of 2 /2
589 insistence on interpreting his findings in terms of evolutionary theory and Jacksonian thought, and his habit of inventing anatomical structures to fulfil his ideas, had rendered him an easy target for criticism, and tended to obscure much that was valuable in his work. However, recent studies on the anatomy and physiology of sensory receptors, and on modality analysis in posterior horn cells, had brought us closer to Head’s concept of the organisation of the sensory system, although his idea of a peripheral dual afferent system had not stood the test of time. The researches of Mountcastle and his colleagues at Johns Hopkins on duality in the somatosensory system suggested that Head’s speculations on duality might find fulfilment, though in a different way from the one he envisaged; his ideas on the thalamus might prove less wide of the mark than had been supposed. In general it could be said that Head’s conception of the afferent system approximated more closely to our own than those of his contemporaries, and that his theories still provided a stimulus to those working on sensation. Dr. Macdonald Critchley, speaking on Head’s Con- tribution to our Conceptions of Aphasia, said that Head seemed to enter this last field of activity rather hesitantly at a time when the marks of his long and disabling illness were becoming apparent. Before Head the clinical examination of aphasic patients had been haphazard; he introduced a battery of tests which form a landmark in aphasiology. This system of testing was time-consuming and repetitive and took no account of the unusual case. Nevertheless, Head’s deep exploration of aphasics had contributed greatly to our knowledge, and much of what we teach we owed to him. His classification was based on his view that aphasia is a defect of symbolic formulation and each variety of aphasia represents a partial disturbance of this function. He recognised four types of aphasia: verbal, nominal, syntactical, and semantic. Although his principles were right his classification was less successful than its predecessors in differentiating clinical types of aphasia and had not replaced them. His approach was functional, and he deprecated precise localisation of speech functions; he seemed uninterested in the problem of dominance. Dr. Critchley concluded that the future study of aphasia demanded the linguistic approach advocated by Head. Sir Russell Brain spoke on Henry Head, the Man and His Ideas. Head was born in Stoke Newington of Quaker stock. He had always determined to study medicine, and at Charterhouse he was much influenced by his biology master. Before going up to Trinity College, Cambridge, he spent a year learning various scientific techniques in Germany. He qualified at University College Hospital, but in 1894 became medical registrar at the London Hospital, where he was elected to the staff. Head was a born teacher and his enthusiasm was infectious. His interests were wide, embracing literature, art, and music, and he was closely associated with several of the Georgian poets. Sir Russell revealed that after the 1914-18 war Head was approached with a view to his becoming the first professor of medicine at The London, but although he formulated his requirements nothing came of the proposal. Speaking of Head’s ideas Sir Russell said that fertile error was preferable to sterile fact, and even in his errors Head had accomplished much by stimulating the thoughts of others. The proceedings of the meeting will be published in Brain. 1. Papper, E. M., Brodie, B. B., Rovenstine, E. A. Surgery, 1952, 32, 107. 2. Shaw, R. Brit. med. J. 1961, i, 825. 3. Deacock, A. R. ibid. p. 1465. 4. Campbell, E. J. M., Howell, J. B. L. ibid. 1960, i, 458. 5. Rolinson, G. N., Stevens, S. ibid. July 22, 1961, p. 191. 6. Sevitt, S., Gallagher, N. G. Lancet, 1959, ii, 981. POSTOPERATIVE DRUG TREATMENT AFTER operation the patient, who has already been submitted to preoperative medication and anxsthesia, may receive antibiotics; analgesics, sedatives, and tran- quillisers ; purgatives and enemas; hypotensive or hypertensive agents; anticoagulants; cardiac stimulants or depressants; steroids, diuretics, and bronchodilators; and parenteral blood-volume expanders. To eliminate un- necessary drugs and reduce the use of others would be an act of clemency besides a welcome economy. Papper et aLl demonstrated that analgesics are administered needlessly for postoperative pain, which may often be controlled equally well by placebos. The investigation was initiated to determine whether the analgesic action of intravenous procaine was exerted through its metabolite, diethylaminoethanol. At the end of each operation, a group of 118 patients received diethylaminoethanol and a control group of 119 patients intravenous saline solution. Postoperative pain was held to be absent if no analgesic drugs were required; moderate if no more than two doses of morphine or pethidine were needed in twenty-four hours, and severe if more than two doses were necessary. There was no significant difference in results between the diethylaminoethanol and saline groups. The investigators were surprised to find that postoperative pain was absent in nearly half, moderate in a third, and severe in less than a quarter of the combined group of 237 patients. Of a further 49 patients complaining of severe pain after hysterectomy, two-thirds were relieved by intra- venous saline. New analgesics, such as phenazocine, are competing with morphine and pethidine. Shaw found that phena- zocine did not cause any important blood-pressure changes and it was associated with a pleasant absence of post- operative vomiting, but he criticised its depressant effect on respiration. In a controlled trial, however, Deacock,3 found that phenazocine and pethidine affected respiration equally. The simple bedside method of estimating the blood pCO2 introduced by Campbell and Howel1,4 would be useful in assessing the effect of these drugs on respiration. Some surgeons cover every operation with an umbrella consisting of the antibiotic with the widest spectrum or with the mixture of antibiotics in which they have the greatest confidence. But there is no evidence to recommend prophylactic administration in clean surgery; indeed, such sequels as diarrhoea, staphylococcal enterocolitis, and drug resistance strongly contraindicate routine prophy- lactic administration. For operative chemoprophylaxis surgeons commonly rely on streptomycin, largely because it kills gram-negative organisms which are so liable to contaminate surgical wounds. But the small prophylactic doses often given soon lead to a single-step high level of bacterial resistance, and streptomycin is consequently ineffective. Worse, if administration is continued, notably in the presence of poor renal excretion, labyrinthine function may suffer. Where antibiotic cover is essential, Penbritin ’ 5 may prove a suitable alternative. The problem of prophylactic anticoagulant administra- tion has been largely resolved by a trial at the Birmingham Accident Hospital. In this trial Sevitt and Gallagher 6 selected elderly patients with fractured hips, who are particularly prone to venous thrombosis and embolism. A group of 150 patients given phenindione was matched by an equal number not given

