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Annotations

HANDOUTS FOR PATIENTS

THOSE doctors who are justly criticised by patientsbecause " they don’t tell you anything " are not alwaysout to make a mystery : often they cannot spare thetime to give the patient a detailed simplified accountof the- pathology of his condition ; and rather thanmislead him with a word or two they take refuge insilence. How can this difficulty be overcome to thepatient’s satisfaction but without further encroachmenton -the doctor’s time Dr. Charles Fletcher 1 suggeststhat, for patients with recurrent or chronic conditions,much might be done with simply written leaflets. As a

pilot model he has drafted such a leaflet on the natureand treatment of dyspepsia, defined (though not in theseterins to the patient) as " painful gastric or duodenaldysfunction whether due to peptic ulcer or other causes."This leaflet can be handed to the patient to take homeand read ; and at his next visit-Dr. Fletcher emphasisesthe importance of this-his questions about it can beanswered quickly and clearly, without much tedious.explanation. -

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The leaflet (which may be had from the Practitioneroffice 2) begins with a brief account of digestion, illus-trated by a diagram of the stomach and its associatedorgans. A paragraph on indigestion follows, and here wethink Dr. Fletcher has been rather too informative, orperhaps has told the facts in too alarming a way. Is itwise, or is it unwise, to tell a patient of the " ulcer typeabout the dangers of perforation and hoemorrhage ?And, if he should be told, is it wise to use such phrasesas " the stomach or duodenum gets digested rightthrough," and " a blood vessel is digested away " ; or

to warn the patient that a severe haemorrhage may leadto fainting or need treatment by transfusion These arestriking phrases which will stand out vividly in the mindof an anxious patient. The issue is difficult, for whilesome patients are over-anxious about their condition,

others take refuge from fear in bravado, and refuse totake the slightest precautions. On the one hand, know-ledge-will encourage patients of the second type to do asthey are told ; on the other, it will scarcely promote-

in patients of either type-the peace of mind on whichDr. Fletcher later puts so much emphasis. The sectionsof the leaflet which follow, however, will be generallyaccepted. He describes the ulcer diet and the regimenclearly and cleverly, explains the action and purpose of

. :antacids,: belladonna and olive oil, vitamins, and seda-tives, gives good little homilies on rest for the mind andfor the body, and ends with three detailed diets-strict,

moderate, and convalescent.The principle he has here outlined has long beenapplied by many doctors, who keep a stock of their own

printed or multigraphed instructions to hand to suitable; patients. Especially where explanations are attempted,such notes are by no means easy to write, and there ismuch to be said for using those produced by experts.It would be useful to many practitioners to have reliabletracts for -distribution to patients with various chronicor recurrent complaints, such as asthma and, hay fever,=varicose ulcer, bronchiectasis, rheumatism, psycho-somatic skin conditions, compensated or uncompensatedheart-disease, hypertension, and diabetes. At the sametime it should be remembered that many people absorbthe spoken word more easily than the written-especiallyif it is well spoken by a doctor who takes pains to makehis patient understand. A great deal of anxiety has beengenerated by patients reading about their maladies andgetting the subject out of focus. Moreover in these

1. Practitioner, 1949, 162, 51.2. From 5, Bentinck Street, London, W.1; at 6d. post free.

mechanistic days we must keep watch against anytendency to standardise medicine; whether by directivesto the doctor or by directives to’ the patient. Suchhandouts as Dr. Fletcher has devised should be used(as he insists) as an aid to, rather than a substitute for,frank discussion of his case with the patient.

SURGERY OF INOPERABLE GROWTHS

THE place of ultraradical surgery in the treatment ofso-called inoperable malignant growths has been muchdiscussed. In this country, Gordon-Taylor, Grey Turner,and others have published reports of successful cases ofmultiple " eviscerating

,., procedures requiring skill,

speed, and courage ; but heroic procedures of this kindhave usually carried so high a mortality-rate that manyhave deemed them unjustifiable, at any -rate in lesscapable hands. However, the advent of improvements inanaesthesia, the use of the sulpha drugs and penicillin,and the simplicity of blood-transfusion have materiallylessened the risks, and in our present issue Mr. Ravenpleads for a more enterprising outlook on the surgery ofadvanced malignant disease, giving examples of itssuccess.

