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BEDS FOR THE TUBERCULOUS
414 in a few cases and an urticarial eruption in 1 case. Involvement of the eighth nerve was not observed. If this initial promise is fulfilled a major public-health problem may be solved in the countries concerned, and we may hail another victory for the new antibiotics.
pruritus
Annotations BEDS
.
FOR
THE TUBERCULOUS
WHEN beds are scarce tuberculosis presents a double problem. Should the late and hopeless case be kept in the sanatorium, while new cases, awaiting admission, lose ground and perhaps pass from the easily curable to the chronic phase of the disease ? Or should the late cases be sent home, possibly to infect others, while the early cases are admitted for the treatment which may Dr. Frederick save them from a life of invalidism ? Heaf recently offered his solution of this problem in his presidential address1 to the Tuberculosis Association. At present, he says, nearly 8000 people are awaiting their turn to enter a sanatorium ; but of the 32,800 beds approved for the treatment of tuberculosis, 4200 are closed owing to lack of nursing and domestic staff. Even the working beds, in his opinion, are not used economically. Surgery is often tried on cases known to be bad risks, and superintendents cling to chronic cases, hoping for a miracle-though they have only to picture the large necrotic masses in the lungs, seen as X-ray shadows, to give a true prognosis. He therefore proposes that cases needing thoracic surgery should be concentrated in regional centres, and that surgery should not be undertaken in the smaller sanatoria. Institutions with fully developed surgical units should The as far as possible be cleared of chronic cases. latter are of three kinds-the advanced bedridden case, the case needing either limited nursing care or convalescence, and the ambulant case which must be segregated. He has no hesitation in suggesting that the bedridden case should be sent home. The risk of infection, she believes, can be controlled to a few feet around the bed, and such patients are less dangerous to others than the ambulant positive case. Nevertheless, as he points out, slum conditions may be dreadful, and childrento protect them from danger-may have to be sent away if the sick person comes home. Conscious, no doubt, of the objections, he proposes that these children from poor homes should attend residential open-air schools, and be boarded-out in the holidays. Meanwhile the household domestic difficulties could be relieved by a team of orderlies organised by the local authority. In some cases the provision of an open-air shelter in the back yard may make it possible for a patient to be received at home who would otherwise have to stay in a sanatorium bed. The patient convalescent after an operation might, Dr. Heaf thinks, be taken into a small home in the country, of the type seen in Scandinavia and Holland. Such homes need only 10-15 nurses for every 100 beds ; and they could also house patients for whom protracted sanatorium treatment could have no effect in prolonging life. Some of the smaller existing sanatoria, instead of attempting to undertake thoracic surgery, and duplicating expensive equipment, should be developed on these lines. For the ambulant case needing segregation he recommends that sinall units of 50-100 beds should be set up in towns, or on the outskirts of towns, where a sheltered workshop would offer some remunerative work. A visiting doctor would look after the residents’ health. Since the patients themselves would- be able to help in the work of the home, the only staff needed 1.
Tubercle, 1948, 29, 2.
