- Email: [email protected]
PROCEDURE RE-EXAMINED
1153
Points of View PROCEDURE RE-EXAMINED DAVID ABRAHAMSON
Goodmayes Hospital, Goodmayes, Ilford, Essex
IG3
8XJ
A DISTINGUISHED professor of neurology once described psychiatrists as the last doctors still to take histories, and both the truth of the statement and the usefulness of the procedure are frequently confirmed by referrals from other specialties. Despite this, despite their importance in psychiatry itself, and despite promotion in teaching and examinations, in practice many histories are inadequate, a proportion useless, and a minority actively harmful. This statement is probably less contentious than it seems, since dissatisfaction with current standards is widespread. But, though recognised, the
prevalent failings are usually blamed on incidental factors-notably lack of time, as well as inexperience, language problems, or even the patient, who, as Richardson1 points out, is more commonly described as a bad historian than the doctor. This expectation that circumstances and patients should adapt to the tools rather than the reverse is not confined to psychiatry, but seems especially unrealistic when the aspiration is for ample time; presumably the needs of developing countries are not even recognised if this hope is entertained.2
Furthermore, the orthodox pattern of history has its failures, even in ideal form. Its examplars at formal case conferences are usually carefully prepared, faithful to the pattern laid down by teachers and texts, and very time-consuming: but they are not noted for their practical value. Indeed, so firm is the expectation that the outcome of presentation and discussion will be inconclusive that it is commonplace for no arrangements to be made for feedback of the results.
Biography The conventional model is built around a biographical core that attempts to present a chronological picture of the patient’s development, leading to an understanding of the personality; and, by implication, of the symptoms as well-to some extent. To what extent is rarely made clear, puzzlingly for the student, although this must depend on the theoretical viewpoint being taught, which may differ fundamentally from that which originally inspired the development of this format. It is not my purpose to attempt to trace this development, nor to belittle the respect for the individuality of the patient and the distrust "of preconceptions integral to the " psychobiological approach of Adolf Meyer which is one of its most important roots. But, whatever the intention, the construction of a valid biography is a difficult task demanding unusual skill and judgment (as well as time-consuming research). Published pathographies by psychiatrists, let alone routine case-histories, do not suggest we are specially favoured with these attributes; yet belief in our unique prowess persists. "To do justice to a not known to patient him, the consultant previously at least one hour ... thus permitprobably requires
ting an assessment of the uniqueness of his personality and the development of his illness ", modestly proclaims a Royal College of Psychiatrists memorandum.3 Such information should not be confined to a document of limited circulation: biographers, historians, even theologians, would be interested to learn of the techniques that enable some amongst us to assess the uniqueness of a personality (not to speak of the development of an illness) so adeptly. Childhood Events Such pseudobiographies are likely to be inaccurate, especially when they deal with childhood development. Yet even the best teachers seem unable to bring themselves to let traditional items about early childhood sink into their deserved oblivion. A recent authoritative and largely excellent manual on case-taking on the traditional model7 still includes 35 items on childhood behaviour, many of which are ill-defined to the brink of absurdity (" serious mischief, frequent fights ... excessive conformity ... fears ") or actually known to correlate poorly with adult psychiatric disturbance, including our old friend bed-wetting8; and the same is true even of texts aimed at the undergraduate and the general practitioner 9·lo It may be their teachers’ devotion to such items that leads many beginners to believe that the assiduity with which they collect information about the patient’s early life is the main test of the adequacy of their history, even if the information is finally presented in the familiar leaden cliches. This is especially unfortunate when, as frequently seems to be the case, it contributes to neglect of the patient’s adult personality and circumstances
Discontinuity The biographical format also inevitably tends to stress continuity from phase to phase of the history; whereas it is discontinuities the clinical historian should be most alert for. As therapists our effectiveness lies in the gap between the habitual and the temporary-between personality and illness, character and temporary social pressures distorting it, or fixed and labile aspects of the personality. The semantics and validity of such distinctions are open to debate and criticism and are properly the subject of investigation 11; but in daily practice they are essential for realistic decisions and treatment. It is here that many histories come to grief. Either an attempt is made at a categorical classification of the personality as paranoid ", schizoid ", hysterical ", despite the established limitations of such a system,12 or a list of adjectives is applied - nor, more correctly misapplied, since they are usually vague when they are not contradictory, lifeless when not pejorative, and more informative about the personality of the historian than of the patient. The manual previously referred to7 requires a one- or two-paragraph description of the patient’s personality in non-technical language ", a task not likely to be made easier by the list of 102 attitudes and attributes it offers the neophyte to choose from " only "
"
"
"
as
guide-lines ". partial solutions
Three wise not
to
be
are suggested. First, it may be over-ambitious, especially in what we ask of
beginner. Even the most unsophisticated and hurried historian must be able to establish the timing and dimension of a change once he is clear this is what he is looking A change in mood-and thus necessarily a clear for. description of the normal mood. A change in travel habitshow far used the phobic be able to journey? A change in consultation pattern-was today’s hypochondriac always a haunter of his G.P.’S surgery? A change in work attitudes - what was the past work record of the man now afraid of a job and in danger of being categorised as " inadethe
Or a change in a marriage, necessitating some of the pattern established in it over the years. With grasp
quate " ?
