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Hospital Beds
449
which is characteristically low in rheumatoid arthritis,
increases, mainly owing to an increase in the polymerisation of its hyaluronic acid-an effect which may, as ZIFF et awl. point out, be due either to the suppiession of inflammation or to a direct action on the polysaccharide. The superior activity of hydrocortisone, as compared with cortisone, when applied locally suggests that hydrocortisone (which is probably the principal glucocorticoid elaborated by the adrenal cortex 10-14) or a metabolic product is the agent that suppresses inflammatory reactions in the tissues. If this is -so, the activity of cortisone after oral or intramuscular administration must depend on the ability of certain tissues to reduce it, and its poor effect after intra-articular injection may indicate inability of synovial tissue to accomplish this reduction.5 Differences in the rate of absorption are unlikely to account for the unequal activity of the two steroids on inflamed joint tissues ; WILSON et al.15 found that cortisone, hydrocortisone, and their acetates all disappeared rapidly from the joint fluid after injection-only about 14% of an injected dose could be recovered after one hour. HOLLANDER 1 16 found that, compared with the microcrystals of cortisone acetate, those of hydrocortisone acetate were absorbed by the lining cells of the synovial membrane to a greater extent and were retained longer therein. The true explanation of the difference between the two hormones may be much simpler. BOLAND 17 has estimated that hydrocortisone (free alcohol) is approximately twice as effective weight-for-weight as cortisone when given by mouth, md FEnRNLEY’-8 believes that this is also true when the two steroids are injected directly into joints in the form of their acetates. When cortisone acetate was injected by this route in doses of 100 mg. (for a large joint) the clinical response did not differ from that following injection of 50 mg. of
site of the lesion has been found very useful in acute non-infective bursitis 3 19-21 ; in acute subdeltoid bursitis, for example, relief may be prompt and lasting, though in chronic cases this treatment fails. CYRIAX and TROISIER 22 have reported " outright cures in a week or two " in lesions of tendons, ligaments, and joint-capsules caused by injury or over-use ; they were particularly impressed with the response in tennis-elbow, as also were STEIN et al.23 BROWN et al.3 and HOWARD et al.24 had some encouraging results from local hydrocortisone treatment, alone or in conjunction with surgical measures, in triggerfinger, tenosynovitis, and Dupuytren’s contracture. Hydrocortisone has even found its way into bunions.3 17 Most clinicians in this country must wait for hydrocortisone to become more freely available before appraising for themselves this new method of treatment. Initial enthusiasm for therapeutic innovations in this field has almost always abated as experience has grown. Local administration of hydrocortisone promises, nevertheless, to establish itself as a useful measure in some patients with locomotor diseases. -
Hospital Beds WAITING-LISTS for admission to hospitals may be reduced either by providing more accommodation or by increasing the turnover ; and, since there is little money for capital expenditure, attention is now focused on turnover. The figures for bed occupancy and turnover suggest that there is still room for improvement,25 and the Minister of Health has asked senior administrative medical officers of regional boards, in collaboration with management committees, to review the utilisation of beds in general
hospitals. The position seems to be much the same in each of the regions. In the Liverpool region, for example, hydrocortisone. 7 of the 24 general or mainly general hospitals In osteo-arthritis treated by intra-articular injec- only have a bed-occupancy rate above 85%, and the rate tions of hydrocortisone HOLLANDER’S1 results were varies considerably between comparable hospitals.; unexpectedly encouraging, in view of the rather in hospitals with 400 or more beds the rate varies from equivocal response to systemic treatment with hor- 74% to 93%.26 In an 800-bed hospital an occupancymones. In his cases with involvement of the knee, rate of 85% means that every night an average of 120 as in those of RAMSEY and KEY,19 the outcome was beds are not in use. These beds are over many regarded as satisfactory in about 85%, and relief of units and subdivided for the sexes. spread Some are needed in rheumasymptoms usually lasted longer than for emergency admissions, but others represent delay toid - .arthritis1 19but DAVISON 8 classified the in admissions or variations in pressure-particularly response as satisfactory in only a third of his cases. in maternity and psediatric departments. The other Results are less impressive when the hip-joint is index is the average length of stay, which treated,! perhaps because of the technical difficulty important varies remarkably between comparable hospitals. of injecting this joint. Arthritis due to gout, trauma, again Thus of two very similar hospitals a few miles apart in and bleeding into the joint cavity is also said to West London, one has an stay of 17 days and respond to locally administered hydrocortisone.1 the other of 24 days. Inaverage a large general hospital in Administration of hydrocortisone directly into the ,
. ’
10. Conn, J. W., Lawrence, H. L., Fajans, S. S.
133, 713.
