1367
just tedious to have to change. Many of the facts have been available for a long time, and for those who feel that they are innovators it is salutary to learn that the treatment of surgical conditions without the allocation of inpatient beds was well established at the turn of the century. 1,2 Yet it takes at least a generation to change habits, even if fashions are modified overnight. So it has been with outpatient surgery, and though FARQUHARSON3 introduced the idea for what is conventionally regarded as surgery of moderate severity (hernia in particular) and subse4 quent workers built on his achievement the general attitude has remained very conservative. Duration of stay after herniorrhaphy and varicosevein surgery in the 1970s still tends to be of the order of 5-7 days. All these facts and the organisation that can make for change are reviewed in a publication from the Scottish Home and Health Department5 which records, among other things, The Lancet’s insistence in 1951 that upwards of ten days should be spent in hospital for any surgical condition and the journal’s condemnation of those who pushed their patients out of bed as soon as they were conscious and out of hospital whenever they could totter.6 Times have changed 7: it is no longer remarkable for a patient to have a herniorrhaphy as an outpatient, and there is good evidence that the patient is medically neither better nor worse off as a consequence of very or
early discharge.8 The Scottish report reveals that day-care, shortstay, and planned-early-discharge techniques have now been applied in general surgery, psediatric
gynaecology, traumatic surgery, and investigative medicine-to name only the major areas. Most of the initial work was done with existing facilities for homogeneous groups of conditions such as hernia 3,9 and varicose veins or for diagnostic dilatation and curettage,lO,ll but increasingly in Britain and elsewhere purpose-designed units are being developed 12,13 and studied. 14-17 The last part of the report is an operational-research analysis of one such unit undertaking a wide variety of minor procedures and investigations. From the wealth of data certain factors are salient. First, enthusiasts have inevitably concentrated on the freedom from surgery,
1. Nicoll, J. H. Br. med. J. 1909, ii, 753. 2. Fullerton, A. ibid. 1913, i, 470. 3. Farquharson, E. L. Lancet, 1955, ii, 517. 4. Ruckley, C. V., Maclean, M., Ludgate, C. M., Espley, A. J. ibid. 1973, ii, 1193. 5. The Value of the Day Bed Unit in General Hospital Practice. By IAN W. KEMP, M.D. Scottish Health Service Studies, no. 32. Scottish Home and Health Department, 1975. £1.15. 6. Lancet, 1951, i, 95. 7. ibid. 1972, ii, 23. 8. Morris, D., Ward, A. W. M., Handyside, A. J. ibid. 1968, i, 681. 9. Stephens, F. O., Dudley, H. ibid. 1961, i, 1042. 10. Littlepage, B. N. C., et al. J. Obstet. Gynœc. Br. Commonw. 1969, 76, 163. 11. Wagman, H., Bamford, D. S. Br. med. J. 1971, i, 450. 12. Calnan, J., Martin, P. ibid. 1971, iv, 92. 13. Berrill, T. H. ibid. p. 348. 14. Brown, F. M. Nursing Times, 1964, 60, 696. 15. Lawther, A. The Hospital, 1967, 63, 47. 16. Levy, M. L., Oakley, C. S. Sth. med. J. 1968, 61, 995. 17. Follis, P. Pulse, 1969, 18, 4.
complications of what they do, and have not sufficiently considered the patient and his personality. medical
There may be domestic strains and unexpressed or apparently irrational fears which few specialists hear about; the transport problems are different from those of ordinary hospital patients, and rethinking of many facilities is called for. Second, there seems to be a tendency for day-bed facilities to expand until they become short-stay units, taking on an increasingly varied cross-section of surgery and investigation-becoming in fact little hospitals on their own. It is far from certain that this is the best way to practise medicine, either for the doctor or the patient. Furthermore, this does mean more directed and therefore inflexible allocation of resources, and possibly increased rather than decreased capital and running costs. One of the aims of the day-bed concept, and indeed in these troubled times of all hospital medicine, should be to do more with less. Somehow it must be shown that a change in the pattern of care which is without medical and, in properly selected cases, social drawbacks has real economic advantages. Can it reduce the number of acute beds needed, or alternatively permit a reallocation ? Can there be a saving in running costs for a given output ? These important economic questions are not tackled by the Scottish report. However, there are some modest pointers from studies in Stockton-on- Tees 18 that savings can be made. To achieve them, careful integrated planning inside the reorganised Health Service is required so that specialist, general practitioner, nurse, and social worker can all ensure that in every way the patientour customer-receives a package which is as good as or better than that offered by the conventional hospital bed. Outpatient and short-stay management for surgery and investigation is now through its preliminary phase. It is neither new nor controversial. Now we need to know just what part it can play in individual areas of medical practice and for particular communities.
