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BILIGRAFIN FOR HYSTEROSALPINGOGRAPHY
785 "
As to detailed histological changes and " mixed types to which your leading article refers, type-ii nephritis sometimes shows exacerbations during its course and hsematuria, may well occur. In such a case, or even where coritinued activity has been indicated by persistent microscopic hsematuria, epithelial crescent formation may be seen in a few glomeruli. Ellis was not concerned to show that any individual lesion of the glomerulus was ,specific for a particular type of nephritis ; he attempted rather to demonstrate that the pattern and progress of histological change had a separate natural history in the two types, which corresponded to the clinical picture. There is a close analogy with the two manifestations of rheumatism which we call acute rheumatic fever and rheumatoid arthritis. The separation of these as two distinct forms of collagen disease is in no way invalidated because occasionally patients with rheumatoid arthritis are found to have rheumatic carditis, or because in both disorders acute fibrinoid necrosis may be found in the tissues, or because there are (as in nephritis) indeterminate forms which merge into the other collagen diseases. The old terms " acute haemorrhagic nephritis " and "subacute cedematous nephritis " have, as they had fifty years ago, a certain descriptive value in relation to "cross-sections" of Bright’s ’disease, but they convey nothing of course or prognosis and they remain unsatisfactory because the syndromes they describe may be due to different pathological processes. HORACE EVANS The London Hospital CLIFFORD WILSON. E.1. POLIOMYELITIS AND THE SEASONS SIR,-Dr. Warren Browne’s letter last week raises again the vexed question of the free supply of washing facilities in public lavatories. It is gratifying to learn that in his own city free washing facilities are available. This must be a rare arrangement ; yet what ordinary person is going to spend 3d. on what he probably regards Exhortations on doors and as an unnecessary fill‘? walls to " wash your hands now please " are unlikely to be heeded so long as their fulfilment causes an added
financial
outlay.
London, N.W.9.
J. D. OWEN.
SHORTAGE OF MIDWIVES
SiR,-I think that Mr. Terence Robinson (Sept. 8) is right in
saying that the future of the maternity services depends adequate number of trained midwives. The reason for the present shortage of midwives is that apprehensive obstetricians up and down the country on an
incentive to trained midwives to use their knowledge to the full. In most parts of the country 75% of patients are delivered in hospitals. These hospitals have insufficient staff and beds to cope with such a large turnover of patients. The result is that patients have to be discharged early and hospital midwives see their patients for no longer than 2-7 days after delivery ; while the district midwives have a sense of frustration from having to nurse so many patients delivered in hospital and very few of their own delivered on the district. As for the pupil midwives, I agree with Mr. Robinson that there might be some introduction to midwifery during general training, to stimulate their interest. As it is, they see in part i large numbers of abnormal cases in the treatment of which they are not allowed to participate. The turnover of patients being so great, no-one has time to give the pupils any individual attention which would help to allay their apprehensions. This makes them thoroughly frightened of going on with their training or of having a baby themselves. So,
give
as
no
many
the first-part training, they refuse to take the second part and thereby
jobs require only
naturally become fully trained.
If the attitude of doctors is that district midwives are longer necessary, and that hospital midwives are to be only " maternity nurses " who are overworked because of the rapid turnover, then why, says the nurse, should I take the trouble to train as a midwife ?
no
BERYL D. THOMAS of District Midwives’ Home.
Royal Nursing Institute,
Superintendent
London Road, Derby.
INSULIN AND CHLORPROMAZINE IN SCHIZOPHRENIA
SiR,-We read with great interest Dr. May’s letter (Sept. 22) criticising our article. We agree with some of his comments, but after all we made no very extravagant claims. We feel that some of his points cannot be left unanswered.
Firstly, the shorter stay in hospital of chlorpromazinetreated patients cannot simply be explained by the imponderable factor of further treatment, for either fewer patients in the chlorpromazine group needed further treatment or they needed a shorter course of this. Secondly, our paper dealt with an investigation into the treatment of schizophrenia, certain data of which were subjected to the X2 test. This procedure does not invalidate other conclusions appertaining to data assessed nonstatistically. Thirdly, Dr. May reiterates much of what we had already stressed in regard to past investigations and their shortcomings. We would draw his attention to the fact that all our conclusions were in fact based on immediate results only, and that we had embarked on a two-year follow-up of all the cases so investigated. This already suggests that, in the thirty cases so far interviewed, chlorpromazine is in fact the better form of treatment. Lastly, Dr. May does not consider the observation that we felt most needful of emphasis. There is nothing in our study to suggest that insulin has any advantages over chlorpromazine, and the latter is undoubtedly a safer and simpler form
of
therapy. R. H. BOARDMAN J. LOMAS MORRIS MARKOWE.
