- Email: [email protected]
THE NURSE IN PREVENTIVE MEDICINE
924 still under discussion and must be modified by experience ; but at present we are using 10 minutes of the normal 30 minutes’ P.T. session. To operate this scheme, it has been necessary to give lectures on general posture to the school-teachers, and to instruct them in the selected remedial exercises. We have found them most cooperative, for they realise the benefit of the non-interruption of the child’s schooling. This has been coupled with talks and demonstrations to the parents, to point out the value to general health of continued good posture. Although the scheme has been in progress less than a year, it is already yielding most HORACE DAVIES encouraging results. Consultant orthopædic surgeon, County Borough of Birkenhead. PULMONARY ŒDEMA I be allowed to bring another point of view SiR,-May on this fascinating problem, so well defined by Prof. G. R. Cameron?1 If the patient calls you in, early, if the doctor arrives promptly before the pink sputum appears in abundance, and if the previous reading of the systolic and diastolic blood-pressures are known-then, in my experience, the pressure will be found considerably raised. The systolic pressure may go up 30 mm. or 50 mm. Hg and the diastolic one correspondingly. It does not seem to me very easy to explain that by an oncoming heart-failure. It is probably the result of the angiospasm in the pulmonary area-hence the prompt and life-saving effect of a liberal venesection. Moreover, I usually inject intravenously or intramuscularly a hypertonic solution of magnesium, and the patient is much better within a few hours. But I agree that heartfailure supervenes very quickly, and later it completely dominates the picture. N. PINES. Ijondon, E.1. MODE OF ACTION OF THE
SULPHONAMIDE
DERIVATIVES recent publications 23 make desirable brief account of our current investigations on the above subject, since the interpretation of the results obtained elsewhere is likely to be influenced by our
SiR,—Two
a
findings. O’Meara, McNally, and Nelson4 first correlated the activity of the sulphonamides with the production of reductone by bacteria especially during the logarithmic phase of growth. They showed that p-(2 : 3-dihydroxy2-ene-propylideneamino) benzoic acid (reductone-paminobenzoic acid) can be utilised by bacteria, whereas the corresponding sulphapyridine and sulphathiazole analogues cannot. They thus showed that the sulphonamides are lethal for bacteria because they condense with reductone, thereby depriving the cell of this substance. Forrest and BValker3 suggest, on chemical grounds, that reductone-p-aminobenzoic acid is built into pteridines in normal bacterial metabolism, whereas in the presence of sulphonamides the analogous sulphonamido We prefer to hold that compounds are formed. reductone-p-aminobenzoic acid is the starting-point for many normal intracellular growth reactions. including (a) those yielding energy, (b) assimilation of carbon, (c) synthesis of purines,5 and (d) synthesis of pteridines. It follows that all these reactions are blocked simul. taneously by union of reductone with sulphonamides, and that the made of action of the sulphonamides is to combine with reductone, as stated by O’Meara et al.3 This view is much more ih accord with the known lethal activity of the sulphonamides in the logarithmic phasit, of growth than is the attribution of their activity to inhibition of a single isolated function of the cell such as the synthesis of folic acid. We have repeated the work of O’Meara et aL3 and have investigated the products obtained when reductone, in crude solution, is condensed with p-aminobenzoic acid,
sulphanilamide, sulphathiazole, sulphapyridine, sulpha-
Lancet, May 1, p. 680. The lecture appears in full in the British Medical Journal of May 22. Angier et al. J. Amer. chem. Soc. 1948, 70, 25. Forrest, H. S., Walker, J. Nature, Lond. 1948, 161, 721. 4. O’Meara, R. A. Q., McNally, P. A., Nelson, H. G. Ibid, 1944, 1. See
2. 3.
154, 796; Lancet, 1947, ii, 747.
5. Shive et al.
J. Amer. chem. Soc. 1947, 69, 725.
mezathine, and p.p’-diaminodiphenyl sulphone. clear that these condensation anils of the type
products
are
It is
monohydrated .
