- Email: [email protected]
CERVICAL-ROOT IRRITATION
499 Nurses found to be free of tuberculosis
on
X-ray
examination may have already contracted the disease,
for there may be a long latent period ’between contracting the disease and the appearance of radiographic signs of it. Some persons contract the disease and die of it within a few months of a normal radiograph ; consequently a yearly or even half-yearly examination will only catch disease in the less susceptible or in those infected with the less virulent organism. As an alternative scheme I would suggest that: 1. Only patients with clinical history, signs, and symptoms of disease of -the respiratory tract should be sent for radiography as part of their clinical examination. 2. In the training of nurses in the preliminary school the greatest-attention should be paid to the essentials of nursing. 3. Any money available for the scheme to’prevent nurses contracting tuberculosis should be devoted to the provision of better food and conditions for nurses. 4. No case of open tuberculosis should be admitted to a general hospital, and when discovered in the hospital a case should be transferred as promptly as the patient’s condition and accommodation permit. JAMES F. BRAILSFORD. Birmingham. ,
NICOTINIC-ACID TOLERANCE TEST
SIR,-Since the amount of nicotinic acid by mouth -needed to produce vasodilatation is so variable in a normal subject, the test reported by Dr. Erdei on March 6 is of little value in assessing liver function. If the test he describes is carried out immediately after a meal, at least 500 mg. may be taken by a healthy person without any apparent effect ; whereas 100 mg. taken two or three hours later usually produces in a few minutes a diffuse and unpleasant flushing. Now that nicotinic acid is being widely used as a vasodilator in a variety of conditions, this point is of some importance. I would like to suggest that vasodilatation occurs only when the rate of absorption exceeds the liver’s aminising capacity. G. E. SPEAR. London, S.W.I. GASTRO-ENTERITIS IN INFANTS diarrhoea and vomiting of infants under year of age has been the subject of much discussion.l There seems to be some measure of agreement that otitis media precedes the diarrhoea and that bronchitis or bronchopneumoniaalso occurs at some stage. Many varieties of bacteria have been isolated from these cases and a virus has been suggested as the causal agent.2 In a great many of these very ill children a coagulasepositive staphylococcus has been isolated from the middle ears, lungs, empyema, or rectum at autopsy ; from the nose, throat, or rectum during life ; and, in some cases, from the mastoid, incised ear-drum, or ear discharge at
SlR,—The
one
Treatment with penicillin and/or sulphoneffects considerable improvement, but the mortality is still high. I should like to suggest that staphylococcal antitoxin be tried-preferably in a controlled and extensive series-where pathogenic staphylococci have been isolated from one of these sites at an early stage in the disease ; penicillin and sulphonamides should not be withheld. Staphylococcus enterotoxin would not be neutralised, of course. The use of staphylococcus antitoxin has hitherto not been tried or suggested for these cases, and to that extent its value might be judged hypothetical. But it is known that under certain circumstances staphylococci produce a potent exotoxin, and I ’am of the opinion that the administration of staphylococcal antitoxin might be life-saving in these young children who are unable to manufacture their own immune bodies.3 There was nothing hypothetical about the Bundaberg disaster. FRANK MARSH. Pathological Department, St. Margaret’s Hospital, Epping. 1. Lancet, annotation, 1946, ii, 951. Stern, D. M. Ibid, 1947, i, 80.
operation. amides
Cook, G. T., Marmion, B. P.
Brit. med. J. 1947, ii, 446. the Association of Otitis Media with Acute Non-specific Gastro-enteritis of Infants. Proc. R. Soc. Med.
