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CALCIFEROL IN PULMONARY TUBERCULOSIS
526 In Dutch hospitals ordinary wards and private wards (small wards and single rooms) have been incorporated for some decades in the same hospitals. The ordinary wards have isolation rooms in which third-class patients The are nursed, when need be, without extra charge. private rooms (classes 2A and 1) are separated from
azotaemia is noticed, even with extremely high doses, nor are. there any clinical, digestive, renal, or general disturbances ; but it remains to be seen if, corresponding to this better tolerance, the parenteral route does not entail loss of thera-
each other only if separation is medically indicated (for instance in separate departments for medical and surgical diseases), and they are never placed in the ordinary ward units or blocks but are grouped together in separate units ; and it is the same with the small wards (class 2B). It should be explained that the nursing and medical attention are exactly the same in the ordinary wards as in the small wards or single rooms. Units of singleor two-bedded rooms have relatively more nurses, but only because these are less economical than larger wards : a decreasing number of beds in a -ward or room means an increasing nurse-bed ratio. Why, then, do patients wish to be accommodated in small wards or single rooms ? For three reasons : (1) greater privacy, (2) better catering, and (3) longer and more visiting hours. Points (1) and (3) are most important to the patients. Experience has proved the awkwardness of mixing classes. In particular, the difference in visiting hours gives rise to jealousy among the patients nursed in the Moreover, nursing supervision and ordinary wards. administration is difficult. The idea of making no distinction, save any that is medically indicated, in nursing attention is a fine one ; but in our country I fear it is impracticable at this time, since the deficits of the private hospitals are not covered by the public treasury ; third-class rates do not meet costs, and the hospitals need the financial surplus derived from first- and second-class accommodation. There is a very strong feeling in the Netherlands against privately owned nursing-homes, run as a business enterprise, for the nursing of the wealthier patients : we prefer that all should enter hospital. In our experience, however, it is necessary two group ordinary wards, small wards, and single rooms in separate blocks or nursing units ; and this separation does not impede administration. J. C. J. BURKENS Diaconess Hospital, Meppel, Holland. Medical Director.
peutic efficacy. 6. It is important
to pursue the study of calciferol in pulmonary tuberculosis of adults. This can be justified by the proved efficacy of calciferol in certain types of extrapulmonary tuberculosis-for example, lupus, other cutaneous
In 1930 Meerseman3 stressed and serous tuberculosis. the importance of vitamin D in the treatment of experimental tuberculosis in the guineapig ; in guineapigs which were infected with tuberculosis and were at the same time given calciferol, a remarkable proportion did not develop clinical tuberculosis ; whereas in a control’series, without vitamin therapy, all the animals died. Levaditi and Li Yan Po4 showed that irradiated ergosterol produced in the rabbit an elective calcium precipitation at the point of bacillary infec. tion ; and, according to Raab,5 cultures of tubercle bacilli do not grow but degenerate in the presence of calciferol. This impressive array of clinical and experimental results calls for further investigations. 7. Other questions remain unanswered. Does addition of calcium facilitate, as suggested by some authors, the appearance of signs of intoxication, in the same way as in the animal ? Should vitamin A, held by many to act as an antagonist to vitamin D 2, be utilised as a regulator ?
forms,
it should be emphasised that these studies oust or delay the application of classical such as collapse therapy, whose value has been
Finally,
-
must
never
methods,
proved. Centre de Recherches de HUGUES GOUNELLE. l’Hôpital Foch, Paris.
ABUSE OF THE EMERGENCY BED SERVICE on record two examples of cases which we have been receiving from doctors through the Emergency Bed Service. The first was a man who arrived with an unintelligible note which when deciphered said that he was suffering from acute appendicitis and required admission. No details of any clinical findings were included in the note. On examination of the patient it was quite apparent that the doctor had not examined him previously as he had no symptom and bore not a single sign of the emergency " condition from which he was reported to have been suffering. The second was a case which I accepted at 2.30 in the morning. According to the doctor the patient was suffering from severe vomiting through food-poisoning and was in a state of collapse. Preparations were made to admit her and carry out emergency treatment, but when she arrived she felt perfectly well. Furthermore it transpired that she had not even been seen by the doctor concerned, and all the arrangements had been made over the telephone. The Emergency Bed Service is an excellent organisation, and I feel it is a pity that unfair advantage is taken of it by a certain section of the profession. R. S. KAGAN Westminster Hospital, Resident Medical Officer. London, S.W.1.
SiR,—I should like to put
"
CALCIFEROL IN PULMONARY TUBERCULOSIS
SiB,—Iread with great interest Dr. Phelan’s letter certain of my publications, following the article by Dr. Feeny, Dr. Sandiland, and Dr. Franklin, published on April 5. I should like in a few words to indicate my view of the present status of calciferol in pulmonary tuberculosis of adults. 1. My first two publications with Bachet concerned patients who had been severely undernourished and were in a Vitamin-calcium grave state of nutritional deficiency. therapy had, in these subjects, a manifest action in slowing down the evolutionary process ; almost all of them had very advanced tuberculosis, apparently beyond therapeutic reach, which incited us to try this medication ; it proved very
(May 31) quoting
_
,
useful for them.
