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EXEMPLARY EATING
1944
Annotations EXEMPLARY EATING time when hospital patients on dieta carnis (or even dieta dimidia) left chunks of mutton fat on the side of their plates, when the sewage disposal unit was blocked with putrefying fat from the kitchen effluent, and when rats frequented the dump to pick up the protective foods on which they could rear Victorian families. Waste in this gross sense has diminished, often to vanishing point, in many of our hospitals, primarily no doubt on economic grounds, but also as one of the results of the absorbing interest in food which has made it the most discussed subject of ourtime. The memo1 of the King’s Fund came at an opportune moment. It had a good press and not only but was distributed reached the voluntary as well by the Ministry of Health to municipal hospitals and sanatoria. From the beginning of the year the help of Miss Margaret Broatch, secretary of the Fund’s advisory committee, has been available to any hospital in need of it. Miss Broatch has had wide experience in America and in ,this country where she has supervised school meals over the whole LCC area. The Ministry of Health has now appointed two women dietitians of its own : Miss H. G. Cairney, lately in charge of the LCC diabetic unit at Brentwood, and Miss M. R. Muriel of the Ministry of Food, who has made surveys of hospital feeding. During the past four years 300 THERE
was
a
hospitals
hospitals have had the benefit of Captain J. Fraser’s expert advice on catering and kitchen equipment. Obviously the spirit is willing ; but the body to be moved is of terrific size and inertia. We are not a whit behind any other country in nutritional research, as Mottram has assured Usbut it is not much use, he says, finding out what people ought to eat if there is no, satisfactory way of letting them know about it. Few people pay attention to what is written, even by the Ministry of Health. Experience is the only effective teacher and in the hospital ward is unparalleled opportunity for providing this experience at a time when attention both of patient and his friends is keen. Set an example there and it will be carried into the homes of the people. Offer them day after day the same tepid rice pudding, the same congealed gravy, the same familiar fish with its coating of salmon-coloured sauce (our repetition is intentionall) and you can hardly expect them to realise " the value of rightlychosen and well-prepared food as a basic factor in the treatment of every patient "-let alone write home about it. The King’s Fund memo lays down the principle : the food service should be regarded as one of the essential remedial services offered by the hospitals. Diet is just as important for the man with a fractured femur or a septic wound as it is for the diabetic or the ansemic. Special diets have followed closely on medical knowledge, but the general dietary has dropped behind the times, and financial stringency has pressed more hardly and unfairly on the catering department than on other hospital services. At the Vancouver General Hospital the director of dietetics controls a quarter of the total hospital expenditure, and his department has moved upward from mere " food service " status to high therapeutic rank. Greater variety and nutritional value in meals can be secured without increased material cost ; but the price of knowledge and imagination must be paid for them. It is a question of organisation. The memo puts it incisively : " The steward may regard economy as the measure of his efficiency; for the matron difficulties of staff may tend to be predominant ; while a dietitian may concentrate rather on food values than on practical considerations." Every hospital therefore 1. Hospital Diet. From the Secretary, King Edward’s Hospital Fund for London, 10, Old Jewry, London, E.C.2. 6d. post free. See Lancet, 1943, ii, 673. 2. Lancet. 1943, i, 475.
.
