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| 694 May 17, 1947
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| The health visitors of the local authority to act as: investigators in the homes along with the sanitary inspectors, and
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| “ specialized’ health visitors to be attached to the various
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| medical, nursing, and clerical teams operating at the hospital
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| group and local authority levels.
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|
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| Taking the tuberculosis service as an example. The primary
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| notification of tuberculosis would be visited by the health
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| visitor, who would report on the housing conditions and general
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| sociological circumstances. -The primary notification would
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| by law be sent to the local medical officer of health as chief
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| epidemiologist, who would delegate the subsequent measures
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| to the senior tuberculosis officer of the hospital team; the
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| subsequent visits to be carried out by the “ specialized ” health
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| visitors who attend the various clinics and are kept informed
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| of everything affecting the patient and his family ; the senior
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| medical officer of the team to work in close harmony with the
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| medical officer of health, particularly as regards housing and
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| other necessary conditions. So far as after-care is concerned,
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| this should be in the hands of the committee at the hospital
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| group-local authority level and advised not only by the senior:
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| medical officer but also by the medical officer of health.
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|
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| The framework could be extended to meet the needs of all
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| other services, but modified according to the special needs of
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| this service. Once the framework is accepted, the details can
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| easily be filled in provided there is good will and a wide understanding.—I am, etc.,
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| Bradford, HAROLD VALLOw.
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|
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| S1r,—There are two facts apposite to the impending changes
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| in the tuberculosis service which have so far received scant
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| recognition. The first is that the relationship of the patient
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| to his domestic, social, and economic background, which is
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| now receiving so much attention and which to general medicine
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| is a relatively new conception, has in fact been the everyday
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| concern of the tuberculosis officer for many years. Secondly,
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| the anti-tuberculosis organization as it has developed since 1914
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| has given us the nearest approach we have known to a public
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| medical service providing hospital, clinic, and domiciliary treatment at a high clinical level for sick persons in large numbers.
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| Despite certain inherent weaknesses and inequalities, and
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| despite in some quarters official apathy and parsimony, it has
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| emerged with a record of which it may well be proud.
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|
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| For these two reasons the views of tuberculosis workers claim
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| the special attention of those -who will formulate the new
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| regional schemes. It is to be hoped that the well-timed suggestions put forward by Dr. Lissant Cox (April 26, p. 577) will
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| stimulate a lively discussion prior to the Minister of Health’s
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| address in July. Dr. Lissant Cox rightly stresses the need for
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| medical teamwork. This can only be obtained where all
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| concerned are responsible to the same employer. If only one
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| person—for instance the health visitor—owes allegiance to a
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| different authority from that of the tuberculosis officer, almoner,
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| and clerk there is a sense of divided loyalties and the team
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| spirit suffers accordingly.
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|
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| Each tuberculosis area within a region will require a headquarters with office accommodation. It will be years before
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| new establishments are available, and until then I suggest that
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| in some areas the smaller institutions could, with minor alterations or extensions, be adapted for this purpose. Beds would
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| continue to be available as before, and in those institutions
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| where x-ray facilities are already provided out-patient clinics
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| could be held as in country districts ; this would be an added
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| convenience for patients. In this way the institution would
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| become a strongly defined centre, clinical and administrative,
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| for the area.—I am, etc.,
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|
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| Chichester. J. E. WALLACE.
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|
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| . Sanitary Control of Ice-cream
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| Sir,—May I draw your attention to an inaccuracy in the
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| epidemiological note (April 26, p. 583) on the above subject ?
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| The maintenance of a sufficiently low temperature after freezing
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| and until sale is.required in the case of a cold mix product as
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| in the case of a pasteurized mix. Circular 69/47, which was
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| issued with the regulations, points out in respect of the complete cold mix that after conversion of the reconstituted product into ice-cream Regulation 4 shall apply.
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|
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| ‘
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| CORRESPONDENCE \
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| BRITISH
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| MEDICAL JOURNAL
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| This regulation forbids the sale or offer for sale unless one
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| of two conditions is met. One requiring further heat treatment should the temperature of the ice-cream be found to be
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| above 28° F. (—2.2° C.) cannot obviously apply to the complete
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| cold mix product ; the other stipulates that ice-cream shall not
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| be sold unless it has been kept at a temperature not exceeding
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| 28° F. since it was frozen.
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|
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| I should be grateful if you would draw the attention of your
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| readers to this rather important aspect of ice-cream control.—
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| I am, etc.,
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|
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| Birmingham.
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|
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| W. R. MarrTINE.
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| Massive Penicillin Doses
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|
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| Sir,—Dr. D. P. Wheatley (April 19, p. 530) has shown that
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| the daily parenteral administration of penicillin can accelerate
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| the resolution of localized septic foci if the doses are large
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| enough. Thus, for the treatment of what he calls “seven
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| cases of minor conditions commonly met with in general
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| practice ” he used 4,550,000 units of penicillin. The total period
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| of convalescence from the commencement of treatment was at
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| least 30 days.
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|
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| From the few cases that I have treated I have been under the
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| impression that a more rapid cure can be achieved by the
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| combined used of local penicillin and free surgical drainage.
