415

trial can establish or refute the practical value of anytreatment. Freedman did, in fact, treat a group of

patients for a longer period. This part of his investi-gation was, however, uncontrolled, and serves mainlyto establish the superiority of chloroquine over mepacrinein terms of toxic effects. Freedman wisely concludedthat the trial did not definitely prove the value of

prolonged treatment with chloroquine in rheumatoidarthritis, but he believed that his data warranted a

larer investigation.

1. London County Council : Report of the County Medical Officerof Health and Principal School Medical Officer for the Year1955. Issued from County Hall, S.E.1. Pp. 193. 2s. 6d.

HELP IN THE HOME

TODAY any report worthy of the name-whether aboutold people or babies, hospitals or clinics, general prac-titioners or consultants, the family or the isolate,tuberculosis or mental disease-is likely to recommend" the development of the domiciliary services." In aworld of almost frightening scientific progress and mech-anical complexity, it is perhaps rather consoling that theanswer to many urgent medical problems should be thesimple words " more help in the home." But theirsimplicity is deceptive, and some of the difficulties,achievements, and resources which they cover will befound by the attentive reader of the recent report onLondon’s health.lThe three principal services which offer help in the

home are the home nurses, the home helps, and thehealth visitors. In London the home nurses are providedby 27 voluntary associations acting as agents for theLondon County Council through the Central Council forDistrict Nursing in London. At the end of 1955, 572whole- or part-time nurses were available, of whom 49were men. This force paid nearly 2 million visits, givingan average of 13 visits daily and a case-load of 24 foreach nurse. 41 % of the patients were over sixty-five yeai sof age and 6% were children under five. Besides pro-viding the associations with a grant of 93% of their

expenses, the L.C.C. lent them 21 cars, and at the

beginning of 1955 it appointed a supervisor who hasduring the year visited all the associations and where

necessary advised in day-to-day problems. Through theBritish Red Cross Society the L.C.C. also lends nursingequipment for patients who are getting care in theirhomes. The demand for expensive and unusual equip-ment is growing because many chronic sick and disabledwho were formerly held to be hospital cases are now ableto live at home. For example, as a result of the workof the National Spinal Injuries Unit at Stoke MandevilleHospital, many more paraplegics are now able to lookafter themselves.The home-help service is also growing steadily if

slowly. At the end of 1955, there were 3148 helps-theequivalent of 2029 full-timers-compared with 2996 and1866 respectively in 1953. Over 80% of their work in1955 was for the aged and chronic sick. This service isshort of staff; but, thanks to the policy of giving someassistance to all in need, only 61 applications had to bedeferred or refused in 1955 compared with 161 in 1954.Night helps sit with patients in their homes to allowrelatives to get some sleep ; but, surprisingly, the demandon this useful aid is not heavy, and in 1955 the 48 newapplications were met.The scheme, started as an experiment, to provide help

in a family crisis so that the children need not be receivedinto care is being extended and is now offered for familieswith only one child. (Previously it was limited to familieswith at least two children.) The demand on this serviceis not yet as heavy as was - expected-5 families (16children) in 1955-but early morning and evening help,arranged to cover the gaps between school hours andparents’ working hours, was supplied for 205 new families

in 1955 compared to 85 in 1954. At the end of the yeara scheme was being started to prepare selected homehelps to work with the health visitors and teach therudiments of housecraft to inexperienced mothers inhomes which are in danger of breaking down. Thesuccess of this preventive work is most clearly shown inthe detailed reports from the boroughs, which recordthat in two L.C.C. divisions it was possible to avoidtaking 75 and 135 children into care.These divisional reports also show how much the 375

health visitors are contributing and how their work iswidening. In many London boroughs there are menthlyreviews of problem families and potential problemfamilies who with a little timely help can make a reason-ably speedy return to normal. One division also recordsthat the health visitors are finding it possible to givemore time to the lonely ailing old people. Informalmeetings are being held with the local family doctors athealth and welfare centres. Another successful experi-ment was to attach a health visitor for part of her timeto a group practice. Valuable domiciliary work is beingdone by health visitors in connection with the diabeticunit at King’s College Hospital, and several healthvisitors have started classes in antenatal relaxationand exercise.These extra pairs of skilled hands, offering timely aid

in a home for even a few hours a day, have freed manyhospital beds and spared many families from anxiety,exhaustion, and separation.