Discussion
1948, 41, 1.
on
2. Brit. med. J. annotation, 1947, i, 187. 3. Lancet, annotation, 1947 i, 72.
CERVICAL-ROOT IRRITATION
SIR,-I wish to thank Dr. Kelly for his criticism (March 6) of my letter of Dec. 13. I shall attempt to explain why his formidable bibliography loses much of its value. " Enormous and grotesque " osteophytic outgrowths
the anterior surfaces of the vertebral bodies may well exist with no further ill effect than local pain. On the other hand, osteophytes of such " dimensions " encroaching upon the intervertebral foramina (the transverse diameter of which, at rest, never exceeds 1 cm.) are impossible without neurological effects. If the disc gives way, movement at the posterolateral angles of slightly hypermobile contiguous vertebral bodies and large osteophytes which develop at such a site of friction, necessarily endanger the fibres forming the roots. With osteophytes of moderate size, the foramen may still accommodate the root at rest, yet friction and even crushing by the sharp and irregular osteophytes of the root and ganglion may occur during movement. If the whole cervical spine is removed at post mortem it is possible to demonstrate some of the effects of our numerous movements in health. Semmes and Murphey,l who operated under local analgesia on 3 patients for the removal of prolapsed cervical inter-vertebral discs, demonstrated the symptoms of irritation of the root affected ; coronary thrombosis had originally been diagnosed in 2 of these patients, both medical men. Ankylosing spondylitis may be painless, especially in the latest stages when maximal ankylosis occurs if the patient lies completely at rest ; pain occurs during movement. (It may be worth mentioning that von Bechterew’s disease is spondylitis deformans associated with root damage, and not spondylitis ankylopoietica.) Ankylosis of two or more adjacent vertebrae, after separating the component bones forming the intervertebral foramina by prolonged extension, is one method of preventing the crushing of the roots during movement. It also prevents overriding of a vertebral body which may directly or indirectly irritate and then damage the cord, even in cases where the disc has prolapsed laterally. A prolapsed intervertebral disc produces a derangement of the spine. It should not be regarded as the same as a slowly growing extradural tumour ; neurofibromata may even enlarge the intervertebral foramen. The discs are normally an integral part of the spinal column and are essential in maintaining fixation of the spine for movements of the head, ribs, and limbs, and for coordinated activities of the spinal column itself. With prolapse into the spinal canal the disc may act as a suddenly appearing extradural tumour or foreign body to which the related structures have had no opportunity of adapting themselves. Consideration should also be directed to the effects on the spine of the approximation of vertebras by lax muscles and ligaments, the secondary effects of osteophytes and fibrosis (both at rest and during on
and the further damage to roots and weakening of those spinal muscle&bgr; which the roots themselves supply. The frequency with which a prolapsed cervical intervertebral disc is to be found in the many patients complaining of pain in the neck, thorax, and arm has not yet been determined. One feels, however, that the symptoms of cervical-root irritation are often encountered though missed for several The widely distributed loss of muscle-fibres may reasons. even be maximal in those muscles which are least amenable to accurate clinical examination ; hence the patient appears " to suffer from a disease of symptoms rather than of signs." the effects may have developed, our powers of Yet, although recognising them may be at fault. Prolapse of a cervical intervertebral disc may take place alone or together with other prolapses in the cervical or other parts of the spine. Other injuries may be sustained simultaneously and may overshadow the disc lesion. There seems a special tendency to disregard such a lesion when it occurs in a spine previously scoliotic and in which, during middle life, evidence of more generalised osteo-arthritis develops. It is difficult if not impossible to examine in detail the muscles supplied by the posterior primary division, which are extremely important in maintaining local integrity and in coordinated movement of the spine ; and it is also difficult to examine the scalenus medius et posterior, partly supplied by the 7th cervical anterior primary division. All these muscles may be affected bilaterally, in which case there is no basis for comparison ; they may be hidden by other healthy muscles supplied by the spinal accessory and other
movement),
1. Semmes, R. E., Murphey, F.
J. Amer. med. Ass. 1943,
121,
1209.
500 cervical nerves. Then muscles covering the trunk in the form of thick sheets but themselves covered by fat, such as the latissimus dorsi at the back and (especially in women) part of the pectoralis major on the front of the chest, have proved another cause of uncertainty in diagnosis. Where C8 and possibly Tl roots are affected the distal effects upon the limb (more easily measured) have resulted in a diagnosis of peripheral neuritis and in the statement that with this disorder the long nerves to the limbs are usually maximally involved. Because of our inadequacy in testing the integrity of the shorter branches from the roots to the neck and trunk muscles-branches which are anatomically peripheral" nerves-we have interested ourselves chiefly in the long nerves, such as the median, to the forearm and hand. Yet both short and long nerves contain sensory and motor fibres ; the median is, however, further concerned with skin innervation. More attention is paid when an extensor plantar response-evidence of severe cord damage-is obtained. If the paralysis is severe the pain may be entirely cervical, though during the process of its development the 46 vaglie " pains and paraesthesias may be due to irritation of the long tracts in the cord. But whether the damage is slight or severe, osteo-arthritis may yet develop at a later date. This feature should be borne in mind before recording as cured "-the many cases in which symptomatic improvement is obtained after resting the irritated and oedematous roots by keeping the patient iri bed.