Science, 1951, ’
11. Ingle, D. J., Kuizenga, M. H. Endocrinology, 1945, 36, 218. 12. Mason, H. L. In Proceedings of the First Clinical A.C.T.H. Conferenbe; 1950, p. 168. 13. Pabst, M. L., Sheppard, R., Kuizenga, M. H. Endocrinology, 1947, 41, 55. 14. Pincus, G. Adrenal cortex function in stress : Transactions of the First Conference. New York, 1949. 15. Wilson, H., Glyn, J., Scull, E., McEwen, C., Ziff, M. Proc. Soc. exp. Biol., N.Y. 1953, 83, 648. 16. Hollander, J. L. See Ann. rheum. Dis. 1953, 12, 347. 17. Boland, E. W. Brit. med. J. 1952, i, 559. 18. Fearnley, M. E. Annual Report of West London Hospital Department of Rheumatic Diseases, 1953, p. 6. 19. R. H., Key, J. A. Missouri Med. 1953, 50, 604. ,
Ramsey,
London admissions
were
to 15,639 in 1951, by rate from 90-15% to
raised from
13,684 in 1949
increasing the bed-occupancy 93-6% and by lowering the
20. Orbach, E. J. J. int. Coll. Surg. 1952, 18, 159. 21. Henderson, E. D., Henderson, C. C. Minnesota Med. 1953, 36, 142. 22. Cyriax, J., Troisier, O. Brit. med. J. 1953, ii, 966. 23. Stein, L., Stein, R. O., Beller, M. L. Amer. J. Surg. 1953, 86, 123. 24. Howard, L. D. jun., Bunnell, S., Pratt, D. R. J. Bone Jt Surg. 1953, 35A, 526. Part II : Annual 25. Report of the Ministry of Health, 1952. Report of the Chief Medical Officer. H.M. Stationery Office, 1953; p. 185. 26. Report by Dr. T. Lloyd Hughes, senior administrative medical officer, to the Liverpool Regional Hospital Board, 1954.
450
and care, and with proper regard for the working average stay of acute cases from 18 to 158 days.27 This increase, achieved without apparent loss of mediconditions of medical, nursing, and, other staff, the cal efficiency, was equivalent to the provision of 100 turnover of many hospitals may be increased by some extra beds. 10% ; but such an increase is possible only when the Often more patients could be treated by simple staff of all departments are fully informed and are rearrangements, including the provision of cubicles Willing to work together. (so that beds could be occupied by patients of either sex) and the redistribution of beds between departAnnotations ments. The medical wards are hard-pressed in the cold winter months when they may need to overflow ANTIBIOTICS IN CHRONIC BRONCHITIS into surgical wards ; but this could be offset in the summer months when the pressure on medical beds EVEN under the best conditions allowed by our fitful is slighter and surgeons could take some over.28 In climate many patients with chronic bronchitis have to the summer, too, perhaps a third of the psediatric lead a completely sedentary life, because of breathlessness due to irreparable damage to their lungs. The severity beds may remain unoccupied, and with some adminisof this damage in advanced chronic bronchitis has been trative anticipation these might be temporarily used for adults. Full use of beds is greatly aided by the emphasised by Dr. Reid,lwho has shown that small nodules scar tissue in the- lungs of such patients represent appointment of an admissions officer empowered to of loss of much functional lung tissue. At necropsy the the admit patients to any ward and to regulate the of a patient with chronic bronchitis may show lungs number of admissions from the waiting-lists after all of inflammation, including not only fibrous stages consultation with the registrars or consultants. Some- nodules, but also patches of acute inflammation of the times the turnover may be improved by arranging bronchial and bronchiolar mucosae, small areas of for patients who have had minor operations to be consolidation, and minute abscesses. These observasupervised for the rest of the day, instead of being tions suggest that the insidious progress of the disease admitted to hospital for the night. Waiting-lists, depends largely on repeated infections, each of which its legacy of further damage until finally insufficient leaves with a registrar in charge of each, should be reviewed functional lung tissue remains. It seems that if this at intervals, and as far as possible investigations is to be averted, very serious attention must progression should be made, or other consultants’ opinions be paid to the prevention or, failing this, prompt treatobtained, before the patient is admitted. Increase in ment of acute respiratory infections, especially in patients turnover may be impeded by various different deficiwho tend to be chesty.’’ encies : the clinical departments may not have enough In the past no single organism was regarded as secretarial- help to enable them to keep properly in primarily responsible for the infection in chronic brontouch with the patients on their waiting-lists or to chitis ; and antibacterial measures were applied more or less " blindly." As might be expected, the results ensure that these can be admitted at very short In recent years much evidence has were unpredictable. notice ; or again, a further operating-theatre may be that the most important pathogen to accumulated suggest needed. The management committee and regional is Hœmophilus influenzœ, with the pneumococcus a board should be fully appraised of such impediments. close second. The importance of H. influenzœ Sometimes the decorating of wards takes inordinately fairly in bronchitis has repeatedly been emphasised by Mulder long, because the newer techniques are not used ; and and his colleagues,2 3 whose observations have been some hospitals have only lately discovered that often confirmed by May45 and Elmes et al.6 This organism walls can suitably be washed rather than repainted. is also important in bronchiectasis.78 8 Mulder believes remains the painters’ that in both bronchitis and bronchiectasis the pneumo(Unfortunately paint-washing is usually a secondary invader after infection by it restrictive seems a that this practice coccus monopoly ; pity H. influenzœ. Stuart-Harris et al.,9 on the other hand, should flourish in the health service.) But increase in attach greater importance to the pneumococcus than turnover does not depend wholly on the initiative of does Mulder, and their findings agree well in this respect the individual hospital. Regional boards should , with those of May. enable the busy hospitals to transfer some of their Several antibiotics inhibit both H. influence and the long-stay cases to other hospitals, perhaps in outlying pneumococcus in vitro, and at first sight it might parts, with a larger proportion of empty beds ; and seem that continuous administration of one or other similarly the appointment by the board of a geriatric of these should be satisfactory in prophylaxis. highly efficient against physician may lead to a decline in the number of old Chloramphenicol has proved and Franklin and Garrod 8 infections, respiratory admitted of and shorten the those to stay people help have demonstrated its value as a prophylactic agent in who do come into hospital. bronchiectasis associated with H. influenzœ in children. Hospital statistics are commonly regarded as These workers, however, abandoned this application uninteresting, inaccurate, and misleading. They would of the drug owing to the development of fatal aplastic undoubtedly be given greater heed if they were laid anaemia in one case. Long-continued administration of out more simply and in a form likely to promote a chloramphenicol is undoubtedly hazardous.10 Other sense of personal responsibility. AvEBY JONES 29 has antibiotics active in vitro against both-,H. influenzœ the that of number vacant-bed bed suggested days per 1. Reid, L. Lancet, Feb. 6, 1954, p. 275. 2. Mulder, J. Acta med. scand. 1938, 94, 98. per year should be worked out not only for the J., Goslings, W. R. O., van der Plas, M. C., Lopes hospital as a whole but also for each department ; and 3. Mulder, Cardozo, P. Ibid, 1952, 143, 32. J. R. Lancet, 1953, ii, 534. similarly a tally should be kept of the number of 4.5. May, May, J. R. Ibid, p. 899. each a in admitted 6. P. C., Knox, K., Fletcher, C. M. Ibid, p. 903. department Elmes, by year. patients 7. Allison, P. R., Gordon, J., Zinneman, K. J. Path. Bact. 1943, with efficient has shown treatment that, Experience 55, 465. I
"
27. Jones, F. A. Lancet, 1953, II, 1113. 28. See Ibid. p. 975. 29. Jones, F. A. Hosp. Offr, November, 1953, p. 26.
8. Franklin, A. W., Garrod, L. P. Brit. med. J. 1953, ii, 1067. 9. Stuart-Harris, C. H., Pownall, M., Scothorne, C. M., Franks, Z. Quart. J. Med. 1953, 22, 121. 10. Hodgkinson, R. Lancet, Feb. 6, 1954, p. 285.