DEALING WITH RABIES
THE rabies virus has broken loose on the continent Europe and may soon be knocking more insistently at the door in Britain. Those who look after imported pets and laboratory animals in quarantine are already at risk, and there is a steady trickle of others who have been exposed abroad. Untreated rabies is a terrible and uniformly fatal disease, but effective methods of prevention and treatment exist and a number of improvements will soon be available generally. In Europe the virus spreads in the fox population, which has increased probably because of reductions in the numbers of competing species, including bears and hawks. A long-term objective should therefore be to reduce the fox population until it can no longer
of
18.
Devlin, B. Unpublished.
1368 support the growth and spread of the virus. In Britain there are plans to act swiftly and drastically against the local fox population if the virus seems to have been
introduced. In the U.S.A., where rabies is widespread in wildlife and will never be eliminated, it is instructive to see how a well-planned programme can reduce the ill-effects. Prophylactic immunisation of dogs has reduced the frequency of canine rabies from 5000 cases per annum in 1946 to 180 in 1973. Together with better treatment regimens, this has reduced the number of human cases from over 20 per year to almost 2 per year; even so, about 30,000 post-exposure treatments are given each year.1 Controlled trials of treatment methods in man are virtually impossible, but a unique study of a group of villagers bitten by a rabid wolf in Iran seemed to show a real protective effect from a combination of antirabies antiserum and rabies vaccine.2 Horse antiserum is available, and also various vaccines, of which the inactivated duck-embryo vaccine is used in the U.S.A. and Britain. Horse serum often produces serum sickness and the vaccine always causes local reactions; up to two-thirds of recipients have general reactions, and a few have serious central-nervoussystem damage. Therefore in each patient the risks of treating must be weighed against those of not treating. A paper by Corey and Hattwick,l illustrated with a flow chart, is very helpful. Firstly, the risk is evaluated on epidemiological principles. Is rabies known to occur in the area, and if so did the animal show signs of rabies such as aggressiveness or paralysis ? Has the animal been caught ? Has the brain been examined and found to contain virus ? Was the exposure by a bite or only by contact of saliva with abrasions ? This enables a scale of risk for rabies to be established and treatment can then be instituted at a corresponding point. If there was no bite and no exposure to saliva, or if rabies is known not to occur, If the as in Britain, then no treatment is necessary. was bitten a or by clinically virologically rabid patient then immediate treatment with serum and animal, vaccine is essential. Serum is given, partly locally into the bitten area and partly intramuscularly, and up to 23 doses of vaccine are given. Corey and Hattwick1 and the W.H.O. report3 outline the action to take in
intermediate
cases.
Research is now directed to improving both the serum and the vaccine. Human immunoglobulins can be obtained from vaccinated subjects and are apparently rather more effective than horse serum in
producing circulating antibody; furthermore, they produce almost no local or general effects. As might be expected, such circulating anti-rabies antibody, by acting as a specific immunosuppressant, diminishes the ability of the vaccine to stimulate production of persisting antibodies (apparently one dose of human globulins can prevent the effect of 16 doses of duckembryo vaccine ), though this interference may be
less serious if more potent vaccines are used.5 After research at the Wistar Institute a new vaccine has been developed containing virus produced in tissuecultures of human diploid fibroblasts. Inactivated, concentrated, and highly purified, this has now been produced in commercial conditions. The latest vaccine to be evaluated is substantially more potent than duck-embryo vaccine and produces only trivial local reactions. It will probably replace duck-embryo vaccine for the protection of those exposed in the course of their work-provided that it can be produced economically and in sufficient quantity. Vaccination schedules have still to be worked out, but immune responses are likely to be so consistent that postvaccination tests for circulating antibodies will be unnecessary. Antibody responses in volunteers will show whether the vaccine can replace duck-embryo vaccine in treatment. As a very potent antigen it may well be less affected by antibody immunosuppression, and it is certainly much less likely to cause side-effects. This more effective vaccine should also make it easier to produce human immune anti-rabies globulin. Finally, it should be remembered that at least one patient has recovered from clinical rabies. A combination of improved immunological treatments and modern intensive care may yet save more, if the disease is recognised very early and treatment started with a minimum of delay.
