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IMMUNOALLERGIC LUNG PURPURA TREATED WITH AZATHIOPRINE
269 In fact about 15 % of acute strokes are associated with lesions in the internal carotid artery in the neck and many of these, especially if caught at the premonitory stage, are amenable
possible.
to surgery.
Finally, it was suggested that anticoagulants were out of favour. It is true that it has been shown they have no place in the management of the completed stroke, but the stroke-inevolution and transient ischaemic attacks undoubtedly benefit. There is a great deal of prevention and treatment which be applied and more will be possible if we remain alert and are not lulled into believing, as was suggested in this programme, that there is nothing to be done about strokes. can
of Clinical Neurology, The National Hospital, Queen Square, London, W.C.1.
University Department
JOHN MARSHALL.
NEW HOSPITALS: SINGLE OR MULTIPLE?
SIR,-There is growing frustration among doctors in this country; we feel we can no longer influence and change a defective service. One day those in authority will we workers in the field are often in the best advise on, and guide, the service. In Leicester position we consultants recommended to our regional hospital board that we should plan for the future a single hospital or hospital centre for our city and county, which have a population of perhaps 500,000. The advantages of such
realise that to
a
plan are:
Economy in cost and personnel-the latter being particularly important in a non-teaching centre. In the physiotherapy, radiology, dietetic, casualty, and pathological departments tremendous economies would be made by centralisation. Furthermore, a single nursing school would have more flexibility in times of shortage and would provide more comprehensive training facilities without the necessity for secondment to special hospitals. Economies in medical manpower would result from the reduction of travelling between hospitals and the availability of a larger resident and non-specialist staff to cover shortages. 2. Much more important, the quality of medicine practised would be improved greatly. Doctors of all levels would be in constant touch with each other; clinical conferences, discussions, and teaching sessions would all be in the same place; and research and teaching would be assisted. General practitioners must be encouraged to come to hospital conferences and informal discussions with consultants; they cannot be expected to go round multiple hospitals. Instead of several hospitals having indifferent and partly duplicated libraries, there would be only one-well-stocked and with a paid librarian able to look up references, get out papers, and generally provide the help needed for research and learning. 3. The ultimate object, of course, is to improve the quality of our service to the patients. I suggest that this would necessarily follow from the foregoing. We are not allowed this vision; we are to have 2, and possibly 3, district general hospitals at different points in the city several miles apart. The only reasons given for 1.
this
that: (a) it is difficult to administer a large unit is no real problem since separate blocks can have separate administrators, but we want them on the same site) and (b) hospitals must be near the people they serve. It is my experience that the public would willingly travel a few more miles if, at the end, there were a better service. In this connection, I am sure we should not are
(clearly this
submit to " popular " pressures where we feel these pressures would impair our service. We are thus having a hospital service planned for us against the advice of local consultants without adequate reasons. Perhaps someone in Whitehall has decided that a district general hospital shall be of a certain maximum
size and that multiple hospitals must be provided where the population requires it. I suggest that this sort of rigid thinking is wrong: our local problems should be considered first and then their best solution. There is surely room for experimentation and flexibility if we are to progress; here we all want a single medical centre; another city might prefer three hospitals. At all events, I hope those in high positions will look at our frustration before it
apathy.
turns to Leicester General Hospital, Leicester.
P. HICKINBOTHAM.
IMMUNOALLERGIC LUNG PURPURA TREATED WITH AZATHIOPRINE SIR,-The report by Dr. Steiner and Dr. Nabrady (Jan. 16) is of considerable interest. They point out that the possibility of spontaneous remission of idiopathic pulmonary haemosiderosis must be excluded. This is most important in a disease characterised by natural remissions, some of which may be complete and last for years. No doubt this fact is responsible for the enthusiastic claims for a wide variety of therapeutic measures.
Although the case-report of Dr. Steiner and Dr. Nabrady suggests a dramatic response to azathioprine, one wonders whether they are justified in precluding "
coincidence ".
mere
Bignold Hospital, Wick, Caithness, Scotland.
