- Email: [email protected]
HEALTH VISITORS
1227 cells
icteric index 6 ; platelets 320,000 per Sternal-marrow biopsy was normal. Liver-function tests.- Norma!. Treatment and Progress Treatment with dimercaprol (BAij) began on June 25, 1952. 1.8 ml. was given every four hours for forty-eight hours, and then 1.6 ml. four times daily. From June 30 until treatment was stopped on July 5 only 1.5 ml. was given twice daily. New skin lesions appeared on July 22; and a second course, with reduced doses, was given from July 23 to 30. After two days’ treatment, the patient felt definitely better. No fresh bullse developed after July 22, and the urine became brighter in colour, especially during the afternoon and evening. The skin lesions regressed after a few days, and finally healed completely, though deep scars remained. The amount of coproporphyrin and uroporphyrin in the urine decreased (see accompanying table of analyses kindly performed by Dr. S. L. Sveinsson in the Central Laboratory of the -Ullevaal Hospital, Oslo).
0-40-0-32% NaCl;
c.mm.
At the outset the prognosis seemed poor, and we felt justified in trying the effect of dimercaprol because a good response has been observed in haemosiderosis due
to multiple blood-transfusion,and haemosiderosis has been found in several organs, especially the liver, in The distinct improvecases of porphyria at necropsy.2 ment after a few days, the regression of the skin lesions, and the urinary changes suggest that dimercaprol may be of benefit in porphyria. They certainly seem to its further trial. justify St. Joseph’s Hospital,
A. SCHRUMPF.
Porsgrunn, Norway.
SUFFERING FROM PERNICIOUS ANÆMIA
SIR,-A patient complained that she had suffered pernicious anaemia for 20 years.
from
When asked how she had suffered, it was apparent that she had ascribed all her aches and pains, headache and giddiness, indigestion, weakness, and palpitation to her ailment, which she clearly believed to be most pernicious. When told that a recent examination showed that her blood was in every way perfect and that she could not have been anaemic for 20 years (for she had attended a most efficient haematological clinic at a large hospital during the whole period) she refused at first to accept the good news. Evidently, no-one had ever told her that the blood of those with pernicious ansemia can be kept normal indefinitely.
Many patients with pernicious anaemia have similar beliefs. During the late war they would attend hospitals with requests that they be given certificates to excuse them from fire-watching and other public duties, and in other circumstances they may ascribe any symptoms to their disease. The most enthusiastic devotees of the psychosomatic theory of disease have never suggested that pernicious anaemia has a psychological basis. But these considerations suggest that even in treating those with this disease attention should be paid to their minds. This attention need only be of the simplest kind ; the doctor has only to tell the patient at the beginning of treatment that within a few weeks his blood will be normal, and, when this time has passed, that his blood is now normal and will always remain normal provided he attends for his regular injections and an occasional blood examination. From time to time in later years these statements may occasionally be repeated, and it be emphasised that if ever the patient does not feel well some other cause than pernicious anaemia must be sought for his complaints. It may be argued that patients who suffer from pernicious anaemia must be of hypochondriacal temper, and if they are deprived of the opportunity of ascribing their symptoms to this disease they will still continue to get symptoms and ascribe them to something else. No doubt there is some truth in this, and those of sound personality do not become invalids when they develop 1. Ohlsson, W. T. L. Oslo, 1952.
2.
23rd Congress of
Berglund, H., Paul, K. G.
Ibid.