invaluable task which he was about to simre with a the doctor. Of course all this effort would tend to the individual patient’s good ; but I would deny even that it should be much more for his sake than for the sake of many other people, such as future patients, medical students, clinical research-workers, pure scientists-mankind in Hence the harmful fallacy in the " Patients’ fact. Hospital." It is the processes which count, and they are for everybody. W. J. PENMAN. Copse Hill, Wimbledon.
I suggest that the diagnosis and successful treatment of root lesions would be most effectively accomplished by considering the combined contributions of experts in the many branches concerned with the problem. To neglect the contributions of any one of them is to perpetuate, if not a neuro-dilemma," at least an incomplete mosaic. I. H. MILNER. London, N.4.
The
’’
neurological
SiR,—I am a male nurse, of 18 months’ experience, who has just finished a period of night duty. An acoount of the last night of that period may be of interest. The staff on duty was : Night sister .
Assistant night sister (a staff nurse) 4 male wards
1 children’s ward
(1student nurse each)
(1student nurse)
"
-
THE PATIENTS’ HOSPITAL
SIR,-The Patients’ Hospital is a contradiction, however admirable the demands made in its name. As we approach this wrong ideal, we find the hospital turning into a kind of hotel. The Doctors’ Hospital is no less of a contradiction. As we approach this equally wrong ideal, we find a club for experimental physiologists. The Occupational Therapists’ Hospital, the Medical Students’ Hospital, and the Clerical Staff’s Hospital (to name a few at random out of many) are contradictions likewise. We shall have made a signal advance when everybody recognises that a hospital neither is " owned " by, nor exists for, any artificial group, but is a place for the carrying out of several difficult processes. The first of these is the collaboration of patient and doctor in a full and careful history and examination. Next come special investigations, and treatment (including,rest) ; but without the first these are futile, and so is every solicitude you please. The measure of a hospital is the facilities which it has for these processes, and the respect which everyone in it accords to them. By this measure, our hospitals do not mbke any great showing : indeed if they were to do so, there would have to be a transformation. Hospitals would be built in quiet places. No sources of loud noise would subsequently be permitted near them : aeroplanes would not be allowed to fly over them. The wards would be small, and to each of them would be attached a supremely important room, the Examining Room. To this every patient who was well enough would be taken for his first interview with the doctor, as well as for any lengthy subsequent interviews. There neither party would be embarrassed by neighbours within earshot, nor by the patient’s public bodily exposure-initigated (more often symbolically than actually) by screens. In the rare instances in which the doctor had to interview the patient in the ward-and they would be rare enough for this to be enforced-there would be real silence. It would be the gravest breach of hospital etiquette for anyone to interrupt, save for urgent reasons, this central function. The doctor would make, and keep, an appointment for the interview ; the nursing staff would have installed the patient in the Examining Room, and would have explained to him the nature of the laborious but
1 " runner " (a student nurse)
5 female wards t student nurse
Maternity unit
each) 1
"
runner
"
a student nurse)
have to assist with " backs," relieve for meals, and fetch and carry generally. Each nurse is supposed to have two breaks of half an hour for meals, between 10 P.JBf. and midnight, and 1.30 A.M. and 3.30 A.M. ; it is obvious that this was impossible on this runners
particular night. I was in charge
of the male acute surgical ward, and the runner for the male wards, was also, fortunately, based on this ward. Events ran as follows : 8 P.M. Read day report and take over from day staff; 23 patients, one very noisy, and trying to get out of bed, 8.15 P.M.. Take 4-hourly one still in operating-theatre.
