674
'Cleator, I G M, and Christie, J, British Journal of Surgery, 1973, 60, 163.
2 Shaffer, R D, Archives of Surgery, 1969, 99, 542. 3Steinberg, D M, Cooke, W T, and Alexander-Williams, J, Gut, 1973, 14, 865. 4Painter, N S, British Medical_Journal, 1968, 3, 475. 5McEwan, A J, British Journal of Urology, 1968, 40, 350. 6 Hoare, E M, British Journal of Surgery, 1973, 60, 407. 7 Nicell, P, et al, Surgery, 1975, 78, 555. 8 Bevan, P G, British Medical J'ournal, 1961, 1, 400. 9 Monro, J L, et al, British Journal of Surgery, 1974, 61, 445. 10 Barrett, N R, Thorax, 1946, 1, 48. 11 Bradbrook, R A, British Journal of Surgery, 1973, 60, 331. 12 Sheil, A G R, et al, British Journal of Surgery, 1969, 56, 840. 13 Bigge, T, and Rothnie, N G, British J'ournal of Surgery, 1974, 61, 545. 14 Prakash, A, Sharma, L K, and Pandit, P N, British J7ournal of Surgery, 1974, 61, 162.
Bundle branch block in acute myocardial infarction Bundle branch block has long been known to carry a poor prognosis in acute myocardial infarction.1 As we have come to know more about the morphology of the conduction system of the heart there have been further inquiries into the problem. Sudden death is frequent in these patients, either during the acute phase or later,2 3 and at first sight it might seem possible to prevent some of these fatalities by using artificial pacemakers. After an acute myocardial infarction conduction defects affect the prognosis to a variable degree. Many patients with severe conduction abnormalities appear clinically well until disaster strikes. Left bundle branch block is associated with a mortality of about 50%,4-6 but it is less widely recognised that right bundle branch block is equally ominous.4 The highest mortality is linked with defects affecting both bundles. Several varieties occur, the most common being right bundle branch block with left anterior hemiblock, but all may produce mortality rates as high as 70%.0 8 On the other hand, the presence of a lone hemiblock is relatively benign and does not appear to influence mortality9 appreciably. While there is often a progressive impairment of conduction culminating in complete heart block, the most frequent cause of death lies in the nature of the infarct itself. Widespread conduction disturbances are usually produced by extensive infarction, and death occurs because of the large-scale muscle damage rather than the accompanying conduction defect, though the mode of death may be asystole. In a few patients damage may be more localised, and then the onset of complete heart block or ventricular asystole may cause death. Recently it has been emphasised that left bundle branch block may indicate an increased susceptibility to ventricular arrythmias.1 0 Not surprisingly, therefore, prophylactic temporary pacing has had little effect on the death rate in these patients.4 11 Individual patients with selective destruction of conduction tissue may benefit from pacing, but their recognition is difficult. Opinion is divided on whether it is better to insert a pacing catheter prophylactically in patients with bundle branch block or to await the development of complete heart block before taking action.6 11 Bundle of His recordings may help identify patients at high risk of developing A-V block.'2 The problem of late sudden deaths has prompted claims that patients who have evidence of bilateral bundle branch block, especially if complicated by transient A-V block in the acute phase, derive benefit from permanent pacemaker implantation.2 3 So far few patients have been studied, however, and it is still uncertain how many of these late deaths are due to
BRITISH MEDICAL JOURNAL
20 MARCH 1976
asystole; ventricular tachycardia or fibrillation might equally be the cause. It seems, then, that the appearance of bundle branch block in a patient with an acute infarction carries a serious prognosis. After the development of complete heart block temporary pacing is of limited value but should certainly be attempted. Prophylactic pacemaker insertion has not yet been shown to be of definite value, and further randomised prospective trials of this treatment seem indicated in high-risk patients. Longterm pacing is a more formidable problem, and there is still little convincing evidence of its worth. Further investigation of the cause of late deaths seems desirable. Permanent pacemaker implantation, which might not be helpful and would certainly be very costly, is indicated at present only as part of a controlled clinical trial. Master, A M, Dack, S, and Jaffe, H L, American Heart Journal, 1938, 16, 283. Atkins, J M, et al, New England3Journal of Medicine, 1973, 288, 281. 