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CRISIS IN NURSING
380 in the process there
are
gaps,
overlapping,
and administrative
waste.
All this gives weight to the recognised fact that the pursuit and maintenance of health is a single operation that should be paid for out of a single purse controlled locally. Whether the money is derived from rates or taxes is mmaterial. What is material is that one body should have the overriding responsibility for deciding how much is spent on hospital services, or on domiciliary services, or on environmental services. Fortunately both the concept of district hospitals based on local populations of 100,000-150,000 and the recent recommendations of the Local Government Boundary Commission could help to make this a reality during the next ten years. The public usually gets what it wants eventually, and in this country for hundreds of years it has shown that it wants social services run locally.
Ever-developing local-authority health services, whether or personal, will absorb what formerly were hospital responsibilities, but comprehensive planning of local-health expenditure would be welcome. Health Offices, J. F. GALLOWAY. Wolverhampton. environmental
ELECTROMYOGRAPHY IN POLYMYALGIA RHEUMATICA Kirstein SIR,-Dr. (Jan. 13) reports short-duration motor units in the muscles of patients with low-amplitude polymyalgia rheumatica. ,
Abnormalities in electrical stimulation tests and electromyography have been described 1-3 in rheumatoid arthritis, and this type of unit has also been reported in the collagenoses, particularly where vascular lesions are present (e.g., periarteritis nodosa). Polymyalgia rheumatica may easily be confused with such conditions. My late colleague, Dr. H. S. Barber, who, describing4 this syndrome in 1947, coined the term " polymyalgia rheumatica ", was aware of this possibility and to differentiate it from low-grade polymyositis we performed electrical investigations on four of his patients. Strengthduration curves and electromyography of a wide sample of muscles were all normal. Department of Physical Medicine, Manchester Royal Infirmary.
R. HARRIS.
TREATMENT OF PYLORIC STENOSIS
SIR,-Dr. Jacoby (Jan. 20) is to be congratulated on the evidence he has produced regarding the relative merits of medical and surgical treatment for pyloric stenosis. I would, however, disagree with him about his criteria for the selection of cases for surgery. For example, he arbitrarily decided to operate on all babies in whom vomiting began in the first three weeks of life, but when he later decided to defer operation in those under three weeks old he found that two out of five did not in fact require one.
For about ten years my practice has been to treat all infants with pyloric stenosis with antispasmodics for forty-eight hours. In those in whom the vomiting is greatly reduced we continue with medical treatment, and the others are referred to the surgeons. The main advantage of this regimen is that selection is made on the basis of results rather than arbitrarily. I have found it impossible to predict which baby will respond and which will not, though I agree with Dr. Jacoby that those with severe dehydration usually require surgery. Occasionally, first impressions prove erroneous, and medical treatment is subsequently found to produce too slow an improvement-if the baby is unfit to go home after one week then we usually switch to Ramstedt’s operation. Sometimes, also, drug treatment is required to stop persistent vomiting 1. Morrison, L. R., Short, C. L., Ludwig, A. Q., Schwab, R. S. Amer. J. 2. 3. 4.
med. Sci. 1947, 33, 214. Harris, R. Electrical Excitability of Muscle in Rheumatoid Arthritis. University of Leeds, 1950. Steinberg, V. L., Wynn Parry, C. B. Brit. med. J. 1961, i, 630. Barber, H. S. ibid. 1957, 16, 230.
after surgery, but in the main I have found this forty-eight-hour trial period of medical treatment to be a sound, practical course. North Middlesex Hospital, London, N.18.
IAN G. WICKES.
