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SURVEY OF HOSPITAL COSTS IN THE U.S.A.
723 lie may well become insulin-sensitive ; and Dr. Bearn and his colleagues now show that an insulin-sensitive diabetic who has ketosis may temporarily lose his
factor
sensitivity.
as
CAUSES AND MANAGEMENT OF PREMATURE BIRTH IN his John Shields Fairbairn lecture given at the Royal College of Obstetricians and Gynaecologists last week, Dr. Nicholson J. Eastman, of the Johns Hopkins Hospital, covered a very large subject in a very large way. The importance of premature birth in keepingup the figures of neonatal mortality is, of course, generally recognised, but it was interesting to get the very latest figures-not yet published by Dr. Bundesen and his colleagues-from the Chicago study of neonatal deaths which now covers fifteen years and 18,000
necropsies. In this Chicago series 7% of all births were premature, and these account for well over 60% of all neonatal deaths. The clinical material is unselected ; but the figures, coming as they do from a source where every effort is made to reduce this mortality, are likely to be better than would apply generally elsewhere. It will be seen, therefore, that there is still a big field for salvage. The prematurity-rate at the Johns Hopkins Hospital is over 11%, but here, of course, the population is more selected. Dr. Eastman divided cases of prematurity into three major groups. The first are those associated with multiple pregnancy, amounting to 12% ; and nothing can be done about them. The second group consists of cases in which pregnancy is prematurely terminated by induction or caesarean section for some complicating factor. These amount to about 13%, and any reduction in prematurity and consequent neonatal mortality involves an examination of the causes for which the pregnancy was terminated. Pre-eminent among the offending diseases are pre-eclampsia (36%), hypertension (17%), and placenta prævia (12%). Dr. Eastman paid tribute to Macafee and others in their work on placenta prævia and the resultant saving of foetal life, but pending fuller knowledge of pre-eclampsia and hypertension in pregnancy there is not vast room left at present for improvement in the prematurity-rate. It is clear from Dr. Eastman’s arguments and figures that pre-eclampsia is the cause of prematurity more through the need for obstetrical intervention than through the spontaneous onset of labour due to this disease. The third group comprises about three-quarters of all cases, and these are still entirely unexplained ; so it is here that the chief attack on the problem should be made and more
knowledge sought. It has long been realised that the social status of the patient has a great bearing on her ability to carry through her pregnancy to term, and Dr. Eastman and his colleagues in Chicago have examined this side of the question in some detail. There is an ever-increasing incidence of premature birth as one descends the economic and social scale, and the rate rises from 41/2% in private patients (who are presumably in comfortable circumstances), to over 11% in the impoverished coloured classes, the ratios being the same at the Johns Hopkins and in the large unselected Chicago series. The incidence of spontaneous prematurity was far less in those having full antenatal supervision; in fact at first sight it seems that good antenatal care cut the prematurity-rate by about three-quarters, and one is tempted to inquire into what features of this care might be responsible. However, it must be remembered that the apparent effect of antenatal supervision is offset by the recollection that those not availing themselves of antenatal care are apt to belong to the shiftless improvident section of the population. Dr. Eastman also drew attention to the feature of recurrent premature labour in the same
woman, from which it would appear that a constitutional
at work. Diet supplements he to such and referred prematurity,
is
that of the
Peoples’ League
of
may
reduce
investigations
Health in this
country. The prematurity-rate is a fairly good index of social and economic conditions, and, though it is undoubtedly related to dietary deficiencies, there is no doubt that the woman of the poorer class is exposed to very much The more overwork than her more fortunate sister. reduction in both neonatal deaths and stillbirths has been truly remarkable, and neonatal deaths in premature babies have been approximately halved since 1926, largely thanks to the use of incubators, oxygen, improved anaesthesia, increasing paediatric service, and better obstetric technique. In discussing this technique, he pleaded for local or caudal anæsthesia and sparing use of forceps. In order to combat the almost universal ansemia which iollows premature birth he recommended that the cord should not be clamped until all pulsation has unquestionably stopped. DR. VAN SLYKE’S LECTURE
ON Oct. 11 a large and distinguished audience assembled in the senate house of the University of London to hear Dr. D. D. Van Slyke, of the Rockefeller Institute, New
York, lecture on the normal and pathological physiology of the
kidney. In a masterly review logy Dr. Van Slyke described
of normal renal physiothe investigations on which the current theories of urine formation were based. In the second part of his lecture he spoke on the values obtained for clearance and extraction rates in He emphasised that, various pathological conditions. both in man and in laboratory animals, renal tubular damage may reduce p-aminohippurate extraction, and that in any study of pathological renal physiology P.A.H. clearances cannot be equated directly with renal plasma-flow. He paid tribute to the investigations made at the Postgraduate Hospital, Hammersmith, into the various types of acute tubular dysfunction, and pointed out how these and similar studies might lead to improvement in the management of patients with chronic renal disease. SURVEY OF HOSPITAL COSTS IN THE U.S.A.
