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SHORTAGE OF NURSES
833
Letters to the Editor SHORTAGE OF NURSES SIR,—Professor McNee has touched on the difficulty of " bridging the gap " between school-leaving age and the age of entering hospital as a student nurse. His plan for nurse-training colleges for girls of school-leaving age would, I suggest, carry specialisation back too far. In such colleges the girls would presumably be working only with those who intended also to enter the nursing profession. Whether he refers to the secondary-school leaver of 16, or the younger primary-school leaver, the " gap " should be a time to widen out and learn to live in the world, rather than to join a community of pros-
pective
nurses.
The training course for the nursing profession is a resident one ; it takes from three to four years, and in spite of increased off-duty time it is still sufficiently strenuous mentally and physically to limit the amount and range of outside interests which a girl can follow while she is training. If she has gone into hospital with a restricted outlook she may develop the " shop " mentality and conversational habit which our patients often deplore in their private nurses, and which have various ill effects in hospital life also. Now that girls can begin the hospital course at 18 or even younger, it seems more important than ever that in the earlier impressionable years the future nurse should make contact with many different interests, learn to mix easily with many different types of her fellow-creatures, and widen her experienceof human nature and of the world around her. Fortunately our present social habits make this easier for girls in their teens than it has ever been before. I realise the practical importance of keeping up interest in nursing during this time. Surely the solution is to be found in the arrangement whereby girls can take a pre-nursing course in the sixth form of their secondary or public school, or a full-time or part-time course at a technical college. These pre-nursing courses, which are approved by the Ministry of Education, already contain all the elements of value in Professor McNee’s plan. The curriculum provides for continued general education and gives also the special subjects for part i of the preliminary State examination for nurses-anatomy, physiology, and hygiene, together with some elementary -chemistry and physics, invalid cookery, first-aid, and visits to hospitals. It may well be that the pre-nursing course is capable of improvement in the light of experience, but even in its present form it is a useful preparation for hospital work. The girl who takes it is working with colleagues preparing for many other occupations and has teachers with a wider equipment than that of the average sistertutor, excellent as she may be for the actual nursing work later. It lightens the work of the first year of training and it is already given in over 200 schools and colleges, the addresses of which can be had from the Nursing Recruitment Centre. H. MORLEY FLETCHER, Chairman, Nursing Recruitment Committee. Nursing Recruitment Centre, 21, Cavendish Square, London, W.1. THYROTOXICOSIS TREATED WITH THIOURACIL SIR,—Dr. Wilson’s interesting paper of May 4, comparing the actions of thiouracil and methyl thiouracil in thyrotoxicosis, prompts me to add some personal --
-
-
-
observations.
I can confirm that, on the whole, the lag period between the start of treatment and the relief of symptoms is shorter with methyl thiouracil than with thiouracil. I have used even smaller doses of the former than Dr. Wilson (0-4-0-6 g. per day) with good results. It seems .to be important to make single doses as small as possible and to spread them evenly over the day (e.g., 8-11 single doses of 0-05 g.). Although gross enlargement of the thyroid gland is Unusual with this dosage of methyl thiouracil, some enlargement of the gland and a definite increase in firmness occurred in most patients. Larger doses produce thyroid hyperplasia, probably to the same extent as does thiouracil. A retrosternal goitre should be regarded as a contra-indication to both drugs, though small doses
methyl thiouracil may be tried. I have seen one patient with a retrosternal goitre who developed severe intrathoracic pressure symptoms (stridor, dyspnoea, Considerable improvement followed cyanosis, &c.). discontinuation of treatment and was kept up by a maintenance dose of 0.025 g. of methyl thiouracil. Exophthalmos in fully developed cases does not seem to be affected, even when small doses of thyroid are added after all the other symptoms have abated. Lidretraction responds well; this effect must not be mistaken for an improvement of the actual proptosis. Like Dr. Wilson, I have seen no successes in cases of anxiety of
’
neurosis.
A complication which, though apparently rare, necessitates discontinuation of treatment is drug,fever. Therise in temperature may be high {102°-103° F). In one case treatment with 0-6 g. of methyl thiouracil per day was tolerated well until the 14th day when high temperature set in. The temperature fell to normal immediately after treatment was stopped but fever recurred after the third tablet was taken on resumption of treatment. Similar observations were made by R. H. Williams et al. (J. clin. Endocrinol. 1946, 6, 23). It is interesting that in my case fever was accompanied by a rise in the number of white blood cells (from 5000 to 9000 per c.mm.) and that the differential white count showed an increase of polymorphs and a decrease of the initial lymphocytosis. I have not found other reports on the blood-count during febrile reactions due to thiouracil or methyl thiouracil, but this observation suggests a stimulation of granulopoiesis contrary to the suppression which these drugs
usuallv produce.
