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PROBLEMS OF RESPIRATORY DISEASE.
524 of traumatic shock and gas gangrene. By completely arresting the circulation in the injured limb, the tourniquet promotes infection in the crushed and torn tissues, and its removal is followed by absorption of toxic products capable of killing a patient already weakened by cold, shock, and loss of blood. At The Hague in 1931, during the sixth International Congress of Military Medicine and Pharmacy, various speakers condemned the tourniquet in unequivocal terms. cause
Colonel
this occasion declared that the be taught too much about cannot personnel the dangers of the application of the tourniquet which should not be permitted in any but cases of extreme urgency. In his report on the " Action du garrot sur le choc traumatique " Colonel Dante Casella was not less emphatic on the same occasion. The errand boy, it would seem, is now the staunchest friend of the tourniquet.
Praag
on
medical
NEW NAMES FOR HOSPITALS.
ASCENDING for once from the practical to the the London County Council decided to improve the names of some of its hospitals by abandoning the territorial and utilitarian in favour of something more aspiring. It has, however, chosen the new designations with a nice regard for local susceptibilities which, even in London, are properly tender. Resisting the temptation to call its hospitals after their chairman or vice-chairman, it has entered the safer field of hagiology. St. Leonard of Shoreditch, St. Alphege of Greenwich, and St. Olave of Bermondsey are names which belong to local history. The comparatively unfamiliar St. Benedict will illuminate the hospital at Tooting which will thus be able to realise a spiritual relationship with the St. Benet to whom the City of London dedicated four of its ancient churches. The Hospital of St. Nicholas, beloved of fishermen, carries on the traditions of Plumstead ; but St. Charles of Marylebone seems to be more picturesque than locally appropriate. Only two saints of that name appear to be known to the Churches-the Roman St. Charles Borromeo and the " Charles, King and Martyr"" of the old Anglican calendar, to whom some five or six churches have been dedicated. That houses of healing should be given distinctive names suggestive of the spiritual basis of hospital work is all to the good. But it rests with the staff of these institutions to make the new designations so familiar that we shall speak, for instance, of St. Olave’s without the need to mention
romantic,
Bermondsey.
____
RELIEF OF VESICAL IRRITATION. As a remedy for painful conditions of the bladder, B. E. Greenberg and M. L. Brodny1 have been using mineral oil sterilised in the autoclave, cooled and then heated to body temperature. Some 4 oz. of the oil are injected slowly into the bladder, and despite the fact that patients with cystitis suffer from increased frequency--partly because of their condition and partly because they are on " forced fluids "-some of it may remain there as long as a week. After its instillation the vesical irritation, tenesmus, and frequency are reduced ; as the burning decreases the patient loses his fear of micturition and consents to drink the large amount of liquid required for adequate therapy. Greenberg and Brodny have used this method not only for ordinary cystitis, but also for tuberculosis of the bladder. They have, moreover, found it useful in alkaline cystitis where the 1 New Eng. Jour. Med., Jan. 21st, p. 114.
bladder wall is encrusted with phosphates ; the oil loosens the encrustations and cleans up the bladder. In a previous paper2 Greenberg has advocatoil the use of sterile mineral oil as a meclium for cystoscopy, finding that with irritated bladders far better distension could be obtained with oil than with boric lotion. Furthermore, the intense discomfort which often follows cystoscopy in such cases was prevented. Finally, the oil was found to encourage haemostasis so that cystoscopy could be undertaken in the presence of bleeding that would otherwise have obscured the view. The method is a simple one, and these claims are so striking that it certainly deserves a trial. PROBLEMS OF RESPIRATORY DISEASE.
