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that period of time which matter. Stevenson,’ reviewing hisown experience and the literature on the subject of spontaneouscures from psychoneurosis, has concluded that " encouragingpatients to practise new behavioural responses in between thetherapeutic sessions will shorten the number of interviews

required ..." The analyst might criticise such activity on thepart of the therapist as an infringement on the patient’s free-dom to find himself and make his own choices. However,even the analyst has to make a selection of the themes offeredhim and accents one thing or another, so implying that a newbehavioural response would be helpful.On the other hand, learning theorists neglect the possibility

of change as a result of interpretation of the doctor-patientrelationship. Few psychotherapists of experience would denythe fact that greater behavioural changes result from " hot "situations than from " cold " ones. A " hot " situation beingdefined as an experience in which the person is totally andsincerely involved, so that there is no denial, splitting, ordistance created by intellectual means.

Surely, if such conditions do arise with the therapist, andhe has the particular personality and skill required, the oppor-tunity should not be neglected to interpret the patient’sbehaviour in a new and revealing way.

I. J. MACDONALD.St. George’s Hospital,

London, S.W.1.

DOCTOR-NURSE RELATIONSHIPS IN AHOSPITAL ENVIRONMENT

RICHARD DE SOLDENHOFF.

JEAN L. MARJOT.

SiR,-In every facet of life where men and women haveto work together, whether it be in business or hospital,sex must play some part. While admitting that NurseRayner’s article (Dec. 30) is in many of its facts true, itis a pity it had to be romanticised by little vignettes ofhospital life.Unfortunately articles in The Lancet and British Medical

Journal are read and transposed in lay newspapers andoften taken out of context. I fear that this article will inno way change the attitude of the doctor, whether he bepatriarch or misogynist. All it will do is tear yet anotherveil from the already cynical eyes of the public, and holdus up to more ridicule on television and in the novel.The article would have made a good lecture, but I

regret that it had to be published.Ayr. RICHARD DE SOLDENHOFF.

SIR,-In the relationship between doctors and nurses,discussed by Miss Rayner in your issue of Dec. 30, oneexpects there to be some personality clashes from timeto time. I have found, in ten years of nursing, that withthe constant changing of staff on a ward any difficultsituations tend to disintegrate as quickly as they form.It is true that a more lasting relationship must be main-tained between the sister and the consultant, but I thinkone must try not to complicate this relationship. If asituation arises which causes so much trouble that it is

actually disturbing the patients, a good matron will quicklydiscover and tactfully intervene.In the case of " attachment to consultant ", quoted by Miss

Rayner, however, one feels that the surgeon was so odd andselfish that he would have great difficulty in getting on entirelywell with anyone who ran his ward, or indeed with his house-men. The sister in question may have been good in the theoryand practice of nursing, but was obviously the type who wouldfind the correct folding of the hand towels and so on, of vitalimportance. I doubt whether any doctors went to her wardfor their " mothering ".Most of the wards which tend to collect the doctors for coffee

and tea sessions have attractions for them not strictly maternal.The nurse who is patient with her patients will undoubtedly

be a good mother, but I doubt very much whether she regardsthe doctor as her " husband ". I think, too, that most con-sultants are not particularly interested in whether they attractthe nurses or not, and merely expect that their wards shouldbe run efficiently. Those who are nice to their wives will benice to their ward sisters, but will not confuse the two relation-ships. Their behaviour, friendly, flirtatious, or otherwise, willbe strictly according to their own personalities.

Is it, I wonder, worth noting that children playing at" mummys and daddys " play an entirely different sortof game from that of

" doctors and nurses " ?Crowthorne,Berks. JEAN L. MARJOT.

SIR,-It is good to comfort my conscience in middleage with the thought that the time spent in the ward linencupboard and other such quiet backwaters in the hospitalof my student days had such social value and psychiatrictherapeutic associations. I thought I did it for otherreasons ! 1

REFORMED!REFORMED! z

ANTICOAGULANTS IN

ACUTE MYOCARDIAL INFARCTION

SIR,-Perhaps even tardy correspondence about theoriginal article by Dr. Hilden and his coworkers (Aug. 12)and the subsequent discussion will be allowed in view of theimportance of the subject.

