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ERYTHEMA EXUDATIVUM MULTIFORME AND PNEUMONIA TREATED WITH AUREOMYCIN
281 and the cardiovascular
HOSPITAL BEDS
SiR.—One of the greatest obstacles to the full implementation of the National Health Service Act is the
shortage of hospital accommodation. It is, therefore, imperative, in the absence of any immediate prospect of building new hospitals, or extending the present ones, that the best use should be made of the existing beds. Your leading article last week lays stress on the average percentage bed occupancy, which was 83% in the big London hospitals in the early 1930s. Although we should aim at the highest figure possible, clearly the hospitals with a reputed 100% occupancy are constantly adding a large number of extra beds for emergency cases. In practice there are many contingencies which inevitably lower the percentage occupied during The number of patients during the Christmas a year. holidays is often reduced by a third. The average Britisher is also very loth to be admitted off the’waitinglist just before Easter, Whitsun, or the August holidays. Further wards have to be closed from time to time for redecoration and cleaning. You urge that the Minister should investigate this matter. I am sure that there are more fruitful lines of inquiry which could reduce " bed wastage " in these days of bed famine." The average stay of patients in similar hospitals varies greatly. It is well known that this figure is at its lowest in the teaching hospitals with their adequate staff and facilities. Many of the smaller hospitals, or ’those situated some distance away from the big centres, depend on infrequent consultant visits. Junior hospital staff tend to delay a clinical decision " until the patient has been seen by the responsible physician or surgeon. The loss, in terms of patient-days, by inadequate consultant staffing, can be very substantial. Hospital beds are still used extensively for patients requiring investigation. This is particularly true in hospitals where the outpatient department is not adequately staffed or equipped. The cost to the State of investigating a patient as an outpatient is much less than that of providing him with a hospital bed. An increase in diagnostic facilities would release a large number of beds urgently required for the patients needing treatment that can only be provided in a hospital. The best and the maximum use should be made of the existing hospital beds. The disturbing factor of nursing shortage may prevent a substantial increase of accommodation even in the future. DAVID G. MORGAN. Cardiff. "
"
ERYTHEMA EXUDATIVUM MULTIFORME AND
PNEUMONIA TREATED WITH AUREOMYCIN
SiR,—In view of Dr. Bettley’s account (Jan. 14) of
a
of pemphigus benefited by ’Aureomycin,’ and of recent reports from the U.S.A. of its trial in some cases of dermatitis herpetiformis and disseminated herpes simplex, I would like to record the following case.
case
A man, aged 69, was admitted to St. Helier Hospital under care of Dr. Prosser Thomas on Oct. 4, 1949, suffering from an acute bullous eruption with severe constitutional reaction. He had been taking phenobarbitone gr. 1/2 twice daily on and off since June, 1948 ; and this was regarded as a possible
the
cause.
On admission, his temperature was 101-4°F, pulse-rate 96 per min., respirations 22 per min. The tongue was heavily furred and there was severe stomatitis with submucosal hemorrhage. The orbits were aedematous and discharging The whole face was swollen and red and later exuded, leaving crusts round the eyes, mouth, and nose. The anogenital area was similarly affected. On the limbs, and to a lesser extent the trunk, wera large patches of erythema or purpuric erythema with thin bhsters of varying size. The appearances were typical of severe erythema bullosum or so-called
Stevens-Johnson syndrome.
On examination a few crepitations were heard at the base of each lung. In the abdomen, the central nervous system,
abnormality was detected The blood-count was within normal limits, and blood-culture was negative ; blood-urea 49 mg. per 100 ml. The urine contained a trace of protein with a moderate number of cellular, granular, and hyaline casts ; culture contained Bact. coli. Radiography of chest showed an unfolded aorta. The patient was treated at first with penicillin intramuscularly, 250,000 units four-hourly,’Phenergan,’ 25 mg. twice daily, and locally with saline compresses and calamine lotion or liniment with 0-5% crystal violet. His condition, however, rapidly deteriorated and by Oct. 7 was regarded as hopeless. He had become semicomatose and was very toxic and eyanosed. There were signs of consolidation at the base of the right lung and to a lesser extent at the left base ; radiographs showed multiple small patches of bronchopneumonia throughout both lungs. On the suggestion of Dr. C. P. Petch, the patient was given aureomycin in 1 g. doses every six hours for four days. The response was dramatic. In twelve hours the temperature became normal and it remained so. The patient soon became rational and the eruption rapidly regressed. blood-pressure 120/80
system,
mm.
no
Hg.
