific movements. These are not synonymous, though under certain controlled conditions they can be correlated. The suggested treatment-i.e., " to excise alternate laminae and transverse processes at the apex of the curve on the convex side "-must
therefore be
highly questionable.
It would be very
to know if the surgeons who referred patients have taken the advice of the authors in this regard. Another serious omission appears to be the absence of
interesting
fibrillation potentials of denervation on the so-called weaker side. Surely it is pertinent to note the presence or the absence of this one sure electromyographic sign of denervation.
Finally, we must conclude from the significant conflict of data with needle and surface electrodes that this study requires greater expansion before any of the conclusions can be considered valid. Of course it has been long held that an imbalance of muscle activity, especially of rotators, is the probable underlying cause of scoliosis. However, the evidence presented in the article could be manipulated by the skilful antagonist of this theory, if such there be, to refute this belief rather than support it. Department of Anatomy, University of Toronto.
J. V. BASMAJIAN.
THE RING AND THE SWOLLEN FINGER
SiR, Many methods have been used to remove rmgs from swollen fingers. For lesser degrees of swelling a little soap may suffice, or a thread wound round the With gross swelling such distal part of the finger. methods may fail and the patient may plead that the ring be cut off. At times a painful struggle may follow, ending with some damage to the finger if suitable instruments are not available. A description of a simpler technique for the removal of rings from grossly swollen fingers and its application in two cases may be of interest. CASE 1.-A housewife, aged 28, had fractures of the left forearm. The displacement was corrected, plaster-of-paris applied, and her wedding ring removed. She was seen on the following evening when she was wearing the ring on the 4th finger of the right hand. She stated that even under normal conditions there was difficulty in putting the ring on this finger, which was now grossly swollen, congested, and painful. The usual methods having been tried without success, a solution of 2000 units of hyaluronidase in 1 ml. of water was injected subcutaneously into the proximal portion of the swollen area and under the ring, on the dorsum and sides of the finger, which was massaged gently to spread the injected solution. A thin rubber tube was then wrapped round the finger, commencing at the tip and continuing proximally up the finger, up to and including the ring. This was left in situ for 5 minutes. When it was removed the swelling had been dispersed sufficiently to permit the withdrawal of the
ring
without
difficulty.
CASE 2.-A van driver, aged 51, had been struck on the dorsum of the left hand with a starting-handle. There was bruising over the 3rd and 4th metacarpophalangeal joints and 4th proximal interphalangeal joint. The 4th finger bore a heavy signet ring and was grossly swollen distal to this. A procedure similar to that used in the first case was carried out and the ring removed with ease. -
An important contra-indication to this method would be evidence of sepsis in the affected digit, when there would be a danger of spreading the infection. I have not seen this method recorded elsewhere, so I should like to draw attention to it because it may avoid injury to the patient and the ring. I should like to thank Mr. H. W. C. to publish these cases.
Bailie,
F.R.C.S., for
permission
Coleraine Hospital,
Northern Ireland.
R. J. W. RYDER.
TUBERCULOSIS OF THE PUBIS
SIR,-Bevan1 has lately pointed out that the pubic bone is an uncommon site for tuberculosis and that coldabscess formation from such a lesion seems peculiarly rare. In view of this apparent rarity I would like briefly to describe a further 4 cases which have occurred in this hospital since 1948. A woman of 50, with a tuberculous left hip and dorsal
spine, had a sinus in the left labia. Subsequent X-ray examination showed destruction and irregularity of the symphysis pubis. She was sent to a sanatorium where rest and chemotherapy resulted in healing of the sinus. A woman of 31 presented with a painless spherical mass about 11/2 in. in diameter attached to the posterior aspect of the left upper border of the symphysis pubis. X-ray examination showed widening and partial destruction with some new bone formation of the symphysis pubis. There was 1. Bevan, P. G. Brit. med. J. Oct. 1, 1955, p. 832.
,