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COMMUNITY CARE

THE Hospital Plan, published last year, has now beenfollowed by a similar plan for statutory health and welfareservices, which was issued this week as a blue-book.l

Although this document may contain little that is new, itshould prove of even greater practical value than theHospital Plan, since the health and welfare services varyenormously according to local enthusiasm and initiative;and, though the report does not aim

" to lay down a

standard pattern nor to state principles and objectivesdogmatically ", it will for the first time enable allauthorities to compare their own performance and planswith those of others.The health and welfare services have already expanded

more than is generally recognised : in the past five yearscurrent expenditure on them has risen by half and capitalexpenditure has quadrupled. Plans drawn up by the 146local health and welfare authorities envisage capitalexpenditure in the ten years to 1972 of well over E200million and an increase of 45% in the staffs employed.The blue-book includes a comprehensive survey which

is pleasingly free from rigidity : " Indeed, the whole

future approach to certain of the needs for which theseservices cater may be radically altered by new methodsand concepts, some of which are already being tried out."The number of hospital confinements is increasing, and

at some point in the coming decade the number of homeconfinements is likely to be reduced everywhere. Domi-

ciliary midwives, however, will continue to have a mostimportant place in the maternity services, and localauthorities are planning to increase the total from 5240 to6500 by 1972. Despite changes in their functions, the useof clinics is increasing. Although in her work the healthvisitor is becoming more selective, her field is broadeningto include the ill and the mentally and physically handi-capped of all ages. The plans provide for increasing thenumber of health visitors from 5213 to over 7600 by1972, but the survey suggests that 8600 or more mayprove to be required. During the next twenty years thenumber of people aged 65 and over is expected to increaseby 32’5%, and of those aged 75 and over by 40-5%. Bythe end of 1961 local authorities were providing 76,000places in homes for old people (14 per 1000 persons aged65 or over). Local authorities plan to provide 63,000 newplaces by 1972, which (allowing for closures) would bringthe provision up to 133,000 (20 per 1000 aged 65 or over).The Minister is asking local health authorities to revise

their plans annually, carrying them forward each timea further year. The first revision is due at the end of 1963.

MYOPATHY AND MYOCARDIAL "NECROSIS"IN THE HAMSTER

LAST year Homburger et al. described a form of

primary generalised polymyopathy and cardiac necrosis inan inbred line of Syrian hamsters. In these animalsmuscular weakness develops gradually at about 180 daysof age; increasing weakness is accompanied by oedema ofdependent parts, and most affected animals die at about220 days of age (about a third of the normal life-span).1. Health and Welfare: The Development of Community Care. Plans for

the Health and Welfare Services of the Local Authorities in England andWales. Cmnd 1973. H.M. Stationery Office, 24s.

2. Homburger, F., Baker, J. R., Nixon, C. W., Whitney, R. Med. exp.1962, 6, 339.

Histological abnormalities can be observed in muscle

biopsy specimens at about the 20th day of life, and takethe form of widespread necrosis of muscle-fibres withsome cellular infiltration and evidence of muscle-fibre

regeneration. Similar necrotic lesions in the myocardiumare prominent in the late stages of the disease.We remarked at the time that the histological charac-

teristics of this condition in the hamster differ in manyrespects from those observed in human muscular dys-trophy 4 and in dystrophic mice of the Bar Harbor

strain, but that if the condition proved to be geneticallydetermined it would be of great interest to all engaged inexperimental work on muscle disease in man and animals.A further report s strongly suggests that the hamster

myopathy is inherited by an autosomal recessive mecha-nism.. Males and females of the affected line were matedwith males and females of two other unrelated inbred lines.All 36 offspring of such matings were found at necropsyto be free from myopathy. First-generation offspringwere then brother/sister mated to produce a further

generation. Among the first 35 members of this generation9 (4 male, 5 female) were found to show both myopathyand cardiopathy, while 26 were unaffected. Manyworkers have had difficulty in establishing colonies of theBar Harbor dystrophic mice, since the life-span of thedystrophic animals is short and there is a substantial earlymortality even in the heterozygotes. Clinical muscularweakness develops considerably later, by comparison, inthe hamsters; and clearly the myopathic trait should easilybe maintained in vigorous, rapidly breeding heterozygousanimals. Biochemical, histochemical, and histopatho-logical research on these animals may well throw light onthe pathogenesis of the genetically determined myopathiesin man.

THE STOVE-IN CHEST

FRACTURE of the ribs is usually treated by strapping thechest. Because of the difficulty of resting the brokenbones, pain and discomfort are a nuisance; but the frac-ture heals without trouble and without special treatment;and in most cases that is the end of the story. Sometimes,however, multiple fracture of the ribs is part of a muchmore serious injury. As a result of a direct blow on thechest (usually in a motor accident), a portion of the chestwall is driven in, and ribs, rib cartilages, or the sternummay be fractured in two places. The intervening part-i.e., the free or " floating " part-becomes " flail ";and respiration is impaired. The patient may becomedyspnoeic, distressed, and cyanosed: his vital capacitymay be so reduced that, having no margin of safety, hedies. Proctor and London reported only one survivorof eight patients admitted to the Birmingham AccidentHospital during the nine years 1945-52.Of the many methods devised for controlling the mobile

portion of the chest wall, nearly all are operative-e.g.,some form of wiring, plating,8 or traction by hooks.Schrire 9 describes a device which he has named the

" limpet ".A rubber cup, like those used to fix luggage racks to the

roofs of cars, is fitted to a brass rod which is tapered at one end3. Lancet, 1962, ii, 138.4. Pearce, G. W., Walton, J. N. J. Path. Bact. 1962, 83, 535.5. Michelson, A. M., Russell, E. S., Harman, P. J. Proc. nat. Acad. Sci.,

Wash. 1955, 41, 1079.6. Homburger, F., Baker, J. R., Nixon, C. W., Wilgram, G. Arch. intern.

Med. 1962, 110, 660.7. Proctor, H., London, P. S. Brit. J. Surg. 1955, 42, 622.8. Selvey, H. M. S. Afr. med. J. 1963, 37, 170.9. Schrire, T. ibid. 1962, 36, 516.