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"URÆMIC LUNG—FLUID LUNG?"
715 Out of the welter of ill-defined acute virus infections which seem to exist in this and other countries, this mild winter epidemic infection seems to be qualifying for
general recognition. "URÆMIC LUNG—FLUID LUNG?" IN an article under this heading Alwall et al.1 answer their own question by saying that this is the first of a " series on electrolyte-fluid retention." Neither of the two names is particularly pleasing, since the disturbance that they describe has often been observed in patients without uraemia, while a " fluid lung " is literally impossible. But the fact that exception can be taken to both these terms does not mean that a more suitable name is easily devised. Pathologists agree that the type of oedema found in the lungs is non-specific ; and the syndrome could be defined as " acute localised pulmonary oedema with X-ray shadowing in association with acute fluid retention and left ventricular failure "-a description that can hardly be shortened except by omitting one or other feature which differentiates this from other syndromes more or less closely related to it. This type of acute localised pulmonary oedema was first reported in the’30s by Continental workers2 3, who found it in association with renal failure and hypertension and gave it the name " uraemic oedema." This name it has now retained with dwindling justification for twenty years. In 1941 the typical radiographic appearance was described of fan-shaped opacities radiating from the hilum, but tending to spare the peripheral lung-fields.44 Doniach,5 who examined the lungs in four cases, found a non-infective albuminous and fibrinous pulmonary oedema in various stages of organisation. lie pointed out6 that the same type of oedema could occur apart from urmmia-for example, with cardiac failure due to myocardial infarction or mitral stenosis. Pathologically, the changes could not be distinguished from those of so-called " rheumatic pneumonia." He added that the " peculiar butterfly-shaped distribution of the transudate7 in the lungs remains an enigma." Bass and Singer were perhaps the first to emphasise the importance of left ventricular failure, noting the disappearance of the altered lung shadows as this responded to treatment ; they also cited Dock’s explanation of the distribution of oedema, based on the relative immobility of the hilar parts of the lung, by comparison with the periphery, in which ventilation might hinder the accumulation of fluid. Alwall and his colleagues now bring forward clinical and experimental evidence confirming the importance of fluid retention in causing this type of pulmonary oedema. They studied fourteen patients with chronic renal failure, and two with anuria from acute tubular necrosis, all of whom were notably dyspnoeic and had the characteristic radiographic appearances. Diarrhoea was induced by a daily dose of 200-400 ml. of 25% or 50% sodium sulphate, no other fluid being given ; if the patient vomited, 100 ml. of 25% sodium sulphate was given as an enema three or four times daily. On this stern regime, the patients’ weight fell by as much as 4 kg. a day ; there was a dramatic recession of the pulmonary shadowing, and dyspnoea was relieved. In experiments on rabbits the ureters were ligated, a control radiograph was taken, and an amount of "liquid" corresponding to 15% of the body-weight was infused ; radiographic examination then showed extensive pulmonary shadowing, which disappeared when the excess of body-fluid was removed by dialysis. In an addendum to their paper they mention the removal of " a life-menacing pulmonary oedema " 1.
by five hours’ treatment with Alwall’s type of artificial kidneg.8 Although retention of fluid may clearly precipitate acute localised pulmonary oedema, many patients with massive cedema, as in type-n nephritis, have no dyspncea and no pulmonary shadowing-suggesting that some additional factor promotes localisation of part of the excess fluid in the lungs. The frequency of this type of not pulmonary change only in chronic nephritis, in which it
first described, but also in anuria and acute that this additional factor may be left ventricular failure secondary to hypertension. The importance of cardiac failure has recently been emphasised both in anuriaand in acute nephritis.1O The recognition of acute localised pulmonary oedema is perhaps more important in these acute and reversible conditions than in chronic renal failure ; and the possibility of it strengthens the case for fluid restriction and complete bed rest in the management of anuria and acute nephritis. was
nephritis, suggests
MENTAL NURSING IN DECLINE OF the hospital beds in this country no less than 40% are in mental hospitals; but this large group does not command anything like its proper proportion of our nursing resources. As is now widely recognised, the nursing service of mental hospitals, though it includes many first-class men and women, is, in general, insufficient Since trained staff are few, and and therefore poor. recruits for training are getting fewer, much of the burden of mental nursing is carried by people for whom no systematic course of training is at present laid down." This is a dangerous situation : we could easily slip back to the cruelty and degradation of the old bedlams, from which we are little more than a century removed. A contributor to the lt2ale Nurses J ournal12 makes some constructive suggestions. He points out that many of the old chronic patients in mental hospitals do not need any mental nursing at all-only kindly care and general nursing of the type given in the geriatric wards of a general hospital or in rest homes for the