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MENTAL NURSING ANALYSED
865 The names of Salk and Jenner are on the lips of countless citizens. Already anxious parents are demanding the vaccine for their children and worried administrators are requesting Presidential action to ensure its fair distribution. It is difficult for laymen here to see the risks of poliomyelitis in their correct perspective. There are 16,000 cases a year: a quarter of the cases have paralytic symptoms, and of these only a further quarter have permanent paralytic sequelse. The risk of a child being killed or maimed by car accidents is incomparably greater. When I arrived in New York I saw everywhere huge posters which told me " Save your child from Leukaemiagive to the American Cancer Society." It was fairly easv for me to see this appeal in perspective, but a great deal less easy for the average parent. The research foundations of America support an enormous amount of valuable and useful research, and in turn they are most generously supported by the public. Unfortunately the public is more generous when its emotions have been stirred; and I don’t myself believe that support for research should be obtained at the cost of arousing unnecessary fear.
informed the public of its wonders.
*
*
*
The peripatetic correspondentwho confessed to his ignorance of the Heat Barrier made the usual mistake of failing to consult the literature. This obviously is the flame belt that divides the two hemispheres of Venus and allowed the simultaneous development of Theron and Treen civilisations. It was first fully described by Dare et al,2 and subsequent references in the literature are too numerous to quote. Should the peripatetic correspondent have difficulty in obtaining the -original paper, an arrangement might be reached with the progeny of the present writer for the loan or exchange (with similar scientific material) of a genuine first edition. *
*
*
Our ward telephone rang the other day-it was a lady ,asking how Mrs. Colby-Brown was getting on after her appendicectomy. Sister replied that the patient was doing famously, and would shortly be sent home. Asked for her name, the lady replied : " Well, Sister, this is Mrs. Colby-Brown. You’re all so busy I just don’t like to bother you
on
the ward rounds." *
*
Last week I bought a book Motor-cars and Health is F.R.C.S. In it he writes : on
*
on
by
motoring. The chapter Sir Henry Thompson,
"
The easy jolting which occurs when a motor-car is driven fair speed over the highway conduces to a healthy agitation ; it ’acts on the liver,’ to use a popular phrase, which means only that it aids the peristaltic movements of the bowels and promotes the performance of their functions ; thus accomplishing the good in this respect which arises from riding on horseback." at
a
The date of publication is 1902. *
*
*
SIR JOHN BLAND-SUTTON
Born April 21, 1855 Rebellious spirit, thou didst fight Thy way from humbleness to might And wealth and fame. Boldly thy knife To ailing women gave new life. With lion’s heart, challenging fate, The pelvic surgeon didst create. didst enliven and beguile Dry teaching With " Ligaments and Tumours," and the while Thy wit did echo and thy cockney quips Delightedly from students’ lips. Wand’ring Elysian fields tonight With Jockie Hunter, kindred spright, And purring Tim with beady eyes, Affection blended with surprise. The man we loved-remote and rare, A London sparrow in the air. "
"
W. R. BETT 1. 2.
Lancet, April 9, 1955, p. 769. Dare, D., Hank, et Pierre. Eagle, July, 1950.
Letters
to
the Editor
DEALING WITH DISASTER
SIR,—You do a much-required service in drawing attention to the need for adequate arrangements for dealing with disasters.l But surely you are wrong in stating that there are few areas in the United Kingdom not within easy reach of big hospitals’? Reference to any railway map and to reports of aircraft accidents will show how wrong you are. In spite of the last sentence in your article of Feb. 5, your antagonistic attitude to resuscitation on the spot has two serious dangers. First, you may prejudice inexperienced practitioners against resuscitation before evacuation. Second, you may well be quoted (or misquoted) by lay administrators and committee members as an authority against making adequate provision for resuscitation at the scene of disasters. The indications for transfusion, &c., before evacuation can only be judged by the medical man treating the patient, with due regard to the patient’s injuries and condition and to the time and methods involved in evacuation. Rather than your lukewarm final sentence, you should write : Arrangements for immediate transfusion must be included in the plan ; they may not be needed, but when they are, they will then save life." "
R.A.F. Hospital, J. B. ROSS. Changi, Singapore. MENTAL NURSING ANALYSED SIR,-In your leading article of April 9 you discuss
study of the function and training of mental nurses carried out at the Bethlem Royal and Maudsley Hospitals in 1951-52. Among other points you draw attention to the discrepancy between theory taught and practical work done by student nurses in mental hospitals, particularly in their first year.
