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The Convalescent Home
568 time actually engaged in the practice of medicine. " It is only in this way," said Lord MORAN, that you can lift the curtain which in recent years has fallen between the Ministry and the profession, leaving so much want of sympathy and understanding." And in this he was endorsing the far-seeing policy by which Sir Wn..SON JAMESON has been widening the medical staff of the Ministry and intends to widen it further.! The new service will succeed if those who hold office in it, whether medical or lay, prove themselves colleagues and are trusted accordingly. The immediate necessity, however, is effective consultation over the framing of the regulations which will bring the service to life. In these consultations our representatives can certainly wield their proper influence, and they can also prove their readiness for real cooperation. The Government, as Lord ADDINGTON said, has yet to win the confidence of the medical profession and the public ; but the profession might itself do more to gain the confidence of its associates in a great, and "
now _
inevitable, undertaking.
Circulatory Effects of Osteitis Deformans
increase in blood-flow through the affected bones. Direct study of the bone blood-flow was then undertaken. It was shown that when one tibia only is affected by Paget’s disease the flow through that leg may be five to seven times as high as -that in the
normal
leg.
Grant-Lewis
By an ingenious adaptation’of the plethysmograph the actual bone blood-
flow was estimated in the humerus of a normal person and the patient with Paget’s disease. It was found that the normal flow was probably about 1 c.cm. per 100 c.cm. of bone per minute, while that through Paget’s bones was about 20 c.cm. Applying these figures to the whole skeleton, the total skeletal blood-flow is normally about 75 c.cm. per minute, while the enlarged skeleton of the case of generalised Paget’s disease received a blood-flow of about 3-3 litres per minute. This work is an important contribution to the living pathology of Paget’s disease, but it is also the first time that bone blood-flow has been measured in man. It adds another thought-provoking instance to the group of conditions in which " cardiac failure " is associated with high output, of which severe anaaamia constitutes a well-established example.7 Comprehension of the nature and sequence of events in these cases of apparent heart-failure would shed much light on other ordinary forms of heart--failure, and we may look forward to further results of such research in the next few years.
WHEN Sir JAMES PAGET1 described the generalised disease of bone now known by his name he recognised that the bones were hypereemic, and this led him to think of an inflammatory cause and hence to use the term " osteitis." Orthopaedic and cranial surgeons are familiar with the highly vascular state of the The Convalescent Home affected bones at operation, and CONE,2 in his studies of the bone pathology, emphasised the impor"LET not thy left hand know what thy right tance of this feature. KLippEL and Well3 in 1908 hand doeth," however apt as advice on personal observed that the temperature of the skin over an almsgiving, is hardly a suitable maxim for charitable affected bone was higher than normal. For a long institutions. Yet convalescent homes in England time cardiovascular complications of the generalised have grown up on this isolationist plan, each pursuing form of Paget’s disease have been recognised. KAY a course of its own, knowing nothing of its neighbour and others4 were struck by the frequency of high in the next street. No complete list of convalescent pulse-pressures in a series which they studied. Out homes has ever been compiled; even the Public of 33 cases, 14 had pulse-pressures over 60 mm. Hg. Health Act of 1936 did not call for a complete survey; Cardiac enlargement was often noted, as were systolic and hospital almoners, local health officers, and murmurs over the precordium. Even in cases in whom must make their own lists of openings the Korotkoff sounds could be heard right down to practitioners available for their patients recovering from illness. zero pressure, there was no satisfactory evidence of homes were closed during the war and not all aortic valvular disease. KAY and his colleagues and also Many have opened again. Moreover, there is no clear SNAPPER 5 ascribed these findings to arteriosclerosis. definition of the term " convalescent home." Some Further light has now been thrown on these offer treatment, others none ; some will not take phenomena by a detailed study 6 of a case in the patients for more than a month, others will not take Britisb Medical School. A patient with them for less ; some insist that patients must be ablp had venous congestion to look after disease generalised Paget’s themselves, others will take the bedand oedema. Cardiac catheterisation showed that his some of the children’s homes are special ridden ; cardiac output was 13-3 litres per minute, or nearly schools, approved by the Ministry of Education, three times the normal average. This is a state of others are not. At many, patients must conform to affairs somewhat similar to that found in arteriovenous certain must be of a given sex or criteria-they aneurysms, and in fact closing the circulation through age-group, or must belong to a given religious sect. the legs of this patient produced effects on the general fraternity, friendly society, or social class, or must work circulation similar to those seen when an arteriovenous at or be retired from a given occupation, including aneurysm is partially shut off, including slowing of the Services, or must live in a given district. the pulse and a rise in diastolic arterial pressure. The varietv of our convalescent homes is an adva,nThis led the investigators to believe that the circutage, for the restrictions on the type of patient are latory phenomena might be explained by a great designed to make those who are accepted feel more at home, the first essential for pleasant convalescence. 1. See Lancet, 1945, ii, 569. A merchant seaman, a distressed gentlewoman, and 1. Paget, J. Med.-chir. Trans. 1876-77, 60, 37. 2. Cone, S. M. J. Bone Jt Surg. 1922, 4, 751. a resident of West Ham, placed in one home, might 3. Klippel, M., Weil, M. P. Rev. neurol. 1908, 16, 1228. 4. Kay, H. D., Simpson, S. L., Riddoch, G., Vilvandré, G. E. be poor company for each other, but they will be at Arch. intern. Med. 1934, 53, 208. ease 5. Snapper, I. Medical Clinics on Bone Diseases, New York, 1943. among those who share their ta,stes, whether in 6.