1154 care such information can be reasonably clear and precise, though always subject to checking and revision. One qualification is essential: it is vital that, whilst pointing the direction for inquiry, the current picture is not allowed to impose preconceptions-including the most basic preconception, that something must have been wrong.13 This is not a new suggestion,l4 and the results are not very impres-
sive in terms of style, petty even beside the more ambitious aims sometimes set before the student. The essence of the human personality is not grappled with, nor the existential meaning of a life distilled in infinite wisdom and understanding. But at least some useful information is obtained: information often conspicuously lacking in more ambitious
attempts.
Second, details are more reliable and useful than judgand generalisations. A careful account of a day or days in the patient’s life may be very illuminating, especially if the patient can prepare it as a diary in his own language and style. Third, the limitations of the interview situation for assessing personality should be explicitly recognised in ments
The value of home assessment and of direct in the ward milieu are both widely accepted; but the invaluable information gathered is often scattered through the notes, if recorded at all, rather than regarded In both cases, also, as an integral part of the history. care has to be taken that preconceptions are not built into the situation-it may be in the daily life of the ward rather than the sometimes stylised verbal transactions of the ward meeting that the least prejudiced information is available. other ways. assessment
The Future
Biographers inevitably emphasise the past, even those who glance forward into the future to reassure themselves they are not actually writing their own autobiographers
Similarly, case summaries used to end with the " disposal " of the patient, a neat conclusion with a a good deal about ring of the Mafia about it, conveying " the attitude to long-term care. Follow-up"is inappropriately backward looking for the realities of psychiatric practice (and possibly of other branches of medicine as well) since chronic or recurrent illness is the rule rather than the exception. " Future management " is in danger of promising more than can be delivered, since such plans as are set out are usually vague, or if detailed overtaken obituary.
by
events. "
Unresolved problems " would seem to form the most suitable heading for use at this stage, even if a full-scale problem-oriented system 15 is not contemplated. (Whilst several features of the system are attractive,the risks of concentration on a particular format at the expense of content and quality, which have been pointed out in the context of general medicine,16 would seem to apply even more cogently in psychiatry.) Recognition of the problems that remain is likely to be both more honest and more to gloss over them in a productive than an attempt " coherent formulation " or unrealistically spuriously clear-cut management plans. As has been pointed out, most admissions are now readmissions, and it is essential that potentiality for development is one of the criteria of a good history. At present a rehash of old information or a " see previous summaries " is the usual fate of the readmission, so that the tenth history may be no advance on the first, or, worse, may contradict it without evidence or exhibit that spurious development by which unsubstantiated opinions, diagnoses, and even guesses become certainties by being repeated from admission to admission. Such questions as the need to continue medication, or the optimum dosage, the causes of relapse, the stresses in a marriage, the effect of parents’ behaviour on a patient and vice versa, and, most fundamentally, the goals to be aimed at, are amongst those which may be illuminated
when the illness is in remission, the patient back in his normal routine, and, paradoxically, when there is less pressure to produce information, if they are clearly formulated in advance. At best such illumination may enable the next crisis to be dealt with more effectively; at worst it will clarify the questions to be asked then.