SEDIMENTATION-RATE IN HYPERNEPHROMA 2. More recent trials in tuberculous patients who had undergone severe dietary restrictions have not afforded Sir.,-The article by Dr. Catlin, Mr. Bintcliffe, and such encouraging results ; and some are disappointing. This Dr. Marson in your issue of Aug. 2 prompts me to record group presented toxic signs more quickly ; thus they had to ’the following case. be given smaller doses than the first group. However, insuffiA man, aged 42, came under treatment for tonsillitis and cient time has elapsed to draw conclusions. sinusitis in November, 1945. The erythrocyte-sedimaxillary 3. Dosage is still undefined ; but in any case it seems mentation rate (E.s.R.) was 47 mm. in 1 hr. (Westergren). reasonable to avoid the appearance of toxic symptoms. When treatment was completed he was kept under observation There is amazing variation in tolerance, perhaps owing to since the E.s.R. remained high, ranging from 47 mm. up to in the variations previous state of vitaminisation in vitamin D 2. 110 mm. in 1 hr. 4. It appears that calciferol preparations used on the Sixteen months after he was first seen he began to complain Continent are better tolerated than certain similar British of tiredness, and he was observed to be mildly pyrexial in the products, which cause intoxication with smaller doses. evenings. The haemoglobin was 75%, and red-cell count 5. Our work, clinical as well as experimental in the dog, 3,900,000 per c.mm. The evening pyrexia continued, and two has already enabled us to state that the intramuscular route months later intravenous pyelography showed compression does not entail intoxication.2 No hyperealea-mia or hyperof the calyces of the right kidney. The patient was treated not
<
1. Gounelle, H., Bachet, M. Bull. Soc. méd. Hôp. Paris, 1946, p. 247; Ibid, 1947, p. 44. 2. Gounelle, H., Bachet, M., Sassier, R. C.R. Soc. Biol. Paris, 1946, 140, 827. Gounelle, H., Sassier, R., Marche, J. Ibid, 1947, 141, 216.
3. Meerseman, F., Thibault, G. Ibid, 1930, 105, 398. Meerseman, F. Rev. Tuberc., Paris, 1936, p. 1055. 4. Levaditi, C., Li, Y. P. Bull. Acad. Méd. Paris, 1930, 103, 502 ; Pr. méd. 1930, p. 168. 5. Raab, W. Dis. Chest, 1946, 12, 68.
azotaemia is noticed, even with extremely high doses, nor are. there any clinical, digestive, renal, or general disturbances ; but it remains to be seen if, corresponding to this better tolerance, the parenteral route does not entail loss of thera-
each other only if separation is medically indicated (for instance in separate departments for medical and surgical diseases), and they are never placed in the ordinary ward units or blocks but are grouped together in separate units ; and it is the same with the small wards (class 2B). It should be explained that the nursing and medical attention are exactly the same in the ordinary wards as in the small wards or single rooms. Units of singleor two-bedded rooms have relatively more nurses, but only because these are less economical than larger wards : a decreasing number of beds in a -ward or room means an increasing nurse-bed ratio. Why, then, do patients wish to be accommodated in small wards or single rooms ? For three reasons : (1) greater privacy, (2) better catering, and (3) longer and more visiting hours. Points (1) and (3) are most important to the patients. Experience has proved the awkwardness of mixing classes. In particular, the difference in visiting hours gives rise to jealousy among the patients nursed in the Moreover, nursing supervision and ordinary wards. administration is difficult. The idea of making no distinction, save any that is medically indicated, in nursing attention is a fine one ; but in our country I fear it is impracticable at this time, since the deficits of the private hospitals are not covered by the public treasury ; third-class rates do not meet costs, and the hospitals need the financial surplus derived from first- and second-class accommodation. There is a very strong feeling in the Netherlands against privately owned nursing-homes, run as a business enterprise, for the nursing of the wealthier patients : we prefer that all should enter hospital. In our experience, however, it is necessary two group ordinary wards, small wards, and single rooms in separate blocks or nursing units ; and this separation does not impede administration. J. C. J. BURKENS Diaconess Hospital, Meppel, Holland. Medical Director.