temperatures. 8.40 P.I. Prepare ward for night and do backs " ; interrupted almost at once by return of patient from theatre (a colostomy aged over 70). 9 P.M. Lights out. Runner departs to assist elsewhere. "
9.45 P.M. Give 3 injections of penicillin and 3 doses of sulphonamide drugs. Runner returns. 10 P.M. Night sister’s round. 10.10 P.M. Send runner to relieve nurses for first break. 10.20 P.M. Message to admit patient, aged 26, with perforated appendix. I prepare accordingly. 10.30 P.M. Abovepatient arrives in ward. 10.40 P.M. Doctor arrives to examine him : patient is for immediate operation. 10.55 P.M. Begin to prepare patient. 11.5 P.M. Runner returns to assist. 11.15 P.M. Give
sedative injection to noisy patient (no effect). 11.20 P.M. Relatives of noisy patient arrive (at least I can take my eyes off him). 11.30 P.M. Runner takes patient to theatre. Prepare bed for return of patient. Speak to visitors. See to
colostomy patient. A.M. Start midnight report (should
12.5
by now).
12.15
have been finished Patient returns from theatre. 12.30 A.M. tea for visitors. Write some more report. A.M.
Runner makes 12.40 A.M. Night sister returns to give noisy patient paraldehyde per rectum. 12.50 A.M. Finish report and hand it in. Visitors depart. 1 A.M. Penicillin injections again (with tea for each victim). Ward now quiet for first time. 1.30 A.M. Go for my supper (15 minutes). Runner then goes to relieve other wards. 2 A.M. Sulphonamides again. Renew a dressing. Give oxygen to colostomy patient (he ought to be sat up now, but I can’t do it on my own).- Attention can now be paid to some of the other patients, neglected all this time. 4 A.M. Penicillin again. Start doing backs of those who happen to be ixi-ake. 5 A.M. Lights on. Start to take all temperatures. Runner gives out washing-bowls, and washes very ill patients. 5.50 A.M. Write additions to report. 6 A.M. Sulphonamides.again. Tea for all patients (luckily an up-patient does this for me-runner is away collecting reports). Finish backs and tidy beds (am supposed to make at least 10 properly : haven’t time). Treatment for certain "
patients-
"
on
X-ray
examination may have already contracted the disease,
for there may be a long latent period ’between contracting the disease and the appearance of radiographic signs of it. Some persons contract the disease and die of it within a few months of a normal radiograph ; consequently a yearly or even half-yearly examination will only catch disease in the less susceptible or in those infected with the less virulent organism. As an alternative scheme I would suggest that: 1. Only patients with clinical history, signs, and symptoms of disease of -the respiratory tract should be sent for radiography as part of their clinical examination. 2. In the training of nurses in the preliminary school the greatest-attention should be paid to the essentials of nursing. 3. Any money available for the scheme to’prevent nurses contracting tuberculosis should be devoted to the provision of better food and conditions for nurses. 4. No case of open tuberculosis should be admitted to a general hospital, and when discovered in the hospital a case should be transferred as promptly as the patient’s condition and accommodation permit. JAMES F. BRAILSFORD. Birmingham. ,
NICOTINIC-ACID TOLERANCE TEST
SIR,-Since the amount of nicotinic acid by mouth -needed to produce vasodilatation is so variable in a normal subject, the test reported by Dr. Erdei on March 6 is of little value in assessing liver function. If the test he describes is carried out immediately after a meal, at least 500 mg. may be taken by a healthy person without any apparent effect ; whereas 100 mg. taken two or three hours later usually produces in a few minutes a diffuse and unpleasant flushing. Now that nicotinic acid is being widely used as a vasodilator in a variety of conditions, this point is of some importance. I would like to suggest that vasodilatation occurs only when the rate of absorption exceeds the liver’s aminising capacity. G. E. SPEAR. London, S.W.I. GASTRO-ENTERITIS IN INFANTS diarrhoea and vomiting of infants under year of age has been the subject of much discussion.l There seems to be some measure of agreement that otitis media precedes the diarrhoea and that bronchitis or bronchopneumoniaalso occurs at some stage. Many varieties of bacteria have been isolated from these cases and a virus has been suggested as the causal agent.2 In a great many of these very ill children a coagulasepositive staphylococcus has been isolated from the middle ears, lungs, empyema, or rectum at autopsy ; from the nose, throat, or rectum during life ; and, in some cases, from the mastoid, incised ear-drum, or ear discharge at
SlR,—The
one
Treatment with penicillin and/or sulphoneffects considerable improvement, but the mortality is still high. I should like to suggest that staphylococcal antitoxin be tried-preferably in a controlled and extensive series-where pathogenic staphylococci have been isolated from one of these sites at an early stage in the disease ; penicillin and sulphonamides should not be withheld. Staphylococcus enterotoxin would not be neutralised, of course. The use of staphylococcus antitoxin has hitherto not been tried or suggested for these cases, and to that extent its value might be judged hypothetical. But it is known that under certain circumstances staphylococci produce a potent exotoxin, and I ’am of the opinion that the administration of staphylococcal antitoxin might be life-saving in these young children who are unable to manufacture their own immune bodies.3 There was nothing hypothetical about the Bundaberg disaster. FRANK MARSH. Pathological Department, St. Margaret’s Hospital, Epping. 1. Lancet, annotation, 1946, ii, 951. Stern, D. M. Ibid, 1947, i, 80.