the
This is
an old problem which has been relieved a little by syllabus which contains " the importance of mental and physical health to the individual, the family, and the community " under the broad heading " personal and communal health." The preliminary syllabus, however, is still concerned mainly with the care of physical conditions and is therefore inappropriate for mental nurses. This is because it is assumed that the care of the sick in body is basic nursing
a new
while the care of the sick in mind is not, and that basic nursing should be learned before something which is thought of as specialised. Another reason is that the practice of teaching the preliminary syllabus in the first year (to allow students to take the examination as soon as possible) has hardened into tradition. Most mental nurses and their tutors do not agree either with the assumptions or the practice, but they accept the tradition, bad as it is, because the preliminary training school does allow an uninterrupted period in which to teach the preliminary subjects-an opportunity which for most tutors does not recur. There is a simple way out-namely, a change in the order in which the syllabus is taken. The purpose of the preliminary training school is to prepare a nurse for her work in the wards. The minimum period required is 8 weeks, some part of each day being spent in the wards. These weeks should be spent in teaching mental nursing, understanding and managing patients, and ward routines and practices. During the following 9 to 12 months psychiatry and mental nursing should be taught. The subjects in the preliminary syllabus, with their bias towards physical nursing, could be taught in the second year together with the medical and surgical nursing usually taught at this time. The preliminary examination could be taken at the end of the second year when the students would have the knowledge and practice, and therefore the confidence, to pass. The only stipulation the General Nursing Council makes is that the preliminary examination shall be taken before the final. The third year should be occupied by advanced psychiatric nursing, and, before taking the final examination, a short revision of the nursing of physically ill patients. 1.
Lancet, 1954, i, 1225 ; Ibid, Feb. 5, 1955, p. 298.
866 The conflict between the needs of the hospital for service and of the student for education is another old problem, one solution to which is suggested by reading the Bethlem and Maudsley study. This compares two ways of arranging nurses’ hours in mental hospitals-the so-called long day and the shift system. The long day is said to need fewer staff but it is very tiring for the nurses. The shift system may need more staff but it can be arranged with overlapping time which could be used by students for lectures and private study. It would be possible to have the best of both systems by letting the trained, auxilliary, and part-time staff work the long day (or night), and the students work overlapping shifts. This would allow the wards to be staffed by those not in training at the times when - the students’ shifts overlapped, and it would allow the students to have some part of every day for study. ’
These simple changes could remove two of the greatest difficulties in the training of mental nurses and help to smooth the furrows from the tutors’ brows. R.M.N. PHARMACOLOGY OF RESERPINE
SIR,—Oversimplification of complex problems by postulation is an old philosophical method which despite its age is unacceptable in science. Your leading article of March 12 contained a striking example. You postulated that reserpine was " the active alkaloid" of Rauwolfia serpentina, and then felt free to treat all data accumulated on any rauwolfia medication as if they had been obtained by using reserpine. 1. Actually there are at least five generically different preparations of rauwolfia : (a) Ground rauwolfia root containing reserpine-like (brady- cardia, hypotension, sedation producing), yohimbine-like, and numerous other alkaloids possibly potent in as yet unassessed The fact that ground crude or undesirable ways. preparations can be made from any of more than one hundred varieties of rauwolfia from all over the world (varieties which have manifestly different constituents), and the fact that even within the most desired species (Rauwolfia serpentina)
desirable
root
exist differences between roots from Siam, Burma, Thailand, and India, make lumping of data hazardous. There there
rauwolfias which apparently contain no reserpine (Rauwolfia parakensis, Rauwolfia cambodiana, and Rauwolfia caffra). (b) The alseroxylon fraction, ’Rauwiloid,’ an alkaloidal extract known to be free of yohimbine-like alkaloids, known to contain reserpine, rescinnamine, and other potent reserpinelike materials, guaranteed by its manufacturer to be made only from Rauwolfia serpentina of Indian origin. (c) Reserpine, a single alkaloid, difficult to purify, extracted from any of Rauwol, fia heterophylla (South American), Rauwolfia hirsuta (South American), Rauwolfia vomitoria (West Africa), Rauwolfia canescens (India), Rauwolfia serpentina (India). The contaminant alkaloids vary with the root of origin, and the difficulty of being sure that the sample is over 80% reserpine varies also. This alkaloid does not produce adrenergic blockade at any dose. It is the tri methoxy benzoic ester of methyl