RECENTLY we quoted observations on draughts and colds published by Winslow and Greenburg in the January number of the Ainerican Jozcyezal of Hygiene. The same issue contains several other papers on various aspects of respiratory disease. Janet Bourn reports a further study of the occurrence of Hcenaophihus influenza (Pfeiffer’s bacillus) in Baltimore, based upon 2600 nasopharyngeal cultures. The bacillus was isolated with no greater frequency from cases of respiratory disease than from healthy persons. In addition, during 19281929 a widespread epidemic of influenza took place. The incidence of 27. i7zlacenzce was no higher in these epidemic months than in the following non-epidemic year, a result in agreement with the conclusions of the report published by the Ministry of Health in 1930 on the nasopharyngeal flora of a group of the Manchester population.3 On the other hand, in the English study there was no evidence that the onset of a cold was associated with any characteristic change in the nasopharyngeal flora. In Bourn’s investigation a more detailed study of cases of upper respiratory disease (which included influenza and other symptoms besides the common cold) showed a higher frequency of the bacillus amongst those with more extensive local symptoms. For example, the bacillus was found in 28 per cent. of cases with cough and in only 16 per cent. of cases without cough, a difference which is unlikely to have arisen by chance. This difference and a tendency to a greater frequency late in the attack in all cases support the general belief that this particular bacillus is of importance as a secondary invader. Frequent examinations showed that practically all persons of the classes studied harboured H. influenza at some time during the two years. With regard to the pneumococcus, Selma M. Shultz found the duration of the carrier state amongst 35 children convalescent from pneumonia to vary between 2 and 152 days. She considers that the convalescing child, possibly carrying the pathogen in its throat for such long periods, may well be considered a potential source of respiratory diseases in others. For 21 children with pneumococcal pneumonia she endeavoured to measure the incidence of pneumococcus carriers amongst contacts. Naturally the search had to be limited to the most intimate contacts, and amongst these (86 in number) 13 per cent. produced the same type of pneumococcus as No that isolated from the pneumonia patient. variation was in the virulence apparent significant of the bacillus isolated from the cases and the corresponding carriers. In a third paper W. E. Brown gives the results 2 Ibid., 1931, cciv., 1366. 3 Min, of Health Rep. on Pub. Health and Med. Subjects. No. 58. London, 1930. See THE LANCET, 1930, ii., 262.
525 of an experiment ill the prevention of the common collected over 7000 ; in 1931 the Exmouth and cold by means of a vaccine. In the experimental District Hospital League increased its membership .group were 80 medical students, and in the control by 1537 ; the Newton Abbot contributory scheme, group were 82. He concludes that the statistical with over 5000 members, brought in f:l500. In view results of the experiment show little, if any, advan- of these and similar figures there is small wonder
to the experimental group. The mean number that other hospitals of varying degrees of importance of colds suffered by the experimental group (over have decided to establish contributory schemes. seven months) was 1-85, with a mean duration of Thus Walsall General Hospital, the scene in its early 7.4 days, while the corresponding figures for the cottage hospital days of the devoted labours of Sister Dora," sees no other way of making neces,control group were 2-17 and 7-6. These figures do not differ significantly, but on the other hand the sary enlargements, and it is proposed to make a estimated average duration of colds during the pre- reciprocal arrangement for treatment of its members vious years amongst the experimental group was with the neighbouring Wolverhampton Royal Hos10-5 days, while the same average for the control pital which has recently established a highly group was 7-6 days. This suggests that some improve- successful scheme with a large basis of miners. Goole is considering a scheme that ment may have taken place amongst the experimental group, but it also points to the weakness of would enable its Bartholomew Hospital, in return for the investigation. Any method of investigation that a contribution of twopence a week, to give free treatallows the experimental group to be unduly weighted ment to persons whose weekly income is under 5, with " susceptibles," as is here apparent, must be with special arrangements for the neighbouring unsatisfactory. To prove that the groups are com- villages. Since Wolverhampton has 210 beds, Walsall parable with regard to such factors as the amount 100, and Goole 24, the advantages of a contributory of water (and/or alcohol), tobacco, chewing-gum, scheme are seen to appeal to hospitals of very varying -and ice-cream they consume, the time when they go dimensions. to bed, and the number of baths they take weekly DISTRICT NURSING IN LONDON. {to mention but a few for which this paper provides seems an idle refinement in the face of statistics), IN her survey of district nursing in London, such a fundamental difference with regard to suspublished by the London County Council last year, ceptibility as is suggested by the previous histories Dr. Margaret Hogarth paid a remarkable tribute to of colds. the thoroughness with which care of the sick poor in their homes is organised. " I was impressed," ACCIDENTS AND HOSPITAL CONTRIBUTORY she wrote, " with the tremendous amount of individual SCHEMES, and collective voluntary effort expended in securing MOST of the annual reports and meetings of the for the poorer classes