CRISIS IN NURSING Nuttall SiR,-Miss (Feb. 3) is opposed to nurses in the main bedside nursing force in training maintaining our hospitals; but it should be pointed out that unless
do this work, then they cease to be of much use to the hospital service and many will be forced to use nursing auxiliaries instead, and stop training student nurses. Her policy is also that of the Royal College of Nursing, but there is no evidence at all that this policy leads to the If the Royal College of nurses being better trained. are in research, then they interested seriously Nursing should encourage experiments with different forms of nurse training, and also compare the end-result in countries which adopt different methods. Hospital doctors are naturally more interested in the way the patients are looked after than in the details of nurse training, and it will surprise’many that those who are concerned with nurse training consider that this should be organised without the student nurse taking responsibility for patient care in hospitals. This conflict seems to many to be quite ridiculous. Perhaps we need an inquiry into nurse training. W. RITCHIE RUSSELL. United Oxford Hospitals.
the student
nurses are
prepared
to
BIRTH ORDER AND MATERNAL AGE OF
HOMOSEXUALS I ask Dr. Slater (Jan. 13) a question? SIR,-May If the birth order of male homosexuals tends to be higher than average, it follows that, since the elder sibs of some will be all males, these will have a larger number of elder brothers than the average person who has no elder sisters. Though it is quite common for parents to wish for a boy as their eldest child, one can assume, at least in Western cultures, that by the time they have two or more sons, most of them strongly wish for a daughter, and their disappointment at having another son will be the more acute the more sons they already have. They then run the risk of unconsciously imposing a feminine role on the child (an attitude which may be reversed if a daughter is subsequently born). This could be one of the causes of homosexuality. If the number of male homosexuals who have elder brothers, but no elder sisters, is higher than one would expect, this would support my hypothesis. No doubt Dr. Slater has the relevant data. Could it be, then, that in some cases homosexuality might be due to a chromosomal abnormality, while one of the environmental causes is as I have described ? This mixed aetiology would, of course, be in line with the view that there are curable " and " incurable " homosexuals. London,
N.8.
L. S. CHAZAN.
*** We showed Dr. Chazan’s letter
to
Dr. Slater,
whose
reply follows.-ED. L. SIR,-Dr. Chazan’s question might, perhaps,
be
answered like this. There were 41 cases where the patient was the second born of 2 sibs-i.e., omitting the case where he was one of twins and a case where the sex of the other sib was not known. In 28 of these 41 cases the elder sib was male and in 13 female. This tends to support the view that parents who have had one son already might tend to feminise a second boy. However, one would not have thought the effect would be a large- one when the family contained only 2 children. If we now go to larger
are
gaps,
overlapping,
and administrative
waste.
All this gives weight to the recognised fact that the pursuit and maintenance of health is a single operation that should be paid for out of a single purse controlled locally. Whether the money is derived from rates or taxes is mmaterial. What is material is that one body should have the overriding responsibility for deciding how much is spent on hospital services, or on domiciliary services, or on environmental services. Fortunately both the concept of district hospitals based on local populations of 100,000-150,000 and the recent recommendations of the Local Government Boundary Commission could help to make this a reality during the next ten years. The public usually gets what it wants eventually, and in this country for hundreds of years it has shown that it wants social services run locally.
Ever-developing local-authority health services, whether or personal, will absorb what formerly were hospital responsibilities, but comprehensive planning of local-health expenditure would be welcome. Health Offices, J. F. GALLOWAY. Wolverhampton. environmental
ELECTROMYOGRAPHY IN POLYMYALGIA RHEUMATICA Kirstein SIR,-Dr. (Jan. 13) reports short-duration motor units in the muscles of patients with low-amplitude polymyalgia rheumatica. ,
Abnormalities in electrical stimulation tests and electromyography have been described 1-3 in rheumatoid arthritis, and this type of unit has also been reported in the collagenoses, particularly where vascular lesions are present (e.g., periarteritis nodosa). Polymyalgia rheumatica may easily be confused with such conditions. My late colleague, Dr. H. S. Barber, who, describing4 this syndrome in 1947, coined the term " polymyalgia rheumatica ", was aware of this possibility and to differentiate it from low-grade polymyositis we performed electrical investigations on four of his patients. Strengthduration curves and electromyography of a wide sample of muscles were all normal. Department of Physical Medicine, Manchester Royal Infirmary.
R. HARRIS.
TREATMENT OF PYLORIC STENOSIS
SIR,-Dr. Jacoby (Jan. 20) is to be congratulated on the evidence he has produced regarding the relative merits of medical and surgical treatment for pyloric stenosis. I would, however, disagree with him about his criteria for the selection of cases for surgery. For example, he arbitrarily decided to operate on all babies in whom vomiting began in the first three weeks of life, but when he later decided to defer operation in those under three weeks old he found that two out of five did not in fact require one.