1. Epstein, S. S., Winston, P. J. Laryng. 1957, 71, 37.2. Barton, R. T. New Engl. J. Med. 1953, 248, 1097.

LARYNGEAL GRANULOMA AFTER INTUBATION

A GRANULOMA involving one or both vocal cords is arare complication of endotracheal an2esthesia. In recent

years it has been gaining recognition as a clinical entityand this increase reflects the wider use of intubation inmodern surgery. Discussing these granulomas, Epsteinand Winston record 10 cases treated at the RoyalNational Throat, Nose and Ear Hospital in London. Allthe patients were adults, and women outnumbered menby 4 to 1. The relatively small laryngeal aperture inthe female may make women more susceptible. Direct

injury to the larynx during the introduction of the tubeseems to play only a small part, since most granulomasfollowed an easy intubation, often performed with theaid of muscular relaxants. Pressure of the tube in the

glottis is probably the most important cause ; and thisview is supported by the fact that the granulomas alwaysarise on the vocal process of the arytenoid and by thedemonstration 2 of the spring-like action of the flexibleendotracheal tube, which exerts pressure posteriorly inthe larynx, increasingly so as the head is flexed. The

rigid bronchoscope, on the other hand, lies against theanterior commissure, and a granuloma has never beenrecorded as a sequel to bronchoscopy.The vocal process of the arytenoid forms a rigid unit ;

the mucoperichondrium is firmly adherent to the cartilageit covers and there is no subepithelial connective-tissuelayer to allow the epithelium to move on underlyingstructures. Injury in this region leads to ulceration andthe formation of non-specific granulation tissue. Constant. trauma from the opposite vocal process causes the granu-lation tissue to proliferate, and it becomes epithelialisedand presents as a sessile granuloma. Healing takes placeby fibrosis, which narrows the base until the granulomabecomes pedunculated. This process may continue untilthe granuloma is shed and expelled. Usually it remains,causing irritation, hoarseness, and sometimes stridor.When an ulcer is seen on the vocal process after an

operation involving intubation, the development of agranuloma may sometimes be prevented by insisting onstrict voice rest. At a later stage, the removal of a

416

sessile granuloma exposes a large bare area which

gradually heals by granulation, so that the granulomamay recur. Provided the airway is adequate, removalshould, therefore, be deferred until the granuloma is

pedunculated ; and it should be followed by absolutevocal rest.

1. Brotherston, J. H. F., Chave, S. P. W. Brit. J. prev. soc. Med.1956, 10, 200.

2. Scharfman, W. B., Propp, S. New Engl. J. Med. 1956, 255, 1207.3. Debre, R., Brissaud, H. E. Ann. Méd. 1949, 50, 417.4. De Langen, C. D., Donath, W. F. Acta med. scand. 1956, 156,

317.5. Sinclair, H. M. Lancet, 1956, i, 381.6. Sinclair, H. M. Ibid, 1956, ii, 101.

NEW POPULATIONS, OLD PATTERNSSix family doctors have surveyed their practice in a

new housing estate 15 miles from the centre of London.It is the first time that such a community has been thesubject of a survey of this kind, by practitioners awareof the possible influence of the new surroundings on thepeople who have come to live in them.

Information was recorded on a modification of theN.H.S. medical-record envelope continuation sheet, thencoded, transferred to punch cards, and sorted mechan-ically. A random 25% sample was taken, including 4800people living in 1018 houses in the area. The consultation-rates and numbers of patients consulting were classifiedby social group as well as by sex and age. The results ofprevious work were confirmed. The presence on the estateof families rehoused on grounds of ill health did notapparently raise the consultation-rate, perhaps becausethe low average age of the community cancelled out anysuch tendency. The extent of the " hard core " of the

practice is interesting. 16% of the registered patientsaccounted for half the consultations, and the 7% whotook up 30% of the consultations represented the realbedrock. This aspect of the practice is to be furtherexamined, and an analysis of the causes of these consulta-tions would be of particular interest.

It is surprising to learn that as many as 99 prescrip-tions were issued for every 100 consultations. Only about5% of the registered population consulted the doctorwithout obtaining a prescription-and most of theseconsultations were for reasons other than sickness. The

prescription-rate seems high, and analysis of the prescrip-tions issued, by an arbitrary estimate of their value,might be a useful means of future study.More inquiries of this kind are needed, and we hope

for further news from this particular community.

