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PUBLIC-HEALTH NURSING
940 1 recall that, shortly before the events described here, I had asked a colleague to examine me, as it had appeared possible that the loss of weight and energy might be attributable to subacute bacterial endocarditis. I had noted phenomena which, in any other patient, I would have assumed to be embolic. These were occasional splinter " hsemorrhages under the nails, and three or four separate Osler’s nodes in distal finger-pulps, and One of these occurred after an once in my upper lip. tennis and was noticed when I drove match, exhausting the car home, as the pulp of my thumb was painful when gripping the steering-wheel, and there had been No heart lesion has ever been detected. no injury. Would it be possible for spontaneous small thrombi to arise in the circulation of debilitated persons1 Thrombophlebitis is more common in these patients, especially in the tropics. I am not suggesting that thrombosis, with or without emboli, accounts for all episodes classified as migraine ; but I have postulated this as a possible explanation of events which might otherwise be inconsistent with Professor Pickering’s conIt might account for the occasional cases tention. sent home from hot countries because of comparatively short-lived attacks of aphasia with hemiplegia, in which the patient appears quite fit when examined in this country and no plausible diagnosis is made. St. Thomas’s Hospital, M. L. H. FLINDT. "
London, S.E.1.
PUBLIC-HEALTH NURSING
MB,—in your reference to the above subject on p. 874 of your last issue you quote me as saying that a new course for health visitors is to be held next year at the London School of Hygiene and Tropical Medicine. If I said this I had no right to do so as the proposal is still under consideration and will have to be approved by the School Council, the Board of Management of the School, and the University. London School of Hygiene and ANDREW TOPPING. Tropical Medicine, London, W.C.1.
ECLAMPSIA TREATED WITH HEXAMETHONIUM
SiR,-The case reported by Dr. Penny and Dr. Shackleton (Oct. 6, p. 617) supports the view that hexamethonium bromide should be of great value in the treatment of eclampsia. It has been shown, however, oedema fluid " is due that the high protein content of to contamination with’ plasma, and I venture to suggest that the oedema with which they were dealing did not arise from vascular permeability but from retention of salt and water. The cause of this is reduced glomerular filtration and/or alteration of tubular reabsorption. If the intracranial oedema was so great as to produce (as they suggest) a restricted outflow," the fall in bloodpressure produced by hexamethonium would surely have led to collapse of the cerebral circulation rather than to relief of cortical oedema. The data indicate that "
"
hexamethonium acts primarily by overcoming angiospasm. In the cerebrum the relief of angiospasm abolishes fits, whilst in the kidney it overcomes the ischaemic state of the nephrons which the oliguria has reflected. Re-establishment of the renal circulation halts the production of renal pressor substances with their over-all control of the vasculature-including that of the brain. Further the increased oxygen supply helps to destroy these products. Yet this is not the whole story. Electroconvulsive therapy has led to lower-nephron nephrosis in man, and Hoff,’ by cerebral stimulation, has produced in cats identical renal changes, via the Oxford shunt. May not the eclamptic fit be a stage in a vicious circle, with diversion of the renal blood-flow at one pole and convulsion at the other1 This would explain the crescendo 1. Hoff, E. C., Kell, J. F. jun., Hastings, N., Sholes, D. M., Gray, E. H. Amer. J. Neurophysiol. 1951, 14, 317.
effects leading to status eclampticus and the recovery when the chain is interrupted at one or other point. It would be instructive to compare and contrast the action of hexamethonium bromide in antepartum and postpartum eclampsia with that of caudal analgesia. And to investigate the part, if any, that oxytocics play in the
aetiology.
J. SOPHIAN.
London, W.1.
INSULIN LOSS DURING INJECTION
SIR,-The article by Dr. Luntz (Nov. 3) is of great His contention that a narrow-bore syringe interest. should be used leaps to the mind as obvious-once he has thought of it ! A small needle, however, has dis. advantages which I think would outweigh in cost the gain on the saving of insulin. I am appalled by the short time that a size 19 or 20 needle lasts in the homes of patients, whether the insulin is injected by themselves or by a nurse ; the smaller the needle the more quickly it becomes blunt, bent, or blocked. G. M. WAUCHOPE.
Hove, Sussex.
MEDICINE IN RUSSIA
SiR,-The description by Mrs. Iwasenko (Nov. 3) of conditions in Russia in 1943 during war-time scarcity of food, shelter, and medical personnel reinforces the admiration of all those who have seen the progress made in these very items during the difficult post-war vears. The following remarks, arising from Mrs. Iwasenko’s letter are based on personal observation in 1950 during a visit which included rural and devastated areas :
Tuberculosis.-At the Yalta sanatorium no patient to spoke had waited as much as three months for admission-all were trade-union (not Party) members.
whom I
Food.-The average worker’s food-checked by myself in shops (which I visited alone), the shopping bags, the kitchens of every type of institution and factory visited, and private homes-now provides a higher intake of protein and fat than does ours at comparative wages and prices. Those with medical permits are provided with extra or special diet at subsidised rates, to be eaten at work or taken home.
Telephones.-These are now available. I saw them in all the homes I visited (both by invitation and unannounced). These, as well as heating and light, are included in the modest rent. - f}MjcteMC!/.—The machinery to remedy this lies in the use by the public of their press and trade union and local soviet. Examples can be quoted from Soviet sources of the eventual success of this method. Status and conditions of doctors.-Thejunior doctors to whom I talked had ample time for home-visits, and cars were provided. Remuneration seemed low to my privileged eyes. but the possibilities of advancement to salaries equivalent to those of a field-marshal seemed more striking.