‘
CH(0:H)=C(OH)-CH-N-C,,H-R. H20. Our work confirms that of Angier et awl. in so far as the p-aminobenzoic acid derivative is concerned. Our conclusions are based on ultimate analysis and for
reductone-p-aminobenzoic
acid on colorimetric estimation of the p-aminobenzoic acid content, using Mhrlich’s reagent, after hydrolysis with sodium hydroxide. It was also shown that the water of hydration could be removed at 100 °C, or in a desiccator. Water is taken up again on standing in air. In view of the condensation of reductone-p-aminobenzoic acid with 2:4:5-triamino-f)hydroxypyrimidine by Forrest and Walker,3we wish to state that we havecondensed reductone-p-aminobenzoic acid with urea. A full account of our work will be published elsewhere. One of us (E. A. B.) is in receipt of a grant from the Sarah Purser Medical Research Fund. E. A. BELL University Chemical Laboratory WESLEY COCKER and School of Pathology, R. A. Q. O’MEARA. Trinity College, Dublin. THE NURSE IN PREVENTIVE MEDICINE SiR,—I should like to endorse the remarks of Dr. Booth in your issue of May 1, particularly in regard to diphtheria immunisation. It will be difficult to keep up the present immunisation-rate if the work is left to general practitioners, who will have little time for it. It should be remembered that diphtheria immunisation must be a continuous process in routine preventive medicine, and not dependent on immunisation campaigns ; these
intermittent periods of intense activity are often followed by periods when insufficient is done to keep pace with the number of births-the crucial number for any area. I firmly believethat diphtheria immunisation should be done principally by medical auxiliaries such as health visitors, and not by medical practitioners. It is well known that people tend to do the work that is approaching the upper limit of their training or capabilities more conscientiously and.with greater care than when it tends towards the lower limits. So with diphtheria immunisation : the nurse finds it interesting. and it adds to her importance, while the doctor finds it irksome and
repetitive. In 1942 in New Zealand I introduced
a
scheme for
diphtheria immunisation, using district health nurses (health visitors) to cover a large, sparsely-populated area. The pre-school immunisation-rate was raised from 8 % to 70 % in eighteen months, which would not have been possible if general practitioners or clinics alone had been used. A high proportion of the injections was given in the homes. during routine visits by nurses. I understand that a scheme of this type, employing district health nurses, has now been introduced to cover the whole countrv. The annual report for 1946 shows that of the 66,500 complete immunisations done in that year (New Zealand’s population is 1,700,000), 24,000 were done by district health nurses in- the six-month period April-September, suggesting that in a full year they do the major part of this work. C. W. DIXON Lecturer and Chief Assistant, Department of Preventive Medicine and Public Health. The University, Leeds. HIGHER
QUALIFICATIONS StR,—Special diplomas are granted in almost all branches of medicine. Their significance appears to lessen with each successive advertisement ; and it now seems that there is no other specialist qualification but the M.R.C.P. Within the last twelve months advertisers have stipulated only a higher medical - qualification when filling posts requiring special knowledge of (1) administrative work, (2) industrial medicine, and (3) child health. I submit that the requirement is really a D.p.H.. D.LH., D.C.H., or whatever is the appropriate diploma : then might be added "and preferably a higher medical qualification." At the present rate no-one at all will be able to practise anything without an M.P.c.p.
BURMA STAR.
SULPHONAMIDE
DERIVATIVES recent publications 23 make desirable brief account of our current investigations on the above subject, since the interpretation of the results obtained elsewhere is likely to be influenced by our
SiR,—Two
a
findings. O’Meara, McNally, and Nelson4 first correlated the activity of the sulphonamides with the production of reductone by bacteria especially during the logarithmic phase of growth. They showed that p-(2 : 3-dihydroxy2-ene-propylideneamino) benzoic acid (reductone-paminobenzoic acid) can be utilised by bacteria, whereas the corresponding sulphapyridine and sulphathiazole analogues cannot. They thus showed that the sulphonamides are lethal for bacteria because they condense with reductone, thereby depriving the cell of this substance. Forrest and BValker3 suggest, on chemical grounds, that reductone-p-aminobenzoic acid is built into pteridines in normal bacterial metabolism, whereas in the presence of sulphonamides the analogous sulphonamido We prefer to hold that compounds are formed. reductone-p-aminobenzoic acid is the starting-point for many normal intracellular growth reactions. including (a) those yielding energy, (b) assimilation of carbon, (c) synthesis of purines,5 and (d) synthesis of pteridines. It follows that all these reactions are blocked simul. taneously by union of reductone with sulphonamides, and that the made of action of the sulphonamides is to combine with reductone, as stated by O’Meara et al.3 This view is much more ih accord with the known lethal activity of the sulphonamides in the logarithmic phasit, of growth than is the attribution of their activity to inhibition of a single isolated function of the cell such as the synthesis of folic acid. We have repeated the work of O’Meara et aL3 and have investigated the products obtained when reductone, in crude solution, is condensed with p-aminobenzoic acid,
sulphanilamide, sulphathiazole, sulphapyridine, sulpha-
Lancet, May 1, p. 680. The lecture appears in full in the British Medical Journal of May 22. Angier et al. J. Amer. chem. Soc. 1948, 70, 25. Forrest, H. S., Walker, J. Nature, Lond. 1948, 161, 721. 4. O’Meara, R. A. Q., McNally, P. A., Nelson, H. G. Ibid, 1944, 1. See
2. 3.
