- Email: [email protected]
ACQUIRED RESISTANCE AGAIN
976
denied the strength and cohesion to be gained from union in a single division. Neither working-party claims official backing for its recommendations; and both would presumably be content if the systems they propose could be tested on a small scale. But what each report makes very clear is the hospital clinician’s duty to gain and to apply knowledge of medical administration: "... every clinical decision affects the administrative running of the hospital" 1; and hospital costs have soared so high that each member of the staff should at least know how his decisions affect the hospital’s administration. If anarchy has a place anywhere, it is certainly not within the walls of a modern hospital.
PSYCHIATRY RAMPANT
helped. It should not call its divisions schools or disciplines, when in reality they were " fragments " of a subject so new and large that no-one could grasp more than a small part of what was happening. Eclecticism, a word often pejoratively used, was the right approach. The place of psychiatry in medicine was so enormous and so important that it should be established first-by not expanding so rapidly, by getting better men into it, and by educating other disciplines in the understanding of
be
those in need. How this education should be supplied was outlined by Prof. Linford Rees, who had helped to increase undergraduate lectures on psychiatry at St. Bartholomew’s Hospital from 30 to 120 hours. Next year each student would do three months full-time at Hackney, working in a comprehensive community service, with 80 beds, for 230,000 people. Liaison was fostered with the area mental hospitals and with general practitioners, who could work as clinical assistants. Mental-welfare officers came to every round and attended teach-ins. The doctorpatient relationship, the interview, was basic to everything. Closer collaboration was needed with other specialties, and a psychiatrist might ultimately be attached to every special unit to advise on the role of emotional factors and on management. Shortage of numbers, however, meant that most psychiatrists had to confine their efforts to manifest illness.
THE ever-provoking debate between psychiatry limited and unlimited was reopened by the Society of Clinical Psychiatrists on Oct. 24. Taking a holistic view, Dr. Henry Dicks felt that conflicting hypotheses about mental health and sickness should first be clarified and validated. Some specialties of psychiatry and social science must be fitted into the total structure. Failure to do this and to relieve confusion would prevent psychiatrists from offering badly needed guidance, not only to their medical colleagues, but to politicians, lawyers, and others in responsible positions. Someone had to step into the gap left by the erosion of religion, to form a rational and humane value system. Who would, if the psychiatrist did not ? ACQUIRED RESISTANCE AGAIN Society had to match physical control of the universe " ASYLUM dysentery " used to have a very bad name, with moral control: psychiatrists could not wield power, and even today enteric infections are only too common in but they could apply influence. What seemed to be an opposing outlook came from mental hospitals. An outbreak (reported by Dr. Lewis on Dr. Denis Williams. Noting the recent explosive expan- p. 953) due to Shigella flexneri type 2a in a ward housing sion of psychiatry, he thought it was no kind of specialty 40 subnormal children seems to have had no unusual in the way ear, nose, and throat work was, for example; features, but the laboratory investigations arising from it it was rather an organisation of individuals. It had grown may give grounds for some alarm. The patients were rapidly because of the failure of those doctors of his gen- treated with ampicillin, alone and with nalidixic acid, eration and later who had received no proper psychiatric tetracycline, and neomycin with nalidixic acid. It is not education. " Neurology gave birth to psychiatry by clear how effective these drugs were, but this ringing of the default, because it could not escape from the reflex arc." changes suggests that clearing the ward of infection was Psychiatry had become large, fairly closely integrated, not easy. During the course of treatment 16 strains of and more and more isolated from the rest of medicineSh. flexneri were found to include 8 different patterns of he the fault of medicine itself. Docantibiotic resistance. Some were sensitive in vitro to all primarily, thought, tors imposed on psychiatry their treatment failures, and the antibiotics tried and some to none-with almost every also their intellectual and emotional failures: " psychiavariety of intermediate pattern. These resistances were trists are being asked constantly to take in other people’s transmissable to Escherichia coli, K12, and so once more washing for which they haven’t yet invented detergents." the potential threat of genetically acquired resistance Then they were blamed for failing. Psychiatrists had seems to complicate clinical medicine. In an epidemic of allowed people to believe that they could give answers to this kind most physicians have assumed that all the all problems between conception and death, and that they organisms isolated in the acute