aged. Such patients might well be transferred to such wards and homes, thus releasing beds for acutely ill mental patients likely to benefit by modern treatment. Accommodation of the type suggested, however, is still very scarce ; it would have to be greatly extended before this proposal could be put into practice. Nevertheless, it would in the use of qualified mental certainly promote economy nurses and help to ensure that they were doing the work for which they were trained. Like us, this writer believes that student nurses in general training might well spend three months in mental hospitals. This plan, we have suggested, might be tried first at Hill End, St. Albans, where a teaching general hospital (St. Bartholomew’s) and a mental hospital are already sharing the same buildings.13 He also proposes an interchange of administrators between general and mental hospitals, so that they may get a better grasp of each other’s background and problems, and thus come to cooperate more easily. In the manner of the Prime Minister, in the days when he offered us blood and tears, he calls for posters pointing out that nurses are needed in mental hospitals and that it is hard work demanding courage and patience. As a long-term policy he advocates converting the mental hospitals into hospitals for the treatment of organic and functional nervous disorders (which would naturally include mental disorders). Such a hospital would carry neurological wards as well as wards for the neurotic and psychotic, and would have an associated research unit. The name of the hospital 1953, could then be changed to " Somebody’s Hospital for
Alwall, N., Lunderquist, A., Olsson, O. Acta med. scand. 146, 157. 2. Rubier, C., Plauchu, M. Arch. méd. chir. Apprar. resp. 1934, 9, 189. 3. Klima, R., Rosegger, H. Med. Klin. 1936, 32, 85. 4. Rendich, R. A., Levy, A. H., Cove, A. M. Amer. J. Roentgenol. 1941, 46, 802. 5. Doniach, I. Ibid, 1947, 58, 620. 6. Doniach, I. Lancet, 1949, ii, 911. 819. 7. Bass, H. E., Singer, E. J. Amer. med. Ass. 1947, 144, 144, 819.
8. 9. 10. 11. 12. 13.
Alwall, N. Acta med. scand. 1947, 128, 317. Swann, R. C., Merrill, J. P. Medicine, Baltimore, 1953, 32, 215. Peters, J. P. Amer. J. Med. 1953, 14, 448. Lancet, July 25, 1953, p. 177. September-October, 1953, p. 13. Lancet, 1953, i, 641.
general recognition. "URÆMIC LUNG—FLUID LUNG?" IN an article under this heading Alwall et al.1 answer their own question by saying that this is the first of a " series on electrolyte-fluid retention." Neither of the two names is particularly pleasing, since the disturbance that they describe has often been observed in patients without uraemia, while a " fluid lung " is literally impossible. But the fact that exception can be taken to both these terms does not mean that a more suitable name is easily devised. Pathologists agree that the type of oedema found in the lungs is non-specific ; and the syndrome could be defined as " acute localised pulmonary oedema with X-ray shadowing in association with acute fluid retention and left ventricular failure "-a description that can hardly be shortened except by omitting one or other feature which differentiates this from other syndromes more or less closely related to it. This type of acute localised pulmonary oedema was first reported in the’30s by Continental workers2 3, who found it in association with renal failure and hypertension and gave it the name " uraemic oedema." This name it has now retained with dwindling justification for twenty years. In 1941 the typical radiographic appearance was described of fan-shaped opacities radiating from the hilum, but tending to spare the peripheral lung-fields.44 Doniach,5 who examined the lungs in four cases, found a non-infective albuminous and fibrinous pulmonary oedema in various stages of organisation. lie pointed out6 that the same type of oedema could occur apart from urmmia-for example, with cardiac failure due to myocardial infarction or mitral stenosis. Pathologically, the changes could not be distinguished from those of so-called " rheumatic pneumonia." He added that the " peculiar butterfly-shaped distribution of the transudate7 in the lungs remains an enigma." Bass and Singer were perhaps the first to emphasise the importance of left ventricular failure, noting the disappearance of the altered lung shadows as this responded to treatment ; they also cited Dock’s explanation of the distribution of oedema, based on the relative immobility of the hilar parts of the lung, by comparison with the periphery, in which ventilation might hinder the accumulation of fluid. Alwall and his colleagues now bring forward clinical and experimental evidence confirming the importance of fluid retention in causing this type of pulmonary oedema. They studied fourteen patients with chronic renal failure, and two with anuria from acute tubular necrosis, all of whom were notably dyspnoeic and had the characteristic radiographic appearances. Diarrhoea was induced by a daily dose of 200-400 ml. of 25% or 50% sodium sulphate, no other fluid being given ; if the patient vomited, 100 ml. of 25% sodium sulphate was given as an enema three or four times daily. On this stern regime, the patients’ weight fell by as much as 4 kg. a day ; there was a dramatic recession of the pulmonary shadowing, and dyspnoea was relieved. In experiments on rabbits the ureters were ligated, a control radiograph was taken, and an amount of "liquid" corresponding to 15% of the body-weight was infused ; radiographic examination then showed extensive pulmonary shadowing, which disappeared when the excess of body-fluid was removed by dialysis. In an addendum to their paper they mention the removal of " a life-menacing pulmonary oedema " 1.