ANOTHER SCANNER FROM EMI
AT the 1972 annual congress of the British Institute of Radiology in London, the audience attending a lecture by J. Ambrose and G. N. Hounsfield with the obscure title Computerised Transverse Axial Tomographywere electrified by the realisation that they were witnessing the introduction of a revolutionary new approach to diagnostic radiology. With this apparatus-the EMI brain scanner-the X-ray tube emits a narrow beam of radiation as it passes, in a series of scanning movements, through a 180° arc around the patient’s head.In contradistinction to the conventional photographic method of recording, the intensity of the emergent X-ray beam is measured by a scintillation counter; the electronic impulses are recorded on a magnetic disc and are then processed by a mini-computer. In a single scan, which takes about four minutes, it is possible to determine the X-ray absorption coefficients of approximately 20,000 individual areas of the brain.9 The sensitivity of the apparatus is such that it displays the very small variations in X-ray absorption coefficients which normally exist in the different parts of the brain so that the subarachnoid space, cerebral cortex, white matter, corpus striatum, internal capsule, and ventricular system are visible; and, of course, calcification is even more readily demonstrable. Dilatation or displacement of the ventricular system, or changes in the subarachnoid Loufborrow, J. C., Cabasso, V. J., Roby, R. E., Anuskiewicz, W. ibid. 1971, 217, 1825. 6. Aoki, F. Y., Tyrrell, D. A. J., Hill, L. E., Turner, G. S. Lancet, March 22, 1975, p. 660. 7. Ambrose, J., Hounsfield, G. Br. J. Radiol. 1973, 46, 148. 8. Hounsfield, G. N. ibid. p. 1016. 9. Hounsfield, G. N. Unpublished.
5.
Corey, L., Hattwick, M. A. W. J. Am. med. Ass. 1975, 232, 272. Habel, K., Koprowski, H. Bull. Wld Hlth Org. 1955, 13, 773. 3. Expert Committee on Rabies, Sixth Report. Tech. Rep. Ser. Wld Hlth Org. no. 523, 1973. 4. Hattwick, M. A. W., Rubin, R. H., Music, S., Sikes, R. K., Smith, J. S., Gregg, M. B. J. Am. med. Ass. 1974, 227, 407.
1. 2.
just tedious to have to change. Many of the facts have been available for a long time, and for those who feel that they are innovators it is salutary to learn that the treatment of surgical conditions without the allocation of inpatient beds was well established at the turn of the century. 1,2 Yet it takes at least a generation to change habits, even if fashions are modified overnight. So it has been with outpatient surgery, and though FARQUHARSON3 introduced the idea for what is conventionally regarded as surgery of moderate severity (hernia in particular) and subse4 quent workers built on his achievement the general attitude has remained very conservative. Duration of stay after herniorrhaphy and varicosevein surgery in the 1970s still tends to be of the order of 5-7 days. All these facts and the organisation that can make for change are reviewed in a publication from the Scottish Home and Health Department5 which records, among other things, The Lancet’s insistence in 1951 that upwards of ten days should be spent in hospital for any surgical condition and the journal’s condemnation of those who pushed their patients out of bed as soon as they were conscious and out of hospital whenever they could totter.6 Times have changed 7: it is no longer remarkable for a patient to have a herniorrhaphy as an outpatient, and there is good evidence that the patient is medically neither better nor worse off as a consequence of very or
early discharge.8 The Scottish report reveals that day-care, shortstay, and planned-early-discharge techniques have now been applied in general surgery, psediatric
gynaecology, traumatic surgery, and investigative medicine-to name only the major areas. Most of the initial work was done with existing facilities for homogeneous groups of conditions such as hernia 3,9 and varicose veins or for diagnostic dilatation and curettage,lO,ll but increasingly in Britain and elsewhere purpose-designed units are being developed 12,13 and studied. 14-17 The last part of the report is an operational-research analysis of one such unit undertaking a wide variety of minor procedures and investigations. From the wealth of data certain factors are salient. First, enthusiasts have inevitably concentrated on the freedom from surgery,
1. Nicoll, J. H. Br. med. J. 1909, ii, 753. 2. Fullerton, A. ibid. 1913, i, 470. 3. Farquharson, E. L. Lancet, 1955, ii, 517. 4. Ruckley, C. V., Maclean, M., Ludgate, C. M., Espley, A. J. ibid. 1973, ii, 1193. 5. The Value of the Day Bed Unit in General Hospital Practice. By IAN W. KEMP, M.D. Scottish Health Service Studies, no. 32. Scottish Home and Health Department, 1975. £1.15. 6. Lancet, 1951, i, 95. 7. ibid. 1972, ii, 23. 8. Morris, D., Ward, A. W. M., Handyside, A. J. ibid. 1968, i, 681. 9. Stephens, F. O., Dudley, H. ibid. 1961, i, 1042. 10. Littlepage, B. N. C., et al. J. Obstet. Gynœc. Br. Commonw. 1969, 76, 163. 11. Wagman, H., Bamford, D. S. Br. med. J. 1971, i, 450. 12. Calnan, J., Martin, P. ibid. 1971, iv, 92. 13. Berrill, T. H. ibid. p. 348. 14. Brown, F. M. Nursing Times, 1964, 60, 696. 15. Lawther, A. The Hospital, 1967, 63, 47. 16. Levy, M. L., Oakley, C. S. Sth. med. J. 1968, 61, 995. 17. Follis, P. Pulse, 1969, 18, 4.
