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DONOR EYES
274 welfare services available to the elderly; (c) radical changes in policies of employment and retirement of reasonably healthy elderly people; and, last but not least, (d) an all-out effort in investigating, and implementing, what may be termed " biochemical prophylaxis ". The latter should apply not to cases of senile dementia or severe atherosclerosis but to the reasonably fit, to those who, as Dr. Kemp says, having dodged most of the lethal illnesses and having reached 70 have every prospect of living 10 or 20 years longer. It seems to me that if various leads which are emerging about the slight but progressive alterations with age of metabolic balance in the organism were properly followed up, some quite fundamental ways of preserving healthy function and activity in old age could be in sight. A reversal of some, or many, such alterations could, conceivably, be achieved by acting on the biochemical processes of the organism. In conclusion, I should like to ask for enlightenment. Through what channels and by what measures could positive and effective action be taken to translate any, or all, of the above suggestions from theory into practice, in our lifetime ? Medical Research Council, Experimental Radiopathology Research Unit, Hammersmith Hospital, London, W.12.
IRENE GORE.
DONOR EYES SiR,—The demand for corneal graft material exceeds the supply by a quite unnecessary amount. This, surely, is the outstanding conclusion of Sir Benjamin Rycroft’s article (Jan. 20), which concerns us all. I have noticed two
preliminary obstacles
to
achieving
a
plentiful supply.
The first is the difficulty of remembering at the time of death. This must usually rest with the ward sister in hospital, and the family’s doctor at home. It will probably be some long time before the public at large become accustomed to think of corneal bequests at a time of bereavement when so many other thoughts abound. And this first step is all important. Many more eyes must have been wasted because no one sought to use them, than from telephone messages going astray. The second obstacle will be eased as more voluntary bequests are made, but even now I think it is overestimated. This is the unpleasantness of asking. A large part of the potential material that passes unused is the result of well-meaning attendants remembering to ask, and then not doing so for fear of adding further to the relatives’ distress. My experience has been exactly the opposite in all but one of thirty instances. On many occasions despairing relatives have been cheered by the comfort of knowing that out of their bereavement, another may have sight restored.
Remove these two hindrances, and the facilities which now exist for the collection of donor eyes could bring the supply much nearer to the demand. HUGH CARPENTER. London, N.W.7. CRISIS IN NURSING
SIR,-It is welcome to read of the recognition, in your columns, of the crisis in nursing; but I do not think the actions of the General Nursing Council have led to its precipitation. The causes are deeper and socioeconomic. It is
that Dr. Arden Jones and Mr. Tagart (Jan. meagre educational requirements of the G.N.C. as " over-ambitious educational ideals ". The requirement is, in fact, 2 passes at 0 level in G.C.E., or its equivalent, which, in these days of educational opportunity can hardly be regarded as unattainable for those who wish to go on to posts as ward sisters, matrons, and tutors. For the woman or girl who wishes to stay at the bedside there remains the two-year training for enrolment. This training requires no statutory educational entry standard. This, coupled with the fact that famous teaching hospitals, such as St. Thomas’s, are starting training schools for the roll should be sufficient to convince everyone that this scheme is worth while.
depressing
13) should deem the
all your correspondents’ letters is the idea that it in training who must maintain the main bedside nursing force in our hospitals. This surely is the idea that has bedevilled nursing in this country for a hundred years. Just at present, with the strides that are being made in medicine and surgery, we need a strong team of trained nurses, both registered and enrolled, who can supervise the ever growing army of untrained nursing auxiliaries and the fewer numbers of nurses in training. This is a policy which would, of course, cost the Exchequer more than it is spending at present in nurses’ salaries. But in the long run it would benefit both the patients and the medical
Implicit in
is
nurses
profession. Goodmayes,
Essex.
P, D. P. j], NUTTALL. ACCIDENTAL HYPOTHERMIA
SIR,-In the article by Dr. Duguid and her colleagues (Dec. 2), fig. 4 is a good example of a common pitfall in medical illustrations. The paired photographs should show the change from " bloated " to normal features; yet the obvious difference in scale does not allow any comparison to be made. Where the inequality in scale is not so obvious, the appearance can be quite misleading. It is remarkable that in such paired figures the difference in scale (if there is any) usually tends to exaggerate rather than to mask the change illustrated. Who but editors of medical journals could treat such blemishes in professional publications ? JOSEFF MUGGIA. Jerusalem.
*** We showed Dr. Muggia’s letter to Dr. Duguid and colleagues and their reply follows.-ED.L. SIR,-Dr. Muggia criticises the two photographs for comparison in fig. 4 because they are not to the same scale. We agree that the two views of the patient could have been better matched if detailed comparison had to be made, but we can assure Dr. Muggia that the contrast in the patient’s her
appearance after recovery from hypothermia was every bit as striking as the photographs depict. In his letter of Dec. 16 Dr. Sclare suggests that some of our " euthyroid " cases of hypothermia might in fact have been suffering from latent hypothyroidism. Unfortunately we did not refer to the thyroid in our necropsy
data, since our account of pathology included only important positive findings. In fact, the thyroid mass was found to be normal for the age-group concerned in all our euthyroid necropsy cases. Since case 3 (depicted in fig. 4) recovered completely there was no pathological confirmation of her euthyroid status, but we cannot accept the suggestion that she was, in fact, myxcedematous, in spite of her appearance in the first photograph. Had she been suffering from myxoedema with hypothermia of such severity, she could not have regained a normal appearance without-or indeed with-replacement therapy, in the space of two or three weeks. It is true that differentiation of euthyroid and hypothyroid cases in accidental hypothermia may be well-nigh impossible on clinical grounds in the early stages, and a normal serumcholesterol value does not necessarily exclude myxoedema. Complete recovery without thyroid therapy must, however, count strongly against myxoedema ; while among those who die in the early stages myxoedema can be excluded only by examination of the thyroid gland at necropsy, since the results of definitive tests of thyroid function-even if practicable in such cases-could not be ascertained quickly can of course be diagnosed the time of admission if the patient is confidently already a known case, where hypothermia-with or without coma-may have been precipitated by such recognised factors
enough. Myxoedema hypothermia at
more
as
pneumonia
or
prolonged lapse of treatment.