a free nursing service of the provincial hospitals which come thick and fast at highest quality obtainable. This service is never this season are concerned with the burden placed denied to anyone who cannot pay for the services of a private nurse.... The qualifications of the nurses upon them by road accidents. In a recent broadcast are the best obtainable in the nursing employed speech Lord Moynihan stated that Leeds Infirmary is losing E2000 a year in this way ; Bradford Infirmary profession." Much ofthe responsibility for eoordinatlast year spent :f600 more than it recovered upon ing the work of the different bodies engaged in such cases ; Southport Infirmary lost z373 ; the domiciliary nursing falls upon the Central Council Devon and Exeter Hospital complains that the for District Nursing, a voluntary organisation founded suggested uniform charge of seven and sixpence a day for this purpose in 1914. Nursing care for the sick for the treatment of victims of road accidents is poor of London in their homes is provided in three district nursing associations, either " totally insufficient." In every part of the country ways : by or affiliated to the Queen’s Institute ; the story is similar, and in some places contributory independent nurses to the nursing branch of the attached by schemes are becoming inadequate to meet the swollen and Mission ; Ranyard motor are one of the in which accidents by a few parish nurses. expenses, items. Birmingham has already raised its contribu- It speaks highly for the work of the Central Council tion ; Sheffield is thinking of doing likewise ; and that Dr. Hogarth found only one part of Londonthe Merseyside Hospitals Council is seeking to widen the new Grove Park Estate-uncovered by the its scheme by, among other means, appealing for organisations now at work ; and even there steps those annual subscribers who in most places show a were being taken to provide a nurse. The changes in tendency to fall away. Just now Liverpool is having administration following the enforcement of the a rather unhappy experience. Last year its port Local Government Act of 1929 could not fail to affect committee sanitary and hospitals spent nearly the position of the Central Council to some extent, of in excess the the whole and at the end of 1929 a deputation was sent before almost :f37,OOO estimates, of which was attributable to capital expenditure the London County Council to explain the Central upon transferred institutions to bring them into line i Council’s work and to offer their experience and with the modern type of hospital. Meanwhile Liver- machinery for the distribution of any future subsidy pool, undaunted, is hastening the completion of its which might be made to district nursing in place of new Samaritan Hospital for Women which is to cost the inadequate and unequal grants previously given about 150,000. by the boards of guardians. The annual report of the Central Council for the year 1931 tells us that are under various names, Contributory schemes, a committee was formed by the London County to every hospital becoming increasingly important fed by them, and several new ones are being launched. Council to consider the question of grants, but that An outstanding example of success is the Leeds no definite conclusion has so far been reached. The Hospital Fund which last year increased its income decision can hardly fail to be one of grave importance by 10,500 ; it now exceeds E56,000. In ten years to district nursing organisations, since the economic the workpeople’s hospital committee of Gloucester- crisis makes it increasingly difficult for them to shire Royal Infirmary has raised just under 100,000 ; obtain financial assistance. It is significant of their last year the Torbay Hospital contributory scheme position that the City Parochial Foundation in making
tage
z
Simultaneously
____
---
Colonel
this occasion declared that the be taught too much about cannot personnel the dangers of the application of the tourniquet which should not be permitted in any but cases of extreme urgency. In his report on the " Action du garrot sur le choc traumatique " Colonel Dante Casella was not less emphatic on the same occasion. The errand boy, it would seem, is now the staunchest friend of the tourniquet.
Praag
on
medical
NEW NAMES FOR HOSPITALS.
ASCENDING for once from the practical to the the London County Council decided to improve the names of some of its hospitals by abandoning the territorial and utilitarian in favour of something more aspiring. It has, however, chosen the new designations with a nice regard for local susceptibilities which, even in London, are properly tender. Resisting the temptation to call its hospitals after their chairman or vice-chairman, it has entered the safer field of hagiology. St. Leonard of Shoreditch, St. Alphege of Greenwich, and St. Olave of Bermondsey are names which belong to local history. The comparatively unfamiliar St. Benedict will illuminate the hospital at Tooting which will thus be able to realise a spiritual relationship with the St. Benet to whom the City of London dedicated four of its ancient churches. The Hospital of St. Nicholas, beloved of fishermen, carries on the traditions of Plumstead ; but St. Charles of Marylebone seems to be more picturesque than locally appropriate. Only two saints of that name appear to be known to the Churches-the Roman St. Charles Borromeo and the " Charles, King and Martyr"" of the old Anglican calendar, to whom some five or six churches have been dedicated. That houses of healing should be given distinctive names suggestive of the spiritual basis of hospital work is all to the good. But it rests with the staff of these institutions to make the new designations so familiar that we shall speak, for instance, of St. Olave’s without the need to mention
romantic,
Bermondsey.
