954

Some senile patients, too, offer special difficulties. Notall are timid and tractable: some are confused,agitated, and disoriented, and might wander off, losetheir way, harm themselves, and be found at last ina state- of neglect and starvation. Where all doors areopen, will there not be a temptation to keep suchpatients in bed—a step backwards, the geriatricianswould think, in the care of old people ? ’? And not

merely the old : will there not be a temptation tokeep all "

uncertain ’

patients sedated and abed,after locking their clothing away ? But, here again,the open hospitals claim that these things do nothappen : their aim is to get the patient up and doing ;and the second is usually ensured by giving him a veryfull programme of occupational therapy and socialactivities.

At present most psychiatrists in mental hospitalsseem unwilling to press on with the policy of the fullyopen door. Many of our largest and most notablehospitals prefer the system at the Crichton Royal(described with the open hospitals on p. 965), wheresome wards are closed and some are fully open, andstagnation is prevented by careful grading of patientsand much flexibility. How much does such a com-

promise differ from the almost-open system adoptedat Warlingham Park and Jfapperley ? Surely verylittle in kind, but somewhat more in degree. In allthree there are locked places and nurses with keys ;and Dr. DUNCAN BELL, of the Dingleton Hospital,Melrose, believes that one locked door is sufficient tovitiate the whole principle of the open hospital. Ifany patient is locked up. even for a few hours, allhave reason to fear restraint ; and the sense offreedom and trust, he holds, cannot survive. As hehas achieved a fully open hospital and maintained itfor two years, his experience carries great weight.It may be that the problems presented by a hospitalof just under 500 beds can be more successfully over-come than those of a hospital of 1000 beds or more ;but he himself does not think so : he would have theopen principle adopted everywhere.

What, then. should be our attitude ? If we pressfor fully open hospitals, with all the unquestionablebenefits these represent, what price shall we have topay in increased sedation of difficult patients, earlyshock treatment of depressives, and too much timein bed for the old ? (For not all hospitals can betrusted to avoid these risks as conscientiously as thethree hospitals under discussion.) Or if we decide forthe practical compromise of the Crichton Royal, orthe greater (but still incomplete) freedom of Mapperleyand Warlingham Park, how far will patients and staffbe able to think of mental hospitals as strictly com-parable with general hospitals No doubt these

questions wilt require time and experience for theiranswering, but meanwhile one or two points are worthbearing in mind Some psychiatrists think we couldopen all our mental hospitals at once—but only ifwe had enough staff. We need not only more doctors- for the theory- if not the practice, is exploded thatone doctor can look after several hundred patientsbut also many more nurses, both men and women.Mental nursing offers more scope for people of goodintelligence and mature personality than any otherbranch of the profession : but. though people of suchcalibre are to be found in mental nursing. little

atterupt is made to attract them in numbers : and

indeed, but for the innate warmth and good humourand the sense of service. to be found among Irishwomen, we should now be hard put to it to get Englishmental patients nursed at all. We may be long aboutsolving this problem of sufficient nursing care : andsome will say that, until it is solved, the ideal of th-unlocked door must remain beyond our reach. Thosewho have tried it, however, agree on one cardinalprinciple : once the doors are open the patients neednot more but less looking after. Perhaps for mosthospitals the right line to take is the one adopted byThe Retreat, at York, which is gradually openingmore and more wards with the purpose of makingthe hospital completely open as and when experiencjustifies that course. Meanwhile, Dr. MACMILLANreminds us, the locked door is merely one of manyrestrictions placed on the mental patient. In establishing a modern mental health service we should seto it that his whole legal position is reconsidered.

1. Nissim. J. A. Lancet. 1947, ii, 49.2. Slack. H. G. B., Wilkinson, J. F. Ibid, 1949, i, 11.

Iron TherapyIRON-DEFICIENCY anaemia is one of the commones

diseases that practitioners are called on to deawith ; and, if it is not secondary to some other disorder, it responds well to proper therapy. Unti1949 iron was almost always given by mouth. Th

injectio ferri of the British Pharmacopœia causemuch pain and had an iron content far below ththerapeutic level. Ferrous-sulphate preparation’were the most used and were very successful ; but sompatients preferred a liquid medicine to pills or capsulesand for them iron and ammonium citrate was prescribed. But although these preparations sufficfor most patients with primary iron-deficiencanaemia, there remained a group who seemed resistanto iron treatment, and whose blood picture continueto show the characteristic changes. These patienwere a pathetic group ; the anaemia rarely endangeretheir lives, and in many ways they became used dragging on with a haemoglobin level of 40-60%but they were always conscious of the disability&mdathe fatigue, the lassitude, the dyspnoea and palpitation exertion, the unpleasant pallor.

In 1947 NISSIM 1 showed that a saecharated iroxide could be given intravenously in large enouamounts to treat anaemia effectively, without untowareactions. In 1949 SLACK and WILKINSON2 showehow effective was such a preparation in the chron’ ‘ resistant " cases of iron-deficiency anaemia. Sinthen several reliable preparations of iron for intvenous administration have been marketed. amuch more has been learnt about these anæmIn most cages the ’’ resistance ’’ is due to a combintion of poor absorption across the intestinal mucomembrane and gradual exhaustion of the holyiron stores. Once these stores are depleted. aabsorbed iron remains in store and is not releasto the red cells until the store is full ; and not enouiron passes across the gastro- intestinal burner

replenish the stores. By intravenous administratithe limitations of alimentary-tract absorption avoided, and altogether up to 1.5-2.5 g. of ircan be given by this route. divided into doses

