SANATORIUM NURSING

366 to use a crane to deposit it outside the kitchen door. Rather hesitantly we asked Sister to come and see how she liked it. She came and admired, for it was superficially quite elegant, and then vainly tried to lift the cover from the food trays. It was so heavy that she could not even budge it, but as we had plenty of helpers this did not seem an insuperable difficulty. The wagon was pressed into use; but a few days of trundling its massive bulk along the verandahs was enough to plough up the thin sandy concrete of which they were built. Finally one of the inadequate wheels fell off and the wagon listed majestically over. It was pulled level by main force, and, supported by a brick, served thereafter as a static-a very static-serving-out counter. For all I know it may still be there, a monument to the

solidity

of the British

Raj. *

*

*

The old man wiped the froth off his face with the back of his hand. " Her’s gorn in agen," he said mournfully but with some pride. " Where ? " I said. " Gaol o’ course " he said eyeing me suspiciously; then, apparently reassured, " always does for the winter; rare spirit her has. Seventy-six convictions when I wed her, turned 70 then, her was." " Why did you wed ? " I asked. " Well rightly I didn’t have much to do with it, it was the W.V.S. and they welfare workers done it. ’Twas worth it though ; they give me a big breakfast, a room looking onto a garden, and a ride in a motor-car. You’d have done the same." I agreed. " They thought I’d keep her out I s’pose, but ’tis no then in her goes." good, if her’s made up her mind, We sipped our beer in silence. " Yes, only last Friday her saidWinter’s acoming Charlie’, her said,’and it’s getting too cold in the shelters for my old bones, so I’m agoing in agen.’ ’Alright my love,’ I said,’I’ll acome up with you’ ; so we went up to the Police, and her stood outside and her swore. After a minute two sergeants come out and take her in. Then they throws her out agen. Then her swore proper. Some fine spirit her has. Then they come out agen and take her in and charge her, and I knowed her was comfortable forthe Winter. Went to court Monday, when her came up before the beak. Her opted for B-- gaol ; it’s warmer in there." *

*

*

YOU’RE HERE Doctor dear, when

NOW

Now you’re here,

Uncle’s leg, Will you come and

see an

you’ve

looked at

Orpington in trouble with

an

egg ?2

Will you look at Rupert’s tonsils and advise about the cat ? Then I’ll take you to the cesspit, you must have a peep at that. The Sanitary Person saw it last in ’41 And assured us it was urgent and that something would be done. Well, nothing was, of course-but just a teeny word from -

you

To the rural district council and what wonders that would do ! Oh, by the by, please certify that Claud is fit for camp Before you see the cottage which is letting in the damp. I can’t believe it’s healthy there, though Mrs. Postlethwaite Has spent her life in it, she says, and now she’s 88 And never has an ache (except the usual catarrh) How illness-proof, it seems, the older generation are ! Do you think Jane should marry that peculiar young man ? If those whiskers will not warn her, you’re the only one who can. If you can’t reintroduce her to the straight and narrow

path, Introduce him to a razor or, at any rate, a bath. May I offer you some, coffee or perhaps a glass of beer Now you’re here ?

Where’s he gone ? How very queer ! I was talking to him-here... But how could he disappear... ?2 Can that be him changing gear ? Yes it is. Oh dear, oh dear.

Letters

to

the Editor

TOXIC EFFECTS OF TRIDIONE

Sm,-In their article of Jan. 8 Dr. Briggs and Dr. Emery report that of 10 patients with petit mal who were treated with ’ Tridione,’ 7 were improved, but that 2 of these displayed serious toxic effects, with death of 1.

The authors conclude that " in this short series the toxic complications of tridione proved more dangerous than the disease it is used to treat." A reader of the case-reports cannot but wonder whether the medicine or the manner of administering it was more at fault.

In case 9, after neutrophils had fallen to 2000 per c.mm. medication was nevertheless continued for two months, presumably without blood examination. The neutrophil count after] that time was only 700 per c.mm. Tridione was then discontinued, but in spite of the fact that the neutrophil count " fell steadily," no active treatment was instituted until five weeks later when the neutrophils had fallen to 100 per c.mm., and there was severe depression of all elements of the bone-marrow. A single transfusion of a quart of fresh blood was then given and fortunately the child eventually recovered. In case 10 the child developed nephrosis, caused, the authors believed, by tridione ; yet this medicine was continued during the last five of the eight months that the child lived.