Examination of the references cited in your leading article will show that numbers 1, 2, 4, 5, 6, 25, and 32 were concerned with preparation (a) ; 6, 8,10,21, and 30 were concerned with preparation (b) ; and the rest with preparation (c). Few papers exist on (d) and (e).35-41 Meanwhile, oversimplification of the situation by postulating that reserpine is clinically and pharmaco. logically typical of all rauwolfia preparations can only interfere with proper stimulation of investigators to clarify further the enigmas involved. References 1-34
a single alkaloid whose structure is thought to be the tri methoxy cinnamic ester of methyl reserpate, found to date only in Rauwolfia serpentina. While rescinnamine is not presently available for purchase, a considerable clinical usage has revealed that it is distinctly less sedative than reserpine, though pharmacologically both quantitatively and by its general potency, it is reserpine-like. (e) Canescine, isolated from Rauwolfia canescens, is probably Idesmethoxy reserpine. Animal work has established that
canescine is a member of the reserpine group, but clinical experience is not wide enough as yet to permit any guess as to its properties as applied to human disease.
2. Present clinical indications suggest that the mixed alkaloids without the yohimbine component (b above) present a better-balanced action less critical in dosage and somewhat less threatened with side-actions. Only further clinical work will establish this and elucidate reasons for it. ‘
contained in the
leading
article
(March
GEORGE L. MAISON.
* ** Dr. Maison earns our thanks for his valuable survey of rauwolfia preparations. In our leading article we tried to resolve confusion caused by the introduction of differ. ent rauwolfia preparations, and in referring briefly to the clinical use of rauwolfia we did not distinguish between experience with different preparations ; but, in fact, all but three of the papers cited on the experimental pharmacology of reserpine, with which we were princi. pally concerned, dealt with pure preparations of this alkaloid.-ED. L. GENETIC EFFECTS OF THERMONUCLEAR EXPLOSIONS
SIR,—Biologists tell us that mutations followed by selection have been the chief factors in improving living species. Yet in current discussion of the genetic effects of radiation, it is widely assumed that any increase in the human mutation rate must be harmful to the species, Are we to infer that for mankind alone selection is impossible ? Or is the human race already so perfect that further improvement is inconceivable ? The public have had ample warning of harmful mutants. Should not equal stress be laid on the relatively rare favourable mutations which could be of great benefit to the race ? R. B. BOURDILLON. -
REGISTRARS AND REGISTRARS
are
reserpate. (d) Rescinnamine,
are
12, 1955, p. 548).
SIR,—At present some medical registrars are quite obviously to be considered solely as trainees. There is, for example, the professorial-unit type, who assists in the investigations and treatment of a handful of patients with obscure maladies, aided by six or so colleagues of similar status, and adequately supervised by his eminent chiefs. He will have much spare time in which to browse in the university library or spend in learned discussion. From time to time he may take part in the preparation of articles of high academic merit for learned journals. Other registrars find themselves so busy with the day’s chores that academic achievement is out of the question. Consider, for instance, the lot of the average registrar at a provincial chest clinic, who shares clinic sessions and domiciliary visits equally with his consultant chest physician and the s.n.M.o., and who deputises for the radiographer, clerk, or health visitor as occasion requires. Indeed, what is meant to be the proper function of the grade has been the subject of much recent controversy. Clearly the current title of registrar covers no more a homogeneous group of appointments than does, say, the military rank of staff-captain. It is worth noting however that the latter designation is rarely used by itself-a letter is usually suffixed in parenthesis to show more exactly the duties of the gentleman in question. Cronheim, G., et al. Proc. Soc. exp. Biol., N.Y. 1954, 86, 120. Cronheim, G., Toekes, I. M. J. Pharmacol. 1955, 113, 13. Klohs, M. W., et al. J. Amer. chem. Soc. 1954, 76, 2843. Hershberger, R., Hughes, W., Dennis, E. Proc. Amer, Fed. clin. Res. 1955, 3, 71. 39. Klohs, M. W., et al. J. Amer. chem. Soc. (in the press). 40. Stoll, A., Hofman, A. Ibid, 1955, 77, 820. 41. Cronheim, G., Orcutt, J., Toekes, I. M. Unpublished. 35. 36. 37. 38.
informed the public of its wonders.