POSTOPERATIVE DRUG TREATMENT

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insistence on interpreting his findings in terms ofevolutionary theory and Jacksonian thought, and hishabit of inventing anatomical structures to fulfil his ideas,had rendered him an easy target for criticism, and tendedto obscure much that was valuable in his work. However,recent studies on the anatomy and physiology of sensoryreceptors, and on modality analysis in posterior horncells, had brought us closer to Head’s concept of the

organisation of the sensory system, although his idea ofa peripheral dual afferent system had not stood the testof time. The researches of Mountcastle and his colleaguesat Johns Hopkins on duality in the somatosensory systemsuggested that Head’s speculations on duality might findfulfilment, though in a different way from the one heenvisaged; his ideas on the thalamus might prove lesswide of the mark than had been supposed. In general itcould be said that Head’s conception of the afferent

system approximated more closely to our own than thoseof his contemporaries, and that his theories still provideda stimulus to those working on sensation.Dr. Macdonald Critchley, speaking on Head’s Con-

tribution to our Conceptions of Aphasia, said that Headseemed to enter this last field of activity rather hesitantlyat a time when the marks of his long and disabling illnesswere becoming apparent. Before Head the clinicalexamination of aphasic patients had been haphazard; heintroduced a battery of tests which form a landmark inaphasiology. This system of testing was time-consumingand repetitive and took no account of the unusual case.Nevertheless, Head’s deep exploration of aphasics hadcontributed greatly to our knowledge, and much of whatwe teach we owed to him. His classification was basedon his view that aphasia is a defect of symbolic formulationand each variety of aphasia represents a partial disturbanceof this function. He recognised four types of aphasia:verbal, nominal, syntactical, and semantic. Although hisprinciples were right his classification was less successfulthan its predecessors in differentiating clinical types ofaphasia and had not replaced them. His approach wasfunctional, and he deprecated precise localisation of

speech functions; he seemed uninterested in the problemof dominance. Dr. Critchley concluded that the futurestudy of aphasia demanded the linguistic approachadvocated by Head.

Sir Russell Brain spoke on Henry Head, the Man andHis Ideas. Head was born in Stoke Newington of

Quaker stock. He had always determined to studymedicine, and at Charterhouse he was much influencedby his biology master. Before going up to TrinityCollege, Cambridge, he spent a year learning variousscientific techniques in Germany. He qualified at

University College Hospital, but in 1894 became medicalregistrar at the London Hospital, where he was electedto the staff. Head was a born teacher and his enthusiasmwas infectious. His interests were wide, embracingliterature, art, and music, and he was closely associatedwith several of the Georgian poets. Sir Russell revealedthat after the 1914-18 war Head was approached with aview to his becoming the first professor of medicine atThe London, but although he formulated his requirementsnothing came of the proposal. Speaking of Head’s ideasSir Russell said that fertile error was preferable to sterilefact, and even in his errors Head had accomplished muchby stimulating the thoughts of others.The proceedings of the meeting will be published in

Brain.

1. Papper, E. M., Brodie, B. B., Rovenstine, E. A. Surgery, 1952, 32, 107.2. Shaw, R. Brit. med. J. 1961, i, 825.3. Deacock, A. R. ibid. p. 1465.4. Campbell, E. J. M., Howell, J. B. L. ibid. 1960, i, 458.5. Rolinson, G. N., Stevens, S. ibid. July 22, 1961, p. 191.6. Sevitt, S., Gallagher, N. G. Lancet, 1959, ii, 981.