operation. amides
Cook, G. T., Marmion, B. P.
Brit. med. J. 1947, ii, 446. the Association of Otitis Media with Acute Non-specific Gastro-enteritis of Infants. Proc. R. Soc. Med.
Discussion
1948, 41, 1.
on
2. Brit. med. J. annotation, 1947, i, 187. 3. Lancet, annotation, 1947 i, 72.
CERVICAL-ROOT IRRITATION
SIR,-I wish to thank Dr. Kelly for his criticism (March 6) of my letter of Dec. 13. I shall attempt to explain why his formidable bibliography loses much of its value. " Enormous and grotesque " osteophytic outgrowths
the anterior surfaces of the vertebral bodies may well exist with no further ill effect than local pain. On the other hand, osteophytes of such " dimensions " encroaching upon the intervertebral foramina (the transverse diameter of which, at rest, never exceeds 1 cm.) are impossible without neurological effects. If the disc gives way, movement at the posterolateral angles of slightly hypermobile contiguous vertebral bodies and large osteophytes which develop at such a site of friction, necessarily endanger the fibres forming the roots. With osteophytes of moderate size, the foramen may still accommodate the root at rest, yet friction and even crushing by the sharp and irregular osteophytes of the root and ganglion may occur during movement. If the whole cervical spine is removed at post mortem it is possible to demonstrate some of the effects of our numerous movements in health. Semmes and Murphey,l who operated under local analgesia on 3 patients for the removal of prolapsed cervical inter-vertebral discs, demonstrated the symptoms of irritation of the root affected ; coronary thrombosis had originally been diagnosed in 2 of these patients, both medical men. Ankylosing spondylitis may be painless, especially in the latest stages when maximal ankylosis occurs if the patient lies completely at rest ; pain occurs during movement. (It may be worth mentioning that von Bechterew’s disease is spondylitis deformans associated with root damage, and not spondylitis ankylopoietica.) Ankylosis of two or more adjacent vertebrae, after separating the component bones forming the intervertebral foramina by prolonged extension, is one method of preventing the crushing of the roots during movement. It also prevents overriding of a vertebral body which may directly or indirectly irritate and then damage the cord, even in cases where the disc has prolapsed laterally. A prolapsed intervertebral disc produces a derangement of the spine. It should not be regarded as the same as a slowly growing extradural tumour ; neurofibromata may even enlarge the intervertebral foramen. The discs are normally an integral part of the spinal column and are essential in maintaining fixation of the spine for movements of the head, ribs, and limbs, and for coordinated activities of the spinal column itself. With prolapse into the spinal canal the disc may act as a suddenly appearing extradural tumour or foreign body to which the related structures have had no opportunity of adapting themselves. Consideration should also be directed to the effects on the spine of the approximation of vertebras by lax muscles and ligaments, the secondary effects of osteophytes and fibrosis (both at rest and during on
and the further damage to roots and weakening of those spinal muscle&bgr; which the roots themselves supply. The frequency with which a prolapsed cervical intervertebral disc is to be found in the many patients complaining of pain in the neck, thorax, and arm has not yet been determined. One feels, however, that the symptoms of cervical-root irritation are often encountered though missed for several The widely distributed loss of muscle-fibres may reasons. even be maximal in those muscles which are least amenable to accurate clinical examination ; hence the patient appears " to suffer from a disease of symptoms rather than of signs." the effects may have developed, our powers of Yet, although recognising them may be at fault. Prolapse of a cervical intervertebral disc may take place alone or together with other prolapses in the cervical or other parts of the spine. Other injuries may be sustained simultaneously and may overshadow the disc lesion. There seems a special tendency to disregard such a lesion when it occurs in a spine previously scoliotic and in which, during middle life, evidence of more generalised osteo-arthritis develops. It is difficult if not impossible to examine in detail the muscles supplied by the posterior primary division, which are extremely important in maintaining local integrity and in coordinated movement of the spine ; and it is also difficult to examine the scalenus medius et posterior, partly supplied by the 7th cervical anterior primary division. All these muscles may be affected bilaterally, in which case there is no basis for comparison ; they may be hidden by other healthy muscles supplied by the spinal accessory and other