H. H. UCKO.
London, W.1.
ARTIFICIAL PNEUMOPERITONEUM
SIR,—Dr. Simmonds’s excellent article (April 13,
prompts me to offer some observations therapeutic pneumoperitoneum.
on
p. 530) the conduct of
Site of Air Injection.—In seems immaterial whether air is introduced on the right or the left side of the abdomen, since, once introduced intraperitoneally, it tends to collect more readily under the paralysed than the non-paralysed hemidiaphragm. This is a point of some importance since trauma of the liver is a possible, though very rare, cause of airembolism, as it was in Dr. Simmonds’s case 1. Position of the Patient.-The fate of the air after injection can be considerably influenced by attention to this factor after induction and refills. My patients are always instructed to assume that position in bed which renders the paralysed hemidiaphragm as nearly as possible the highest part of the abdomen. This device, with moderately vigorous massage of the abdomen, encourages the air to accumulate under the paralysed half of the diaphragm. This is particularly useful on first waking in the morning when much of the air may have become displaced owing to the various postures assumed during the previous night’s sleep. Manometric Pressure Observations.-Dr. Simmonds rightly points out that no negative pressure readings are obtained during induction or refills of pneumoperitoneum. I cannot persuade myself that any true readings are ever obtained during P.P. refills. A manometric " swing " is only observed when the air is actually being introduced. This swing is, however, in no sense a record of intraperitoneal pressure but is merely a reflexion of the varying resistance presented by the apparatus and the contents of the abdomen to the flow of air. Only occasionally is a swing observed which is synchronous with respiratory movements and which reflects alterations in the resistance to the inflow of air relative to those movements. The exact nature, of this swing is determined by the respiratory movements of the unparalysed hemidiaphragm and the abdominal wall. If little movement of the abdominal wall takes place then the manometric pressure goes up during inspiration and down during expiration (the opposite of what is observed during A.P. refills), and vice versa if the respiratory movements of the abdominal wall are well marked. All these manometric readings are, however, not actual measurements of intraperitoneal pressure. It is, therefore, difficult to understand what Dr. Simmonds means when he refers to "pressure + 5 em." in case 1, " pressure 4- 10 em." in case 7, and a "final pressure of +12 em." in case 8, unless he is referring to a pressure recorded with the point of the needle free in the total collection of air and with no air flowing through the apparatus
coupled
Letters to the Editor SHORTAGE OF NURSES SIR,—Professor McNee has touched on the difficulty of " bridging the gap " between school-leaving age and the age of entering hospital as a student nurse. His plan for nurse-training colleges for girls of school-leaving age would, I suggest, carry specialisation back too far. In such colleges the girls would presumably be working only with those who intended also to enter the nursing profession. Whether he refers to the secondary-school leaver of 16, or the younger primary-school leaver, the " gap " should be a time to widen out and learn to live in the world, rather than to join a community of pros-
pective
nurses.
The training course for the nursing profession is a resident one ; it takes from three to four years, and in spite of increased off-duty time it is still sufficiently strenuous mentally and physically to limit the amount and range of outside interests which a girl can follow while she is training. If she has gone into hospital with a restricted outlook she may develop the " shop " mentality and conversational habit which our patients often deplore in their private nurses, and which have various ill effects in hospital life also. Now that girls can begin the hospital course at 18 or even younger, it seems more important than ever that in the earlier impressionable years the future nurse should make contact with many different interests, learn to mix easily with many different types of her fellow-creatures, and widen her experienceof human nature and of the world around her. Fortunately our present social habits make this easier for girls in their teens than it has ever been before. I realise the practical importance of keeping up interest in nursing during this time. Surely the solution is to be found in the arrangement whereby girls can take a pre-nursing course in the sixth form of their secondary or public school, or a full-time or part-time course at a technical college. These pre-nursing courses, which are approved by the Ministry of Education, already contain all the elements of value in Professor McNee’s plan. The curriculum provides for continued general education and gives also the special subjects for part i of the preliminary State examination for nurses-anatomy, physiology, and hygiene, together with some elementary -chemistry and physics, invalid cookery, first-aid, and visits to hospitals. It may well be that the pre-nursing course is capable of improvement in the light of experience, but even in its present form it is a useful preparation for hospital work. The girl who takes it is working with colleagues preparing for many other occupations and has teachers with a wider equipment than that of the average sistertutor, excellent as she may be for the actual nursing work later. It lightens the work of the first year of training and it is already given in over 200 schools and colleges, the addresses of which can be had from the Nursing Recruitment Centre. H. MORLEY FLETCHER, Chairman, Nursing Recruitment Committee. Nursing Recruitment Centre, 21, Cavendish Square, London, W.1. THYROTOXICOSIS TREATED WITH THIOURACIL SIR,—Dr. Wilson’s interesting paper of May 4, comparing the actions of thiouracil and methyl thiouracil in thyrotoxicosis, prompts me to add some personal --
-
-
-
observations.