which is characteristically low in rheumatoid arthritis,
increases, mainly owing to an increase in the polymerisation of its hyaluronic acid-an effect which may, as ZIFF et awl. point out, be due either to the suppiession of inflammation or to a direct action on the polysaccharide. The superior activity of hydrocortisone, as compared with cortisone, when applied locally suggests that hydrocortisone (which is probably the principal glucocorticoid elaborated by the adrenal cortex 10-14) or a metabolic product is the agent that suppresses inflammatory reactions in the tissues. If this is -so, the activity of cortisone after oral or intramuscular administration must depend on the ability of certain tissues to reduce it, and its poor effect after intra-articular injection may indicate inability of synovial tissue to accomplish this reduction.5 Differences in the rate of absorption are unlikely to account for the unequal activity of the two steroids on inflamed joint tissues ; WILSON et al.15 found that cortisone, hydrocortisone, and their acetates all disappeared rapidly from the joint fluid after injection-only about 14% of an injected dose could be recovered after one hour. HOLLANDER 1 16 found that, compared with the microcrystals of cortisone acetate, those of hydrocortisone acetate were absorbed by the lining cells of the synovial membrane to a greater extent and were retained longer therein. The true explanation of the difference between the two hormones may be much simpler. BOLAND 17 has estimated that hydrocortisone (free alcohol) is approximately twice as effective weight-for-weight as cortisone when given by mouth, md FEnRNLEY’-8 believes that this is also true when the two steroids are injected directly into joints in the form of their acetates. When cortisone acetate was injected by this route in doses of 100 mg. (for a large joint) the clinical response did not differ from that following injection of 50 mg. of
site of the lesion has been found very useful in acute non-infective bursitis 3 19-21 ; in acute subdeltoid bursitis, for example, relief may be prompt and lasting, though in chronic cases this treatment fails. CYRIAX and TROISIER 22 have reported " outright cures in a week or two " in lesions of tendons, ligaments, and joint-capsules caused by injury or over-use ; they were particularly impressed with the response in tennis-elbow, as also were STEIN et al.23 BROWN et al.3 and HOWARD et al.24 had some encouraging results from local hydrocortisone treatment, alone or in conjunction with surgical measures, in triggerfinger, tenosynovitis, and Dupuytren’s contracture. Hydrocortisone has even found its way into bunions.3 17 Most clinicians in this country must wait for hydrocortisone to become more freely available before appraising for themselves this new method of treatment. Initial enthusiasm for therapeutic innovations in this field has almost always abated as experience has grown. Local administration of hydrocortisone promises, nevertheless, to establish itself as a useful measure in some patients with locomotor diseases. -
Hospital Beds WAITING-LISTS for admission to hospitals may be reduced either by providing more accommodation or by increasing the turnover ; and, since there is little money for capital expenditure, attention is now focused on turnover. The figures for bed occupancy and turnover suggest that there is still room for improvement,25 and the Minister of Health has asked senior administrative medical officers of regional boards, in collaboration with management committees, to review the utilisation of beds in general
hospitals. The position seems to be much the same in each of the regions. In the Liverpool region, for example, hydrocortisone. 7 of the 24 general or mainly general hospitals In osteo-arthritis treated by intra-articular injec- only have a bed-occupancy rate above 85%, and the rate tions of hydrocortisone HOLLANDER’S1 results were varies considerably between comparable hospitals.; unexpectedly encouraging, in view of the rather in hospitals with 400 or more beds the rate varies from equivocal response to systemic treatment with hor- 74% to 93%.26 In an 800-bed hospital an occupancymones. In his cases with involvement of the knee, rate of 85% means that every night an average of 120 as in those of RAMSEY and KEY,19 the outcome was beds are not in use. These beds are over many regarded as satisfactory in about 85%, and relief of units and subdivided for the sexes. spread Some are needed in rheumasymptoms usually lasted longer than for emergency admissions, but others represent delay toid - .arthritis1 19but DAVISON 8 classified the in admissions or variations in pressure-particularly response as satisfactory in only a third of his cases. in maternity and psediatric departments. The other Results are less impressive when the hip-joint is index is the average length of stay, which treated,! perhaps because of the technical difficulty important varies remarkably between comparable hospitals. of injecting this joint. Arthritis due to gout, trauma, again Thus of two very similar hospitals a few miles apart in and bleeding into the joint cavity is also said to West London, one has an stay of 17 days and respond to locally administered hydrocortisone.1 the other of 24 days. Inaverage a large general hospital in Administration of hydrocortisone directly into the ,
. ’
10. Conn, J. W., Lawrence, H. L., Fajans, S. S.
133, 713.
