BRITISH MEDICAL JOURNAL
Death of a nurse Reformers and pressure groups have been successful in recent years in getting recognition for the legal rights of patients in psychiatric hospitals. Unfortunately their emphasis on the patients' rights and freedoms has overshadowed the problems faced by the medical and nursing staff, as was tragically shown by the death last year of a nurse at Tooting Bec Hospital, who was stabbed to death by a schizophr-nic patient. The committee of inquiry which investigated the circumstances of the death found' that staff at the hospital were anxious and uncertain about the management of disturbed patients with a potential for violence. At present a voluntary patient has a legal right to refuse treatment and to refuse to hand over a potential weapon -and in the words of a recent report2 "Generally, an action for assault will be successful if the doctor has 'touched' the person without his informed consent." The pendulum has swung too far: as the inquiry observes, by letting people who are mentally ill retain their normal freedom, society gives them the freedom to refuse treatment and to deteriorate mentally. Inevitably some mentally disturbed patients will behave unpredictably and irrationally, and staff cannot be expected to handle emergencies quickly and efficiently if they have to be meticulously careful of the legal niceties of each individual patient's freedom to consent or not to the action required. Strict interpretation of the legal position makes the task of nursing some types of psychiatric patients impossible. There is a strong case for wider recognition by society that nurses are dedicated professionals who must be given discretion occasiornally to use force and compulsion when there is no safe alternative.
2
425
22 NOVEMBER 1975
Report of the commitittee of inquirv into the circumstances leading to the death of Mr Daniel Carey at Tooting Bec 'Hospital otn 2 August 1974. London, South-west Thames Regional Health Authority, 1975. Gostin, L 0, A Humnan Condition. London, MIND, 1975.
Aftermath of the ballot By the weekend of 15 November there was little hope that the ballot of hospital junior staff on the proposed new contract might bring an end to the unrest and industrial action in the NHS hospitals. Spokesmen for various groups of doctors had attacked the phrasing of the ballot and its method of distribution and had alleged collusion between the BMA and the Department of Health.1 2 The meeting of the BMA Hospital Junior Staffs Committee on 17 November (see p 476) further compounded the existing confusion. A motion was passed -34 to 20-asserting no confidence in the chairman and the executive; and before the voting figures were known the ballot was said to be of no binding effect on the committee Perhaps the most striking result of the ballot (see p 482) was the high poll-over 14 000 votes out of an electorate of 15 00016 000 NHS contract holders-a return of 90",,, a large majority of whom approved the concept of the new contract. The majority in favour of industrial action was not, however, so convincing: 7355 against 5336 or roughly 6 to 4. The implications of the HJS Committee's threat of industrial action by 27 November are still far from clear: in strict constitutional terms, the only way the BMA as the registered trade union can call for official strike action is by a decision of its Council (meeting next week). Undoubtedly, consultants and general practitioners will have some views on a course of action that
is bound to affect them. Furthermore, 10 days gives little time for a new negotiating team to master the complexities of their brief and persuade a determined Government to allow a more flexible interpretation of its pay policy. The smouldering unrest among junior staff is not (as we have emphasised already) due simply to dissatisfaction with the way their new contracts have been negotiated: the malaise in the NHS goes far deeper.3 But those who have been so vocal in their criticisms of the BMA negotiators should perhaps ask why it proved so difficult to replace the chairman of the HJS Committee. Representing young doctors is a thankless task for anyone with a job to do in the NHS. Time for medicopolitical work has to be found from the off-duty periods that could otherwise be spent with families-and inevitably the work involves long, tedious committee meetings; much travelling; and a vast amount of paper work. The views the negotiators are supposed to represent are seldom either clear or coherent-how can they be when so few resident staff have attended political meetings until recently ? Criticism is easy, especially at a time like this when there is so much that is wrong. Someone has now got to try to find a constructive way out of this impasse. However just their cause many junior doctors will find industrial action that is bound to affect patients' welfare a distasteful exercise. Let us hope that 10 days proves sufficient time in which to avoid such an unhappy outcome. I
2
3
The Guardian, 17 November 1975 Observer, 16 November 1975 British Medical Journal, 1975, 4, 248.
