THE FUTURE OF NURSING

480 health services passed to the London Council as the local health authority under the County National Health Service Act, 1946.

sensitivity to tuberculin. For this reason alone we would not regard this test as reliable. Secondly, in several cases there was no difference-

Public Health Department, V. FREEMAN Metropolitan Borough of Islington, Medical Officer of Health. London, N.1.

very little difference—between the reaction to P.P.D. and the reaction to the vehicle alone ; indeed, in one case the latter was the greater ! Thirdly, after six months some patients still have a dusky red indurated area about half an inch in diameter which shows no signs of disappearing. Although painless, this is aesthetically very unpopular and is probably the greatest disadvantage of depot tuberculin. I am drawing attention to our results because others may encounter the same difficulties. We do not feel we can recommend this technique at present.

for the

personal

TOWARDS PREVENTING SUICIDE

SIR,—We should like to thank correspondents who have written concerning our paper " Towards Preventing Suicide." We set out to establish that more common admission to hospital is one effective answer. to the increasing total mortality from suicide. To achieve this we concluded that changes must be brought about in public attitude and professional awareness. It was not our purpose in a short article to discuss either the aetiology or the prevention of suicide in a comprehensive way, and it was not suggested that admission to a mental hospital is the only worth-while preventive measure. If our figures are representative of what happens in the country as a whole, it means that of an annual total of about 5000 suicides, 2650 are not under medical care at the critical time, but 2000 are under medical care including 500 who have been seen by a psychiatrist but not admitted to hospital. Admission may have been advised and refused ; and it may be the right decision in individual cases, after full assessment, not to advise admission to hospital. But these figures suggest that admission is not achieved sufficiently often, and either the patient or perhaps the doctor too often contracts out of the best proven method of preventing suicide. R. W. PARNELL IAN SKOTTOWE. Warneford Hospital, Oxford. DEPOT TUBERCULIN

SIR,—Last May Dr. James and Dr. Pepys described

technique for giving purified protein derivative of tuberculin (P.P.D.) in an emulsion of light liquid paraffin and anhydrous lanolin, as a tuberculin test.1 This " depot tuberculin " remained in the skin for two or three months and became " positive " as the patient’s allergy developed ; or, if the patient was a positive reactor, it gave a reaction in forty-eight hours. The method seemed to have an important bearing on B.c.G. work, and indeed Dr. James and Dr. Pepys had used it in conjunction with B.C.G. in 9 cases. If depot tuberculin were given at the same time as B.C.G. vaccination, the result could be read at the same time as the vaccination was inspected, thereby simplifying procedure. The authors had seen no non-specific oily reactions, and said that the positive result disappeared within three months. This has not been our experience at Great Ormond Between May and November, 1956, we gave Street. to 200 people (142 newborns, 38 older P.P.D. depot children, and 20 adults) with the following results : a

or

B.C.G. Clinic, Hospital for Sick Children, Great Ormond Street, London, W.C.1.

MARCIA HALL.

THE FUTURE OF NURSING

SIR,—Dr. Thomas Anderson’s latest letter (Feb. 9)

against my laziness in not writing before. The majority of student nurses do not possess the intellectual capacity for university training and few receive financial support from their parents after leaving school. They are anxious to engage in practical nursing as soon as possible without lengthy preliminary academic training; for such, the present State training is perfectly adequate and they rapidly realise their prime ambition, whichis spurs

the emotional satisfaction of nursing the sick patient. There would be a severe drop in the general entry to nursing if a university-trained cadre was available; the simple S.R.N. would feel hopeless of ever attaining high rank in her calling and no longer would a matron’s baton be present in any probationer’s knapsack. Already an excessive theoretical knowledge is demanded: my lectures in surgery to nurses are up to Conjoint diploma level. No-one can decide a nurse’s future quality at the age of 18, and her outlook and possible late mental development may make her a very different person at 21. The advanced course of training should be available after general training has been completed-at the stage of being about to take a ward sister’s post when such a course would be of great value. A nurse will always be subordinate to the doctor because he will always dictate the main line of treatment and take the major responsibility. If a nurse finds her work intellectually unsatisfying then she should (as many have) embark on medicine. At all costs let us avoid the appalling hybrid of nurse cum doctor as envisaged by one of your correspondents of senior nursing rank; though Miss Edwards’s wise letter was a reassuring counterbalance.