3Waugh, R A, et al, Circulation, 1973, 47, 765. Godman, M J, Lassers, B W, and Julian, D G, New England Journal of Medicine, 1970, 282, 237. 5Hunt, D, and Sloman, G, British Medical3Journal, 1969, 1, 85. 6 Scheinman, M, and Brenman, B, Circulation, 1972, 46, 753. 7Godman, M J, Alpert, B A, and Julian, D G, Lancet, 1971, 2, 345. 8 Roos, J C, and Dunning, A J, British Heart Journal, 1970, 32, 847. Kincaid, D T, and Botti, R E, American Journal of Cardiology, 1972, 30, 797. 10 Scheidt, S, and Killip, T, Journal of the American Medical Association, 1972, 222, 919. 11 Nimetz, A A, et al, American Heart journal, 1975, 90, 439. 12 Lie, K I, et al, Circulation, 1974, 50, 935. 2
Breaking down sex barriers There was a time, and that not too long ago, when the metaphorical wall separating the sexes in our mental hospitals was as effective as the physical wall separating East and West Berlin. The penalties for breaching either wall were dire. But it was not always so. For example, the history of Friern Hospital1 (better known perhaps by its original name, Colney Hatch Asylum) records that in 1856 600 patients of both sexes dined daily in harmony in the large "exercising hall." This exemplified the mood of liberalism then prevailing, which found expression in the Asylum Committee's report of 1859: "The more freedom which can with propriety be allowed them [the patients] and the more confidence reposed in them the better it will be for themselves and those whose duty it is to watch over them." That brave new world, for reasons undisclosed, collapsed in a heap; and the history sadly records that by the end of the century all patients were back eating in their wards. The whirligig of time brings in its revenges, however, and midway' through the present century-at first slowly, and thereafter with ever increasing speed-the wall separating the sexes began to crumble to a point where today only vestigial remnants are to be seen. With considerable trepidation female staff had been introduced into male wards and later, with even greater trepidation, male nurses introduced into female wards. In both instances the initial attendant fears generally proved unjustified. Then, as an extension of the same basic principle, mixed wards were established, and these are now a commonplace in many progressive mental hospitals in Britain. Accounts of this recent revolution in the philosophy and in the practice of operating mixed-sex wards have been relatively scanty, so that a detailed description2 from New Zealand,
BRITISH MEDICAL JOURNAL
20 MARCH 1976
bearing as its text "Man was for woman made and woman made for man" is welcome. The paper concerns a rehabilitation unit in the Cornwall Geriatric Hospital in Auckland, where, because of the heavy demand for female admissions, a mixedsex ward was opened as a matter of expediency. It goes on to describe the structural changes needed to convert old wards not designed for the purpose. Particular attention was paid to the number and positioning of lavatories and bedrooms, each ofwhich, according to need, could be occupied exclusively by one or other sex. The day accommodation was common to all. The careful selection of suitable male and female staff was considered crucial and is discussed in some detail. What was a matter of expediency turned out to be a therapeutic success. "The nursing staff felt the atmosphere, rate of recovery and personal relationships improved from male/ female company," the authors concluded-but they were at pains to point out that some of the patients proved unsuitable and had to be moved to other wards. The experience in New Zealand corresponds in most respects with that in mental hospitals and psychogeriatric units in Britain where the same sort of scheme has been introduced. Desirable as these trends may be there are dangers: radical changes may move too fast and go too far or be adopted for doctrinaire rather than rational reasons. In considering the welfare of sick people-and, indeed, the sensitivities of their relatives-there are still matters of propriety to be considered, as the guardians of Colney Hatch Asylum warned a century or more ago. There are those patients, too, who for whatever reason prefer the well of loneliness to the blue lagoon of unisex. 1 Hunter, R, and Macalpine, Ida, Psychiatry for the Poor: 1851 Colney Hatch Asylum-Friern Hospital 1973: A Medical and Social History. Folkestone, Dawsons, 1974. 2 Loten, E G, and Evans, Beatrice, New Zealand Medical Journal, 1975, 82, 201.