Dr. Holten (Sept. 23) pointed out the unequal distribution inthe mortality between treated (55 patients, 12.9%) and non-treated (161 patients, 27.5%) cases in the 216 patients who diedin the first 48 hours. These individuals had been eliminatedfrom consideration by the authors, since they believed that noeffect of anticoagulant treatment could be expected in the first48 hours. Although this view is held by many workers in thisfield, there are others, myself included, who do not agree. Whenheparin is used, an efficient anticoagulation is obtained withinseveral minutes if it is given intravenously, and within 1/2 hourif administered subcutaneously or intramuscularly. This earlyeffect may well be of benefit. Until the study by Dr. Hildenet al. appeared there was no valid evidence available to supporteither point of view as to the effect of heparin therapy withinthe first few days after myocardial infarction.

In answer to the point Dr. Holten raised, Dr. Hilden et al.(Nov. 4) remark that 58 of the excluded 216 patients wereadmitted during " treatment " years but died before treatmentwas given, and so were picked up and classified by the punch-card machine as untreated, thus explaining the difference inthe early mortality between treated and untreated cases. Theythen (Nov. 4) stated that if these 58 cases were transferred backto the treated group the total figures became as follows:admitted in treatment years 484 patients, total deaths 198

(40.9%); admitted in non-treatment years 532 patients, totaldeaths 212 (39.9%).

It is my opinion that the inclusion, of these 58 patients ineither group, treated or untreated, is prejudicial and possiblyconceals meaningful data. These 58 patients should not beincluded in the untreated group as this arbitrarily transfers 58deaths to that group. They also do not deserve inclusion in thetreated group as they did not receive anticoagulant therapywhich may have been effective. If these 58 cases are omitted the

figures become as follows: treated 426 patients, 48-hour deaths55 (12.9%), total deaths 140 (32.9%); untreated 532 patients,48-hour deaths 103 (19.4%), total deaths 212 (39.9%). Thus,there is a higher mortality-rate in the untreated group, a ratioof 3 deaths to 2 in the first 48 hours.

Other considerations come to mind. The difference in theearly mortality-rate may have affected the finding of an

insignificant difference between the mortality-rates of the twogroups after early deaths had been excluded. Severely ill

patients, kept alive by heparin treatment, were now includedin the treated group but excluded from the control group, thus7. Stevenson, I. Amer. J. Psychiat. 1961, 117, 1057.

104

possibly concealing a beneficial effect of the oral anticoagulantssubsequent to the first 48 hours of heparin therapy. It is

possible, however, though unlikely, that the entire benefitderived from anticoagulant therapy was due to the initial periodof heparinisation. We have previously presented preliminaryevidence that continuous heparinisation during the entire

hospital stay after acute myocardial infarction affords superiorresults as compared with an initial few days of heparin therapyfollowed by dicoumarol.1 This remains to be substantiated, butit seems that Dr. Hilden et al. have demonstrated the value ofthe initial period of heparin therapy.

Further investigations are clearly indicated. Four

groups will be needed: (1) a control group without anti-coagulants of any type; (2) a group who receive oral

anticoagulants without initial heparinisation; (3) similarto group 2 but with heparin administered for the first 2-3days; (4) continuous heparin therapy for the entire periodin hospital.

Beverly Hills,California. HYMAN ENGELBERG.HYMAN ENGELBERG.

MALIGNANT MELANOMA

R. M. NEGUS.Masaka Hospital,Masaka, Uganda.

SiR,łI was very interested to read your leadingarticle. Malignant melanoma is one of the commonestforms of growth among the Africans here. At this hospital(which serves a population of 300,000 people) I have seen7 new cases of malignant melanoma during the past year.

In one the primary was in the orbit, but in all the others itwas on the sole of the foot. The vast majority of the local peopledo not wear shoes, so it is very tempting to conclude that this isin some way related to the chronic trauma of walking barefoot.

DISCS, LESIONS, AND SYNDROMES

N. G. C. HENDRY.Orthopaedic Department,

Royal Infirmary,Aberdeen.

SIR,-Dr. Troup (Dec. 30) conducts his rearguardaction with such civility that I am almost sorry to have todispose of his hypothesis.

