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852 present in this way, there is little to support this view. Meyer 44 has attempted to separate depersonalisation from schizophrenic ego disturbance, on the grounds that the depersonalised patient looks into himself for the reason for his separation from the world and never puts it down to outside agencies, as does the schizophrenic. The treatment of depersonalisation remains unsatis- factory. In affective illness, treatment of the depression quite often leads to remission of the depersonalisation. In schizophrenia, however, it tends to be more intractable 1 11; and when depersonalisation arises in temporal-lobe epilepsy, the management is that of the underlying cause. There are, however, some cases in which depersonalisation seems more isolated, severe and permanent. Various treatment such as methylamphetamine, continuous narcosis, intravenous thiopentone, and even leucotomy have been advised (electroconvulsion therapy is said to be contraindicated). The therapeutic possibilities have been reviewed by Davison.13 Despite the despondent feeling that pervades the subject, it must be remembered that this distressing symptom can remit spontaneously. COLONIC RECONSTRUCTION OF THE PHARYNX AFTER RADICAL OPERATION CANCER of the lower part of the pharynx and cervical oesophagus is still very hard to cure; and despite all the recent therapeutic advances, even palliation is often unsatisfactory. The aim must be to eradicate the growth or, if this is impossible, at least to allow the patient to breathe and swallow comfortably and to spend the rest of her life at home with the family. While a biological solution to disordered tissue growth still eludes us, the choice is between irradiation and surgery. Both methods have a low cure-rate, but operation probably offers the best chance of eradication or adequate palliation. Radio- therapy is widely used, but the dysphagia is apt to persist because of oedema, stricture, or recurrence, and dyspnoea may also result from various respiratory complications. Even with the newer supervoltage therapy, the full course of treatment makes heavy demands on the patient, and, if it is unsuccessful, operation may be difficult or impossible because of fibrosis or recurrent growth. Thus, many patients treated with radical irradiation alone spend the remainder of their lives as permanent inpatients, often with a tracheostomy and a feeding fistula.45 The disadvantages of radiotherapy are responsible for the trend towards surgery in many centres. Operation means excision of the pharynx, larynx, and cervical oesophagus in continuity with potentially involved lymph-nodes. The problem here is the restoration of the gullet, and most attempts to solve it have been based on the pioneer work of Trotter 46 and Wookey,47 using skin flaps from the neck and elsewhere. Although some success has been achieved, several operations are required and long periods in hospital; and the growth often recurs before reconstruction is complete. Strictures and fistuÍae are not uncommon, and there are technical limitations on the amount of cervical oesophagus which may be resected. Because of these drawbacks to the staged operations, various methods of excision and repair in one operation have been devised. Tubes of tissue or plastic materials have been used to replace the pharynx, such as split skin over a 44. Meyer, J. E. Psychiat. Neurol. Basle, 1956, 132, 221. 45. Fairman, H. D., Hadley, S. K. J., John, H. T. Brit. J. Surg. 1964, 51, 663. 46. Trotter, W. Lancet, 1913, i, 1075. 47. Wookey, H. Surg. Gynec. Obstet. 1942, 75, 499. plastic tube,48 laryngeal mucosa,49 tracheal 11 and vascular grafts,5l as well as polyethylene, nylon, and tygon. These methods permit low excision of the oesophagus, and suc- cesses have been reported; but there has been a high rate of stenosis and fistula formation. Other workers have therefore used a mucosa-lined viscus for direct anasto- mosis to a divided oropharynx. Such replacement of the pharynx has been achieved with stomach, 52 53 oesophagus,64 jejunum,55 and the right or left colon. 56-59 Usually these new techniques have been described in only one or two cases. The latest paper from Bristol 4s reports 9 patients with carcinoma of the pharynx or cervical oesophagus in whom the defect in the pharynx after excision was bridged at the same operation by a long loop of colon passing from the oropharynx to the stomach via the anterior mediastinum. Palliation was the primary aim, and swallowing was rapidly restored in most cases. Furthermore, the long-term results may be better because the needs of reconstruction can be ignored during the excision. The method needs little special equipment or skills, and it should have a useful place in the treatment of cancer of the pharynx or cervical oesophagus, but because of its magnitude it should probably be restricted to the younger and fitter patients. The importance of collabora- tion between laryngologists, surgeons, and radiotherapists in selecting the primary treatment with the greatest chance of success should not need further emphasis. PATTERNS IN MISMANAGEMENT Stein and Susser 60 discuss the circumstances in which certain patients’ illnesses were mismanaged. Some were seen in hospital practice, others in general practice. Was there any recurring pattern which might make such failure of care predictable and therefore preventible? They suggest that " failures in personal care will be the characteristic failures in hospital practice " and that " failures in technical competence will be the character- istic failures in general practice ". They set out hospital case-histories which illustrate how social or personal factors have been ill considered; how communication has been at fault (sometimes between the hospital and the patient or his relatives, sometimes between different members of the hospital unit); how the rules and procedures of hospital organisation overrode the patient’s needs; and how the hospital staff did not always resolve their disagreements about treatment. The mistakes in general practice included failures in routine examination and in simple diagnosis and failures attributable to the doctor’s woeful inexperience in a par- ticular aspect of medicine or ignorance of recent important developments in diagnosis or treatment. The cases quoted came from many parts of the country, which suggests that the problems they illustrate are general and not local. Though the numbers are small (ten cases from hospital and ten from general practice) there is no doubt that further similar studies would be justified- and equally salutary. 48. Negus, V. E. Proc. R. Soc. Med. 1950, 43, 157. 49. Wilkins, S. A. Cancer, 1955, 8, 1189. 50. Guidice, A. T. Cited by Iskeceli, O. K. Surgery, 1962, 51, 496. 51. Roux, G. Cited by Iskeceli, O. K. ibid. 52. Ong, G. B., Lee, T. C. Brit. J. Surg. 1960, 48, 193. 53. Butler, T. J. Cited by Fairman et al. (footnote 45). 54. Wooler, G. Proc. R. Soc. Med. 1952, 45, 264. 55. Yudin, S. Surg. Gynec. Obstet. 1944, 78, 561. 56. Goligher, J. C., Robin, I. G. Brit. J. Surg. 1954, 42, 283. 57. Beck, A. R., Baronofsky, R. Surgery, 1960, 48, 499. 58. Mustard, R. A. Surg. Gynec. Obstet. 1960, 111, 577. 59. Sherman, C. D., Scanlon, E. F. ibid. p. 349. 60. Stein, Z., Susser, M. Med. Care, 1964, 2, 162.
Transcript of PATTERNS IN MISMANAGEMENT
852
present in this way, there is little to support this view.
Meyer 44 has attempted to separate depersonalisationfrom schizophrenic ego disturbance, on the grounds thatthe depersonalised patient looks into himself for thereason for his separation from the world and never puts itdown to outside agencies, as does the schizophrenic.The treatment of depersonalisation remains unsatis-
factory. In affective illness, treatment of the depressionquite often leads to remission of the depersonalisation. Inschizophrenia, however, it tends to be more intractable 1 11;and when depersonalisation arises in temporal-lobeepilepsy, the management is that of the underlying cause.There are, however, some cases in which depersonalisationseems more isolated, severe and permanent. Varioustreatment such as methylamphetamine, continuousnarcosis, intravenous thiopentone, and even leucotomyhave been advised (electroconvulsion therapy is said to becontraindicated). The therapeutic possibilities have beenreviewed by Davison.13 Despite the despondent feelingthat pervades the subject, it must be remembered thatthis distressing symptom can remit spontaneously.
COLONIC RECONSTRUCTION OF THE PHARYNX
AFTER RADICAL OPERATION
CANCER of the lower part of the pharynx and cervicaloesophagus is still very hard to cure; and despite all therecent therapeutic advances, even palliation is often
unsatisfactory. The aim must be to eradicate the growthor, if this is impossible, at least to allow the patient tobreathe and swallow comfortably and to spend the restof her life at home with the family. While a biologicalsolution to disordered tissue growth still eludes us, thechoice is between irradiation and surgery. Both methodshave a low cure-rate, but operation probably offers thebest chance of eradication or adequate palliation. Radio-
therapy is widely used, but the dysphagia is apt to persistbecause of oedema, stricture, or recurrence, and dyspnoeamay also result from various respiratory complications.Even with the newer supervoltage therapy, the full courseof treatment makes heavy demands on the patient, and, ifit is unsuccessful, operation may be difficult or impossiblebecause of fibrosis or recurrent growth. Thus, manypatients treated with radical irradiation alone spend theremainder of their lives as permanent inpatients, oftenwith a tracheostomy and a feeding fistula.45The disadvantages of radiotherapy are responsible for
the trend towards surgery in many centres. Operationmeans excision of the pharynx, larynx, and cervical
oesophagus in continuity with potentially involved
lymph-nodes. The problem here is the restoration of thegullet, and most attempts to solve it have been based on thepioneer work of Trotter 46 and Wookey,47 using skin flapsfrom the neck and elsewhere. Although some success hasbeen achieved, several operations are required and longperiods in hospital; and the growth often recurs beforereconstruction is complete. Strictures and fistuÍae are notuncommon, and there are technical limitations on theamount of cervical oesophagus which may be resected.Because of these drawbacks to the staged operations, variousmethods of excision and repair in one operation have beendevised. Tubes of tissue or plastic materials have beenused to replace the pharynx, such as split skin over a44. Meyer, J. E. Psychiat. Neurol. Basle, 1956, 132, 221.45. Fairman, H. D., Hadley, S. K. J., John, H. T. Brit. J. Surg. 1964,
51, 663.46. Trotter, W. Lancet, 1913, i, 1075.47. Wookey, H. Surg. Gynec. Obstet. 1942, 75, 499.
