- Email: [email protected]
IRREGULAR DISCHARGE FROM SANATORIA
699
only 5 relapsed while on treatment and 4 after treatment had stopped, and satisfactory results were also obtained in pulmonary embolism. They had some hsemorrhagic incidents, mostly among early cases when they were using a viper-venom method ; none was fatal. Whether manufacturers should emphasise in their literature the dangers of their products is a matter of commercial ethics ; some do give excellent accounts of methods of control and of contra-indications, but others do not. Despite all that has been said and written to the contrary, folic acid is still being advertised for the treatment of pernicious anaemia ; and the pamphlets that accompany active hormone preparations are often not very emphatic about the dangers of overdosage. Yet to place responsibility for proper use on the salesman is hardly fair ; for he is rarely a medical man, and commonly he has little deep knowledge of the properties of his products. The responsibility must be the doctor’s, but there should also be some method of marking plainly drugs that are only suitable for hospital use ; nitrogen inustard-a most dangerous drug in inexpert hands-is on sale to any doctor. DISCHARGE FROM SANATORIA IN the United States, the proportion of irregular discharges of tuberculous patients from sanatoria has caused much concern to the Veterans Administration ; their research division has analysed exhaustively data gathered by the social service staff in an effort to find a reason for so high a figure as 54-4% in 1946-47 leaving prematurely, and against medical advice.1 The rate was 72-5% in 1945. Corresponding figures in Great Britain vary considerably, from 5% in Manchester and 8% in Lancashire, to an average of 24% for a group of Welsh hospitals. These figures for Great Britain are taken from independent reports of local authorities, and refer to adult men and women-not solely, like the United States figures, to men who were in the Forces. " Emotional and psychic factors were found to have an effective - contributory force in most cases of the development of tuberculosis " ; indeed anxiety and fear were very commonly expressed in the behaviour of these tuberculous patients. Many veterans dislike hospital life, detecting in it memories of military discipline. A little less than half the irregular discharges were found to be due to events and conditions outside the hospital. Remedial measures suggested are intensive social case-work with the patient and family before and during the patient’s stay in hospital; psychiatric treatment, and instruction to the staff on the emotional and psychic components and concomitants of tuberculosis ; more individual consideration or treatment by the medical staff ; and more careful and considerate application of hospital rules. The tuberculous patient needs help and support to withstand the emotional strains which sanatorium treatment produces. " Irregular discharge " can be interpreted in more than one way ; a tighter definition is needed before close comparisons can be made with figures in this country. Furthermore, we have no recent survey to compare with this study by the Veterans Association. Our rate of irregular discharge is undoubtedly much lower, however, and this is most likely due to such factors as the effective advice, supervision, and education given by the chest physician and health visitor ; greater confidence of the patient in his treatment, in which he is supported by the family ; and economic help for the patient and family in our " welfare State." It may be, too, that we are as a people more persuasible than Americans, less independent in behaviour, and more inclined to give the doctor credit for knowing what he ia about. There is scope, however, for research in IRREGULAR
1. Irregular Discharge (Veterans Administration pamphlet 10-27). Washington, D.C.: U.S. Government Printing Office. 20 cents.