phase will be sensitive to should conduct everything from marriage guidance to the same range of antibiotics. town planning. War-time psychiatry had illustrated the Among those who talk of the dangers of acquired resistdifferent approaches: the Navy psychiatrists did too ance it seems to be agreed without question that the use of little, R.A.F. ones did about enough, but Army ones antibiotics in treating infections of the bowel is mandatory. tried to take on everything. There were unfortunately Septicsemic infections due to Salmonella spp. are a danger not enough good psychiatrists to go round. Dr. Williams to life and must be treated vigorously with the best antihad repeatedly found substandard people being appointed biotic, but these drugs have not been noticeably successful to consultant posts and he had tried to oppose this. Lack in clearing residual infection from the bowel or gallof techniques defeated the holistic attitude to human bladder. Far commoner are the salmonella and shigella misery and happiness; and he could not recall one patient infections limited to the bowel. These are seldom fatal in referred by him for long-term psychotherapy who had any but the very young or the debilitated aged, and here actually lost the symptoms for which he was referred. the main danger is dehydration. (Infection by Sh. shiga Psychiatry, then, must not hurry. It should not assume is not now a problem in this country.) In institutions tasks just because no-one else wanted to do them; and there is an understandable anxiety to bring an epidemic to it would gain by saying frankly when a patient could not an end before it spreads to other wards, but there is not
977 are the best drugs for the first since the trials of Ever sulphonamides in dysenjob. in the Middle East in 1940-42, many papers have tery of kind which show that the drug A cleared the appeared 5-6 on of infection in the days average, while drug patients B took 6’7 days. Very few of these painstaking trials included untreated controls; and, where the need is to clear an institution of infection, average times may not be of much importance. Perhaps not enough attention has been paid to the work of Dixon1 which gave grounds for thinking that, so far from antibiotics shortening the time during which convalescent patients excreted Salm. typhimurium after an outbreak of food-poisoning, there is a real possibility that by interference with the natural functions of the bowel these drugs prolonged the carrier state. Experience suggests that this may be equally true of shigella infections. No-one, so far as we know, has ever managed to check an epidemic of intestinal infection while it is in full flood, with antibiotics or any other drugs. Those who are susceptible will probably acquire the infection; and for those with insanitary habits, this is a virtual certainty. We suggest that in institutional outbreaks of dysentery the first essential is to prevent the spread of infection to other wards by the strictest measures of control. The time for the bacteriological examination of the inmates and staff is when the epidemic seems to have burned itself out. Those who are then found to harbour the causative organism may or may not be treated, but Ross2 has pointed out that the danger from the convalescent as a source of infection may have been overestimated. Permanent carriers of the organisms commonly associated with these outbreaks are very rare indeed. Such a programme will save a lot of money, it will lessen the potential dangers arising from transmissible resistance to antibiotics, and it will probably give results as good—or as bad-as any.
much evidence that antibiotics
IMPORTANT CONNECTIONS
THE Cape ventilator owes its considerable success to good basic mechanical design, but the report 3 of a death after the connections to a Cape ventilator were incorrectly made emphasises the dangers of a machine in which wrong connections can easily be made. A device was designed to prevent this type of accident after two patients in 1965 had been in distress when a breathing hose was replaced in a wrong port.4 It was expected that future models would adopt a specification of the British Standards Institution,b but new machines are still not entirely safe; there are, of course, many of the older unmodified machines in
use.
At the patient’s end of the cabinet in older machines, having a filter intake port, there are three ports of identical size; and selecting the filter intake as one of the respiratory ports is a danger. The new model has male (cone) outlet and female (socket) inlet and the filter inlet is female (socket) of larger size, in accordance with the British Standard specification. At the far end of the cabinet all machines have three ports of identical size. During sterilisation of the ventilator with formalin, connection is made between two of the ports such that a circle system results. If the machine is used in this state, the patient will 1. Dixon, J. M. S. Br. med. J. 1965, ii, 1343. 2. Ross, A. I. Mon. Bull. Min. Hlth 1955, 14, 16. 3. Daily Telegraph, Oct. 21, 1967. 4. Hannington-Kiff, J. G. Anœsthesia, 1965, 20, 356. 5. British Standard 3806 (1964) Breathing Machines for Medical Use. See also British Standard 3849 (1965) Breathing Attachments for
Anæsthetic Apparatus.