Nordic
Internal Medicine.
even if their medical advisers never tell them the facts about this condition. But this does not excuse the physician who does nothing for his pernicious-ansemia patients except to order them injections and blood-counts. By remembering that they have minds as well as bodies, he can surely do something to discourage them from becoming invalids. J. W. TODD. Farnham, Surrey. J.
pernicious anaemia,
SPLENOMEGALY IN SCARLET FEVER SiR.,-During a recent appointment at an infectiousdiseases hospital in the north of England, I had to deal with a large number of patients with scarlet fever-some Most of these were mild 200 cases in three months. attacks, but I was interested to find that no less than 18 of them showed a moderate splenomegaly. In most patients the spleen was palpable on admission, but in some it was not palpable until a few days later. The spleen was usually firm, and in no case was it tender. The duration of the splenomegaly generally varied from 4 to 16 days ; but in one or two patients the spleen was still palpable on discharge after 21 days. None of the patients had enlarged lymph-glands, other than the enlarged and tender tonsillar glands so commonly found in scarlet fever. Unfortunately, a total and differential white-cell count was carried out in only 6 cases. In 5 of these the differential lymphocyte-count varied from 34 to 50% ; the 6th had only 12% of lymphocytes ; and the highest total white-cell count was 14,600 per c.mm. In none of the cases did the pathologist note any abnormal lymphocytes
absolute mononucleosis. I have not seen enlargement of the spleen mentioned in any textbook as a clinical feature of scarlet fever, and I would be glad of your readers’ opinions on the incidence and significance of this finding. S. O’REILLY. The Radcliffe Infirmary, Oxford. or an
’
HEALTH VISITORS
SiR,-Some weeks ago, during a discussion in the correspondence columns of the Spectator, a general practitioner deplored the activities of ubiquitous health visitors, usually in the form of smart young women who visit our patients in shining cars...." It was obvious from the letter that the " health visitors " referred to were officials of the Ministry of National Insurance. A letter from the secretary of the public health section of the Royal College of Nursing later pointed out that the designation " health visitor " was wrong and misleading in this instance. The Ministry of National Insurance itself directs the members of its staff who visit insured persons in their homes to use the title " visiting officer." These visiting officers do work similar to that of the old " sick visitors " of the approved societies who, "
to 1948, were responsible for the administration of sickness benefit under the National Health Insurance Acts which were the forerunners of the present Act. There seems to be some confusion in the minds of both general practitioners and the public between the very different functions of the visiting officer and the health visitor, and there is little appreciation of the The health nature of the training of health visitors. visitor is employed by the local health authority, and has no connection with the Ministry of National Insurance. Her qualjfleations are prescribed by regulations of the She is a State-registered nurse Ministry of Health. with an additional qualification in midwifery and with the health visitor’s certificate of the Royal Sanitary Institute. Her total training occupies a period of at least four and a half years (and it may extend to over five and a half years). She is a health teacher with an expert knowledge of the care of children and of expectant and nursing mothers. Her work now includes the care of the aged, and advising on the health of the family
prior
1228 whole and on themeasures necessary to prevent the spread of infection. Many health visitors in addition carry out the duties of the school nurse or of the tuberculosis visitor. While in the past the health visitor has in general had little contact with the family doctor, it is hoped that in future she may work in closer contact with him, so that he can readily call upon her services should a as a
- f.TnihT T’ffimT’f ’hm
N. K. Ross General Secretary, Women Public Health Officers’ Association. London, S.W.I. A.C.T.H. IN OIL AND BEESWAX SIR,-During the past eight months the department
of rheumatism of the