Cluster headache The distinctive clinical features of cluster headache or periodic migrainous neuralgia still often escape recognition. Claims for priority in its description remain in dispute. In 1822 Benjamin Hutchinson' recorded "a hemicrania which after recurring for several hours daily for long periods, departs suddenly." In 1921 Harris renewed interest in its symptoms and called it periodic migrainous neuralgia2; Horton3 later coined the useful term of cluster headache and claimed successful results for histamine desensitisation. The attacks occur mainly in men (the male female ratio is 8 to 1) usually aged 20 to 50. They may be precipitated by alcohol or vasodilator drugs or occur spontaneously once to thrice daily, especially during sleep. In some cases attacks recur at precisely the same time each day-hence the term "alarm clock headache." These features are clearly different from ordinary migraine; so too are the enhanced severity of the pain, its localisation to one orbit or temple, and its briefer duration of 30 to 120 minutes. In many episodes the eye becomes suffused and waters, the nostril becomes blocked, and occasionally Horner's syndrome develops. The visual symptoms and vomiting so characteristic of migraine are not seen, and there is no increased incidence of a family history of migraine. After this daily and nightly hell, remission occurs spontaneously after 4 to 12 weeks, and the patient is then totally free of pain for months or years. Variants include a rare chronic form, and attacks confined to the cheek or jaw known as "lower half headache," which is more often accompanied by Horner's syndrome and by peptic ulceration. What is the nature of these features ? The pain is undoubtedly vascular rather than neural; Horner's syndrome suggests
426
BRITISH MEDICAL JOURNAL
sympathetic paralysis due to oedema and dilatation of the wall of the internal carotid artery, and the narrowing of the carotid syphon seen at angiography4 supports this notion. A "cold spot" over one eye was reported in two of five cases studied by thermography, which is consistent with reduced flow in the internal carotid artery and its ophthalmic branch, which supplies the area of the forehead. The presence of adjacent "hot spots" suggests that external carotid dilatation may contribute to the pain.5 Anthony and Lance6 have recently claimed that in a migraine attack the plasma serotonin level falls and plasma histamine is unchanged, whereas in a cluster headache the serotonin level is unchanged and the whole blood histamine is raised. The current concept of cluster headache has therefore moved from a migraine variant to a distinctive clinical picture in which local histamine release could explain both the observed vascular effects and the pain. What remain obscure are the initial release mechanisms and the cause of the periodicity, so that if histamine is to be accepted as the rogue of the piece further information is needed. The diagnosis is based on a carefully taken history, which should exclude migraine, trigeminal neuralgia, sinusitis, and psychogenic facial pain. In the occasional difficult case oral nitroglycerin will reproduce an attack within 30 to 60 minutes during a cluster.7 Radiographs and angiography have no place if the history is adequate. Symonds" introduced treatment with ergotamine, which is much more effective than it is in migraine. It is given one hour before the expected attack.by intramuscular injection (0-25-0-5 mg) or by suppository (1-2 mg) as prophylaxis. Success depends on accurate observation of the timing and may necessitate two or three doses per day for the duration of the cluster. Treatment should be omitted for one day every week to see if the cluster has ended. Patients who do not respond to ergotamine may be relieved by methysergide, 3-6 mg per day, or by pizotifen, 1-5-3 mg per day, for the duration of the bout. In few conditions are patients so grateful for relief of their symptoms. I
Hutchinson, B, Cases of Neuralgia Spasmnodica, 2nd cdn. London, Longman, 1822.