Postgraduate
slight
Edholm, O. G., Howarth, S., McMichael, J. 5, 249.
Clin. Sci. 1945,
7. Sharpey-Schafer, E. P.
Lancet, 1945, ii, 296.
569
navigation, needlework, or darts. The chief feature that the homes have in common is that patients go there after an illness expecting to get better without further.a,ctive treatment. Almshouses may therefore be excluded from the definition-whatever that is finally decided to be--and classed among provisions for the old ; for no-one expects to get better of old age. And so may the active reablement centres which have developed in the last few years, for in these the patients are as much under treatment as they were in hospital, though at a later stage of recovery. English convalescent homes range in size from those taking more than 200 to those taking less than 20 people; and though those who are planning our National Health Service are said to prefer large units there is little doubt that patients prefer small homes of 10 to 20 beds, especially when these are run with The existing homes vary a friendly personal touch. in this, of course, as in everything else : in one home the children make a friendly rush at the chairman the moment he appears, and the matron speaks of the patients by name ; in another the efficient filing system is the keynote of the institution, and the patients are called cases. There is the of the old lady in a run home in Prague who clean, airy, perfectly large, said with a " There’s nothing left but tidiness." The English may respect institutions but are peculiarly ill-fitted for living in them. The main argument in favour of large hospitals-that only they can afford the special equipment and personnel required for modern diagnosis and treatment-does not apply to the general run of homes for convalescents, who need neither apparatus nor highly skilled care. It does, however, apply to the reablement centres which aim, by active and often complex and expensive methods, to get working men and women back to their jobs. In the no-treatment home large size is a handicap, for it necessitates a medical and nursing staff, whereas the small home can rely on local practitioners to attend to minor ailments and keep The small an eye open for unexpected complications. home where the matron and committee know the patients personally, and where freedom- is respected, cups of tea can be had without formality, and no-one is sent packing because he drinks a glass of beer in the local inn, is clearly the right kind for English convalescents. Variety and small size, then, are qualities in conva lescent homes which we should strive -to keep. Their weakness lies in their having no connecting link, no central body to which inquiries can be addressed by almoners and others trying to place a patient, or to which the homes themselves can look for advice or help in moments of difficulty. Some degree of central supervision would clearly improve the service that the homes can offer : and most homes would welcome it as relieving them of the responsibility inherent in isolation. A central organisation would simplify the task of almoners : for though there is probably a suitable type of home for anyone who needs,it, there is not always a bed waiting for a particular patient at a particular moment ; or, if there is. the almoner has no means of knowing it. The central organisation could set up a simple form of admission bureau. on the lines of the bed service run by the King’s Fund in London for emergency admissions’ to hospitals. As a
story
sigh,
King’s Fund and the Institute of Almoners preparing a detailed list of homes, based on personal inspection. This will meet a real need, and will also show which groups of people are poorly served by the homes already existing, and possibly which have more opportunities for convalescence than they require. first step the are
’