The Principles
they are to be capable of adapting it to varying, often difficult, circumstances, trainees must be taught history-taking in terms of principles, rather than solely Most teachers and as a set of detailed procedures. texts make an effort to do this, but the effect tends to be superficial because the implications of the usual biographical format are not squarely faced, and the usual list of dubious items to be inquired into rarely follows long behind the enjoinders to flexibility and individuality. This must contribute to the striking lack of adaptability which is evident in practice. When time demands compression, cuts seem often to be made as the moment dictates, without principle, plan, or objective; when time is plentiful, long narratives are ploughed through for purposes for which they are not required, or for which they may be inappropriate because of the intimate personal details included. If sound principles are to be established the weeding out of unreliable items is an essential preliminary, If
steps in that direction have been reported.17,18 But reliability does not guarantee validity, and the difficult task of establishing what information really counts and why remains to be and
useful
tackled. My purpose has been to point out some implications of the current format that need examination, and to suggest that the area of transition and contrast between the premorbid personality and the illness may be an especially fruitful source of useful information, some of which information may need to be gathered outside the usual interview situation, and involve the patient in a less passive role than is customary. I have also suggested that the history should encompass a wider time-span than is habitual: prediction has been one of its assumed purposes, but its obvious limitations have precluded this being taken " very seriously in practice. A " problem-oriented approach to the future might enable this dimension to be more usefully tackled. Finally, an important qualification. This note has concentrated on the information-gathering aspect of history-taking, to the exclusion of its other important functions, especially its role in establishing empathy and a supportive, working relationship. It may be that these two functions will have to be partially separated in the future. Certainly each requires separate careful scrutiny: it would be as erroneous to assume that gathering inaccurate information is the only way adequate rapport can be established, as to neglect to provide for this function in some other way in any revised system. REFERENCES 1. 2. 3.
Richardson, H. Br. J. Psychiat. 1973, 122, 245. Olatawura, M. O. Bull. Wld psychiat. Ass. 1973, p. 21. Royal College of Psychiatrists memorandum on Norms " for Medical Staffing of a Psychiatric Service. Br. J. Psychiat. 1973, 123, October suppl. p. 6. "
1155
Occasional
Survey
IMPORTANCE OF COAGULASE-NEGATIVE STAPHYLOCOCCI AS PATHOGENS IN THE URINARY TRACT ROSALIND MASKELL Laboratory, Portsmouth and I.O.W. Area Pathological Service and Wessex Renal Unit, St. Mary’s General Hospital, Portsmouth
Public Health
reported frequency of coagulasenegative staphylococci in published studies of urinary infections varies widely, and their importance as pathogens is controversial. It is sugSummary
The
that confusion has arisen as a result of a tendismiss the organisms as contaminants, the use of inappropriate culture methods or inhibitory culture media, and the different age and sex composition of the populations studied. Laboratory data support the view that micrococcus subgroup 3 causes acute infections accompanied by evidence of severe inflammation of the urinary tract, and is virtually confined to women in the sexually active age-group.
gested
dency
to
INTRODUCTION
THE
role of
coagulase-negative staphylococci
as
pathogens in the urinary tract is uncertain. The reported frequency of these organisms in published studies of urinary infection varies widely, from complete absence 1,2 to a figure as high as z Although in most laboratories coagulase-negative staphylococci are now regarded as pathogens when isolated in significant numbers in pure culture, some clinicians still tend
to
attribute their presence
to
contamination.
FREQUENCY Table I summarises the methods used and the relevant findings of some studies of urinary infection in different countries from 1941 onwards. The studies are representative of the differences in methods used and populations The wide range of percentage frequency of studied.