Harris, W, Proceedintgs of the Royal Society of Medicine, 1921, 15, 13. 3 Horton, B T, Maclean, A R, and Craig, W M, Proceedings of the Staff Meetings of the Mayo Clinic, 1939, 14, 257. 4 Ekbom, K, and Greitz, T, Acta Radiologica (Diagnosis), 1970, 10, 1. 5 Lance, J W, and Anthony, M, .Mldical_Journal of Autstralia, 1971, 1, 240. 6 Anthony, M, and Lance, J W, Archives of Neurology, 1971, 25, 225. 7 Ekbom, K, Archives of Neurology, 1968, 19, 487. 8 Symonds, C P, Brain7, 1956, 79, 217. 2
Gastric ulcers and achlorhydria "The idea that the secretion of gastric acid is necessary for the production of ulcer of the stomach is by no means new . . . although not worked out by exact methods," wrote Ewald' towards the end of the last century. The pithy dictum "no acid-no ulcer" was formulated by Schwarz in 1910.2 Its truth has rarely been questioned since. Many studies have reported the invariable presence of gastric acid in patients with chronic peptic ulcer. Conversely, the absence of such ulcers in patients with pernicious anaemia has strengthened the concept that acid is necessary for the development of gastric ulcers. Support for the truth of the dictum is available from other sources. When radiation therapy is used to induce achlorhydria
22 NOVEMBER 1975
in patients with peptic ulcer, healing occurs, and there is no recurrence of ulceration so long as achlorhydria persists. Acute superficial mucosal ulcers may be found in patients with achlorhydria, but these lesions do not become chronic and they apparently heal rapidly.3 Until the introduction4 of the maximal stimulus to secretion of acid in 1953 tests measuring acid secretion were of limited value. It is true that, when standard but submaximal doses of histamine were used, some patients were reported with benign gastric ulcers who were apparently achlorhydric. In fact, hypochlorhydria is a common accompaniment of chronic gastric ulceration and reflects the mucosal lesions of gastritis. If a maximal stimulus had been used, whether in the form of histamine, ametazole hydrochloride (Histalog), or pentagastrin, some acid would have been found in these patients-or so it has been assumed. More recently, and at a time when the usefulness of measuring the secretion of gastric acid in patients with gastric ulcers has been questioned,) a few patients have been described with benign gastric ulcers in whom there has been achlorhydria after maximal stimulation. Wald and Burbige6 gave details of two such patients and a case had previously been recorded by Isenberg et al. The acid studies were performed punctiliously and repeated on several occasions preoperatively, each time failing to show the presence of titratable acid. The ulcers were examined endoscopically, and in two of the three cases detailed histological sections became available after surgical resection, confirming that there was no evidence of malignancy. The gastric mucosa of one patient was reported as atrophic, and in another biopsies showed atrophic gastritis and a greatly reduced number of parietal cells. This combination of benign gastric ulcer and achlorhydria, if genuine, must be an extreme rarity. It is just possible that the methods used on these patients were not sufficiently sensitive to induce or detect acid secretion. Patients have not so far been described in whom pentagastrin was used as the stimulus, nor in whom a continuous infusion of histamine was given. Whereas there is little difference in the results from giving histamine or pentagastrin by the same route, the one-shot technique gives an acid output only about 90O11 of that obtained by continuous infusion of histamine.8 Alternatively it might be postulated that gastric ulceration might be present in a patient with only transient achlorhydria. It has been suggested that sufficient back diffusion of hydrogen ions through an extensively damaged mucosa might take place to render particular acid secretion tests invalid. Whatever the explanation, accounts of such patients are likely to remain few. Endoscopic examination and biopsy of gastric ulcers have now largely superseded the performance of acid secretion studies in clinical diagnostic practice. If acid studies are performed in patients with gastric ulcers, the finding of achlorhydria after a maximal stimulus should signify that the ulcer is almost certainly, though perhaps not inevitably, cancerous. The cases recently described may represent genuine exceptions to Schwarz's dictum, but further examples are necessary before its absolute validity is finally questioned. Ewald, C A, Lectuires otn Diseases of the Digestive ()iygans, vol 2. London, The New Sydenham Society, 1892. 2 Schwarz, K, Beitrage zur klinischeni Chirurgie, 1910, 67, 96. Rodgers, H W, and Jones, F A, St Bartholomewcu's Hospital Reports 1938,71, 141. Kay, A W, British MedicallJoirnial, 1953, 2, 77. Baron, J H, and Williams, J A, British Medical 7ournial. 1971,1, 196. Wald, A, and Burbige, E J,Johns Hopkins Medical Joural, 1974. 135. 436. 7 Isenberg, J K, et al, Nezw England Journal of Medicinle, 1971, 285, 620. 8 Hobsley, M, British Journal of Hospital Medicine,1975, 14, 383.