Annotations WINTER IN EUROPE this winter, and particularly in the occupied Europe The Control zones, hardship is likely to be extreme. Commission recently announced that during the last week of July, in the British zone of Germany, 12 people died of hunger, while 1189 cases of famine oedema were reported in Hamburg alone. During six months the new-case rate of tuberculosis, it was stated, rose by a third. In a pamphlet lately issued,’ Viennese rations for a day during the past summer are described by Mr. G. E. R. Gedye.2 They were two rounds of bread (under 9 oz.), a teaspoonful of sugar, a tablespoonful of coffee and coffee substitute, half,a square inch of sausage and an equal amount of tinned ham, a tablespoonful each of maize flour, dried peas, oatmeal, and lard, a seventh share in a shell egg, a pinch of egg powder, half a soup cube, a dessertspoonful of salt, and two tablespoonfuls of meat-and-vegetable ration (threequarters vegetable) : the total calorie value being estimated at 1181-about half the figure (2200) regarded as adequate for a non-worker. These embittering privations can only be ended by good harvests and political decisions but in the meantime there is room and to spare for voluntary effort. Since 1945 British voluntary societies have been doing welfare work in the British zone of Germany.3 They are grouped in teams of 12 and represent the British Red Cross and Order of St. John, the Friends Relief Service and Friends Ambulance Unit, the Salvation Army, the Girl Guides, the Save the Children Fund, the Catholic Committee for Relief Abroad, and the International Voluntary Service for Peace. Many of these bodies, of course, are sending help to other distressed countries -to France, Poland,Austria, Italy, Yugoslavia, and Greece. The relief workers in Germany receive their rations, petrol, and other stores through the Army, and use Army vehicles ; but they are not paid or regulated by the Army and many of them receive no pay at all. for refugees and victims of They began by epidemics and starvation in Normandy, Belgium, Holland, and Rhineland, while the fighting was still going on ; later they helped to repatriate displaced persons of Allied nationality in Germany. Later still some of them became free to give help to the German population, and additional teams arrived from England to supplement them. Supplies of course are limited, and are used primarily for children, sick people, and the aged. Wherever possible German organisations which understand local needs are asked to help with distribution. In towns with a population over 5000 the education branch of Control Commission has arranged for schoolchildren to receive a coupon-free midday meal ; and supplementary feeding schemes for children under school age have been arranged by the relief teams. The Swedish Red Cross and the Swiss relief organisation known as Don Suisse are helping with this work. Swedish teams in the Ruhr have provided a daily hot meal for IN
caring
120,000 children in the past six months, and Don Suisse Thought What Winter will be Like in Europe this Year ? Issued by Save Europe Now, 14, Henrietta Street, London, W.C.2. 2. Reprinted from the Tribune of August 2. 3. Council of British Societies for Relief Abroad. Leaflet, September, 1946, 75, Victoria Street. London. S.W.1. 1. Have You
now _
inevitable, undertaking.
Circulatory Effects of Osteitis Deformans
increase in blood-flow through the affected bones. Direct study of the bone blood-flow was then undertaken. It was shown that when one tibia only is affected by Paget’s disease the flow through that leg may be five to seven times as high as -that in the
normal
leg.
Grant-Lewis
By an ingenious adaptation’of the plethysmograph the actual bone blood-
flow was estimated in the humerus of a normal person and the patient with Paget’s disease. It was found that the normal flow was probably about 1 c.cm. per 100 c.cm. of bone per minute, while that through Paget’s bones was about 20 c.cm. Applying these figures to the whole skeleton, the total skeletal blood-flow is normally about 75 c.cm. per minute, while the enlarged skeleton of the case of generalised Paget’s disease received a blood-flow of about 3-3 litres per minute. This work is an important contribution to the living pathology of Paget’s disease, but it is also the first time that bone blood-flow has been measured in man. It adds another thought-provoking instance to the group of conditions in which " cardiac failure " is associated with high output, of which severe anaaamia constitutes a well-established example.7 Comprehension of the nature and sequence of events in these cases of apparent heart-failure would shed much light on other ordinary forms of heart--failure, and we may look forward to further results of such research in the next few years.
