BEDS FOR THE TUBERCULOUS

414

pruritus in a few cases and an urticarial eruption in1 case. Involvement of the eighth nerve was notobserved. If this initial promise is fulfilled a majorpublic-health problem may be solved in the countriesconcerned, and we may hail another victory for thenew antibiotics.

Annotations

BEDS FOR THE TUBERCULOUS

WHEN beds are scarce tuberculosis presents a doubleproblem. Should the late and hopeless case be kept inthe sanatorium, while new cases, awaiting admission,lose ground and perhaps pass from the easily curable tothe chronic phase of the disease ? Or should the latecases be sent home, possibly to infect others, while theearly cases are admitted for the treatment which maysave them from a life of invalidism ? Dr. Frederick -Heaf recently offered his solution of this problem inhis presidential address 1 to the Tuberculosis Association.At present, he says, nearly 8000 people are awaiting

their turn to enter a sanatorium ; but of the 32,800beds approved for the treatment of tuberculosis, 4200are closed owing to lack of nursing and domestic staff.Even the working beds, in his opinion, are not usedeconomically. Surgery is often tried on cases knownto be bad risks, and superintendents cling to chroniccases, hoping for a miracle-though they have only topicture the large necrotic masses in the lungs, seen asX-ray shadows, to give a true prognosis. He thereforeproposes that cases needing thoracic surgery shouldbe concentrated in regional centres, and that surgeryshould not be undertaken in the smaller sanatoria.Institutions with fully developed surgical units shouldas far as possible be cleared of chronic cases. Thelatter are of three kinds-the advanced bedridden case,the case needing either limited nursing care or con-

valescence, and the ambulant case which must be

segregated. He has no hesitation in suggesting that thebedridden case should be sent home. The risk of infection,she believes, can be controlled to a few feet around thebed, and such patients are less dangerous to others thanthe ambulant positive case. Nevertheless, as he pointsout, slum conditions may be dreadful, and children-to protect them from danger-may have to be sent awayif the sick person comes home. Conscious, no doubt,of the objections, he proposes that these children frompoor homes should attend residential open-air schools,and be boarded-out in the holidays. Meanwhile thehousehold domestic difficulties could be relieved bya team of orderlies organised by the local authority.In some cases the provision of an open-air shelter in theback yard may make it possible for a patient to bereceived at home who would otherwise have to stay in asanatorium bed.The patient convalescent after an operation might,

Dr. Heaf thinks, be taken into a small home in the country,of the type seen in Scandinavia and Holland. Suchhomes need only 10-15 nurses for every 100 beds ; andthey could also house patients for whom protractedsanatorium treatment could have no effect in prolonginglife. Some of the smaller existing sanatoria, instead ofattempting to undertake thoracic surgery, and duplicatingexpensive equipment, should be developed on theselines. For the ambulant case needing segregation herecommends that sinall units of 50-100 beds shouldbe set up in towns, or on the outskirts of towns, where

. a sheltered workshop would offer some remunerativework. A visiting doctor would look after the residents’health. Since the patients themselves would- be ableto help in the work of the home, the only staff needed

1. Tubercle, 1948, 29, 2.

would be a matron and 6-8 nurses or nursing orderliesfor every 100 patients. Also hostels might be establishedin connexion with Remploy factories, having a residentwarden who would be a nurse, assisted by a housekeeperand domestic staff.These suggestions all deserve study. It is easy to

criticise their drawbacks on the grounds that they do notaccord first place to the happiness of patients and theirfamilies ; but Dr. Heaf does not claim that they are morethan a makeshift to meet what Dr. Toussaint in hisletter on p. 422 rightly calls an appalling situation.

A NEW SOURCE OF STREPTOMYCIN

IN the early days of penicillin therapy, when the drugwas very scarce, useful quantities were recovered fromthe urine of patients under treatment and the samehas been done more recently in Germany for the samereason. The procedure was soon given up here as notworth while when supplies improved, for the urinaryexcretion of penicillin is highly variable - and the drugitself unstable. Rather more than a year ago the

suggestion was made in these columns 2 that strepto-mycin should similarly be recovered from the urine,because it seemed likely to be as scarce as penicillinwas five years before and because a higher proportion isexcreted unchanged. Much streptomycin has flowed downthe sewers since then, but in this issue Mr. Miller and Mr.Rowley, PH.D., of St. Mary’s Hospital, show clearlythat recovery from the urine is both a feasible anda commendable proposition. About half of the strepto-mycin administered therapeutically is excreted in theurine, and Miller arid Rowley found that 50-60% of thisamount can be recovered in a form having not less thanfour-fifths of the original potency. The over-all recovery,therefore, is of the order of 25-30% of the dosage given.The streptomycin recovered in this way has been tested forhistamine-like substances, toxicity, and the presence ofpyrogens, and in each case the result has satisfied the

requirements’of the American Food and Drug Adminis-tration, which have been adopted as the standards ofpurity in this country. This means that for every 100

patients receiving streptomycin therapy for tuberculosis,in the customary dose of 2 g. daily, about 50-60 g. of thedrug could be recovered for readministration every day,if all the urine (about 150 litres per day) was collectedfor this purpose. The experience with penicillin suggeststhat, far from being of inferior quality, the streptomycinobtained in this way will be particularly free from harmfulimpurities.

LIAISON WITH THE COLONIES

To improve the two-way flow of information betweenBritain and some of the Colonies, a panel of eighteenspecialists are each to pay two visits to East or WestAfrica at intervals of three years. As announced in ournews columns, this scheme is being subsidised for sixyears by the Nuffield Foundation, and, though the visitsare to be informal, the plan is supported by the ColonialOffice. The hope is that if it proves a success itwill eventually be taken over and extended by theGovernment.The disinclination of graduates in the United Kingdom

to serve in the Colonies has long dismayed those who wishto see a first-class Colonial Medical Service. On anotherpage a peripatetic correspondent partly explains thisreluctance by the severance of professional ties whichseems to be inevitable if a doctor remains out of this

country for even a year or two. This correspondentevidently shares Sir Wilson Jameson’s view 3 that the

young man should be enabled to serve overseas for a

1. Abraham, E. P., Chain, E., Fletcher, C. M., Gardner, A. D.,Heatley, N. G., Jennings, M. A., Florey, H. W. Lancet, 1941,ii, 177.

2. Leading article, Ibid, 1946, ii, 758.3. See Lancet, 1945, ii, 569.