Death of a nurse Reformers and pressure groups have been successful in recent years in getting recognition for the legal rights of patients in psychiatric hospitals. Unfortunately their emphasis on the patients' rights and freedoms has overshadowed the problems faced by the medical and nursing staff, as was tragically shown by the death last year of a nurse at Tooting Bec Hospital, who was stabbed to death by a schizophr-nic patient. The committee of inquiry which investigated the circumstances of the death found' that staff at the hospital were anxious and uncertain about the management of disturbed patients with a potential for violence. At present a voluntary patient has a legal right to refuse treatment and to refuse to hand over a potential weapon -and in the words of a recent report2 "Generally, an action for assault will be successful if the doctor has 'touched' the person without his informed consent." The pendulum has swung too far: as the inquiry observes, by letting people who are mentally ill retain their normal freedom, society gives them the freedom to refuse treatment and to deteriorate mentally. Inevitably some mentally disturbed patients will behave unpredictably and irrationally, and staff cannot be expected to handle emergencies quickly and efficiently if they have to be meticulously careful of the legal niceties of each individual patient's freedom to consent or not to the action required. Strict interpretation of the legal position makes the task of nursing some types of psychiatric patients impossible. There is a strong case for wider recognition by society that nurses are dedicated professionals who must be given discretion occasiornally to use force and compulsion when there is no safe alternative.
2
425
22 NOVEMBER 1975
Report of the commitittee of inquirv into the circumstances leading to the death of Mr Daniel Carey at Tooting Bec 'Hospital otn 2 August 1974. London, South-west Thames Regional Health Authority, 1975. Gostin, L 0, A Humnan Condition. London, MIND, 1975.
Aftermath of the ballot By the weekend of 15 November there was little hope that the ballot of hospital junior staff on the proposed new contract might bring an end to the unrest and industrial action in the NHS hospitals. Spokesmen for various groups of doctors had attacked the phrasing of the ballot and its method of distribution and had alleged collusion between the BMA and the Department of Health.1 2 The meeting of the BMA Hospital Junior Staffs Committee on 17 November (see p 476) further compounded the existing confusion. A motion was passed -34 to 20-asserting no confidence in the chairman and the executive; and before the voting figures were known the ballot was said to be of no binding effect on the committee Perhaps the most striking result of the ballot (see p 482) was the high poll-over 14 000 votes out of an electorate of 15 00016 000 NHS contract holders-a return of 90",,, a large majority of whom approved the concept of the new contract. The majority in favour of industrial action was not, however, so convincing: 7355 against 5336 or roughly 6 to 4. The implications of the HJS Committee's threat of industrial action by 27 November are still far from clear: in strict constitutional terms, the only way the BMA as the registered trade union can call for official strike action is by a decision of its Council (meeting next week). Undoubtedly, consultants and general practitioners will have some views on a course of action that
is bound to affect them. Furthermore, 10 days gives little time for a new negotiating team to master the complexities of their brief and persuade a determined Government to allow a more flexible interpretation of its pay policy. The smouldering unrest among junior staff is not (as we have emphasised already) due simply to dissatisfaction with the way their new contracts have been negotiated: the malaise in the NHS goes far deeper.3 But those who have been so vocal in their criticisms of the BMA negotiators should perhaps ask why it proved so difficult to replace the chairman of the HJS Committee. Representing young doctors is a thankless task for anyone with a job to do in the NHS. Time for medicopolitical work has to be found from the off-duty periods that could otherwise be spent with families-and inevitably the work involves long, tedious committee meetings; much travelling; and a vast amount of paper work. The views the negotiators are supposed to represent are seldom either clear or coherent-how can they be when so few resident staff have attended political meetings until recently ? Criticism is easy, especially at a time like this when there is so much that is wrong. Someone has now got to try to find a constructive way out of this impasse. However just their cause many junior doctors will find industrial action that is bound to affect patients' welfare a distasteful exercise. Let us hope that 10 days proves sufficient time in which to avoid such an unhappy outcome. I
2
3
The Guardian, 17 November 1975 Observer, 16 November 1975 British Medical Journal, 1975, 4, 248.