should have its food service committee, representingall parties, competent to set an exemplary standard and determined to see it carried out. TWO
METHODS OF
ANALGESIA
Nitrous oxide in subanaesthetic doses is a well proved analgesic and is used every day for that purpose in obstetrics. Some American work suggests that the potentialities of even lower concentrations than thoseusually employed have not been sufficiently investigated Chapman, Arrowood and Beecher1 have studied the painrelieving action of very low concentrations of nitrous oxide in oxygen and compared it with that of average clinical doses of morphine. Every effort was made to control the possible sources of error. They observed the effect of inhaling mixtures of nitrous oxide and oxygen on the thresholds. for pain of two sorts-from heating theskin of the forehead, and from exercising the hand while the upper limb was rendered ischaemic by a cuff tourniquet on the arm. In normal healthy adults a mixture of 20% nitrous oxide and 80% oxygen raised the threshold to these two types of pain to the same extent as gr. 4 of morphine. Nitrous oxide in this concentration did not produce any undesirable side effects, nor did it impair consciousness ; indeed it must surprise many that it produced even analgesia. The elevation of the pain threshold rem;1ins constant as long as the administration is continued ; the effect of a single dose of morphine, on the other hand, rises to a maximum and then as it is. metabolised gradually passes off. Another method of producing analgesia, first described by Lundy,2is the intravenous injection of dilute procaine. Procaine, although strikingly safe when used for infiltration in the orthodox manner, has been followed by grave reactions on occasions when it has been inadvertently injected intravenously. But Gordon s has given up to 1 gramme in l hours as a 0-1% solution by intravenous drip to ten patients with extensive burns, obtaining effective analgesia with no apparent undesirable effects. It is interesting to know that the body can tolerate such large amounts of procaine administered slowly in dilute solution, but a clear case has not yet been made out for their superiority over morphine or subanaesthetic doses of the common anaesthetics. Thus, during the " blitz " and the Battle of Britain, when large numbers of burnt people had to be treated, morphine or small doses offPentothal ’ proved safe and efficient for tiding over their most painful periods. CHRONIC MELIOIDOSIS IN A EUROPEAN SINCE Whitmore and Krishnaswami described a " glanders-like " disease in a man in Rangoon in 1912 many similar cases have been reported in Burma, Ceylon, French Indo-China, the Dutch East Indies, Malaya and Siam. Stanton and Fletcher in 1925 named the disease melioidosis and the causative organism B. whitmori. Topley and Wilson assigned the organisms to the pfeifferella group and it is now called Pf. whitmori. Most of the recorded cases have been in natives and have been acute. Of the chronic cases the first in a European was published in 1943 by Grant and Barwell.4 In that case there was long-continued pyrexia before vertebral tuberculosis with radiological signs widespread active pulmonary disease; no tubercle bacilli were discovered in many sputum examinations ; various sulphonamide treatments had uncertain results. Besides the vertebral column one external malleolus and the frontal bone were involved. A second chronic case in a European has been described by Mayer and Finlayson.s A Regular Army soldier was 33 when his illness started in Malaya in June, 1940, with pain in the
suggested
1. Chapman, W. P. Arrowood, J. G. and Beecher, H. K. J. clin. Invest. 1943, 22, 871. 2. Lundy, J. S. Clinical Anesthesia, Philadelphia, 1942, p. 583. 3. Gordon, R. A. Canad. med. Ass. J. 1943, 49, 478. 4. Grant, A. and Barwell, C. Lancet, 1943, i, 199. 5. Mayer, J. H., Finlayson, M. H. J. R. Army med. Cps, 1944, 82, 4.
.
Annotations EXEMPLARY EATING time when hospital patients on dieta carnis (or even dieta dimidia) left chunks of mutton fat on the side of their plates, when the sewage disposal unit was blocked with putrefying fat from the kitchen effluent, and when rats frequented the dump to pick up the protective foods on which they could rear Victorian families. Waste in this gross sense has diminished, often to vanishing point, in many of our hospitals, primarily no doubt on economic grounds, but also as one of the results of the absorbing interest in food which has made it the most discussed subject of ourtime. The memo1 of the King’s Fund came at an opportune moment. It had a good press and not only but was distributed reached the voluntary as well by the Ministry of Health to municipal hospitals and sanatoria. From the beginning of the year the help of Miss Margaret Broatch, secretary of the Fund’s advisory committee, has been available to any hospital in need of it. Miss Broatch has had wide experience in America and in ,this country where she has supervised school meals over the whole LCC area. The Ministry of Health has now appointed two women dietitians of its own : Miss H. G. Cairney, lately in charge of the LCC diabetic unit at Brentwood, and Miss M. R. Muriel of the Ministry of Food, who has made surveys of hospital feeding. During the past four years 300 THERE
was
a
hospitals
hospitals have had the benefit of Captain J. Fraser’s expert advice on catering and kitchen equipment. Obviously the spirit is willing ; but the body to be moved is of terrific size and inertia. We are not a whit behind any other country in nutritional research, as Mottram has assured Usbut it is not much use, he says, finding out what people ought to eat if there is no, satisfactory way of letting them know about it. Few people pay attention to what is written, even by the Ministry of Health. Experience is the only effective teacher and in the hospital ward is unparalleled opportunity for providing this experience at a time when attention both of patient and his friends is keen. Set an example there and it will be carried into the homes of the people. Offer them day after day the same tepid rice pudding, the same congealed gravy, the same familiar fish with its coating of salmon-coloured sauce (our repetition is intentionall) and you can hardly expect them to realise " the value of rightlychosen and well-prepared food as a basic factor in the treatment of every patient "-let alone write home about it. The King’s Fund memo lays down the principle : the food service should be regarded as one of the essential remedial services offered by the hospitals. Diet is just as important for the man with a fractured femur or a septic wound as it is for the diabetic or the ansemic. Special diets have followed closely on medical knowledge, but the general dietary has dropped behind the times, and financial stringency has pressed more hardly and unfairly on the catering department than on other hospital services. At the Vancouver General Hospital the director of dietetics controls a quarter of the total hospital expenditure, and his department has moved upward from mere " food service " status to high therapeutic rank. Greater variety and nutritional value in meals can be secured without increased material cost ; but the price of knowledge and imagination must be paid for them. It is a question of organisation. The memo puts it incisively : " The steward may regard economy as the measure of his efficiency; for the matron difficulties of staff may tend to be predominant ; while a dietitian may concentrate rather on food values than on practical considerations." Every hospital therefore 1. Hospital Diet. From the Secretary, King Edward’s Hospital Fund for London, 10, Old Jewry, London, E.C.2. 6d. post free. See Lancet, 1943, ii, 673. 2. Lancet. 1943, i, 475.