Royal Free Hospital has treated from active rheumatoid arthritis, with A.C.T.H. made up in an oil and beeswax base. Bruce and Parkes,l as a result of experiments on rats, have suggested that this preparation will act for several days. In 12 of the 17 cases pain relief and increased freedom of movement resulted from injection of 100 mg. twice a week ; the improvement lasted one to three days after each injection; and of 10 outpatients who received this treatment for three to six months, 8 have maintained their improvement during this period. In 4 cases the erythrocyte-sedimentation rate has fallen to normal levels ; and in patients who were ansemic the haemoglobin has risen. The urinary 17-ketosteroid output and the eosinophil-count have not been significantly altered by this dosage. We have warned patients to attend the hospital if any untoward symptoms arise ; but so far no complications have appeared, and we find it a convenient and satisfactory method of using the hormone. Patients attend the follow-up clinic every month. In addition to the convenience of reducing the number of injections, there is also a saving in material. The only difficulty we have encountered with A.C.T.H. in an oil and beeswax medium is that it has to be used at the right temperature (about 60°C) ; for otherwise it is difficult to inject. We believe, however, that this preparation effectively prolongs the action of A.C.T.H. and is therefore useful. It may be that in the future some base which is easier to handle will be found more satisfactory, but so far this is the best method we have used. 17
patients, suffering
Mrs. V. David, B.sc., performed the biochemical investigaMr. J. W. Hadgraft, PH.C., A.R.LC., prepared the tions. suspensions of A.C.T.H., and is willing to send details to those interested. Royal Free Hospital, ERNEST FLETCHER North Western Branch, P. O. WILLIAMS. Lawn Road, London, N.W.3. GONORRHŒA IN ANCIENT ROME
SiR,-Can anyone give me a reference to gonorrhoea in Latin literature of the classical periodI It is always taught that this disease was known to the Romans in the palmy days of Rome, but I have come to doubt the truth of this assertion. It is strange that Ovid in his treatise on love has nothing on the dangers of promiscuous amours ; stranger still that Catullus is silent on a subject that he could hardly have resisted, and equally strange is it with Petronius ; but most strange that the satirists should have ignored so obvious an
to say
opportunity to point a moral. An acquaintanceship with Juvenal that extends for forty-six years convinces me that he, had he known of gonorrhoea, would have made good use of his knowledge. Then, there is the medical authority of the period, Celsus ; but in his work I can find no mention of venereal disease. Again, the Roman system of morals seems to depend upon immunity from this disaster, for the use of prostitutes was defended on the ground that thereby the chastity of wives was less likely- to be assailed. If gonorrhoea had been endemic, surely, since there were no means of protection, we should have heard of the terrible results ?g 1.
Bruce, H. M., Parkes, A. S.
Lancet, 1952, i, 71.
Authors of books on gonorrhoea, do not cite the passages give the texts or translations from writers who are supposed to support their view that the disease existed in Rome of the classical period. H. St. H. VERTUE. IIOrpington, Kent. nor
TOXIC DOSES OF ADRENALINE SiR,-Scant attention is given in our textbooks to
the toxicology of adrenaline. The latest annual report of the Medical Protection Society describes a case in which 5 ml. of a solution from a bottle marked " adrenaline 1/1000 " caused rapid death when injected subcutaneously into the neck of a presumably healthy man. Nine years ago I witnessed the death of a young man after more than twice this dose had been injected into the muscles of the anterior abdominal wall. This man, who had a large kidney abscess, survived several hours-significantly longer than the man who received 5 ml. In neither case was there cerebral haemorrhage ; in both instances the mode of death was abrupt failure of the heart’s action. I do not know of any case in which less than 5 ml. of a 1/1000 solution of adrenaline hydrochloride has caused death. I do know, however, of a man who survived the injection into a ruptured quadriceps muscle It is of 10 ml. of 1/1000 adrenaline hydrochloride. apparent, therefore, that the distance from the vital centres, as well as the amount, of the accidental injection will determine the outcome. The site of injection will also determine, to a certain extent, the time before "
death. Pathological Laboratory, Edward Memorial Hospital, London, W.13.
King
W. S. KILLPACK.
CONTAINERS FOR TRANSFUSION CUT-DOWN SETS
standard transfusion giving-set box are plates, each measuring 4 x 95/8 in. The lower plate (holding the pair of scissors in the accompanying figure) is flat and lies on the bottom of the box. The upper plate, which is flanged, fits snugly over the lower plate when the box is closed. These plates. are made into containers, as follows :
Sm,-Inside
a
two metal
Universal-type metal clips, which hold the usual cutdown instruments, are firmly attached to the plates at suitable levels. Into the flanged plate is let a metal cup, to hold an antiseptic solution. The whole is readily sterilised. When the sterile set is required for use the seal is broken, and the colour of the Brown’s control tube checked. The flanged plate is then lifted out and placed in the open lid of the box, so that all instruments are readily available (see figure). Apart from the usual administration bloodtransfusion set, all that is required is a packet of sterile dressings, catgut. and a bottle of antiseptic solution.