coagulase-negative staphylococci may be due tothree factors. First, when specimens were collected by catheter all organisms were regarded as important, and staphylococci were not dismissed as contaminants. The validity of this viewpoint, however, depends upon the culture methods used. Marple warned that " To avoid the occurrence of false positives a rigid laboratory procedure must be employed. Immediate inoculation of media will prevent false positives resulting from the multiplication of a few contaminants.... In routine laboratory studies of urinary tract infection quantitative counts of colonies are necesThis caution remained largely unheeded. In sary 11.4 1956 Guze and Beeson 13 stated that " the usual method of culturing urine is to obtain a specimen from the bladder by catheterisation and inoculate it into liquid media". They pointed out that the anterior urethra has a bacterial flora which may be introduced into the bladder by the passage of a catheter. Broth culture may then give a false impression of infection as a result of multiplication of a few contaminant organisms. This almost certainly accounts for the very high frequency of staphylococci in Rantz’s study.5 Once attention had been drawn to contamination, the role of staphylococci as urinary pathogens was discounted. In 1963 Freedman 14 said " In the older literature staphylococci were reported as causing about 10% of urinary infections. With the advent of quantitative bacteriologic techniques it has become apparent that staphylococcal urinary infection is comparatively rare ". However, in several studies during the past fifteen years in which catheterisation 6,8,9 or supra-pubic aspiration 3,10,11 and quantitative culture methods have been used, an appreciable frequency of coagulase-negative staphylococci has been reported. A second factor which may be relevant is the choice of culture-media. When blood-agar or cystine lactose electrolyte-deficient (C.L.E.D.) agar has been used, the reported frequency has varied from 7 to 26% (table I). In the two studies in which no staphylococci were found 1.2 the media used were MacConkey agar and nutrient agar. Although MacConkey agar can support the growth of staphylococci, it does not do so reliably, and some batches of medium may be very inhibitory, even to gram-negative organisms. The third factor which might explain the differences in frequency is the nature of the populations studied. This varies in the studies quoted from hospital patients to domiciliary patients, and from mixed populations of both sexes and all ages to groups of women of childbearing age. Staphylococcal urinary infection may be particularly common in one group of the population, and this may well account for the very high frequency in some
studies.3,10,11 4. Yarrow, M.
R., Campbell, J. D., Burton, R. V. Monogr. Soc. Res. Child Devel. 1970, 35, no. 5. 5. Wenar, C., Coulter, J. B. Child Devel. 1962, 33, 453. 6. Haggard, E. A., Brekstad, A., Skard, A. G. J. abnorm. soc. Psychol. 1960, 61, 311. 7. Department of Psychiatry Teaching Committee. Notes on Eliciting and Recording Clinical Information. Institute of Psychiatry, London, 1973. 8. Rutter, M. L. Acta psychiat. scand. 1972, 48, 3. 9. Merskey, H., Tongue, W. L. Psychiatric Illness: Diagnosis and Management for General Practitioners and Students. London, 1965. 10. Pollitt, J. Psychological Medicine for Students. Edinburgh, 1973. 11. Foulds, G. A., Caine, T. M. Personality and Personal Illness. London, 1965. 12. Walton, H. J., Presley, A. S. Br. J. Psychiat. 1973, 122, 259. 13. Rosenham, D. L. Science, 1973, 179, 250. 14. Mayer-Gross, W., Slater, E., Roth, M. Clinical Psychiatry. London, 1960. 15. Hayes-Roth, F., Langabaugh, R., Ryback, R. Br. J. Psychiat. 1972, 121, 27. 16. Carson, P. H. M. Br. med. J. 1973, ii, 713. 17. Beckett, P. G. S., Grisell, J., Crandell, R. G., Gudabba, R. Archs gen. Psychiat. 1967, 16, 407. 18. Eastwood M. R., Ross, H. E. Br. J. Psychiat. 1974, 124, 357.