Cluster headache The distinctive clinical features of cluster headache or periodic migrainous neuralgia still often escape recognition. Claims for priority in its description remain in dispute. In 1822 Benjamin Hutchinson' recorded "a hemicrania which after recurring for several hours daily for long periods, departs suddenly." In 1921 Harris renewed interest in its symptoms and called it periodic migrainous neuralgia2; Horton3 later coined the useful term of cluster headache and claimed successful results for histamine desensitisation. The attacks occur mainly in men (the male female ratio is 8 to 1) usually aged 20 to 50. They may be precipitated by alcohol or vasodilator drugs or occur spontaneously once to thrice daily, especially during sleep. In some cases attacks recur at precisely the same time each day-hence the term "alarm clock headache." These features are clearly different from ordinary migraine; so too are the enhanced severity of the pain, its localisation to one orbit or temple, and its briefer duration of 30 to 120 minutes. In many episodes the eye becomes suffused and waters, the nostril becomes blocked, and occasionally Horner's syndrome develops. The visual symptoms and vomiting so characteristic of migraine are not seen, and there is no increased incidence of a family history of migraine. After this daily and nightly hell, remission occurs spontaneously after 4 to 12 weeks, and the patient is then totally free of pain for months or years. Variants include a rare chronic form, and attacks confined to the cheek or jaw known as "lower half headache," which is more often accompanied by Horner's syndrome and by peptic ulceration. What is the nature of these features ? The pain is undoubtedly vascular rather than neural; Horner's syndrome suggests
426
BRITISH MEDICAL JOURNAL
sympathetic paralysis due to oedema and dilatation of the wall of the internal carotid artery, and the narrowing of the carotid syphon seen at angiography4 supports this notion. A "cold spot" over one eye was reported in two of five cases studied by thermography, which is consistent with reduced flow in the internal carotid artery and its ophthalmic branch, which supplies the area of the forehead. The presence of adjacent "hot spots" suggests that external carotid dilatation may contribute to the pain.5 Anthony and Lance6 have recently claimed that in a migraine attack the plasma serotonin level falls and plasma histamine is unchanged, whereas in a cluster headache the serotonin level is unchanged and the whole blood histamine is raised. The current concept of cluster headache has therefore moved from a migraine variant to a distinctive clinical picture in which local histamine release could explain both the observed vascular effects and the pain. What remain obscure are the initial release mechanisms and the cause of the periodicity, so that if histamine is to be accepted as the rogue of the piece further information is needed. The diagnosis is based on a carefully taken history, which should exclude migraine, trigeminal neuralgia, sinusitis, and psychogenic facial pain. In the occasional difficult case oral nitroglycerin will reproduce an attack within 30 to 60 minutes during a cluster.7 Radiographs and angiography have no place if the history is adequate. Symonds" introduced treatment with ergotamine, which is much more effective than it is in migraine. It is given one hour before the expected attack.by intramuscular injection (0-25-0-5 mg) or by suppository (1-2 mg) as prophylaxis. Success depends on accurate observation of the timing and may necessitate two or three doses per day for the duration of the cluster. Treatment should be omitted for one day every week to see if the cluster has ended. Patients who do not respond to ergotamine may be relieved by methysergide, 3-6 mg per day, or by pizotifen, 1-5-3 mg per day, for the duration of the bout. In few conditions are patients so grateful for relief of their symptoms. I
Hutchinson, B, Cases of Neuralgia Spasmnodica, 2nd cdn. London, Longman, 1822.