icteric index 6 ; platelets 320,000 per Sternal-marrow biopsy was normal. Liver-function tests.- Norma!. Treatment and Progress Treatment with dimercaprol (BAij) began on June 25, 1952. 1.8 ml. was given every four hours for forty-eight hours, and then 1.6 ml. four times daily. From June 30 until treatment was stopped on July 5 only 1.5 ml. was given twice daily. New skin lesions appeared on July 22; and a second course, with reduced doses, was given from July 23 to 30. After two days’ treatment, the patient felt definitely better. No fresh bullse developed after July 22, and the urine became brighter in colour, especially during the afternoon and evening. The skin lesions regressed after a few days, and finally healed completely, though deep scars remained. The amount of coproporphyrin and uroporphyrin in the urine decreased (see accompanying table of analyses kindly performed by Dr. S. L. Sveinsson in the Central Laboratory of the -Ullevaal Hospital, Oslo).
0-40-0-32% NaCl;
c.mm.
At the outset the prognosis seemed poor, and we felt justified in trying the effect of dimercaprol because a good response has been observed in haemosiderosis due
to multiple blood-transfusion,and haemosiderosis has been found in several organs, especially the liver, in The distinct improvecases of porphyria at necropsy.2 ment after a few days, the regression of the skin lesions, and the urinary changes suggest that dimercaprol may be of benefit in porphyria. They certainly seem to its further trial. justify St. Joseph’s Hospital,
A. SCHRUMPF.
Porsgrunn, Norway.
SUFFERING FROM PERNICIOUS ANÆMIA
SIR,-A patient complained that she had suffered pernicious anaemia for 20 years.
from
When asked how she had suffered, it was apparent that she had ascribed all her aches and pains, headache and giddiness, indigestion, weakness, and palpitation to her ailment, which she clearly believed to be most pernicious. When told that a recent examination showed that her blood was in every way perfect and that she could not have been anaemic for 20 years (for she had attended a most efficient haematological clinic at a large hospital during the whole period) she refused at first to accept the good news. Evidently, no-one had ever told her that the blood of those with pernicious ansemia can be kept normal indefinitely.
Many patients with pernicious anaemia have similar beliefs. During the late war they would attend hospitals with requests that they be given certificates to excuse them from fire-watching and other public duties, and in other circumstances they may ascribe any symptoms to their disease. The most enthusiastic devotees of the psychosomatic theory of disease have never suggested that pernicious anaemia has a psychological basis. But these considerations suggest that even in treating those with this disease attention should be paid to their minds. This attention need only be of the simplest kind ; the doctor has only to tell the patient at the beginning of treatment that within a few weeks his blood will be normal, and, when this time has passed, that his blood is now normal and will always remain normal provided he attends for his regular injections and an occasional blood examination. From time to time in later years these statements may occasionally be repeated, and it be emphasised that if ever the patient does not feel well some other cause than pernicious anaemia must be sought for his complaints. It may be argued that patients who suffer from pernicious anaemia must be of hypochondriacal temper, and if they are deprived of the opportunity of ascribing their symptoms to this disease they will still continue to get symptoms and ascribe them to something else. No doubt there is some truth in this, and those of sound personality do not become invalids when they develop 1. Ohlsson, W. T. L. Oslo, 1952.
2.
23rd Congress of
Berglund, H., Paul, K. G.
Ibid.
Nordic
Internal Medicine.
even if their medical advisers never tell them the facts about this condition. But this does not excuse the physician who does nothing for his pernicious-ansemia patients except to order them injections and blood-counts. By remembering that they have minds as well as bodies, he can surely do something to discourage them from becoming invalids. J. W. TODD. Farnham, Surrey. J.