DAVID H. A. BOYD.
ANTIVIRAL AGENTS
SIR,-Your annotation (Jan. 16) discusses the imporof toxicity in the use of these compounds and their limitations if used at a time when characteristic pathological changes have appeared, but when virus titres have already commenced to fall. Support for this can certainly be found in the treatment of recurrent herpes simplex skin infections, in which 5-iodo2’-deoxyuridine has been shown to be ineffective in the majority of cases treated by topical applications, and which is too toxic for parenteral administration. An investigation in virus isolation from the lesions of herpes genitalis was recently carried out in conjunction with the Virus Reference Laboratory, Colindale. Herpes simplex virus was isolated from superficial scrapings of most lesions which had persisted for an average duration of 3-85 days, but rarely from lesions which had persisted for an average of more than 8-26 days. In those lesions which had persisted for 1 day the virus was present in 81-8% of cases, whereas no virus was isolated from lesions which had persisted for more than 14 days: it was, however, present in 50% of cases in lesions which had persisted for 5, 6, or 8 days. In
tance
the virus was isolated from fluid obtained from bullae, which were seen in 25 % of patients attending. During this investigation it was noted that most patients attended with lesions that had been present for an average time of 5-7 days, or at a time in which the virus was found to be present in 50% of cases. Topical therapy with an antiviral agent given at this time would be fully effective in only 50% of cases. Parenteral therapy, however, might still be effective in all cases should the virus be in cells deeper in the lesions or in nerve-endings or in other places hitherto unknown. Parenteral therapy would also probably be more effective in vesicular lesions, since the virus is concentrated in the basal layers and fluid of vesicles, or in a situation relatively inaccessible to topical application, unless ruptured mechanically. Parenteral therapy would appear to be the effective form of treatment for recurrent cases, in which the virus is thought to remain latent in the tissues between attacks and for which topical applications of an antiviral agent have been found to be useless.l Finally, it might be the only effective method of treatment in cases of
every
case
vesicles
or
1.
Hutfield,
D. C. Brit.
J.
vener.
Dis. 1964,
40,
210.
possible.
to surgery.
Finally, it was suggested that anticoagulants were out of favour. It is true that it has been shown they have no place in the management of the completed stroke, but the stroke-inevolution and transient ischaemic attacks undoubtedly benefit. There is a great deal of prevention and treatment which be applied and more will be possible if we remain alert and are not lulled into believing, as was suggested in this programme, that there is nothing to be done about strokes. can
of Clinical Neurology, The National Hospital, Queen Square, London, W.C.1.
University Department
JOHN MARSHALL.
NEW HOSPITALS: SINGLE OR MULTIPLE?
SIR,-There is growing frustration among doctors in this country; we feel we can no longer influence and change a defective service. One day those in authority will we workers in the field are often in the best advise on, and guide, the service. In Leicester position we consultants recommended to our regional hospital board that we should plan for the future a single hospital or hospital centre for our city and county, which have a population of perhaps 500,000. The advantages of such
realise that to
a
plan are:
Economy in cost and personnel-the latter being particularly important in a non-teaching centre. In the physiotherapy, radiology, dietetic, casualty, and pathological departments tremendous economies would be made by centralisation. Furthermore, a single nursing school would have more flexibility in times of shortage and would provide more comprehensive training facilities without the necessity for secondment to special hospitals. Economies in medical manpower would result from the reduction of travelling between hospitals and the availability of a larger resident and non-specialist staff to cover shortages. 2. Much more important, the quality of medicine practised would be improved greatly. Doctors of all levels would be in constant touch with each other; clinical conferences, discussions, and teaching sessions would all be in the same place; and research and teaching would be assisted. General practitioners must be encouraged to come to hospital conferences and informal discussions with consultants; they cannot be expected to go round multiple hospitals. Instead of several hospitals having indifferent and partly duplicated libraries, there would be only one-well-stocked and with a paid librarian able to look up references, get out papers, and generally provide the help needed for research and learning. 3. The ultimate object, of course, is to improve the quality of our service to the patients. I suggest that this would necessarily follow from the foregoing. We are not allowed this vision; we are to have 2, and possibly 3, district general hospitals at different points in the city several miles apart. The only reasons given for 1.