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| The solution recommended for local use by Roxburgh contains
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| between 500 and 1,000 units per ml. of distilled water and gives
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| satisfactory results. In one case a pyogenic abscess of three
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| days’ duration was opened by a 1-in. (2.54-cm.) incision, and
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| a cavity 1/2 in. (1.25 cm.) in diameter was found. A drain
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| was inserted and penicillin was instilled. Twelve hours later
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| the discharge was slight, and the drain was removed. On
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| the fourth day, after daily instillations of the penicillin solution, the cavity was obliterated and the skin incision was clean
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| and dry and healing rapidly. (Total amount of penicillin used
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| was 4,000 units.)
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|
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| If, as Dr. Wheatley has noted, the systemic treatment with
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| penicillin is commenced early enough, the inflammation will
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| abort. But, in cases where there is scme delay in starting
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| treatment, the generalized symptoms of toxaemia and the signs
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| of inflammation will subside, leaving a localized collection of
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| pus which requires surgical treatment. It is suggested that,
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| once it is decided that the inflammation is progressing to abscess
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| formation, but before localization is complete, the area should
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| be incised to relieve the local tension and pain. The level
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| of penicillin in the blood stream will prevent a spread of infection through the channels opened up by the incision. Thereafter the systemic penicillin may be discontinued as soon as
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| the general condition of the patient merits it—usually three
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| injections of 30,000 units each is the total amount of penicillin
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| required. The local treatment is continued daily until the
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| purulent discharge ceases, when the further treatment is the
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| same as for a clean surgical wound. Such a procedure, however, could only be justified if the organism is sensitive to
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| penicillin. This can be assessed by the progressive localization
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| of the inflammation under the systemic treatment.
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|
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| In this way greater economy in the use of penicillin can be
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| achieved, the discomfort of repeated intramuscular injections
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| is reduced, and the patient’s convalescence is shortened. In addition it is suggested that a stronger scar and a better cosmetic
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| result is achieved because the tension of the abscess is relieved
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| before the overlying skin has become stretched and atrophic.—
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| I am, etc.,
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| Ayr. C. O. KENNEDy.
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| REFERENCE
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|
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| Penicillin: Its Practical Application (Dermatological Section). Edited by Sir
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| Alexander Fleming. London: Butterworth and Co. 1946.
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| Rubella in Pregnancy and Congenital Defects | | Rubella in Pregnancy and Congenital Defects |
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| father and mother, are all well—I am, etc., | | father and mother, are all well—I am, etc., |
| London, S.E.21. G. D. Pirie. | | London, S.E.21. G. D. Pirie. |
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| Treatment of Post-operative Pulmonary Atelectasis
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| Sir,—In an effort to prove that his pen is mightier than the
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| spear, Mr. R. C. Brock, in his letter (April 19, p. 543), outQuixotes Quixote by tilting at illusory windmills. Indeed, all
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| must agree with practically everything he says, but the tone of
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| his letter requires that I should explain myself in rather more
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| detail.
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|
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| In saying that bronchoscopic aspiration is the ideal method
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| of treating post-operative atelectasis I of course meant that
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| it was the most effective (as Mr. Brock himself admits), not that
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| it had no imperfections; nor must he condemn me as ignorant
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| of the well-known benefits of prophylaxis and of conservative
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| methods of treatment simply because, in describing one
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| particular manceuvre (this word suggests less of charlatanism
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| than “trick ”), these benefits were not stressed ; nor, of course,
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| is it material to that manceuvre whether water be introduced
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| into the trachea by injection through the windpipe or by instillation through the glottis, so long as coughing results. Incidentally, injection is not so unpleasant as it sounds, and there
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| is little to choose between the two methods.
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|
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| On all the above points Mr. Brock and [J are in agreement.
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| Where we really differ is on his statement that the objections
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| to bronchoscopic aspiration are, first, that it encourages laziness,
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| which might more reasonably. be used as an argument against
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| penicillin or the sulphonamides, and, secondly, that bronchoscopy is dangerous in unskilled hands. This latter may be true,
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| but it is no more an argument against bronchoscopy than it is
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| against appendicectomy ; on the contrary, it is an extremely
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| good reason why anaesthetists should become, as I said in my
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| last letter, experts in bronchoscopic aspiration and in thoracic
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| disease.—I am, etc.,
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|
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| Newcastle-upon-Tyne. M. H. ARMSTRONG DAVISON.
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|
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| Treatment of Ingrowing Toenail
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| Sir,—I was very interested to read the remarks by Dr. S. J.
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| D. Esser (Jan. 4, p. 33) on the above subject, and entirely agree
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| with him. I have performed a similar operation on over fifty
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| patients, only one of which was temporarily unsatisfactory.
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| The patient, a very conscientious engineer officer, would not
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| remain in bed but got about immediately, with the result that
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| convalescence was delayed. Some of my more athletic patients
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| played football a month after the operation with no ill effects.