THE New
York
Times for
Sept.
17
reported
an
announcement, at the annual convention of the American
Hospital Association, that a comprehensive study is to be undertaken of " the financing and cost aspects of the nation’s hospitals." This study, extending over two years and costing 500,000 dollars, will have as its chairman Mr. Gordon Gray, president of the University of North Carolina, who was formerly Secretary of the Army and later a special assistant to the President. Mr. Graham L. Davis, of the Kellogg Foundation, has been appointed director, and the members of the commission will include representatives of agriculture, education, labour, and religion, in addition to those from the medical and hospital fields. Besides reporting on the financial position of the country’s hospitals, they are to determine- the need and demand for hospital services, to analyse the effect of medical practice on hospital costs, and compare systems of payment for hospital care. A significant objective is " the preparation of recommendations for accomplishing changes that appear desirable as the result of the study." The survey is made possible by grants from various public bodies including the John Hancock Mutual Life Insurance Co., the Health Information Foundation, the Milbank Memorial Fund, the National Foundation for Infantile Paralysis, the Rockefeller Foundation, and the Kellogg Foundation. A pilot survey to be made in North Carolina will also seek to ascertain whether related health services meet the needs of the population.
factor
sensitivity.
as
CAUSES AND MANAGEMENT OF PREMATURE BIRTH IN his John Shields Fairbairn lecture given at the Royal College of Obstetricians and Gynaecologists last week, Dr. Nicholson J. Eastman, of the Johns Hopkins Hospital, covered a very large subject in a very large way. The importance of premature birth in keepingup the figures of neonatal mortality is, of course, generally recognised, but it was interesting to get the very latest figures-not yet published by Dr. Bundesen and his colleagues-from the Chicago study of neonatal deaths which now covers fifteen years and 18,000
necropsies. In this Chicago series 7% of all births were premature, and these account for well over 60% of all neonatal deaths. The clinical material is unselected ; but the figures, coming as they do from a source where every effort is made to reduce this mortality, are likely to be better than would apply generally elsewhere. It will be seen, therefore, that there is still a big field for salvage. The prematurity-rate at the Johns Hopkins Hospital is over 11%, but here, of course, the population is more selected. Dr. Eastman divided cases of prematurity into three major groups. The first are those associated with multiple pregnancy, amounting to 12% ; and nothing can be done about them. The second group consists of cases in which pregnancy is prematurely terminated by induction or caesarean section for some complicating factor. These amount to about 13%, and any reduction in prematurity and consequent neonatal mortality involves an examination of the causes for which the pregnancy was terminated. Pre-eminent among the offending diseases are pre-eclampsia (36%), hypertension (17%), and placenta prævia (12%). Dr. Eastman paid tribute to Macafee and others in their work on placenta prævia and the resultant saving of foetal life, but pending fuller knowledge of pre-eclampsia and hypertension in pregnancy there is not vast room left at present for improvement in the prematurity-rate. It is clear from Dr. Eastman’s arguments and figures that pre-eclampsia is the cause of prematurity more through the need for obstetrical intervention than through the spontaneous onset of labour due to this disease. The third group comprises about three-quarters of all cases, and these are still entirely unexplained ; so it is here that the chief attack on the problem should be made and more