ERIC DOLTON.

SIR,—One month after my 18th birthday I entered the

preliminary training school of a large teaching hospital in Cape Town. Six weeks later I was sent to 5, surgical ward as its mostjunior nurse and spent by far the greater part of my time making beds, giving out bedpans, keeping the sluiceroom clean, and washing dirty bedlinen. We were also required to do a certain amount of purely domestic work, such as dusting and washing-up. After two months of this I still felt exhausted every evening

(one was almost never off duty dead on time), but as the atmosphere of the ward was cheerful and few, of the cases doubts about carrying on. I was then sent on extra relief-a job which involved moving round from ward to ward wherever additional help was needed, and one which usually went to the most junior nurse on duty. During my first three weeks of this I nursed the following a two-and-a-half-year-old girl dying of tuberculous cases : meningitis ; a young man in the terminal stages of laryngeal carcinoma whom I specialled for three nights until he died; and a case of advanced pemphigus who smelt so appalling that joss-sticks were burnt in the room. Every morning I was required to change and sluice his linen and every morning chronic I had

night duty

Thus no fewer than 47

cases out of 200 were negative in the oily vehicle, although positive Mantoux reactions demonstrated that the patients had developed

to

P.P.D.

1. James, D.

G., Pepys, J. Lancet, 1956, i, 602.

no

as an

481 I was sick. What made things a great deal worso was that there was virtually nothingI could do to help any of the throe. At the end of the three weeks I went to my family doctor who was the only person with whom I felt I coutd discuss things, and told him what I had been doing and that, -1 fctt I could not carry on. Other girls might bo ablo to cope, hut I had had too much. He told mo that if I could stick it, I should as I would never come across anything worso. 1 took his advice, found that what he had said was truo, and finished my training. One does not wish to give too gloomy a picturo. During those three and a half years I enjoyed myself a great deal, I never both on and off duty, and made many friends. regretted for long my decision to stay. But during that first on the whole very unhappy year I worked under only one ward sister who tried to help me as an individual and who taught me what nursing could be at all levels.

Now I have a very small daughter, and if she should wish to become a nurse I shall try to dissuade her from starting until she is 21-that is unless all the people, matrons, sisters, tutors, and particularly doctors, who are concerned with the training of student nurses, have made a real and sympathetic attempt to understand the special problems they are called upon to face. CLODAGH WILKINSON. " REGISTRARS "

SIR,—Since hospital registrars no longer compile the register, could they not revert to the title of assistant-first, chief, senior, junior, medical, surgical, or what vou will ? St. Mary’s Hospital. London, W.2.

A. J. HARROLD.

MULTIPLE PRIMARY GROWTHS

SIR,—For a patient to have three primary growths removed from different organs all in one year must be uncommon.

A woman, aged 62, was admitted to Hackney Hospital on Jan. 19, 1956, with a two-month history suggestive of pyloric stenosis. Barium-meal examination confirmed this, and at laparotomy on Jan. 27 a mobile carcinoma of’ the pyloric antrum was found with no apparent local or distal spread. In addition there was a mobile carcinoma of the caecum. Partial gastrectomy was undertaken, but owing to the patient’s poor general condition it was decided to removethe cæcal growth later. Convalescence was protracted, and it was not until March that she was regarded as fit for further operation. On March9 right hemicolectomy was undertaken and bowel continuity was restored by an end-to-side anastomosis. On this occasion, as previously, no abnormality was found in the pelvis. Convalescence was uneventful, and she was discharged on April 25. On Aug. 23 she attended the surgical outpatient clinic, complaining of slight loss of blood per vaginam twice during the past three months. On examination there were no abnormal physical signs, but dilatation and curettage on Sept. 14 showed a well-differentiated adenocarcinoma. On Sept. 28 total hysterectomy and bilateral salpingo-oophorectomy was undertaken. The uterus showed a raised ulcerated area 1/2 X 1/2 in. on the posterior wall of’ the fundus with no extension to the peritoneum or myometrium. The patient’s convalescence was uneventful and she was discharged on Oct. 22. When last seen as an outpatient on Nov. 15 she appeared quite well, having no trouble with her bowels and an excellent appetite.

