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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.
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.
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.