VITAMIN-D POISONING

VITAMIN D is often prescribed or taken in large doses,despite the known dangers, for conditions such as arthritisand skin tuberculosis for which more effective and safertreatment is now available. Scharfman and Propp 2 havelately described 4 patients with vitamin-D intoxicationin which a normochromic and normocytic anaemia was apresenting feature. They concluded that this anaemiawas probably secondary to the azotaemia which in turndepended on renal impairment caused by the hyper-calcaemia of vitamin-D poisoning, which may often beunsuspected. Debre and Brissaud 3 mentioned anaemiaas one of the features in their series of 27 children who hadbeen poisoned by vitamin D.Another suggestion,4 based on animal experiments, is

that excess of vitamin D and cholesterol may be relatedto the development of atherosclerosis. It would be

virtually impossible to substantiate this work in man,but it may provide a link with Sinclair’s thesis 5 thatmany modern dietaries are deficient in the essential

polyethenoid fatty acids (E.F.A.) and -that cholesterol

consequently becomes esterified with abnormal or

unusually saturated fatty acids which the body findsdifficult to dispose of and which could cause atheroma.Sinclair has taken his argument a step further s by

attributing a part in the aetiology of infantile hypercal-csemia to E.F.A. deficiency. Sensitivity to vitamin D hasbeen suggested as a cause of infantile hypercalcsemia.’Sinclair has pointed out that roller-dried milk, such asNational dried, is relatively low in E.F.A. and rich invitamin D and that this combination might enhancethe action of unesterified vitamin D and thus lead to

hyperealemmia. Such a consequence might be regardedas a physiological penalty for our persistence in feedingbabies with milk designed for the young of another

species, and to which too much vitamin D has been added.Infantile hypercalcaemia is virtually unknown in the

United States, where babies are more often fed on evapor-ated milk or on modified-dried-milk formulse, which arericher in E.F.A. and contain less vitamin D. But lack ofE.F.A. cannot be the only factor since millions of tabiesare fed on National dried milk and only a few get hyper.calcsemia ; something else seems necessary to initiatethe hypercalcaemia. Infection * and adrenocorticaldysfunction 9 have been suggested as possibilities.

These new findings are a reminder that vitamin D isnot without its dangers and that there is nothing to begained by giving amounts vastly in excess of physiologicalneeds.lO Ideal growth and the prevention of rickets ininfants can probably be achieved by a daily dose ofabout 500 international units ; and if the vitamin is tobe prescribed for older children and adults a similar doseshould suffice and should not, as far as we know at

present, do any harm.

7. See leading article, Ibid, 1956, i, 1052.8. Creery, R. D. G., Neill, D. W. Ibid, 1956, ii, 1357.9. Anderson, J., Brewis, E. G., Taylor, W. Personal communication

(see ref. 8).10. British Paediatric Association. Lancet, 1956, ii, 136.

TIRED YOUNG NURSES

IN the autumn of 1954 correspondents in the NursingMirror discussed whether young nurses are overtaxedand overstrained. A few months later, as a result of theseletters, a committee, representative of all grades of nursesin training-schools, was set up under the chairmanship ofMr. H. A. Goddard, the director of the Nuffield Investi.gation Team, to consider the problem further. In their

report, published this week, the committee attribute muchof the overstrain and fatigue of these young women (andmen) to mental and emotional rather than physical causes,They point out that the nurse, unlike other students, iscut off from her ordinary home life and spends her wholetime in an " abnormal atmosphere of sickness and in anartificial’ community."To lessen this strain they suggest that for the first

year the student nurse’s training should follow more

closely the conventional academic pattern. The nurseshould enter the hospital without any preliminarytraining, but she should live in a, hostel not run by thehospital authorities, keep college terms, and go home forvacations. She should be on duty for regular hours andher first year should be spent in lectures and ward workentirely under supervision " with no responsibility forward." At first sight this restriction on contact withpatients may seem yet another stitch in the nurse’sacademic gown. But the committee’s report shows thatthere may well be a real need to protect the young nursefrom some of the rigours of hospital work. The cornmittee sent to 5284 nurses in the South-West Metro-politan Region a questionnaire dealing with such subjectsas their hours of work, ward equipment, catering arrange-ments. The 1965 replies show, for instance, that half ofthe students in general hospitals work overtime eitherregularly or often, compared with just over a quarter inmental hospitals. In mental-deficiency hospitals allstudents do some overtime and half of them " often or

regularly." Slightly over a third of the students hanlectures in off duty times. These rigours are no doubtdue not to harshness but to shortage of staff and the