THE COMPLICATIONS OF HOSPITAL ADMISSION

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1377 cure inasmuch as, in a week or so, the swelling, sponginess and congestion of the gum margin dis- appear, the pus discharge, fcetor, and tendency to bleed stop, and the gums appear to become quite normal. In acute cases fever and other constitutional symptoms’ of toxasmia clear up within 48 hours. The clinical improvement is accompanied by a correspond- ing change in the bacterial picture, cultures showing a decided diminution of growth. These results were obtained with M. & B. 693, in a dosage of 2-3 g. daily for from seven to fourteen days, and with sulphanilamide in a dosage of 3-4 g. for from fourteen to twenty-one days. Most cases relapsed both clinic- ally and bacteriologically some weeks after the end of the chemotherapy. Cokkinis found, however, that by preceding and accompanying the chemotherapy by active immunisation (using a mixed stock or auto- genous vaccine of parodontal streptococci) the clinical improvement was more prolonged and the tendency to relapse less. By giving repeated courses of chemo- therapy and a full course of vaccine (six to eight weeks) several cases of marginal pyorrhoea were made well for from six months to a year after the end of treatment. Cases of advanced pyorrhoea, with paro- dontal pockets, periapical changes, pulp infection, loosening of the teeth, or marked retraction of the gum, responded only partly or not at all to this com- bination of chemotherapy and immunotherapy, and had to be referred back for odontological treatment. A number of cases of parodontal infection with the organisms of Vincent’s angina showed no response to sulphonamide therapy. Cokkinis’s work shows clearly that unaided chemo- therapy is unlikely to do more than produce a temporary improvement in cases of gum infection, and also that even when its action is enhanced, by immunisation prolonged results can only be expected in the early stage of streptococcal pyorrhoea, when the infection has not yet seriously involved the periodontal membrane or the dental structures. An incidental benefit claimed by Cokkinis for sulphon- amide compounds is that they can prevent or abort the post-extraction septicaemia caused by a " bacterial shower" liberated into the blood-stream after multiple extractions for parodontal infection. THE SEX HORMONES IN OTOSCLEROSIS FROM time to time it has been suggested that the causation of otosclerosis is connected in some way with the sexual organs. This supposition is based on certain peculiarities of the disease, especially its pre- ponderance in females, that it often begins at puberty, and that it is very definitely made worse by each pregnancy. It is, at any rate, reasonable to try the effect of the administration of sex hormones. This has been done by Bernstien and Gillis in 56 cases, and their results are published in this issue. They obtained improvement of hearing in 31 of their 56 patients ; of the total 18 were males, of whom only 7 were improved, as compared with 24 of the 38 females. The authors rightly say that their results are suffi- ciently good to encourage further investigation, but they will no doubt not be surprised if they are received with a considerable degree of caution. Many diverse methods have been advocated in the past for the treatment of this intractable condition, accompanied by encouraging case-reports, but they have sunk again into oblivion. Every otologist knows that sufferers from chronic deafness are pathetically anxious for improvement and inclined to believe that they hear better after treatment. It is therefore a pity that the audiometer was not used in this investigation, for the voice is not a sufficiently reliable method of testing results. It is to be hoped that others will give the method a stricter trial. THE COMPLICATIONS OF HOSPITAL ADMISSION "Hospitals’ ‘ No ’ to Dying Man" made an arrest- ing headline in a Manchester newspaper not long ago. A Salford doctor had notified the public health department of the borough of Stretford that a Stret- ford man of 63 was suffering from bronchopneumonia, that it was necessary to remove him to hospital, and that efforts to find hospital accommodation for him had failed. The doctor had visited the patient at 11.30 A.M. The chief clerk of the department, who received the message at about 2 P.M., undertook to do what he could to find a bed, but while he was thus engaged the doctor telephoned that he had succeeded in persuading the Manchester Royal Infirmary to admit his patient " as a special favour." The patient was admitted in the evening and died at 3.30 next morning. No local authority is under a legal obligation to provide hospital accommodation unless it is a public- assistance authority, and here the county and not the borough council is responsible for providing hospital treatment for the destitute. Application for such treatment may be made to a relieving officer, a district medical officer, the medical superintendent or master of a public assistance institution, or the administrative medical officer of the responsible public assistance authority. None of these seem to have been approached by the doctor concerned. The county council’s Park Hospital at Davyhulme had been closed to civilian patients and alternative accommodation was being sought. The county medical officer of health was at this very time sending all medi- cal practitioners a circular letter about the proposed arrangements. Until a temporary hospital was estab- lished in the new year it had been agreed that urgent cases should be admitted- to other hospitals, admission being arranged by the county medical officer’s depart- ment. It thus appears that the difficulties due to war-time improvisation were being met, but the arrangements made were not fully known to local doctors. There is an obligation upon every medical practitioner to make himself acquainted with the resources available for his patients. Lectures on such subjects are given to candidates for the D.P.H., and they might well be a part of the medical student’s course on public health. DARK ADAPTATION SINCE the function of vitamin A, stated in the most general terms, is to safeguard the welfare of epithelia, it is not surprising that its lack should fall most severely on such a specialised structure as the eye. The occurrence of xeropthalmia in cases of great deficiency falls logically into line with this view, and even the experimental production of nerve degenera- tion occasions no surprise so long as we are merely generalising, since the nervous system is of ectodermal origin. There is a touch of irony in the discovery that vitamin A is a constituent of visual purple, the pigment of the rods of the retina, and that when this substance is broken down and bleached by the action of bright light its re-synthesis in the dark depends on a certain amount of fresh vitamin A being available. Nothing could be more precise in defining function than the detection of the vitamin in the act of chemical combination, but nothing could have less apparent relation to chemical events in the rest of the body than those concerned in vision. Nevertheless, there is no longer any doubt of the importance of vitamin A in this respect, for one of the functions of the rods is to

