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HANDOUTS FOR PATIENTS

THOSE doctors who are justly criticised by patientsbecause " they don’t tell you anything " are not alwaysout to make a mystery : often they cannot spare thetime to give the patient a detailed simplified accountof the- pathology of his condition ; and rather thanmislead him with a word or two they take refuge insilence. How can this difficulty be overcome to thepatient’s satisfaction but without further encroachmenton -the doctor’s time Dr. Charles Fletcher 1 suggeststhat, for patients with recurrent or chronic conditions,much might be done with simply written leaflets. As a

pilot model he has drafted such a leaflet on the natureand treatment of dyspepsia, defined (though not in theseterins to the patient) as " painful gastric or duodenaldysfunction whether due to peptic ulcer or other causes."This leaflet can be handed to the patient to take homeand read ; and at his next visit-Dr. Fletcher emphasisesthe importance of this-his questions about it can beanswered quickly and clearly, without much tedious.explanation. -

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The leaflet (which may be had from the Practitioneroffice 2) begins with a brief account of digestion, illus-trated by a diagram of the stomach and its associatedorgans. A paragraph on indigestion follows, and here wethink Dr. Fletcher has been rather too informative, orperhaps has told the facts in too alarming a way. Is itwise, or is it unwise, to tell a patient of the " ulcer typeabout the dangers of perforation and hoemorrhage ?And, if he should be told, is it wise to use such phrasesas " the stomach or duodenum gets digested rightthrough," and " a blood vessel is digested away " ; or

to warn the patient that a severe haemorrhage may leadto fainting or need treatment by transfusion These arestriking phrases which will stand out vividly in the mindof an anxious patient. The issue is difficult, for whilesome patients are over-anxious about their condition,

others take refuge from fear in bravado, and refuse totake the slightest precautions. On the one hand, know-ledge-will encourage patients of the second type to do asthey are told ; on the other, it will scarcely promote-

in patients of either type-the peace of mind on whichDr. Fletcher later puts so much emphasis. The sectionsof the leaflet which follow, however, will be generallyaccepted. He describes the ulcer diet and the regimenclearly and cleverly, explains the action and purpose of

. :antacids,: belladonna and olive oil, vitamins, and seda-tives, gives good little homilies on rest for the mind andfor the body, and ends with three detailed diets-strict,

moderate, and convalescent.The principle he has here outlined has long beenapplied by many doctors, who keep a stock of their own

printed or multigraphed instructions to hand to suitable; patients. Especially where explanations are attempted,such notes are by no means easy to write, and there ismuch to be said for using those produced by experts.It would be useful to many practitioners to have reliabletracts for -distribution to patients with various chronicor recurrent complaints, such as asthma and, hay fever,=varicose ulcer, bronchiectasis, rheumatism, psycho-somatic skin conditions, compensated or uncompensatedheart-disease, hypertension, and diabetes. At the sametime it should be remembered that many people absorbthe spoken word more easily than the written-especiallyif it is well spoken by a doctor who takes pains to makehis patient understand. A great deal of anxiety has beengenerated by patients reading about their maladies andgetting the subject out of focus. Moreover in these

1. Practitioner, 1949, 162, 51.2. From 5, Bentinck Street, London, W.1; at 6d. post free.

mechanistic days we must keep watch against anytendency to standardise medicine; whether by directivesto the doctor or by directives to’ the patient. Suchhandouts as Dr. Fletcher has devised should be used(as he insists) as an aid to, rather than a substitute for,frank discussion of his case with the patient.

SURGERY OF INOPERABLE GROWTHS

THE place of ultraradical surgery in the treatment ofso-called inoperable malignant growths has been muchdiscussed. In this country, Gordon-Taylor, Grey Turner,and others have published reports of successful cases ofmultiple " eviscerating

,., procedures requiring skill,

speed, and courage ; but heroic procedures of this kindhave usually carried so high a mortality-rate that manyhave deemed them unjustifiable, at any -rate in lesscapable hands. However, the advent of improvements inanaesthesia, the use of the sulpha drugs and penicillin,and the simplicity of blood-transfusion have materiallylessened the risks, and in our present issue Mr. Ravenpleads for a more enterprising outlook on the surgery ofadvanced malignant disease, giving examples of itssuccess.

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About a year ago we commented on the exenterationoperations of Prof. Alexander Brunschwig, late of

Chicago and now of the Memorial Hospital, New YorkCity. Brunschwig claims little more than palliation forthese extensive operations, and the advantages of suchpalliation have to be judged in relation to a primaryoperative mortality approaching 25% and some inevit-able postoperative discomfort. An occasional " cure "

goes far, of course, to justify such tremendous surgicalundertakings ; and some of Raven’s results are certainlyimpressive. On the other hand, in a case sufficientlyadvanced to require Brunschwig’s operation of hystero-vaginectomy, total cystectomy, transplantation ofureters, and rectosigmoidectomy with what he calls a" wet " colostomy, it is likely that the lymphatic systemwill already be widely affected ; and, unless one has faithin the ability of deep X-ray therapy to eradicate second-ary deposits in abdominal lymph-glands, the prospectsof " cure " are correspondingly poor. It has yet to beproved that for the survivors of such an operation life isprolonged, and (more important still) that life is lessuncomfortable or more happy. The decision must rest

largely with the patient: some people would prefer to bealive with severe disability, while others would not thinkthe price worth paying. The fact that, without operation,the outlook is hopeless does not justify the surgeon-and especially the relatively inexperienced surgeon-intaking great risks,’ unless he believes that a successfulresult would be reckoned successful by the patient.

RICE AND HYPERTENSION

THE diet for hypertension popularised in the UnitedStates by Kempner 3 includes 250-300 g. of rice a day.No less than 95% of the 2000 calories in this diet ’isfurnished by carbohydrate : otherwise it comprises 20 g.of protein (from rice and fruit) and not more than 5 g -of fat, 200 mg. of chloride, and 150 mg. of sodium. Fluidintake is restricted to 700-1000 ml. of fruit juice. Thisregime, which is a clever if somewhat dull blend of low-protein, low-sodium, and low-fluid diets, Kempner claimsto be effective in the treatment of hypertension andcardiac cedema. Brams,3 too, reports "excellent results... with the patient at work provided he cooperatedfaithfully"; while Contratto and Rogers;4 of Boston,1. Lancet, 1947, ii, 918.2. Kempuer, W. N. Carolina med. J. 1944, 5, 125, 273 ; Ibid, 1945,

6, 61, 117 ; Ibid, 1947, 8, 128.3. Brams, W. A. Treatment of Heart Disease. London, 1948;

p. 135.4. Contratto, A. W., Rogers, M. B. New Engl. J. Med. 1948, 239,

531.