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Annotations

COMMON PRESSURES

Andre Maurois once defined the British as a peopleentirely surrounded by mal de mer. While this is no longertrue-thanks to air travel-opinions, discussions and

reports in this country too often take no account of othercountries’ reactions to similar problems. The King’sFund and the International Hospital Federation are doingtheir bit to reduce this kind of insularity by holding con-ferences of hospital administrators from European coun-tries in London. At the first conference in 1962 the

hospital systems of the participating countries were

described; at the second, in 1964, the main problems wereoutlined; and at the third,2 the most important problem-pressures on hospital services-was selected for moredetailed discussion. In addition to individual papers from17 countries, the report contains an informative openingaddress by Sir Arnold France and a summary on a subject-basis by the rapporteur, Dr. Neville Goodman. Statisticsfrom every country showed that demands on the hospitalservices were increasing faster than supply. 25 causes ofthis rising pressure were listed, of which the most

important was the extension of " free " medical care; the

increased proportion of old people in the population; theincreased complexity and cost of medical care; and risingeconomic, social, and educational standards. Other causeswere the growth of confidence in hospitals (or Spital-freudigkeit), health education of the public, the increase ofmedical screening procedures, and pressures from medicalor lay " interest groups."

Opinions were divided on whether the removal of directfinancial barriers to hospital treatment had led to unneces-sary pressures, and objective data were almost totallylacking. But all were agreed that, once removed, suchbarriers could not for political reasons be reimposed andthat other ways of relieving pressure must be sought.Shortages of money and staff acted everywhere as nega-tive-and undesirable-checks, but much more could bedone through the three R’s-regionalisation, rationalisa-tion, and research. In these three directions Britainseemed to have little to be ashamed of, though Swedenstill was ahead in operational research.

Pressure varied in different medical specialties; buteverywhere it was heaviest in departments for geriatrics,maternity, reablement, casualties, and mental sub-

normality. France alone among the " northern tier " ofcountries felt she needed many more beds for mentalillness. Beds per 1000 population ranged from 4-6

(Belgium) and 4-8 (Spain) up to 20-8 (Eire). But cautionis needed in making comparisons, for estimation of theneed for hospital beds is still more of an art than a science,despite a formula from Germany which would make amathematician blench. In any case " the bed " is losingits status as a norm of hospital services.The old utopian, and socialist, belief that ill health will

" wither away " as poverty, ignorance, and the other socialevils of mankind diminish has proved to be a dream.There was general agreement at the conference that theuse of medical services was proportional to their supply1. See Lancet, 1964, i, 1147.2. Hospital Services of Europe. King Edward’s Hospital Fund for London.

Report of the Western European Conference held in October, 1966.1967. Pp. 241. 10s. Obtainable from the Hospital Administrative StaffCollege, 2, Palace Court, London W.2.

and was almost infinitely expansible. Methods to establishpriorities were, therefore, becoming all-important, and" cost-benefit analysis "-hitherto an unknown or a dirtyword in hospital services-had to be taken into account.The report, which is packed with facts and figures,

throws up some beguiling nuggets of information.Portugal, for instance, regulates all its hospital admissionsthrough regional bed bureaux. Italy pays its hospitaldoctors a considerable lump sum for every admission,and in a Swiss hospital a staff of 2780 had 1300 changesin a year.

BARBITURATE FITS

IN this issue Dr. Gardner reports 4 cases in which

abrupt withdrawal of barbiturate drugs from addicts whohad been taking large doses was followed by fits. Thissequel of withdrawal is well known to neurologists andpsychiatrists, but is less well known to other clinicians.Of 24 general physicians from various hospitals and4 general practitioners whom Dr. Gardner questioned,only 1 was aware of this association. Furthermore, ineach of 4 cases of barbiturate addiction in doctors whichhave come to Dr. Gardner’s notice, sudden self-with-drawal in an attempt to end the addiction resulted in

fits; and it can only be supposed that none of thesepatients knew in advance of this serious complication.The matter is of consequence, since (as Dr. Gardnerremarks in his article) misdiagnosis can lead to the patientbeing given further supplies of barbiturate.