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cure inasmuch as, in a week or so, the swelling,sponginess and congestion of the gum margin dis-appear, the pus discharge, fcetor, and tendency tobleed stop, and the gums appear to become quitenormal. In acute cases fever and other constitutionalsymptoms’ of toxasmia clear up within 48 hours. Theclinical improvement is accompanied by a correspond-ing change in the bacterial picture, cultures showing adecided diminution of growth. These results wereobtained with M. & B. 693, in a dosage of 2-3 g.daily for from seven to fourteen days, and withsulphanilamide in a dosage of 3-4 g. for from fourteento twenty-one days. Most cases relapsed both clinic-ally and bacteriologically some weeks after the end ofthe chemotherapy. Cokkinis found, however, that bypreceding and accompanying the chemotherapy byactive immunisation (using a mixed stock or auto-genous vaccine of parodontal streptococci) the clinicalimprovement was more prolonged and the tendency torelapse less. By giving repeated courses of chemo-therapy and a full course of vaccine (six to eightweeks) several cases of marginal pyorrhoea were madewell for from six months to a year after the end oftreatment. Cases of advanced pyorrhoea, with paro-dontal pockets, periapical changes, pulp infection,loosening of the teeth, or marked retraction of thegum, responded only partly or not at all to this com-bination of chemotherapy and immunotherapy, andhad to be referred back for odontological treatment.A number of cases of parodontal infection with theorganisms of Vincent’s angina showed no response tosulphonamide therapy.

Cokkinis’s work shows clearly that unaided chemo-therapy is unlikely to do more than produce a

temporary improvement in cases of gum infection,and also that even when its action is enhanced, byimmunisation prolonged results can only be expectedin the early stage of streptococcal pyorrhoea, whenthe infection has not yet seriously involved theperiodontal membrane or the dental structures. Anincidental benefit claimed by Cokkinis for sulphon-amide compounds is that they can prevent or abortthe post-extraction septicaemia caused by a " bacterialshower" liberated into the blood-stream after multipleextractions for parodontal infection.