____
RELIEF OF VESICAL IRRITATION. As a remedy for painful conditions of the bladder, B. E. Greenberg and M. L. Brodny1 have been using mineral oil sterilised in the autoclave, cooled and then heated to body temperature. Some 4 oz. of the oil are injected slowly into the bladder, and despite the fact that patients with cystitis suffer from increased frequency--partly because of their condition and partly because they are on " forced fluids "-some of it may remain there as long as a week. After its instillation the vesical irritation, tenesmus, and frequency are reduced ; as the burning decreases the patient loses his fear of micturition and consents to drink the large amount of liquid required for adequate therapy. Greenberg and Brodny have used this method not only for ordinary cystitis, but also for tuberculosis of the bladder. They have, moreover, found it useful in alkaline cystitis where the 1 New Eng. Jour. Med., Jan. 21st, p. 114.
bladder wall is encrusted with phosphates ; the oil loosens the encrustations and cleans up the bladder. In a previous paper2 Greenberg has advocatoil the use of sterile mineral oil as a meclium for cystoscopy, finding that with irritated bladders far better distension could be obtained with oil than with boric lotion. Furthermore, the intense discomfort which often follows cystoscopy in such cases was prevented. Finally, the oil was found to encourage haemostasis so that cystoscopy could be undertaken in the presence of bleeding that would otherwise have obscured the view. The method is a simple one, and these claims are so striking that it certainly deserves a trial. PROBLEMS OF RESPIRATORY DISEASE.
RECENTLY we quoted observations on draughts and colds published by Winslow and Greenburg in the January number of the Ainerican Jozcyezal of Hygiene. The same issue contains several other papers on various aspects of respiratory disease. Janet Bourn reports a further study of the occurrence of Hcenaophihus influenza (Pfeiffer’s bacillus) in Baltimore, based upon 2600 nasopharyngeal cultures. The bacillus was isolated with no greater frequency from cases of respiratory disease than from healthy persons. In addition, during 19281929 a widespread epidemic of influenza took place. The incidence of 27. i7zlacenzce was no higher in these epidemic months than in the following non-epidemic year, a result in agreement with the conclusions of the report published by the Ministry of Health in 1930 on the nasopharyngeal flora of a group of the Manchester population.3 On the other hand, in the English study there was no evidence that the onset of a cold was associated with any characteristic change in the nasopharyngeal flora. In Bourn’s investigation a more detailed study of cases of upper respiratory disease (which included influenza and other symptoms besides the common cold) showed a higher frequency of the bacillus amongst those with more extensive local symptoms. For example, the bacillus was found in 28 per cent. of cases with cough and in only 16 per cent. of cases without cough, a difference which is unlikely to have arisen by chance. This difference and a tendency to a greater frequency late in the attack in all cases support the general belief that this particular bacillus is of importance as a secondary invader. Frequent examinations showed that practically all persons of the classes studied harboured H. influenza at some time during the two years. With regard to the pneumococcus, Selma M. Shultz found the duration of the carrier state amongst 35 children convalescent from pneumonia to vary between 2 and 152 days. She considers that the convalescing child, possibly carrying the pathogen in its throat for such long periods, may well be considered a potential source of respiratory diseases in others. For 21 children with pneumococcal pneumonia she endeavoured to measure the incidence of pneumococcus carriers amongst contacts. Naturally the search had to be limited to the most intimate contacts, and amongst these (86 in number) 13 per cent. produced the same type of pneumococcus as No that isolated from the pneumonia patient. variation was in the virulence apparent significant of the bacillus isolated from the cases and the corresponding carriers. In a third paper W. E. Brown gives the results 2 Ibid., 1931, cciv., 1366. 3 Min, of Health Rep. on Pub. Health and Med. Subjects. No. 58. London, 1930. See THE LANCET, 1930, ii., 262.