I can confirm that, on the whole, the lag period between the start of treatment and the relief of symptoms is shorter with methyl thiouracil than with thiouracil. I have used even smaller doses of the former than Dr. Wilson (0-4-0-6 g. per day) with good results. It seems .to be important to make single doses as small as possible and to spread them evenly over the day (e.g., 8-11 single doses of 0-05 g.). Although gross enlargement of the thyroid gland is Unusual with this dosage of methyl thiouracil, some enlargement of the gland and a definite increase in firmness occurred in most patients. Larger doses produce thyroid hyperplasia, probably to the same extent as does thiouracil. A retrosternal goitre should be regarded as a contra-indication to both drugs, though small doses
methyl thiouracil may be tried. I have seen one patient with a retrosternal goitre who developed severe intrathoracic pressure symptoms (stridor, dyspnoea, Considerable improvement followed cyanosis, &c.). discontinuation of treatment and was kept up by a maintenance dose of 0.025 g. of methyl thiouracil. Exophthalmos in fully developed cases does not seem to be affected, even when small doses of thyroid are added after all the other symptoms have abated. Lidretraction responds well; this effect must not be mistaken for an improvement of the actual proptosis. Like Dr. Wilson, I have seen no successes in cases of anxiety of
’
neurosis.
A complication which, though apparently rare, necessitates discontinuation of treatment is drug,fever. Therise in temperature may be high {102°-103° F). In one case treatment with 0-6 g. of methyl thiouracil per day was tolerated well until the 14th day when high temperature set in. The temperature fell to normal immediately after treatment was stopped but fever recurred after the third tablet was taken on resumption of treatment. Similar observations were made by R. H. Williams et al. (J. clin. Endocrinol. 1946, 6, 23). It is interesting that in my case fever was accompanied by a rise in the number of white blood cells (from 5000 to 9000 per c.mm.) and that the differential white count showed an increase of polymorphs and a decrease of the initial lymphocytosis. I have not found other reports on the blood-count during febrile reactions due to thiouracil or methyl thiouracil, but this observation suggests a stimulation of granulopoiesis contrary to the suppression which these drugs
usuallv produce.
H. H. UCKO.
London, W.1.
ARTIFICIAL PNEUMOPERITONEUM
SIR,—Dr. Simmonds’s excellent article (April 13,
prompts me to offer some observations therapeutic pneumoperitoneum.
on
p. 530) the conduct of
Site of Air Injection.—In seems immaterial whether air is introduced on the right or the left side of the abdomen, since, once introduced intraperitoneally, it tends to collect more readily under the paralysed than the non-paralysed hemidiaphragm. This is a point of some importance since trauma of the liver is a possible, though very rare, cause of airembolism, as it was in Dr. Simmonds’s case 1. Position of the Patient.-The fate of the air after injection can be considerably influenced by attention to this factor after induction and refills. My patients are always instructed to assume that position in bed which renders the paralysed hemidiaphragm as nearly as possible the highest part of the abdomen. This device, with moderately vigorous massage of the abdomen, encourages the air to accumulate under the paralysed half of the diaphragm. This is particularly useful on first waking in the morning when much of the air may have become displaced owing to the various postures assumed during the previous night’s sleep. Manometric Pressure Observations.-Dr. Simmonds rightly points out that no negative pressure readings are obtained during induction or refills of pneumoperitoneum. I cannot persuade myself that any true readings are ever obtained during P.P. refills. A manometric " swing " is only observed when the air is actually being introduced. This swing is, however, in no sense a record of intraperitoneal pressure but is merely a reflexion of the varying resistance presented by the apparatus and the contents of the abdomen to the flow of air. Only occasionally is a swing observed which is synchronous with respiratory movements and which reflects alterations in the resistance to the inflow of air relative to those movements. The exact nature, of this swing is determined by the respiratory movements of the unparalysed hemidiaphragm and the abdominal wall. If little movement of the abdominal wall takes place then the manometric pressure goes up during inspiration and down during expiration (the opposite of what is observed during A.P. refills), and vice versa if the respiratory movements of the abdominal wall are well marked. All these manometric readings are, however, not actual measurements of intraperitoneal pressure. It is, therefore, difficult to understand what Dr. Simmonds means when he refers to "pressure + 5 em." in case 1, " pressure 4- 10 em." in case 7, and a "final pressure of +12 em." in case 8, unless he is referring to a pressure recorded with the point of the needle free in the total collection of air and with no air flowing through the apparatus
coupled