BACTERIOLOGICAL
AND
STAPHYLOCOCCAL
CLINICAL
URINARY
NATURE
OF
INFECTION
In 1967 Roberts 15 performed supra-pubic aspiration (S.P.A.) on forty pregnant women from whom staphylococci had been isolated from midstream urine
(M.s.u.) specimens. Coagulase-negative staphylococci were isolated from the supra-pubic aspirate in twenty patients, and these organisms were classified by the Baird-Parker 16 technique. 14 (70%) of the 20 organisms were micrococci and 6 (30%) were staphylococci. In contrast, 17 (85 %) of 20 similar organisms contaminating M.s.u. specimens were staphylococci and only 3 (15%) were micrococci. In
1968
Mitchell 17
classified
147
strains
of
coagulase-negative staphylococci isolated from M.s.u. specimens in pure growth of 100,000 organisms per ml. He found that infections after instrumentation
or
Points of View PROCEDURE RE-EXAMINED DAVID ABRAHAMSON
Goodmayes Hospital, Goodmayes, Ilford, Essex
IG3
8XJ
A DISTINGUISHED professor of neurology once described psychiatrists as the last doctors still to take histories, and both the truth of the statement and the usefulness of the procedure are frequently confirmed by referrals from other specialties. Despite this, despite their importance in psychiatry itself, and despite promotion in teaching and examinations, in practice many histories are inadequate, a proportion useless, and a minority actively harmful. This statement is probably less contentious than it seems, since dissatisfaction with current standards is widespread. But, though recognised, the
prevalent failings are usually blamed on incidental factors-notably lack of time, as well as inexperience, language problems, or even the patient, who, as Richardson1 points out, is more commonly described as a bad historian than the doctor. This expectation that circumstances and patients should adapt to the tools rather than the reverse is not confined to psychiatry, but seems especially unrealistic when the aspiration is for ample time; presumably the needs of developing countries are not even recognised if this hope is entertained.2
Furthermore, the orthodox pattern of history has its failures, even in ideal form. Its examplars at formal case conferences are usually carefully prepared, faithful to the pattern laid down by teachers and texts, and very time-consuming: but they are not noted for their practical value. Indeed, so firm is the expectation that the outcome of presentation and discussion will be inconclusive that it is commonplace for no arrangements to be made for feedback of the results.
Biography The conventional model is built around a biographical core that attempts to present a chronological picture of the patient’s development, leading to an understanding of the personality; and, by implication, of the symptoms as well-to some extent. To what extent is rarely made clear, puzzlingly for the student, although this must depend on the theoretical viewpoint being taught, which may differ fundamentally from that which originally inspired the development of this format. It is not my purpose to attempt to trace this development, nor to belittle the respect for the individuality of the patient and the distrust "of preconceptions integral to the " psychobiological approach of Adolf Meyer which is one of its most important roots. But, whatever the intention, the construction of a valid biography is a difficult task demanding unusual skill and judgment (as well as time-consuming research). Published pathographies by psychiatrists, let alone routine case-histories, do not suggest we are specially favoured with these attributes; yet belief in our unique prowess persists. "To do justice to a not known to patient him, the consultant previously at least one hour ... thus permitprobably requires
ting an assessment of the uniqueness of his personality and the development of his illness ", modestly proclaims a Royal College of Psychiatrists memorandum.3 Such information should not be confined to a document of limited circulation: biographers, historians, even theologians, would be interested to learn of the techniques that enable some amongst us to assess the uniqueness of a personality (not to speak of the development of an illness) so adeptly. Childhood Events Such pseudobiographies are likely to be inaccurate, especially when they deal with childhood development. Yet even the best teachers seem unable to bring themselves to let traditional items about early childhood sink into their deserved oblivion. A recent authoritative and largely excellent manual on case-taking on the traditional model7 still includes 35 items on childhood behaviour, many of which are ill-defined to the brink of absurdity (" serious mischief, frequent fights ... excessive conformity ... fears ") or actually known to correlate poorly with adult psychiatric disturbance, including our old friend bed-wetting8; and the same is true even of texts aimed at the undergraduate and the general practitioner 9·lo It may be their teachers’ devotion to such items that leads many beginners to believe that the assiduity with which they collect information about the patient’s early life is the main test of the adequacy of their history, even if the information is finally presented in the familiar leaden cliches. This is especially unfortunate when, as frequently seems to be the case, it contributes to neglect of the patient’s adult personality and circumstances
Discontinuity The biographical format also inevitably tends to stress continuity from phase to phase of the history; whereas it is discontinuities the clinical historian should be most alert for. As therapists our effectiveness lies in the gap between the habitual and the temporary-between personality and illness, character and temporary social pressures distorting it, or fixed and labile aspects of the personality. The semantics and validity of such distinctions are open to debate and criticism and are properly the subject of investigation 11; but in daily practice they are essential for realistic decisions and treatment. It is here that many histories come to grief. Either an attempt is made at a categorical classification of the personality as paranoid ", schizoid ", hysterical ", despite the established limitations of such a system,12 or a list of adjectives is applied - nor, more correctly misapplied, since they are usually vague when they are not contradictory, lifeless when not pejorative, and more informative about the personality of the historian than of the patient. The manual previously referred to7 requires a one- or two-paragraph description of the patient’s personality in non-technical language ", a task not likely to be made easier by the list of 102 attitudes and attributes it offers the neophyte to choose from " only "
"
"
"
as
guide-lines ". partial solutions
Three wise not
to
be
are suggested. First, it may be over-ambitious, especially in what we ask of
beginner. Even the most unsophisticated and hurried historian must be able to establish the timing and dimension of a change once he is clear this is what he is looking A change in mood-and thus necessarily a clear for. description of the normal mood. A change in travel habitshow far used the phobic be able to journey? A change in consultation pattern-was today’s hypochondriac always a haunter of his G.P.’S surgery? A change in work attitudes - what was the past work record of the man now afraid of a job and in danger of being categorised as " inadethe
Or a change in a marriage, necessitating some of the pattern established in it over the years. With grasp
quate " ?