For about ten years my practice has been to treat all infants with pyloric stenosis with antispasmodics for forty-eight hours. In those in whom the vomiting is greatly reduced we continue with medical treatment, and the others are referred to the surgeons. The main advantage of this regimen is that selection is made on the basis of results rather than arbitrarily. I have found it impossible to predict which baby will respond and which will not, though I agree with Dr. Jacoby that those with severe dehydration usually require surgery. Occasionally, first impressions prove erroneous, and medical treatment is subsequently found to produce too slow an improvement-if the baby is unfit to go home after one week then we usually switch to Ramstedt’s operation. Sometimes, also, drug treatment is required to stop persistent vomiting 1. Morrison, L. R., Short, C. L., Ludwig, A. Q., Schwab, R. S. Amer. J. 2. 3. 4.
med. Sci. 1947, 33, 214. Harris, R. Electrical Excitability of Muscle in Rheumatoid Arthritis. University of Leeds, 1950. Steinberg, V. L., Wynn Parry, C. B. Brit. med. J. 1961, i, 630. Barber, H. S. ibid. 1957, 16, 230.
after surgery, but in the main I have found this forty-eight-hour trial period of medical treatment to be a sound, practical course. North Middlesex Hospital, London, N.18.
IAN G. WICKES.
CRISIS IN NURSING Nuttall SiR,-Miss (Feb. 3) is opposed to nurses in the main bedside nursing force in training maintaining our hospitals; but it should be pointed out that unless
do this work, then they cease to be of much use to the hospital service and many will be forced to use nursing auxiliaries instead, and stop training student nurses. Her policy is also that of the Royal College of Nursing, but there is no evidence at all that this policy leads to the If the Royal College of nurses being better trained. are in research, then they interested seriously Nursing should encourage experiments with different forms of nurse training, and also compare the end-result in countries which adopt different methods. Hospital doctors are naturally more interested in the way the patients are looked after than in the details of nurse training, and it will surprise’many that those who are concerned with nurse training consider that this should be organised without the student nurse taking responsibility for patient care in hospitals. This conflict seems to many to be quite ridiculous. Perhaps we need an inquiry into nurse training. W. RITCHIE RUSSELL. United Oxford Hospitals.
the student
nurses are
prepared
to
BIRTH ORDER AND MATERNAL AGE OF
HOMOSEXUALS I ask Dr. Slater (Jan. 13) a question? SIR,-May If the birth order of male homosexuals tends to be higher than average, it follows that, since the elder sibs of some will be all males, these will have a larger number of elder brothers than the average person who has no elder sisters. Though it is quite common for parents to wish for a boy as their eldest child, one can assume, at least in Western cultures, that by the time they have two or more sons, most of them strongly wish for a daughter, and their disappointment at having another son will be the more acute the more sons they already have. They then run the risk of unconsciously imposing a feminine role on the child (an attitude which may be reversed if a daughter is subsequently born). This could be one of the causes of homosexuality. If the number of male homosexuals who have elder brothers, but no elder sisters, is higher than one would expect, this would support my hypothesis. No doubt Dr. Slater has the relevant data. Could it be, then, that in some cases homosexuality might be due to a chromosomal abnormality, while one of the environmental causes is as I have described ? This mixed aetiology would, of course, be in line with the view that there are curable " and " incurable " homosexuals. London,
N.8.
L. S. CHAZAN.
*** We showed Dr. Chazan’s letter
to
Dr. Slater,
whose
reply follows.-ED. L. SIR,-Dr. Chazan’s question might, perhaps,
be
answered like this. There were 41 cases where the patient was the second born of 2 sibs-i.e., omitting the case where he was one of twins and a case where the sex of the other sib was not known. In 28 of these 41 cases the elder sib was male and in 13 female. This tends to support the view that parents who have had one son already might tend to feminise a second boy. However, one would not have thought the effect would be a large- one when the family contained only 2 children. If we now go to larger