knowledge sought. It has long been realised that the social status of the patient has a great bearing on her ability to carry through her pregnancy to term, and Dr. Eastman and his colleagues in Chicago have examined this side of the question in some detail. There is an ever-increasing incidence of premature birth as one descends the economic and social scale, and the rate rises from 41/2% in private patients (who are presumably in comfortable circumstances), to over 11% in the impoverished coloured classes, the ratios being the same at the Johns Hopkins and in the large unselected Chicago series. The incidence of spontaneous prematurity was far less in those having full antenatal supervision; in fact at first sight it seems that good antenatal care cut the prematurity-rate by about three-quarters, and one is tempted to inquire into what features of this care might be responsible. However, it must be remembered that the apparent effect of antenatal supervision is offset by the recollection that those not availing themselves of antenatal care are apt to belong to the shiftless improvident section of the population. Dr. Eastman also drew attention to the feature of recurrent premature labour in the same
woman, from which it would appear that a constitutional
at work. Diet supplements he to such and referred prematurity,
is
that of the
Peoples’ League
of
may
reduce
investigations
Health in this
country. The prematurity-rate is a fairly good index of social and economic conditions, and, though it is undoubtedly related to dietary deficiencies, there is no doubt that the woman of the poorer class is exposed to very much The more overwork than her more fortunate sister. reduction in both neonatal deaths and stillbirths has been truly remarkable, and neonatal deaths in premature babies have been approximately halved since 1926, largely thanks to the use of incubators, oxygen, improved anaesthesia, increasing paediatric service, and better obstetric technique. In discussing this technique, he pleaded for local or caudal anæsthesia and sparing use of forceps. In order to combat the almost universal ansemia which iollows premature birth he recommended that the cord should not be clamped until all pulsation has unquestionably stopped. DR. VAN SLYKE’S LECTURE
ON Oct. 11 a large and distinguished audience assembled in the senate house of the University of London to hear Dr. D. D. Van Slyke, of the Rockefeller Institute, New
York, lecture on the normal and pathological physiology of the
kidney. In a masterly review logy Dr. Van Slyke described
of normal renal physiothe investigations on which the current theories of urine formation were based. In the second part of his lecture he spoke on the values obtained for clearance and extraction rates in He emphasised that, various pathological conditions. both in man and in laboratory animals, renal tubular damage may reduce p-aminohippurate extraction, and that in any study of pathological renal physiology P.A.H. clearances cannot be equated directly with renal plasma-flow. He paid tribute to the investigations made at the Postgraduate Hospital, Hammersmith, into the various types of acute tubular dysfunction, and pointed out how these and similar studies might lead to improvement in the management of patients with chronic renal disease. SURVEY OF HOSPITAL COSTS IN THE U.S.A.
THE New
York
Times for
Sept.
17
reported
an
announcement, at the annual convention of the American
Hospital Association, that a comprehensive study is to be undertaken of " the financing and cost aspects of the nation’s hospitals." This study, extending over two years and costing 500,000 dollars, will have as its chairman Mr. Gordon Gray, president of the University of North Carolina, who was formerly Secretary of the Army and later a special assistant to the President. Mr. Graham L. Davis, of the Kellogg Foundation, has been appointed director, and the members of the commission will include representatives of agriculture, education, labour, and religion, in addition to those from the medical and hospital fields. Besides reporting on the financial position of the country’s hospitals, they are to determine- the need and demand for hospital services, to analyse the effect of medical practice on hospital costs, and compare systems of payment for hospital care. A significant objective is " the preparation of recommendations for accomplishing changes that appear desirable as the result of the study." The survey is made possible by grants from various public bodies including the John Hancock Mutual Life Insurance Co., the Health Information Foundation, the Milbank Memorial Fund, the National Foundation for Infantile Paralysis, the Rockefeller Foundation, and the Kellogg Foundation. A pilot survey to be made in North Carolina will also seek to ascertain whether related health services meet the needs of the population.