Britain to ascertain
accurately
the
irregular-discharge
rate, matching the result of investigations elsewhere
by factor. Here is a chance for one or more of regional hospital boards to investigate a factor which affects greatly our success in preventing and treating tuberculosis. factor
our new
ENCEPHALOPATHY FOLLOWING PERTUSSIS VACCINE
SINCE 1933 there have been several reports of convulsive attacks, and even of fatal encephalopathy,
following the prophylactic use of pertussis vaccine ; but they have attracted little attention. The publication by Byers and Mollof a series of 15 such cases from the Children’s Hospital in Boston airs a problem which is the more disturbing in that it remains unsolved. The incidence of the cases was spread over a period of eight years ; they were geographically dispersed, and the products of eight different manufacturers were used. The age of the infants varied from five to eighteen males. Convulsions followed the interval injection varying from twenty minutes to seventy-two hours, and in 6 of the cases the first dose precipitated the attack. Sensitisation therefore appears unlikely. The convulsions were followed by coma in some, or hemiplegia and exaggerated tendon-reflexes. The cerebrospinal fluid showed a slight excess both of protein and of mononuclear cells. An infective agent therefore appears improbable. The illness lasted from thirty-six hours to ten days, and the most sinister feature has been the persistence, in all but 1 infant of neurological residua of different kinds. Thus about half have shown retardation of mental development, 3 being grossly defective ; 2 became blind ; 3 continued to have convulsions ; and 5 were hemiplegic. In 2 cases the infant later died of pneumonia, and at necropsy on one of these, performed at a State institution, the brain was said to show diffuse atrophy and gliosis. The demonstration of ventricular dilatation by means of graphy in 6 out of 8 of the others certainly indicates a similar order of structural change. But the fundamental pathology of this encephalopathy remains obscure. The scattering of the cases in space and time seems to exonerate the preparations used for the injections, and suggests rather that the infants were in some way constitutionally vulnerable. And this suggestion finds some support in the record of epilepsy, hydrocephalus, or convulsions in the siblings of 3 cases of the series. It is of interest that Byers and Moll report, within the same period, the admission to the Children’s Hospital of 26 infants showing encephalopathy during an attack of pertussis, of whom 7 died. It cannot therefore be said that the casualties arising from prophylactic treatment are of an order that outweighs its
months, and 12 after
were
an
pneumoencephalo-
advantages. AN INCONCLUSIVE
INQUIRY
IN the autumn of 1946 a group of workers appointed the American Trudeau Society set out to investigate several questions surrounding the use of streptomycin in tuberculosis. Among the points they sought to determine were : (1) the types of pulmonary tuberculosis most likely to benefit from this drug ; (2) the most satisfactory methods and frequency of treatment, the optimum daily dosage, and the optimum duration of treatment ; and (3) the most timely integration of streptomycin with other therapeutic procedures. Their report is to be published in full as a book. Meanwhile a summary2 records that altogether 566 patients were treated under this scheme and analyses the findings in 332 with pulmonary tuberculosis who were observed for at least
by
1. 2.
Byers, R. K., Moll, F. C. Pediatrics, 1948, 1, 437. Rigging, H. M., Hinshaw, H. C. Amer. Rev. Tuberc. 1949, 59, 140.
only 5 relapsed while on treatment and 4 after treatment had stopped, and satisfactory results were also obtained in pulmonary embolism. They had some hsemorrhagic incidents, mostly among early cases when they were using a viper-venom method ; none was fatal. Whether manufacturers should emphasise in their literature the dangers of their products is a matter of commercial ethics ; some do give excellent accounts of methods of control and of contra-indications, but others do not. Despite all that has been said and written to the contrary, folic acid is still being advertised for the treatment of pernicious anaemia ; and the pamphlets that accompany active hormone preparations are often not very emphatic about the dangers of overdosage. Yet to place responsibility for proper use on the salesman is hardly fair ; for he is rarely a medical man, and commonly he has little deep knowledge of the properties of his products. The responsibility must be the doctor’s, but there should also be some method of marking plainly drugs that are only suitable for hospital use ; nitrogen inustard-a most dangerous drug in inexpert hands-is on sale to any doctor. DISCHARGE FROM SANATORIA IN the United States, the proportion of irregular discharges of tuberculous patients from sanatoria has caused much concern to the Veterans Administration ; their research division has analysed exhaustively data gathered by the social service staff in an effort to find a reason for so high a figure as 54-4% in 1946-47 leaving prematurely, and against medical advice.1 The rate was 72-5% in 1945. Corresponding figures in Great Britain vary considerably, from 5% in Manchester and 8% in Lancashire, to an average of 24% for a group of Welsh hospitals. These figures for Great Britain are taken from independent reports of local authorities, and refer to adult men and women-not solely, like the United States figures, to men who were in the Forces. " Emotional and psychic factors were found to have an effective - contributory force in most cases of the development of tuberculosis " ; indeed anxiety and fear were very commonly expressed in the behaviour of these tuberculous patients. Many veterans dislike hospital life, detecting in it memories of military discipline. A little less than half the irregular discharges were found to be due to events and conditions outside the hospital. Remedial measures suggested are intensive social case-work with the patient and family before and during the patient’s stay in hospital; psychiatric treatment, and instruction to the staff on the emotional and psychic components and concomitants of tuberculosis ; more individual consideration or treatment by the medical staff ; and more careful and considerate application of hospital rules. The tuberculous patient needs help and support to withstand the emotional strains which sanatorium treatment produces. " Irregular discharge " can be interpreted in more than one way ; a tighter definition is needed before close comparisons can be made with figures in this country. Furthermore, we have no recent survey to compare with this study by the Veterans Association. Our rate of irregular discharge is undoubtedly much lower, however, and this is most likely due to such factors as the effective advice, supervision, and education given by the chest physician and health visitor ; greater confidence of the patient in his treatment, in which he is supported by the family ; and economic help for the patient and family in our " welfare State." It may be, too, that we are as a people more persuasible than Americans, less independent in behaviour, and more inclined to give the doctor credit for knowing what he ia about. There is scope, however, for research in IRREGULAR
1. Irregular Discharge (Veterans Administration pamphlet 10-27). Washington, D.C.: U.S. Government Printing Office. 20 cents.