Harris, W, Proceedintgs of the Royal Society of Medicine, 1921, 15, 13. 3 Horton, B T, Maclean, A R, and Craig, W M, Proceedings of the Staff Meetings of the Mayo Clinic, 1939, 14, 257. 4 Ekbom, K, and Greitz, T, Acta Radiologica (Diagnosis), 1970, 10, 1. 5 Lance, J W, and Anthony, M, .Mldical_Journal of Autstralia, 1971, 1, 240. 6 Anthony, M, and Lance, J W, Archives of Neurology, 1971, 25, 225. 7 Ekbom, K, Archives of Neurology, 1968, 19, 487. 8 Symonds, C P, Brain7, 1956, 79, 217. 2
Gastric ulcers and achlorhydria "The idea that the secretion of gastric acid is necessary for the production of ulcer of the stomach is by no means new . . . although not worked out by exact methods," wrote Ewald' towards the end of the last century. The pithy dictum "no acid-no ulcer" was formulated by Schwarz in 1910.2 Its truth has rarely been questioned since. Many studies have reported the invariable presence of gastric acid in patients with chronic peptic ulcer. Conversely, the absence of such ulcers in patients with pernicious anaemia has strengthened the concept that acid is necessary for the development of gastric ulcers. Support for the truth of the dictum is available from other sources. When radiation therapy is used to induce achlorhydria
22 NOVEMBER 1975
in patients with peptic ulcer, healing occurs, and there is no recurrence of ulceration so long as achlorhydria persists. Acute superficial mucosal ulcers may be found in patients with achlorhydria, but these lesions do not become chronic and they apparently heal rapidly.3 Until the introduction4 of the maximal stimulus to secretion of acid in 1953 tests measuring acid secretion were of limited value. It is true that, when standard but submaximal doses of histamine were used, some patients were reported with benign gastric ulcers who were apparently achlorhydric. In fact, hypochlorhydria is a common accompaniment of chronic gastric ulceration and reflects the mucosal lesions of gastritis. If a maximal stimulus had been used, whether in the form of histamine, ametazole hydrochloride (Histalog), or pentagastrin, some acid would have been found in these patients-or so it has been assumed. More recently, and at a time when the usefulness of measuring the secretion of gastric acid in patients with gastric ulcers has been questioned,) a few patients have been described with benign gastric ulcers in whom there has been achlorhydria after maximal stimulation. Wald and Burbige6 gave details of two such patients and a case had previously been recorded by Isenberg et al. The acid studies were performed punctiliously and repeated on several occasions preoperatively, each time failing to show the presence of titratable acid. The ulcers were examined endoscopically, and in two of the three cases detailed histological sections became available after surgical resection, confirming that there was no evidence of malignancy. The gastric mucosa of one patient was reported as atrophic, and in another biopsies showed atrophic gastritis and a greatly reduced number of parietal cells. This combination of benign gastric ulcer and achlorhydria, if genuine, must be an extreme rarity. It is just possible that the methods used on these patients were not sufficiently sensitive to induce or detect acid secretion. Patients have not so far been described in whom pentagastrin was used as the stimulus, nor in whom a continuous infusion of histamine was given. Whereas there is little difference in the results from giving histamine or pentagastrin by the same route, the one-shot technique gives an acid output only about 90O11 of that obtained by continuous infusion of histamine.8 Alternatively it might be postulated that gastric ulceration might be present in a patient with only transient achlorhydria. It has been suggested that sufficient back diffusion of hydrogen ions through an extensively damaged mucosa might take place to render particular acid secretion tests invalid. Whatever the explanation, accounts of such patients are likely to remain few. Endoscopic examination and biopsy of gastric ulcers have now largely superseded the performance of acid secretion studies in clinical diagnostic practice. If acid studies are performed in patients with gastric ulcers, the finding of achlorhydria after a maximal stimulus should signify that the ulcer is almost certainly, though perhaps not inevitably, cancerous. The cases recently described may represent genuine exceptions to Schwarz's dictum, but further examples are necessary before its absolute validity is finally questioned. Ewald, C A, Lectuires otn Diseases of the Digestive ()iygans, vol 2. London, The New Sydenham Society, 1892. 2 Schwarz, K, Beitrage zur klinischeni Chirurgie, 1910, 67, 96. Rodgers, H W, and Jones, F A, St Bartholomewcu's Hospital Reports 1938,71, 141. Kay, A W, British MedicallJoirnial, 1953, 2, 77. Baron, J H, and Williams, J A, British Medical 7ournial. 1971,1, 196. Wald, A, and Burbige, E J,Johns Hopkins Medical Joural, 1974. 135. 436. 7 Isenberg, J K, et al, Nezw England Journal of Medicinle, 1971, 285, 620. 8 Hobsley, M, British Journal of Hospital Medicine,1975, 14, 383.