THE SEX HORMONES IN OTOSCLEROSIS

FROM time to time it has been suggested that thecausation of otosclerosis is connected in some waywith the sexual organs. This supposition is based oncertain peculiarities of the disease, especially its pre-ponderance in females, that it often begins at puberty,and that it is very definitely made worse by eachpregnancy. It is, at any rate, reasonable to try theeffect of the administration of sex hormones. Thishas been done by Bernstien and Gillis in 56 cases,and their results are published in this issue. Theyobtained improvement of hearing in 31 of their 56patients ; of the total 18 were males, of whom only 7were improved, as compared with 24 of the 38 females.The authors rightly say that their results are suffi-ciently good to encourage further investigation, butthey will no doubt not be surprised if they are receivedwith a considerable degree of caution. Many diversemethods have been advocated in the past for thetreatment of this intractable condition, accompaniedby encouraging case-reports, but they have sunk againinto oblivion. Every otologist knows that sufferersfrom chronic deafness are pathetically anxious for

improvement and inclined to believe that they hearbetter after treatment. It is therefore a pity thatthe audiometer was not used in this investigation, forthe voice is not a sufficiently reliable method of testing

results. It is to be hoped that others will give themethod a stricter trial.

THE COMPLICATIONS OF HOSPITAL ADMISSION

"Hospitals’ ‘ No ’ to Dying Man" made an arrest-ing headline in a Manchester newspaper not long ago.A Salford doctor had notified the public healthdepartment of the borough of Stretford that a Stret-ford man of 63 was suffering from bronchopneumonia,that it was necessary to remove him to hospital, andthat efforts to find hospital accommodation for himhad failed. The doctor had visited the patient at11.30 A.M. The chief clerk of the department, whoreceived the message at about 2 P.M., undertook to dowhat he could to find a bed, but while he was thusengaged the doctor telephoned that he had succeededin persuading the Manchester Royal Infirmary toadmit his patient " as a special favour." The patientwas admitted in the evening and died at 3.30 next

morning.No local authority is under a legal obligation to

provide hospital accommodation unless it is a public-assistance authority, and here the county and not theborough council is responsible for providing hospitaltreatment for the destitute. Application for suchtreatment may be made to a relieving officer, a districtmedical officer, the medical superintendent or masterof a public assistance institution, or the administrativemedical officer of the responsible public assistanceauthority. None of these seem to have been approachedby the doctor concerned.The county council’s Park Hospital at Davyhulme

had been closed to civilian patients and alternativeaccommodation was being sought. The county medicalofficer of health was at this very time sending all medi-cal practitioners a circular letter about the proposedarrangements. Until a temporary hospital was estab-lished in the new year it had been agreed that urgentcases should be admitted- to other hospitals, admissionbeing arranged by the county medical officer’s depart-ment. It thus appears that the difficulties due towar-time improvisation were being met, but thearrangements made were not fully known to localdoctors. There is an obligation upon every medicalpractitioner to make himself acquainted with theresources available for his patients. Lectures on suchsubjects are given to candidates for the D.P.H., andthey might well be a part of the medical student’scourse on public health.

DARK ADAPTATION

SINCE the function of vitamin A, stated in the mostgeneral terms, is to safeguard the welfare of epithelia,it is not surprising that its lack should fall mostseverely on such a specialised structure as the eye.The occurrence of xeropthalmia in cases of greatdeficiency falls logically into line with this view, andeven the experimental production of nerve degenera-tion occasions no surprise so long as we are merelygeneralising, since the nervous system is of ectodermalorigin. There is a touch of irony in the discoverythat vitamin A is a constituent of visual purple, thepigment of the rods of the retina, and that when thissubstance is broken down and bleached by the actionof bright light its re-synthesis in the dark depends ona certain amount of fresh vitamin A being available.Nothing could be more precise in defining functionthan the detection of the vitamin in the act of chemicalcombination, but nothing could have less apparentrelation to chemical events in the rest of the body thanthose concerned in vision. Nevertheless, there is nolonger any doubt of the importance of vitamin A inthis respect, for one of the functions of the rods is to