peutic efficacy. 6. It is important
to pursue the study of calciferol in pulmonary tuberculosis of adults. This can be justified by the proved efficacy of calciferol in certain types of extrapulmonary tuberculosis-for example, lupus, other cutaneous
In 1930 Meerseman3 stressed and serous tuberculosis. the importance of vitamin D in the treatment of experimental tuberculosis in the guineapig ; in guineapigs which were infected with tuberculosis and were at the same time given calciferol, a remarkable proportion did not develop clinical tuberculosis ; whereas in a control’series, without vitamin therapy, all the animals died. Levaditi and Li Yan Po4 showed that irradiated ergosterol produced in the rabbit an elective calcium precipitation at the point of bacillary infec. tion ; and, according to Raab,5 cultures of tubercle bacilli do not grow but degenerate in the presence of calciferol. This impressive array of clinical and experimental results calls for further investigations. 7. Other questions remain unanswered. Does addition of calcium facilitate, as suggested by some authors, the appearance of signs of intoxication, in the same way as in the animal ? Should vitamin A, held by many to act as an antagonist to vitamin D 2, be utilised as a regulator ?
forms,
it should be emphasised that these studies oust or delay the application of classical such as collapse therapy, whose value has been
Finally,
-
must
never
methods,
proved. Centre de Recherches de HUGUES GOUNELLE. l’Hôpital Foch, Paris.
ABUSE OF THE EMERGENCY BED SERVICE on record two examples of cases which we have been receiving from doctors through the Emergency Bed Service. The first was a man who arrived with an unintelligible note which when deciphered said that he was suffering from acute appendicitis and required admission. No details of any clinical findings were included in the note. On examination of the patient it was quite apparent that the doctor had not examined him previously as he had no symptom and bore not a single sign of the emergency " condition from which he was reported to have been suffering. The second was a case which I accepted at 2.30 in the morning. According to the doctor the patient was suffering from severe vomiting through food-poisoning and was in a state of collapse. Preparations were made to admit her and carry out emergency treatment, but when she arrived she felt perfectly well. Furthermore it transpired that she had not even been seen by the doctor concerned, and all the arrangements had been made over the telephone. The Emergency Bed Service is an excellent organisation, and I feel it is a pity that unfair advantage is taken of it by a certain section of the profession. R. S. KAGAN Westminster Hospital, Resident Medical Officer. London, S.W.1.
SiR,—I should like to put
"
CALCIFEROL IN PULMONARY TUBERCULOSIS
SiB,—Iread with great interest Dr. Phelan’s letter certain of my publications, following the article by Dr. Feeny, Dr. Sandiland, and Dr. Franklin, published on April 5. I should like in a few words to indicate my view of the present status of calciferol in pulmonary tuberculosis of adults. 1. My first two publications with Bachet concerned patients who had been severely undernourished and were in a Vitamin-calcium grave state of nutritional deficiency. therapy had, in these subjects, a manifest action in slowing down the evolutionary process ; almost all of them had very advanced tuberculosis, apparently beyond therapeutic reach, which incited us to try this medication ; it proved very
(May 31) quoting
_
,
useful for them.
SEDIMENTATION-RATE IN HYPERNEPHROMA 2. More recent trials in tuberculous patients who had undergone severe dietary restrictions have not afforded Sir.,-The article by Dr. Catlin, Mr. Bintcliffe, and such encouraging results ; and some are disappointing. This Dr. Marson in your issue of Aug. 2 prompts me to record group presented toxic signs more quickly ; thus they had to ’the following case. be given smaller doses than the first group. However, insuffiA man, aged 42, came under treatment for tonsillitis and cient time has elapsed to draw conclusions. sinusitis in November, 1945. The erythrocyte-sedimaxillary 3. Dosage is still undefined ; but in any case it seems mentation rate (E.s.R.) was 47 mm. in 1 hr. (Westergren). reasonable to avoid the appearance of toxic symptoms. When treatment was completed he was kept under observation There is amazing variation in tolerance, perhaps owing to since the E.s.R. remained high, ranging from 47 mm. up to in the variations previous state of vitaminisation in vitamin D 2. 110 mm. in 1 hr. 4. It appears that calciferol preparations used on the Sixteen months after he was first seen he began to complain Continent are better tolerated than certain similar British of tiredness, and he was observed to be mildly pyrexial in the products, which cause intoxication with smaller doses. evenings. The haemoglobin was 75%, and red-cell count 5. Our work, clinical as well as experimental in the dog, 3,900,000 per c.mm. The evening pyrexia continued, and two has already enabled us to state that the intramuscular route months later intravenous pyelography showed compression does not entail intoxication.2 No hyperealea-mia or hyperof the calyces of the right kidney. The patient was treated not
<
1. Gounelle, H., Bachet, M. Bull. Soc. méd. Hôp. Paris, 1946, p. 247; Ibid, 1947, p. 44. 2. Gounelle, H., Bachet, M., Sassier, R. C.R. Soc. Biol. Paris, 1946, 140, 827. Gounelle, H., Sassier, R., Marche, J. Ibid, 1947, 141, 216.
3. Meerseman, F., Thibault, G. Ibid, 1930, 105, 398. Meerseman, F. Rev. Tuberc., Paris, 1936, p. 1055. 4. Levaditi, C., Li, Y. P. Bull. Acad. Méd. Paris, 1930, 103, 502 ; Pr. méd. 1930, p. 168. 5. Raab, W. Dis. Chest, 1946, 12, 68.