be inadequately ventilated. A special unmistakable connector must be supplied for use in the sterilisation procedure. In the meantime the home-made safety device will be helpful. The Cape is quiet in operation, and little change is audible if a connection comes adrift; and since it is volume/ time cycled no obvious rush of gas is heard, as with a pressure-cycled ventilator. An alarm might therefore be particularly useful; but the alarm now supplied as an optional extra is not entirely reliable. It is designed to ring a bell when no positive pressure is detected during inspiration. On the machines which were tested the bell rang if the inspiratory hose was disconnected; but it did not ring if the expiratory hose was disconnected, because sufficient positive pressure could still build up, although, of course, ventilation would have been inadequate in these circumstances. Furthermore, incorrect selection of ports which made a circle allowed positive pressure during inspiration, so that the alarm did not sound in this dangerous situation of complete rebreathing without inflow of fresh gas. The attachment for adding oxygen to enrich the air supplied to the patient can be fitted into the " expired air to atmosphere " port, so that pressure will build up in the circuit. There are some other problems in the setting up of the ventilator. But, with these reservations, the Cape ventilator is a very reliable and efficient machine. Finally it cannot be said too often that when a patient who is being ventilated mechanically deteriorates in any way which could be caused by faulty ventilation, the first measure is to disconnect the patient from the ventilator and ventilate with a hand-operated device which should always be readily available. It is good practice to write these instructions on the ventilator.
TREATMENT OF TUBERCULOSIS OVERSEAS
AT a symposium on the chemotherapy of tuberculosis in developing countries, lately held at the Royal College of Surgeons of England, Dr. H. T. Waaler emphasised the need for cost/benefit analysis. The best budget would be one in which an extra sum spent on any of the several parts of the programme would produce the same reduction in suffering or in the future incidence of disease. Although financial priorities cannot yet be estimated with such precision, several speakers indicated where money was being spent inefficiently. For instance, Dr. L. Mokhtari said that 92% of the money available in Algeria for tuberculosis control was spent on hospital beds, leaving only 7% for clinics and 1% for B.C.G. vaccine. The efficacy of present methods was questioned by Dr. P. W. Kent of Kenya, where only about a third of cases were diagnosed, and, of these, only a half were made non-infectious by chemotherapy. Dr. J. Frimodt-Moller reported early results of work in India, where a period of intensive case-finding and treatment with isoniazid alone or isoniazid plus P.A.S. in several small towns resulted in sputum conversion of only half of those treated and an increase in isoniazid resistance in tubercle bacilli. Part of the economic problem is to find effective and cheap regimens. Dr. J. F. Heffernan reviewed cooperative studies in East Africa which led to the widespread use of a low-cost regimen of thiacetazone 150 mg. and isoniazid 300 mg. daily, shown to be as effective as a standard regimen of P.A.S. and isoniazid. But its applicability outside East Africa was in doubt because of variations from one community to another in the natural sensitivity of tubercle bacilli to thiacetazone and also in the
denied the strength and cohesion to be gained from union in a single division. Neither working-party claims official backing for its recommendations; and both would presumably be content if the systems they propose could be tested on a small scale. But what each report makes very clear is the hospital clinician’s duty to gain and to apply knowledge of medical administration: "... every clinical decision affects the administrative running of the hospital" 1; and hospital costs have soared so high that each member of the staff should at least know how his decisions affect the hospital’s administration. If anarchy has a place anywhere, it is certainly not within the walls of a modern hospital.
PSYCHIATRY RAMPANT
helped. It should not call its divisions schools or disciplines, when in reality they were " fragments " of a subject so new and large that no-one could grasp more than a small part of what was happening. Eclecticism, a word often pejoratively used, was the right approach. The place of psychiatry in medicine was so enormous and so important that it should be established first-by not expanding so rapidly, by getting better men into it, and by educating other disciplines in the understanding of
be
those in need. How this education should be supplied was outlined by Prof. Linford Rees, who had helped to increase undergraduate lectures on psychiatry at St. Bartholomew’s Hospital from 30 to 120 hours. Next year each student would do three months full-time at Hackney, working in a comprehensive community service, with 80 beds, for 230,000 people. Liaison was fostered with the area mental hospitals and with general practitioners, who could work as clinical assistants. Mental-welfare officers came to every round and attended teach-ins. The doctorpatient relationship, the interview, was basic to everything. Closer collaboration was needed with other specialties, and a psychiatrist might ultimately be attached to every special unit to advise on the role of emotional factors and on management. Shortage of numbers, however, meant that most psychiatrists had to confine their efforts to manifest illness.
