- Email: [email protected]
SHORTAGE OF HOSPITAL BEDS
571
Counoils, and, other bodies might then be able to make to the Minister. I should like to add that I am a whole-time consultant. Bracebridge Heath Hospital, F. A. BLEADEN. near Lincoln.
effectual
representations
SHORTAGE OF HOSPITAL BEDS
SIR,-A daily newspaper published recently
a
leading
article pointing out that the strain upon British hospitals has reached a dangerous point. The paper suggests that the shortage of hospital accommodation must be met
by economies, reorganisation, and reallocation of funds, or
by the provision of
more
buildings containing
more
beds, staff, and equipment. I think the emphasis should be placed on reorganisation and reallocation of funds. The turnover of patients in hospital beds for acute cases can undoubtedly be greatly increased and- many hospital beds thus made available. Approximately 10-15% of acute beds are occupied by the chronic sick and by old people requiring care and attention only. New buildings of the pavilion type are required to accommodate these patients. They could be constructed much more cheaply than modern hospitals. Active geriatric and rehabilitation departments should be closely associated with these centres, and this again would free many beds in acute hospitals. There are sites in the grounds of many hospitals on which such buildings could be erected. There are some hospitals with long waiting-lists working under great pressure, whereas a neighbouring hospital has not to face the same demands for its services. Cooperation and coordination is the obvious answer to this problem. The shortage of hospital accommodation in many parts of the country could, therefore, be largely met without building new and expensive hospitals. Wanstead, London,
ERIC FRANKEL.
E. 11.
CONGENITAL PNEUMONIA
SIR,-Your annotation of March
6
expresses
the
general belief that congenital pneumonia is the result of the inhalation of infected liquor amnii in utero. Doubtless some cases are the result of this but they must not be accepted as proved unless undoubted elements from the liquor are demonstrated in the pneumonic patches. In some babies dying within a day or so of birth the grey hepatisation is found confined to the regions where inhaled squames
are
abundant.
These inhaled squames
necessarily from the liquor ; they may be from masses desquamated in the oropharynx of the baby. I am unable to accept the time of six hours after birth as proving that the pneumonia is congenital. An examination of the lungs of those dying within an hour or two of a motor accident will often give proof that alveoli can fill with polymorphs (grey hepatisation) in a very short time. For this reason I reject every pneumonia as congenital in a baby born alive unless there is some lesion, such as a fibrinous pleurisy, which could not possibly have developed in the time. By this standard I found pneumonia in roughly 1 in 8 of the stillbirths, and 1 in 3 of the live births ; in the live births I only accepted 1 as definitely congenital. Doubtless many observers would haveaccepted more than this, but I did not see the proof. It seems to me quite certain that an important proportion of cases of pneumonia developing in utero are the are
not
result of infection of the foetus from the maternal circulation via the placenta. Two conditions in the mother are especially liable to be associated with positive bloodcultures-respiratory infections and pyelitis. Before the late war, when potent antibiotics were not available, it was quite common to diagnose pneumonia by finding pneumococci in the blood-cultures from cases of pyrexia of unknown origin. This common lesson from the past
to enter the experience of younger pathomust realise that, in the untreated disease, pneumococci are to be expected in the mother’s blood and can pass the placental barrier. The 1 congenital pneumonia in a live birth that I did accept had a fully developed fibrinous pleurisy. I learned that the mother had had an attack of "influenza" one week before delivery, and I think the fcetus was infected then. Pneumonia developing in utero may kill the foetus and so be the cause of an abortion. I think it quite likely that this is the reason for upwards of one-eighth of abortions. With Dr. D. M. D. Evans, I have recently seen a very interesting example of this. A mother who had lost her first baby had pyelitis when 16-weeks pregnant. She aborted at 18 weeks. The foetus was sent to us to see if we could explain the abortion. It was not autolysed. Although the alveoli had not yet differentiated, there was a perfectly developed bilateral pneumonia. The organisms were coliforms and enterococci, and almost certainly came from the mother’s blood when she had
is not
likely
logists,
but
they
pyelitis.
Derbyshire Royal Infirmary, Derby.