1154 care such information can be reasonably clear and precise, though always subject to checking and revision. One qualification is essential: it is vital that, whilst pointing the direction for inquiry, the current picture is not allowed to impose preconceptions-including the most basic preconception, that something must have been wrong.13 This is not a new suggestion,l4 and the results are not very impres-
sive in terms of style, petty even beside the more ambitious aims sometimes set before the student. The essence of the human personality is not grappled with, nor the existential meaning of a life distilled in infinite wisdom and understanding. But at least some useful information is obtained: information often conspicuously lacking in more ambitious
attempts.
Second, details are more reliable and useful than judgand generalisations. A careful account of a day or days in the patient’s life may be very illuminating, especially if the patient can prepare it as a diary in his own language and style. Third, the limitations of the interview situation for assessing personality should be explicitly recognised in ments
The value of home assessment and of direct in the ward milieu are both widely accepted; but the invaluable information gathered is often scattered through the notes, if recorded at all, rather than regarded In both cases, also, as an integral part of the history. care has to be taken that preconceptions are not built into the situation-it may be in the daily life of the ward rather than the sometimes stylised verbal transactions of the ward meeting that the least prejudiced information is available. other ways. assessment
The Future
Biographers inevitably emphasise the past, even those who glance forward into the future to reassure themselves they are not actually writing their own autobiographers
Similarly, case summaries used to end with the " disposal " of the patient, a neat conclusion with a a good deal about ring of the Mafia about it, conveying " the attitude to long-term care. Follow-up"is inappropriately backward looking for the realities of psychiatric practice (and possibly of other branches of medicine as well) since chronic or recurrent illness is the rule rather than the exception. " Future management " is in danger of promising more than can be delivered, since such plans as are set out are usually vague, or if detailed overtaken obituary.
by
events. "
Unresolved problems " would seem to form the most suitable heading for use at this stage, even if a full-scale problem-oriented system 15 is not contemplated. (Whilst several features of the system are attractive,the risks of concentration on a particular format at the expense of content and quality, which have been pointed out in the context of general medicine,16 would seem to apply even more cogently in psychiatry.) Recognition of the problems that remain is likely to be both more honest and more to gloss over them in a productive than an attempt " coherent formulation " or unrealistically spuriously clear-cut management plans. As has been pointed out, most admissions are now readmissions, and it is essential that potentiality for development is one of the criteria of a good history. At present a rehash of old information or a " see previous summaries " is the usual fate of the readmission, so that the tenth history may be no advance on the first, or, worse, may contradict it without evidence or exhibit that spurious development by which unsubstantiated opinions, diagnoses, and even guesses become certainties by being repeated from admission to admission. Such questions as the need to continue medication, or the optimum dosage, the causes of relapse, the stresses in a marriage, the effect of parents’ behaviour on a patient and vice versa, and, most fundamentally, the goals to be aimed at, are amongst those which may be illuminated
when the illness is in remission, the patient back in his normal routine, and, paradoxically, when there is less pressure to produce information, if they are clearly formulated in advance. At best such illumination may enable the next crisis to be dealt with more effectively; at worst it will clarify the questions to be asked then.