*
*
*
The peripatetic correspondentwho confessed to his ignorance of the Heat Barrier made the usual mistake of failing to consult the literature. This obviously is the flame belt that divides the two hemispheres of Venus and allowed the simultaneous development of Theron and Treen civilisations. It was first fully described by Dare et al,2 and subsequent references in the literature are too numerous to quote. Should the peripatetic correspondent have difficulty in obtaining the -original paper, an arrangement might be reached with the progeny of the present writer for the loan or exchange (with similar scientific material) of a genuine first edition. *
*
*
Our ward telephone rang the other day-it was a lady ,asking how Mrs. Colby-Brown was getting on after her appendicectomy. Sister replied that the patient was doing famously, and would shortly be sent home. Asked for her name, the lady replied : " Well, Sister, this is Mrs. Colby-Brown. You’re all so busy I just don’t like to bother you
on
the ward rounds." *
*
Last week I bought a book Motor-cars and Health is F.R.C.S. In it he writes : on
*
on
by
motoring. The chapter Sir Henry Thompson,
"
The easy jolting which occurs when a motor-car is driven fair speed over the highway conduces to a healthy agitation ; it ’acts on the liver,’ to use a popular phrase, which means only that it aids the peristaltic movements of the bowels and promotes the performance of their functions ; thus accomplishing the good in this respect which arises from riding on horseback." at
a
The date of publication is 1902. *
*
*
SIR JOHN BLAND-SUTTON
Born April 21, 1855 Rebellious spirit, thou didst fight Thy way from humbleness to might And wealth and fame. Boldly thy knife To ailing women gave new life. With lion’s heart, challenging fate, The pelvic surgeon didst create. didst enliven and beguile Dry teaching With " Ligaments and Tumours," and the while Thy wit did echo and thy cockney quips Delightedly from students’ lips. Wand’ring Elysian fields tonight With Jockie Hunter, kindred spright, And purring Tim with beady eyes, Affection blended with surprise. The man we loved-remote and rare, A London sparrow in the air. "
"
W. R. BETT 1. 2.
Lancet, April 9, 1955, p. 769. Dare, D., Hank, et Pierre. Eagle, July, 1950.
Letters
to
the Editor
DEALING WITH DISASTER
SIR,—You do a much-required service in drawing attention to the need for adequate arrangements for dealing with disasters.l But surely you are wrong in stating that there are few areas in the United Kingdom not within easy reach of big hospitals’? Reference to any railway map and to reports of aircraft accidents will show how wrong you are. In spite of the last sentence in your article of Feb. 5, your antagonistic attitude to resuscitation on the spot has two serious dangers. First, you may prejudice inexperienced practitioners against resuscitation before evacuation. Second, you may well be quoted (or misquoted) by lay administrators and committee members as an authority against making adequate provision for resuscitation at the scene of disasters. The indications for transfusion, &c., before evacuation can only be judged by the medical man treating the patient, with due regard to the patient’s injuries and condition and to the time and methods involved in evacuation. Rather than your lukewarm final sentence, you should write : Arrangements for immediate transfusion must be included in the plan ; they may not be needed, but when they are, they will then save life." "
R.A.F. Hospital, J. B. ROSS. Changi, Singapore. MENTAL NURSING ANALYSED SIR,-In your leading article of April 9 you discuss
study of the function and training of mental nurses carried out at the Bethlem Royal and Maudsley Hospitals in 1951-52. Among other points you draw attention to the discrepancy between theory taught and practical work done by student nurses in mental hospitals, particularly in their first year.