this
that: (a) it is difficult to administer a large unit is no real problem since separate blocks can have separate administrators, but we want them on the same site) and (b) hospitals must be near the people they serve. It is my experience that the public would willingly travel a few more miles if, at the end, there were a better service. In this connection, I am sure we should not are
(clearly this
submit to " popular " pressures where we feel these pressures would impair our service. We are thus having a hospital service planned for us against the advice of local consultants without adequate reasons. Perhaps someone in Whitehall has decided that a district general hospital shall be of a certain maximum
size and that multiple hospitals must be provided where the population requires it. I suggest that this sort of rigid thinking is wrong: our local problems should be considered first and then their best solution. There is surely room for experimentation and flexibility if we are to progress; here we all want a single medical centre; another city might prefer three hospitals. At all events, I hope those in high positions will look at our frustration before it
apathy.
turns to Leicester General Hospital, Leicester.
P. HICKINBOTHAM.
IMMUNOALLERGIC LUNG PURPURA TREATED WITH AZATHIOPRINE SIR,-The report by Dr. Steiner and Dr. Nabrady (Jan. 16) is of considerable interest. They point out that the possibility of spontaneous remission of idiopathic pulmonary haemosiderosis must be excluded. This is most important in a disease characterised by natural remissions, some of which may be complete and last for years. No doubt this fact is responsible for the enthusiastic claims for a wide variety of therapeutic measures.
Although the case-report of Dr. Steiner and Dr. Nabrady suggests a dramatic response to azathioprine, one wonders whether they are justified in precluding "
coincidence ".
mere
Bignold Hospital, Wick, Caithness, Scotland.
DAVID H. A. BOYD.
ANTIVIRAL AGENTS
SIR,-Your annotation (Jan. 16) discusses the imporof toxicity in the use of these compounds and their limitations if used at a time when characteristic pathological changes have appeared, but when virus titres have already commenced to fall. Support for this can certainly be found in the treatment of recurrent herpes simplex skin infections, in which 5-iodo2’-deoxyuridine has been shown to be ineffective in the majority of cases treated by topical applications, and which is too toxic for parenteral administration. An investigation in virus isolation from the lesions of herpes genitalis was recently carried out in conjunction with the Virus Reference Laboratory, Colindale. Herpes simplex virus was isolated from superficial scrapings of most lesions which had persisted for an average duration of 3-85 days, but rarely from lesions which had persisted for an average of more than 8-26 days. In those lesions which had persisted for 1 day the virus was present in 81-8% of cases, whereas no virus was isolated from lesions which had persisted for more than 14 days: it was, however, present in 50% of cases in lesions which had persisted for 5, 6, or 8 days. In
tance
the virus was isolated from fluid obtained from bullae, which were seen in 25 % of patients attending. During this investigation it was noted that most patients attended with lesions that had been present for an average time of 5-7 days, or at a time in which the virus was found to be present in 50% of cases. Topical therapy with an antiviral agent given at this time would be fully effective in only 50% of cases. Parenteral therapy, however, might still be effective in all cases should the virus be in cells deeper in the lesions or in nerve-endings or in other places hitherto unknown. Parenteral therapy would also probably be more effective in vesicular lesions, since the virus is concentrated in the basal layers and fluid of vesicles, or in a situation relatively inaccessible to topical application, unless ruptured mechanically. Parenteral therapy would appear to be the effective form of treatment for recurrent cases, in which the virus is thought to remain latent in the tissues between attacks and for which topical applications of an antiviral agent have been found to be useless.l Finally, it might be the only effective method of treatment in cases of
every
case
vesicles
or
1.
Hutfield,
D. C. Brit.
J.
vener.
Dis. 1964,
40,
210.