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|
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| I first came across a description of the operation in question
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| some years ago in a French medical journal ;
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| French surgeon ; unfortunately at this date I cannot recall his
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| name. In his description a diamond-shaped portion of the soft
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| tissue is removed, the knife cutting down to the bone; three
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| salmon-gut sutures are inserted—the end ones being tied first,
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| the middle one last—and there should be little or no tension.
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| Performed in this way the final result is a linear scar, the overhanging soft tissues being drawn well away from the lateral
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| margin of the nail. He emphasized the importance of a thorough
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| preparation of the part prior to operation and insisted on
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| complete rest afterwards until removal of the sutures. This,
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| although rather irksome to the patient, is essential if a good
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| result is to be obtained.
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|
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| Following these instructions I have never had to perform a
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| second operation for the relief of this condition. As Dr. Esser
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| says, there is no doubt about the operation being simple, logical,
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| and effective, and I congratulate him on bringing it to the notice
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| of the profession.—I am, etc.,
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|
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| W. E. Roserts,
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| Sydney, Australia. Surgeon Commander, R.A.N. (retd.).
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|
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| the writer was a ~
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| Safety in Electric Convulsion Therapy
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|
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| Sir,—I have read the letter by Dr. R. A. Sandison (April 26,
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| p. 579), and I am very gratified by such common-sense thought.
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| His experience is entirely in accord with my own over seven
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| years’ experience of electric convulsion therapy. I have treated a
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| large number of cases both as in- and out-patients by this
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| method in the last two years withéut traumatic occurrence, and
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| between 1940 and 1945 had only three cases which showed
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| evidence of compression of one vertebra after x-ray examination. I came to the conclusion that this compression was more
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| a radiological disease than a pathological one, and I have not
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| seen any disability resulting from it.
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|
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| I always use a firm surface with a pillow placed under the
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| thoracic spine and no other mechanical restraint. It is, therefore, in my opinion quite unnecessary to use curare. As far as
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| lessening the apprehension by means of thiopentone, as Dr.
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| Sandison says, patients are not afraid of the treatment but
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| sometimes are upset by the amnesia and confusion, which as a
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| rule are only transient, and again are very readily relieved by a
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| chat with the patient following treatment, or by warning the
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| patient before that such symptoms may arise for a short time.
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| No advantage, therefore, in my opinion can be obtained by
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| the use of curare or thiopentone apart from the very dangerous
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| results which may follow its use.
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|
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| Again let me congratulate Dr. Sandison.—I am, etc.,
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|
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| J. P. McGuINNESS.
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| The Shortage of Nurses
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|
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| Sir,—The purpose of this letter is twofold: first, to bring
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| to the notice of the medical profession a very real danger to
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| the future supply of nurses ; and, secondly, to ask whether the
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| theoretical training of the modern nurse has not reached the
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| stage when it is endangering the practice of nursing.
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|
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| It seems to me that the following decision of the General
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| Nursing Council has not received sufficient attention in the
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| medical Press—namely, that as from May 31, 1937, no hospital
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| with less than an average of 100 occupied beds per day will
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| be recognized as a complete training school. By this decision
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| the General Nursing Council would appear to be following the
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| present-day trend of the pursuit of ideologies without regard
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| to the practical issues involved. The law of economics is one
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| of demand and supply ; if the supply is inadequate and further
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| demands are put upon it the result must be chaos.
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|
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| The smaller hospitals throughout this country have for many
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| years supplied a large number of trained nurses. They have
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| instructed and individually spoon-fed girls who, from lack of
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| primary education, would have failed to stay the course in the
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| larger hospitals, and have turned them into reliable nurses. In
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| the future these smaller hospitals can never be staffed by senior
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| nurses, and they will have great difficulty in attracting junior
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| nurses, who will prefer to enter the complete training schools.
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|
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| It is generally acknowledged that the standard of education
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| of the present-day nursing recruit is not as high as it was ten
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| years ago. Yet with insufficient grounding the nurse of to-day
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| is expected to have a knowledge of medicine, surgery, gynaecology, and many other subsidiary subjects that would not
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| disgrace the average medical’student. Of what practical use is
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| the nurse full of theory who cannot make her patient comfortable, and, who, for example, though she can quote correctly
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| the precise figures of the normal blood urea, yet is unable to
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| see that her patient is in the early stages of renal failure by
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| his drowsiness, his breath, his tongue, and his diminished output of urine? The nurse should have sufficient textbook knowledge to enable her to take an intelligent interest in her work.
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| She should be trained not to the theory of medicine but to
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| the art of nursing : the class-room can never replace the ward.
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| In my opinion it will be cold comfort for the patient when a
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| graduate nurse does his dressing, a student nurse gives his
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| enema, an assistant nurse washes him, and an orderly looks
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| after his meals, with a complete change of personnel for every
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| eight-hour shift. Not one of them will look upon him as
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| her individual responsibility, and the faith of the patient will
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| be correspondingly lessened.
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|
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| It is admitted that the smaller hospital is no longer an
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| economic unit, and that the larger one of 400 to 500 beds is
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| the hospital of the future. At the present rate of building it
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| may well be twenty years before the latter comes into existence.
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| Bromsgrove.
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