955

300-500 mg. Occasionally, however, there are

difficulties in this method. The patient-usuallyan obese woman-may have no visible or palpableveins suitable for giving the injection of 10 ml. ormore that is needed. Again, the solution of saccharatediron is very dark and therefore not too easy to givesince it is alkaline, if a little gets outside the veininto the tissues an unpleasant local reaction mayresult. So it is necessary to use well-fitting syringes,preferably all-glass or of glass except for a metalnozzle. and the injection must be given slowly.Many busy general practitioners find that intra-

venous injections of iron take up too much time bothin preparation and in administration.) In some

natients iron cannot be given intravenously, becauseit causes unpleasant reactions.3 One of the com-monest is pain over the kidneys in the back ; anotheris an allergic type of dyspnoea, and a few deathsdue to allergic reactions have been reported. Buton the whole intravenous iron has been very successful,and obstetricians in particular have found it usefulin treating the iron-deficiency anaemia of pregnancywhen time is short and iron by mouth is uselessbecause of gastro-intestinal disturbances.

It was clear that some of the difficulties of intra-venous administration would be avoided if insteadthe iron could be given intramuscularly. The intra-venous-iron solution was unsafe for intramuscular

mjection, because of its alkalinity. But now a dextran-iron solution has been prepared which, so far at least,seems safe and effective ; and in this issue Dr. BAIRDand Mr. PODMORE, of Sheffield, describe their experi-enees with it. This dextran-iron is isotonic with tissue-fluids and has a pH of 60-7-0. It is more concentratedthan the intravenous-iron solutions, containing 5%of iron. compared with 2%. This is just as well, sincefew people comfortably tolerate large intramuscularinyections, and the dose of intramuscular iron islarger than that of intravenous iron. BAIRD andPODMORE consider that an increase of 0-34 g. haemo-alobin per 100 ml. blood can be expected for every190 mg. of iron injected (i.e., every 2 ml.) ; in otherwonls. 43 mg. iron is needed for every 1% hæmo-Alobin (leficit (intravenous doses of iron are usuallyalculated on the basis of 25 mg. iron for every 1%hæmoglobin deficit, though sometimes up to 37 mg.ziven). The intramuscular injection must be givenarefully; otherwise the skin will be seriously stained,Mel the patient will have notable discomfort at thetion site. Even when the injection is given with ’ in. needle inserted on a Z-shaped track the

may be stained for several weeks, so the injectionbe made into the gluteal muscles. As might be

ted, there is considerable individual variationthe effectiveness of the intramuscular injection,

judged by the serum-iron peak ; for example,Bugd and PODMORE gave 250 mg. of iron to two

of about the same weight with a haemoglobinand the peak serum-iron levels reached were

and 1000 µg. per 100 ml. Corresponding varia-were found in the response of the haemoglobinand. as with intravenous iron. it was usuallydays after starting treatment before the haeino-level rose notably. BAIRD and PODMORE

doses of 5 ml., equivalent to 250 mg. of metallic3. Nissim, J. A. Brit. med. J. 1954, i, 352.

iron ; this dose could be given as often as twice dailyto inpatients, but for outpatients twice weeklyproved more convenient : -. in either case the requisitetotal dose of iron is soon given.The introduction of a satisfactory preparation

of iron for intramuscular injection should make it

possible for every iron-deficient patient to be effectivelytreated. But it would be unwise without clear causeto substitute intramuscular iron for intravenousiron ; and oral iron. where this will suffice, shouldbe given in preference to either. Iron preparationsfor intramuscular injection are still about five timesas expensive as those for intravenous injection,and their absorption may be less regular. Intra-muscular iron is. at present, essentially a therapeuticweapon to be kept in reserve.

All this work on iron preparations has led to

improvements in the way oral iron is presentedPlain ferrous sulphate, in tablets or capsules, is stila.s efficient as any preparation. and it is very cheapThe difficulty with it is that some patients-usuallyestimated at about a third—get gastro-intestinadisturlamces which are severe enough to preventhe proper dose. or any of the dose, being takenThis difficulty is often avoided when the patientakes enteric-coated ferrous-sulphate tablets, provided the coating is done properly and thtablet disintegrates beyoncl the pylorus. Intravenouadministration of ferric hydroxide has revived ituse for oral preparations, and really effective tabletand liquid are now to be had. It is well tolerated an

effectively absorbed -, ferric hydroxide yields abou50"o of metallic iron, compared with 27.5%from ferrous sulphate. Some organic salts oiron are also on trial. Ferrous gluconate yieldonly 11.5% of metallic iron ; it is said to be betteabsorbed,4 but the evidence is not very convincingFerrous succinate is a similar salt, but there is stino firm evidence of its efficieney and it is considerablmore expensive. There are also preparations of irocombined with vitamins, liver, folic acid, and manother substances that the devisers of these " blunderbusses " believe to be useful. In dealing with potenremedies, however, there are not only disadvantagesbut positive dangers in the use of complex mixtures and the more a physician knows of haematology thmore likely he is to abjure methods which ar

therapeutically imprecise.With ferrous sulphate or ferric hydroxide fo

administration by mouth, and preparations for intravenous and intramuscular injection, every patienwith primary iron-deficiency anapmia can now b

successfully treated.

4. Haler, D. Ibid, 1952. ii, 1241.5. Farber, S. J., Alexander, J. D., Pellegrino, E. D., Earle, D.

Circulation, 1951, 4, 378.

DigitalisIN congestive heart-failure digitalis folia or i

purified derivatives should still be the sheet-anohoof treatment : but preoccupation with reducinoedema by restriction of salt intake and administratioof diuretic agents has lately tended to obscure thfact that the primary disorder lies in the heart anthat the renal disturbances are secondary. WITHERINhimself thought that the diuretic effect of digitalwas due to a direct action on the kidney, and recestudies 5 suggest that digoxin may influence t