POSTOPERATIVE DRUG TREATMENT

AFTER operation the patient, who has already beensubmitted to preoperative medication and anxsthesia,may receive antibiotics; analgesics, sedatives, and tran-quillisers ; purgatives and enemas; hypotensive or

hypertensive agents; anticoagulants; cardiac stimulants ordepressants; steroids, diuretics, and bronchodilators; andparenteral blood-volume expanders. To eliminate un-

necessary drugs and reduce the use of others would be anact of clemency besides a welcome economy.Papper et aLl demonstrated that analgesics are

administered needlessly for postoperative pain, which mayoften be controlled equally well by placebos.The investigation was initiated to determine whether the

analgesic action of intravenous procaine was exerted throughits metabolite, diethylaminoethanol. At the end of eachoperation, a group of 118 patients received diethylaminoethanoland a control group of 119 patients intravenous saline solution.Postoperative pain was held to be absent if no analgesic drugswere required; moderate if no more than two doses of morphineor pethidine were needed in twenty-four hours, and severe ifmore than two doses were necessary. There was no significantdifference in results between the diethylaminoethanol andsaline groups. The investigators were surprised to find thatpostoperative pain was absent in nearly half, moderate in athird, and severe in less than a quarter of the combined groupof 237 patients. Of a further 49 patients complaining of severepain after hysterectomy, two-thirds were relieved by intra-venous saline.

New analgesics, such as phenazocine, are competingwith morphine and pethidine. Shaw found that phena-zocine did not cause any important blood-pressure changesand it was associated with a pleasant absence of post-operative vomiting, but he criticised its depressant effecton respiration. In a controlled trial, however, Deacock,3found that phenazocine and pethidine affected respirationequally. The simple bedside method of estimating theblood pCO2 introduced by Campbell and Howel1,4 wouldbe useful in assessing the effect of these drugs onrespiration.Some surgeons cover every operation with an umbrella

consisting of the antibiotic with the widest spectrum orwith the mixture of antibiotics in which they have thegreatest confidence. But there is no evidence to recommendprophylactic administration in clean surgery; indeed, suchsequels as diarrhoea, staphylococcal enterocolitis, anddrug resistance strongly contraindicate routine prophy-lactic administration. For operative chemoprophylaxissurgeons commonly rely on streptomycin, largely becauseit kills gram-negative organisms which are so liable tocontaminate surgical wounds. But the small prophylacticdoses often given soon lead to a single-step high level ofbacterial resistance, and streptomycin is consequentlyineffective. Worse, if administration is continued, notablyin the presence of poor renal excretion, labyrinthinefunction may suffer. Where antibiotic cover is essential,Penbritin ’ 5 may prove a suitable alternative.The problem of prophylactic anticoagulant administra-

tion has been largely resolved by a trial at the BirminghamAccident Hospital.

In this trial Sevitt and Gallagher 6 selected elderly patientswith fractured hips, who are particularly prone to venousthrombosis and embolism. A group of 150 patients givenphenindione was matched by an equal number not given

Page 2: POSTOPERATIVE DRUG TREATMENT

590

7. Sevitt, S. in Symposium on Anticoagulant Therapy (edited by SirGeorge Pickering); p. 249. London, 1961.

8. Paris, J. Proc. Mayo Clin. 1961, 36, 305.9. Conley, J. J. Arch. Otolaryng., Chicago, 1957, 65, 437.

10. Crile, G., Humphries, A. W. Amer. J. Surg. 1957, 94, 649.11. Westbury, G. Brit. J. Surg. 1960, 47, 605.12. Jepson, R. P., Opit, L. J. Aust. N.Z. J. Surg. 1961, 30, 175.

anticoagulants. Embolism did not occur in any patient receiv-ing adequate anticoagulant therapy; but it was observed in18% of the control series, and it led to death in 10%. Clinicalevidence of venous thrombosis was found in 29% of cases inthe control series compared with 3% of the phenindione-treated group. The necropsy evidence was equally striking, forsignificant thrombosis was found in 83% of 35 patients in thecontrol group who died, compared with 14% of 21 patients inthe phenindione group who died.The present policy in the Birmingham Accident

Hospital 7 is to start prophylactic administration of

phenindione on the day of admission or the following dayin all patients over the age of 45 admitted with fractures ofthe femur, tibia, or ankle or with severe bruises and burnscovering less than 5% of the body-area. Prophylacticanticoagulants are also given to patients with fractures ofpelvis and ribs if it is certain that there are no internalinjuries which are liable to bleed. Phenindione is continuedfor about one week after the patient has become ambulant.The now widespread use of corticosteroids adds a

special hazard to modern surgery; for adrenal suppressionfollowing their prolonged use contributes to postoperativeshock and is associated with an appreciable postoperativemortality. At the Mayo Clinic patients who have hadadrenocortical drugs are given intramuscular cortisoneacetate in doses of 200 mg. forty-eight, twenty-four, andone to two hours before operation. Short operations maybe covered by oral cortisone just before and just aftersurgery, whereas longer operations may call for supple-mentary intramuscular prednisolone phosphate or intra-venous hydrocortisone hemisuccinate; and, if need be, thelatter can be given intravenously during anxsthesia andrecovery.

