MILKERS' NODES

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    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 andreports in this country too often take no account of othercountries reactions to similar problems. The KingsFund 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 weredescribed; 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 mostimportant was the extension of

    " free " medical care; theincreased 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 Rs-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 Edwards 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 whichabrupt 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. Gardners 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 Jenners 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 furtherexperience. 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 frompseudo-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 constitutional1. 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 areasonable 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. 1