pernicious anaemia,
SPLENOMEGALY IN SCARLET FEVER SiR.,-During a recent appointment at an infectiousdiseases hospital in the north of England, I had to deal with a large number of patients with scarlet fever-some Most of these were mild 200 cases in three months. attacks, but I was interested to find that no less than 18 of them showed a moderate splenomegaly. In most patients the spleen was palpable on admission, but in some it was not palpable until a few days later. The spleen was usually firm, and in no case was it tender. The duration of the splenomegaly generally varied from 4 to 16 days ; but in one or two patients the spleen was still palpable on discharge after 21 days. None of the patients had enlarged lymph-glands, other than the enlarged and tender tonsillar glands so commonly found in scarlet fever. Unfortunately, a total and differential white-cell count was carried out in only 6 cases. In 5 of these the differential lymphocyte-count varied from 34 to 50% ; the 6th had only 12% of lymphocytes ; and the highest total white-cell count was 14,600 per c.mm. In none of the cases did the pathologist note any abnormal lymphocytes
absolute mononucleosis. I have not seen enlargement of the spleen mentioned in any textbook as a clinical feature of scarlet fever, and I would be glad of your readers’ opinions on the incidence and significance of this finding. S. O’REILLY. The Radcliffe Infirmary, Oxford. or an
’
HEALTH VISITORS
SiR,-Some weeks ago, during a discussion in the correspondence columns of the Spectator, a general practitioner deplored the activities of ubiquitous health visitors, usually in the form of smart young women who visit our patients in shining cars...." It was obvious from the letter that the " health visitors " referred to were officials of the Ministry of National Insurance. A letter from the secretary of the public health section of the Royal College of Nursing later pointed out that the designation " health visitor " was wrong and misleading in this instance. The Ministry of National Insurance itself directs the members of its staff who visit insured persons in their homes to use the title " visiting officer." These visiting officers do work similar to that of the old " sick visitors " of the approved societies who, "
to 1948, were responsible for the administration of sickness benefit under the National Health Insurance Acts which were the forerunners of the present Act. There seems to be some confusion in the minds of both general practitioners and the public between the very different functions of the visiting officer and the health visitor, and there is little appreciation of the The health nature of the training of health visitors. visitor is employed by the local health authority, and has no connection with the Ministry of National Insurance. Her qualjfleations are prescribed by regulations of the She is a State-registered nurse Ministry of Health. with an additional qualification in midwifery and with the health visitor’s certificate of the Royal Sanitary Institute. Her total training occupies a period of at least four and a half years (and it may extend to over five and a half years). She is a health teacher with an expert knowledge of the care of children and of expectant and nursing mothers. Her work now includes the care of the aged, and advising on the health of the family
prior
1228 whole and on themeasures necessary to prevent the spread of infection. Many health visitors in addition carry out the duties of the school nurse or of the tuberculosis visitor. While in the past the health visitor has in general had little contact with the family doctor, it is hoped that in future she may work in closer contact with him, so that he can readily call upon her services should a as a
- f.TnihT T’ffimT’f ’hm
N. K. Ross General Secretary, Women Public Health Officers’ Association. London, S.W.I. A.C.T.H. IN OIL AND BEESWAX SIR,-During the past eight months the department
of rheumatism of the
Royal Free Hospital has treated from active rheumatoid arthritis, with A.C.T.H. made up in an oil and beeswax base. Bruce and Parkes,l as a result of experiments on rats, have suggested that this preparation will act for several days. In 12 of the 17 cases pain relief and increased freedom of movement resulted from injection of 100 mg. twice a week ; the improvement lasted one to three days after each injection; and of 10 outpatients who received this treatment for three to six months, 8 have maintained their improvement during this period. In 4 cases the erythrocyte-sedimentation rate has fallen to normal levels ; and in patients who were ansemic the haemoglobin has risen. The urinary 17-ketosteroid output and the eosinophil-count have not been significantly altered by this dosage. We have warned patients to attend the hospital if any untoward symptoms arise ; but so far no complications have appeared, and we find it a convenient and satisfactory method of using the hormone. Patients attend the follow-up clinic every month. In addition to the convenience of reducing the number of injections, there is also a saving in material. The only difficulty we have encountered with A.C.T.H. in an oil and beeswax medium is that it has to be used at the right temperature (about 60°C) ; for otherwise it is difficult to inject. We believe, however, that this preparation effectively prolongs the action of A.C.T.H. and is therefore useful. It may be that in the future some base which is easier to handle will be found more satisfactory, but so far this is the best method we have used. 17