Analgesics over the counter The balance of advantages and hazards is more obvious with aspirin than almost any other drug. It is by far the most popular simple analgesic. In Britain 2000 tons are swallowed every year1 and it is still the drug of first choice for many rheumatic and arthritic conditions and for the symptomatic treatment of fever. Yet it is also responsible for many cases of fatal and non-fatal poisoning and for a substantial amount of gastrointestinal bleeding, while analgesic mixtures have caused enormous suffering by their action on the kidneys, though aspirin taken alone seems innocent in this respect.2 Last week the Government proposed controls on the sale of analgesics which would ban self-service sales of aspirin, aloxiprin, and paracetamol in supermarkets and chemists' shops. Consultations are taking place with the medical and pharmaceutical professions, but it seems likely these changes will come into force in the autumn together with regulations to limit over-the-counter sales of aspirin to 25 tablets and to require warnings to be displayed on packets. These proposals have been formulated by the Medicines Commission, which also intends to restrict more medicines to prescription-only categories and to limit public sales of others to chemists' shops. Certainly the public seems unaware of the dangers of simple analgesics and other common remedies. In particular the considerable risk of mixing aspirin and alcohol is too little known. Perhaps these restrictions on the availability of anal-
675
gesics and other medicines will discourage potential suicides. They are unlikely to have much effect on patients addicted to analgesics, or indeed those who regularly take laxatives or antacid tablets and mixtures for chronic indigestion. Yet one of the ill effects of the NHS may have been its discouragement of self-reliance in the management of colds, coughs, and aches and pains of the kind formerly treated by home remedies; General practitioners are weary of the succession of patients with trivial complaints who occupy much of their time. Statements about the potential hazards of selfmedication should be paralleled by advice on the circumstances in which self-treatment is justified and the remedies that may be taken. 1 2
British Medical Journal, 1974, 3, 5. British 1974, 1, 593.
MedicalyJournal,
The absent-minded shoplifter Undoubtedly much absent-minded shoplifting does occur; if in doubt, reminisce or ask your friends. The charge of theft, let alone the conviction, can wreak disproportionate havoc on the small proportion of individuals who are caught. Though not as damaging as gross sexual indecency, theft is not socially acceptable. With magistrates, clergymen, and doctors the effects of newspaper publicity are easy to see and behind these few cases lie many highly respected but less well-known citizens whose lives are severely damaged by two or three lines in the local paper. Many of them are innocently absentminded, but their solicitors advise them to plead guilty to avoid the increased publicity and great expense of what may be an unsuccessful plea of not guilty. It is surprisingly common,' too, for unrepresented defendants to plead guilty and then to tell the magistrate in mitigation that there was no intention to steal. The plea was tendered merely because the accused had left the store with goods for which he had not paid. How, then, is it possible for apparently respectable people with unblemished records to be convicted with such regularity ? For a charge of shoplifting to be sustained the prosecution must not only show that the defendant left the shop with an item for which he had not paid (actus reus) but also that he had the intention to steal it (mens rea). There is seldom doubt about actus reus, but who, apart from the defendant, can tell whether his intention was to steal? The law has struggled with this problem for centuries and has established working rules based on the inferences that can be drawn from the accused's behaviour; and, in practice,' the courts are influenced by the demeanour of the accused and what he said when stopped. Many lawyers believe that since shoplifting is such a burden to the courts and since so many shoplifters are motivated only by greed magistrates have ceased to give the accused the benefit of the doubt. So the absent-minded shoplifter is convicted along with the rest. Some shoplifters take goods without paying while under the influence of mental stress, drugs, or a combination of both.2 Should more use be made of medical evidence in such cases ? Do we wish to add to the burden of the courts the spectacle of armies of expert witnesses arguing about time-disintegration and the effect of insomnia, depression, domestic anxiety, and suchlike influences on the cognitive processes of shoppers ? Yet we need to protect the shops against the large amount of
'Cleator, I G M, and Christie, J, British Journal of Surgery, 1973, 60, 163.
