81

To Match the Name

THE LANCETLONDON: : SATURDAY, JULY 21, 1945

To alter the Imme of the thing is not to change itsessence. The agreeable word" asylum," blackenedby its associations,. was discarded thankfully for theterm " mental hospital," but the alias has done littleto rid patients or their relatives of their dread of theactual place. Lieut.-Colonel J. IVISON RUSSELL,speaking on Thursday at the annual meeting of theMental Hospitals Association, suggested that it is themental hospitals themselves that need changing. Itis our duty to make them acceptable.As a medical superintendent, RUSSELL has an

opportunity of judging the causes of public dread ofthese institutions ; and he puts the custom of retain-ing

" settlers " as their most objectionable feature.He recognises four main classes of settlers, amountingto 70% of the hospital population in any largeinstitution. These can be roughly grouped as

follows : recovered but homeless 5%, chronic psycho-tics 45%, seniles 10%, and mental defectives 10%.The first and third groups, and some of the second, hebelieves, could be more suitably housed in subsidiaryhomes, and the congenitally defective would be betterplaced in colonies. The recovered but homeless

patient is at present difficult to cater for : the hospitalauthorities have to decide whether, if they dischargehim, he is stable enough to stand competitive lifeoutside, when he lacks friends, work, and money.If he is not, it seems only a kindness to keep him inhospital. But it may be bad for a recovering orrecovered patient to remain in the company of thosewho are still acutely or chronically ill. RUSSELL

suggests that he. should be transferred to a

: resettlement unit at a distance from the hospital,and that finally, if he cannot be fitted for

ordinary life, he should go on to an aftercare unit.Units of both types would be administered from the.main hospital though placed some thirty miles away.They would each take 20-30 patients and would carryon outdoor and indoor industries. Some. patientsnot fit for full life outside would be able to go flomthe unit daily to work for . employers near at hand.Many patients with chronic psychosis of a mild andinoffensive type could also live happily in a countryaftercare home, and this would help to reduce thepermanent population in the main hospital. Separateinfirmaries for the old people have usually beenopposed, but, given a fair trial with adequate staffand equipment, they might work well.The hospital itself would be in two parts-the main

buildings and (some 300 yards or more away) theannexe. Chronic psychotics unfit for aftercare homes,because of their disorderly or unpleasant behaviour,would go into the annexe. These form about 30% ofthe present hospital population, and would make upabout half the number under RussELL’s scheme. Inthe main hospital the reception wards for anxious ordepressed patients would be in another building fromthose used by the excited or socially disagreeable. Hethinks it important that separate rooms should be

set aside in the main building for separate purposes.At present, in. order to economise space in our over-crowded mental hospitals, one room may be used forseveral purposes. Thus half the occupants of asick-room may be using it merely as a dormitory ; ordormitory beds may be used J3y patients havinginsulin treatment or resting after convulsion therapy.The main buildings should include shock-therapyrooms, narcohypnosis and psychotherapy rooms,

outpatient consulting-rooms, the occupational centre,the operating-theatre, the radiological department,laboratories, and sick-rooms..

Colonel RUSSELL estimates. that his plan wouldhalve the incurables at the main hospital, and sochange the atmosphere that patients and their rela-tives would take much more kindly to the modernpsychiatric treatment offered there. People, talkingtogether about their experiences, quickly publish thepassing of an. unsatisfactory tradition in favour of abetter. Our mental hospitals badly need these andother reforms to bring them up to date. Once theyhave won the good word of patients and their relatives,all stigma will be wiped out in time, - and they willbecome the first, not the last, resources of the mentallysick.