I fear that
opinion biased by political and economic will continue to masquerade as statement of fact until we achieve the free exchange of visits, with factual observations and criticism, between the two systems. This correspondence may at least stimulate those who wish for knowledge to reinforce the efforts of those who work to make this possible. NORA JOHNS. Farnham, Surrey.
backgrounds
most interested in the letter from illrs, and perhaps my own experience might be of interest. Travelling through Russia from Leningrad to Odessa some months before the attack by Germany I was fortunate enough to meet a man whose work caused him to travel extensivelv. We discussed medical services in some detail. Moscow, he
SIR,-I
Iwasenko
was
(Nov. 3),
’
said,
city
"
was
a
closed to
show-piece," and Leningrad (at that foreigners) was considerably inferior.
time
a
Next,
London, S.E.1.
PUBLIC-HEALTH NURSING
MB,—in your reference to the above subject on p. 874 of your last issue you quote me as saying that a new course for health visitors is to be held next year at the London School of Hygiene and Tropical Medicine. If I said this I had no right to do so as the proposal is still under consideration and will have to be approved by the School Council, the Board of Management of the School, and the University. London School of Hygiene and ANDREW TOPPING. Tropical Medicine, London, W.C.1.
ECLAMPSIA TREATED WITH HEXAMETHONIUM
SiR,-The case reported by Dr. Penny and Dr. Shackleton (Oct. 6, p. 617) supports the view that hexamethonium bromide should be of great value in the treatment of eclampsia. It has been shown, however, oedema fluid " is due that the high protein content of to contamination with’ plasma, and I venture to suggest that the oedema with which they were dealing did not arise from vascular permeability but from retention of salt and water. The cause of this is reduced glomerular filtration and/or alteration of tubular reabsorption. If the intracranial oedema was so great as to produce (as they suggest) a restricted outflow," the fall in bloodpressure produced by hexamethonium would surely have led to collapse of the cerebral circulation rather than to relief of cortical oedema. The data indicate that "
"
hexamethonium acts primarily by overcoming angiospasm. In the cerebrum the relief of angiospasm abolishes fits, whilst in the kidney it overcomes the ischaemic state of the nephrons which the oliguria has reflected. Re-establishment of the renal circulation halts the production of renal pressor substances with their over-all control of the vasculature-including that of the brain. Further the increased oxygen supply helps to destroy these products. Yet this is not the whole story. Electroconvulsive therapy has led to lower-nephron nephrosis in man, and Hoff,’ by cerebral stimulation, has produced in cats identical renal changes, via the Oxford shunt. May not the eclamptic fit be a stage in a vicious circle, with diversion of the renal blood-flow at one pole and convulsion at the other1 This would explain the crescendo 1. Hoff, E. C., Kell, J. F. jun., Hastings, N., Sholes, D. M., Gray, E. H. Amer. J. Neurophysiol. 1951, 14, 317.
effects leading to status eclampticus and the recovery when the chain is interrupted at one or other point. It would be instructive to compare and contrast the action of hexamethonium bromide in antepartum and postpartum eclampsia with that of caudal analgesia. And to investigate the part, if any, that oxytocics play in the
aetiology.
J. SOPHIAN.
London, W.1.
INSULIN LOSS DURING INJECTION
SIR,-The article by Dr. Luntz (Nov. 3) is of great His contention that a narrow-bore syringe interest. should be used leaps to the mind as obvious-once he has thought of it ! A small needle, however, has dis. advantages which I think would outweigh in cost the gain on the saving of insulin. I am appalled by the short time that a size 19 or 20 needle lasts in the homes of patients, whether the insulin is injected by themselves or by a nurse ; the smaller the needle the more quickly it becomes blunt, bent, or blocked. G. M. WAUCHOPE.
Hove, Sussex.
MEDICINE IN RUSSIA
SiR,-The description by Mrs. Iwasenko (Nov. 3) of conditions in Russia in 1943 during war-time scarcity of food, shelter, and medical personnel reinforces the admiration of all those who have seen the progress made in these very items during the difficult post-war vears. The following remarks, arising from Mrs. Iwasenko’s letter are based on personal observation in 1950 during a visit which included rural and devastated areas :
Tuberculosis.-At the Yalta sanatorium no patient to spoke had waited as much as three months for admission-all were trade-union (not Party) members.
whom I
Food.-The average worker’s food-checked by myself in shops (which I visited alone), the shopping bags, the kitchens of every type of institution and factory visited, and private homes-now provides a higher intake of protein and fat than does ours at comparative wages and prices. Those with medical permits are provided with extra or special diet at subsidised rates, to be eaten at work or taken home.
Telephones.-These are now available. I saw them in all the homes I visited (both by invitation and unannounced). These, as well as heating and light, are included in the modest rent. - f}MjcteMC!/.—The machinery to remedy this lies in the use by the public of their press and trade union and local soviet. Examples can be quoted from Soviet sources of the eventual success of this method. Status and conditions of doctors.-Thejunior doctors to whom I talked had ample time for home-visits, and cars were provided. Remuneration seemed low to my privileged eyes. but the possibilities of advancement to salaries equivalent to those of a field-marshal seemed more striking.
I fear that
opinion biased by political and economic will continue to masquerade as statement of fact until we achieve the free exchange of visits, with factual observations and criticism, between the two systems. This correspondence may at least stimulate those who wish for knowledge to reinforce the efforts of those who work to make this possible. NORA JOHNS. Farnham, Surrey.
backgrounds
most interested in the letter from illrs, and perhaps my own experience might be of interest. Travelling through Russia from Leningrad to Odessa some months before the attack by Germany I was fortunate enough to meet a man whose work caused him to travel extensivelv. We discussed medical services in some detail. Moscow, he
SIR,-I
Iwasenko
was
(Nov. 3),
’
said,
city
"
was
a
closed to
show-piece," and Leningrad (at that foreigners) was considerably inferior.
time
a
Next,