MILKERS’ NODES

THE benefits to man of Edward Jenner’s experiments oncowpox have been beyond calculation, but even in his ownday they were recognised as faulty in design and imperfectin execution. After the publication of ’ An Inquiry into... a Disease ... known by the name of the Cow Pox’,such part of his time as he could spare from attempts to

gain suitable recognition was largely devoted to attemptsto explain the anomalies brought to light by further

experience. One of these was the discovery that not everystrain of cowpox protected against subsequent smallpox,and he was forced into some rather mystical argumentswhich included a distinction between " true " and" spurious " cowpox. Perhaps he was nearer the truththan he knew. To the farmer (and, no doubt, to the cowdoctors of the day) any ulcerative lesion of the teats wascowpox and it is only within recent years that theveterinarians have distinguished the true disease from

pseudo-cowpox or milk-pox or paravaccinia (and theseare not the only synonyms). Within the past few years thevirologists have confirmed this distinction.2 Both diseasesare caused by poxviruses, and it is characteristic of thisgroup that they are almost but not entirely specific toone host, the cow. In man the clinical pictures are verydifferent. Cowpox is usually a feverish illness with a localulcerated papule and often considerable oedema and pain.Healing is slow and a scar remains. Pseudo-cowpox ormilkers’ nodes produces only single or multiple granulo-matous nodules on the fingers without constitutional

1. Greenwood, M. Epidemics and Crowd-Diseases; p. 245. London, 1935.2. Timmel, H. Acta biol. med. germ. 1962, 9, 79.

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disturbance, and unless secondary bacterial infectionensues these disappear completely within a few weeks.Cowpox is now a rare disease, largely owing to the higher

standards of modern dairy farming, but it may appear" out of the blue ". Some epidemics have been traced to

a milker who has acquired his infection in his previousemployment. Pseudo-cowpox is commoner both in cowsand man, but many human infections are too slight to beseen by a doctor. A recent account of a small epidemicin an enclosed community of nuns illustrates some of theusual features.3 Most of the 32 cows in milk belongingto the sisterhood had papular lesions on the udders. Thedry cows were unaffected. The permanent herdswomanwas not infected, but in all the 5 nuns being taught theart of milking small painless lumps developed on thefingers. None of them was ill, and all the lesions healeduneventfully except for one which became secondarilyinfected. It is common experience that pseudo-cowpox islimited to those who are fresh to milking, so it is a

reasonable guess that one attack gives some immunity.Those who have seen the two diseases in man will not

usually find the distinction difficult, and diagnosis can beconfirmed simply and quickly by examination of thevirus in the overlying scab under an electron microscope.The farmer may know both diseases by the same namebut ought to be able to differentiate the mild eruptionwhich spreads through his herd slowly from the moreinfectious variolar vaccinx veras which run through hisherd like lightning and make a large hole in the milkcheque.

CHROMOSOMES IN CONGENITAL RUBELLA

RUBELLA virus readily parasitises the developing humanembryo, in some cases causing intrauterine death andabortion and in others producing cataract, deafness,heart-disease, and mental retardation in the newborninfant. Sometimes, however, the infection is confined tothe placenta, and the infant is normal. Virus-isolationstudies in pregnancies terminated by surgery suggest thatthe infection may die out in some pregnancies, whereasin others, virus can be recovered from many tissues andorgans at birth and for several months thereafter.4 5 Whatdetermines the outcome in any particular pregnancy isstill largely unknown. Embryonic age at the time ofinfection is clearly one factor, but there must be manyothers. Investigations in human embryonic cells culti-vated in vitro are easier to control than in-vivo studies,and they may throw some light upon the problem.Rubella virus produces no clear cytopathic effect onnormal human embryonic cells, but virus-infected cul-tures behave differently from normal cultures. Fibro-blasts from normal lungs or pituitary fail to grow whensubcultivated after infection with rubella virus, whereascells from normal embryonic skin and pharyngeal mucosa,when infected, continue to grow well after many serialsubcultivations but remain infected with virus and show a

high proportion of chromosome breaks. Clearly the celltype is important. Normal embryonic lung cells infectedin vitro seem to behave differently from lung cells infectedin vivo and cultured after surgical termination of preg-3. Neale, E. J. E., Calvert, H. T. Br. J. Derm. 1967, 79, 318.4. Monif, G., Avery, S. B., Korones, S. B., Sever, J. L. Lancet, 1965, i, 723.5. Sever, J. L. in Advances in Teratology (edited by D. H. M. Woollam);

vol. II, p. 127. London, 1967.6. Plotkin, S. A., Boué, A., Boué, J. G. Am. J. Epidemiol. 1965, 81, 71.