Britain to ascertain
accurately
the
irregular-discharge
rate, matching the result of investigations elsewhere
by factor. Here is a chance for one or more of regional hospital boards to investigate a factor which affects greatly our success in preventing and treating tuberculosis. factor
our new
ENCEPHALOPATHY FOLLOWING PERTUSSIS VACCINE
SINCE 1933 there have been several reports of convulsive attacks, and even of fatal encephalopathy,
following the prophylactic use of pertussis vaccine ; but they have attracted little attention. The publication by Byers and Mollof a series of 15 such cases from the Children’s Hospital in Boston airs a problem which is the more disturbing in that it remains unsolved. The incidence of the cases was spread over a period of eight years ; they were geographically dispersed, and the products of eight different manufacturers were used. The age of the infants varied from five to eighteen males. Convulsions followed the interval injection varying from twenty minutes to seventy-two hours, and in 6 of the cases the first dose precipitated the attack. Sensitisation therefore appears unlikely. The convulsions were followed by coma in some, or hemiplegia and exaggerated tendon-reflexes. The cerebrospinal fluid showed a slight excess both of protein and of mononuclear cells. An infective agent therefore appears improbable. The illness lasted from thirty-six hours to ten days, and the most sinister feature has been the persistence, in all but 1 infant of neurological residua of different kinds. Thus about half have shown retardation of mental development, 3 being grossly defective ; 2 became blind ; 3 continued to have convulsions ; and 5 were hemiplegic. In 2 cases the infant later died of pneumonia, and at necropsy on one of these, performed at a State institution, the brain was said to show diffuse atrophy and gliosis. The demonstration of ventricular dilatation by means of graphy in 6 out of 8 of the others certainly indicates a similar order of structural change. But the fundamental pathology of this encephalopathy remains obscure. The scattering of the cases in space and time seems to exonerate the preparations used for the injections, and suggests rather that the infants were in some way constitutionally vulnerable. And this suggestion finds some support in the record of epilepsy, hydrocephalus, or convulsions in the siblings of 3 cases of the series. It is of interest that Byers and Moll report, within the same period, the admission to the Children’s Hospital of 26 infants showing encephalopathy during an attack of pertussis, of whom 7 died. It cannot therefore be said that the casualties arising from prophylactic treatment are of an order that outweighs its
months, and 12 after
were
an
pneumoencephalo-
advantages. AN INCONCLUSIVE
INQUIRY
IN the autumn of 1946 a group of workers appointed the American Trudeau Society set out to investigate several questions surrounding the use of streptomycin in tuberculosis. Among the points they sought to determine were : (1) the types of pulmonary tuberculosis most likely to benefit from this drug ; (2) the most satisfactory methods and frequency of treatment, the optimum daily dosage, and the optimum duration of treatment ; and (3) the most timely integration of streptomycin with other therapeutic procedures. Their report is to be published in full as a book. Meanwhile a summary2 records that altogether 566 patients were treated under this scheme and analyses the findings in 332 with pulmonary tuberculosis who were observed for at least
by
1. 2.
Byers, R. K., Moll, F. C. Pediatrics, 1948, 1, 437. Rigging, H. M., Hinshaw, H. C. Amer. Rev. Tuberc. 1949, 59, 140.