2 Shaffer, R D, Archives of Surgery, 1969, 99, 542. 3Steinberg, D M, Cooke, W T, and Alexander-Williams, J, Gut, 1973, 14, 865. 4Painter, N S, British Medical_Journal, 1968, 3, 475. 5McEwan, A J, British Journal of Urology, 1968, 40, 350. 6 Hoare, E M, British Journal of Surgery, 1973, 60, 407. 7 Nicell, P, et al, Surgery, 1975, 78, 555. 8 Bevan, P G, British Medical J'ournal, 1961, 1, 400. 9 Monro, J L, et al, British Journal of Surgery, 1974, 61, 445. 10 Barrett, N R, Thorax, 1946, 1, 48. 11 Bradbrook, R A, British Journal of Surgery, 1973, 60, 331. 12 Sheil, A G R, et al, British Journal of Surgery, 1969, 56, 840. 13 Bigge, T, and Rothnie, N G, British J'ournal of Surgery, 1974, 61, 545. 14 Prakash, A, Sharma, L K, and Pandit, P N, British J7ournal of Surgery, 1974, 61, 162.
Bundle branch block in acute myocardial infarction Bundle branch block has long been known to carry a poor prognosis in acute myocardial infarction.1 As we have come to know more about the morphology of the conduction system of the heart there have been further inquiries into the problem. Sudden death is frequent in these patients, either during the acute phase or later,2 3 and at first sight it might seem possible to prevent some of these fatalities by using artificial pacemakers. After an acute myocardial infarction conduction defects affect the prognosis to a variable degree. Many patients with severe conduction abnormalities appear clinically well until disaster strikes. Left bundle branch block is associated with a mortality of about 50%,4-6 but it is less widely recognised that right bundle branch block is equally ominous.4 The highest mortality is linked with defects affecting both bundles. Several varieties occur, the most common being right bundle branch block with left anterior hemiblock, but all may produce mortality rates as high as 70%.0 8 On the other hand, the presence of a lone hemiblock is relatively benign and does not appear to influence mortality9 appreciably. While there is often a progressive impairment of conduction culminating in complete heart block, the most frequent cause of death lies in the nature of the infarct itself. Widespread conduction disturbances are usually produced by extensive infarction, and death occurs because of the large-scale muscle damage rather than the accompanying conduction defect, though the mode of death may be asystole. In a few patients damage may be more localised, and then the onset of complete heart block or ventricular asystole may cause death. Recently it has been emphasised that left bundle branch block may indicate an increased susceptibility to ventricular arrythmias.1 0 Not surprisingly, therefore, prophylactic temporary pacing has had little effect on the death rate in these patients.4 11 Individual patients with selective destruction of conduction tissue may benefit from pacing, but their recognition is difficult. Opinion is divided on whether it is better to insert a pacing catheter prophylactically in patients with bundle branch block or to await the development of complete heart block before taking action.6 11 Bundle of His recordings may help identify patients at high risk of developing A-V block.'2 The problem of late sudden deaths has prompted claims that patients who have evidence of bilateral bundle branch block, especially if complicated by transient A-V block in the acute phase, derive benefit from permanent pacemaker implantation.2 3 So far few patients have been studied, however, and it is still uncertain how many of these late deaths are due to
BRITISH MEDICAL JOURNAL
20 MARCH 1976
asystole; ventricular tachycardia or fibrillation might equally be the cause. It seems, then, that the appearance of bundle branch block in a patient with an acute infarction carries a serious prognosis. After the development of complete heart block temporary pacing is of limited value but should certainly be attempted. Prophylactic pacemaker insertion has not yet been shown to be of definite value, and further randomised prospective trials of this treatment seem indicated in high-risk patients. Longterm pacing is a more formidable problem, and there is still little convincing evidence of its worth. Further investigation of the cause of late deaths seems desirable. Permanent pacemaker implantation, which might not be helpful and would certainly be very costly, is indicated at present only as part of a controlled clinical trial. Master, A M, Dack, S, and Jaffe, H L, American Heart Journal, 1938, 16, 283. Atkins, J M, et al, New England3Journal of Medicine, 1973, 288, 281. 