complications of what they do, and have not sufficiently considered the patient and his personality. medical
There may be domestic strains and unexpressed or apparently irrational fears which few specialists hear about; the transport problems are different from those of ordinary hospital patients, and rethinking of many facilities is called for. Second, there seems to be a tendency for day-bed facilities to expand until they become short-stay units, taking on an increasingly varied cross-section of surgery and investigation-becoming in fact little hospitals on their own. It is far from certain that this is the best way to practise medicine, either for the doctor or the patient. Furthermore, this does mean more directed and therefore inflexible allocation of resources, and possibly increased rather than decreased capital and running costs. One of the aims of the day-bed concept, and indeed in these troubled times of all hospital medicine, should be to do more with less. Somehow it must be shown that a change in the pattern of care which is without medical and, in properly selected cases, social drawbacks has real economic advantages. Can it reduce the number of acute beds needed, or alternatively permit a reallocation ? Can there be a saving in running costs for a given output ? These important economic questions are not tackled by the Scottish report. However, there are some modest pointers from studies in Stockton-on- Tees 18 that savings can be made. To achieve them, careful integrated planning inside the reorganised Health Service is required so that specialist, general practitioner, nurse, and social worker can all ensure that in every way the patientour customer-receives a package which is as good as or better than that offered by the conventional hospital bed. Outpatient and short-stay management for surgery and investigation is now through its preliminary phase. It is neither new nor controversial. Now we need to know just what part it can play in individual areas of medical practice and for particular communities.
DEALING WITH RABIES
THE rabies virus has broken loose on the continent Europe and may soon be knocking more insistently at the door in Britain. Those who look after imported pets and laboratory animals in quarantine are already at risk, and there is a steady trickle of others who have been exposed abroad. Untreated rabies is a terrible and uniformly fatal disease, but effective methods of prevention and treatment exist and a number of improvements will soon be available generally. In Europe the virus spreads in the fox population, which has increased probably because of reductions in the numbers of competing species, including bears and hawks. A long-term objective should therefore be to reduce the fox population until it can no longer
of
18.
Devlin, B. Unpublished.
1368 support the growth and spread of the virus. In Britain there are plans to act swiftly and drastically against the local fox population if the virus seems to have been
introduced. In the U.S.A., where rabies is widespread in wildlife and will never be eliminated, it is instructive to see how a well-planned programme can reduce the ill-effects. Prophylactic immunisation of dogs has reduced the frequency of canine rabies from 5000 cases per annum in 1946 to 180 in 1973. Together with better treatment regimens, this has reduced the number of human cases from over 20 per year to almost 2 per year; even so, about 30,000 post-exposure treatments are given each year.1 Controlled trials of treatment methods in man are virtually impossible, but a unique study of a group of villagers bitten by a rabid wolf in Iran seemed to show a real protective effect from a combination of antirabies antiserum and rabies vaccine.2 Horse antiserum is available, and also various vaccines, of which the inactivated duck-embryo vaccine is used in the U.S.A. and Britain. Horse serum often produces serum sickness and the vaccine always causes local reactions; up to two-thirds of recipients have general reactions, and a few have serious central-nervoussystem damage. Therefore in each patient the risks of treating must be weighed against those of not treating. A paper by Corey and Hattwick,l illustrated with a flow chart, is very helpful. Firstly, the risk is evaluated on epidemiological principles. Is rabies known to occur in the area, and if so did the animal show signs of rabies such as aggressiveness or paralysis ? Has the animal been caught ? Has the brain been examined and found to contain virus ? Was the exposure by a bite or only by contact of saliva with abrasions ? This enables a scale of risk for rabies to be established and treatment can then be instituted at a corresponding point. If there was no bite and no exposure to saliva, or if rabies is known not to occur, If the as in Britain, then no treatment is necessary. was bitten a or by clinically virologically rabid patient then immediate treatment with serum and animal, vaccine is essential. Serum is given, partly locally into the bitten area and partly intramuscularly, and up to 23 doses of vaccine are given. Corey and Hattwick1 and the W.H.O. report3 outline the action to take in
intermediate
cases.