He made an uninterrupted recovery and was discharged to convalescence on Nov. 7, when radiography showed the lungs to be completely clear. He is now quite fit again and back at work. W. E. CHURCH. St. Helier Hospital, Carshalton, Surrey. THE FIRST MEDICAL EXAMINATION
Sm,-Mr. Hentschel, in his letter of Jan. 28, says : " There is no doubt that the same standard is maintained for the external and internal examinations for London 1st M.B." It must, however, be extremely difficult to ensure a uniform standard even if, as he says, it is the practice for the same outside examiners to act in both examinations. I suggest that it would be fairer to all candidates if identical papers were set for the external and internal examinations, with a uniform system of marking : internal students at some colleges already take the same papers as external students, and there is no apparent reason why the remaining colleges should not fall into line. This suggestion also applies to the 2nd M.B., where again many medical schools have their own papers, so that the examination may well be easier at some schools than at others, and for internal students than for external (or vice versa). In the final &bgr;-LB. examination there are common papers for all students. F. WHITWAM JONES. London, BV.2. SiR,-In her letter of Jan. 21, Dr. Johnson expresses doubt whether the training, especially in schools,- is really inadequate. May I be permitted to tell my experience of training from a student’s viewpoint ?’? I was at school during the late war, and because of evacuation and other causes my education was badly interrupted. The final result was that although for higher school certificate I could study biology, there were no facilities or tutor for chemistry and, I think, also no teacher in physics. Hence, after National Service, when I found it difficult to gain entry to a medical school for 1st M.B., I decided to take intermediate B.SC. externally for an exemption. In September, 1947, there were just over 20 students in my class taking the intermediate B.SC. course at a London technical college. The students’ ages varied between 18 and 26 years. All studied physics, some 15 chemistry, but only 8 of us botany and zoology. The majority were aiming for an engineering qualification, and the rest for such varied ones as pharmaceutical (2), veterinary (1), pure chemistry (2), agricultural (1), and medical (2). The course lasted until July, 1948. when the examinations took place. The students agreed that the lectures in physics were of However, the lecturer found good standard and himself obliged to use the calculus notation quite frequently, and this proved a handicap to the biologists. In chemistry the teacher was proficient in his subject but designed his lectures to cover only the main parts of the syllabus. For both zoology and botany, however, there was only one Nine-tenths of his lectures tutor and he was
adequate.
incompetent.
HOSPITAL BEDS
SiR.—One of the greatest obstacles to the full implementation of the National Health Service Act is the
shortage of hospital accommodation. It is, therefore, imperative, in the absence of any immediate prospect of building new hospitals, or extending the present ones, that the best use should be made of the existing beds. Your leading article last week lays stress on the average percentage bed occupancy, which was 83% in the big London hospitals in the early 1930s. Although we should aim at the highest figure possible, clearly the hospitals with a reputed 100% occupancy are constantly adding a large number of extra beds for emergency cases. In practice there are many contingencies which inevitably lower the percentage occupied during The number of patients during the Christmas a year. holidays is often reduced by a third. The average Britisher is also very loth to be admitted off the’waitinglist just before Easter, Whitsun, or the August holidays. Further wards have to be closed from time to time for redecoration and cleaning. You urge that the Minister should investigate this matter. I am sure that there are more fruitful lines of inquiry which could reduce " bed wastage " in these days of bed famine." The average stay of patients in similar hospitals varies greatly. It is well known that this figure is at its lowest in the teaching hospitals with their adequate staff and facilities. Many of the smaller hospitals, or ’those situated some distance away from the big centres, depend on infrequent consultant visits. Junior hospital staff tend to delay a clinical decision " until the patient has been seen by the responsible physician or surgeon. The loss, in terms of patient-days, by inadequate consultant staffing, can be very substantial. Hospital beds are still used extensively for patients requiring investigation. This is particularly true in hospitals where the outpatient department is not adequately staffed or equipped. The cost to the State of investigating a patient as an outpatient is much less than that of providing him with a hospital bed. An increase in diagnostic facilities would release a large number of beds urgently required for the patients needing treatment that can only be provided in a hospital. The best and the maximum use should be made of the existing hospital beds. The disturbing factor of nursing shortage may prevent a substantial increase of accommodation even in the future. DAVID G. MORGAN. Cardiff. "
"
ERYTHEMA EXUDATIVUM MULTIFORME AND
PNEUMONIA TREATED WITH AUREOMYCIN
SiR,—In view of Dr. Bettley’s account (Jan. 14) of
a
of pemphigus benefited by ’Aureomycin,’ and of recent reports from the U.S.A. of its trial in some cases of dermatitis herpetiformis and disseminated herpes simplex, I would like to record the following case.
case
A man, aged 69, was admitted to St. Helier Hospital under care of Dr. Prosser Thomas on Oct. 4, 1949, suffering from an acute bullous eruption with severe constitutional reaction. He had been taking phenobarbitone gr. 1/2 twice daily on and off since June, 1948 ; and this was regarded as a possible
the
cause.