the
This is
an old problem which has been relieved a little by syllabus which contains " the importance of mental and physical health to the individual, the family, and the community " under the broad heading " personal and communal health." The preliminary syllabus, however, is still concerned mainly with the care of physical conditions and is therefore inappropriate for mental nurses. This is because it is assumed that the care of the sick in body is basic nursing
a new
while the care of the sick in mind is not, and that basic nursing should be learned before something which is thought of as specialised. Another reason is that the practice of teaching the preliminary syllabus in the first year (to allow students to take the examination as soon as possible) has hardened into tradition. Most mental nurses and their tutors do not agree either with the assumptions or the practice, but they accept the tradition, bad as it is, because the preliminary training school does allow an uninterrupted period in which to teach the preliminary subjects-an opportunity which for most tutors does not recur. There is a simple way out-namely, a change in the order in which the syllabus is taken. The purpose of the preliminary training school is to prepare a nurse for her work in the wards. The minimum period required is 8 weeks, some part of each day being spent in the wards. These weeks should be spent in teaching mental nursing, understanding and managing patients, and ward routines and practices. During the following 9 to 12 months psychiatry and mental nursing should be taught. The subjects in the preliminary syllabus, with their bias towards physical nursing, could be taught in the second year together with the medical and surgical nursing usually taught at this time. The preliminary examination could be taken at the end of the second year when the students would have the knowledge and practice, and therefore the confidence, to pass. The only stipulation the General Nursing Council makes is that the preliminary examination shall be taken before the final. The third year should be occupied by advanced psychiatric nursing, and, before taking the final examination, a short revision of the nursing of physically ill patients. 1.
Lancet, 1954, i, 1225 ; Ibid, Feb. 5, 1955, p. 298.
866 The conflict between the needs of the hospital for service and of the student for education is another old problem, one solution to which is suggested by reading the Bethlem and Maudsley study. This compares two ways of arranging nurses’ hours in mental hospitals-the so-called long day and the shift system. The long day is said to need fewer staff but it is very tiring for the nurses. The shift system may need more staff but it can be arranged with overlapping time which could be used by students for lectures and private study. It would be possible to have the best of both systems by letting the trained, auxilliary, and part-time staff work the long day (or night), and the students work overlapping shifts. This would allow the wards to be staffed by those not in training at the times when - the students’ shifts overlapped, and it would allow the students to have some part of every day for study. ’
These simple changes could remove two of the greatest difficulties in the training of mental nurses and help to smooth the furrows from the tutors’ brows. R.M.N. PHARMACOLOGY OF RESERPINE
SIR,—Oversimplification of complex problems by postulation is an old philosophical method which despite its age is unacceptable in science. Your leading article of March 12 contained a striking example. You postulated that reserpine was " the active alkaloid" of Rauwolfia serpentina, and then felt free to treat all data accumulated on any rauwolfia medication as if they had been obtained by using reserpine. 1. Actually there are at least five generically different preparations of rauwolfia : (a) Ground rauwolfia root containing reserpine-like (brady- cardia, hypotension, sedation producing), yohimbine-like, and numerous other alkaloids possibly potent in as yet unassessed The fact that ground crude or undesirable ways. preparations can be made from any of more than one hundred varieties of rauwolfia from all over the world (varieties which have manifestly different constituents), and the fact that even within the most desired species (Rauwolfia serpentina)
desirable
root
exist differences between roots from Siam, Burma, Thailand, and India, make lumping of data hazardous. There there
rauwolfias which apparently contain no reserpine (Rauwolfia parakensis, Rauwolfia cambodiana, and Rauwolfia caffra). (b) The alseroxylon fraction, ’Rauwiloid,’ an alkaloidal extract known to be free of yohimbine-like alkaloids, known to contain reserpine, rescinnamine, and other potent reserpinelike materials, guaranteed by its manufacturer to be made only from Rauwolfia serpentina of Indian origin. (c) Reserpine, a single alkaloid, difficult to purify, extracted from any of Rauwol, fia heterophylla (South American), Rauwolfia hirsuta (South American), Rauwolfia vomitoria (West Africa), Rauwolfia canescens (India), Rauwolfia serpentina (India). The contaminant alkaloids vary with the root of origin, and the difficulty of being sure that the sample is over 80% reserpine varies also. This alkaloid does not produce adrenergic blockade at any dose. It is the tri methoxy benzoic ester of methyl
Examination of the references cited in your leading article will show that numbers 1, 2, 4, 5, 6, 25, and 32 were concerned with preparation (a) ; 6, 8,10,21, and 30 were concerned with preparation (b) ; and the rest with preparation (c). Few papers exist on (d) and (e).35-41 Meanwhile, oversimplification of the situation by postulating that reserpine is clinically and pharmaco. logically typical of all rauwolfia preparations can only interfere with proper stimulation of investigators to clarify further the enigmas involved. References 1-34
a single alkaloid whose structure is thought to be the tri methoxy cinnamic ester of methyl reserpate, found to date only in Rauwolfia serpentina. While rescinnamine is not presently available for purchase, a considerable clinical usage has revealed that it is distinctly less sedative than reserpine, though pharmacologically both quantitatively and by its general potency, it is reserpine-like. (e) Canescine, isolated from Rauwolfia canescens, is probably Idesmethoxy reserpine. Animal work has established that
canescine is a member of the reserpine group, but clinical experience is not wide enough as yet to permit any guess as to its properties as applied to human disease.