movement),
1. Semmes, R. E., Murphey, F.
J. Amer. med. Ass. 1943,
121,
1209.
500 cervical nerves. Then muscles covering the trunk in the form of thick sheets but themselves covered by fat, such as the latissimus dorsi at the back and (especially in women) part of the pectoralis major on the front of the chest, have proved another cause of uncertainty in diagnosis. Where C8 and possibly Tl roots are affected the distal effects upon the limb (more easily measured) have resulted in a diagnosis of peripheral neuritis and in the statement that with this disorder the long nerves to the limbs are usually maximally involved. Because of our inadequacy in testing the integrity of the shorter branches from the roots to the neck and trunk muscles-branches which are anatomically peripheral" nerves-we have interested ourselves chiefly in the long nerves, such as the median, to the forearm and hand. Yet both short and long nerves contain sensory and motor fibres ; the median is, however, further concerned with skin innervation. More attention is paid when an extensor plantar response-evidence of severe cord damage-is obtained. If the paralysis is severe the pain may be entirely cervical, though during the process of its development the 46 vaglie " pains and paraesthesias may be due to irritation of the long tracts in the cord. But whether the damage is slight or severe, osteo-arthritis may yet develop at a later date. This feature should be borne in mind before recording as cured "-the many cases in which symptomatic improvement is obtained after resting the irritated and oedematous roots by keeping the patient iri bed.
invaluable task which he was about to simre with a the doctor. Of course all this effort would tend to the individual patient’s good ; but I would deny even that it should be much more for his sake than for the sake of many other people, such as future patients, medical students, clinical research-workers, pure scientists-mankind in Hence the harmful fallacy in the " Patients’ fact. Hospital." It is the processes which count, and they are for everybody. W. J. PENMAN. Copse Hill, Wimbledon.
I suggest that the diagnosis and successful treatment of root lesions would be most effectively accomplished by considering the combined contributions of experts in the many branches concerned with the problem. To neglect the contributions of any one of them is to perpetuate, if not a neuro-dilemma," at least an incomplete mosaic. I. H. MILNER. London, N.4.
The
’’
neurological
SiR,—I am a male nurse, of 18 months’ experience, who has just finished a period of night duty. An acoount of the last night of that period may be of interest. The staff on duty was : Night sister .