Springfield Hospital London, S.W.17.
BILIGRAFIN FOR HYSTEROSALPINGOGRAPHY can confirm views expressed by Mr. and Dr. Sheach (Sept. 29).’Biligrafin’ would appear to be quite satisfactory as a hysterogram medium 1; in fact we use the more concentratedEndografin ’ with no untoward effects. In Professor J effcoate’s unit the medium has now been used in some 30 cases with good results. We have investigated the mode of excretion by means of serial films, and the findings confirm the accepted view that excretion is into the gastroThe bile-ducts and gall-bladder fill intestinal tract. rapidly and this fact is of some practical value in the investigation ; so far we have not demonstrated the medium in the urinary tract as described by your correspondents. It is true that pelvic collections seen 30-45 minutes after injection can look like the bladder, and it is also true that vaginal shadows are seen if the medium is not removed from the fornices, but these should be readily distinguishable from a cystogram.
SIR,-We
MacGregor
D. N. MENZIES.
Liverpool Royal Infirmary.
APHONIA ASSOCIATED WITH TUBERCULOSIS
SiR,-The following In 1950 the
case
is somewhat unusual:
then aged 49, was found by patient, radiography to have pulmonary tuberculosis, of which he had no symptoms. Thereafter he was admitted to hospital more than once and received large amounts of antituberculous drugs. On Nov. 11, 1955, he was admitted to Holywell Hospital because of poor general condition and dyspnoea, and a course of antituberculous drugs was started. Radiography at the time of admission showed " contracted left lung with considerable disease in all zones and pneumonic a man
mass
1.
Menzies, D. N.
J. Obstet. Gynœc., Brit. Emp. (in the press).
As to detailed histological changes and " mixed types to which your leading article refers, type-ii nephritis sometimes shows exacerbations during its course and hsematuria, may well occur. In such a case, or even where coritinued activity has been indicated by persistent microscopic hsematuria, epithelial crescent formation may be seen in a few glomeruli. Ellis was not concerned to show that any individual lesion of the glomerulus was ,specific for a particular type of nephritis ; he attempted rather to demonstrate that the pattern and progress of histological change had a separate natural history in the two types, which corresponded to the clinical picture. There is a close analogy with the two manifestations of rheumatism which we call acute rheumatic fever and rheumatoid arthritis. The separation of these as two distinct forms of collagen disease is in no way invalidated because occasionally patients with rheumatoid arthritis are found to have rheumatic carditis, or because in both disorders acute fibrinoid necrosis may be found in the tissues, or because there are (as in nephritis) indeterminate forms which merge into the other collagen diseases. The old terms " acute haemorrhagic nephritis " and "subacute cedematous nephritis " have, as they had fifty years ago, a certain descriptive value in relation to "cross-sections" of Bright’s ’disease, but they convey nothing of course or prognosis and they remain unsatisfactory because the syndromes they describe may be due to different pathological processes. HORACE EVANS The London Hospital CLIFFORD WILSON. E.1. POLIOMYELITIS AND THE SEASONS SIR,-Dr. Warren Browne’s letter last week raises again the vexed question of the free supply of washing facilities in public lavatories. It is gratifying to learn that in his own city free washing facilities are available. This must be a rare arrangement ; yet what ordinary person is going to spend 3d. on what he probably regards Exhortations on doors and as an unnecessary fill‘? walls to " wash your hands now please " are unlikely to be heeded so long as their fulfilment causes an added
financial
outlay.
London, N.W.9.