The relevant

pathological reports

were

as

follows :

Stomach.-An irregular prepyloric ulcer 9 X6 cm. with hard edges ; microscopically, a moderately well differentiated adenocarcinoma with few mitoses. Cœcum.—An ulcerating growth 3 X 4 cm. reaching the serosal surface,

apparently involving no glands; microscopically, a poorly differentiated adenocareinoma, not extending to the serosal surface in the portion examined. Ute,rus.-A thickened area of endomotrium near the fundus 1-5 cm. in diameter ; microscopically, a well-differentiated adenocareinoma. R. F. READ. Hackney Hospital, London, E.9.

" DOCTOR "

SIR, — Your leadiry article of Feb. 16 does not do

justice

to Hie

Whether

spirit

of the

quotation with

which it, closes.

man "thinketh hi his heart" that he is

a.

doctor, or a phyeician aud surgeon, or a tnerlic;ml officer will uot, I think, be likely to affect what he is. The surgeon who profers to he called "Mister" may recognise, irr his heart, that. he can assume no higher title than that of a man. C. M. SMALL. a

ACUTE POLYNEURITIS TREATED WITH CORTISONE

SIR, — Following upon the report bv Dr. Graveson

(Feb. 1(i)

of the successful

use

of cortisone in acute

neuritis, it may be of interest to record of

neuritis

serum

which

quickly

an

resolved

polyexample following

prednisone therapy. The patient, a man aged 37, injured his thumb and was given an injection of’ anti-tetanus serum on the next day. Eight days after the inoculation he had an acute systemic reaction, with fever, generalised body pains, and a diffuse erythematous macular rash which lasted twenty-four hours. The generalised body pains cleared in two days but severe pain persisted in the right shoulder, and the musculature of the shoulder-girdle, especially the deltoid, was very weak. The C.S.F. obtained by lumbar puncture showed : cells 17 per c.mm., protein 90 mg. per 100 ml., globulin + +, and Lange 1223330000. Oral prednisone5 mg. six-hourly was prescribed. «’ithin a day the pain had cleared. Muscular power returned to almost normal in ten days. The dosage of prednisone was tapered off and discontinued after three weeks. A repeat of the c.s.r. examination ten days after the original lumbar puncture revealed : cells 5 per c.mm., protein 50 mg. per 100 ml., globulin -, and Lange 1110000000.

The concept of acute polyneuritis as an allergic manifestation and the general agreement that neurological sequels of serum therapy have a similar basis1 suggest that steroid therapy, promptly administered, may prevent irreversible damage in serum neuropathy. Victoria

Hospital, Burnley, Lanes.

J. SHAFAR. HEAD INJURIES

SIR,—Mr. T. G. Lowden (Jan. 12), writing about patients with head injuries admitted to peripheral hospitals, asks what should guide us in deciding whether to send on a case, to ask a neurosurgeon out to see it, or to get on with it ourselves." May I suggest that there is one kind of case which the local surgeon should get on with himself. It is the patient who sustains a head injury without impairment of consciousness or with only momentary impairment, who is apparently well for an hour or so, and who then complains of headache or vomits or becomes drowsy or exhibits any neurological sign. Such a sequence must suggest an extradural haemorrhage and there is no time to transfer the patient or to summon a neurosurgeon. Many fruitless journeys into the country have convinced me that the local surgeon must assume responsibility for such cases. He may be diffident in tackling them for two reasons : (1) he feels that he has not enough neurological experience to be with the sure of the diagnosis ; (2) I he is unfamiliar out that the clinical operative technique. May point when the certain is is near death. only patient diagnosis The only way to make certain before that stage is to make The rule is : a burr-hole on an exploratory burr-hole. an when the suspicion is confirmed. operation suspicion, If the surgeon looks on a burr-hole as a purely diagnostic procedure, not as an operation, he will be much more likely to tackle these cases early. The surgical technique "

dealing with a middle-meningeal lmernorcould be rhage acquired by any general surgeon who takes a week off to loiter in a neurosurgical centre. When necessary for

1. Brit. med. J.

1956, i, 972.