IRENE GORE.
DONOR EYES SiR,—The demand for corneal graft material exceeds the supply by a quite unnecessary amount. This, surely, is the outstanding conclusion of Sir Benjamin Rycroft’s article (Jan. 20), which concerns us all. I have noticed two
preliminary obstacles
to
achieving
a
plentiful supply.
The first is the difficulty of remembering at the time of death. This must usually rest with the ward sister in hospital, and the family’s doctor at home. It will probably be some long time before the public at large become accustomed to think of corneal bequests at a time of bereavement when so many other thoughts abound. And this first step is all important. Many more eyes must have been wasted because no one sought to use them, than from telephone messages going astray. The second obstacle will be eased as more voluntary bequests are made, but even now I think it is overestimated. This is the unpleasantness of asking. A large part of the potential material that passes unused is the result of well-meaning attendants remembering to ask, and then not doing so for fear of adding further to the relatives’ distress. My experience has been exactly the opposite in all but one of thirty instances. On many occasions despairing relatives have been cheered by the comfort of knowing that out of their bereavement, another may have sight restored.
Remove these two hindrances, and the facilities which now exist for the collection of donor eyes could bring the supply much nearer to the demand. HUGH CARPENTER. London, N.W.7. CRISIS IN NURSING
SIR,-It is welcome to read of the recognition, in your columns, of the crisis in nursing; but I do not think the actions of the General Nursing Council have led to its precipitation. The causes are deeper and socioeconomic. It is
that Dr. Arden Jones and Mr. Tagart (Jan. meagre educational requirements of the G.N.C. as " over-ambitious educational ideals ". The requirement is, in fact, 2 passes at 0 level in G.C.E., or its equivalent, which, in these days of educational opportunity can hardly be regarded as unattainable for those who wish to go on to posts as ward sisters, matrons, and tutors. For the woman or girl who wishes to stay at the bedside there remains the two-year training for enrolment. This training requires no statutory educational entry standard. This, coupled with the fact that famous teaching hospitals, such as St. Thomas’s, are starting training schools for the roll should be sufficient to convince everyone that this scheme is worth while.
depressing
13) should deem the
all your correspondents’ letters is the idea that it in training who must maintain the main bedside nursing force in our hospitals. This surely is the idea that has bedevilled nursing in this country for a hundred years. Just at present, with the strides that are being made in medicine and surgery, we need a strong team of trained nurses, both registered and enrolled, who can supervise the ever growing army of untrained nursing auxiliaries and the fewer numbers of nurses in training. This is a policy which would, of course, cost the Exchequer more than it is spending at present in nurses’ salaries. But in the long run it would benefit both the patients and the medical
Implicit in
is
nurses
profession. Goodmayes,
Essex.
P, D. P. j], NUTTALL. ACCIDENTAL HYPOTHERMIA
SIR,-In the article by Dr. Duguid and her colleagues (Dec. 2), fig. 4 is a good example of a common pitfall in medical illustrations. The paired photographs should show the change from " bloated " to normal features; yet the obvious difference in scale does not allow any comparison to be made. Where the inequality in scale is not so obvious, the appearance can be quite misleading. It is remarkable that in such paired figures the difference in scale (if there is any) usually tends to exaggerate rather than to mask the change illustrated. Who but editors of medical journals could treat such blemishes in professional publications ? JOSEFF MUGGIA. Jerusalem.
*** We showed Dr. Muggia’s letter to Dr. Duguid and colleagues and their reply follows.-ED.L. SIR,-Dr. Muggia criticises the two photographs for comparison in fig. 4 because they are not to the same scale. We agree that the two views of the patient could have been better matched if detailed comparison had to be made, but we can assure Dr. Muggia that the contrast in the patient’s her
appearance after recovery from hypothermia was every bit as striking as the photographs depict. In his letter of Dec. 16 Dr. Sclare suggests that some of our " euthyroid " cases of hypothermia might in fact have been suffering from latent hypothyroidism. Unfortunately we did not refer to the thyroid in our necropsy
data, since our account of pathology included only important positive findings. In fact, the thyroid mass was found to be normal for the age-group concerned in all our euthyroid necropsy cases. Since case 3 (depicted in fig. 4) recovered completely there was no pathological confirmation of her euthyroid status, but we cannot accept the suggestion that she was, in fact, myxcedematous, in spite of her appearance in the first photograph. Had she been suffering from myxoedema with hypothermia of such severity, she could not have regained a normal appearance without-or indeed with-replacement therapy, in the space of two or three weeks. It is true that differentiation of euthyroid and hypothyroid cases in accidental hypothermia may be well-nigh impossible on clinical grounds in the early stages, and a normal serumcholesterol value does not necessarily exclude myxoedema. Complete recovery without thyroid therapy must, however, count strongly against myxoedema ; while among those who die in the early stages myxoedema can be excluded only by examination of the thyroid gland at necropsy, since the results of definitive tests of thyroid function-even if practicable in such cases-could not be ascertained quickly can of course be diagnosed the time of admission if the patient is confidently already a known case, where hypothermia-with or without coma-may have been precipitated by such recognised factors
enough. Myxoedema hypothermia at
more
as
pneumonia
or
prolonged lapse of treatment.