Research is now directed to improving both the serum and the vaccine. Human immunoglobulins can be obtained from vaccinated subjects and are apparently rather more effective than horse serum in
producing circulating antibody; furthermore, they produce almost no local or general effects. As might be expected, such circulating anti-rabies antibody, by acting as a specific immunosuppressant, diminishes the ability of the vaccine to stimulate production of persisting antibodies (apparently one dose of human globulins can prevent the effect of 16 doses of duckembryo vaccine ), though this interference may be
less serious if more potent vaccines are used.5 After research at the Wistar Institute a new vaccine has been developed containing virus produced in tissuecultures of human diploid fibroblasts. Inactivated, concentrated, and highly purified, this has now been produced in commercial conditions. The latest vaccine to be evaluated is substantially more potent than duck-embryo vaccine and produces only trivial local reactions. It will probably replace duck-embryo vaccine for the protection of those exposed in the course of their work-provided that it can be produced economically and in sufficient quantity. Vaccination schedules have still to be worked out, but immune responses are likely to be so consistent that postvaccination tests for circulating antibodies will be unnecessary. Antibody responses in volunteers will show whether the vaccine can replace duck-embryo vaccine in treatment. As a very potent antigen it may well be less affected by antibody immunosuppression, and it is certainly much less likely to cause side-effects. This more effective vaccine should also make it easier to produce human immune anti-rabies globulin. Finally, it should be remembered that at least one patient has recovered from clinical rabies. A combination of improved immunological treatments and modern intensive care may yet save more, if the disease is recognised very early and treatment started with a minimum of delay.
ANOTHER SCANNER FROM EMI
AT the 1972 annual congress of the British Institute of Radiology in London, the audience attending a lecture by J. Ambrose and G. N. Hounsfield with the obscure title Computerised Transverse Axial Tomographywere electrified by the realisation that they were witnessing the introduction of a revolutionary new approach to diagnostic radiology. With this apparatus-the EMI brain scanner-the X-ray tube emits a narrow beam of radiation as it passes, in a series of scanning movements, through a 180° arc around the patient’s head.In contradistinction to the conventional photographic method of recording, the intensity of the emergent X-ray beam is measured by a scintillation counter; the electronic impulses are recorded on a magnetic disc and are then processed by a mini-computer. In a single scan, which takes about four minutes, it is possible to determine the X-ray absorption coefficients of approximately 20,000 individual areas of the brain.9 The sensitivity of the apparatus is such that it displays the very small variations in X-ray absorption coefficients which normally exist in the different parts of the brain so that the subarachnoid space, cerebral cortex, white matter, corpus striatum, internal capsule, and ventricular system are visible; and, of course, calcification is even more readily demonstrable. Dilatation or displacement of the ventricular system, or changes in the subarachnoid Loufborrow, J. C., Cabasso, V. J., Roby, R. E., Anuskiewicz, W. ibid. 1971, 217, 1825. 6. Aoki, F. Y., Tyrrell, D. A. J., Hill, L. E., Turner, G. S. Lancet, March 22, 1975, p. 660. 7. Ambrose, J., Hounsfield, G. Br. J. Radiol. 1973, 46, 148. 8. Hounsfield, G. N. ibid. p. 1016. 9. Hounsfield, G. N. Unpublished.
5.
Corey, L., Hattwick, M. A. W. J. Am. med. Ass. 1975, 232, 272. Habel, K., Koprowski, H. Bull. Wld Hlth Org. 1955, 13, 773. 3. Expert Committee on Rabies, Sixth Report. Tech. Rep. Ser. Wld Hlth Org. no. 523, 1973. 4. Hattwick, M. A. W., Rubin, R. H., Music, S., Sikes, R. K., Smith, J. S., Gregg, M. B. J. Am. med. Ass. 1974, 227, 407.
1. 2.