plastic tube,48 laryngeal mucosa,49 tracheal 11 and vasculargrafts,5l as well as polyethylene, nylon, and tygon. Thesemethods permit low excision of the oesophagus, and suc-cesses have been reported; but there has been a high rateof stenosis and fistula formation. Other workers havetherefore used a mucosa-lined viscus for direct anasto-mosis to a divided oropharynx. Such replacement of thepharynx has been achieved with stomach, 52 53 oesophagus,64jejunum,55 and the right or left colon. 56-59
Usually these new techniques have been described inonly one or two cases. The latest paper from Bristol 4sreports 9 patients with carcinoma of the pharynx or
cervical oesophagus in whom the defect in the pharynxafter excision was bridged at the same operation by a longloop of colon passing from the oropharynx to the stomachvia the anterior mediastinum. Palliation was the primaryaim, and swallowing was rapidly restored in most cases.Furthermore, the long-term results may be better becausethe needs of reconstruction can be ignored during theexcision. The method needs little special equipment orskills, and it should have a useful place in the treatment ofcancer of the pharynx or cervical oesophagus, but becauseof its magnitude it should probably be restricted to theyounger and fitter patients. The importance of collabora-tion between laryngologists, surgeons, and radiotherapistsin selecting the primary treatment with the greatest chanceof success should not need further emphasis.
PATTERNS IN MISMANAGEMENT
Stein and Susser 60 discuss the circumstances in whichcertain patients’ illnesses were mismanaged. Some wereseen in hospital practice, others in general practice. Wasthere any recurring pattern which might make suchfailure of care predictable and therefore preventible?They suggest that " failures in personal care will be thecharacteristic failures in hospital practice " and that" failures in technical competence will be the character-istic failures in general practice ".They set out hospital case-histories which illustrate
how social or personal factors have been ill considered;how communication has been at fault (sometimes betweenthe hospital and the patient or his relatives, sometimesbetween different members of the hospital unit); how therules and procedures of hospital organisation overrodethe patient’s needs; and how the hospital staff did notalways resolve their disagreements about treatment.The mistakes in general practice included failures in
routine examination and in simple diagnosis and failuresattributable to the doctor’s woeful inexperience in a par-ticular aspect of medicine or ignorance of recent importantdevelopments in diagnosis or treatment.The cases quoted came from many parts of the country,
which suggests that the problems they illustrate are
general and not local. Though the numbers are small (tencases from hospital and ten from general practice) there isno doubt that further similar studies would be justified-and equally salutary.
48. Negus, V. E. Proc. R. Soc. Med. 1950, 43, 157.49. Wilkins, S. A. Cancer, 1955, 8, 1189.50. Guidice, A. T. Cited by Iskeceli, O. K. Surgery, 1962, 51, 496.51. Roux, G. Cited by Iskeceli, O. K. ibid.52. Ong, G. B., Lee, T. C. Brit. J. Surg. 1960, 48, 193.53. Butler, T. J. Cited by Fairman et al. (footnote 45).54. Wooler, G. Proc. R. Soc. Med. 1952, 45, 264.55. Yudin, S. Surg. Gynec. Obstet. 1944, 78, 561.56. Goligher, J. C., Robin, I. G. Brit. J. Surg. 1954, 42, 283.57. Beck, A. R., Baronofsky, R. Surgery, 1960, 48, 499.58. Mustard, R. A. Surg. Gynec. Obstet. 1960, 111, 577.59. Sherman, C. D., Scanlon, E. F. ibid. p. 349.60. Stein, Z., Susser, M. Med. Care, 1964, 2, 162.
