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INTRUSION
298 TOXIC REACTION TO CORYNEBACTERIUM ULCERANS
SIR,-Although Corynebacterium ulcerans is known to produce an exotoxin indistinguishable from that of C. diphtheria, pharyngeal infections with this organism have not previously been reported to be associated with severe toxicity. In May last year, a 60-year-old man was admitted to hospital in Plymouth, under the care of Dr. G. R. Steed. He had been unwell for 10 days, and was found to have a pyrexia and typical diphtheritic membrane in the nostrils and over the fauces. There was complete palatal palsy. C. ulcerans was cultured from the pharynx, and he was treated with penicillin and antitoxin. Recovery was slow. During the 4th week, there were electrocardiographic changes, including T-wave inversion in leads 11, III, aVF, and V4-V 6, and Q-TC prolongation. These were taken as evidence of myocarditis. At this time there was a transitory right facial palsy. After 8 weeks, distal parmsthesioe occurred, rapidly followed by a nearly complete flaccid quadriplegia with glove-and-stocking anaesthesia to light touch. The only abnormality in the cerebrospinal fluid was a raised protein of 116 mg. per 100 ml. The neuropathy did not involve respiratory muscles, and recovery was complete after 20 weeks of illness. The electrocardiogram was, by this time, normal. An unexplained finding was a raised blood-urea (100 mg. per 100 ml.) in the 6th week; it later returned to normal. Although living in the country, the patient had minimal contact with cattle, and the source of infection could not be traced. This case confirms the importance of full antitoxin treatment for cases of C. ulcerans infection. St. George’s Hospital, R. W. FAKES. London S.W.17. Plymouth General Hospital, M. DOWNHAM. Plymouth, Devon.
INTRUSION SIR,-The current laudable concern for privacy prompts me to comment on a further bureaucratic intrusion. As you know, the Hospital Inpatient Enquiry provides information on every tenth patient discharged from hospital. This is used by the General Register Office to compile statistics. However, on the forms for 1970, returns include the name, address, and occupation of the patient. The disclosure of the name and address is surely unnecessary, and is a breach of the doctor-patient relationship because the patient is not required to give his consent to the disclosure. Chadwell Heath Hospital, Romford, Essex.
I. M. LIBRACH.
SCREENING CLINICS who has had screening experience for SIR,-As cervical cancer as long as anyone in this country I was interested in your account of the multiple screening clinics held in Rotherham (Jan. 31, p. 257). I am perplexed at the estimate of "up to E1000 per case of cervical cancer discovered ". The Womens Cancer Detection Society, a charity based on Newcastle upon Tyne of which I have been chairman and honorary medical director since its inception in 1963, has held clinics solely for the detection of cervical cancer since 1964. The collection cost of our society has been S78 per cervical cancer. If technician screening-time is added to this (and your note gives no evidence that this has been the case in Rotherham) the cost rises to E104 per case. If treatment as well is added, then, according to the latest published figures of costing for a bed in my ward, the total cost of collection, discovery, and treatment is E168. one
The only way I could justify a cost of E1000 would be by screening a large series of nuns using disposable solid gold spatulaE and fixing the slides in the finest brandy. STANLEY WAY.
WHO BENEFITS?
SIR,-There is much wisdom in Dr. Nisbett’s article (Jan. 17, p. 133), and its contents should be carefully considered by all interested in planning social and medical services for the elderly. We are often faced with the agonising decision as to whether frail, elderly patients whose acute illness is over should be discharged to a home environment which is unsatisfactory, because they would be alone or unwanted. Many hands would be raised in horror if an unwanted child were discharged back to a home where it would be liable to ill-treatment, yet in effect this is what we may be doing with our elderly patients. Are we perhaps using the patient in an attempt at punishing the children, rather than doing what is best for all concerned. We know, however, that if we do not discharge patients who no longer need hospital care, we cannot free beds for those in dire need of treatment and we cannot provide the optimum service for our community. We are agreed on the necessity for acute geriatric units backed by a certain number of long-stay hospital beds for patients who are incapacitated and require inpatient nursing care. At the moment, however, we are faced with an inadequate amount of suitable accommodation for those patients who, after treatment, no longer need to remain in hospital-that is to say, sheltered housing, warden-supervised flats, residential homes, day hospitals, day centres, and also domiciliary supportive services. Our objective’ must still be to return as many fit patients as possible to their own homes, but many elderly patients whose discharge from hospital we find difficult, are on the borderline between being suitable for Welfare accommodation or long-term hospital care, being occasionally confused and incontinent and very frail. With the present division of services and financial responsibilities, these unfortunate patients are particularly difficult to place and some are " shunted " between hospital and welfare home in a thoroughly unsatisfactory manner. The responsibility for special residential care and hospitals for the elderly should rest with a single authority, and some form of grading should be achieved, varying from the welfare home for those who merely require supervision and for frail, elderly patients or the mentally confused, to those requiring long-stay medical and nursing care. It should be possible for the hospital to place patients directly in these various types of accommodation following their assessment and treatment in the acute geriatric unit. We should also establish more old people’s homes complete with sick-bay, so that residents may be nursed there during transient or terminal illness rather than admitted to hospital. In this way, they may remain in a familiar environment amongst friends and staff who are known to them, for the rest of their daysunless of course hospital transfer becomes essential on medical grounds. Such homes could also accommodate elderly couples, one being fit, the other sick or frail, who otherwise would have to - be separated. It might well be that, if such residential homes were associated with the hospital service, then appropriate medical and nursing staff would be more readily available than they are in scattered welfare homes. More use could also be made of contractural arrangements between hospital board and nursing homes. Not only would this ease the burden on our long-stay beds, but such arrangements would also encourage and help the establishment of suitable nursing homes. Political con-
SIR,-Although Corynebacterium ulcerans is known to produce an exotoxin indistinguishable from that of C. diphtheria, pharyngeal infections with this organism have not previously been reported to be associated with severe toxicity. In May last year, a 60-year-old man was admitted to hospital in Plymouth, under the care of Dr. G. R. Steed. He had been unwell for 10 days, and was found to have a pyrexia and typical diphtheritic membrane in the nostrils and over the fauces. There was complete palatal palsy. C. ulcerans was cultured from the pharynx, and he was treated with penicillin and antitoxin. Recovery was slow. During the 4th week, there were electrocardiographic changes, including T-wave inversion in leads 11, III, aVF, and V4-V 6, and Q-TC prolongation. These were taken as evidence of myocarditis. At this time there was a transitory right facial palsy. After 8 weeks, distal parmsthesioe occurred, rapidly followed by a nearly complete flaccid quadriplegia with glove-and-stocking anaesthesia to light touch. The only abnormality in the cerebrospinal fluid was a raised protein of 116 mg. per 100 ml. The neuropathy did not involve respiratory muscles, and recovery was complete after 20 weeks of illness. The electrocardiogram was, by this time, normal. An unexplained finding was a raised blood-urea (100 mg. per 100 ml.) in the 6th week; it later returned to normal. Although living in the country, the patient had minimal contact with cattle, and the source of infection could not be traced. This case confirms the importance of full antitoxin treatment for cases of C. ulcerans infection. St. George’s Hospital, R. W. FAKES. London S.W.17. Plymouth General Hospital, M. DOWNHAM. Plymouth, Devon.