3Waugh, R A, et al, Circulation, 1973, 47, 765. Godman, M J, Lassers, B W, and Julian, D G, New England Journal of Medicine, 1970, 282, 237. 5Hunt, D, and Sloman, G, British Medical3Journal, 1969, 1, 85. 6 Scheinman, M, and Brenman, B, Circulation, 1972, 46, 753. 7Godman, M J, Alpert, B A, and Julian, D G, Lancet, 1971, 2, 345. 8 Roos, J C, and Dunning, A J, British Heart Journal, 1970, 32, 847. Kincaid, D T, and Botti, R E, American Journal of Cardiology, 1972, 30, 797. 10 Scheidt, S, and Killip, T, Journal of the American Medical Association, 1972, 222, 919. 11 Nimetz, A A, et al, American Heart journal, 1975, 90, 439. 12 Lie, K I, et al, Circulation, 1974, 50, 935. 2
Breaking down sex barriers There was a time, and that not too long ago, when the metaphorical wall separating the sexes in our mental hospitals was as effective as the physical wall separating East and West Berlin. The penalties for breaching either wall were dire. But it was not always so. For example, the history of Friern Hospital1 (better known perhaps by its original name, Colney Hatch Asylum) records that in 1856 600 patients of both sexes dined daily in harmony in the large "exercising hall." This exemplified the mood of liberalism then prevailing, which found expression in the Asylum Committee's report of 1859: "The more freedom which can with propriety be allowed them [the patients] and the more confidence reposed in them the better it will be for themselves and those whose duty it is to watch over them." That brave new world, for reasons undisclosed, collapsed in a heap; and the history sadly records that by the end of the century all patients were back eating in their wards. The whirligig of time brings in its revenges, however, and midway' through the present century-at first slowly, and thereafter with ever increasing speed-the wall separating the sexes began to crumble to a point where today only vestigial remnants are to be seen. With considerable trepidation female staff had been introduced into male wards and later, with even greater trepidation, male nurses introduced into female wards. In both instances the initial attendant fears generally proved unjustified. Then, as an extension of the same basic principle, mixed wards were established, and these are now a commonplace in many progressive mental hospitals in Britain. Accounts of this recent revolution in the philosophy and in the practice of operating mixed-sex wards have been relatively scanty, so that a detailed description2 from New Zealand,
BRITISH MEDICAL JOURNAL
20 MARCH 1976
bearing as its text "Man was for woman made and woman made for man" is welcome. The paper concerns a rehabilitation unit in the Cornwall Geriatric Hospital in Auckland, where, because of the heavy demand for female admissions, a mixedsex ward was opened as a matter of expediency. It goes on to describe the structural changes needed to convert old wards not designed for the purpose. Particular attention was paid to the number and positioning of lavatories and bedrooms, each ofwhich, according to need, could be occupied exclusively by one or other sex. The day accommodation was common to all. The careful selection of suitable male and female staff was considered crucial and is discussed in some detail. What was a matter of expediency turned out to be a therapeutic success. "The nursing staff felt the atmosphere, rate of recovery and personal relationships improved from male/ female company," the authors concluded-but they were at pains to point out that some of the patients proved unsuitable and had to be moved to other wards. The experience in New Zealand corresponds in most respects with that in mental hospitals and psychogeriatric units in Britain where the same sort of scheme has been introduced. Desirable as these trends may be there are dangers: radical changes may move too fast and go too far or be adopted for doctrinaire rather than rational reasons. In considering the welfare of sick people-and, indeed, the sensitivities of their relatives-there are still matters of propriety to be considered, as the guardians of Colney Hatch Asylum warned a century or more ago. There are those patients, too, who for whatever reason prefer the well of loneliness to the blue lagoon of unisex. 1 Hunter, R, and Macalpine, Ida, Psychiatry for the Poor: 1851 Colney Hatch Asylum-Friern Hospital 1973: A Medical and Social History. Folkestone, Dawsons, 1974. 2 Loten, E G, and Evans, Beatrice, New Zealand Medical Journal, 1975, 82, 201.