G. R. OSBOTW.
POLIOMYELITIS IN CHILDREN’S WARDS to congratulate Dr. Stanley Banks
SiR,-I would like
his letter of Feb. 27. The time is running short before enter the season of poliomyelitis and it seems pertinent that the danger of treating acute poliomyelitis in the wards of general hospitals is clearly understood. Nevertheless, it is not this part of Dr. Banks’s letter upon which I venture to comment but on his remark that paralysis was preceded in all the 6 children affected in the legs by a course of penicillin injections in the buttocks and thighs. We have seen similar cases, the more recent of them still in the immediate postparalytic stage at the present moment. A child of two was admitted to a surgical ward to undergo an operation : in the routine investigation streptococci were reported in his throat from the day after the operation and penicillin were injected into the right leg for six days, the left leg having been operated upon. Ten days after operation he became pyrexial and on the fifteenth day it was found that both legs were paralysed. About four weeks from the onset of paralysis, only the right leg was severely affected. May it be that, as an American colleague stated the other day, the indiscriminate use of penicillin injections in America has something to do with the recent prevalence of the disease there ?However this might be, we should not be deterred from controlling the main cause of poliomyelitis epidemics-that is, human contact and its bete 7aoire, the human carriers. In the absence of active immunisation, only the control of the contacts seems likely to be effective in reducing the chances of becoming affected. Nearly fifty years ago Wickmanrecognised the abortive and meningitic forms of the disease and placed the primary centre of infection in the village school, tracing the contacts that spread the infection from school to village and from one village to another. In spite of this very early evidence and the amount of conclusive data recently provided, we do not seem interested in searching for the virus in the throats and hands of those really responsible. Who can as yet say that a simple method of protecting the nasopharynx from becoming contaminated or of getting rid of the virus would not do the trick ’? The poliomyelitis virus seems particularly resistant to many antiseptics, but it does not seem able to resist a 2% solution of hydrogen peroxide and also menthol. Perhaps, for the time being at least, some energies should be devoted to the investigation of this pressing problem. An investigation has been initiated in this centre into the mechanism that enhances the susceptibility to on
we
1.
Wickman, I. Krankheit.
Beiträge zur Kenntnis der Heine-Medinsehen Berlin, 1907.
Counoils, and, other bodies might then be able to make to the Minister. I should like to add that I am a whole-time consultant. Bracebridge Heath Hospital, F. A. BLEADEN. near Lincoln.
effectual
representations
SHORTAGE OF HOSPITAL BEDS
SIR,-A daily newspaper published recently
a
leading
article pointing out that the strain upon British hospitals has reached a dangerous point. The paper suggests that the shortage of hospital accommodation must be met
by economies, reorganisation, and reallocation of funds, or
by the provision of
more
buildings containing
more
beds, staff, and equipment. I think the emphasis should be placed on reorganisation and reallocation of funds. The turnover of patients in hospital beds for acute cases can undoubtedly be greatly increased and- many hospital beds thus made available. Approximately 10-15% of acute beds are occupied by the chronic sick and by old people requiring care and attention only. New buildings of the pavilion type are required to accommodate these patients. They could be constructed much more cheaply than modern hospitals. Active geriatric and rehabilitation departments should be closely associated with these centres, and this again would free many beds in acute hospitals. There are sites in the grounds of many hospitals on which such buildings could be erected. There are some hospitals with long waiting-lists working under great pressure, whereas a neighbouring hospital has not to face the same demands for its services. Cooperation and coordination is the obvious answer to this problem. The shortage of hospital accommodation in many parts of the country could, therefore, be largely met without building new and expensive hospitals. Wanstead, London,
ERIC FRANKEL.
E. 11.
CONGENITAL PNEUMONIA
SIR,-Your annotation of March
6
expresses
the
general belief that congenital pneumonia is the result of the inhalation of infected liquor amnii in utero. Doubtless some cases are the result of this but they must not be accepted as proved unless undoubted elements from the liquor are demonstrated in the pneumonic patches. In some babies dying within a day or so of birth the grey hepatisation is found confined to the regions where inhaled squames
are
abundant.