patients, suffering
Mrs. V. David, B.sc., performed the biochemical investigaMr. J. W. Hadgraft, PH.C., A.R.LC., prepared the tions. suspensions of A.C.T.H., and is willing to send details to those interested. Royal Free Hospital, ERNEST FLETCHER North Western Branch, P. O. WILLIAMS. Lawn Road, London, N.W.3. GONORRHŒA IN ANCIENT ROME
SiR,-Can anyone give me a reference to gonorrhoea in Latin literature of the classical periodI It is always taught that this disease was known to the Romans in the palmy days of Rome, but I have come to doubt the truth of this assertion. It is strange that Ovid in his treatise on love has nothing on the dangers of promiscuous amours ; stranger still that Catullus is silent on a subject that he could hardly have resisted, and equally strange is it with Petronius ; but most strange that the satirists should have ignored so obvious an
to say
opportunity to point a moral. An acquaintanceship with Juvenal that extends for forty-six years convinces me that he, had he known of gonorrhoea, would have made good use of his knowledge. Then, there is the medical authority of the period, Celsus ; but in his work I can find no mention of venereal disease. Again, the Roman system of morals seems to depend upon immunity from this disaster, for the use of prostitutes was defended on the ground that thereby the chastity of wives was less likely- to be assailed. If gonorrhoea had been endemic, surely, since there were no means of protection, we should have heard of the terrible results ?g 1.
Bruce, H. M., Parkes, A. S.
Lancet, 1952, i, 71.
Authors of books on gonorrhoea, do not cite the passages give the texts or translations from writers who are supposed to support their view that the disease existed in Rome of the classical period. H. St. H. VERTUE. IIOrpington, Kent. nor
TOXIC DOSES OF ADRENALINE SiR,-Scant attention is given in our textbooks to
the toxicology of adrenaline. The latest annual report of the Medical Protection Society describes a case in which 5 ml. of a solution from a bottle marked " adrenaline 1/1000 " caused rapid death when injected subcutaneously into the neck of a presumably healthy man. Nine years ago I witnessed the death of a young man after more than twice this dose had been injected into the muscles of the anterior abdominal wall. This man, who had a large kidney abscess, survived several hours-significantly longer than the man who received 5 ml. In neither case was there cerebral haemorrhage ; in both instances the mode of death was abrupt failure of the heart’s action. I do not know of any case in which less than 5 ml. of a 1/1000 solution of adrenaline hydrochloride has caused death. I do know, however, of a man who survived the injection into a ruptured quadriceps muscle It is of 10 ml. of 1/1000 adrenaline hydrochloride. apparent, therefore, that the distance from the vital centres, as well as the amount, of the accidental injection will determine the outcome. The site of injection will also determine, to a certain extent, the time before "
death. Pathological Laboratory, Edward Memorial Hospital, London, W.13.
King
W. S. KILLPACK.
CONTAINERS FOR TRANSFUSION CUT-DOWN SETS
standard transfusion giving-set box are plates, each measuring 4 x 95/8 in. The lower plate (holding the pair of scissors in the accompanying figure) is flat and lies on the bottom of the box. The upper plate, which is flanged, fits snugly over the lower plate when the box is closed. These plates. are made into containers, as follows :
Sm,-Inside
a
two metal
Universal-type metal clips, which hold the usual cutdown instruments, are firmly attached to the plates at suitable levels. Into the flanged plate is let a metal cup, to hold an antiseptic solution. The whole is readily sterilised. When the sterile set is required for use the seal is broken, and the colour of the Brown’s control tube checked. The flanged plate is then lifted out and placed in the open lid of the box, so that all instruments are readily available (see figure). Apart from the usual administration bloodtransfusion set, all that is required is a packet of sterile dressings, catgut. and a bottle of antiseptic solution.