CAROTID-BODY TUMOURS

A CAROTID-BODY tumour usually presents as a symptomlessswelling of the carotid triangle in a young or mature adult.In most cases it has been present for a considerable time, andthis may suggest lymph-node enlargement due to tuber-culous infection or to reticulosis. The diagnosis becomesclear when exploration reveals a highly vascular swellingadherent to the carotid vessels; but the surgeon may wellwonder what to do. By and large, experience has shownthat operations for carotid-body tumour tend to be moredangerous than the condition itself. The mortality ofresection of the carotid bifurcation, even in youngpatients, is as high as 30%; and without resection removalof the tumour has carried a 15% fatality-rate. Arterialreconstruction seemed to offer a solution, but only a fewreports so far exist. 9 10 This operation does not seem tobe generally applicable to the cases in which surgery ismost needed 11 12-namely, large tumours in which theupper stump of the internal carotid artery is much tooclose to the base of the skull to allow manipulation forsuccessful anastomosis by suture.

Is carotid resection ever justified ? Only a real suspicionof malignancy, supported by histological evidence, couldbe sufficient reason for the surgeon to take this grave step.But this evidence itself may be open to question. Otherlocally malignant and slowly metastasising tumours of thecarotid region-for example, some types of thyroidcarcinoma-may be hard to distinguish. The incidence of

13. Gordon-Taylor, G. Brit. J. Surg. 1940, 28, 163.14. See Lancet, 1961, i, 706.15. See ibid. 1958, ii, 1269.16. H.M. (61) 68.

malignant change in true carotid-body tumour has pro-bably been overestimated. Most are benign, and a plane ofcleavage can generally be found by a careful and experi-enced operator, as was shown by Gordon-Taylor overtwenty years ago.13 But there are cases in which the

vascularity is such (and this may be suspected from theappearances at angiography before the operation) as togive rise to difficulty, and the surgeon may feel obliged toapply carotid ligatures. In this type of case Jepson andOpit 12 have tried a compromise: with or without tem-porary carotid occlusion a subcapsular dissection and

piecemeal removal of the whole tumour is quickly carriedout, the space is packed until the bleeding stops, and thecapsule is resutured. These workers recommend subse-quent radiotherapy.We may, then, conclude that a limited operation of

some kind should always be preferred in this generallybenign disease, and that when in doubt the prudentsurgeon will ascertain by biopsy that he is not dealing withsome other malignant tumour for which carotid resectionwould be unjustified.

NOISE IN HOSPITALS

IN the past few years efforts have been made to makethe patient’s stay in hospital shorter and more pleasant,"and much attention has been paid to noise control. KingEdward’s Hospital Fund for London has published tworeports 15 analysing the reactions of hospital patients todifferent noises, and following these reports the Ministryof Health has circulated a memorandum 16 which

publishes a report by the Standing Nursing AdvisoryCommittee of the Central Health Services Council.Not all patients are distressed by the same noise; but

sick people in general are more easily disturbed than thosewho are well, and hospitals are asked to consider and toact on reports from convalescent patients about dis-

tressing noises. The memorandum recommends thateach hospital should have its own noise-control sub-committee to deal with these reports. The idea of yetanother subcommittee may suggest more noise ratherthan less ; but some means of sifting the complaints anddealing with the noises must be devised, and if such

groups could make changes they might prove extremelyvaluable.The site of the hospital is of course important-no

patient can expect perfect peace in one flanked by a milkdepot and backing on to a night club-but within thehospital itself much can be done to influence the amountof noise by careful arrangement of wards for specialgroups of patients. A recovery ward for those who haveundergone operation ensures more peace for the othersurgical patients. The noisy senile patients with dis-turbed sleep rhythm who abound in most orthopaedic andgeneral medical wards, and who may require clean

bedding twice in a night, could be placed in sound-proofcubicles in hospitals (and they are many) which have noward for acute geriatric cases. It is notoriously difficult tosleep in an obstetric unit, even for those whose labours areover; and when the labour rooms are at the far end of themain ward, sleep is constantly broken by attendants andstudents hurrying to the labourers.The provision of silent or near-silent equipment must

often be restricted by lack of money, but in some cases the