would be a matron and 6-8 nurses or nursing orderlies for every 100 patients. Also hostels might be established in connexion with Remploy factories, having a resident warden who would be a nurse, assisted by a housekeeper and domestic staff. These suggestions all deserve study. It is easy to criticise their drawbacks on the grounds that they do not accord first place to the happiness of patients and their families ; but Dr. Heaf does not claim that they are more than a makeshift to meet what Dr. Toussaint in his letter on p. 422 rightly calls an appalling situation. A
NEW SOURCE OF STREPTOMYCIN
IN the early days of penicillin therapy, when the drug very scarce, useful quantities were recovered from the urine of patients under treatmentand the same has been done more recently in Germany for the same reason. The procedure was soon given up here as not worth while when supplies improved, for the urinary excretion of penicillin is highly variable - and the drug itself unstable. Rather more than a year ago the suggestion was made in these columns2 that streptomycin should similarly be recovered from the urine, because it seemed likely to be as scarce as penicillin was five years before and because a higher proportion is excreted unchanged. Much streptomycin has flowed down the sewers since then, but in this issue Mr. Miller and Mr. Rowley, PH.D., of St. Mary’s Hospital, show clearly that recovery from the urine is both a feasible and a commendable proposition. About half of the streptomycin administered therapeutically is excreted in the urine, and Miller arid Rowley found that 50-60% of this amount can be recovered in a form having not less than four-fifths of the original potency. The over-all recovery, therefore, is of the order of 25-30% of the dosage given. The streptomycin recovered in this way has been tested for histamine-like substances, toxicity, and the presence of pyrogens, and in each case the result has satisfied the requirements’of the American Food and Drug Administration, which have been adopted as the standards of purity in this country. This means that for every 100 patients receiving streptomycin therapy for tuberculosis, in the customary dose of 2 g. daily, about 50-60 g. of the drug could be recovered for readministration every day, if all the urine (about 150 litres per day) was collected for this purpose. The experience with penicillin suggests that, far from being of inferior quality, the streptomycin obtained in this way will be particularly free from harmful
was
impurities. LIAISON
WITH
THE COLONIES
improve the two-way flow of information between Britain and some of the Colonies, a panel of eighteen specialists are each to pay two visits to East or West Africa at intervals of three years. As announced in our news columns, this scheme is being subsidised for six years by the Nuffield Foundation, and, though the visits are to be informal, the plan is supported by the Colonial Office. The hope is that if it proves a success it will eventually be taken over and extended by the Government. The disinclination of graduates in the United Kingdom to serve in the Colonies has long dismayed those who wish to see a first-class Colonial Medical Service. On another To
page a peripatetic correspondent partly explains this reluctance by the severance of professional ties which seems to be inevitable if a doctor remains out of this country for even a year or two. This correspondent evidently shares Sir Wilson Jameson’s view3 that the young man should be enabled to serve overseas for a Abraham, E. P., Chain, E., Fletcher, C. M., Gardner, A. D., Heatley, N. G., Jennings, M. A., Florey, H. W. Lancet, 1941, ii, 177. 2. Leading article, Ibid, 1946, ii, 758. 3. See Lancet, 1945, ii, 569. 1.
pruritus
Annotations BEDS
.
FOR
THE TUBERCULOUS
WHEN beds are scarce tuberculosis presents a double problem. Should the late and hopeless case be kept in the sanatorium, while new cases, awaiting admission, lose ground and perhaps pass from the easily curable to the chronic phase of the disease ? Or should the late cases be sent home, possibly to infect others, while the early cases are admitted for the treatment which may Dr. Frederick save them from a life of invalidism ? Heaf recently offered his solution of this problem in his presidential address1 to the Tuberculosis Association. At present, he says, nearly 8000 people are awaiting their turn to enter a sanatorium ; but of the 32,800 beds approved for the treatment of tuberculosis, 4200 are closed owing to lack of nursing and domestic staff. Even the working beds, in his opinion, are not used economically. Surgery is often tried on cases known to be bad risks, and superintendents cling to chronic cases, hoping for a miracle-though they have only to picture the large necrotic masses in the lungs, seen as X-ray shadows, to give a true prognosis. He therefore proposes that cases needing thoracic surgery should be concentrated in regional centres, and that surgery should not be undertaken in the smaller sanatoria. Institutions with fully developed surgical units should The as far as possible be cleared of chronic cases. latter are of three kinds-the advanced bedridden case, the case needing either limited nursing care or convalescence, and the ambulant case which must be segregated. He has no hesitation in suggesting that the bedridden case should be sent home. The risk of infection, she believes, can be controlled to a few feet around the bed, and such patients are less dangerous to others than the ambulant positive case. Nevertheless, as he points out, slum conditions may be dreadful, and childrento protect them from danger-may have to be sent away if the sick person comes home. Conscious, no doubt, of the objections, he proposes that these children from poor homes should attend residential open-air schools, and be boarded-out in the holidays. Meanwhile the household domestic difficulties could be relieved by a team of orderlies organised by the local authority. In some cases the provision of an open-air shelter in the back yard may make it possible for a patient to be received at home who would otherwise have to stay in a sanatorium bed. The patient convalescent after an operation might, Dr. Heaf thinks, be taken into a small home in the country, of the type seen in Scandinavia and Holland. Such homes need only 10-15 nurses for every 100 beds ; and they could also house patients for whom protracted sanatorium treatment could have no effect in prolonging life. Some of the smaller existing sanatoria, instead of attempting to undertake thoracic surgery, and duplicating expensive equipment, should be developed on these lines. For the ambulant case needing segregation he recommends that sinall units of 50-100 beds should be set up in towns, or on the outskirts of towns, where a sheltered workshop would offer some remunerative work. A visiting doctor would look after the residents’ health. Since the patients themselves would- be able to help in the work of the home, the only staff needed 1.