THE ever-provoking debate between psychiatry limited and unlimited was reopened by the Society of Clinical Psychiatrists on Oct. 24. Taking a holistic view, Dr. Henry Dicks felt that conflicting hypotheses about mental health and sickness should first be clarified and validated. Some specialties of psychiatry and social science must be fitted into the total structure. Failure to do this and to relieve confusion would prevent psychiatrists from offering badly needed guidance, not only to their medical colleagues, but to politicians, lawyers, and others in responsible positions. Someone had to step into the gap left by the erosion of religion, to form a rational and humane value system. Who would, if the psychiatrist did not ? ACQUIRED RESISTANCE AGAIN Society had to match physical control of the universe " ASYLUM dysentery " used to have a very bad name, with moral control: psychiatrists could not wield power, and even today enteric infections are only too common in but they could apply influence. What seemed to be an opposing outlook came from mental hospitals. An outbreak (reported by Dr. Lewis on Dr. Denis Williams. Noting the recent explosive expan- p. 953) due to Shigella flexneri type 2a in a ward housing sion of psychiatry, he thought it was no kind of specialty 40 subnormal children seems to have had no unusual in the way ear, nose, and throat work was, for example; features, but the laboratory investigations arising from it it was rather an organisation of individuals. It had grown may give grounds for some alarm. The patients were rapidly because of the failure of those doctors of his gen- treated with ampicillin, alone and with nalidixic acid, eration and later who had received no proper psychiatric tetracycline, and neomycin with nalidixic acid. It is not education. " Neurology gave birth to psychiatry by clear how effective these drugs were, but this ringing of the default, because it could not escape from the reflex arc." changes suggests that clearing the ward of infection was Psychiatry had become large, fairly closely integrated, not easy. During the course of treatment 16 strains of and more and more isolated from the rest of medicineSh. flexneri were found to include 8 different patterns of he the fault of medicine itself. Docantibiotic resistance. Some were sensitive in vitro to all primarily, thought, tors imposed on psychiatry their treatment failures, and the antibiotics tried and some to none-with almost every also their intellectual and emotional failures: " psychiavariety of intermediate pattern. These resistances were trists are being asked constantly to take in other people’s transmissable to Escherichia coli, K12, and so once more washing for which they haven’t yet invented detergents." the potential threat of genetically acquired resistance Then they were blamed for failing. Psychiatrists had seems to complicate clinical medicine. In an epidemic of allowed people to believe that they could give answers to this kind most physicians have assumed that all the all problems between conception and death, and that they organisms isolated in the acute phase will be sensitive to should conduct everything from marriage guidance to the same range of antibiotics. town planning. War-time psychiatry had illustrated the Among those who talk of the dangers of acquired resistdifferent approaches: the Navy psychiatrists did too ance it seems to be agreed without question that the use of little, R.A.F. ones did about enough, but Army ones antibiotics in treating infections of the bowel is mandatory. tried to take on everything. There were unfortunately Septicsemic infections due to Salmonella spp. are a danger not enough good psychiatrists to go round. Dr. Williams to life and must be treated vigorously with the best antihad repeatedly found substandard people being appointed biotic, but these drugs have not been noticeably successful to consultant posts and he had tried to oppose this. Lack in clearing residual infection from the bowel or gallof techniques defeated the holistic attitude to human bladder. Far commoner are the salmonella and shigella misery and happiness; and he could not recall one patient infections limited to the bowel. These are seldom fatal in referred by him for long-term psychotherapy who had any but the very young or the debilitated aged, and here actually lost the symptoms for which he was referred. the main danger is dehydration. (Infection by Sh. shiga Psychiatry, then, must not hurry. It should not assume is not now a problem in this country.) In institutions tasks just because no-one else wanted to do them; and there is an understandable anxiety to bring an epidemic to it would gain by saying frankly when a patient could not an end before it spreads to other wards, but there is not
977 are the best drugs for the first since the trials of Ever sulphonamides in dysenjob. in the Middle East in 1940-42, many papers have tery of kind which show that the drug A cleared the appeared 5-6 on of infection in the days average, while drug patients B took 6’7 days. Very few of these painstaking trials included untreated controls; and, where the need is to clear an institution of infection, average times may not be of much importance. Perhaps not enough attention has been paid to the work of Dixon1 which gave grounds for thinking that, so far from antibiotics shortening the time during which convalescent patients excreted Salm. typhimurium after an outbreak of food-poisoning, there is a real possibility that by interference with the natural functions of the bowel these drugs prolonged the carrier state. Experience suggests that this may be equally true of shigella infections. No-one, so far as we know, has ever managed to check an epidemic of intestinal infection while it is in full flood, with antibiotics or any other drugs. Those who are susceptible will probably acquire the infection; and for those with insanitary habits, this is a virtual certainty. We suggest that in institutional outbreaks of dysentery the first essential is to prevent the spread of infection to other wards by the strictest measures of control. The time for the bacteriological examination of the inmates and staff is when the epidemic seems to have burned itself out. Those who are then found to harbour the causative organism may or may not be treated, but Ross2 has pointed out that the danger from the convalescent as a source of infection may have been overestimated. Permanent carriers of the organisms commonly associated with these outbreaks are very rare indeed. Such a programme will save a lot of money, it will lessen the potential dangers arising from transmissible resistance to antibiotics, and it will probably give results as good—or as bad-as any.