On admission, his temperature was 101-4°F, pulse-rate 96 per min., respirations 22 per min. The tongue was heavily furred and there was severe stomatitis with submucosal hemorrhage. The orbits were aedematous and discharging The whole face was swollen and red and later exuded, leaving crusts round the eyes, mouth, and nose. The anogenital area was similarly affected. On the limbs, and to a lesser extent the trunk, wera large patches of erythema or purpuric erythema with thin bhsters of varying size. The appearances were typical of severe erythema bullosum or so-called
Stevens-Johnson syndrome.
On examination a few crepitations were heard at the base of each lung. In the abdomen, the central nervous system,
abnormality was detected The blood-count was within normal limits, and blood-culture was negative ; blood-urea 49 mg. per 100 ml. The urine contained a trace of protein with a moderate number of cellular, granular, and hyaline casts ; culture contained Bact. coli. Radiography of chest showed an unfolded aorta. The patient was treated at first with penicillin intramuscularly, 250,000 units four-hourly,’Phenergan,’ 25 mg. twice daily, and locally with saline compresses and calamine lotion or liniment with 0-5% crystal violet. His condition, however, rapidly deteriorated and by Oct. 7 was regarded as hopeless. He had become semicomatose and was very toxic and eyanosed. There were signs of consolidation at the base of the right lung and to a lesser extent at the left base ; radiographs showed multiple small patches of bronchopneumonia throughout both lungs. On the suggestion of Dr. C. P. Petch, the patient was given aureomycin in 1 g. doses every six hours for four days. The response was dramatic. In twelve hours the temperature became normal and it remained so. The patient soon became rational and the eruption rapidly regressed. blood-pressure 120/80
system,
mm.
no
Hg.
He made an uninterrupted recovery and was discharged to convalescence on Nov. 7, when radiography showed the lungs to be completely clear. He is now quite fit again and back at work. W. E. CHURCH. St. Helier Hospital, Carshalton, Surrey. THE FIRST MEDICAL EXAMINATION
Sm,-Mr. Hentschel, in his letter of Jan. 28, says : " There is no doubt that the same standard is maintained for the external and internal examinations for London 1st M.B." It must, however, be extremely difficult to ensure a uniform standard even if, as he says, it is the practice for the same outside examiners to act in both examinations. I suggest that it would be fairer to all candidates if identical papers were set for the external and internal examinations, with a uniform system of marking : internal students at some colleges already take the same papers as external students, and there is no apparent reason why the remaining colleges should not fall into line. This suggestion also applies to the 2nd M.B., where again many medical schools have their own papers, so that the examination may well be easier at some schools than at others, and for internal students than for external (or vice versa). In the final &bgr;-LB. examination there are common papers for all students. F. WHITWAM JONES. London, BV.2. SiR,-In her letter of Jan. 21, Dr. Johnson expresses doubt whether the training, especially in schools,- is really inadequate. May I be permitted to tell my experience of training from a student’s viewpoint ?’? I was at school during the late war, and because of evacuation and other causes my education was badly interrupted. The final result was that although for higher school certificate I could study biology, there were no facilities or tutor for chemistry and, I think, also no teacher in physics. Hence, after National Service, when I found it difficult to gain entry to a medical school for 1st M.B., I decided to take intermediate B.SC. externally for an exemption. In September, 1947, there were just over 20 students in my class taking the intermediate B.SC. course at a London technical college. The students’ ages varied between 18 and 26 years. All studied physics, some 15 chemistry, but only 8 of us botany and zoology. The majority were aiming for an engineering qualification, and the rest for such varied ones as pharmaceutical (2), veterinary (1), pure chemistry (2), agricultural (1), and medical (2). The course lasted until July, 1948. when the examinations took place. The students agreed that the lectures in physics were of However, the lecturer found good standard and himself obliged to use the calculus notation quite frequently, and this proved a handicap to the biologists. In chemistry the teacher was proficient in his subject but designed his lectures to cover only the main parts of the syllabus. For both zoology and botany, however, there was only one Nine-tenths of his lectures tutor and he was
adequate.
incompetent.