by five hours’ treatment with Alwall’s type of artificial kidneg.8 Although retention of fluid may clearly precipitate acute localised pulmonary oedema, many patients with massive cedema, as in type-n nephritis, have no dyspncea and no pulmonary shadowing-suggesting that some additional factor promotes localisation of part of the excess fluid in the lungs. The frequency of this type of not pulmonary change only in chronic nephritis, in which it
first described, but also in anuria and acute that this additional factor may be left ventricular failure secondary to hypertension. The importance of cardiac failure has recently been emphasised both in anuriaand in acute nephritis.1O The recognition of acute localised pulmonary oedema is perhaps more important in these acute and reversible conditions than in chronic renal failure ; and the possibility of it strengthens the case for fluid restriction and complete bed rest in the management of anuria and acute nephritis. was
nephritis, suggests
MENTAL NURSING IN DECLINE OF the hospital beds in this country no less than 40% are in mental hospitals; but this large group does not command anything like its proper proportion of our nursing resources. As is now widely recognised, the nursing service of mental hospitals, though it includes many first-class men and women, is, in general, insufficient Since trained staff are few, and and therefore poor. recruits for training are getting fewer, much of the burden of mental nursing is carried by people for whom no systematic course of training is at present laid down." This is a dangerous situation : we could easily slip back to the cruelty and degradation of the old bedlams, from which we are little more than a century removed. A contributor to the lt2ale Nurses J ournal12 makes some constructive suggestions. He points out that many of the old chronic patients in mental hospitals do not need any mental nursing at all-only kindly care and general nursing of the type given in the geriatric wards of a general hospital or in rest homes for the aged. Such patients might well be transferred to such wards and homes, thus releasing beds for acutely ill mental patients likely to benefit by modern treatment. Accommodation of the type suggested, however, is still very scarce ; it would have to be greatly extended before this proposal could be put into practice. Nevertheless, it would in the use of qualified mental certainly promote economy nurses and help to ensure that they were doing the work for which they were trained. Like us, this writer believes that student nurses in general training might well spend three months in mental hospitals. This plan, we have suggested, might be tried first at Hill End, St. Albans, where a teaching general hospital (St. Bartholomew’s) and a mental hospital are already sharing the same buildings.13 He also proposes an interchange of administrators between general and mental hospitals, so that they may get a better grasp of each other’s background and problems, and thus come to cooperate more easily. In the manner of the Prime Minister, in the days when he offered us blood and tears, he calls for posters pointing out that nurses are needed in mental hospitals and that it is hard work demanding courage and patience. As a long-term policy he advocates converting the mental hospitals into hospitals for the treatment of organic and functional nervous disorders (which would naturally include mental disorders). Such a hospital would carry neurological wards as well as wards for the neurotic and psychotic, and would have an associated research unit. The name of the hospital 1953, could then be changed to " Somebody’s Hospital for
Alwall, N., Lunderquist, A., Olsson, O. Acta med. scand. 146, 157. 2. Rubier, C., Plauchu, M. Arch. méd. chir. Apprar. resp. 1934, 9, 189. 3. Klima, R., Rosegger, H. Med. Klin. 1936, 32, 85. 4. Rendich, R. A., Levy, A. H., Cove, A. M. Amer. J. Roentgenol. 1941, 46, 802. 5. Doniach, I. Ibid, 1947, 58, 620. 6. Doniach, I. Lancet, 1949, ii, 911. 819. 7. Bass, H. E., Singer, E. J. Amer. med. Ass. 1947, 144, 144, 819.
8. 9. 10. 11. 12. 13.
Alwall, N. Acta med. scand. 1947, 128, 317. Swann, R. C., Merrill, J. P. Medicine, Baltimore, 1953, 32, 215. Peters, J. P. Amer. J. Med. 1953, 14, 448. Lancet, July 25, 1953, p. 177. September-October, 1953, p. 13. Lancet, 1953, i, 641.