1120

1. Naimark, A., Brodovsky, D. M., Cherniack, R. M. Amer J. Med. 1960,28, 368.

The turnover of hospital domestic workers is high,mainly because of the competition from industry, and thereport deals with the non-financial factors which con-tribute to good relations between management and staff,and includes suggestions for training and supervision.Domestic work in hospitals presents many problems,and, as correspondents pointed out last year, many ofour hospitals are dangerously dirty. This report is a

timely reminder that in the control of infection cleanlinessis more important, and often cheaper, than polish.

DICHLORPHENAMIDE FOR RESPIRATORYINSUFFICIENCY

MUCH can now be done to tide the patient with chronicbronchitis and emphysema over an acute episode of

respiratory insufficiency, but chronic hypoxia and hyper-capnia tend speedily to exhaust therapeutic ingenuity.A favourable report by Naimark et al.I on the effect ofdichlorphenamide in this condition is, therefore, welcome.Dichlorphenamide, a new carbonic anhydrase inhibitorwith an activity estimated as 30 times that of acetazolamide,was given in a dosage of 200 mg. daily for from two to thirtyweeks to 15 hospital patients with hypercapnia persistingafter intensive routine therapy.

11 of these patients had emphysema, 1 had undergonethoracoplasty on account of pulmonary tuberculosis, 1 had

kyphoscoliosis, and 2 had pulmonary fibrosis; all had clinicalevidence of severe respiratory insufficiency associated with

hypoxia and hypercapnia. With 1 exception these patientsclaimed to have less dyspnoea, greater effort tolerance, and afeeling of well-being while receiving the drug. Clinical

improvement was associated with favourable changes in arterialgas .tensions : there was pronounced reduction in hypercapniain every patient but 1 (mean decrease 10-9 mm. Hg) and aconsistent rise in oxygen tension (mean increase 16-3 mm. Hg).Side-effects were absent, except for transient nausea in 2

patients and severe headache in 1. Withdrawal of the drug wasfollowed by clinical deterioration, increased hypercapnia, andhypoxia, and further administration by clinical recovery andmore favourable arterial gas tensions. The alveolar oxygentension rose in 7 out of 9 patients studied, and this changewas accompanied by a rise in arterial oxygen tension althoughin 5 of these subjects the alveolar-arterial oxygen gradientincreased: on the other hand, in 2 patients the arterial oxygentension rose although the alveolar oxygen tension did not, sothat in these the alveolar-arterial oxygen tension gradientdecreased. Alveolar ventilation was increased in the 7 patientswith a rise in alveolar oxygen tension: the mean increase was0’67 litre per minute, and the mean increase in minute ventila-tion was 0-6 litre per minute. The respiratory rate tended toslow and the tidal volume to increase.

Significant diuresis during dichlorphenamide therapy wasnoted in only 2 patients, and the arterial pH after an initialfall tended to return to the control level. The effect of the

drug on water and electrolyte excretion was specially studied in3 patients. In 2 receiving the standard ward diet, administra-tion of the drug resulted in significant diuresis with an

increased output of sodium, potassium, and chloride associatedwith a fall in arterial pH, serum-bicarbonate, and serum-sodiumand, despite the chloruresis, a rise in serum-chloride. The otherpatient was put on a fixed sodium-chloride intake, and herethere was transient diuresis, an increased output of sodiumand potassium, and very slight chloruresis; there was a fall inserum sodium and potassium and in arterial bicarbonate, arise in serum-chloride, and a gradual rise in arterial pH to thecontrol level after an initial fall.

Naimark et al. point out that the reduction in arterialcarbon-dioxide tension during dichlorphenamide therapy

2. Tenney, S. M., Tschetter, A. B. Amer. J. med. Sci. 1959, 237, 23.3. Mithoefer, J. C. J. appl. Physiol. 1959, 14, 109.

could be accounted for by increased alveolar ventilation,decreased tissue carbon-dioxide production, or a combina-tion of these factors. Alveolar ventilation did, in fact,increase in most patients, and, although changes incarbon-dioxide elimination or oxygen consumption werenot observed, Naimark et al. do not exclude the possibilitythat they may have been present. The hypothesis ofdecreased tissue carbon-dioxide production is supportedby the evidence that acetazolamide decreases the meta-bolic rate in rats.2 Although the resting ventilationincreased during dichlorphenamide therapy, the ventila-tory response to inhaled carbon dioxide in 3 healthy andin 3 emphysematous subjects did not indicate heightenedsensitivity of the respiratory centre to changes in arterialcarbon-dioxide tension. But in dogs acetazolamide hasbeen found to decrease elimination of carbon dioxide byincreasing the body carbon-dioxide stores 3; and Naimarket al. suggest that, owing to the carbonic-anhydrase-inhibiting effect of dichlorphenamide, the carbon-dioxide tension in the tissues and in the respiratorycentre may actually have been higher than it was beforetreatment, thus accounting for the increased ventilationand the lowered arterial-blood level. They do not considerthat relief of pulmonary congestion as a result of diuresisis likely to account for the improvement in gas tensions,for a significant diuretic effect was not demonstrated inmost patients who were notably benefited by treatment.

Further investigation is obviously needed to determineexactly how dichlorphenamide works, but meanwhile theresults of this interesting study strongly suggest that itwill prove valuable in the management of chronic

respiratory insufficiency.

HEALTH AND PRACTICE

Darbishire House is six years old, and without furtherdescription doctors throughout the world identify thisactive youngster as the child of Manchester Universityand the city of Manchester. A new pattern of medicalcare is being developed in centres such as this wherepractice, without (it is hoped) losing its personal char-acter, is being adapted to the advances of the presentday. At Darbishire House the general practitioner canwork to the same standard of efficiency as his hospitalcolleague, and he can teach this standard to others. Thestudent is taught that the practitioner’s responsibilityis towards the whole person-indeed the whole family-and that where he cannot himself fulfil this responsibilityhe should do so through the special skills of others whowork with him. A full-time social worker is based on theManchester unit; and the district nurses and midwivesare also members of the practice team in whose workprevention and therapy merge.

If the. idea of integrated preventive and therapeutichealth care based on general practice is now accepted,the methods by which this is to be achieved are still farfrom settled. In centres such as Darbishire Housedifferent methods can be tested. Further operationalresearch into the activities of general practitioners is

urgently needed both in health-centre practices and inthose of conventional type. The universities of Man-chester, Edinburgh, and Bristol, each of which has

developed its teaching health centre in its own way, haveshown that the partnership between don and practitionercan be fertile. Others might usefully do the same.