The Principles
they are to be capable of adapting it to varying, often difficult, circumstances, trainees must be taught history-taking in terms of principles, rather than solely Most teachers and as a set of detailed procedures. texts make an effort to do this, but the effect tends to be superficial because the implications of the usual biographical format are not squarely faced, and the usual list of dubious items to be inquired into rarely follows long behind the enjoinders to flexibility and individuality. This must contribute to the striking lack of adaptability which is evident in practice. When time demands compression, cuts seem often to be made as the moment dictates, without principle, plan, or objective; when time is plentiful, long narratives are ploughed through for purposes for which they are not required, or for which they may be inappropriate because of the intimate personal details included. If sound principles are to be established the weeding out of unreliable items is an essential preliminary, If
steps in that direction have been reported.17,18 But reliability does not guarantee validity, and the difficult task of establishing what information really counts and why remains to be and
useful
tackled. My purpose has been to point out some implications of the current format that need examination, and to suggest that the area of transition and contrast between the premorbid personality and the illness may be an especially fruitful source of useful information, some of which information may need to be gathered outside the usual interview situation, and involve the patient in a less passive role than is customary. I have also suggested that the history should encompass a wider time-span than is habitual: prediction has been one of its assumed purposes, but its obvious limitations have precluded this being taken " very seriously in practice. A " problem-oriented approach to the future might enable this dimension to be more usefully tackled. Finally, an important qualification. This note has concentrated on the information-gathering aspect of history-taking, to the exclusion of its other important functions, especially its role in establishing empathy and a supportive, working relationship. It may be that these two functions will have to be partially separated in the future. Certainly each requires separate careful scrutiny: it would be as erroneous to assume that gathering inaccurate information is the only way adequate rapport can be established, as to neglect to provide for this function in some other way in any revised system. REFERENCES 1. 2. 3.
Richardson, H. Br. J. Psychiat. 1973, 122, 245. Olatawura, M. O. Bull. Wld psychiat. Ass. 1973, p. 21. Royal College of Psychiatrists memorandum on Norms " for Medical Staffing of a Psychiatric Service. Br. J. Psychiat. 1973, 123, October suppl. p. 6. "
1155
Occasional
Survey
IMPORTANCE OF COAGULASE-NEGATIVE STAPHYLOCOCCI AS PATHOGENS IN THE URINARY TRACT ROSALIND MASKELL Laboratory, Portsmouth and I.O.W. Area Pathological Service and Wessex Renal Unit, St. Mary’s General Hospital, Portsmouth
Public Health
reported frequency of coagulasenegative staphylococci in published studies of urinary infections varies widely, and their importance as pathogens is controversial. It is sugSummary
The
that confusion has arisen as a result of a tendismiss the organisms as contaminants, the use of inappropriate culture methods or inhibitory culture media, and the different age and sex composition of the populations studied. Laboratory data support the view that micrococcus subgroup 3 causes acute infections accompanied by evidence of severe inflammation of the urinary tract, and is virtually confined to women in the sexually active age-group.
gested
dency
to
INTRODUCTION
THE
role of
coagulase-negative staphylococci
as
pathogens in the urinary tract is uncertain. The reported frequency of these organisms in published studies of urinary infection varies widely, from complete absence 1,2 to a figure as high as z Although in most laboratories coagulase-negative staphylococci are now regarded as pathogens when isolated in significant numbers in pure culture, some clinicians still tend
to
attribute their presence
to
contamination.
FREQUENCY Table I summarises the methods used and the relevant findings of some studies of urinary infection in different countries from 1941 onwards. The studies are representative of the differences in methods used and populations The wide range of percentage frequency of studied.