154, 796; Lancet, 1947, ii, 747.
5. Shive et al.
J. Amer. chem. Soc. 1947, 69, 725.
mezathine, and p.p’-diaminodiphenyl sulphone. clear that these condensation anils of the type
products
are
It is
monohydrated .
‘
CH(0:H)=C(OH)-CH-N-C,,H-R. H20. Our work confirms that of Angier et awl. in so far as the p-aminobenzoic acid derivative is concerned. Our conclusions are based on ultimate analysis and for
reductone-p-aminobenzoic
acid on colorimetric estimation of the p-aminobenzoic acid content, using Mhrlich’s reagent, after hydrolysis with sodium hydroxide. It was also shown that the water of hydration could be removed at 100 °C, or in a desiccator. Water is taken up again on standing in air. In view of the condensation of reductone-p-aminobenzoic acid with 2:4:5-triamino-f)hydroxypyrimidine by Forrest and Walker,3we wish to state that we havecondensed reductone-p-aminobenzoic acid with urea. A full account of our work will be published elsewhere. One of us (E. A. B.) is in receipt of a grant from the Sarah Purser Medical Research Fund. E. A. BELL University Chemical Laboratory WESLEY COCKER and School of Pathology, R. A. Q. O’MEARA. Trinity College, Dublin. THE NURSE IN PREVENTIVE MEDICINE SiR,—I should like to endorse the remarks of Dr. Booth in your issue of May 1, particularly in regard to diphtheria immunisation. It will be difficult to keep up the present immunisation-rate if the work is left to general practitioners, who will have little time for it. It should be remembered that diphtheria immunisation must be a continuous process in routine preventive medicine, and not dependent on immunisation campaigns ; these
intermittent periods of intense activity are often followed by periods when insufficient is done to keep pace with the number of births-the crucial number for any area. I firmly believethat diphtheria immunisation should be done principally by medical auxiliaries such as health visitors, and not by medical practitioners. It is well known that people tend to do the work that is approaching the upper limit of their training or capabilities more conscientiously and.with greater care than when it tends towards the lower limits. So with diphtheria immunisation : the nurse finds it interesting. and it adds to her importance, while the doctor finds it irksome and
repetitive. In 1942 in New Zealand I introduced
a
scheme for
diphtheria immunisation, using district health nurses (health visitors) to cover a large, sparsely-populated area. The pre-school immunisation-rate was raised from 8 % to 70 % in eighteen months, which would not have been possible if general practitioners or clinics alone had been used. A high proportion of the injections was given in the homes. during routine visits by nurses. I understand that a scheme of this type, employing district health nurses, has now been introduced to cover the whole countrv. The annual report for 1946 shows that of the 66,500 complete immunisations done in that year (New Zealand’s population is 1,700,000), 24,000 were done by district health nurses in- the six-month period April-September, suggesting that in a full year they do the major part of this work. C. W. DIXON Lecturer and Chief Assistant, Department of Preventive Medicine and Public Health. The University, Leeds. HIGHER
QUALIFICATIONS StR,—Special diplomas are granted in almost all branches of medicine. Their significance appears to lessen with each successive advertisement ; and it now seems that there is no other specialist qualification but the M.R.C.P. Within the last twelve months advertisers have stipulated only a higher medical - qualification when filling posts requiring special knowledge of (1) administrative work, (2) industrial medicine, and (3) child health. I submit that the requirement is really a D.p.H.. D.LH., D.C.H., or whatever is the appropriate diploma : then might be added "and preferably a higher medical qualification." At the present rate no-one at all will be able to practise anything without an M.P.c.p.
BURMA STAR.