INTRUSION SIR,-The current laudable concern for privacy prompts me to comment on a further bureaucratic intrusion. As you know, the Hospital Inpatient Enquiry provides information on every tenth patient discharged from hospital. This is used by the General Register Office to compile statistics. However, on the forms for 1970, returns include the name, address, and occupation of the patient. The disclosure of the name and address is surely unnecessary, and is a breach of the doctor-patient relationship because the patient is not required to give his consent to the disclosure. Chadwell Heath Hospital, Romford, Essex.
I. M. LIBRACH.
SCREENING CLINICS who has had screening experience for SIR,-As cervical cancer as long as anyone in this country I was interested in your account of the multiple screening clinics held in Rotherham (Jan. 31, p. 257). I am perplexed at the estimate of "up to E1000 per case of cervical cancer discovered ". The Womens Cancer Detection Society, a charity based on Newcastle upon Tyne of which I have been chairman and honorary medical director since its inception in 1963, has held clinics solely for the detection of cervical cancer since 1964. The collection cost of our society has been S78 per cervical cancer. If technician screening-time is added to this (and your note gives no evidence that this has been the case in Rotherham) the cost rises to E104 per case. If treatment as well is added, then, according to the latest published figures of costing for a bed in my ward, the total cost of collection, discovery, and treatment is E168. one
The only way I could justify a cost of E1000 would be by screening a large series of nuns using disposable solid gold spatulaE and fixing the slides in the finest brandy. STANLEY WAY.
WHO BENEFITS?
SIR,-There is much wisdom in Dr. Nisbett’s article (Jan. 17, p. 133), and its contents should be carefully considered by all interested in planning social and medical services for the elderly. We are often faced with the agonising decision as to whether frail, elderly patients whose acute illness is over should be discharged to a home environment which is unsatisfactory, because they would be alone or unwanted. Many hands would be raised in horror if an unwanted child were discharged back to a home where it would be liable to ill-treatment, yet in effect this is what we may be doing with our elderly patients. Are we perhaps using the patient in an attempt at punishing the children, rather than doing what is best for all concerned. We know, however, that if we do not discharge patients who no longer need hospital care, we cannot free beds for those in dire need of treatment and we cannot provide the optimum service for our community. We are agreed on the necessity for acute geriatric units backed by a certain number of long-stay hospital beds for patients who are incapacitated and require inpatient nursing care. At the moment, however, we are faced with an inadequate amount of suitable accommodation for those patients who, after treatment, no longer need to remain in hospital-that is to say, sheltered housing, warden-supervised flats, residential homes, day hospitals, day centres, and also domiciliary supportive services. Our objective’ must still be to return as many fit patients as possible to their own homes, but many elderly patients whose discharge from hospital we find difficult, are on the borderline between being suitable for Welfare accommodation or long-term hospital care, being occasionally confused and incontinent and very frail. With the present division of services and financial responsibilities, these unfortunate patients are particularly difficult to place and some are " shunted " between hospital and welfare home in a thoroughly unsatisfactory manner. The responsibility for special residential care and hospitals for the elderly should rest with a single authority, and some form of grading should be achieved, varying from the welfare home for those who merely require supervision and for frail, elderly patients or the mentally confused, to those requiring long-stay medical and nursing care. It should be possible for the hospital to place patients directly in these various types of accommodation following their assessment and treatment in the acute geriatric unit. We should also establish more old people’s homes complete with sick-bay, so that residents may be nursed there during transient or terminal illness rather than admitted to hospital. In this way, they may remain in a familiar environment amongst friends and staff who are known to them, for the rest of their daysunless of course hospital transfer becomes essential on medical grounds. Such homes could also accommodate elderly couples, one being fit, the other sick or frail, who otherwise would have to - be separated. It might well be that, if such residential homes were associated with the hospital service, then appropriate medical and nursing staff would be more readily available than they are in scattered welfare homes. More use could also be made of contractural arrangements between hospital board and nursing homes. Not only would this ease the burden on our long-stay beds, but such arrangements would also encourage and help the establishment of suitable nursing homes. Political con-