Assistant night sister (a staff nurse) 4 male wards
1 children’s ward
(1student nurse each)
(1student nurse)
"
-
THE PATIENTS’ HOSPITAL
SIR,-The Patients’ Hospital is a contradiction, however admirable the demands made in its name. As we approach this wrong ideal, we find the hospital turning into a kind of hotel. The Doctors’ Hospital is no less of a contradiction. As we approach this equally wrong ideal, we find a club for experimental physiologists. The Occupational Therapists’ Hospital, the Medical Students’ Hospital, and the Clerical Staff’s Hospital (to name a few at random out of many) are contradictions likewise. We shall have made a signal advance when everybody recognises that a hospital neither is " owned " by, nor exists for, any artificial group, but is a place for the carrying out of several difficult processes. The first of these is the collaboration of patient and doctor in a full and careful history and examination. Next come special investigations, and treatment (including,rest) ; but without the first these are futile, and so is every solicitude you please. The measure of a hospital is the facilities which it has for these processes, and the respect which everyone in it accords to them. By this measure, our hospitals do not mbke any great showing : indeed if they were to do so, there would have to be a transformation. Hospitals would be built in quiet places. No sources of loud noise would subsequently be permitted near them : aeroplanes would not be allowed to fly over them. The wards would be small, and to each of them would be attached a supremely important room, the Examining Room. To this every patient who was well enough would be taken for his first interview with the doctor, as well as for any lengthy subsequent interviews. There neither party would be embarrassed by neighbours within earshot, nor by the patient’s public bodily exposure-initigated (more often symbolically than actually) by screens. In the rare instances in which the doctor had to interview the patient in the ward-and they would be rare enough for this to be enforced-there would be real silence. It would be the gravest breach of hospital etiquette for anyone to interrupt, save for urgent reasons, this central function. The doctor would make, and keep, an appointment for the interview ; the nursing staff would have installed the patient in the Examining Room, and would have explained to him the nature of the laborious but
1 " runner " (a student nurse)
5 female wards t student nurse
Maternity unit
each) 1
"
runner
"
a student nurse)
have to assist with " backs," relieve for meals, and fetch and carry generally. Each nurse is supposed to have two breaks of half an hour for meals, between 10 P.JBf. and midnight, and 1.30 A.M. and 3.30 A.M. ; it is obvious that this was impossible on this runners
particular night. I was in charge
of the male acute surgical ward, and the runner for the male wards, was also, fortunately, based on this ward. Events ran as follows : 8 P.M. Read day report and take over from day staff; 23 patients, one very noisy, and trying to get out of bed, 8.15 P.M.. Take 4-hourly one still in operating-theatre.
temperatures. 8.40 P.I. Prepare ward for night and do backs " ; interrupted almost at once by return of patient from theatre (a colostomy aged over 70). 9 P.M. Lights out. Runner departs to assist elsewhere. "
9.45 P.M. Give 3 injections of penicillin and 3 doses of sulphonamide drugs. Runner returns. 10 P.M. Night sister’s round. 10.10 P.M. Send runner to relieve nurses for first break. 10.20 P.M. Message to admit patient, aged 26, with perforated appendix. I prepare accordingly. 10.30 P.M. Abovepatient arrives in ward. 10.40 P.M. Doctor arrives to examine him : patient is for immediate operation. 10.55 P.M. Begin to prepare patient. 11.5 P.M. Runner returns to assist. 11.15 P.M. Give
sedative injection to noisy patient (no effect). 11.20 P.M. Relatives of noisy patient arrive (at least I can take my eyes off him). 11.30 P.M. Runner takes patient to theatre. Prepare bed for return of patient. Speak to visitors. See to
colostomy patient. A.M. Start midnight report (should
12.5
by now).
12.15
have been finished Patient returns from theatre. 12.30 A.M. tea for visitors. Write some more report. A.M.
Runner makes 12.40 A.M. Night sister returns to give noisy patient paraldehyde per rectum. 12.50 A.M. Finish report and hand it in. Visitors depart. 1 A.M. Penicillin injections again (with tea for each victim). Ward now quiet for first time. 1.30 A.M. Go for my supper (15 minutes). Runner then goes to relieve other wards. 2 A.M. Sulphonamides again. Renew a dressing. Give oxygen to colostomy patient (he ought to be sat up now, but I can’t do it on my own).- Attention can now be paid to some of the other patients, neglected all this time. 4 A.M. Penicillin again. Start doing backs of those who happen to be ixi-ake. 5 A.M. Lights on. Start to take all temperatures. Runner gives out washing-bowls, and washes very ill patients. 5.50 A.M. Write additions to report. 6 A.M. Sulphonamides.again. Tea for all patients (luckily an up-patient does this for me-runner is away collecting reports). Finish backs and tidy beds (am supposed to make at least 10 properly : haven’t time). Treatment for certain "
patients-
"