Analgesics over the counter The balance of advantages and hazards is more obvious with aspirin than almost any other drug. It is by far the most popular simple analgesic. In Britain 2000 tons are swallowed every year1 and it is still the drug of first choice for many rheumatic and arthritic conditions and for the symptomatic treatment of fever. Yet it is also responsible for many cases of fatal and non-fatal poisoning and for a substantial amount of gastrointestinal bleeding, while analgesic mixtures have caused enormous suffering by their action on the kidneys, though aspirin taken alone seems innocent in this respect.2 Last week the Government proposed controls on the sale of analgesics which would ban self-service sales of aspirin, aloxiprin, and paracetamol in supermarkets and chemists' shops. Consultations are taking place with the medical and pharmaceutical professions, but it seems likely these changes will come into force in the autumn together with regulations to limit over-the-counter sales of aspirin to 25 tablets and to require warnings to be displayed on packets. These proposals have been formulated by the Medicines Commission, which also intends to restrict more medicines to prescription-only categories and to limit public sales of others to chemists' shops. Certainly the public seems unaware of the dangers of simple analgesics and other common remedies. In particular the considerable risk of mixing aspirin and alcohol is too little known. Perhaps these restrictions on the availability of anal-
675
gesics and other medicines will discourage potential suicides. They are unlikely to have much effect on patients addicted to analgesics, or indeed those who regularly take laxatives or antacid tablets and mixtures for chronic indigestion. Yet one of the ill effects of the NHS may have been its discouragement of self-reliance in the management of colds, coughs, and aches and pains of the kind formerly treated by home remedies; General practitioners are weary of the succession of patients with trivial complaints who occupy much of their time. Statements about the potential hazards of selfmedication should be paralleled by advice on the circumstances in which self-treatment is justified and the remedies that may be taken. 1 2
British Medical Journal, 1974, 3, 5. British 1974, 1, 593.
MedicalyJournal,
The absent-minded shoplifter Undoubtedly much absent-minded shoplifting does occur; if in doubt, reminisce or ask your friends. The charge of theft, let alone the conviction, can wreak disproportionate havoc on the small proportion of individuals who are caught. Though not as damaging as gross sexual indecency, theft is not socially acceptable. With magistrates, clergymen, and doctors the effects of newspaper publicity are easy to see and behind these few cases lie many highly respected but less well-known citizens whose lives are severely damaged by two or three lines in the local paper. Many of them are innocently absentminded, but their solicitors advise them to plead guilty to avoid the increased publicity and great expense of what may be an unsuccessful plea of not guilty. It is surprisingly common,' too, for unrepresented defendants to plead guilty and then to tell the magistrate in mitigation that there was no intention to steal. The plea was tendered merely because the accused had left the store with goods for which he had not paid. How, then, is it possible for apparently respectable people with unblemished records to be convicted with such regularity ? For a charge of shoplifting to be sustained the prosecution must not only show that the defendant left the shop with an item for which he had not paid (actus reus) but also that he had the intention to steal it (mens rea). There is seldom doubt about actus reus, but who, apart from the defendant, can tell whether his intention was to steal? The law has struggled with this problem for centuries and has established working rules based on the inferences that can be drawn from the accused's behaviour; and, in practice,' the courts are influenced by the demeanour of the accused and what he said when stopped. Many lawyers believe that since shoplifting is such a burden to the courts and since so many shoplifters are motivated only by greed magistrates have ceased to give the accused the benefit of the doubt. So the absent-minded shoplifter is convicted along with the rest. Some shoplifters take goods without paying while under the influence of mental stress, drugs, or a combination of both.2 Should more use be made of medical evidence in such cases ? Do we wish to add to the burden of the courts the spectacle of armies of expert witnesses arguing about time-disintegration and the effect of insomnia, depression, domestic anxiety, and suchlike influences on the cognitive processes of shoppers ? Yet we need to protect the shops against the large amount of