much evidence that antibiotics
IMPORTANT CONNECTIONS
THE Cape ventilator owes its considerable success to good basic mechanical design, but the report 3 of a death after the connections to a Cape ventilator were incorrectly made emphasises the dangers of a machine in which wrong connections can easily be made. A device was designed to prevent this type of accident after two patients in 1965 had been in distress when a breathing hose was replaced in a wrong port.4 It was expected that future models would adopt a specification of the British Standards Institution,b but new machines are still not entirely safe; there are, of course, many of the older unmodified machines in
use.
At the patient’s end of the cabinet in older machines, having a filter intake port, there are three ports of identical size; and selecting the filter intake as one of the respiratory ports is a danger. The new model has male (cone) outlet and female (socket) inlet and the filter inlet is female (socket) of larger size, in accordance with the British Standard specification. At the far end of the cabinet all machines have three ports of identical size. During sterilisation of the ventilator with formalin, connection is made between two of the ports such that a circle system results. If the machine is used in this state, the patient will 1. Dixon, J. M. S. Br. med. J. 1965, ii, 1343. 2. Ross, A. I. Mon. Bull. Min. Hlth 1955, 14, 16. 3. Daily Telegraph, Oct. 21, 1967. 4. Hannington-Kiff, J. G. Anœsthesia, 1965, 20, 356. 5. British Standard 3806 (1964) Breathing Machines for Medical Use. See also British Standard 3849 (1965) Breathing Attachments for
Anæsthetic Apparatus.
be inadequately ventilated. A special unmistakable connector must be supplied for use in the sterilisation procedure. In the meantime the home-made safety device will be helpful. The Cape is quiet in operation, and little change is audible if a connection comes adrift; and since it is volume/ time cycled no obvious rush of gas is heard, as with a pressure-cycled ventilator. An alarm might therefore be particularly useful; but the alarm now supplied as an optional extra is not entirely reliable. It is designed to ring a bell when no positive pressure is detected during inspiration. On the machines which were tested the bell rang if the inspiratory hose was disconnected; but it did not ring if the expiratory hose was disconnected, because sufficient positive pressure could still build up, although, of course, ventilation would have been inadequate in these circumstances. Furthermore, incorrect selection of ports which made a circle allowed positive pressure during inspiration, so that the alarm did not sound in this dangerous situation of complete rebreathing without inflow of fresh gas. The attachment for adding oxygen to enrich the air supplied to the patient can be fitted into the " expired air to atmosphere " port, so that pressure will build up in the circuit. There are some other problems in the setting up of the ventilator. But, with these reservations, the Cape ventilator is a very reliable and efficient machine. Finally it cannot be said too often that when a patient who is being ventilated mechanically deteriorates in any way which could be caused by faulty ventilation, the first measure is to disconnect the patient from the ventilator and ventilate with a hand-operated device which should always be readily available. It is good practice to write these instructions on the ventilator.
TREATMENT OF TUBERCULOSIS OVERSEAS
AT a symposium on the chemotherapy of tuberculosis in developing countries, lately held at the Royal College of Surgeons of England, Dr. H. T. Waaler emphasised the need for cost/benefit analysis. The best budget would be one in which an extra sum spent on any of the several parts of the programme would produce the same reduction in suffering or in the future incidence of disease. Although financial priorities cannot yet be estimated with such precision, several speakers indicated where money was being spent inefficiently. For instance, Dr. L. Mokhtari said that 92% of the money available in Algeria for tuberculosis control was spent on hospital beds, leaving only 7% for clinics and 1% for B.C.G. vaccine. The efficacy of present methods was questioned by Dr. P. W. Kent of Kenya, where only about a third of cases were diagnosed, and, of these, only a half were made non-infectious by chemotherapy. Dr. J. Frimodt-Moller reported early results of work in India, where a period of intensive case-finding and treatment with isoniazid alone or isoniazid plus P.A.S. in several small towns resulted in sputum conversion of only half of those treated and an increase in isoniazid resistance in tubercle bacilli. Part of the economic problem is to find effective and cheap regimens. Dr. J. F. Heffernan reviewed cooperative studies in East Africa which led to the widespread use of a low-cost regimen of thiacetazone 150 mg. and isoniazid 300 mg. daily, shown to be as effective as a standard regimen of P.A.S. and isoniazid. But its applicability outside East Africa was in doubt because of variations from one community to another in the natural sensitivity of tubercle bacilli to thiacetazone and also in the