WHEN Sir JAMES PAGET1 described the generalised disease of bone now known by his name he recognised that the bones were hypereemic, and this led him to think of an inflammatory cause and hence to use the term " osteitis." Orthopaedic and cranial surgeons are familiar with the highly vascular state of the The Convalescent Home affected bones at operation, and CONE,2 in his studies of the bone pathology, emphasised the impor"LET not thy left hand know what thy right tance of this feature. KLippEL and Well3 in 1908 hand doeth," however apt as advice on personal observed that the temperature of the skin over an almsgiving, is hardly a suitable maxim for charitable affected bone was higher than normal. For a long institutions. Yet convalescent homes in England time cardiovascular complications of the generalised have grown up on this isolationist plan, each pursuing form of Paget’s disease have been recognised. KAY a course of its own, knowing nothing of its neighbour and others4 were struck by the frequency of high in the next street. No complete list of convalescent pulse-pressures in a series which they studied. Out homes has ever been compiled; even the Public of 33 cases, 14 had pulse-pressures over 60 mm. Hg. Health Act of 1936 did not call for a complete survey; Cardiac enlargement was often noted, as were systolic and hospital almoners, local health officers, and murmurs over the precordium. Even in cases in whom must make their own lists of openings the Korotkoff sounds could be heard right down to practitioners available for their patients recovering from illness. zero pressure, there was no satisfactory evidence of homes were closed during the war and not all aortic valvular disease. KAY and his colleagues and also Many have opened again. Moreover, there is no clear SNAPPER 5 ascribed these findings to arteriosclerosis. definition of the term " convalescent home." Some Further light has now been thrown on these offer treatment, others none ; some will not take phenomena by a detailed study 6 of a case in the patients for more than a month, others will not take Britisb Medical School. A patient with them for less ; some insist that patients must be ablp had venous congestion to look after disease generalised Paget’s themselves, others will take the bedand oedema. Cardiac catheterisation showed that his some of the children’s homes are special ridden ; cardiac output was 13-3 litres per minute, or nearly schools, approved by the Ministry of Education, three times the normal average. This is a state of others are not. At many, patients must conform to affairs somewhat similar to that found in arteriovenous certain must be of a given sex or criteria-they aneurysms, and in fact closing the circulation through age-group, or must belong to a given religious sect. the legs of this patient produced effects on the general fraternity, friendly society, or social class, or must work circulation similar to those seen when an arteriovenous at or be retired from a given occupation, including aneurysm is partially shut off, including slowing of the Services, or must live in a given district. the pulse and a rise in diastolic arterial pressure. The varietv of our convalescent homes is an adva,nThis led the investigators to believe that the circutage, for the restrictions on the type of patient are latory phenomena might be explained by a great designed to make those who are accepted feel more at home, the first essential for pleasant convalescence. 1. See Lancet, 1945, ii, 569. A merchant seaman, a distressed gentlewoman, and 1. Paget, J. Med.-chir. Trans. 1876-77, 60, 37. 2. Cone, S. M. J. Bone Jt Surg. 1922, 4, 751. a resident of West Ham, placed in one home, might 3. Klippel, M., Weil, M. P. Rev. neurol. 1908, 16, 1228. 4. Kay, H. D., Simpson, S. L., Riddoch, G., Vilvandré, G. E. be poor company for each other, but they will be at Arch. intern. Med. 1934, 53, 208. ease 5. Snapper, I. Medical Clinics on Bone Diseases, New York, 1943. among those who share their ta,stes, whether in 6.
Postgraduate
slight
Edholm, O. G., Howarth, S., McMichael, J. 5, 249.
Clin. Sci. 1945,
7. Sharpey-Schafer, E. P.
Lancet, 1945, ii, 296.