Curare in AnæsthesiaDURING the hundred or so years which have elapsed

since BENJAMIN BRODIE, and then CLAUDE BERNARD,initiated the scientific investigation of curare, thearrow-poison used by South American natives to

paralyse game, pharmacologists and physiologists,perhaps abetted by novelists seeking new means oftorturing their heroes, have maintained its horrid

reputation. As a result, until recently it was nomore than a valuable laboratory tool for renderinganimals immobile, the voluntary muscles being pra-lysed by a block at the neuromuscular junction,without interfering with their nervous system.About ten years ago some sporadic investigationswere made into the possibilities of using curare tocontrol the spasms of tetanus, but these researches,though promising, do not seem to have arousedmore than academic interest. In 1940, however,BENNETT,2 of Nebraska, injected curare to soften theviolent muscular response to electric shock therapy inpsychiatric patients, and it was so effective that alarge number of mental hospitals in the United Statesnow use the drug for that purpose. This success,which revealed curare as a readily controllable drug,may be said to have opened the story of curare inanaesthesia ; for, as Dr. GRIFFITH recalls on anotherpage, it was as a direct result that, still with some mis-givings, he and JoHNSON decided to apply thenew knowledge of the drug in their own specialty.They found that profound muscular relaxation couldeasily be obtained during abdominal operations by atimely dose of curare, thus obviating the need for deepgeneral anaesthesia. This proved particularly valu-able in resistant subjects, for whom the only alter-native would perhaps have been a spinal anaesthetic.GRIFFITH now reports over five hundred cases in whichcurare has been used without a death, while CuLLEN,41. Cole, L. Lancet, 1934, ii, 475 ; Mitchell, J. S. Ibid, 1935, i, 262 ;

West, R. Ibid, 1936, i, 12.2. Bennett, A. E. J. Amer. med. Ass. 1940, 114, 3222.3. Griffith, H. R., Johnson, G. E. Anethesiology, 1944, 3, 418.4. Cullen, S. C. Surgery, 1943, 14, 2.

82

who took up the investigation shortly after him,has had an even larger and equally successful series.British anaesthetists were cautious in following theirlead, and were hampered by the lack of suitable pre-parations of the drug. But this year a purified curarehas been coming in from America, and many centresin this country, such as those at Oxford, - London,Liverpool, and Southend, are using it and confirmingits usefulness and safety, though the only Britishreport so far published is the brief one by Dr.MALLINSON in this issue. There is already enough’published and unpublished experience available to makeit possible to assess the value of curare as an adjunctto anaesthesia, and consider its future developments.z Two thirigs at least seem certain-that like manyother potentially noxious drugs, curare, in proper andcontrolled dosage, is safe and produces a desirableeffect, in this case muscular relaxation ; and that whenan unduly generous dose is given, respiratory paralysisoccurs with a suddenness as dramatic as after anoverdose of ’ Pentothal ’ or cyclopropane. This

complication holds no terrors for the modern anws-thetist, since it responds to artificial respiration. If

pentothal is " safe " curare is safe. And if curare is

to be condemned because a little too much stopsbreathing, so must pentothal. The safety of thesedrugs depends on the administrator. He should beable to judge the correct dose and have the skill toavert, and the facilities to treat, the complicationswhich attend an overdose. All the anaesthetists whohave published their experiences with curare haveused ’ Intocostrin ’ (Squibb), standardised to contain20 mg. of " active substance " per c.cm. The curarein this preparation is assayed biologically, and it isclearly a great advance on previous preparations, butit is to be hoped that an alkaloid will soon be availableso that a more accurate and reliable dosage scale canbe worked out. GRIFFITH and JOHNSON, CULLEN, andother American workers use curare mainly in asso-ciation with cyclopropane, giving it intravenously individed doses whenever relaxation is insufficient forthe surgery to be done. The average dose of into-costrin is in the neighbourhood of 5 c.cm., containing100 mg. of " active substance." The disadvantage ofanaesthetics like cyclopropane is that the admini-strator has no accurate idea of how much of the drughis patient is having or how deeply anaesthetised he is.Obviously the amount of curare required depends onhow much anaesthetic is given at the same time. Forthe study of the dosage of curare, therefore, exactdosimetric administration of the general anaesthetic isimperative, and such an apparatus as the OxfordVaporiser is proving a boon in this connexion.When using curare, the anaesthetist soon learns that