525 of an experiment ill the prevention of the common collected over 7000 ; in 1931 the Exmouth and cold by means of a vaccine. In the experimental District Hospital League increased its membership .group were 80 medical students, and in the control by 1537 ; the Newton Abbot contributory scheme, group were 82. He concludes that the statistical with over 5000 members, brought in f:l500. In view results of the experiment show little, if any, advan- of these and similar figures there is small wonder
to the experimental group. The mean number that other hospitals of varying degrees of importance of colds suffered by the experimental group (over have decided to establish contributory schemes. seven months) was 1-85, with a mean duration of Thus Walsall General Hospital, the scene in its early 7.4 days, while the corresponding figures for the cottage hospital days of the devoted labours of Sister Dora," sees no other way of making neces,control group were 2-17 and 7-6. These figures do not differ significantly, but on the other hand the sary enlargements, and it is proposed to make a estimated average duration of colds during the pre- reciprocal arrangement for treatment of its members vious years amongst the experimental group was with the neighbouring Wolverhampton Royal Hos10-5 days, while the same average for the control pital which has recently established a highly group was 7-6 days. This suggests that some improve- successful scheme with a large basis of miners. Goole is considering a scheme that ment may have taken place amongst the experimental group, but it also points to the weakness of would enable its Bartholomew Hospital, in return for the investigation. Any method of investigation that a contribution of twopence a week, to give free treatallows the experimental group to be unduly weighted ment to persons whose weekly income is under 5, with " susceptibles," as is here apparent, must be with special arrangements for the neighbouring unsatisfactory. To prove that the groups are com- villages. Since Wolverhampton has 210 beds, Walsall parable with regard to such factors as the amount 100, and Goole 24, the advantages of a contributory of water (and/or alcohol), tobacco, chewing-gum, scheme are seen to appeal to hospitals of very varying -and ice-cream they consume, the time when they go dimensions. to bed, and the number of baths they take weekly DISTRICT NURSING IN LONDON. {to mention but a few for which this paper provides seems an idle refinement in the face of statistics), IN her survey of district nursing in London, such a fundamental difference with regard to suspublished by the London County Council last year, ceptibility as is suggested by the previous histories Dr. Margaret Hogarth paid a remarkable tribute to of colds. the thoroughness with which care of the sick poor in their homes is organised. " I was impressed," ACCIDENTS AND HOSPITAL CONTRIBUTORY she wrote, " with the tremendous amount of individual SCHEMES, and collective voluntary effort expended in securing MOST of the annual reports and meetings of the for the poorer classes a free nursing service of the provincial hospitals which come thick and fast at highest quality obtainable. This service is never this season are concerned with the burden placed denied to anyone who cannot pay for the services of a private nurse.... The qualifications of the nurses upon them by road accidents. In a recent broadcast are the best obtainable in the nursing employed speech Lord Moynihan stated that Leeds Infirmary is losing E2000 a year in this way ; Bradford Infirmary profession." Much ofthe responsibility for eoordinatlast year spent :f600 more than it recovered upon ing the work of the different bodies engaged in such cases ; Southport Infirmary lost z373 ; the domiciliary nursing falls upon the Central Council Devon and Exeter Hospital complains that the for District Nursing, a voluntary organisation founded suggested uniform charge of seven and sixpence a day for this purpose in 1914. Nursing care for the sick for the treatment of victims of road accidents is poor of London in their homes is provided in three district nursing associations, either " totally insufficient." In every part of the country ways : by or affiliated to the Queen’s Institute ; the story is similar, and in some places contributory independent nurses to the nursing branch of the attached by schemes are becoming inadequate to meet the swollen and Mission ; Ranyard motor are one of the in which accidents by a few parish nurses. expenses, items. Birmingham has already raised its contribu- It speaks highly for the work of the Central Council tion ; Sheffield is thinking of doing likewise ; and that Dr. Hogarth found only one part of Londonthe Merseyside Hospitals Council is seeking to widen the new Grove Park Estate-uncovered by the its scheme by, among other means, appealing for organisations now at work ; and even there steps those annual subscribers who in most places show a were being taken to provide a nurse. The changes in tendency to fall away. Just now Liverpool is having administration following the enforcement of the a rather unhappy experience. Last year its port Local Government Act of 1929 could not fail to affect committee sanitary and hospitals spent nearly the position of the Central Council to some extent, of in excess the the whole and at the end of 1929 a deputation was sent before almost :f37,OOO estimates, of which was attributable to capital expenditure the London County Council to explain the Central upon transferred institutions to bring them into line i Council’s work and to offer their experience and with the modern type of hospital. Meanwhile Liver- machinery for the distribution of any future subsidy pool, undaunted, is hastening the completion of its which might be made to district nursing in place of new Samaritan Hospital for Women which is to cost the inadequate and unequal grants previously given about 150,000. by the boards of guardians. The annual report of the Central Council for the year 1931 tells us that are under various names, Contributory schemes, a committee was formed by the London County to every hospital becoming increasingly important fed by them, and several new ones are being launched. Council to consider the question of grants, but that An outstanding example of success is the Leeds no definite conclusion has so far been reached. The Hospital Fund which last year increased its income decision can hardly fail to be one of grave importance by 10,500 ; it now exceeds E56,000. In ten years to district nursing organisations, since the economic the workpeople’s hospital committee of Gloucester- crisis makes it increasingly difficult for them to shire Royal Infirmary has raised just under 100,000 ; obtain financial assistance. It is significant of their last year the Torbay Hospital contributory scheme position that the City Parochial Foundation in making
tage
z
Simultaneously
____
---