569
navigation, needlework, or darts. The chief feature that the homes have in common is that patients go there after an illness expecting to get better without further.a,ctive treatment. Almshouses may therefore be excluded from the definition-whatever that is finally decided to be--and classed among provisions for the old ; for no-one expects to get better of old age. And so may the active reablement centres which have developed in the last few years, for in these the patients are as much under treatment as they were in hospital, though at a later stage of recovery. English convalescent homes range in size from those taking more than 200 to those taking less than 20 people; and though those who are planning our National Health Service are said to prefer large units there is little doubt that patients prefer small homes of 10 to 20 beds, especially when these are run with The existing homes vary a friendly personal touch. in this, of course, as in everything else : in one home the children make a friendly rush at the chairman the moment he appears, and the matron speaks of the patients by name ; in another the efficient filing system is the keynote of the institution, and the patients are called cases. There is the of the old lady in a run home in Prague who clean, airy, perfectly large, said with a " There’s nothing left but tidiness." The English may respect institutions but are peculiarly ill-fitted for living in them. The main argument in favour of large hospitals-that only they can afford the special equipment and personnel required for modern diagnosis and treatment-does not apply to the general run of homes for convalescents, who need neither apparatus nor highly skilled care. It does, however, apply to the reablement centres which aim, by active and often complex and expensive methods, to get working men and women back to their jobs. In the no-treatment home large size is a handicap, for it necessitates a medical and nursing staff, whereas the small home can rely on local practitioners to attend to minor ailments and keep The small an eye open for unexpected complications. home where the matron and committee know the patients personally, and where freedom- is respected, cups of tea can be had without formality, and no-one is sent packing because he drinks a glass of beer in the local inn, is clearly the right kind for English convalescents. Variety and small size, then, are qualities in conva lescent homes which we should strive -to keep. Their weakness lies in their having no connecting link, no central body to which inquiries can be addressed by almoners and others trying to place a patient, or to which the homes themselves can look for advice or help in moments of difficulty. Some degree of central supervision would clearly improve the service that the homes can offer : and most homes would welcome it as relieving them of the responsibility inherent in isolation. A central organisation would simplify the task of almoners : for though there is probably a suitable type of home for anyone who needs,it, there is not always a bed waiting for a particular patient at a particular moment ; or, if there is. the almoner has no means of knowing it. The central organisation could set up a simple form of admission bureau. on the lines of the bed service run by the King’s Fund in London for emergency admissions’ to hospitals. As a
story
sigh,
King’s Fund and the Institute of Almoners preparing a detailed list of homes, based on personal inspection. This will meet a real need, and will also show which groups of people are poorly served by the homes already existing, and possibly which have more opportunities for convalescence than they require. first step the are
’
Annotations WINTER IN EUROPE this winter, and particularly in the occupied Europe The Control zones, hardship is likely to be extreme. Commission recently announced that during the last week of July, in the British zone of Germany, 12 people died of hunger, while 1189 cases of famine oedema were reported in Hamburg alone. During six months the new-case rate of tuberculosis, it was stated, rose by a third. In a pamphlet lately issued,’ Viennese rations for a day during the past summer are described by Mr. G. E. R. Gedye.2 They were two rounds of bread (under 9 oz.), a teaspoonful of sugar, a tablespoonful of coffee and coffee substitute, half,a square inch of sausage and an equal amount of tinned ham, a tablespoonful each of maize flour, dried peas, oatmeal, and lard, a seventh share in a shell egg, a pinch of egg powder, half a soup cube, a dessertspoonful of salt, and two tablespoonfuls of meat-and-vegetable ration (threequarters vegetable) : the total calorie value being estimated at 1181-about half the figure (2200) regarded as adequate for a non-worker. These embittering privations can only be ended by good harvests and political decisions but in the meantime there is room and to spare for voluntary effort. Since 1945 British voluntary societies have been doing welfare work in the British zone of Germany.3 They are grouped in teams of 12 and represent the British Red Cross and Order of St. John, the Friends Relief Service and Friends Ambulance Unit, the Salvation Army, the Girl Guides, the Save the Children Fund, the Catholic Committee for Relief Abroad, and the International Voluntary Service for Peace. Many of these bodies, of course, are sending help to other distressed countries -to France, Poland,Austria, Italy, Yugoslavia, and Greece. The relief workers in Germany receive their rations, petrol, and other stores through the Army, and use Army vehicles ; but they are not paid or regulated by the Army and many of them receive no pay at all. for refugees and victims of They began by epidemics and starvation in Normandy, Belgium, Holland, and Rhineland, while the fighting was still going on ; later they helped to repatriate displaced persons of Allied nationality in Germany. Later still some of them became free to give help to the German population, and additional teams arrived from England to supplement them. Supplies of course are limited, and are used primarily for children, sick people, and the aged. Wherever possible German organisations which understand local needs are asked to help with distribution. In towns with a population over 5000 the education branch of Control Commission has arranged for schoolchildren to receive a coupon-free midday meal ; and supplementary feeding schemes for children under school age have been arranged by the relief teams. The Swedish Red Cross and the Swiss relief organisation known as Don Suisse are helping with this work. Swedish teams in the Ruhr have provided a daily hot meal for IN
caring
120,000 children in the past six months, and Don Suisse Thought What Winter will be Like in Europe this Year ? Issued by Save Europe Now, 14, Henrietta Street, London, W.C.2. 2. Reprinted from the Tribune of August 2. 3. Council of British Societies for Relief Abroad. Leaflet, September, 1946, 75, Victoria Street. London. S.W.1. 1. Have You