.
should have its food service committee, representingall parties, competent to set an exemplary standard and determined to see it carried out. TWO
METHODS OF
ANALGESIA
Nitrous oxide in subanaesthetic doses is a well proved analgesic and is used every day for that purpose in obstetrics. Some American work suggests that the potentialities of even lower concentrations than thoseusually employed have not been sufficiently investigated Chapman, Arrowood and Beecher1 have studied the painrelieving action of very low concentrations of nitrous oxide in oxygen and compared it with that of average clinical doses of morphine. Every effort was made to control the possible sources of error. They observed the effect of inhaling mixtures of nitrous oxide and oxygen on the thresholds. for pain of two sorts-from heating theskin of the forehead, and from exercising the hand while the upper limb was rendered ischaemic by a cuff tourniquet on the arm. In normal healthy adults a mixture of 20% nitrous oxide and 80% oxygen raised the threshold to these two types of pain to the same extent as gr. 4 of morphine. Nitrous oxide in this concentration did not produce any undesirable side effects, nor did it impair consciousness ; indeed it must surprise many that it produced even analgesia. The elevation of the pain threshold rem;1ins constant as long as the administration is continued ; the effect of a single dose of morphine, on the other hand, rises to a maximum and then as it is. metabolised gradually passes off. Another method of producing analgesia, first described by Lundy,2is the intravenous injection of dilute procaine. Procaine, although strikingly safe when used for infiltration in the orthodox manner, has been followed by grave reactions on occasions when it has been inadvertently injected intravenously. But Gordon s has given up to 1 gramme in l hours as a 0-1% solution by intravenous drip to ten patients with extensive burns, obtaining effective analgesia with no apparent undesirable effects. It is interesting to know that the body can tolerate such large amounts of procaine administered slowly in dilute solution, but a clear case has not yet been made out for their superiority over morphine or subanaesthetic doses of the common anaesthetics. Thus, during the " blitz " and the Battle of Britain, when large numbers of burnt people had to be treated, morphine or small doses offPentothal ’ proved safe and efficient for tiding over their most painful periods. CHRONIC MELIOIDOSIS IN A EUROPEAN SINCE Whitmore and Krishnaswami described a " glanders-like " disease in a man in Rangoon in 1912 many similar cases have been reported in Burma, Ceylon, French Indo-China, the Dutch East Indies, Malaya and Siam. Stanton and Fletcher in 1925 named the disease melioidosis and the causative organism B. whitmori. Topley and Wilson assigned the organisms to the pfeifferella group and it is now called Pf. whitmori. Most of the recorded cases have been in natives and have been acute. Of the chronic cases the first in a European was published in 1943 by Grant and Barwell.4 In that case there was long-continued pyrexia before vertebral tuberculosis with radiological signs widespread active pulmonary disease; no tubercle bacilli were discovered in many sputum examinations ; various sulphonamide treatments had uncertain results. Besides the vertebral column one external malleolus and the frontal bone were involved. A second chronic case in a European has been described by Mayer and Finlayson.s A Regular Army soldier was 33 when his illness started in Malaya in June, 1940, with pain in the
suggested
1. Chapman, W. P. Arrowood, J. G. and Beecher, H. K. J. clin. Invest. 1943, 22, 871. 2. Lundy, J. S. Clinical Anesthesia, Philadelphia, 1942, p. 583. 3. Gordon, R. A. Canad. med. Ass. J. 1943, 49, 478. 4. Grant, A. and Barwell, C. Lancet, 1943, i, 199. 5. Mayer, J. H., Finlayson, M. H. J. R. Army med. Cps, 1944, 82, 4.
.