Tubercle, 1948, 29, 2.
would be a matron and 6-8 nurses or nursing orderlies for every 100 patients. Also hostels might be established in connexion with Remploy factories, having a resident warden who would be a nurse, assisted by a housekeeper and domestic staff. These suggestions all deserve study. It is easy to criticise their drawbacks on the grounds that they do not accord first place to the happiness of patients and their families ; but Dr. Heaf does not claim that they are more than a makeshift to meet what Dr. Toussaint in his letter on p. 422 rightly calls an appalling situation. A
NEW SOURCE OF STREPTOMYCIN
IN the early days of penicillin therapy, when the drug very scarce, useful quantities were recovered from the urine of patients under treatmentand the same has been done more recently in Germany for the same reason. The procedure was soon given up here as not worth while when supplies improved, for the urinary excretion of penicillin is highly variable - and the drug itself unstable. Rather more than a year ago the suggestion was made in these columns2 that streptomycin should similarly be recovered from the urine, because it seemed likely to be as scarce as penicillin was five years before and because a higher proportion is excreted unchanged. Much streptomycin has flowed down the sewers since then, but in this issue Mr. Miller and Mr. Rowley, PH.D., of St. Mary’s Hospital, show clearly that recovery from the urine is both a feasible and a commendable proposition. About half of the streptomycin administered therapeutically is excreted in the urine, and Miller arid Rowley found that 50-60% of this amount can be recovered in a form having not less than four-fifths of the original potency. The over-all recovery, therefore, is of the order of 25-30% of the dosage given. The streptomycin recovered in this way has been tested for histamine-like substances, toxicity, and the presence of pyrogens, and in each case the result has satisfied the requirements’of the American Food and Drug Administration, which have been adopted as the standards of purity in this country. This means that for every 100 patients receiving streptomycin therapy for tuberculosis, in the customary dose of 2 g. daily, about 50-60 g. of the drug could be recovered for readministration every day, if all the urine (about 150 litres per day) was collected for this purpose. The experience with penicillin suggests that, far from being of inferior quality, the streptomycin obtained in this way will be particularly free from harmful
was
impurities. LIAISON
WITH
THE COLONIES
improve the two-way flow of information between Britain and some of the Colonies, a panel of eighteen specialists are each to pay two visits to East or West Africa at intervals of three years. As announced in our news columns, this scheme is being subsidised for six years by the Nuffield Foundation, and, though the visits are to be informal, the plan is supported by the Colonial Office. The hope is that if it proves a success it will eventually be taken over and extended by the Government. The disinclination of graduates in the United Kingdom to serve in the Colonies has long dismayed those who wish to see a first-class Colonial Medical Service. On another To
page a peripatetic correspondent partly explains this reluctance by the severance of professional ties which seems to be inevitable if a doctor remains out of this country for even a year or two. This correspondent evidently shares Sir Wilson Jameson’s view3 that the young man should be enabled to serve overseas for a Abraham, E. P., Chain, E., Fletcher, C. M., Gardner, A. D., Heatley, N. G., Jennings, M. A., Florey, H. W. Lancet, 1941, ii, 177. 2. Leading article, Ibid, 1946, ii, 758. 3. See Lancet, 1945, ii, 569. 1.