Like many other

potent drugs, tridione must be

care-

fully supervised and medication stopped promptly if symptoms of serious toxicity appear. The danger is increased if the anticonvulsant, methylphenylethyl hydantoin (’Mesantoin’), is given coincidentally. During the past four years, we have given tridione, or its analogue, ’ Paradione,’ to nearly 300 patients with epilepsy. One death from aplastic an2emia, the first encountered anywhere, occurred early in the series. Since the institution of monthly blood examinations and prompt cessation of medication when neutrophils fall below 1600 per c.mm., no serious blood complications have ensued. In some patients medication has had to be interrupted a number of times. One other patient displayed evidence of nephrosis ; medicine was stopped promptly, and neither kidney symptoms nor petit mal have returned. In compensation for these two instances of serious toxicity, the great majority of patients with petit mal The saving in (pyknolepsy) are greatly improved. petit mal for this single group of patients amounts to something like 300,000 a year. Like any potent weapon of offence, tridione can cause grave harm if not handled with respect and conscientious care, but this would seem to be a poor reason for not using it. WILLIAM

G.

LENNOX.

Neurological Institute, Children’s Medical Center, Boston, Mass.

SANATORIUM NURSING

Sm,-Dr. F. J. Bentley, in his article of May 8, suggested that we should adopt in British institutions the less rigid regime of bed rest which he observed when visiting Swiss sanatoria. In this way, he thinks, the depressing outlook for patients awaiting admission to sanatoria, where wards have been closed because of the shortage of nurses, might be alleviated. Correspondence on his article indicated the interest it aroused. May I, be allowed to add a few as a sanatorium matron, comments ? In the thoracic surgery unit of.a sanatorium as many nurses will always be required as in the surgical ward of a busy general hospital ; but in the ordinary sanatorium wards it would be possible almost to halve the numbers of nurses at present employed, if the long rounds of bed-pannings, bed-washings, and bed-makings could be cut by half. Sanatorium doctors in this country are rightly reluctant to make any move towards lowering the standards of nursing ; but if, after weighing all the evidence, they could satisfy themselves that gentle walks to the ward washrooms and sanitary annexes would involve the expenditure of no more energy than the straining on bed-pans and washing in bed ; that a patient making his own bed, slowly taking his own time to do it (especially where the spring mattress which does not have to be turned is provided) is tiring himself less than

367 when he sits up for

an

hour to work at

occupational the staffing

therapy-then changes likely to alter outlook completely would be at hand1

Constant filling of hot-water bottles in the winter takes up many sanatorium nurse-hours. Is it likely that electric heaters will ever come into use ?P In sanatoria built in the pavilion style, the provision of a central office into which bells from every bedside would ring, might perhaps make it possible for a night sister (doing frequent rounds and having two " runner " nurses at her disposal) to give as good attention at night as five or six nurses do under the present system where a nurse must sit throughout the night in every ward. MARIE A. SIMPSON. ESTIMATION OF BASAL METABOLIC RATE SiR,-Your correspondents Miss Lovell and Dr. Martin (Feb. 12) are not quite fair to Dr. Bene. If their figures be tabulated in broad classes we obtain : R.P.

>

Basal metabolic rate +45

+25 to +45

<900

index.

900-

1300-

1300 *

1700

1700 +

5

8

..

2

4

..

2

- 5 to +25

1

8

1

< +5

6

3

4

2 ..

*

3

*

Of the 49 results which are all I can find in the scatterdiagram, 9 show gross lack of correlation between the basal metabolic rate and the R.P. index ; I have marked these with an asterisk. Dr. Bene claims a good correof results in about two-thirds of cases ; I submit that this claim is supported by the figures of Miss Lovell and Dr. Martin. I cannot help wondering whether Miss Lovell and Dr. Martin are not getting somewhat high basal metabolicrate results. A respiration-rate of 18 per min. and a pulse-rate of 64 per min. give an R.P. index of 1150 ; according to the scatter-diagram, in most cases this would be associated with a basal metabolic rate of at least + 20. ARTHUR JORDAN. Sheffield.