those reflexes he calls " the signs of anaesthesia "’canno longer be elicited, however little general anaesthetichas been given. They form no guide as to whether hispatient is feeling pain or is unconscious. Care musttherefore be taken to deaden sensation and ensureunconsciousness, or the worst imaginings of thenovelist may come true, for the patient can give nosign if the general anaesthetic is ineffective.. Thedanger of curare is paralysis of the respiratory muscles.Intercostal paralysis, which every anaesthetist shouldbe able to recognise without fail, usually occurs befprediaphragmatic.’ If this point is passed, respirationquickly fails. Reliance should then be placed on

artificial respiration by inflating the lungs with

oxygen, .and since this has always been carried out nopatient has come to any harm through this complica-tion, according to the published reports. The

pharmacological antidote to curare is ’ Prostigmin ’;but, while this should not be withheld, no dramaticeffect is to be expected from it in such an emergency.

Curare, then, justifies further study. Here is a sub-stance which when injected into the circulation pro-duces relaxation of the voluntary muscles, so eliminat-ing

" the cause of more profanity by the surgeons andsweat and tears by the anaesthetist than any otheroccurrence in the operating-room." In addition, therelaxation necessary- for the satisfactory performanceof abdominal operations is. procured without the

postoperative complications which follow the largedoses of the more familiar anaesthetics needed to givethe same relaxation. But as GRIFFITH 5 puts it,"

curare is still a poison, and like every other poisonit should be handled intelligently and only byexperienced physicians."

Tropical Ulcers" TROPICAL ulcer is a straightforward subject," to

quote a contributor last week.6 But the term is still

applied to two different conditions. To some medicalofficers abroad the tropical ulcer is an acute and laterintractable ulcerative skin infection of the extremities,variously known to the troops as veldt sore, desertsore, or jungle sore. To others, particularly thosestationed in certain parts of the Mediterranean basinand the lands lying eastward, it may mean cutaneousleishmaniasis-oriental sore, Delhi boil, or Bagdadbutton. The fuller descriptions

"

tropical phage-daenic ulcer " and " cutaneous leishmaniasis " leaveno doubt about the kind of lesion, and they mightwell be more widely employed.The past few years’ study of the various types

of tropical phagedaenic ulcer so often seen in bothcoloured and white troops has not materially advancedour knowledge of its aetiology. Nutritional defici-

encies, spirochaetes and fusiform bacilli, variousbacteria and diplococci, viruses, and other agencieshave each had their supporters as causative agents,and any or all. of them may play a part. MARSH andWILSON 7 epitomise their opinion of the basic factors inthe mnemonic " filth: food: friction: fusospirillosis."They think that the almost invariable presence ofVincent’s organisms in the lesions is of aetiologicalsignificance, and that the banishment of these organ-isms presages complete and speedy healing. This

conception of tropical phagedaenic ulcer has been,current for some time, and cannot lightly be dismissedin the absence of a more conclusive explanation. Ontreatment also agreement is lacking. Cleansing of thelesion is an obvious first step in the limitation of itsspread, the promotion of healing, and the avoidanceof scarring. Supposedly more specific remediesinclude arsenicals, such as arsphenoxide (’Mapharsen’)intravenously 8 and local application of powderedsulphonamides, ointments such as BIPP or zipp,crystals of potassium permanganate, and ointmentsand lotions containing perchloride of mercury,9 each

5. Griffith, H. R. Canad. med. Ass. J. 1945, 52, 391.6. Walker-Taylor, P. N. Lancet, July 14, p. 40.7. Marsh, F., Wilson, H. A. Trans. R. Soc. trop. med. Hyg. 1945, 38, 259.8. Feirnman, M. H. New Engl. J. Med. 1944, 231, 578.9. Pattanayak, C. G. Ind. med. Gaz. 1944, 19, 521.