These inhaled squames
necessarily from the liquor ; they may be from masses desquamated in the oropharynx of the baby. I am unable to accept the time of six hours after birth as proving that the pneumonia is congenital. An examination of the lungs of those dying within an hour or two of a motor accident will often give proof that alveoli can fill with polymorphs (grey hepatisation) in a very short time. For this reason I reject every pneumonia as congenital in a baby born alive unless there is some lesion, such as a fibrinous pleurisy, which could not possibly have developed in the time. By this standard I found pneumonia in roughly 1 in 8 of the stillbirths, and 1 in 3 of the live births ; in the live births I only accepted 1 as definitely congenital. Doubtless many observers would haveaccepted more than this, but I did not see the proof. It seems to me quite certain that an important proportion of cases of pneumonia developing in utero are the are
not
result of infection of the foetus from the maternal circulation via the placenta. Two conditions in the mother are especially liable to be associated with positive bloodcultures-respiratory infections and pyelitis. Before the late war, when potent antibiotics were not available, it was quite common to diagnose pneumonia by finding pneumococci in the blood-cultures from cases of pyrexia of unknown origin. This common lesson from the past
to enter the experience of younger pathomust realise that, in the untreated disease, pneumococci are to be expected in the mother’s blood and can pass the placental barrier. The 1 congenital pneumonia in a live birth that I did accept had a fully developed fibrinous pleurisy. I learned that the mother had had an attack of "influenza" one week before delivery, and I think the fcetus was infected then. Pneumonia developing in utero may kill the foetus and so be the cause of an abortion. I think it quite likely that this is the reason for upwards of one-eighth of abortions. With Dr. D. M. D. Evans, I have recently seen a very interesting example of this. A mother who had lost her first baby had pyelitis when 16-weeks pregnant. She aborted at 18 weeks. The foetus was sent to us to see if we could explain the abortion. It was not autolysed. Although the alveoli had not yet differentiated, there was a perfectly developed bilateral pneumonia. The organisms were coliforms and enterococci, and almost certainly came from the mother’s blood when she had
is not
likely
logists,
but
they
pyelitis.
Derbyshire Royal Infirmary, Derby.
G. R. OSBOTW.
POLIOMYELITIS IN CHILDREN’S WARDS to congratulate Dr. Stanley Banks
SiR,-I would like
his letter of Feb. 27. The time is running short before enter the season of poliomyelitis and it seems pertinent that the danger of treating acute poliomyelitis in the wards of general hospitals is clearly understood. Nevertheless, it is not this part of Dr. Banks’s letter upon which I venture to comment but on his remark that paralysis was preceded in all the 6 children affected in the legs by a course of penicillin injections in the buttocks and thighs. We have seen similar cases, the more recent of them still in the immediate postparalytic stage at the present moment. A child of two was admitted to a surgical ward to undergo an operation : in the routine investigation streptococci were reported in his throat from the day after the operation and penicillin were injected into the right leg for six days, the left leg having been operated upon. Ten days after operation he became pyrexial and on the fifteenth day it was found that both legs were paralysed. About four weeks from the onset of paralysis, only the right leg was severely affected. May it be that, as an American colleague stated the other day, the indiscriminate use of penicillin injections in America has something to do with the recent prevalence of the disease there ?However this might be, we should not be deterred from controlling the main cause of poliomyelitis epidemics-that is, human contact and its bete 7aoire, the human carriers. In the absence of active immunisation, only the control of the contacts seems likely to be effective in reducing the chances of becoming affected. Nearly fifty years ago Wickmanrecognised the abortive and meningitic forms of the disease and placed the primary centre of infection in the village school, tracing the contacts that spread the infection from school to village and from one village to another. In spite of this very early evidence and the amount of conclusive data recently provided, we do not seem interested in searching for the virus in the throats and hands of those really responsible. Who can as yet say that a simple method of protecting the nasopharynx from becoming contaminated or of getting rid of the virus would not do the trick ’? The poliomyelitis virus seems particularly resistant to many antiseptics, but it does not seem able to resist a 2% solution of hydrogen peroxide and also menthol. Perhaps, for the time being at least, some energies should be devoted to the investigation of this pressing problem. An investigation has been initiated in this centre into the mechanism that enhances the susceptibility to on
we
1.
Wickman, I. Krankheit.
Beiträge zur Kenntnis der Heine-Medinsehen Berlin, 1907.