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About a year ago we commented on the exenterationoperations of Prof. Alexander Brunschwig, late of

Chicago and now of the Memorial Hospital, New YorkCity. Brunschwig claims little more than palliation forthese extensive operations, and the advantages of suchpalliation have to be judged in relation to a primaryoperative mortality approaching 25% and some inevit-able postoperative discomfort. An occasional " cure "

goes far, of course, to justify such tremendous surgicalundertakings ; and some of Raven’s results are certainlyimpressive. On the other hand, in a case sufficientlyadvanced to require Brunschwig’s operation of hystero-vaginectomy, total cystectomy, transplantation ofureters, and rectosigmoidectomy with what he calls a" wet " colostomy, it is likely that the lymphatic systemwill already be widely affected ; and, unless one has faithin the ability of deep X-ray therapy to eradicate second-ary deposits in abdominal lymph-glands, the prospectsof " cure " are correspondingly poor. It has yet to beproved that for the survivors of such an operation life isprolonged, and (more important still) that life is lessuncomfortable or more happy. The decision must rest

largely with the patient: some people would prefer to bealive with severe disability, while others would not thinkthe price worth paying. The fact that, without operation,the outlook is hopeless does not justify the surgeon-and especially the relatively inexperienced surgeon-intaking great risks,’ unless he believes that a successfulresult would be reckoned successful by the patient.

RICE AND HYPERTENSION

THE diet for hypertension popularised in the UnitedStates by Kempner 3 includes 250-300 g. of rice a day.No less than 95% of the 2000 calories in this diet ’isfurnished by carbohydrate : otherwise it comprises 20 g.of protein (from rice and fruit) and not more than 5 g -of fat, 200 mg. of chloride, and 150 mg. of sodium. Fluidintake is restricted to 700-1000 ml. of fruit juice. Thisregime, which is a clever if somewhat dull blend of low-protein, low-sodium, and low-fluid diets, Kempner claimsto be effective in the treatment of hypertension andcardiac cedema. Brams,3 too, reports "excellent results... with the patient at work provided he cooperatedfaithfully"; while Contratto and Rogers;4 of Boston,1. Lancet, 1947, ii, 918.2. Kempuer, W. N. Carolina med. J. 1944, 5, 125, 273 ; Ibid, 1945,

6, 61, 117 ; Ibid, 1947, 8, 128.3. Brams, W. A. Treatment of Heart Disease. London, 1948;

p. 135.4. Contratto, A. W., Rogers, M. B. New Engl. J. Med. 1948, 239,

531.

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say that it offers " the greatest hope so far for the medicaltreatment " of hypertension. A major difficulty seemsto be that the regime does not commend itself to patients ;for only 34 of Contratto and Rogers’s 55 patientscooperated well enough for their cases to be included inthe report. At the end of three months’ treatment theirblood-pressures had fallen on average from 210/120 to158/100 mm. Hg ; a " definite and persistent drop inblood-pressure" was recorded in 25 (70%). There wasalso a drop in weight of about 10-15 lb. in the first andsecond months, and all patients had a period of weakness,accompanied sometimes by severe mental depression,during the first few weeks. Apparently relief of headache,emotional tension, and nervousness was an outstandingfeature of the response. There was also a pronouncedfall in urinary chlorides (indeed this fall was estimatedas a check of the extent* to which patients were adheringto the diet) ; and lately Kempner et al.5 have reportedthat substantially less phosphate and sulphate is excretedwith this than with a " regular " diet or while fasting.Contratto and Rogers conclude that improvement is due,to the low sodium intake. There is some evidence forthis in a. report by Rosenberg and his colleagues,6 whofound that of 7 hypertensives on a low-sodium diet 4had a statistically significant fall in blood-pressure, whileof 5 on a rice diet 3 had such a fall-=--though without reliefof symptoms.

ADVANCES IN EPILEPSY

THE fight against epilepsy is progressing on manyfronts. A better understanding of its history, newlaboratory devices, and new methods of therapy, and astudy of the ravages of war are all factors in the forwardpush. The report of a joint meeting of the Associationfor Research into Nervous and Mental Disease with theAmerican chapter of the International League AgainstEpilepsy shows how varied is the approach to the generalattack. Thus it may be made through the investigationand classification of the various clinical forms of fit,through the study of cerebral anatomy and cerebrallocalisation, through evaluation of the acquired andgenetic factors in aetiology, through electro-encephalo-graphic (E.E.G.) patterns, through the physical andchemical changes underlying neuronic metabolism andtheir modification by drugs, or through the study ofassociated mental conditions and of social reactions.An outstanding feature is the growing knowledge of theeleetrophysiology of the nervous system. Its value inlocalisation is great, but it must always be rememberedthat E.E.G. aberrations are an accompaniment, and not acause, of epileptic manifestations, and that the physicaland chemical processes underlying the electrical abnor-malities must be understood before the root of thematter can be reached. We may indeed yet return tothe old concept of epilepsy as primarily a metabolicdisorder. Perhaps we need to stop and reflect where all thisnew research is leading us. There is a place now for a bookon epilepsy in the English language, embodying ourrecent advances in knowledge.A volume 8 containing 15 papers on epilepsy read

before the American Psychopathological Associationdeals mostly with psychiatric aspects of the complaintand their social implications. The case for a specificepileptic personality is considered, but the generalconclusion is that there is little evidence to substantiate it.