Science, 1951, ’
11. Ingle, D. J., Kuizenga, M. H. Endocrinology, 1945, 36, 218. 12. Mason, H. L. In Proceedings of the First Clinical A.C.T.H. Conferenbe; 1950, p. 168. 13. Pabst, M. L., Sheppard, R., Kuizenga, M. H. Endocrinology, 1947, 41, 55. 14. Pincus, G. Adrenal cortex function in stress : Transactions of the First Conference. New York, 1949. 15. Wilson, H., Glyn, J., Scull, E., McEwen, C., Ziff, M. Proc. Soc. exp. Biol., N.Y. 1953, 83, 648. 16. Hollander, J. L. See Ann. rheum. Dis. 1953, 12, 347. 17. Boland, E. W. Brit. med. J. 1952, i, 559. 18. Fearnley, M. E. Annual Report of West London Hospital Department of Rheumatic Diseases, 1953, p. 6. 19. R. H., Key, J. A. Missouri Med. 1953, 50, 604. ,
Ramsey,
London admissions
were
to 15,639 in 1951, by rate from 90-15% to
raised from
13,684 in 1949
increasing the bed-occupancy 93-6% and by lowering the
20. Orbach, E. J. J. int. Coll. Surg. 1952, 18, 159. 21. Henderson, E. D., Henderson, C. C. Minnesota Med. 1953, 36, 142. 22. Cyriax, J., Troisier, O. Brit. med. J. 1953, ii, 966. 23. Stein, L., Stein, R. O., Beller, M. L. Amer. J. Surg. 1953, 86, 123. 24. Howard, L. D. jun., Bunnell, S., Pratt, D. R. J. Bone Jt Surg. 1953, 35A, 526. Part II : Annual 25. Report of the Ministry of Health, 1952. Report of the Chief Medical Officer. H.M. Stationery Office, 1953; p. 185. 26. Report by Dr. T. Lloyd Hughes, senior administrative medical officer, to the Liverpool Regional Hospital Board, 1954.
450
and care, and with proper regard for the working average stay of acute cases from 18 to 158 days.27 This increase, achieved without apparent loss of mediconditions of medical, nursing, and, other staff, the cal efficiency, was equivalent to the provision of 100 turnover of many hospitals may be increased by some extra beds. 10% ; but such an increase is possible only when the Often more patients could be treated by simple staff of all departments are fully informed and are rearrangements, including the provision of cubicles Willing to work together. (so that beds could be occupied by patients of either sex) and the redistribution of beds between departAnnotations ments. The medical wards are hard-pressed in the cold winter months when they may need to overflow ANTIBIOTICS IN CHRONIC BRONCHITIS into surgical wards ; but this could be offset in the summer months when the pressure on medical beds EVEN under the best conditions allowed by our fitful is slighter and surgeons could take some over.28 In climate many patients with chronic bronchitis have to the summer, too, perhaps a third of the psediatric lead a completely sedentary life, because of breathlessness due to irreparable damage to their lungs. The severity beds may remain unoccupied, and with some adminisof this damage in advanced chronic bronchitis has been trative anticipation these might be temporarily used for adults. Full use of beds is greatly aided by the emphasised by Dr. Reid,lwho has shown that small nodules scar tissue in the- lungs of such patients represent appointment of an admissions officer empowered to of loss of much functional lung tissue. At necropsy the the admit patients to any ward and to regulate the of a patient with chronic bronchitis may show lungs number of admissions from the waiting-lists after all of inflammation, including not only fibrous stages consultation with the registrars or consultants. Some- nodules, but also patches of acute inflammation of the times the turnover may be improved by arranging bronchial and bronchiolar mucosae, small areas of for patients who have had minor operations to be consolidation, and minute abscesses. These observasupervised for the rest of the day, instead of being tions suggest that the insidious progress of the disease admitted to hospital for the night. Waiting-lists, depends largely on repeated infections, each of which its legacy of further damage until finally insufficient leaves with a registrar in charge of each, should be reviewed functional lung tissue remains. It seems that if this at intervals, and as far as possible investigations is to be averted, very serious attention must progression should be made, or other consultants’ opinions be paid to the prevention or, failing this, prompt treatobtained, before the patient is admitted. Increase in ment of acute respiratory infections, especially in patients turnover may be impeded by various different deficiwho tend to be chesty.’’ encies : the clinical departments may not have enough In the past no single organism was regarded as secretarial- help to enable them to keep properly in primarily responsible for the infection in chronic brontouch with the patients on their waiting-lists or to chitis ; and antibacterial measures were applied more or less " blindly." As might be expected, the results ensure that these can be admitted at very short In recent years much evidence has were unpredictable. notice ; or again, a further operating-theatre may be that the most important pathogen to accumulated suggest needed. The management committee and regional is Hœmophilus influenzœ, with the pneumococcus a board should be fully appraised of such impediments. close second. The importance of H. influenzœ Sometimes the decorating of wards takes inordinately fairly in bronchitis has repeatedly been emphasised by Mulder long, because the newer techniques are not used ; and and his colleagues,2 3 whose observations have been some hospitals have only lately discovered that often confirmed by May45 and Elmes et al.6 This organism walls can suitably be washed rather than repainted. is also important in bronchiectasis.78 8 Mulder believes remains the painters’ that in both bronchitis and bronchiectasis the pneumo(Unfortunately paint-washing is usually a secondary invader after infection by it restrictive seems a that this practice coccus monopoly ; pity H. influenzœ. Stuart-Harris et al.,9 on the other hand, should flourish in the health service.) But increase in attach greater importance to the pneumococcus than turnover does not depend wholly on the initiative of does Mulder, and their findings agree well in this respect the individual hospital. Regional boards should , with those of May. enable the busy hospitals to transfer some of their Several antibiotics inhibit both H. influence and the long-stay cases to other hospitals, perhaps in outlying pneumococcus in vitro, and at first sight it might parts, with a larger proportion of empty beds ; and seem that continuous administration of one or other similarly the appointment by the board of a geriatric of these should be satisfactory in prophylaxis. highly efficient against physician may lead to a decline in the number of old Chloramphenicol has proved and Franklin and Garrod 8 infections, respiratory admitted of and shorten the those to stay people help have demonstrated its value as a prophylactic agent in who do come into hospital. bronchiectasis associated with H. influenzœ in children. Hospital statistics are commonly regarded as These workers, however, abandoned this application uninteresting, inaccurate, and misleading. They would of the drug owing to the development of fatal aplastic undoubtedly be given greater heed if they were laid anaemia in one case. Long-continued administration of out more simply and in a form likely to promote a chloramphenicol is undoubtedly hazardous.10 Other sense of personal responsibility. AvEBY JONES 29 has antibiotics active in vitro against both-,H. influenzœ the that of number vacant-bed bed suggested days per 1. Reid, L. Lancet, Feb. 6, 1954, p. 275. 2. Mulder, J. Acta med. scand. 1938, 94, 98. per year should be worked out not only for the J., Goslings, W. R. O., van der Plas, M. C., Lopes hospital as a whole but also for each department ; and 3. Mulder, Cardozo, P. Ibid, 1952, 143, 32. J. R. Lancet, 1953, ii, 534. similarly a tally should be kept of the number of 4.5. May, May, J. R. Ibid, p. 899. each a in admitted 6. P. C., Knox, K., Fletcher, C. M. Ibid, p. 903. department Elmes, by year. patients 7. Allison, P. R., Gordon, J., Zinneman, K. J. Path. Bact. 1943, with efficient has shown treatment that, Experience 55, 465. I
"
27. Jones, F. A. Lancet, 1953, II, 1113. 28. See Ibid. p. 975. 29. Jones, F. A. Hosp. Offr, November, 1953, p. 26.
8. Franklin, A. W., Garrod, L. P. Brit. med. J. 1953, ii, 1067. 9. Stuart-Harris, C. H., Pownall, M., Scothorne, C. M., Franks, Z. Quart. J. Med. 1953, 22, 121. 10. Hodgkinson, R. Lancet, Feb. 6, 1954, p. 285.