It is based, as I see it, on two assumptions: first, that thetissue changes my colleagues and I have found (Dec. 16) arethe result of some reflex, origin and pathways unknown, whichcontrols the metabolism of the intervertebral segment and the

overlying soft tissues; second, that the blood changes are ofinflammatory origin. As neither of these assumptions alonecan explain the findings, it suffices to dispose of both (in thiscontext, at any rate) that the serum of every patient wasnegative for C-reactive protein. As to the reflex, I have noevidence against it, any more than Dr. Troup has any evidencefor it: it may well exist, but I find it very hard to account for sosignificant a rise (sometimes as high as 25%) in serum protein-bound sugars on the basis only of a lesion confined to a singlesegment of the spine.However difficult it may be to reconcile these findings with

some of the preconceptions about disc prolapse, and howeverpunctiliously one reserves one’s position in view of the immenseignorance that remains in this field, I can still conclude onlythat the evidence points to a widespread and primary upset inpolysaccharide metabolism. If that is the case, then it is

inescapable that the nucleus pulposus is the structure in thel.vj.c. (perhaps even in the body as a whole) where the earliestand most profound local changes are to be expected. This isnot to say that it is only, or invariably, the principal cause ofsymptoms. In terms of our current very imperfect treatment,we should look more closely than we usually do at the inter-vertebral segment as a functional unit: in terms of aetiology, Ithink we have to look much farther afield.

EXTERNAL CARDIAC MASSAGE

J. G. MCLEOD.Royal Prince Alfred Hospital,

Camperdown,New South Wales.

SIR,-Dr. Julian 1 recommends the application of thetechnique of external cardiac massage in the resuscitationof patients with cardiac arrest in acute myocardial infarc-tion. The following case illustrates one of the possiblecomplications of this procedure:A man aged 69 was admitted with severe chest pain of four

hours’ duration. A pericardial friction-rub was audible overthe precordium, but blood-pressure was 140/70 mm. Hg andthere were no signs of cardiac failure. An electrocardiogramshowed a recent myocardial infarct. Treatment with heparinand phenindione was begun, but after six hours the patientsuddenly became unconscious and pulseless, though slow

voluntary respirations persisted. With hard boards placedbehind the patient’s back, external cardiac massage was

instituted and positive-pressure respiration applied throughan intratracheal tube. Although good peripheral pulses weremaintained, the colour remained pink, and the pupils remainedconstricted, the procedure was abandoned after ten minutesbecause spontaneous ventricular contractions failed to return.At necropsy, there was an extensive very recent anterior

myocardial infarct with cardiac rupture causing haemoperi-cardium, and a fractured sternum. It was considered thatrupture was caused directly by cardiac massage and that incombination with a fractured sternum this may be in extensivemyocardial infarction a complication of a procedure whichshould nevertheless be applied without delay in sudden cardiacarrest.

DELIBERATE EMERGENCIES

SIR,-What a pity that Mr. Garland (Dec. 9) shouldsurround his plea for a unified and integrated midwiferyservice with so many red herrings and idiosyncrasies.Anybody who has the welfare of mothers and babies at

heart must work for an integrated service, but not, I

suggest, in the way he proposed, and I should like to joinissue on certain points in his letter.

It seems to me that the region in which Mr. Garland worksdoes not conform to the general pattern of London. The latestreturns for 1960 show that there were in London 58,420births of which 10,945 were domiciliary cases.Mr. Garland also states, speaking of his area, that no further

maternity beds are needed-this despite the fact that in partsof south London there are large areas with no maternity unitsin the vicinity and where " social cases " are farmed out by theregional board to a non-N.H.S. hospital in Surrey. Again, thelarge number of unfortunate mothers who need hospital con-finement, and then can get in only by courtesy of the EmergencyBed Service when they are already in labour, should suggestthat all is not well with the bed state and that even in thoseareas where there are an adequate number of beds there is notproper selection of cases.Mr. Garland seems in doubt whether enough general-

practitioner obstetricians would be willing to avail themselvesof the use of hospital beds, and I would ask him to contact theLondon Local Medical Committee, who would, once again,tell him of the large number who are willing and anxious forthe use of general-practitioner beds. I am quite sure that theywould not lean on the resident medical staff and expect themto cover them and allow their work to be done for them.He does not equivocate about where the mother should have

her baby: indeed, he says she should no more have it at homethan have a D. & c. on the kitchen table. This is his personalopinion and as such must be noted, but not necessarily put intoeffect, even if that were possible-which (thank goodness) itis not.His remark that " maternity is, no doubt, fashionable at the

1. Engelberg, H. Calif. Med. 1959, 91, 327.2. Griffith, G. C., Zinn, W. J., Engelberg, H., Dooley, J. V., Anderson, R.

J. Amer. med. Ass. 1960, 174, 1157.3. Lancet, 1961, ii, 585. 1. Lancet, 1961, ii, 840.