1944

Annotations

EXEMPLARY EATING

THERE was a time when hospital patients on dietacarnis (or even dieta dimidia) left chunks of mutton faton the side of their plates, when the sewage disposalunit was blocked with putrefying fat from the kitcheneffluent, and when rats frequented the dump to pickup the protective foods on which they could rear Vic-torian families. Waste in this gross sense has diminished,often to vanishing point, in many of our hospitals,primarily no doubt on economic grounds, but alsoas one of the results of the absorbing interest in foodwhich has made it the most discussed subject of our-time. The memo 1 of the King’s Fund came at anopportune moment. It had a good press and not onlyreached the voluntary hospitals but was distributedas well by the Ministry of Health to municipal hospitalsand sanatoria. From the beginning of the year the helpof Miss Margaret Broatch, secretary of the Fund’s

advisory committee, has been available to any hospitalin need of it. Miss Broatch has had wide experiencein America and in ,this country where she has supervisedschool meals over the whole LCC area. The Ministryof Health has now appointed two women dietitiansof its own : Miss H. G. Cairney, lately in charge of theLCC diabetic unit at Brentwood, and Miss M. R. Murielof the Ministry of Food, who has made surveys of

hospital feeding. During the past four years 300

hospitals have had the benefit of Captain J. Fraser’sexpert advice on catering and kitchen equipment.Obviously the spirit is willing ; but the body to bemoved is of terrific size and inertia.We are not a whit behind any other country in

nutritional research, as Mottram has assured Us butit is not much use, he says, finding out what people oughtto eat if there is no, satisfactory way of letting themknow about it. Few people pay attention to what iswritten, even by the Ministry of Health. Experienceis the only effective teacher and in the hospital ward isunparalleled opportunity for providing this experienceat a time when attention both of patient and his friendsis keen. Set an example there and it will be carried intothe homes of the people. Offer them day after daythe same tepid rice pudding, the same congealed gravy,the same familiar fish with its coating of salmon-colouredsauce (our repetition is intentionall) and you can

hardly expect them to realise " the value of rightly-chosen and well-prepared food as a basic factor in thetreatment of every patient "-let alone write homeabout it. The King’s Fund memo lays down the

principle : the food service should be regarded as one ofthe essential remedial services offered by the hospitals.Diet is just as important for the man with a fracturedfemur or a septic wound as it is for the diabetic or theansemic. Special diets have followed closely on medicalknowledge, but the general dietary has dropped behindthe times, and financial stringency has pressed morehardly and unfairly on the catering department thanon other hospital services. At the Vancouver GeneralHospital the director of dietetics controls a quarter ofthe total hospital expenditure, and his department hasmoved upward from mere " food service " status to

high therapeutic rank. Greater variety and nutritionalvalue in meals can be secured without increased materialcost ; but the price of knowledge and imagination mustbe paid for them. It is a question of organisation.The memo puts it incisively : " The steward may regardeconomy as the measure of his efficiency; for the matrondifficulties of staff may tend to be predominant ; whilea dietitian may concentrate rather on food values thanon practical considerations." Every hospital therefore1. Hospital Diet. From the Secretary, King Edward’s Hospital

Fund for London, 10, Old Jewry, London, E.C.2. 6d. postfree. See Lancet, 1943, ii, 673. 2. Lancet. 1943, i, 475.

should have its food service committee, representing-all parties, competent to set an exemplary standard and

. determined to see it carried out.TWO METHODS OF ANALGESIA

Nitrous oxide in subanaesthetic doses is a well provedanalgesic and is used every day for that purpose inobstetrics. Some American work suggests that thepotentialities of even lower concentrations than those-usually employed have not been sufficiently investigatedChapman, Arrowood and Beecher 1 have studied the pain-relieving action of very low concentrations of nitrousoxide in oxygen and compared it with that of averageclinical doses of morphine. Every effort was made tocontrol the possible sources of error. They observed theeffect of inhaling mixtures of nitrous oxide and oxygenon the thresholds. for pain of two sorts-from heating the-skin of the forehead, and from exercising the hand whilethe upper limb was rendered ischaemic by a cuff tourni-quet on the arm. In normal healthy adults a mixture of20% nitrous oxide and 80% oxygen raised the thresholdto these two types of pain to the same extent as gr. 4 ofmorphine. Nitrous oxide in this concentration did notproduce any undesirable side effects, nor did it impairconsciousness ; indeed it must surprise many that itproduced even analgesia. The elevation of the painthreshold rem;1ins constant as long as the administrationis continued ; the effect of a single dose of morphine, onthe other hand, rises to a maximum and then as it is.metabolised gradually passes off. Another method of

producing analgesia, first described by Lundy,2 is theintravenous injection of dilute procaine. Procaine,although strikingly safe when used for infiltration inthe orthodox manner, has been followed by gravereactions on occasions when it has been inadvertentlyinjected intravenously. But Gordon s has given up to1 gramme in l hours as a 0-1% solution by intra-venous drip to ten patients with extensive burns,obtaining effective analgesia with no apparent undesir-able effects. It is interesting to know that the bodycan tolerate such large amounts of procaine administeredslowly in dilute solution, but a clear case has not yet beenmade out for their superiority over morphine or sub-anaesthetic doses of the common anaesthetics. Thus,during the " blitz " and the Battle of Britain, when largenumbers of burnt people had to be treated, morphine orsmall doses off Pentothal ’ proved safe and efficient fortiding over their most painful periods.

CHRONIC MELIOIDOSIS IN A EUROPEAN

SINCE Whitmore and Krishnaswami described a

" glanders-like " disease in a man in Rangoon in 1912many similar cases have been reported in Burma,Ceylon, French Indo-China, the Dutch East Indies,Malaya and Siam. Stanton and Fletcher in 1925named the disease melioidosis and the causative organismB. whitmori. Topley and Wilson assigned the organismsto the pfeifferella group and it is now called Pf. whitmori.Most of the recorded cases have been in natives and havebeen acute. Of the chronic cases the first in a Europeanwas published in 1943 by Grant and Barwell.4 Inthat case there was long-continued pyrexia beforeradiological signs suggested vertebral tuberculosis with .widespread active pulmonary disease; no tuberclebacilli were discovered in many sputum examinations ;various sulphonamide treatments had uncertain results.Besides the vertebral column one external malleolus andthe frontal bone were involved. A second chronic casein a European has been described by Mayer and Fin-layson.s A Regular Army soldier was 33 when hisillness started in Malaya in June, 1940, with pain in the1. Chapman, W. P. Arrowood, J. G. and Beecher, H. K. J. clin.

Invest. 1943, 22, 871.2. Lundy, J. S. Clinical Anesthesia, Philadelphia, 1942, p. 583.3. Gordon, R. A. Canad. med. Ass. J. 1943, 49, 478.4. Grant, A. and Barwell, C. Lancet, 1943, i, 199.5. Mayer, J. H., Finlayson, M. H. J. R. Army med. Cps, 1944, 82, 4.