2. Present clinical indications suggest that the mixed alkaloids without the yohimbine component (b above) present a better-balanced action less critical in dosage and somewhat less threatened with side-actions. Only further clinical work will establish this and elucidate reasons for it. ‘
contained in the
leading
article
(March
GEORGE L. MAISON.
* ** Dr. Maison earns our thanks for his valuable survey of rauwolfia preparations. In our leading article we tried to resolve confusion caused by the introduction of differ. ent rauwolfia preparations, and in referring briefly to the clinical use of rauwolfia we did not distinguish between experience with different preparations ; but, in fact, all but three of the papers cited on the experimental pharmacology of reserpine, with which we were princi. pally concerned, dealt with pure preparations of this alkaloid.-ED. L. GENETIC EFFECTS OF THERMONUCLEAR EXPLOSIONS
SIR,—Biologists tell us that mutations followed by selection have been the chief factors in improving living species. Yet in current discussion of the genetic effects of radiation, it is widely assumed that any increase in the human mutation rate must be harmful to the species, Are we to infer that for mankind alone selection is impossible ? Or is the human race already so perfect that further improvement is inconceivable ? The public have had ample warning of harmful mutants. Should not equal stress be laid on the relatively rare favourable mutations which could be of great benefit to the race ? R. B. BOURDILLON. -
REGISTRARS AND REGISTRARS
are
reserpate. (d) Rescinnamine,
are
12, 1955, p. 548).
SIR,—At present some medical registrars are quite obviously to be considered solely as trainees. There is, for example, the professorial-unit type, who assists in the investigations and treatment of a handful of patients with obscure maladies, aided by six or so colleagues of similar status, and adequately supervised by his eminent chiefs. He will have much spare time in which to browse in the university library or spend in learned discussion. From time to time he may take part in the preparation of articles of high academic merit for learned journals. Other registrars find themselves so busy with the day’s chores that academic achievement is out of the question. Consider, for instance, the lot of the average registrar at a provincial chest clinic, who shares clinic sessions and domiciliary visits equally with his consultant chest physician and the s.n.M.o., and who deputises for the radiographer, clerk, or health visitor as occasion requires. Indeed, what is meant to be the proper function of the grade has been the subject of much recent controversy. Clearly the current title of registrar covers no more a homogeneous group of appointments than does, say, the military rank of staff-captain. It is worth noting however that the latter designation is rarely used by itself-a letter is usually suffixed in parenthesis to show more exactly the duties of the gentleman in question. Cronheim, G., et al. Proc. Soc. exp. Biol., N.Y. 1954, 86, 120. Cronheim, G., Toekes, I. M. J. Pharmacol. 1955, 113, 13. Klohs, M. W., et al. J. Amer. chem. Soc. 1954, 76, 2843. Hershberger, R., Hughes, W., Dennis, E. Proc. Amer, Fed. clin. Res. 1955, 3, 71. 39. Klohs, M. W., et al. J. Amer. chem. Soc. (in the press). 40. Stoll, A., Hofman, A. Ibid, 1955, 77, 820. 41. Cronheim, G., Orcutt, J., Toekes, I. M. Unpublished. 35. 36. 37. 38.