5. Kempner, W., Lesesne, J. M., Newborg, B., Whicker, C. F.Amer. J. med. Sci. 1948, 216, 687.

6. Rosenberg, B., Rosenthal, A. E., Rosenbluth, M. B. Amer. J.Med. 1948, 5, 815.

7. Research Publications: Association for Research in Nervous andMental Disease; vol. 26, 1947. Williams and Wilkins Company,Baltimore.

8. Epilepsy. Proceedings of the 36th annual meeting of the AmericanPsychopathological Association, New York, 1946. Editors :Hoch, P. H.; Knight, R. P. London : Heinemann MedicalBooks. 1948. Pp. 214. 21s.

PSYCHOTHERAPY IN GENERAL PRACTICE

IN response to an obvious need, the CommonwealthFund provided in April, 1946, at the University ofMinnesota a short postgraduate course in psychotherapyfor general practitioners. The number of those attend-ing was limited to 25, and during the fortnight that thecourse lasted these doctors lived, along with --theirinstructors, in the Centre for Continuation Study, abuilding designed for such purposes and including"

dormitories, a cafeteria, a garage, classrooms andan ample lounge, all under one roof." The aim of thecourse was to accustom the practitioners to use essentialpsychiatric modes of thought in their approach to patientswith neurotic and kindred disorders; the methods ofinstruction were clinical practice under supervision,coherent simple presentation of a few basic concepts,and abundant informal discussion. Much thought wasgiven to the planning of the course, and a distinguishedgroup of psychiatrists, with two general physicians,provided the instruction. The content of the teachingand a good deal of the method is now disclosed in adetailed report.! No-one who reads this can doubt theskill with which the teachers avoided the pitfalls in soambitious and difficult a venture, or the success theyattained-not, of course, in turning the practitionersinto psychiatrists, but-in enabling them to deal muchmore confidently and effectively with the emotional andother mental ills of their patients. The teachersuniformly avoided jargon and the use of concepts tooabstract and involved or superficially improbable fortheir listeners’ acceptance : much of the exposition isreminiscent of T. A. Ross’s The Common Neuroses.An ounce of teaching such as this course afforded isworth many pounds of " psychosomatic

" propaganda.The demands on the teachers, however, and the materialrequirements, are exacting. The account of how wellthese demands were met in the Minnesota experimentalcourse is stimulating and informative.

THE NAVIGATION OF BIRDS

Two American ornithologists 2 took seventeen adultgannets from their nests, transported them rapidly 215miles, and released them one by one -a hundred milesfrom salt water ; 63% returned to their nests, at anaverage speed of 99 miles per day (m.p.d.). This sort of

experiment has often been done before ; the figures- forthe swallow, for instance, were 67% and 141 m.p.d.,for the herring gull 97% and 90 m.p.d. One of themost spectacular was the taking of a Manx shearwaterfrom her nest off the Welsh coast to Venice,-whenceshe made the return trip in fourteen days. What is

peculiar about this experiment with gannets is thatnine birds were followed after release at a discreetdistance by the ornithologists in an aeroplane and theircourses were charted. The results show that in every casethe birds spiralled round after release, as though- castingabout for a clue to the way home.. This is similar :tothe behaviour of homing pigeons. How do the birds findtheir way home ? (Let it be firmly stated. that we arenot here concerned with migration, which is probably-an instinctive process apart.) Many theories have beenpropounded-that they are oriented by the positionof the sun as bees are ; that they are guided bygeo-magnetic waves, though in fact they seem unaffectedby a strong artificial magnetic field ; that their- semi-circular canals are sensitive to the Coriolis force ; thatthey have topographical memories ; that they find theirway in fog by infra-red vision. No doubt birds. have

1. Teaching Psychotherapeutic Medicine : an Experimental Coursefor General Physicians. Editor: Helen Leland Witner,PH.D. New York: The Commonwealth Fund. LondonOxford University Press. 1948. Pp. 464. 21s.

2. Griffin, D. R. Scientific American, 1948, 179, 18.