J. D. OWEN.
SHORTAGE OF MIDWIVES
SiR,-I think that Mr. Terence Robinson (Sept. 8) is right in
saying that the future of the maternity services depends adequate number of trained midwives. The reason for the present shortage of midwives is that apprehensive obstetricians up and down the country on an
incentive to trained midwives to use their knowledge to the full. In most parts of the country 75% of patients are delivered in hospitals. These hospitals have insufficient staff and beds to cope with such a large turnover of patients. The result is that patients have to be discharged early and hospital midwives see their patients for no longer than 2-7 days after delivery ; while the district midwives have a sense of frustration from having to nurse so many patients delivered in hospital and very few of their own delivered on the district. As for the pupil midwives, I agree with Mr. Robinson that there might be some introduction to midwifery during general training, to stimulate their interest. As it is, they see in part i large numbers of abnormal cases in the treatment of which they are not allowed to participate. The turnover of patients being so great, no-one has time to give the pupils any individual attention which would help to allay their apprehensions. This makes them thoroughly frightened of going on with their training or of having a baby themselves. So,
give
as
no
many
the first-part training, they refuse to take the second part and thereby
jobs require only
naturally become fully trained.
If the attitude of doctors is that district midwives are longer necessary, and that hospital midwives are to be only " maternity nurses " who are overworked because of the rapid turnover, then why, says the nurse, should I take the trouble to train as a midwife ?
no
BERYL D. THOMAS of District Midwives’ Home.
Royal Nursing Institute,
Superintendent
London Road, Derby.
INSULIN AND CHLORPROMAZINE IN SCHIZOPHRENIA
SiR,-We read with great interest Dr. May’s letter (Sept. 22) criticising our article. We agree with some of his comments, but after all we made no very extravagant claims. We feel that some of his points cannot be left unanswered.
Firstly, the shorter stay in hospital of chlorpromazinetreated patients cannot simply be explained by the imponderable factor of further treatment, for either fewer patients in the chlorpromazine group needed further treatment or they needed a shorter course of this. Secondly, our paper dealt with an investigation into the treatment of schizophrenia, certain data of which were subjected to the X2 test. This procedure does not invalidate other conclusions appertaining to data assessed nonstatistically. Thirdly, Dr. May reiterates much of what we had already stressed in regard to past investigations and their shortcomings. We would draw his attention to the fact that all our conclusions were in fact based on immediate results only, and that we had embarked on a two-year follow-up of all the cases so investigated. This already suggests that, in the thirty cases so far interviewed, chlorpromazine is in fact the better form of treatment. Lastly, Dr. May does not consider the observation that we felt most needful of emphasis. There is nothing in our study to suggest that insulin has any advantages over chlorpromazine, and the latter is undoubtedly a safer and simpler form
of
therapy. R. H. BOARDMAN J. LOMAS MORRIS MARKOWE.
Springfield Hospital London, S.W.17.
BILIGRAFIN FOR HYSTEROSALPINGOGRAPHY can confirm views expressed by Mr. and Dr. Sheach (Sept. 29).’Biligrafin’ would appear to be quite satisfactory as a hysterogram medium 1; in fact we use the more concentratedEndografin ’ with no untoward effects. In Professor J effcoate’s unit the medium has now been used in some 30 cases with good results. We have investigated the mode of excretion by means of serial films, and the findings confirm the accepted view that excretion is into the gastroThe bile-ducts and gall-bladder fill intestinal tract. rapidly and this fact is of some practical value in the investigation ; so far we have not demonstrated the medium in the urinary tract as described by your correspondents. It is true that pelvic collections seen 30-45 minutes after injection can look like the bladder, and it is also true that vaginal shadows are seen if the medium is not removed from the fornices, but these should be readily distinguishable from a cystogram.
SIR,-We
MacGregor
D. N. MENZIES.
Liverpool Royal Infirmary.
APHONIA ASSOCIATED WITH TUBERCULOSIS
SiR,-The following In 1950 the
case
is somewhat unusual:
then aged 49, was found by patient, radiography to have pulmonary tuberculosis, of which he had no symptoms. Thereafter he was admitted to hospital more than once and received large amounts of antituberculous drugs. On Nov. 11, 1955, he was admitted to Holywell Hospital because of poor general condition and dyspnoea, and a course of antituberculous drugs was started. Radiography at the time of admission showed " contracted left lung with considerable disease in all zones and pneumonic a man
mass
1.
Menzies, D. N.
J. Obstet. Gynœc., Brit. Emp. (in the press).