nancy. In the latter case, serial cultivation may be carried

through many generations with the, virus still present inthe cultures,’ although cell growth may be less vigorous,than in cultures of normal embryonic lungs.8 9

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It is possible that rubella virus produces its teratogeniceffect by acting upon the genetic apparatus of cells. Thevirus certainly produces chromosome breaks in somehuman embryo cells in’vitro. Is there any evidence thatit also produces chromosome damage in vivo? Firstreports failed to show any clear chromosome effects incultured leucocytes from infants born with congenitalrubella 10 or in cultures from-tissues removed by surgicaltermination of pregnancy.:> - but more positive findingswere later reported.9 11’Ì2 These findings are interesting,but they leave many questions unanswered. A number ofviruses have been reported to produce chromosomebreaks in leucocytes cultured from patients with virusinfections, and the addition of rubella virus to this list isnot remarkable in itself. Evidence of chromosome

damage in cultures prepared directly from naturallyinfected embryos is more convincing, but here there isthe problem that severely damaged cells may fail to

undergo even a single cycle of cell division on cultivationin vitro. There is the further complication that chromo-some breaks are not uncommonly found in spontaneousabortions not associated with rubella, so that it is not easyto know what should be taken as a normal baseline.The long-term persistence of rubella virus in human

embryonic cells raises important questions about theeventual fate of a virus in the descendants of these cells.Is the infectivity of rubella virus lost for ever when

attempts to recover the virus in post-natal life fail, orcould it be reactivated by some later event in vivo or inresponse to some manipulation of cultured cells in vitro ?Rubella virus is probably the most important infectiousagent producing a teratogenic effect in man, but it isalmost certainly not alone in this respect.

A BIOLOGICAL BAROMETER

FOR millions of children malnutrition means a poorstart in life, and for some it means death. With a healthproblem of this magnitude there is need for a cheap, easy,and accurate method of assessing nutritional status in

large population surveys. The late Dr. B. T. Squires, ofBulawayo, devised a simple test 13 which seems to fit thebill. In 1963 14 he described characteristic changes in theappearance of cells from the buccal mucosa (dueapparently to increased keratinisation) in malnourishedchildren and in young animals kept on a low-protein-calorie diet, and after experimenting with various stainingmethods he found one that gave a reliable indication ofkeratinisation. The stain he used was acid-fuchsin with

light-green (fall),15 which, unexpectedly, produces a blue-7. Kay, H. E. M., Peppercorn, M. E., Porterfield, J. S., McCarthy, K.,

Taylor-Robinson, C. H. Br. med. J. 1964, ii, 166.8. Rawls, W. E., Melnick, J. L. J. exp. Med. 1966, 123, 795.9. Chang, T. H., Moorhead, P. S., Boué, J. G., Plotkin, S. A., Hoskins,

J. M. Proc. Soc. exp. Biol. Med. 1966, 122, 236.10. Mellman, W. J., Plotkin, S. A., Moorhead, P. S., Hartnett, E. M.

Am. J. Dis. Child. 1965, 110, 473.11. Nusbacher, J., Hirschhorn, K., Cooper, L. Z. New Engl. J. Med. 1967,

276, 1409.12. Kuroki, Y., Makino, S., Aya, T., Nagayama, T. Jap. J. hum. Genet.

1966, 11, 17.13. Squires, B. T. Cent. Afr. J. Med. 1966, 12, 223.14. Squires, B. T. Br. J. Nutr. 1963, 17, 303.15. MacConail, M. A., Gurr, E. Ir. J. med. Sci. April, 1960, p. 182.