coagulase-negative staphylococci may be due tothree factors. First, when specimens were collected by catheter all organisms were regarded as important, and staphylococci were not dismissed as contaminants. The validity of this viewpoint, however, depends upon the culture methods used. Marple warned that " To avoid the occurrence of false positives a rigid laboratory procedure must be employed. Immediate inoculation of media will prevent false positives resulting from the multiplication of a few contaminants.... In routine laboratory studies of urinary tract infection quantitative counts of colonies are necesThis caution remained largely unheeded. In sary 11.4 1956 Guze and Beeson 13 stated that " the usual method of culturing urine is to obtain a specimen from the bladder by catheterisation and inoculate it into liquid media". They pointed out that the anterior urethra has a bacterial flora which may be introduced into the bladder by the passage of a catheter. Broth culture may then give a false impression of infection as a result of multiplication of a few contaminant organisms. This almost certainly accounts for the very high frequency of staphylococci in Rantz’s study.5 Once attention had been drawn to contamination, the role of staphylococci as urinary pathogens was discounted. In 1963 Freedman 14 said " In the older literature staphylococci were reported as causing about 10% of urinary infections. With the advent of quantitative bacteriologic techniques it has become apparent that staphylococcal urinary infection is comparatively rare ". However, in several studies during the past fifteen years in which catheterisation 6,8,9 or supra-pubic aspiration 3,10,11 and quantitative culture methods have been used, an appreciable frequency of coagulase-negative staphylococci has been reported. A second factor which may be relevant is the choice of culture-media. When blood-agar or cystine lactose electrolyte-deficient (C.L.E.D.) agar has been used, the reported frequency has varied from 7 to 26% (table I). In the two studies in which no staphylococci were found 1.2 the media used were MacConkey agar and nutrient agar. Although MacConkey agar can support the growth of staphylococci, it does not do so reliably, and some batches of medium may be very inhibitory, even to gram-negative organisms. The third factor which might explain the differences in frequency is the nature of the populations studied. This varies in the studies quoted from hospital patients to domiciliary patients, and from mixed populations of both sexes and all ages to groups of women of childbearing age. Staphylococcal urinary infection may be particularly common in one group of the population, and this may well account for the very high frequency in some
studies.3,10,11 4. Yarrow, M.
R., Campbell, J. D., Burton, R. V. Monogr. Soc. Res. Child Devel. 1970, 35, no. 5. 5. Wenar, C., Coulter, J. B. Child Devel. 1962, 33, 453. 6. Haggard, E. A., Brekstad, A., Skard, A. G. J. abnorm. soc. Psychol. 1960, 61, 311. 7. Department of Psychiatry Teaching Committee. Notes on Eliciting and Recording Clinical Information. Institute of Psychiatry, London, 1973. 8. Rutter, M. L. Acta psychiat. scand. 1972, 48, 3. 9. Merskey, H., Tongue, W. L. Psychiatric Illness: Diagnosis and Management for General Practitioners and Students. London, 1965. 10. Pollitt, J. Psychological Medicine for Students. Edinburgh, 1973. 11. Foulds, G. A., Caine, T. M. Personality and Personal Illness. London, 1965. 12. Walton, H. J., Presley, A. S. Br. J. Psychiat. 1973, 122, 259. 13. Rosenham, D. L. Science, 1973, 179, 250. 14. Mayer-Gross, W., Slater, E., Roth, M. Clinical Psychiatry. London, 1960. 15. Hayes-Roth, F., Langabaugh, R., Ryback, R. Br. J. Psychiat. 1972, 121, 27. 16. Carson, P. H. M. Br. med. J. 1973, ii, 713. 17. Beckett, P. G. S., Grisell, J., Crandell, R. G., Gudabba, R. Archs gen. Psychiat. 1967, 16, 407. 18. Eastwood M. R., Ross, H. E. Br. J. Psychiat. 1974, 124, 357.
BACTERIOLOGICAL
AND
STAPHYLOCOCCAL
CLINICAL
URINARY
NATURE
OF
INFECTION
In 1967 Roberts 15 performed supra-pubic aspiration (S.P.A.) on forty pregnant women from whom staphylococci had been isolated from midstream urine
(M.s.u.) specimens. Coagulase-negative staphylococci were isolated from the supra-pubic aspirate in twenty patients, and these organisms were classified by the Baird-Parker 16 technique. 14 (70%) of the 20 organisms were micrococci and 6 (30%) were staphylococci. In contrast, 17 (85 %) of 20 similar organisms contaminating M.s.u. specimens were staphylococci and only 3 (15%) were micrococci. In
1968
Mitchell 17
classified
147
strains
of
coagulase-negative staphylococci isolated from M.s.u. specimens in pure growth of 100,000 organisms per ml. He found that infections after instrumentation
or