spondence

CONSCIOUSNESS AND ITS DISTURBANCES will be grateful to Dr. Purdon Martin for his lucid exposition of current knowledge of the cortical and hypothalamic foundations of consciousness (Lunileian lectures, Lancet, Jan. 1 and 8). Some, however, will find something to ponder over in his statement that it is generally agreed that we cannot detect any awareness of mental processes ; all awareness of self seems to be bodily." The terminology here used is open to misunderstanding unless it is clearly understood that the same processes which, on the one hand, can be registered as biological epiphenomena of nervous activity (objective consciousness), can, on the other hand, also be seen in the light of psychology (subjective consciousness). In subsequent passages Dr. Purdon Martin does, indeed, more justice to these dual aspects by introducing ’ which, he argues, may be subjective self-awareness, based on a " body-and-mind image analogous to the body-image so important for objective consciousness. As regards the awareness of mental processes, it is true that we are never aware of their activation on the biological (neuro-associative) level. It has, however, been1 shown by a certain school of experimental psychology that we can reflect upon the formal characteristics (apart from the contents) of mental processes, not concurrently but immediately after we have performed them (e.g., on how we have reached a conclusion or on how we have formed a new concept). Mental processes are too often thought of as atolllistic and momentary, whereas they can be embodied into dynamic wholes extending over a period of time, as in a mental conflict when we may be aware of its various phases. Even in " dream work," which is going on while the awareness

SiR,,-Psychiatrists

"

1. Kuelpe, O.

Report of Congress of Experimental Psychology, 1904. Ach, N. On Volitional Activity and Thinking. 1905. Buehler, K. Facts and Problems of a Psychology of Thinking, Arch. Psychol. 1907, 9. Titchener, E. B. Lectures on the Experimental Psychology of Thought-Processes. New York, 1913. 1909. Selz, O. The Laws of Ordered Thinking.

of the body-self is relatively dormant, there can be full recollective awareness of formal features as well as of contents extending over a sequence of scenes. The great bearing which problems of self-awareness have on psychopathology and psychotherapy need hardly be stressed. STEPHEN KRAUSS. Sedgefield, co. Durham. GOLDS

SiB,—Colds do not affect those who live and sleep in the open air, children kept in open-air schools, or patients living and sleeping in the open air ; while nurses who attend them and occupy warmed rooms suffer. Soldiers in trenches suffered colds only when coming home on leave ; lumberers, working in arctic cold, had pneumonia only when given a warmed hut to sleep in ; arctic travellers marooned on an ice-floe for weeks and exposed to the greatest cold were free from illness such as is attributed to exposure to cold in the popular mind. In Open Air and Sunshine (London, 1924) I dealt at length with the great protective effect of cold air on the respiratory membrane. Such air, even if misty, when heated up to nearly body-temperature in the breathing passages, becomes relatively dry ; and taking up much moisture, evaporated from their membranes, is expired almost saturated with water vapour at that temperature to which it is warmed. This means much blood flowing through the capillaries of the membranes, and secretion by these. Comparing a crowded room at 72’F, and almost saturated with moisture, with open air at 40°F, the evaporation will be in the whole day about 200 g. of water in the former and about 350 g. in the latter case.

The increased breathing produced by much active exercise may double this output, and heat-loss from the membranes may become nearly 4 times greater in the open air, and the evaporation 31/2 times greater. The mucous membranes are then far more thoroughly swept with arterial blood and washed with secretion, and so defended from infection, which in its turn is minimal out of doors. The dusty air in rooms may also be of evil influence in the cleansing of the membranes by the ciliated epithelium. In the cold wind the eyes water and the nose runs, through the enhancement of secretion, to keep the membranes at near body-temperature. In the case of air saturated at 85°F, as might be in a very crowded warm room, the evaporative and heat losses might be 10 times less than in the open air. Workers in chemical factories where there is escape of a small quantity of an irritant, such as sulphur dioxide, are reported to be relatively free from colds ; so too snuff-takers. The Victorian habit of using smelling-salts may have been of benefit by exciting secretion. In the summer people are far more in the open air, and return from holidays to stuffy heated railway carriages, and rooms where infection is spread. Thus colds become prevalent when wintry weather begins. LEONARD HILL. Smallfield, Surrey.

SIR9

A PUBLIC DIET RESTAURANT W’hen in Prague last December, I dined at the

Public Diet Restaurant. This interesting new social service is being developed by U.R.O. (the Czech T.U.C.) in conjunction with three doctors. Two meals are served-at midday and in the evening. The restaurant is subsidised by -U.R.O., so the price of the meal is halved ; it is 2s. for the regular customer and 3-4s. for the casual diner. As is usual in Czechoslovakia, some ration tickets have to be given up ; but the special-diet rations provided make this less of a hardship than for the average person. A doctor’s prescription is necessary to entitle one to a meal. The cooking is done, by two dietitians and two cooks, under the supervision of a doctor, who visits the restaurant daily and whose name is printed on the The food is really good-well chosen and cooked, menu. and served in style, as might be expected of a good restaurant. This attractive presentation must be doubly welcome to people faced with the deprivations and difficulties of a special diet, and bereft of the comforts of favourite foods. Still more helpful must be the restful and luxurious atmosphere of the dining-room,